Subtyping OCD: Prospects and problems

Obsessive-compulsive disorder (OCD) is characterized by the presence of obsessions and/or compulsions that fall into a variety of well-established categories. Some recent arguments have been made supporting the creation of OCD subtypes in order to better understand the psychopathology of different manifestations of OCD. It is hoped that recent advances in our knowledge of the cognitions associated with OCD could be beneficial in this endeavor. This article will review the advantages, possible obstacles, and' problems that may result from this effort. Ultimately, the creation of OCD subtypes could hold promise for improved assessment and treatment strategies, although a series of theoretical, conceptual, and practical considerations must be addressed before this categorization of OCD is undertaken.     

Differential performance on the go/no-go task as a function of the autogenous-reactive taxonomy of obsessions: Findings from a non-treatment seeking sample

It has been suggested that obsessive-compulsive disorder is characterized by impaired inhibitory control. Response inhibition is a cognitive process required for one to cancel or suppress dominant but inappropriate responses. The present study examined response inhibition among non-treatment seeking individuals diagnosed with OCD and individuals with low levels of OCD symptoms using a computerized visual go/no-go task. Specifically, we sought to examine a prediction from the autogenous-reactive subtype model of obsessions (Lee, H.-J., & Kwon, S.-M. (2003). Two different types of obsession: autogenous obsessions and reactive obsessions. Behaviour Research and Therapy, 41, 11-29; Lee, H.-J., & Telch, M. J. (2008). Autogenous obsessions and reactive obsessions. In J. Abramowitz, S. Taylor, & D. McKay (Eds.), Obsessive-compulsive disorder: subtypes and spectrum conditions. New York: Elsevier., asserting that OCD individuals presenting with the autogenous subtype of obsessions will display greater difficulty in inhibitory control relative to individuals presenting with obsessions of the reactive subtype. Results showed that individuals with OCD of the autogenous subtype displayed more deficient inhibitory control on the visual go/no-go task as indexed by a longer response delay between the original stimuli set and the reversed stimuli set compared to individuals with OCD of the reactive subtype or individuals with low levels of OCD symptoms.     

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.     

Obsessive-Compulsive Disorder in Late Life

Although obsessive-compulsive disorder (OCD) has received increasing attention, the study and treatment of OCD in late life has been neglected. The obsessions and compulsions seen with older adults do not appear to differ from the symptoms experienced by other age groups, although developmental issues might influence symptom focus (e.g., memory functioning-related obsessions). Hoarding difficulties might be prevalent in late life, although additional studies are needed. Seniors with OCD can present with comorbid psychiatric disorders, multiple general medical problems, and impaired cognitive functioning, complicating evaluation. There have not been controlled clinical trials of cognitive-behavioral therapy (CBT) for late-life OCD, although initial reports suggest older adults respond to CBT that includes age-related treatment modifications. We illustrate the challenges to assessing and treating older adults with OCD with case examples involving memory-related obsessions and clinical hoarding. The successful strategies used for adapting CBT for the treatment of late-life generalized anxiety disorder might serve as a model for advancing the study and treatment of late-life OCD.     

Differences in latent inhibition as a function of the autogenous-reactive OCD subtype

We examined differences in a visual search-based latent inhibition (LI) task in 48 non-treatment seeking individuals diagnosed with obsessive-compulsive disorder (OCD) and 26 non-OCD controls, using a visual search-based LI task as a function of participants’ primary obsessional presentation based on the autogenous-reactive subtype model of obsessions ( [Lee and Telch, 2005] and [Lee and Telch, 2007]). We hypothesized that LI would be significantly attenuated among OCD participants whose primary obsessions were characterized by aversive impulses, images, or thoughts with sexual, aggressive, blasphemous, and repulsive themes (autogenous obsessions) due to their weakened attentional inhibitory mechanisms and elevated schizotypal personality features, as compared with those whose primary obsessions were characterized by somewhat realistic aversive mental intrusions about contamination, mistakes, accidents, or disarray (reactive obsession) and non-OCD controls. Results showed that those primarily displaying autogenous obsessions failed to display LI, whereas those primarily displaying reactive obsessions and non-OCD controls displayed significant LI effects. Our data suggest that the magnitude of LI varies as a function of primary obsessional presentations among individuals with OCD.     

