A cognitive theory of obsessions

Anxiety disorders and control related beliefs: the exemplar of Obsessive–Compulsive Disorder (OCD)

Beliefs about control have been postulated to be important to anxiety and mood disorders. In particular, the phenomenology of Obsessive-Compulsive Disorder (OCD) suggests that it may be an exemplar of an anxiety disorder where control issues related to the self (behavior and thoughts) and world (the external environment) are particularly important. However, only beliefs concerning the need to control thoughts have been incorporated into contemporary theories of OCD. This article summarizes the theoretical and empirical research relevant to control-related beliefs in OCD. It is suggested that discrepancies between an individual's desired level of control and their perceived level of control could contribute to OCD symptoms, and exacerbate the tendency for individuals with OCD to engage in magical ideation and superstitious rituals. Overall, this review demonstrates how consideration of control cognitions could enhance our understanding of OCD and further improve its treatment.

The normalcy of neurosis: evolutionary origins of obsessive-compulsive disorder and related behaviors

One of the most curious questions plaguing subscribers of evolutionary theory is how natural selection's fine-tuned editing function could allow disease to persist. For evolutionary psychiatrists, the existence of psychopathology is thus perplexing. To illustrate a potential answer to one instance of this broad question, we examine the correlates of obsessive-compulsive disorder (OCD) within our normal repertoire of thought and action. The evidence presents a picture of OCD as a dysregulation of normal behaviors and mental states throughout the course of human development. We speculate that such correspondence may be more than a coincidence and that OCD is a consequence of a dysregulation of the neural circuits that are crucially involved in threat detection and harm avoidance. These neural systems are also likely to underlie aspects of religious experience and ritual as well as the wonders of romantic and early parental love.

Cognitive specificity of anxiety disorders: a review of selected key constructs

Cognitive models of anxiety disorders propose that certain cognitive constructs, that is, underlying beliefs and cognitive processes, may be specific for particular disorders. In this article, we review the specificity of four representative cognitive constructs-anxiety sensitivity, pathological worry, intolerance of uncertainty, and thought-action fusion-for particular disorders. Conceptual overlap, inconsistent definitions, and insufficient consideration of the components of these constructs are limitations of the existing literature. We suggest that the constructs are unlikely to be pathognomonic for any given disorder or to occur in isolation. Rather, the association of each cognitive construct is evident, to varying degrees, with different disorders. Relative to other disorders, anxiety sensitivity is to a certain extent specific for panic disorder, as are pathological worry for generalized anxiety disorder, intolerance of uncertainty for generalized anxiety disorder and obsessive-compulsive disorder, and thought-action fusion for obsessive-compulsive disorder. We discuss the implications of these findings for diagnostic systems and treatment, and suggest areas for further research.

Psychotherapy of obsessive-compulsive disorder and spectrum: established facts and advances, 1995-2005

Dropout rates and refractory cases persist, for reasons that remain unexplained. There are few predictor variables and few innovative approaches to deal with them. New treatment approaches must be developed to improve treatment response even for the responders. Studies show that symptoms are reduced minimally (30% 50%). No new ways of dealing with treatment-refractory cases have been developed. Studies now include more co-morbid cases, however, and their inclusion may account for some of the lack of progress in improvement rates. It needs to be seen whether patients who have one or more comorbid conditions do as well as patients who do not have comorbidity and whether the number or type of comorbid disorders accounts for treatment response. Perhaps better results would be seen with pure OCD cases. Certainly results now are more generalizable to clinical practice. Now it is important to look for alternative treatment approaches and to apply cognitive therapy to more specific problems. Cognitive therapy seems to be helpful with the disorders of the obsessive-compulsive spectrum. The attrition rate is lower when cognitive therapy is used in the treatment of hypochondriasis, and cognitive therapy also is helpful in reducing OVI , which is more severe in body dysmorphic disorder and hypochondriasis. The role of cognitive therapy in OVI needs further exploration.

Obsessive-compulsive disorder as a disturbance of security motivation: Constraints on comorbidity

Patients with OCD often meet criteria for additional psychiatric disorders, with the incidence of comorbidity being as high as 75% in some studies. Here we examine the theoretical plausibility that in OCD much of the domain of co-morbid presentations encompasses related perturbations of the security motivation system. According to a recent proposal, the security motivation system represents a biologically primitive special motivation that is activated by potential (as opposed to imminent) danger to self or intimate others and engages a set of specialized species-typical behaviors (such as checking and washing) to handle potential danger. Because the task of security motivation is open ended, in the sense that no consummatory stimuli can exist in the real world to indicate the absence of potential danger, the shutdown of security motivation is produced by a self-generated feeling of knowing, a satiety signal termed yedasentience. In this schema, OCD results from a failure to generate or respond to the yedasentience signal: without this negative feedback the patient persists abnormally long in a strong motivational state having to do with primal, basic threats to existence, a condition that leads to prolonged engagement in security-related behaviors, such as the checking and washing, characteristic of OCD compulsions and obsessions. Considering the proposed neuronatomy of security motivation system and OCD, we discuss the likelihood that the phenomenon of "spread of allied reflexes" can produce other security-related psychiatric conditions, as well as the possibility that disturbances along different pathways of the security motivation system can lead to apparently different disorders.

