Journal of Child Psychology and Psychiatry 45:6 (2004), pp 1076–1084
Cognitive appraisals in young people
with obsessive-compulsive disorder
Sarah Libby,1 Shirley Reynolds,2 Jo Derisley,3 and Sarah Clark2
1
United Bristol Healthcare Trust, UK; 2University of East Anglia, UK; 3Norfolk Mental Health Care Trust, Bethel Child
and Family Centre, UK
Background: A number of cognitive appraisals have been identified as important in the manifestation
of obsessive-compulsive disorder (OCD) in adults. There have, however, been few attempts to explore
these cognitive appraisals in clinical groups of young people. Method: This study compared young
people aged between 11 and 18 years with OCD (N ¼ 28), young people with other types of anxiety
disorders (N ¼ 28) and a non-clinical group (N ¼ 62) on three questionnaire measures of cognitive
appraisals. These were inflated responsibility (Responsibility Attitude Scale; Salkovskis et al., 2000),
thought–action fusion – likelihood other (Thought–Action Fusion Scale; Shafran, Thordarson & Rachman, 1996) and perfectionism (Multidimensional Perfectionism Scale; Frost, Marten, Luhart &
Rosenblate, 1990). Results: The young people with OCD had significantly higher scores on inflated
responsibility, thought–action fusion – (likelihood other), and one aspect of perfectionism, concern over
mistakes, than the other groups. In addition, inflated responsibility independently predicted OCD
symptom severity. Conclusions: The results generally support a downward extension of the cognitive
appraisals held by adults with OCD to young people with the disorder. Some of the results, however,
raise issues about potential developmental shifts in cognitive appraisals. The findings are discussed in
relation to implications for the cognitive model of OCD and cognitive behavioural therapy for young
people with OCD. Keywords: Cognitive models, inflated responsibility, obsessive-compulsive disorder,
perfectionism, thought–action fusion. Abbreviations: ADIS-C: Anxiety Disorders Interview Schedule
for Children; ADIS-P: Anxiety Disorders Interview Schedule for Parents; E/RP: Exposure/Response
Prevention; LOI-CV: Leyton Obsessional Inventory – Child Version; MPS: Multidimensional Perfectionism Scale; OCD: Obsessive-Compulsive Disorder; RAS: Responsibility Attitude Scale; TAF-LO:
Thought–Action Fusion – (Likelihood Other).
Over recent years there have been proposals that
specific cognitions are associated with ObsessiveCompulsive Disorder (OCD) in adults (e.g., Obsessive-Compulsive Cognitions Working Group, 1997;
Salkovskis, Forrester, & Richards, 1998; Steketee,
Frost, Rhéaume, & Wilhelm, 1998) and mounting
evidence to support this (e.g., Frost & Steketee,
1997; Salkovskis et al., 2000; Shafran et al., 1996).
Evaluating whether or not young people with OCD
have similar cognitive appraisals could help inform
debates on differences and similarities between OCD
in childhood and adulthood. Although cognitive
abilities continue to develop through childhood and
adolescence (Kail & Bisanz, 1991; Kuhn, Amsel, &
O’Loughlin, 1988), studies with non-clinical samples
suggest that young people hold similar cognitive
appraisals about anxiety as adults (Chorpita,
Albano, & Barlow, 1996; Hadwin, Frost, French, &
Richards, 1997). Nevertheless, studies have rarely
included young people who meet diagnostic criteria
for anxiety disorders.
OCD was once thought to be rare in young people;
however, it has now been established that OCD in
children and adolescents is broadly similar in prevalence and symptomatology when compared to
adults with the disorder. Lifetime prevalence is estimated at 3% for young people (Valleni-Basille et al.,
1994) and 2.5% for adults (Karno, Golding, Sorenson,
& Burnham, 1988). Between half and three-quarters
of adults with OCD identify the onset of their symptoms before the age of 18 years (Pauls, Alsobrook,
Goodman, Rasmussen, & Leckman, 1995; Rasmussen & Eisen, 1990). OCD is characterised by recurrent, intrusive and distressing thoughts or
images (obsessions) that are typically ego-dystonic,
going against the value system of the individual.
Obsessional thoughts are usually confined to fears of
contamination, fear of harm to self or others, sexual
themes, aggressive thoughts, religiosity, scrupulosity and urge for symmetry or exactness (Swedo,
Rapoport, Leonard, & Lenane, 1989). Compulsions
are completed in an attempt to alleviate the distress
generated by the obsessional thoughts. They are
most commonly washing or checking (Riddle et al.,
1990; Swedo et al., 1989), but can also present as
repeating, touching, counting, ordering and hoarding.
Behaviour therapy comprising Exposure/Response prevention (E/RP) is currently the dominant
therapeutic approach for young people with OCD
(March, 1995). This approach uses graded exposure
to the actual or imagined obsessional fear whilst
resisting the urge to complete a ritual. E/RP is
reported to be helpful for approximately 60% of
young people with OCD (De Haan, Hoogduin,
Buitelaar, & Keijsers, 1998), but as many as a third
Ó Association for Child Psychology and Psychiatry, 2004.
Published by Blackwell Publishing, 9600 Garsington Road, Oxford OX4 2DQ, UK and 350 Main Street, Malden, MA 02148, USA
Cognitive appraisals in OCD
drop out of this treatment (Allsopp & Verduyn,
1990). Furthermore, long-term follow-up studies of
young people with OCD indicate that it is one of the
most intractable anxiety disorders, with approximately 50% having persistent difficulties even with
therapeutic input (Bolton, Luckie, & Steinberg,
1995; Flament et al., 1990).
It has been demonstrated that most adults
experience intrusive thoughts and these are similar
in content to those reported by individuals with OCD
(Salkovskis & Harrison, 1984). It is hypothesised
that for those who develop OCD it is the appraisal of
these thoughts, rather than the thoughts per se, that
causes distress. This has led to the proposal that
certain cognitive appraisals are central to the development and maintenance of the disorder (Salkovskis
et al., 1998; Steketee et al., 1998) and need to be
addressed within therapy.
