Journal of Anxiety Disorders 69 (2020) 102175

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Journal of Anxiety Disorders

journal homepage: www.elsevier.com/locate/janxdis

Incompleteness, harm avoidance, and disgust: A comparison of youth with T

OCD, anxiety disorders, and no psychiatric disorder
Matti Cervina,b,*, Sean Perrinc, Elin Olssonb, Emma Claesdotter-Knutssona,b, Magnus Lindvalla,b
a
Lund University, Faculty of Medicine, Department of Clinical Sciences Lund, Child and Adolescent Psychiatry, Lund, Sweden
b
Skåne Child and Adolescent Psychiatry, Lund, Sweden
c
Lund University, Department of Psychology, Lund, Sweden

ARTICLE INFO ABSTRACT

Keywords: Psychological models of pediatric obsessive-compulsive disorder (OCD) place a heavy emphasis on harm
Obsessive-compulsive disorder avoidance as a maintaining factor and target for treatment. Incompleteness and disgust may also play a role in
Incompleteness pediatric OCD but remain understudied. Youth with OCD (n = 100), anxiety disorders (n = 96), and no im-
Disgust pairing psychiatric symptoms (n = 25) completed self-report measures of trait-level incompleteness, harm
Harm avoidance
avoidance, and disgust and current symptoms of OCD, anxiety, and depression. Group differences and asso-
Children
Emotion
ciations between emotions, symptoms, and pre- to post-treatment change in overall OCD severity were ex-
amined. Youth with OCD and anxiety disorders scored higher on harm avoidance and disgust than youth with no
psychiatric disorder. Youth with OCD scored higher on incompleteness than youth with anxiety disorders and
youth with no psychiatric disorder. Harm avoidance showed unique associations to self-reported symptoms of
OCD, anxiety, and depression while incompleteness was uniquely related to OCD and disgust to anxiety. Within
the OCD sample, incompleteness and harm avoidance were differentially related to the major OCD symptom
dimensions, and change in incompleteness was uniquely related to pre- to post-treatment change in OCD se-
verity. Trait-level incompleteness appears to play a central role in pediatric OCD and studies investigating its
direct involvement in symptoms and associations with treatment outcome are needed. The role of disgust in
relation to pediatric OCD remains unclear.

1. Introduction
Pediatric obsessive-compulsive disorder (OCD) is a persistent and
highly disabling condition (Hofer et al., 2018; Piacentini, Bergman,
Keller, & McCracken, 2003). Its cardinal symptoms of obsessions and
compulsions can take on a myriad of forms resulting in highly hetero-
geneous clinical presentations and uncertainty about how to best de-
scribe the disorder from a taxonomic perspective (Mataix-Cols, Rosario-
Campos, & Leckman, 2005). With the release of the DSM-5, OCD was
removed from the anxiety disorders section and placed in a new section
called Obsessive-Compulsive and Related Disorders (American
Psychiatric Association, 2013). This move was in part based on the
highly repetitive and often ritualized nature of OCD symptoms, a fea-
ture that OCD shares more with trichotillomania, body dysmorphic
disorder, and excoriation disorder than with the anxiety disorders
(Abramowitz & Jacoby, 2015; Bartz & Hollander, 2006; Stein et al.,
2010). Moreover, it was argued that the experience of anxiety, even
though very common in OCD, is not present in or crucial for all OCD
sufferers (Van Ameringen, Patterson, & Simpson, 2014).
The division of OCD and the anxiety disorders has been the subject
of much debate (Abramowitz & Jacoby, 2015; Stein et al., 2010), not
least because of the central role ascribed to fear and anxiety in evi-
dence-based treatments for OCD, particularly exposure and response
prevention (ERP) based cognitive behavioral therapy (CBT) in which
patients are asked to confront stimuli/situations that cause them fear or
distress (exposure), while refraining from compulsive behaviors (re-
sponse prevention) (Abramowitz, Taylor, & McKay, 2009; Foa &
McLean, 2016). Although this form of treatment has been shown to be
effective, partial or non-response and subsequent relapse is common
(Pediatric OCD Treatment Study Team, 2004; Skapinakis et al., 2016)
which highlights the need for a better understanding of vulnerability
and maintaining factors in pediatric OCD.
The limitations of a solely fear-based view of OCD has been raised
by numerous researchers, with a recurring theme being that with a

⁎
Corresponding author at: Lund University, Faculty of Medicine, Department of Clinical Sciences Lund, Child and Adolescent Psychiatry, Sofiavägen 2D, SE-22241
Lund, Sweden.
E-mail address: matti.cervin@med.lu.se (M. Cervin).

