A study of doubt in obsessive-compulsive disorder.

BACKGROUND AND OBJECTIVES: Obsessive-compulsive disorder (OCD) has been referred to as the "doubting disease," yet there has been little foundational research on its phenomenology and characteristics. Studies of doubt have relied on researchers' idiosyncratic conceptualizations of the construct, resulting in varied assessment methods and different prevalence rates (11-75%). We examined the nature and characteristics of doubt in people with clinical and subclinical OCD so as to identify its nature and characteristics, and factors that may be unique to OCD. METHODS: A semi-structured interview about doubt was administered to people with OCD (N = 44) and with subclinical OCD (N = 21). RESULTS: Doubt was highly prevalent and manifested as a form of obsession, uncertainty about whether a task was done properly, and/or lack of confidence in memory and perceptions. All participants took action to resolve doubt and/or proactively pre-empt or reduce future doubt. Doubt was deeply connected to negative core beliefs about the self. The groups did not differ on their experience of doubt, except that greater symptom severity was associated with greater interference from doubt, less ability to resist it, and less success of proactive, but not reactive, strategies to manage it. LIMITATIONS: We relied on retrospective report, and the subclinical group was relatively small. CONCLUSIONS: In subclinical and clinical OCD, doubt is pervasive, manifests in three domains, is connected to negative core beliefs, and is highly aversive. Continued empirical study of doubt is essential to proper assessment and to development of theories and treatment of OCD.

Context matters: criticism and accommodation by close others associated with treatment attitudes in those with anxiety.

BACKGROUND: Many people with anxiety do not seek therapy due to negative views of treatment. Although close others (e.g. romantic partners, family members, close friends) are highly involved in treatment decisions, the role of specific relational behaviours in treatment ambivalence has yet to be studied. AIMS: This study examines the relationship between social predictors (perceived criticism and accommodation of anxiety symptoms by close others) and treatment ambivalence. METHOD: Community members who met diagnostic criteria for an anxiety-related disorder (N = 65) and students who showed high levels of anxiety (N = 307) completed an online study. They were asked to imagine they were considering starting cognitive behavioural therapy (CBT) for their anxiety and complete a measure of treatment ambivalence accordingly. They then completed measures of perceived criticism and accommodation by close others. Linear regression was used to examine the predictive value of these variables while controlling for sample type (clinical/analogue) and therapy experience. RESULTS: Greater reactivity to criticism from close others and greater accommodation of anxiety symptoms by close others were associated with greater treatment ambivalence in those with anxiety. These predictors remained significant even when controlling for therapy history and sample type. CONCLUSIONS: When it comes to treatment attitudes, relational context matters. Clients demonstrating ambivalence about starting therapy may benefit from discussion about the impact of their social environment on ambivalence.

Criticism and accommodation are associated with treatment concerns in close others to those with anxiety.

OBJECTIVES: Those close to people with mental health difficulties (e.g., family members, romantic partners and close friends) are often involved in their care decisions. Research shows that criticism by close others and accommodation of symptoms are associated with symptom severity and treatment response. Recent research has found that those close to someone with an anxiety disorder report a range of concerns about their loved one starting cognitive-behaviour therapy (e.g., that treatment will cause the person to change in undesirable ways). The purpose of this study was to examine the relationship between close others' criticism and symptom accommodation and their treatment concerns, hypothesizing that these relationships would be significant. DESIGN: Close others to those with notable anxiety (N = 287) completed self-report measures online. Multiple regression was used to test our hypothesis. METHODS: Respondents who identified as being close to someone with notable anxiety completed measures of their accommodation of anxiety symptoms, feelings of criticism/hostility towards them, concerns about them starting treatment, perceived impairment due to anxiety, and their own and their loved ones' treatment history. RESULTS: Greater criticism and accommodation significantly predicted greater treatment concerns, with a medium effect size, controlling for degree of impairment due to anxiety and treatment history. CONCLUSIONS: Criticism and accommodation may reflect appraisal of the person with anxiety as weak or fragile, which may evoke concerns about treatment success. Implications for clinicians and anxiety treatment are discussed.

Dr. Jack Rachman's contributions to our understanding and treatment of obsessive-compulsive disorder.

