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taboo thoughts in obsessive–compulsive disorder
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Comprehensive Psychiatry xx (2013) xxx – xxx www.elsevier.com/locate/comppsych
The characteristics of unacceptable/taboo thoughts in obsessive–compulsive disorder Vlasios Brakoulias a,⁎, Vladan Starcevic a , David Berle b , Denise Milicevic b , Karen Moses b , Anthony Hannan b , Peter Sammut c , Andrew Martin d a
University of Sydney, Sydney Medical School-Nepean, Discipline of Psychiatry, Sydney/Penrith, NSW, Australia b Nepean Anxiety Disorders Clinic, Nepean/Blue Mountains Local Health District, Penrith, NSW, Australia c Nepean Hospital, Department of Psychiatry, Penrith, NSW, Australia d NHMRC Clinical Trials Centre, University of Sydney, Sydney, NSW, Australia
Abstract Background: In the quest to unravel the heterogeneity of obsessive–compulsive disorder (OCD), an increasing number of factor analytic studies are recognising unacceptable/taboo thoughts as one of the symptom dimensions of OCD. Aims: This study aims to examine the characteristics associated with unacceptable/taboo thoughts. Methods: Using the Yale–Brown Obsessive–Compulsive Scale Symptom Checklist (YBOCS-SC) with 154 individuals with OCD, obsessive–compulsive symptoms were subjected to principal components analysis. The characteristics associated with the resulting symptom dimensions were then assessed using logistic and linear regression techniques. Results: Unacceptable/taboo thoughts comprised of sexual, religious and impulsive aggressive obsessions, and mental rituals. Higher scores on an unacceptable/taboo thoughts symptom dimension were predicted by higher Y-BOCS obsession subscores, Y-BOCS time preoccupied by obsessions scores, Y-BOCS distress due to obsessions scores, importance of control of thought ratings, male gender, and having had treatment prior to entering into the study. Unacceptable/taboo thoughts were also predicted by greater levels of hostility, and a past history of non-alcohol substance dependence. Conclusions: An unacceptable/taboo thought symptom dimension of OCD is supported by a unique set of associated characteristics that should be considered in the assessment and treatment of individuals with these symptoms. Crown Copyright © 2013 Published by Elsevier Inc. All rights reserved.
1. Introduction Unacceptable/taboo thoughts, also known as “pure obsessions”, refer to impulsive aggressive, sexual and religious obsessions. The observation that some obsessions occurred in the apparent absence of compulsions was first made by Baer [1] in a study employing factor analysis techniques. Since then, there have been a number of factor
No conflicts of interest. This study was funded by the Nepean Medical Research foundation, a competitive Pfizer Neuroscience Grant and a grant from the Discipline of Psychiatry at The University of Sydney. ⁎ Corresponding author. Nepean Hospital, Department of Psychiatry, PO Box 63, Penrith, NSW 2751, Australia. Tel.: +61 2 4734 2585; fax: +61 2 4734 3343. E-mail addresses: [email protected], [email protected] (V. Brakoulias).
analytic studies [2–9] that have revealed a symptom dimension of obsessive–compulsive disorder (OCD) characterised predominantly by obsessions and in particular aggressive, sexual and religious obsessions. More recently, studies [10,11] have demonstrated that “pure obsessions” is a misnomer in that unacceptable/taboo thoughts tend to be accompanied by compulsions. Unacceptable/taboo thoughts are distinctly ego-dystonic with a repugnant quality that tends not to be so prominent in other OCD symptoms [12]. As their name suggests, the content of these obsessions typically involves unacceptable, taboo or forbidden themes such as stabbing a relative, incest or blasphemy. Studies have associated unacceptable/ taboo thoughts with mental rituals [10], reassuranceseeking [6,10], avoidance [13,14], good insight [15], male gender [16,17], and being more likely to seek professional help [18].
0010-440X/$ – see front matter. Crown Copyright © 2013 Published by Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.comppsych.2013.02.005
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In addition to the obvious phenomenological differences between unacceptable/taboo thoughts and other OCD symptoms, unacceptable/taboo thoughts also appear to have clinical utility as they have been associated with a differential response to treatment. Although studies examining the response of unacceptable/taboo thoughts to pharmacotherapy have resulted in conflicting findings [19], some studies investigating the response to behavioural interventions [20–22] have reported a poorer outcome. This study aimed to illustrate that unacceptable/taboo thoughts are associated with different characteristics to other symptom dimensions of OCD and that these characteristics may have implications for the treatment of individuals with unacceptable/taboo thoughts. It was hypothesised that unacceptable/taboo thoughts would be associated with greater severity, specifically higher Y-BOCS obsession scores and higher levels of distress. These hypotheses were based on clinical observation and the findings of previous studies [23,24]. Having hypothesized that greater degrees of severity and distress would be associated with unacceptable/ taboo thoughts, it was additionally hypothesised that unacceptable/taboo thoughts would be associated with higher rates of having obtained treatment prior to entering the study, greater reassurance-seeking, greater levels of avoidance, higher rates of comorbid depression and stronger beliefs relating to a need to control one's thoughts. These hypotheses were based on limited evidence relating unacceptable/taboo thoughts to higher rates of previous treatment [18], greater reassurance-seeking [6,10], greater levels of avoidance [13,14], higher rates of comorbid depression [25,26] and cognitive beliefs relating to the importance of controlling one's thoughts [27–30]. 2. Methods 2.1. Recruitment This report has resulted from the Nepean OCD Study, conducted in Sydney and several other Australian cities. Participants (N = 154) were recruited from the Nepean Anxiety Disorders Clinic, OCD support groups, newspaper advertisements and referrals from general practitioners, psychiatrists, clinical psychologists and mental health services. Participants were included if they had a primary diagnosis of OCD which was determined on the basis of a clinician-administered semi-structured interview, the Mini International Neuropsychiatric Interview plus version (MINI [31,32]), and the qualifier that OCD was the condition for which they sought help or which caused the most distress or impairment in functioning. Individuals with a current comorbid diagnosis of psychosis, bipolar affective disorder, a pervasive developmental disorder, severe intellectual disability, or substance abuse or dependence were excluded. The MINI was also used to determine co-occurring diagnoses and age of onset. Participants needed to be over the age of 18. Institutional ethics committee approval was
