Obsessional ruminations

'Visible' compulsions: OCD and the politics of science in British clinical psychology, 1948-1975

This article historicizes a single stage in how the contemporary obsessive-compulsive disorder (OCD) category was built. Starting from the position that the two central components which make up OCD are 'obsessions' and 'compulsions', it illustrates how these concepts were taken apart by a small group of clinical psychologists working at the Institute of Psychiatry and the Maudsley psychiatric hospital in south London in the early 1970s, and why compulsions were investigated whilst obsessions were ignored. The decision to distinguish the previously undifferentiated symptoms is attributed to the commitment amongst psychologists at the Maudsley, most notably Stanley Rachman, to an empirical conception of science which emphasized observability. Two aspects of this are discussed. First, compulsions were deemed 'visible' through their correspondence with animal behaviour. Second, the symptom was seen as open to an experimental modification procedure which privileged visible outcomes. Ultimately, the article concludes that the historical division between 'obsessions' and 'compulsions', and the extensive investigation of the latter, has had substantial implications for the development of OCD as a category centred on visible behaviours and treated through behavioural means.

Dr. Jack Rachman's contributions to our understanding and treatment of obsessive-compulsive disorder

BACKGROUND AND OBJECTIVES

This paper reviews the development of the cognitive-behavioural model of obsessive-compulsive disorder (OCD) through the work of Dr. Jack Rachman and the research his ideas inspired or shaped.

METHODS

A narrative review of Rachman's work and important developments in related areas was conducted.

RESULTS

Rachman was highly responsive to theoretical and empirical developments in the field, and continuously developed his model of OCD over the course of his career. Key developments in his thinking and of those in related areas are described.

LIMITATIONS

This is a narrative review that highlights important developments in the cognitive behavioural model of OCD only.

CONCLUSIONS

The CBT model of OCD has strong empirical support and CBT treatment is the most effective psychotherapy. Continued development in our understanding of attachment and in the persistence of compulsions is warranted.

Changes in Volume of Subregions Within Basal Ganglia in Obsessive–Compulsive Disorder: A Study With Atlas-Based and VBM Methods

Background

The role of basal ganglia in the pathogenesis of obsessive–compulsive disorder (OCD) remains unclear. The studies on volume changes of basal ganglia in OCD commonly use the VBM method; however, the Atlas-based method used in such research has not been reported. Atlas-based method has a lower false positive rate compared with VBM method, thus having advantages partly.

Objectives

The current study aimed to detect the volume changes of subregions within basal ganglia in OCD using Atlas-based method to further delineate the precise neural circuitry of OCD. What is more, we explored the influence of software used in Atlas-based method on the volumetric analysis of basal ganglia and compared the results of Atlas-based method and regularly used VBM method.

Methods

We analyzed the brain structure images of 37 patients with OCD and 41 healthy controls (HCs) using the VBM method, Atlas-based method based on SPM software, or Freesurfer software to find the areas with significant volumetric variation between the two groups, and calculated the effects size of these areas.

Results

VBM analysis revealed a significantly increased volume of bilateral lenticular nucleus in patients compared to HCs. In contrast, Atlas-based method based on Freesurfer revealed significantly increased volume of left globus pallidus in patients, and the largest effect size of volumetric variation was revealed by Freesurfer analysis.

Conclusions

This study showed that the volume of bilateral lenticular nucleus significantly increased in patients compared to HCs, especially left globus pallidus, which was in accordance with the previous findings. In addition, Freesurfer is better than SPM and a good choice for Atlas-based volumetric analysis of basal ganglia.

