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Guy Doron

Individuals suffering from OCD experience commonly occurring intrusive phenomena as highly distressing, personally threatening and unacceptable (Clark & Purdon, 1993; de Silva & Rachman, 1998; Rachman, 1998; Salkovskis, 1985). It is not surprising that OCD is associated with high degrees of psychiatric comorbidity, including major depression and other anxiety disorders (American Psychiatric Association, 1994). A range of dysfunctional beliefs have been associated with maladaptive appraisals of intrusive phenomena (for review see Frost & Steketee, 2002). Findings consistently suggest that the severity of dysfunctional beliefs is associated with OCD symptom severity in OCD samples (e.g., OCCWG, 2003; 2005) and non-clinical samples (e.g., Tolin et al., 2003; also see chapter 4 and 6 of this thesis). However, little research has investigated the specificity of these dysfunctional beliefs to OCD. The little research that has investigated whether the severity of such dysfunctional beliefs distinguishes between individuals suffering from OCD and individuals suffering from other anxiety disorders has been somewhat equivocal.

For instance, research (e.g., OCCWG , 2003; Steketee, Frost, & Cohen, 1998) and theory (see Clark & Wells, 1995) implicate overestimation of threat in OCD and other anxiety disorders such as panic disorder and social phobia. Perfectionism has been associated with a range of disorders such as eating disorders, GAD, OCPD, and depression (see Frost & DiBartolo, 2002 and Shafran & Mansell, 2001 for reviews). Finally, while there is some evidence indicating inflated sense of responsibility and importance/control of thoughts may be specific to OCD (e.g., OCCWG; 2001, 2003), however, recent studies are less conclusive with regards to inflated responsibility (OCCWG, 2005; Tolin et al., 2006).

Specifically, in a study using the revised OBQ (OCCWG, 2005; for detailed description see chapter 4 of this thesis), individuals suffering from OCD (n=244) showed significantly higher scores than individuals suffering from other anxiety disorders (AD; n=103) on inflated responsibility/overestimation of threat and on importance/control of thoughts, but not on the perfectionism/intolerance for Uncertainty subscale. Both clinical groups showed significantly higher conviction than students (n=284) and community controls (CC; n=86) of all these subscales. However, in a different study comparing an OCD cohort (n=89) with anxiety disorder (n=72) and community (n=33) controls, Tolin et al. (2006) found that their OCD group differed from anxiety controls on beliefs about perfectionism/ intolerance for uncertainty and importance/control of thoughts, but not on beliefs about threat estimation and inflated responsibility. Again, both clinical groups showed higher scores on OBQ than the community group. Importantly, when controlling for depression and anxiety scores, only importance/control of thoughts differentiated between the OCD and anxiety groups. While, the OCD group showed higher scores on the OBQ than the community group, no differences between the anxiety and community group were indicated. Thus, findings are equivocal with regard to the specificity of some dysfunctional beliefs in OCD, although evidence for specificity of dysfunctional beliefs about the importance/control of thoughts has been more consistent. However, research findings have also suggested that a significant proportion of individuals with OCD do not show more severe dysfunctional beliefs than individuals in the community (Calamari et al., in press; Taylor et al., 2006).

While dysfunctional beliefs identified as important in the phenomenology of OCD may not be specific to those presenting with the disorder (Steketee, Frost, & Wilson, 2002), this does not preclude the relevance or even specificity to particular OC symptom dimensions or OCD subtypes (McKay et al., 2004). Given that anxious controls usually report relatively high rates of OC symptoms (OCCWG, 2003), finding differences between OCD and anxious controls on cognitions measures may be contingent on large effect sizes. However, the lack of significant differences between anxious and OCD cohorts on cognitions measures does not necessarily reflect the lack of specificity of specific cognitions to either specific OCD dimensions or OCD subtypes.

Further, although previously identified OC relevant dysfunctional beliefs may play an important role in the maintenance of OC symptoms for some individuals with OCD, such dysfunctional beliefs may not account totally for negative interpretations of intrusions or the associated dysfunctional responses across OCD cohorts. Identification of additional cognitive structures relevant and/or specific to OCD or OC dimensions may further our understanding of why OCD develops in some individuals but not in others (Steketee et al., 2002), as well as facilitate focused treatments.

