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Background and objectives: Criticism is thought to play an important role in obsessivecompulsive disorder (OCD), and obsessive behaviors have been considered as childhood strategies to avoid criticism. Often, patients with OCD report memories characterized by guilt-inducing reproaches. Starting from these assumptions, the aim of this study is to test whether intervening in memories of guilt-inducing reproaches can reduce current OCD symptoms. The emotional valence of painful memories may be modified through imagery rescripting (ImRs), an experiential technique that has shown promising results. Methods: After monitoring a baseline of symptoms, 18 OCD patients underwent three sessions of ImRs, followed by monitoring for up to 3 months. Indexes of OCD, depression, anxiety, disgust, and fear of guilt were collected. Results: Patients reported a significant decrease in OCD symptoms. The mean value on the Yale−Brown Obsessive Compulsive Scale (Y-BOCS) changed from 25.94 to 14.11. At the 3-month follow-up, 14 of the 18 participants (77.7%) achieved an improvement of ≥35% on the Y-BOCS. Thirteen patients reported a reliable improvement, with ten reporting a clinically significant change (reliable change index = 9.94). Four reached the asymptomatic criterion. Clinically significant changes were not detected for depression and anxiety. Conclusions: Our findings suggest that after ImRs intervention focusing on patients' early experiences of guilt-inducing reproaches there were clinically significant changes in OCD symptomatology. The data support the role of ImRs in reducing OCD symptoms and the previous cognitive models of OCD, highlighting the role of guilt-related early life experiences in vulnerability to OCD.

Cognitive Behavioral Therapy has been identified as the first choice treatment for Obsessive Compulsive Disorder (OCD). Although a significant proportion of patients benefit from Cognitive Behavioral Therapy, another still fails to respond to CBT. To improve outcomes, new targets of intervention have been broadened, but no clear and comprehensive conceptualizations of the disorder have been suggested. In the last few years, in the context of Schema Therapy (ST), several specific models have been proposed for the treatment of Axis I diagnostic categories (according to the classification of DSM IV), in addition to the more well-known conceptualizations related to Personality Disorders. Concerning OCD, several studies have investigated the effectiveness of ST in the treatment of OCD, but only few have tried to elaborate a conceptualization of the disorder in terms of modes. This lack of knowledge and shared conceptualization might lead to difficulties in planning and evaluating effective interventions. The aim of this work is to present a conceptualization of the Obsessive Compulsive Disorder that results from the integration between the Cognitive Therapy framework, as proposed by Mancini and collaborators, and the framing in terms of modes, in line with ST, starting from the research data available. In particular, the rationale of the intervention will be proposed, aimed at accepting the risk of committing mistakes or of coming into contact with disgusting substances. This general aim will then be articulated in sub-aims, which may direct it, in a more specific way, on the basis of the different modes that characterize the experience of obsessive patients.

This final article is part of the trilogy presenting a possible integration of Schema Therapy (ST) and Cognitive Therapy (CT) in Obsessive-compulsive disorder (OCD) treatment. It aims at describing how experiential and cognitive based acceptance techniques might be applied to treat this psychopathological condition. In the first article published in this special issue (Luppino et al., 2018) we reported the main data supporting the role of proximal psychological determinants in the genesis and maintenance of the obsessive symptomatology, highlighting the role of deontological guilt and disgust, and of the Not Just Right Experience. According to these, we described the internal profile of the disorder as conceptualized by Mancini's (2018) cognitive model. In the second manuscript (Tenore et al., 2018) we proposed a conceptualization of OCD, in terms of schemas and modes (as proposed by ST), integrating it with the previously described cognitive model. In agreement with these two articles, the aim of this work is to explain how experiential and cognitive techniques can be integrated to explain obsessive functioning and to achieve a successful treatment. We first describe emotion focused-experiential procedures derived from the ST framework, specifically focusing on imagery techniques, such as diagnostic imagery, rescripting and Healthy Adult imagery. Secondly we explain how chairwork can be applied to change obsessive dysfunctional schema modes. Finally, we focus on cognitive based acceptance intervention aimed at reducing the typical feelings of deontological guilt and disgust, two core emotions in OCD. In the conclusion we briefly resume the major aspects proposed in the three articles, and we present some potential further applications of a joined approach applied to other psychopathological How to cite this paper:

