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Obsessive Compulsive Disorder and Thought Action Fusion: Relationships with Eating Disorder OutcomesEric B. LeeJennifer L. BarneyMichael P. TwohigUtah State UniversityTera Lensegrav-BensonBenita QuakenbushAvalon Hills Residential Treatment FacilityAuthor NoteCorrespondence concerning this article should be addressed to Jennifer L. Barney, Department of Psychology, Utah State University, 2810 Old Main Hill, Logan, UT 84322-2810. E-mail address: jen.barney4@aggiemail.usu.edu; Telephone: 860-918-8701AbstractObsessive Compulsive Disorder (OCD) is among the most common psychiatric comorbidities with eating disorders (EDs) and most studies have only examined this relationship at a diagnostic level. More research is needed to determine whether specific symptom domains and cognitive patterns commonly observed in OCD are most salient among individuals with clinically significant EDs, and whether these symptoms appear to change and/or influence treatment outcomes. Thought Action Fusion (TAF) is one cognitive pattern that may underlie OCD-ED comorbidity. The current study assessed 112 adolescent and adult female patients at a residential ED treatment facility on levels of ED severity, OCD symptom severity, and TAF at pre- and post-treatment. All OCD symptom dimensions were positively correlated with ED severity at pretreatment, with Obsessing, Neutralizing and Ordering OCD symptoms being most elevated. TAF was also positively correlated with ED severity at pre-treatment, and higher levels of TAF at pretreatment significantly predicted greater ED severity at post-treatment after controlling for all other OCD symptoms. Improvements in TAF specific to thoughts about others also predicted improvements in ED severity after controlling for changes in OCD symptoms. Clinically, these results indicate that efforts targeting specific OCD symptom dimensions and TAF in addition to ED-focused treatment as usual may be beneficial for enhancing overall treatment outcomes. Key Words: Eating Disorders; Treatment; Obsessive Compulsive Disorder; Comorbidity; Thought Action FusionObsessive Compulsive Disorder and Thought Action Fusion: Relationships with Eating Disorder OutcomesPsychiatric comorbidities are incredibly common among individuals with eating disorders (EDs), with current research indicating that between 43% and 95% of individuals also meet criteria for at least one other psychiatric illness at the time of their ED diagnosis PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5HcmlsbzwvQXV0aG9yPjxZZWFyPjIwMDk8L1llYXI+PFJl
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ADDIN EN.CITE.DATA (Blinder, Cumella, & Sanathara, 2006; Grilo, White, & Masheb, 2009; Ulfvebrand, Birgeg?rd, Norring, H?gdahl, & von Hausswolff-Juhlin, 2015). While several mood disorders, anxiety disorders, and substance-related disorders have shown increased prevalence among individuals diagnosed with an ED at some point in their lifetime ADDIN EN.CITE <EndNote><Cite><Author>Ulfvebrand</Author><Year>2015</Year><RecNum>2</RecNum><DisplayText>(Ulfvebrand et al., 2015)</DisplayText><record><rec-number>2</rec-number><foreign-keys><key app="EN" db-id="w9zzfxep7efxxhe9ts7pszafwz5eppr0tdwr" timestamp="1577413866">2</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Ulfvebrand, Sara</author><author>Birgeg?rd, Andreas</author><author>Norring, Claes</author><author>H?gdahl, Louise</author><author>von Hausswolff-Juhlin, Yvonne</author></authors></contributors><titles><title>Psychiatric comorbidity in women and men with eating disorders results from a large clinical database</title><secondary-title>Psychiatry research</secondary-title></titles><periodical><full-title>Psychiatry research</full-title></periodical><pages>294-299</pages><volume>230</volume><number>2</number><dates><year>2015</year></dates><isbn>0165-1781</isbn><urls></urls></record></Cite></EndNote>(Ulfvebrand et al., 2015), Obsessive Compulsive Disorder (OCD) has consistently been identified as one of the most commonly occurring comorbidities ADDIN EN.CITE <EndNote><Cite><Author>Godart</Author><Year>2002</Year><RecNum>3</RecNum><DisplayText>(Godart, Flament, Perdereau, & Jeammet, 2002; Ulfvebrand et al., 2015)</DisplayText><record><rec-number>3</rec-number><foreign-keys><key app="EN" db-id="w9zzfxep7efxxhe9ts7pszafwz5eppr0tdwr" timestamp="1577413867">3</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Godart, Nathalie T</author><author>Flament, MF</author><author>Perdereau, F</author><author>Jeammet, P</author></authors></contributors><titles><title>Comorbidity between eating disorders and anxiety disorders: a review</title><secondary-title>International Journal of Eating Disorders</secondary-title></titles><periodical><full-title>International Journal of Eating Disorders</full-title></periodical><pages>253-270</pages><volume>32</volume><number>3</number><dates><year>2002</year></dates><isbn>0276-3478</isbn><urls></urls></record></Cite><Cite><Author>Ulfvebrand</Author><Year>2015</Year><RecNum>2</RecNum><record><rec-number>2</rec-number><foreign-keys><key app="EN" db-id="w9zzfxep7efxxhe9ts7pszafwz5eppr0tdwr" timestamp="1577413866">2</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Ulfvebrand, Sara</author><author>Birgeg?rd, Andreas</author><author>Norring, Claes</author><author>H?gdahl, Louise</author><author>von Hausswolff-Juhlin, Yvonne</author></authors></contributors><titles><title>Psychiatric comorbidity in women and men with eating disorders results from a large clinical database</title><secondary-title>Psychiatry research</secondary-title></titles><periodical><full-title>Psychiatry research</full-title></periodical><pages>294-299</pages><volume>230</volume><number>2</number><dates><year>2015</year></dates><isbn>0165-1781</isbn><urls></urls></record></Cite></EndNote>(Godart, Flament, Perdereau, & Jeammet, 2002; Ulfvebrand et al., 2015). When compared to non-clinical samples, the prevalence of OCD tends to be much higher in samples of individuals with EDs ADDIN EN.CITE <EndNote><Cite><Author>Kaye</Author><Year>2004</Year><RecNum>4</RecNum><Prefix>approximately 1%–-3% vs. approximately 16–%-69% respectively`; </Prefix><DisplayText>(approximately 1%–-3% vs. approximately 16–%-69% respectively; Kaye et al., 2004; Tyagi et al., 2015)</DisplayText><record><rec-number>4</rec-number><foreign-keys><key app="EN" db-id="w9zzfxep7efxxhe9ts7pszafwz5eppr0tdwr" timestamp="1577413867">4</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Kaye, Walter H</author><author>Bulik, Cynthia M</author><author>Thornton, Laura</author><author>Barbarich, Nicole</author><author>Masters, Kim</author><author>Price Foundation Collaborative Group</author></authors></contributors><titles><title>Comorbidity of anxiety disorders with anorexia and bulimia nervosa</title><secondary-title>American Journal of Psychiatry</secondary-title></titles><periodical><full-title>American Journal of Psychiatry</full-title></periodical><pages>2215-2221</pages><volume>161</volume><number>12</number><dates><year>2004</year></dates><isbn>0002-953X</isbn><urls></urls></record></Cite><Cite><Author>Tyagi</Author><Year>2015</Year><RecNum>5</RecNum><record><rec-number>5</rec-number><foreign-keys><key app="EN" db-id="w9zzfxep7efxxhe9ts7pszafwz5eppr0tdwr" timestamp="1577413867">5</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Tyagi, Himanshu</author><author>Patel, Rupal</author><author>Rughooputh, Fabienne</author><author>Abrahams, Hannah</author><author>Watson, Andrew J</author><author>Drummond, Lynne</author></authors></contributors><titles><title>Comparative prevalence of eating disorders in obsessive-compulsive disorder and other anxiety disorders</title><secondary-title>Psychiatry journal</secondary-title></titles><periodical><full-title>Psychiatry journal</full-title></periodical><volume>2015</volume><dates><year>2015</year></dates><isbn>2314-4327</isbn><urls></urls></record></Cite></EndNote>(approximately 1%–-3% vs. approximately 16–%-69% respectively; Kaye et al., 2004; Tyagi et al., 2015).Most studies that have examined the relationship between EDs and OCD have approached it at a diagnostic level, focusing on comorbidity prevalence rates ADDIN EN.CITE <EndNote><Cite><Author>Kaye</Author><Year>2004</Year><RecNum>4</RecNum><Prefix>e.g. </Prefix><DisplayText>(e.g. Kaye et al., 2004; Ulfvebrand et al., 2015)</DisplayText><record><rec-number>4</rec-number><foreign-keys><key app="EN" db-id="w9zzfxep7efxxhe9ts7pszafwz5eppr0tdwr" timestamp="1577413867">4</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Kaye, Walter H</author><author>Bulik, Cynthia M</author><author>Thornton, Laura</author><author>Barbarich, Nicole</author><author>Masters, Kim</author><author>Price Foundation Collaborative Group</author></authors></contributors><titles><title>Comorbidity of anxiety disorders with anorexia and bulimia nervosa</title><secondary-title>American Journal of Psychiatry</secondary-title></titles><periodical><full-title>American Journal of