Attention to the heterogeneous manifestations of OCD symptoms observed in clinical populations, along with different treatment responses, has led researchers to the possibility that OCD is a heterogeneous condition with broad manifestations and different causes. This has motivated researchers to identify distinct and homogeneous subgroups of patients with OCD and to improve treatment strategies by eliminating heterogeneity. As a result, in recent decades, significant studies with different methods have investigated these subgroups and their potential differences in terms of cause and treatment response [1, 2].
In the first classification of OCD, symptoms, and comorbidities were emphasized, including washing versus checking and the presence versus absence of tics [3]. However, this approach's conceptual and methodological challenges, including significant overlap between apparently separate "subsets" of symptoms, led to the formation of the second OCD classification scheme based on cognitive models [4]. This plan considered dysfunctional beliefs to be the basis of the pathology of OCD and emphasized the feeling of personal responsibility, the overestimation of threats, the importance of thoughts, and the need to control them. These beliefs affect the interpretation of events in a way that leads to an increase in anxiety and then an increase in the motivation to try to avoid harm [5]. Despite the abundance of evidence supporting the role of these obsessive beliefs in creating and maintaining OCD, it was found that these cognitive constructs do not fully explain the variability in OCD symptoms. Some studies, using cluster analysis methods and the Obsessive Beliefs Questionnaire (OBQ-44) - a measure of beliefs related to obsessive-compulsive disorder in all fields - have identified a subgroup of patients with OCD who have low levels of these beliefs. This subgroup does not have beliefs related to harm avoidance playing a central role, but instead has a different motivation to avoid "not just right experiences and incompleteness" which strongly influences its underlying pathology [6].
Therefore, to more accurately classify symptoms and use an appropriate therapeutic strategy, recent researchers have paid attention to the motivational dimensions of OCD and the functional relationship between symptoms. They consider the “why” of a behavior (e.g., to avoid harm) more important than the form of that behavior (e.g., checking). Understanding the function of symptoms in patients with OCD is very important due to its motivational heterogeneity. In OCD treatment models, knowing "fear" or the main motivation underlying symptoms and avoidance behaviors helps the therapist better manage obsessive behaviors during treatment [7].
On the other hand, new approaches such as ACT recognize avoidance in patients with OCD as experiential avoidance (EA). EA is defined as a rigid pattern of trying to avoid or escape from unwanted internal experiences such as distressing thoughts, emotions, or physical sensations [8]. It has received particular attention and is recognized as the most vital functional process in psychopathology related to disorders, including OCD. Studies have shown that while these avoidance behaviors may reduce discomfort in the short term, ultimately, by preventing obsessive thoughts from being encountered and understanding them only as unwanted and disturbing thoughts on the part of the person, they can maintain obsessive thoughts and contribute to the continuation of the disorder as a motivation [9].
Most of the studies that have investigated this construct and its relationship with OCD symptoms have focused only on its behavioral dimension and examined its role along with the cognitive fusion component (two cognitive and context constructs of ACT treatment) of OCD symptoms. Some of these studies have shown that these constructs, in higher dimensions and beyond obsessive beliefs, can predict and explain the unacceptable symptoms of OCD [9]. However, some studies have not obtained such ability for the construct of experimental avoidance and have attributed the inconsistency of results to the challenges related to EA measurement criteria [10, 11]. Questionnaires such as the Acceptance and Action Questionnaire (AAQ-II) have been criticized for excessive overlap with related constructs such as thought suppression and negative affect [12] and the Multidimensional Experiential Avoidance Questionnaire (MEAQ), which assesses general measures of EA, may not effectively assess EA in a specific domain such as obsession [13].
Therefore, in the last two decades, Rasmussen and Eisen developed the main dimensions model based on the OCD motivation model. They aimed to focus on the motivational dimension of EA as the main motivation underlying OCD symptoms. They grouped people with OCD based on two identified motivations: harm avoidance (HA) and incompleteness (INC). HA refers to symptoms that act to avoid harm to oneself or others (such as contracting an illness or unwanted aggression). INC refers to symptoms associated with internalized feelings of inadequacy and incompleteness of actions or intentions [14]. Summerfeldt et al. further developed and adapted the motivation model to depict motivations more dimensionally rather than categorically. They hypothesized that HA and INC underlie compulsions, sometimes alone and sometimes in combination. It is important to evaluate the motivations of people with OCD before treatment, given the various motivations underlying OCD and their significant role in treatment [15]. For this purpose, Summerfeldt et al. developed the Obsessive-Compulsive Core Dimensions Questionnaire (OC-CDQ), a two-dimensional questionnaire used to assess HA and INC [16].
To date, several studies have evaluated the psychometric properties of the OC-CDQ and validated its English and German versions in both OCD patients and nonclinical participants [15, 17, 18]. Some studies have also examined the relationship between HA and INC motivational dimensions with other OCD measures. Researchers found that HA was significantly associated with doubting/checking, obsessing, and washing, while INC was significantly associated with doubting/checking, ordering, neutralizing, OCPD features (such as perfectionism), and lower quality of life [7, 19, 20]. Bragdon & Coles reported that the subgroup with high HA had greater beliefs about responsibility/overestimation of threat, but the subgroup with high INC had more perfectionistic beliefs and greater intolerance of uncertainty [15].
Although these studies confirmed the two-factor structure, validity, and reliability of the OC-CDQ and examined the relationships between HA and INC dimensions and other criteria related to obsessions, most of these studies were conducted in Western cultures. However, some studies have shown that there are cultural differences in OCD patients, and the validation of OCD criteria in different cultures is an important issue. For example, individuals in Eastern cultures show greater OC symptom severity and obsessive beliefs than those in Western cultures [21]. The results of the study by Asadi et al. showed that Iranian patients with OCD are different from patients of other nations in terms of obsessions such as aggression, sexuality, and religion. Additionally, cultural factors such as the family system, values, religion, and cultural norms can affect the content of obsessions and compulsions [22].
On the other hand, studies have shown that although cultural differences may affect the experience or severity of OCD symptoms, these differences may not cause different OCD symptoms in different cultures [23, 24]. Additionally, several studies conducted in various cultures have found the same construct for other OCD measurement tools [25, 26]. Therefore, the OC-CDQ in Eastern countries such as Iran may also have a two-factor structure similar to that of Western cultures.
Considering that the Persian version of the OC-CDQ, used to assess the level of HA and INC motivations has not yet been published, and that psychometric properties of the OC-CDQ have not been systematically investigated in a clinical and nonclinical peer sample, the present study aimed to investigate the psychometric properties of the Persian translation of the OC-CDQ in two Iranian samples (clinical with OCD to evaluate the two motivational dimensions underlying obsessive-compulsive symptoms (HA and INC) and in a nonclinical peer population to assess these dimensions as traits). Additionally, the relationships between HA and INC dimensions and obsessive symptoms and severity, obsessive beliefs, and other related clinical phenomena were investigated.