BOZZA ERICKSON
Erickson
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Erickson
Volume 18 - n. 1 • 2012
Volume 18 – n. 1 • 2012
Marta Ghisi e Gioia BottesiCriteri e classificazione diagnostica della tricotillomania nell’ottica del DSM-V
Marco Innamorati, Anna Contardi, Massimo Continisio, Ettore De Monte, Mariantonietta Fabbricatore, Paolo Scapellato, Stella Tamburello e Antonino TamburelloBurnout, attaccamento e stili temperamentali affettivi
Luisa Scaduto, Francesca Cuzzocrea e Rosalba Larcan«Sensory Premonitory Urge» e trattamento cognitivo-comportamentale di un disturbo da tic associato a disturbo ossessivo-compulsivo: studio di un caso
Gideon E. Anholt, Omer Linkovski, Eyal Kalantrof e Avishai HenikIf I do it, it must be important: Integrating basic cognitive research findings with cognitive behavior theory of obsessive-compulsive disorder
Guy Doron, Dahlia Talmor, Ohad Szepsenwol e Danny S. DerbyRelationship centered obsessive-compulsive phenomena
Jonathan D. Huppert e Elad ZlotnickCore fears, values, and obsessive-compulsive disorder: A preliminary clinical-theoretical outlook
Marcel A. van den Hout, Eliane C.P. Dek, Catharina L. Giele e Marieke B.J. ToffoloHow compulsive perseveration undermines trust in cognitive operations
Volume 18 – n.12012
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BOZZA ERICKSON
2012 - Volume 18 • n. 1
Editorial 9
Theory Marta Ghisi and Gioia Bottesi 13DSM-Vdiagnosticcriteriaandclassificationoftrichotillomania
Communications Marco Innamorati, Anna Contardi, Massimo Continisio, Ettore 39De Monte, Mariantonietta Fabbricatore, Paolo Scapellato, Stella Tamburello and Antonino TamburelloBurnout,adultattachmentandaffectivetemperamentalstyles
Clinical cases Luisa Scaduto, Francesca Cuzzocrea and Rosalba Larcan 53SensoryPremonitoryUrgeandcognitivebehaviouraltreatmentofaticdisorderassociatedwithanobsessive-compulsivedisorder:Acasestudy
EABCT: Special interest group – Obsessive-compulsive disorder (Barbara Barcaccia and Francesco Mancini, Eds)
Gideon E. Anholt, Omer Linkovski, 69Eyal Kalantrof and Avishai HenikIfIdoit,itmustbeimportant:Integratingbasiccognitiveresearchfindingswithcognitivebehaviortheoryofobsessive-compulsivedisorder
Guy Doron, Dahlia Talmor, Ohad Szepsenwol and Danny S. Derby 79Relationship-centeredobsessive-compulsivephenomena
Jonathan D. Huppert and Elad Zlotnick 91Corefears,values,andobsessive-compulsivedisorder:Apreliminaryclinical-theoreticaloutlook
Marcel A. van den Hout, Eliane C.P. Dek, Catharina L. Giele 103and Marieke B.J. ToffoloHowcompulsiveperseverationunderminestrustincognitiveoperations
International meetings 115
Reviews 117
Inde
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BOZZA ERICKSON
2012 - Volume 18 • n. 1
Editoriale 9
Teoria Marta Ghisi e Gioia Bottesi 13Criterieclassificazionediagnosticadellatricotillomanianell’otticadelDSM-V
Comunicazioni Marco Innamorati, Anna Contardi, Massimo Continisio, Ettore 39De Monte, Mariantonietta Fabbricatore, Paolo Scapellato, Stella Tamburello e Antonino TamburelloBurnout,attaccamentoestilitemperamentaliaffettivi
Casi clinici Luisa Scaduto, Francesca Cuzzocrea e Rosalba Larcan 53«SensoryPremonitoryUrge»etrattamentocognitivo-comportamentalediundisturbodaticassociatoadisturboossessivo-compulsivo:studiodiuncaso
EABCT: Special interest group – Disturbo ossessivo-compulsivo(a cura di Barbara Barcaccia e Francesco Mancini)
Gideon E. Anholt, Omer Linkovski, 69Eyal Kalantrof e Avishai HenikSelofaccio,deveessereimportante:integrareirisultatidellaricercadibaseconlateoriacognitivo-comportamentaledeldisturboossessivo-compulsivo
Guy Doron, Dahlia Talmor, Ohad Szepsenwol e Danny S. Derby 79Isintomiossessivo-compulsivicentratisullerelazioni
Jonathan D. Huppert e Elad Zlotnick 91Paurecentrali,valoriedisturboossessivo-compulsivo:unprimosguardoteorico-clinico
