Anxiety Sensitivity, Obsessive Beliefs, and the

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compulsive disorder (OCD) although a significant proportion of clients remain symp- ... CBT has been found to be an effective treatment for OCD (e.g., Hofmann and Smits ... With respect to OCD, patient participants with OCD have consis-.
Anxiety Sensitivity, Obsessive Beliefs, and the Prediction of CBT Treatment Outcome for OCD Danielle Katz, Judith M. Laposa & Neil A. Rector

International Journal of Cognitive Therapy e-ISSN 1937-1217 J Cogn Ther DOI 10.1007/s41811-018-0007-z

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Anxiety Sensitivity, Obsessive Beliefs, and the Prediction of CBT Treatment Outcome for OCD Danielle Katz 1 & Judith M. Laposa 2,3 & Neil A. Rector 1,2

# International Association of Cognitive Psychotherapy 2018

Abstract Cognitive behavioral therapy (CBT) is an effective treatment for obsessivecompulsive disorder (OCD) although a significant proportion of clients remain symptomatic following treatment. Knowledge regarding individual differences that influence treatment response could help guide future augmentations to CBT. The current study examined two potential predictors of treatment response to CBT for OCD: anxiety sensitivity and obsessive beliefs. Participants (n = 93) with a primary diagnosis of OCD completed measures of anxiety sensitivity (Anxiety Sensitivity Index (ASI); Reiss et al. in Behaviour Research and Therapy, 24(1), 1–8, 1986) and obsessive beliefs (Obsessive Belief Questionnaire (OBQ): OCCWG in Behaviour Research and Therapy, 35(7), 667–681, 1997, 39(8), 987–1006, 2001) before engaging in a course of group CBT for OCD. Obsessive-compulsive symptom severity was measured (Yale-Brown ObsessiveCompulsive Scale; Goodman et al. in Archives of General Psychiatry, 46(11), 1012– 1016, 1989a, 1006–1011, 1989b) before and upon treatment completion. Results indicated a significant two-way interaction, whereby elevated ASI-Physical scores by elevated OBQ-Importance/Control significantly predicted higher posttreatment symptom severity. These results have implications for the cognitive modeling of OCD and its treatment with CBT. Keywords Obsessive-compulsive disorder . Cognitive behavioral therapy . Anxiety sensitivity . Obsessive beliefs

* Neil A. Rector [email protected]

1

Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, 2075 Bayview Ave., Toronto, ON M4N 3M5, Canada

