Appraisals of and recommendations for managing intrusive thoughts: An empirical investigation

Psychiatry Research 245 (2016) 207–216

Contents lists available at ScienceDirect

Psychiatry Research journal homepage: www.elsevier.com/locate/psychres

Appraisals of and recommendations for managing intrusive thoughts: An empirical investigation Alina Z. Levine, Debbie M. Warman n University of Indianapolis, School of Psychological Sciences, 1400 East Hanna Avenue, Indianapolis, IN 46227, USA

art ic l e i nf o

a b s t r a c t

Article history: Received 31 August 2015 Received in revised form 10 July 2016 Accepted 13 August 2016 Available online 15 August 2016

The present study investigated strategies for managing intrusive thoughts. Eighty undergraduate students read vignettes of intrusive thoughts – blasphemous, sexual, and violent – which varied in frequency of the thought (high or low) and who experienced the thought (self or other). Appraisal ratings of thoughts were completed and participants completed a response strategy survey where they indicated how much they would endorse various methods for dealing with the thoughts. Some response strategies were theorized to help with intrusive thoughts and some were theorized to be unhelpful. Measures of obsessive-compulsive tendencies were completed to determine relationships between beliefs and appraisals as well as responses to the intrusive thoughts. Results indicated the more distressing a thought was perceived to be, the more likely participants were to recommend unhelpful strategies. Conversely, the less distressing the thought was, the more likely participants were to recommend helpful strategies. Ratings of distress and patterns of responses were related to obsessive-compulsive beliefs as well. Findings are discussed in terms of their relationship to the cognitive behavioral model of OCD, intrusive thoughts, and how future work may serve to educate and reduce stigma related to these common yet distressing experiences. & 2016 Elsevier Ireland Ltd. All rights reserved.

Keywords: Obsessive-compulsive disorder Intrusive thoughts Stigma Cognitive behavior therapy Mental health

1. Introduction Although it is widely known that individuals with ObsessiveCompulsive Disorder (OCD) are distressed by their intrusive thoughts (e.g., Ólafsson et al., 2014), limited attention has been paid to how individuals in the general population perceive others with intrusions or how they would interpret hypothetical intrusive thoughts if they experienced them themselves (see Corcoran and Woody, 2008). What little research has been conducted in the area of perceptions of intrusive thoughts demonstrates that individuals with such thoughts are evaluated negatively (e.g., Simonds and Thorpe, 2003). It is possible this negative evaluation would influence recommendations people make for how to deal with the thoughts, though this has, to date, not been tested. The present study served to expand upon previous work exploring factors related to the evaluation of intrusive thoughts, such as the frequency of intrusive thoughts (Corcoran and Woody, 2008), the person experiencing the intrusive thoughts (Cathey and Wetterneck, 2013), and the type of thought experienced (Corcoran and Woody, 2008), and determining if these factors are related to how individuals would anticipate behaving in response to, or n

Corresponding author. E-mail address: [email protected] (D.M. Warman).

http://dx.doi.org/10.1016/j.psychres.2016.08.040 0165-1781/& 2016 Elsevier Ireland Ltd. All rights reserved.

recommending others behave in response to, these intrusions. Although a consistent relationship has been found in terms of how individuals with OCD respond to their thoughts, by using thought suppression or behaviors such as compulsions that appear to increase, rather than decrease the likelihood that the thoughts occur (Parrish and Radomsky, 2010), it remains unknown how personal evaluations of thoughts in the general population relate to the perceived benefit of various strategies for managing these intrusions. Such an investigation would help develop theories for why people engage in certain behaviors in response to intrusive thoughts, despite the data indicating such behaviors are unhelpful (e.g. Salkovskis et al., 1997). One explanation for why intrusive thoughts are evaluated so poorly is that these thoughts are not generally identified as being due to OCD. Research has demonstrated that participants generally have no knowledge that “taboo” thoughts may occur at a high frequency for individuals with OCD and, thus, mislabel the problem the person is having (Warman et al., 2015). It is not surprising individuals in the general population struggle with identifying symptoms of OCD (Coles et al., 2013), as even mental health clinicians struggle with identifying taboo thoughts as symptoms of OCD (Glazier et al., 2013). In a recent study, Warman et al. (2015) demonstrated that even when participants were told a person with violent thoughts had OCD, the OCD diagnosis was rejected. In contrast to Cognitive Behavioral Theory, which posits intrusive

208

A.Z. Levine, D.M. Warman / Psychiatry Research 245 (2016) 207–216

thoughts are meaningless thoughts given too much significance by the person (e.g., Salkovskis, 1989), taboo thoughts often are considered significant and meaningful thoughts to people and, thus, are evaluated negatively (e.g., Corcoran and Woody, 2008). This is particularly true for individuals who have high levels of OCD beliefs, even when investigations have not been limited to individuals with OCD, but have examined these relationships in individuals in the general population or participants from university participant pools (e.g., Corcoran and Woody, 2008). Although vignette research of intrusive thoughts is rare, as noted earlier preliminary data suggests taboo thoughts are perceived negatively. Simonds and Thorpe (2003) presented vignettes to participants that varied in terms of their OCD presentations and found the target with violent thoughts was perceived the most negatively. Further, Cathey and Wetterneck (2013) found sexual taboo thoughts were perceived more negatively than intrusive thoughts related to contamination. In sum, of the limited research conducted to date of perceptions of individuals with OCD, individuals with intrusive taboo thoughts are rated the most negatively. In arguably the most comprehensive experimental examination of perceptions of intrusive thoughts associated with OCD, Corcoran and Woody (2008) found a number of factors related to appraisals of taboo intrusive thoughts. In their first study, they manipulated the person in their vignette who experienced the occasional intrusive thought presented – the self or another person – and found participants did not report finding the occasional intrusive thoughts in the vignettes too significant, regardless of the thought's source. They did find, however, that the perceived significance of the thought varied depending on the theme of the thought; violent obsessions were seen as the most significant. Although the initial study found no difference between self and other, the study only explored thoughts occurring at a low frequency, which has consistently been shown to correlate with low appraisals of personal significance. Cathey and Wetterneck (2013) additionally found compelling and conflicting evidence that disclosure of an intrusion by a friend was judged more harshly than disclosure of one by a significant other. As personal responsibility is a factor considered highly related to evaluations made by individuals with OCD in response to their intrusive thoughts (e.g. Barrera and Norton, 2011), continued investigation of how people make evaluations of intrusive thoughts and how these evaluations are related to whether they are experienced by the self or another person, particularly under conditions considered more disturbing, such as when the thought occurs at a high frequency (Corcoran and Woody, 2008) is valuable. Although Corcoran and Woody's (2008) first experimental investigation examined only thoughts that occurred at a low frequency, a second study they reported varied how often the person in the vignette experienced the thought. As expected, taboo thoughts that happened at a higher frequency were evaluated as more significant than low frequency thoughts. In contrast to their first study, the sexual thought emerged as the most distressing in their second study. In addition, they found individuals with higher levels of OC related beliefs rated the intrusive thoughts to be particularly meaningful, regardless of the frequency of the thought. Corcoran and Woody's studies are unique in their investigation of perceptions of taboo thoughts and participants’ appraisals of such thoughts. What remains unclear is how these negative interpretations of intrusive thoughts might be related to strategies individuals would recommend for dealing with such thoughts and how those strategies may relate to OC related beliefs. Individuals with OCD often use unhelpful strategies, or strategies with the potential to backfire by increasing frequency of and distress associated with an intrusion, to manage such upsetting thoughts (e.g., Rachman, 1997). While for many, these thoughts

