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David Baxter

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Thinking the Unthinkable
by Steven Phillipson, Ph.D., Center for Cognitive-Behavioral Psychotherapy
Originally printed in the Obsessive-Compulsive Newsletter, 5 (4), 1991

As I conceptualize Obsessive-Compulsive Disorder, the tree of the overall syndrome has three main branches: the "obsessive-compulsive," the "responsibility O-C," and the focus of this paper, the purely obsessional thinker "Pure-O" (Baer, 1994). With this branch the anxiety emerges in response to an unwanted thought or question, which in the future will be referred to as a "spike." The ritual involves pushing away the thought, avoiding the recurrence of the thought, or attempting to solve the question. Keep in mind that most persons who come into therapy tend to have a combination of these problems. Successfully treating one branch typically has minimal effect on the others.

The "Pure-O" is manifested by a two part process: the originating unwanted thought (spike) and the mental activity which attempts to escape, solve, or undo the spike, called rumination. The following are examples of these varieties of spikes:

A man is involved in sexual relations with his female lover. Just prior to orgasm the thought of his friend Bob pops into his head. This is the fourth time in a month that this has happened. In response to this he becomes very upset and wonders whether he is gay. His sexual activity is terminated in order to avoid having to deal with this concern.

A mother is changing the diapers of her infant. As she lovingly looks down at this helpless child the thought occurs to her to "take a pillow and smother the child." In response to this thought, the mother panics and runs to another room to diminish the possibility of acting on this thought, since she figures that being able to think such a thing may be similar to acting on it.

For the "Pure-O" a tremendous amount of anxiety accompanies the spike, and the mental ritual is an attempt to shut off the anxiety, either by attempting to solve the question or avoid having the thought recur. It is during the rumination phase that the person's mind becomes extremely preoccupied and distracted. Spending eight hours a day with one's thoughts wrapped up with this endless mental escape is not unusual. The emotional pull to undue the thought is tremendous. Perhaps it would be comparable to what it would be like if a loved one were on a plane that crashed and all you knew was that there was a fifty percent survival rate. Imagine what it would be like if you were asked not to problem solve in an attempt to ascertain the condition of your loved one. A common misnomer among "Pure-O" sufferers is that they can mentally find the key to turn off the obsessing. It seems that with each new spike, if they could only get that perfect answer, the whole disorder would just vanish. A large majority are aware that this is an impossible task, but the temptation to unlock their mental chains is tremendous with each ensuing spike.

I've illustrated this endless cycle of spiking and ruminating in the accompanying diagram. Start out with the top left symbol, a circled "R". This represents a part of the brain that is creative and always on the lookout for pertinent information. I refer to this as the resource part of the brain. Proof of its existence lies in a phenomenon known as the "Tip-of-the-Tongue" effect (Brown & McNeil, 1966). I'm sure, on many occasions while searching for a name or significant memory, you have given up your active conscious search just to have it pop into your consciousness later while your mind is preoccupied with another topic. It would seem that there exists a non-conscious portion of the brain which searches out meaningful material and sends this information to one's consciousness if it deems this information as significant. Another aspect of the resource center is our brain's reliance on associations which facilitate information processing. An example of an association would be when the sight of a red light draws our attention that a hazard might exist. For the "Pure-O," the sight of a knife might spike the thought of stabbing a loved one. The resource center transmits information to our conscious awareness "C" as it deems material relevant or significant. It is at this juncture that most "Pure-O's" become fixated and distraught.

