Obsessive-compulsive disorder subtypes: an attempted replication and extension of a symptom-based taxonomy

A symptom-based subgroup taxonomy for obsessive-compulsive disorder (OCD) was evaluated and refined. The Yale-Brown Obsessive-Compulsive Scale symptom checklist was scored and cluster analysis was conducted with a sample of OCD patients (N = 114). Results were compared to Calamari et al.'s (Behaviour Research and Therapy 37 (1999) 113) five subgroup model. Rules for determining the number of subgroups supported a more complex model. In between sample comparisons, a stable contamination subgroup was found in both a five and seven subgroup taxonomy. Between sample stability was not as strong for Harming, Obsessionals, Symmetry, and Certainty subgroups. Hoarding, as a distinctive subgroup, was unstable in separate samples. When the Calamari et al. sample and the present sample were combined (N = 220), we found a reliable Hoarding subgroup. More interpretable and stable models emerged with the combined samples suggesting that large clinical samples are needed to identify OCD subgroups. Greater support was found for a seven subgroup taxonomy based subgroup interpretability and validation measure differences. The potential utility of symptom-based subgroup models of OCD and alternative approaches are discussed. Identification of reliable and valid OCD subtypes may advance theory and treatment.     

Thought control strategies in obsessive-compulsive disorder: a replication and extension

Previous research suggests that individuals with OCD use maladaptive strategies to control their unpleasant thoughts (Behav Res Ther (1977) 35, 775). These include worry and self-punishment strategies. In the present study we replicated and extended the previous findings by comparing thought control strategies used by patients with OCD to strategies used by anxious and non-anxious control participants. We also examined changes in thought control strategies for OCD patients who underwent cognitive-behavioral therapy. Compared to controls, OCD patients reported more frequent use of worry and punishment strategies, and less frequent use of distraction. Following successful treatment, OCD patients evidenced increased use of distraction and decreased use of punishment. Findings are discussed in terms of the cognitive model of OCD.     

Directed forgetting in obsessive-compulsive disorder: replication and extension

Previous research indicates that patients with obsessive-compulsive disorder (OCD) show impaired ability to forget negative material (Behav Res Ther 34 (1996) 633). The present study was intended to replicate and extend these findings by separating emotional valence from personal relevance, using idiographic stimulus selection to control for heterogeneity of OCD concerns, and the addition of an anxious control group. We used a directed forgetting paradigm, in which participants were instructed to either remember or forget a series of words. No differences in impairment were found among the groups during a free recall test, in which they were asked to recall both "remember" and "forget" words. However, during a recognition test, OCD patients showed greater impaired forgetting for OCD-relevant words than did nonanxious and anxious controls. Valence of words did not emerge as a contributing factor to impaired forgetting.     

Anxiety and selective attention in obsessive-compulsive disorder

Recently, there has been increasing evidence for information-processing deficits in individuals with obsessive-compulsive disorder (OCD). While impairments in selective attention have been identified to be central to the symptomatology of OCD, the role that situational anxiety plays in attentional processes has not been fully explored. Previous research findings were limited to tasks containing anxiety-relevant materials, only permitting for the evaluation of the impact of anxiety on simultaneous cognitive processing. Furthermore, it has not yet been determined whether the impact of anxiety is limited to selective attention or is indicative of a more general cognitive impairment. This study was designed to examine the role that situational anxiety plays in selective attention impairments. OCD participants and controls were presented with an anxiety producing statement and a neutral statement, followed by the Stroop Task. Results indicated that situational anxiety plays a significant role in the performance of tasks that require selective attention in OCD. A significant deterioration was detected in performance on selective attention tasks for the OCD participants after confronting anxiety-provoking scenarios, as compared to neutral scenarios. Anxiety did not impair performance on simple reading tasks. Possible explanations are discussed.     

Implicit awareness of ambiguity: a role in the development of obsessive-compulsive disorder

The cognitive-behavioral model of obsessive-compulsive disorder proposes that obsessional symptoms are the consequence of the manner in which intrusive cognitions are interpreted [e.g., Salkovskis, P. M. (1998). Cognitive-behavioral approach to understanding obsessional thinking. British Journal of Psychiatry, 173(35S), 53-63]. The present study suggests that this may be attributable to maladaptive implicit cognitive processing, a deficit that results in the explicit awareness of ambiguity in idiographic obsessive-compulsive disorder (OCD) stimuli. The present study examines decision-making responses of low and high OCD scorers in a non-clinical undergraduate sample. Via a computer console, participants were shown sentence statements for three levels of ambiguity. They were then presented with a propositional statement for which they had to indicate agreement or disagreement for sentences of varying ambiguity. After this, the participants indicated whether they were completely confident or unconfident as regards their previous agree-disagree decisions. Results indicate that the high compared to the low OCD scoring group had less agreement and subsequent less confidence in decisions made for sentences of varying ambiguity. Response latencies partially fitted the predicted hypotheses. Consequently, an addition to Salkovskis, Forester, and Richards' [1998. Cognitive-behavioral approach to understanding obsessional thinking. The British Journal of Psychiatry, 173(35S), 53-63] model of OCD is suggested: namely that an implicit ambiguity deficit mediates the likelihood of normally occurring intrusions developing into abnormal obsessions. Methodological limitations and future research are considered.     

