Frederick Aardema

Evaluation of an Inference‐Based Approach to Treating Obsessive‐Compulsive Disorder

This study evaluated an inference‐based approach (IBA) to the treatment of obsessive‐compulsive disorder (OCD) by comparing its efficacy with a treatment based on the cognitive appraisal model (CAM) and exposure and response prevention (ERP). IBA considers initial intrusions in OCD (e.g. “Maybe the door is open”, “My hands could be dirty”) as idiosyncratic inferences about possible states of affairs arrived at through inductive reasoning. In IBA such primary inferences represent the starting point of obsessional doubt, and the reasoning maintaining the doubt forms the focus for therapy. This is unlike CAM, which regards appraisals of intrusions as the maintaining factors in OCD. Fifty‐four OCD participants, of whom 44 completed, were randomly allocated to CAM, ERP or IBA. After 20 weeks of treatment all groups showed a significant reduction in scores on the Yale‐Brown Obsessive Compulsive Scale (Y‐BOCS) and the Padua Inventory. Participants with high levels of obsessional conviction showed greater benefit from IBA than CAM. Appraisals of intrusions changed in all treatment conditions. Strength of primary inference was not correlated with symptom measures except in the case of strong obsessional conviction. Strength of primary inference correlated significantly with the Y‐BOCS insight item. Treatment matching for high and low conviction levels to IBA and CAM, respectively, may optimize therapy outcome.

Beyond Reasonable Doubt: Reasoning Processes in Obsessive-Compulsive Disorder and Related Disorders

Traditionally, obsessive-compulsive disorder has been classified as an anxiety disorder, but there is increasing evidence that it has schizotypal features ? in other words it is a belief disorder. Beyond Reasonable Doubt moves comprehensively through theoretical, experimental, clinical and treatment aspects of reasoning research, and contains a detailed treatment manual of great value to practitioners, including assessment and treatment protocols and case studies

Cognitive behaviour therapy and medication in the treatment of obsessive–compulsive disorder

Objective:  To compare cognitive behaviour therapy (CBT) with CBT plus medication; medication alone; and placebo in the treatment of adult obsessive–compulsive disorder (OCD).

The Menace Within: Obsessions and the Self

The current article attempts to provide a theoretical account of obsessions about blasphemy, sexuality, and aggression from an inference-based perspective. It is argued that self-evaluative and self-representational dimensions in obsessions need to be taken into account to allow for the misrepresentation of mental states. A persuasive narrative containing rhetorical devices informs the misrepresentation of mental states and gives credibility to the obsession. These narrative devices seem to originate from a distrust of the self where the person overinvests in a sense of self-as-could-be rather than a sense of self-as-is, which consequently gives rise to a discordance between the person and the obsession (i.e., egodystonicity). The article concludes with some theoretical and clinical implications for cognitive models of obsessive-compulsive disorder.

Seeing White Bears That Are Not There: Inference Processes in Obsessions

Meta-cognition refers to the notion of thoughts about one’s own thoughts and has been defined as knowledge and cognition about cognitive phenomena (Flavell, 1979). In recent years, meta-cognitive models have provided accounts of the maintenance of anxiety disorders (e.g., Wells, 2000). Meta-cognitive models would argue that the thoughts about the appearance and utility of otherwise normal thoughts generate anxiety. In this article we apply a meta-cognitive approach to understanding obsessions but, rather than thoughts about thoughts, we suggest that the ruminations in obsessive-compulsive disorder (OCD) without overt compulsions result largely from thoughts about thoughts that do not actually occur. Persons with obsessions thinks they might have or might have had the thoughts, and through a meta-cognitive process termed “inferential confusion,” confuse these imagined thoughts with actual thoughts. This account would explain the repetitive, compulsive yet ego-dystonic nature of obsessions. The justification, provided by patients with OCD, for treating imaginary thoughts as actual thoughts appears to be an imaginary narrative, which produces and maintains the obsessional preoccupation, and seems imposed on reality by a distorted inductive reasoning process.

