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Key points
- OCD is known to involve alterations in cognitive systems such as memory, decision-making, and attention.
- New theorizing argues that OCD is caused by general deficits in individual ability to access internal states.
- Obsessions are failed introspections; compulsions are proxies enacted in lieu of internal clarity.
Obsessive-compulsive disorder (OCD) is characterized by the presence of obsessions and/or compulsions. Obsessions are repetitive, intrusive, distressing, and persistent thoughts, images, impulses, or urges that raise a person’s anxiety. Compulsions are repetitive, rigid behaviors or mental acts that the individual feels driven to perform to reduce anxiety or achieve a sense of ‘completeness.’ With a 2-3% lifetime prevalence, OCD is surprisingly common (more so among females). It tends to appear early (before age 30), has a long, chronic trajectory, and its symptoms are similar across cultures and socioeconomic classes. It often appears together with other disorders, including anxiety, mood, substance abuse, tic and impulse control disorders.
Obsessions and compulsions often appear together: contamination worries tend to beget washing or cleaning compulsions; concerns over safety or harm appear with checking behaviors; aggressive or sexual thoughts pair with mental rituals; and symmetry obsessions are linked to ordering or counting behaviors. As with other disorders, OCD often leads to avoidance behavior in an attempt to reduce exposure to triggers. Most people with OCD are aware that their compulsive behaviors are ineffective and excessive and wish to control them, yet they find themselves repeatedly unable to do so.
Cognitive-behavioral models of OCD conceptualize obsessions as noxious stimuli that are misinterpreted as dangerous, thus producing anxiety to be reduced by compulsive rituals. Yet the reliance on compulsions prevents individuals from habituating to the discomfort of obsessions and recognizing their inertness. Thus, the treatment emphasizes cognitive work on belief disconfirmation along with behavioral exposure work for fear habituation and to extinguish the fear associations related to the obsessions.
Research has revealed “strong evidence for a neurobiological basis of this disorder,” finding that OCD clients show altered functions across multiple cognitive domains, including memory, attention, and decision-making. Researchers, however, have struggled to explain how such deficits may translate into the particular symptoms of OCD.
Recently (2023), Israeli researcher Nira Liberman and her colleagues proposed a new model attempting to fill that gap. The authors note that “doubt in OCD typically revolves around internal states, such as one’s morality, motivations, emotions, or level of understanding, rather than, for example, the validity of news reports or accident statistics.” The authors propose that individuals with OCD have difficulty accessing their own internal states (feelings, emotions, preferences, and motivations). To circumvent this introspection deficit, they activate “proxies” in the form of rigid rituals. According to this model, individuals experiencing obsessional doubts are stuck in the process of looping through their proxy search and re-verification.
For example, an individual may question their own feelings toward a romantic partner. Introspecting on their internal state, they fail to find a clear answer and thus seek a proxy, such as counting the number of text messages they sent their partner in the past month. If the proxy fails, the person continues to loop through the proxy search cycle in a quest for clarity. Obsessions in this model are unsuccessful inquiries with oneself ("Are my hands clean enough? I don’t know"). Compulsions are attempts to find clarity by alternative means ("washing my hands ten times will make them clean enough").
To support their hypothesis, the authors cite research showing that people with OCD are less accurate in gauging their own experienced emotions and report difficulties in assessing everyday internal states such as hunger, interpersonal closeness, preferences, and comprehension. The authors also cite biofeedback research showing that OCD participants have difficulty judging their own levels of relaxation and muscle tension without biofeedback and tend to rely on biofeedback proxy to gauge their internal states even when provided with fabricated biofeedback data.
The authors describe several paths by which a deficit in introspective ability may disrupt cognitive processes, leading to OCD symptomatology.
Action control: Often, we rely on internal cues to decide when an action should be terminated when we have done enough (for example, when disinfecting a place to prevent disease). But for those with OCD, such introspection does not work; thus, “they resort to using proxies, such as rules, procedures, behaviors, and environmental stimuli, to instruct them when to stop. For example, unable to access a sense of satisfaction with how clean their hands feel, they might resort to rules such as ‘wash until you finish a whole bar of soap’ or ‘wash each finger 10 times.'"
Metacognition: Many of us experience periodic intrusive or negative thoughts. Yet most people can dismiss such thoughts, in part by reflecting on their emotions and motivations. If you can easily access your internal emotion of love and caring for your child and your motivation to protect them, then the occasional thought of hurting them is more easily dismissed as mental noise and is thus less likely to elicit high anxiety. This introspection process is deficient in OCD, leading to extreme discomfort and fear related to such thoughts and to the urgent attempt to neutralize them via compulsive rituals.
Decision-making: We all need to make decisions. To do so, we are often required to terminate the search for a better option at some point. Most of us do so once we find a satisfactory solution. Yet if the feeling of satisfaction is inaccessible, we may continue to search forever, thus entering self-doubt and second-guessing characteristic of OCD.
Introspection: All of us periodically inquire with ourselves about our own emotions, feelings, motivations, and preferences. (Do I love my partner? Do I want to retire? Do I understand the instructions?) Most of us can achieve reasonable clarity on these questions. Yet people with OCD find it difficult to introspect, and so they turn to proxies to get indirect confirmation about their internal states.
The proposed model aligns with previous research. It expands on existing models because its mechanism is not limited to specific, typical OCD-related obsessional contents or compulsive behavior but generalizes across (and beyond) different manifestations. In addition, unlike previous work, this model views compulsions not as byproducts of a malfunctioning extinction learning system but as functional proxies used to compensate for vague, inaccessible internal states.
The model, if supported further by future research, carries several implications for psychotherapy. First, it may be used to explain to OCD clients that their condition relates to diminished access to internal states. Realizing that their obsessive thoughts recur due to their inability to gauge their true internal states may help alleviate clients’ worries that their bad thoughts mean they are bad people. Second, recognizing that their compulsions are proxies activated to gain clarity about internal states may help clients search for and activate equally clear but less extreme and taxing ones. Finally, if the proposed introspection deficit is the culprit in OCD, then future research on the causes of such deficit may lead to new interventions for OCD.
