visual, tactile, and auditory “not just right” experiences: associations with...

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Visual, Tactile, and Auditory ‘Not Just Right’ Experiences: Associations withObsessive-Compulsive Symptoms and Perfectionism

Berta J. Summers, Kristin E. Fitch, Jesse R. Cougle

PII: S0005-7894(14)00057-4DOI: doi: 10.1016/j.beth.2014.03.008Reference: BETH 486

To appear in: Behavior Therapy

Received date: 6 December 2013Revised date: 14 February 2014Accepted date: 17 March 2014

Please cite this article as: Summers, B.J., Fitch, K.E. & Cougle, J.R., Visual, Tactile,and Auditory ‘Not Just Right’ Experiences: Associations with Obsessive-CompulsiveSymptoms and Perfectionism, Behavior Therapy (2014), doi: 10.1016/j.beth.2014.03.008

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http://dx.doi.org/10.1016/j.beth.2014.03.008

http://dx.doi.org/10.1016/j.beth.2014.03.008

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ACCEPTED MANUSCRIPTVisual, Tactile, and Auditory NJREs 1

Running head: Visual, Tactile, and Auditory NJREs

Visual, Tactile, and Auditory ‘Not Just Right’ Experiences: Associations with Obsessive-

Compulsive Symptoms and Perfectionism

Berta J. Summers, B. A.

Kristin E. Fitch, M. S.

Jesse R. Cougle, Ph. D.

Department of Psychology, Florida State University, Tallahassee, FL, USA

Correspondence: Jesse R. Cougle, Department of Psychology, Florida State University, 1107 W.

Call Street, Tallahassee, FL, 32306. Email: [email protected]. Tel: 850-645-8729. Fax: 850-

644-7739

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Abstract

‘Not Just Right’ Experiences (NJREs), or uncomfortable sensations associated with the

immediate environment not feeling ‘right,’ are thought to contribute to obsessive-compulsive

disorder (OCD) symptomatology. The literature suggests that NJREs are experienced across

sensory modalities; however, existing in vivo measures have been restricted to visual inductions

(e.g., viewing and/or rearranging a cluttered table). The present study used a large undergraduate

sample (N = 284) to examine four in vivo tasks designed to elicit and assess NJREs across

separate sensory modalities (i.e., visual, tactile, and auditory). Task ratings (discomfort evoked,

and urge to counteract task-specific stimuli) were uniquely associated with self-report measures

of NJREs, OC symptoms (ordering/arranging, checking, and washing), and certain maladaptive

domains of perfectionism (doubts about actions, and organization). Findings have implications

for experimental research and clinical work targeting NJREs specific to particular senses.

Keywords: Obsessive-compulsive disorder; ‘not just right’ experiences; incompleteness; in vivo

tasks; perfectionism.

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Introduction

Obsessive-compulsive disorder (OCD) is characterized by persistent, unwanted thoughts

(obsessions), and/or repetitive behaviors (compulsions) performed to curb associated anxiety or

other uncomfortable sensations (American Psychiatric Association, 2013). Research efforts

examining the driving forces underlying OC symptomatology have revealed two distinct

motivational domains for compulsions: harm avoidance and incompleteness (Summerfeldt,

2004). Compulsions motivated by harm avoidance are intended to reduce anticipatory anxiety

associated with a feared consequence or safety concern (Salkovskis, 1991). Compulsions

motivated by incompleteness are intended to prevent or quiet uncomfortable sensations

associated with the immediate environment feeling ‘not just right.’ Pierre Janet first described

the construct of incompleteness as “an inner sense of imperfection” when an action or perception

was “incompletely achieved” (Janet, 1903, as cited in Pitman, 1987b, p. 266; Rasmussen &

Eisen, 1992). These sensations are commonly referred to within the literature as ‘not just right’

experiences (NJREs; Coles, Frost, Heimberg, & Rhéaume, 2003), deficits in the “feeling of

knowing” (Rapoport, 1991), and “sensory phenomena” (Miguel et al., 2000). To minimize

confusion that may result from differing labels across studies, we will refer to these phenomena

as ‘NJREs’ throughout this paper, both when discussing previous research as well as the current

study. Research indicates that NJREs can be experienced across separate sensory modalities

(e.g., looking, feeling, sounding ‘right’; Rosário et al., 2009; Summerfeldt, 2004). NJREs may

reflect dysfunction of the sensory-affective system in which sensory and emotional experiences

are not effectively used to guide behavior (Summerfeldt, 2004).

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Of the two motivational domains, harm avoidance has been most heavily discussed

within the literature and is the focus of traditional treatments. For example, cognitive-behavioral

therapy (CBT) with exposure and response prevention (ERP) largely targets thoughts and

behaviors related to a feared consequence of not engaging in compulsive behavior.

Consequently, individuals who cannot articulate a specific feared consequence experience

modest treatment gains from ERP in comparison to those who can identify a particular negative

outcome (Foa, Abramowitz, Franklin, & Kozak, 1999). This discrepancy in treatment gains is

problematic given that up to 40% of patients with OCD are unable to identify a feared

consequence associated with not carrying out compulsions (Tolin, Abramowitz, Kozak, & Foa,

2001).

NJREs are strongly related to certain OC symptom clusters, including ordering and

arranging, checking, washing, and obsessing (see Taylor et al., 2014, for a meta-analysis). With

regard to ordering and arranging symptoms, studies examining both student (Coles et al., 2003;

Pietrefesa & Coles, 2009) and clinical samples (Ecker & Gönner, 2008) have demonstrated a

unique relationship between NJREs and ordering behavior and the need for symmetry.