Responsibility and obsessive-compulsive disorder: an experimental test

To test the causal status of responsibility in obsessive-compulsive disorder (OCD), an experiment was executed in which responsibility was experimentally manipulated. OCD patients, non-OCD anxiety controls, and non-patients executed a classification task in either a high or a low responsibility (LoRes) condition. Subjective ratings related to danger and responsibility indicated that the manipulation was successful. Subjective OCD-like experiences and checking behaviors were higher in OCD patients in the high responsibility (HiRes) condition than in all other groups. Although the checking subscale of the Padua Inventory correlated with subjective ratings in the OCD patients in the HiRes condition, it was not associated with checking behaviors. The results confirm the hypothesis that responsibility plays a causal role in OCD.     

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.     

Experimental modification of beliefs in obsessive-compulsive disorder: a test of the metacognitive model

Metacognitive beliefs about the threatening meaning and significance of intrusions are fundamental to the development and maintenance of obsessive-compulsive disorder (OCD) in the metacognitive model (Cognitive therapy of anxiety disorders: a practice manual and conceptual guide, Chichester, UK, Wiley, 1997; Emotional disorders and metacognition: innovative cognitive therapy, Chichester, UK, Wiley, 2000). This predicts that reductions in metacognitive beliefs about intrusions will result in decreased anxiety and compulsions. It was hypothesized that brief (5min) exposure and response prevention configured as a behavioural experiment to challenge metacognitive beliefs would lead to reductions in anxiety, thought fusion beliefs and the urge to neutralize. Furthermore, these reductions would be greater than the effects observed in the same exposure and response prevention task, accompanied by a habituation rationale. The results were consistent with the hypotheses. The clinical implications for the treatment of OCD are discussed.     

Attenuation of attention bias in obsessive-compulsive disorder

Cognitive theories of obsessive-compulsive disorder (OCD) suggest that the disorder is characterized by an attention bias towards personally relevant threatening material. However, existing research on attention bias in OCD has yielded conflicting findings. One possibility that might account for the null findings is that attention bias may diminish over the course of the experiment. The present study tested this hypothesis using a visual dot-probe task with idiographic word selection. Results from our study confirmed that individuals with OC symptoms show an attention bias towards idiographically selected, threatening information in the first block of trials, and that the degree of this bias is correlated with the severity of OC symptoms. The temporal pattern of attention bias over the course of the experiment was consistent with our hypothesis. A comparison of early and late blocks of trials revealed an attenuation of attention bias in individuals with OC symptoms, potentially reflecting habituation to threatening information over the course of the experiment.     

Cognitive inhibition in trichotillomania and obsessive-compulsive disorder

Cognitive inhibition was investigated in 21 trichotillomania (TTM), 21 obsessive-compulsive disorder (OCD) and 26 healthy control (HC) participants using a block cued directed forgetting task. After encoding a word list, participants were instructed to intentionally FORGET these words and to REMEMBER another word list. Both lists included TTM-related and neutral (kitchen-related) words in equal proportions, with the TTM-related words generally of negative valence and the kitchen-related words generally of neutral valence for all participants. A superior free recall of REMEMBER versus FORGET words suggests intact cognitive inhibition. The performance of OCD participants indicated a specific deficit in inhibiting the retrieval of information with negative valence, which was not found in TTM. HC participants, in contrast to TTM and OCD participants, were rather inattentive to negative information. In conclusion, although attention was disproportionately directed towards negative information in both disorders, cognitive inhibition deficits appeared specific to OCD.     

Inferential confusion in obsessive-compulsive disorder: the inferential confusion questionnaire

The current article represents the further validation of the construct of inferential confusion amongst clinical samples. Inferential confusion is proposed to be a meta-cognitive confusion particularly relevant to obsessive compulsive disorder (OCD) that leads a person to confuse an imagined possibility with an actual probability. As such, it conceptualizes OCD as a form of belief disorder similar to a delusion or overvalued idea that is a product of distorted reasoning processes. In contrast, other cognitive models of OCD emphasize a phobic model of development in OCD, and thus consider the exaggerated interpretation of intrusions as an essential element in OCD. The present study administered a revised version of the Inferential Confusion Questionnaire, and the Obsessive Belief Questionnaire (OBQ), to a total of 183 participants in three clinical groups and a non-clinical control group. Results suggest that OCD, at least in part, follows a non-phobic model of development with inferential confusion significantly related to obsessive-compulsive symptoms independently of cognitive domains as measured by the OBQ, and mood states. Further, scores on inferential confusion were particularly high in those with OCD and delusional disorder as compared to anxious and non-clinical controls.     

