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Intrusive thoughts in non-clinical subjects: The role of frequency and unpleasantness on appraisal ratings and control strategies

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This study explores the frequency of the appearance of intrusive thoughts in normal people, as well their association with cognitive appraisals and control strategies. A total of 336 subjects completed the Spanish adaptation of the Obsessional Intrusions Inventory-Revised (ROII), designed by Purdon and Clark (1993, 1994a, 1994b). Most of the subjects (99.4%) reported experiencing intrusive thoughts occasionally, but only 13% reported having them with some frequency. The intrusions were included in two factors: aggression, sexually and socially inappropriate behaviours, and doubts, checking, and cleanliness. The frequency of appearance of the most upsetting intrusive thought was associated with: the likelihood/probability bias, the need to control the thoughts, and neutralizing strategies. Nevertheless, the unpleasantness was associated with the morality bias and a broad range of control strategies. These results are discussed in relation to the different roles that the appraisal and the thought control responses play, both regarding the persistence as well as the unpleasantness associated with the most upsetting intrusions. Copyright © 2004 John Wiley & Sons, Ltd.
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Clinical Psychology and Psychotherapy
Clin. Psychol. Psychother. 11, 100–110 (2004)
Copyright © 2004 John Wiley & Sons, Ltd.
Published online in Wiley InterScience (www.interscience.wiley.com). DOI: 10.1002/cpp.397
Intrusive Thoughts in Non-Clinical
Subjects: The Role of Frequency and
Unpleasantness on Appraisal
Ratings and Control Strategies
Amparo Belloch,*1Carmen Morillo,1Mariela Lucero,2
Elena Cabedo3and Carmen Carrió4
1Department of Personality, University of Valencia, Spain
2Department of Psychology, University of San Luis, Argentina
3Adult Mental-Health Outpatient Service, Area 4, Valencia, Spain
4Adult Mental-Health Outpatient Service, Area 5, Valencia, Spain
This study explores the frequency of the appearance of intrusive
thoughts in normal people, as well their association with cognitive
appraisals and control strategies. A total of 336 subjects completed the
Spanish adaptation of the Obsessional Intrusions Inventory-Revised
(ROII), designed by Purdon and Clark (1993, 1994a, 1994b). Most of
the subjects (99.4%) reported experiencing intrusive thoughts occa-
sionally, but only 13% reported having them with some frequency.
The intrusions were included in two factors: aggression,sexually and
socially inappropriate behaviours, and doubts,checking,and cleanli-
ness. The frequency of appearance of the most upsetting intrusive
thought was associated with: the likelihood/probability bias, the need
to control the thoughts, and neutralizing strategies. Nevertheless, the
unpleasantness was associated with the morality bias and a broad
range of control strategies. These results are discussed in relation to
the different roles that the appraisal and the thought control
responses play, both regarding the persistence as well as the unpleas-
antness associated with the most upsetting intrusions. Copyright ©
2004 John Wiley & Sons, Ltd.
*Correspondence to: Professor A. Belloch, Department of
Personality Psychology, Facultad de Psicología, Avda. Blasco
Ibáñez 21, Valencia-46010, Spain. Fax: +34-96-3864669.
E-mail: Amparo.Belloch@uv.es
Contract/grant sponsor: Spanish Ministerio de Ciencia y
Tecnología.
Contract/grant number: BS02002-02330.
INTRODUCTION
The persistent presence of obsessions, whether or
not they are accompanied by associated compul-
sive behaviours, is the core feature of the obsessive-
compulsive disorder (OCD). Some of the more
influential and recent cognitive-behavioural
theories about OCD (i.e. Purdon & Clark, 1999;
Rachman 1997, 1998; Salkovskis 1985, 1989) have
made the assumption that obsessive thoughts have
their roots in some of the thoughts currently expe-
rienced by normal individuals. In a classic and
pioneer study in this field, Rachman and de Silva
(1978) verified that normal people reported experi-
encing unpleasant intrusive thoughts that were
often indistinguishable from clinical obsessions in
content and form. These results have been repeat-
edly verified in other studies, which indicate that
between 80% and 99% of mentally healthy individ-
uals reported occasionally having intrusions that
Intrusive Thoughts 101
Copyright © 2004 John Wiley & Sons, Ltd. Clin. Psychol. Psychother. 11, 100–110 (2004)
can be experienced as thoughts, images or impulses
(Clark, 1992; Clark & de Silva, 1985; England &
Dickerson, 1988; Freeston, Ladouceur, Gagnon, &
Thibodeau, 1991; Freeston, Ladouceur, Thibodeau
& Gagnon, 1992; Niler & Beck, 1989; Parkinson &
Rachman, 1981; Purdon & Clark, 1993, 1994a,
1994b; Reynolds & Salkovskis, 1991; Salkovskis &
Harrison, 1984). These intrusive cognitions are con-
sidered the ‘normal’ analogous to clinical obses-
sions, and their study makes it possible to better
comprehend the nature of obsessive thoughts.
As stated by Salkovskis, Richards and Forrester
(1995), this line of investigation has at least three
implications: (a) The need to offer empirical
support for the assumed existence of a continuity
from normality to clinical obsessions, in contrast to
the models that propose a normality versus psy-
chopathology breakdown; (b) To show that the
mere occurrence of intrusive thoughts does not
explain per se the development of obsessions, and
(c) that the results from studies employing non-
clinical samples can be reasonably generalized to
the clinical population.