There is a growing evidence base that cognitive
therapy is more effective than E/RP with adults (Van
Oppen et al., 1995), although when administered in
a group format E/RP has been found to be superior
to cognitive therapy alone (McLean et al., 2001).
There have been a few case studies indicating that
these cognitive techniques can also be applied
effectively with adolescents (Shafran & Somers,
1998; Williams, Salkovskis, Forrester, & Allsopp,
2002). These are promising findings but at present
there is no direct evidence that the cognitions associated with OCD in adults are also widely held by
young people with OCD.
A number of cognitive appraisals have been proposed as critical in OCD. Obsessive Compulsive
Working Group (1997) suggest that beliefs pertaining
to (1) inflated responsibility, (2) overimportance of
thoughts, (3) excessive concern about the importance
of controlling one’s thoughts, (4) overestimation of
threat, (5) intolerance of uncertainty and (6) perfectionism are implicated. To date, the most empirical
evidence has been found for inflated responsibility,
overimportance of thoughts and perfectionism and
these are evaluated in the current study.
Salkovskis (1989) suggested that individuals with
OCD experience excessive responsibility for intrusive
thoughts and external events and believe they could
be accountable for the perceived consequence. This
leads to distress and attempts to neutralise the
intrusive thoughts by completing compulsive behaviour. Evidence for inflated responsibility relating to
OCD comes primarily from experimental studies
(Ladouceur et al., 1995; Ladouceur, Rhéaume, &
Aublet, 1997) and questionnaires with non-clinical
samples (Rhéaume, Ladouceur, Freeston, & Letarte,
1994; Wilson & Chambless, 1999). Salkovskis et al.
(2000) is the only published study to compare clinical groups. They used the Responsibility Attitude
Scale (RAS) to measure belief about responsibility.
Adults with OCD had significantly higher scores on
this measure when compared to individuals with
other anxiety problems and a non-clinical group.
1077
Although Salkovskis, Shafran, Rachman, and Freeston (1999) hypothesise that these beliefs emerge
from childhood experiences, this has not yet been
evaluated empirically.
Overestimating the importance of thoughts also
appears to be critical in the presentation of OCD
(Rachman, 1997). The specific error of equating an
intrusive thought as increasing the likelihood of an
event occurring to significant others, for example ‘if I
think of a relative falling ill this increases the risk
that he/she will fall ill’ is defined as Thought–Action
Fusion – (Likelihood Other) (TAF-LO) (Shafran et al.,
1996). Shafran et al. (1996) found that individuals
with OCD had significantly higher scores on TAF-LO
when compared to a student population and a
community sample. Rassin, Merckelbach, Muris,
and Schmidt (2001), however, found no difference
between scores on TAF-LO in a group with OCD and
a group with other anxiety disorders. More recently,
Muris, Meesters, Rassin, Merckelbach, and Campbell (2001) developed a measure of thought–action
fusion for adolescents and also found that it was
correlated with anxiety and depression symptoms as
well as OCD in a non-clinical sample. So, although
TAF-LO is associated with obsessive-compulsive
behaviours, it may also be found in other disorders.
The other type of cognitive appraisal that has been
found to be elevated in adults with OCD is perfectionism. Perfectionism is often defined as striving for
high standards of performance that are accompanied
by overly critical evaluations (Antony, Purdon, Huta,
& Swinson, 1998). It is underpinned by the belief
that a perfect state exists and that one should always
try to attain this (Pacht, 1984). Research with adults
has predominantly used the Multidimensional Perfectionism Scale (MPS, Frost et al., 1990). The MPS
identifies six factors, (a) perceiving high parental
expectations, (b) perceiving parents as overly critical,
(c) negative reaction to mistakes, (d) setting high
personal standards, (e) doubting the quality of one’s
actions and (f) emphasising the importance of
organisation. The doubts about action subscale is
confounded with OCD symptoms because these
items are taken from the Maudsley Obsessional
Compulsive Inventory (Hodgson & Rachman, 1977),
so this subscale does not reveal meaningful cognitive
appraisals (Shafran & Mansell, 2001) and will not be
considered here.
Frost and Steketee (1997) found that a group of
individuals with OCD had higher total perfectionism
scores and concern over mistakes scores on the MPS
than a non-clinical group but were not distinguishable from a group with panic disorder. Antony et al.
(1998) compared a group of adults with OCD to
individuals with panic disorder, social phobia, specific phobia and non-clinical controls. They also
found that those with OCD did not differ from the
other clinical groups on the other dimensions. All
groups with anxiety disorders were significantly
higher on concern over mistakes compared to the
1078
Sarah Libby et al.
non-clinical controls. In non-clinical samples concern over mistakes is related to sub-clinical obsessive-compulsive symptoms (Frost et al., 1990; Frost,
Steketee, Cohn, & Griess, 1994). So, concern over
mistakes appears to be the critical factor in distinguishing non-anxious and anxious individuals.
Parental criticism has also been found to be higher in
adults with anxiety disorders compared to nonclinical groups (Antony et al., 1998; Frost & Steketee, 1997; Saboonchi, Lundh, & Öst, 1999),
although it has not been found to be associated with
OCD.
