Primary obsessional slowness: a nursing treatment programme with a 13-year-old male adolescent

A 13-year-old male adolescent inpatient with a 5-year history of primary obsessional slowness was treated using a nursing intervention programme involving prompting, pacing and shaping, or participant modelling of four types of self-care behaviour. The treatments produced an immediate increase in response rate of three of the four behaviour targets. Treatment gains were not maintained during the gradual fading of the intervention programme. Possible reasons for failure to achieve treatment maintenance are discussed in light of the literature on primary obsessional slowness.     

Worry and obsessional symptoms: a correlational analysis.

Several studies have suggested that worry and obsessional symptoms are systematically associated. In the present study, the relationship between worry and obsessional symptoms was confirmed. Measures included a worry content measure, a worry visual analogue scale, a modification of the everyday checking behaviours scale, and the MOCI. Worry was found to be more consistently associated with checking and doubting, than washing and slowness. It is suggested that worry and obsessional symptoms both occur in response to stress. In addition, it is suggested that worry and checking are functionally similar, and Generalised Anxiety Disorder may represent a 'cognitive' variant of obsessional checking.     

Obsessional slowness: a meticulous replication.

The treatment of an apparently authentic case of obsessional slowness is described. The relationship between behaviour change and emotional events is discussed. The findings replicate those of Rachman (1974).     

The exclusion of the other2

The author begins by noting that the subject of obsessions and obsessional neurosis seems to have fallen out of favour with the analytic community in spite of the important part it played in the formation of Freud's theories, and notwithstanding the significance of its mechanisms in the maturation of the ego. He then discusses some theoretical considerations regarding the development of the taboo on touching and, by extension, contact. Attention is drawn to the parallels with autistic functioning emphasised by other authors. Particular importance is attached to the distinction between internal and external reality that arises during the anal‐sadistic phase and that leads to polarisation and splitting in obsessional neurosis. Following a discussion of the transference' countertransference situation with obsessional patients and of their concretistic experience in the treatment situation, as also featured in the literature, an extensive case history exemplifies the author's contentions and shows how the patient concerned developed during the course of his analysis. After pointing out the importance of the avoidance of identifications as a mechanism of obsessional defence, the author concludes the paper with a brief comparison of obsessional and hysteriform functioning and a characterisation of the obsessional defence as the excessive recourse to perverted thought functions so as to ward off paranoid anxieties.     

Converting a Freudian analysis into a Jungian one: obsession,addiction, and an answer from Job

In his analyses of obsessional patients, Sigmund Freud suggested that they suffered from intrusive cognitions and compulsive activities. Early psychoanalysts delineated the phenomenology of obsessionality, but did not differentiate what is currently termed obsessive‐compulsive disorder from obsessional personality. However, it was widely recognized that the success of psychoanalysis with obsessional patients was limited due to rigid characterological defences and transference resistances. The present paper examines the case of a middle‐aged obsessional academic who had been treated for nearly twenty years in a ‘classical' Freudian psychoanalysis prior to entering Jungian analysis. It examines how persistent focus on Oedipal conflicts undesirably reinforced the transference resistance in this obsessional man, and suggests that focusing instead on diminishing the harshness of the super‐ego via the therapeutic alliance, and fostering faith in the salutary aspects of unconscious processing has led to salutary results in this case. The biblical book of Job is adopted as ancient instruction in how to address the scrupulosity and addictive mental structuring of obsessionality in analysis.     

Responsibility attitudes and interpretations are characteristic of obsessive compulsive disorder

The cognitive-behavioural theory of Obsessive Compulsive Disorder (OCD) proposes that a key factor influencing obsessional behaviour is the way in which the intrusive cognitions are interpreted. The present paper reports an investigation of links between clinical symptoms (of anxiety, depression and obsessionality) and responsibility beliefs. These beliefs include not only measures of general responsibility attitudes (assumptions) but also more specific responsibility appraisals consequent on intrusive cognitions. The characteristics of two new questionnaires specifically designed to measure these beliefs were assessed in patients suffering from Obsessive Compulsive Disorder, in patients suffering from other anxiety disorders and in non-clinical controls. The scales measuring negative beliefs about responsibility were found to have good reliability and internal consistency. Comparisons between criterion groups indicate considerable specificity for both assumptions and appraisals with respect to OCD. There was also good evidence of specificity in the association between responsibility cognitions and obsessional symptoms across groups, and that this association was not a consequence of links with anxiety or depressive symptoms. Although the two measures were correlated, they each made unique contributions to the prediction of obsessional symptoms. Overall, the results are consistent with the hypothesis that responsibility beliefs are important in the experience of obsessional problems.     

