Inferential confusion

Last updated February 21, 2024

Inferential confusion is a meta-cognitive state of confusion that becomes pathological when an individual fails to interpret reality correctly and considers an obsessional belief or subjective reality as an actual probability.^[1] It causes an individual to mistrust their senses and rely on self-created narratives ignoring evidence and the objectivity of events. These self-created narratives come from memories, information, and associations that aren't related- therefore, it deals with the fictional nature of obsessions.^{[ clarification needed ]} It causes the individual to overestimate the threat.^[2]

Inverse Inference

Inverse inference, the inverse of normal inference, is a critical concept of inferential confusion. A person starts out believing in the truthfulness of a theory even though evidence suggests otherwise creating uncertainty about an actual state causing distress.^[2]^[3]^[1] Inverse inference limits a person's ability to refrain from neutralising behaviour, which could explain how attempting to neutralise distressing thoughts actually causes more uncertainty and distress.^[1]

Inferential confusion and OCD

Inferential confusion is a predictor of obsessive–compulsive disorder (OCD) symptoms since value is not placed on the content of the imaginative obsessions but rather on how they are interpreted.The inference-based approach suggests that OCD is a product of distorted inductive thinking where the obsessions are conceptualised as conclusions about possible states of affairs, based on an inductive narrative that holds distinctive emotional themes.^[4] Individuals with OCD also report that their obsessions are largely based on a hypothetical reality lacking direct sensory evidence leading to feelings of distress and anxiety.^[5] The role of inferential confusion therefore leads to formations of obsessions that include a probability of imagined, frightened selves. A person tends to fear the development of this attribute for which there is again no direct evidence- this fear of oneself and inferential confusion are attributes of those with OCD.^[6] Several reasoning errors have been identified by O'Connor & Robillard (1995), which could provide credence to the obsessional inference. Specifically, category errors, drawing inferences from irrelevant memories, facts, and unconnected associations, and a dismissal of actual data while basing action on a hypothetical reality. These reasoning errors bring about inferential confusion where an individual mixes an imagined possibility with a genuine probability leading to more severe symptoms of OCD. Therefore, OCD is considered as a belief disorder alike delusion highlighting the role of non-phobic factors in the onset and maintenance of this disorder.^[7]

Aardema et al. (2005) developed the inferential questionnaire to further expand on the construct of inferential confusion by collecting data from participants suffering from OCD. The questionnaire involved two critical thinking strategies: Inverse reasoning and a distrust of senses. The results from the questionnaire demonstrated a strong correlation between inferential confusion and OCD symptoms suggesting that inferential confusion is a characteristic of OCD.^[2]

Diagnosis: The Inference Based Approach (IBA)

The IBA (inference-based approach)/IBT (inference based therapy) is a common technique to treat highly OCD symptoms that are usually explained by inferential confusion. It conceptualizes OCD as a belief disorder that highlights the remoteness of obsessional cognitive representation from the frightening object or event and signifies the reasoning process behind OCD.^[8] This approach suggests how a person reacts to a possibility of what might happen and not what is actually happening or even an exaggerated version of it.^[9]^[2] One of the treatments of OCD involve cognitive-behaviour therapy (CBT) which conceptualises that a person holding pre-existing beliefs may be more sensitized to strongly reacting to intrusive thoughts. It focuses more on the pre-existing beliefs an individual holds instead of the initial intrusions of doubt. Even though this treatment has gained recognition there are still a substantial number of patients with abnormal investment in obsessional beliefs who haven't improved.^[10] Therefore, over the past 10 years an improved model called the inference-based approach (IBA) was developed which suggested that obsessions can come in various degrees of belief and practicality- this treatment was more effective than CBT amongst patients causing a significant decline in the symptoms.^[9]

Recently, a series of psychological experiments in the 2000s have explored the Inference-based approach and thereby inferential confusion as well. A study conducted by Aardema, Connor, Delorme, and Audet tested the inference-based approach treatment on OCD patients and its symptom subtypes. Later this study was replicated, and extensions were added to test ideas further and expand on the findings- the studies concluded that the inference-based approach treatment was effective in improving OCD patients who had overvalued ideation.^[9]

Criticisms of the Inference Based Approach

Only a few research studies looked for the crucial assumptions of the Inference Based Approach,^[11] other aspects of inferential confusion such as irrelevant associations, category errors, facts taken out of context, and individual differences in the level of absorption have not yet been integrated in research.^[8]
Because some of these studies used non-clinical samples or did not include an anxious control group, there is ambiguity about the findings and if they can be generalised to OCD (in the first case) or are specific to OCD (in the second case).^[11]
Despite the fact that the majority of the investigations were done by a single research group, they have been replicated by other groups. Nonetheless, the model requires more empirical evidence. Internal narratives are being investigated to see if they precede obsessional doubts or are a post-hoc justification for obsessional doubts, as well as the process of transformation during IBT (Inference Based Therapy).^[12]

