Nonclinical populations in research on obsessive-compulsive disorder: A critical review

This article provides a review of the literature on nonclinical obsessive-compulsives (NCOCs). The main areas of focus include: (a) prevalence of obsessive-compulsive symptoms in nonclinical populations, (b) symptom profile, (c) associated psychopathology, (d) personality and psychological characteristics, (e) cognitive dysfunction, and (f) coping styles. For all six areas, findings on NCOCs are compared with research on clinical samples. Results suggest that: (a) lowlevel obsessive compulsive symptoms, as well as OCD, occur frequently in the general population; (b) a comparison of the symptom profile of NCOCs and OCD patients reveals both similarities and differences; (c) levels of associated anxiety, depression, and personality traits are consistent across studies and indicate that the scores of NCOCs fall between those of normal controls and OCD patients; (d) basic research on personality and psychological aspects of NCOCs has identified potential etiological factors in the development of OCD, including inflated responsibility and guilt, obsessive-compulsive personality traits, excessive need for control over the environment, and exaggerated responsiveness to emotional provocation; (e) NCOCs perform significantly worse on measures of executive functioning, memory, and information processing in comparison to control subjects, but unlike their OCD counterparts, their scores lie within the normal range; (f) the most common types of strategies employed by NCOCs and OCD patients in an effort to cope with obsessive-compulsive symptoms are qualitatively similar but less effective for OCD patients. The nature of the relationship between nonclinical obsessive-compulsive symptomatology and OCD is discussed with these findings in mind. In addition, critical commentary regarding methodological issues, as well as unanswered research questions which await empirical research, are addressed.     

Obsessive beliefs and their relation to obsessive–compulsive symptoms

Relationships between obsessive–compulsive symptoms and beliefs identified as relevant to obsessive–compulsive disorder (OCD) are investigated among university students and a small clinical sample. One hundred and fifty‐four participants completed measures of OCD‐related beliefs, OCD symptoms, and anxiety and depression symptoms. Results showed that belief domains were strongly interrelated and were not sufficiently separate to use individually in further analysis. The summed obsessive beliefs score was significantly correlated with all measured obsessional symptom subtypes, after controlling for anxiety and depression. Possible explanations and clinical implications of the results are discussed. Copyright © 2004 John Wiley & Sons, Ltd.     

Obsessive compulsive symptoms in Gilles de la Tourette syndrome and obsessive compulsive disorder

The distribution of obsessive compulsive symptoms was compared in 16 individuals with primary obsessive compulsive disorder (OCD) and 16 individuals with Gilles de la Tourette syndrome (GTS) and associated obsessive compulsive behaviors (OCB). The two groups showed significant differences in the distribution of OC symptomatology. Furthermore, those OCD probands who shared a similar symptom profile with GTS individuals all had a positive family history of OCD. All of the other OCD probands were isolated cases. Implications of this finding on the etiology and pathogenesis of the two disorders are discussed. Am. J. Med. Genet. 74:432–438, 1997. © 1997 Wiley-Liss, Inc.     

The associations of obsessive–compulsive symptom dimensions and general severity with suicidal ideation in patients with obsessive–compulsive disorder: The role of specific stress responses to COVID-19

Suicidal ideation is prevalent in patients with obsessive–compulsive disorder (OCD); but, during COVID-19, it may be increased. The present study aimed to examine the effects of obsessive–compulsive (OC) symptom dimensions and OCD severity on suicidal ideation by considering the role of stress responses in reaction to COVID-19 in a clinical sample of patients with OCD. In a cross-sectional study, 304 patients with OCD completed measures of OC symptom dimensions, OCD severity, general mental health (depression and anxiety), and COVID-19-related stress. Results showed that after controlling for depression, anxiety, comorbidity, and lifetime suicide attempts, the OC symptom dimensions of responsibility for harm and unacceptable obsessional thoughts as well as general severity had indirect effects on suicidal ideation through the specific stress responses to COVID-19, including traumatic stress and compulsive checking. The study shows that OCD patients with specific OC symptom dimensions and severe OCD are more likely to have suicidal ideation during the pandemic. Further, the specific stress responses to COVID-19 may be an underlying mechanism. Clinicians should carefully assess suicidal ideation in patients with OCD who experience responsibility for harm and unacceptable thoughts, particularly during the pandemic.     