2

Department of Psychiatry, University of Toronto, Toronto, ON, Canada

3

Centre for Addiction and Mental Health, Toronto, ON, Canada

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Obsessive-compulsive disorder (OCD) affects roughly 2.5% of individuals over the course of their lifetime (Kessler et al. 2012) and often entails impairments in social and occupational functioning and quality of life (e.g., Adam et al. 2012; Cassin et al. 2009; Masellis et al. 2003; Norberg et al. 2008; Torres et al. 2006). Cognitive behavioral therapy (CBT) is the most researched psychotherapeutic treatment for OCD. Although CBT has been found to be an effective treatment for OCD (e.g., Hofmann and Smits 2008; Öst et al. 2015; Rosa-Alcázar et al. 2008; Stewart and Chambless 2009), a significant proportion of individuals with OCD remain symptomatic following treatment (Fisher and Wells 2005). The identification of individual differences among clients that influence their responsiveness to treatment would allow practitioners to modify CBT in order to enhance its effectiveness. Anxiety sensitivity describes an individual difference in the degree to which the consequences of experiencing anxiety are feared (Reiss et al. 1986). It is typically described as having three dimensions: fear of the physical consequences of anxiety, fear of the social consequences of anxiety, and fear of cognitive dyscontrol as a result of anxiety (Taylor et al. 2007). Anxiety sensitivity has been linked to symptom severity across many disorders, including generalized anxiety disorder, social anxiety disorder, posttraumatic stress disorder, and depression (Carleton et al. 2010; Deacon and Abramowitz 2006; Hendriks et al. 2014; Naragon-Gainey 2010; Rector et al. 2007; Taylor et al. 1992). With respect to OCD, patient participants with OCD have consistently demonstrated higher levels of AS than healthy controls (Deacon and Abramowitz 2006; Naragon-Gainey 2010; Robinson and Freeston 2014; Taylor et al. 1992; Wheaton et al. 2012b), and higher AS has been associated with greater obsessive-compulsive (O-C) symptom severity in clinical (Calamari et al. 2008; Laposa et al. 2015; Raines et al. 2014b; Storch et al. 2014) and nonclinical populations (Keough et al. 2010; Smith et al. 2014). Beyond symptom severity, AS has also been found to play an important role in the mediation between OCD and other related negative outcomes, such as suicidality (Raines et al. 2014a) or insomnia (Raines et al. 2015). Given the cross-sectional associations between AS and O-C symptom severity, it could be hypothesized that AS levels could impact O-C change throughout CBT treatment and influence end-point symptom reduction. In a recent study, Blakey et al. (2017) found that higher baseline levels of total AS (but not specific AS dimensions) predicted higher post-treatment O-C symptoms even after controlling for baseline O-C symptoms and depression severity. One possible explanation for these results is that individuals with OCD with comparatively higher AS may experience greater challenges in completing and benefiting from exposure exercises due to their difficulty managing the anxiety experienced during exposure tasks (Blakey and Abramowitz 2018). Consequentially, these individuals may be more likely to avoid fully engaging in exposure exercises and less likely to experience optimal outcomes. The majority of research examining AS as a predictor of treatment outcome for OCD has done so by focusing on the higher order dimension of AS rather than the lower order dimensions of physical, cognitive, and social concerns. However, lower order dimensions of AS have been found to be differentially predictive of obsessivecompulsive symptom severity (Deacon and Abramowitz 2006; Nowakowski et al. 2016; Wheaton et al. 2012a) and obsessive-compulsive symptom dimensions (e.g., Poli et al. 2017; Raines et al. 2014b; Wheaton et al. 2012b) and therefore could conceivably be differentially related to outcomes.

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While AS (and/or its distinct subfactors) could potentially influence how an individual responds to anxiety in the midst of the obsessional cycle, it has been proposed that negative cognitive appraisals of intrusions stemming from obsessive beliefs also intensify the resulting anxiety following the intrusion (Clark 2007; Obsessive Compulsive Cognitions Working Group (OCCWG) 1997, 2001, 2003, 2005; Rachman 1997, 1998; Salkovskis 1985). For instance, obsessive beliefs have been associated with O-C symptom severity and distress cross-sectionally as well as longitudinally in clinical and nonclinical samples (e.g., Abramowitz et al. 2007; Coles and Horng 2006; Coles et al. 2008; Tolin et al. 2003, 2008; Viar et al. 2011). Obsessive beliefs may also be potential moderators of treatment outcome for CBT. As measured by the obsessive beliefs questionnaire (OBQ), a frequently used and well-validated measure, obsessive beliefs can fall into one of six categories: (1) inflated responsibility, (2) overestimated threat, (3) importance of thoughts, (4) control of thoughts, (5) intolerance of uncertainty, (6) perfectionism (OCCWG 2003). These categories are often demarcated into three domains: (1) responsibility/threat, (2) importance/control of thought, (3) perfectionism/ certainty (OCCWG 2005). Though the general, higher order OBQ dimension can be studied as a predictor of OCD symptoms, distinguishing among the lower order dimensions provides additional, important information as they have been found to differentially predict OCD symptoms (Tolin et al. 2008; Viar et al. 2011; Wheaton et al. 2010) and changes in OBQ dimensions over the course of treatment have been found to differentially predict treatment response (Adams et al. 2012). The research examining baseline OBQ dimensions as predictors of treatment outcome is sparse and mixed. In a study of participants with OCD in a residential setting, Adams et al. (2012) found that pre-treatment scores on the OBQ dimension of responsibility/threat significantly predicted post-treatment symptom severity, though the total amount of variance accounted for was small. Another study found that the OBQ dimension of importance/control of thoughts predicted post-treatment symptom severity, and that this relationship did not remain significant when controlling for depressive symptoms (Manos et al. 2010). Yet another found that baseline OBQ did not predict clinically significant change (Kyrios et al. 2015). While AS and obsessive beliefs have been examined in OCD separately in prior CBT outcome research, it could be proposed that these key cognitive vulnerabilities interact to impact on the process and outcome of CBT treatment. As conceptualized based on a CBT framework, obsessive beliefs and AS influence the obsessional cycle at different stages of the path from intrusion ➔ appraisal ➔ distress ➔ compulsion and therefore could be hypothesized to produce an interactive rather than additive effect within the same obsessional cycle. For instance, the greater the negative appraisals of the intrusion (e.g., as shaped by OBQ beliefs) and the greater the AS activated around the resulting anxiety, the higher the likely ultimate level of distress resulting within the obsessional cycle. As stated, while it is known that obsessive beliefs and AS impact on the O-C cycle cross-sectionally, and in relation to clinical outcomes, no research that we are aware of has examined their interactive potential in the context of OCD, although conceptual models would appear to suggest this likely outcome. The objective of the present study was to examine AS and obsessive beliefs as both individual and joint predictors of treatment outcome of CBT for OCD. We hypothesized a main effect of AS dimensions on outcome, such that higher scores would

