Task 4 - It Is Your Fault - PDF

Task 4 - It is your fault Introductory chapters & Fenske (2001) Definition Obsessive compulsive disorder (OCD) - a disorder characterized either by obsessions (intrusive & recurring thoughts/images that the individual finds disturbing and uncontroll...

Task 4 - It is your fault Introductory chapters & Fenske (2001) Definition Obsessive compulsive disorder (OCD) - a disorder characterized either by obsessions (intrusive & recurring thoughts/images that the individual finds disturbing and uncontrollable), or compulsions (ritualized behavior patterns that the individual feels driven to perform in order to prevent some negative outcome happening), or both. Common obsessions include causing harm/distress to oneself or another important person, fear of contamination, thoughts about harm, accidents, and unacceptable sex. Obsessions can also take the form of doubting & indecision, which leads sufferers to develop repetitive behavior patterns (e. g. compulsive checking/washing). Obsessive thoughts are often autogenous, i.e. uncontrollable and appearing out of nowhere. This is often what makes them distressing. Compulsions include ritualized & persistent checking of doors/windows (e.g. to ensure that the house is safe), washing activi ties designed to prevent infection/contamination, compulsive hoarding, hair-pulling or skin picking, superstitious ritualized movements, or the systematic arranging of objects. Such ritualized compulsions reduce the anxiety caused by obsessive fears. Compulsions are excessive, and are usually recognized so by the sufferer. Symptoms are often accompanied by feelings of shame and secrecy because patients realize the thoughts & behaviors are excessi ve & unreasonable. Magical thinking is often the link between the obsession and compulsion - believing that repeating a behavior a certain number of times will ward off danger to oneself and others. OCD people's rituals often become stereotyped and rigid, and they develop obsessions and compulsions about not performing the m correctly (e.g. thinking that one needs to read a paragraph 25 times perfectly, otherwise something bad may happen to his family if he does not). DSM-5 criteria (left 2); Subtypes of OCD (right 1) Diagnosis & prevalence OCD onset is usually gradual and begins to manifest itself in early adolescence/adulthood after a stressful event (e.g. pregn ancy, childbirth, relationship or work problems). OCD symptoms are a common way for anxiety to manifest itself in childhood. Children often hide their symptoms. As a result, the symptoms can go undetected for years. Psychopathology Page 1  Children often hide their symptoms. As a result, the symptoms can go undetected for years. Lifetime prevalence = 2.5% (1.6% in Fenske article). Women are marginally more affected than men. Culture can mediate expression of the disorder (e.g. obsessions in Brazilian & Middle Eastern samples are aggressive or relig ious compared with North America, Europe and Africa). OCD is often comorbid with depression (66% of cases), panic attacks, social anxiety disorder, specific phobias, and substance abuse. 50% experience suicidal ideation, and 15% have attempted suicide. OCD-related disorders There are several associated disorders that have similar features and respond to the same therapies used to treat OCD. Body dysmorphic disorder - a pre-occupation with perceived flaws in physical appearance that are usually not perceived by others. If there is actually a physical anomaly, those suffering from BDD will greatly exaggerate its importance. Appearance-related obsessive thoughts result in compulsions - grooming, mirror checking, and reassurance seeking. These usually add to the distress that is experienced. 80% of individuals with BDD will repetitively check their appearance in mirrors, often for a long period of time. The remaining 20% tend to avoid mirrors altogether. People with BDD spend an average of 3-8 hours per day on their preoccupations and their checking/grooming behavior, and they may even seek surgery to correct their perceived flaws. If preoccupations with weight & shape are part of an eating disorder, then BDD is not diagnosed. Most people avoid social activities because of their perceived flaws, many become housebound, or obtain surgery. 30% attempt suicide. Hoarding disorder - collecting too many items and difficulty discarding possessions to the point where the individual's living area is severely c ongested by clutter. People who have the disorder often try to organize their possessions, but due to their lack of organizational skills, they ma ke the chaos worse. People who hoard differ from those with OCD as they do not experience anxiety about their hoarding behavior, but they may bec ome extremely upset when pressured to get rid of their hoarded possessions. People who hoard often have an exaggerated sense of responsibility, feel guilty about wasting things, have an excessive need to be 'ready just in case', and feel responsible for not 'hurting' the item. Hoarding begins in childhood/adolescence and has a chronic & progressive course throughout the lifespan. Hair-pulling disorder (trichotillomania) - the individual compulsively pulls out their own hair resulting in significant hair loss. Skin-picking disorder - recurrent picking of the skin that results in significant skin lesions that often become infected and cause scars. Etiology of OCD OCD is quite heterogenous (e.g. obsessions do not always occur with compulsions and the 2 main types of compulsions - washing & checking - rarely occur together). For this reason, etiology theories of OCD sometimes address only some of its features. Biological factors OCD is highly heritable. Different genes may be involved in vulnerability to OCD, hoarding or BDD. Onset of OCD can be associated with traumatic brain injury or encephalitis. This may result in a neuropsychological deficit, which may result in the 'doubting' that things have been done properly, whic h is a central feature of OCD. Important areas for this are the frontal lobes & basal ganglia. A circuit projecting from the frontal cortex, through the basal ganglia, to the thalamus, looping back to the frontal cortex is implicated in OCD. People with OCD, hair-pulling & skin-picking disorder show changes in the structure & activity of these areas and the connections between them. Dysfunction in this circuit may result in inability to turn off the urges or the execution of the stereotyped behaviors. People with OCD who respond to behavioral therapy tend to show decreases in caudate & thalamus activity. Due to response to SSRIs, it is hypothesized that the serotonin system is heavily involved in the neurochemistry of OCD. OCD sufferers show a variety of information processing & executive functioning deficits, including spatial WM deficits, spati al recognition, visual attention, visual memory, and motor response initiation. Psychological factors Intrusive thoughts usually occur more when one is distressed. People with OCD may be depressed or generally anxious much of t he time so that even the minor negative events are likely to invoke intrusive, negative thoughts. It has been suggested that OCD sufferers have a memory deficit that gives rise to doubting. This memory deficit may take seve ral forms: A general memory deficit Less confidence in the validity of one's memories A deficit in the ability to distinguish between the memory of real and imagined actions. However, evidence for this is limited. Recent research suggests that OCD 'doubting' is a result of an executive functioning d eficit. Spending a lot of time checking things on a daily basis overloads executive processes and results in poor encoding of informa tion & poor attention to relevant information, which in turn will cause memory deficits. The lack of confidence in memory recall may be a consequence of compulsive checking/washing rather than a cause of it. Psychopathology Page 2  The lack of confidence in memory recall may be a consequence of compulsive checking/washing rather than a cause of it. Even though everyone experiences uncontrollable intrusive thoughts, healthy people can attribute their thoughts to distress a nd ignore them, while people with OCD have developed a set of dysfunctional beliefs about their obsessions. They feel responsible for the content of their thoughts - e.g. if a sufferer thinks of murdering their child, they believe they may be going crazy and will actually murder their child. Obsessive thoughts are perceived as having potentially harmful consequences, which leads to anxiety and compulsive acts desig ned to remove the thought or make sure the perceived harm does not occur. Inflated responsibility - people with OCD have an inflated idea of their own responsibility for preventing harm. They believe that they have the power to cause/prevent crucial outcomes, and that it's important to cause/prevent these outcomes. Inflated responsibility is an important OCD vulnerability factor. Experimental studies show that it increases compulsions. Thought-action fusion (TAF) - a dysfunctional assumption held by OCD sufferers that simply having thoughts can directly affect what happens in the world. People with OCD commonly think that their unacceptable thoughts can influence events in the world (e.g. that if they have a t hought about a plane crashing, it may crash because of that, or that thinking they will become ill makes them more likely to become ill). If the supposed consequences of thoughts are negative, this will cause the sufferer to try and suppress these thoughts, and i t will generate considerable distress & anxiety. TAF is related to the degree to which an individual assigns importance to thoughts, which is also related to Christian religi osity. Moral TAF is associated with OCD symptoms only in religious groups where the importance of thoughts is not the norm. Mental contamination - for some OCD sufferers, feelings of dirtiness can be provoked without any physical contact with a contaminant. Mental contamination can be caused by images, thoughts and tends to be caused by a violation by another person - degradation, betrayal, emotional/physical