Indeed, recent research has implicated the idea of underlying cognitive-affective structures these as perceptions of self, others and the world as vulnerability factors operating in individuals with obsessive-compulsive thoughts and behaviors (e.g., Bhar & Kyrios, 2000; Guidano & Liotti, 1983; Sookman, Pinard, & Beauchemin, 1994). For instance, attachment related internal representations were found to be linked to OCD in clinical (e.g., Myhr, Sookman, & Pinard, 2004) and non-clinical student cohorts (see chapter 6 of this thesis). OCD has also been associated with individuals overestimating how threatening the world is (OCCWG, 1997, 2005), perceiving others as having unrealistic perfectionistic expectations of them (e.g., Bhar & Kyrios, 1999), and self perceptions as dangerous to others (Ferrier & Brewin, 2005) and responsible for preventing harm (see Salkovskis & Forrester, 2002 for review).

Importantly, cognitive conceptualizations of importance/control of thoughts are particularly related to underlying cognitive affective structures such as self concept. For instance, individuals vulnerable to OCD are argued to appraise commonly occurring intrusive experiences as endangering their view of self (Rachman, 1997, 1998), distressing by virtue of their contradiction with valued aspects of self (Purdon & Clark, 1999), and as indicating personal responsibility for preventing harm to self/or others (Salkovskis, 1985). Thus, the importance attributed to intrusions suggests dysfunctional self perceptions may be of particular importance in OCD.

Doron and Kyrios (2005; see chapter 2 of this thesis) proposed that recent developments in attachment, self concept, and world-view research may provide clues for the links between such cognitive-affective structures and identifying vulnerability factors for obsessive-compulsive symptoms and cognitions. Recent findings have linked attachment experiences with dysfunctional cognitive processes similar to those identified in current cognitive models of OCD (OCCWG, 1997) such as increased threat appraisals, dysfunctional perfectionistic tendencies and difficulty in suppressing thoughts (Mikulincer, Dolev, & Shaver, 2004; Wei et al., 2004).

It is suggested in this thesis that negative internal working models (IWMs) of self (expressed as anxiety related to abandonment) and IWMs of others (expressed as avoidance of intimacy or dependence) stemming from negative attachment experiences may also increase the likelihood that particular perceptions of self and the world may form. For instance, negative IWMs of self and others may increase the chances of developing ´┐¢sensitive´┐¢ self perceptions (i.e., feelings of incompetence in valued domains of self) in the domains of morality, job competence and social acceptability. Negative IWMs of others and the fear of rejection associated with such representations may lead to the development of a particular combination of assumptions about others and the world (e.g., threatening). These cognitive affective structures will then further increase vulnerability to both OC symptoms and OC related cognitions.

Up to this point, three studies have examined the proposed model in this thesis. Overall, the results of these studies are consistent with the model proposed. Specifically, it was found that a particular combination of world view assumptions is associated with more severe OC symptoms (see chapter 4 of this thesis). World assumptions were found to relate to OC related beliefs. Negative perceptions of the world and more complex relationship between self and world perceptions (e.g., perceptions of oneself as undeserving, moderated by strong beliefs in a just world) predicted OC symptom severity after controlling for OC related cognition and depressive symptoms. Finally, some evidence was found that different dimensions of OC symptoms (i.e., overt vs covert) are predicted by different world view assumptions.

In a second study (see chapter 5 of this thesis), sensitivity (i.e., feelings of incompetence in valued domains) in the particular self domains (e.g., morality, job and scholastic competence, and social acceptability) were found to be associated with higher levels of OC symptoms and related beliefs. These findings were generally maintained when controlling for global self-worth. Finally, in a third study (see chapter 6 of this thesis), support was found for a fully mediated model linking attachment representations with OC symptoms via perceptions of self and world. IWMs of self, but not IWMs of others were linked to OC symptoms via OC related cognitions. Thus, overall results of previous studies support the proposed relationship between OC symptoms and these cognitive affective structures.

Nevertheless, these studies used an analogue student cohort. While particular structures of self, world and others were associated with OC symptoms in these analogue samples, such findings need to be replicated in older sample groups and with clinical cohorts. This will enable stronger inferences regarding the importance and relevance of these constructs to clinical groups. Comparing the extent to which individuals suffering from OCD posses such cognitive-affective structures may enable us to better understand the degree in which these structures are relevant and/or specific to OCD and clarify the role they might have in the development of this disorder. Finally, the particular relationship between these cognitive-affective structures and OC dimensions needs to be further explored.

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