Researchers into the cognitive-behavioral models of OCD propose that OCD arises from specific obsessive–compulsive core beliefs (Clark, 2004; Frost & Steketee, 2002; Salkovskis, 1996). The Obsessive Compulsive Cognitions Working Group (OCCWG, 1997, 2001) identified six distinct types of OC-related beliefs (i.e., inflated sense of responsibility, overestimation of harm, perfectionism, need to control thoughts, intolerance of uncertain, and over-importance of thoughts) that may become overvalued. If the individual is convinced that the belief is reasonable and true, and it remains steady over a long period of time, it may become overvalued. If this individual has good insight, however, s/he would be able to recognize the belief as unreasonable and irrational and begin to challenge the belief. If the individual has poor insight, s/he would understand that the obsession is causing distress, but be unable to use this information effectively due to the high risk that the consequence may occur.

Wernicke (1900) first introduced the concept of OVI, defining it as a solitary belief that one feels is strongly justified and determines one’s actions. He noted that the individual’s misperception of his surroundings is due to the intense affect that they experience. This affective reaction drives the individual to ignore reality and selectively focus on information that confirms his/her belief.

Wernicke (1900) believed that in comparison to obsessions, overvalued ideas were never believed to be senseless by the individual experiencing them. Although Wernicke does not specifically mention OCD, the process by which beliefs become overvalued may be applicable to any thought. Certain obsessions can develop into overvalued ideas as information is processed, and therefore, the strength of conviction in that belief increases.

In contrast to Wernicke, Jaspers (1913) believed that overvalued ideas are challengeable, transient, isolated, and bound to personality and situation, while delusions are unchangeable and not bound to personality. He believed that overvalued ideas are seen in any individual of strong conviction, whereas delusions are strictly seen in individuals diagnosed with a mental disorder. Jaspers noted that overvalued ideas are understandable (verstandlich) convictions that are incorrectly held to be true (e.g., I will get AIDS from this red “blood” spot). On the other hand, delusions are not understandable (undverstandlich) convictions, but perplexing irrational thoughts that are held as true (e.g., I will get pregnant from sitting on the toilet where a man sat).

McKenna (1984) echoes the work of Jaspers, viewing OVI as different from delusions. He notes that OVI is neither delusional nor obsessional. It is an isolated belief that is not intrusive and not viewed as senseless, whereas delusions are both intrusive and senseless.

In the past, some have suggested that high OVI is a temporary psychotic state in individuals with OCD, calling it a “transient loss of insight” or transitional psychosis (Insel & Akiskal, 1986; Roth, 1978). Insel and Akiskal (1986) used clinical vignettes to illustrate that delusions may be temporarily present in OCD, but they are not markers of schizophrenia. Twenty-three patients with OCD were examined on four aspects of obsessive–compulsive beliefs: (1) perceived validity, (2) resistance, (3) strength of belief in harmful consequences, and (4) perceived absurdity when compared to social and cultural norms. Results suggested that OCD represents a continuum of insight with poor insight being described as obsessive–compulsive psychosis.

Matsunaga et al. (2002) compared OCD individuals with good insight (OCD GI), poor insight (OCD PI), and schizophrenia and OCD (OCD+S) at pretreatment, posttreatment, and 6-month follow-up. Treatment consisted of a combination of clomipramine and cognitive-behavioral therapy (CBT). Item 11 of the Yale-Brown Obsessive–Compulsive Scale (Y-BOCS; see below) was used to assess insight. At pretreatment, 36% of the patients displayed intact insight; however, OCD PI patients exhibited a similar degree of impairment to the OCD+S group. At posttreatment, 56% of OCD PI patients no longer fell into that group; rather, they had gained good insight. This illustrates that some patients with poor insight may gain insight with treatment, while others may continue to have overvalued beliefs that are more resistant to change.

Yaryura-Tobias and McKay (2002) pointed to similarities between high OVI and delusions in schizophrenia. They discussed how thought action fusion and magical thinking are both symptoms in OCD and in schizophrenia and can be conceptualized as either OVI or delusional depending on the disorder. They went on to illustrate that as thought action fusion gets stronger the ability to resist the compulsion gets weaker, suggesting a strengthening of the belief.

In order to illustrate how OVI presents in clinical practice, a case that displayed severe OCD symptomology and OVI, which appeared at times to take on a delusional quality, is presented below. This vignette further evidences the challenges presented in diagnoses.

