Common Rituals in Obsessive–Compulsive Disorder and Implications for Treatment

Rituals are behaviors that OCD sufferers engage in to try to reduce anxiety, distress, or prevent some feared outcome related to their obsessive thoughts. Common rituals include excessive washing or cleaning, repeating actions, checking things repeatedly, ordering items, counting, seeking reassurance, etc.

Rituals are time-consuming and interfere significantly with daily activities or functioning. People may spend hours each day engaged in rituals. People with OCD typically recognize the irrational or excessive nature of the rituals but feel unable to control or resist the intense urge to perform them.

Rituals provide temporary relief from anxiety, but the obsessions and distress soon return. This drives the vicious cycle of ongoing ritualizing behavior.

Rituals prevent new learning and reinforce OCD beliefs. Avoiding triggers maintains fears rather than allowing opportunities to disconfirm them.

Pinciotti, C. M., Bulkes, N. Z., Bailey, B. E., Storch, E. A., Abramowitz, J. S., Fontenelle, L. F., & Riemann, B. C. (2023). Common rituals in obsessive–compulsive disorder and implications for treatment: A mixed-methods study. Psychological Assessment, 35(9), 763–777. https://doi.org/10.1037/pas0001254

Rationale

Prior research demonstrates that compulsions are functionally distinct from obsessions in OCD and drive much of the impairment associated with the disorder (Abramowitz et al., 2003; Storch et al., 2008).

However, common assessment measures often combine obsessions and compulsions into overarching content dimensions (e.g., contamination, religious; Storch et al., 2010).

This conflation provides a limited understanding of the heterogeneous nature of rituals, their patterns of co-occurrence, and their ability to predict outcomes (Leckman et al., 2010; Subira et al., 2015) differentially.

Cluster analysis allows the examination of interrelationships among rituals that may better inform treatment planning compared to a singular focus on content (Rufer et al., 2005).

Further, identifying poor prognostic factors upfront, such as certain hard-to-treat ritual subgroups, can lead to improved care delivery and outcomes for those patients (Jakubovski et al., 2013).

This study aimed to address gaps in research by using mixed qualitative and quantitative methods to categorize OCD rituals beyond existing measures, examine common co-occurrences, and determine their impact on symptom trajectories and treatment response.

Method

• Retrospective cohort design using 641 adults with OCD receiving intensive treatment
• Extraction of rituals from patient records, coding into categories
• Validation against Y-BOCS compulsions
• Cluster analysis of rituals
• Regressions for severity and treatment outcomes

Sample

• 85.8% white, 52.1% assigned female at birth, predominately cisgender adults, mean age 29 years
• 100% had provider-identified rituals, 67% had overlap with rituals on Y-BOCS
• Received intensive OCD treatment in residential or partial hospitalization

Statistical Analysis

• Agglomerative hierarchical cluster analysis with complete linkage
• Multivariate linear regressions for admission variables, discharge variables, and length of stay

Results

• Identified 62 rituals extending beyond Y-BOCS, moderate validity with Y-BOCS.
• 8 clusters: avoidance, reassurance, checking, cleaning/handwashing, just right, rumination, self-assurance, and other.
• Reassurance is associated with uncertainty, rumination, and OCD severity.
• Just right predicted uncertainty at discharge, 7 more treatment days.

Insight

• Compulsions are functionally distinct and not interchangeable, warranting nuanced rather than umbrella approaches.
• Highlights limitations of predetermined compulsions checklists.

Strengths

• Novel mixed methodology and analytic approach
• Large clinical sample receiving gold standard ERP treatment
• Examined both admission and discharge variables

Limitations

• Sample lacked diversity, limiting generalizability
• Nonstandardized identification/documentation of rituals
• Unable to confirm if rituals tied specifically to OCD vs. comorbidities

Implications

Using mixed methods identifies more nuanced compulsions

• Self-report measures like the YBOCS provide a helpful starting point to identify rituals, but are inherently limited in scope.
• Clinical observation picks up on individualized or atypical rituals not represented on standard checklists. This allows treatment to target the most relevant behaviors.
• For example, a patient with primarily mental rituals like counting or repeating phrases may not endorse any overt compulsions on the YBOCS. Observation ensures these hidden rituals are identified and included in the exposure hierarchy.
• Asking about rituals through open dialogue versus checklists also promotes insight building into the full range of compulsive behaviors.

