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Comprehensive Psychiatry xx (2013) xxx – xxx

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The characteristics of unacceptable/taboo thoughts in

obsessive–compulsive disorder
Vlasios Brakoulias a,⁎, Vladan Starcevic a , David Berle b , Denise Milicevic b , Karen Moses b ,
Anthony Hannan b , Peter Sammut c , Andrew Martin d
a
University of Sydney, Sydney Medical School-Nepean, Discipline of Psychiatry, Sydney/Penrith, NSW, Australia
b
Nepean Anxiety Disorders Clinic, Nepean/Blue Mountains Local Health District, Penrith, NSW, Australia
c
Nepean Hospital, Department of Psychiatry, Penrith, NSW, Australia
d
NHMRC Clinical Trials Centre, University of Sydney, Sydney, NSW, Australia

Abstract

Background: In the quest to unravel the heterogeneity of obsessive–compulsive disorder (OCD), an increasing number of factor analytic
studies are recognising unacceptable/taboo thoughts as one of the symptom dimensions of OCD.
Aims: This study aims to examine the characteristics associated with unacceptable/taboo thoughts.
Methods: Using the Yale–Brown Obsessive–Compulsive Scale Symptom Checklist (YBOCS-SC) with 154 individuals with OCD,
obsessive–compulsive symptoms were subjected to principal components analysis. The characteristics associated with the resulting symptom
dimensions were then assessed using logistic and linear regression techniques.
Results: Unacceptable/taboo thoughts comprised of sexual, religious and impulsive aggressive obsessions, and mental rituals. Higher scores
on an unacceptable/taboo thoughts symptom dimension were predicted by higher Y-BOCS obsession subscores, Y-BOCS time preoccupied
by obsessions scores, Y-BOCS distress due to obsessions scores, importance of control of thought ratings, male gender, and having had
treatment prior to entering into the study. Unacceptable/taboo thoughts were also predicted by greater levels of hostility, and a past history of
non-alcohol substance dependence.
Conclusions: An unacceptable/taboo thought symptom dimension of OCD is supported by a unique set of associated characteristics that
should be considered in the assessment and treatment of individuals with these symptoms.
Crown Copyright © 2013 Published by Elsevier Inc. All rights reserved.

