Journal of Obsessive-Compulsive and Related Disorders 1 (2012) 54–61
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Journal of Obsessive-Compulsive and Related Disorders
journal homepage: www.elsevier.com/locate/jocrd
Differences in obsessional beliefs and emotion appraisal in obsessive
compulsive symptom presentation
Angela H. Smith a,b,n, Chad T. Wetterneck b,c,1, John M. Hart b,d,2,
Mary B. Short c,3, Thröstur Björgvinsson b,e,4
a
University of Houston, Department of Psychology, 4505 Cullen Blvd. MS 5022, Houston, TX 77204, United States
Houston OCD Program, Houston, TX, United States
c
University of Houston-Clear Lake, Houston, TX, United Sates
d
Center for Anxiety and Depression Treatment of Houston, TX, United States
e
McLean Hospital, Boston, MA, United States
b
a r t i c l e i n f o
a b s t r a c t
Article history:
Received 23 June 2011
Received in revised form
7 November 2011
Accepted 16 November 2011
Available online 25 November 2011
Obsessive-compulsive disorder (OCD) is a heterogeneous condition with symptom presentation that
includes contamination, harm, unacceptable thoughts, and symmetry. Researchers have begun to
examine the ideographic nature of OCD symptoms to aid the development of specialized treatment
approaches. Obsessional beliefs are often implicated in the development and maintenance of the
disorder; however, much of the variance in symptom severity is not accounted for by these beliefs. Less
attention has been paid to the role of emotions in OCD, and to date, no study has investigated beliefs
about emotions (i.e., emotion appraisal) in clinical samples of OCD. In the present study, 44 participants
were recruited from residential and intensive outpatient facilities and private practitioners specializing
in OCD treatment. Participants completed measures of OCD severity, obsessional beliefs and emotion
appraisal. Results indicated that both obsessional beliefs and emotion appraisal were correlated with
each of the symptom presentations to varying degrees, and severity in each of the subtypes was
predicted by a different model. Implications for cognitive and emotional conceptualizations of OCD are
discussed.
& 2011 Elsevier Ltd. All rights reserved.
Keywords:
Obsessive-compulsive disorder
Obsessional beliefs
Emotions
Subtypes
1. Introduction
Obsessive-compulsive disorder (OCD) is a debilitating disorder
characterized by recurring distressing thoughts or images (obsessions), and behaviors intended to reduce distress, including
repetitive overt or mental rituals (compulsions; American
Psychiatric Association (APA), 2000) and avoidance. The relationship between obsessions and compulsions is such that obsessions
evoke anxiety (or another state of negative affect), and compulsions are enacted to ameliorate the aversive feeling. This simplified explanation defines the struggle for many OCD sufferers; yet,
OCD is a heterogeneous disorder with highly varied symptom
n
Corresponding author at: University of Houston, Department of Psychology,
4505 Cullen, Blvd. MS 5022, Houston, TX 77204, United States.
Tel.: þ1 713 743 8600; fax: þ1 713 743 8633.
E-mail addresses: ahsmith2@uh.edu (A.H. Smith),
wetterneck@uhcl.edu (C.T. Wetterneck), drhart@cadthouston.com (J.M. Hart),
shortmb@uhcl.edu (M.B. Short), tbjorgvinsson@partners.org (T. Björgvinsson).
1
Tel.: þ1 281 283 3364.
2
Tel.: þ1 832 264 8152.
3
Tel.: þ1 281 283 3324.
4
Tel.: þ1 617 855 4180.
2211-3649/$ - see front matter & 2011 Elsevier Ltd. All rights reserved.
doi:10.1016/j.jocrd.2011.11.003
presentation. The phenomenology of both the obsessions and
compulsions is diverse. Common obsessions include fears about
contamination, causing harm, neatness or exactness, and violent,
sexual, or religious thoughts. Compulsions may include washing,
checking, ordering, counting, and praying. In the past decade,
researchers have begun to systematically investigate the differences in symptom dimensions to contribute to the development
of specialized treatment approaches. The present study adds to
the existing body of literature by investigating correlates and
predictors of severity in four symptom presentations.
1.1. Classification of OCD symptom presentation
The surge in research related to the differences in OCD was
initiated in part by the fact that up to 50% of individuals with OCD
do not respond optimally to treatment (Baer & Minichiello, 1998;
Cottraux, Bouvard, & Milliery, 2005; Fisher & Wells, 2005; Stanley
& Turner, 1995). While there are several possible explanations for
treatment ‘‘failures,’’ one approach to improving treatment outcomes is to target the idiographic nature of the symptoms by
examining the correlates and predictors for each presentation
type. While the heterogeneity of OCD is widely accepted, there is
A.H. Smith et al. / Journal of Obsessive-Compulsive and Related Disorders 1 (2012) 54–61
some disagreement about the content and number of categories
represented. A meta-analysis of 12 factor-analytic studies representing over 2000 patients with OCD supported four consistent
symptom dimensions including contamination, harm, symmetry,
and hoarding (Mataix-Cols, Rosario-Campos, & Leckman, 2005).
However, researchers are now conceptualizing hoarding as distinct enough to warrant its own diagnostic category (cf., MataixCols et al., 2010); therefore, the present study used the classification derived by Abramowitz et al., 2010) and grouped obsessions
and compulsions into the following: (1) thoughts related to
contamination and washing behaviors, (2) thoughts related to
responsibility for causing harm and checking behaviors, (3)
thoughts related to symmetry and ordering behaviors, and (4)
repulsive thoughts related to sex, religion, or violence and mental
compulsions or neutralizing behaviors.
