Journal Mobile Options
Table of Contents
Vol. 46, No. 6, 2013
Issue release date: October 2013
Psychopathology 2013;46:365-376

Symptom Dimensions in Obsessive-Compulsive Disorder: Phenomenology and Treatment Outcomes with Exposure and Ritual Prevention

Williams M.T. · Mugno B. · Franklin M. · Faber S.
aCenter for Mental Health Disparities, Department of Psychological and Brain Sciences, University of Louisville, Louisville, Ky., bDepartment of Psychology, Bryn Mawr College, and cDepartment of Psychiatry, School of Medicine, University of Pennsylvania, Philadelphia, Pa., USA; dBioville GmbH, Leipzig, Germany

Individual Users: Register with Karger Login Information

Please create your User ID & Password

Contact Information

I have read the Karger Terms and Conditions and agree.

To view the fulltext, please log in

To view the pdf, please log in


Background: Obsessive-compulsive disorder (OCD) is a severe condition with varied symptom presentations. Currently, the cognitive-behavioral treatment with the most empirical support is exposure and ritual prevention (EX/RP); however, clinical impression and some empirical data suggest that certain OCD symptoms are more responsive to treatment than others. Methods: Prior work identifying symptom dimensions within OCD is discussed, including epidemiological findings, factor analytic studies, and biological findings. Symptom dimensions most reliably identified include contamination/cleaning, doubt about harm/checking, symmetry/ordering, and unacceptable thoughts/mental rituals. The phenomenology of each of these subtypes is described and research literature is summarized, emphasizing the differential effects of EX/RP and its variants on each of these primary symptom dimensions. Results: To date it appears that EX/RP is an effective treatment for the various OCD dimensions, although not all dimensions have been adequately studied (i.e. symmetry and ordering). Conclusions: Modifications to treatment may be warranted for some types of symptoms. Clinical implications and directions for future research are discussed.

Copyright / Drug Dosage

Copyright: All rights reserved. No part of this publication may be translated into other languages, reproduced or utilized in any form or by any means, electronic or mechanical, including photocopying, recording, microcopying, or by any information storage and retrieval system, without permission in writing from the publisher or, in the case of photocopying, direct payment of a specified fee to the Copyright Clearance Center.
Drug Dosage: The authors and the publisher have exerted every effort to ensure that drug selection and dosage set forth in this text are in accord with current recommendations and practice at the time of publication. However, in view of ongoing research, changes in goverment regulations, and the constant flow of information relating to drug therapy and drug reactions, the reader is urged to check the package insert for each drug for any changes in indications and dosage and for added warnings and precautions. This is particularly important when the recommended agent is a new and/or infrequently employed drug.
Disclaimer: The statements, opinions and data contained in this publication are solely those of the individual authors and contributors and not of the publishers and the editor(s). The appearance of advertisements or/and product references in the publication is not a warranty, endorsement, or approval of the products or services advertised or of their effectiveness, quality or safety. The publisher and the editor(s) disclaim responsibility for any injury to persons or property resulting from any ideas, methods, instructions or products referred to in the content or advertisements.


  1. Sussman N: Obsessive-compulsive disorder: a commonly missed diagnosis in primary care. Prim Psychiatry 2003;10:14.
  2. Ruscio A, Stein D, Chiu W, Kessler R: The epidemiology of obsessive-compulsive disorder in the National Comorbidity Survey Replication. Mol Psychiatry 2010;15:53-63.
  3. Goodman W, Price LH, Rasmussen SA, Mazure C, Fleischmann RL, Hill CL, Charney D: The Yale-Brown Obsessive Compulsive Scale Part I. Development, use and reliability. Arch Gen Psychiatry 1989;46:1006-1011.
  4. Baer L: Factor analysis of symptom subtypes of obsessive-compulsive disorder and their relation to personality and tic disorders. J Clin Psychiatry 1994;55:18-23.

    External Resources

  5. Leckman JF, Grice DE, Boardman J, Zhang H, Vitale A, Bondi C, Alsobrook J, Peterson BS, Cohen DJ, Rasmussen SA, et al: Symptoms of obsessive-compulsive disorder. Am J Psychiatry 1997;154:911-917.

