Behao. Res. Ther. Vol. 32, No. 3, pp.

343-353, 1994
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OBSESSIONS, OVERVALUED IDEAS, AND DELUSIONS IN

OBSESSIVE-COMPULSIVE DISORDER

MICHAEL J. KOZAK and EDNA B.FOA

Center for the Treatment and Study of Anxiety, Department of Psychiatry,
Medical College of Pennsylvania, 3300 Henry Ave, Philadelphia, PA 19129, U.S.A.

(Received 30 April 1993)

Summary-The prevailing view is that individuals with obsessive-compulsive disorder (OCD) are able to
think rationally about their obsessive concerns and are thus able to recognize them as senseless. However,
clinical observations indicate that at least some obsessive-compulsives do not regard their symptoms as
unreasonable or excessive, and their ideas have been characterized as overvalued or delusional. In the
present paper the concepts of obsessions, overvalued ideas, and delusions are discussed and compared,
and the available studies of insight among obsessive-compulsives are reviewed. It is concluded that
obsessive-compulsive ideas can not satisfactorily be dichotomized according to patients’ insight, and that
the notion of a continuum of strength of obsessivecompulsive beliefs is more appropriate. The
relationship between degree of obsessive-compulsive conviction and outcome of therapy remains unclear.
Methodological issues that complicate our understanding of OCD are considered, and theories of
delusions are examined in relation to their development in OCD.

INTRODUCTION

The contemporary nosology of obsessive-compulsive disorder (OCD) owes much to the definition
that was offered by Esquirol in 1838, who characterized OCD as a
“recurrent or persistent idea, thought, image, feeling or movement which is accompanied by a sense of
subjective compulsion and a desire to resist it, the event being recognized by the individual as foreign to
his personality, and into the abnormality of which he has insight” (Pollitt, 1956, p. 842).

This definition has persisted relatively unchanged, despite subsequent observations that OCD is
characterized by irrationality and insanity (Westphal, 1878). The prevailing view maintains that
individuals with OCD are able to think rationally about their obsessive concerns and are thus able
to recognize that they are senseless. The influence of this idea is reflected in the most recent
diagnostic criteria of the American Psychiatric Association (DSM-III-R; APA, 1987) in the
statement that in OCD “the person recognizes that his or her behavior is excessive or unreasonable”
(p. 247).
Clinical observations that at least some obsessivecompulsives do not regard their symptoms as
unreasonable or excessive have been a focus of discussion in more recent psychiatric literature, and
the traditional assumption of insight has been questioned. Recognition that irrational, fixed beliefs
can characterize obsessive-compulsive thinking has led to consideration of the presence of
overvalued ideas (OVI) and delusions in patients diagnosed with OCD.

OBSESSIONS, OVERVALUED IDEAS (OVI) AND DELUSIONS: DIFFICULTIES

WITH DEFINITIONS

Theorists have been grappling with the concepts of OVI and delusions since the turn of the
century, and the contemporary distinctions among obsessions, OVI, and delusions evolved from
the work of these thinkers. The concept of OVI was introduced by Wernicke (1900), who construed
it as a solitary belief that the person felt to be justified, and which strongly determined the person’s
actions.
According to Jaspers (1959), OVI are understandable (verst2indlich ) convictions that are wrongly
taken to be true, and are characterized by especially strong affect; “Psychologically, there is no
difference between scientific adherence to truth, passionate political or ethical conviction, and the

