Obsessional Problems Research Articles

An experimental study in community volunteers of the effects of focusing on views about seeking help for obsessional problems

People typically delay many years after developing OCD before they seek help. Factors linked to the decision whether to seek treatment have been identified. Decision-making literature suggests that outcomes of decision making are related to the factors which form the focus of attention and awareness. We evaluated whether focussing on enablers for treatment seeking has an impact on predictions of key treatment seeking behaviours in community controls, examining the likelihood of hypothetically seeking treatment. Participants (125) completed a focussing intervention where they were asked to rate how likely they would be to seek help before and after reading and rating for self-applicability specific information designed to focus their attention either on (a) ‘enabler’ factors taken from previous research or (b) on general information about OCD and its treatment.Findings indicated that focussing on either type of information increased the likelihood of hypothetically seeking treatment, with the enabler information facilitating greater increases in the likelihood of active treatment seeking.Health education efforts for those delaying seeking help for mental health difficulties such as OCD may benefit from more specific attention to increasing the salience of treatment enablers as well as problem specific information.

A network perspective on comorbid depression in adolescents with obsessive-compulsive disorder

People with obsessive-compulsive disorder [OCD] frequently suffer from depression, a comorbidity associated with greater symptom severity and suicide risk. We examined the associations between OCD and depression symptoms in 87 adolescents with primary OCD. We computed an association network, a graphical LASSO, and a directed acyclic graph (DAG) to model symptom interactions. Models showed OCD and depression as separate syndromes linked by bridge symptoms. Bridges between the two disorders emerged between obsessional problems in the OCD syndrome, and guilt, concentration problems, and sadness in the depression syndrome. A directed network indicated that OCD symptoms directionally precede depression symptoms. Concentration impairment emerged as a highly central node that may be distinctive to adolescents. We conclude that the network approach to mental disorders provides a new way to understand the etiology and maintenance of comorbid OCD-depression. Network analysis can improve research and treatment of mental disorder comorbidities by generating hypotheses concerning potential causal symptom structures and by identifying symptoms that may bridge disorders.

Does cognitive self-consciousness link older adults' cognitive functioning to obsessive-compulsive symptoms?

To elucidate how obsessional symptoms might develop or intensify in late-life, we tested a risk model. We posited that cognitive self-consciousness (CSC), a tendency to be aware of and monitor thinking, would increase reactivity to aging-related cognitive changes and mediate the relationship between cognitive functioning and obsessive-compulsive disorder (OCD) symptoms. Older adults (Mage = 76.7 years) completed the Dementia Rating Scale-2 (DRS-2), a CSC measure, and an OCD symptom measure up to four times over 18 months. A model that included DRS-2 age and education adjusted total score as the indicator of cognitive functioning fit the data well, and CSC score change mediated the relationship between initial cognitive functioning and changes in OCD symptoms. In tests of a model that included DRS-2 Initiation/Perseveration (I/P) and Conceptualization subscale scores, the model again fit the data well. Conceptualization scores, but not I/P scores, were related to later OCD symptoms, and change in CSC scores again mediated the relationship. Lower scores on initial cognitive functioning measures predicted increases in CSC scores over time, which in turn predicted increases in OCD symptoms over the 18 months of the study. Implications for understanding late-life obsessional problems are discussed.

Still Cognitive After All These Years? Perspectives for a Cognitive Behavioural Theory of Obsessions and Where We Are 30 Years Later: A Commentary

Salkovskis and Millar (this issue) observe a number of shortcomings in our paper entitled “New Perspectives for a Cognitive Theory of Obsessions” (Clark & Purdon, 1993), which include: (a) an under‐emphasis on the role of responsibility, (b) an under‐emphasis on the influence of neutralisation; and (c) an over‐emphasis on the relative importance of mental control in the pathogenesis of obsessions. They also contend that our emphasis on ego‐dystonicity as a defining feature of obsessions has been discredited. We agree that certain aspects of our original cognitive model of obsessions may have been overstated in light of the past 22 years of research but several key points have been upheld, especially the importance of failed mental control in the persistence of obsessional problems. This paper addresses each of these criticisms in turn.

