A latent profile analysis of age of onset in trichotillomania.

BACKGROUND: Trichotillomania (TTM) onset may occur across the lifespan; however, adolescent onset is most frequently reported. Several studies have explored clinical differences between TTM age-of-onset groups with mixed results. We investigated empirically defined age-of-onset groups in adults with TTM, and clinical differences between groups. METHODS: Participants included 1,604 adult respondents to an internet survey who endorsed DSM-IV-TR TTM criteria. Latent profile analysis was performed to identify TTM age-of-onset subgroups, which were then compared on demographic and clinical features. RESULTS: The most optimal model was a 2-class solution comprised of a large group with average TTM onset during adolescence (n = 1,539; 95.9% of the sample; mean age of onset = 12.4) and a small group with average onset in middle adulthood (n = 65; 4.1% of the sample; mean age of onset = 35.6). The late-onset group differed from the early-onset group on several clinical variables (eg, less likely to report co-occurring bodyfocused repetitive behaviors). CONCLUSIONS: Findings suggest the presence of at least 2 distinct TTM age-of-onset subgroups: an early-onset group with onset during adolescence, and a late-onset group with onset in middle adulthood. Future research is needed to further validate these subgroups and explore their clinical utility.

Characteristics of outpatients diagnosed with the selective/neophobic presentation of avoidant/restrictive food intake disorder.

OBJECTIVE: Although Avoidant/Restrictive Food Intake Disorder (ARFID) has existed since the publication of DSM-5 in 2013, research on the descriptive psychopathology of treatment-seeking patients with formal ARFID diagnoses is sparse, and limited to tertiary eating disorder-focused treatment settings where most patients present with weight loss/malnutrition. In these settings, the selective/neophobic symptom presentation is rare compared to other primary eating restrictions. We aimed provide initial descriptive psychopathology of ARFID primary selective/neophobic symptom presentation in an outpatient setting, and to explore the prevalence of the core ARFID symptoms and clinical differences among patients meeting criteria based on weight/nutritional symptoms versus psychosocial impairment only. METHOD: We reviewed the charts of 22 consecutive outpatients diagnosed with ARFID caused by selective/neophobic eating, and describe symptoms, impairment, illness trajectory, and demographic features. Patients who met ARFID criteria because of weight loss/nutritional problems were compared to those who met for psychosocial impairment only on demographic and clinical characteristics. RESULTS: Patients were predominantly male (81.8%) and school-aged (4-11 years). 81.8% had no weight/nutritional symptoms documented by a medical provider. All met criteria for significant psychosocial impairment. There were few differences between patients who did versus did not meet weight loss/nutritional criteria for ARFID; they differed only in age and in the presence of appetite disturbances consistent with another proposed presentation of ARFID. DISCUSSION: These results provide novel data on the clinical characteristics of individuals who present with a primary presentation of selective/neophobic ARFID, including support for psychosocial impairment as sufficient for fulfilling ARFID criterion A.

A latent profile analysis of age of onset in pathological skin picking.

BACKGROUND: Pathological Skin Picking (PSP) may begin at any age, but the most common age of onset is during adolescence. Age of onset is a potentially useful clinical marker to delineate subtypes of psychiatric disorders. The present study sought to examine empirically defined age of onset groups in adults with PSP and assess whether groups differed on clinical characteristics. METHOD: Participants were 701 adult respondents to an internet survey, who endorsed recurrent skin picking with tissue damage and impairment. Latent profile analysis (LPA) was conducted to identify subtypes of PSP based on age of onset. Then subgroups were compared on demographic and clinical characteristics. RESULTS: The best fitting LPA model was a two-class solution comprised of a large group with average age of onset in adolescence (n = 650; 92.9% of the sample; Mean age of onset = 13.6 years) and a small group with average onset in middle adulthood (n = 50; 7.1% of the sample; Mean age of onset = 42.8 years). Relative to the early onset group, the late onset group reported significantly less focused picking, less skin picking-related impairment, lower rates of co-occurring body-focused repetitive behaviors, and trends towards reduced family history of PSP. Individuals in the late onset group also reported increased rates of comorbid depression, anxiety and posttraumatic stress disorder, and were more likely to report that initial picking onset seemed related to or followed depression/anxiety and physical illness. CONCLUSION: Findings suggest the presence of two distinct PSP age of onset groups: (1) an early onset group with average onset in adolescence, clinical characteristics suggestive of greater picking-related burden and familiality, and a profile more representative of the general PSP population; and (2) a late onset group with average onset in middle adulthood, increased co-occurring affective and trauma conditions, and initial onset associated with or following other mental health and physical problems. Future replication is needed to assess the validity and clinical utility of these subgroups.

