Cognitive control of obsessional thoughts

A defining characteristic of obsessive-compulsive disorder (OCD) is unsuccessful suppression of unwanted thoughts. Recent evidence of individual differences in ability to control intrusive thoughts may inform our understanding of failures of cognitive control associated with OCD symptomatology. The current study investigated characteristics of cognitive style that are potentially associated with OCD symptoms and may influence response to unwanted thoughts, including perceived ability to control thoughts and tendency to ruminate. Undergraduate students (N = 166) completed self-report measures of OCD symptoms, perceived thought control, and ruminative thinking. They were then presented with a distressing target thought and completed a standard thought suppression paradigm. Correlational results indicated that, controlling for anxiety and depression, OCD symptoms were positively associated with rumination and inversely associated with perceived thought control ability. In addition, OCD symptoms were associated with higher levels of distress and greater spontaneous efforts to suppress the target thought during a baseline period, while perceived thought control ability predicted frequency of target thoughts during suppression. Finally, results of the experimental manipulation confirmed that participants instructed to suppress experienced more intrusions during the recovery period. Clinical implications and future directions are discussed.     

Are "obsessive" beliefs specific to OCD?: a comparison across anxiety disorders

Cognitive models of obsessive-compulsive disorder (OCD) assign a central role to maladaptive beliefs about threat, uncertainty, importance and control of thoughts, responsibility, and perfection. Previous research has demonstrated that such beliefs relate to specific OCD symptoms in a theoretically meaningful way. The aim of the present study was to determine whether these beliefs are endorsed more strongly by OCD patients than by those with other anxiety disorders. Eighty-nine adult OCD patients, 72 anxious control (AC) patients, and 33 nonclinical control (NCC) participants completed a measure of obsessive beliefs as well as measures of depression and trait anxiety. Compared to NCCs and ACs, OCD patients more strongly endorsed beliefs related to threat estimation, tolerance of uncertainty, importance and control of thoughts, and perfectionism, but not inflated responsibility. Using revised, condensed subscales, OCD patients differed from ACs on beliefs about perfectionism and certainty and about importance and control of thoughts, but not on beliefs about threat estimation and inflated responsibility. When controlling for depression and trait anxiety, the OCD and AC group did not differ on most belief domains, except for a belief that it is possible and necessary to control one's thoughts. Results are discussed in light of evolving cognitive-behavioral theories that highlight appraisals of thought control and the use and effectiveness of varying thought control strategies.     

Sexual disorders not otherwise specified: compulsive, addictive, or impulsive?

Paraphilias are recurrent and intense sexually arousing fantasies, sexual urges, or behaviors generally involving nonhuman objects. These paraphilias cause the suffering or humiliation of the patient or patient's partner, or children, or other nonconsenting persons. However, in many patients symptoms involve more culturally acceptable patterns (eg, repetitive masturbation, Internet pornography); such hypersexual symptoms have been labeled as compulsive, addictive, or impulsive. Growing evidence supports the existence of a discrete syndrome characterized by recurrent and intense sexually arousing fantasies, sexual urges, or behaviors involving patterns that fall outside the definition of paraphilia. There is, however, high comorbidity with paraphilia. While such symptoms have been labeled as sexual compulsion or addiction, these terms are problematic in this context. Modern nosology has neglected this entity, although the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV), category of sexual disorders not otherwise specified includes hypersexual behaviors as an example. We suggest that the DSM-IV category of sexual disorders be modified to include explicitly diagnostic criteria for a disorder characterized by hypersexual symptoms involving patterns that fall outside of the current definition of paraphilia. The disorder might be classified as one of the paraphilias, or as paraphilia-related. In the absence of a comprehensive understanding of the pathogenesis of this disorder, we suggest that it simply be termed hypersexual disorder.     

Assessing Sexual Orientation Symptoms in Obsessive-Compulsive Disorder: Development and Validation of the Sexual Orientation Obsessions and Reactions Test (SORT)

Obsessive-compulsive disorder (OCD) includes many symptom presentations, which creates unique diagnostic challenges. Fears surrounding one’s sexual orientation are common within OCD (also called SO-OCD), but SO-OCD is consistently misdiagnosed by physicians and psychologists. To address this issue, we describe the development of a self-report measure for assessing SO-OCD to help distinguish OCD from distress caused by a sexual orientation identity crisis. The current paper details two studies that established the psychometric properties and clinical utility of this measure. In Study 1, the factor structure, validity, and reliability were examined for the measure’s 12 items in a sample of 1,673 university students. The results revealed a two-factor solution for the measure (Factor 1: Transformation Fears; Factor 2: Somatic Checking) and preliminary evidence of validity and reliability. In Study 2, the measure was tested with LGBTQ and heterosexual community samples and clinical samples of individuals with SO-OCD and other types of OCD. The two-factor solution and evidence of validity and reliability were supported in these samples. Cut-off points were established to distinguish between community members and SO-OCD sufferers, as well as between those experiencing SO-OCD and other types of OCD. Limitations and future directions are discussed.     