343
344 MICHAEL J. KOZAK and EDNA B. FOA

retention of over-valued ideas. The contrast between these phenomena lies in the falsity of the
overvalued idea” (Jaspers, 1959, p. 107). Jaspers construed delusions, on the other hand, as
qualitatively different from normal beliefs in that they involve an abnormal way by which events
take on meaning. Accordingly, the content of a delusion is not reasonably understandable
(undversttindlich): a delusion appears not only to be false, but also perplexingly irrational.
Fish (in Hamilton, 1974) similarly distinguished between OVI and delusions, but emphasized a
discrepancy between belief and action in delusions and concordance between belief and action in
OVI. Accordingly, action is more likely to be taken on the basis of OVI than of delusions because
“true delusions are the result of a disintegration of personality, while overvalued ideas occur in
an intact personality” (Hamilton, 1974, pp. 52-53). Like Jaspers, Fish maintained that an
overvalued idea is accompanied by strong affect, and that “because of the associated feeling tone,
takes precedence of all other ideas and maintains this precedence permanently” (Hamilton, 1974,
p. 43).
In his review of disorders with OVI, McKenna (1984) mentioned examples of psychopathological
phenomena characterized by OVI: the querulous paranoid state, morbid jealousy, hypochondriasis,
and anorexia nervosa. These disorders exemplify the occurrence of OVI that are nonintrusive,
unresisted, and not seen as senseless, as distinct from intrusive, resisted, senseless obsessions.
However, the examples do not clarify the distinction between OVI and delusion. Like Jaspers,
McKenna maintained that delusions are characterized by an “undefinable but easily recognizable
alien quality” (p. 583). This traditional view that delusions have an important “indefinable” quality
that distinguishes them from OVI is not very helpful in illuminating these concepts. In general,
although obsessions, OVI and delusions have been defined in the literature, the distinctions among
these phenomena remain murky.
A recent attempt to clarify the distinctions can be found in DSM-III-R (APA, 1987). Obsessions
are defined as “recurrent and persistent ideas, thoughts, impulses, or images that are experienced
at least initially as intrusive and senseless” and “the person attempts to ignore or suppress such
thoughts or impulses or neutralize them with some other thought or action” (p. 247). An OVI is
an “unreasonable and sustained belief or idea that is maintained with less than delusional intensity.
Accordingly, it differs from an obsessional thought in that the person does not recognize its
absurdity and thus does not struggle against it” (p. 402). Thus, OVI are almost unshakable beliefs,
which can be acknowledged as potentially unfounded only after considerable discussion. A delusion
is defined as a “false personal belief based on an incorrect inference about external reality and firmly
sustained in spite of what almost everyone else believes” (p. 395). It follows that OVI are
distinguished from delusions by their less than delusional intensity; OVI are strongly held
unreasonable beliefs that are not as firmly held as delusional ideas. It is troublesome that although
the distinctions among obsessions, OVI and delusions rest on howjirmly the erroneous idea is held,
there is no conventionally accepted method for determining the firmness or shakability of such
beliefs. This leaves no formal way to determine whether a given idea is an obsession, an OVI or
a delusion.
Although the distinctions among obsessions, OVI, and delusions seem clearly stated in
DSM-III-R, further examination reveals ambiguities. One problem is that the diagnostic criteria
allow obsessions to be very strongly held beliefs, like OVI and delusions. Because they are defined
as ideas that have been experienced “at least initially” as senseless, obsessions need not be always
recognized as senseless. In addition, because there is no requirement that OVI or delusional ideas
are always strongly held, the proviso that obsessions were at one point recognized as senseless does
not help to distinguish them from OVI and delusions.

OVI AND DELUSIONS IN OCD

Janet (1908) and, later, Schneider (1925) specified the following criteria for OCD: (1) subjective
feeling of being forced, or compelled to think, feel, or act; (2) content of the obsession is perceived
as absurd or nonsensical and ego alien; (3) the obsession is resisted.
These criteria notwithstanding, clinicians have recognized that many obsessive-compulsives do
not ‘fit’ this definition. Following Lewis (1935), Solyom, Sookman, Solyom and Morton (1985)
noted that not all obsessive patients report the subjective feeling of forced thoughts or action, nor
 Obsessions, overvalued ideas and delusions in OCD 345

