Analysis of OCD Using Relational Frame Theory, Experiential Avoidance and Emotion Regulation

Obsessive-compulsive disorder (OCD) is classified as an anxiety disorder by the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR) (American Psychiatric Association, 2000). It is characterized by distressing intrusive thoughts or sensations, known as obsessions, and unwanted repetitive behaviors aimed at reducing the distress associated with obsessions, known as compulsions, that cause functional interference and decreased quality of life. There is a functional relationship between obsessions and compulsions, with 90% of people with OCD engaging in compulsions in response to obsessions (Foa & Kozak, 1995). Although there is usually a predominant obsession and corresponding compulsion, most people with OCD tend to have multiple obsessions and compulsions varying in intensity and severity. According to current estimates, approximately 1% of the U.S. population (or 2.2 million people) meet criteria for OCD each year (Kessler, Chiu, Demler, & Walters, 2005).

The obsessional aspect of OCD can be explained by Relational Frame Theory (RFT), which is a psychological theory of human language and cognition (Hayes, Barnes- Holmes, & Roche, 2001). RFT claims that verbal human beings respond to stimuli based on their histories of interaction with them as well as the mutual relations of stimuli to other events. To illustrate this concept, a rat, for example, must interact with a stimulus in order to learn its functions, but a human can be told or assume that a novel stimulus is “the same as” or “different than” something that he or she has interacted with; based on this information, the new stimulus will gain a meaning and function based on the relational network that these cues establish. Humans have the ability to form bi-directional stimulus relations, where a word and the actual item or event describing that word each can equally stand for the other. For example, the word “biscuit” and an actual biscuit are equal for humans because of language; we do not need to see the biscuit in order to anticipate getting one. Another example of this phenomenon is a child learning that touching a hot stove will burn him or her without having the direct experience of touching a hot stove and getting burned. Even if someone has never experienced a particular event, the ability to use language allows people to learn things about it. The concept of bi-directional stimulus relations explains why evaluative conditioning can occur and why arbitrary associations can be made, and these two processes are integral parts of Neziroglu’s (2012) learning model of body dysmorphic disorder (BDD); BDD is a subtype of OCD characterized by the obsessive idea that some aspect of one’s own appearance is severely flawed and warrants exceptional measures to hide or fix it (Cororve & Gleaves, 2001; Neziroglu & Mancusi). The principles of RFT, their associated explanatory functions of OCD symptomology, and relevant conclusions for the practice of clinical psychology will be elaborated upon.

 Experiential avoidance (EA) frequently occurs in response to obsessions and their associated anxiety (Barlow, 2002). EA is defined as the tendency to engage in behaviors to alter the frequency, duration, or form of unwanted private events (i.e., thoughts, feelings, physical sensations, and memories) and the situations that occasion them (Hayes, 1994; Hayes et al., 1996). People with OCD tend to avoid situations that give rise to their obsessions by actively avoiding, engaging in compulsions, rationalizing, distracting, and thought-suppressing in response to the distress associated with their obsessions. Therefore, EA serves as a form of negative reinforcement for such response behaviors in OCD. EA also serves as a form of emotion regulation (ER), which is defined as any action that is designed to influence “which emotions we have, when we have them, and how we experience and express them” (Gross, 2002, p. 282). ER is not a dysfunctional process in itself, but it can become a dysfunctional part of OCD when the anxiety one is attempting to regulate cannot and need not be regulated, and when the very act of ER gets in the way of meaningful life activities[1]. The compulsion-maintenance and ER functions of EA as well as related conclusions for the practice of clinical psychology will be further discussed.

An RFT Explanation of Obsessions in OCD and BDD[2]