Accommodation in Youth With OCD and Anxiety

Accommodation refers to the ways in which family members act to alleviate a child's symptoms and distress. In the context of youth obsessive‐compulsive disorder (OCD) and anxiety, accommodation may contribute to the development and maintenance of the disorder. We review the theory and research literature on accommodation, including measures of accommodation. Findings support the idea that accommodation is not a preferred parenting strategy; the sequelae of accommodation are negative and are often associated with both parent and sibling distress. Accommodation should be assessed and targeted in treatment for youth OCD and anxiety. We conclude by identifying several areas for future research, including the development of interventions that specifically target accommodation, the evaluation of potential family factors implicated in accommodation, and the exploration of the construct of accommodation in other childhood disorders.     

The effect of childhood maltreatment on suicidal ideation through cognitive emotion regulation strategies and specific obsessive–compulsive symptoms in obsessive–compulsive disorder

Childhood maltreatment is thought to be associated with suicidality in patients with obsessive–compulsive disorder (OCD). Although the underlying mechanism of this relationship is not clear, cognitive emotion regulation strategies (CERSs) and the specific OC symptoms including unacceptable obsessional thoughts (UOTs) and responsibility for harm (RFH) may underlie this link. Accordingly, the study aimed to assess the effect of childhood maltreatment on suicidal ideation through UOTs, RFH and adaptive and maladaptive CERSs in OCD patients. Three hundred patients meeting a DSM-5 diagnosis of OCD were selected and completed the scales measuring childhood maltreatment, OCD, suicidality and depressive symptoms. After controlling for depressive symptoms and OCD severity, childhood maltreatment was shown to affect suicidal ideation directly. Also, the indirect effect of childhood maltreatment on suicidal ideation was mediated by adaptive CERSs, UOTs and RFH. The findings show that OCD patients with a history of childhood maltreatment, less use of adaptive CERSs and the experiences of UOTs and RFH should be carefully considered regarding suicidal risk.     

Continuity between DSM‐5 Section II and Section III personality traits for obsessive–compulsive personality disorder

Objective

Obsessive–compulsive personality disorder (OCPD) is formally operationalized in Section II of the DSM‐5 by a heterogeneous collection of 8 categorical criteria. Section III contains an alternative model operationalizing personality disorders via dimensional personality traits and associated impairment. The extent to which the personality traits used to define OCPD in Section III correspond with the Section II operationalization of the disorder is contested. The current study aims to contribute to the evidence base necessary to solidify the optimal trait profile for this disorder via a more fine‐tuned examination of OCPD.

Method

The research questions were examined using a clinical sample of 142 Danish adults who completed the Structured Clinical Interview for DSM‐IV Axis II Disorders and the Personality Inventory for DSM‐5 to index both the Sections II and III (personality traits) operationalizations of OCPD, respectively.

Results

Bivariate correlations supported Rigid Perfectionism and Perseveration as traits relevant to OCPD; however, hierarchical regression analyses indicated that of the 4 traits used in the Section III operationalization of OCPD, only Rigid Perfectionism uniquely predicted OCPD (p < .05). In addition to Rigid Perfectionism, the conceptually relevant traits of Submissiveness, Suspiciousness, and (low) Impulsivity were also found to uniquely predict OCPD and its specific symptoms in a regression model.

Conclusions

These findings indicate that the traits proposed in Section III are only partially aligned with the traditional, Section II conceptualization of OCPD, and may be augmented by incorporating Submissiveness, Suspiciousness, and (low) Impulsivity. In light of the current findings and existing literature, a modified constellation of traits to operationalize OCPD is likely justified.     

Vulnerability factors in OCD symptoms: cross‐cultural comparisons between Turkish and Canadian samples

Recent findings have suggested some potential psychological vulnerability factors for development of obsessive‐compulsive (OC) symptoms, including cognitive factors of appraisal and thought control, religiosity, self‐esteem and personality characteristics such as neuroticism. Studies demonstrating these associations usually come from Western cultures, but there may be cultural differences relevant to these vulnerability factors and OC symptoms. The present study examined the relationship between putative vulnerability factors and OC symptoms by comparing non‐clinical samples from Turkey and Canada, two countries with quite different cultural characteristics. The findings revealed some common correlates such as neuroticism and certain types of metacognition, including appraisals of responsibility/threat estimation and perfectionism/need for certainty, as well as thought–action fusion. However, culture‐specific factors were also indicated in the type of thought control participants used. For OC disorder symptoms, Turkish participants were more likely to utilize worry and thought suppression, while Canadian participants tended to use self‐punishment more frequently. The association with common factors supports the cross‐cultural validity of some factors, whereas unique factors suggest cultural features that may be operative in cognitive processes relevant to OC symptoms. Copyright © 2009 John Wiley & Sons, Ltd. Key Practitioner Message: ? Despite cross‐cultural validity in the cognitive accounts for OCD, there are some evidences implying the impact of cultural characteristics on some cognitive factors across different cultures. Thus, it is important for clinicians who work with people from different cultural backgrounds to be vigilant for possible variations in the cognitive processes during psychotherapy and psychological assessment.     

