- Email: [email protected]
The potential application of obsessions to reduce compulsions in individuals with obsessive–compulsive disorder
Medical Hypotheses 74 (2010) 216–218
Contents lists available at ScienceDirect
Medical Hypotheses journal homepage: www.elsevier.com/locate/mehy
The potential application of obsessions to reduce compulsions in individuals with obsessive–compulsive disorder Jonathan R. Scarff Department of Psychiatry and Behavioral Sciences, University of Louisville, 501 E Broadway, Suite 340, Louisville, KY 40202, USA
a r t i c l e
i n f o
Article history: Received 7 September 2009 Accepted 13 September 2009
s u m m a r y Obsessive–compulsive disorder is characterized by obsessions that cause distress and compulsions that temporarily alleviate that distress. Despite numerous pharmacological and psychotherapeutic approaches available for treating obsessions and compulsions, their effectiveness is limited. Exploring the etiologies of obsessions reveals how obsessions develop to cause distress. It is hypothesized that the strength of obsessions can be used in a self-talk technique to reduce the frequency of compulsions. The patient would incorporate the self-talk technique while engaged in a compulsion meant to lessen the distress caused by an obsession. While performing the compulsive behavior, he or she then identifies a separate obsession, and applies a limit to stop the compulsive ritual while telling himself or herself that the second obsession will occur unless the limit is met. Although the technique has potential as a flexible tool that may be incorporated into other treatments to reduce compulsions, the therapist who chooses to use it should closely monitor its effectiveness and discontinue the technique in case of adverse effects. Ó 2009 Elsevier Ltd. All rights reserved.
Introduction Current treatments for OCD Obsessive–compulsive disorder (OCD) is an anxiety disorder with a lifetime prevalence of approximately 2.5% and is considered a worldwide mental health problem [1,2]. Essential features of OCD are recurrent obsessions or compulsions that are severe enough to be time-consuming or to cause marked distress or impairment [3]. Obsessions are persistent ideas, thoughts, impulses or images that are experienced as inappropriate and which cause marked anxiety or distress; compulsions are repetitive behaviors aimed at preventing or reducing the anxiety or distress that accompany an obsession [3]. The limitations of pharmacotherapy and psychotherapy warrant continuing investigation for new approaches for treating obsessions and compulsions. This article describes a self-talk technique with potential for reducing compulsions in individuals with OCD. The combination of pharmacotherapy and behavioral therapy is still regarded as the optimal treatment for OCD [4]. Pharmacotherapy includes selective serotonin reuptake inhibitors (SSRIs), tricyclic antidepressants (TCAs), and occasional augmentation by antipsychotic medications [5]. However, up to 50% of patients with OCD fail to fully respond to SSRI treatment [5]. Psychotherapies used to treat OCD include behavioral therapy, cognitive-behavioral therapy (CBT), danger ideation reduction E-mail address: [email protected] 0306-9877/$ - see front matter Ó 2009 Elsevier Ltd. All rights reserved. doi:10.1016/j.mehy.2009.09.026
therapy (DIRT), and family therapy. A recent meta-analysis found that psychological treatment of OCD achieves a clinically relevant effectiveness [6]. One form of behavioral therapy, exposure and response prevention (ERP), involves exposing the patient to feared stimuli (often obsessions) while preventing the compulsion response; it has been shown to reduce symptoms in patients with OCD [6]. Imaginal exposure (having the patient vividly imagine feared consequences from not performing rituals) combined with response prevention is superior to response prevention alone in patients with checking rituals [2]. Cognitive therapy in the form of cognitive restructuring is also effective in reducing obsessions and compulsions [6]. DIRT has been used successfully for patients with contamination fears who have failed conventional treatments [7]. Lastly, family-assisted behavioral therapy helps target problematic family responses that may perpetuate OCD symptoms [8]. Current treatment limitations Despite the success of psychotherapy in treating OCD, there are inherent limitations worth mentioning. Despite compliance with treatment demands, there are instances where individuals fail to benefit from behavioral therapy. Patients who hold very strong beliefs that their compulsive rituals are in reality necessary to prevent some catastrophe are said to have overvalued insight; such patients tend to have a poorer outcome with behavioral treatments [2]. In addition, individuals who perform rituals to feel complete, or who do not have fear or anxiety-based OCD symptoms are also not as responsive to behavior therapy [2]. The presence of
J.R. Scarff / Medical Hypotheses 74 (2010) 216–218