and reactions to them can be absorbed within a normal mood state (see Julien, O′Conner, and Aardema, 2007, for a review), for others, such as those with OCD, neutralization, thought suppression, or rituals may increase the overwhelming personal significance assigned to the thought (Abramowitz, 2006). Cognitive Behavioral Therapy works to reduce misinterpretation of intrusions and reduce the use of strategies, such as thought control or avoidance, which may paradoxically increase thought frequency rather than reduce it (Rachman, 2003). Other treatment types, such as stress management training, have also shown promise in reducing the experience of obsessional thoughts (Woody et al., 2011). It is noted that appraisals may also follow a reduction in obsessions through treatment rather than predict them (Woody et al., 2011). This body of research has focused extensively on the potential relationships between appraisal and type of therapy on the experience of intrusive thoughts. However, it has yet to be extended to study the relationship between appraisal, factors related to evaluation of intrusive experiences (including thought content, frequency, and who is experiencing the thought), and specific strategies, such as thought suppression, avoidance, or acceptance, which the literature has identified as common responses to intrusive experiences. This comprehensive study could provide fruitful contribution to the understanding, assessment, and treatment of intrusive thoughts. Given the extant findings reviewed above and the questions left unanswered to date, we posed the question of what participants would do when asked what they would recommend to a person experiencing intrusive thoughts in vignettes and how this would relate to the frequency of the intrusive thought, the content of the intrusive thought, the person experiencing the thought, and levels of OC related beliefs. Given Corcoran and Woody's (2008) comprehensive investigation of many of these variables, we utilized their general methodology but sought to make it more comprehensive by investigating the person experiencing the thought as well as how participants would respond to the thoughts or make recommendations for someone else experiencing such thoughts. The survey completed listed helpful and unhelpful strategies for dealing with intrusive thoughts that were determined from a review of the literature (e.g. Berry et al., 2010). We tested a number of hypotheses in the present study. First, we expected, following the findings of Corcoran and Woody, to find that high frequency taboo thoughts would be interpreted more negatively than low frequency thoughts. Corcoran and Woody (2008) found no effect for self vs. other in their study, but they limited their examination of self vs other to low frequency thoughts, a condition perceived less negatively than high frequency thoughts in one of their investigations. As a result, we expected no self vs other effect to emerge in our low frequency conditions. However, as personal responsibility is linked to increased distress associated with intrusive thoughts (Parrish and Radomsky, 2010), participants were expected to evaluate intrusive thoughts more negatively if experienced by the self than if reported by another in the high frequency condition, as the high frequency condition has been shown to be considered more meaningful (Corcoran and Woody, 2008). Corcoran and Woody found conflicting results in terms of which taboo thought was the most distressing to participants, and therefore, we did not have a specific hypothesis for which would be interpreted the most negatively. Corcoran and Woody did, however, find across both of their studies that the blasphemous thought was seen in the least negative light. As a result, we expected to find the least negative appraisals for the blasphemous thought. Consistent with Corcoran and Woody, we also expected appraisals of significance of the thoughts to be stronger for individuals with higher OC related beliefs. As individuals with OCD adopt unhelpful strategies to deal

A.Z. Levine, D.M. Warman / Psychiatry Research 245 (2016) 207–216

with thoughts they find distressing and meaningful (e.g., Rachman, 1997), it was expected that the higher the negative evaluation for the thought (indicating they may find them more disturbing and more meaningful), the more participants would endorse strategies that are unhelpful. In addition, as previous research has suggested that pre-existing belief systems guide how cognitions or intrusions are understood and appraised (e.g. Teachman et al., 2006), we expected individuals with higher levels of OC related beliefs to endorse more unhelpful strategies than individuals with lower levels of OC related beliefs.

209

The researchers based the development of the scale on the Personal Significance Scale (Rachman, 2003), the Distressing Thoughts Questionnaire (Clark and de Silva, 1985) and the Responsibility Interpretations Questionnaire (Salkovskis et al., 2000), which are used commonly to assess obsessive-compulsive tendencies (Corcoran and Woody, 2008). This process resulted in 16 questions assessing the personally meaningful appraisal of the intrusive thought, for which the participant endorsed each item on a 0 (not at all) to 8 (totally/definitely) Likert scale. These items were summed to produce a “total score,” with range from 0 (each item appraised as not at all significant) to 128 (each of the 16 items endorsed at the highest significance rating, an 8).

2. Method 2.1. Participants Eighty participants were recruited from a university in the Midwest. Participants received course credit for their participation. In order to be eligible for the study, participants were required to be over the age of 18, be able to read and write English, and be able to provide informed consent. See Table 1 for sample demographics. 2.2. Materials 2.2.1. Vignettes The present study included a total of twelve vignettes (adapted from Corcoran and Woody, 2008) that asked participants to imagine having, or having a close friend report, the experience of aggressive, blasphemous or sexual intrusive thoughts. Each thought content type was constructed in a total of four ways, which varied in terms of the source of the intrusive thought (self or other) and frequency of the intrusive thoughts (low or high), following the procedures of Corcoran and Woody (2008). Therefore, in total there were four conditions for the study: 1) self – lowfrequency condition; 2) self – high-frequency condition; 3) other – low-frequency condition; 4) other – high-frequency condition. For each of the conditions, participants responded to a total of three vignettes – one sexual, one aggressive and one blasphemous. Participants were randomly assigned to one of the four conditions. See Appendix A for vignettes. 2.2.2. Appraisal ratings Following each vignette, participants were asked to complete Corcoran and Woody's (2008) Appraisal Ratings Questionnaire.

2.2.3. Obsessional Beliefs Questionnaire (OBQ-44) The OBQ-44 is a 44-item self-report inventory of statements used to measure characteristics of obsessive thinking and beliefs, including responsibility and threat estimation, perfectionism and intolerance for uncertainty, and importance and control of thoughts (OCCWG, 2005). The OBQ-44 has been shown to be a reliable and valid measure of obsessive-compulsive related beliefs, as the internal consistency across the subscales ranged from, r's ¼.64–.72, within non-clinical samples, and the content validity for each domain to range from, r's ¼.89–.93, (Obsessive-Compulsive Cognitions Working Group, 2003, 2005). This scale is a popular way to examine the continuum of obsessive beliefs in the general population or undergraduate samples as part of university participant pools (e.g., Brand, McKay, Wheaton, and Abramowitz, 2013; Corcoran and Woody, 2008). 2.2.4. Thought-Action Fusion Scale (TAF) The TAF is a 19-item questionnaire that measures the level of fusion between thoughts and actions (Shafran et al., 1996). Research has found this scale to be valid and reliable, as TAF scores have found to be stable over time (r ¼0.52), and have been found to be significantly correlated with self-reports of obsessional problems (e.g., Shafran and Rachman, 2004). The TAF has been also used with samples recruited from participant pools at universities in an effort to understand the continuum of thoughtaction fusion in the general population (e.g., Barrera and Norton, 2011). 2.2.5. Response strategies survey For each vignette, participants were presented a form that listed 5 potentially helpful ways of dealing with intrusive thoughts (based on findings from previous research) and 5 potentially

Table 1 Sample demographics as a function of study condition. Conditions Self

Self

Low frequency

High frequency *

%

15.8 84.2

3 18

78.9 15.8 5.3 0 4.19

15 4 1 1 20.90

%

Sex Male Female

3 16

Race Caucasian African American Hispanic Other Age þ

15 3 1 0 21.11

Percentages are reported for number of participants in each condition. Age is reported in mean and standard deviation.