abuse or humiliation. It gives rise of feelings of dirtiness/pollution and may be associated with compulsive washing or cleansing. In addition to the feelings of contamination, individuals also experience anxiety, disgust, shame, anger, guilt and sadness. Thought suppression - a defense mechanism used by OCD people - actively suppressing thoughts using thought suppression or distraction techniques. Rebound effect - actively suppressing an unwanted thought will actually cause it to occur more frequently once the period of suppression is ov er. Suppressing an unpleasant thought induces a strong negative emotional state that results in the suppressed thought becoming a ssociated with that negative mood state. When that negative mood state occurs in the future, it may also elicit the thought, which may contribute to OCD sufferers experiencing regular, uncontrollable intrusions. Perseverative psychopathologies - disorders characterized by the dysfunctional perseveration of certain thoughts & behaviors (e.g. pathological worrying & chronic rumination). The perseveration is excessive, out of proportion for the functional purpose it serves, and a source of distress. OCD is a preservative psychopathology and there are several theories explaining why OCD sufferers persevere at an activity fo r a significantly longer time than non-sufferers. Mood-as-input hypothesis - OCD sufferers persevere with their compulsive activities because they use an implicit 'stop rule' for the compulsive activity and they start the task in a strong negative mood. They use their mood as information to assess whether they have met the stop rule criteria. Their negative mood is interpreted as information that they have not completed the task properly, so they persevere. Inflated responsibility is not a sufficient condition for an individual to persevere at a compulsive activity - negative mood is also necessary (presumably to provide feedback that the important goals of the compulsive activity have not been met). Treatment of OCD Although full remission is rare in OCD patients, significant improvement is common. Exposure and ritual prevention (ERP) treatments Psychopathology Page 3 Exposure and ritual prevention (ERP) treatments Exposure and ritual prevention treatment (a.k.a. exposure and response prevention treatment) - exposure to the thoughts that trigger distress, followed by the development of behaviors designed to prevent the individuals' compulsive rituals. Triggers are encountered in a graded exposure procedure until distress levels have significantly decreased (e.g. touching a d irty dish or imagining touching it). Response is prevented by practicing competing behaviors, habit reversal, or modification of compulsive rituals. Preventing the patient from engaging in their rituals allows obsession -anxiety link to extinguish, eliminates the anxiety-reinforcing rituals and helps disconfirm dysfunctional beliefs (e.g. I will catch an infectious disease if I touch a dirty cup). Cognitive behavioral therapy (CBT) Not everyone with OCD can enter & stay in ERP due to inability to expose oneself to one's fear triggers or to prevent acting out one's rituals. CBT is an alternative that aims to modify OCD sufferers' dysfunctional beliefs about their fears, thoughts, and the significa nce of their rituals. Some beliefs challenged by CBT for OCD include: Responsibility appraisals, where the sufferer believes they are solely responsible for preventing any harmful outcomes. The over-importance of thoughts, where sufferers engage in TAF. Exaggerated perception of threat CBT can also include educating clients that their thoughts are normal and providing behavioral exercises that disconfirm thei r dysfunctional beliefs. CBT leads to significant improvement in obsessions and compulsive behavior in 60 -90% of OCD clients. In most clients, the improvement remains for up to 6 years. The combination of CBT with medication is the most effective. Pharmacological and neurosurgical treatments Pharmacological treatments for OCD are effective short-term and cheap. However, relapse usually occurs after stopping drug treatment. SSRIs (Fluoxetine (Prozac), fluvoxamine, paroxetine (Paxil), and sertraline (Zoloft)) are most commonly prescribed. 50 -80% of OCD patients experience decreases in their obsessions and compulsions while on antidepressants. SSRI dosage is usually higher than the recommended dosages for other disorders. Some patients require lifelong medical therapy. Tricyclic antidepressants only have effect when OCD is comorbid with depression. Second-line pharmacological treatments (e.g. if no response to >= 2 SSRIs) include clomipramine, Venlafaxine (Effexor) and mirtazapi ne (Remeron). Both SSRIs and tricyclic drugs are less effective than standard psychotherapies, such as ERP. For patients who have partially responded to SSRI therapy, adding an atypical antipsychotic can help. Antipsychotic augmentation is especially useful in patients with comorbid tics. Neurosurgery is a last resort treatment to OCD, after psychotherapy and pharmacological treatments