The cross-cultural and transdiagnostic nature of unwanted mental intrusions

www.elsevier.es/ijchp

International

Journal

of

Clinical

and

Health

Psychology

ORIGINAL

ARTICLE

The

cross-cultural

and

transdiagnostic

nature

of

unwanted

mental

intrusions

Belén

Pascual-Vera

_,

_Burcin

_Akin

_,

_Amparo

_Belloch

_,

_Gioia

_Bottesi

_,

David

A.

Clark

_,

_Guy

_Doron

_,

_Héctor

_{Fernández-Alvarez}

_,

_Marta

_Ghisi

_,

Beatriz

Gómez

_,

_Mujgan

_Inozu

_,

_Antonia

_Jiménez-Ros

_,

_Richard

_Moulding

_,

M.

Angeles

Ruiz

_,

_Giti

_Shams

_,

_Claudio

_Sica

a_{DepartmentofPersonalityPsychology,UniversidaddeValencia,Spain} b_{DepartmentofPsychology,HacettepeUniversity,Turkey}

c_{DepartmentofGeneralPsychology,UniversityofPadova,Italy} d_{DepartmentofPsychology,UniversityofNewBrunswick,Canada} e_{DepartmentofPsychology,InterdisciplinaryCenterHerzliya,Israel} f_{AigléFoundation,Argentina}

g_{DepartmentofPsychologyandEducation,AlgarveUniversity,Portugal} h_{DepartmentofPsychology,DeakinUniversity,Australia}

i_{UniversidadNacionaldeEducaciónaDistanciaUNED,Spain}

j_{DepartmentofPsychiatry,TehranUniversityofMedicalScience,RoozbehHospital,Iran} k_{DepartmentofHumanHealthScience,UniversityofFirenze,Italy}

Received6November2018;accepted11February2019 Availableonline11March2019

KEYWORDS Obsessive-Compulsive spectrumdisorders; Cross-culturalstudy; Unwantedmental intrusions; Transdiagnostic; Cross-sectionalstudy Abstract

Background/Objective: Unwantedmentalintrusions(UMIs),typicallydiscussedinrelationto

Obsessive-CompulsiveDisorder(OCD),arehighlyprevalent,regardlessofthespecific

nation-ality, religion,and/or cultural context. Studieshave also shown that UMIsrelated to Body

DysmorphicDisorder(BDD),Illnessanxiety/Hypochondriasis(IA-H),andEatingDisorders(EDs)

arecommonlyexperienced.However,theinfluenceofcultureontheseUMIsandtheir

transdi-agnosticnaturehasnotbeeninvestigated.

Method: Participantswere1,473non-clinicalindividualsfromsevencountriesinEurope,the

Middle-East,andSouthAmerica.AllthesubjectscompletedtheQuestionnaireofUnpleasant

IntrusiveThoughts,whichassessestheoccurrenceanddiscomfortoffourUMIcontentsrelated

toOCD,BDD,IA-H,andEDs,andsymptomquestionnairesonthefourdisorders.

∗_{Correspondingauthor.Dept.ofPersonalityPsychology,FacultyofPsychology,UniversityofValencia,Avda.BlascoIbá˜nez21.}

46010-Valencia,Spain

E-mailaddress:amparo.belloch@uv.es(A.Belloch). https://doi.org/10.1016/j.ijchp.2019.02.005

1697-2600/©2019Asociaci´onEspa˜noladePsicolog´ıaConductual.PublishedbyElsevierEspa˜na,S.L.U.Thisisanopenaccessarticleunder theCCBY-NC-NDlicense(http://creativecommons.org/licenses/by-nc-nd/4.0/).

Results:Overall,64%ofthetotalsamplereportedhavingexperiencedthefourUMIs.TheEDs

intrusionswerethemostfrequentlyexperienced,whereashypochondriacalintrusionswerethe

leastfrequent butthemostdisturbing.AlltheUMIsweresignificantlyrelatedtoeachother

infrequencyanddisturbance,andallofthemwereassociatedwithclinicalmeasuresofOCD,

BDD,IA-H,andEDs.

Conclusions:UMIsareacommonphenomenonacrossdifferentculturalcontextsandoperate

transdiagnosticallyacrossclinicallydifferentdisorders.

©2019Asociaci´onEspa˜noladePsicolog´ıaConductual.PublishedbyElsevierEspa˜na,S.L.U.This

isanopenaccessarticleundertheCCBY-NC-NDlicense(http://creativecommons.org/licenses/

by-nc-nd/4.0/). PALABRASCLAVE Trastornosdel espectro obsesivo-compulsivo; Estudiotranscultural; Intrusionesmentales nodeseadas; Transdiagnóstico; Estudiotransversal

Expresióntransculturalynaturalezatransdiagnósticadelasintrusionesmentalesno deseadas

Resumen

Introducción/Objetivo: Lasintrusionesmentalesnodeseadas(IM),clásicamenteestudiadasen

relaciónconeltrastornoobsesivo-compulsivo(TOC),tienenunaprevalenciaelevada

independi-entementedelanacionalidad,religión,y/oelcontextocultural.Lasinvestigacionesmuestran

quetambiéneshabitualexperimentarIMsobrecontenidosrelacionadosconeltrastorno

dis-mórfico corporal (TDC),la ansiedad por la enfermedad/hipocondría (AE-H)y los trastornos

alimentarios(TCA). Sin embargo,la influenciade la culturasobreestas IMy sunaturaleza

transdiagnósticanosehaninvestigado.

Método: Participaron1.473personasdesietepaísesdeEuropa,OrienteMedioySuramérica.

TodascompletaronelCuestionariodePensamientosIntrusosDesagradables,queevalúala

ocur-renciaymalestarasociadosacuatrocontenidosdeIMrelacionadosconTOC,TDC,AE-HyTCA,

ycuestionariossobresíntomasdeloscuatrotrastornos.

Resultados: El64%dela muestra total habíaexperimentadolascuatro modalidadesde IM.

LasIM-TCAfueronlasmásfrecuentesylashipocondríacaslasmenos,perolasmásmolestas.

TodaslasIMmantuvieronrelacionesentresí,tantoenfrecuenciacomoenmolestia,ytodasse

asociaronconlasmedidasclínicasdeTOC,TDC,AE-HyTCA.

Conclusiones:LasIMsonunaexperienciahabitualendiferentescontextosculturalesyoperan

demodotransdiagnósticoentrastornosclínicamentedistintos.

