Cogn Ther Res (2012) 36:685–693
DOI 10.1007/s10608-011-9404-9
ORIGINAL ARTICLE
Initial Data Characterizing the Progression from Obsessions and
Compulsions to Full-Blown Obsessive Compulsive Disorder
Meredith E. Coles • Ashley S. Hart • Casey A.
Schofield
Published online: 13 October 2011
Springer Science+Business Media, LLC 2011
Abstract Most individuals who develop obsessive
compulsive disorder (OCD) experience years of
obsessions and/or compulsions preceding onset of
the full-blown disorder (Angst in Current insights in
obsessive compulsive disorder, Wiley, Chirchester,
New York, Brisbane, 1994; Coles et al. in Behav
Cogn Psychother 11:1–11, 2011; Pinto et al. in J
Clin Psychiatry 67(5):703–711, 2006). However,
little is known about experiences during this period
and about factors that are involved in the generation
of interference or distress that signals the onset of
diagnosable OCD. Therefore, the current study was
designed to provide data on the characteristics of the
symptom phase of OCD and potential markers of the
transition from symptoms to the full-blown disorder.
Individuals that eventually developed full-blown
OCD retrospectively reported that generalized
anxiety, perfectionism, impaired work or school
performance, social isolation, preoccupation with
details and intolerance of uncertainty, frequently
emerged after their initial OC symptoms but before
full-criteria for OCD were met. Increases in stress
level, the desire for things to feel ‘just right’, and the
amount of attention paid to one’s thoughts were
perceived as having played an important role in the
transition to OCD. Additional data and theory
development regarding the progression from
symptoms to OCD is warranted.
M. E. Coles (&)
Department of Psychology, Binghamton University,
Binghamton, NY 13902-6000, USA e-mail:
mcoles@binghamton.edu
A. S. Hart
Rhode Island Hospital, Boston, MA, USA
C. A. Schofield
Brown University, Providence, RI, USA
Keywords OCD Etiology Prodrome Course
Obsessions Compulsions
Introduction
Obsessive Compulsive Disorder (OCD) is associated
with significant impairments in daily life, including
impairments in both social functioning (Albert et al.
2010; Bobes et al. 2001; Eisen et al. 2006; Hou et al.
2010; Mancebo et al. 2008) and occupational
functioning (Bobes et al. 2001; Mancebo et al.
2008). For example, upwards of one in three patients
with OCD is unable to work, and nearly one-half of
these individuals receive disability payments
primarily related to their OCD (Mancebo et al.
2008). Suicidal ideation and attempts are common in
OCD, with over 50% of individuals with OCD
having experienced suicidal ideation and nearly one-
third having attempted suicide (Kamath et al. 2007).
OCD is also associated with substantial direct and
indirect costs. Specifically, OCD costs an estimated
$14.36 billion annually (adjusted for inflation at a
rate of $1 in 1990 = $1.71 in 2010; DuPont et al.
1996).
Interventions to reduce the negative impact of
OCD have focused on treatment of the condition
after it has crossed the clinical threshold, an
approach that fails to capitalize on the disorder’s
gradual onset. Individuals who develop OCD
typically experience several years of obsessions
and/or compulsions prior to the onset of the
fullblown disorder. Early qualitative studies asking
patients’ impressions of the onset of their OCD
suggested that the disorder’s onset is gradual in
approximately two-thirds of cases (Angst 1994;
Lensi et al. 1996). Recent quantitative data
separately dating the onset of symptoms and the
onset of interference or distress has shown that this
symptom phase, or risk period, typically lasts several
years or more (Coles et al. 2011). Consistent with
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this pattern of protracted onset, several studies have
shown that subclinical obsessions or compulsions
often begin in early adolescence (12.3, 12.4 years)
but that the onset of diagnosable OCD typically
occurs later, often beginning in late adolescence or
early adulthood (16.9, 18.5 years; (Pinto et al. 2006;
Sobin et al. 1996). Subclinical symptoms
experienced in late childhood have been shown to be
associated with elevated risk for full-blown OCD in
adulthood (Fullana et al. 2009).1
Little is known about the OC symptom phase
beyond when it typically onsets and how long it
usually lasts. For example, data are not available
regarding other symptoms, individual characteristics,
or experiences that are present during this period.
