Psychiatry Research 200 (2012) 560–567

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Psychiatry Research

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Interpersonal reassurance seeking in obsessive-compulsive disorderand its relationship with checking compulsions

Vladan Starcevic a,n, David Berle b, Vlasios Brakoulias a, Peter Sammut c, Karen Moses b,Denise Milicevic b, Anthony Hannan b

a University of Sydney, Sydney Medical School—Nepean, Discipline of Psychiatry, Sydney/Penrith, NSW, Australiab Nepean Anxiety Disorders Clinic, Nepean Blue Mountains Local Health District, Penrith, NSW, Australiac Nepean Hospital, Department of Psychiatry, Penrith, NSW, Australia

a r t i c l e i n f o

Article history:

Received 11 November 2011

Received in revised form

10 April 2012

Accepted 23 June 2012

Keywords:

Obsessive-compulsive disorder

Reassurance seeking

Checking

Obsessions

Harm-related obsessions

81/$ - see front matter & 2012 Elsevier Irelan

x.doi.org/10.1016/j.psychres.2012.06.037

espondence to: Nepean Hospital, Departmen

, NSW 2751, Australia. Tel.: þ61 2 4734 2585

ail address: starcev@wahs.nsw.gov.au (V. Star

a b s t r a c t

This study aimed to examine interpersonal reassurance seeking (IRS) in obsessive-compulsive disorder

(OCD) and the relationship between IRS and checking compulsions. One hundred and forty adults with

OCD underwent a comprehensive assessment, which included obtaining information on seeking

reassurance from others because of their obsessions. Sixty-seven (47.9%) participants reported IRS.

They exhibited more psychopathology than participants without IRS, tended to have a greater overall

severity of OCD and were far more likely to have checking compulsions. Participants with IRS also had

more severe obsessions, suggesting that IRS plays a role as an additional coping strategy when

obsessions are more prominent. The severity of obsessions and the absence of obsessions about a need

to collect and keep objects were independent predictors of IRS, whereas the presence of obsessions

about unintentional harm and not being married or in a de facto relationship independently predicted

checking compulsions. Although a close relationship exists between IRS and checking compulsions,

these results suggest important differences, with implications for understanding the factors that

contribute to IRS and checking compulsions.

& 2012 Elsevier Ireland Ltd. All rights reserved.

1. Introduction

Excessive reassurance seeking is a common feature of obses-sive-compulsive disorder (OCD), other anxiety disorders, depres-sion and hypochondriasis. Individuals with OCD may reassurethemselves by thinking in a certain way, with the aim ofexperiencing some relief from an obsession-related distress. Thisself-reassurance has a comforting effect and often appears asmental compulsion. Reassurance can also be sought from othersand is here referred to as interpersonal reassurance seeking (IRS).For example, people with OCD often ask others whether certainobjects in their household are contaminated or dirty, whetherthey have hurt someone or caused some damage, whether theyare doing things right, whether the appliances have been turnedoff or something bad happened, etc. Whether reassurance isreceived or not and the impact of reassurance may depend onthe vicissitudes of interpersonal dynamics inherent to IRS. Thisalso refers to various reinforcing effects of IRS.

d Ltd. All rights reserved.

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; fax: þ61 2 4734 3343.

cevic).

IRS can be conceptualized as the solicitation of informationfrom others that would provide a sense of security, provide reliefand diminish threat. In the context of OCD, IRS is best understood as away of coping with obsessions, i.e., as a strategy to diminish distressand anxiety associated with obsessions (Freeston and Ladouceur,1997; Rachman, 1997, 1998). IRS may help reduce such distress andanxiety by decreasing one’s sense of responsibility for a catastrophicor harmful event (Salkovskis, 1996). Repeated IRS has been regardedas similar to compulsions (Salkovskis, 1985; Salkovskis and Warwick,1985; Freeston and Ladouceur, 1997; de Silva and Rachman, 1998;Rachman, 2002; Starcevic, 2005; Williams et al., 2011) or as a ‘‘subtlecompulsion’’ (Pato et al., 1998).

Our view is that IRS is not a type of compulsion, but rather, oneof many strategies of coping with obsessions, which also includecompulsions and avoidance. Compulsions reduce the obsession-related distress by directly addressing the risk of a catastrophe(e.g., checking the locks to reduce the risk of break-in, washinghands to reduce the risk of contamination, etc.) or by symbolicallyreducing the risk of a moral catastrophe (e.g., performing acomplex compulsions with magical/superstitious elements). Incontrast, IRS reduces the obsession-related distress indirectly, byseeking additional information from others and thereby attempt-ing to change threat estimates, that is, reappraising one’s threatexpectancy or one’s ability to effectively respond to the threat.

V. Starcevic et al. / Psychiatry Research 200 (2012) 560–567 561

Repeated IRS in OCD has been linked with checking compul-sions (Rasmussen and Eisen, 1992; Rachman and Shafran, 1998;Rachman, 2002; Starcevic, 2005; Parrish and Radomsky, 2010).Thus, it has been considered a ‘‘form of checking by proxy’’(Rachman and Shafran, 1998) and a functional equivalent ofchecking (Rasmussen and Eisen, 1992; Parrish and Radomsky,2010), with IRS and checking compulsions both found to serve thefunction of decreasing anxiety and/or preventing general harm(Parrish and Radomsky, 2010).

