Thought Content and Appraisals in Cognitive Behavioral Therapy for Obsessive-Compulsive Disorder

A premise for cognitive behavioral therapy (CBT) for obsessive-compulsive disorder (OCD) is that appraisal of obsessions maintains OCD symptoms whereas obsessive content is less important. The main aim of this study was therefore to explore this notion using the autogenous and reactive classification of obsessive content and by assessing changes in appraisals and symptoms following CBT for OCD. More specifically, the study investigates whether recovery from OCD is associated with changes in appraisal and explores how thought content relates to appraisal and symptoms both before and CBT. Data from 156 adults with OCD completing CBT for OCD were analyzed. Changes in appraisals were related to improvement in OCD symptoms. Slightly more participants reported reactive intrusions (47%) than autogenous (29%), but combinations of the two were common (24%). These classifications of thought content were not related to levels of appraisal or change in symptoms, with the exception of patients with autogenous thoughts who appraised their intrusions as more important than others. OCD is heterogeneous regarding thought content and strength of appraisals but can be quite homogeneous in terms of CBT treatment response. Also, and in line with cognitive theory, recovery from OCD is associated with changes in appraisals.Keywords: obsessive-compulsive disorder (OCD); cognitive behavioral therapy (CBT); intrusive thoughts; appraisal; cognition; metacognitionSeveral theories attempting to explain the pathogenesis and treatment of obsessive-compulsive disorder (OCD) emphasize the importance of cognitive factors (Clark & Purdon, 1993; Rachman, 1997; Salkovskis, 1985). These theories have often been termed appraisal theories given the significance of subjective interpretation of intrusions. Appraisal theories postulate that intrusions can be placed on a dimension of normal cognitive phenomenon and that appraisal is partly derived from more enduring underlying beliefs and determine whether or not intrusions develop into clinical obsessions.Given the increasing number of cognitive theories hypothesizing the significance of beliefs and appraisals of intrusive thoughts in OCD as well as a lack of validated and reliable measures of these cognitive constructs, the Obsessive-Compulsive Cognitions Working Group (OCCWG; 1997, 2001, 2003, 2005) developed the Obsessive Beliefs Questionnaire (OBQ) and the Interpretation of Intrusions Inventory (III). In contrast to the OBQ, which was designed to assess general beliefs relevant to OCD, the III is a semi-idiographic self-report questionnaire designed to measure immediate appraisals or interpretations of intrusions (OCCWG, 1997, 2001). The III provides examples of intrusive thoughts and asks participants to list their two main intrusive thoughts. Appraisal of these two thoughts are measured using 31 items which were originally believed to reflect three theoretically derived domains important in understanding the etiology and persistence of OCD: (a) inflated responsibility, (b) overimportance of thoughts, and (c) excessive concern about the importance of controlling one's thoughts.Inflated responsibility refers to beliefs and appraisals of intrusions that one has power to both create and avert negative outcomes (OCCWG, 1997) and is largely based on the inflated responsibility theory developed by Salkovskis (1985). The theory proposes that normal unwanted intrusive thoughts will develop into clinical obsessions only if the trigger thoughts are appraised or interpreted as indicating personal responsibility. Overimportance of thoughts refers to the beliefs and appraisals concerning that "the mere presence of a thought indicates that it is important" (OCCWG, 1997, p. 678) and is largely based on the misinterpretation of significance theory developed by Rachman (1997). Control of thoughts refers to the tendency to overestimate the significance of controlling one's thoughts and that this is attainable and desirable (OCCWG, 1997) and is largely based on the cognitive control theory developed by Clark and Purdon (Clark & Purdon, 1993; Purdon & Clark, 1994). …