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Sensory properties of obsessive thoughts in OCD and the relationship to psychopathology
Psychiatry Research 230 (2015) 592–596
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Sensory properties of obsessive thoughts in OCD and the relationship to psychopathology Jana Röhlinger 1, Falk Wulf 1, Martina Fieker, Steffen Moritz n University Medical Center Hamburg Eppendorf, Department of Psychiatry and Psychotherapy, Martinistraße 52, 20246 Hamburg, Germany
art ic l e i nf o
a b s t r a c t
Article history: Received 27 February 2015 Received in revised form 6 August 2015 Accepted 5 October 2015 Available online 26 October 2015
For decades hallucinations and perception-laden thoughts were considered specific indicators of schizophrenia. This assumption has been revised over the years. Novel studies indicate that a subgroup of patients with obsessive-compulsive disorder (OCD), borderline disorder or depression display hallucinations and “loud”/perceptual thoughts. The present study examined the frequency of sensory-laden obsessive thoughts and their relationship with the severity of obsessive-compulsive, paranoid and depressive symptoms in a sample of 137 OCD patients who were recruited via the Internet. Participants were asked to fill out the Sensory Properties of Obsessions Questionnaire (SPOQ), the Obsessive-Compulsive Inventory-Revised (OCI-R), the Paranoia Checklist and the Patient Health Questionnaire (PHQ9). In line with a prior study, a total of 72% displayed perceptual intrusions (i.e. vivid obsessions). Correlations emerged between perceptual thoughts and obsessive-compulsive, paranoid and depressive symptoms. Results further strengthen the assumption of a continuum ranging from “silent” thoughts to vivid intrusions and hallucinations. & 2015 Elsevier Ireland Ltd. All rights reserved.
Keywords: Obsessive-compulsive disorder Intrusion Perception Psychopathology Continuum
1. Introduction Obsessive-compulsive disorder (OCD) has a lifetime prevalence between 1% and 3% (Grabe et al., 2007; Ruscio et al., 2010). Its core symptoms are obsessions and compulsions. Obsessions are defined as intrusive, repetitive thoughts, which severely disturb its holder and are neutralized by compulsions such as mental or motor rituals (Veale, 2004). Notwithstanding that OCD and schizophrenia are separate diagnostic entities with distinct clinical pictures, some important overlap exists. Several reports suggest that OCD is a comorbid condition in people with schizophrenia in 7.8–26% of the cases (Tibbo et al., 2000; Nechmad et al., 2003). Single obsessive-compulsive symptoms are found in even up to 62% of patients with schizophrenia (Bland et al., 1987; Kayahan et al., 2005). Moreover, studies indicate that OCD patients with poor insight share a higher risk to develop a schizophrenia spectrum disorder (Catapano et al., 2001; Bellino et al., 2005; Catapano et al., 2010). Hearing or seeing things without source (i.e. hallucinations) is traditionally viewed as a strong sign for severe mental illness and reality distortion, presumably indicative of psychosis/schizophrenia. Sensory irritations to the point of hallucinations are less n
Corresponding author. Fax: þ49 40 7410 52999. E-mail address: [email protected] (S. Moritz). 1 Both authors share first authorship.
http://dx.doi.org/10.1016/j.psychres.2015.10.009 0165-1781/& 2015 Elsevier Ireland Ltd. All rights reserved.
rare than previously supposed and not confined to psychosis (Baethge et al., 2005; Teeple et al., 2009; Brewin et al., 2010). For example the prevalence of voice hearing in healthy subjects has been estimated at 10–15% (Johns, 2005; Beavan et al., 2011; de Leede-Smith and Barkus, 2013) and under special stressful situations, for example sleep deprivation, nonclinical individuals may develop sensory irritations (Larøi et al., 2012). It has been proposed that the conformity with personality discriminates such phenomena from clinical hallucinations: the non-psychotic hallucinator usually does not judge these images as real or can sufficiently distance him- or herself from these perceptions (Moritz and Larøi, 2008). Patients with psychosis in turn appraise these images as authentic and often equip them with a delusional superstructure. Recently, a number of studies demonstrated that sensory properties of thoughts are frequent in people diagnosed with depression, anxiety disorders, OCD or tic disorder (Hirsch and Holmes, 2007; Prado et al., 2008; Ferrão et al., 2012; Moritz et al., 2014b). A study on patients diagnosed from OCD (psychosis served as an exclusion criterion) reported that 73% of the sample experienced their obsessive intrusive thoughts at least mildly perceptual on at least one of the major (somatic, visual, tactile, acoustic, olfactory) sensory channels (Moritz et al., 2014a). Similar results in other clinical pictures were found by Holmes and Mathews (2010) as well as Williams and Moulds (2007). Importantly, a strong correlation with illness insight emerged. The more vivid the perceptions, the less the patient acknowledged that the obsessive thoughts were absurd. These findings are largely in
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line with another study by the same study group: compared to OCD and schizophrenia patients, healthy subjects perceived their intrusions as simple thoughts, which are not to be taken seriously and did not bother their holder (Moritz and Larøi, 2008; Moritz et al., 2014b). To sum up, there is growing evidence that the presence of sensory perceptions in mental phenomena is not a clear discriminator between normal and abnormal cognition and is a poor indicator to differentiate among psychological disorders. Rather, these phenomena may emerge on a continuum (van Os et al., 2000; Johns and van Os, 2001), whereby other symptoms like delusional ideation, lack of illness insight and depression determine if these phenomena deserve direct treatment or not. As shown, only few studies dealt with sensory experiences in patients diagnosed with OCD (Rachman, 2007; Speckens et al., 2007; Moritz et al., 2014a) although the relation between sensory perceptions and clinical features such as illness insight speaks for its importance. The present study aimed to consolidate findings from earlier studies (Moritz and Larøi, 2008; Moritz et al., 2014a). At the same time it addressed limitations of past research. In comparison to earlier surveys we aimed to recruit a larger number of cases and examined more dependent variables. We employed a novel measure to tap into the sensory character of thoughts, the Sensory Properties of Obsessions Questionnaire (SPOQ). Furthermore, all participants of the sample had a verified diagnosis of OCD. The present study pursued three aims. Firstly, we examined to which extent OCD patients experience their obsessive thoughts as vivid and perceptual. We suggested, based on earlier research, that the majority of participants would experience obsessive thoughts in a perceptual manner (e.g. hearing obsessive thoughts, having visual images in combination with obsessive fears). Secondly we assumed a positive correlation between the intensity of the perceptual-like obsessions with different psychopathological characteristics. Thirdly, we investigated if subgroups (OCD patients with sensory perceptions vs. OCD patients without sensory perceptions) vary in their perception of their normal, every day thoughts. We hypothesized that experiencing normal thoughts as more vivid, less controllable and alien (not part of the own personality) would be associated with sensory obsessions in OCD patients.