Similarly, research on thoughts analogous to
obsessions in the normal population raises at least
two questions: first, where do the differences lie
between normal intrusions and clinical obsessions?
And second, why do normal phenomena become
upsetting obsessions in a minority?
Regarding the first question, Rachman and de
Silva (1978) postulated that the differences
between normal intrusions and obsessions were of
a quantitative nature, and they referred to the
intensity and frequency with which these thoughts
are experienced. Some studies indicate that, apart
from the aforementioned variables, there are also
differences in other aspects, such as the associated
unpleasantness and the level of anxiety caused by
the obsessions, the difficulty in controlling them or
getting them off one’s the mind, the extent to
which people make use of neutralizing behaviours
to reduce discomfort, and the resulting conse-
quences in the person’s life, as clinical obsessions
interfere markedly with the daily lives of patients
(Oltmanns & Gibbs, 1995; Parkinson & Rachman,
1981; Rachman & de Silva, 1978; Salkovskis &
Harrison, 1984). Among all these variables, the
unpleasantness associated with intrusive thoughts
is the most important variable, at least from the
perspective of its clinical significance. As indicated
by Freeston and Ladouceur (1997), the assessment
of this feature can be considered a clinical change
indicator that can be used to evaluate therapeutic
effectiveness.
As for the second question, several authors
(Clark & Purdon, 1993; Freeston et al., 1991, 1992;
Niler & Beck, 1989; OCCWG, 1997; Purdon &
Clark, 1994a, 1994b; Rachman, 1993), following the
Salkovskis (1989) proposal, have postulated that
the responsibility for the transition from normality
to pathology lies in cognitive and behavioural vari-
ables. The former refer to the evaluative processes
related to the meaning individuals attribute to the
appearance and contents of their intrusions, while
the behavioural variables are related to the
responses, either covert or overt, of the individ-
ual’s intent to decrease or neutralize the discom-
fort caused by the intrusion. In short, the content
of the intrusions in normal people and clinical
obsessives is essentially similar; the difference lies
in the way the intrusions are processed. In both
cases, the individual carries out an evaluative
process (cognitive appraisal) about the occurrence
and/or content of the intrusions, which means
assigning them a significance that, in the case of
clinical obsessions, will be highly threatening.
Next, diverse overt and/or covert strategies are
performed, in order to control the unpleasant
intrusive thoughts, in an attempt to remove them
or to alleviate the resulting discomfort. And this
neutralizing response is the key element in the
final development of obsessions, according to
Salkovskis (1989).
The differences between the current theoretical
models are basically related to the beliefs (and
associated appraisals) that are considered to be the
most important in the transition from intrusive
thoughts to obsessions. Salkovskis (1985, 1989;
Salkovskis et al., 1995) has pointed out that the
obsessive pattern is generated due to a specific
kind of appraisal: the responsibility for possible
harm derived from the content of the thought.
Rachman (1997, 1998) describes similar mecha-
nisms, but he also emphasizes the role of the cata-
strophic appraisals made by the subject about the
personal meaning of the thought. From this point
of view, the subject mistakenly believes that the
thought reveals his ‘hidden nature’, which has
negative moral characteristics. Other authors
have emphasized other modalities of evaluative
appraisals about intrusions. For instance, Purdon
and Clark (1993, 1999) postulate that the appraisals
the subject makes about the need for and impor-
tance of controlling and/or suppressing undesir-
able thoughts are essential.
Considering the importance that the current
OCD cognitive models give to intrusive thoughts,
it is necessary to ensure that empirical investiga-
102 A. Belloch et al.
Copyright © 2004 John Wiley & Sons, Ltd. Clin. Psychol. Psychother. 11, 100–110 (2004)
tion of these cognitions is accurate; in other words,
that these thoughts can be appropriately consid-
ered valid analogies to clinical obsessions.
Rachman (1981) proposed a widely accepted def-
inition of this kind of thought: ‘Repetitive thoughts,
images or impulses, that are unwanted or unacceptable,
and that (a) interrupt the ongoing activity, (b) are inter-
nally attributed, and, (c) are difficult to control’. Clark
and Purdon (1995; Purdon & Clark, 1999) pointed
out that some instruments employed in studies
about intrusive thoughts in normal populations
have construct validity problems, because they are
based on an excessively broad definition of these
thoughts (as in the case of Rachman’s definition).
This flaw has given rise to the assessment of
thoughts more related to anxious and depressive
symptoms than to obsessive ones (i.e. automatic
thoughts, or worrisome thinking). Along the lines
of these authors, in order to define these thoughts,
it is necessary to consider not only their cognitive
characteristics (intrusiveness, difficulty to control),
but also their content. In addition, these authors
point out egodistonity as a key differential charac-
teristic of obsessions compared to other kinds of
unpleasant thoughts.
