Seeing White Bears That Are Not There: Inference Processes in Obsessions

Meta-cognition refers to the notion of thoughts about one’s own thoughts and has been defined as knowledge and cognition about cognitive phenomena (Flavell, 1979). In recent years, meta-cognitive models have provided accounts of the maintenance of anxiety disorders (e.g., Wells, 2000). Meta-cognitive models would argue that the thoughts about the appearance and utility of otherwise normal thoughts generate anxiety. In this article we apply a meta-cognitive approach to understanding obsessions but, rather than thoughts about thoughts, we suggest that the ruminations in obsessive-compulsive disorder (OCD) without overt compulsions result largely from thoughts about thoughts that do not actually occur. Persons with obsessions thinks they might have or might have had the thoughts, and through a meta-cognitive process termed “inferential confusion,” confuse these imagined thoughts with actual thoughts. This account would explain the repetitive, compulsive yet ego-dystonic nature of obsessions. The justification, provided by patients with OCD, for treating imaginary thoughts as actual thoughts appears to be an imaginary narrative, which produces and maintains the obsessional preoccupation, and seems imposed on reality by a distorted inductive reasoning process.