do they all recognize the senselessness of their obsessions or rituals. Accordingly, “when the
resistance becomes zero, the content of the thought is accepted and the obsession becomes a
delusion” (p. 177).
Solyom et al. (1985) noted Schneider’s observation that in some patients with OCD, insight was
present only “upon quiet reflection.” Although there are few research findings to support this
observation (cf. Insel & Akiskal, 1986) clinicians experienced with OCD recognize that insight into
the senselessness of obsessive-compulsive fears is often situation-bound: an individual is more likely
to demonstrate insight under nonthreat conditions, i.e. when there is no impending contact with
the feared situation, than when facing such a situation. Thus, when patients are asked during a
clinical interview how they assess danger ‘objectively’, they are more likely to show insight than
when they are afraid. Observations of lack of insight by patients about their obsessive-compulsive
beliefs raise the question of whether such patients should be considered psychotic. According to
DSM-III-R, a major diagnostic criterion for psychosis is impaired reality testing, and the presence
of delusions constitutes an indicator of such impairment. If delusions entail psychosis, can
obsessive-compulsives who perceive their obsessions as sensible and do not resist them be
considered delusional, and therefore psychotic? That some obsessivecompulsives have psychotic
features has been suggested by Insel and Akiskal (1986). On the basis of case reports, they argued
that psychotic experiences belong to the severe end of the obsessive-compulsive spectrum.
To study such “atypical” obsessivecompulsives, Solyom et al. (1985) selected 8 of 45 patients
with OCD who differed from typical obsessive-compulsives in that they had severely debilitating
main obsessions “bordering on the delusional” but showed no schizophrenic symptoms. Differ-
ences between the typical and atypical groups in etiology and prognosis were examined via
structured interviews and standardized questionnaires, The atypical group was found to have
earlier onset of OCD symptoms and poorer prognosis.
Notably, in the Solyom et al. (1985) study, severe debilitation was a criterion for “atypical”
OCD. Furthermore, patients were assigned to a variety of treatments, according to symptom
severity, many of which had no established efficacy with OCD (e.g. thought stopping, aversion
relief, imipramine, phenothiazines). Thus, although delusion-like thinking may have contributed
to poor prognosis, symptom severity and treatment type were confounding variables.
Studying obsessivecompulsives with psychotic symptoms, Eisen and Rasmussen (1989) ident-
ified 30 of 250 OCD patients with delusions, hallucinations, and/or thought disorder. Such patients
with psychotic symptoms (atypical OCD) were compared to more typical obsessivecompulsives
on demographic variables, clinical features, and response to treatment. Based on their psychotic
symptoms, the 30 atypical patients were subtyped into 4 groups: (1) meeting criteria for both OCD
and schizophrenia (7/30); (2) meeting criteria for schizotypal personality disorder with magical
thinking (delusional) and an obsessive concern with symmetry in their actions or environment
(8/30); (3) meeting criteria for OCD and delusional disorder (8/30); and (4) OCD with transient
obsessional delusions (9/30). These 4 subtypes were combined into two groups: schizophrenia
spectrum (subtypes I and II); and OCD with delusions (subtypes III and IV).
Like Solyom et al.‘s (1985) patients, Eisen and Rasmussen’s (1989) 30 “atypical” obses-
sive-compulsives with psychotic features showed more severe OCD symptoms than did those
without psychosis. The schizophrenia spectrum subtypes fared poorly with pharmacotherapy by
serotonin reuptake inhibitors compared to the subtypes with OCD and delusions. Unfortunately,
a lack of information about treatments received by these patients, and about the outcome measures
used, limit the conclusions that can be drawn from these results. For example, it is unclear from
the report what criteria were used for treatment assignment, what medication dosages were
received, and how the psychotic symptoms were differentiated from OCD symptoms.
In a more recent investigation, using a larger sample including subjects (Ss) included in the 1989
study, Eisen and Rasmussen (in press) identified 67 of 475 OCD patients with hallucinations,
delusions, and/or thought disorder in addition to OCD. Of these 67 patients, 27 had as their only
psychotic symptom lack of insight and strong conviction in the validity of their obsessive fears.
Although probands with OCD and psychotic features were found to have poorer prognoses than
those with OCD alone, it was concluded that this was largely associated with the presence of
schizophrenia spectrum symptoms, rather than lack of insight.
Another approach to studying insight in OCD was pursued by Lelliott, Noshirvani, Basoglu,
346 MICHAEL J. KOZAK and EDNA B. FOA

Marks and Monteiro (1988) and by Basoglu, Lax, Kasvikis and Marks (1988). Rather than dividing
patients into typical and atypical groups, these investigators used a structured interview to allow
ratings of each patient’s beliefs on several dimensions: (1) fixity-how strong is the obsessive belief
held; (2) bizarreness-how valid is the belief; (3) resistance-frequency of attempts to resist urges;
and (4) controllability-ease with which the patient can control compulsive urges. The fixity
dimension had 3 subscales: (a) strength of belief in feared consequence; (b) patients perceived
absurdity of belief in feared consequences, (i.e. the patient’s appraisal of whether others would
regard the belief as absurd); and (c) response to evidence contradicting the obsessional belief. Of
the 45 patients studied: 33% believed that without their rituals, the consequences they feared would
occur; 12% never tried to resist their compulsions; and 43% denied having control over intrusive
thoughts and urges to ritualize. Furthermore, patients were distributed over the entire range of the
scales. These results run counter to Schneider’s and Janet’s assertions that obsessional beliefs are
recognized by obsessive-compulsives as senseless, are resisted, and are ‘ego alien’.
Using the scales described above, Insel and Akiskal (1986) assessed insight and resistance to
obsessions in 23 patients with OCD. They rated 4 aspects of obsessivecompulsive ideas: (1)
perceived validity; (2) resistance; (3) strength of belief in harmful consequences; and (4) perceived
absurdity compared to culturally accepted norms. Most patients perceived their obsessions as
absurd, but many of these were nevertheless quite confident that harmful consequences would occur
if they did not perform rituals. Additionally, more than half of the patients reported that they tried
to resist obsessive ideas only sometimes. Interestingly, the authors noted that resistance often varied
within patients, depending on environmental situation and fatigue.
More recently, the question of whether obsessivecompulsives display insight into the senseless-
ness of their obsessions and compulsions was investigated in a field trial (Foa & Kozak, 1993)
conducted in connection with efforts to develop DSM-IV, the latest revision of the Diagnostic and
Statistical Manual of the American Psychiatric Association. The study addressed several issues, and
was conducted at 7 sites: Brown University (Eisen & Rasmussen); Clark Institute (Richter);
Columbia University (Hollander); Emory University (Rothbaum); Massachusetts General Hospital
(Jenike & Riccardi); The Medical College of Pennsylvania (Kozak); and Yale University
(Goodman). Standardized interviews were conducted with 430 patients who met DSM-III-R
criteria for OCD. Fixity of beliefs was assessed with face-valid interview questions based partly on
those used previously by Lelliott et al. (1988).
The results of the DSM-IV field trial converged with those of previous studies to indicate a broad
range of insight among obsessivecompulsives. Clear harmful feared consequences were identified
for 250 of the 430 Ss. The large majority of Ss expressed various degrees of uncertainty about
whether their obsessions and compulsions were reasonable; 4% were certain, and 25% were almost
certain, that if they did not perform their rituals, the harmful consequences would ensue. These
results suggest that strength of obsessive-compulsive beliefs is distributed on a continuum ranging
from full recognition of their senselessness to complete absence of such recognition. Coincidentally,
Hollander (1989) arrived at a similar conclusion with regard to the beliefs of patients with body
dysmorphia, a syndrome with many formal similarities to OCD.

