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

doi:10.1016/j.cpr.2006.12.004

Clinical Psychology Review

Volume 27, Issue 3, April 2007, Pages 366-383

https://doi.org/10.1016/j.cpr.2006.12.004 Get rights and content

Abstract

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.

Section snippets

First condition: universality of ITs in non-clinical samples

According to the appraisal model, the majority of the people experience ITs from time to time. We conducted a review of the literature via PsycINFO database, using such search words as intrusive thoughts, intrusions, cognitive intrusions, unwanted thoughts, and normal obsessions. Thirteen studies investigating the occurrence of ITs in non-clinical populations were found (Edwards & Dickerson, 1987, England & Dickerson, 1988, Freeston et al., 1991, Niler & Beck, 1989, Parkinson & Rachman, 1981a,

Second key premise: the role of appraisals in the escalation of ITs into obsessions

The OCCWG (1997) originally concluded that six rationally derived belief domains were of central importance in OCD: (a) Inflated responsibility (belief that one has power that is pivotal to bring about or prevent subjectively crucial negative outcomes perceived as essential to prevent and that may have consequences in the real world and/or at a moral level); (b) overimportance of thoughts (belief that the mere presence of a thought indicates that it is important); (c) need to control thoughts

Clinical relevance of ITs to obsessional development

Most authors agree that the content of ITs and obsessions is similar. Experienced clinicians have shown difficulty discriminating ITs from obsessions purely on the basis of content (Rachman & de Silva, 1978). However, Warren et al. (2002) point out that in Rachman and de Silva' study, the accuracy of the raters ranged from 68 to 88%, and that the coefficient kappa ranged from .21 to .70. According to them, it could be argued from these figures that some clinicians can differentiate obsessions

Discussion

The aim of this article was to review two key premises of the appraisal model of OCD, namely that ITs are part of normal experience and that the interpretation given to the presence and content of ITs according to dysfunctional belief domains explains why ITs escalate into obsessions. Clearly, non-clinical populations present ITs similar to some obsessions encountered in OCD. However, ITs may not be that frequent, and the most common ITs seem to occur not more than a few times a year (Purdon &

Acknowledgments

This work was supported by grant number 8920 to the first author from the Fonds de la recherche en santé du Québec and by grant number 67059 to the second author from the Canadian Institutes of Health Research. The authors would like to thank Anick Laverdure for the translation of parts of the article.