Hoarding in Children and Adolescents: A Review.

The diagnostic conceptualization of hoarding has recently changed, and yet the application of these changes to hoarding in youth remains to be clarified. In this review we examine the literature on hoarding in youth. We discuss issues related to the assessment of pediatric hoarding, and the nature of hoarding in youth. We consider evidence for hoarding disorder as a distinct diagnosis in youth, and review the relationship between pediatric hoarding and other psychiatric disorders. Finally, we describe preliminary models of treatment for pediatric hoarding. We conclude that there is support for hoarding disorder as a distinct diagnosis in youth. However, more precise and developmentally appropriate assessment tools are needed to provide stronger evidence for this claim and to further our knowledge of prevalence and associated clinical characteristics. Although there is no evidence-based treatment for pediatric hoarding, preliminary evidence from case studies suggests that cognitive and behavioral methods may have promise.

Dental Fear and Avoidance in Treatment Seekers at a Large, Urban Dental Clinic.

PURPOSE: The prevalence and correlates of dental fear have been studied in representative population studies, but not in patients presenting for dental treatment. We hypothesized that dental fear among patients presenting at a large, urban college of dentistry would be similar to that of the population (e.g. 11% high dental fear, 17% to 35% moderate or higher fear) and that fear would be associated with avoidance of routine dental care, increased use of urgent dental care and poor oral health. MATERIALS AND METHODS: Participants were 1070 consecutive patients at a large, urban dental care center. All patients completed a clinical interview, including demographics, medical history, dental history and presenting concerns, and behavioral health history. Patients were also asked to rate their dental anxiety/fear on a 1 (none) to 10 (high) scale. RESULTS: Over 20% of patients reported elevated anxiety/fear, of which 12.30% reported moderate and 8.75% high fear. Severity of dental anxiety/fear was strongly related to the likelihood of avoiding dental services in the past and related to myriad presenting problems. CONCLUSIONS: As hypothesized, the prevalence of moderate or higher fear in dental patients was considerable and closely matched that found in general population surveys. Thus, the 'dental home' is an ideal location to treat clinically significant dental anxiety/fear.

Residential treatment outcomes for adolescents with obsessive-compulsive disorder.

OBJECTIVE: We examined outcomes from a residential treatment program emphasizing exposure and response prevention (ERP) to determine if the typically robust response to this treatment in outpatient settings extends to patients treated in this unique context. METHOD: One hundred and seventy-two adolescents with primary Obsessive-compulsive disorder (OCD) completed measures at admission and discharge. Almost all (92.4%) participants had at least two diagnoses and nearly half (44.2%) had three or more. Treatment consisted of intensive ERP (i.e., approximately 26.5 hr per week), additional cognitive behavioral therapy interventions, and medication management within a residential setting. In contrast to the samples reported on in the vast majority of other pediatric OCD trials, participants in the current study were living apart from their families and were immersed within the treatment setting, with staff members available at all times. RESULTS: Paired sample t-tests revealed significant decreases in OCD and depression severity. CONCLUSIONS: Results suggest that residential treatment for adolescents with OCD using a multimodal approach emphasizing ERP can be effective for complex cases with significant comorbidity. Results were comparable with several randomized controlled trials.

Examining DSM criteria for trichotillomania in a dimensional framework: implications for DSM-5 and diagnostic practice.

BACKGROUND: Diagnosis of trichotillomania (TTM) requires meeting several criteria that aim to embody the core pathology of the disorder. These criteria are traditionally interpreted monothetically, in that they are all equally necessary for diagnosis. Alternatively, a dimensional conceptualization of psychopathology allows for examination of the relatedness of each criterion to the TTM latent continuum. OBJECTIVES: First, to examine the ability of recently removed criteria (B and C) to identify the latent dimensions of TTM psychopathology, such that they discriminate between individuals with low and high degrees of hair pulling severity. Second, to determine the impact of removing criteria B and C on the information content of remaining diagnostic criteria. Third, to determine the psychometric properties of remaining TTM diagnostic criteria that remain largely unchanged in DSM-5; that is, whether they measure distinct or overlapping levels of TTM psychopathology. Fourth, to determine whether information content derived from diagnostic criteria aid in the prediction of disease trajectory (i.e., can relapse propensity be predicted from criteria endorsement patterns). METHOD: Statistics derived from item response theory were used to examine diagnostic criteria endorsement in 91 adults with TTM who underwent psychotherapy. RESULTS: The removal of two criteria in DSM-5 and psychometric validity of remaining criteria was supported. Additionally, individual trait parameters were used to predict treatment progress, uncovering predictive power where none previously existed. CONCLUSIONS: Diagnostic criteria for TTM should be examined in dimensional models, which allow for nuanced and sensitive measurement of core symptomology in treatment contexts.

