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.     

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.     

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.     

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.     

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.     

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.     

Psychometric characteristics of the Penn State Worry Questionnaire and Metacognitions Questionnaire‐30 and metacognitive predictors of worry and obsessive–compulsive symptoms in a Turkish sample

The purpose of the present study was twofold. First, to examine the psychometric properties of the Penn State Worry Questionnaire (PSWQ) and the Metacognitions Questionnaire‐30 (MCQ‐30) in a Turkish sample. Second, to investigate metacognitive predictors of pathological worry and obsessive–compulsive (o–c) symptoms in this group. The sample included 561 non‐clinical participants. Consistent with non‐English versions, the Turkish version of the PSWQ was found to have a two‐factor structure. The MCQ‐30 was shown to be composed of five factors similar to the English version. Reliability analyses indicated that both the PSWQ and MCQ‐30 possessed high internal consistency, split‐half reliability and test–retest coefficients. As expected, both scales positively correlated with measures of o–c symptoms, trait anxiety, and anxiety and depression, as well as with each other. Negative and positive metacognitive beliefs about worry were significant predictors of both pathological worry and o–c symptoms. Cognitive confidence emerged as a specific predictor of worry, while beliefs about the need to control thoughts emerged as a unique predictor of o–c symptoms. Copyright © 2008 John Wiley & Sons, Ltd.     

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.     

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.     

The cognitive–behavioural model of hoarding disorder: Evidence from clinical and non‐clinical cohorts

The cognitive–behavioural model of hoarding disorder incorporates information processing difficulties, maladaptive attachment to possessions, erroneous beliefs about the nature of possessions, and mood problems as etiologically significant factors, although developmental experiences such as a compromised early family environment have also been proposed in an augmented model. This study examined the specificity and relevance of variables highlighted in the augmented cognitive–behavioural model. Various clinical participants (n = 89) and community controls (n = 20) were assessed with structured clinical interviews to verify diagnosis. Participants completed self‐report measures of hoarding severity, cognitions, meta‐memory, and early developmental experiences (e.g., memories of warmth and security in one's family). Hoarding cohorts (with and without obsessive–compulsive disorder) reported poor confidence in memory, but relative to other groups (obsessive–compulsive disorder without hoarding disorder, anxiety disorders, and healthy controls), hoarding‐relevant cognitions, need to keep possessions in view, and concerns about the consequences of forgetting were significantly higher. Hoarding groups reported the lowest recollections of warmth in their family, although no differences were found between hoarding and non hoarding clinical cohorts for uncertainty about self and others. Nonetheless, clinical cohorts reported generally higher scores of uncertainty than healthy controls. When predicting hoarding severity, after controlling for age and mood, recollections of lack of warmth in one's family was a significant predictor of hoarding severity, with hoarding‐related cognitions and fears about decision‐making being additional unique predictors. The study supports the augmented cognitive–behavioural model of hoarding, inclusive of the importance of early developmental influences in hoarding.     

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.

     

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.     

Spanish version of the Inferential Confusion Questionnaire‐Expanded Version: Further support for the role of inferential confusion in obsessive–compulsive symptoms

The purposes of this research were (1) to analyse the psychometric properties of the Inferential Confusion Questionnaire‐Expanded Version (ICQ‐EV) in a Spanish population; (2) to explore the role of inferential confusion in obsessive–compulsive disorder (OCD); and (3) to compare the inferential confusion construct in nonclinical and clinical samples. A sample of 342 nonclinical participants and 66 patients with OCD completed the ICQ‐EV Spanish adaptation as well as a set of questionnaires. Results confirmed a good fit of the ICQ‐EV Spanish version to the original unifactorial structure and excellent internal consistency and test–retest reliability. Moreover, results confirmed that the ICQ‐EV predicts Obsessing, Checking, Washing, and Hoarding symptoms, independently of the contribution of dysfunctional beliefs. In addition, OCD patients scored significantly higher on the ICQ‐EV than nonclinical participants. The Spanish version of the ICQ‐EV is a reliable instrument to assess inferential confusion, and further support is provided for the relevance of the inferential confusion construct in OCD.     

