Exploring the role of obsessive–compulsive relevant self-worth contingencies in obsessive–compulsive disorder patients

Psychiatry Research 198 (2012) 94–99

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Exploring the role of obsessive–compulsive relevant self-worth contingencies in obsessive–compulsive disorder patients Gemma García-Soriano ⁎, Amparo Belloch Departamento de Personalidad, Evaluación y Tratamientos Psicológicos, Facultad de Psicología, Universidad de Valencia, Valencia, Spain

a r t i c l e

i n f o

Article history: Received 25 March 2011 Received in revised form 8 October 2011 Accepted 16 November 2011 Keywords: OCD Self-worth Self-esteem Self-concept OCD domains Dysfunctional beliefs OCSQ

a b s t r a c t This article examines whether self-worth contingencies in the personal domains of cleanliness, morality, hoarding, certainty, accuracy, religion and respect for others have specific associations with obsessive symptoms and cognitions in individuals with obsessive–compulsive disorder (OCD). Fifty-seven patients with a primary diagnosis of OCD completed the Obsessional Concerns and Self Questionnaire (OCSQ), designed to assess the extent to which respondents consider OCD content domains relevant to their self-worth, along with a battery of other instruments. Results indicate that the OCSQ is more associated with OCD than with non-OCD anxiety symptoms, and that it is also associated with comorbid depressive symptoms in OCD patients. Moreover, the OCSQ—Order and Cleanliness and Hoarding dimensions are associated with their symptom counterparts (i.e., contamination, checking, order, hoarding and neutralizing). OCSQ domains were highly associated with dysfunctional beliefs about obsessions. However, only the OCSQ scores, but not the dysfunctional beliefs, predicted OCD symptoms. These results support cognitive conceptualizations implicating self-concept in OCD development, and they suggest the need to further analyze the influence of selfworth in OCD development and maintenance. © 2011 Elsevier Ireland Ltd. All rights reserved.

1. Introduction Contemporary cognitive theories on obsessive–compulsive disorder (OCD) emphasize the role of faulty appraisals in explaining why normal intrusive thoughts escalate into clinical obsessions and can lead to compulsions (Salkovskis, 1985; Rachman, 1998; Purdon and Clark, 1999; Clark, 2004). However, why individuals misinterpret some types of intrusive thoughts but not others is still a matter of debate. Some authors have hypothesized that intrusive cognitions that give rise to obsessions have particular significance (Rachman, 1998) or an idiosyncratic meaning (Salkovskis, 1985) for the individual, which involves ascribing a significant role to the self-view in the escalation of normal intrusive cognitions into obsessions. In fact, Purdon and Clark (1999) describe an obsessional thought as “inconsistent with one's sense of self” (pp. 106). In sum, these authors suggest that intrusive thought contents that contradict one's self-concept have an increased risk of attaining a negative personal meaning. Despite these suggestions, empirical research on the association between obsessional contents and the different aspects of selfconcept has been scarce. Ferrier and Brewin (2005) reported that OCD patients' feared self consisted of bad and immoral traits. Rowa and colleagues (Rowa and Purdon, 2003; Rowa et al., 2005) found ⁎ Corresponding author at: Departamento de Personalidad, Evaluación y Tratamientos psicológicos, Facultad de Psicología, Universidad de Valencia, Avda. Blasco Ibáñez 21, Valencia-46010, Spain. Tel.: + 34 963 983 439; fax: + 34 963 864 669. E-mail address: [email protected] (G. García-Soriano). 0165-1781/$ – see front matter © 2011 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.psychres.2011.11.011

