Obsessions & Delusions

8/8/2019 Obsessions & Delusions

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344 MICHAEL J. KOZAK and EDNA B. FOA

retention of over-valued ideas. The contrast between these phenomena lies in the falsity of theovervalued idea (Jaspers, 1959, p. 107). Jaspers construed delusions, on the other hand, asqualitatively different from normal beliefs in that they involve an abnormal way by which eventstake on meaning. Accordingly, the content of a delusion is not reasonably understandable(undversttindlich): a delusion appears not only to be false, but also perplexingly irrational.

Fish (in Hamilton, 1974) similarly distinguished between OVI and delusions, but emphasized adiscrepancy between belief and action in delusions and concordance between belief and action inOVI. Accordingly, action is more likely to be taken on the basis of OVI than of delusions becausetrue delusions are the result of a disintegration of personality, while overvalued ideas occur inan intact personality (Hamilton, 1974, pp. 52-53). Like Jaspers, Fish maintained that anovervalued idea is accompanied by strong affect, and that because of the associated feeling tone,takes precedence of all other ideas and maintains this precedence permanently (Hamilton, 1974,p. 43).

In his review of disorders with OVI, McKenna (1984) mentioned examples of psychopathologicalphenomena characterized by OVI: the querulous paranoid state, morbid jealousy, hypochondriasis,and anorexia nervosa. These disorders exemplify the occurrence of OVI that are nonintrusive,unresisted, and not seen as senseless, as distinct from intrusive, resisted, senseless obsessions.However, the examples do not clarify the distinction between OVI and delusion. Like Jaspers,McKenna maintained that delusions are characterized by an undefinable but easily recognizablealien quality (p. 583). This traditional view that delusions have an important indefinable qualitythat distinguishes them from OVI is not very helpful in illuminating these concepts. In general,although obsessions, OVI and delusions have been defined in the literature, the distinctions amongthese phenomena remain murky.

A recent attempt to clarify the distinctions can be found in DSM-III-R (APA, 1987). Obsessionsare defined as recurrent and persistent ideas, thoughts, impulses, or images that are experiencedat least initially as intrusive and senseless and the person attempts to ignore or suppress suchthoughts or impulses or neutralize them with some other thought or action (p. 247). An OVI isan unreasonable and sustained belief or idea that is maintained with less than delusional intensity.Accordingly, it differs from an obsessional thought in that the person does not recognize itsabsurdity and thus does not struggle against it (p. 402). Thus, OVI are almost unshakable beliefs,which can be acknowledged as potentially unfounded only after considerable discussion. A delusionis defined as a false personal belief based on an incorrect inference about external reality and firmlysustained in spite of what almost everyone else believes (p. 395). It follows that OVI aredistinguished from delusions by their less than delusional intensity; OVI are strongly heldunreasonable beliefs that are not as firmly held as delusional ideas. It is troublesome that althoughthe distinctions among obsessions, OVI and delusions rest on howjirmly the erroneous idea is held,there is no conventionally accepted method for determining the firmness or shakability of suchbeliefs. This leaves no formal way to determine whether a given idea is an obsession, an OVI ora delusion.

Although the distinctions among obsessions, OVI, and delusions seem clearly stated inDSM-III-R, further examination reveals ambiguities. One problem is that the diagnostic criteriaallow obsessions to be very strongly held beliefs, like OVI and delusions. Because they are definedas ideas that have been experienced at least initially as senseless, obsessions need not be alwaysrecognized as senseless. In addition, because there is no requirement that OVI or delusional ideasare always strongly held, the proviso that obsessions were at one point recognized as senseless doesnot help to distinguish them from OVI and delusions.

OVI AND DELUSIONS IN OCDJanet (1908) and, later, Schneider (1925) specified the following criteria for OCD: (1) subjective

feeling of being forced, or compelled to think, feel, or act; (2) content of the obsession is perceivedas absurd or nonsensical and ego alien; (3) the obsession is resisted.

These criteria notwithstanding, clinicians have recognized that many obsessive-compulsives donot fit this definition. Following Lewis (1935), Solyom, Sookman, Solyom and Morton (1985)noted that not all obsessive patients report the subjective feeling of forced thoughts or action, nor


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Obsessions, overvalued ideas and delusions in OCD 345

do they all recognize the senselessness of their obsessions or rituals. Accordingly, when theresistance becomes zero, the content of the thought is accepted and the obsession becomes adelusion (p. 177).