 The principles of RFT offer explanations for the obsessional component of OCD. As mentioned previously, BDD is a subtype of OCD, and its obsessional symptomology related to bodily appearance can also be explained by RFT. Neziroglu’s learning model of BDD suggests that early experiences and conditioning begin to shape an individual’s cognitions and emotions, and language mediates learning and conditioning and development of appearance-related beliefs (Neziroglu & Mancusi, 2012). RFT then explains the role of language and how it influences cognitions and emotions in BDD. According to this model, evaluative conditioning strengthens obsessions in BDD. Evaluative conditioning is a type of classical conditioning defined as a change in liking, which occurs due to an association with a positive or negative stimulus (Hofmann, De Houwer, Perugini, Baeyens, & Crombez, 2010). Language supports classical conditioning by stimulating complex networks of associated ideas, images, and evaluations; for example, someone could learn that having a pimple (unconditioned stimulus or US) is associated with disgust (unconditioned response or UR), and later any blemish (conditioned stimulus or CS) would elicit disgust (conditioned response or CR). The word pimple is similar to acne or blemish, and thus those similar words alone gain the ability to elicit the same aversive affect through classical conditioning via the relational frame of coordination or similarity. This is why an individual with BDD may respond with aversive affect to any word or event that reminds him or her of his or her “defective” bodily feature. So, for example, if an individual with BDD has a disgust reaction at some point to a pimple, anything similar may give rise to the same reaction by thinking about it, even if it no longer exists. To summarize the role of evaluative conditioning in the development of BDD, a negative event about one’s physical appearance may serve as a US (e.g., being made fun of because of one’s weight or the size of one’s stomach), which leads to an unconditioned emotional response (e.g., anxiety, depression, shame, or disgust), then the US (being teased about one’s weight or stomach) is evaluated as negative, and finally anything paired with it is evaluated as negative as well. For example, if a person is made fun of for having a big stomach, this evokes negative affect, and subsequently, a word like “big” (CS) or a body part like the stomach (CS) is evaluated as negative. According to evaluative conditioning, any previously neutral word or body part can lead to the same negative reaction as the unconditioned stimulus (being teased about one’s weight or stomach), and when the individual is then exposed to the body part of concern, a negative emotional response occurs. Not only is the CS (the word “big” or a body part like the stomach) evaluated negatively, but it evokes the same response (e.g., anxiety or disgust) as the US (being teased about one’s weight or stomach). The interplay between language and evaluative conditioning seem to factor in to the obsessional component of BDD.

 Another idea within RFT called arbitrary associations, or the use of language as a way of making connections that may or may not be factual, also contributes to the explanation of BDD symptomology. It is possible that in people with BDD, arbitrary associations between appearance, social success, and/or undesirable physical traits are made, and these faulty associations rarely are tested and thus not likely to be extinguished (Neziroglu & Mancusi, 2012). To illustrate this point, a child may hear a parent comment about another child who is annoying to invite over because she is a finicky eater. However, the parent may also comment that this other child is so cute and pretty and it is a shame that she is such a difficult and finicky eater. Due to this, the first child may learn that people tolerate unpleasantness (finicky eating) when the person is pretty, and the child may start comparing herself with her friend in terms of looks in order for people to accept her as well. These faulty arbitrary associations could lead to BDD symptoms in the form of obsessing about appearance and associated emotional responses such as anxiety. Another example of an arbitrary association is if one thinks of using a spoon to eat, he or she may have a neutral response, but if one thinks of using a spoon that fell in a toilet bowl to eat, then he or she may have a disgust reaction; due to language, we make arbitrary associations and have certain emotional responses to thoughts. In addition, referring back to the role of conditioning and language in creating and perpetuating obsessions in BDD, language may be mediating the direct conditioning of the CS (the word “big” or a person’s stomach) and the US (being made fun for one’s weight or stomach size); as the CS (the word “big” or a person’s stomach) is paired with the CR (e.g., anxiety or disgust), a set of cognitions is strengthened and a set of beliefs initially introduced through life experiences continues to be reinforced. In line with this example, these beliefs may center on thoughts such as “Looking fit is the most important thing in the world,” “I can only succeed in life if I look fit,” “I am worthless if I do not look fit,” etc[3]. Arbitrary associations created using language seem to play an important role in causing the problematic obsessions associated with BDD.

 Building upon the role of language and evaluative conditioning in producing obsessions in BDD, higher-order conditioning also interacts with language to perpetuate obsessional symptoms. Higher-order conditioning is a form of learning in which a stimulus is first made meaningful for an organism through an initial step of learning, and then that stimulus is used as a basis for learning about some new stimulus (Jara, Vila, & Maldonado, 2006). An example of higher-order conditioning in BDD would be while someone is mirror-checking one body part, a secondary body part becomes more noticeable and elicits the same negative response as the original area of concern. In fact, it is common for individuals with BDD to obsess about more than one body part, as research has found that people with BDD are typically dissatisfied with up to three body parts, with one usually causing the most distress (Khemlani-Patel, 2001; Neziroglu, Khemlani-Patel, & Yaryura-Tobias, 2006b).