Cognitive-behavioural theory and therapy for obsessive-compulsive disorder in children and adolescents: current status and future directions

Obsessive-compulsive disorder is recognised to be much more common than once thought, and increased awareness of prevalence has been associated with an increase in clinical and research attention. However, while the cognitive behavioural model of OCD has received considerable empirical support from adult studies, there has been relatively little investigation of this model in childhood populations. Although this literature is beginning to emerge, initial evaluations suggest there may be important differences between childhood and adult OCD with regard to the cognitive, behavioural, and family factors implicated in the etiology and maintenance of the disorder. Despite this, cognitive-behavioural interventions have been largely modelled on their adult counterparts, and there has been little evaluation of the effectiveness of various treatment components. This paper therefore seeks to critically review the current status of CBT for children and adolescents with OCD, addressing both cognitive behavioural theory and therapy. Current issues in clinical practice will be identified, gaps in the knowledge base will be highlighted, and the paper will conclude by making specific recommendations regarding the integration of research and practice.

Dissociation and symptom dimensions of obsessive-compulsive disorder. A replication study

BACKGROUND

Obsessive-compulsive disorder (OCD) is a phenotypically very heterogeneous disease with high rates of comorbid psychiatric pathology. Previous studies have indicated that OCD is associated with higher levels of dissociation. The aims of the present study were to replicate and extend previous findings of a significant link between certain OCD symptom dimensions and dissociation.

METHODS

The study sample comprised 50 patients with OCD, as confirmed by the Mini International Neuropsychiatric Interview,who had a score of at least 16 on the Yale-Brown Obsessive-Compulsive Scale. All patients were assessed with the short version of the Hamburg Obsessive-Compulsive Inventory and the Dissociative Experience Scale (DES). Correlation analyses and multiple regression analyses were performed to evaluate the relationship between OCD symptom dimensions and dissociation.

RESULTS

The checking dimension was most strongly related to dissociation, followed by the symmetry/ordering and obsessive thoughts dimensions. In contrast, no significant relationship was found between dissociation and the washing/cleaning, counting/touching, and aggressive impulses/fantasies dimensions. Multiple regression analyses revealed that: (1) only the checking dimension showed an independent positive correlation with dissociation, and (2) only higher scores on the DES subscale "amnestic dissociation" were associated with higher scores for checking compulsions.

CONCLUSIONS

Our results suggest that there might be a specific link between checking behavior and dissociation in OCD. Moreover, checking compulsions seem to be particularly associated with amnestic dissociation. Further studies focusing on amnestic dissociation as a potentially important determinant of checking compulsions are warranted.

Increasing willingness to experience obsessions: acceptance and commitment therapy as a treatment for obsessive-compulsive disorder

This study evaluated the effectiveness of an 8-session Acceptance and Commitment Therapy for OCD intervention in a nonconcurrent multiple-baseline, across-participants design. Results on self-reported compulsions showed that the intervention produced clinically significant reductions in compulsions by the end of treatment for all participants, with results maintained at 3-month follow-up. Self-monitoring was supported with similar decreases in scores on standardized measures of OCD. Positive changes in anxiety and depression were found for all participants as well as expected process changes in the form of decreased experiential avoidance, believability of obsessions, and need to respond to obsessions. All participants found the treatment to be highly acceptable. Implications and future directions are discussed.

Repeated checking really does cause memory distrust

Memory phenomena associated with obsessive-compulsive disorder (OCD) have received increased attention in the recent literature. Some debate remains about whether OCD is characterized by deficits in memory per se, or by poor memory confidence. Following from a recent study that demonstrated memory distrust results from repeated checking of a virtual computerized stove, we asked 50 undergraduate students to repeatedly turn on, turn off and check either a real kitchen stove (relevant checking) or a real kitchen faucet (irrelevant checking) in a standardized, ritualized manner. All participants completed a final check of the stove following these 19 checking trials. Results indicated that following repeated relevant checking, participants reported significantly reduced memory confidence, vividness and detail. Repeated irrelevant checking did not produce these decreases. Results are discussed in terms of cognitive-behavioural formulations of OCD and in terms of the effects of repetition on memory and metamemory.

A cognitive behavioral workshop for subclinical obsessions and compulsions

The present study investigates the effectiveness of a 3-h cognitive behavioral workshop for individuals, ages 18-22, with subclinical obsessions and compulsions. It was hypothesized that, compared to individuals in an assessment-only waitlist group (n = 42), individuals assigned to the workshop group (n = 43) would experience a significant decrease in obsessive-compulsive (OC) symptomatology, comorbidity, and thought action fusion endorsement at 1-month and 5-month follow-up assessments. An additional outcome of interest was the number of incident cases of obsessive-compulsive disorder (OCD) over the course of the study. The results indicated that the workshop group reported a significantly fewer number of OC symptoms at 5-month follow-up and endorsed significantly less thought action fusion at both follow-up points. However, there were no differences between groups in severity of OC symptoms and number of comorbid diagnoses endorsed. Only one incident case of OCD was observed during the study, from a participant in the waitlist group. These results are discussed in reference to treatment of subclinical anxiety symptoms.