Cognitive-behavioural factors and the persistence of intrusive thoughts in obsessional problems

Jakes' critique fails to consider (i) the importance of appraisal of responsibility in initiating neutralising activity, and that (ii) obsessional patients negatively evaluate the occurrence as well as the content of intrusive thoughts. These factors are crucial because neutralising is presumed to be central to the development and maintenance of obsessional disorders. The current form of the hypothesis is outlined and recent data reviewed. Possible experimental investigations on the focus of therapeutic interventions are considered.     

Time series analysis of obsessional behavior and mood during self-imposed delay and response prevention

Time series analysis of more than a year of daily self-report of three subjects showed that self-imposed delay and response prevention was effective in decreasing obsessions and compulsions. The subject-controlled treatment had a varied effect on mood—anxiety decreased in two subjects, but depression increased in one. (A similar worsening of mood after elimination of obsessional behavior was found in a previous case study.) Apparently, successful treatment of obsessional behavior will not necessarily lead to an improvement in mood. Concurrent mood symptoms need to be targeted separately; and, plans should be made to deal with mood symptoms that may occur once obsessional behavior is removed.     

Pre-morbid personality traits and responsiveness to flooding in obsessive-compulsive patients

Clinical and psychophysiological assessments were carried out before and after completion of flooding treatment in two groups of obsessive-compulsive patients, matched for age and duration of the illness but differing in pre-morbid obsessional personality traits.

Patients with such traits appear to demonstrate a specific autonomic sensitivity to flooding, probably related to either the reduction of anxiety after treatment or to certain qualities of the treatment itself. Significant changes after treatment regarding neutral stimuli and attitude ratings of untreated obsessional manifestations suggest a more global response to flooding in such patients.

Some suggestions for further research are presented.     

The thought-action fusion scale: further evidence for its reliability and validity

Thought-action fusion (TAF) refers to a set of cognitive biases that are thought to play a role in the development of obsessional phenomena. To measure these biases, R. Shafran, D. S. Thordarson, and S. Rachman (1996; Journal of Anxiety Disorders, 10, 379-391) developed the TAF-scale. They concluded that the TAF-scale possesses adequate psychometric qualities. The current study sought to further explore the reliability and validity of the TAF-scale. Results indicate that the TAF-scale has good internal consistency. TAF-scores correlated with self-reports of obsessional problems. Furthermore, mean scores in a mixed sample of anxiety disordered patients were higher than those in a normal sample. However, temporal consistency was somewhat disappointing. Also, the question remains whether TAF is specific to obsessive-compulsive disorder or taps more pervasive biases that play a role in a variety of disorders.     

Obsessional Disorders: A Developmental Systems Perspective

The paper resumes the discussion of obsessional disorders in view of developments that have followed the 1965 Congress of the International Psychoanalytical Association when the last systematic analytic discussion of the Obsessional Neuroses took place. The paper reexamines principal contributions to that congress in an attempt to understand the failure of psychoanalysis to favorably influence the course of these disorders. It notes the subsequent findings of a burgeoning field of child observation that have called attention to the larger infant-caregiver constitutive system within which the intrapsychic phenomenology of the obsessional neuroses is produced and maintained. It draws attention to the crucial impact of the analyst and his causal theories, insufficiently recognized at the lime, in the co-determination of the course and outcome of analytic treatment and proposes a contextual systems approach to the reconfigured understanding of normal and pathological development.

