What makes an obsession? A systematic-review and meta-analysis on the specific characteristics of intrusive cognitions in OCD in comparison with other clinical and non-clinical populations.

The Diagnostic and Statistical Manual 5th ed. defines obsessions in obsessive-compulsive disorder (OCD) as frequent, persistent, intrusive, unwanted thoughts that provoke anxiety and distress and lead to attempts to neutralize them with either thoughts or actions. However, no systematic review has yet evaluated characteristics that are specific to obsessions occurring in OCD. The aim of the current systematic review and meta-analysis was to investigate the specific features of obsessions occurring in OCD by comparing them to both obsessionally and non-obsessionally-themed intrusions in non-clinical and other clinical populations. Based on a registered protocol, 832 records were found, of which 15 were included in the systematic review and meta-analysis, with a total of 1891 participants. Obsessionally-themed intrusions that occur among those with OCD caused more distress, guilt, negative emotion and interference as compared to similarly-themed intrusions that occur within the general population. The distinction between obsessionally-themed intrusions among those with OCD as compared to those occurring in anxiety and depressive disorder primarily revolves around a higher level of persistence, pervasiveness and distress associated with their occurrence. Further, unacceptability, uncontrollability, ego-dystonicity, alienness, guilt, the form of the intrusion, association with the self and lack of any basis in reality also differentiates between obsessions and intrusions occurring in other disorders. Obsessions share many characteristics with thoughts occurring in other disorders and can be distinguished using a combination of characteristics specific to individual disorders.

Diagnostic Differential Between Pedophilic-OCD and Pedophilic Disorder: An Illustration with Two Vignettes.

Despite the prevalence of atypical sexual thoughts in OCD presentations, research suggests that treatment providers often misclassify OCD with pedophilic obsessions (P-OCD) as pedophilic disorder. Such misdiagnoses can have adverse effects including inappropriate treatment, worsening of symptoms, and potential legal complications. Given these iatrogenic effects, clinicians must be competent in differentiating between these two conditions. To clarify the difficult differential between P-OCD and pedophilic disorder, the current paper provides readers with two vignettes that illustrate the differential process. These vignettes highlight important distinctions in symptom presentations and common pitfalls when assessing for P-OCD and pedophilic disorder. The first vignette describes a 32-year-old married woman who experienced pedophilic-themed intrusive thoughts, leading her to avoid children and certain interactions with her daughter. The second vignette describes a 42-year-old married man who experienced ego-dystonic attraction toward minors, particularly 8-10-year-old girls. Following these vignettes, treatment implications and forensic implications are discussed. Finally, recommendations for future clinical and empirical work are made.

What do Italian healthcare professionals think about orthorexia nervosa? Results from a multicenter survey.

PURPOSE: Orthorexia nervosa (ON) is an obsession for healthy and proper nutrition. Diagnostic criteria for ON are lacking and the psychopathology of ON is still a matter of debate in the clinical and scientific community. Our aim was to better understand the Italian clinical and scientific community's opinion about ON. METHODS: Anonymous online survey for Italian healthcare professionals, implemented with the REDCap platform and spread through a multicenter collaboration. Information was gathered about socio-demographic, educational and occupational features, as well as about experience in the diagnosis and treatment of EDs. The main part of the survey focused on ON and its features, classification and sociocultural correlates. RESULTS: The survey was completed by 343 participants. Most responders (68.2%) considered ON as a variant of Eating Disorders (EDs), and 58.6% a possible prodromal phase or evolution of Anorexia Nervosa (AN). Most participants (68.5%) thought the next DSM should include a specific diagnostic category for ON, preferably in the EDs macro-category (82.1%). Moreover, 77.3% of responders thought that ON deserves more attention on behalf of researchers and clinicians, and that its treatment should be similar to that for EDs (60.9%). Participants thinking that ON should have its own diagnostic category in the next DSM edition had greater odds of being younger (p = 0.004) and of considering ON a prodromic phase of another ED, such as AN (p = 0.039). DISCUSSION: Our survey suggests that the scientific community still seems split between those who consider ON as a separate disorder and those who do not. More research is still needed to better understand the construct of ON and its relationship with EDs; disadvantages and advantages of giving ON its own diagnosis should be balanced. LEVEL OF EVIDENCE: V (descriptive cohort study).