Confirmatory Factor Analysis of the White Bear Suppression Inventory and the Thought Control Questionnaire

The White Bear Suppression Inventory (WBSI) was developed to assess chronic thought suppression, whereas the Thought Control Questionnaire (TCQ) measures different strategies to suppress unpleasant intrusive thoughts. The present study examines the latent factor structure of these instruments in a sample of 540 normal subjects using confirmatory factor analyses (CFA). Regarding the WBSI, the CFAs indicated that the tested models did not provide a good fit for the data. Data analysis showed that the TCQ with five factors and 30 items did not reach a reasonable fit. Therefore, in order to present a five-factor structure with an adequate fit, those items with problematic factor loadings were eliminated. Correlational analyses indicated that the WBSI had a significant association with depression, obsessive-compulsive symptoms, and pathological worry, whereas only two TCQ subscales, punishment and worry, were related to these psychopathological symptoms.

Mechanisms of change in dialectical behavior therapy: Theoretical and empirical observations

Dialectical behavior therapy (DBT) can be considered a well-established treatment for borderline personality disorder (BPD) as evidenced by seven well-controlled randomized clinical trials across four independent research teams. The primary purpose of this article is to address a variety of potential mechanisms of change that may be associated with those aspects of DBT that are unique to the treatment and its theoretical underpinnings. Based on the biosocial theory of BPD, many of these mechanisms can be distilled down to the following process: the reduction of ineffective action tendencies linked with dysregulated emotions. Specifically we address the following interventions and associated mechanisms of change: mindfulness, validation, targeting and chain analysis, and dialectics. Patient change in BPD is conceptualized primarily as helping the patient to engage in functional, life-enhancing behavior, even when intense emotions are present. Ultimately, our goal was to provide guidance for theoretically and empirically grounded research on the mechanisms of change in DBT.

Testing the autogenous-reactive model of obsessions

Two independent studies were conducted to examine the autogenous-reactive subtype model of obsessions [Lee and Kwon, 2003]. Study 1 demonstrated that 30 obsessive-compulsive (OCD) patients' responses to autogenous versus reactive obsessions differed significantly with respect to emotional reactions, cognitive appraisals, and control strategies. Study 2 compared OCD patients whose primary obsessions were of the autogenous subtype (n=13) with OCD patients whose primary obsessions were of the reactive subtype (n=14). Results revealed significant differences between these two groups on several OCD-related domains including OCD symptom profiles, perfectionistic personality features, and dysfunctional beliefs. Theoretical and clinical implications are discussed.

Treatment of obsessive–compulsive disorder: Cognitive behavior therapy vs. exposure and response prevention

The efficacy of contemporary cognitive therapy for obsessive-compulsive disorder (OCD) has only recently been investigated. The current study compares exposure and response prevention (ERP) and cognitive behavior therapy (CBT) delivered in an individual format. Participants were randomly assigned to the 12 consecutive-week CBT or ERP treatment. Based on 59 treatment completers, there was no significant difference in YBOCS scores between CBT and ERP at post-treatment or at 3-month follow-up. A higher percentage of CBT participants obtained recovered status at post-treatment (67%) and at follow-up (76%), compared to ERP participants (59% and 58%, respectively), but the difference was not significant. Effect sizes (ESs) were used to compare the results of the current study with a previous study conducted at our center that utilized group CBT and ERP treatments, as well as other controlled trials that have compared CBT and ERP. The significance of these results is discussed and a comparison is made with the existing literature.

Psychometric validation of the obsessive belief questionnaire and interpretation of intrusions inventory—Part 2: Factor analyses and testing of a brief version

The Obsessive Belief Questionnaire (OBQ) and the Interpretation of Intrusions Inventory (III) were designed to assess beliefs and appraisals considered critical to the pathogenesis of obsessions. In previous reports we have described the construction and psychometric properties of these measures. In this study a battery of questionnaires assessing anxiety, depression, and obsessive compulsive symptoms was completed by 410 outpatients diagnosed with obsessive compulsive disorder, 105 non-obsessional anxious patients, 87 non-clinical adults from the community, and 291 undergraduate students. Items from 6 theoretically derived subscales of the OBQ were submitted to factor analysis. Three factors emerged reflecting (1) Responsibility and threat estimation, (2) Perfectionism and intolerance for uncertainty, and (3) Importance and control of thoughts. A 44-item version (OBQ-44) composed of high-loading items from the 3 factors showed good internal consistency and criterion-related validity in clinical and non-clinical samples. Subscales showed less overlap than original scales. Factor analysis of the III yielded a single factor, suggesting the total score be used in lieu of the 3 rationally derived subscales. The scales performed well on tests of convergent validity. Discriminant validity was promising; hierarchical regression analyses indicated that the OBQ subscales and III generally predicted OC symptoms after controlling for general distress. A revision of the OBQ, the OBQ-44, is included in the appendix

Why are some obsessions more upsetting than others?

Little is known about why certain obsessional thoughts are more upsetting than others for people with obsessive compulsive disorder (OCD). Obsessional thought content often seems arbitrary to sufferers. The current study examined three possible reasons why particular thoughts would be especially upsetting for individuals, based on suggestions put forth by cognitive theories of obsessional thoughts. Twenty-eight individuals with a principal diagnosis of OCD completed questionnaires and interviews at two different periods of time on (1) their most upsetting current obsession and (2) their least upsetting current obsession. Results suggested that more upsetting obsessions were evaluated as more meaningful or significant than less upsetting obsessions, and more upsetting obsessions contradicted valued aspects of the self to a greater degree. All examples of current obsessions, both most and least upsetting, arose in the context of life concerns or issues. Results support cognitive theories in that the strength and nature of appraisal appears to be linked with the distress associated with a thought, and more upsetting thoughts are those that have implications for a person's sense of self.