While IRS in OCD may pertain to events that did or did nothappen in the past, checking refers to both past events andanticipated future events, so that checking may be used in a greatervariety of situations and serve more purposes than reassuranceseeking (Starcevic, 2005). Other authors have proposed that re-assurance may be sought when there is a concern about otherpeople’s opinion regarding one’s performance, whereas checking ismore likely to occur when there is no need to rely on others forevaluation of one’s performance (Parrish and Radomsky, 2010).With IRS and checking being closely related, it still remains to beelucidated under what circumstances individuals with OCD aremore likely to use one or the other coping strategy, or both.

Excessive IRS has been considered a factor in maintaining OCD,analogous to the way checking compulsions help perpetuate OCD(Salkovskis, 1985; Rachman, 2002). This has important clinicalimplications in that excessive IRS can interfere with treatment ofOCD, especially with the behavioral technique of exposure andresponse prevention (Kyrios, 2003). Therefore, it has been sug-gested to target IRS to improve the outcome of therapy (Salkovskisand Warwick, 1985; de Silva and Rachman, 1998; Clark, 2004).

Considering that IRS in OCD and nuances in the relationshipbetween IRS and checking compulsions have received littleresearch attention, this study had several objectives. First, weaimed to ascertain the content and frequency of IRS in OCD. Inother words, our aim was to investigate what individuals withOCD seek reassurance for and how often they do that. Secondly,we wanted to compare OCD individuals with and without IRS interms of the frequency of their obsessions and compulsions,intensity of OCD symptom dimensions and severity of OCD andoverall psychopathology. Our final objective was to examine therelationship between IRS and checking compulsions, also compar-ing factors that predict IRS with factors that predict checkingcompulsions.

Based on the literature reviewed above and clinical observation,we first hypothesized that individuals with OCD were likely to seekreassurance for concerns about harm and contamination; secondly,that those with IRS were more likely than those without IRS to haveharm-related and contamination obsessions and checking compul-sions. Moreover, we hypothesized that individuals with IRS weremore severely ill because they needed to use an additional copingstrategy, i.e., IRS, in response to their obsessions. This hypothesiswas also based on reports that excessive IRS tends to be encoun-tered in patients with treatment-resistant OCD (Bruch and Prioglio,2003). We did not have any particular hypothesis about thepotential differences between IRS and checking compulsions andwe aimed to test the prevailing assumption that these behaviorsand their correlates have many similarities.

2. Methods

2.1. Participants

One hundred and forty adults with OCD were recruited for the Nepean OCD

Study, a large project conducted in several Australian cities but based in the

metropolitan Sydney (Starcevic et al., 2011). The recruitment occurred mainly

through newspaper advertisements and referrals from general practitioners,

mental health professionals and others. The inclusion criterion was the presence

of current OCD as the principal diagnosis, meaning that help was sought for it or that

it caused the most distress or impairment in functioning. Individuals with co-

occurring psychosis, bipolar disorder or other conditions that were considered more

severe or disabling than OCD were excluded. The study had been approved by the

local ethics committee and all participants provided signed informed consent.

2.2. Measures

Several instruments were administered. Findings obtained from the Mini

International Neuropsychiatric Interview (MINI; Sheehan et al., 1999), Yale-Brown

Obsessive-Compulsive Scale (Y-BOCS; Goodman et al., 1989) and self-report scales

Vancouver Obsessional Compulsive Inventory (VOCI; Thordarson et al., 2004) and

Symptom Checklist 90-Revised (SCL-90R; Derogatis, 1994) are reported in this

article.

The MINI is a widely used, validated, semi-structured clinician-administered

interview. Its purpose was to establish OCD as the principal diagnosis and

ascertain the presence of co-occurring DSM-IV disorders.

The Y-BOCS is also a semi-structured interview, considered to be the gold-

standard measure of the severity of OCD owing to its excellent psychometric

properties. It consists of a checklist of obsessions and compulsions and a 10-item

severity scale. Up to three most prominent obsessions and compulsions are rated

for severity on the 5-point Likert scale, providing separate scores for the severity

of obsessions and severity of compulsions and a total Y-BOCS score, which

represents the overall severity of OCD.

The Y-BOCS does not assess IRS and during the Y-BOCS interview we asked

participants the following additional question: ‘‘Have you been asking anyone to

reassure you because of your obsessions/thoughts, for example if you thought you

did something wrong or punishable?’’ Our assessment of IRS was nuanced in that

we made sure that participants understood what is meant by IRS and that it

pertained only to OCD phenomena and not to other issues (e.g., self-esteem

problems). If participants endorsed IRS, we asked them what they needed to be

reassured about and whom they asked for reassurance.