An observational study of parent–child behaviours in paediatric OCD: Examining the origins of inflated responsibility

Inflated responsibility is a well-established belief domain relevant to the development of obsessive–compulsive disorder (OCD), and is proposed to develop during childhood (Salkovskis, P.M., Shafran, R., Rachman, S., & Freeston, M.H. (1999). Multiple pathways to inflated responsibility beliefs in obsessional problems: possible origins and implications for therapy and research. Behaviour Research and Therapy, 37(2), 1055–1072). However, parental enhancement of such beliefs have rarely been examined. This study explored the proposed pathways of development for responsibility biases in paediatric OCD by examining parent–child behaviours during a family discussion task. 24 children with OCD (mean age=12.96), 20 control children (mean age=13.13) and their parents participated in this study. Dyads discussed an ambiguous scenario for five minutes with the goal of finding a solution. Parent behaviours of autonomy granting and overinvolvement, as well as parent–child behaviours of warmth, withdrawal, aversiveness and confidence were independently coded along with parent and child enhancement of responsibility for solving the problem. Parents in OCD dyads were observed to be significantly more aversive than control parents. Children with OCD were significantly less warm and more withdrawn than control children. Irrespective of group membership, parents enhanced their child's responsibility more than their own when generating solutions. These findings add to the literature on parent–child variables that play a role in enhancing OCD related beliefs such as inflated responsibility.

Obsessive‐compulsive disorder in the DSM‐5.

Whereas the specific diagnostic criteria for obsessive-compulsive disorder (OCD) have changed in only minor ways in the transition from DSM-IV to DSM-5, a more substantial change is that OCD is no longer classified as an anxiety disorder. Rather, it is now the flagship diagnosis of a new diagnostic category: the obsessive-compulsive and related disorders (OCRDs). In this article, we describe the nature of obsessional problems as determined through empirical research before turning to a consideration of how OCD is defined in previous editions of the DSM and in DSM-5. We then critically consider the DSM criteria, as well as the basis for removing OCD from the anxiety disorders and creating the new OCRD category. Finally, we consider the implications of these changes for clinical practice and research on OCD.

The Appraisal of Intrusive Thoughts in Relation to Obsessional–Compulsive Symptoms

Research has shown that although intrusive thoughts occur universally, the majority of individuals do not view intrusive thoughts as being problematic (Freeston, Ladouceur, Thibodeau, & Gagnon, 1991; Rachman & de Silva, 1978; Salkovskis & Harrison, 1984). Thus, it is not the presence of intrusive thoughts that leads to obsessional problems but rather some other factor that plays a role in the development of abnormal obsessions. According to the cognitive model of obsessive–compulsive disorder (OCD) put forth by Salkovskis (1985), the crucial factor that differentiates between individuals with OCD and those without is the individual's appraisal of the naturally occurring intrusive thoughts. This study aimed to test Salkovskis's model by examining the role of cognitive biases (responsibility, thought–action fusion, and thought control) as well as distress in the relationship between intrusive thoughts and obsessive–compulsive symptoms in an undergraduate sample of 326 students. An existing measure of intrusive thoughts (the Revised Obsessional Intrusions Inventory) was modified for this study to include a scale of distress associated with each intrusive thought in addition to the current frequency scale. When the Yale-Brown Obsessive-Compulsive Scale was used as the measure of OCD symptoms, a significant interaction effect of frequency and distress of intrusive thoughts resulted. Additionally, a significant three-way interaction of Frequency × Distress × Responsibility was found when the Obsessive Compulsive Inventory–Revised was used as the measure of OCD symptoms. These results indicate that the appraisal of intrusive thoughts is important in predicting OCD symptoms, thus providing support for Salkovskis's model of OCD.

Evaluation of an In Vivo Measure of Thought–Action Fusion

Thought–action fusion (TAF) refers to maladaptive beliefs about the relationship between mental events and behaviors, and is associated with obsessional problems. Currently, the self-report Thought–Action Fusion Scale (TAFS) is the most widely used measure of TAF, but a single assessment modality limits research that can be conducted on this phenomenon. This study evaluated the validity of an in vivo paradigm that assesses both Moral TAF (the belief that thoughts are the moral equivalent of actions) and Likelihood TAF (the belief that thinking about a negative event increases the probability of the event itself). In this paradigm, participants were asked to contemplate two negative events involving a beloved relative: (a) I hope (relative) is in a car accident today and (b) I hope I have sex with (relative). Participants then provided in vivo ratings of anxiety, estimates of likelihood, and moral wrongness related to the negative thoughts. Results provided evidence for the convergent validity of the in vivo ratings for both sentences. These findings are discussed in terms of clinical care, the assessment of TAF, and the implications for future research on this theoretically important construct.

