Everyone finds their mind wandering occasionally. Being distracted by our thoughts is a common experience, but people with OCD experience intrusive thoughts that are more intense, insistent, distressing, and longer-lasting than the usual interruptions faced by those without OCD. Most cognitive psychologists agree that although we may be unable to control the initial generation of such thoughts, there are individual differences in terms of the further processing that is conducted and people’s subsequent behavioural responses. 

There is a wealth of research in this area, and this page focuses on two of the main cognitive theorists: Paul Salkovskis and Stanley Rachman. Both argue that beliefs about obsessions are critical in the development and persistence of the disorder.

The role of schema: An inflated sense of responsibility

Salkovskis (1985) proposed that intrusive thoughts activate dysfunctional beliefs about the degree of responsibility individuals should have over their own or a significant others' safety. These beliefs lead to the conclusion that something must be done about the thought in order to put matters right again.  Taking actions to neutralize the thoughts leads to a reinforcement of the belief that one's actions - the compulsion - played a key role in protecting oneself or others. The reinforcement of these thoughts then makes the thoughts more likely.

The overestimation of one's responsibility for others may stem from strict or overprotective parenting or an experience where an individual actually did cause harm to themselves or others. This response may be the result of past experience which has led to maladaptive schema. These schema include mistrust, shame, social isolation, and vulnerability to harm.

Atalay et al (2006) administered the Young Schema Questionnaire (YSQ) and the Yale-Brown Obsessive-Compulsive Scale (Y-BOCS) to 45 patients with OCD and 45 healthy controls. The average scores of the patients with OCD on certain schemas were significantly higher than the average scores of the control group.

Salkovskis’ emphasis on perceived responsibility is supported by research such as the study by Lopatka and Rachman (1995). Participants living with OCD were put into situations that normally would provoke compulsive behaviour but they were told that they wouldn't be to blame for any negative outcomes that arose if they did not conduct their usual checking rituals. This significantly reduced discomfort and compulsive urges, as well as the perceived likelihood of a negative outcome. This important finding supports the role of an inflated sense of responsibility as a trigger for compulsive behaviour, and demonstrates how compulsions can be reduced through treatments focused on dysfunctional beliefs. 

Such treatments have been shown to be effective. Ladouceur et al. (1996) found that 32 treatment sessions focused on personal responsibility reduced OCD symptoms and these gains were still present six and twelve months later. This said, there were only four people living with OCD in the study, thus responsibility may only play an important part for some people with OCD and not others

Furthermore, the treatment etiology fallacy suggests we should not assume that the success of a specific therapy proves the cause of the disorder. For example, an inflated sense of personal responsibility may be an effect of other dysfunctional beliefs associated with OCD, rather than the cause. Lopatka and Rachman’s study is somewhat helpful in resolving this issue, but their participants already had OCD, and therefore it is impossible to deduce whether inflated responsibility caused the development of the disorder in the first place.

Rachman (1997): Catastrophic misinterpretation

Rachman argues that obsessive thinking results from “catastrophic misinterpretation” of the significance of one's intrusive thoughts. Obsessions develop when the individual believes that an intrusive thought reveals something meaningful and up until now unknown about themselves, that it is a warning sign that a negative event will come true, or that it is an indication that the individual is in danger of losing control. The obsession will persist as long as the thought is interpreted as being catastrophic, and it will diminish when the misinterpretations are weakened.

While he also emphasizes the role of inflated responsibility, his theory focuses on several additional dysfunctional beliefs.   

Rachman proposed that attributions of significance are critical in transforming normal intrusive thoughts into an obsession. People with OCD describe their thoughts as repugnant, alarming, and dangerous; they believe that their thoughts make them immoral, disgusting and/or insane. Often they believe hidden aspects of their character are revealed in their obsessive thoughts - that is, that deep down they are evil and at some point in the future they could be a risk to themselves or others. The anxiety that this side of them will be discovered, leading to rejection, imprisonment, or being sent to hell appears can be overwhelming.

Whereas when most people have a strange or frightening thought they are able to let it go, a person with OCD may become “stuck” on the thought and be intensely afraid that they might somehow lose control and act on it. Or worse, they believe that having the thought is just as bad as doing it. This is called thought-action fusion [TAF]. For example, a patient with OCD experienced intrusive images of throwing hot coffee in her daughter’s face or pushing her face underwater when she was giving her a bath. These images were so terrifying to the patient that she would no longer allow herself any physical contact with her daughter. She was unable to determine that the thought itself was not the same as the act or the threat of carrying out the act.

Researchers use the term thought-event fusion (TEF) to refer to the mistaken belief that thoughts can make certain events more likely (TEF), e.g. imagining the school burning down makes it more likely that the school will actually burn down.

It is interesting here to remember the pink elephant thought experiment from the video: the harder you try not to think about the pink elephant, the more impossible it becomes. Here the same can be true for people with OCD; the more they try to control their thoughts, the worse the obsessional thoughts about danger and harm become, and the more they are compelled to take responsibility by performing neutralizing behaviours.

These suggestions have been supported by experimental attempts to artificially create TAF beliefs. For example, Myers and Wells (2013) showed that intrusive thoughts, discomfort, and efforts to control thinking could all be increased in a group of people who showed no prior vulnerability to OCD-like symptoms. This was achieved by falsely telling them that an EEG was reading their thoughts, and if they thought about water or drinking this would cause them to be subjected to an aversive, but harmless noise. This is an important study as it shows that thought-action fusion may play a causal role in the development of OCD.

One problem with this study is that it only examines how obsessional thoughts about harm to self might arise through thought-action fusion and not about harm to others. This means it is difficult to say whether thought-action fusion determines intrusive thinking and distress to the same or greater degree when the harm caused by certain thoughts would befall some other person, particularly a beloved family member.