THE EVOLUTION OF OBSESSIONS INTO OVI AND DELUSIONS

The language of DSM-III-R seems to imply that when OVI occur in OCD, they must necessarily
have evolved from obsessions: “the person recognizes that his or her behavior is excessive or
unreasonable. . it may no longer be true for people whose obsessions have evolved into overvalued
ideas” (APA, 1987, p. 247). Although no controlled studies document such an evolution, there are,
however, case reports that describe transitions from obsessions to delusions (e.g. Gordon, 1950;
Insel & Akiskal, 1986).
Insel and Akiskal (1986) noted that “an appreciable proportion of obsessivecompulsive patients
become psychotic only in the sense of a transient loss of insight” (p. 1528). Similar observations
of the temporary nature of psychotic manifestations in OCD were made by Roth (1978). To
illustrate the occurrence of “transitional” psychoses that occur in OCD, Insel and Akiskai (1986)
described 2 cases. The first case was an obsessivecompulsive patient with severe checking and
washing rituals, and who developed delusional guilt about having contaminated others. After 3
 Obsessions, overvalued ideas and delusions in OCD 341

weeks, the patient regained his insight but remained obsessive-compulsive at 2-year followup. In
the second case, a patient with an 8-year history of fears of poisoning children, that he recognized
as irrational, developed a paranoid conviction that the hospital staff blamed him for poisonings.
This case does not exemplify a transition from an obsession to an OVI, but rather, the development
of a subsequent delusion that was related to an obsession. Again, the delusion disappeared after
a short period, while the obsession remained.
Indirect evidence about transitions from obsessions to delusions in OCD can be gleaned from
Rosen’s (1957) examination of 848 cases of schizophrenia: 30 patients had marked obsessional
symptoms but only 7 (< 1%) evidenced a transition from an obsession to a delusion; in the
remaining 23 patients, the obsessional symptoms either preceded or coincided with the onset of
schizophrenia. A direct investigation of the hypothesis that OVI develop from insightful obsessions
was conducted in the DSM-IV field trial for OCD (Foa & Kozak, 1993). In this study, patients
were questioned about whether they always believed in the validity of their obsessional fears, or
whether at some time in the past they had thought the fears to be unrealistic. Of 454
obsessive-compulsives, 34 patients (7.5%) were rated as lacking insight about the senselessness of
their symptoms. Of these 34 patients, 35% reported having had insight in the past and 65%
reported never having had such recognition. Thus, 4.8% of the OCD sample were considered never
to have had insight about the senselessness of their symptoms. Although the method of
retrospective self-report used has limitations, the results are at least suggestive, and are of interest
in the absence of studies employing more robust assessment methods.
In summary, although it seems plausible to suppose that OVI and delusions of a particular
content might have started as intrusive ideas that were at one time more malleable, few relevant
findings are available. The available information does not clearly indicate that OVI or delusions
in OCD necessarily develop from obsessions, and this issue remains unresolved.
It is not clear whether delusions that do develop from obsessions differ in any fundamental way
from those that are related to, but do not evolve from, obsessions. The apparent difference is in
the ideational content of the delusion: one that has evolved from an obsession is a strongly held
version of the obsessional idea, whereas a delusion that is only related to an obsession has a
different content than the obsession itself. It is also unclear what to make of the topographical
difference between the transient losses of insight in OCD and delusions: the apparent difference
is the stability of delusions, but it is unknown whether there are qualitative differences in the
psychopathological processes that underlie these two phenomena. It is possible that the same
processes subserve the development of fluctuating obsessions of delusional intensity, more stable
obsessional delusions, and delusions that are related to obsessions.

