How can I know what I'm feeling? Obsessive-compulsive tendencies and induced doubt are related to reduced access to emotional states

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.

A study of doubt in obsessive-compulsive disorder

BACKGROUND AND OBJECTIVES

Obsessive-compulsive disorder (OCD) has been referred to as the "doubting disease," yet there has been little foundational research on its phenomenology and characteristics. Studies of doubt have relied on researchers' idiosyncratic conceptualizations of the construct, resulting in varied assessment methods and different prevalence rates (11-75%). We examined the nature and characteristics of doubt in people with clinical and subclinical OCD so as to identify its nature and characteristics, and factors that may be unique to OCD.

METHODS

A semi-structured interview about doubt was administered to people with OCD (N = 44) and with subclinical OCD (N = 21).

RESULTS

Doubt was highly prevalent and manifested as a form of obsession, uncertainty about whether a task was done properly, and/or lack of confidence in memory and perceptions. All participants took action to resolve doubt and/or proactively pre-empt or reduce future doubt. Doubt was deeply connected to negative core beliefs about the self. The groups did not differ on their experience of doubt, except that greater symptom severity was associated with greater interference from doubt, less ability to resist it, and less success of proactive, but not reactive, strategies to manage it.

LIMITATIONS

We relied on retrospective report, and the subclinical group was relatively small.

CONCLUSIONS

In subclinical and clinical OCD, doubt is pervasive, manifests in three domains, is connected to negative core beliefs, and is highly aversive. Continued empirical study of doubt is essential to proper assessment and to development of theories and treatment of OCD.

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.

[Obsessive Doubting as a Philosophical-Psychopathological Phenomenon]

Obsessive doubting (OD) is a rather forgotten and underestimated psychopathological phenomenon, although clinically it seems to exist in many patients with e. g. obsessive-compulsive disorder. The few primary psychoanalytic and cognitive-scientific studies in the literature concerning OD do not explain the phenomenon completely, nor do they offer treatment perspectives. Here, another way is proposed. Doubting whether one's perception of objects, other people and one's own self is correct, which is part of human nature, can reach pathological dimensions as in OD. Doubting is regarded as an existential problem of human beings, and is one of the major questions of philosophy from very early times, but is especially central to scepticism. If grounds against such doubting can be found, mental solution strategies within the framework of theoretical depth psychotherapy including cognitive training approaches can be established for treatment of patients with OD.

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.

Attenuated Access to Emotions in Obsessive-Compulsive Disorder

The Seeking Proxies for Internal States (SPIS) model of obsessive-compulsive disorder (OCD) posits that OCD is associated with attenuated access to internal states. Here we explored the implications of this model in the realm of emotions. Participants with OCD, anxiety disorders, and nonclinical control participants completed the Mayer-Salovey-Caruso Emotional Intelligence Test (MSCEIT), assessing two domains of emotional intelligence: Experiential emotional intelligence (EI), reflecting the ability to perceive and feel emotions accurately, and Strategic EI, reflecting the ability to understand and manage emotions correctly. As only Experiential EI requires accurate perception of one's emotions for adequate performance, we predicted an interaction between group and EI area. Specifically, we predicted that compared to both anxiety disorders and healthy control participants, OCD participants would show a larger deficit in Experiential area of the MSCEIT relative to the Strategic area. Results were fully in line with this prediction. Moreover, supporting the specificity of the hypothesized deficit to OCD, participants with anxiety disorders did not differ from nonclinical control participants in their performance, and findings were not attributable to anxiety or depression levels. These results replicate and extend previous findings obtained with analogue samples and suggest that OCD is associated with attenuated access to emotional states, which may be partially compensated for by reliance on semantic knowledge of emotion.

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

The Seeking Proxies for Internal States (SPIS) model of obsessive-compulsive disorder (OCD) proposes an account of OCD symptoms in terms of two core components: attenuation of access to internal states and seeking proxies for internal states. Specifically, the SPIS model posits that OCD is associated with difficulty in accessing various internal states, including feelings, preferences, memories, and even physiological states. This difficulty drives obsessive-compulsive individuals seek and rely on compensatory proxies, or substitutes, for their internal states. These proxies are perceived by the individual with OCD to be more easily discernible or less ambiguous compared to the internal states for which they substitute, and can take the form of fixed rules, rituals, or reliance on external sources of information. In the present article we first provide a detailed explanation of the SPIS model, and then review empirical studies that examined the model in a variety of domains, including bodily states, emotions, and decision-making. Next, we elaborate on the SPIS model's novel account of compulsive rituals, obsessions and doubt and relate them to extant theoretical accounts of OCD. To conclude, we highlight open questions that can guide future research and discuss the model's clinical implications.

