html xmlns=”http://www.w3.org/1999/xhtml” xmlns:mml=”http://www.w3.org/1998/Math/MathML” xmlns:epub=”http://www.idpf.org/2007/ops”>
This chapter examines how “the self” is implicated in obsessive–compulsive disorder (OCD). The chapter begins by presenting the phenomenology of OCD and theoretical accounts that credit the involvement of self-processes in OCD, with emphasis given to Guidano and Liotti’s (1983) theory of self-ambivalence. Then, empirical support for a relationship between obsessive–compulsive (OC) phenomena and various self constructs is reviewed. Ambivalence about moral self-worth, and burgeoning research into implicit self processes, are proposed to have particular relevance in our understanding of the development, maintenance and treatment of OCD.
Phenomenology of OCD
Both the DSM 5.0 (American Psychiatric Association [APA], 2013) and ICD 10 (World Health Organization, 2015) recognize the central feature of OCD to be the presence of obsessions and/or compulsions. Obsessions are defined as thoughts, images or impulses that are intrusive and occur repetitively. In contrast to the intrusive phenomena observed in other psychiatric disorders, obsessions are considered to be ego-dystonic, that is individuals with OCD recognize that the content of their obsessions is incongruent with their self-view or ideas about the world (Clark & Rhyno, 2004).
Individuals with OCD experience obsessions as unwanted, but such obsessions are hard to ignore and difficult to control; thus marked anxiety or distress ensues. In response, repetitive, rigid, and intentional behaviors or mental acts are performed in order to help prevent or reduce the anxiety or distress that follows an obsession, or to prevent the occurrence of some future perceived threat (APA, 2013). While these compulsions are designed to reduce discomfort, they are maladaptive safety-seeking behaviors and recognized to be central to the persistence of obsessional problems; they alleviate discomfort in the short term but are associated with longer-term maintenance of discomfort and increases in the urge to engage in further neutralizing responses (Salkovskis, 1989; Salkovskis, Thorpe, Wahl, Wroe, & Forrester, 2003; Salkovskis, Westbrook, Davis, Jeavons, & Gledhill, 1997).
OCD is increasingly recognized to be a heterogeneous condition. Although the current diagnostic criteria suggest a discrete disorder, the manifestation of OCD symptoms can vary widely and variant symptoms can have differential responses to treatment (McKay et al., 2004). The most popular basis for classification of OCD is based on overt symptom presentation, with common compulsive themes including checking, cleaning, counting, reassurance-seeking, repeating actions and acting out behavioral patterns in a specific order (Rasmussen & Eisen, 1994; Rasmussen & Tsuang, 1986). Hoarding, arranging, and counting compulsions are the least common but have been rated as the most distressing of the compulsions (Foa et al., 1995). More recently, hoarding has been regarded as a separate disorder (APA, 2013) and is discussed by Moulding and colleagues in Chapter 13 of this book.
Theoretical discourse about self processes in OCD
Investigation into self-processes may be a logical extension of current cognitive accounts of OCD. In Rachman’s (1997) influential cognitive theory of obsessions, he notes that one of the pivotal reasons that unwanted intrusions are so distressing to people with OCD is because these individuals believe they reveal something about the person’s true self.
[Patients with OCD] interpreted these thoughts, impulses or images as revealing important but usually hidden elements in their character, such as: these obsessions mean that deep down I am an evil person, I am dangerous, I am unreliable, I may become totally uncontrollable… I am weird, I am going insane (and will lose control), I am a sinful person, I am fundamentally immoral. (p. 794)
Along these lines, Purdon and Clark (1999) theorize that ego-dystonic intrusions are more likely to turn into obsessions because they represent a threat to the individual’s self-view. Clark (2004) argues that individuals who are uncertain in their self-concept are vulnerable to perceiving their unwanted intrusions as a “threat to core personal values and ideals” (p. 139). Likewise, Doron and Kyrios (2005) propose that perceived incompetence in highly valued self-domains informs a “sensitive” self-concept, which is easily threatened by unwanted intrusions, and thus serves as a vulnerability to the development of OCD. Similarly, Aardema and O’Connor (2007) propose that an underdeveloped self-concept leads to self-doubt, excessive self-monitoring and distrust in an individual’s self-concept, and consequent absorption in imaginary possibilities of self. This makes such individuals vulnerable to noticing intrusions and promotes discordance between a person’s actual self and their feared possible self. The authors suggest that the resulting distress leads to compulsive attempts to correct or safeguard the self (Aardema & O’Connor, 2007). Certainly, there are a number of cognitive accounts that credit the involvement of self-processes in OCD (Bhar & Kyrios, 2007; Doron & Kyrios, 2005; Moulding, Aardema, & O’Connor, 2014; O’Neill, 1999; Rowa, Purdon, Summerfeldt, & Antony, 2005). Guidano and Liotti’s (1983) model of self-ambivalence is an early influential model that directly addresses the self in OCD and its developmental prequelae.