What Drives OCD Symptom Change During CBT Treatment? Temporal Relationships Among Obsessions and Compulsions

Cognitive behavior therapy (CBT) is an effective treatment for obsessive-compulsive disorder (OCD). However, less is known about how obsessions and compulsions change during treatment, either in tandem, sequentially, or independently. The current study used latent difference score analysis to show path-analytic dynamic modeling of OCD symptom change during CBT. Four competing models of the temporal relationship between obsessions and compulsions were examined: no coupling (obsessions and compulsions are not dynamically related), goal directed (obsessions lead to subsequent changes in compulsions), habit driven (compulsions lead to subsequent changes in obsessions), and reciprocal. Treatment seeking participants (N = 84) with a principal diagnosis of OCD completed 12 weeks of CBT group therapy and completed measures assessing obsession and compulsion severity at pretreatment, Sessions 4 and 8, and end of treatment. Bivariate results supported the goal directed traditional CBT model, where obsession scores are temporally associated with subsequent changes in compulsion scores. These results have implications for theoretical and treatment modelling of obsessions and compulsions in OCD treatment.     

Cognitive Behavior Therapy for Obsessions and Compulsions: New Applications and Emerging Trends

This paper describes recent developments in the cognitive behavioral treatment (CBT) of obsessive compulsive disorder (OCD). Although behavioral treatment of OCD consisting of exposure and response prevention (ERP) has been shown to be clinically effective, certain limitations with ERP have led clinical researchers to propose that treatment should be augmented with direct cognitive interventions. Modification of dysfunctional beliefs and faulty appraisals or interpretations of the obsession are now considered a crucial component of CBT for obsessions and compulsions. This paper discusses the conceptual basis of the new CBT for OCD and reviews its limited empirical status. A case example is provided in which CBT is used to treat obsessional ruminations of becoming sick. The article concludes with a discussion of the challenges and pitfalls involved in offering CBT for obsessions and compulsions.     

The Treatment of Mental Contamination: A Case Series

The recommended treatment for obsessive-compulsive disorder (OCD) is cognitive behavior therapy (CBT) incorporating exposure and response prevention (ERP), which is effective for approximately 50% of patients. However, there has been little advance in treatment outcomes since the introduction of ERP in 1979. It has been suggested that some progress can be made in treating contamination obsessions and washing compulsions by addressing feelings of dirtiness and contamination that arise without physical contact with a tangible contaminant. To date, the treatment of these “mental contamination” fears in OCD has not been systematically explored. This paper reports on a case series of 12 participants with OCD who received 10 to 20 sessions of a CBT-based treatment for mental contamination. At the end of treatment, 7 participants no longer met the diagnostic criteria for OCD and mental contamination and these gains were maintained at 6-month follow-up. The clinical implications of these findings are discussed.     

Lumping versus splitting: A commentary on subtyping in OCD

This commentary discusses a number of pertinent concerns that were raised in this special series on subtyping in obsessive-compulsive disorders (OCD). The central question addressed in the three articles in the series is whether a better subtype classification of OCD could be developed if it is based on type of faulty cognition as well as symptom presentation. It is concluded that a more cognitive approach to OCD subtyping may not address many of the problems inherent in subtype research, nor will the development of special manualized treatment protocols for OCD subtypes necessarily yield significant improvements in treatment effectiveness. An alternative to OCD subtyping based on a categorical perspective is some form of profiling that recognizes the dimensional nature of OCD symptom and cognition variables.     