Solyom et al. (1985) noted Schneiders observation that in some patients with OCD, insight waspresent only upon quiet reflection. Although there are few research findings to support thisobservation (cf. Insel & Akiskal, 1986) clinicians experienced with OCD recognize that insight intothe senselessness of obsessive-compulsive fears is often situation-bound: an individual is more likelyto demonstrate insight under nonthreat conditions, i.e. when there is no impending contact withthe feared situation, than when facing such a situation. Thus, when patients are asked during aclinical interview how they assess danger objectively, they are more likely to show insight thanwhen they are afraid. Observations of lack of insight by patients about their obsessive-compulsivebeliefs raise the question of whether such patients should be considered psychotic. According toDSM-III-R, a major diagnostic criterion for psychosis is impaired reality testing, and the presenceof delusions constitutes an indicator of such impairment. If delusions entail psychosis, canobsessive-compulsives who perceive their obsessions as sensible and do not resist them beconsidered delusional, and therefore psychotic? That some obsessivecompulsives have psychoticfeatures has been suggested by Insel and Akiskal (1986). On the basis of case reports, they arguedthat psychotic experiences belong to the severe end of the obsessive-compulsive spectrum.

To study such atypical obsessivecompulsives, Solyom et al. (1985) selected 8 of 45 patientswith OCD who differed from typical obsessive-compulsives in that they had severely debilitatingmain obsessions bordering on the delusional but showed no schizophrenic symptoms. Differ-ences between the typical and atypical groups in etiology and prognosis were examined viastructured interviews and standardized questionnaires, The atypical group was found to haveearlier onset of OCD symptoms and poorer prognosis.

Notably, in the Solyom et al. (1985) study, severe debilitation was a criterion for atypicalOCD. Furthermore, patients were assigned to a variety of treatments, according to symptomseverity, many of which had no established efficacy with OCD (e.g. thought stopping, aversionrelief, imipramine, phenothiazines). Thus, although delusion-like thinking may have contributedto poor prognosis, symptom severity and treatment type were confounding variables.

Studying obsessivecompulsives with psychotic symptoms, Eisen and Rasmussen (1989) ident-ified 30 of 250 OCD patients with delusions, hallucinations, and/or thought disorder. Such patientswith psychotic symptoms (atypical OCD) were compared to more typical obsessivecompulsiveson demographic variables, clinical features, and response to treatment. Based on their psychoticsymptoms, the 30 atypical patients were subtyped into 4 groups: (1) meeting criteria for both OCDand schizophrenia (7/30); (2) meeting criteria for schizotypal personality disorder with magicalthinking (delusional) and an obsessive concern with symmetry in their actions or environment(8/30); (3) meeting criteria for OCD and delusional disorder (8/30); and (4) OCD with transientobsessional delusions (9/30). These 4 subtypes were combined into two groups: schizophreniaspectrum (subtypes I and II); and OCD with delusions (subtypes III and IV).

Like Solyom et a l.s (1985) patients, Eisen and Rasmussens (1989) 30 atypical obses-sive-compulsives with psychotic features showed more severe OCD symptoms than did thosewithout psychosis. The schizophrenia spectrum subtypes fared poorly with pharmacotherapy byserotonin reuptake inhibitors compared to the subtypes with OCD and delusions. Unfortunately,a lack of information about treatments received by these patients, and about the outcome measuresused, limit the conclusions that can be drawn from these results. For example, it is unclear fromthe report what criteria were used for treatment assignment, what medication dosages werereceived, and how the psychotic symptoms were differentiated from OCD symptoms.In a more recent investigation, using a larger sample including subjects (Ss) included in the 1989study, Eisen and Rasmussen (in press) identified 67 of 475 OCD patients with hallucinations,delusions, and/or thought disorder in addition to OCD. Of these 67 patients, 27 had as their onlypsychotic symptom lack of insight and strong conviction in the validity of their obsessive fears.Although probands with OCD and psychotic features were found to have poorer prognoses thanthose with OCD alone, it was concluded that this was largely associated with the presence ofschizophrenia spectrum symptoms, rather than lack of insight.