that OCD patients appraised their most disturbing obsession as more significant and as contradicting more valued aspects of the self than the least distressing obsession. Doron and Kyrios (2005) proposed a different approach when hypothesizing that obsessional contents are related to those highly valued self-domains in which individuals do not feel competent. In a study with OCD participants, obsessive–compulsive (OC) symptoms and beliefs were related to sensitivity in moral domains (Doron et al., 2008). While this study appraised some general self-domains (e.g., social acceptance, job and scholastic competence), it might be more cogent to analyze the degree to which the contents of intrusive thoughts/obsessions are important for self-worth. Although it can be hypothesized that an intrusive thought is more likely to become a clinical obsession when its content is coherent with one or more self-worth domains, research on obsession-specific self-worth contingencies is hampered by a lack of assessment instruments. Crocker and Wolfe (2001) introduced a different perspective, describing a model of self-esteem in which staking self-worth on certain domains, called “contingencies of self-worth”, constitutes a psychological vulnerability factor. These authors developed an instrument to measure these domains, the Contingencies of Self-worth Scale (CSW; Crocker et al., 2003), which has been shown to predict psychopathological symptoms in non-clinical populations (Sargent et al., 2006; ZeiglerHill, 2006; Kim and Williams, 2009; García-Soriano et al., 2010). Based on the CSW, the Obsessional Concerns and Self Questionnaire (OCSQ; Garcia-Soriano, 2008) assesses whether OC domains (i.e., cleanliness, order, hoarding, checking) are relevant to the individual's

G. García-Soriano, A. Belloch / Psychiatry Research 198 (2012) 94–99

self-worth. The underlying hypothesis is that violations in one or more of these obsession-specific self-evaluative domains, due to the intrusion of unwanted thoughts, images or impulses, could cause the intrusion to have greater relevance, increasing the need to control it and the likelihood that it will escalate into a clinical obsession. With this in mind, three specific main hypotheses can be formulated: first, higher associations are expected between OC selfcontingencies and OCD symptoms than between the former and non-OCD symptoms; second, higher associations between OC selfworth contingency domains and their OC symptom counterparts are expected (i.e., OCSQ-orderliness and cleanliness will be more associated with contamination, neutralizing and checking than with pure obsessions); and third, significant associations between OC selfcontingencies and OC relevant metacognitions (i.e., dysfunctional beliefs and thought control strategies) are expected. 2. Method 2.1. Participants Fifty-seven consecutive treatment-seeking individuals with a primary diagnosis of OCD participated in the study (Diagnostic and Statistical Manual of Mental Disorders— fourth edition, text revision (DSM-IV-TR) criteria, American Psychiatric Association (APA), 2000). Of them, 47.4% were women, their mean age was 35.02 ± 11.89 years (age range: 18 to 64 years), and 44.60% were married. Most of them had high school or university education (76.90%). On average, they had a severe disorder (Yale– Brown Obsessive–Compulsive Severity Scale, YBOCS: 25.31 ± 6.80), and the duration of OCD was 9.26 ± 7.76 years. Scores on depression and anxiety were also high (see Table 1). The majority of patients had received no previous treatments (72%), 14% (eight patients) had received previous pharmacological treatment, 3.5% (two) psychological treatment, and 10.5% (six patients) both treatments. The psychological Table 1 Means and standard deviations of study measures (n = 57 and *n = 47). Instruments

Mean Standard deviation

Yale–Brown Obsessive Compulsive Scale—Obsessions Yale–Brown Obsessive Compulsive Scale—Compulsions Beck Depression Inventory-II Beck Anxiety Inventory Obsessional Concerns and Self Questionnaire—avoid aggression Obsessional Concerns and Self Questionnaire—hoarding Obsessional Concerns and Self Questionnaire—sexual Obsessional Concerns and Self Questionnaire—order and cleanliness Obsessional Concerns and Self Questionnaire—religion/ moral Obsessive Compulsive Inventory Revised—contamination Obsessive Compulsive Inventory Revised—obsession Obsessive Compulsive Inventory Revised—hoarding Obsessive Compulsive Inventory Revised—order Obsessive Compulsive Inventory Revised—checking Obsessive Compulsive Inventory Revised—neutralizing Obsessive Beliefs Spanish Inventory—responsibility Obsessive Beliefs Spanish Inventory—importance of thoughts Obsessive Beliefs Spanish Inventory—thought–action fusion, likelihood Obsessive Beliefs Spanish Inventory—thought–action fusion, morality Obsessive Beliefs Spanish Inventory—importance of thought control Obsessive Beliefs Spanish Inventory—overestimation of threat Obsessive Beliefs Spanish Inventory—intolerance to uncertainty Obsessive Beliefs Spanish Inventory—perfectionism *Thought Control Questionnaire—distraction *Thought Control Questionnaire Revised—social control *Thought Control Questionnaire Revised—worry *Thought Control Questionnaire Revised—punishment *Thought Control Questionnaire Revised—reappraisal *White Bear Suppression Inventory

