Obsessive compulsive disorder: A review of possible specific internal representations within a broader cognitive theory

Abstract

Obsessive Compulsive Disorder (OCD) is one of the most incapacitating of anxiety disorders, and is rated as a leading cause of disability by the World Health Organization (1996). Current cognitive models of OCD have focused on beliefs and management strategies involved in the development, maintenance, and exacerbation of OCD. However, despite evidence of their association to psychopathology, few researchers have applied the idea of underlying cognitive-affective structures, such as perceptions about the self and world, as operating in individuals with obsessive-compulsive thoughts and behaviors. This paper critically engages with current cognitive, developmental, and attachment research associated with views about the self and world. It is argued that consideration of such underlying cognitive-affective vulnerabilities may lead to a broader understanding of the development and maintenance of OCD. Consistent with previous theoretical work (e.g. Guidano, V. F., & Liotti, G. (1983). Cognitive processes and emotional disorders. New York: The Guilford Press.), we also argue that early experiences of parenting lead to the development of a dysfunctional self-structure and world-view relevant to OCD. Thus, this paper aims to extend the focus of current OCD research by exploring the possible role of a broader range of underlying vulnerability structures in the development and maintenance of OCD-related dysfunctional beliefs and symptoms.

Introduction

The idea that enduring cognitive-affective structures sensitize individuals to psychopathology is central to cognitive theory. Beck (1976) described the triangle of negative views of self, the world and the future in the dynamic of depression. Young (1990) identified several early maladaptive schemas underlying personality difficulties. Others (Bowlby, 1969, Bowlby, 1973, Bowlby, 1988b, Guidano & Liotti, 1983, Janoff-Bulman, 1991, Kyrios, 1998) invoked terms such as internal working models of self and other and world-view in their explanations of a range of different disorders. However, few researchers have applied the idea of an underlying cognitive-affective vulnerability operating in individuals with obsessive-compulsive thoughts and behaviors (e.g., Bhar & Kyrios, 2000, Guidano & Liotti, 1983, Sookman et al., 1994).

Obsessive Compulsive Disorder (OCD) is one of the most incapacitating of the anxiety disorders, having been rated as a leading cause of disability by the World Health Organization (1996). OCD affects all cultural and ethnic groups and, unlike many related disorders, males and females are equally affected (Rasmussen & Eisen, 1992). Further, OCD is associated with high degrees of psychiatric comorbidity, including major depression and other anxiety disorders (American Psychiatric Association, 1994). The central features of OCD comprise obsessions and/or compulsions. Obsessions are defined as persistent unwanted thoughts, images, or impulses that intrude into consciousness and give rise to active resistance. Compulsions are defined as deliberate, repetitive and rigid behaviors or mental acts that a person performs, often in response to obsessions, in order to prevent or reduce anxiety, distress or threat (Rachman & Hodgston, 1980). Recent epidemiological studies suggest that OCD affects more than two per cent of the population, making it the fourth most common psychiatric disorder and more common than severe mental illnesses such as schizophrenia and bipolar disorder (Rasmussen & Eisen, 1992).

Although a range of etiological theories for OCD have been proposed (e.g., neuropsychological, psychological, and biological), cognitive-behavioral models of OCD have generated a large body of empirical support and have led to the development of effective treatments (see Frost & Steketee, 2002). These models suggest that dysfunctional beliefs and maladaptive appraisals underlie unhelpful strategies in the management of intrusive phenomena. Such strategies lead to extreme reactions to specific intrusive thoughts, images, or urges resulting in obsessive and compulsive symptoms (Clark & Purdon, 1993, de Silva & Rachman, 1998, Rachman, 1998a, Salkovskis, 1985).

Recent cognitive-behavioral research by the Obsessive Compulsive Cognitions Working Group (OCCWG, 1997) has focused on six main belief domains that play an important role in the development of obsessions from intrusive thoughts: inflated personal responsibility; over-importance of thought; beliefs about the importance of controlling one's thoughts; overestimation of threat; intolerance for uncertainty; and perfectionism. More recently, the OCCWG (Steketee et al., 2003, Taylor et al., 2002) reported not only a high degree of association between the identified belief domains and obsessive-compulsive (OC) symptoms, but also high intercorrelations between scales measuring the six domains. This raises questions about possible higher order cognitive vulnerabilities that may account for such high intercorrelations.