In order to solve problems such as the afore-
mentioned, Purdon and Clark developed an
instrument to evaluate intrusive thoughts analo-
gous to obsessions: the Obsessive Compulsive
Inventory (OII; Purdon & Clark, 1993, 1994a),
which was later reformulated (The Revised Obses-
sive Intrusions Inventory, ROII; Purdon & Clark,
1994b). The results on this instrument have shown
higher correlations with measures of obsessive
symptoms than with anxiety and depression mea-
sures. An additional advantage lies in the useful-
ness of the instrument for evaluating other aspects
related to the cognitive processing of the intrusive
thought chosen by each person as the most upset-
ting: the appraisals of it and the control strategies
used to control it. As has been said before, current
OCD models emphasize the great involvement of
appraisals and control strategies in the transition
from normal intrusions to clinical obsessions.
Moreover, the fact that subjects choose their own
most upsetting thoughts makes it possible to
regard these thoughts as reliable analogues of
obsessions.
The general aim of the present study was to
explore the presence, in a Spanish normal popula-
tion, of intrusive thoughts analogous to obsessions,
using the ROII as the key instrument. Furthermore,
the following additional objectives are also pro-
posed: first, to analyse the contents of the most
habitual intrusive thoughts in our context, taking
into account the eventual gender differences.
Second, to explore the relationships among the
frequency of appearance of the most upsetting
thoughts, the unpleasantness caused by them, the
cognitive appraisals and the strategies that arise to
control them.
METHOD
Subjects
The sample consisted of 336 normal subjects (203
women and 133 men), with a mean age of 27 ±10
years (range =19–62 years). The age distribution
shows that 66% of the subjects were between 20
and 27 years of age. Most of them were single
(79%), with a medium socio-economic level
(67.3%), and had undertaken advanced (univer-
sity) studies (63%). None of the subjects reported
suffering psychological disorders or receiving psy-
chological/psychiatric treatment in the last year,
and for this reason we can conclude that all of them
were currently healthy.
The recruitment of subjects was carried out using
as a basis a series of seminars for final year
Psychology students that were trained in the
purpose of the study, the current OCD cognitive
models, and the management of the instruments to
be used. Each of the participants administered the
assessment instruments individually (described in
detail in the following paragraph) to five subjects.
The instructions about the requirements for select-
ing the sample of subjects were as follows: aged
between 18 and 60 years, having a good reading
level, and not having a recent history of mental dis-
orders or disabling medical disease (in the preced-
ing year). We also required students not to collect
the data exclusively from their relatives. After a
week, they had to re-administer the ROII to three
of the previously assessed subjects.
Instruments
Initial Interview
All the subjects were administered an initial stan-
dardized interview, recording the basic demo-
graphic data (age, gender, occupation, educational
level, socio-economic status), as well as the pres-
ence of mental disorders, medical conditions and
psychological or pharmacological treatments
received during the year preceding the time of the
study.
Intrusive Thoughts 103
Copyright © 2004 John Wiley & Sons, Ltd. Clin. Psychol. Psychother. 11, 100–110 (2004)
Obsessional Intrusions Inventory–Revised (ROII;
Purdon & Clark 1994b).
This is a self-report questionnaire designed to
assess the presence and frequency of unwanted
intrusive thoughts, images and impulses having an
egodystonic content, analogous to clinic obses-
sions, as well the appraisals and control strategies
associated with the most upsetting intrusive
thought referred to by the subjects. The instrument
includes some initial instructions offering a
detailed characterization of the nature of intrusive
thoughts. We transcribe here these instructions,
which were slightly modified from the original
ROII in order to favour the Spanish adaptation:
This questionnaire includes a list of annoying and
unpleasant thoughts that everyone sometimes
has. These thoughts INTRUDE IN OUR
MINDS against our will, and they suddenly
interrupt what we were doing or thinking at that
moment, and THEY ARE DIFFICULT TO
CONTROL. Moreover, they become EMBAR-
RASSING, UNPLEASANT and sometimes even
UNACCEPTABLE because they refer to things
that we don’t like to think about, or because they
go against our beliefs, values or morality, or
simply because they seem to be odd. We call these
types of thoughts ‘INTRUSIVE THOUGHTS’,
and they can appear in one (or more) of these
forms:
In the form of IMAGES, that is, as pho-
tographs that suddenly appear in our minds.
In the form of IMPULSES, as an imperative
and urgent need to do or to say something.
Or, simply, as THOUGHTS about something.
We would like to know if you have ever experi-
enced intrusive thoughts.
The instrument consists of two parts: the first
part consists of 52 statements concerning thoughts
of aggression, sex, dirt and contamination. Respon-
dents rate each statement on a 7-point scale from 0
(‘I have never had this thought’) to 6 (‘I have this
thought frequently during the day’). An ROII total
score (frequency of intrusive thoughts) is derived
by adding the scale scores for the 52 items. In the
second part, subjects are required to select from
the previous list the single most upsetting intru-
sive thought that they have experienced at least
‘rarely’ (score =1), and to evaluate it along 10
appraisal dimensions (unpleasantness, guilt,
worry thought will come true, uncontrollability or
difficulty to remove, unacceptability, likelihood
that thought will come true, importance of control,
harm/danger, responsibility, and desire to avoid
thought triggers), using 5-point Likert scales (from
0 =‘Absolutely nothing’ to 4 =‘Extremely’). After
this, subjects are presented with a list of 10 possi-
ble thought control strategies, and they are asked
to rate (from 0 =‘Never’ to 4 =‘Always’) to what
extent they use each of these strategies to deal with
the most upsetting intrusive thought previously
chosen.