Focus on “Cognition” in Cognitive Behavior Therapy for OCD: Is it Really Necessary?

The past decade has witnessed a significant shift toward a more cognitive emphasis in our understanding and treatment of obsessive-compulsive disorders (OCD). This article discusses the shortcomings in more standard behavioral treatment of OCD, which despite its demonstrated efficacy, led to the recent cognitive-behavioral approaches to the disorder. Current cognitive behavior therapy for OCD is described and a short critical review of the comparative treatment outcome literature on cognitive behavior therapy vs exposure and response prevention is provided. The article concludes that although the clinical utility of a more cognitive approach to OCD has not been consistently demonstrated, it would be premature to abandon cognitive formulations until some key research questions have been addressed.

Induction of compulsive-like washing by blocking the feeling of knowing: an experimental test of the security-motivation hypothesis of obsessive-compulsive disorder

BACKGROUND

H. Szechtman and E. Woody (2004) hypothesized that obsessive-compulsive disorder results from a deficit in the feeling of knowing that normally terminates thoughts or actions elicited by security motivation. To test the plausibility of this proposed mechanism, an experiment was conducted to produce an analog of washing in obsessive-compulsive disorder by eliciting a scenario of potential harm and using hypnosis to block changes in internally generated feelings that would normally occur during washing.

RESULTS

Participants reacted with increased disgust, anxiety, and heart rate to their mental images of contamination and potential danger. As predicted, high but not low hypnotizable participants showed a significant prolongation of washing when change in feelings during washing was blocked hypnotically.

CONCLUSION

Results show that blocking the affective signal that is normally generated during security-related behaviors, such as washing, leads to prolonged performance of these behaviors. This finding lends support to the plausibility of the proposed model of obsessive-compulsive disorder.

Implicit and explicit appraisals of the importance of intrusive thoughts

To evaluate cognitive theories of obsessions, the current study experimentally manipulated appraisals of the importance of intrusive thoughts. Undergraduate students (N = 156) completed measures of obsessive-compulsive disorder (OCD) symptoms and beliefs and were primed with a list of commonly reported unwanted thoughts. Participants were then informed that unwanted thoughts are either (1) significant and indicative of their personal values, or (2) meaningless, or participants (3) received no instructions about unwanted thoughts. Participants then completed implicit and explicit measures of self-evaluation and interpretations of their unwanted thoughts. Results indicated that the manipulation shifted implicit appraisals of unwanted thoughts in the expected direction, but not self-evaluations of morality or dangerousness. Interestingly, explicit self-esteem and beliefs about the significance of unwanted thoughts were associated with measures of OCD beliefs, whereas implicit self-evaluations of dangerousness were better predicted by the interaction of pre-existing OCD beliefs with the manipulation. Results are discussed in terms of divergent predictors of implicit and explicit responses to unwanted thoughts.

Obsessive compulsive disorder: A review of possible specific internal representations within a broader cognitive theory

Obsessive Compulsive Disorder (OCD) is one of the most incapacitating of anxiety disorders, and is rated as a leading cause of disability by the World Health Organization (1996). Current cognitive models of OCD have focused on beliefs and management strategies involved in the development, maintenance, and exacerbation of OCD. However, despite evidence of their association to psychopathology, few researchers have applied the idea of underlying cognitive-affective structures, such as perceptions about the self and world, as operating in individuals with obsessive-compulsive thoughts and behaviors. This paper critically engages with current cognitive, developmental, and attachment research associated with views about the self and world. It is argued that consideration of such underlying cognitive-affective vulnerabilities may lead to a broader understanding of the development and maintenance of OCD. Consistent with previous theoretical work (e.g. ), we also argue that early experiences of parenting lead to the development of a dysfunctional self-structure and world-view relevant to OCD. Thus, this paper aims to extend the focus of current OCD research by exploring the possible role of a broader range of underlying vulnerability structures in the development and maintenance of OCD-related dysfunctional beliefs and symptoms.

Effectiveness of Cognitive Therapy for Obsessive-Compulsive Disorder: An Open Trial

This study examined the effectiveness of a new type of purely Beckian cognitive treatment for Obsessive-Compulsive Disorder (OCD). The manualized treatment used a flexible format permitting therapists to choose among several modules developed to address specific OCD belief domains identified by the Obsessive-Compulsive Cognition Working Group (1997). Fifteen participants diagnosed with OCD were treated individually for 14 weekly sessions. Ten participants had never received behavior therapy, and 5 participants had failed to benefit from exposure and response prevention (ERP) in the past. Participants improved with respect to their depressive and obsessive-compulsive symptoms over the course of the treatment. However, those who had never received ERP improved more than those who had failed to benefit from prior ERP. Implications of the study are discussed.

