The role of cognitive factors in the pathogenesis of obsessive-compulsive symptoms: a prospective study

Cognitive models of obsessive-compulsive disorder (OCD) posit that specific kinds of dysfunctional beliefs (e.g., pertaining to responsibility and the significance of intrusive thoughts) underlie the development of this disorder. The present study was designed to prospectively evaluate whether dysfunctional beliefs thought to underlie OCD act as a specific vulnerability factor in the pathogenesis of obsessive-compulsive symptomatology. Eighty-five individuals were prospectively followed over a period of time thought to be associated with an increased onset of OCD symptoms -- childbirth and the postpartum. The majority of these new mothers and fathers experienced intrusive infant-related thoughts and performed neutralizing behaviors similar to, but less severe than, those observed in OCD. Scores on a measure of dysfunctional beliefs thought to underlie OCD predicted the development of obsessive-compulsive symptoms after controlling for pre-existing OCD symptoms, anxiety, and depression. Dysfunctional beliefs also predicted the severity of checking, washing, and obsessional OCD symptom dimensions, but not neutralizing, ordering, or hoarding symptom dimensions. These data provide evidence for specific dysfunctional beliefs as risk factors in the development of some types of OCD symptoms.     

Obsessional Beliefs and Symptoms of Obsessive–Compulsive Disorder in a Clinical Sample

The aim of the present study was to investigate the relationships among a broad range of obsessive–compulsive disorder (OCD) symptoms and obsessional beliefs in a clinical sample of OCD patients. Ninety-nine treatment-seeking adult OCD patients completed the Obsessive Beliefs Questionnaire and the Obsessive–Compulsive Inventory-Revised. Hierarchical regression analyses, controlling for comorbid symptoms, suggested that washing was predicted by responsibility/threat estimation beliefs. Checking/doubting was not predicted by any obsessional beliefs. Hoarding was predicted by perfectionism/certainty beliefs. Neutralizing was predicted by responsibility/threat estimation beliefs. Obsessing was predicted by importance/control of thoughts and perfectionism/certainty beliefs. Ordering was predicted by perfectionism/certainty beliefs. A principal components analysis of OCD symptom dimensions and accompanying beliefs yielded two components, accounting for 53% of the variance: one, which was labeled “Fear/Threat,” consisted of importance/control of thoughts, obsessing, responsibility/threat estimation, and washing. The second, which was labeled “Incompleteness/Not Just Right,” consisted of neutralizing, perfectionism/certainty, checking/doubting, and hoarding.     

Cognitive Beliefs Across the Symptom Dimensions of Pediatric Obsessive-Compulsive Disorder: Type of Symptom Matters

The cognitive model of obsessive-compulsive disorder (OCD) posits that dysfunctional cognitive beliefs are crucial to the onset and maintenance of OCD; however, the relationship between these cognitive beliefs and the heterogeneity of OCD symptoms in children and adolescents remains unknown. We examined how the major belief domains of the cognitive model (inflated responsibility/threat estimation, perfectionism/intolerance of uncertainty, importance/control of thoughts) and dysfunctional metacognitions were related to OCD symptoms across the following dimensions: doubting/checking, obsessing, hoarding, washing, ordering, and neutralization. Self-report ratings from 137 treatment-seeking youth with OCD were analyzed. When cognitive beliefs and symptom dimensions were analyzed in tandem, inflated responsibility/threat estimation and dysfunctional metacognitions were uniquely related to doubting/checking, obsessing, and hoarding and perfectionism/intolerance of uncertainty to ordering. Cognitive beliefs explained a large proportion of variation in doubting/checking (61%) and obsessing (46%), but much less so in ordering (15%), hoarding (14%), neutralization (8%), and washing (3%). Similar relations between cognitive beliefs and symptom dimensions were present in children and adolescents. Cognitive beliefs appear to be relevant for pediatric OCD related to harm, responsibility, and checking, but they do not map clearly onto contamination and symmetry-related symptoms. Implications for OCD etiology and treatment are discussed.     

