Experiential avoidance in OCD Wetterneck et al.
Experiential avoidance in symptom dimensions of OCD Chad T. Wetterneck, PhD Daniel S. Steinberg, MA John Hart, PhD
Experiential avoidance (EA) involves an unwillingness to remain in contact or experience unpleasant private events through attempts to avoid or escape from these experiences. EA is hypothesized to play a role in obsessive-compulsive disorder (OCD); however, previous studies have not found a significant relationship between EA and OCD severity. The present study examined the relationship between EA and OCD severity as measured by an updated measure of EA, an established measure of OCD severity (i.e., the Obsessive-Compulsive Inventory-Revised [OCI-R]), and a new measure of OCD symptom dimension severity, the Dimensional Obsessive-Compulsive Scale (DOCS). A sample of 83 nonreferred individuals meeting criteria for OCD completed the measures. Correlations between EA and the OCI-R corroborated previous findings; however, EA was significantly correlated with the DOCS. There were differences across the symptom dimensions, with EA significantly correlated with unacceptable thoughts, responsibility for harm, and symmetry, but not with contamination. (Bulletin of the Menninger Clinic, 78[3], 253–269)
Obsessive-compulsive disorder (OCD) is an anxiety disorder characterized by compulsions (repetitive behaviors or internal mental acts aimed at reducing anxiety) and/or obsessions (recurrent and intrusive thoughts or images that result in increased anxiety and distress) (American Psychiatric Association, 2000).
Chad T. Wetterneck is at Rogers Memorial Hospital, Oconomowoc, Wisconsin. Daniel S. Steinberg is at the University of North Texas, Denton, Texas. John Hart is at the Menninger Clinic, Houston, Texas. Correspondence may be sent to Chad T. Wetterneck at Rogers Memorial Hospital, 34700 Valley Rd., Oconomowoc, WI 53066; e-mail: [email protected] (Copyright © 2014 The Menninger Foundation)
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The 12-month prevalence of OCD in the United States adult population is estimated to be 1%, and 50.6% of these cases are classified as severe (Kessler, Chiu, Demler, & Walters, 2005). The current preferred treatment for OCD, cognitive-behavioral therapy, specifically, exposure and ritual prevention (ERP), has been demonstrated to have a clinically significant impact on a majority of patients; however, ERP also suffers from a 25% dropout rate (Abramowitz, Taylor, & McKay, 2009; Fisher & Wells, 2005). Other studies have indicated that a number of individuals (5%–22%) seeking treatment for OCD refuse ERP as a treatment option (Foa et al., 2005; McLean et al., 2001) and that clinicians and the general public often find ERP to be aversive (Richard & Gloster, 2007). Although ERP remains the “gold standard” for OCD treatment, it may prove worthwhile to explore additional treatment options to offer to those individuals who either drop out of, fail to respond to, or reject exposure-based treatment. It has been suggested that experiential avoidance (EA) may play an important role in OCD, and that treatments targeting it may be effective (Eifert & Forsyth, 2005). EA can be defined as an unwillingness to remain in contact or experience unpleasant private events through attempts to avoid or escape from these experiences (Hayes, Wilson, Gifford, Follette, & Strosahl, 1996). One treatment that targets EA is acceptance and commitment therapy (ACT; Hayes, Strosahl, & Wilson, 1999). A test of ACT with a small sample of individuals meeting criteria for OCD found reductions in EA and OC symptoms; however, the small sample size prevented an analysis of any possible relationship (Twohig, Hayes, & Masuda, 2006). Importantly, a recent more robust study demonstrated that ACT was an effective treatment for OCD severity in a randomized clinical trial (Twohig et al., 2010). Although these initial results of ACT for OCD seem to be promising, they do not include an analysis of the relationship between EA and OCD severity. Other recent studies that have evaluated this relationship have not found a significant connection between measures of EA and measures of OCD severity (Abramowitz, Lackey, & Wheaton, 2009; Manos et al., 2010).
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Research has shown that EA is associated with higher levels of anxiety, depression, general psychopathology, and symptoms related to trauma (Hayes et al, 2004). Eifert and Forsyth (2005) have hypothesized that EA may manifest itself as compulsions in OCD. Some evidence suggests that reductions in EA can lead to reductions in symptom severity within an anxiety-disordered sample (Chawla & Ostafin, 2007). Studies examining the relationship between EA and OCD severity have also examined relationships with obsessional beliefs, which involve dysfunctional appraisals of thoughts such as the overestimating of threat, personal responsibility, importance of and need to control thoughts, the need for perfectionism, and the intolerance of uncertainty (Obsessive Compulsive Cognitions Working Group, 2005). Abramowitz, Lackey, and Wheaton (2009) conducted a study in a nonclinical sample to determine whether EA predicts obsessive-compulsive (OC) symptoms above that which can be explained by obsessional beliefs and depression. This study was later replicated in a clinical sample with similar results (Manos et al., 2010). EA was not found to predict severity above and beyond obsessional beliefs and depression in these studies. Manos and colleagues (2010) suggested that the measure of EA used may have been an important limiting factor and may have been inadequate to find a result if there had been a relationship between EA and OC symptoms due to its questionable internal consistency. The Acceptance and Action Questionnaire (AAQ; Hayes et al, 2004) was developed as an initial measure of EA and was used in the study by Manos et al. (2010). However, a major limitation in this instance for the AAQ is that it has a fairly low measure of internal consistency in the initial psychometric study (a = .70) (Hayes et al., 2004) and other studies important in this area (e.g., a = .58 in Manos et al., 2010). The AAQ has been replaced by the Acceptance and Action Questionnaire-II (AAQII), which has better psychometric consistency (a = .84) and may be a better measure of EA (Bond et al., 2011). The AAQ-II addresses issues with scale brevity, item wording, and item selection procedures that were found in the original measure. A further revision of the AAQ-II reduced the measure from a 10-