1. Introduction analytic studies [2–9] that have revealed a symptom

Unacceptable/taboo thoughts, also known as “pure
obsessions”, refer to impulsive aggressive, sexual and
religious obsessions. The observation that some obsessions
occurred in the apparent absence of compulsions was first
made by Baer [1] in a study employing factor analysis
techniques. Since then, there have been a number of factor
No conflicts of interest. This study was funded by the Nepean Medical
Research foundation, a competitive Pfizer Neuroscience Grant and a grant
from the Discipline of Psychiatry at The University of Sydney.
⁎ Corresponding author. Nepean Hospital, Department of Psychiatry,
PO Box 63, Penrith, NSW 2751, Australia. Tel.: +61 2 4734 2585; fax: +61
2 4734 3343.
E-mail addresses: vbrakoulias@bigpond.com,
vlasios.brakoulias@sydney.edu.au (V. Brakoulias).
0010-440X/$ – see front matter. Crown Copyright © 2013 Published by Elsevier Inc. All rights reserved.
http://dx.doi.org/10.1016/j.comppsych.2013.02.005
dimension of obsessive–compulsive disorder (OCD) char-
acterised predominantly by obsessions and in particular
aggressive, sexual and religious obsessions. More recently,
studies [10,11] have demonstrated that “pure obsessions” is a
misnomer in that unacceptable/taboo thoughts tend to be
accompanied by compulsions.
Unacceptable/taboo thoughts are distinctly ego-dystonic
with a repugnant quality that tends not to be so prominent
in other OCD symptoms [12]. As their name suggests, the
content of these obsessions typically involves unacceptable,
taboo or forbidden themes such as stabbing a relative,
incest or blasphemy. Studies have associated unacceptable/
taboo thoughts with mental rituals [10], reassurance-
seeking [6,10], avoidance [13,14], good insight [15], male
gender [16,17], and being more likely to seek professional
help [18].
2 V. Brakoulias et al. / Comprehensive Psychiatry xx (2013) xxx–xxx
In addition to the obvious phenomenological differences
between unacceptable/taboo thoughts and other OCD
symptoms, unacceptable/taboo thoughts also appear to
have clinical utility as they have been associated with a
differential response to treatment. Although studies examin-
ing the response of unacceptable/taboo thoughts to pharma-
cotherapy have resulted in conflicting findings [19], some
studies investigating the response to behavioural interven-
tions [20–22] have reported a poorer outcome.
This study aimed to illustrate that unacceptable/taboo
thoughts are associated with different characteristics to other
symptom dimensions of OCD and that these characteristics
may have implications for the treatment of individuals with
unacceptable/taboo thoughts. It was hypothesised that
unacceptable/taboo thoughts would be associated with
greater severity, specifically higher Y-BOCS obsession
scores and higher levels of distress. These hypotheses were
based on clinical observation and the findings of previous
studies [23,24]. Having hypothesized that greater degrees of
severity and distress would be associated with unacceptable/
taboo thoughts, it was additionally hypothesised that
unacceptable/taboo thoughts would be associated with
higher rates of having obtained treatment prior to entering
the study, greater reassurance-seeking, greater levels of
avoidance, higher rates of comorbid depression and stronger
beliefs relating to a need to control one's thoughts. These
hypotheses were based on limited evidence relating
unacceptable/taboo thoughts to higher rates of previous
treatment [18], greater reassurance-seeking [6,10], greater
levels of avoidance [13,14], higher rates of comorbid
depression [25,26] and cognitive beliefs relating to the
importance of controlling one's thoughts [27–30].
2. Methods
2.1. Recruitment
This report has resulted from the Nepean OCD Study,
conducted in Sydney and several other Australian cities.
Participants (N = 154) were recruited from the Nepean
Anxiety Disorders Clinic, OCD support groups, newspaper
advertisements and referrals from general practitioners,
psychiatrists, clinical psychologists and mental health
services. Participants were included if they had a primary
diagnosis of OCD which was determined on the basis of a
clinician-administered semi-structured interview, the Mini
International Neuropsychiatric Interview plus version (MINI
[31,32]), and the qualifier that OCD was the condition for
which they sought help or which caused the most distress or
impairment in functioning. Individuals with a current