The relationship between miscellaneous symptoms and major symptom factors in obsessive-compulsive disorder

The diverse symptomatology of obsessive-compulsive disorder (OCD) is being increasingly regarded as reducible to a few symptom dimensions. However, prevailing factor-analytically derived models of symptom structure omit a number of the well-recognized “miscellaneous” symptoms of OCD. This study sought to determine whether miscellaneous OCD symptoms, ascertained by the Yale-Brown Obsessive-Compulsive Scale symptom checklist, could be differentially and reliably predicted by four symptom factors (obsessions and checking, symmetry and ordering, contamination and cleaning, and hoarding) in two independent groups of individuals with OCD (n = 381 and n = 107). Logistic regression analyses were used to determine the association of each of the miscellaneous symptoms with the symptom factors; then a single confirmatory factor analysis was conducted to test the model of associations in the smaller sample. Sixteen (89%) of the 18 symptoms examined were reliably predicted by one (11 items) or two (5 items) of the factors, with obsessions and checking and symmetry and ordering emerging as foremost predictors. The expanded four-factor model showed good fit with data from the second sample. Results are conceptually meaningful, but suggest the inadequacy of groupings based solely upon overt behaviors. These findings may aid clinical understanding of OCD and be of value to studies using symptom factors to guide investigation of its causes and correlates.     

Associations between miscellaneous symptoms and symptom dimensions: an examination of pediatric obsessive-compulsive disorder

Obsessive-compulsive disorder (OCD) in children and adults is a heterogeneous disorder associated with significant psychosocial impairment. Although factor analytic studies have identified symptom dimensions, these analyses do not capture the varied miscellaneous symptoms that fail to load on a specific dimension despite being functionally related. The present study sought to extend the findings of previous research in adults to a sample of youth with OCD (n=131). Logistic regression analyses were used to examine the predictive value of each of the four symptom factors (contamination symptoms, obsessions and checking, symmetry and ordering, and hoarding) to the miscellaneous OCD symptoms. The vast majority of miscellaneous symptoms (17 of the 18 symptoms) were associated with one or more symptoms factors (i.e., contamination symptoms, obsessions and checking, symmetry, and ordering). Hoarding was not related to any miscellaneous symptom. In addition to improving our understanding about the clinical presentation of pediatric OCD, findings also have important assessment (e.g., understanding which miscellaneous symptoms relate to certain dimensions) and treatment implications (e.g., hierarchy development).     

The relationship between obsessive beliefs and symptom dimensions in obsessive-compulsive disorder

Research findings on the specific relationships between beliefs and OCD symptoms have been inconsistent, yet the existing studies vary in their approach to measuring the highly heterogeneous symptoms of this disorder. The Dimensional Obsessive-Compulsive Scale (DOCS) is a new measure that allows for the assessment of OCD symptom dimensions, rather than types of obsessions and compulsions per se. The present study examined the relationship between OCD symptom dimensions and dysfunctional (obsessive) beliefs believed to underlie these symptom dimensions using a large clinical sample of treatment-seeking adults with OCD. Results revealed that certain obsessive beliefs predicted certain OCD symptom dimensions in a manner consistent with cognitive-behavioral conceptual models. Specifically, contamination symptoms were predicted by responsibility/threat estimation beliefs, symmetry symptoms were predicted by perfectionism/certainty beliefs, unacceptable thoughts were predicted by importance/control of thoughts beliefs and symptoms related to being responsible for harm were predicted by responsibility/threat estimation beliefs. Implications for cognitive conceptualizations of OCD symptom dimensions are discussed.     