https://doi.org/10.1016/j.janxdis.2019.102175
Received 26 April 2019; Received in revised form 12 November 2019; Accepted 16 December 2019
Available online 19 December 2019
0887-6185/ © 2019 Elsevier Ltd. All rights reserved.
M. Cervin, et al.
condition as heterogeneous as OCD, it is likely that the motivational
influences are equally heterogeneous (Gillan & Sahakian, 2015;
Lazarov, Liberman, Hermesh, & Dar, 2014; Nutt & Malizia, 2006; Stein
et al., 2010; Summerfeldt, Kloosterman, Antony, & Swinson, 2014).
Within the Core Dimensions Model of OCD (Summerfeldt et al., 2014),
fear (or harm avoidance) is acknowledged to play a central role in OCD,
but no less so than a heightened feeling of things being not just right or
a disturbing feeling that behaviors or thoughts have not been completed
in a satisfactory way (termed incompleteness). Experiences of in-
completeness are common in the general population and can be elicited
by a line of stimuli, e.g. a drawer not being completely closed, wrinkled
clothes, lines not running in parallel, or a sense that something was not
written in a correct enough way (Ravid, Franklin, Khanna, Storch, &
Coles, 2014).
In relation to OCD, it has been suggested that feelings of in-
completeness may help explain the repetitive nature of compulsive
behavior and the rigid rules that often guide such behavior.
Accordingly, it has been shown that trait incompleteness is heightened
in individuals diagnosed with OCD compared to those with anxiety,
gambling, and eating disorders (Chik, Calamari, Rector, & Riemann,
2010; Ecker, Kupfer, & Gonner, 2014; Ghisi, Chiri, Marchetti, Sanavio,
& Sica, 2010; Sica et al., 2015) and is more strongly related to OCD than
to general distress (Taylor et al., 2014). Trait incompleteness has also
been found to be uniquely related to OCD symptoms after controlling
for harm avoidance and co-occurring psychiatric symptoms in clinical
and non-clinical samples (Belloch et al., 2016; Ecker & Gonner, 2008),
and reduced as an effect of OCD treatment (Coles & Ravid, 2016). In
relation to youth, few studies exist, but it has been shown that everyday
experiences of incompleteness (or a very similar phenomena termed not
just right-experiences) are as common in adolescents as in adults with
around 80 % of adolescents reporting such experiences; but in the only
study to date, such experiences were not related to self-reported OCD
symptoms (Ravid et al., 2014). Research on symmetry-related OCD in
youth (a symptom dimension in which incompleteness may play a
central role) has suggested that this class of symptoms may be related to
an earlier age of OCD onset and more frequent OCD in first-degree
relatives (Jacobsen & Smith, 2017). However, no studies have ex-
amined the role of incompleteness in youth with OCD, leaving the
possible role of incompleteness in symmetry (and other) OCD symptoms
empirically unaddressed in this age group.
Disgust is another emotion that has long been associated with OCD,
particularly the contamination subtype, but disgust is not included in
the Core Dimensions model of OCD which may limit a fuller under-
standing of emotion involvement in OCD (e.g., Ecker & Gonner, 2008).
The feeling of disgust is argued to play a key evolutionary role in
avoiding contact with noxious and infectious substances (Davey, 2011;
Van Overveld, de Jong, Peters, Cavanagh, & Davey, 2006) and an ac-
cumulating body of evidence suggests that the tendency to react fre-
quently and with intense feelings of disgust to external and internal
stimuli (i.e., disgust proneness) may be involved in the onset and
maintenance of various forms of psychiatric symptoms, including OCD
(for a review, see Olatunji, Ebesutani, Kim, Riemann, & Jacobi, 2017).
Within this body of research, a great deal of attention has been directed
toward whether disgust is more specifically related to contamination-
related OCD or to OCD more generally, with mixed results (Olatunji,
Unoka, Beran, David, & Armstrong, 2009; Olatunji, Cisler, McKay, &
Phillips, 2010; Olatunji, Ebesutani, & Kim, 2016). Only a small number
of studies have examined the role of disgust in relation to OCD in youth.
In a non-clinical sample of 8−12 year old children, self-reported dis-
gust propensity correlated in the moderate range with self-reported
OCD symptoms, but correlations of similar or stronger magnitude were
also found in relation to phobic symptoms, with the strongest correla-
tions emerging in relation to animal and blood-injury phobia (Muris,
van der Heiden, & Rassin, 2008). Olatunji et al. (2017) found disgust
proneness to be related to overall OCD symptom severity in a sample of
youth with mixed mental disorders, even after controlling for general
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Journal of Anxiety Disorders 69 (2020) 102175
distress. Taboas et al. (2015) found that children receiving CBT for OCD
showed significantly greater reductions in disgust propensity than
children receiving CBT for a primary anxiety disorder. Similarly,
Knowles, Viar-Paxton, Riemann, Jacobi, and Olatunji (2016)) found
that changes in disgust propensity were significantly correlated with
changes in OCD symptoms during CBT, even after controlling for
changes in anxiety and depression.
As OCD tends to onset during childhood or adolescence and follow a
chronic course without effective treatment (Kessler et al., 2005), and as
a significant proportion of youth do not achieve a full and durable re-
sponse to the first-line OCD treatment (CBT) (Skapinakis et al., 2016),
studies are needed to identify factors that may help explain the onset
and persistence of the disorder. Furthermore, research on etiological/
maintaining factors that are specifically related to OCD may inform
genetic and neurobiological research, which in turn may result in better
prevention and treatment. In an endeavor to examine factors that may
be specifically related to OCD, incompleteness and disgust are strong
candidates for further investigation. If these emotions are important to
pediatric OCD, this may have implications for treatment. For example,
it is possible that symptoms driven by (or patients with a strong pro-
neness for) these emotions may need individually tailored treatments
and that ERP may be less effective when symptoms are more motivated
by these emotions than by fear. For instance, it has been suggested that
habit reversal exercises may be beneficial or needed for patients with
symptoms driven by incompleteness (Summerfeldt, 2004), and in-
completeness have been shown to predict poorer treatment outcomes
for adults with elevated contamination fears receiving a short ERP
based intervention (Mathes, Kennedy, Wilver, Carlton, & Cougle, 2019).
Further, disgust has been shown to habituate slower than fear to re-
peated exposures (Olatunji, Smits, Connolly, Willems, & Lohr, 2007).
As indicated above, disgust correlates with phobic (and other forms)
of childhood anxiety, and thus does not appear to be uniquely related to
pediatric OCD. The same may be true of incompleteness, but no studies
of incompleteness and OCD have been carried out with clinical youth
samples; further, no studies have conjointly investigated harm avoid-
ance, incompleteness, and disgust in relation to clinical OCD (either in
children or adults). Thus, studies with clinical youth samples, that in-
clude measures of both incompleteness and disgust, may help clarify
the importance of both incompleteness and disgust to pediatric OCD.
Furthermore, it is reasonable to expect that in youth with OCD, disgust
may be more related to contamination symptoms (e.g., in relation to the
common concerns with sticky and noxious substances), and in-
completeness to ordering (in which repetition until it feels just right are
commonly reported). However, as noted above, studies with adults find
that incompleteness and disgust may also be related to OCD more
generally. To further elucidate the relationship between these emotion-
related constructs and the heterogeneous symptoms of OCD, studies are
needed that address how incompleteness and disgust relate not only to
overall severity of pediatric OCD but also to OCD at the symptom di-
mension level.
The aim of the present study was to address these present gaps in
the literature. As a first step, we examine whether scores on self-report
measures of harm avoidance, incompleteness, and disgust can be used
to differentiate youth with OCD, youth with anxiety disorders, and
community youth without clinically impairing psychiatric symptoms. In
line with theoretical notions and empirical evidence (mainly from re-
search with adults), we hypothesize that harm avoidance and disgust
will be equally elevated in youth with OCD and anxiety disorders when
compared to non-clinical youth and that incompleteness will be ele-
vated only in youth with OCD. Second, we use structural equation
modelling (SEM) to assess how harm avoidance, incompleteness, and
disgust are related to self-reported symptom severity of OCD (at the
disorder and dimensional level), anxiety, and depression. Based on the
Core Dimensions Model, we hypothesize that harm avoidance will be
related to both OCD and anxiety while incompleteness will be related
only to OCD. For disgust, we hypothesize that it will be related to OCD
M. Cervin, et al.
and anxiety. All examinations in relation to self-reported depression
will be exploratory. In relation to OCD symptom dimensions (given the
dearth of studies with youth) our examinations are mainly exploratory,
but we expect that harm avoidance will be related to intrusive thoughts
(obsessing), incompleteness to ordering, and disgust to washing.
Finally, we examine to which degree changes in OCD symptoms fol-
lowing treatment for this condition are associated with changes in harm
avoidance, incompleteness, and disgust and we hypothesize that change
in OCD will be related to change in all of these constructs.
2. Methods
2.1. Participants and diagnostic status
Participants were 100 clinically referred youth with a primary (93
%) or secondary (7 %) DSM-V diagnosis of OCD, 89 clinically referred
youth with a primary DSM-V anxiety disorder but no OCD, and 25
youth recruited from the community who had no clinically impairing
psychiatric symptoms and were not seeking treatment. Participants
with OCD and anxiety disorders were recruited from a specialized child
and adolescent (outpatient) clinic in the south of Sweden. The non-
clinical controls were recruited from schools near to the clinic. Of the
seven participants with OCD as a secondary diagnosis, three had a
primary anxiety disorder (generalized, separation, and social anxiety
disorders), two had primary bipolar disorder (medicated, symptoms
stable), and two a primary depressive disorder. These conditions were
deemed ´primary’ because it was the condition for which the youth was
initially referred and treated. However, all participants in the OCD
sample received treatment for OCD.
Of the 100 participants with OCD, 66 were reassessed after treat-
ment (mean follow-up time = 12.81 months, SD = 6.95) and com-
prised the follow-up sample. Of the 34 OCD participants not included in
the follow-up sample, 15 were still in treatment for OCD at manuscript
completion, 15 had failed to complete the self-report measures at
follow-up, two could not be reached, and two refused a follow-up as-
sessment. All 66 OCD participants in the follow-up sample received
OCD-specific CBT involving psychoeducation, cognitive restructuring,
and exposure plus response prevention (mean number of CBT ses-
sions = 10.6, SD = 9.0), but fourteen (21.2 %) refused to engage in ERP
exercises. Nineteen (28.8 %) were treated with selective serotonin re-
uptake inhibitors. Sociodemographic and diagnostic data for all three
groups are presented in Table 1. An a priori decision was made to
control for age and sex in all group comparisons, and groups did differ