Information is also lacking regarding whether distal
and proximal markers of the transition to full-blown
OCD can be identified. Therefore, empirical data on
the nature of the pre-onset period of OCD is likely to
be of benefit. Such information will inform theory,
clarify the impact of symptoms on normal
development and may suggest potential targets for
intervention. Ultimately, characterization of the
behavioral features of the OCD endophenotype is of
great interest (Chamberlain and Menzies 2009).
Success of prior research on the pre-onset phases of
psychosis and mania also foreshadow the potential
benefits of studying the pre-onset phase of OCD. For
example, many years of systematic investigation of
the symptom phase, or prodromal state, of
schizophrenia has led to the ability to reliably predict
conversion to the fullblown disorder (Cannon et al.
2008; Yung et al. 2004). This knowledge of risk
markers (e.g., disturbances of receptive language,
derealization) has been drawn upon to identify
individuals at high-risk for psychosis and to
intervene before the full-blown disorder has onset
(Morrison et al. 2004, 2007; Yung et al. 2004).
Subclinical symptoms may be one marker of
increased risk for developing full-blown OCD but
are likely to yield a high rate of false positives given
that the prevalence of obsessions and compulsions in
the general population far exceeds the prevalence of
OCD (Stein et al. 1997). As noted by Stein (2009),
the accuracy of predicting who is at high risk for the
onset of full-blown OCD may be improved by
identifying what other behaviors or symptoms
combine with the presence of obsessions and
compulsions to predict OCD onset. However, we are
1 The period characterized by the presence of OC symptoms
without significant interference or distress is referred to as the
‘‘symptom phase’’ throughout the paper.
123
2008). Extrapolating from Pierre Janet’s theory of stages
leading to the development of OCD, more salient feelings of incompleteness or of things being not ‘‘just
right’’ may be involved in the transition to clinically significant
Cogn Ther Res (2012) 36:685–693
aware of only one published report examining
factors that co-occurred with OC symptoms prior to
the onset of the disorder. Patients with OCD were
interviewed retrospectively regarding the presence of
20 depression-related symptoms during the 6 months
prior to the onset of diagnosable OCD (Fava et al.
1996). Generalized anxiety, irritability, and phobic
anxiety were common (60%, 57%, and 53%,
respectively; Fava et al. 1996). These data are useful
in suggesting that obsessions or compulsions are
only part of the clinical picture during the OC
symptom phase.
Potential additional factors that occur during the
OC symptom phase were drawn from theories of the
etiology of OCD, the literature on subclinical OC
symptoms, and clinical experience. Regarding risk
markers, cognitive models of OCD propose that a
preoccupation with ones thoughts and beliefs that
lead to biased interpretations of intrusions (e.g.,
thought-action fusion, intolerance of uncertainty)
increase risk for OCD (Rachman 2002; Salkovskis
1985, 1989; Steketee et al. 1998). Psychoanalytic
models propose a progression from Obsessive
Compulsive Personality Disorder (OCPD;
‘psychasthenia’) to full-blown OCD (Pitman 1987),
thereby suggesting that OCPD symptoms may be
present during the OC symptom phase. Given that
individuals with subclinical OC symptoms have
elevated rates of other anxiety disorders (de Bruijn et
al. 2010; Degonda et al. 1993), mood disorders, and
schizophrenia (de Bruijn et al. 2010), such
symptoms in combination with obsessions or
compulsions may signal increased risk for the
development of full-blown OCD. For example,
individuals with subclinical OC symptoms have been
shown to have symptoms that overlap with mood
disturbance including having fewer friends and
experiencing increased loneliness (de Bruijn et al.
2010) along with lower self-esteem (Degonda et al.
1993).