Characterizing the building blocks of Problematic Use of the Internet (PUI): The role of obsessional impulses and impulsivity traits among Italian young adults.

BACKGROUND: Problematic Use of the Internet (PUI) is a considerable issue of the modern era, but its risk factors are still poorly understood. Impulsivity and obsessive-compulsive symptoms have been associated with PUI, but this relationship is still debated. In this article we focus on the relationships of PUI with obsessive-compulsive and impulsive symptoms in a cohort of Italian young adults, in order to identify possible vulnerability factors for PUI. METHODS: A sample of 772 Italian individuals aged 18-30 (mean age 23.3 ± 3.3 years old; 38% males and 62% females) was assessed via online survey using the Internet Addiction Test (IAT), the Mini International Neuropsychiatric Interview (MINI) Screen, the Padua Inventory-Washington State University Revision (PI-WSUR) and the Barratt Impulsiveness Scale (BIS-11). RESULTS: Ninety-seven subjects (12.6% of the sample) reported IAT scores at risk for PUI. PUI participants reported higher levels of impulsivity, obsessive-compulsive symptoms and a higher burden of co-occurrent psychiatric symptoms. In a logistic regression model, obsessional impulses to harm (OR = 1.108, p < 0.001), attentional impulsivity (OR = 1.155, p < 0.001) and depressive symptomatology (OR = 1.246, p = 0.012) had significant association with PUI. Finally, higher severity of PUI has been associated with manic/psychotic symptoms and with attentional impulsivity. CONCLUSIONS: Our findings confirmed the role of impulsivity in PUI, while also underling the association of obsessional impulses with this pathological behavior. We could hypothesize a trigger role of obsessive impulses for the engagement in PUI, together with factors as negative affective states. Further research is needed with respect to more severe forms of PUI, also for establishing tailored interventions.

Is context a crucial factor in distinguishing between intrusions and obsessions in patients with obsessive-compulsive disorder?

OBJECTIVE: Some cognitive models of obsessive-compulsive disorder (OCD) posit that intrusions exist on a continuum with obsessions; others consider that they may be unrelated phenomena that differ in the context where they occur. We aimed to examine and compare, at two different moments, the context of the occurrence of intrusions and obsessions. METHOD: Sixty-eight patients with OCD completed an interview appraising their most upsetting obsession and intrusion. RESULTS: At their onset, the obsessions/intrusions were associated with experiencing negative emotional states and life events, and they were more likely to appear in "inappropriate" contexts. The context of the obsessions/intrusions differed the last time they were experienced. Autogenous obsessions/intrusions occurred more frequently in contexts with an indirect link. CONCLUSIONS: The context distinguishes between intrusions and obsessions, not when they emerge, but when the obsession is already established. The results support that there is a continuum or progression from intrusions to obsessions.

Is it time to change the gold standard of obsessive-compulsive disorder severity assessment? Factor structure of the Yale-Brown Obsessive-Compulsive Scale.

OBJECTIVES: The Yale-Brown Obsessive-Compulsive Scale has been considered the gold standard scale to assess obsessive-compulsive disorder severity. Previous studies using exploratory factor analysis and confirmatory factor analysis with this scale showed mixed findings in terms of factor structure and fit of models. Therefore, we used confirmatory factor analysis to compare different Yale-Brown Obsessive-Compulsive Scale models in a large sample aiming to identify the best model fit. METHODS: We assessed adult obsessive-compulsive disorder patients (n = 955) using three measures: Yale-Brown Obsessive-Compulsive Scale severity ratings, the Dimensional Yale-Brown Obsessive-Compulsive Scale and the clinical global impression scale. We tested all factor structures reported by previous studies to investigate which model best fitted the data: one-factor, two-factor, three-factor and their equivalent high-order solutions. We also investigated Yale-Brown Obsessive-Compulsive Scale items correlations with scores from the other measures of obsessive-compulsive disorder severity. RESULTS: Confirmatory factor analysis models presented mediocre to fair goodness-of-fit indexes. Severity items related to resistance to obsessions and compulsions presented low factor loadings. The model with the best fit indexes was a high-order model without obsessive-compulsive disorder resistance items. These items also presented small correlations with other obsessive-compulsive disorder severity measures. CONCLUSION: The obsessive-compulsive disorder field needs to discuss further improvements in the Yale-Brown Obsessive-Compulsive Scale and/or continue to search for better measures of obsessive-compulsive disorder severity.