Investigating Treatment Outcomes Across OCD Symptom Dimensions in a Clinical Sample of OCD Patients

Despite the heterogeneous nature of obsessive-compulsive disorder (OCD), many self-report assessments do not adequately capture the clinical picture presenting within each symptom dimension, particularly unacceptable thoughts (UTs). In addition, obsessions and ordering/arranging compulsions are often underrepresented in samples of treatment outcome studies for OCD. Such methodological discrepancies may obscure research findings comparing treatment outcomes across OCD symptom dimensions. This study aimed to improve upon previous research by investigating treatment outcomes across OCD symptom dimensions using the Dimensional Obsessive-Compulsive Scale, which offers a more comprehensive assessment of UTs. The study included a primarily residential sample of 134 OCD patients. Results indicated that there were no significant differences in treatment outcomes across symptom dimensions. However, the severity of UTs remained significantly greater than other symptom dimensions at both admission and discharge. Thus, it is possible that UTs may exhibit uniquely impairing features, compared with other symptom dimensions. It is also possible that these findings may reflect the characteristics of the residential OCD samples. These speculations as well as implications for OCD treatment and future research are discussed.     

An investigation of traumatic life events and obsessive-compulsive disorder

Obsessive-compulsive disorder (OCD), like most other psychiatric disorders, is suspected of being influenced by an interaction between life events and genes, both with regard to onset and course of illness. To date, no specific genes have been identified as playing a frequent role, and only a relatively few empirical studies have assessed the association between stressful life events (SLEs) and OCD. The present study builds on past research by examining the potential contributions from traumatic life events (TLEs) on the severity and symptom features in 265 individuals with Structured Clinical Interview for DSM-IV (SCID)-diagnosed OCD. Of these participants 54% endorsed having experienced at least one TLE in their life time. The presence of one or more TLEs was associated with increased OCD symptom severity. This relationship remained significant despite controlling for key variables including age, OCD age-of-onset, comorbidity, and depressive symptoms. In addition, obsessions/checking and symmetry/ordering were two of four symptom factors that were specifically associated with the occurrence of TLEs. These results are generally supportive of a pathoplastic relationship between TLEs and OCD symptomatology and thus suggest the need for greater systematic consideration of life stresses in research focused on the nature and treatment of OCD.     

Subtyping obsessive-compulsive disorder: A taxometric analysis

Obsessive-compulsive disorder (OCD) is a heterogeneous condition comprising multiple symptoms. Researchers have identified OCD subtypes using a range of symptom-based research methods, including factor and cluster analyses and examination of differential treatment response. These methods can be challenged on the grounds that they fail to demonstrate the existence of discrete taxonomic entities. Furthermore, no study has examined subtyping on the basis of cognitive characteristics. In the present study, the categorical vs. dimensional status of 6 possible subtypes of OCD was examined using taxometric methods. Three potential cognitive subtypes (based on high levels of responsibility/threat estimation, perfectionism/certainty, and importance/control of thoughts) and 3 potential symptomatic subtypes (based on elevated levels of contamination obsessions and cleaning compulsions, checking, and obsessionality) were examined using the MAXEIG and MAMBAC procedures in a sample of 404 diagnosed cases of OCD. Findings favored dimensional models of the potential responsibility, perfectionism, checking, and contamination subtypes, but offered qualified support for taxonic models of the importance/control of thoughts and obsessional subtypes. Implications for the subclassification of OCD are discussed.     

Attentional control in OCD and GAD: specificity and associations with core cognitive symptoms

Obsessive–compulsive disorder (OCD) and generalized anxiety disorder (GAD) are both defined by excessive negatively-valenced cognitions. Although obsessional thoughts are considered essential to OCD and perseverative worry is considered essential to GAD, these excessive cognitions have been found to co-occur in both disorders. Accordingly, a common diathesis may influence the emergence of excessive thoughts in both disorders. The present study examined deficits in attentional control as a cognitive vulnerability that may contribute to both obsessional thought and perseverative worry. Patients with OCD (n = 30), GAD (n = 29), and non-clinical controls (NCC; n = 29) completed measures of obsessional thoughts, perseverative worry, and attentional control. Deficits in self-reported attentional control were found in both OCD and GAD relative to the NCC. However, attentional control was only related to excessive cognition in the GAD patient group, where deficits were associated with increased perseverative worry. Mediational modeling suggested that trait anxiety mediated the relationship between attentional control and perseverative worry in GAD. Implications of these findings for conceptualizing the role of attentional control in the genesis of excessive cognitions in OCD and GAD are discussed.     

