Seeking proxies for internal states (SPIS): Towards a novel model of obsessive-compulsive disorder

Compulsive rituals in Obsessive-Compulsive Disorder - A qualitative exploration of thoughts, feelings and behavioral patterns

BACKGROUND AND OBJECTIVES

Rituals are common among healthy individuals and across cultures and often serve adaptive purposes. In individuals with obsessive-compulsive disorder (OCD), rituals become compulsive, time-consuming and distressing, and may lead to functional impairment. Previous research has examined the functions and characteristics of compulsive rituals, but there is paucity of in-depth, first-person reports about this topic.

METHOD

We used a qualitative approach to explore thoughts, feelings, and behavioral patterns that characterize OCD rituals. Ten individuals with OCD participated in a semi-structured interview that focused on their most prominent compulsive ritual. The interviews were subjected to a thematic analysis.

RESULTS

Eight themes emerged from the analysis and were organized in two main categories: Micro Level perspective, comprising triggers, attention, emotional changes, and stopping criteria; and Macro Level perspective, comprising feelings and perceptions, change over time, motives, and inhibitors. The findings shed light on the role of fixed rules and feelings of "completeness" in OCD rituals, the nature of emotional and attentional characteristics during rituals performance, and the evolution of compulsive rituals over time.

LIMITATIONS

This study used a qualitative approach based on a small number of participants, which limits the generalizability of the findings.

CONCLUSION

Our results, if replicated, may have clinical implications. The reported patterns of anxiety reduction during ritual performance may contribute to the fine-tuning of CBT for OCD. The findings concerning the nature of attention during ritual performance and the development of rituals over time may be important for understanding the mechanisms that maintain compulsive rituals.

An investigation of the experience of control through the sense of agency in people with obsessive-compulsive disorder: a review and meta-analysis

The construct of sense of agency (SoA) has proven useful for understanding mechanisms underlying obsessive-compulsive disorder (OCD) phenomenology, especially in explaining the apparent dissociation in OCD between actual and perceived control over one's actions. Paradoxically, people with OCD appear to experience both diminished SoA (feeling unable to control their actions) and inflated SoA (having "magical" control over events). The present review investigated the extent to which the SoA is distorted in OCD, in terms of both implicit (ie, inferred from correlates and outcomes of voluntary actions) and explicit (ie, subjective judgment of one's control over an outcome) measures of SoA. Our search resulted in 15 studies that met the criteria for inclusion in a meta-analysis, where we also examined the potential moderating effects of the type of measure (explicit versus implicit) and of the actual control participants had over the outcome. We found that participants with OCD or with high levels of OCD symptoms show lower implicit measures of SoA and at the same time tend to overestimate their control in situations where they do not actually have it. Together, these findings support the hypothesized dissociation in OCD between actual and perceived control over one's actions.

The Seeking Proxies for Internal States (SPIS) Model of OCD - A Comprehensive Review of Current Findings and Implications for Future Directions

The Seeking Proxies for Internal States (SPIS) model of obsessive-compulsive disorder (OCD) explains symptoms of OCD as stemming from attenuated access to internal states, which is compensated for by using proxies, which are indices of these states that are more discernible or less ambiguous. Internal states in the SPIS model are subjective states that are not accessible to others, encompassing physiological states, motivations, preferences, memories, and emotions. Compensatory proxies in OCD include fixed rules and rituals as well as seeking and relying on external information. In the present review, we outline the SPIS model and describe its basic tenets. We then use the SPIS conceptualization to explain two pivotal OCD-related phenomena - obsessive doubt and compulsive rituals. Next, we provide a detailed overview of current empirical evidence supporting the SPIS in several domains, including physiological states, emotions, sense of understanding, decision-making, and sense of agency. We conclude by discussing possible neural correlates of the difficulty in accessing internal states, focusing on the anterior insular cortex (AIC) and highlighting potential clinical implications of the model to the treatment of OCD.

Obsessive-Compulsive Symptoms in Children Are Related to Sensory Sensitivity and to Seeking Proxies for Internal States

Symptoms of obsessive-compulsive disorder are related to atypical sensory processing, particularly sensory over-responsivity, in both children and adults. In adults, obsessive-compulsive symptoms are also associated with the attenuation of access to the internal state and compensatory reliance on proxies for these states, including fixed rules and rituals. We aimed to examine the associations between sensory over-responsivity, the tendency to seek proxies for internal states, and obsessive-compulsive symptoms in children. Parents of 404 children between 5 and 10 years of age completed online measures of obsessive-compulsive symptoms, seeking proxies for internal states, sensory over-responsivity, and anxiety. Linear regression, dominance analysis, and network analysis were used to explore the unique associations between these variables. The tendency to seek proxies for internal states was more strongly associated with obsessive-compulsive symptoms than with anxiety symptoms and uniquely associated with all major obsessive-compulsive symptom dimensions except obsessing. Both the tendency to seek proxies for internal states and sensory over-responsivity were significantly associated with obsessive-compulsive symptoms, but the association was significantly stronger for the tendency to seek proxies for internal states. While limited by the sole reliance on the parent-report, the present study shows that the tendency to seek proxies for internal states could help clarify the developmental processes involved in the onset of obsessive-compulsive symptoms during childhood and that sensory sensitivity may be important to consider in this process.

