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Introduction: A global perspective on unwanted intrusive thoughts
Journal of Obsessive-Compulsive and Related Disorders ∎ (∎∎∎∎) ∎∎∎–∎∎∎
Contents lists available at ScienceDirect
Journal of Obsessive-Compulsive and Related Disorders journal homepage: www.elsevier.com/locate/jocrd
Introduction: A global perspective on unwanted intrusive thoughts David A. Clark a, Adam S. Radomsky b,n a b
University of New Brunswick, Canada Concordia University, Canada
art ic l e i nf o
a b s t r a c t
Article history: Received 15 January 2014 Received in revised form 9 February 2014 Accepted 11 February 2014
Because of Rachman and de Silva's (1978) influential research on normal and abnormal obsessions, it is now a basic tenet of cognitive behavioral theories (CBT) that clinical obsessions have their origins in the normal intrusive thought phenomena that characterizes the stream of consciousness. However much of the empirical research on unwanted intrusive thoughts has utilized retrospective self-report questionnaires that have weak construct validity and the samples have been drawn primarily from Western European and North American populations. To enhance the measurement precision and investigate the universality of unwanted intrusions, a structured intrusive thoughts interview was developed and administered to 777 nonclinical individuals drawn from 13 countries. The three papers in this special issue present findings based on this large data set. Together it was found that unwanted intrusive thoughts are reported by the majority of individuals in all countries, that significant cross-cultural differences are apparent in primary intrusive thought content, that faulty appraisals and confrontational control strategies are related to the distress of intrusions, and that the frequency of dirt/contamination, doubt, and miscellaneous intrusions are specifically related to obsessive compulsive symptom distress. The authors discuss these findings in terms of their consistency with predictions derived from the CBT perspective on obsessions. The special issue concludes with a discussion paper by Professor Jack Rachman, originator of the obessional intrusions concept. & 2014 Elsevier Inc. All rights reserved.
Keywords: Unwanted intrusive thoughts Obsessions Cross-cultural differences Cognitive behavioral theory of obsessions OCD
1. Introduction This year marks the 36th anniversary of Rachman and de Silva's (1978) seminal article that introduced the concept of unwanted intrusive thoughts as a potential etiological factor in the development of obsessive compulsive disorder (OCD). Their paper reported on three studies that sought to determine whether healthy, nonclinical individuals experience unwanted thoughts, images or impulses that are similar in content to clinical obsessions (i.e., thoughts of contamination, doubt, aggression, sexuality, etc.). In the first study based on an intrusive thoughts questionnaire 99/124 (80%) nonclinical individuals reported fairly frequent unwanted thoughts or images involving obsessional content, although they were considered fairly easy to dismiss. The second study consisted of a detailed interview of intrusive thoughts conducted on 40 nonclinical individuals and 8 patients with OCD. A list of 23 obsessions from the clinical sample and 58 obsessive-like intrusions from the nonclinical individuals were reproduced in the article and have since become the basis of numerous self-report measures of intrusive thoughts.
n Correspondence to: Department of Psychology, Concordia University, 7141 Sherbrooke St. West, Montreal, QC, Canada. E-mail address: [email protected] (A.S. Radomsky).
Comparison between the clinical and nonclinical samples revealed similarities in thought content, although the OCD patients reported greater frequency, discomfort and difficulty controlling their obsessions. In the third study OCD patients and nonclinical participants were asked to repeatedly form their obsession or intrusive thought. Habituation was evident in both samples, although the nonclinical group had more difficulty forming their intrusion upon request than the OCD patients. Although Rachman and de Silva's (1978) findings raised many questions about the nature of intrusive thoughts, it also provided the first empirical evidence that obsessions might have their origins in the normal thought processes that characterize the stream of consciousness. The conceptual significance of “normal obsessions” was subsequently emphasized in Rachman and Hodgson's (1980) text, Obsessions and Compulsions, which in many respects provides the theoretical underpinnings for contemporary cognitive-behavioral (CB) models of OCD. In their chapter entitled An Anatomy of Obsessions, the occurrence of unwanted, unacceptable intrusive thoughts or images initiated a process of faulty meta-cognitive appraisal and control efforts that could spiral into the development of obsessions. Later publications elaborating on a CBT model of obsessions and compulsions also reiterated the occurrence of mental intrusions as a key determinant in the pathogenesis of obsessions (e.g., Clark, 2004; Freeston, Rhéaume, & Ladouceur, 1996; Rachman, 1997, 1998;
http://dx.doi.org/10.1016/j.jocrd.2014.02.001 2211-3649 & 2014 Elsevier Inc. All rights reserved.
