The role of avoidance in the phenomenology of obsessive-compulsive disorder

Background: Pathologic levels of ritualistic avoidance (also known as active avoidance) are common in the clinical presentation of obsessive-compulsive disorder (OCD). Despite its clinical relevance, there has been little examination of active avoidance as a ritualistic compulsion in adults with OCD. Objective: The objective of this study is to determine if adults with OCD who engage in ritualistic avoidance have greater obsessive-compulsive, anxiety, and depressive symptom severity and different comorbidity patterns than adults who do not engage in ritualistic avoidance. Method: Adults with OCD (n = 133) completed an evaluation that included clinician ratings of obsessive-compulsive severity; overall illness severity; and self-reported ratings of anxiety, depression, and obsessive-compulsive severity. Results: Ritualized avoidance was endorsed by greater than 25% of the sample. Avoidant subjects and, more specifically, contaminant avoidant and reading-writing avoidant subjects presented with elevated levels of obsessive-compulsive symptom severity and greater overall clinical severity than comparison patients who did not engage in each respective avoidance ritual. Conclusions: Patients who engage in ritualized avoidance exhibited greater obsessive-compulsive symptom severity than patients who did not. These findings suggest that ritualized avoidance functions as a compulsion for adults with OCD and that avoidance should receive careful consideration in assessment and treatment.