The paper discusses the special role of cumulative trauma in the infant-caregiver system on the formation of enduring obsessional and compulsive patterns. It suggests that in the traumatic developmental system, endangerment to the self and unbearable pain are ever-present threats lo the child, and protective strategies, including importantly the processes of pathological accommodation, occupy a primary motivational status. It describes the automatic shaping of subsequent experience by the internalization of such processes in template formation. Freud's emphasis on aggression and unconscious guilt in the pathogenesis of the obsessional neuroses system is reexamined in the light of the contextual perspective proposed, and a clinical excerpt is offered to illustrate the thesis of aggression and guilt as contextual products of a traumatic developmental system. Special considerations that enter into the reconfigured analytic treatment of obsessional disorders are proposed, and some observations follow about problems commonly encountered in the new approach.

The paper argues for the systematic extension of the quintessential psychoanalytic tools of empathic-introspective investigation and illumination into the contextualization of inner experience in a fresh approach to the psychoanalytic treatment of these disorders.     

Towards a comprehensive treatment for obsessional thoughts

A systematic treatment approach for obsessional thoughts is proposed. It is based upon an analysis of the chain of convert events and incorporates the distinction between the obsessional idea or fear and the cognitive rituals which follow. Systematic Disruption of covert rituals and Cognitive Restructuring of obsessional ideas are included within the treatment programme. The application of this approach is demonstrated with three cases treated for severe obsessional thoughts and followed up after 2 years.     

Causing harm and allowing harm: a study of beliefs in obsessional problems

This study investigates two factors hypothesised as relevant to obsessional problems because of the way in which they influence decisions whether or not to act to prevent harm. These are (i) the way in which intrusive thoughts increase the internal awareness of harm, and confront the person with the possibility of taking action to prevent such harm and (ii) the extent to which there is some obvious external factor which increases awareness of the possibility of preventing harm. Obsessional patients, anxious and non-clinical controls completed a scale which systematically measured these factors across a wide range of situations. Results across all situations evaluated confirmed previous findings that both obsessionals and nonobsessionals were more likely to report acting to prevent harm when awareness of it is prompted by an intrusion than when it is not. It was also found that participants in all groups acted more ‘obsessionally’ when a scenario is described in ways which suggest that harm may be by ‘commission’ than when it is described in terms of an ‘omission’. When scenarios about which each individual is most disturbed were analysed, anxious and non-clinical controls continued to differentially rate omission and commission situations; as predicted, this differential was not present for obsessional patients.

It is concluded that obsessionals are more sensitive to omission than are nonobsessionals when considering scenarios about which they are concerned, and that this sensitivity is one factor influencing the decision whether to act to prevent harm.     

The little obsessional alchemist

Using the psychoanalytic experience with an obsessional child, this paper looks at the moment of insight, that precipitation of coherence which occurs when we say that we suddenly realize something. This is contrasted with the approach of consciously trying to fit theory to the observed facts. Analogies with alchemy are drawn. In addition, the balancing process occurring in obsessional mentality is compared with strangulation by hanging, the opposing forces being comprised of prematurely solidified states of mind such as mania or paranoia which interfere with that fluid state of mind optimal for the precipitation of insight.     

Obsessional beliefs and the implicit and explicit morality of intrusive thoughts

Cognitive models of obsessive-compulsive disorder (OCD) suggest that misinterpreting intrusive thoughts exacerbates obsessional thinking. To evaluate this hypothesis, healthy participants (N=91) were prompted to recollect their unwanted thoughts, and then beliefs about the immorality of these thoughts were manipulated. Next, participants completed implicit and explicit measures of self-evaluation and appraisals of unwanted thoughts. Results from structural regression analyses indicated that explicit responses to unwanted thoughts, such as evaluations of the significance of intrusive thoughts and state self-esteem, were predicted by pre-existing obsessional beliefs, but not by the morality instruction manipulation. In contrast, implicit responses, such as appraisals of unwanted thoughts as relatively important and evaluations of the self as relatively immoral and dangerous, were predicted by the interaction between specific obsessional beliefs (e.g., intolerance of uncertainty) and the morality instructions. Findings largely support cognitive models of OCD and suggest unique predictors of implicit and explicit responses to unwanted thoughts.     