comorbid medical conditions with OCD symptoms also limits the effectiveness of CBT [9]. Reports of the effectiveness of CBT may be of limited relevance due to the way in which findings have been reported: for example, an individual with severe OCD can improve according to an arbitrary goal, yet still remain functionally similar to a pretest state [10]. In addition, many studies evaluating the effectiveness of a given psychotherapeutic approach lack follow up data for treatment and control groups, which is concerning given the chronic nature of OCD [6]. Lastly, despite its effectiveness, ERP is underexploited due to its high cost [6]. Neziroglu and colleagues noted that current psychological approaches to OCD are not much different from those of the early 1980s, except for the addition of cognitive therapy [11]. They note that symptoms are reduced minimally (30–50%), dropout rates and refractory cases persist without explanation, and no new methods for increasing treatment efficacy or dealing with treatment refractory cases have been developed [11]. They call for the development of new and alternative treatment approaches to improve treatment response, even for treatment responders [11]. Given the shortcomings noted above, it is imperative that mental health providers continue to search for innovative treatments that can be used alone or in conjunction with established therapies. Obsessions and available therapies There is a normal range of obsessiveness that can be considered a parameter of adaptation [12]. Existing in the majority of individuals, obsessions are deemed pathological when they cause distress and are not easily dismissed. According to the theory of paradoxical thought, attempts to suppress a thought may cause a paradoxical increase in the frequency of that thought [13]. Thought-action fusion (TAF) occurs when an intrusive thought is overvalued to the point where it is considered the equivalent of the unwanted action [14]. Many of the psychotherapies used in treating compulsions are also used to treat obsessions with one notable exception. In the treatment of obsessions, paradoxical intention therapy utilizes the strength of paradoxical thought in treating obsessions. In two trials of paradoxical intention therapy, participants exaggerated their obsessions and told themselves that the dreaded obsession would occur. Despite being initially strong, both anxiety and the belief in the obsession lost strength over time from constant exposure [15,16]. Hypothesis Obsessions begin and power the obsessive–compulsive cycle. Obsessions evoke distress which may cause the sufferer to perform hours of unwanted compulsions to reduce the distress. It is plausible that an obsession’s power can be harnessed to end the compulsive activity that it (or another obsession) started in the first place. Theoretically, if obsessions are powerful enough to start compulsions, they may be powerful enough to stop compulsions as well. The power of obsessions, coupled with the individual’s fervent desire to cease performing a compulsion, has potential application for treating compulsions in individuals with OCD. The self-talk technique The self-talk technique is not grounded in current psychotherapy approaches to treat OCD, although there is an element of imaginal exposure and some resemblance to paradoxical intention therapy. The small parallel between paradoxical intention therapy and the proposed self-talk technique is the common use of obsessions to reduce the severity of either obsessions or compulsions. In
217
paradoxical intention therapy, individuals are asked to exaggerate their beliefs that the obsession will occur, which over time results in decreased anxiety produced by the obsession. In contrast, the self-talk technique asks individuals to treat their obsession as real and to recognize the anxiety it evokes. This anxiety, coupled with the desire to prevent the obsession from occurring, keeps individuals from surpassing a limit that they have assigned for a compulsion. The three components of the self-talk technique are an obsession, the compulsive activity related to it, and another obsession. While performing a compulsion related to the original obsession, the individual would set a limit for stopping the compulsion (e.g., a time limit, repetition limit). To ensure adherence to this limit, the individual would introduce another obsession, telling himself that if he did not cease the compulsive activity as planned, the second obsession would occur. The reasoning behind this technique is that the power of any obsession is so great that it will override the need to continue any compulsive behavior. Ideally, the fear of an obsession becoming reality, and the passionate desire to avoid that at all cost, would overshadow any need to continue ritualizing. As an example, consider a patient with obsessions of contamination (original obsession) and financial difficulty (second obsession). Corresponding compulsions could include repeated handwashing and collecting purchase receipts, respectively. While in the midst of handwashing (the compulsion related to the original obsession), the patient would set a limit for washing his or her hands (e.g., one more minute, three more times). Now the individual must incorporate the second obsession, telling himself or herself that he or she must adhere to the limit or else be confronted with financial difficulty (e.g., will be a victim of credit card fraud, will suffer a loss in the value of investments). It is predicted that the individual’s fear of financial difficulty (second obsession) would force adherence to his or her limit, and the compulsive handwashing will end as planned. Ideally, with successful application, an individual would spend minutes instead of hours on a compulsion. This decrease in time spent on compulsions would be due to the presence of a limit, a limit enforced by the threat of an obsession coming true.