The transmission of the information from "R" to our "C" is a purely reflexive one and completely beyond our control but not beyond our influence. When the spike reaches our "C" we have a choice as to how to process the thought. (Note the two descending arrows.) The arrow to the left suggests that the thought represents or reflects something deep and meaningful about the person, e.g. "only a vicious loathsome human being could possible think of stabbing their loved one." This represents, as Albert Ellis (1987, 1991) would suggest, a dysfunctional emotional response "ER." The tremendous effort one puts into escaping the unwanted thoughts or preventing their recurrence (e.g. hiding knives), in effect reinforces its importance to the nonconscious brain and thereby feeds the vicious cycle. Similar notions have been proposed by Wenzlaff, Wegner, & Roper (1988). These authors suggest that attempting to suppress thoughts has the effect of a mental boomerang whereby the cognitive backlash is actually stronger as one makes more efforts to bury the thoughts. Becoming upset over a thought places a mental marker on it and therefore increases the likelihood of the thought recurring. For the "Pure-O," the spike is a double barrel shot of anxiety. On the one hand, there is anxiety for having such an unpleasant thought, and on the other, the tremendous repetition of the thoughts gives the appearance that one is losing his or her mind and this is a very anxiety provoking experience. This vicious cycle is applicable for both the spiking and rumination type "Pure-O."

The pertinent issue, though, is not how or why these thoughts become out of control, but what to do about them when they're racing around in one's head eight hours a day. Before discussing what works, first it is critical to discuss what does not work.

Thought stopping, either through shouting "STOP" or snapping a rubber band in response to the spike is clearly not recommended and may actually be detrimental. As discussed previously, this technique would in effect sensitize the brain to the unwanted thought by alerting the "R" that potential punishment is associated with the spike. Theoretically, the spikes would thus increase due to this heightened sensitivity. Future research may bare this out.

Although logically pointing out the absurdity of the "Pure-O's" mental rituals is very tempting, it is often insulting and clearly ineffective. You can not "outlogic" OCD. Similarly, the use of analytic interpretations to provide insight is absurd and harmful. A person's natural inclination is to investigate what implications certain spikes might signify. A therapist who reinforces this inclination is naive and incompetent. Whether it be stabbing one's loved ones, or having sex with one's mother, these thoughts will only become more deeply entrenched by placing emotionally laden meanings on them, such as underlying aggressive impulses or unresolved Oedipal conflicts.

Ultimately, as with all forms of OCD, living with uncertainty and risk taking are the antidotes to this disorder. The treatment of the "Pure-O" is theoretically based on the principles of classical conditioning and extinction. The disorder is perpetuated by a person's intolerance of having bizarre and noxious thoughts. The efforts a person makes to avoid or escape these thoughts reinforces their recurrence. Therefore, the removal of the reinforcement (extinction) entails the following.

But first - a warning. You will know the disorder is getting better when the frequency of spikes increases. Our brain is resistant to change and will be predictably inclined to throwing tantrums, as one attempts to make space for what has been given for so long a great deal of importance in getting rid of. A common occurrence is that a person who previously would spike four times a day, but ruminate incessantly for the duration of the day, will often spike much more frequently as their amount of rumination substantially decreases.

THE CRITICAL VARIABLE IS THE RUMINATION AND NOT THE NUMBER OF SPIKES! This statement is paramount for a successful treatment. The target response is having the person not respond to the spike, it is not to have the spikes go away. The long term effect of not attending to the spike will be that the spikes will decrease in frequency and emotional intensity. This will happen only if the person becomes desensitized to these thoughts by allowing them to occur. A common phrase often mentioned in my groups is "let the thoughts be there," give yourself permission to have the thoughts. In conclusion, four suggestions are offered. These procedures have been very successful in turning lives around and freeing up thoughts for contemplation of more meaningful material. The research is still preliminary, but the treatment outcomes have been significant enough to spread the word. As with all forms of OCD, behavioral therapy is effective to the extent that the subject adheres to the procedures (Dar & Greist, 1992).

The Antidote:
The spike often presents itself as a paramount question or disastrous scenario. A response which answers the spike in a way that leaves ambiguity is sometimes warranted. "If I don't remember what I had for breakfast yesterday my mother will die of cancer!" Using the antidote procedure, a cognitive response would be one in which the subject accepts this possibility and is willing to take the risk of his mother dying of cancer or the question recurring for eternity. No effort is expended in directly answering the question in an effort to find resolution. In another example, the spike would be "Maybe I said something offensive to my boss yesterday," a recommended response would be "Maybe I did. I'll live with the possibility and take the risk he'll fire me tomorrow." Using this procedure it is imperative that the distinction be made between the therapeutic response and rumination. The therapeutic response has no aspect of answering the question to it.