Development of a Measure of Egodystonicity

The term egodystonicity is a distinguishing feature of obsessional thoughts (American Psychiatric Association, 2000) but has not been consistently nor comprehensively defined. These two studies present the development and initial validation of the Ego-Dystonicity Questionnaire (EDQ). A definition of the term egodystonicity was developed, drawing from existing definitions and theoretical models of obsessive-compulsive disorder (OCD). An item pool was developed and refined through initial testing, the product of which was a 37-item self-report measure. Respondents identify a specific type of thought (e.g., their most upsetting obsession, most upsetting worry) and then answer each item with respect to that thought. In study 1, two nonclinical samples (N = 278) and one sample of individuals with OCD (N = 17) were administered the EDQ along with self-report measures of mood, personality, OCD symptoms, and appraisal of obsessional thoughts. A principal components analysis of the nonclinical sample yielded four factors. Scales based on these factors had acceptable internal reliability. The EDQ distinguished between obsessional thoughts and common worries, and individuals in the clinical sample had higher scores than the nonclinical sample. The EDQ showed low to moderate correlations with OCD symptoms, mood, and appraisal of obsessions but was not associated with personality traits such as neuroticism. In study 2, individuals with OCD (N = 28) completed the EDQ in reference to their most or least upsetting obsession. As predicted, egodystonicity varied according to obsession type. These data indicate that the EDQ is a valid measure with potential for use in understanding and treating obsessional problems.

Thought Control Strategies Used by Parents Reporting Postpartum Obsessions

Previous research has established that parents commonly experience intrusive harm-related thoughts pertaining to their infants (e.g., “My baby might die from SIDS”). Cognitive-behavioral models of obsessive-compulsive disorder (OCD) posit that maladaptive strategies for managing such thoughts play a role in the development and maintenance of obsessional problems. In the present study, we examined (1) the strategies parents used to manage unwanted infant-related thoughts and (2) the relationships between thought control strategies and obsessional and depressive symptoms. Non-treatment-seeking parents (n = 75) of healthy newborns completed measures of intrusive thoughts, thought control strategies, and obsessional and depressive symptoms. Mothers and fathers did not differ in their use of various thought control strategies. Strategies involving distraction, self-punishment, and reappraisal of the intrusive thought were positively related to the severity of obsessional symptoms. Punishment was also positively associated with depressive symptoms. Results are discussed in terms cognitive-behavioral models of OCD.

New parenthood as a risk factor for the development of obsessional problems

Research on emotional disturbance during pregnancy and the postpartum period has focused primarily on mood disorders and psychosis, yet preliminary evidence suggests that early parenthood is also associated with an increased risk for the development and exacerbation of obsessional problems. In this article we describe the nature of “postpartum obsessive-compulsive disorder” (ppOCD) and present a cognitive-behavioural model to account for these signs and symptoms. The model outlines features of early parenthood that might increase vulnerability to ppOCD and proposes a conceptual framework similar to that described in cognitive-behavioural models of OCD in general. The empirical status of the model described herein is discussed, along with suggestions for future research and implications for treatment.

Cognitive self-consciousness, implicit learning and obsessive–compulsive disorder

The negative appraisal of commonly experienced intrusive thoughts is posited to play an important role in obsessive–compulsive disorder (OCD), although why some people focus on thought experiences and have difficulties dismissing intrusions is not well understood. To elucidate how intrusive thoughts might become obsessional problems, relations between thought-focused attention (cognitive self-consciousness; CSC), implicit sequence learning and OCD were evaluated in individuals with OCD ( n = 43) and in a nonclinical comparison group ( n = 41). Impaired performance on a serial reaction time test, but enhanced recognition of the embedded stimulus pattern, was predicted for the OCD group based on hypothesized nonconscious processing differences. Predicted differences were found and CSC score predicted reaction time and pattern recognition. CSC might be a consequence of conscious processing gating problems that increase thought salience and the likelihood of the negative appraisal of intrusive thoughts. Implications for theory and treatment are discussed.

Life and Death Decisions: Psychological and Ethical Considerations in End-of-Life Care

Life and Death Decisions: Psychological and Ethical Considerations in End-of-Life Care

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.

Is thought–action fusion specific to obsessive–compulsive disorder?: a mediating role of negative affect

Thought–action fusion (TAF) is a cognitive bias presumed to underlie the development of obsessional problems (i.e. obsessive–compulsive disorder; OCD). Previous studies have found that TAF is related to not only OCD, but also to other anxiety disorders. In the present study we compared levels of TAF in OCD patients and in patients with other anxiety disorders, depression, and healthy controls to examine whether TAF is characteristic of individuals with emotional distress in general, as opposed to anxiety disorders per se. We also examined whether negative affect (i.e. anxiety and depression) mediates the relationship between OCD and TAF. Results indicated that OCD patients were characterized by higher scores on likelihood-self and likelihood-other TAF, but that this difference was predominately due to differences in negative affect. These findings support a model in which negative affect mediates the relationship between OCD and TAF.

