Why compulsions persist: An ecological momentary assessment study of the reinforcement of compulsions

Background The cognitive-behavioral model (CBM) for obsessive-compulsive disorder (OCD) posits that compulsions are negatively reinforced by providing temporary relief from distress, removal of unwanted thoughts, and reinforcement of obsessive beliefs. However, research has yet to test these assumptions using longitudinal and ecological methods. Method We examined the CBM using an intensive-repeated measures ecological-momentary assessment design. Participants with OCD (n = 45) completed items assessing momentary compulsion severity, anxiety, unwanted thoughts, and perceived threat 7×/day for 7 days. Results Greater anxiety, unwanted thoughts, and perceived threat immediately before compulsions were associated with greater compulsion severity. Greater compulsion severity was also associated with greater reduction from before to after compulsions of anxiety and was nonlinearly associated with unwanted thoughts, such that both large increases and decreases in unwanted thoughts were associated with greater compulsion severity. All levels of anxiety reduction and no change or smaller (relative to larger) increases in anxiety from before to after a compulsion were associated with a greater likelihood of compulsions at the next timepoint. Conclusions This is the first study to provide ecological validity to several aspects of the CBM for OCD. Anxiety reduction and avoidance of a negative emotional contrast (no change or small increase in anxiety from before to after the compulsion) were significant predictors of future compulsions, and were the only longitudinal reinforcers of compulsions. Findings underscore the importance of addressing anxiety tolerance in treatment and show the first evidence for a novel contrast avoidance effect in the reinforcement of compulsions.