The development of self-report measures including the Padua
Inventory (PI; Sanavo, 1988), the Obsessive Compulsive Inventory
(OCI; Foa, Kozak, Salkovskis, Coles, & Amir, 1998) and OCI-Revised
(OCI-R, Foa et al., 2002), and the Dimensional Obsessive Compulsive Scale (DOCS; Abramowitz et al., 2010) have allowed researchers to examine the differences between these psychometrically
derived OCD symptom dimensions. The OCI-R and PI are frequently employed to this end; however, several differences
between these measures and the DOCS suggest that the DOCS
may be a more informative measure. Firstly, the DOCS assesses
severity in each symptom presentation multidimensionally, by
inquiring about distress, functional impairment, and frequency of
symptoms. The DOCS also assesses avoidance behaviors, a core
characteristic of OCD not addressed in the OCI-R or PI. Finally,
consistent with the structural framework of OCD, the DOCS does
not include items related to hoarding. As research on the OCD
symptom dimensions expands, utilizing measures that address
each component of OCD symptomology, such as the DOCS, will
increase the utility of the findings.
The extant research examining the heterogeneity of OCD has
largely focused on specific maladaptive beliefs, but many other
factors (e.g., emotion appraisal) also may contribute to OCD
development, maintenance, severity, and prognosis. Treatmentenhancing modifications are an anticipated outcome of research
on the symptom dimensions, and broadening the scope of
possible factors related to each subtype will further inform
treatment innovations. A review of obsessional beliefs and emotions as they relate to OCD will provide the context for the
present study.
1.2. Thought appraisal
The appraisal theory of obsessions dominates OCD research
and practice (Clark, 2004). These theories (Rachman, 1997, 1998;
Salkovskis, 1985) posit that the interpretation of thoughts significantly contributes to the development of obsessions. More
recently, belief-based models of OCD have been theorized
(Rachman, 2002, 2004) and OCD researchers have distinguished
three obsessional belief domains: over responsibility and overestimation of threat (RT), perfectionism and intolerance of uncertainty (PC), and importance of thoughts and need to control
thoughts (ICT; Obsessive-Compulsive Cognitions Working Group
[OCCWG], 2005). There is empirical evidence to suggest that these
belief domains are associated with OCD; however, the results are
not completely conclusive and much of the variance in symptom
severity is not accounted for by obsessional beliefs (cf., Julien,
O’Connor, & Aardema, 2007).
Clinical observation alludes to specific relationships between
belief domains and OCD symptom dimensions (e.g., over-responsibility and harm subtype), and limited empirical evidence provides support for the specificity of belief domains in the symptom
55
dimensions (Manos et al., 2010; Wheaton, Abramowitz, Berman,
Riemann, & Hale, 2010). While there is considerable evidence
to support the role of obsessional beliefs, the lack of a coherent
model, varied empirical findings in clinical samples, and unaccounted variance in severity are causing researchers to look
beyond cognitive appraisals to explain the OCD symptomology.
1.3. Emotions in OCD
Anxiety, a universal experience with important protective
functions, becomes problematic when the cue to danger is inproportionate to the actual threat in the environment. Calamari,
Rector, Woodard, Cohen, and Chik (2008) found that anxiety
sensitivity (AS; i.e., the fear of anxiety-related bodily sensations)
contributed to models predicting OCD severity, beyond the cognitive appraisal constructs described above. The same study found
that the relationship between AS and OCD symptom severity
varied across symptom dimensions. Obviously, experiences of
anxiety play a central role in anxiety disorders! However, there
is evidence to suggest that anxiety is experienced with some
variability in OCD (Nutt & Malizia, 2006) and that it may not be
the primary feeling, or the only threatening feeling, experienced by
individuals with this disorder. Rather, one’s relationship with their
emotions in general, including other aversive emotions may also be
implicated in problematic anxiety. Several emotions have been
theorized as being fairly universal, including fear, disgust, and guilt
(Power, 2006), and these emotions are suspected to be relevant to
OCD etiology and phenomenology as well.
1.3.1. Disgust
Disgust is a universal guttural response characterized by
withdrawal from repulsive stimuli, such as animal and food
products (Rozin & Fallon, 1987). Individuals experience disgust
to varying degrees and greater disgust sensitivity has been related
to OCD symptom presentation and severity (Berle & Phillips,
2006; Olatunji, Williams, Lohr, & Sawchuk, 2005; Tolin, Woods,
& Abramowitz, 2006). In addition to elicitation by physical
stimuli, Borg, Lieberman, and Kiehl (2008) identified that disgust
may be elicited by incest and non-sexual immoral acts (e.g., theft
and murder). This is consistent with cross cultural research
findings that suggest a relationship between disgust and moral
judgment (e.g., Haidt, Rozin, McCauley, & Imada, 1997; Schnall,
Haidt, Clore, & Jordan, 2008). Research related to disgust and
OCD has increased in recent years; yet this body of research is
primarily related to contamination symptom presentations. Evidence supporting disgust related to immoral acts suggests that
disgust may be implicated in the harm and unacceptable thoughts
symptom dimensions as well. The appraisal of disgust experiences has yet to be examined in OCD, warranting an investigation.
1.3.2. Guilt
Feelings of guilt have been related to greater symptom severity
and poorer treatment prognosis in OCD (cf., Shapiro & Stewart,
2011). However, much of the research on guilt has primarily
focused on the relationship between guilt feelings and beliefs
about responsibility. Salkovskis and Forrester (2002) explain that
over-responsibility is derived from the threat of physical or moral
danger, a primary goal of preventing a negative outcome, and an
inflated belief that one has the power to prevent the aversive
outcome. Guilt is a natural response for an individual who feels
wholly responsible for a negative outcome, particularly if they
perceive their actions as morally unjust (Mancini & Gangemi,
2004). These findings blur the lines between feeling guilt and
beliefs about responsibility and the fused relationship between
these constructs may lend to a greater focus on the cognitive
56
A.H. Smith et al. / Journal of Obsessive-Compulsive and Related Disorders 1 (2012) 54–61
construct of responsibility over the emotional construct of guilt in
both research and clinical practice. Examining threat from guilt in
the various symptom presentations may help clarify when guilt is
problematic in individuals with OCD, independent of feelings of
responsibility.
