Abstract
This paper proposes an integrated account of the etiology of OCD that accommodates both dysfunctional cognitions and sensorimotor features of compulsive action. It is argued that cognitive/metacognitive theories do not aspire to address all obsessive-compulsive phenomenal properties and that empirical evidence concerning some of these requires the incorporation of motor deficits as an independent factor in a plausible conception of OCD. The difference in agency attribution between obsessive-compulsive persons and schizophrenia patients with delusions of control is also accounted for in terms of bottom-up processes.
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Notes
I will describe the differences between cognitive and metacognitive theories in some detail in Section 3. When talking about cognitive/metacognitive theories, I will use only those features that both types have in common.
“I use the term “cognitive” in a narrow sense, in contradistinction from “perceptual”, as well as from “motivational” and “affective”. “Cognitive” as applied to “higher-order”, conceptual and propositional states and processes only is somewhat old-style, as the “cognitive” of cognitive science encompasses all information-processing. There are sufficient current examples of the more narrow usage, though, in philosophy and psychology in general, as well as in literature on OCD specifically, to make this use acceptable. See, e.g. Stillings et al. 1995; recent examples are Block 2014 and Marchi and Newen 2015.
The most obvious exception is the “pure obsession” subtype, which does not involve compulsive features (see Section 4).
Elevated sense of control should be distinguished from self-attributional bias. In both cases, the subject ascribes causal influence to themselves in a way that is not appropriately grounded in evidence. In self-attributional bias, successful outcomes tend to be self-attributed, while failures tend to be attributed to external factors. Elevated sense of control in OCD does not favour positive outcomes. Patients self-ascribe responsibility for bringing about or not preventing specific negative outcomes by performing compulsive acts. The motivation behind this is not the need for the maintaining or enhancement of self-esteem, but the prevention of negative outcomes.
It should be noted that this is not an exaggerated sense of motor control, but rather a sense of being able to influence the state of the world in a particular way, that is, the action having particular consequences. This is why I labelled the contradiction ‘apparent’. More will be said about this in Section 3.
The hierarchical model Krigolson and Holroyd suggest has been used by Gentsch, in Gentsch 2011.
In the study cited, the authors correlated washing symptoms with the parental expectations dimension only. Therefore, similar conclusions might apply to washing, which also involves motor activity. Further, out of six dimension of perfectionism on the Frost Multidimensional Perfectionism Scale (Frost et al. 1990)--víz. Personal standards, doubts about actions, concern over mistakes, parental expectations, parental criticism, and organization—parental expectations and parental criticism did not show correlation with checking behavior, and doubts about action were found uniquely predictive of checking symptoms (Martinelli et al. 2014: 151).
Over 80% of OCD patients have checking compulsions (Antony et al. 1998), associated with motor movements and feelings of incompleteness, so if OCD-related behavior originates in motor deficiencies, properties of checking-related behavior may carry over to non-checking behavior. This would explain the fact that, while the relationship is especially strong with checking and ordering, as it was found in another study, feelings of incompleteness statistically predict obsessive-compulsive symptoms of all types (Taylor et al. 2014).
This does not mean that the OCD patient experiences herself as ‘making up’ the action task, i.e., what she has to do to avoid catastrophe. Rather, it appears to her as something objective, non-arbitrary, discovered rather than invented by her.
Functionality was measured against the standards of the behavior of controls (e.g., what belongs to lighting a cigarette and what the superfluous elements are). Non-functional movements included waving hands, touching the floor, and shaking the object to be handled.
That the feeling of incompleteness has a causal role in ritualization is in line with Ecker and Gönner’s claim that the motivation for ritualization is the feeling of incompleteness (Ecker and Gönner 2008).
Ritualization itself may also influence agentive experience and the perception of action, perhaps even contributing to the perceptual deficit described, so there may be a dynamic, two-way relationship between both. There is some evidence from research on non-functional action sequences suggesting that this is the case. Nielbo, Schjoedt, and Sorensen found that behaviour dominated by ritualization increases cognitive load and focuses the subject’s attention on low-level details of executing the act (Nielbo et al. 2013). Non-functionality makes an action sequence less predictable, goes with a high error signal in prediction and a higher rate of sensory update (78).
That checking is not readily categorizable as either harm avoidance or incompleteness dominated is an empirical statement by Ecker and Gönner (2008) to the effect that both motivational factors can be present and there may be no way of assigning more weight to one over the other. The subject has a sense that the checking needs to be performed due to the threat of harm and the repeated movements are meant to counter the feeling that the previous ones did not achieve their goal. The repeated motion cannot be explained by either the pursuit of avoiding harm (which might be averted by, e.g., a single motion) or the feeling of incompleteness (the motions being specifically directed at potential sources of physical harm) alone. This can be contrasted with symmetry/ordering, which was found to be “predominantly” incompleteness-related, that is, motivated by feelings of incompleteness. When, e.g., two rows of soda bottles have to exactly mirror each other, the theme of harm is fully absent.
An exception is Gillan and Robbins (2014), as above.
In passing, I would like to mention some therapeutic implications and a possible direction for further research. Apart from whether, at present, the underlying motor control deficits can be effectively treated or not, feelings of incompleteness, as well as cognitions attached to those feelings, can be targeted by therapy. Feelings of incompleteness can be influenced by brain stimulation methods: there is evidence to the effect that transcranial magnetic stimulation can reduce the sense of incompleteness (Mantovani et al. 2013). Deep brain stimulation, used in some very severe, treatment-refractory cases of OCD, may also have an impact on the sense of incompleteness, in that, according to subjects’ reports, it makes the experience of ‘rightness’ appear sooner, that is, shortens the period of NJREs (de Haan et al. 2015). Targeting the feelings of incompeteness themselves thus seems to constitute a promising direction of clinical practice.
Patient’s focus on the details of action execution and stopping action when the outcome “feels right” suggests that they attach significance to the completeness/incompleteness of the action. Besides the feelings themselves, the cognitions that give meaning to them could also be modified. There is some evidence that the relevant cognitions can be influenced by cognitive-behavioral therapy: subjects reported fewer and less distressing episodes of NJREs after the completion of treatment (Coles and Ravid 2016).
The inquiry undertaken in this paper could be extended to other conditions. One of the more obvious candidates would be major depressive disorder, which involves disbalanced motor control (see, e.g., Walther et al. 2012), difficulties choosing responses and initiating fewer movements (Hoffstaedter et al. 2012). The depressive patients’ perception that they are merely ‘struggling’ to perform simple motor tasks, the feeling of reduced control in action, and the sense of inability to initiate and complete actions, is likely to be at least partly attributable to the sensorimotor features of the action and not simply a consequence of lack of motivation to act. Besides pathologies with more or less explicit links to motor movement—such as eating disorders, phobias, and kleptomania—the influence of sensorimotor mechanisms on properties of agentive self-awareness and action identification could constitute a promising line of research even in the case of healthy persons as well.
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The writing of this paper was funded by Hungarian Scientific Research Fund (OTKA) project no. 120375.
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Szalai, J. The Sense of Agency in OCD. Rev.Phil.Psych. 10, 363–380 (2019). https://doi.org/10.1007/s13164-017-0371-2
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DOI: https://doi.org/10.1007/s13164-017-0371-2