Compulsions involving symmetry, ordering, and arranging appear to occur more frequently and

are rated as more severe when preceded by NJREs (Ferrão et al., 2012).

Checking symptoms have been linked to NJREs (Coles et al., 2003) and harm avoidance

in both student (Pietrefesa & Coles, 2009) and clinical samples (Feinstein, Fallon, Petkova, &

Liebowitz, 2003). Cougle, Fitch, Jacobson, and Lee (2013) examined the relationship between

NJREs and checking through three studies, the first of which involved participants looking at a

cluttered table. Discomfort while viewing the table and urge to straighten the clutter were

uniquely associated with checking symptoms. In the second study, self-report measures of

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NJREs predicted urge to check a stove following a stove-checking task. In the third study, an

experimental NJRE induction protocol was administered in which participants viewed either a

cluttered or straightened table after completion of the same stove-checking task. Participants

high in dispositional checking endorsed greater urge to check the stove after viewing a cluttered

table (NJRE induction) compared to the straightened table (control). Similarly, those high in trait

NJREs reported greater urge to check following the NJRE induction compared to the control

condition.

The relationship between washing and NJREs has also been examined. Self-report

measures of washing and contamination symptoms demonstrated strong relationships with both

motivational domains of OCD (incompleteness and harm avoidance) in a student sample

(Pietrefesa & Coles, 2009). The presence of NJREs has been related to increased frequency and

severity of washing compulsions (Ferrão et al., 2012), and both dispositional as well as in vivo

measures of NJREs have been related to washing duration (Cougle, Goetz, Fitch, & Hawkins,

2011). Individuals with washing compulsions were more likely than those without washing

compulsions to report using conscious, subjective internal reference criteria when determining

when to discontinue washing (i.e., continue washing until the ‘just right’ feeling is reached;

Wahl, Salkovskis, & Cotter, 2008); however, it has been suggested that internal reference

criteria, when present, may be a byproduct of NJREs (Cougle et al., 2011).

Obsessional thoughts typical of OCD have traditionally been linked to harm avoidance,

rather than NJREs, as the content and motivation behind these thoughts are often related to

prevention of harm to self or others (Ecker & Gönner, 2008). However, a recent meta-analysis of

16 studies exploring the relationship between motivational domains of OCD (harm avoidance

and/or NJREs) and OC symptom patterns revealed that obsessing symptoms are also

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significantly associated with NJREs (Taylor et al., 2014). Based on clinical observation,

Summerfeldt and colleagues (1999) have proposed that symmetry and exactness obsessions

accompanied by magical thinking are primarily motivated by safety concerns, whereas symmetry

and exactness obsessions without magical thinking seem to be driven by the need to have things

‘just right’ (also see Leckman, Walker, Goodman, Pauls, Cohen, 1994; Rasmussen & Eisen,

1992)

Though the topic of NJREs is gaining recognition within the field, few attempts have

been made to measure NJREs directly. To date, only two self-report questionnaires have been

validated: the Obsessive-Compulsive Core Dimensions Questionnaire (OC-CDQ; Summerfeldt,

Kloosterman, Antony, & Swinson, 2014), which contains both incompleteness and harm

avoidance subscales, and the Not Just Right Experiences Questionnaire-Revised (NJRE-Q-R;

Coles, Heimberg, Frost, & Steketee, 2005), which evaluates the presence and frequency of

NJREs in daily life. Retrospective self-report assessments have inherent limitations and do not

allow for the constructs of interest to be manipulated in an experimental context. Relationships

found between multiple self-report measures raise concerns related to common-method variance.

Furthermore, though these self-report NJRE measures include some items pertaining to sensory

experiences, they do not individually evaluate the severity of NJREs corresponding to specific

sensory modalities (e.g., visual, tactile, auditory).

In an effort to move beyond self-report methodology, one research group developed and

validated the University of Sao Paulo Sensory Phenomena Scale (USP-SPS), a semi-structured

interview designed to investigate the presence and severity of sensory NJREs (Rosário et al.,

2009). This interview includes a checklist of various types of NJREs, and the interviewer must

ascertain the severity (i.e., frequency; level of distress and interference) of these phenomena.

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Though this semi-structured interview format may provide a more in-depth assessment of NJREs

experienced across the senses, it is not always feasible in an experimental context, as

interviewing requires a certain degree of clinical skill and training. Thus, there is a great need for

supplementary in vivo measures that allow for experimental manipulation and thorough

assessment of NJREs across sensory modalities, while requiring minimal experimental training.

Some researchers have used in vivo tasks to elicit NJREs in a laboratory setting (Coles et

al., 2005; Cougle et al., 2011; Fitch & Cougle, 2013). For example, Coles and colleagues (2005)

asked participants to view messy or unbalanced stimuli (e.g., an unorganized bookshelf, a dirty

area rug, a desk with one drawer ajar) and rate discomfort, urge to change some part of the room,

and fear of something bad happening. The results indicated that these tasks were effective in

eliciting discomfort (incompleteness/NJREs) and did not evoke feelings of fear or threat (harm

avoidance), demonstrating task specificity in eliciting NJREs. Pietrefesa and Coles (2009)

designed behavioral tasks to elicit NJREs (e.g., hanging pictures), and found that dispositional

incompleteness was related to task-specific feelings of discomfort and a desire to perform tasks

perfectly. Cougle and colleagues (2011) assessed discomfort while viewing a cluttered table,

which was correlated with NJRE intensity. In vivo measures designed to elicit NJREs have

primarily been confined to visual inductions (e.g. cluttered table, crooked pictures). Thus, it is

necessary to develop methods of assessing multiple forms of NJREs to capture the full scope of

the construct.