    External Resources

  6. Mataix-Cols D, Rauch S, Manzo P, Jenike M, Baer L: Use of factor-analyzed symptom dimensions to predict outcome with serotonin reuptake inhibitors and placebo in the treatment of obsessive-compulsive disorder. Am J Psychiatry 1999;156:1216-1409.

    External Resources

  7. Abramowitz JS, Franklin ME, Schwartz SA, Furr JM: Symptom presentation and outcome of cognitive-behavioral therapy for obsessive-compulsive disorder. J Consult Clin Psychol 2003;71:1049-1057.
  8. Denys D, de Geus F, van Megen H, Westenberg H: Symptom dimensions in obsessive-compulsive disorder: factor analysis on a clinician-rated scale and self-report measure. Psychopathology 2004;37:181-189.
  9. Pinto A, Eisen J, Mancebo M, Greenberg B, Stout R, Rasmussen S: Taboo thoughts and doubt/checking: a refinement of the factor structure for obsessive-compulsive disorder symptoms. Psychiatry Res 2007;151:255-258.
  10. Pinto A, Greenberg B, Grados M, Bienvenu III O, Samuels J, Murphy D, Shugart Y: Further development of Y-BOCS dimensions in the OCD collaborative genetics study: symptoms versus categories. Psychiatry Res 2008;160:83-93.
  11. Williams MT, Farris SG, Turkheimer E, Pinto A, Ozanick K, Franklin ME, Liebowitz M, Simpson HB, Foa EB: The myth of the pure obsessional type in obsessive-compulsive disorder. Depress Anxiety 2011;28:495-500.
  12. Bloch M, Landeros-Weisenberger A, Rosario M, Pittenger C, Leckman J: Meta-analysis of the symptom structure of obsessive-compulsive disorder. Am J Psychiatry 2008;165:1532-1542.
  13. Abramowitz JS, Deacon BJ, Olatunji BO, Wheaton MG, Berman NC, Losardo D, Timpano KR, McGrath PB, Riemann BC, Adams T, et al: Assessment of obsessive-compulsive symptom dimensions: development and evaluation of the Dimensional Obsessive-Compulsive Scale. Psychol Assess 2010;22:180-198.
  14. Garcia-Soriano G: Pensamientos intrusos obsesiones clinicas: contenidos y significado personal. Servei de Publicaciones 2008.
  15. Garcia-Soriano G, Belloch A, Morillo C, Clark D: Symptom dimensions in obsessive-compulsive disorder: from normal cognitive intrusions to clinical obsessions. J Anxiety Disord 2011;25:474-482.
  16. Viar M, Bilsky S, Armstrong T, Olatunji B: Obsessive beliefs and dimensions of obsessive-compulsive disorder: an examination of specific associations. Cogn Ther Res 2011;35:108-117.
  17. Wheaton M, Abramowitz J, Berman N, Riemann B, Hale L: The relationship between obsessive beliefs and symptom dimensions in obsessive-compulsive disorder. Behav Res Ther 2010;48:949-954.
  18. Lee H, Kwon S: Two different types of obsessions: autogenous obsessions and reactive obsessions. Behav Res Ther 2003;41:11-29.
  19. Besiroglu L, Uguz F, Ozbebit O, Guler O, Cilli A, Askin R: Longitudinal assessment of symptom and subtype categories in obsessive-compulsive disorder. Depress Anxiety 2007;24:461-466.
  20. Moulding R, Kyrios M, Doron G, Nedeljkovic M: Autogenous and reactive obsessions: further evidence for a two factor model of obsessions. J Anxiety Disord 2007;21:677-690.
  21. Taberner J, Fullana M, Caseras X, Pertusa A, Bados A, van den Bree M, Mataix-Cols D: Are obsessive-compulsive symptom dimensions familial in non-clinical individuals? Depress Anxiety 2009;26:902-908.
  22. Hasler G, Pinto A, Greenberg BD, Samuels J, Fyer AJ, Pauls D, Knowles JA, McCracken JT, Piacentini J, Riddle MA, et al: Familiality of factor analysis-derived YBOCS dimensions in OCD-affected sibling pairs from the OCD Collaborative Genetics Study. Biol Psychiatry 2007;61:617-625.
  23. Katerberg H, Delucchi KL, Stewart SE, Lochner C, Denys DA, Stack DE, Andresen JM, Grant JE, Kim SW, Williams KA, et al: Symptom dimensions in OCD: item-level factor analysis and heritability estimates. Behav Genet 2010;40:505-517.
  24. Jenike M, Baer L, Minichiello W, Rauch S, Buttolph M: Placebo-controlled trial of fluoxetine and phenelzine for obsessive-control disorder. Am J Psychiatry 1997;154:1261-1264.

