ABNORMAL AND NORMAL OBSESSIONS

S. RACHMAS and P. DE SILVA

Psychology Department. lnstttute of Psychmtry. De Crespigny Park. London. SE5 YAF

Summary-Three related. e.xploratory studies were carrted out in order to ascertatn the occur-

rence and nature of normal obsesstons. and to relate them to abnormal obsessions. The subjects included S obsessional patients, and up to 121 non-chnical SubJectS.

Broadly. the findings were that normal obsessions are a common experience and they resemble the form of abnormal obsessions. They also show some notable similarittes of content. However. normal and abnormal obsessions differ in several respects. includin g frequency. duration. inten-

sity and consequences. among others. With repeated practice, the frequency. duration and discomfort of obsessions are observed

to decrease. Overall. the findings are considered to be consistent with the noxious stimulus cum habituation theory.

In the course of developing a theory to account for obsessions it became necessary to assume that all people experience a phenomenon akin to ‘clinical’ or ‘abnormal’ obsessions (Rachman, 1971). The first aim of the present investigation was to test this

assumption. Secondly, we set out to determine the similarities and differences between normal

and abnormal obsessions. And finally, we attempted to gather some preliminary experi- mental data pertinent to that part of the theory which postulates that obsessions are subject to an habituation-like process.

In the earliest form of the theory it was proposed that obsessional material should be construed as (largely internal) noxious stimuli to which the person has failed to habituate. Such failures to habituate were assumed to be the result of a combination of factors including mood disturbance, pre-disposing hyper-sensitivity, specially signifi- cant material. heightened arousal and in a majority of cases, a precipitating event. Habi- tuation to potentially or actually disturbing material was (presumably) facilitated by lowered arousal, stable mood, repeated presentations of evoking stimuli, prolonged expo- sures. The subsequent elaborations of the theory (Rachman, 1977; Rachman and Hodg- son. 1978) are of marginal relevance to the present experiment and will not be taken

up here. The first study, which aimed to find out whether non-psychiatric subjects experience

obsessions, consisted of a simple questionnaire survey. The second study. in which we sought to discover the similarities and differences between clinical (abnormal) and non-

clinical (normal) obsessions, consisted of standardized interviews of obsessional patients and non-clinical subjects with obsessions. The third study, in which we tested whether obsessions can be formed to instruction and whether they show signs of habituation, consisted of a simple experiment carried out on clinical and non-clinical subjects.

For purposes of the investigations, obsessions were defined as repetitive, unwanted, intrusive thoughts of internal origin. A full discussion of this definition and its conceptual justification is provided elsewhere (Rachman, 1978, and Rachman and Hodgson, 1978).

STUDY I-NORMAL OBSESSIONS

A simple questionnaire was given to 124 normal people, inquiring about the presence or otherwise of intrusive, unacceptable thoughts and impulses, their frequency, and about whether or not these could be easily dismissed. The questionnaire inquired about thoughts and impulses separately.

The sample was not random. but was determined by easy availability. Most were students-postgraduate, undergraduate or professional-and some were employed as

233

research workers. nurses. clinicians etc. Fifty-seven of the sample were males. and 67 were females. Their age ranged from 16 to 51. with a mean of 17.7 years. The average age of the males was 38 vears (range 19-51) and that of the females 27.5 years (range I&15).

Respondent’s characterljtlcs

\lalr Female Total

\lCln age 2Y 27.5 27.7

RXlge Ii)-51 I6A.s 16-51 Number 57 67 171

Of the 12-t respondents, 99 reported that they had either thoughts or images. Twenty-

five responded negatively-i.e. they had neither thoughts nor impulses. In other words, 79.8-l of the total sample of normals were positives. and 20.16 were negatives. This substantially confirms the first hypothesis of this investigation-vi:. that non-psychiatric subjects commonly experience obsessions. There were no age or sex-related differences in presence or absence of obsessional experiences.

/Vryari~ rrspo~tler~rs. No systematic study was made of the negative respondents. However. some of them made unsolicited comments and observations on the question- naire forms and verbally. Five subjects emphasized that they did have obsessions of the type given in the examples in the questionnaire. but did not consider them to be unacceptable: they had therefore responded in the negative. Of these five, three admitted to having both thoughts and impulses of this sort. one to having thoughts only. and the other impulses only. One of the positive respondents, a female who had responded positively to impulses only. also indicated she had some of the thoughts in question. but did not consider them to be unacceptable.

The conclusion from these unsystematic data seems to be that people vary in the level of tolerance. or criterion. of what is an acceptable thought or impulse, and what

is not. One subject stated that: ‘My criterion of what is unacceptable is high’. Another subject observed that: ‘I do not consider these unacceptable. But they are by ethical standards of society.’

For the present purposes. it must be noted that 5 out of a total of 25 negatives in the sample would have been classed positives, if not for the problem of unacceptabi- lity. If the present frequency data are revised. by re-classifying these 5 subjects as positive. then 104 out of 124 (i.e. 844;) would be positives. The explanation of why 16% have no obsessions is unknown.

Positike 37 57 IOA (S2.5)’ (35. I ) (93 91

Negative (,:.:I $9,

20 (16.1)

Total 57 67 124

* Figures within brackets show the number in ths cell 3s a percentage of the total in category-mats. female. total.