Patterns of neural response to emotive stimuli distinguish the different symptom dimensions of obsessive-compulsive disorder

Despite its heterogeneous symptomatology, obsessive-compulsive disorder (OCD) is currently conceptualized as a unitary diagnostic entity. Recent factor-analytic studies have identified several OCD symptom dimensions that are associated with different demographic variables, comorbidity, patterns of genetic transmission, and treatment response. Functional abnormalities in neural systems important for emotion perception, including the orbitofrontal cortex, lateral prefrontal cortex, anterior cingulate gyrus, and limbic regions, have been reported in OCD. In this review, we discuss the extent to which neurobiological markers may distinguish these different symptom dimensions and whether specific symptom dimensions, such as contamination/washing, are associated with abnormalities in emotion and, in particular, disgust, perception in OCD. Also discussed are findings that indicate that anxiety can be induced in healthy volunteers in response to OCD symptom-related material, and that associated increases in activity within neural systems important for emotion perception occur to washing- and hoarding-related material in particular in these subjects. Further examination of neural responses during provocation of different symptom dimensions in OCD patients will help determine the extent to which specific abnormalities in neural systems underlying emotion perception are associated with different symptom dimensions and predict treatment response in OCD.     

Obsessional beliefs and the implicit and explicit morality of intrusive thoughts

Cognitive models of obsessive-compulsive disorder (OCD) suggest that misinterpreting intrusive thoughts exacerbates obsessional thinking. To evaluate this hypothesis, healthy participants (N=91) were prompted to recollect their unwanted thoughts, and then beliefs about the immorality of these thoughts were manipulated. Next, participants completed implicit and explicit measures of self-evaluation and appraisals of unwanted thoughts. Results from structural regression analyses indicated that explicit responses to unwanted thoughts, such as evaluations of the significance of intrusive thoughts and state self-esteem, were predicted by pre-existing obsessional beliefs, but not by the morality instruction manipulation. In contrast, implicit responses, such as appraisals of unwanted thoughts as relatively important and evaluations of the self as relatively immoral and dangerous, were predicted by the interaction between specific obsessional beliefs (e.g., intolerance of uncertainty) and the morality instructions. Findings largely support cognitive models of OCD and suggest unique predictors of implicit and explicit responses to unwanted thoughts.     

The status of hoarding as a symptom of obsessive-compulsive disorder

Hoarding is considered by many to be a symptom of obsessive-compulsive disorder (OCD). Yet although it is observed in people with OCD, hoarding symptoms also appear in a number of other psychological and psychiatric conditions. The present studies were conducted using samples of OCD patients, patients with other anxiety disorders, and a non-clinical sample to further elucidate the relationship between hoarding and OCD. Across two investigations, we found that (a) whereas OCD patients had higher scores than the other groups on non-hoarding symptoms, this was not the case for hoarding symptoms; (b) hoarding tended to correlate more weakly with other OCD symptoms (e.g., washing, checking) than these other symptoms intercorrelated; (c) items measuring hoarding had the weakest factor loadings when a measure of OCD symptoms was submitted to factor analysis; (d) hoarding symptoms were not correlated with global OCD or anxiety severity, whereas other OCD symptoms were; and (e) hoarding did not show consistent relationships with OCD-related cognitive variables. These results do not support a specific relationship between hoarding and OCD; and they call into question hoarding's status as a specific symptom of OCD. Results are also discussed in terms of the importance of functional assessment of hoarding and OCD symptoms.     