Definition and diagnostic criteria for orthorexia nervosa: a narrative review of the literature.

AIM: In some cases, detrimental consequences on health are generated by self-imposed dietary rules intended to promote health. The pursuit of an "extreme dietary purity" due to an exaggerated focus on food may lead to a disordered eating behavior called "orthorexia nervosa" (ON). ON raises a growing interest, but at present there is no universally shared definition of ON, the diagnostic criteria are under debate, and the psychometric instruments used in the literature revealed some flaws. This narrative review of the literature aims at assessing state of the art in ON definition, diagnostic criteria and related psychometric instruments and provides research propositions and framework for future analysis. METHODS: The authors collected articles through a search into Pubmed/Medline, Scopus, Embase and Google Scholar (last access on 07 August 2018), using "orthorexia", "orthorexia nervosa" and "obsessive healthy eating" as search terms, and filled three tables including narrative articles (English), clinical trials (English), and articles in languages different from English. The data extrapolated from the revised studies were collected and compared. In particular, for each study, the diagnostic criteria considered, the specific psychometric instrument used, the results and the conclusions of the survey were analyzed. RESULTS: The terms employed by the different authors to define ON were fixation, obsession and concern/preoccupation. Several adjectives emphasized these expressions (e.g. exaggerated/excessive, unhealthy, compulsive, pathological, rigid, extreme, maniacal). The suitable food and the diet were defined in different ways. Most of the papers did not set the diagnostic criteria. In some cases, an attempt to use DSM (edition IV or 5) criteria for anorexia nervosa, or avoidant/restrictive food intake disorder, or body dysmorphic disorder, was done. Specific diagnostic criteria proposed by the authors were used in few studies. All these studies indicated as primary diagnostic criteria: (a) obsessional or pathological preoccupation with healthy nutrition; (b) emotional consequences (e.g. distress, anxieties) of non-adherence to self-imposed nutritional rules; (c) psychosocial impairments in relevant areas of life as well as malnutrition and weight loss. The ORTO-15 and the Orthorexia Self-Test developed by Bratman were the most used psychometric tools. CONCLUSIONS: The present review synopsizes the literature on the definition of ON, proposed diagnostic criteria and psychometric instruments used to assess ON attitudes and behaviors. This work represents a necessary starting point to allow a further progression of the studies on the possible new syndrome and to overcome the criticisms that have affected both research and clinical activity until now. LEVEL OF EVIDENCE: Level V, narrative review.

Confirmatory factor analyses of the ORTO 15-, 11- and 9-item scales and recommendations for suggested cut-off scores.

AIMS: To explore the validity and recommend cut-off scores in an English-speaking sample for 9, 11, and 15-item versions of the ORTO measure for orthorexia, a proposed eating disorder characterised by a pathological obsession with consuming only 'healthy' foods. MATERIALS AND METHODS: The sample comprised of 585 participants (82.4% female) who completed an online questionnaire containing the ORTO-15, Eating Attitudes test, Obsessive Compulsive Inventory Revised. A series of Confirmatory Factor Analyses were conducted to test model fit. Binary logistic linear regression and receiver-operating-characteristics (ROC) analyses were used to obtain cut-offs. RESULTS AND CONCLUSION: Results showed that none of the three published versions (9, 11, and 15-item) of the ORTO produced an acceptable model. Subsequent exploratory and confirmatory factor analyses yielded a seven-item version of the ORTO (ORTO-7) with a strong and stable factor structure. Analysis of cut-offs revealed that a cut-off score of equal or greater than 19 on the ORTO-7 represents probable orthorexia. LEVEL OF EVIDENCE: Level V, descriptive study.

Atypical symptom presentations in children and adolescents with obsessive compulsive disorder.