The nature of normal obsessions. Of the 99 positive respondents, 32 had only obses- sional thoughts. 1-I had only impulses. while 53 admitted to having both. The male- female breakdown for these data is as follows:

Thoughts only Impulses only Both Total

?&IS: IS (40)’ 5 (I 1.1) ‘1 (4S.9) 45

Female: I-l (75.9) 9 116.7) 31 (57.1) 5-l Total 32 (32.3) 14 (II.11 53 (53.5) 99

* Figures within brackets show number in cell as a percent- age of the total position in the catrgor)-male. female. total.

-\bnormal and normal obsesstonj 235

The following figures are for positives for thoughts and impulses separately. irrciudiny in each category those u-ho had both.

Thoughts Impulses Total

Xf&: 40 (59.7)’ 27 (10.3) 67 Female: 4.5 (52.9) JO (17. f 1 S5 Total: Y5 (55 9) 67 WI) 152

* Figures within brackets show number in cell as 3. percentage of total in category-male. female. total.

(Note that the tot& here exceed the total casrs, as some subjects had both thoughts and impulses, as indicated above). Evidently obsessional thoughts are somewhat more common than impulses.

The frequency of the occurrence of thoughts is given below. Also indicated in the table is the respective number of cases who found it was easy to dismiss the thought or not, including a ‘doubtful’ category.

Frequency and dismissability of obsessional thoughts

Easily Not easily

dismissed dismissed Doubtful Total

IO+,day I z 0 3 IO+ week 13 3 0 16 IO+ ‘month 25 4 1 33 Less 27 4 2 33 Total 69 13 3 85

Frequency and dismissability of obsessional impulses

Easily Not easily dismissed dismissed Doubtful Totat

IO+,day 1 0 0 I IO+,week 5 0 0 5 IO+/month 22 4 0 26 Less 31 4 0 35 Total 59 8 0 67

The patterns of frequency. and ease of dismissal, are similar for the two sexes. Impulses tend to be slightly less frequent in that, in the majority, they occur less than 10 times a month. Also. people seem to find impulses very easily dismissible, and obsessional thoughts easily dismissible. We were unable to identify any individual factors determin- ing ease of dismissal. Cases positive for both, who found it difficult to dismiss thoughts did not necessarily find it difficult to dismiss impulses-or vice versa. The general tend- ency is for impulses to be more easily dismissible even in these cases, although numbers are too small to draw any firm conclusions,

To conclude Study I, obsessions (thoughts andior impulses) are a very common experi- ence. There are no sex or age-related differences in occurrence, and most thoughts and impulses are easily dismissed. There are individual variations in the threshold of acceptability of obsessional thoughts or impulses.

STUDY II-SIMILXRITIES TO ABNORMAL OBSESSIONS

The second stage of the investigation consisted of standardized interviews of a sample of the positive respondents. and a sample of clinical obsessionals-i.e. patients who had come for psychiatric help for their obsessions. Our aim was to coliect detailed information about their obsessions and related matters, and to test the short-term effects of repeatedly provoking the obsessions. It was planned to compare the two groups

236 S. RACHMAL 2nd P. DE SILL%

so that similarities and diffrrrnces between them. with regard to the obsessions and their response to repeated evocation, could be explored.

The interview sessions were carried out by the same experimenter (P. de S.) for all subjects, clinical and non-clinical. The interview was a structured one. using a prepared

schedule and a set of agreed guidelines for its use. After recording the essential back- ground data and relevant data on the target obsession s, the repeated evocation tests were given.

If a subject was unable to produce the obsession on request in one session. another session was arranged wherever possible. No subject was seen for this purpose more than thrice.

T/W ~KXI-clinicnl sample. A total of 40 subjects chosen from the positive respondents to the questionnaire. comprised the non-clinical sample. Although it was originally in- tended to choose the sample from among those whose obsessions had a frequency of at least 10 per vveek. the final sample was determined mainly by availability. It had the following composition :

The clinical sample consisted of eight subjects, as follows:

MZllC Female Total

hlcan 3gt’ 42.S 38.3 41.1 Number 5 3 8

They were all obsessional patients who had come for psychiatric treatment and in whom the obsessions were either the sole complaint or one of the major complaints. They were from the Maudsley. Bethlem Royal, Guy’s. and Queen Elizabeth II Hospitals.

C’o~tte~~t analr;sis. The contents of the obsessions are reported below. Only current obsessions of the subjects have been included. Verbatim descriptions are given when the obsession concerned takes a particular. invariant verbal form. The presence of im- agery is noted only when the image constitutes an essential and/or prominent part of the obsession. Circumstances of occurrence, and the specific target person or object. are given only when the content is inextricably bound up with them.

An obsession has been considered as a single, independent one, on the basis of the judgement of the subject himself. Sometimes, common themes with slightly varying details were reported; in such cases. the obsession has been considered as WIT. On the other hand. certain subjects reported more than one obsession with an underlying theme (e.g. violence). where the individual obsessions were reported to be independent and specific in terms of target person, object, circumstances etc. despite the common theme. These have been considered as individual units. The total number of obsessions exceeds the number of subjects as some of them reported several obsessions.