Another approach to studying insight in OCD was pursued by Lelliott, Noshirvani, Basoglu,


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Marks and Monteiro (1988) and by Basoglu, Lax, Kasvikis and Marks (1988). Rather than dividingpatients into typical and atypical groups, these investigators used a structured interview to allowratings of each patients beliefs on several dimensions: (1) fixity-how strong is the obsessive beliefheld; (2) bizarreness-how valid is the belief; (3) resistance-frequency of attempts to resist urges;and (4) controllability-ease with which the patient can control compulsive urges. The fixitydimension had 3 subscales: (a) strength of belief in feared consequence; (b) patients perceivedabsurdity of belief in feared consequences, (i.e. the patients appraisal of whether others wouldregard the belief as absurd); and (c) response to evidence contradicting the obsessional belief. Ofthe 45 patients studied: 33% believed that without their rituals, the consequences they feared wouldoccur; 12% never tried to resist their compulsions; and 43% denied having control over intrusivethoughts and urges to ritualize. Furthermore, patients were distributed over the entire range of thescales. These results run counter to Schneiders and Janets assertions that obsessional beliefs arerecognized by obsessive-compulsives as senseless, are resisted, and are ego alien.

Using the scales described above, Insel and Akiskal (1986) assessed insight and resistance toobsessions in 23 patients with OCD. They rated 4 aspects of obsessivecompulsive ideas: (1)perceived validity; (2) resistance; (3) strength of belief in harmful consequences; and (4) perceivedabsurdity compared to culturally accepted norms. Most patients perceived their obsessions asabsurd, but many of these were nevertheless quite confident that harmful consequences would occurif they did not perform rituals. Additionally, more than half of the patients reported that they triedto resist obsessive ideas only sometimes. Interestingly, the authors noted that resistance often variedwithin patients, depending on environmental situation and fatigue.

More recently, the question of whether obsessivecompulsives display insight into the senseless-ness of their obsessions and compulsions was investigated in a field trial (Foa & Kozak, 1993)conducted in connection with efforts to develop DSM-IV, the latest revision of the Diagnostic andStatistical Manual of the American Psychiatric Association. The study addressed several issues, andwas conducted at 7 sites: Brown University (Eisen & Rasmussen); Clark Institute (Richter);Columbia University (Hollander); Emory University (Rothbaum); Massachusetts General Hospital(Jenike & Riccardi); The Medical College of Pennsylvania (Kozak); and Yale University(Goodman). Standardized interviews were conducted with 430 patients who met DSM-III-Rcriteria for OCD. Fixity of beliefs was assessed with face-valid interview questions based partly onthose used previously by Lelliott et al. (1988).

The results of the DSM-IV field trial converged with those of previous studies to indicate a broadrange of insight among obsessivecompulsives. Clear harmful feared consequences were identifiedfor 250 of the 430 Ss. The large majority of Ss expressed various degrees of uncertainty aboutwhether their obsessions and compulsions were reasonable; 4% were certain, and 25% were almostcertain, that if they did not perform their rituals, the harmful consequences would ensue. Theseresults suggest that strength of obsessive-compulsive beliefs is distributed on a continuum rangingfrom full recognition of their senselessness to complete absence of such recognition. Coincidentally,Hollander (1989) arrived at a similar conclusion with regard to the beliefs of patients with bodydysmorphia, a syndrome with many formal similarities to OCD.

THE EVOLUTION OF OBSESSIONS INTO OVI AND DELUSIONSThe language of DSM-III-R seems to imply that when OVI occur in OCD, they must necessarily

have evolved from obsessions: the person recognizes that his or her behavior is excessive orunreasonable. . it may no longer be true for people whose obsessions have evolved into overvaluedideas (APA, 1987, p. 247). Although no controlled studies document such an evolution, there are,however, case reports that describe transitions from obsessions to delusions (e.g. Gordon, 1950;Insel & Akiskal, 1986).