Conclusion Benefits and risks There are several possible benefits to the self-talk technique. The technique could be integrated with current psychotherapy or pharmacotherapy, and its flexibility and simplicity should allow individuals to incorporate any obsession to reduce any mental or physical compulsion. This remains to be evaluated further, however. A technique that asks sufferers to fear their obsessions and to pretend that the obsessions are going to happen if they do not cease ritualizing is bound to raise ethical questions. Such questions may include the following: Is there a possibility that evoking obsessions will raise their distress level? Can the frequent use of obsessions cause obsessions to become more intrusive and frequent? Can obsessions become more important and concrete, and therefore more difficult to treat? Given that this is an untested technique, it would be prudent to educate patients about risks and to introduce the technique in the context of other psychotherapy. Therapists should be vigilant when evaluating effects on their clients’ symptoms. There is indeed a possibility that obsessions may increase in severity or distress, in which case clients should be asked to discontinue the self-talk technique. Therapy to realistically evaluate the obsession should be implemented in an effort to reduce any overvalued ideation that exists.
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J.R. Scarff / Medical Hypotheses 74 (2010) 216–218
Despite the success of psychotherapy in treating OCD, certain individuals with OCD respond minimally, if at all, to treatment. This proposed self-talk approach provides a cost-effective and flexible alternative to help the individual reduce compulsions. The ability to use it anytime, anywhere for a variety of compulsions could help sufferers to regain some control over their symptoms and to loosen the grasp that OCD holds on their lives. It should therefore be explored further for effectiveness and possible incorporation into current treatment modalities. Conflicts of interest statement None declared. References [1] Weissman MM, Bland RC, Canino CH, et al. The cross national epidemiology of obsessive–compulsive disorder. J Clin Psychiat 1994;55:5–10. [2] Jenike MA. An update on obsessive compulsive disorder. Bull Menninger Clin 2001;65(1):4–25. [3] American Psychiatric Association. Diagnostic and statistical manual of mental disorders. Text revision. 4th ed. Washington, DC: American Psychiatric Association; 2000. [4] Denys D. Pharmacotherapy of obsessive–compulsive disorder and obsessive– compulsive spectrum disorders. Psychiat Clin North Am 2006;29:553–84.
[5] Bandelow B. The medical treatment of obsessive–compulsive disorder and anxiety. CNS Spectr 2008;9(Suppl. 14):37–46. [6] Rosa-Alcázar AI, Sánchez-Meca J, Gómez-Conesa A, Marín-Martínez F. Psychological treatment of obsessive–compulsive disorder: a meta-analysis. Clin Psychol Rev 2008;28(8):1310–25. [7] Jones MK, Menzies RG. Danger ideation reduction therapy (DIRT) for obsessive–compulsive washers. A controlled trial. Behav Res Ther 1998;8:121–5. [8] Maina G, Saracco P, Albert U. Family-focused treatments for obsessive– compulsive disorder. Clin Neuropsychiat J Treat Eval 2006;3(6):382–90. [9] Carmin CN, Wiegartz PS. Successful and unsuccessful treatment of obsessive– compulsive disorder in older adults. J Contemp Psychother 2000;30(2):181–93. [10] Abramowitz JS. Does cognitive-behavioral therapy cure obsessive–compulsive disorder? A meta-evaluation of clinical significance. Behav Ther 1998;29:339–55. [11] Neziroglu F, Henricksen J, Yaryura-Tobias JA. Psychotherapy of obsessive– compulsive disorder and spectrum: established facts and advances, 1995– 2005. Psychiat Clin North Am 2006;29:585–604. [12] Freedman DA. Obsessiveness in context. Annu Psychoanal 1999;26–27:25–46. [13] Rachman S. A cognitive theory of obsessions: elaborations. Behav Res Ther 1998;36:385–401. [14] Rassin E, Merckelbach H, Muris P. Paradoxical and less paradoxical effects of thoughts suppression: a critical review. Clin Psychol Rev 2000;20(8):973–95. [15] Solyom L, Garza-Perez J, Ledwidge BL, Solyom C. Paradoxical intention in the treatment of obsessive thoughts: a pilot study. Compr Psychiat 1972;13(3):291–7. [16] Gertz HO. Experience with the logotherapeutic technique of paradoxical intention in the treatment of phobic and obsessive–compulsive patients. Am J Psychiat 1966;123:548–53.
