Responsibility, probability, and severity of harm: An experimental investigation of cognitive factors associated with checking-related OCD
Introduction
Obsessive-compulsive disorder (OCD) is a serious and often debilitating disorder that affects approximately 1–3 percent of the population (RuscioStein et al., 2010; Stein et al., 1997). It is characterized by obsessions (unwanted intrusive thoughts, images and impulses that cause distress/interference) and/or compulsions (repetitive behaviours that are designed either to reduce distress, or to prevent negative outcomes; American Psychiatric Association, 2013). One of the most common compulsions is repeated checking (Rachman & Hodgson, 1980).
A number of efficacious treatments exist for OCD, including psychopharmacological (Fineberg et al., 2012) and psychological interventions (Rosa-Alcásar et al., 2008). Exposure and response prevention (ERP), a behavioural treatment, is considered the current ‘gold standard’ in the effective treatment of the disorder (for reviews see Öst et al., 2015; PodeaSuciu et al., 2009; Kozak & Coles, 2005). ERP has been found to outperform waitlist control (Fritzler et al., 1997), progressive muscle relaxation (Marks et al., 1975), anxiety management (Lindsay et al., 1997), and stress management training in the context of pharmacological augmentation (Simpson et al., 2008). Recent trials have also demonstrated that more cognitively based approaches are also efficacious (e.g., Whittal et al., 2010). Despite these findings, intervention response rates remain non-optimal (e.g., 48% Haland et al., 2010, p. 50% Jonsson et al., 2011). In addition, a number of studies employing ERP for OCD are characterized by high rates of drop outs and refusals (e.g., Foa et al., 2005). As such, there is considerable room to enhance both the efficacy and the acceptability of treatments for OCD.
One promising avenue with potential to enhance outcomes is to refine our understanding of OCD by developing and assessing theoretical frameworks for particular symptoms or symptom clusters in OCD (McKay et al., 2004; Shafran et al., 2013). This focus should foster a better understanding of the psychological mechanisms underlying particular manifestations of OCD, thus facilitating our ability to tailor treatments to individual clients by targeting these mechanisms. This approach successfully resulted in Hoarding Disorder being separated from OCD (Frost & Hartl, 1996; Rachman et al., 2009), and has led to the development of tailored treatments for obsessions (Rachman, 1997, 1998, 2003; Whittal et al., 2010), of mental contamination (Rachman, 2004; Rachman et al., 2015), and of compulsive checking (Rachman, 2002; Alcolado & Radomsky, 2016; Radomsky, Giraldo-O’Meara, et al., 2020,b).
Although OCD is a highly heterogeneous disorder (McKay et al., 2004), symptom presentations of OCD are not mutually exclusive (Pinto et al., 2006; Radomsky & Taylor, 2005). Indeed, although checking, one of the most common symptoms of OCD (Rachman & Hodgson, 1980; RuscioStein et al., 2010), may prototypically apply to the verification of doors and appliances, it may also manifest itself as a component of other obsessive-compulsive symptom domains. For example, individuals who fear contamination may check to make sure that something is sufficiently clean and/or check certain aspects of their cleaning rituals. Similarly, individuals with symmetry, ordering and/or arranging compulsions may verify their work, and even those who struggle with primary obsessions have been known to check their thoughts and/or behaviour. Doubting and checking may well then be considered the norm across forms of OCD, rather than as a form itself. As checking and the doubt that propels its action are ubiquitous in this respect, it stands to reason that a fine-grained understanding of this behaviour in particular would have the potential to yield fruitful interventions with the most wide-ranging applicability within the disorder.
The ubiquity of doubting and checking within OCD is entirely consistent with recent findings related to the prevalence of different types of unwanted intrusive thoughts, images and impulses in nonclinical populations. In a recent large international study, intrusions about doubting were by far the most common in each site across six continents (Radomsky et al., 2014). This study expanded upon seminal earlier work showing that “normal obsessions” are indeed extremely common (Rachman & de Silva, 1978). Consistent with this is the notion that OCD symptoms in general (Abramowitz et al., 2014), and checking-related symptoms in particular (Apter et al., 1996) lie on a continuum, such that checking is a common experience, but wherein some individuals check more than others. Thus in addition to informing novel intervention approaches, research on mechanisms underlying checking behaviour may have implications beyond the treatment of those with pathological instances of doubting and checking (e.g., providing helpful preventative psychoeducation to the general public).