Psychiatry</full-title></periodical><pages>2215-2221</pages><volume>161</volume><number>12</number><dates><year>2004</year></dates><isbn>0002-953X</isbn><urls></urls></record></Cite><Cite><Author>Ulfvebrand</Author><Year>2015</Year><RecNum>2</RecNum><record><rec-number>2</rec-number><foreign-keys><key app="EN" db-id="w9zzfxep7efxxhe9ts7pszafwz5eppr0tdwr" timestamp="1577413866">2</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Ulfvebrand, Sara</author><author>Birgeg?rd, Andreas</author><author>Norring, Claes</author><author>H?gdahl, Louise</author><author>von Hausswolff-Juhlin, Yvonne</author></authors></contributors><titles><title>Psychiatric comorbidity in women and men with eating disorders results from a large clinical database</title><secondary-title>Psychiatry research</secondary-title></titles><periodical><full-title>Psychiatry research</full-title></periodical><pages>294-299</pages><volume>230</volume><number>2</number><dates><year>2015</year></dates><isbn>0165-1781</isbn><urls></urls></record></Cite></EndNote>(e.g. Kaye et al., 2004; Ulfvebrand et al., 2015). The combined results of these studies generally indicate that rates of both anorexia nervosa/OCD and bulimia nervosa/OCD are considerably higher than if they were to occur by chance ADDIN EN.CITE <EndNote><Cite><Author>Altman</Author><Year>2009</Year><RecNum>6</RecNum><DisplayText>(Altman & Shankman, 2009)</DisplayText><record><rec-number>6</rec-number><foreign-keys><key app="EN" db-id="w9zzfxep7efxxhe9ts7pszafwz5eppr0tdwr" timestamp="1577413868">6</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Altman, Sarah E</author><author>Shankman, Stewart A</author></authors></contributors><titles><title>What is the association between obsessive–compulsive disorder and eating disorders?</title><secondary-title>Clinical psychology review</secondary-title></titles><periodical><full-title>Clinical psychology review</full-title></periodical><pages>638-646</pages><volume>29</volume><number>7</number><dates><year>2009</year></dates><isbn>0272-7358</isbn><urls></urls></record></Cite></EndNote>(Altman & Shankman, 2009). Altman & Shankman (2009) summarized the longitudinal study of ED/OCD comorbidity illustrating a pattern of evidence, which largely supports an overlapping underlying etiological relationship between the two. ADDIN EN.CITE <EndNote><Cite AuthorYear="1"><Author>Cederl?f</Author><Year>2015</Year><RecNum>7</RecNum><DisplayText>Cederl?f et al. (2015)</DisplayText><record><rec-number>7</rec-number><foreign-keys><key app="EN" db-id="w9zzfxep7efxxhe9ts7pszafwz5eppr0tdwr" timestamp="1577413868">7</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Cederl?f, Martin</author><author>Thornton, Laura M</author><author>Baker, Jessica</author><author>Lichtenstein, Paul</author><author>Larsson, Henrik</author><author>Rück, Christian</author><author>Bulik, Cynthia M</author><author>Mataix‐Cols, David</author></authors></contributors><titles><title>Etiological overlap between obsessive‐compulsive disorder and anorexia nervosa: a longitudinal cohort, multigenerational family and twin study</title><secondary-title>World Psychiatry</secondary-title></titles><periodical><full-title>World Psychiatry</full-title></periodical><pages>333-338</pages><volume>14</volume><number>3</number><dates><year>2015</year></dates><isbn>1723-8617</isbn><urls></urls></record></Cite></EndNote>Cederl?f et al. (2015) expanded upon this hypothesis, finding that individuals diagnosed with OCD had a 16-37 times greater likelihood of having a comorbid diagnosis of anorexia nervosa. Further, longitudinal analyses indicated that individuals diagnosed with only OCD or anorexia nervosa were at significantly greater risk for developing the other later in life and that first- and second-degree relatives of probands with OCD were significantly more likely of being diagnosed with anorexia, with the magnitude of this risk increasing as the degree of genetic relatedness increased (Cederlof et al., 2015). More recent research has also examined the underlying genetic bases of both disorders and denotes high genetic correlation between anorexia and OCD and significant SNP-based heritability (i.e. estimated heritability based on the genetic and phenotypic variation among unrelated individuals of mixed ethnic backgrounds) for the cross-disorder phenotype ADDIN EN.CITE <EndNote><Cite><Author>Yilmaz</Author><Year>2018</Year><RecNum>34</RecNum><DisplayText>(Yilmaz et al., 2018)</DisplayText><record><rec-number>34</rec-number><foreign-keys><key app="EN" db-id="w9zzfxep7efxxhe9ts7pszafwz5eppr0tdwr" timestamp="1577414017">34</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Yilmaz, Zeynep</author><author>Halvorsen, Matthew</author><author>Bryois, Julien</author><author>Yu, Dongmei</author><author>Thornton, Laura M.</author><author>Zerwas, Stephanie</author><author>Micali, Nadia</author><author>Moessner, Rainald</author><author>Burton, Christie L.</author><author>Zai, Gwyneth</author><author>Erdman, Lauren</author><author>Kas, Martien J.</author><author>Arnold, Paul D.</author><author>Davis, Lea K.</author><author>Knowles, James A.</author><author>Breen, Gerome</author><author>Scharf, Jeremiah M.</author><author>Nestadt, Gerald</author><author>Mathews, Carol A.</author><author>Bulik, Cynthia M.</author><author>Mattheisen, Manuel</author><author>Crowley, James J.</author><author>Eating Disorders Working Group of the Psychiatric Genomics Consortium, Tourette Syndrome Obsessive–Compulsive Disorder Working Group of the Psychiatric Genomics Consortium</author></authors></contributors><titles><title>Examination of the shared genetic basis of anorexia nervosa and obsessive–compulsive disorder</title><secondary-title>Molecular Psychiatry</secondary-title></titles><periodical><full-title>Molecular psychiatry</full-title></periodical><dates><year>2018</year><pub-dates><date>2018/08/07</date></pub-dates></dates><isbn>1476-5578</isbn><urls><related-urls><url>;(Yilmaz et al., 2018). Taken together, this research suggests a strong link between the genetic etiology and maintenance of OCD and EDs, which may have implications for our clinical understanding and treatment of both disorders. While much of the existent data supports a common etiological relationship between EDs and OCD, our understanding of the exact nature of this relationship beyond common genetic markers is much more limited. Thus, research efforts have begun to examine possible commonalities across behavioral, cognitive, personality, and maintenance factors of both EDs and OCD to identify potential core disease processes and/or mechanisms of maintenance (Altman & Shankman, 2009). Overlapping core personality traits have been identified as characteristic of individuals diagnosed with either OCD or an ED such as perfectionism, neuroticism, conscientiousness, and impulsivity PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5BbmRlcmx1aDwvQXV0aG9yPjxZZWFyPjIwMDM8L1llYXI+
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ADDIN EN.CITE.DATA (e.g. Anderluh, Tchanturia, Rabe-Hesketh, & Treasure, 2003; Benatti, Dell’Osso, Arici, Hollander, & Altamura, 2014; Halmi et al., 2005). Neuroticism and perfectionism traits have also been found to mediate associations between OCD checking and cleaning symptoms and eating restraint or binge eating behaviors ADDIN EN.CITE <EndNote><Cite><Author>Pollack</Author><Year>2013</Year><RecNum>12</RecNum><DisplayText>(Pollack & Forbush, 2013)</DisplayText><record><rec-number>12</rec-number><foreign-keys><key app="EN" db-id="w9zzfxep7efxxhe9ts7pszafwz5eppr0tdwr" timestamp="1577413869">12</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Pollack, Lauren O</author><author>Forbush, Kelsie T</author></authors></contributors><titles><title>Why do eating disorders and obsessive–compulsive disorder co-occur?