Higher-order conditioning can occur through relational framing. For example, initially a child is taught to see an object, then hear its name, and then say its name. Later, the child can hear the name and point to the object; this is an example of the training of the object-word and word-object relations and derived relational responding. So, if a child is taught about his nose, ear, and mouth, then the child can identify the those facial parts when asked about their locations even in the absence of reinforcement for doing so. This phenomenon is known as a derived arbitrarily applicable relation or relational frame, and it is under the control of contextual cues through a process of differential reinforcement. So, after a history of reinforcement, a derived relation emerges without reinforcement (the child being able to identify his or her nose simply by being asked about its location), and generalization to novel situations without direct reinforcement of these situations happens by using what was learned in the past. Relating this phenomenon to BDD and higher order conditioning, if a person has a disgust reaction to a big stomach and then equates a fatty stomach with fatty arms or any other body part, then the other body parts can elicit the same disgust response; this is similar to higher order conditioning where the conditioned stimulus (fatty stomach) is paired with another conditioned stimulus (fatty arms) and thus evokes the same response. Higher order conditioning, assisted by language, seems to play an integral role in the formation and perpetuation of obsessions in BDD.

 Moving away from BDD, RFT also provides explanations for obsessions in OCD. The abilities to relate stimuli based on arbitrary properties and to derive relations that were never directly trained are, together, known as arbitrarily applicable derived relational responding (AADRR). AADRR consists of three main processes known as mutual entailment, combinatorial entailment, and transformation of stimulus functions, all of which can be seen in an individual with OCD (Smith, Bluett, Lee, & Twohig, 2017; Twohig, 2009). For example, a person with obsessions related to contamination fears becoming ill due to germs, and consequently avoids the use of public bathrooms. Through language, illness is related to germs, germs are related to public bathrooms, and the person avoids bathrooms as he or she would avoid illness. In this example, germs are in a causal relation or frame with illness (in other words, germs cause the illness) and a hierarchical relation or frame with public bathrooms (in other words, germs are in restrooms). Both of these relations may have been directly trained at some point in the individual’s life, but due to language, the individual now derives that public bathrooms cause illness, which is a relation that was never directly trained between two stimuli that share no formal properties. The process by which the germs, illness, and bathroom become related is combinatorial entailment, and if the relation were only between two stimuli — such as illness and germs — this would be called mutual entailment. Transformation of stimulus function in this case would be the bathroom having acquired the same functions for the person as illness, and therefore leading to avoidance of the bathroom. Through AADRR, obsessions in OCD can be accounted for.

 The notion that language as explained by RFT can account for obsessions in OCD and BDD brings up important implications to the practice of clinical psychology. Acceptance and commitment therapy (ACT) promotes the therapeutic development of the self-as-context through awareness of a sense of perspective that RFT shows emerges through the diectic relational frames of I/you, here/there, and now/then. Self-as-context is a difficult concept to grasp at first, but it is known as the perspective/locus/space from where observing happens, the observing self, the silent self, self-as-perspective, pure awareness, or pure consciousness (Harris, 2009). This sense of self supports contact with the present moment that is open, undefended, and effective. Patients suffering from conditions such as OCD are helped to develop this sense of perspective in which experiences are noticed from an accepting and open stance and not judged as either good or bad (Twohig, Plumb, Mukherjee, & Hayes, 2010). Non-evaluative description and observation can help grow a sense of perspective for which thoughts and other private events have less power. Self-as-context can help people suffering from OCD recognize that they are not controlled by or defined by their private experiences or OCD symptoms, and they may learn to contain those experiences and observe them non-threateningly. [4]

The Role of EA In the Maintenance of Compulsive Responding and EA for ER

 Thus far, we have seen how RFT can explain language’s role in the production and perpetuation of obsessions. This is only one component of OCD, however, and does not address the compulsive aspect or emotional aspect of the disorder. Simply put, obsessions lead to distress/anxiety, and consequently people with OCD tend engage in EA of situations that give rise to obsessions and their associated anxiety.