BACKGROUND: Common symptom presentations in youth with Obsessive Compulsive Disorder (OCD) are easily recognized and are included in the Children's Yale Brown Obsessive Compulsive Scale (CY-BOCS) symptom checklist. However, some youth may occasionally present with atypical or unusual symptoms that are less readily recognized as OCD and may be confused with other disorders that sometimes overlap, such as autism spectrum disorder or even psychosis. METHODS: Case synopses which are thematically linked and exemplify and illustrate two distinct types of unusual or atypical symptom presentations are described. These symptoms are embedded in the subjects' broader clinical picture, that more correctly identifies the atypical symptoms as a variant feature of OCD rather than some other diagnostic condition. RESULTS: We describe twenty-four children with OCD. Twelve children had obsessions related to adverse experiences of places, times or other people that were felt as horrific, abhorrent or disgusting. These obsessions led to contamination fears of any thoughts or actions associated with those places, events or people. In those whose OCD was a reaction to another person, the contamination obsession often took the form of fear of acquiring an unwanted trait or characteristic by association, which was then avoided. Twelve other youth had obsessions driven by a primary sensory experience that was intolerable, including tactile, olfactory, and auditory stimuli. These sensory experiences were sometimes linked to specific objects or people, driving time-consuming repetitive behaviors to avoid or alleviate the sensory discomfort. CONCLUSION: Recognition of atypical presentations of OCD, such as fear of contamination by association with adverse experiences and primary sensory intolerance leading to OCD will help clinicians to better identify and treat these unique symptoms.

Psychometric validation of a Danish version of the Obsessive Beliefs Questionnaire - Child Version (OBQ-CV).

AIM: The aim of the study was to examine the psychometric properties of a Danish version of the Obsessive Beliefs Questionnaire - Child Version (OBQ-CV). The OBQ-CV assesses dysfunctional beliefs concerning responsibility/threat estimation, perfectionism/uncertainty, and importance/control of thoughts, which according to cognitive theories are important in the development and maintenance of obsessive-compulsive disorder (OCD). METHODS: The study included a pediatric sample (age 7-17 years) consisting of 57 children and adolescents with OCD, 49 children and adolescents with an anxiety disorder (AD), and 58 typically developing (TD) children and adolescents without a psychiatric diagnosis. All participants completed the OBQ-CV and the Child Behavior Checklist - the School Age Scales (CBCL/6-18). The Children's Yale-Brown Obsessive-Compulsive Scale (CY-BOCS) was used to assess OCD symptom severity in the OCD group. RESULTS: Confirmatory factor analyses supported the three-factor structure and thereby the construct validity of the OBQ-CV. Gender was not associated with subscale scores, whereas age influenced the subscale scores differently in the three groups. Reliability analyses showed acceptable to excellent internal consistency and acceptable test-retest reliability of the instrument. There were significant differences between the OCD group and the TD group, supporting the criterion validity. Results on convergent validity were mixed. CONCLUSIONS: Overall, results supported the reliability and validity of the Danish OBQ-CV and thus the use of the questionnaire for future clinical and research purposes.

Structural validation of ORTO-11-ES for the diagnosis of orthorexia nervosa, Spanish version.

PURPOSE: The ORTO-11-ES questionnaire is a tool to assess the pathological obsession displayed by some individuals regarding healthy eating. The aims of this study were (1) to confirm the factor structure of the Spanish version of ORTO-11-ES using confirmatory factor analysis (CFA) and (2) to examine the possible association between the ORTO-11-ES score, gender and body mass index (BMI). METHODS: The sample comprised 492 students from the University of Castilla la Mancha, Spain. Of these, 280 were women (56.9%). Participants were surveyed using the ORTO-11-ES questionnaire. RESULTS: The confirmatory factor analysis (CFA) supported the 11 elements and 3 domains of this tool as the better fitting model; for the Comparative Fit Index (CFI) and the Tucker-Lewis Index (TLI), the values were 0.94 and 0.91, respectively, and the Root Mean-Square Error of Approximation (RMSEA) was 0.058. The tendency towards orthorexic behavior is more associated with the female gender. The BMI had no influence on the tendency for ON. CONCLUSIONS: This study is the first attempt to confirm the three-factor structure of a Spanish version of the ORTO-15 questionnaire. These findings suggest that the ORTO-11-ES may be a valuable tool for identifying subjects with specific eating behavior patterns. This information may be useful for health professionals involved in the research, development and implementation of interventions catered to individuals suffering from this eating disorder. LEVEL OF EVIDENCE: Level V, descriptive cross-sectional study.

Orthorexia nervosa: Assessment and correlates with gender, BMI, and personality.