BACKGROUND AND OBJECTIVES: This paper reviews the development of the cognitive-behavioural model of obsessive-compulsive disorder (OCD) through the work of Dr. Jack Rachman and the research his ideas inspired or shaped. METHODS: A narrative review of Rachman's work and important developments in related areas was conducted. RESULTS: Rachman was highly responsive to theoretical and empirical developments in the field, and continuously developed his model of OCD over the course of his career. Key developments in his thinking and of those in related areas are described. LIMITATIONS: This is a narrative review that highlights important developments in the cognitive behavioural model of OCD only. CONCLUSIONS: The CBT model of OCD has strong empirical support and CBT treatment is the most effective psychotherapy. Continued development in our understanding of attachment and in the persistence of compulsions is warranted.

How do close others to those with anxiety feel about treatment? Development and validation of the Treatment Concerns Questionnaire-Close Others.

Background: The close others (e.g., family members, romantic partners) of people with anxiety and related disorders are typically involved in their treatment decisions. However, we know little about close others' attitudes towards and concerns about their loved one starting cognitive-behavioural therapy (CBT). Methods: Study one surveyed close others of those with anxiety and related disorders (n = 33) about their concerns about their loved one starting CBT. Thematic coding was completed, and items were developed to reflect these themes, comprising a measure of treatment concerns in close others. Study two involved the administration of the novel measure to a larger sample (n = 287) to evaluate its structure, reliability, and validity. Results: Close others endorsed having treatment concerns of moderate intensity. The final 17-item measure, the Treatment Concerns Questionnaire-Close Others (TCQ-C), has a robust four-factor structure, with internally consistent subscales including "Adverse Reactions", "Personal/Family Consequences", "Lack of Commitment", and "Ineffectiveness". The measure shows moderate correlations with treatment expectations (convergent validity) and small correlations with respondent distress (discriminant validity). Conclusions: The value of this measure for clinicians and future directions for research are discussed. Supplementary Information: The online version contains supplementary material available at 10.1007/s10608-022-10318-9.

Anxiety disorders, COVID-19 fear, and vaccine hesitancy.

Development of the COVID-19 vaccines unfolded in real-time, lending a sense that they were developed more rapidly than other vaccines. Long-term data on their safety and effectiveness is not yet available. Thus, people may have greater uncertainty about the COVID-19 vaccines than other vaccines. We know that people high in anxiety have greater intolerance of uncertainty (IUS) and may have greater fears of adverse effects and concerns about the vaccine failing to prevent COVID-19. Ultimately, people with anxiety disorders may have greater COVID-19 vaccine hesitancy (VH). This study examined the degree of VH in people with (n = 96) and without (n = 52) anxiety disorders, whether anxiety status has an additive effect on factors known to predict hesitancy, and whether reasons for VH differed across groups. Groups did not differ in VH, but IUS was associated with greater hesitancy in those without anxiety but with less hesitancy in those with anxiety. Both groups' strongest predictors of hesitancy were influenza vaccine history, conspiracy beliefs, individualism, and trust. The top reasons for VH were concerns about adverse effects and efficacy, and the top reasons to get the vaccine were to protect others and self. Implications for reducing VH are discussed.

Avoidance of mild threat observed in generalized anxiety disorder (GAD) using eye tracking.

Attentional biases towards threat are assumed to be a causal factor in the development of anxiety disorders, including generalized anxiety disorder (GAD). However, findings have been inconsistent, and studies often examine single time-point bias during threat exposure, instead of across time. Attention to threat may shift throughout exposure (e.g., from initial engagement to avoidance), and research suggests that threat intensity and state anxiety influence attentional biases. No studies to our knowledge have examined biases across time and with varying threat intensity and state anxiety. Participants with GAD (n=38) and non-anxious controls (n=25) viewed emotional (high threat, mild threat, and positive) and neutral image pairs under calm and anxious mood states while their eye movements were tracked. Participants showed an initial orientation to emotional images, and, under the anxious mood induction, demonstrated a bias towards threatening images at first fixation and over time. Results suggest it may be normative to attend to threat cues over other stimuli while in an anxious state. Individuals with GAD uniquely showed a bias away from mild (but not high) threat images over time relative to controls. Implications for theories of attentional biases to threat and clinical implications for GAD and anxiety disorders broadly are discussed.

