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Emotion Regulation in Patients with Obsessive Compulsive Disorder: Unique Effects for Those with “Taboo Thoughts”

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Abstract

Emotion regulation (ER) is a modifiable and transdiagnostic construct that has been widely studied across the affective disorders; however, little research has evaluated the relationship between ER and obsessive–compulsive (OC) features (e.g., OC symptom dimensions, OC symptom severity, and obsessive beliefs). The current study therefore evaluates the relationship between ER difficulties and OC features in the largest sample of adults with OCD to date. Participants (N = 57) completed a clinician-administered diagnostic and OC symptom assessment, as well as self-report questionnaires. Results revealed a specific relationship between ER difficulties, the unacceptable thoughts dimension, and obsessive beliefs, even after controlling for co-occurring depressive symptomology. Specifically, patients with “taboo thoughts” and elevated obsessive beliefs experienced greater difficulties accepting unwanted emotions, engaging in goal-directed behaviors when upset, accessing ER strategies, and clarifying emotions. Pending replication with a longitudinal framework, results highlight the utility of integrating emotion regulation modules into typical behavior therapy protocols for patients with unacceptable thoughts. Additional clinical implications, limitations and future directions are discussed.

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References

  • Abramowitz, J. S., Deacon, B. J., Olatunji, B. O., Wheaton, M. G., Berman, N. C., Losardo, D., … Hale, L. R. (2010). Assessment of obsessive-compulsive symptom dimensions: Development and evaluation of the Dimensional Obsessive-Compulsive Scale. Psychological Assessment, 22(1), 180–198. https://doi.org/10.1037/a0018260.

    Article  PubMed  Google Scholar 

  • Abramowitz, J. S., Fabricant, L. E., Taylor, S., Deacon, B. J., McKay, D., & Storch, E. A. (2014). The relevance of analogue studies for understanding obsessions and compulsions. Clinical Psychology Review, 34(3), 206–217. https://doi.org/10.1016/j.cpr.2014.01.004.

    Article  PubMed  Google Scholar 

  • Abramowitz, J. S., Tolin, D., & Street, G. (2001). Paradoxical effects of thought suppression: A meta-analysis of controlled studies. Clinical Psychology Review, 21(5), 683–703.

    Article  PubMed  CAS  Google Scholar 

  • Aldao, A., Gee, D. G., De Los Reyes, A., & Seager, I. (2016). Emotion regulation as a transdiagnostic factor in the development of internalizing and externalizing psychopathology: Current and future directions. Developmental Psychopathology, 28(4), 927–946. https://doi.org/10.1017/S0954579416000638.

    Article  Google Scholar 

  • Aldao, A., Nolen-Hoeksema, S., & Schweizer, S. (2010). Emotion-regulation strategies across psychopathology: A meta-analytic review. Clinical Psychology Review, 30(2), 217–237. https://doi.org/10.1016/j.cpr.2009.11.004.

    Article  PubMed  Google Scholar 

  • Aldao, A., Sheppes, G., & Gross, J. J. (2015). Emotion regulation flexibility. Cognitive Therapy and Research, 39(3), 263–278.

    Article  Google Scholar 

  • Allen, L. B., & Barlow, D. H. (2009). Relationship of exposure to clinically irrelevant emotion cues and obsessive-compulsive symptoms. Behavior Modification, 33(6), 743–762. https://doi.org/10.1177/0145445509344180.

    Article  PubMed  Google Scholar 

  • Alonso, P., Menchon, J. M., Pifarre, J., Mataix-Cols, D., Torres, L., Salgado, P., & Vallejo, J. (2001). Long-term follow-up and predictors of clinical outcome in obsessive-compulsive patients treated with serotonin reuptake inhibitors and behavioral therapy. Journal of Clinical Psychiatry, 62(7), 535–540.

    Article  PubMed  CAS  Google Scholar 

  • American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (Fifth edn.). Arlington, VA: American Psychiatric Publishing.

    Book  Google Scholar 

  • Barlow, D. H., Farchione, T. J., Bullis, J. R., Gallagher, M. W., Latin, H., Sauer-Zavala, S., … Cassiello-Robbins, C. (2017). The unified protocol for transdiagnostic treatment of emotional disorders compared to diagnosis-specific CBT for anxiety disorders: A randomized clinical equivalence trial. JAMA Psychiatry, 74(9), 875–884.

    Article  PubMed  PubMed Central  Google Scholar 

  • Bender, P. K., Pons, F., Harris, P. L., Esbjorn, B. H., & Reinholdt-Dunne, M. L. (2015). Emotion understanding in clinically anxious children: A preliminary investigation. Frontiers in Psychology, 6, 1916.