Please cite this article as: Clark, D. A., & Radomsky, A. S. Introduction: A global perspective on unwanted intrusive thoughts. Journal of Obsessive-Compulsive and Related Disorders (2014), http://dx.doi.org/10.1016/j.jocrd.2014.02.001i
2
D.A. Clark, A.S. Radomsky / Journal of Obsessive-Compulsive and Related Disorders ∎ (∎∎∎∎) ∎∎∎–∎∎∎
Salkovskis, 1985, 1989). Today the universality of obsession-related intrusive thoughts, images and impulses is a central tenet of CBT explanations for the development of obsessions. While the conceptual significance of the Rachman and de Silva (1978) publication cannot be overstated, their work has also had a significant impact on empirical research on unwanted intrusions. In the last three decades research on intrusions has taken two broad pathways; the most common approach is questionnaire based, whereas the other is more experimental, examining the impact of intentional mental control efforts on unwanted intrusive thoughts. These two broad research pathways are represented in the first and third studies reported in the Rachman and de Silva (1978) publication. Interestingly there has been little research that has employed the interview format; a neglect that we think is serious given the complexity of intrusive thoughts. There are important conceptual and methodological weaknesses that have been raised with questionnaire and experimental measurement of unwanted intrusive thoughts. Questionnaire measures of intrusions present individuals with a predetermined list of thought statements which respondents are then instructed to rate for frequency of occurrence. However concerns have been raised about the veridicality of these item responses (Brown & Clark, 2014). When individuals indicate that they frequently experience an unwanted intrusive thought by endorsing an item statement, does this reflect their actual memory of specific thought occurrences, or might it reflect an emotional state or self-identity that is congruent with the item content (Glass & Arnkoff, 1997)? In addition the content validity of many intrusive thought questionnaires is problematic because they can contain a broad range of negative thought content that often includes general anxiety and depressive thought content (Clark & Purdon, 1995). As well the lists of intrusions are always predetermined so how well these pre-established items represent the intrusive thought content of specific individuals is doubtful. Rachman (1981) has noted that unwanted mental intrusions are often quite idiosyncratic and triggered by external cues. Questions have also been raised about the specificity and discriminative validity of intrusive thoughts questionnaires (Julien, O’Connor, & Aardema, 2007). These are fundamental questions about the construct validity of retrospective self-report of unwanted intrusions that leave us uncertain about the interpretability of a high score on such measures. When a person indicates that s/he frequently has an intrusion (e.g., “I have unwanted intrusive thoughts, images or impulses of verbalizing something rude or embarrassing that would hurt a person's feelings”), is this based on memories of actual thought occurrences, recalling times when feeling anxious about one's verbal interaction, a single recent experience of “embarrassed verbalization”, or a self-identity that acknowledges you are the type of person who is concerned about your impact on others? In sum questionnaires may not be the most accurate method for assessing people's actual experience of unwanted intrusive thoughts. Unfortunately experimental approaches to the investigation of unwanted mental intrusions and their control also have significant drawbacks. The first problem is ecological validity. When an individual is brought into a laboratory setting and asked to produce an intrusive thought, it is no longer intrusive. The intentional production of the thought is no longer unwilful and so lacks generalizability to the spontaneous, unintended intrusions that occur in the natural world. As well, a diffusion of responsibility occurs such that the participant can now attribute responsibility to the experimenter for the generation of the intrusion rather than the self. This transfer of responsibility to the experimenter could significantly affect the participant's appraisal of the intrusive thought. Even if the intrusion is induced, difficulties arise because it may be difficult to ensure that the induction was
successful across all research participants. Finally, the control of unwanted negative thoughts under controlled laboratory conditions for very brief time periods will be quite different from the experience of repeated unwanted intrusions over an extended period of time in a context-rich, everchanging naturalistic setting. Thus the findings derived from laboratory-contrived intrusive phenomena raise questions about their relevance to the spontaneous, distressing intrusive thoughts, images and impulses that can “haunt” individuals in their everyday life.
2. Current research objectives The present research was initiated to address two major shortcomings in the intrusive thoughts literature. From a methodological perspective, our first objective was to explore the use of a structured interview format to assess individuals' experience of unwanted intrusive thoughts, images and impulses specifically related to the major themes of OCD; dirt/contamination, doubt, harm/injury, sex, religion/morality, and minor or miscellaneous themes. [Though not normally represented in obsessional fears, we also assessed intrusive thoughts about being a victim of violence because these thoughts may be common in nonclinical populations]. The use of an interview would allow us to collect qualitative data to ensure that participants reported on intrusive thoughts relevant to OCD rather than a range of negative thoughts that might be more relevant to worry, dysphoria or anger. In addition the qualitative information would help interpret the quantitative data on the phenomenology of intrusions and their sequellae (see below). Trained interviewers were provided with strict definitions and examples of obsession-relevant intrusive thoughts and participants' responses were written down for subsequent verification that the intrusion fit the study criteria. In addition the interview ensured that participants responded to the six types of obsessive intrusive thoughts and the interviewer could probe to ensure that participants really did experience an intrusion. Another advantage of the interview is that participants were asked to describe specific instances of the unwanted intrusion. This increased the likelihood that endorsement reflected actual thought occurrences rather than personal conjectures on the types of thoughts a person experiences. Thus our intention was to develop an interview that would provide a more accurate measurement of intrusive thought content highly specific to OCD. A second objective of the interview method was to provide a more comprehensive and detailed assessment of individual's appraisal and perceived control of their most distressing intrusive thought. First, general ratings of frequency, distress and control were collected on the six OCD-relevant intrusions. Then individuals selected their most distressing intrusion and detailed ratings of several appraisal and control constructs were obtained. This part of the interview utilized an endorsement approach with participants providing their own ratings on appraisal and control dimensions. Six point rating scales were used so individuals could rate their level of agreement to specific questions about their appraisal of the most distressing intrusion and frequency of using various mental control strategies. Our intent was to provide the participant with appraisal statements that accurately reflect the most common evaluative constructs in contemporary CBT theories of OCD, while keeping them broad enough to encompass a wide range of intrusive phenomena. In addition to these methodological considerations, we also wanted to investigate the cross-cultural expression of unwanted intrusive thoughts. The universality of unwanted intrusive thoughts is a central assumption of CBT theories of obsessions (Rachman, 2003). However, there are no published studies that have compared the occurrence of unwanted intrusions across
Please cite this article as: Clark, D. A., & Radomsky, A. S. Introduction: A global perspective on unwanted intrusive thoughts. Journal of Obsessive-Compulsive and Related Disorders (2014), http://dx.doi.org/10.1016/j.jocrd.2014.02.001i
D.A. Clark, A.S. Radomsky / Journal of Obsessive-Compulsive and Related Disorders ∎ (∎∎∎∎) ∎∎∎–∎∎∎
a diverse range of countries with varying social and cultural traditions. The majority of studies have documented the occurrence of intrusions in North American or Western European countries. A primary goal of the current research was to compare individuals' experience of obsession-relevant intrusive thoughts across several countries using the same assessment methodology that would allow a direct test of cultural influences on intrusions. Our intention was to conduct the first large-scale international study of unwanted intrusive thoughts in nonclinical individuals. This would provide the most direct test of the universality of unwanted mental intrusions.
