'Things that shouldn't be': a qualitative investigation of violation-related appraisals in individuals with OCD and/or trauma histories.

BACKGROUND: Cognitive models of mental contamination (i.e. feelings of internal dirtiness without contact with a contaminant) propose that these feelings arise when individuals misappraise a violation. However, an operational definition of 'violation' and identification of specific violation misappraisals is limited. AIMS: This study's aim was to elaborate on cognitive models using qualitative data from those with lived experience to fill these gaps. METHOD: Twenty participants with a diagnosis of obsessive-compulsive disorder and/or a trauma history took part in a semi-structured interview about violation. Grounded theory was used to analyse interview transcripts. DISCUSSION: Three categories emerged, each with several themes - qualities of violation, violation-related appraisals, and violation-related behaviours. Different violation-related appraisals were associated with different emotions and urges. Specific self-focused appraisal sub-themes (i.e. permanence of consequences; self-worth; responsibility, self-blame and regret) were most closely related to emotions tied to mental contamination. These findings support and expand upon existing cognitive models of mental contamination, identifying key violation-related appraisals and differentiating between mental contamination-related appraisals and those related to other emotional sequelae. Future quantitative and experimental research can evaluate the potential of these appraisals as intervention targets.

What's control got to do with it? A systematic review of control beliefs in obsessive-compulsive disorder.

Current conceptualizations of control-related beliefs in Obsessive-Compulsive Disorder (OCD) have largely been limited to beliefs about the need to control thoughts. Although growing evidence supports the notion of considering broader control-related constructs in this disorder, there has been limited research aimed at integrating findings across studies, making it difficult to determine how different control-related beliefs may influence OCD symptoms. The current review sought to systematically analyze findings from all studies investigating the relationship between control beliefs and OCD. The systematic search identified 157 eligible articles that assessed the relationship between control beliefs and OCD symptoms. Results suggested that certain control beliefs (e.g., importance of/need to control of thoughts, sense of control, beliefs about losing control) may be more closely associated with OCD than others (e.g., locus of control, and desire for control). In general, control beliefs were positively associated with OCD, with effect sizes ranging from small to large depending on the symptom domain. Based on limited studies, the only control belief which demonstrated specificity to OCD was ICT. Findings support the importance of integrating additional control beliefs in conceptualizations of OCD and provide evidence to support the benefits of targeting these beliefs in cognitive behavioural therapy.

At the mercy of myself: A thematic analysis of beliefs about losing control.

PURPOSE: Concerns about the likelihood, consequences, and meaning of losing control are commonplace across anxiety-related disorders. However, several experimental studies have suggested that individuals without a diagnosis of a mental disorder also believe that they can and will lose control under the right circumstances. Understanding the range of beliefs about the nature and consequences of losing control can help us to better understand the continuum of negative beliefs about losing control. METHODS: The present study used thematic analysis to identify common beliefs about losing control in an unselected sample. Twenty-one participants, half of whom met criteria for at least one anxiety-related disorder, were interviewed about their beliefs about losing control. RESULTS: All 21 participants reported that losing control was possible. Losses of control were defined as multifaceted cognitive-behavioural processes and were seen as negative considering the perceived consequences of the losses. Commonly described consequences were harm to oneself or others, powerlessness, and unpleasant emotions during (e.g., sadness, frustration, and anxiety) and following (e.g., regret, shame, and humiliation) a loss of control. CONCLUSIONS: These results suggest that perceived losses of control are common and that negative beliefs about losing may only become problematic when the losses are personally significant. Further, they offer important insight into what is common among clinical and non-clinical beliefs about losing control and inform how these beliefs might be worth targeting in cognitive and behavioural interventions.

Can immorality be contracted? Appraisals of moral disgust and contamination fear.

While extant research underlines the role of disgust in obsessive-compulsive disorder (OCD) with contamination fear, less research attention has been devoted to moral disgust. This study endeavored to examine the types of appraisals that are elicited by moral disgust in comparison to core disgust, and to examine their associations with both contact and mental contamination symptoms. In a within-participants design, 148 undergraduate students were exposed to core disgust, moral disgust, and anxiety control elicitors via vignettes, and provided appraisal ratings of sympathetic magic, thought-action fusion and mental contamination, as well as compulsive urges. Measures of both contact and mental contamination symptoms were administered. Mixed modeling analyses indicated that core disgust and moral disgust elicitors both provoked greater appraisals of sympathetic magic and compulsive urges than anxiety control elicitors. Further, moral disgust elicitors elicited greater thought-action fusion and mental contamination appraisals than all other elicitors. Overall, these effects were greater in those with higher contamination fear. This study demonstrates how a range of contagion beliefs are evoked by the presence of 'moral contaminants', and that such beliefs are positively associated with contamination concerns. These results shed light on moral disgust as an important target in the treatment of contamination fear.