The interaction of state and trait aspects of self-focused attention affects genital, but not subjective, sexual arousal in sexually functional women

In this study we investigated the effects of state and trait aspects of self-focused attention on genital and subjective sexual arousal of sexually functional, healthy women during presentation of audiovisual erotic stimuli. Psychophysiological sexual response was measured as vaginal pulse amplitude using a vaginal photoplethysmograph. Experiential aspects of sexual arousal were measured both during stimulus presentation and retrospectively after stimulus offset. Trait level of sexual self-focus was measured with the Sexual Self-Consciousness Scale. State self-focus was induced by switching on a TV camera that pointed at the participant's face and upper torso. A manipulation check revealed that both groups experienced equally elevated levels of self-focused attention of their physical appearance. Induction of state self-focus per se did not affect genital responses, but an interaction effect of self-focus and participants' level of trait sexual self-focus was revealed. Compared with women with low scores on this trait, women with high scores exhibited smaller genital responses when state self-focus was induced. Both groups did not differ when no self-focus was induced. Increase of state self-focus did not affect subjective sexual arousal, but participants with a high level of trait sexual self-focus reported stronger subjective arousal, compared with those with low trait level. The results were discussed with reference to previous work in this field. Some implications for treatment of sexual arousal disorder were discussed.     

Cognitive behavior therapy in treatment-naive children and adolescents with obsessive-compulsive disorder: an open trial

This work aims is to evaluate the therapeutic efficacy of cognitive behavior therapy (CBT) in pediatric patients with obsessive-compulsive disorder (OCD) who had not previously been treated with either pharmacotherapy or psychotherapy and who remained medication-free during CBT. Sixteen OCD outpatients, 8-17 years of age, were treated in a 12-week open trial with manualized CBT. Target symptoms were rated at two-week intervals with the Children's Yale-Brown Obsessive Compulsive Scale (CY-BOCS), the National Institute of Mental Health Global Obsessive-Compulsive Scale (NIMH Global), the Clinical Global Impression Scale (CGI), and the Hamilton Anxiety Rating Scale (Ham-A). Statistical analyses showed a significant benefit for treatment. Ten patients experienced at least a 50% reduction in symptoms on the CY-BOCS; seven were asymptomatic on the NIMH Global. These results build on previous reports that CBT may be effective in the acute treatment of pediatric OCD. Further, the results of this study suggest that CBT can be efficacious in alleviating OCD symptoms in the absence of pharmacotherapy. These results must be considered preliminary, given the small sample size and open administration of treatment.     

Implicit learning for probable changes in a visual change detection task

Previous research demonstrates that implicitly learned probability information can guide visual attention. We examined whether the probability of an object changing can be implicitly learned and then used to improve change detection performance. In a series of six experiments, participants completed 120–130 training change detection trials. In four of the experiments the object that changed color was the same shape (trained shape) on every trial. Participants were not explicitly aware of this change probability manipulation and change detection performance was not improved for the trained shape versus untrained shapes. In two of the experiments, the object that changed color was always in the same general location (trained location). Although participants were not explicitly aware of the change probability, implicit knowledge of it did improve change detection performance in the trained location. These results indicate that improved change detection performance through implicitly learned change probability occurs for location but not shape.     

Self-focused attention and safety behaviors across group therapies for social anxiety disorder

Background: Self-focused attention (SFA) and safety behaviors are two variables implicated in the maintenance of social anxiety disorder (SAD).

Design: The present study examined SFA and safety behaviors across two therapies for SAD, cognitive behavioral group therapy (CBGT) and mindfulness and acceptance-based group therapy (MAGT).

Method: Participants with symptoms meeting criteria for SAD (N?=?137) were randomly assigned to the 12-week-treatment groups (n?=?53 for each condition) or a waitlist control (n?=?31). Variables were assessed at baseline, midtreatment, posttreatment, and a 3-month follow-up.

Results: Both treatment conditions reported significantly lower SFA and safety behaviors compared to control, but did not differ from one another at posttreatment. Mediation analyses supported the following models: (1) safety behaviors mediating the relationship between SFA and social anxiety, and (2) SFA mediating the relationship between safety behaviors and social anxiety. These models were supported for both treatment groups.

Conclusions: Both treatments may have the potential to reduce the SFA and safety behaviors that serve to maintain SAD.     

