Disclosure of Negative Intrusions: The

Relationship with Thought-Action Fusion,

Shame, Guilt and Fear

Kaighley Wells-Britton

Submitted for the degree of

Doctor of Psychology (Clinical Psychology)

School of PsychologyFaculty of Health and Medical Sciences

University of SurreyUnited KingdomSeptember 2017

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Statement of Originality

This thesis and the work to which it refers are the results of my own efforts. Any ideas, data, images, or text resulting from the work of others (whether published or unpublished) are fully identified as such within the work and attributed to their originator in the text. This thesis has not been submitted in whole or in part for any other academic degree or professional qualification.

Name: Kaighley Wells-Britton

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Overview

The notion that unwanted negative intrusions are commonplace in the general

population is central to the cognitive model of OCD. This model suggests that

obsessionality arises from maladaptive beliefs (e.g. thought-action fusion (TAF))

applied to ‘normal’ intrusions. Intrusions are associated with negative affect in that

their content can induce fear, shame and guilt especially when individuals ‘fuse’ with

these intrusions believing that they reflect something fundamentally bad about their

core identity. This belief can reduce willingness to disclose for fear of others ‘finding

out’ about their immoral character. This thesis explored the phenomenology of

intrusive thoughts and assessed the relationship between maladaptive beliefs,

negative affect, and disclosure of intrusions in a non-clinical general population

sample. Part one of this portfolio presents a narrative review of the form, frequency,

content and distress associated with non-clinical intrusions and discusses

comparability with clinical obsessions. The findings of the review suggested that

intrusions are highly prevalent in the non-clinical population and are generally

similar to clinical obsessions, however the frequency with which obsessions are

experienced is significantly greater than non-clinical intrusions. Part two presents an

empirical paper that investigated the relationship between maladaptive beliefs (TAF-

moral), anticipated affective response to negative intrusions, and anticipated

disclosure of intrusions in a non-clinical general population sample. Findings

suggested a strong positive relationship between TAF-Moral beliefs and anticipated

negative affect from experiencing negative intrusions. More highly unacceptable

intrusions and TAF-Moral beliefs were associated with lower likelihood of

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disclosure whereas, interestingly, negative affect predicted increased likelihood of

disclosure.

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Contents

Acknowledgements………………………………………………… 6

Research Part 1: Literature Review………………………………….7

Appendix to the Literature Review………………….………………56

Research Part 2: Empirical Paper……………………………………57

Appendices to the Empirical Paper………………………………….96

Part 3: Summary of Clinical Experience…………………………… 122

Part 4: Table of Assessments Completed During Training………… 124

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Acknowledgements

Primarily I thank Dr Laura Simonds, my research supervisor. I consider myself

incredibly lucky to have been in receipt of her support, empathy, patience, time and

wealth of knowledge that she has kindly shared with me.

I would also like to thank my PPD group colleagues whom I have built a strong and

supportive friendship with over the past three years. They have contributed

immensely towards my research learning.

Last but by no means least, I thank my wonderful husband and family for looking

after me and showing pride in me during both stressful and successful times. Without

them I would not have been able to create this thesis and pursue my dream career.

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Research Part 1: Literature Review with Appendix

Is the form, content, frequency and distress associated with non-clinical intrusions similar to clinical

obsessions?

Word count : 7688

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Abstract

Background and aim: The comparability of non-clinical intrusions and clinical

obsessions is central to the cognitive model of obsessions. Due to contrary findings

about this an up to date review of the literature describing the form, content,

frequency and distress associated with non-clinical intrusions was conducted to

assess evidence for their comparability with clinical obsessions.

Method: A systematic literature search yielded nineteen eligible papers whose aim

was to describe the phenomenology of non-clinical intrusions. Data were extracted

and grouped by common theme for analysis.

Results: Intrusions are commonplace in the non-clinical population and are global

phenomena that are observed across different countries internationally. The content

of intrusions was comparable amongst clinical and non-clinical samples with the

exception of aggressive type intrusions which were less common in non-clinical

samples. The overall frequency at which intrusions were experienced was

significantly greater in OCD samples. The majority of intrusions took the form of

thoughts or a combination of thoughts, images and impulses and distress was in some

cases associated with intrusion frequency and, in others, with the specific content of

thoughts.

Conclusion: The findings suggest that non-clinical intrusions are generally

comparable with clinical obsessions. However further research is required to

understand why certain intrusions are less reported in the non-clinical population and

to explore the factors associated with distress in response to intrusions. Limitations

and recommendations are discussed.

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1.0 Introduction

Intrusions or intrusive thoughts are negative unwanted thoughts, images or urges

which present involuntarily into a person’s mind (Rachman, 1997). The repeated

presence of an intrusion into one’s mind is referred to as an obsession (NICE, 2005).

Obsessions are commonly associated with the mental health diagnosis of Obsessive

Compulsive Disorder (OCD).

The cognitive model of the development of obsessions is underpinned by the

concept that intrusions are on a continuum of ‘normal’ experience (Salkovskis,

1985); that is, that people in the general population experience intrusions similar to

those in the clinical population. These ‘normal’ intrusions, when associated with

maladaptive appraisals and beliefs, develop into obsessions (Rachman, 1997). In the

cognitive-behavioural model, biased appraisals and maladaptive beliefs (Salkovskis,

1985, 1989) are said to mediate distress associated with intrusions – those that are

appraised as indicating imminent harm or blame, for example, provoke anxiety and

other negative affect such as shame and guilt. Within OCD, compulsions are

repetitive overt or covert behaviours or mental acts that the person feels compelled to

perform in order to neutralise the obsession and associated distress (NICE, 2005).

The Obsessive Compulsive Cognitions Working Group (1997) summarised a

number of maladaptive appraisals and beliefs associated with OCD. These include

inflated responsibility, over-importance of thoughts (e.g. thought-action fusion),

beliefs that one’s thoughts are controllable, overestimation of threat, intolerance of

uncertainty, perfectionism and fixity of beliefs. In essence, in the cognitive model it

is proposed that the misinterpretation of intrusive thoughts, images or urges as being

highly significant catalyses the transition from ‘normal’ intrusion to tormenting

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obsession. It is further proposed that only when these misinterpretations are

diminished will distress from obsessions reduce (Rachman, 1997).

The seminal paper by Rachman and de Silva (1978) investigated the nature

and similarity of normal and abnormal obsessions. Within the paper ‘normal’

referred to intrusive thoughts in a non-clinical sample whilst ‘abnormal’ referred to

obsessions in clinically referred OCD patients. Rachman and de Silva examined

whether non-clinical individuals experience obsessions similar to those in the clinical

population. They concluded that normal obsessions are similar to abnormal

obsessions in form and content; however, they argued that the frequency, intensity

and subsequent distress are notably distinguishable. An easily obtained non-clinical

sample (N=124) were recruited for their study. An overwhelming number of non-

clinical participants reported experiencing intrusive unacceptable thoughts and

impulses (N=99). Rachman and de Silva did not investigate why some of the sample

(N=25) did not experience any intrusions whatsoever; however, some (N=5)

informally commented that they did experience intrusions but did not view these as

unacceptable. The researchers found that obsessional thoughts were more common

than impulses in the non-clinical sample and that both thoughts and impulses were

easily dismissed by the non-clinical sample.

In a second study, 40 non-clinical and 8 clinical participants reported the

content of their obsessions. Rachman and de Silva concluded that the content was

somewhat similar in the two samples. As part of the study six judges (five

psychologists and a psychiatric nurse) sorted these obsessions into whether they

deemed that they were reported by patients (abnormal obsessions) or non-patients

(normal obsessions). The researchers concluded that judges were not very successful

at identifying clinical obsessions and were moderately successful at identifying

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normal obsessions and tentatively stated that ‘abnormal’ obsessions are not distinct

from ‘normal’ obsessions.

Three decades later, Rassin and Muris (2007) challenged Rachman and de

Silva’s findings and suggested subsequent researchers, themselves included, had

over-interpreted their findings. Initially, Rassin and Muris re-analysed the data from

Rachman and de Silva’s second study. Using sensitivity analysis they concluded that

expert practitioners in Rachman and de Silva’s study were more able to identify

normal obsessions (significantly better than chance) than abnormal obsessions (not

significantly better than chance). In this respect, they supported Rachman and de

Silva’s assertion. In a follow up to this re-analysis, Rassin and Muris took a sample

of both experienced psychotherapists (N=11) and undergraduate psychology students

(N=90) and asked them to categorise the clinical and non-clinical obsessions from

Rachman and de Silva’s study into ‘normal’ and ‘abnormal’ obsessions. Findings

indicated that the student sample were as successful as the psychotherapist sample at

categorising normal and abnormal obsessions. Additionally, Rassin and Muris’

psychotherapist and student samples combined were more able than Rachman and de

Silva’s experienced clinician sample to correctly identify differences in the content

of obsessions between clinical and non-clinical individuals. Therefore, whilst

Rachman and de Silva concluded that normal and abnormal obsessions were

indistinguishable, Rassin and Muris concluded the contrary, although they

acknowledge that it might only be the content of some clinical obsessions that makes

them diagnostically distinguishable from normal obsessions because identification

performance was closer to 50% (i.e. chance level) than 100% in both groups.

The Rassin and Muris paper details the percentage of their sample (n=101)

who correctly classified each obsession. Interestingly through visual inspection of the

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content of the ‘normal’ obsessions, those that might be construed as more

unacceptable and repugnant were least likely to be categorised as ‘normal’. For

instance, ‘harm to small children’ was classified as a ‘normal’ obsession by only 3%

of participants; ‘to violently attack and kill a dog’ by only 2% and ‘to sexually

assault a woman’ by only 1%.

Similarly, a greater number of the sample correctly categorised the

‘abnormal’ obsessions that were more unacceptable and repugnant. ‘To strangle

children and sometimes adults’ was correctly categorised as ‘abnormal’ by 96% of

participants; ‘to attack or strangle cats’ by as many as 97% and 100% of the sample

correctly categorised ‘to harm children with physical violence’ as ‘abnormal’. This is

an interesting finding as it highlights that it is possible that the sample of both

experienced clinicians and students in the general population have a perception that

more unacceptable and repugnant obsessions are abnormal and that when a ‘normal’

obsession is more extreme, judges have more difficulty identifying it as a ‘normal’

obsession. Furthermore, some of the ‘abnormal’ obsessions had low classification

accuracy, for instance, ‘my eyes are or will be harmed’ was correctly classified as

‘abnormal’ by 34.7% of the sample and ‘to utter swear words’ was correctly

classified by only 20.8% of the sample. Interestingly, one would assume that the

‘abnormal’ obsession ‘to look at the buttocks of boys and youths’ would be one that

is more unacceptable and hence categorised as ‘abnormal’ but was only correctly

categorised as such by 13.9% of the sample. This highlights some difference within

the categorising in Rassin and Muris’ study. There are likely both normal and

abnormal obsessions that will be incorrectly classified due to expectations about how

unacceptable or unusual a thought needs to be to be considered ‘abnormal’.

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Given the central importance of the comparability of non-clinical intrusions

and clinical obsessions to the cognitive model of obsessions, and in light of the

contrary findings within the above papers, an up to date consideration of the

phenomenology of non-clinical intrusions is required in order to assess evidence for

their comparability with clinical obsessions. Rassin and Muris note that

substantiating this is important because it suggests that obsessions are not clinical

phenomena per se (it is how they are evaluated/appraised that is important) and that

assessing comparability between normal and abnormal obsessions has implications

for the validity of analogue samples in OCD research. The review therefore aimed to

investigate whether the form, content, frequency and distress associated with non-

clinical intrusions are similar to clinical obsessions.

2.0 Method

2.1 Database search strategy

To conduct the literature search, a number of databases, search terms and

inclusion/exclusion criteria were established. These are presented in Table 1. Once

these criteria were established, a systematic search of the databases was conducted in

March 2017 using the search terms outlined in Table 1. Other limiting parameters

were used during database searching (e.g. peer-reviewed articles published in

English). To be eligible for inclusion, studies needed to have explored

intrusions/obsessions in a non-clinical sample with the explicit aim of considering

their comparability with clinical obsessions, or to have compared clinical and non-

clinical groups on intrusion/obsession phenomenology.

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Table 1 – Databases, terms and inclusion/exclusion criteria used for literature

search.

Databases Search terms Inclusion criteria Exclusion criteria

Medline

Psychology and Behavioural Sciences Collection

PsycINFO

PsycARTICLES

Non-Clinical Obsessions

OR

Non-Clinical Intrusions

OR

Normal Obsessions

OR

Normal Intrusions

English language

Peer reviewed articles

Any age

Quantitative or Qualitative

Intrusions/Obsessions in non-clinical population or compares clinical and non-clinical populations

Articles not in English language

Articles in which full text is inaccessible

Dissertations

Articles that do not include non-clinical population

2.2 Additional search strategy

To identify additional papers that might not have been identified through database

searches, the seminal paper by Rachman and de Silva (1978) was entered into a

Google Scholar search. This allowed use of Google Scholar’s ‘cited by’ function.

Selecting this function produced 15 papers citing Rachman and de Silva.

Additionally, a hand search of the reference lists of papers shortlisted was conducted

for any further potentially eligible studies. In all cases, those papers that described

the phenomenology of non-clinical intrusions and/or compared clinical and non-

clinical intrusions with the aim to describe the differences and similarities between

these were considered eligible for inclusion. The search and selection process

flowchart is show in Figure 1.

The initial database and Google Scholar ‘cited by’ search produced 128

papers. Duplicates and papers considered irrelevant based on title and abstract

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screening were excluded (n=79). The full text of the remaining 49 papers was

screened for suitability. Of these, 31 were excluded as they were theoretical papers or

the focus was not on the content, form, frequency or distress associated with

intrusions in non-clinical samples. An additional paper was identified from reference

list hand searching. The total number of eligible papers included was 19.

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Figure 1 – Flowchart indicating process of selection of papers for sample.

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Potentially eligible papers (N = 128)

Papers obtained from reference lists of potentially eligible papers (N=1)

Full text papers assessed for eligibility (N = 49)

Exclusion of duplicate papers/ irrelevant based on title and abstract (N = 79)

Potentially eligible papers identified through databases: PsycINFO; PsycARTICLES; Medline and Psychology and Behavioural Sciences Collection.

Using the terms: non-clinical obsessions OR non-clinical intrusions OR normal obsessions OR normal intrusions

(N = 113)

Potentially eligible papers that cited Rachman and de Silva (1978) identified through Google Scholar

(N = 15)

Final sample of papers included in the review (N = 19)

Excluded based on full text – did not meet criteria (N = 31):

Papers whose focus was not on the content, form, frequency or distress associated with intrusions or that were theoretical

2.3 Data extraction

Data from the final sample of papers was extracted into an Excel file. The focus of

the extraction was principally on the form, content, frequency and distress arising

from intrusions/obsessions. However, additional features considered relevant to

phenomenological comparison between clinical and non-clinical

intrusions/obsessions were also extracted. A quality appraisal checklist developed by

NICE (2012) based on the Graphic Appraisal Tool for Epidemiological studies

(GATE) frame (Jackson, Ameratunga, Broad, Connor, Lethaby, Robb and Heneghan,

2006) was used as a guideline for critical appraisal of the studies. A link to the

checklist is included in Appendix B.

3.0 Results

3.1 Papers included in the review

The nineteen papers included in the review comprised studies utilising either

questionnaire measures or questionnaires in combination with a structured interview.

Respondents were asked either to endorse predetermined lists of intrusions, or they

were asked to provide examples of intrusions and to rate them on associated features

such as frequency and distress. The analytic method in all studies was quantitative;

the studies utilising an interview to elicit information about intrusions experienced

used a structured format and open-ended responses were converted into numeric

data. For example, raters would classify the intrusions reported by participants into

different content categories and the frequency of intrusions in each category would

be calculated. All of the studies recruited non-clinical samples. Two recruited both

non-clinical samples and clinical OCD samples, and two recruited non-clinical

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samples, clinical OCD samples, depressed and/or non-OCD anxious samples. All

studies but one (Crye et al., 2010) recruited adult samples and mostly comprised

undergraduate students. Table 2 details a summary of each of the papers included

within the review.

3.2 Findings

Findings were extracted from each of the papers and grouped according to similar

themes. The summaries of these themes are detailed in Table 3.