The questionnaire was submitted to a double
translation process (English–Spanish) and back-
translation (Spanish–English), with the aim of
guaranteeing that the items’ contents were equal to
the original instrument.
RESULTS
Intrusive Thoughts in the General Population
Table 1 shows the main descriptive statistics
obtained with the first part of ROII. As can be
observed, the mean scores are relatively low, with
the dispersion of scores being very high. The fre-
quency distribution presents a remarkable positive
asymmetry, indicating that the deviations from the
mean are higher for upper scores than for the lower
ones. These data reveal the presence of broad dif-
ferences between the assessed subjects in relation
to the frequency with which intrusive thoughts are
experienced. The reliability values of the instru-
ment indicate that it possesses a good internal con-
sistency (a=0.93), and temporal stability (ICC =
0.88; range =0.82-0.92).
Regarding gender differences, men presented a
significantly higher number of intrusions (21 ±
11.07) than women (18 ±9.72) (t =2.69; p <0.007),
Table 1. ROII-part I: Descriptive statistics and reliability
ROII-1 Mean (SD) Md A aICC 95%
Total sample 38.00 (27.1) 31.5 1.16 0.93 0.88
Men (n=133) 42.08 (27.8) 36.5 0.89 0.92 0.87
Women (n=203) 35.50 (26.4) 29.0 1.38 0.93 0.89
Md, median; A, asymmetry; a, Cronbach’s alpha; ICC, Intraclass Correlation Coefficient.
104 A. Belloch et al.
Copyright © 2004 John Wiley & Sons, Ltd. Clin. Psychol. Psychother. 11, 100–110 (2004)
and, consequently, their mean score on frequency
(total score on the ROII) was also higher (t =2.17;
p <0.03).
From the 336 subjects examined, only two
obtained a score of 0 on the first part of the ques-
tionnaire (list of intrusive thoughts). Therefore
99.4% of the subjects referred, on at least one occa-
sion, to having an intrusive thought, image or
impulse similar to an obsession. Nevertheless,
given that the mean scores on frequency were
around values of 1 (‘rarely, on one or two occasions’),
we examined the rates of appearance of the 10
thoughts reported as the most experienced. To
carry out this selection, the chosen thoughts had to
meet two criteria: (a) that they were among the
thoughts with higher mean scores, and (b) that
they registered the higher frequencies, once the
percentages of the responses were accumulated: 4,
Often, on one or two occasions per week; 5, Very often,
daily’ and 6, ‘Always, frequently throughout the day’.
According to this criterion, the thought that regis-
tered the highest occurrence rates was item 22 (‘I
left the heat, stove, or lights on in the house, which may
cause a fire’). This thought was reported by 13.4%
of the subjects assessed as being very frequent. The
remainder of the more frequently experienced
intrusive thoughts, as well as their occurrence
rates, are shown in Table 2.
The three thoughts most frequently experienced
made reference to uncertainty in relation to their
own behaviour, as behaviours that affect (or can
affect) personal safety (items 22 and 23), as well as
those related to checking and ordering (item 50).
When the same procedure was applied for both
genders separately, we observed that the two
genders coincided on seven of the 10 listed
thoughts. However, two of the items (16 and 37)
appeared among those registered more only by
women, and one of them (18) was among those
registered more only by men. These data are
shown in the last column of Table 2.
Next, we examined which thoughts were those
least experienced by the subjects. With this
purpose in mind, we selected all the intrusive
thoughts that were rated with responses of 0 (‘I
have never had this thought’) by the majority of the
subjects (80% or more). According to these criteria,
the seven least frequent intrusive thoughts make
reference to aggressive behaviours against other
persons (driving into window, holding up bank, fatally
pushing friend, pushing family under train, car, stab-
bing family member) or against oneself (cutting off
finger), or related to bizarre contamination fears
(transmit fatal disease).
In order to examine the clustering of the intru-
sive thoughts, a principal components factorial
analysis was conducted, excluding the seven items
that had never been experienced by 80% of the
sample. The best factorial solution was provided
by the oblimin rotation, with two correlated factors
(r =0.36) that explained 36% of the total variance.
All the items obtained loadings 0.40. The first
factor (29.6% of variance) contained 36 items
related to self and hetero-aggression thoughts,
sexual thoughts, and socially unacceptable behav-
iours. The second factor explained a variance of
6.4%, and included 10 items referring to doubts,
fears of contamination, and checking behaviours.
When the analysis was conducted for both genders
separately, we obtained identical results to the
aforementioned for the total sample.
To examine the differences between men and
women in the factor solution obtained, two t-tests
were conducted. There were significant differences
Table 2. The 10 most frequent intrusive thoughts experienced by subjects
ROII item Content of the intrusive thought Mean (SD) S%* Men/Women
22 Heat/stove on, accident 1.64 (1.64) 13.4% M & W
50 Everything away 1.45 (1.62) 12.9% M & W
23 Home unlocked, intruder 1.40 (1.56) 13.1% M & W
15 Insulting stranger 1.31 (1.41) 3% M & W
8 Jumping off high place 1.30 (1.37) 9.3% M & W
43 Sex in public 1.27 (1.39) 6.3% M & W
45 Catching STD 1.22 (1.48) 8.4% M & W
16 Bumping into people 1.17 (1.41) 7.5% W
37 Fly/blouse undone 1.17 (1.36) 6.3% W
18 Insulting family 1.11 (1.37) 7.5% M
* Accumulated percentages of item responses between 4 and 6 (the intrusive thought has a frequency between ‘often’ and ‘always’).