</title><secondary-title>Eating behaviors</secondary-title></titles><periodical><full-title>Eating behaviors</full-title></periodical><pages>211-215</pages><volume>14</volume><number>2</number><dates><year>2013</year></dates><isbn>1471-0153</isbn><urls></urls></record></Cite></EndNote>(Pollack & Forbush, 2013). Finally, a recent study examining the core dimensions of anorexia nervosa and OCD in relation to psychological and personality factors previously implicated in both disorders found that concern over mistakes appears to be a transdiagnostic factor associated with all core dimensions of both anorexia and OCD ADDIN EN.CITE <EndNote><Cite><Author>Levinson</Author><Year>2019</Year><RecNum>13</RecNum><Prefix>i.e. body dissatisfaction`, drive for thinness`, obsessions`, and compulsions`; </Prefix><DisplayText>(i.e. body dissatisfaction, drive for thinness, obsessions, and compulsions; Levinson et al., 2019)</DisplayText><record><rec-number>13</rec-number><foreign-keys><key app="EN" db-id="w9zzfxep7efxxhe9ts7pszafwz5eppr0tdwr" timestamp="1577413870">13</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Levinson, Cheri A</author><author>Zerwas, Stephanie C</author><author>Brosof, Leigh C</author><author>Thornton, Laura M</author><author>Strober, Michael</author><author>Pivarunas, Bernadette</author><author>Crowley, James J</author><author>Yilmaz, Zeynep</author><author>Berrettini, Wade H</author><author>Brandt, Harry</author></authors></contributors><titles><title>Associations between dimensions of anorexia nervosa and obsessive–compulsive disorder: An examination of personality and psychological factors in patients with anorexia nervosa</title><secondary-title>European Eating Disorders Review</secondary-title></titles><periodical><full-title>European Eating Disorders Review</full-title></periodical><pages>161-172</pages><volume>27</volume><number>2</number><dates><year>2019</year></dates><isbn>1072-4133</isbn><urls></urls></record></Cite></EndNote>(i.e. body dissatisfaction, drive for thinness, obsessions, and compulsions; Levinson et al., 2019). While such preliminary evidence supports the idea that EDs and OCD share common etiological and maintenance factors, continued efforts to expand our understanding of this relationship are crucial and may possess both diagnostic and treatment implications.A large body of research denotes that OCD symptomology is highly heterogeneous across patients and the validity of different symptom dimensions which may or may not be present, in varying degree, for any given patient ADDIN EN.CITE <EndNote><Cite><Author>Huppert</Author><Year>2007</Year><RecNum>14</RecNum><DisplayText>(Huppert et al., 2007; Mataix‐Cols, Baer, Rauch, & Jenike, 2000)</DisplayText><record><rec-number>14</rec-number><foreign-keys><key app="EN" db-id="w9zzfxep7efxxhe9ts7pszafwz5eppr0tdwr" timestamp="1577413870">14</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Huppert, Jonathan D</author><author>Walther, Michael R</author><author>Hajcak, Greg</author><author>Yadin, Elna</author><author>Foa, Edna B</author><author>Simpson, H Blair</author><author>Liebowitz, Michael R</author></authors></contributors><titles><title>The OCI-R: validation of the subscales in a clinical sample</title><secondary-title>Journal of anxiety disorders</secondary-title></titles><periodical><full-title>Journal of anxiety disorders</full-title></periodical><pages>394-406</pages><volume>21</volume><number>3</number><dates><year>2007</year></dates><isbn>0887-6185</isbn><urls></urls></record></Cite><Cite><Author>Mataix‐Cols</Author><Year>2000</Year><RecNum>15</RecNum><record><rec-number>15</rec-number><foreign-keys><key app="EN" db-id="w9zzfxep7efxxhe9ts7pszafwz5eppr0tdwr" timestamp="1577413870">15</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Mataix‐Cols, David</author><author>Baer, Lee</author><author>Rauch, Scott L</author><author>Jenike, Michael A</author></authors></contributors><titles><title>Relation of factor‐analyzed symptom dimensions of obsessive‐compulsive disorder to personality disorders</title><secondary-title>Acta Psychiatrica Scandinavica</secondary-title></titles><periodical><full-title>Acta Psychiatrica Scandinavica</full-title></periodical><pages>199-202</pages><volume>102</volume><number>3</number><dates><year>2000</year></dates><isbn>0001-690X</isbn><urls></urls></record></Cite></EndNote>(Huppert et al., 2007; Mataix‐Cols, Baer, Rauch, & Jenike, 2000). 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ADDIN EN.CITE.DATA (OCI-R; Foa et al., 2002) categorizes symptoms into six different dimensions: obsessing, checking, ordering, washing, hoarding, and neutralizing. Obsessions are characterized by recurrent unwanted thoughts, images, or impulses that cause an individual anxiety (e.g., thoughts or images about being contaminated, committing acts of violence, or making mistakes). In response to obsessions individuals with OCD engage in one or more compulsive rituals to resist or neutralize their anxiety: checking (e.g., ensuring one has not made a mistake); ordering (e.g., organizing or arranging in a specific way); washing (e.g., cleaning one’s self or one’s surroundings); hoarding (e.g., accumulating or saving unneeded items), and/or neutralizing (e.g., mentally analyzing, praying, or mentally “replacing” unwanted thoughts). One aspect of the potentially common etiology underlying OCD and EDs in need of further exploration is whether some or all of these specific OCD symptom dimensions may be differentially associated with ED pathologies and/or differentially influence ED treatment outcomes. Early work in this regard has found that EDs appear to be uniquely associated with specific obsessive-compulsive characteristics such as ordering, symmetry, and contamination ADDIN EN.CITE <EndNote><Cite><Author>Hasler</Author><Year>2005</Year><RecNum>17</RecNum><DisplayText>(Davies, Liao, Campbell, & Tchanturia, 2009; Hasler et al., 2005)</DisplayText><record><rec-number>17</rec-number><foreign-keys><key app="EN" db-id="w9zzfxep7efxxhe9ts7pszafwz5eppr0tdwr" timestamp="1577413871">17</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Hasler, Gregor</author><author>LaSalle-Ricci, V Holland</author><author>Ronquillo, Jonne G</author><author>Crawley, Sarah A</author><author>Cochran, Lauren W</author><author>Kazuba, Diane</author><author>Greenberg, Benjamin D</author><author>Murphy, Dennis L</author></authors></contributors><titles><title>Obsessive–compulsive disorder symptom dimensions show specific relationships to psychiatric comorbidity</title><secondary-title>Psychiatry Research</secondary-title></titles><periodical><full-title>Psychiatry research</full-title></periodical><pages>121-132</pages><volume>135</volume><number>2</number><dates><year>2005</year></dates><isbn>0165-1781</isbn><urls></urls></record></Cite><Cite><Author>Davies</Author><Year>2009</Year><RecNum>18</RecNum><record><rec-number>18</rec-number><foreign-keys><key app="EN" db-id="w9zzfxep7efxxhe9ts7pszafwz5eppr0tdwr" timestamp="1577413871">18</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Davies, H</author><author>Liao, P-C</author><author>Campbell, IC</author><author>Tchanturia, K</author></authors></contributors><titles><title>Multidimensional self reports as a measure of characteristics in people with eating disorders</title><secondary-title>Eating and Weight Disorders-Studies on Anorexia, Bulimia and Obesity</secondary-title></titles><periodical><full-title>Eating and Weight Disorders-Studies on Anorexia, Bulimia and Obesity</full-title></periodical><pages>e84-e91</pages><volume>14</volume><number>2-3</number><dates><year>2009</year></dates><isbn>1124-4909</isbn><urls></urls></record></Cite></EndNote>(Davies, Liao, Campbell, & Tchanturia, 2009; Hasler et al., 2005). By further examining this relationship in a more dimensional way, we can broaden our current understanding of ED/OCD etiology, which may have important implications for the diagnosis and more targeted treatment of OCD and EDs. Specifically, identifying whether core OCD symptomology differentially relates to varying ED presentations can provide insight for specific treatment targets or symptomology that may be interfering with current ED-specific treatment approaches.An additional cognitive construct relevant to the unwanted, intrusive thoughts that are a central feature of OCD is thought action fusion (TAF). TAF is a cognitive phenomenon in which individuals believe that the existence of their obsessional thoughts can influence the actual occurrence of events in the world ADDIN EN.CITE <EndNote><Cite><Author>Shafran</Author><Year>2004</Year><RecNum>41</RecNum><DisplayText>(Shafran & Rachman, 2004)</DisplayText><record><rec-number>41</rec-number><foreign-keys><key app="EN" db-id="w9zzfxep7efxxhe9ts7pszafwz5eppr0tdwr" timestamp="1585700319">41</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Shafran, R</author><author>Rachman, S</author></authors></contributors><titles><title>Thought-action fusion: A review</title><secondary-title>Journal of Behavior Therapy and Experimental Psychiatry</secondary-title></titles><periodical><full-title>Journal of Behavior Therapy and Experimental Psychiatry</full-title></periodical><pages>87-107</pages><volume>35</volume><number>2</number><dates><year>2004</year></dates><isbn>0005-7916</isbn><urls></urls></record></Cite></EndNote>(Shafran & Rachman, 2004). Two forms of this cognitive distortion have emerged within empirical research: Likelihood-TAF and Moral-TAF. Likelihood-TAF refers to the belief that having a thought about something increases the likelihood of it actually happening and is commonly differentiated in terms of beliefs about events related to one’s self (i.e. “Likelihood-Self”) or beliefs about events involving someone else (i.e. “Likelihood-Other”; Shafran & Rachman, 2004). Moral-TAF however, refers to beliefs that having a thought is morally equivalent to actually engaging in the content of the thought. TAF illustrates a salient cognitive pattern present among individuals who experience obsessional symptoms, such as those with OCD. TAF has also been theorized to similarly relate to the thinking patterns of individuals high in weight and shape concerns such that these individuals form connections between unwanted, intrusive thoughts about their body and their truth or likelihood