Obsessive– Compulsive Disorder 487
summary anD ConClusionIn many respects OCD is one of the most difficult and perplexing of the anxiety dis-
orders given its heterogeneous and idiosyncratic symptom presentation. It is a puzzling
condition because individuals report intense anxiety over the most innocuous, even
incredulous, thought (e.g., “Might I spread a deadly sickness to others because I am
contaminated with radioactivity”) while at the same time acknowledging the absurdity
and impossibility of the fear. Such an irrational fear requires a refinement of the stan-
dard cognitive approach.
This chapter presented a metacognitive theory that explains the persistence of
obsessive and compulsive symptoms in terms of faulty appraisals and beliefs that lead
to exaggerated evaluations that the obsession represents a significant personal threat
that could be associated with catastrophic consequences (Rachman, 1997). Apprais-
als involving overestimated threat, inflated responsibility, overimportance of thought
(i.e., TAF), control of thoughts, intolerance of uncertainty, and perfectionism are impli-
cated as key cognitive processes, along with faulty inductive reasoning, that cause the
obsession-prone individual to misinterpret normal unwanted intrusive thoughts. Once
the mental intrusion is considered a highly significant personal threat, the individual
engages in various overt and covert responses to control or neutralize the obsessional
fear. However, repeated neutralization (e.g., compulsive ritual) and misinterpretations
of the significance of failed control will also contribute to the persistence of the obses-
sion. This sets in motion an escalating cycle of heightened anxiety with increased fre-
quency and salience of the obsession associated with repeated failure to achieve effec-
tive neutralization or a satisfactory state of calm. As reviewed in the chapter, there is
mounting empirical evidence for the cognitive model of obsessions, especially overesti-
mated threat, inflated responsibility, TAF, and need for control of thoughts. An eight-
component cognitive therapy for OCD was presented in which the main therapeutic
ingredients are cognitive restructuring, exposure-based behavioral experimentation,
and response prevention that target the faulty appraisals and beliefs specific to OCD.
The last few years have witnessed a burgeoning research on the cognitive basis of
OCD. However, we are only beginning to develop a cognitive approach to OCD and
many questions remain for future research. Are the faulty appraisals and beliefs specific
to OCD, and are they causes or consequences of the disorder? Do individuals with OCD
suffer from poor mental control or is the problem with their subjective appraisal of
control and its anticipated consequences? Do some individuals have a cognitive vulner-
ability for OCD? Do cognitive interventions add significant therapeutic value beyond
the effects of exposure and response prevention? Is a cognitive approach to treatment
more effective for some subtypes of OCD than others? Might the addition of cognitive
interventions enhance the prophylactic effects of CBT like that seen in the treatment
of depression? Although there are many issues that remain for future investigation, the
cognitive perspective is providing fresh insights into our understanding and treatment
of obsessions, in particular.