Internet-delivered, family-based treatment for early-onset OCD: a preliminary case series.

Given the burdens of early-onset obsessive-compulsive disorder (OCD), limitations in the broad availability and accessibility of evidence-based care for affected youth present serious public health concerns. The growing potential for technological innovations to transform care for the most traditionally remote and underserved families holds enormous promise. This article presents the rationale, key considerations, and a preliminary case series for a promising behavioral telehealth innovation in the evidence-based treatment of early-onset OCD. We developed an Internet-based format for the delivery of family-based treatment for early-onset OCD directly to families in their homes, regardless of their geographic proximity to a mental health facility. Videoteleconferencing (VTC) methods were used to deliver real-time cognitive-behavioral therapy centering on exposure and response prevention to affected families. Participants in the preliminary case series included 5 children between the ages of 4 and 8 (M Age = 6.5) who received the Internet-delivered treatment format. All youth completed a full treatment course, all showed OCD symptom improvements and global severity improvements from pre- to posttreatment, all showed at least partial diagnostic response, and 60% no longer met diagnostic criteria for OCD at posttreatment. No participants got worse, and all mothers characterized the quality of services received as "excellent." The present work adds to a growing literature supporting the potential of VTC and related computer technology for meaningfully expanding the reach of supported treatments for OCD and lays the foundation for subsequent controlled evaluations to evaluate matters of efficacy and engagement relative to standard in-office evidence-based care.

"Not Just Right Experiences" in adolescents: phenomenology and associated characteristics.

Efforts to understand the nature of "Not Just Right Experiences" (NJREs) have expanded the scientific understanding of obsessive-compulsive (OC) behavior. Approximately 80% of unselected adults report experiencing NJREs and these experiences have been found to highly correlate with OC behavior. The purpose of this study was to assess NJREs in an unselected sample of adolescents (ages 14-17; N = 152), to compare their experience with adults (N = 237), and to assess the relation between NJREs and OC symptoms. Findings from questionnaires completed on the Internet were consistent with previous findings in adults, 81% of adolescents endorsed recently having an NJRE. Some reactions differed according to age: adults reported NJREs as more frequent and adolescents endorsed feeling more compelled to respond. Surprisingly, OC symptoms were not significantly related to NJREs in the adolescents. Implications, limitations, and future directions for the study of NJREs in youth are discussed.

The trichotillomania impact project in young children (TIP-YC): clinical characteristics, comorbidity, functional impairment and treatment utilization.

The aim was to investigate clinical characteristics of young children with a hair pulling problem. Parents/caregivers of young children (0-10 years old) with a hair pulling problem (N = 110) completed an online survey. The majority reported that their child experienced mild to moderate impairment/distress due to hair pulling, and overall clinical characteristics were similar to adult samples, although some differences were noted (e.g., less awareness of pulling). We also compared preschool-aged and school-aged children within the sample. Symptom severity, pleasure during pulling and gender ratio remained stable across the age groups. The preschool-aged children demonstrated less impairment/distress, comorbidity, and treatment seeking; pulled from fewer body areas; and were less likely to be aware of the act or experience tension prior to pulling. In conclusion, clinical characteristics of childhood hair pulling are largely similar to adult/adolescent hair pulling problems, but there are some notable differences, particularly among pre-school aged children.

Neurocognitive functioning in adults with trichotillomania: Predictors of treatment response and symptom severity in a randomized control trial.