1.3.3. Not just right feelings
In addition to these emotions, many individuals with OCD may
have trouble clarifying their emotions, and naming their internal
experiences (i.e., alexithymia), and these individuals may report
experiencing ‘‘not just right’’ feelings (NJRFs). Alexithymia is a
personality construct characterized by difficulties in understanding, processing, and describing emotions (Sifneos, 1973). Research
findings have suggested an association between alexithymia and
OCD severity (Bankier, Aigner, & Bach, 2001; Rufer et al., 2004,
2006), and individuals with these difficulties may describe their
experiences as ‘‘not just right,’’ when they are unable to articulate
their specific experience. Additionally, OCD has been conceptualized as an inability to put closure to an experience (Reed, 1985),
as exemplified by an individual who washes his hands until they
‘‘feel clean.’’ Similarly, many individuals with OCD describe
needing to perform compulsions until they ‘‘feel right.’’ While
research suggests that these feelings are distressing (Coles et al.,
2005), it is not clear how these unnamed feelings compare to
experiences of anxiety, disgust, and guilt. This forms the basis for
examining threat from NJRFs in each of the OCD symptom
dimensions.
1.3.4. Emotion appraisal
Barlow (1991) suggested that anxiety disorders may be characterized as ailments of emotion processing. Recently, the role of
emotion regulation has received attention in the research on
anxiety and mood disorders (cf., Allen & Barlow, 2009). This
research indicates that individuals with anxiety, including OCD,
engage in maladaptive strategies (e.g., suppression) to regulate
the frequency and experiences of emotions. There are differences
in the ease with which individuals elicit, respond to, and recover
from emotions, as well as individual differences in acceptance
of emotions (i.e., judgment as appropriate, tolerable, or logical;
Amstadter, 2008). Over-two decades of research on meta-emotion
across disciplines suggests that there are individual differences in
the way in which people evaluate their emotions. Mayer and
Gaschke (1988) explain that emotion is experienced first directly
and then reflectively. That is, the emotion is experienced, and
one’s reflection on the emotion causes a secondary experience of
emotion. Bartsch, Vorderer, Mangold, and Viehoff (2008) suggest
that meta-processes (e.g., appraisal) influence the way in which
emotions are expressed and regulated. Ultimately, the way in
which appraises their emotions may impact the use of maladaptive emotion regulation strategies in OCD. However, elucidating
how emotions are appraised and whether emotion appraisal is
related to symptom severity in OCD is a necessary first step.
Experiential avoidance, the avoidance of aversive private
experiences including thoughts, feelings, and bodily sensations
(Hayes, Wilson, Gifford, Follette, & Strosahl, 1996), has begun to
receive attention in the OCD literature, and the relationship
between overall experiential avoidance and OCD symptomology
is inconclusive (e.g., Abramowitz, Lackey, & Wheaton, 2009;
Briggs & Price, 2009; Manos et al., 2010). Some have suggested
that an overall measure of experiential avoidance may be too
broad to reflect symptoms in specific disorders (Manos et al.).
Therefore, it may be more useful to investigate the appraisal of
specific emotions rather than the appraisal of internal experiences
in general. McCubbin and Sampson (2006) investigated the extent
to which an individual feels that having a certain emotion (e.g.,
fear/anxiety) is dangerous (i.e., feeling threat from emotions).
They posited that this trait characteristic is related to heightened
awareness of danger, attempts to avoid emotions, and the use of
maladaptive methods to cope with unpleasant emotions (e.g.,
performing compulsions). Their results found that threat from
specific emotions significantly predicted obsessionality in a nonclinical sample, but this construct has yet to be examined in
clinical populations. The present study examined individuals’
appraisal of anxiety, disgust, guilt, and NJRFs, as well as the
frequency with which these emotions are experienced in a clinical
sample.
1.4. Aim and hypotheses
The current study contributes to the line of research investigating OCD symptom dimensions by exploring obsessional beliefs
and emotion appraisal in four OCD symptom dimensions: contamination, harm, unacceptable thoughts, and symmetry. Based
on previous findings (Julien et al., 2007; Wheaton et al., 2010), we
predicted that each subtype would be partially predicted by at
least one obsessional belief; (1) the contamination subtype would
be associated with beliefs about responsibility/overestimation of
threat and perceptions of threat from anxiety, disgust, and guilt;
(2) the harm subtype would also be most closely associated with
beliefs about responsibility/overestimation of threat and threat
from anxiety and guilt; (3) the unacceptable thoughts subtype
would be associated with beliefs about importance and need to
control thoughts and threat from anxiety, disgust, and guilt; and
(4) the symmetry subtype would be associated with beliefs
about perfectionism/intolerance of uncertainty and threat from
NJRFs. However, as this is the first study to examine threat from
emotion, the investigation is somewhat exploratory, and perceived threat from each emotion was examined in relation to each
of the symptom dimensions.
2. Method
2.1. Data collection
A multi-site recruitment strategy was implemented in order to obtain a wide
representation of symptom severity. Participants were recruited from residential
and intensive outpatient programs in Texas and Maryland and from outpatient
treatment providers in Texas, Kansas, and Wisconsin. Participants included 44
adults receiving residential (RES; n¼ 20), intensive outpatient (IOP; n¼ 10) or
outpatient treatment (OP; n¼ 14) for OCD. Diagnoses of OCD were determined by
treating clinicians, all of whom were behaviorally oriented psychologists and
psychiatrists specializing in the treatment of OCD. A multi-site recruitment
strategy that targeted individuals with varying levels of symptomatology was
employed to increase the generalizability of the results. Eligible individuals in
residential and IOP treatment were offered the opportunity to participate by a
research assistant, and individuals in OP treatment were provided the opportunity
from their treating clinician. Participants were also offered $10 for their participation; however, several individuals declined to accept payment. After informed
consent was obtained, participants received a paper version of the study, which
took approximately 30 min to complete.