The risk markers just discussed above provide
information about the period in which individuals
experienced subclinical OC symptoms but do not
provide specific information regarding factors that
played a role in the transition to OCD. It is useful to
consider not only risk factors that are present during
the prodromal period of OCD, but also changes that
mark or contribute to the onset of clinically
significant interference and/or distress that signifies
full-blown OCD. Looking to the extant literature,
previous studies have pointed to a role of
environmental changes, such as a major life event
Cogn Ther Res (2012) 36:685–693
(e.g., marriage, pregnancy/having a child) in
changes in distress associated with OCD symptoms;
(Coles and Horng 2006; Coles et al. 2008; Khanna et
al. 1988). Changes in beliefs related to OCD, such as
increased perceptions of personal responsibility,
have also been hypothesized to trigger full-blown
OCD (Salkovskis et al. 1999, 2000), and prospective
data point to a link between maladaptive cognitions
and OCD symptom severity (Abramowitz et al.
2006; Coles et al. obsessions and compulsions. Both
the traditionally recognized desire to avoid harm and
feelings of incompleteness and ‘‘not just right
experiences’’ have been identified as distinct core
underlying features of OCD (Pietrefesa and Coles
2009; Summerfeldt 2004). Finally, neurocognitive
models of OCD propose a role of impaired executive
functions in the onset of OCD (see Bannon et al.
2002; Menzies et al. 2008).
The current study was designed to gather
additional data regarding the prodromal experiences
of individuals with OCD. As done by Fava et al.
(1996) and studies of the prodromal periods
preceding psychosis (Bechdolf et al. 2002; Moller
and Husby 2000; see Yung and McGorry 1996 for a
review) and bipolar disorder (Correll et al. 2007;
Ozgurdal et al. 2009; see Howes et al. 2011 for a
review), participants were interviewed
retrospectively regarding their experiences prior to
onset of the full-blown disorder. Specifically,
participants were asked about symptoms that began
during the OC symptom phase and changes that may
have played a role in the transition from symptoms
to full-blown disorder.
Several characteristics of the design used in the
current study are worth noting. First, consistent with
the ultimate goal of identifying markers of the
progression from initial symptoms to full-blown
disorder, only symptoms and events that occurred
after the onset of (subclinical) obsessions or
compulsions but before the onset of OCD were
included. Second, in order to more fully characterize
the prodromal period, information was gathered for
the entire symptom period experienced by each
respondent (in contrast to only the 6-months
immediately prior to OCD onset (Fava et al. 1996)).
Third, given that there is very limited data about
symptoms during the OC prodrome, a wide range of
symptoms that began during the OC symptom phase
were assessed.
687
Methods
Participants and Procedure
Retrospective reports of symptoms that developed
during the pre-onset phase of OCD were gathered
from 18 adults (age range of 19–59, M = 33.22)
meeting current full DSM-IV criteria for a principal
diagnosis of OCD (cf, Correll et al. 2007). Thirty-
nine percent of the sample met criteria for comorbid
social phobia, 28% met criteria for a comorbid
unipolar mood disorder, 11% met criteria for
substance abuse and 11% met criteria for
generalized anxiety disorder. All diagnoses were
formulated using structured clinical interviews
(Anxiety Disorders Interview Schedule, n = 16,
DiNardo et al. 1994), or Structured Clinical
Interview for DSM-IV Axis I Disorders, n = 2, (First
et al. 1995). Approximately one half (55.6%) of the
sample reported being female, and all participants
identified their race as Caucasian. Individuals were
asked to participate in a semi-structured interview
related to the development of their OC symptoms
and associated consequences. Informed consent was
obtained prior to participation.
Sixteen participants were treatment-seeking and
participated at or before session two of cognitive-
behavioral therapy. Two participants were recruited
from a prospective study of OC severity over time.
Symptom severity for the current sample was
consistent with other samples of individuals
diagnosed with OCD. For example, mean frequency
and distress scores on the self-report Obsessive
Compulsive Inventory (OCI: Foa et al. 1998) were
71.33 (SD = 19.70) and 65.78 (SD = 22.26),
respectively. These scores were consistent with prior
scores found for individuals with OCD (OCI-F =
66.36 (31.9), OCID = 66.33 (29.4); Foa et al. 1998).