A Case Report of Harm‐Related Obsessions in Pediatric Obsessive‐Compulsive Disorder

Harm‐related, or “aggressive,” obsessions are a symptom subtype in obsessive‐compulsive disorder (OCD). Given the violent nature of these thoughts, the stark contrast between the child's character and the content of these obsessions often results in high levels of distress for not only the patient but also the family. This case report illustrates the application of family‐based exposure and response prevention (ERP) for a 15‐year‐old male presenting with harm‐related obsessions and mild depressive symptoms secondary to the OCD. The obsessions primarily revolved around the fear of acting on unwanted impulses (e.g., stabbing a family member, pushing a friend onto oncoming traffic), and the compulsions entailed avoidance (both mental and physical), excessive reassurance seeking, and ritualistic confessions. The client underwent a 14‐week course of ERP involving repeated imaginal and in vivo exposures and behavioral activation to alleviate depressive symptoms. Significant improvements in obsessive‐compulsive symptom severity and depressive symptoms were observed posttreatment, elucidating the efficacy of treating harm‐related obsessions with a course of ERP.     

Self‐compassion and emotion regulation difficulties in obsessive–compulsive disorder

Lack of self‐compassion and deficits in emotion regulation are associated with various psychopathological symptoms and may play a role in the development and maintenance of obsessive–compulsive disorder (OCD). However, further empirical research is still needed to better understand these constructs in the context of this disorder. The present study investigated the relation between self‐compassion, emotion regulation difficulties, obsessive beliefs, and obsessive–compulsive symptom severity in 90 patients with OCD using self‐report questionnaires. Symptom severity and obsessive beliefs were negatively correlated to self‐compassion and positively associated with emotion regulation difficulties. Additionally, self‐compassion showed a negative relation to emotion regulation difficulties. Emotion regulation difficulties—but not self‐compassion—predicted symptom severity when controlling for obsessive beliefs and depression in a hierarchical regression analysis. Further analyses showed that emotion regulation deficits mediated the relationship between self‐compassion and OCD symptom severity. Our results provide preliminary evidence that targeting self‐compassion and putting more emphasis on emotion regulation deficits might be promising treatment approaches for patients with OCD. Future studies could investigate which specific interventions that directly address these variables improve treatment outcome.     

Parental Bonding Reports of Clients with Obsessive–Compulsive Disorder and Agoraphobia

The study was designed to address two broad purposes: (a) to investigate further the reliability and validity of the Parental Bonding Instrument (PBI) and (b) to examine the relationship of parental warmth and overprotection to specific anxiety disorders and their symptoms, anxious personality traits, and social functioning. The PBI was administered, before and after exposure treatment, to an outpatient sample of 52 adults with obsessive–compulsive disorder and 35 with panic disorder with agoraphobia, and to their parents (n=42), if they resided with the patient. PBI scores remained stable despite improvement in symptom severity and mood. Parents' and patients' recollections of the parents' behaviour towards the patient did not agree. According to patients, their parents most often raised them using affectionless control, whereas parents most often rated themselves as having provided optimal parenting. Patients' PBI scores were not related to type or severity of anxiety disorder. However, reports of poorer parenting were associated with worse social adjustment and higher levels of anxious personality disorder characteristics.     

Associations of neural error-processing with symptoms and traits in a dimensional sample recruited across the obsessive–compulsive spectrum

The error-related negativity (ERN), a neural response to errors, has been associated with several forms of psychopathology and assumed to represent a neural risk marker for obsessive–compulsive disorder (OCD) and anxiety disorders. Yet, it is still unknown which specific symptoms or traits best explain ERN variation. This study investigated performance-monitoring in participants (N = 100) recruited across a spectrum of obsessive–compulsive characteristics (n = 26 patients with OCD; n = 74 healthy participants including n = 24 with low, n = 24 with medium, and n = 26 with high OC-characteristics). Several compulsivity- and anxiety-associated characteristics were assessed and submitted to exploratory principal axis factor analysis. Associations of raw measures and derived factors with ERN and correct-related negativity (CRN) were examined. Patients with OCD showed increased ERN amplitudes compared to healthy participants. The ERN was associated with a variety of traits related to anxiety and negative affect. Factor analysis results revealed a most prominent association of the ERN with a composite measure of anxiety and neuroticism, whereas the CRN was specifically associated with compulsivity. Results support differential associations for the ERN and CRN and demonstrate that a dimensional recruitment approach and use of composite measures can improve our understanding of characteristics underlying variation in neural performance monitoring.     