Increased attention allocation to stimuli reflecting end-states of compulsive behaviors among obsessive compulsive individuals

Attentional research in OCD has focused solely on threat stimuli, assumed to provoke related obsessions and ensuing compulsions. OCD-related stimuli depicting the completion of compulsive acts ("end-states") have yet to be examined. Past research also neglected to explore the reliability of tasks used. Here, attention allocation to both stimuli types was examined. Participants with high (HOC) and low (LOC) levels of obsessive-compulsive symptoms freely viewed three blocks of 30 two-by-two picture matrices, each including two OCD-related (cleaning\checking\ordering) and two neutral pictures, presented for eight seconds, while their gaze was recorded. Participants completed two task versions - one with traditional threat stimuli and one with novel stimuli signaling compulsions end-states. Only the end-state version yielded significant results, showing that HOC participants, compared to LOC participants, spent significantly more time fixating on OCD-related stimuli. Results remained significant after controlling for anxiety, stress, and depression. Task reliability was high. OCD-related stimuli signaling end-states of compulsive behavior should be incorporated in attentional research in OCD.

Obsessive-compulsive symptoms and dissociative experiences: Suggested underlying mechanisms and implications for science and practice

A strong and specific link between obsessive-compulsive disorder or symptoms (OCD/S) and a tendency for dissociative experiences (e.g., depersonalization-derealization, absorption and imaginative involvement) cannot be explained by trauma and is poorly understood. The present theoretical formulation proposes five different models conceptualizing the relationship. According to Model 1, dissociative experiences result from OCD/S through inward-focused attention and repetition. According to Model 2, dissociative absorption causally brings about both OCD/S and associated cognitive risk factors, such as thought-action fusion, partly through impoverished sense of agency. The remaining models highlight common underlying causal mechanisms: temporo-parietal abnormalities impairing embodiment and sensory integration (Model 3); sleep alterations causing sleepiness and dreamlike thought or mixed sleep-wake states (Model 4); and a hyperactive, intrusive imagery system with a tendency for pictorial thinking (Model 5). The latter model relates to Maladaptive Daydreaming, a suggested dissociative syndrome with strong ties to the obsessive-compulsive spectrum. These five models point to potential directions for future research, as these theoretical accounts may aid the two fields in interacting with each other, to the benefit of both. Finally, several dissociation-informed paths for further developing clinical intervention in OCD are identified.

Obsessive-Compulsive Disorder: The Underlying Role of Diminished Access to Internal States

We suggest that individuals with obsessive-compulsive disorder (OCD) experience difficulty accessing their internal states, including their feelings, emotions, preferences, and motivations. Instead, they rely on proxies to inform them of these states—that is, discernible substitutes in the form of fixed rules and rituals, observable behavior, and indexes. The Seeking Proxies for Internal States (SPIS) model of OCD proposes that compulsions, obsessions, indecision, and doubt result from seeking and using such proxies. The SPIS model not only accounts for these OCD symptoms but also sheds new light on normal processes of action control, metacognition, decision-making, and introspection.

Dr. Jack Rachman's contributions to our understanding and treatment of obsessive-compulsive disorder

BACKGROUND AND OBJECTIVES

This paper reviews the development of the cognitive-behavioural model of obsessive-compulsive disorder (OCD) through the work of Dr. Jack Rachman and the research his ideas inspired or shaped.

METHODS

A narrative review of Rachman's work and important developments in related areas was conducted.

RESULTS

Rachman was highly responsive to theoretical and empirical developments in the field, and continuously developed his model of OCD over the course of his career. Key developments in his thinking and of those in related areas are described.

LIMITATIONS

This is a narrative review that highlights important developments in the cognitive behavioural model of OCD only.

CONCLUSIONS

The CBT model of OCD has strong empirical support and CBT treatment is the most effective psychotherapy. Continued development in our understanding of attachment and in the persistence of compulsions is warranted.

Are people with obsessive-compulsive disorder under-confident in their memory and perception? A review and meta-analysis

People with obsessive-compulsive disorder (OCD) tend to distrust their memory, perception, and other cognitive functions, and many OCD symptoms can be traced to diminished confidence in one's cognitive processes. For example, poor confidence in recall accuracy can cause doubt about one's memory and motivate repeated checking. At the same time, people with OCD also display performance deficits in a variety of cognitive tasks, so their reduced confidence must be evaluated in relation to their actual performance. To that end, we conducted an exhaustive review and meta-analysis of studies in which OCD participants and non-clinical control participants performed cognitive tasks and reported their confidence in their performance. Our search resulted in 19 studies that met criteria for inclusion in the quantitative analysis, with all studies addressing either memory or perception. We found that both performance and reported confidence were lower in OCD than in control participants. Importantly, however, confidence was more impaired than performance in participants with OCD. These findings suggest that people with OCD are less confident in their memory and perception than they should be, indicating a genuine under-confidence in this population. We discuss potential mechanisms that might account for this finding and suggest avenues for further research into under-confidence and related meta-cognitive characteristics of OCD.