The objectives of the current study were three-fold. The primary aim was to individually

evaluate four in vivo tasks developed to elicit and measure NJREs across separate sensory

modalities. These tasks measured discomfort in response to and urge to counteract: (1) viewing

cluttered table, (2) wearing asymmetrically arranged lab coat, (3) wiping a portion of non-

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dominant hand with a hand wipe, and (4) listening to a music clip played out of tune. We

predicted significant positive relationships on ratings of discomfort and urge to counteract

stimuli among tasks, as they were all intended to assess NJREs, albeit across a range of senses.

For all four tasks, we predicted that discomfort evoked by, and urge to counteract task stimuli

(make things ‘just right’) would be positively correlated with existing self-report measures of

NJREs, and these relationships would remain after controlling for negative affect. Further, we

predicted that task ratings (discomfort and urge to counteract stimuli) would be less consistently

related to a self-report measure of harm avoidance; though measures of harm avoidance and

incompleteness are positively correlated, the literature suggests they are distinct phenomena

(e.g., Pietrefesa & Coles, 2009; Taylor et al., 2014).

Our second objective was to further establish the importance of NJREs by determining

the extent to which responses to in vivo NJRE task measures correlate with OC symptom

patterns (e.g., checking, ordering, washing and obsessing). We also predicted significant positive

associations between these task ratings and checking, ordering, washing, and obsessing

symptoms, as each of these symptom clusters has been linked with NJREs (Taylor et al., 2014).

Our third objective was to examine the relationship between in vivo NJRE task ratings

and perfectionism, an important trans-diagnostic construct theoretically related to OCD (Coles et

al., 2003; Lee et al., 2009; Summerfeldt, 2004). NJREs have been described as a form of

“sensation-based perfectionism” (e.g., Pitman, 1987a). Although perfectionism is related to

NJREs and harm avoidance, research has demonstrated a more robust relationship between

perfectionism and NJREs (e.g., Lee et al., 2009; Pietrefesa & Coles, 2009). Coles and colleagues

(2003) found retrospective measures of the intensity and importance of past week NJREs to be

strongly correlated with several maladaptive domains of perfectionism (e.g., disadvantages of

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perfectionism, concern over mistakes, doubts about actions, and personal standards). Similarly,

Lee and colleagues (2009) found that the frequency and severity of NJREs, as rated by patients

with OCD, were associated with greater perfectionism. Thus, we also predicted that in vivo task

ratings (discomfort and urge to counteract stimuli) would exhibit strong positive associations

with perfectionism.

Method

Participants

Participants (N = 284) were recruited via undergraduate psychology courses at a large

southeastern university. Taxometric studies have indicated that OC symptoms and related

cognitions are dimensional in nature (Haslam, Williams, Kyrios, McKay, & Taylor, 2005;

Olatunji, Williams, Haslam, Abramowitz, & Tolin, 2008) and research suggests that analogue

samples are appropriate for examining these phenomena (Abramowitz, Fabricant, Taylor,

Deacon, McKay, & Storch, 2014; Gibbs, 1996). Previous work has further demonstrated similar

patterns of relationships between NJREs and OC symptoms in clinical (Ecker & Gönner, 2008;

Feinstein et al., 2003; Ferrão et al., 2012) and unselected populations (Coles et al., 2003; Cougle

et al., 2011, Pietrefesa & Coles, 2009). Thus, we utilized a large unselected sample to examine

assessments of NJREs within a heterogeneous population. This approach was most suitable for

study aims as it allowed for a wide range of scores. Students enrolled in introductory psychology

were given the option of writing a research paper or participating in research studies conducted

by laboratories in the psychology department. Upper-level students were offered the same

opportunity and awarded extra credit for their participation. The sample was 68% female, ranged

in age from 18 to 51 (M = 19.77, SD = 3.10) and consisted of diverse ethnic groups: Caucasian

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(68%), Hispanic (15%), African American (10%), Asian or Pacific Islander (3%), and

other/indicated more than one (4%).

Procedure

Participants first completed a questionnaire battery containing questions regarding

retrospective NJREs as well as OC traits and symptom patterns of interest. Second, participants

engaged in four in vivo behavioral tasks designed to elicit feelings of discomfort across sensory

modalities (outlined below). Before each task began, participants rated their baseline level of

discomfort (i.e., “How uncomfortable, tense, or ‘not just right’ do you feel right now?”) on a

scale from 0 (none) to 100 (extreme). After exposure to stimulus, participant ratings of

discomfort evoked by, and urge to counteract or correct the stimulus (e.g., “How strong is your

urge to arrange or straighten this table?”) were collected. These ratings were also on a scale from

0 (none) to 100 (extreme). In order to reduce the likelihood of order or carryover effects, tasks

were presented in a counterbalanced order and participants completed unrelated word-search

puzzles for two minutes between tasks.

Self-Report Measures

Not Just Right Experiences-Questionnaire-Revised (NJRE-Q-R; Coles et al., 2005). The

NJRE-Q-R is a 19-item measure designed to assess past month NJREs (e.g., “I have had the

sensation after getting dressed that parts of my clothes (tags, collars, pant legs, etc.) didn’t feel

just right”). To measure severity, participants are asked to concentrate on the most recent NJRE

and report the frequency, intensity, distress, rumination, urge, and responsibility associated with

the experience on a 6-point Likert scale from 1 (none) to 7 (extreme). The first 10 items

containing sample NJREs have good internal consistency (α = .79) and the full 19 items have

shown good convergent and discriminant validity, as evidenced by consistently stronger

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correlations with symptoms of OCD than other anxiety constructs (e.g., trait anxiety, social

anxiety, worry) or depressive symptoms (Coles et al., 2003; 2005). Internal consistency for the

measure in the current study was adequate to good (sample items α = .66; severity α = .85).

