Casey Donaghey, Jonathan Egan and Páraic S. O’Súilleabháin.
Objectives: Intrusive thoughts are a relatively common experience in community samples. They are also commonly reported in patients who present with a range of psychiatric diagnoses, yet underlying mechanisms of effect remain unclear. As such, the overall objective of the present study was to elucidate psychological predictors of intrusive thoughts. Methods – The sample consisted of 186 (M ± SD = 22.41 ± 6.96 years) individuals who completed a series of validated measures pertaining to hypothesized psychological factors to consider in the context of intrusive thoughts. Results: The model emerged as significant and accounted for 32 percent of the variance in relation to current experiences of intrusive thoughts. Current depressive mood (p<0.001), high absorption (p=.01), previous experiences of trauma (p=.002), and low openness to experience (p=0.03) scores were observed as significant predictors of intrusive thoughts. Conclusions: The findings suggest that depressive mood, high absorption, experiences of trauma, and low openness to experience are important factors to consider in the context of intrusive thoughts. These findings further suggest that clinical practice should consider these factors in the treatment of individuals with intrusive thoughts.
Intrusive thoughts are unwanted thoughts that intrude on our consciousness. These thoughts are universal and are common in everyday life. Radomsky and colleagues1 in a large cross-cultural sample (N = 777), found that over 94 percent of their sample of university students reported experiencing intrusive thoughts. Intrusive thoughts when distressing and affecting quality of life and engagement are also common symptoms of clinical disorders such as anxiety, PTSD, insomnia, depression, and OCD.2,3,4 There are many contributing factors which have been highlighted to contribute to the expression of intrusive thoughts, such as: psychological trauma, anxiety, depression, personality traits (high neuroticism and low extraversion) and poor emotional regulation strategies.5,6,7,8,9 This article will discuss these various relationship and will analyse these relationships both individually and collectively.
Cognitive theorists have suggested that the key moderating factor when considering intrusive thoughts is a person’s interpretation of their initial automatic thought about an event. This interpretation can lead to or maintain a negative affect and increase levels of anxiety, or lower mood.10 Adrian Wells’s Meta-Cognitive Theory11 examines how an appraisal of an event can positively or negatively impact peoples’ stress levels. It suggests that there are two levels of fear related cognitions (fear related to specific illness or finance and then the person perceives the act of worrying as having some portentous result). This theory is supported by the cognitive behavioural theory of anxiety and obsessive-compulsive thoughts or disorder,12,13 endorsing the interaction between cognitive processes and thoughts and behaviours.
Separately, other theorists have focused on the environmental triggers and a person’s stress responses and how they manage their emotions which may mediate the experience of intrusive thoughts.14 Situations can elicit emotions such as fear or anger, and then these emotions can contribute to thoughts such as ‘I am feeling guilty, I must have done something wrong’. Researchers note that there is a reciprocal feedback and amplification effect between cognition and affect and vice-versa.15,16 How we react to events is idiosyncratic and can often be guided by a person’s personality and life history.
As previously mentioned, personality traits such as low extraversion and high neuroticism have been identified as being related to intrusive thoughts.17,18 In addition, agreeableness and openness to experience have also been found to be related to occurrence of intrusive thoughts. These traits have been implicated as a central component to an individual’s stress responsivity, and adaptation or resilience across time.19,20,21,22 Indeed, these traits have been linked to different coping mechanisms. Individual’s reporting higher extraversion have been observed as being recharged by interacting with others, while their introverted counterparts achieve this by withdrawing to their own personal process.23 As intrusive thoughts are a symptom of a diagnosis of Obsessive Compulsive Disorder (OCD), considerable research has focused on patients with OCD to investigate how personality traits relate to intrusive thoughts.18,24 Extraversion and neuroticism have been observed to correlate with cognitive functioning and therefore affect the severity of intrusive thoughts.25 In a study of patients awaiting a cancer diagnosis,26 the personality trait of openness was related to higher intrusive thoughts and anxiety about seeking help. Neuroticism has also been highly correlated with cognitive functioning affecting event perception16 mediating this relationship between cognition and intrusive thoughts even further.