12.91 4.01 12.40 4.16 22.58 12.78 9.26 11.93 5.20 1.25 3.47 3.85 5.00

1.22 1.45 0.99

4.41

1.43

4.72 8.04 3.07 4.00 6.38 3.02 4.69 2.46

4.27 3.52 2.98 3.65 4.53 3.97 1.25 1.33

3.28

1.73

3.49

1.45

5.09

1.33

4.31

1.45

4.86

1.29

3.60 9.30 6.15 3.74 6.63 6.85 61.40

1.49 3.36 2.32 1.34 2.93 2.30 8.27

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treatments were applied more than 5 years before the study, and consisted of several non-structured forms of psychotherapy. The initial diagnosis was confirmed using the Anxiety Disorder Interview Schedule for the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) (ADIS-IV; Brown et al., 1994). Because of the high comorbidity commonly found in OCD, other comorbid conditions were allowed, provided that they were not primary (i.e., OCD was the most severe condition). Based on the ADIS-IV, 17 OCD patients had a comorbid disorder at the time of the study: four patients presented major depression, four had dysthymia, two had panic disorder, one had social phobia, two had generalized anxiety disorder, one had body dysmorphic disorder, and three had a personality disorder (dependent, avoidant, and histrionic, respectively). Primary diagnosis of OCD according to the DSM-IV-TR (APA, 2000) was determined by the clinician after the ADIS-IV interview and after studying a record of the complete history of the patient's OCD. 2.2. Measures The Obsessional Concerns and Self Questionnaire (OCSQ; García-Soriano, 2008) contains 39 items that assess the extent to which respondents consider OC content domains relevant to their self-worth. Items are rated from 1 = ‘strongly agree’ to 7 = ‘strongly disagree’. Items are clustered into five empirically derived dimensions: avoids aggression and injury to others (nine items; e.g., The possibility that I may have hurt or injured another person would lower my self-respect), values collecting or hoarding (seven items; e.g., If I discarded even the smallest item that I later needed, I would be very upset with myself.), control of sexuality (seven items; e.g., I could not have any self-respect knowing there was the slightest hint of sexual perversion in my character), orderliness and cleanliness (10 items; e.g., I feel good about myself knowing that I've done my best to protect the health and safety of others), and maintains moral/religious values (six items; e.g., My self-esteem is greatly influenced by whether or not my actions and decisions have been guided by my religious or moral values and beliefs). The scale showed excellent psychometric properties in non-clinical samples from three different countries: Spain, Argentina and Canada (García-Soriano et al., 2008). The OCSQ domains and total score reliabilities ranged from α = 0.76 (hoarding) to α = 0.89 (total score) in the current study. A copy of the OCSQ is available upon request to the first author. The Obsessive Beliefs Spanish Inventory—Revised (OBSI-R; Belloch et al., 2010) is a 50-item questionnaire with eight factor-derived scales: inflated responsibility; overimportance of thoughts; thought action fusion—likelihood; thought action fusion— moral; importance of controlling one's thoughts; overestimation of threat; intolerance to uncertainty; and perfectionism. Subjects are asked to indicate their degree of agreement with each statement on a seven-point rating scale. The OBSI-R has demonstrated excellent psychometric properties in OCD samples (Belloch et al., 2010). In the current sample, reliability ranged from α = 0.71 (responsibility) to α = 0.89 (thought–action fusion—likelihood). The Yale–Brown Obsessive–Compulsive Severity Scale (YBOCS; Goodman et al., 1989a, 1989b) is a one-on-one interview assessing the severity of the most distressing obsessions and compulsions regarding these items: time occupied or spent, interference, distress, resistance and degree of control. The scale does not assess the contents or symptom dimensions. The Spanish translation was applied (Nicolini et al., 1996), and the reliability in the current sample was α = 0.89. The Obsessive–Compulsive Inventory—Revised (OCI-R; Foa et al., 2002) is an 18-item questionnaire that assesses distress associated with various obsessive–compulsive symptoms on six subscales: washing, checking, ordering, obsessing, hoarding and neutralizing (Spanish version: Fullana et al., 2005). In the current study, reliability ranged from α = 0.74 (hoarding) to α = 0.92 (checking). The Beck Anxiety Inventory (BAI; Beck and Steer, 1993. Spanish translation: Sanz and Navarro, 2003) is a 21-item self-report measuring anxiety symptoms. The reliability in the current study was α = 0.87. The Beck Depression Inventory—II (BDI-II; Beck et al., 1996. Spanish version: Sanz et al., 2003) is a widely used and validated self-report assessing depressive symptoms. In the present study, the reliability was α = 0.79. The White Bear Suppression Inventory (WBSI; Wegner and Zanakos, 1994; Spanish version: Luciano et al., 2006) contains 15 items that assess the tendency to suppress negative and/or unwanted thoughts. The items are scored on a five-point Likert scale. The reliability in the present study was α = 0.80. The Thought Control Questionnaire (TCQ; Wells and Davies, 1994. Spanish version: Luciano et al., 2006) is a self-report instrument that assesses the frequency of the use of different strategies to control negative unwanted thoughts. It includes five empirically derived subscales: distraction, punishment, reappraisal, social control and worry. Reliability ranged from α = 0.56 (worry) to α = 0.84 (punishment) in the present sample. 2.3. Procedure Participants were consecutively recruited at two outpatient mental health clinics in the public National Health System and at the OCD Research Unit of the University. All potential participants were individually screened with a full history and examination by a Licensed Clinical Psychologist (Doctoral level) with experience in the assessment of OCD, as well as in the use of ADIS-IV and the other study measures. The intake assessment consisted of a diagnostic interview using the ADIS-IV in a session lasting 120–150 min. Information about basic demographic data (age, gender, occupation, level of education), medical conditions, and current/past psychological or