    Article  PubMed  PubMed Central  Google Scholar 

  • Berking, M. (2010). The affect regulation training. New York: Springer.

    Google Scholar 

  • Berking, M., Ebert, D., Cuijpers, P., & Hofmann, S. G. (2013). Emotion regulation skills training enhances the efficacy of inpatient cognitive behavioral therapy for major depressive disorder: A randomized controlled trial. Psychotherapy and Psychosomatics, 82(4), 234–245.

    Article  PubMed  Google Scholar 

  • Berking, M., Wupperman, P., Reichardt, A., Pejic, T., Dippel, A., & Znoj, H. (2008). Emotion-regulation skills as a treatment target in psychotherapy. Behavior Research and Therapy, 46(11), 1230–1237.

    Article  Google Scholar 

  • Bonanno, G. A., & Burton, C. L. (2013). Regulatory flexibility: An individual differences perspective on coping and emotion regulation. Perspectives on Psychological Science, 8(6), 591–612.

    Article  PubMed  Google Scholar 

  • Brakoulias, V., Starcevic, V., Berle, D., Milicevic, D., Moses, K., Hannan, A., … Martin, A. (2013). The characteristics of unacceptable/taboo thoughts in obsessive-compulsive disorder. Comprehensive Psychiatry, 54(7), 750–757.

    Article  PubMed  Google Scholar 

  • Campbell-Sills, L., & Barlow, D. H. (2007). Incorporating emotion regulation into conceptualizations and treatments of anxiety and mood disorders. In J. J. Gross (Ed.), Handbook of emotion regulation (pp. 542–559). New York: Guilford Press.

    Google Scholar 

  • Consedine, N., Strongman, K., & Magai, C. (2003). Emotions and behavior: Data from a cross-cultural recognition study. Cognition and Emotion, 17(6), 881–902.

    Google Scholar 

  • Corruble, E., Legrand, J. M., Duret, C., Charles, G., & Guelfi, J. D. (1999). IDS-C and IDS-SR: Psychometric properties in depressed in-patients. Journal of Affective Disorders, 56(2–3), 95–101.

    Article  PubMed  CAS  Google Scholar 

  • de la Cruz, L. F., Landau, D., Iervolino, A. C., Santo, S., Pertusa, A., Singh, S., & Mataix-Cols, D. (2013). Experiential avoidance and emotion regulation difficulties in hoarding disorder. Journal of Anxiety Disorders, 27(2), 204–209. https://doi.org/10.1016/j.janxdis.2013.01.004.

    Article  Google Scholar 

  • Dimidjian, S., Arch, J., Schneider, R., Desormeau, P., Felder, J., & Segal, Z. (2016). Considering meta-analysis, meaning, and metaphor: A systematic review and critical examination of “third wave” cognitive and behavioral therapies. Behavior Therapy, 47(6), 886–905.

    Article  PubMed  Google Scholar 

  • Egan, S. J., Piek, J. P., Dyck, M. J., & Rees, C. S. (2007). The role of dichotomous thinking and rigidity in perfectionism. Behavior Research and Therapy, 45(8), 1813–1822. https://doi.org/10.1016/j.brat.2007.02.002.

    Article  Google Scholar 

  • Ehring, T., Tuschen-Caffier, B., Schnulle, J., Fischer, S., & Gross, J. J. (2010). Emotion regulation and vulnerability to depression: Spontaneous versus instructed use of emotion suppression and reappraisal. Emotion, 10(4), 563–572. https://doi.org/10.1037/a0019010.

    Article  PubMed  Google Scholar 

  • Fergus, T. A., & Bardeen, J. R. (2014). Emotion regulation and obsessive compulsive symptoms: A further examination of associations. Journal of Obsessive-Compulsive and Related Disorders, 3(3), 243–248.

    Article  Google Scholar 

  • Frost, R. O., & Steketee, G. (2002). Cognitive approaches to obsessions and compulsions: Theory, assessment, and treatment. Oxford: Elsevier.

    Google Scholar 

  • Garnefski, N., & Kraaij, V. (2006). Cognitive emotion regulation questionnaire—Development of a short 18-item version (CERQ-short). Personality and Individual Differences, 41(6), 1045–1053.

    Article  Google Scholar 

  • Gillan, C. M., Apergis-Schoute, A. M., Morein-Zamir, S., Urcelay, G. P., Sule, A., Fineberg, N. A., … Robbins, T. W. (2015). Functional neuroimaging of avoidance habits in obsessive-compulsive disorder. American Journal of Psychiatry, 172(3), 284–293. https://doi.org/10.1176/appi.ajp.2014.14040525.