Cultural Differences

Culture tends to influence several aspects of an individual's psychology, including their perceptions, beliefs, and interpretations of the situation around them and their symptoms. Evolutionarily these cultural groups tend to socially boycott and avoid individuals that are ‘contaminated or sinful’.^[13] Due to gene-culture co-evolution , these deep-rooted beliefs have been passed on over generations creating exaggerated obsessions where an individual persistently feels ‘contaminated’ even though direct sensory evidence suggests otherwise.^[14]

Religion

Several cross-sectional research studies have demonstrated a link between religiosity and OCD-related maladaptive attitudes such as overvaluing responsibility, perfectionism, and the importance and control of thoughts.^[15] Some religions' rigorous and meticulous rules may cause misinterpretation of intrusive thoughts, as well as a persistent desire to control these ideas and guilt. These ideas cause the individual to obsess over hypothetical reality even though their sensory evidence suggests otherwise in order to maintain being ‘virtuous’ and an ingroup member. In many cases the severity of these obsessions may vary, causing the degree of inferential confusion to differ.^[16]^[17] The three processes, main threat evaluations of intrusions, increased mental control effort, and misunderstanding of unsuccessful thought control, are regarded to be especially important in strongly religious people who value personal control over undesired and undesirable intrusive thoughts and pictures.^[17]

Related Research Articles

Obsessive–compulsive personality disorder (OCPD) is a cluster C personality disorder marked by a spectrum of obsessions with rules, lists, schedules, and order, among other things. Symptoms are usually present by the time a person reaches adulthood, and are visible in a variety of situations. The cause of OCPD is thought to involve a combination of genetic and environmental factors, namely problems with attachment.

Hoarding disorder (HD) or Plyushkin's disorder, is a mental disorder characterised by persistent difficulty in parting with possessions and engaging in excessive acquisition of items that are not needed or for which no space is available. This results in severely cluttered living spaces, distress, and impairment in personal, family, social, educational, occupational, or other important areas of functioning. Excessive acquisition is characterized by repetitive urges or behaviours related to amassing or buying property. Difficulty discarding possessions is characterized by a perceived need to save items and distress associated with discarding them. Accumulation of possessions results in living spaces becoming cluttered to the point that their use or safety is compromised. It is recognised by the eleventh revision of the International Classification of Diseases (ICD-11) and the Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5).

Scrupulosity is the pathological guilt/anxiety about moral or religious issues. Although it can affect nonreligious people, it is usually related to religious beliefs. It is personally distressing, dysfunctional, and often accompanied by significant impairment in social functioning. It is typically conceptualized as a moral or religious form of obsessive–compulsive disorder (OCD), The term is derived from the Latin scrupus, a sharp stone, implying a stabbing pain on the conscience. Scrupulosity was formerly called scruples in religious contexts, but the word scruple now commonly refers to a troubling of the conscience rather than to the disorder.

In psychoanalysis, egosyntonic refers to the behaviors, values, and feelings that are in harmony with or acceptable to the needs and goals of the ego, or consistent with one's ideal self-image. Egodystonic is the opposite, referring to thoughts and behaviors that are conflicting or dissonant with the needs and goals of the ego, or further, in conflict with a person's ideal self-image.

Thought broadcasting is a type of delusional condition in which the affected person believes that others can hear their inner thoughts, despite a clear lack of evidence. The person may believe that either those nearby can perceive their thoughts or that they are being transmitted via mediums such as television, radio or the internet. Different people can experience thought broadcasting in different ways. Thought broadcasting is most commonly found among people that have a psychotic disorder, specifically schizophrenia.

An intrusive thought is an unwelcome, involuntary thought, image, or unpleasant idea that may become an obsession, is upsetting or distressing, and can feel difficult to manage or eliminate. When such thoughts are associated with obsessive-compulsive disorder (OCD), Tourette's syndrome (TS), depression, body dysmorphic disorder (BDD), and sometimes attention-deficit hyperactivity disorder (ADHD), the thoughts may become paralyzing, anxiety-provoking, or persistent. Intrusive thoughts may also be associated with episodic memory, unwanted worries or memories from OCD, post-traumatic stress disorder, other anxiety disorders, eating disorders, or psychosis. Intrusive thoughts, urges, and images are of inappropriate things at inappropriate times, and generally have aggressive, sexual, or blasphemous themes.