2. Methods
593
data collection and that no (negative) consequences would occur if they decided against participating in the study or if they dropped out. The survey was part of a larger series of investigations for which ethical approval has been obtained. 2.2. Participants A total of 194 individuals completed the study. Inclusion criterion was a diagnosis of OCD according to DSM-IV. As mentioned before, diagnostic status was either verified during a prior stay in our hospital or via phone interviews. For patients recruited via online forums we requested that they met a minimum score of 21 on the Obsessive-Compulsive Inventory-Revised (OCI-R) and also affirmed that a health professional had previously determined a diagnosis of OCD (e.g. psychologist, psychiatrist). Exclusion criteria were a history of psychosis or bipolar disorder as well as Alzheimer disease; only four participants reported a diagnosis of a psychosis. Furthermore we excluded data from one person who completed the survey more than once and 52 persons who did not fully complete the survey or who showed stereotypical response behavior (e.g., if the same value was entered throughout). A total of 137 participants met study criteria and were asked to complete the below instruments. 2.3. Questionnaires 2.3.1. Obsessive-Compulsive Inventory-Revised (OCI-R; Foa et al., 2002) The OCI-R is an 18-item self-report instrument capturing information about the severity of six cardinal OCD domains (washing, controlling, symmetry, obsessive thoughts, hoarding and mental neutralization with numbers). The OCI-R is a recommended and empirically validated tool with good to excellent psychometric properties (Abramowitz and Deacon, 2006; Huppert et al., 2007): The internal consistency amounts to α ¼0.83, the test retest reliability ranges from r¼ 0.75 to 0.86 (Moritz et al., 2010; Moritz et al., 2012). In the present study we used the official German version from Gönner et al. (2009). 2.3.2. Paranoia Checklist (Freeman et al., 2005) The Paranoia Checklist consists of 18 items covering paranoid thoughts and suspiciousness. The internal consistency is excellent (α ¼0.90). It has good psychometric properties, which have been affirmed for the German version that was utilized in the present study (Lincoln et al., 2010a, Lincoln et al., 2010b).
2.1. Recruitment The study was performed via the Internet. Apart from advantages pertaining to economy and time, Internet studies allow to contact people, who had never approached the psychological– medical help system before, for example because of fear stigmatization or insufficient insight. We contacted participants who had taken part in a prior study on OCD and whose diagnostic status was verified by specialists via a phone interview with the MINI questionnaire (Sheehan et al., 1998). Another large subgroup was recruited from former OCD patients from the University Medical Center Hamburg-Eppendorf (Germany), again with an externally verified diagnosis. These patients had given permission to be contacted for further research studies. Furthermore the study was published on a German Internet platform where people with OCD are invited to exchange their experiences. Interested participants were directed to the online survey where they first received information about the purpose of the study. As an incentive, participants could download a manual with relaxation techniques at no cost after finishing the entire survey. They were reassured about the anonymity of the
2.3.3. Patient Health Questionnaire (PHQ9; Kroenke et al., 2001) The PHQ9 is a self-report instrument derived from the Primary Care Evaluation of Mental Disorders (PRIME-MD). This subscale is used to evaluate depressive symptoms. Its nine items mirror the nine diagnostic criteria for depression in the DSM-IV. Its psychometric properties can be judged as excellent with a sensitivity of 0.80 and a specificity of 0.92 (Gilbody et al., 2007). 2.3.4. Sensory Properties of Obsessions Questionnaire (SPOQ; Moritz et al., 2014a) After completion of the PHQ9, participants were administered the SPOQ. The instruction is as follows: “Obsessions are sometimes described by patients as very strong thoughts which are hard to get rid of but are still just perceived as thoughts. Some people with obsessions also report sensory or bodily sensations associated with obsessions. For example, people with checking compulsions (almost) see how the house burns down or those with washing compulsions (almost) feel dirt on their skin. Are your obsessive thoughts sometimes associated with such sensations?” Subjects could then endorse on a five-point scale (none, mild, moderate,
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strong, extreme) and the presence of such perceptions should be quantified across five modalities (visual, acoustic, tactile, bodily (somatic), olfactory). Cronbach’s α of the SPOQ is 0.73. 2.3.5. Thinking Scale (Moritz and Larøi, 2008) The Thinking Scale presented three questions pertaining to normal thoughts. Thoughts were introduced as “tools of rationality” which the person uses purposefully (e.g. for problem solving or to select a drink on the menu) unlike intrusions and hallucinations, which are unwanted and occur passively. Participants were asked to make a statement concerning the loudness of their normal thoughts, the controllability of these thoughts and the degree of ego-syntony. Four response options were given for acoustic properties (silent, like a whisper, somewhat audible, as loud as an external voice), for controllability (fully controllable, predominantly controllable, rarely controllable, not controllable) and for ego-syntony (thoughts fully correspond to my personality, from time to time strange thoughts enter my mind, my thoughts are frequently really strange, my thoughts do not correspond to my personality).