The obsessions of the clinical sample are given below. There is a total of 23, elicited

from 8 subjects. to attack, or strangle, cats or kittens to strangle children, sometimes adults to jump out of window to attack and harm someone, especially own son, with bat. knife or heavy

object Thought of ‘disgusting’ sexual acts with males (male subject) Itnpulsr to look at buttocks of boys and youths (male subject) Thoqht whether he has been poisoned by chemicals

Thought that his eyes will be/are harmed

Abnormal and normal obsessions 237

Thought that he will get;has got cancer Thotcght whether he has been affected by radiation

Thought ‘These boys when they were young’-a mechanically-repeated phrase Thoughr of ‘bad’ people doing ‘all sorts of harm’. of a violent form. to ‘good’

people-i.e. family. relatives, religious persons Thoughr that she might harm someone Thought ‘I wish heishe were dead. with reference to persons close and dear. also

others Thought of swear words. with large, clear images of the words in print Impulse to utter swear words Thought ‘Did I commit this crime?‘. when reading or hearing reports of crime Thought that he may become insane, and end up in an institution Thought that he may go berserk all of a sudden Thought that he might push someone under a bus or train Impulse to harm girl-friend with physical violence

Impulse to physically attack and harm dog, mainly own dog, but also to some extent other dogs

Impulse to harm children with physical violence The obsessions of the non-clinical sample are given below. There is a total of 58.

from 40 subjects. In a very few cases, there was failure to record the content of a second (or third) obsession of the subject. A total of 7 have been omitted in this way (the second obsession of three subjects; the third of two subjects; and the second and the third of one subject).

Impulse to hurt or harm someone Thought ‘what is the calorie content of that food?’ Impulse to jump on to rails, when tube train is approaching Thought of intense anger towards someone, related to a past experience Thought of accident occurring to a loved one Impulse to say something nasty and damning to someone Thoughr of harm to, or death of, close friend or family member Thought of acts of violence in sex Thought that something is wrong with her health

Impulse to physically and verbally attack someone Impulse to do something--e.g. shout, throw things-to disrupt peace in a gathering Impulse to jump in front of tube train, or bus Thouglir of harm befalling her children, especially accidents Thought that probability of air-crash accident to herself would be minimised if a

relative had such an accident

Thought whether an accident, especially car accident, had occurred to a loved one Impulse of violence towards objects Impulse to buy unwanted things Though? identifying himself with person executed, when reading or hearing reports

of executions--‘How would I feel at that moment if I were him?‘, also clear image sequence

Thought that she, her husband and baby (due) would be greatly harmed because of exposure to asbestos, with conviction that there are tiny asbestos dust particles in the house

Thought whether any harm has come to his wife Impulse to shout at and abuse someone Impulse to harm, or be violent towards children, especially smaller ones Impuse to crash car, when driving Thought ‘Why should they do that? They shouldn’t do that’, in relation to people

‘misbehaving’ Impulse to attack and violently punish some0ne-e.g. to throw a child out of bus Thought whether any harm has come to his wife

738 s. RACHMA\ and P DE SILL h

Thoughr

Thought

ltnpulsr

Thought

It?7pLilsr

Impulse

Ti7ought Itnp1rlw

Thougi7t

ltr7plrlsr

It1rp7rl.w

Thoughr Itnpulsc

ThougIlt

Thoughr

Thought

Impulse Itt7plclsr

Tl7ougl7 t

with clear visual image sequence. of walking along a crowded passage. and suddenly discovering that he is naked with image sequence. of the details of an accident that she had experienced

to say rude things to people about accidents or mishaps, usually when about to travel to push peopls away and OK in a crowd-e.g. a queue to attack certain persons of being aggressive tokvards some persons to say inappropriate things--‘wrong things at wrong place’ of hurting someone by doing something nasty, not physical violence- ‘Would I or would I not do it’?’ to hurt someone by saying something nasty. or deliberately shaming him.‘her sexual impulse towards attractive females. knoivn and unknown wishing that someone disappeared from the face of the earth

of violence towards a person that harm would have befallen to someone near and dear of ‘unnatural’ sexual acts wishing and imagining that someone close to her was hurt or harmed to hurt. or harm, someone

Implrl.%~

It?7plrlsr

Thoughr It?lplrls~~

T17oughr

ln7p1rlsr

Itt7pdsr

Tl7oughr

to shake someone hard and shout at him/her of experience/s many years ago when he was embarrassed. humiliated, or was a failure to violently attack and kill a dog to violently attack and kill someone that she might do something dramatic like trying to rob a bank to jump from top of a tall building or mountain/‘cliff of being violent towards a known person. causing harm, in revenge to sexually assault a female, known or unknown to say rude and unacceptable things of an embarrassing or painful experience he has had, with visual image sequence

I tl7plclsr to engage in certain sexual practices which involve pain to the partner