 EA can maintain compulsive responding in OCD through negative reinforcement. Oftentimes, people with OCD tend to follow the verbal rule that obsessions cause behaviors, as well as the corollary that obsessions are dangerous and must be controlled (Hayes, Strosahl, Wilson, Bissett, Pistorello, J. et al., 2004); Hayes, Luoma, Bond, Masuda, & Lillis, 2006). This way of thinking leads to the problematic response style of EA. EA sustains itself through negative reinforcement, because it rewards the individual with a sense of temporary relief from the anxiety associated with obsessions (Bouton, Mineka, & Barlow, 2001).  EA can occur by way of compulsions, which are behaviors performed in the service of controlling obsessions (Twohig et al., 2010). For example, an individual who experiences distressing obsessions with regard to the symmetry of his or her work environment may engage in compulsive EA by ordering his or her work environment. This behavior will temporarily relieve anxiety or distress associated with the obsessions regarding symmetry, but this relief is only temporary as obsessions and compulsions will occur again when there is change to the work environment. EA also maintains compulsive responding in OCD by preventing opportunities for corrective emotional learning that would come about through direct experience with the distressing stimulus (e.g., Eysenck, 1987). It is evident that EA maintains compulsive behavior in OCD.

EA also serves as a method of ER in OCD. Anxiety in itself is a painful [5]emotion, but it transforms into problematic suffering through EA, because oftentimes EA occurs in response to the thoughts that anxiety is bad, dangerous, and requires a response (Eifert & Forsyth, 2005). Thoughts transform from just thoughts into bad thoughts, anything associated with anxiety or the likelihood of experiencing anxiety becomes a problem, and thus, anxiety is likely to be responded to with anxiety, and fear with fear. EA follows as an effort to manage anxiety and the circumstances that give rise to it — EA works as a form of ER. Marsha Linehan (1993) defined suffering as pain plus non-acceptance, and EA is exactly the response that results from the non-acceptance of pain [6]associated with anxiety; when we do not accept our feelings of anxiety and instead struggle to get rid of them, the pain [7]of normal anxiety turns into the suffering associated with OCD. Suffering manifests when we do not accept and acknowledge the reality of our experiences and instead act to escape from or avoid them. We can see how EA works as a form of ER in OCD and creates a sense of suffering.[8]

Social learning also creates a context where EA can thrive (Hayes, Strosahl, & Wilson, 1999). ER evidences maturity, health and wellness, emotional stability, success, happiness, and fulfillment, and therefore, we typically do not question how life might be if unpleasant emotions and thoughts were treated simply as events to be experienced as part of being human and not as experiences to be managed or controlled. We do not question that culture equates failures of ER with suffering and positive thoughts and feelings with the ability to engage life to its fullest. What results is the widespread attitude that feelings and thoughts must be managed and controlled through the response style of EA, which comes at a significant cost to the individual.[9]

Addressing EA and its negative outcomes is an important issue in the practice of clinical psychology. Acceptance is considered an alternative response to EA, and it is defined as a behavior involving the experience of private events as they are and not taking steps to regulate or control them (Twohig et al., 2010); it involves an active embrace of one’s inner experiences. Acceptance has been shown to increase an individual’s willingness to make contact with obsessive-like thoughts (Marcks & Woods, 2005, 2007). Acceptance is also central to many mindfulness-based therapies (e.g., Segal, Teasdale, & Williams, 2004), and the more that individuals with OCD are in contact with their obsessions — as seen in ERP –  the more effective the exposure therapy is likely to be (e.g., Abramowitz, Franklin, & Foa, 2002). So, when treating OCD from an ACT model, clients are encouraged to accept the presence of obsessions and their associated anxiety without attempting to change these experiences through EA in the form of avoidance, compulsions, cognitive actions or any other control strategy (Smith, et al., 2017). ACT can promote acceptance through the use of powerful metaphors. One such metaphor likens the struggle of OCD to an unfair match of basketball between amateurs and professionals. Acceptance is likened to a fair game of basketball that results in increased quality of life due to moving forward. In other words, rather than winning the unfair game, acceptance involves playing a different game that is fair.