obtained prior to commencing the study and all participants provided signed informed consent. 2.2. Measures Participant characteristics were assessed via structured clinical interviews and self-report instruments. In this article, we report findings derived from standard demographics, the MINI, the Yale–Brown Obsessive–Compulsive Scale (YBOCS) [33], Avoidance and Reassurance-seeking Interview, Overvalued Ideas Scale (OVIS) [34], Symptom Checklist 90-Revised (SCL-90R) [35] and Obsessive Beliefs Questionnaire (OBQ) [36,37]. The MINI (plus version) is a clinician-administered semistructured interview that was used to determine co-occurring DSM-IV diagnoses and their age of onset, in addition to ascertaining whether the DSM-IV criteria for OCD have been met. The MINI has been validated against other widely used structured diagnostic interviews and its psychometric properties have been good [38,39]. The severity of OCD was assessed by means of the YBOCS, whereas OCD symptoms were assessed via the YBOCS Symptom Checklist (YBOCS-SC). The YBOCS-SC is a semi-structured interview which includes a comprehensive list of 64 obsessions and compulsions arranged by content into 15 categories. The categories for obsessions are: aggressive; contamination; sexual; hoarding/saving; religious; symmetry/exactness; miscellaneous; and somatic. The categories for compulsions are: cleaning/washing; checking; repeating; counting; ordering/arranging; hoarding/collecting; and miscellaneous. All the categories were used for the principal components analysis (PCA) except for aggressive and miscellaneous. Two items from the aggressive obsessions category were re-classified as “unintentional harm”. These were: “fear will harm others because not careful enough” and “fear will be responsible for something else terrible happening”. All other items were categorised as “impulsive aggression” obsessions. This method has been used in other studies [3,4] in an attempt to reduce the heterogeneity within the aggressive obsessions category. Similarly, in an attempt to reduce the heterogeneity of the miscellaneous categories [10], only the item “mental rituals” was used. Interviews were conducted by a psychiatrist or clinical psychologist trained in the use of the MINI and YBOCS-SC. Interrater reliability was assessed for the first 49 participants (this involved two raters completing the MINI and the YBOCS-SC in the same assessment without corroborating their findings), and for the YBOCS-SC categories this was excellent (94.3% agreement). Avoidance and reassurance-seeking were assessed by an interview-based instrument that was constructed for the study and administered alongside the Y-BOCS. This instrument assesses the presence of avoidance and/or reassurance-seeking and the extent of avoidance and/or reassurance-seeking with a 5-point Likert scale. Avoidance
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is assessed with the question: “Have you been avoiding anything because of your obsessions/thoughts or because you were concerned you would perform compulsions?” Reassurance-seeking is assessed with the question: “Have you been asking anyone to reassure you because of your obsessions/thoughts or because you think you did something wrong or punishable?” Both questions give examples to ensure the subject has understood what is meant by avoidance and reassurance-seeking in the context of OCD. The instrument has demonstrated good convergent validity with higher scores on avoidance and reassurance-seeking predicting greater OCD severity and higher levels of anxiety [40,41]. Insight and other characteristics of belief related to OCD were measured using the OVIS. This structured clinical interview has been shown to have better predictive validity than the single item that assesses insight on the Y-BOCS [42]. Symptom distress and psychopathology were measured by the SCL-90R. This 90-item psychometrically sound instrument [43], provides scores on the Global Severity Index and nine subscales: Somatization, Obsessive–compulsive, Interpersonal sensitivity, Depression, Anxiety, Hostility, Phobic anxiety, Paranoid ideation and Psychoticism. Cognitive styles along the dimensions of responsibility/ threat estimation, perfectionism/intolerance of uncertainty and importance/control of thoughts were assessed with the 44-item OBQ. The psychometric properties of the OBQ in samples with OCD, where it has been used in a large number of studies, have been reported to be good [44]. 2.3. Statistical methods All data were entered into the Statistical Package for the Social Sciences (SPSS) version 17 [45] and analysed. Additional analyses were conducted using SAS version 9.2 [46]. PCA was conducted on the 15 YBOCS-SC categories as described above. Oblique (direct Oblimin) and orthogonal (Varimax) rotational methods yielded comparable results. The study used the technique for factor loading described by Baer (1994) and Mataix-Cols et al. (1999) when analysing the YBOCS-SC. According to this technique, Y-BOCS symptom categories regarded as principal symptoms were given a value of 2, whereas other symptoms categories that were currently present were given a value of 1 and when there was no symptom in a given category, it was given a value of 0. Suitability of the data for PCA was assessed using a Kaiser–Meyer–Olkin Measure of Sampling Adequacy value of 0.6 or above [47,48] and a Bartlett's Test of Sphericity significance value less than 0.05 [49]. Parallel analysis [50,51] was used to determine the number of factors to be extracted for rotation. Items loading N0.4 were regarded as robust. A series of regression models were constructed to examine the relationship between each participant characteristic assessed (fitted individually as the outcome variable)
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and the 5 YBOCS-SC-derived symptom dimensions (fitted together as covariates). Multiple linear regression was applied to the continuous outcome variables and logistic regression to the binary outcome variables. In each case a backwards elimination approach was applied to the full regression model, comprising the 5 YBOCS-SC-derived symptom dimensions, in order to produce a parsimonious model comprising those YBOCS-SC-derived symptom dimensions that remained statistically significant (at the 5% level). Results from final models that included the unacceptable/taboo thoughts symptom dimension as a covariate are presented in the results. The False Discovery Rate (FDR) approach was used to adjust P-values for the multiple comparisons [52,53].
3. Results The characteristics of the sample are shown in Table 1. The specified YBOCS-SC categories that were subjected to PCA yielded a five-factor structure explaining 64.9% of the variance (Table 2). This included an unacceptable/ taboo thoughts symptom factor that explained 8.7% of the variance and that consisted of impulsive aggressive, sexual and religious obsessions and mental rituals. Logistic and linear regression analyses revealed that higher Y-BOCS obsession scores, higher levels of distress, more time spent on obsessions, greater levels of hostility, beliefs regarding the importance of controlling one's thoughts, having had treatment prior to the study, being male and having had a past diagnosis of non-alcohol drug dependence significantly predicted higher scores on the unacceptable/taboo factor after adjustment for multiple comparisons (Table 3). There was no significant relationship between unacceptable/taboo thoughts and avoidance, reassurance-seeking and level of insight.