Emotional regulation strategies have been shown to have a significant impact on the presence of intrusive thoughts.24,27,28 There are several types of emotion regulation strategies such as appraisal, suppression, repression, depersonalisation, and dissociation. In a sample of non-clinical participants, the presence of dissociation was found to be highly correlated with the experience of traumatic events as a form of diminishing the emotional impact that these traumas had and reducing traumatic memories and intrusive thoughts.29
Dissociation is an involuntary way of regulating acute stress and emotions in threatening situations. Biologically it is related to the release and presence of higher levels of cortisol.30 It results in people reporting confusion, poor memory consolidation and difficulty in tracking themselves across place and time. Following the initial fight-flight stage of the sympathetic branch of the autonomic system arousal it is associated with a deactivation of the limbic system and a hyper-arousal of the pre-frontal cortex, allowing cognition to remain intact whilst also numbing emotional reactions. 29,31,32,33,34 Recently an Irish study with a sample of 761 young adults35 found that depersonalization mediated the relationship between insecure attachment style and depression, anxiety and stress. Depersonalization was higher in those who experience maltreatment and emotional abuse than those who experienced physical or sexual abuse. In addition, those who were in the clinical cut-off range of depersonalization were found to have higher somatic symptoms on the PHQ15 as well as almost double the levels of anxiety, depression and stress.
Dissociation measures have been found to contain three factors; (a) depersonalization/derealisation, (b) amnesia and (c) absorption. Absorption allows an individual to remove themselves in thought from a current stressor. In a study by Naring and Nijenhuis,28 they found that absorption was the most significant factor in peoples’ trauma responses. In an effort to decrease a person’s reaction to a trauma, they automatically detach from the stressor, focussing their consciousness on everything else. Failure to absorb the daily moments in detail helps the individual to dissociate from what is going on around them. Brand and Stadnik36 and Seffer-Dudek37 found that absorption elicits obsessive ruminations and resulting compulsive behaviours. Seffer-Dudek and colleagues 38 reports absorption to have similar effects to inferential confusion on attention where individuals get too absorbed in their own imagination during their reasoning process bringing about obsessions that do not match reality.
Traumatic experiences often reduce a person’s ability to cope with regular life stressors. 39 When someone experiences trauma, their body produces stress hormones causing high activity in the hypothalamus region of the brain. This often results in more frequent intrusive thoughts. For example, a study by Ironson and colleagues40 examined survivors following Hurricane Andrew for a period of a year. The participants stress hormone levels were investigated as well as scores of intrusive thoughts and avoidant thoughts. Both the levels of cortisol and adrenaline were higher at times close to the trauma, as were the levels of intrusive thoughts. Over the year, all variables decreased, showing a strong temporal relationship between the experience of trauma and intrusive thoughts. Recent research from Northern Ireland41 in a sample of 49 patients found a relationship between trauma, parental bonding and current diagnosis of bipolar disorder or depression.
To conclude, the studies reviewed indicate that a variety of factors are distinctly associated with intrusive thoughts, namely, personality traits, dissociation, anxiety, depression and traumatic experiences. Empirical evidence has shown low extraversion and high neuroticism personality traits, previous experiences of trauma as well as dissociative experiences to increase the presence of intrusive thoughts in clinical and non-clinical samples. The overall purpose of the current study is to determine the relationships of these factors and intrusive thoughts. In doing so, we are seeking to develop a more robust and encompassing set of indicators of potential associations which may then result in assessing the clinical impact of focusing treatments on each predictor found, with the knowledge that anxiety and depression are key moderators to control for in any analysis. Considering research hasn’t investigated the interaction between all of these variables on intrusive thoughts, at once, this research aspires to increase knowledge in the clinical field about the connection between dissociation, personality traits and intrusive thoughts in the aim of aiding diagnostic models and improving quality of care. All in all, this research aims to give a broader view of the symptoms and possible treatments of intrusive thoughts/OCD.
The current sample consisted of undergraduate university students (N = 186; females = 142, males = 43, non-binary = 1; age M ± SD = 22.41 ± 6.96 years; range = 18 – 52 years). 65% of the participants were aged from 18-21. 37% of the population reported experiencing trauma while 63% did not. The overall response rate was 96% with 186 out of 193 people answering the questionnaires. All participants were voluntary and received partial course credit for participating. Exclusion criteria excluded anyone under the age of 18 and who did not speak English as their first language.