Insel and Akiskal (1986) noted that an appreciable proportion of obsessivecompulsive patientsbecome psychotic only in the sense of a transient loss of insight (p. 1528). Similar observationsof the temporary nature of psychotic manifestations in OCD were made by Roth (1978). Toillustrate the occurrence of transitional psychoses that occur in OCD, Insel and Akiskai (1986)described 2 cases. The first case was an obsessivecompulsive patient with severe checking andwashing rituals, and who developed delusional guilt about having contaminated others. After 3


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Obsessions, overvalued ideas and delusions in OCD 341weeks, the patient regained his insight but remained obsessive-compulsive at 2-year followup. Inthe second case, a patient with an 8-year history of fears of poisoning children, that he recognizedas irrational, developed a paranoid conviction that the hospital staff blamed him for poisonings.This case does not exemplify a transition from an obsession to an OVI, but rather, the developmentof a subsequent delusion that was related to an obsession. Again, the delusion disappeared aftera short period, while the obsession remained.

Indirect evidence about transitions from obsessions to delusions in OCD can be gleaned fromRosens (1957) examination of 848 cases of schizophrenia: 30 patients had marked obsessionalsymptoms but only 7 (< 1%) evidenced a transition from an obsession to a delusion; in theremaining 23 patients, the obsessional symptoms either preceded or coincided with the onset ofschizophrenia. A direct investigation of the hypothesis that OVI develop from insightful obsessionswas conducted in the DSM-IV field trial for OCD (Foa & Kozak, 1993). In this study, patientswere questioned about whether they always believed in the validity of their obsessional fears, orwhether at some time in the past they had thought the fears to be unrealistic. Of 454obsessive-compulsives, 34 patients (7.5%) were rated as lacking insight about the senselessness oftheir symptoms. Of these 34 patients, 35% reported having had insight in the past and 65%reported never having had such recognition. Thus, 4.8% of the OCD sample were considered neverto have had insight about the senselessness of their symptoms. Although the method ofretrospective self-report used has limitations, the results are at least suggestive, and are of interestin the absence of studies employing more robust assessment methods.

In summary, although it seems plausible to suppose that OVI and delusions of a particularcontent might have started as intrusive ideas that were at one time more malleable, few relevantfindings are available. The available information does not clearly indicate that OVI or delusionsin OCD necessarily develop from obsessions, and this issue remains unresolved.

It is not clear whether delusions that do develop from obsessions differ in any fundamental wayfrom those that are related to, but do not evolve from, obsessions. The apparent difference is inthe ideational content of the delusion: one that has evolved from an obsession is a strongly heldversion of the obsessional idea, whereas a delusion that is only related to an obsession has adifferent content than the obsession itself. It is also unclear what to make of the topographicaldifference between the transient losses of insight in OCD and delusions: the apparent differenceis the stability of delusions, but it is unknown whether there are qualitative differences in thepsychopathological processes that underlie these two phenomena. It is possible that the sameprocesses subserve the development of fluctuating obsessions of delusional intensity, more stableobsessional delusions, and delusions that are related to obsessions.

OCD AND SCHIZOPHRENIAIt is clear from the foregoing discussion that obsessions can occur with delusional intensity. Insel

and Akiskal (1986) noted that early diagnosticians such as Bleuler (Berner & Zapotoczky, 1976)and Westphal (1878) viewed the obsessive-compulsive syndrome as a form of schizophrenia.Moreover, obsessive-compulsive symptoms were conceptualized as compensating for schizo-phrenia, and thus as masking schizophrenic symptoms (e.g. Pious, 1950; Stengel, 1945). Does ourrecognition of delusional thinking in OCD give credence to the old idea that this disorder is avariant of schizophrenia?

Clearly, some individuals meet criteria for both OCD and schizophrenia, but the availableempirical studies fail to support the notion of OCD as a form of schizophrenia. Rachman andHodgson (1980) noted that the prevalence of schizophrenia in obsessive-compulsives does not differsignificantly from that in the general population. Some recent data suggest that the percentage ofschizophrenics in OCD probands is higher than the 1% rate (Keith, Regier & Rae, 199 1) foundin the general population. In Eisen and Rasmussens (1989) survey of 250 obsessivecompulsives,7 patients (2.8%) were also schizophrenics. Among schizophrenic probands, the 3.5% rate ofobsessional symptoms (Rosen, 1957) is similar to that found for OCD in the general population(Karno & Golding, 1991). Notably, comorbidity of OCD with other anxiety disorders and withdepression is considerably higher than that with schizophrenia. Thus, the rates of schizophreniaamong those with OCD do not indicate a special association of these disorders.