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item scale to a 7-item scale after further psychometric analysis (Bond et al., 2011). In addition to the availability of a revised measure of EA, a new measure for use with OC symptoms has also become available. The studies just mentioned used the Obsessive-Compulsive Inventory-Revised (OCI-R; Foa et al., 2002) as a measure of OC symptom severity. What may be problematic about the OCI-R is that it measures severity based on the extent to which a limited set of symptoms caused distress over the previous month, which may not be a complete measure of the severity. It also fails to take into account the wide variety of types of symptoms (e.g., no specific reference to violent, sexual, or scrupulous obsessions or compulsions), which precludes the inclusion of all types of OC symptoms in the measure. The OCI-R also does not measure avoidance, measures only obsessions in some symptom dimensions and only compulsions in others, and, importantly, contains a one-dimensional assessment of severity (Abramowitz et al., 2010). The development of the Dimensional ObsessiveCompulsive Scale (DOCS; Abramowitz et al., 2010) addresses the limitations of the OCI-R and assesses OC symptoms on the following four dimensions: “contamination,” “responsibility for harm, injury or bad luck,” “unacceptable obsessional thoughts,” and “symmetry, completeness, and exactness.” The use of a multidimensional approach for measuring OC symptom severity in the DOCS takes into account distress, functional interference, and the frequency or duration of obsessions and compulsions (Abramowitz et al., 2010). Thus, this measure is consistent with research that indicates that OC symptoms fall into several psychometrically diverse categories (Mataix-Cols, Rosario-Campos, & Leckman, 2005). Focusing research on individual symptom dimensions rather than OC symptom severity as a whole may be an important step in finding ways to improve treatment for OCD (Smith, Wetterneck, Hart, Short, & Björgvinsson, 2012). We hypothesized that the new measures available would provide the best opportunity to adequately investigate the relationship between EA and OC symptom dimensions short of creating an OC symptom–specific measure of EA, and this aspect of the
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study is exploratory in nature. In light of the results of the previous studies examining this relationship, we also hypothesized that the aspects of the study, which are a replication of prior studies, would yield similar results, with significant correlations found only between the AAQ-II and the OCI-R obsessing subscale (Abramowitz, Lackey, & Wheaton, 2009; Manos et al., 2010). Method Participants Respondents included 111 nonreferred individuals meeting criteria for OCD; 28 participants were excluded from the analysis because they did not meet criteria for OCD. The presence of OCD symptoms was assessed with the Copperfield-Clear Lake Screener (C-CLS), which is described in the Measures section of this article. The mean age for the sample was 33.60 years (SD = 12.81); 71.1% of the respondents were female and 83.1% were White. Individuals were included in the study if they indicated the presence of obsessions and/or compulsions, that these obsessions and/or compulsions caused significant distress or were time consuming, and that these obsessions and/or compulsions were recognized at some point as being excessive or unreasonable. Most of the sample (79.5%; n = 66) indicated that they had been formally diagnosed with OCD. A wide range of previously diagnosed secondary comorbid conditions were self-reported in the sample, including 45.8% (n = 38) with generalized anxiety disorder, 14.5% (n = 12) with posttraumatic stress disorder, 13.3% (n = 13) with social phobia, 13.3% (n = 13) with a personality disorder, 10.8% (n = 9) with an eating disorder, 9.6% (n = 8) with trichotillomania, 5.1% (n = 5) with general phobia, 6.0% (n = 5) with a substance-related disorder, 3.6% (n = 3) with Tourette’s syndrome, and 2.4% (n = 2) with a dissociative disorder. Procedure Study participation was made available and advertised to individuals through several organizations catering to sufferers of Vol. 78, No. 3 (Summer 2014)
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OCD, including websites for the International OCD Foundation, the Peace of Mind Foundation, and the Houston OCD Program. Participants took the survey in an online format. After giving informed consent to participate in the study, respondents were directed to a secure website where demographic and diagnostic information were collected, followed by a screener designed to filter out individuals who did not meet criteria for OCD. Participants then took a variety of measures, including the AAQ-II and the DOCS. Measures Acceptance and Action Questionnaire-II (AAQ-II). The AAQII (Bond et al., 2011) is a seven-item measure of EA and psychological flexibility (a related construct inversely related to EA and measured on the same dimension) that is a revised version of the original AAQ. It has good psychometric properties and good convergent, incremental, and discriminant validity (Bond et al., 2011). Higher scores on the AAQ-II indicate higher levels of EA and low psychological flexibility (Bond et al., 2011). Internal consistency for this measure was good in the current sample (a = .86). Dimensional Obsessive-Compulsive Scale (DOCS). The DOCS (Abramowitz et al., 2010) is a 20-item measure that evaluates OC symptom severity across four dimensions: contamination, responsibility for harm, unacceptable thoughts, and symmetry. For each dimension, it assesses the time spent engaging in or thinking about obsessions and compulsions, avoidance of situations in order to prevent concerns, distress related to being unable to perform compulsions, disruption in daily routine, and ability to disregard thoughts about obsessions when refraining from compulsions. The DOCS performed well on indices of reliability and validity and was sensitive to both treatment and diagnostic sensitivity. Higher scores on the DOCS indicate greater severity in each symptom dimension (Abramowitz et al., 2010). All subscales demonstrated excellent internal consistency in the current sample (contamination, a = .96; responsibility for harm, a = .93; unacceptable thoughts, a = .94; symmetry a = .96). 258