have failed. Cingulotomy - a neurosurgical treatment that involves destroying cells in the cingulum, close to the corpus callosum. There is evidence of some improvement in symptoms after a cingulotomy. There is no evidence for longer term gains & possible side effects. Maximizing exposure therapy: an inhibitory learning approach - Craske (2014) Inhibitory learning model of extinction In exposure therapy, an individual is repeatedly exposed to fear-provoking stimuli (CS) in the absence of aversive outcomes (US), and the goal is to extinguish learned CS-US associations. Inhibitory learning - the original CS-US association learned during fear conditioning is not erased during extinction, but rather a new, secondary inhibitory learn ing about the CS-US develops (i.e. that the CS no longer predicts the US). The amygdala, which is particularly active during fear conditioning, is inhibited by the medial PFC as a result of extinction learning. After extinction, the CS has 2 meanings: its original excitatory meaning (CS-US) and a new additional inhibitory learning (CS-no US). Therefore, even though fear reduces after exposure therapy, at least a part of the original association is still there and can be uncovered. Conditional fear shows spontaneous recovery (the strength of the CR increases in proportion to the amount of time since the e nd of extinction). This makes individuals vulnerable to their fears returning in time after therapy is over. Conditioned fear returns if the surrounding context is changed between extinction and retest, as shown by clinical samples un dergoing exposure therapy and then tested in the same vs. different contexts. This means that if exposure therapy is completed in a limited number of contexts (e.g. only with a therapist), fear is likely to return when the feared stimulus appears in a different context. Conditioned fear also returns if unpaired US presentations occur between extinction and retest. This means that adverse events after exposure therapy may cause the fear to return if the previously feared stimulus is encountered in an anxiety- inducing context. For example, fear of asking questions in work meetings may return after being rejected in another social situation, or even after an unrelated adverse event (e.g. a motor vehicle accident). Rapid reacquisition of the CR happens if the CS-US pairings are repeated following extinction. Therefore, fears that have subsided may be easily & quickly reacquired with re-traumatization. Psychopathology Page 4 Deficits in inhibition and anxiety disorders Many people do not benefit from exposure-based therapies or their fear returns thereafter. This may be due to deficits in inhibitory learning & inhibitory neural processing during extinction, which characterize people with anxiety disorders or elevated trait anxiety. These deficits may contribute to both poor response to exposure therapy and the development of excessive fear and anxiety in the first place. Therefore, it is important to optimize inhibitory learning during exposure therapy in order to compensate for the deficits th at are present in anxious people. Inhibitory learning vs. habituation Habituation-based models of exposure therapy state that fear reduction during an exposure trial is necessary for subsequent, longer -lasting cognitive changes in the perceived harm associated with the feared stimulus. On the other hand, inhibitory learning models do not emphasize fear reduction during trials and instead sometimes use strateg ies to maintain elevated fear throughout exposure trials. The amount by which fear has reduced at the end of exposure trials does not predict expressed fear at a follow -up assessment. This is consistent with the idea that the expression of fear and conditional associations may not always change together. Fear expressed at follow-up is influenced more strongly by passage of time, context shifts, adverse events or relearning, rather than by level of fear experienced at the end of exposure. Therapeutic strategies for enhancing inhibitory learning and its retrieval Expectancy violation Expectancy violation - designing exposures that maximally violate expectations regarding the frequency or intensity of aversive outcomes. This is based on the idea that the mismatch between expectation & outcome is critical for new learning (remember L&M predicti on errors) and for the development of new inhibitory expectations that will compete with the excitatory ones. Study: this approach yielded the same long-term benefits after just 1 trial of exposure compared to repeated trials of exposure each day. Study: interoceptive conditioning that continued until the patient's expectation of an aversive outcome reached less than 5% was superior to standard exposure that lasts until fear declines. In this approach, tasks are designed according to what one needs to learn. In contrast, in habituation -based models of exposure therapy, the patient stays in the situation until the fear declines. In clinical practice it is important for the client to identify the expected US (e.g. in social anxiety