3.2.1 Theme 1: The prevalence of non-clinical intrusions

All studies reported the experience of intrusive thoughts within their samples. In two

separate studies, Purdon and Clark (1993; 1994(b)) found that between 97% and 99%

of non-clinical participants endorsed the experience of at least one intrusive thought

or impulse. Similarly high prevalence was reported in Belloch et al (2004; 99.4%)

and Niler and Beck (1989; 99%). Parkinson and Rachman (1981) reported that 96%

of their sample experienced intrusions with 682 classifiable intrusive

thoughts/images and or impulses reported. Radomsky et al (2014) reported 94.3% of

respondents experienced intrusive thoughts within their cross-cultural sample

(N=777) with as many as 100% of people in two of their North American and Tehran

samples reporting intrusions.

Relatively fewer participants reported intrusions in the studies by Salkovskis

and Harrison (1984; 88.2%); Edwards and Dickerson (1988; 83%); and O’Neill et al

(2009; 75%). Amongst a non-referred adolescent sample Crye et al (2010) found an

obsession prevalence rate of 77%. Fourty-eight participants reported having

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experienced at least one obsession with a total of 146 obsessions being reported by

62 adolescents.

Morillo et al (2007) asked how many of 52 predetermined ‘obsessional

intrusive thoughts’ participants experienced. Non-clinical participants experienced

fewer (M=12.83 (SD=8.87) than the three clinical comparison groups: non-obsessive

anxiety group (M=17.92 (SD=10.54), OCD group (M=17.8 (SD=10.77), and

depressed group (M=15 (7.27).

In a sample of 117 parents, 76 (approx. 64%) reported the experience of

intrusive thoughts as judged by the researchers in Abramowitz et al’s (2003) study.

However, Abramowitz et al. asked parents about the experience of intrusive thoughts

related to their children. Lower occurrence of intrusions might reflect greater

reluctance or fear regarding reporting such intrusions. Substantially fewer obsessions

were reported by participants in Rassin et al’s (2007) study with only 29.1%

endorsing normal obsessions and 12.2% endorsing abnormal obsessions. Further, in

O’Neill et al’s (2009) incarcerated sample only 28% endorsed the experience of

intrusive thoughts or impulses.

Variability in occurrence of intrusions across studies may be explained by

variability in measures used. Whilst all studies provided participants with a definition

of intrusive thoughts or obsessions, some studies used structured instruments that

gave examples of intrusions. The most common instruments used were the Revised

Obsessive Intrusions Inventory (ROII; Purdon and Clark, 1994b) comprising 52

items, and the International Intrusive Thoughts Interview Schedule (IITIS; RCIF,

2007) comprising 101 items. The time period reference for these measures varied

with the ROII mostly having a time frame of ‘ever experienced’ whereas the IITIS

typically asked participants to recall the past three months. Additionally, some

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studies developed lists of intrusions for purpose of the study (e.g. Niler & Beck,

1989, generated 60 example intrusions) or used lists based on those reported in

Rachman and de Silva’s seminal paper (e.g. Rassin et al., 2007; Salkovskis &

Harrison, 1984; Reynolds & Salvokskis, 1991). In these studies, the time reference

point was not always clear. Therefore, prevalence estimates might vary as a function

of the number of items included as well as the time reference. In contrast, other

studies provided a definition of intrusive thoughts but asked participants to generate

examples of their own experience. This less structured approach might result in

fewer reported intrusions especially if participants are uncertain about the definition

of an intrusion.

3.2.2 Theme 2: The form of non-clinical intrusions

Some of the reviewed papers identified different forms in which intrusions occur.

These included thoughts, images, impulses/ urges or a combination of all three. The

studies that compared clinical vs. non-clinical participants did not compare form.

Salkovskis and Harrison’s (1984) adult student sample experienced a

combination of thoughts and impulses (N=86) which were more frequent than

thoughts (N=69) and impulses (N=2) alone. Similarly thoughts, impulses and images

combined were the most common forms of intrusion for Edwards and Dickerson’s

(1988) adult sample (43.8%). In contrast, only a minority of Crye et al’s (2010)

adolescent sample (15%) reported a combination of intrusion forms with the most

common experience of intrusions being in the form of impulses (45%). However,

there were contrasting statistics across studies in relation to the occurrence of

combined forms of intrusions in adult samples. Only a quarter of O’Neill et al’s

(2009) sample of inmates and non-incarcerated students reported experiencing a

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combination of intrusion forms with the majority reporting either thoughts/images

alone (55%) or impulses/urges alone (20%). Similarly, only 35% of Parkinson and

Rachman’s (1981) adult opportunity sample reported experiencing a combination of

intrusion forms. Intrusive thoughts/images alone were experienced by 55%. Far

fewer reported impulses alone (9%). Similarly, Niler and Beck’s (1989) adult sample

endorsed a significantly greater number of thoughts than impulses (t(72) = 8.77, P <

0.0001).

As for thought frequency, variation in frequency of different intrusion types

might reflect variation in methods for enquiring about the experience of intrusions.

One notable finding seems to be the higher occurrence of impulses in the adolescent

sample compared to the adult samples. However, only one study with adolescent

samples was identified which limits the conclusions that can be drawn.

3.2.3 Theme 3: The frequency of non-clinical intrusions

The frequency of reported intrusions differed greatly in the studies reviewed. The

majority of Crye et al’s (2010) adolescent participants experienced their most

frequent obsession more than 10 times a week (42%) or 10 times a month (17%) with

a further 10% experiencing it more than ten times a day. The majority of the student

and inmate samples (64% combined) in O’Neill et al’s (2009) experienced intrusions

less frequently than 10 or more times a month. The sample in Reynolds and

Salkovskis (1991) study reported a mean frequency of unpleasant thoughts per month

as M=2.04 (SD=1.1). Purdon and Clark (1994b) reported that the frequency of

participants’ most upsetting thought ranged from a few times a year to once or twice

a month (M=2.21, SD=1.4). Niler and Beck (1989) separated thoughts and impulses

experienced by participants and found that there was no significant difference with

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respect to frequency of occurrence per month (t(73) = - 1.46, P > 0.05). Similar to

O’Neill et al., Salkovskis and Harrison (1984) found the frequency of intrusions was

most often less than 10 or more times a month (37%). Notably though, a substantial

proportion reported frequency as 10 or more times a week/a month (both 28%).

Some of the studies compared frequency of intrusions in non-clinical

participants with clinical groups or by level of obsessionality. Bouvard et al (2016)

found that the OCD patients in their sample rated the frequency of their intrusions as

significantly greater (M=4.07 (SD=0.71)) than non-clinical participants (M=2.64

(1.12)) F=32.1, p<0.0001) as did Morillo et al (2007; f(3,107) = 20.74, p<0.001) with

non-clinical participants in the latter study experiencing intrusions less frequently

compared to participants with OCD, as well as anxious and depressed groups of

participants. When non-clinical participants were grouped by level of obsessionality

according to their Padua Inventory score, Purdon and Clark (1994a) found that the

frequency of intrusive thoughts was significantly greater in the higher obsessional

participants (M=2.6 (0.9), p<0001).

Differences in frequency according to intrusion theme were reported by some

authors. When comparing non-clinical and clinical groups, Garcia-Soriano et al

(2011) found that there was a significantly lower frequency of aggressive intrusions

(t (108)=2.87 p<0.001), doubts/checking intrusions (t(108)=3.45 p<0.001),

contamination intrusions (t(108)=6.09 p<0.001) and superstition intrusions

(t(108)=6.98 p<0.001) with large effect sizes and sexual/ religious/ immoral

intrusions (t(108)=2.20 p<0.01 with medium effect sizes in non-clinical participants

compared with OCD participants. Frequency of symmetry/ order intrusions were not

significantly different between samples. Similarly, Morillo et al (2007) found that

intrusion themes of aggression, doubts and contamination were significantly more

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frequent in their OCD group. Belloch et al. (2004) found that the most frequently

reported intrusive thoughts related to common everyday checking concerns such as

leaving the stove on or the home unlocked. However the frequencies were fairly low

overall. Sexual intrusive thoughts were least frequently reported by the non-clinical

sample within Clark et al’s (2014) study with the most frequently endorsed being

doubt related intrusive thoughts. Similarly, Purdon and Clark (1993) found that

sexual intrusive thoughts were least commonly endorsed by non-clinical participants

as were violence-related intrusions. However, men reported more frequent

sexual/aggressive intrusions than women whereas women reported more frequent dirt

and contamination related intrusions.

With regard to the form of intrusions, Niler and Beck (1989) found no

significant difference between thoughts and impulses with respect to the frequency of

occurrence per month (t(73) = - 1.46, P > 0.05).

Finally, when compared with positive intrusions, negative intrusions tended

to occur significantly less frequently (Edwards and Dickerson, 1988; Kendall’s Tau

= 0.227, P < 0.04).

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Table 2 – Summary of papers included within the review.

Paper Design Location Sample (N) ParticipantsAbramowitz et al (2003) Mailed survey United States 117 Mothers and fathers of young infants, non-clinicalAudet et al (2016) Online survey plus

clinician ratingsCanada 248 Undergraduate students, non-clinical

Belloch et al (2004) Survey Spain 336 Mostly students, non-clinicalBouvard et al (2016) Questionnaires plus

structured interviewFrance 56 OCD patients (n=28) and non-clinical participants

(n=28)Clark et al (2014) Survey plus structured

interviewArgentina, Australia, Canada, China, Greece, Iran, Israel, Sierra Leone, Spain, Turkey, United States

554 University students, non-clinical

Crye et al (2010) Survey plus semi-structured interview

United Kingdom 62 Adolescent school pupils aged between 12-14, non-clinical

Edwards & Dickerson (1988)

Survey Australia 98 Psychology students, non-clinical

Garcia-Soriano et al (2011)

Survey Spain 789 OCD patients (n=55) and non-clinical participants (n=734)

Morillo et al (2007) Survey Spain 108 OCD patients (n=31), depressed patients (n=22), anxious patients (n=25) and non-clinical participants (n=30)

Niler & Beck (1989) Survey United States 70 University students, non-clinicalO’Neill et al (2009) Survey plus structured

interviewCanada 165 University students (n=86) and Correctional Centre

inmates (n=79), non-clinicalParkinson & Rachman (1981)

Structured interview United Kingdom 60 Non-clinical opportunity sample

Purdon & Clark (1993) Survey Canada 293 Undergraduate psychology students, non-clinicalPurdon & Clark (1994a) Survey Canada 293 Undergraduate psychology students, non-clinicalPurdon & Clark (1994b) Survey Canada 159 Undergraduate psychology students, non-clinicalRadomsky et al (2014) Survey plus structured

interviewArgentina, Australia, Canada, China, France, Greece, Iran, Israel, Italy, Sierra Leone, Spain, Turkey, United States

777 University students, non-clinical

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Rassin et al (2007) Survey Holland 133 Undergraduate psychology students, non-clinicalReynolds & Salkovskis (1991)

Survey United Kingdom 169 Occupational Therapy and Nursing students, non-clinical

Salkovskis & Harrison (1984)

Survey United Kingdom 178 Undergraduate students (n=112) and student psychiatric nurses (n=75), non-clinical

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Table 3 – Summary of main findings of papers.

Paper Aim of study Finding 1 prevalence, form and frequency

Finding 2 content Finding 3 distress Finding 4 duration Finding 5 other findings

Abramowitz et al (2003)

To study phenomenology of parents’ intrusive obsessional thoughts about their young infants.

76 of 117 parents (53 mothers, 23 fathers) experienced intrusions about their young infant

Suffocation (44.6%), accidents (26.4%), intentional harm (21.5%), losing baby (6.6%), illness (2.5%), sexual (1.7%), contamination (0.8%).

Similar for both mothers and fathers.

Distress of intrusions (scale of 0 (none) – 4 (severe)) significantly greater for mothers (m=1.28 (SD 0.84)) than fathers (m=0.87 (SD 0.55)); t(74)=2.6, p<0.05

0 – ≥ 8 hr per day significantly greater for mothers (m=1.08 (SD 0.33)) than fathers (m=0.91 (SD 0.29)); t(74)=2.04, p<0.05

1 (extremely uncomfortable) – 5 (extremely comfortable) neither mothers (m=3.12 (SD 1.50) nor fathers (m=3.45 (SD 1.22) entirely comfortable disclosing intrusions

Audet et al (2016)

To investigate whether lack of evidence for the potential reality of the intrusion and ego-dystonicity are contextual determinants of unwanted intrusive thoughts and clinical obsessions.

Categorised as Unacceptable thoughts (46.4%), Checking (15.4%), Contamination (6.5%), Other (28.2%), Unable to estimate (1.2%). Rater average agreement only 81%

Ego-dystonic (32%), ego-systonic (61.9%), unable to estimate (6.1%). Rater average agreement only 55%

OCD relevant (32.4%), not OCD relevant (66.4%) unable to estimate (1.2%). Rater average agreement (72.3%)

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Paper Aim of study Finding 1 prevalence, form and frequency

Finding 2 content Finding 3 distress Finding 4 duration Finding 5 other findings

Belloch et al (2004)

To explore the presence in a normal population of intrusive thoughts analogous to obsessions; to analyse contents of the most habitual intrusive thoughts; explore relationships among the frequency of appearance of most upsetting thoughts and the unpleasantness caused by them.

99.4% at least one intrusive thought.

Most frequent: heat/stove on accident (m=1.64), home unlocked intruder (m=1.45) and everything away (m=1.40)

Least frequent: drive into window, hold up bank, fatally push friend, push family under train, stab family member, cut off finger, transmit fatal disease

Highest endorsed content: Heat/stove on accident, giving everything away, home unlocked, intruder, insulting stranger, jumping off high place, sex in public, catching STD, bumping into people, fly/blouse undone, insulting family

Self and hetero-aggression thoughts, sexual thoughts, and socially unacceptable behaviours significantly greater for men than women t=2.60; p<0.01

Most upsetting included: Jumping off a high place (10%); I left the heat, stove or lights on in the house/apartment which may cause a fire (9.7%); I left the door of the house/apartment unlocked and there is an intruder inside (7.6%); I am going to catch a sexually transmitted disease (STD) from touching a toilet seat or tap (6.7%), and, Having sex with a person who I would never want to have sex with (5.7%).

Bouvard et al (2016)

Compare unwanted intrusive thoughts reported in a group of patients with OCD and a non-clinical group.

All at least one intrusion, OCD more intrusive thoughts than non-clinical F(1,54) = 2.46 p=0.01.

Frequency greater in OCD (m=4.07 (.71)) than non-clinical (m=2.64 (1.12)) F=32.1, p<0.0001

Doubting intrusions greatest for non-clinical, contamination/dirt/ disease and doubting intrusions greatest for OCD patients.

Harm/injury/ aggression intrusions second greatest in non-clinical and third in OCD and similar number in both OCD and non-clinical

Doubt most distressing for OCD (n=11) and non-clinical participants (n=12) followed by contamination for OCD patients (n=10) and harm for non-clinical participants (n=5). Interfered more with daily life, were considered more important to get out of the mind, more difficult to stop than in non-clinical

Unacceptability/ ego-dystonicity higher in OCD group (m=2.17 (2.22)) than non-clinical group (m=1.50 (1.95))

27

Paper Aim of study Finding 1 prevalence, form and frequency

Finding 2 content Finding 3 distress Finding 4 duration Finding 5 other findings

Clark et al (2014)

To clarify the extent that different types of intrusive thoughts in non-clinical individuals are associated with obsessionality; the relative contribution of frequency, distress and control ratings to obsessionality and the extent that existing findings generalise to other countries in the world.

Greatest frequency was doubt intrusive thoughts followed by ‘other’ and lowest frequency was sexual intrusive thoughts

Dirt/contamination, doubt, and other/miscellaneous obsessions most significant variables for obsessionality

Intrusions of harm/ aggression, sex, and religion/immorality less common in non-clinical samples

Other/miscellaneous intrusions: repeated songs/ phrases, superstitious ideas or numbers, unwanted thoughts about death to self or others, and negative memories of arguments, conflict and the like

Crye et al (2010)

To estimate the prevalence of obsessions in a non-referred sample of young adolescents.

48 (77%) at least 1 obsession; 42% reported frequency of main obsession 10x a week.

Frequency: +10x day = 72.2 (6.6); +10x week = 62.3 (8.2); +10x month = 60.4 (9.3); and >10x month = 55.9 (7.9).

Impulses most common experience (46%)

Most common: harm coming to self or others, urge to check

N=44 reported intrusions of harm coming to self or someone else; 34 urge to check something; 27 thoughts about germs and dirt; urges of symmetry or exactness; 13 other and 8 repeating things

28

Paper Aim of study Finding 1 prevalence, form and frequency

Finding 2 content Finding 3 distress Finding 4 duration Finding 5 other findings

Edwards & Dickerson (1988)

To assess the characteristics of positive and negative intrusive thoughts in normal subjects.

83% participants had experienced unpleasant intrusions

Negative intrusions tended to occur less frequently than positive

Nearly half negative intrusions thoughts of violence or harm to self or others. 2nd most common thoughts about being physically ill or diseased.

