Am I mad, bad or dangerous? : A novel intervention approach for unwanted intrusive thoughts

Abstract: Background: Unwanted intrusive thoughts (UITs) containing unacceptable and taboo themes is regarded as a common and, for most, transient cognitive phenomenon. However, these thoughts can become so frequent and distressing that the individual’s daily functioning and well-being are impaired, even to the extent that the individual fulfils the criteria for obsessivecompulsive disorder (OCD). Among parents of infants and toddlers, distressing and impairing UITs, mainly of infant-related harm, are a very common symptom. Patients who suffer from OCD with taboo obsessions as well as parents with UITs of infant-related harm are reluctant to reveal their thoughts to healthcare personnel, due to the shame or stigma related to the thought content. Some OCD patients with taboo obsessions avoid seeking treatment and may respond less well to standard psychological treatment for OCD. There are no recommended treatment options for the larger population of parents who suffer from UITs. Therefore, there is a need to develop alternative treatments targeting both taboo obsessions among OCD patients and UITs among parents of infants and toddlers. Aims: The overall aim of this thesis was to develop and evaluate the effect and the mechanism of change of a novel, online intervention approach for OCD patients with taboo obsessions and for parents of infants and toddlers with distressing UITs of infant-related harm. Method: The online intervention developed and investigated in this thesis was based on the cognitive model of obsessions, and was evaluated among patients with OCD and taboo obsessions and parents of infants and toddlers with distressing UITs of infant-related harm. Study I was a pilot study including 19 patients with OCD, primarily taboo obsessions. The participants received therapist-supported online cognitive therapy (I-CT) for 10 weeks. Study II was a randomized controlled trial with a mediation analysis including 68 OCD patients with taboo obsessions. Participants were randomized to either the therapist-supported I-CT for eight weeks or control condition containing online general psychological support. Study III was a cross-sectional survey study including 594 parents of infants and toddlers. Study IV was a randomized controlled pilot trial with a mediation analysis including 43 parents of infants and toddlers who reported daily distressing UITs about intentionally harming their child. Participants were randomized to either eight-week self-guided I-CT or waiting-list control. Study V was a qualitative interview study using thematic analysis to investigate parents’ experiences of taking part in the self-guided I-CT for parents with excessive levels of UITs. Results: Results from Study I showed that intervention completion was high and that most participants were satisfied with the I-CT intervention. I-CT was associated with a large reduction in OCD-symptom severity (bootstrapped within-group d = 1.67 [95% CI; 0.67 to 2.66]). The effect was driven mainly by the participants who understood and were able to apply the cognitive model to their own situation. A time-series analysis indicated that the reduction of OCD-symptom severity was preceded by a reduction in negative appraisals of the taboo obsessions. In Study II, participants in both the I-CT group and the control condition had a significant reduction of OCD-symptoms from pre- to post-intervention. The reduction of OCD-symptoms was significantly larger in the I-CT group, with a moderate effect size (bootstrapped betweengroup d = 0.69 [95% CI; 0.20 to 1.19]). The mediation analysis revealed that 55% of the treatment effect was mediated by a reduction in negative appraisals. In Study III, 56% of the parents’ reported experiencing or previously having experienced UITs about intentionally harming their child. For around one fifth of the parents the UITs were difficult to control and/or had a negative impact on their relationship or attachment to the child. Positive attitudes toward internet-delivered interventions for UITs were endorsed by 51% of the parents. Study IV showed that participants randomized to the self-guided I-CT had a significantly larger reduction of UITs compared to participants in the waiting-list control condition (bootstrapped between-group d = 0.99 [95% CI; 0.56 to 1.43]). The effect of the intervention was mediated by a reduction in negative appraisals. The thematic analysis conducted in Study V divided the parents’ experiences of the selfguided I-CT into two main themes: (1) Changed perception of the unwanted intrusive thoughts, and (2) Different paths to recovery. Overall, results showed that the parents believed that the intervention was helpful by changing the way they interpreted their thoughts, and they reported experiencing several benefits in their daily life due to the intervention. Conclusions: I-CT targeting UITs is an acceptable and feasible intervention, both delivered in a therapist-guided format for OCD patients with taboo obsessions and in a self-guided format for parents with UITs of infant-related harm. Results from Studies I, II and VI suggest that the intervention is effective in reducing distressing and impairing taboo obsessions and UITs. The effect appears to be mediated by a change in negative appraisals. The online cognitive intervention is therefore a promising complementary intervention alternative to standard psychological treatments for OCD patients with taboo obsessions, and an easily accessible, scalable intervention for the large population of parents suffering from UITs.

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