The VOCI is a psychometrically sound measure of OCD symptoms, with its 55

items rated on a 5-point Likert-type scale. Unlike the Y-BOCS, it was not designed to

measure the severity of OCD. The VOCI provides scores on six subscales (Contam-

ination, Checking, Obsessions, Hoarding, Just Right Experiences and Indecisiveness)

and a total score.

The SCL-90R is a 90-item, validated measure of the severity of symptom

distress and psychopathology. It uses a 5-point Likert-type scale and provides a

total score (the Global Severity Index) and scores on nine subscales: Somatization,

Obsessive-Compulsive, Interpersonal Sensitivity, Depression, Anxiety, Hostility,

Phobic Anxiety, Paranoid Ideation and Psychoticism. For the purpose of this study,

we report scores on the Global Severity Index and scores on the Depression and

Anxiety subscales.

2.3. Procedure

After providing an informed written consent, participants completed the

scales and were interviewed by a psychiatrist or clinical psychologist trained in

the use of the MINI and Y-BOCS. Inter-rater reliability of the DSM-IV diagnosis of

OCD, based on 46 MINI interviews, was excellent (97.8% agreement).

Information on IRS was carefully recorded. Some participants had more than

one instance of IRS, that is, they sought reassurance about more than one

obsession or OCD-related concern. Participants with and without IRS were then

compared.

To examine more closely the relationship between IRS and checking compul-

sions, all participants were divided into four groups: (1) those with both IRS and

checking compulsions (as one of their three most prominent compulsions);

(2) those with IRS, but without checking compulsions (‘‘reassurance seekers’’);

(3) those with checking compulsions, but without IRS (‘‘checkers’’), and (4) those

without IRS and checking compulsions. Groups comprised of ‘‘reassurance

seekers’’ and ‘‘checkers’’ were then compared.

2.4. Data analysis

All instances of IRS were thematically grouped into several categories and the

number of these categories was calculated. Chi-square tests were used to determine

whether there were differences in the frequencies of demographic variables, various

obsessions and compulsions and co-occurring conditions between participants with

and without IRS and between ‘‘reassurance seekers’’ and ‘‘checkers’’. Independent

samples t-tests were conducted to determine whether there were differences on

continuous variables between participants with and without IRS and between

‘‘reassurance seekers’’ and ‘‘checkers’’. Where multiple statistical tests were per-

formed, the familywise error rate was controlled using the False Discovery Rate

method of Benjamini and Hochberg (1995). Finally, we conducted two post-hoc

logistic regression analyses to determine the independent contribution of symptom-

based and demographic variables to the presence of IRS and checking compulsions,

respectively.

V. Starcevic et al. / Psychiatry Research 200 (2012) 560–567562

3. Results

Of 140 OCD participants, 89 (63.6%) were women. Their meanage was 45.46 years (S.D.¼16.07). Fifty-seven (41.3%) partici-pants were married or in a de facto relationship and 46 (33.3%)

Table 1Frequency of current co-occurring conditions in OCD participants with and

without interpersonal reassurance seeking (IRS).

Participants

with IRS

N¼67

Participants

without IRS

N¼73

w2 testa

(d.f.¼1)

n (%) n (%) w2 P

Major depressive disorder 14 20.9 9 12.3 1.87 0.172

Dysthymic disorder 7 10.4 3 4.1 2.12 0.146

Panic disorder 10 14.9 10 13.7 0.04 0.836

Agoraphobia 4 6.0 11 15.1 3.02 0.082

Generalized anxiety disorder 25 37.3 20 27.4 1.58 0.209

Social anxiety disorder 9 13.4 12 16.4 0.25 0.619

Specific phobia 17 25.4 12 16.4 1.70 0.193

Posttraumatic stress disorder 5 7.5 4 5.5 0.23 0.633

Hypochondriasis 2 3.0 1 1.4 0.44 0.510

Body dysmorphic disorder 2 3.0 1 1.4 0.44 0.510

Bulimia nervosa 2 3.0 0 0 2.21 0.137

Alcohol abuse or dependence 4 6.0 3 4.1 0.26 0.614

Other drug abuse or dependence 0 0 0 0

a Fisher’s exact test was performed in cases where more than 20% of cells had

a minimum expected count of less than 5.

Table 2The content of interpersonal reassurance seeking in obsessive-compulsive disorder (N

Harm and damage reassurance: reassurance that the person is not going to harm othe

or cause damage or that the person has not harmed others, caused damage or don

something wrong

‘‘Doing right’’ reassurance

Reassurance related to contamination obsessions

Reassurance related to health

Reassurance that others have not been harmed by some external agency

Reassurance related to hoarding

Reassurance about not upsetting or offending others

Reassurance about other issues/matters

a Some participants had more than one instance of reassurance seeking and the num

were never married. Sixty-four (46.7%) participants had post-highschool qualifications, 52 (37.7%) had a full-time or a part-time joband 32 (23.2%) were disabled by OCD to the point of being unableto work.