OCD AND SCHIZOPHRENIA

It is clear from the foregoing discussion that obsessions can occur with delusional intensity. Insel
and Akiskal (1986) noted that early diagnosticians such as Bleuler (Berner & Zapotoczky, 1976)
and Westphal (1878) viewed the obsessive-compulsive syndrome as a form of schizophrenia.
Moreover, obsessive-compulsive symptoms were conceptualized as compensating for schizo-
phrenia, and thus as masking schizophrenic symptoms (e.g. Pious, 1950; Stengel, 1945). Does our
recognition of delusional thinking in OCD give credence to the old idea that this disorder is a
variant of schizophrenia?
Clearly, some individuals meet criteria for both OCD and schizophrenia, but the available
empirical studies fail to support the notion of OCD as a form of schizophrenia. Rachman and
Hodgson (1980) noted that the prevalence of schizophrenia in obsessive-compulsives does not differ
significantly from that in the general population. Some recent data suggest that the percentage of
schizophrenics in OCD probands is higher than the 1% rate (Keith, Regier & Rae, 199 1) found
in the general population. In Eisen and Rasmussen’s (1989) survey of 250 obsessivecompulsives,
7 patients (2.8%) were also schizophrenics. Among schizophrenic probands, the 3.5% rate of
obsessional symptoms (Rosen, 1957) is similar to that found for OCD in the general population
(Karno & Golding, 1991). Notably, comorbidity of OCD with other anxiety disorders and with
depression is considerably higher than that with schizophrenia. Thus, the rates of schizophrenia
among those with OCD do not indicate a special association of these disorders.
348 MICHAELJ. KOZAK and EDNA B. FDA

The question can still be posed, however, of whether OCD is a precursor of schizophrenia.
Followup studies can address this question. Muller (1953) found that when diagnostic criteria were
broad, up to 12% of patients with OCD later were diagnosed as schizophrenic. However, studies
using narrower criteria have yielded much lower percentages. Goodwin, Guze and Robins (1969)
reviewed 13 followup studies and concluded that obsessivecompulsives developed schizophrenia
no more frequently than nonobsessional patients. In contrast to the low incidence of schizophrenia
in OCD, a relatively high occurrence of other psychoses among obsessive-compulsives was found
in the studies reviewed by Goodwin et al. (1969).
Treatment outcome studies of OCD are also incongruent with the hypothesis that OCD
symptoms mask schizophrenia. Most obsessive-compulsives improve significantly with either
pharmacological or behavioral treatment (DeVeaugh-Geiss, Landau & Katz, 1989; Foa, Grayson,
Steketee, Doppelt, Turner & Latimer, 1983). In the many studies that evaluated the efficacy of
behavioral treatment of OCD, there has been not one report of schizophrenic decompensation
following reduction of OCD symptoms (Rachman & Hodgson, 1980).
Taken together, the available findings reveal that OCD occasionally co-occurs with schizo-
phrenia. However, there does not appear to be any special association between the two disorders.

OVI, DELUSIONS, AND OUTCOME OF THERAPY

Distinctions among the types of thinking that characterize OCD are useful to the extent that
they are related to etiology and/or treatment. The prognosis of OCD with OVI has been the subject
of some speculation since Foa (1979) reported the failure of behavior therapy for 4 patients with
OCD who expressed strong convictions in the validity of their obsessive beliefs.
In apparent contrast to Foa’s (1979) findings, Lelliott and Marks (1987) and Salkovskis and
Warwick (1985) reported successful outcomes with single cases of OCD with strongly held beliefs.
Also apparently at odds with Foa’s observation of an association of fixed ideas and poor outcome
of behavior therapy is a subsequent study of therapy outcome by Lelliott et al. (1988). This study
involved 49 obsessive-compulsives with a range of insight. Patients with strong convictions
responded as well to treatment as those whose obsessions were recognized as senseless. Pursuing
correlational analyses of these data, Basoglu et al. (1988) found no relationship between
pretreatment degree of conviction and outcome immediately posttreatment, and a weak (Y = -0.3)
relationship at 1-year followup.
It is unclear how to resolve the inconsistencies among (1) observations that patients with OVI
show poor outcome of therapy, (2) reports of successful outcomes with such patients, and (3)
findings of no relationship between strength of obsessional beliefs and outcome. It is conceivable
that only patients with the most strongly held obsessions would be especially resistant to treatment:
it is certainly plausible to suppose that attempts to persuade such delusional individuals to confront
their feared situations in behavior therapy often could be futile. Individual reports of successful
exposure with patients with strong beliefs are insufficient to negate the observations of difficulties
often encountered with such individuals. Furthermore, it would be premature to conclude that there
is no relationship between fixity and therapy outcome based on the failure to find a linear
relationship between strength of obsessional conviction and therapy outcome. If only the most
strongly held, delusion-like obsessions portended poor outcome, this nonlinear relationship would
not ordinarily be detectable with linear regression procedures. Thus, it appears that the available
evidence is inconclusive about the relationship of strength of obsessional conviction and outcome
of therapy.
Can therapy procedures directed specifically at strongly fixed ideas reduce strength of conviction
in such beliefs? Successful modification of fixed ideas in obsessive-compulsives through behavior
therapy would seem to have some precedent in case reports of behavioral treatment of delusions
in schizophrenia. Watts, Powell and Austin (1973) reported two cases of paranoid delusions in
schizophrenia that were weakened via a ‘belief modification procedure’ that involved gentle
challenges of evidential support for the beliefs, and practice by the patient in mounting arguments
against the target beliefs. In a more recent study, Chadwick and Lowe (1990) found that a
cognitive-behavioral treatment combining verbal challenges and reality testing exercises reduced
the strength of delusional beliefs in 5 of 6 schizophrenics with delusions.
 Obsessions, overvalued ideas and delusions in OCD 349