The relationship between miscellaneous symptoms and major symptom factors in obsessive-compulsive disorder

The diverse symptomatology of obsessive-compulsive disorder (OCD) is being increasingly regarded as reducible to a few symptom dimensions. However, prevailing factor-analytically derived models of symptom structure omit a number of the well-recognized "miscellaneous" symptoms of OCD. This study sought to determine whether miscellaneous OCD symptoms, ascertained by the Yale-Brown Obsessive-Compulsive Scale symptom checklist, could be differentially and reliably predicted by four symptom factors (obsessions and checking, symmetry and ordering, contamination and cleaning, and hoarding) in two independent groups of individuals with OCD (n=381 and n=107). Logistic regression analyses were used to determine the association of each of the miscellaneous symptoms with the symptom factors; then a single confirmatory factor analysis was conducted to test the model of associations in the smaller sample. Sixteen (89%) of the 18 symptoms examined were reliably predicted by one (11 items) or two (5 items) of the factors, with obsessions and checking and symmetry and ordering emerging as foremost predictors. The expanded four-factor model showed good fit with data from the second sample. Results are conceptually meaningful, but suggest the inadequacy of groupings based solely upon overt behaviors. These findings may aid clinical understanding of OCD and be of value to studies using symptom factors to guide investigation of its causes and correlates.

Memory and attention in Obsessive-Compulsive Disorder: a review

The present manuscript reviewed studies investigating biases and deficits in memory and attention related to Obsessive-Compulsive Disorder (OCD). Although the research has been mixed concerning memory for verbal information, there is more consistent evidence suggesting impairment for non-verbal information, particularly for complex visual stimuli and the individual's own actions. Further, a number of studies indicate that patients with OCD report less confidence in their judgments about recognition memory. Finally, OCD appears to be associated with an attentional bias favoring threatening information, as well as reduced levels of cognitive inhibition. The manuscript concludes with a number of recommendations for future research.

Thought–action fusion: Review of the literature and future directions

Thought-action fusion (TAF) is the tendency for individuals to assume that certain thoughts either imply the immorality of their character or increase the likelihood of catastrophic events. The burgeoning literature on TAF is reviewed. It is not clear whether TAF refers to a specific appraisal style, a more enduring belief, or a combination of both. Inconsistent definitions of magical thinking have hindered better understanding of the relationship between TAF and magical thinking. Much work remains to be done to improve assessment and measurement of TAF. TAF is associated with tendencies towards obsessive-compulsive disorder (OCD) and may contribute to its symptoms. However, the literature investigating TAF and other variables implicated in OCD remains inconclusive. It is suggested that TAF is not specific to OCD, but also prevalent in other anxiety disorders. TAF appears to be moderately related to depressive symptoms and a similar bias may contribute to preoccupations in eating disorders. TAF is also associated with the presence of psychological disorders in children and adolescents. Educational and cognitive therapy approaches to reduce TAF and consequent symptoms are discussed, and suggestions for further research made.

Responsibility attitude in a sample of Iranian obsessive-compulsive patients

BACKGROUND

The study of distorted beliefs about responsibility attitude and interpretation has become the central theme in Salkovskis' (1985) and Rachman and Hodgson's (1980) models of Obsessive-Compulsive Disorder (OCD).

AIMS

The aim of this research is to assess the responsibility attitude in Iranian OCD patients.

METHODS

Twenty OCD patients were selected through available sampling from the case referred to psychology clinics. Two other patient groups comprised of 20 non-OCD anxiety disorder patients and 20 non-clinical participants were also chosen as comparison groups. All participants completed the Responsibility Attitude Scale (RAS) and Responsibility Interpretation Questionnaire (RIQ).

RESULTS

Analyses revealed statistically significant differences between OCD group and comparison groups on both RAS and RIQ. In addition, both RAS and RIQ scores were associated with the severity of OCD assessed by the Yale-Brown scale.

CONCLUSIONS

These findings suggest that responsibility attitude and interpretations are the prominent features of OCD in Iranian patients and are associated with the severity of illness.

Inferential confusion in obsessive–compulsive disorder: the inferential confusion questionnaire

The current article represents the further validation of the construct of inferential confusion amongst clinical samples. Inferential confusion is proposed to be a meta-cognitive confusion particularly relevant to obsessive compulsive disorder (OCD) that leads a person to confuse an imagined possibility with an actual probability. As such, it conceptualizes OCD as a form of belief disorder similar to a delusion or overvalued idea that is a product of distorted reasoning processes. In contrast, other cognitive models of OCD emphasize a phobic model of development in OCD, and thus consider the exaggerated interpretation of intrusions as an essential element in OCD. The present study administered a revised version of the Inferential Confusion Questionnaire, and the Obsessive Belief Questionnaire (OBQ), to a total of 183 participants in three clinical groups and a non-clinical control group. Results suggest that OCD, at least in part, follows a non-phobic model of development with inferential confusion significantly related to obsessive-compulsive symptoms independently of cognitive domains as measured by the OBQ, and mood states. Further, scores on inferential confusion were particularly high in those with OCD and delusional disorder as compared to anxious and non-clinical controls.