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pharmacological treatment was also recorded. The evaluator also completed the YBOCS, informed the patient about the study's purpose and assessment procedure, and asked for his or her explicit consent to participate. After consent had been given, each OCD patient was given an appointment the following week to complete the self-report questionnaires described in the instruments section. In this session, the patient individually filled in all the instruments under the supervision of the evaluator to ensure that the questionnaires were fully understood. Only 47 patients completed the TCQ-r and WBSI instruments.

OCI-R. Moreover, OCSQ-hoarding was moderately to strongly related to the OCI-R hoarding, ordering, checking and neutralizing subscales. No significant associations were found between the OCSQ and the OCI-R obsessing scale. When the BDI scores were partialled out, this pattern of correlations did not change.

3.3. Self-worth contingencies, dysfunctional beliefs and thought control strategies

3. Results First, the means and standards deviations of all study measures were calculated. Results are included in Table 1. 3.1. Self-worth contingencies, OCD and non-OCD symptoms Pearson correlations among the OCSQ subscales and measures of obsessive–compulsive severity (YBOCS) and symptoms (OCI-R), as well as anxiety and depression, are presented in Table 2. Data indicated that the OCSQ-total score was significantly related to YBOCS—compulsions and to OCI-R total score. In contrast, there were no significant relationships between YBOCS—obsessions and the OCSQ. Regarding the OCSQ dimensions, only the religion and moral dimensions were not associated with either of the two OCD measures, while avoid aggression was not related to the OCI-R, and hoarding was not related to the YBOCS. Regarding the relationships between the OCSQ and the non-OCD measures, no correlation was observed with anxiety. However, there were significant correlations between the BDI and OCSQ total score. The Fisher z test showed that these correlation coefficients were equivalent to those observed between the OCSQ and YBOCS— compulsions (z = 0.38, P = 0.35), and OCI-R (z = 0.38, P = 0.35). Then, to rule out the possibility that depression mediated associations between OCSQ and OCD measures, the BDI score was partialled out. The results indicated that the associations between the OCSQ and YBOCS-compulsions (r = 0.337; P = 0.006) and OCI-R (r = 0.442; P = 0.001) remained significant. 3.2. Self-worth contingencies and OCD content domains Significant associations were found between the respective content domains of the OCSQ and the OCI-R subscales, with the exception of OCSQ—aggression and OCSQ—sex, which are not included as separate symptom dimensions in the OCI-R. As Table 2 shows, OCSQ-order and cleanliness was moderately to strongly associated with the washing, ordering, checking, neutralizing and hoarding subscales of the