Let it Be There:
Using this procedure, it is suggested that the person create a mental pigeon hole for the thoughts and accept the presence of the thoughts into one's preconscious (those thoughts which are not currently in one's awareness but can easily be brought there by turning one's attention to them, i.e. your name or phone number). It is suggested that a mental "hotel" be created whereby you encourage your brain to create unsolvable questions so as to fill up the register. The more unsolved questions the better. It is critical that the "Pure-O" acknowledge the presence of the thought but pay no further attention to it, as in the form of problem solving. The brain can only juggle a certain amount of information at one time. If you purposely overload the brain, rather than insanity, your brain's response would be to just give up trying. As can be imagined, attempting this goal takes a lot of faith and trust in the person suggesting it.

The Capsule Technique:
During the initial phases of therapy, there is a great resistance to letting go of the rumination. A procedure which addresses this resistance is to set aside a specified period of time, perhaps once or twice a day, to purposely ruminate. It is suggested that the time periods be predetermined and time limited. At exactly 8:15 am and 8:15 pm I will ruminate for exactly 45 minutes. As thoughts occur to me during the day I can feel comforted that the problem solving will be given sufficient time later that evening or early the next morning. Typically, people report that it is difficult to fill the allotted rumination time. Regardless, every minute must be spent on the designated topic so the brain can habituate to these irrelevant thoughts. A novel application of this technique was reported in the Journal of Behavior Therapy and Experimental Psychiatry. Using audiotaped spiking material a woman was desensitized to her obsessional themes by exposing herself to them 10 times a day. After the 50th day, her actual spiking dramatically decreased.

Creating 4-5 Larger Spikes:
Rather than attempting to escape the spikes, the "Pure-O" is encouraged to purposely create the thought repeatedly following it's occurrence. This has the effect of desensitizing the brain to these spikes by sending the message that not only am I not going to attempt to escape these thoughts, but I am at such peace with them I can create a multitude of them. In response to the thought "I might have run over someone on my way to work," a beneficial response would be "There is probably a stack of bodies all along the street; I probably wiped out half the population of my home town yesterday as well; and I can't wait to drive home tonight and kill the other half."

Some people report that they have difficulty distinguishing between spikes and "legitimate important thoughts." A fool proof litmus test for telling the difference is to ask yourself did the thought or question come with an associated anxiety or feeling of guilt. Ultimately all such thoughts can be placed in the realm of OCD. When asked "What if it's not OCD," I say "Take the risk and live with the uncertainty."

At this point, my skills as a therapist are not nearly as valuable as the client's willingness to utilize the procedures. Unless you are thoroughly fed up with the disorder, behavior therapy will be of limited help. Often I have been informed that the treatment is as painful as the disorder. My only response is that with this treatment there is a light at the end of the tunnel. The disorder offers only endless suffering. If you find that after six months to a year there is limited movement in a positive direction, it might be worth your while to take a temporary leave of absence from therapy until you are fully committed to letting go of the problem. Published clinical notations suggest that this step might assist in bringing about an increased willingness to confront the nightmare rather than continuing to mentally run away from it.

References
Baer, L. (1994). Factor analysis of symptom subtypes of obsessive compulsive disorder and their relation to personality and tic disorders. Journal of Clinical Psychiatry, 55(3, Suppl), 18-23.

Brown, R. W., & McNeil, D. (1966). The "tip-of-the-tongue" phenomenon. Journal of Verbal Learning and Verbal Behavior, 5, 325-337.

Dar, R., & Greist, J. H. (1992). Behavior therapy for obsessive compulsive disorder. Psychiatric Clinics of North America, 15(4), 885-894.

Ellis, A. (1987). The Practice of Rational Emotive Therapy. New York: Springer.

Ellis, A. (1991). The revised ABC's of rational emotive therapy (RET). Journal of Rational-Emotive and Cognitive Behavior Therapy, 9(3), 139-172.