Marcel A. van den Hout, Eliane C.P. Dek, Catharina L. Giele 103e Marieke B.J. ToffoloComelaperseverazionecompulsivacompromettelafiducianelleoperazionicognitive
Congressi 115
Recensioni 117
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BOZZA ERICKSON 69
Summary1
Cognitive behavior accounts of obsessive-compulsive disorder ascertain that the catastrophic interpretation of (normally occurring) intrusive thoughts as a sign of danger plays a major role in the etiology and maintenance of OCD. Various researchers have placed particular importance on metacognitive beliefs such as thought importance and control of thoughts as paramount forces driving such interpretations. Obsessive-compulsive patients and their family members have been found to show diminished capability of response inhibition relative to healthy controls. We propose that deficits in response inhibition are related to the development and maintenance of obsessive-compulsive metacognitive beliefs. We further suggest that patients observe their own behavioral tendencies and subtle reactions associated with intrusions and interpret these as indicating that the intrusions are important. Over time generalizations of this process are established in the form of metacognitive beliefs. Specific hypotheses for future research and clinical implications are suggested.
Keywords: metacognitive beliefs, obsessive-compulsive disorder, response inhibition.
RiassuntoSe lo faccio, deve essere importante: integrare i risultati della ricerca di base con la teoria cognitivo-comportamentale del disturbo ossessivo-compulsivoLe spiegazioni cognitivo-comportamentali del disturbo ossessivo-compulsivo (DOC) rilevano che l’interpretazione catastrofica di pensieri intrusivi (che si presentano normalmente) come di segnali di
* BarbaraBarcacciaandFrancescoMancini,Eds.
If I do it, it must be important: Integrating basic cognitive research findings with cognitive behavior theory of obsessive-compulsive disorderGideon E. Anholt a,b, Omer Linkovski a,c, Eyal Kalantrof a,c and Avishai Henik a,c
a Department of Psychology, Ben-Gurion University of the Negev, Beer-Sheva, Israelb Department of Psychiatry and Institute for Research in Extramural Medicine, VU-University Medical Center
and Academic Outpatient Clinic for Anxiety Disorders, GGZ InGeest, Amsterdam, the Netherlandsc Zlotowski Center for Neuroscience, Ben-Gurion University of the Negev, Beer-Sheva, Israel
Edizioni Erickson - Trento Psicoterapia Cognitiva e Comportamentale - Vol. 18 - n. 1 • 2012 (pp. 69-77)
EABCT: Special interest group – Obsessive-compulsive disorder*
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pericolo gioca un ampio ruolo nell’eziologia e nel mantenimento del disturbo ossessivo-compulsivo. Vari ricercatori hanno posto particolare attenzione sulle credenze metacognitive quali l’importanza e il controllo dei pensieri come forze supreme che determinano tali interpretazioni. I pazienti ossessivi e le loro famiglie mostrano una minore capacità di inibizione della risposta rispetto al gruppo di controllo sano. Noi proponiamo che tali deficit nell’inibizione della risposta siano legati allo sviluppo e al mantenimento delle credenze metacognitive ossessivo-compulsive. Suggeriamo inoltre che i pazienti osservino le loro tendenze comportamentali e le sottili reazioni associate alle intrusioni e che le interpretino come l’indicazione che le intrusioni siano importanti. Le generalizzazioni di questo processo sono stabilite col passare del tempo sotto forma di credenze metacognitive. Vengono suggerite ipotesi specifiche per la ricerca futura e le implicazioni cliniche.
Parole chiave: credenze metacognitive, disturbo ossessivo-compulsivo, inibizione della risposta.