comorbid diagnosis of psychosis, bipolar affective disorder,
a pervasive developmental disorder, severe intellectual
disability, or substance abuse or dependence were excluded.
The MINI was also used to determine co-occurring
diagnoses and age of onset. Participants needed to be over
the age of 18. Institutional ethics committee approval was
obtained prior to commencing the study and all participants
provided signed informed consent.
2.2. Measures
Participant characteristics were assessed via structured
clinical interviews and self-report instruments. In this article,
we report findings derived from standard demographics, the
MINI, the Yale–Brown Obsessive–Compulsive Scale (Y-
BOCS) [33], Avoidance and Reassurance-seeking Interview,
Overvalued Ideas Scale (OVIS) [34], Symptom Checklist
90-Revised (SCL-90R) [35] and Obsessive Beliefs Ques-
tionnaire (OBQ) [36,37].
The MINI (plus version) is a clinician-administered semi-
structured interview that was used to determine co-occurring
DSM-IV diagnoses and their age of onset, in addition to
ascertaining whether the DSM-IV criteria for OCD have
been met. The MINI has been validated against other widely
used structured diagnostic interviews and its psychometric
properties have been good [38,39].
The severity of OCD was assessed by means of the Y-
BOCS, whereas OCD symptoms were assessed via the Y-
BOCS Symptom Checklist (YBOCS-SC). The YBOCS-SC
is a semi-structured interview which includes a comprehen-
sive list of 64 obsessions and compulsions arranged by
content into 15 categories. The categories for obsessions are:
aggressive; contamination; sexual; hoarding/saving; reli-
gious; symmetry/exactness; miscellaneous; and somatic. The
categories for compulsions are: cleaning/washing; checking;
repeating; counting; ordering/arranging; hoarding/collecting;
and miscellaneous. All the categories were used for the
principal components analysis (PCA) except for aggressive
and miscellaneous. Two items from the aggressive obses-
sions category were re-classified as “unintentional harm”.
These were: “fear will harm others because not careful
enough” and “fear will be responsible for something else
terrible happening”. All other items were categorised as
“impulsive aggression” obsessions. This method has been
used in other studies [3,4] in an attempt to reduce the
heterogeneity within the aggressive obsessions category.
Similarly, in an attempt to reduce the heterogeneity of the
miscellaneous categories [10], only the item “mental rituals”
was used.
Interviews were conducted by a psychiatrist or clinical
psychologist trained in the use of the MINI and YBOCS-SC.
Interrater reliability was assessed for the first 49 participants
(this involved two raters completing the MINI and the
YBOCS-SC in the same assessment without corroborating
their findings), and for the YBOCS-SC categories this was
excellent (94.3% agreement).
Avoidance and reassurance-seeking were assessed by an
interview-based instrument that was constructed for the
study and administered alongside the Y-BOCS. This
instrument assesses the presence of avoidance and/or
reassurance-seeking and the extent of avoidance and/or
reassurance-seeking with a 5-point Likert scale. Avoidance
 V. Brakoulias et al. / Comprehensive Psychiatry xx (2013) xxx–xxx
is assessed with the question: “Have you been avoiding
anything because of your obsessions/thoughts or because
you were concerned you would perform compulsions?”
Reassurance-seeking is assessed with the question: “Have
you been asking anyone to reassure you because of your
obsessions/thoughts or because you think you did some-
thing wrong or punishable?” Both questions give examples
to ensure the subject has understood what is meant by
avoidance and reassurance-seeking in the context of OCD.
The instrument has demonstrated good convergent validity
with higher scores on avoidance and reassurance-seeking
predicting greater OCD severity and higher levels of
anxiety [40,41].
Insight and other characteristics of belief related to OCD
were measured using the OVIS. This structured clinical
interview has been shown to have better predictive validity
than the single item that assesses insight on the Y-BOCS [42].
Symptom distress and psychopathology were measured
by the SCL-90R. This 90-item psychometrically sound
instrument [43], provides scores on the Global Severity
Index and nine subscales: Somatization, Obsessive–compul-