Another angle on the relationship of obsessions of delusional intensity and treatment efficacy
can be found in work on schizotypal thinking in treatment-resistant obsessive-compulsives. Several
DSM-III (APA, 1980) criteria for schizotypy refer to disordered thinking: (1) magical thinking; (2)
ideas of reference; and (3) suspiciousness. In a retrospective study, Jenike, Baer, Minichiello,
Schwartz and Carey (1986) examined 43 ‘treatment-resistant’ obsessivecompulsives and found
that those with concomitant schizotypal personality disorder had a high rate of treatment failure:
of 29 treated nonschizotypal obsessive-compulsives, 26 (90%) improved at least moderately,
whereas only one of 14 (7%) schizotypal obsessivecompulsive patients improved. Notably,
inspection of the data suggested that the presence of ideas of reference and suspiciousness were
more predictive of poor outcome than were magical ideas of the sort that might be expected in
delusions, which occurred in both treatment successes and failures for both schizotypes and non
schizotypes.
Perhaps ideas of reference and suspiciousness are more specifically linked to schizophrenia-spec-
trum disorders than are magical thinking and delusions, and perhaps it is the schizophrenia
spectrum characteristics that account for the poorer outcome. Jenike et d’s (1986) results converge
with the findings of Eisen and Rasmussen (1989) who reported that “atypical” obses-
sive-compulsives with concomitant schizophrenia or schizotypy responded more poorly to
serotonin reuptake inhibitors than did patients with obsessional delusions.

METHODOLOGICAL CONSIDERATIONS

A number of methodological issues that underlie our concepts of obsessions, OVI, and delusions
merit attention here. One fundamental point of concern is the propriety of dichotomous
categorization of beliefs as delusional or nondelusional. We have argued above that strength of
belief in obsessive-compulsive ideas is broadly distributed, and that a continuum seems more
accurately descriptive than discrete categories. This observation is not peculiar to the ideation of
OCD: similar suggestions have been offered with respect to delusions in schizophrenics.
Data from interviews of 119 acutely schizophrenic patients in the World Health Organization
International Pilot Study of Schizophrenia (Strauss, 1969) revealed intermediate levels of disbelief
in ideational and perceptual distortions, temporal variations in strength of belief, and intermediate
degrees of distortion. However, evaluations of delusions were frequently complicated by difficulties
in ascertaining realistic evidence for a particular belief, so that conclusions about degree of
distortion depended on the clinician’s uncertain view of evidential support for the belief in question.
Strauss (1969) concluded that beliefs are better characterized on a continuum than dichotomized
into delusional and nondelusional categories.
The concept of delusion as a unitary categorical phenomenon has been questioned not only on
the basis of evidence for a continuum of strength of belief, but also because the concept involves
multiple aspects or dimensions. Commonly ascribed dimensions include conviction, self-evidence,
resistance to reason, unlikely content, and absence of cultural support (Mullen, 1979). Assessment
studies using multidimensional approaches have found desynchrony among different aspects of
delusional beliefs. Using clinical rating scales that measured several aspects of delusional belief
(conviction, preoccupation, bizarreness, disorganization), Kendler, Glazer and Morgenstern (1983)
found low correlations among the dimensions in 52 delusional patients. Based on clinical interviews
with 8 delusional inpatients, Hole, Rush and Beck (1979) also concluded that there is divergence
among several dimensions of delusions (conviction, accommodation, pervasiveness, and encapsu-
lation). Longitudinal investigations of delusional beliefs have revealed that they are multidimen-
sional and desynchronous and, moreover, that no consistent temporal patterns emerged among the
different aspects of delusions (Garety, 1985; Brett-Jones, Garety & Hemsley, 1987).
Findings regarding the multidimensionality of delusional experiences suggest that fixed ideas of
obsessive-compulsives should not be equated with the delusions observed in other disorders, based
solely on similarity in degree of conviction. Some studies of obsessivecompulsives have measured
multiple aspects of beliefs (e.g. Basoglu et al., 1988; Lelliott et al., 1988) and desynchrony among
dimensions has been observed in the DSM-IV OCD field trial. However, studies of delusions in
other disorders, using the same multidimensional measures of delusional beliefs, are not available.
Thus, the relevant comparisons of the multidimensional structures of obsessions and delusions
350 MICHAEL J. KOZAK and EDNA B. FOA

