Dissociation Shown to Have Key Role in OCD

Nancy A. Melville

August 19, 2015

Dissociative thinking and the related concept of inferential confusion appear to be key predictors obsessive-compulsive disorder (OCD), showing strong associations after controlling for negative mood states, new research suggests.

"After controlling for a number of other factors, we were able to pinpoint that there is really something about dissociation and inferential confusion that are involved in OCD," coauthor Frederick Aardema, PhD, codirector of the Obsessive-Compulsive and Tic Disorder Studies Centre (CETOCT) and assistant professor in the Department of Psychology at the University of Montreal, in Quebec, Canada, told Medscape Medical News.

Their findings were published in the Journal of Clinical Psychology.

Negative Mood States

Although the processes of dissociation, in which patients confuse reality with their imagination, and inferential confusion, involving overriding feelings of obsessive doubt, have been previously linked to OCD, few studies have evaluated their role in a clinical population after controlling for negative mood states, such as depression and anxiety.

The study involved 75 adult patients (mean age, 37 years) who met criteria for OCD and who completed a battery of self-reporting questionnaires regarding their schizotypal, dissociative, and imaginative processes.

The questionnaires included the Yale-Brown Obsessive-Compulsive Scale–Obsessions Subscale; the Beck Anxiety Inventory; the Beck Depression Inventory; the Obsessive Beliefs Questionnaire– Importance/Control Subscale; the OBQ-Perfectionism/Certainty Subscale; the OBQ-Responsibility/Threat Subscale; the Schizotypal PersonalityQuestionnaire; the Dissociative Experiences Scale; the Vancouver Obsessional Compulsive Inventory; and the Inferential Confusion Questionnaire–Expanded Version.

"There are currently no studies that have investigated these three constructs simultaneously to identify the most crucial variables relevant to OCD," the authors write.

The results confirmed their hypothesis that dissociation and inferential confusion were significantly correlated with OCD symptoms after controlling for negative mood states.

Inferential confusion, for instance, was linked to variance in repetitive checking, beliefs of contamination, and "just right" experiences, the authors write.

"In these cases, individuals with OCD may become so involved in their imagination and subjective narratives that they come to distrust reality-based information provided by their senses or common sense."

Dissociation was a predictor of other compulsions, such as obsessions, compulsions, and indecisiveness.

Schizotypal processes were not as strongly associated with OCD symptoms and were instead linked primarily to OCD focusing on hoarding.

"We had expected schizotypal symptoms would have more of an independent association with OCD, but in the end, after controlling for all of the other variables, it was only related to the one subtype of hoarding," Dr Aardema said.

The findings offer clues to the processes that prompt patients to transition from realistic thinking to becoming absorbed in a thought pattern based on unrealistic beliefs, or an "OCD bubble," he said.

"It's common that clinicians will struggle to get patients out of this 'OCD bubble,' involving extremely strong obsessions, but it can help to understand these processes of how they transition from reality to their imagination."

Dr Aardema and his team are conducting ongoing research to take the next step of determining whether therapy that focuses on dissociation can be relevant to treatment outcome.

"We're looking to see whether treatment of dissociation results in improvements in OCD, and our preliminary findings do point in that direction," he said.

The treatment approach the researchers are evaluating for dissociative symptoms involves inferential-based cognitive-behavioral therapy (CBT), which focuses on the initial doubting inferences that drive the worry of something being wrong and increasingly override the assurances of more rational thought.

"In an indirect way, we already address dissociation in conventional CBT, but there are in fact very few treatment options available for dissociation, and there is still a lot we need to understand in terms of cognitive formulations of it," Dr Aardema said.

Healthy Disagreement

Jonathan Abramowitz, PhD, who is professor and associate chair of psychology at the UNC-Chapel Hill Clinical Psychology Program, in North Carolina, said that although he felt the study was interesting, he questioned the role of dissociation in OCD.

"Certainly patients with OCD may vary in terms of their degree of insight, but I think when push comes to shove, they can be brought back to reality, whereas when a person has delusions, they are convinced of them, and if you try to show them evidence to the contrary, they will twist reality around to conform to their delusions," he told Medscape Medical News.

He agreed, however, that much more needs to be understood about OCD and that such investigations and debates are important.

"One of the reasons for these different theories is we don't know what the causes are. The underlying problems can be very elusive, but it's healthy to have disagreement about it," Dr Abramowitz said.

"The bottom line is that cognitive-behavioral therapy is typically successful and certainly has the best supporting evidence, but by no means are we all the way home. There are plenty who don't respond, so we need to continue to look at other explanations."

The authors and Dr Abramowitz have disclosed no relevant financial relationships.

J Clin Psychol. 2015;71:606-662. Abstract

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