for these variables (sex: χ2[2] = 14.52; p < .01; age: F[2]=7.71, p <
.01, anxiety > OCD = non-clinical).
Table 1
Sociodemographic and diagnostic data across groups.
OCD
(n = 100)
Age, M (SD) 13.34 (2.65)
Proportion female, n (%) 59 (59.0 %)
Family economy, good or excellent, n (%) 79 (79.0 %)
Living with two legal guardians, n (%) 67 (67 %)
University education mothers, n (%) 79 (79.8 %)
University education fathers, n (%) 57 (57.6 %)
Ongoing OCD, n (%) 100 (100.0 %)
Ongoing anxiety disorder, n (%) 48 (48.0 %)
Ongoing major depression n (%) 10 (10.0 %)
Previous major depression n (%) 34 (34.0 %)
ADHD n (%) 17 (17.0 %)
Autism n (%) 7 (7.0 %)
Note. OCD = Obsessive-Compulsive Disorder. ADHD = Attention Deficit Hyperactivity Disorder.
3
Journal of Anxiety Disorders 69 (2020) 102175
2.2. Measures
2.2.1. Diagnostic status and OCD severity
Diagnostic status for all participants, including non-clinical controls,
was assessed using the Mini International Neuropsychiatric Interview
for Children and Adolescents (MINI-KID), a structured diagnostic in-
terview covering the most common mental disorders in youth (Sheehan
et al., 2010). For OCD participants, study inclusion was a primary or
secondary diagnosis of OCD, and for anxiety participants, study inclu-
sion was a primary anxiety disorder while not meeting diagnostic cri-
teria for OCD. DSM-5 criteria were used to establish OCD and anxiety
disorder status. The non-clinical participants recruited from schools
were excluded if they fulfilled diagnostic criteria for any current psy-
chiatric disorder with three excluded on this basis. Two youth recruited
from schools who met the symptom but not the functional impairment
criteria for a diagnosis of specific phobia, and not in need of treatment,
were included in the non-clinical comparison group.
OCD severity was assessed with the Children’s Yale-Brown
Obsessive Compulsive Scale (CY-BOCS), a clinician-rated measure of
the overall severity of obsessions and compulsions (Scahill et al., 1997).
All CY-BOCS interviews were carried out by clinical psychologists
trained to use the CY-BOCS and with extensive experience in the as-
sessment and treatment of pediatric OCD. The Swedish version of the
CY-BOCS used in the present study has been shown to possess high
levels of convergent and criterion validity (Cervin, Perrin, Olsson,
Claesdotter-Knutsson, & Lindvall, 2019; Valderhaug & Ivarsson, 2005).
2.3. Self-reported symptoms of OCD, anxiety and depression
Self-reported symptoms of OCD, depression, and anxiety were as-
sessed with validated, Swedish-language versions of the following self-
report measures (described below): the Obsessive Compulsive
Inventory – Child Version (OCI-CV) (Foa et al., 2010; Aspvall et al.,
2019); the Children’s Depression Inventory – Short Version (CDI-SV)
(Allgaier et al., 2012); and the Screen for Child Anxiety Related Emo-
tional Disorders – Revised (SCARED-R) (Muris, Merckelbach, Schmidt,
& Mayer, 1998; Muris, Merckelbach, Van Brakel, & Mayer, 1999).
The 21-item OCI-CV is designed to assess the severity of OCD
symptoms (both obsessions and compulsions; e.g., I repeatedly check
doors, window drawers, etc.; I frequently get nasty thoughts and have dif-
ficulty in getting rid of them) grouped into the following dimensions:
doubting/checking, obsessing, washing, hoarding, ordering, and neu-
tralizing. All items are rated on an 0–2 scale (0 = Never, 2 = Always),
yielding a total score of 0–42, with higher scores indicating more severe
symptoms. The Swedish translation of the OCI-CV used in this study has
been found to have high levels of internal consistency, a similar factor
structure to the English-language original, and to be sensitive to the
effects of treatment for OCD (Aspvall et al., 2019). In the current study,
Anxiety disorders Non-clinical
(n = 96) (n = 25)
14.68 (2.52) 13.03 (3.11)
79 (82.3 %) 14 (56.0 %)
50 (52.1 %) 14 (56 %)
50 (61.7 %) 13 (59.1 %)
44 (56.4 %) 15 (88.3 %)
41 (52.6 %) 11 (73.3 %)
0 (0.0 %) 0 (0.0 %)
96 (100.0 %) 2 (8.0 %)a
31 (32.3 %) 0 (0.0 %)
55 (57.3 %) 4 (16.0 %)
5 (5.2 %) 0 (0.0 %)
1 (1.6 %) 0 (0.0 %)
a
Threshold specific phobia.
M. Cervin, et al.
internal reliability coefficients for the OCI-CV were as follows: Total
Scale: a = .87; Doubting/Checking: a = .80; Obsessing: a = .74;
Washing: a = .84; Hoarding: a = .76; Ordering: a = .84; Neutralizing:
a = .54. The internal reliability coefficients for the OCI-CV dimensions
are based only on scores for the OCD sample because in the present
study the dimension scores are only used for this sample.
The CDI-SV is a 10-item measure of depressive symptoms in youth
(e.g., I feel like crying every day; I am sad all the time). For each item,
respondents select from among three statements representing differing
frequencies for that symptom, scored 0–2, yielding a total score ranging
from 0 to 20, with higher scores indicating more severe symptoms. The
Swedish version of the CDI-SV used in this study has been shown to
have high levels of internal reliability and convergent validity (Ahlen &
Ghaderi, 2017). Internal reliability for the CDI-SV in the present sample
was a = .87.
The SCARED-R is a 41-item measure of anxiety symptoms in youth
(e.g., I worry about the future; I am nervous), with subscales measuring
panic, social, generalized, separation, and school anxiety. Only the total
score is used in this study. All items are rated on an 0–2 Scale (0 = Not
True, 2 = Very True), with higher scores indicating more severe
symptoms. The Swedish translation used in this study has been shown
to have high levels of internal consistency and convergent validity
(Ivarsson, Skarphedinsson, Andersson, & Jarbin, 2017). The internal
reliability coefficient for the SCARED-R in the present sample was a =
.93.
2.4. Incompleteness and harm avoidance
Trait-level incompleteness and harm avoidance were measured with
the Obsessive–Compulsive Trait Core Dimensions Questionnaire
(OCTCDQ) (Summerfeldt et al., 2014). The 20-item OCTCDQ includes
10 items covering the frequency of everyday experiences of in-
completeness (e.g., I must do things in a certain way or I will not feel right; I
am very particular about how things must appear or be done) and 10 items
covering the frequency of everyday experiences of harm avoidance
(e.g., Even if harm is very unlikely, I feel the need to prevent it at any cost; I
have fears that I wish I could ignore, but can’t.). All items are rated on a
0–4 scale of frequency/intensity (0 = Never, 4 = Always). Each sub-
scale has a total score of 0–40 with higher scores indicating more fre-
quent experiences. The OCDTCDQ was originally developed for use
with adults where it has been found to have good psychometric prop-
erties (Cervin & Perrin, 2019; Summerfeldt et al., 2014). The Swedish
translation used in this study has been found to possess high levels of
internal consistency and convergent validity in Swedish youth seeking
treatment for OCD and anxiety disorders (Cervin & Perrin, 2019). The
internal consistency coefficients for the Incompleteness and Harm
Avoidance subscales in the present sample were a = .89 and a = .93,
respectively.
2.5. Disgust propensity
Disgust propensity was assessed with the 30-item Disgust Emotion
Scale – Child Version (DES-C) (Muris et al., 2012). All items are rated on
a 0–4 scale of the degree of disgust intensity in relation to different
stimuli (e.g., A slice of bread with green mold on it; The smell of the re-
stroom at school; 0 = Not disgusted, 4 = Extremely disgusted). The DES-C
consists of five subscales related to rotting foods, injection and blood,
odors, mutilation and death, and animals. Higher scores on the sub-
scales and the total scale indicate higher disgust propensity. Only the
total score is used in this study. The DES-C has been found to possess
high levels of internal consistency and convergent validity (Cervin &
Perrin, 2019; Muris et al., 2012). A Swedish version of the DES-C was
made by the authors following internationally-recognized guidelines on
the translation of patient reported outcome measures (Wild et al.,
2005), which was found to possess high levels of internal reliability and
convergent validity (Cervin & Perrin, 2019). The internal consistency
4
Journal of Anxiety Disorders 69 (2020) 102175
coefficient for the total score on the DES-C in the present sample was a
= .92.
2.6. Statistical analysis
Group differences for the scores on the measures of incompleteness,
harm avoidance, disgust, OCD, anxiety, and depression were examined
by fitting six analysis of covariance (ANCOVA) models, adjusted for age
and sex, to the data. Follow-up, pairwise comparisons (based on the
marginal means), and using Sidak correction for multiple comparisons,
were performed to examine differences between the three groups.
To explore the associations between incompleteness, harm avoid-
ance, and disgust and self-reported OCD, anxiety, and depression, we
used SEM. First, using maximum likelihood estimation, a model was fit
with paths from emotion measures (incompleteness, harm avoidance,
disgust) to symptom measures (OCD, anxiety, depression) while ac-
counting for covariance between emotion and symptom measures, re-
spectively. Following Williams and Hazer (1986), measurement error
was accounted for by including the known internal consistency coeffi-
cients for each measure in the model. An identical SEM procedure was
used to examine the relationships between emotion measures and the
individual OCD symptom dimensions for the OCD participants only (in
which we used the internal consistency coefficients of the measures in
the OCD sample presented above).
For all OCD participants in the follow-up sample, changes in pre-to-
post treatment scores for harm avoidance, incompleteness, and disgust
were assessed via paired samples t-tests. Then, pre-to-post-treatment
change scores were computed for the measures of trait-level harm
avoidance, incompleteness, and disgust and used as independent vari-
ables in a multiple linear regression model, adjusted for age and sex,
with pre-to-post-treatment change scores for overall OCD severity (CY-
BOCS) as the dependent variable. Because our main interest in this
latter analysis was whether changes in harm avoidance, incomplete-
ness, and disgust were related to change in OCD (and not for whom
change had occurred), we used data from all participants that under-
went follow-up assessments, including those who had engaged in OCD-
focused CBT but refused to engage in the ERP component.
2.7. Ethical considerations
The study protocol was reviewed and approved by the regional
ethics committee (Dnr2015/663-3/12 and Dnr2016/92-12/5). All
participants and their legal guardian/s gave written informed consent
to participate in the study.
3. Results
3.1. Group differences for incompleteness, harm avoidance, and disgust
The distribution of scores for incompleteness, harm avoidance, and
disgust across groups are depicted in Fig. 1. Table 2 presents the means,
standard deviations, ANCOVA results, and group comparisons (based
on the marginal means) for all study measures.
3.2. Path models (SEM)
Table 3 presents the pairwise zero-order correlations for the mea-
sures of harm avoidance, incompleteness, disgust, OCD, anxiety, and
depression for all participants with OCD and anxiety disorders. Corre-
lations were in the moderate to strong range with the strongest corre-
lation emerging between incompleteness and self-reported symptom
severity of OCD. Fig. 2 presents the statistically significant paths for the
two SEM models. Model (a) depicts the relationships between harm
avoidance, incompleteness, and disgust and depression, anxiety, and
OCD – for the OCD and anxiety disordered participants. Model (b)
depicts the relationship between harm avoidance, incompleteness,
M. Cervin, et al. Journal of Anxiety Disorders 69 (2020) 102175