ObSESSIvE-cOmPuLSIvE dISORdER And cOGnItIvE bEHAvIOR tHERAPy
Obsessive-compulsivedisorder(OCD)isananxietydisorderwithalifetimeprevalenceof2%-3%(Weissmanetal.,1994).OCDishighlydebilitating,negativelyaffectingqualityoflifeandleveloffunctioning(Huppertetal.,2009)andisinvolvedwithhighratesofco-morbidityasmorethanhalfthepatientspresentwithatleastoneotherDSM-IVdiagnosis(SteketeeandBarlow,2004).Cognitivebehaviortherapy(CBT)consistingofexposureandresponsepreventionorcognitivetherapyisthemostefficaciouspsychologicaltreat-mentofOCD(Rosa-Alcázar,Sánchez-Meca,Gómez-ConesaandMarín-Martínez,2008).Unfortunately,manypatientsdropoutordonotbenefitsufficientlyfromtreatment,andoncestringentcriteriaofrecovery(i.e.,minimalsymptoms)areapplied,only25%reachrecovery(FisherandWells,2005).Therefore,thereseemstobegreatroomforimprove-mentinourunderstandingandtreatmentofOCD.
ApredominantpsychologicalmodeltounderstandthesymptomsofOCDisthecog-nitivebehavioralmodel(Salkovskis,ForresterandRichards,1998).Salkovskis(1999)presentsthemaintenetsofthismodelasfollows:(1)Intrusionsoccurinatleast90%ofthegeneralpopulation;(2)Thedifferencebetweennormalintrusivecognitionsandobsessionalintrusivecognitionsliesintheirinterpretation;(3)FortheOCDpatienttheintrusivecognitionisanindicationthatheisresponsibleforharmoritsprevention.Asaconsequenceofthisinterpretation,theOCDpatientexperiencesanxiety,discomfortandengagesinanxiety-neutralizing(compulsive)behavior.Furtherattemptsofmentalcontrolelicitparadoxicaleffectsofincreasingthesethoughts,perpetuatingaviciouscircle(PurdonandClark,2002).Wellsandcolleaguesstresstheimportanceofmetacognitivebeliefs(i.e.beliefsaboutthinking)inthecatastrophicinterpretationofthoughtcrucialtothede-velopmentandmaintenanceofOCD(WellsandMatthews,1994;Solem,Myers,Fisher,VogelandWells,2010).Metacognitivebeliefsincludedomainssuchasoverimportanceofthoughts,inwhichthemerepresenceofathoughtappearstogiveitstatus(e.g.,«Ithinkaboutathoughtbecauseitisimportant,anditisimportantbecauseIthinkaboutit»)and
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beliefsabouttheimportanceofcontrollingone’sthoughts(e.g.,«Oneshould(andcan)exercisecontroloverone’sthoughts»,ClarkandPurdon,1993;OCCWG,1997).OtherconceptualizationsofmetacognitivebeliefsinOCDhavereferredtothought-actionfusionwhichconsistsoftwotypesofbeliefs(1)thathavinganimmoralthoughtequalstocar-ryingitout(TAFmorality),and(2)thathavingathoughtincreasesthelikelihoodofits’occurringinreallife(TAFlikelihood;Shafran,ThordarsonandRachman,1996).Thus,fortheOCDpatienthavingathoughtofharminghischildequalstobeingapsychopathcapableandmaybeevendesiringtodoso.
SeverallinesofempiricalevidencesupporttheimportanceofmetacognitivebeliefstothedevelopmentandmaintenanceofOCD.Forexample,inastudyusingastudentpopula-tion,participantswereaskedtowritethesentence«IhopethatXisinacaraccident»andtheninsertthenameofalovedone(Rachman,Shafran,Mitchell,TrantandTeachman,1996).Participantshighonthoughtactionfusiondemonstratedincreasedanxietyandurgetoneutralize(e.g.,bydestroyingthepaper).Metacognitivebeliefswerefoundtodif-ferentiatebetweenOCDpatientsandcommunitycontrols(Solem,Myers,Fisher,VogelandWells,2010).Further,ananalysisoftreatmentpredictorsofbehaviorandresponsepreventionforOCDpatientshasdemonstratedthatonlychangesinmetacognitionweresignificantwhenoverlapbetweenpredictorswascontrolledfor(Solem,Håland,Vogel,HansenandWells,2009).