In summary, studies using self-report questionnaires with adults indicate that cognitive appraisals associated with inflated responsibility are
unique to individuals with OCD. Thought–action
fusion – likelihood other and concern over mistakes
may also be important in our understanding of OCD
but are also held by adults with other anxiety disorders. Theorists have proposed that these cognitive
appraisals emerge in childhood (Salkovskis et al.,
1999), yet there have been few attempts to evaluate
this empirically. This study used the measures of
inflated responsibility (RAS, Salkovskis et al., 2000),
thought–action fusion – (likelihood other) (TAF-LO,
Shafran et al., 1996) and perfectionism (MPS, Frost
et al., 1990) to evaluate cognitive appraisals in young
people with OCD, young people with other anxiety
problems and a non-clinical group of 11- to 18-yearolds. Although adapted measures of thought–action
fusion (Muris et al., 2001) and inflated responsibility
(Williams, personal communication) are being
developed specifically for adolescents, these were not
available at the outset of this project. The study’s
principal aim was to investigate whether the same
pattern of cognitive appraisals found in studies with
adults will be observed in this younger population. A
secondary aim of the study is to establish the relationship between cognitive appraisals and the extent
these predict obsessive-compulsive symptoms.
had OCD, 28 had other anxiety disorders and 62 were
in a non-clinical group. The non-clinical group were
recruited from a High School in the UK. The clinical
groups were recruited by clinicians from a number of
Child and Adolescent Mental Health Services in the east
of England.
Parents of young people in the non-clinical group
were asked to report if their child had previous or
current problems with anxiety and whether or not they
had consulted a professional about these problems.
Eight families reported problems with anxiety but none
had sought help from a professional and remained in
the sample as they were classed as non-clinical. One
young person was excluded from the non-clinical
group because of a score on the Leyton Obsessional
Inventory – Child Version (LOI-CV, Berg, Whitaker,
Davies, Flament, & Rapoport, 1988) that was in
the clinical range according to criteria laid down by
Flament et al. (1988).
Diagnostic status for the clinical groups was established using two parallel versions of a structured
interview for young people and parents. The Anxiety
Disorders Interview Schedule for Children and Parents
(ADIS-C and ADIS-P, Silverman & Albano, 1996)
applies DSM-IV criteria (American Psychiatric Association, 1994) to diagnose anxiety disorder in children
aged between 6 and 18 years. For the purposes of this
study, only the sections pertinent to the diagnoses for
inclusion were used. If a young person met criteria for
more than one diagnoses the primary diagnosis was
established by considering which produced the most
distress from symptoms and the greatest interference in
the young person’s life. The diagnoses for the group
with anxiety disorder were separation anxiety (N ¼ 4),
generalised anxiety disorder (N ¼ 6), panic disorder
with agoraphobia (N ¼ 8) and social phobia (N ¼ 10). All
young people in the OCD group met criteria for the
disorder according to the ADIS. The level of comorbidity
with other anxiety disorders was high, with all the
young people in the anxious group meeting criteria for
more than one diagnosis and all but two cases (93%)
with OCD meeting criteria for more than one diagnosis.
The comorbidity across the anxiety disorders is displayed in Table 1. Young people were excluded if the
referring clinician had diagnosed Asperger’s syndrome,
psychosis or drug abuse. Individuals who had comorbidity with other diagnoses (e.g., depression), according
to clinician reports, remained in the sample.
Participants were not excluded if they were on medication for their anxiety symptoms. In the OCD group 17
(60.7%) young people were taking medication and in the
Method
Participants
Three groups of young people aged between 11 and
18 years old were recruited for this study. Twenty-eight
Table 1 Comorbid diagnoses of the participants in the clinical groups
Comorbid diagnoses
Primary diagnosis
OCD
Separation anxiety
Social anxiety
Panic disorder & agoraphobia
Generalised anxiety disorder (GAD)
Separation
anxiety
Social
anxiety
Panic
agoraphobia
GAD
N
N
%
N
%
N
%
N
%
28
4
10
8
6
13
–
2
2
1
50.0%
–
20.0%
25.0%
16.7%
14
2
–
6
3
50.0%
50.0%
–
75.0%
50.0%
3
2
6
–
3
10.7%
50.0%
60.0%
–
50.0%
20
2
7
6
–
71.4%
50.0%
70.0%
75.0%
–
Cognitive appraisals in OCD
anxious group 12 (42.8%) young people were taking
medication.
The mean age in years of the participants in the three
groups (OCD, M ¼ 14;08, SD ¼ 1;10; Anxious, M ¼
14;09, SD ¼ 1;10; Non-clinical, M ¼ 14;08, SD ¼ 1;08)
did not differ significantly (F(2, 115) ¼ .04, p ¼ .96).
The gender ratio for the three groups (male:female, OCD
12:16; Anxious 6:22; Non-clinical 31:31) was significantly different (v2(2) ¼ 6.51, Fisher’s exact test p ¼ .04).
The anxious group had significantly more girls than the
other two groups.
Measures
Leyton Obsessional Inventory – Child Version
(Berg et al., 1988). The revised Leyton Obsessional
Inventory – Child Version (LOI-CV) was used to measure
the severity of OCD symptoms. It is a 20-item self-report
measure with yes/no ratings; if a yes rating is given it is
then ranked for level of interference in daily life on a fourpoint scale. LOI-CV is not a diagnostic tool but a yes
score greater than 15 and an interference score greater
than 25 have been used as indicative of obsessivecompulsive psychopathology in previous studies (e.g.,
Flament et al., 1988). The LOI-CV has acceptable sensitivity but poor specificity (Flament et al., 1988). The
total scale has a Cronbach’s a of .82 (Berg et al., 1988).
Responsibility Attitude Scale (Salkovskis et al.,
2000). The Responsibility Attitude Scale (RAS) reflects
general beliefs that would predispose for inflated
responsibility. It is the only measure of inflated
responsibility that has been used with clinical groups of
adults. The RAS is a 26-item questionnaire where
individuals rate a series of statements such as ‘I often
feel responsible for things which go wrong’ on a 7-point
scale.
The RAS has good test–retest reliability (k ¼ .94) and
high internal consistency (a ¼ .92) (Salkovskis et al.,
2000). Some wording was changed from the original
version to make it suitable for a younger population.
There were four changes: question 2 ‘see danger coming’ replaced ‘foresee danger’, question 14 ‘punished’
replaced ‘condemned’, question 17 ‘unforgivable’ replaced ‘inexcusable’ and question 18 ‘actions’ replaced
‘intentions’.