þ

Other

Low frequency

N

N

*

Other

*

High frequency N

%*

10.0 90.0

5 15

75.0 25.0

89.5 5.3 0 5.3 1.79

14 3 0 3 21.25

70.0 15.0 0 15.0 3.51

N

%

85.7 14.3

2 18

71.4 19.0 4.8 4.8 5.99

17 1 0 1 20.05

*

210

A.Z. Levine, D.M. Warman / Psychiatry Research 245 (2016) 207–216

Table 2 Response strategy items for each vignette by type of strategy.

Aggressive Vignette

Potentially unhelpful strategies*

Potentially helpful strategies*

1. Tell yourself to stop thinking about it 4. Say ‘I love my niece’ three times whenever you have the thought

2. Just ignore it and do nothing 3. Let yourself experience the thought until it isn’t distressing anymore 5. Accept that the thought is just a thought

6. Pray, silently in your head, that you won’t hurt her until the thought passes 7. When you have the thought, stay out of the same room as your niece 8. Just take notice of the thought, and let it pass 9. Avoid babysitting, and/or kitchen knives 10. Tell yourself that it's normal to sometimes have weird, random thoughts Sexual Vignette

1. Tell yourself to stop thinking about it 4. Say ‘sex with my brother is wrong’ three times whenever you have the thought 6. Say a prayer silently in your head until the thought passes 7. When you have the thought, get out of the car or don’t look at your brother 9. Avoid any alone time with your brother

2. Just ignore it and do nothing 3. Let yourself experience the thought until it isn’t distressing anymore 5. Accept that the thought is just a thought 8. Just take notice of the thought, and let it pass 10. Tell yourself that it's normal to sometimes have weird, random thoughts

Blasphemous Vignette 1. Tell yourself to stop thinking about it 4. Do three extra prayers every time you have the thought

2. Just ignore it and do nothing 3. Let yourself experience the thought until it isn’t distressing anymore 6. Think about your love of God until the thought passes 5. Accept that the thought is just a thought 7. When you have the thought, stop your prayer and walk away from your 8. Just take notice of the thought, and let it pass Bible 9. Avoid praying silently or touching a Bible 10. Tell yourself that it's normal to sometimes have weird, random thoughts

*

items are listed by item number as indicated on each survey.

unhelpful ways of dealing with intrusive thoughts (based on findings from previous research) which were intermingled on the form. For each of the 10 items on the form, participants were asked how likely, on a Likert scale, from 0 (“not at all”) to 100 (“definitely”), they would be to either use the response strategy outlined themselves – if they were assigned to the “self” condition – or recommend the response strategy to someone else – if they were assigned to the “other” condition. Potentially helpful and potentially unhelpful scores were determined by averaging the total Likert scale endorsement for each of the five helpful and unhelpful items for each vignette, so scores could range from 0 to 100 for helpful strategies and 0–100 for unhelpful strategies. Each vignette had its own response strategies that were designed to be relevant to the intrusive thought itself and were, thus, considered separate scores. Thus, in summary, each participant had 6 Response Strategy Scores, one “helpful response strategy” score for each of the 3 types of intrusive thoughts, and one “unhelpful response strategy” score for each of the types of intrusive thoughts. The items for the Response Strategy Surveys can be found in Table 2.

first in order to determine their relationships to each of the dependent variables in the study – appraisal ratings for each of the three vignettes (sexual, blasphemous and aggressive) and response strategy recommendations (potentially helpful or potentially unhelpful) for each of the three vignettes. None of the variables was related (age all p's4.05, sex all p's4 .16 and race all p's4.05) and, so, will not be considered further. Of note, our student sample was overall, based on responses to the OBQ-44, more anxious (M ¼153.8; SD ¼39.68) as compared to the OCCWG (2005) original Student Control norm group (M ¼ 131.3, SD ¼ 44.3. Instead, the group means more closely resembled the Anxious Control group (M ¼159.3; SD ¼53.0) from the OBQ-44's development. For means and standard deviations of all measures and dependent variables, see Table 3. 3.2. Primary analyses 3.2.1. OC Related beliefs and appraisal ratings of thoughts Correlational analyses were conducted to test the hypothesis that higher OC related beliefs would be related to higher appraisal ratings of significance of the thoughts. Correlational analyses

2.3. Procedure Participants completed the study in groups of up to five individuals, following the general procedures of Corcoran and Woody (2008). Participants were given a paper and pencil packet of materials and were told to complete all items of the packet in order. The packet included a demographic questionnaire, three vignettes presented in a randomized order, an Appraisal Ratings Questionnaire for vignette, and a response strategy survey for each vignette.

3. Results 3.1. Preliminary analyses The demographic variables of age, sex and race were examined

Table 3 Means and standard deviations for all measures and dependent variables. Mean

Standard Deviation

153.8 25.63 35.61 66.63 48.13

39.68 12.91 21.84 30.96 25.92

Average of unhelpful strategies for the blasphemous vignette violent vignette Sexual vignette

46.13 61.32 52.98

19.42 23.17 23.81

Average of helpful strategies for the blasphemous vignette violent vignette Sexual vignette

52.81 45.25 47.01

20.51 20.83 19.31

Obsessive Beliefs Questionnaire  44 Thought Action Fusion Scale Appraisal rating for the blasphemous vignette violent vignette Sexual vignette

A.Z. Levine, D.M. Warman / Psychiatry Research 245 (2016) 207–216

Table 4 Correlations measures.

between

average

appraisal

ratings

and

obsessive-compulsive

Average Appraisal Ratings

OBQ – 44 (total) OBQ – Responsibility/ Threat Estimation OBQ – Perfectionism/ Certainty OBQ – Importance/Control of Thoughts TAF (total) TAF –Moral TAF – Likelihood Other TAF – Likelihood Self

Blasphemous Vignette

Sexual Vignette

Violent Vignette

.367** .320**

.268* .205

.280* .198

.242*

.082

.101

.155

.148

.062

***

.363 .302** .242* .318**

**

.295 .265* .217 .171

.272* .226* .186 .191

*

indicates correlation is significant at the .05 level. ** indicates correlation is significant at the .01 level. *** indicates correlation is significant at the .001 level.

