Dose meta‐cognition or responsibility predict obsessive–compulsive symptoms: a test of the metacognitive model

Cognitive models of Obsessive–Compulsive disorder (OCD) have emphasized inflated responsibility (Salkovskis, 1985), thought–action fusion (Rachman, 1993), and metacognitive beliefs (Wells, 1997; Wells & Matthews, 1994), as factors contributing to disorder. The metacognitive model views responsibility as a by‐product of metacognitions that make little additional contribution to OCD, and gives rise to the following hypotheses: (1) responsibility and meta‐cognitive beliefs are positively correlated with obsessive–compulsive symptoms, (2) the relationship between responsibility and obsessive–compulsive symptoms is statistically dependent on meta‐cognition, (3) meta‐cognitions positively correlate with obsessive–compulsive symptoms independently of responsibility. The results supported each of these hypotheses and exploratory analyses were conducted to find the best unique set of predictors among a range of metacognitive dimensions. Metacognitive beliefs concerning need to control thoughts, thought–action fusion, and negative beliefs about cognitive competence emerged as reliable predictors. An additional contribution was made by thought–event fusion in one equation. The results provide support for the meta‐cognitive model. Copyright © 2004 John Wiley & Sons, Ltd.     

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.     

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.     

Obsessive–compulsive disorder beliefs,metacognitive beliefs and obsessional symptoms: relations between parent beliefs and child symptoms

Investigations of obsessive–compulsive disorder (OCD) have increasingly emphasized the role of cognition in symptom development and maintenance. In the present study, relationships between parent and adolescent child OCD symptoms and OCD cognition measures were explored to elucidate how OCD related beliefs and OCD symptoms might develop. One hundred and twenty‐six non‐clinical parent–adolescent pairs completed measures of OCD symptoms, OCD related beliefs and metacognitive beliefs (cognitive self‐consciousness [CSC], the tendency to focus attention on thought processes). A significant indirect relationship was found between parent OCD symptoms and adolescent OCD symptoms through specific adolescent OCD related beliefs. Contrary to expectations, parent and adolescent CSC were not correlated. Although findings were limited by the correlational and cross‐sectional design, implications of the observed associations for theory and treatment are discussed. Copyright © 2006 John Wiley & Sons, Ltd.     

Are the dysfunctional beliefs that predict worry different from those that predict obsessions?

Chronic worry present in Generalized Anxiety Disorder (GAD) and obsessions characteristic of the Obsessive–Compulsive Disorder (OCD) are cognitive phenomena that share some features, but they also differ on others. Based on current cognitive approaches, dysfunctional meta‐cognitive beliefs underlie the development and/or maintenance of both GAD and OCD. However, to date, there has been little empirical evidence about the differences between the beliefs that predict the occurrence of obsessions and those that predict worry. This study focuses on the search for these differences and examines to what extent worry and obsessions are associated with a similar or different pattern of dysfunctional cognitive contents. One hundred and seventy‐five community subjects completed measures of worry and obsessional intrusive thoughts, as well as questionnaires assessing obsession‐related and worry‐related meta‐cognitive beliefs. Results showed that beliefs about uncontrollability and danger, as well as cognitive self‐consciousness, play a central role in predicting worry, whereas the beliefs concerning the importance of thoughts and Thought–Action Fusion probability are relevant in accounting for the frequency of obsessive intrusive thoughts. Copyright © 2007 John Wiley & Sons, Ltd.     

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.     

Inferential confusion,obsessive beliefs and obsessive–compulsive symptoms: a multidimensional investigation of cognitive domains