Trichotillomania (TTM) is associated with impairments in response inhibition and cognitive flexibility, but it is unclear how such impairments relate to treatment outcome. The present study examined pre-treatment response inhibition and cognitive flexibility as predictors of treatment outcome, change in these domains from pre-to post-treatment, and associations with TTM severity. Participants were drawn from a randomized controlled trial comparing acceptance-enhanced behavior therapy (AEBT) to psychoeducation and supportive therapy (PST) for TTM. Adults completed assessments at pre-treatment (n = 88) and following 12 weeks of treatment (n = 68). Response inhibition and cognitive flexibility were assessed using the Stop Signal Task and Object Alternation Task, respectively. Participants completed the MGH-Hairpulling Scale. Independent evaluators administered the NIMH-Trichotillomania Severity Scale and Clinical Global Impressions-Improvement Scale. Higher pre-treatment TTM severity was associated with poorer pre-treatment cognitive flexibility, but not response inhibition. Better pre-treatment response inhibition performance predicted positive treatment response and lower post-treatment TTM symptom severity, irrespective of treatment assignment. Cognitive flexibility did not predict treatment response. After controlling for age, neither neurocognitive variable changed during treatment. Response inhibition and cognitive flexibility appear uniquely related to hair pulling severity and treatment response in adults with TTM. Implications for treatment delivery and development are discussed.

Long-term follow-up of acceptance-enhanced behavior therapy for trichotillomania.

Acceptance-enhanced behavior therapy for trichotillomania (AEBT-TTM) is effective in reducing trichotillomania (TTM) symptoms, but the durability of treatment effects remains in question. This study analyzed 6-month follow-up data from a large randomized clinical trial comparing AEBT-TTM to an active psychoeducation and supportive therapy control (PST). Adults with TTM (N=85; 92% women) received 10 sessions of AEBT-TTM or PST across 12 weeks. Independent evaluators assessed participants at baseline, post-treatment, and 6 months follow-up. For both AEBT-TTM and PST, self-reported and evaluator-rated TTM symptom severity decreased from baseline to follow-up. TTM symptoms did not worsen from post-treatment to follow-up. At follow-up, AEBT-TTM and PST did not differ in rates of treatment response, TTM diagnosis, or symptom severity. High baseline TTM symptom severity was a stronger predictor of high follow-up severity for PST than for AEBT-TTM, suggesting AEBT-TTM may be a better option for more severe TTM. Results support the efficacy of AEBT-TTM and show that treatment gains were maintained over time. Although AEBT-TTM yielded lower symptoms at post-treatment, 6-month follow-up outcomes suggest AEBT-TTM and PST may lead to similar symptom levels in the longer term. Future research should examine mechanisms that contribute to long-term gain maintenance.

Treatment of obsessive-compulsive disorder complicated by comorbid eating disorders.

PURPOSE: Eating disorders and obsessive-compulsive disorder (OCD) commonly co-occur, but there is little data for how to treat these complex cases. To address this gap, we examined the naturalistic outcome of 56 patients with both disorders, who received a multimodal treatment program designed to address both problems simultaneously. METHODS: A residential treatment program developed a cognitive-behavioral approach for patients with both OCD and an eating disorder by integrating exposure and response prevention (ERP) treatment for OCD with ERP strategies targeting eating pathology. Patients also received a supervised eating plan, medication management, and social support. At admission and discharge, patients completed validated measures of OCD severity (the Yale-Brown Obsessive-Compulsive Scale--Self Report [Y-BOCS-SR]), eating disorder severity (the Eating Disorders Examination-Questionnaire), and depressive severity (the Beck Depression Inventory II [BDI-II]). Body mass index (BMI) was also measured. Paired-sample t-tests examined change on these measures. MAIN RESULTS: Between 2006 and 2011, 56 individuals completed all study measures at admission and discharge. Mean length of stay was 57 days (SD = 27). Most (89%) were on psychiatric medications. Significant decreases were observed in OCD severity, eating disorder severity, and depression. Those with bulimia nervosa showed more improvement than those with anorexia nervosa. BMI significantly increased, primarily among those underweight at admission. CONCLUSION: Simultaneous treatment of OCD and eating disorders using a multimodal approach that emphasizes ERP techniques for both OCD and eating disorders can be an effective treatment strategy for these complex cases.

The Skin Picking Impact Scale: Factor structure, validity and development of a short version.