An Experimental Investigation of Moral Self-Violation and Mental Contamination.

Purpose: Cognitive models of mental contamination (feelings of dirtiness/washing behaviour that arise without direct contact with a contaminant) highlight the central role of perceptions of violation in the onset and maintenance of these feelings. Little research has been done to clarify violation-specific appraisals relevant to mental contamination. Perceptions of violation of one's moral self-concept may represent one such appraisal domain. This experiment aimed to examine the impact of these appraisals on feelings of mental contamination. Methods: One hundred and fifty participants received false feedback that they scored high on a morality subscale of a bogus personality test. They then completed a writing task wherein their degree of moral self-violation was manipulated. They received a writing prompt corresponding to one of three randomly assigned conditions (violated self (VS), bolstered self (BS), general negative (GN)). Finally, participants completed measures of mental contamination. Results: The manipulation was effective at violating participants' moral self-concept. Those in the VS condition reported significantly higher levels of feelings of mental contamination than those in the BS or GN conditions. There were no significant differences between conditions regarding urges to wash. Conclusions: Findings highlight the relevance of moral self-violation in the understanding and treatment of mental contamination.

The fear of losing control.

Although a great deal of research has focused on various aspects of control and their relations to psychopathology, new insights and therapeutic potential could be revealed through an examination and perhaps emphasis on fears of losing control. Although elements of control-related beliefs and phenomena have been highlighted in association with obsessive-compulsive disorder and social anxiety disorder, this paper will give a fresh perspective on fears and beliefs about losing control, with implications for understanding and perhaps treating a broad range of psychological problems including panic disorder, posttraumatic stress disorder (PTSD), and others. New research questions and hypotheses are proposed, along with potential implications for expanded research into this domain and for clinical applications within a cognitive-behavioural approach.

Always Saying the Wrong Thing: Negative Beliefs About Losing Control Cause Symptoms of Social Anxiety.

Background: Individuals with social anxiety disorder (SAD) often report a fear that they will lose control of their emotions or report intense, unpleasant thoughts or images of uncontrollably humiliating themselves in social situations. These fears and associated beliefs that one is likely to lose control may underlie the anxiety and/or cognitive biases (e.g., self-focused attention and negative post-event processing) experienced during and following social situations. The present experiment examined whether manipulating beliefs about losing control would cause changes in symptoms of SAD. Methods: One hundred and twenty-six undergraduate psychology students were given false feedback that they were either at high or low risk of losing control, and then completed a social interaction task with an actor. Participants rated their anxiety before and during the interaction and completed a post-event processing questionnaire 24-hours later. Results: Participants in the high beliefs about losing control (HLC) condition reported significantly greater subjective anxiety than those in the low beliefs about losing control (LLC) condition leading up to the social interaction task, and significantly more negative post-event processing. Conclusion: Results suggest beliefs about losing control may play a causal role in the development and maintenance of SAD. These beliefs may represent a novel domain to be targeted in CBT. Supplementary Information: The online version contains supplementary material available at 10.1007/s10608-022-10325-w.

Responsibility, probability, and severity of harm: An experimental investigation of cognitive factors associated with checking-related OCD.

The cognitive model of compulsive checking (Rachman, 2002) proposes that perceptions of responsibility, seriousness of harm and probability of harm interact to promote checking behaviour. We examined these factors in an ecologically valid experimental paradigm. Two groups of participants (participants with OCD who compulsively check and undergraduate controls) were assigned to a high or low responsibility condition, and then checked objects representing: (a) high seriousness of harm (stove burners), (b) low seriousness of harm (light bulbs), (c) high probability of harm (functional burners and bulbs), and (d) low probability of harm (non-functional burners and bulbs). In general, a diagnosis of OCD, as well as conditions of increased severity/likelihood of harm, and to a lesser degree, increased responsibility, led to a greater period of time spent checking. Implications for the cognitive-behavioural model of and treatment for compulsive checking are discussed.