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Obsessive-Compulsive Inventory-Revised (OCI-R). The OCIR (Foa et al., 2002), which was included primarily as a replication of previous studies, is an 18-item measure that assesses the degree to which an individual is bothered or distressed by OC symptoms over the previous month. It evaluates symptoms in six dimensions: washing, checking/doubting, obsessing, neutralizing, ordering, and hoarding. The OCI-R has good internal consistency (Cronbach’s alpha = .81 to .93), good construct validity, and has an established clinical cutoff score of 21 (Abramowitz & Deacon, 2006; Foa et al., 2002). All subscales demonstrated from good to excellent internal consistency in the current sample (washing, a = .93; checking, a = .88; ordering, a = .92; obsessing, a = .86; hoarding, a = .95; neutralizing a = .82). Copperfield-Clear Lake Screener (C-CLS). The C-CLS (Hong et al., 2013) is a four-item measure designed for use in a self-report assessment battery to assess for an OCD diagnosis. It provides a definition of both obsessions and compulsions and asks the respondent to indicate if these are present and whether these obsessions or compulsions cause significant distress. It also assesses whether they are time consuming (over 1 hour per day on average) or significantly interfere with normal routine, occupation or academic functioning, and social activities or relationships. In addition, the C-CLS evaluates whether the respondent has recognized that the obsessions or compulsions are excessive or unreasonable. Previous research has found use of this measure to be effective in screening out those without OCD or those with nonclinical levels of OCD (Hong et al., 2013). The Depression Anxiety and Stress Scale-21 Item (DASS-21). The DASS-21 (Lovibond & Lovibond, 1995) is a short form of the original 42-item measure developed by Lovibond and Lovibond. It is a self-report measure of depression, anxiety, and stress. The DASS-21 has good internal consistency (Cronbach’s alpha = .88) and good convergent and discriminative reliability. The current study used only the depression scale of the DASS21, which also has good internal consistency (Cronbach’s alpha
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= .82; Lovibond & Lovibond, 1995). Internal consistency for this measure was good in the current sample (a = .89). Analytic Plan Pearson’s correlations were conducted first with the AAQ-II and the OCI-R total score and subscales to examine the relationships found between these constructs in previous studies (Abramowitz, Lackey, & Wheaton, 2009; Manos et al., 2010) and to assess the differences that may be found with the updated version of the AAQ-II used in the present study. Additional Pearson’s correlations were conducted examining the relationship between the AAQ-II and the DOCS subscales and total score. Finally, multiple regressions were conducted to determine if the AAQ-II remains a predictor for DOCS scores when controlled for depression (with the DASS-21 depression scale), as was done previously in the aforementioned studies. The DASS21 depression scale was entered first, followed by the AAQ-II score. Each variable that was significantly related to the AAQ-II was included in an independent regression analysis. Results Pearson’s correlations On average, participants’ scores on the OCI-R (M = 33.39, SD = 13.85) indicated that the sample as a whole had clinically significant OCD severity. The individuals who were excluded from analysis via the C-CLS, on average, did not have clinically significant OCD severity (M = 16.32, SD = 9.73). Pearson’s correlations were calculated first examining the relationship between the AAQ-II scores and the OCI-R scores. The results are presented in Table 1. A weak, nonsignificant correlation (r = .20, p > .05) was found between the OCI-R total score and the AAQ-II, which largely corroborates the previous findings that found no significant relationships between the AAQ and the OCI-R. No significant correlations were found between the AAQ-II and five of the six subscales of the OCI-R (washing, checking, ordering, neutralizing, and hoarding), with r values ranging from −.20 to .12. However, a significant relationship
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.041 1.0
-.020 .022 1.0
OCI-Hoarding .119 .421** .127 1.0
OCI-Checking .118 .304** .457** .368** 1.0
OCI-Symmetry
.161 1.0
.338** .326** 1.0
DOCS-Harm .435** .073 .435** 1.0
DOCS-Unacceptable
.240* .351** .535** .140 1.0
.198 .627** .492** .677** .754** .698** .206 1.0
OCI-Total
.415** .648** .817** .569** .743** 1.0
DOCS-Total
.392** .026 -.123 .037 -.051 .049 1.0
OCI-Obsessing
DOCS-Symmetry
AAQ-II, Acceptance and Action Questionnaire–II; DOCS, Dimensional Obsessive Compulsive Scale. *p < .05. **p < .01.
AAQ-II DOCS-Contamination DOCS-Harm DOCS-Unacceptable DOCS-Symmetry DOCS-Total
DOCS-Contamination
.123 .356** .094 .457** .454** 1.0
OCI-Neutralizing
Table 2. Correlations between AAQ-II and DOCS
AAQ-II, Acceptance and Action Questionnaire–II; OCI-R, Obsessive Compulsive Inventory-Revised. **p < .01.
AAQ-II OCI-Contamination OCI-Hoarding OCI-Checking OCI-Symmetry OCI-Neutralizing OCI-Obsessing OCI-Total
OCI-Contamination
Table 1. Correlations between AAQ-II and OCI-R
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was found between the OCI-R obsessing subscale and the AAQII (r = .39, p < .001). Additional Pearson’s correlations were calculated examining the relationship between the AAQ-II and the DOCS. These results are presented in Table 2. A strong significant correlation was found between the AAQ-II and the DOCS total score (r = .42, p < .001). Significant correlations were also found between three out of four of the DOCS subscales: responsibility for harm, unacceptable thoughts, and symmetry. A weak, nonsignificant correlation was found between the AAQ-II and the remaining DOCS subscale, contamination. Finally, Pearson’s correlations were calculated to examine the intercorrelations among all of the measures used in the current study. Depression was significantly correlated with one of the DOCS subscales: unacceptable thoughts (r = .30). Likewise, depression was significantly correlated with one of the OCI-R subscales, obsessing (r = .31), and the AAQ-II (r = .62). The OCI-R and DOCS total scores were also significantly correlated (r = .71), and there were multiple significant correlations between the subscales of these measures ranging from .27 to .90. Multiple regression analyses The first multiple regression analysis examined whether the AAQ-II was a predictor for the OCI-R obsessing subscale when depression was held constant; the results for all regressions are presented in Table 3. This analysis found that the AAQ-II remained a significant predictor for OCI-R obsessing (β = .324, t = 2.476, p = .015). The second analysis was performed examining the AAQ-II and the DOCS total score. The result indicated that the AAQ-II remained a significant predictor for the DOCS total score (β = .476, t = 3.60, p < .001). The third analysis examined the DOCS responsibility for harm subscale. The results indicated that the AAQ-II remained a significant predictor for the DOCS responsibility for harm subscale (β = .427, t = 3.199, p = .002). The DOCS unacceptable thoughts subscale was examined next, and the AAQ-II was also found to remain a significant predictor (β = .404, t = 3.138, p = .002). The final
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t
p
Control Variable
.310
2.940
.004**
AAQ-II
.324
2.476
.015*
.199
1.830
.071
.476
3.670
.001**
R2 OCI-Obsessing
DOCS-Total
.140
.158
Control Variable AAQ-II DOCS-Harm
.105
Control Variable
.123
1.114
.269
AAQ-II
.427
3.199
.002**
Control Variable
.301
2.842
.006**
AAQ-II
.404
3.138
.002**
Control Variable
.088
.794
.430
AAQ-II
.302
2.186
.032*
DOCS-Unacceptable
DOCS-Symmetry
.170
.040
β , standardized regression coefficient; AAQ-II, Acceptance and Action Questionnaire –II; DOCS, Dimensional Obsessive Compulsive Scale. *p < .05. **p < .01.