Six questionnaires were used in this study. Firstly, there was a demographic questionnaire administered which had questions about the participants’ age, gender and previous experience of trauma. In addition, there were questionnaires on dissociation, personality, presence of intrusive thoughts, depressive tendencies as well as experiences of anxiety.
The Dissociative Experiences Scale42 (DES) is a 28 item self-report scale used to measure the presence of dissociation in a person’s life. The scores were scaled from 0 to 100% comprising of 10% increments. The scores for each question were totalled and averaged to get the mean DES score. Van IJzendoorn and Schuengel43 have shown robust discriminant and convergent validity (d=1.82; N = 5,916) in association with interviews (d = 2.05) and questionnaires (d=1.81). Cronbach’s alpha for the DES when assessing students was 0.93 in Frischholz, Braun, Sachs and Hopkins44 and was 0.94 in the present study. Often this scale is divided into the 3 subscales of depersonalisation, amnesia, and absorption.45 The Cronbach’s alpha for each scale in this study were; depersonalisation (0.83), amnesia (0.80), and absorption (0.83).
To evaluate the participants’ personality traits, the NEO – Five Factor Inventory46 (NEO FFI-3) was used. This is a 60 item self-report scale used to measure the personality traits of extraversion, openness to experience, conscientiousness, agreeableness, and neuroticism. A five-point Likert scale was used to measure it ranging from ‘strongly disagree’ to ‘strongly agree’. In Schwartz, Chapman, Duberstein, Weinstock-Guttman and Benedict,47 the Cronbach’s alpha was calculated for each subscale (extraversion = 0.80, neuroticism = 0.87, agreeableness = 0.74, openness to experience = 0.71, and conscientiousness = 0.84), showing good internal consistency in this measure. Good convergent and discriminant validity was also shown for the five key personality traits in Hopwood and colleagues.48 The Cronbach’s alpha scores in the current study were; extraversion = 0.80, neuroticism = 0.87, agreeableness = 0.74, openness to experience = 0.61, and conscientiousness = 0.86.
To check for the presence of intrusive thoughts, the participants filled out the Revised Obsessional Intrusions Inventory48 (ROII). This was a 52 item self-report scale. A seven-point Likert scale was used to measure it from ‘not at all’ to ‘all of the time’. Cronbach’s alpha for the ROII ranged from 0.82-0.93 showing great internal consistency.49 The Cronbach’s alpha for this measure was 0.95 in the present study.
Depression was investigated using the Patient Health Questionnaire-950 (PHQ-9). This was a 9 item self-report questionnaire used to measure the presence of depression in a person’s life. It was measured by frequency on a 4 point Likert scale from ‘not at all’ to ‘nearly every day’. Cronbach’s alpha for the PHQ-9 has been observed as 0.85 in existing research.50 The present study Cronbach’s alpha was observed as 0.86.
Anxiety was then measured using the Generalised Anxiety Disorder-751 (GAD-7). This was a 7 item self-report questionnaire used to measure the presence of anxiety in a person’s life. It was measured by frequency on a 4-point Likert scale from ‘not at all’ to ‘nearly every day’. Spitzer and colleagues52 found that the GAD-7 had good discriminant and convergent validity. Zhong and colleagues53 confirmed this while evaluating the Cronbach’s alpha for GAD-7 to be 0.89. When analysing anxiety measures, Cameron and colleagues54 found that the GAD-7 had greater validity and reliability when compared to the HADS-A, HRSD-17 and the William’s test. For this sample, the Cronbach’s alpha was 0.91.
Prior to commencement the present study procedure received full ethical approval in accordance with the Declaration of Helsinki from the institutional Research Ethics Committee at the National University of Ireland, Galway. Following approval, all materials were made available through an online research survey medium (Survey Monkey). Participants were then invited to participate in the study through the Sona System which was linked to the online survey. Each participant received course credits for participating in the study. An information sheet and consent form were given to each participant before they completed the questionnaires. Just enough information was given to the participants to prevent any experimenter bias. They completed a battery of six questionnaires; a demographics questionnaire, the Dissociative Experiences Scale (DES), the NEO – Five Factor Inventory, the Revised Obsessional Intrusions Inventory (ROII), the PHQ-9 and the GAD-7. After completion of the questionnaires, the purpose of the study was explained in full and contact details for support services were provided to all the participants.