Symptom structure in obsessive-compulsive disorder: a confirmatory factor-analytic study

Although obsessive-compulsive disorder (OCD) has long been a unitary diagnosis, there is much recent interest in its potential heterogeneity, as manifested by symptom subgroups. This study evaluated existing models of symptom structure in a sample of 203 individuals with OCD. Using confirmatory factor analysis, we examined the ability of each model to account for two levels of data: a priori symptom groupings (second-order) and individual symptoms, identified by the Yale-Brown Obsessive Compulsive Scale symptom checklist. Four models were examined: a single-factor, a two-factor (i.e., obsessions and compulsions), and two multidimensional models, comprising three and four factors. Adequate fit was found solely for the four-factor model--specifying obsessions/checking, symmetry/ordering, contamination/cleaning, and hoarding--but only at the second-order level; it did not account for relationships among discrete symptoms. Parameter estimates showed within-factor heterogeneity, as well as overlap between factors, most notably the two representing checking and contamination-related symptoms. The implications of these findings are discussed. Results provide evidence for the multidimensionality of OCD symptoms, but suggest that a comprehensive model has yet to be identified. They also point to the inadequacy of groupings based solely upon overt behavioural similarities (e.g., 'checking'). Recommendations are made for future research.     

Event‐based prospective memory and obsessive–compulsive disorder intrusive obsessional thoughts

Recent studies have found poorer prospective remembering among students selected for elevated obsessive–compulsive disorder (OCD) checking and washing. However, as prospective memory performance also requires retrospective remembering, it is not clear from earlier work whether deficits in prospective memory in samples with OCD symptomatology are due to problems with prospective remembering, or to retrospective memory failures that result in poorer performance on prospective memory tasks. The present study examines performance on matched prospective and retrospective memory tasks among students selected for high (n = 48) and low (n = 44) scores on the Obsessive–Compulsive Inventory‐Revised Obsession subscale. Significant differences between the groups were found in prospective memory (regardless of whether the word was neutral or harm/danger‐related), but not retrospective memory. The findings are consistent with the prediction that obsessional thoughts that occupy working memory capacity would have a deleterious effect on a resource‐demanding prospective memory task. An additional finding was that there were no group differences in self‐reported complaints of problems with prospective memory.     

"Not just right experiences": perfectionism,obsessive-compulsive features and general psychopathology

Individuals with obsessive-compulsive disorder (OCD) frequently report uncomfortable sensations of things not being just right ("not just right experiences"; NJREs) and a need to ritualize until they quiet these sensations. However, very little work has been conducted to empirically examine the nature and characteristics of this phenomenon. In this paper, we present two studies that systematically examine NJREs in large undergraduate samples. In Study 1, NJREs were shown to be related to both OCD features and maladaptive domains of perfectionism. In Study 2, NJREs were again significantly related to OCD features. Further, NJREs were shown to have particularly strong relationships with specific OCD symptom clusters (e.g., checking, ordering). Finally, NJREs were significantly more strongly correlated with features of OCD than symptoms from other domains of psychopathology (e.g., social anxiety, trait anxiety, worry, depression). General conclusions are drawn, and future directions are discussed.     

Responsibility attitudes and interpretations are characteristic of obsessive compulsive disorder

The cognitive-behavioural theory of Obsessive Compulsive Disorder (OCD) proposes that a key factor influencing obsessional behaviour is the way in which the intrusive cognitions are interpreted. The present paper reports an investigation of links between clinical symptoms (of anxiety, depression and obsessionality) and responsibility beliefs. These beliefs include not only measures of general responsibility attitudes (assumptions) but also more specific responsibility appraisals consequent on intrusive cognitions. The characteristics of two new questionnaires specifically designed to measure these beliefs were assessed in patients suffering from Obsessive Compulsive Disorder, in patients suffering from other anxiety disorders and in non-clinical controls. The scales measuring negative beliefs about responsibility were found to have good reliability and internal consistency. Comparisons between criterion groups indicate considerable specificity for both assumptions and appraisals with respect to OCD. There was also good evidence of specificity in the association between responsibility cognitions and obsessional symptoms across groups, and that this association was not a consequence of links with anxiety or depressive symptoms. Although the two measures were correlated, they each made unique contributions to the prediction of obsessional symptoms. Overall, the results are consistent with the hypothesis that responsibility beliefs are important in the experience of obsessional problems.     