Generally, research into the relationship between cognitive domains and obsessive–compulsive symptoms involves the use of scales that are highly intercorrelated with each other. The current study investigates the relationship between cognitive constructs and obsessive–compulsive symptoms using the item set of the Obsessive Beliefs Questionnaire and the Inferential Confusion Questionnaire. In order to create constructs that would not be excessively correlated with each other, factor scores were used to investigate the relationship between cognitive domains and obsessive–compulsive symptoms. Factor analysis followed by oblique rotation resulted in four moderately correlated cognitive constructs (importance/control of thoughts, inferential confusion/threat estimation, perfectionism/certainty and responsibility for preventing harm). With the exception of responsibility for preventing harm, the cognitive constructs under investigation were quite strongly related to obsessive–compulsive symptoms. In particular, hierarchical regression revealed the construct inferential confusion/threat estimation to be a global and strong predictor of obsessive–compulsive symptoms, followed by the constructs of perfectionism/certainty and the construct importance/control. Responsibility for preventing harm acted to be a negative predictor of obsessive–compulsive symptoms. It is concluded that the construct of inferential confusion acts as a more powerful predictor of obsessive–compulsive symptoms than any specific obsessive belief Copyright © 2008 John Wiley & Sons, Ltd.     

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.     

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.     

The role of feared possible selves in obsessive–compulsive and related disorders: A comparative analysis of a core cognitive self‐construct in clinical samples

Increasingly, cognitive‐behavioural models have been considering the role of beliefs about the self in the development and maintenance of obsessive–compulsive disorder (OCD), including sensitive domains of self‐concept and feared self‐perceptions. This has led to the development of the Fear of Self Questionnaire (FSQ; Aardema et al., 2013 ), which has shown strong internal consistency, divergent and convergent validity, and found to be a major predictor of unwanted thoughts and impulses (i.e., repugnant obsessions). The current study aimed to investigate fear of self‐perceptions using the FSQ in an OCD sample (n = 144) and related psychological disorders (eating disorders, n = 57; body dysmorphic disorder, n = 33) in comparison to a non‐clinical (n = 141) and clinical comparison group (anxiety/depressive disorders, n = 27). Following an exploratory factor analysis of the scale in the OCD sample, the results showed that participants with OCD in general did not score significantly higher on fear of self‐perceptions than did the clinical comparison participants. However, consistent with previous findings, fear of self was highly characteristic among OCD patients with unwanted repugnant thoughts and impulses. In addition, fear of self‐perceptions were significantly more elevated in those with eating or body dysmorphic disorders relative to the other non‐clinical and clinical groups. The construct of a “feared possible self” may be particularly relevant in disorders where negative self‐perception is a dominant theme, either involving concerns about one's inner self or concerns related to perceived bodily faults.     

Compulsive behaviours and levels of belief in obsessive–compulsive disorder: a case‐series analysis of their interrelationships

This study examined interrelationships of changes in compulsive behaviours and two levels of belief over treatment of obsessive–compulsive disorder (OCD). Levels were individual‐specific obsessive beliefs (termed here manifest beliefs) and OCD‐relevant general beliefs. If OCD‐relevant general beliefs are functionally linked to manifest beliefs and compulsive behaviours, changes in compulsive behaviours and both belief types should occur mostly in tandem, even if only one or two of these three elements are explicitly targeted. Baselines consisting of time performing compulsive behaviours, strength of manifest belief and strength of OCD‐relevant general beliefs were monitored daily by six participants over three phases in an A/B/B + C design. (A = no treatment, B = exposure/response prevention and C = cognitive therapy targeting only OCD‐relevant general beliefs.) Changes in compulsive behaviours, manifest beliefs and OCD‐relevant general beliefs moved primarily in tandem over treatment phases, suggesting functional links between these elements. Copyright © 2006 John Wiley & Sons, Ltd.     

Processes of change in cognitive–behavioural treatment of obsessive–compulsive disorder: Current status and some future directions

The present paper discusses theoretical and methodological issues involved in the processes of change in cognitive–behavioural treatment (CBT) of obsessive–compulsive disorder (OCD). Treatment outcome studies showed that CBT is effective in reducing obsessive–compulsive symptoms. However, why and how CBT works cannot be corroborated by comparing pre‐ and post‐assessment. Recently, there has been a resurgence of interest in theory driven process studies. By showing patterns of change over time, process studies can contribute to our insight into the actual mechanisms of change during treatment. We review process research in the field of OCD and discuss methodological issues involved in process studies for this particular disorder. It is concluded that studying the processes of change harbours promising possibilities for bridging the gap between theory and clinical practice. Copyright © 2009 John Wiley & Sons, Ltd. Key Practitioner Message:

• Process studies can contribute to the scientific underpinning of treatment.
• Process studies can provide clinicians with useful information for application of treatment.
• Decreases in dysfunctional beliefs seem related to successful treatment of OCD.