The data was collected on http://www.surveymonkey.com and was transferred into a SPSS file for analysis.55 This programme then conducted descriptive analysis, correlation matrices and hierarchical regression to investigate the relationship between the different categories of independent variables on intrusive thoughts. The inclusion of variables into steps within the multiple regression are as follows; step one (anxiety and depression); step two (trauma); step three, (neuroticism, extraversion, openness to experience, agreeableness, and conscientiousness); and finally step four (the three subscales of dissociation; depersonalisation, amnesia & absorption).
Scale reliability was assessed using Cronbach’s alpha and there was a range from 0.61 – 0.95. The data distributions were then examined. Intrusive thought measures were positively skewed and required a log transformation. As the remaining data was normal, further analysis was conducted using SPSS.
Descriptive statistics for intrusive thoughts, the two emotional regulation strategies, the five personality traits, demographic variables (see Table 1.) and control variables (depression, anxiety and experience of trauma) are presented in Table 2. below. This shows the variety in the participants’ scores. A table for the ROII scores is included in Table 3.
Table 1. Demographics of Participants
Table 2. Descriptive Statistics for Predictor and Criterion Variables
Table 3: Percentages Scored on the ROII
A correlation matrix was conducted to evaluate the relationships between all the variables and to check for any multicollinearity. Trauma, neuroticism, openness, agreeableness, conscientiousness, depression, anxiety, depersonalisation, amnesia and absorption all correlated significantly with intrusive thoughts (p<0.05). Table 4. below shows the inter-correlations between variables.
Table 4. Summary of Pearson’s Product Correlations for Predictor and Criterion Variables
Further analysis involving a single multiple hierarchical regression was conducted to investigate the impact that these variables had on intrusive thoughts separately and as a whole. For the hierarchical regression, the overall model was significant, contributing to 32% of the variance accounting to the presence of intrusive thoughts (see Table 5). Within this model, step one, both depression and anxiety were entered. This step accounted for 14% of the variance (F(2, 161 =14.72), p<0.00, R2 =.16, Adj R2=0.14). Depression was the sole contributor and had a significant beta weight (β=.38, p<0.001). Introducing prior trauma within step two further contributed to the model (F(1,160)=9.48, p=.002, R2 =.20 Adj R2=0.19). This added 5% of variance to the model (β=.22, p=.002). Evaluation of personality traits within step three further contributed to the model (F(2,158)=2.38, p = 0.04, R2 = .22 Adj R2 =0.21). Openness to experience was the only trait that emerged to be significant (β=-.16, p=0.03), contributing to a further 2% of variance to the model. Finally, in step four, depersonalization, absorption, and amnesia were added and they significantly contributed to the overall model (F(3,155)=9.75, p<0.01, R2=.35 Adj R2=.0.32), resulting in an additional 11% of variance leading to a total of 32% of variance explained in the occurrence of intrusive thoughts. An examination of the separate contributions revealed that absorption (β=.30, p=.01) was the significant contributor.
Table 5. Hierarchical Regression of the predictor variables
This study aimed to investigate the different variables that have an impact on the presence of intrusive thoughts in a non-clinical sample. Intrusive thoughts are a common experience and it was important to investigate the impact that personality traits, personal trauma history and mood states could have on the presence of intrusive thoughts. The findings of this research can help to both normalise these thoughts and also to guide treatment protocols. It seems timely to explore the importance of personal trauma, tendency to use absorption as a defence and also to invite clients to be open to explore the connection between these and their intrusive thoughts.