Guidano and Liotti’s (1983) theory of self-ambivalence
Following from the work of Bowlby (1969), and drawing from psychoanalytic, attachment, cognitive, developmental, and social frameworks, Guidano and Liotti (1983) developed a theoretical model expounding the etiology of obsessionality; early ambivalent attachment experiences and a broad focus on moral perfectionism lead towards the development of an ambivalent self-concept and predisposition towards developing OCD. As explained in the following paragraphs, their theory of self-ambivalence is based upon three related features: contradictory self-views, uncertainty about self-worth, and preoccupation in verifying one’s self-worth.
Guidano and Liotti (1983) postulated that during the developmental period, children begin to structure a self-image through interaction with the people closest to them. They contend that the reciprocity within the attachment relationship of self-ambivalent individuals is poor, where parental behavior toward the child is perceived to give plausible but competing interpretations by the child about their worth and loveability. For example, the parent may constantly care for and show interest in the child, but be unaffectionate and undemonstrative. This leads towards development of a self-concept based on contradictory and competing views about self-worth; such children perceive themselves to be concurrently “worthy” and “unworthy.” The experience of recurrent oscillations between contradictory feelings makes it difficult for the individual to be certain about evaluations of the self.
In order to achieve clarification of their self-worth, Guidano and Liotti (1983) proposed, self-ambivalent individuals are in constant pursuit of certainty in self-worth. They vigilantly monitor their thoughts and behaviors as a meaningful measure of self, such that their “sense of personal worth is intertwined with omnipotence of thought” (Guidano, 1987, p. 178). In this way, self-ambivalent individuals are particularly predisposed to notice unwanted intrusions. Unwanted intrusions that challenge the reliability of one’s self-worth arouse excessive alarm, partly due to their uncontrollable nature, but mostly because they threaten the self-ambivalent individual’s rigid standards of moral perfectionism (Guidano & Liotti, 1983).
As obsessions develop from excessive attention to intrusions that threaten valued self-views, the self-ambivalent individual seeks to reinstate their self-worth. Thus, as Guidano and Liotti (1983) suggested, neutralization strategies, such as compulsions, become solutions for self-ambivalent individuals to control their mixed feelings. For instance, an individual may compulsively recite prayers in order to resolve blasphemous thoughts. Another individual may engage in compulsive checking in order to avoid feelings of personal irresponsibility. Doing so provides the individual with evidence that they are adhering to their moral values, and thus their moral self-worth is temporarily reinstated. So, rather than acknowledging their limitations, the self-ambivalent individual strives for total control, believing that there is a need to be more vigilant, to try harder; “the solution is to become more perfect, and thus even more obsessional” (Guidano, 1987, p. 186).
Guidano and Liotti’s model has received renewed interest as researchers from both psychoanalytic (Kempke & Luyten, 2007) and cognitive (Bhar & Kyrios, 2007) frameworks recognize the importance of an ambivalent self in the etiology of OC phenomena. Although direct examination of the theoretical model proposed by Guidano and Liotti (1983) has received little empirical attention, the following section outlines mounting support for the self-constructs implied in their theory, and in their relationship with OCD phenomena.