Thought–Action Fusion Scale (Shafran et al.,
1996). The TAF has three subscales, Moral TAF, TAF(likelihood other) and TAF-(likelihood self). Only the
TAF-(likelihood other) subsection (TAF-LO) has been
found to be associated with OCD in adults (Shafran
et al., 1996) and was the only subsection used in this
study. This comprises four questions that evaluate the
extent negative thoughts are believed to have consequences for other people (e.g., If I think of a friend/
relative falling ill, this increases the risk that he/she
will fall ill). Items are rated on a five-point scale. Internal
consistency for TAF-LO is good, ranging from a’s of .93–
.96 depending on the population sampled (Shafran
et al., 1996).
Multidimensional Perfectionism Scale (Frost et al.,
1990). The Multidimensional Perfectionism Scale
1079
(MPS) has previously been used with adults with OCD
(Antony et al., 1998; Frost & Steketee, 1997) and a
non-clinical sample of 10- to 12-year-olds (Stumpf &
Parker, 2000). The MPS is a 35-item questionnaire
which asks participants to rate statements on a fivepoint scale. It has six subscales that reflect concern
over mistakes, personal standards, parental expectations, parental criticism, doubts about actions and
organisation. All subscales have an internal consistency alpha value greater than .77 (Frost et al.,
1990). The subscale Doubts about Action was not
evaluated in this study because it is confounded with
OCD symptoms (Shafran & Mansell, 2001). Wording
was changed from the original so questions referring to
parents were in the present tense (e.g., my parents
want me to be the best at everything) rather than the
past tense (e.g., my parents wanted me to be the best
at everything).
Procedure
Clinical group. Families in this group were given information packs about the project by their clinician
and returned consent forms to the researchers if they
were interested in participating. The young person and
parents were then interviewed by one of the authors
either in the clinic or in the family’s home. The young
person was always interviewed first with the ADIS-C
followed by the parent using the ADIS-P. While the
parent was being interviewed the young person completed the four questionnaire measures. The questionnaires were presented in a booklet and always
completed in the same order, MPS, TAF-LO, RAS and
LOI-CV.
Non-clinical group. Two hundred and fifty names were
selected randomly from the school register and sent
information packs about the project. Consent forms
were returned to the researchers and the questionnaires were then posted to the young people to be
completed. Eighty-eight families (35.2%) consented to
participate and were sent the questionnaires to complete; 63 returned the questionnaires; this is 71.6% of
those sent the questionnaires and 25.2% of all the
families invited.
As most of these questionnaires had not been used
with young people before, the participants were asked
to place a star by any questions they failed to understand. Using a conservative measure including stars
and items missed out, this occurred in 17 young people
(14.4%). Forty-six questions in total were not answered,
which is less than 1% of the total number of questions
posed.
Results
Internal consistency of questionnaires
As many of the questionnaires had not been used
with this age group previously, internal consistency
for each of the questionnaires and their subscales
was measured using Cronbach a. These data are
presented in Table 2. All had acceptable internal
consistency ranging from .79 to .96.
1080
Sarah Libby et al.
Table 2 Internal consistency and comparison of the groups on item means for each of the questionnaire measures
OCD(N ¼ 28)
M
Cronbach a
Leyton yes/no
Leyton interference
Responsibility Attitude Scale
Thought Action Fusion – Likelihood Other1
Multidimensional Perfectionism Scale
(Concern over Mistakes)
Multidimensional Perfectionism Scale
(Personal Standards)
Multidimensional Perfectionism Scale
(Parental Expectations)
Multidimensional Perfectionism Scale
(Parental Criticism)
Multidimensional Perfectionism Scale
(Organisation)
SD
a
Anxious
(N ¼ 28)
M
SD
b
.88
.93
.95
.96
.91
.75
1.33a
4.75a
1.96a
2.59a
.83
3.07
.79
2.75
.79
.83
2.13a
.75
2.28
1.01
.79
1.91
.80
2.07
.90
3.48
.88
3.02
.22
.79
1.25
1.29
.96
.47
.54b
3.88b
1.01b
2.41
.24
.35
.98
1.04
.92
Non-clinical
(N ¼ 62)
M
SD
b
.39
.27b
3.57b
.56c
2.04b
.39
.31
.94
1.04
.66
F(2,115) ¼ 27.93**
F(2,115) ¼ 48.45**
F(2,115) ¼ 12.68**
H(2, 115) ¼ 24.75**
F(2,115) ¼ 4.71**
2.99
.73
F(2, 115) ¼ 1.16
2.62b
.84
F(2, 115) ¼ 3.75*
.74
2.00
.81
F(2, 115) ¼ .23
.83
3.42
.83
F(2, 115) ¼ 2.24
Different superscripts indicate significant differences between the groups.
*Significant at p < .05.
**Significant at p < .01.
All analyses were based on one-way ANOVAs and post-hoc Scheffé tests except1 where Kruskal–Wallis and Mann–Whitney U tests
were used because the data was not normally distributed.
Group comparisons
Table 2 also presents the mean item scores for the
measures used in the study. Item means are used so
participants who missed a question could be included in all the analyses. Using a one-way ANOVA
and post-hoc Scheffé tests, the OCD group had significantly higher item means on the LOI-CV yes/no
ratings (F(2, 115) ¼ 27.93, p < .01) than the anxious
group (p < .01) and the non-clinical group (p < .01).
The OCD group also had higher mean item scores on
the LOI-CV interference scale (F(2, 115) ¼ 48.45,
p ¼ .01) than the anxious group (p < .01) and the
non-clinical group (p < .01).