Wenzlaff, R. M., Wegner, D. M., & Roper, D. W. (1988). Depression and mental control: The resurgence of unwanted negative thoughts. Journal of Personality and Social Psychology, 55(6), 882-892.
 

Daniel

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More articles by the same author:

OCD ONLINE - Articles by Dr. Steven Phillipson

From his followup article Rethinking the Unthinkable, which was also written in 2004:

The following useful suggestions are offered towards managing obsessions.

The research is still preliminary, but the treatment outcomes have been significant enough to spread the word. As with all forms of OCD, behavioral therapy is effective to the extent that the patient adheres to the procedures (Dar & Greist, 1992). Since this article’s original version, two procedures (index card therapy and spike hunts) have been added to the therapeutic arsenal and have been proven effective. I am just outlining these procedures because behavior therapy needs to be done with an experienced practitioner. Attempting to implement these techniques without expert guidance can be problematic and prevent goal attainment.

1. The Antidote Procedure

The spike often presents itself either as a question or potential disastrous scenario. A response, which answers the spike in a way that leaves ambiguity, is the antidote to preventing rumination. For instance, if the patient has the thought "If I don't remember what I had for breakfast yesterday my mother will die of cancer!" Under the Antidote Procedure, to manage the obsession, the most therapeutic response a patient can have is to accept this possibility and be willing to take the risk of his mother dying cancer or the question reoccurring for eternity. There is often a question regarding the degree to which one “really needs to believe” that their mother might die. In response, it is important to understand that ones’ beliefs are really not a significant component of treatment success. Instead, the behaviors and choices one engages in are key to conveying to one’s brain that the theme is no longer going to be any importance The goal is to expend the least amount of effort is responding to the question. In another example, a spike might be, "Maybe I said something offensive to my boss yesterday." A recommended response would be, "Maybe I did. I'll live with the possibility and take the risk he'll fire me tomorrow." Using this procedure, it is imperative that the distinction be made between the therapeutic response and rumination. The therapeutic response does not answer the question posed by a spike.

2. Let It Be There:

Using this procedure, it is suggested that the person create a mental pigeon hole for the disturbing thoughts and accept the presence of the thoughts into one's preconscious (those thoughts which are not currently in one's awareness but can easily be brought there by turning one's attention to them, i.e. your name or phone number). It is suggested that a mental "hotel" be created whereby you encourage your brain to store all the unsolvable questions so as to fill up the register. The more unsolved questions the better. It is critical that the person suffering from the “Pure-O” acknowledge the presence of these thoughts, but pay no further attention to them by trying to solve the problems presented by them. The brain can only juggle a certain amount of information at one time. If you purposely overload the brain, rather than going insane, your brain’s response will be to just give up trying. A key to this technique is that the person trying it has to have a great deal of faith and trust in the therapist suggesting it.

3. Spike Hunt

Very similar to the “let it be there” approach is the spike hunt. Using this procedure the patient is encouraged to purposely seek out spikes. This process actually is a 180-degree reversal of the reflexive OCD momentum. Most people’s OCD desperately hope for the associations to go away and never return. This frame of mind actually increases the susceptibility of the mind to these thoughts and exacerbates the condition.

A good example of a spike hunt is:

Patient X is terrified that he might get up in the middle of the night and violently assault his wife and child. He is so fearful that he might act on these thoughts, that any bump or strange shadow in the bedroom prompts him to consider that it might be a place where he’s hidden a knife or a gun with which to harm his family. Even familiar objects, which are out-of-place, seem to suggest that he is capable of acting in a non-conscious way and thereby lend support to the idea that his family is in danger of his uncontrollable/non-conscious actions. Using the spike hunt, this patient was instructed to purposely find unidentifiable shadows or mysteriously placed objects and gather together evidence that the world of the unknown lurks out there and represents possible unforeseen peril. After using this technique for two months and sleeping next to a steak knife, the patient achieved approximately 75% symptom relief. The rationale for this seemingly contradictory approach lies in the behavioral principles of reconditioning. Reconditioning retrains the brain to consider its warnings to be non-relevant. For human brains non-relevant information equals experiences that are not perceived.