Involuntary Autobiographical Memories in Schizophrenia: Characteristics and Conditions of Elicitation

Involuntary autobiographical memories are mental representations of personally experienced past events that come to mind spontaneously, with no preceding attempt to recall them. They have been showed to be more frequent and more emotional in the psychosis continuum. Although schizophrenia is strongly associated with thought disorders, including cognitive intrusions of thought, images, semantic knowledge, research on patients' involuntary autobiographical memories is limited. We undertook two studies to compare involuntary and voluntary remembering in schizophrenia and the conditions in which involuntary memories occurs in those patients, both in daily life (n = 40), using a diary method, and in an experimental context (n = 50). Overall, results showed that the conditions of elicitation of involuntary memories differ in patients, as patients were more sensitive to memory triggers, especially internal triggers, in comparison to controls. Relatedly, patients' involuntary memories-mostly related to mundane events with low emotional load-were experienced more frequently. Although patients' involuntary and voluntary memories were less clear, more poorly contextualized and associated with a lower belief in occurrence than those of controls, patients considered them as more central to the self, in comparison to controls. The results are discussed in relation to patients' self-reflective impairments.

Obsessive-compulsive disorder

Obsessive-compulsive disorder (OCD) is a highly prevalent and chronic condition that is associated with substantial global disability. OCD is the key example of the 'obsessive-compulsive and related disorders', a group of conditions which are now classified together in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, and the International Classification of Diseases, 11th Revision, and which are often underdiagnosed and undertreated. In addition, OCD is an important example of a neuropsychiatric disorder in which rigorous research on phenomenology, psychobiology, pharmacotherapy and psychotherapy has contributed to better recognition, assessment and outcomes. Although OCD is a relatively homogenous disorder with similar symptom dimensions globally, individualized assessment of symptoms, the degree of insight, and the extent of comorbidity is needed. Several neurobiological mechanisms underlying OCD have been identified, including specific brain circuits that underpin OCD. In addition, laboratory models have demonstrated how cellular and molecular dysfunction underpins repetitive stereotyped behaviours, and the genetic architecture of OCD is increasingly understood. Effective treatments for OCD include serotonin reuptake inhibitors and cognitive-behavioural therapy, and neurosurgery for those with intractable symptoms. Integration of global mental health and translational neuroscience approaches could further advance knowledge on OCD and improve clinical outcomes.

Obsessive-Compulsive Disorder in Paediatric and Adult Samples: Nature, Treatment and Cognitive Processes. A Review of the Theoretical and Empirical Literature

The appraisal model of obsessive-compulsive disorder (OCD) suggests that six key appraisal domains contribute to the aetiology and maintenance of OCD symptoms. An accumulating body of evidence supports this notion and suggests that modifying cognitive appraisals may be beneficial in reducing obsessive-compulsive symptomatology. This literature review first summarises the nature of OCD and its treatment, followed by a summary of the existing correlational and experimental research on the role of cognitive appraisal processes in OCD across both adult and paediatric samples. While correlational data provide some support for the relationship between cognitive appraisal domains and OCD symptoms, results are inconclusive, and experimental methods are warranted to determine the precise causal relationship between specific cognitive appraisal domains and OCD symptoms.

Vigour in active avoidance

It would be maladaptive to learn about catastrophes by trial and error alone. Investment in planning and effort are necessary. Devoting too many resources to averting disaster, however, can impair quality of life, as in anxiety and paranoia. Here, we developed a novel task to explore how people adjust effort expenditure (vigor) so as to avoid negative consequences. Our novel paradigm is immersive, enabling us to measure vigor in the context of (simulated) disaster. We found that participants (N = 118) exerted effort to avoid disaster-associated states, adjusting their effort expenditure according to the baseline probability of catastrophe, in agreement with theoretical predictions. Furthermore, negative subjective emotional states were associated both with threat level and with increasing vigor in the face of disaster. We describe for the first time effort expenditure in the context of irreversible losses, with important implications for disorders marked by excessive avoidance.

Treatment of Obsessive Thoughts and Cognitive Rituals Using Exposure and Response Prevention

This case study describes the application of cognitive-behavioral therapy by exposure and response prevention (EX/RP) to a young man with obsessive-compulsive disorder (OCD) involving primarily obsessional thoughts and mental rituals. Although patients with primarily cognitive OCD symptoms have been previously considered treatment resistant, novel approaches to EX/RP have been developed and validated. Successful treatment of such symptoms requires a thorough and informed assessment. The theoretical and empirical basis for these procedures is described, along with a cognitive-behavioral analysis of the problem. The course of treatment, use of assessment data, and recommendations to clinicians are also discussed.