The first cognitive-behavioural model of OCD was centered on the concept of inflated responsibility (Salkovskis, 1985). This approach construed obsessions and compulsions as resulting from a perceived “pivotal power to provoke or prevent subjectively crucial negative outcomes” (Salkovskis et al., 1992). There is now a robust body of literature to support this theory (e.g., Obsessive CompulsiveCognitions Working Group, 2005; Lopatka & Rachman, 1995, see below). Beyond a general cognitive disposition towards an inflated sense of responsibility, present moment interpretations have also been proposed to contribute to the expression of OCD symptoms. Rachman proposed that catastrophic misinterpretations of the personal significance of one's own thoughts play a causal role in the development of obsessions (Rachman, 1997; 1998). More recently, the Obsessive Compulsive Cognitions Working Group (2005) examined six obsessive-compulsive belief domains which ultimately clustered into three factors, and which were predictive of OCD symptomatology. They are 1) overestimation of threat/responsibility, 2) perfectionism/intolerance of uncertainty, and 3) importance of/control over thoughts (Obsessive CompulsiveCognitions Working Group, 2005), of which the first has been found to be most relevant to checking (Brakoulias et al., 2014).
Stemming from the above work, a specific cognitive model for checking compulsions was proposed (Rachman, 2002). This model contains several components. Firstly, it posits that a series of cognitive multipliers determine how much the individual checks in a given situation. These multipliers are 1) an increased sense of personal responsibility for the harm to be prevented, 2) an increased perceived sense that the threat or harm to be prevented is likely or probable, and 3) an increased perceived sense that the threat or harm to be prevented would be severe in nature. This behaviour is subsequently proposed to be repeated because of a ‘self-perpetuating mechanism’, wherein the act of checking paradoxically reduces memory confidence as to whether one has actually checked, increases the sense of responsibility for and likelihood of the potential threat, and lacks a clear end point. This last component has received much empirical support (e.g., Ashbaugh & Radomsky, 2007; Boschen & Vuksanovic, 2007; Coles et al., 2006; Radomsky & Alcolado, 2010; Radomsky, Dugas, et al., 2014; Radomsky, Gilchrist, & Dussault, 2006; van den Hout & Kindt, 2003a,b; 2004). The cognitive multipliers, however, have not benefitted from the same attention in the literature.
There have been a number of investigations which have examined the role of responsibility on checking behaviour. An early experiment by Rachman and Hodgson (1980) noted that when responsibility was removed, clinical patients exhibited reduced, almost nil distress over their obsessions and compulsions. Lopatka and Rachman (1995) found that decreasing responsibility via a responsibility contract in a sample of individuals with compulsive checking resulted in decreased distress and decreased urges to check objects at home, as well as decreased estimations of the probability and severity of the harm that was to be incurred. Relatedly, increasing responsibility has been shown to induce a memory bias for threat-relevant details of a checking episode, as well as significantly reduced confidence in memory for completed actions, suggesting that compulsive checkers behave differently when responsibility is inflated (Radomsky et al., 2001). A similar experimental manipulation in a student population found that decreasing responsibility decreased subsequent urges to check task performance (Parrish & Radomsky, 2006). Another more recent student investigation using imaginary vignettes examined both responsibility and severity of harm, and found that increasing levels of both factors resulted in increased urges to check (Parrish & Radomsky, 2011). Arntz et al. (2007) found that checking behaviour during a pill classification task was higher in individuals with (heterogeneous) OCD under conditions of high responsibility, but that increasing responsibility had no such differential effect on checking in the anxious control and non-clinical participants (Arntz et al., 2007). In a study of OCD symptoms, students with elevated symptoms also evidenced elevated probability and severity of possible negative events (Woods et al., 2002). In contrast, in the OCD sample, only elevated severity ratings were associated with elevated symptoms (Woods et al., 2002). Berenbaum et al. (2007) demonstrated in a non-clinical sample that individuals with elevated levels of worry also gave higher probability estimates and higher perceived cost (i.e., severity) of the possible negative outcomes of the events they worried about. Similarly, individuals with OCD seem to lack the “unrealistic optimism bias”, which non-clinical individuals have with respect to the perceived (low) probability of negative events occurring (Moritz & Jelinek, 2009).