Indicates whether the intrusive thought appeared among the 10 most frequently experienced by men (M), women (W) or both (M
& W).
Intrusive Thoughts 105
Copyright © 2004 John Wiley & Sons, Ltd. Clin. Psychol. Psychother. 11, 100–110 (2004)
the most endorsed by men (9%), along with item
45 (11.5%).
Cognitive Appraisals of the Most Upsetting
Intrusive Thought
In general we obtained low mean scores on the
appraisals subjects made in response to their
most upsetting intrusive thoughts. No differences
between men and women were observed in their
mean scores for each of the appraisal dimensions,
or for the total score on this part of the question-
naire. The highest mean scores were for the
appraisals of unpleasantness (2.13 ±1.15), unaccept-
ability (1.83 ±1.31), and importance of controlling the
thought (1.46 ±1.30).
The analysis of the endorsement frequencies for
each appraisal showed similar results to those
obtained on the mean scores: the majority of sub-
jects made low estimations on the different
appraisals about the thought intrusion when it
happened (values between 15 and 39% on endorse-
ment option 1 (‘somewhat’). In any case, the
dimensions of unpleasantness and unacceptability of
the thought registered the greatest accumulations
of extreme negative responses.
Next, the associations between the appraisals of
the most upsetting thought and the frequency of its
occurrence were analysed. Only significant corre-
lations (Spearman) were observed between fre-
quency and the appraisals of worry thought will come
true (r =0.25; p <0.001), uncontrollability (r =0.28; p
<0.0001), likelihood that thought will come true (r =
0.27; p <0.001), and importance of controlling the
thought (r =0.19; p <0.01). It is interesting to note
that the appraisal of unpleasantness of the most
upsetting intrusive thought was not significantly
associated with the frequency with which this
thought was experienced (r =0.14; p=0.07).
Strategies Used to Control the Most Upsetting
Intrusive Thought
On the last part of the ROII, subjects are requested
to identify the strategies they employ to control
their most upsetting intrusive thought. The
descriptive analysis on this variable showed, in
general, that subjects used a wide repertory of
strategies in order to control their most upsetting
intrusive thought, except the strategy of ‘say a
prayer’. Anyway, the three most used were of a cog-
nitive nature: reason with self (2.53 ±1.38), covert dis-
traction (2.04 ±1.75), and covert neutralizing (1.95 ±
only in the case of the first factor (t =2.60; p<0.01)
in which men obtained a higher mean score (31.83
±22.83) than women (22.89 ±20.55). Therefore, we
could assume that the gender differences previ-
ously found are mainly due to the gender differ-
ences observed in the first factor.
The Most Upsetting Intrusive Thoughts
From the 52 items listed in the ROII, 42 were
selected by at least one subject as his/her most
upsetting intrusive thought. The frequency distri-
bution had an extremely skewed shape, indicating
that there were wide individual differences when
the subjects had to identify such a thought. This
selection was not only determined by the fre-
quency with which the thought was experienced,
since in 34% of the cases the chosen thought had a
frequency of 1 (‘rarely’), with a mean of 2.47 ±1.48.
Figure 1 represents the results obtained regarding
the frequency of occurrence of the chosen thought.
In relation to the contents of these most upsetting
thoughts, the five that were selected most, and the
percentage of subjects who endorsed them, were
the following: 8, Jumping off a high place (10%); 22,
I left the heat, stove or lights on in the house/apartment
which may cause a fire (9.7%); 23, I left the door of the
house/apartment unlocked and there is an intruder
inside (7.6%); 45, I am going to catch a sexually trans-
mitted disease (STD) from touching a toilet seat or tap
(6.7%), and, 35, Having sex with a person who I would
never want to have sex with (5.7%).
The two most endorsed by women were items 8
(11.6%), and 22 (10%). The latter was also one of
0
5
10
15
20
25
30
35
40
F
r
e
q
u
e
n
c
i
e
s
Rarely Occasionally Sometimes
Often Very often Always
Figure 1. Frequencies of occurrence of the most upset-
ting intrusive thought
106 A. Belloch et al.
Copyright © 2004 John Wiley & Sons, Ltd. Clin. Psychol. Psychother. 11, 100–110 (2004)
1.27). Women employed all the strategies more fre-
quently than men (all comparisons were significant
at p<0.05), except for the strategies of reason with
self and do nothing, in which there were no gender
differences.
With regard to the associations between the fre-
quency of the most upsetting thought and the
control strategies employed to manage it, only four
significant correlations were obtained: overt neu-
tralizing (r =0.18; p <0.01), covert neutralizing (r =
0.21; p <0.005), tell myself to stop (r =0.19; p <0.01),
and self-reassurance (r =0.30; p <0.0001).