For instance, cognitive conceptualizations of OCD have implicated, explicitly or implicitly, the significance of self perceptions in the determination of responses to intrusions. Rachman, 1997, Rachman, 1998b has argued that “catastrophic misinterpretations” of the personal significance of intrusive thoughts are the main cause of the development and maintenance of obsessions. According to Rachman, intrusive thoughts which are perceived by the individual as endangering their view of self will trigger an escalation in dysfunctional behaviors, or cause a more intense use of thought-control strategies (e.g., thought-suppression). Rachman, 1997, Rachman, 1998b, Rachman & Hodgston, 1980 further suggested that the specific content of intrusions, such as themes of aggression, sex, and blasphemy, plays an important role in this process by serving as the initial trigger for dysfunctional appraisals. Hence, Rachman emphasizes both the content of the intrusions and the presence of dysfunctional beliefs, including self-appraisals, in the process of intrusions becoming obsessions.

Similarly, Clark & Purdon, 1993, Purdon & Clark, 1999 proposed that the appraisal of a thought as inconsistent with an individual's sense of self and/or beliefs and values (i.e., as ego-dystonic) together with higher-order beliefs regarding the importance of thought control (e.g., “I should be able to control my thoughts”) are the main contributors to the exacerbation of obsessions. Recent evidence (Rowa & Purdon, 2003) supports the idea that the distress evoked by intrusive thoughts is related to the content of the intrusions and the individual's self-perceptions.

Salkovskis, 1985, Salkovskis, 1999 proposed that specific intrusions become more frequent, intense, and distressing as a result of a person's inflated sense of personal responsibility. Salkovskis defined an inflated sense of responsibility as a person's tendency to believe that they may be pivotally responsible for causing or failing to prevent harm to themselves or others. According to this view, an inflated sense of responsibility causes one to develop certain patterns of response to specific (rather than all) intrusive thoughts, impulses, or images. Salkovskis, Shafran, Rachman, & Freeston, (1999) also suggested that the development of an inflated sense of personal responsibility may be associated with “a high degree of conscientiousness, marked by dedication to work and an acute sense of social obligation” (Salkovskis et al., 1999, p. 1060). This implies that such individuals are likely to attribute an increased importance to specific domains of self (e.g., self as a moral being) and that this influences their response to specific intrusive thoughts.

While traditional cognitive models have facilitated knowledge and treatment of OCD and theoretical discourse has considered the origins of OCD-related beliefs (Bhar & Kyrios, 2000, Salkovskis et al., 1999), there has been a general neglect of developmental issues, such as early attachment and parenting (Guidano & Liotti, 1983, Safran, 1990), and the role they play in the development and maintenance of dysfunctional beliefs (Bhar & Kyrios, 2000). Traditional cognitive theories of OCD have also neglected some important aspects of Beck's (1976) cognitive triad, most particularly the assumptions regarding the individual's perceptions of the world and others.

It is in the context of identifying enduring cognitive-affective structures that underlie OCD that this article considers an individual's perceptions of the self and their world-view as vulnerability factors for obsessive-compulsive symptoms and cognitions. This paper draws upon recent developments in cognitive (e.g., Clark & Purdon, 1993, Lee & Kwon, 2003, Purdon & Clark, 1993, Purdon & Clark, 1994, Rachman, 1997, Rachman, 1998b), attachment (e.g., Hazan & Shaver, 1987), self concept (e.g., Harter, 1998), and world-view research (e.g., Janoff-Bulman, 1989, Janoff-Bulman, 1991). This paper firstly considers attachment theory and the role of early experiences in the development of perceptions of self and reality. This is followed by a discussion of the role of such perceptions in the psychopathology of OCD. Next, a model of obsessive-compulsive vulnerability is developed, incorporating current understandings of self-concept and world-view into a model of susceptibility to the development of obsessive-compulsive symptoms and cognitions. The role of parent–child interactions in the generation of such vulnerability is then explored before a discussion of future directions for research. Overall, it is argued that consideration of the individual's perception of self and world view may lead to a broader understanding of the development and maintenance of OCD.