between the appraisal ratings of each of the three vignettes (blasphemous, sexual, violent) and the two obsessive-compulsive measures that were included in this study – the Obsessional Beliefs Questionnaire – 44 (OBQ-44), both its total and its 3 components, and the Thought-Action Fusion Scale (TAF), both its total and its 3 components. As displayed in Table 4, the OBQ-44 and the TAF total scores were significantly related to the appraisal ratings for each of the 3 vignettes; there was support for our hypothesis that higher levels of OC related beliefs would be related to higher levels of personal significance given to the intrusive thoughts. When examining the OBQ-44 in terms of its specific components, significant relationships emerged only for the blasphemous vignette and were significant for two OBQ-44 components, Responsibility/Threat Estimation and Perfectionism/Certainty. For the TAF, only the Moral subscale emerged as related to all 3 vignettes when examined in terms of specific components of the scale, though all 3 components of the scale (Moral, Likelihood-Other and Likelihood-Self) were related to appraisals of the Blasphemous vignette. Of note, the OBQ-44 total score and the TAF total score were significantly correlated in our sample, r ¼.34, p ¼.006. 3.2.2. Appraisal ratings and condition assignment It was expected that higher frequency thoughts would be related to higher appraisals of significance of the thoughts, that blasphemous thoughts would be appraised as the least significant, and that those in the self condition would endorse higher appraisal ratings than those in the other condition for the high frequency thoughts (i.e., in the high frequency condition). To test these hypotheses, a 2 (Frequency Level: High versus Low) x 2 (Self versus Other) x 3 (Type of Intrusive Thought: Sexual, Blasphemous and Violent) Mixed Model ANOVA was conducted with Frequency Level and Self versus Other as between group variables, and Type of Intrusive Thought (sexual, blasphemous and violent) as the within group variable. A main effect for Type of Intrusive Thought emerged, F(2, 146) ¼75.41, p o.001, ηp2 ¼.51. This main effect was subsumed by a Type of Intrusive Thought x Self versus Other interaction, F(2, 146) ¼3.23, p ¼.04, ηp2 ¼ .04. Follow up tests indicated no differences between the Self vs. Other groups for any of the 3 vignette types (all p's4 .24). For the Self and the Other conditions, patterns of appraisals were the same for the intrusive thoughts: violent thoughts were given the highest appraisal ratings, (M ¼62.6, SD ¼34. 56 for Self condition; M ¼70.77, SD ¼27.16 for Other condition), followed by the sexual thoughts (M ¼48.95, SD ¼29.12 for the Self condition; M¼ 47.33, SD ¼22.72 for the Other condition) and then by the blasphemous thoughts

211

(M ¼37.40, SD ¼22.51 for the Self condition; M¼33.75, SD ¼21.57 for the Other condition), all of which differed from one another. The magnitude of the difference in appraisals between violent thoughts relative to sexual thoughts was significantly greater for individuals in the Other group (M¼ 23.21, SD ¼22.58) than it was for individuals in the Self group (M ¼12.36, SD ¼18.03), t(76) ¼  2.13, p ¼.04. The same pattern emerged for violent thoughts relative to blasphemous thoughts – the magnitude of the difference in appraisals between violent thoughts relative to blasphemous thoughts was greater for individuals in the Other group (M ¼36.87, SD ¼24.71) than it was for individuals in the Self group (M ¼25.15, SD ¼25.63) t(76) ¼  2.06, p ¼.04. The magnitude of the difference in appraisals for the sexual thoughts relative to violent thoughts was similar across the Self and Other groups (M ¼12.03, SD ¼19.79, M¼13.58, SD ¼19.51, respectively), t(76) ¼ .  .35, p ¼.73. 3.2.3. Response strategies survey For the Response Strategies Survey, Chronbach's alphas were determined separately for the surveys for each of the three types of intrusive thoughts (blasphemous, aggressive, and sexual) since the wording was slightly different for each. In addition, Chronbach's alphas are reported separately for the 5 potentially helpful strategies and the 5 potentially unhelpful strategies, as they were considered separate survey components. For the Blasphemous Response Strategies Questionnaire, Chronbach's alpha for the Helpful strategies was .676 and for Unhelpful strategies was .681. For the Sexual Response Strategies Questionnaire, Chronbach's alpha for Helpful strategies was .625 and for Unhelpful strategies was .754. For the Violent Response Strategies Questionnaire, Chronbach's alpha was .763 for Unhelpful strategies and for Helpful strategies was .693. Thus, all of the internal consistencies fell in at least the acceptable range. 3.2.4. Recommendations for unhelpful strategies and OC related beliefs It was expected that individuals with higher levels of OC related beliefs would report being more likely to recommend unhelpful strategies on the Response Strategies Survey than individuals with lower levels of OC related beliefs. To test this, correlational analyses were conducted to examine these relationships. Results supported this hypothesis, as endorsement of unhelpful strategies for each of the vignettes was significantly related to participants’ levels of OC-related beliefs, as determined by both the OBQ-44 total score and the TAF total score (see Table 5). When examining the OBQ-44 in terms of its specific components, only Responsibility/Threat Estimation remained related to endorsement of unhelpful strategies for all 3 vignettes. Perfectionism/ Certainty was not related to any of the vignettes and Importance/ Control of Thoughts was related to both the Blasphemous and Sexual vignettes, but not the Violent vignette. The TAF moral subscale was the only subscale of the TAF that showed relationships with all three vignette appraisals. The only other significant relationship between the TAF components and unhelpful strategies was a significant relationship between TAF Likelihood Self and the Sexual vignette. 3.2.5. Recommendations for unhelpful strategies and condition assignment It was expected that recommendations for unhelpful strategies would be higher in conditions that were expected to be more significantly appraised. Specifically, it was expected that individuals would endorse more agreement with unhelpful strategies in the high frequency than in the low frequency condition and that they would endorse more agreement with unhelpful strategies in the self than in the other condition, when thoughts occurred at a high frequency. To test these hypotheses, a 2

212

A.Z. Levine, D.M. Warman / Psychiatry Research 245 (2016) 207–216

Table 5 Correlations between obsessive-compulsive measures and potentially unhelpful strategies. Number of potentially unhelpful strategies recommended

OBQ – 44 OBQ – Responsibility/ Threat Estimation OBQ – Perfectionism/ Certainty OBQ – Importance/Control of Thoughts TAF TAF –Moral TAF – Likelihood Other TAF – Likelihood Self * **

Blasphemous Vignette

Sexual Vignette

Violent Vignette

.424** .395**

.385** .331**

.356** .286*

.193

.108

.128

.343

**

.290 .360** .007 .035

**

.172

**

.280 .273* .142 .144

.353

.329 .306** .216 .223*

indicates correlation is significant at the .05 level. indicates correlation is significant at the .01 level.

(Frequency Level: High versus Low) x 2 (Self versus Other) x 3 (Type of Intrusive Thought: Sexual, Blasphemous and Violent) Mixed Model ANOVA was conducted, with Type of Intrusive Thought as the within subject variable and Self versus Other and Frequency Level as between group variables. A main effect for Type of Intrusive Thought emerged, F(2, 150) ¼ 24.75, p o.001, ηp2 ¼.25, which was subsumed by a Type of Intrusive Thought by Frequency Level interaction, F(2, 150) ¼3.63, p ¼.03, ηp2 ¼ .05, which is displayed in Fig. 1 and outlined below. Follow-up tests were conducted to determine within group differences (i.e., differences across the 3 vignettes for individuals in the low and then in the high frequency groups). Individuals in the Low-Frequency condition endorsed similar likelihood to use unhelpful strategies for the blasphemous intrusive thought as they did for the sexual intrusive thought (M ¼50.72, SD ¼ 19.98; M¼ 52.26, SD ¼ 21.71, respectively), but recommended increased likelihood to use unhelpful strategies for the aggressive vignette (M ¼61.49, SD ¼21.11), than they did for either of the other two vignettes. Individuals in the High-Frequency condition endorsed the lowest level of agreement with unhelpful strategies for the blasphemous vignette (M ¼41.76, SD ¼18.04), followed by the sexual vignette (M ¼53.66, SD ¼25.91), and endorsed the highest level of agreement for unhelpful strategies for the aggressive intrusive thoughts (M¼61.15, SD ¼ 25.29), all of which differed from one another. Follow-up tests were also conducted to determine between group (i.e., Frequency Level) differences for each of the 3 vignettes.