     

Development and validation of the multidimensional version of the fear of self questionnaire: Corrupted,culpable and malformed feared possible selves in obsessive–compulsive and body-dysmorphic symptoms

In recent years, cognitive-behavioural models of OCD have increasingly recognized the potential role of feared possible selves in the development and maintenance of OCD, while simultaneously re-examining factors that have historically been linked to self-perceptions in OCD. The current article describes the development and validation of a multidimensional version of the Fear of Self Questionnaire (FSQ-EV) in a non-clinical (N = 626) and clinical OCD sample (N = 79). Principal component analyses in the non-clinical sample revealed three conceptually and factorially distinct components revolving around a feared corrupted possible self, a feared culpable possible self and a feared malformed possible self. The questionnaire showed a strong internal inconsistency, and good divergent and convergent validity, including strong relationships to obsessional symptoms. In particular, the corrupted feared self predicted OCD symptoms independently from depression and other related self-constructs and obsessive beliefs, while also strongly interacting with importance and control of thoughts in the prediction of almost all specific symptoms of OCD. Results are consistent with the notion that self-constructs can be conceptually and empirically distinguished from obsessive beliefs and appraisals with significant potential to improve our understanding of OCD and related disorders.     

Intrusive thoughts, obsessions, and appraisals in obsessive-compulsive disorder: a critical review

This article reviews empirical findings on two key premises of the appraisal model of obsessive-compulsive disorder (OCD): (a) non-clinical populations experience intrusive thoughts (ITs) that are similar in form and in content to obsessions; and (b) ITs develop into obsessions because they are appraised according to dysfunctional beliefs. There is support for the universality of ITs. However, the samples used are not representative of the general population. IT measures do not relate systematically or exclusively to OCD symptom measures, and are not specific enough to exclude other types of intrusive thoughts such as negative automatic thoughts or worries, nor are they representative of all types of obsessions. When general distress is controlled, there is so far no evidence that participants with OCD endorse obsessive belief domains more strongly than anxious participants, and inconclusive evidence that OCD and non-clinical samples differ on the belief domains. Some OCD symptom subtypes are associated with belief domains. Currently, there is no coherent model to offer strong predictions about the specificity of the empirically derived belief domains in OCD symptom subtypes. Cognitive therapy based on the appraisal model is an effective treatment for OCD, although it does not add to the treatment efficacy of behaviour therapy. It is unclear how appraisals turn ITs into obsessions. Implications for future research are discussed.     

Dysfunctional beliefs in the process of change of cognitive treatment in obsessive compulsive checkers

Cognitive behaviour therapy (CBT) is considered to be effective in the reduction of obsessive compulsive symptoms. However, questions remain as to how CBT works. Cognitive-behavioural models postulate that negative appraisals of intrusive thoughts and dysfunctional beliefs that give rise to them underlie the development and maintenance of obsessive-compulsive disorder (OCD). The current study aimed to study this hypothesis by investigating the processes of change over the course of cognitive treatment for OCD. Furthermore, a new theoretical approach and method for studying processes of change was presented. The participants were seven patients suffering from OCD with predominantly checking symptoms. Process variables (beliefs, anxiety and compulsions) were measured using idiosyncratic diaries and were analysed on an intra- and inter-individual level using dynamic systems methods. Results showed significant decreases in credibility of dysfunctional beliefs in six out of the seven participants, which is in line with the cognitive-behavioural model. Associations between process variables were in general medium to high. However, the actual patterns of change showed important intra- and interpersonal differences. Results indicated that different paths can lead to clinical recovery, and it was concluded that process studies that focus on individual trajectories of change can contribute to our understanding of OCD and its treatment. Furthermore, dynamic systems methods provide insight into intra-individual processes and shed a new light on variability.     