to occur (Rachman & Shafran, 1999). For example, individuals with high levels of TAF and weight and shape concern may have the belief that just thinking about eating a ‘forbidden’ food has increased the likelihood that they have gained weight (Rachman & Shafran, 1999). This variation has been described as “thought-shape fusion” and has been found to be significantly associated with ED pathology (Shafran & Robinson, 2004, Coelho et al, 2008). While TAF has been examined in relation to both OCD and ED samples independently, TAF as a possible etiological factor underlying high ED/OCD comorbidity has yet to be explored. This study aimed to examine potential relationships between ED severity, OCD symptoms and TAF. Due to lack of prior data on these topics, the hypotheses were exploratory and broad in nature. First, we hypothesized that different ED diagnoses would differentially be associated with OCD symptom dimensionality and TAF. Second, we hypothesized that pretreatment OCD symptom severity and TAF would predict ED severity at posttreatment. Third, we hypothesized that changes in OCD symptom severity and TAF levels occur over the course of residential ED-focused treatment and sought to explore whether observed changes in these symptoms would predict changes in ED severity from pre to post treatment.MethodParticipants Participants included 112 female inpatients at a residential ED treatment facility. All participants were diagnosed with an ED as defined by the Diagnostic and Statistical Manual of Mental Disorders-Fourth Edition ADDIN EN.CITE <EndNote><Cite><Author>American Psychiatric Association</Author><Year>2000</Year><RecNum>19</RecNum><Prefix>DSM-IV`; </Prefix><DisplayText>(DSM-IV; American Psychiatric Association, 2000)</DisplayText><record><rec-number>19</rec-number><foreign-keys><key app="EN" db-id="w9zzfxep7efxxhe9ts7pszafwz5eppr0tdwr" timestamp="1577413872">19</key></foreign-keys><ref-type name="Book">6</ref-type><contributors><authors><author>American Psychiatric Association,</author></authors></contributors><titles><title>Diagnostic and statistical manual of mental disorders: DSM-IV-TR</title></titles><edition>4th</edition><dates><year>2000</year></dates><pub-location>Washington, DC</pub-location><publisher>American Psychiatric Association</publisher><urls></urls></record></Cite></EndNote>(DSM-IV; American Psychiatric Association, 2000). Participant diagnoses included anorexia nervosa (50.9%, n = 57), bulimia nervosa (17.9%, n = 20), and ED not otherwise specified (31.3%, n = 35). Participants were split between the adolescent and adult treatment facilities (56.3%, n = 63 and 43.8%, n = 49, respectively) and had a mean age of 18.90 (SD = 5.67, range 12–45).ProceduresAvalon Hills Eating Disorder Specialists is a for-profit residential treatment facility that consists of separate adolescent (11 to 17 years) and adult (18 and older) programs. Treatment is transtheoretical and includes forms of cognitive-behavioral, psychodynamic, and attachment-based therapies, applied neuroscience and supplemental interventions and activities, such as recreation, equine therapy, yoga, art, and body image challenges. Participants engage in daily process oriented and didactic group therapies, twice-weekly individual therapy, and a weekly family therapy session. All aspects of the current study were approved by a university institutional review board. All clients were informed about the opportunity to participate in research while receiving treatment at Avalon Hills at the time of intake and were given details regarding what their participation would entail if they chose to do so. All individuals were informed that participation in the study was voluntary, and whether or not they chose to participate would have no impact on their individual treatment at the facility. Individuals who agreed to participate completed an assessment battery within the first three days following their intake, and then completed the same battery when discharging residential treatment. The battery covered demographic information and assessment of a variety of psychological disorders, processes, and treatment outcome. The current study used a subset of these measures to explore relationships between ED severity, OCD, and TAF.MeasuresEating Disorder Inventory-3 ADDIN EN.CITE <EndNote><Cite><Author>Garner</Author><Year>2004</Year><RecNum>20</RecNum><Prefix>EDI-3`; </Prefix><DisplayText>(EDI-3; Garner, 2004)</DisplayText><record><rec-number>20</rec-number><foreign-keys><key app="EN" db-id="w9zzfxep7efxxhe9ts7pszafwz5eppr0tdwr" timestamp="1577413872">20</key></foreign-keys><ref-type name="Book">6</ref-type><contributors><authors><author>Garner, David M</author></authors></contributors><titles><title>EDI 3: Eating Disorder Inventory-3: Professional Manual</title></titles><dates><year>2004</year></dates><publisher>Psychological Assessment Resources</publisher><urls></urls></record></Cite></EndNote>(EDI-3; Garner, 2004). The EDI-3 is a self-report ED assessment that covers a wide range of ED symptoms and pathology. It consists of 91 items that are rated on a 6-point Likert-type scale (0 = never to 6 = always). The current study used only the eating disorders risk composite portion of the assessment. The ED risk composite provides a global measure of ED severity that is total score of the Drive for Thinness, Bulimia, and Body Dissatisfaction subscale’s T-scores. Higher scores denote greater ED severity. It is commonly used as a measure of ED severity and has been shown to predict the development of disordered eating behavior ADDIN EN.CITE <EndNote><Cite><Author>Garner</Author><Year>2004</Year><RecNum>20</RecNum><DisplayText>(Garner, 2004)</DisplayText><record><rec-number>20</rec-number><foreign-keys><key app="EN" db-id="w9zzfxep7efxxhe9ts7pszafwz5eppr0tdwr" timestamp="1577413872">20</key></foreign-keys><ref-type name="Book">6</ref-type><contributors><authors><author>Garner, David M</author></authors></contributors><titles><title>EDI 3: Eating Disorder Inventory-3: Professional Manual</title></titles><dates><year>2004</year></dates><publisher>Psychological Assessment Resources</publisher><urls></urls></record></Cite></EndNote>(Garner, 2004). The ED risk composite has demonstrated excellent psychometric properties, including test-retest reliability and convergent and discriminant validity ADDIN EN.CITE <EndNote><Cite><Author>Garner</Author><Year>2004</Year><RecNum>20</RecNum><DisplayText>(Garner, 2004)</DisplayText><record><rec-number>20</rec-number><foreign-keys><key app="EN" db-id="w9zzfxep7efxxhe9ts7pszafwz5eppr0tdwr" timestamp="1577413872">20</key></foreign-keys><ref-type name="Book">6</ref-type><contributors><authors><author>Garner, David M</author></authors></contributors><titles><title>EDI 3: Eating Disorder Inventory-3: Professional Manual</title></titles><dates><year>2004</year></dates><publisher>Psychological Assessment Resources</publisher><urls></urls></record></Cite></EndNote>(Garner, 2004) and displayed excellent internal consistency in the current study (α = .93).Obsessive Compulsive Inventory-Revised PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5Gb2E8L0F1dGhvcj48WWVhcj4yMDAyPC9ZZWFyPjxSZWNO
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ADDIN EN.CITE.DATA (OCI-R; Foa et al., 2002). The OCI-R is a self-report measure of OCD symptoms. It measures six symptom subscales: checking, ordering, obsessing, washing, neutralizing, and hoarding. The OCI-R consists of 18 items that are rated on a 5-point Likert-type scale (0 = not at all to 4 = extremely). Items are summed into a total score (0–72), with higher scores denoting greater OCD severity. A cutoff score of 21 has been established as optimally distinguishing those with OCD from non-anxious individuals PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5Gb2E8L0F1dGhvcj48WWVhcj4yMDAyPC9ZZWFyPjxSZWNO