The Yale–Brown Obsessive–Compulsive Scale (Y-BOCS) is a test to rate the severity of obsessive–compulsive disorder (OCD) symptoms.

The obsessive–compulsive spectrum is a model of medical classification where various psychiatric, neurological and/or medical conditions are described as existing on a spectrum of conditions related to obsessive–compulsive disorder (OCD). "The disorders are thought to lie on a spectrum from impulsive to compulsive where impulsivity is said to persist due to deficits in the ability to inhibit repetitive behavior with known negative consequences, while compulsivity persists as a consequence of deficits in recognizing completion of tasks." OCD is a mental disorder characterized by obsessions and/or compulsions. An obsession is defined as "a recurring thought, image, or urge that the individual cannot control". Compulsion can be described as a "ritualistic behavior that the person feels compelled to perform". The model suggests that many conditions overlap with OCD in symptomatic profile, demographics, family history, neurobiology, comorbidity, clinical course and response to various pharmacotherapies. Conditions described as being on the spectrum are sometimes referred to as obsessive–compulsive spectrum disorders.

Sexual obsessions are persistent and unrelenting thoughts about sexual activity. In the context of obsessive-compulsive disorder (OCD), these are extremely common, and can become extremely debilitating, making the person ashamed of the symptoms and reluctant to seek help. A preoccupation with sexual matters, however, does not only occur as a symptom of OCD, they may be enjoyable in other contexts.

<span class="mw-page-title-main">Compulsive behavior</span> Habit and impulse disorder

Compulsive behavior is defined as performing an action persistently and repetitively. Compulsive behaviors could be an attempt to make obsessions go away. Compulsive behaviors are a need to reduce apprehension caused by internal feelings a person wants to abstain from or control. A major cause of compulsive behavior is said to be obsessive–compulsive disorder (OCD). "The main idea of compulsive behavior is that the likely excessive activity is not connected to the purpose to which it appears directed." There are many different types of compulsive behaviors including shopping, hoarding, eating, gambling, trichotillomania and picking skin, itching, checking, counting, washing, sex, and more. Also, there are cultural examples of compulsive behavior.

Exposure therapy is a technique in behavior therapy to treat anxiety disorders.

Primarily obsessional obsessive–compulsive disorder, also known as purely obsessional obsessive–compulsive disorder, is a lesser-known form or manifestation of OCD. It is not a diagnosis in the DSM-5. For people with primarily obsessional OCD, there are fewer observable compulsions, compared to those commonly seen with the typical form of OCD. While ritualizing and neutralizing behaviors do take place, they are mostly cognitive in nature, involving mental avoidance and excessive rumination. Primarily obsessional OCD takes the form of intrusive thoughts often of a distressing, sexual, or violent nature.

Obsessive–compulsive disorder (OCD) is a mental and behavioral disorder in which an individual has intrusive thoughts and feels the need to perform certain routines (compulsions) repeatedly to relieve the distress caused by the obsession, to the extent where it impairs general function.

The cause of obsessive–compulsive disorder is understood mainly through identifying biological risk factors that lead to obsessive–compulsive disorder (OCD) symptomology. The leading hypotheses propose the involvement of the orbitofrontal cortex, basal ganglia, and/or the limbic system, with discoveries being made in the fields of neuroanatomy, neurochemistry, neuroimmunology, neurogenetics, and neuroethology.

In psychology, relationship obsessive–compulsive disorder (ROCD) is a form of obsessive–compulsive disorder focusing on close or intimate relationships. Such obsessions can become extremely distressing and debilitating, having negative impacts on relationships functioning.

The delayed-maturation theory of obsessive–compulsive disorder suggests that obsessive–compulsive disorder (OCD) can be caused by delayed maturation of the frontal striatal circuitry or parts of the brain that make up the frontal cortex, striatum, or integrating circuits. Some researchers suspect that variations in the volume of specific brain structures can be observed in children that have OCD. It has not been determined if delayed-maturation of this frontal circuitry contributes to the development of OCD or if OCD is the ailment that inhibits normal growth of structures in the frontal striatal, frontal cortex, or striatum. However, the use of neuroimaging has equipped researchers with evidence of some brain structures that are consistently less adequate and less matured in patients diagnosed with OCD in comparison to brains without OCD. More specifically, structures such as the caudate nucleus, volumes of gray matter, white matter, and the cingulate have been identified as being less developed in people with OCD in comparison to individuals that do not have OCD. However, the cortex volume of the operculum (brain) is larger and OCD patients are also reported to have larger temporal lobe volumes; which has been identified in some women patients with OCD. Further research is needed to determine the effect of these structural size differences on the onset and degree of OCD and the maturation of specific brain structures.