Finally, a multiple regression analysis (stepwise
method) was conducted (DV, frequency of the most
upsetting thought), entering simultaneously as
independent variables all the appraisal and strat-
egy ratings that had previously shown a significant
relation with the DV. This analysis revealed that
only three variables entered in the final regression
equation: the first and second were appraisals
(Likelihood, R2=0.153; Uncontrollability, R2=0.225),
and the third was the strategy of Covert Neutraliz-
ing (R2=0.253). The multiple R(0.517) resulted
highly significant, with a value of F(3,163) =19.32
(p<0.0001).
The Unpleasantness Associated with the
Most Upsetting Intrusive Thought: is it
Related to the Appraisals and Thought
Control Strategies?
Given that in the preceding analyses the unpleas-
antness associated with the intrusive thought
chosen by each subject was so significant, we
decided to explore this appraisal dimension in
depth.
The bilateral correlations (Spearman) showed
that this variable was significantly associated (p <
0.0001) with the rest of the cognitive appraisals, in
a range from r =0.26 (uncontrollability) to r =0.64
(unacceptability), except for the appraisal of likeli-
hood that thought will come true (r =0.03, p =0.11).
As for the associations between the unpleasantness
appraisal and the control strategies, the correla-
tion coefficients were low (range, r =0.13 self-
reassurance, to r =0.33, tell myself to stop), and they
were not significant in two of the cases (do nothing,
and say a prayer).
A regression analysis (stepwise method) was
conducted with unpleasantness as the dependent
variable (DV), and all the appraisals and strategies
significantly associated with the DV as indepen-
dent variables. This analysis revealed the emer-
gence of four variables as significant predictors in
the regression equation. The first was the appraisal
of unacceptability (R2=0.413), followed by the strat-
egy Tell myself to stop (R2=0.444), and the appraisals
of guilt (R2=0.467) and importance of controlling or
suppressing the thought (R2=0.478). The multiple R
(0.696) proved to be highly significant, with F(10,328)
=51.98 (p <0.0001).
DISCUSSION
As has been demonstrated in other studies (Free-
ston & Ladouceur, 1993; Freeston et al., 1991, 1992;
Niler & Beck, 1989; Purdon & Clark, 1993, 1994a,
1994b; Rachman & de Silva, 1978; Salkovskis &
Harrison, 1984), the experience of intrusive
thoughts in non-clinical Spanish subjects was espe-
cially high: almost all subjects (99.4%) reported
having experienced at least occasionally one of the
52 intrusive thoughts listed in the inventory, as
was also found by the authors of the ROII with
Canadian subjects (99% of subjects in the study
by Purdon and Clark, 1993). Furthermore, the
mean rate of intrusive thoughts endorsed by our
subjects was slightly higher than that reported by
Purdon & Clark (1994b), who pointed out that, on
average, their subjects had experienced 14 intru-
sive thoughts at least once or twice a year. As a
result, our total score on the ROII (frequency of
intrusive thoughts) was also somewhat higher
than that reported by the above-mentioned authors
(31.21 ±27.14). Perhaps the Canada–Spain differ-
ences are attributable to age: the Spaniards were
older than the Canadians (mean age: 27 years and
18 years, respectively), and most of them were uni-
versity students or people holding university
degrees, compared with the undergraduate stu-
dents in the Purdon and Clark (1993, 1994b)
studies. If this assumption is correct, we must con-
clude that the age variable should be taken into
account in designing studies on intrusive thoughts
in non-clinical subjects.
The low frequency with which the intrusions are
experienced by normal subjects supports the
hypothesis that postulates quantitative differences
in the frequency of appearance between clinical
obsessions and intrusive cognitions. However, it
should be pointed out that there was a wide range
of between-individual differences on the frequency
and number of intrusions experienced. In fact,
a more detailed analysis of the questionnaire
responses revealed that, when we take into con-
sideration not merely the occasional appearance of
Intrusive Thoughts 107
Copyright © 2004 John Wiley & Sons, Ltd. Clin. Psychol. Psychother. 11, 100–110 (2004)
intrusions, but also an increased frequency of
them, the rate of non-clinical subjects who experi-
ence cognitive intrusions dramatically decreases to
13%. These subjects can be considered low-level
clinically obsessive (Gibbs, 1996), and this percent-
age is similar to that reported by Salkovskis and
Campbell (1994).
When the contents of intrusions were examined,
in most cases they referred to doubts and checking
behaviours, which are common in daily life (22,
heat/stove on, accident; 23, home unlocked,
intruder, 50, everything away); moreover, men and
women coincided in selecting them as highly fre-
quent. These results do not fully coincide with
those obtained in the Purdon and Clark (1993)
study, since these authors observed some gender
differences: for example, the most common intru-
sions reported by men had sexual and aggressive
contents (Strangers naked; Sex in public), whereas
women reported checking and doubts intrusions
(specifically, the above-mentioned 22 and 23);
however, in our study these latter thoughts were
the most frequent in both sexes.
We also observed, as in the Canadian study, an
increased frequency of some thoughts that are not
usually reported by clinically obsessive patients:
for instance, a self-aggressive thought (8, jumping
off high place), and an antisocial thought (43, sex in
public). This finding casts some doubt on the gen-
erally accepted assumption that the contents of
normal intrusions are similar to the obsessions
reported by the OCD patients (i.e. Rachman & de
Silva, 1978). However, it is also possible that intru-
sions like the one summarized in item 8 was linked
to the dysphoria which follows a previously expe-
rienced obsession: obsessive patients can differ-
entiate between their obsessional ideas and self-
aggressive or self-deprecating thoughts, which
probably appeared as a result of their perceived
inability to control the obsession, and which are
more related to the dysphoria accompanying the
OCD states than to OCD symptoms themselves,
while healthy people cannot make that distinction.
