‘I wash until it feels right’: The phenomenology of stopping criteria in obsessive–compulsive washing

https://doi.org/10.1016/j.janxdis.2007.02.009Get rights and content

Abstract

Recent elaborations of cognitive behavioral theory in OCD suggest that difficulties in deciding when to stop a compulsive action may be related to the use of counter-productive termination criteria by obsessional patients [Salkovskis, P. M. (1999). Understanding and treating obsessive–compulsive disorder. Behaviour Research and Therapy, 37, s29–s52]. Such criteria are characterized by their subjective nature, i.e. a primarily internal reference point (e.g. ‘just right’ feelings), and are conceptualized as the “top level” of a general strategy involving elevated evidence requirements. Thirty-eight obsessional washers, 41 obsessionals with other problems and 43 healthy controls were interviewed about and rated two situations varying in the degree of urgency to wash; they also washed their hands in a behavioral test. Washers reported using subjective criteria more frequently and rated them as more important for the termination of the washes than the other groups in questionnaire, interview and laboratory data. Both obsessional groups considered more criteria before stopping than the healthy controls, suggesting that using multiple criteria is a general strategy. The data are consistent with the predictions of the elaborated cognitive-behavioral model of OCD. They indicate that the use of subjective criteria and elevated evidence requirements is affected by the perceived significance of the situation in a similar way for obsessional and non-obsessional individuals.

Introduction

Obsessive compulsive disorder (OCD) is a severe and persistent psychological problem with immense negative effects on the individual's social and working life as well as on their family (Bobes et al., 2001, Koran, 2000; Koran, Thienemann, & Davenport, 1996; Parkin, 1997). Patients suffer not only from marked anxiety and discomfort associated with their obsessional thoughts but also from the compulsive or neutralizing behavior that is performed in order to prevent the feared consequences from happening (Zaudig, 2006). Obsessional patients characteristically engage in repeated and/or prolonged episodes of compulsive behavior, feeling unable to stop repeating some action over and over again.

Although other phenomena related to compulsions, such as the motivation to ritualize in the first place, or the anxiety reduction which follows it, have been extensively examined both theoretically and experimentally (Rachman & Hodgson, 1980; Rachman & Shafran, 1998; Salkovskis, Thorpe, Wahl, Wroe, & Forrester, 2003) factors influencing the termination of (and failure to terminate) compulsive activities have received comparatively little research attention. It has been proposed that the repetitiveness of some compulsive behavior, particularly checking, can be accounted for by poor memory for actions (Ecker & Engelkamp, 1995). However, when memory for OCD relevant stimuli is assessed this is found to be intact or event enhanced in OCD (e.g. Radomsky, Rachman, & Hammond, 2001). Data on memory in OCD suggests that the most consistent effects are low levels of confidence in memory for OCD related stimuli (Tolin et al., 2001).

The focus on the current study is on the difficulty people suffering from OCD have in stopping behaviors such as washing and checking once they have started what would otherwise be a normal activity. Rather than taking a memory perspective, we instead re-conceptualize the difficulty in stopping behavior as a problem of decision making, specifically the process of deciding that enough has been done. The idea that there are problems in decision making processes fit better with the basic phenomenology of OCD. The patient who has washed until their hands bleed does not report doubt that they have been washing or even how long they have washed, but instead report being uncertain whether they have washed enough.

This phenomenon can be understood by extending current cognitive theories of OCD, particularly those described by Freeston, Rheaume, and Ladouceur (1996), Rachman (1998) and Salkovskis (1999). The CB model is based on the idea that it is not the intrusive thoughts per se which leads to discomfort and compulsive actions, but the meaning that the person attaches to them. Only if an obsession is interpreted as indicating that one might be responsible for serious harm to oneself or others does it result in the range of reactions and responses characteristic of OCD. The CB-model (Salkovskis, 1999) proposes that a common response to fears of being responsible for harm is the use of potentially counter-productive “stop criteria”, where the person actively seeks to achieve a particular subjective or emotional state as a way of deciding that they have completed an activity. This includes the deliberate seeking of a particular mood state, a sense of satisfaction or completeness and “just right” feelings as a way of deciding that it is appropriate to stop behavior. Such internal states are inherently more difficult for the person to evaluate than sensory input and it therefore takes longer to decide whether they have been met or not. The use of “just right” and other subjective states to decide on the termination of an action could be regarded as an example of the operation of “Elevated Evidence Requirements”, motivated by the perception of importance of the outcome of the “stop” decision (Wahl & Salkovskis, submitted for publication). The idea of “elevated evidence requirements” has been discussed previously as an important maintaining factor in chronic worry (Tallis, Eysenck, & Mathews, 1991).