To examine links among OC self-relevant domains (OCSQ), dysfunctional thought beliefs and thought control strategies, Pearson correlations were computed (Table 3). Results indicated, first, that all OCD-related cognitions (OBSI-R) maintained medium-high relationships with the OCSQ-total score. Responsibility and intolerance to uncertainty maintained significant correlations with all OCSQ dimensions. Overestimation of threat was also significantly associated with all OCSQ dimensions, except for OCSQ—following moral/religious principles, and thought–action fusion—morality was again significantly correlated with all OCSQ dimensions, except OCSQ—hoarding. The beliefs of perfectionism, importance of thought control, over-importance of thoughts, and thought–action fusion—likelihood, respectively, showed significant associations with three, two and one OCSQ domain. This pattern of associations remained stable when the BDI score was controlled. Regarding relationships between the OCSQ and thought control strategies, results showed that the use of self-punishment was significantly associated with all OCSQ domains, except OCSQ—religion/ moral. Distraction was significantly associated with OCSQ—hoarding, and social control was negatively related to OCSQ—religion/moral. Moreover, moderate associations were found between suppression (WBSI) and OCSQ—avoids aggression and control of sexuality. Given the strong association previously observed between the OCSQ and the OBSI-R, we wondered whether these two sets of variables could be considered equivalent regarding OCD. To explore this question, Pearson correlations between total scores on self-worth (OCSQ) and OCI-R controlling obsessional beliefs (OBSI-R) were first calculated. The association remained significant (r = 0.309; P = 0.026). However, when the inverse was done, the significant association found between obsessional beliefs (OBSI-R) and the OCI-R (r = 0.368; P = 0.007) disappeared after controlling the influence of self-worth (r = 0.078). To further clarify these results, a hierarchical regression analysis was conducted with the OC symptoms (OCI-R-total score) as dependent variable. In order to control for common covariance among depressive and OCD symptoms, BDI was entered into the equation in

Table 2 Correlation coefficients between OCSQ and different symptom measures in the OCD sample (n = 57). Obsessional Concerns and Self Questionnaire Avoid aggression YBOCS obsessions YBOCS compulsions BDI-II BAI OCI-R contamination OCI-R obsession OCI-R hoarding OCI-R order OCI-R checking OCI-R neutralizing OCI-R total score

0.076 0.284⁎ 0.346⁎⁎ 0.105 0.195 − 0.047 0.150 0.195 0.203 0.138 0.258

Hoarding

Sexual

Order and cleanliness

Religion/moral

Total

0.024 0.221 0.221 0.144 0.083 − 0.045 0.454⁎⁎⁎ 0.372⁎⁎ 0.453⁎⁎⁎ 0.307⁎ 0.429⁎⁎⁎

0.091 0.278⁎ 0.350⁎⁎

− 0.033 0.415⁎⁎

− 0.043 0.175 0.128 − 0.023 − 0.038 0.087 0.044 0.185 0.124 − 0.012 0.098

0.037 0.411⁎⁎ 0.348⁎⁎

0.100 0.162 0.250 0.065 0.216 0.136 0.246 0.280⁎

0.118 − 0.028 0.326⁎ − 0.123 0.452⁎⁎⁎ 0.598⁎⁎⁎ 0.496⁎⁎⁎ 0.304⁎ 0.559⁎⁎⁎

0.088 0.232 0.073 0.334⁎ 0.455⁎⁎ 0.409⁎⁎ 0.296 0.479⁎⁎⁎

OCSQ = Obsessional Concerns and Self Questionnaire; avoid aggression = avoids aggression and injury to others; hoarding = values collecting or hoarding; sexual = control of sexuality; order and cleanliness = orderliness and cleanliness; religion/moral = maintain moral/religious values; YBOCS obsession = Yale–Brown Obsessive–Compulsive Severity obsession Scale; YBOCS compulsion = Yale–Brown Obsessive–Compulsive Severity compulsion Scale; BDI-II = Beck Depression Inventory-II; BAI = Beck Anxiety Inventory; OCIR: Obsessive–Compulsive Inventory—Revised. ⁎ P ≤ 0.05 (two-tailed). ⁎⁎ P ≤ 0.01 (two-tailed). ⁎⁎⁎ P ≤ 0.001 (two-tailed).