Although the cognitive multipliers proposed by Rachman (2002) have not been investigated concurrently in studies of checking, related research on reassurance seeking has demonstrated that increased probability and severity of harm promote higher urges to seek reassurance and urges to check (Parrish & Radomsky, 2011). To our knowledge, however, responsibility, probability, and severity of harm, have never been examined or manipulated together in one experimental protocol using an ecologically valid paradigm to measure checking behaviour. It is worth noting that a functional approach to understanding obsessive-compulsive symptoms suggests that compulsions such as checking can be understood from the motivation that drives the behaviour (e.g., out of a desire to avoid being viewed as responsible by others, to avoid causing harm, to obtain a feeling of completeness; Dean & Purdon, 2021, Summerfeldt et al., 2004; 2014), rather than from the topographical structure of the behaviour itself (i.e., the nature and duration of a behavioural check). A functional approach was not employed or explored in the current study, but may well have implications for the results (see Discussion, below).
The current study thus sought to examine the impact of manipulations of the three cognitive multipliers proposed by Rachman (2002) to promote checking. Using an enhanced ecologically valid checking paradigm, individuals with OCD who exhibited clinical levels of compulsive checking and non-clinical student controls were randomly assigned to check both functional and non-functional stove burners and light bulbs under conditions of either high or low responsibility (see Methods, for details). We hypothesized that overall, clinical participants would spend more time checking than the non-clinical participants. We further expected that regardless of group, individuals under conditions of high responsibility would check more than those under conditions of low responsibility. We also hypothesized that all participants would spend more time checking objects that were associated with a more severe level of harm (i.e., a stove burner as compared to a light bulb), and that they would similarly spend more time checking objects with a higher probability of harm (e.g., functional, as opposed to non-functional appliances). As such, we expected that the most checking would be exhibited in clinical individuals in the high responsibility condition, while checking highly threatening items (i.e., the stove burners, rather than the light bulbs) under conditions of higher probability (i.e., functional rather than non-functional burners/bulbs).
Section snippets
Participants
The clinical group was comprised of thirty participants who participated in individual experimental sessions (16 females and 14 males). (Two additional participants were excluded from this group because they refused to sign the responsibility contract.) On average, clinical participants were 42.10 (SD = 16.1) years old and ranged in age from 19 to 73 years. Clinical participants were non-treatment seeking. They were recruited from local community newspaper advertisements and from our
Results
Manipulation Check An ANOVA with responsibility condition and group membership as the between-participants variables and responsibility ratings (from 0 to 100) as the dependent variable revealed a significant main effect of responsibility condition, F (3,56) = 65.14, p < .001, = 0.54, such that those in the high responsibility condition (M = 87.13, SD = 21.86) felt significantly more responsible than those in the low responsibility condition (M = 33.83, SD = 28.46). There was no main effect
Discussion
This is the first study, to our knowledge, where all three cognitive multipliers in the cognitive model of compulsive checking were investigated simultaneously. Participants checked stove burners and light bulbs under varying degrees of responsibility, severity, and probability of harm. As predicted, clinical participants spent more time checking than did nonclinical participants. Also as hypothesized, increasing the severity of the threat increased checking time for all participants, as they
Funding
This work was supported by funding from the Canadian Institutes of Health Research, MOP 64199. The funding agency played no role in data collection, analyses, writing, interpretation of the results, or decision to publish.
Author declaration
We wish to confirm that there are no known conflicts of interest associated with this publication and there has been no significant financial support for this work that could have influenced its outcome.
We confirm that the manuscript has been read and approved by all named authors and that there are no other persons who satisfied the criteria for authorship but are not listed. We further confirm that the order of authors listed in the manuscript has been approved by all of us.
We confirm that we
CRediT authorship contribution statement
Adam S. Radomsky: Conceptualization, Methodology, Resources, Writing – original draft, Writing – review & editing, Supervision, Funding acquisition. Gillian M. Alcolado: Formal analysis, Data curation, Writing – original draft, Writing – review & editing. Michel J. Dugas: Conceptualization, Methodology. Stefanie L. Lavoie: Methodology, Data curation, Project administration.
Declarations of interest
None.
Acknowledgements
The authors would like to gratefully acknowledge the contributions of Monique Lahoud, Andrea Ashbaugh, Chris Parrish, Laurie Gelfand, Corinna Elliott, Irena Milosevic, Oded Greemberg, Roz Shafran, and Jack Rachman for their help with recruitment, data collection, protocol design and other aspects of the work, in addition to the most helpful comments from anonymous reviewers. Portions of this data were presented at the 2006 European Association for Behavioural and Cognitive Therapies conference,
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- 1
Present address: Department of Clinical Health Psychology, University of Manitoba, Winnipeg, Manitoba.
- 2
Present address: Département de Psychoéducation et de Psychologie, Université du Québec en Outaouais, Outaouais, Québec.