Table 1 Medians, means and standard deviations of sociodemographic and psychopathological data. Variable
Frequency
Sex (female/male) Age (in years)
103/34
Obsessive-Compulsive Inventory – Revised total Paranoia Checklist total Patient Health Questionnaire 9 total Sensory Properties of Obsessions Questionnaire total
M (SD)
39.58 (11.83)
Mdn
M (SD)
25
26.44 (12.28)
27 20 9
32.35 (14.77) 20.54 (6.85) 10.26 (4.18)
Notes: Mdn ¼medians, M ¼means, SD ¼standard deviation.
Spearman’s correlation coefficients were computed to assess the relationship between variables. For the differences between groups or features, we used chisquare test for categorical (dichotomous) variables. To compare group differences, Mann–Whitney-U-tests were used. To allow comparison with other research, we will however also report means and standard deviations. The level of statistical significance was set at 5%. All statistical analyses were performed with IBM SPSS Statistics, version 21.0 (IBM Corp., New York, USA). In a study with a mainly exploratory approach like ours, a conservative correction method suggested for multiple testing may miss or disregard meaningful results generated by the data (Bender and Lange, 2001).
sensory property of obsessive thoughts (72%) versus those who did not (28%) report higher scores on the PHQ9 total score, the Paranoia Checklist total score and the OCI-R total score mirroring results from the correlational analyses. Table 3 compares patients with sensory properties and those without, with respect to the perceptual properties of their normal thoughts showing significant results only for loudness. The correlation between the acoustic subscale of the SPOQ and the loudness of normal thoughts was significant and of small to moderate magnitude (ρ ¼ 0.30, p o0.001). Finally, we examined the properties of normal thoughts in participants who reported at least one mild paranoid thought (84.7%) versus those without as measured with to the Paranoia Checklist. Individuals with paranoid thoughts showed significantly lowered ego-syntony (U¼873.50, Z¼ 2.199, p ¼ 0.028) and controllability (U¼863.50, Z¼ 2.396, p¼ 0.017) of their normal daily thoughts than those without paranoid thoughts (15.3%).
3. Results
4. Discussion
Table 1 provides information about sociodemographic characteristics of the sample. A total of 72% (n ¼99) of the participants affirmed that their obsessive thoughts were at least mildly perceptual. The most dominant perceptual channels were bodily and visual, where 56.2% respectively 46.6% reported at least mild perceptions. Acoustic hallucinations were confirmed by 37.2%. A small but significant negative correlation between the SPOQ total score and age of the participants (ρ ¼ 0.17, p¼ 0.04) emerged. As expected, a significant positive correlation between the SPOQ total score and all psychopathological scales was found. The magnitude for this and the subsequent correlations was only small to moderate. The strongest correlation was observed with the PHQ9, ρ ¼0.37, po 0.001. The SPOQ total score and the OCI-R total score showed a correlation of ρ ¼0.23, p ¼0.007. When looking at OCI-R subscales, the highest correlation emerged with obsessive thoughts at ρ ¼ 0.32, p o0.001. Subsequent analyses found that the OCI-R total score was particularly related to tactile (ρ ¼ 0.30, p o0.001) and olfactory (ρ ¼0.24, p ¼0.004) modalities. A correlation with a small to moderate magnitude of ρ ¼0.27, p ¼0.001, emerged for the SPOQ total score with the Paranoia Checklist total score. Substantial correlations with small to moderate magnitudes between the Paranoia Checklist total score and subscales of the SPOQ can be seen in Table 2. Table 3 shows that participants who reported at least one mild
This study examined the prevalence and correlates of sensory properties of obsessive thoughts in OCD patients. Almost three out of four (72%) participants described their thoughts as at least mildly perceptual, which confirms our first hypothesis, that sensory sensations are rather common in patients suffering from OCD. The result is consistent with an earlier albeit smaller study (N ¼26) (Moritz et al., 2014a). In the present study, perceptions of mild degree were reported most often, predominantly in the bodily (somatic) and visual modalities, followed by the acoustic and tactile modalities. In comparison to the aforementioned study, three times more participants of the present study experienced acoustic thoughts. As a diagnosis of schizophrenia was ruled out in the sample, our results lend support to the claim that the presence of sensory irritations is not a valid discriminator between OCD and “psychosis”. Corresponding to our second hypothesis, all three questionnaires (OCI-R, Paranoia Checklist, PHQ9) showed a small to moderate positive correlation with the experience of sensory properties. The causal direction is unclear at this point. Stronger perceptual irritations may promote greater despair and foster search for an (at times paranoid) explanation. Vice versa, greater psychopathology may exacerbate sensory phenomena. Longitudinal studies are needed to examine whether sensory irritations in OCD are indeed a risk factor for a later psychosis or hallucinations, as proposed by earlier studies (Niendam et al., 2009; van Dael et al., 2011). Our third hypothesis (differences in the perception of normal,
2.4. Statistical methods
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595
Table 2 Spearman’s rho correlations between selected SPOQ scores with psychopathological variables. Variables
Obsessive-Compulsive Inventory – Revised total Paranoia Checklist total Patient Health Questionnaire 9 total * **
Sensory Properties of Obsessions Questionnaire (SPOQ) Total Visual Acoustic Tactile
Bodily
Olfactory
0.23** 0.24** 0.37**
0.09 0.15 0.24**
0.25** 0.34** 0.35**
0.19* 0.31** 0.27**
0.14 0.06 0.18*
0.30** 0.25** 0.31**
p r 0.05. pr 0.01.
