Obsessive– Compulsive Disorder 461
thought as increasing the probability that a dreaded outcome will occur (TAF—
Likelihood) or considering a disturbing thought as morally equivalent to a forbid-
den action (Rachman, 1993; Rachman & Shafran, 1998; e.g., “The more that I
have disturbing thoughts of stabbing my children when I use a kitchen knife, the
more dangerous I become because I could weaken and actually do it”).
••Threat estimation—exaggerated estimates of the probability and severity of
harm associated with an intrusive thought (Carr, 1974; “I have to check if I left
the stove burner on because it could cause a fire”).
••Importance and control—evaluating the significance of thoughts in terms of
their attentional priority and the importance of exerting effective control over
the intrusion (Thordarson & Shafran, 2002; Purdon & Clark, 2002; “If I don’t
get more effective control over these agonizing thoughts of death, I will become
overwhelmed with anxiety”).
••Intolerance of uncertainty—significance of thoughts are evaluated in terms of
their deviation from a certain and expected outcome (Sookman & Pinard, 2002;
e.g., “If I’m not absolutely certain that I locked the door, this means my obsessive
doubt might have some significance”).
••Perfectionism—evaluating thoughts in terms of an absolute, complete, or perfect
criterion (Frost, Novara, & Rhéaume, 2002; e.g., “I need to continue to check
this form until I have eliminated any concerns of the possibility of even the slight-
est error”).According to the cognitive model unwanted intrusive thoughts that are appraised in the
above manner will result in an exaggerated evaluation of their personal significance and
potential to cause harm or danger to self or others (Rachman, 2003). This metacogni-
tive elaborative faulty appraisal of the intrusion as a personally significant threat is
associated with heightened anxiety or distress leading to a sense of urgency to find relief
from the distress and neutralize the imagined danger.
Secondary Appraisals of Control
In addition to these primary appraisals of the obsession, D. A. Clark (2004) proposed
that obsession-prone individuals also engage in a secondary appraisal of their ability
to cope with or control the obsession. Repeated failures to exert effective control over
obsessional thinking will also contribute to an increased evaluation of the significance
and threatening nature of the obsession as well as a heightened sense of personal vulner-
ability. Thus both primary appraisals of the obsession and secondary appraisals of one’s
control efforts are important elaborative processes that contribute to an escalation in
the obsessional state.
Neutralization
In OCD cognitive and behavioral responses that seek to reduce distress and neutralize
the obsession are an important feature of the elaborative phase that contributes to the
persistence of the disorder. Individuals with OCD will engage in a number of neutraliza-
tion strategies, including compulsive rituals, that are intended to reduce perceived threat
and its associated anxiety as well as establish a sense of safety through cessation of the