It must be kept in mind that the thought repre-
sented in item 8 was also chosen as one of the most
upsetting by the subjects, and it is perhaps associ-
ated in their daily experiences with a state of dis-
phoria. In any case, it is important to note that
these non-usual OCD thoughts had both a low fre-
quency of appearance and a low percentage of sub-
jects who experienced them.
The intrusive thoughts listed on the ROII were
clustered in two related factors: first, aggressive,
sexual and inadequate social behaviours, and
second, checking/dirt/contamination. There were
no gender differences in the factorial solution
obtained. These results once again partially coin-
cide with those reported by Purdon and Clark
(1993): they found this two-factorial solution only
in the female analysis, whereas in their men’s
group the best factorial solution was accounted for
by one factor. In our study, the gender differences
were observed only in relation to the first factor,
since men reported more intrusive aggressive
thoughts, as in the Purdon and Clark study, but
these authors also found more dirt and contami-
nation intrusions among women when compared
with men, whereas the women in our study did not
differ from men in the rate of these latter intru-
sions. We again suggest that the age variable may
be the main source of differences between both
studies.
With regard to the thought subjects must to select
as their most upsetting intrusion, it is interesting to
note that only 10 out of the 52 intrusions listed in
the ROII were not chosen by anyone. These non-
eligible thoughts referred to clearly aggressive
impulses or behaviours (for example, ‘stabbing
friend/family member’), or extremely bizarre
thoughts (for instance, ‘transmit fatal disease by
using public facilities’).
The frequency with which the most upsetting
intrusive thought was experienced by subjects was
relatively low, as in the Purdon and Clark (1994b)
study (2.21 ±1.4), and it was not related to the
unpleasantness that the intrusion itself provoked.
However, the mean score on this unpleasantness
dimension was higher than that observed on the
other evaluative appraisals. Moreover, most of the
correlations between the frequency of the most
upsetting thought and the evaluative appraisals
were quite low: the only significant coefficients
were obtained with uncontrollability, likelihood that
thought will come true, worry that thought will come
true, and importance of controlling thought. Only the
two former appraisals predicted the frequency
rate.
In our opinion, the above-mentioned results
suggest, first, that the frequency of a cognitive
intrusion is not considered by non-clinical subjects
as the main parameter for assessing the intrusion
as upsetting; and secondly, that the appraisal
dimensions associated with the frequency of the
most upsetting intrusive thought are different from
those related to the unpleasantness experienced
when the intrusion comes to mind.
The frequency of the most upsetting thought was
related to two distinguishable dimensions: thought
108 A. Belloch et al.
Copyright © 2004 John Wiley & Sons, Ltd. Clin. Psychol. Psychother. 11, 100–110 (2004)
control (uncontrollability and importance of control-
ling) and likelihood/probability bias (worry and
likelihood that though will come true). It may well be
that this bias could serve as an activator of the
need, or the impulse, to control the intrusion fre-
quency. Favouring that assumption is the fact that
the only thought control strategy that predicted
the frequency of that upsetting thought was covert
neutralizing. The likelihood/probability bias is
an essential part of the so-called ‘thought–action
fusion’ bias (TAF, Shafran, Thordarson, &
Rachman, 1996), which can be considered as a
cause or a consequence (Rachman 1997) of an
‘inflated sense of responsibility’ (Salkovskis, 1985;
Rachman, Thordarson, Shafran, & Woody, 1995;
Rassin, 2001). In spite of this, the dimension of
Responsibility to protect self/others was, paradoxi-
cally, not associated with the frequency, as was the
case in the study by the ROII authors (Purdon &
Clark, 1994b). As they argue, ‘it is likely that the
problem lies in the wording of the item itself’. We
agree with this possibility, since the writing of the
item implicitly assumes, to a large extent, that
the respondent believes that merely having the
thought is harmful to others.
In order to study in depth the variables involved
in the evaluation of a thought as highly upsetting,
and following the suggestions made by the Laval
group (Freeston & Ladouceur, 1993, 1997; Freeston
et al., 1991, 1992), we decided to take the unpleas-
antness appraisal as a framework for the analyses.
Let us remember that this appraisal dimension
obtained the highest rating. From this framework,
the results offer a quite different view from that
obtained when the frequency of the most upsetting
thought was the target variable, since the unpleas-
antness rating was significantly related to all the
appraisal dimensions. This result supports the sug-
gestion made above: in normal subjects, the upset-
ting quality of an intrusion is not mainly related to
its frequency, but rather to the unpleasantness
caused by the content of the thought. Moreover, the
rating of unpleasantness was associated, as in the
case of frequency, with thought control and par-
tially with the likelihood/probability bias (i.e.
worry thought will come true, but not with likelihood
that thought will come true). Above all, it was related
to unacceptability and guilt, that is, with cognitive
appraisals referring to the other bias implied in the
TAF, the morality bias. However, it remains to
be investigated whether these results are also
observed when OCD patients are examined, or if,
in contrast, they are characteristic of non-clinical
subjects.