Knowledge and competency standards for specialized cognitive behavior therapy for adult obsessive-compulsive disorder.

Obsessive-Compulsive Disorder (OCD) is a leading cause of disability world-wide (World Health Organization, 2008). Treatment of OCD is a specialized field whose aim is recovery from illness for as many patients as possible. The evidence-based psychotherapeutic treatment for OCD is specialized cognitive behavior therapy (CBT, NICE, 2005, Koran and Simpson, 2013). However, these treatments are not accessible to many sufferers around the world. Currently available guidelines for care are deemed to be essential but insufficient because of highly variable clinician knowledge and competencies specific to OCD. The phase two mandate of the 14 nation International OCD Accreditation Task Force (ATF) created by the Canadian Institute for Obsessive Compulsive Disorders is development of knowledge and competency standards for specialized treatments for OCD through the lifespan deemed by experts to be foundational to transformative change in this field. This paper presents knowledge and competency standards for specialized CBT for adult OCD developed to inform, advance, and offer a model for clinical practice and training for OCD. During upcoming ATF phases three and four criteria and processes for training in specialized treatments for OCD through the lifespan for certification (individuals) and accreditation (sites) will be developed based on the ATF standards.

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.

"Was I asking for it?": An experimental investigation of perceived responsibility, mental contamination and workplace sexual harassment.

BACKGROUND AND OBJECTIVES: Mental contamination (i.e., contamination concerns that arise in the absence of direct contact with a contaminant) is a common symptom in obsessive-compulsive disorder (OCD). Cognitive theories suggest that it results from individuals' misinterpretations of perceived violations. Cognitive theories of OCD also highlight the importance of appraisals of inflated responsibility in the maintenance of other OCD symptoms. However, the role of responsibility in mental contamination has not yet been examined experimentally. The present study examined the role of perceived responsibility and violation in the relationship between workplace sexual harassment imagery and subsequent mental contamination. METHODS: One hundred and forty-nine participants listened to a workplace sexual harassment imagery task, wherein responsibility was manipulated. Participants were randomly assigned to one of three conditions (high responsibility (HR), low responsibility (LR), no responsibility (NR)). Participants completed questionnaires assessing mental contamination and completed a hand washing task. RESULTS: Those in the NR condition reported significantly lower levels of responsibility than those in the LR or HR conditions. Accordingly, those in the NR condition also reported significantly lower levels of anxiety and dirtiness than in the LR condition. There were no significant differences between the LR and HR condition on variables of interest. LIMITATIONS: The nature of the victim blaming used for the responsibility induction may have elicited compensatory responses from participants. CONCLUSIONS: Findings may highlight the central role of perceptions of violation in the understanding and treatment of mental contamination.

The Covert and Overt Reassurance Seeking Inventory (CORSI): Development, validation and psychometric analyses.

BACKGROUND: Reassurance seeking (RS) is motivated by perceived general and social/relational threats across disorders, yet is often under-recognized because it occurs in covert (i.e. subtle) and overt forms. Covert safety-seeking behaviour may maintain disorders by preventing corrective learning and is therefore important to identify effectively. AIMS: This study presents the validation and psychometric analyses of a novel measure of covert and overt, general and social/relational threat-related interpersonal RS. METHOD: An initial 30-item measure was administered to an undergraduate sample (N = 1626), as well as to samples of individuals diagnosed with obsessive compulsive disorder (OCD; n = 50), anxiety disorders (n = 60) and depression (n = 30). The data were subjected to exploratory and confirmatory factor analyses, and validation analyses. RESULTS: An exploratory factor analysis using principal axis factoring with oblique rotation yielded five interpretable factors, after removing four complex items. The resulting 26-item measure, the Covert and Overt Reassurance Seeking Inventory (CORSI), evidenced good convergent and divergent validity and accounted for 54.99% of the total variance after extraction. Factor correlations ranged from r = .268 to .736, suggesting that they may be tapping into unique facets of RS behaviour. In comparison with undergraduate participants, all clinical groups had significantly higher total scores [t (51.80-840) = 3.92-5.84, p < .001]. The CFA confirmed the five-factor model with good fit following the addition of four covariance terms (goodness of fit index = .897, comparative fit index = .918, Tucker-Lewis index = .907, root mean square error approximation = .061). CONCLUSION: The CORSI is a brief, yet comprehensive and psychometrically strong measure of problematic RS. With further validation, the CORSI has potential for use within clinical and research contexts.