sive, Interpersonal sensitivity, Depression, Anxiety, Hostil-
ity, Phobic anxiety, Paranoid ideation and Psychoticism.
Cognitive styles along the dimensions of responsibility/
threat estimation, perfectionism/intolerance of uncertainty
and importance/control of thoughts were assessed with the
44-item OBQ. The psychometric properties of the OBQ in
samples with OCD, where it has been used in a large number
of studies, have been reported to be good [44].
2.3. Statistical methods
All data were entered into the Statistical Package for the
Social Sciences (SPSS) version 17 [45] and analysed.
Additional analyses were conducted using SAS version 9.2
[46]. PCA was conducted on the 15 YBOCS-SC categories
as described above. Oblique (direct Oblimin) and orthogonal
(Varimax) rotational methods yielded comparable results.
The study used the technique for factor loading described by
Baer (1994) and Mataix-Cols et al. (1999) when analysing
the YBOCS-SC. According to this technique, Y-BOCS
symptom categories regarded as principal symptoms were
given a value of 2, whereas other symptoms categories that
were currently present were given a value of 1 and when
there was no symptom in a given category, it was given a
value of 0.
Suitability of the data for PCA was assessed using a
Kaiser–Meyer–Olkin Measure of Sampling Adequacy
value of 0.6 or above [47,48] and a Bartlett's Test of
Sphericity significance value less than 0.05 [49]. Parallel
analysis [50,51] was used to determine the number of
factors to be extracted for rotation. Items loading N0.4 were
regarded as robust.
A series of regression models were constructed to
examine the relationship between each participant charac-
teristic assessed (fitted individually as the outcome variable)
3
and the 5 YBOCS-SC-derived symptom dimensions (fitted
together as covariates). Multiple linear regression was
applied to the continuous outcome variables and logistic
regression to the binary outcome variables. In each case a
backwards elimination approach was applied to the full
regression model, comprising the 5 YBOCS-SC-derived
symptom dimensions, in order to produce a parsimonious
model comprising those YBOCS-SC-derived symptom
dimensions that remained statistically significant (at the
5% level). Results from final models that included the
unacceptable/taboo thoughts symptom dimension as a
covariate are presented in the results. The False Discovery
Rate (FDR) approach was used to adjust P-values for the
multiple comparisons [52,53].
3. Results
The characteristics of the sample are shown in Table 1.
The specified YBOCS-SC categories that were subjected
to PCA yielded a five-factor structure explaining 64.9% of
the variance (Table 2). This included an unacceptable/
taboo thoughts symptom factor that explained 8.7% of the
variance and that consisted of impulsive aggressive, sexual
and religious obsessions and mental rituals. Logistic and
linear regression analyses revealed that higher Y-BOCS
obsession scores, higher levels of distress, more time
spent on obsessions, greater levels of hostility, beliefs
regarding the importance of controlling one's thoughts,
having had treatment prior to the study, being male and
having had a past diagnosis of non-alcohol drug
dependence significantly predicted higher scores on the
unacceptable/taboo factor after adjustment for multiple
comparisons (Table 3). There was no significant relation-
ship between unacceptable/taboo thoughts and avoidance,
reassurance-seeking and level of insight.
4. Discussion
This study presented new findings indicating that
unacceptable/taboo thoughts might be characterised by
higher rates of previous non-alcohol substance dependence
and greater levels of hostility. One may hypothesise that there
is a need to use substances to reduce the distress associated
with unacceptable/taboo thoughts, or that substance abuse
plays an aetiological role in the occurrence of these
obsessions. However, the cross-sectional nature of our
study does not allow us to speculate about the direction of
causality, if any, between unacceptable/taboo thoughts and
substance abuse. The role of substance abuse in the aetiology
of unacceptable/taboo thoughts is not supported by the
finding that 70% of individuals with OCD and comorbid
substance abuse believe that their OCD preceded their
substance abuse [54]. Although there are higher rates of
substance dependence in individuals with OCD [55–57], no
4 V. Brakoulias et al. / Comprehensive Psychiatry xx (2013) xxx–xxx

