Incompleteness, harm avoidance, and disgust: A comparison of youth with OCD, anxiety disorders, and no psychiatric disorder

Highlights

• Incompleteness, harm avoidance, and disgust were investigated in clinical and non-clinical youth.

• Harm avoidance was associated with OCD, depression, and anxiety.

• Incompleteness was uniquely related to OCD and the role of disgust in relation to OCD was unclear.

• Change in incompleteness following treatment for OCD was uniquely related to change in overall OCD.

• The role of incompleteness in pediatric OCD needs to be further studied.

Abstract

Psychological models of pediatric obsessive-compulsive disorder (OCD) place a heavy emphasis on harm avoidance as a maintaining factor and target for treatment. Incompleteness and disgust may also play a role in pediatric OCD but remain understudied. Youth with OCD (n = 100), anxiety disorders (n = 96), and no impairing psychiatric symptoms (n = 25) completed self-report measures of trait-level incompleteness, harm avoidance, and disgust and current symptoms of OCD, anxiety, and depression. Group differences and associations between emotions, symptoms, and pre- to post-treatment change in overall OCD severity were examined. Youth with OCD and anxiety disorders scored higher on harm avoidance and disgust than youth with no psychiatric disorder. Youth with OCD scored higher on incompleteness than youth with anxiety disorders and youth with no psychiatric disorder. Harm avoidance showed unique associations to self-reported symptoms of OCD, anxiety, and depression while incompleteness was uniquely related to OCD and disgust to anxiety. Within the OCD sample, incompleteness and harm avoidance were differentially related to the major OCD symptom dimensions, and change in incompleteness was uniquely related to pre- to post-treatment change in OCD severity. Trait-level incompleteness appears to play a central role in pediatric OCD and studies investigating its direct involvement in symptoms and associations with treatment outcome are needed. The role of disgust in relation to pediatric OCD remains unclear.

Introduction

Pediatric obsessive-compulsive disorder (OCD) is a persistent and highly disabling condition (Hofer et al., 2018; Piacentini, Bergman, Keller, & McCracken, 2003). Its cardinal symptoms of obsessions and compulsions can take on a myriad of forms resulting in highly heterogeneous clinical presentations and uncertainty about how to best describe the disorder from a taxonomic perspective (Mataix-Cols, Rosario-Campos, & Leckman, 2005). With the release of the DSM-5, OCD was removed from the anxiety disorders section and placed in a new section called Obsessive-Compulsive and Related Disorders (American Psychiatric Association, 2013). This move was in part based on the highly repetitive and often ritualized nature of OCD symptoms, a feature that OCD shares more with trichotillomania, body dysmorphic disorder, and excoriation disorder than with the anxiety disorders (Abramowitz & Jacoby, 2015; Bartz & Hollander, 2006; Stein et al., 2010). Moreover, it was argued that the experience of anxiety, even though very common in OCD, is not present in or crucial for all OCD sufferers (Van Ameringen, Patterson, & Simpson, 2014).

The division of OCD and the anxiety disorders has been the subject of much debate (Abramowitz & Jacoby, 2015; Stein et al., 2010), not least because of the central role ascribed to fear and anxiety in evidence-based treatments for OCD, particularly exposure and response prevention (ERP) based cognitive behavioral therapy (CBT) in which patients are asked to confront stimuli/situations that cause them fear or distress (exposure), while refraining from compulsive behaviors (response prevention) (Abramowitz, Taylor, & McKay, 2009; Foa & McLean, 2016). Although this form of treatment has been shown to be effective, partial or non-response and subsequent relapse is common (Pediatric OCD Treatment Study Team, 2004; Skapinakis et al., 2016) which highlights the need for a better understanding of vulnerability and maintaining factors in pediatric OCD.