3. History and development The idea for an international/cross-cultural study of OCD-related intrusions was first raised at one of the final meetings of the Obsessive Compulsive Cognitions Working Group (OCCWG) in Chambery, France in 2006. A cross-cultural working group was formed, initially consisting of OCCWG members (but later expanded). This group drafted a preliminary version of a structured interview for intrusive thoughts called the International Intrusive Thoughts Interview Schedule (IITIS). Initial elements of the IITIS included a carefully worded introductory section in which a variety of examples and definitions of obsessional intrusions were provided, as well as a number of content-related sections, asking about intrusions related to contamination, aggression, doubt, blasphemy, immorality, sex, victimization, and miscellaneous intrusions. The early IITIS incorporated questions about frequency, distress and challenges associated with dismissing intrusions, appraisals/interpretations of intrusions, and control strategies used by individuals to try to get rid of or otherwise manage their intrusions. The first meeting of a newly constituted research group called the Research Consortium on Intrusive Fear (RCIF) took place in Barcelona, Spain in 2007, at which point the membership was expanded beyond the OCCWG. In addition to continued drafting of IITIS elements, discussions at this meeting also began to include issues associated with translation and back-translation, training guidelines, and elements associated with study design (e.g., measures, samples, protocols, etc.). Successive drafts of the IITIS unfolded over the next few years, largely in light of problems that emerged with meaning and nuance during initial translation exercises. These were incrementally resolved, and once a final version of the IITIS was obtained, a standardized translation/backtranslation protocol was adopted by all authors. The IITIS (now in its 6th version) in English was translated by a team at each nonEnglish-speaking site containing at least one person familiar with research on OCD and intrusive thoughts. This produced translated versions of the IITIS in nine languages (English, Cantonese, French, Greek, Hebrew, Italian, Persian, Spanish, and Turkish). Each translated version was then back-translated to English by a separate team, and the back-translated versions were then sent to D. Clark and A. Radomsky for review. There were very few differences between the English IITIS and back-translated versions. Some of the more interesting differences that emerged were associated with the fact that some languages/cultures do not have a simple term or expression for ‘intrusive’. These issues were resolved collaboratively, and often involved a particular version of the IITIS using a phrase to convey the meaning of particular constructs rather than a specific word. Importantly, the phrase employed was assessed to determine if it mirrored the internal experience of those in the relevant culture/country. Whenever such issues arose, pivotal importance was placed on having the different linguistic versions of the IITIS be both equivalent to each other, and meaningful within the person's cultural context. These attributes were confirmed by fully bilingual members of the RCIF at each site (for a
3
list of translators, consult the author list of the empirical articles in this issue). An initial pilot study of the IITIS, Version 6 was conducted between February and May, 2011; some of the primary questions we hoped to address included: Are unwanted intrusive thoughts normative human experiences across countries and cultures? Are there differences in the nature and types of intrusions reported across countries and cultures? Data from this initial piloting were presented and discussed at a meeting of the RCIF in Cordoba, Spain in 2011. At that meeting and shortly thereafter, new sites were added (e.g., Buenos Aires, Sierra Leone), and it was agreed that each site would collect additional data (to a requested total of approximately 50 nonclinical participants per site). Nearly all of these data were in place by the most recent meeting of the RCIF in Montreal in 2012, during which analysis and dissemination plans were developed, and strategies to complete data collection were discussed.