©2019Asociaci´onEspa˜noladePsicolog´ıaConductual.Publicado porElsevierEspa˜na,S.L.U.

Esteesunart´ıculoOpenAccessbajola licenciaCCBY-NC-ND(http://creativecommons.org/

licenses/by-nc-nd/4.0/).

Unwantedmental intrusions (UMIs) are discrete, unde-sired,andunexpectedcognitiveeventsthatareconsciously experienced in the form of thoughts, images, sensations, and impulses. They interfere with the normal flow of thoughts, tend to be recurrent, and promote subjective resistance efforts (Clark & Rhyno, 2005). Like worry and rumination,UMIsarea modalityofmaladaptive conscious thought processes, although there are subtle but impor-tantdifferencesamongthem.Worryhasbeendefinedas‘‘a chainofthoughtsandimages,negativelyaffect-ladenand relativelyuncontrollable’’ (Borkovec,Robinson, Pruzinsky, & Depree,1983, p. 10),and ruminationhasbeen defined as‘‘the tendency torepetitively analyze one’s problems, concerns,andfeelingsofdistresswithouttakingaction to makepositivechanges’’(Nolen-Hoeksema&Watkins,2011, p.596).The contentofruminationtendstobemore past-oriented than the content of either worry or unwanted intrusivethoughts(Nolen-Hoeksema,Wisco,&Lyubomirsky, 2008).Moreover,althoughthethreethoughtmodalitiesare highlyuncontrollable,individualshaveastrongerdesireto

engagein neutralizing behaviorsin responseto unwanted intrusivethoughtsthaninresponsetoeitherworryor rumi-nation(Fergus,2013).Wahl,vandenHout,andLieb(2019) showed that when individuals are instructed to ruminate on an idiosyncratic UMI, they have stronger urges to be engaged inneutralizationefforts, comparedtothosewho engagein rumination onnegativemood. Finally,although worry,rumination,andUMIswereinitiallyproposedas typi-callyoccurringinGeneralizedAnxietyDisorder,Depression, andOCDandrelateddisorders,respectively, theyare cur-rentlythoughttobetransdiagnosticacrossseveraldifferent disorders in which anxiety and negative mood states are prominent.

RegardingUMIs, currentcognitivemodelsof Obsessive-Compulsive Disorder (OCD) postulate that those with obsessive content(e.g.,concerning injury/harm,religion, sexuality,contamination,doubt,scrupulosity,relationships, etc.)constitutethe‘‘normal’’variantsofclinically signifi-cantobsessions(Clark&Radomsky,2014).Acorollaryofthis assumptionisthatobsessiveUMIsshouldbeexperiencedby

thevastmajorityofpeople.Therefore,theywouldbea nor-mative,commoncognitiveconsciousexperiencethatoccurs independently of the cultural and/or social context. The researchhassupported this.Radomskyetal.(2014)found thatin13countriesacross6continents,themajorityof non-clinicalindividuals(93.6%)reportedexperiencingUMIswith obsessional content. In the same sample, Moulding et al. (2014) observed that, although therewere differences in the overall rates of these intrusive thoughts across sites, the relationshipsbetween their frequency and the mean-ings people attributed to them did not differ among the participants.Thesefindingsshowed,first,thatobsessional intrusive thoughts are highly prevalent in the nonclinical populationandthatthesecognitivephenomenaare experi-encedregardlessofnationality,religion,orculture.Second, they support the applicability of the cognitive model of OCD to different cultures, that is, the generalizability of aWestern-derivedpsychologicalmodeltonon-Western cul-tures.

EventhoughmostoftheresearchonUMIshasbeen con-ductedonobsessionalcontents,UMIs havebeendescribed as occurring in other disorders, such as Body Dysmor-phic Disorder (BDD; Giraldo-O’Meara & Belloch, 2017, 2018;Onden-Lim&Grisham,2014),Health/Illness Anxiety-Hypochondriasis (IA-H; Arnáez, García-Soriano,& Belloch, 2017; Fergus,2013; Muse,McManus,Hackmann, Williams, & Williams, 2010), and Eating Disorders (EDs; Belloch, Roncero, & Perpi˜ná, 2016; Blackburn, Thompson, & May, 2012; García-Soriano, Roncero, Perpi˜ná, & Belloch, 2014; Halmietal., 2003).Onden-Lim andGrisham (2014)found that up to 84% of non-clinical communityindividuals had intrusive images with similar contents to those reported byBDDpatients.Giraldo-O’MearaandBelloch(2018)found similar results in community participants and in patients withBDD,thus supportingtheuniversality and dimension-alityofdysmorphicUMIsfromnormalcytopsychopathology. Regardinghypochondriasis,Museetal.(2010)showedthat patientswithhypochondriasisexperienceddistressing intru-siveimagesandthoughtsaboutillnessesanddeathwitha highfrequency.Instudieswithnon-clinicalcommunity indi-viduals, Arnáez et al. (2017) found that UMIs related to illnesses anddeathwerealsocommon, andFergus (2013) reported that these intrusive cognitions shared unique relations with health anxiety after accounting for nega-tiveaffect. Withregard toEDs,datafromseveralstudies (e.g.,Avargues-Navarroetal.,2017; Bellochetal.,2016; Blackburn etal.,2012;García-Soriano etal.,2014; Halmi et al., 2003) indicate that both patients with EDs and non-clinical community individuals experience recurrent cognitions in the form of thoughts, images, and impulses aboutfood,diet,physicalexercise,andappearance.Taken together, all the above-mentioned studies support the notionexpressedbyClarkandRhyno(2005)thatthe expe-rienceofUMIs‘‘canencompassanytopic...thatispertinent totheindividualorsituationathand’’(p.3).Fromthis per-spective, UMIs can be said to be a transdiagnostic factor operating across different clinical disorders and, accord-ingly, may be a universal experience free from cultural and/orsocialinfluences.

Nonetheless, with the exception of OCD-related intru-sions,thestudiesaboutUMIsrelatedtoBDD,IA-H,andEDs havebeenconductedinsinglecitiesinEuropeandAustralia.

Consequently,thesestudiesdidnotexplorewhetherthefour UMIcontentsareuniversallyexperiencedandcause compa-rablelevels of disturbance across differentcultures. This wastheprimaryaimofthecurrentstudy.