the patient needs to predict more than "I will get anxious", for example "I will be ignored/rejected." Then, using the expectancy violation approach, exposure is designed so that is directly violates consciously stated expectati ons for aversive events. Exposure finishes when the expectations are violated, not when one's fear is reduced (as in habituation -based approaches). After each exposure trial, the learning is consolidated by asking the patient to judge what they learned (e.g. the non -occurrence of the feared event (The bad thing I expected did not happen), discrepancies between what was predicted & what occurred (It wasn't as bad as I expected), and the degree of surprise from the exposure). This mental rehearsal is an important component of memory consolidation. The expectancy violation model states that attention needs to be directed to both the CS and the non -occurrence of US, because extinction learning will be directed to the most salient cue. In the expectancy violation model, gradual exposure means gradually violating expectations, and not gradually increasing fear level. For example, for people who fear having a heart attack from a panic attack in an elevator, exposure should be done to gradual ly longer trials in the elevator even though fear does not decline with each exposure trial. Cognitive interventions before exposure (e.g. ones that persuade the patient that nothing bad will happen during exposure) ma y have a negative impact on inhibitory learning because they reduce the expectancy violation. Therefore, the authors propose that cognitive interventions only need to happen after the exposure in order to facilitate mem ory consolidation. Deepened extinction Deepened extinction - a strategy in which either multiple fear CSs (that predict the same US) are separately extinguished before being combined dur ing extinction, or a previously extinguished cue is paired with a novel CS. Exposure to feared bodily sensations (e.g. caffeine consumption), and in vivo exposure to feared external agoraphobic situati ons (e.g. shopping in a crowded mall) followed by including interoceptive exposure during in vivo exposure (e.g. drinking coffee while shopping in th e mall) is an example of deepened extinction for panic disorder & agoraphobia. Occasional reinforced extinction Occasional reinforced extinction - involves occasional CS-US pairings during extinction training. This may be beneficial due to an expectancy violation effect where the patient is less likely to expect the next CS presentation to predict the US because CS- US pairings have been associated with both further CS-US pairings and CS-no US pairings. It is also possible that occasional reinforcement during extinction may enhance the salience of CS. In clinical settings, this may involve adding occasional social rejections or deliberate induction of panic attacks (by subst ances) to exposures. Removal of safety signals Psychopathology Page 5 Removal of safety signals Removal of safety signals - in phobic samples, the availability & use of safety signals & behaviors is detrimental to exposure therapy, while instruction s to refrain from using safety behaviors improves outcomes. This is because safety behaviors reduce inhibitory learning because they decrease the expectation of US. The general consensus is to gradually phase out safety signals/behaviors over the course of exposure therapy. If the client i s willing, immediate removal of safety signals is preferred. Variability Another strategy is to vary the stimulus throughout exposure - varying the to-be learned task enhances retention of learned non-emotional material Variability pairs the information to-be learned with more retrieval cues, which improves later retrieval. Variability is also more likely to characterize contexts in which phobic stimuli are encountered once exposure therapy is com plete. While in traditional exposure stimuli are presented starting from the least feared to the most feared, in variable exposure t he order is random (but still begins with least feared to avoid treatment refusal). Such variability usually leads to higher anxiety during exposure that does not habituate, but also to beneficial long -term effects. Emotional state (fear level) serves as a retrieval cue and varying fear levels are likely to occur in situations after exposu re therapy when retrieval is required. Therefore, if fear level is varied during exposure, it will offset context renewal after exposure therapy. Variability in emotional state may also enhance phobic stimulus salience. Retrieval cues Using retrieval cues of the CS-no US association during extinction training, which can be used in other contexts after the therapy is over, enhances retriev al of extinction learning and prevents context renewal. However, one risk is that the retrieval cues may become a safety signal. The retrieval cues need to retrieve the CS -no US relationship, while safety signals are directly associated with the non-occurrence of the US. For example, the office of the therapist can be a retrieval cue, while benzodiazepines