    External Resources

  25. Stein D, Anderson E, Overo K: Response of symptom dimensions in obsessive-compulsive disorder to treatment with citalopram or placebo. Rev Bras Psiquiatr 2007;29:303-307.
  26. Saxena S, Brody A, Maidment K, Baxter L: Paroxetine treatment of compulsive hoarding. J Psychiatr Res 2007;41:481-487.
  27. Alonso P, Menchon JM, Pifarre J, Mataix-Cols D, Torres L, Salgado P, Vallejo J: Long term follow-up and predictors of clinical outcome in obsessive-compulsive patients treated with serotonin reuptake inhibitors and behavioral therapy. J Clin Psychiatry 2001;62:535-540.
  28. Rauch S, Dougherty D, Shin L, Alpert N, Manzo P, Leahy L: Neural correlates of factor-analyzed OCD symptom dimensions: a PET study. CNS Spectr 1998;3:37-43.
  29. Mataix-Cols D, Woodersons S, Lawrence N, Brammer M, Speckens A, Phillips M: Distinct neural correlates of washing, checking, and hoarding symptom dimensions in obsessive-compulsive disorder. Arch Gen Psychiatry 2004;61:564-576.
  30. Van den Heuvel O, Remijnse P, Mataix-Cols D, Vrenken H, Groenewegen H, Uylings H, Veltman D: The major symptom dimensions of obsessive-compulsive disorder are mediated by partially distinct neural systems. Brain 2009;132:853-868.
  31. Alonso P, Gratacos M, Segalas C, Escaramis G, Real E, Bayes M, Labad J, Pertusa A, Vallejo J, Estivill X, et al: Variants in estrogen receptor alpha gene are associated with phenotypical expression of obsessive-compulsive disorder. Psychoneuroendocrinology 2011;36:473-483.
  32. Taylor S, Jang KL: Biopsychosocial etiology of obsessions and compulsions: an integrated behavioral-genetic and cognitive-behavioral analysis. J Abnorm Psychol 2011;120:174-186.
  33. Taylor S, Jang KL, Asmundson GG: Etiology of obsessions and compulsions: a behavioral-genetic analysis. J Abnorm Psychol 2010;119:672-682.
  34. Taylor S: Molecular genetics of obsessive-compulsive disorder: a comprehensive meta-analysis of genetic association studies. Mol Psychiatry, E-pub ahead of print.
  35. Meyer V: Modification of expectations in cases with obsessional rituals. Behav Res Ther 1966;4:273-280.
  36. March J, Frances A, Kahn D, Carpenter D: The expert consensus guideline series: treatment of obsessive-compulsive disorder. J Clin Psychiatry 1997;58:1-72.
  37. NCCMH: Obsessive-compulsive disorder: core interventions in the treatment of obsessive-compulsive disorder and body dysmorphic disorder. London, British Psychological Society and Royal College of Psychiatrists, 2006.