Individuals responding to the Low-Frequency blasphemous vignette showed higher endorsement of unhelpful strategies (M¼ 50.72, SD ¼19.98) than did individuals responding to the High-Frequency blasphemous vignette (M¼ 41.76, SD ¼18.04), t (78) ¼2.11, p ¼.04. Individuals in the High and Low-Frequency conditions endorsed similar agreement with unhelpful strategies for the sexual vignette, t(78) ¼  .26, p¼ .79, and for the aggressive vignette, t(77)¼.06, p¼ .95. No other significant effects emerged. 3.2.6. Recommendations for helpful strategies and OC related beliefs It was expected that higher OC-related beliefs would be related to less endorsement of helpful strategies on the Response Strategies Survey. Correlational analyses were conducted to determine the relationship between scores on the OBQ-44 and TAF and levels of endorsement of potentially helpful strategies for dealing with the intrusive thoughts in the vignettes. The only significant relationship that emerged was between the OBQ-44 total and helpful strategies recommended for the sexual thought (see Table 6). No significant relationships emerged for TAF total. Thus, in contrast to the findings for unhelpful thoughts, for which the OBQ and TAF totals were related to all of the vignettes, the overall finding for helpful strategies and OC related beliefs is that there was no relationship. When examining the OBQ-44 in terms of its components, increased agreement with helpful strategies was related to higher levels of Responsibility/Threat Estimation and also Perfectionism/Certainty for the Sexual vignette. In addition, higher levels of Perfectionism/Certainty was related to more endorsement of helpful strategies for the Violent vignette. Higher levels of Importance/Control of Thoughts was also related to increased endorsement of helpful strategies for the Blasphemous vignette. When examining the TAF in terms of its components, results remained minimal. The only relationship that emerged was that TAF-Likelihood Self was related to recommendations for helpful strategies in the Violent vignette. 3.2.7. Recommendations for helpful strategies and condition assignment It was expected that helpful strategies would be recommended on the Response Strategies Survey in a manner consistent with hypotheses for appraisal of significance, such that conditions expected to elicit more beliefs of personal significance were expected to result in lower endorsements of helpful strategies for dealing with the thoughts. Specifically, lower frequency thoughts were hypothesized to be related to increased endorsement of helpful strategies. Furthermore, thoughts reported by another person were expected to be related to more recommendations of helpful strategies as compared to those experienced by oneself in the high frequency condition. In order to test these hypotheses, a 2

Fig. 1. Mean number of “unhelpful” strategies recommended for each of the vignettes as a function of frequency of the thought.

A.Z. Levine, D.M. Warman / Psychiatry Research 245 (2016) 207–216

Table 6 Correlations between obsessive-compulsive measures and potentially helpful strategies. Number of helpful strategies recommended Blasphemous Vignette OBQ – 44 OBQ – Responsibility/ Threat Estimation OBQ – Perfectionism/ Certainty OBQ – Importance/Control of Thoughts TAF TAF –Moral TAF – Likelihood Other TAF – Likelihood Self

 .024 .068 .184

Sexual Vignette

Violent Vignette

.274* .249*

.169 .224

.392**

.249*

 .291*

 .076

 .005

 .146  .217  .037 .091

 .145  .185  .028 .043

.120 .039 .159 .252*

(Frequency Level: High versus Low) x 2 (Self versus Other) x 3 (Type of Intrusive Thought: Sexual, Blasphemous and Violent) Mixed Model ANOVA was conducted, with Type of Intrusive Thought as the within subject variable and Self versus Other and Frequency Level as between group variables. A main effect emerged for the Type of Intrusive Thought, F(2, 148) ¼8.26, p o.001, ηp2 ¼.10. Follow up tests indicated that individuals had higher endorsement of potentially helpful strategies when responding to the blasphemous vignette (M ¼53.31, SE ¼2.21), than they did when responding to the sexual (M¼ 46.83, SE ¼2.16) or aggressive vignette (M¼ 44.98, SE¼2.29), which did not differ from one another. No other significant effects emerged. 3.2.8. Relationship between appraisals and strategy recommendations It was expected that more significant participants considered thoughts to be, the less they would endorse possibly helpful, and the more they would endorse the use of potentially unhelpful, strategies on the Response Strategies Survey. Correlational analyses were conducted to test this hypothesis (see Table 7). For blasphemous thoughts, there was no relationship between appraisal ratings and endorsement of helpful strategies, but higher appraisals of significance for blasphemous thoughts were associated with increased endorsement of unhelpful strategies. For sexual thoughts, it was found that the higher the appraisals of significance, the lower the likelihood of recommending helpful strategies and the higher the likelihood of recommending

213

unhelpful strategies. For violent thoughts, the same pattern as the sexual thoughts emerged. The higher the appraisals were for violent thoughts, the lower the likelihood of recommending helpful strategies and the higher the likelihood of recommending unhelpful strategies. Correlations for appraisals of the 3 intrusive thoughts were all significantly and positively related to one another, as were unhelpful strategies for all 3 vignettes, and the helpful strategies for all 3 vignettes. For the sexual and the violent vignettes, the relationship between the average endorsement of helpful and unhelpful strategies was significantly negatively correlated for the sexual and for the violent vignette, though no relationship emerged for the blasphemous vignette. In sum, the more negatively participants appraised intrusive thoughts, the more unhelpful strategies were endorsed. In addition, for the two most negatively appraised thoughts (the sexual and the violent thoughts), participants were more likely to use unhelpful rather than helpful strategies.