4. The special issue This special issue on cross-cultural expressions of unwanted intrusive thoughts consists of three papers that report on several findings from the same international study using the IITIS (v.6). The research group consists of 19 researchers from 13 countries who administered the IITIS (v.6) to 777 nonclinical individuals along with self-report measures of OCD symptoms, beliefs and negative affect. Due to the wealth of information contained within this dataset, and the many research questions we hoped to address, this special issue contains three papers designed to highlight different aspects of our findings. The first paper by Radomsky et al. (in this issue) addresses the question of whether or not unwanted intrusive thoughts, images and impulses are as common in an international context as they have previously been found to be in British or North American samples. This aspect of our work focused on providing information about the nature of intrusions and appraisals reported by participants; between-country comparisons of the frequency and content of unwanted intrusive thoughts are highlighted. In the second paper Molding et al. (in this issue) hierarchical linear modeling was utilized to examine cross-cultural differences in the relationship between appraisals and control of individuals' most distressing intrusive thoughts. The latter were categorized into repugnant (i.e., harm/injury, religious/immoral, sexual) and nonrepugnant (i.e., contamination/dirt, doubt, victim of violence) intrusions. Specifically, we sought to understand the degree to which theoretically derived appraisals were predictive of intrusive phenomenology, and how these relationships, if shown, vary from site to site and across different categories of intrusions. The third study by Clark et al. (in this issue) examined the relationship between unwanted intrusive thoughts and obsessional symptoms. We felt this to be important as very little work has been conducted to elucidate the connections between intrusive phenomenology and OCD symptoms, much less in an international context. This special issue on a global perspective on unwanted intrusive thoughts concludes with a commentary by Professor Jack Rachman. Professor Rachman can be considered the “founder of intrusive thoughts”, at least in reference to OCD, and so it is fitting that he should situate the current findings within the historical context of intrusions and cognitive-behavioral approaches to OCD.
Acknowledgments We are grateful for financial support for this research provided by an International Opportunities Fund Grant awarded to
Please cite this article as: Clark, D. A., & Radomsky, A. S. Introduction: A global perspective on unwanted intrusive thoughts. Journal of Obsessive-Compulsive and Related Disorders (2014), http://dx.doi.org/10.1016/j.jocrd.2014.02.001i
D.A. Clark, A.S. Radomsky / Journal of Obsessive-Compulsive and Related Disorders ∎ (∎∎∎∎) ∎∎∎–∎∎∎
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Drs. Clark and Radomsky from the Social Sciences and Humanities Research Council of Canada (Grant #861-2009-0076) and to Adriana del Palacio-Gonzalez for assistance during the data collection phase of the research. References Brown, G. P., & Clark, D. A. (2014). “Better the devil you know”? A conceptual critique of endorsement methods in cognitive therapy assessment. In: G. P. Brown, & D. A. Clark (Eds.), Cognitive therapy assessment, diagnosis and case formulation. (submitted for publication). Clark, D. A. (2004). Cognitive-behavioural therapy for OCD. New York: Guilford Press. Clark, D. A., Abramowitz, J., Alcolado, G. M., Alonso, P., Belloch, A., Bouvard, M., et al. (2014). Part 3. A question of perspective: The association between intrusive thoughts and obsessionality in 11 countries. Journal of Obsessive-Compulsive and Related Disorders (in this issue) Clark, D. A., & Purdon, C. L. (1995). The assessment of unwanted intrusive thoughts: A review and critique of the literature. Behaviour Research and Therapy, 33, 967–976. Freeston, M. H., Rhéaume, J., & Ladouceur, R. (1996). Correcting faulty appraisals of obsessional thoughts. Behaviour Research and Therapy, 34, 433–446. Glass, C. R., & Arnkoff, D. B. (1997). Questionnaire methods of cognitive selfstatement assessment. Journal of Consulting and Clinical Psychology, 65, 911–927.
Julien, D., O'Connor, K. P., & Aardema, F. (2007). Intrusive thoughts, obsessions, and appraisals in obsessive–compulsive disorder: A critical review. Clinical Psychology Review, 27, 366–383. Molding, R., Coles, M. E., Abramowitz, J. S., Alcolado, G. M., Alonso, P., Belloch, A., et al. (2014). Part 2. Do we dislike intrusive thoughts for the same reasons? Links between appraisals, control strategies and intrusions across countries. Journal of Obsessive Compulsive and Related Disorders (in this issue) Rachman, S. J. (1997). A cognitive theory of obsessions. Behaviour Research and Therapy, 35, 793–802. Rachman, S. J. (1981). Part I. Unwanted intrusive cognitions. Advances in Behaviour Research and Therapy, 3, 89–99. Rachman, S. J. (1998). A cognitive theory of obsessions: Elaborations. Behaviour Research and Therapy, 36, 385–401. Rachman, S. J. (2003). The treatment of obsessions. Oxford: Oxford University Press. Rachman, S., & de Silva, P. (1978). Abnormal and normal obsessions. Behaviour Research and Therapy, 16, 233–248. Rachman, S., & Hodgson, R. J. (1980). Obsessions and compulsions. Englewood Cliffs, NJ: Prentice Hall. Radomsky, A. S., Alcolado, G. M., Abramowitz, J., Alonso, P., Belloch, A., Bouvard, M., et al. (2014). Part 1. You can run but you can't hide: Intrusive thoughts on six continents. Journal of Obsessive Compulsive and Related Disorders (in this issue) Salkovskis, P. M. (1985). Obsessional-compulsive problems: A cognitive-behavioural analysis. Behaviour Research and Therapy, 23, 571–583. Salkovskis, P. M. (1989). Cognitive-behavioural factors and the persistence of intrusive thoughts in obsessional problems. Behaviour Research and Therapy, 27, 677–682.
