MALADAPTIVE APPRAISALS AND INTRUSIVE THOUGHTS ASSOCIATED WITH OBSESSIVE COMPULSIVE DISORDER : A SEMIIDIOGRAPHIC APPROACH Geoffrey T. Hutchinson, B.A., M.S. Dissertation Prepared for the Degree of DOCTOR OF PHILOSOPHY UNIVERSITY OF NORTH TEXAS August 2004 APPROVED: Kenneth Sewell, Major Professor and Coordinator of the Program in Clinical Psychology Joe Barnhart, Committee Member Craig Neumann, Committee Member Shelley Riggs, Committee Member Linda Marshall, Interim Chair of the Department of Psychology Sandra L. Terrell, Dean of the Robert B. Toulouse School of Graduate Studies Hutchinson, Geoffrey T., Maladaptive appraisals and intrusive thoughts associated with obsessive compulsive disorder: A semiidiographic approach. Doctor of Philosophy (Clinical Psychology), August 2004, 122 pp., 5 tables, references, 160 titles. This project investigated the metacognitive strategies used to appraise obsessive thoughts employed by individuals with different anxiety symptoms. Two hundred and eighty seven undergraduate students completed two repertory grids and three anxiety scales. The repertory grids respectively examined the appraisal process of intrusive thoughts both from the perspective of the rater and the rater’s imagined average person. Variables quantified from the rep grid related to the construal process of raters’ own intrusions, failed to demonstrate robust differences between OCD, non-OCD anxious, and non-anxious individuals. However, it appears that anxious individuals, not just those with OCD, use metacognitive strategies to suppress rigid constructions under perceived social evaluation. Future studies may wish to use related grid variables to explore the relation between obsessions and social anxiety. ACKNOWLEDGEMENTS I would like to acknowledge all the research assistants who helped me collect and code the data, along with faculty members who offered me guidance in this project. I also would like to acknowledge the soon-to-be Dr. Brenda Drake of Baylor University. Her willingness to grant me access to Baylor’s libraries and computers helped me progress at a reasonable pace. More importantly, her input and general encouragement greatly reduced my stress during these times. I also would like to acknowledge my newly born son, who has given me incentive to complete this project as I was awaiting his birth. Finally, I wish to acknowledge Providence who has ultimately directed my steps and led me to the fulfillment of my Ph.D. ii TABLE OF CONTENTS Page ACKNOWLEDGEMENTS..........................................................................................................ii Chapter 1. INTRODUCTION ...................................................................................................... 1 Overview of OCD Etiological Theories and Treatment Behavioral Theories Early Cognitive Theories Modern Cognitive Therapy Semiidiographic Methods for Studying OCD The Current Study Hypotheses 2. METHOD ................................................................................................................. 36 3. RESULTS ................................................................................................................. 46 Data Transformations and Correlation Matrix Group Membership Hypothesis Testing Alternative Group Membership Hypothesis Retesting Exploratory Findings from Research Questions 4. DISCUSSION........................................................................................................... 71 Evaluation of Hypotheses Summary of Findings from Both Sets of Analyses Evaluation of Research Questions Clinical Applications Study Limitations and Future Research iii Summary and Conclusions APPENDICES ............................................................................................................................ 89 REFERENCE LIST .................................................................................................................. 111 iv CHAPTER 1 INTRODUCTION Overview of OCD Obsessive-compulsive disorder (OCD) is an anxiety disorder that affects about two percent of Americans, roughly about five million people (Robins & Regier, 1991). OCD is one of the most difficult psychological disorders to treat; although some people show significant improvements, the disorder often persists throughout life (White & Cole, 1990). The disorder may begin in childhood, but initial onset usually occurs in adolescence or early adulthood. Nearly two-thirds of individuals with OCD develop symptoms by the age of 25, and almost all develop their symptoms by the age of 35 (Rasmussen & Eisen, 1990). People with OCD often hide their symptoms from others and will not seek therapy for many years in order to avoid embarrassment (Abramowitz, 1997). It is not uncommon for individuals with