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The relationship between inferential confusion, obsessive compulsiveness, schizotypy and dissociation in a non-
clinical sample.
Nakita O’Leary
Submitted for the Degree of
Doctor of Psychology(Clinical Psychology)
School of PsychologyFaculty of Arts and Human Sciences
University of SurreyGuildford, SurreyUnited Kingdom
October 2015
1
Abstract
Objective: Inferential confusion is a reasoning process that has been
theoretically and empirically linked to obsessive-compulsiveness in the
literature. Little is known about the mechanisms by which some people
become more or less inferentially confused and in what contexts. Dissociation
has been postulated as a process related to inferential confusion, yet findings
to date are limited and have been inconclusive. There is preliminary evidence
to support the notion that inferential confusion may also be relevant in other
belief disorders such as delusional disorder but this has not received much
empirical attention. The current study aimed to investigate the relationship
between inferential confusion, obsessive-compulsiveness, dissociation and
schizotypy in a non-clinical sample. Design: Participants (n=107) from the
general population took part in a within-participants experimental study,
designed to assess the propensity to experience inferential confusion in
obsessive-compulsive and delusion-relevant situations and in a threat-neutral
situation. Participants also completed self-report measures of inferential
confusion, obsessive-compulsiveness, dissociation and schizotypy. Results:
As expected, inferential confusion, obsessive-compulsiveness, dissociation
and schizotypy were all significantly positively correlated with each other.
Propensity to experience inferential confusion was only related to measures of
inferential confusion, obsessive-compulsiveness, schizotypy, and dissociation
in the context of the delusion-relevant scenario. Conclusions: There is little
evidence linking measures of obsessive-compulsiveness, dissociation and
schizotypy with experimental measures of inferential confusion. However,
there is evidence that these measures relate to self-report measures of
2
inferential confusion. The implications of this are discussed in terms of
understanding inferential confusion as a process. However, an alternative
explanation for the findings lies in the critique of the methodology of the
experimental task. Inferential confusion still requires experimental
investigation that can be replicated.
3
Acknowledgements
My deepest thanks and appreciation goes to my Major Research
Project supervisor, Dr Laura Simonds, for her constant and consistent support
and guidance in the design, implementation and write up of my Major
Research Project. I would also like to thank Andrew Barnes for his practical
help with creating the study and with using the online programme that runs it.
I would like to show my appreciation to the service users who consulted on
my project during the design phase and the ethics committee for ensuring that
my project was ethically sound. In addition, I express my gratitude to all of the
participants who voluntarily took part in the study without direct or immediate
reward.
I would like to thank Dr Simon Draycott for supervising the
implementation and write up of my Service Related Research Project. I would
also like to thank Nicolette De Villiers for supervising the design of the
project and for her help raising awareness of the survey amongst potential
participants. I would like to give thanks to all the clinical psychologists who
participated in the survey and to Andrew Barnes again for his support in
creating the online programme that the survey was delivered on.
I have appreciated the support of my clinical tutor Dr Vikky Petch and
my honorary clinical tutor Dr Heidi Adshead throughout all of my clinical
placements. I am thankful for their guidance, encouragement and support. I am
also thankful to all of my clinical placement supervisors, as I have learnt so
much from each of them and they have all contributed to my personal and
professional development as a clinical psychologist. I will hold them all in
4
mind as well as the other professionals that I have worked with and learnt
from on my clinical placements.
I would like to extend my thanks to the academic team for providing
me with such a challenging, relevant and innovative learning experience. I
have particularly valued the emphasis on feedback and how this has constantly
been listened to and acted on. My greatest thanks goes to Charlotte King for
always going above and beyond to provide the administrative support that all
trainee clinical psychologists need. Finally, I would like to thank cohort 41 for
sharing this experience of growth and self-development with me, as well as
my friends and family for supporting me through this journey, during both the
good times and the bad times.
5
Contents
Major Research Project Empirical Paper 7
Major Research Project Proposal 103
Major Research Project Literature Review 121
A Brief Overview of Clinical Placements 164
Table of Title of all Academic Assignments 167
6
The relationship between inferential confusion,
obsessive compulsiveness, schizotypy and dissociation
in a non-clinical sample.
Major research project: Empirical paper.
By
Nakita O’Leary
Submitted: April 2015
Word Count: 9,277
7
Abstract
Objective: Inferential confusion is a reasoning process that has been
theoretically and empirically linked to obsessive-compulsiveness in the
literature. Little is known about the mechanisms by which some people
become more or less inferentially confused and in what contexts. Dissociation
has been postulated as a process related to inferential confusion, yet findings
to date are limited and have been inconclusive. There is preliminary evidence
to support the notion that inferential confusion may also be relevant in other
belief disorders such as delusional disorder but this has not received much
empirical attention. The current study aimed to investigate the relationship
between inferential confusion, obsessive-compulsiveness, dissociation and
schizotypy in a non-clinical sample. Design: Participants (n=107) from the
general population took part in a within-participants experimental study,
designed to assess the propensity to experience inferential confusion in
obsessive-compulsive and delusion-relevant situations and in a threat-neutral
situation. Participants also completed self-report measures of inferential
confusion, obsessive-compulsiveness, dissociation and schizotypy. Results:
As expected, inferential confusion, obsessive-compulsiveness, dissociation
and schizotypy were all significantly positively correlated with each other.
Propensity to experience inferential confusion was only related to measures of
inferential confusion, obsessive-compulsiveness, schizotypy, and dissociation
in the context of the delusion-relevant scenario. Conclusions: There is little
evidence linking measures of obsessive-compulsiveness, dissociation and
schizotypy with experimental measures of inferential confusion. However,
there is evidence that these measures relate to self-report measures of
8
inferential confusion. The implications of this are discussed in terms of
understanding inferential confusion as a process. However, an alternative
explanation for the findings lies in the critique of the methodology of the
experimental task. Inferential confusion still requires experimental
investigation that can be replicated.
Keywords
Inferential confusion, Obsessive-compulsiveness, Obsessive-compulsive
disorder, Schizotypy, Dissociation, Delusional disorder
Statement of Journal Choice
This paper presents research on inferential confusion, which has previously
been linked in the literature to obsessive-compulsiveness. It also includes the
study of other related phenomena i.e. dissociation and schizotypy. For these
reasons, the Journal of Obsessive-Compulsive and Related Disorders is the
target journal for this paper. This international journal has an impact factor of
0.812 and publishes high quality research from studies with both clinical and
non-clinical samples. The journal’s broad focus allows for the inclusion of the
novel area in which the current study investigates.
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Introduction
O’Connor, Aardema and Pelissier (2005) developed a novel theory of
reasoning, termed Inferential Confusion (IC), based upon observation of
individuals diagnosed with obsessive-compulsive disorder (OCD) and over-
valued ideas (OVI). OCD is characterised by the presence of obsessions
(persistent and recurrent thoughts, impulses or images that cause distress)
and/or compulsions (mental strategies or overt behaviours that are aimed at
reducing distress) that are perceived by the individual as either distressing,
time consuming or disruptive to functioning (DSM V, 2014). Obsessions often
involve fears that have a remote basis in reality or, at least, might be
considered implausible by others and involve strategies (i.e. compulsions) that
are unconnected to the obsession or are clearly excessive (e.g. checking a tap
multiple times). OVI have been conceptualised as a variant of obsessive-
compulsiveness (OC) defined as near delusional beliefs (DSM V, 2014)
because they lack the criterion of ego-dystonicity that applies to OCD. In
inferential confusion theory, it is proposed that the persistent doubt evident in
OCD and OVI is the result of a faulty reasoning style that privileges
hypothetical possibilities over reality (O’Connor et al., 2005).
O’Connor and Rollibard (1995) theorized that mental intrusions in
OCD were primary inferences of doubt about reality that led the individual to
distrust their physical senses in preference of an imaginary possibility. An
example of a primary inference of doubt would be thinking that one has left
the cooker on. Subsequent compulsions fail to overcome the primary inference
given that the individual is attempting to use reality to modify an imaginary
possibility. Therefore, a compulsion to check that the cooker is off will
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inevitably be unsuccessful in resolving doubt about the state of the cooker
because the doubt is imagined; instead, this process only reinforces the doubt
and the cycle of unusual reasoning continues (O’Connor & Aardema, 2003).
In light of these observations, O’Connor et al. (2005) developed the
Inference Based Approach to treatment (IBA). The treatment aims to modify
the inference process and therefore the narrative preluding the primary
inference of doubt (mental intrusion). The IBA has been tested empirically
against Cognitive Behavioural Therapy (CBT), since this is the most
commonly prescribed psychological therapy for OCD. In support of the
relevance of inferential confusion in OCD, Aardema, Emmelkamp and
O'Connor (2005) found that a reduction in obsessive-compulsive symptoms
during a course of CBT coincided with a reduction in inferential confusion.
The IBA has been supported by studies that found it significantly reduces
obsessive-compulsive symptoms (Aardema, Wu, Careau, O’Connor, Julien &
Dennie, 2010). In addition to this, O’Connor, Koszegi, Aardema, van Niekerk
and Taillon (2009) conducted a randomized controlled trial to demonstrate the
effectiveness of IBA in reducing obsessive-compulsive symptoms compared
to behavioural and cognitive-behavioural approaches. In this trial IBA was
found to be superior at reducing obsessive-compulsive symptoms when
compared to other approaches across a range of particular obsessive-
compulsive presentations.
However, whilst Aardema and O’Connor (2012) found that the IBA
produced significant reductions in inferential confusion, obsessionality and
negative mood states, while making significant improvements in the ability to
resolve doubt, a quarter of their participants who could not resolve doubt at the
11
beginning of treatment still could not resolve it at the end. This indicated that
the IBA was not universally effective in resolving doubt. In spite of this,
participants’ symptoms still reduced, suggesting that the IBA can produce
improvement in obsessive-compulsive symptoms even when participants
cannot resolve doubt. This implies that the IBA might also be used as a
general treatment model for distressing symptoms in other thought disorders
that do not necessarily involve the initial doubting process outlined by the
authors of inferential confusion theory. If this were so, it would be reasonable
to deduce that inferential confusion may relate to thought disorders other than
that of OCD or OCD and OVI, such as delusional disorder.
The self-report Inferential Confusion Questionnaire (ICQ; Aardema,
O'Connor, Emmelkamp, Marchand & Todorov, 2005) was developed to
operationalise inferential confusion in empirical studies. High scores on the
measure indicate a reasoning process in which the person recognises their
imagination as a source of inference and acts on the possibility of threat
despite evidence to suggest that no threat exists (O’Connor, Aardema &
Pelissier, 2005). Scores on the ICQ have been found to correlate significantly
with scores on measures of obsessive-compulsiveness in a non-clinical sample
(Aardema, Radomsky, O'Connor & Julien 2008). In a clinical population,
Aardema, O'Connor and Emmelkamp (2006) found that while controlling for
the three domains of the Obsessive Beliefs Questionnaire-44 (OBQ-44;
Obsessive Compulsive Cognitions Working Group, 2005) the relationship
between scores on obsessive-compulsive symptom measures and the ICQ
remained significant (r= 0.43), suggesting that inferential confusion
12
contributes to obsessive-compulsive symptoms independent of obsessive-
compulsive beliefs.
Aardema et al. (2010) subsequently extended the ICQ to include
consideration of an over-reliance on possibility during reasoning; absorption
into imaginary sequences; category errors; irrelevant associations; selective
use of out-of-context facts and apparently comparable events; as well as the
original inverse inference and distrust of senses components of inferential
confusion. The researchers considered these additions to be central facets to
the reasoning process involved in inferential confusion. The new measure,
ICQ-EV (extended version), showed good convergent validity with strong
relationships with measures of obsessive-compulsive symptoms in all samples
when other cognitive domains and general distress were controlled for.
To further investigate inferential confusion, Aardema, O'Connor,
Pélissier and Lavoie (2009) developed a novel experimental paradigm – the
Inference Process Task (IPT) - and compared participants with a diagnosis of
OCD to a non-clinical control group. The IPT is a reasoning task that presents
participants with ambiguous situations (e.g. a situation in which it is unclear
whether there has been a car accident). The IPT involves asking participants
to estimate the probability that an accident has happened. After this,
information is presented that is intended to either reduce doubt (‘reality-based
information’) or to increase it (‘possibility-based information’). The IPT was
designed to emulate the dynamic process of reasoning observed in OCD in
which hypothetical possibilities overturn evidence of the senses (i.e. reality).
As predicted, Aardema et al. (2009) found that the influence of possibility-
based information on doubt was higher in those with OCD than in a non-
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clinical control group. There was also a strong positive relationship between
the levels of doubt in the IPT and obsessive-compulsive symptom severity.
In spite of the positive findings linking inferential confusion and
obsessive-compulsiveness, there remains a lack of understanding as to why
people with OCD might be more susceptible to the impact of possibility-based
information, or why it is that some people become so absorbed into imaginary
states that the possibility of what might be there overrides their perception of
what is there. In the case of the latter, O’Connor and Aardema (2012) propose
that the reasoning process of inferential confusion may be related to
dissociative absorption. They suggest that by making inferences about possible
states of affairs, the individual is likely to feel a sense of dissociation between
the world their senses perceive and the world inferential confusion has led
them to understand. In support of this, Aardema and Wu (2011) found that the
absorption subscale of the Dissociative Experiences Scale (DES-II, Carlson &
Putnam, 1993) was significantly positively correlated with inferential
confusion (r=.53). This finding suggests that dissociative absorption may be
similar to, or play a role in, the “immersion in possible worlds” that O’Connor
and Aardema (2012) describe as characteristic of inferential confusion.
As noted by Morrison (2014), the literature shows inconsistent results
from studies investigating the relationship between OC and dissociation.
Inferential Confusion theory indicates that, although people with OCD can
perceive reality accurately, they do not integrate this information effectively
into reasoning. This, Morrison (2014) observed, is similar to the lack of
integration noted in dissociation by Van Ijzendoorn and Schuengel (1996).
Van Ijzendoorn and Schuengel (1996) highlight the disruption of usually
14
integrated functions of consciousness, identity, memory and perception of
one’s environment as an essential feature of dissociation. Morrison (2014)
replicated Aardema et al.’s (2009) experimental paradigm in order to explore
the relationship between dissociation and susceptibility to possibility-based
information, in those high and low in obsessive-compulsiveness.
Unexpectedly, Morrison (2014) did not find a relationship between
dissociation and participant’s level of inferential confusion, and neither was
there evidence of a relationship between inferential confusion and obsessive-
compulsiveness. However, Morrison (2014) argued that these findings could
not be interpreted as definitive evidence that there was no relationship
between inferential confusion and dissociation since they were based on a
single novel study and, furthermore, a competing explanation might be the
lack of validity of the IPT. That is, at that time, the IPT task had not been
replicated outside the team who had devised the task and, Morrison (2014)
argued, it was plausible that the paradigm may not measure inferential
confusion in the way it claims to. Morrison (2014) did not utilise a self-report
measure of inferential confusion to provide validity for the IPT data.
Therefore, one principal aim of the current study was to replicate Morrison’s
(2014) use of Aardema et al.’s (2009) paradigm, with the addition of the ICQ-
EV (Aardema et al., 2010) to measure inferential confusion alongside the
experimental IPT. The intention was to explore whether lack of IPT validity
might have contributed to the null results found by Morrison (2014) regarding
the relationship between inferential confusion and dissociation and obsessive-
compulsiveness.
15
The current study also extended the IPT to consider a delusion-relevant
situation. Evidence indicates that inferential confusion is higher in participants
with OCD than in those with other anxiety diagnoses but that it is equally high
in participants with delusional disorder (DD; Aardema et al., 2005). Delusions
are defined as false beliefs despite evidence to the contrary (DSM V, 2014).
Claridge, McCreery, Mason, Bentall, Boyle, Slade and Popplewell (1996)
used the term schizotypy to denote non-clinical delusional type beliefs that lie
on a continuum with delusions in clinical populations. When considering
obsessive-compulsiveness and delusions (or schizotypy to refer to the non-
clinical terminology) together, the current study defines them both as unusual
ways of thinking about reality, that are not shared by others, that are causally
implausible and which lie on a continuum of severity. Proponents of
inferential confusion suggest that, like DD, OCD is a belief disorder and that
inferential confusion might underpin both presentations. This, and the
empirical evidence cited, suggests the IPT (which currently only focuses on an
OCD-relevant and a neutral situation) might be usefully extended by including
a delusion-relevant scenario in order to assess inferential confusion processes
in that context. In addition, Aardema at al. (2009) suggested that their study
would benefit from replication with the addition of more pairs of reality- and
possibility-based information (three pairs are used in the original paradigm)
and more hypothetical scenarios. The current study follows up these
recommendations, extending the current IPT in these ways.
In summary, the current state of knowledge highlights inferential
confusion as a reasoning process that is likely involved in obsessive-
compulsiveness. Given the largely correlational nature of the current evidence
16
to support these claims, more experimental work is needed. Morrison (2014) is
the only study to date to replicate the IPT paradigm outside of the research
group that devised it. Morrison was unable to support the main predictions
arising from inferential confusion theory and was unable to support the novel
hypothesis that the tendency to dissociate was related to inferential confusion.
Furthermore, whilst there is preliminary evidence to suggest that delusional
experiences are related to inferential confusion (Aardema et al., 2005), to date,
there are no experimental studies that assess inferential confusion in the
context of both obsessive-compulsiveness and delusions. Therefore, the aim of
the current study was to extend the IPT paradigm to measure inferential
confusion in the context of both obsessive-compulsiveness and delusions and
to assess the relationship between inferential confusion, obsessive-
compulsiveness, dissociation and schizotypy (i.e. non-clinical delusion-
proneness) in a non-clinical sample. A non-clinical sample was used since
obsessive-compulsiveness and schizotypy are considered to be phenomena
experienced by the general population to different degrees (Gibbs, 1996; Johns
& Os, 2001). Therefore, the intensity of these phenomena can be measured on
a continuum rather than with distinct categorical criteria. In addition,
transdiagnostic models of clinical problems focus on how phenomena might
underpin multiple psychological problems. In the context of these models, this
research moves away from studying diagnostic categories per se towards
studying the underlying cognitive processes involved in a range of
presentations.
17
In the current study, it was hypothesised that:
(1) Following from Aardema et al. (2009), possibility-based information
presented after each imagined scenario will increase participants’ self-reported
level of doubt, whereas reality-based information presented after each
imagined scenario will reduce participants’ self-reported level of doubt.
(2) Participants who score higher on the ICQ-EV will report significantly
higher levels of doubt in response to the possibility-based information in all
three scenarios presented to them in the IPT task.
(3) Doubt as a result of possibility-based information will be positively
correlated with obsessive-compulsiveness and this effect will be strongest for
the OC-related scenario of the IPT. Doubt as a result of possibility-based
information will be positively correlated with schizotypy, and this effect will
be strongest in the delusion-related scenario of the IPT.
(4) Frequency of dissociative experiences will be positively correlated with
inferential confusion as operationalized by self-report (ICQ-EV) and
experimental (IPT) measures.
Method
Overview of design
Experimental Design: The study used a within-participants
experimental design. The independent variable ‘scenario type’ had three
levels: OC-relevant (hitting a pedestrian when driving), delusion-relevant
(being followed by another car) and neutral (a bus strike). The independent
variable ‘information type’ had two levels: reality and possibility-based
information. The dependant variable was the level of doubt experienced by
18
participants. This was operationalized by the participants’ reports of perceived
probability that the inferred event in each scenario had occurred. Similar to
Aardema et al.’s (2009) study, higher probability scores indicated a greater
level of doubt with regards to the idea that the incident had not occurred. Self-
report measures were also completed by participants to assess levels of
inferential confusion, obsessive-compulsiveness, dissociation and schizotypy.
The study was designed for remote completion using Qualtrics survey
software, hosted at the University of Surrey.
Participants
Participants were recruited from the general population in a non-
clinical setting. A diagnosis of OCD or delusional disorder was not an
inclusion criterion since obsessive-compulsiveness, dissociation and
schizotypy are construed as continuous variables in the general population.
Variability in these measures would be expected in a non-clinical sample.
Participants who scored above the cut off for clinical significance on the OCI
were not excluded from the study, despite the sample being intended to
represent a non-clinical population. This was because the OCI is not a
clinically recognised diagnostic tool and therefore cannot determine whether
participants’ are considered clinical or non-clinical in their presentations. The
study was designed to be completed by participants aged 16 and older,
allowing them to give independent informed consent. However, as the study
was completed remotely, it was not possible to verify participant age. The
study was advertised on websites that promote psychological studies online
and via social networking sites. Snowball sampling was also utilised in that
19
participants were asked to share the online study advertisement with others
connected to their social network.
An a priori sample size calculation based on correlation analysis
indicated a sample size of 100 would be sufficient to detect a moderate effect
size of r =.3 at 80% power for a two tailed hypothesis (alpha .05). 206
participants started the online study. There was a 51.94% completion rate with
107 participants submitting complete data. The sample was therefore sufficient
to detect at least moderate effect sizes. Participant characteristics are reported
in the Results section.
Measures
The Inference Process Task (IPT): This followed the design used by
Aardema et al. (2009) and Morrison (2014). The basic design of the IPT
involves the following stages: (1) an ambiguous scenario is presented; (2) the
participant rates how anxious they would feel should the incident implied by
the scenario really occur; (3) the participant rates the probability that the
implied incident has occurred; (4) the participant is presented with pairs of
reality and possibility based information designed to influence doubt about the
incident. After each piece of information, the participant re-rates the
probability that the incident implied occurred. These stages will now be
described below indicating how the current study extended the paradigm
utilised by Aardema et al. (2009) and Morrison (2014). All materials for the
IPT can be seen in Appendix B.
(1) In Aardema et al. (2009) and Morrison (2014), two written
vignettes were given to participants. The OC-relevant scenario was designed
20
to emulate a common concern in OCD (hitting a pedestrian whilst driving).
Abramowitz, Taylor and McKay (2009) reported this experience to be one out
of the five main dimensions of obsessions and compulsions seen in OCD. The
non-OC-relevant scenario (a bus strike) was designed to be the neutral (i.e.
non-threat) condition. Aardema et al. (2009) explained that inferential
confusion is only expected in relation to threat-laden information. Therefore
the neutral scenario acts as a control condition. The additional scenario
devised for this study was designed to emulate a common concern in
delusional disorder (being persecuted by others). Bell, Halligan and Ellis
(2006) report this to be common theme for people experiencing clinical
delusions. The delusions-relevant scenario was designed to replicate the
structure of the OC-relevant scenario. It used the activity of driving a car to
keep the scenarios as similar as possible. In the delusion-relevant scenario,
instead of the inferred event regarding the participant hitting a pedestrian with
their car, it was regarded them being followed by people that wanted to steal
their car.
(2) The initial anxiety rating question in all three scenarios was: ‘How
anxious would you feel in the above situation?’ measured on a scale of 0 to 10.
(3) The initial probability rating question required participants’ to rate
the probability that an event had occurred in each of the three ambiguous
situations presented to them. This was taken to represent participants’ level of
doubt that the event had not happened, which was interpreted as their
propensity to experience inferential confusion. For example, in the OC-
relevant scenario, the probability rating question was: ‘What do you consider
the probability that an accident has happened under these circumstances?’
21
measured on a scale of 10 – 100%. A scale of 10 to 100 as opposed to 0 to 100
was used for the probability rating, since a score of zero would negate the
assumed probability that something had occurred altogether.