Fig. 1. Violin plots showing the distribution of scores for harm avoidance, incompleteness, and disgust across groups.
Note. OCD = Obsessive-Compulsive Disorder. Quartiles from a kernel density estimate depicted as solid lines within the violin plots. The boxes correspond to the first
(Q1, lower hinge) and third (Q3, upper hinge) quartiles, with median in the middle and the maximum and minimum values at the end of the lines. (For interpretation
of the references to colour in this figure legend, the reader is referred to the web version of this article).

disgust and scores on the major OCD symptom dimension – for the OCD For the larger clinical sample (youth with OCD and anxiety dis-
participants only. All path coefficients for models (a) and (b) are re- orders), when accounting for covariance between emotion and
ported in Table 4. symptom variables, respectively, harm avoidance was significantly

5
M. Cervin, et al. Journal of Anxiety Disorders 69 (2020) 102175

Table 2
Means, standard deviations, effects of group (F statistics) on the outcome variables, and pairwise group comparisons (Sidak adjusted) across the measures included in
the study. Post-treatment data for 66 OCD participants is also reported.
OCD Anxiety disorders Non- F ηp2 OCD vs. anxiety† OCD vs. Anxiety vs. NC†
clinical (NC) df: 2, 216 NC†

Pre-treatment
N 100 96 25 39.4** .27 OCD > Anx** OCD > NC** Anx = NC
OCI-CV, M (SD) 18.6 (7.3) 12.5 (6.3) 7.8 (5.9)
CDI-SV, M (SD) 5.2 (4.2) 7.5 (4.6) 2.0 (2.8) 9.9** .08 OCD = Anx OCD > NC* Anx > NC**
SCARED-R, M (SD) 30.1 (14.5) 39.9 (13.4) 16.0 (10.8) 23.5** .18 OCD < Anx* OCD > NC** Anx > NC**
Harm avoidance, M (SD) 20.3 (9.8) 20.3 (9.3) 9.3 (7.6) 13.9** .11 OCD = Anx OCD > NC** Anx > NC**
Incompleteness, M (SD) 23.4 (8.2) 17.2 (8.2) 11.6 (9.2) 30.7** .22 OCD > Anx** OCD > NC** Anx = NC
DES-C, M (SD) 54.6 (21.9) 56.2 (18.7) 39.8 (20.9) 6.1* .05 OCD = Anx OCD > NC* Anx > NC*
CY-BOCS, M (SD) †† 23.47 (4.15)
Post-treatment
N 66 – –
Age, M (SD) 13.3 (2.4) – –
Proportion female, N (%) 37.0 (56.1 %) – –
Harm avoidance, M (SD) 16.2 (8.9) – –
Incompleteness, M (SD) 20.3 (9.0) – –
DES-C, M (SD) 52.3 (20.9) – –
CY-BOCS, M (SD) 16.6 (6.8) – –