An update on the efficacy of psychological therapies in the treatment of obsessive-compulsive disorder in adults

We conducted a review to provide an update on the efficacy of psychological treatments for OCD in general and with regard to specific symptom presentations. The PubMed and PsycINFO databases were searched for randomized controlled trials (RCTs) published up to mid February 2012. Forty-five such studies were identified. Exposure and response prevention (ERP) and cognitive-behavioral therapy (CBT) were found to be efficacious and specific for OCD. More purely cognitive interventions that did not include ERP or behavioral experiments were found to be possibly efficacious, as were Acceptance and Commitment Therapy, Motivational Interviewing as an adjunct to the established treatments, Eye Movement Desensitization and Reprocessing, and Satiation Therapy. There was little support for Stress Management or Psychodynamic Therapy. Although the majority of the studies recruited mixed or unspecified samples of patients and did not test for moderation, CBT was efficacious for obsessional patients who lacked overt rituals. One more purely cognitive intervention named Danger Ideation Reduction Therapy was found to be possibly efficacious for patients with contamination obsessions and washing compulsions. Although ERP and CBT are the best established psychological treatments for OCD, further research is needed to help elucidate which treatments are most effective for different OCD presentations.

Brain functional connectivity during induced sadness in patients with obsessive-compulsive disorder

BACKGROUND

Obsessive-compulsive disorder (OCD) is associated with a range of emotional abnormalities linked to its defining symptoms, comorbid illnesses and cognitive deficits. The aim of this preliminary study was to examine functional changes in the brain that are associated with experimentally induced sad mood in patients with OCD compared with healthy controls in a frontolimbic circuit relevant to both OCD and mood regulation.

METHODS

Participants underwent a validated sad mood induction procedure during functional magnetic resonance imaging. Analyses focused on mapping changes in the functional connectivity of the subgenual anterior cingulate cortex (ACC) within and between the 2 groups in response to successfully induced sadness.

RESULTS

We enrolled 11 patients with OCD and 10 age-, sex- and IQ-matched controls in our study. Unlike controls, patients with OCD did not demonstrate predicted increases in functional connectivity between the subgenual ACC and other frontal regions during mood induction. Instead, patients demonstrated heightened connectivity between the subgenual ACC and ventral caudate/nucleus accumbens region and the hypothalamus.

LIMITATIONS

Our study included a small, partially medicated patient cohort that precluded our ability to investigate sex or drug effects, evaluate behavioural differences between the groups and perform a whole-brain analysis.

CONCLUSION

The ventral striatum and ventral frontal cortex were distinctly and differentially modulated in their connectivity with the subgenual ACC during the experience of sad mood in patients with OCD. These results suggest that, in patients with OCD, induced sadness appears to have provoked a primary subcortical component of the hypothesized "OCD circuit," which may offer insights into why OCD symptoms tend to develop and worsen during disturbed emotional states.

Obsessions and Compulsions Are Associated With Different Cognitive and Mood Factors

This study examined whether nonclinical obsessions and nonclinical compulsions relate differently to cognitive and mood factors such as responsibility, perfectionism, trait anxiety and depressed mood. Two hundred and three nonclinical undergraduate psychology students (70.4% females, 29.6% males, mean age = 18.7,SD= 1.1) completed questionnaires. After controlling for the relationship between obsessions and compulsions, obsessions were found to relate significantly more strongly to depressed mood, trait anxiety, socially prescribed perfectionism and responsibility than compulsions. Conversely, compulsions were found to relate more strongly to self-oriented perfectionism than obsessions. These results were interpreted as providing support for the notion that obsessive-compulsive disorder (OCD) is maintained by a conflicted mental representation of the self and the world. Obsessions were interpreted as reflecting an overdeveloped vigilance for threat, responsibility and need for social approval. Compulsions were interpreted as emanating from the belief that the self is self-sufficient and resourceful, and that the world is ordered and systematic. Implications for the treatment of OCD were discussed.