4. Discussion This study presented new findings indicating that unacceptable/taboo thoughts might be characterised by higher rates of previous non-alcohol substance dependence and greater levels of hostility. One may hypothesise that there is a need to use substances to reduce the distress associated with unacceptable/taboo thoughts, or that substance abuse plays an aetiological role in the occurrence of these obsessions. However, the cross-sectional nature of our study does not allow us to speculate about the direction of causality, if any, between unacceptable/taboo thoughts and substance abuse. The role of substance abuse in the aetiology of unacceptable/taboo thoughts is not supported by the finding that 70% of individuals with OCD and comorbid substance abuse believe that their OCD preceded their substance abuse [54]. Although there are higher rates of substance dependence in individuals with OCD [55–57], no
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Table 1 Characteristics of the study participants. Characteristic Age (in years) Mean (standard deviation) Median Range Y-BOCS total score Mean (standard deviation) Gender Male Female Marital status Never married Married/in a de facto relationship Divorced/separated Widowed Number of children Nil One or more Employment status Full-time (≥24 h/week) Part-time (b24 h/week) Unemployed Highest level of educational attainment Primary school Secondary school Technical college certificate or diploma University degree Comorbid conditions Generalised anxiety disorder Specific phobia Past alcohol abuse Major depressive disorder Social phobia Panic disorder Tic disorder Past alcohol dependence Past psychotic disorder Past non-alcohol drug abuse Past non-alcohol drug dependence Hypochondriasis Treatment with psychotropic agent at the time of assessment Previous behavioural intervention
OCD Sample (N = 154) 45.5 (16.2) 47.0 18 to 79 22.0 (6.7) n
%
62 92
40.3 59.7
56 60 32 6
36.4 39.0 20.8 3.8
73 81
47.3 52.7
42 21 91
27.3 13.7 59.0
4 78 40 32
2.6 50.6 26.0 20.8
49 32 28 25 25 21 17 16 14 11 6 3 93
31.8 20.8 18.2 16.2 16.2 13.6 11.0 10.4 9.1 7.1 3.9 1.9 60.4
71
46.1
study reported higher rates in individuals with unacceptable/ taboo thoughts compared to individuals with other OCD symptoms. Furthermore, the relationship between current substance abuse or dependence was not assessed in this study as such patients were excluded from participating. Therefore, the finding of an association between unacceptable/taboo thoughts and past substance abuse requires replication. Neuroimaging data [58] have revealed similarities between pathways involved with reward dependence in addiction and pathways involved in OCD. These suggest that addiction, and in particular substance dependence [57,59,60] acts to reward in a similar manner to compulsions. In the absence of overt compulsions with unacceptable/taboo thoughts, there may be an increased tendency to develop substance dependence.
According to the SCL-90R, hostility refers to thoughts, feelings, or actions that are characteristic of the negative affect state of anger and this includes aggression, irritability, rage and resentment [35]. Although it is possible that repetitive, distressing unacceptable/taboo thoughts may make the person more hostile, hostility may also predispose to the development of unacceptable/taboo thoughts and perhaps to substance abuse too. Our finding that individuals with unacceptable/taboo thoughts are more likely to be male may also influence the rates of substance abuse and hostility levels, as these are both more associated with males [61–63]. As studies have associated low levels of serotonin with hostility [64], some authors have concluded that aggressive obsessions may be more effectively treated with SSRIs [65]. The finding of a link between unacceptable/taboo thoughts and male gender is consistent with previous studies [16,17,66]. Potential explanations for this association include sexual dimorphism in brain regions accounting for unacceptable/taboo thoughts, as has been suggested for contamination/cleaning symptoms [17,67], or the existence of gender-specific environmental factors that mediate the expression of unacceptable/taboo thoughts. There were also a number of other findings that were consistent with previous studies and thus support the validity of the new findings. As hypothesised, the unacceptable/taboo thoughts symptom dimension revealed by factor analysis in this study comprised mental rituals, sexual obsessions, religious obsessions and impulsive aggression obsessions. The inclusion of mental rituals in an unacceptable/taboo thoughts symptom dimension of OCD replicates the findings of a previous study [10]. In support of the ego-dystonic nature of unacceptable/taboo thoughts, the Y-BOCS revealed that higher obsession scores, higher obsession-related distress, and more time spent on obsessions predicted higher scores on the unacceptable/taboo symptom factor. The OBQ confirmed previous findings relating the importance of control of thoughts to unacceptable/taboo thoughts [27,29,30,68]. Individuals with unacceptable/taboo thoughts were also more likely than individuals with other OCD symptoms to have received treatment for their condition, and this is again consistent with previous findings [18]. These findings suggest that unacceptable/taboo thoughts are experienced with much distress, which may motivate many sufferers to seek help and treatment earlier than individuals with other symptoms of OCD. Unlike previous studies [6,10,13], there was no relationship between unacceptable/taboo thoughts and avoidance or reassurance-seeking. This finding is likely to be explained by differences in the methods used to assess OCD symptoms, avoidance and reassurance-seeking. This primarily relates to the grouping of checking compulsions with unacceptable/ taboo thoughts in previous studies. Reassurance-seeking is viewed by some [69] as a form of checking and there are some studies indicating that reassurance-seeking has a stronger relationship with checking than unacceptable/
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Table 2 The frequency of principal YBOCS-SC categories or items and Varimax-rotated factor structure using three-point ordinal rating principal components analysis (N = 154). YBOCS-SC categories⁎
Frequency (%)
Hoarding
Contamination/ Cleaning
Doubt/ Checking
Symmetry/ Ordering
Unacceptable/Taboo Thoughts
Hoarding/saving obsessions Hoarding compulsions Contamination obsessions Cleaning/washing compulsions Symmetry obsessions Ordering/arranging compulsions Mental rituals⁎ Sexual obsessions Impulsive aggression⁎ Religious obsessions Checking compulsions Unintentional harm⁎ Repeating rituals Somatic obsessions Counting compulsions Percentage of variance explained (%)
20.8 23.4 26.6 26.0 9.1 7.1 5.2 3.2 17.5 1.9 29.9 16.9 3.9 3.2 13.0 -
0.964 0.957 −0.165 −0.108 −0.046 −0.047 0.039 −0.081 −0.187 −0.037 −0.095 −0.139 0.151 0.017 −0.092 18.5
−0.126 −0.145 0.921 0.913 −0.003 0.033 0.071 0.009 −0.223 0.054 0.109 −0.109 0.157 0.372 0.046 14.8
−0.075 −0.076 −0.060 −0.075 0.026 0.037 −0.105 0.120 0.410 0.118 0.848 0.709 0.565 0.398 0.129 13.3
−0.058 −0.042 0.018 0.036 0.953 0.952 0.042 −0.104 0.014 0.209 −0.012 0.017 0.134 −0.083 0.202 9.6
−0.083 −0.069 −0.025 −0.008 0.061 −0.048 0.745 0.701 0.535 0.550 −0.014 0.108 0.101 0.126 0.026 8.7
Robust loadings (N0.4) are printed in bold and are underlined. ⁎ Symptoms with an asterisk indicate that “mental obsessions” are an item from the miscellaneous compulsions category and that “unintentional harm” and “impulsive aggression” pertain to certain items from the aggressive obsessions category.