The mean total score on the Beck Depression
Inventory-II (BDI-II: Beck et al. 1996) was 16.39
(SD = 12.50) suggesting that on average participants
reported experiencing mild mood disturbance. OC
symptom content varied across patients with
obsessing being the most frequently endorsed
symptom domain (50%), followed by checking
(33.3%) and neutralizing (33.3%). Washing (22.2%),
ordering (22.2%) and hoarding (22.2%) were the
least frequently endorsed types of OC symptoms.
These findings were consistent with prior findings
showing that checking and neutralizing are typically
among the most common manifestations of OCD,
while ordering and hoarding are often less common
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(Holzer et al. 1994; Pinto et al. 2006; Rasmussen and
Eisen 1990; Rasmussen and Tsuang 1986).
Semi-structured interviews assessing the course of
OCD onset and potential risk and transition markers
were conducted by trained interviewers (advanced-
level graduate students and the first author of this
paper). The interview was composed of three
sections. Section 1 assessed onset patterns of OC
symptoms and the full-blown disorder. Participants
were first asked to describe how their OCD unfolded
for them. They were then asked more directly about
their perception of whether the onset of their OCD
was ‘gradual’ or ‘sudden’, followed by questions
assessing the age at which: (a) they first experienced
obsessions, (b) they first experienced compulsions,
(c) their obsessions and/or compulsions began
creating significant interference in their life, and (d)
their obsessions and/or compulsions began creating
significant distress for them. Each participant’s
symptom phase was defined as the time period from
which they reported the onset of obsessions or
compulsions until when they reported the onset of
interference or distress due to these symptoms.
Section 2 systematically assessed onset, frequency
and severity of 51 symptoms and signs that may
emerge prior to meeting criteria for fullblown OCD
(‘‘risk markers’’).
The section on risk markers assessed
characteristics of OCPD, and symptoms of
depression, psychosis, mania, and general
psychopathology. For each risk marker endorsed as
having begun during the OC symptom phase,
severity was rated from ‘mild’ (1) to ‘moderate’ (2)
to ‘severe’ (3). Assessment of these symptoms was
modeled after the Bipolar Prodrome Symptom Scale-
Retrospective (BPSS-R; Correll et al. 2007), an
established semi-structured assessment of the bipolar
prodrome. The current paper focused on risk markers
that began during the symptom phase and were of at
least moderate severity. Finally, Section 3 presented
a separate list of variables potentially involved in the
onset of associated interference/distress (‘‘transition
markers’’). The extent to which each transition
marker was perceived to play a role in the transition
to symptoms causing significant interference or
distress in the respondent’s life was rated from ‘did
not play a role in the transition’ (0) to ‘may have
played a role in the transition’
(1) to ‘likely played a role in the transition’ (2).
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Results
Course and Duration of OC Symptom Phase
As hypothesized, the majority of the patients with
OCD reported the onset of their disorder to be
‘gradual’ (88.9%), as opposed to ‘sudden’ (11.1%).
On average, patients reported a period of 7.28 years
(SD = 7.61) between the development of obsessions
or compulsions and negative consequences
associated with them (onset of symptoms: M =
14.56, SD = 9.06; interference/distress: M = 21.83,
SD = 10.22). Notably, 100% of the sample reported
having experienced a symptom phase lasting a year
or more, 50% of the sample reported having
experienced a symptom phase lasting 5 years or
more, and 33.3% reported having experienced a
symptom phase lasting ten or more years.