can act as a safety signal. In anxiety disorder treatment, this approach includes carrying cues (e.g. a wristband) with the individual that reminds them of what they learned during exposure therapy or a prompt to remind oneself what one has learned in exposure therapy every time one encounters previously feared st imuli. Multiple contexts Conducting exposure in multiple different contexts (e.g. alone, in unfamiliar places, at varying times of day/week) offsets c ontext renewal. Reconsolidation Introducing phobic stimuli for a brief period 30 min before repeated trials of exposure may affect how the memory of the stim ulus is reconsolidated, weakening the memory of fear. Still, most patients retrieve their fear memories to a certain degree whenever they enter treatment sessions. More research i s needed to determine how retrieval opens the reconsolidation window and provides the opportunity to update the underlying memories. Therapeutic strategy for enhancing inhibitory regulation Linguistic processing activates the right ventrolateral PFC, which reduces activity in the amygdala and anxious responding. Study: for people with spider phobia, affect labeling during exposure has been found to reduce SCR and increase approach beha vior in a different context than the exposure context 1 week later. The effect is compared to cognitive reappraisal of thoughts, distraction, and exposure alone. Abnormal and normal obsessions - Rachman (1978) Study I - Normal obsessions This study was a questionnaire survey aiming to investigate whether non-psychiatric subjects experience obsessions. The questionnaire was given to 124 normal people and asked if they have intrusive, unacceptable thoughts and impulses, their frequency, and if they can be easily dismissed. 79.84% of all respondents reported that they had either thoughts or images => the hypothesis that non -psychiatric subjects commonly experience obsessions was confirmed. Of these 99 positive respondents, 32 had only obsessional thoughts, 14 had only impulses, while 53 admitted to having both. 20% of the negative respondents said that they had thoughts listed in the questionnaires, but they did not consider them unac ceptable. => if the criterion is refined, 84% would be positives. Therefore, people vary in the criterion of what is an acceptable thought/impulse. Psychopathology Page 6 Study II - Similarities to abnormal obsessions This study involved standardized interviews aiming to discover similarities & differences between clinical (abnormal) and non -clinical (normal) obsessions. The nonclinical sample consisted of 40 subjects chosen from the positive respondents to the questionnaire in study 1. The clinical sample consisted of people who had sought psychiatric help for their obsessions. Differences between the clinical & non-clinical sample Differences in the content between clinical and non-clinical obsessions could not be identified by clinicians, who were given cards with the obsessions printed on them. The differences between normal & abnormal obsessions were: Clinical obsessions last longer, are more discomforting, more intense and more frequent. Clinical obsessions have lower acceptability, are more alien to the self, provoke more urges to neutralize and are more likel y to be of known onset. Clinical obsessions are more strongly resisted and are harder to dismiss. Study III - Repeated-practice effects In this study, clinical & non-clinical samples are instructed to form obsessions on demand. Most obsessional patients were able to form their obsessions when instructed to do so. A large number of non-clinical subjects were unable to do so. The obsessions produced discomfort, which was greater in the abnormal instances than in the normal ones. Abnormal obsessions formed due to instruction were moderately intense, while normal ones were mildly intense. In repeated trials of 4 minutes, the following short-term changes were observed: The latency to obsession formation increases. The duration of the obsession decreases. The accompanying discomfort decreases. The intensity of the obsession may decrease. Habituation - a decrease in responsiveness to a stimulus after repeated exposure to it. In the case of obsessions, repeated exposure to the same obsessive thoughts or images can lead to a decrease in their frequen cy and discomfort over time. This is supported by the findings in the studies discussed in this article, which suggest that repeated practice can lead to habituation of both normal and abnormal obsessions. Link to exposure therapy (not in article): exposure therapy involves repeated exposure to the obsessive thoughts or images, which can lead to habituation and a decrease in their frequency and discomfort over time. Repeated checking really does cause memory distrust - Radomksy (2006) There is research that suggests that inflated responsibility and perceived severity & probability of harm interact to produce checking behavior, which is then maintained by a self-perpetuating mechanism. However, previous studies have low ecological validity (e.g. because