(4) Different pieces of information about the scenario are then
introduced. ’Reality-based information’ aims to reduce doubt by referring to
the senses. In the OC-relevant scenario, an example of this is, ‘you turn your
head and see no one lying on the street’. In contrast ‘possibility-based
information’ aims to increase doubt by referring to hypothetical situations. In
the OC-relevant scenario, an example of this is, ‘you may not have seen
anything because it is quite crowded’. These pieces of information were
presented as pairs (Table 1); each pair consisted of a reality-based piece of
information and a possibility-based piece of information. This was in order to
mimic the dynamic doubting process seen in OCD (Aardema et al., 2009).
Aardema et al. (2009) calculated two variables from this data representing the
overall impact of each different type of information (known as the cumulative
impact of reality and possibility-based information). The current study
included a further pair of reality and possibility-based piece of information to
the OC-relevant and neutral scenario, to investigate whether this relationship
continued to strengthen, as would be expected given the persistent nature of
obsessional doubt (Aardema et al., 2009). New reality and possibility-based
pairs of information were created for the delusion-relevant scenario, which
attempted to replicate the style of the OC-relevant and non-OC-relevant pairs
of reality and possibility-based information from Aardema et al.’s (2009) and
Morrison’s (2014) studies. The pieces of information were designed to either
22
sustain doubt about whether an inferred event had occurred (possibility-based)
or challenge the idea that the event had occurred at all (reality-based).
TABLE 1. Pairs of reality and possibility-based information for the OC-
relevant, delusion-relevant and neutral scenarios for the current study.
OC relevant scenario Non-OC relevant scenario
Delusions relevant scenario
R1 “You look in the rear-view mirror and see a pothole in the road.”
“At the end of the street you see a bus driving on what appears to be a different route.”
“The expressions on the men’s faces in the car are not menacing or threatening in anyway.’
P1 “The pothole may not have been deep enough to cause the bump.”
“Maybe the bus was out of service since you could not see whether there were any people in it.”
“The lack of expression in their faces may be because they want to take you by surprise.”
R2 “You turn your head and see no one lying on the street.”
“A person tells you he took the bus earlier in the day.”
“It is not very busy and you are in a much safer place for the car to overtake you now than at other points in the journey.”
P2 “You may not have seen everything, because it’s quite crowded.”
“The strike may have only started later in the day.”
“Other cars have overtaken you and the car behind at other points in your journey.”
R3 “You watch the expressions on people’s faces and see no emotion that might indicate an accident.”
“You call the information service and get an auto- mated message with no mention of any strike.”
“The number plate indicates that the drivers are from a country where they drive on the other side of the road.”
P3 “The lack of expression in people’s faces may have been shock.”
“Maybe the bus company doesn’t give out this type of information that quickly.”
“The drivers have managed to stay on the correct side of the road for the whole journey up until this point.”
R4 “The car behind you did not stop as you would expect had there been an accident.”
“The bus you want to get has been late a lot recently due to there having been roads works on its route.”
“You realise that you are driving way below the speed limit.”
P4 “Perhaps the driver of the car behind you did not see what had happened either because it was so busy.”
“The road works were expected to have finished by now.”
“You have been driving below the speed limit at other points in the journey and the car has not overtaken you.”
Self-report measures: The Inferential Confusion Questionnaire (ICQ-
EV) (Aardema et al., 2010) is a 30-item measure in which each statement is
rated on a 6-point scale from 1: ’strongly disagree’, to 6: ‘strongly agree’. This
gives a total score ranging from 30 to 180. The ICQ-EV measures
23
subcomponents of inferential confusion such as inverse inference, a tendency
to distrust the senses and an over- reliance on possibility during reasoning,
absorption into imaginary sequences, category errors, irrelevant associations,
selective use of out-of-context facts and apparently comparable events. A total
score is derived. High scores on this measure indicate a greater tendency for
the individual to experience inferential confusion-characteristic reasoning
processes. Internal reliability (Cronbachs’s alpha) in the current sample
was .962 indicating excellent reliability.
Dissociative Experiences Scale-II (DES-II; Carlson & Putnam, 1993)
is a 28-item self-report questionnaire. Each item is rated on a scale from 0%
‘never happens to me’ to 100% ‘always happens to me’. To estimate a total
score that is interpretable on a percentage scale, the sum of the item scores is
divided by 28 to achieve a score ranging from 0 to 100. Dissociation is
operationalized here as experiences of memory loss, depersonalisation,
derealisation and absorption into the imaginary. Higher scores on this measure
indicate that the individual has dissociative experiences more frequently than
individuals with lower scores. Internal reliability (Cronbachs’s alpha) in the
current sample was .961 indicating excellent reliability.
Obsessive Compulsive Inventory - Revised (OCI-R; Foa, Huppert,
Leiberg, Langner, Kichic, Hajcak & Salkovskis, 2002) is an 18-item self-
report measure of obsessive-compulsiveness. The intensity of obsessive-
compulsiveness experiences is rated on a 5-point scale ranging from 0 ‘not at
all’ to 4 ‘extremely’. The total score on this measure can range from 0 to 72.
The OCI-R provides an overall indication of obsessive-compulsiveness related
distress as well as subscale scores for checking, doubting, ordering,
24
obsessions, hoarding and neutralising although only the total score was used in
this study. High scores on this measure indicate a greater intensity of
obsessive-compulsiveness experiences. Internal reliability (Cronbachs’s alpha)
in the current sample was .896 indicating very good reliability.
The Magical Ideation Scale (MIS; Eckblad & Chapman, 1983) is a 30-
item true-false measure of magical ideation, which is a symptom of
schizotypy. Items rated true are scored 1 and false items scored 0 resulting in a
total score ranging from 0 to 30. It identifies whether an individual has
paranormal and delusion-like beliefs about subjects such as telepathy,
astrology, conspiracy theories and UFO’s. High scores on this measure
indicate symptoms suggestive of a predisposition to psychosis. Internal
reliability (Cronbachs’s alpha) in the current sample was .85 indicating very
good reliability. All measures used in the study can be seen in Appendix B.
Apparatus
The online survey was created using Qualtrics software. The software
was set such that each participant received the scenarios in randomized order.
This software presented all the measures included in the study to each
individual participant. The Qualtrics programme recorded all participants’
responses. These were then downloaded from Qualtrics into an SPSS data file.
IBM SPSS statistics 22 was used to manage and analyse the data.
Procedure
The study was advertised on social media websites and on the
psychology testing website ‘Psychological Research on the Net’. This site was
25
located via another researcher who had recommended it. Participants who had
taken part were asked to send the study link to others in their social network.
Participants accessed the study by clicking a link embedded within the study
advert. The information screen that initially appeared orientated participants to
the study. An informed consent screen was also presented which required
participants to actively give consent to participate in the study (Appendix C).
Participants were then directed to demographic questions that they were
required to answer (Appendix D). The IPT was presented next (Appendix A).
The order in which each of the three scenarios included in the task were
presented was randomised and participants had to respond to each and every
question regarding each scenario before they had the ability to continue to the
next element of the study. Participants were then required to complete the
ICQ-EV, DES, OCI-R and the MIS (Appendix B). Finally, the debrief screen
was presented. This informed participants of who to contact should they have
any questions or want a summary of the findings (Appendix C). The debrief
also directed participants to sources of support should the study have brought
up any difficulties for them.
Ethics
This study was reviewed and granted a favourable ethical opinion by
the Faculty of Arts & Human Sciences Ethics Committee at the University of
Surrey prior to data collection (see appendix E for ethics committee letter).
Informed consent: The information sheet presented at the beginning
of the online study informed participants that the purpose of the study was to
26
test the relationship between reasoning processes, beliefs and behaviours.
While this was true information, the type of reasoning process, beliefs and
behaviours were not initially revealed, in order to avoid demand
characteristics. The BPS code of research ethics states that withholding the
exact nature of the study is necessary in experimental designs (BPS Ethics
committee, 2009). This omission of information was not expected to cause any
distress to participants and full details regarding the nature of the research was
revealed in the debrief. This was presented once participants had completed all
parts of the online study. The information sheet also indicated that participants
had a right to withdraw at any time before the survey was completed without
having to give a reason and without consequence. Participants were required
to actively indicate their consent to participate before they could proceed to
the study.
Risk to participants: There was minimal foreseeable risk that
participants may have been disturbed by the nature of the measures and/or the
inference task included in the study. It was considered that any potential stress
caused by this study would have been no greater than would be expected for
participants to experience in their ordinary life. However, to manage potential
upset, relevant sources of information and support were outlined in the
debrief.
Data protection: All information gathered by the online study was
treated as confidential. Data was used and stored in line with the Data
Protection Act 1998, in that it was stored on an online password protected
programme. Participation was anonymous as the online survey did not require
participants to enter any identifiable information. Participants were informed
27
that they would not be identifiable in any publication or presentations that
arose from the study’s results.
Data preparation and analysis
The study data was collected online between September 2014 and
February 2015. The study was set up to force responses, therefore, there was
no missing data to manage. The data were imported into SPSS and prepared
for analysis. This involved checking the responses, calculating total scores and
assessing the distribution of each of the study variables and whether this
suggested use of parametric or non-parametric tests (See Appendix F for
normality plots). Following from Aardema et al.’s (2009) study, the target
dependent variable was cumulative impact of possibility-based information.
The formula that was used to calculate this was (P1-R1) + (P2-R2) + (P3-R3)
+ (P4-R4) with P meaning probability-based and R meaning reality based
piece of information and the numbers referring to at what time point each
piece of information was presented. This formula calculated the changes in
levels of doubt that were directly influenced by the possibility-based
information across the four time points measured. The formula used for
cumulative impact of reality-based information was -1 x ((R1 – B) + (R2 – P1)
+ (R3 – P2) + (R4 – P3)) with B representing the baseline level of doubt
measured by the initial probability question. This formula calculated the
changes in level of doubt that were a direct impact of reality-based
information across the four time points. A positive value was obtained due to
the use of -1.
28
Results
The overall sample consisted of 107 participants, aged between 15 and
73 years old with a mean age of 28.73 years (SD 11.43). While the research
was designed for adults who could give their own consent, there was no way
to prevent younger adults taking part in the online study, nor was there a way
to be certain of the veracity of anyone’s self-reported age. The majority of
participants were White British (43.9%), and most were single/never married
(61.7%). 48.6% were employed for wages and (29.0%) were educated to
Bachelor degree level. More participants reported being of no religion (43.9%)
and half of participants completed the study from the UK (50.5%). See
Appendix G for full table of demographics of the overall sample.
TABLE 2. Distribution of total scores on questionnaire measures for
whole sample.
Questionnaire measures
Mean SD Possible score range
Score range in sample
ICQ-EV 83.95 28.56 30 - 180 34 - 164
OCI 14.91 11.18 0 - 72 0 - 51
DES (II) 24.17 19.08 0 - 100 0 - 100
MIS 7.26 5.46 0 - 30 0 - 23
In this sample, the distribution suggests that there was no restricted
range on any of the measures, meaning that a wide spread of scores for each
measure are represented. The mean scores are as might be expected for a non-
29
clinical sample, suggesting that the sampling strategy was effective. In
comparison to Aardema et al.’s (2009) non-clinical sample, the inferential
confusion mean in this sample is much higher. However, this is likely due to
Aardema et al. (2009) having used the ICQ containing 5 scale points, as
opposed to the current study, which used the ICQ-EV, containing 6 scale
points.
The distribution of scores in this sample on the IPT variables (Table 3)
suggests that there were no restricted ranges. The average score for initial
anxiety rating was twice as high in the OC-relevant scenario than the neutral
scenario. This supports the concept that the OC-relevant scenario is threat
laden. The delusion-relevant scenario mean initial anxiety rating was midway
between the other two scenarios, suggesting that it did imply more threat than
the neutral scenario, but not to the extent of the OC-relevant scenario. The
baseline probability scores were higher in the OC-relevant and neutral
scenarios than in the delusion-relevant scenario, suggesting that there may
have been less doubt induced by this scenario than the other two. The impact
of possibility and reality-based information was lower in the delusion-relevant
scenario than in the OC-relevant or neutral scenario, suggesting that, overall,
the desired effect was less pronounced in this scenario of the IPT. The impact
of reality-based information was much higher than the impact of possibility-
based information in all three scenarios.
30
TABLE 3. Descriptive statistics for IPT variables
For the OC-relevant scenario, baseline anxiety and baseline probability
were strongly positively correlated (r = .603, n = 107, p = .001). Baseline
anxiety was also positively correlated with cumulative impact of possibility-
based information (r = .291, n = 107, p = .002) and cumulative impact of
reality-based information (r = .485, n = 107, p = 000). A similar relationship
was found between baseline anxiety and baseline probability in the delusion-
31
IPT Mean SD Score range in sample
OC-relevant scenario
Initial anxiety (0-10)
8.82 1.88 0 - 10
Baseline probability (10-100)
73.60 24.26 10 - 100
Cumulative Impact of probability-based information
35.46 45.94 -73 – 185
Cumulative Impact of reality-based information
81.19 52.38 -44 - 196
Delusion-relevant scenario
Initial anxiety (0-10)
6.24 2.66 0 - 10
Baseline probability (10-100)
46.41 27.43 10 - 100
Cumulative impact of possibility-based information
14.09 28.66 -35 - 165
Cumulative impact of reality-based information
26.49 33.36 -75 - 175
Neutral scenario Initial anxiety (0-10)
4.04 2.43 0 - 10
Baseline probability (10-100)
65.96 23.99 11 - 100
Cumulative impact of possibility based information
34.75 50.52 -114 - 250
Cumulative impact of reality-based information
62.99 52.42 -74 - 300
relevant scenario although the effect size was stronger (r =.825, n = 107, p
= .000). In this scenario, baseline anxiety also positively correlated with
cumulative impact of possibility-based information (r = .671, n = 107, p
= .000) and reality-based information (r = .467, n = 107, p = .000). These
findings would be expected given that perceived anxiety in a situation is likely
to be associated with higher threat likelihood in that situation.
In contrast, baseline anxiety and baseline probability in the neutral
scenario were not significantly correlated (r = .160, n = 107, p = .100).
Additionally, baseline anxiety did not correlate with cumulative impact of
possibility-based information (r = .151, n = 107, p = .121) or reality-based
information (r = .173, n = 107, p = .075) in this scenario.
Histograms were used to check if all variables were sufficiently
normally distributed. As to be expected from a non-clinical sample, most of
the variables demonstrated a negative skew. This was with the exception of
the ICQ-EV and the cumulative impact of reality-based information in the
OC-relevant scenario, which were both sufficiently normally distributed.
Given this outcome, non-parametric tests were used throughout. (See
Appendix G for histograms).
Hypothesis 1: Following from Aardema et al. (2009), possibility-
based information presented after each imagined scenario will increase
participants’ self-reported level of doubt about the outcome of each scenario,
whereas reality-based information presented after each imagined scenario will
reduce participants’ self-reported level of doubt.
Figure 1 demonstrates how participants’ level of doubt fluctuated over
the different time points in all three scenarios. For all three scenarios, the
32
impact of reality and possibility-based information showed the characteristic
pattern as predicted by inferential confusion theory, with reality-based
information reducing doubt and possibility-based information increasing
doubt. However, there is part of the sequence in the delusion-relevant scenario
where this does not happen. Of note is that the characteristic effect seems to
persist with the inclusion of the additional pair of reality and possibility-based
information. However, it is evident that, in the OC-relevant and neutral
scenarios, doubt at the end of the experiment was much lower than at the start.
For the delusion-relevant scenario, doubt did not reduce as much from start to
finish. This may be because doubt started at a lower point relative to the other
two scenarios.
FIGURE 1: The cumulative impact of possibility and reality-based
information
B R1 P1 R2 P2 R3 P3 R4 P4102030405060708090
100
OC-relevant scenarioDelusions-relevant scenarioNeutral scenario
Reality and Possibility based information points
Patic
ipan
ts' j
udge
men
ts o
f pr
obab
ility
that
infe
rred
in-
cide
nt h
ad o
ccur
red
Hypothesis 2: Participants who score higher on the ICQ-EV will
report significantly higher levels of doubt in response to the possibility-based
information in all three scenarios presented to them in the IPT task.
33
Spearman’s rho correlation was conducted to measure the relationship
between inferential confusion (as measured by the ICQ-EV) and the
cumulative impact of possibility-based information on participants reported
level of doubt in the IPT. No significant relationship was found between the
two variables in either the OC-relevant scenario (r = .158, n = 107, p = .105)
or in the neutral scenario (r =.118, n = 107, p = .227). Conversely, a
significant positive correlation was found between inferential confusion and
the cumulative impact of possibility-based information on participants’ self-
reported doubt in the delusions-relevant scenario with a moderate effect size (r
= .359, n = 107, p = .000). These findings suggest that the two ways of
measuring inferential confusion are correlated only in the delusion-relevant
scenario.
Hypothesis 3: (a) Doubt as a result of possibility-based information
will be positively correlated with obsessive-compulsiveness and this effect
will be strongest for the OC-related scenario of the IPT; (b) doubt as a result
of possibility-based information will be positively correlated with schizotypy,
and this effect will be strongest in the delusion-related scenario of the IPT.
No significant relationship was found between obsessive-
compulsiveness (as measured by the OCI-R) and the cumulative impact of
possibility-based information on participants’ reported levels of doubt in the
OC-relevant scenario (r = .049, n = 107, p = .617) or the neutral scenario (r =
-.048, n = 107, p = .622). A significant positive relationship was found
between obsessive-compulsiveness and the impact of possibility-based
information on participants’ reported levels of doubt in the delusions-related
scenario (r = .320, n = 107, p = .001). Part (a) of the hypothesis was partially
34
supported in that the impact of possibility-based information relates to
obsessive-compulsiveness but only in the delusion-related scenario. However,
there was no correlation between obsessive-compulsiveness and doubt in OC-
related scenario, which was contrary to prediction.
No significant relationship was found between schizotypy (as
measured by the MIS) and the impact of possibility-based information on
participants’ reported levels of doubt in either the OC-relevant scenario (r =
-.014, n = 107, p = .887) or the neutral scenario (r = -.005, n = 107, p = .961).
However there was a significant positive correlation found between
schizotypy and the impact of possibility-based information on participants’
reported level of doubt in the delusion-relevant scenario with a moderate
effect size (r = .281, n = 107, p = .003). Similarly, part (b) of the hypothesis
was mostly supported, given that the impact of possibility-based information
related to schizotypy, but only in the delusion relevant scenario.
Hypothesis 4: Frequency of dissociative experiences will be positively
correlated with inferential confusion as operationalized by (a) self-report
(ICQ-EV) and (b) experimental (IPT) measures.
No significant relationship was found between dissociation (as
measured by the DES II) and the impact of possibility-based information on
participants’ reported levels of doubt in the OC-relevant scenario (r = -.010, n
= 107, p = .917), or the neutral scenario (r = -.040, n = 107, p = .679).
However, a significant positive relationship was found between dissociation
and the impact of possibility-based information on participants’ reported
levels of doubt in the delusion-relevant scenario (r = .252, n = 107, p = .009).
35
In addition, dissociation positively correlated with obsessive-
compulsiveness (r = .543, n = 107, p = .000). Obsessive-compulsiveness
positively correlated with schizotypy (r = .556, n = 107, p = .000) and
schizotypy was correlated with dissociation (r = .548, n = 107, p = .000).
Inferential confusion (as measured by ICQ-EV) also positively correlated with
dissociation (r = .359, n = 107, p = .000), OC (r = .470, n = 107, p = .000)
and schizotypy (r = .361, n = 107, p = .000). These correlations evidence
moderate to large effect sizes in the direction that would be expected.
Discussion
The overall purpose of this study was to derive new information
regarding the relationship between inferential confusion and obsessive-
compulsive, schizotypal and dissociative experiences. The aim was to
replicate and extend the experimental paradigm created by Aardema et al.
(2009) and used by Morrison (2014) to measure the inferential confusion
reasoning process in action, in a non-clinical sample; then to explore the
relationship between inferential confusion and other phenomena that had been
theoretically linked to inferential confusion such as obsessive-compulsiveness
(O’Connor et al., 2005) schizotypy (Aardema et al., 2005) and dissociation
(Aardema & O’Connor, 2012).
The hypotheses proposed were partially supported. The findings
appeared to support the contention that the IPT successfully operationalizes
the dynamic doubting process that is said to characterise obsessive-
compulsiveness. The expected oscillation of levels of doubt in response to
36
reality and possibility-based information were seen in all three scenarios. They
were more pronounced in the original two scenarios of the task designed by
Aardema et al. (2009) (OC-relevant and Neutral) than in the additional
scenario designed to extend the experimental remit of the IPT (delusion-
relevant). These findings suggest there may be something different about the
process of inferential confusion when in the context of a delusion-relevant
scenario, as opposed to the OC-relevant or neutral scenarios. The cumulative
impact of possibility and reality-based information continued to have an effect
with the inclusion of an additional possibility and reality-based information
pair in the current study. This supports Aardema et al’s (2009) hypothesis that
additional possibility and reality-based information will continue to impact the
individual’s reasoning as to whether an event has occurred or not. This is
considered to represent the doubting process seen in obsessive-
compulsiveness, whereby the individual will act in response to what might be
there over what their senses tell them is there. For example, washing ones
hands at the thought of them possibly being dirty, despite being able to see
that they look clean. The reasoning behind this is what O’Connor et al. (2005)
describe as inferential confusion.
In Aardema et al. (2009) and Morrison (2014) the cumulative impact of
possibility-based information on participants’ levels of doubt was taken to
represent inferential confusion in action. However, the current study also used
an empirically tested self-report measure of inferential confusion, which was
found not to correlate with the cumulative impact of possibility-based
information on doubt in the two original scenarios of the IPT. This suggests
that the IPT and the ICQ_EV might not have been measuring the same
37
construct, a possibility raised by Morrison (2014) who failed to replicate
Aardema et al.’s (2009) findings. However, scores on the ICQ_EV did
significantly correlate with the cumulative impact of possibility-based
information on doubt in the delusion-relevant scenario created for the current
study. One explanation for this could be that the delusion-relevant scenario
presented an ambiguous situation (potential car-jacking) that can be assumed
to be quite an unusual experience to the majority of participants. This is in
comparison to the other two scenarios, which may be more familiar to most
participants (potential car accident, potential bus strike). Therefore, the
positive correlation between experimental inferential confusion (i.e. doubt
arising from the delusion scenario) and self-report inferential confusion might
be due to both measures accessing reasoning that is considered unusual. That
is, the reasoning in the car accident and bus scenarios might represent the
essence of inferential confusion less then the delusion-related scenario.
The cumulative impact of possibility-based information on doubt (i.e.
experimentally-induced inferential confusion) was not shown to relate to
obsessive-compulsiveness, schizotypy and dissociation in the two original
scenarios developed by Aardema et al. (2009). This finding is similar to
Morrison (2014) who used only the two original scenarios and measures of
obsessive-compulsiveness and dissociation. However, experimentally-induced
inferential confusion did relate to these measures in the context of the
delusion-relevant scenario. One explanation for this might be that the OC-
relevant scenario is not sufficiently representative of obsessive-compulsive
concerns and, therefore, might not have shown a correlation with the self-
report measure of obsessive-compulsiveness. Therefore results for this
38
scenario were more in line with what was expected from the neutral scenario.