How are OCD patients and their families coping with the COVID-19 pandemic? A qualitative study.

Patients with obsessive-compulsive disorder (OCD) are likely to be affected by the COVID-19 crisis since fear of contamination is highly prevalent in this illness and disease reminders are omnipresent during this crisis. The current study aimed to investigate the impact of the pandemic and the lockdown on the mental health, well-being and coping abilities of OCD patients and their families in order to increase our understanding of the underlying mechanisms of the disorder. Twenty-two patients and 13 family members were interviewed one-to-one about their experiences and challenges caused by the pandemic and home-confinement directives. Verbatim transcripts of the interviews were analyzed using inductive thematic analysis. Five overarching themes were identified: (1) changing point of reference: confusion and legitimization of OCD behavior, (2) coping strategies were challenged: too much or too little exposure to obsessional concerns, (3) distress but also relief in some areas, (4) developing a new equilibrium within the family, (5) changes in accessibility and nature of therapy: perils and merits of online treatment. These findings make clear the importance of the accessibility of mental health services during this pandemic through direct patient contacts or in a remote format. In therapy therapists should focus on challenging the changing point of reference, providing practical advice on coping, stimulating to engage in exposure and encouraging patients to seek social support. Furthermore, it is important to involve family members in therapy to support and coach them to be validating, supportive and encouraging, without accommodating to the OCD behaviour.

How are OCD Patients and Family Members Dealing with the Waxing and Waning Pattern of the COVID-19 Pandemic? Results of a Longitudinal Observational Study.

The current study aimed to investigate the impact of the COVID-19 pandemic on the mental health of people with OCD and the degree of family accommodation (FA) by live-in family members across phases of the lockdown measures imposed by the Belgian government. Forty-nine OCD patients and 26 live-in family members participated in the study. We assessed OCD symptom severity and FA of the live-in family members, as well as depressive symptoms, anxiety and stress levels and COVID-19 related psychological distress of patients and family members at four different timepoints: one month after the start of the lockdown (T1), during the gradual relaxation (T2), between the two waves (T3) and during the second wave (T4). Results showed that although COVID-19 related stress increased and decreased in accordance with the waxing and waning pattern of the pandemic, OCD symptoms showed an initial slight increase followed by a decrease at T3 and again at T4. Changes in family members' accommodation of symptoms followed the same course as the OCD symptoms. Furthermore, OCD symptoms correlated with depressive symptoms, anxiety and stress levels and COVID-19 related distress at all timepoints. It is important to involve family members in the treatment of OCD even during a pandemic. Clinicians should also pay attention to symptoms of depression, anxiety and stress during OCD treatment. Further research is necessary to entangle the causal relationship between OCD symptoms, FA and symptoms of depression, anxiety and stress.

Fear of compassion is associated with treatment ambivalence and negative expectations for treatment in people with anxiety.

OBJECTIVES: Fears of compassion are hypothesized to be associated with treatment attitudes, but this relationship has not yet been explored. METHODS: Measures of fear of compassion and treatment expectations and ambivalence were administered to those with above-average anxiety (N = 302) and those who met criteria for an anxiety or related disorder (N = 40). RESULTS: In those with anxiety disorders, fear of receiving compassion and fear of self-compassion were strongly correlated with treatment ambivalence. In both samples, higher fear of receiving compassion was associated with more negative expectations for treatment. CONCLUSIONS: Fear of compassion is associated with treatment ambivalence and treatment expectations and may be an important target early in treatment. PRACTITIONER POINTS: Fears of receiving compassion and self-compassion were related to treatment ambivalence and negative treatment expectations There may be benefit in targeting fear of compassion early in treatment.

Scared of compassion: Fear of compassion in anxiety, mood, and non-clinical groups.