cannot be made. Until comparable results are forthcoming, conclusions about the formal
equivalence of delusional beliefs observed in various disorders, including OCD, must remain
tentative.
Another issue that merits further consideration is the extent to which delusions are resistant to
change. We have noted earlier that the delusions of schizophrenics have been found to vary over
time and that psychotherapy can influence the strength of delusional beliefs in schizophrenics
(Watts et al., 1973; Chadwick & Lowe, 1990). These results converge to support the hypothesis
that delusional beliefs are dimensional in character and that, like strength of belief, mutability may
be more accurately conceptualized as a continuum than as a dichotomized entity.
Interestingly, the finding that delusional beliefs can be modified has potential implications for
treatment of delusions in obsessivecompulsives. Supplementing the usual exposure and response
prevention program with interventions of the sort that have been reported to be helpful with
delusions in schizophrenics might enhance the efficacy of the established behavioral regimen for
patients who are treatment resistant.

THEORETICAL CONSIDERATIONS

Our understanding of OVI and delusions in OCD can be advanced by knowledge of the
formation and maintenance of delusional beliefs found in other disorders. Despite substantial
conceptual and empirical work in the area of delusions, no consensually accepted theory has
emerged. Nevertheless, one theory that has achieved some prominence is Maher’s (1970, 1974,
1988) proposal that delusions constitute attempts to rationalize anomalous experiences. Accord-
ingly, Maher views delusions as ‘normal’ theories that account for an individual’s abnormal
experiences. Thus, the cognitive process involved in developing delusions is seen not to differ from
that of forming nondelusional beliefs.
Three lines of evidence have been invoked in support of Maher’s theory. First, delusions have
been observed in many disorders with vastly different symptoms and etiologies (Maher & Ross,
1984). The common thread appears to be that the delusions involve reactions to bodily disability,
anomalous sensory or motor features, or both. Second, there is no evidence of generally impaired
reasoning ability in delusional patients (Maher, 1988). In contrast, the few relevant studies (Nims,
1959; Williams, 1964) have suggested that deluded and nondeluded patients made the same types
of errors, although the former made more errors and showed performance deficits in a wide range
of tasks. Therefore, no unique reasoning deficit could be inferred. Third, experimental and natural
instigations of anomalous experiences have been found to provoke irrational beliefs in normal Ss
(Cooper & Curry, 1976; Jones, 1966; Zimbardo, Andersen & Kabat, 1981).
Can Maher’s formulation help to explain the OVI and delusions of OCD? For the theory to be
applicable, one must postulate anomalous experiences in OCD that would give rise to delusional
explanations. What characteristic of obsessive-compulsive experience might underlie the formation
of delusional beliefs?
Perhaps the frequent and persistent obsessional intrusions that characterize OCD constitute the
kind of anomalous experience that could underlie the development of delusional beliefs. That is
to say, the mistaken theories of harm of obsessivecompulsives may be attempts to explain fearful
obsessional intrusions that arise repeatedly and persistently.
Although this speculative account of delusions in OCD appears consistent with Maher’s view,
weaknesses in Maher’s formulation itself leave this account problematic. Specifically, neither all
schizophrenics, nor all individuals with perceptual impairments, nor all obsessivecompulsives,
develop delusions. Assuming that obsessive intrusions are anomalous experiences, Maher’s theory
does not explain why some obsessivecompulsives develop delusions, and others do not. It follows
that something more than anomalous obsessive-compulsive intrusions is required to account for
the development of delusions in OCD.
Experimental findings on selective processing of threat information suggest that certain cognitive
abnormalities may be implicated in delusions. Using a Stroop paradigm, Bentall and Kaney (1989)
found that for patients suffering from persecutory delusions, paranoid content interfered with
color-naming of words. The authors hypothesized that attentional bias toward delusion-relevant
material leads to preferential coding of such material and thus to the persistence of delusional
 Obsessions, overvalued ideas and delusions in OCD 351