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Table 3 Associations between OCSQ subscales and dysfunctional beliefs about thoughts (OBSI-R; n = 57) and thought control strategies (TCQ-r; WBSI; n = 47) in the OCD sample. Obsessional Concerns and Self Questionnaire Avoid aggression Responsibility Importance of thoughts TAF—likelihood TAF—moral Thought control Threat overestimation Intolerance uncertainty Perfectionism OBSI-R total TCQ—distraction TCQ—social control TCQ—worry TCQ-Punishment TCQ—reappraisal WBSI

Hoarding

0.483⁎⁎⁎

0.341⁎⁎

0.119 0.171 0.543⁎⁎⁎ 0.485⁎⁎⁎ 0.327⁎ 0.337⁎

0.110 0.205 0.075 0.313⁎ 0.436⁎⁎⁎ 0.459⁎⁎⁎ 0.354⁎⁎ 0.392⁎⁎ 0.336⁎

0.200 0.493⁎⁎⁎ 0.000 0.028 − 0.074 0.364⁎

0.183 0.219 0.379⁎⁎ 0.274 0.278

− 0.011 0.337⁎

Sexual

Order and cleanliness

0.325⁎ 0.433⁎⁎⁎ 0.352⁎⁎ 0.509⁎⁎⁎ 0.262 0.436⁎⁎⁎ 0.366⁎⁎ 0.292⁎ 0.530⁎⁎⁎ − 0.115 − 0.137 0.020 0.400⁎⁎ − 0.003 0.392⁎⁎

Religion/moral

0.639⁎⁎⁎ 0.112 0.137 0.377⁎⁎ 0.485⁎⁎⁎ 0.447⁎⁎⁎ 0.642⁎⁎⁎ 0.439⁎⁎⁎ 0.594⁎⁎⁎ 0.011 0.019 − 0.033 0.357⁎ 0.258 0.228

0.353⁎⁎ 0.272⁎ 0.246 0.384⁎⁎ 0.191 0.225 0.273⁎ 0.188 0.380⁎⁎ − 0.110 − 0.297⁎ − 0.211 − 0.010 − 0.223 0.091

Total 0.624⁎⁎⁎ 0.303⁎ 0.320⁎ 0.565⁎⁎⁎ 0.511⁎⁎⁎ 0.541⁎⁎⁎ 0.598⁎⁎⁎ 0.422⁎⁎⁎ 0.703⁎⁎⁎ 0.026 − 0.064 − 0.026 0.445⁎⁎ 0.082 0.402⁎⁎

OBSI-R = Obsessive Beliefs Spanish Inventory—Revised; TAF: thought action fusion; TCQ: Thought Control Questionnaire; WBSI: White Bear Suppression Inventory. ⁎ P ≤ 0.05 (two-tailed). ⁎⁎ P ≤ 0.01 (two-tailed). ⁎⁎⁎ P ≤ 0.001 (two-tailed).

the first step, and the beliefs (OBSI-R) and self-worth (OCSQ) were entered in step two. Results (Table 4) indicated that in the final equation, self-worth was the only variable that significantly contributed to OCI-R variance (F3,53 = 4.267; P = 0.009). 4. Discussion This study aims to provide empirical support for cognitive conceptualizations that hypothesize a role for self-concept in OCD development, looking for a possible convergence between OC symptom contents and self-worth domains with comparable contents. This approach is different from those examining fluctuations in self-esteem level (i.e., Ehntholt et al., 1999), feared self (i.e., Ferrier and Brewin, 2005), or perceived competence in generally valued self-domains not specifically related to OCD (i.e., Doron et al., 2007, 2008). Our first hypothesis was that OCSQ domains would be more associated with OCD symptoms than with other symptomatology usually found in OCD patients, such as depressive and/or non-OCD anxious symptoms (e.g., Weissman et al., 1994). As expected, we found that the OCSQ was more related to OCD than to anxious symptoms measured by the BAI. This result suggests that OC self-worth domains are related to obsessions and compulsions but not to other anxiety symptoms. However, the OCSQ maintained similar associations with obsessive–compulsive and depressive symptoms. Although we discard the possibility that depression was mediating the relationships between the OCSQ and OCD measures, the fact is that depression was at least as relevant as obsessions to the self-worth contingencies.