Table 3 Means, standard deviations, medians and interquartile ranges for participants who did not report sensory properties of their obsessive thoughts versus those who did. Variables
No sensory properties of obsessive thoughts Sensory properties of obsessive thoughts (n ¼38) (n¼ 99)
Mdn M (SD) Background variables Age (in years) 36.50 41.34 (12.69) Sex (female/male) 29/9 Psychopathological variables Obsessive-Compulsive 21 23.47 (12.68) Inventory – Revised total Paranoia Checklist total 26 27.47 (11.13) Patient Health Questionnaire 9 total 16 17.87 (6.31) Properties of normal thoughts Loudness 1 1.32 (0.70) Ego-syntony 2 1.82 (0.90) Controllability 2 2.11 (0.69) Properties of normal thoughts No paranoid symptoms (n¼ 21) Loudness 1 1.38 (0.74) Ego-syntony 1 1.57 (0.81) Controllability 2 1.90 (0.70)
Mann–Whitney statistics
Mdn (IQR)
M (SD)
38 74/25
38.91 (11.48)
U ¼1692.00, Z¼ 0.909, p ¼ 0.363 χ2 (1, N ¼ 137) ¼0.04, p¼ 0.849
28
27.58 (11.98)
U ¼1447.50, Z¼ 2.085, p ¼ 0.037
31 21
34.22 (15.60) 21.57 (6.80)
U ¼1389.00, Z¼ 2.371, p ¼ 0.018 U ¼1283.50, Z ¼ 2.876, p ¼ 0.004
1 1.68 (1.00) 2 1.95 (0.79) 2 2.32 (0.71) Paranoid symptoms (n ¼116) 1 1.61 (0.97) 2 1.97 (0.81) 2 2.33 (0.70)
U ¼1540.50, Z¼ 1.968, p ¼0.049 U ¼1664.50, Z ¼ 1.112, p¼ 0.266 U ¼1544.00, Z¼ 1.833, p¼ 0.067 U ¼1079.50, Z¼ 0.995, p ¼ 0.320 U ¼873.50, Z¼ 2.199, p¼ 0.028 U ¼863.50, Z¼ 2.396, p ¼0.017
Notes: Mdn¼ medians, M ¼ means, SD ¼ standard deviation.
everyday thoughts between OCD patients with sensory perceptions vs. OCD patients without sensory perceptions) was only partially confirmed. Although no significant differences between the subgroups occurred for ego-syntony or controllability, participants with obsessions containing sensory properties reported a significant higher loudness of normal thoughts. The small to moderate correlation between SPOQ data and the OCI-R subscale obsessive thoughts strengthens this assumption. Results speak for the conclusion that the experience of normal daily thoughts as loud, vivid and intensive might serve as a risk factor for perceptual intrusions. The present study has to face up to some limitations. More women than men participated in the survey (n ¼103; n ¼34). Furthermore, only one item per sensory domain was used which may raise concerns about reliability. Future research should use a set of items for each sensory channel or even offer an interview form of the SPOQ. Online surveys are often confronted with the preoccupation that they are less reliable than paper–pencil-tests, but this assumption has been challenged (Riva et al., 2003; Gosling et al., 2004). Finally, the current survey did neither examine the influence of past or actual psychotherapeutic or medical treatment, nor comorbid diseases. Although we proceeded many correlations, in a study with mainly exploratory approach like ours, a conservative correction method recommended for multiple testing may miss or disregard meaningful results generated by the data (Bender and Lange, 2001). Despite the above limitations, several strengths should be highlighted. Psychopathological properties were measured with reliable and valid standardized questionnaires. As data were also examined from non-health-care-seekers on an Internet platform, the sample was more diverse than a mere treatment-seeking
(often insightful) clinical population, which is not representative in view of the high treatment gap in OCD (Kohn et al., 2004). Furthermore the exclusion criteria were intended to avoid recruitment of individuals with bipolar disorder, psychosis or Alzheimer disease. The study has a number of implications for future research as well as therapeutic strategies. Future investigation could turn its attention to explore the relation between sensory perceptions and repetitive behavior in OCD, as findings from Ferrão et al. (2012) postulate (see also Moritz et al., 2014a). Regarding the therapeutic measurements it has to be taken into consideration, that both, pharmacotherapy and psychotherapy can alter subjective experiences of the patient (Leckman et al., 1992). The preferred medication for OCD patients is selective serotonin reuptake inhibitors (SSRI) (Geller et al., 2003). In case sensory irritations are severe and particularly bothersome, non-pharmacological treatments have to be considered as well (Abramowitz et al., 2005). The therapist should be in charge to administer techniques like “normalization” or “depathologizing”. Portraying sensory perceptions as a rather frequent experience and not a clear sign of psychotic symptoms might help to reduce the patient's preoccupation (Johns, 2005; Beavan et al., 2011; de Leede-Smith and Barkus, 2013). Important in this regard is, that in an older study sensory irritations were associated with poorer outcome of cognitive behavioral therapy (CBT) for OCD (Moritz et al., 2004). The above named techniques should be integrated in future clinical studies to examine its benefit for OCD patients suffering from sensory perceptions. Even though sensory-laden thoughts are mostly not taken into consideration when exploring OCD patients, our study demonstrated that sensory properties of obsessive thoughts are a
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common experience and connected with psychopathological variables. Therefore, in future research sensory perceptions should be routinely measured in OCD.
Contributors Jana Röhlinger designed the study and wrote most of the manuscript. Falk Wulf wrote some parts of the article and Martina Fieker helped with revision. Steffen Moritz helped to design the survey and was responsible for the supervision of the entire paper. All authors contributed to and have approved the final manuscript.
Conflict of interest All authors declare that they have no conflicts of interest.