3.1. Interpersonal reassurance seeking

Sixty-seven (47.9%) participants reported IRS. Participants withand without IRS did not differ significantly with regards to demo-graphic variables, except that those with IRS were significantlyyounger (mean¼40.32 years, S.D.¼15.29) than those without IRS(mean¼50.14 years, S.D.¼15.52; t¼3.751, d.f.¼137, Po0.001).The proportion of employed participants was noticeably larger inthe group with IRS (47.0% vs. 29.2%), but the difference in employ-ment status did not reach statistical significance (w2

¼5.464, d.f.¼2,P¼0.065). There were no statistically significant differences betweenparticipants with and without IRS in terms of the frequency ofcurrent co-occurring mental disorders (Table 1).

Table 2 shows the content and number of instances of IRS.About one-half of participants with IRS sought reassurance aboutharm or damage that they might have caused in the past or aboutharm or damage for which they may be responsible in the future.Participants also commonly sought reassurance about doingthings right (whether in the past, currently or in the future),cleanliness of their surroundings and not being in contact withcontaminants.

Tables 3 and 4 compare the frequency of various types ofobsessions and compulsions in participants with and without IRS.

¼67 participants).

Number of instances of

reassurance seekinga

Examples of reassurance

rs

e

33 � Reassurance that the person is not going to hurt

someone in the future.

� Reassurance about doors being locked, stove/

appliances being turned off, etc.

� Reassurance about not having run someone over,

not having caused someone’s disease, etc.

� Reassurance that something bad did not happen

as a result of the person’s action or negligence.

16 � Reassurance about doing things right.

� Reassurance about having done things right.

� Reassurance about things looking right.

� Reassurance about having made the right

decision.

13 � Reassurance that other people and objects are

clean or uncontaminated.

� Reassurance that the person has not been in

contact with a contaminant.

� Reassurance that the person is not dirty or

contaminated.

3 � Reassurance that the person is not going to

become ill or that the person is not already ill.

2

2 � Reassurance that keeping possessions is OK.

2

5 � Reassurance about the person’s body appearance.

� Reassurance that the person is not pregnant.

� Reassurance that the person is not going insane.

� Reassurance that the person is not perceived

negatively by others.

� Reassurance that spiders are not around.

ber of instances of reassurance seeking is greater than the number of participants.

Table 3Type and frequency of obsessionsa in 140 OCD participants with and without interpersonal reassurance seeking.

Obsessions Obsessions in

participants with

reassurance seeking

N¼67

Obsessions in

participants without

reassurance seeking

N¼73

w2 testb (d.f.¼1)

n (%) n (%) w2 P

Contamination 29 43.3 20 27.4 3.88 0.049

Need to collect and keep objects 6 9.0 32 43.8 21.49 o0.001*

Unintentional harm (implying person’s responsibility,

e.g., negligence, fire, burglary, theft, running over a pedestrian, causing a traffic accident, etc.)

22 32.8 12 16.4 5.11 0.024

Impulsive aggression 16 23.9 13 17.8 0.78 0.376

Need for ordering/arranging (exactness/symmetry) 13 19.4 14 19.2 0.001 0.973

Expectation of harm (to self/others and generally) 8 11.9 7 9.6 0.20 0.653

Sexual 8 11.9 5 6.8 1.08 0.300

Intrusive songs/tunes/music/noise/sounds 4 6.0 4 5.5 0.02 1.000

Fear of saying something wrong/‘‘forbidden’’ 4 6.0 3 4.1 0.26 0.710

Significance of numbers 3 4.5 4 5.5 0.07 1.000

Fear of losing things 3 4.5 4 5.5 0.07 1.000

Need to know/remember 4 6.0 2 2.7 0.89 0.426

Self-harming 2 3.0 3 4.1 0.13 1.000

Fear of forgetting 4 6.0 1 1.4 2.15 0.143

Fear of making a mistake 4 6.0 0 0 4.49 0.050

Somatic 4 6.0 0 0 4.49 0.050

Religious 3 4.5 0 0 3.34 0.107

Other (fear of stealing things, fear of doing something embarrassing, doubting,

obsessions about morality [e.g., right or wrong], significance of words,

fear of being impregnated, fear of one’s possessions being stolen,

fear of one’s identity being stolen, intrusive thoughts of spiders)

8 11.9 6 8.2 0.54 0.463

a The type and frequency of obsessions are derived from up to three most prominent obsessions recorded in the Y-BOCS Symptom Checklist and used to rate the

severity of OCD for each participant.b Fisher’s exact test was performed in cases where more than 20% of cells had a minimum expected count of less than 5.n Po0.05 using False Discovery Rate correction for 18 comparisons.

Table 4Type and frequency of compulsionsa in 140 OCD participants with and without interpersonal reassurance seeking.