This result could be due to the higher depression rates usually found among OCD patients, which are around one-third at referral (Overbeek et al., 2002). Indeed, the BDI mean in our study indicates that most of the OCD patients exhibit depressive symptoms, and eight of them have a co-morbid depressive disorder. Moreover, some of the self-worth domains may be more susceptible to being associated with the depressive affect that accompanies OCD than others. In fact, the BDI score was only significantly related to the avoid aggression and control of sexuality OCSQ domains. From a clinical perspective, the aggressive and sexual obsessive contents are usually experienced as more egodystonic than others, like order or cleanliness, which could at least partly explain their greater association with depression. The unexpected lack of associations between the OCSQ and obsession severity (YBOCS-obsessions) could be due to the fact that the OCSQ was not designed to assess OCD symptoms or OCD severity. The rationale behind the self-worth contingencies construct is analogous to the hypothesized relationships between OCD and metacognitions, such as beliefs and thought control strategies, i.e., cognitive products that promote the escalation of normal intrusive thoughts into clinical obsessions. In this sense, the absence of relationships between the severity of obsessions and OC self-worth domains is analogous to data reported in studies exploring relationships between dysfunctional beliefs and appraisals about obsessions and OCD severity. In a prospective study with subjects at potential risk for OCD, Abramowitz et al. (2006) found that dysfunctional beliefs predicted the severity of checking, washing and obsessional OCD symptom

Table 4 Regression statistics for each block of variables and summary statistics for the final equation with the OCI total score as dependent variable.

Step 1 BDI-II Step 2 OBSI-R, OCSQ

R2

Adj. R2

R2 change

F change

d.f.

0.012

− 0.007

0.012

0.615

1, 55

0.43

0.207

0.159

0.195

6.032

2, 53

b0.005

P

Individual variables in final equation

BDI-II OBSI-R OCSQ

β

t

P

− 0.05 0.25 1.12

− 0.36 0.78 2.10

0.71 0.43 0.04

OCI-R: Obsessive–Compulsive Inventory—Revised; BDI-II = Beck Depression Inventory-II; OBSI-R = Obsessive Beliefs Spanish Inventory—Revised; OCSQ = Obsessional Concerns and Self Questionnaire.

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dimensions, but not neutralizing, ordering or hoarding symptom dimensions. Wheaton et al. (2010), using the Dimensional Obsessive–Compulsive Scale to assess the severity of four OCD symptom dimensions, found that only the responsibility for harm subscale was significantly related to all the dysfunctional beliefs assessed with the Obsessive Beliefs Questionnaire (OBQ), whereas contamination severity symptoms were only associated with the OBQ—responsibility and threat overestimation subscale. Moreover, only the contamination dimension was not significantly related to the BDI. In sum, it seems that not all OC domains in which patients posit their self-worth are associated with OCD severity, just as what occurs when relationships between faulty appraisals about OC symptoms and severity of the disorder are examined. Regarding our second hypothesis, results show specific associations between two OCSQ-domains and their respective OCD-content, as assessed by the OCI-R. Higher associations were found between OCSQ —hoarding and OCSQ—order/cleanliness and the OCI-R washing, ordering, checking and hoarding subscales. These results indicate that Type II non-moral based obsessions (Garcia-Soriano et al., 2011) were related to their analogous self-worth domains, as assessed by the OCSQ. However, this was not true for Type I-moral based obsessions (e.g., aggressive, sexual, and moral/religious). The absence of significant associations between the aggressive, sexual and religion/moral OCSQ dimensions and the OCI-R subscales is not surprising, since none of the OCI-R subscales assess those domains. Only one item on the OCI-R obsessions subscale refers to “repugnant thoughts”, and the nearly significant association between OCSQ—sexuality and OCI-R obsessionality suggests that our hypothesis could be verified with other OCD symptom instruments that include aggressive, sexual and moral symptoms. Nonetheless, our results coincide with findings from studies using OCD samples that report a lack of specificity between sensitive self-domains, that is, relevant domains in which subjects feel incompetence, and OCD symptom dimensions assessed with the Padua Inventory (Doron et al., 2008). Our third hypothesis was that the OCSQ domains share characteristics with two sets of variables that play a central role in the cognitive explanation of OCD: dysfunctional beliefs associated with symptoms and neutralizing strategies. Our findings show that the more important the OCSQ domains are for OCD patients' self-worth, the greater the presence of dysfunctional beliefs about thoughts. And this was especially true for the responsibility, thought–action fusion—moral, overestimation of threat, and intolerance to uncertainty beliefs. Other authors (Doron et al., 2007, 2008) have also found associations between sensitive self-domains and beliefs. They found that, in OCD patients, sensitivity in moral domains was associated with higher responsibility and over-estimation of threat beliefs. The high association found between dysfunctional beliefs and selfrelevant OC domains could be an indicator that the two sets of variables share common elements, as both could be conceived of as beliefs (i.e., self-related and thought-related beliefs). From this perspective, these two groups of beliefs play a similar, but not identical, role in the development and/or maintenance of OCD. Our data reveal that OC self-worth contingencies play a more relevant role than dysfunctional beliefs in predicting OC symptoms assessed by the OCI-R. With regard to patients' use of thought control strategies, results indicate that positing self-esteem in OC-domains was associated with the use of two of the most dysfunctional thought control strategies: punishment for having negative intrusions and suppression efforts. Punishment is the only thought control strategy that differentiates OCD patients from depressed and anxious individuals (Belloch et al., 2009), and a large number of studies have found counterproductive effects of suppression on OCD symptoms (e.g., Trinder and Salkovkis, 1994; Purdon and Clark, 2001; Belloch et al., 2004). However, the lack of associations between punishment and the OCSQ dimension about the importance for the self-worth of maintaining religious/moral values was not expected. Throughout the