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348 MICHAEL . KOZAK an d EDNA B. FDAThe question can still be posed, however, of whether OCD is a precursor of schizophrenia.

Followup studies can address this question. Muller (1953) found that when diagnostic criteria werebroad, up to 12% of patients with OCD later were diagnosed as schizophrenic. However, studiesusing narrower criteria have yielded much lower percentages. Goodwin, Guze and Robins (1969)reviewed 13 followup studies and concluded that obsessivecompulsives developed schizophreniano more frequently than nonobsessional patients. In contrast to the low incidence of schizophreniain OCD, a relatively high occurrence of other psychoses among obsessive-compulsives was foundin the studies reviewed by Goodwin et al. (1969).

Treatment outcome studies of OCD are also incongruent with the hypothesis that OCDsymptoms mask schizophrenia. Most obsessive-compulsives improve significantly with eitherpharmacological or behavioral treatment (DeVeaugh-Geiss, Landau & Katz, 1989; Foa, Grayson,Steketee, Doppelt, Turner & Latimer, 1983). In the many studies that evaluated the efficacy ofbehavioral treatment of OCD, there has been not one report of schizophrenic decompensationfollowing reduction of OCD symptoms (Rachman & Hodgson, 1980).

Taken together, the available findings reveal that OCD occasionally co-occurs with schizo-phrenia. However, there does not appear to be any special association between the two disorders.

OVI, DELUSIONS, AND OUTCOME OF THERAPYDistinctions among the types of thinking that characterize OCD are useful to the extent that

they are related to etiology and/or treatment. The prognosis of OCD with OVI has been the subjectof some speculation since Foa (1979) reported the failure of behavior therapy for 4 patients withOCD who expressed strong convictions in the validity of their obsessive beliefs.

In apparent contrast to Foas (1979) findings, Lelliott and Marks (1987) and Salkovskis andWarwick (1985) reported successful outcomes with single cases of OCD with strongly held beliefs.Also apparently at odds with Foas observation of an association of fixed ideas and poor outcomeof behavior therapy is a subsequent study of therapy outcome by Lelliott et al. (1988). This studyinvolved 49 obsessive-compulsives with a range of insight. Patients with strong convictionsresponded as well to treatment as those whose obsessions were recognized as senseless. Pursuingcorrelational analyses of these data, Basoglu et al. (1988) found no relationship betweenpretreatment degree of conviction and outcome immediately posttreatment, and a weak (Y = -0.3)relationship at 1 year followup.

It is unclear how to resolve the inconsistencies among (1) observations that patients with OVIshow poor outcome of therapy, (2) reports of successful outcomes with such patients, and (3)findings of no relationship between strength of obsessional beliefs and outcome. It is conceivablethat only patients with the most strongly held obsessions would be especially resistant to treatment:it is certainly plausible to suppose that attempts to persuade such delusional individuals to confronttheir feared situations in behavior therapy often could be futile. Individual reports of successfulexposure with patients with strong beliefs are insufficient to negate the observations of difficultiesoften encountered with such individuals. Furthermore, it would be premature to conclude that thereis no relationship between fixity and therapy outcome based on the failure to find a linearrelationship between strength of obsessional conviction and therapy outcome. If only the moststrongly held, delusion-like obsessions portended poor outcome, this nonlinear relationship wouldnot ordinarily be detectable with linear regression procedures. Thus, it appears that the availableevidence is inconclusive about the relationship of strength of obsessional conviction and outcomeof therapy.

Can therapy procedures directed specifically at strongly fixed ideas reduce strength of convictionin such beliefs? Successful modification of fixed ideas in obsessive-compulsives through behaviortherapy would seem to have some precedent in case reports of behavioral treatment of delusionsin schizophrenia. Watts, Powell and Austin (1973) reported two cases of paranoid delusions inschizophrenia that were weakened via a belief modification procedure that involved gentlechallenges of evidential support for the beliefs, and practice by the patient in mounting argumentsagainst the target beliefs. In a more recent study, Chadwick and Lowe (1990) found that acognitive-behavioral treatment combining verbal challenges and reality testing exercises reducedthe strength of delusional beliefs in 5 of 6 schizophrenics with delusions.