Adapting Mindfulness-based Stress Reduction for the Treatment of Obsessive-compulsive Disorder: A Case Report

Obsessive-compulsive disorder (OCD) is an illness characterized by intrusive and distressing thoughts, images, or impulses (i.e., obsessions) and by repetitive mental or behavioral acts (i.e., compulsions) performed to prevent or reduce distress. Efficacious treatments for OCD include psychotropic medications and exposure and response prevention (EX/RP). The following case report presents an individual diagnosed with OCD who refused treatment with medication or EX/RP and was treated using an adapted Mindfulness-Based Stress Reduction (MBSR) program. After an 8-week adapted MBSR program, the endpoint evaluation revealed clinically significant reductions in symptoms of OCD as well as an increased capacity to evoke a state of mindfulness. Discussion includes generalizability of these findings, potential mechanisms of action, and the role of an adapted MBSR in the treatment of OCD.     

Diagnostic issues,multiple paraphilias,and comorbid disorders in sexual offenders: Their incidence and treatment

This paper critically appraises the criteria for DSM diagnoses of the paraphilias relevant to sexual offenders. It is concluded that these criteria leave a lot to be desired and that a more helpful approach would be to rate the features of each type of sexual offender along dimensions ranging from normal to seriously problematic. Next consideration is given to the evidence on the incidence of multiple paraphilias and comorbid disorders. It is not yet completely clear from this evidence that sexual offenders typically have multiple sexual outlets although some obviously do. What is clear is that incidence of comorbid disorders is sufficiently high to warrant concerns about how to effectively address these additional disordered aspects of sexual offenders in treatment. Finally, suggestions are offered about how to address in treatment both multiple paraphilic offenders and those with associated comorbid disorders.     

Intrusive thoughts in patients with obsessive compulsive disorder and non-clinical participants: a comparison using the International Intrusive Thought Interview Schedule

The International Intrusive Thought Interview Schedule (IITIS) was used to assess and compare the unwanted intrusive thoughts (UITs) reported in a group of patients with obsessive compulsive disorder (OCD) and a non-clinical group. Although all participants reported at least one type of intrusion, OCD patients experienced more intrusive thoughts than non-clinical participants, and this difference was statistically significant. In the OCD group, intrusive thoughts were more frequent, interfered more with daily life, were considered to be more important to get out of the mind, and were more difficult to stop than in non-clinical participants. The two groups did not differ significantly in terms of five appraisals of the most distressing intrusive thought. One appraisal (importance) was used far more by the OCD group than the non-clinical group. For three appraisals (intolerance of anxiety, need to control, and intolerance of uncertainty), the difference was smaller. Only two of the strategies for controlling the most upsetting intrusive thought (ritual and avoidance) were of value in differentiating between the two groups. The IITIS (an instrument used to assess intrusions in non-clinical samples) appears to be of value for the assessment of patients with OCD.     

Obsessive-compulsive disorder with comorbid major depression: what is the role of cognitive factors?

Individuals with obsessive-compulsive disorder (OCD) commonly experience comorbid mood disturbances such as major depressive disorder (MDD). Previous studies that have compared OCD patients with and without MDD have revealed differences in demographic characteristics, clinical severity, and symptom presentation between these two patient groups. Previous studies have not, however, examined whether there are differences with respect to cognitive processes. The present study therefore aimed to address this gap in the literature. Eighty patients with OCD and no unipolar mood disorders were compared with 34 OCD patients with comorbid major depression on measures of OCD symptoms, cognitions, and insight, as well as on measures of depression and functional impairment. Whereas depressed OCD patients evidenced higher scores than non-depressed OCD patients on semi-idiographic measures of OCD symptoms and cognitions, this was not the case for nomothetic measures. Functional impairment and the tendency to misinterpret innocuous intrusive thoughts as significant emerged as unique predictors of depression within the entire sample of OCD patients. Results are discussed in terms of (a) the importance of semi-idiographic assessment of OCD, (b) possible explanations for the relationship between OCD symptoms, depression, and cognitive processes, and (c) the psychological treatment of comorbid OCD and MDD.     