In the present study, we examined the psychometric properties of the Skin Picking Impact Scale (SPIS; Keuthen, Deckersbach, Wilhelm et al., 2001), a 10 item self-report questionnaire designed to assess the psychosocial impact of skin picking disorder (SPD). Participants were 650 individuals who met criteria for SPD in an online survey. Exploratory and confirmatory factor analyses demonstrated a unitary factor structure with high internal consistency (α = 0.94). Consequently, we constructed an abbreviated 4-item version that retained good internal consistency (α = 0.87) and a robust factor structure. Both the short and the full versions demonstrated discriminant and convergent/concurrent validity. In conclusion, the findings indicate that both versions are psychometrically sound measures of SPD related psychosocial impact; however, some potential limitations of the full scale are discussed.

The role of psychological flexibility in acceptance-enhanced behavior therapy for trichotillomania: Moderation and mediation findings.

Trichotillomania is characterized by recurrent pulling out of one's hair, leading to significant hair loss and accompanied by clinically significant distress and/or functional impairment. The current study used data from a randomized controlled trial comparing the effectiveness of acceptance-enhanced behavior therapy (AEBT) to psychoeducation plus supportive therapy (PST; active control) for trichotillomania in an adult sample. The objectives were to examine the moderating and mediating influence of trichotillomania-specific psychological flexibility in treatment for trichotillomania. Participants with lower baseline flexibility performed better in AEBT than PST in terms of greater symptom reduction and quality of life. Lower baseline flexibility also predicted higher likelihood of disorder recovery in AEBT relative to PST. In addition, relative to PST, symptom reduction in AEBT was mediated by psychological flexibility, controlling for anxiety and depression. These findings suggest that psychological flexibility is a relevant process of change in the treatment of trichotillomania. Clinical implications and directions for future research are discussed.

Skin picking disorder is associated with other body-focused repetitive behaviors: findings from an internet study.

BACKGROUND: There is a lack of consensus on how to conceptualize skin picking disorder (SPD). It has been proposed that SPD is related to other problematic body-focused repetitive behaviors (BFRBs), such as hair pulling disorder (HPD) and problematic nail biting and cheek biting. METHODS: We compared rates of BFRBs in online samples of SPD sufferers and college students. We also examined family history of HPD and skin picking problems and correlates of BFRB comorbidity in the SPD sample. RESULTS: Prevalence of BFRBs was significantly higher in the SPD sample compared with the college student sample. One-half (50.8%) of the SPD sample had a first-degree relative with problematic skin picking, and 7.9% had a first-degree relative with diagnosed HPD. Finally, correlates of BFRB comorbidity indicated that when multiple habits co-occur in an individual, they tend to involve the same body area. CONCLUSIONS: These findings are the first to show that SPD and BFRBs other than HPD frequently co-occur. Furthermore, they extend previous work showing that SPD has a family component and suggest that SPD and HPD may run in the same families. Given the recruitment method and the self-report nature of the comorbidity data, replication in clinical samples is needed.

Maternal and child expressed emotion as predictors of treatment response in pediatric obsessive-compulsive disorder.

Expressed emotion (EE) is associated with symptoms and treatment outcome in various disorders. Few studies have examined EE in pediatric OCD and none of these has assessed the child's perspective. This study examined the relationship among maternal and child EE, child OCD severity, and OCD-related functioning pre- and post-treatment. At pre-treatment, mothers completed speech samples about the child with OCD and an unaffected sibling. Children with OCD completed speech samples about parents. There were low rates of high maternal EE (child with OCD: 16.1%; sibling: 2.6%) and high child EE about parents (mothers: 11.9%; fathers: 10.2%). High EE was primarily characterized by high criticism, not high overinvolvement. High maternal EE and child EE regarding fathers were associated with pre-treatment child OCD severity but not post-treatment severity. High child and maternal EE were predictive of post-treatment OCD-related functioning. EE may be an important child and maternal trait associated with pre-treatment OCD severity and generalization of treatment gains.

Acceptance-enhanced behavior therapy for trichotillomania in adults: A randomized clinical trial.