Obsessional thoughts and compulsive behaviors in a sample of women with postpartum mood symptoms

Postpartum psychiatric disorders are widely recognized by clinicians and researchers, yet while much attention has been paid to perinatal mood disorders, considerably less has been given to anxiety and obsessive–compulsive symptoms in this population. The present study examined anxiety and obsessive–compulsive symptoms among postpartum women with mood complaints, with the aim of delineating the relationship between these symptoms. Sixty postpartum women seeking treatment in a perinatal mood disorders clinic completed measures of depression, anxiety, and obsessive–compulsive symptoms. Obsession-like thoughts and compulsive-like (“neutralizing”) strategies were present among the majority of the sample, yet the severity of these symptoms ranged widely. Depressive and anxiety symptoms were associated with obsessive and neutralizing compulsive symptoms. It may be helpful to consider anxiety and depressive symptoms as part of a broad spectrum of perinatal psychiatric illness. Clinicians should assess for anxiety and obsessive–compulsive symptoms as routinely as they assess for depressive symptoms in the perinatal period.     

Not just thinking,but believing: Obsessive beliefs and domains of cognitive fusion in the prediction of OCD symptom dimensions

Cognitive fusion (CF) involves the tendency to “buy in” to thoughts and feelings and consists of three empirically established domains: somatic concerns, emotion regulation, and negative evaluation. CF is hypothesized to play a role in obsessive–compulsive disorder (OCD). The present study examined how well the CF domains, relative to traditional cognitive–behavioural constructs (i.e., obsessive beliefs such as inflated responsibility), predict OCD symptoms. Fifty‐two treatment‐seeking adults with OCD completed self‐report measures of CF, obsessive beliefs, OCD symptoms, and general distress. Domains of CF were differentially associated with the responsibility for harm, symmetry, and unacceptable thoughts of OCD dimensions; yet after accounting for obsessive beliefs, only the negative evaluation domain of CF significantly predicted symmetry OCD symptoms. Obsessive beliefs significantly predicted all OCD dimensions except for contamination. These findings provide additional support for existing cognitive–behavioural models of OCD across symptom dimensions, with the exception of contamination symptoms, and suggest that the believability of thoughts and feelings about negative evaluation adds to the explanation of symmetry symptoms. Conceptual and treatment implications, study limitations, and future directions are discussed.     

Thought‐action fusion and inflated responsibility beliefs in obsessive‐compulsive disorder

In obsessive‐compulsive disorder (OCD), inflated responsibility (IR) beliefs and thought‐action fusion (TAF) are two cognitive schema argued to contribute to obsessions and compulsions. We investigated whether IR and TAF are OCD‐specific or whether they occur in other anxiety disorders. Adults diagnosed with OCD (n = 20) or other anxiety disorders (n = 21), and non‐clinical controls (n = 22) completed measures of OCD symptomatology and severity, TAF, appraisals and interpretations of responsibility, and depression. IR was more prominent in those with OCD as compared with those with other anxiety disorders, with correlational analyses confirming that a high sense of personal responsibility was associated with high levels of obsessionality even after controlling for depression. No group differences, however, emerged between the clinical groups on measures of TAF, both groups showing elevated TAF compared with controls. Indeed, TAF and obsessional symptoms were correlated only in the presence of negative affect. These results suggest that although IR may be higher in those with OCD compared with other anxiety disorders, TAF is not specific to OCD. Results are discussed in the context of cognitive appraisal models of OCD.     

Multidimensional assessment of OCD: integration and revision of the vancouver obsessional‐compulsive inventory and the symmetry ordering and arranging questionnaire

This article reports on the integration and revision of two self‐report measures of obsessive‐compulsive symptoms based on data from an obsessive‐compulsive disorder (OCD) sample (n=228): the Vancouver Obsessional‐Compulsive Inventory (VOCI) and the Symmetry Ordering and Arranging Questionnaire (SOAQ). The revised measure provides scores on five symptom subscales (Contamination, Checking, Hoarding, Symmetry and Ordering, Obsessions). It shows improvement upon current versions in several ways: it has a good model fit, eliminates redundancy, reduces overlap across subscales, is much shorter, and covers those OCD dimensions most frequently identified in factor‐analytic studies. Strengths of the revision compared with other measures are high distinctiveness of subscales, discriminant validity with depression and anxiety, and a more fine‐grained and comprehensive assessment of obsessional contents. © 2010 Wiley Periodicals, Inc. J Clin Psychol: 66:1–19, 2010.     