Compulsions Compulsions in participants

with reassurance seeking

N¼67

Compulsions in participants

without reassurance seeking

N¼73

w2 testb (d.f.¼1)

n (%) n (%) w2 P

Checking 40 59.7 20 27.4 14.89 o0.001*

Washing/cleaning 32 47.8 24 32.9 3.23 0.073

Hoarding 7 10.4 32 43.8 19.38 o0.001*

Counting 16 23.9 19 26.0 0.09 0.769

Arranging/ordering, precision-driven compulsions 12 17.9 16 21.9 0.35 0.554

Mental compulsions 6 9.0 9 12.3 0.42 0.519

Complex compulsions (rituals) 7 10.4 7 9.6 0.03 0.866

Repeating 6 9.0 5 6.8 0.21 0.644

Asking/confessing/asking for forgiveness 6 9.0 2 2.7 2.51 0.152

Touching, tapping, rubbing 5 7.5 1 1.4 3.16 0.104

Making lists 3 4.5 2 2.7 0.31 0.670

Compulsive praying 3 4.5 0 0 3.34 0.107

Other (superstitious rituals, doing things a certain number of times,

timing activities to a certain period of time, handling food in a certain way, etc.)

4 6.0 5 6.8 0.05 1.000

a The type and frequency of compulsions are derived from up to three most prominent compulsions recorded in the Y-BOCS Symptom Checklist and used to rate the

severity of OCD for each participant.b Fisher’s exact test was performed in cases where more than 20% of cells had a minimum expected count of less than 5.n Po0.05 using False Discovery Rate correction for 13 comparisons.

V. Starcevic et al. / Psychiatry Research 200 (2012) 560–567 563

A significantly larger proportion of participants without IRS had aneed to collect and keep objects and hoarding compulsions,whereas a significantly larger proportion of participants withIRS had checking compulsions.

Table 5 compares participants with and without IRS in termsof their mean scores on the Y-BOCS, VOCI and SCL-90R. Partici-pants with IRS had a significantly greater severity of obsessions.They also scored significantly higher on the VOCI dimensions of

checking, contamination and indecisiveness and had more OCDsymptoms (VOCI total score), higher levels of depression andanxiety and more symptom distress and overall psychopathology.

3.2. Interpersonal reassurance seeking and checking compulsions

Forty participants had both IRS and checking compulsions.This number represents 59.7% of all participants with IRS and

V. Starcevic et al. / Psychiatry Research 200 (2012) 560–567564

66.7% of all participants with checking compulsions, suggesting asubstantial, but not complete overlap between IRS and checkingcompulsions. There were 27 ‘‘reassurance seekers’’ (participantswith IRS and no checking compulsions) and 20 ‘‘checkers’’(participants with checking compulsions and no IRS).

Several statistically significant differences emerged when‘‘reassurance seekers’’ and ‘‘checkers’’ were compared with regardsto their demographic variables. First, ‘‘reassurance seekers’’ weremuch younger (mean¼38.30 years, S.D.¼16.19) than ‘‘checkers’’(mean¼53.30 years, S.D.¼16.53; t¼�3.114, d.f.¼45, P¼0.003).Second, the proportion of those in full-time or part-time paidemployment was much higher among ‘‘reassurance seekers’’ (44.4%vs. 10.0%; w2

¼14.452, d.f.¼2, P¼0.001). Third, there were propor-tionately more people who were married or in a de facto relationshipamong ‘‘reassurance seekers’’ (44.4% vs. 15.0%; w2

¼6.024, d.f.¼2,P¼0.049).

Table 6 compares the frequency of various types of obsessionsbetween ‘‘reassurance seekers’’ and ‘‘checkers’’. A significantlygreater proportion of ‘‘reassurance seekers’’ had contaminationobsessions, whereas a significantly greater proportion of

Table 5Comparisons between OCD participants with and without interpersonal reassurance se

Participants with IRS N¼67

Mean S.D.

Y-BOCS Obsessions 11.39 3.83

Y-BOCS Compulsions 11.57 3.47

Y-BOCS—Total score 22.96 6.90

VOCI Contamination 18.31 14.36

VOCI Checking 12.16 8.09

VOCI Obsessions 13.03 9.33

VOCI Hoarding 8.42 8.19

VOCI Just Right Experiences 21.22 11.50

VOCI Indecisiveness 12.09 6.36

VOCI–Total score 85.24 37.33

SCL-90R Depression 1.95 0.89

SCL-90R Anxiety 1.63 1.03

SCL-90R—Total score (Global Severity Index) 1.46 0.72

Y-BOCS¼Yale-Brown Obsessive-Compulsive Scale; VOCI¼Vancouver Obsessional Comn Po0.05 using False Discovery Rate correction for 13 comparisons.

Table 6Type and frequency of obsessionsa in ‘‘reassurance seekers’’ and ‘‘checkers’’.

Obsessions

Contamination

Need to collect and keep objects

Unintentional harm (implying person’s responsibility,

e.g., negligence, fire, burglary, theft, running over a pedestrian, causing a traffic ac

Impulsive aggression

Need for ordering/arranging (exactness/symmetry)

Expectation of harm (to self/others and generally)

Need to know/remember

Sexual

Intrusive songs/tunes/music/noise/sounds

Fear of saying something wrong/‘‘forbidden’’

Fear of losing things

Other (fear of forgetting, significance of numbers, self-harming, somatic,

fear of stealing things, fear of being impregnated, fear of doing something embarr

a The type and frequency of obsessions are derived from up to three most promin

severity of OCD for each participant.b Fisher’s exact test was performed in cases where more than 20% of cells had a mn Po0.05 using False Discovery Rate correction for 12 comparisons.