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ADDIN EN.CITE.DATA (Foa et al., 2002). The OCI-R has demonstrated good psychometric properties, including test-retest reliability and convergent and discriminant validity ADDIN EN.CITE <EndNote><Cite><Author>Abramowitz</Author><Year>2006</Year><RecNum>21</RecNum><DisplayText>(Abramowitz & Deacon, 2006; Hajcak, Huppert, Simons, & Foa, 2004)</DisplayText><record><rec-number>21</rec-number><foreign-keys><key app="EN" db-id="w9zzfxep7efxxhe9ts7pszafwz5eppr0tdwr" timestamp="1577413872">21</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Abramowitz, Jonathan S</author><author>Deacon, Brett J</author></authors></contributors><titles><title>Psychometric properties and construct validity of the Obsessive–Compulsive Inventory—Revised: Replication and extension with a clinical sample</title><secondary-title>Journal of anxiety disorders</secondary-title></titles><periodical><full-title>Journal of anxiety disorders</full-title></periodical><pages>1016-1035</pages><volume>20</volume><number>8</number><dates><year>2006</year></dates><isbn>0887-6185</isbn><urls></urls></record></Cite><Cite><Author>Hajcak</Author><Year>2004</Year><RecNum>22</RecNum><record><rec-number>22</rec-number><foreign-keys><key app="EN" db-id="w9zzfxep7efxxhe9ts7pszafwz5eppr0tdwr" timestamp="1577413872">22</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Hajcak, Greg</author><author>Huppert, Jonathan D</author><author>Simons, Robert F</author><author>Foa, Edna B</author></authors></contributors><titles><title>Psychometric properties of the OCI-R in a college sample</title><secondary-title>Behaviour research and therapy</secondary-title></titles><periodical><full-title>Behaviour research and therapy</full-title></periodical><pages>115-123</pages><volume>42</volume><number>1</number><dates><year>2004</year></dates><isbn>0005-7967</isbn><urls></urls></record></Cite></EndNote>(Abramowitz & Deacon, 2006; Hajcak, Huppert, Simons, & Foa, 2004). The OCI-R displayed good internal consistency in the current study (αs: Total = .93, Checking = .80, Hoarding = .80, Neutralizing = .84, Obsessing = .84, Ordering = .91, Washing = .87).Thought Action Fusion Questionnaire ADDIN EN.CITE <EndNote><Cite><Author>Shafran</Author><Year>1996</Year><RecNum>23</RecNum><Prefix>TAF`; </Prefix><DisplayText>(TAF; Shafran, Thordarson, & Rachman, 1996)</DisplayText><record><rec-number>23</rec-number><foreign-keys><key app="EN" db-id="w9zzfxep7efxxhe9ts7pszafwz5eppr0tdwr" timestamp="1577413873">23</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Shafran, R</author><author>Thordarson, D. S.</author><author>Rachman, S.</author></authors></contributors><titles><title>Thought-action fusion in obsessive compulsive disorder</title><secondary-title>Journal of Anxiety Disorders</secondary-title></titles><periodical><full-title>Journal of anxiety disorders</full-title></periodical><pages>379-391</pages><volume>10</volume><number>5</number><dates><year>1996</year></dates><urls><related-urls><url>(96)00018-7</electronic-resource-num><remote-database-name>Scopus</remote-database-name></record></Cite></EndNote>(TAF; Shafran, Thordarson, & Rachman, 1996). The TAF is a self-report measure of TAF. It measures three subscales: Moral (e.g., blasphemous thought is equal to blasphemous action), Others (e.g., thoughts about harm happening to others increase the likelihood of harm occurring to others), and Self (e.g., thoughts about harm happening to oneself increase the likelihood of that harm occurring). The TAF consists of 19 items that are rated on a 5-point Likert-type scale (0 = disagree strongly to 4 = agree strongly). Scores are totaled for each subscale with higher scores indicating greater levels of TAF (Moral: 12 items, range = 0–48; Others: 4 items, range = 0–16; Self: 3 items, range = 0–12). The TAF has demonstrated good psychometric properties in multiple studies PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5TaGFmcmFuPC9BdXRob3I+PFllYXI+MTk5NjwvWWVhcj48
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The TAF displayed good internal consistency in the current study (αs: Total = .96, Moral = .93, Others = .83, Self = .84)Data Analytic PlanData were analyzed using Jamovi ADDIN EN.CITE <EndNote><Cite><Year>2018</Year><RecNum>25</RecNum><DisplayText>("Jamovi project," 2018)</DisplayText><record><rec-number>25</rec-number><foreign-keys><key app="EN" db-id="w9zzfxep7efxxhe9ts7pszafwz5eppr0tdwr" timestamp="1577413873">25</key></foreign-keys><ref-type name="Computer Program">9</ref-type><contributors><authors><author> </author></authors></contributors><titles><title>Jamovi project</title></titles><edition>0.9</edition><dates><year>2018</year></dates><urls><related-urls><url>;("Jamovi project," 2018) and R studio ADDIN EN.CITE <EndNote><Cite><Author>Team</Author><Year>2015</Year><RecNum>26</RecNum><DisplayText>(Team, 2015)</DisplayText><record><rec-number>26</rec-number><foreign-keys><key app="EN" db-id="w9zzfxep7efxxhe9ts7pszafwz5eppr0tdwr" timestamp="1577413873">26</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Team, RStudio</author></authors></contributors><titles><title>RStudio: integrated development for R</title><secondary-title>RStudio, Inc., Boston, MA URL . rstudio. com</secondary-title></titles><periodical><full-title>RStudio, Inc., Boston, MA URL . rstudio. com</full-title></periodical><dates><year>2015</year></dates><urls></urls></record></Cite></EndNote>(Team, 2015) based on R statistical software ADDIN EN.CITE <EndNote><Cite><Author>R Development Core Team</Author><Year>2016</Year><RecNum>27</RecNum><DisplayText>(R Development Core Team, 2016)</DisplayText><record><rec-number>27</rec-number><foreign-keys><key app="EN" db-id="w9zzfxep7efxxhe9ts7pszafwz5eppr0tdwr" timestamp="1577413874">27</key></foreign-keys><ref-type name="Computer Program">9</ref-type><contributors><authors><author>R Development Core Team,</author></authors></contributors><titles><title>R: A language and environment for statistical computing</title></titles><dates><year>2016</year></dates><pub-location>Vienna, Austria</pub-location><publisher>R Foundation for Statistical Computing</publisher><urls><related-urls><url>;(R Development Core Team, 2016) and the following packages: jmv ADDIN EN.CITE <EndNote><Cite><Author>Selker</Author><Year>2017</Year><RecNum>28</RecNum><DisplayText>(Selker, Love, & Dropmann, 2017)</DisplayText><record><rec-number>28</rec-number><foreign-keys><key app="EN" db-id="w9zzfxep7efxxhe9ts7pszafwz5eppr0tdwr" timestamp="1577413874">28</key></foreign-keys><ref-type name="Web Page">12</ref-type><contributors><authors><author>Selker, R.</author><author>Love, J.</author><author>Dropmann, D.</author></authors></contributors><titles><title>jmv: The 'jamovi' Analyses</title></titles><dates><year>2017</year></dates><urls><related-urls><url>;(Selker, Love, & Dropmann, 2017) and tidyverse ADDIN EN.CITE <EndNote><Cite><Author>Wickham</Author><Year>2017</Year><RecNum>29</RecNum><DisplayText>(Wickham, 2017)</DisplayText><record><rec-number>29</rec-number><foreign-keys><key app="EN" db-id="w9zzfxep7efxxhe9ts7pszafwz5eppr0tdwr" timestamp="1577413874">29</key></foreign-keys><ref-type name="Web Page">12</ref-type><contributors><authors><author>Wickham, H.</author></authors></contributors><titles><title>tidyverse: Easily install and load 'Tidyverse' packages. R package version 1.1.1.</title></titles><dates><year>2017</year></dates><urls><related-urls><url>;(Wickham, 2017). Cronbach’s alpha was calculated for all measures to assess internal consistency. Means and standard deviations were calculated for all measures and subscales for all participants and by ED diagnostic category. ANOVAs with Tukey’s post hoc comparisons were used to examine potential differences between diagnostic categories with regard to each measure. Pearson’s correlations were then calculated between all measures and subscales using scores at intake as well as change scores from pretreatment to posttreatment. Next, hierarchical multiple regressions were used to further examine these relationships, controlling for ED severity at pretreatment. The first hierarchical multiple regression predicted ED risk scores at posttreatment using OCI-R and TAF scores at pretreatment. 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ADDIN EN.CITE.DATA (18.82; Foa et al., 2002). The current sample demonstrated significantly lower OCD symptomology than the normed OCD sample, t(228) = 3.35, p < .001, and nonsignificant differences compared to the normed non-anxious controls, t(228) = 1.51, p = .132. On average, the sample’s OCI-R scores were above the clinical cutoff for OCD of 21. Moreover, nearly half (45.5%) of the participants in the sample met the cutoff for OCD. With regard to specific OCD symptoms, three subscales appeared to be elevated on average. These included Obsessing (5.25), Neutralizing (3.06), and Ordering (4.79) that were well above non-anxious controls (2.86, 1.82, and 4.40, respectively) and at or near patients with OCD PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5Gb2E8L0F1dGhvcj48WWVhcj4yMDAyPC9ZZWFyPjxSZWNO