Impulse to be rude and say something nasty to people

ltt7pulse to jump off the platform when a train is arriving

Thought of physically punishing a loved one T17oright that she might commit suicide Clit7ical cs non-clinical. In an attempt to examine the similarity between the two

types, a small sub-study was carried out to determine whether the obsessions of clinical and non-clinical subjects are discriminable on the basis of the content alone. For this purpose. the 81 obsessions were printed on cards, giving only the content (as summarised above). These were shuffled and given to six judges (five psychologists and one psychia- tric nurse) who had clinical experience with obsessional patients. along with instructions to sort the 81 obsessions into 2 piles-normal and abnormal-in terms of whether they came from patients or non-patients. The number of correctly identified ‘clinical’ obsessions were 10, 13. 13. 10. 13 and 18 for the six judges. Their response as ‘clinical’. were as follows:

Judg .A B c D E F

Correct positive guesses (out of 23 clinical obsessions)

SS Non-clinical obsessions judged to be clinical

Abnormal and normal obsessions 239

It appears that the judges were not able to identify the clinical obsessions too well. but on the other hand they were moderately good at identifying non-clinical obsessions. From this we can conclude that clinical obsessions are not as readily discernible-even to experienced clinicians-as might be expected.

DIFFERENCES BETWEEN THE CLIKICAL AND NON-CLINICAL SAMPLE

(a) Number oj obsessions at present

(b) Time

Clinical sample Non-clinical sample

Range I-7 l-3 Mean 2.9 I.45 .\ s 40

since onset*

Clinical sample Non-clinical sample

Range Mean

IV

I yr-46 yr I5

8

3 m-24 yr

9.4 yr 40

+ In cases where more than one obsession was present. the duration given is that for the one

of which the duration was longest. It must also be noted that there is a difficulty in comparing

the two samples on this, as the clinical sample was considerably older.

(c) Ocert compulsions unrelated to obsessions

In the clinical sample, five (5/S) reported having compulsive behaviour (e.g. checking, washing), while in the non-clinical sample. eleven (1 l/40) reported having them.

Other rituals No other rituals Total

Clinical 5 3 8 Non-clinical II 29 40

(d) Other problems

In the clinical sample, one (l/8) also had a social phobia. but none of the other 7 had psychiatric complaints (other than obsessional behaviour noted above). In the non-clinical sample none had any such condition.

(e) Family

Only one (l/S) person in the clinical sample said a parent was obsessional. One had an aunt who was obsessional. In the non-clinical sample nine (9/40) had parents described as obsessional. Three others had a close relative who was obsessional.

Parent Other close relative No relative obsessional obsessional obsessional Total

Clinical 1 I 6 8 Non-clinical 9 3 28 40

CHARACTERISTICS OF THE OBSESSIONS

Data were obtained in detail from every subject on one obsession. In cases of multiple obsessions, although it was hoped to obtain data on another obsession as well, in practice it was not possible to do this in detail. Thus, full data are available only on one obsession for each subject; and this was the one the subject considered to

be his her current obsession. The form and content of all current obsessions were how- eher recorded.

Clinicul. The relevant data for the eight clinical subjects are given belobv. Form. Three were impulses. and 5 were thoughts. Three (2 thoughts and 1 impulse)

had invariant and clear visual imagery associated with them.

Oct~rc~il ci~atiori. Mean of 15 years. range 1-46 yr. 011st~r. Four subjects had a clear idea as to the onset. One had a vague and uncertain

association Lvith a certain event (father’s death) with the onset of the obsession, and the other three had no idea as to the specific onset. Of the four who did claim clear memory of onset. in one it was change of residence and associated reservations and doubts (leading to impulses to harm son). In another. it was the death of known co- workers due to suspected radiation effects (leadin g to thought he may have been poi- soned by chemicals); in one, it was a common sight of some children in a certain place at a certain time in his life (leading to a senseless thought about the same children); and in the other, the death of a kno\vn person which the patient’s mother kept secret from her for some time (leading to the thought that she wished death to others).

Dctrariotl. Reported duration of each obsession varied from 2 XC to 5 min. with a mean of 80.7 sec. In five cases. the duration was 20 set or less.

Frrqrtencr~. Frequency of occurrence varied from 3 per day to 150 times per day. with a mean of 27. Five reported frequencies of 10 or more per day. Most said the frequency varied. especially in relation to mood (see below).

Rrpetiri~nrss. Only three described a tendency for the obsession to return immedi- ately, or almost immediately. having occurred and gone away.

R~sisra~lcr. Four reported high resistance to the obsession, three moderate resistance, and one low resistance. Two of those reporting moderate resistance and the one report- ing low resistance stated that initially they had resisted strongly, but now they were ‘used to it’. This decline in resistance over time has also been independently observed

among other types of obsessional-compulsive patients (Rachman and Hodgson. 1976). Pro~~ation. Five said their obsessions occurred with no identifiable external provoca-

tion; one said that subjective anxiety was the provoking factor. Interestingly. all rhesejce

bvere rhortghrs, as against impulses. In the case of the three impulses. sight of the target,‘s (e.g. children) or associated stimuli (e.g. bats or heavy objects, bvhere impulse was to attack child with such object). that is external stimuli. inrariclb/y rriggereri the impulse.

Of these three subjects, one would also sometimes get the impulse without provocation, and another would also sometimes get the impulse at the thought of going out.

Senselrssness. Only two subjects had obsessions that they considered senseless. One of these was the mere mechanical repetition of a string of words (‘these boys when they were young’). The other was not senseless so much as vague.

