OCD Type Reactions in Alcoholics – Thought Action Fusion and Uncontrollabilty




Alcoholics and addicts and those with other addictive behaviours appear to have the same general cognitive distortions as well as distortions of errors in thinking specific to their manifest addictive behaviour.

However, there seem to be overlaps in certain cognitive distortions as in the case of thought-action fusion in OCD having similarities with thought-shape fusion in eating disorders as discussed in yesterday’s blog.

Here we consider some of the overlaps with alcoholics and those with OCD in terms of thinking errors.

We look mainly in this study (1) at thought action fusion and the idea of behaviour being uncontrollable as the result of thoughts. Both these ideas suggest thinking about e.g. alcohol will inevitably lead to drinking.

There are also other similarities with OCD and alcoholism such as  intolerance of uncertainty in which we find it difficult not knowing what is going to happen next, in the future, so import negative and catastrophic thinking about what is likely to occur.

In fact catastrophic thinking is another cognitive distortion shared with OCD, alcoholism and other anxiety disorders.

The overlaps or commonalities in cognitive errors suggest there is a common neural mechanism at work in the brain of all these disorders which creates heightened distress/anxiety and results in catastrophic and distorted/deluded thoughts.

These thoughts create such much heightened distress that compulsive behaviors are used to relieve this distress.

So, in short, there seems to be a common neural mechanism which gives rise to similar cognitive distortions and general thought errors across addictive behaviours as well as specific cognitive distortions within and particular to certain addictive  behaviours.

In a future blog we will consider an article from 6-7 years ago co-authored by Aaron Beck, one of the originators of cognitive behavioural therapy who has come to be conclusion that cognitive distortions are related to the neural mechanism of amgyldaloid hyperactivity or overactive fear/threat responding in various anxiety disorders and other psychiatric disorders.


“Relatively little is known about how alcohol abusers appraise their alcohol-related thoughts. Are they aware that alcohol-related thoughts occur naturally and are highly likely during abstinence? Or do they interpret these thoughts in a negative way, for example, as unexpected, shameful, and bothersome?

Finding answers to these questions has implications for relapse prevention, because misinterpretations of naturally occurring thoughts may be detrimental for abstinence (Marlatt & Gordon, 1985).

Metacognitive theory provides a theoretical context for analyzing these open questions about alcohol-related thoughts. It focuses on the role that beliefs about one’s thoughts and appraisal of these thoughts play in the development and persistence of psychological disorders (Nelson, Stuart, Howard, & Crowley, 1999; Purdon & Clark, 1999; Wells, 2000; Wells & Matthews, 1994). A number of conceptual papers and empirical studies have shown that individuals’ appraisal of their intrusive thoughts as detrimental and potentially out of their control may lead them to dysfunctional and counterproductive efforts to control their thinking.

These efforts to control can explain the development and maintenance of various disturbed cognitive processes, including those seen in generalized anxiety disorder (Wells, 1999), obsessive-compulsive disorder (Purdon & Clark, 1999; Rachman & Shafran, 1999), depression (Teasdale, 1999), hypochondriasis (Bouman & Mijer, 1999), and test anxiety (Matthews, Hillyard, & Campbell, 1999).

Although these disorders clearly differ from one another in their clinical presentation, the basic assumption unifying the metacognitive models for each of them is that ‘‘metacognitive beliefs are always involved in guiding the content and nature of cognition that modulates emotional disturbance’’ (Wells, 2000, p. 31).

In this study the researchers conducted a series of semi-structured interviews with patients in the clinic, in order to develop items that represented alcohol abusers’ typical, naturally occurring intrusive thoughts.

Metacognition items

Rather than describe the universe of possible alcohol-related metacognitions, our aim was to identify and operationalize those metacognitive appraisals that best predict clinically relevant variables, such as craving, drug-taking confidence (according to Annis, Martin, & Graham, 1992), and alcohol-related thought suppression.

In accordance with previous results on cognitive and emotional responses to upsetting intrusive thoughts (e.g., Purdon & Clark, 1994), we generated only items tapping selected dimensions that are generally seen as clinically relevant in the cognitive behavioral literature and could be labeled as uncontrollability, unpleasantness, avoidance, and thought-action fusion (the idea that  the belief that having a specific thought makes it more likely that a given behaviour will actually occur).

Sample items include the following: (1) uncontrollability (‘‘I cannot do anything about this thought’’), (2) unpleasantness (‘‘I feel bad when this thought comes up’’), (3) avoidance of the thought (‘‘I do not want to have this thought’’), and (4) thought-action fusion (‘‘This thought forces me to drink, if I cannot abandon it’’).

Craving was operationalized as having a large number of highly intense alcohol related thoughts (Modell et al., 1992), which were expected to be associated with negative cognitive appraisals.

Subjective interpretations of mental events as being uncontrollable often stimulate (mostly counterproductive) efforts to control them, namely, ‘‘thought suppression,’’ which has been extensively investigated in other areas of psychopathology, such as anxiety and depression. There is no reason to believe that thought suppression is not also prominent in alcohol addiction. Thought suppression is necessary only if thoughts occur that are evaluated as negative, uncontrollable, or unpleasant. Therefore, a positive correlation between thought suppression and negative metacognitions was expected.

If negative metacognitions about alcohol exist, this does not seem compatible with high self-expectancy in drug-taking situations, because negative metacognitions are expected to be negatively correlated with drug-taking confidence.

Thus in this study one hypothesis is that  factors (a) Uncontrollability and Thought-Action Fusion and (b) Unpleasantness would correlate positively with measures of thought suppression and craving, and negatively with drug taking confidence.


Based on the results of two samples of alcohol abusers receiving cognitive-behavioral treatment, the Metacognition Questionnaire for Alcohol Abusers (MCQ-A) named Uncontrollability/Thought-Action Fusion and Unpleasantness as prominent cognitive factors in relation to intrusive thoughts.

Uncontrollability/Thought-Action Fusion and Unpleasantness scales were positively correlated, as expected, with detrimental social-cognitive variables, such as craving and thought suppression, and negatively with drug-taking confidence.

The study clearly showed that metacognitive appraisal of alcohol-related thinking can be measured in alcohol-abusing patients.

The appraisal is linked to symptoms such as craving and may lead to counterproductive coping efforts, such as thought suppression.

Although these results call for replication, it seems clear that problematic metacognitive beliefs should be addressed in the cognitive-behavioral treatment of alcohol abuse.

Interestingly, it has already been shown that cognitive interventions can change problematic metacognitions in other kinds of psychopathology, namely anxiety disorders and depression (Wells, 2000). The possibility of using these techniques in the treatment of individuals with alcohol abuse offers promise. However, if problematic metacognitions are not appropriately conceptualized, they cannot be accurately diagnosed and treated.”



  1. Hoyer, J., Hacker, J., & Lindenmeyer, J. (2007). Metacognition in alcohol abusers: How are alcohol-related intrusions appraised?. Cognitive Therapy and Research, 31(6), 817-831.



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