An ironic effect of monitoring closeness

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 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.

Formal vs. intuitive categorization and obsessive-compulsive symptoms

BACKGROUND AND OBJECTIVES

Obsessive-compulsive disorder (OCD) is often characterized by rigidity regarding rules and perfectionism, which suggests a formal reasoning style. However, other characterizations suggest an overreliance on internal cues for behavior termination, which suggests a more intuitive reasoning style. We examine reasoning styles in OCD by assessing categorization preferences traditionally classified to rule-based and family resemblance categorization.

METHOD

An initial study (n = 41) and an online replication (n = 85) were conducted. In both studies, groups scoring high and low on OCD symptoms were compared. Categorization preferences and confidence ratings were examined via a modification of a classic categorization task. The task was administered in three conditions: under time limits, with no time limits, and with explicit explanation of both categorization styles.

RESULTS

Aggregating results from both studies showed that obsessive-compulsive symptoms were associated with a reduced preference for rule-based categorization reflecting a tendency towards a more intuitive, non-formal reasoning style. This preference was apparent even when rules were explicitly described. Group differences regarding confidence were inconclusive.

LIMITATIONS

Generalizing results to the clinical population requires further research, and specificity to OC symptoms should be determined.

CONCLUSIONS

Challenging the expected association between OCD and rigidity and perfectionism, findings support suggestions that OCD reasoning strays from formal reasoning. This may explain some of the subjective and idiosyncratic rules adopted by individuals with OCD.

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.

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.

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.

Explicit instructions facilitate performance of OCD participants but impair performance of non-OCD participants on a serial reaction time task

Previous studies have shown that individuals diagnosed with OCD tend to rely on explicit processing while performing implicit learning tasks. We sought to investigate whether individuals with OCD are capable of implicit learning, but would demonstrate improved performance when explicit processing strategies are enhanced. Twenty-four participants with OCD and 24 non-psychiatric control (NPC) participants performed an implicit learning task in which they responded to a single target stimulus that successively appears at one of four locations according to an underlying sequence. We manipulated the learning strategy by informing half of the participants that the target stimulus location was determined by an underlying sequence, which they should identify (intentional learning). The other half of the participants was not informed of the existence of the underlying sequence, and was expected to learn the sequence implicitly (standard learning). We predicted that OCD participants will exhibit inferior performance compared to NPC participants in the standard learning condition, and that intentional learning instructions would impair the performance of NPC participants, but enhance the performance of OCD participants. The results supported these predictions and suggest that individuals with OCD prefer controlled to automatic processing. We discuss the implications of this conclusion to our understanding of OCD.

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

BACKGROUND AND OBJECTIVE

People's feelings are not always accessible to them, and this might be especially the case for some individuals and in some situations. Based on our model of obsessive-compulsive disorder, we predicted that obsessive-compulsive (OC) tendencies and situationally induced doubt would be associated with decreased access to one's own emotions.

METHODS

In the first two studies we examined the relationships between OC tendencies and performance on the Mayer-Salovey-Caruso Emotional Intelligence Test (MSCEIT). In Study 3 we undermined participants' confidence in their ability to accurately assess their own emotions and assessed the effect of this manipulation on MSCEIT performance.

RESULTS

As predicted, OC tendencies were associated with lower scores on the Experiential area of the MSCEIT, which relies on access to experienced emotions, but not on the Strategic area, which relies on semantic knowledge about emotions. Similarly, undermining participants' confidence in their own emotions reduced their scores on the Experiential, but not on the Strategic area of the MSCEIT.

LIMITATIONS

The findings should be replicated with a clinical OCD population and with other measures of emotional experience.

CONCLUSION

These studies suggest that impaired access to emotional states may be caused by doubting those states, that it characterizes people with high OC tendencies, and that it might be a manifestation of a more general difficulty in accessing internal states.

Can doubt attenuate access to internal states? Implications for obsessive-compulsive disorder

BACKGROUND AND OBJECTIVES

We have previously reported that obsessive-compulsive individuals perform more poorly on tasks that require accurate perception of internal states. As these individuals are also characterized by elevated levels of doubt regarding internal states, the causal relationship between doubt and accurate perception remained unclear. The presented study examines whether undermining participants' confidence in their ability to accurately produce a specific internal state would affect their performance on a task that requires accurate perception of this state.

METHODS

Participants were trained to produce specific levels of forearm muscle tension and then required to produce various tension levels in four experimental phases. The first three alternated in terms of whether the participants viewed a biofeedback monitor while the fourth offered participants several times the choice to view the monitor. Prior to the task, half of the participants received instructions that undermined their confidence in their ability to accurately assess their own muscle tension. We measured participants' accuracy in producing the required muscle tension levels and the number of times they requested to view the monitor in the final phase.

RESULTS

Undermined confidence participants were less accurate in producing the required muscle tension levels in the absence of biofeedback, and were also more likely to request the monitor in the final phase.

CONCLUSIONS

Doubt can affect performance on tasks that require perceiving and experiencing internal states. This finding supports the possibility that access to internal states in OCD is attenuated due to elevated levels of doubt regarding these states.

Always on guard: test of high vs. low control conditions in obsessive-compulsive disorder patients

Obsessive-compulsive disorder (OCD) is a relatively common psychiatric disorder characterized by recurrent obsessive thoughts and/or compulsive behaviors. It has been shown that OCD patients suffer from deficits in executive control. During Stroop task performance, it was found that cognitive control in healthy participants adjusts adaptively - control is reduced when conflict is less likely. Twenty-four individuals meeting criteria for OCD and 27 controls carried out two blocks of a Stroop task; one with high control (a third of the trials were neutral) and one with low control (75% of the trials were neutral). In the healthy control group, results replicated previous findings showing increased interference and decreased facilitation in the low control condition compared to the high control condition. OCD participants, on the other hand, showed no difference in results between the two blocks. Moreover, in the high control condition, interference was larger and facilitation was smaller compared to healthy controls, indicating less efficient executive control for both the informational and task conflict. We concluded that healthy controls adjust the level of control to changing circumstances whereas OCD patients have difficulties to adaptively make such adjustments. Implications for this novel evidence of deficient executive control of flexibility in OCD patients are discussed.

Right or flawed: relationship obsessions and sexual satisfaction

INTRODUCTION

Relationship obsessive-compulsive disorder (ROCD) is marked by the presence of obsessions and compulsions focusing on romantic relationships. ROCD symptoms were previously linked with decreased relationship quality and might interfere with sexual functioning.

AIM

The study aims to examine the association between ROCD symptoms and sexual satisfaction.

METHODS

Participants completed an online survey assessing ROCD symptoms and relationship and sexual satisfaction levels. Depression, general worry, obsessive-compulsive disorder (OCD) symptoms, and attachment orientation were also measured.

MAIN OUTCOME MEASURE

The main outcome measures were self reported relationship satisfaction and sexual satisfaction.

RESULTS

ROCD symptoms were associated with decreased sexual satisfaction over and above symptoms of depression, general worry, OCD, and attachment orientation. The link between ROCD symptoms and sexual satisfaction was mediated by relationship satisfaction.

CONCLUSIONS

Identifying and addressing ROCD symptoms may be important for treatment of sexual functioning.