OCD to have co- existing mood disorders, personality disorders, substance abuse, tics, or other anxiety disorders (Baer, Rauch, & Jenike, 2000; Jenike, Baer, & Minichiello, 1998; Leonard et al., 1992). Obsessions are recurrent, persistent, impulses or images that create considerable anxiety, and are considered by the individual as both intrusive and inappropriate (DSM-IV-TR, American Psychiatric Association, 2000). Compulsions are repetitive behaviors or mental acts that the individual feels driven to commit in order to neutralize, reduce, or prevent the distress associated with the obsessions. The compulsions themselves may not represent appropriate or logical ways of handling the obsession. Degree of insight into the rationality of these symptoms ranges from good to poor, although many people with OCD are aware that their obsessions are a product of their own minds. 1 Individuals with OCD report a variety of obsessions and compulsions. In their sample of individuals with OCD (N = 200), Rasmussen and Eisen (1989) reported that almost 50% had contamination obsessions and pathological doubt, almost 33% had aggressive and sexual obsessions and 60% had multiple obsessions. This corroborates Rachman’s (1997) view that most obsessions tend to revolve around three main themes: religion/morality, sexuality, and harm. More than half of Rasmussen and Eisen’s sample had checking, washing and cleaning compulsions, and approximately a third had counting and reassurance/confession compulsions. These investigators reported that hoarding compulsions and other obsessions (excluding somatic and symmetrical obsessions) were reported by less than 20% of these individuals. Individuals with OCD often report substantial interference in their social and occupational spheres. One study reported that individuals with OCD were approximately four times more likely to be unemployed than people in the general population (Koran, Thienemann, & Davenport, 1996). Obsessions and compulsions take considerable energy and time away from individuals with OCD. For example, washing, checking and praying compulsions may leave a person housebound and isolated from others. Individuals plagued with symmetry obsessions and perpetual doubts may have difficulty performing basic tasks, taking a long time to make simple decisions. Individuals can suffer exclusively from obsessions, even though most individuals with the disorder have compulsions as well (Clark & Purdon, 1993). Obsessions are very difficult to treat and do not respond to traditional “talk therapy” (Stern, 1978). Although most individuals can identify specific compulsions following their obsessions, there exists a significant minority who are simply unaware of their mental rituals, or who cannot identify associated compulsions (Clark, 2000). The treatment of individuals who suffer exclusively from obsessions without 2 compulsions has been a recent focus of clinical and theoretical interest (Baer, 2001; Clark, 2000; Rachman, 1997, 1998). Summary OCD is an anxiety disorder that involves the occurrence of compulsions and/or obsessions, often accompanied by other types of psychopathology (e.g., mood disorders). Although OCD may begin in childhood, its onset is usually during adolescence or adulthood. Individuals often hide their symptoms for many years, resist their intrusive thoughts, and consider them to be highly inappropriate. Most use compulsions to lower the associated anxiety, but some individuals do not report mental or behavioral compulsions. Religion/morality, sex, and harm seem to be the themes of major obsessions; people with OCD usually have multiple obsessions and compulsions. These symptoms often make life extremely difficult, interfering with work and social functions. Etiological Theories and Treatment Applications Theories regarding the origin of OCD have primarily surfaced from three camps: neurobiological, behavioral, and more recently cognitive. Currently, the recommended treatment of OCD integrates all these theories, usually relying on medication management and cognitive- behavior therapy as primary treatment interventions (Steketee, Pigott, & Schemmel, 1999). Effective cognitive techniques used to treat OCD have surfaced within the last decade. However, workable formulations of both cognitive and behavioral techniques have emerged as early as the 1960s. Similarly, biological therapies used to treat OCD can be traced back to responses to classic antidepressant drugs like clomipramine. These etiological theories will be reviewed briefly and their contributions to a comprehensive modern treatment will be assessed. 3 Neurobiological Theories OCD has some strong biological contributions, given the evidence of genetic contributions, neuroanatomical abnormalities, and patient response