Not-Just-Right OCD involves a sense of incompleteness or things feeling “not right,” leading to distress and repetitive behaviors to achieve a sense of completeness. It is distinct from OCD symptoms driven by anxiety and feared consequences.
Coles, M. E., & Ravid, A. (2016). Clinical presentation of not-just right experiences (NJREs) in individuals with OCD: Characteristics and response to treatment. Behaviour Research and Therapy, 87, 182-187.
Key Points
- Individuals with OCD experience significantly more not-just-right experiences (NJREs) and are more distressed by them compared to anxious and unselected controls.
- The number and severity of NJREs are significantly correlated with self-reported OCD symptom severity. NJRE severity is also correlated with clinician-rated OCD symptoms, especially obsessions.
- NJREs are more strongly associated with incompleteness motivations and ordering/arranging symptoms than harm avoidance and obsessing symptoms in OCD.
- After cognitive-behavioral therapy (CBT) for OCD, patients report experiencing significantly fewer NJREs and less distress associated with them. Changes in NJREs correlate with changes in OCD symptoms.
- The findings support the importance of studying NJREs in OCD and suggest CBT can effectively reduce both OCD symptoms and NJREs, even when NJREs are specifically targeted.
Rationale
Obsessive-compulsive disorder (OCD) has long been conceptualized as a disorder driven by anxiety and harm avoidance.
According to this prevailing model, individuals with OCD experience intrusive thoughts, images, or impulses that provoke anxiety, and engage in compulsive behaviors to reduce this anxiety and prevent feared outcomes (Abramowitz, 1997; Salkovskis, 1985).
This understanding has informed the development of exposure and response prevention (ERP). This well-established cognitive-behavioral treatment aims to reduce anxiety through repeated exposure to feared stimuli without engaging in compulsions (Abramowitz, Deacon, & Whiteside, 2019).
However, accumulating evidence suggests that anxiety and harm avoidance may not account for all OCD symptoms. Research has identified a subset of symptoms that appear to be motivated by a sense of incompleteness or things being not “just right” rather than anxiety.
These experiences, termed “not just right experiences” (NJREs), are characterized by uncomfortable sensations of things being incomplete, imperfect, or not quite right, which drive repetitive behaviors until a sense of completeness or rightness is achieved (Coles, Frost, Heimberg, & Rhéaume, 2003; Summerfeldt, 2004).
Several studies have found that NJREs are common in OCD and are associated with specific symptom dimensions, such as symmetry, ordering, and arranging (Ferrao et al., 2012; Ecker & Gönner, 2008).
However, the majority of this research has been conducted in non-clinical samples, limiting our understanding of the clinical presentation and correlates of NJREs in individuals with OCD (Coles et al., 2003; Ghisi et al., 2010).
Furthermore, despite the growing recognition of NJREs as a distinct motivational process in OCD, research on the treatment of NJRE-related symptoms is limited.
Given that NJREs are not primarily driven by anxiety, it is unclear whether standard cognitive-behavioral interventions that target anxiety and harm avoidance, such as ERP, are effective for these symptoms (Summerfeldt, 2004).
To address these gaps in the literature, the current study aimed to characterize NJREs in a clinical sample of individuals with OCD and compare their experiences to anxious and non-clinical controls.
Additionally, the study sought to examine the relationship between NJREs and specific OCD symptom dimensions and the response of NJREs to cognitive-behavioral therapy.
Method
The study compared the prevalence and severity of NJREs in individuals with OCD (n = 45) to anxious (n = 34) and unselected (n = 242) control groups using the Not Just Right Experiences Questionnaire-Revised.
Associations between NJREs, OCD symptoms, and motivational factors were examined. Changes in NJREs were assessed in a subset of OCD patients (n = 19) before and after receiving CBT.
Sample
- The OCD group (n = 45) was recruited from a specialty anxiety disorders clinic and had a primary OCD diagnosis. They had a mean age of 28.36 years, were mostly male (62.2%), and had a mean OCD symptom onset age of 14.03 years. Comorbidities included unipolar depression (n=11) and social phobia (n=9).
