Differences in obsessional beliefs and emotion appraisal in obsessive compulsive symptom presentation
Introduction
Obsessive-compulsive disorder (OCD) is a debilitating disorder characterized by recurring distressing thoughts or images (obsessions), and behaviors intended to reduce distress, including repetitive overt or mental rituals (compulsions; American Psychiatric Association (APA), 2000) and avoidance. The relationship between obsessions and compulsions is such that obsessions evoke anxiety (or another state of negative affect), and compulsions are enacted to ameliorate the aversive feeling. This simplified explanation defines the struggle for many OCD sufferers; yet, OCD is a heterogeneous disorder with highly varied symptom presentation. The phenomenology of both the obsessions and compulsions is diverse. Common obsessions include fears about contamination, causing harm, neatness or exactness, and violent, sexual, or religious thoughts. Compulsions may include washing, checking, ordering, counting, and praying. In the past decade, researchers have begun to systematically investigate the differences in symptom dimensions to contribute to the development of specialized treatment approaches. The present study adds to the existing body of literature by investigating correlates and predictors of severity in four symptom presentations.
The surge in research related to the differences in OCD was initiated in part by the fact that up to 50% of individuals with OCD do not respond optimally to treatment (Baer and Minichiello, 1998, Cottraux et al., 2005, Fisher and Wells, 2005, Stanley and Turner, 1995). While there are several possible explanations for treatment “failures,” one approach to improving treatment outcomes is to target the idiographic nature of the symptoms by examining the correlates and predictors for each presentation type. While the heterogeneity of OCD is widely accepted, there is some disagreement about the content and number of categories represented. A meta-analysis of 12 factor-analytic studies representing over 2000 patients with OCD supported four consistent symptom dimensions including contamination, harm, symmetry, and hoarding (Mataix-Cols, Rosario-Campos, & Leckman, 2005). However, researchers are now conceptualizing hoarding as distinct enough to warrant its own diagnostic category (cf., Mataix-Cols et al., 2010); therefore, the present study used the classification derived by Abramowitz et al., 2010) and grouped obsessions and compulsions into the following: (1) thoughts related to contamination and washing behaviors, (2) thoughts related to responsibility for causing harm and checking behaviors, (3) thoughts related to symmetry and ordering behaviors, and (4) repulsive thoughts related to sex, religion, or violence and mental compulsions or neutralizing behaviors.
The development of self-report measures including the Padua Inventory (PI; Sanavo, 1988), the Obsessive Compulsive Inventory (OCI; Foa, Kozak, Salkovskis, Coles, & Amir, 1998) and OCI-Revised (OCI-R, Foa et al., 2002), and the Dimensional Obsessive Compulsive Scale (DOCS; Abramowitz et al., 2010) have allowed researchers to examine the differences between these psychometrically derived OCD symptom dimensions. The OCI-R and PI are frequently employed to this end; however, several differences between these measures and the DOCS suggest that the DOCS may be a more informative measure. Firstly, the DOCS assesses severity in each symptom presentation multidimensionally, by inquiring about distress, functional impairment, and frequency of symptoms. The DOCS also assesses avoidance behaviors, a core characteristic of OCD not addressed in the OCI-R or PI. Finally, consistent with the structural framework of OCD, the DOCS does not include items related to hoarding. As research on the OCD symptom dimensions expands, utilizing measures that address each component of OCD symptomology, such as the DOCS, will increase the utility of the findings.
The extant research examining the heterogeneity of OCD has largely focused on specific maladaptive beliefs, but many other factors (e.g., emotion appraisal) also may contribute to OCD development, maintenance, severity, and prognosis. Treatment-enhancing modifications are an anticipated outcome of research on the symptom dimensions, and broadening the scope of possible factors related to each subtype will further inform treatment innovations. A review of obsessional beliefs and emotions as they relate to OCD will provide the context for the present study.
The appraisal theory of obsessions dominates OCD research and practice (Clark, 2004). These theories (Rachman, 1997, Rachman, 1998, Salkovskis, 1985) posit that the interpretation of thoughts significantly contributes to the development of obsessions. More recently, belief-based models of OCD have been theorized (Rachman, 2002, Rachman, 2004) and OCD researchers have distinguished three obsessional belief domains: over responsibility and overestimation of threat (RT), perfectionism and intolerance of uncertainty (PC), and importance of thoughts and need to control thoughts (ICT; Obsessive-Compulsive Cognitions Working Group [OCCWG], 2005). There is empirical evidence to suggest that these belief domains are associated with OCD; however, the results are not completely conclusive and much of the variance in symptom severity is not accounted for by obsessional beliefs (cf., Julien, O’Connor, & Aardema, 2007).