AsecondaimwastotestwhetherUMIsmightbea transdi-agnosticfactoroperatingacrossdifferentclinicaldisorders suchasOCD,BDD,IA-H,andEDs,giventhattransdiagnostic approachestopsychopathologyseektoidentify fundamen-taland/orcoreprocessesandconstructsunderlyingdiverse disorders(e.g.,Nolen-Hoeksema&Watkins,2011).Todate, thepublishedresearchhasseparatelystudiedthefour dif-ferentintrusive-cognitioncontentsinbothnon-clinicaland clinical samples, but without examining whether the fre-quencyanddistressassociatedwiththeexperienceofone specific UMI content correlate with the distress and fre-quencyofother UMIcontents. Thisapproachseemstobe more adequate to ascertain whether UMI could operate transdiagnosticallyacrossthefoursetsofdisordersandthen beavulnerabilityfactortothedevelopmentofmental dis-orderssuchasOCD,BDD,HYP,andEDs.Toexplorethis,we soughttoexaminetheexperienceoftheUMIswithcontents relatedtothesedisordersinthesameindividual.

Method

Asampleof1,473participantsin10citiesinsevencountries and three continents volunteered to participate in the currentstudy.ThesiteswerelocatedintheMiddleEast (Her-zliya,TelAvivinIsrael;AnkarainTurkey;andTehraninIran), Europe (Firenze and Padova in Italy; Algarve in Portugal; ValenciaandMadridin Spain),andSouthAmerica(Buenos Airesin Argentina).Of the totalsample, 74% participants (N=1,086)were women,and26%(n= 387)weremen(2₌

331.705,p<.0001).Theiragesrangedfrom18to64years(M= 28.09,SD=11.24years),withtheIsraeliandArgentinian par-ticipantsbeingtheoldest,whereastheItalian,Iranian,and Turkishparticipantsweretheyoungest(F6,1458=142.95,p<

.0001).Themajorityoftheparticipantsinallthecountries haduniversitystudies.SeeTable1foradditionalparticipant characteristics.

Instruments

Socio-demographicdatasheet.Thedatarequiredwerethe following:age,gender,yearsofeducation,maritalstatus, andsocio-economic level. Two additionalquestions about the participants’ current mental-health status were also included.

Fortheself-report questionnairemeasures thatfollow, publishedtranslationswithestablishednormswereused.

Obsessive-Compulsive Inventory-Revised (OCI-R; Foa etal.,2002).This is an 18-item self-report questionnaire thatassessesdistressassociatedwithobsessive-compulsive symptoms(washing,checking,ordering, obsessing, hoard-ing,andneutralizing).Thetotalscorerangesfrom0to72, andinthisstudy,theCronbach’s˛was.91.

BodyDysmorphicDisorderQuestionnaire(BDDQ;Phillips, Atala,&Pope,1995).Thisscreeningmeasurefor BDDcan becompletedeitherasaself-reportorbyaninterviewer.In

Table1 Demographicinformationbysite.

Continent Country Age

M(SD) Gender %Female Education: %University studies n Mediterranean Europe Spain 28.10(10.25)a _70.9a _{77.8 326} Portugal 30.58(12.14)a _68.6a _{64.7 255} Italy 22.06(2.37)b _70.3a _{61.6 209}

Middle-EastAsia Iran 22.63(4.38)b _70.9a _{100 55}

Israel 40.79(12.52)c _48.6b _{72.4 105}

Turkey 21.54(4.50)b _86.1c _{92.6 366}

SouthAmerica Argentina 40.70(11.22)c _81.5ac _{79.6 157}

Overall 28.09(11.12) 73.7 78.3 1473

Note.Valueswhich sharethesamesuperscript letterwerenotsignificantlydifferentfrom eachother.Differingsuperscriptletters indicatepost-hocbetween-groupsdifferences(Bonferroni).

thisstudy,theBDDQwasappliedasaself-report question-naire.Itincludes 11 itemswithvarious responseformats. Theinternalconsistencyinthisstudywas˛=.76.

WhiteleyIndex(WI;Pilowsky,Spence,Cobb,&Katsikitis, 1984).Thisself-reportwasoneofthefirstdimensional meas-ures developedto assesshealth anxiety and itsitems are based on clinicians’ experiences of illness characteristics ofseverehealthanxietyorhypochondriasis.Itcontains14 True/Falseitemsyieldingatotalscorerangeof0---14.Inthis study,thereliabilityvaluewas˛=.94(totalscore).

Eating Attitudes Test (EAT-26; Garner, Olmsted, Bohr, &Garfinkel,1982). Thisself-report assesses attitudesand behaviorsrelatedtoEDs.The totalscore measures symp-tomseverity.Internalconsistencyinthecurrentstudywas ˛=.91.

QuestionnaireofUnpleasant IntrusiveThoughts(QUIT). The QUIT is a newly developed measure. A preliminary Spanishversion of the QUIT wasdesigned onthe basis of previouslyvalidated self-report questionnairesthat assess OCD-relatedintrusions(García-Soriano,Belloch,Morillo,& Clark, 2011), BDD-related intrusions (Giraldo-O’Meara & Belloch,2017,2018),hypochondriasisorillnessand death-related intrusions (Arnáez et al., 2017), and EDs-related intrusions (Belloch et al., 2016). The most frequent and disturbing mental intrusions experienced by non-clinical andclinicalindividualsintheaforementionedstudieswere selected for inclusion in the QUIT. All these self-report instrumentsfollowthestructureoftheRevisedObsessional Intrusions Inventory(ROII; Purdon & Clark, 1993) andthe InternationalIntrusive ThoughtsInterviewSchedule (IITIS; Clarketal.,2014;Moulding etal.,2014;Radomskyetal., 2014),whichassessthefrequencyofUMIswithobsessional contents as well as their functional consequences. Pilot studies of the QUIT were conducted in Spanish and Por-tuguesecommunitysamples(n=438;Pascual-Vera,Roncero, &Belloch,2017;Pascual-Vera&Belloch,2018a,2018b)and inTurkishuniversitystudents(n=259;Akin&Inozu,2018).

Similar to the ROII, the QUIT starts with a detailed definition of UMIs and the different ways they can be experienced (i.e., as images, thoughts/doubts, impulses, or physical sensations). After the initial description, four separate sets of intrusions are presented: Obsessional-related(OCD-related;12items),appearancedefect-related

(BDD-related;9items),illnessand death/hypochondriasis-related(IA-H-related;10items)andeatingdisorders-related (EDs-related; 8 items). Respondents must evaluate each intrusionfromasetonitsfrequency(from0=never,to6=

always,frequentlythroughouttheday)andthediscomfort

(from0=notatall,to4=extremelydisturbing)itproduces whenitoccurs.ThenumberandfrequencyofUMIsreported bytheparticipantineachsetwerecomputedasthe aver-agefrequencyoftheintrusionsactuallyexperiencedbythe respondent at least once in his/her lifetime;that is, the totalscoresforeachsetweredividedbythenumberofitems withafrequency≥1.InternalconsistencyofthefourUMI contentswerebetweengoodandexcellentintermsoftheir frequency and disturbance across the different countries (Table2).