Negative intrusions more likely to take form of thoughts alone

Negative intrusions were reported as being very brief, less than one minute.

Garcia-Soriano et al (2011)

Similarities and differences in obsessional intrusive thought content in clinical and non-clinical individuals.

OCD group (n=55) and matched non-clinical sample (n=55) significantly lower frequency of aggressive (t (108)=2.87 p<0.001), doubts/checking (t(108)=3.45 p<0.001), contamination (t(108)=6.09 p<0.001), superstition (t(108)=6.98 p<0.001) and sexual/ religious/ immoral (t(108)=2.20 p<0.01. Not significantly lower for symmetry/ order

Doubts chosen more frequently as most disturbing for non-clinical group (54%) than the OCD group (x² = 4.90, p=0.027) and contamination (24.5%) (x² = 4.76, p=0.029) and superstition (24.5%) (x² = 4.76, p=0.0279) more frequently for OCD group.

Aggressive, sexual and symmetry similar for clinical and non-clinical

Type II intrusions were more often selected as participants most disturbing in both OCD group (74.9%) and non-clinical group (74%)

29

Paper Aim of study Finding 1 prevalence, form and frequency

Finding 2 content Finding 3 distress Finding 4 duration Finding 5 other findings

Morillo et al (2007)

Compare clinical obsessions of subjects with OCD with the obsessional intrusive thoughts experienced by depressed patients, anxious patients and non-clinical individuals.

Similar number of OIT's in groups (OCD m=17.8 (10.77); DEP m=15 (7.27); AD 17.92 (10.54); NC m=12.83 (8.87), fewer in NC.

Aggressive thoughts and or impulses, doubts and contamination more frequent in OCD

Greater frequency in OCD f(3,107)=20.74 p<0.001. Least frequent in NC. Frequency of most upsetting obsession significantly greater for OCD group f(3,107)=52.15 p<0.001. Least frequent in NC

Aggressive thoughts, doubts and contamination significantly more frequent in OCD

Most upsetting obsession significantly greater unpleasantness for OCD group f(3,107)=19.18 p<0.001. Least unpleasant in NC.

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Paper Aim of study Finding 1 prevalence, form and frequency

Finding 2 content Finding 3 distress Finding 4 duration Finding 5 other findings

Niler & Beck (1989)

To shed light on the relationship in a normal population between trait anxiety and dysphoria to the frequency and ease of dismissability of intrusive thoughts and impulses; to examine association between guilt and obsessions with this nonclinical sample.

99% reported experiencing intrusive thoughts or impulses

No significant difference between thoughts and impulses with respect to frequency of occurrence per month (t(73) = - 1.46, P > 0.05).

the difficulty that one has in being able to dismiss intrusive thoughts is moderately correlated with their frequency of occurrence per month (r = 0.46, p< 0.0001)

Greater thoughts than impulses (t(72) = 8.77, P < 0.0001). Thoughts more difficult to dismiss than impulses (t(69) = 2.86, P < 0.01, difficulty dismissing intrusive thoughts is moderately correlated with variety of thoughts experienced (r = 0.29, P < 0.01).

Males endorsed 6.87 impulses (SD = 4.15), greater than average of 4.87 different impulses (SD = 3.88) endorsed by females (t(71) = 2.12, p<0.05).

Thoughts more distressing than impulses t(69) = 5.59, p<0.0001).

Distress, variety of thoughts and frequency per month 0.38 (p<0.001) and 0.28 (p<0.05) respectively. Correlation between the variety of thoughts and their frequency per month fairly high (r = 0.45, p<0.0001).

The difficulty in dismissing intrusive thoughts moderately correlated with distress that they elicit (r = 0.53, p<0.0001)

O’Neill et al (2009)

To examine intrusive thoughts and impulses in student and incarcerated sample.

53 (75%) students reported experiencing intrusive thoughts or impulses, 19 inmates. Majority of both samples frequency of 10+ month

62.9% students reported only intrusive thoughts or images, 18.6% reported only impulses or urges, 20% reported both. 25% reported absence of any.

28% inmates thoughts/ impulses, 13% only thoughts/ images and 9% reported only impulses/ urges, 6% both thoughts & impulses, 72% none.Harm thoughts & impulses most common

In student sample distress increased as intrusions became more frequent f(2,111)=5.7, p=0.005. No significant difference in inmate sample.

Higher psychopathic traits lower IT's x²(n=68) =4.7, p=0.03 and impulses x²(n=68)=7.5, p=0.007 significantly but only within inmate sample.

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Paper Aim of study Finding 1 prevalence, form and frequency

Finding 2 content Finding 3 distress Finding 4 duration Finding 5 other findings

Parkinson & Rachman (1981)

Gather information about the content, form, structure and functional characteristics of intrusive, unwanted thoughts, images and impulses.

58 experienced IT's

682 classifiable intrusive thought/image and or impulse reported by sample

Thoughts: highest- themes of death 18%, 2nd highest- harm coming to others. Impulses: themes of aggression, verbal or physical extremely common followed by disrupting peace inappropriate place etc. Images: mostly aggressive sexual themes.

Discomfort, unpleasantness and anxiety means greatest for a combination of thoughts, images and impulses followed by impulses, images and then thoughts.

Duration in months was most frequent for impulses (m=126.93 (83.13)) followed by thoughts (m=120.07 (100.33)) images (m=113.35 (77.94)) and a combination (m=103.52 (86.87))

Purdon & Clark (1993)

Investigate whether non-clinical individuals would report aggressive/ sexual/ disease intrusive thoughts; are obsessive thoughts different from depressive/ anxious/ panic-related thoughts and significant association between such thinking and OC tendencies.

99% endorsed IT's/impulses.

Women average of 7 intrusive thoughts, men average of 8.

Significant differences in OII score between men and women F(52,229) = 3.89, p<0.001

Thought intrusions involving self-doubt, reckless driving, impulsive sexual behaviour and less serious acts of verbal or physical aggression toward friends and family were reported by approximately half of the sample.

Violent, sexual, disease, contamination least endorsed.

Men higher on sexual/aggressive, women higher on dirt/contamination

Purdon & Clark (1994a)

To investigate subjects cognitive and emotional responses to their most upsetting intrusive thought, image or impulse.

Frequency of intrusive thoughts significantly greater in the higher obsessional participants (m=2.6 (0.9), p<0001)

Most common: “run car off road” (6%); “leaving the heat/ stove on” (10%); “sex with unacceptable person” (11%); “activity contrary to sexual preference” (8%) no sig difference men and women.

Unpleasantness of most upsetting intrusive thought was significantly greater for higher obsessional participants (m=2.5 (1.2) p<0.05)

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Paper Aim of study Finding 1 prevalence, form and frequency

Finding 2 content Finding 3 distress Finding 4 duration Finding 5 other findings

Purdon & Clark (1994b)

Examine relationship between tendency to experience obsessional intrusive thoughts and tendency to worry.

97% reported at least 1 IT. ROII mean 31.21 SD 27.14.

Frequency of most upsetting thought ranged from a few times a year to once or twice a month (m=2.21, SD=1.4)

Almost all of intrusions in ROII reported as most distressing IT 49/52

Radomsky et al (2014)

To assess the nature and prevalence of intrusions in non-clinical populations.

94.3% IT's with as many as 100% in some samples.

Doubting (m=3.47 (1.13)) most common. Religion/immorality (m=2.58 (1.09)) and sexual (m=2.69 (1.14)) least common

Most distressing intrusive thoughts were sexual (m=3.13 (1.31)) religious/immoral (m=2.62 (1.40)) followed by ‘other’ (m=2.59 (1.28)) and contamination (m=2.56 (1.26)). Least distressing was harm intrusions (m=2.18 (1.45))

Rassin et al (2007)

To investigate the similarities and differences between clinical and normal obsessions.

Sample endorsed 13.7 (29.1%) of normal obsessions and only 2.8 (12.2%) of abnormal. Difference was significant t(132)=19.6, p<0.001. No gender differences.

Abnormal obsessions correlated with OCD symptoms

Reynolds & Salkovskis (1991)

Replicate Niler and Beck’s (1989) results investigating guilt, dysphoria, anxiety and obsessions.

Frequency of unpleasant thoughts per month m=2.04 (1.1)

Frequency of thoughts per month and unpleasantness rating (distress), was r = 0.33, p<0.0002

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Paper Aim of study Finding 1 prevalence, form and frequency

Finding 2 content Finding 3 distress Finding 4 duration Finding 5 other findings

Salkovskis & Harrison (1984)

To investigate the incidence and characteristics of intrusive cognitions in non-clinical populations; relationship between frequency, discomfort, dismissability and type of intrusion.

88.2% reported positively to experiencing IT's.

Both thoughts and impulses (N=86) more frequent than thoughts (N=69) and impulses (N=2) alone. All intrusions: 10+/day (N=9), 10+/week (N=44), 10+/month (N=44), Less (N=58)

Discomfort is related to ease of dismissal but not to frequency or type of intrusion

Ease of dismissal appears to be a crucial variable with regard to intrusions, with the strongest relationships found being associated with it.

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3.2.4 Theme 4: The content of non-clinical intrusions

As noted, the methods with which authors enquired about the occurrence of

intrusions varied. Some studies used structured checklists whilst others asked

participants to generate intrusions experienced after providing a definition of an

intrusion. Given this, the intrusion content dimensions reported amongst the studies

reviewed was vast and the frequency with which these were experienced by

participants differed greatly. Content themes endorsed by the samples included:

accidents, doubts, contamination, disease, aggression/ intentional harm, sexual,

religious, immoral, unacceptable, order/ exactness and other/ miscellaneous (e.g.

repeated songs/ phrases; numbers).

Doubting (e.g. leaving hob on; door unlocked) was reported as the most

common or one of the most common intrusions in many of the reviewed papers

(Belloch et al, 2004; Bouvard et al, 2016; Clark et al, 2014; Garcia-Soriano et al,

2011; Morillo et al, 2007; Purdon and Clark, 1993; Purdon and Clark, 1994a;

Radomsky et al, 2014).

Contamination/ dirt and or disease intrusions were the second most

commonly experienced intrusions in Edwards and Dickerson (1988) non-clinical

sample. They were also highly prevalent for OCD samples and non-clinical samples

with higher scores on measures of obsessionality (Bouvard, 2016; Clark et al, 2014;

Garcia-Soriano et al, 2011; Morillo et al, 2007).

Suffocation (44.6%) and accidents (26.4%) coming to their infant were the

most frequent intrusive thoughts for the total sample of mothers and fathers in

Abramowitz’s (2003) study. This indicates that parents experience external harm

coming to their infant as their most prevalent intrusions. Similarly Crye et al (2010)

found that the most common category of obsessions reported was ‘thoughts about

35

harm coming to yourself or someone else’ and Parkinson and Rachman’s (1981)

sample experienced ‘harm coming to others’ (e.g. family and friends) as their second

most common intrusion theme.

The commonality of intrusive thought/ image and/ or impulse content around

themes of intentional harm, sex and/or aggression was found to differ amongst the

papers reviewed. Belloch et al (2004) found that intrusions of this content (e.g.

fatally pushing friend; stabbing family member; pushing family under a train) were

the least frequent amongst their non-clinical student sample. Similarly Abramowitz

(2003) found that intentional harm (21.5%) and sexual thoughts (1.7%) towards their

infants were less frequently occurring intrusion content in parents. Sexual thoughts

were also the least common intrusions among Radomsky et al’s (2014) and Clark et

al’s (2014) sample. Intrusions of harm/ aggression were also much less common in

Clark et al’s non-clinical samples.

On the contrary, almost half of the intrusions in Audet et al’s (2016),

Edwards and Dickerson’s (1988) and Purdon and Clark (1993) samples endorsed

intrusions classified as (i) unacceptable thoughts, (ii) violence or harm to self or

others and (iii) reckless driving, impulsive sexual behaviour and verbal or physical

aggression respectively. Two of the three most common obsessions reported by

Purdon and Clark’s (1994a) sample involved sexual content. The participants in

Parkinson and Rachman’s (1981) study experienced content differences between

thoughts, images and impulses. Impulses commonly contained themes of verbal or

physical aggression and images were commonly of aggressive sexual themes.

Morillo et al (2007) found that aggressive thoughts were present amongst their non-

clinical group but were significantly more frequent in their OCD group.

Contrastingly Bouvard et al (2016) found that harm/ aggression intrusions (such as

36

being violent towards others) were more often endorsed by their non-clinical sample

compared with their OCD sample; however this difference was not significant.

O’Neill et al (2009) do not comment on the content of their participants’ thoughts or

impulses; however they provided a list of those described by both samples. Through

visual inspection of this list it became apparent that the majority of intrusions

concerned thoughts and impulses to harm others e.g. “to kick a cat across a room”;

“to commit violent acts towards strangers”; “throwing a baby off a bridge and seeing

the reaction of people” and “shooting someone in the back of the head” for the

inmate sample and “stabbing my girlfriend”; “strangling my boyfriend while having

sex”; “to cause physical harm to a person” and “to smother my child or smash his

head” for the student sample. Lastly it is of note that Crye et al (2010) did not ask

their adolescent participants about intentional harm or aggressive thoughts

potentially due to ethical issues.

Rassin et al (2007) suggest that there was a difference in the content of

normal and abnormal obsessions since significantly fewer of their participants

endorsed experiencing abnormal intrusions (t(132)=19.6, p<0.001); however the

majority of the findings in the papers reviewed did not suggest that there are

differences in the content between clinical and non-clinical intrusions.

3.2.5 Theme 5: The distress associated with non-clinical intrusions

Distress related to experiencing intrusions was measured in some of the studies

reviewed. As noted previously, the content of intrusions within the samples was vast

and many were reported as participants’ most distressing intrusion (Purdon and

Clark, 1994b). In Belloch et al’s (2004) sample, the thoughts rated as most upsetting

were largely related to harm to self (i.e. jumping off a high place). Distress was also

37

associated with doubt intrusions (e.g. I left the heat, stove or lights on - may cause

fire) for some of the OCD and non-clinical samples (Belloch et al, 2004; Bouvard et

al, 2016; Garcia-Soriano et al, 2011). After doubt, one of the most distressing

intrusions for OCD participants was contamination and for non-clinical participants

was aggressive/ harm intrusions. This was associated with frequency of thoughts in

that doubt and contamination were the most frequent for the OCD group in Bouvard

et al’s (2016) study and doubt and harm/ injury/ aggression were the most frequent

for the non-clinical group.

In Radomsky et al’s (2014) study aggression/ harm related intrusions were

rated as the least distressing. However other unacceptable intrusions (those of sexual/

religious and immoral themes) were rated the most distressing.

The distress associated with intrusion content appears to be mixed among the

samples in the papers reviewed although doubt appeared to be one of the most

distressing intrusion themes among both clinical and non-clinical participants.

In some papers, distress was associated with frequency. O’Neill et al (2009)

found that distress increased as intrusions became more frequent f(2,111)=5.7,

p=0.005. Similarly Niler and Beck (1989) and Reynolds and Salkovskis (1991)

found a significant positive correlation between distress and frequency but only with

moderate effect sizes (r = 0.28, p<0.05) and r = 0.33, p<0.0002 respectively).

However despite high endorsement of intrusions, distress was relatively low for both

mothers and fathers in Abramowitz’s (2003) study. This might reflect theory related

to obsessions in that intrusions are only associated with distress in the context of

maladaptive appraisals about thinking.

In some studies, discomfort or unpleasantness was assessed rather than

distress. Salkovskis and Harrison (1984) found that rather than frequency of type of

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intrusion, the discomfort related to intrusions was related to ease of dismissal.

Morillo et al (2007) found that unpleasantness ratings of intrusions were greater in

their OCD group than their non-clinical, anxious and depressed groups

f(3,107)=19.18 p<0.001. A similar finding was reported for higher obsessional non-

clinical participants in Purdon and Clark’s (1994a) study.

With regards to the form of intrusions, Niler and Beck (1989) found that

intrusive thoughts elicited more distress than impulses (t(69) = 5.59, p<0.0001). On

the contrary, Parkinson and Rachman (1981) reported that discomfort,

unpleasantness and anxiety was higher for intrusions that were a combination of

thoughts, images and impulses. This was followed by impulses and images.

Thoughts were rated as least distressing.

3.2.6 Theme 6: The duration of non-clinical intrusions

Only three studies, all recruiting a non-clinical sample, investigated the duration of

intrusions. Furthermore, each study measured this with regard to either duration of a

discrete intrusion (Edwards & Dickerson, 1988), the amount of time occupied each

day by intrusions (Abramowitz et al., 2003), or the amount of time intrusions had

been experienced in months (Parkinson & Rachman, 1981). Given this variability in

operationalizing duration, it is therefore difficult to draw comparisons.