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Another angle on the relationship of obsessions of delusional intensity and treatment efficacycan be found in work on schizotypal thinking in treatment-resistant obsessive-compulsives. SeveralDSM-III (APA, 1980) criteria for schizotypy refer to disordered thinking: (1) magical thinking; (2)ideas of reference; and (3) suspiciousness. In a retrospective study, Jenike, Baer, Minichiello,Schwartz and Carey (1986) examined 43 treatment-resistant obsessivecompulsives and foundthat those with concomitant schizotypal personality disorder had a high rate of treatment failure:of 29 treated nonschizotypal obsessive-compulsives, 26 (90%) improved at least moderately,whereas only one of 14 (7%) schizotypal obsessivecompulsive patients improved. Notably,inspection of the data suggested that the presence of ideas of reference and suspiciousness weremore predictive of poor outcome than were magical ideas of the sort that might be expected indelusions, which occurred in both treatment successes and failures for both schizotypes and nonschizotypes.

Perhaps ideas of reference and suspiciousness are more specifically linked to schizophrenia-spec-trum disorders than are magical thinking and delusions, and perhaps it is the schizophreniaspectrum characteristics that account for the poorer outcome. Jenike et ds (1986) results convergewith the findings of Eisen and Rasmussen (1989) who reported that atypical obses-sive-compulsives with concomitant schizophrenia or schizotypy responded more poorly toserotonin reuptake inhibitors than did patients with obsessional delusions.

METHODOLOGICAL CONSIDERATIONSA number of methodological issues that underlie our concepts of obsessions, OVI, and delusions

merit attention here. One fundamental point of concern is the propriety of dichotomouscategorization of beliefs as delusional or nondelusional. We have argued above that strength ofbelief in obsessive-compulsive ideas is broadly distributed, and that a continuum seems moreaccurately descriptive than discrete categories. This observation is not peculiar to the ideation ofOCD: similar suggestions have been offered with respect to delusions in schizophrenics.

Data from interviews of 119 acutely schizophrenic patients in the World Health OrganizationInternational Pilot Study of Schizophrenia (Strauss, 1969) revealed intermediate levels of disbeliefin ideational and perceptual distortions, temporal variations in strength of belief, and intermediatedegrees of distortion. However, evaluations of delusions were frequently complicated by difficultiesin ascertaining realistic evidence for a particular belief, so that conclusions about degree ofdistortion depended on the clinicians uncertain view of evidential support for the belief in question.Strauss (1969) concluded that beliefs are better characterized on a continuum than dichotomizedinto delusional and nondelusional categories.

The concept of delusion as a unitary categorical phenomenon has been questioned not only onthe basis of evidence for a continuum of strength of belief, but also because the concept involvesmultiple aspects or dimensions. Commonly ascribed dimensions include conviction, self-evidence,resistance to reason, unlikely content, and absence of cultural support (Mullen, 1979). Assessmentstudies using multidimensional approaches have found desynchrony among different aspects ofdelusional beliefs. Using clinical rating scales that measured several aspects of delusional belief(conviction, preoccupation, bizarreness, disorganization), Kendler, Glazer and Morgenstern (1983)found low correlations among the dimensions in 52 delusional patients. Based on clinical interviewswith 8 delusional inpatients, Hole, Rush and Beck (1979) also concluded that there is divergenceamong several dimensions of delusions (conviction, accommodation, pervasiveness, and encapsu-lation). Longitudinal investigations of delusional beliefs have revealed that they are multidimen-sional and desynchronous and, moreover, that no consistent temporal patterns emerged among thedifferent aspects of delusions (Garety, 1985; Brett-Jones, Garety & Hemsley, 1987).

Findings regarding the multidimensionality of delusional experiences suggest that fixed ideas ofobsessive-compulsives should not be equated with the delusions observed in other disorders, basedsolely on similarity in degree of conviction. Some studies of obsessivecompulsives have measuredmultiple aspects of beliefs (e.g. Basoglu et al., 1988; Lelliott et al., 1988) and desynchrony amongdimensions has been observed in the DSM-IV OCD field trial. However, studies of delusions inother disorders, using the same multidimensional measures of delusional beliefs, are not available.Thus, the relevant comparisons of the multidimensional structures of obsessions and delusions


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cannot be made. Until comparable results are forthcoming, conclusions about the formalequivalence of delusional beliefs observed in various disorders, including OCD, must remaintentative.