4. The Capsule Technique

During the initial phases of therapy, there is a great resistance to letting go of the rumination. A procedure to handle this resistance is to have the person with OCD to set aside a specified period of time, perhaps once or twice a day, to purposefully ruminate. It is suggested that the time periods be predetermined and time limited. The patient should tell himself “At exactly 8:15 a.m. and 8:15 p.m. I will ruminate for exactly 45 minutes. As thoughts occur to me other times during the day, I can feel comforted that the problem solving will be given sufficient time later that evening or early the next morning.” Typically, people report that it is difficult to fill the allotted rumination time. Regardless, every minute must be spent on the designated topic so the brain can habituate to these irrelevant thoughts. A novel application of this technique was reported in the Journal of Behavior Therapy and Experimental Psychiatry. Using audiotaped spiking material a woman was desensitized to her obsessional themes by exposing herself to them ten times a day. After the fiftieth day, her actual spiking dramatically decreased.

5. Turning Up the Volume

Rather than attempting to escape the spikes, the person with "Pure-O" is encouraged to purposely create the thought, repeatedly, following its initial occurrence. One is also encouraged to take the presented topic and actually amplify the threatening component. This has the effect of desensitizing the brain to these spikes by sending the message that not only am I not going to attempt to escape these thoughts; but I am at such peace with them I can create a multitude of them. In response to the thought, "I might have run over someone on my way to work," a beneficial response would be; "There is probably a stack of bodies all along the street; I probably wiped out half the population of my home town yesterday as well. I can't wait to drive home tonight and kill the other half."

6. Index Card Therapy

The index card therapy procedure has been an extremely useful in treating people with “Pure-O.” What baffled behaviorists for years in attempting to treat this form of OCD was that there was no object with which the patient could actually perform an exposure exercise. It seemed rather difficult to have a person touch the thought “Kill my baby” or “I hate God” and then spread it all over the place. To concretize these thoughts Dr. Foa has suggested using loop tapes in which a patient would sit and listen to his/her their particular obsession played over and over ad-nausea. The possible limitation of this procedure is that the patient might become habituated to the voice on the tape and not the actual theme represented on the tape. In addition, carrying a tape recorder around with you might be cumbersome and most people do not have an hour each day to sit and just listen to the same message played over and over again. So to remedy these problems I created index card therapy, where the patient writes the topic of the spike down on an index card. The patient would also record the date, the intensity of the spike, and the level of resistance to the spike on the index card. The writer carries the index card with him at all times, preferably in a pocket. The patient periodically reviews the index card or cards, usually about six to ten times per day, until the level of associated anxiety and resistance is below a rating of two out of ten for two consecutive days.

OCD ONLINE - Rethinking the Unthinkable
 

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Pure O 101 -- OCD Center of Los Angeles
May 30, 2019

The bottom line is that you are not responsible for the unending stream of thoughts that pop into your consciousness. Thoughts just happen, and many (most?) range anywhere from unimportant to ridiculous. If you were to keep a running log of all of the thoughts you have in a given day, you would quickly discover just how few are actually meaningful or important...

The great majority of your thoughts do not need to be monitored, evaluated or responded to. They are just the idle chatter of the thinking machine in your head. A far better way of addressing Pure O thoughts is to just let them exist, without attending to them, or valuing them, or responding to them. Just let them exist unanswered. They are just thoughts.
 

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Predictive Values of Obsessive Beliefs and Metacognitions in OCD Symptom Dimensions
Psychiatry and Behavioral Sciences 2020

In this study, 'perfectionism and intolerance of uncertainty' was the only variable associated with the contamination dimension. 'Importance of and need to control thoughts,' which is the metacognitive subscale of OBQ [Obsessive Beliefs Questionnaire], was associated with all OCD symptom dimensions except contamination. These findings could imply that obsessive patients have different cognitive profiles according to their symptom dimensions. In addition to obsessive beliefs and generic metacognitions, further studies, including OCD specific metacognitions, will clarify our knowledge about OCD symptom dimensions.
 