The addition of the concept of EER to cognitive theories of OCD suggests that not only is the quality of the criteria that are used to stop an action different for individuals with and without OCD – obsessional patients emphasizing subjective criteria – but also the quantity of criteria that are taken into consideration. We suggest that obsessional patients are likely to consider multiple criteria before they can reach a decision, whereas individuals without any obsessional problems consider only few criteria. Only if they are satisfied that all criteria have been met can they make a decision about whether to stop.

An implication of the active use of elevated evidence requirements is that the decision making process is controlled in the sense that it requires mental effort, is deliberate and conscious (McNally, 1995). Decision making at the end of a non-compulsive wash, on the other hand, would be relatively automatic, i.e. involve little or no mental effort, is not necessarily conscious and not deliberately initiated or terminated. We suggest that the deployment of elevated evidence requirements in decision making is not necessarily a pathological strategy or a generalized cognitive style. Instead, the theory suggests that everybody can and does use elevated evidence requirements given the right circumstances. The extent to which people require more evidence before reaching a decision varies according to the perceived personal importance of that decision. For most people, the decision about which sock to put on first requires little consideration of the factors involved. However, deciding whether to take a new job would normally lead to seeking a range of objective information (salary, conditions, location and so on) combined with the general felt sense of whether this was the right thing to do or not. Thus, the perception of personal significance and importance of any particular decision is likely to determine the extent to which more evidence is actively sought in order to reach a decision. The more important a decision is, the more likely it is that the evidence sought will include subjective (“it feels right”) elements. These subjective elements can override the objective elements (“It seemed like a good job, but it didn’t feel right for me”). This ties in with the proposed link between an inflated sense of responsibility for harm in people suffering from OCD (Salkovskis, 1985, Salkovskis, 1999). The harm which they perceive might occur in OCD relevant situations will lead them to treat normally unimportant decisions as if they were dangerous leading not only to the tendency to engage in neutralizing, but also to a requirement for elevated levels of evidence in the decision that they had completed the task.

Our conceptualization of elevated evidence requirements is related to other concepts of internal states in OC patients that have recently been investigated by Coles et al., Richards and Davey et al. Coles et al. (2003) examined “not just right experiences (NJRE)” in large undergraduate samples. They found that self-rated NJRE were moderately correlated with OCD features, in particular checking and ordering, and maladaptive domains of perfectionism. Correlations were higher than correlations with depression, social anxiety, trait anxiety or worry. However, the study examined the existence of NJRE in an undergraduate sample and did not investigate its relationship to the termination of compulsive action in OCD patients. This is the aim of the current study. Richards (1995) found that obsessional patients reported relying on internal states such as feelings of rightness or completeness when deciding when to stop a compulsive action, whereas non-clinical controls reported relying on more objective or external criteria like the sound of the door lock. However, Richards investigated the importance of a number of reasons relative to each other, but not their absolute importance—which is the aim of the current study. Additional evidence for the importance of subjective criteria (such as mood) in the termination of compulsive actions comes from studies by Davey, Startup, Zara, MacDonald, and Field (2003) and MacDonald and Davey (2005). They found that perseveration in a checking task depended on the combination of two stopping rules (“Have I checked as many as possible?” versus “Do I feel like checking?”) with positive and negative mood inductions. In particular, perseveration was most significant when negative mood was combined with the rule “as many as possible”.

A recent account of problematic ‘stop mechanisms’ in OCD by Szechtman and Woody (2004) postulates that compulsive rituals are prolonged by the absence of a “feeling of knowing” which normally terminates a biologically based security motivational system. Similar to our model, the “feeling of knowing” refers to a state of internal origin and thus emphasizes the importance of subjective criteria in the termination of a compulsive ritual. However, they claim that the “feeling of knowing” is entirely based on internal perceptions such as the performance of a certain (checking or washing) behavior and it is assumed to operate automatically. In contrast, we assume that the “feeling of rightness” is a part of a conscious, i.e. non-automatic, decision making process combining both external and internal cues.

The idea of elevated evidence requirements in OC patients supplements current cognitive theories which emphasize the importance of certain dysfunctional beliefs such as “intolerance of uncertainty” (Sookman & Pinard, 2002) by specifying the way in which OC patients deal with their uncertainty. A general belief about the necessity of being certain is not sufficient in order to explain why obsessional patients have difficulties in stopping their compulsive behavior. Our theory provides a plausible mechanism that links “intolerance of uncertainty” with the clinically observed difficulty in stopping a compulsive action by specifying the decision making criteria.