    Article  PubMed  Google Scholar 

  • Goodman, W. K., Price, L. H., Rasmussen, S. A., Mazure, C., Delgado, P., Heninger, G. R., & Charney, D. S. (1989a). The Yale-Brown Obsessive Compulsive Scale. II. Validity. Archives of General Psychiatry, 46(11), 1012–1016.

    Article  PubMed  CAS  Google Scholar 

  • Goodman, W. K., Price, L. H., Rasmussen, S. A., Mazure, C., Fleischmann, R. L., Hill, C. L., … Charney, D. S. (1989b). The Yale-Brown Obsessive Compulsive Scale. I. Development, use, and reliability. Archives of General Psychiatry, 46(11), 1006–1011.

    Article  PubMed  CAS  Google Scholar 

  • Gratz, K. L., & Roemer, L. (2004). Multidimensional assessment of emotion regulation and dysregulation: Development, factor structure, and initial validation of the Difficulties in Emotion Regulation Scale. Journal of Psychopathology and Behavior Assessment, 26(1), 41–54.

    Article  Google Scholar 

  • Hale, L., Strauss, C., & Taylor, B. (2013). The effectiveness and acceptability of mindfulness-based therapy for obsessive compulsive disorder: A review of the literature. Mindfulness, 4(4), 375–382.

    Article  Google Scholar 

  • 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.

    Article  PubMed  CAS  Google Scholar 

  • Haynos, A. F., Roberto, C. A., Martinez, M. A., Attia, E., & Fruzzetti, A. E. (2014). Emotion regulation difficulties in anorexia nervosa before and after inpatient weight restoration. International Journal of Eating Disorders, 47(8), 888–891. https://doi.org/10.1002/eat.22265.

    Article  PubMed  Google Scholar 

  • Helbig-Lang, S., Rusch, S., & Lincoln, T. M. (2015). Emotion regulation difficulties in social anxiety disorder and their specific contributions to anxious responding. Journal of Clinical Psychology, 71(3), 241–249. https://doi.org/10.1002/jclp.22135.

    Article  PubMed  Google Scholar 

  • Hershfield, J., & Corboy, T. (2013). The mindfulness workbook for OCD: A guide to overcoming obsessions and compulsions using mindfulness and cognitive behavioral therapy. Oakland, CA: New Harbinger Publications.

    Google Scholar 

  • Jacob, M. L., Morelen, D., Suveg, C., Brown Jacobsen, A. M., & Whiteside, S. P. (2012). Emotional, behavioral, and cognitive factors that differentiate obsessive-compulsive disorder and other anxiety disorders in youth. Anxiety Stress and Coping, 25(2), 229–237. https://doi.org/10.1080/10615806.2011.571255.

    Article  Google Scholar 

  • Joormann, J., & Gotlib, I. H. (2010). Emotion regulation in depression: Relation to cognitive inhibition. Cognition & Emotion, 24(2), 281–298.

    Article  Google Scholar 

  • Joormann, J., & Stanton, C. H. (2016). Examining emotion regulation in depression: A review and future directions. Behavior Research and Therapy, 86, 35–49.

    Article  Google Scholar 

  • LaSalle, V. H., Cromer, K. R., Nelson, K. N., Kazuba, D., Justement, L., & Murphy, D. L. (2004). Diagnostic interview assessed neuropsychiatric disorder comorbidity in 334 individuals with obsessive-compulsive disorder. Depression and Anxiety, 19(3), 163–173. https://doi.org/10.1002/da.20009.

    Article  PubMed  Google Scholar 

  • Lecrubier, Y., Sheehan, D. V., Weiller, E., Amorim, P., Bonora, I., Harnett Sheehan, K., … Dunbar, G. C. (1997). The Mini International Neuropsychiatric Interview (MINI): A short diagnostic structured interview: Reliability and validity according to the CIDI. European Psychiatry, 12(5), 224–231.

    Article  Google Scholar 

  • Lee, H. J., Kwon, S., Kwon, J., & Telch, M. J. (2005). Testing the autogenous-reactive model of obsessions. Depression and Anxiety, 21, 118–129.

    Article  PubMed  Google Scholar 

  • Lee, H. J., & Kwon, S. M. (2003). Two different types of obsession: Autogenous obsessions and reactive obsessions. Behavior Research and Therapy, 41, 11–29.