This study investigated whether orthorexia nervosa (ON; characterized by an obsessive fixation on eating healthy) may be predicted from the demographics variables of gender and BMI, and from the personality variables of self-esteem, narcissism, and perfectionism. Participants were 459 college students, who completed several online questionnaires that assessed these variables. A principal components analysis confirmed that the Eating Habits Questionnaire (Gleaves, Graham, & Ambwani, 2013) assesses three internally-consistent ON components: healthy eating behaviors, problems resulting from those behaviors, and positive feelings associated with those behaviors. A MANOVA and its tests of between subjects effects then revealed significant interactions between gender and BMI, such that for men but not women, a higher BMI was associated with greater symptomatology for all ON components. Partial correlation analyses, after controlling for gender and BMI, revealed that both narcissism and perfectionism were positively correlated with all aspects of ON symptomatology.

Factor Structure, Reliability, and Validity of the Spanish Version of the Children's Florida Obsessive Compulsive Inventory (C-FOCI).

The Children's Florida Obsessive Compulsive Inventory (C-FOCI) is a promising self-report measure of the presence and severity of obsessive-compulsive symptoms in children and adolescents. Although initial research showed it to have adequate psychometric properties, only one study has been published to date, which dealt exclusively with children. The aim of this report was to examine the psychometric properties of the C-FOCI across clinical and community samples of children and adolescents. The sample consisted of 94 Spanish-speaking patients with obsessive-compulsive disorder (OCD) and 1068 healthy community controls, aged 8-19 years. Factor analysis supported two single and independent factors (severity and symptoms), as well as metric invariance across groups for the symptom checklist and the Severity Scale. Results also indicated good reliability in terms of internal consistency and temporal stability, significant and high correlations with other OCD measures, and acceptable sensitivity and specificity for detect OCD. In summary, the C-FOCI is a promising, brief measure of 22 items for screening OCD symptoms and severity in children and adolescents.

Further Psychometric Evaluation of the Child Disgust Scale.

This study evaluated the psychometric properties of the Child Disgust Scale (CDS) among 457 youth (ages 8-17, M = 14.77 ± 1.98 years) initiating residential treatment for obsessive-compulsive disorder and anxiety disorders. Confirmatory factor analysis supported a bifactor model with two distinct factors of Disgust Avoidance and Disgust Affect, in addition to an overall General Disgust factor. Strong internal consistency was observed for the CDS total and factor scores. In addition, CDS scores demonstrated generally modest and positive correlations with child-reported obsessive-compulsive and anxiety symptoms, weaker correlations with parent-reported anxiety and child-rated impairment, and non-significant correlations with parent-rated impairment. Findings suggest that the CDS displays strong psychometric properties and is developmentally appropriate for use in pediatric clinical populations with obsessive-compulsive and anxiety disorders.

Distinguishing Fear Versus Distress Symptomatology in Pediatric OCD.

Prior research has identified OCD subtypes or "clusters" of symptoms that differentially relate to clinical features of the disorder. Given the high comorbidity between OCD and anxiety, OCD symptom clusters may more broadly associate with fear and/or distress internalizing constructs. This study examines fear and distress dimensions, including physical concerns (fear), separation anxiety (fear), perfectionism (distress), and anxious coping (distress), as predictors of previously empirically-derived OCD symptom clusters in a sample of 215 youth diagnosed with primary OCD (ages 7-17, mean age = 12.25). Self-reported separation fears predicted membership in Cluster 1 (aggressive, sexual, religious, somatic obsessions, and checking compulsions) while somatic/autonomic fears predicted membership in Cluster 2 (symmetry obsessions and ordering, counting, repeating compulsions). Results highlight the diversity of pediatric OCD symptoms and their differential association with fear, suggesting the need to carefully assess both OCD and global fear constructs that might be directly targeted in treatment.

A Comparative Study of Obsessionality in Medical Students, Law Students, and Controls.

Understanding obsessive-compulsive behavior in medical students and law students is necessary for administrators and educators to properly work with students struggling with obsessionality. We aim to compare the differences in obsessive symptoms between medical students, law students and a control population. A total of 100 third-year medical students, 102 third-year law students and 103 control subjects drawn from the general population completed the Leyton Obsessional Inventory (LOI). Subjects were examined on all three sections (symptoms/traits, resistance and interference) of the LOI. Obsessional symptom scores for medical students (14.29 ± 7.33) and law students (13.65 ± 6.61) were significantly greater than for the control group (11.58 ± 7.45). Medical and law students were both more likely to report checking, order, routine and attention to detail as obsessive symptoms. Medical students were more likely than law students to possess the obsessive symptoms of cleanliness and conscientiousness, while law students were more likely than medical students to possess obsessive symptoms related to difficulty in making up their mind and doubting themselves. While medical students and law students are more obsessional than the control population, each group is more likely to report different obsessive symptoms.