taboo thoughts [69–71]. In addition, a more comprehensive assessment of reassurance-seeking was conducted in this study compared to previous studies [6,10] where the single miscellaneous item of the Y-BOCS (“Need to ask, tell or confess”) was used to represent reassurance-seeking. The finding that participants with unacceptable/taboo thoughts were more likely to have received treatment would support an association with good insight. However, a relationship between unacceptable/taboo thoughts and insight was absent in this study. Unlike the previous positive study [15] which used a single item of the Y-BOCS to assess insight and combined “forbidden” thoughts with checking, insight in our study was measured with a tool specifically designed to assess belief in OCD (the OVIS). Despite using a validated assessment tool that assesses insight in a multidimensional manner, there are many limitations that arise when assessing insight. These limitations relate to the complex nature of insight, the difficulties associated with identifying a belief relating to a subject's primary OCD symptoms and the inconsistent use of terms used to characterise belief in assessment tools [72]. Although the finding of this study in relation to the frequency of co-occurring depression did not reach statistical significance after adjustment for multiple comparisons, this finding is likely to require further investigation. Previous studies [25,26] indicating an association between unacceptable/taboo thoughts and higher comorbidity with major depression again grouped unacceptable/taboo thoughts with checking. The higher levels of distress associated with unacceptable/taboo thoughts may be a confounding factor in the assessment of depression. The increased rate of seeking treatment among participants with unacceptable/taboo thoughts may reflect increased levels of motivation and
energy, or perceived worthiness or hope. These characteristics are less likely to be present in participants with comorbid depression. The number of instruments used in the study was limited by the potential burden on volunteering participants. This was a cross-sectional study focusing primarily on descriptive characteristics, which precluded us from examining possible aetiological factors and longitudinal relationships that may be relevant for unacceptable/taboo thoughts. Despite the widespread use of the Y-BOCS in assessing symptoms for factor analysis, its use has been criticised as potentially biased, because symptoms are categorised prior to the analysis. As discussed, this has resulted in categories such as aggressive obsessions and miscellaneous compulsions, which are generally regarded as heterogeneous. The sample size is relatively small if we consider that participants with unacceptable/taboo thoughts represented a proportion of the total sample of subjects with OCD. The finding relating to past non-alcohol substance dependence is also limited by the small number of participants who reported past substance dependence.
5. Conclusions Unacceptable/taboo thoughts appear to form a distinct symptom dimension of OCD and their validity is further supported by their association with descriptive characteristics that are not commonly associated with other OCD symptom dimensions. The ego-dystonic nature of unacceptable/taboo thoughts and their association with the belief that it is important to control one's thoughts support psychological therapies that target underlying beliefs and
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Table 3 Regression analyses results. Dependent variable
Unacceptable/taboo thoughts symptom dimension
Logistic regression results (Dichotomous variables): Percentage of whole sample N (%) Odds Ratio a 95% Confidence Interval Standard Error P-value MINI diagnosis • Major depressive episode: Current • Alcohol abuse: Past • Non-alcohol drug dependence: Past* • Hypochondriasis: Past Treatment prior to entry to study* Male gender* Being a parent
25 (19.4%) 28 (18.2%) 6 (3.9%) 4 (2.6%) 40 (30.0%) 62 (40.3%) 79 (51.3%)
3.94 3.82 27.90 11.31 9.09 5.69 0.26
Dependent variable
1.7–12.3 1.3–11.5 3.3–233.0 1.2–104.4 2.2–33.3 2.1–15.7 0.1–0.7
1.78 1.75 2.95 3.11 2.09 1.68 1.66
0.0180 0.0167 0.0021* 0.0325 0.0025* 0.0008* 0.0075
Unacceptable/taboo thoughts symptom dimension
Linear regression results (Continuous variables):
Parameter Estimate (β)
Y-BOCS obsession score* Y-BOCS total score Y-BOCS: Time spent on obsessions* Y-BOCS: Interference due to obsessions Y-BOCS: Distress due to obsessions* OBQ: Importance/control of thought* SCL-90R: Hostility* Age at assessment
2.41 4.13 0.85 0.71 0.96 32.77 0.60 −9.30
b
95% Confidence Interval
Standard Error
P-value
0.7–4.1 1.1–7.2 0.4–1.3 0.2–1.2 0.6–1.4 28.7–36.8 0.2–1.0 −16.3–−2.3
0.86 1.54 0.24 0.24 0.21 2.06 0.60 3.52
0.0058* 0.0082 0.0006* 0.0040 b0.0001* b0.0001* 0.0021* 0.0092
Only models that obtained p-values lower than 0.05 for the unacceptable/taboo thoughts symptom dimension are shown. P-values less than 0.007 are asterisked and represent findings that remained statistically significant after application of the False Discovery Rate (FDR) procedure. a Reflects the increase in the odds of an outcome for each 1-point increase in the unacceptable/taboo thoughts symptom dimension. b Reflects the increase in outcome score for each 1-point increase in the unacceptable/taboo thoughts symptom dimension.
cognitive processes in addition to the standard behavioural treatment approach to OCD in the form of ERP. Substance abuse and hostility may also be associated with unacceptable/taboo thoughts. Although this finding requires replication, it indicates that clinicians should not neglect substance abuse in their assessment of individuals with unacceptable/taboo thoughts and that they should also note associated hostility, if present. An awareness of the presence of these associated characteristics may assist in the understanding of the development and/or maintenance of unacceptable/taboo thoughts.
