Mistaken imagination may underlie obsessive-compulsive disorder

People with obsessive-compulsive disorder (OCD) have a recognizable diagnosis, but researchers aren’t as clear about what causes it. Is OCD an anxiety disorder, or is it better understood as a delusional disorder?

To help answer that question, a study published in the June 2015 Journal of Clinical Psychology has identified two important characteristics—confusing reality with imagination (inferential confusion) and losing contact with reality (dissociation)—that appear to play a role in OCD development.

“In general, researchers agree on the diagnostic criteria of OCD. However, there is no consensus on the mechanisms underlying them,” said Frederick Aardema, PhD, co-director of the Obsessive-Compulsive Disorder and Tic Disorder Studies Centre at the Montreal Mental Health University Institute, in Montreal, Quebec, Canada.

“Theories about OCD stipulate that it is not the content of thought that is involved in the development of obsessions, but the way these thoughts are interpreted by the person,” said Dr. Aardema. “While most people will dismiss an idea if they feel it has no meaning, people with OCD will say that if they think that way, there must be a reason.”

In earlier research, Dr. Aardema and his colleagues observed that people who relied heavily on their imagination and had a strong tendency to dissociate from reality also had more obsessive symptoms.

In this study, the researchers aimed to confirm those earlier observations in an OCD population. They recruited 75 adults (mean age of 38; 61.3% female) who were diagnosed with OCD, and asked them to complete a battery of self-report questionnaires that measured inferential confusion, schizotypal personality, dissociative experiences, strength of obsessive beliefs, and depressive and anxiety symptoms.

“First, inferential confusion is a reasoning process in which obsessive doubt takes hold. Individuals make subjective connections between different elements. For example, the person believes that the water in a municipal swimming pool is contaminated because chlorine has been put into it, so inevitably there are bacteria in the water,” explained the study’s lead author Stella-Marie Paradisis, a doctoral student in psychology at the University of Montreal. “Second, schizotypical personality is characterized by bizarre ideas, rigid belief, lack of discernment, and a tendency to overrely on imagination. For example, individuals are convinced that what they hear on the news or read in the newspaper concerns them personally and directly. Finally, dissociation is characterized by loss of contact with reality and memory lapses in certain situations—a phenomenon that can be observed especially in people who display checking behavior. Some people feel that they can behave so differently depending on the situation that they are two different people.”

When the researchers analyzed the questionnaires, their results revealed that inferential confusion and dissociation were the strongest predictors of OCD symptoms. Factors such as anxiety and depressive symptoms, schizotypal personality, and obsessive beliefs didn’t seem to play a significant role in the development of OCD symptoms, but in the severity of the disorder.

“It seems that people with OCD are so absorbed by their obsession due to inferential confusion that there is a break with reality,” Dr. Aardema said. “Specifically, we found that individuals no longer rely on their sensory perceptions or common sense but on their imagination. For example, they are afraid that their hands are contaminated with germs, so they wash them over and over again because they are convinced that their hands are dirty even though they are visibly clean.”