Cognitive therapy for compulsive checking in obsessive-compulsive disorder: A pilot trial.

We evaluated a novel, empirically-based cognitive therapy for compulsive checking - a common form of obsessive-compulsive disorder. Twelve adults completed 12 sessions of the therapy. Significant reductions in checking-related symptoms were found pre- to post-treatment, and pre-treatment to 6-month follow-up (moderate to large effect sizes). Participants reported high treatment acceptability after the third session, which was maintained at post-treatment. This pilot trial provides preliminary support for treating compulsive checking using this novel cognitive approach.

Beliefs about losing control, obsessions, and caution: An experimental investigation.

Fear of acting on unwanted impulses (e.g., stabbing a loved one) and avoidance of threatening stimuli (e.g., knives) are common phenomena in obsessive-compulsive disorder (OCD). Cognitive models of OCD suggest that maladaptive beliefs underlie the development and maintenance of symptoms. The goal of this experiment was to determine whether beliefs about losing control over one's behaviour lead to experiencing anxiety and intrusive thoughts while approaching stimuli that are commonly feared in OCD, and to behaving more cautiously while interacting with the stimuli. Undergraduate participants (N = 128) were provided with false feedback about the meaning of their intrusive thoughts: "having intrusive thoughts means that you are likely to lose control over your behaviour" versus "intrusive thoughts are normal". Participants were then asked to approach sharp knives in a stepwise manner (i.e., behavioural approach test; BAT). Afterwards, they sorted the stimuli in a knife block as quickly as possible. Participants with higher (versus lower) beliefs about losing control experienced significantly increasing anxiety throughout the BAT. They also remembered experiencing more intrusive thoughts throughout the protocol and perceived themselves as less cautious while sorting the knives. Interestingly, objective measures of intrusive thoughts and caution were not significantly different between conditions.

What do you really need? Self- and partner-reported intervention preferences within cognitive behavioural therapy for reassurance seeking behaviour.

BACKGROUND: Reassurance seeking (RS) in obsessive compulsive disorder (OCD) is commonly addressed in cognitive behavioural therapy (CBT) using a technique called reducing accommodation. Reducing accommodation is a behaviourally based CBT intervention that may be effective; however, there is a lack of controlled research on its use and acceptability to clients/patients, and case studies suggest that it can be associated with negative emotional/behavioural consequences. Providing support to encourage coping with distress is a cognitively based CBT intervention that may be an effective alternative, but lacks evidence regarding its acceptability. AIMS: This study aimed to determine whether support provision may be a more acceptable/endorsed CBT intervention for RS than a strict reducing accommodation approach. METHOD: Participants and familiar partners (N = 179) read vignette descriptions of accommodation reduction and support interventions, and responded to measures of perceived intervention acceptability/adhereability and endorsement, before completing a forced-choice preference task. RESULTS: Overall, findings suggested that participants and partners gave significantly higher ratings for the support than the accommodation reduction intervention (partial η2 = .049 to .321). Participants and partners also both selected the support intervention more often than the traditional reducing accommodation intervention when given the choice. CONCLUSIONS: Support provision is perceived as an acceptable CBT intervention for RS by participants and their familiar partners. These results have implications for cognitive behavioural theory and practice related to RS.

The development and validation of the Beliefs About Losing Control Inventory (BALCI).

Cognitive theory of obsessive-compulsive disorder (OCD) proposes that maladaptive beliefs play a pivotal role in the development and maintenance of symptoms. Clinical reports as well as recent psychometric and experimental investigations suggest that control-related beliefs in OCD may benefit from expansion to include aspects of losing control. However, currently available measures either focus on other facets of control (e.g., sense of control) or do not put emphasis on beliefs about losing control (e.g., beliefs about control over thoughts). The current study aimed to develop and validate the Beliefs About Losing Control Inventory (BALCI), a self-report measure of negative beliefs about losing control, in a sample of undergraduate participants (N= 488). An exploratory factor analysis revealed that the BALCI's 21 items capture negative beliefs about losing control over one's thoughts, behaviour, and emotions (Factor 1), beliefs about the importance of staying in control (Factor 2), and beliefs about losing control over one's body/bodily functions (Factor 3). The BALCI was also found to have good convergent and divergent validity and to be associated with elevated OCD symptoms above and beyond previously identified obsessive beliefs. Theoretical implications and recommendations for the field of cognitive-behaviour therapy are discussed.

