by Michael D. Anestis, M.S.
Obsessive-compulsive disorder (OCD) is one of the most well known mental illnesses. It is frequently depicted in films and television (e.g., "Monk," "As Good as it Gets") and has a lifetime prevalence rate of 2.5% (APA, 2000). If asked to think about the meaning of OCD, most people would not struggle to come up with examples of obsessions (e.g., being contaminated by germs) and compulsive behaviors (e.g., excessive hand washing). In this sense, OCD is not much of a mystery; however, our understanding of the phenomenon is nonetheless incomplete. Today, I would like to discuss a study recently published in Behavior Therapy by Ashley Pietrefesa and Meredith Coles (2009) of the University of Binghamton. The authors' central aim was to extend our understanding of OCD by examining two different potential characteristics that could drive compulsive behaviors: harm avoidance and incompleteness.
Pietrefesa and Coles (2009) opened up their article by listing the DSM-IV-TR description of the motivation behind compulsive behaviors in OCD:
- Preventing or reducing distress
- Preventing some dreaded event or situation
Despite these two distinct potential motivations for compulsive behaviors as described by the DSM, almost all of the research conducted on OCD has focused on behaviors used in an effort to prevent harm. In this sense, we think of people who excessively wash their hands to avoid contamination, who compulsively check if they turned the oven off to avoid burning down their house, who count to a particular number in a specific fashion to prevent harm from coming to loved ones, and countless other examples. The authors, however, contend that the desire to correct incompleteness and to have things be "just right" represents a second and distinct drive for individuals with OCD.
In an earlier study on this same phenomenon, Pietrefesa and Coles (2008) used self-report measures to show that harm avoidance and incompleteness demonstrated unique relationships to OCD symptoms; however, the authors noted that self-report measures, while certainly useful, are an imperfect method of measurement. As such, in the current study, the authors utilized behavioral observations in an effort to attain more objective evidence regarding their hypotheses.
The sample included 97 undergraduates, 64% of whom were female. At the onset of the experiment, each participant filled out a series of self-report questionnaires, including measures of depression and OCD symptoms. Participants were told that the goal of the study was to help the university determine if certain personality characteristics could be used to match students with specific jobs on campus. Additionally, they were told that the tasks they would be completing during the experiment represented examples of the types of responsibilities characteristic of those jobs. Each participant took part in six five-minute tasks, three of which were aimed to tap harm avoidance and three of which were aimed to tap incompleteness.
Harm Avoidance Tasks:
- Washing dirty dishes - preventing individuals from becoming sick from contaminated plates
- Checking and sorting vials of reportedly hazardous chemicals - preventing exposure to harmful substances
- Proofreading a student's resume - preventing student from losing job opportunity
Incompleteness Tasks:
- Arranging books on a bookshelf
- Hanging pictures on the wall
- Sorting the contents of a paper recycling bin
The authors listed several hypotheses.
- Self-reported levels of harm avoidance, but not incompleteness, would be significantly related to ratings of anxiety and nervousness experienced during the tasks
- Self-reported levels of incompleteness, but not harm avoidance, would be significantly related to ratings of discomfort and tension experienced during the tasks
- Even when controlling for the overlap between harm avoidance and incompleteness, the harm avoidance but not incompleteness would predict anxiety and nervousness and incompleteness but not harm avoidance would predict discomfort and tension
- Both harm avoidance and incompleteness would significant predict the degree to which participants hesitated, checked, and repeated behaviors during the tasks.
As it turns out, the findings were highly supportive of the authors' hypotheses. With respect to hypothesis 1, harm avoidance was significantly correlated with the level of anxiety and nervousness experienced during the tasks as well as with participants' ratings of the degree to which they were concerned with preventing harm during the tasks. Incompleteness, on the other hand, was not significantly correlated with anxiety and nervousness and only modestly correlated with the degree to which participants were concerned about preventing harm during the tasks.
With respect to hypothesis 2, Pietrefesa and Coles (2009) found that harm avoidance was significantly correlated with the amount of discomfort and tension experienced during the tasks as well as participants ratings of their desire to perform the tasks perfectly or until they were done "just right" whereas harm avoidance was not significantly related to those outcomes. Importantly, the findings for the first two hypotheses demonstrated that, depending upon whether an individual was high in harm avoidance or incompleteness, the emotional response to the behavioral tasks would change. This is consistent with the idea that these are two distinct characteristics.
Perhaps more importantly, hypothesis 3 was supported by the data. In this hypothesis, the authors used regression equations to ensure that harm avoidance predicted its unique outcomes above and beyond the effects of incompleteness and incompleteness predicted its unique outcomes above and beyond the effects of harm avoidance. This type of analysis, much more so than an examination of simple correlations, allows researchers to make sure that the relationship between two variables is not better accounted for by something other than those variables themselves. In this sense, the authors provided some basic evidence for the possibility that harm avoidance and incompleteness are two distinct but important characteristics of OCD that drive compulsive behaviors through different mechanisms.
The authors' final hypothesis - that both harm avoidance and incompleteness would be associated with the degree to which participants hesitated, checked, and repeated behaviors during the tasks - was also supported by the data. This is important because it indicates that both harm avoidance and incompleteness related to the key behavioral components of OCD.
So what can we learn from this experiment? First of all, OCD behaviors may not always be about avoiding harm. For some individuals, the drive to ritualistically engage in certain behaviors might be better accounted for by the need for things to be "just right" and to reduce feelings of tension rather than anxiety. Along these lines, the authors mentioned that clinicians might want to assess for tics, trichotillomania, and obsessive-compulsive personality disorder (OCPD) in clients with OCD exhibiting high levels of incompleteness rather than harm avoidance.
All in all, this study had a lot of strengths, particularly in its use of behavioral experiments. By doing this, the experimenters were not simply asking participants to think back to how they felt about some past behavior. Instead, they could immediately evaluate feelings following a specific experience. In terms of limitations, the authors freely admitted that an undergraduate sample, while useful, is not ideal and that future research should use clinical samples to ensure that their findings apply to individuals who actually meet criteria for OCD. Additionally, however, the authors may have benefited from measuring OCPD in their participants. As you might recall from Joye's article on OCPD, that diagnosis is characterized by extreme perfectionism and the need for things to be a certain way. Additionally, although OCPD and OCD are distinct from one another, they frequently co-occur. As such, it would have been useful for the authors to make sure that incompleteness truly represents a component of OCD and does not simply reflect the overlap between OCD and OCPD. All of that being said, this study was highly useful and a great starting point for future research on the topic. Our understanding of OCD as well as other mental illnesses benefits greatly from empirical tests examining different models of conceptualizing the nature each diagnosis.
If you would like to learn more about OCD, we recommend the following resources, all of which are available through our online store:
by Edna Foa and Reid Wilson
- Mastery of Obsessive-Compulsive Disorder: A Cognitive-Behavioral Approach Therapist Guide
by Edna Foa and Michael Kozak
- Mastery of Obsessive-Compulsive Disorder: A Cognitive-Behavioral Approach Client Workbook
by Edna Foa and Michael Kozak
Mike Anestis is a doctoral candidate in the clinical psychology department at Florida State University
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