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Psychiatry Research journal homepage: www.elsevier.com/locate/psychres
Sensory properties of obsessive thoughts in OCD and the relationship to psychopathology Jana Röhlinger 1, Falk Wulf 1, Martina Fieker, Steffen Moritz n University Medical Center Hamburg Eppendorf, Department of Psychiatry and Psychotherapy, Martinistraße 52, 20246 Hamburg, Germany
art ic l e i nf o
a b s t r a c t
Article history: Received 27 February 2015 Received in revised form 6 August 2015 Accepted 5 October 2015 Available online 26 October 2015
For decades hallucinations and perception-laden thoughts were considered specific indicators of schizophrenia. This assumption has been revised over the years. Novel studies indicate that a subgroup of patients with obsessive-compulsive disorder (OCD), borderline disorder or depression display hallucinations and “loud”/perceptual thoughts. The present study examined the frequency of sensory-laden obsessive thoughts and their relationship with the severity of obsessive-compulsive, paranoid and depressive symptoms in a sample of 137 OCD patients who were recruited via the Internet. Participants were asked to fill out the Sensory Properties of Obsessions Questionnaire (SPOQ), the Obsessive-Compulsive Inventory-Revised (OCI-R), the Paranoia Checklist and the Patient Health Questionnaire (PHQ9). In line with a prior study, a total of 72% displayed perceptual intrusions (i.e. vivid obsessions). Correlations emerged between perceptual thoughts and obsessive-compulsive, paranoid and depressive symptoms. Results further strengthen the assumption of a continuum ranging from “silent” thoughts to vivid intrusions and hallucinations. & 2015 Elsevier Ireland Ltd. All rights reserved.
Keywords: Obsessive-compulsive disorder Intrusion Perception Psychopathology Continuum
1. Introduction Obsessive-compulsive disorder (OCD) has a lifetime prevalence between 1% and 3% (Grabe et al., 2007; Ruscio et al., 2010). Its core symptoms are obsessions and compulsions. Obsessions are defined as intrusive, repetitive thoughts, which severely disturb its holder and are neutralized by compulsions such as mental or motor rituals (Veale, 2004). Notwithstanding that OCD and schizophrenia are separate diagnostic entities with distinct clinical pictures, some important overlap exists. Several reports suggest that OCD is a comorbid condition in people with schizophrenia in 7.8–26% of the cases (Tibbo et al., 2000; Nechmad et al., 2003). Single obsessive-compulsive symptoms are found in even up to 62% of patients with schizophrenia (Bland et al., 1987; Kayahan et al., 2005). Moreover, studies indicate that OCD patients with poor insight share a higher risk to develop a schizophrenia spectrum disorder (Catapano et al., 2001; Bellino et al., 2005; Catapano et al., 2010). Hearing or seeing things without source (i.e. hallucinations) is traditionally viewed as a strong sign for severe mental illness and reality distortion, presumably indicative of psychosis/schizophrenia. Sensory irritations to the point of hallucinations are less n
Corresponding author. Fax: þ49 40 7410 52999. E-mail address: [email protected] (S. Moritz). 1 Both authors share first authorship.
http://dx.doi.org/10.1016/j.psychres.2015.10.009 0165-1781/& 2015 Elsevier Ireland Ltd. All rights reserved.
rare than previously supposed and not confined to psychosis (Baethge et al., 2005; Teeple et al., 2009; Brewin et al., 2010). For example the prevalence of voice hearing in healthy subjects has been estimated at 10–15% (Johns, 2005; Beavan et al., 2011; de Leede-Smith and Barkus, 2013) and under special stressful situations, for example sleep deprivation, nonclinical individuals may develop sensory irritations (Larøi et al., 2012). It has been proposed that the conformity with personality discriminates such phenomena from clinical hallucinations: the non-psychotic hallucinator usually does not judge these images as real or can sufficiently distance him- or herself from these perceptions (Moritz and Larøi, 2008). Patients with psychosis in turn appraise these images as authentic and often equip them with a delusional superstructure. Recently, a number of studies demonstrated that sensory properties of thoughts are frequent in people diagnosed with depression, anxiety disorders, OCD or tic disorder (Hirsch and Holmes, 2007; Prado et al., 2008; Ferrão et al., 2012; Moritz et al., 2014b). A study on patients diagnosed from OCD (psychosis served as an exclusion criterion) reported that 73% of the sample experienced their obsessive intrusive thoughts at least mildly perceptual on at least one of the major (somatic, visual, tactile, acoustic, olfactory) sensory channels (Moritz et al., 2014a). Similar results in other clinical pictures were found by Holmes and Mathews (2010) as well as Williams and Moulds (2007). Importantly, a strong correlation with illness insight emerged. The more vivid the perceptions, the less the patient acknowledged that the obsessive thoughts were absurd. These findings are largely in
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line with another study by the same study group: compared to OCD and schizophrenia patients, healthy subjects perceived their intrusions as simple thoughts, which are not to be taken seriously and did not bother their holder (Moritz and Larøi, 2008; Moritz et al., 2014b). To sum up, there is growing evidence that the presence of sensory perceptions in mental phenomena is not a clear discriminator between normal and abnormal cognition and is a poor indicator to differentiate among psychological disorders. Rather, these phenomena may emerge on a continuum (van Os et al., 2000; Johns and van Os, 2001), whereby other symptoms like delusional ideation, lack of illness insight and depression determine if these phenomena deserve direct treatment or not. As shown, only few studies dealt with sensory experiences in patients diagnosed with OCD (Rachman, 2007; Speckens et al., 2007; Moritz et al., 2014a) although the relation between sensory perceptions and clinical features such as illness insight speaks for its importance. The present study aimed to consolidate findings from earlier studies (Moritz and Larøi, 2008; Moritz et al., 2014a). At the same time it addressed limitations of past research. In comparison to earlier surveys we aimed to recruit a larger number of cases and examined more dependent variables. We employed a novel measure to tap into the sensory character of thoughts, the Sensory Properties of Obsessions Questionnaire (SPOQ). Furthermore, all participants of the sample had a verified diagnosis of OCD. The present study pursued three aims. Firstly, we examined to which extent OCD patients experience their obsessive thoughts as vivid and perceptual. We suggested, based on earlier research, that the majority of participants would experience obsessive thoughts in a perceptual manner (e.g. hearing obsessive thoughts, having visual images in combination with obsessive fears). Secondly we assumed a positive correlation between the intensity of the perceptual-like obsessions with different psychopathological characteristics. Thirdly, we investigated if subgroups (OCD patients with sensory perceptions vs. OCD patients without sensory perceptions) vary in their perception of their normal, every day thoughts. We hypothesized that experiencing normal thoughts as more vivid, less controllable and alien (not part of the own personality) would be associated with sensory obsessions in OCD patients.