OBJECTIVES: Fear of receiving compassion from others, expressing compassion to others, and being compassionate towards oneself have been identified as potentially important factors in the persistence of depression, stress disorders, and eating disorders. There is good reason to expect that these fears may play a role in anxiety and related difficulties, but there is little available information on the extent to which they are present and associated with symptom severity. METHODS: This study compared the severity of the three fears of compassion (receiving, expressing to others, and showing to oneself) in those with a principal diagnosis of depression (n = 34), obsessive-compulsive disorder (OCD; n = 27), social anxiety disorder (SAD; n = 91), generalized anxiety disorder (GAD, n = 43), and a control sample with no mental health difficulties (n = 212). RESULTS: Those with depression, OCD, SAD, and GAD exhibited greater fear of receiving compassion and fear of self-compassion than controls, and the differences between anxious and control groups remained significant even when controlling for depressed mood. Whereas fears of compassion did not predict symptom severity over and above depressed mood in people with GAD, fear of receiving compassion uniquely predicted SAD symptom severity, and fear of expressing compassion for others uniquely predicted OCD symptom severity in those high on fear of self-compassion. CONCLUSIONS: Fear of compassion is higher in those with anxiety and related disorders than non-anxious controls. Although further research is needed, clinicians may benefit from assessing fear of compassion and addressing it in treatment. PRACTITIONER POINTS: Those with anxiety and related disorders may fear receiving compassion from others or expressing compassion for themselves, even when controlling for depression. It may be informative to assess for fear of compassion and incorporate discussions about these fears into treatment, as these fears may interfere with treatment progress.

A transdiagnostic perspective of constructs underlying obsessive-compulsive and related disorders: An international Delphi consensus study.

BACKGROUND: The Research Domain Criteria seeks to bridge knowledge from neuroscience with clinical practice by promoting research into valid neurocognitive phenotypes and dimensions, irrespective of symptoms and diagnoses as currently conceptualized. While the Research Domain Criteria offers a vision of future research and practice, its 39 functional constructs need refinement to better target new phenotyping efforts. This study aimed to determine which Research Domain Criteria constructs are most relevant to understanding obsessive-compulsive and related disorders, based on a consensus between experts in the field of obsessive-compulsive and related disorders. METHODS: Based on a modified Delphi method, 46 experts were recruited from Australia, Africa, Asia, Europe and the Americas. Over three rounds, experts had the opportunity to review their opinion in light of feedback from the previous round, which included how their response compared to other experts and a summary of comments given. RESULTS: Thirty-four experts completed round one, of whom 28 (82%) completed round two and 24 (71%) completed round three. At the final round, four constructs were endorsed by ⩾75% of experts as 'primary constructs' and therefore central to understanding obsessive-compulsive and related disorders. Of these constructs, one came from the Positive Valence System (Habit), two from the Cognitive Control System (Response Selection/Inhibition and Performance Monitoring) and the final construct was an additional item suggested by experts (Compulsivity). CONCLUSION: This study identified four Research Domain Criteria constructs that, according to experts, cut across different obsessive-compulsive and related disorders. These constructs represent key areas for future investigation, and may have potential implications for clinical practice in terms of diagnostic processes and therapeutic management of obsessive-compulsive and related disorders.

A study of the Repeated Actions Diary in patients suffering from obsessive compulsive disorder.

The structured Repeated Action Diary (RAD) collects in vivo data on compulsions and their various characteristics. Certain compulsions (i.e., those ending because the patient feels certain that it is safe to stop) are then compared with uncertain compulsions. The compulsion profile in patients with obsessive compulsive disorder (OCD) was assessed by using the RAD. Thirty-two patients from two sources participated in the study. Before pooling the two subgroups, we checked that they did not differ significantly with regard to demographic and clinical variables. Patients reported several categories of compulsion. The most frequently reported compulsions were washing and checking. In a given person, checking compulsions (in contrast to washing compulsions) were often produced by several different obsessions. Almost all the patients reported repeating the compulsions because of a need to feel sure. There were far more "certain" compulsions than "uncertain" compulsions. The number of repetitions was significantly lower for certain compulsions than for uncertain compulsions. The person felt greater relief from guilt and responsibility and a greater decrease in discomfort at the end of a compulsive episode for certain compulsions than for uncertain compulsions. In conclusion, the need to ritualize (prompted by uncertainty, i.e., potential danger) might explain the maintenance (or posttreatment recurrence) of OCD in many patients. The need for certainty in the completion of a compulsion may be worth considering as a therapeutic tool. The development of an approach based on the need for certainty might help to improve treatment outcomes.