- Anxious controls (n = 34): This group consisted of individuals who presented to the same anxiety disorders clinic as the OCD group but were diagnosed with other anxiety disorders, such as social phobia, generalized anxiety disorder, panic disorder, and agoraphobia.
- Unselected controls (n = 242): This group consisted of undergraduate students who completed the study measures as part of a research requirement.
Measures
- Not Just Right Experiences Questionnaire-Revised (NJRE-QR) – assesses recent NJREs and their severity
- Obsessive-Compulsive Trait Core Domains Questionnaire (OC-TCDQ) – measures harm avoidance and incompleteness motivations
- Yale-Brown Obsessive Compulsive Scale (Y-BOCS) – clinician-rated OCD symptom severity
- Obsessive Compulsive Inventory (OCI) – self-report measure of OCD symptom frequency and distress
CBT Treatment
The study provided CBT for OCD, emphasizing exposure and response/ritual prevention, delivered by trained clinicians in a university-affiliated outpatient setting.
Treatment included assessment, psychoeducation, collaborative hierarchy development, and response/ritual prevention, with final sessions focusing on maintenance and relapse prevention.
Participants completed 14-17 sessions. Clinicians adapted treatment to address NJRE-motivated symptoms through targeted inquiries and exposures. Independent, trained clinicians conducted post-treatment assessments.
Statistical Analysis
ANOVAs compared NJRE scores between groups. Correlations examined associations between NJREs, OCD symptoms and motivations. Repeated measures ANOVAs assessed pre-post treatment changes.
Results
Relations between NJREs and OC symptoms
- NJRE scores significantly correlated with self-reported OCD severity.
- NJRE severity also correlated with clinician-rated OCD symptoms, particularly obsessions.
- Both the number and severity of NJREs were significantly correlated with ordering/arranging symptoms.
- The number of NJREs and their severity were only modestly correlated with obsessing symptoms.
- NJRE severity was significantly more strongly correlated with ordering/arranging symptoms than with obsessing symptoms.
Relations between NJREs and motivations associated with OCD symptoms
- The number of NJREs experienced was significantly more strongly correlated with incompleteness than harm avoidance.
- The severity of NJREs was strongly correlated with both incompleteness and harm avoidance, but the correlation with incompleteness was stronger, although not significantly so.
Changes in NJREs from treatment
- After completing cognitive-behavioral therapy (CBT) for OCD, patients reported experiencing significantly fewer NJREs and less distress associated with NJREs.
- The magnitude of change in NJREs was significantly correlated with the magnitude of change in self-reported OCD symptoms overall and in the obsessing domain.
- Changes in the number and severity of NJREs were not significantly correlated with changes in ordering/arranging symptoms.
- Exploratory analyses suggested that the largest reductions in NJRE severity were related to difficulty dismissing NJREs and perceived responsibility to respond to them, while the intensity and immediate distress associated with NJREs showed the smallest changes.
Insight
This study provides important insights into the under-recognized role of NJREs in the clinical presentation of OCD.
Not only do individuals with OCD experience more frequent and severe NJREs than controls, but these experiences are associated with overall OCD severity, especially incompleteness-related and ordering/arranging symptoms.
Crucially, the significant reductions in NJREs seen after CBT suggest that NJREs are treatable and that CBT can effectively target both classic anxiety/harm-avoidance symptoms and incompleteness-related symptoms.
The CBT protocol included specific NJRE-focused elements, so future research should examine if standard CBT produces similar NJRE improvements.
Overall, the findings highlight the utility of assessing NJREs and incompleteness motivations in OCD. An exclusive focus on anxiety and harm avoidance is insufficient.
Continued research on this topic can refine our understanding of OCD’s heterogeneous clinical presentation and potentially optimize treatment approaches. The next steps could include examining neural and behavioral correlates of NJREs and conducting controlled trials of NJRE-focused CBT.