Safety behaviors are coping behaviors used to reduce anxiety and fear when the user feels threatened. An example of a safety behavior in social anxiety is to think of excuses to escape a potentially uncomfortable situation. These safety behaviors, although useful for reducing anxiety in the short term, might become maladaptive over the long term by prolonging anxiety and fear of nonthreatening situations. This problem is commonly experienced in anxiety disorders. Treatments such as exposure and response prevention focus on eliminating safety behaviors due to the detrimental role safety behaviors have in mental disorders. There is a disputed claim that safety behaviors can be beneficial to use during the early stages of treatment.

<span class="mw-page-title-main">Jonathan Abramowitz</span> American clinical psychologist

Jonathan Stuart Abramowitz is an American clinical psychologist and Professor in the Department of Psychology and Neuroscience at the University of North Carolina at Chapel Hill (UNC-CH). He is an expert on obsessive-compulsive disorder (OCD) and anxiety disorders whose work is highly cited. He maintains a research lab and currently serves as the Director of the UNC-CH Clinical Psychology PhD Program. Abramowitz approaches the understanding and treatment of psychological problems from a cognitive-behavioral perspective.

The Dimensional Obsessive-Compulsive Scale (DOCS) is a 20-item self-report instrument that assesses the severity of Obsessive-Compulsive Disorder (OCD) symptoms along four empirically supported theme-based dimensions: (a) contamination, (b) responsibility for harm and mistakes, (c) incompleteness/symmetry, and (d) unacceptable (taboo) thoughts. The scale was developed in 2010 by a team of experts on OCD led by Jonathan Abramowitz, PhD to improve upon existing OCD measures and advance the assessment and understanding of OCD. The DOCS contains four subscales that have been shown to have good reliability, validity, diagnostic sensitivity, and sensitivity to treatment effects in a variety of settings cross-culturally and in different languages. As such, the DOCS meets the needs of clinicians and researchers who wish to measure current OCD symptoms or assess changes in symptoms over time.

Inference-based therapy (IBT), also known as inference-based cognitive behavioral therapy (I-CBT), originated as a form of cognitive therapy developed for treating obsessive-compulsive disorder. IBT followed the observation that people with OCD often inferred danger on the basis of inverse inference. Later the model was extended to inferential confusion, where inverse inference leads to distrust of the senses and investment in remote possibility. In this model, individuals with obsessive-compulsive disorder are hypothesized to put a greater emphasis on an imagined possibility than on what can be perceived with the senses, and to confuse the imagined possibility with reality. According to inference-based therapy, obsessional thinking occurs when the person replaces reality and real probabilities with imagined possibilities; the obsession is hypothesized to concern a doubt about a possible state of affairs.