Contents lists available at ScienceDirect
Medical Hypotheses journal homepage: www.elsevier.com/locate/mehy
The potential application of obsessions to reduce compulsions in individuals with obsessive–compulsive disorder Jonathan R. Scarff Department of Psychiatry and Behavioral Sciences, University of Louisville, 501 E Broadway, Suite 340, Louisville, KY 40202, USA
a r t i c l e
i n f o
Article history: Received 7 September 2009 Accepted 13 September 2009
s u m m a r y Obsessive–compulsive disorder is characterized by obsessions that cause distress and compulsions that temporarily alleviate that distress. Despite numerous pharmacological and psychotherapeutic approaches available for treating obsessions and compulsions, their effectiveness is limited. Exploring the etiologies of obsessions reveals how obsessions develop to cause distress. It is hypothesized that the strength of obsessions can be used in a self-talk technique to reduce the frequency of compulsions. The patient would incorporate the self-talk technique while engaged in a compulsion meant to lessen the distress caused by an obsession. While performing the compulsive behavior, he or she then identifies a separate obsession, and applies a limit to stop the compulsive ritual while telling himself or herself that the second obsession will occur unless the limit is met. Although the technique has potential as a flexible tool that may be incorporated into other treatments to reduce compulsions, the therapist who chooses to use it should closely monitor its effectiveness and discontinue the technique in case of adverse effects. Ó 2009 Elsevier Ltd. All rights reserved.
Introduction Current treatments for OCD Obsessive–compulsive disorder (OCD) is an anxiety disorder with a lifetime prevalence of approximately 2.5% and is considered a worldwide mental health problem [1,2]. Essential features of OCD are recurrent obsessions or compulsions that are severe enough to be time-consuming or to cause marked distress or impairment [3]. Obsessions are persistent ideas, thoughts, impulses or images that are experienced as inappropriate and which cause marked anxiety or distress; compulsions are repetitive behaviors aimed at preventing or reducing the anxiety or distress that accompany an obsession [3]. The limitations of pharmacotherapy and psychotherapy warrant continuing investigation for new approaches for treating obsessions and compulsions. This article describes a self-talk technique with potential for reducing compulsions in individuals with OCD. The combination of pharmacotherapy and behavioral therapy is still regarded as the optimal treatment for OCD [4]. Pharmacotherapy includes selective serotonin reuptake inhibitors (SSRIs), tricyclic antidepressants (TCAs), and occasional augmentation by antipsychotic medications [5]. However, up to 50% of patients with OCD fail to fully respond to SSRI treatment [5]. Psychotherapies used to treat OCD include behavioral therapy, cognitive-behavioral therapy (CBT), danger ideation reduction E-mail address: [email protected] 0306-9877/$ - see front matter Ó 2009 Elsevier Ltd. All rights reserved. doi:10.1016/j.mehy.2009.09.026
therapy (DIRT), and family therapy. A recent meta-analysis found that psychological treatment of OCD achieves a clinically relevant effectiveness [6]. One form of behavioral therapy, exposure and response prevention (ERP), involves exposing the patient to feared stimuli (often obsessions) while preventing the compulsion response; it has been shown to reduce symptoms in patients with OCD [6]. Imaginal exposure (having the patient vividly imagine feared consequences from not performing rituals) combined with response prevention is superior to response prevention alone in patients with checking rituals [2]. Cognitive therapy in the form of cognitive restructuring is also effective in reducing obsessions and compulsions [6]. DIRT has been used successfully for patients with contamination fears who have failed conventional treatments [7]. Lastly, family-assisted behavioral therapy helps target problematic family responses that may perpetuate OCD symptoms [8]. Current treatment limitations Despite the success of psychotherapy in treating OCD, there are inherent limitations worth mentioning. Despite compliance with treatment demands, there are instances where individuals fail to benefit from behavioral therapy. Patients who hold very strong beliefs that their compulsive rituals are in reality necessary to prevent some catastrophe are said to have overvalued insight; such patients tend to have a poorer outcome with behavioral treatments [2]. In addition, individuals who perform rituals to feel complete, or who do not have fear or anxiety-based OCD symptoms are also not as responsive to behavior therapy [2]. The presence of
J.R. Scarff / Medical Hypotheses 74 (2010) 216–218