Littleisknownabouttheetiologicalbasisformeta-cognitivebeliefsofOCDpatients.Shafran(2005)suggestedseveralfactorsthatmightcontributetothedevelopmentofthesebeliefs:(1)Rigidandextremecodesofconductandduty(e.g.,thereligiousbelief«sinbythought,sinbydeed»),(2)anincidentinwhichitappearedthatone’sthoughtsand/orac-tionsorinactioncontributedtoaseriousmisfortune(e.g.,wishingsomeonewasdeadandfindingoutthattheydiedlaterthatday),and(3)experiencesinvolvingcriticismorblame,aswellassituationalincreasesinresponsibility(e.g.,birthofachild/havinganinfant;Abramowitz,SchwartzandMoore,2003).However,thesefactorsaremostlydescriptiveandprovidelimitedexplanationforindividualdifferencesinpronenesstodevelopthesebeliefs.Littleisknownaboutbasiccognitiveprocessesordeficitsrelatedtothedevelop-mentofmetacognitivebeliefs.
ObSESSIvE-cOmPuLSIvE dISORdER And RESPOnSE InHIbItIOn
NeuropsychologicalresearchofOCDpatientshasindicatedthattheyshowvariousdeficitsinexecutivefunctions(Abramovitch,Dar,SchweigerandHermesh,2011).Oneofthefunctionsmostextensivelyinvestigatedisresponseinhibition;OCDpatientswerefoundtoperformpoorlyonresponseinhibitionrelativetocontrolsubjects(Bannon,Gonsalvez,CroftandBoyce,2002;Penadesetal.,2007).Perhapsthemostcommontaskofresponseinhibition,demonstratingdeficitsinOCDpatientsandtheirfamiliesrelativetohealthcontrols,isthestopsignaltask(Chamberlain,Fineberg,Blackwell,Robbins,andSahakian,2006;Menziesetal.,2007;Morein-Zamir,Fineberg,RobbinsandSahakian,2010).Thestop-signaltask(Logan,1994;LoganandCowan,1984)examinestheabilitytosuppressanalreadyinitiatedactionorthoughtthatisnolongerappropriate.Inthecommonversion
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ofthetask,participantsareaskedtoaddressavisualstimulus(gosignal)withamotorresponseasfastaspossible.Inaboutonethirdofthetrials,anauditorystimulus(stopsignal)comesrightafterthevisualgosignal.Participantsareinstructedtoinhibittheirmotorresponsewhentheyhearthestopsignal.Thedurationbetweenthevisualstimulusandthestopsignal(stop-signaldelay;SSD)changesfromonetrialtothenextbyatrack-ingprocedureandisbasedontheparticipant’ssuccessininhibitinghisresponse.Whenparticipantssucceedinresponseinhibition,thenextstoppingtrialismoredifficult(theSSDislonger)andwhenparticipantsfailtoinhibittheirresponse,thenextstoppingtrialiseasier(theSSDisshorter).Eventually,itispossibletoestimatethestop-signalreactiontime(SSRT),whichisthetimeneededforsuccessfulinhibition.Stop-signalreactiontimehasproventobeanimportantmeasureofcognitivecontrol(VerbruggenandLogan,2008).
IntEGRAtInG fIndInGS Of RESPOnSE InHIbItIOn dEfIcItS wItH cOGnI-tIvE bEHAvIOR tHEORy
WesuggestthatinhibitiondifficultiesinOCDpatientsmayserveanetiologicalroleinthedevelopmentandmaintenanceofmetacognitivebeliefs,andpossiblyserveasapredictorfortreatmentresponse.Ourtheoryfollowsasimilarlogictooneoftheclassicalemotiontheoriesinthefieldofpsychology,thatofWilliamJames(Ellsworth,1994).Jamesquestionedthetemporallogicofourunderstandingofrelationsbetweenphysiologicalreac-tions,emotionandbehavior.Hesuggestedthat«Common-sensesaysweloseourfortune,aresorryandweep;wemeetabear,arefrightenedandrun;weareinsultedbyarival,areangryandstrike.Thehypothesisheretobedefendedsaysthatthisorderofsequenceisincorrect,thattheonementalstateisnotimmediatelyinducedbytheother,thatthebod-ilymanifestationsmustfirstbeinterposedbetween,andthatthemorerationalstatementisthatwefeelsorrybecausewecry,angrybecausewestrike,afraidbecausewetremble»(James,1884/1969;1890/1950).OCDpatientsmayexperiencethebehavioraltendenciesassociatedwiththoughtsasmoredifficulttoinhibitandencountermoreinstancesinwhich(subtle)reactionstothoughtsoccur.Thesephenomenamaybelaterinterpretedasasignthattheassociatedthoughtshavespecialsignificance.Overtime,generalmetacognitivebeliefsaboutimportanceofintrusivethoughtsandneedtocontrolthesethoughtsmayarise.Agrowingbodyofresearchsupportsthenotionthatavarietyofmotormovementssuchasfacialexpressions(e.g.,Buck,1980),posture(e.g.,StepperandStrack,1993)andarmmovements(e.g.,FörsterandStrack,1997)caninfluenceindividuals’thoughtsandfeelings(ChandlerandSchwartz,2009).ImagineforexampleanOCDpatienthavingthethoughtthatalovedonemightdieinacaraccidentandtouchingsomethingasaconse-quence.Observingherownbehavior,thispatientmaybeinclinedto(implicitly)maketheinterpretationthat«ifIreactedtothisthoughtitmustbeimportantandthereforemylovedoneisreallyindanger».Inasense,OCDpatientsdoindeedhavethoughtactionfusion;thedistancebetweenthoughtsandbehaviorinthesepatentsisdecreasedsinceinhibitioncapabilityisdiminished.