Alternatively, these findings might raise the question of whether inferential
confusion in the context of delusions is more strongly related to schizotypy,
obsessive-compulsiveness and dissociation. While a positive relationship
between cumulative impact of possibility-based information (inferential
confusion as measured by the IPT) and schizotypy was expected (Aardema et
al., 2005), this relationship was hypothesised to be seen in all scenarios and
strongest in the delusion-relevant scenario. A positive relationship between
cumulative impact of possibility-based information (inferential confusion as
measured by the IPT) and obsessive-compulsiveness was also expected
(Aardema et al., 2009) and hypothesised to be present in all scenarios, but
strongest in the OC-relevant scenario. The current findings do not support
these theoretical assertions, although the current study would need replication
before firm conclusions are drawn.
Further complicating the interpretation of the IPT is that inferential
confusion, as measured by the ICQ-EV, was positively correlated with scores
on measures of obsessive-compulsiveness, schizotypy and dissociation. This
further questions whether the IPT, as operationalized through the original
scenarios in Aardema et al. (2009) and self-report ICQ-EV measure different
constructs. It may be that the IPT measures participants’ state of oscillation
between their levels of doubt about whether an inferred event has occurred or
not, whereas the ICQ-EV measures a trait of subjectively reported unusual
experiences. These two components of the inferential confusion theory, as
outlined by Aardema et al. (2009) and Aardema et al. (2010) respectively, may
be too dissimilar to correlate under statistical investigation. If this is the case,
39
the mechanisms by which inferential confusion operates need to be explored
and inferential confusion as a theory needs to be additionally operationalized.
Whilst the findings from the current study are inconsistent with
Aardema et al.’s (2009) results, they are consistent with Morrison (2014). This
finding is unexpected given the body of evidence that links obsessive-
compulsiveness and inferential confusion. However, until now, most studies
have used either the self-report ICQ or ICQ-EV (Aardema et al., 2005;
Aardema et al., 2008, Aardema et al., 2006; Aardema et al., 2010). It could be
argued that the ICQ-EV might correlate with the self-report measures in this
study because inferential confusion is merely another re-expression of the
issues measured by the OCI-R, MIS and DES-II. Like them, the ICQ-EV is
also a self -report tool and so a subjective measure of participants’ experience.
Despite the strong relationship found between experimentally-induced
inferential confusion and dissociation in the delusions-relevant scenario of the
IPT, similarly to Morrison’s (2014) findings, no significant relationship was
found between dissociation and experimentally-induced inferential confusion
in either of the original OC-relevant or neutral scenarios. This finding could be
taken to support the notion that dissociation is involved in inferential
confusion, but only when inferential confusion is occurring in a realm that
relates to delusions and/or schizotypy. In addition, it could be used to support
O’Connor and Aardema’s (2012) idea that dissociation may be what enables
absorption into the imaginary for people experiencing inferential confusion.
However, that this outcome was only evident in the delusion-relevant scenario
of the IPT allows for an alternative explanation to be made regarding the
hypotheses that were not supported. Dissociation was strongly correlated with
40
the measures of both schizotypy and obsessive-compulsiveness, which is
consistent with previous literature that has linked dissociation and obsessive-
compulsiveness (Aardema & Wu, 2011) and dissociation and schizotypy
(Merckelbach Rassin & Muris, 2000). Inferential confusion as measured by
the ICQ-EV also correlated with all measures as expected, whereas the IPT
did not. Therefore, rather than the findings of the current study going against
what is in the literature with regards to the relationship between inferential
confusion and obsessive-compulsiveness, it might be postulated that the IPT
does not operationalize inferential confusion in the manor by which it claims
to.
The main limitation of the current study is that the delusion-relevant
scenario of the IPT is yet to be replicated. This was the only condition of the
experimental task that yielded positive results. However, these single findings
cannot be considered reliable or valid until replication is undertaken. The
delusion-relevant scenario could have been designed to represent a more
common delusional experience, rather than that of being car-jacked. For
example, the experience of walking home at night alone and suspecting one
may be being followed. In retrospect, the possibility-based information in the
delusion-relevant scenario may have been different to that of the other two
scenarios. P2, P3 and P4 appear to be based on ‘reality’ as opposed to
‘possibility’, when compared to the Ps in the other two scenarios, which are
more based on ‘maybe’. For example, P2 in the delusion-relevant scenario
uses definite language such as “Other cars have overtaken you and the car
behind at other points in your journey” whereas P2 in the OC-relevant uses
more ambiguous language, “You may not have seen everything, because it’s
41
quite crowded.” In hindsight, the possibility-based pieces of information at
time points P2, P3 and P4 in the delusion- relevant scenario were in fact more
like the reality-based pieces of information in the other two scenarios. Based
on the results of the other two scenarios, P2 of the delusion-relevant scenario
being more like a reality-based piece of information. This may explain why P2
reduced doubt in this scenario rather than increased it, as P2 did in the other
two scenarios. However, P3 and P4 of the delusion-relevant scenario increased
doubt even though they were more reality-based than the P’s in the other two
scenarios. An explanation for this could be that P3 and P4 of the delusion-
relevant scenario may have re-triggered the initial threat induced by the
scenario itself, as opposed to the possibility of what might have happened in
the scenario. If so, a possible conclusion could be that threat is a core
component of inferential confusion, as opposed to doubt, since this was the
scenario that related to the other measures of the study, including the self-
report measure of inferential confusion. “Possibly, the impact of reality-based
information is more attenuated in ego-syntonic obsessions, or obsessions that
resemble overvalued ideas or delusions.” (Aardema et al., 2009, p. 202). In
addition, it is unlikely that the impact of P3 and P4 in the delusion-relevant
scenario was due to the practice effects of the other scenarios, as the order that
the scenarios were presented in was randomised.
A further limitation is while the positive relationships found were strong
and in the expected direction, due to the correlational design of the study,
causation cannot be inferred. This does not allow conclusions as to whether
obsessive-compulsiveness, schizotypy or dissociative tendencies influence
inferential confusion or vice versa. Due to these reasons, the findings do not
42
aid the understanding of the causal sequence in inferential confusion but rather
what phenomena relate to the inferential confusion reasoning style. Direct
comparison with the findings of Aardema et al. (2009) and Morrison (2014)
are hampered somewhat by the studies using different measures of obsessive-
compulsiveness and inferential confusion. However, Morrison did use the
DES-II and the experimental IPT and the findings of the current study are
broadly consistent with Morrison’s (2014).
While Aardema and Wu (2011) found the absorption subscale of the
DES-II to correlate with inferential confusion, Morrison (2014) reported that
other aspects of dissociation had been linked with obsessive-compulsiveness
in the literature. For this reason, and for the purposes of comparison with the
results of Morrison’s (2014) study, the DES-II was used as a broad measure of
dissociation in the current study. This allowed for the investigation of the
relationship between inferential confusion, obsessive-compulsiveness,
schizotypy and dissociation, despite the lack of clarity around what aspects or
subtypes of dissociation may be most relevant to the other variables. Magical
Ideation was measured by the MIS as a symptom of schizotypy. This scale
was used since magical ideation is a phenomena that has also been linked to
some aspects of obsessive-compulsiveness (Tolin, Abramowitz, Kozac and
Foa, 2001). Therefore it was considered to be a relevant measure given the
variables that were investigated in the current study. However, the limitations
of this measure imply that schizotypy, as discussed in this paper, may not
completely represent the phenomena of schizotypy that the study was claiming
to investigate. The use of this measure may have inflated the observed
relationship between schizotypy and obsessive-compulsiveness, due to the
43
previously identified relationship between obsessive-compulsives and magical
ideation. Alternative measures of schizotypy such as the Oxford-Liverpool
Inventory of Feelings & Experiences (O-LIFE, Mason, Claridge & Jackson,
1995) may have been more representative of the phenomena in its entirety. In
turn, this may have enhanced the validity of the relationships found between
schizotypy and the other variables measured.
In both the current study and Morrison’s (2014) study, a non-clinical
sample was used, which while appropriate in this kind of research, does not
represent the clinical population to whom the findings from this type of
research may impact. The completion rate of the study was low, however the
demographics of those who dropped out were not included in the study. This
was in order to respect participants’ right to withdraw at any time, but it also
means that an understanding of the high drop out rate cannot be acquired.
The results support the idea that dissociation plays a role in inferential
confusion, obsessive-compulsiveness and schizotypy, as predicted by
Morrison (2014) and in line with the previous findings of Aardema and Wu
(2011) and O’Connor & Aardema (2012). The null results question Aardema
et al.’s (2009) claims that possibility-based information induces a doubting
process that emulates inferential confusion in people who experience high
levels of obsessive-compulsiveness, in OC-relevant threat situations. Since
Aardema et al. (2009) are the only research team to have found this effect,
which has not been found in two subsequent replications, it cannot currently
be supported and alternative explanations should be investigated.
Future research could focus on continuing to develop an experimentally
valid method to operationalize inferential confusion. Since this reasoning style
44
has been implicated in different phenomena that involve unusual thinking, the
IPT could be further extended to reflect this. Given the possibility-based
information in the delusion-relevant scenario later appeared to be more reality-
based than intended, adaptation of the IPT to encapsulate this could be useful
in deciphering what it was about the impact of information in the delusion-
relevant scenario that correlated with the ICQ-EV. For example, cumulative
impact of pairs of reality-based information concerning a inferred event
having occurred and not occurred could be compared to cumulative impact of
pairs of possibility-based information for the same scenario using a between
subjects design. This may help to identify what type of information is more
likely to induce inferential confusion, which would add to the accurate
explanation of why this reasoning process occurs.
To allow for causation to be implied, future studies may benefit from
including an experimental condition that induces the other variables of
interest, if ethically sound. For example, inducing and measuring feelings of
dissociation in participants before and after the IPT, to evaluate whether
dissociation increases an individual’s propensity to inferential confusion or
vice versa. Studies utilising a clinical sample to participate in expanded and
adapted versions of the IPT would also be useful. These would investigate
whether the same patterns are seen in clinical populations, which would in
turn enable findings to be generalised and utilized in a way that might inform
treatment for those significantly distressed by inferential confusion and the
phenomena related to it, i.e. obsessive-compulsiveness, schizotypy and
dissociation.
45
The finding that inferential confusion as measured by the ICQ-EV is
significantly related to obsessive-compulsiveness, schizotypy and dissociation
might have implications for the use of the IBA in treating delusional disorders
and dissociative disorders as well as OCD and related disorders. To further
quantify the trandiagnostic properties of the inferential confusion theory,
research has been conducted into other obsessive-compulsive spectrum
disorders, where beliefs are more akin to delusions or overvalued ideas, given
that they are ego-syntonic. Body-dysmorphic disorder and hoarding have both
been shown to be positively responsive to the IBA to treatment, suggesting
that inferential confusion theory could explain the unusual reasoning also seen
in these disorders (Tallion, O’Connor, Dupuis & Lavoie, 2013; St-Pierre-
Delorme, Lalonde, Perreault, Koszegi & O’Connor, 2011), supporting the
inferential confusion theory’s position as a possible transdiagnostic model for
disorders on the continuum of obsessive-compulsiveness, OVI and delusions.
In addition, findings from this study highlight the potential conceptual
similarities between self-report inferential confusion, obsessive-
compulsiveness schizotypy and dissociation. That is, inferential confusion
might merely be a re-expression of obsessive-compulsiveness, schizotypal and
dissociative phenomenology. To investigate this further, future research could
examine the relationship between the ICQ-EV and experimentally induced
inferential confusion using the IPT, while controlling for levels of obsessive-
compulsiveness, schizotypy and dissociation. This line of inquiry could help to
either validate inferential confusion as a state and trait construct separate to
similar phenomenology, or further question its construct and clinical reliability
and validity.
46
Conclusion
This study demonstrates that inferential confusion, obsessive-
compulsiveness, schizotypy and dissociation are linked. However, it does not
determine the causation of these relationships. In highlighting the need for
further investigation of the mechanisms by which inferential confusion occurs,
the current study offers threat activation as an alternative explanation of
inferential confusion to the doubting process that is put forward by the original
inferential confusion theory (O’Connor et al., 2005). This study questions the
validity of the Inference Process Task claimed by Aardema et al (2009) to
measure inferential confusion and provides a novel level to the task to widen
the remit of what it investigates. The present study suggests adaptations to be
made to the IPT to investigate alternative avenues that may represent
inferential confusion more accurately and proposes methodological
adaptations that future studies could make to enhance the reliability and
validity of possible findings. Future research in this area is shown to be both
justifiable and desirable. The need to decipher whether inferential confusion is
an independent construct or merely a re-expression of obsessive-
compulsiveness, schizotypy and dissociation still remains, as does the need for
the replication of a valid experimental measure of inferential confusion. Future
research that can demonstrate the direction of the relationships found by the
current study could enhance the use of the inference based approach to therapy
for adults and children experiencing a wide range of obsessive-compulsive and
related phenomena, as well as those experiencing other thought disorders,
including but not limited to schizotypy and dissociation.
47
References
Aardema, F., Emmelkamp, P. M. G., & O'Connor, K. P. (2005).
Inferential confusion, cognitive change and treatment outcome in obsessive-
compulsive disorder. Clinical Psychology & Psychotherapy,12, 338-345.
Aardema, F., O'Connor, K. P., & Emmelkamp, P. M. G. (2006).
Inferential confusion and obsessive beliefs in obsessive-compulsive
disorder. Cognitive Behaviour Therapy, 35, 138-147.
Aardema, F., O'Connor, K. P., Emmelkamp, P. M. G., Marchand, A.,
& Todorov, C. (2005). Inferential confusion in obsessive-compulsive disorder:
The inferential confusion questionnaire. Behaviour Research and Therapy, 43,
293-308.
Aardema, F., & O'Connor, K. (2012). Dissolving the tenacity of
obsessional doubt: Implications for treatment outcome. Journal of Behavior
Therapy and Experimental Psychiatry, 43, 855-861.
Aardema, F., O'Connor, K. P., Pélissier, M., & Lavoie, M. E. (2009).
The quantification of doubt in obsessive-compulsive disorder. International
Journal of Cognitive Therapy, 2, 188-205.
Aardema, F., Radomsky, A. S., O'Connor, K. P., & Julien, D. (2008).
Inferential confusion, obsessive beliefs and obsessive-compulsive symptoms:
A multidimensional investigation of cognitive domains. Clinical Psychology
& Psychotherapy, 15, 227-238.
Aardema, F., & Wu, K. D. (2011). Imaginative, dissociative, and
schizotypal processes in obsessive-compulsive symptoms. Journal of Clinical
Psychology, 67, 74-81.
48
Aardema, F., Wu, K.D., Careau, Y., O’Connor, K., Julien, D., &
Dennie, S. (2010). The Expanded Version of the Inferential Confusion
Questionnaire: Further Development and Validation in Clinical and Non-
Clinical Samples. J Psychopathol Behav Assess, 32, 448-462.
American Psychiatric Association (2014). Diagnostic and statistical
manual of mental disorders (5th ed., Text Revision). Arlington: VA.
Abramowitz, J. S., Taylor, S., & McKay, D. (2009). Obsessive-
compulsive disorder. The Lancet, 374(9688), 491-499.
Bell, V., Halligan, P. W., & Ellis, H. D. (2006). Explaining delusions:
a cognitive perspective. Trends in cognitive sciences, 10(5), 219-226.
Ethics Committee of the British Psychological Society (2009). Code of
Ethics and Conduct: Guidance published by the Ethical Committee of the
British Psychological Society. Leicester: The British Psychological Society.
Carlson, E. B., & Putnam, F. W. (1993). An update on the dissociative
experiences scale. Dissociation: Progress in the Dissociative Disorders, 6(1),
16-27.
Claridge, G., McCreery, C., Mason, O., Bentall, R., Boyle, G., Slade,
P., & Popplewell, D. (1996). The factor structure of ‘schizotypal’ traits: A
large replication study. British Journal of Clinical Psychology, 35,103-115.
UK Parliament (1998). Data Protection Act. London: HMSO.
Eckblad, M., & Chapman, L. J. (1983). Magical ideation as an
indicator of schizotypy. Journal of consulting and clinical psychology, 51(2),
215.
49
Foa, E. B., Huppert, J. D., Leiberg, S., Langner, R., Kichic, R., Hajcak,
G., & Salkovskis, P. M. (2002). The Obsessive-Compulsive Inventory:
development and validation of a short version. Psychological assessment,
14(4), 485.
Gibbs, N.A. (1996). Nonclinical populations in research on obsessive
compulsive disorder: A critical review. Clinical Psychology Review, 16, 729-
773.
Johns, L.C., & Os, J.V. (2001). The continuity of psychotic
experiences in the general population. Clinical Psychology Review, 21, 1125-
1141.
Mason, O., Claridge, G., & Jackson, M. (1995). New scales for the
assessment of schizotypy. Personality and Individual differences, 18(1), 7-13.
Morrison, K. (2014). The Relationship Between Dissociation,
Susceptibility to Doubt and Obsessive- Compulsiveness. Unpublished
Manuscript.
Merckelbach, H., Rassin, E., & Muris, P. (2000). Dissociation,
schizotypy, and fantasy proneness in undergraduate students. The Journal of
nervous and mental disease, 188(7), 428-431.
O'Connor, K., & Aardema, F. (2003). Fusion or confusion in
obsessive-compulsive disorder. Psychological Reports, 93, 227-232.
O'Connor, K., & Aardema, F. (2012). Living in a Bubble Dissociation,
Relational Consciousness, and Obsessive Compulsive Disorder. Journal of
Consciousness Studies, 19(7-8), 216-246.
Obsessive Compulsive Cognitions Working Group. (2005).
Psychometric validation of the obsessive belief questionnaire and
50
interpretation of intrusions inventory—Part 2: Factor analyses and testing of a
brief version. Behaviour Research and Therapy, 43(11), 1527-1542.
O’Connor, K., Aardema, F., & Pelissier, M. (2005). BEYOND
REASONABLE DOUBT: Reasoning Processes in Obsessive-Compulsive
Disorder and Related Disorders. England: John Wiley & Sons, Ltd.
O'Connor, K., Koszegi, N., Aardema, F., van Niekerk, J., & Taillon, A.
(2009). An inference-based approach to treating obsessive-compulsive
disorders. Cognitive and Behavioral Practice, 16(4), 420-429.
O'Connor, K., & Robillard, S. (1995). Inference processes in
obsessive-compulsive disorder: Some clinical observations. Behaviour
Research and Therapy, 33, 887-896.
Tallion, A., O’Connor, K., Dupius, G., & Lavoie, M. (2013).
Inference-Based Therapy for Body Dysmorphic Disorder. Clinical Psychology
and Psychotherapy, 20, 67-76.
Tolin, D. F., Abramowitz, J. S., Kozak, M. J., & Foa, E. B. (2001).
Fixity of belief, perceptual aberration, and magical ideation in obsessive–
compulsive disorder. Journal of Anxiety Disorders, 15(6), 501-510.
St-Pierre-Delorme, M., Lalonde, M.P., Perreault, V., Koszegi, N., &
O’Connor, K. (2001). Inference-Based Therapy for Compulsive Hoarding: A
Clinical Case Study. Clinical Case Studies, 10, 291-303.
Van Ijzendoorn, M. H., & Schuengel, C. (1996). The measurement of
dissociation in normal and clinical populations: Meta-analytic validation of the
Dissociative Experiences Scale (DES). Clinical Psychology Review, 16(5),
365-382.
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Major Research Project – List of Appendices
Appendix A – Journal Guidelines for authors
Appendix B – IPT
Appendix C – ICQ-EV, DES, OCI, MI
Appendix D – Information/consent/debrief/advertising material
Appendix E - Demographic questions
Appendix F – Ethics committee letter
Appendix G – Tables of demographics
Appendix H – Normality plots/histograms
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Appendix A – Journal Guidelines for authors
Retrieved from http://www.elsevier.com/journals/journal-of-obsessive-compulsive-and-related-disorders/2211-3649?generatepdf=true
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Authors must declare their individual contributions to the manuscript. All authors must have materially participated in the research and/or the manuscript preparation. Roles for each author should be described. The disclosure must also clearly state and verify that all authors have approved the final manuscript.
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Article structure
Introduction
State the objectives of the work and provide an adequate background, avoiding a detailed literature survey or a summary of the results. If the focus of the paper is on a disorder other than OCD (as defined in DSM-IV.TR), provide a rationale for including the disorder as an obsessive-compulsive related disorder (see Editorial Guidance section).
Methods
Provide sufficient detail to allow the work to be reproduced. Methods already published should be indicated by a reference: only relevant modifications should be described.
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A Theory section should extend, not repeat, the background to the article already dealt with in the Introduction and lay the foundation for further work. In contrast, a Calculation section represents a practical development from a theoretical basis.
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Results should be clear and concise.
Discussion
This should explore the significance of the results of the work, not repeat them. Avoid extensive citations and discussion of published literature. Be sure to include limitations of the present study and suggestions for future research.
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The main conclusions of the study may be presented in a short Conclusions section, which may stand alone or form a subsection of a Discussion or Results and Discussion section.
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If there is more than one appendix, they should be identified as A, B, etc. Formulae and equations in appendices should be given separate numbering: Eq. (A.1), Eq. (A.2), etc.; in a subsequent appendix, Eq. (B.1) and so on. Similarly for tables and figures: Table A.1; Fig. A.1, etc.
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The Journal will consider clinical reports that articulate the treatment of OCD or related disorders using any theoretical framework (biological, behavioral, cognitive, gestalt, humanistic, psychodynamic, and others). Clinical reports should use the following format (maximum manuscript length is 30 pages in total):
1. Theoretical and Research Basis for the Treatment2. Case Introduction (presenting complaints, history, etc.)3. Assessment (what instruments were used [and justification if needed])4. Case Conceptualization (discuss the clinician's thinking about the case and the treatment selection) 5. Course of Treatment and Assessment of Progress (Describe what happened during treatment and the outcome at post-treatment and follow up. If possible, use single case research design methodology; see Barlow, Nock, &Hersen [2009])
6. Complicating Factors (if any, including medical management) 7. Treatment Implications of the Case8. Recommendations to Clinicians and Students
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This option is designed to allow publication of research reports that are not suitable for publication as regular articles. Shorter Communications or Brief Reports are appropriate for articles with a specialized focus or of particular didactic value. Manuscripts should be between 3000-5000 words, and must not exceed the upper word limit. This limit includes the abstract, text, and references, but not the title page, tables and figures.
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Authors can make use of Elsevier's Illustration and Enhancement service to ensure the best presentation of their images and in accordance with all technical requirements: Illustration Service.
Highlights
Highlights are mandatory for this journal. They consist of a short collection of bullet points that convey the core findings of the article and should be submitted in a separate editable file in the online submission system. Please use 'Highlights' in the file name and include 3 to 5 bullet points (maximum 85 characters, including spaces, per bullet point). See http://www.elsevier.com/highlights for examples.
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Keywords
Immediately after the abstract, provide a maximum of 6 keywords, using American spelling and avoiding general and plural terms and multiple concepts (avoid, for example, 'and', 'of'). Be sparing with abbreviations: only abbreviations firmly established in the field may be eligible. These keywords will be used for indexing purposes.
Acknowledgements
Collate acknowledgements in a separate section at the end of the article before the references and do not, therefore, include them on the title page, as a footnote to the title or otherwise. List here those individuals who provided help during the research (e.g., providing language help, writing assistance or proof reading the article, etc.).