Empirical support for self processes in OCD
Self-esteem
The reciprocal relationship of self-esteem to personal goals, self-beliefs, and interactions with others means that it is fundamentally related to our experience of daily life (Crocker & Park, 2004). Consequently, it is not surprising that a relationship between low self-esteem and psychopathology has been widely implicated in both the expression and development of psychological disorders (see Zeigler-Hill, 2011 for a review). In their retrospective examination into prodromal symptoms, Fava, Savron, Rafanelli, Grandi, and Canestrari (1996) found that low self-esteem was one of the common symptoms preceding the onset of OCD, suggesting that it may be a vulnerability factor for OCD. However, it is perhaps a non-specific predisposing factor because other disorders also demonstrate pre-morbid signs of low self-esteem (e.g., depression; Orth, Robins, & Meier, 2009). Furthermore, although a wealth of research shows that OCD symptoms have an association with low self-esteem, it appears that it cannot distinguish OCD from other mental disorders (Bhar & Kyrios, 2007; Ehntholt, Salkovskis, & Rimes, 1999; Teachman & Clerkin, 2007). For instance, Ehntholt et al. (1999) showed that depressive, anxious, and obsessive symptoms all had significant correlations with self-esteem.
It is likely, however, that examination of self-esteem in isolation from other variables is not specific enough to detect differences between disorders. For instance, Wu, Clark, and Watson (2006) found that the combination of low self-esteem and low entitlement was able to distinguish OCD patients from other psychiatric outpatients. Similarly, Ehntholt et al. (1999) showed that compared to anxious controls, low self-esteem of individuals in an OCD group was characterized by specific concerns about criticism from others. Although low self-esteem appears to have an association with mental distress in general, we next discuss how it is the concurrent endorsement of both positive and negative self-esteem that may have more relevance to OCD phenomena.
Self-ambivalence
According to Guidano and Liotti (1983), the self-concept in self-ambivalent individuals is structured in such a way that they concurrently endorse positive and negative self-evaluations. The resultant uncertainty in self-beliefs then leads self-ambivalent individuals to look to their environment for confirming evidence of either of their self-views, and this way they are predisposed to attending to their unwanted intrusions and vulnerable to threats to self. Along these lines, Riketta and Zeigler (2007) showed that contradictory self-beliefs and feelings (experienced ambivalence) and the co-presence of positive and negative self-views (structural ambivalence) lead to a labile self-esteem that varies according to the environmental context. In an experiment following explicit success or failure feedback, the self-esteem of unambivalent individuals remained constant. In contrast, the self-esteem of highly ambivalent individuals became more positive or negative following success or failure, respectively. Later related work using subtle priming methods showed similar results (DeMarree, Morrison, Wheeler, & Petty, 2011), suggesting that self-ambivalence can lead to interpreting both explicit and implicit self-relevant information in a way that is associated with greater negative effects on self-esteem.
Drawing from Guidano and Liotti’s (1983) work, Bhar and Kyrios (2007) developed the Self- Ambivalence Measure (SAM) to assess the three features central to the theory of self-ambivalence: dichotomous self-views, uncertainty about self-worth, and preoccupation with verifying self-worth. After controlling for anxious and depressive symptoms, the SAM significantly predicted OCD symptoms (Bhar & Kyrios, 2000, 2007), with this relationship fully mediated by OC beliefs identified as being of particular relevance to OCD (e.g., an inflated sense of personal responsibility, threat overestimation, importance and need to control thoughts, perfectionism and intolerance for uncertainty [Obsessive-Compulsive Cognitions Working Group, 1997, 2005]). Individuals with OCD also reported higher SAM scores than a non-clinical control cohort, but not an anxious group. While there was no significant difference between the clinical groups, this potentially reflected a sampling issue as the anxious group endorsed specific OC beliefs at the same levels of the OCD group. Alternatively, self-ambivalence may have greater relevance to a broader range of disorders. There is now a small but growing amount of empirical literature to demonstrate that self-ambivalence, as measured by the SAM, has been implicated in OC-related disorders such as compulsive hoarding (Frost, Kyrios, McCarthy, & Matthews, 2007), body dysmorphic disorder and social anxiety (Labuschagne, Castle, Dunai, Kyrios, & Rossell, 2010; Phillips, Moulding, Kyrios, Nedeljkovic, & Mancuso, 2011).