Validation of the Serbian version of the Metacognitions Questionnaire‐30 in nonclinical and clinical samples

The Metacognitions Questionnaire (MCQ‐30) is a brief multidimensional measure used for assessment of metacognitive beliefs in psychopathology. The aim of this study was to assess the psychometric properties of MCQ‐30 in Serbian nonclinical (n = 246) and clinical (n = 171; anxiety and depressive disorders) samples. The reliability of the questionnaire and its subscales was satisfactory. An exploratory factor analysis yielded a five‐factor solution in both groups, whereas a confirmatory factor analysis showed a somewhat weaker fit of the model. The MCQ‐30 showed positive associations with measures of anxiety, pathological worry, depressive, and obsessive–compulsive symptoms in both samples, demonstrating adequate convergent validity. The instrument was sensitive to differences in metacognitive beliefs between nonclinical and clinical samples. MCQ‐30 subscales showed incremental contributions in predicting pathological worry after controlling for the variance in obsessive–compulsive symptoms and vice versa. Our results suggest that the MCQ‐30 is a reliable and valid instrument for assessing metacognitive beliefs in both nonclinical and clinical samples. Moreover, the findings support the use of the MCQ‐30 in Serbian population and extend support for the metacognitive model.     

Cognitive Predictors of Obsessive–Compulsive Symptoms in Adolescence: A Preliminary Investigation

This study examined relations among responsibility attitudes, metacognitive beliefs, and obsessive–compulsive (O–C) symptoms in youth. One hundred sixty-six nonclinical youth (ages 13 to 17 years) completed the following: Responsibility Attitude Scale (RAS; Salkovskis et al., 2000); Meta-Cognitions Questionnaire–Adolescent Version (MCQ–A; Cartwright-Hatton et al., 2004); Children's Depression Inventory–Short Form (CDI–S; Kovacs, 1985); Revised Children's Manifest Anxiety Scale (RCMAS; Reynolds & Richmond, 1978); the Leyton Obsessional Inventory–Child Version Survey Form (LOI–CVS; Berg, Whitaker, Davies, Flament, & Rapoport, 1988). Participants endorsed a range of responsibility and metacognitive beliefs, and both responsibility and metacognition were positively correlated with O–C symptoms. However, when age, sex, and depression were controlled, only metacognition was a predictor of O–C symptoms. The findings suggest metacognition and responsibility may be important correlates of O–C symptoms in youth.     

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.     

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.     

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.     

Responsibility attitude,obsession and compulsion: further support in a non‐clinical sample

Responsibility is one of the most investigated constructs in obsessive‐compulsive disorder (OCD). Although there are an increasing number of studies on this topic, results seem to be questionable. Whereas several authors reported a significant link between OC behaviour and responsibility in nonclinical as well as in clinical samples, the findings of many authors failed to demonstrate the presence of such an association. In the current study, we examined the relationship between obsessive‐compulsive behaviour and responsibility. To this aim, participants filled in five inventories: the Responsibility Attitude Scale (RAS), the Responsibility Questionnaire (RQ), the Padua Inventory Revised (PI‐R), the State‐Trait Anxiety Inventory (STAI), and the Beck Depression Inventory (BDI). Results showed a relationship between obsessive‐compulsive behaviour (PI‐R scores) and responsibility, as measured by both RAS and RQ. A principal component analysis showed that RAS can be interpreted as a four‐factor scale, accounting for 63% of the variance overall. Regression analyses showed that responsibility can be considered a significant predictor of obsession and compulsion behaviour, as measured by PI‐R. Furthermore, showing a connection between specific factors of responsibility and certain kinds of obsessive‐compulsive behaviour, results seem to confirm the hypothesis that responsibility is more salient in checking than in cleaning symptoms. Copyright © 2001 John Wiley & Sons, Ltd.     

DIRT—danger ideation reduction therapy for obsessive–compulsive washers: a comprehensive guide to treatment

Danger ideation reduction therapy (DIRT) for obsessive compulsive disorder (OCD) is a new intervention focusing on providing corrective information, and is the subject of a new comprehensive guide to treatment for compulsive washing. The components of DIRT are well presented in this manual‐based treatment and the documentation includes dialogues, filmed interviews with workers in dangerous occupations, and fact sheets to persuade the client to exchange beliefs about danger for beliefs about safety. The book is well organized and user friendly. Clinical trials have shown DIRT to be an effective treatment. Although DIRT as a stand alone therapy seems to offer some advantages over conventional CBT, it may function currently more as an adjunct to help cognitive restructuring. DIRT certainly encourages us to rethink some assumptions about the use of corrective information in treating OCD. Copyright © 2009 John Wiley & Sons, Ltd. Key Practitioner Message: ? Danger ideation therapy is principally a cognitive approach. ? Corrective information may help in the treatment of OCD for washing. ? The application of DIRT in other types of OCD and symbolic contamination remains uncertain.