Symptoms and Markers of the OC Symptom Phase
Next we examined the frequency of symptoms that
newly emerged during the OC symptom phase
(‘‘risk markers’’; see Table 1). Obsessive–
compulsive personality features and general anxiety
symptoms were frequently reported as having begun
during the OC symptom phase: generalized anxiety
(46.7%), perfectionism (46.7%), impaired work/
school performance (33.3%), social isolation
(33.3%), preoccupation with details (33.3%) and
intolerance of uncertainty (33.3%).2 Some of the
subsyndromal
Table 1 Proportion of participants experiencing various
symptoms during the OC symptom phase. (‘‘risk markers’’
from Section 2 of the
interview)
Symptoms %
OCD-related beliefs
Intolerance of uncertainty 33.3
Preoccupied with thoughts 13.3
Superstitious beliefs 13.3
Magical ideation/thought action fusion 6.7
OCPD features
Perfectionism 46.7
Preoccupied with details, rules, lists, schedules 33.3
Devoted to work/school 26.7
Overly conscientious, scrupulous, inflexible regarding 20.0
morality/ethics/values
2 Formal statistical tests were not conducted due to the
exploratory nature of the study and the large number of
comparisons that would need to be conducted.
Cogn Ther Res (2012) 36:685–693 689
Unable to discard worthless objects that lack sentimental value Low energy/fatigue 26.7
Insomnia (early, middle or late) 20.0
Reluctant to delegate tasks or work with others
Anhendonia 13.3
Miserly/need to save money for future catastrophes (if young
ask about resources) Changes in appetite-increased 13.3

Rigid and/or stubborn Changes in appetite-decreased 13.3

Depressive symptoms Pessimism/hopelessness 13.3

Depressed mood Increased sleep 0.0
Self-esteem/confidence-lowered General psychopathology
Guilt Generalized anxiety 46.7
Impaired work/school performance 33.3
Social isolation 33.3
Indecision 26.7
Frequent mood swings/lability 20.0
Somatic anxiety 20.0
Panic 20.0
Hypochondriasis 13.3
Oppositionality 6.7
Phobic anxiety 6.7
Depersonalization 6.7
Blunted or inappropriate affect 6.7
Somatic symptoms 6.7
Anorexia 0.0
Hysterical symptoms 0.0
Impaired personal hygiene 0.0
Markedly peculiar behavior 0.0
Table 1 continued
Symptoms %

Subsyndromal manic symptoms

Increased energy/activity 13.3
Irritability/easily angered 13.3
Self-esteem/confidence-increased (grandiose) 6.7
Subsyndromal manic or depressive symptoms
Change in concentration-decrease 26.7
Physically agitated 13.3
Change in memory-increase 6.7
Change in concentration-increase 0.0
Change in memory-decrease 0.0
Subsyndromal psychotic symptoms
Strange or unusual ideas 0.0
Seeing or hearing things 0.0
Suspiciousness 0.0
Subsyndromal manic, depressive or psychotic symptoms
Difficulty thinking or communicating clearly 13.3

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depressive symptoms were also common, occurring
in at least 25% of the cases. These included
depressed mood (26.7%), lowered self-esteem/self-
confidence (26.7%), guilt (26.7%), low
energy/fatigue (26.7%), and decreased concentration
(26.7%). Finally, indecision was also frequently
experienced during the OC symptom phase
(26.7%).
In addition to examining the frequency of the
various symptoms of the OC symptom phase, we
conducted additional analyses examining the timing
of these potential markers. Specifically, for the six
most commonly reported symptoms from the OC
symptom phase, the number of years
thatitprecededtheonsetofOCDwascalculated(seeFig.
1). Relatively speaking, onset of generalized anxiety
was found to be the most distant (M = 5.00, SD =
4.00 years), whereas social isolation and impaired
work or school performance were the most proximal
to the onset of OCD (M = 1.79, SD = 1.46 years, and
M = 1.57, SD = 1.47 years, respectively). Intolerance
of uncertainty, perfectionism, and preoccupation
with details typically preceded the onset of full-
blown OCD by a period of 2–3 years (M = 3.10, SD
= 1.95 years, M = 2.86, SD = 2.34 years and M =
2.00, SD = 2.19 years, respectively).