comorbid medical conditions with OCD symptoms also limits the effectiveness of CBT [9]. Reports of the effectiveness of CBT may be of limited relevance due to the way in which findings have been reported: for example, an individual with severe OCD can improve according to an arbitrary goal, yet still remain functionally similar to a pretest state [10]. In addition, many studies evaluating the effectiveness of a given psychotherapeutic approach lack follow up data for treatment and control groups, which is concerning given the chronic nature of OCD [6]. Lastly, despite its effectiveness, ERP is underexploited due to its high cost [6]. Neziroglu and colleagues noted that current psychological approaches to OCD are not much different from those of the early 1980s, except for the addition of cognitive therapy [11]. They note that symptoms are reduced minimally (30–50%), dropout rates and refractory cases persist without explanation, and no new methods for increasing treatment efficacy or dealing with treatment refractory cases have been developed [11]. They call for the development of new and alternative treatment approaches to improve treatment response, even for treatment responders [11]. Given the shortcomings noted above, it is imperative that mental health providers continue to search for innovative treatments that can be used alone or in conjunction with established therapies. Obsessions and available therapies There is a normal range of obsessiveness that can be considered a parameter of adaptation [12]. Existing in the majority of individuals, obsessions are deemed pathological when they cause distress and are not easily dismissed. According to the theory of paradoxical thought, attempts to suppress a thought may cause a paradoxical increase in the frequency of that thought [13]. Thought-action fusion (TAF) occurs when an intrusive thought is overvalued to the point where it is considered the equivalent of the unwanted action [14]. Many of the psychotherapies used in treating compulsions are also used to treat obsessions with one notable exception. In the treatment of obsessions, paradoxical intention therapy utilizes the strength of paradoxical thought in treating obsessions. In two trials of paradoxical intention therapy, participants exaggerated their obsessions and told themselves that the dreaded obsession would occur. Despite being initially strong, both anxiety and the belief in the obsession lost strength over time from constant exposure [15,16]. Hypothesis Obsessions begin and power the obsessive–compulsive cycle. Obsessions evoke distress which may cause the sufferer to perform hours of unwanted compulsions to reduce the distress. It is plausible that an obsession’s power can be harnessed to end the compulsive activity that it (or another obsession) started in the first place. Theoretically, if obsessions are powerful enough to start compulsions, they may be powerful enough to stop compulsions as well. The power of obsessions, coupled with the individual’s fervent desire to cease performing a compulsion, has potential application for treating compulsions in individuals with OCD. The self-talk technique The self-talk technique is not grounded in current psychotherapy approaches to treat OCD, although there is an element of imaginal exposure and some resemblance to paradoxical intention therapy. The small parallel between paradoxical intention therapy and the proposed self-talk technique is the common use of obsessions to reduce the severity of either obsessions or compulsions. In
217
paradoxical intention therapy, individuals are asked to exaggerate their beliefs that the obsession will occur, which over time results in decreased anxiety produced by the obsession. In contrast, the self-talk technique asks individuals to treat their obsession as real and to recognize the anxiety it evokes. This anxiety, coupled with the desire to prevent the obsession from occurring, keeps individuals from surpassing a limit that they have assigned for a compulsion. The three components of the self-talk technique are an obsession, the compulsive activity related to it, and another obsession. While performing a compulsion related to the original obsession, the individual would set a limit for stopping the compulsion (e.g., a time limit, repetition limit). To ensure adherence to this limit, the individual would introduce another obsession, telling himself that if he did not cease the compulsive activity as planned, the second obsession would occur. The reasoning behind this technique is that the power of any obsession is so great that it will override the need to continue any compulsive behavior. Ideally, the fear of an obsession becoming reality, and the passionate desire to avoid that at all cost, would overshadow any need to continue ritualizing. As an example, consider a patient with obsessions of contamination (original obsession) and financial difficulty (second obsession). Corresponding compulsions could include repeated handwashing and collecting purchase receipts, respectively. While in the midst of handwashing (the compulsion related to the original obsession), the patient would set a limit for washing his or her hands (e.g., one more minute, three more times). Now the individual must incorporate the second obsession, telling himself or herself that he or she must adhere to the limit or else be confronted with financial difficulty (e.g., will be a victim of credit card fraud, will suffer a loss in the value of investments). It is predicted that the individual’s fear of financial difficulty (second obsession) would force adherence to his or her limit, and the compulsive handwashing will end as planned. Ideally, with successful application, an individual would spend minutes instead of hours on a compulsion. This decrease in time spent on compulsions would be due to the presence of a limit, a limit enforced by the threat of an obsession coming true.