Note. OCD = Obsessive-Compulsive Disorder. OCI-CV = Obsessive Compulsive Inventory – Child Version. CDI-SV = Children’s Depression Inventory – Short Version.
SCARED-R = Screen for Child Anxiety Related Emotional Disorders – Revised. DES-C = Disgust Emotion Scale – Child Version. CY-BOCS = Children’s Yale-Brown
Obsessive Compulsive Scale. †Based on age and sex adjusted marginal means. ††Data for 98 OCD participants. * indicates p < .01. ** indicates p < .001.

Table 3 0.362) were not statistically significant predictors in the model.

Zero-order Pearson correlations for self-reported harm avoidance, incomplete-
ness, and disgust and self-reported symptom severity of OCD, depression, and
anxiety for the clinical participants (n = 196). 4. Discussion
Variable 1 2 3 4 5
Traditional models of OCD place a heavy emphasis on the role
1. Harm avoidance played by fear and anxiety in the onset and maintenance of symptoms
2. Incompleteness .51** (Abramowitz et al., 2009; Foa & McLean, 2016). However, OCD is a
3. Disgust .45** .37**
highly heterogeneous condition and it is likely that the emotion-related
4. OCD .60** .71** .35**
5. Depression .28** .16* .19** .24** motivators that underpin the disorder extend beyond fear; particularly,
6. Anxiety .46** .25** .44** .31** .72** incompleteness and disgust have been suggested to be strong candi-
dates for further investigation. With the exception of disgust, studies
Note. OCD = Obsessive-Compulsive Disorder. * indicates p < .05. ** indicates investigating emotion-related motivators in OCD have been carried out
p < .01. with adults only. Moreover, no studies have conjointly assessed harm
avoidance, incompleteness, and disgust in clinical samples, and the
related to self-reported symptom severity of OCD, anxiety, and de- relationship between these emotions and symptom change is unclear.
pression. Incompleteness was uniquely related to self-reported The purpose of the present study was to address these gaps in the lit-
symptom severity of OCD and disgust uniquely related to self-reported erature.
symptom severity of anxiety. For the OCD sample, incompleteness, According to the Core Dimensions Model of OCD, both harm
harm avoidance, and disgust were all significantly related to the OCD avoidance (a proxy for fear-related emotions) and incompleteness un-
symptom dimensions. Harm avoidance was statistically significantly derpin OCD, but only the latter is specific to this disorder. Consistent
related to doubting/checking, obsessing, and washing. Incompleteness with this assumption, and our hypotheses, youth with OCD and anxiety
was significantly related to doubting/checking, ordering, and neu- disorders reported similarly high levels of harm avoidance in the pre-
tralizing. Disgust was significantly related to hoarding. sent study, with both groups scoring significantly higher than youth
with no psychiatric disorder. Further, in the SEM model, harm avoid-
3.3. Pre-to-post treatment changes in the OCD sample ance showed unique associations with self-reported symptoms of OCD,
anxiety, and depression. These findings provide support for the view
Paired samples t-tests showed pre-to-post treatment reductions of that trait-level proneness for fear and anxiety is a transdiagnostic
incompleteness (t[65] = 2.39, p = .010, d = 0.29) and harm avoid- emotional vulnerability factor linking anxiety disorders and OCD (and
ance (t[65] = 2.65, p = .020, d = 0.33) but not disgust (t[64] = 0.54, possibly depression) (Chasson, Bello, Luxon, Graham, & Leventhal,
p = 0.594, d = 0.07) in participants undergoing treatment for OCD. 2017; Norton & Paulus, 2017; Sharp, Miller, & Heller, 2015).
Change scores for the emotion measures following treatment correlated Also consistent with the Core Dimensions Model of OCD, and our
in the moderate range and change in harm avoidance and in- hypotheses, incompleteness was elevated only in youth with OCD in the
completeness (but not disgust) correlated with change in CY-BOCS (see present study. The specificity of incompleteness was further evidenced
Table 5). Using a multiple linear regression model, and adjusting for using SEM, where it was related to self-reported symptom severity of
age and sex, pre-to-post treatment change scores for incompleteness, OCD but not to anxiety or depression. These results, together with
ham avoidance, and disgust accounted for 47.3 % of the variance in compelling evidence from research with adults, suggest that in-
pre-to-post-treatment change in OCD severity as measured by the CY- completeness may play a central role in OCD and lend some support for
BOCS (F[5, 64] = 10.57, p < .001). Change in incompleteness (β = the removal of OCD from the anxiety disorders chapter in the DSM-5.
.70, p < .001), but not harm avoidance (β = 0.09, p = 0.450), or Incompleteness or the “not just right” phenomenon have been im-
disgust (β = -0.16, p = 0.165), was statistically significantly related to plicated particularly in relation to checking and ordering-related OCD,
change in OCD severity. The covariates of age (p = 0.259) and sex (p = but studies that investigate this construct in relation to OCD

6
M. Cervin, et al. Journal of Anxiety Disorders 69 (2020) 102175

Fig. 2. SEM path diagrams for the associations between self-reported harm avoidance, incompleteness, and disgust and symptoms in (a) the full clinical sample and
(b) in the OCD sample.
Note. Only statistically significant paths are shown. Indicators accounting for measurement error are not depicted. SEM = Structural Equation Modeling.
OCD = Obsessive-Compulsive Disorder. * indicates p < .05. ** indicates p < .01. *** indicates p < .001. (For interpretation of the references to colour in this figure
legend, the reader is referred to the web version of this article).

heterogeneity are few and have seldom controlled for harm avoidance.
The results of the present study suggest that incompleteness and harm
avoidance play different roles in relation to OCD heterogeneity in that
incompleteness was related to ordering, neutralizing, and doubting/
checking while harm avoidance was related to obsessing, washing, and
doubting/checking. Hence, the only symptom dimension to which both
incompleteness and harm avoidance made a unique contribution was
doubting/checking. These results, which are in line with findings with
adults (Ecker & Gonner, 2008), warrant further investigation in an
experimental fashion. For example, experimental inductions of different
emotion-related motivators can be used to investigate the onset and
persistence of compulsive streaks (Szechtman & Woody, 2004).
Our findings for disgust propensity largely mirror previous studies
with both adults and children, and which suggest that disgust pro-
pensity exerts influences on both anxiety and OCD symptoms, and that
its relationship to OCD may be indirect (Melli, Poli, Chiorri, & Olatunji,
2018). In the present study, disgust propensity was not uniquely related
to OCD diagnostic status; it was equally elevated in the OCD and an-
xiety disorder groups, and although disgust was positively and mod-
erately correlated with the severity of self-reported OCD symptoms, this
association disappeared after controlling for incompleteness and harm
avoidance in the SEM model. However, a unique relationship to anxiety
emerged. Similarly, disgust propensity was not associated with OCD at
the symptom dimension level, except for a positive association with
hoarding. Overall, these results were not in line with our hypotheses
about a unique role of disgust in relation to washing symptoms, and as
such they add to a small body of literature in which the links between
disgust and OCD are weak when controlling for other variables (Melli
et al., 2018).
Lastly, and importantly, we examined if incompleteness, harm
avoidance and disgust were affected by OCD treatment, and the degree
to which change in these constructs were related to change in overall