Obsessive-Compulsive Core Dimensions Questionnaire (OC-CDQ; Summerfeldt, et al.,

2014). The OC-CDQ is composed of 20 items, 10 of which assess incompleteness and 10 of

which assess harm avoidance. The incompleteness subscale includes questions such as, “I must

do things a certain way or I will feel bad” and “I know I’ve done something right when I get a

certain feeling inside.” The harm avoidance subscale includes questions such as, “even if harm is

very unlikely, I feel I need to prevent it at any cost” and “situations or things seem so scary that I

wish I could avoid them altogether.” Each item is rated on a 4-point Likert scale from 1 (never

applies to me) to 5 (always applies to me). The OC-CDQ factors have demonstrated good

internal consistency both with clinical (incompleteness α = .92; harm avoidance α = .91) and

nonclinical (incompleteness α = .88; harm avoidance α = .89) populations. Internal consistency

for both subscales in the current study was good (incompleteness α = .89; harm avoidance α =

.91).

Obsessive–Compulsive Inventory—Revised (OCI-R; Foa et al., 2002). The OCI-R is an

18-item questionnaire that assesses the presence of the 6 primary OCD symptom clusters (i.e.,

checking, washing, ordering, hoarding, obsessing, neutralizing). Each subscale is composed of 3

items (e.g., ordering: “I get upset if objects are not arranged properly”); respondents are asked to

indicate how much each experience distressed or bothered them over the past month on a 5-point

Likert scale from 0 (not at all) to 4 (extremely). For the present study, participants completed

items corresponding to checking, washing, ordering, and obsessing symptoms. Hoarding and

neutralizing items were not included in analyses, given that hoarding is now considered a

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separate disorder from OCD (American Psychiatric Association, 2013) and the neutralizing

subscale has demonstrated poor psychometrics (Hajcak, Huppert, Simons, & Foa, 2004). The

OCI-R has demonstrated good internal consistency with a clinical sample (α = .83) and adequate

convergent and discriminant validity (Abramowitz & Deacon, 2006). Internal consistency for

these subscales in the current study ranged from good to excellent (checking α = .88; washing α

= .75; ordering α = .89; obsessing α = .90).

Multidimensional Perfectionism Scale (MPS; Frost, Marten, Lahart, & Rosenblate, 1990).

The MPS is a 35-item questionnaire designed to assess perfectionistic beliefs (e.g., “If I do not

set the highest standards for myself, I am likely to end up a second rate person.”). Perfectionism

is measured across six dimensions: concern over mistakes, personal standards, parental

expectations, parental criticism, doubts about actions, and organization. For each item,

respondents are asked to indicate the extent to which they agree with the statement on a 5-point

Likert scale ranging from 1 (strongly disagree) to 5 (strongly agree). The MPS total score is

computed by summing all subscales except the organization subscale. The total score has

demonstrated excellent internal consistency (α = .90) and convergent validity with other

perfectionism measures (Frost et al., 1990). Internal consistency for the measure in the current

study ranged from good to excellent (concern over mistakes α = .90, personal standards α = .84;

parental expectations α = .81; parental criticism α = .79; doubts about actions α = .79;

organization α = .94; total score α = .92).

Depression Anxiety Stress Scales – 21 Item Version (DASS-21; Henry & Crawford,

2005). The DASS-21 is a shortened version of the original, 42-item DASS (Lovibond &

Lovibond, 1995). For the current study, DASS-21 was used to assess symptoms of depression

(e.g., “I felt that life was meaningless”) and anxiety (e.g., “I felt scared without any good

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reason”). Respondents rate how much each item applied to them over the past week on a 4-point

Likert scale from 0 (never) to 3 (almost always). The DASS-21 has demonstrated excellent

internal consistency for depression (α = .82 - .94) and anxiety (α = .87 - .90) subscales, as well as

good factor structure (Clara, Cox, & Enns, 2001), and good convergent and discriminant validity

(Antony, Bieling, Cox, Enns, & Swinson, 1998; Henry & Crawford, 2005). Internal

consistencies for the relevant subscales were good in this study (depression α = .89; anxiety α =

.78).

In Vivo Assessment of NJREs

Visual NJRE task

In order to evoke visual NJREs (i.e., the sensation that things don’t look right),

participants were asked to direct their attention toward a cluttered table. Everyday items such as

crumpled notebook paper, magazines, pens, paperclips, and three-ring binders were scattered in

an unorganized fashion across the surface of the table. After viewing the clutter for 10 seconds,

participants were asked to rate their level of current discomfort while looking at the table, as well

as their urge to arrange or straighten the clutter. After participants completed the ratings, the

table was covered so that the items were no longer in view.

Tactile NJRE tasks

Coat Task

In order to evoke tactile NJREs (i.e., the sensation that things don’t feel right),

participants were asked to put on an over-sized lab coat and button it in an asymmetric manner.

Participants were then asked to roll up one sleeve to the elbow and stand wearing the coat for 10

seconds. After the time had elapsed, participants were asked to keep the coat on as they rated

their current discomfort due to the way the coat was arranged and the urge to straighten the coat.