2. Methods
593
data collection and that no (negative) consequences would occur if they decided against participating in the study or if they dropped out. The survey was part of a larger series of investigations for which ethical approval has been obtained. 2.2. Participants A total of 194 individuals completed the study. Inclusion criterion was a diagnosis of OCD according to DSM-IV. As mentioned before, diagnostic status was either verified during a prior stay in our hospital or via phone interviews. For patients recruited via online forums we requested that they met a minimum score of 21 on the Obsessive-Compulsive Inventory-Revised (OCI-R) and also affirmed that a health professional had previously determined a diagnosis of OCD (e.g. psychologist, psychiatrist). Exclusion criteria were a history of psychosis or bipolar disorder as well as Alzheimer disease; only four participants reported a diagnosis of a psychosis. Furthermore we excluded data from one person who completed the survey more than once and 52 persons who did not fully complete the survey or who showed stereotypical response behavior (e.g., if the same value was entered throughout). A total of 137 participants met study criteria and were asked to complete the below instruments. 2.3. Questionnaires 2.3.1. Obsessive-Compulsive Inventory-Revised (OCI-R; Foa et al., 2002) The OCI-R is an 18-item self-report instrument capturing information about the severity of six cardinal OCD domains (washing, controlling, symmetry, obsessive thoughts, hoarding and mental neutralization with numbers). The OCI-R is a recommended and empirically validated tool with good to excellent psychometric properties (Abramowitz and Deacon, 2006; Huppert et al., 2007): The internal consistency amounts to α ¼0.83, the test retest reliability ranges from r¼ 0.75 to 0.86 (Moritz et al., 2010; Moritz et al., 2012). In the present study we used the official German version from Gönner et al. (2009). 2.3.2. Paranoia Checklist (Freeman et al., 2005) The Paranoia Checklist consists of 18 items covering paranoid thoughts and suspiciousness. The internal consistency is excellent (α ¼0.90). It has good psychometric properties, which have been affirmed for the German version that was utilized in the present study (Lincoln et al., 2010a, Lincoln et al., 2010b).
2.1. Recruitment The study was performed via the Internet. Apart from advantages pertaining to economy and time, Internet studies allow to contact people, who had never approached the psychological– medical help system before, for example because of fear stigmatization or insufficient insight. We contacted participants who had taken part in a prior study on OCD and whose diagnostic status was verified by specialists via a phone interview with the MINI questionnaire (Sheehan et al., 1998). Another large subgroup was recruited from former OCD patients from the University Medical Center Hamburg-Eppendorf (Germany), again with an externally verified diagnosis. These patients had given permission to be contacted for further research studies. Furthermore the study was published on a German Internet platform where people with OCD are invited to exchange their experiences. Interested participants were directed to the online survey where they first received information about the purpose of the study. As an incentive, participants could download a manual with relaxation techniques at no cost after finishing the entire survey. They were reassured about the anonymity of the
2.3.3. Patient Health Questionnaire (PHQ9; Kroenke et al., 2001) The PHQ9 is a self-report instrument derived from the Primary Care Evaluation of Mental Disorders (PRIME-MD). This subscale is used to evaluate depressive symptoms. Its nine items mirror the nine diagnostic criteria for depression in the DSM-IV. Its psychometric properties can be judged as excellent with a sensitivity of 0.80 and a specificity of 0.92 (Gilbody et al., 2007). 2.3.4. Sensory Properties of Obsessions Questionnaire (SPOQ; Moritz et al., 2014a) After completion of the PHQ9, participants were administered the SPOQ. The instruction is as follows: “Obsessions are sometimes described by patients as very strong thoughts which are hard to get rid of but are still just perceived as thoughts. Some people with obsessions also report sensory or bodily sensations associated with obsessions. For example, people with checking compulsions (almost) see how the house burns down or those with washing compulsions (almost) feel dirt on their skin. Are your obsessive thoughts sometimes associated with such sensations?” Subjects could then endorse on a five-point scale (none, mild, moderate,
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strong, extreme) and the presence of such perceptions should be quantified across five modalities (visual, acoustic, tactile, bodily (somatic), olfactory). Cronbach’s α of the SPOQ is 0.73. 2.3.5. Thinking Scale (Moritz and Larøi, 2008) The Thinking Scale presented three questions pertaining to normal thoughts. Thoughts were introduced as “tools of rationality” which the person uses purposefully (e.g. for problem solving or to select a drink on the menu) unlike intrusions and hallucinations, which are unwanted and occur passively. Participants were asked to make a statement concerning the loudness of their normal thoughts, the controllability of these thoughts and the degree of ego-syntony. Four response options were given for acoustic properties (silent, like a whisper, somewhat audible, as loud as an external voice), for controllability (fully controllable, predominantly controllable, rarely controllable, not controllable) and for ego-syntony (thoughts fully correspond to my personality, from time to time strange thoughts enter my mind, my thoughts are frequently really strange, my thoughts do not correspond to my personality).