As the SAM total score relates to general ambivalence in self-worth, it does not capture specific notions regarding the multidimensional and contingent nature of self-worth (Harter & Whitesell, 2003; Marsh, Parada, & Ayotte, 2004), particularly relating to Guidano and Liotti’s (1983) focus on compliance with moral rules. In line with their theoretical predictions and a multidimensional view of self, Bhar and Kyrios (2007) created a subscale of the SAM to assess ambivalence about morality. Like the total SAM score, the moral ambivalence subscale significantly predicted OC beliefs and symptoms and even outperformed the SAM in predicting OC beliefs of inflated self-worth. As will be discussed, the idea that morality has relevance to the self-worth of individuals with OCD is not unique to these researchers.
Self-concept
Obsessions as ego-dystonic
Some of the prominent cognitive models of OCD suggest that the very reason that obsessions are distressing is because they are ego-dystonic; contradictory to one’s sense of self (Clark, 2004; Purdon & Clark, 1999; Rachman, 1997). This idea stemmed from the landmark work by Rachman and de Silva (1978), where they demonstrated that the intrusions reported by a cohort with OCD were more alien to individuals’ sense of self than the intrusions of a non-clinical sample. Subsequent empirical research further supports this notion. For instance, Clark, Purdon, and Byers (2000) showed that sexually anxious and erotophobic students reported feeling more disapproval and more distress about sexual intrusions, and a greater desire to avoid sexual intrusions, than students with a positive disposition toward sexuality. Similarly, Rowa and colleagues (Rowa & Purdon, 2003; Rowa et al., 2005) compared the most and least upsetting current obsessions in both non-clinical and clinical OCD samples and found that distress ratings were best explained by the degree to which intrusions contradicted the individual’s sense of self.
Recent related work suggests that the distress associated with intrusions may not only be due to their ego-dystonic nature, but also because individuals fear these intrusions reflect an undesired facet of themselves. In their assessment of the intrusive images in an OCD and anxious control cohorts, Lipton, Brewin, Linke, and Halperin (2010) found that imagery of an OCD cohort was distinct in being more likely to contain unacceptable themes of harm, and in making inferences of the self as dangerous. Similarly, Aardema et al. (2013) created a questionnaire measuring fear of self and found that it significantly predicted obsessions and cognitions related to OCD. This measure also had strong relationships with measures of self-ambivalence and distrust of self, which the authors contend supports the notion that obsessions are distressing to those individuals with high self-doubt as they fear that the intrusion represents a possibility for who they are, or could become (Aardema & O’Connor, 2007).
Moral self in OCD
Research supports that a contingent self-worth is associated with specific attachment styles, where inconsistent feedback from parents, such as fluctuations in approval and disapproval, provide conflicting messages to the child (Crocker & Park, 2004; Harter & Whitesell, 2003). When combined with pressures to feel or behave in specific ways, often very high and unrealistic standards, the individual is vulnerable to developing an unstable sense of self-worth that is dependent on perceived competence in personally important domains.
In line with Guidano and Liotti’s (1983) theory, a self-worth that is highly contingent upon moral standards may have particular relevance to OCD. Rachman (1997) argued that those individuals who strive for moral perfectionism are more prone to obsessions as they view all of their actions and thoughts as significant markers of their moral standing. Similarly, Shafran, Thordarson, and Rachman (1996) propose that individuals with OCD have a tendency to view their unacceptable thoughts as morally equivalent to unacceptable actions, an appraisal process that has predicted thought suppression, which in turn predicted OCD symptoms on an undergraduate sample (Rassin, Muris, Schmidt, & Merckelbach, 2000). In later work comparing an OCD cohort with anxious and community controls, Ferrier and Brewin (2005) demonstrated that individuals with OCD were significantly more likely to make negative moral inferences about themselves based on their intrusions, and that their “feared self” traits were significantly more likely to consist of being bad and immoral. Additionally, in a culturally diverse non-clinical sample, García-Soriano, Clark, Belloch, del Palacio, and Castañeiras (2012) demonstrated a relationship between OCD symptoms and a measure of self-worth contingent upon meeting life domains relevant to obsessionality (including morality, responsibility, and saving/collecting). Finally, Doron, Szepsenwol, Elad-Strenger, Hargil, and Bogoslavsky (2013) showed that perceptions of morality and character as a stable and fixed trait was associated with increased severity of OC symptoms, and that this relationship was mediated by OC beliefs about the importance and control of thoughts, and inflated responsibility/overestimation of threat. The authors propose that these individuals have high desire to maintain positive self-evaluations and are vulnerable to experiences that challenge moral competence, such as unwanted intrusions.