‘‘checkers’’ had obsessions about a need to collect and keepobjects. Table 7 presents further comparisons between thesetwo groups. ‘‘Reassurance seekers’’ had a significantly greaterseverity of obsessions and a significantly more severe OCD(Y-BOCS Total score). They also scored significantly higher onthe symptom dimensions of contamination and indecisiveness.

We performed logistic regression analyses to determine whichfactors independently predicted IRS and checking compulsions.Our analyses were post-hoc in that the variables included in eachequation were derived from the results in Table 3 and Tables 5–7.Consequently, we chose to include as clinical predictor variablesthe severity of obsessions (as determined by the Y-BOCS Obses-sions subscale score) and presence of obsessions about the needto collect and keep objects. We also included the presence ofobsessions about increased likelihood to cause or to have causedunintentional harm as a predictor variable of IRS and checkingcompulsions both on theoretical grounds (Parrish and Radomsky,2010) and because our results suggested some, albeit not astatistically significant relationship with IRS and checking com-pulsions. The demographic predictors that we included were age,

eking (IRS).

Participants without IRS N¼73 Independent t-test (d.f.¼138)

Mean S.D. t P

9.64 3.85 �2.69 0.008*

11.04 3.37 �0.91 0.364

20.68 6.70 �1.98 0.050

11.12 11.22 �3.28 0.001*

8.26 8.26 �2.82 0.006*

10.29 11.58 �1.53 0.127

11.36 9.95 1.92 0.058

17.34 12.12 �1.94 0.054

9.03 6.04 �2.92 0.004*

67.40 40.89 �2.69 0.008*

1.49 1.06 �2.75 0.007*

1.15 1.03 �2.77 0.006*

1.11 0.83 �2.702 0.008*

pulsive Inventory; SCL-90R¼Symptom Checklist 90-Revised.

Obsessions in participants

with reassurance seeking,

but without checking

(‘‘reassurance seekers’’)

N¼27

Obsessions in

participants with

checking, but without

reassurance seeking

(‘‘checkers’’) N¼20

w2 testb

(d.f.¼1)

N (%) n (%) w2 P

15 55.6 3 15.0 8.00 0.005*

4 14.8 11 55.0 8.54 0.003*

cident, etc.)

4 14.8 9 45.0 5.23 0.022

3 11.1 4 20.0 0.72 0.438

8 29.6 5 25.0 0.12 0.726

3 11.1 3 15.0 0.16 1.000

3 11.1 2 10.0 0.02 1.000

3 11.1 1 5.0 0.55 0.626

3 11.1 0 0 2.37 0.251

2 7.4 1 5.0 0.11 1.000

1 3.7 2 10.0 0.76 0.567

assing)

5 18.5 3 15.0 0.10 1.000

ent obsessions recorded in the Y-BOCS Symptom Checklist and used to rate the

inimum expected count of less than 5.

Table 7Comparisons between ‘‘reassurance seekers’’ and ‘‘checkers’’.

Participants with reassurance seeking, but

without checking (‘‘reassurance seekers’’) N¼27

Participants with checking, but without

reassurance seeking (‘‘checkers’’) N¼20

Independent t-test

(d.f.¼45)

Mean S.D. Mean S.D. t P

Y-BOCS Obsessions 12.33 3.69 8.45 4.01 3.44 0.001*

Y-BOCS Compulsions 12.07 3.56 10.35 3.65 1.62 0.111

Y-BOCS—Total score 24.41 6.75 18.80 6.98 2.78 0.008*

VOCI Contamination 21.96 14.24 8.90 9.28 3.58 o0.001*

VOCI Checking 9.19 7.79 15.05 6.72 �2.70 0.010*

VOCI Obsessions 12.11 9.59 9.40 9.88 0.95 0.349

VOCI Hoarding 9.41 8.56 11.30 9.59 �0.71 0.480

VOCI Just Right Experiences 23.93 11.51 20.90 10.50 0.93 0.360

VOCI Indecisiveness 13.37 6.80 8.80 5.49 2.47 0.018*

VOCI—Total score 89.96 33.28 74.35 35.14 1.55 0.127

SCL-90R Depression 1.99 0.929 1.50 0.966 1.729 0.091

SCL-90R Anxiety 1.60 1.036 1.19 0.948 1.396 0.170

SCL-90R—Total score (Global Severity Index) 1.48 0.767 1.07 0.716 1.846 0.072

Y-BOCS¼Yale-Brown Obsessive-Compulsive Scale; VOCI¼Vancouver Obsessional Compulsive Inventory; SCL-90R¼Symptom Checklist 90-Revised.n Po0.05 using False Discovery Rate correction for 13 comparisons.

Table 8Logistic regression model predicting interpersonal reassurance seeking in OCDa.