2.2. Participants
Participants (N ¼ 44) ranged in age from 18 to 62 (M¼ 31.86, SD ¼10.08), and
were primarily Caucasian (n¼ 35, 79.5%). Other races/ethnicities were limited in
representation and included Bi-racial (n¼ 3, 6.8%), Asian/Pacific Islander (n¼ 2,
4.5%), Hispanic (n ¼1, 2.3%), Middle Eastern (n¼1, 2.3%), other (n¼ 1, 2.3%), and
not reported (n¼ 1, 2.3%). Males (n¼ 21) and females (n¼ 23) were equally
represented in the study.
2.3. Measures
Two measures were utilized to assess OCD severity. The Yale-Brown Obsessive
Compulsive Scale- Self-Report (Y-BOCS-SR; Steketee, Frost, & Bogart, 1996) is a
10- item measure that contains five items related to obsessions and five related to
A.H. Smith et al. / Journal of Obsessive-Compulsive and Related Disorders 1 (2012) 54–61
compulsions. Scores range from 0 to 40 (0–7¼ subclinical, 8–15 ¼ mild, 16–23¼
moderate, 24–31¼ severe, and 32–40 ¼ extreme), and scores of 16 and above
indicate clinical levels of severity. The Y-BOCS-SR is highly correlated with the
clinician conducted interview version of the Y-BOCS (r¼ .97; Baer, Brown-Beasley,
Sorce, & Henriques, 1993), the gold standard for assessing OCD severity. The
YBOCS-SR has shown acceptable internal consistency (Cronbach’s a ¼ .78 in an
OCD sample) and test re-test reliability (r ¼.88, p o .001 in a non-clinical sample)
over a 1 week period (Steketee et al., 1996). The internal consistency in this
sample was excellent (Cronbach’s a ¼ .92).
The Dimensional Obsessive Compulsive Scale (DOCS; Abramowitz et al., 2010)
individually assesses severity from four types of obsessions: contamination, harm,
unacceptable thoughts, and symmetry. For each subtype, severity is measured
by the summation of (1) time occupied by symptoms, (2) avoidance behaviors,
(3) distress from symptoms, (4) functional interference, and (5) ability to
disregard obsessions and refrain from compulsions. Scores for individual symptom
dimensions range from 0 to 20, with higher scores indicating greater severity. The
DOCS has shown strong internal consistency for each of the symptom dimensions
(a’s ranging from .94 to .96; Abramowitz et al.). Each of the DOCS subscales has
acceptable test-re-test reliability over a 12 week period (r’s ranging from .12 to .6).
The DOCS has also demonstrated strong concurrent validity with the Y-BOCS-SR
(r¼ .54, p o .01) and OCI-R (r ¼.69, po .01). The internal consistencies in this
sample were all excellent (Cronbach’s a’s¼ .95–.97).
The Obsessive Beliefs Questionnaire-44 (OBQ-44; OCCWG, 2005) is a 44-item
measure of belief domains related to obsessive thinking. The OBQ-44 consists of
three factors: over responsibility and over estimation of threat (RT), over importance or need to control thoughts (ICT), and perfectionism or intolerance of
uncertainty (PC). The level of agreement with each statement is rated on a 7-point
scale from disagree very much (1) to agree very much (7), with a neutral (4) option. All
items are scored in the same direction, and higher scores indicate greater strength
of beliefs. Internal consistency coefficients (Cronbach’s a) for the three subscales
ranged from .89 to .95 in a clinical sample (OCCWG). The OBQ-44 subscales were
highly correlated with associated subscales on the PI-R (Burns, Keortge, Formea, &
Sternberger, 1996), indicating strong convergent validity (OCCWG). The internal
consistencies in this sample were all excellent (Cronbach’s a’s¼ .90–.95).
The Perceived Threat from Emotions Questionnaire- Revised (PTEQ-R; McCubbin &
Sampson, 2006) measures beliefs about emotions using nine questions for each of
eight emotions: happiness, sadness, anger, fear/anxiety, disgust, guilt, lust, and strong
emotions in general. Four subscales (i.e., anxiety, guilt, and disgust) were used in the
present study because of their theoretical coherence with the OCD symptom
dimensions and their relationship with OCD symptoms as previously reported in
the literature. In addition to these, the questions were modified to ask about threat
from NJRFs. The PTEQ was utilized in the study, because it seems to measure how one
experiences their emotions, rather than the frequency of certain emotions. For
example, questions include ‘‘Do you think it is dangerous to feel anxiety?’’, ‘‘Could
anxiety cause you to lose control and do things you would later regret?’’, ‘‘When you
feel anxiety does it seem it will last forever?’’, and ‘‘Could anxiety overwhelm you so
that you are unable to function?’’ Responses are rated on a five-point scale ranging
from not at all (0) to definitely (5). Subscale scores are generated by adding the first
seven items of each scale, with higher scores indicating greater overall threat from
emotion. The PTEQ also asks ‘‘Do you feel anxiety quite often?’’ This question was
analyzed to determine the frequency of other emotional experiences in OCD. The
PTEQ has demonstrated strong convergent validity with measures of mood, responsibility, and thought-action fusion (i.e., a measure of beliefs; McCubbin & Sampson).
The internal consistencies in this sample ranged from good (PTEQ-Anxiety;
Cronbach’s a ¼.86) to excellent (PTEQ-NJRFs; Cronbach’s a ¼.94).
57
Table 1
Symptom severity and independent variable means (and standard deviations).