Edwards and Dickerson’s (1988) sample reported a brief duration of their

intrusions, less than one minute. Abramowitz et al (2003) found that the duration, in

hours per day, of experiencing intrusions was significantly greater for mothers

(M=1.08 (SD 0.33)) than fathers of infants (M=0.91 (SD 0.29)); t(74)=2.04, p<0.05.

With regard to the length of intrusion episode, Edwards and Dickerson (1988)

found that over half of the sample had experienced their intrusions for one month or

39

longer although they do not present exact durations. Parkinson and Rachman (1981)

separated the duration of each form of intrusion and found that intrusive impulses

(m=126.93 (83.13)) were experienced for a greater number of months than thoughts

(m=120.07 (100.33)), images (m=113.35 (77.94)) and a combination (m=103.52

(86.87)). Furthermore, intrusions with an earlier onset were associated with less

discomfort.

4.0 Discussion

The aim of this review was to assess the literature surrounding the phenomenology of

non-clinical intrusions and to investigate whether the form, content, frequency and

distress associated with non-clinical intrusions are similar to clinical obsessions.

Nineteen papers were included in the review. Studies were conducted mostly with

adult samples, across a number of different countries, and used a range of methods

for enquiring about intrusions and associated features.

Findings from the papers were grouped into six themes including: prevalence,

form, frequency, content, distress and duration. With regards to prevalence, the

findings were consistent in that all of the studies reported the existence of unwanted

intrusive thoughts/ images and or impulses in non-clinical populations across six

continents with the endorsement rate for some of the samples as high as 100%

(Radomsky et al, 2014). This finding is important as it supports the notion that

intrusions are common, cross-national, cross-cultural (Radomsky et al, 2014) and

global phenomena (Rachman & de Silva, 1978) which is the central premise of the

cognitive model of OCD (Salkovskis, 1985). However, the occurrence of intrusions

per se is not sufficient support for the central premises of the cognitive model –

evidence is required that they share similarities with clinical obsessions. The findings

40

of this review suggest that comparison between non-clinical and clinical groups is

hindered by the relative lack of studies that include both groups in a single study.

Nonetheless, whilst only a small number of studies in this review addressed this

comparison directly, the studies that focus only on non-clinical groups provide useful

information regarding the phenomenology of non-clinical obsessions. Where

possible, descriptive comparison with clinical obsessions is attempted below.

Within the group of studies that recruited only non-clinical participants, there

was wide variation in the methodology used to enquire about intrusions. The review

suggests some consistency in the proportion of the samples that experience intrusions

but considerable variability in relation to frequency and the most common forms of

intrusions experienced. This is likely due to some studies using checklists of

intrusions (and not the same one across studies) whilst others used an open-ended

format with participants asked to generate intrusions they have experienced. The

non-clinical data do however suggest some parity with clinical obsessions in terms of

the form and content of intrusions.

The majority of non-clinical intrusions took the form of thoughts or a

combination of thoughts, images and impulses (Edwards and Dickerson, 1988; Niler

and Beck, 1989; O’Neill et al, 2009; Parkinson and Rachman, 1981; Salkovskis and

Harrison, 1984). Fewer of the papers reported the experience of images or impulses

alone. Interestingly impulses were more prevalent within the one study recruiting an

adolescent sample (Crye et al., 2010). This could have had an association with the

stage of development that the participants were at since inhibition of impulsivity is

less developed in childhood and adolescence (Blakemore and Choudhury, 2006;

Zelazo, 2010). The search only identified one study with adolescents though and

other studies are required to assess if this is a consistent finding. Thoughts or a

41

combination of thoughts, images and impulses were found to be the most distressing

form of intrusions (Niler and Beck, 1989; Parkinson and Rachman, 1981). This may

be related with the higher frequency at which these forms of intrusions occur. It is of

note that the studies that included clinical and non-clinical samples did not compare

the form of intrusions so it is unclear whether there are similarities or differences

with regard to intrusion form between these populations.

Some evidence in this review suggests that non-clinical groups experience

intrusions less frequently than clinical groups (Bouvard et al., 2016; Garcia-Soriano

et al., 2011; Morillo et al. 2007). This has some parity with Rachman and Hodgson’s

(1980) early suggestion, subsequently endorsed by a number of researchers, that

people with OCD simply experience more intrusive thoughts than non-clinical

participants and this is what makes them become problematic.

On the basis of content, the current review suggests a broad range of intrusion

themes in non-clinical participants. At this level of analysis, it could be argued that

non-clinical intrusions and clinical obsessions are similar. However, the studies

reviewed indicated variability in the occurrence of different content types both within

non-clinical samples and, importantly, when compared to clinical samples although

studies that recruited both groups were fewer in number. Doubts were endorsed as

the most, or one of the most, common intrusive thoughts (Belloch et al, 2004;

Bouvard et al, 2016; Clark et al, 2014; Garcia-Soriano et al, 2011; Morillo et al,

2007; Purdon and Clark, 1993; Purdon and Clark, 1994a; Radomsky et al, 2014) and

were also considered one of the most distressing (Belloch et al, 2004; Bouvard et al,

2016; Garcia-Soriano et al, 2011). Alongside doubt, contamination intrusions were

common within both non-clinical and OCD participants (Bouvard et al, 2016; Clark

et al, 2014; Edwards and Dickerson, 1988); Garcia-Soriano et al, 2011; Morillo et al,

42

2007). Evidence of the experience of aggressive/ harm and sexual intrusions was

more mixed with some samples endorsing these types of intrusion highly (Audet et

al, 2016; Edwards and Dickerson, 1988; Purdon and Clark, 1993; O’Neill et al, 2009)

and others less so (Abramowitz et al, 2003; Belloch et al, 2004; Clark et al, 2014;

Radomsky et al, 2014).

In two of the three papers that compared OCD groups with non-clinical

groups, aggressive/ harm and sexual intrusions were significantly more frequent in

the OCD groups (Garcia-Soriano et al, 2011; Morillo et al, 2007). In Radomsky et

al’s (2014) large cross-cultural non-clinical sample, sexual and religious/immoral

thoughts were reported as the most distressing despite them being experienced least

frequently. This suggests that these thoughts are not required to be experienced often

to be considered highly upsetting, unlike doubts.

Given that stronger evidence on the comparability of clinical and non-clinical

intrusions comes from studies that compare both groups, the evidence cited above

might be taken to indicate that clinical and non-clinical intrusions are not similar in

terms of themes of sex and aggression. However, in terms of the endorsement of

sexual and harm-related intrusions within non-clinical samples, it is possible that

more unacceptable and repugnant thoughts are underreported due to the individuals’

high distress or concern that they would be judged for disclosing these thoughts

(Newth and Rachman, 2001; Simonds and Elliott, 2001). This could have similarly

occurred with the parents in Abramowitz et al’s (2003) study who reported very few

intrusions about themselves being the agent of harm to their infant. These parents

reported that they were not entirely comfortable reporting the intrusions that they did

report. Reporting a greater number of thoughts of intentional harm to their infant

may have led them to fear appearing to be a bad or dangerous parent. Should these

43

thoughts have been reported more commonly, parents may have reported that they

were even less comfortable with disclosure.

The evidence regarding duration of intrusions in non-clinical samples is

limited to only three studies, none of which also utilised a clinical sample. In

Edwards and Dickerson’s (1988) sample intrusions presented briefly (<1 minute).

Whilst they presented somewhat longer in Abramowitz et al’s (2003) sample (0.91 -

1.08 hours), it is not clear from Abramowitz et al’s (2003) findings whether they

were measuring the duration of a single intrusion or how long separate intrusions

occurred during the day (i.e. not as a continuous experience). The duration of onset

ranged from at least a month (Edwards and Dickerson, 1988) to many years

(Parkinson and Rachman, 1981). However, it was difficult to draw conclusions about

the duration of intrusions since the measures of duration differed and findings might

be dissimilar because of this. Interestingly, Parkinson and Rachman (1981) found

that more longstanding intrusions were associated with less discomfort in a non-

clinical sample. The authors hypothesise that the participants may have become more

accustomed to these thoughts and therefore found them less uncomfortable. This is

consistent with the cognitive behavioural model in that repeated exposure to a

stimulus (the intrusion) enables habituation and a reduction in anxiety (Clark, 1999;

Freeston and Ladouceur, 1999).

Significantly fewer intrusions were reported in O’Neill et al’s (2009)

incarcerated sample and this was associated with higher psychopathic traits. It is

possible that intrusions are considered by those with psychopathic traits to be ego-

syntonic and hence are not experienced as unwanted and alien to the self. Since this

finding was not replicated amongst the comparison student sample, another

possibility may have been that inmates were reluctant to admit some thoughts/

44

images/ impulses in case it impacted on their sentences. However, this would not

account for the finding that intrusions were significantly greater in those prisoners

with lower psychopathic traits. The lower occurrence of intrusions in those higher in

psychopathic traits was expected because it had been hypothesised that the brains of

people high in psychopathic traits have structural and functional differences that

make the occurrence of intrusive thoughts less likely.

Although not a theme extracted for the current review given the limited

number of studies focussing on this dimension of intrusions, ego-dystonicity was

greater in OCD samples compared to non-clinical samples (Bouvard et al, 2016) and

was associated with those thoughts rated as OCD relevant (Audet et al, 2016). Given

ego-dystonicity is such a principal feature of obsessions it is important for future

studies to assess this in non-clinical samples and, ideally, to compare clinical and

non-clinical groups in the same study.

In non-clinical samples, Niler and Beck (1989) found that dismissability was

more difficult for thoughts experienced more frequently. Further, Salkovskis and

Harrison (1984) reported that those who found intrusive thoughts and impulses hard

to dismiss reported greater discomfort. These findings make sense in that being

unable to remove negative unwanted thoughts from one’s mind would likely make

them more memorable and, therefore, more upsetting. Since obsessions are more

frequent in OCD, dismissability may be more challenging and in turn distress is

greater.

Taken together, the findings of the review indicate that intrusions are

extremely prevalent globally. The difference between clinical and non-clinical

45

intrusions appears to be primarily related to frequency of occurrence rather than

qualitative differences (i.e. the content) although there is some suggestion that

intrusions related to sex and aggression are more frequent in clinical samples.

However, concerns about reporting intrusions of this type might be a concern for

non-clinical participants who are not in contact with services. Intrusions tended to

most commonly present in the form of thoughts or a combination of thoughts, images

and impulses. Distress was in some cases associated with intrusion frequency and in

others, with the specific content of thoughts.

The conclusions of this review need to be seen in the light of a critical

analysis of study methodology. In most studies, respondents were overwhelmingly

female. This was particularly an issue in O’Neill et al’s (2009) study comparing

inmates with students; all of their inmate sample was male in comparison to only

39% of their community sample. Many studies recruited psychology students who

may have had a greater depth of knowledge of the concept of intrusions and/or OCD.

This poses a problem as knowledge may instil understanding and desensitisation that

a lay person may not have and this leads the sample to be less representative of the

general population. Alongside this, samples volunteered to engage with the studies

which indicates that they are interested and motivated to take part in research. They

may also feel more comfortable in sharing information about their inner world

particularly around intrusive thoughts, the content of which can be frightening and

repugnant. Those who were very distressed by their thoughts may not have consented

to take part. Alternatively, those who experience intrusions but do not find them

particularly upsetting or troubling may not volunteer as they may not view their

46

thoughts as unusual and hence not necessary to research. This in turn may bias the

results to a greater level of distress.

Response rate was an issue for Abramowitz et al (2003) as only one fifth of

surveys sent to new parents were returned completed with significantly fewer

completed by fathers. As noted earlier, there may be a particularly strong bias against

disclosure of negative intrusions towards ones children. Further studies of intrusions

in particular subgroups like this are required to extend the evidence base.

The majority of samples were recruited from Western cultures, although

Clark et al. (2014) and Radomsky et al. (2014) carried out large scale studies in order

to assess non-clinical intrusions cross-culturally. These (though they were a joint

research project) were the only two papers that reported the characteristics of

intrusions across a number of continents.

The studies that compared clinical vs non-clinical or high vs low

obsessionality or any other group comparison had quite low sample sizes but, more

importantly, did not give sample size calculations. Therefore any non-significant

findings might be due to being underpowered.

As noted, the methods and measures used to enquire about the occurrence of

intrusions varied. Whilst the majority used validated intrusion checklists that are

helpful for gathering information from large samples, an issue with these measures is

that some concepts and definitions may not exist in different cultures and detail could

get lost in translation when making measures accessible in other languages. This was

the case for Clark et al. (2014) who could not include any Italian or French samples

due to one of the measures being unavailable in those languages. Furthermore

47

measures rely on recall and may not be as representative of thoughts and emotion

when these are not live.

Some of the studies required participants to describe in an interview or hold

an intrusion that they experience in mind when completing measures which may

have improved ecological validity and enabled ratings to be more authentic. To

facilitate this, studies provided a brief psychoeducation about intrusions which would

have helped participants to understand the types of thoughts the studies were

investigating, and might also have normalised the experience for anyone concerned

about disclosing these thoughts. A possible challenge however is that it may have

produced a demand characteristic and primed participants to describe and respond in

a certain way. Additionally, this approach still relies on individual interpretation of

what constitutes an intrusion and therefore might result in less reliable estimates of

the occurrence of intrusions than checklist measures.

As in the seminal paper by Rachman and de Silva (1978), some studies

utilised raters to classify the content of intrusions. Abramowitz (2003) utilised two

raters who they described as having expertise in assessing and diagnosing OCD and

asked them to categorise intrusions into common obsessional themes; however,

agreement was met for only 87% of the 121 thoughts. Other researchers, such as

O’Neill et al. (2009), did not give any detail about how intrusions were categorised

by raters or the agreement level between raters. Audet et al (2016) did recruit

experienced clinicians to classify intrusions but gave only partial detail of the

systematic protocol followed to categorise intrusive thoughts. This was similarly the

case in a number of other papers. Audet et al (2016) reported that the highest average

agreement ratings between clinicians was only 81% for categorising intrusive

thought content. The average ego-dystonicity rater agreement was only 55%

48

indicating that ego-dystonicity might be difficult to define. The process of defining

and classifying intrusions, obsessions and other factors associated with these

phenomena appear to be a challenging and subjective process, even for highly

experienced clinicians.

A number of recommendations for future research are evident aside from the

methodological improvements noted above with regard to response rate, gender

composition of samples, and greater consistency in methods used to enquire about

intrusions. The nature and occurrence of intrusions in specific subgroups is an area

where further data are needed. The current review suggests there may be important

variation in intrusions experienced at different life-stages (e.g. during adolescence,

when becoming a parent); the data at present are too limited to draw conclusions.

Secondly, the current evidence on comparability of clinical and non-clinical groups

is limited to some extent by the relatively smaller number of studies that recruited

both groups of participants. Further studies are needed that provide direct

comparison between clinical and non-clinical groups. However, the small number of

studies identified might also be a limitation of the search strategy of the current

review; any studies that involved this comparison but did not reference the specific

terms used in the search methodology would not have been included. Thirdly, the

literature reviewed indicates that clinical and non-clinical groups experience

intrusions considered repugnant and unacceptable and distress is associated with

these intrusions. Furthermore it is well documented that disclosure of these types of

intrusions is less likely (Newth and Rachman, 2001; Simonds and Elliott, 2001). In

light of this, it was surprising to discover that only one of the papers reviewed

investigated non-clinical participants’ comfort in disclosing intrusions (Abramowitz

49

et al, 2003). It is important that future research investigates how people feel about

disclosing the intrusions they experience because this has a bearing on understanding

more fully the occurrence of intrusive cognitions. With unacceptable and repugnant

intrusions, such as those with aggressive/ harming and sexual themes, less often

endorsed in the papers reviewed, it is important to further explore whether these

thoughts are in fact experienced less often in non-clinical samples, or if the nature of

these intrusions leads people to want to conceal them. Additionally, since some

people experience greater distress from their intrusions than others, the way that

people think about highly unacceptable intrusions warrants continued investigation.

Cognitive biases and appraisals have been the focus of much investigation but

emotional reactions to intrusions, such as moral emotions that are particularly

pertinent in the context of unacceptable intrusions, have been the subject of less

investigation even though they are recognised responses to intrusions in the cognitive

model. This would be another dimension on which the comparability of the

experience of clinical versus non-clinical intrusions might be assessed.