A Comparison of Checking-related Beliefs in Individuals with Obsessive Compulsive Disorder and Normal Controls

The potential roles of perceived danger, responsibility, thought-action fusion, confidence in memory, intolerance of uncertainty and need to control one's thoughts in mediating compulsive checking were examined. Belief ratings were obtained from 21 individuals with compulsive checking concerns and 21 nonclinical controls about the most prominent checking concern of each individual with obsessive compulsive disorder (OCD), with controls being yoked to individuals with OCD on the basis of gender and age. If control participants and individuals with OCD have some similar beliefs regarding, for example, locking their front door, then it follows that those beliefs are unlikely to be mediating or driving the disorder. Large and significant differences were found between sufferers of OCD and nonclinical controls on ratings of beliefs concerning the probability and severity of harm, intolerance of uncertainty and the need to control thoughts. However, no differences were found between individuals with OCD checking concerns and nonclinical controls in ratings of beliefs concerning perceived personal responsibility, thought-action fusion (TAF) and confidence in memory. The findings concerning personal responsibility are of particular interest and suggest that perceptions of harm or a negative outcome may be a necessary precursor to perceptions of responsibility and the decision to act.

Differences and similarities between obsessive and ruminative thoughts in obsessive-compulsive and depressed patients: a comparative study

Repetitive, intrusive cognitive phenomena are central both to obsessive-compulsive patients - typically as obsessive thoughts - and to depressed patients - typically as ruminative thoughts. The objective of the present study is to compare obsessive and ruminative thoughts in non-depressed obsessive-compulsive and depressed patients. Thirty-four patients diagnosed with obsessive-compulsive disorder and 34 patients diagnosed with major depression disorder were asked to identify both a personally relevant obsessive and a personally relevant ruminative thought and to subsequently evaluate these thoughts on a modified version of the Cognitive Intrusions Questionnaire (CIQ) developed by Freeston, Ladouceur, Thibodeau, and Gagnon (1991). The CIQ assesses general descriptors, emotional reactions, appraisal and coping strategies on a nine-point Likert scale. A mixed-model ANOVA demonstrated that obsessive and ruminative thoughts are distinct cognitive processes, clearly distinguishable in form, appraisal and temporal orientation across disorders. In obsessive-compulsive patients, ruminative thoughts were more common and more emotionally distressing than predicted. In depressed patients, obsessive thoughts occurred infrequently and were not associated with high negative emotions. Clarifying similarities and differences between ruminative and obsessive thoughts and understanding their interaction might ultimately help to expand on the role of cognitive vulnerability factors in obsessive-compulsive and major depression disorder.

Prevalence and clinical characteristics of mental rituals in a longitudinal clinical sample of obsessive-compulsive disorder

BACKGROUND

Obsessive-compulsive disorder (OCD) is a chronic and debilitating anxiety disorder associated with significant impairment in quality of life and functioning. Research examining the differences in clinical correlates and treatment response associated with different obsessions in OCD has yielded important findings underscoring the heterogeneous nature of this disorder. To date, most of this research has focused on differences associated with primary obsessions, and little attention has been paid to the clinical utility of studying how compulsive symptoms affect clinical course. Virtually no systematic research has explored the clinical characteristics of one understudied symptom presentation, mental rituals, and what impact this primary symptom has on severity and course of illness. Mental rituals, or compulsions without overt signs, represent unique clinical challenges but often go understudied for numerous methodological and clinical reasons.

METHODS

In this study, we explored the impact of primary mental rituals on clinical severity and chronicity in a large, longitudinal sample of OCD patients (N = 225) over 4 years.

RESULTS

Mental rituals were a primary presenting symptom for a sizable percentage of the sample (12.9%). Primary mental rituals were associated with greater clinical severity and lower functioning at intake, as well as a more chronic course of illness, as participants with primary mental rituals spent nearly 1 year longer in full DSM-IV criteria episodes over the 4-year follow-up interval than OCD patients without mental rituals.

CONCLUSIONS

These results suggest that mental rituals are uniquely impairing and highlight the need for further empirical exploration and consideration in treatment.

Distress From Sexual Thoughts: Do Religiosity, Emotions, and Thought Appraisal Matter?