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predict higher post-treatment O-C symptom severity, as well as a main effect of obsessive beliefs on outcome, such that higher pre-treatment obsessive belief scores would predict higher post-treatment O-C symptom severity. However, we also hypothesized an interaction between AS and OBQ dimensions whereby the presence of heightened AS and OBQ scores would interact to produce poorer treatment outcomes, as demonstrated through elevated post-treatment O-C symptom severity. As the dimensions of these questionnaires have not been previously studied in interactions of this nature, and as the research literature on the moderating role of these dimensions is scant and mixed, we did not have specific predictions regarding individual interactions between the AS and OBQ dimensions, although these patterns would be explored.

Methods Participants The sample for this study included 93 participants referred to a universityaffiliated outpatient OCD, mood, and anxiety disorder clinic. All participants had received a primary psychiatric diagnosis of OCD using the Diagnostic and Statistical Manual of Mental Disorders, Version 5 criteria (American Psychiatric Association 2013). Diagnoses were based on expert clinician diagnoses although a subset (n = 28) also completed the OCD module of the Structured Clinical Interview for DSM-5, Research Version (SCID-5; First et al. 2015) revealing 100% diagnostic concordance. Inclusion criteria included a primary diagnosis of OCD and a pre-treatment Y-BOCS of 16 or higher, indicating at least moderate OCD symptom severity. Exclusion criteria included the following: (1) active psychosis or bipolar disorder, (2) substance use at a level that would interfere with treatment engagement, (3) participation in concurrent or recent adequate course of CBT for OCD, (4) recent suicide attempt or active suicidality/selfharm. The average age of participants was 31.88 (SD = 9.19). The participant sample was 49.5% female, 48.4% male, and 1.1% did not respond. In terms of ethnicity, 63.4% identified as Caucasian, 11.8% as Asian, 8.6% as Black, 4.3% as Hispanic, 1.1% as Arabic, and 8.6% as BOther.^ In terms of marital status, 62.4% identified as single, 22.6% as married, 9.7% as co-habiting, 3.2% as separated, 1.1% as divorced, and 1.1% did not respond. Materials Anxiety Sensitivity Index-3 The Anxiety Sensitivity Index-3 (ASI-3; Taylor et al. 2007) is an 18-item measure of anxiety sensitivity, or the degree to which individuals fear the consequences of experiencing anxiety. It is composed of three subscales: physical concerns, or the degree to which individuals fear the physical consequences of anxiety (ASI-P; e.g., BWhen I feel a pain in my chest, I worry that I’m going to have a heart attack^); cognitive concerns, or the degree to which individuals fear a loss of cognitive control as a result of anxiety (ASI-C; e.g., BWhen my thoughts speed up, I worry that I might be going crazy^); and social