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Just a thought?​

The average person has tens of thousands of thoughts every day. Most of these are fairly mundane and ordinary, but given the sheer amount of chatter running through our brains, it’s no surprise that we sometimes get strange, even disconcerting, thoughts that appear to come from nowhere. You’re walking across a bridge and suddenly think of jumping off. You’re cradling a newborn baby and get an image of throwing her down the stairs. You enter a hushed cathedral and have the sudden urge to swear at the top of your voice.

Psychologists call these ‘intrusive thoughts’, and research has shown that everybody gets them. “When we asked people whether they experience these kinds of thoughts, 93 per cent said yes,” says Prof Paul Salkovskis, Professor of Clinical Psychology and Applied Science at the University of Bath. “In a follow-up study, we tried to interview those who said they didn’t, and they didn’t want to speak to us. I’m as convinced as it’s possible to be that the real figure is 100 per cent.”

Salkovskis believes that we’re hardwired to have these thoughts. “Intrusive thoughts are our brain’s way of dealing with uncertain circumstances, which we’ve had throughout our evolution,” he says. “Thoughts will come into our minds that are loosely connected with what’s going on around us – some of them will be good ideas, and some will be bad.” According to this view, intrusive thoughts are part of our brain’s in-built problem-solving system – a literal brainstorming mechanism that’s designed to keep us alive. Just as our ancient ancestor, when faced with a tiger, might have thoughts about running away (good idea) or trying to befriend it (bad idea), so our brains today are constantly coming up with ideas to help us make sense of our surroundings – ideas which might be helpful, weird, or just downright scary.

Most people are able to dismiss the unhelpful intrusive thoughts as quickly as they arrive. But someone with OCD is unable to ignore them. They’ll interpret them as saying something fundamental about who they are. What if I’m a danger to myself? What if I harm this baby? What if I’m evil?
 
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Obsessional Beliefs Questionnaire