In this study, the aim was to investigate what variables would influence the presence of intrusive thoughts. It was hypothesised that five NEO FFI-3 personality traits, depression, anxiety, trauma and dissociation would predict intrusive thoughts.,54,55,56,57,58 The correlation matrix showed most personality traits were significantly (with the exception of extraversion) correlated with the occurrence of intrusive thoughts. The hierarchical regression found that depression, experience of prior trauma, openness to experience, and absorption had a significant impact on present of intrusive thoughts. Significant positive relationships between depression, prior experience of trauma, dissociation and intrusive thoughts were found. A negative correlation between openness to experience and intrusive thoughts meant that a lower openness to experience led to a higher presence of intrusive thoughts. These findings that openness to experience supports previous literature which suggested that there is a significant relationship between low openness to experience scores and intrusive thoughts. The personality trait of openness to experience refers to an individual’s propensity to be open to a variety of experiences, with a need to enlarge and examine experience.42,59 As with all personality traits, it is an adaptive mechanism that has been naturally selected. While much research has historically overlooked the relevance of openness to experience more generally, the present findings have implicated lower openness to experience as particularly relevant within the context of intrusive thoughts. This may relate to the cognitive functioning and flexibility which underpins the trait. Considerable literature exists which highlighting the positive association between openness to experience and cognitive functioning.60 Indeed, further research suggests a decreased ability for cognitive restructuring in persons lower in openness to experience.61 Taken together, possessing a decreased tendency for cognitive flexibility may infer a risk for intrusive thoughts with those lower in openness to experience.
A previous experience of trauma was related to an increased presence of intrusive thoughts. This finding reflects Pujol and colleagues62 research where intrusive thoughts were a key symptom for patients with PTSD who were receiving a lung cancer diagnosis. Childhood trauma was shown to result in an increase an individual’s chance of having PTSD and or OCD at a younger age.63 This research emphasised the relationship between trauma and the presence of intrusive thoughts.
Depression has been shown to affect a person’s cognitive processing which results in higher intrusive thoughts.64,64 On the other hand, anxiety was proposed to alter a person’s cognitive processes, like in Robinson, Vytal, Cornwell and Grillon66 where anxiety was found to affect perception and attention among other cognitive processes. The findings found a correlation between these two variables but did not get significant results in the hierarchical regression suggestion that there is a connection between anxiety and intrusive thoughts but anxiety does not significantly influence the presence of intrusive thoughts. As the minimum score for anxiety was 7, this study had no participants who were not anxious and therefore the study could not investigate the levels of intrusive thoughts for people with no anxiety.
These findings on absorption highlight its impact on cognitive processes and intrusive thoughts. A person who practices absorption as a coping strategy will be unable to absorb their daily moments effectively and often live in a tranced state. A lot of past literature has focused on dissociation as a whole and its impact on intrusive thoughts.67 These findings build on pieces of literature showing absorption, as a part of dissociation, to have a strong influence on emotional regulation and intrusive thoughts.29
There were many strengths to this study such as a large sample size with a high response rate of 96% but limitations still arose. This sample was an undergraduate student sample meaning that the data may not generalizable to the whole population. As students often want to appear ‘normal’ they may submit incorrect answers causing bias to the scores, a manifestation of the ‘good subject effect’. This may explain the correlation between low neuroticism and high intrusive thoughts or the reason why depersonalisation is not significantly correlated with intrusive thoughts as observed in other studies. Another limitation is that it was a self-report study which may not be as accurate as using experimental design. Unfortunately, those participants who scored high in dissociation may not remember things about themselves that could give the researchers a different score.
Suggestions for future research
With this study supporting results from past research as well as showing new findings on the relationship between the presence of intrusive thoughts and other variables, further research in this area is possible. This could involve experimental designs where different measures can be used to confirm these findings in a more sophisticated way. Researchers could also perform the same procedure on a larger more generalizable sample. This would hopefully confirm the hypotheses and then these findings could be used to add to knowledge of dissociation that is used in therapy worldwide.
Summary and Conclusions
From this research, one can conclude that the sub-component of dissociation, absorption has a strong influence on the frequency of intrusive thoughts, as well as prior to experience of trauma and openness to experience. Those who experienced intrusive thoughts were more likely to be prone to dissociation, have experienced a personal trauma, and may have low openness to experience.
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Casey Donaghey, BA, NUI Galway. firstname.lastname@example.org
Dr. Jonathan Egan, Director of Clinical Practice, NUI Galway.
Dr Páraic S. O’Súilleabháin, Post Doctoral Researcher, NUI Galway.