4. Discussion The present study was an investigation of appraisals that people make of intrusive thoughts associated with OCD (e.g., Morillo et al., 2007), recommendations to manage those thoughts, and how appraisals and recommendations related to one's own obsessive-compulsive related beliefs. The frequency and content of the hypothetical thoughts were experimentally manipulated, as was the person experiencing the thought. Of the three intrusive thoughts examined – violent, sexual, and blasphemous – the violent intrusive thought was appraised as the most significant, followed by the sexual and then the blasphemous thought, regardless of the person who experienced the thought or the frequency of the thought. Individuals with higher levels of OC-related beliefs considered the thoughts more significant than did individuals with lower levels of OC-related beliefs. Interestingly, participants were most likely to endorse unhelpful strategies to manage the thought they saw as the most important and were most likely to recommend helpful strategies for the thought they perceived as the least significant. When examining these results together, an interesting framework for understanding perceptions of and behaviors in response to intrusive thoughts emerges: when a thought is quite concerning to someone, especially if they already have beliefs consistent with obsessive-compulsive tendencies, they are more likely to engage in behaviors (or to recommend behaviors to a person experiencing those thoughts) that have been shown, in

Table 7 Correlation matrix of appraisals of significance for each of the thoughts presented in the vignettes and recommendations for helpful and unhelpful strategies. AR Blas AR Sex AR Vio US Blas US Sex US Vio HS Blas HS Sex HS Vio

AR Sex

AR Vio

US Blas

.747** .281* .617** .442**  .274*  .428**  .240*

.267* .401** .522**  .162  .266*  .387**

.530** .634**  .132  .081  .012

.680 .579** .376** .438** .400**  .131  .162 .012

Notes: AR ¼ appraisal rating US ¼ unhelpful strategy HS ¼ helpful strategy Blas ¼ blasphemous thought Sex ¼ sexual thought Vio ¼ violent thought * **

US Sex

US Vio

HS Blas

HS Sex

 .147  .123  .317**

.606** .563**

.512**

**

Indicates correlation is significant at the .05 level. Indicates correlation is significant at the .01 level.

. .691**  .172  .246*  .188

214

A.Z. Levine, D.M. Warman / Psychiatry Research 245 (2016) 207–216

research, to be counterproductive by increasing frequency and overall distress associated with an intrusion. Our findings support the cognitive model of OCD, which promotes that intrusive thoughts become problematic due to the significance attached to them and problematic responses to the thoughts (Salkovskis, 1989). Our results, however, expand findings as they demonstrate that these beliefs and potential reliance on problematic responses to taboo thoughts are apparent even lower on the continuum of OCD, supporting the usefulness of approaches, such as Cognitive Behavioral Therapy, that target both beliefs about and responses to taboo thoughts (Beck, 2011). Consistent with Corcoran and Woody's (2008) original study using these vignettes, we found that violent thoughts were appraised as the most concerning of the taboo thoughts examined. Our results are consistent with the body of literature regarding violent intrusions. Simonds and Thorpe (2003), for example, found that a person with violent thoughts was perceived more negatively than targets with other forms of non-taboo thought OCD. Warman et al. (2015) found that violent thoughts were not only perceived negatively, but that an OCD diagnosis was almost entirely rejected by participants until they were educated about OCD. As the public is unaware of the symptoms of OCD, especially in terms of taboo thought presentations (e.g., Coles et al., 2013), these findings may not be surprising. Interestingly, very few studies have examined multiple intrusive thoughts to determine how they may fare relative to one another. When our results are taken together with others’, it appears that violent thoughts are viewed particularly negatively, and blasphemous thoughts are not considered as meaningful. Consistent with Corcoran and Woody (2008), we did not find significant differences between how individuals asked to evaluate a hypothetical other's thoughts appraised intrusive thoughts relative to how they would evaluate their own thoughts, and we found this was not limited to low-frequency thoughts despite our prediction it would be. We did find, however, that participants asked to evaluate an Other were more affected by the violent thought relative to the sexual and the blasphemous thought than participants asked to imagine the thought was experienced by the self. It seems likely this is due to how negatively violent thoughts were perceived. Perceived dangerousness of others is considered a significant factor in understanding negative evaluations of others (see Jorm et al., 2012). Although the sexual and the blasphemous vignettes detailed distressing thoughts, it is possible they were considered less dangerous. It is possible that for thoughts not perceived as negatively participants were able to put such experiences in perspective for themselves and for others. Consistent with what would be predicted by the fundamental attribution error commonly discussed in the field of social psychology (Aronson, 2012), it is also possible that for such a negatively viewed thought, participants viewed others as being bad people, without having enough information about the person to correct for misinterpretations of the thoughts. Although one finding emerged for Self versus Other, as detailed above, it is notable that we did not get the expected effect for Self vs. Other in the high frequency condition, which was predicted given how personal responsibility has been identified as a component of self-blame when experiencing intrusions that are in conflict with a specific and personal moral or other value (Salkovskis et al., 2000). It may be important to consider how the methodology of our study and Corcoran and Woody's may have muted findings related to this question, as in both studies the “other” person in the vignettes was detailed as the participant's “best friend.” When one considers the two-step process of attribution, people first determine a personal or trait explanation is best suited to explain a person's behavior, and then we, at times, adjust for this attribution (see Gilbert et al., 1992). It is possible

that because the person in the vignette was described as the participant's best friend, the participant adjusted far more quickly than he/she would for a person described as a stranger. Supporting that the specific relationship towards the target may be relevant, Cathey and Wetterneck (2013) vignette study assessed disclosure by a friend versus a significant other and found individuals were more likely to reject disclosure of intrusive thoughts by a friend rather than those by a significant other, indicating positive feelings towards another may influence appraisal. Exploration of a thought reported by a stranger would be a fruitful avenue for future research. We developed a new survey for the present study to determine how participants would make recommendations for a person with intrusive thoughts. The survey was developed carefully through review of common strategies used to manage intrusions and whether or not such strategies have a tendency to backfire/be unhelpful or reduce the frequency of intrusions (e.g., Freeston, Ladouceur, Thibodeau, and Gagnon, 1991; Marcks and Woods, 2007; Salkovskis, 1999). As the surveys reflected commonly used strategies, the scale has some overlap with the obsessive-compulsive beliefs measures used, potentially explaining some correlation between response strategies and obsessive compulsive beliefs. However, the pattern of recommendations revealed by vignette types suggests variability in response style may relate to the content of the thought and is not only explained by overlap with the OC measures. This provides compelling insight into factors related to how individuals manage intrusive experiences, which can provide a basis for future research. Future research may seek to include measures of obsessive compulsive symptoms, as opposed to only obsessive compulsive beliefs as reported in the present study, to further understand the relationship between obsessive compulsive beliefs and recommendations of various strategies in response to intrusive thoughts. Interestingly, participants demonstrated the highest endorsement of unhelpful strategies for the target with violent thoughts and demonstrated the highest endorsement of helpful strategies for the target with blasphemous thoughts. Taken together, our results indicate that for the most negatively appraised of the thoughts examined, the most unhelpful strategies were recommended and for the least negatively appraised of the thoughts, the most helpful strategies were recommended. This is important in what it has the potential to communicate to individuals with thoughts that are particularly negatively perceived – do the very behaviors that ultimately may increase their risk of getting stuck in the thought (see Rachman, 1998). This is in stark contrast to what is recommended in the gold standard treatment of OCD – Cognitive Behavioral Therapy - in which people are encouraged to view even their most disturbing thoughts as unimportant (see Rachman, 1997). It is clear to see how the approach recommended by people in the general population can leave a person with OCD in such distress, as they may be encouraged not only by themselves, but by others as well, to deal with their intrusive thoughts in ways that increase the frequency of, and then likely the meaning attached to, the thought. Our finding that OC related beliefs were related to higher ratings of personal significance is consistent with the limited research that has investigated this question in vignette research to date (e.g., Corcoran and Woody, 2008). This finding is not surprising given the Cognitive Behavioral model of OCD, such that individuals with OCD are more likely to attribute significance to intrusive thoughts than individuals without OCD (e.g., Rachman, 1997). Our findings demonstrate, however, that these relationships are present even in individuals lower on the continuum of OCD. What is perhaps even more intriguing is how OC-related beliefs showed a clear relationship to the increased likelihood to use unhelpful strategies if they or another experienced intrusive

