قسمت 3. آنها می ترسانند چون برای ما مهم است: رابطه بین افکار مزاحم وسواسی و ارزیابی و استراتژی های کنترل در سراسر 15 شهر

A key assumption of contemporary cognitive-behavioral models of obsessive–compulsive disorder (OCD) is that obsessional thoughts exist on a continuum with “normal” unwanted intrusive thoughts. Recently, however, some authors have challenged this notion. The present study aimed to clarify (a) the extent that different types of intrusive thoughts in nonclinical individuals are associated with obsessionality, (b) the relative contribution of frequency, distress and control ratings to obsessionality, and (c) the extent that existing findings (primarily from North American or European samples) generalize to other countries in the world. Five hundred and fifty-four non clinical individuals from 11 different countries were administered an interview assessing the presence, frequency, distress, and perceived control of different types of intrusive thoughts. Participants also completed measures of obsessional beliefs, obsessive–compulsive (OC) symptoms, and depression. Results from data analyses supported the universality of unwanted intrusive thoughts, the continuity of normal and abnormal obsessions, and the specificity of dirt/contamination, doubt and miscellaneous intrusions to OC symptoms. Implications for intrusive thoughts as a potential vulnerability factor for OCD are discussed.

Cognitive-behavioral researchers and practitioners widely believe that obsessions arise from the normal unwanted intrusive thoughts, images or impulses that are universally experienced by all individuals. Born out of the seminal study by Rachman and de Silva (1978), showing that the majority of individuals experience occasional unwanted intrusive thoughts that are indistinguishable from the content of clinical obsessions, subsequent cognitive-behavioral treatment (CBT) models of obsessive–compulsive disorder (OCD) have embraced the assumption of continuity between “normal” and abnormal obsessions (Clark, 2004, Freeston et al., 1996, Rachman, 1997, Rachman, 1998, Rachman, 2003, Rachman and Hodgson, 1980, Salkovskis, 1985 and Salkovskis, 1989a). CBT models contend that any normal intrusive thought can escalate into an obsession if it is erroneously interpreted as signifying a serious personal threat to self or significant others and the person attempts to reduce or neutralize the distressing qualities of the intrusion by engaging in some futile behavioral or mental activity (Rachman, 1997 and Rachman, 1998). From this perspective, any thought, regardless of content or context, could morph into a clinical obsession if associated with pathological appraisal and neutralization processes (Salkovskis & Freeston, 2001). Most of the published research on intrusive thoughts has been conducted on western samples and there have been no large scale investigations of intrusive thoughts across a diverse range of nationalities. Thus the universality of unwanted intrusions, their relationship to OC symptoms and, by extension, the cross-cultural relevance of the CBT model of OCD has not been tested in a multinational comparative study. Like the other papers in this special issue, a major objective of the current study is to determine the cross-cultural generalizability of the intrusion/OC symptom relationship in a large multinational comparative study. Not all OCD researchers readily embrace the continuity of normal and abnormal obsessions, or the universality of obsessive-like intrusive thoughts. Prior to the Rachman and de Silva (1978) research, the prevailing notion in psychiatry was that obsessions represented aberrant thinking that was distinct from normal cognition (Black, 1974, Lewis, 1936 and Pollitt, 1957). The view that clinical obsessions are qualitatively distinct from normal cognition is more consistent with the categorical approach to psychiatric nosology represented in DSM-5 than is the continuity assumption of obsessions ( American Psychiatric Association, 2013). Moreover, several recent empirical studies have challenged the continuity assumption. In their review of the intrusive thoughts literature, Julien, O'Connor, and Aardema (2007) concluded that intrusive thoughts do not always exhibit a stronger correlation with OCD symptoms than with other anxiety symptoms or depression, nor do the phenomena show the expected distinctiveness from other types of negative cognitions such as worry and negative automatic thoughts. In support of this argument, Rassin and Muris (2006), Rassin, Cougle, and Muris (2007) reported on two studies that appear to indicate that some “abnormal” intrusions have a closer relationship to obsessionality than do other more normal intrusions, with nonclinical participants reporting more of the latter than the former. This finding challenges the assumption of continuity between nonclinical and clinical intrusions. There are, however, two difficulties with the conclusions reached in these studies. First, there was a very strong correlation between frequency of “normal” and “abnormal” intrusive thoughts (r=.80), indicating that people who tended to endorse one type of thought also endorsed the other. Second, their list of “normal” and “abnormal” intrusions may have low content validity because the list of “normal intrusions” included many