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After participants completed the ratings, they were permitted to remove the coat and it was

placed out of view.

Hand Wipe Task

In a second tactile NJRE task, participants were given a moist hand wipe and instructed

to wipe the back of their non-dominant hand one time, in order to create a sensation of imbalance

on the skin (they were not permitted to also wipe their dominant hand). To prevent participants

from rubbing their hands in a way to neutralize the action, they were instructed to place their

non-dominant hand on the table. Participants were then asked to rate their current discomfort and

urge to wipe their hands. After participants completed the ratings, they were given another hand

wipe to use on their dominant hand if they wished.

Auditory NJRE task

In order to evoke auditory NJREs (i.e., the sensation that things don’t sound right),

participants listened to a clip of a nursery rhyme (Frère Jacques) played out of tune in a

discordant fashion with guitar and piano. The clip was played through headphones and lasted 1

minute and 20 seconds. Participants were asked to rate their peak discomfort and their urge to

counteract or ‘make things right’ while listening to the clip.

Results

Task discomfort, urge to counteract stimuli, and intercorrelational analyses of task

responses are presented in Table 1. On average, the four tasks produced mild to moderate

discomfort (M = 19.6 - 32.8) and urge to counteract task-specific stimuli (M = 36.8 - 41.8) with

possible scores ranging from 0 (none) to 100 (extreme). Across all four tasks, moderate to strong

relationships were observed between ratings of discomfort and urge (p <. 001); these

relationships remained significant after Bonferroni corrections (.05/28 = .002). Descriptive data,

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zero-order correlations, and partial correlations for ratings on each task (discomfort evoked, and

urge to counteract task stimuli) and other study measures are presented in Tables 2 through 4.

Partial correlations for discomfort evoked by task stimuli were computed by covarying for pre-

task discomfort. Further, to ensure relationships are not better accounted for by co-occurring

negative affect, DASS depression and DASS anxiety scores were covaried when calculating

partial correlations. Due to the large number of variables examined, tests of a priori hypotheses

were conducted using Bonferroni corrections.

Relationships between NJRE task ratings and self-report measures of incompleteness and harm

avoidance

To evaluate the validity of each in vivo task, correlations between task ratings

(discomfort evoked and urge to counteract stimuli) with existing measures of NJREs were

examined using Bonferroni adjusted alpha levels of .002 per test (.05/32; Table 2). As expected,

discomfort and urge to counteract stimuli for all four tasks were strongly associated with self-

report measures of NJREs (NJRE-Q-R; OC-CDQ incompleteness subscale; rs = .26 - .45, ps <

.002). Partial correlations controlling for pre-task discomfort and DASS variables remained

significant with the exception of the correlation between discomfort evoked by the Auditory task

and both dispositional incompleteness measures, the correlation between discomfort while

wearing the lab coat and the NJRE-Q-R severity rating, and the correlation between discomfort

after hand wipe and the OC-CDQ incompleteness subscale. Overall, these associations suggest

that the tasks are valid assessments of NJREs. Significant relationships were observed between

task ratings and the harm avoidance subscale of OC-CDQ (rs = .24 - .30, ps < .002); however,

the majority of these relationships were no longer significant in partial correlation analyses of the

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harm avoidance subscale. This is suggestive of divergent validity, consistent with our hypotheses

that task ratings would be less consistently related to harm avoidance.

Relationships between NJRE task ratings and OCD symptoms

We also evaluated correlations between task ratings (discomfort evoked, and urge to

counteract stimuli) and OCD symptom subtypes of interest (ordering/arranging, checking,

washing, and obsessing) again using Bonferroni adjusted alpha levels of .002 per test (.05/32;

Table 3). The hypothesized relationships across tasks and ordering/arranging, checking, and

washing symptoms were observed: task ratings were moderately correlated with

ordering/arranging (rs = .26 - .59, ps < .002), checking (rs = .20 - .34, ps < .002), and washing

(rs = .24 - .43, ps < .002). With some exceptions, particularly in discomfort evoked by the

Auditory task, these relationships remained significant when analyses included covariates. More

robust associations were noted for urge to counteract stimuli across tasks. While obsessing

symptoms were significantly associated with ratings of both discomfort and urge to counteract

on each task (rs = .21 - .31, ps < .002), the majority of these relationships were no longer

significant in partial correlation analyses.

Relationships between NJRE task ratings and perfectionism

Finally, we examined correlations between task ratings (discomfort evoked, and urge to

counteract stimuli) and various aspects of perfectionism using Bonferroni adjusted alpha levels

of .001 per test (.05/56; Table 4). In line with our hypotheses, ratings for all tasks of discomfort

and urge to counteract stimuli were significantly correlated with MPS total score (rs = .22 - .26,

ps < .001), with the exception of urge to straighten in the Visual task, which was just above the

Bonferroni cutoff (r = .20, p = .001). However, these associations no longer remained significant

after controlling for pre-task discomfort and DASS depression and anxiety. Further correlation

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analyses examining subscales of the MPS revealed interesting patterns between tasks. Urge to

counteract ratings for all tasks (with the exception of the hand wipe task), as well as discomfort

ratings for the Visual task were uniquely associated with ‘doubts about actions’ (rs = .22 - .23, ps

< .001). Further, ratings of both discomfort and urge to counteract in the Visual task, as well as

urge to counteract in the lab coat task, were uniquely associated with ‘organization’ (rs = .23 -

.39, ps < .001). Though associations were observed with ratings across tasks and ‘concern over

mistakes,’ these relationships did not remain significant when analyses included covariates.