Sexually intrusive thoughts (SITs) are commonly experienced; yet, there is a paucity of research on distress related to them. Given that the content is similar for intrusive thoughts and obsessions, examining factors related to obsessions in obsessive-compulsive disorder (e.g., thought appraisal and relationships to emotions) may help explain distress from SITs in nonclinical populations. Differences in affective experiences and religiosity may also explain variations in distress from SITs. Nonclinical participants (N = 291) completed questionnaires about frequency of, and distress from, SITs, thought appraisal, beliefs about sexual desire, and emotions. Distress from SITs was correlated with thought appraisal and beliefs about sexual desire, but not with religiosity. In regression analyses, beliefs about sexual desire and the frequency of SITs each predicted distress from SITs. Although thought appraisal is often implicated in obsessive-compulsive symptoms, these results indicate that beliefs about emotions may have a greater impact on distress.

Treatment of Obsessions: Relevant v. Irrelevant Exposure

Six patients suffering from obsessional ruminations were treated with prolonged exposure in imagination. Two variants were compared in a cross-over design: (1) relevant exposure, consisting of exposure to the obsessions and (2) irrelevant exposure, consisting of exposure to ordinary frightening experiences. Relevant exposure proved to be significantly superior to irrelevant exposure. The data of this study suggest that habituation training by means of prolonged exposure to obsessions is a valuable treatment but not the panacea for the treatment of obsessional ruminations.

The Relationship Between Obsessional Problems and Intrusive Thoughts

According to the cognitive theory, obsessional problems occur when the occurrence and/or content of intrusive thoughts are interpreted as a sign of increased personal responsibility for some harmful outcome to oneself or others. The link between normal intrusive thoughts and obsessional thoughts is outlined. Current definitions of “neutralizing” and “responsibility” within the cognitive framework are examined and clarified. Responsibility-driven attempts to control cognitive activity explain obsessional and compulsive phenomena better than generalized deficit models. Recent descriptions of “meta-cognitive” factors in obsessions echo the existing cognitive model and have similar implications. An extension of the cognitive-behavioural model suggests a link between thought suppression and the perception of responsibility and to concerns about failure to act (omissions).

Rapid Audio-tape Treatment of Obsessional Ruminations. A Case Report

An audio-tape technique was used in the treatment of a 35-year-old male with a 13 year history of obsessional rituals and ruminations. His rituals responded to exposure and self-imposed response prevention but the ruminations remained as before.

The audio-tape treatment, which involved him listening to his own voice reciting his ruminative content, resulted in a rapid and substantial reduction in frequency of ruminations and this was maintained to one month follow-up.

The clinical and theoretical implications of this treatment approach are discussed.

Thought Suppression Induces Intrusions

An experiment was conducted to investigate whether deliberate attempts to avoid a thought content have paradoxical effects. Twenty-four Ss received thought suppression instructions, 16 neutral instructions. Thought suppression resulted in an increased number of occurrences of the thought to be suppressed. The contribution of the results to the theory of obsessions is discussed.

Autogenous and reactive obsessions: further evidence for a two-factor model of obsessions

Obsessive-compulsive disorder is a highly disabling anxiety disorder, characterized by occurrence of intrusive and unwanted thoughts (obsessions), which lead to performance of repetitive compulsions and/or rituals in order to reduce distress. Recently, it has been proposed that obsessions may be divided into two categories, termed autogenous and reactive obsessions [Lee, H.-J., & Kwon, S.-M. (2003). Two different types of obsessions: autogenous obsessions and reactive obsessions. Behavior Research and Therapy, 41, 11-29]. In this study, we aimed to further validate this subtyping of obsessions, and to investigate the cognitive and emotional correlates of the subtypes. Evidence was found for the division, using a confirmatory factor analysis in an analogue sample (N=372). It was found that frequency of reactive obsessions related more strongly to distress caused by overt OC symptoms (e.g., washing, checking), whereas frequency of autogenous obsessions related to distress from impulses of harm. Compared to autogenous obsessions, frequency of reactive obsessions correlated more strongly with all OC-related beliefs. Few differences were found between autogenous and reactive obsessions with respect to depression, anxiety, and view about self (self-ambivalence, self-esteem). It is suggested that existing OC-belief measures are more relevant to reactive obsessions. Implications for theory and treatment are discussed.