multiple regression examined the AAQ-II and the DOCS symmetry subscale and found that the AAQ-II remained a predictor for this subscale (β = .302, t = 2.186, p = .032). Discussion The primary purpose of this study was to investigate the relationship between EA and OCD severity using an improved measure of EA with better psychometric properties and a more thorough measure of OCD symptom dimension severity, the DOCS. Pearson’s correlations performed assessing the relationship between the OCI-R and the AAQ-II largely corroborated previous findings: weak, nonsignificant correlations were found, indicating that there is not a significant relationship between EA and OCD severity as measured by the OCI-R. However, it is important to note that the DOCS was developed because measures
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of OCD severity that existed prior to its creation had a number of drawbacks that interfered with their ability to provide a conceptually clear assessment of OCD severity (Abramowitz et al., 2010). Pearson’s correlations performed evaluating the relationship between the DOCS and the AAQ-II revealed significant relationships between EA and OCD severity for the DOCS total score as well as for the responsibility for harm, unacceptable thoughts, and symmetry subscales. The fourth DOCS subscale, contamination, was not significantly related to the AAQ-II. These results indicate that EA is significantly related to OCD severity as measured by the DOCS, specifically for the symptom dimensions of responsibility for harm, unacceptable thoughts, and symmetry. These findings contradict the findings in the previous studies by Abramowitz, Lackey, and Wheaton (2009) and Manos et al. (2010). That is, EA is related to OCD severity when exploring individual symptom dimensions. This may be attributed to the newer measures used in the present study. Two older versions of the AAQ were used in the previous studies, the original AAQ with its questionable reliability and the 10-item AAQ-II. This can be illustrated by the findings that the internal consistency for the AAQ was significantly lower in Manos et al.’s sample (a = .58) compared to the present study’s sample (a = .86). The current study uses the 7-item AAQ-II, which further improved upon the psychometric properties of the 10-item AAQ-II version by removing the three reverse-scored items (Bond et al., 2011). Furthermore, the OCI-R itself may be a measure that does not sufficiently assess OCD severity (Abramowitz et al., 2010). Although improvements in the psychometric properties of the AAQ-II may have helped to improve the accuracy of the results, there was still only one significant correlation that was different than previous findings between the AAQ-II and the OCI-R: obsessing.Multiple regression analyses indicated that the AAQ-II contributed unique variance above and beyond depression scores in the DOCS total and DOCS responsibility for harm, unacceptable thoughts, and symmetry subscales. This suggests that EA contributes something meaningful or unique
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to most symptom dimensions of OCD that is different than depression. The previous studies performed several analyses above and beyond Pearson’s correlations: Multiple regression analyses were performed to determine whether EA contributed unique variance in OCD severity above and beyond that of both obsessional beliefs and depression. Unfortunately, the present study did not include an assessment of obsessional beliefs, and this aspect of the previous studies cannot be addressed. Another difference in measures occurred with assessing depression. The present study used the DASS-21; however, the previous studies used the Beck Depression Inventory (BDI). Although this means that a direct comparison may be more problematic, the depression subscale of the DASS-21 has been demonstrated to have acceptable concurrent validity (r = .79) with the BDI. These results indicate that more work needs to be done to clarify the differences between this study and previous findings because EA seems to be related to OCD severity as measured by the DOCS, and unique variance above and beyond depression was found. However, it is important to note that although this was the case for the responsibility for harm, unacceptable thoughts, and symmetry subscales, no significant relationship was found for contamination. This aspect of our findings may support the notion that treatments that target EA (e.g., ACT) might be an effective alternative or enhancement to ERP for some symptom presentations, but perhaps not all. Conversely, this finding may indicate a need to develop a disorder-specific measure of EA that is tailored to be used with OCD and might be more sensitive to differences in psychological flexibility within symptom dimensions. Another interpretation of these results is that EA/psychological flexibility is related to more ego-dystonic OCD symptom presentations. Although all intrusive thoughts are, by definition, unwanted, thoughts of being responsible for harm to others either indirectly or through other means (e.g., images of oneself being violent or fears of molesting children; related to the concept of autogenous obsessions) may be more aversive than thoughts of contamination (e.g., reactive obsessions). Previous
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research has made a distinction between two types of obsessions, autogenous and reactive (Lee & Kwon, 2003). Autogenous obsessions are thought to be more bizarre, unacceptable, and guilt-provoking than reactive thoughts. In addition, autogenous obsessions are considered more threatening, with a greater need to control the thought itself, and may result in more avoidant thought control strategies as opposed to the behavioral control strategies associated with reactive obsessions. Therefore, we speculate that EA as measured by the AAQ-II may be more related to autogenous obsessions than to reactive obsessions. Another possibility is that contamination is likely not a unitary construct and may be more difficult to measure. Future research is needed to investigate this possibility. There are a few limitations worth mentioning for the current study. First, this was a nonreferred sample, which was collected online. Although a screener was used to filter and assess for the presence of OCD and most of the sample seemed to endorse significant severity, the fact that the treatment-seeking status of the sample is unknown is important to note. As mentioned previously, the current study utilized the DASS-21 depression scale while previous studies used the BDI; ultimately we believe that a useful comparison can be made here, but it might have removed a confounding variable to have been able to use the same measure. Finally, the current study did not include obsessional beliefs in its analysis. Although demonstrating that there is a relationship between EA and OCD severity as measured by the DOCS is probably a useful contribution to the literature itself, the fact that this aspect of the previous studies was not replicated should certainly be considered a limitation and is something that future research should examine.