Table 1 According to the SCL-90R, hostility refers to thoughts,

Characteristics of the study participants. feelings, or actions that are characteristic of the negative
Characteristic OCD Sample affect state of anger and this includes aggression, irritability,
(N = 154) rage and resentment [35]. Although it is possible that
Age (in years) repetitive, distressing unacceptable/taboo thoughts may
Mean (standard deviation) 45.5 (16.2) make the person more hostile, hostility may also predispose
Median 47.0
to the development of unacceptable/taboo thoughts and
Range 18 to 79
Y-BOCS total score perhaps to substance abuse too. Our finding that individuals
Mean (standard deviation) 22.0 (6.7) with unacceptable/taboo thoughts are more likely to be male
n % may also influence the rates of substance abuse and hostility
Gender levels, as these are both more associated with males [61–63].
Male 62 40.3
As studies have associated low levels of serotonin with
Female 92 59.7
Marital status hostility [64], some authors have concluded that aggressive
Never married 56 36.4 obsessions may be more effectively treated with SSRIs [65].
Married/in a de facto relationship 60 39.0 The finding of a link between unacceptable/taboo
Divorced/separated 32 20.8 thoughts and male gender is consistent with previous studies
Widowed 6 3.8
[16,17,66]. Potential explanations for this association
Number of children
Nil 73 47.3 include sexual dimorphism in brain regions accounting for
One or more 81 52.7 unacceptable/taboo thoughts, as has been suggested for
Employment status contamination/cleaning symptoms [17,67], or the existence
Full-time (≥24 h/week) 42 27.3 of gender-specific environmental factors that mediate the
Part-time (b24 h/week) 21 13.7
expression of unacceptable/taboo thoughts.
Unemployed 91 59.0
Highest level of educational attainment There were also a number of other findings that were
Primary school 4 2.6 consistent with previous studies and thus support the
Secondary school 78 50.6 validity of the new findings. As hypothesised, the
Technical college certificate or diploma 40 26.0 unacceptable/taboo thoughts symptom dimension revealed
University degree 32 20.8
by factor analysis in this study comprised mental rituals,
Comorbid conditions
Generalised anxiety disorder 49 31.8 sexual obsessions, religious obsessions and impulsive
Specific phobia 32 20.8 aggression obsessions. The inclusion of mental rituals in
Past alcohol abuse 28 18.2 an unacceptable/taboo thoughts symptom dimension of
Major depressive disorder 25 16.2 OCD replicates the findings of a previous study [10]. In
Social phobia 25 16.2
support of the ego-dystonic nature of unacceptable/taboo
Panic disorder 21 13.6
Tic disorder 17 11.0 thoughts, the Y-BOCS revealed that higher obsession
Past alcohol dependence 16 10.4 scores, higher obsession-related distress, and more time
Past psychotic disorder 14 9.1 spent on obsessions predicted higher scores on the
Past non-alcohol drug abuse 11 7.1 unacceptable/taboo symptom factor. The OBQ confirmed
Past non-alcohol drug dependence 6 3.9
previous findings relating the importance of control of
Hypochondriasis 3 1.9
Treatment with psychotropic agent at the 93 60.4 thoughts to unacceptable/taboo thoughts [27,29,30,68].
time of assessment Individuals with unacceptable/taboo thoughts were also
Previous behavioural intervention 71 46.1 more likely than individuals with other OCD symptoms to
have received treatment for their condition, and this is
again consistent with previous findings [18]. These findings
study reported higher rates in individuals with unacceptable/ suggest that unacceptable/taboo thoughts are experienced
taboo thoughts compared to individuals with other OCD with much distress, which may motivate many sufferers to
symptoms. Furthermore, the relationship between current seek help and treatment earlier than individuals with other
substance abuse or dependence was not assessed in this study symptoms of OCD.
as such patients were excluded from participating. Therefore, Unlike previous studies [6,10,13], there was no relation-
the finding of an association between unacceptable/taboo ship between unacceptable/taboo thoughts and avoidance or
thoughts and past substance abuse requires replication. reassurance-seeking. This finding is likely to be explained by
Neuroimaging data [58] have revealed similarities between differences in the methods used to assess OCD symptoms,
pathways involved with reward dependence in addiction and avoidance and reassurance-seeking. This primarily relates to
pathways involved in OCD. These suggest that addiction, and the grouping of checking compulsions with unacceptable/
in particular substance dependence [57,59,60] acts to reward taboo thoughts in previous studies. Reassurance-seeking is
in a similar manner to compulsions. In the absence of overt viewed by some [69] as a form of checking and there are
compulsions with unacceptable/taboo thoughts, there may be some studies indicating that reassurance-seeking has a
an increased tendency to develop substance dependence. stronger relationship with checking than unacceptable/
 V. Brakoulias et al. / Comprehensive Psychiatry xx (2013) xxx–xxx 5