Intrusive thoughts, obsessions, and appraisals in obsessive–compulsive disorder: A critical review

This article reviews empirical findings on two key premises of the appraisal model of obsessive-compulsive disorder (OCD): (a) non-clinical populations experience intrusive thoughts (ITs) that are similar in form and in content to obsessions; and (b) ITs develop into obsessions because they are appraised according to dysfunctional beliefs. There is support for the universality of ITs. However, the samples used are not representative of the general population. IT measures do not relate systematically or exclusively to OCD symptom measures, and are not specific enough to exclude other types of intrusive thoughts such as negative automatic thoughts or worries, nor are they representative of all types of obsessions. When general distress is controlled, there is so far no evidence that participants with OCD endorse obsessive belief domains more strongly than anxious participants, and inconclusive evidence that OCD and non-clinical samples differ on the belief domains. Some OCD symptom subtypes are associated with belief domains. Currently, there is no coherent model to offer strong predictions about the specificity of the empirically derived belief domains in OCD symptom subtypes. Cognitive therapy based on the appraisal model is an effective treatment for OCD, although it does not add to the treatment efficacy of behaviour therapy. It is unclear how appraisals turn ITs into obsessions. Implications for future research are discussed.

Seeing White Bears That Are Not There: Inference Processes in Obsessions

Meta-cognition refers to the notion of thoughts about one’s own thoughts and has been defined as knowledge and cognition about cognitive phenomena (Flavell, 1979). In recent years, meta-cognitive models have provided accounts of the maintenance of anxiety disorders (e.g., Wells, 2000). Meta-cognitive models would argue that the thoughts about the appearance and utility of otherwise normal thoughts generate anxiety. In this article we apply a meta-cognitive approach to understanding obsessions but, rather than thoughts about thoughts, we suggest that the ruminations in obsessive-compulsive disorder (OCD) without overt compulsions result largely from thoughts about thoughts that do not actually occur. Persons with obsessions thinks they might have or might have had the thoughts, and through a meta-cognitive process termed “inferential confusion,” confuse these imagined thoughts with actual thoughts. This account would explain the repetitive, compulsive yet ego-dystonic nature of obsessions. The justification, provided by patients with OCD, for treating imaginary thoughts as actual thoughts appears to be an imaginary narrative, which produces and maintains the obsessional preoccupation, and seems imposed on reality by a distorted inductive reasoning process.

Cognitive analysis of unwanted intrusive thoughts and facial hair: an idea before its time?

Durac (1997, Behaviour Research and Therapy, 35, 371-372) recently attempted a cognitive analysis of unwanted intrusive thoughts and the growth of facial hair. Though provocative, there are a number of conceptual, methodological and clinical issues that are inadequately addressed by this paper. Based on a thorough reading of a relevant body of literature from 1963 to 1994, five issues are addressed in a hirsute manner: (1) the origin of the phenomenon, (2) behavioral analysis of unwanted intrusive thoughts and the growth of facial hair (UIFHG), (3) the role of behavioral exercises in the disappearance of unwanted facial hair, (4) the serotonin connection underlying this disorder, and (5) ethical concerns in the treatment of UIFHG. Finally, important theoretical and clinical implications of the cognitive model are not discussed here: they will be reported elsewhere in a more extensive analysis.

A cognitive theory of obsessions

It is proposed that obsessions are caused by catastrophic misinterpretations of the significance of one's thoughts (images, impulses). The obsessions persist as long as these misinterpretations continue and diminish when the misinterpretations are weakened. Evidence and arguments in support of the theory are presented, and the questions of vulnerability and the origins of the thoughts are addressed. A firmly focused treatment strategy is deduced from the theory.

What do patients do with their obsessive thoughts?