Alternatively,inhibitiondifficultiesinOCDpatientsmayberelatedtotaskcontrol.Cognitivecontrolisinvolvedinsolvingtaskconflict;performingonetaskwhileplaying
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downirrelevanttasks.Usuallyirrelevanttasksconsistofautomatictriggers.Thiscor-respondswithfindingsthatdemonstratethatstimulimaytriggerperformanceoftasksthathavestrongassociationswiththem(AllportandWylie,2000;RogersandMonsell,1995;Waszak,HommelandAllport,2003).Inrecentyears,studiesdemonstratedtheex-istenceoftaskconflictinvarioustasks:e.g.,GoldfarbandHenik(2007)withtheStrooptask;BravermanandMeiran(2010)withthetaskswitchingparadigm;LaHeij,BoelensandKuipers(2010)withtheobjectinterferencetask).LaHeijandBoelens(2011)andKalantrhroff,GoldfarbandHenik(inpreparation)arguedthattaskcontrolshouldbecon-ceptualizedasinhibitionofpre-potentresponsesandthattaskconflictisstrongerwhenthiscontrolislow.WesuggestthatadeficitininhibitorycontrolmakesitharderforOCDpatientstoinhibitirrelevantautomatictasksthatareusuallysuppressedwithoutawareness.Asmentionearlier,theperformanceofthesebehaviorslaterreceivesmeaning.
dIREctIOnS
Severalinterestingpredictionsforfutureresearchariseasconsequenceoftheideaswesuggest.First,weexpectthatthoughtsthatwillbeexperimentallypairedwithirrelevantmotoractions(thusartificiallyformingthoughtsthatpossessbehavioraltendencies)willbeperceivedasmoresignificantandlikelytooccurthanthoughtsthathavenotbeenpairedwithsuchmotoractions.ThishypothesisstemsfromtheobservationthatOCDphenomenaareoftensenselessandevenirrelevantforthetasksrelatedtotheintrusivethoughts(e.g.,Zoretal.,2009).Second,measuresofresponseinhibition(indicesofthestopsignaltask)areexpectedtocorrelatewithmeasuresofOCDbeliefs,particularlybe-liefsaboutimportanceofthoughtsandcontrolofthoughts.Third,weexpectsignificantclinicalimplicationsforthetreatmentofOCDthroughthetrainingofresponseinhibition.WeexpectthattrainingofinhibitionwouldaidinthetreatmentofOCDby(1)changingofmetacognitivebeliefsabouttheimportanceofthoughtsandthoughtcontrol,and(2)improvingefficacyofexposureandresponseprevention(enhancingself-control).Fourth,wesuggestthatdifferencesinresponseinhibitionmaypredictdifferentialresponsestoinducedcompulsive-likebehaviors.vandenHout’sseminalwork(vandenHoutandKindt,2003;vandenHout,Engelhard,deBoer,duBoisandDek,2008)hasdemonstratedthatcompulsive-likebehaviorssuchascheckingorstaringinduceuncertaintyinhealthycon-trols.However,theseexperimentsdonotsuggestetiologicalfactorsexplainingwhysomepeoplearemorepronetoengageinthesebehaviorsandbecomeentangledintheviciouscircleofdoubt,uncertaintyandcompulsivebehaviors.Wesuggestthatsubjectswithlowinhibitionasmeasuredbythestopsignalparadigmmayexhibitmoreuncertaintyontasksinducingcompulsivebehaviorsthansubjectswithstronginhibitioncapabilities.Furthermore,wehypothesizethatsubjectswhoperformthesecompulsive-liketasksmayshowdecreasedinhibitiononthestopsignalparadigmonceitadjustedtocontainthesamestimuli(e.g.,avirtualgasstove).