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Comprehensive Psychiatry xx (2013) xxx – xxx www.elsevier.com/locate/comppsych
The characteristics of unacceptable/taboo thoughts in obsessive–compulsive disorder Vlasios Brakoulias a,⁎, Vladan Starcevic a , David Berle b , Denise Milicevic b , Karen Moses b , Anthony Hannan b , Peter Sammut c , Andrew Martin d a
University of Sydney, Sydney Medical School-Nepean, Discipline of Psychiatry, Sydney/Penrith, NSW, Australia b Nepean Anxiety Disorders Clinic, Nepean/Blue Mountains Local Health District, Penrith, NSW, Australia c Nepean Hospital, Department of Psychiatry, Penrith, NSW, Australia d NHMRC Clinical Trials Centre, University of Sydney, Sydney, NSW, Australia
Abstract Background: In the quest to unravel the heterogeneity of obsessive–compulsive disorder (OCD), an increasing number of factor analytic studies are recognising unacceptable/taboo thoughts as one of the symptom dimensions of OCD. Aims: This study aims to examine the characteristics associated with unacceptable/taboo thoughts. Methods: Using the Yale–Brown Obsessive–Compulsive Scale Symptom Checklist (YBOCS-SC) with 154 individuals with OCD, obsessive–compulsive symptoms were subjected to principal components analysis. The characteristics associated with the resulting symptom dimensions were then assessed using logistic and linear regression techniques. Results: Unacceptable/taboo thoughts comprised of sexual, religious and impulsive aggressive obsessions, and mental rituals. Higher scores on an unacceptable/taboo thoughts symptom dimension were predicted by higher Y-BOCS obsession subscores, Y-BOCS time preoccupied by obsessions scores, Y-BOCS distress due to obsessions scores, importance of control of thought ratings, male gender, and having had treatment prior to entering into the study. Unacceptable/taboo thoughts were also predicted by greater levels of hostility, and a past history of non-alcohol substance dependence. Conclusions: An unacceptable/taboo thought symptom dimension of OCD is supported by a unique set of associated characteristics that should be considered in the assessment and treatment of individuals with these symptoms. Crown Copyright © 2013 Published by Elsevier Inc. All rights reserved.
1. Introduction Unacceptable/taboo thoughts, also known as “pure obsessions”, refer to impulsive aggressive, sexual and religious obsessions. The observation that some obsessions occurred in the apparent absence of compulsions was first made by Baer [1] in a study employing factor analysis techniques. Since then, there have been a number of factor
No conflicts of interest. This study was funded by the Nepean Medical Research foundation, a competitive Pfizer Neuroscience Grant and a grant from the Discipline of Psychiatry at The University of Sydney. ⁎ Corresponding author. Nepean Hospital, Department of Psychiatry, PO Box 63, Penrith, NSW 2751, Australia. Tel.: +61 2 4734 2585; fax: +61 2 4734 3343. E-mail addresses: [email protected], [email protected] (V. Brakoulias).
analytic studies [2–9] that have revealed a symptom dimension of obsessive–compulsive disorder (OCD) characterised predominantly by obsessions and in particular aggressive, sexual and religious obsessions. More recently, studies [10,11] have demonstrated that “pure obsessions” is a misnomer in that unacceptable/taboo thoughts tend to be accompanied by compulsions. Unacceptable/taboo thoughts are distinctly ego-dystonic with a repugnant quality that tends not to be so prominent in other OCD symptoms [12]. As their name suggests, the content of these obsessions typically involves unacceptable, taboo or forbidden themes such as stabbing a relative, incest or blasphemy. Studies have associated unacceptable/ taboo thoughts with mental rituals [10], reassuranceseeking [6,10], avoidance [13,14], good insight [15], male gender [16,17], and being more likely to seek professional help [18].
0010-440X/$ – see front matter. Crown Copyright © 2013 Published by Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.comppsych.2013.02.005
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In addition to the obvious phenomenological differences between unacceptable/taboo thoughts and other OCD symptoms, unacceptable/taboo thoughts also appear to have clinical utility as they have been associated with a differential response to treatment. Although studies examining the response of unacceptable/taboo thoughts to pharmacotherapy have resulted in conflicting findings [19], some studies investigating the response to behavioural interventions [20–22] have reported a poorer outcome. This study aimed to illustrate that unacceptable/taboo thoughts are associated with different characteristics to other symptom dimensions of OCD and that these characteristics may have implications for the treatment of individuals with unacceptable/taboo thoughts. It was hypothesised that unacceptable/taboo thoughts would be associated with greater severity, specifically higher Y-BOCS obsession scores and higher levels of distress. These hypotheses were based on clinical observation and the findings of previous studies [23,24]. Having hypothesized that greater degrees of severity and distress would be associated with unacceptable/ taboo thoughts, it was additionally hypothesised that unacceptable/taboo thoughts would be associated with higher rates of having obtained treatment prior to entering the study, greater reassurance-seeking, greater levels of avoidance, higher rates of comorbid depression and stronger beliefs relating to a need to control one's thoughts. These hypotheses were based on limited evidence relating unacceptable/taboo thoughts to higher rates of previous treatment [18], greater reassurance-seeking [6,10], greater levels of avoidance [13,14], higher rates of comorbid depression [25,26] and cognitive beliefs relating to the importance of controlling one's thoughts [27–30]. 2. Methods 2.1. Recruitment This report has resulted from the Nepean OCD Study, conducted in Sydney and several other Australian cities. Participants (N = 154) were recruited from the Nepean Anxiety Disorders Clinic, OCD support groups, newspaper advertisements and referrals from general practitioners, psychiatrists, clinical psychologists and mental health services. Participants were included if they had a primary diagnosis of OCD which was determined on the basis of a clinician-administered semi-structured interview, the Mini International Neuropsychiatric Interview plus version (MINI [31,32]), and the qualifier that OCD was the condition for which they sought help or which caused the most distress or impairment in functioning. Individuals with a current comorbid diagnosis of psychosis, bipolar affective disorder, a pervasive developmental disorder, severe intellectual disability, or substance abuse or dependence were excluded. The MINI was also used to determine co-occurring diagnoses and age of onset. Participants needed to be over the age of 18. Institutional ethics committee approval was