Please cite this article as: Clark, D. A., & Radomsky, A. S. Introduction: A global perspective on unwanted intrusive thoughts. Journal of Obsessive-Compulsive and Related Disorders (2014), http://dx.doi.org/10.1016/j.jocrd.2014.02.001i
Contents lists available at ScienceDirect
Journal of Obsessive-Compulsive and Related Disorders journal homepage: www.elsevier.com/locate/jocrd
Introduction: A global perspective on unwanted intrusive thoughts David A. Clark a, Adam S. Radomsky b,n a b
University of New Brunswick, Canada Concordia University, Canada
art ic l e i nf o
a b s t r a c t
Article history: Received 15 January 2014 Received in revised form 9 February 2014 Accepted 11 February 2014
Because of Rachman and de Silva's (1978) influential research on normal and abnormal obsessions, it is now a basic tenet of cognitive behavioral theories (CBT) that clinical obsessions have their origins in the normal intrusive thought phenomena that characterizes the stream of consciousness. However much of the empirical research on unwanted intrusive thoughts has utilized retrospective self-report questionnaires that have weak construct validity and the samples have been drawn primarily from Western European and North American populations. To enhance the measurement precision and investigate the universality of unwanted intrusions, a structured intrusive thoughts interview was developed and administered to 777 nonclinical individuals drawn from 13 countries. The three papers in this special issue present findings based on this large data set. Together it was found that unwanted intrusive thoughts are reported by the majority of individuals in all countries, that significant cross-cultural differences are apparent in primary intrusive thought content, that faulty appraisals and confrontational control strategies are related to the distress of intrusions, and that the frequency of dirt/contamination, doubt, and miscellaneous intrusions are specifically related to obsessive compulsive symptom distress. The authors discuss these findings in terms of their consistency with predictions derived from the CBT perspective on obsessions. The special issue concludes with a discussion paper by Professor Jack Rachman, originator of the obessional intrusions concept. & 2014 Elsevier Inc. All rights reserved.
Keywords: Unwanted intrusive thoughts Obsessions Cross-cultural differences Cognitive behavioral theory of obsessions OCD
1. Introduction This year marks the 36th anniversary of Rachman and de Silva's (1978) seminal article that introduced the concept of unwanted intrusive thoughts as a potential etiological factor in the development of obsessive compulsive disorder (OCD). Their paper reported on three studies that sought to determine whether healthy, nonclinical individuals experience unwanted thoughts, images or impulses that are similar in content to clinical obsessions (i.e., thoughts of contamination, doubt, aggression, sexuality, etc.). In the first study based on an intrusive thoughts questionnaire 99/124 (80%) nonclinical individuals reported fairly frequent unwanted thoughts or images involving obsessional content, although they were considered fairly easy to dismiss. The second study consisted of a detailed interview of intrusive thoughts conducted on 40 nonclinical individuals and 8 patients with OCD. A list of 23 obsessions from the clinical sample and 58 obsessive-like intrusions from the nonclinical individuals were reproduced in the article and have since become the basis of numerous self-report measures of intrusive thoughts.
n Correspondence to: Department of Psychology, Concordia University, 7141 Sherbrooke St. West, Montreal, QC, Canada. E-mail address: [email protected] (A.S. Radomsky).
Comparison between the clinical and nonclinical samples revealed similarities in thought content, although the OCD patients reported greater frequency, discomfort and difficulty controlling their obsessions. In the third study OCD patients and nonclinical participants were asked to repeatedly form their obsession or intrusive thought. Habituation was evident in both samples, although the nonclinical group had more difficulty forming their intrusion upon request than the OCD patients. Although Rachman and de Silva's (1978) findings raised many questions about the nature of intrusive thoughts, it also provided the first empirical evidence that obsessions might have their origins in the normal thought processes that characterize the stream of consciousness. The conceptual significance of “normal obsessions” was subsequently emphasized in Rachman and Hodgson's (1980) text, Obsessions and Compulsions, which in many respects provides the theoretical underpinnings for contemporary cognitive-behavioral (CB) models of OCD. In their chapter entitled An Anatomy of Obsessions, the occurrence of unwanted, unacceptable intrusive thoughts or images initiated a process of faulty meta-cognitive appraisal and control efforts that could spiral into the development of obsessions. Later publications elaborating on a CBT model of obsessions and compulsions also reiterated the occurrence of mental intrusions as a key determinant in the pathogenesis of obsessions (e.g., Clark, 2004; Freeston, Rhéaume, & Ladouceur, 1996; Rachman, 1997, 1998;
http://dx.doi.org/10.1016/j.jocrd.2014.02.001 2211-3649 & 2014 Elsevier Inc. All rights reserved.
