Comprehensive insights into Obsessive-Compulsive Disorder

Müller, Celina Liane (2025): Comprehensive insights into Obsessive-Compulsive Disorder: investigating assessment, attentional processes, and emotion regulation. Dissertation, LMU München: Fakultät für Psychologie und Pädagogik

Abstract

Obsessive-Compulsive Disorder (OCD) is a heterogeneous and debilitating condition that remains frequently under- and misdiagnosed, delaying not only effective treatment but also worsening long-term outcomes. In addition to diagnostic challenges, the underlying mechanisms contributing to OCD remain insufficiently understood. This thesis addresses these gaps by enhancing symptom assessment and investigating key mechanisms implicated in the disorder’s development and maintenance, specifically anger suppression and attentional biases. To enhance assessment of OCD symptoms and diagnostic precision, Study I and Study II translated and validated the 12- and 4-item Obsessive Compulsive Inventory (OCI-12 and OCI-4, respectively), testing the factor structure, reliability, validity, and diagnostic accuracy in clinical and non-clinical samples. Participants with OCD (n = 102), anxiety-related disorders (n = 69), and non-clinical controls (n = 248) were recruited and asked to fill out several online questionnaires assessing OCD symptoms, but also other symptoms such as anxiety, depression, and worry. The German version of the OCI-12 replicated the four-factor structure representing the most common OCD symptom clusters (i.e., checking, washing, ordering, and obsessing), with a higher-order factor for general OCD symptoms accounting for their covariance and improving model fit. Both, the OCI-4 and OCI-12, showed good reliabilities, moderate-to-good construct validity, and good-to-excellent diagnostic accuracy. Thereby, the findings support these measures as resource-efficient and clinically applicable screening tools, providing standardised cut-off criteria for improved assessment in routine care and research. To contribute to a more comprehensive understanding of underlying factors of OCD, Study III and Study IV examine the role of anger suppression and attentional biases, respectively. Considering the divergent views of psychodynamic and cognitive theories on anger suppression, Study III explores whether anger suppression precedes or emerges as a consequence of OCD symptoms. The temporal relationship between anger suppression, the sense of responsibility, and OCD symptoms was investigated in participants with OCD (n = 48), who were recruited as part of an intervention study evaluating the effects of a metacognitive intervention for OCD. Obsessive beliefs, OCD symptoms, and anger suppression were assessed at three timepoints: pre-intervention, post-intervention, and at a six-month follow-up. Results of the structural equation models indicated that OCD symptoms predicted increased anger suppression over time, independent of depressive symptoms and medication intake. The reverse directionality, with anger suppression predicting OCD symptoms, did not yield significant results, further corroborating the cognitive perspective. The association between an inflated sense of responsibility and anger suppression was less clear and appeared to be present only in individuals with high levels of checking-related symptoms, who generally exhibit greater responsibility concerns and increased anger suppression. While OCD symptoms significantly decreased throughout the metacognitive intervention, anger suppression remained stable, indicating differential treatment effects on these mechanisms. Overall, these results provide further support for cognitive models of OCD, highlighting the role of emotion regulation processes (i.e., anger suppression) and cognitive beliefs (i.e., sense of responsibility) in OCD, with their associations differing across specific OCD symptom clusters. Study IV tested cognitive-behavioural theories on attentional biases in OCD, addressing inconsistencies in prior research. Using a free-viewing eye-tracking paradigm, attentional processes were examined in individuals with OCD (n = 51), spider phobia (n = 50), and non-clinical controls (n = 64). Stimuli were individually rated for their idiosyncratic disorder relevance, allowing for a more tailored analysis. Strikingly, of those pictures deemed OCD-related on average only one-third was considered actually OCD-relevant by participants with OCD, highlighting the need for idiosyncratic material in this heterogeneous disorder. Contrary to theoretical expectations, the multilevel models did not provide evidence for a vigilance bias, as participants with OCD were neither more likely to fixate first nor did they fixate more quickly on disorder-relevant stimuli. Furthermore, no general maintenance bias (i.e., longer fixation durations) emerged for OCD-relevant images. However, attentional maintenance seemed to be more fine-grained, as analyses revealed symptom-specific effects, with avoidance of contamination/washing-related pictures but increased maintenance on checking-related pictures in OCD. As individuals with spider phobia showed a general strategic avoidance of phobia-relevant pictures, the findings challenge that anxiety-based models on attentional biases can be transferred to OCD. Instead, the possibility of distinct underlying emotions that drive different attentional and behavioural responses is discussed. Accordingly, the importance of considering both the heterogeneity of OCD symptoms and emotional experiences in basic research to enhance the understanding of underlying mechanisms in OCD is emphasised. Overall, this thesis advances symptom assessment for the heterogeneous nature of OCD while emphasising the need for refined theoretical conceptualisations that account for both diverse symptom presentations and underlying emotional experiences. By validating the OCI-4 and OCI-12, this thesis contributes to improving early OCD diagnosis and enabling more precise symptom assessment in both clinical and research settings. Furthermore, the findings on underlying factors of OCD challenge the assumption of universal mechanisms in its development, instead highlighting symptom-specific cognitive-affective processes, such as anger suppression in checking-related compulsions or attentional biases shaped by distinct symptoms and presumably linked to specific emotional states. The discussion underscores the need for further investigation into the interplay between cognitive, behavioural, and affective processes, considering both theoretical implications and methodological challenges. The potential for refining theoretical models and returning to basic research to investigate the emotional facets of OCD is highlighted. Moreover, as cognitive-behavioural factors addressed in the current thesis can be related to emotion regulation frameworks, the role of emotion regulation difficulties as a potential factor underlying OCD is discussed. If successfully replicated, these findings could inform clinical practice, leading to more personalised interventions that integrate emotion regulation and symptom-specific mechanisms, thereby potentially enhancing the effectiveness of OCD treatment.

• Dokumententyp: Dissertationen (Dissertation, LMU München)
• Keywords: Obsessive-Compulsive Disorder, Symptom Assessment, Attentional Biases, Anger Suppression, Emotion Regulation
• Themengebiete: 100 Philosophie und Psychologie ; 100 Philosophie und Psychologie > 150 Psychologie
• Fakultäten: Fakultät für Psychologie und Pädagogik
• Sprache der Hochschulschrift: Englisch
• Datum der mündlichen Prüfung: 9. Juli 2025
• 1. Bericht­erstatter:in: Cludius, Barbara