50

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Appendix to the Literature Review

Appendix A Link to the NICE (2012) quality appraisal checklist based on the

Graphic Appraisal Tool for Epidemiological studies (GATE) frame (Jackson,

Ameratunga, Broad, Connor, Lethaby, Robb and Heneghan, 2006)

https://www.nice.org.uk/process/pmg4/

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Research Part 2 Empirical Paper with Appendices

Disclosure of Negative Intrusions: The Relationship

with Thought-Action Fusion, Shame, Guilt and Fear.

Word count: 7019

57

Abstract

Background: Given their highly unacceptable nature, negative intrusions are likely

to promote the experience of negative affect such as fear, shame and guilt. Moreover,

moral thought-action fusion (believing that negative thinking is the equivalent of

acting immorally) is likely to inflate the occurrence of negative affect when

intrusions are experienced. In turn, negative affect is likely related to disclosure. The

current study investigated whether thought-action fusion beliefs predict anticipated

disclosure of hypothetical negative intrusions, and whether this was mediated by

anticipated negative affect.

Method: An online survey was completed by a sample from the general population

(n=175). The survey assessed anticipated negative affect and anticipated disclosure

of hypothetical negative intrusions, guilt and shame proneness, frequency of negative

intrusions, thought-action-fusion beliefs, and general self-concealment.

Results: A strong positive relationship was found between TAF-Moral beliefs and

anticipated negative affect from experiencing negative intrusions. The analysis

indicated evidence of co-operative suppression: when both TAF-moral beliefs and

negative affect were entered into a model predicting anticipated disclosure, the effect

of both predictors increased. Whereas TAF-Moral beliefs predicted lower likelihood

of disclosure, negative affect predicted increased likelihood of disclosure.

Conclusion: The current findings add to the literature in that they suggest that

individuals may be less inclined to disclose unacceptable intrusions. Further work is

needed to understand the conditions under which negative intrusions are more or less

likely to be disclosed. Limitations and recommendations are discussed.

58

1.0 Introduction

Intrusions are negative unwanted thoughts, images or urges which present

involuntarily into a person’s mind (Rachman, 2007). Intrusions are a feature of a

number of clinical disorders, most notably Obsessive Compulsive Disorder (OCD)

and Post-Traumatic Stress Disorder (PTSD), however they also occur commonly in

the general population (Rachman & de Silva, 1978; Purdon & Clark, 1993). As

intrusive thoughts are often experienced by individuals who do not meet the

diagnosis threshold for OCD, research has endeavoured to understand what makes

intrusive thoughts distressing (Purdon & Clark, 1994) and what makes someone

more likely to develop obsessive-compulsive problems than another.

The observation that intrusions are commonplace in the general population is

central to the cognitive-behavioural model of disorders such as OCD. This model

proposes that obsessional disorders arise from maladaptive beliefs and appraisals

applied to ‘normal’ intrusions. In the cognitive-behavioural model, biased appraisals

and maladaptive beliefs concerning the likelihood of harm and ones responsibility in

avoiding it (Salkovskis, 1985, 1989) are said to mediate distress associated with

intrusions – those that are appraised as indicating imminent harm or blame, for

example, provoke anxiety and other negative affect such as shame and guilt as well

as attempts to neutralise the implied harm by conducting neutralising behaviour such

as compulsions. Figure 1 displays an example demonstrating the link between

intrusion, appraisal, affect and compulsive activity using an adapted version of

Salkovskis’ (1985) cognitive-behavioural model of obsessive-compulsive disorder.

59

Figure 1. Adapted Salkovskis (1985) Cognitive-Behavioural Model of Obsessive-

Compulsive Disorder.

60

TriggerTrain approaching platform

IntrusionImage of pushing person in front of

train

Appraisal (Meaning)I am a terrible personMaladaptive Belief

Having this image is as bad as acting on it (Thought action fusion-Moral (TAF-

Moral))

DistressAnxiety/shame/guilt

Urge to neutralise (compulsion)

Pray

Shame and guilt are ‘self-conscious’ moral emotions often considered part of

the affective response in obsessive-compulsive related disorders (Weingarden and

Renshaw, 2015; Shapiro and Stewart, 2011). Shame and guilt can co-occur but have

different attributional styles and behavioural and affective correlates (Kim,

Thibodeau and Jorgensen, 2011). The seminal work of Lewis (1971), proposed that

the fundamental difference between shame and guilt is focus on the self: whereas

shame is associated with a perceived defect at the person’s core identity, guilt arises

from perceiving ones actions as blameworthy. Lewis (1971) stated that shame is

focused more so on the ‘self’ than in guilt, which is more focused on the

action/experience (e.g. “I am a bad person for imaging that” vs. “I imagined a bad

thing”). The central focus on the self in the former would more likely evoke feelings

of shame whereas the focus on action in the latter would more likely evoke feelings

of guilt. The experience of guilt tends to motivate approach and repair behaviour

(e.g. apologising) whilst shame provokes a motivation to hide the perceived

‘defective’ self and avoid others (Kim et al., 2011). It is also possible that the

occurrence of a negative intrusion provokes both shame and guilt. For example, a

person might initially feel guilty about thinking about a loved one being harmed but

subsequently experience shame if they considered that such thinking was reflective

of being a fundamentally unpleasant person.

As indicated in Figure 1, thought-action fusion (TAF) is a maladaptive belief

that has been associated with negative affect and neutralising behaviour in obsessive-

compulsiveness. TAF takes on two forms: likelihood (‘having this thought/ image/

urge increases the likelihood that it will happen’) and morality (‘having this thought/

image/ urge is the moral equivalent of it happening’) (Berle & Starcevic, 2005).

61

TAF-moral beliefs promote the likelihood that negative affect such as shame and

guilt will be felt when an intrusion is experienced because it entails the belief that

thinking of negative acts equates to being immoral. Valentiner and Smith (2008)

suggest that TAF-moral beliefs, alongside general shame-proneness, mediate the

relationship between the occurrence of an intrusion and distress.

Generally, TAF biases involve a fusion of internal and external worlds. In the

case of likelihood TAF beliefs, this fusion raises the idea that the imagined negative

event is more likely to occur due merely to it being present in the person’s mind.

Given that intrusions focus on threat, this type of fusion is likely to generate forms of

negative affect other than shame and guilt, such as fear. Furthermore, the belief that

thought and action can be readily fused is likely to impact disclosure. That is, TAF

beliefs are likely to promote concealment because articulating an intrusion is

considered to make it more likely to materialise, either in real world or in moral

terms (i.e. in the latter case, there is likely a perception that other people will make

moral judgements). In a theoretical paper, Newth and Rachman (2001) proposed that

fear of judgement and rejection from others due to the revealing of unwanted and

repugnant intrusions influences disclosure and, by extension, help-seeking. In a

general population sample, Simonds and Thorpe (2003) found that anticipated delay

in disclosure of thoughts involving harm was partly related to anticipated fear and

shame. Treatment delay in OCD is considerable, often around 11 years (Salkovskis,

1998). In a review of the help-seeking literature, Simonds and Elliott (2001)

proposed that individuals would be reluctant to report obsessions of a violent, sexual

and unacceptable nature. In contrast, a more recent review of non-treatment or

treatment delay in OCD (García-Soriano, Rufer, Delsignore and Weidt; 2014) found

62

that violent and unpleasant obsessions predicted help-seeking and OCD patients

seeking help showed a greater number of aggressive and religious obsessions This

may be related to the fear associated with these types of obsessions especially if TAF

beliefs are evident.

In summary, the foregoing discussion indicates that, given their highly

unacceptable nature, the occurrence of intrusions is likely to promote negative affect.

A tendency to conflate thought and action is proposed to make the occurrence of

negative affect more likely and this tendency is also likely to inhibit disclosure.

However, the evidence seems mixed as to the effect that negative affect might have

on disclosure. The aim of the current study was to assess the relationship between

TAF-moral beliefs, anticipated affective response to negative intrusions, and

anticipated disclosure of intrusions in a non-clinical general population sample. This

sample was chosen for two reasons: first, because anticipated stigma is a substantial

issue for people who experience negative intrusions. Research on general population

response to obsessive-compulsive like negative intrusions is, therefore, important

(Simonds & Thorpe, 2003). Second, given the cognitive-behavioural model proposes

that obsessive-compulsiveness develops from ‘normal’ intrusions, the study of non-

clinical samples in intrusion research is a widely-used strategy. General population

responses to intrusions are potentially useful, therefore, in elaborating the

understanding of reluctance to disclose in clinical samples. The study hypotheses

were:

1. TAF will be positively correlated with negative affect (shame, guilt and fear)

in response to negative intrusions.

63

2. Negative affect (shame, guilt and fear) in response to negative intrusions will

mediate the relationship between TAF-Moral and disclosure of negative

intrusions.

The conceptual diagram is shown in Figure 2. Pre-existing TAF beliefs (X) predict

negative affect when thinking of hypothetical negative intrusions which, in turn,

predicts anticipated likelihood of disclosure of negative intrusions (Y). However,

there is also expected to be a direct effect between TAF and anticipated disclosure.

Figure 2. Hypothesised mediation model for anticipated negative affect from

intrusions mediating the relationship between TAF and anticipated disclosure.

In the absence of an existing measure of negative affect related to, and

disclosure of, hypothetical negative intrusions, a measure was developed for the

purpose of the current study. Therefore, the current study also assessed: (a) whether

scores on an established measure of concealment were related to anticipated

likelihood of disclosing negative intrusions; and, (b) whether scores on measures of

general shame and guilt proneness were related to negative affect related to

64

Thought-Action-Fusion (TAF)

(X)

Anticipated negative affect(M)

Anticipated Disclosure(Y)

hypothetical intrusions. General propensity to experience negative intrusions was

also assessed in order to describe the sample on this dimension.

2.0 Method

2.1 Design

The study used a cross-sectional survey design. Participants completed questionnaire

measures of thought-action fusion (TAF), anticipated affective response to and

disclosure of hypothetical negative intrusions, general propensity to experience

negative intrusions, self-concealment, and shame and guilt proneness. The survey

was developed in Qualtrics survey software and could be accessed remotely and

completed electronically.

2.2 Participants

2.2.1 Inclusion Criteria and Recruitment

Anyone above the age of 18 years old who accessed the survey via the online survey

link and who consented to taking part in the survey were included within the study.

Eligible participants were given information on the content of the survey including

the fact that the content could be upsetting. Participants were informed that their

responses would be anonymised and that should they choose, they could withdraw

their participation at any time during the survey. Exclusion was therefore based on

participant consent. Participants were recruited from a number of sources: the study

was advertised on social media websites (Facebook; Twitter); on a research study

website (www.onlinespsychresearch.co.uk); and posters were displayed on the

University of Surrey campus. In addition, snowball sampling was used by asking 65

participants to distribute the study advertisement to their social networks. The study

link was also made available to ‘share’ on social media sites in order for snowball

sampling to be achieved.

2.2.2 Sample Size Calculation

According to Fritz and MacKinnon (2007), a sample size of 162 is required to detect

medium to small effect sizes in a mediation analysis. Therefore 162 participants was

the sample size aim for the study.

2.3 Measures

Anticipated Response to Negative Intrusions (ARNI) (Appendix D (i))

In order to assess participants’ anticipated affective responses to and

disclosure of hypothetical negative intrusions, a measure was developed for the

current study. Although vignette studies have investigated the perception of how

much shame a fictitious person experiencing intrusions might feel (e.g. Simonds &

Thorpe, 2003; Cathey and Wetterneck, 2013), no study to date has assessed a range

of different negative intrusions and a person’s perception of how they might feel

themselves were they to experience them, or if they would disclose such intrusions to

another person. As such, no suitable instrument exists. In the current study, the ARNI

was modelled on the Test of Self-Conscious Affect (TOSCA: Tangney, Wagner and

Gramzow, 1989). The TOSCA is a widely-used and psychometrically validated

scenario-based measure of shame and guilt.

Tangney et al. (1989) developed the TOSCA by identifying situations that

would likely elicit feelings of shame and guilt in the general population. Unlike

checklists, scenario-based measures enable individuals to imagine themselves in a

66

specific situation. The ARNI was developed based on common negative intrusion

themes identified in research by Purdon and Clark (1992) and Burns, Keortge,

Formea and Sternberger (1996). Broadly, the eleven ARNI scenarios focus on

thoughts, images and urges relating to harming self or others physically or

emotionally, committing crime or indecent acts, and being offensive. Based on the

literature indicating that common negative affect following negative intrusions is

anxiety/fear and self-conscious emotions, the ARNI scenarios are each followed by

four items assessing likelihood of anticipated shame, guilt, fear and disclosure. Each

item is rated on a scale from 0% (‘not likely’) to 100% (‘extremely likely’). Shame

and guilt items were developed based on the distinction drawn in the literature

between focus on the self as globally bad (shame) or focus on the action (in this case,

thinking) not the self (guilt). To provide an initial assessment of concurrent validity

of the negative affect items, participants also completed the Guilt and Shame

Proneness Scale (Cohen, Wolf, Panter & Insko, 2011; described below).

The Thought-Action Fusion (TAF) Scale (Revised) (Appendix D (iv))

The TAF Scale (Revised), (Shafran, Thordarson & Rachman, 1996) is a 19-

item scale measuring thought-action fusion in terms of moral (12-items) and

likelihood (7-items). Each item is measured on a 5-point scale from 0 (‘disagree

strongly’) to 4 (‘agree strongly’) with total scores range from 0 to 76. Higher scores

indicate greater thought-action-fusion. In their validation sample, Shafran,

Thordarson & Rachman (1996) showed that the measure has good levels of internal

consistency (Cronbach’s alpha of .93 for each of the two subscales).

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Guilt and Shame Proneness Scale (GASP scale) (Appendix D (ii))

The Guilt and Shame Proneness Scale (GASP scale; Cohen, Wolf, Panter &

Insko, 2011) is a 16-item scenario-based measure of guilt and shame proneness. Each

item is measured on a 7-point scale from 1 (‘very unlikely’) to 7 (‘very likely’) with

total scores ranging from 16 to 112. The GASP comprises four subscales: Guilt-

Negative-Behaviour-Evaluation (NBE); Guilt-Repair; Shame-Negative-Self-

Evaluation (NSE) and Shame-Withdraw. The GASP is scored by averaging the four

items in each subscale. In their validation sample, Cohen et al. (2011) reported that

the GASP subscales had reasonable internal reliability (α .60 to .70).

The Self-Concealment Scale (SCS) (Appendix D (v))

The Self-Concealment Scale (SCS; Larson & Chastain, 1990) is a 10-item

scale measuring an individual’s active concealment of personal information. Each

item is measured on a 5-point scale from 1 (‘strongly disagree’) to 5 (‘strongly

agree’) with total scores ranging from 10 to 50. Higher scores indicate greater self-

concealment. In their validation sample, Larson and Chastain (1990) reported a

Cronbach’s alpha of .83 and a test-retest reliability coefficient of .81.

The Padua Inventory-Washington State University Revision (PI—WSUR) (Appendix

D (iii))

To provide an assessment of participants’ general propensity to experience

negative intrusions, two subscales of the Padua Inventory-Washington State

University Revision (PI—WSUR; Burns, Keortge, Formea and Sternberger, 1996)

were used: (1) obsessional thoughts about harm to self/others (7-items) and (2)

obsessional impulses to harm self/others (9-items). Each item is measured on a 5-

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point scale from 0 (‘not at all’) to 4 (‘very much’) with total scores ranging from 0 to

64. Higher scores indicate a greater frequency of negative intrusions. In their

validation sample, Burns, Keortge, Formea and Sternberger (1996) reported a

Cronbach’s alpha of .77 for obsessional thoughts about harm to self/others and .82

for obsessional impulses to harm self/others.

2.4 Procedure

Once potential participants accessed the survey by clicking on the study link, the

information screen was presented. This outlined the purpose of the study and advised

of potential upset that could be experienced when reading the content of the survey.

Participants were required to click a ‘proceed’ button in order to move to the consent

stage. Following completion of consent statements, participants completed

demographic questions (see Appendix C). At this stage, if any participant indicated

they were younger than 18 years old, the survey closed due to ineligibility.

Participants were then presented with the study measures in the following order:

ARNI, GASP, PI-WSUR, TAF and SCS. The location of the ARNI measure

response items (guilt, shame, fear and disclosure) were varied across questions so

that participants did not get into a response set.

Following completion of the questionnaires, participants were presented with

a debrief screen which thanked them for their participation and provided some brief

psycho-education about intrusions. Alongside this, participants were signposted to

sources of support if necessary. If participants decided to end the survey prior to

completion, they were able to access this debrief information.