Thought suppression in obsessive-compulsive disorder

Social cognition research has indicated that attempts to suppress thoughts can lead to a paradoxical increase in the frequency of that thought. This phenomenon has been a central component of cognitive-behavioural models of obsessive-compulsive disorder (OCD); however, research has yet to demonstrate deficient thought suppression ability in OCD patients. We examined whether individuals with OCD (OCs) exhibit a deficit in the ability to suppress thoughts. In Experiment 1, attempted thought suppression led to a paradoxical increase in self-reported thoughts for OCs, but not for nonanxious controls (NACs) or anxious controls (ACs). In order to rule out self-report biases, in Experiment 2 we utilized a lexical decision paradigm that measured priming strength of a target word under thought suppression conditions. Results paralleled those of Experiment 1: OCs showed decreased lexical decision latency of the 'suppressed' thought (thought to reflect either increased priming strength or disrupted processing of nonsuppressed thoughts), thus exhibiting a paradoxical effect of thought suppression. This effect was not seen in NACs or ACs. These findings suggest that deficits in cognitive inhibitory processes may underlie the intrusive, repetitive nature of clinical obsessions.     

Appraisals of obsessional thoughts in normal samples

Cognitive theories of obsessive-compulsive disorder (OCD) posit that appraisals about the significance of thoughts are critical in the development and persistence of obsessions. Rachman [(1997). A cognitive theory of obsessions. Behaviour Research and Therapy, 35, 793-802.] proposes that appraisals of unwanted thoughts distinguish clinical obsessions from normal intrusive thoughts; thoughts appraised as important and personally significant are expected to be upsetting and recur. Appraisals are also expected to be related to symptoms of OCD. To explore the features of normal appraisals of obsession-like thoughts, nonclinical participants in two studies rated the personal significance of intrusive thoughts portrayed in vignettes containing prototypical themes associated with primary obsessions: aggressive, sexual, and blasphemous thoughts. Unwanted intrusive thoughts that were described as occurring more frequently were appraised as more personally significant, but participants appraised these socially unacceptable thoughts similarly whether they imagined having personally experienced them or a friend confiding about having experienced them. Appraisals in both studies were related to subclinical OC symptoms and OC beliefs.     

Obsessive-compulsive behaviours in specific situations: the relative influence of appraisals of control, responsibility and threat

Obsessive-compulsive disorder (OCD) is characterized by repeated and persistent attempts by the individual to control their thoughts and by taking action through rituals in order to prevent feared or personally distressing outcomes. While cognitive theories of OCD have generated supportive research findings and effective treatments, they have not considered broader control beliefs that may motivate aspects of OC-phenomenology. We have previously proposed that broader control beliefs, specifically desire for control and sense of control, may play a role in OC-symptoms (Moulding & Kyrios, 2006). In the present study, non-clinical participants (N=219) were presented with four hypothetical scenarios relevant to an OCD-checking concern, and using a manipulation paradigm, the relationship between control constructs and appraisals hypothesized to be relevant to OCD (threat, responsibility) was examined. Desire for control was moderately affected to responsibility and threat appraisals, while sense of control did not relate to these constructs. The relationship between aspects of OC-phenomenology and appraisals of control, responsibility and threat were also investigated. Higher desire for control predicted both affect and action, while a lower sense of control predicted higher distress and action, over-and-above appraisals of threat and responsibility. Control appraisals were particularly relevant to use of action, and to affect in the low responsibility situations. A possible interactive model of desire for control, threat and responsibility is discussed.     

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.     

Obsessive‐compulsive disorder across developmental trajectory: Cognitive processing of threat in children,adolescents and adults

Background . While the cognitive theory of obsessive‐compulsive disorder (OCD) is one of the most widely accepted accounts of the maintenance of the disorder in adults, no study to date has systematically evaluated the theory across children, adolescence and adults with OCD. Method . This paper investigated developmental differences in the cognitive processing of threat in a sample of children, adolescents and adults with OCD. Using an idiographic assessment approach, as well as self‐report questionnaires, this study evaluated cognitive appraisals of responsibility, probability, severity, thought‐action fusion (TAF), thought‐suppression, self‐doubt and cognitive control. It was hypothesised that there would be age related differences in reported responsibility for harm, probability of harm, severity of harm, thought suppression, TAF, self‐doubt and cognitive control. Results . Results of this study demonstrated that children with OCD reported experiencing fewer intrusive thoughts, which were less distressing and less uncontrollable than those experienced by adolescents and adults with OCD. Furthermore, responsibility attitudes, probability biases and thought suppression strategies were higher in adolescents and adults with OCD. Cognitive processes of TAF, perceived severity of harm, self‐doubt and cognitive control were found to be comparable across age groups. Conclusions . These results suggest that the current cognitive theory of OCD needs to address developmental differences in the cognitive processing of threat. Furthermore, for a developmentally sensitive theory of OCD, further investigation is warranted into other possible age related maintenance factors. Implications of this investigation and directions for future research are discussed.     