Imaginative, dissociative, and schizotypal processes in obsessive-compulsive symptoms

This study investigates imaginative, dissociative, and schizotypal processes that are potentially relevant to obsessive-compulsive (OC) symptoms. Students (n = 377) completed questionnaires that assessed inferential confusion, absorption, schizotypal personality, and other domains. Hierarchical regression revealed that inferential confusion and absorption were the most consistent predictors of OC symptoms; other content predicted variance for specific OC symptoms. For example, schizotypal personality predicted checking and hoarding symptoms, but not cleanliness or ordering rituals. Immersive tendencies predicted cleanliness and hoarding but not checking or ordering rituals. Results are consistent with an inference-based model of OC, in which an overreliance on imagination during reasoning gives rise to experiences that are inconsistent with reality. This study suggests additional domains that may help explain why intrusive thoughts become obsessions.

Inferential Confusion and Obsessive Beliefs in Obsessive‐Compulsive Disorder

The goal of the present study was to investigate whether inferential confusion could account for the relationships between obsessional beliefs and obsessive‐compulsive disorder (OCD). The Inferential Confusion Questionnaire and the Obsessive Beliefs Questionnaire were administered to a sample of 85 participants diagnosed with OCD. Results showed that the relationship between obsessive beliefs and obsessive‐compulsive symptoms decreased considerably when controlling for inferential confusion. Conversely, the relationship between inferential confusion and obsessive‐compulsive symptoms was not substantially affected when controlling for obsessive beliefs. Since inferential confusion has an overlap with overestimation of threat, a competing hypothesis for the results was investigated. Results indicated that inferential confusion was factorially distinct from overestimation of threat, and that the independent construct of inferential confusion remains significantly related to obsessive‐compulsive symptoms when controlling for anxious mood. These results are consistent with the claim that inferential confusion may be a more critical factor in accounting for OCD symptoms than are obsessive beliefs and appraisals.

Treating Delusional Disorder: A Comparison of Cognitive-Behavioural Therapy and Attention Placebo Control

Objective: Cognitive-behavioural therapy (CBT) has proved effective in treating delusions, both in schizophrenia and delusional disorder (DD). Clinical trials of DD have mostly compared CBT with either treatment as usual, no treatment, or a wait-list control. This current study aimed to assess patients with DD who received CBT, compared with an attention placebo control (APC) group. Method: Twenty-four individuals with DD were randomly allocated into either CBT or APC groups for a 24-week treatment period. Patients were diagnosed on the basis of structured clinical interviews for mental disorders and the Maudsley Assessment of Delusion Schedule (MADS). Results: Completers in both groups (n = 11 for CBT; n = 6 for APC) showed clinical improvement on the MADS dimensions of Strength of Conviction, Insight, Preoccupation, Systematization, Affect Relating to Belief, Belief Maintenance Factors, and Idiosyncrasy of Belief. Conclusion: When compared with APC, CBT produced more impact on the MADS dimensions for Affect Relating to Belief, Strength of Conviction, and Positive Actions on Beliefs.

Intrusions related to obsessive‐compulsive disorder: a question of content or context?

The aim of the current study was to investigate whether intrusions of individuals with obsessive-compulsive disorder (OCD) and nonclinical individuals differed in content and in context of occurrence. The results suggest that although the intrusions of OCD and nonclinical individuals are similar in content, they differ in their context of occurrence. Chi square analyses revealed that the intrusions of nonclinical participants were more likely to be directly linked than indirectly linked to observations in the here and now, whereas the intrusions of participants with OCD were more prone to be indirectly linked than directly linked to triggers in the environment at the time they occurred. The implications of the results for cognitive models of OCD are discussed.

Fusion or Confusion in Obsessive-Compulsive Disorder:

Inferential confusion occurs when a person mistakes an imagined possibility for a real probability and might account for some types of thought-action and other fusions reported in obsessive-compulsive disorder. Inferential confusion could account for the ego-dystonic nature of obsessions and their recurrent nature, since the person acts “as if” an imagined aversive inference is probable and tries unsuccessfully to modify this imaginary probability in reality. The clinical implications of the inferential confusion model focus primarily on the role of the imagination in obsessive-compulsive disorder rather than on cognitive beliefs.