Clinical observation alludes to specific relationships between belief domains and OCD symptom dimensions (e.g., over-responsibility and harm subtype), and limited empirical evidence provides support for the specificity of belief domains in the symptom dimensions (Manos et al., 2010, Wheaton et al., 2010). While there is considerable evidence to support the role of obsessional beliefs, the lack of a coherent model, varied empirical findings in clinical samples, and unaccounted variance in severity are causing researchers to look beyond cognitive appraisals to explain the OCD symptomology.
Anxiety, a universal experience with important protective functions, becomes problematic when the cue to danger is inproportionate to the actual threat in the environment. Calamari, Rector, Woodard, Cohen, and Chik (2008) found that anxiety sensitivity (AS; i.e., the fear of anxiety-related bodily sensations) contributed to models predicting OCD severity, beyond the cognitive appraisal constructs described above. The same study found that the relationship between AS and OCD symptom severity varied across symptom dimensions. Obviously, experiences of anxiety play a central role in anxiety disorders! However, there is evidence to suggest that anxiety is experienced with some variability in OCD (Nutt & Malizia, 2006) and that it may not be the primary feeling, or the only threatening feeling, experienced by individuals with this disorder. Rather, one's relationship with their emotions in general, including other aversive emotions may also be implicated in problematic anxiety. Several emotions have been theorized as being fairly universal, including fear, disgust, and guilt (Power, 2006), and these emotions are suspected to be relevant to OCD etiology and phenomenology as well.
Disgust is a universal guttural response characterized by withdrawal from repulsive stimuli, such as animal and food products (Rozin & Fallon, 1987). Individuals experience disgust to varying degrees and greater disgust sensitivity has been related to OCD symptom presentation and severity (Berle and Phillips, 2006, Olatunji et al., 2005, Tolin et al., 2006). In addition to elicitation by physical stimuli, Borg, Lieberman, and Kiehl (2008) identified that disgust may be elicited by incest and non-sexual immoral acts (e.g., theft and murder). This is consistent with cross cultural research findings that suggest a relationship between disgust and moral judgment (e.g., Haidt et al., 1997, Schnall et al., 2008). Research related to disgust and OCD has increased in recent years; yet this body of research is primarily related to contamination symptom presentations. Evidence supporting disgust related to immoral acts suggests that disgust may be implicated in the harm and unacceptable thoughts symptom dimensions as well. The appraisal of disgust experiences has yet to be examined in OCD, warranting an investigation.
Feelings of guilt have been related to greater symptom severity and poorer treatment prognosis in OCD (cf., Shapiro & Stewart, 2011). However, much of the research on guilt has primarily focused on the relationship between guilt feelings and beliefs about responsibility. Salkovskis and Forrester (2002) explain that over-responsibility is derived from the threat of physical or moral danger, a primary goal of preventing a negative outcome, and an inflated belief that one has the power to prevent the aversive outcome. Guilt is a natural response for an individual who feels wholly responsible for a negative outcome, particularly if they perceive their actions as morally unjust (Mancini & Gangemi, 2004). These findings blur the lines between feeling guilt and beliefs about responsibility and the fused relationship between these constructs may lend to a greater focus on the cognitive construct of responsibility over the emotional construct of guilt in both research and clinical practice. Examining threat from guilt in the various symptom presentations may help clarify when guilt is problematic in individuals with OCD, independent of feelings of responsibility.
In addition to these emotions, many individuals with OCD may have trouble clarifying their emotions, and naming their internal experiences (i.e., alexithymia), and these individuals may report experiencing “not just right” feelings (NJRFs). Alexithymia is a personality construct characterized by difficulties in understanding, processing, and describing emotions (Sifneos, 1973). Research findings have suggested an association between alexithymia and OCD severity (Bankier et al., 2001, Rufer et al., 2004, Rufer et al., 2006), and individuals with these difficulties may describe their experiences as “not just right,” when they are unable to articulate their specific experience. Additionally, OCD has been conceptualized as an inability to put closure to an experience (Reed, 1985), as exemplified by an individual who washes his hands until they “feel clean.” Similarly, many individuals with OCD describe needing to perform compulsions until they “feel right.” While research suggests that these feelings are distressing (Coles et al., 2005), it is not clear how these unnamed feelings compare to experiences of anxiety, disgust, and guilt. This forms the basis for examining threat from NJRFs in each of the OCD symptom dimensions.
Barlow (1991) suggested that anxiety disorders may be characterized as ailments of emotion processing. Recently, the role of emotion regulation has received attention in the research on anxiety and mood disorders (cf., Allen & Barlow, 2009). This research indicates that individuals with anxiety, including OCD, engage in maladaptive strategies (e.g., suppression) to regulate the frequency and experiences of emotions. There are differences in the ease with which individuals elicit, respond to, and recover from emotions, as well as individual differences in acceptance of emotions (i.e., judgment as appropriate, tolerable, or logical; Amstadter, 2008). Over-two decades of research on meta-emotion across disciplines suggests that there are individual differences in the way in which people evaluate their emotions. Mayer and Gaschke (1988) explain that emotion is experienced first directly and then reflectively. That is, the emotion is experienced, and one's reflection on the emotion causes a secondary experience of emotion. Bartsch, Vorderer, Mangold, and Viehoff (2008) suggest that meta-processes (e.g., appraisal) influence the way in which emotions are expressed and regulated. Ultimately, the way in which appraises their emotions may impact the use of maladaptive emotion regulation strategies in OCD. However, elucidating how emotions are appraised and whether emotion appraisal is related to symptom severity in OCD is a necessary first step.