Persotlnl it7mlretmwt. Five had direct personal involvement. one had no personal in- volvement at all (one referred to in the above paragraph). and in two the involvement was indirect (harm coming to people known; harm being wished by self to others).

Intrnsit~l. Subjectively felt intensity was high in six, and moderate in two. The latter. hoivever. reported it was high initially but had weakened over time.

:\iemity. All except one (whose obsession was a string of words), said it had meaning for him/her. (However. this variable proved to be difficult to assess properly. particularly as senselessness was also inquired into--see above).

Alietwess to selj: Six felt the obsession was quite contrary to their normal self. In one. it was in keeping with his nature-he \vas prone to worry and anxiety about everything, mainly his health. and his obsession was whether he had been poisoned by chemicals. The eighth felt her obsession (wishing death of others) was not entirely alien to herself; however, the thought aroused guilt.

Discomfort. The felt discomfort/anxiety/uneasiness. on a O-100 scale, varied from 10 to 90, with a mean of 63. One (whose rating of discomfort was 10). reported that somatic reactions (palpitations. pain at back of neck) accompanied the obsession. She also said the subjective discomfort was 100 initially, but it had come down.

-\bnormal and normal obsessions 241

Urge to neutrake. The three subjects referred to in the above paragraph reported distinct neutralizing activities. and rated their urges to do so as 70. 90 and 100 respect- ively. One (impulse to strange children) patient would be extra nice to the target person (overt), or. if the obsession arose in the absence of a target person, she would imagine being extra nice (covert). One (thoughts about ‘good’ people being harmed by ‘bad’ people) would wash his hands (overt). and this was an act to prevent real harm coming to loved persons. The third (thought wishing death to others) would utter a phrase (‘I take the curse’) silently (covert). so that the person concerned would not die. Carrying out the neutralizing activity brought relief. but total relief only in one of the above cases.

Other coping tnechanims. All the eight subjects had other coping mechanisms to deal with their obsessions. including the three who had specific neutralizing activities noted in the above paragraph. One would say ‘stop’ to herself, five would try to distract themselves (one would sing. another count. another pray aloud). One would leave the place (escape). and another avoid instruments which would trigger the obsession (avoid- ance). The success of these. however. was limited.

Fate. The obsession would generally cease after a while. However. in one case it would sometimes linger on. In three cases. it would return immediately or almost immediately.

Relation to mood. Except in two, mood was felt to relate to the obsession. Four said depression led to greater frequency and discomfort, while one of them said depres- sion led to greater discomfort only. In two, it was generalized anxiety. rather than depression, which led to greater frequency and greater discomfort.

General cotnmenrs. In general, the subjects were able to talk about their obsessions without difficulty; in one case, however, the subject was able to describe and articulate the obsession only with difficulty, and he was somewhat vague in his account. His general level of anxiety was high.

It was clear that the nature of the problem had undergone some change during the course of the disorders. As noted above, three reported that their resistance to the obsession had lessened over time. One of these three, plus another, also reported the intensity was now moderate-it had been high earlier. Another of these three reported a reduction of felt discomfort from 100 initially to 10 after one year since onset, but the somatic correlates remained. All this may be taken to indicate that people get accustomed to obsessions, without necessarily achieving full relief-is this incomplete habituation perhaps?

Non-clinical sample. In order to simplify comparisons with the clinical data described above, the following Tables summarize the main findings. Data for the clinical and the non-clinical samples are given together under the separate headings to facilitate comparison. Due to smallness of the clinical sample (N = 8) statistical tests of signifi- cance are strictly not applicable; all the data are given in raw form.

(a) Fornr

(b) Durarion o/problem. in yors

Impulses Thoughts

Clinical (N = S)

Non-clinical (N = 40)

3 5

16 24

Between Between 10 years 5 and I and I year

Range Mean or more 10 years 5 years or less

Clinical (.V = 8) I-46 I5 5 0 3 0

Non-clinical (N = 40) f-22 8.6 I6 4 I3 7

S RACHMA~ and P. DE SILL A

Between 10 3K or 10 WC and More thJn

Range llran Ias I min I min

ClInical (.V = S) J-300 so7 7 3 3

Non-cllnlcal (.Y = 101 I-300 17.4 2: 6 I I

IO or Less th,ln I da). Less more l-9 but not less than

Range M2,itn d,l) da) than I wk I Lb:,

Cllniclll (.V = 8) 2-l50d 27d 5 ? 0 0

Non-climcal 20 d-

(.V = -101 l j 2 5 :2 ! 1

Yes No

Clinical (.L’ = 8) 3 5

Non-clinical (:V = 40) I4 16

Strong Moderate Weak Non?

Clinical (!V = S) 4 3 1 0

Non-clinical i.v = 10) 6 13 12 9

External Internal External No trl_eyrr trigger or trtgger

0nl> only Internal v.harevrr Doubtiul

Cltnical (.V = 8) 2 I I 4 0

Non-clinical (.t’ = 10) 22 8 2 1 1

* This does not mean an inrnriuhk relation between trigger and obsession.

