تکرار و گسترش: استراتژی های کنترل فکر در اختلال وسواسی- اجباری

Previous research suggests that individuals with OCD use maladaptive strategies to control their unpleasant thoughts (Behav Res Ther (1977) 35, 775). These include worry and self-punishment strategies. In the present study we replicated and extended the previous findings by comparing thought control strategies used by patients with OCD to strategies used by anxious and non-anxious control participants. We also examined changes in thought control strategies for OCD patients who underwent cognitive-behavioral therapy. Compared to controls, OCD patients reported more frequent use of worry and punishment strategies, and less frequent use of distraction. Following successful treatment, OCD patients evidenced increased use of distraction and decreased use of punishment. Findings are discussed in terms of the cognitive model of OCD.

Evidence suggests that the vast majority of the general population experiences intrusive thoughts that are indistinguishable in content from those reported by people with obsessive-compulsive disorder (OCD), but that do not assume obsessional qualities such as high frequency, intensity, or duration (Rachman and de Silva, 1978 and Salkovskis and Harrison, 1984). Cognitive theories of OCD (Rachman, 1998 and Salkovskis, 1999) posit that the ways in which intrusive upsetting thoughts are interpreted differentiates normal intrusions from obsessions. For example, the appraisal of an unwanted thought about harming one’s child as indicating that one is indeed responsible for harm (or for preventing harm) leads to increased distress associated with this thought. What, then, is the mechanism by which dysfunctional interpretations may lead to obsessional problems? One possibility, as proposed by Rachman (1998), is that the appraisal of intrusive thoughts as highly threatening evokes urges to take action to control such thoughts. Perhaps some methods by which individuals attempt to manage intrusive thoughts are more adaptive than are others. Wells and Davies (1994) found that individuals use five general strategies to control intrusive thoughts: (a) distraction (e.g. I keep myself busy), (b) social control (e.g. I talk to a friend about the thought), (c) worry (e.g. I think about past worries instead), (d) punishment (e.g. I tell myself something bad will happen if I think the thought), and (e) reappraisal (e.g. I challenge the thought’s validity). These authors observed that the use of worry and punishment strategies was related to higher scores on measures of trait anxiety, indicating that these particular strategies may be especially maladaptive. Why might the use of worry and self-punishment to control intrusive thoughts be particularly maladaptive? Borkovec and Inz (1990) hypothesized that worrying impedes the use of more pragmatic behavioral and mental coping styles by diverting the worrier from facing the problem at hand. Another possibility is that both worry and self-punishment preserve levels of anxiety and threat (affective distress) associated with the intrusion, thereby increasing the motivation to dismiss the thought. However, a large body of literature suggests that attempts to suppress intrusive thoughts lead to paradoxical increases in the frequency of such thoughts (for a meta-analytic review see Abramowitz, Tolin, & Street, 2001), and that this is a particular problem for people with OCD (Tolin, Abramowitz, Przeworski, & Foa, in press). Moreover, individuals with OCD tend to attribute their failure to control or suppress thoughts to internal weaknesses (e.g. ‘I can’t stop this terrible thought, thus there is something wrong with my brain’), which may lead to greater distress and further failed attempts to suppress (Tolin, Abramowitz, Hamlin, & Synodi, in press). One previous study has examined the use of thought control strategies in OCD. Amir, Cashman and Foa (1997) compared OCD patients with non-anxious controls and reported that OCD patients used distraction less frequently, and the other four strategies more frequently, than non-patients. Punishment and worry most clearly differentiated OCD patients from non-patients, mostly because non-patients used these methods very little. Maladaptive thought control strategies have also been observed in individuals with other anxiety disorders such as acute stress disorder (Warda & Bryant, 1998) and generalized social phobia (Abramowitz, Dorfan, & Tolin, in press). These findings, along with correlations between trait anxiety and the use of punishment and worry strategies (Wells & Davies, 1994), raise questions about the degree to which maladaptive thought control strategies observed in OCD patents are related to this disorder per se, or attributable to higher levels of trait anxiety. A shortcoming of the study by Amir et al. (1997) is that these authors failed to include an anxious control group, thus leaving the possibility that differences between OCD patients and nonpatients were due to the presence of anxiety in general, rather than specifically to OCD. We addressed this issue in two ways in the present study. First, we included a comparison group of individuals with panic disorder to control for the presence of an anxiety disorder. Second, we administered measures of depression and trait anxiety to all participants, and controlled for the severity of these symptoms in our between-group comparisons of control strategy use. We hypothesized that OCD patients would show higher use of punishment and worry strategies compared to anxious controls (with panic disorder) and non-anxious controls even when depression and trait anxiety were accounted for. An additional aim of our study was to determine whether the use of maladaptive strategies in OCD is reduced following successful cognitive-behavioral therapy by exposure and response prevention (EX/RP). Exposure entails systematic confrontation with stimuli that evoke obsessional doubt. Response prevention involves prolonging exposure by refraining from engaging in neutralizing and rituals to demonstrate that feared catastrophes do not occur and that anxiety does not persist indefinitely. Although these treatment procedures are primarily ‘behavioral,’ Foa and Kozak (1986) hypothesized that they promote changes in dysfunctional cognitions via the provision of corrective information. Such changes are fostered in EX/RP treatment via discussions about dysfunctional cognitions in the context of exposure. This treatment was found to reduce cognitions related to pathological responsibility in OCD patients (McLean et al., 2001). If patients worry or punish themselves in response to intrusive obsessional thoughts, demonstrations that such thoughts are not threatening might result in changes in beliefs about such thoughts and decreased motivation to use these maladaptive thought control strategies. Since the aim of EX/RP is to encourage more functional ways of appraising and responding to intrusive thoughts and obsessional fears, one might also expect increases in the use of distraction and reappraisal thought control strategies among OCD patients successfully treated in this way. To summarize, in the present study we first compared the use of thought control strategies between patients with OCD, anxious controls, and non-anxious controls. We predicted that maladaptive patterns utilized by the OCD group would be specific to OCD. Thus, we expected to find that the OCD group would evidence increased use of punishment and worry strategies compared to the anxious and non-anxious control groups. Second, we examined changes in the use of thought control strategies among OCD patients from pre- to post-treatment with EX/RP. We predicted that successfully treated patients would show decreases in the use of punishment and worry strategies, and increases in the use of distraction and reappraisal strategies.