Current models of Obsessive-Compulsive Disorder (OCD) accord a key role to neutralization in the maintenance of obsessional thoughts. Although overt compulsions are well known and have frequently been described in the literature, their cognitive equivalents have not been described to any great extent. This study systemically described the repertoire of strategies used by 29 OCD patients with dominant obsessive thoughts. Extensive repertoires were reported, characterized by low to moderate mean efficacy in removing the thoughts. The majority of strategies were not cognitive rituals nor neutralization in the narrow sense of 'attempts at putting right', even though they were effortful, intentional, and deployed in a strategic way. The results are discussed in terms of the need for a broad definition of neutralization that includes all strategies including coping strategies. Clinical implications are discussed and comprehensive response prevention is recommended for the treatment of obsessive thoughts.

Morbid jealousy as a variant of obsessive-compulsive disorder

OBJECTIVE

To present a representative case vignette and review several previous reports, and to then suggest that a percentage of those with morbid jealousy may have a variant of obsessive-compulsive disorder (OCD).

CLINICAL PICTURE

A patient presented volunteering a diagnosis of depression and anxiety following recent work and marital stresses, before describing recent jealousy and harassment of his wife over an earlier relationship. Obsessional thinking patterns and compulsive behaviours are described, and it is proposed that the picture supports a diagnosis of obsessive-compulsive disorder.

TREATMENT AND OUTCOME

The patient was treated as if he had an obsessive-compulsive disorder, and reported dissipation of his concerns after cognitive-behavioural intervention.

CONCLUSIONS

The proposition is an important one as a diagnosis of morbid jealousy often invites therapeutic pessimism, and as managements effective for OCD (both drug and behavioural) may well be helpful.

The assessment of unwanted intrusive thoughts: a review and critique of the literature

In this paper we review the assessment and measurement of normal unwanted intrusive thoughts, images, and impulses that are considered the basis of clinical obsessions. After highlighting some difficulties with how the definition of cognitive intrusion has been applied to the development of assessment measures, we evaluate the construct validity of a number of retrospective self-report instruments such as the Intrusive Thoughts Questionnaire, Cognitive Intrusions Questionnaire, and Obsessional Intrusions Inventory, as well as interview and diary procedures. Measures of personal responsibility and meta-cognitive beliefs, which are still in the developmental phase, are also discussed. We conclude with a number of recommendations and areas of further research which would strengthen the construct validity of measures of intrusive thoughts and related constructs.

Personally relevant intrusions outside the laboratory: long-term suppression increases intrusion

It has been suggested that the suppression of unwanted thoughts may increase their frequency and that this effect may contribute to some psychological problems. Previous studies have examined this over a period of minutes, in an artificial setting. Suppression over a four day period was evaluated in the present study. Each S was asked to identify a negative intrusive thought which he or she experienced and to record each occurrence of it in conditions designed to maximise the similarity to those experienced by obsessional patients. Ss were randomly allocated to one of three groups. One group was asked to suppress their thoughts whenever they occurred, another group was asked to think about their thoughts whenever they occurred and the third group just recorded the thoughts whenever they occurred. This design allowed experimental control of both attention to and manipulation of the target thoughts in contrast to attention and active suppression. It was found that Ss who suppressed their thoughts experienced more thoughts and found them more uncomfortable than Ss in the other two groups. This is consistent with the theory that suppression increases thought frequency and may be important in the development and maintenance of some disorders.

Idiographic considerations in the behavioral treatment of obsessional thoughts

Despite impressive improvement in the behavioral treatment of obsessive-compulsive disorder over the last 15 years, progress has been slower for obsessional thoughts with few or no overt rituals. Encouraging case reports suggest that exposure to obsessional thoughts combined with covert response prevention is an effective treatment. Three cases are presented that required adaptation from the guidelines laid out by Salkovskis and Westbrook (1989). They provide clear evidence of the need to adopt a creative and flexible approach to exposure that enables access and activation of fear structures.

Do patients suffering from obsessions alone differ from other obsessive-compulsives?