Abnormal and normal obsessions

Senseless Nor senseless

ClinIcal (Y = 8) I 7

Non-chnlcal

(.V = 401 0 10

ClInical (.V = dl 5 2 I

Xon-cllnlcal (.V = 10) 31 7 2

High Moderate Lou

Clmical (.V = 8) 6 z 0

Son-clinical (V = 10) I I 20 9

Yes No

Chnlcnl (IV = 8) 7 I

Son-clinical

(.V = 40) 40 0

Yes No Doubtful

Clinical

(.V = Y) 6 I I Non-chnical

(.V = 40) I9 18 3

No. wth NO. No.

clear with NO. No. NO. less

somatic SO or betiveen between bs t~een than

Range Mean correlales mars 60-79 J&59 x-39 20

Clinical (.V = S) IO-90 61 I 3 3 0 I I

Non-clinical (.V = 40) S-90 12.75 3 6 8 10 7 9

No. with distinct No with no urge 10 distinct Range for Mean for

neutralize urgs positives positives

Cllnical (5 = S)

Non-clinical (.V = 40)

3 5 7Sloo 86.1

5 35 IS90 5O.S

S RACHMA\ and P. DE SILLA

s3’* ‘Stop’ Reassurance

to Reassurance from

self self others Distract Escxpr .4vold Other Non?

ClInIcal (.\’ = 8) I 0 0 5 I I 0 0

Non-clinical (:V = 40) 7 5 0 12” 7 0 1 17

* Of these. 3 had other coping mechanisms as well (I ‘stop’, 2 ‘self-reassurance’) which have also been listed under these headings.

Related Unrelated Doubtful

Chnical

(IV = ?I) 6 1 0 Non-clinical

(‘L’ = JO) 17 3 20

11~ surnr~lar~. the normal and abnormal obsessions are similar in form, in expressed relation to mood, and in meaningfulness; and are fairly similar in content.

They differ in that abnormal. clinical obsessions last longer both in general and in particular, are more discomforting. more intense and more frequent. They have lower acceptability, are more alien. provoke more urges to neutralize and are more likely to be of known onset. They are more often and more strongly resisted, and are harder to dismiss.

At risk of over-generalizing, we can state that they are similar in form and content but not in frequency and intensity, or in their consequences.

Thus far we have been able to identify some quantitative differences between normal and abnormal obsessions. The presence of qualitative differences remains to be demon-

strated.

STUDY III-REPEATED-PRACTICE EFFECTS

As noted earlier, one of the main aims of the present study was to investigate the effects of repeatedly forming and holding the obsession. Due to limited time and resources. it was decided to study short-term effects only, in this preliminary study.

In order to investigate the effects of repeated formations, as an approximation to brief habituation training, subjects obtained obsessions to instruction. After the basic descriptive data were obtained and recorded. the subject was asked to produce. upon instruction, a target obsession. The details of this (latency. duration, intensity, meaning, discomfort, urge to engage in specific neutralizing ritual, effects of such activity. others) were recorded, and used as the pre-intervention baseline. Then. the subject went through three obsession-formation (habituation) trials of 4 min each, with a I-min inter-trial interval. Here the subject had to obtain the obsession upon instruction and keep it, until asked to stop at the end of the 4-min period; he/she was also instructed not to carry out any neutralizing ritual. After the three trials, a further production-on-request

.-ibnormal and normal obsesstons 245

trial was carried out. as a post-intervention trial. In both types of trials, a pre-arranged signal (raised index finger) was used for the subject to indicate to the experimenter the presence of the obsession.

Originally, it was intended to carry out the experimental trials for each subject with two target obsessions-one experimental (procedure as above). and the other, control (where. instead of the three trials, the subject would engage in a neutral activity of comparable duration between the two production-upon-instruction trials). Using a design balancing order, it was hoped that this would enable the testing of the effects of repetition against a control. Regrettably, practical obstacles prevented completion of the plan.

Some subjects. particularly in the non-clinical sampie. found it dihicult to get the obsession on request with the same quality as it would normally occur. This had the effect of lowering intensity and discomfort, mainly. Many failed to get the obsession altogether (see below). One clinical subject failed on one occasion, but was able to obtain his obsession during a second interview a few days later. In order to facilitate the production of the obsession, each subject was asked to imagine that he was in the setting and circumstances where it would normally occur, whenever this was applic- able. He was encouraged to close his eyes if he felt it would help. In a small number of cases. triggering material were provided for the subjects (knives, cutting instruments, heavy objects: newpaper reports etc.).

EXPERIMENTAL DATA: THE CLINICAL SAMPLE

AI1 8 patients were able to produce a target obsession on request. Three had neutraliz- ing rituals, which had the effect of bringing down both discomfort and urge to neutralize (Mean Discomfort: 60% down to 23%; Mean Urge: 75% to 3%, respectively in the pre-intervention trial), The rituals were: imagine being extra-nice to target person; wash hands; and say ‘I take the curse’ silently. There were similar effects in the post-interven- tion sessions (Mean Discomfort: 53% down to 13%; and Urge: 56 to 0%. respectively).