A self-worth contingent on moral standards may not be in and of itself an etiological factor for OCD, but that concurrent uncertainty or ambivalence about morality has more relevance to the disorder. For instance, Ahern, Kyrios, and Mouding (2015) found no association between moral contingent self-worth and OCD symptoms in a non-clinical sample, but an interaction with self-ambivalence was significant, whereby individuals who were concurrently self-ambivalent and endorsed high moral standards reported the highest levels of OCD symptoms. Moreover, for individuals who were not ambivalent, there was no relationship between endorsement of OCD symptoms and adherence to morality-contingent self-worth. Related work by Doron and colleagues (Doron, Kyrios, & Moulding, 2007; Doron, Moulding, Kyrios, & Nedeljkovic, 2008) demonstrates a relationship between OCD phenomena and sensitivity in moral self-worth. Students who had a “sensitive” moral self-concept, conceptualized as highly valuing morality yet concurrently feeling incompetent in that domain, demonstrated significantly greater levels of all OC beliefs and symptoms than students not sensitive in moral self-concept, or sensitive in other domains (e.g., sport; Doron et al., 2007). A follow-up study with a clinical sample confirmed that moral self-sensitivity was related to higher severity of OCD symptoms (specifically, obsessional thoughts of harm, contamination, and checking) and OCD cognitions within the OCD cohort, while anxious and non-clinical control samples did not show sensitivity in moral self-worth (Doron et al., 2008).
In addition, there is now some experimental support for the relationship between moral ambivalence and OC phenomena. In a series of experiments on nonclinical samples, Doron, Sar-El, and Mikulincer (2012) developed a subtle priming task to induce high versus low competence in the self-concept domains of either morality or sport. The authors showed that priming moral incompetence increased participants’ reported urge to engage, and likelihood of engaging in, contamination-related behaviors. Moreover, in a follow-up study using similar methodology, Abramovitch (2013) demonstrated that inducing negative moral self-perceptions led to greater endorsement of the OC belief that thoughts are important and must be controlled. Finally, as an analogue to OC symptoms, Perera-Delcourt, Nash, and Thorpe (2014) examined the deliberative behavior of non-clinical individuals (length and time taken to respond to moral dilemmas) after experimental priming of either moral self-ambivalence, general uncertainty, or neither. Individuals who received the moral self-ambivalence prime and reported pre-existing high levels of moral self-ambivalence displayed significantly more deliberative behavior than the control conditions.
Overall, the theoretical and empirical studies provide mounting evidence that self-ambivalence and uncertainty about moral self-worth have a particular association with OC phenomena. However, this research is primarily based on self-report data, which are problematic because self-report measures of self-concept and self-esteem are vulnerable to response distortions and difficulty with introspection (Bosson, 2006; Dijksterhuis, Albers, & Bongers, 2009; Olson, Fazio, & Hermann, 2007). As the next section illustrates, our understanding of OCD may be enhanced through use of methodologies that capture implicit self-processes.
Implicit self and OCD
When one considers that implicit measures have demonstrated they can outperform explicit measures in predicting specific aspects of psychopathology that are involved in OCD (see Egloff & Schmukle, 2002; Spalding & Hardin, 1999; Van Bockstaele et al., 2011), it is surprising that few OCD studies have included measures of implicit cognitive processes. Nonetheless, research by Nicholson and colleagues (Nicholson & Barnes-Holmes, 2012; Nicholson, Dempsey, & Barnes-Holmes, 2014; Nicholson, McCourt, & Barnes-Holmes, 2013) showed that implicit appraisals of disgust and contamination predicted self-reported OCD tendencies, OC-related beliefs and behavioral avoidance. Using an experimental design, Teachman and colleagues (Teachman, 2007; Teachman, Woody, & Magee, 2006) examined how aspects of the cognitive theory of OCD relate to implicit self. Teachman et al. (2006) experimentally manipulated appraisals of the importance of intrusive thoughts, giving participants either no information or informing them that their intrusions were either important or meaningless. For individuals with high convictions on OCD beliefs, information that their intrusions were important led to implicit appraisals of themselves as more dangerous than harmless. In a related study that manipulated the moral meaning of intrusions, Teachman and Clerkin (2007) showed that for individuals who had a high need for certainty, the moral condition related to implicit ratings of self as dangerous. The authors suggested that these results are in line with the cognitive model of OCD and mood-state dependent hypotheses; when under conditions that induce stress, OCD beliefs may serve as a cognitive vulnerability to negative implicit self-judgments (Teachman et al., 2006).