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2.5 Ethics

The study was given a favourable ethical opinion by the Faculty of Health and

Medical Sciences Ethics Committee (see Appendix H). Informed consent was

obtained. Participants were informed that they could withdraw their participation

during the survey; however, they would be unable to withdraw their data once they

had completed the survey as participation was anonymous and there would be no

way to identify a person from their data once they had completed the survey. It was

made clear to participants that they could not withdraw data if they completed the

survey. Some of the content within the measures such as harm intrusion scenarios

may have caused some upset or discomfort. Participants were made aware of the

potential for upset in the information sheet. Debrief information was given following

the survey including details for sources of support such as Mind, Samaritans, OCD

Action and signposting to their GP.

2.6 Data analysis strategy

The data file was exported from Qualtrics study software to IBM SPSS Version 23.

The data were screened for dropout and missing values. Prior to hypothesis testing,

variable distributions were plotted and assessed for normality. The factor structure of

the ARNI was assessed and subscales computed. Internal reliability was assessed for

all study measures. Correlations between the ARNI, the GASP and the SCS were

computed to assess validity of the ARNI scale as follows: (i) GASP scales and

ARNI Negative Affect; and, (ii) SCS and ARNI Disclosure. Prior to mediation

analysis, correlations between the ARNI and TAF scales were computed. Depending

on the outcome of distribution-checking, either Spearman’s or Pearson’s correlation

was used. Hayes’ PROCESS command (http://www.processmacro.org) was used to

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address the mediation hypothesis (see Figure 2). Two mediation models were run: (1)

with TAF-moral and (2) with TAF-likelihood as the antecedent (X) variable.

3.0 Results

3.1 Sample characteristics

A total of 325 participants accessed the survey and 186 completed it. Of these, 175

could be included in the analysis. Figure 3 below indicates the stages at which

participants dropped out of the study.

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Figure 3. Flow diagram indicating the stages at which participants dropped out of

the study.

As indicated in the flowchart, eleven participants had more than 20% of data

missing. They were not included as it was considered that mean replacement would

result in an unrepresentative score. For the small number of participants (N=5) who

had less than 20% of data missing, mean replacement was used. For instance, if a

participant had one fear item missing then this was replaced with the average of their

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Dropped out/missing data within measures: 32

12 - dropped out following ARNI3 - dropped out following GASP5 - dropped out following Padua1 - dropped out following TAF11 - over 20% missing data within ARNI

Total participants who accessed survey: 325

Did not proceed past consent: 36

1 - did not consent15 - under 18

Dropped out following demographics: 82

Proceeded to demographics: 289

Proceeded to measures: 207

Final sample: 175

completed fear items. Demographic characteristics of the sample used in the analyses

are shown in Table 1. As indicated, the majority of the participants were female,

White, married or cohabiting, employed and educated to degree level or higher.

Table 1. Demographic characteristics of the total sample (N=175)

CharacteristicGender N (%)

FemaleMaleFemale to male transgender

149 (85)25 (14)1 (0.5)

AgeMean(SD)

35 (11)

Relationship status N (%)SingleRelationship, co-habitingRelationship, not co-habitingMarriedSeparatedDivorced/DissolvedWidowed

34 (19)50 (29)19 (11)62 (35)1 (0.5)5 (3)4 (2)

Employment status N (%)Employed (full-time, part-time or self -employed)UnemployedStudentHomemakerOther

141 (80) 7 (4)16 (9)7 (4)4 (2)

Education N (%)No formal qualifications GCSEs/O-Levels/EquivalentA-Levels/EquivalentUndergraduate DegreePostgraduate Degree

Ethnic group N (%)WhiteBlackAsianChineseMixedOtherNot stated

5 (3)22 (13)33 (19)52 (30)63 (36)

160 (91)2 (1)4 (2)2 (1)3 (2)3 (2)1 (0.5)

A measure of participants’ propensity to experience negative intrusions was

taken to see if it was comparable to a typical general population sample. The sample

(N = 175) scored higher on both subscales of the Padua Inventory (Obsessional

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Thoughts M = 5.81 (SD 4.17), Obsessional Impulses M = 4.1 (SD 4.26)) than Burns

et al’s. (1996) normative sample (N = 5010; Obsessional Thoughts M = 2.92 (SD

3.51), Obsessional Impulses M = 2.83 (4.14)) but lower than their OCD sample (N =

15; Obsessional Thoughts M = 10 (SD 5.01), Obsessional Impulses M = 6 (SD

3.87)). Although PI scores were higher than Burns et al’s (1996) normative sample,

this was likely due to the much larger sample size in Burns et al (1996) providing an

estimate with less error. Overall, the means in the current sample are more typical of

a non-clinical sample than a clinical sample.

3.2 Factor Structure - Anticipated Response to Negative Intrusions (ARNI)

As recommend by Costello and Osborne (2005) for an initial exploratory factor

analysis with factors that are likely to be correlated, Principle Axis Factoring (PAF)

with oblique rotation (direct oblimin) was conducted. Visual inspection of the

distribution of the ARNI items did not suggest that any item should not enter the

factor analysis. The Kaiser-Meyer-Olkin measure of sampling adequacy gave a value

of .93, exceeding the recommended value of .6 (Kaiser, 1960). Bartlett’s Test of

Sphericity was highly significant (p <0.001). Most of the inter-item correlations

were above .3 but were not above .8. Overall, these analyses indicated that factor

analysis was appropriate with this dataset. The initial analysis indicated six factors

with eigenvalues exceeding 1, explaining 74% of the variance. However, given

eigenvalue alone is not recommended in determining the number of factors (Costello

& Osborne, 2005), the scree plot was examined and suggested the extraction of two

factors. Therefore, the exploratory factor analysis was re-run extracting two factors.

The extracted two-factor solution explained a total of 62% of the variance (Factor 1

contributing 47% and Factor 2 contributing 15%). The rotated solution obtained two

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distinct dimensions based on item content. The criterion for inclusion of an item in a

factor was set at .4 (Costello & Osborne, 2005). All items loaded at this level on one

factor only demonstrating simple structure. Factor 1 (33 items) was labelled

‘Anticipated Negative Affect’ and comprised all fear, shame and guilt items from the

eleven scenarios. Factor 2 (11 items) was labelled ‘Anticipated Disclosure’ and

comprised all disclosure items from the eleven scenarios. The factor loadings are

shown in Appendix I.

Item mean scores were calculated to better reflect the 0 to 100 measurement

scale used. The item mean score for ARNI Disclosure was 23.66 (SD 23) and for

ARNI Negative Affect was 45.69 (SD 29.44) indicating moderate levels of

anticipated negative affect and low levels of anticipated disclosure overall.

Cronbach’s alpha was computed to assess the internal reliability of the two ARNI

scales. The two scales showed high reliability within the sample - α .931 for

Anticipated Disclosure and α .968 for Anticipated Negative Affect.

3.3 Descriptive analysis of responses to ARNI scenarios

Table 2 indicates which negative intrusion scenarios were rated as the most and least

likely to prompt negative affect and which were more or less likely to hinder

disclosure. The scenario describing harming a vulnerable child had the highest

ratings of anticipated negative affect and one of the lowest ratings of anticipated

disclosure. The scenario describing an urge to kick a vulnerable kitten had the lowest

endorsement of anticipated disclosure and the second highest rating of anticipated

guilt. Shouting a racist remark (item 6) was the third lowest endorsed for anticipated

disclosure and this also produced high ratings of anticipated negative affect. The urge

to smash items in a store (item 11) produced the lowest level of anticipated negative

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affect and highest anticipated disclosure. These findings indicate that the more

unacceptable the intrusion, the more intense the experience of negative affect and the

less likely a person is to tell others that they have had the intrusion.

Table 2. ARNI item descriptive statistics (N=175)

ARNI Item Shame (%)Mean (SD)Median

Guilt (%)Mean (SD) Median

Fear (%)Mean (SD) Median

Disclosure (%)Mean (SD) Median

1. Image of stabbing family member with knife

29.15 (32.67 )15

57.87 (39.16) 70

54.16 (37.63) 60

25.04 (32.06) 10

2. Urge to shout insult at a funeral

44.88 (36.37) 41

56.52 (37.09) 60

37.18 (36.12) 21

25.52 (30.51) 10

3. Urge to push a person in front of tube train

44.33 (38.21) 36

48.46 (39.12) 48

47.80 (39.75) 43

24.94 (32.41) 10

4. Urge to steer car into an oncoming car

28.7 (33.98)10

41.86 (37.81) 30

49.32 (37.92) 49

29.3 (32.63) 16

5. Image of kicking a stray kitten

48.34 (40.36) 50

64.32 (36.55) 79

47.25 (41.16) 39

14.55 (22.41) 5

6. Urge to shout a racist remark at neighbour

51.85 (37.67) 52

59.28 (37.42) 69

47.02 (39.99) 44

17.06 (25.77) 5

7. Image of smothering baby nephew with blanket

64.28 (39) 81

71.97 (35.66) 94

65.78 (38.31) 85

14.57 (28.27)1

8. Image of throwing self off a cliff

25.13 (25.13) 10

32.09 (35.51) 15

44.57 (37.92) 32

31.88 (31.84) 20

9. Thought of stripping clothes and exposing genitals in public

45.50 (41.29) 30

47 (40.31) 38 48.97 (41.75) 44

19.94 (29.36) 4

10. Urge to steal friend’s collection of items from their home

45.34 (36.4) 41

44.47 (37.77) 36

34.28 (36.46) 18

19.41 (27.62) 6

11. Urge to break fragile displayed items in a department store

23.8 (31.11) 9

30.69 (33.65) 16

25.63 (32.56) 10

38.08 (33.74) 30

Note. Min-max scores for all items was 0-100

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3.4 Descriptive statistics of other study measures

Descriptive statistics for the other study measures are shown in Table 3. The

measures showed good to excellent internal reliability within the sample with the

exception of the GASP scales. All GASP scales demonstrated unacceptably low

internal reliability. The GASP authors noted that reliability is often lower within

scenario-based measures; however, the reliability of two of the GASP subscales fell

below the value of .6 reported by the measure authors. Although reliability of the

total scale in the current sample was acceptable, the GASP authors do not

recommend using the total score. Given the low reliability of the GASP scales, their

correlation with the ARNI Anticipated Negative Affect scale was interpreted with

caution.

Table 3. Measure descriptive statistics (N=175)

Measure Min-Max Mean (SD) Median (Range)

Cronbach’s Alpha

GASP nbe 4- 28 20.03 (5.33) 20 (24) .660GASP rep 4- 28 21.26 (4.13)

23.24 (4.12)13.04 (4.75)14.63 (10.1)5.36 (5.6)30.3 (8.54)

22 (24) .509GASP nse 4- 28

4- 280- 480- 2810- 50

24 (20)13 (23)15 (39)4 (25)30 (40)

.615GASP with .589TAF Moral .921TAF Likelihood .924SCS total .895

GASP nbe – GASP Guilt Negative Behaviour Evaluation subscale; GASP rep – GASP Guilt Repair subscale; GASP nse – GASP Shame Negative Self Evaluation subscale; GASP with – GASP Shame-Withdraw subscale

3.5 Distribution Checking

The measures were assessed for normality using visual inspection of histograms. In

this sample, scores for self-concealment and most of the guilt and shame scale scores

were approximately normally distributed. Shame Negative Self-Evaluation showed

evidence of negative skew. TAF-Likelihood and ARNI Anticipated Disclosure were

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positively skewed. TAF-Moral and ARNI Anticipated Negative Affect did not show

evidence of skew. With the exception of the latter two variables (which would have

been expected to be positively skewed for TAF-Moral and negatively skewed for

Anticipated Negative Affect), distributions were in keeping with a non-clinical

general population sample and theoretical expectation.

Pearson product-moment correlation coefficient was used where scores on

one or both measures was normally distributed (Clark-Carter, 1997). For those

correlations where both measures were not normally distributed, Spearman’s

correlation analysis was also used to compare with Pearson’s in order to assess the

robustness of the parametric analysis (see Appendix J for histograms). In the text

below, all correlations reported are Pearson’s.

3.6 Concurrent Validity of the ARNI

Self-concealment (SCS scores) was significantly negatively correlated with ARNI

Anticipated Disclosure with a moderate effect. (r=-30, p<.001). The higher the

general self-concealment, the lower the anticipated disclosure. Correlations between

the GASP scales and ARNI Negative Affect are shown in Table 4. Each of the GASP

dimensions was significantly positively correlated with the ARNI Anticipated

Negative Affect scale. The correlations were small to moderate. The size of the

correlations might be deflated due to the low internal reliability of the GASP scales.

These analyses provide some initial support for the validity of the ARNI scales as

they indicate that the greater the guilt and shame proneness, the greater the likelihood

of negative affect in anticipation of negative intrusions. Furthermore, the lower the

general tendency to conceal, the greater the anticipated likelihood of disclosing

negative intrusions.

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Table 4. Pearson’s correlation between shame, guilt, self-concealment and ARNI negative affect and disclosure scores (N=175)

Variable  1 2 3 4 51. ARNI Negative Affect .31** .28** .23* .24**2. GASP nbe3. GASP rep4. GASP nse5. GASP with

Note. GASP nbe – GASP Guilt Negative Behaviour Evaluation subscale; GASP rep – GASP Guilt Repair subscale; GASP nse – GASP Shame Negative Self Evaluation subscale; GASP with – GASP Shame-Withdraw subscale*p<.05; **p<.01

3.7 Hypothesis testing

Hypothesis 1: TAF will be positively correlated with negative affect (shame, guilt

and fear) in response to negative intrusions.

The correlations between both TAF subscales and ARNI are displayed in Table 5. As

hypothesised, there was a significant positive correlation between both TAF

subscales and ARNI Anticipated Negative Affect. The effect size was stronger for

the correlation with TAF-Moral.

Table 5. Pearson’s correlations between TAF subscales and ARNI subscales

Variable  1 2 3 41. TAF-Moral .59** .18*2. TAF-Likely .28** -.0023. ARNI Negative Affect .0584. ARNI Disclosure

Note. *p<.05; **p<.001

Hypothesis 2: Negative affect (shame, guilt and fear) in response to negative

intrusions will mediate the relationship between TAF-Moral and disclosure of

negative intrusions.

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The correlation analysis (Table 5) indicated a significant small positive relationship

between TAF-Moral and ARNI Disclosure. There was no evidence of a relationship

between TAF-Likelihood and ARNI Disclosure or between the two ARNI subscales

(see Table 5). As TAF-Likelihood and ARNI Anticipated Disclosure showed

evidence of skew, Spearman’s correlation analysis was run. The resulting coefficient

did not differ from the Pearson’s coefficient (rs = -.007).

Hayes’ (2013) PROCESS Model 4 was used to test the mediation hypothesis.

Two analyses were run with the antecedent X variable being either TAF-moral or

TAF-likelihood. Bias-corrected bootstrap confidence intervals were calculated to test

indirect effects based on 20,000 bootstrap samples. The regression coefficients,

standard errors and model summary information are shown in Table 7.

TAF-moral. The mediation analysis indicated that strength of TAF-moral

belief was related to anticipated disclosure independent of anticipated negative affect

(c’ = -.753, p = .0004). Stronger TAF-moral beliefs were associated with less

willingness to disclose hypothetical negative intrusions. However, the mediation

analysis also indicated that the indirect effect of TAF-moral beliefs on anticipated

disclosure through anticipated negative affect was significantly positive. The bias-

corrected bootstrap confidence interval for the indirect effect was entirely above zero

(.1304 to .5823). The regression coefficients indicate the greater the TAF-moral

beliefs the higher the anticipated negative affect (1.720), and the higher the

anticipated negative affect the greater the anticipated likelihood of disclosing

(0.198).

However, the mediation analysis results need to be seen in the context of the

lack of evidence of a correlation between anticipated negative affect and anticipated

disclosure (r = .058, p = .446, N = 175), as well as examination of the regression

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coefficients of the effect of TAF-moral on anticipated disclosure both with (B =

-.754) and without negative affect (B = -.413) in the model. The lack of correlation

between affect and disclosure as well as the increase in the beta coefficient for TAF-

moral with negative affect in the model indicates a potential suppressor effect

(Paulhus, Robins, Trzesniewski & Tracy (2004). In a suppressor effect, the

suppressor variable (in this case negative affect) suppresses the power of a predictor

variable (TAF moral) as a predictor of outcome (anticipated disclosure) when the

suppressor is not in the model (Cohen, Cohen, West & Aiken, 2003). In essence, the

inclusion of the suppressor in the model allows the actual power of the predictor to

be seen; that is, its effect becomes unsuppressed (Paulhus et al., 2004). Furthermore,

the beta weights with one or both variables in the model predicting anticipated

disclosure suggests evidence of ‘cooperative suppression’. Paulhuis et al. (2004) note

that cooperative suppression is indicated where both predictors are positively

correlated (in this case, TAF moral and negative affect r=.59) and where the

inclusion of both predictors therefore “controls for their overlap and their mutual

suppression is revealed by boosts in both regression weights” (p309). Table 6 below

demonstrates evidence for cooperative suppression. The regression beta weights are

shown before and after entry of the other predictor and indicate an improvement in

the beta weight of both predictors.