Factorial validity of the death obsession scale in African University students.

In this study the factor structure of the Death Obsession Scale (DOS) was examined using confirmatory factor analysis. Data used consisted of DOS reports of 328 Black African students. Confirmatory factor analysis revealed that two- and three-factor models obtained among female and male African students, respectively, provided the best fit to the data. The two factors in female African students were Death Rumination and Apprehension, and the three factors of their male counterparts were Death Ruminations, Apprehension, and Comprehensibility of Death. Factor intercorrelations did not resolve the dimensionality issue of the measure, leading to the conclusion that the factors must be investigated further.

Development and Validation of the Morphing Fear Questionnaire (MFQ).

Morphing fears (also called transformation obsessions) involve concerns that a person may become contaminated by and acquire undesirable characteristics of others. These symptoms are found in patients with obsessive-compulsive disorder (OCD) and are thought to be related to mental contamination. Given the high levels of distress and interference morphing fears can cause, a reliable and valid assessment measure is needed. This article describes the development and evaluation of the Morphing Fear Questionnaire (MFQ), a 13-item measure designed to assess for the presence and severity of morphing fears. A sample of 900 participants took part in the research. Of these, 140 reported having a current diagnosis of OCD (SR-OCD) and 760 reported never having had OCD (N-OCD; of whom 24 reported a diagnosis of an anxiety disorder and 23 reported a diagnosis of depression). Factor structure, reliability and construct and criterion-related validity were investigated. Exploratory and confirmatory factor analyses supported a one-factor structure replicable across the N-OCD and SR-OCD group. The MFQ was found to have high internal consistency and good temporal stability and showed significantly greater associations with convergent measures (assessing obsessive-compulsive symptoms, mental contamination, thought-action fusion and magical thinking) than with divergent measures (assessing depression and anxiety). Moreover, the MFQ successfully discriminated between the SR-OCD sample and the N-OCD group, anxiety disorder sample and depression sample. These findings suggest that the MFQ has sound psychometric properties and that it can be used to assess morphing fear. Clinical implications are discussed. Copyright © 2015 John Wiley & Sons, Ltd. KEY PRACTITIONER MESSAGE: Little remains known about morphing fears, but it is an important area of investigation due to symptoms being highly distressing and often debilitating Because morphing fears commonly present as obscure symptoms, they may not be recognized as a type of OCD The MFQ is a robust measure with clinical utility; it can facilitate recognition and assessment of morphing fears The MFQ will allow for further investigations of the prevalence, correlates and treatment outcomes of morphing fears.

Psychometric properties of the Chinese version of the Obsessive Beliefs Questionnaire-44 (OBQ-44).

BACKGROUND: The Obsessive Beliefs Questionnaire-44 (OBQ-44) is originally developed by the Obsessive Compulsive Cognitions Working Group and has been translated into several languages. This paper is aimed to investigate the psychometric properties of the Chinese version of the Obsessive Beliefs Questionnaire-44 (OBQ-44) in both clinical and non-clinical samples. METHODS: Five hundred and sixty-nine undergraduate volunteers and sixty-six OCD patients were included in the study. All participants have completed Chinese version of OBQ-44, Yale-Brown Obsessive-Compulsive Scale (Y-BOCS), and Beck Depression Inventory (BDI). Confirmatory factor analysis was conducted to examine the construct validity of Chinese version of OBQ-44. The internal consistency and test-retest reliabilities at 4-week interval were examined in both non-clinical and clinical groups. RESULTS: The confirmatory factor analysis of the non-clinical sample confirmed a 3-factor model which was suggested by the original authors of the instrument (χ (2)/d.f = 2.96, GFI = 0.83, NFI = 0.82, CFI = 0.88 and RMSEA = 0.06). The internal consistency and test-retest reliability were at an acceptable range for the two samples. CONCLUSIONS: The Chinese version of OBQ-44 is a valid and reliable instrument for assessing dysfunctional beliefs related to the etiology and maintenance of obsessions and compulsions.