Table 2
The frequency of principal YBOCS-SC categories or items and Varimax-rotated factor structure using three-point ordinal rating principal components analysis
(N = 154).
YBOCS-SC categories⁎ Frequency (%) Hoarding Contamination/ Doubt/ Symmetry/ Unacceptable/Taboo
Cleaning Checking Ordering Thoughts
Hoarding/saving obsessions 20.8 0.964 −0.126 −0.075 −0.058 −0.083
Hoarding compulsions 23.4 0.957 −0.145 −0.076 −0.042 −0.069
Contamination obsessions 26.6 −0.165 0.921 −0.060 0.018 −0.025
Cleaning/washing compulsions 26.0 −0.108 0.913 −0.075 0.036 −0.008
Symmetry obsessions 9.1 −0.046 −0.003 0.026 0.953 0.061
Ordering/arranging compulsions 7.1 −0.047 0.033 0.037 0.952 −0.048
Mental rituals⁎ 5.2 0.039 0.071 −0.105 0.042 0.745
Sexual obsessions 3.2 −0.081 0.009 0.120 −0.104 0.701
Impulsive aggression⁎ 17.5 −0.187 −0.223 0.410 0.014 0.535
Religious obsessions 1.9 −0.037 0.054 0.118 0.209 0.550
Checking compulsions 29.9 −0.095 0.109 0.848 −0.012 −0.014
Unintentional harm⁎ 16.9 −0.139 −0.109 0.709 0.017 0.108
Repeating rituals 3.9 0.151 0.157 0.565 0.134 0.101
Somatic obsessions 3.2 0.017 0.372 0.398 −0.083 0.126
Counting compulsions 13.0 −0.092 0.046 0.129 0.202 0.026
Percentage of variance explained (%) - 18.5 14.8 13.3 9.6 8.7
Robust loadings (N0.4) are printed in bold and are underlined.
⁎ Symptoms with an asterisk indicate that “mental obsessions” are an item from the miscellaneous compulsions category and that “unintentional harm” and
“impulsive aggression” pertain to certain items from the aggressive obsessions category.

taboo thoughts [69–71]. In addition, a more comprehensive
assessment of reassurance-seeking was conducted in this
study compared to previous studies [6,10] where the single
miscellaneous item of the Y-BOCS (“Need to ask, tell or
confess”) was used to represent reassurance-seeking.
The finding that participants with unacceptable/taboo
thoughts were more likely to have received treatment would
support an association with good insight. However, a
relationship between unacceptable/taboo thoughts and
insight was absent in this study. Unlike the previous positive
study [15] which used a single item of the Y-BOCS to assess
insight and combined “forbidden” thoughts with checking,
insight in our study was measured with a tool specifically
designed to assess belief in OCD (the OVIS). Despite using a
validated assessment tool that assesses insight in a multi-
dimensional manner, there are many limitations that arise
when assessing insight. These limitations relate to the
complex nature of insight, the difficulties associated with
identifying a belief relating to a subject's primary OCD
symptoms and the inconsistent use of terms used to
characterise belief in assessment tools [72].
Although the finding of this study in relation to the
frequency of co-occurring depression did not reach statistical
significance after adjustment for multiple comparisons, this
finding is likely to require further investigation. Previous
studies [25,26] indicating an association between unaccept-
able/taboo thoughts and higher comorbidity with major
depression again grouped unacceptable/taboo thoughts with
checking. The higher levels of distress associated with
unacceptable/taboo thoughts may be a confounding factor in
the assessment of depression. The increased rate of seeking
treatment among participants with unacceptable/taboo
thoughts may reflect increased levels of motivation and
energy, or perceived worthiness or hope. These character-
istics are less likely to be present in participants with
comorbid depression.
The number of instruments used in the study was limited
by the potential burden on volunteering participants. This
was a cross-sectional study focusing primarily on descrip-
tive characteristics, which precluded us from examining
possible aetiological factors and longitudinal relationships
that may be relevant for unacceptable/taboo thoughts.
Despite the widespread use of the Y-BOCS in assessing
symptoms for factor analysis, its use has been criticised as
potentially biased, because symptoms are categorised prior
to the analysis. As discussed, this has resulted in categories
such as aggressive obsessions and miscellaneous compul-
sions, which are generally regarded as heterogeneous. The
sample size is relatively small if we consider that
participants with unacceptable/taboo thoughts represented
a proportion of the total sample of subjects with OCD. The
finding relating to past non-alcohol substance dependence is
also limited by the small number of participants who
reported past substance dependence.
5. Conclusions
Unacceptable/taboo thoughts appear to form a distinct
symptom dimension of OCD and their validity is further
supported by their association with descriptive characteris-
tics that are not commonly associated with other OCD
symptom dimensions. The ego-dystonic nature of unac-
ceptable/taboo thoughts and their association with the belief
that it is important to control one's thoughts support
psychological therapies that target underlying beliefs and
6 V. Brakoulias et al. / Comprehensive Psychiatry xx (2013) xxx–xxx