7
M. Cervin, et al. Journal of Anxiety Disorders 69 (2020) 102175

Table 4
Path coefficients (β) and 95 % confidence intervals for the path regression coefficients (estimated on standardized data) for the SEM analyses.
OCD Anxiety Depression
Full clinical sample β (95% CI) β (95% CI) β (95% CI)

Harm avoidance 0.32*** 0.39*** 0.28**

(0.18, 0.44) (0.21, 0.56) (0.07, 0.46)
Incompleteness 0.64*** −0.07 −0.01
(0.50, 0.77) (-0.25, 0.10) (-0.20, 0.18)
Disgust −0.03 0.32*** 0.09
(-0.15, 0.09) (0.17, 0.48) (-0.09, 0.26)

Doubting/ Obsessing Hoarding Washing Ordering Neutralizing

checking
OCD sample β (95% CI) β (95% CI) β (95% CI) β (95% CI) β (95% CI) β (95% CI)

Harm avoidance 0.50** 0.64*** 0.26 0.40* 0.02 0.19

(0.20, 0.73) (0.29, 0.86) (-0.05, 0.52) (0.08, 0.69) (-0.25, 0.29) (-0.12, 0.40)
Incompleteness 0.31* −0.09 0.05 −0.21 0.46** 0.77***
(0.01, 0.60) (-0.40, 0.23) (-0.27, 0.36) (-0.54, 0.13) (0.16, 0.75) (0.32, 0.90)
Disgust −0.16 −0.05 0.31* 0.13 0.23 −0.06
(-0.38, 0.09) (-0.30, 0.21) (0.03, 0.53) (-0.14, 0.40) (-0.01, 0.46) (-0.27, 0.19)

Note. SEM = Structural Equation Modeling. OCD = Obsessive-Compulsive Disorder.

* indicates p < .05. ** indicates p < .01, *** indicates p < .001.

Table 5 in relation to potential true differences for incompleteness between

Zero-order Pearson correlations for change in CY-BOCS, harm avoidance, in-
completeness, and disgust following treatment for followed-up OCD partici-
pants (n = 66).
Variable 1 2 3 all measures used in the present study were Swedish language versions
1. CY-BOCS
2. Harm Avoidance .37*
3. Incompleteness .66* .52*
4. Disgust .18 .48* .45*
Note. CY-BOCS = Children’s Yale-Brown Obsessive Compulsive Scale.
OCD = Obsessive-Compulsive Disorder. * indicates p < .01.
OCD severity. Our results showed that incompleteness and harm
avoidance, but not disgust, were reduced by treatment. Similarly,
changes in incompleteness and harm avoidance, but not disgust, were
positively correlated with change in OCD severity. Importantly, when
accounting for covariance between variables, incompleteness alone was
uniquely associated with change in OCD severity. This is one of the first
studies to investigate the relationship between changes in harm
avoidance, incompleteness, and disgust and the relationship to change
in OCD severity. The association between change in incompleteness and
OCD is in line with a recent study that showed that change in in-
completeness was associated with change in contamination symptoms
in adults with elevated contamination fears even after controlling for
other relevant variables (Mathes et al., 2019). Contrary to previous
findings (Taboas, Ojserkis, & McKay, 2015), changes in disgust pro-
pensity were unrelated to changes in OCD severity. These results were
not in line with our expectation that change in all emotions would be
related to change in OCD severity, but they further highlight the central
role of incompleteness in relation to OCD in the present sample. Clinical
translations of these findings may suggest that exposure and cognitive
restructuring interventions should more readily address incomplete-
ness, and research examining whether such interventions lead to better
treatment gains are greatly needed. Moreover, as noted in the in-
troduction, habit reversal techniques may be used or combined with
ERP to more effectively treat incompleteness-driven OCD. However,
such investigations should follow further study of the moment-to-mo-
ment experience of emotion in OCD symptoms.
The present results need to be interpreted in the light of certain
limitations. First, the majority of analyses were carried out on cross-
sectionally collected data which precludes examinations of direction-
ality of effects. Second, the non-clinical sample was small, yielding low
statistical power to test group differences. This was particularly evident
youth with an anxiety disorder and non-clinical youth, where the nu-
merical (but non-significant) difference was on par with the significant
difference for youth with OCD and those with anxiety disorders. Third,
of the English original versions; replications using other language ver-
sions of these scales are warranted. Fourth, the internal consistency of
the neutralizing OCI-CV scale was low. Future studies on emotion in-
volvement in OCD employing other measures of neutralizing should be
carried out. Fifth, a non-negligible proportion of participants completed
a course of OCD-focused CBT but did not engage in the ERP exercises,
and thus did not receive gold standard OCD treatment. Hence, future
studies are needed that examine how changes in these emotion-related
constructs are related to change in OCD severity when treatment is
delivered under more controlled conditions. Last, there is no consensus
in the literature with respect to the measurement of disgust; future
studies should include a broader range of disgust measures.
In sum, the present study provides preliminary evidence for the
central role that incompleteness plays in pediatric OCD. Incompleteness
was specifically related to OCD at the disorder and symptom level, with
changes in incompleteness uniquely related to change in overall OCD
severity following treatment for this condition. The present study also
highlights the importance of harm avoidance in pediatric OCD, even
though it was clearly transdiagnostic in nature and cut across both di-
agnostic groups (i.e., OCD and anxiety disorders) and self-reported
symptoms of OCD, anxiety, and depression. With regard to disgust
propensity, no definitive conclusions about its role in pediatric OCD can
be drawn from the present study. If anything, it was less relevant than
expected, but research with other measures and of the moment-to-
moment experience of disgust in OCD symptoms are needed. Taken
together, our results suggest the need for more research about the role
of incompleteness in OCD, not the least in youth samples. Specifically,
future studies that assess the direct involvement of incompleteness (and
harm avoidance and disgust) in the moment-to-moment experience of
OCD symptoms are needed. Such research may help improve our un-
derstanding of the etiology and treatment of pediatric OCD.
Funding
The corresponding author have received funding from L.J. Boëthius
Foundation, Lindhaga Foundation, The Sven Jerring Foundation, and
Region Skåne that made possible data analysis for and drafting of the
present manuscript.