instances of angry, worrisome, and generally negative automatic thoughts (e.g., “they shouldn't do that”). Thus it is not surprising that the Rassin et al. findings are inconsistent with those of Lee, Lee, Kim, Kwon, and Telch (2005), who found that the more realistic reactive intrusions, which are similar to Rassin and Muris' (2006) “normal obsession” content, had a stronger relation to obsessive compulsive (OC) symptoms than the bizarre, highly aversive and unrealistic “autogenous” intrusions, which are like Rassin and Muris' abnormal obsessions category. There have now been several replication studies documenting the almost unanimous presence of unwanted intrusive thoughts in healthy, nonclinical samples (Freeston et al., 1991, Parkinson and Rachman, 1981 and Salkovskis and Harrison, 1984), even when more stringent criteria of intrusions are utilized (Belloch et al., 2004, Lee and Kwon, 2003 and Purdon and Clark, 1993). Radomsky et al. (2014) found that across 13 countries the vast majority of nonclinical individuals (93.6%) reported experiencing unwanted intrusive thoughts with obsessional content within the past three months, although some differences were evident between countries. These findings, then, support one of the basic assertions of the cognitive-behavioral model of OCD; that unwanted obsessive-like intrusive thoughts are highly prevalent in the nonclinical population, and this phenomenon may be present regardless of nationality, religion or culture. A second major premise of the cognitive-behavioral perspective is that the frequency, appraisal and control of intrusive thoughts will exhibit a specific relationship with obsessional symptoms. The most stringent version of this hypothesis argues for a causal relation between intrusions and obsessional symptoms. Although most studies, including the present, are cross-sectional in nature and so cannot investigate causal relations, these studies have been able to test a precondition of causality; that is, whether unwanted intrusive thoughts have a unique and significant relationship with obsessionality. Various studies report that the frequency of intrusive thoughts has a stronger association with obsessional than with anxious or depressive symptoms (Barrera and Norton, 2011, García-Soriano et al., 2011, Lee et al., 2005 and Purdon and Clark, 1993), although failure to find specificity has also been reported (Clark, 1992). Other studies find that it is not the frequency of intrusive thoughts that is uniquely associated with OC symptoms, but rather how the thought is appraised or evaluated (Corcoran and Woody, 2008, Freeston and Ladouceur, 1993 and Freeston et al., 1992). Still other studies report that it is perceived uncontrollability or effort to control intrusions that is specific to obsessionality (Grisham and Williams, 2009 and Morillo et al., 2007; see Magee, Harden, & Teachman, 2012 for further discussion). To date several fundamental issues about the relation between unwanted intrusive thoughts and obsessional symptoms remain unresolved. First, it is not clear whether the content of intrusive thoughts is entirely irrelevant to OC symptoms. It may be that some types of intrusions have a closer association with or relevance to obsessionality than do others, but answers to this question have been hampered by studies that use small, relatively homogenous samples and rely on retrospective self-report intrusion and symptom measures that have high levels of shared method variance. Second although the most consistent finding is that frequency of unwanted intrusions is related to OC symptoms, the relative contribution of appraisal and control efforts is still not well understood. Finally, much of the work on intrusions and obsessionality is based on North American or European samples. It is unknown whether these relationships generalize to populations in other regions of the world. Nevertheless, based on the research to date, we can expect that unwanted intrusive thoughts with varying content will have a specific relationship to OC symptoms across all cultures and that perceived distress and control of intrusions will have a significant relationship with OC symptoms even after controlling for the frequency of intrusive thoughts. To determine content-specificity, generalizability across cultures and contribution of appraisals to the intrusion/OC symptom relationship, the present study focuses on analyses conducted on the frequency, distress, importance of control, and difficulty of control ratings completed for the seven types of intrusive thoughts assessed in the International Intrusive Thoughts Interview Schedule (IITIS; RCIF, 2007). Between-group comparisons across country as well as a series of hierarchical regression analyses investigated the specific relation between frequency, distress and perceived control of unwanted intrusions and distress ratings for OCD symptoms. It was hypothesized that frequency of all seven types of intrusions would have a significantly greater association with OC than with depressive symptoms, and that frequency of intrusions would be a more significant correlate of OC symptoms than would evaluations of distress or controllability. Moreover it was predicted that the intrusion-OC symptom relation would be evident after controlling for differences between countries.