    Article  Google Scholar 

  • Mataix-Cols, D., Marks, I. M., Greist, J. H., Kobak, K. A., & Baer, L. (2002). Obsessive-compulsive symptom dimensions as predictors of compliance with and response to behaviour therapy: Results from a controlled trial. Psychotherapy and Psychosomatics, 71(5), 255–262.

    Article  PubMed  Google Scholar 

  • Mataix-Cols, D., Rosario-Campos, M. C., & Leckman, J. F. (2005). A multidimensional model of obsessive-compulsive disorder. American Journal of Psychiatry, 162(2), 228–238. https://doi.org/10.1176/appi.ajp.162.2.228.

    Article  PubMed  Google Scholar 

  • Mauss, I. B., & Robinson, M. D. (2009). Measures of emotion: A review. Cognition and Emotion, 23(2), 209–237. https://doi.org/10.1080/02699930802204677.

    Article  PubMed  Google Scholar 

  • Mennin, D. S., & Fresco, D. M. (2009). Emotion regulation as an integrative framework for understanding and treating psychopathology. In A. M. Kring & D. S. Sloan (Eds.), Emotion regulation and psychopathology: A transdiagnostic approach to etiology and treatment (pp. 356–379). New York: Guilford Press.

    Google Scholar 

  • Najmi, S., Reese, H., Wilhelm, S., Fama, J., Beck, C., & Wegner, D. M. (2010). Learning the futility of the thought suppression enterprise in normal experience and in obsessive compulsive disorder. Behavioral and Cognitive Psychotherapy, 38(1), 1–14. https://doi.org/10.1017/S1352465809990439.

    Article  Google Scholar 

  • Nolen-Hoeksema, S., Wisco, B. E., & Lyubomirsky, S. (2008). Rethinking rumination. Perspectives on Psychological Science, 3(5), 400–424.

    Article  PubMed  Google Scholar 

  • 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. Behavior Research and Therapy, 43(11), 1527–1542.

    Article  Google Scholar 

  • Öst, L., Havnen, A., Hansen, B., & Kvale, G. (2015). Cognitive behavioral treatments of obsessive–compulsive disorder: A systematic review and meta-analysis of studies published 1993–2014. Clinical Psychology Review, 40, 156–169.

    Article  PubMed  Google Scholar 

  • Pedhazur, E. J. (1982). Multiple regression in behavioral research: Explanation and prediction, 3rd Edition. London: Thomas Learning, Inc.

    Google Scholar 

  • Rachman, S. (1997). A cognitive theory of obsessions. Behavior Research and Therapy, 35(9), 793–802. https://doi.org/10.1016/S0005-7967(97)00040-5.

    Article  CAS  Google Scholar 

  • Rachman, S. (1998). A cognitive theory of obsessions: Elaborations. Behavior Research and Therapy, 36(4), 385–401.

    Article  CAS  Google Scholar 

  • Reynolds, S., & Steiner, D. (1998). Why we do not abstract analogue studies of treatment outcome and scale development. Evidence-Based Mental Health, 1, 101–102.

    Article  Google Scholar 

  • Rufer, M., Fricke, S., Moritz, S., Kloss, M., & Hand, I. (2006). Symptom dimensions in obsessive-compulsive disorder: Prediction of cognitive-behavior therapy outcome. Acta Psychiatrica Scandinavica, 113(5), 440–446. https://doi.org/10.1111/j.1600-0447.2005.00682.x.

    Article  PubMed  CAS  Google Scholar 

  • Ruscio, A. M., Stein, D. J., Chiu, W. T., & Kessler, R. C. (2010). The epidemiology of obsessive-compulsive disorder in the National Comorbidity Survey Replication. Molecular Psychiatry, 15(1), 53–63. https://doi.org/10.1038/mp.2008.94.

    Article  PubMed  CAS  Google Scholar 

  • Rush, A. J., Trivedi, M. H., Ibrahim, H. M., Carmody, T. J., Arnow, B., Klein, D. N., … Keller, M. B. (2003). The 16-Item Quick Inventory of Depressive Symptomatology (QIDS), clinician rating (QIDS-C), and self-report (QIDS-SR): A psychometric evaluation in patients with chronic major depression. Biological Psychiatry, 54(5), 573–583.

    Article  PubMed  Google Scholar 

  • Shafran, R., & Mansell, W. (2001). Perfectionism and psychopathology: A review of research and treatment. Clinical Psychology Review, 21(6), 879–906.

    Article  PubMed  CAS  Google Scholar 

  • Shaw, A. M., Carbonella, J. Y., Arditte Hall, K. A., & Timpano, K. R. (2017). Obsessive-compulsive and depressive symptoms: The role of depressive cognitive styles. Journal of Psychology, 151, 532–546.