obtained prior to commencing the study and all participants provided signed informed consent. 2.2. Measures Participant characteristics were assessed via structured clinical interviews and self-report instruments. In this article, we report findings derived from standard demographics, the MINI, the Yale–Brown Obsessive–Compulsive Scale (YBOCS) [33], Avoidance and Reassurance-seeking Interview, Overvalued Ideas Scale (OVIS) [34], Symptom Checklist 90-Revised (SCL-90R) [35] and Obsessive Beliefs Questionnaire (OBQ) [36,37]. The MINI (plus version) is a clinician-administered semistructured interview that was used to determine co-occurring DSM-IV diagnoses and their age of onset, in addition to ascertaining whether the DSM-IV criteria for OCD have been met. The MINI has been validated against other widely used structured diagnostic interviews and its psychometric properties have been good [38,39]. The severity of OCD was assessed by means of the YBOCS, whereas OCD symptoms were assessed via the YBOCS Symptom Checklist (YBOCS-SC). The YBOCS-SC is a semi-structured interview which includes a comprehensive list of 64 obsessions and compulsions arranged by content into 15 categories. The categories for obsessions are: aggressive; contamination; sexual; hoarding/saving; religious; symmetry/exactness; miscellaneous; and somatic. The categories for compulsions are: cleaning/washing; checking; repeating; counting; ordering/arranging; hoarding/collecting; and miscellaneous. All the categories were used for the principal components analysis (PCA) except for aggressive and miscellaneous. Two items from the aggressive obsessions category were re-classified as “unintentional harm”. These were: “fear will harm others because not careful enough” and “fear will be responsible for something else terrible happening”. All other items were categorised as “impulsive aggression” obsessions. This method has been used in other studies [3,4] in an attempt to reduce the heterogeneity within the aggressive obsessions category. Similarly, in an attempt to reduce the heterogeneity of the miscellaneous categories [10], only the item “mental rituals” was used. Interviews were conducted by a psychiatrist or clinical psychologist trained in the use of the MINI and YBOCS-SC. Interrater reliability was assessed for the first 49 participants (this involved two raters completing the MINI and the YBOCS-SC in the same assessment without corroborating their findings), and for the YBOCS-SC categories this was excellent (94.3% agreement). Avoidance and reassurance-seeking were assessed by an interview-based instrument that was constructed for the study and administered alongside the Y-BOCS. This instrument assesses the presence of avoidance and/or reassurance-seeking and the extent of avoidance and/or reassurance-seeking with a 5-point Likert scale. Avoidance
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is assessed with the question: “Have you been avoiding anything because of your obsessions/thoughts or because you were concerned you would perform compulsions?” Reassurance-seeking is assessed with the question: “Have you been asking anyone to reassure you because of your obsessions/thoughts or because you think you did something wrong or punishable?” Both questions give examples to ensure the subject has understood what is meant by avoidance and reassurance-seeking in the context of OCD. The instrument has demonstrated good convergent validity with higher scores on avoidance and reassurance-seeking predicting greater OCD severity and higher levels of anxiety [40,41]. Insight and other characteristics of belief related to OCD were measured using the OVIS. This structured clinical interview has been shown to have better predictive validity than the single item that assesses insight on the Y-BOCS [42]. Symptom distress and psychopathology were measured by the SCL-90R. This 90-item psychometrically sound instrument [43], provides scores on the Global Severity Index and nine subscales: Somatization, Obsessive–compulsive, Interpersonal sensitivity, Depression, Anxiety, Hostility, Phobic anxiety, Paranoid ideation and Psychoticism. Cognitive styles along the dimensions of responsibility/ threat estimation, perfectionism/intolerance of uncertainty and importance/control of thoughts were assessed with the 44-item OBQ. The psychometric properties of the OBQ in samples with OCD, where it has been used in a large number of studies, have been reported to be good [44]. 2.3. Statistical methods All data were entered into the Statistical Package for the Social Sciences (SPSS) version 17 [45] and analysed. Additional analyses were conducted using SAS version 9.2 [46]. PCA was conducted on the 15 YBOCS-SC categories as described above. Oblique (direct Oblimin) and orthogonal (Varimax) rotational methods yielded comparable results. The study used the technique for factor loading described by Baer (1994) and Mataix-Cols et al. (1999) when analysing the YBOCS-SC. According to this technique, Y-BOCS symptom categories regarded as principal symptoms were given a value of 2, whereas other symptoms categories that were currently present were given a value of 1 and when there was no symptom in a given category, it was given a value of 0. Suitability of the data for PCA was assessed using a Kaiser–Meyer–Olkin Measure of Sampling Adequacy value of 0.6 or above [47,48] and a Bartlett's Test of Sphericity significance value less than 0.05 [49]. Parallel analysis [50,51] was used to determine the number of factors to be extracted for rotation. Items loading N0.4 were regarded as robust. A series of regression models were constructed to examine the relationship between each participant characteristic assessed (fitted individually as the outcome variable)
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and the 5 YBOCS-SC-derived symptom dimensions (fitted together as covariates). Multiple linear regression was applied to the continuous outcome variables and logistic regression to the binary outcome variables. In each case a backwards elimination approach was applied to the full regression model, comprising the 5 YBOCS-SC-derived symptom dimensions, in order to produce a parsimonious model comprising those YBOCS-SC-derived symptom dimensions that remained statistically significant (at the 5% level). Results from final models that included the unacceptable/taboo thoughts symptom dimension as a covariate are presented in the results. The False Discovery Rate (FDR) approach was used to adjust P-values for the multiple comparisons [52,53].
3. Results The characteristics of the sample are shown in Table 1. The specified YBOCS-SC categories that were subjected to PCA yielded a five-factor structure explaining 64.9% of the variance (Table 2). This included an unacceptable/ taboo thoughts symptom factor that explained 8.7% of the variance and that consisted of impulsive aggressive, sexual and religious obsessions and mental rituals. Logistic and linear regression analyses revealed that higher Y-BOCS obsession scores, higher levels of distress, more time spent on obsessions, greater levels of hostility, beliefs regarding the importance of controlling one's thoughts, having had treatment prior to the study, being male and having had a past diagnosis of non-alcohol drug dependence significantly predicted higher scores on the unacceptable/taboo factor after adjustment for multiple comparisons (Table 3). There was no significant relationship between unacceptable/taboo thoughts and avoidance, reassurance-seeking and level of insight.