Connections among symptoms of obsessive-compulsive disorder and posttraumatic stress disorder: a case series

Theoretical, clinical, and empirical implications of the functional connections between symptoms of obsessive-compulsive disorder (OCD) and posttraumatic stress disorder (PTSD) are abundant. As such, four cases are presented here of men and women who met criteria for comorbid OCD and PTSD. All had been diagnosed with treatment-resistant OCD and were seeking treatment from an OCD specialty clinic or institute, all reported a history of traumatic experiences prior to the onset of OCD, and all appeared to demonstrate negative treatment outcomes. Upon examination, it appeared that symptoms of OCD and PTSD were connected such that decreases in OCD-specific symptoms related to increases in PTSD-specific symptoms, and increases in OCD-specific symptoms related to decreases in PTSD-specific symptoms. Speculations about the function of OCD symptoms in relation to post-traumatic psychopathology are put forth; and theoretical, research, and treatment implications are discussed.     

Rates of abuse in body dysmorphic disorder and obsessive-compulsive disorder

Body dysmorphic disorder (BDD) continues to challenge professionals due to symptom severity, co-morbidity, suicidal ideation, and overvalued ideation. Despite the disorder's severity, little research exists. Clinical observation suggests a noteworthy history of abuse; therefore the present study investigated the reported rate of physical, sexual, and emotional abuse in BDD patients. OCD patients were chosen as a comparison group because BDD is considered to be an obsessive-compulsive spectrum disorder. A group survey design was used (N = 50 for each group). Results show significantly higher levels of emotional and sexual abuse in the BDD sample versus the OCD sample. No significant differences were found in physical abuse. Abuse may be a contributing factor in BDD, but not in OCD.     

Behavioural group therapy for obsessive-compulsive disorder in Norway. An open community-based trial

The aim of the current study was to test the effectiveness of ERP-based 12 weeks group therapy for OCD patients in a community-based, general Norwegian outpatient clinic. The sample consisted of 54 patients diagnosed with OCD. The Yale-Brown Obsessive-Compulsive Scale (Y-BOCS), the Beck Depression Inventory (BDI) and the Spielberger State Anxiety Inventory (STAI-S) were administered before treatment, after treatment and at 3- and 12-month follow-ups. Analyses with mixed models for repeated measurements showed that group behavioural therapy offered to OCD patients significantly improved ratings of obsessive-compulsive symptoms, depression and anxiety. These improvements were maintained at 3- and 12-month follow-ups and an additional reduction in obsessive-compulsive symptoms was observed from post-treatment to 3-month follow-up. However, the delayed effect of therapy was no longer present at 12-month follow-up. The results also revealed that the patients had a lower chance for an increased outcome category (e.g. from unchanged to improved or recovered) with high scores on STAI-S at the given observation times (post-treatment, 3- and 12-months follow-ups). Depressive symptoms (BDI) at post-treatment and follow-ups had no significant influences on the three categories of outcome for OCD. In conclusion, the results indicate that behavioural group therapy can successfully be delivered to patients with considerable comorbidity in a real world setting conducted by therapists with limited training in the CBT.     

Implicit sequence learning in a search task

This study investigated the effects of selection demands on implicit sequence learning. Participants in a search condition looked for a target among seven distractors and responded on the target identity. The responses followed a deterministic sequence, and sequence learning was compared to that found in two control conditions in which the targets were presented alone, either at a central location or over a series of unpredictable locations. Sequence learning was obtained in all conditions, and it was equivalent for the two variable location conditions, regardless of the perceptual demands. Larger effects of learning were observed in the central location, both on the indirect measures and on the measures taken from a cued-generation task. The expression of learning decreased selectively in this condition when the sequence validity was reduced over a test block. These results are consistent with the claims that implicit and explicit learning are mixed in this central condition and that implicit learning is not affected by selection difficulty.     

Memory and metamemory in obsessive-compulsive disorder

Studies on the link between checking and memory problems have produced equivocal results regarding a general memory deficit in patients with obsessive-compulsive disorder and subclinical checkers. However, there is clear and consistent evidence that patients with obsessive-compulsive disorder (OCD) show lack of confidence in their memory performance. The purpose of the present study was to investigate memory and metamemory performance (feeling-of-knowing judgments) for neutral and threat-related material in three groups: OCD patients (OCs), subclinical checkers (SCs), and normal controls (NCs). Participants studied a list of neutral and threat word pairs. After an initial cued-recall test, they provided feeling-of-knowing (FOK) judgments for unrecalled word pairs, followed by a recognition test. The results showed that OCs but not SCs were impaired in both recall and recognition compared to NCs. OCs were also less confident about their future memory performance than the other two groups, as reflected in their lower FOK ratings. Moreover, FOK judgments of the OCs were not reliable predictors of their recognition performance. Finally, neither OCs nor SCs showed any evidence of memory bias for threat-relevant information. The results support the idea of a general memory and a metamemory deficit in OCs.