Reasoning processes in the development and maintenance of obsessive-compulsive disorder

Cognitive distortions and beliefs have been found to be associated with obsessive-compulsive disorder. Most of these beliefs and cognitive distortions are supposed to be non-specifically related to obsessivecompulsive behaviour in general, rather than specific domains of belief being related to specific forms of obsessive-compulsive behaviours. In this study 305 subjects from the community completed a number of questionnaires assessing specific belief domains, obsessive-compulsive behaviour (PaduaR) and depressed mood (CES-D). Multiple regression analyses provided support for the notion that specific beliefs are associated with specific forms of obsessive-compulsive behaviour (i.e. washing, checking, precision, rumination and impulses). Further, as expected, meta-cognitive beliefs or distortions such as Thought-Action Fusion and Inverse Inference were found to be related to most forms of obsessive-compulsive behaviour. Depressed mood did not affect the results substantially. 1 Emmelkamp, P. M. G. and Aardema, F. (1999). Metacognition, specific obsessivecompulsive beliefs and obsessive-compulsive behaviour. Clinical Psychology and Psychotherapy, 6, 139-145. © John Wiley and sons Ltd. Reproduced with permission. Cognitive distortions and beliefs in obsessive-compulsive symptoms 23 INTRODUCTION In the last decade an increasing number of studies have focused on beliefs and cognitive processes characteristic of obsessive-compulsive patients. A number of belief domains appear to be particularly relevant to obsessive-compulsive disorder (OCD), including specific obsessivecompulsive beliefs and meta-cognitive beliefs (Nelson, Stuart, Howard & Crowley, 1999). Several authors attribute an important role to inflated responsibility in OCD, particularly in checking (e.g. Salkovskis, 1985; Rachman, 1993; van Oppen & Arntz, 1995) which was indeed supported in several experimental studies (e.g. Ladouceur, Rheaume, Freeston, Aublet, Jean, Lachance, Langlois & De Pokomandy-Morin, 1995; Lopatka & Rachman, 1985). Further, responsibility was significantly correlated with obsessive-compulsive behaviour (Rheaume, Freeston, Dugas, Letarte & Ladouceur, 1995; Rheaume, Ladouceur, Freeston, Letarte, 1995). Inflated responsibility may be related to a lack of attributional processes characteristic of normal individuals originally described by Spranca, Minsk & Baron (1991). In contrast to non-OCD patients, who hold that they are to blame for errors of commission, rather than for errors of omission, OCD patients are supposed to believe that they are equally culpable for errors of omission as for errors of commission (OCCWG, 1997). Another cognitive belief described as Thought-Action Fusion (TAF) is defined as the belief that (one’s) specific intrusive thoughts can directly influence the relevant external event and/or the belief that having these intrusive thoughts is morally equivalent to carrying out a prohibited action (Rachman & Shafran, 1999). TAF was found to correlate significantly with measures of obsessionality, guilt and depression (Rachman, Thordarson, Shafran & Woody, 1995). Others have argued that OCD is related to perfectionism, but there is no evidence for the discriminability of measures of perfectionism across different patient categories. Although there is a relationship between OCD and perfectionism (Rheaume, Freeston, Dugas, Letarte & Ladouceur, 1995a; Frost & Steketee, 1997) this is not specific to OCD, since perfectionism has also been found to be related to performance anxiety (Mor, Day, Flet & Hewitt, 1995), social phobia (Juster, Heimberg, Frost, Holt, Cognitive distortions and beliefs in obsessive-compulsive symptoms 24 Mattia & Facenda, 1996), panic disorder (Frost & Steketee, 1997), anorexia nervosa (Bastiani, Rao, Weltzin & Kaye, 1995) and depression (Hewitt & Flett, 1991). It does seem that perfectionism is a dispositional trait for the development of psychopathology in general, rather than for obsessivecompulsive disorder in particular. Indecisiveness has also been suggested to be related to obsessive-compulsive disorder (see e.g. Reed, 1985), but results are as yet inconclusive (Frost & Shows, 1993). In a study of Frost & Shows (1993) indecisiveness was found to be related perfectionism, hoarding, compulsivity and procrastination, Although it has been suggested over the years that Magical Thinking is related to obsessive-compulsive behaviour (see e.g. Saltzman, 1968), few studies have addressed this issue directly. However, Leonard, Goldberger, Rapoport, Cheslow & Swedo (1990) found obsessive-compulsive children to hold more superstitious beliefs than non-clinical groups. Further, Frost, Steketee, Cohn & Griess (1994) found that compulsive checking but not compulsive cleaning was related to Magical Thinking. Aversion to risk taking and guilt have also been found to be related to OCD (Frost, Steketee, Cohn & Griess, 1994). Finally, Purdon & Clark (1999) suggest that obsessional individuals hold dysfunctional beliefs concerning the need to control thoughts. In recent years two other related cognitive distortions have been proposed: Pollution of the Mind (Rachman, 1994) and Inferential Confusion (O’Connor & Robillard, 1995). Pollution of the Mind has been defined as a sense of internal uncleanness, which can and usually does arise and persist regardless of the presence or absence of external, observable dirt (Rachman, 1994, p. 311). O’Connor & Robillard (1995) emphasize distorted inference processes in understanding obsessive-compulsive thoughts and behaviors. They hold that obsessive-compulsive patients are characterized by inferring the plausibility of events on the basis of several reasoning distortions, which leads the person to confuse what might be there (a probability), what is actually there (a certainty), and what is purely imaginary (a fictitious entity. A crucial aspect of the reasoning errors characterizing inferential confusion is inverse inference – an inverse type of reasoning where the person does not start out with the senses in reaching an obsessional inference or doubt, but instead comes to infer this doubt without any actual indication of it being present or even in contradiction to what is seen or sensed. The hypothesis with respect to the importance of distorted Cognitive distortions and beliefs in obsessive-compulsive symptoms 25 inference processes such as Pollution of the Mind and Inverse Inference in obsessive-compulsive symptoms has not yet been tested. Most of the cognitive distortions and beliefs discussed above are supposed to be non-specifically related to obsessive-compulsive behaviour in general, rather than that specific domains of beliefs or cognitive processes are related to specific forms of obsessive-compulsive behaviour, i.e. washing, checking, impulsive behaviour, rumination and precision. The aim of the present study is a first attempt to examine whether specific cognitive domains are related to specific obsessive-compulsive behaviours. More specifically, one would expect that metacognitve beliefs or distortions such as Thought-Action Fusion, Inferential Confusion, and beliefs about consequences of thoughts (thought appraisal) would be related to obsessive-compulsive behaviour irrespective of the form (Wells & Papageorgiou, 1997). Further, one would expect specific patterns between Inflated Responsibility and checking on the one hand and Pollution of the Mind and washing on the other.

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