4. Discussion This study presented new findings indicating that unacceptable/taboo thoughts might be characterised by higher rates of previous non-alcohol substance dependence and greater levels of hostility. One may hypothesise that there is a need to use substances to reduce the distress associated with unacceptable/taboo thoughts, or that substance abuse plays an aetiological role in the occurrence of these obsessions. However, the cross-sectional nature of our study does not allow us to speculate about the direction of causality, if any, between unacceptable/taboo thoughts and substance abuse. The role of substance abuse in the aetiology of unacceptable/taboo thoughts is not supported by the finding that 70% of individuals with OCD and comorbid substance abuse believe that their OCD preceded their substance abuse [54]. Although there are higher rates of substance dependence in individuals with OCD [55–57], no
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Table 1 Characteristics of the study participants. Characteristic Age (in years) Mean (standard deviation) Median Range Y-BOCS total score Mean (standard deviation) Gender Male Female Marital status Never married Married/in a de facto relationship Divorced/separated Widowed Number of children Nil One or more Employment status Full-time (≥24 h/week) Part-time (b24 h/week) Unemployed Highest level of educational attainment Primary school Secondary school Technical college certificate or diploma University degree Comorbid conditions Generalised anxiety disorder Specific phobia Past alcohol abuse Major depressive disorder Social phobia Panic disorder Tic disorder Past alcohol dependence Past psychotic disorder Past non-alcohol drug abuse Past non-alcohol drug dependence Hypochondriasis Treatment with psychotropic agent at the time of assessment Previous behavioural intervention
OCD Sample (N = 154) 45.5 (16.2) 47.0 18 to 79 22.0 (6.7) n
%
62 92
40.3 59.7
56 60 32 6
36.4 39.0 20.8 3.8
73 81
47.3 52.7
42 21 91
27.3 13.7 59.0
4 78 40 32
2.6 50.6 26.0 20.8
49 32 28 25 25 21 17 16 14 11 6 3 93
31.8 20.8 18.2 16.2 16.2 13.6 11.0 10.4 9.1 7.1 3.9 1.9 60.4
71
46.1
study reported higher rates in individuals with unacceptable/ taboo thoughts compared to individuals with other OCD symptoms. Furthermore, the relationship between current substance abuse or dependence was not assessed in this study as such patients were excluded from participating. Therefore, the finding of an association between unacceptable/taboo thoughts and past substance abuse requires replication. Neuroimaging data [58] have revealed similarities between pathways involved with reward dependence in addiction and pathways involved in OCD. These suggest that addiction, and in particular substance dependence [57,59,60] acts to reward in a similar manner to compulsions. In the absence of overt compulsions with unacceptable/taboo thoughts, there may be an increased tendency to develop substance dependence.
According to the SCL-90R, hostility refers to thoughts, feelings, or actions that are characteristic of the negative affect state of anger and this includes aggression, irritability, rage and resentment [35]. Although it is possible that repetitive, distressing unacceptable/taboo thoughts may make the person more hostile, hostility may also predispose to the development of unacceptable/taboo thoughts and perhaps to substance abuse too. Our finding that individuals with unacceptable/taboo thoughts are more likely to be male may also influence the rates of substance abuse and hostility levels, as these are both more associated with males [61–63]. As studies have associated low levels of serotonin with hostility [64], some authors have concluded that aggressive obsessions may be more effectively treated with SSRIs [65]. The finding of a link between unacceptable/taboo thoughts and male gender is consistent with previous studies [16,17,66]. Potential explanations for this association include sexual dimorphism in brain regions accounting for unacceptable/taboo thoughts, as has been suggested for contamination/cleaning symptoms [17,67], or the existence of gender-specific environmental factors that mediate the expression of unacceptable/taboo thoughts. There were also a number of other findings that were consistent with previous studies and thus support the validity of the new findings. As hypothesised, the unacceptable/taboo thoughts symptom dimension revealed by factor analysis in this study comprised mental rituals, sexual obsessions, religious obsessions and impulsive aggression obsessions. The inclusion of mental rituals in an unacceptable/taboo thoughts symptom dimension of OCD replicates the findings of a previous study [10]. In support of the ego-dystonic nature of unacceptable/taboo thoughts, the Y-BOCS revealed that higher obsession scores, higher obsession-related distress, and more time spent on obsessions predicted higher scores on the unacceptable/taboo symptom factor. The OBQ confirmed previous findings relating the importance of control of thoughts to unacceptable/taboo thoughts [27,29,30,68]. Individuals with unacceptable/taboo thoughts were also more likely than individuals with other OCD symptoms to have received treatment for their condition, and this is again consistent with previous findings [18]. These findings suggest that unacceptable/taboo thoughts are experienced with much distress, which may motivate many sufferers to seek help and treatment earlier than individuals with other symptoms of OCD. Unlike previous studies [6,10,13], there was no relationship between unacceptable/taboo thoughts and avoidance or reassurance-seeking. This finding is likely to be explained by differences in the methods used to assess OCD symptoms, avoidance and reassurance-seeking. This primarily relates to the grouping of checking compulsions with unacceptable/ taboo thoughts in previous studies. Reassurance-seeking is viewed by some [69] as a form of checking and there are some studies indicating that reassurance-seeking has a stronger relationship with checking than unacceptable/
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Table 2 The frequency of principal YBOCS-SC categories or items and Varimax-rotated factor structure using three-point ordinal rating principal components analysis (N = 154). YBOCS-SC categories⁎
Frequency (%)
Hoarding
Contamination/ Cleaning
Doubt/ Checking
Symmetry/ Ordering
Unacceptable/Taboo Thoughts
Hoarding/saving obsessions Hoarding compulsions Contamination obsessions Cleaning/washing compulsions Symmetry obsessions Ordering/arranging compulsions Mental rituals⁎ Sexual obsessions Impulsive aggression⁎ Religious obsessions Checking compulsions Unintentional harm⁎ Repeating rituals Somatic obsessions Counting compulsions Percentage of variance explained (%)
20.8 23.4 26.6 26.0 9.1 7.1 5.2 3.2 17.5 1.9 29.9 16.9 3.9 3.2 13.0 -
0.964 0.957 −0.165 −0.108 −0.046 −0.047 0.039 −0.081 −0.187 −0.037 −0.095 −0.139 0.151 0.017 −0.092 18.5
−0.126 −0.145 0.921 0.913 −0.003 0.033 0.071 0.009 −0.223 0.054 0.109 −0.109 0.157 0.372 0.046 14.8
−0.075 −0.076 −0.060 −0.075 0.026 0.037 −0.105 0.120 0.410 0.118 0.848 0.709 0.565 0.398 0.129 13.3
−0.058 −0.042 0.018 0.036 0.953 0.952 0.042 −0.104 0.014 0.209 −0.012 0.017 0.134 −0.083 0.202 9.6
−0.083 −0.069 −0.025 −0.008 0.061 −0.048 0.745 0.701 0.535 0.550 −0.014 0.108 0.101 0.126 0.026 8.7
Robust loadings (N0.4) are printed in bold and are underlined. ⁎ Symptoms with an asterisk indicate that “mental obsessions” are an item from the miscellaneous compulsions category and that “unintentional harm” and “impulsive aggression” pertain to certain items from the aggressive obsessions category.