95% Confidence interval

Variable B (SE) Wald test (z-ratio) Exp (B) P-value Lower Upper

Presence of checking compulsions 1.97 (0.53) 13.85 7.14 o0.001 2.54 20.12

Y-BOCS Obsessions score 0.19 (0.07) 8.44 1.21 0.004 1.06 1.37

Presence of unintentional harm obsessions 0.04 (0.55) 0.005 1.04 0.944 0.36 3.03

Presence of obsessions about the need to collect and keep objects �1.53 (0.56) 7.51 0.22 0.006 0.07 0.65

Age �0.03 (0.02) 3.28 0.97 0.070 0.94 1.04

Being married or in a de facto relationship 0.94 (0.52) 3.27 2.56 0.071 0.92 7.08

Being in part- or full-time employment 0.83 (0.50) 2.77 2.28 0.096 0.86 6.03

(Constant) �1.96 (1.23) 2.57 0.14 0.109

�2 Log Likelihood¼133.37

Y-BOCS¼Yale-Brown Obsessive Compulsive Scale.a For these analyses, n¼138 as marital and employment status data were missing for two participants.

Table 9Logistic regression model predicting checking compulsions in OCDa.

95% Confidence interval

Variable B (SE) Wald test (z-ratio) Exp(B) P-value Lower Upper

Presence of interpersonal reassurance seeking 1.95 (0.52) 13.88 7.01 o0.001 2.52 19.52

Y-BOCS Obsessions score �0.12 (0.06) 3.61 0.89 0.057 0.79 1.00

Presence of unintentional harm obsessions 2.19 (0.53) 17.20 8.96 o0.0001 3.18 25.24

Presence of obsessions about the need to collect and keep objects �0.07 (0.52) 0.02 0.93 0.890 0.34 2.57

Age 0.02 (0.02) 1.11 1.02 0.293 0.99 1.05

Being married or in a de facto relationship �0.98 (0.48) 4.24 0.37 0.039 0.15 0.95

Being in part- or full-time employment �0.55 (0.49) 1.24 0.58 0.266 0.22 1.51

(Constant) �0.69 (1.17) 0.35 0.50 0.556

�2 Log Likelihood¼143.57

Y-BOCS¼Yale-Brown Obsessive Compulsive Scale.a For these analyses, n¼138 as marital and employment status data were missing for two participants.

V. Starcevic et al. / Psychiatry Research 200 (2012) 560–567 565

being married or in a de facto relationship and having a part-time/full-time job, as our results suggested that these variablesmight relate in a different way to IRS and checking compulsions.

Results of the logistic regression analyses are shown inTables 8 and 9. When controlling for the presence of checkingcompulsions, the severity of obsessions and the absence of obses-sions about the need to collect and keep objects emerged asindependent predictors of IRS (Table 8). In contrast, when control-ling for the presence of IRS, it was the presence of unintentionalharm obsessions and not being married or in a de facto relationshipthat independently predicted checking compulsions (Table 9).

4. Discussion

The first aim of this study was to ascertain the frequency of IRSin individuals with OCD and determine what they seek IRS for.We found that almost one half of participants asked someone forreassurance, suggesting that IRS is a relatively common way of copingwith obsessions. In accordance with our hypothesis, about one-half ofthese participants sought reassurance about either harm or damagethat they might have caused in the past, or about harm or damagethat they may cause in the future. This suggests that obsessions aboutharm or damage caused by the person may be experienced with the

V. Starcevic et al. / Psychiatry Research 200 (2012) 560–567566

level of distress that calls for reassurance seeking as a coping strategyin addition to compulsions such as checking. Less often, our partici-pants sought reassurance related to obsessions about having to dothings right and contamination obsessions, suggesting that IRS is lesslikely to be used as an additional coping strategy by individuals withthese types of obsessions.

In partial agreement with our second hypothesis, individualswith IRS were more severely ill than those without IRS in terms ofhaving more prominent obsessions. Individuals with IRS also hadhigher levels of depression, anxiety, symptom distress and overallpsychopathology, which might have contributed to the greaterseverity of their illness. These findings have important implicationsas they add more weight to the suggestions that OCD individualswith IRS may be more difficult to treat (Bruch and Prioglio, 2003).That may be because of their greater overall psychopathology andas a consequence of the interference with techniques of behaviortherapy (Salkovskis and Warwick, 1985; de Silva and Rachman,1998; Kyrios, 2003; Clark, 2004), e.g., through the use of IRS as aform of ‘‘safety behavior’’ that makes it more difficult to learn thatobsession-related fears are unfounded.

The finding that obsessions in individuals with IRS are sig-nificantly more severe than obsessions in those without IRS is inaccordance with our hypothesis that individuals who have moresevere obsessions tend to use coping strategies such as IRS, inaddition to compulsions. However, the results regarding thetype of obsessions associated with IRS were inconsistent. Ourfinding of more prominent indecisiveness among individuals withIRS accords well with results of previous research (Summerfeldtet al., 1998).

All analyses demonstrated that checking was likely to beassociated with IRS. This is in agreement with a large body ofliterature (Rasmussen and Eisen, 1992; Rachman and Shafran,1998; Rachman, 2002; Starcevic, 2005; Parrish and Radomsky,2010) and supports the notion that many OCD individuals exhibitboth IRS and checking compulsions.