Genetic meta‐analysis of obsessive–compulsive disorder and self‐report compulsive symptoms

We investigated whether obsessive–compulsive (OC) symptoms from a population‐based sample could be analyzed to detect genetic variants influencing obsessive–compulsive disorder (OCD). We performed a genome‐wide association studies (GWAS) on the obsession (rumination and impulsions) and compulsion (checking, washing, and ordering/precision) subscales of an abbreviated version of the Padua Inventory (N = 8,267 with genome‐wide genotyping and phenotyping). The compulsion subscale showed a substantial and significant positive genetic correlation with an OCD case–control GWAS (r _G = 0.61, p = .017) previously published by the Psychiatric Genomics Consortium (PGC‐OCD). The obsession subscale and the total Padua score showed no significant genetic correlations (r _G = ?0.02 and r _G = 0.42, respectively). A meta‐analysis of the compulsive symptoms GWAS with the PGC‐OCD revealed no genome‐wide significant Single‐Nucleotide Polymorphisms (SNPs combined N = 17,992, indicating that the power is still low for individual SNP effects). A gene‐based association analysis, however, yielded two novel genes (WDR7 and ADCK1). The top 250 genes in the gene‐based test also showed a significant increase in enrichment for psychiatric and brain‐expressed genes. S‐Predixcan testing showed that for genes expressed in hippocampus, amygdala, and caudate nucleus significance increased in the meta‐analysis with compulsive symptoms compared to the original PGC‐OCD GWAS. Thus, the inclusion of dimensional symptom data in genome‐wide association on clinical case–control GWAS of OCD may be useful to find genes for OCD if the data are based on quantitative indices of compulsive behavior. SNP‐level power increases were limited, but aggregate, gene‐level analyses showed increased enrichment for brain‐expressed genes related to psychiatric disorders, and increased association with gene expression in brain tissues with known emotional, reward processing, memory, and fear‐formation functions.     

Obsessive‐Compulsive Disorder in the DSM‐5

Whereas the specific diagnostic criteria for obsessive‐compulsive disorder (OCD) have changed in only minor ways in the transition from DSM‐IV to DSM‐5, a more substantial change is that OCD is no longer classified as an anxiety disorder. Rather, it is now the flagship diagnosis of a new diagnostic category: the obsessive‐compulsive and related disorders (OCRDs). In this article, we describe the nature of obsessional problems as determined through empirical research before turning to a consideration of how OCD is defined in previous editions of the DSM and in DSM‐5. We then critically consider the DSM criteria, as well as the basis for removing OCD from the anxiety disorders and creating the new OCRD category. Finally, we consider the implications of these changes for clinical practice and research on OCD.     

Volitional saccade performance in a large sample of patients with obsessive‐compulsive disorder and unaffected first‐degree relatives

Recent evidence indicates that patients with obsessive‐compulsive disorder (OCD) as well as their unaffected first‐degree relatives show deficits in the volitional control of saccades, suggesting that volitional saccade performance may constitute an endophenotype of OCD. Here, we aimed to replicate and extend these findings in a large, independent sample. One hundred and fifteen patients with OCD, 103 healthy comparison subjects without a family history of OCD, and 31 unaffected first‐degree relatives of OCD patients were examined using structured clinical interviews and performed a volitional saccade task as well as a prosaccade task. In contrast to previous reports, neither patients nor relatives showed impairments in the performance of volitional saccades compared to healthy controls. Notably, medicated patients did not differ from nonmedicated patients, and there was no effect of depressive comorbidity. Additional analyses investigating correlations between saccade performance and OCD symptom dimensions yielded no significant associations. In conclusion, the present results do not support the notion that volitional saccade execution constitutes an endophenotype of OCD. Possible explanations for inconsistencies with previous studies are discussed.     

Modified Cognitive Behavior Therapy for Severe,Treatment‐Resistant Obsessive‐Compulsive Disorder in an Adolescent With Autism Spectrum Disorder

There is a high rate of comorbidity between obsessive‐compulsive disorder (OCD) and autism spectrum disorders (ASD). Standard cognitive‐behavior therapy (CBT) protocols have been shown to be less effective in treating OCD in young people with ASD than in typically developing youth. This case study describes the treatment of an adolescent boy with severe, treatment‐resistant OCD and ASD using a modified CBT approach. Modifications to a standard evidence‐based CBT for OCD protocol included extended psychoeducation about anxiety; regular home‐based sessions; and increased involvement of systems, including family and school. Multi‐informant outcome data indicated significant improvements in OCD symptoms over the course of treatment with gains being maintained over a 12‐month follow‐up period. These findings demonstrate the potential efficacy of modified CBT for pediatric OCD in the context of ASD.