    External Resources

  38. Franklin M, Abramowitz J, Levitt J, Foa E: Effectiveness of exposure and ritual prevention for obsessive-compulsive disorder: randomized compared with non-randomized samples. J Consult Clin Psychol 2000;68:594-602.
  39. Foa E, Yadin E, Lichner T: Exposure and response (ritual) prevention for obsessive-compulsive disorder, ed 2. New York, Oxford University Press, 2012.
  40. Williams M, Powers M, Foa E: Psychological treatment for obsessive-compulsive disorder; in: Handbook of Evidence-Based Practice in Clinical Psychology. Vol II. Adult Disorders. New York, Wiley, 2012.
  41. Sookman D, Abramowitz JS, Calamari JE, Wilhelm S, McKay D: Subtypes of obsessive-compulsive disorder: implications for specialized cognitive behavior therapy. Behav Ther 2005;36:393-400.
  42. Salkovskis P: Cognitive-behavioral factors and the persistence of intrusive thoughts in obsessional problems. Behav Res Ther 1989;27:677-682.
  43. Leckman JF, Denys D, Simpson HB, Mataix-Cols D, Hollander E, Saxena S, Miguel EC, Rauch SL, Goodman WK, Phillips KA, et al: Obsessive-compulsive disorder: a review of the diagnostic criteria and possible subtypes and dimensional specifiers for DSM-V. Depress Anxiety 2010;27:507-527.
  44. Mataix-Cols D, Frost RO, Pertusa A, Clark LA, Saxena S, Leckman JF, Stein DJ, Matsunaga H, Wilhelm S: Hoarding disorder: a new diagnosis for DSM-V? Depress Anxiety 2010;27:556-572.
  45. Ball SG, Baer L, Otto M: Symptom subtypes of obsessive-compulsive disorder in behavioral treatment studies: a quantitative review. Behav Res Ther 1996;34:47-51.
  46. Radomsky A, Rachman S: Symmetry, ordering and arranging compulsive behavior. Behav Res Ther 2004;42:893-913.
  47. Feinstein S, Fallon B, Petkova E, Leibowitz M: Item-by-item factor analysis of the Yale-Brown Obsessive Compulsive Scale Symptom Checklist. J Neuropsychiatry Clin Neurosci 2003;15:187-193.
  48. Foa E, Goldstein A: Continuous exposure and complete response prevention of obsessive-compulsive disorder. Behav Ther 1978;9:821-829.
  49. Foa E, Kozak M, Steketee G, McCarthy P: Treatment of depressive and obsessive-compulsive symptoms in OCD by imipramine and behaviour therapy. J Clin Psychol 1992;31:279-292.
  50. De Araujo L, Ito L, Marks I, Deale A: Does imagined exposure to the consequences of not ritualising enhance live exposure for OCD? A controlled study. Br J Psychiatry 1995;167:18165-70189.
  51. McLean PD, Whittal ML, Thordarson DS, Taylor S, Sochting I, Koch WJ, Paterson R, Anderson KW: Cognitive versus behavior therapy in the group treatment of obsessive-compulsive disorder. J Consult Clin Psychol 2001;69:205-214.
  52. Greist JH, Marks IM, Baer L, Kobak KA, Wenzel KW, Hirsch MJ, Mantle JM, Clary CM: Behavior therapy for obsessive-compulsive disorder guided by a computer or by a clinician compared with relaxation as control. J Clin Psychiatry 2002;63:138-145.