The limitations of a solely fear-based view of OCD has been raised by numerous researchers, with a recurring theme being that with a condition as heterogeneous as OCD, it is likely that the motivational influences are equally heterogeneous (Gillan & Sahakian, 2015; Lazarov, Liberman, Hermesh, & Dar, 2014; Nutt & Malizia, 2006; Stein et al., 2010; Summerfeldt, Kloosterman, Antony, & Swinson, 2014). Within the Core Dimensions Model of OCD (Summerfeldt et al., 2014), fear (or harm avoidance) is acknowledged to play a central role in OCD, but no less so than a heightened feeling of things being not just right or a disturbing feeling that behaviors or thoughts have not been completed in a satisfactory way (termed incompleteness). Experiences of incompleteness are common in the general population and can be elicited by a line of stimuli, e.g. a drawer not being completely closed, wrinkled clothes, lines not running in parallel, or a sense that something was not written in a correct enough way (Ravid, Franklin, Khanna, Storch, & Coles, 2014).

In relation to OCD, it has been suggested that feelings of incompleteness may help explain the repetitive nature of compulsive behavior and the rigid rules that often guide such behavior. Accordingly, it has been shown that trait incompleteness is heightened in individuals diagnosed with OCD compared to those with anxiety, gambling, and eating disorders (Chik, Calamari, Rector, & Riemann, 2010; Ecker, Kupfer, & Gonner, 2014; Ghisi, Chiri, Marchetti, Sanavio, & Sica, 2010; Sica et al., 2015) and is more strongly related to OCD than to general distress (Taylor et al., 2014). Trait incompleteness has also been found to be uniquely related to OCD symptoms after controlling for harm avoidance and co-occurring psychiatric symptoms in clinical and non-clinical samples (Belloch et al., 2016; Ecker & Gonner, 2008), and reduced as an effect of OCD treatment (Coles & Ravid, 2016). In relation to youth, few studies exist, but it has been shown that everyday experiences of incompleteness (or a very similar phenomena termed not just right-experiences) are as common in adolescents as in adults with around 80 % of adolescents reporting such experiences; but in the only study to date, such experiences were not related to self-reported OCD symptoms (Ravid et al., 2014). Research on symmetry-related OCD in youth (a symptom dimension in which incompleteness may play a central role) has suggested that this class of symptoms may be related to an earlier age of OCD onset and more frequent OCD in first-degree relatives (Jacobsen & Smith, 2017). However, no studies have examined the role of incompleteness in youth with OCD, leaving the possible role of incompleteness in symmetry (and other) OCD symptoms empirically unaddressed in this age group.

Disgust is another emotion that has long been associated with OCD, particularly the contamination subtype, but disgust is not included in the Core Dimensions model of OCD which may limit a fuller understanding of emotion involvement in OCD (e.g., Ecker & Gonner, 2008). The feeling of disgust is argued to play a key evolutionary role in avoiding contact with noxious and infectious substances (Davey, 2011; Van Overveld, de Jong, Peters, Cavanagh, & Davey, 2006) and an accumulating body of evidence suggests that the tendency to react frequently and with intense feelings of disgust to external and internal stimuli (i.e., disgust proneness) may be involved in the onset and maintenance of various forms of psychiatric symptoms, including OCD (for a review, see Olatunji, Ebesutani, Kim, Riemann, & Jacobi, 2017). Within this body of research, a great deal of attention has been directed toward whether disgust is more specifically related to contamination-related OCD or to OCD more generally, with mixed results (Olatunji, Unoka, Beran, David, & Armstrong, 2009; Olatunji, Cisler, McKay, & Phillips, 2010; Olatunji, Ebesutani, & Kim, 2016). Only a small number of studies have examined the role of disgust in relation to OCD in youth. In a non-clinical sample of 8−12 year old children, self-reported disgust propensity correlated in the moderate range with self-reported OCD symptoms, but correlations of similar or stronger magnitude were also found in relation to phobic symptoms, with the strongest correlations emerging in relation to animal and blood-injury phobia (Muris, van der Heiden, & Rassin, 2008). Olatunji et al. (2017) found disgust proneness to be related to overall OCD symptom severity in a sample of youth with mixed mental disorders, even after controlling for general distress. Taboas et al. (2015) found that children receiving CBT for OCD showed significantly greater reductions in disgust propensity than children receiving CBT for a primary anxiety disorder. Similarly, Knowles, Viar-Paxton, Riemann, Jacobi, and Olatunji (2016)) found that changes in disgust propensity were significantly correlated with changes in OCD symptoms during CBT, even after controlling for changes in anxiety and depression.