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ADDIN EN.CITE.DATA (7.23, 3.18, and 4.76, respectively; Foa et al., 2002). On average, participants reported levels of TAF (Moral = 18.09, Likelihood-Others = 3.49, Likelihood-Self = 2.97) well above a community sample of adults (Moral = 12.74, Others = 1.03, Self = 2.09) and below that of a sample of participants with OCD ADDIN EN.CITE <EndNote><Cite><Author>Shafran</Author><Year>1996</Year><RecNum>23</RecNum><Prefix>Moral = 20.03`, Likelihood-Others = 4.77`, Likelihood-Self = 4.41`; </Prefix><DisplayText>(Moral = 20.03, Likelihood-Others = 4.77, Likelihood-Self = 4.41; Shafran et al., 1996)</DisplayText><record><rec-number>23</rec-number><foreign-keys><key app="EN" db-id="w9zzfxep7efxxhe9ts7pszafwz5eppr0tdwr" timestamp="1577413873">23</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Shafran, R</author><author>Thordarson, D. S.</author><author>Rachman, S.</author></authors></contributors><titles><title>Thought-action fusion in obsessive compulsive disorder</title><secondary-title>Journal of Anxiety Disorders</secondary-title></titles><periodical><full-title>Journal of anxiety disorders</full-title></periodical><pages>379-391</pages><volume>10</volume><number>5</number><dates><year>1996</year></dates><urls><related-urls><url>(96)00018-7</electronic-resource-num><remote-database-name>Scopus</remote-database-name></record></Cite></EndNote>(Moral = 20.03, Likelihood-Others = 4.77, Likelihood-Self = 4.41; Shafran et al., 1996).From pre to posttreatment, participants demonstrated statistically significant reduction in OCI-R, t(110) = 7.11, p < .001 and ED severity, t(110) = 10.06, p < .001. With regard to TAF subscales, participant TAF-Moral, t(110) = 3.78, p < .001 and TAF-Self, t(110) = 2.43, p = .017 scores reduced significantly over the course of treatment. TAF-Others scores did not significantly change from pre to posttreatment, t(110) = 1.99, p = .05..Comparisons were made between participant ED diagnostic categories to examine potential differences in ED severity, OCD symptomology, and TAF. No differences were found between diagnoses for meeting OCD cutoff criteria, ED risk, or any of the TAF subscales, indicating that the diagnoses categories endorsed similar levels of TAF. With regard to OCD symptomology, only the OCI-R Ordering subscale demonstrated a statistically significant difference between groups. Participants with a diagnosis of bulimia indicated significantly fewer ordering-related OCD symptoms than those diagnosed with anorexia (η? = .07, p = .017).Participants above the OCI-R cutoff for OCD demonstrated significantly higher levels of ED severity at pretreatment (61.24) compared to participants below the cutoff (44.33), t(110) = 3.92, p < .001, d = .74). Despite differences in ED symptom severity between the groups, on average both groups responded to treatment with the OCD group demonstrating a 27.25 point decrease in ED severity scores and the non-OCD group demonstrating an average decrease of 18.67 points. Changes in ED severity over the course of treatment were not statistically significant between participants above and below the OCI-R cutoff, t(110) = 1.98, p = .050, d = .38), however, the small to moderate effect size indicates a potentially clinically significant difference. At posttreatment, participants above the OCI-R cutoff for OCD reported somewhat similar levels of OCD (33.98) compared to those below the cutoff (25.66), t(110) = 1.97, p = .051, d = .37). It appears that participants with higher levels of OCD entered treatment with significantly higher levels of ED severity and left treatment with higher levels of ED severity, however at post-treatment this difference was no longer statistically significant.Pearson’s correlations were calculated to examine relationships between ED and OCD symptoms and TAF at pretreatment and from pre to posttreatment. Results are presented in Table 2. At pretreatment statistically significant, positive, moderate correlations were demonstrated between ED risk scores and all symptom subscales of the OCI-R (rs = .24–.49, ps < .05) and all subscales of the TAF scale (rs = .20–.25, ps < .05). Analysis of change scores from pre- to post-treatment demonstrated moderate correlations between ED risk and the subscales of the OCI-R (rs = .20–.55, ps < .05). However, with regard to the TAF subscales, only the Others subscale change score demonstrated a statistically significant relationship with the ED risk change score (r = .31, p < .01). Associations between OCI-R and TAF pretreatment scores and ED risk change scores from pre- to post-treatment were next examined. The OCI-R Obsessing subscale was the only variable at pretreatment to be significantly correlated with changes in ED risk from pre- to post-treatment (r = .38, p < .01).These relationships were then examined further using hierarchical multiple regressions. Table 3 displays the results of the first regression that tested posttreatment ED risk scores as the outcome variable. R2 changes were significant following the first and second steps which controlled for pretreatment ED risk scores and age. Pretreatment OCI-R subscales were added at step three, resulting in no significant change in R2 and no individual OCD symptom subscale significantly contributing to the explained variance. Finally, pretreatment TAF subscales were added at step four, resulting in a significant change in R2 that contributed an additional approximately 7% of explained variance. Only the TAF Self subscale was statistically significant, indicating that levels of TAF related to self at pretreatment contribute a significant amount of variation in ED risk scores at posttreatment. The findings of this analysis indicate that pretreatment levels of OCD did not significantly predict ED treatment outcome. However, greater levels of self-focused TAF scores at pretreatment significantly predicted greater ED symptom severity at post-treatment.Changes in these variables were then examined using an additional hierarchical multiple regression. Table 4 displays this model that tested changes in ED risk scores as the outcome variable. Step one consisted of OCI-R subscale change scores, which contributed to a significant amount of explained variance (R2 = .32, p < .001). The obsessing subscale was the only statistically significant symptom dimension. Step two added the TAF subscale change scores, which were statistically significant and explained an additional approximately 3% of variance beyond changes in OCD symptomology alone. Changes in the Others subscale was the only TAF subscale to significantly contribute to variance in ED risk change scores (p = .008). The findings of this analysis indicate that decreases in OCI-R obsessing scores, and to a lesser degree decreases in others-focused TAF scores, significantly predicted better ED treatment outcome.DiscussionThis study aimed to examine potential relationships between ED severity, OCD symptoms and TAF, as well as the potential influence OCD symptoms and TAF may have on ED treatment outcomes. Obsessing, neutralizing, and ordering were the most elevated and commonly experienced OCD symptoms among our sample of individuals with diagnosed EDs, and scores on all OCD subscales were largely consistent between various ED diagnoses. Additionally, all forms of TAF examined were elevated above the norms observed in non-clinical samples suggesting that TAF is a salient experience for individuals in treatment for an ED. Our findings also suggest a strong relationship between ED and OCD symptom severity. The significant positive correlation between ED symptom severity and OCD symptom severity as a whole, as well as all six symptom clusters individually, suggests that clients struggling with more severe symptoms related to one disorder tend to display more severe symptomology related to the other, and therefore present with an overall more severe clinical profile. One possible explanation for this is that there is a synergistic effect of ED/OCD symptoms such that the simultaneous presentation of both disorders exacerbates overall clinical severity beyond that which might be observed if only one symptom profile was present. Additionally, it is possible that there are one or more underlying maintenance mechanisms that are particularly salient within individuals who have a comorbid ED and OCD symptoms. While surprisingly little research has been done in relation to the bidirectionality of symptom severity in this way among other common psychiatric comorbidities with ED, there is also initial research suggesting that comorbid depression and/or anxiety diagnoses are similarly associated with increased ED symptom severity ADDIN EN.CITE <EndNote><Cite><Author>Spindler</Author><Year>2007</Year><RecNum>39</RecNum><DisplayText>(Brand-Gothelf, Leor, Apter, & Fennig, 2014; Spindler & Milos, 2007)</DisplayText><record><rec-number>39</rec-number><foreign-keys><key app="EN" db-id="w9zzfxep7efxxhe9ts7pszafwz5eppr0tdwr" timestamp="1581814339">39</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Spindler, Anja</author><author>Milos, Gabriella</author></authors></contributors><titles><title>Links between eating disorder symptom severity and psychiatric comorbidity</title><secondary-title>Eating Behaviors</secondary-title></titles><periodical><full-title>Eating behaviors</full-title></periodical><pages>364-373</pages><volume>8</volume><number>3</number><dates><year>2007</year></dates><isbn>1471-0153</isbn><urls></urls></record></Cite><Cite><Author>Brand-Gothelf</Author><Year>2014</Year><RecNum>38</RecNum><record><rec-number>38</rec-number><foreign-keys><key app="EN" db-id="w9zzfxep7efxxhe9ts7pszafwz5eppr0tdwr" timestamp="1581814329">38</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Brand-Gothelf, Ayelet</author><author>Leor, Shani</author><author>Apter, Alan</author><author>Fennig, Silvana</author></authors></contributors><titles><title>The impact of comorbid depressive and anxiety disorders on severity of anorexia nervosa in adolescent girls</title><secondary-title>The Journal of nervous and mental disease</secondary-title></titles><periodical><full-title>The Journal of