Suppression of obsession-like thoughts in nonclinical individuals: impact on thought frequency, appraisal and mood state

Wegner's (1994, Psychological Review, 101, 34-52) research on the paradoxical effect of thought suppression has been incorporated into contemporary cognitive-behavioural models of obsessive-compulsive disorder. However, findings on the effects of thought suppression on thought frequency have been inconsistent and few studies have actually examined the suppression of thoughts that are obsessional in nature. In the present study 219 nonclinical participants were randomly assigned to suppress or not suppress a neutral, obsessional or positive thought during an initial monitoring interval. In a second thought monitoring interval, all participants received instructions not to suppress their target thought. No paradoxical effect of suppression on frequency was observed for any type of thought, although suppression of obsessional thoughts was associated with greater subsequent discomfort and a more negative mood state than suppression of positive or neutral target thoughts.     

Speed and accuracy on tests of executive function in obsessive-compulsive disorder

Slowness in obsessive-compulsive disorder (OCD) has been attributed to intrusive thoughts or meticulousness. Recent research suggests that slowness in OCD may be particularly evident on tests of executive function subserved by frontostriatal circuitry. In the present study, the speed and accuracy of responding on neuropsychological tests of executive functions and psychomotor speed were investigated in 27 non-depressed, unmedicated adults with OCD and 27 healthy controls. The only group difference was that patients took significantly longer to copy a complex geometric design than controls. This finding was unrelated to residual depression or overall OCD symptom severity. Results suggest that slowness in OCD may be most apparent on executive tests requiring self-initiated organizational strategies, consistent with frontostriatal abnormality.     

Thought suppression and its effects on thought frequency, appraisal and mood state in individuals with obsessive-compulsive disorder

Leading models of obsessive-compulsive disorder (OCD) implicate thought suppression as a key factor in the escalation and persistence of the disorder. This experiment examined the effects of suppression on the frequency of obsessional thoughts in 50 individuals with a primary diagnosis of OCD, and also investigated the effects of participants' appraisals regarding their failures in thought control on distress about intrusive thoughts and on mood. Participants' most upsetting obsessional thought was primed and they then monitored its occurrence over two 4-min intervals. In the first interval, half of the participants were instructed to suppress their obsessional thought and half were instructed not to suppress any thoughts. In the second interval, all participants were given the 'Do Not Suppress' instructions. Participants rated their suppression effort and discomfort over thought occurrences after each interval and recorded their appraisals of thought recurrences during the first interval. Mood state was then reassessed. No ironic effect of suppression on frequency was noted. However, negative appraisals of thought recurrences were associated with more discomfort over thought occurrences and more negative mood at Time 2. These findings suggest that interpretations regarding failures in thought control may be of central importance in understanding obsessional problems.     

A Structural Analysis of the Obsessional Character: A Fairbairnian Perspective

This paper reviews the object relations model of W.R.D. Fairbairn and applies it to the understanding of the obsessional personality. Fairbairn's model sees attachment to good objects as the immutable component of normal development. Parental failures are seen as intolerable to the child and trigger the splitting defense that isolates (via repression) the frustrating aspects of the object along with the part of the child's ego that relates only to that part-object. This fundamental defense protects the child from the knowledge that he is dependent on indifferent objects and preserves his attachment. The split-off part-self and part-object structures are too disruptive to remain conscious, yet despite being repressed make themselves known through repetition compulsions and transference. The specific characteristics of families that produce obsessional children impact the child's developing ego structures in similar ways. This style of developmental history creates predictable self and object configurations in the inner world, which then translate via repetition compulsion into obsessional behavior in adulthood.     

Cognitive self-consciousness and meta-worry and their relations to symptoms of worry and obsessional thoughts

The relation between cognitive self-consciousness and meta-worry, and their association with symptoms of worry and obsessional thoughts were examined. 53 undergraduate students completed the expanded version of the Cognitive Self-consciousness Scale, the Meta-worry subscale of the Anxious Thoughts Inventory, the Penn State Worry Questionnaire, and the Padua Inventory-Revised. Analysis showed that cognitive self-consciousness and meta-worry were moderately correlated (r =.57). Further, both constructs were positively associated with symptoms of worry and obsessional thoughts. When controlling for cognitive self-consciousness, metaworry remained significantly correlated to both types of symptoms. Yet, when controlling for meta-worry, correlations between cognitive self-consciousness and symptoms of worry and obsessional thoughts clearly attuned and were no longer significant. These findings suggest that meta-worry is more important for understanding excessive, intrusive thought patterns than the mere tendency to monitor one's thoughts.