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concerns, or the degree to which individuals fear negative social consequences as a result of experiencing anxiety (ASI-S; e.g., BI worry that other people will notice my anxiety^). Each subscale loads on to a dimension measuring general anxiety sensitivity. Participants indicate on a five-point Likert scale the degree to which they agree or disagree with each item. The ASI-3 has been shown to have strong psychometric properties (Taylor et al. 2007). In the current sample, the reliability of the ASI-3 dimensions of physical concerns, cognitive concerns, and social concerns ranged from good to excellent (α = 0.91, α = 0.92, α = 0.80, respectively). Obsessive Beliefs Questionnaire-44 The Obsessive Beliefs Questionnaire-44 (OBQ-44; OCCWG 2001, 2005) is a 44-item measure of the extent to which individuals agree with certain maladaptive beliefs associated with OCD. The scale has three dimensions: (1) Responsibility/threat estimation (OBQ-R/T) or the extent to which individuals fear potential negative consequences and see themselves as responsible for preventing harm to themselves or others (e.g., BFor me, not preventing harm is as bad as causing harm^), (2) Perfectionism/certainty (OBQ-P/C), or the need to meet a rigid standard or have absolute certainty about situations or events (e.g., BI must be certain of my decisions^), (3) Importance/ control of thoughts (OBQ-I/C), or concern regarding the implications of having intrusive thoughts and the need to control the intrusions (e.g., BHaving a bad thought is morally no different than doing a bad deed^). Participants indicate on a seven-point Likert scale the degree to which they agree or disagree with each statement. The OBQ-44 has good psychometric properties (OCCWG 2005). The internal consistency in this sample for the R/T, P/C, and I/C dimensions was excellent (α = 0.95, α = 0.94, α = 0.92, respectively). Yale-Brown Obsessive Compulsive Scale The Yale-Brown Obsessive Compulsive Scale (Y-BOCS; Goodman et al., 1989a, b) is a well-validated self-report measure of OCD symptom severity and impairment. The Y-BOCS has excellent psychometric properties (Goodman et al., 1989a, b). The internal consistency in this sample was good (α = 0.82).

Procedure Participants were enrolled in a 12-session course of group CBT for OCD. The groups typically had 8–10 participants, met for two hours once a week, and were co-led by psychologists and psychology graduate students. Therapy was based on manualized cognitive and behavioral interventions for CBT (Clark 2007; Foa and Kozak 1997; Wilhelm and Steketee 2006). Therapy involved exposure and response prevention, as well as cognitive restructuring of maladaptive appraisals, and homework assignments reflecting exposure-based and cognitive restructuring interventions. Participants completed the Y-BOCS, OBQ-44, and ASI-3 prior to their first session. The Y-BOCS was also completed at the end of treatment.

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Results Pearson correlations were calculated in order to determine the relationships between the ASI-3 dimensions, OBQ-44 dimensions, and pre- and post-treatment Y-BOCS. Hierarchical regression analysis was then used to determine the amount of post-treatment YBOCS variance accounted for by the predictor variables while controlling for pretreatment Y-BOCS scores. See Table 1 for descriptive statistics and Table 2 for correlations. A paired t test showed a significant change in mean Y-BOCS scores between pre- and post-treatment measurements (t(66) = 10.17, p < 0.001, 95% CI [6.36, 9.46], d = 1.28 using pooled SD), demonstrating that the treatment was effective at reducing O-C symptom severity. Non-completion of treatment occurred at a rate of approximately 30%. Based on logistic regression, non-completers did not significantly differ from completers in terms of pre-treatment Y-BOCS scores nor on ASI-3 or OBQ-44 at the total or dimensional level (all ps > 0.05). See Table 3 for hierarchical regression results. Variance inflation factors for main effect variables in the model were less than 2.5 and for interactions were less than 5.0 following centering of the predictors. No case resulted in a Cook’s Distance of greater than 0.2, indicating no undue influence. As the first step of the hierarchical regression, post-treatment Y-BOCS scores were regressed on pre-treatment Y-BOCS scores. Pretreatment Y-BOCS accounted for a significant amount of post-treatment Y-BOCS variance, B = 0.64, F(1, 60) = 14.94, p < 0.001, explaining 19.94% of post-treatment Y-BOCs variance. In the next step of the hierarchical regression, ASI-P, ASI-C, ASI-S, and the dimensions of the OBQ-44 were added as predictor variables. Out of all of the dimensions of the ASI-3, only ASI-P accounted for a significant amount of posttreatment Y-BOCS variance, B = 0.33, p ≤ 0.03. None of the other dimensions of the ASI-3 or OBQ-44 significantly accounted for variance in post-treatment YBOCS (all ps > 0.05). In total, the inclusion of the dimensions of the ASI-3 and Table 1 Mean and standard deviations for study measures at pre- and post-treatment Mean