Conclusion Benefits and risks There are several possible benefits to the self-talk technique. The technique could be integrated with current psychotherapy or pharmacotherapy, and its flexibility and simplicity should allow individuals to incorporate any obsession to reduce any mental or physical compulsion. This remains to be evaluated further, however. A technique that asks sufferers to fear their obsessions and to pretend that the obsessions are going to happen if they do not cease ritualizing is bound to raise ethical questions. Such questions may include the following: Is there a possibility that evoking obsessions will raise their distress level? Can the frequent use of obsessions cause obsessions to become more intrusive and frequent? Can obsessions become more important and concrete, and therefore more difficult to treat? Given that this is an untested technique, it would be prudent to educate patients about risks and to introduce the technique in the context of other psychotherapy. Therapists should be vigilant when evaluating effects on their clients’ symptoms. There is indeed a possibility that obsessions may increase in severity or distress, in which case clients should be asked to discontinue the self-talk technique. Therapy to realistically evaluate the obsession should be implemented in an effort to reduce any overvalued ideation that exists.
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J.R. Scarff / Medical Hypotheses 74 (2010) 216–218
Despite the success of psychotherapy in treating OCD, certain individuals with OCD respond minimally, if at all, to treatment. This proposed self-talk approach provides a cost-effective and flexible alternative to help the individual reduce compulsions. The ability to use it anytime, anywhere for a variety of compulsions could help sufferers to regain some control over their symptoms and to loosen the grasp that OCD holds on their lives. It should therefore be explored further for effectiveness and possible incorporation into current treatment modalities. Conflicts of interest statement None declared. References [1] Weissman MM, Bland RC, Canino CH, et al. The cross national epidemiology of obsessive–compulsive disorder. J Clin Psychiat 1994;55:5–10. [2] Jenike MA. An update on obsessive compulsive disorder. Bull Menninger Clin 2001;65(1):4–25. [3] American Psychiatric Association. Diagnostic and statistical manual of mental disorders. Text revision. 4th ed. Washington, DC: American Psychiatric Association; 2000. [4] Denys D. Pharmacotherapy of obsessive–compulsive disorder and obsessive– compulsive spectrum disorders. Psychiat Clin North Am 2006;29:553–84.
[5] Bandelow B. The medical treatment of obsessive–compulsive disorder and anxiety. CNS Spectr 2008;9(Suppl. 14):37–46. [6] Rosa-Alcázar AI, Sánchez-Meca J, Gómez-Conesa A, Marín-Martínez F. Psychological treatment of obsessive–compulsive disorder: a meta-analysis. Clin Psychol Rev 2008;28(8):1310–25. [7] Jones MK, Menzies RG. Danger ideation reduction therapy (DIRT) for obsessive–compulsive washers. A controlled trial. Behav Res Ther 1998;8:121–5. [8] Maina G, Saracco P, Albert U. Family-focused treatments for obsessive– compulsive disorder. Clin Neuropsychiat J Treat Eval 2006;3(6):382–90. [9] Carmin CN, Wiegartz PS. Successful and unsuccessful treatment of obsessive– compulsive disorder in older adults. J Contemp Psychother 2000;30(2):181–93. [10] Abramowitz JS. Does cognitive-behavioral therapy cure obsessive–compulsive disorder? A meta-evaluation of clinical significance. Behav Ther 1998;29:339–55. [11] Neziroglu F, Henricksen J, Yaryura-Tobias JA. Psychotherapy of obsessive– compulsive disorder and spectrum: established facts and advances, 1995– 2005. Psychiat Clin North Am 2006;29:585–604. [12] Freedman DA. Obsessiveness in context. Annu Psychoanal 1999;26–27:25–46. [13] Rachman S. A cognitive theory of obsessions: elaborations. Behav Res Ther 1998;36:385–401. [14] Rassin E, Merckelbach H, Muris P. Paradoxical and less paradoxical effects of thoughts suppression: a critical review. Clin Psychol Rev 2000;20(8):973–95. [15] Solyom L, Garza-Perez J, Ledwidge BL, Solyom C. Paradoxical intention in the treatment of obsessive thoughts: a pilot study. Compr Psychiat 1972;13(3):291–7. [16] Gertz HO. Experience with the logotherapeutic technique of paradoxical intention in the treatment of phobic and obsessive–compulsive patients. Am J Psychiat 1966;123:548–53.