Alexithymia Is a Key Mediator of the Relationship Between Magical Thinking and Empathy

Thought action fusion (TAF), whereby internal thoughts are perceived to exert equivalent effects to external actions, is a form of magical thinking. Psychiatric disorders associated with TAF (e.g. schizophrenia; obsessive compulsive disorder) can feature atypical social cognition. We explored relationships between TAF and empathy in 273 healthy young adults. TAF was directly correlated with higher personal distress, but not perspective taking, fantasy or empathic concern. TAF moral (the belief that thinking about an action/behaviour is morally equivalent to actually performing that behaviour) was predicted by emotion contagion, alexithymia and need for closure. TAF likelihood (the belief that simply having a thought about an event makes that event more likely to occur) was predicted by personal distress, sense of agency and alexithymia. Both cognitive (TAF and negative sense of agency) and emotional (emotion contagion, alexithymia) factors contributed to personal distress. TAF, negative sense of agency and personal distress mediated the effect of emotion contagion on alexithymia. Our findings reveal complex relationships between emotional processes and TAF, shedding further light on the social cognitive profile of disorders associated with magical thinking. Furthermore, they emphasise the potential importance of alexithymia and emotion contagion as mediators or potential risk factors in the development of psychiatric symptoms linked to TAF, such as intrusive thoughts about harm to others.

Obsessive-compulsive symptoms are related to reduced awareness of emotional valence

BACKGROUND

The Seeking Proxies for Internal States (SPIS) model of OCD asserts that obsessive-compulsive (OC) tendencies are associated with attenuated access to internal states. Here we explore the implications of this model for awareness of emotional valence.

METHODS

In Study 1, participants with high and low OC tendencies (n = 30 in each group) rated how they felt while viewing different pictures with positive, neutral, or negative valence taken from the International Affective Picture System. Study 2 replicated Study 1 among non-selected participants (n = 99) that rated positive and negative pictures chosen from the recently developed Basic-Emotions Nencki Affective Picture System. In both studies, mean deviation from norm ratings (of each picture system) served as the primary outcome measure.

RESULTS

Study 1 showed that high OC participants' mean deviation score was significantly higher, compared with low OC participants, across positive, neutral, and negative pictures (p=.01). Follow-up analyses revealed that while no group difference emerged for mean valence rating (p=.16), groups differed on the mean standard deviation of ratings within each valence category (p=.002). In Study 2, only OC tendencies, not depressive or anxiety symptoms, were positively correlated with mean deviation from norm ratings (p=.026). Dividing the sample to high and low OC groups based on an OC cutoff score yielded similar group differences to those observed in Study 1 (p<.001).

LIMITATIONS

Analog samples and a relative small sample size (Study 1).

CONCLUSIONS

This study suggests that OC symptoms are associated with reduced awareness of emotional valence, possibly emanating from a noisier emotional perception.

Attenuation of access to internal states in high obsessive-compulsive individuals might increase susceptibility to false feedback: Evidence from a visuo-motor hand-reaching task

BACKGROUND AND OBJECTIVES

The Seeking Proxies for Internal States (SPIS) model of obsessive-compulsive disorder (OCD) posits that obsessive-compulsive (OC) individuals have attenuated access to their internal states. Hence, they seek and rely on proxies, or discernible substitutes for these internal states. In previous studies, participants with high OC tendencies and OCD patients, compared to controls, showed increased reliance on external proxies and were more influenced by false feedback when judging their internal states. This study is the first to examine the effects of false feedback on performance of hand movements in participants with high and low OC tendencies.

METHOD

Thirty-four participants with high OC tendencies and 34 participants with low OC tendencies were asked to perform accurate hand reaches without visual feedback in two separate sessions of a computerized hand-reaching task: once after valid feedback training of their hand location and once with false-rotated feedback. We assessed the accuracy and directional adaptation of participants' reaches.

RESULTS

As predicted, high OC participants evidenced a larger decrease in their hand positioning accuracy after training with false feedback compared to low OC participants.

LIMITATIONS

The generalization of our findings to OCD requires replication with a clinical sample.

CONCLUSIONS

These results suggest that in addition to self-perceptions, motor performance of OC individuals is prone to be overly influenced by false feedback, possibly due to attenuated access to proprioceptive cues. These findings may be particularly relevant to understanding the distorted sense of agency in OCD.

Obsessive-compulsive tendencies predict seeking proxies for understanding

BACKGROUND AND OBJECTIVES

The Seeking Proxies for Internal States (SPIS) model of obsessive-compulsive disorder (OCD) postulates that obsessive-compulsive (OC) individuals have reduced access to their internal states and must therefore seek and rely on external proxies for these states. The present study extended this hypothesis to the feeling of understanding, which had not been examined previously in relation to OCD.