As far as the strategies used by subjects in
response to their most upsetting intrusive thought,
we could hypothesize that the most usual strategy
would be to do nothing, or to show indifference to
the intrusion, given the low frequency of these
thoughts. However, the results show just the oppo-
site: normal people display a vast range of ‘effort-
ful’ strategies in order to suppress the distressing
thought or to alleviate the distress experienced for
having the thought, even when the frequency of
appearance was low. It was interesting to note
some gender differences regarding the strategies
displayed to remove the distressing intrusion:
women endorsed all the strategies more than men,
with the exception of ‘reason with self’ and ‘do
nothing’. One striking feature was the very low rate
of the ‘say a prayer’ strategy: in our socio-cultural
context, it might be reasonable to obtain at least a
moderate rating on this strategy. In addition, our
OCD patients often tell us that praying is a
common strategy to avoid or control their obses-
sions (regardless of the content of the obsessive
thoughts). We think that generational and cultural
differences are probably among the reasons for this
discrepancy.
With regard to the relationships between fre-
quency of the most upsetting thoughts and the use
of strategies to deal with them, a few relationships
were observed: in fact, there was the reassure myself
strategy, the only one that showed a moderate
correlation, followed by suppressing thoughts
strategies (covert and overt neutralizing, say stop).
Moreover, only the covert neutralizing strategy pre-
dicted the frequency of intrusion. This result sup-
ports the role of thought suppression strategies in
the maintenance of unwanted intrusions, as has
been hypothesized by Salkovskis (1985, 1989).
However, when unpleasantness was the criterion
variable, the range of relationships between this
appraisal dimension and the strategies used to
manage the intrusion increased, indicating a direct
and positive relationship between increased
unpleasantness and an increased use of a variety
of control strategies. Furthermore, overt and
covert distraction, apart from being a thought-
suppression strategy (tell myself to stop), predicted
the unpleasantness score.
As a whole, these results suggest that when an
unwanted intrusion is assessed based on its recur-
rence (i.e. frequency), we must conclude that the
subjects make use of suppression strategies.
However, when the intrusion is appraised based
on the unpleasantness experienced with its appear-
ance, we can conclude that people use all kinds of
Intrusive Thoughts 109
Copyright © 2004 John Wiley & Sons, Ltd. Clin. Psychol. Psychother. 11, 100–110 (2004)
control strategies, but especially distraction. Amir,
Cashman and Foa (1997) reported that normal sub-
jects, compared with OCD patients, employed the
distraction strategy (as measured by the Thought
Control Questionnaire, Wells & Davies, 1994). In
contrast, OCD patients used punishment and worry,
which can be characterized as suppression strate-
gies. Even though it is hard to put together the
above-mentioned study with the present research,
the possibility of a difference between the repeated
occurrence and the unpleasantness caused by
unwanted intrusions in relation to strategies is
hinted at: in the first case, people are mainly prone
to suppressing the intrusion, whereas when the
distress is the most relevant characteristic associ-
ated with the thought, people try to distract them-
selves. As frequency of intrusion is not very high
in normal subjects, and they choose the most
upsetting intrusion on the basis of the distress
experienced, it is probable that normal subjects pri-
marily use distraction, and not suppression, the
management strategy most commonly used by
OCD patients.
To conclude, the results obtained in the present
research suggest, first, that in non-clinical subjects
the frequency of an unwanted and upsetting intru-
sion is linked to the responsibility dimension
through the likelihood/probability bias, which, in
turn, activates the need to control the thought by
means of suppression strategies. Secondly, the
unpleasantness caused by the intrusion is associ-
ated with the inflated sense of responsibility
through the morality bias, which gives rise to dis-
playing a vast range of control strategies, espe-
cially the distraction variety. The Purdon and Clark
(1994b) suggestion, that in normal subjects the per-
sistence of an unwanted intrusion does not rely on
management strategies, but rather on the meaning
attributed to the intrusion, is applicable when the
thought is assessed in terms of its occurrence
(frequency), but not according to the content
(meaning) and its associated unpleasantness: in the
latter case, the thought produces not only its inter-
pretation but also the display of coping strategies
in order to control them. Third, given the low fre-
quency of intrusions in non-clinical subjects, it
seems that the appraisal dimensions for the
unwanted cognitions should be the main point of
interest in order to investigate these cognitions as
valid clinical analogues for obsessions. Fourth, the
age of subjects should be taken into account when
examining the content of unwanted intrusions, at
least in normal subjects. And finally, the results
obtained on the appraisals and coping strategies
must be looked at carefully as far as their general-
ization to OCD patients is concerned, as they are
based on the assessment of a single thought, with
a low frequency of appearance, and thus do not
take into account the diversity and frequency of
obsessional intrusions usually experienced by
OCD individuals.
ACKNOWLEDGEMENTS
The authors wish to thank Dr David A. Clark and
Dr Christine Purdon for their kind permission to
translate the Obsessional Intrusions Inventory-
Revised (ROII) into Spanish.
This study was supported in part by the Spanish
Ministerio de Ciencia y Tecnología (Grant no.
BSO2002-02330).
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