Obsessional thoughts in postpartum females and their partners: Content, severity, and relationship with depression

Only a few studies have examined the development or exacerbation of obsessive–compulsive disorder (OCD) during pregnancy and the postpartum. Although the available literature suggests that OCD symptoms, particularly obsessional problems, develop at higher than expected rates among postpartum females, the overall prevalence of such symptoms in the postpartum remains unknown. Previous findings also suggest that intrusive distressing thoughts related to situational stressors are common in the general population. Therefore, the present study was designed to assess the presence and phenomenology of postpartum obsessive-like intrusive thoughts, images, and impulses in a large sample of parents with very young infants. Surveys were mailed to 300 childbearing women and their partners. Results were obtained from approximately one fifth of the sample; and 65% of respondents indicated the presence of obsessional intrusive thoughts. Intrusions were similar to “normal obsessions” as reported in previous research. Results are discussed in terms of the content of intrusive thoughts, their relationship to depression, and implications for etiological models of OCD and perinatal education.

Obsessions, compulsions, motivation, and responsibility for harm

In a recent critique of current cognitive approaches to obsessional problems, O'Kearney (1998) suggests that there are significant problems with the theory and seeks to propose an alternative conceptualisation. Cognitive theories of obsessive-compulsive disorder (OCD) are criticised because he believes them (a) to be silent on motivational components specific to the disorder, (b) to not adequately explain why people are upset by their negative evaluation of intrusive thoughts, (c) to not provide an adequate account of the compulsive and repetitive quality of obsessional symptoms, and (d) to disregard the emotional concerns of the sufferer as influential factors in the etiology and maintenance of the disorder. We argue in this paper that O'Kearney's critique is mistaken as all of these issues are adequately addressed by current cognitive theorising. Specifically, we point out that (a) motivation is a central and crucial aspect of cognitive theories of anxiety disorders, (b) the link between responsibility beliefs concerning subjectively crucial negative events and distress is understandable, (c) compulsiveness and repetitiveness are readily accounted for by the cognitive theory, and (d) the cognitive theory regards the emotional concerns of the sufferer as central issues in both the etiology and maintenance of obsessional problems. Careful examination of O'Kearney's alternative theory suggests that it is inconsistent with both research evidence and the phenomenology of OCD. Further, as a heuristic for the treatment of OCD his account is, at best, of no value in bringing about change in the way in which patients react to their problems, and at worst may lead the therapists in directions that may prove to be counterproductive for their patients.

The thought-action fusion scale: further evidence for its reliability and validity

Thought-action fusion (TAF) refers to a set of cognitive biases that are thought to play a role in the development of obsessional phenomena. To measure these biases, R. Shafran, D. S. Thordarson, and S. Rachman (1996; Journal of Anxiety Disorders, 10, 379–391) developed the TAF-scale. They concluded that the TAF-scale possesses adequate psychometric qualities. The current study sought to further explore the reliability and validity of the TAF-scale. Results indicate that the TAF-scale has good internal consistency. TAF-scores correlated with self-reports of obsessional problems. Furthermore, mean scores in a mixed sample of anxiety disordered patients were higher than those in a normal sample. However, temporal consistency was somewhat disappointing. Also, the question remains whether TAF is specific to obsessive–compulsive disorder or taps more pervasive biases that play a role in a variety of disorders.

Causing harm and allowing harm: a study of beliefs in obsessional problems

This study investigates two factors hypothesised as relevant to obsessional problems because of the way in which they influence decisions whether or not to act to prevent harm. These are (i) the way in which intrusive thoughts increase the internal awareness of harm, and confront the person with the possibility of taking action to prevent such harm and (ii) the extent to which there is some obvious external factor which increases awareness of the possibility of preventing harm. Obsessional patients, anxious and non-clinical controls completed a scale which systematically measured these factors across a wide range of situations. Results across all situations evaluated confirmed previous findings that both obsessionals and nonobsessionals were more likely to report acting to prevent harm when awareness of it is prompted by an intrusion than when it is not. It was also found that participants in all groups acted more ‘obsessionally’ when a scenario is described in ways which suggest that harm may be by ‘commission’ than when it is described in terms of an ‘omission’. When scenarios about which each individual is most disturbed were analysed, anxious and non-clinical controls continued to differentially rate omission and commission situations; as predicted, this differential was not present for obsessional patients. It is concluded that obsessionals are more sensitive to omission than are nonobsessionals when considering scenarios about which they are concerned, and that this sensitivity is one factor influencing the decision whether to act to prevent harm.

White bears and other elusive intrusions. Assessing the relevance of thought suppression for obsessional phenomena.

According to recent research, deliberate suppression of unwanted thoughts may result in a paradoxical increase in their frequency. Recent cognitive-behavioral theories of obsessive-compulsive disorder now consider active thought suppression to be a crucial factor in the pathogenesis of obsessions. However, there are considerable inconsistencies in the results of studies investigating the thought suppression paradox that make it difficult to apply findings to obsessional problems. Furthermore, many studies have low ecological validity for obsessional problems. This article reviews the thought suppression research, discusses methodological issues relevant to application of the thought suppression paradox to obsessional problems, and offers recommendations for future research.