Given the limited treatment options for trichotillomania (TTM), or Hair Pulling Disorder, this large randomized clinical trial evaluated the efficacy of acceptance-enhanced behavior therapy for TTM (AEBT-TTM) in reducing TTM severity relative to psychoeducation and supportive therapy (PST). Eighty-five adults (78 women) with TTM received 10 sessions (over 12 weeks) of either AEBT-TTM or PST. Independent evaluators masked to treatment assignment assessed participants at baseline (week 0), midpoint (week 6), and endpoint (week 12). Consistent with a priori hypotheses, 64% of the adults treated with AEBT-TTM were classified as clinical responders at post-treatment relative to 38% treated with PST. Clinical responders were identified by a score of 1 or 2 on the Clinical Global Impressions-Improvement (CGI-I) scale. Relative to the PST group, the AEBT-TTM group demonstrated significantly greater pre-to post-treatment reductions on the self-report Massachusetts General Hospital-Hairpulling Scale (MGH-HS) and the evaluator-rated National Institute of Mental Health Trichotillomania Severity Scale (NIMH-TSS). There were no significant post-treatment group differences on the Clinical Global Impressions-Severity (CGI-S) scale, or rate of TTM diagnoses. Results suggest AEBT-TTM provides greater treatment benefit than PST. Future research should continue to investigate AEBT-TTM along with mediators and moderators of its efficacy.

Systematic Review and Meta-analysis: An Empirical Approach to Defining Treatment Response and Remission in Pediatric Obsessive-Compulsive Disorder.

OBJECTIVE: A lack of universal definitions for response and remission in pediatric obsessive-compulsive disorder (OCD) has hampered the comparability of results across trials. To address this problem, we conducted an individual participant data diagnostic test accuracy meta-analysis to evaluate the discriminative ability of the Children's Yale-Brown Obsessive-Compulsive Scale (CY-BOCS) in determining response and remission. We also aimed to generate empirically derived cutoffs on the CY-BOCS for these outcomes. METHOD: A systematic review of PubMed, PsycINFO, Embase and CENTRAL identified 5,401 references; 42 randomized controlled clinical trials were considered eligible, and 21 provided data for inclusion (N = 1,234). Scores of ≤2 in the Clinical Global Impressions Improvement and Severity scales were chosen to define response and remission, respectively. A 2-stage, random-effects meta-analysis model was established. The area under the curve (AUC) and the Youden Index were computed to indicate the discriminative ability of the CY-BOCS and to guide for the optimal cutoff, respectively. RESULTS: The CY-BOCS had sufficient discriminative ability to determine response (AUC = 0.89) and remission (AUC = 0.92). The optimal cutoff for response was a ≥35% reduction from baseline to posttreatment (sensitivity = 83.9, 95% CI = 83.7-84.1; specificity = 81.7, 95% CI = 81.5-81.9). The optimal cutoff for remission was a posttreatment raw score of ≤12 (sensitivity = 82.0, 95% CI = 81.8-82.2; specificity = 84.6, 95% CI = 84.4-84.8). CONCLUSION: Meta-analysis identified empirically optimal cutoffs on the CY-BOCS to determine response and remission in pediatric OCD randomized controlled clinical trials. Systematic adoption of standardized operational definitions for response and remission will improve comparability across trials for pediatric OCD.

Myth of the pure obsessional type in obsessive--compulsive disorder.

BACKGROUND: Several studies have identified discrete symptom dimensions in obsessive-compulsive disorder (OCD), derived from factor analyses of the individual items or symptom categories of the Yale-Brown Obsessive-Compulsive Scale Symptom Checklist (YBOCS-SC). This study aims to extend previous work on the relationship between obsessions and compulsions by specifically including mental compulsions and reassurance-seeking. Because these compulsions have traditionally been omitted from prior factor analytic studies, their association to what have been called "pure obsessions" may have been overlooked. METHOD: Participants (N = 201) were recruited from two multi-site randomized clinical treatment trials for OCD. The YBOCS-SC was used to assess OCD symptoms, as it includes a comprehensive list of obsessions and compulsions, arranged by content category. Each category was given a score based on whether symptoms were present and if the symptom was a primary target of clinical concern, and a factor analysis was conducted. Mental compulsions and reassurance-seeking were considered separate categories for the analysis. RESULTS: Using an orthogonal geomin rotation of 16 YBOCS-SC categories/items, we found a five-factor solution that explained 67% of the total variance. Inspection of items that composed each factor suggests five familiar constructs, with mental compulsions and reassurance-seeking included with sexual, aggressive, and religious obsessions (unacceptable/taboo thoughts). CONCLUSIONS: This study suggests that the concept of the "pure obsessional" (e.g., patients with unacceptable/taboo thoughts yet no compulsions) may be a misnomer, as these obsessions were factorially associated with mental compulsions and reassurance-seeking in these samples. These findings may have implications for DSM-5 diagnostic criteria.