According to the Cognitive Appraisal Model of OCD, almost everyone has unwelcome thoughts (Rachman, 1998; Salkovskis, 1985). However, for individuals with OCD, the thoughts tend to “stick,” because they are more meaningful and therefore more difficult to dismiss (Rees & Anderson, 2013). In this way, the importance of the thoughts is inflated because, in some regard, their occurrence is more personally relevant. In other words, the fact that these thoughts even occur at all is perceived to be significant and evidence that something is wrong. Therefore, they are seen as more important than they really are.

For example, a mom may be cutting up vegetables for dinner, look up from her work and see her child doing homework at the kitchen table. A thought may occur to her, “what if I took this knife and stabbed my son?” If this thought is seen as insignificant (“just a thought”) and therefore easily dismissed, there is no distress and no problem. On the other hand, if having the thought is perceived to be significant (e.g. “if I’m having this thought, maybe I will actually carry it out”), then it is more difficult to dismiss and can turn into an obsession.

In this example, the specific type of appraisal is an example of thought-action fusion (TAF). TAF is comprised of two subtypes. The first subtype is probability TAF whereby the individual believes that having a thought increases the likelihood that the behavior will ensue, as in the above example. Hence, if a thought about being a pedophile occurs, then pedophilic behavior is much more likely to follow. In the second subtype, moral TAF, thoughts are considered behavioral equivalents. Consequently, thinking about killing someone is deemed as morally reprehensible as actually carrying it out. In this respect, the appraisal of the intrusion as immoral makes it more likely to become an obsession.

Several studies have provided support for the idea that intrusive and unwelcome thoughts are experienced by persons without diagnosable OCD (Wilhelm & Steketee, 2006). Studies of undergraduate and community samples have shown in 80-90% of participants endorsement of thoughts that could easily be considered “OCD” thoughts (Freeston, Ladouceur, Thibodeau & Gagnon, 1991; Rachman & de Silva, 1978; Salkovskis & Harrison, 1984). Further, intrusions occur as thoughts, images or impulses (Julien, O’Connor & Aardema, 2006). Consequently, what distinguishes persons with and without OCD, is not the occurrence of these thoughts, but their importance and how easy or difficult they are to dismiss.

Other evidence provides support for the Cognitive Appraisal Model. In a recent study (Bouvard et al., 2017), thought importance distinguished between clinical and non-clinical samples whereas for other types of thoughts (e.g. intolerance of uncertainty, intolerance of anxiety, and need for control) the difference was not as large. Moreover, among persons with OCD the meaningfulness and significance of thoughts distinguishes between the most and least distressing intrusions, in that the most distressing intrusions are the most meaningful and significant (Rowa et al., 2005). Further, the distress caused by intrusions has been shown to be associated with OCD symptom severity on the Yale-Brown Obsessive Compulsive Scale (Barrera & Norton, 2011).

Although there are other thought patterns common to people with OCD (e.g. intolerance of uncertainty, perfectionism), a tendency toward inflating the significance of intrusions and an inability to reduce their importance is pervasive across all OCD-related problematic thinking patterns. While many of these other patterns are focused on content (e.g. a tendency to assume responsibility), “importance of thoughts” is a more generalized thought pattern that represents a deeper and more process oriented aspect of thinking (Rees & Anderson, 2013). For example, a person may have a thought that they might have run over a person after driving over a pot hole. Even though this is considered inflated responsibility, the fact that the thought sticks and cannot be easily dismissed attests to its over-importance.

Common among treatments for OCD is the implied objective of shrinking the importance of OCD thoughts. With exposure plus response prevention (ERP), repeated exposure leads to threat decrease and the consequent reduction in the importance of thoughts. Scarier thoughts are more important as they imply a real threat. As our fear is reduced, so is the importance of these intrusive thoughts. Response prevention is a key component of ERP as failure to thwart rituals can reduce the effectiveness of exposure. In other words, rituals imply that these thoughts are important as rituals are required to counteract them. Similarly, cognitive strategies also have as their implicit goal the reduction of thought importance.

With Acceptance and Commitment Therapy (ACT; Hayes, Strosahl, & Wilson, 2012), the focus is on accepting and observing cognitions and avoiding being swept up into content. One goal of treatment is to strengthen the part of the mind involved in observing thoughts. All of these efforts serve to lessen the importance of thoughts so that they are not so overpowering and can be accepted. In ACT, accepting thoughts means not being so overwhelmed that the immediate reaction is to “get rid of them.” Instead, as thoughts are accepted, their importance is diminished.

Although thought dismissal has not been studied as extensively as other interventions, it is considered a desirable objecting as persons without OCD who experience intrusive thoughts dismiss them after they are deemed unimportant (Rees & Anderson, 2013). In the popular book Brain Lock, by Jeffrey Schwartz (1996), he advises readers to tell themselves “it’s only my OCD.” Being able to dismiss thoughts is considered a worthwhile objective in OCD treatment. It is often difficult to attain initially, but can be easier with successful treatment. And, at the core of thought dismissal is the understanding that the thought is unimportant so that it can be dismissed.

Although the relationship between over-importance of thoughts and difficulty dismissing them can be considered circular (Freeston et al., 1994; Rees & Anderson, 2013), identifying these thoughts as overly important does have conceptual value. It provides a linkage between conceptual models, research literature and interventions that is easily conveyed to and understood by lay people with OCD. Thoughts are intrusive because the person believes that they are important (often because they pop up). This triggers efforts to get rid of them, which only increases their perceived importance. It is only through utilizing treatment strategies that implicitly reduce thought importance and promote abandoning control strategies, that the power of these thoughts diminishes. The appeal of the Cognitive Appraisal Model is that it identifies a universal target for treatment: the importance of thoughts. In doing so, It offers a common mechanism to explain why diverse treatments may work for OCD and helps patients understand what can be a very complex disorder.

References

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By Cynthia Radnitz, Ph.D.

July 5, 2019