The Cognitive Architecture of Obsessional Doubt: Inferential Confusion and Feared Selves in OCD-Relevant Intrusions

Although previous research has examined the individual roles of unwanted intrusive thoughts (UITs), inferential confusion and feared selves in obsessive-compulsive disorder (OCD), no study to date has evaluated their combined effects on OCD severity. This is particularly relevant given that the inference-based approach (IBA) posits a close link between inferential confusion and feared selves in the context of obsessional doubt. The present study with a cross-sectional design investigated the role of inferential confusion and feared selves in mediating the relationship between OCD-relevant UITs and OCD severity. A clinical sample of 306 individuals with a primary diagnosis of OCD (mean age = 32.95, SD = 9.99, female = 58.8%) who also had some comorbid psychiatric disorders, with the exception of a current or previous history of personality disorders, psychotic disorders and substance use disorders, completed a battery of self-reported measures-including the Questionnaire of Unpleasant Intrusive Thoughts, Fear of Self Questionnaire-Multidimensional Version, Patient Health Questionnaire and Expanded Version of the Inference Confusion Questionnaire)-as well as the clinician-administered version of the Yale-Brown Obsessive-Compulsive Scale. Bootstrapped mediation analyses (5000 resamples, 95% confidence interval) revealed that UITs were indirectly associated with OCD severity via inferential confusion and one specific dimension of feared selves: the feared corrupted self. Mediation was not supported for the feared culpable or malformed selves in this model. However, a serial mediation pathway emerged wherein inferential confusion and both feared corrupted and culpable selves sequentially mediated the link between UITs and clinician-rated OCD severity. The findings suggest that inferential confusion, along with specific feared self domains, plays a critical role in differentiating intrusive thoughts that are common in the general population from obsessional doubt, as conceptualised in the IBA. Within the inference-based framework, these processes do not merely escalate UITs; rather, they actively produce obsessional doubts that disconnect the individual from reality and render the imagined threat personally meaningful, persistent and in need of resolution.