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Wetterneck et al. Hayes, S. C., Strosahl, K. D., Wilson, K. G., Bissett, R. T., Pistorello, J., Toarmino, D., ... McCurry, S. M. (2004). Measuring experiential avoidance: A preliminary test of a working model. Psychological Record, 54, 553–578. Hayes, S. C., Wilson, K. W., Gifford, E. V., Follette, V. M., & Strosahl, K. (1996). Experiential avoidance and behavioral disorders: A functional dimensional approach to diagnosis and treatment. Journal of Consulting and Clinical Psychology, 64, 1152–1168. Hong, J., Bravo, M., Wetterneck, C. T., Lee, E. B., Björgvinsson, T., & Hart, J. (2013). The Copper-Clear Lake OCD Screener: Comparisons across non-referred and treatment seeking samples. Poster presented at the 20th Annual International Obsessive-Compulsive Disorder Foundation Conference, Atlanta, GA. Kessler, R. C., Chiu, W. T., Demler, O., & Walters, E. E. (2005). Prevalence, severity, and comorbidity of twelve-month DSM-IV disorders in the National Comorbidity Survey Replication (NCS-R). Archives of General Psychiatry, 62(6), 617–627. Lee, H.-J., & Kwon, S.-M. (2003). Two different types of obsession: Autogenous obsessions and reactive obsessions. Behaviour Research and Therapy, 41, 11–29. Lovibond, S. H., & Lovibond, P. F. (1995). Manual for the Depression Anxiety Stress Scales. Sydney: Psychology Foundation of Australia. Manos, R. C., Cahill, S. P., Wetterneck, C. T., Conelea, C. A., Ross, A. R., & Riemann, B. C. (2010). The impact of experiential avoidance and obsessive beliefs on obsessive-compulsive symptoms in a severe clinical sample. Journal of Anxiety Disorders, 24, 700–708. Mataix-Cols, D., Rosario-Campos, M. C. dos, & Leckman, J. F. (2005). A multidimensional model of obsessive-compulsive disorder. American Journal of Psychiatry, 162(2), 228–238. McLean, P. D., Whittal, M. L., Thordarson, D. S., Taylor, S., Söchting, I., Koch, W. J., . . . Anderson, K. W. (2001). Cognitive versus behavior therapy in the group treatment of obsessive-compulsive disorder. Journal of Consulting and Clinical Psychology, 69, 205–214. Obsessive Compulsive Cognitions Working Group. (2005). Psychometric validation of the Obsessive Belief Questionnaire and Interpretation of Intrusions Inventory. Part 2. Factor analyses and testing of a brief version. Behaviour Research and Therapy, 43, 1527–1543. Richard, D. C. S., & Gloster, A. T. (2007). Exposure therapy has a public relations problem: A dearth of litigation amid a wealth of concern. In D. C. S. Richard & D. Lauterbach (Eds.), Handbook of the exposure therapies (pp. 409–425). New York, NY: Academic Press. Smith, A. H., Wetterneck, C. T., Hart, J. M., Short, M. B., & Björgvinsson, T. (2012). Differences in obsessional beliefs and emotion appraisal in obsessive compulsive symptom presentation. Journal of Obsessive-Compulsive and Related Disorders, 1, 54–61.
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Experiential avoidance in symptom dimensions of OCD Chad T. Wetterneck, PhD Daniel S. Steinberg, MA John Hart, PhD
Experiential avoidance (EA) involves an unwillingness to remain in contact or experience unpleasant private events through attempts to avoid or escape from these experiences. EA is hypothesized to play a role in obsessive-compulsive disorder (OCD); however, previous studies have not found a significant relationship between EA and OCD severity. The present study examined the relationship between EA and OCD severity as measured by an updated measure of EA, an established measure of OCD severity (i.e., the Obsessive-Compulsive Inventory-Revised [OCI-R]), and a new measure of OCD symptom dimension severity, the Dimensional Obsessive-Compulsive Scale (DOCS). A sample of 83 nonreferred individuals meeting criteria for OCD completed the measures. Correlations between EA and the OCI-R corroborated previous findings; however, EA was significantly correlated with the DOCS. There were differences across the symptom dimensions, with EA significantly correlated with unacceptable thoughts, responsibility for harm, and symmetry, but not with contamination. (Bulletin of the Menninger Clinic, 78[3], 253–269)
Obsessive-compulsive disorder (OCD) is an anxiety disorder characterized by compulsions (repetitive behaviors or internal mental acts aimed at reducing anxiety) and/or obsessions (recurrent and intrusive thoughts or images that result in increased anxiety and distress) (American Psychiatric Association, 2000).
Chad T. Wetterneck is at Rogers Memorial Hospital, Oconomowoc, Wisconsin. Daniel S. Steinberg is at the University of North Texas, Denton, Texas. John Hart is at the Menninger Clinic, Houston, Texas. Correspondence may be sent to Chad T. Wetterneck at Rogers Memorial Hospital, 34700 Valley Rd., Oconomowoc, WI 53066; e-mail: [email protected] (Copyright © 2014 The Menninger Foundation)
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The 12-month prevalence of OCD in the United States adult population is estimated to be 1%, and 50.6% of these cases are classified as severe (Kessler, Chiu, Demler, & Walters, 2005). The current preferred treatment for OCD, cognitive-behavioral therapy, specifically, exposure and ritual prevention (ERP), has been demonstrated to have a clinically significant impact on a majority of patients; however, ERP also suffers from a 25% dropout rate (Abramowitz, Taylor, & McKay, 2009; Fisher & Wells, 2005). Other studies have indicated that a number of individuals (5%–22%) seeking treatment for OCD refuse ERP as a treatment option (Foa et al., 2005; McLean et al., 2001) and that clinicians and the general public often find ERP to be aversive (Richard & Gloster, 2007). Although ERP remains the “gold standard” for OCD treatment, it may prove worthwhile to explore additional treatment options to offer to those individuals who either drop out of, fail to respond to, or reject exposure-based treatment. It has been suggested that experiential avoidance (EA) may play an important role in OCD, and that treatments targeting it may be effective (Eifert & Forsyth, 2005). EA can be defined as an unwillingness to remain in contact or experience unpleasant private events through attempts to avoid or escape from these experiences (Hayes, Wilson, Gifford, Follette, & Strosahl, 1996). One treatment that targets EA is acceptance and commitment therapy (ACT; Hayes, Strosahl, & Wilson, 1999). A test of ACT with a small sample of individuals meeting criteria for OCD found reductions in EA and OC symptoms; however, the small sample size prevented an analysis of any possible relationship (Twohig, Hayes, & Masuda, 2006). Importantly, a recent more robust study demonstrated that ACT was an effective treatment for OCD severity in a randomized clinical trial (Twohig et al., 2010). Although these initial results of ACT for OCD seem to be promising, they do not include an analysis of the relationship between EA and OCD severity. Other recent studies that have evaluated this relationship have not found a significant connection between measures of EA and measures of OCD severity (Abramowitz, Lackey, & Wheaton, 2009; Manos et al., 2010).