These findings provide an initial indication of how implicit measurement tools can enhance our understanding of OCD. They do not, however, elucidate what type of pre-existing self-profile makes one vulnerable to making negative self-appraisals in the context of unwanted intrusions. Given that research into the self in OCD primarily focuses on known, or explicit, processes (Aardema & O’Connor, 2007; Bhar & Kyrios, 2007; Doron et al., 2007, 2008; Ferrier & Brewin, 2005), and Guidano and Liotti’s notion of contrasting and competing self-views, questions are raised as to whether self-reported ambivalent self-esteem and sensitivity in moral self-concept may involve a discrepancy between implicit and explicit self-views.
Self-discrepancy and OCD
A growing body of research supports the notion that, regardless of the direction, discordance between implicit and explicit self-esteem is associated with a variety of negative affective experiences (Lupien, Seery, & Almonte, 2010; Petty, Briñol, Tormala, Blair, & Jarvis, 2006; Rudolph, Schröder-Abé, Riketta, & Schütz, 2010; Schröder-Abé, Rudolph, & Schütz, 2007; Vater et al., 2013). Briñol, Petty, and Wheeler (2006) further show that individuals with these discrepancies engage in a greater elaboration of discrepancy-related information, presumably in an effort to reduce the discrepancy. Although implicit–explicit discrepancies can take two forms (Zeigler-Hill, 2006), it is the discrepant low self-esteem (high implicit–low explicit) that may have particular relevance to OCD phenomena. Zeigler-Hill and Terry (2007) contend that high implicit self-esteem in the context of a low explicit self-esteem provides individuals with an inner optimism, and a sense that they only need to “try harder” and persevere. Unrealistically high and rigid perfectionistic standards may then be adopted in an effort to raise levels of explicit self-esteem and resolve their inconsistent self-attitudes (Guidano & Liotti, 1983). Indeed, this self-discrepancy profile show the highest levels of maladaptive perfectionism (Zeigler-Hill & Terry, 2007).
Recent research from our own research group has lent preliminary support that it is not implicit self-processes per se that are most closely related to OC phenomena, but their concurrent discrepancy with explicit self-esteem. Specifically, in a combined clinical OCD and non-clinical sample, discrepant low self-esteem (high implicit self-esteem, low explicit self-esteem) significantly predicted self-ambivalence, and OCD symptom scores, while implicit moral self-worth did not. When comparing non-clinical and OCD cohorts, not surprisingly, individuals with OCD held the highest levels of OCD symptoms. Of the non-clinical participants, however, individuals with this particular self-profile reported the highest level of OC symptoms (Ahern, 2013). These results add to the growing literature on the internal discomfort or conflict associated with a discrepant explicit and implicit self-esteem (Briñol et al., 2006; Lupien et al., 2010; Schröder-Abé et al., 2007; Vater, Schröder-Abé, Schütz, Lammers, & Roepke, 2010), and suggests that findings of low self-esteem in OCD in previous research (Fava et al., 1996; Wu et al., 2006) may need to be interpreted in the context of a high implicit self-esteem. Within Guidano and Liotti’s (1983) model, these findings suggest that individuals with OCD have an internal conflict between explicit beliefs that they are not yet worthy or good and an inner optimism that they can or should be.
Related posts:
The self in bipolar disorder
The self in schema therapy
The self in posttraumatic stress disorder
Painful incoherence: the self in borderline personality disorder
Basic self disturbance in the schizophrenia spectrum: a review and future directions
Future directions in examining the self in psychological disorders
Stay updated, free articles. Join our Telegram channel
Full access? Get Clinical Tree