Treatment of a Child With Obsessive‐Compulsive Disorder With Limited Motivation: Course and Outcome of Cognitive‐Behavior Therapy

Motivation is a key ingredient in the successful treatment of pediatric obsessive‐compulsive disorder (OCD). As a first‐line treatment, cognitive‐behavior therapy (CBT) requires extensive client engagement, including participating in exposures and doing homework tasks. A lack of motivation to comply with these tasks may seriously affect treatment outcome. This case study identifies factors interfering with motivation and illustrates motivational strategies to enhance compliance of a child with OCD. The patient was an 11‐year‐old boy with severe OCD and symptoms of oppositional defiant disorder (ODD). He had extensive OCD‐related avoidance behavior but denied the presence of symptoms or did not acknowledge them as a problem. In this article, we discuss the different techniques used to enhance motivation, which subsequently led to a favorable outcome.     

Metacognitive beliefs and strategies predict worry,obsessive–compulsive symptoms and coping styles: A preliminary prospective study on an Italian non‐clinical sample

Eighty undergraduate students completed the Italian versions of the Metacognition Questionnaire and Thought Control Questionnaire along with well‐established measures of worry, obsessive–compulsive symptoms and coping styles on two occasions four months apart. A series of hierarchical regression analyses revealed that, after controlling the initial level of both worry and obsessionality, negative beliefs about worry focused on uncontrollability and danger appeared consistently associated with worry and obsessive symptoms at a four‐month distance. In addition, positive beliefs about worry predicted maladaptive coping styles whereas cognitive self‐consciousness and thought strategies aimed at distraction appeared to foster or facilitate adaptive coping styles. Results, implications and limitations are discussed according to Well's metacognitive model of emotional disorders. Copyright © 2007 John Wiley & Sons, Ltd.     

Exploring the paths between dysfunctional attitudes towards motherhood and postpartum depressive symptoms: The moderating role of self‐compassion

Better understanding how cognitive processes operate to influence women's depressive symptoms during the postpartum period is crucial for informing preventive and treatment approaches. The present study aimed to examine the relationship between women's dysfunctional attitudes towards motherhood and depressive symptoms, considering the mediating role of negative automatic thoughts and the moderating role of self‐compassion. A sample of 387 women in the postpartum period cross‐sectionally answered a set of questionnaires to assess dysfunctional attitudes towards motherhood, negative automatic thoughts (general and postpartum‐specific), depressive symptoms, and self‐compassion. Women with clinically significant depressive symptoms presented more dysfunctional attitudes towards motherhood, more frequent negative thoughts, and lower self‐compassion. More dysfunctional beliefs about others' judgments and about maternal responsibility were associated with higher depressive symptoms, and this effect occurred through both general and postpartum‐specific thoughts related to the metacognitive appraisal of the thought content. Moreover, these relationships occurred only when women presented low or moderate levels of self‐compassion. These results highlight the need to comprehensively assess women's cognitive variables during the postpartum period with appropriate measures, for the early identification of women with more dysfunctional beliefs about motherhood, who may be at higher risk of depression. Moreover, preventive/treatment approaches should aim not only to challenge women's preexisting dysfunctional beliefs but also to promote a more self‐compassionate attitude towards themselves.     

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.     

Obsessional beliefs,compulsive behaviours and symptom severity: their evolution and interrelation over stages of treatment

The current study reports a case series examining (1) the variation in strength of obsessional doubt and belief in consequences of the doubt; and (2) the interaction between these cognitive components and symptom measures of duration and severity of obsessive–compulsive disorder (OCD), over 24 weeks of cognitive behaviour therapy. Eight participants diagnosed with OCD, four with contamination‐related rituals and four with checking behaviours, were selected on the basis of the Yale–Brown obsessive–compulsive scale (Y‐BOCS) and Padua ratings. All participants completed daily diaries measuring strength of principal obsessional doubt (0–100), strength of belief in consequences of the doubt (0–100) and the duration of the compulsive rituals throughout the 24 weeks of therapy. Severity of symptomatology was measured pre‐ and post‐treatment using the Y‐BOCS. Change in all measures was analysed over time following the procedure outlined by Storchheim and O'Mahoney (2006). Results showed that decrease in belief in secondary consequences is always accompanied by a decrease in strength of obsessions, but the converse does not hold. Furthermore, change in OCD symptomatology may precede cognitive changes. Copyright © 2008 John Wiley & Sons, Ltd.