The results of a one-way ANOVA and post-hoc
Scheffé tests revealed a significant difference between groups on the RAS (F(2, 115) ¼ 12.68,
p < .01), with the young people in the OCD group
scoring significantly higher than the anxious group
(p < .01) and the non-clinical group (p < .01). Scores
on the TAF-LO were not normally distributed and
could not be transformed; a Kruskal–Wallis H test
was significant (H(2,115) ¼ 24.75, p < .01). Mann–
Whitney U tests identified significant differences
between the OCD and anxious group (z(56) ¼
)2.57, p ¼ .01) and the OCD and non-clinical group
(z(90) ¼ )1.82, p < .01). The anxious group also
had significantly higher scores than the non-clinical
group (z(90) ¼ )2.32, p ¼ .02). On the MPS the only
subscales that had significant differences were the
concern over mistakes subscale (F(2, 115) 4.71,
p ¼ .01) and the parental expectations subscale
(F(2, 115) ¼ 3.75, p ¼ .03). On the concern over
mistakes subscale the OCD group scored significantly higher than the non-clinical group (p ¼ .02)
but not the anxious group. On the parental expectations subscale the non-clinical group scored sig-
nificantly higher than the OCD group (p ¼ .05) but
did not differ significantly from the anxious group.
The groups did not differ on the Parental Criticism
subscale as predicted from studies with adults.
Relationship between variables
Correlations between the measures are presented in
Table 3. There are modest correlations between the
variables that were found to distinguish the OCD
group. These variables also correlate with LOI-CV
yes/no. Personal Standards (MPS-PS) and Organisation (MPS-O) also had low correlations with this
measure of OCD.
Regression analysis
A standard multiple regression with simultaneous
entry was conducted with RAS, TAF-LO and MPSCM as predictors for obsessive-compulsive symptoms (LOI-CV yes/no). The data from all participants
was used (N ¼ 118). As TAF-LO was not normally
distributed and could not be transformed, the
variable was dichotomised as recommended by
Tabachnick and Fidell (1996). The sample was divided into those who rated all questions on this
measure as ‘strongly disagree’ (0) and those who
rated one or more questions as ‘slightly disagree’ (1),
‘neutral’ (2), ‘slightly agree’ (3) or ‘strongly agree’ (4).
As there were many individuals who rated all questions as 0 on this measure (43.2%), this seemed the
most meaningful dichotomisation. The model had an
R2 of .39 (F(3, 114) ¼ 23.85, p < .01); only RAS made
a significant contribution to symptom severity,
although Concern over Mistakes approaches significance (see Table 4).
Cognitive appraisals in OCD
1081
Table 3 Correlations between measures for all three groups combined
LOI-CV
yes/no
RAS
TAF-LOa
MPS-CM
MPS-PS
MPS-PC
MPS-PE
RAS
TAF-LOa
MPS-CM
MPS-PS
MPS-PC
.58**
.51**
.49**
.31**
.14
–
–
–
–
–
–
.57**
–
–
–
–
–
.65**
.47**
–
–
–
–
.46**
.28*
.60**
.25*
.22*
.39**
–.01
–
–
–
–
MPS-PE
.04
.15
.08
.35*
.20*
.75**
–
MPS-O
.31**
.15
).06
.03
.36**
).24*
).14a
*Significant at 0.05 level.
**Significant at 0.01 level.
a
Correlations with TAF-LO were calculated using Spearman’s rho Correlation Coefficient. All other correlations were calculated
using Pearson’s Product Moment Correlation Coefficient.
Abbreviations:
LOI-CV yes/no (Leyton Obsessional Inventory – Child Version yes/no rating).
RAS (Responsibility Attitude Scale).
TAF-LO (Thought–Action Fusion – Likelihood Other).
MPS (Multidimensional Perfectionism Scale).
CM (Concern Over Mistakes).
PS (Personal Standards).
PC (Parental Criticism).
PE (Parental Expectations).
Table 4 Multiple regression on RAS, TAF-LO and MPS-CM
predicting LOI-CV Yes / no scores
Independent variables
Responsibility Attitude Scale
Thought–Action Fusion –
Likelihood Other
Multidimensional Perfectionism
Scale (Concern Over Mistakes)
b
t
p
Partial r
.49
.13
4.76
1.36
<.01
.18
.41
.13
.06
.76
.45
.07
(R2 of .39 (F(3, 114) ¼ 23.85, p < .01).
Discussion
The results of this study demonstrate that young
people with OCD have higher levels of inflated
responsibility than young people with other anxiety
disorders and a non-clinical group. In addition,
inflated responsibility was the only significant predictor of OCD. These results map on to the findings
with adults and the mean scores obtained in this
study for the three groups are very close to those
reported for adults (Salkovskis et al., 2000). The
findings support Salkovskis et al.’s (1999) proposition that inflated responsibility is associated with
OCD in young people. It remains to be established if
cognitions associated with inflated responsibility
precede the development of OCD, as predicted by
Salkovksis et al. (1999), or emerge following the
onset and only have a maintaining role.
Some recent studies have found thought–action
fusion to be associated with other anxiety symptoms
as well as OCD (Muris et al., 2001; Rassin et al.,
2001). This study, however, found that TAF-LO was
significantly higher in the OCD group compared with
the anxious group and the non-clinical group, suggesting a specific association. The anxious group,
however, had scores that were significantly higher
than the non-clinical group and this may indicate
that TAF-LO has a minor role in anxiety disorders in
young people. It is of interest to note that the mean
total score obtained by the OCD group in this study
(M ¼ 7.82) was higher than that observed in studies
with adults who have OCD (e.g., Rassin et al., 2001,
M ¼ 4.43; Shafran et al., 1996, M ¼ 4.77). Scores for
the anxious group were broadly similar to the scores
obtained in studies with adults (Rassin et al., 2001;
Shafran et al., 1996). The non-clinical group’s total
score (M ¼ 2.25) was similar to scores reported by
Shafran et al. (1996) for students (M ¼ 2.59) but
higher than scores found for a general non-clinical
population (M ¼ 1.03). The findings suggest that
TAF-LO may be more important in the presentation
of OCD in young people and may be more prevalent
in young people generally. This difference may reflect
developmental influences. For example, it may be
associated with the emergence of formal operational
thinking at the age of 11 years which is characterised by abstract reasoning, hypothetical deduction
and metacognition, including the ability to reflect on
one’s own thinking (Inhelder & Piaget, 1958). Elkind
(1967) has argued that the emergence of formal operations results in young people believing that they
are the focus of others’ attention and that they are
unique and omnipotent. This cognitive backdrop
may make young people more likely to report
thought–action fusion. Thought–action fusion has
also been associated with a greater sense of uncertainty (Keinan, 1994). Uncertainty is inevitable for
adolescents and young adults and may help explain
some of these data.