SD

Pre- Y-BOCS

24.43

4.93

Post- Y-BOCS

16.27

7.04

ASI-P

7.89

6.66

ASI-C

10.82

7.08

ASI-S

12.08

5.54

OBQ-RT

73.67

24.79

OBQ-PC

77.21

22.05

OBQ-IC

45.45

17.82

Y-BOCS Yale-Brown Obsessive Compulsive Scale, ASI-P Anxiety Sensitive Index-3, Physical dimension, ASI-C Anxiety Sensitive Index-3, Cognitive dimension, ASI-S Anxiety Sensitive Index-3, Social dimension, OBQ-RT Obsessive Beliefs Questionnaire-44, Responsibility/Threat dimension, OBQ-PC Obsessive Beliefs Questionnaire-44, Perfectionism/Certainty dimension; OBQ-IC Obsessive Beliefs Questionnaire-44, Importance of Thoughts/Control of Thoughts dimension

Author's personal copy J Cogn Ther Table 2 Zero-order Pearson correlations for study measures 1.

2.

3.

4.

5.

6.

1.

Pre- Y-BOCS

2.

Post- Y-BOCS

0.47**

3.

ASI-P

0.08

0.25*

4.

ASI-C

0.19

0.04

0.60**

5.

ASI-S

0.02

− 0.02

0.40**

0.38**

6.

OBQ-R/T

0.21

0.17

0.33**

0.42**

0.25*

7.

OBQ-P/C

0.08

− 0.00

0.26*

0.47**

0.42**

0.55**

8.

OBQ-I/C

0.01

− 0.03

0.33**

0.56**

0.34**

0.52**

7.

0.58**

Y-BOCS Yale-Brown Obsessive Compulsive Scale, ASI-P Anxiety Sensitive Index-3, Physical dimension, ASI-C Anxiety Sensitive Index-3, Cognitive dimension, ASI-S Anxiety Sensitive Index-3, Social dimension, OBQ-RT Obsessive Beliefs Questionnaire-44, Responsibility/Threat dimension, OBQ-PC Obsessive Beliefs Questionnaire-44, Perfectionism/Certainty dimension, OBQ-IC Obsessive Beliefs Questionnaire-44, Importance of Thoughts/Control of Thoughts dimension *Correlation is significant at the 0.05 level; ** Correlation is significant at the 0.01 level

OBQ-44 accounted for an additional 10.43% of post-treatment Y-BOCS variance, though this change was not significant (p ≤ 0.25). When the model was restricted to only the two significant predictors (pre-treatment Y-BOCS and ASI-P), ASI-P accounted for an additional 3.72% of the variance of post-treatment Y-BOCS compared to a model with only pre-treatment Y-BOCS as a predictor. As the final step of the hierarchical regression, variables were centered around their means and interactions between each of the three dimensions of the ASI-3 and OBQ-44 were added to the model, resulting in nine interactions in total. Of the tested interactions, the two-way interaction between ASI-P and OBQ-IC was found to be significant, B = 0.03, p ≤ 0.01. All other interactions failed to reach significance, all ps > 0.05. The addition of the interaction between ASI-P and OBQ-I/C accounted for 11.53% of the variance, a significant improvement when all other interactions were removed, p ≤ 0.01. In order to explore the interaction between OBQ-I/C and ASI-P, all non-significant predictors and interactions were dropped from the model and simple slope analysis was used with OBQ-I/C centered one standard deviation above the mean. At higher levels of OBQ-I/C, higher pre-treatment ASI-P significantly predicted higher post-treatment Y-BOCS scores, B = 0.52, p = 0.001 (Fig. 1).