Please cite this article as: Clark, D. A., & Radomsky, A. S. Introduction: A global perspective on unwanted intrusive thoughts. Journal of Obsessive-Compulsive and Related Disorders (2014), http://dx.doi.org/10.1016/j.jocrd.2014.02.001i
2
D.A. Clark, A.S. Radomsky / Journal of Obsessive-Compulsive and Related Disorders ∎ (∎∎∎∎) ∎∎∎–∎∎∎
Salkovskis, 1985, 1989). Today the universality of obsession-related intrusive thoughts, images and impulses is a central tenet of CBT explanations for the development of obsessions. While the conceptual significance of the Rachman and de Silva (1978) publication cannot be overstated, their work has also had a significant impact on empirical research on unwanted intrusions. In the last three decades research on intrusions has taken two broad pathways; the most common approach is questionnaire based, whereas the other is more experimental, examining the impact of intentional mental control efforts on unwanted intrusive thoughts. These two broad research pathways are represented in the first and third studies reported in the Rachman and de Silva (1978) publication. Interestingly there has been little research that has employed the interview format; a neglect that we think is serious given the complexity of intrusive thoughts. There are important conceptual and methodological weaknesses that have been raised with questionnaire and experimental measurement of unwanted intrusive thoughts. Questionnaire measures of intrusions present individuals with a predetermined list of thought statements which respondents are then instructed to rate for frequency of occurrence. However concerns have been raised about the veridicality of these item responses (Brown & Clark, 2014). When individuals indicate that they frequently experience an unwanted intrusive thought by endorsing an item statement, does this reflect their actual memory of specific thought occurrences, or might it reflect an emotional state or self-identity that is congruent with the item content (Glass & Arnkoff, 1997)? In addition the content validity of many intrusive thought questionnaires is problematic because they can contain a broad range of negative thought content that often includes general anxiety and depressive thought content (Clark & Purdon, 1995). As well the lists of intrusions are always predetermined so how well these pre-established items represent the intrusive thought content of specific individuals is doubtful. Rachman (1981) has noted that unwanted mental intrusions are often quite idiosyncratic and triggered by external cues. Questions have also been raised about the specificity and discriminative validity of intrusive thoughts questionnaires (Julien, O’Connor, & Aardema, 2007). These are fundamental questions about the construct validity of retrospective self-report of unwanted intrusions that leave us uncertain about the interpretability of a high score on such measures. When a person indicates that s/he frequently has an intrusion (e.g., “I have unwanted intrusive thoughts, images or impulses of verbalizing something rude or embarrassing that would hurt a person's feelings”), is this based on memories of actual thought occurrences, recalling times when feeling anxious about one's verbal interaction, a single recent experience of “embarrassed verbalization”, or a self-identity that acknowledges you are the type of person who is concerned about your impact on others? In sum questionnaires may not be the most accurate method for assessing people's actual experience of unwanted intrusive thoughts. Unfortunately experimental approaches to the investigation of unwanted mental intrusions and their control also have significant drawbacks. The first problem is ecological validity. When an individual is brought into a laboratory setting and asked to produce an intrusive thought, it is no longer intrusive. The intentional production of the thought is no longer unwilful and so lacks generalizability to the spontaneous, unintended intrusions that occur in the natural world. As well, a diffusion of responsibility occurs such that the participant can now attribute responsibility to the experimenter for the generation of the intrusion rather than the self. This transfer of responsibility to the experimenter could significantly affect the participant's appraisal of the intrusive thought. Even if the intrusion is induced, difficulties arise because it may be difficult to ensure that the induction was
successful across all research participants. Finally, the control of unwanted negative thoughts under controlled laboratory conditions for very brief time periods will be quite different from the experience of repeated unwanted intrusions over an extended period of time in a context-rich, everchanging naturalistic setting. Thus the findings derived from laboratory-contrived intrusive phenomena raise questions about their relevance to the spontaneous, distressing intrusive thoughts, images and impulses that can “haunt” individuals in their everyday life.
2. Current research objectives The present research was initiated to address two major shortcomings in the intrusive thoughts literature. From a methodological perspective, our first objective was to explore the use of a structured interview format to assess individuals' experience of unwanted intrusive thoughts, images and impulses specifically related to the major themes of OCD; dirt/contamination, doubt, harm/injury, sex, religion/morality, and minor or miscellaneous themes. [Though not normally represented in obsessional fears, we also assessed intrusive thoughts about being a victim of violence because these thoughts may be common in nonclinical populations]. The use of an interview would allow us to collect qualitative data to ensure that participants reported on intrusive thoughts relevant to OCD rather than a range of negative thoughts that might be more relevant to worry, dysphoria or anger. In addition the qualitative information would help interpret the quantitative data on the phenomenology of intrusions and their sequellae (see below). Trained interviewers were provided with strict definitions and examples of obsession-relevant intrusive thoughts and participants' responses were written down for subsequent verification that the intrusion fit the study criteria. In addition the interview ensured that participants responded to the six types of obsessive intrusive thoughts and the interviewer could probe to ensure that participants really did experience an intrusion. Another advantage of the interview is that participants were asked to describe specific instances of the unwanted intrusion. This increased the likelihood that endorsement reflected actual thought occurrences rather than personal conjectures on the types of thoughts a person experiences. Thus our intention was to develop an interview that would provide a more accurate measurement of intrusive thought content highly specific to OCD. A second objective of the interview method was to provide a more comprehensive and detailed assessment of individual's appraisal and perceived control of their most distressing intrusive thought. First, general ratings of frequency, distress and control were collected on the six OCD-relevant intrusions. Then individuals selected their most distressing intrusion and detailed ratings of several appraisal and control constructs were obtained. This part of the interview utilized an endorsement approach with participants providing their own ratings on appraisal and control dimensions. Six point rating scales were used so individuals could rate their level of agreement to specific questions about their appraisal of the most distressing intrusion and frequency of using various mental control strategies. Our intent was to provide the participant with appraisal statements that accurately reflect the most common evaluative constructs in contemporary CBT theories of OCD, while keeping them broad enough to encompass a wide range of intrusive phenomena. In addition to these methodological considerations, we also wanted to investigate the cross-cultural expression of unwanted intrusive thoughts. The universality of unwanted intrusive thoughts is a central assumption of CBT theories of obsessions (Rachman, 2003). However, there are no published studies that have compared the occurrence of unwanted intrusions across
Please cite this article as: Clark, D. A., & Radomsky, A. S. Introduction: A global perspective on unwanted intrusive thoughts. Journal of Obsessive-Compulsive and Related Disorders (2014), http://dx.doi.org/10.1016/j.jocrd.2014.02.001i
D.A. Clark, A.S. Radomsky / Journal of Obsessive-Compulsive and Related Disorders ∎ (∎∎∎∎) ∎∎∎–∎∎∎
a diverse range of countries with varying social and cultural traditions. The majority of studies have documented the occurrence of intrusions in North American or Western European countries. A primary goal of the current research was to compare individuals' experience of obsession-relevant intrusive thoughts across several countries using the same assessment methodology that would allow a direct test of cultural influences on intrusions. Our intention was to conduct the first large-scale international study of unwanted intrusive thoughts in nonclinical individuals. This would provide the most direct test of the universality of unwanted mental intrusions.