A comparison of pre- and post-intervention production trials gives an idea of the short-term effects of the repeated trials. Comparison was possible on the following par- ameters: Latency, Duration, Discomfort and Intensity. ‘Meaning’ proved to be a difficult category to assess, and the findings are therefore incomplete and omitted. Latency: In 6, latency increased, in 1 it decreased and in 1 there was no change. (Mean: pre 9 set; post 19.9 set). Duration: In 5 duration decreased, in 1 it increased and in 2 there was no change. (Mean: pre 41.5 see; post 29.9 set). Discomfort: In 6 there was a decrease, in 1 it increased, and in 1 there was no change. (Mean: pre 47.5%; post 40%). Itztrnsity: In 2 there was a decrease and in 6 no change. Srarisrical tesrs: Of the above, the first three were in quantitative form, and t tests for non-independent samples were carried out to test if the changes were significant. Laretlc~, r = 0.72, df= 7, p > 0.05, one-tailed; Duratim, t = 1.89, df = 7, p just fails to reach significance at p = 0.05 level, one tailed; Discomfort, t = 1.56, lif= 7, p > 0.05, one-tailed. Because of the small numbers, tests of significance may be misleading. How-

ever, all changes were in the expected directions: i.e. latency increased, duration de- creased, discomfort decreased, and intensity decreased, in the post-intervention trial. It must be stressed that these were only short-term effects of the repeated trials. Long- term effects were not investigated in this study. Further, there was no control procedure.

Records were also kept of the three repeated trials themselves. Latency, discomfort, urge (where relevant), intensity and meaning were recorded for each trial. In addition, the time, within the 4 min trial period, for which the obsession was present or absent was also recorded. On this information, it was possibfe to calculate for each trial the number of times the obsession ‘slipped away’, or faded, and the total time within a trial that the subject was able to keep the obsession. In addition, the longest time he was able to keep the obsession continuousIy within a triat was recorded.

Due to small numbers it was not possible to examine whether there were significant changes trial b? trial in these measures. However. inspection indicated unsystematic variation. The data indicated a trend for the obsession to become increasingly hard

to form and maintain. but firm conclusions are not narrantzd.

EXPERIMENTAL D.ATA: THE NO&-CLIVUIC.AL SAiMPLE

The data for the non-clinicaI sample of 13 subjects are given beloiv. The experimental procedure was tried on all 30 subjects who were inrerviewed. but 12 failed to obtain the obsession upon instruction. Of the others. two failed to complete the session. Data on two others had to be rejected due to faulty procedure. Of the rest. data for 9 were omitted from the analysis as the frequency of their obsessions \vas less than I per week. Of the 15 CYSTS thus left. 1 were omitted as their discomfort upon production of the obsession. ~‘as zero. This left I3 subjects in the non-clinical sample.

The di~ctilty many had in producing the obsession to request. was noted above. Even of those \vho were able to form it. most felt it \vas ‘artificial’ or -unreal’. Felt

discomfort and intensit) were thus generally low. Some found external triggers useful. Of the 13 whose data have been used in the analysis reported in the sequel. only

one had a neutralizing ritual (mentally counting calories of food taken in the day). Carrying this out led to reduction of discomfort and urge to neutralize in both pre- and post-inter~,ention trials (Discomfort: 10 --+ 0 and IO--+ 0; Urge: 60 d 0 and 60 -+ 0).

Comparison of pre- and post-intervention trials on latency, duration, discomfort and intensity provides an indication of the efYects of the repeated trials procedure. Lnter~c~,. In 9. latency increased. in 2 it decreased. and in 2 remained same. (Mean: pre 13. I5 set: post 15.05 sec.) D~~r~ltiQ~i~ In 7. duration decreased. in Z it increased. and in 4, there was no change. (Mean: pre 12.31 SK; post Ii.31 sec.)

Di.scor?ljkt: In 9. discomfort decreased, in :! it increased. and in 2 there was no change. (Mean: pre 3 I. IS”,;,; post 16.97?;.) Irl!rrlsiry: In 3 there was a decrease, in Z an increase, and in S no chanpe. (In six of these 8. no downward change was possible, as they were ‘mild’ in the pre-trial.) Sr~z~~srjcfil resr.5: r tests for non-independent samples were carried out to test the signifi- cance of the pre- post differences with regard to latency. duration and discomfort. kterlcy: r = 0.47. IY = 13. p > 0.05. one-tailed ; Discm~brt: t = I .04, df‘ = 13. p > 0.05, one-tailed.

Although the differences were not statistically significant. the changes Lvere in the expected direction, as in the clinical sample. In the case of discomfort. the initial (pre-) levels were too low to show any significant reduction.

In two subjects. the pre- post differences were consistsntly in the opposite direction

on discomfort (30- 60; 20 -+ 40). duration (30 --+ 45: 15 --) 35). and intensity (mi --t mo;

mo--+ hi). On latency. one showed shorter latency while the other remained the same. Both these subjects verbally reported that the exposure to the obsession in the three 4-min periods of the repeated practice trials made the obsession affect them more. This “sensitizing” effect was not observed in any of the other subjects. clinical or non-clinical.

Records of the changes occurring during repeated practice were kept for the non-clini- cal sample as well. They showed unsystematic variations, with some tendency for in- creased latency (i.e. harder to get), decreased total time of obsession. and longest time obsession held, and increased number of ‘slippages’ (i.e. harder to maintain), and de- creased discomfort. The data do not warrant further analysis.