Math formulae
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Footnotes
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Artwork
Electronic artwork General points
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• Make sure you use uniform lettering and sizing of your original artwork.• Preferred fonts: Arial (or Helvetica), Times New Roman (or Times), Symbol, Courier.• Number the illustrations according to their sequence in the text.• Use a logical naming convention for your artwork files.• Indicate per figure if it is a single, 1.5 or 2-column fitting image.• For Word submissions only, you may still provide figures and their captions, and tables within a single file at the revision stage.• Please note that individual figure files larger than 10 MB must be provided
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in separate source files. A detailed guide on electronic artwork is available on our website: http://www.elsevier.com/artworkinstructions.You are urged to visit this site; some excerpts from the detailed information are given here. FormatsRegardless of the application used, when your electronic artwork is finalized, please 'save as' or convert the images to one of the following formats (note the resolution requirements for line drawings, halftones, and line/halftone combinations given below):EPS (or PDF): Vector drawings. Embed the font or save the text as 'graphics'.TIFF (or JPG): Color or grayscale photographs (halftones): always use a minimum of 300 dpi.TIFF (or JPG): Bitmapped line drawings: use a minimum of 1000 dpi.TIFF (or JPG): Combinations bitmapped line/half-tone (color or grayscale): a minimum of 500 dpi is required.Please do not:• Supply files that are optimized for screen use (e.g., GIF, BMP, PICT, WPG); the resolution is too low. • Supply files that are too low in resolution.• Submit graphics that are disproportionately large for the content.
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Please note: Because of technical complications that can arise by converting color figures to 'gray scale' (for the printed version should you not opt for color in print) please submit in addition usable black and white versions of all the color illustrations.
Figure captions
Ensure that each illustration has a caption. A caption should comprise a brief title (not on the figure itself) and a description of the illustration. Keep text in the illustrations themselves to a minimum but explain all symbols and abbreviations used.
Tables
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Number tables consecutively in accordance with their appearance in the text and place any table notes below the table body. Be sparing in the use of tables and ensure that the data presented in them do not duplicate results described elsewhere in the article. Please avoid using vertical rules.
References
Citation in text
Please ensure that every reference cited in the text is also present in the reference list (and vice versa). Any references cited in the abstract must be given in full. Unpublished results and personal communications are not recommended in the reference list, but may be mentioned in the text. If these references are included in the reference list they should follow the standard reference style of the journal and should include a substitution of the publication date with either 'Unpublished results' or 'Personal communication'. Citation of a reference as 'in press' implies that the item has been accepted for publication.
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Web references
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References in a special issue
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Reference management software
Most Elsevier journals have a standard template available in key reference management packages. This covers packages using the Citation Style Language, such as Mendeley (http://www.mendeley.com/features/reference-manager) and also others like EndNote (http://www.endnote.com/support/enstyles.asp) and Reference Manager (http://refman.com/support/rmstyles.asp). Using plug-ins to word processing packages which are available from the above sites, authors only need to select the appropriate journal template when preparing their article and the list of references and citations to these will be formatted according to the journal style as described in this Guide. The process of including templates in these packages is constantly ongoing. If the journal you are looking for does not have a template available yet, please see the list of sample references and
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citations provided in this Guide to help you format these according to the journal style.
If you manage your research with Mendeley Desktop, you can easily install the reference style for this journal by clicking the link below: http://open.mendeley.com/use-citation-style/journal-of-obsessive-compulsive-and-related-disorders When preparing your manuscript, you will then be able to select this style using the Mendeley plug- ins for Microsoft Word or LibreOffice. For more information about the Citation Style Language, visit http://citationstyles.org.
Reference formatting
There are no strict requirements on reference formatting at submission. References can be in any style or format as long as the style is consistent. Where applicable, author(s) name(s), journal title/book title, chapter title/article title, year of publication, volume number/book chapter and the pagination must be present. Use of DOI is highly encouraged. The reference style used by the journal will be applied to the accepted article by Elsevier at the proof stage. Note that missing data will be highlighted at proof stage for the author to correct. If you do wish to format the references yourself they should be arranged according to the following examples:
Reference styleText: Citations in the text should follow the referencing style used by the American Psychological Association. You are referred to the Publication Manual of the American Psychological Association, Sixth Edition, ISBN 978-1-4338-0561-5, copies of which may be ordered from http://books.apa.org/books.cfm?id=4200067 or APA Order Dept., P.O.B. 2710, Hyattsville, MD 20784, USA or APA, 3 Henrietta Street, London, WC3E 8LU, UK.List: references should be arranged first alphabetically and then further sorted chronologically if necessary. More than one reference from the same author(s) in the same year must be identified by the letters 'a', 'b', 'c', etc., placed after the year of publication.Examples:Reference to a journal publication:Van der Geer, J., Hanraads, J. A. J., & Lupton, R. A. (2010). The art of writing a scientific article. Journal of Scientific Communications, 163, 51–59.Reference to a book:Strunk, W., Jr., & White, E. B. (2000). The elements of style. (4th ed.). New York: Longman, (Chapter 4).Reference to a chapter in an edited book:Mettam, G. R., & Adams, L. B. (2009). How to prepare an electronic version of your article. In B. S. Jones, & R. Z. Smith (Eds.), Introduction to the electronic age (pp. 281–304). New York: E-Publishing Inc.
Journal abbreviations source
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Journal names should be abbreviated according to the List of Title Word Abbreviations: http://www.issn.org/services/online-services/access-to-the-ltwa/.
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Video data
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AudioSlides
The journal encourages authors to create an AudioSlides presentation with their published article. AudioSlides are brief, webinar-style presentations that are shown next to the online article on ScienceDirect. This gives authors the opportunity to summarize their research in their own words and to help readers understand what the paper is about. More information and examples are available at http://www.elsevier.com/audioslides. Authors of this journal will automatically receive an invitation e-mail to create an AudioSlides presentation after acceptance of their paper.
Supplementary material
Elsevier accepts electronic supplementary material to support and enhance your scientific research. Supplementary files offer the author additional possibilities to publish supporting applications, high- resolution images, background datasets, sound clips and more. Supplementary files supplied will be published online alongside the electronic version of your article in Elsevier Web products, including ScienceDirect: http://www.sciencedirect.com. In
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order to ensure that your submitted material is directly usable, please provide the data in one of our recommended file formats. Authors should submit the material in electronic format together with the article and supply a concise and descriptive caption for each file. For more detailed instructions please visit our artwork instruction pages at http://www.elsevier.com/artworkinstructions.
3D neuroimaging
You can enrich your online articles by providing 3D neuroimaging data in NIfTI format. This will be visualized for readers using the interactive viewer embedded within your article, and will enable them to: browse through available neuroimaging datasets; zoom, rotate and pan the 3D brain reconstruction; cut through the volume; change opacity and color mapping; switch between 3D and 2D projected views; and download the data. The viewer supports both single (.nii) and dual (.hdr and .img) NIfTI file formats. Recommended size of a single uncompressed dataset is maximum 150 MB. Multiple datasets can be submitted. Each dataset will have to be zipped and uploaded to the online submission system via the '3D neuroimaging data' submission category. Please provide a short informative description for each dataset by filling in the 'Description' field when uploading a dataset. Note: all datasets will be available for downloading from the online article on ScienceDirect. If you have concerns about your data being downloadable, please provide a video instead. For more information see: http://www.elsevier.com/3DNeuroimaging.
Submission checklist
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• E-mail address• Full postal addressAll necessary files have been uploaded, and contain: • Keywords• All figure captions• All tables (including title, description, footnotes) Further considerations
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• Manuscript has been 'spell-checked' and 'grammar-checked'• All references mentioned in the Reference list are cited in the text, and vice versa• Permission has been obtained for use of copyrighted material from other sources (including the Internet)
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Printed version of figures (if applicable) in color or black-and-white• Indicate clearly whether or not color or black-and-white in print is required.• For reproduction in black-and-white, please supply black-and-white versions of the figures for printing purposes.For any further information please visit our customer support site at http://support.elsevier.com.
AFTER ACCEPTANCE
Use of the Digital Object Identifier
The Digital Object Identifier (DOI) may be used to cite and link to electronic documents. The DOI consists of a unique alpha-numeric character string which is assigned to a document by the publisher upon the initial electronic publication. The assigned DOI never changes. Therefore, it is an ideal medium for citing a document, particularly 'Articles in press' because they have not yet received their full bibliographic information. Example of a correctly given DOI (in URL format; here an article in the journal Physics Letters B):
http://dx.doi.org/10.1016/j.physletb.2010.09.059
When you use a DOI to create links to documents on the web, the DOIs are guaranteed never to change.
Online proof correction
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If preferred, you can still choose to annotate and upload your edits on the PDF version. All instructions for proofing will be given in the e-mail we send to authors, including alternative methods to the online version and PDF.We will do everything possible to get your article published quickly and accurately. Please use this proof only for checking the typesetting, editing, completeness and correctness of the text, tables and figures. Significant changes to the article as accepted for publication will only be considered at this stage with permission from the Editor. It is important to ensure that all corrections are sent back to us in one communication. Please check carefully before replying, as inclusion of any subsequent corrections cannot be guaranteed. Proofreading is solely your responsibility.
Offprints
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The corresponding author, at no cost, will be provided with a personalized link providing 50 days free access to the final published version of the article on ScienceDirect. This link can also be used for sharing via email and social networks. For an extra charge, paper offprints can be ordered via the offprint order form which is sent once the article is accepted for publication. Both corresponding and co-authors may order offprints at any time via Elsevier's WebShop (http://webshop.elsevier.com/myarticleservices/offprints). Authors requiring printed copies of multiple articles may use Elsevier WebShop's 'Create Your Own Book' service to collate multiple articles within a single cover (http://webshop.elsevier.com/myarticleservices/booklets).
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Appendix B – Inference Process Task (IPT)
You will read three scenarios. Take the time to use your imagination to visualise yourself in each scenario. After each scenario, you will be asked to rate your anxiety as if you were truly involved in the situation. You will also be asked to rate what you think the probability is that a possible event had occurred in each scenario. You will be presented with 8 statements about each scenario and asked to consider your rating of the probability of each possible event having occurred, in the light of each of these statements.
Scenario 1: You’re on your way to work with the car. This morning you read about an accident where a van driver unknowingly drove over someone, and left the scene of the accident without realising. You wonder how it is possible that someone could not notice this while driving. As you drive along, you come across an intersection and come to a halt at the red light. It is quite busy, with a lot of people on the other side of the intersection, waiting to cross the road. You notice a group of young people, boys and girls, chasing each other, running off and on the road. As the light turns green you start to accelerate. Then, just as you pass the intersection you hear a scream and feel a bump!
How anxious would you feel in the above situation?
Please rate this on a scale 0-100%……………………………………………..
What do you consider to be the probability that an accident has happened under these circumstances?
Please rate this on a scale 10-100%……………………………………………
R1. You look in the rear view mirror and see a pothole in the road.
What do you consider to be the probability that an accident has happened under these circumstances?
Please rate this on a scale 10-100%……………………………………………
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P1. The pothole may not have been deep enough to cause the bump.
What do you consider to be the probability that an accident has happened under these circumstances?
Please rate this on a scale 10-100%……………………………………………
R2. Your turn your head and see no one lying on the street.
What do you consider to be the probability that an accident has happened under these circumstances?
Please rate this on a scale 10-100%……………………………………………
P2. You may not have seen anything because it is quite crowded.
What do you consider to be the probability that an accident has happened under these circumstances?
Please rate this on a scale 10-100%……………………………………………
R3. You watch the expressions on people’s faces and see no emotion that may indicate an accident.
What do you consider to be the probability that an accident has happened under these circumstances?
Please rate this on a scale 10-100%…………………………………………….
P3. The lack of expression in people’s faces may have been shock.
What do you consider to be the probability that an accident has happened under these circumstances?
Please rate this on a scale 10-100%……………………………………………
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R4. The car behind you did not stop as you would expect had there been an accident.
What do you consider to be the probability that an accident has happened under these circumstances?
Please rate this on a scale 10-100%…………………………………………….
P4. Perhaps the driver of the car behind you did not see what had happened either because it was so busy.
What do you consider to be the probability that an accident has happened under these circumstances?
Please rate this on a scale 10-100%……………………………………………
Scenario 2: You’re on your way to work with the car. This morning you read about the rise of carjacking’s in your local area. The article explained that carjacking is the forceful theft of an occupied vehicle that often involves the victim being robbed of other valuables, abducted and assaulted. The carjackers had been forcing their victims to stop the car by overtaking them and halting abruptly in front of them. You wonder how it is possible that the police have not yet caught the perpetrators. As you drive along, you come to an intersection and come to a halt at the red light. The roads are not that busy and you noticed that a car with an overseas licence plate has been driving behind you the whole journey. As the light turns green you start to accelerate. Then as you pass the intersection, the car behind drives to the side of you and the men inside the car stare into your car.
How anxious would you feel in the above situation?
Please rate this on a scale 0-100%……………………………………………
What do you consider to be the probability that the men in the car are going to car jack you?
Please rate this on a scale 10-100%……………………………………………
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R1. The expressions on the men’s faces in the car are not menacing or threatening in anyway.
What do you consider to be the probability that the men in the car are going to car jack you?
Please rate this on a scale 10-100%……………………………………………
P2. The lack of expression in their faces may be because they want to take you be surprise.
What do you consider to be the probability that the men in the car are going to car jack you?
Please rate this on a scale 10-100%……………………………………………
R2. It is not very busy and you are in a much safer place for the car to overtake you now than at other points in the journey.
What do you consider to be the probability that the men in the car are going to car jack you?
Please rate this on a scale 10-100%…………………………………………….
P2. Other cars have overtaken you and the car behind at other points in your journey.
What do you consider to be the probability that the men in the car are going to car jack you?
Please rate this on a scale 10-100%……………………………………………
R3. The number plate indicates that the drivers are from a country where they drive on the other side of the road.
What do you consider to be the probability that the men in the car are going to car jack you?
Please rate this on a scale 10-100%……………………………………………
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P3. The drivers have managed to stay on the correct side of the road for the whole journey up until this point.
What do you consider to be the probability that the men in the car are going to car jack you?
Please rate this on a scale 10-100%……………………………………………
R4. You realise that you are driving way below the speed limit.
What do you consider to be the probability that the men in the car are going to car jack you?
Please rate this on a scale 10-100%…………………………………………….
P4. You have been driving below the speed limit at other points in the journey and the car has not overtaken you.
What do you consider to be the probability that the men in the car are going to car jack you?
Please rate this on a scale 10-100%……………………………………………
Scenario 3: You are on your way to a restaurant for an evening out with your friends. You have decided to take the bus to save some money, even though the possibility of a bus strike was announced on the news yesterday. Once you arrive at the bus stop you wait for 20 minutes with several people standing beside you and still no bus has arrived. Then you overhear something about a ‘strike’. Soon afterwards most of the people around you disappear.
How anxious would you feel in the above situation?
Please rate this on a scale 0-100%……………………………………………..
What do you consider to be the probability that there was a bus strike under these circumstances?
Please rate this on a scale 10-100%……………………………………………
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R1. At the end of the street you see a bus driving on what appears to be a different route.
What do you consider to be the probability that there was a bus strike under these circumstances?
Please rate this on a scale 10-100%……………………………………………
P1. Maybe the bus was out of service since you could not see whether there were any people in it.
What do you consider to be the probability that there was a bus strike under these circumstances?
Please rate this on a scale 10-100%……………………………………………
R2. A person tells you he took the bus earlier in the day.
What do you consider to be the probability that there was a bus strike under these circumstances?
Please rate this on a scale 10-100%……………………………………………
P2. The strike may have only started later in the day.
What do you consider to be the probability that there was a bus strike under these circumstances?
Please rate this on a scale 10-100%……………………………………………
R3. You call the information service and get an automated message with no mention of any strike.
What do you consider to be the probability that there was a bus strike under these circumstances?
Please rate this on a scale 10-100%……………………………………………
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P3. Maybe the bus station doesn’t give out this type of information that quickly.
What do you consider to be the probability that there was a bus strike under these circumstances?
Please rate this on a scale 10-100%……………………………………………
R4. The bus you want to get has been late a lot recently due to there having been roads works on its route.
What do you consider to be the probability that there was a bus strike under these circumstances?
Please rate this on a scale 10-100%……………………………………………
P4. The road works were expected to have finished by now.
What do you consider to be the probability that there was a bus strike under these circumstances?
Please rate this on a scale 10-100%……………………………………………
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Appendix C – ICQ-EV, DES, OCI, MI
Inferential Confusion Questionnaire – Expanded Version Please rate your agreement or disagreement with the following statements using the scale
1 Strongly disagree2 Disagree3 Somewhat disagree 4 Somewhat agree 5 Agree6 Strongly agree
Answer 1-61. I am sometimes more convinced about what might be here than by what I actually see2. I sometimes invent stories about certain problems that night be here without paying attention to what I actually see3. Sometimes certain far fetched ideas feel so real they could just as well be happening4. Often my mind starts to race and I come up with all kinds of far fetched ideas5. I can get very easily absorbed in remote possibilities that feel as if they are real6. I often confuse different events as if they were the same7. I often connect ideas or events in my mind that would seem far fetched to others or even me8. Certain disturbing thoughts of mine sometimes cast a shadow on to everything around me9. I sometimes forget who or where I am when I get absorbed in to certain ideas or stories10. My imagination is sometimes so strong that I feel stuck and unable to see things differently11. I invent arbitrary rules, which I then feel I have to live by12. I often cannot tell if something is safe, because things are not what they appear to be13. Sometimes every far fetched possibility my mind comes up with feel real to me14. I sometimes get so absorbed in certain ideas that I am completely unable to see things differently even if I try15. In order to tell whether there is problem or not I tend to look more for that which is hidden than what I can actually see16. Even if I don’t have any actual proof of a certain problem, my imagination can convince me otherwise17. Just the thought that there could be a problem or something wrong is proof enough for me that there is
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18. I can get so caught up in certain ideas of mine that I totally forget about everything around me
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19. Often when I feel certain about something a small detail comes to mind that puts everything into doubt20. I sometimes come up with far fetched reasons why there is a problem or something wrong, which then suddenly starts to feel real to me21. I often cannot get rid of certain ideas because I keep coming up with possibilities that confirm my ideas22. My imagination can make me loose confidence in what I actually perceive23. A mere possibility often has as much impact on me as reality itself24. Even if I have all sorts of visible evidence against the existence for a certain problem, I sill feel it will occur25. Even the smallest possibility can make can make me loose confidence in what I know26. I can imagine something and end up living it27. I am more often concerned with something that I cannot see rather than something I can see28. I sometimes come up with bizarre possibilities that feel real to me29. I often react to a scenario that might happen as if it is actually happening30. I sometimes cannot tell whether all the possibilities that enter my mind are real or not
Dissociative Experiences Scale-II (DES-II)
Directions: This questionnaire consists of 28 questions about experiences that you may have in your daily life. We are interested in how often you have these experiences. It is important, however, that your answers show how often these experiences happen to you when you are not under the influence of alcohol or drugs. To answer the questions, please determine to what degree the experience described in the question applies to you, and insert a number from the example below to show what percentage of the time you have the experience.
For example:
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
(Never) (Always)
Some people……. Percentage of time that this happens to you. Please use 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% or 100%
1…have the experience of driving or riding in a car or bus or subway and suddenly realizing that they don’t remember what has happened during all or part of the trip.2... find that sometimes they are listening to someone talk and they suddenly realize that they did not hear part or all of what was said.3… have the experience of finding themselves in a place and have no idea how they got there.4… have the experience of finding themselves dressed in clothes that they don’t remember putting on.
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5… have the experience of finding new things among their belongings that they do not remember buying.6… sometimes find that they are approached by people that they do not know, who call them by another name or insist that they have met them before.7… sometimes have the experience of feeling as though they are standing next to themselves or watching themselves do something and they actually see themselves as if they were looking at another person.8… are told that they sometimes do not recognise friends or family members.9… find that they have no memory for some important event in their lives (for example a wedding or graduation.10… have the experience of being accused of lying when they do not think that they have lied.11… have the experience of looking in a mirror and not recognising themselves.12… have the experience of feeling that other people, objects, and the world around them are not real.13… have the experience of feeling that their body does not seem to belong to them.14… have the experience of sometimes remembering a past event so vividly that they feel as if they were reliving that event.15… have they experience of not being sure whether things that they remember happening really did happen or whether they just dreamt them.16… have the experience of being in a familiar place but finding it strange and unfamiliar.17… find that when they are watching television or a movie they become so absorbed in the story that they are unaware of other
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events happening around them.18… find that they become so involved in a fantasy or daydream that it feels as though it were really happening to them.19… find that they sometimes are able to ignore pain.20… find that they sometimes sit staring off into space, thinking of nothing, and are not aware of the passage of time.21… sometimes find that when they are alone they talk out loud to themselves.22…find that in one situation they may act so differently compared with another situation that they feel almost as if they were two different people.23… sometimes find that in certain situations they are able to do things with amazing ease and spontaneity that would usually be difficult for them (for example, sports, work, social situations, etc.).24… sometimes find that they cannot remember whether they have done something or have just thought about doing that thing (for example, not knowing whether they have just mailed a letter or have just thought about mailing it).25… find evidence that they have done things that they do not remember doing.26… sometimes find writings, drawings, or notes among their belongings that they must have done but cannot remember doing.27… sometimes find that they hear voices inside their head that tell them to do things or comment on things that they are doing.28… sometimes feel as if they are looking at the world through a fog, so that people and objects appear far away or unclear.
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OCI – R
The following statements refer to experiences that many people have in their everyday lives. Circle the number that best describes HOW MUCH that experience has DISTRESSED OR BOTHERED you during the PAST MONTH. The numbers refer to the following verbal labels: 0 = Not at all, 1 = A little, 2 = Moderately, 3 = A lot, 4 = Extremely.
1. I have saved up so many things that they get in the way 0 1 2 3 4
2. I check things more often than necessary 0 1 2 3 4
3. I get upset if objects are not arranged properly 0 1 2 3 4
4. I feel compelled to count while I am doing things 0 1 2 3 4
5. I find it difficult to touch an object when I know it has been touched by strangers or certain people 0 1 2 3 4
6. I find it difficult to control my own thoughts 0 1 2 3 4
7. I collect things I don’t need 0 1 2 3 4
8. I repeatedly check doors, windows, drawers etc 0 1 2 3 4
9. I get upset if others change the way I have arranged things 0 1 2 3 4
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10. I feel I have to repeat certain numbers 0 1 2 3 4
11. I sometimes have to wash or clean myself simply because I feel contaminated 0 1 2 3 4
12. I am upset by unpleasant thoughts that come into my mind against my will 0 1 2 3 4
13. I avoid throwing things away because I am afraid I might need them later 0 1 2 3 4
14. I repeatedly check gas and water taps and light switches after turning them off 0 1 2 3 4
15. I need things to be arranged in a particular way 0 1 2 3 4
16. I feel that there are good and bad numbers 0 1 2 3 4
17. I was my hands more often and for longer than necessary 0 1 2 3 4
18.I frequently get nasty thoughts and have difficulty in getting rid of them 0 1 2 3 4
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Magical Ideation Scale
1. Some people can make me aware of them just by thinking about me.
True False
2. I have had the momentary feeling that I might not be human.
True False
3. I have sometimes been fearful of stepping on sidewalk cracks.
True False
4. I think I could learn to read other’s minds if I wanted to.
True False
5. Horoscopes are right to often for it to be coincidence.
True False
6. Things sometimes seem to be in different places when I get home, even though no one has been there.
True False
7. Numbers like 13 and 7 have no special powers.
True False
8. I have occasionally had the silly feeling that a TV or radio broadcaster knew I was listening to him.
True False
9. I have worried that people on other planets may be influencing what happens on earth.
True False
10. The government refuses to tell us the truth about flying saucers.
True False
11. I have felt that there were messages for me in the way things were arranged, like in a store window.
True False
12. I have never doubted that my dreams are the products of my own mind.
True False
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13. Good luck charms don’t work.