Procedure

Participantswererecruitedbytheauthorsineachsitefrom severalsources:undergraduatestudentswhoattendedtheir lecturesattheUniversity,advertisementsontheUniversity Campus,andthewebpageofeachresearchgroup, request-ingvoluntaryparticipationinastudyonvaluesandbeliefs aboutthoughts.Thosewhoexplicitlyagreedtoparticipate andprovidedinformedwrittenconsentwerescheduledto attend an assessment session.In thissession, thebooklet containingtheself-reportinstrumentswasadministeredto groups of 25-35 individuals in the presence of one of the authors.Acommondatatemplatewascreatedtoenterthe samelabelsandcategoriesacross sites.Theresearch pro-tocol wasapprovedbythe researchethics boardsofeach researchsite.

Datacleaningandmissingdata

Having diagnosed mental health problems in the past six months,undergoingpsychologicalorpharmacological treat-ment(criterion a),ornotbeingin the18-to-65agerange (criterionb)werenon-inclusioncriteria.Atotalof123 indi-viduals (criteriona n = 108; criterion b n =15) were not includedinthedataanalyses.

Table2 Internalconsistency(Cronbach’salpha)oftheQUITscoresacrosscountries.

Country OCD-related intrusions BDD-related intrusions IA/H-related intrusions EDs-related intrusions

F D F D F D F D Spain .84 .83 .90 .89 .90 .92 .88 .90 Portugal .80 .85 .89 .90 .87 .90 .88 .90 Italy .83 .87 .89 .91 .89 .91 .88 .89 Iran .85 .81 .87 .91 .87 .84 .84 .89 Israel .92 .91 .93 .93 .94 .92 .92 .93 Turkey .79 .81 .91 .90 .88 .90 .92 .90 Argentina .89 .91 .92 .95 .91 .94 .92 .92

Note.OCD:Obsessive-compulsiveDisorder;BDD:BodyDysmorphicDisorder;IA-H:IllnessAnxiety/Hypochondriasis;EDs:EatingDisorders. F=Frequency;D=Disturbance.

Dataanalyses

One-factorANOVAswereusedtoexaminethemeannumber ofintrusionsexperiencedbysite.Post-hoctestswerealso computedusingaT3Dunnettcorrectionforpost-hoc analy-ses.ThefrequencyanddisturbancewithwhichthefourUMI wereexperiencedacrossthesevencountrieswereexamined usingtwodifferent two-waymixedMANOVAs. The within-subjectsfactor wasthecontentoftheUMI(4levels),and thebetween-groupsfactorwasthesiteoftheparticipants (7levels),withthedependentvariablebeingthefrequency orthedisturbance.Theseanalyseswereperformedwiththe Huynh-FeldtcorrectionbecauseMauchly’stestsof spheric-itywereviolated.Toexplorethetransdiagnosticnatureof UMIs, Spearman correlations were calculated of the fre-quencyand disturbancecaused bythe fourUMI contents, aswellastheUMIsandsymptommeasuresofthedifferent disorders.To overcome thedifficulties in interpreting the results,giventhedifferentsamplesizesacrosssites,Cohen’s (1988)criteriawereusedtoevaluatethesignificanceofthe correlations:largecorrelationsaredefinedasthose≥.50, mediumcorrelationsarefrom.30to.49,andsmall correla-tionsare.10to.29.Additionally,differencesincorrelations weretestedusingFisher’srtoztransformation.

Results

PrevalenceofthefourUMIcontentareas

Overall, 64.2% (n = 945, Mage = 27.74, SD = 10.95; 73%

women) of the sample reported having experienced the foursetsof UMI onceor more intheir lives (seeFigure 1 fora breakdownbysite).Furthermore,2%(n=31)of the participantsdidnotexperienceany UMIs,and5% (n= 75) reportedhavingonlyoneUMImodalityorcontent.The per-centageratesofparticipantswhoexperiencedthefourUMI modalitiesdifferedacrosscountries(2_{=78.349,p<.0001).}

Between-groupcomparisonsshowedthatthehighestrates of participantswho experiencedthe fourUMIs were from PortugalandSpain,whereasthelowestratewasfrom Argen-tinianparticipants.

ThenumberofUMIsfromthefoursetsexperienced dif-feredacrosscountries(seeTable3).ParticipantsfromItaly and Israelexperienced fewer OCD-related intrusions than

individualsfromtheother countries,whereasthenumber ofBDD-intrusionswashigheramongPortugueseandTurkish participants.The IA-H intrusions were the least endorsed by Italian and Argentinian participants, but Spanish, Por-tuguese,Iranian,andIsraeliindividuals endorsedasimilar numberoftheseintrusions.Finally,Spanish,Portuguese,and Israeliparticipants endorsed EDs-related intrusions more, but Italian participants reported the smallest number of theseUMIs. In thefull data set,participants endorsedup to57% of OCD-related, 50% of BDD-related, 46% of IA-H-related,and51%ofEDs-relatedintrusions.

Differencesinthefrequencyanddisturbance causedbytheOCD,BDD,IA-H,andEDs-related mentalintrusionsintheparticipantsfromthe differentcountries

TheMANOVAresultsshowedmaineffectsforcountry(F6,938

=14.84,p≤.001;2_{=.087)andforthefrequencyofthefour}

UMIcategories(F2.77,2602 =62.26,p≤.001;2=.062).

More-over,aninteractioneffectbetweenthecategoryoftheUMI contents and the sample location on frequency was also observed, indicating that the pattern of UMI frequencies differedbetweensites(F16.64,2602=5.801,p≤.001;2=.036).

Table3shows which countriesweresignificantlydifferent fromeach other inthe frequencyof thefoursetsofUMI. Between-group comparisons (i.e., country of the sample) indicatedthatIranianandTurkishparticipantsendorsedthe highestmeanfrequencyofOCD-relatedintrusions,whereas Israeliparticipantsendorsedthelowestfrequency.Post-hoc analysesindicatethatbothItalianandArgentinian partici-pantsexperiencedOCD-relatedintrusionswithafrequency similarto that of the Israeli participants. By contrast, in every site, the BDD-related intrusions were experienced withthesamefrequency,withtheexceptionofTurkish indi-viduals,who reported higher rates of dysmorphic-related intrusions. In the case of hypochondriacal intrusions, Ira-nianparticipantsreportedthehighestfrequency,andItalian participantsthelowest.Finally, Turkishparticipants expe-rienced EDs-related intrusions more frequently than the Israeliand Italianparticipants,whodidnot differintheir respectiveratesofEDs-UMIfrequency.