    Article  PubMed  Google Scholar 

  • Sheehan, D. V., Lecrubier, Y., Sheehan, K. H., Amorim, P., Janavs, J., Weiller, E., … Dunbar, G. C. (1998). The Mini-International Neuropsychiatric Interview (M.I.N.I.): The development and validation of a structured diagnostic psychiatric interview for DSM-IV and ICD-10. Journal of Clinical Psychiatry, 59(Suppl 20), 22–33.

    PubMed  Google Scholar 

  • Shrive, F. M., Stuart, H., Quan, H., & Ghali, W. A. (2006). Dealing with missing data in a multi-question depression scale: A comparison of imputation methods. BMC Medical Research Methodology, 6, 57.

    Article  PubMed  PubMed Central  Google Scholar 

  • Siddiqui, O. I. (2015). Methods for computing missing item response in psychometric scale construction. American Journal of Biostatistics, 5(1), 1–6.

    CAS  Google Scholar 

  • Sloan, E., Hall, K., Moulding, R., Bryce, S., Mildred, H., & Staiger, P. (2017). Emotion regulation as a transdiagnostic treatment construct across anxiety, depression, substance, eating and borderline personality disorder: A systematic review. Clinical Psychology Review, 57, 141–163.

    Article  PubMed  Google Scholar 

  • Stern, M. R., Nota, J. A., Heimberg, R. G., Holaway, R. M., & Coles, M. E. (2014). An initial examination of emotion regulation and obsessive compulsive symptoms. Journal of Obsessive-Compulsive and Related Disorders, 3(2), 109–114. https://doi.org/10.1016/j.jocrd.2014.02.005.

    Article  Google Scholar 

  • Trivedi, M. H., Rush, A. J., Ibrahim, H. M., Carmody, T. J., Biggs, M. M., Suppes, T., … Kashner, T. M. (2004). The inventory of depressive symptomatology, clinician rating (IDS-C) and self-report (IDS-SR), and the quick inventory of depressive symptomatology, clinician rating (QIDS-C) and self-report (QIDS-SR) in public sector patients with mood disorders: A psychometric evaluation. Psychological Medicine, 34(1), 73–82.

    Article  PubMed  CAS  Google Scholar 

  • Troy, A. S., Shallcross, A. J., & Mauss, I. B. (2013). A person-by-situation approach to emotion regulation: Cognitive reappraisal can either help or hurt, depending on the context. Psychological Science, 24, 2505–2514.

    Article  PubMed  Google Scholar 

  • Twohig, M., Abramowitz, J., Bluett, E., Fabricant, L., Jacoby, R., Morrison, K., … Smith, B. (2015). Exposure therapy for OCD from an acceptance and commitment therapy (ACT) framework. Journal of Obsessive-Compulsive and Related Disorders, 6, 167–173.

    Article  Google Scholar 

  • Wetterneck, C., Steinberg, D., & Hart, J. (2014). Experiential avoidance in symptom dimensions of OCD. Bulletin of Menninger Clinic, 78(3), 253–269.

    Article  Google Scholar 

  • Whitehead, M. R., & Suveg, C. (2016). Difficulties in emotion regulation differentiate depressive and obsessive-compulsive symptoms and their co-occurrence. Anxiety Stress and Coping, 29(5), 507–518. https://doi.org/10.1080/10615806.2015.1088523.

    Article  Google Scholar 

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Funding

This study was funded by the Kaplen Fellowship on Depression at Harvard Medical School, the Charles A. King Postdoctoral Fellowship (Harold Whitworth Pierce Charitable Trust) and the David Judah Fund.

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Authors and Affiliations

  1. Massachusetts General Hospital/Harvard Medical School, 185 Cambridge St., Boston, MA, 02114, USA

    Noah Chase Berman & Sabine Wilhelm

  2. College of the Holy Cross, 1 College St., Beaven 316, Worcester, MA, 01610, USA

    Noah Chase Berman

  3. University of Miami, 5565 Ponce de Leon Blvd., Coral Gables, FL, 33124, USA

    Ashley M. Shaw

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Correspondence to Noah Chase Berman.

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Berman, N.C., Shaw, A.M. & Wilhelm, S. Emotion Regulation in Patients with Obsessive Compulsive Disorder: Unique Effects for Those with “Taboo Thoughts”. Cogn Ther Res 42, 674–685 (2018). https://doi.org/10.1007/s10608-018-9911-z

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