On the MPS, concern over mistakes was the only
subsection that was significantly higher for the OCD
group compared to the non-clinical group. The
1082
Sarah Libby et al.
scores obtained by the anxious group fell between
the two other groups, but did not differ significantly
from either. Studies with adults have found concern
over mistakes to be high in individuals with OCD and
in those with other anxiety problems (Antony et al.,
1998; Frost & Steketee, 1997). The difference in this
study appears to relate to the anxious group attaining lower scores than studies with adults with panic
disorder (Antony et al., 1998; Frost & Steketee,
1997) or social phobia (Antony et al. 1998; Saboonchi et al., 1999). The OCD group and the non-clinical
group had scores that were comparable to those
observed in adult studies. This is an interesting
finding but is not easily explained. There may be
specific developmental shifts associated with the
presentation of anxiety or the findings may be related to some aspect of the study’s design; further
investigation is required. Concern over mistakes
could link to inflated responsibility and thought–
action fusion because all are associated with a fear of
being judged by others or having intolerable anxiety
if they make an error.
Parental criticism was not significantly higher in
the clinical groups as predicted from studies with
adults and parental expectation was significantly
lower in the OCD group compared with the nonclinical group. The cognitive model emphasises the
importance of belief systems about parents being
important in the development of disorders (Beck,
1976) but there is no evidence for this in this study.
The difference in the findings here compared to the
adult literature could be accounted by a number of
factors. Adults with anxiety disorders may only perceive their parents as critical retrospectively but
these beliefs may not have existed or been accessible
at the conscious level when they were children.
Alternatively, there may have been a selection bias
against young people who had these beliefs about
their parents, with these families choosing not to
take part in the study.
The findings broadly replicate studies with adults
who have OCD, suggesting that there is continuity in
these cognitive appraisals from adolescence to
adulthood. There are, however, some interesting
differences in the extent to which some of these beliefs are held. Further studies are required that directly compare individuals at different points across
the lifespan or collect longitudinal data. These data
could enrich cognitive models by providing a developmental perspective on risk factors for specific
cognitions.
The study demonstrates that these questionnaires
are valid when used with young people and may be
helpful in assessment and evaluating change in
therapy. The findings support the incorporation of
cognitive techniques in the treatment of young
people with OCD. These may include the use of
responsibility pie charts (van Oppen & Arntz, 1994),
thought–action defusion (Wells, 1997) and normalisation of intrusive thoughts (Freeston et al., 1996)
as a precursor or adjunct to E/RP. Using generic
cognitive techniques to address concern over mistakes is also likely to be important with some individuals. Within E/RP it is also important that the
therapist remains aware of whether or not the child
is passing their sense of responsibility to the therapist or a parent in order to complete tasks. If this is
occurring it will prevent behavioural tasks resulting
in any cognitive change and is likely to compromise
improvements in symptoms. Consideration of the
other belief domains highlighted by the Obsessive
Cognitions Working Group (1997) would be of
interest in future studies. Further case studies with
young people that expand on the work completed by
Williams et al. (2002) and Shafran and Somers
(1998) is an important next step. Randomised control trials are also critical to evaluate if the cognitive
component adds to the efficacy of treatment as has
been found in adults (McLean et al., 2001; Van
Oppen et al., 1995).
The current study is limited by a number of factors. Like many questionnaire studies, only a
proportion of families asked to participate agreed, so
the participants may not be representative of the
sampled population. It is impossible to know if the
children who decided to participate had different
profiles from those who did not. The OCD group was
treated as homogenous and there was no attempt to
evaluate tic disorders that may be related to a distinctive subgroup in children (Eichstedt & Arnold,
2001). The anxious group was also treated as
homogenous, although adult studies have found
differences in cognitive appraisals associated with
specific disorders. The study did not control for
anxiety and depression and there is some evidence
from studies with adults that some of the measures
evaluated here (e.g., TAF-LO, MPS) would be associated with these symptoms and, therefore, future
studies may consider evaluating them.
In conclusion, this study has demonstrated that
the use of questionnaires designed to assess cognitive appraisals in adults with OCD can be used with
young people. The findings indicate that young
people with OCD and adults with the disorder hold
similar cognitive appraisals. There are, however,
possible developmental shifts in the extent to which
these beliefs are held and this warrants further
investigation. Consideration of cognitive appraisals
in therapy and future research with young people
with OCD could lead to fruitful advances in both
theory and practice.
Acknowledgements
The authors would like to thank all the families who
participated in this study. We are also grateful to all
the people who helped in the recruitment of families
and the many people who offered comments on this
piece of research.
Cognitive appraisals in OCD
Correspondence to
Sarah Libby, Child & Adolescent Mental Health
Service, United Bristol Healthcare Trust, Bristol
Royal Children’s Hospital, Paul O’Gorman Building,
Upper Maudlin Street, Bristol, BS2 8BJ, UK;
Tel: 01179 294530; Email: sarah.libby@ubht.swest.
nhs.uk
References
Allsopp, M., & Verduyn, C. (1990). Adolescents with
obsessive-compulsive disorder: A case note review of
consecutive patients referred to a provincial regional
adolescent psychiatry unit. Journal of Adolescence,
13, 157–169.
