The characteristics of unacceptable/taboo thoughts in obsessive–compulsive disorder
Introduction
Unacceptable/taboo thoughts, also known as “pure obsessions”, refer to impulsive aggressive, sexual and religious obsessions. The observation that some obsessions occurred in the apparent absence of compulsions was first made by Baer [1] in a study employing factor analysis techniques. Since then, there have been a number of factor analytic studies [2], [3], [4], [5], [6], [7], [8], [9] that have revealed a symptom dimension of obsessive–compulsive disorder (OCD) characterised predominantly by obsessions and in particular aggressive, sexual and religious obsessions. More recently, studies [10], [11] have demonstrated that “pure obsessions” is a misnomer in that unacceptable/taboo thoughts tend to be accompanied by compulsions.
Unacceptable/taboo thoughts are distinctly ego-dystonic with a repugnant quality that tends not to be so prominent in other OCD symptoms [12]. As their name suggests, the content of these obsessions typically involves unacceptable, taboo or forbidden themes such as stabbing a relative, incest or blasphemy. Studies have associated unacceptable/taboo thoughts with mental rituals [10], reassurance-seeking [6], [10], avoidance [13], [14], good insight [15], male gender [16], [17], and being more likely to seek professional help [18].
In addition to the obvious phenomenological differences between unacceptable/taboo thoughts and other OCD symptoms, unacceptable/taboo thoughts also appear to have clinical utility as they have been associated with a differential response to treatment. Although studies examining the response of unacceptable/taboo thoughts to pharmacotherapy have resulted in conflicting findings [19], some studies investigating the response to behavioural interventions [20], [21], [22] have reported a poorer outcome.
This study aimed to illustrate that unacceptable/taboo thoughts are associated with different characteristics to other symptom dimensions of OCD and that these characteristics may have implications for the treatment of individuals with unacceptable/taboo thoughts. It was hypothesised that unacceptable/taboo thoughts would be associated with greater severity, specifically higher Y-BOCS obsession scores and higher levels of distress. These hypotheses were based on clinical observation and the findings of previous studies [23], [24]. Having hypothesized that greater degrees of severity and distress would be associated with unacceptable/taboo thoughts, it was additionally hypothesised that unacceptable/taboo thoughts would be associated with higher rates of having obtained treatment prior to entering the study, greater reassurance-seeking, greater levels of avoidance, higher rates of comorbid depression and stronger beliefs relating to a need to control one's thoughts. These hypotheses were based on limited evidence relating unacceptable/taboo thoughts to higher rates of previous treatment [18], greater reassurance-seeking [6], [10], greater levels of avoidance [13], [14], higher rates of comorbid depression [25], [26] and cognitive beliefs relating to the importance of controlling one's thoughts [27], [28], [29], [30].
Section snippets
Recruitment
This report has resulted from the Nepean OCD Study, conducted in Sydney and several other Australian cities. Participants (N = 154) were recruited from the Nepean Anxiety Disorders Clinic, OCD support groups, newspaper advertisements and referrals from general practitioners, psychiatrists, clinical psychologists and mental health services. Participants were included if they had a primary diagnosis of OCD which was determined on the basis of a clinician-administered semi-structured interview, the
Results
The characteristics of the sample are shown in Table 1. The specified YBOCS-SC categories that were subjected to PCA yielded a five-factor structure explaining 64.9% of the variance (Table 2). This included an unacceptable/taboo thoughts symptom factor that explained 8.7% of the variance and that consisted of impulsive aggressive, sexual and religious obsessions and mental rituals. Logistic and linear regression analyses revealed that higher Y-BOCS obsession scores, higher levels of distress,
Discussion
This study presented new findings indicating that unacceptable/taboo thoughts might be characterised by higher rates of previous non-alcohol substance dependence and greater levels of hostility. One may hypothesise that there is a need to use substances to reduce the distress associated with unacceptable/taboo thoughts, or that substance abuse plays an aetiological role in the occurrence of these obsessions. However, the cross-sectional nature of our study does not allow us to speculate about
Conclusions
Unacceptable/taboo thoughts appear to form a distinct symptom dimension of OCD and their validity is further supported by their association with descriptive characteristics that are not commonly associated with other OCD symptom dimensions. The ego-dystonic nature of unacceptable/taboo thoughts and their association with the belief that it is important to control one's thoughts support psychological therapies that target underlying beliefs and cognitive processes in addition to the standard
Acknowledgment
The authors are grateful to Colin Slocombe from ACEDA Adelaide, Michelle Graeber from ARCVIC Melbourne, Scott Blair-West of the Melbourne Clinic, the Blacktown and Kogarah OCD Support Groups, the Mental Health Association of NSW and the Penrith Mental Health Practitioners' Network.
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2022, Journal of Obsessive-Compulsive and Related DisordersCitation Excerpt :In contrast to this theory, it has been proposed that the relationship between OCD and SUD is enmeshed with each disorder perpetuating the other, ultimately increasing the symptoms of OCD (e.g., Back & Brady, 2008; Brady & Lydiard, 1993; Schuckit, 1996). In fact, there is a robust relation between the severity of alcohol use and the severity of obsessive-compulsive symptoms (Campos, Yoshimi, Simão, Torresan, & Torres, 2015; Lima, Pechansky, Fleck, & De Boni, 2005; Mancebo et al., 2009), especially in the symptom dimension of obsessing as measured with the OCI-R (obsessions of harm, sex, or religion; Brakoulias, Starcevic, Berle, et al., 2013; Torres et al., 2016; Torres et al., 2006). This comorbidity of AUD among treatment-seeking OCD patients has shown an increased risk for poor treatment outcomes, increased impairment, and distress (Angst, Gamma, Endrass, et al., 2005; Fineberg et al., 2013), as well as enhanced suicidality (Gentil et al., 2009).
No conflicts of interest. This study was funded by the Nepean Medical Research foundation, a competitive Pfizer Neuroscience Grant and a grant from the Discipline of Psychiatry at The University of Sydney.