Discussion

The present study examined four in vivo tasks designed to evoke feelings of ‘not just

right’ experiences (NJREs) across separate sensory modalities: (1) viewing cluttered table (visual

NJRE); (2) wearing asymmetrically arranged lab coat (tactile NJRE); (3) wiping a portion of

non-dominant hand with hand wipe (tactile NJRE); (4) listening to a music clip played out of

tune (auditory NJRE). Each task produced mild to moderate levels of discomfort and urge to

counteract task-specific stimuli, indicating that relevant phenomena were tapped. Ratings of

discomfort and urge to counteract across tasks were strongly correlated, which was consistent

with our predictions. The pattern of these associations and some of the unique relationships

found between specific NJRE tasks and OC symptoms and perfectionism are consistent with the

perspective that these types of NJREs are related but somewhat distinct phenomena.

Task ratings (discomfort and urge to counteract) for each task showed moderate

associations with self-report measures of NJREs, providing support for task validity. Weaker,

less consistent associations were observed between task ratings and dispositional harm

avoidance; this is important evidence of discriminant validity. The relationship between

dispositional NJREs and sensory-specific in vivo assessments corroborates previous literature

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suggesting that NJREs underlying obsessive-compulsive symptomatology are experienced across

sensory modalities (e.g., Rosário et al., 2009; Summerfeldt, 2004). These findings likewise

substantiate the validity of current self-report measures (i.e., NJRE-Q-R; incompleteness

subscale of the OC-CDQ), as they do not appear to be limited to any single sensory modality.

Although the NJRE-Q-R assesses frequency of several NJREs related to not looking or

feeling ‘right,’ it only includes one item related to not sounding ‘right.’ The NJRE-Q-R also does

not assess severity of the range of these items; rather, only the most recent NJRE is further

examined (Coles et al., 2005). Incompleteness items from the OC-CDQ, on the other hand, do

not classify NJREs by sensory modality and rather broadly probe the amount of time spent

engaged in activities until things are ‘just right,’ perfect, or certain (Summerfeldt et al., 2014).

Thus, though these self-report measures of NJREs are useful for generally assessing these

experiences, the findings from the current study suggest that specificity could be improved by

emphasizing particular sensory modalities through which the ‘not just right’ sensations are

experienced.

We also examined task ratings (discomfort and urge to counteract) and their relationship

to OC symptom patterns. Ratings for all four tasks exhibited unique associations with

ordering/arranging, checking, and washing symptoms, whereas associations with obsessing

symptoms were not as strong or consistent. Research indicates that cognitive symptoms of OCD

such as obsessions are more strongly associated with harm avoidance (Ecker & Gönner, 2008),

while compulsions are more closely related to feelings of incompleteness (Summerfeldt, 2007).

However, recent findings indicate that harm avoidance and incompleteness are not entirely

orthogonal constructs, as previous literature might suggest (Taylor et al., 2014). This may

explain the small associations observed between task ratings of urge to counteract with harm

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avoidance. It is also important to note that obsessions most closely related to NJREs are likely

those regarding symmetry and exactness. However, the items on the OCI-R obsessing scale (i.e.,

“I find it difficult to control my own thoughts”; “I am upset by unpleasant thoughts that come

into my mind against my will”; “I frequently get nasty thoughts and have difficulty in getting rid

of them”) may be more consistent with repugnant, sexual, religious, and violent obsessions. This

may partially account for the inconsistent relationships observed between NJRE task ratings and

obsessing symptoms.

Ordering/arranging symptoms were more strongly associated with task ratings

(discomfort and urge) for each of the four in vivo tasks than any of the other OC symptoms

examined in this study. This provides further evidence of task validity, as previous research has

demonstrated a high overlap between ordering/arranging symptoms and incompleteness (Coles et

al., 2003; Ecker & Gönner, 2008; Ferrão et al., 2012; Pietrefesa & Coles, 2009). Of the four

tasks, ordering/arranging symptoms exhibited the strongest relationship to ratings on the visual

NJRE task.

Checking symptoms were also associated with NJRE task ratings (discomfort and urge).

These data corroborate findings from previous studies examining the relationship between visual

NJRE tasks and checking symptoms (e.g., Cougle et al., 2013) and extend these findings to

tactile and auditory NJRE inductions.

Washing symptoms were most strongly related to task ratings (discomfort and urge) in

the two tactile tasks. The relationship between response to the hand wipe task and washing

symptoms is unsurprising, though it was interesting to note the associations that emerged

between washing symptoms and response to the coat task, as well. This suggests that both

domain-specific and general tendencies towards the experience of tactile NJREs may contribute

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to washing symptoms. These findings are consistent with previous research linking NJREs to

washing behavior (Cougle et al., 2011).

NJREs are often referred to within the literature and assessment measures as the sense

that things are imperfect (e.g., Coles et al., 2003; Lee et al., 2009; Pietrefesa & Coles, 2009;

Summerfeldt, 2004). Thus, we were interested in examining perfectionistic beliefs as they related

to each task. Though associations were observed between the total MPS score and task ratings

(discomfort and urge to counteract), they did not remain after partialling out pre-task discomfort

and negative affect. Analyses of the MPS subscales, however, revealed interesting patterns

across tasks. Broadly, concern over mistakes, doubts about actions, and organization exhibited

nuanced relationships with task ratings (discomfort and urge). Specifically, ‘concern over

mistakes’ was most strongly related to ratings during the lab coat (Tactile) task, though these

relationships did not hold once covariates were included, while ‘doubts about actions’ and

‘organization’ were uniquely related to ratings during the Visual task. These results partially

corroborate those of Coles and colleagues (2003), as they found the frequency and intensity of

past week NJREs to be moderately associated with concern over mistakes and doubts about

actions. However, they did not observe a relationship between these NJRE variables and

organization, as was found in the current study; rather, they found a relationship between past-

week NJREs and personal standards (Coles et al., 2003). Discrepancies in these findings suggest

that dispositional (retrospective) and in vivo (induced in the laboratory) NJREs may

differentially relate to multiple facets of perfectionism. Although NJREs and perfectionism are

often discussed in tandem within the literature, these data suggest that incompleteness/NJREs are

distinct from perfectionism. Further research on the relationship between these two constructs is

warranted, as this may have implications for how each is understood and treated.