3. History and development The idea for an international/cross-cultural study of OCD-related intrusions was first raised at one of the final meetings of the Obsessive Compulsive Cognitions Working Group (OCCWG) in Chambery, France in 2006. A cross-cultural working group was formed, initially consisting of OCCWG members (but later expanded). This group drafted a preliminary version of a structured interview for intrusive thoughts called the International Intrusive Thoughts Interview Schedule (IITIS). Initial elements of the IITIS included a carefully worded introductory section in which a variety of examples and definitions of obsessional intrusions were provided, as well as a number of content-related sections, asking about intrusions related to contamination, aggression, doubt, blasphemy, immorality, sex, victimization, and miscellaneous intrusions. The early IITIS incorporated questions about frequency, distress and challenges associated with dismissing intrusions, appraisals/interpretations of intrusions, and control strategies used by individuals to try to get rid of or otherwise manage their intrusions. The first meeting of a newly constituted research group called the Research Consortium on Intrusive Fear (RCIF) took place in Barcelona, Spain in 2007, at which point the membership was expanded beyond the OCCWG. In addition to continued drafting of IITIS elements, discussions at this meeting also began to include issues associated with translation and back-translation, training guidelines, and elements associated with study design (e.g., measures, samples, protocols, etc.). Successive drafts of the IITIS unfolded over the next few years, largely in light of problems that emerged with meaning and nuance during initial translation exercises. These were incrementally resolved, and once a final version of the IITIS was obtained, a standardized translation/backtranslation protocol was adopted by all authors. The IITIS (now in its 6th version) in English was translated by a team at each nonEnglish-speaking site containing at least one person familiar with research on OCD and intrusive thoughts. This produced translated versions of the IITIS in nine languages (English, Cantonese, French, Greek, Hebrew, Italian, Persian, Spanish, and Turkish). Each translated version was then back-translated to English by a separate team, and the back-translated versions were then sent to D. Clark and A. Radomsky for review. There were very few differences between the English IITIS and back-translated versions. Some of the more interesting differences that emerged were associated with the fact that some languages/cultures do not have a simple term or expression for ‘intrusive’. These issues were resolved collaboratively, and often involved a particular version of the IITIS using a phrase to convey the meaning of particular constructs rather than a specific word. Importantly, the phrase employed was assessed to determine if it mirrored the internal experience of those in the relevant culture/country. Whenever such issues arose, pivotal importance was placed on having the different linguistic versions of the IITIS be both equivalent to each other, and meaningful within the person's cultural context. These attributes were confirmed by fully bilingual members of the RCIF at each site (for a
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list of translators, consult the author list of the empirical articles in this issue). An initial pilot study of the IITIS, Version 6 was conducted between February and May, 2011; some of the primary questions we hoped to address included: Are unwanted intrusive thoughts normative human experiences across countries and cultures? Are there differences in the nature and types of intrusions reported across countries and cultures? Data from this initial piloting were presented and discussed at a meeting of the RCIF in Cordoba, Spain in 2011. At that meeting and shortly thereafter, new sites were added (e.g., Buenos Aires, Sierra Leone), and it was agreed that each site would collect additional data (to a requested total of approximately 50 nonclinical participants per site). Nearly all of these data were in place by the most recent meeting of the RCIF in Montreal in 2012, during which analysis and dissemination plans were developed, and strategies to complete data collection were discussed.