participants were not in conditions where they perceived their actions as meaningful and important). The current study aims to remedy these limitations under conditions of promoting increased responsibility and a real perceive d threat. It is expected that, under these conditions, repeated relevant checking should lead to reductions in memory confidence, vividness, and detail, while repeated irrelevant checking should not. Methods Participants are tested individually in the laboratory's fully equipped kitchenette. They are randomly assigned to be trained either on the stove followed by the sink or the sink followed by the stove. All participants are trained to "open/turn-on", "close/turn-off" and "check" both the complete set of knobs on the stove and the knobs and faucet on the sink in a standardized, ritualized way. After the training phase, participants are told that they will be left alone in the kitchenette (in order to increase perceiv ed responsibility). Communication with the experimenter is remote (through an intercom) from this moment onwards. After each instruction provided ("open/turn-on", "close/turn-off" or "check"), participants are asked to walk back to the intercom and let the experimenter know they had completed the task. The participants are first asked to "turn on", then "turn off" and finally to "check" a set of 3 knobs on the stove. After these 3 tasks are completed, participants are guided out of the kitchen into a testing room where they provided pre -test ratings assessing memory Psychopathology Page 7  After these 3 tasks are completed, participants are guided out of the kitchen into a testing room where they provided pre -test ratings assessing memory confidence, vividness and detail, as well as memory accuracy ('which 3 knobs did you check') and a question about memory sour ce ('remember' vs 'know' - a more episodic memory, or a more semantic, respectively). Next, participants are randomly assigned to complete 19 sets of additional trials on the stove ( relevant checking condition) or 19 sets of trials on the sink (irrelevant checking condition). Each trial included "turn-on", "turn-off" and "check" instructions given for a randomized set of 3 knobs or sink elements (e.g. "Please turn on knobs 2, 3 and 5", "Please turn them off", "Please turn on the cold water to half way, the hot water to full and turn the faucet to the left ", "Please close them", etc.). The trials are concluded by a trial on the stove for all participants. Finally, all participants are guided to a test room where they are asked to complete a post -test assessing memory and metamemory for the last trial on the stove, identical to the pre-test. Results Memory accuracy (answer to the question On the last checking trial you completed, which 3 knobs did you check?) was high for both conditions at pre- and post-tests. There were no significant differences from pre- to post-test and no significant differences between the 2 conditions. Still, all participants in the irrelevant checking condition had a perfect memory score post-test, and some of the participants in the relevant checking condition had an imperfect score. A z-test showed a significant (but very small) difference from perfect memory score for the relevant checking condition. At post-test, the relevant checking condition reported significantly less confidence in memory, less memory vividness, and less detail in memory than the irrelevant checking condition. At pre-test, there were no significant differences between the conditions in metamemory. At post-test, in the relevant checking condition, significantly more participants reported only "knowing" which knobs they checked, compared with the irrelevant checking condition, in which participants primarily "remembered" which knobs they checked. Discussion When participants were asked to repeatedly check a stove, their memory confidence, vividness and detail significantly decline d both compared to pre-test scores following only one check of the stove, and compared to a group of participants who were asked to engage in repeated irrelevan t checking of a kitchen faucet This suggests that repeated relevant checking does indeed lead to memory distrust. The results also suggest that repeated relevant checking under ecologically valid conditions may produce very small but signi ficant declines in memory accuracy. Thought-action fusion: a review - Shafran (2004) Introduction Likelihood TAF - the belief that having an unacceptable intrusive thought increases the likelihood that a specific adverse event will occur. Likelihood-Self TAF - likelihood TAF regarding self-relevant events (e.g. If I think about falling ill, it makes it more likely that I will become ill ). Likelihood-Other TAF - likelihood TAF regarding events concerning others (e.g. If I think about someone else falling ill, it makes it more likely that they will become ill). Moral TAF - the belief that having an intrusive thought is the moral equivalent of carrying out that particular act (e.g. If I think about swearing in Church, this is almost as bad as actually