Another issue that merits further consideration is the extent to which delusions are resistant tochange. We have noted earlier that the delusions of schizophrenics have been found to vary overtime and that psychotherapy can influence the strength of delusional beliefs in schizophrenics(Watts et al., 1973; Chadwick & Lowe, 1990). These results converge to support the hypothesisthat delusional beliefs are dimensional in character and that, like strength of belief, mutability maybe more accurately conceptualized as a continuum than as a dichotomized entity.

Interestingly, the finding that delusional beliefs can be modified has potential implications fortreatment of delusions in obsessivecompulsives. Supplementing the usual exposure and responseprevention program with interventions of the sort that have been reported to be helpful withdelusions in schizophrenics might enhance the efficacy of the established behavioral regimen forpatients who are treatment resistant.

THEORETICAL CONSIDERATIONSOur understanding of OVI and delusions in OCD can be advanced by knowledge of the

formation and maintenance of delusional beliefs found in other disorders. Despite substantialconceptual and empirical work in the area of delusions, no consensually accepted theory hasemerged. Nevertheless, one theory that has achieved some prominence is Mahers (1970, 1974,1988) proposal that delusions constitute attempts to rationalize anomalous experiences. Accord-ingly, Maher views delusions as normal theories that account for an individuals abnormalexperiences. Thus, the cognitive process involved in developing delusions is seen not to differ fromthat of forming nondelusional beliefs.

Three lines of evidence have been invoked in support of Mahers theory. First, delusions havebeen observed in many disorders with vastly different symptoms and etiologies (Maher & Ross,1984). The common thread appears to be that the delusions involve reactions to bodily disability,anomalous sensory or motor features, or both. Second, there is no evidence of generally impairedreasoning ability in delusional patients (Maher, 1988). In contrast, the few relevant studies (Nims,1959; Williams, 1964) have suggested that deluded and nondeluded patients made the same typesof errors, although the former made more errors and showed performance deficits in a wide rangeof tasks. Therefore, no unique reasoning deficit could be inferred. Third, experimental and naturalinstigations of anomalous experiences have been found to provoke irrational beliefs in normal Ss(Cooper & Curry, 1976; Jones, 1966; Zimbardo, Andersen & Kabat, 1981).

Can Mahers formulation help to explain the OVI and delusions of OCD? For the theory to beapplicable, one must postulate anomalous experiences in OCD that would give rise to delusionalexplanations. What characteristic of obsessive-compulsive experience might underlie the formationof delusional beliefs?

Perhaps the frequent and persistent obsessional intrusions that characterize OCD constitute thekind of anomalous experience that could underlie the development of delusional beliefs. That isto say, the mistaken theories of harm of obsessivecompulsives may be attempts to explain fearfulobsessional intrusions that arise repeatedly and persistently.

Although this speculative account of delusions in OCD appears consistent with Mahers view,weaknesses in Mahers formulation itself leave this account problematic. Specifically, neither allschizophrenics, nor all individuals with perceptual impairments, nor all obsessivecompulsives,develop delusions. Assuming that obsessive intrusions are anomalous experiences, Mahers theorydoes not explain why some obsessivecompulsives develop delusions, and others do not. It followsthat something more than anomalous obsessive-compulsive intrusions is required to account forthe development of delusions in OCD.

Experimental findings on selective processing of threat information suggest that certain cognitiveabnormalities may be implicated in delusions. Using a Stroop paradigm, Bentall and Kaney (1989)found that for patients suffering from persecutory delusions, paranoid content interfered withcolor-naming of words. The authors hypothesized that attentional bias toward delusion-relevantmaterial leads to preferential coding of such material and thus to the persistence of delusional


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beliefs. Interestingly, findings of color-naming interference by threat cues have been obtained withother disorders that are sometimes associated with fixed ideas of a delusional intensity: depression(Gotlib & McCann, 1984); anorexia nervosa (Channon, Hemsley & de Silva, 1988); and OCD (Foa,Illai, McCarthy, Shoyer & Murdock, 1993).