M (SD)
Measures of OCD severity
Y-BOCS-SR
DOCS-contamination
DOCS-harm
DOCS-unacceptable thoughts
DOCS-symmetry
21.18
7.34
7.07
8.89
3.93
(6.95)
(6.48)
(5.87)
(5.29)
(5.00)
Predictor variables
OBQ-44-RT
OBQ-44-PC
OBQ-44-ICT
PTEQ-anxiety
PTEQ-disgust
PTEQ-guilt
PTEQ-NJRF
67.00
66.80
47.32
16.55
9.34
11.09
9.45
(25.66)
(22.91)
(17.00)
(6.55)
(8.14)
(6.92)
(8.45)
Note: Y-BOCS-SR ¼ Yale Brown Obsessive Compulsive Scale-Self-Report; DOCS¼Dimensional Obsessive Compulsive Scale; OBQ-44 ¼ Obsessive Compulsive
Questionnaire; RT ¼ responsibility/overestimation of threat; PC ¼perfectionism/
intolerance of uncertainty; ICT¼ importance/control of thoughts; PTEQ ¼Perception of Threat from Emotions Questionnaire; NJRF ¼not just right feelings.
score of 21.18 (SD ¼6.95). Mean severity scores for each of the
three groups were as follows: RES ¼24.15 (sd ¼6.52), IOP ¼21.50
(sd ¼8.34), and OP¼16.71 (sd ¼3.75). Each group in the current
sample had an average severity score of 16 or higher, indicating
clinical levels of severity for each group. An analysis of variance
(ANOVA) was used to compare mean severity scores by group on
the Y-BOCS-SR. The analysis revealed a significant difference in
OCD symptom severity on the Y-BOCS-SR (F(2,41)¼ 5.79, p o.01).
Due to unequal sample sizes, post-hoc comparisons were conducted using Gabriel’s procedure. Post-hoc contrasts revealed a
significant difference between RES and OP groups (t ¼7.44,
po.05); however, there was no significant difference between
RES and IOP or IOP and OP groups. Although there were some
differences in severity between groups, the remaining analyses
were conducted using a combined data set because the disparity
in the number of participants in each group limited the utility of
between-group comparisons. In addition, 10 participants had
Y-BOCS-SR scores below 16, the cut-off widely used to indicate
clinical level of severity. It was the authors’ intention to allow for
generalizability of the results by not excluding participants who
endorsed symptom severity at slight levels; therefore, all 44
participants were included in the remaining analyses.
3.2. Obsessional beliefs and emotion appraisal
2.4. Analytic plan
OCD symptom severity was compared across treatment settings using an
Analysis of Variance (ANOVA); ultimately, all participants were analyzed as a single
group. Next, Pearson’s r correlations were conducted to determine zero-order
relationships between OCD severity, obsessional beliefs, and emotion appraisal.
Finally, a series of regressions were computed to test hypotheses about the prediction
of symptom severity from obsessional beliefs and emotion appraisal. To adjust for the
familywise error rate associated with running multiple regressions, the alpha rate for
a significant model was adjusted from .05 to .0125 (i.e., .05/4). The DOCS subscales
were used as dependent variables, and OBQ-44 and PTEQ factors were entered
simultaneously into each regression. Beta coefficients were analyzed to determine
the unique variance attributed to each predictor.
3. Results
Mean scores for obsessional beliefs and emotion appraisal are
presented in Table 1. Obsessional beliefs in the present sample
were similar to those reported in the OBQ-44 validation study
(OCCWG, 2005). Levels of responsibility/overestimation of threat
and perfectionism/intolerance of uncertainty were endorsed more
highly than importance/control of thoughts. Levels of threat from
anxiety were higher than threat from disgust, guilt, and NJRFs.
Additionally, the frequency of anxiety, disgust, and guilt experiences in this sample were substantially higher than those reported
in a non-clinical sample. In the present sample, 88.6% of participants reported feeling anxiety quite often compared to 39.8% of
participants in a non-clinical sample (McCubbin & Sampson, 2006).
Similarly, in the present study participants endorsed feeling disgust (47.7%), guilt (86.4%), and NJRFs (51.2%) quite often.
3.1. Overall symptom severity
3.3. OCD symptom dimensions
Symptom severity data are presented in Table 1. Overall, the
sample reported a moderate level of severity. Y-BOCS-SR scores
ranged from 10 (mild) to 38 (extreme), with an average severity
Correlations between the Y-BOCS-SR and DOCS subscales
indicate that the Y-BOCS-SR was significantly correlated with
58
A.H. Smith et al. / Journal of Obsessive-Compulsive and Related Disorders 1 (2012) 54–61
Table 2
Correlations between DOCS subscales and independent variables.
Measure
OBQ-44-RT
OBQ-44-PC
OBQ-44-ICT
PTEQanxiety
PTEQdisgust
PTEQ-guilt
PTEQ-NJRF
Table 3
Correlations among independent variables.
DOCS subscale
Contamination
Harm
Unacceptable
thoughts
.31n
.02
.01
.20
.56nn
.29
.19
.51nn
.30n
.37n
.43nn
.44nn
.29
.47nn
.14
.40n
.29
.42nn
.37n
.16
.00
.18
n
.37
.39n
nn
.51
.44nn
Symmetry
nn
.56
.65nn
1.
2.
3.
4.
5.
6.
7.
OBQ-44-RT
OBQ-44-PC
OBQ-44-ICT
PTEQ-anxiety
PTEQ-guilt
PTEQ-disgust
PTEQ-NJRF
p o .05.
nn
p o.01.
n
the DOCS-Contamination (r ¼.50, p o.01), DOCS-Harm (r ¼.34,
p o.05), DOCS-Unacceptable Thoughts (r ¼.41, p o.01), and
DOCS-Symmetry (r ¼.45, p o.01) subscales, supporting the use
of the DOCS scales as measures of OCD severity. Additionally,
although there was significant collinearity among the DOCSHarm, -Unacceptable Thoughts, and -Symmetry scales, there is
enough variation to indicate that the scales measure severity
unique to different symptom clusters.