IthastobenotedthatsomeresearchershavenotfoundinhibitiondifficultiesinOCDpatients(e.g.,Moritz,KlossandJelinek,2009;thoughtheyhaveinvestigatedcognitiveinhibitionandnotresponseinhibition).Moritzandcolleagues(2009)havearguedthata
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fundamentalinhibitiondeficitisunlikelyinOCDsince(1)patientsaretroubledonlybysomethoughtsandcognitions,and(2)patientscanresistactingaccordingtotheseurges.Inresponsetotheseconcernswesuggestthatemotionalvalencemayinteractwithresponseinhibitiondifficultiesandaccentuatesubtledysfunctions.Furthermore,wesuggestthatthemereexperienceofastrongbehavioraltendencyortheexecutionofsubtleresponsessufficefortheincreaseinthepersonalrelevanceofintrusivethoughts.OurhypothesisdoesnotcontradicttheintactabilityofOCDpatientstocontrolthemselvesfromperformingthefullbehaviorsportrayedbytheirintrusivethoughts.Wesuggestthatresearcheffortshouldnotconcentrateoncognitivecontrolasintrusionsareanaturallyoccurringphenomenonbutratheron(failuresin)responseinhibition.ThisparallelstheCBTrationaleinthesensethatintrusions(representingcognitivecontrol)arenotthetargetofintervention(onthecontrary,suppressingthoughtsisdiscouraged)butreactionstointrusionsareprevented(thus,responseinhibitionisbeingpromoted).
Inconclusion,wesuggestthatimpairedresponseinhibitionisrelatedtothedevel-opmentofOCDmetacognitivebeliefs.Theexperienceofdifficultytoinhibitbehaviortendenciesrelatedtointrusivethoughtsmayleadtotheperceptionsofthesethoughtsasimportantandlikelytooccur.Asaconsequence,thesepatientsmayengageinthoughtsuppressionaswellascompulsivebehavior,andbecomeentangledinaviciouscircle.ImpairedresponseinhibitionmaybeabasiccognitiveprocessunderlyingvulnerabilitytodevelopOCDsymptomsandmaybecomeexacerbatedwhenhighvalencesemotionalstimuliareencountered.
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correspondence address
Gideon E. Anholt Department of Psychology Ben-Gurion University of the Negev, Beer-Sheva, Israele-mail: [email protected]
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Erickson
Volume 18 - n. 1 • 2012
Volume 18 – n. 1 • 2012
Marta Ghisi e Gioia BottesiCriteri e classificazione diagnostica della tricotillomania nell’ottica del DSM-V
Marco Innamorati, Anna Contardi, Massimo Continisio, Ettore De Monte, Mariantonietta Fabbricatore, Paolo Scapellato, Stella Tamburello e Antonino TamburelloBurnout, attaccamento e stili temperamentali affettivi
Luisa Scaduto, Francesca Cuzzocrea e Rosalba Larcan«Sensory Premonitory Urge» e trattamento cognitivo-comportamentale di un disturbo da tic associato a disturbo ossessivo-compulsivo: studio di un caso
Gideon E. Anholt, Omer Linkovski, Eyal Kalantrof e Avishai HenikIf I do it, it must be important: Integrating basic cognitive research findings with cognitive behavior theory of obsessive-compulsive disorder
Guy Doron, Dahlia Talmor, Ohad Szepsenwol e Danny S. DerbyRelationship centered obsessive-compulsive phenomena
Jonathan D. Huppert e Elad ZlotnickCore fears, values, and obsessive-compulsive disorder: A preliminary clinical-theoretical outlook
Marcel A. van den Hout, Eliane C.P. Dek, Catharina L. Giele e Marieke B.J. ToffoloHow compulsive perseveration undermines trust in cognitive operations
Volume 18 – n.12012
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