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Research has shown that EA is associated with higher levels of anxiety, depression, general psychopathology, and symptoms related to trauma (Hayes et al, 2004). Eifert and Forsyth (2005) have hypothesized that EA may manifest itself as compulsions in OCD. Some evidence suggests that reductions in EA can lead to reductions in symptom severity within an anxiety-disordered sample (Chawla & Ostafin, 2007). Studies examining the relationship between EA and OCD severity have also examined relationships with obsessional beliefs, which involve dysfunctional appraisals of thoughts such as the overestimating of threat, personal responsibility, importance of and need to control thoughts, the need for perfectionism, and the intolerance of uncertainty (Obsessive Compulsive Cognitions Working Group, 2005). Abramowitz, Lackey, and Wheaton (2009) conducted a study in a nonclinical sample to determine whether EA predicts obsessive-compulsive (OC) symptoms above that which can be explained by obsessional beliefs and depression. This study was later replicated in a clinical sample with similar results (Manos et al., 2010). EA was not found to predict severity above and beyond obsessional beliefs and depression in these studies. Manos and colleagues (2010) suggested that the measure of EA used may have been an important limiting factor and may have been inadequate to find a result if there had been a relationship between EA and OC symptoms due to its questionable internal consistency. The Acceptance and Action Questionnaire (AAQ; Hayes et al, 2004) was developed as an initial measure of EA and was used in the study by Manos et al. (2010). However, a major limitation in this instance for the AAQ is that it has a fairly low measure of internal consistency in the initial psychometric study (a = .70) (Hayes et al., 2004) and other studies important in this area (e.g., a = .58 in Manos et al., 2010). The AAQ has been replaced by the Acceptance and Action Questionnaire-II (AAQII), which has better psychometric consistency (a = .84) and may be a better measure of EA (Bond et al., 2011). The AAQ-II addresses issues with scale brevity, item wording, and item selection procedures that were found in the original measure. A further revision of the AAQ-II reduced the measure from a 10-
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item scale to a 7-item scale after further psychometric analysis (Bond et al., 2011). In addition to the availability of a revised measure of EA, a new measure for use with OC symptoms has also become available. The studies just mentioned used the Obsessive-Compulsive Inventory-Revised (OCI-R; Foa et al., 2002) as a measure of OC symptom severity. What may be problematic about the OCI-R is that it measures severity based on the extent to which a limited set of symptoms caused distress over the previous month, which may not be a complete measure of the severity. It also fails to take into account the wide variety of types of symptoms (e.g., no specific reference to violent, sexual, or scrupulous obsessions or compulsions), which precludes the inclusion of all types of OC symptoms in the measure. The OCI-R also does not measure avoidance, measures only obsessions in some symptom dimensions and only compulsions in others, and, importantly, contains a one-dimensional assessment of severity (Abramowitz et al., 2010). The development of the Dimensional ObsessiveCompulsive Scale (DOCS; Abramowitz et al., 2010) addresses the limitations of the OCI-R and assesses OC symptoms on the following four dimensions: “contamination,” “responsibility for harm, injury or bad luck,” “unacceptable obsessional thoughts,” and “symmetry, completeness, and exactness.” The use of a multidimensional approach for measuring OC symptom severity in the DOCS takes into account distress, functional interference, and the frequency or duration of obsessions and compulsions (Abramowitz et al., 2010). Thus, this measure is consistent with research that indicates that OC symptoms fall into several psychometrically diverse categories (Mataix-Cols, Rosario-Campos, & Leckman, 2005). Focusing research on individual symptom dimensions rather than OC symptom severity as a whole may be an important step in finding ways to improve treatment for OCD (Smith, Wetterneck, Hart, Short, & Björgvinsson, 2012). We hypothesized that the new measures available would provide the best opportunity to adequately investigate the relationship between EA and OC symptom dimensions short of creating an OC symptom–specific measure of EA, and this aspect of the
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study is exploratory in nature. In light of the results of the previous studies examining this relationship, we also hypothesized that the aspects of the study, which are a replication of prior studies, would yield similar results, with significant correlations found only between the AAQ-II and the OCI-R obsessing subscale (Abramowitz, Lackey, & Wheaton, 2009; Manos et al., 2010). Method Participants Respondents included 111 nonreferred individuals meeting criteria for OCD; 28 participants were excluded from the analysis because they did not meet criteria for OCD. The presence of OCD symptoms was assessed with the Copperfield-Clear Lake Screener (C-CLS), which is described in the Measures section of this article. The mean age for the sample was 33.60 years (SD = 12.81); 71.1% of the respondents were female and 83.1% were White. Individuals were included in the study if they indicated the presence of obsessions and/or compulsions, that these obsessions and/or compulsions caused significant distress or were time consuming, and that these obsessions and/or compulsions were recognized at some point as being excessive or unreasonable. Most of the sample (79.5%; n = 66) indicated that they had been formally diagnosed with OCD. A wide range of previously diagnosed secondary comorbid conditions were self-reported in the sample, including 45.8% (n = 38) with generalized anxiety disorder, 14.5% (n = 12) with posttraumatic stress disorder, 13.3% (n = 13) with social phobia, 13.3% (n = 13) with a personality disorder, 10.8% (n = 9) with an eating disorder, 9.6% (n = 8) with trichotillomania, 5.1% (n = 5) with general phobia, 6.0% (n = 5) with a substance-related disorder, 3.6% (n = 3) with Tourette’s syndrome, and 2.4% (n = 2) with a dissociative disorder. Procedure Study participation was made available and advertised to individuals through several organizations catering to sufferers of Vol. 78, No. 3 (Summer 2014)
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OCD, including websites for the International OCD Foundation, the Peace of Mind Foundation, and the Houston OCD Program. Participants took the survey in an online format. After giving informed consent to participate in the study, respondents were directed to a secure website where demographic and diagnostic information were collected, followed by a screener designed to filter out individuals who did not meet criteria for OCD. Participants then took a variety of measures, including the AAQ-II and the DOCS. Measures Acceptance and Action Questionnaire-II (AAQ-II). The AAQII (Bond et al., 2011) is a seven-item measure of EA and psychological flexibility (a related construct inversely related to EA and measured on the same dimension) that is a revised version of the original AAQ. It has good psychometric properties and good convergent, incremental, and discriminant validity (Bond et al., 2011). Higher scores on the AAQ-II indicate higher levels of EA and low psychological flexibility (Bond et al., 2011). Internal consistency for this measure was good in the current sample (a = .86). Dimensional Obsessive-Compulsive Scale (DOCS). The DOCS (Abramowitz et al., 2010) is a 20-item measure that evaluates OC symptom severity across four dimensions: contamination, responsibility for harm, unacceptable thoughts, and symmetry. For each dimension, it assesses the time spent engaging in or thinking about obsessions and compulsions, avoidance of situations in order to prevent concerns, distress related to being unable to perform compulsions, disruption in daily routine, and ability to disregard thoughts about obsessions when refraining from compulsions. The DOCS performed well on indices of reliability and validity and was sensitive to both treatment and diagnostic sensitivity. Higher scores on the DOCS indicate greater severity in each symptom dimension (Abramowitz et al., 2010). All subscales demonstrated excellent internal consistency in the current sample (contamination, a = .96; responsibility for harm, a = .93; unacceptable thoughts, a = .94; symmetry a = .96). 258