References

1 2 3 Aardema, Frederick; O’Connor, Kieron P.; Emmelkamp, Paul M. G.; Marchand, André; Todorov, Christo (2005-03-01). "Inferential confusion in obsessive–compulsive disorder: the inferential confusion questionnaire". Behaviour Research and Therapy. 43 (3): 293–308. doi:10.1016/j.brat.2004.02.003. ISSN 0005-7967. PMID 15680927.
1 2 3 4 Wong, Shiu F.; Grisham, Jessica R. (April 1, 2017). "Inverse reasoning processes in obsessive-compulsive disorder". Journal of Anxiety Disorders. 47: 75–82. doi:10.1016/j.janxdis.2016.12.005. PMID 28057396. S2CID 28637070 – via ScienceDirect.
↑ "Inferential confusion moderates the effects of dissociative experiences on OCD symptoms severity in a clinical sample with Obsessive-Compulsive Disorder | Clinical Neuropsychiatry". 2019-05-10. Retrieved 2022-02-08.
↑ Wu, Kevin D.; Aardema, Frederick; O’Connor, Kieron P. (2009-08-01). "Inferential confusion, obsessive beliefs, and obsessive-compulsive symptoms: A replication and extension". Journal of Anxiety Disorders. 23 (6): 746–752. doi:10.1016/j.janxdis.2009.02.017. ISSN 0887-6185. PMID 19345557.
↑ "Inferential confusion moderates the effects of dissociative experiences on OCD symptoms severity in a clinical sample with Obsessive-Compulsive Disorder | Clinical Neuropsychiatry". 2019-05-10. Retrieved 2022-02-10.
↑ Audet, Jean-Sébastien; Wong, Shiu F.; Radomsky, Adam S.; Aardema, Frederick (2020-07-01). "Not all intrusions are created equal: The role of context, feared-self perceptions and inferential confusion in the occurrence of abnormal intrusions". Journal of Obsessive-Compulsive and Related Disorders. 26: 100537. doi:10.1016/j.jocrd.2020.100537. ISSN 2211-3649. S2CID 219033486.
↑ Aardema, Frederick; o'Connor, Kieron P.; Emmelkamp, Paul M.G.; Marchand, André; Todorov, Christo (2005). "Inferential confusion in obsessive-compulsive disorder: The Inferential Confusion Questionnaire". Behaviour Research and Therapy. 43 (3): 293–308. doi:10.1016/j.brat.2004.02.003. PMID 15680927.
1 2 Aardema, Frederick; O’Connor, Kieron P.; Emmelkamp, Paul M. G.; Marchand, André; Todorov, Christo (2005-03-01). "Inferential confusion in obsessive–compulsive disorder: the inferential confusion questionnaire". Behaviour Research and Therapy. 43 (3): 293–308. doi:10.1016/j.brat.2004.02.003. ISSN 0005-7967. PMID 15680927.
1 2 3 Aardema, Frederick; O`Connor, Kieron P.; Delorme, Marie-Eve; Audet, Jean-Sebastien (2017). "The Inference-Based Approach (IBA) to the Treatment of Obsessive–Compulsive Disorder: An Open Trial Across Symptom Subtypes and Treatment-Resistant Cases". Clinical Psychology & Psychotherapy. 24 (2): 289–301. doi:10.1002/cpp.2024. ISSN 1099-0879. PMID 27279350.
↑ Aardema, Frederick; O Connor, Kieron P.; Delorme, Marie-Eve; Audet, Jean-Sebastien (March 2017). "The Inference-Based Approach (IBA) to the Treatment of Obsessive-Compulsive Disorder: An Open Trial Across Symptom Subtypes and Treatment-Resistant Cases". Clinical Psychology & Psychotherapy. 24 (2): 289–301. doi:10.1002/cpp.2024. ISSN 1099-0879. PMID 27279350.
1 2 Julien, Dominic; O’Connor, Kieron; Aardema, Frederick (2016-09-15). "The inference-based approach to obsessive-compulsive disorder: A comprehensive review of its etiological model, treatment efficacy, and model of change". Journal of Affective Disorders. 202: 187–196. doi:10.1016/j.jad.2016.05.060. ISSN 0165-0327. PMID 27262641.
↑ "Education Session on Burnout Makes a Plan to Prioritize Physician Well-Being". Default Digital Object Group. 2021-04-21. doi:10.1200/adn.21.200514. S2CID 240602893 . Retrieved 2022-02-15.
↑ Hunt, Christopher (July 1, 2020). "Differences in OCD symptom presentations across age, culture, and gender: A quantitative review of studies using the Y-BOCS symptom checklist". Journal of Obsessive-Compulsive and Related Disorders. 26: 100533. doi:10.1016/j.jocrd.2020.100533. S2CID 226207804 – via ScienceDirect.
↑ Yorulmaz, Orçun; Gençöz, Tülin; Woody, Sheila (2009-04-01). "OCD cognitions and symptoms in different religious contexts". Journal of Anxiety Disorders. 23 (3): 401–406. doi:10.1016/j.janxdis.2008.11.001. ISSN 0887-6185. PMID 19108983.
↑ Yorulmaz, Orçun; Gençöz, Tülin; Woody, Sheila (2009-04-01). "OCD cognitions and symptoms in different religious contexts". Journal of Anxiety Disorders. 23 (3): 401–406. doi:10.1016/j.janxdis.2008.11.001. ISSN 0887-6185. PMID 19108983.
↑ Yorulmaz, Orçun; Gençöz, Tülin; Woody, Sheila (April 2009). "OCD cognitions and symptoms in different religious contexts". Journal of Anxiety Disorders. 23 (3): 401–406. doi:10.1016/j.janxdis.2008.11.001. ISSN 1873-7897. PMID 19108983.
1 2 Inozu, Mujgan; Karanci, A. Nuray; Clark, David A. (September 1, 2012). "Why are religious individuals more obsessional? The role of mental control beliefs and guilt in Muslims and Christians". Journal of Behavior Therapy and Experimental Psychiatry. 43 (3): 959–966. doi:10.1016/j.jbtep.2012.02.004. PMID 22484698 – via ScienceDirect.