True False
14. I have noticed sounds on my records that are not there at other times.
True False
15. The hand motions that strangers make seem to influence me at times.
True False
16. I almost never dream about things before they happen.
True False
17. I have had the momentary feeling that someone’s place has been taken by a look-alike.
True False
18. It is not possible to harm others merely by thinking bad thoughts about them.
True False
19. I have sometimes sensed and evil presence around me, although I could not see it.
True False
20. I sometimes have a feeling of gaining or losing energy when certain people look at me or touch me.
True False
21. I have sometimes had the passing thought that strangers are in love with me.
True False
22. I have never had the feeling that certain thoughts of mine really belonged to someone else.
True False
23. When introduced to strangers, I rarely wonder whether I have known them before.
True False
24. If reincarnation were true, it would explain some unusual experiences I have had.
True False
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25. People often behave so strangely that one wonders if they are part of an experiment.
True False
26. At certain times I perform certain little rituals to ward off negative influences.
True False
27. I have felt that I might cause something to happen just by thinking too much about it.
True False
28. I have wondered whether the spirits of the dead can influence the living.
True False
29. At times I have felt that a professor’s lecture was meant especially for me.
True False
30. I have sometimes felt that strangers were reading my mind.
True False
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Appendix D – Information/consent/debrief/advertising material
INFORMATION SHEETTitle of study: The relationship between beliefs, behaviours and reasoning.
Background to the study: The study will investigate a type of reasoning process and how it relates to the different ways people can think, feel and behave. What participation involves:
1. You will be presented with a fictional scenario and asked to imagine yourself in it.
2. You will then be asked to complete two ratings about the scenario. 3. You will then be presented with 8 additional pieces of information
about the scenario and asked to re-rate one of your original ratings about the scenario in the light of each new piece of information.
4. You will be required to repeat the same process in relation to a further two different scenarios that you will imagine yourself in.
5. You will complete 4 questionnaires about specific ways you might think, feel or behave.
6. You will be given some space to write any additional comments you have about the study.
7. You will be debriefed about the study.Your entire participation is expected to last approximately 30 minutes. You may experience mild psychological distress or discomfort from engaging in the tasks that require you to imagine fictional scenarios. Should this be the case, relevant sources of information and advice for you to use will presented in the debrief at the end of the study.Withdrawing from the study: You have a right to withdraw from the study at any time without having to give a reason. You can do this by closing the online programme that the study is provided on. Any partially completed data will not be included in the study. As participation is anonymous, once you have completed the study your data cannot be withdrawn. Data protection: Your participation will remain confidential. The data you supply will be annoymised and you will never be identifiable from any publications or presentations arising from this research. All data will be stored securely on a password protected computer programme and processed in accordance with the principles of the Data Protection Act (1998).
This study has received a favourable ethical opinion from the Ethics Committee of the Faculty of Arts and Human Sciences at the University of Surrey. Concerns about any aspect of this study should be referred to Nakita O’Leary, Principle Investigator, or Dr Laura Simonds, the Research Supervisor.
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Nakita O’Leary Dr Laura SimondsTrainee Clinical Psychologist Lecturer University of Surrey School of Psychology Email: n.o’[email protected] University of SurreyTelephone: 01483689447 Email: [email protected]
Telephone: 01483 68 6936
CONSENT FORM
I the undersigned voluntarily agree to take part in this study on the relationship between beliefs, behaviours and reasoning.
I have read and understood the information provided. I have been advised about any discomfort and possible ill effects on my health and well-being which may result. I have been given the opportunity to ask questions about the study and have understood the advice and information given as a result.
I agree to comply and fully co-operate with any virtual instruction given to me during my participation with the online study.
I understand that all personal data relating to volunteers is held and processed in the strictest confidence, and in accordance with the Data Protection Act (1998). I agree that I will not seek to restrict the use of the results of the study on the understanding that my anonymity is preserved.
I understand the data I supply may be used in other studies or for teaching purposes.
I understand that I am free to withdraw from the study at any time without needing to justify my decision and without prejudice.
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 and agree to comply with the instructions and restrictions of the study.
Click here if you consent to taking part in this study.
DEBRIEF
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This study is concerned with a reasoning process called inferential confusion and its relationship to obsessive compulsiveness and delusions. Inferential confusion happens when a person is more influenced by what might be possible than by what their senses are telling them is probable and likely. Previous studies have found inferential confusion to be related to obsessive and compulsive thoughts, feelings and behaviour and there has been some preliminary evidence to support a similar link between inferential confusion and the experience of delusions.
How was this tested?In this study, you were asked to complete questionnaires that measured your levels of inferential confusion, dissociation, magical ideation and obsessive compulsiveness. You were also asked to consider three scenarios and rate the probability that an inferred event had occurred in each. You were then presented with 8 additional pieces of reality and possibility based information for each of the three scenarios and asked to reconsider your probability rating in the light of each of these pieces of information. All participants completed the same questionnaires and the same tasks, the order in which the scenarios were presented were randomly alternated for each participant.
Hypotheses and main questions:We expect to find that those who are more influenced by the possibility based information of the inference task (i.e. those that significantly increase their rating regarding the probability of the inferred even having occurred in light of possibility based information as compared to their responses to the reality based information) will score higher on the measures of inferential confusion, dissociation, magical ideation and obsessive compulsiveness.
Why is this important to study?Understanding the reasoning processes behind experiences such as obsessive compulsiveness and delusions will contribute to the development of therapy that can be used to help people for whom these experiences become significantly distressing, i.e. those diagnosed with obsessive-compulsive disorder and delusional disorder. It also promotes the understanding of such phenomena as that of a variation of human experience. This helps to reduce the stigma that people with these diagnoses may experience.
How can I access further information?Everyone in the general population has some level of obsessive compulsiveness and delusional thinking so this is nothing unusual. None of the questionnaires in this study can be used to diagnose obsessive compulsive disorder or delusional disorder. If participating in this study has caused you to feel upset in any way, or you would like further information with any of the issues raised by this study, you can find information and advice via the following national charitiesRethink Mental Illness0300 5000 927 (Monday - Friday 10am - 2pm, not including bank holidays)
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www.rethink.org
OCD-UK0845 120 [email protected]
What if I want to know more?If you are interested in learning more about inferential confusion, you may want to consult the book: Beyond reasonable doubt: Reasoning Processes in Obsessive Compulsive Disorder and related disorders (2005) by Kieron O’Connor, Frederick Aardema and Marie-Claude Pelissier.
If you would like to receive a report of this research when it is completed (or a summary of the findings), please contact Nakita O’Leary at n.o’[email protected].
If you have concerns about your rights as a participant in this experiment, please contact Nakita O’Leary, Principle Investigator, or Dr Laura Simonds, the Research Supervisor.
Nakita O’Leary Dr Laura SimondsTrainee Clinical Psychologist Lecturer University of Surrey School of Psychology Email: n.o’[email protected] University of Surrey
Email: [email protected]
Thank you again for your participation. Please refrain from discussing the full details of this study to other potential participants until the study is complete in October 2014. This is so the study can maintain its validity.
Text for Poster and Online advert
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The relationship between beliefs, behaviour and reasoning
I am a trainee clinical psychologist and as part of my doctorate I am conducting a research study investigating the relationship between beliefs, behaviours and reasoning. I require men and women above the age of 17 who have experience of driving a car to participate.
This study involves accessing electronic questionnaires and an online task via the link below. The entire study participation is expected to last 30 minutes.
The data collected in this study will be treated confidentially and all information will be handled in accordance with the Data Protection Act of 1998. Participation is anonymous. You may withdraw from participation during the study without having to give a reason. Once you have completed the study your data cannot be withdrawn.
The study has received a favourable ethical opinion from the University of Surrey Faculty of Arts and Human Sciences Ethics Committee. Further questions or concerns about any aspect of this study may be referred to the Principle Investigator:
Nakita O’LearyTrainee Clinical PsychologistUniversity of SurreyEmail: n.o’[email protected] Telephone: 01483689447
or the research supervisor:
Dr. Laura Simonds LecturerSchool of PsychologyUniversity of SurreyEmail: [email protected] Telephone: 01483 68 6936
Appendix E - Demographic questions
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Please answer each question as best as it describes you.
1. What is your age?
2. What is your gender?
Male Female Other?
3. How would you describe your ethnicity?
WhiteEnglish / Welsh / Scottish / Northern Irish / BritishIrish Gypsy or Irish Traveller Any other White background, please describe
Mixed / Multiple ethnic groupsWhite and Black Caribbean White and Black African White and Asian Any other Mixed / Multiple ethnic background, please describe
Asian / Asian BritishIndian Pakistani Bangladeshi Chinese Any other Asian background, please describe
Black / African / Caribbean / Black BritishAfrican Caribbean Any other Black / African / Caribbean background, please describe
Other ethnic groupArab Any other ethnic group, please describe
4. What is the highest level of education you have completed?
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General certificate secondary education A-levels Trade/Technical/Vocational training Associate Degree Bachelor’s Degree Master’s Degree Professional Degree Doctorate degree
5. What is your marital status?
Single, never married Married or civil partnership Widowed Divorces Separated
6. What is your employment status?
Employed for wages Self-employed Out of work and looking for work Out of work but not currently looking for work A homemaker A student Military Retired Unable to work
7. What is your religion?
No religion Christian (C.O.E, Catholic, Protestant and all other Christian denominations)Buddhist Hindu Jewish Muslim Sikh Any other religion (please describe)
8. From which country are you currently completing this survey?
Appendix F – Ethics committee letter
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Faculty of Arts and Human SciencesEthics Committee
Chair’s Action
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Proposal Ref: 1022-PSY-14
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Name of Student/Trainee:
NAKITA O’LEARY
Title of Project: The relationship between beliefs, behaviours and reasoning
Supervisor: Dr Laura Simonds
Date of submission:
Date of confirmation email:
8th April 2014
5th June 2014
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The above Research Project has been submitted to the FAHS Ethics Committee and has received a favourable ethical opinion from the Faculty of Arts and Human Sciences Ethics Committee with conditions. The conditions stipulated after ethical review have now been addressed and the relevant amended documents submitted as evidence prior to commencement of your study. The final list of documents reviewed by the Committee is as follows:Protocol Cover sheet Summary of the projectDetailed protocol for the projectParticipant Information sheetConsent FormThis documentation should be retained by the student/trainee in case this project is audited by the Faculty Ethics Committee.
Signed: _________________Professor Bertram OpitzChair
Dated:
Please note: If there are any significant changes to your proposal which require further scrutiny, please contact the Faculty Ethics Committee before proceeding with your Project
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Appendix G - Tables of demographics
Demographic n %Gender Male 18 16.8%
Female 87 81.3%Other 3 1.9%
Ethnicity White British 47 43.9%White Irish 6 5.6%White Other 25 23.4%White and Black Caribbean 4 3.7%White and Black African 4 3.7%Mixed Other 4 3.7%Indian 3 2.8%Pakistani 1 0.9%Asian Other 2 1.9%Black or Black British Caribbean 2 1.9%Black or Black British African 3 2.8%Black or Black British Other 2 1.9%Chinese 1 0.9%Other 3 2.8%
Marital Status Single/never married 66 61.7%Married or in Civil Partnership 24 22.4%Widowed 1 0.9%Divorced 3 2.8%Separated 2 1.9%Other 11 10.3%
Employment Status Employed for wages 52 48.6%Self-employed 7 6.5%Out of work and looking for work 3 2.8%Homemakers 5 4.7%Students 32 29.9%Military 1 0.9%Retired 3 2.8%Unable to work 1 0.9%Other 2 1.9%
Education No formal qualifications 23 21.5%GCSE/O-Levels/NVQ/ 19 17.8%Trade/Technical/Vocational 4 3.7%Associates Degree 9 8.4%Bachelor’s Degree 31 29.0%Master’s Degree 13 12.1%Professional Degree 1 0.9%Doctoral Degree 7 6.5%
Religion No religion 47 43.9%Christian C.O.E, Catholic, Protestant 45 42.1%Buddhist 1 0.9%Hindu 2 1.9%Jewish 2 1.9%Muslim 1 0.9%Sikh 1 0.9%Other 8 7.5%
Country United Kingdom 54 50.47%United States of America 43 40.19%Canada 5 4.6%Australia 2 1.9%Argentina 1 0.9%India 1 0.9%Singapore 1 0.9%
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Appendix H – Normality plots/histograms
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Major Research Project Proposal Form
URN: 6242742
Project Title: An experimental induction of Inferential Confusion and its
relationship to Obsessive-Compulsiveness and Schizotypy.
Introduction
Obsessional doubt has long been considered a feature of obsessive-
compulsive disorder (OCD). OCD is characterised by the presence of
obsessions (persistent and recurrent thoughts, impulses or images that cause
distress) and/or compulsions (mental acts or behaviours that are aimed at
reducing distress) that are perceived by the individual as either distressing,
time consuming or disruptive to functioning (DSM IV, 2000). Obsessive-
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compulsiveness is also seen in non-clinical populations and thus an obsessive-
compulsive continuum has been proposed, with diagnosable OCD at the
extreme end of this continuum (Gibbs, 1996).
O’Connor, Aardema and Pelissier (2005) propose a novel theory of
OCD that conceptualises it as a belief disorder. According to this theory,
obsessions are constructed as primary inferences of doubt about a possible
state of affairs that are influenced by unusual reasoning styles. In this theory, a
mental intrusion is an inference of doubt about reality that leads the individual
to distrust their physical senses in preference of this imaginary possibility
(O’Connor & Rollibard, 1995). An example of this would be, thinking that
one has left the cooker on. Subsequent compulsions (e.g. checking that the
cooker is off) fail to overcome the primary doubt given that the individual is
attempting to use reality to modify the imaginary. Thus, the doubt is never
resolved, only reinforced, and the cycle continues (O’Connor & Aardema,
2003). Due to the confusion noted between reality-based and imaginary states
of affairs, this theory of obsessive-compulsiveness (OC) is coined Inferential
Confusion (IC) (O’Connor et al., 2005).
Delusions are defined as false beliefs despite evidence to the contrary
(DSM IV, 2000). Johns and Os (2001) reviewed research on the experience of
delusions in the non-clinical population, concluding that the experience of
delusions lies on a continuum. Unusual experiences such as delusions are part
of what is termed by Claridge et al. (1996) as schizotypy. Schizotypy is a way
of construing non-clinical delusional type beliefs that lie on a continuum with
the delusions that are referred to in clinically diagnosed disorders. If we
consider OC and delusions together, unusual ways of thinking about reality,
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that are not shared by others and that are causally implausible and which lie on
a continuum of severity, appear to characterise both OC and delusions. In the
case of the latter, the term schizotypy has been used to characterise non-
clinical delusional phenomena. Given the similarities between these concepts
of human experience, IC has been proposed to be a possible explanation of
delusions as well as OC (Aardema, O’Connor, Emmelkamp, Marchand &
Todorovc, 2005).
The current evidence suggests that IC is consistently found to correlate
positively and significantly with OC symptoms and that it emerges as an
independent predictor of OC symptoms when controlling for OC beliefs,
mood and anxiety. Degree of IC is significantly related to OC symptom
severity and it has been demonstrated to explain some of the relationship
between doubt and OC (Aardema et al., 2008; Wu et al., 2009; Aardema, et
al., 2006; Polman et al., 2011; Grenier et al., 2010; Aardema et al., 2009;
Aardema et al., 2010). There is some moderate support for differences in
inductive and probabilistic reasoning in OC (Pelissier & O’Connor, 2002;
Pelissier et al., 2009; Fear & Healey, 1997) and delusions and schizotypy
(John & Dodgson, 1994; Sellen et al., 2005; Conway et al., 2002; Tsakanikos,
2004). The Inferential Based Approach (IBA) to treating OC symptoms has
been supported (Aardema et al., 2005; Aardema et al., 2010; Aardema &
O’Connor, 2012) with preliminary evidence to show that the IBA to treatment
is effective in reducing OC symptoms to the same degree as cognitive-
behavioural approaches and to a better degree in particular OC presentations
(O’Connor et al., 2009). In addition, the relationship found between delusional
disorders and IC has provided impetus for the researchers to conceptualize
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OCD as a belief disorder (Aardema et al., 2005). However, there has only
been one research team to study IC in OC and delusional disorders (DD)
empirically and replication is required by other researchers.
From a review of the literature (O’Leary, unpublished), additional
evidence is needed in the area of IC, OC and DD. Given the largely
correlational nature of the current evidence, studies utilising ecologically valid
experimental paradigms to measure IC are needed. There are few studies that
have experimentally tested IC and OC and none that experimentally assess this
in addition to delusions. Therefore the aim of the current study is to
experimentally manipulate the process of IC and assess its relationship with
OC and schizotypy in a non-clinical sample. Aardema (2009) used a vignette
describing a situation to operationalize IC experimentally. In this paradigm,
the participant reads a scenario the conclusion of which leaves doubt about
whether an accident has occurred. The participant rates the probability that an
accident has occurred (i.e. doubt that it has not occurred). Then, subsequent
pieces of information are given with the aim of reducing or increasing doubt
about whether the accident has happened. This is an analogue doubt in OC
and is an operationalization of IC because it looks at reasoning following the
inclusion of reality and possibility based information.
The current study will also be assessing the role of dissociation in the
relationship between IC, OC and DD given that absorption into the imaginary
has been postulated by the IC theory as part of the IC reasoning process
(O’Connor et al. 2005).
Main Hypotheses Correlation
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Scores on a self-report measure of IC will be positively correlated with levels
of doubt in two computerised tasks.
Regression
Scores on IC, OC, schizotypy and dissociation will predict levels of doubt in
two computerised tasks.
Method
Participants
A non-clinical sample of 50 participants will be recruited for the
experiment. This sample size is deemed the achievable sample size for an
experimental design of this scale. For correlation analysis, a sample of 50 can
achieve a moderate effect size of r=.4 at 80% power for a two tailed
hypothesis (alpha .05). For the regression analysis with 4 predictors, 50
participants can achieve an effect size of R2=.20 - .26 at 80% power, with the
alpha at .05. Given that the experimental tasks will be conducted in a driving
simulator, participants will be aged 18 or over and must hold a valid driving
licence. The study will recruit students and non-students. The university’s
electronic participant recruitment system (Sona) will be used to advertise the
study and recruit students. Undergraduate psychology students will be able to
earn two lab tokens for their participation. All participants will be offered a
sweet to thank them for their time. A recent simulator study conducted by the
research supervisor recruited 44 participants over the course of 4 months, so
the target sample of 50 seems feasible in the proposed timeframe of data
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collection for this study. It might also be possible for assistance in testing to
be provided by a research apprentice working with the research supervisor.
Design
A mixed methods design is proposed, utilising a within participants
experimental design and a descriptive thematic analysis. For the experimental
aspect, the within participants IV is simulation condition and has 2 levels: OC
type simulation and delusional-type simulation. Order of presentation will be
counterbalanced across participants. The dependant variable will be the level
of doubt that is induced in each participant by each simulation condition.
Participants will also complete measures of IC, dissociation, OC and
schizotypy in order to examine the associations between these and levels of
experimentally induced doubt. Participants will be asked how much time they
spend playing video games to assess whether this has any bearing on the
outcome variable.
Apparatus
A STISIM Drive Build 2.08.05 driving simulator system connected to
a 1990 registered Rover Metro car mounted on axle stands will be used. 4
projector screens are connected to the car to achieve a rear view mirror image
and a panoramic wraparound road environment display. Mounted on both
door mirrors are TV cameras that give the driver rear and side views of the
driving environment. Drivers are monitored on a PC screen during the
simulation via a camera that is installed on the dashboard.There will be three
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driving simulations. One practice simulation lasting approximately 4 minutes
and two experimental simulations lasting approximately 9 minutes each. The
practice simulation will be an opportunity for the participant to familiarise
themselves with the driving controls and to check that they do not have a
simulator sickness reaction, in which case they would be advised to
discontinue with the study. The OC condition consists of a challenging driving
situation the result of which is the participant is left unsure whether they have
hit a cyclist or another road user. A key part of the simulation is that the
cyclist disappears from view. This is designed to induce doubt and the content
is related to a common OC concernsince it is focused on a common OC
experience and it includes the responsibility bias often seen in OC. A previous
study by the research supervisor using this simulation found that it induced
doubt about a collision in 98% of participants. The delusion simulation is
designed to induce doubt about whether the driver is being deliberately
pursued. In this simulation, a car stays behind the participant for the whole
journey despite having possible reason to overtake. This is related to
delusional experiences since it is based on a common persecutory delusional
experience. At the end of the simulation, the participant will be left unaware as
to whether the car behind was following them or not. Both simulations will be
piloted prior to the main study.
Measures (Appendix A)
The Inferential Confusion Questionnaire - Expanded Version (ICQ-
EV) (Frederick Aardema, Kevin D. Wu, Yves Careau, Kieron
O’Connor, Dominic Julien, & Susan Dennie, 2010) is a 30 item
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measure of IC, where each statement is rated on a 6 point scale from
strongly disagree to strongly agree. It has been shown to have excellent
internal consistency, with an English-speaking sample providing an
average item-total correlation of .66 (range .46 to .76) and a
Cronbach’s alpha of .96. Convergent, group criterion and clinical
validity has all also been demonstrated.
Dissociative Experiences Scale-II (DES-II) (Eve Bernstein Carlson &
Frank W. Putnam, 1986) is a 28 item self-report questionnaire, using
100mm continuums to scale each item measuring frequency of
dissociative experiences. This measure has been shown to have good
test re-test reliability and good split half reliability. Good internal
consistency and construct validity have also been indicated.
Obsessive Compulsive Inventory - Revised (OCI-R) (Edna B. Foa,
Jonathan D. Huppert, Susanne Leiberg, Robert Langner, Rafael
Kichic, Greg Hajcak & Paul M. Salkovskis, 2002) is an 18-item self-
report measure of OC. The intensity of OC experiences is rated on a 5-
point scale ranging from not at all to extremely. Excellent test re-test
reliability, excellent discriminant validity and satisfactory convergent
validity have been shown.
Magical Ideation Scale (MIS) (Mark Eckblad & Loren J. Chapman,
1983) is a 30-item true-false measure of psychosis proneness and
schizotypy.
Measuring induced levels of doubt: This follows from the design used
by Aardema (2009) to experimentally investigate IC and OC. In
Aardema’s study a written vignette was given to induce doubt whereas
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in the current study a more immersive experimental paradigm, the
simulations, will be used. After each simulation condition, the
participants will be asked to rate their anxiety and the probability that
they think the incident inferred by the simulations has happened, i.e.
that they caused an accident involving the cyclist or that they were
being deliberately followed by the car behind. Participants will then be
given a series of possibility and reality based information. A paper
sheet with three reality and three possibility-based pieces of
information will be presented in alternating order. The purpose of the
reality-based information is to confirm the idea that the inferred
incident did not occur, in attempts to reduce doubt. The purpose of the
possibility-based information is to negate the previous piece of reality-
based information and potentially induce doubt. This is relevant to the
IC theory, since it mimics the process, which is postulated to represent
the reasoning processes in OC. Participants will then be required to
rate the probability that the inferred incident occurred after each piece
of reality and probability information presented. This is to identify if
doubt has been manipulated and how this affects the participant’s
reasoning about what happened in the simulation.
