افکار مزاحم ناخواسته: فرهنگی،عوامل متنوع زمینه ای، تغییر همگام و خوی شناسی

Cognitive behavioral theories trace the origins of clinical obsessions to common unwanted intrusive thoughts, images or impulses that are universally experienced in the general population. It is the erroneous interpretation of the intrusion as a personally significant threat that must be diminished or neutralized that result in the vicious escalation into a clinical obsession. This paper reviews four critical determinants of individuals׳ diverse experience of unwanted intrusive thoughts (UITs). First we consider the role that culture may play in the types of thoughts that become intrusive, repetitive and persistent. Next the role of context is considered and the differences found between UITs and obsessions that are externally precipitated versus those that are more autonomous. A third section considers the role of current clinical state and whether there is a specific relation between certain types of intrusions and obsessional states in particular. The final section examines the role of personality, enduring dysfunctional beliefs and self-view discrepancies as potential vulnerability factors for UITs and obsessions. The paper concludes with a summary of current status and future directions for research on UITs.

Contemporary cognitive behavioral theories (CBT) and treatment protocols for obsessions assume continuity between the unwanted intrusive thoughts, images and impulses found in healthy populations and the clinical obsessions that characterize diagnosable obsessive compulsive disorder (OCD). This dimensional assumption is critical to CBT because the models propose that obsessions arise from faulty appraisals and maladaptive control efforts that seek to neutralize naturally occurring intrusive thoughts (e.g., Clark, 2004, Rachman, 1997, Rachman, 1998, Salkovskis, 1985 and Salkovskis, 1989). Beginning with the seminal research by Rachman and de Silva (1978), numerous studies have since demonstrated that nonclinical individuals experience unwanted intrusive thoughts (UITs) of dirt/contamination, doubt, harm/injury, sex, religion, order/symmetry, superstition, etc. that are similar in form and content to the clinical obsessions of individuals with OCD, although their frequency and distress are much less than in clinical samples (e.g., Freeston et al., 1991, García-Soriano et al., 2011, Lee and Kwon, 2003, Parkinson and Rachman, 1981 and Purdon and Clark, 1993). More recently, a large international study of UITs across 13 countries found that over 90% of individuals experienced unwanted intrusions within the last 3 months (Radomsky et al., in press). Thus we can now say with considerable confidence that the majority of healthy, nonclinical individuals experience unwanted intrusions that are similar in content to the obsessions of OCD patients. After 25 years of research on obsessions and normal UITs, two observations remain constant across studies. Regardless of sample characteristics, whether OCD patients, nonobsessional patients or nonclinical individuals, there is a remarkable diversity across individuals in the content and form of their intrusions/obsessions. By form we mean a diverse range of parameters that define the experience of UITs such as frequency, intensity (or distress), intrusiveness, unexpectedness, persistence (duration), controllability, vividness, valence (positive versus negative), adhesiveness (durability), and modality (verbal- versus imagery-based). Unfortunately only three parameters, frequency, distress and controllability, have been researched with any degree of consistency by the most popular OCD measures (e.g., Yale–Brown Obsessive Compulsive Scale (Y-BOCS); Obsessive Compulsive Inventory (OCI), Vancouver Obsessive Compulsive Inventory (VOCI), etc). The second finding is of considerable inter-individual differences in the frequency and negative consequence of UITs. It ranges from the tiny minority who deny any UITs (less than 10%) to those who report daily occurrences of unwanted cognitions. However much of this research is hampered by methodological weaknesses such as an overreliance on retrospective questionnaires that assume individuals can accurately report on their intrusion experiences. The purpose of the current review paper is to examine several broad factors that might account for the diverse form and content of UITs and obsessions as well as individual differences in the propensity to experience unwanted intrusions. Four determinants of UIT/obsession diversity are considered; cultural factors, context, psychopathology, and enduring individual differences in personality and cognition. Variables related to both form and content are reviewed in each category, and both nonclinical and clinical obsessive intrusive phenomena are evaluated, based on the continuity of UITs and obsessions. We conclude with a summary of the findings to date and offer suggestions for further investigation.

Unwanted intrusive thoughts, images and impulses (UITs) have been cognitive phenomena of great interest to CBT researchers, given the proposed link between UITs and clinical obsessions. Of course the overarching issue driving this research over the past 25 years is to determine whether UITs might be a cognitive vulnerability construct for clinical obsessions, and if so, whether faulty appraisal and control processes are responsible for transforming normal intrusions into obsessions. As indicated in this review, we have learned much about the nature of UITs, their function in OCD, and the processes responsible for their persistence. Four general classes of variables have been found to determine the experience of UITs; cultural upbringing, context, current psychopathology or emotional state, and cognitive personality predisposition. Culture may influence the content of obsessive-compulsive symptoms but not its prevalence (Weissman et al., 1994). We have only begun to explore cultural differences in UITs. There is emerging evidence that UITs are a global phenomenon and one’s cultural experience may have a small but significant influence on the types of UITs people experience. Moreover the functional relation between appraisals, control strategies and the frequency and distress of UITs appears invariant across countries, as does the specific relation of UITs to obsessional symptoms. Nevertheless, much of the research has compared UITs in different developed countries where cultural variation may be limited. More research is needed in emerging and non-developed countries where greater cultural variability may be found in order to truly gauge the impact of culture on UITs. As well, it may be that particular aspects of culture such as religion, health-related beliefs, treatment-seeking practices, ethnic/racial identity and the like may have a greater impact on UITs than assuming cultural homogeneity within countries (e.g., Williams et al., 2012).