Hailey, a junior high school student, recently began being home-schooled due to the increasing intensity of her OCD symptomology. She had excessive concerns of illness and contamination and believed that touching or coming into contact with people or items from certain countries that were known to have outbreaks of disease could infect her and inevitably cause her death. Hailey was particularly sensitive to Mexico or Mexican products due to the fear of getting the H1N1 virus. At first, she started to avoid touching things while out in public, but soon enough the fear generalized and she became home bound. She believed that a Mexican person or product from Mexico was contaminated and if a person touched that object, they were too contaminated. As the symptoms increased, Hailey became restricted to only certain rooms that she deemed acceptable in her home. She believed that if there was a Mexican person on television in the living room, the living room was now contaminated due to the possibility that the person’s saliva from speaking would come through the television set. When speaking with Hailey about this impossibility, she was able to acknowledge that it was most likely impossible, but still had such fear that she refused to enter the room for a certain period of time. In addition, her home schooling was interrupted because she was reading a book for English class, which ­featured a Mexican boy. Not only did this contaminate the room that she was in, but also contaminated her home-school teacher, and Hailey urged her family not to enter the room so that they too would not become contaminated. Upon working with Hailey using CBT, going outside, she often believed that an object, such as a garbage can, five feet away, had touched her. Despite her agreement that the garbage can was far away and most likely did not touch her, she was convinced she was still infected by it. She would respond that the wind blew the dirt and contamination from the garbage can onto her skin and hair and that she needed to immediately shower to disinfect herself. Hailey’s fears were so great that she would become enraged, blaming all that were with her for putting her in danger, and at one point, refused to continue in treatment. Hailey was tried on a various number of medications and began inpatient CBT treatment, slowly displaying progress to overcome her fears.

As observed by reading the vignette above, Hailey clearly is exhibiting obsessive–compulsive behavior. Despite occasional delusional beliefs, such as saliva coming through a television screen, she was able to acknowledge that this was improbable or scientifically impossible when her anxiety decreased. She was less likely to justify this possibility while in a state of increased anxiety. Even though, she could acknowledge the irrationality of her belief at a later time, she remained resistant to entering the room with the television until a specified time period passed, displaying that she continued to believe that the probability of a negative outcome was too great to chance. Therefore, this belief is in excess of solely being considered an obsession, but rather would be referred to as an overvalued idea. However, as you can see from the example above, there is great difficulty in distinguishing between obsessions, overvalued ideas, and delusions in real-life situations due to the fact that Hailey interprets the same situation differently depending on her affect at the time of questioning. These affect-driven reactions make diagnosis and treatment a challenge.

The Y-BOCS (Goodman et al., 1989) is comprised of a symptom checklist and severity scale. The symptom checklist contains obsessions and compulsions that the patient notes as having currently, having had in the past, or never experienced. The severity scale is a ten-item (five for obsessions and compulsions each) clinician-rated assessment that rates the intensity or strength of OCD symptoms. The five items (frequency, interference, distress, resistance, and control) are assessed to compile a total score for each domain. Each item is rated on a five-point Likert scale (0–4), with higher scores signifying a more pathological profile. Total scores range from 0, which would signify no pathology, to 40, a very severe symptom profile. It was reported by McKay, Danyko, Neziroglu, and Yaryura-Tobias (1995) that the items assessing obsessions and compulsions may be factorially distinct and therefore form two dimensions. As a result, it is best to report the obsessions subscale and compulsions subscale scores separately. In addition to these items, additional items are provided to gain more insight into the patient’s profile; however, they are not included in the Y-BOCS total score. Item 11 is an additional item that directly assesses a patients’ degree of insight or overvalued ideas.

The Y-BOCS displayed excellent inter-rater reliability and a high degree of internal consistency (Goodman et al., 1989). Therefore, the Y-BOCS is considered a reliable instrument for the measurement of severity of symptoms in OCD patients that vary in severity and subtype.

As mentioned previously, due to the lack of instruments that reliably measured overvalued ideas, attempts were made to assess this domain via single-item assessment with item 11 on the Y-BOCS (Goodman et al., 1989). Since only this additional item was used to assess for insight, there was a lack of reliability and validity data (Lelliott et al., 1988; Neziroglu et al., 1999).