METHODS

We presented 148 participants with a computerized task requiring them to read and understand a text on medieval architecture. Participants were randomly assigned to an ongoing feedback condition (comprehension quiz and answers provided after each text segment) or no-feedback condition (quiz and answers provided only at the end). Throughout, participants were offered proxies in the form of "learning aids," which were unrelated to text comprehension. Participants were divided to high vs. low OC tendencies based on a median split on a measure of OCD symptoms.

RESULTS

As predicted, lacking feedback on understanding was associated with higher use of proxies and high OC participants used more proxies than low OC participants in the no-feedback condition. Actual understanding, as assessed by comprehension scores, was unrelated to OC tendencies.

LIMITATIONS

Among other limitations discussed in the article, our results were obtained on a non-selected sample of students varying on OC tendencies. It would be important to replicate these findings with diagnosed OCD participants as compared to both non-clinical and anxiety disorders control participants.

CONCLUSIONS

These findings extend the SPIS model to the domain of understanding and may have important clinical implications.

Obsessive-compulsive tendencies are related to seeking proxies for internal states in everyday life

BACKGROUND AND OBJECTIVES

In recent years we have proposed and investigated the Seeking Proxies for Internal States (SPIS) model of obsessive-compulsive disorder (OCD), which postulates that deficient access to internal states is a key feature of the disorder. According to this model, rules and rituals that often characterize people with OCD can be understood as proxies for deficiently accessible internal states. Here we compliment this earlier experimental work by examining whether reliance on proxies for internal states in everyday life is associated with OCD.

METHODS

We developed an inventory for assessing reliance on proxies in everyday life and examined its relationship with obsessive-compulsive tendencies in two internet panel studies. The internal states included hunger, enjoyment, interpersonal liking, preferences, a sense of understanding, and intuitions about correct solutions to problems. The proxies included one's own behavior, the opinion of others, and objective indices such as grades and elapsed time since eating.

RESULTS

In both studies, participants with obsessive-compulsive tendencies reported relying more on external, discernible proxies for a variety of internal states. These results remained significant after controlling for concurrent anxiety and depression.

LIMITATIONS

Our inventory is by necessity limited in its sampling of internal states and proxies and further correlational and experimental studies will be needed to examine additional areas of application, such as decision making and interpersonal liking.

CONCLUSIONS

These results are consistent with and expand the Seeking Proxies for Internal States (SPIS) model and may have implications for understanding and treating individual with OCD.

High obsessive-compulsive individuals may have attenuated access to internal cues associated with active movement: Evidence from a head repositioning study

BACKGROUND AND OBJECTIVES

The Seeking Proxies for Internal States model of OCD posits that obsessive-compulsive (OC) individuals have attenuated access to their internal states. Consequently, they seek and rely on discernible substitutes for these internal states. Previous research has supported these conjectures. Other studies, using a variety of measures, reported a reduced sense of agency (SoA) in OCD. The current study aimed to connect these two bodies of research by focusing on internal signals associated with active movement, which are related to the SoA. We hypothesized that the performance accuracy of high OC participants would be similar for active and passive movements, while that of low OC participants would be higher when the movement is acquired actively.

METHOD

Participants with high vs. low OC tendencies were asked to reposition their head to a target angle that was acquired actively or passively. This was repeated with eyes blindfolded to evaluate reliance on visual information. Accuracy of repositioning was measured with a cervical range-of-motion device.

RESULTS

As predicted, while low OC participants presented a significant decrease in their accuracy after passive (compared to active) acquisition, high OC participants' accuracy did not differ between acquisition types. Contrary to our predictions, reliance on vision was similar across groups.

LIMITATIONS

The generalization of our findings to OCD requires replication with a clinical sample.

CONCLUSIONS

This study implies that high OC individuals have a deficient access to internal cues involved in active movement. This might contribute to their doubt regarding their actions and to their reduced SoA.

Obsessive-Compulsive Tendencies Are Related to a Maximization Strategy in Making Decisions

The present studies were motivated by the hypothesis that attenuated access to internal states in obsessive-compulsive (OC) individuals, which leads to extensive reliance on external proxies, may manifest in a maximizing decision making style, i.e., to seeking the best option through an exhaustive search of all existing alternatives. Following previous research, we aimed to explore the possible relationships between OC tendencies, seeking proxies for internal states, indecisiveness and maximization. In Study 1, we measured levels of OC tendencies, seeking proxies for internal states, indecisiveness, maximization, depression and anxiety in an online Hebrew speaking sample (N = 201). In Study 2, we administrated the same questionnaires to an online English speaking sample (N = 240) and in addition, examined participants' decision making strategies in a hypothetical situation. The participants in both studies were unscreened adults. Correlational and linear regressions analyses indicated that OC tendencies are related to maximization, even when levels of indecisiveness, depression and anxiety are controlled for. Moreover, the findings suggested that reliance on external proxies may partially account for the aforementioned association. Possible implications and future directions are discussed.