American Psychiatric Association. (1994). Diagnostic
and statistical manual of mental disorders (4th edn).
Washington DC: American Psychiatric Association.
Antony, M.M., Purdon, C.L., Huta, V., & Swinson, R.P.
(1998). Dimensions of perfectionism across the
anxiety disorders. Behaviour Research and Therapy,
36, 1143–1154.
Beck, A.T. (1976). Cognitive therapy and the emotional
disorders. New York: International Universities Press.
Berg, C.Z., Whitaker, A., Davies, M., Flament, M.F., &
Rapoport, J.L. (1988). The survey form of the Leyton
Obsessional Inventory-Child version: Norms from an
epidemiological study. Journal of the American Academy of Child and Adolescent Psychiatry, 27, 759–763.
Bolton, D., Luckie, M., & Steinberg, D. (1995). Longterm course of obsessive-compulsive disorder
treated in adolescence. Journal of the American
Academy of Child and Adolescent Psychiatry, 34,
1441–1450.
Chorpita, B.F., Albano, A.M., & Barlow, D.H. (1996).
Cognitive processing in children: Relation to anxiety
and family influences. Journal of Clinical Child
Psychology, 25, 170–176.
De Haan, E., Hoogduin, K.A.L., Buitelaar, J.K., &
Keijsers, G.P.J. (1998). Behaviour therapy versus
clomipramine for the treatment of obsessive-compulsive disorder in children and adolescents. Journal of
the American Academy of Child and Adolescent
Psychiatry, 37, 1022–1029.
Eichstedt, J.A., & Arnold, S.L. (2001). Childhood-onset
obsessive-compulsive disorder. A tic-related subtype
of OCD? Clinical Psychology Review, 21, 137–158.
Elkind, D. (1967). Egocentrism in adolescence. Child
Development, 38, 1025–1034.
Flament, M.F., Koby, E., Rapoport, J.L., Berg, C.J.,
Zahn, T., Cox, C., Denckla, M., & Lenane, M. (1990).
Childhood obsessive-compulsive disorder: A prospective study. Journal of Child Psychology and Psychiatry, 31, 363–380.
Flament, M.F., Whitaker, A., Rapoport, J.L., Davies, M.,
Berg, C.Z., Kalikow, K., Sceery, W., & Shaffer, D.
(1988). Obsessive compulsive disorder in adolescence: An epidemiological study. Journal of the
American Academy of Child and Adolescent Psychiatry, 27, 764–771.
Freeston, M.H., Rhéaume, J., & Ladouceur, R. (1996).
Correcting faulty appraisals of obsessional thought.
Behaviour Research and Therapy, 34, 433–446.
1083
Frost, R.O., Marten, P., Lahart, C., & Rosenblate, E.
(1990). The dimensions of perfectionism. Cognitive
Therapy and Research, 14, 449–468.
Frost, R.O., & Steketee, G. (1997). Perfectionism in
obsessive-compulsive disorder patients. Behaviour
Research and Therapy, 35, 291–296.
Frost, R.O., Steketee, G., Cohn, L., & Griess, K. (1994).
Personality traits in subclinical and non-obsessivecompulsive volunteers and their parents. Behaviour
Research and Therapy, 32, 47–56.
Hadwin, J., Frost, S., French, C.C., & Richards, A.
(1997). Cognitive processing and trait anxiety in
typically developing children: Evidence for an interpretation bias. Journal of Abnormal Psychology, 106,
486–490.
Hodgson, R.J., & Rachman, S. (1977). Obsessionalcompulsive complaints. Behaviour Research and
Therapy, 15, 389–395.
Inhelder, B., & Piaget, J. (1958). The growth of logical
thinking from childhood to adolescents. New York:
Basic Books.
Kail, R., & Bisanz, J. (1991). The information processing perspective on cognitive development in childhood
and adolescence. In J. McShane (Ed.), Cognitive
development: An information processing approach.
London: Basil Blackwell.
Karno, M., Golding, J.M., Sorenson, S.B., & Burnham,
M.A. (1988). The epidemiology of obsessive-compulsive disorder in 5 US communities. Archives of
General Psychiatry, 45, 1094–1099.
Keinan, G. (1994). Effects of stress and tolerance of
ambiguity on magical thinking. Journal of Personality
and Social Psychology, 67, 48–55.
Kuhn, D., Amsel, E., & O’Loughlin, M. (1988). The
development of scientific thinking skills. Academic
Press: San Diego.
Ladouceur, R., Rhéaume, J., & Aublet, F. (1997).
Excessive responsibility in obsessional concerns:
A fine grained experimental analysis. Behaviour
Research and Therapy, 35, 423–427.
Ladouceur, R., Rhéaume, J., Freeston, M.H., Aublet, F.,
Jean, K., LaChance, S., Langlois, F., & De Pokomandy-Morin, K. (1995). Experimental manipulation of
responsibility: An analogue test for models of obsessive compulsive disorder. Behaviour Research and
Therapy, 35, 937–946.
March, J.S. (1995). Cognitive-behavioral psychotherapy for children and adolescents with OCD: A review
and recommendations for treatment. Journal of the
American Academy of Child and Adolescent Psychiatry, 34, 7–18.
McLean, P.D., Whittal, M.L., Thordarson, D.S., Taylor,
S., Söchting, I., Koch, W.J., Paterson, R., & Anderson,
K.W. (2001). Cognitive versus behavior therapy in the
group treatment of Obsessive-Compulsive Disorder.
Journal of Consulting and Clinical Psychology, 69,
205–214.
Muris, P., Meesters, C., Rassin, E., Merckelbach, H., &
Campbell, J. (2001). Thought–action fusion and
anxiety disorder symptoms in normal adolescents.
Behaviour Research and Therapy, 39, 843–852.
Obsessive Compulsive Cognitions Working Group.
(1997). Cognitive assessment of obsessive-compulsive disorder. Behaviour Research and Therapy, 35,
667–681.