A.Z. Levine, D.M. Warman / Psychiatry Research 245 (2016) 207–216

thoughts. The Cognitive Behavioral model posits that when individuals take too much meaning from their intrusive thoughts and then use unhelpful strategies, such as thought suppression, to manage the thoughts, OCD is more likely to develop and the thoughts run the risk of becoming even more distressing (Salkovskis, 1989). Our findings, even in our sample of undergraduate students, appear to align perfectly with this theory. With further consideration for OC beliefs, it was noted that the TAF was not as useful for understanding appraisals and responses to intrusive thoughts. However, the subscales of the OBQ-44 related to the thought control strategies in a manner consistent with our understanding of the development of OCD. The higher the estimated threat and the greater need to control, the more likely participants were to promote the use of potentially unhelpful strategies, but not the use of potentially helpful ones. This is consistent with the cognitive model of OCD, where an increased perceived significance of a thought is associated with heightened perceived dangerousness of that thought and therefore an increased need to control or get rid of it. Often this control or thought suppression occurs in the form of a strategy that has the potential to backfire. The domain of perfectionism, conversely, was not overall related to promoting the use of unhelpful strategies but was related to increased agreement with helpful strategies, particularly for the sexual and violent vignettes. Clinical use of the OBQ often serves to inform clinicians about appraisal of obsessional content by identifying constructs crucial to understanding obsessions (OCCWG, 2003). This preliminary data supports this notion and also extends the idea that these core constructs are also related to response styles. A strength of this study was its examination of multiple taboo thoughts, as opposed to just one (e.g., Warman et al., 2015), in an effort to understand not just how such thoughts are perceived, but also their relative evaluations. In addition, using vignettes as opposed to asking participants to reflect on their own experiences (e.g., Belloch et al., 2004) permitted an exceptional amount of control, such that all participants evaluated the same thoughts. Limitations of our study, however, highlight that caution is recommended in drawing conclusions from our study. Our sample size was small, and participants were mostly female and Caucasian, limiting the generalizability of our findings. As attitudes towards individuals with intrusive thoughts are so understudied, we hope that our study adds to the general understanding of perceptions of taboo thoughts and relationships to one's beliefs. In summary, we found that violent intrusive thoughts were considered the most meaningful of the thoughts we examined, followed by sexual and then blasphemous thoughts. Individuals with higher levels of OC beliefs found the intrusive thoughts to be particularly significant. We also found that the more meaningful participants determined sexual and violent thoughts to be, the more likely they were to recommend strategies that have the potential to be unhelpful, and the less likely participants were to recommend strategies that have the potential to be helpful. Individuals with higher levels of OC related beliefs endorsed more agreement with unhelpful strategies for dealing with the thoughts than did individuals with lower levels of OC related beliefs. These results not only provide continued empirical support for the cognitive model of OCD, but also suggest that a lack of awareness of taboo thoughts as they occur in OCD and a lack of awareness of how to productively manage distressing thoughts is pervasive. Continued work regarding stigma of intrusive experiences and education programs for OCD may be a fruitful area of future research and may serve to impact the population's understanding of these experiences which, in turn, may result in decreased reliance on strategies to manage distressing thoughts that have been shown to increase, as opposed to decrease, distress.

215

Conflicts of interest None.

Human and animal rights The present study was done in accord with human rights protections and was approved by the IRB of the institution. Informed consent was obtained from all participants.

Role of the funding source This was an unfunded study.

Appendix A Vignettes Aggressive Vignette (self condition) Imagine that you often go over to babysit your six-year-old niece. Occasionally (or several times per week for high frequency), while babysitting and preparing sandwiches for your lunch, you have a sudden, horrific impulse to stab your niece with a sharp kitchen knife. You are very upset about having this thought. Aggressive Vignette (other condition) Your best friend approaches you looking for advice. Your friend confides in you that occasionally (or several times per week for high frequency condition) while babysitting her six-year-old niece and preparing sandwiches for her lunch, she has a sudden, horrific impulse to stab her niece with a sharp kitchen knife. Your friend explains that she is very upset about having this thought. Sexual Vignette (self condition) Imagine that occasionally (or several times per week for high frequency condition), while driving to school with your brother, you have a sudden intrusive thought about having sex with your brother. You are noticeably upset about having this thought. (please note: if you do not have a brother, imagine that you occasionally have a sudden intrusive thought about having sex with a close family member). Sexual Vignette (other condition) Your best friend approaches you looking for advice. Your friend confides in you that occasionally (or several times per week for high frequency condition) while driving to school with her brother, she has a sudden intrusive thought about having sex with her brother. Your friend explains that she is very upset about having this thought. Blasphemous Vignette (self condition) Imagine that you are a very religious person. From time to time (or several times per week for high frequency condition) while engaged in silent prayer, you have a sudden, terrible image of urinating on the Bible. You are very upset by this thought. (Please note: If this does not relate to your own religion, please imagine yourself urinating on a Holy Text of your religion.) Blasphemous Vignette (other condition) Your best friend is a very religious person. She confides in you that from time to time (or several times per week for high frequency condition) while engaged in silent prayer, she have a

216

A.Z. Levine, D.M. Warman / Psychiatry Research 245 (2016) 207–216

sudden, terrible image of urinating on the Bible. Your friend explains that she is very upset by this thought. (Please note: If this does not relate to your friend's own religion, please imagine she confides a thought about urinating on a Holy Text of her own religion.)