Although intriguing, the findings of cognitive biases in several disorders that are sometimescharacterized by delusions shed little light on the mechanisms underlying delusions in thesedisorders. Notably, such biases have also been found in anxiety disorders that are not associatedwith the occurrence of delusions, such as phobia (Watts, McKenna, Sharrock & Trezise, 1986;Watts & Dalgleish, 1991) and posttraumatic stress disorder (Foa, Feske, Murdock, Kozak &McCarthy, 1991). Nevertheless, the findings on cognitive biases are heuristic: perhaps especiallystrong cognitive biases occurring in some individuals contribute to the development and mainten-ance of delusional beliefs. Of course, cognitive biases may also be causally implicated inpathological fears of nondelusional intensity.

In contrast to Maher, von Domarus (1944) hypothesized that delusions are related to systematicepistemological errors. Mahers (1988) discounting of this hypothesis may have been premature.Brennan and Hemsley (1984) studied reasoning errors using Chapmans (1967) illusory correlationparadigm, in which series of word pairs were presented to delusional and nondelusionalschizophrenics, who later estimated their rates of co-occurrence. They found that paranoid patientsperceived illusory relationships between words, particularly of paranoid content. This findingindicates that these patients may indeed have deficits in reasoning, and that the deficits are specificto threat-relevant tasks. Perhaps impairments in syllogistic reasoning related to delusions ariseparticularly under threat conditions, and are supported by strong cognitive bias for threat-relatedinformation. If this were the case, the failure to find deficits in general reasoning in delusionalpatients need not contradict a reasoning deficit theory of delusions. Data on reasoningimpairments under threat conditions are not available for obsessive-compulsives but, as mentionedabove, clinical observations suggest that the strength of obsessional beliefs for these patients oftencovaries with context: such patients seem to be more logical thinkers about their obses-siveecompulsive fears when they are not being threatened with exposure to their feared situation.

CONCLUSIONSIn the psychiatric literature on OCD, distinctions among obsessions, delusions, and OVI are not

sufficiently clear to be of diagnostic utility. In principle, distinction can be made betweenobsessions, delusions, and OVI.However, in practice drawing the line is rather arbitrary. Thedistinction between delusions and OVI is at best vague; the two concepts have often been usedinterchangeably. The impetus to maintain such a diagnostic distinction may derive from theseeming contradiction between the classification of OCD as a neurosis and the observation thatobsessive-compulsives can manifest psychotic thinking. To resolve this dissonance, the intermedi-ate concept of overvalued ideas was embraced in descriptions of OCD.

Although a categorical distinction between obsessions and delusions or OVI is conceptuallypossible, clinical observations as well as research findings reveal difficulties with this kind ofconceptualization. Obsessive-compulsives vary greatly among one another in degree of insight andresistance. The two studies that measured these variables showed their samples to occupy the entirerange of scores. It follows that obsessivecompulsive beliefs cannot satisfactorily be dichotomizedinto senseless and sensible, and that the notion of a continuum seems more satisfactory.

The usefulness of a dichotomous view of insight about obsessional beliefs is not supported bytreatment outcome findings. Whereas some clinical observations suggested that obses-siveecompulsives with OVI are unresponsive to behavioral treatment, several reports found suchpatients quite responsive to treatment by drugs and/or behavior therapy. Thus, the relationshipbetween strength of conviction and outcome of therapy remains unresolved. While insight into thesenselessness of an obsessional belief may or may not predict treatment outcome, available reportsagree that the presence of schizophrenia spectrum symptoms in obsessive-compulsive patientsindicates poor prognosis.

A number of methodological and conceptual issues complicate attempts to understand delusionsin OCD. It has been argued that delusional beliefs are multidimensional, and that the traditional


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notion of their immutability bears reexamination. A satisfactory understanding of the relationshipbetween delusional beliefs in OCD and those of other disorders awaits longitudinal multidimen-sional assessment studies that use comparable measures.

No generally accepted theory of delusions is available, and the view that delusions constituteattempts to rationalize anomalous experiences is not itself a satisfactory account of delusions inOCD. Perhaps failures in syllogistic reasoning under threat conditions, abetted by cognitive biasesto threat cues, play a role in the formation and maintenance of the most strongly held obsessionalbeliefs. Such processes, however, may also operate in nondelusional obsessions.

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