In the present study, we have sought to apply the extended cognitive theory to obsessional washing because hand washing is an almost universal behavior (rather than being confined to people suffering from OCD), allowing comparison between obsessional washers, obsessional patients who do not have a problem with washing and healthy controls. In washing, the use of elevated evidence requirements is likely to involve some combination of the person looking at their hands, feeling (in a tactile sense) whether they are still sticky, and seeking to feel right about it and not to have any doubts that their hands are clean. These criteria would be operated in a deliberate (strategic) way. In contrast, a “ordinary”, non obsessive wash would be finished once the person sees that the hands are not dirty any more (if they had been visibly dirty before the wash), or after the passage of a brief period of time, and would be terminated with little deliberate effort (relatively automatically).

In order to evaluate the use of elevated evidence requirements as predicted by our theory, we conducted three connected studies: (1) a standardized and structured interview, (2) an inventory and (3) a behavioral test. Participants were obsessional washers, obsessional patients who did not have a washing problem and healthy controls. The use of an obsessional control group is more stringent than the typical comparison with anxious controls since non-washing obsessionals limit confounding variables that can complicate the interpretation of group differences, such as indecision, memory deficits and so on. Additionally, we investigated all groups in two different situations, one with high perceived significance and one with low perceived significance. These two different situations allow us to assess the role of the importance of the situation in applying elevated evidence requirements.

The hypotheses being investigated were: firstly, for obsessional washers, internally referenced criteria are more important than for non-washing obsessionals or non-clinical controls. These group differences are expected to be more pronounced in the “most needed wash” compared to a “least needed wash”. It was expected that objective criteria would be at least as important for the washers than for the control groups. Secondly, it was predicted that the total number of criteria being taken into consideration would be higher for obsessional washers than for controls. Thirdly, the decision making process was expected to be more conscious and effortful for obsessional washers than controls. Finally, we predicted that the importance of the situation interacts with the use of elevated evidence requirements: the higher the perceived personal significance of the situation, the more likely the use of elevated evidence requirements.

Section snippets

Part 1: A semi-structured interview

A standardized interview technique was chosen since to date little is known about stopping criteria in OCD patients. The main objective of this part of the study was to generate ideas about stopping criteria in obsessional washing. Additionally, we categorized the qualitative data according to our own theory in order to see whether we could find indication of the use of elevated evidence requirements. It was predicted that washers report subjective or internally referenced criteria more often

Part 2: The washing inventory

The second part of the study was designed specifically to evaluate the elevated requirement for evidence in a more structured way using ratings tailored to these concepts. The hypotheses therefore addressed in this study are: (i) for obsessional washers, internally referenced criteria will be rated as more important than for non-washing obsessionals and healthy controls. These group differences should be more pronounced in the most important wash relative to the least important wash. Objective

Behavioral test

Washing was elicited in the laboratory in order to evaluate aspects of elevated evidence requirements “on line”, and to seek to relate this strategy to observational measures of the wash itself. All participants washed at baseline and after rubbing wax into their hands as part of a standardized procedure. Self-report measures (the washing inventories) of the importance of various stopping criteria were taken. In order to test whether counterproductive stopping criteria are related to the length

Overall discussion

This study is the first investigating the use of elevated evidence requirements in obsessional washers, patients with other obsessional problems and healthy controls. The investigation involved three connected studies: a standardized interview with open ended questions, a questionnaire study which assessed the importance of subjective and objective criteria quantitatively and finally, a behavioral test which assessed elevated evidence requirements immediately after a standardized laboratory

References (34)

  • F. Tallis et al.

    Elevated evidence requirements and worry

    Personality and Individual Differences

    (1991)
  • D.F. Tolin et al.

    Memory and memory confidence in obsessive–compulsive disorder

    Behaviour Research and Therapy

    (2001)
  • A.T. Beck et al.

    An inventory for measuring depression

    Archives of General Psychiatry

    (1961)
  • W. Ecker et al.

    Memory for actions in obsessive–compulsive disorder

    Behavioural and Cognitive Psychotherapy

    (1995)
  • M.B. First et al.

    The structured clinical interview for DSM-III-R personality disorders (SCID-II): II. Multi-site testetest reliability study

    Journal of Personality Disorders

    (1995)
  • E.B. Foa et al.

    The validation of a new obsessive–compulsive disorder scale: The Obsessive–compulsive Inventory

    Psychological Assessment

    (1998)
  • L.M. Koran et al.

    Quality of life for patients with obsessive–compulsive disorder

    American Journal of Psychiatry

    (1996)
  • Cited by (0)

    View full text