study, this domain showed few significant associations with the study measures, which suggests that it may not be adequately assessed or, alternatively, that its influence on the OC self-worth contingencies is questionable. In conclusion, our results first suggest that OC self-relevant domains are more related to OCD than to anxiety, as hypothesized. Additionally, the avoid aggression and control of sexuality self-worth domains are relevant both for OCD and for the co-morbid depressive symptoms. Second, the OC self-worth contingencies are associated with their corresponding OC symptoms of washing, hoarding, ordering, and checking. However, the associations between moral-based self-worth contingencies and their corresponding obsessional contents (i.e., aggressive, sexual, and religious) were not clearly established, probably due to the limitations of the OCD symptoms measure (i.e., OCI-R). Third, the obsessional self-worth contingencies share a significant amount of variance with metacognitive constructs, such as beliefs and control strategies, which indicates that they could be considered metacognitive constructs. Particularly important is the fact that these self-worth contingencies explain OCD symptoms better than the dysfunctional beliefs associated with those symptoms. Taken together, our results suggest that the obsessional self-worth contingencies could be conceived as a vulnerability factor for OCD, similar to those postulated by current cognitive models of the disorder (i.e., appraisals and control strategies). This seems to be especially true for some OCD modalities or symptoms, such as cleaning, hoarding, ordering and checking. From a clinical perspective, the importance for the self-worth of certain self-related beliefs, such as being a clean and ordered person, could explain why a normal intrusive thought becomes an obsession in some patients but not in others. In fact, our data indicate that these self-worth domains explain their obsessional symptom counterparts better than the adscription to dysfunctional beliefs postulated by the current cognitive explanations for OCD. An additional possibility would be that some of these selfworth domains contribute to the maintenance of the disorder and/ or to resistance to treatments. From this perspective, the specific role that the self-worth contingencies play in the development and/ or maintenance of OCD, as well as their change with treatment, is an issue that warrants further investigation. Limitations of the present study should be considered as well. First, both the use of a cross-sectional design and the correlational nature of the study limit the conclusions that can be drawn. To adequately assess the impact of self-worth domains on the pathogenesis and/or maintenance of OCD, a longitudinal design would be needed. Second, our patients do not adequately represent all the OCD symptom dimensions; thus, we could not compare differences in self-contingencies among OCD “subtypes”. Future research with larger OCD samples will allow us to analyze differences between OCD subtypes in relation to OC self-worth areas. Another limitation of this study is that the OCSQ does not separately assess all OCD symptom dimensions, as order and washing are included in the same subscale/factor, and checking does not have a separate subscale, whereas other less prevalent dimensions (aggression, sex, or religion) (Welkowitz et al., 2000) have separate factors.

Acknowledgments This study was supported by the Spanish Ministerio de Ciencia e Innovación (grant no. PSI2010-18340; main researcher: A.B.).

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