We found several differences between IRS and checking com-pulsions. People with IRS and no checking compulsions (‘‘reassur-ance seekers’’) were more likely to have more severe obsessionsthan people with checking compulsions and no IRS (‘‘checkers’’),again supporting the link between greater severity of obsessionsand use of IRS as an additional coping strategy. ‘‘Reassuranceseekers’’ were also more likely to report contamination obsessionsthan ‘‘checkers’’. It is possible that due to the often microscopicnature of the contaminants, checking may not be a sufficient oradequate strategy to allay contamination fears, and individualsconcerned about contamination may therefore request reassurancefrom others that there are no contaminants around. Our findingthat ‘‘checkers’’ had obsessions about the need to collect and keepobjects more often than ‘‘reassurance seekers’’ may reflect theirgreater confidence in checking as a way of coping with these more‘‘tangible’’ obsessions. An association presumed to exist betweenreassurance seeking on one hand and the ‘‘unacceptable thoughts’’cluster (impulsive aggression, sexual, somatic and religious obses-sions) on the other (Abramowitz et al., 2003; Williams et al., 2011),was not supported by the results of this study. This may be aconsequence of issues such as the number of these obsessions andthe way that they are grouped.

In accordance with other findings of the study, a logisticregression analysis identified the severity of obsessions andabsence of obsessions about the need to collect and keep objectsas independent predictors of IRS. In another logistic regressionanalysis, checking compulsions were independently predicted bythe presence of unintentional harm obsessions, which corre-sponds to the findings by Williams et al. (2011). Thus, whenunintentional harm obsessions occur in people with both check-ing compulsions and IRS, they may be more related to checking

compulsions, as these obsessions did not predict IRS whenchecking compulsions were controlled for. Perhaps individualswith obsessions pertaining to the possibility of unintentionallycausing harm or damage are more likely to check than seekreassurance from others because of the frequently embarrassingnature of these obsessions. Independent prediction of checkingcompulsions by not being married or in a de facto relationshipaccords with one report that patients with checking compulsionstend to be single (Khanna and Mukherjee, 1992). As they cannotshare obsession-related responsibility for the potentially adverseoutcome with a partner or a spouse, single individuals with OCDmay have to rely more on themselves than those with a partner ora spouse and may therefore be more likely to resort to checking.

This study has a number of strengths and limitations. Ourparticipants seem to be fairly well representative of OCD sufferersin Australia and elsewhere, and they included both people seekingtreatment and those already under care from general practitionersand mental health clinicians. However, we cannot entirely rule outsome referral bias or other bias related to the study sample. Resultsof the study have been based on cross-sectional assessment, whichdoes not permit any inferences to be made about the relationshipsbetween IRS, checking compulsions, OCD severity and other aspectsof OCD over time. In this context, it should be noted that we do notassume temporal primacy of either IRS or compulsions such aschecking. Another limitation pertains to the way in which weassessed IRS (for example, we did not assess the impact of receivingreassurance), but until very recently (Rector et al., 2011) there havebeen no instruments designed specifically to measure IRS. Also, weonly focused on reassurance seeking that occurs in the interperso-nal context. The assessment of other forms of reassurance seekingwould have been complex and was beyond the scope of this study.We made no attempt to clearly distinguish between ‘‘normal’’ andexcessive IRS, as we had no tools for doing that. Also, we could notcontrol for the impact of treatment received currently and in thepast on the reporting of IRS. Finally, our findings are also limited bythe small number of certain obsessions and compulsions and arelatively small number of ‘‘reassurance seekers’’ and ‘‘checkers’’.Still, this study provides the most comprehensive analysis of IRS inOCD to date and of the relationship between IRS and checkingcompulsions.

5. Conclusions

In conclusion, this study contributes to the literature first bydemonstrating that the presence of IRS may be associated withgreater overall severity of OCD. Secondly, IRS tends to occur in thecontext of greater severity of obsessions, suggesting its role as anadditional coping strategy when obsessions are more severe. Thestudy confirms a close link between IRS and checking compul-sions, but also suggests differences, mainly in that they areassociated with somewhat different types of obsessions. Thismay help us better understand the circumstances that give riseto IRS and checking compulsions.

Acknowledgments

The Nepean OCD Study was supported by the Nepean MedicalResearch Foundation and by a Grant from the Pfizer NeuroscienceResearch Grants Program. These funding bodies played no role inthe design of the study, collection, analysis and interpretation ofdata, writing of this report and decision to submit the paper forpublication. The authors are grateful to Colin Slocombe (ACEDAAdelaide), Michelle Graeber (ARCVIC Melbourne), Dr. Scott Blair-West (Melbourne Clinic), the Blacktown OCD Support Group, Julie

V. Starcevic et al. / Psychiatry Research 200 (2012) 560–567 567

Leitch (Kogarah OCD Support Group), Linda Junee (Mental HealthAssociation of New South Wales) and the Penrith Mental HealthPractitioners Network for referring patients.

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