ROCD and cognitive models of OCD

ROCD and cognitive models of OC-related disorders.

Cognitive behavioral models of OC-related disorders give a central role to maladaptive appraisals of internal or external stimuli in the development and maintenance of these disorders. According to such models (e.g., Rachman, 1997; Storch, Abramowitz & Goodman, 2008; Wilhelm et al., 2010; Wilhelm & Neziroglu, 2002), obsessive preoccupation is a result of catastrophic misinterpretations of common phenomena. In the case of OCD, individuals catastrophically interpret the presence or consequence of naturally occurring intrusive thoughts as indicating imminent danger to self or others (Rachman, 1997; Salkovskis, 1985). Similarly, in the case of Body Dysmorphic Disorder (BDD), individuals catastrophically misinterpret the significance and social consequences of aesthetic features and minor flaws in their own appearance (e.g., “people will be disgusted of me”; Wilhelm et al., 2010; Veale, 2004).

Cognitive beliefs and biases, such as threat overestimation, perfectionism, intolerance of uncertainty, importance of thoughts and their control, and inflated responsibility increase the likelihood of catastrophic appraisals in OC-related disorders (OCCWG, 2005; Storch et al., 2008). These appraisals, in turn, increase selective attention towards potentially distressing stimuli (OCCWG, 1997; Veal, 2004). Moreover, ineffective strategies for dealing with such stimuli, such as repeated checking and reassurance seeking, paradoxically exacerbate the frequency and emotional impact of such preoccupations.

ROCD symptoms involve cognitive beliefs and biases similar to those underlying other OC phenomena (Doron, Szepsenwol, Derby, & Nahaloni, 2012). Some dysfunctional OCD related processes, however, may be more pertinent to the relational OCD theme. In the following paragraphs, we first describe the way beliefs previously identified as important in OCD may play a role in ROCD. We then refer to processes that may be more germane to ROCD symptoms.

Beliefs previously linked with OCD have also been found to be linked with ROCD (Doron, Derby et al., 2012a, 2012b). In the case of relationship-centered symptoms, OC-related beliefs may influence interpretations of intrusive thoughts pertaining to the relationships itself. For instance, overestimation of threat may bias individuals’ interpretations of others’ feelings towards them (e.g., “He didn’t call for hours, he doesn’t really love me”). Perfectionist tendencies and striving for “just right” experiences may promote preoccupation with the “rightness” of the relationship (e.g., “I don’t feel perfect with him all the time so maybe he is not THE ONE?”). Intolerance for uncertainty may increase distress and maladaptive management of commonly occurring doubts regarding one’s feelings towards the partner (e.g., “Do I really love her?”). Finally, the tendency to overestimate the importance of mere thought occurrences may increase the likelihood of attempts at suppressing relationship doubts, thereby increasing their frequency.

Maladaptive cognitive beliefs may also influence appraisals of intrusive experiences relating to partner’s attributes, thereby increasing the likelihood of such intrusions becoming obsessive. For instance, threat overestimation beliefs may bias individuals’ interpretations of the severity and consequences of perceived deficits (e.g., “he is extremely unstable, hence he will never be able to provide for our family”). Perfectionist tendencies, particularly other-oriented perfectionism (Hewitt & Flett, 1991), may lead to extreme preoccupation with specific features of a romantic partner’s personality or appearance (e.g., “she is not moral enough”, “her nose is too big”). Finally, the belief that one can and should control one’s thoughts may promote suppression efforts of negative thoughts about the partner, thereby increasing their occurrence.

Recent studies have identified additional cognitive processes that might contribute to the development and maintenance of OC-related disorders. For example, Liberman and Dar (2009) suggested that obsessive-compulsive tendencies are characterized by increased attempts to monitor internal states (e.g., love, intimacy, happiness). This tendency paradoxically decreases rather than increases the ability to achieve and evaluate such internal states. According to this model, individuals with OCD show a decreased capacity to access these internal states and therefore tend to over rely on external feedback for assessing them. In support of this hypothesis, Shapira, Gundar-Goshen, Liberman and Dar (2013) found that intense monitoring of one’s feelings of emotional closeness in an intimate conversation hampers achieving these feelings, as measured by sitting distance between pair members. Other studies have found that, as compared to participants with low obsessive-compulsive tendencies, participants with high obsessive-compulsive tendencies are (a) less accurate in assessing internal states, such as their own level of relaxation or muscle tension, and (b) rely more on external feedback in assessing these internal states (Lazarov, Dar, Oded, & Liberman, 2010, Lazarov, Dar, Liberman, & Oded, 2012).