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Obsessive-Compulsive Inventory-Revised (OCI-R). The OCIR (Foa et al., 2002), which was included primarily as a replication of previous studies, is an 18-item measure that assesses the degree to which an individual is bothered or distressed by OC symptoms over the previous month. It evaluates symptoms in six dimensions: washing, checking/doubting, obsessing, neutralizing, ordering, and hoarding. The OCI-R has good internal consistency (Cronbach’s alpha = .81 to .93), good construct validity, and has an established clinical cutoff score of 21 (Abramowitz & Deacon, 2006; Foa et al., 2002). All subscales demonstrated from good to excellent internal consistency in the current sample (washing, a = .93; checking, a = .88; ordering, a = .92; obsessing, a = .86; hoarding, a = .95; neutralizing a = .82). Copperfield-Clear Lake Screener (C-CLS). The C-CLS (Hong et al., 2013) is a four-item measure designed for use in a self-report assessment battery to assess for an OCD diagnosis. It provides a definition of both obsessions and compulsions and asks the respondent to indicate if these are present and whether these obsessions or compulsions cause significant distress. It also assesses whether they are time consuming (over 1 hour per day on average) or significantly interfere with normal routine, occupation or academic functioning, and social activities or relationships. In addition, the C-CLS evaluates whether the respondent has recognized that the obsessions or compulsions are excessive or unreasonable. Previous research has found use of this measure to be effective in screening out those without OCD or those with nonclinical levels of OCD (Hong et al., 2013). The Depression Anxiety and Stress Scale-21 Item (DASS-21). The DASS-21 (Lovibond & Lovibond, 1995) is a short form of the original 42-item measure developed by Lovibond and Lovibond. It is a self-report measure of depression, anxiety, and stress. The DASS-21 has good internal consistency (Cronbach’s alpha = .88) and good convergent and discriminative reliability. The current study used only the depression scale of the DASS21, which also has good internal consistency (Cronbach’s alpha
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= .82; Lovibond & Lovibond, 1995). Internal consistency for this measure was good in the current sample (a = .89). Analytic Plan Pearson’s correlations were conducted first with the AAQ-II and the OCI-R total score and subscales to examine the relationships found between these constructs in previous studies (Abramowitz, Lackey, & Wheaton, 2009; Manos et al., 2010) and to assess the differences that may be found with the updated version of the AAQ-II used in the present study. Additional Pearson’s correlations were conducted examining the relationship between the AAQ-II and the DOCS subscales and total score. Finally, multiple regressions were conducted to determine if the AAQ-II remains a predictor for DOCS scores when controlled for depression (with the DASS-21 depression scale), as was done previously in the aforementioned studies. The DASS21 depression scale was entered first, followed by the AAQ-II score. Each variable that was significantly related to the AAQ-II was included in an independent regression analysis. Results Pearson’s correlations On average, participants’ scores on the OCI-R (M = 33.39, SD = 13.85) indicated that the sample as a whole had clinically significant OCD severity. The individuals who were excluded from analysis via the C-CLS, on average, did not have clinically significant OCD severity (M = 16.32, SD = 9.73). Pearson’s correlations were calculated first examining the relationship between the AAQ-II scores and the OCI-R scores. The results are presented in Table 1. A weak, nonsignificant correlation (r = .20, p > .05) was found between the OCI-R total score and the AAQ-II, which largely corroborates the previous findings that found no significant relationships between the AAQ and the OCI-R. No significant correlations were found between the AAQ-II and five of the six subscales of the OCI-R (washing, checking, ordering, neutralizing, and hoarding), with r values ranging from −.20 to .12. However, a significant relationship
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.041 1.0
-.020 .022 1.0
OCI-Hoarding .119 .421** .127 1.0
OCI-Checking .118 .304** .457** .368** 1.0
OCI-Symmetry
.161 1.0
.338** .326** 1.0
DOCS-Harm .435** .073 .435** 1.0
DOCS-Unacceptable
.240* .351** .535** .140 1.0
.198 .627** .492** .677** .754** .698** .206 1.0
OCI-Total
.415** .648** .817** .569** .743** 1.0
DOCS-Total
.392** .026 -.123 .037 -.051 .049 1.0
OCI-Obsessing
DOCS-Symmetry
AAQ-II, Acceptance and Action Questionnaire–II; DOCS, Dimensional Obsessive Compulsive Scale. *p < .05. **p < .01.
AAQ-II DOCS-Contamination DOCS-Harm DOCS-Unacceptable DOCS-Symmetry DOCS-Total
DOCS-Contamination
.123 .356** .094 .457** .454** 1.0
OCI-Neutralizing
Table 2. Correlations between AAQ-II and DOCS
AAQ-II, Acceptance and Action Questionnaire–II; OCI-R, Obsessive Compulsive Inventory-Revised. **p < .01.
AAQ-II OCI-Contamination OCI-Hoarding OCI-Checking OCI-Symmetry OCI-Neutralizing OCI-Obsessing OCI-Total
OCI-Contamination
Table 1. Correlations between AAQ-II and OCI-R
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was found between the OCI-R obsessing subscale and the AAQII (r = .39, p < .001). Additional Pearson’s correlations were calculated examining the relationship between the AAQ-II and the DOCS. These results are presented in Table 2. A strong significant correlation was found between the AAQ-II and the DOCS total score (r = .42, p < .001). Significant correlations were also found between three out of four of the DOCS subscales: responsibility for harm, unacceptable thoughts, and symmetry. A weak, nonsignificant correlation was found between the AAQ-II and the remaining DOCS subscale, contamination. Finally, Pearson’s correlations were calculated to examine the intercorrelations among all of the measures used in the current study. Depression was significantly correlated with one of the DOCS subscales: unacceptable thoughts (r = .30). Likewise, depression was significantly correlated with one of the OCI-R subscales, obsessing (r = .31), and the AAQ-II (r = .62). The OCI-R and DOCS total scores were also significantly correlated (r = .71), and there were multiple significant correlations between the subscales of these measures ranging from .27 to .90. Multiple regression analyses The first multiple regression analysis examined whether the AAQ-II was a predictor for the OCI-R obsessing subscale when depression was held constant; the results for all regressions are presented in Table 3. This analysis found that the AAQ-II remained a significant predictor for OCI-R obsessing (β = .324, t = 2.476, p = .015). The second analysis was performed examining the AAQ-II and the DOCS total score. The result indicated that the AAQ-II remained a significant predictor for the DOCS total score (β = .476, t = 3.60, p < .001). The third analysis examined the DOCS responsibility for harm subscale. The results indicated that the AAQ-II remained a significant predictor for the DOCS responsibility for harm subscale (β = .427, t = 3.199, p = .002). The DOCS unacceptable thoughts subscale was examined next, and the AAQ-II was also found to remain a significant predictor (β = .404, t = 3.138, p = .002). The final
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t
p
Control Variable
.310
2.940
.004**
AAQ-II
.324
2.476
.015*
.199
1.830
.071
.476
3.670
.001**
R2 OCI-Obsessing
DOCS-Total
.140
.158
Control Variable AAQ-II DOCS-Harm
.105
Control Variable
.123
1.114
.269
AAQ-II
.427
3.199
.002**
Control Variable
.301
2.842
.006**
AAQ-II
.404
3.138
.002**
Control Variable
.088
.794
.430
AAQ-II
.302
2.186
.032*
DOCS-Unacceptable
DOCS-Symmetry
.170
.040
β , standardized regression coefficient; AAQ-II, Acceptance and Action Questionnaire –II; DOCS, Dimensional Obsessive Compulsive Scale. *p < .05. **p < .01.