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Table 6: Beta weights for prediction of anticipated disclosure indicating cooperative suppression

Predictor Beta weight before entry of other predictor

Beta weight after entry of other predictor

Moral TAF -.413 (p=.016) -.754 (p<.001)

Negative Affect .045 (p=.446) .198 (p=.006)

TAF-likelihood. The mediation analysis indicated that there was no effect of

TAF-likelihood belief on anticipated disclosure (c = -.0084, p = .978). Given Hayes

(2013) notes that mediation analysis “no longer imposes evidence of a simple

association between X and Y as a precondition” (p88), the bias-corrected bootstrap

confidence interval for the indirect effect of TAF-likelihood belief on anticipated

disclosure through anticipated negative emotion was examined. This showed no

evidence of an effect. The bias-corrected bootstrap confidence interval spanned zero

(-.0960 to .3014).

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Table 7. Regression coefficients, standard errors and model summary information for TAF-moral (row 1) and TAF-likelihood (row 2) mediation models

M (Negative Affect) Y (Disclosure)Coeff. SE p Coeff. SE p

X (TAF-Moral) 1.720 0.178 <.001 -0.753 0.206 <.001

M (Negative Affect) - - - 0.198 0.071 .0059

Constant -0.126 5.092 .980 34.695 4.756 <.001

R2 = 0.348

F(1,173) = 92.535, p <.001

R2 = 0.074

F(2,172) = 6.946, p = .0013X (TAF-Likelihood) 1.470 0.383 <.001 -.081 0.325 .802

M (Negative Affect) - - - 0.049 0.061 .424

Constant 27.514 5.202 <.001 22.403 4.569 <.001

R2 = 0.078

F(1,173) = 14.710, p <.001

R2 = 0.003

F(2,172) = 0.321, p = .725Note. Table format modelled on Hayes (2013, p152)

4.0 Discussion

4.1 Summary of Findings

The aim of the study was to assess the relationship between TAF beliefs, anticipated

response to negative intrusions and anticipated disclosure of intrusions.

Hypothesis one, that TAF beliefs would be positively correlated with

anticipated negative affect from hypothetical negative intrusions was supported.

There was a significant positive correlation between each of the TAF subscales and

ARNI Anticipated Negative Affect with a stronger effect size for TAF-Moral.

Hypothesis two, that anticipated negative affect from experiencing negative

intrusions would mediate the relationship between TAF beliefs and anticipated

likelihood of disclosure of negative intrusions, received mixed support. There was no

evidence of a significant indirect relationship for TAF likelihood beliefs on

disclosure through negative affect. The findings for TAF moral suggested 83

‘inconsistent mediation’ (i.e. a suppressor effect); this was evidenced by the signs of

the direct and indirect pathways being opposite (MacKinnon, Krull & Lockwood,

2000). Further analysis indicated evidence of what Paulhuis et al. (2004) call

‘cooperative suppression’; the beta weights of both predictors increased when both

were included in the model in contrast to when each predictor was entered in the

model alone. In explaining a cooperative suppression effect, Paulhuis et al. (2004)

propose that a specific construct might be captured by the shared variance between

two predictors “the removal of which enhances the clarity of both” (p319). In the

current study, it could be proposed that TAF moral and anticipated negative affect

share variance because both assess the idea that immorality arises from thinking.

However, in the case of TAF moral, the construct is a belief (“my thoughts make me

a bad person”) and this might inhibit disclosure (“others will think I am bad”). In

contrast, the negative affect variable represents a consideration of the emotional

consequences of having bad thoughts along the lines of shame, guilt and fear and this

might motivate disclosure (e.g. to gain reassurance that one is not immoral or

dangerous). However, given this is the first study to investigate TAF moral,

anticipated response to intrusions and anticipated disclosure replication studies are

needed to clarify these effects.

4.2 Theoretical significance of the findings

Before considering the application of the findings to current evidence and theory, it

is important to note that whilst the findings support a putative model from TAF-

moral to anticipated willingness to disclose, the use of regression analysis in a cross-

sectional study cannot establish causal relationships. A tendency to avoid disclosure

might influence a person’s beliefs about the connection between their thinking and

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their moral character. Instead, the analytic techniques used in this study allow

theoretically derived propositions to be tested whilst acknowledging that other ways

of modelling variables is possible. With this caveat in mind the theoretical

significance of the findings is considered.

TAF beliefs were positively associated with anticipated negative affect. This

suggests that a general belief in the equivalence of thought and action provides a

context in which thinking of highly unacceptable situations provokes the anticipation

of fear, shame and guilt. This finding supports Salkovskis et al’s. (2000) suggestion

that both types of TAF belief are associated with negative affect. The study findings

indicated that anticipated negative affect from intrusions was more strongly related to

TAF-Moral beliefs than TAF-Likelihood beliefs. It is possible that this is due to the

ARNI Negative Affect factor comprising two moral emotions – shame and guilt –

and, as a result, TAF-moral shares more variance with anticipated negative affect

than TAF-likelihood. Additionally, TAF-likelihood was not related to anticipated

disclosure of negative intrusions whereas TAF-moral was negatively associated with

anticipated disclosure. Additionally, the effect of TAF-moral on anticipated

disclosure was stronger when negative affect was controlled. This finding is

consistent with existing literature that suggests people would avoid revealing a

potential immoral character to other people for fear of being socially

rejected/stigmatised (Simonds & Thorpe, 2003; Cathey & Wetterneck, 2013).

Interestingly, the analysis indicated that anticipated negative affect was associated

with increased likelihood of disclosure when TAF-moral was controlled. Violent,

aggressive and unpleasant obsessions are likely to induce negative affect (e.g. fear,

shame and guilt) and interestingly it was obsessions of this content that were found

to be associated with help-seeking in García-Soriano et al’s (2014) review.

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Theoretically it might be expected that this would be the case because guilt is

associated with approach behaviour (Kim et al, 2011) and fear is likely to prompt

disclosure in order to seek reassurance that one is not bad or dangerous. However

shame is theorised to have the opposite effect (i.e. should produce concealment

rather than disclosure). The factor structure of the ARNI provides further insight into

why negative affect was positively related to disclosure despite it comprising shame

items.

In developing the ARNI, shame, guilt and fear were operationalized as

components of the affective response to negative intrusions based on the literature

(Kim et al, 2011; Lewis (1971); Salkovskis, (1985); Shapiro and Stewart, 2011;

Valentiner and Smith, 2008; Weingarden and Renshaw, 2015). It was anticipated that

the items corresponding with these components would aggregate into separate factors

given that shame and guilt, but not fear, are self-conscious ‘moral’ emotions and that

shame and guilt can be differentiated in terms of cognitive, affective and behavioural

responses. Instead, all the affect items loaded onto a single factor suggesting that the

affective response to intrusions is not differentiated along the lines of these separate

emotions. As such, participants in this study responded to an imagined negative

intrusion with both shame and guilt and with fear. This potentially suggests that

targeting a person’s emotional response to an intrusion, such as feelings of shame,

might also have an effect on other components such as guilt and fear. It might be the

case that the intrusions investigated are so extreme in negative content that they have

the ability to provoke relatively high levels of all three emotions. And, as noted in the

Introduction, the same situation can prompt both guilt and shame (Kim et al, 2011).

Other possibilities are likely though. For example the shame and guilt items might

not have adequately differentiated these two emotions as the distinction is very subtle

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– a contrast between being bad and doing a bad thing. Future research could use

qualitative methods to explore participants’ emotional response to hypothetical

intrusions in much more detail to assess if distinctions are made between fear, shame

and guilt and the nature of those distinctions.

The current study is the first to provide evidence about reluctance to disclose

a large number of hypothetical intrusions in a non-clinical sample. Some of the help-

seeking literature indicates that individuals would be reluctant to report obsessions of

a violent, sexual and unacceptable nature (Simonds and Elliott, 2001; Newth, and

Rachman, 2001). Descriptive analysis of the individual ARNI scenarios indicated

that some of the more unacceptable intrusions (i.e. harming a vulnerable child;

kicking a vulnerable kitten) resulted in the lowest likelihood of disclosure. However,

the findings noted above suggested that higher anticipated negative affect is

associated with greater likelihood of disclosure. This supports García-Soriano et al

(2014) who found that violent and unpleasant obsessions predicted help-seeking. The

current findings suggest therefore that some scenarios are considered to result in less

disclosure than others, typically those that are the most unacceptable, but that higher

anticipated negative affect is likely to promote disclosure and, possibly, help-

seeking.

4.3 Strengths, limitations and recommendations for further research

The ARNI was developed for the purposes of this study due to the absence of a

scenario-based instrument measuring response to negative intrusions. No previous

study has attempted to assess response to several negative intrusion scenarios in the

general population. Although the ARNI does not capture every possible negative

intrusion experienced, the scenarios were based on those commonly presented in the

87

clinical and theoretical literature (Purdon and Clark, 1992; Burns, Keortge, Formea

and Sternberger, 1996). The descriptions also distinguished the different ways in

which intrusions can present (i.e. as images, urges, or thoughts). The internal

reliability of the two ARNI subscales was excellent, however, it was not possible to

gain test-retest reliability within the constraints of the study. The subscales were

assessed against established scales of general self-concealment (SCS) and general

guilt and shame proneness (GASP). ARNI Anticipated Disclosure was significantly

negatively related to general self-concealment (as disclosure reduces, concealment

increases) which was as expected. Establishing the validity of ARNI Negative Affect

was more challenging because the GASP had low internal reliability in the sample.

Alongside this, the ARNI Negative Affect factor contained fear items as well and

this may have deflated the correlation with the GASP, a measure of guilt and shame

proneness. However, given that shame, guilt and fear items all loaded together on to

the one factor, it was reasonable to correlate them with GASP to assess validity.

ARNI Anticipated Negative Affect was significantly positively correlated with

general guilt and shame proneness with a small effect size. In light of the limited

validity data for the ARNI, further psychometric assessment is needed. However, as

noted above, a step back might be needed to establish qualitatively, and in more

detail, emotional responses to hypothetical intrusions.

The study met the required sample size for hypothesis-testing, although was

modest for a factor analysis. The sample was homogenous comprising of mostly

White, females who were employed, in relationships and educated to degree level or

higher. Furthermore the participants were volunteers agreeing to take part in the

research of their own volition. This presents a barrier to the generalisability of the

findings. Due to the lack of diversity within the sample, further research is needed on

88

more diverse samples. For example, responses to hypothetical intrusions in terms of

affect and concealment may be more or less impacted by belief systems. Individuals

with strong religious beliefs may have a general tendency to attribute unacceptable

thoughts as immoral and, in turn, experience inflated affect (Steketee, Quay &

White, 1991) and maladaptive beliefs about their own moral character (Siev,

Chambless & Huppert, 2010) more so than non-religious individuals. There are also

known cultural differences in the experience and expression of shame and guilt and

in attitudes towards formal help-seeking.

This study offers insight into the possible relationship between TAF, affect

and disclosure in the non-clinical individuals. However, the extent to which the

findings are representative of the wider non-clinical population is unclear since the

sample was relatively homogenous. Future research could replicate this study’s

methodology with different non-clinical groups. Clinical samples could also be

recruited to investigate whether there are differences in OCD and non-clinical

populations with regard to TAF, affect and disclosure in relation to intrusions.

It is important to note that around half of the respondents who began the

survey dropped out. It is not clear why this was the case although it was observed

that the greatest number of drop-outs or missing data occurred during completion of

the ARNI. It is possible that this measure provoked negative affect or activated TAF

beliefs for some participants that prompted termination. As a result, those who

completed the study might be more motivated and less affected by considering

hypothetical negative intrusions. Future studies should gain consent to use data of

those who withdraw prior to completion so that they can be compared with those

89

who complete. Additionally, qualitative information could be gathered from

participants regarding their reasons for dropping out.

Causality could not be drawn from the findings and so further research could

address the hypotheses through an experimental design. This of course reduces the

ecological validity that studies of this nature offer to the literature base. The current

study is valuable because it has given a sense of how participants would respond to a

range of different negative intrusions, however a qualitative study could usefully

follow this up by understanding what it is about the different scenarios that make

them more or less likely to result in shame, guilt, fear and disclosure and how

participants would make decisions about disclosing. This could be carried out in both

clinical and non-clinical groups.

4.4 Clinical implications

The study has two broad potential implications. Firstly, the findings suggest that

people in the general population anticipate feeling shame, guilt and fear if they were

to experience negative intrusions of the type presented within the study and they

express unwillingness to disclose these intrusions. Given these are the types of

intrusions that people with OCD experience (Purdon and Clark, 1992; Burns,

Keortge, Formea and Sternberger, 1996), this says something important about the

difficulties that people with OCD face. For example, it supports their reluctance to

tell others about their intrusions due to anticipating that other people will find their

thinking unacceptable. As noted above, participants deemed some thoughts more

unacceptable than others in terms of their ability to promote guilt, shame, fear and

90

concealment. This is important as it highlights some of the clinical implications for

treatment in that even when seeking help, individuals may be more willing to

disclose some intrusions and not others. Newth and Rachman (2001) proposed that

some individuals are less likely to share their more shameful obsessions even within

therapy due to shame, embarrassment and fears of being ostracised. They also

describe the tentative role of the therapist in enabling the individual to disclose their

obsessions noting disclosure as a therapeutic experience. One of the benefits of

researching within the general population is that, through participation, knowledge

around intrusions will have increased and this knowledge may serve to reduce stigma

related to negative intrusions. Ideally in turn, this will enable those experiencing life-

limiting intrusions to seek help sooner, thus targeting the clinical population at an

earlier stage.

Secondly, the current findings suggest potential intervention implications

although these are very tentative and further research is needed. There appear to be

opposing forces in terms of disclosure. The data suggest that TAF moral beliefs

might inhibit disclosure and, as such, targeting such beliefs in therapy might make it

easier for people to disclose their more feared intrusions. Equally, given the cross-

sectional design and that the relationships might be bi-directional, it is possible that a

strong therapeutic relationship that models positive response to disclosures could

have an impact on TAF-moral beliefs because it would indicate the people may not

necessarily make moral judgements on the basis of intrusive thoughts alone (i.e. the

therapist demonstrates acceptance of the person despite them revealing intrusions).

91

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Appendices to the Empirical Paper

Appendix A – Survey Participant Information Sheet

Appendix B – Survey Consent Form

Appendix C – Survey Demographic Information

Appendix D – Survey Measures

Appendix E – Survey Debrief Screen

Appendix F – Advertisment Poster

Appendix G – Advertising Email

Appendix H – Ethical Approval

Appendix I – Pattern Matrix for ARNI Factor Loadings

Appendix J – Histograms for Measures

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Appendix A Survey Participant Information Sheet

Participant Information Sheet 23rd February 2016 (version 2)

PROJECT TITLE Emotions and Sharing Negative Thoughts.

IntroductionMy name is Kaighley Wells-Britton, a Trainee Clinical Psychologist studying at the University of Surrey. I invite you to take part in a research project, the details of which are below. Please take the time to read the following information carefully and talk to others about the study if you wish.What is the purpose of the study?I am looking at intrusions, which are thoughts, images or urges that enter your mind suddenly. In this study, I am focusing particularly on negative intrusions (e.g. an image of you doing something bad such as hurting animals, children or other people). Everyone has negative intrusions that suddenly come into their mind so there is nothing unusual about this. I want to find out how people feel about negative intrusions and whether the way that they feel about them would influence whether they told other people that they have had them.

What will my involvement require?If you choose to take part, you will be taken to a consent page before proceeding to an online survey which consists of a series of questionnaires. The survey should take approximately 20 minutes to complete.

Do I have to take part?No, your participation is voluntary and you can withdraw at any time during completion of the survey without giving a reason.

What are the possible disadvantages or risks of taking part?You may find some of the content within the questions upsetting as there are descriptive examples of negative intrusions (e.g. ideas about people being hurt). A page at the end of the survey provides information for sources of support or information, should you feel that you need this. If you are unable to complete the survey but would like to receive information for sources of support, you can click ‘end survey’ at the bottom of any of the pages (rather than the ‘X’ at the top of the page) and this will direct you to the sources of support page.

What are the possible benefits of taking part?It is unlikely that you will benefit directly from taking part but it is hoped that your contribution will add to the understanding of intrusions and what factors may prevent people from disclosing these to others.

What if there is a problem?