Once participants have completed the two simulator conditions, they will
be asked some brief questions about their experience. This will be done with
the aim of assessing whether participants’ account of their reasoning processes
in relation to the two conditions are consistent with the sorts of reasoning
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processes postulated in IC theory. This material will undergo a descriptive
thematic analysis. The questions will be as follows:
You initially rated the probability of you hitting the cyclist with the car
as X and the probability of you being followed as X. What influenced
your ratings?
How did the various pieces of new information influence your
probability ratings?
Prompt: why do you think your ratings changed?
Prompt: did your reasoning change over time?
Prompt: did you become more sure of less sure about what you
thought happened in the simulation?
Do you notice this sort of reasoning in your everyday life?
How do you think you would respond if the situations were real?
Any other comments?
Procedure (Appendix B for flow chart)
Participants will be recruited through the Sona online recruitment
system and via posters displayed around University campus. Snowball
sampling from people who take part will also be used. The Sona system is
used to advertise the study and allows scheduling of testing sessions. On
arrival, the participants will be given an information sheet and consent form.
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The information sheet will inform the participant that the experiment is about
personality and driving performance as this will provide a rationale for their
completion of the measures. Participants will be encouraged to drive as well as
possible throughout the stimulation. They will also be informed that they can
withdraw from the experiment at any time without having to give a reason.
Each participant will complete the measures of IC, dissociation, OC
and schizotypy. Half of the participants will then do the OC simulation first
and half will do the delusion simulation first to control for order effects. Once
each participant has completed their first driving simulation, they will be
required to complete the corresponding measure of induced doubt. They will
then complete their second simulation and the corresponding measure of
induced doubt. All participants will be asked to vocalise the process during a
brief interview, which will be recorded with their consent. They will be
debriefed about the true nature of the study and rewarded with research tokens
and/or a sweet for their participation. The experiment is expected to last about
45 minutes. All procedures will be piloted and refined prior to main data
collection. This will be particularly important for the analysis of reasoning
process, in terms of refining the questions to be used in the brief interview.
Ethical considerations
Deception regarding the purpose of the experiment (necessary to avoid
demand characteristics). In the information sheet participants will be informed
that the experiment is designed to test the relationship between driving ability
and personality characteristics, when it is in fact about the relationship
between the levels of doubt they display and the measures completed. This
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small deception is not expected to cause distress and the true nature of the
research will be revealed once the measures and driving simulation have been
completed. A similar study conducted by the research supervisor with 44
participants similar to those who will be recruited in this study reported no
adverse effects from the deception. In fact, some participants commented
positively on the ingenuity of the experiment. An unexpected potentially
beneficial effect was that some participants reported that the simulator had
made them more aware of the need to use their mirrors in real driving
situations. While participants will be initially deceived about the nature of the
study, the information sheet given before participation will accurately explain
the procedures involved in the research, any foreseeable risks and discomforts
to the participant, the benefit of the research to society and the individual, the
length of time the participants will be expected to participate, their right to
withdraw at any time, the person to contact if they have any further questions
and that the study has a favourable ethical opinion by the university ethics
committee.
The debrief will explain what was being investigated and why. The
participants will be told that the information sheet had a cover story to conceal
the real purpose of the study and why and have any questions answered
honestly. They will also be given an opportunity to withdraw the data that they
have supplied.
Participant distress. Participants may become distressed by the nature
of the individual measures, the driving simulation or the brief interview. To
manage this, information regarding access to support services relating to the
information presented will be given to each participant.
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In general, any potential stress caused by this study will be no greater
than that expected in their ordinary life. However, it is known that the
simulator can cause nausea in people who suffer from motion sickness. The
information sheet and study advert will make this clear and suggest that
participants should not volunteer if they are likely to have this reaction. Also,
a series of medical exclusions will be given on all information as used in the
previous study by the research supervisor.
Confidentiality. All information will be treated as confidential.
Participant information will be anonymised and they will be informed of this
process. Participants will also be informed of by what means, where and for
how long any data they provide will be stored for.
Name of Ethics Committee: University of Surrey Ethics Committee: Faculty
of Arts and Human Sciences.
R&D Considerations
Name of R&D department:
.......N/A......................................................................................
Proposed Data Analysis
Data checking: the researcher will check Data for erroneous scores
being entered or missing data points.
Descriptive Statistics: SPSS will be used to calculate measures of
central tendency (means, median and mode), measures of variability
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(distribution and standard error) and measures of the shape of distribution
(kurtosis and skewness).
Inferential Analysis: Correlation and regression will be used to
investigate how participants’ levels of OC, schizotypy and IC predict the
levels of doubt induced by the experiment.
Descriptive Thematic Analysis: Data from the brief interview will be
coded according to themes relevant to the IC theory.
Service User and Carer Consultation / Involvement
At a service user a carer drop session, consultation about the projects aims and
design were sought. Their feedback has been considered in this proposal
(Appendix C).
Feasibility Issues
The main threat is recruiting a sufficient number of participants. A
recent simulator study conducted by the research supervisor recruited 44
participants over the course of 4 months. Of those who initiated the study
none dropped out due to simulator sickness or other reasons.
Dissemination strategy
The findings will hopefully be disseminated via journal publication and
conference presentation.
118
Study Timeline
(Appendix D)
References
Aardema, F., O'Connor, K. P., Pélissier, M., & Lavoie, M. E. (2009). The
quantification of doubt in obsessive-compulsive disorder. International
Journal of Cognitive Therapy, 2, 188-205.
Aardema, F., & O'Connor, K. (2012). Dissolving the tenacity of obsessional
doubt: Implications for treatment outcome. Journal of Behavior Therapy and
Experimental Psychiatry, 43, 855-861.
Aardema, F., O'Connor, K. P., & Emmelkamp, P. M. G. (2006). Inferential
confusion and obsessive beliefs in obsessive-compulsive disorder. Cognitive
Behaviour Therapy, 35, 138-147.
119
Aardema, F., O'Connor, K. P., Emmelkamp, P. M. G., Marchand, A., &
Todorov, C. (2005). Inferential confusion in obsessive-compulsive disorder:
The inferential confusion questionnaire. Behaviour Research and Therapy, 43,
293-308.
Aardema, F., O'Connor, K. P., Pélissier, M., & Lavoie, M. E. (2009). The
quantification of doubt in obsessive-compulsive disorder. International
Journal of Cognitive Therapy, 2, 188-205.
Aardema, F., Radomsky, A. S., O'Connor, K. P., & Julien, D. (2008).
Inferential confusion, obsessive beliefs and obsessive-compulsive symptoms:
A multidimensional investigation of cognitive domains. Clinical Psychology
& Psychotherapy, 15, 227-238.
Aardema, F., Wu, K.D., Careau, Y., O’Connor, K., Julien, D., & Dennie, S.
(2010). The Expanded Version of the Inferential Confusion Questionnaire:
Further Development and Validation in Clinical and Non-Clinical Samples. J
Psychopathol Behav Assess, 32, 448-462.
American Psychiatric Association (2000). Diagnostic and statistical manual
of mental disorders (4th ed., Text Revision).
Arlington: VA.Claridge, G., McCreery, C., Mason, O., Bentall, R., Boyle, G.,
Slade, P., & Popplewell, D. (1996). The factor structure of ‘schizotypal’
120
traits: A large replication study. British Journal of Clinical Psychology,
35,103-115.
Gibbs, N.A. (1996). Nonclinical populations in research on obsessive
compulsive disorder: A critical review. Clinical Psychology Review, 16,
729-773.
Conway, C. R., Bollini, A. M., Graham, B. G., Keefe, R. S. E., Schiffman, S.
S., & McEvoy, J. P. (2002). Sensory acuity and reasoning in delusional
disorder. Comprehensive Psychiatry, 43, 175-178.
Grenier, S., O’Connor, K.P., & Belanger, C. (2010). Belief in the obsessional
doubt as a real probability and its relation to other obsessive-compulsive
beliefs and to the severity of symptomatology. British Journal of Clinical
Psychology, 49, 67-85.
John, C., & Dodgson, G. (1994). Inductive reasoning in delusional
thought. Journal of Mental Health, 3, 31-49.
Johns, L.C., & Os, J.V. (2001). The continuity of psychotic experiences in
the general population. Clinical Psychology Review, 21, 1125-1141.
121
O’Connor, K. (2009). Cognitive and meta-cognitive dimensions of
psychoses. The Canadian Journal of Psychiatry / La Revue Canadienne De
Psychiatrie, 54, 152-159.
O’Connor, K., Aardema, F., & Pelissier, M. (2005). BEYOND REASONABLE
DOUBT: Reasoning Processes in Obsessive-Compulsive Disorder and
Related Disorders. England: John Wiley & Sons, Ltd.
O'Connor, K., & Aardema, F. (2003). Fusion or confusion in obsessive-
compulsive disorder. Psychological Reports, 93, 227-232.
O'Connor, K., Koszegi, N., Aardema, F., van Niekerk, J., & Taillon, A.
(2009). An inference-based approach to treating obsessive-compulsive
disorders. Cognitive and Behavioral Practice, 16(4), 420-429.
O'Connor, K., & Robillard, S. (1995). Inference processes in obsessive-
compulsive disorder: Some clinical observations. Behaviour Research and
Therapy, 33, 887-896.Pélissier, M., &
O'Connor, K. P. (2002). Deductive and inductive reasoning in obsessive-
compulsive disorder. British Journal of Clinical Psychology, 41, 15-27.
Pelissier, M., O’Connor, K.P., & Dupius. (2009). When doubting begins:
Exploring inductive reasoning in obsessive-compulsive disorder. Journal of
Behaviour Therapy Experimental Psychiatry, 40, 39-49.
122
Sellen, J. L., Oaksford, M., & Gray, N. S. (2005). Schizotypy and conditional
reasoning. Schizophrenia Bulletin, 31, 105-116.
Tsakanikos, E. (2004). Logical reasoning in schizotypal
personality. Personality and Individual Differences, 37, 1717-1726.
Wu, K. D., Aardema, F., & O'Connor, K.,P. (2009). Inferential confusion,
obsessive beliefs, and obsessive-compulsive symptoms: A replication and
extension. Journal of Anxiety Disorders, 23, 746-752.
Inference-based reasoning in obsessive-compulsiveness, delusions and schizotypy.
Literature Review
Year 1
April 2013
Word Count: 7,755
This review has been aimed towards publication in Clinical Psychology
Review, as this is a high impact journal (7.071) that aims to publish cutting
edge articles and advance the practice of clinical psychology. Since this
123
review has implications for the understanding of obsessive-compulsiveness,
classification and treatment of obsessive-compulsive disorder and delusional
disorders, Clinical Psychology Review is an appropriate source for researchers
and practitioners to be made aware of the empirical evidence in this area. If
not accepted by Clinical Psychology Review, an alternative Journal to aim for
publication in would be The Journal of Anxiety Disorders. This journal has an
impact factor of 2.965 and accepts review articles that contribute substantially
to current knowledge in the field of anxiety disorders, which this review does
via OCD.
124
Abstract
Obsessive-compulsiveness is seen on a continuum between traits held
by the non-clinical population and those with a clinically diagnosed obsessive-
compulsive-disorder (OCD). The same type of continuum is seen between
schizotypy in the non-clinical population and the clinically defined disorders
of delusions. Inferential confusion is proposed as a possible transdiagnostic
model that explains the reasoning process behind both of these phenomena,
reclassifies OCD as a belief disorder and promotes a novel cognitive approach
to the treatment of these disorders. This review critically evaluates 20studies
published between 1994 and 2012 that empirically investigate inferential
confusion and inference based reasoning in both obsessive-compulsiveness
and delusions. The evidence provides moderate to strong support for the
validity of inferential confusion as a construct present in obsessive-
compulsiveness, the explanatory power of inferential confusion as a theory of
reasoning processes in obsessive-compulsiveness and for an inference based
approach to treatment. While there is preliminary evidence for the presence of
the inferential confusion process in people who experience delusions, more
research is needed to support the notion that inferential confusion may explain
the delusional experience. This is since other reasoning styles such as the
jumping to conclusions bias, have a stronger evidence base in the
understanding of the experience of delusions. Additional research is needed to
further the understanding of the relationship between obsessive-
compulsiveness, delusions and inferential confusion.
125
Introduction
The relationship between obsessional doubt and delusions has
appeared in the literature for over 100 years. Knapp (1890) was one of the first
to review the literature in this area which had mostly been informed by case
studies and clinical observation. Obsessional doubt has long been considered a
feature of obsessive-compulsive disorder (OCD). OCD is characterised by the
presence of obsessions (persistent and recurrent thoughts, impulses or images
that cause distress) and/or compulsions (mental acts or behaviours that are
aimed at reducing distress) that are perceived by the individual as either
distressing, time consuming or disruptive to functioning (DSM IV, 2000).
Obsessive-compulsiveness is also seen in non-clinical populations and thus an
obsessive-compulsive continuum has been proposed, with diagnosable OCD at
the extreme end of this continuum (Gibbs, 1996).
O’Connor, Aardema and Pelissier (2005) propose a novel theory of
OCD that conceptualises it as a belief disorder. According to this theory,
obsessions are constructed as primary inferences of doubt about a possible
state of affairs that are influenced by unusual reasoning styles. In this theory, a
mental intrusion is an inference of doubt about reality that leads the individual
to distrust their physical senses in preference of this imaginary possibility
(O’Connor & Rollibard, 1995). An example of this would be, thinking that
one has left the cooker on. Subsequent compulsions fail to overcome the
primary doubt given that the individual is attempting to use reality to modify
the imaginary. An example of this would be, checking that the cooker is off.
Thus, the doubt is never resolved, only reinforced, and the cycle continues
126
(O’Connor & Aardema, 2003). Due to the confusion noted between reality-
based and imaginary states of affairs, this theory of obsessive-compulsiveness
is coined Inferential Confusion (IC) (O’Connor et al., 2005).
IC theory was developed through observation of individuals diagnosed
with OCD and over-valued ideas (OVI) (Aardema, Emmelkamp & O’Connor,
2005). OVI are defined as near delusional beliefs (DSM IV, 2000) because
they lack the criterion of ego-dystonicity that applies to obsessive-
compulsiveness. Kozak and Foa (1994) found that the comorbidity of OVI in
obsessive-compulsiveness could moderate the strength of the obsessive-
compulsive belief so that it appears more akin to a delusion. In this way,
obsessive-compulsive phenomena and delusions have been linked
conceptually in the literature.
Delusions are defined as false beliefs despite evidence to the contrary
(DSM IV, 2000). Johns and Os (2001) reviewed research on the experience of
delusions in the non-clinical population, concluding that the experience of
delusions lies on a continuum. Unusual experiences such as delusions are part
of what is termed by Claridge et al. (1996) as schizotypy. Schizotypy is a way
of construing non-clinical delusional type beliefs that lie on a continuum with
the delusions that are referred to in clinically diagnosed disorders. If we
consider obsessive-compulsiveness and delusions together, unusual ways of
thinking about reality, that are not shared by others and that are causally
implausible and which lie on a continuum of severity, appear to characterise
both obsessive-compulsiveness and delusions. In the case of the latter, the
term schizotypy has been used to characterise non-clinical delusional
phenomena.
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What marks these two categories of phenomena apart appears to be the
presence of insight, with obsessive-compulsiveness considered ego-dystonic
and delusions ego-syntonic (Yaryura-Tobias, 2004). When OCD is comorbid
with OVI however, it seems that insight is reduced and the experience is more
ego-syntonic (Veale, 2002). OVI have been conceptualised as sustained
isolated beliefs, which are ego-syntonic and strongly held, yet with less
intensity than delusions (Veale, 2002). OVI have been suggested to act as
barrier between obsessions and delusions (Yaryura-Tobias, 2004), which
implies that OVI may be on the same continuum between obsessive-
compulsiveness and delusions. Schizotypy refers to the experience of
delusional thoughts or beliefs with or without OVI, and thus, insight could be
considered variable. Given the similarities between these concepts of human
experience, IC has been proposed to be a possible explanation of delusions as
well as obsessive-compulsiveness (Aardema, O’Connor, Emmelkamp,
Marchand & Todorovc, 2005). IC is therefore expected to be relevant to
obsessive-compulsiveness and OCD, delusional disorders and schizotypy, all
with or without OVI.
O’Connor (2009) proposes that IC may be one of the reasoning styles
that make fictional narratives seem so real in delusions and obsessive-
compulsiveness. Given that the main body of research on IC has been gathered
from studies on obsessive-compulsiveness, there is more literature in this area
than in the area of in delusions. This review will aim to evaluate the evidence
for the IC theory of obsessive-compulsiveness. It will also consider the current
evidence for this theory in delusional disorders and schizotypy. If supported,
there may be reason to further investigate IC as a possible trandiagnostic
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model across disorders. This would prove clinically advantageous as the
inference-based approach to treatment, could add to traditional cognitive and
behavioural treatments of obsessive-compulsive and belief disorders,
improving client choice and treatment variability.
Method
The literature search aimed to identify references that related to all
inference based reasoning in obsessive compulsiveness, delusional disorders
and schizotypy. A computerised search of the literature for all relevant articles
was performed using the databases, PsychINFO, Medline, Web of Science and
Scopus. The Boolean search terms used were: ‘inferential confusion’ OR
inference OR ‘reasoning process*’ AND obsess* compuls* OR schizotypy
OR delusion*. Inferential confusion was used as well as the word inference to
capture articles on the reasoning process termed inferential confusion and on
inference-based reasoning. Reasoning process* was also included to capture
any inferential reasoning processes that may have been named differently or
not at all. The term obsess* compuls* allowed the databases to search for
research both on the study of people diagnosed with OCD as well as those
measured on the continuum of obsessive-compulsiveness. Schizotypy was
used instead of schizo* to minimise the identification of the large body of
research conducted with people with a diagnosis of schizophrenia, as this was
not the focus of the current review. Delusion* was included to allow access to
studies in relation to delusional disorder or other delusional thought.
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There were no date restrictions placed on the original search, and the
search terms were identified in the abstracts of available materials. Reviews,
editorials, case studies, books, abstracts and dissertations were excluded, and
only peer reviewed journal articles written in English were considered. The
inclusion criteria consisted of empirical research on inferential confusion,
inference-based reasoning and reasoning processes that involved making
inferences in OCD, obsessive compulsiveness, schizotypy, delusional
disorders or delusions. Studies looking at schizophrenia rather than
schizotypy were excluded unless participants with a diagnosis of
schizophrenia were recruited for the purpose of studying delusions.
The search resulted in a total of 319 hits, 99 from PsychINFO, 53 from
Medline, 162 from Web of Science and 5 from Scopus. After accounting for
duplicates found across databases and evaluating the studies based on the
inclusion and exclusion criteria defined, 16 unique articles were selected. A
manual search of the reference lists of these 18 articles produced a further 4
articles not identified by the computerised search. The total sample was 20
articles all published between 1994 and 2012. See Appendix A for figure 1.
In this review, it may help focus to concentrate on the following: that
IC theory is a theory that has arisen and been most researched in OC, but that
this type of reasoning, as discussed, may be relevant to belief disorders.
This review presents evidence for the role of IC in OC and then goes
on to consider the relatively smaller evidence base on the relationship between
IC and delusional disorders or schizotypy. Overall, the review aims to
consider the relevance of the IC reasoning style for OC, schizotypy and
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delusional disorders, in order to consider implications for theory, research and
practice.
Results
The literature has been separated into the following subheadings;
Inductive and deductive reasoning in obsessive-compulsiveness; Inferential
Confusion and obsessive-compulsiveness; Inference-Based Approach to
treating obsessive-compulsiveness; and Inferential-based reasoning in
delusions and schizotypy. All of the research considered in this review is
quantitative as no qualitative studies were found in this research area based on
the search terms described above.
Inductive and deductive reasoning in obsessive compulsiveness
The authors of the IC model propose that OCD is an inductive
reasoning disorder. Of the studies found that focused on inference-based
reasoning styles in OC, one cross-sectional design aimed to understand the
differences between groups in inductive and deductive reasoning, while the
other quasi-experiment investigated inductive reasoning specifically (Pelissier
& O’Connor, 2002; Pelissier, O’Connor & Dupius, 2009). Differences in
inductive reasoning style would support IC theory because it is essentially a
theory that proposes that people with OC reason in different ways to those
without OC (O’Connor et al., 2005).
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Pelissier and O’Connor (2002) compared participants with OCD,
generalised anxiety disorder and a non-clinical control group (N=12, 10, 10
respectively) on a series of inductive and deductive reasoning tasks. When
compared on the deductive reasoning tasks, the 3 groups did not differ.
However, when comparing the groups on the inductive tasks, the OCD group
took longer to make inferences and seemed to express more doubt during the
tasks than the other groups. The authors speculate that people with OCD
create too many mental models during inductive reasoning tasks, which
increases their cognitive load resulting in slower performance and greater
doubt. Caution should be taken when generalizing these results due to the
small sample size and subsequent lack of statistical power. Also, it is not clear
whether the inductive reasoning tasks that were developed by the authors had
been tested for reliability or validity, so there may have been increased
chances of a type 1 error.
Pelissier et al. (2009) developed and validated the ‘Reasoning with
Inductive Arguments Task’ (RIAT) to measure the strength of inference in
inductive reasoning. They found that while all 74 participants in their quasi-
experiment doubted at the same level on the task, when the researchers
provided other possibilities for a conclusion to the task, those diagnosed with
OCD doubted significantly more than non-clinical control group, suggesting
that they generated more inferences from the given information. They
concluded that people diagnosed with OCD are more reliant on external
information to make inferences about a possible state of affairs. This is in line
with the IC theory, in that it supports the circularity of OCD. The compulsion
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of checking the cooker is off, which is reality based, is ineffective in
neutralizing the hypothetical inference that “maybe the cooker is on”, since the
hypothetical possibilities are endless (O’Connor, 2009).
In both of these studies, it might be suggested that the participant’s
level of intelligence could have been a confounding variable related to their
reasoning performance. To some extent, Pelissier et al. (2009) try to account
for this in that their participant groups did not differ on education level.
However, this may not be a valid proxy for intelligence therefore the findings
cannot be considered representative of only differing reasoning styles in these
groups. In addition to this, attention and memory biases that have been noted
in those with a diagnosis of OCD compared to those without (Muller &
Roberts, 2005), were not controlled for and hence, may have also been
accountable for some of the differences between the groups. While Pelissier
and O’Connor (2002) utilized an anxiety comparison group, neither study
included a mood or belief disorder group, meaning that it is not clear whether
the findings are in fact specific to anxiety or OC anxiety.
Inferential Confusion in obsessive-compulsiveness
Seven out of the 20 studies reviewed concentrated on the nature of the
relationship between IC and OC. These consisted of five correlational studies,
two that recruited non-clinical participants (Aardema, Radomsky, O’Connor &
Julien, 2008; Wu, Aardema & O’Connor, 2009) three with clinically
diagnosed participants (Aardema, O’Connor & Emmelkamp, 2006; Aardema
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et al., 2010; Grenier, O’Connor & Belanger, 2010; Polman, O’Connor &
Hiusman, 2011;) and one quasi-experiment that compared clinical and non-
clinical participants (Aardema, O’Connor, Pelissier & Lavoie, 2009).
Batteries of questionnaires were administered to large samples of
undergraduate students (N=130, N=317) with the aim of investigating the
relationship between IC and OC (Aardema et al., 2008; Wu et al., 2009). Both
of these studies measured the presence and strength of six obsessive belief
domains, IC and OC thoughts and behaviour while controlling for anxiety and
depression. Before determining the relationships between the constructs,
Aardema et al. (2008) used factor analysis to define the underlying factor
structure of the combined OC beliefs and IC so that the overlap between
variables would be reduced. The result of this analysis was that IC/threat
estimation was analysed as a single variable.