The aim of this study was to determine whether a group of 48 patients with obsessions and compulsions differed from a group of 26 patients with obsessions alone, on the basis of demographic variables, variables relating to obsessive-compulsive neurosis, psychological variables and treatment outcome. It was found that they differed significantly in the following areas: marital status, level of education, age at onset of complaints, psychoactive medication taken when admitted for treatment, severity of obsessive-compulsive complaints, depression and intelligence. No difference was found as far as treatment outcome was concerned. Patients suffering from obsessions alone, would appear to form a distinct sub-group within the group of obsessive-compulsive patients as a whole.

Cognitive intrusions in a non-clinical population. II. Associations with depressive, anxious, and compulsive symptoms

The relationships between experimental dimensions of cognitive intrusions and depressive, anxious, and compulsive symptoms were studied among 125 university students. The students completed a questionnaire describing and evaluating seven cognitive intrusions and inventories of depressive, anxious, and compulsive symptoms. Principal component factor analysis on the 14 cognitive intrusion questionnaire dimensions identified five factors that were interpreted as general distress, evaluation, control, diversity and attention. Hierarchical regression analysis showed that effortful strategies in response to cognitive intrusions, general distress and diversity were predictors of both Beck Depression and Beck Anxiety Inventory scores. The evaluation factor consisting of perceived responsibility, disapproval and guilt ratings was also associated with depression and was the only significant predictor of Compulsive Activity Checklist scores. The control factor, consisting of items describing successful application of response strategies, was negatively related to BAI scores. The results are discussed as providing support for Salkovskis' formulation of obsessive-compulsive disorder.

Salkovskis on obsessional-compulsive neurosis: a critique

Salkovskis (Behav. Res. Ther. 23, 571-583, 1985) offers of cognitive-behavioural analysis of obsessional-compulsive disorder and the treatment implications of the analysis are discussed by Salkovskis (1985) and Salkovskis and Warwick (Behav. Psychother. 13, 243-255, 1985). A number of criticisms and objections to this work are set out.

Illness-related worry among cancer patients: prevalence, severity, and content

The present study assessed the prevalence, severity, and other parameters of illness-related worry among 83 cancer patients receiving active treatment for their illness. Participants completed questionnaires assessing a variety of worry dimensions. In addition, a family member of each patient completed a brief questionnaire regarding their perception of the patient's illness-related worry. Nurse ratings of patients' clinic-related behaviors were obtained. Fifty-one percent (n = 43) of patients reported worry to be at least "somewhat of a problem." Fifteen percent (n = 12) reported it to be a significant to severe problem. Significant correlations included patients self-rating of worry and: nurse rating of clinic behavior, total score on a Worry Content Scale, ability to stop worrying once started, and impact of worry on mood and functioning. Rating by the significant other of how much of a problem worry was for the patient and whether the patient was a worrier preillness was also significantly correlated. There were no significant differences between "worriers" and "nonworriers" on demographic or disease variables. A logistic regression model using the categories of "worries" or "nonworriers" as a dependent variable found that women and patients reporting poor social support were more likely to report a problem with worry. However, a large amount of the variance remained unexplained.

The relationship among guilt, dysphoria, anxiety and obsessions in a normal population

Seventy-six college students reported intrusive thoughts and impulses on a checklist. These students also completed questionnaires assessing depression, trait anxiety and perceived guilt. Results indicated for this normal population that intrusive thoughts were more distressful, more difficult to dismiss and occur with a greater variety of content compared to intrusive impulses. Multiple regression analysis showed that guilt was the best predictor of intrusive thoughts and impulses. Self-reported depression and anxiety were not strong predictors with respect to nonclinical obsessions and impulses. Discussion focuses on the utility of assessing guilt with obsessional disorders, the lack of a relationship between self-report trait anxiety and nonclinical obsessions, and the need to examine the relationship between guilt and anxiety with clinically obsessional subjects.

Obsessional symptomatology and adverse mood states

Patients suffering from obsessional neurosis without other psychiatric diagnosis were examined with reference to the association of the mood disorders of depression, anxiety, and outwardly and inwardly directed irritability. All mood disorders were common, and many occurred together in individual patients, but anxiety was the most prevelant. Inwardly directed irritability was significantly related to the overall severity of obsessions, and to the degree of handicap or interference in everyday life experienced by the patient.