  53. Foa E, Steketee G, Grayson J, Turner R, Latimer P: Deliberate exposure and blocking of obsessive-compulsive rituals: immediate and long-term effects. Behav Ther 1984;15:450-472.
  54. Jones M, Menzies R: Danger ideation reduction therapy (DIRT) for obsessive-compulsive washers. A controlled trial. Behav Res Ther 1998;36:959-970.
  55. Krochmalik A, Jones M, Menzies R, Kirkby K: The superiority of danger ideation reduction therapy (DIRT) over exposure and response prevention (ERP) in treating compulsive washing. Behav Change 2004;21:251-268.
  56. Smits J, Talch M, Randall P: An examination of the decline in fear and disgust during exposure-based treatment. Behav Res Ther 2002;40:1243-1253.
  57. Olatunji B, Wolitzky-Taylor K, Willems J, Lohr J, Armstrong T: Differrential habituation of fear and disgust during exposure to threat-relevant stimuli in contamination-based OCD: an analogue study. J Anxiety Disord 2009;23:118-123.
  58. McKay D: Treating disgust reactions in contamination-based obsessive-compulsive disorder. J Behav Ther Exp Psychiatry 2006;37:53-59.
  59. McKay D, Abramowitz J, Calamari J, Kyrios M, Radomsky A, Sookman D, Wilhelm S: A critical evaluation of obsessive-compulsive disorder subtypes: symptoms versus mechanisms. Clin Psychol Rev 2004;24:283-313.
  60. Shafran R, Thordarson DS, Rachman S: Thought-action fusion in obsessive-compulsive disorder. J Anxiety Disord 1996;10:379-391.
  61. Woods C, Vevea J, Chambless D, Bayen U: Are compulsive checkers impaired in memory? A meta-analytic review. Clin Psychol 2002;9:353-366.
  62. Rachman S: A cognitive theory of compulsive checking. Behav Res Ther 2002;40:625-639.
  63. Boschen MJ, Vuksavonic D: Deteriorating memory confidence, responsibility perceptions and repeated checking: comparisons in OCD and control samples. Behav Res Ther 2007;45:2098-2109.
  64. Whiteside S, Abramowitz J: The expression of anger and its relationship to symptoms and cognitions in obsessive-compulsive disorder. Depress Anxiety 2005;21:106-111.
  65. Radomsky A, Ashbaugha A, Gelfand L: Relationships between anger, symptoms, and cognitive factors in OCD checkers. Behav Res Ther 2007;45:2712-2725.
  66. Foa E, Huppert E, Leiberg S, Langner R, Kichic R, Hajcak G, Salkovskis P: The obsessive-compulsive inventory: development and validation of a short version. Psychol Assess 2002;14:485-496.
  67. Cromer K, Schmidt N, Murphy D: An investigation of traumatic life events and obsessive-compulsive disorder. Behav Res Ther 2007;45:1683-1691.
  68. Basoglu M, Lax T, Kavikis Y, Marks I: Predictors of improvement in obsessive-compulsive disorder. J Anxiety Disord 1988;2:299-317.
  69. Drummond L: The treatment of severe, chronic, resistant obsessive-compulsive disorder: an evaluation of an in-patient program using behavioral psychotherapy in combination with other treatments. Br J Psychiatry 1993;163:223-229.
  70. Foa E, Kozak M, Goodman W, Hollander E, Jenike M, Rasmussen S: DSM-IV field trial: obsessive-compulsive disorder. Am J Psychiatry 1995;152:90-96.