Table 1 Medians, means and standard deviations of sociodemographic and psychopathological data. Variable
Frequency
Sex (female/male) Age (in years)
103/34
Obsessive-Compulsive Inventory – Revised total Paranoia Checklist total Patient Health Questionnaire 9 total Sensory Properties of Obsessions Questionnaire total
M (SD)
39.58 (11.83)
Mdn
M (SD)
25
26.44 (12.28)
27 20 9
32.35 (14.77) 20.54 (6.85) 10.26 (4.18)
Notes: Mdn ¼medians, M ¼means, SD ¼standard deviation.
Spearman’s correlation coefficients were computed to assess the relationship between variables. For the differences between groups or features, we used chisquare test for categorical (dichotomous) variables. To compare group differences, Mann–Whitney-U-tests were used. To allow comparison with other research, we will however also report means and standard deviations. The level of statistical significance was set at 5%. All statistical analyses were performed with IBM SPSS Statistics, version 21.0 (IBM Corp., New York, USA). In a study with a mainly exploratory approach like ours, a conservative correction method suggested for multiple testing may miss or disregard meaningful results generated by the data (Bender and Lange, 2001).
sensory property of obsessive thoughts (72%) versus those who did not (28%) report higher scores on the PHQ9 total score, the Paranoia Checklist total score and the OCI-R total score mirroring results from the correlational analyses. Table 3 compares patients with sensory properties and those without, with respect to the perceptual properties of their normal thoughts showing significant results only for loudness. The correlation between the acoustic subscale of the SPOQ and the loudness of normal thoughts was significant and of small to moderate magnitude (ρ ¼ 0.30, p o0.001). Finally, we examined the properties of normal thoughts in participants who reported at least one mild paranoid thought (84.7%) versus those without as measured with to the Paranoia Checklist. Individuals with paranoid thoughts showed significantly lowered ego-syntony (U¼873.50, Z¼ 2.199, p ¼ 0.028) and controllability (U¼863.50, Z¼ 2.396, p¼ 0.017) of their normal daily thoughts than those without paranoid thoughts (15.3%).
3. Results
4. Discussion
Table 1 provides information about sociodemographic characteristics of the sample. A total of 72% (n ¼99) of the participants affirmed that their obsessive thoughts were at least mildly perceptual. The most dominant perceptual channels were bodily and visual, where 56.2% respectively 46.6% reported at least mild perceptions. Acoustic hallucinations were confirmed by 37.2%. A small but significant negative correlation between the SPOQ total score and age of the participants (ρ ¼ 0.17, p¼ 0.04) emerged. As expected, a significant positive correlation between the SPOQ total score and all psychopathological scales was found. The magnitude for this and the subsequent correlations was only small to moderate. The strongest correlation was observed with the PHQ9, ρ ¼0.37, po 0.001. The SPOQ total score and the OCI-R total score showed a correlation of ρ ¼0.23, p ¼0.007. When looking at OCI-R subscales, the highest correlation emerged with obsessive thoughts at ρ ¼ 0.32, p o0.001. Subsequent analyses found that the OCI-R total score was particularly related to tactile (ρ ¼ 0.30, p o0.001) and olfactory (ρ ¼0.24, p ¼0.004) modalities. A correlation with a small to moderate magnitude of ρ ¼0.27, p ¼0.001, emerged for the SPOQ total score with the Paranoia Checklist total score. Substantial correlations with small to moderate magnitudes between the Paranoia Checklist total score and subscales of the SPOQ can be seen in Table 2. Table 3 shows that participants who reported at least one mild
This study examined the prevalence and correlates of sensory properties of obsessive thoughts in OCD patients. Almost three out of four (72%) participants described their thoughts as at least mildly perceptual, which confirms our first hypothesis, that sensory sensations are rather common in patients suffering from OCD. The result is consistent with an earlier albeit smaller study (N ¼26) (Moritz et al., 2014a). In the present study, perceptions of mild degree were reported most often, predominantly in the bodily (somatic) and visual modalities, followed by the acoustic and tactile modalities. In comparison to the aforementioned study, three times more participants of the present study experienced acoustic thoughts. As a diagnosis of schizophrenia was ruled out in the sample, our results lend support to the claim that the presence of sensory irritations is not a valid discriminator between OCD and “psychosis”. Corresponding to our second hypothesis, all three questionnaires (OCI-R, Paranoia Checklist, PHQ9) showed a small to moderate positive correlation with the experience of sensory properties. The causal direction is unclear at this point. Stronger perceptual irritations may promote greater despair and foster search for an (at times paranoid) explanation. Vice versa, greater psychopathology may exacerbate sensory phenomena. Longitudinal studies are needed to examine whether sensory irritations in OCD are indeed a risk factor for a later psychosis or hallucinations, as proposed by earlier studies (Niendam et al., 2009; van Dael et al., 2011). Our third hypothesis (differences in the perception of normal,
2.4. Statistical methods
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595
Table 2 Spearman’s rho correlations between selected SPOQ scores with psychopathological variables. Variables
Obsessive-Compulsive Inventory – Revised total Paranoia Checklist total Patient Health Questionnaire 9 total * **
Sensory Properties of Obsessions Questionnaire (SPOQ) Total Visual Acoustic Tactile
Bodily
Olfactory
0.23** 0.24** 0.37**
0.09 0.15 0.24**
0.25** 0.34** 0.35**
0.19* 0.31** 0.27**
0.14 0.06 0.18*
0.30** 0.25** 0.31**
p r 0.05. pr 0.01.