Both studies demonstrated that IC/threat estimation or IC correlated
most strongly with OC symptoms, above all other measures. Aardema et al.
(2008) demonstrated the construct of IC/threat estimation to be the strongest
predictor for all OC subtypes, even when the OBQ subscales of responsibility
and threat estimation were controlled for, with effect sizes ranging from 0.36
to 0.57. Wu et al. (2009) discovered that the relationship between IC and OC
symptoms on all measures was not consistent across OC symptomology. The
ICQ-EV used to measure IC, significantly predicted checking and rituals such
as grooming, but not washing symptoms (Wu et al., 2009).
The highly correlated IC/threat-estimation factor and the
threat/responsibility subscale of the OBQ in the original study by Aardema et
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al. (2008) could be seen as a significant limitation (effect size = 0.74). It
implies that IC may be measuring the same phenomena as a pre-existing
cognitive domain, rendering it redundant. The authors addressed this weakness
by identifying that the overlap between IC/threat-estimation and the
threat/responsibility subscale was due to the tendency of people experiencing
OC symptoms to make threat related inferences on the basis of subjective
information. This overlap mirrors the IC theory, which postulates that IC and
cognitive explanations of OC, including OC beliefs, are complimentary
(O’Connor et al., 2005). While findings from non-clinical populations can
contribute to theory development for clinicians to draw on, these findings
required replication with individuals that are diagnosed with OCD, as it is not
clear if subtype differences would emerge in a clinical sample.
In a sample of 85 participants diagnosed with OCD, Aardema et al.
(2006) used correlational analysis to assess the relationship between OC
beliefs, OC symptoms, IC and anxiety. While controlling for the three
domains of the OBQ-44 that the ICQ correlated highly with, the relationship
between OC symptoms and IC remained significant (r= 0.43). Aardema et al.
(2010) also measured a large number of participants (N=100) with a primary
diagnosis of OCD on OC symptoms, IC, depression, anxiety and OC beliefs.
They compared the results with all measures in a non-clinical sample and an
anxiety control group. Their findings replicated the correlational analysis of
previous research in non-clinical samples (Aardema et al., 2008) in regards to
the moderate to strong relationship between and specificity of IC to OCD (r=
0.50, r=0.42 when mood controlled for). IC remained moderately correlated
135
with the responsibility/threat subscale of the OBQ (r=. 57), however this was
not considered to affect the construct validity of the measure, since the IC
remained significantly correlated with overall OC symptoms, when the OBQ
was controlled for (r = .40). A discrepancy in subtype specificity compared to
other studies occurred, with the results from this study suggesting that IC
significantly relates to harm thoughts, checking and contamination, when
controlling for obsessive beliefs (Aardema et al., 2010).
The small sample size of the anxiety control group in the cross-
sectional correlation could be considered a limitation of the methodology
(N=16). However, the ICQ-EV was able to differentiate between the anxious
and OCD group despite this inconsistency. The significance of the present
findings may have been enhanced by the large sample size for the OCD group
(N=100) and the non-clinical control group (N=550). Aardema et al. (2010)
found a moderate correlation between the ICQ-EV and negative mood states,
suggesting that mood and anxiety may account for some of the relationship
between IC and OC. When controlling for negative mood and OC beliefs, the
ICQ-EV no longer related to the grooming and dressing compulsions and
obsessional impulses of harm to self or others subscales. Aardema et al. (2010)
attribute this finding to the inadequacy of OCD measure used in the study.
While they present good argument for this, it highlights the disadvantages of
using questionnaires to measure socially defined human phenomena.
Polman et al. (2011) assessed OC beliefs and symptom severity in 174
participants with a diagnosis of OCD. Cluster analysis revealed that a
substantial number of participants from this sample, between 38.4% and
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64.5%, could be classified as a low obsessive belief subgroup. This meant that
they scored low on the obsessive beliefs questionnaire, which had been
previously shown to predict OC symptoms. Participants from this low belief
group did not significantly differ in IC from the high belief subgroup of
participants. The high belief subgroup was comprised of those participants that
scored highly on the obsessive beliefs questionnaire, as you would expect
somebody with a diagnosis of OCD to do. Since the high and low obsessive
belief groups did not did differ on OC symptom severity or levels of IC, the
results from this study demonstrate the presence of IC in OC without
obsessive beliefs, regardless of symptom severity. This highlights IC as
statistically, significantly and independently related to OC. The authors
interpret their findings to challenge criticism regarding the impact of the
overlap between IC and obsessive beliefs, particularly the overestimation of
threat, in that IC is a separate experience to the overestimation of threat belief
that someone with OCD may have.
Each study differed in the measures used to tap the constructs included
in their analysis. See Appendix B for table 1. In spite of this, the variation of
measures used was not that wide spread. Utilising additional questionnaire
measures as well as using experimental methods to quantify the constructs
investigated in these studies may make for a more reliable and generalizable
evidence base.
Grenier et al. (2010) collated cross-sectional and longitudinal data
from three separate experiments previously conducted in the same research
centre (O’Connor et al., 2005; O’Connor et al., 2006; O’Connor et al., 2009).
In support of the IC theory, they found that all 108 participants diagnosed with
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moderate-severe OCD, were able to identify a primary inference of doubt.
Correlational analysis showed that the consequence of not acting on the doubt,
for example, the house will catch fire, was made more realistic by the strength
of belief in the probability of the content of the doubt occurring, such as,
“maybe I have left the cooker on”. The stronger the belief in the probability of
the content of the doubt occurring, the weaker the participants perceived their
ability to resist their compulsive behaviour, checking that the cooker is off.
Perceived ability to resist compulsions was significantly negatively related to
anxiety and obsessive symptom severity. This suggests that strength of belief
in the probability of the content of the doubt occurring relates to the severity
of the OC symptoms. In all of these analyses, medium to large effect sizes
were found in the range of 0.22 - 0.47.
Hierarchical regression analysis further showed that perceived ability
to resist compulsions was independently and significantly predicted by
strength of belief in the probability of the content of the doubt occurring,
whereas realism of anticipated consequences of the doubt occurring did not
significantly independently predict perceived ability to resist compulsions.
This suggests that the belief in the primary inference of doubt occurring might
better explain OC than the secondary appraisal or anticipated consequences
that are proposed in cognitive-behavioral models. This supports O’Connor et
al.’s (2005) proposal that IC is the primary process in obsessions with
appraisal of consequences being secondary to this. While this study
demonstrates the relationship between doubt and OC, it does not show the
direction of such a relationship, and therefore IC cannot be supported as a
generator of OC symptoms. This is since alternative conclusions can still be
138
made, i.e. that OC might cause higher levels of doubt in those diagnosed with
the disorder.
Quasi-experimental research by Aardema .. (2009) compared
participants with a diagnosis of OCD to a non-clinical control group, in a
reasoning task designed to measure levels of doubt in response to possibility
and reality based information. According to IC theory, people with OCD
should doubt more than those without OCD when presented with possibility-
based information. This is since the experimental paradigm is designed to
emulate the occurrence of obsessive-compulsive-like hypothetical inferences
towards which people with OCD are proposed to respond to with greater
doubt. As predicted, doubt in those with OCD was higher than that in the non-
clinical group when presented with possibility-based information. There was a
strong relationship between the levels of doubt and OC symptom severity,
further supporting the IC theory in he notion that doubt and OC symptoms are
linked. As with Grenier et al.’s (2010) study however, these results do not
conclude that IC predisposes OC as speculated by the IC theory, since it may
still be that having OC distorts ones reasoning processes or that a third
variable is responsible for the IC/OC relationship, something that cannot be
falsified due to the quasi-experimental design.
Since alternative conclusion can be made about the direct of the
relationship between IC and doubt and OC symptoms, more longitudinal and
studies are needed to enhance the developmental understanding of the IC/OC
relationship. In spite of that, current knowledge provides strong evidence for
the IC theory’s premise of the importance of the initial doubt in OC. Given
that the comparisons studies presented here only include OC and non-OC
139
groups, it in turn remains an empirical question whether this type of reasoning
style may be evident in other clinical presentations.
Inference-Based Approach (IBA) to treating obsessive-compulsiveness
The IBA is the intervention that was developed based on the IC
theory. Therefore, studies investigating the effectiveness of IBA can add
support to IC theory. Three quasi-experiments investigated the effectiveness of
CBT and IBA for OCD (Aardema, Emmelkamp & O’Connor, 2005; Aardema
et al., 2010; Aardema & O’Connor, 2012) and one randomised controlled
experiment (O’Connor et al., 2009) explored the efficacy of IBA in
comparison to other cognitive-behavioural treatments for OCD.
35 participants from Aardema et al.’s (2005) quasi-experiment
received 20-sessions of individual CBT for OCD, with the aim of investigating
the effect of change in OC symptoms on IC. Paired sample t-tests showed on
average there was significant reduction in their OC symptoms, anxiety and
depression scores. IC, primary inference and secondary inference, as measured
by clinical interview, were all also significantly lower post-treatment
(p<0.001). 19 participants whose scores improved by 33% from pre-treatment
to post-treatment, they were classified as responders and the remaining 11
were classified as non-responders. While the two groups of responders and
non-responder did not significantly differ in the amount their IC scores
changed, there was less change in IC scores for non-responders, compared to
responders. Pearson’s r correlations demonstrated that change in IC score was
140
significantly related to change in OC symptoms scores overall, on two
different measures (r= 0.44, r= 0.46). By dichotomising the group into
responders versus non-responders there is a reduction in statistical power.
Aardema et al. (2010) selected 38 participants from their original
sample of those diagnosed with OCD to investigate the effects of inference-
based-therapy (IBT) on OC symptoms. T-tests showed that after IBT, OC
symptoms significantly reduced to a mild level on two measures. OC beliefs
as well as negative mood states decreased to that seen in non-clinical control
groups and while IC reduced, it remained higher than seen in the non-clinical
control group. All differences in scores were significant to the 0.001 level. The
participants were dived into responder and non-responder groups based on a
30% improvement rate in OC symptom scores. Individual t-tests demonstrated
that responders and non-responders could only be significantly differentiated
by improvement on the OBQ subscale responsibility/threat and the ICQ-EV,
both at the 0.05 confidence level (Aardema et al., 2010).
Limitations of Aardema et al.’s (2010) study are the lack of
information regarding how the 38 participants from the larger sample were
chosen to take part in IBT. Selection bias may have caused regression to the
mean, which could have enhanced the efficacy of IBT. Endogenous change
and expectancy effects could have been responsible for the success rates of the
treatment in either study and so more research is needed into IBA to see if
effect sizes are supported across studies.
Aardema and O’Connor (2012) evaluated the outcome of a 24-week
IBT in 35 participants, diagnosed with OCD. Paired t-tests showed significant
141
decreases on two measures of OC symptoms post-treatment (Cohen’s d = 2.15
and 1.06), as well as a significant improvement in anxiety (Cohen’s d = 0.58)
and depression scores (Cohen’s d = 0.79). There was a significant reduction in
IC and in participants’ ability to resolve doubt by the end of treatment
(Cohen’s d = 0.63). Based on a measure of doubt resolution, the authors
classified participants into one of three groups. ANOVAS showed that
resolution, pre-resolution and no resolution groups all experienced a
significant reduction in OC symptoms but that the resolution group improved
the most on IC scores. Results confirm that IBT produces significant
reductions in IC, obsessionality and negative mood states, while making
significant improvements in the ability to resolve doubt. Even with a small
sample size, this study provides support for the IBA to treating OC. Findings
did show however, that a quarter of the participants who could not resolve
doubt at the beginning of treatment still could not resolve it at the end,
suggesting that IBT was not universally effective. In spite of this symptoms
still reduced, which suggests that the IBA can produce change in OC
symptoms even when participants cannot resolve doubt. This implies that IBA
might be a general treatment model for distressing symptoms in other
disorders that do not involve the initial doubting process outlined by the
authors of IC theory in OC.
O’Connor et al. (2009) conducted a randomised control trial to assess
the efficacy of IBT. Participants with OCD were randomly allocated to one of
three treatment groups. 16 participants received an IBA, 16 received a
Cognitive Appraisal Model (CAM) treatment and 12 received Exposure with
Response Prevention (ERP). Results showed that the three treatments were
142
equally efficacious in reducing OCD scores. Therapist, treatment integrity,
motivation, dropouts, model integration and client satisfaction were all well
controlled for. All participants’ scores decreased significantly on OC
symptoms with no treatment by group effects. The effect size for Y-BOCS
was 0.68 and 0.57 for the PI. When those with a significantly high belief in
their primary inference of doubt were analysed, greater improvements were
shown by the IBA to treatment over the CAM on both measures of OC
symptoms (ERP was excluded due to low primary inference scores at pre-
treatment). Duration and distress equally significantly reduced in all treatment
groups, with cognitive intrusions showing a trend of better outcome in the IBA
group as opposed to the CAM and ERP groups. Levels of depression
significantly reduced in all groups with a significantly better outcome for
depression in the IBA group. Anxiety did not significantly reduce in all
groups, but did significantly reduce in those with a high primary inference
conviction in the IBA and CAM groups, with no treatment by effect
interaction. These results suggest that the IBA may be as effective as current
CBT in treating OC symptoms and more effective for those who have a strong
belief in their primary inference of obsessional doubt. However, it is important
to note that the ERP group had lower belief in primary doubt at the beginning
of the trial, suggesting that the IBA groups’ reduction in scores may have been
increased by regression to the mean, since the IBA group were working on
primary doubt in participants who originally scored higher on this measure. A
further limitation is the lack of placebo or control group to provide maximum
contrast with the therapies evaluated. This may have been due to ethical issues
regarding withholding effective treatment. The better treatment outcome
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observed here in those with OCD and OVI promotes the possibility that IC
may account for OVI in delusions as well.
Inferential-based reasoning in delusions and schizotypy
Eight of the studies reviewed focus on the relationship between IC,
OCD, delusional disorder and schizotypy. One cross-sectional study and three
quasi-experiments focus on reasoning in OCD and delusional disorder (DD) in
clinical samples (Aardema et al., 2005; John & Dodgson, 1994; Conway et al.,
2002; Fear & Healy, 1997). Two quasi-experiments and two correlational
studies utilize non-clinical samples to investigate reasoning in schizotypy
(Jacobson, Freeman & Salkovskis, 2012; Sellen, Oaksford & Gray, 2005;
Tsakanikos, 2004; Aardema & Wu, 2011).
Aardema et al. (2005) used questionnaires to measure IC, OC beliefs,
OC symptoms, thought-action-fusion, anxiety and depression in 85
participants with OCD, 31 participants with other anxiety disorders, 16
participants with DD and 51 non-clinical controls. Analysis showed that
participants with OCD scored significantly higher on IC than the participants
with anxiety and the non-clinical controls, as did the participants with DD (p<
0.05). There were no significant differences between the IC scores of the
participants with OCD and those with DD. Interestingly, IC in the DD group
was significantly related to all subscales of the OC symptoms measure,
whereas IC in the OCD group was only significantly related to overall OC
symptoms severity and three of the subscales; thoughts about harm,
144
contamination and checking (p< 0.05). The participants diagnosed with
anxiety did not show any significant relationship between their scores on IC
and OC symptoms. This highlights the possibility that IC may be more
relevant to belief disorders than anxiety disorders and indeed, the authors
interpret these findings as support to conceptualize OCD as a belief disorder.
However, participants diagnosed with DD also reported more OC symptoms
than the other non-OC groups, perhaps indicating that the classification of this
group as having primarily DD was questionable.
Probabilistic reasoning tasks have been used in quasi-experiments to
investigate reasoning in DD (Conway et al., 2002; Fear & Healy, 1997). One
such task, originally devised by Garety, Hemsley and Wesseley (1991),
requires participants to draw beads one at a time from a jar in order to allow
them to estimate the proportion of beads of different colours in the jar to
decide on the colour status of jar. The jars contained different ratios of two
different colour beads and so participants had to use probabilistic reasoning to
make a judgement. John & Dodgson’s (1994) quasi-experiment was based on
the same principles, but used familiar contextual stimuli to enhance ecological
validity. Their reasoning task was a game of 20 questions, in which
participants (12 people experiencing delusions, 12 people with depression and
12 non-clinical participants) had to judge whom the researcher was thinking of
by asking up to twenty questions that would elicit a yes or no answer. John
and Dodgon’s (1994) data showed that people experiencing delusions
requested significantly less information when coming to a conclusion. Conway
et al. (2002) used a probabilistic task to demonstrate the same findings while
controlling for intelligence, sensory and neurological deficits, in the
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comparison of 10 participants diagnosed with DD and 10 non-clinical control
participants. The findings from both of these studies suggest that participants
with DD jump to conclusions when making inferences about a possible state
of affairs, sooner and with less information to make that conclusion than
participants who without DD. The authors of both these studies discuss
jumping to conclusions (JTC) as an unusual style of reasoning not dependent
on material presented (John & Dodgson, 1994; Conway et al., 2002). For all of
the research that has used the probabilistic tasks to assess reasoning style in
DD, the motivation, understanding and premorbid personality characteristic of
the participant group may have confounded the significance of findings (John
& Dodgson, 1994).
The opposite trend has been found in studies that investigate the JTC
reasoning style in OC. This is significant since the IC theory proposes that
reasoning in OC and DD might be similar, however, the JTC reasoning style
seen in DD appears different to the IC style of reasoning seen in OC. In cross-
sectional comparisons of people diagnosed with OCD, anxiety and non-
clinical controls, participants with OCD required near significantly more
information to come to a decision (p< 0.06) (Pelissier & O’Connor, 2002). In
comparing the performance of people with OCD to people with DD, Fear and
Healy (1997) replicated this finding in participants with OCD (N=29)
(p<0.0001) when compared to a group of participants diagnosed with DD
(N=30). In addition, they concluded that the reasoning style of those in a
mixed disorder group (OC and delusions, N=16) was closer to the non-clinical
norm than either the delusional group or the OCD group. Not only do these
findings support the idea that reasoning processes in OCD and DD are
146
qualifiedly different from non-clinical reasoning, but also that they are
different from each other. The between group differences in age of onset of the
OCD and DD groups limit the internal validity of the task, as did the higher
Maudsley assessment of delusions schedule score of the group diagnosed with
DD compared to the mixed diagnosis group (Fear & Healy, 1997).
Jacobsen, Freeman & Salkovskis (2012) separated 32 participants
diagnosed with OCD into two groups of those with either high or low
conviction in the strength of their obsessive beliefs, and compared their
performance on a reasoning task with 16 participants currently experiencing
delusions and 16 non-clinical controls. This was to ascertain if conviction
levels are what accounts for the distinction between reasoning in obsessive
compulsiveness and reasoning in delusional thought. Order and practice
effects were controlled for, as was IQ. The probability inference task showed
no significant difference in the JTC reasoning style between the OCD high and
low conviction groups. The researchers inferred from this that while
conviction levels in OC can be equal to that of the conviction seen in
delusional thought, the reasoning processes underlying them is different. In
this study the OCD group was split into high and low conviction level groups
based on scoring in the top and lowest 50%. Differences between these groups
may not have been significant since what the researchers classified as high
scorers were relative to the participant groups scores, which may not have
been that high in conviction generally and therefore the high group may not
have represented conviction in obsessive beliefs as high as it can be seen, high
enough to be considered delusion like. Jacobsen et al. (2012) did not replicate
the differences in JTC between the groups diagnosed with delusions and the
147
non-clinical control group, that has been found in previous research (John &
Dodgson, 1994; Conway et al., 2002; Fear & Healy, 1997). This may have
been a type 2 error due to small sample size since the trend was in the
expected direction but not significant.
Sellen, Oaksford & Gray (2005) measured 64 non-clinical participants
on schizotypy (O-LIFE) and a logical reasoning task. Those with higher
shizotypy scores evidenced greater JTC reasoning on the logical reasoning
task, with the subscale impulsivity/non-conformity predicting participants
performance. In an almost identical designed study by Tsakanikos (2004), the
negative schizotypy subscale was found to be the most reliable predictor of
logical reasoning deficit, in a non-clinical sample of 205 participants.
Aardema et al. (2006) measured on IC, schizotypy and OC in a non-
clinical sample of 108 participants. Results showed that the IC and schizotypy
scores were both significantly related to OC. Multiple regression analysis
showed IC and schizotypy both predicted unique variance in OC while
controlling for neuroticism (Aardema et al., 2006). Using a larger sample size
and controlling for negative mood state, these results were replicated by
Aardema and Wu (2011). Questionnaires were used to measure OC symptoms,
IC, schizotypy and other imaginative processes in 377 non-clinical
participants. Most of these measures correlated highly enough with each other
to emphasize the positive relationship between the constructs, without being
so high as to render any of them redundant. While all measures where
significantly related to the OC symptoms, IC (.58), schizotypy (.42) and
absorption in dissociative experiences (.41) showed the strongest correlations.
148
The above studies are limited by their cross-sectional and quasi-
experimental designs that do not allow for causality to be inferred. The
correlational analyses do not allow for directional conclusions to be made and
the use of non-clinical samples limits generalizability of the findings to
clinical samples. The lack of comparison group in the latter studies (Aardema
et al., 2006; Aardema & Wu, 2011) also prevents further understanding of the
specificity of IC, versus its potential transdiagnostic properties.
Discussion
The present review aimed to provide an overview of the empirical
evidence for the role of IC in OC and delusions. The main findings and
limitations of this body of research will be discussed, ending with future
implications for theory, practice and research.
Summary of Findings
Overall, the evidence reviewed suggests that IC is consistently found
to correlate positively and significantly with OC symptoms and that it emerges
as an independent predictor of OC symptoms when controlling for OC beliefs,
mood and anxiety. The degree of IC is significantly related to OC symptom
severity and it has been demonstrated to explain some of the relationship
between doubt and OC (Aardema et al., 2008; Wu et al., 2009; Aardema, et
al., 2006; Polman et al., 2011; Grenier et al., 2010; Aardema et al., 2009;
Aardema et al., 2010). There is some moderate support for the differences in
149
inductive and probabilistic reasoning in OC (Pelissier & O’Connor, 2005;
Pelissier et al., 2009; Fear & Healey, 1997) and delusions and schizotypy
(John & Dodgson, 1994; Sellen et al., 2005; Conway et al., 2002; Tsakanikos,
2004), supporting the initial premise that the IC theory for OC is based on, and
providing a complimentary or counter explanation to reasoning in delusions.
The IBA to treating OC symptoms has been supported (Aardema et al., 2005;
Aardema et al., 2010; Aardema & O’Connor, 2012) with preliminary evidence
to show that the IBA to treatment is effective in reducing OC symptoms to the
same degree as cognitive-behavioural approaches and to a better degree in
particular OC presentations (O’Connor et al., 2009).
The findings from this review also suggest that IC is more related to
specific subtypes of OC symptoms; obsessions about harm and washing
(Aardema et al., 2006), checking and grooming rituals (Wu et al., 2009) and
harm thoughts, checking and contamination (Aardema et al., 2010). The
information regarding the specific subtypes that IC may be more or less
related to varies between studies and while the IBA is successful in treating
OC symptoms whether OVI are present or belief in initial doubt left
unresolved (Aardema & O’Connor, 2011), it may be more helpful to consider
IC as a general model of OC rather than match it to symptoms subtype.
A transdiagnostic model?