    External Resources

  71. Ghisi M, Chiri L, Marchetti I, Sanavio E, Sica C: In search of specificity: ʼnot just right experiencesʼ and obsessive-compulsive symptoms in non-clinical and clinical Italian individuals. J Anxiety Disord 2010;24:879-886.
  72. OCCW Group: Psychometric validation of the Obsessive Beliefs Questionnaire and the Interpretation of Intrusions Inventory. Part 1. Behav Res Ther 2003;41:1245-1264.
  73. Rachman S: A cognitive theory of obsessions: elaborations. Behav Res Ther 1998;36:385-401.
  74. Williams M, Farris S: Sexual orientation obsessions in obsessive-compulsive disorder: prevalence and correlates. Psychiatry Res 2011;187:156-159.
  75. Grant J, Pinto A, Gunnip B, Mancebo M, Eisen J, Rasmussen S: Sexual obsessions and clinical correlates in adults with obsessive-compulsive disorder. Compr Psychiatry 2006;47:325-329
  76. Rufer M, Fricke S, Moritz S, Kloss M, Hand I: Symptom dimensions in obsessive-compulsive disorder: prediction of cognitive-behavior therapy outcome. Acta Psychiatr Scand 2006;113:440-446.
  77. Mataiz-Cols D, Marks I, Greist J, Kobak KA, Baer L: Obsessive-compulsive symptom dimensions as predictors of compliance with and response to behaviour therapy: results from a controlled trial. Psychother Psychosom 2002;71:255-262.
  78. Gillihan S, Williams MT, Malcoun E, Yadin E, Foa EB: Common pitfalls in exposure and ritual prevention (EX/RP) for obsessive-compulsive disorder. J Obsessive Compuls Relat Disord 2012;14:251-257.
  79. Freeston M, Ladouceur R, Gagnon F, Thibodeau N, Rheaume J, Letarte H, Bujold A: Cognitive-behavioral treatment of obsessive thoughts: a controlled study. J Consult Clin Psychol 1997;653:405-413.
  80. Freeston K, Leger E, Ladouceur R: Cognitive therapy of obsessive thoughts. Cogn Behav Pract 2001;8:61-78.
  81. Abramowitz J, Zoellner L: Cognitive-behavior therapy as an adjunct to medication for obsessive-compulsive disorder with mental rituals: a pilot study. J Cogn Behav Psychother 2002;2:11-22.
  82. Whittal M, McLean P, Woody S, Rachman S, Robichaud M: Treatment of obsessions: a randomized controlled trial. Behav Res Ther 2010;48:295-303.
  83. Summerfeldt L: Understanding and treating incompleteness in obsessive-compulsive disorder. J Clin Psychol 2004;60:1155-1168.
  84. Calamari J, Cohen R, Rector N, Szacun-Shimizu K, Riemann B, Norberg M: Dysfunctional belief-based obsessive-compulsive disorder subgroups. Behav Res Ther 2006;44:1347-1360.
  85. Taylor S, Abramowitz J, McKay D, Calamari J, Sookman D, Kyrios M, Wilhelm S, Carmin C: Do dysfunctional beliefs play a role in all types of obsessive-compulsive disorder? J Anxiety Disord 2006;20:85-97.
  86. Grabe H, Goldschmidt F, Lehmkuhl L, Gänsicke M, Spitzer C, Freyberger H: Dissociative symptoms in patients with obsessive-compulsive disorder. Psychopathology 1999;32:319-324.
  87. Hasler G, LaSalle-Ricci VH, Ronquillo JG, Crawley SA, Cochran LW, Kazuba D, Greenberg BD, Murphy DL: Obsessive-compulsive disorder symptom dimensions. Biol Psychiatry 2005;135:121-132.
  88. Albert U, Maina G, Forner F, Bogetto F: DSM-IV obsessive-compulsive personality disorder: prevalence in patients with anxiety disorders and in healthy comparison subjects. Compr Psychiatry 2004;45:325-332.
  89. Garyfallos G, Katsigiannopoulos K, Adamopoulou A, Papazisis G, Karastergiou A, Bozikas V: Comorbidity of obsessive-compulsive disorder with obsessive-compulsive personality disorder: does it imply a specific subtype of obsessive-compulsive disorder? Psychiatry Res 2010;177:156-160.
  90. Pinto A, Mancebo M, Eisen J, Pagano M, Rasmussen S: The Brown Longitudinal Obsessive-Compulsive Study: clinical features and symptoms of the sample of intake. J Clin Psychiatry 2006;67:703-711.
  91. Samuels J, Eaton W, Bienvenu IO, Brown C, Costa JP, Nestadt G: Prevalence and correlates of personality disorders in a community sample. Br J Psychiatry 2002;180:536-542.
  92. Eisen JL, Coles ME, Shea MT, Pagano ME, Stout RL, Yen S, Grilo CM, Rasmussen SA: Clarifying the convergence between obsessive-compulsive personality disorder criteria and obsessive-compulsive disorder. J Pers Disord 2006;20:294-305.
  93. Alonso P, Segalas C, Real E, Pertusa A, Labad J, Jimenez-Murcia S, Jaurrieta N, Bueno B, Vallejo J, Menchon JM: Suicide in patients treated for obsessive-compulsive disorder: a prospective follow-up study. J Affect Disord 2010;124:300-308.
  94. Daniel S, Goldston D, Erklani A, Franklin J, Mayfield A: Trait anger, anger expression, and suicide attempts among adolescents and young adults: a prospective study. J Clin Child Adolesc Psychol 2009;38:661-671.
  95. Rufer M, Grothusen A, Mass R, Peter H, Hand I: Temporal stability of symptom dimensions in adult patients with obsessive-compulsive disorder in the National Survey Comorbidity Survey Replication. J Affect Disord 2005;88:99-102.
  96. Mataix-Cols D, Rosario-Campos M, Leckman J: A multidimensional model of obsessive-compulsive disorder. Am J Psychiatry 2005;162:228-238.
  97. Leckman J, Grice D, Barr L, de Vries A, Martin C, Cohen D, McDougle C, Goodman W, Rasmussen S: Tic-related versus non-tic-related obsessive compulsive disorder. Anxiety 1995;1:208-221.

    External Resources

Pay-per-View Options
Direct payment This item at the regular price: USD 38.00
Payment from account With a Karger Pay-per-View account (down payment USD 150) you profit from a special rate for this and other single items.
This item at the discounted price: USD 26.50