Atthewithin-groupcomparisonlevel(i.e.,UMIcontent), the results indicate that the four UMIs were experienced

2.5 _.8 2.9 _1.8 3.8 _2.2 1.3 1.8 2.4 8.1 5.5 7.6 6.6 ₇ 7.7 2.7 12.4 7.3 7.6 _10.4 15.3 16.6 15.3 22 21,8 13,3 23,8 24,2 71.5 78.8 54.5 63.6 67.6 57.1 52.2 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

Spain Portugal Italy Iran Israel Turkey Argentina

No UMIs One UMI Two UMIs Three UMIs All UMIs

Figure1 Percentageratesoftheexperiencedunwantedmentalintrusionscontent-numbersbysite.

Table3 Numberofunwantedmentalintrusionsendorsedbycountry.

Country OCD intrusions (range0-12) BDD intrusions (range0-9) IA/H intrusions (range0-10) EDs intrusions (range0-8) Spain 7.24(3.09)a _4.84(3.08)a _5.19(3.29)a _4.56(2.62)a Portugal 6.98(2.70)a _4.93(2.90)b _5.90(3.11)a _4.92(2.49)a Italy 5.41(2.93)b _4.08(2.84)a.c _3.03(2.88)c _2.95(2.60)c Iran 7.29(3.29)a _4.81(2.79)a _5.63(2.90)a _3.80(2.44)a.b Israel 5.23(6.64)b _3.80(3.18)a.c _5.43(3.52)a _4.22(2.92)a Turkey 7.24(3.09)a _4.99(3.17)b _4.28(3.30)b _3.75(3.03)b Argentina 6.95(3.04)a _3.19(3.19)c _3.57(3.18)b.c _3.65(2.64)b F6.1472 16.157* 9.528* 22.646* 13.409* 2 _{.062 .037 .084 .052}

Note.*p_≤.001.DataareMeans(SD).Valueswhichsharethesamesuperscriptletterwerenotsignificantlydifferentfromeachother. Differingsuperscriptlettersindicatepost-hocdifferences(T3Dunnettcorrectionfor7post-hocanalyses---1persite).OCD: Obsessive-compulsiveDisorder;BDD:BodyDysmorphicDisorder;IA-H:IllnessAnxiety/Hypochondriasis;EDs:EatingDisorders.

withdifferentratesoffrequencyacrosscountries.Overall, theEDsintrusions were themost frequentlyexperienced, whereastheIA-H-relatedintrusionsweretheleastfrequent. No differences were observed between the frequency of theOCDandBDDintrusions.Regardingthespecificlocation ofthesample,somesimilaritiesanddifferencesemerged: Spanish, Israeli, Argentinian, and Italian participants

experiencedOCDintrusionsandEDs-relatedintrusionswith similarfrequency,andIranianparticipantsexperiencedall theUMIswithsimilarfrequency,regardlessoftheir respec-tivecontents.

RegardingthediscomfortcausedbytheUMI,theMANOVA producedmaineffectsforboththesamplesite(F6,681=9.77, p≤.001,2 _{=.079)andthedisturbancecaused bythefour}

Table4 Differencesinthefrequencyanddisturbanceoffoursetsofmentalintrusionsacrosscountries.

Locationof sample

Frequencyofmentalintrusions Disturbanceduetomentalintrusions

OCD BDD IA-H EDs OCD BDD IA-H EDs

Spain (frequency: n=233; disturbance: n=157) 2.26 (0.77)a c/1 2.14 (0.99)a/1 1.83 (0.87)b/1 2.36 (1.04)c/1 1.99 (0.59)a.b/1 1.97 (0.78)a/1 2.15 (0.91)b/1 1.93 (0.80)a/1 Portugal (frequency: n=201; disturbance: n=161) 2.24 (0.71)a/1 2.13 (0.94)ab/1 1.97 (0.82)b/1 2.59 (1.06)c/1.3 2.16 (0.69)a/2 1.99 (0.84)b/1 2.39 (0.90)c/1 2.00 (0.87)ab/1 Italy (frequency: n=114; disturbance: n=90) 2.06 (0.78)a/1 3 1.99 (0.88)a/1 1.54 (0.59)b/3 2.13 (0.96)a/2 1.90 (0.70)a/3 1.91 (0.76)a/1 1.94 (0.87)a/2 1.75 (0.79)a/2 Iran (frequency: n=35; disturbance: n=26) 2.76 (0.97)a/2 2.37 (1.17)a/1.2 2.79 (1.27)a/2 2.66 (1.56)a/1.2.3 2.01 (0.63)a/1.2.3 1.90 (0.85)a/1.2 2.28 (0.97)a/1 1.95 (0.90)a/2 Israel (frequency: n=71; disturbance: n=54) 1.85 (0.77)ab/3 1.77 (0.82)a/1 1.76 (0.75)a/1 2.12 (0.98)b/2 1.49 (0.46)a/3 1.47 (0.63)a/2 1.55 (0.55)a/3 1.66 (0.68)a/2 Turkey (frequency: n=209; disturbance: n=133) 2.57 (0.74)a/2 2.57 (1.04)a/2 1.82 (0.73)b/1 2.82 (1.20)c/3 2.01 (0.55)a/1 1.99 (0.72)a/1 2.03 (0.78)a/2 1.52 (0.58)b/2.3 Argentina (frequency: n=82; disturbance: n=67) 1.97 (0.82)a c/1.3 1.78 (0.87)ab/1 1.57 (0.88)b/1.3 2.22 (1.12)c/1 1.65 (0.63)a/3 1.73 (0.86)a/1.2 1.57 (0.68)a/3 1.81 (0.87)a/2

Note.DataareMean(SD).Valueswhichsharethesamesuperscriptwerenotsignificantlydifferentfromeachother.Superscriptsa.b.c

indicatepost-hocwithin-group(UMIscontent)differences(Bonferroni).Superscripts1.2.3_{indicatepost-hocamonglocationdifferences}

(sameUMIcontent)(Bonferroni).Samesuperscriptmeansnodifferences.