Discussion The purpose of this study was to examine AS and obsessive beliefs as joint predictors of post-treatment symptom levels when controlling for pre-treatment symptom severity. Our prediction of a main effect of AS in the prediction of post-treatment O-C symptom severity was only partially supported. Clinical outcomes were significantly predicted by ASI-P but not by ASI-S or ASI-C. The results may be best understood in the context of exposure and response

Author's personal copy J Cogn Ther Table 3 Regression results predicting post-treatment symptom severity on the Y-BOCS Step

Predictors

B

SE

p

95% CI

R2

1

Pre- Y-BOCS

0.64

0.17

< 0.001

0.31 to 0.97

0.20

2

Pre- Y-BOCS

0.64

0.17

< 0.001

0.30 to 0.98

ASI-P

0.33

0.15

0.03

0.04 to 0.62

3*

ASI-C

− 0.15

0.16

0.36

− 0.46 to 0.17

ASI-S

− 0.23

0.18

0.20

− 0.59 to 0.13

OBQ-RT

0.03

0.04

0.54

− 0.06 to 0.11

OBQ-PC

− 0.00

0.05

0.97

− 0.09 to 0.09

OBQ-IC

− 0.02

0.06

0.77

− 0.13 to 0.10

Pre- Y-BOCS

0.48

0.17

0.01

0.14 to 0.82

ASI-P

0.40

0.15

0.01

0.09 to 0.71

ASI-C

− 0.17

0.17

0.32

− 0.50 to 0.16

ASI-S

− 0.39

0.18

0.04

− 0.75 to − 0.02

OBQ-RT

0.00

0.05

0.97

− 0.10 to 0.11

OBQ-PC

0.03

0.05

0.49

− 0.07 to 0.13

OBQ-IC

− 0.03

0.06

0.63

− 0.15 to 0.09

ASI-P × OBQ-RT

− 0.01

0.01

0.11

− 0.03 to 0.00

ASI-P × OBQ-PC

0.00

0.01

0.60

− 0.01 to 0.02

ASI-P × OBQ-IC

0.03

0.01

0.01

0.01 to 0.05

ASI-C × OBQ-RT

− 0.01

0.01

0.46

− 0.02 to 0.01

ASI-C × OBQ-PC

− 0.00

0.01

0.61

− 0.02 to 0.01

ASI-C × OBQ-IC

0.01

0.01

0.42

− 0.01 to 0.03

ASI-S × OBQ-RT

0.00

0.01

0.63

− 0.01 to 0.02

ASI-S × OBQ-PC

− 0.00

0.01

0.64

− 0.03 to 0.02

ASI-S × OBQ-IC

− 0.01

0.02

0.74

− 0.04 to 0.03

ΔR2

0.10

0.20

Y-BOCS Yale-Brown Obsessive Compulsive Scale, ASI-P Anxiety Sensitive Index-3, Physical dimension, ASI-C Anxiety Sensitive Index-3, Cognitive dimension, ASI-S Anxiety Sensitive Index-3, Social dimension, OBQ-RT Obsessive Beliefs Questionnaire-44, Responsibility/Threat dimension, OBQ-PC Obsessive Beliefs Questionnaire-44, Perfectionism/Certainty dimension, OBQ-IC Obsessive Beliefs Questionnaire-44, Importance of Thoughts/Control of Thoughts dimension *Variables have been centered around their means to ease interpretation

prevention, an exercise in CBT for OCD that directly heightens anxiety. Previously, it has been theorized that AS may impede engagement in exposure exercises by augmenting the anxiety caused by exposure (Blakey and Abramowitz 2018). The ASI-P domain in particular is relevant for exposure exercises, as it might lead participants to interpret the physical sensations of anxiety induced by the exposure as further proof of impending danger caused by the exposure (Blakey and Abramowitz 2017). For example, a client with fears of contamination and high ASI-P may interpret the physical signs of anxiety during exposure to contaminants as symptoms of an illness. The subsequent increase of anxiety may be too much for clients to contend with, leading to a decreased engagement in therapy and higher post-treatment symptom severity.