The BABS (Eisen et al., 1998) originally consisted of 15 items. Currently, the BABS is a seven-item clinician administered semi-structured scale, and was developed to assess a patient’s degree of conviction and insight into their beliefs across a broad range of psychiatric diagnoses. These beliefs consist of delusions and cognitions that underlie obsessional thinking. As mentioned above, it is controversial as to whether delusions are dichotomous, present or absent, or dimensional, or exist on a continuum of insight (Eisen et al., 1998). Overvalued Ideation (Poor Insight) is conceptualized as the midway point between rational identification of obsessional thinking (intrusive ego-dystonic thoughts; Eisen et al., 1998; Insel & Akiskal, 1986; Kozak & Foa, 1994; Neziroglu et al., 1999) and delusionality (firmly held false beliefs with a lack of insight into the irrationality of the content of the belief). Traditionally, obsessions and delusions were viewed as dichotomous; however, currently it is believed that beliefs are better conceptualized on a continuum. A variety of disorders, such as body dysmorphic disorder (BDD), obsessive–compulsive disorder (OCD), anorexia nervosa, hypochondriasis, schizophrenia, and delusional disorder, are among those that could be considered on this continuum. The BABS is based on this idea.

Prior to administration of this scale, the dominant obsession or concern from throughout the past week is identified, along with the consequence of the identified obsession (Eisen et al., 1998). If the patient has a rapidly fluctuating course of symptoms, it may be more clinically appropriate to assess their status from the past day, rather than the past week. In order to identify this belief, the rater should aid the patient in identifying the specific underlying belief of a vague fear or worry and ensure that if a compulsion is present that it is incorporated into the belief. For example, instead of saying “I’ll get fat,” the statement should be reformulated as “I’ll get fat if I eat more than 20 Cheerios per day.” If multiple beliefs are present, but are related to the same disorder (e.g., two thoughts relating to OCD), they should be scored as a composite; however separate ratings should be given for thoughts that are based on differing disorders (e.g., BDD and OCD thoughts).

The BABS assesses nine dimensions, six (i.e., Conviction, Perception of others’ views of beliefs, Explanation of differing views, Fixity of ideas, Attempt to disprove ideas, and Insight) of which are summed to a total BABS score. The remaining three domains (i.e., Ideas/Delusions of Reference, Bizarreness, and Ego-syntonicity) are additional and experimental items, the former being the additional item, and the latter two the experimental items. Despite item 7 “Ideas and delusions of reference” not being included in the total BABS score, due to it not being characteristic of disorders that may be characterized by delusional thinking, it is considered part of the seven-item scale.

All domains are structured in a similar format and consist of specific probe questions, such as “What do you think other people (would) think of your beliefs?” However, additional questions and information from other sources may be posed for clarification. Therefore, ratings are based on both patient report and clinical judgment. Each item is scored when the rater chooses from one of the following five anchors: 0 (non-delusional or completely certain beliefs are false), 1 (fairly certain beliefs are false), 2 (indecisive with regard to truth of beliefs), 3 (fairly certain beliefs are true), and 4 (delusional or completely certain beliefs are true).

It was first administered to 46 subjects of varying disorders; OCD spectrum disorders, such as OCD and body dysmorphic disorder (BDD), as well as, mood disorders with psychotic features (Eisen et al., 1998). Inter-rater reliability was reported as good to excellent and Intraclass correlations (ICCs) for total score and individual items were 0.95 and 0.81–0.99, respectively. In addition, Cronbach’s alpha coefficient was 0.83 and factor analysis yielded three factors (core features, severity, and psychosis), which accounted for 67% of the variance.

The current form of the BABS, that includes seven items and two experimental items, was assessed for reliability and validity by utilizing a similar patient population (Eisen et al., 1998). Within this study, an acceptable homogeneity was indicated by the Cronbach’s alpha coefficient of 0.87 and individual ICCS ranged from 0.79 to 0.98 (Eisen et al., 1998). Factor analysis identified one factor, which accounted for 56% of the variance. With regard to discriminant validity, the BABS was compared to a battery of instruments. The BABS showed a weak correlation with the Brief Psychiatric Rating Scale (BPRS; Overall & Gorham, 1962), however this was only found within the BDD group. The BABS displayed convergent validity with the Characteristics of Delusions Rating Scale (Garety & Helmsley, 1987) total score and high correlations on the delusional thinking and conviction items. On the former, the correlation was with the Scale to assess Unawareness of Mental Disorder (Amador et al., 1993), while the latter was found with the Dimensions of Delusional Experience (Kendler, Glazer, & Morgenstern, 1983), the Fixity of Beliefs Scale (Foa, Kozak, et al., 1995), and the Characteristics of Delusions Rating Scale.