Tailoring treatment for ritual profiles

• The study highlights that those with just right/incompleteness rituals benefitted less from the standard ERP approach.
• Exposure tasks could be designed around violating the desire for perfection or symmetry rather than a fear of harm. Specialized ERP may help overcome the unique uncertainty brought on by “not just right” feelings.
• Similarly, adapting exposures for predominant mental rituals may increase compliance versus behavioral rituals that are easier to monitor.

Assessing linked uncertainty

• Uncertainty drives the majority of compulsive rituals, but the nature and focus likely differ across ritual clusters.
• Tailoring ERP based on the idiosyncratic uncertainty profile for each patient’s rituals can enhance effectiveness.
• For example, trigger uncertainty over imperfect symmetry for just right rituals versus uncertainty over causing harm for checking compulsions.

Keep Learning

1. What implications would using a mixed methodology and more nuanced approach to identifying rituals in OCD have for improving patient outcomes in a clinical practice? How could practitioners practically implement this in assessment, case conceptualization, and treatment delivery? What challenges might they face?
2. How could treatment for OCD patients presenting with primarily just right rituals be adapted to better meet their needs? What are some examples of exposures and response prevention techniques tailored for just right experiences?
3. What are some of the risks or downsides of conceptualizing obsessive-compulsive disorder too narrowly based only on commonly used measures? How might this impact not only research but the individuals seeking treatment?
4. This study lacked diversity among participants. What impact could this have on the findings and their generalizability? How might compulsions manifest differently across gender, racial, or cultural backgrounds? What steps could researchers and clinicians take to make sure people from marginalized groups are adequately represented?

References

Primary paper

Pinciotti, C. M., Bulkes, N. Z., Bailey, B. E., Storch, E. A., Abramowitz, J. S., Fontenelle, L. F., & Riemann, B. C. (2023). Common rituals in obsessive–compulsive disorder and implications for treatment: A mixed-methods study. Psychological Assessment, 35(9), 763–777. https://doi.org/10.1037/pas0001254

Other references

Abramowitz, J. S., Franklin, M. E., Schwartz, S. A., & Furr, J. M. (2003). Symptom presentation and outcome of cognitive-behavioral therapy for obsessive-compulsive disorder. Journal of Consulting and Clinical Psychology, 71(6), 1049–1057. https://doi.org/10.1037/0022-006X.71.6.1049

Jakubovski, E., Diniz, J. B., Valerio, C., Fossaluza, V., Belotto-Silva, C., Gorenstein, C., Shavitt, R. G., & Miguel, E. C. (2013). Clinical predictors of long-term outcome in obsessive-compulsive disorder. Depression and Anxiety, 30(8), 763–772. https://doi.org/10.1002/da.22129

Leckman, J. F., Rauch, S. L., & Mataix-Cols, D. (2010). Symptom dimensions in obsessive-compulsive disorder. CNS Spectrums, 12(5), 376–387. https://doi.org/10.1017/S1092852900023904

Rufer, M., Fricke, S., Moritz, S., Kloss, M., & Hand, I. (2006). Symptom dimensions in obsessive-compulsive disorder: Prediction of cognitive-behavior therapy outcome. Acta Psychiatrica Scandinavica, 113(5), 440–446. https://doi.org/10.1111/j.1600-0447.2005.00682.x

Storch, E. A., Abramowitz, J. S., & Goodman, W. K. (2008). Where does obsessive-compulsive disorder belong in DSM-V? Depression and Anxiety, 25(4), 336–347. https://doi.org/10.1002/da.20488

Storch, E. A., Merlo, L. J., Larson, M. J., Marien, W. E., Geffken, G. R., Jacob, M. L., Murphy, T. K., & Goodman, W. K. (2010). Clinical features associated with treatment-resistant pediatric obsessive-compulsive disorder. Comprehensive Psychiatry, 51(1), 35–42. https://doi.org/10.1016/j.comppsych.2009.02.004

Subira, M., Alonso, P., Segalàs, C., Real, E., López-Solà, C., Mas, S., Jiménez-Murcia, S., Bueno, B., Fernández-Aranda, F., & Menchón, J. M. (2015). A cluster analysis to find clinical phenotypes in obsessive-compulsive disorder: Results from a large family study. The Canadian Journal of Psychiatry, 60(9), 387–396. https://doi.org/10.1177/070674371506000904