Significant correlations between the DOCS subscales and the
independent variables are presented in Table 2. Relationships
between each of the OCD symptom dimensions and the independent variables varied, and the number of variables correlated with
each of the subscales ranged widely, further supporting the
heterogeneity of OCD. For example, the DOCS-contamination
subscale was significantly correlated with only one obsessional
belief (i.e., OBQ-44-RT) and had a near significant relationship
with PTEQ-disgust, whereas the DOCS-unacceptable thoughts
subscale was significantly correlated with all seven independent
variables. The harm and symmetry symptom dimensions were
each significantly related to several factors including multiple
PTEQ factors and at least one OBQ-44 factor. Finally, threat from
anxiety was significantly correlated with three of the four
symptom dimensions (excluding contamination).
3.4. Relationships among independent variables
The intercorrelations among the independent variables are
presented in Table 3. Each of the PTEQ scales was highly related to
each other, while there were fewer significant relationships
between the PTEQ and OBQ-44 factors (i.e., only 5 of the possible
10 relationships were significant). These results suggest that
obsessional beliefs and emotion appraisal are unrelated constructs. A notable addition to the above finding is that PTEQ-guilt
was not significantly related to beliefs about responsibility/overestimation of threat.
3.5. Predictors of severity in the OCD symptom dimensions
Results for the regression analyses are presented in Table 4. The
model in this study did not significantly predict severity in the
contamination dimension (F(1,42)¼1.95, p¼.09). The model predicting the harm dimension accounted for 40% of the variance in
severity (F(5,38)¼5.08, po.001), with beliefs about responsibility/
overestimation of threat uniquely contributing to variance. The
3.
4.
5.
6.
7.
.66nn
.37n
.49nn
.38n
.23
.30n
.22
.39nn
.38n
.57nn
.28
.28
.25
.30n
.36n
.23
.38n
.16
.50nn
.63nn
.46nn
Notes: OBQ-44 ¼ Obsessive Compulsive Questionnaire-44; RT ¼ responsibility/
overestimation of threat; PC ¼perfectionism/intolerance of uncertainty; ICT¼
importance/control of thoughts; PTEQ ¼Perception of Threat from Emotion;
NJRF¼ not just right feelings; GI ¼Guilt Inventory.
n
Note: DOCS ¼ Dimensional Obsessive Compulsive Scale; OBQ-44 ¼Obsessive
Beliefs Questionnaire-44; RT ¼responsibility/overestimation of threat; PC¼ perfectionism/intolerance of uncertainty; ICT¼importance/control of thoughts;
PTEQ¼ Perception of Threat from Emotions Questionnaire, NJRF¼ not just right
feelings; GI ¼Guilt Inventory.
2.
nn
¼ po .05.
¼p o .01.
Table 4
Summary of the regression equations predicting the DOCS subscale scores.
Adjusted R2
DV¼ DOCS-contamination
Constant
OBQ-44-RT
OBQ-44-PC
OBQ-ICT
PTEQ-anxiety
PTEQ-disgust
PTEQ-guilt
PTEQ-NJRF
DV¼ DOCS-harm
Constant
OBQ-44-RT
OBQ-44-PC
OBQ-ICT
PTEQ-anxiety
PTEQ-disgust
PTEQ-guilt
PTEQ-NJRF
DV¼ DOCS-UT
Constant
OBQ-44-RT
OBQ-44-PC
OBQ-ICT
PTEQ-anxiety
PTEQ-disgust
PTEQ-guilt
PTEQ-NJRF
DV¼ DOCS-symmetry
Constant
OBQ-44-RT
OBQ-PC
OBQ-ICT
PTEQ-anxiety
PTEQ-disgust
PTEQ-guilt
PTEQ-NJRF
B
SE B
b
p
5.44
.12
.08
.07
.08
.20
.16
.13
3.60
.05
.06
.07
.19
.13
.20
.16
.46
.28
.18
.08
.25
.17
.17
ns
.03
ns
ns
ns
ns
ns
ns
2.54
.13
.06
.03
.18
.14
.09
.056
2.72
.04
.05
.05
.15
.10
.15
.12
.56
.21
.08
.20
.20
.11
.09
.ns
o.01
ns
ns
ns
ns
ns
ns
.64
.00
.01
.07
.11
.08
.13
.09
2.70
.04
.05
.05
.15
.10
.15
.12
.15
.06
.23
.14
.12
.18
.15
2.84
.00
.07
.04
.05
.13
.18
.27
2.17
.03
.04
.04
.12
.08
.12
.10
.02
.30
.15
.07
.21
.25
.45
.13
.40
.27
ns
ns
ns
ns
ns
ns
ns
ns
.47
ns
ns
ns
ns
ns
ns
ns
o.01
Notes: DOCS ¼Dimensional Obsessive Compulsive Scale; UT ¼unacceptable
thoughts; OBQ-44 ¼Obsessive Beliefs Questionnaire-44; RT¼ responsibility/overestimation of threat; ICT¼importance/control of thoughts; PTEQ ¼Perception of
Threat from Emotions Questionnaire; NJRF ¼not just right feelings.
unacceptable thoughts dimension was predicted by the model,
which accounted for 24% of the variance in symptom severity
(F(7,36)¼3.23, po.01), with no factor emerging as a unique
predictor. Finally, the model predicting the symmetry dimension
accounted for 47% of the variance in severity (F(4,39)¼6.40,
po.001), with threat from NJRFs contributing uniquely to the
model. Post-hoc analyses revealed that the validity of the findings
was not threatened by collinearity among the predictor variables.
A.H. Smith et al. / Journal of Obsessive-Compulsive and Related Disorders 1 (2012) 54–61
4. Discussion
OCD is a heterogeneous disorder with varied symptom presentation, and the differences in OCD have received increased
attention in recent years. The current study contributed to the line
of research on OCD symptom presentation by examining obsessional beliefs and emotion appraisal as they related to distress
from four OCD symptom dimensions: contamination, harm, unacceptable thoughts, and symmetry. Results indicated that symptoms in each of the four symptom dimensions were predicted by a
different model, supporting the heterogeneity of OCD symptoms.