Table 3
Regression analyses results.
Dependent variable Unacceptable/taboo thoughts symptom dimension
Logistic regression results (Dichotomous variables): Percentage of whole sample N (%) Odds Ratio a 95% Confidence Interval Standard Error P-value
MINI diagnosis
• Major depressive episode: Current 25 (19.4%) 3.94 1.7–12.3 1.78 0.0180
• Alcohol abuse: Past 28 (18.2%) 3.82 1.3–11.5 1.75 0.0167
• Non-alcohol drug dependence: Past* 6 (3.9%) 27.90 3.3–233.0 2.95 0.0021*
• Hypochondriasis: Past 4 (2.6%) 11.31 1.2–104.4 3.11 0.0325
Treatment prior to entry to study* 40 (30.0%) 9.09 2.2–33.3 2.09 0.0025*
Male gender* 62 (40.3%) 5.69 2.1–15.7 1.68 0.0008*
Being a parent 79 (51.3%) 0.26 0.1–0.7 1.66 0.0075

Dependent variable Unacceptable/taboo thoughts symptom dimension

b
Linear regression results (Continuous variables): Parameter Estimate (β) 95% Confidence Interval Standard Error P-value
Y-BOCS obsession score* 2.41 0.7–4.1 0.86 0.0058*
Y-BOCS total score 4.13 1.1–7.2 1.54 0.0082
Y-BOCS: Time spent on obsessions* 0.85 0.4–1.3 0.24 0.0006*
Y-BOCS: Interference due to obsessions 0.71 0.2–1.2 0.24 0.0040
Y-BOCS: Distress due to obsessions* 0.96 0.6–1.4 0.21 b0.0001*
OBQ: Importance/control of thought* 32.77 28.7–36.8 2.06 b0.0001*
SCL-90R: Hostility* 0.60 0.2–1.0 0.60 0.0021*
Age at assessment −9.30 −16.3–−2.3 3.52 0.0092
Only models that obtained p-values lower than 0.05 for the unacceptable/taboo thoughts symptom dimension are shown. P-values less than 0.007 are asterisked
and represent findings that remained statistically significant after application of the False Discovery Rate (FDR) procedure.
a
Reflects the increase in the odds of an outcome for each 1-point increase in the unacceptable/taboo thoughts symptom dimension.
b
Reflects the increase in outcome score for each 1-point increase in the unacceptable/taboo thoughts symptom dimension.

cognitive processes in addition to the standard behavioural
treatment approach to OCD in the form of ERP. Substance
abuse and hostility may also be associated with unaccept-
able/taboo thoughts. Although this finding requires repli-
cation, it indicates that clinicians should not neglect
substance abuse in their assessment of individuals with
unacceptable/taboo thoughts and that they should also note
associated hostility, if present. An awareness of the
presence of these associated characteristics may assist in
the understanding of the development and/or maintenance
of unacceptable/taboo thoughts.
Acknowledgment
The authors are grateful to Colin Slocombe from ACEDA
Adelaide, Michelle Graeber from ARCVIC Melbourne,
Scott Blair-West of the Melbourne Clinic, the Blacktown
and Kogarah OCD Support Groups, the Mental Health
Association of NSW and the Penrith Mental Health
Practitioners' Network.
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