1. Frederick Aardema 1,2 , Jean-Sebastien Audet 1,2 & Richard Moulding 3
Contextual determinants of abnormal intrusive cognitions in obsessive-compulsive disorder
Frederick Aardema 1,2 , Jean-Sebastien Audet 1,2 & Richard Moulding 3
1 University of Montreal, Canada
2 Institut universitaire en santé mentale de Montréal
3 Deakin University, Burwood, Australia
28th Annual Convention APS, Chicago, May, 2016

2. Obsessive Compulsive Disorder (OCD)
Characterized by recurrent and persistent thoughts, urges, or images that are experienced as intrusive and inappropriate, and that cause marked anxiety and distress (American Psychiatric Association [APA], 2013).
Common subtypes of OCD include those with intrusions about contamination, checking, symmetry, rituals and repugnant obsessions.
“.....horrific repulsive debilitating violent thoughts of suffocating, stabbing, dismembering, shooting, raping, etc....you imagine it, I've thought it. My thoughts mostly surround those who I hold near & dear to my heart which pains me the most.”

3. Definition of Ego-dystonicity
“…a thought that is perceived as having little or no context within one’s own sense of self or personality. That is, the thought is perceived, at least initially, as occurring outside the context of one’s morals, attitudes, beliefs, preferences, past behavior and/or one’s expectations about the kinds of thoughts one would or should experience…” (Purdon et al., 2007)

4. The role of ego-dystonicity in OCD
Repugnant thoughts recognized by the person as ego-dystonic may result in attempts by the individual to understand their meaning and lead to over-interpretation of the thought, subsequently giving rise to distress and attempts to neutralize the thought. (Rachman, 1997, 1998, 2006)
Ego-dystonic thoughts that run contrary to the person’s self-view, they are more likely to be interpreted as significant and threatening (Clark, 2004; Purdon & Clark, 1999).
Yet, ego-dystonicity is not strongly related to symptoms of OCD.
Also, a significant portion of OCD patients experience ego-syntonic obsessions – the opposite of ego-dystonicity (i.e. the obsession is experienced as reasonable and realistic.)

5. The (lack of) reality of obsessions
Obsessions are discordant with reality whether or not they are experienced as ego-dystonic or ego-syntonic . They are false representations of reality independent from personal experience or evaluation (Aardema & O’Connor, 2007).
The person with OCD does not react "... to what is there, and not even to the exaggerated consequences of what is there, but to what might possibly be there even though the person's senses say otherwise" (O'Connor & Robillard, 1995, p. 889).

6. Inferential confusion
Inferential confusion is a reasoning process characterized by a tendency to arrive obsessional conclusions (inferences) about reality (or the self) on a completely subjective basis, or even despite evidence to the contrary in the here-and-now (Aardema, et al., 2010; O`Connor & Aardema, 2003).
In other words, intrusions in the normal population occur with direct evidence for their potential reality, while obsessions as seen in OCD occur without such direct evidence.
Intrusions of OCD participants (i.e. obsessions) are more indirectly linked to observations in the here and now (Julien et al., 2009).

7. Aim and hypotheses
To investigate whether evidence for the potential reality of an intrusion and ego-dystonicity are relevant determinants of normal and abnormal intrusive thoughts in a non-clinical population.
Lack of evidence for the reality of an intrusion and ego-dystonicity are related, but partially independent constructs.
Lack of evidence for the reality of the intrusion would be significantly related to self-reported levels of inferential confusion and OCD symptoms
Ego-dystonicity would be positively related to obsessive belief domains and OCD symptoms;
Expert clinicians would be able to adequately identify intrusions associated with higher levels of OCD symptoms when taking into account the context in which the intrusion occurred.

8. Method
Participants English speaking undergraduate students (210 females, 38 males). Mean age of years (SD = 5.01).
Questionnaires
Vancouver Obsessional Compulsive Inventory (Thordarson et al., 2004)
Ego Dystonicity Questionnaire (Purdon et al, 2007)
Inferential Confusion Questionnaire – Expanded Version (Aardema et al., 2009)
Obsessive Beliefs Questionnaire (TRIP version)- (Moulding et al., 2011).