Table 3 Means, standard deviations, medians and interquartile ranges for participants who did not report sensory properties of their obsessive thoughts versus those who did. Variables
No sensory properties of obsessive thoughts Sensory properties of obsessive thoughts (n ¼38) (n¼ 99)
Mdn M (SD) Background variables Age (in years) 36.50 41.34 (12.69) Sex (female/male) 29/9 Psychopathological variables Obsessive-Compulsive 21 23.47 (12.68) Inventory – Revised total Paranoia Checklist total 26 27.47 (11.13) Patient Health Questionnaire 9 total 16 17.87 (6.31) Properties of normal thoughts Loudness 1 1.32 (0.70) Ego-syntony 2 1.82 (0.90) Controllability 2 2.11 (0.69) Properties of normal thoughts No paranoid symptoms (n¼ 21) Loudness 1 1.38 (0.74) Ego-syntony 1 1.57 (0.81) Controllability 2 1.90 (0.70)
Mann–Whitney statistics
Mdn (IQR)
M (SD)
38 74/25
38.91 (11.48)
U ¼1692.00, Z¼ 0.909, p ¼ 0.363 χ2 (1, N ¼ 137) ¼0.04, p¼ 0.849
28
27.58 (11.98)
U ¼1447.50, Z¼ 2.085, p ¼ 0.037
31 21
34.22 (15.60) 21.57 (6.80)
U ¼1389.00, Z¼ 2.371, p ¼ 0.018 U ¼1283.50, Z ¼ 2.876, p ¼ 0.004
1 1.68 (1.00) 2 1.95 (0.79) 2 2.32 (0.71) Paranoid symptoms (n ¼116) 1 1.61 (0.97) 2 1.97 (0.81) 2 2.33 (0.70)
U ¼1540.50, Z¼ 1.968, p ¼0.049 U ¼1664.50, Z ¼ 1.112, p¼ 0.266 U ¼1544.00, Z¼ 1.833, p¼ 0.067 U ¼1079.50, Z¼ 0.995, p ¼ 0.320 U ¼873.50, Z¼ 2.199, p¼ 0.028 U ¼863.50, Z¼ 2.396, p ¼0.017
Notes: Mdn¼ medians, M ¼ means, SD ¼ standard deviation.
everyday thoughts between OCD patients with sensory perceptions vs. OCD patients without sensory perceptions) was only partially confirmed. Although no significant differences between the subgroups occurred for ego-syntony or controllability, participants with obsessions containing sensory properties reported a significant higher loudness of normal thoughts. The small to moderate correlation between SPOQ data and the OCI-R subscale obsessive thoughts strengthens this assumption. Results speak for the conclusion that the experience of normal daily thoughts as loud, vivid and intensive might serve as a risk factor for perceptual intrusions. The present study has to face up to some limitations. More women than men participated in the survey (n ¼103; n ¼34). Furthermore, only one item per sensory domain was used which may raise concerns about reliability. Future research should use a set of items for each sensory channel or even offer an interview form of the SPOQ. Online surveys are often confronted with the preoccupation that they are less reliable than paper–pencil-tests, but this assumption has been challenged (Riva et al., 2003; Gosling et al., 2004). Finally, the current survey did neither examine the influence of past or actual psychotherapeutic or medical treatment, nor comorbid diseases. Although we proceeded many correlations, in a study with mainly exploratory approach like ours, a conservative correction method recommended for multiple testing may miss or disregard meaningful results generated by the data (Bender and Lange, 2001). Despite the above limitations, several strengths should be highlighted. Psychopathological properties were measured with reliable and valid standardized questionnaires. As data were also examined from non-health-care-seekers on an Internet platform, the sample was more diverse than a mere treatment-seeking
(often insightful) clinical population, which is not representative in view of the high treatment gap in OCD (Kohn et al., 2004). Furthermore the exclusion criteria were intended to avoid recruitment of individuals with bipolar disorder, psychosis or Alzheimer disease. The study has a number of implications for future research as well as therapeutic strategies. Future investigation could turn its attention to explore the relation between sensory perceptions and repetitive behavior in OCD, as findings from Ferrão et al. (2012) postulate (see also Moritz et al., 2014a). Regarding the therapeutic measurements it has to be taken into consideration, that both, pharmacotherapy and psychotherapy can alter subjective experiences of the patient (Leckman et al., 1992). The preferred medication for OCD patients is selective serotonin reuptake inhibitors (SSRI) (Geller et al., 2003). In case sensory irritations are severe and particularly bothersome, non-pharmacological treatments have to be considered as well (Abramowitz et al., 2005). The therapist should be in charge to administer techniques like “normalization” or “depathologizing”. Portraying sensory perceptions as a rather frequent experience and not a clear sign of psychotic symptoms might help to reduce the patient's preoccupation (Johns, 2005; Beavan et al., 2011; de Leede-Smith and Barkus, 2013). Important in this regard is, that in an older study sensory irritations were associated with poorer outcome of cognitive behavioral therapy (CBT) for OCD (Moritz et al., 2004). The above named techniques should be integrated in future clinical studies to examine its benefit for OCD patients suffering from sensory perceptions. Even though sensory-laden thoughts are mostly not taken into consideration when exploring OCD patients, our study demonstrated that sensory properties of obsessive thoughts are a
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common experience and connected with psychopathological variables. Therefore, in future research sensory perceptions should be routinely measured in OCD.
Contributors Jana Röhlinger designed the study and wrote most of the manuscript. Falk Wulf wrote some parts of the article and Martina Fieker helped with revision. Steffen Moritz helped to design the survey and was responsible for the supervision of the entire paper. All authors contributed to and have approved the final manuscript.
Conflict of interest All authors declare that they have no conflicts of interest.
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