456 TREATMENT OF SPECIFIC ANXIETY DISORDERS
(Rachman & de Silva, 1978; Salkovskis & Harrison, 1984; Morillo, Belloch, & Garcia-
Soriano, 2007; Purdon & Clark, 1993). However, whether these obsession- relevant
intrusive thoughts and images become pathological depends on how the thoughts are
appraised (Salkovskis, 1985, 1989; Rachman, 1997, 1998). If an intrusive thought is
considered irrelevant, benign, even nonsensical, the person is likely to ignore it. If, on
the other hand, the mental intrusion is considered a significant personal threat involv-
ing some possible action or outcome that the person could prevent, then some distress
will be experienced and the person will feel compelled to engage in responses to relieve
the situation. This faulty appraisal of significance will lead to a compulsive ritual or
some other type of neutralization strategy that is intended to relieve distress or prevent
some dreaded outcome from occurring (Rachman, 1997, 1998). Although neutraliza-
tion may lead to an immediate reduction in anxiety or distress and a heightened sense
of perceived control by diverting attention away from the obsession, in the longer term
appraisals of significance and neutralization will lead to an increase in the salience and
frequency of the obsession (Salkovskis, 1999). Thus a vicious cycle is established that
leads to increasingly more frequent, intense, and distressing obsessions. Figure 11.2
presents four types of clinical obsessions (contact contamination, mental contamina-
tion, checking, and pure obsessions) that illustrate the role of faulty appraisals in the
persistence of obsessions.
Automatic Processes (Phase I)
The cognitive basis of OCD begins with the occurrence of an unwanted intrusive
thought, image, or impulse. O’Connor, Aardema, and Pélissier (2005) note that the
intrusion rarely occurs in a vacuum but instead must be understood in a context that
might involve a particular mood state, memory, or some current event. Moreover, in
their inferential model of OCD, O’Connor and colleagues argue that obsessions are
not due to intrusions but instead are a primary inference embedded in a narrative of
imagined possibilities (see also O’Connor, 2002; O’Connor & Robillard, 1999). In the
current model, an unwanted intrusive thought or image would be the stimulus for the
immediate fear response. Particular internal or external cues might provide a context
that elicits an unwanted intrusion such as the person with contact contamination who
becomes preoccupied with whether he contracted a deadly disease after opening the
door to a public washroom, or the person who worries that she may have run over a
pedestrian after driving over a bump in the road. With repeated experiences of the intru-
sive thought, the orienting mode would be primed to automatically detect occurrences
of the obsessive intrusive thought. Thus individuals who are prone to OCD are expected
to have more frequent unwanted intrusive thoughts and to be more hypervigilant or
oriented toward the detection of these intrusions in the stream of consciousness (e.g.,
Wegner, 1994).
OCD Schemas (Beliefs)
In the last several years considerable progress has been made in characterizing the pri-
mary schematic activation in OCD. A number of cognitive themes have been identified
that together constitute primal threat mode activation in OCD. Table 11.2 presents