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It is important to consider the limitations of the current study. Our sample was large (N =

284), though the generalizability of our findings to individuals with OCD is unclear as we used

an unselected student sample that was relatively young and predominately female. However, the

sample we chose allowed for the examination of a wide range of symptoms. Additionally,

research with unselected populations is highly relevant for understanding OC symptomatology

(Abramowitz et al., 2014; Gibbs, 1996). These findings notwithstanding, future studies

conducted with more severe clinical samples that are more demographically diverse would serve

to increase generalizability of findings and might also reveal stronger relationships between the

constructs studied. With regard to the tasks, we limited our assessment of sensory NJREs to

visual, tactile, and auditory modalities; however, it is likely that NJREs may also be experienced

via taste and/or smell. Perhaps future research could explore novel tasks that tap these other

senses. It is important to mention that the tasks used in the current study to evoke tactile NJREs

also included some visual information (i.e., participants looked at the coat in order to arrange it

asymmetrically; participants may have seen moisture on their non-dominant hand following use

of the hand wipe). Future research utilizing these tasks might be improved by blindfolding

participants during non-visual NJRE inductions in order to reduce sensory overlap between

tasks. Finally, our findings were correlational and thus directionality of the relationships between

sensory-specific NJREs and OC symptom domains and perfectionism is not specified.

Future studies should further explore the validity and utility of these tasks using

experimental designs. For example, previous studies have successfully manipulated visual

NJREs in the laboratory using an in vivo task (i.e., cluttered table versus organized table; Cougle

et al., 2013). Future research efforts could similarly manipulate stimuli presented in the tactile

NJRE tasks (e.g., asymmetrically arranged versus symmetrically arranged lab coat; wiping one

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hand versus both hands with hand wipe) and the auditory NJRE tasks (distorted versus original

music clip). Comparisons of group differences (NJRE induction versus control group) with

regard to their effect on OC symptoms, perfectionism, and other outcomes of interest (e.g.,

performance on subsequent tasks) may further elucidate the role of sensory-specific NJREs in

OCD symptomatology.

Findings presented in the current study also have clinical implications. Patients with

NJRE-related symptoms may benefit from repeated engagement in tasks that evoke discomfort

and urge to counteract stimuli across separate sensory modalities. As with any exposure and

response prevention (ERP) protocol, this treatment would require patients to resist the urge to

counteract sensory-specific stimuli (e.g., the urge to straighten the lab coat so it lays ‘just right’

on the body) and habituate to the ‘not just right’ feeling evoked by the tasks over repeated

exposure and extended durations. It would also be informative to examine how such exposure

techniques might concurrently influence OC symptom patterns and maladaptive domains of

perfectionism.

The present study corroborates previous literature suggesting that NJREs are experienced

across sensory modalities (visual, tactile, and auditory) and contributes four valid sensory-

specific tasks that can be used to induce and assess these phenomena. Further, ratings of

discomfort during the tasks and urge to counteract task-specific stimuli were uniquely associated

with OC symptom clusters (ordering/arranging, checking, and washing), and specific

maladaptive domains of perfectionism (doubts about actions, and organization). Clinicians and

researchers interested in NJRE phenomenology may consider incorporating sensory specific

tasks into their work for more a comprehensive assessment of these experiences.

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Declaration of interest: The authors report no conflicts of interest.

Highlights:

We validated four in vivo tasks to induce and assess NJREs across sensory modalities

Task responses were associated with OC symptoms and maladaptive domains of

perfectionism

Sensory specific NJRE tasks may offer a more comprehensive assessment of NJREs

Tasks may have utility in experimental and clinical contexts

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Table 1

Descriptives and correlational analyses of responses to in vivo assessments of NJREs

Mean SD 1 2 3 4 5 6 7 8

1. Visual task

discomfort

22.27 26.43 —

2. Visual task urge to

straighten

39.72 31.63 .76* —

3. Lab coat (tactile) task

discomfort

32.77 29.73 .56* .57* —

4. Lab coat (tactile) task

urge to straighten

41.77 33.04 .56* .69* .79* —

5. Hand wipe (tactile)

task discomfort

19.61 22.98 .53* .45* .58* .47* —

6. Hand wipe (tactile)

task urge to counteract

37.52 31.06 .51* .62* .58* .57* .70* —

7. Auditory task

discomfort

31.37 30.40 .41* .37* .46* .41* .41* .42* —

8. Auditory task urge to

counteract

36.84 32.56 .40* .49* .46* .50* .36* .43* .75* —

Note: * p< .001

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ACCEPTED MANUSCRIPT

Visual, Tactile, and Auditory NJREs 31

Table 2

Correlational and partial correlational† analyses of responses to in vivo assessments of NJREs and self-report measures of NJREs,