To summarize. the results of the experimental study are consistent with the hypothesis that obsessions are subject to an habituation process. The data are of course insufficient but as far as they go. they follow the predicted pattern. With repeated practice. the latency to form the obsession increases. Also, the duration decreases, and similarly the attendant discomfort decreases. Perhaps most telling of all if it can be confirmed with more practice triais. the intensity of the obsession may decrease-our data are uncon- vincing on this point.

On all of these measures. the effects of repeated practice are in line with an habituation process: moreover, we found a similar pattern for normal and abnormal obsessions. It will be recalled that in the original statement of the theory (Rachman. 1971) it was

postulated that abnormal obsessions present a problem because of their failure to habi- tuate satisfactorily. A continuation of the present line of investigation will enable us to test this postulate directly. It is also worth noticing that in part 2 of the present studies, we obtained information suggestin g that partial habituation had already taken

place in some instances-the subjects had become ‘accustomed’ to their obsessions and were less disturbed by them.

We are unsure why the non-clinical subjects found it harder to form their obsessions to instruction than did the patients. Presumably, the intensity and frequency of their past obsessional experiences enables the patients to re-form or recall the material more easily-practice makes near-perfect. In a sense, this is a paradoxical finding. Here we have an example in which obsessional patients demonstrate a greater degree of control over their intrusive thoughts than do the non-clinical subjects.

If the habituation model is to be developed, we need confirmation on several points. It has to be shown that the obsession weakens with repeated practice i.e. that it decreases in intensity and duration. and increases in latency. Further. this process should be

facilitated by low arousal, stable mood. long presentations and frequent repetitions. The ensuing reductions will recover. in part at least, after an adequate rest period. Sensitization presumably occurs if the obsessional material has special significance for the person. if repetitions are limited, if they are too brief, if the person is overly aroused or experiencing an adverse mood.

CONCLUSIONS

Notwithstanding the exploratory nature of these 3 studies, some tentative conclusions are permissible. The need for replications and development of the studies is obvious.

I. Obsessions, in the form of thoughts and/or impulses, are a common experience. A large majority of people report experiencing obsessions; it is unknown why the small minority fail to do so. There are no age or sex-related differences in occurrence.

2. The form. and to some extent the content as well, of obsessions reported by non-psy- chiatric respondents and by obsessional patients are similar.

3. So-called ‘normal’ obsessions are also similar to ‘abnormal’ obsessions in their expressed relation to mood and in their meaningfulness to the respondent.

4. Despite some similarities of form and content, normal and abnormal obsessions differ in these respects:

(a) The threshold of acceptibility is higher for abnormal obsessions. (b) Normal obsessions are easier to dismiss.

(c) Abnormal obsessions last longer-overall, and in particular instances. (d) Abnormal obsessions are more intense. (e) And produce more discomfort. (f) They are more frequent. (g) They are more ego-alien. (h) They are more strongly resisted. (i) They are more likely to be of known onset. (j) They provoke more urges to neutralize. Broadly speaking, normal and abnormal obsessions are similar in form and content,

but differ in frequency, intensity and in their consequences. 5. (a) Obsessional patients are more likely to have multiple obsessions, and are

(b) more likely to exhibit associated compulsions. 6. The execution of neutralizing behaviour, overt or covert, reduces discomfort and

urges in both clinical and non-clinical subjects. 7. IMost obsessional patients can form their obsessions to instruction; a large number

of non-clinical subjects are unable to do so. 7. (a) The obsessions were formed within less than a minute, in both groups.

243 S R~CHMA> and P. DE SILVS

Y. The obsession produces discomfort: the level is greater in the abnormal instances than in the normal ones.

9. Overall. abnormal obsessions formed to instruction are moderately intense, normal ones are of mild intensity.

10. With repeated trials of 4-min duration. the following (statistically non-significant)

but predicted, short-term changes were observed: (a) The latency to obsession formation increases. (b) The duration of the obsession decreases. (c) The accompanying discomfort decreases. (d) The intensity of the obsession may decrease.

I 1. There was evidence. in 2 of our non-clinical subjects. of sensitization rather than

habituation. It can fairly he stated that these findings are generally consistent with the theory.

but some unexplained pieces must be noted. We cannot explain at present. why some people apparently do not experience obsessions. Nor do we know why non-clinical subjects find it more difhcult to form their obsessions.

The findings relative to the habituation postulates of the theory are re-assuring but wholly insufficient at present. Experimental analyses of the effects (short- and long-term) of habituation training on normal and abnormal obsessions. are essential before this part of the theory can develop.

.-l~~Jlor~/rdyl~1~l~~~lr.s- This research was supported in part by a grant from the M.R.C. We gratefully acknowl-

edge the helpful suggestions oHered by many colleagues. includln g V. de Silva. C. Philips, H. Shackleton

and L. Porklnson.

REFERENCES

RACHLIAN S. (1971) Obsessional ruminations. Brhar. Rrs. Thur. 9. ??!?-?_;j. RACHUAN S. (1977) The modification of obsessions: A new formulation. B&K. Rrs. The-. 14. 43743.

RACHVAN S. (lY7Y) An anatomy of obsessions. Brhrrr. ._(M/. ,\/otlrf:. in press. RACHUAN S. and Hwcso~ R. (1978) 0h.ww~ur1.s UI[/ Cwrrprrlsio~~s. In press. Prentice Hall. Neti Jersey.