References Abramowitz, J.S., 2006. Obsessive-Compulsive Disorder: Advances in Psychotherapy, Evidence-Based Practice. Hogrefe & Huber Publishers, Cambridge, MA. Aronson, E., 2012. The Social Animal, 11th ed. Worth Publishers, New York, NY. Barrera, T.L., Norton, P.J., 2011. The appraisal of intrusive thoughts in relation to obsessional-compulsive symptoms. Cognit. Behav. Ther. 40 (2), 98–110. http: //dx.doi.org/10.1080/16506073.2010.545072. Beck, J.S., 2011. ). Cognitive Behavior Therapy: Basics and Beyond, 2nd ed. The Guilford Press, New York, NY. Belloch, A., Morillo, C., Lucero, M., Cabedo, E., Carrio, C., 2004. Intrusive thoughts in non-clinical subjects: the role of frequency and unpleasantness on appraisal ratings and control strategies. Clin. Psychol. Psychother. 11 (2), 100–110. http: //dx.doi.org/10.1002/cpp.397. Berry, L.M., May, J., Andrade, J., Kavanagh, D., 2010. Emotional and behavioral reaction to intrusive thoughts. Assessment 17 (1), 126–137. http://dx.doi.org/ 10.1177/1073191109344694. Brand, J., McKay, D., Wheaton, M.G., Abramowitz, J., 2013. The relationship between obsessive compulsive beliefs and symptoms, anxiety and disgust sensitivity, and Swine flu fears. J. Obsessive-Compuls. Relat. Disord. 2, 200–206. http://dx. doi.org/10.1016/j.jocrd.2013.01.007. Cathey, A.J., Wetterneck, C.T., 2013. Stigma and disclosure of intrusive thoughts about sexual themes. J. Obsessive-Compuls. Relat. Disord. 2, 439–443. http://dx. doi.org/10.1016/j.jocrd.2013.09.001. Clark, D.A., de Silva, P., 1985. The nature of depressive and anxious, intrusive thoughts: distinct or uniform phenomena? Behav. Res. Ther. 38, 439–455. http: //dx.doi.org/10.1016/0005-7967(85)90166-4. Coles, M.E., Heimberg, R.G., Weiss, B.D., 2013. The public's knowledge and beliefs about obsessive compulsive disorder. Depress. Anxiety 30 (8), 778–785. http: //dx.doi.org/10.1002/da.22080. Corcoran, K.M., Woody, S.R., 2008. Appraisals of obsessional thoughts in normal samples. Behav. Res. Ther. 46, 71–83. http://dx.doi.org/10.1016/j. brat.2007.10.007. Freeston, M.H., Ladouceur, R., Thibodeau, N., Gagnon, F., 1991. Cognitive intrusions in a non-clinical population. I. Response style, subjective experience, and appraisal. Behav. Res. Ther. 29 (6), 585–597. http://dx.doi.org/10.1016/0005-7967 (91)90008-Q. Gilbert, D.T., McNulty, S.E., Guiliano, T.A., Benson, J.E., 1992. Blurry words and fuzzy deeds: the attribution of obscure behavior. J. Personal. Soc. Psychol. 62, 18–25. Glazier, K., Calixte, R., Rothschild, R., Pinto, A., 2013. High rates of OCD symptom misidentification by mental health professionals. Ann. Clin. Psychiatry 25 (3), 201–209. Jorm, A.F., Reavley, N.J., Ross, A.M., 2012. Belief in the dangerousness of people with mental disorders: a review. Aust. N.Z. J. Psychiatry 46 (11), 1029–1045. http: //dx.doi.org/10.1177/0004867412442406. Julien, D., O’Connor, K.P., Aardema, F., 2007. Intrusive thoughts, obsessions, and appraisals in obsessive-compulsive disorder: A critical review. Clinical Psychology Rev. 27 (3), 366–383, http://dx.doi.org/10.1016/j.cpr.2006.12.004. Marcks, B.A., Woods, D.W., 2007. Role of thought-related beliefs and coping strategies in the escalation of intrusive thoughts: an analog to obsessive-

compulsive disorder. Behav. Res. Ther. 45, 2640–2651. http://dx.doi.org/ 10.1016/j.brat.2007.06.012. Morillo, C., Belloch, A., García-Soriano, G., 2007. Clinical obsessions in obsessivecompulsive patients and obsession relevant intrusive thoughts in non-clinical, depressed and anxious subjects: where are the differences? Behav. Res. Ther. 45 (6), 1319–1333. http://dx.doi.org/10.1016/j.brat.2006.11.005. Obsessive-compulsive Cognitions Working Group, 2003. Psychometric validation of the Obsessive Beliefs Questionnaire and the Interpretation of Intrusions Inventory: Part 1. Behav. Res. Ther. 41 (8), 863–878. http://dx.doi.org/10.1016/ S0005-7967(02)00099-2. Obsessive-Compulsive Cognitions Working Group, 2005. Psychometric validation of the Obsessive Beliefs Questionnaire and the Interpretation of Intrusions Inventory: Part 2: Factor analysis and testing of a brief version. Behav. Res. Ther. 43 (11), 1527–1542. http://dx.doi.org/10.1016/j.brat.2004.07.010. Ólafsson, R.P., Snorrason, Í., Bjarnason, R.K., Emmelkamp, P.M.G., Ólason, P., Kristjánsson, 2014. Replacing intrusive thoughts: investigating thought control in relation to OCD symptoms. J. Behav. Ther. Exp. Psychiatry 45 (4), 506–515. http: //dx.doi.org/10.1016/j.jbtep.2014.07.007. Parrish, C.L., Radomsky, 2010. Why do people seek reassurance and check repeatedly? An investigation of factors involved in compulsive behavior in OCD and depression. J. Anxiety Disord. 24, 211–222. http://dx.doi.org/10.1016/j. janxdis.2009.10.010. Rachman, S., 1997. A cognitive theory of obsessions. Behav. Res. Ther. 35 (9), 793–802. http://dx.doi.org/10.1016/S0005-7967(97)00040-5. Rachman, S., 1998. A cognitive theory of obsessions: Elaborations. Behav. Res. Ther. 36, 385–401. http://dx.doi.org/10.1016/S0005-7967(97)10041-9. Rachman, S., 2003. The Treatment of Obsessions. Oxford University Press, New York. Salkovskis, P.M., 1999. Understanding and treating obsessive-compulsive disorder. Behav. Res. Ther. 37, S29–S52. http://dx.doi.org/10.1016/S0005–7967(99) 00049-2. Salkovskis, P.M., 1989. Cognitive-behavioral factors and the persistence of intrusive thoughts in obsessional problems. Behav. Res. Ther. 27 (6), 677–682. http://dx. doi.org/10.1016/0005–7967(89)90152-6. Salkovskis, P.M., Westbrook, D., Davis, J., Jeavons, A., Gledhill, A., 1997. Effects of neutralizing on intrusive thoughts: an experiment investigating the etiology of obsessive-compulsive disorder. Behav. Res. Ther. 35 (3), 211–219. http://dx.doi. org/10.1016/S0005–7967(96)00112-X. Salkovskis, P.M., Wroe, A.L., Gledhill, A., Morrison, E., Forrester, E., Richards, C., Reynolds, M., Thorpe, S., 2000. Responsibility attitudes and interpretations are characteristic of obsessive compulsive disorder. Behav. Res. Ther. 38, 347–372. Shafran, R., Rachman, S., 2004. Thought-action fusion: a review. J. Behav. Ther. Exp. Psychiatry 35 (2), 87–107. http://dx.doi.org/10.1016/j.jbtep.2004.04.002. Shafran, R., Thordarson, D.S., Rachman, S., 1996. Thought-action fusion in obsessive-compulsive disorder. J. Anxiety Disord. 10 (5), 379–391. http://dx.doi. org/10.1016/0887–6185(96)00018-7. Simonds, L.M., Thorpe, S.J., 2003. Attitudes toward obsessive-compulsive disorders —an experimental investigation. Soc. Psychiatry Psychiatr. Epidemiol. 38 (6), 331–336. http://dx.doi.org/10.1007/s00127-003-0637-0. Teachman, B.A., Woody, S.R., Magee, J.C., 2006. Implicit and explicit appraisals of the importance of intrusive thoughts. Behav. Res. Ther. 44, 785–805. http://dx. doi.org/10.1016/j.brat.2005.05.005. Warman, D.M., Phalen, P., Martin, J.M., 2015. Impact of a brief education about mental illness on stigma of OCD and violent thoughts. J. Obsessive-Compuls. Relat. Disord., 5, 16–23. http://dx.doi.org/10.1016/j.jocrd.2015.01.003. Woody, S.R., Whittal, M.L., McLean, P.D., 2011. Mechanisms of symptom reduction in treatment of obsessions. J. Consult. Clin. Psychol. 79 (5), 653. http://dx.doi. org/10.1037/a0024827.