1. I often think things around me are unsafe.

2. If I am not absolutely sure of something, I am bound to make a mistake.

3. Things should be perfect according to my own standards.

4. In order to be a worthwhile person, I must be perfect at everything I do.

5. When I see any opportunity to do so, I must act to prevent bad things from happening.

6. Even if harm is very unlikely, I should try to prevent it at any cost.

7. For me, having bad urges is as bad as actually carrying them out.

8. If I don’t act when I foresee danger, then I am to blame for any consequences.

9. If I can’t do something perfectly, I shouldn’t do it at all.

10. I must work to my full potential at all times.

11. It is essential for me to consider all possible outcomes of a situation.

12. Even minor mistakes mean a job is not complete.

13. If I have aggressive thoughts or impulses about my loved ones, this means I may secretly want to hurt them.

14. I must be certain of my decisions.

15. In all kinds of daily situations, failing to prevent harm is just as bad as deliberately causing harm.

16. Avoiding serious problems (for example, illness or accidents) requires constant effort on my part.

17. For me, not preventing harm is as bad as causing harm.

18. I should be upset if I make a mistake.

19. I should make sure others are protected from any negative consequences of my decisions or actions.

20. For me, things are not right if they are not perfect.

21. Having nasty thoughts means I am a terrible person.

22. If I do not take extra precautions, I am more likely than others to have or cause a serious disaster.

23. In order to feel safe, I have to be as prepared as possible for anything that could go wrong.

24. I should not have bizarre or disgusting thoughts.

25. For me, making a mistake is as bad as failing completely.

26. It is essential for everything to be clear cut, even in minor matters.

27. Having a blasphemous thought is as sinful as committing a sacrilegious act.

28. I should be able to rid my mind of unwanted thoughts.

29. I am more likely than other people to accidentally cause harm to myself or to others.

30. Having bad thoughts means I am weird or abnormal.

31. I must be the best at things that are important to me.

32. Having an unwanted sexual thought or image means I really want to do it.

33. If my actions could have even a small effect on a potential misfortune, I am responsible for the outcome.

34. Even when I am careful, I often think that bad things will happen.

35. Having intrusive thoughts means I'm out of control.

36. Harmful events will happen unless I am very careful.

37. I must keep working at something until it's done exactly right.

38. Having violent thoughts means I will lose control and become violent.

39. To me, failing to prevent a disaster is as bad as causing it.

40. If I don’t do a job perfectly, people won’t respect me.

41. Even ordinary experiences in my life are full of risk.

42. Having a bad thought is morally no different than doing a bad deed.

43. No matter what I do, it won’t be good enough.

44. If I don't control my thoughts, I'll be punished.
 
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The author proposes a new, combined theory: that self-doubt (or an ambivalent self-view) likely influences the nature, as well as the interpretation of intrusive thoughts, and this appraisal and the presence of ongoing intrusions perpetuate the self-doubt beliefs...

A general issue in the literature on self-ambivalence and fear of self is their specificity to OCD. Based on the finding that people with OCD did not differ from those with other anxiety disorders in self-ambivalence, Bhar and Kyrios (2007) concluded that self-ambivalence might be more appropriately conceptualized as being relevant to OCD rather than specific to it. Moreover, Higgins' (1987) self-discrepancy theory and subsequent investigations related to it suggest that internally inconsistent representations of the self are associated with a variety of affective difficulties. Nevertheless, irrespective of specificity to OCD, this literature review further supports arguments about incorporating a focus on fear of self and self-ambivalence in interventions for OCD...

Initial research provides strong evidence that fear of self and self-ambivalence are able to significantly predict OCD symptom severity. In particular, research suggests that there is a strong link between self-doubt beliefs and obsessions and obsessional beliefs related to OCD.
 
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Findings from this review reinforce that self-themes may contribute to the development and/or maintenance of OCD. This is broadly consistent with established cognitive appraisal models (CAMs; e.g., Clark & Purdon, 1993, 2016; Rachman, 1997, 1998; Salkovskis, 1985, 1989). These models posit that intrusions become clinically significant obsessions when they co-occur with negative automatic thoughts, or appraisals, regarding their importance. That is, the individual interprets the intrusions in a way that elevates their significance and invites repeated attempts to alleviate distress, often in the form of compulsions (Rachman & de Silva, 1978). For example, a person who experiences obsessional thoughts of harm to others and associated checking compulsions may engage in doubts such as “Even though I saw potholes in the road, the bump I drove over could actually have been a pedestrian.” This doubt may be motivated in part by the individual’s fear that they are in fact a reckless person capable of harming others (responsibility appraisal reflecting feared self); or that they are equally capable of being conscientious and culpable (self-ambivalence). This appears to be most potent when one’s personal morality is called into question.
 

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Age Factors

Adults under the age of 40 seem to be the most affected by intrusive thoughts. Individuals in this age range tend to be less experienced at coping with these thoughts, and the stress and negative affect induced by them. Younger adults also tend to have stressors specific to that period of life that can be particularly challenging especially in the face of intrusive thoughts. Although, when introduced with an intrusive thought, both age groups immediately look for ways to reduce the recurrence of the thoughts.

Those in middle adulthood (40-60) have the highest prevalence of OCD and therefore seem to be the most susceptible to the anxiety and negative emotions associated with intrusive thought. Middle adults are in a unique position because they have to struggle with both the stressors of early and late adulthood. They may be more vulnerable to intrusive thought because they have more topics to relate to. Even with this being the case, middle adults are still better at coping with intrusive thoughts than early adults, although it takes them longer at first to process an intrusive thought. Older adults tend to see the intrusive thought more as a cognitive failure rather than a moral failure in opposition to young adults. They have a harder time suppressing the intrusive thoughts than young adults causing them to experience higher stress levels when dealing with these thoughts.

Intrusive thoughts appear to occur at the same rate across the lifespan, however, older adults seem to be less negatively affected than younger adults. Older adults have more experience in ignoring or suppressing strong negative reactions to stress.
 

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