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Introduction
Obsessive-compulsive disorder is a chronic and often disabling anxiety disorder, and has been recognized for more than 300 years (Salzman and Thaler, 1981). Although several etiological theories of OCD have been proposed, including psychogenic factors, learning theory, neurological and biological models, most of the theories offer only sketches of putative mechanism and unfortunately fail to account for the full picture of pathological processes. Clark and Purdon (1993) suggested that high rate of drop-out, poor treatment compliance, limitation of exposure and response prevention for many patients, and the treatment resistant nature of pure obsession (Rachman and Hodgson, 1980; Salkovskis and Westbrook, 1989) have led researchers to explore cognitive processes in the aetiology and treatment of OCD.
The first comprehensive cognitive model of OCD was developed by Salkovskis (1985, 1989). Consistent with previous studies in non-clinical populations (e.g. Rachman and de Silva, 1978), Salkovskis suggested that cognitive intrusions are universally experienced and may be triggered by external and internal stimuli, and cause a problem to individuals only if they appraise the intrusions as having important adverse personal implications for them. Salkovskis argued that if an appraisal does not include an element of responsibility, the person is likely to be anxious or depressed rather than developing obsessional problems.
Responsibility appraisals lead both to more adverse mood, such as anxiety and depression, and the decisions and motivation to engage in neutralizing behaviours to decrease discomfort, diminish the intrusion, and avoid being responsible for the feared catastrophic consequences. The successful completion of these neutralizing behaviours not only increases the likelihood of further intrusions, but also increases the perceived threat and the perception of responsibility. The role of the exaggerated responsibility was supported by clinical observations (e.g. Rachman, 1993), questionnaires (e.g. Foa, Amir, Bogert, Minar and Preworski, 2001; Foa, Sacks, Tolin, Preworski and Amir, 2002), experimental manipulations (e.g. Arntz, Voncken and Goosen, 2007; Shafran, 1997), and treatment efficacy studies (e.g. Freeston, Rheaume and Ladouceur, 1996; Ladouceur, Leger, Rheaume and Dube, 1996). Moreover, the inflated sense of responsibility in OCD was further supported by the findings from non-Western countries, such as Iran (Ghassemzadeh, Bolhari, Birashk and Salavati, 2005) and Turkey (Altin and Gençöz, 2007; Altin and Karanci, 2008; Yorulmaz, Karanci and Tekok-Kiliç, 2006; Yorulmaz, Altin...