multiple regression examined the AAQ-II and the DOCS symmetry subscale and found that the AAQ-II remained a predictor for this subscale (β = .302, t = 2.186, p = .032). Discussion The primary purpose of this study was to investigate the relationship between EA and OCD severity using an improved measure of EA with better psychometric properties and a more thorough measure of OCD symptom dimension severity, the DOCS. Pearson’s correlations performed assessing the relationship between the OCI-R and the AAQ-II largely corroborated previous findings: weak, nonsignificant correlations were found, indicating that there is not a significant relationship between EA and OCD severity as measured by the OCI-R. However, it is important to note that the DOCS was developed because measures
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of OCD severity that existed prior to its creation had a number of drawbacks that interfered with their ability to provide a conceptually clear assessment of OCD severity (Abramowitz et al., 2010). Pearson’s correlations performed evaluating the relationship between the DOCS and the AAQ-II revealed significant relationships between EA and OCD severity for the DOCS total score as well as for the responsibility for harm, unacceptable thoughts, and symmetry subscales. The fourth DOCS subscale, contamination, was not significantly related to the AAQ-II. These results indicate that EA is significantly related to OCD severity as measured by the DOCS, specifically for the symptom dimensions of responsibility for harm, unacceptable thoughts, and symmetry. These findings contradict the findings in the previous studies by Abramowitz, Lackey, and Wheaton (2009) and Manos et al. (2010). That is, EA is related to OCD severity when exploring individual symptom dimensions. This may be attributed to the newer measures used in the present study. Two older versions of the AAQ were used in the previous studies, the original AAQ with its questionable reliability and the 10-item AAQ-II. This can be illustrated by the findings that the internal consistency for the AAQ was significantly lower in Manos et al.’s sample (a = .58) compared to the present study’s sample (a = .86). The current study uses the 7-item AAQ-II, which further improved upon the psychometric properties of the 10-item AAQ-II version by removing the three reverse-scored items (Bond et al., 2011). Furthermore, the OCI-R itself may be a measure that does not sufficiently assess OCD severity (Abramowitz et al., 2010). Although improvements in the psychometric properties of the AAQ-II may have helped to improve the accuracy of the results, there was still only one significant correlation that was different than previous findings between the AAQ-II and the OCI-R: obsessing.Multiple regression analyses indicated that the AAQ-II contributed unique variance above and beyond depression scores in the DOCS total and DOCS responsibility for harm, unacceptable thoughts, and symmetry subscales. This suggests that EA contributes something meaningful or unique
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to most symptom dimensions of OCD that is different than depression. The previous studies performed several analyses above and beyond Pearson’s correlations: Multiple regression analyses were performed to determine whether EA contributed unique variance in OCD severity above and beyond that of both obsessional beliefs and depression. Unfortunately, the present study did not include an assessment of obsessional beliefs, and this aspect of the previous studies cannot be addressed. Another difference in measures occurred with assessing depression. The present study used the DASS-21; however, the previous studies used the Beck Depression Inventory (BDI). Although this means that a direct comparison may be more problematic, the depression subscale of the DASS-21 has been demonstrated to have acceptable concurrent validity (r = .79) with the BDI. These results indicate that more work needs to be done to clarify the differences between this study and previous findings because EA seems to be related to OCD severity as measured by the DOCS, and unique variance above and beyond depression was found. However, it is important to note that although this was the case for the responsibility for harm, unacceptable thoughts, and symmetry subscales, no significant relationship was found for contamination. This aspect of our findings may support the notion that treatments that target EA (e.g., ACT) might be an effective alternative or enhancement to ERP for some symptom presentations, but perhaps not all. Conversely, this finding may indicate a need to develop a disorder-specific measure of EA that is tailored to be used with OCD and might be more sensitive to differences in psychological flexibility within symptom dimensions. Another interpretation of these results is that EA/psychological flexibility is related to more ego-dystonic OCD symptom presentations. Although all intrusive thoughts are, by definition, unwanted, thoughts of being responsible for harm to others either indirectly or through other means (e.g., images of oneself being violent or fears of molesting children; related to the concept of autogenous obsessions) may be more aversive than thoughts of contamination (e.g., reactive obsessions). Previous
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research has made a distinction between two types of obsessions, autogenous and reactive (Lee & Kwon, 2003). Autogenous obsessions are thought to be more bizarre, unacceptable, and guilt-provoking than reactive thoughts. In addition, autogenous obsessions are considered more threatening, with a greater need to control the thought itself, and may result in more avoidant thought control strategies as opposed to the behavioral control strategies associated with reactive obsessions. Therefore, we speculate that EA as measured by the AAQ-II may be more related to autogenous obsessions than to reactive obsessions. Another possibility is that contamination is likely not a unitary construct and may be more difficult to measure. Future research is needed to investigate this possibility. There are a few limitations worth mentioning for the current study. First, this was a nonreferred sample, which was collected online. Although a screener was used to filter and assess for the presence of OCD and most of the sample seemed to endorse significant severity, the fact that the treatment-seeking status of the sample is unknown is important to note. As mentioned previously, the current study utilized the DASS-21 depression scale while previous studies used the BDI; ultimately we believe that a useful comparison can be made here, but it might have removed a confounding variable to have been able to use the same measure. Finally, the current study did not include obsessional beliefs in its analysis. Although demonstrating that there is a relationship between EA and OCD severity as measured by the DOCS is probably a useful contribution to the literature itself, the fact that this aspect of the previous studies was not replicated should certainly be considered a limitation and is something that future research should examine.
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