1084
Sarah Libby et al.
Pacht, A.R. (1984). Reflections on perfection. American
Psychologist, 39, 386–390.
Pauls, D.L., Alsobrook, J.P., Goodman, W., Rasmussen,
S., & Leckman, J. (1995). A family study of obsessivecompulsive disorder. American Journal of Psychiatry,
152, 76–84.
Rachman, S. (1997). A cognitive theory of obsessions.
Behavior Research and Therapy, 35, 793–802.
Rasmussen, S.A., & Eisen, J.L. (1990). Epidemiology of
obsessive compulsive disorder. Journal of Clinical
Psychiatry, 55(Suppl.), 10–14.
Rassin, E., Merckelbach, H., Muris, P., & Schmidt, H.
(2001). The thought–action fusion scale: Further
evidence for its reliability and validity. Behaviour
Research and Therapy, 39, 537–544.
Rhéaume, J., Ladouceur, R., Freeston, M.H., & Letarte,
H. (1994). Inflated responsibility in obsessive-compulsive disorder: Psychometric studies of a semiidiographic measure. Journal of Psychopathology and
Behavioural Assessment, 16, 265–276.
Riddle, M., Scahill, L., King, R., Hardin, M.T., Towbin,
K.E., Ort, S.I., Leckman, J.F., & Cohen, D.J. (1990).
Obsessive compulsive disorder in children and adolescents: Phenomenology and family history. Journal
of the American Academy of Child and Adolescent
Psychiatry, 29, 766–772.
Saboonchi, F., Lundh, L.-G., & Öst, L.-G. (1999).
Perfectionism and self-consciousness in social phobia
and panic disorder with agoraphobia. Behaviour
Research and Therapy, 37, 799–808.
Salkovskis, P.M. (1989). Cognitive-behavioural factors
and the persistence of intrusive thoughts in obsessional problems. Behaviour Research and Therapy,
27, 677–682.
Salkovskis, P., Forrester, E., & Richards, C. (1998).
Cognitive-behavioural approach to understanding
obsessional thinking. British Journal of Psychiatry,
173, 53–63.
Salkovskis, P.M., & Harrison, J. (1984). Abnormal
and normal obsessions – a replication. Behaviour
Research and Therapy, 22, 549–552.
Salkovskis, P., Shafran, R., Rachman, S., & Freeston,
M.H. (1999). Multiple pathways to inflated responsibility beliefs in obsessional problems: Possible
origins and implications for therapy and research.
Behaviour Research and Therapy, 37, 1055–1072.
Salkovskis, P.M., Wroe, A.L., Gledhill, A., Morrison, N.,
Forrester, E., Richards, C., Reynolds, M., & Thorpe, S.
(2000). Responsibility, attitudes and interpretations
are characteristic of obsessive compulsive disorder.
Behaviour Research and Therapy, 38, 347–372.
Shafran, R., & Mansell, W. (2001). Perfectionism and
psychopathology: A review of research and treatment.
Clinical Psychology Review, 21, 879–906.
Shafran, R., & Somers, J. (1998). Treating adolescent
obsessive-compulsive disorder: Applications of the
cognitive theory. Behaviour Research and Therapy,
36, 93–97.
Shafran, R., Thordarson, D.S., & Rachman, S. (1996).
Thought–action fusion in obsessive compulsive disorder. Journal of Anxiety Disorders, 10, 379–391.
Silverman, W.K., & Albano, A.M. (1996). Anxiety Disorders Interview Schedule for DSM-IV: Child Version.
San Antonio, TX: Psychological Corporation.
Steketee, G.S., Frost, R.A., Rhéaume, J., & Wilhelm, S.
(1998). Cognitive theory and treatment of obsessivecompulsive disorder. In M. Jenike & L. Baer (Eds.),
Obsessive compulsive disorders: Practical management (3rd edn, 368–399). St.Louis: Mosby.
Stumpf, H., & Parker, W.D. (2000). A hierarchical
structural analysis of perfectionism and its relation
to other personality characteristics. Personality and
Individual Differences, 28, 837–852.
Swedo, S.E., Rapoport, J.L., Leonard, H., & Lenane, M.
(1989). Obsessive-compulsive disorder in children
and adolescents. Archives of General Psychiatry, 46,
335–341.
Tabachnick, B.G., & Fidell, L.S. (1996). Using multivariate statistics (3rd edn). New York: HarperCollins.
Valleni-Basile, L.A., Garrison, C.Z., Jackson, K.L.,
Waller, J.L., McKeown, R.E., Addy, C.L., & Cuffe,
S.P. (1994). Frequency of obsessive-compulsive disorder in a community sample of young adolescents.
Journal of the American Academy of Child and
Adolescent Psychiatry, 33, 782–791.
Van Oppen, P., & Arntz, A. (1994). Cognitive therapy for
Obsessive Compulsive Disorder. Behaviour Research
and Therapy, 32, 79–87.
Van Oppen, P., De Haan, E., Van Balkom, A.J.L.M.,
Spinhoven, P., Hoodgduin, K., & Van Dyck, R.,
(1995). Cognitive therapy and exposure in vivo
in the treatment of obsessive-compulsive disorder.
Behaviour Research and Therapy, 33, 379–390.
Wells, A. (1997). Cognitive therapy of anxiety disorders:
A practical manual and conceptual guide. New York:
John Wiley & Son.
Williams, T.I., Salkovskis, P.M., Forrester, E.A., &
Allsopp, M.A. (2002). Changes in symptoms of OCD
and appraisal of responsibility during cognitive
behavioural treatment: A pilot study. Behavioural
and Cognitive Psychotherapy, 30, 69–78.
Wilson, K.A., & Chambless, D.L. (1999). Inflated
perceptions of responsibility and obsessive-compulsive symptoms. Behaviour Research and Therapy, 37,
325–335.
Manuscript accepted 1 October 2003