Association between Protestant religiosity and obsessive-compulsive symptoms and cognitions

There is evidence that religion and other cultural influences are associated with the presentation of obsessive-compulsive symptoms, as well as beliefs and assumptions presumed to underlie the development and maintenance of these symptoms. We sought to further examine the relationship between Protestant religiosity and (1) various symptoms of obsessive-compulsive disorder (OCD) (e.g., checking, washing) and (2) OCD-related cognitions. Using self-report questionnaires, we compared differences in these OCD-related phenomena between highly religious Protestants, moderately religious Protestants, and atheist/agnostic participants drawn from an undergraduate sample. Highly religious versus moderately religious Protestants reported greater obsessional symptoms, compulsive washing, and beliefs about the importance of thoughts. Additionally, the highly religious evinced more obsessional symptoms, compulsive washing, intolerance for uncertainty, need to control thoughts, beliefs about the importance of thoughts, and inflated responsibility, compared to atheists/agnostics. Results are discussed in terms of the relationship between religion and OCD symptoms in the context of the cognitive-behavioral conceptualization of OCD.

Feared identity and obsessive-compulsive disorder

We tested predictions from cognitive-behavioural theory that people with obsessive-compulsive disorder (OCD) regard their intrusions as revealing unacceptable aspects of their character. We compared an OCD sample with anxious controls (AC) and non-anxious controls (NAC) on a measure of the extent to which intrusions led to negative inferences about the self, assessed the discrepancy between their actual and feared self, and recorded the traits making up the feared self. The OCD sample did not differ from AC on self-discrepancies, but did differ from both control groups on the measure of negative inferences about the self. In addition, the feared self of the OCD sample was significantly more likely to consist of bad and immoral traits.

Thought suppression and its effects on thought frequency, appraisal and mood state in individuals with obsessive-compulsive disorder

Leading models of obsessive-compulsive disorder (OCD) implicate thought suppression as a key factor in the escalation and persistence of the disorder. This experiment examined the effects of suppression on the frequency of obsessional thoughts in 50 individuals with a primary diagnosis of OCD, and also investigated the effects of participants' appraisals regarding their failures in thought control on distress about intrusive thoughts and on mood. Participants' most upsetting obsessional thought was primed and they then monitored its occurrence over two 4-min intervals. In the first interval, half of the participants were instructed to suppress their obsessional thought and half were instructed not to suppress any thoughts. In the second interval, all participants were given the 'Do Not Suppress' instructions. Participants rated their suppression effort and discomfort over thought occurrences after each interval and recorded their appraisals of thought recurrences during the first interval. Mood state was then reassessed. No ironic effect of suppression on frequency was noted. However, negative appraisals of thought recurrences were associated with more discomfort over thought occurrences and more negative mood at Time 2. These findings suggest that interpretations regarding failures in thought control may be of central importance in understanding obsessional problems.

A critical evaluation of obsessive-compulsive disorder subtypes: symptoms versus mechanisms

Recently, experts have suggested that obsessive-compulsive disorder (OCD), a highly heterogeneous condition, is actually composed of distinct subtypes. Research to identify specific subtypes of OCD has focused primarily on symptom presentation. Subtype models have been proposed using factor analyses that yield dimensional systems of symptom categories, but not necessarily distinct subtypes. Other empirical work has considered the role of neuropsychological functioning and comorbidity as part of a comprehensive scheme for subtyping OCD. The identified dimensions from all of these studies have implications for the treatment of OCD. In this article, we review the research on subtypes of OCD, focusing on subtype schemes based upon overt symptom presentation and neuropsychological profiles. We also review research pertinent to alternative subtyping schemes, both conceptually and methodologically. The research is critically examined and implications for treatment are discussed. Recommendations for future investigations are offered.

Psychometric properties of the Thought–Action Fusion Scale in a Turkish sample

The aim of the present study was to reveal the cross-cultural utility of the Thought-Action Fusion Scale (TAFS; J. Anxiety Disord. 10 (1996) 379). Thought-action fusion (TAF) refers to the tendency to overvalue the significance and the consequences of thoughts. Two hundred and fifty one undergraduate Turkish students participated in the current study. The reliability and validity analyses of the Turkish version of the scale indicated that the TAFS had adequate psychometric properties in a Turkish sample. Consistent with the original TAF, the Turkish version of TAFS revealed two subscales as TAF-Likelihood and TAF-Morality. Reliability analysis showed that TAF Scale and its factors had adequate internal consistencies and split-half reliability coefficients. Confirming the expectations, TAFS scores were found to be significantly and positively correlated with obsessive-compulsive symptoms, responsibility, and guilt measures. Moreover, it was found that people with high obsessive-compulsive symptoms had higher TAFS scores than those with low symptoms.

Cognitive appraisals in young people with obsessive-compulsive disorder

BACKGROUND

A number of cognitive appraisals have been identified as important in the manifestation of obsessive-compulsive disorder (OCD) in adults. There have, however, been few attempts to explore these cognitive appraisals in clinical groups of young people.

METHOD

This study compared young people aged between 11 and 18 years with OCD (N = 28), young people with other types of anxiety disorders (N = 28) and a non-clinical group (N = 62) on three questionnaire measures of cognitive appraisals. These were inflated responsibility (Responsibility Attitude Scale; Salkovskis et al., 2000), thought-action fusion--likelihood other (Thought-Action Fusion Scale; Shafran, Thordarson & Rachman, 1996) and perfectionism (Multidimensional Perfectionism Scale; Frost, Marten, Luhart & Rosenblate, 1990).

RESULTS

The young people with OCD had significantly higher scores on inflated responsibility, thought-action fusion--(likelihood other), and one aspect of perfectionism, concern over mistakes, than the other groups. In addition, inflated responsibility independently predicted OCD symptom severity.