OCD:Obsessive-compulsiveDisorder;BDD:BodyDysmorphicDisorder;IA/H:IllnessAnxiety/Hypochondriasis;EDs:EatingDisorders.

UMIs(F2.73,1865=9.08,p≤.001;2=.013),withan

interac-tioneffectbetweendisturbanceandsite(F16.43,1865=5.63, p≤.001;2_{=.047).Between-groupcomparisons(seeTable4)} showedbothsimilaritiesanddifferencesinthediscomfort caused bythefourtypes ofUMIs acrosscountries.On the whole, the OCD-related intrusions were endorsed as the most disturbing for Portuguese participants, whereas the BDD-relatedintrusionsweresimilarlydisturbingacrosssites, withtheexceptionofIsraeliparticipants,whoexperienced thelowestratesofdiscomfort.Spanish,Portugueseand Ira-nian participants reported the greatest discomfort when havingIA-H-relatedintrusions,whereasIsraelisand Argen-tinian participants reported the least. Similarly, Spanish, Portuguese and Iranian participants reported the great-est discomfort with the EDs-related intrusions, whereas

Turkishparticipantsreportedtheleast.Nodifferenceswere observedinthediscomfortcausedbyEDs-relatedintrusions acrosstheothersites.

Atthewithin-groupcomparisonlevel(i.e.,UMIcontent), thefourUMItypesprovokeddifferentdisturbancelevelsin theparticipantsfromthedifferentsites.ThefourUMIs pro-vokeda similardegree of disturbance, regardlessof their content, in Iranian, Israeli, Argentinian, and Italian par-ticipants,whereastheIA-H-relatedintrusionscausedmore distress than the BDD-related and EDs-related intrusions in Spanish participants. The IA-H-related intrusions were alsothemostdisturbingtothePortugueseparticipants,but Turkishparticipants experiencedsimilardisturbancewhen experiencingOCD,BDDandIA-H-relatedintrusions,whereas EDs-relatedintrusionsdisturbedthemless.

Relationshipsbetweenthefrequencyand disturbancecausedbyobsessional,dysmorphic, hypochondriac,andEDs-relatedunwanted intrusions

Ineachsite,thefoursetsofUMIwereassociatedintermsof boththeirfrequency(rrangefrom.32to.70;allp’s≤.01)

anddisturbance(rrangefrom.26to.71;allp’s≤.01).For the UMIs’ frequency, the largest coefficients were found between BDD and EDs intrusions in Spain (r=.58), Portu-gal (r=.47), Iran (r=.63), and Italy (r=.57), and between OCDandBDDintrusionsinIsrael(r=.70)andTurkey(r=.53), whereasin Argentina thelargest coefficient wasbetween OCDandIA-H intrusions (r=.60). Bycontrast,the smallest coefficientswereobservedbetweenIA-HandEDsintrusions inallcountries(rrangefrom.32to.48).Regardingthe dis-comfortcausedby theUMIs, thelargestcoefficientswere observedbetweenBDDandEDsintrusionsinSpain(r=.63), Iran(r=.63),Israel(r=.71),Turkey(r=.51)andItaly(r=.70), andbetweenBDD andIA-H intrusionsinArgentina(r=.56) andPortugal(r=.50).Althoughremainingstatistically signif-icant(p≤.05),thesmallestcorrelationswerebetweenIA-H andEDsintrusionsinSpain(r=.26), Portugal(r=.33),Israel (r=.39),Argentina(r=.30),andTurkey(r=.19),andbetween OCDandEDsintrusionsinIran(r=.42)andItaly(r=.52). Relationshipsamongthefrequencyanddiscomfort provokedbyUMIsandsymptommeasuresofthe differentdisorders

Table5showstheassociationsbetweenthefrequencyand discomfortduetotheUMIsandsymptommeasuresofOCD, BDD,HypochondriasisandEDs.EachsetofUMIscorrelated with its corresponding clinical measure on both the fre-quencyanddiscomfortscores.Moreover,cross-associations were alsofound between the frequency and the disturb-ancecausedbythefourUMIsandtheirnon-specificclinical measures(i.e.,OCI-Randfrequency ofBDD-related intru-sions). The largest coefficients were found between the OCI-Rscore and the frequency of OCD-related intrusions, andbetweentheclinicalmeasureofBDDandthefrequency ofEDsintrusions.The smallestcoefficientswereobserved fortherelationship betweentheWI andboththe disturb-ancecausedbyIA-H-relatedintrusionsandthefrequencyof BDD-relatedintrusions.

The correlation coefficients between the frequency of OCDintrusionsandtheOCI-Rscoresweresignificantlyhigher thanthecorrelationsobservedbetweentheOCI-Randthe frequencyofBDDintrusions(z=2.83,p=.002)andEDs intru-sions(z=3.58p=.001).Bycontrast,theassociationbetween thefrequencyofBDDintrusionsandtheBDDQwassmaller thanthe association observedbetween theBDDQ andthe frequencyofEDsintrusions(z=1.68,p=.04).RegardingIA-H intrusions, the correlation between the WI and the fre-quencyoftheseintrusionswashigherthantheassociation betweentheWIandthefrequencyofBDDintrusions(z=3.06,

p=.001). Finally, the correlation coefficient between the

EAT-26andthefrequencyofEDsintrusionswassignificantly higherthantheassociationsfoundbetweentheEAT-26and thefrequencyofOCDintrusions(z=3.38,p=.001),BDD intru-sions(z=2.09,p=.01),andIA-Hintrusions(z=2.79,p=.001).

Totestforspecificity,partialcorrelationswerealso cal-culated examining whethereach ofthe fourUMIsetswas relatedtothesymptommeasures,bypartialling-outits cor-responding symptom measure (e.g., correlations between OCD intrusions and symptom measures when controlling for OCD symptoms; correlations between BDD intrusions and symptoms measures controlling for BDD symptoms, etc.). As Table 5 shows, the pattern of relationships was comparable to the one observed without partialling out the symptom measures, with some minor exceptions for the WI, which was related to the disturbance caused by theOCDandBDDintrusions.Thefourself-report question-nairesassessingthesymptomswerecorrelated,withsmall tomediumcoefficients.

Discussion

Thisstudyaimedtoexamineforthefirsttimetwokey inter-related issues about four different contents of unwanted mental intrusions: first, theiruniversality across different cultural and social contexts, and second, their putative transdiagnosticvalue.