Obsessional Thoughts in Postpartum Females and Their Partners: Content, Severity, and Relationship with Depression

Only a few studies have examined the development or exacerbation of obsessive–compulsive disorder (OCD) during pregnancy and the postpartum. Although the available literature suggests that OCD symptoms, particularly obsessional problems, develop at higher than expected rates among postpartum females, the overall prevalence of such symptoms in the postpartum remains unknown. Previous findings also suggest that intrusive distressing thoughts related to situational stressors are common in the general population. Therefore, the present study was designed to assess the presence and phenomenology of postpartum obsessive-like intrusive thoughts, images, and impulses in a large sample of parents with very young infants. Surveys were mailed to 300 childbearing women and their partners. Results were obtained from approximately one fifth of the sample; and 65% of respondents indicated the presence of obsessional intrusive thoughts. Intrusions were similar to normal obsessions as reported in previous research. Results are discussed in terms of the content of intrusive thoughts, their relationship to depression, and implications for etiological models of OCD and perinatal education.     

The structure of childhood obsessions and compulsions: dimensions in an outpatient sample

While obsessive-compulsive disorder (OCD) is defined as a unitary condition, prior research has identified meaningful and distinct symptom dimensions in adult samples. In contrast, there have been no investigations of symptom dimensions in samples of children diagnosed with OCD. The present study sought to address this gap. Children diagnosed with OCD (n = 137) were administered the Children's Yale-Brown Obsessive-Compulsive Scale symptom checklist and severity index. Symptoms were analyzed using principal components analysis. As with adult samples, four factors were identified from the checklist. However, these four factors (compulsions, sexual/aggressive obsessions, superstitions, and hoarding/ordering/somatic concerns) were different in content from adult studies. Further, several symptoms significantly contributed to more than one dimension. Each dimension was significantly correlated with scores from the severity index, with the exception of the obsession score with the hoarding/ordering/somatic concerns factor. Results suggest that there are distinct dimensions of symptoms in childhood OCD, but that these dimensions do not correspond to those identified in adults. Instead, it appears that some factors share variance, and the dimensions themselves are separated based upon developmental trajectories. The dimensions examined may be useful in future treatment studies using pharmacological and/or behavioral interventions.     

Violent obsessions are associated with suicidality in an OCD analog sample of college students

The picture of suicide in obsessive-compulsive disorder (OCD) is unclear because previous research did not uniformly control for depressive symptoms when examining the relationship between OCD and suicidality. Specific links between OC symptom dimensions and suicidality were also not adequately studied. As such, we investigated specific associations between OC symptom dimensions and suicidality, beyond the contribution of depressive symptoms, in an OCD analog sample of college students, a group traditionally at risk for suicide. One hundred and forty-six college students (103 females; 43 males) who exceeded the clinical cut-off for OC symptoms on the Obsessive-Compulsive Inventory, Revised (OCI-R) were recruited. Participants completed an online questionnaire containing measures that assessed suicidality and OC and depressive symptom severity. Total OC symptom severity, unacceptable thoughts, and especially violent obsessions exhibited significant positive zero-order correlations with suicidality. However, analyses of part correlations indicated that only violent obsessions had a significant unique association with suicidality after controlling for depressive symptoms. Our findings support the hypothesis that violent obsessions have a specific role in suicidality beyond the influence of depressive symptoms in an OCD analog sample of college students. A strong clinical focus on suicide risk assessment and safety planning in college students reporting violent obsessions is therefore warranted. Future related research should employ longitudinal or prospective designs and control for other possible comorbid symptoms in larger and more representative samples of participants formally diagnosed with OCD in order to verify the generalizability of our findings to these groups.