Experiential avoidance, the avoidance of aversive private experiences including thoughts, feelings, and bodily sensations (Hayes, Wilson, Gifford, Follette, & Strosahl, 1996), has begun to receive attention in the OCD literature, and the relationship between overall experiential avoidance and OCD symptomology is inconclusive (e.g., Abramowitz et al., 2009, Briggs and Price, 2009, Manos et al., 2010). Some have suggested that an overall measure of experiential avoidance may be too broad to reflect symptoms in specific disorders (Manos et al.). Therefore, it may be more useful to investigate the appraisal of specific emotions rather than the appraisal of internal experiences in general. McCubbin and Sampson (2006) investigated the extent to which an individual feels that having a certain emotion (e.g., fear/anxiety) is dangerous (i.e., feeling threat from emotions). They posited that this trait characteristic is related to heightened awareness of danger, attempts to avoid emotions, and the use of maladaptive methods to cope with unpleasant emotions (e.g., performing compulsions). Their results found that threat from specific emotions significantly predicted obsessionality in a non-clinical sample, but this construct has yet to be examined in clinical populations. The present study examined individuals' appraisal of anxiety, disgust, guilt, and NJRFs, as well as the frequency with which these emotions are experienced in a clinical sample.
The current study contributes to the line of research investigating OCD symptom dimensions by exploring obsessional beliefs and emotion appraisal in four OCD symptom dimensions: contamination, harm, unacceptable thoughts, and symmetry. Based on previous findings (Julien et al., 2007, Wheaton et al., 2010), we predicted that each subtype would be partially predicted by at least one obsessional belief; (1) the contamination subtype would be associated with beliefs about responsibility/overestimation of threat and perceptions of threat from anxiety, disgust, and guilt; (2) the harm subtype would also be most closely associated with beliefs about responsibility/overestimation of threat and threat from anxiety and guilt; (3) the unacceptable thoughts subtype would be associated with beliefs about importance and need to control thoughts and threat from anxiety, disgust, and guilt; and (4) the symmetry subtype would be associated with beliefs about perfectionism/intolerance of uncertainty and threat from NJRFs. However, as this is the first study to examine threat from emotion, the investigation is somewhat exploratory, and perceived threat from each emotion was examined in relation to each of the symptom dimensions.
Section snippets
Data collection
A multi-site recruitment strategy was implemented in order to obtain a wide representation of symptom severity. Participants were recruited from residential and intensive outpatient programs in Texas and Maryland and from outpatient treatment providers in Texas, Kansas, and Wisconsin. Participants included 44 adults receiving residential (RES; n=20), intensive outpatient (IOP; n=10) or outpatient treatment (OP; n=14) for OCD. Diagnoses of OCD were determined by treating clinicians, all of whom
Overall symptom severity
Symptom severity data are presented in Table 1. Overall, the sample reported a moderate level of severity. Y-BOCS-SR scores ranged from 10 (mild) to 38 (extreme), with an average severity score of 21.18 (SD=6.95). Mean severity scores for each of the three groups were as follows: RES=24.15 (sd=6.52), IOP=21.50 (sd=8.34), and OP=16.71 (sd=3.75). Each group in the current sample had an average severity score of 16 or higher, indicating clinical levels of severity for each group. An analysis of
Discussion
OCD is a heterogeneous disorder with varied symptom presentation, and the differences in OCD have received increased attention in recent years. The current study contributed to the line of research on OCD symptom presentation by examining obsessional beliefs and emotion appraisal as they related to distress from four OCD symptom dimensions: contamination, harm, unacceptable thoughts, and symmetry. Results indicated that symptoms in each of the four symptom dimensions were predicted by a
Role of funding sources
The study was not funded by an external grant. The authors are solely responsible for the study design, collection, analysis and interpretation of the data, writing the manuscript, and the decision to submit the paper for publication.
Contributors
Authors Smith, Wetterneck, and Hart designed the study. Author Smith conducted the literature searches, provided summaries of previous research, and collected the data. Data collection was conducted primarily at the Houston OCD Program, an institution headed by Author Bjorgvinsson. Authors Smith and Wetterneck conducted the statistical analysis. Author Smith wrote the first draft of the manuscript and all authors contributed to and have approved the final manuscript.
Conflict of interest
All authors declare that they have no conflicts of interest.
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