The Children's Yale-Brown Obsessive-Compulsive Scale: item structure in an outpatient setting

The Children's Yale-Brown Obsessive-Compulsive Scale (CY-BOCS) is one of the most popular measures of symptom severity for childhood obsessive-compulsive disorder (OCD). This study describes the factor structure of the CY-BOCS. A total of 233 children diagnosed with OCD were evaluated with the CY-BOCS. The results indicated that 2 alternate 2-factor solutions (obsessions and compulsions; severity and disturbance) fit the data set best. The results also suggested that items assessing resistance to obsessions and compulsions provide unreliable evaluations of these symptoms in children with OCD. Recommendations for modifications to the CY-BOCS as well as clinical applications and for future research with the measure are made.     

Content difference between normal and abnormal obsessions

Although it has long been thought that experiencing an obsession is a psychiatric symptom, more recent literature, has seen the normalisation of obsessions and other presumably clinical phenomena. That is, not only people suffering from psychiatric disorders experience obsessions but non-clinical individuals also do so. Furthermore, it has been argued that such normal obsessions are very similar to abnormal ones, in terms of content. However, in the present study, evidence was obtained indicating that normal and abnormal obsessions do differ in content. A sample of 133 healthy undergraduates was given a list of 70 obsessions, with some originating from obsessive-compulsive disorder (OCD) patients, and others stemming from healthy volunteers. Participants were asked to indicate whether they had ever experienced these obsessions. Participants endorsed significantly more normal than abnormal obsessions, suggesting that the two kinds of obsessions do differ from each other. In addition, the experience of clinical obsessions was more strongly associated with scores on a measure of OCD symptoms, than was the experience of normal obsessions.     

The concealment of obsessions

Patients' deliberate concealment from others of the content and frequency of their obsessions is a common and important aspect of obsessive-compulsive disorder (OCD). It is an overlooked manifestation of the safety behaviour that is believed to sustain OCD (e.g., neutralizing, thought suppression, avoidance behaviour, concealment). The phenomenon of concealment is understandable in terms of the cognitive theory of obsessions which states that obsessions are caused when the person attaches catastrophic personal significance to their unwanted intrusive thoughts. It is suggested that the selected, planned, suitable disclosure of obsessions can be therapeutic--presumably because it exposes the patient to alternative interpretations of the significance of the unwanted thoughts.     

Subtypes of obsessive-compulsive disorder: Implications for specialized cognitive behavior therapy

Although obsessive-compulsive disorder (OCD) is a heterogeneous condition, OCD subtypes have received limited attention in trials of cognitive behavior therapy (CBT). Because many patients with OCD do not respond optimally to CBT, it is important for clinicians to consider whether variability in treatment response is related to symptom presentation. Treatment modifications for patients without overt compulsions or with hoarding symptoms show promise. In this article we discuss the available research addressing the treatment of OCD subtypes, review the clinical characteristics and treatment recommendations for prominent OCD subtypes, raise the prospect of using dysfunctional beliefs as a potentially helpful conceptual approach to subtyping OCD and matching treatment to subtypes, and consider future directions in the treatment of OCD subtypes.     

Obsessive-compulsive disorder: beyond segregated cortico-striatal pathways

Obsessive-compulsive disorder (OCD) affects approximately 2-3% of the population and is characterized by recurrent intrusive thoughts (obsessions) and repetitive behaviors or mental acts (compulsions), typically performed in response to obsessions or related anxiety. In the past few decades, the prevailing models of OCD pathophysiology have focused on cortico-striatal circuitry. More recent neuroimaging evidence, however, points to critical involvement of the lateral and medial orbitofrontal cortices, the dorsal anterior cingulate cortex and amygdalo-cortical circuitry, in addition to cortico-striatal circuitry, in the pathophysiology of the disorder. In this review, we elaborate proposed features of OCD pathophysiology beyond the classic parallel cortico-striatal pathways and argue that this evidence suggests that fear extinction, in addition to behavioral inhibition, is impaired in OCD.     