If it is absurd, then why do you do it? The richer the obsessional experience, the more compelling the compulsion.

Mounting evidence suggests that obsessive intrusions are often accompanied and amplified by perceptual experiences of different modalities (e.g., feeling dirt on one's skin while experiencing intrusive thoughts about contamination). Pilot studies conducted online with individuals endorsing mild obsessive-compulsive symptoms have linked the co-occurrence of perceptual experiences and obsessions to the severity of subsequent compulsive behaviour as well as low insight. However, it is presently unclear whether sensory experiences accompany all types of obsessional thoughts or are restricted to certain preoccupations (e.g., contamination and aggression). The present study examined a clinical inpatient and outpatient sample with a formally diagnosed obsessive-compulsive disorder (N = 34). Perceptual properties of intrusive thoughts were assessed with the Sensory Properties of Obsessions Questionnaire. The prevalence of perception-laden obsessive thoughts was comparable with prior studies (73.5%), but the intensity was significantly greater. No association was observed between perceptual experiences and expert-rated insight. However, the severity of perception-laden obsessions predicted the frequency of and impairment associated with compulsive behaviour. This was particularly strong for obsessions about contamination. The present study confirms the high prevalence and clinical relevance of perceptual experiences that accompany obsessions and further challenges the traditional trichotomy splitting mental phenomena into thoughts, intrusions, and hallucinations.

Mindfulness and mind wandering: The protective effects of brief meditation in anxious individuals.

Mind wandering can be costly, especially when we are engaged in attentionally demanding tasks. Preliminary studies suggest that mindfulness can be a promising antidote for mind wandering, albeit the evidence is mixed. To better understand the exact impact of mindfulness on mind wandering, we had a sample of highly anxious undergraduate students complete a sustained-attention task during which off-task thoughts including mind wandering were assessed. Participants were randomly assigned to a meditation or control condition, after which the sustained-attention task was repeated. In general, our results indicate that mindfulness training may only have protective effects on mind wandering for anxious individuals. Meditation prevented the increase of mind wandering over time and ameliorated performance disruption during off-task episodes. In addition, we found that the meditation intervention appeared to promote a switch of attentional focus from the internal to present-moment external world, suggesting important implications for treating worrying in anxious populations.

Intrusive thoughts: linking spontaneous mind wandering and OCD symptomatology.

One recent line of research in the literature on mind wandering has been concerned with examining rates of mind wandering in special populations, such as those characterized by attention-deficit/hyperactivity disorder, dysphoria, and schizophrenia. To best conceptualize mind wandering in studies examining special populations, it has recently been suggested that researchers distinguish between deliberate and spontaneous subtypes of this experience. Extending this line of research on mind wandering in special populations, in a large non-clinical sample (N = 2636), we examined how rates of deliberate and spontaneous mind wandering vary with symptoms of obsessive-compulsive disorder (OCD). Results indicate that, whereas deliberate mind wandering is not associated with OCD symptomatology, spontaneous mind wandering is, with higher reports of spontaneous mind wandering being associated with higher reports of OCD symptoms. We discuss the implications of these results for understanding both mind wandering and OCD.

Stove checking behaviour in people with OCD vs. anxious controls.

BACKGROUND AND OBJECTIVES: A growing body of research suggests that the repetition of an action degrades memory for that action, as well as confidence that is has been done correctly. This has important implications for understanding the compulsive repetition of actions characteristic of obsessive compulsive disorder (OCD). At this time, though, much of the research has been conducted on analogue or nonclinical OCD samples in comparison to healthy controls and often using virtual, as opposed to actual, threat stimuli. Furthermore, although it has been argued that people with OCD are overly attentive to threat stimuli, the research on actual attention to threat is scant. METHODS: People with a principal diagnosis of OCD (n = 30) and people with a clinically significant diagnosis of an anxiety disorder, but no OCD (n = 18) completed measures of memory confidence and responsibility and then underwent a stove-checking task in a functioning kitchen while wearing a portable eye tracking device. Pre- and post-task ratings of harm and responsibility were taken, along with post-task ratings of memory and certainty. RESULTS: People with OCD did not exhibit poorer memory confidence than the anxious control (AC) group, but did report greater trait and state responsibility for harm. The OCD group checked longer than did the AC group and check duration predicted post-task ratings of harm, but to the same extent in both groups. People with OCD attended to threat items less than did the AC group. Greater visual attention to the stove during the checking period was associated with greater post-task ratings of responsibility and harm and with less certainty in and memory for the check - but only for the AC group. LIMITATIONS: The sample size was modest, women were over-represented and problems with the eye tracking device reduced the amount of reliable data available for analysis. CONCLUSIONS: Compulsions are complex actions that are mediated by many trait, state and contextual factors. People with OCD may be able to circumvent self-perpetuating checking processes under certain circumstances. Future research should explore the factors that determine whether or not self-perpetuating mechanisms are activated.