It seems the relationship found between DD and IC provides
preliminary evidence to support the conceptualization of OCD as a belief
150
disorder (Aardema et al., 2005). One of the main limitations of Aadema et
al.’s (2005) study however, was the heterogeneity of the participants within
the OCD group. This may have been the reason that some subscales of OC
symptoms did not significantly relate to IC. IC therefore, may measure
underlying processes of OCD that are more attuned to schizotypy, rather than
be a transdiagnostic model for OCD and all belief disorders. Despite the need
for clarity, Aardema et al. (2005) have been the only research team to study IC
in OC and DD empirically. The larger body of knowledge for reasoning in
delusions lies with the JTC explanation (John & Dodgson, 1994; Sellen et al.,
2005; Conway et al., 2002; Tsakanikos, 2004). IC and JTC as explanations of
different human phenomena have some similarities in that they both frame the
respective disorders as arising from a lack of using ones senses to come to a
conclusion.
Jacobsen et al. (2012) interpret their results as verification of OCD as
an anxiety disorder, which should not be re-categorised as a belief disorder
even if conviction is akin to that seen in delusions or OVI. They also state that
transdiagnostic models of obsessions and delusions are not evident. This
research however only illustrates that the JTC reasoning bias seen in delusions
is not present in OC, it does not consider the presence of IC, so heavily
implicated in OC, as a reasoning bias in delusions. Thus, the possibility of IC
as a transdiagnostic model for both OC and delusions has not been falsified by
current findings. Overall, it seems that the conceptualisation of IC as an
explanation for belief disorders is more speculative than would have been
originally thought based on reviews by the originators of the IC theory
(O’Connor, 2009). The preliminary empirical work that has brought
151
obsessive-compulsiveness, delusions and schizotypy together under the
explanation of inferential-reasoning processes (Aardema et al., 2006), suggests
that much more investigation is needed before IC can be considered a
transdiagnostic model of reasoning in OC and belief disorders.
To further quantify the trandiagnostic properties of the IC theory,
research has been conducted into other OC spectrum disorders, where beliefs
are more akin to delusions or overvalued ideas, given their ego-syntonicity.
Body-dysmorphic disorder and hoarding have both been shown to be
positively responsive to the IBA to treatment, suggesting that IC theory could
explain the unusual reasoning also seen in these disorders (Tallion, O’Connor,
Dupuis & Lavoie, 2013; St-Pierre-Delorme, Lalonde, Perreault, Koszegi &
O’Connor, 2011), supporting the IC theory’s position as a possible
transdiagnostic model for disorders on the continuum of OC, OVI and
delusions.
Limitations of studies reviewed
The inconsistency between correlations of specific subtypes of OC
with IC across studies questions the validity of the findings reviewed. The
discrepancy could have been due to the use of different IC measures (ICQ and
ICQ-EV), given that the ICQ-EV has been shown to have higher internal
consistency (.96 Conbrach’s alpha) than the ICQ and less overlap with
subscales of the OBQ (Aardema et al., 2010). This limitation could also have
been as a result of the heterogeneity of OC phenomena. The varying
presentations of OC symptoms will have affected the prevalence of subtypes
152
in each study and thus the outcome of subtype correlations. Screening for
specific subtype of OC within and across studies could help to control for this
effect, however findings from studies that select homogeneous participants
would be less generalizable to OC phenomena as a whole. In addition, the
screening out of participants with co-morbid disorders occurred in most of the
studies reviewed. While this was in effort to portray the specificity of IC in
OC, it reduced the ecological validity of most of the findings since it is not
representative of the high co-morbidity seen in those with a diagnosis of OCD
(Weissman et al., 1994). Defining OC based on the underlying mechanisms
defined by factor analysis, as opposed to the varying subtypes, may be a more
clinically relevant as it explains the functionality of the symptoms, which
could enable a more specific choice of treatment for those who have been
diagnosed with OCD (Polman et al., 2011).
Since most of the research in this area used the same OC symptoms
and general distress measures (See Appendix B, Table 1) variability of
measures may make for more experimentally valid and reliable results that can
be better generalized. Most of the research utilized a cross-sectional (Pelissier
& O’Connor, 2005; Aardema et al., 2008; Wu et al., 2009; Aardema et al,
2006; Polman et al., 2011; Grenier et al., 2010; Aardema et al., 2005;
Aardema & Wu., 2010; Jacobsen et al., 2012) or quasi-experimental design
(Pelissier et al., 2009; Aardema et al., 2009; Aardema et al., 2005; Aardema et
al., 2010; Aardema & O’Connor, 2012; John & Dodgson, 1994; Conway et al.,
2002; Fear & Healy, 1997; Sellen et al., 2005; Tsakanikos, 2004), the
statistical remits of which do not allow for accountability to be given to IC as
a theory of reasoning processes that causes obsessional doubt and therefore
153
OC. There is also a distinct lack of controlled experiments to enable any cause
and effect to be implied between IC and OC, IC and delusions and IBA in
treating belief disorders as well as OCD. Qualitative data was not apparent and
so as it stands, there is no empirical knowledge on the individuals experience
and perception of IC, whether in OC or delusions. There are only case studies
to represent this (O'Connor, Koszegi, Aardema, Niekerk, & Taillon, 2009).
Due to the content of research in this area thus far, there is currently no
understanding of how trauma, culture, society, family, attachment and
parenting may influence the presence and development of IC in either OC or
delusions. One of the most notable limitations to the research is that the
evidence presented to support IC in OC mostly emanates from the same
research team who devised the theory, which may have affected the objectivity
of their findings. Therefore, replication of the findings in this review by other
research teams is needed.
Future directions and implications
Additional evidence is needed in the area of IC and OC, IC and
delusions and IBA to treating OC, delusions and other belief disorders or OC
spectrum disorders such as OVI, BDD, hoarding, hypochondrias, anorexia
nervosa and trichotillomania. Studies should use ecologically valid
experimental paradigms to measure IC, be randomly controlled, include
individuals with co-morbid diagnoses and make comparisons with non-clinic
groups and no therapy variables. Further research should be considered to
154
allow for a greater understanding of the context that IC develops in and how
this interacts with the presentation of symptoms that could be diagnosed as
either a belief or anxiety disorder. More research into the difference between
belief and anxiety disorders would be interesting in investigating the
transdiagnostic properties of the IC theory, as would research into the presence
of IC in those with no diagnosable symptomology. Dismantling studies would
allow for the understanding of what components of the IBA approach are
beneficial to which OC or delusional experiences. O’Connor et al. (2009)
suggest that the IBA approach would be beneficial for children and
adolescents, given that it may be easier to understand than other cognitive-
behavioural approaches to OC. Research investigating IBA in young people
would be beneficial as the potential is for it to be used as an early intervention
for children who may be distressed by OC or delusional experiences.
155
References
Aardema, F., Emmelkamp, P. M. G., & O'Connor, K. P. (2005). Inferential
confusion, cognitive change and treatment outcome in obsessive-compulsive
disorder. Clinical Psychology & Psychotherapy,12, 338-345.
Aardema, F., & O'Connor, K. (2012). Dissolving the tenacity of obsessional
doubt: Implications for treatment outcome. Journal of Behavior Therapy and
Experimental Psychiatry, 43, 855-861.
Aardema, F., O'Connor, K. P., & Emmelkamp, P. M. G. (2006). Inferential
confusion and obsessive beliefs in obsessive-compulsive disorder. Cognitive
Behaviour Therapy, 35, 138-147.
Aardema, F., O'Connor, K. P., Emmelkamp, P. M. G., Marchand, A., &
Todorov, C. (2005). Inferential confusion in obsessive-compulsive disorder:
The inferential confusion questionnaire. Behaviour Research and Therapy, 43,
293-308.
Aardema, F., O'Connor, K. P., Pélissier, M., & Lavoie, M. E. (2009). The
quantification of doubt in obsessive-compulsive disorder. International
Journal of Cognitive Therapy, 2, 188-205.
156
Aardema, F., Radomsky, A. S., O'Connor, K. P., & Julien, D. (2008).
Inferential confusion, obsessive beliefs and obsessive-compulsive symptoms:
A multidimensional investigation of cognitive domains. Clinical Psychology
& Psychotherapy, 15, 227-238.
Aardema, F., & Wu, K. D. (2011). Imaginative, dissociative, and schizotypal
processes in obsessive-compulsive symptoms. Journal of Clinical
Psychology, 67, 74-81.
Aardema, F., Wu, K.D., Careau, Y., O’Connor, K., Julien, D., & Dennie, S.
(2010). The Expanded Version of the Inferential Confusion Questionnaire:
Further Development and Validation in Clinical and Non-Clinical Samples. J
Psychopathol Behav Assess, 32, 448-462.
American Psychiatric Association (2000). Diagnostic and statistical manual
of mental disorders (4th ed., Text Revision). Arlington: VA.
Conway, C. R., Bollini, A. M., Graham, B. G., Keefe, R. S. E., Schiffman, S.
S., & McEvoy, J. P. (2002). Sensory acuity and reasoning in delusional
disorder. Comprehensive Psychiatry, 43, 175-178.
Claridge, G., McCreery, C., Mason, O., Bentall, R., Boyle, G., Slade, P., &
Popplewell, D. (1996). The factor structure of ‘schizotypal’ traits: A large
replication study. British Journal of Clinical Psychology, 35,103-115.
157
Fear, C.F., & Healy, D. (1997). Probabilistic reasoning in obsessive-
compulsive and delusional disorders. Psychological Medicine, 27, 199-208.
Garety, P.A., Hemsley, D.R., & Wessely, S. (1991). Reasoning in Deluded
Schizophrenic and Paranoid Patients: Biases in Performance on a
Probabilistic Inference Task. The Journal of Nervous and Mental Disease,
179, 181-241.
Gibbs, N.A. (1996). Nonclinical populations in research on obsessive
compulsive disorder: A critical review. Clinical Psychology Review, 16,
729-773.
Grenier, S., O’Connor, K.P., & Belanger, C. (2010). Belief in the obsessional
doubt as a real probability and its relation to other obsessive-compulsive
beliefs and to the severity of symptomatology. British Journal of Clinical
Psychology, 49, 67-85.
Jacobsen, P., Freeman, D., & Salkovskis, P. (2012). Reasoning bias and belief
conviction in obsessive-compulsive disorder and delusions: Jumping to
conclusions across disorders? British Journal of Clinical Psychology, 51, 84-
99.
158
John, C., & Dodgson, G. (1994). Inductive reasoning in delusional
thought. Journal of Mental Health, 3, 31-49.
Johns, L.C., & Os, J.V. (2001). The continuity of psychotic experiences in
the general population. Clinical Psychology Review, 21, 1125-1141.
Knapp, P. C. (1890). The insanity of doubt. The American Journal of
Psychology, 3(1), 1-23.
Kozak, M.J., & Foa, E.B. (1994). Obsessions, overvalued ideas, and
delusions in obsessive-compulsive disorder. Behaviour Research and
Therapy, 32, 343-353.
Muller, J., & Roberts, J.E. (2005). Memory and attention in Obsessive-
Compulsive Disorder: a review. Journal of Anxiety Disorders, 19, 1-28.
O’Connor, K. (2009). Cognitive and meta-cognitive dimensions of
psychoses. The Canadian Journal of Psychiatry / La Revue Canadienne De
Psychiatrie, 54, 152-159.
O'Connor, K., & Aardema, F. (2003). Fusion or confusion in obsessive-
compulsive disorder. Psychological Reports, 93, 227-232.
159
O'Connor, K. P., Aardema, F., Bouthillier, D., Fournier, S., Guay, S.,
Robillard, S., Pelissier, M.C., Landry, C., Torodov, M., & Pitre, D. (2005).
Evaluation of an inference-based approach to treating obsessive-compulsive
disorder. Cognitive Behaviour Therapy, 34, 148-163.
O’Connor, K., Aardema, F., & Pelissier, M. (2005). BEYOND REASONABLE
DOUBT: Reasoning Processes in Obsessive-Compulsive Disorder and Related
Disorders. England: John Wiley & Sons, Ltd.
O'Connor, K., Koszegi, N., Aardema, F., van Niekerk, J., & Taillon, A.
(2009). An inference-based approach to treating obsessive-compulsive
disorders. Cognitive and Behavioral Practice, 16(4), 420-429.
O'Connor, K., & Robillard, S. (1995). Inference processes in obsessive-
compulsive disorder: Some clinical observations. Behaviour Research and
Therapy, 33, 887-896.
Pélissier, M., & O'Connor, K. P. (2002). Deductive and inductive reasoning in
obsessive-compulsive disorder. British Journal of Clinical Psychology, 41, 15-
27.
Pelissier, M., O’Connor, K.P., & Dupius. (2009). When doubting begins:
Exploring inductive reasoning in obsessive-compulsive disorder. Journal
of Behaviour Therapy Experimental Psychiatry, 40, 39-49.
160
Polman, A., O'Connor, K. P., & Huisman, M. (2011). Dysfunctional belief-
based subgroups and inferential confusion in obsessive–compulsive
disorder. Personality and Individual Differences, 50, 153-158.
Sellen, J. L., Oaksford, M., & Gray, N. S. (2005). Schizotypy and conditional
reasoning. Schizophrenia Bulletin, 31, 105-116.
St-Pierre-Delorme, M., Lalonde, M.P., Perreault, V., Koszegi, N., &
O’Connor, K. (2001). Inference-Based Therapy for Compulsive Hoarding: A
Clinical Case Study. Clinical Case Studies, 10, 291-303.
Tallion, A., O’Connor, K., Dupius, G., & Lavoie, M. (2013). Inference-Based
Therapy for Body Dysmorphic Disorder. Clinical Psychology and
Psychotherapy, 20, 67-76.
Tsakanikos, E. (2004). Logical reasoning in schizotypal
personality. Personality and Individual Differences, 37, 1717-1726.
Veale, D. (2002). Over-valued ideas: a conceptual analysis. Behaviour
Research and Therapy, 40, 383-400.
Weissman, M. M., Bland, R.C., Canino, G.J., Greenwald, S., Hwu, H.G., Lee,
C.K., Nweman, S.C., Oakley-Browne, M.A., Rubio-Stipec, M.,
Wickramarantne, P.J., Wittchen, H.U., & Yeh, E.K. (1994). The cross national
161
epidemiology of obsessive compulsive disorder. The Cross National
Collaborative Group. Journal of Clinical Psychiatry, 55, 5-10.
Wu, K. D., Aardema, F., & O'Connor, K.,P. (2009). Inferential confusion,
obsessive beliefs, and obsessive-compulsive symptoms: A replication and
extension. Journal of Anxiety Disorders, 23, 746-752.
Yaryura-Tobias, J.A. (2004). An overview on delusions, obsessions and
overvalued ideas. An intimate cluster of thought pathology. Clinical
Neuropsychiatry, 1, 5-12.
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Appendices
163
Appendix A
319 records were identified
through database searching;
PsychINFO, Medline, Web of
33 records were screened using
exclusions/inclusions criteria of
article type
254 records were excluded
319 records were screened using
exclusion/inclusions criteria of
article subject
33 records after duplicates
removed
17 records were excluded
(abstracts, thesis, case studies,
editorials)
4 records identified from manual
search of remaining 16 articles
Identification
Identification
Eligibility
Eligibility
Screening
164
Appendix B
Table 1. Summary of measures used in studies presented in review
Measures References of studies that used this measure
Padua Inventory Washington State University Revision (PI-WSUR)
Aardema et al. (2008), Wu et al. (2009), Aardema et al. (2006), Polman et al. (2011),
Vancouver Obsessional Compulsive Inventory (VOCI)
Aardema et al. (2008),
Inferential Confusion Questionnaire 15 Aardema et al. (2008), Aardema et al. (2006), Polman et al. (2011),
Schedule of Compulsions, Obsessions and Pathological Impulses (SCOPI)
Wu et al. (2009), Aardema & Wu. (2011),
Obsessive Compulsive Inventory Revised (OCI-R)
Wu et al. (2009),
Inferential Confusion Questionnaire Expanded (ICQ-EV)
Wu et al. (2009),
Beck Anxiety Inventory (BAI) Aardema et al. (2008), Aardema et al. (2006), Polman et al. (2011),
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Beck Depression Inventory (BDI) Aardema et al. (2008), Polman et al. (2011),
Mood and Anxiety Symptoms Questionnaire (MASQ)
Wu et al. (2009),
Obsessive Beliefs Questionnaire 44 Aardema et al. (2008), Wu et al. (2009), Aardema et al. (2006), Polman et al. (2011),
Yale Brown Obsessive Beliefs Questionnaire (YBOCS)
Polman et al. (2011),
Thought Action Fusion Questionnaire (TAF) Aardema et al. (2005),
O-LIFE Sellen et al. (2005),
The Schizotypal Syndrome Questionnaire Aardema et al. (2006), Aardema & Wu. (2010),
Aardema & Wu (2011),Dissociative Experiences Scale Aardema & Wu. (2011),
166
Adult Mental Health – Community Mental Health Recovery Service (CMHRS)
I used Cognitive Behavioural Therapy (CBT) and Narrative Therapy (NT)
individually with adults aged 18 to 65 years old with a range of enduring, severe,
mild, transitional and psychosocial problems. I also worked with acute presentations
as part of a family therapy clinic, offering systemic interventions to individuals,
couples and families on an adult mental health ward. I conducted two
neuropsychological assessments and worked with clients from a range of ethnic,
cultural, social and religious backgrounds. I used standardised measures and gathered
information from care-coordinators, general practitioners, ward staff and clinical
records. I conducted on-going risk assessment and implemented risk management
plans. I provided teaching to ward staff on genograms and I attended regular multi-
disciplinary team (MDT) meetings. I engaged with service users outside of the
clinical setting by attending the local Service User Engagement Network meeting.
Older People – Older people’s Community Mental Health Team (OPCMHT)
I worked therapeutically with individuals and couples with a wide range of enduring,
severe, mild, transitional, biological and psychosocial problems, between the ages of
66 and 89 using CBT and systemic therapy in either the OPCMHT base, on a physical
health ward or in the client’s home. I co-facilitated psychoeducational groups, a
continuous mindfulness group and a ten-week cognitive stimulation therapy group. As
part of the memory clinic, I completed a dementia assessment, which included
administering a battery of neuropsychological tests. I also used cognitive and memory
screening tools on several occasions. I worked with clients with severe memory
problems and those with physical disabilities. I provided supervision for an assistant
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psychologist and consulted to the staff team. I worked with another trainee clinical
psychologist to develop a new referral pathway for psychology groups.
People with Learning Disabilities – Community Learning Disabilities Team (CLDT)
I worked therapeutically with individuals with mild to severe learning disabilities and
mental health problems such as low mood and anxiety. I also completed two dementia
assessments for older men with downs syndrome. I conducted challenging behaviour
assessments and helped to create and implement positive behavioural support
programmes. I conducted this work in a range of settings including the team base, the
client’s homes and community centres. I worked independently and jointly with other
psychologists and members of the MDT. I consulted with staff teams, carers and
families.
Specialist Placement – Charity Project
I worked therapeutically in a third sector organisation with young men aged between
15 and 30 years old who were either offending or at risk of offending and may have
had an unmet mental health needs. This charity project was based in the local
community of the young people it served. The clients were referred by peers and
utilised the service on a drop in basis. I worked with young people who were assumed
to be from a socially disadvantaged social background, most of who were black
British, Caribbean or African. As a team we used a model that emphasised
metalisation as the main therapeutic approach. I also worked on engaging young
people with the service, helped them set goals, provided access to
education/employment/community, provide psychoeducation on mental and physical
health and encouraged thinking about social action. I provided consultation to the
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team regarding an audit I conducted on the formulation sessions we held. I gathered
information from other staff members during meetings and debriefs and engaged in
continuous risk assessment and management. In addition to having mentalising
conversations, CBT and systemic theories influence my conversations with the young
people. I used social inequalities formulations to guide my thinking and motivational
interviewing techniques to help promote a culture of change. I created and presented
information sheets on common mental health problems for the staff team and devised
training on motivational interviewing. I engaged in CPD relevant to the placement
and helped designed a qualitative piece of research on the employment scheme that
the project had been running.
Child and Adolescent Mental Health - Child and Adolescent Mental Health Service
(CAMHS)
I provided CBT, NT, systemic therapy, psychoeducation and social skills training to
children and adolescents aged between 6 and 15 years old and their families. I used a
range of standardised clinical measures and gathered information from clinical
records as well as from people in the child or adolescents professional and personal
networks. I used a range of standardised clinical measures and conducted three
neuropsychological assessments. I conducted observations in homes and schools and
consulted with schools regarding the outcome of individual therapy programmes. I
assessed for risk and made referrals to relevant agencies for issues of safeguarding. I
observed my supervisor conduct eye movement desensitisation and reprocessing. I
contributed to service development by jointly working with an educational support
worker to develop a leaflet for parents on the topic of school refusing. I provided CBT
supervision for a social worker and delivered a presentation at a team meeting.
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Year I Assessments
PROGRAMME COMPONENT TITLE OF ASSIGNMENT
Fundamentals of Theory and Practice in Clinical Psychology (FTPCP)
Short report of WAIS-III data and practice administration
Research –SRRP
Practice case report Recovery model for a young man experiencing negative symptoms of psychosis
Problem Based Learning – Reflective Account
Reflections on problem based learning: The relationship to change
Research – Literature Review
Inference-based reasoning in obsessive-compulsiveness, delusions and schizotypy.
Adult – case report
Reflections-on-action: The use of Cognitive Behavioural Therapy with a single man in his late 30’s presenting with moderate to severe depressed mood, mild anxiety problems and unstable emotional personality traits; a notice therapists approach
Adult – case report
Cognitive Behavioural Therapy for anxiety and panic disorder with a man in his late 30’s with a diagnosis of schizo-affective disorder and a long term physical health condition that significantly impacted his presentation.
Research – Qualitative Research Project
What is the experience of low-intensity IAPT workers transitioning to clinical psychology training?
Research – Major Research Project Proposal
Inference-based reasoning in obsessive-compulsiveness, delusions and schizotypy.
170
Year II Assessments
PROGRAMME COMPONENT
TITLE OF ASSESSMENT
Research - SRRP
Research Research Methods and Statistics test
Professional Issues Essay
Successfully promoting psychological services to men, working class young people and cultural minorities present considerable challenges to clinical psychology, where the majority of practitioners are White European females”. To what extent can clinical psychology services reach out to these groups and what challenges does this pose for the profession?
Problem Based Learning – Reflective Account The Stride Family
People with Learning Disabilities/Child and Family/Older People – Case Report
Assignment Title: A Neurological assessment for dementia with a man in his mid sixties who presented with risk factors and significant concern.
Personal and Professional Learning Discussion Groups – Process Account
Personal and Professional Learning Discussion Group Process Account
People with Learning Disabilities/Child and Family/Older People – Oral Presentation of Clinical Activity
Working with Social Inequality, Difference and Diversity: Oral Case Presentation
171
Year III Assessments
PROGRAMME COMPONENT ASSESSMENT TITLE
Research - SRRPThe generic and specific supervisory competencies used by clinical psychologists in adult mental health services in a NHS Mental Health Trust
Research – MRP PortfolioThe relationship between inferential confusion, obsessive compulsiveness, schizotypy and dissociation in a non-clinical sample.
Personal and Professional Learning – Final Reflective Account
On becoming a clinical psychologist: A retrospective, developmental, reflective account of the experience of training
Child and Family/People with Learning Disabilities/ Older People/Specialist – Case Report
Observation, assessment and initial intervention with a primary school aged boy with selective mutism.
172
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