Symptoms and Experiences of the Transition to
FullBlown OCD
Finally, we evaluated patients’ ratings of the
perceived role that symptoms and experiences
played in transitioning from the symptom phase to
diagnosable OCD (‘‘transition markers’’; see Table
2). Markers of executive function (i.e., attention paid
to thoughts, ability to resist acting on an impulse),
environmental changes (i.e., stress level, changes in
living situation, experiencing a major life event),
intolerance of uncertainty, and a heightened desire
for things to feel ‘just right’ were perceived as
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Cogn Ther Res (2012) 36:685–693
playing an important role in the transition to full-
blown OCD. Of these, changes in the participant’s
stress level was endorsed as the most strongly linked
to the transition from symptom phase to full-blown
OCD (M = 1.65, SD = 0.70), followed by an
increase in the desire for things to feel ‘just right’ (M
= 1.41, SD = 0.71) and the amount of attention paid
to one’s thoughts (M = 1.41, SD = 0.80).
Discussion
Results of the current study suggest the utility of
systematically investigating the pre-onset phase or
‘‘OC symptom phase’’ of OCD. First, findings of
this study replicate prior data indicating that OCD
typically onsets gradually (Coles et al. 2011; Pinto et
al. 2006; Sobin et al. 1996). Specifically, in the
current sample of patients with principal OCD,
100% reported having experienced a period of at
least 1 year between when obsessions or
compulsions manifested and when these symptoms
began to cause significant interference or distress.
On average, the delay between the
Table 2 Ratings of likelihood that particular changes played a
role in the transition from OC symptoms to full-blown OCD
(‘‘transition markers’’ from Section 3 of the interview)
Mean SD
OC-related beliefs
Changes in intolerance of uncertainty 1.12 0.928
Changes in perception of how important thoughts 0.88 0.857
were
Changes in perceived likelihood of threat 0.76 0.903
Changes in perceived need to control thoughts 0.76 0.970
Changes in perceived need to be perfect 0.71 0.920
Changes in perceived responsibility 0.65 0.862
Cogn Ther Res (2012) 36:685–693
Executive functions
Changes in how much attention I paid to my thoughts 1.41
Changes in my ability to not act on an impulse or 1.24
urge
Changes in my attention to potential long-term 0.94
consequences
Changes in my ability to shift from one thing to 0.71
another
Changes in my ability to stop doing something that I 0.71
started
OC core features
Changes in my desire for things to feel ‘just right’ 1.41
Changes in my desire to avoid harm to myself or 0.94
others
Environmental changes
Change in stress level 1.65
Changes in living situation 1.18
Experienced a major life event 1.00
Changes in other people’s responses to my symptoms 0.65
Changes in work or school situation 0.53
Changes in social support 0.44
Change in bioregulatory habits
Changes in sleep habits 0.59
Changes in eating habits 0.29
Each of the above factors was rated on the following scale
regarding the extent to which the individual believed the
factor played a role in the transition to their symptoms causing
significant interference or distress in the respondent’s life:
‘did not play a role in the transition’ (0), ‘may have played a
role in the transition’’ (1), ‘likely played a role in the
transition’ (2)
presence of symptoms and diagnosable OCD was
found to exceed 7 years. Next, symptomatic and
behavioral changes during the OC symptom phase
(‘risk markers’) were examined. Using a semi-
structured interview of onset, frequency and
intensity during the OC symptom phase, particular
experiences that may occur with elevated likelihood
during this period were identified. These included
symptoms of general psychopathology, obsessive–
compulsive personality features, and to a lesser
extent, subsyndromal depressive symptoms.
Comparing the current findings to results of a
previous study of the OCD prodrome (Fava et al.
1996) revealed that both studies found elevated rates
of generalized anxiety, indecision, decreased self-
confidence, depressed mood and low energy/fatigue.
The final aim of the current study addressed
patients’ reports of various factors that may have
691
played a role in the transition from the presence of
0.795
obsessions and compulsions to full-blown OCD.
Data from the sample of individuals with OCD
0.903
studied herein show that elevations in overall stress
levels are commonly endorsed as related to the
0.966
disorder’s onset. Interestingly, increases in the
strength of urges for things to feel ‘just right’ and
0.772
increases in attention to one’s thoughts were also
commonly viewed as contributing to the onset of
0.920
OCD.