CONCLUSIONS

The results generally support a downward extension of the cognitive appraisals held by adults with OCD to young people with the disorder. Some of the results, however, raise issues about potential developmental shifts in cognitive appraisals. The findings are discussed in relation to implications for the cognitive model of OCD and cognitive behavioural therapy for young people with OCD.

Les troubles obsessionnels-compulsifs : appartiennent-ils aux troubles anxieux ou à une autre famille de troubles mentaux ?

Cet article passe en revue les quatre conceptions du trouble obsessionnel-compulsif (TOC) : la première conception présuppose que le TOC est un trouble du mouvement, la deuxième soutient que cette maladie fait partie du spectre TOC incluant, à la fois, les troubles impulsifs et compulsifs, la troisième fait référence à la classification actuelle (DSM-IV-TR) qui répartit le TOC dans la famille des troubles anxieux et la dernière conception suggère qu’il est, en fait, un trouble du raisonnement qui pourrait s’inscrire sur un continuum avec, par exemple, le trouble délirant. Même s’il existe des arguments en faveur des quatre conceptions, le TOC semble se différencier des troubles du mouvement, des troubles impulsifs et des troubles anxieux. En effet, il serait plus juste et raisonnable de concevoir le TOC comme un trouble du raisonnement qui provoque de l’anxiété associée aux croyances obsessionnelles.

Symmetry, ordering and arranging compulsive behaviour

Compulsive ordering and arranging, and a preoccupation with symmetry are features of obsessive-compulsive disorder (OCD) that have not been examined experimentally. Three connected studies were conducted to examine this phenomenon: a self-report measure of this behaviour was developed and validated, participants were asked to engage in tasks designed to assess preferences for order, and to assess the interference of disorderly surroundings in the completion of a stressful activity. The self-report measure has sound psychometric properties and validity. Participants with a strong preference for order were made more anxious by having to complete a difficult task in a disorganized environment. Participants without this preference did not show this effect. The results are discussed in terms of the phenomenology of compulsive ordering and arranging, and its relationships with both OCD and normal human behaviour. It is suggested that compulsive ordering and a drive for symmetry are extreme manifestations of the common preference for order and symmetry.

Effects of suppressing neutral and obsession-like thoughts in normal subjects: beyond frequency

Recent cognitive-behavioral theories on obsessive-compulsive disorder (OCD) show that deliberate attempts to suppress intrusive and undesirable thoughts lie at the genesis of clinical obsessions. In this paper the results of an experimental study on the suppression of neutral and obsession-like thoughts in normal subjects are presented. Eighty-seven university students performed in three experimental periods: (1) base-line monitoring, (2) experimental instruction, and (3) monitoring. For each of these periods, the frequency of the occurrence of a "white bear" thought or a personally relevant intrusive thought was registered. Half of the subjects received instructions to suppress the target-thought in period 2, and the other half were instructed to only monitor the target-thought in each of the experimental periods. Several measures were also obtained before and after the experiment: annoyance caused by the intrusion, suppression effort, subjective success, and evaluative appraisals of the target-thought. The results showed neither immediate nor delayed frequency increases of the target thought. However, evidence was found that deliberate thought suppression efforts, regardless of their content, had greater negative consequences than did non suppression. These results are discussed in relation to the recent cognitive proposals about OCD.

Empirical investigations of thought suppression in OCD

Cognitive-behavioural models of obsessive-compulsive disorder (OCD) implicate thought suppression as a key factor in the development and persistence of the disorder. There is now more than a decade of research on thought suppression and its effects as they pertain to OCD. This paper briefly reports on initial thought suppression research and then offers a detailed review of recent thought suppression research that has directly examined the role of suppression in OCD. Theoretical and methodological issues in using thought suppression paradigms to understand OCD are discussed. It is concluded that this body of work continues to yield inconsistent findings with respect to the effects of suppression on thought frequency, although there are some consistent findings that suggest that suppression is driven by negative thought appraisal and is associated in turn with greater OCD symptomatology. Thus, there is support in this work for key tenets of cognitive-behavioural models of OCD. Suggestions for future research directions are offered.

The importance of importance in OCD memory research

Investigations of memory and associated phenomena in obsessive-compulsive disorder (OCD) can advance our understanding of this often debilitating problem. Theoretical models predict both the presence and absence of memory biases in favour of threat-relevant information in association with anxiety disorders generally, and with OCD specifically. Two previous experiments (one involving compulsive washing and another involving compulsive checking) that demonstrated such a memory bias are reviewed in the context of the existing literature. Additionally, a new experiment failing to demonstrate such a bias (in association with compulsive ordering and arranging) is presented. The results are discussed in terms of cognitive-behavioural and information processing approaches to understanding OCD. It is argued that experiments which utilize stimuli that are low in ecological validity are unlikely to detect explicit memory biases in OCD. As such, experimental paradigms that are perceived as particularly significant, relevant and important to participants with OCD are encouraged.