depression, and anxiety

NJRE-Q-R

count

NJRE-Q-R

severity

ratings

OC-CDQ-

incompleteness

OC-CDQ-

harm

avoidance

DASS

depression

DASS

anxiety

M 3.45 21.87 18.38 14.86 3.66 3.34

SD 2.29 7.75 7.05 7.33 4.03 3.41

Visual task

Discomfort (r) .39* .33* .38* .25* .21* .29*

Discomfort (partial r) .29* .22* .29* .07

Urge to straighten (r) .44* .31* .43* .27* .15 .21*

Urge to straighten (partial r) .40* .27* .39* .20*

Lab coat (tactile) task

Discomfort (r) .45* .28* .41* .24* .19 .28*

Discomfort (partial r) .34* .15 .30* .05

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ACCEPTED MANUSCRIPT


Urge to straighten (r) .41* .26* .39* .24* .21* .25*

Urge to straighten (partial r) .35* .20* .33* .14

Hand wipe (tactile) task

Discomfort (r) .35* .36* .28* .26* .30* .34*

Discomfort (partial r) .22* .29* .15 .03

Urge to counteract (r) .34* .35* .37* .30* .18 .25*

Urge to counteract (partial r) .27* .30* .31* .21*

Auditory task

Discomfort (r) .30* .27* .30* .27* .19* .25*

Discomfort (partial r) .16 .19 .17 .10

Urge to counteract (r) .37* .26* .37* .24* .15 .20*

Urge to counteract (partial r) .33* .22* .33* .17

Note: NJRE-Q-R = Not Just Right Experiences Questionnaire-Revised; OC-CDQ = Obsessive-Compulsive Core Dimensions

Questionnaire; DASS = Depression Anxiety Stress Scale-21; †partial correlations for ‘discomfort’ controlling for pre-task discomfort,

DASS depression and DASS anxiety, partial correlations for ‘urge to counteract’ controlling for DASS depression and DASS anxiety;

* p< .002

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ACCEPTED MANUSCRIPT


Table 3

Correlational and partial correlational† analyses of responses to in vivo assessments of NJREs and self-report measures of OCD

symptoms

OCI-R ordering OCI-R checking OCI-R washing OCI-R obsessing

M 2.47 1.70 1.51 2.10

SD 2.77 2.53 2.17 2.72

Visual task

Discomfort (r) .45* .29* .30* .23*


Urge to straighten (r) .59* .28* .37* .21*

Urge to straighten (partial r) .56* .23* .33* .12


Discomfort (r) .42* .31* .42* .26*


Urge to straighten (r) .44* .34* .34* .30*

Urge to straighten (partial r) .40* .28* .28* .19*

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ACCEPTED MANUSCRIPT



Discomfort (r) .33* .20* .34* .31*

Discomfort (partial r) .26* .10 .22* .14

Urge to counteract (r) .43* .30* .43* .28*


Auditory task

Discomfort (r) .26* .20* .24* .27*

Discomfort (partial r) .15 .11 .13 .14

Urge to counteract (r) .35* .28* .34* .26*


Note: OCI-R = Obsessive-Compulsive Inventory-Revised; DASS = Depression Anxiety Stress Scale-21; †partial correlations for

‘discomfort’ controlling for pre-task discomfort, DASS depression and DASS anxiety, partial correlations for ‘urge to counteract’

controlling for DASS depression and DASS anxiety; * p< .002

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Table 4

Correlational and partial correlational† analyses of responses to in vivo assessments of NJREs and facets of perfectionism

Concern

over

mistakes

Personal

Standards

Parental

Expectations

Parental

Criticism

Doubts

about

actions

Organization MPS total

M 24.05 25.31 15.93 8.68 9.25 21.51 83.23

SD 7.96 5.13 4.40 3.90 3.42 5.60 18.28

Visual task

Discomfort (r) .23* .14 .07 .13 .34* .27* .25*

Discomfort (partial r) .12 .14 .04 .05 .22* .32* .15

Urge to straighten (r) .19* .10 .04 .11 .30* .39* .20

Urge to straighten (partial r) .12 .07 .02 .06 .23* .39* .03


Discomfort (r) .28* .17 -.02 .07 .32* .19 .24*

Discomfort (partial r) .18 .12 -.09 -.02 .15 .18 .11

Urge to straighten (r) .29* .15 .02 .12 .32* .22* .26*

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Urge to straighten (partial r) .20 .14 .00 .05 .23* .23* .18


Discomfort (r) .28* .11 .06 .12 .25* .10 .24*

Discomfort (partial r) .10 .09 -.01 -.01 .03 .10 .07

Urge to counteract (r) .23* .10 .11 .15 .28* .17 .24*

Urge to counteract (partial r) .15 .07 .09 .09 .19 .17 .16

Auditory task

Discomfort (r) .22* .17 .02 .13 .28* .02 .23*

Discomfort (partial r) .11 .13 -.02 .07 .11 .00 .11

Urge to counteract (r) .20 .17 .03 .12 .30* .13 .22*

Urge to counteract (partial r) .13 .15 .01 .07 .23* .12 .16

Note: MPS = Multidimensional Perfectionism Scale (CM = Concern over Mistakes; PS = Personal Standards; PE = Parental

Expectations; PC = Parental Criticism; D = Doubts about actions; O = Organization); DASS = Depression Anxiety Stress Scale-21;

†partial correlations for ‘discomfort’ controlling for pre-task discomfort, DASS depression and DASS anxiety, partial correlations for

‘urge to counteract’ controlling for DASS depression and DASS anxiety; *p< .001

visual, tactile, and auditory “not just right” experiences: associations with...

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