swearing in Church). Origins TAF has been found to be related to obsessions and it is measured using the specially developed TAF scale. Psychopathology Page 8 TAF has been found to be related to obsessions and it is measured using the specially developed TAF scale. Question 1: How has TAF been assessed? TAF has been measured with a self-report questionnaire (TAF scale) and this has led to the discovery of the 2 factors (likelihood & moral TAF) in clinical samp les. TAF can also be induced experimentally with a sentence paradigm, in which the following instructions are given: Keeping in mind a friend or relative who is close to you (pause), I would like you to write out the following sentence on this piece of paper inserting the name of the person in the blank. Participants are then given a blank piece of paper, a pen and the typed sentence: I hope _____ is in a car accident. After copying the sentence with the name of a friend/relative in the blank, participants are instructed to close their eyes a nd think about the situation for a few seconds. The sentence paradigm elicits anxiety, discomfort and the urge to neutralize, which is considered to reflect the operation of TAF. Study: the correlation between formerly reported Likelihood-TAF (with the TAF scale) and estimates of probability of the adverse event described in the sentence occurring within the next 24 hours was significantly correlated (r = 0.6). However, this effect has only been shown in samples high on TAF. Question 2: Where does TAF fit within current cognitive models? TAF has been regarded as an example of excessive responsibility for harm that interacts with intrusive thoughts. Even though attaching significance to intrusive thoughts has been thought of as a separate construct, it is entangled with in flated responsibility. For example, a person is likely to believe that he has contributed to the cause of a negative event if he believes that the l ikelihood of that negative event occurring is increased just because he thought of it. In this case, TAF is an internal trigger for appraisals of responsibility for harm. In more recent cognitive models, TAF is just one condition (neither necessary nor sufficient) for interpreting intrusive thou ghts in a catastrophic way, which is a hallmark of OCD. Question 3: What is the relationship between TAF and obsessional complaints? Likelihood TAF is significantly related to obsessional psychopathology. Moral TAF is also related to obsessions, but only in clinical samples. Moral TAF tends to be more related to depression than to OCD. Moral TAF has been found to correlate with religiosity. This may not indicate pathology. The authors hypothesize that in combination with depression, moral TAF becomes more dysfunctional. Specificity Even though there are significant differences in Likelihood-Other between students and people with obsessional symptoms, there aren't such for Moral TAF and Likelihood-Self. These findings are consistent with the idea that Likelihood-Other is indicative of psychopathology in OCD. Likelihood TAF is not specific to OCD - it also occurs in anxiety disorders and depression. Moral TAF has been found not to differ between OCD, GAD, panic disorder, major depressive disorder and social anxiety disorde r. This is consistent with the idea that moral TAF is not necessarily associated with psychopathology - many people are "superstitious." TAF has been found to be particularly prominent in anorexia nervosa. Question 4: What are the components of TAF? In clinical samples, the optimal factor structure is a 2-factor structure (Likelihood & Moral), while in non-clinical samples, a 3-factor structure (Likelihood-Self, Likelihood-Other & Moral) is optimal. Question 5: Is TAF confined to negative unwanted thoughts, or does the belief extend to positive, even desired outcomes? There is evidence that obsessional symptoms are related to harm avoidance (e.g. If I think of a relative/friend being able to avoid a car accident, this increases the chance that they will be able to avoid it). Therefore, avoiding harm may also be a form of TAF. Many people with GAD report believing that worrying prevents harm, which may indicate prevalence of this specific type of TAF in GAD. The authors don't mention any evidence for positive TAF (i.e. believing that positive thoughts increase the likelihood of spe cific, positive outcomes), but they argue that it clinically, it is unusual for OCD patients to believe that. Question 6: Evidence that TAF plays a role in the etiology and maintenance of OCD and treatment implications Psychopathology Page 9 The evidence so far is insufficient to show whether TAF plays a role in the maintenance of OCD due to high reliance on non -clinical samples. Implications of TAF for treatment There is evidence that TAF decreases with successful OCD treatment, even if it is not specifically addressed. This suggests that TAF may only need to be addressed in cases which prove to be resistant to standard interventions. Strategies for reducing TAF exist but have not been evaluated yet. Psychopathology Page 10