taboo thoughts [69–71]. In addition, a more comprehensive assessment of reassurance-seeking was conducted in this study compared to previous studies [6,10] where the single miscellaneous item of the Y-BOCS (“Need to ask, tell or confess”) was used to represent reassurance-seeking. The finding that participants with unacceptable/taboo thoughts were more likely to have received treatment would support an association with good insight. However, a relationship between unacceptable/taboo thoughts and insight was absent in this study. Unlike the previous positive study [15] which used a single item of the Y-BOCS to assess insight and combined “forbidden” thoughts with checking, insight in our study was measured with a tool specifically designed to assess belief in OCD (the OVIS). Despite using a validated assessment tool that assesses insight in a multidimensional manner, there are many limitations that arise when assessing insight. These limitations relate to the complex nature of insight, the difficulties associated with identifying a belief relating to a subject's primary OCD symptoms and the inconsistent use of terms used to characterise belief in assessment tools [72]. Although the finding of this study in relation to the frequency of co-occurring depression did not reach statistical significance after adjustment for multiple comparisons, this finding is likely to require further investigation. Previous studies [25,26] indicating an association between unacceptable/taboo thoughts and higher comorbidity with major depression again grouped unacceptable/taboo thoughts with checking. The higher levels of distress associated with unacceptable/taboo thoughts may be a confounding factor in the assessment of depression. The increased rate of seeking treatment among participants with unacceptable/taboo thoughts may reflect increased levels of motivation and
energy, or perceived worthiness or hope. These characteristics are less likely to be present in participants with comorbid depression. The number of instruments used in the study was limited by the potential burden on volunteering participants. This was a cross-sectional study focusing primarily on descriptive characteristics, which precluded us from examining possible aetiological factors and longitudinal relationships that may be relevant for unacceptable/taboo thoughts. Despite the widespread use of the Y-BOCS in assessing symptoms for factor analysis, its use has been criticised as potentially biased, because symptoms are categorised prior to the analysis. As discussed, this has resulted in categories such as aggressive obsessions and miscellaneous compulsions, which are generally regarded as heterogeneous. The sample size is relatively small if we consider that participants with unacceptable/taboo thoughts represented a proportion of the total sample of subjects with OCD. The finding relating to past non-alcohol substance dependence is also limited by the small number of participants who reported past substance dependence.
5. Conclusions Unacceptable/taboo thoughts appear to form a distinct symptom dimension of OCD and their validity is further supported by their association with descriptive characteristics that are not commonly associated with other OCD symptom dimensions. The ego-dystonic nature of unacceptable/taboo thoughts and their association with the belief that it is important to control one's thoughts support psychological therapies that target underlying beliefs and
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Table 3 Regression analyses results. Dependent variable
Unacceptable/taboo thoughts symptom dimension
Logistic regression results (Dichotomous variables): Percentage of whole sample N (%) Odds Ratio a 95% Confidence Interval Standard Error P-value MINI diagnosis • Major depressive episode: Current • Alcohol abuse: Past • Non-alcohol drug dependence: Past* • Hypochondriasis: Past Treatment prior to entry to study* Male gender* Being a parent
25 (19.4%) 28 (18.2%) 6 (3.9%) 4 (2.6%) 40 (30.0%) 62 (40.3%) 79 (51.3%)
3.94 3.82 27.90 11.31 9.09 5.69 0.26
Dependent variable
1.7–12.3 1.3–11.5 3.3–233.0 1.2–104.4 2.2–33.3 2.1–15.7 0.1–0.7
1.78 1.75 2.95 3.11 2.09 1.68 1.66
0.0180 0.0167 0.0021* 0.0325 0.0025* 0.0008* 0.0075
Unacceptable/taboo thoughts symptom dimension
Linear regression results (Continuous variables):
Parameter Estimate (β)
Y-BOCS obsession score* Y-BOCS total score Y-BOCS: Time spent on obsessions* Y-BOCS: Interference due to obsessions Y-BOCS: Distress due to obsessions* OBQ: Importance/control of thought* SCL-90R: Hostility* Age at assessment
2.41 4.13 0.85 0.71 0.96 32.77 0.60 −9.30
b
95% Confidence Interval
Standard Error
P-value
0.7–4.1 1.1–7.2 0.4–1.3 0.2–1.2 0.6–1.4 28.7–36.8 0.2–1.0 −16.3–−2.3
0.86 1.54 0.24 0.24 0.21 2.06 0.60 3.52
0.0058* 0.0082 0.0006* 0.0040 b0.0001* b0.0001* 0.0021* 0.0092
Only models that obtained p-values lower than 0.05 for the unacceptable/taboo thoughts symptom dimension are shown. P-values less than 0.007 are asterisked and represent findings that remained statistically significant after application of the False Discovery Rate (FDR) procedure. a Reflects the increase in the odds of an outcome for each 1-point increase in the unacceptable/taboo thoughts symptom dimension. b Reflects the increase in outcome score for each 1-point increase in the unacceptable/taboo thoughts symptom dimension.
cognitive processes in addition to the standard behavioural treatment approach to OCD in the form of ERP. Substance abuse and hostility may also be associated with unacceptable/taboo thoughts. Although this finding requires replication, it indicates that clinicians should not neglect substance abuse in their assessment of individuals with unacceptable/taboo thoughts and that they should also note associated hostility, if present. An awareness of the presence of these associated characteristics may assist in the understanding of the development and/or maintenance of unacceptable/taboo thoughts.
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Acknowledgment [8]
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