8
M. Cervin, et al. Journal of Anxiety Disorders 69 (2020) 102175

Role of the funding source National Comorbidity Survey Replication. Archives of General Psychiatry, 62,
593–602.
Knowles, K. A., Viar-Paxton, M. A., Riemann, B. C., Jacobi, D. M., & Olatunji, B. O.
The funding sources had no role in study design, data collection, (2016). Is disgust proneness sensitive to treatment for OCD among youth?:
analysis of the data, or writing of the report. Examination of diagnostic specificity and symptom correlates. Journal of Anxiety
Disorders, 44, 47–54.
Lazarov, A., Liberman, N., Hermesh, H., & Dar, R. (2014). Seeking proxies for internal
Declaration of Competing Interest states in obsessive-compulsive disorder. Journal of Abnormal Psychology, 123,
695–704.
None. Mataix-Cols, D., Rosario-Campos, M. C., & Leckman, J. F. (2005). A multidimensional
model of obsessive-compulsive disorder. The American Journal of Psychiatry, 162,
228–238.
References Mathes, B. M., Kennedy, G. A., Wilver, N. L., Carlton, C. N., & Cougle, J. R. (2019). A
multi-method analysis of incompleteness in behavioral treatment of contamination-
based OCD. Behaviour Research and Therapy, 114, 1–6.
Abramowitz, J. S., & Jacoby, R. J. (2015). Obsessive-compulsive and related disorders: A
Melli, G., Poli, A., Chiorri, C., & Olatunji, B. O. (2018). Is heightened disgust propensity
critical review of the new diagnostic class. Annual Review of Clinical Psychology, 11,
truly a risk factor for contamination-related obsessive-compulsive disorder? Behavior
165–186.
Therapy.
Abramowitz, J. S., Taylor, S., & McKay, D. (2009). Obsessive-compulsive disorder. Lancet
Muris, P., Huijding, J., Mayer, B., Langkamp, M., Reyhan, E., & Olatunji, B. (2012).
(London, England), 374, 491–499.
Assessment of disgust sensitivity in children with an age-downward version of the
Ahlen, J., & Ghaderi, A. (2017). Evaluation of the children’s depression inventory—Short
Disgust Emotion Scale. Behavior Therapy, 43, 876–886.
version (CDI–S). Psychological Assessment, 29, 1157.
Muris, P., Merckelbach, H., Schmidt, H., & Mayer, B. (1998). The revised version of the
Allgaier, A. K., Fruhe, B., Pietsch, K., Saravo, B., Baethmann, M., & Schulte-Korne, G.
Screen for Child Anxiety Related Emotional Disorders (SCARED-R): factor structure in
(2012). Is the Children’s Depression Inventory Short version a valid screening tool in
normal children. Personality and Individual Differences, 26, 99–112.
pediatric care? A comparison to its full-length version. Journal of Psychosomatic
Muris, P., Merckelbach, H., Van Brakel, A., & Mayer, B. (1999). The revised version of the
Research, 73, 369–374.
screen for child anxiety related emotional disorders (SCARED-R): Further evidence
American Psychiatric Association (2013). Diagnostic and statistical manual of mental dis-
for its reliability and validity. Anxiety, Stress, and Coping, 12, 411–425.
orders (5th ed). Washington, DC.
Muris, P., van der Heiden, S., & Rassin, E. (2008). Disgust sensitivity and psychopatho-
Aspvall, K., Cervin, M., Andrén, P., Perrin, S., Mataix-Cols, D., & Andersson, E. (2019).
logical symptoms in non-clinical children. Journal of Behavior Therapy and
Validity and clinical utility of the Obsessive Compulsive Inventory - Child Version:
Experimental Psychiatry, 39, 133–146.
Further evaluation in clinical samples. PsyArXiv. https://doi.org/10.31234/osf.io/
Norton, P. J., & Paulus, D. J. (2017). Transdiagnostic models of anxiety disorder: theo-
ebmk5.
retical and empirical underpinnings. Clinical Psychology Review, 56, 122–137.
Bartz, J. A., & Hollander, E. (2006). Is obsessive-compulsive disorder an anxiety disorder?
Nutt, D., & Malizia, A. (2006). Anxiety and OCD - the chicken or the egg? Journal of
Progress in Neuro-psychopharmacology & Biological Psychiatry, 30, 338–352.
Psychopharmacology (Oxford, England), 20, 729–731.
Belloch, A., Fornes, G., Carrasco, A., Lopez-Sola, C., Alonso, P., & Menchon, J. M. (2016).
Olatunji, B. O., Cisler, J., McKay, D., & Phillips, M. L. (2010). Is disgust associated with
Incompleteness and not just right experiences in the explanation of Obsessive-
psychopathology? Emerging research in the anxiety disorders. Psychiatry Research,
Compulsive Disorder. Psychiatry Research, 236, 1–8.
175, 1–10.
Cervin, M., & Perrin, S. (2019). Measuring harm avoidance, incompleteness, and disgust
Olatunji, B. O., Ebesutani, C., & Kim, E. H. (2016). Does the measure matter? On the
in youth with obsessive-compulsive disorder and anxiety disorders. Journal of
association between disgust proneness and OCD symptoms. Journal of Anxiety
Obsessive-compulsive and Related Disorders, 22.
Disorders, 44, 63–72.
Cervin, M., Perrin, S., Olsson, E., Claesdotter-Knutsson, E., & Lindvall, M. (2019).
Olatunji, B. O., Ebesutani, C., Kim, J., Riemann, B. C., & Jacobi, D. M. (2017). Disgust
Validation of an interview-only version of the Dimensional Yale-Brown Obsessive-
proneness predicts obsessive-compulsive disorder symptom severity in a clinical
Compulsive Scale (DY-BOCS) in treatment-seeking youth with obsessive-compulsive
sample of youth: Distinctions from negative affect. Journal of Affective Disorders.
disorder. Psychiatry Research, 271, 171–177.
Olatunji, B. O., Smits, J. A., Connolly, K., Willems, J., & Lohr, J. M. (2007). Examination
Chasson, G. S., Bello, M. S., Luxon, A. M., Graham, T. A., & Leventhal, A. M. (2017).
of the decline in fear and disgust during exposure to threat-relevant stimuli in
Transdiagnostic emotional vulnerabilities linking obsessive‐compulsive and depres-
blood–injection–injury phobia. Journal of Anxiety Disorders, 21, 445–455.
sive symptoms in a community‐based sample of adolescents. Depression and Anxiety,
Olatunji, B. O., Unoka, Z. S., Beran, E., David, B., & Armstrong, T. (2009). Disgust sen-
34, 761–769.
sitivity and psychopathological symptoms: distinctions from harm avoidance. Journal
Chik, H. M., Calamari, J. E., Rector, N. A., & Riemann, B. C. (2010). What do low-dys-
of Psychopathology and Behavioral Assessment, 31, 137.
functional beliefs obsessive–compulsive disorder subgroups believe? Journal of
Pediatric OCD Treatment Study Team (2004). Cognitive-behavior therapy, sertraline, and
Anxiety Disorders, 24, 837–846.
their combination for children and adolescents with obsessive-compulsive disorder:
Coles, M. E., & Ravid, A. (2016). Clinical presentation of not-just right experiences
the Pediatric OCD Treatment Study (POTS) randomized controlled trial. JAMA, 292,
(NJREs) in individuals with OCD: Characteristics and response to treatment.
1969–1976.
Behaviour Research and Therapy, 87, 182–187.
Piacentini, J., Bergman, R. L., Keller, M., & McCracken, J. (2003). Functional impairment
Davey, G. C. (2011). Disgust: The disease-avoidance emotion and its dysfunctions.
in children and adolescents with obsessive-compulsive disorder. Journal of Child and
Philosophical Transactions Biological Sciences, 366, 3453–3465.
Adolescent Psychopharmacology, 13(Suppl. 1), S61–69.
Ecker, W., & Gonner, S. (2008). Incompleteness and harm avoidance in OCD symptom
Ravid, A., Franklin, M. E., Khanna, M., Storch, E. A., & Coles, M. E. (2014). Not just right
dimensions. Behaviour Research and Therapy, 46, 895–904.
Experiences" in adolescents: Phenomenology and associated characteristics. Child
Ecker, W., Kupfer, J., & Gonner, S. (2014). Incompleteness as a link between obsessive-
Psychiatry and Human Development, 45, 193–200.
compulsive personality traits and specific symptom dimensions of obsessive-com-
Scahill, L., Riddle, M. A., McSwiggin-Hardin, M., Ort, S. I., King, R. A., Goodman, W. K.,
pulsive disorder. Clinical Psychology & Psychotherapy, 21, 394–402.
et al. (1997). Children’s Yale-Brown Obsessive Compulsive Scale: Reliability and
Foa, E. B., Coles, M., Huppert, J. D., Pasupuleti, R. V., Franklin, M. E., & March, J. (2010).
validity. J. Am. Acad. Child Adolesc. Psychiatry, 36, 844–852.
Development and validation of a child version of the obsessive compulsive inventory.
Sharp, P. B., Miller, G. A., & Heller, W. (2015). Transdiagnostic dimensions of anxiety:
Behavior Therapy, 41, 121–132.
Neural mechanisms, executive functions, and new directions. International Journal of
Foa, E. B., & McLean, C. P. (2016). The efficacy of exposure therapy for anxiety-related
Psychophysiology, 98, 365–377.
disorders and its underlying mechanisms: The case of OCD and PTSD. Annual Review
Sheehan, D. V., Sheehan, K. H., Shytle, R. D., Janavs, J., Bannon, Y., Rogers, J. E., et al.
of Clinical Psychology, 12, 1–28.
(2010). Reliability and validity of the mini international neuropsychiatric interview
Ghisi, M., Chiri, L. R., Marchetti, I., Sanavio, E., & Sica, C. (2010). In search of specificity:
for children and adolescents (MINI-KID). The Journal of Clinical Psychiatry, 71,
“not just right experiences” and obsessive–Compulsive symptoms in non-clinical and
313–326.
clinical Italian individuals. Journal of Anxiety Disorders, 24, 879–886.
Sica, C., Bottesi, G., Orsucci, A., Pieraccioli, C., Sighinolfi, C., & Ghisi, M. (2015). Not just
Gillan, C. M., & Sahakian, B. J. (2015). Which is the driver, the obsessions or the com-
right Experiences" are specific to obsessive-compulsive disorder: Further evidence
pulsions, in OCD? Neuropsychopharmacology : Official Publication of the American
from Italian clinical samples. Journal of Anxiety Disorders, 31, 73–83.
College of Neuropsychopharmacology, 40, 247–248.
Skapinakis, P., Caldwell, D., Hollingworth, W., Bryden, P., Fineberg, N., Salkovskis, P.,
Hofer, P. D., Wahl, K., Meyer, A. H., Miche, M., Beesdo-Baum, K., Wong, S. F., et al.
et al. (2016). A systematic review of the clinical effectiveness and cost-effectiveness
(2018). Obsessive-compulsive disorder and the risk of subsequent mental disorders: A
of pharmacological and psychological interventions for the management of obsessive-
community study of adolescents and young adults. Depression and Anxiety, 35(4),
compulsive disorder in children/adolescents and adults. Health Technology Assessment
339–345.
(Winchester, England), 20, 1–392.
Ivarsson, T., Skarphedinsson, G., Andersson, M., & Jarbin, H. (2017). The validity of the
Stein, D. J., Fineberg, N. A., Bienvenu, O. J., Denys, D., Lochner, C., Nestadt, G., et al.
screen for child anxiety related emotional disorders revised (SCARED-R) scale and
(2010). Should OCD be classified as an anxiety disorder in DSM‐V? Depression and
sub-scales in Swedish youth. Child Psychiatry and Human Development, 49(2),
Anxiety, 27, 495–506.
234–243.
Summerfeldt, L. J. (2004). Understanding and treating incompleteness in obsessive-
Jacobsen, A. M., & Smith, A. J. (2017). Symmetry and ordering in youth with obsessive
compulsive disorder. Journal of Clinical Psychology, 60, 1155–1168.
compulsive disorder. The Wiley Handbook of Obsessive Compulsive Disorders, 1,
Summerfeldt, L. J., Kloosterman, P. H., Antony, M. M., & Swinson, R. P. (2014).
405–420.
Examining an obsessive-compulsive core dimensions model: Structural validity of
Kessler, R. C., Berglund, P., Demler, O., Jin, R., Merikangas, K. R., & Walters, E. E. (2005).
harm avoidance and incompleteness. Journal of Obsessive-compulsive and Related
Lifetime prevalence and age-of-onset distributions of DSM-IV disorders in the
Disorders, 3, 83–94.