The longitudinal association of relationship satisfaction and sexual satisfaction in long-term relationships.

Several prominent models of relationship satisfaction and sexual satisfaction imply directional relationships between these constructs (e.g., attachment theory, social exchange models of relationship satisfaction, the interpersonal exchange model of sexual satisfaction). Previous research has demonstrated that sexual satisfaction and relationship satisfaction are distinct but correlated constructs, but relatively few studies have examined how they are related over time. Thus, the purpose of this study was to examine this association. A sample of heterosexual couples (N = 113) completed a longitudinal study spanning 2 years. At Times 1 and 2 they completed measures of relationship satisfaction and sexual satisfaction. Data were analyzed according to the principles of the actor-partner interdependence model using structural equation modeling. Significant actor effects were detected such that, for both men and women, one's own earlier sexual satisfaction predicted one's later relationship satisfaction. In contrast, one's own earlier relationship satisfaction did not significantly predict one's subsequent sexual satisfaction. Sexual satisfaction was a stronger predictor of subsequent relationship satisfaction for men than women. There were no significant partner effects. These results contribute to our theoretical understanding of sexuality and sexual satisfaction in the context of long-term relationships by providing support for theories that conceptualize sexual satisfaction as one factor that contributes to relationship satisfaction. (PsycINFO Database Record

Responsibility and hand washing behaviour.

BACKGROUND AND OBJECTIVES: Recent research suggests that compulsions persist due to a self-perpetuating mechanism of poor memory confidence and repetition. However, most of this work has examined checking compulsions and findings may not generalize well to washing compulsions. This study examined the role of responsibility in the persistence of washing behaviour. METHODS: Hand washing was examined in undergraduates (n = 80) high and low in contamination fears (CF) under conditions of high or low responsibility (RL). Wash duration and number of visits to objects/locations key to the wash (e.g., soap) were examined. RESULTS: Overvalued responsibility predicted washing duration across groups. Neither wash duration nor number of visits was associated with memory for the wash. Wash duration predicted post-wash certainty that the wash had prevented harm, but only in the high CF group, and that effect varied according to RL: longer wash duration predicted greater certainty under conditions of low RL but predicted less certainty under conditions of high RL. Greater repetition predicted poorer sensory confidence, but only in the high CF group under high RL conditions. LIMITATIONS: The data were collected in an analogue sample of modest size. Replication in a clinical sample is required. CONCLUSIONS: Self-perpetuating mechanisms identified in perseverative checking seem to also be present in perseverative washing, but only under conditions of high responsibility. Sensory confidence may be more important to perseverative washing than memory confidence. More research is required to understand self-perpetuating mechanisms at play when washing to under conditions of high responsibility.

A Model for Recruiting Clinical Research Participants With Anxiety Disorders in the Absence of Service Provision: Visions, Challenges, and Norms Within a Canadian Context.

High-quality research in clinical psychology often depends on recruiting adequate samples of clinical participants with formally diagnosed difficulties. This challenge is readily met within the context of a large treatment center, but many clinical researchers work in academic settings that do not feature a medical school, hospital connections, or an in-house clinic. This article describes the model we developed at the University of Waterloo Centre for Mental Health Research for identifying and recruiting large samples of people from local communities with diagnosable mental health problems who are willing to participate in research but for whom treatment services are not offered. We compare the diagnostic composition, symptom profile, and demographic characteristics of our participants with treatment-seeking samples recruited from large Canadian and American treatment centers. We conclude that the Anxiety Studies Division model represents a viable and valuable method for recruiting clinical participants from the community for psychopathology research.