Another metaphor to build acceptance involves the therapist holding a piece of paper, which is likened to be the obsession in OCD. The therapist instructs the patient to not let the paper touch him or her, and the patient puts in a large amount of effort to avoid contact with the paper or push it away when contact is made. Next, the therapist puts the paper on the client’s lap and asks the client to let the paper lay there. The therapist would then explain that the thought was touching the client in both situations, but the former situation took much more effort — the contrast between struggling and acceptance thus becomes clear (Twohig, 2009). Still another metaphor likens the experience of obsessions in the life of an individual with OCD to the fact that it rains sometimes. We could fight against the rain (our obsessions) every day, or we could learn how to live the lives that we want regardless of the weather (our mental state).

A clinically useful allegory for acceptance (and contact with difficult experiences) is the story of a moth. A man finds the cocoon of a moth, and notices that the moth starts forcing its body through a little hole in the cocoon. Thinking that the moth was stuck and stopped making progress, the man takes a pair of scissors and cuts off the remaining bit of the cocoon in order to help the moth get out. However, this stunts the moth’s growth and the moth is never able to fly. The reason for this is because the moth did not struggle getting out of the cocoon, fluid was not forced from its body into its wings, which would have allowed it to fly once out of the cocoon. For the moth, freedom and flight would only come after contact with difficult experiences, and by depriving the moth of this struggle, the man deprived the moth of health.

Exposure and response prevention (ERP) is another effective treatment for OCD to counteract the negative effects of EA. With at least 50% improvement as the cutoff, approximately 75% to 80% of those suffering with OCD can be treated successfully with ERP (Foa, Steketee, Grayson, Turner, & Latimer, 1984). ERP may work because it undermines the use of EA by promoting approach behaviors in a structured way. Fortunately, EA can be addressed through ACT and ERP.[10]

Conclusion

 OCD is an anxiety disorder characterized by distressing obsessions and functionally interfering compulsions, which combine to decrease quality of life and cause suffering (American Psychiatric Association, 2000). RFT acts as a framework utilizing the role of language to explain the occurrence of obsessions in OCD; through processes such as arbitrary associations, AADRR, bi-directional stimulus relations, and relational framing, evaluative and higher-order conditioning can occur and lead to BDD-related obsessions. Thus, obsessions in OCD and BDD are ultimately created through language and can be explained by RFT. Development of the self-as-context, as conceptualized by ACT, can support contact with the present moment that is open, undefended, and effective (i.e., acceptance). Acceptance of obsessions can ultimately give obsessions less power over the individual and reduce suffering. Further research and theorizing regarding the implications of RFT in the practice of clinical psychology could prove tremendously helpful, similar to acceptance. [11]

In response to the anxiety associated with obsessions, EA can act to maintain compulsive responding through negative reinforcement. Avoiding contact with an aversive experience through active avoidance, engaging in compulsions, rationalizing, distracting, and thought-suppressing (forms of EA) negatively reinforces such behavior by temporarily relieving anxiety. However, in the long-term, EA reduces quality of life and prevents individuals from engaging in meaningful and valuable activities. EA also serves as a dysfunctional method of ER and creates suffering by transforming the pain of normal anxiety into the suffering of disordered anxiety. Social learning contributes to the context in today’s society that allows EA to thrive by cultural norms associating positive emotions with happiness and negative emotions with dysfunction. Acceptance and ERP are two methods that promote engagement with difficult experiences, promote approach behavior, and reduce EA. Further research of metaphors and their associated increases with acceptance behavior would be useful. Studying the quality of what makes certain metaphors more effective than others for promoting acceptance behavior could be useful, and studying ways to combine acceptance and ERP more effectively could lead to positive outcomes for anxiety disorders such as OCD.

References

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[1]reword this sentence

[2]This was an amazing account. So well done!

[3]Avoid “etc.” in formal writing. “and so on” works as an alternative.

[4]Such a great point.

[5]Perhaps “aversive”?

[6]Distress?

[7]Maybe “unpleasantness”?

[8]So well said!

[9]Brilliantly said.

[10]All correct. Seems like maybe an example of how ERP treats EA would be useful.

[11]not fully clear idea/logic