Strengths
- Use of both clinical and non-clinical control groups,
- Examination of NJREs in a treatment-seeking OCD sample and assessment of changes with a well-established intervention (CBT).
- Sample sizes were respectable
- Range of well-validated measures were used
Limitations
- Modest size of the OCD sample, which precluded analyses of the impact of comorbidities and demographics
- The measures relied on self-report
- Only a small subset completed the CBT protocol
- There was no control treatment condition.
- The CBT protocol was NJRE-informed, so the effects of standard CBT are unclear
Clinical Implications
The results underscore the importance of assessing for NJREs and considering incompleteness motivations in the conceptualization and treatment of OCD. An exclusive focus on harm avoidance will fail to capture important symptom dimensions for many patients.
While CBT appears effective for reducing NJREs, explicitly targeting NJREs may optimize outcomes, especially for patients with predominant incompleteness symptoms who may be less responsive to standard CBT.
For example, exposure exercises designed to provoke NJREs and practice tolerating the associated discomfort without engaging in compulsive behaviors.
However, it is important to note that the current study did not directly compare standard CBT to NJRE-focused CBT.
Randomized controlled trials comparing these two approaches would provide valuable information about the incremental benefits of targeting NJREs and help guide treatment decision-making for individuals with incompleteness-related OCD symptoms.
References
Primary reference
Coles, M. E., & Ravid, A. (2016). Clinical presentation of not-just right experiences (NJREs) in individuals with OCD: Characteristics and response to treatment. Behaviour Research and Therapy, 87, 182-187.
Other references
Abramowitz, J. S. (1997). Effectiveness of psychological and pharmacological treatments for obsessive-compulsive disorder: A quantitative review. Journal of Consulting and Clinical Psychology, 65(1), 44-52.
Abramowitz, J. S., Deacon, B. J., & Whiteside, S. P. (2019). Exposure therapy for anxiety: Principles and practice (Second edition). Guilford Press.
Coles, M. E., Frost, R. O., Heimberg, R. G., & Rhéaume, J. (2003). “Not just right experiences”: Perfectionism, obsessive–compulsive features, and general psychopathology. Behaviour Research and Therapy, 41(6), 681-700.
Ecker, W., & Gönner, S. (2008). Incompleteness and harm avoidance in OCD symptom dimensions. Behaviour Research and Therapy, 46(8), 895-904.
Ferrao, Y. A., Shavitt, R. G., Prado, H., Fontenelle, L. F., Malavazzi, D. M., de Mathis, M. A., … & do Rosário, M. C. (2012). Sensory phenomena associated with repetitive behaviors in obsessive-compulsive disorder: An exploratory study of 1001 patients. Psychiatry Research, 197(3), 253-258.
Ghisi, M., Chiri, L. R., Marchetti, I., Sanavio, E., & Sica, C. (2010). In search of specificity: “Not just right experiences” and obsessive–compulsive symptoms in non-clinical and clinical Italian individuals. Journal of Anxiety Disorders, 24(8), 879-886.
Salkovskis, P. M. (1985). Obsessional-compulsive problems: A cognitive-behavioural analysis. Behaviour Research and Therapy, 23(5), 571-583.
Summerfeldt, L. J. (2004). Understanding and treating incompleteness in obsessive-compulsive disorder. Journal of Clinical Psychology, 60(11), 1155-1168.
Keep Learning
- How do the motivations underlying OCD symptoms impact clinical presentation and treatment response? What are the implications for assessment and treatment planning?
- What are some potential reasons why NJREs and incompleteness have been relatively neglected in OCD research and treatment compared to anxiety and harm avoidance?
- How might neurobiological and behavioral research paradigms be leveraged to further elucidate the mechanisms underlying NJREs in OCD?
- What are some ways that CBT protocols could be adapted to optimally target NJREs? What additional treatment elements might be beneficial?
- How do these findings inform our understanding of the heterogeneity within OCD? What are the pros and cons of dimensional vs. categorical approaches to characterizing OCD symptoms?