nervous and mental disease</full-title></periodical><pages>759-762</pages><volume>202</volume><number>10</number><dates><year>2014</year></dates><isbn>0022-3018</isbn><urls></urls></record></Cite></EndNote>(Brand-Gothelf, Leor, Apter, & Fennig, 2014; Spindler & Milos, 2007). Notably however, these studies have not looked at whether the severity of the comorbid disorder’s symptom profile also appears exacerbated above and beyond those of individuals without a comorbid ED as was observed between EDs and OCD in our study. It is therefore essential that more comprehensive research is conducted to determine the exact nature of these comorbid psychiatric relationships among individuals with EDs to better understand how best to prioritize and target symptoms of comorbid diagnoses to improve overall treatment outcomes among this population. Despite treatment being primarily targeted at decreasing ED symptoms, OCD symptoms also decreased significantly on average across patients and changes in ED severity and OCD symptom severity were strongly associated. Despite generally entering treatment with greater ED severity, participants who met OCI-R cutoff criteria for OCD saw similar overall treatment improvements as those who did not meet the cutoff, relative to their incoming symptom severity. However, these relative changes in ED severity also demonstrate that, on average, those entering treatment with higher levels of OCD are seeing similar overall improvements as their peers without severe OCD symptoms but are still leaving treatment with greater levels of ED symptoms. Consistent with previous findings, changes in OCD symptom severity also predicted changes in ED severity ADDIN EN.CITE <EndNote><Cite><Author>Olatunji</Author><Year>2010</Year><RecNum>30</RecNum><DisplayText>(Olatunji, Tart, Shewmaker, Wall, & Smits, 2010)</DisplayText><record><rec-number>30</rec-number><foreign-keys><key app="EN" db-id="w9zzfxep7efxxhe9ts7pszafwz5eppr0tdwr" timestamp="1577413874">30</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Olatunji, Bunmi O</author><author>Tart, Candyce D</author><author>Shewmaker, Shona</author><author>Wall, David</author><author>Smits, Jasper AJ</author></authors></contributors><titles><title>Mediation of symptom changes during inpatient treatment for eating disorders: The role of obsessive–compulsive features</title><secondary-title>Journal of psychiatric research</secondary-title></titles><periodical><full-title>Journal of psychiatric research</full-title></periodical><pages>910-916</pages><volume>44</volume><number>14</number><dates><year>2010</year></dates><isbn>0022-3956</isbn><urls></urls></record></Cite></EndNote>(Olatunji, Tart, Shewmaker, Wall, & Smits, 2010) suggesting that ED-focused treatment appears to also provide therapeutic benefits for OCD symptomology, and that improvements in the symptoms of one disorder are associated with improvements in the other. This suggests that, despite initial benefits observed in both ED and OCD symptoms following residential ED-focused treatment, additional efforts targeting specific OCD symptoms in addition to ED-focused treatment among this population may be beneficial for enhancing overall treatment outcomes. All types of TAF were associated with greater ED severity at pretreatment. Moreover, levels of TAF related to one’s self at pretreatment significantly contributed to the variation in ED severity following treatment such that higher pretreatment self-oriented TAF predicted poorer treatment outcome. Changes in TAF when oriented to others across treatment were significantly predictive of changes in ED severity; however, this was not the case for changes in TAF oriented to oneself. These findings may be indicative of changes among individual’s interpersonal awareness and interpersonal interaction styles across treatment. Throughout residential treatment the use of social support is encouraged and facilitated through the implementation of group therapy and family member integration, and there is evidence suggesting that interpersonal and family-based psychotherapies are efficacious in the treatment of EDs, particularly when working with adolescents ADDIN EN.CITE <EndNote><Cite><Author>Murphy</Author><Year>2012</Year><RecNum>31</RecNum><DisplayText>(Couturier, Kimber, & Szatmari, 2013; Murphy, Straebler, Basden, Cooper, & Fairburn, 2012)</DisplayText><record><rec-number>31</rec-number><foreign-keys><key app="EN" db-id="w9zzfxep7efxxhe9ts7pszafwz5eppr0tdwr" timestamp="1577413875">31</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Murphy, Rebecca</author><author>Straebler, Suzanne</author><author>Basden, Shawnee</author><author>Cooper, Zafra</author><author>Fairburn, Christopher G</author></authors></contributors><titles><title>Interpersonal psychotherapy for eating disorders</title><secondary-title>Clinical psychology & psychotherapy</secondary-title></titles><periodical><full-title>Clinical psychology & psychotherapy</full-title></periodical><pages>150-158</pages><volume>19</volume><number>2</number><dates><year>2012</year></dates><isbn>1063-3995</isbn><urls></urls></record></Cite><Cite><Author>Couturier</Author><Year>2013</Year><RecNum>32</RecNum><record><rec-number>32</rec-number><foreign-keys><key app="EN" db-id="w9zzfxep7efxxhe9ts7pszafwz5eppr0tdwr" timestamp="1577413875">32</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Couturier, Jennifer</author><author>Kimber, Melissa</author><author>Szatmari, Peter</author></authors></contributors><titles><title>Efficacy of family‐based treatment for adolescents with eating disorders: A systematic review and meta‐analysis</title><secondary-title>International Journal of Eating Disorders</secondary-title></titles><periodical><full-title>International Journal of Eating Disorders</full-title></periodical><pages>3-11</pages><volume>46</volume><number>1</number><dates><year>2013</year></dates><isbn>0276-3478</isbn><urls></urls></record></Cite></EndNote>(Couturier, Kimber, & Szatmari, 2013; Murphy, Straebler, Basden, Cooper, & Fairburn, 2012). Thus, it is possible that ED patients entering residential treatment place a stronger emphasis on self-oriented TAF, but throughout treatment increase their awareness and perceived importance of others and the impact their disorder may have on them. While this is one possible explanation for our results, additional research in this regard is necessary.It is also possible that TAF is a transdiagnostic factor that is more closely related to the underlying personality characteristics of individuals at increased risk for/diagnosed with EDs, OCD, and similar disorders. A review of the literature on TAF in this regard suggests the possibility that TAF represents a “tendency or way of thinking” that may transcend the specificity of specific disorder symptomology ADDIN EN.CITE <EndNote><Cite><Author>Berle</Author><Year>2005</Year><RecNum>40</RecNum><DisplayText>(Berle & Starcevic, 2005)</DisplayText><record><rec-number>40</rec-number><foreign-keys><key app="EN" db-id="w9zzfxep7efxxhe9ts7pszafwz5eppr0tdwr" timestamp="1581889346">40</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Berle, David</author><author>Starcevic, Vladan</author></authors></contributors><titles><title>Thought–action fusion: Review of the literature and future directions</title><secondary-title>Clinical psychology review</secondary-title></titles><periodical><full-title>Clinical psychology review</full-title></periodical><pages>263-284</pages><volume>25</volume><number>3</number><dates><year>2005</year></dates><isbn>0272-7358</isbn><urls></urls></record></Cite></EndNote>(Berle & Starcevic, 2005). However, our finding that TAF appeared to decrease in response to treatment, even when it was not a specified treatment target, supports the indication that TAF is less likely to be a personality “trait” unlikely to change over time, and thus may be an appropriate target of therapeutic intervention. While our preliminary findings provide further support that TAF is prevalent among individuals with EDs, future research exploring its relationship to personality characteristics such as neuroticism and perfectionism, as well as its relationship with other common comorbid diagnoses and symptoms such as depression, anxiety disorders, guilt, and shame within this population are needed to specify and appropriately target TAF in treatments. When considering the implications of our results, limitations of the current study should be acknowledged. Data collection only occurring at pre- and post-treatment precludes our ability to identify directionality or potential causality between treatment processes. More explicitly, it remains unclear whether changes in OCD and TAF levels occur simultaneously, before, or after changes in ED symptoms. Without the ability to determine this temporal precedence, it is also therefore uncertain whether changes in OCD and/or TAF are causally predictive of changes in ED severity and future research continuing to explore the temporal timeline of such changes is needed. Additionally, the