97

Any complaint or concern about any aspect of the study will be addressed; please contact me, Kaighley Wells-Britton (Principal researcher) in the first instance or alternatively my supervisor. Our contact details are below.

Will my taking part in the study be kept confidential?Yes. At no point in this survey will you be asked to given personally identifiable data (e.g. your name or email address). So, all of the information given is anonymous. This does mean that once you complete the survey and submit your data there will be no way of withdrawing it afterwards. Data will be stored securely in accordance with the Data Protection Act 1998.

What if I want to know the results of the study?If you wish to know the results of the study, please email me using the email address below in May 2017 and I can forward these on to you.

Contact detailsKaighley Wells-Britton (Principle Researcher)Trainee Clinical Psychologist PsychD Doctoral Training ProgrammeUniversity of Surrey k.wells-britton@surrey.ac.uk

Prof Derek MooreHead of School of Psychologyd.moore@surrey.ac.uk01483 686933

Who has reviewed the project?

The study has been reviewed and received a Favourable Ethical Opinion (FEO) from the Faculty of Health and Medical Sciences Ethics Committee at the University

Thank you for taking the time to read this Information Sheet.

Appendix B Survey Consent Form

98

Dr Laura Simonds (Supervisor)Lecturer in Clinical PsychologyPsychD Doctoral Training ProgrammeUniversity of Surrey l.simonds@surrey.ac.uk

Consent Form [version 2, date 23/02/16]

Emotions and Sharing Negative Thoughts

Please indicate that you understand and consent to each of the below statements by ticking each box.

I have read and understood the Information Sheet provided (version 2, date 23/02/16). I have been given a full explanation by the investigators of the nature, purpose and likely duration of the study, and of what I will be expected to do.

I have been advised about any disadvantages of taking part in the study.

I agree to comply with the requirements of the study as outlined to me to the best of my abilities.

I agree for my anonymised data to be used for this study.

I understand that all project data will be held for at least 6 years and all research data for at least 10 years in accordance with University policy and that my personal data is held and processed in the strictest confidence, and in accordance with the UK Data Protection Act (1998).

I understand that I can withdraw my participation from the study at any time during the completion of the survey but that following completion, I cannot withdraw my data.

I understand that the group data may be published in an academic journal, but that all data supplied are anonymous

I confirm that I have read and understood the above and freely consent to participating in this study. I have been given adequate time to consider my participation.

I agree for my data to be used in future research that will have received all relevant legal, professional and ethical approvals.

Name of participant ......................................................

Signed ......................................................

Date ......................................................

Appendix C Survey Demographic Information

99

Main StudyDEMOGRAPHIC INFORMATION

Please provide some demographic information about yourself. All information you provide will remain completely confidential and will not be used for identification purposes.

AGE:_________ years

WHAT IS YOUR GENDER IDENTITY:

FemaleFemale to male transgenderMaleMale to female transgenderNot sureOther (please specify): _______________________________

RELATIONSHIP STATUS:

SingleRelationship, co-habitingRelationship, not co-habitingMarriedSeparatedDivorced/DissolvedWidowed

EMPLOYMENT STATUS:

Employed full-timeEmployed part-timeUnemployedSelf-employedStudentRetiredHomemakerOther (please state) _________________________

EDUCATION/QUALIFICATIONS:

No formal qualificationsGCSEs/O-Levels/NVQ/EquivalentA-Levels/EquivalentUndergraduate DegreePostgraduate DegreeETHNICITY:

100

To which ethnic group do you feel you belong?

White

BritishIrishEuropeanOther

Black or Black British

CaribbeanAfricanOther

Asian or Asian British

IndianPakistaniBangladeshiOther

Chinese

ChineseChinese British

Mixed

White and Black CaribbeanWhite and Black AfricanWhite and AsianOther

Other(please specify) _______________________________

From which country are you completing this survey? _________________________

Appendix D (i) Survey Measures: Anticipated Response to Negative Intrusions (ARNI)

101

Anticipated Response to Negative Intrusions (ARNI)

Appendix D (ii) Survey Measures: Guilt and Shame Proneness Scale (GASP)

102

Guilt and Shame Proneness Scale (GASP Scale, Cohen, Wolf, Panter & Insko, 2011)

Appendix D (iii) Survey Measures: The Padua Inventory-Washington State University Revision (PI-WSUR)

103

The Padua Inventory-Washington State University Revision (PI—WSUR; Burns, Keortge, Formea & Sternberger, 1996)

Appendix D (iv) Survey Measures: The TAF Scale (Revised)

The TAF Scale (Revised), (Shafran, Thordarson & Rachman, 1996)

104

Appendix D (v) Survey Measures: Self-Concealment Scale (SCS)

Self-concealment Scale (SCS; Larson and Chastain, 1990)

105

Appendix E Survey Debrief Screen

Debrief Screen

106

Thank you for taking the time to complete this survey. Your responses are very valuable. In this study, I am trying to understand how people feel about having negative intrusions. Negative intrusions are unwanted thoughts, images or urges which suddenly seem to pop into your mind and are usually about things that we do not want to happen (e.g. someone being hurt or us hurting someone). Lots of research evidence suggests that people in the general population experience negative intrusions so there is nothing unusual about this. Some people can become quite upset by their intrusions and feel they make them a bad person. This makes them want to hide them and not tell others. This can become a problem because hiding them can lead to anxiety problems and depression. If people tell others they can realise that these experiences are normal and do not make them bad. I hope this study will help us understand more about why people don’t tell others when they have these thoughts.

If you feel that you want to know more about negative intrusions or think that you need help or some support for any negative intrusions you might experience, please find information below which details sources of support and information.

- NHS Choices is a website run by the NHS and provides information about mental and physical healthWebsite: http://www.nhs.uk

- Anxiety UK provides information for people affected by anxiety problemsWebsite: https://www.anxietyuk.org.uk/ Tel: 08444 775 774

- Mind provides information and support for people affected by mental health problemsWebsite: http://www.mind.org.uk/ Tel: 0300 123 3393

- OCD UK is a support group for people affected by obsessive-compulsive disorderWebsite: http://www.ocduk.org/ Tel: 0845 120 3778

- Samaritans provides support for people in crisisWebsite: http://www.samaritans.org/ Tel: 116 123

- Your GP can provide advice and information and is the first port of call should you become concerned about having thoughts of harming yourself

Thank you for taking part in the survey, your responses are invaluable to the study and will add to the ever growing research in psychology.For more online psychology studies visit www.onlinepsychresearch.co.uk

Kaighley Wells-BrittonTrainee Clinical PsychologistUniversity of Surrey

Appendix F Advertisement Poster

107

TAKE PART IN A STUDY ON

Emotions and Sharing Thoughts

By completing a 20 minute online survey

Any questions please contact kw00267@surrey.ac.uk

This study has received a favourable ethical opinion from the Faculty of Health and Medical Sciences Ethics Committee at the University

Appendix G Advertisement Email

108

My name is Kaighley Wells-Britton, a Trainee Clinical Psychologist studying at the University of Surrey.

I am currently researching into the relationship between emotions and the sharing of negative thoughts .

My research requires participants to take part in an online survey which I invite you to complete.

Your responses to the survey will be a valuable contribution to ongoing research in psychology.

The survey should take around 20 minutes and the link is included below.

 

For more information please e-mail me on:

kw00267@surrey.ac.uk

 

This study has received a favourable ethical opinion from the School of Psychology Ethics Committee, FHMS, University of Surrey

Many thanks.

Kaighley Wells-BrittonTrainee Clinical PsychologistUniversity of Surrey

Appendix H Ethical approval

Faculty of Health and Medical Sciences Ethics Committee

109

Chair’s Action for Amendment

Proposal Ref: 1158-PSY-16

Name of Student/Trainee: KAIGHLEY WELLS-BRITTON

Title of Project: Shame, Guilt and the Concealment of Negative Intrusions

Supervisor: Dr Laura Simonds

Date of submission of original proposal:

Date of FEO being granted:

Date of submission of proposed amendment:

Date of FEO for Amendment:

7th January 2016

17th March 2016

24th May 2016

25th May 2016

An amendment for the above Research Project has been submitted to the Faculty of Health and Medical Sciences Ethics Committee and has received a favourable ethical opinion on the basis described in the protocol and supporting documentation.

The final list of documents reviewed by the Committee may include:

Ethics Application FormDetailed Protocol for the projectParticipant Information sheetConsent FormDebrief Page

All documentation from this project should be retained by the student/trainee in case they are notified and asked to submit their dissertation for an audit.

Signed and Dated: 25/05/2016. Dr Anne Arber, Professor Bertram Opitz, Co-Chairs, Ethics Committee

Please note: If there are any significant changes to your proposal which require further scrutiny, please contact the Faculty of Health and Medical Sciences Ethics Committee, before proceeding with your Project.

Appendix I Pattern Matrix for ARNI factor loadings

Pattern Matrixa

110

Factor

1 2

Stab family fear .734 .064

Stab family shame .670 -.064

Stab family guilt .734 -.032

Stab family tell .017 .832

Funeral insult guilt .675 -.027

Funeral insult shame .772 -.057

Funeral insult fear .784 -.039

Funeral insult tell .022 .728

Train push tell -.022 .816

Train push shame .872 -.025

Train push guilt .868 -.042

Train push fear .853 .064

Car oncoming shame .716 .036

Car oncoming guilt .869 -.096

Car oncoming fear .853 .057

Car oncoming tell -.004 .862

Kitten kick guilt .700 .106

Kitten kick shame .791 -.021

Kitten kick tell -.033 .737

Kitten kick fear .821 .028

Neighbour racist fear .758 .083

Neighbour racist shame .831 .036

Neighbour racist guilt .776 -.014

Neighbour racist tell .046 .723

Baby smother shame .796 -.080

Baby smother fear .831 .011

Baby smother tell .096 .725

Baby smother guilt .793 .014

Cliff jump tell .009 .706

Cliff jump shame .705 .036

Cliff jump fear .758 .055

Cliff jump guilt .749 .005

Expose fear .774 .114

Expose shame .788 .024

Expose tell -.044 .715

Expose guilt .785 .013

Steal shame .863 -.074

Steal tell -.044 .652

Steal guilt .871 -.055

Steal fear .776 .004

111

Smash guilt .796 -.080

Smash shame .746 -.056

Smash fear .693 .024

Smash tell -.024 .712

Extraction Method: Principal Axis Factoring.

Rotation Method: Oblimin with Kaiser Normalization.a

a. Rotation converged in 3 iterations.

Appendix J (i) Histograms for measures

Anticipated Response to Negative Intrusions (ARNI) Disclosure

112

Appendix J (ii) Histograms for measures

ARNI Negative Affect

113

Appendix J (iii) Histograms for measures

TAF-Moral

114

Appendix J (iv) Histograms for measures

TAF-Likelihood

115

Appendix J (v) Histograms for measures

Guilt and Shame Proneness (GASP) Scale - Guilt Negative Behaviour Evaluation

116

Appendix J (vi) Histograms for measures

GASP - Guilt Repair

117

Appendix J (vii) Histograms for measures

GASP - Shame Negative Self Evaluation

118

Appendix J (viii) Histograms for measures

GASP - Shame Withdraw

119

Appendix J (ix) Histograms for measures

Self-Concealment Scale (SCS)120

Part 3 – Summary of Clinical Experience

121

Summary of clinical placement experience from November 2014 – September 2017

YEAR 1: Adult Mental Health (November 2014 – September 2015)

Setting: Community Mental Health Recovery Service for Working Age Adults. Clients and presenting difficulties: Working age adults (aged 18 – 65 years) with severe and enduring mental health problems. Presentations of clients I worked with included bipolar disorder, depression, social anxiety, generalised anxiety disorder psychosis, obsessive compulsive disorder (OCD) and borderline personality disorder and cognitive difficulties.Main models used: CBT, ACT and neuropsychological models.Modes and types of work: Direct individual work, group work, indirect work, consultation, joint working with other professionals, presentations to carers, case presentations and CBT teaching to staff.

YEAR 2: Children and Adolescents (October 2015 – March 2016)

Setting: Child and Adolescent Mental Health ServiceClients and presenting difficulties: Children and adolescents (aged up to 18 years) with moderate to severe mental health problems. Presentations of clients included depression, eating disorders, separation anxiety, emotional dysregulation, ADHD, obsessive compulsive disorder, ASC, anxiety and Tourette’s. Main models: CBT, ACT, systemic and neuropsychological models. Modes and types of work: Direct individual work, systemic family practice, indirect work with families and schools, neuropsychological assessments, consultation, joint working with other professionals, presentation and training to staff.

YEAR 2: Older Adults (April 2016 – September 2016)

Setting: Split placement across a Community Mental Health Team for Older Adults, a dementia assessment ward, and a functional mental health ward for older adults.Clients and presenting difficulties: Older adults (aged 65 + years plus one working age adult with early onset dementia) affected by dementia and/or mental health problems. Presentations

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included depression, obsessive compulsive disorder, anxiety, social anxiety, early onset dementia and difficulties associated with dementia. Main models: CBT, systemic, ACT and functional analysis and neuropsychological models.Modes and types of work: Direct work with individuals and families indirect work with and staff teams, PBS work with ward staff, facilitation of formulating session with staff, case presentation, CBT supervision of staff, joint working with other MDT professionals and neuropsychological assessments.YEAR 3: Learning Disabilities (October 2016 – March 2017)

Setting: Community Learning Disabilities Team working with adults with learning disabilities.Clients and presenting difficulties: Adults (aged 18 + years) with a learning disability, ASC and mental health difficulties. Presentations included depression, trauma, anxiety, relational difficulties, behaviour that challenges, ASC and dementia.Main models: CAT, systemic, functional analysis and neuropsychological models.Modes and types of work: Direct work with individuals, families, carers and staff teams, consultations and indirect work with support workers and families, presentation to psychology teams, PBS work, neuropsychological assessments for LD, dementia and ASC.

YEAR 3: Specialist Chronic Pain and Health Psychology (April 2017 – September 2017)Setting: Split placement across Chronic Pain and Health Psychology services Clients and presenting difficulties: Adults (aged 18+ years) with chronic pain and health conditions, inpatient and outpatients. Presentations included chronic pain, low mood, anxiety, difficulties adjusting to health conditions, trauma following medical procedures / accidents, stroke / cognitive difficulties, difficulties associated with loss.Main models: CBT, ACT, multidisciplinary pain management, Integrative, neuropsychological models.Modes and types of work: Direct work with individuals, couples work, group work, joint work with MDT, indirect work with ward staff / outpatient staff, presentations to physiotherapists, community support group and health psychology team, neuropsychological assessment.

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Part 4 – Table of Assessments Completed During Training

PSYCHD CLINICAL PROGAMME

TABLE OF ASSESSMENTS COMPLETED DURING TRAINING

Year I AssessmentsASSESSMENT TITLE

WAIS WAIS Interpretation (online assessment).Practice Report of Clinical Activity

A cognitive behavioural therapy (CBT) assessment with a woman in her late forties experiencing anxiety and low mood.

Audio Recording of Clinical Activity with Critical Appraisal

A critical appraisal of a cognitive behavioural therapy (CBT) intervention with a British woman in her thirties experiencing social anxiety.

Report of Clinical Activity N=1

A cognitive behavioural therapy (CBT) assessment and intervention with a British woman in her early thirties experiencing social anxiety.

Major Research Project Literature Survey

To what extent are moral concerns a feature of different obsessive compulsive subtypes.

Major Research Project Proposal

Shame, guilt and the concealment of negative intrusions.

Service-Related Project Evaluating the effectiveness of a course of ‘Mindfulness for Staff’ sessions.

Year II AssessmentsASSESSMENT TITLE

Report of Clinical Activity/Report of Clinical Activity – Formal Assessment

Assessing and treating a primary school age girl experiencing separation anxiety using cognitive behavioural therapy (CBT) and systemic models.

PPLD Process Account The personal and professional learning discussion group – reflections on group process.

Year III Assessments ASSESSMENT TITLE

Presentation of Clinical Activity

An assessment, formulation and integrative intervention with a woman in her 80’s experiencing anxiety, low mood and cognitive changes.

Major Research Project Literature Review

Is the form, content, frequency and distress associated with non-clinical intrusions similar to clinical obsessions?

Major Research Project Empirical Paper

Disclosure of Negative Intrusions: The Relationship with Thought-Action Fusion, Shame, Guilt and Fear.

Report of Clinical Activity/Report of

Formal assessment of a man in his early 20’s to determine the level of his learning disability and to assess for autism

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Clinical Activity – Formal Assessment

spectrum disorder

Final Reflective Account

A reflective account of my development during clinical psychology training focusing on the themes of ‘acceptance of feelings’ and ‘confidence’.

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