The results also implicate emotion appraisal as an important factor
related to OCD and a possible contributing factor to differentiating
the symptom dimensions. Together, these findings help clarify
what is known about the OCD symptom dimensions and may
provide potential for new targets for treatment.
4.1. OCD contamination dimension
A majority of the research on OCD has examined the contamination dimension. Contrary to our hypothesis that contamination
would be related to beliefs about responsibility/overestimation of
threat as well as threat from anxiety, disgust, and guilt, in the
present study, severity in the contamination dimension only was
significantly correlated with one factor, beliefs about responsibility/overestimation of threat.
One explanation for the current findings is that the construct
of contamination itself may be heterogeneous. Often, individuals
with contamination OCD either fear being contaminated by
others or contaminating others. Beyond these, ‘‘emotional contamination’’ concerns arise for individuals who appraise certain
stimuli as contaminated because of the emotions they elicit. For
example, an individual may judge an article of clothing as
contaminated not because of its physical properties, but because
the item elicits feelings of guilt related to an event that occurred
when they were wearing the clothing. Emotional contamination,
or mental pollution (Rachman, 1994) may be responded to with
overt rituals such as hand washing; however, this may occur until
one feels ‘‘just right,’’ rather than for a specified amount of time.
Therefore, a heterogeneous contamination subtype may explain
the lack of significant relationships in the present study.
Similarly, depending on the type of contamination concern,
feelings other than anxiety may be elicited and feared, such as
disgust related to contracting and guilt related to contaminating
others. It was somewhat surprising that fear of disgust was not
significantly correlated with contamination concerns in the present study (although the relationship was near significance). It is
possible that obsessions in the present sample were more
characteristic of fear of contaminating others rather than fear of
self-contamination, in which case, disgust would be a less salient
emotion. Thus, if the appraisal of specific emotions (i.e., PTEQ
factor) is related to the specific type of contamination fear, it is
possible that the limited sample size in the present study
contributed to low power in detecting the relationship (i.e., not
enough representation for each type of contamination fear).
Finally, regression analyses revealed that the model was not a
significant predictor of variance in contamination severity. These
results are similar to those by Wheaton et al. (2010), who found that
a model of obsessional beliefs and depression left almost 90% of the
variance in contamination unaccounted for. Thus, other factors not
included in the present study likely contribute to severity.
4.2. OCD harm dimension
Consistent with our hypothesis, the harm dimension was correlated with obsessional beliefs about responsibility/overestimation of
59
threat as well as threat from anxiety and guilt. Harm obsessions also
were correlated with threat from disgust and NJRFs; thus, threat from
each of the emotions examined was significantly related to harm
obsessions. Intuitively, most individuals would feel guilty if they
unintentionally caused harm or failed to prevent harm to themselves
or another; however, guilt may be more problematic when the feeling
itself is appraised as threatening. Additionally, the lack of a significant
relationship between beliefs about responsibility/overestimation of
threat and threat from guilt in this sample is notable. We previously
suggested that responsibly and guilt are often treated as fused
constructs in the literature, and that the clinical emphasis on
responsibility implies that problematic guilt is addressed indirectly
by targeting beliefs about responsibility. These results suggest that
the appraisal of guilt as threatening is independent of responsibility,
and therefore, guilt may need to be addressed directly in therapy
rather than treated as a byproduct of responsibility.
The relationship between harm and beliefs about disgust may
be explained by the idea of moral disgust. While the PTEQ does
not differentiate between pathogen-related disgust and moral
disgust, it is reasonable that an individual would feel morally
disgusted if they caused or failed to prevent harm. Finally, the
multiple regression analysis revealed that obsessional beliefs
about responsibility accounted for unique variance in symptom
severity related in the harm dimension. These results indicate
that OCD symptomology is related to not only experiences of guilt
but also feeling threatened by these guilt feelings.
4.3. OCD unacceptable thoughts dimension
There is less research on unacceptable thoughts compared to
contamination and checking. Consistent with our hypotheses,
severity from unacceptable thoughts was related to importance/
control of thoughts and threat from anxiety, guilt, and disgust.
This symptom dimension was also associated with threat from
NJRFs. Severity from unacceptable thoughts was the only dimension in the present sample related to all three obsessional beliefs
and all four PTEQ factors. However, no one factor contributed
unique variance to the model.
One explanation for numerous correlations is that grouping all
unacceptable thoughts together increases the likelihood that
many factors will be related to the construct. Repugnant thoughts
are often violent, sexual, or religious in nature. Inquiring about
each of these types of thoughts separately may narrow the factors
related to each type of specific thought; further research is
needed to determine if separating the unacceptable thoughts
would be useful. Recent research on a non-clinical sample
(Wetterneck, Smith, Hart, & Burgess, 2011) indicated that distress
from sexually intrusive thoughts is related to both thought-action
fusion (i.e., another common obsessional belief) and feeling threat
from lust. However, only threat from lust and the frequency with
which the thoughts occurred added unique variance to the model
predicting distress. These findings bolster the argument for
further examination of the relationship between obsessive-compulsive symptoms and beliefs about emotions. It is possible that
the factors that cause distress from violent, sexual, and religious
thoughts are just as varied as the factors that cause distress in the
existing symptom dimensions.
Improving the effectiveness of ERP for sexual, violent, and
religious obsessions is a concern for OCD researchers and clinicians. These results indicate that several emotions are salient and
threatening for individuals with this symptom presentation,
providing a new treatment target for those who have typically
focused on treating the anxiety. Future research is needed to
clarify and specify these relationships so that treatment enhancements may be developed.