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Fig. 1 Estimation of the coefficients of ASI-P by values of OBQ-I/C in simplified model containing only pretreatment Y-BOCS, ASI-P, OBQ-IC, and ASI-P × OBQ-IC interaction

In addition to a significant main effect of ASI-P, a significant interaction was demonstrated between ASI-P and OBQ-I/C, such that strong OBQ-I/C augmented the effects of ASI-P on post-treatment symptom severity. An example of this type of moderation was provided by Blakey and Abramowitz (2018), in which a client with ego-dystonic intrusive thoughts related to pedophilia and high ASI-P may interpret physical symptoms of anxiety during exposures as signs of sexual arousal, thus confirming his or her belief that the intrusive thought is significant and must be controlled. The I/C belief is unique among the other OBQ domains in that it is metacognitive in nature (Myers et al. 2008; OCCWG 1997). Both AS and I/C are similar in that, unlike R/T or P/C, the object of fear is not an external threat but rather the inability to control the mind or the body’s reactions and the danger that this lack of control might entail. The combination of high AS-P and I/C might therefore lead participants to believe that momentarily increasing anxiety in therapeutic tasks would lead to consequences too great to risk. While the interaction between AS-P and I/C was significant, the main effects of the OBQ dimensions failed to reach significance. This is counter to previously reported findings in which baseline OBQ-RT predicted post-treatment symptom severity (Adams et al. 2012), though the results are in keeping with other studies that failed to identify baseline OBQ scores as significant predictors of post-treatment clinically significant change (Kyrios et al. 2015). The present findings provide a possible explanation for the somewhat contradictory nature of the existing research literature. Based on the results of this study, baseline obsessive beliefs can predict post-treatment symptom severity, but only in the presence of high AS. Differing levels of AS and other potential moderators of obsessive beliefs could explain previous inconsistent findings. The findings of this study may have clinical implications for the tailoring of CBT for OCD to enhance its effectiveness. For clients with high pre-treatment I/C beliefs, such as those who experience disturbing thoughts or images that they deem to be unacceptable (Wu and Carter 2008), therapy might be augmented with interventions designed to

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target AS-P, such as interoceptive exposure (Blakey and Abramowitz 2018; Timpano et al. 2016). For example, before embarking on traditional exposures for OCD, clients might induce sensations associated with anxiety in order to observe that anxious stimulation is not dangerous nor does it have significant implications. After the initial interoceptive exposures and decrease in AS, clients may then be more ready to engage in traditional exposure therapy. On the other hand, for clients without high I/C beliefs, interoceptive exposure in addition to traditional CBT may not be necessary. Equally, given that higher I/C beliefs potentiate the effect of ASI-P on outcome, clients with I/C beliefs and high ASI-P may benefit from additional focus on the cognitive restructuring of their O-C appraisals through CBT techniques (e.g., Clark 2007; Whittal and McLean 1999) in order to decrease the strength of their I/C beliefs. There are several limitations to the present study. Not all participants were assessed using standardized structured diagnostic interviews. However, the psychiatrists completing the initial psychiatric consultation were employed in a large university-affiliated center specializing in mood, anxiety, and obsessive-compulsive disorders, with clinical approaches that had been honed for over two decades. Furthermore, diagnosis had been verified for roughly one third of participants using a structured diagnostic interview. Information on diagnostic comorbidity was not collected, creating the possibility that the results are further moderated by the presence of additional, unmeasured diagnoses. Another potential limitation is that all measures used in this study were self-report in nature and thus relationships between measures may have been influenced by a common reporting style. Despite this limitation, all the measures used were wellvalidated and have been frequently used in the research literature. Future research directions include replicating the study with a larger sample that has been uniformly assessed for comorbid diagnoses. Future research can also include more measurements of symptom severity throughout treatment and after termination in order to allow for mediation analysis. Finally, future research can expand the participant sample to include those with anxiety disorders in order to determine if the significant interaction described in the results is specific to OCD. In conclusion, based on the results of this study, the ability of AS to predict symptom outcome in individuals with OCD is dependent on the presence of obsessive beliefs. Individuals with high AS-P and high I/C completed treatment with higher symptom severity. These results have important implications for future augmentations of CBT for OCD. Acknowledgments and Michelle Li.

We would like to acknowledge the contributions of Jane Yating Ding, Argie Gingoyon,

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