9
M. Cervin, et al.
Szechtman, H., & Woody, E. (2004). Obsessive-compulsive disorder as a disturbance of
security motivation. Psychological Review, 111, 111–127.
Taboas, W., Ojserkis, R., & McKay, D. (2015). Change in disgust reactions following
cognitive-behavioral therapy for childhood anxiety disorders. International Journal of
Clinical and Health Psychology, 15, 1–7.
Taylor, S., McKay, D., Crowe, K. B., Abramowitz, J. S., Conelea, C. A., Calamari, J. E.,
et al. (2014). The sense of incompleteness as a motivator of obsessive-compulsive
symptoms: An empirical analysis of concepts and correlates. Behavior Therapy, 45,
254–262.
Valderhaug, R., & Ivarsson, T. (2005). Functional impairment in clinical samples of
Norwegian and Swedish children and adolescents with obsessive-compulsive dis-
order. European Child & Adolescent Psychiatry, 14, 164–173.
Van Ameringen, M., Patterson, B., & Simpson, W. (2014). DSM‐5 obsessive‐compulsive
10
Journal of Anxiety Disorders 69 (2020) 102175
and related disorders: clinical implications of new criteria. Depression and Anxiety, 31,
487–493.
Van Overveld, W., de Jong, P. D., Peters, M., Cavanagh, K., & Davey, G. (2006). Disgust
propensity and disgust sensitivity: separate constructs that are differentially related
to specific fears. Personality and Individual Differences, 41, 1241–1252.
Wild, D., Grove, A., Martin, M., Eremenco, S., McElroy, S., Verjee‐Lorenz, A., et al.
(2005). Principles of good practice for the translation and cultural adaptation process
for patient‐reported outcomes (PRO) measures: Report of the ISPOR Task Force for
Translation and Cultural Adaptation. Value in Health : the Journal of the International
Society for Pharmacoeconomics and Outcomes Research, 8, 94–104.
Williams, L. J., & Hazer, J. T. (1986). Antecedents and consequences of satisfaction and
commitment in turnover models: a reanalysis using latent variable structural equa-
tion methods. The Journal of Applied Psychology, 71, 219.