9. Measuring intrusions and context of occurrence
Participants were asked to report an intrusive cognition they had experienced and to describe the context surrounding its occurrence with the following questions:
1) “What caused these thoughts to occur when they started?” and 2) “Why do you think these thoughts keep coming back?”

10. Examples of Participant’s Reports

11. Expert Clinicians rated the following dimensions
1) Content (i.e., repugnant thoughts and impulses, checking, contamination and other),
2) Ego-dystonicity (Experienced as Egodystonic vs. Experienced as Ego-syntonic),
3) Evidence (With direct evidence vs. No direct evidence), and
4) OCD-Relevancy (OCD relevant vs. Non-OCD relevant).

12. Evidence for the Potential Reality of the Intrusion
The phrase “`without direct evidence” refers to the occurrence of the intrusion without any direct evidence for the potential reality of the intrusion. For example, if a person experiences an intrusive thought about the door being unlocked without actually having evidence from the senses that it is unlocked, then it is said to occur “without direct evidence”. Likewise, if a person experiences a thought about harm towards another person without actually being in an angry frame of mind, then this would also indicate that the thought occurred “without direct evidence”.
 The phrase “`with direct evidence” refers to the occurrence of the intrusion with direct evidence for the potential reality of the intrusion. For example, if a person experiences an intrusive thought about the door being unlocked occurs after hearing a strange sound while locking it, then this would indicate the thought occurred “with direct evidence”. Likewise, if a thought about hitting someone occurs when the person is angry, then this would be considered to occur “with direct evidence”.

13. Clinician’s ratings on Content: Frequencies and Average % Agreement

14. Clinician’s ratings on Ego-dystonicity: Frequencies and Average % Agreement

15. Clinician’s ratings on Evidence: Frequencies and Average % Agreement

16. Clinician’s ratings on OCD-Relevancy: Frequencies and Average % Agreement

17. Relationship between Ego-dystonicity and Evidence

18. Relationship of clinician’s ratings on evidence and ego-dystonicity with OCD symptoms and related variables

19. Relationship of clinician’s ratings on OCD relevancy with OCD symptoms and related variables

20. Conclusion
The construct of (lack of) evidence for the intrusion is partially independent from one’s personal experience of the thought (i.e. ego-dystonicity) - representing a type of “objective discordance” between the obsession and reality that cuts across both ego-dystonic and ego-syntonic obsessions.
Lack of evidence for the potential reality of the intrusion might be a stronger indicator of obsessionality than whether or not a thought is experienced as ego-dystonic or ego-syntonic perse.
Lack of evidence for intrusive thoughts may be a source of threat itself where the person starts to question and interact with the thought, trying to find evidence for the thought, even though no such evidence exists.

21. Conclusion
Clinicians were able to identify whether or not an intrusive thought was potentially indicative of OCD.
So while ordinarily clinicians are unable to distinguish between the content of intrusions in non-clinical and clinical populations, they are able to do so when information surrounding the context of the intrusion is provided.
These decisions seemed to be guided to a considerable degree by whether or not the intrusion occurred without evidence.

22. Limitations
Non-clinical sample. Study requires replication directly comparing non-clinical and OCD participants on (lack of) evidence for the potential reality of the intrusion.
Clinicians had the most difficulty assessing ego-dystonicity potentially introducing type II errors although their assessment was strongly related to self report levels of ego-dystonicity.
The construct of “intrusions occurring without direct evidence” requires further validation and elaboration.

23. Clinical Implications
Even though the content of the intrusions and obsessions may be very similar, normal intrusions appear to be more reality based than obsessions.
Educating OCD patients to rely more on reality based criteria during reasoning might help them to easier dismiss their obsessions as unrealistic.
For example, Inference Based Therapy for OCD identifies triggers and the reasoning associated with these triggers that lead people to experience obsessions without direct evidence in the here-and-now. (O`Connor et al, 2005 Aardema et al. 2016)

24. Thank you Email: frederick.aardema@umontreal.ca
Article reprints are available after the symposium.