These findings raise the possibility that a
phenotype of OCD may be identified based on a
0.712
combination of obsessions and compulsions with
tendencies towards perfectionism, anxiety in general,
0.899
and a desire for certainty. With time, this profile of
symptoms increasingly leads to social isolation and
impaired performance (i.e., at work/school). This is
0.702
consistent with recent writings suggesting that an
0.883
exclusive focus on obsessions and compulsions
1.000
alone may not be sufficient in demarcating risk for
0.931
OCD, but that instead, efforts should be devoted to
identifying additional factors that suggest high risk
0.800
when experienced in combination with obsessions
0.814
and compulsions (Stein 2009). For example, Stein
(2009) questioned whether one’s ability to ‘‘cope
with, rebut, ignore, repress, resist, or regulate’’ OC
0.795
symptoms leads to the expression of OCD. Findings
0.686
presented herein suggest that cognitive (intolerance
of uncertainty, preoccupation with details,
perfectionism) and affective (generalized anxiety)
factors may manifest several years before the onset
of full-blown OCD, whereas changes in social
interaction and school or work performance may
manifest more closely in time to OCD onset.
Data collected herein on markers of the actual
transition to full-blown OCD suggest that both
individual characteristics and external environmental
factors may play a role. This evidence suggesting
that changes in the ability to resist acting on urges
(i.e., response inhibition) and the amount of attention
paid to thoughts are important in the disorder’s onset
is consistent with recent writings describing a
potential neurocognitive endophenotype of OCD
(Chamberlain et al. 2005, 2008; Menzies et al.
2007). Specifically, deficits in response inhibition
and set-shifting have been posited to represent
endophenotypic markers for OCD (Menzies et al.
2007). In someone with subclinical OC symptoms, a
deterioration in response inhibition may manifest as
increasing difficulty resisting the urge to perform
compulsions or rituals. Similarly, impairment in
setshifting may contribute to continued attention to
123
692
one’s obsessive thoughts, further exacerbating the
impact of symptoms that were previously
subclinical. However, future research should
investigate whether these markers precede OC
symptoms and consider measuring relevant domains
of executive functioning via objective assessments
(e.g., Wisconsin Card Sorting Task) rather than
relying exclusively on self-report data. Data
comparing the symptom phase prior to OCD versus
other disorders will clarify the specificity of factors
identified herein as unique to OCD versus broader
markers of risk to multiple forms of
psychopathology.
The results of this study suggest that external
environmental factors (in particular, stress), may
compromise otherwise relatively effective coping
strategies, resulting in individuals being particularly
vulnerable to the development of pathological
coping strategies (e.g., compulsions). Finally, the
experience of increased stress levels may heighten
perceptions of threat and diminish perceptions of
coping abilities. However, given the retrospective
design of the current study, we cannot establish with
certainty that memory biases have not impacted
participants’ reports on their experiences of stress.
Thus, prospective research is required in order to
clearly establish a connection between the self-
reported experience of stress, the relevant
characteristics of stressors, and the subsequent onset
of symptoms of OCD.
In conclusion, results of the current study support
the utility of studying the pre-onset OC symptom
phase of OCD and point to several factors that may
mark progression toward the disorder. However,
additional work is clearly needed to replicate and
extend this research, particularly prospective
longitudinal studies that use community samples to
identify factors that differentiate individuals who
develop OCD from those who maintain only
subclinical symptoms or develop other psychiatric
conditions. Prospective studies will reduce potential
biases associated with the use of retrospective self-
reports as used in this study. Memory is not exact
and is open to influences from current experiences.
Future research can also evaluate characteristics of
individuals who maintain OC symptoms (without the
full-blown disorder) in comparison to those who
eventually develop full-blown OCD. Such
comparisons may provide meaningful information
about what buffers individuals from the insidious
development of OCD. Such work will continue to
benefit from the strides made in research addressing
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Cogn Ther Res (2012) 36:685–693
the pre-onset phases of psychosis and bipolar
disorder.
Acknowledgments The authors thank Barbara Cornblatt for
her valuable input regarding the development of this study.
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