Discovering what is hidden: The role of non-ritualized covert neutralizing strategies in Obsessive–Compulsive Disorder

• In patients with moral-based obsessions covert strategies are related to OCD severity.
• OCD patients use more covert neutralizing strategies than overt compulsions.
• Covert strategies are associated with sadness, guilt and dysfunctional appraisals.
• Overt strategies are associated with anxiety and the personal meaning of obsessions.
• A decrease in the use of control strategies is an index of treatment efficacy.

Background and objectivesNeutralizing strategies are secondary to obsessions and an additional cause of distress and interference, but they have received little attention in theories and research, especially the non-ritualized covert strategies. This study focuses on the comparative impact of non-ritualized covert and compulsive-overt strategies in the course of OCD.MethodsEighty-two OCD adult patients completed measures assessing distress, interference, appraisals and overt and covert neutralizing strategies to control obsessions. Thirty-eight patients who had completed cognitive therapy were assessed again after treatment.ResultsOnly overt compulsions are associated with OCD severity. Nonetheless, considering the main symptom dimension, covert strategies are also associated with severity in patients with moral-based obsessions. Patients who used covert strategies more frequently, compared to those who use them less, reported more sadness, guilt, control importance, interference, and dysfunctional appraisals. Regarding the overt strategies, patients who used them more reported more anxiety and ascribed more personal meaning to their obsessions than the patients who used them less. After treatment, recovered patients decreased their use of both covert and overt strategies, while non-recovered patients did not. There was a higher rate of non-recovered patients among those who used more non-ritualized covert strategies before treatment.LimitationsEmotions and appraisals were assessed with a single item. OCD symptom dimensions were only assessed by the Obsessive–Compulsive Inventory.ConclusionsIn addition to studying overt compulsions, the impact of covert neutralizing strategies on the OCD course and severity warrants more in-depth study.