beliefs. Interestingly, findings of color-naming interference by threat cues have been obtained with
other disorders that are sometimes associated with fixed ideas of a delusional intensity: depression
(Gotlib & McCann, 1984); anorexia nervosa (Channon, Hemsley & de Silva, 1988); and OCD (Foa,
Illai, McCarthy, Shoyer & Murdock, 1993).
Although intriguing, the findings of cognitive biases in several disorders that are sometimes
characterized by delusions shed little light on the mechanisms underlying delusions in these
disorders. Notably, such biases have also been found in anxiety disorders that are not associated
with the occurrence of delusions, such as phobia (Watts, McKenna, Sharrock & Trezise, 1986;
Watts & Dalgleish, 1991) and posttraumatic stress disorder (Foa, Feske, Murdock, Kozak &
McCarthy, 1991). Nevertheless, the findings on cognitive biases are heuristic: perhaps especially
strong cognitive biases occurring in some individuals contribute to the development and mainten-
ance of delusional beliefs. Of course, cognitive biases may also be causally implicated in
pathological fears of nondelusional intensity.
In contrast to Maher, von Domarus (1944) hypothesized that delusions are related to systematic
epistemological errors. Maher’s (1988) discounting of this hypothesis may have been premature.
Brennan and Hemsley (1984) studied reasoning errors using Chapman’s (1967) illusory correlation
paradigm, in which series of word pairs were presented to delusional and nondelusional
schizophrenics, who later estimated their rates of co-occurrence. They found that paranoid patients
perceived illusory relationships between words, particularly of paranoid content. This finding
indicates that these patients may indeed have deficits in reasoning, and that the deficits are specific
to threat-relevant tasks. Perhaps impairments in syllogistic reasoning related to delusions arise
particularly under ‘threat conditions’, and are supported by strong cognitive bias for threat-related
information. If this were the case, the failure to find deficits in general reasoning in delusional
patients need not contradict a ‘reasoning deficit’ theory of delusions. Data on reasoning
impairments under threat conditions are not available for obsessive-compulsives but, as mentioned
above, clinical observations suggest that the strength of obsessional beliefs for these patients often
covaries with context: such patients seem to be more logical thinkers about their obses-
siveecompulsive fears when they are not being threatened with exposure to their feared situation.

CONCLUSIONS

In the psychiatric literature on OCD, distinctions among obsessions, delusions, and OVI are not
sufficiently clear to be of diagnostic utility. In principle, distinction can be made between
obsessions, delusions, and OVI.However, in practice drawing the line is rather arbitrary. The
distinction between delusions and OVI is at best vague; the two concepts have often been used
interchangeably. The impetus to maintain such a diagnostic distinction may derive from the
seeming contradiction between the classification of OCD as a neurosis and the observation that
obsessive-compulsives can manifest psychotic thinking. To resolve this dissonance, the ‘intermedi-
ate’ concept of overvalued ideas was embraced in descriptions of OCD.
Although a categorical distinction between obsessions and delusions or OVI is conceptually
possible, clinical observations as well as research findings reveal difficulties with this kind of
conceptualization. Obsessive-compulsives vary greatly among one another in degree of insight and
resistance. The two studies that measured these variables showed their samples to occupy the entire
range of scores. It follows that obsessivecompulsive beliefs cannot satisfactorily be dichotomized
into senseless and sensible, and that the notion of a continuum seems more satisfactory.
The usefulness of a dichotomous view of insight about obsessional beliefs is not supported by
treatment outcome findings. Whereas some clinical observations suggested that obses-
siveecompulsives with OVI are unresponsive to behavioral treatment, several reports found such
patients quite responsive to treatment by drugs and/or behavior therapy. Thus, the relationship
between strength of conviction and outcome of therapy remains unresolved. While insight into the
senselessness of an obsessional belief may or may not predict treatment outcome, available reports
agree that the presence of schizophrenia spectrum symptoms in obsessive-compulsive patients
indicates poor prognosis.
A number of methodological and conceptual issues complicate attempts to understand delusions
in OCD. It has been argued that delusional beliefs are multidimensional, and that the traditional
352 MICHAEL J. KOZAK and EDNA B. FOA

notion of their immutability bears reexamination. A satisfactory understanding of the relationship

between delusional beliefs in OCD and those of other disorders awaits longitudinal multidimen-
sional assessment studies that use comparable measures.
No generally accepted theory of delusions is available, and the view that delusions constitute
attempts to rationalize anomalous experiences is not itself a satisfactory account of delusions in
OCD. Perhaps failures in syllogistic reasoning under threat conditions, abetted by cognitive biases
to threat cues, play a role in the formation and maintenance of the most strongly held obsessional
beliefs. Such processes, however, may also operate in nondelusional obsessions.

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