The present work is the first of a trilogy of articles whose purpose, as a whole, is to present a theoretical conceptualization of OCD functioning, which results from the integration between the Cognitive Therapy model, as proposed by Mancini (2018), and the Schema Therapy Mode model. In particular, this first paper aims to synthetically present the cognitive model of OCD functioning. According to the frame offered by Mancini, we will provide some evidence demonstrating the central role of deontological guilt and disgust as proximal psychological determinants in the genesis and maintenance of obsessive symptoms. The theoretical assumptions and the dynamics of the recursive processes at the basis of the maintenance of OCD will be clarified through a clinical exemplification and the clinical intervention goals will be presented. In order to plan an intervention on the experiences representing the historical vulnerability of OCD, the work also aims to present the important role played by particular kinds of early experiences in sensitizing to deontological guilt and disgust. To summarize, the current work presents the theoretical bases of a cognitive OCD conceptualization, in terms of goals and beliefs that are the drivers of obsessive behaviors. This introduction is preparatory to our proposal of integration between the cognitive model and the Schema Therapy Mode model that will be developed in the next two articles.

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I disturbi esternalizzanti rappresentano la piu comune e persistente forma di disadattamento nell'infanzia. Proprio per questo motivo lo sviluppo di trattamenti basati sull'evidenza costituisce un'urgenza sociale. L'obiettivo del presente studio e quello di condurre una metaanalisi sistematica e quantitativa di studi randomizzati controllati finalizzati a valutare l'efficacia di programmi di intervento psicologico sui disturbi esternalizzanti in eta evolutiva. La ricerca bibliografica e stata condotta sulle banche dati PsycInfo e PsycArticles, Medline, PubMed ed EBSCO. Gli articoli sono stati selezionati e valutatati da giudici indipendenti. Dai risultati si evince che i trattamenti cognitivo comportamentali sono efficaci nel trattamento delle condotte esternalizzanti, quando invece si prendono in considerazione i comportamenti internalizzanti e la depressione materna non si evincono differenze significative tra il gruppo sperimentale trattato con interventi cognitivo-comportamentali ed il gruppo di controllo. Al fine di produrre un miglioramento del funzionamento globale i trattamenti per le condotte esternalizzanti potrebbero beneficiare di interventi diretti ai sintomi internalizzanti del bambino e alla depressione genitoriale.

Guilt plays a role in various forms of psychopathology. However, different types of guilt might be involved in different mental disorders. Obsessive-compulsive (OC) patients are prone to a type of guilt in which the violation of an internalized moral norm is necessary and sufficient, whereas data suggest that depression might be linked to more interpersonal types of guilt. However, the extent to which a specific guilt phenomenology is involved in each condition is yet to be determined. Here we assessed the association between different types of guilt and different diagnostic groups. Two clinical samples (33 OCD and 35 non-OCD) filled in the Moral Orientation Guilt Scale (MOGS) along with other OCD and depression measures. Regression was employed to test group differences in the MOGS subscales and to test the influence of MOGS subscales on OCD and depression levels. Results confirm that different types of guilt might be implicated in different psychopathological conditions. Specifically, moral norm violation guilt is more present in OC patients than in other disorders. Depression seems to be associated with different guilt feelings depending on the psychopathological condition, specifically in non-OC patients, with types of guilt involving a “victim”, supporting the accounts viewing interpersonal guilt as involved in the emergence of depressive symptomatology and hyper-altruistic behavior as a vulnerability factor for depression.