When it's at: An examination of when cognitive change occurs during cognitive therapy for compulsive checking in obsessive-compulsive disorder.

BACKGROUND AND OBJECTIVES: The cognitive theory of compulsive checking in OCD proposes that checking behaviour is maintained by maladaptive beliefs, including those related to inflated responsibility and those related to reduced memory confidence. This study examined whether and when specific interventions (as part of a new cognitive therapy for compulsive checking) addressing these cognitive targets changed feelings of responsibility and memory confidence. METHODS: Participants were nine adults with a primary or secondary diagnosis of OCD who reported significant checking symptoms (at least one hour per day) on the Yale-Brown Obsessive-Compulsive Scale. A single-case multiple baseline design was used, after which participants received 12 sessions of cognitive therapy. From the start of the baseline period through to the 1 month post-treatment follow-up assessment session, participants completed daily monitoring of feelings of responsibility, memory confidence, and their time spent engaging in compulsive checking. RESULTS: Results revealed that feelings of responsibility significantly reduced and memory confidence significantly increased from baseline to immediately post-treatment, with very high effect sizes. Multilevel modelling revealed significant linear changes in feelings of responsibility (i.e., reductions over time) and memory confidence (i.e., increases over time) occurred following the sessions when these were addressed. Finally, we found that improvements in these over the course of the treatment significantly predicted reduced time spent checking. LIMITATIONS: The small sample size limits our ability to generalize our results. CONCLUSIONS: Results are discussed in terms of a focus on the timing of change in cognitive therapy.

Different Disgust Domains Specifically Relate to Mental and Contact Contamination Fear in Obsessive-Compulsive Disorder: Evidence From a Path Analytic Model in an Italian Clinical Sample.

Both contact contamination (CC) and mental contamination (MC) fears-which combined represent the most common manifestation of obsessive-compulsive disorder (OCD)-have been widely associated with disgust propensity. However, extant research explored this relationship using measures assessing only pathogen-related disgust, not taking into account the potential role played by sexual and moral disgust, despite literature about MC suggesting that this might be particularly relevant. In Study 1, the psychometric properties of the Italian version of the Three Domains of Disgust Scale (TDDS) were assessed in a large Italian community sample. Exploratory and confirmatory factor analyses confirmed the three-factor structure of the TDDS. The scale also showed good internal consistency and construct validity. In Study 2, the differential patterns of relationships between CC and MC and the three disgust domains were explored in an Italian clinical OCD sample using a path analytic approach. The TDDS-Pathogen subscale was a unique predictor of CC while the TDDS-Sexual subscale was a unique predictor of MC, after controlling for anxiety and depression. Surprisingly, the TDDS-Moral subscale was not a predictor of either domain of contamination fear. Limitations and clinical implications are discussed.

Hoping for more: How cognitive science has and hasn't been helpful to the OCD clinician.

Cognitive-behavioural models of obsessive-compulsive disorder (OCD) stemmed from knowledge acquired from cognitive science. Researchers continue to apply basic cognitive-affective science methods to understanding OCD, with the overarching goal of improving and refining evidence-based treatments. However, the degree to which such research has contributed to this goal is unclear. We reviewed OCD research in the general areas that comprise basic cognitive science, and evaluated the degree to which it has contributed to our understanding of the development, maintenance, and treatment of OCD. We focused on studies that either compared people with and without OCD and/or used experimental psychopathology methods with human participants, and attempted to resolve some of the conflicting theories related to the importance of cognitive deficits vs. cognitive biases. Overall, we observed equivocal findings for deficits in perception, attention, memory, and executive functioning. Moreover, many so-called deficits were moderated and/or explained by OCD-relevant beliefs, highlighting the role of confidence in cognitive processes as integral to our understanding of OCD. We discussed these findings in terms of cognitive measurement, cognitive-behavioural models, and clinical applicability, and made recommendations for future research that may offer innovation and insight helpful to clinicians working to improve the symptoms and lives of people with OCD.