Thought-action fusion: a review

The cognitive bias of "Thought Action Fusion" (TAF) has received significant research attention in the past decade. The review addresses the assessment of TAF, its place in cognitive theories of obsessional difficulties, and the evidence demonstrating that TAF is relevant to disorders beyond Obsessive Compulsive Disorder (OCD). Data on the components of TAF, its extension to positive outcomes and its role in the aetiology, maintenance and treatment of OCD are reviewed. It is concluded that the moral form of TAF is less robust than the likelihood form and that scales may be best used as a starting point in identifying beliefs and conducting experimental investigations. It is also suggested that the scales be amended to include harm avoidance, which would also increase their clinical utility.

Fear of guilt from behaving irresponsibly in obsessive-compulsive disorder

Previous cognitive models of obsessive-compulsive disorder (OCD) propose that inflated responsibility plays a key role in the maintenance of symptoms (Behav.Res.Ther. 28 (1985) 571). In this manuscript, we propose that this thesis may be improved by emphasizing that instead, OCD may be characterized by a fear of guilt that would result from behaving irresponsibly and/or from not behaving responsibly. We believe that this concept provides a better explanation for the anxious and fearful nature of OCD than do more traditional conceptualizations of inflated responsibility. We support this idea with empirical evidence and propose that OCD symptoms are consistent with patients acting in a prudential mode because of their fears of guilt.

Obsessive-compulsive disorder as a disturbance of security motivation

The authors hypothesize that the symptoms of obsessive-compulsive disorder (OCD), despite their apparent nonrationality, have what might be termed an epistemic origin--that is, they stem from an inability to generate the normal "feeling of knowing" that would otherwise signal task completion and terminate the expression of a security motivational system. The authors compare their satiety-signal construct, which they term yedasentience, to various other senses of the feeling of knowing and indicate why OCD-like symptoms would stem from the abnormal absence of such a terminator emotion. In addition, they advance a tentative neuropsychological model to explain its underpinnings. The proposed model integrates many previous disparate observations and concepts about OCD and embeds it within the broader understanding of normal motivation.

Cognitive-behavioral treatment of repugnant obsessions

Obsessions often occur in the form of repugnant sexual, aggressive, or blasphemous thoughts, images, impulses, or doubts. This article describes the phenomenon of repugnant obsessions and reviews the cognitive-behavioral model of obsessive-compulsive disorder (OCD). Caveats and recommendations are provided and a case illustration is presented. Repugnant obsessions are highly amenable to treatment; but developing an idiographic conceptualization of the client's obsessive-compulsive cycle is important. Treatment resources are presented throughout.

Psychometric validation of the Obsessive Beliefs Questionnaire and the Interpretation of Intrusions Inventory: Part I

This article reports on the validation of the Obsessive Beliefs Questionnaire (OBQ) and Interpretations of Intrusions Inventory (III) developed by the Obsessive Compulsive Cognitions Working Group (OCCWG) to assess the primary beliefs and appraisals considered critical to the pathogenesis of obsessions. A battery of questionnaires that assessed symptoms of anxiety, depression, obsessive-compulsive symptoms and worry was administered to 248 outpatients with a DSM-IV diagnosis of Obsessive-Compulsive Disorder (OCD), 105 non-obsessional anxious patients, 87 non-clinical adults from the community, and 291 undergraduate students. Tests of internal consistency and test-retest reliability indicated that the OBQ and III assessed stable aspects of OC-related thinking. Between-group differences and correlations with existing measures of OC symptoms indicated that the OBQ and III assess core cognitive features of obsessionality. However, the various subscales of the OBQ and III are highly correlated, and both measures evidenced low discriminant validity. The findings are discussed in terms of the relevance and specificity of cognitive constructs like responsibility, control and importance of thoughts, overestimated threat, tolerance of uncertainty and perfectionism for OCD.

Too much thinking about thinking?: Metacognitive differences in obsessive-compulsive disorder

Negative appraisals of intrusive thoughts and beliefs about the importance of thoughts are considered core mechanisms in cognitive models of obsessive-compulsive disorder (OCD). In refinements of cognitive theory, differences in metacognitive processes have been emphasized. Cartwright-Hatton and Wells [J. Anxiety Disord. 37 (1997) 279-296] found that cognitive self-consciousness (CSC), a tendency to be aware of and monitor thinking, was the only metacognitive dimension that differentiated OCD patients from patients with generalized anxiety disorder. To evaluate the relative importance of different cognitive processes to OCD, we administered an expanded CSC scale and two state-of-the-art measures of thought appraisals and beliefs. Scores on the CSC scale reliably differentiated OCD patients (n=30), from an anxious comparison group (OAD, n=25) after controlling for scores on the two cognition measures. The tendency to excessively reflect upon one's cognitive processes may increase opportunities for negative appraisals of intrusive thoughts, foster over-importance of thought beliefs, and increase the likelihood of developing OCD.

Science and Philosophy: Comparison of Cognitive Therapy and Rational Emotive Behavior Therapy

Aaron T. Beck’s Cognitive Therapy (CT) and Albert Ellis’ Rational Emotive Behavior Therapy (REBT) are compared. A major difference between these therapies is that CT is an empirically based therapy and REBT is philosophically based. The origins and subsequent development of the therapies are reviewed with this difference highlighted. Comparisons between CT and REBT practice are made regarding attitudes toward client beliefs, use of guided discovery, types of cognition addressed, and the nature of the client-therapist relationship. The scientific foundations of CT are summarized in terms of the specificity of its conceptual models, the construction of targeted treatment protocols, and empirical findings that support both CT conceptualizations and treatments.