60
A.H. Smith et al. / Journal of Obsessive-Compulsive and Related Disorders 1 (2012) 54–61
4.4. OCD symmetry dimension
Consistent with our hypothesis and the findings by Wheaton
et al. (2010), severity in the symmetry dimension was correlated
with obsessional beliefs about perfectionism/intolerance of
uncertainty. Our hypothesis that the symmetry dimension would
be related to threat from NJRFs is also supported by the present
findings. Overall, the symmetry dimension was more strongly
associated with threat from emotions than with obsessional
beliefs, as it was related threat from three emotions (i.e., anxiety,
guilt, and NJRFs) and one obsessional belief.
Additionally, nearly half of the variance in the symmetry
dimension was accounted for by the present model, whereas only
21% of the variance was accounted for in the model by Wheaton
et al. (2010). Perhaps for a nebulous presentation like NJRFs, it is
more difficult to verbalize the experiences and thus feelings are
more strongly highlighted. Overall, these findings further support
the importance of perceptions of emotions in OCD.
4.5. Conclusions
While the results support the heterogeneity of OCD symptoms,
patterns across symptom dimensions emerged as well. This is the
first study to investigate perceptions about emotions in an OCD
population and feeling threatened by emotions could be seen across
all symptom dimensions. In addition, threat from emotions was
substantially higher in this sample compared to a non-clinical
sample. For example, 86.4% of the present sample reported experiencing guilt quite often, compared to 21.1% of participants in a nonclinical sample (McCubbin & Sampson, 2006). Similarly, 47.7% of
participants in the current sample reported experiencing disgust
quite often compared to 15.4% in the McCubbin and Sampson study.
Thus, while threat from emotions did not uniquely predict severity
in three of the four dimensions, the findings suggest that beliefs
about emotions are not irrelevant to individuals with OCD.
OCD treatments focus on the functional role between obsessions and compulsions and explain that compulsions are performed in order to reduce anxiety. However, these results suggest
that some individuals may benefit if other emotions are targeted
in treatment, especially guilt, disgust, and NJRFs. While NJRFs may
differ somewhat from traditional conceptualizations of emotion,
they represent an unpleasant internal experience that is highly
relevant for some individuals with OCD. At minimum, it may be
useful to discuss these other emotions when providing the treatment rationale, so that individuals who experience emotions
other than anxiety feel that the treatment is relevant to their
specific experience. Furthermore these emotions may need to be
addressed differently than anxiety. There is empirical evidence to
show that anxiety reduces as a result of ERP for OCD; disgust also
reduces as a result of ERP, but at a slower rate (McKay, 2006).
Additionally, focusing exposure work on overcoming fear from
NJRFs may enhance the treatment for those presenting with
symmetry concerns. Different ways of addressing emotions such
as guilt, disgust, and NJRFs may also be effective; however future
research will need to explore this further. Future research may
also explore how emotion appraisal is related to maladaptive
emotion regulation strategies in individuals with OCD.
4.6. Limitations
Despite the new findings, limitations of the study should be
noted. Firstly, the generalizability of the results is hindered by the
fairly small sample size and lack of racial and ethnic diversity.
A larger sample would benefit the investigation by providing the
opportunity to compare participants by subtype and analyze
comorbidity between symptom clusters. Additionally, individuals
with OCD commonly experience more than one symptom dimension (e.g., primary contamination concerns and less frequent or
intense unacceptable thoughts), and participants were not classified by their primary symptom dimension in this study. It is also
unknown how many participants had more than one symptom
presentation. Another limitation is that these findings are based
solely on self-report measures of symptom severity. The use of a
clinician directed semi-structured interview would lend to diagnostic validity of the sample as well as clarify the symptom
dimensions (i.e., make it possible to determine the primary
dimension for those with more than one symptom presentation).
Unknown comorbid diagnoses and the absence of depression
scores are another limitation to the present findings. Depression
has been used as a control variable in several studies addressing
symptomology (e.g., Manos et al., 2010; Tolin, Worhunsky, Brady,
& Maltby, 2007), as it is widely viewed as an aspect of general
negative affect that also may lead to more negative cognitions.
However, previous findings indicate that depression accounts for
limited and disparate variance in the OCD symptom dimensions
as measured by the DOCS (Abramowitz et al., 2010) and thus may
not have significantly impacted the present findings. In addition
to a lack of information about other psychiatric disorders, we
did not ask participants to report their medications, which are
likely to have an impact on one’s mood state and might also
influence the way in which one appraises certain emotional
experiences. Finally, the cross-sectional design of the study limits
our ability to make causal inferences about the relationships.
Future studies that examine threat from emotions over time will
help determine whether emotional appraisal is a worthy treatment target.
With these considerations in mind, the results from the
present study make a unique contribution to the existing literature on the heterogeneity of OCD. A large body of research on
obsessional beliefs has informed treatment interventions for OCD,
with promising results related to treatment outcome. Ultimately
we would like to know how threat from emotions is related to
treatment outcome and whether this is an appropriate target for
treatment. Based on the findings from this diverse sample of
individuals with OCD, it seems that threat from specific emotions
is at least worthy of future investigation.
Role of funding sources
The study was not funded by an external grant. The authors
are solely responsible for the study design, collection, analysis
and interpretation of the data, writing the manuscript, and the
decision to submit the paper for publication.
Contributors
Authors Smith, Wetterneck, and Hart designed the study.
Author Smith conducted the literature searches, provided summaries of previous research, and collected the data. Data collection was conducted primarily at the Houston OCD Program, an
institution headed by Author Bjorgvinsson. Authors Smith and
Wetterneck conducted the statistical analysis. Author Smith
wrote the first draft of the manuscript and all authors contributed
to and have approved the final manuscript.
Conflict of interest
All authors declare that they have no conflicts of interest.
A.H. Smith et al. / Journal of Obsessive-Compulsive and Related Disorders 1 (2012) 54–61
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