4. The special issue This special issue on cross-cultural expressions of unwanted intrusive thoughts consists of three papers that report on several findings from the same international study using the IITIS (v.6). The research group consists of 19 researchers from 13 countries who administered the IITIS (v.6) to 777 nonclinical individuals along with self-report measures of OCD symptoms, beliefs and negative affect. Due to the wealth of information contained within this dataset, and the many research questions we hoped to address, this special issue contains three papers designed to highlight different aspects of our findings. The first paper by Radomsky et al. (in this issue) addresses the question of whether or not unwanted intrusive thoughts, images and impulses are as common in an international context as they have previously been found to be in British or North American samples. This aspect of our work focused on providing information about the nature of intrusions and appraisals reported by participants; between-country comparisons of the frequency and content of unwanted intrusive thoughts are highlighted. In the second paper Molding et al. (in this issue) hierarchical linear modeling was utilized to examine cross-cultural differences in the relationship between appraisals and control of individuals' most distressing intrusive thoughts. The latter were categorized into repugnant (i.e., harm/injury, religious/immoral, sexual) and nonrepugnant (i.e., contamination/dirt, doubt, victim of violence) intrusions. Specifically, we sought to understand the degree to which theoretically derived appraisals were predictive of intrusive phenomenology, and how these relationships, if shown, vary from site to site and across different categories of intrusions. The third study by Clark et al. (in this issue) examined the relationship between unwanted intrusive thoughts and obsessional symptoms. We felt this to be important as very little work has been conducted to elucidate the connections between intrusive phenomenology and OCD symptoms, much less in an international context. This special issue on a global perspective on unwanted intrusive thoughts concludes with a commentary by Professor Jack Rachman. Professor Rachman can be considered the “founder of intrusive thoughts”, at least in reference to OCD, and so it is fitting that he should situate the current findings within the historical context of intrusions and cognitive-behavioral approaches to OCD.
Acknowledgments We are grateful for financial support for this research provided by an International Opportunities Fund Grant awarded to
Please cite this article as: Clark, D. A., & Radomsky, A. S. Introduction: A global perspective on unwanted intrusive thoughts. Journal of Obsessive-Compulsive and Related Disorders (2014), http://dx.doi.org/10.1016/j.jocrd.2014.02.001i
D.A. Clark, A.S. Radomsky / Journal of Obsessive-Compulsive and Related Disorders ∎ (∎∎∎∎) ∎∎∎–∎∎∎
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Drs. Clark and Radomsky from the Social Sciences and Humanities Research Council of Canada (Grant #861-2009-0076) and to Adriana del Palacio-Gonzalez for assistance during the data collection phase of the research. References Brown, G. P., & Clark, D. A. (2014). “Better the devil you know”? A conceptual critique of endorsement methods in cognitive therapy assessment. In: G. P. Brown, & D. A. Clark (Eds.), Cognitive therapy assessment, diagnosis and case formulation. (submitted for publication). Clark, D. A. (2004). Cognitive-behavioural therapy for OCD. New York: Guilford Press. Clark, D. A., Abramowitz, J., Alcolado, G. M., Alonso, P., Belloch, A., Bouvard, M., et al. (2014). Part 3. A question of perspective: The association between intrusive thoughts and obsessionality in 11 countries. Journal of Obsessive-Compulsive and Related Disorders (in this issue) Clark, D. A., & Purdon, C. L. (1995). The assessment of unwanted intrusive thoughts: A review and critique of the literature. Behaviour Research and Therapy, 33, 967–976. Freeston, M. H., Rhéaume, J., & Ladouceur, R. (1996). Correcting faulty appraisals of obsessional thoughts. Behaviour Research and Therapy, 34, 433–446. Glass, C. R., & Arnkoff, D. B. (1997). Questionnaire methods of cognitive selfstatement assessment. Journal of Consulting and Clinical Psychology, 65, 911–927.
Julien, D., O'Connor, K. P., & Aardema, F. (2007). Intrusive thoughts, obsessions, and appraisals in obsessive–compulsive disorder: A critical review. Clinical Psychology Review, 27, 366–383. Molding, R., Coles, M. E., Abramowitz, J. S., Alcolado, G. M., Alonso, P., Belloch, A., et al. (2014). Part 2. Do we dislike intrusive thoughts for the same reasons? Links between appraisals, control strategies and intrusions across countries. Journal of Obsessive Compulsive and Related Disorders (in this issue) Rachman, S. J. (1997). A cognitive theory of obsessions. Behaviour Research and Therapy, 35, 793–802. Rachman, S. J. (1981). Part I. Unwanted intrusive cognitions. Advances in Behaviour Research and Therapy, 3, 89–99. Rachman, S. J. (1998). A cognitive theory of obsessions: Elaborations. Behaviour Research and Therapy, 36, 385–401. Rachman, S. J. (2003). The treatment of obsessions. Oxford: Oxford University Press. Rachman, S., & de Silva, P. (1978). Abnormal and normal obsessions. Behaviour Research and Therapy, 16, 233–248. Rachman, S., & Hodgson, R. J. (1980). Obsessions and compulsions. Englewood Cliffs, NJ: Prentice Hall. Radomsky, A. S., Alcolado, G. M., Abramowitz, J., Alonso, P., Belloch, A., Bouvard, M., et al. (2014). Part 1. You can run but you can't hide: Intrusive thoughts on six continents. Journal of Obsessive Compulsive and Related Disorders (in this issue) Salkovskis, P. M. (1985). Obsessional-compulsive problems: A cognitive-behavioural analysis. Behaviour Research and Therapy, 23, 571–583. Salkovskis, P. M. (1989). Cognitive-behavioural factors and the persistence of intrusive thoughts in obsessional problems. Behaviour Research and Therapy, 27, 677–682.
Please cite this article as: Clark, D. A., & Radomsky, A. S. Introduction: A global perspective on unwanted intrusive thoughts. Journal of Obsessive-Compulsive and Related Disorders (2014), http://dx.doi.org/10.1016/j.jocrd.2014.02.001i