To date, the universality of UMIs and the differences in their expression depending on the cultural and social context have only been examined in the case of OCD-relatedintrusions(Clarketal.,2014;Mouldingetal.,2014; Radomskyetal.,2014).Ourfindingsshowedthatmorethan halfoftheparticipantsinthesevencountriesinvolvedinthe studyreportedhavinghadthefourtypesofUMIcontents. Furthermore,itwasmorecommonforparticipantsto expe-rience more than one UMI than to experience only one, whichsuggeststhatthepropensitytohaveUMIs,regardless oftheircontent,isasourceofindividualdifferences.This propensitymighthelptoexplain,atleastinpart,the comor-biditiesamongdisorderswhereUMIsplayakeyrole;thatis, thetendency tohave unwantedintrusions maybea com-monvulnerabilityfactorthatcomesintoplayinanumber ofdisorders.

Therewereboth similaritiesanddifferencesacrossthe sites in terms of the frequency and disturbance caused bytheOCD,BDD,IA-H,andEDs-relatedmentalintrusions. Overall,IranianandTurkishparticipantsshowedthehighest frequencyonalltheUMIs,whereasSpanishandPortuguese participantsreportedthemost discomfortassociatedwith thefourUMIs.Bycontrast,Argentinian,Israeli,andItalian participants experiencedthelowest frequenciesand least discomfort. As such, whereas the UMIs were experienced similarlyacrosssites,wecansuggestthattherewerethree patternsofresponsesacrosscountries:thefirstincludes Ira-nianandTurkishindividuals,thesecondinvolvesPortuguese and Spanish subjects, and the third affects participants fromArgentina,Israel,andItaly.Wecannotknowwhether thesepatternsreflectdeepersocio-culturalfactorsbecause we did not include specific culturally-relevant constructs thatwouldallowustomakeculturally-specificpredictions. Nonetheless,somereasonsforthethreeobservedpatterns intheparticipants’responsescanbetentativelysuggested. For example, the individuals in the first group (Iran and Turkey) share Muslim valuesthatare notprevalentin the othercountriesthatparticipatedinthestudy.Islamicrules are a determinant of self-identity and everyday life, and

cross-cultural expression and transdiagnostic nature of unwanted mental intr 93

Table5 CorrelationsbetweentheUMIsfrequencyanddiscomfortwithsymptommeasures.

OCDintrusions BDDintrusions IA/Hintrusions EDsintrusions Symptommeasures

Frequency Disturb. Frequency Disturb. Frequency Disturb. Frequency Disturb. OCI-R BDDQ WI EAT-26

OCI-R r .55** – .43** – .43** .30** .33** .24** .31** .24** .27** .07 .40** .35** .226** .04 1 n 761 713 633 591 662 614 638 492 808 BDDQ r .39** .31** .24** .49** .41** – .25** – .28** .37** .10 .07 .57** .49** .41** .31** .32** ₁ n 125 117 116 112 117 106 126 121 132 132 WI r .19** .14** .01 .14* .10** .18** .03 .11* .27** – .10* – .07 .05 .00 .05 .22** _.20* ₁ n 734 689 609 571 636 591 615 472 776 132 783 EAT-26 r .26** .34** .19** .26** .35** .43** .26** .35** .31** .34** .17** .22** .45** – .46** – .27** _.37** _.30** ₁ n 710 666 588 550 612 571 593 451 749 754 732 119

Note.*p≤.05**p≤.01. Thecoefficientsin italicscorrespondto partialcorrelations. Disturb.:Disturbance dueto UMIs.OCI-R:Obsessive-CompulsiveInventory-Revised; BDDQ: BodyDysmorphicDisorder Questionnaire;WI:WhiteleyIndex;EAT-26:EatingAttitudesTest.OCD:Obsessive-compulsiveDisorder;BDD:BodyDysmorphicDisorder;IA/H:Illness Anxi-ety/Hypochondriasis;EDs:EatingDisorders.

mentalintrusionsaboutfollowingcertainruleswhilepraying inanear-ritualisticmanner,orabouttheneedtomaintaina highdegreeofmentalandphysicalpurity,couldexplainthe observedsimilarities betweenthe participantsfromthese twocountries(Shams,2018).

The association between obsessional symptoms and religiosityhasbeen notedin studiesperformed in Middle-Easterncountries.Religiousobsessions arepredominantin thesesamples,comparedtotheirlowprevalenceintherest ofthecontinents, aswerecheckingandcleaning compul-sions (e.g., Fontenelle, Mendlowicz,Marques, & Versiani, 2004;Okasha,2004).Karadag,Oguzhanoglu,Özdel,Ates¸ci, and Amuk. (2006) observed that Egyptians, who live in a predominantly Muslim society, reported a high degree of egodystonicity related to checking and cleaning compul-sions,whichmightresultfromculturallyboundedreligious practicesthat emphasize cleanlinessandpurity. Similarly, Yorulmaz, Yilmaz, and Genc¸öz (2004) showed that Turk-ish individuals experienced more morality thought-action fusion beliefs than what was reported in other nations, which might be a reflection of Turkish culture aswell as aconceptof morality linkedtoreligiousvalues. Nonethe-less,giventhattheIranianandTurkishparticipantsinour studywere amongtheyoungest participants inthe entire sample,theroleofageinourfindingscannotberuledout. InthecaseofSpanishandPortugueseparticipants,the sim-ilaritiescouldbeexplainedbythefactthattheysharednot onlythesamegeographicalspaceinpastcenturies,butalso that they have a common history that includes Christian Catholic religion and values. Again, age could be a fac-torbecauseparticipantsfromthesetwocountrieswerein asimilarage range.Regarding thethirdgroup(Argentina, Israel,andItaly),thesimilaritiesbetweenArgentinianand Israeliparticipantscouldhavetodowithagebecause partic-ipantsfromthesecountriesweretheoldestmembersofthe entiresample.However,contradictingthissuggestion,the Italianparticipantswereamongtheyoungest.Thus,other reasonsrelatedtotheimmigrationofItalianindividualsto Argentina,especiallyinthe19th_{century,andIsraelcouldlie}

behindthesimilarities amongthe participantsfromthese threecountries.