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.     

A standardized behavioral group treatment program for obsessive-compulsive disorder: preliminary outcomes

This paper provides outcome data about the efficacy of a behavioral group therapy program for obsessive-compulsive disorder (OCD). Thirty-six patients completed a 7-week outpatient treatment program which provides: (1) education about OCD and its treatment, (2) instruction in a cognitive and behavioral approach to the self-treatment of OCD and (3) guided behavioral treatment. Significant improvement in obsession, compulsion, and depression scores were observed at completion of the group and at 3 month follow-up. Significant improvement in obsessions and compulsions was observed for both patients taking anti-obsessional medications and those who did not.     

A cross-sectional investigation of autogenous and reactive obsessions and associated cognitive and symptom correlates in China

Categorizing clinical obsessions as either autogenous or reactive, a model that has been supported by several studies, may represent a parsimonious approach to characterizing individuals with obsessive-compulsive disorder (OCD). However, most published studies on autogenous and reactive obsessions have been carried out with participants in highly developed nations (e.g., United States, Australia). No studies have been carried out in less developed countries, such as China. It was hypothesized that the nature of autogenous and reactive obsessions and their correlates would generalize to China. This cross-sectional study incorporated three groups from China: a college student sample (N = 1,701), a clinical sample of patients with OCD (N = 158), and a clinical control group of patients with anxiety disorder other than OCD (N = 88). Confirmatory factor analysis provided support for the autogenous and reactive model of obsessions in a Chinese sample. The results also showed that autogenous and reactive obsessions demonstrated a pattern of associations with cognitive and symptom correlates (e.g., obsessive beliefs, traditional OCD subtype themes) that were comparable to those found in previous research. The current study supports the autogenous and reactive obsessions model of OCD and its correlates in China, providing additional evidence for the cultural invariance of the model.     

Why are some obsessions more upsetting than others?

Little is known about why certain obsessional thoughts are more upsetting than others for people with obsessive compulsive disorder (OCD). Obsessional thought content often seems arbitrary to sufferers. The current study examined three possible reasons why particular thoughts would be especially upsetting for individuals, based on suggestions put forth by cognitive theories of obsessional thoughts. Twenty-eight individuals with a principal diagnosis of OCD completed questionnaires and interviews at two different periods of time on (1) their most upsetting current obsession and (2) their least upsetting current obsession. Results suggested that more upsetting obsessions were evaluated as more meaningful or significant than less upsetting obsessions, and more upsetting obsessions contradicted valued aspects of the self to a greater degree. All examples of current obsessions, both most and least upsetting, arose in the context of life concerns or issues. Results support cognitive theories in that the strength and nature of appraisal appears to be linked with the distress associated with a thought, and more upsetting thoughts are those that have implications for a person's sense of self.     

Sex-specific clinical correlates of hoarding in obsessive-compulsive disorder

Little is known about whether the clinical correlates of hoarding behavior are different in men and women with obsessive-compulsive disorder (OCD). In the current study, we evaluated the association of hoarding with categories of obsessions and compulsions, psychiatric disorders, personality dimensions, and other clinical characteristics separately in 151 men and 358 women with OCD who were examined during the OCD Collaborative Genetics Study. We found that, among men but not women, hoarding was associated with aggressive, sexual, and religious obsessions and checking compulsions. In men, hoarding was associated with generalized anxiety disorder and tics whereas, among women, hoarding was associated with social phobia, post-traumatic stress disorder, body dysmorphic disorder, nail biting, and skin picking. In women but not men, hoarding was associated with schizotypal and dependent personality disorder dimensions, and with low conscientiousness. These findings indicate that specific clinical correlates of hoarding in OCD are different in men and women and may reflect sex-specific differences in the course, expression, and/or etiology of hoarding behavior in OCD.