measures used in this study to assess OCD and TAF were created from an OCD-focused orientation, thus they may not be fully representative of how similar behavioral patterns manifest for individuals with EDs ADDIN EN.CITE <EndNote><Cite><Author>Shafran</Author><Year>1999</Year><RecNum>33</RecNum><DisplayText>(Shafran, Teachman, Kerry, & Rachman, 1999)</DisplayText><record><rec-number>33</rec-number><foreign-keys><key app="EN" db-id="w9zzfxep7efxxhe9ts7pszafwz5eppr0tdwr" timestamp="1577413875">33</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Shafran, R</author><author>Teachman, B</author><author>Kerry, S</author><author>Rachman, S</author></authors></contributors><titles><title>A cognitive distortion associated with eating disorders: Thought‐shape fusion</title><secondary-title>British Journal of Clinical Psychology</secondary-title></titles><periodical><full-title>British Journal of Clinical Psychology</full-title></periodical><pages>167-179</pages><volume>38</volume><number>2</number><dates><year>1999</year></dates><isbn>0144-6657</isbn><urls></urls></record></Cite></EndNote>(Shafran, Teachman, Kerry, & Rachman, 1999). Thus, future research utilizing measures of behavioral and cognitive processes based on an OCD symptom dimension framework, but adapted to ED specific thoughts and behaviors, such as the Thought-shape Fusion Questionnaire ADDIN EN.CITE <EndNote><Cite><Author>Shafran</Author><Year>1999</Year><RecNum>33</RecNum><DisplayText>(Shafran et al., 1999)</DisplayText><record><rec-number>33</rec-number><foreign-keys><key app="EN" db-id="w9zzfxep7efxxhe9ts7pszafwz5eppr0tdwr" timestamp="1577413875">33</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Shafran, R</author><author>Teachman, B</author><author>Kerry, S</author><author>Rachman, S</author></authors></contributors><titles><title>A cognitive distortion associated with eating disorders: Thought‐shape fusion</title><secondary-title>British Journal of Clinical Psychology</secondary-title></titles><periodical><full-title>British Journal of Clinical Psychology</full-title></periodical><pages>167-179</pages><volume>38</volume><number>2</number><dates><year>1999</year></dates><isbn>0144-6657</isbn><urls></urls></record></Cite></EndNote>(Shafran et al., 1999) may provide further insight into the prevalence and impact these processes have within ED populations. Finally, our study specifically highlighted the comorbid relationship between OCD and EDs, however there is a significant amount of research indicating that other psychiatric comorbidities including depression and anxiety disorders are also frequently common within this population. It is possible that individuals within our sample also had one or more additional comorbidities not evaluated in this study, and that symptoms of these disorders may have influenced ED and/or OCD symptom severity in some way.Overall, our results provide additional insights into the relationship between comorbid OCD and ED symptoms and possess implications for future treatment implementation and research. It appears that obsessing, neutralizing, and ordering OCD symptom dimensions may be particularly prevalent among individuals with EDs, and it therefore may be beneficial to incorporate treatment processes specifically targeting these symptoms within OCD-focused treatments as additional processes within current ED treatment approaches. Further, it appears that although symptoms of both EDs and OCD significantly decreased following residential ED-focused treatment, there may be synergistic effects when ED/OCD comorbidity is present such that overall symptom severity is exacerbated and remains at clinically significant levels for many individuals at post treatment. TAF also appears elevated among individuals with EDs, and appears to be impacted throughout residential treatment despite the fact that it is not specifically defined as a treatment target. Importantly, it appears that pretreatment levels of TAF (in particular Likelihood-Self TAF) and changes in TAF throughout treatment (particularly Likelihood-Others TAF) appear to predict overall treatment outcomes. It is therefore possible that by specifically including TAF as a targeted treatment component for individuals with EDs may be influential in improving overall treatment outcomes. However, additional research replicating and expanding upon our initial findings to better understand the specific role this construct plays in the maintenance and treatment of ED symptoms is essential to effectively address TAF in this way. Similarly, research specifically evaluating the inclusion of specific treatment components targeting OCD symptoms, as well as the possible influence of comorbid ED/OCD pathology on treatment efficacy is necessary in order to improve overall treatment outcomes for these individuals. ADDIN EN.REFLIST ReferencesAbramowitz, J. S., & Deacon, B. J. (2006). 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Molecular psychiatry. doi:10.1038/s41380-018-0115-4Table 1Pretreatment total scores, standard deviations, and ANOVA or chi square test statistics between eating disorder diagnosesAnorexia (n = 57)Bulimia(n = 20)EDNOS(n = 35)All(n = 112)F or χ2pη?Tukey’s post hocMet cutoff for OCD30(52.6%)7(35.0%)14(40.0)51(45.5%)2.48.289--EDRC50.16(22.18)62.20(24.04)49.26(26.39)52.03(24.15)2.22.113.04-OCI-R Total 23.65 (15.48)17.00(14.27)20.66(16.98)21.53(15.82)1.39.252.02- Washing2.95(3.44)2.45(3.41)2.43(3.23)2.70(3.35).32.725.01- Obsessing5.40(3.55)5.55(3.63)4.83(3.76)5.25(3.61).35.702.01- Neutralizing3.40(3.97)2.35(3.08)2.91(3.84)3.06(3.78).61.545.01- Ordering5.51(4.02)2.60(2.93)4.86(3.98)4.79(3.95)4.26*.017.07AN>BN (p=.012) Hoarding2.98(3.11)2.20(2.46)3.06(3.32)2.87(3.06).58.563.01- Checking3.40(2.95)1.85(2.32)2.57(3.00)2.87(2.90)2.45.091.04-TAF Moral19.30(13.56)16.75(13.88)16.89(13.04)18.09(13.40).47.627.01- Others4.07(4.59)3.00(4.09)2.83(3.70)3.49(4.24)1.09.339.02- Self3.32(3.63)2.45(3.14)2.71(3.17)2.97(3.39).63.537.01-Note. AN = anorexia; BN = bulimia; EDNOS = eating disorder not otherwise specified; EDRC = EDI-3 Eating Disorder Risk Composite; OCI-R = Obsessive-Compulsive Inventory-Revised; TAF = Thought Action Fusion.Table 2Pearson’s correlations between change scores and pretreatment EDRC, OCI-R, and TAF scoresVariableEDRC pretreatmentpEDRC change scorepEDRC pre--.54***<.001OCI-R Total pre.43***<.001.24**.011 Washing pre.27**.005.17.078 Obsessing pre.49***<.001.38***<.001 Neutralizing pre.32***<.001.14.141 Ordering pre.38***<.001.12.207 Hoarding pre.24*.010.16.085 Checking pre.24*.011.12.214TAF Moral pre.20*.033-.04.690 Others pre.23*.015.08.391 Self pre.25**.008-.03.763OCI-R Total change.41***<.001 Washing change.24*.011 Obsessing change.55***<.001 Neutralizing change.28**.002 Ordering change.20*.31 Hoarding change.23*.016 Checking change.21*.027TAF Moral change.13.169 Others change.31***<.001 Self change.07.444Note. Change = change scores from pre to posttreatment; EDRC = EDI-3 Eating Disorder Risk Composite; OCI-R = Obsessive-Compulsive Inventory-Revised; pre = pretreatment; TAF = Thought Action Fusion. Table 3Hierarchical multiple regressions predicting EDRC scores at posttreatment from OCI-R and TAF scores at pretreatmentVariableBβpR2ΔR2FStep 1 EDRC pre.48***.51***<.001<.001.26.26***39.23***Step 2 EDRC pre.42***.45***<.001 Age-39.70*-.20*.018.018.30.04*23.36*Step 3 EDRC pre.43***.46***<.001 Age-39.89*-.20*.018 OCI-R Neutralizing pre.96.16.173 OCI-R Checking pre-.95-.12.373 OCI-R Ordering pre1.16.20.116 OCI-R Hoarding pre-.27-.04.720 OCI-R Obsessing pre-1.32-.21.050 OCI-R Washing pre-.39-.06.570 .360.34.046.71Step 4 EDRC pre.45***.48***<.001 Age-25.14-.13.144 OCI-R Neutralizing pre1.19.20.083 OCI-R Checking pre-1.50-.19.151 OCI-R Ordering pre.98.17.169 OCI-R Hoarding pre-.70-.09.343 OCI-R Obsessing pre-1.37*-.22*.037 OCI-R Washing pre-.47-.07.480 TAF Self pre2.50**.38**.008 TAF Others pre-1.36-.26.057 TAF Moral pre.21.13.184.016.41.07*6.23*Note. EDRC = EDI-3 Eating Disorder Risk Composite; OCI-R = Obsessive-Compulsive Inventory-Revised; pre = pretreatment; TAF = Thought Action Fusion.Table 4Hierarchical multiple regressions predicting EDRC changes scores from OCI-R and TAF change scoresVariableBβpR2ΔR2FStep 1 Age-.06-.01.885.001.001.02Step 2 Age.20.05.561 OCI-R Neutralizing change1.08.13.159 OCI-R Checking change-.82-.08.531 OCI-R Ordering change.04.01.958 OCI-R Hoarding change.37.04.688 OCI-R Obsessing change3.66***.54***<.001 OCI-R Washing change-.41-.04.691<.001.32.32***8.14***Step 3 Age.19.05.584 OCI-R Neutralizing change.94.11.217 OCI-R Checking change-.81-.07.549 OCI-R Ordering change-.04-.01.959 OCI-R Hoarding change.33.04.731 OCI-R Obsessing change3.34***.50***<.001 OCI-R Washing change-.28-.03.785 TAF Self change-1.01-.13.226 TAF Others change1.51*.24*.026 TAF Moral change.00.00.989<.001.35.031.80Note. Change = change scores from pre to posttreatment; EDRC = EDI-3 Eating Disorder Risk Composite; OCI-R = Obsessive-Compulsive Inventory-Revised; TAF = Thought Action Fusion. ................
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