Onthewhole,thestudyfindingsshowedmoresimilarities thandifferencesacrosssiteswithrespecttotheoccurrence andrelated disturbance of the four UMI types examined. The findingssuggest thatexperiencing UMIs is quite com-mon,regardlessoftheirspecificcontentsandthenationality or cultural context. Additionally, age differences among thesamples, ratherthancultural variables,couldexplain someoftheobserveddifferences.Inanycase,ourresults about theuniversality of UMIs agree withstudies indicat-ing that the disorderswith which they arerelated, OCD, BDD,Hypochondriasis,andEDs,arepresentinalmostevery cultureand social context,withonly slight differencesin theirrespectiveprevalence rates(i.e., Eli& Warin,2018; Nedeljkovic, Moulding, Foroughi, Kyrios, & Doron, 2012). Fromthis perspective, the data onEDs-related intrusions as the most frequently experienced across the different countriesagree with perspectivesof Anorexia Nervosa as aWestern‘culture-boundsyndrome’transportabletoother cultures through a ‘‘westernization’’ process. For exam-ple,Cheney (2011) argued that, among young US women fromimmigrantbackgrounds,thinnessbecomesanemblem

of ‘‘whiteness’’, such that a disordered eating pattern is viewedasameanstoimprovesocialrelationships,mobility, andpower.

Thesecondaimofthestudywastoexaminetheputative transdiagnostic nature of UMIs. We focused on four spe-cific contents, OCD, BDD, IA-H, and EDs-related,because of thephenomenological similaritiesof thedisorderswith whichtheyareassociated.Thesesimilaritiesincludehigher comorbidityratesthanwhatwouldbeexpectedbychance, analogous cognitiveexplanatory modelsfor each disorder, comparable response to similar treatments, and similar ages of onset. The four disorders also share the experi-enceofUMIs,whichmightbeinstigatorsoftheirrespective clinical symptoms and/or of rumination on their pres-enceandtheassociatednegativecausesandconsequences (Wahl et al., 2019). Our findings showed close relation-ships among the four UMI types, both in the frequency of appearance and in the discomfort they caused. These results support the notion that having a disturbing UMI aboutaspecificthemeorcontentisassociatedwithhaving disturbing UMIs about other different contents, suggest-ing that the tendency or propensity to experience UMIs related to OCD, BDD, IA-H, and EDs could be a vul-nerability factor for these disorders (Pascual-Vera et al., 2017).TheassociationsbetweenBDDandOCD-related intru-sions andbetweenBDD andEDs-relatedintrusionssuggest that a complex network of relationships exists between the disorders in which the UMIs play a key role. The current psychiatric diagnostic systems based on categori-calratherthan dimensional andnetwork (i.e.,Borsboom, 2017) perspectives,which excludeorminimize thesearch for sharedpsychopathologicalaspectsunderlyingdifferent clinical manifestations, are unable to adequately explain these relationships that are commonly observed in clini-calpractice.Forexample,asHalmietal.(2003)suggested in their study about OCD symptoms in patients with Anorexia Nervosa (AN), some common phenotype charac-teristics sharedbymost ANandOCDpatientssuggest that thesedisordersmayshare commonbrainbehavioral path-ways.

The relationship between the frequency and discom-fort provoked by the four UMI types and the respective symptommeasuresofOCD,BDD,Hypochondriasis,andEDs wasanexpectedresult.Nonetheless,wefoundthatthese clinical measureswerealsocorrelatedwiththefrequency of all the UMI types, regardless of their specific content, withtheonlyexception ofthe WhiteleyIndex,whichwas associatedwiththefrequency ofOCD andBDD intrusions, but not withthe EDs-related ones. The association found between the Whiteley Index and the frequency of both OCD and BDD-related intrusions supports the inclusion of Hypochondriasisintheobsessive-compulsivespectrum dis-orders (Kogan et al., 2016; Stein et al., 2016). The lack of relationships between theWI and EDs-intrusions would suggest that thoughts about the ‘‘dangers’’ of eating or not doing exercise in trying to reach and/or maintain a desiredstateofthinnessaredifferentfrompreoccupations aboutone’shealthstatus.Infact,somestudiesfoundthat, unlike OCD-related intrusions, EDs-related intrusions are egosyntonic,evenbeingviewedaspositiveremindersofthe ‘‘rightbehaviors’’ intermsofeatinghabits,both for non-clinicalparticipantsandforpatientswithAnorexiaNervosa

(Belloch, Roncero, & Perpi˜ná, 2012; Belloch et al.,2016; García-Sorianoetal.,2014).

Several limitations of the study should be mentioned. First, thestudy was designedto assess theprevalence of and disturbancecaused by four UMI contents in different countries.Thus,itdidnotincludeculturally-relevant con-structstodrawculturally-specificconclusions.Second,the study results rely ona questionnaire. Wetried to control thepossible biasesassociatedwiththeusesofself-report questionnairesby designing theQUIT onthe basis of pre-viously validated self-report measures, employing highly rigorous translation and back translation, administration, coding,anddataentryprotocolsacrossallsites.The differ-enceinsamplesizesacrosscountriesisanotherlimitation. Nonetheless,itisimportanttonotethatthisstudyincludes adiverserangeof non-westerncountriesthathave hardly been represented in the research. Other representative cross-culturalstudiesareneededtogeneralizeresultsfrom Western-drivenstudies and advance ourknowledge about howpsychologicalphenomenavaryacrossdifferentcultural andsocialcontexts.

Limitations notwithstanding, the present results sup-port the universality and prevalence of unwanted mental intrusions in different content areas (obsessive, dysmor-phic,hypochondriacal,andEDs-related)acrossavarietyof countriesandculturalcontexts.Moreover,thedataobtained refernotonlytothefrequencyoroccurrenceofthese intru-sions, but also to the disturbance they cause, an aspect thatwasnotpreviously studied andthathasmore impor-tanceforthepossibleclinicalimplicationsofUMIsthanthe meredeterminationofthepresenceofUMIs.Theadoption ofawithin-subjectdesignisanadditionalstrengthbecause itfurthersupports thenotionthat theseUMIscould oper-atetransdiagnosticallyacrossclinicallydifferentdisorders, specificallyOCD,BDD,IA-H,andtheEDs.Additionally,this couldhelpustobetterunderstand thecomorbidities usu-allyfound between thesedisordersthroughthe detection of individuals withan increasedpropensity toexperience disturbingmentalintrusions.Futureresearchshould specif-ically test the dimensionality of the four sets of UMIs, as well as their transdiagnostic nature, in clinical sam-plesrepresentativeofthefourdisorderstowhichtheyare related.

Funding

This work was supported by the Spanish Ministerio de EconomíayCompetitividad,MINECO(Grant PSI2013-44733-R) and by the Generalitat Valenciana (GVA), Conselleria d’Educació,CulturaiEsport(GrantPROMETEO/2013/066).

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