Relationship-centered OC symptoms, by definition, involve preoccupation with internal states (e.g., love for a partner or feeling right). In order to assess or reduce uncertainty regarding their own feelings, ROCD clients often invest time and effort in monitoring their feelings and emotions. We often hear clients describe continuous monitoring of their feelings towards their partner (e.g., “Do I feel love right now?”; “Does this feel right?”). In such instances, monitoring of internal states is used as a neutralizing strategy – a deliberate attempt to reassure oneself about the strength and quality of one’s own feelings.

ROCD clients also describe using what they perceive as “objective” signs in order to judge their feelings. For instance, one client quantified her partner’s love for her by compulsively comparing the time he spent with her to the time he spent with others (e.g., his mother). Another client reported ‘time spent crying’ following a relationship breakup as a retrospective indicator of his feelings. More often, however, clients gage relationship quality or rightness by referring to the cognitive (e.g., doubts and preoccupations) and behavioral (e.g., looking at other women) features of ROCD symptoms. For instance, clients may identify experiencing doubts as a negative indicator of relationship “rightness” or of their feelings towards their partner. Accordingly, clients may treat thoughts about partner’s deficiencies as negative indicators of their own feelings (e.g., “if I see so many flaws, I do not love him”; see below for further discussion of this link). Referring to external feedback for the evaluation of internal states, at least initially, can alleviate distress. Like other neutralizing behaviors, however, repetitive use of such strategies results in ROCD symptoms’ exacerbation.

Recently, Doron and colleagues (Doron, Derby et al., 2012a) proposed that maladaptive relational beliefs can uniquely contribute to the development and maintenance of ROCD. Following Rachman’s model (1997, 1998), they suggested several biases implying catastrophic consequences of relationship-related thoughts, images, and urges. These may include beliefs focusing on the disastrous consequences of leaving a relationship (e.g., “If I leave, I will hurt my partner”) and the catastrophic consequences of remaining in a less than perfect relationship (e.g., “If I maintain a relationship I am not sure about, I will be miserable forever”).

In this context, research on relational commitment may particularly relevant. Adams and Jones (1997) proposed a three-dimensional conceptualization of relational commitment, including (a) a personal commitment dimension (feelings of affection, intimacy, and love toward a partner); (b) a moral-normative dimension (one’s moral obligation to the relationship and the partner); and (c) a constraining dimension (social, financial and emotional negative costs of relationship dissolution). Studies have found that high levels of personal commitment help romantically involved people to appreciate the good qualities of a partner and shields them from the temptation of attractive alternatives (see Lydon, 2010 for a review). In the case of clients with ROCD, low levels of personal commitment may intensify obsessional doubts concerning the rightness of their relationship and the attractiveness of their partner. Moreover, these doubts may further reduce personal commitment, which, in turn, may decrease the effectiveness of temptation-shielding mechanisms and then intensify the severity of ROCD symptoms.

The normative and constraining dimensions of relational commitment may also play an important role in ROCD. In our view, these two dimensions reflect the presence of catastrophic negative beliefs regarding the moral (e.g., “If I leave her I will be an immoral person”) and practical (e.g., “I will have to move out of my home”, “I will be excommunicated by my church”) consequences of relationship termination that may exacerbate ROCD symptoms. Indeed, it is not uncommon for clients with ROCD to express strong commitment-related moral beliefs (e.g., “you should only marry once”). Such beliefs seem to amplify the need for certainty about the relationship or the partner, thereby increasing ROCD clients’ tendency to use neutralizing behaviors (e.g., monitoring of internal states, monitoring of partner’s behaviors). Similarly, focusing on the social, emotional and financial negative consequences of relationship dissolution may magnify fears of making the “wrong decision”, leading to catastrophic interpretations of relational doubts and even encouraging avoidance of relationships all together.

An additional relationship-related factor that may be involved in the maintenance of ROCD symptoms is anticipated regret. Regret is the emotion that we experience when we realize that our current situation could have been more satisfying had we made a different choice. Anticipated regret refers to regret that we anticipate experiencing in the future (Zeelenberg, 1999). Fear of anticipated regret may significantly heighten reactivity to relational intrusions. For instance, one of our clients expressing strong fears of anticipated regret described an “extremely distressing situation”. While on Facebook, the thought that his partner is not intelligent enough “popped” into his head. He reported the following thought sequence: “There are so many women out there, if I stay with one that may not be smart enough I will regret it forever, but if I leave, I may realize that I missed the love of my life”. Indeed, one core feature of ROCD is extreme fear of making the wrong relationship-related decision. Clients alternate between being terrorized by thoughts of separation (e.g., “I will always think that I may have missed THE ONE”) and being trapped in the wrong relationship (e.g., “I will always feel that I have compromised”).