An investigation of self-ambivalence in obsessive-compulsive disorder

Individuals vulnerable to obsessive-compulsive disorder (OCD) are hypothesized to have ambivalence about their self-worth, morality and lovability [Guidano, V., & Liotti, G. (1983). Cognitive processes and emotional disorders. New York: Guildford Press]. The purpose of this study was to examine whether self-ambivalence was associated with OCD phenomena and beliefs relevant to OCD. It also examined whether patients with OCD had higher levels of self-ambivalence compared to non-clinical controls and patients with other anxiety disorders. Participants were 73 OCD patients, 50 patients with another anxiety disorder, 225 non-clinical undergraduate students and 43 non-clinical community controls. They completed measures of self-ambivalence, OCD phenomena, OCD-relevant beliefs, depression, anxiety and self-esteem. Self-ambivalence was significantly associated with OCD phenomena and OCD-relevant beliefs, after controlling for self-esteem, depression and anxiety. Further, OCD participants were significantly more ambivalent than the non-clinical groups, but did not differ from anxious controls. It was argued that these results provide a basis for extending the cognitive-behavioural model of OCD to include ambivalent self-perceptions as a component of the cognitive mechanisms relevant to the disorder.     

Call to Action: Recommendations for Justice-Based Treatment of Obsessive-Compulsive Disorder With Sexual Orientation and Gender Themes

Gender and sexual minorities are subjected to minority stress in the form of discrimination and violence that leads to vigilance; identity concealment and discomfort; and internalized homophobia, biphobia, and transphobia. These experiences are related to increased susceptibility to mental health concerns in this population. Historically, the behavioral treatment of sexual orientation (SO) and gender-themed obsessive-compulsive disorder (OCD) has inadvertently reinforced anti-lesbian, gay, bisexual, transgender, queer/questioning (LGBTQ+) stigma and contributed to minority stress in clients, treatment providers, and society at large. We present updated recommendations for treatment of SO- and gender-themed OCD through a more equitable, justice-based lens, primarily through eliminating exposures that contribute to minority stress and replacing them with psychoeducation about LGBTQ+ identities, and exposures to neutral and positive stimuli, uncertainty, and core fears. We also present recommendations for equitable research on SO- and gender-themed OCD.     

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.     

Diagnose und Therapie der Zwangsstörung

Obsessive-compulsive disorder (OCD) is the fourth common psychiatric disorder with a life-time prevalence of 1–3% world wide. Symptoms of OCD are intrusive, repetitive thoughts (obsessions) with disturbing content. Often, repetitive acts (compulsions) are performed in order to defend oneself or others against suspected threats or evil. Genetic and neurobiological factors are assumed to generate a disorder-specific vulnerability. Cognitive-behavioural models however, may serve to clarify the pathological interplay between dysfunctional thoughts and learning processes. The article offers an actual view on symptoms, diagnostic criteria, aetiology and therapeutic principles, such that OCD no longer stays the “hidden disease” which causes high individual and socioeconomic burden.     

The hoarding dimension of OCD: psychological comorbidity and the five-factor personality model

Although hoarding has been associated with several psychological disorders, it is most frequently linked to obsessive-compulsive disorder (OCD). The present study assessed hoarding obsessions and compulsions in 204 individuals with OCD, and evaluated how hoarding was related to obsessive-compulsive symptom severity, psychological comorbidity, and personality as measured by the five-factor model. Results indicated that hoarding in OCD is a dimensional variable that is positively associated with dysphoria, total number of lifetime Axis I disorders, and lifetime histories of bipolar I, PTSD, and body dysmorphic disorder. Hoarding was negatively correlated with the NEO-Personality Inventory-Revised (NEO-PI-R) factor of Conscientiousness and positively associated with the NEO-PI-R factor of Neuroticism. When all personality and psychopathology variables were entered into a regression equation, dysphoria, bipolar II disorder, Conscientiousness, age, and Extraversion emerged as significant predictors of hoarding severity. Recommendations are made for clinicians and for future research.     

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.