As OCD tends to onset during childhood or adolescence and follow a chronic course without effective treatment (Kessler et al., 2005), and as a significant proportion of youth do not achieve a full and durable response to the first-line OCD treatment (CBT) (Skapinakis et al., 2016), studies are needed to identify factors that may help explain the onset and persistence of the disorder. Furthermore, research on etiological/maintaining factors that are specifically related to OCD may inform genetic and neurobiological research, which in turn may result in better prevention and treatment. In an endeavor to examine factors that may be specifically related to OCD, incompleteness and disgust are strong candidates for further investigation. If these emotions are important to pediatric OCD, this may have implications for treatment. For example, it is possible that symptoms driven by (or patients with a strong proneness for) these emotions may need individually tailored treatments and that ERP may be less effective when symptoms are more motivated by these emotions than by fear. For instance, it has been suggested that habit reversal exercises may be beneficial or needed for patients with symptoms driven by incompleteness (Summerfeldt, 2004), and incompleteness have been shown to predict poorer treatment outcomes for adults with elevated contamination fears receiving a short ERP based intervention (Mathes, Kennedy, Wilver, Carlton, & Cougle, 2019). Further, disgust has been shown to habituate slower than fear to repeated exposures (Olatunji, Smits, Connolly, Willems, & Lohr, 2007).

As indicated above, disgust correlates with phobic (and other forms) of childhood anxiety, and thus does not appear to be uniquely related to pediatric OCD. The same may be true of incompleteness, but no studies of incompleteness and OCD have been carried out with clinical youth samples; further, no studies have conjointly investigated harm avoidance, incompleteness, and disgust in relation to clinical OCD (either in children or adults). Thus, studies with clinical youth samples, that include measures of both incompleteness and disgust, may help clarify the importance of both incompleteness and disgust to pediatric OCD. Furthermore, it is reasonable to expect that in youth with OCD, disgust may be more related to contamination symptoms (e.g., in relation to the common concerns with sticky and noxious substances), and incompleteness to ordering (in which repetition until it feels just right are commonly reported). However, as noted above, studies with adults find that incompleteness and disgust may also be related to OCD more generally. To further elucidate the relationship between these emotion-related constructs and the heterogeneous symptoms of OCD, studies are needed that address how incompleteness and disgust relate not only to overall severity of pediatric OCD but also to OCD at the symptom dimension level.

The aim of the present study was to address these present gaps in the literature. As a first step, we examine whether scores on self-report measures of harm avoidance, incompleteness, and disgust can be used to differentiate youth with OCD, youth with anxiety disorders, and community youth without clinically impairing psychiatric symptoms. In line with theoretical notions and empirical evidence (mainly from research with adults), we hypothesize that harm avoidance and disgust will be equally elevated in youth with OCD and anxiety disorders when compared to non-clinical youth and that incompleteness will be elevated only in youth with OCD. Second, we use structural equation modelling (SEM) to assess how harm avoidance, incompleteness, and disgust are related to self-reported symptom severity of OCD (at the disorder and dimensional level), anxiety, and depression. Based on the Core Dimensions Model, we hypothesize that harm avoidance will be related to both OCD and anxiety while incompleteness will be related only to OCD. For disgust, we hypothesize that it will be related to OCD and anxiety. All examinations in relation to self-reported depression will be exploratory. In relation to OCD symptom dimensions (given the dearth of studies with youth) our examinations are mainly exploratory, but we expect that harm avoidance will be related to intrusive thoughts (obsessing), incompleteness to ordering, and disgust to washing. Finally, we examine to which degree changes in OCD symptoms following treatment for this condition are associated with changes in harm avoidance, incompleteness, and disgust and we hypothesize that change in OCD will be related to change in all of these constructs.