The Role of Self-Construals in Obsessive-Compulsive Disorder Claire Terese Ahern Submitted in partial fulfilment of the requirements of the degree of Doctor of Philosophy (Clinical) 2012 Department of Psychology Swinburne University of Technology ii
 ABSTRACT Cognitive accounts of Obsessive-Compulsive Disorder (OCD) recognise that maladaptive beliefs are central to the maintenance of the disorder. Unhelpful beliefs underlie one’s appraisal of unwanted intrusions as important and personally revealing, so that they become associated with negative affect and liable to developing into obsessions. Cognitive models additionally suggest that neutralising responses are responsible for the persistence of obsessional problems; they alleviate discomfort in the short term, but are associated with longer term maintenance of discomfort, increases in the urge to engage in further neutralising responses, and strengthening of maladaptive beliefs (Salkovskis, 1989, 1998). Given that our belief systems are intimately intertwined with self-concepts, the current thesis proposes the inclusion of such concepts in the cognitive framework for OCD. This thesis shows that there is mounting support that self-processes are implicated in OC phenomena. In particular, ambivalence in self-worth and sensitivity in moral self-worth. There is currently, however, limited research on those aspects of the self that are less under conscious awareness, such as the implicit self. The overall aim of the current thesis is therefore to examination how both implicit and explicit self- construals relate to OCD. It was hypothesised that a discrepancy between implicit and explicit self-processes are relevant to OCD, specifically a discrepant low self-esteem (high implicit, low explicit self-esteem). In particular, the thesis aimed to investigate three aspects of the relationship between self-construals and OCD. First, it examined whether self-beliefs (implicit and explicit) relate to OCD symptoms and beliefs. Second, it addressed the relationship that obsessions and compulsions have on self-beliefs. Finally, this thesis investigated how self-beliefs may serve as a liability to experiencing unwanted intrusions. Three studies iii
 were conducted to address each of these questions. Each study comprised a sample of 20 individuals with OCD (M age = 42.25; SD = 14.98) and 120 non-clinical student participants or community controls (M age = 23.05; SD = 6.96). In Study 1, the relative influence of implicit and explicit self-processes was examined for their impact on OC phenomena. In a combined clinical and non-clinical sample, self-ambivalence and specific discrepant implicit-explicit self views were both associated with higher levels of OC-related beliefs and OC-symptoms. Further examination revealed that discrepant implicit-explicit self views particularly relating to moral self-worth were associated with self-ambivalence, adding to our understanding of the nature of self-ambivalence in OCD. Comparisons between samples additionally revealed that non-clinical individuals with high levels of self-ambivalence and discrepant self-views showed comparable levels of OC phenomena to the clinical OCD sample. Study 2 utilised an experimental neutralising task that tracked the experience of participants when continually exposed to their own unwanted intrusion under two different conditions, when they actively used a neutralising strategy or when they used a refocussing technique. Results on the combined clinical and non-clinical sample showed that, over time, neutralising responses increased distress and urge to neutralise, and decreased beliefs in self-worth and self-confidence. The final study combined the data from the previous studies to examine which self-profiles make one more liable to having an aversive experience in the neutralising task. The results showed that a vulnerable self-profile (high levels of self-ambivalence, discrepant low self-esteem, sensitivity in moral self-worth) was associated with drops in self-worth and self-confidence on exposure to intrusions, which in turn was linked with increased distress and urge to neutralise. iv
 Taken together, the results of this thesis support that a conceptual model self- construals and processes in OCD is important in understanding of the experience, development and maintenance of this disabling disorder. The thesis supports that intrusions are distressing because they are perceived to be threatening to an uncertain self-esteem. Furthermore, within the context of an ambivalent self-construal, compulsions assist initially with maintaining self-worth but are ultimately maladaptive. The limitations of the current research and clinical implications of the findings are discussed, and suggestions for future research outlined. v
 DECLARATION 
 
 This is to certify that the thesis comprises only my original work towards the PhD, due acknowledgment has been made in the text to all other material used, the thesis is less than 100, 000 words in length, exclusive of tables, maps, bibliographies and appendices. __________________________ Claire Terese Ahern 2012 vi
 ACKNOWLEDGEMENTS This thesis represents the combined effort of many. First thanks have to go to my principal supervisor Professor Mike Kyrios. His shared enthusiasm for the subject area and dedication to my overall professional development kept me encouraged, inspired, and always entertained. Richard Moulding, Maja Nedeljkovic, Sunil Bhar, Denny Myer, Leah Kauffman and David Shields also held important roles. Thanks for help with conception, implementation, constructive critiques, statistics-saving and fine- tuning of ideas. Particular appreciation goes to Richard for the attention to detail and dry sense of humour. Collectively, the support from the staff and academic members of Swinburne demonstrated the joy of working in collaboration with others. Thank you to all participants for their time, effort and openness. Special thanks goes to clinical participants who bravely chose to partake in something that may have been confronting. To my fellow students, Roz, Sam, and Jim; you know the pain, thanks for keeping me sane! Likewise, to my family and friends for their tireless encouragement, never-ending cups of tea, and genuine interest (despite being baffled with the length of the project), and for importantly reminding me that there is life outside thesis. Particular thanks to Mum and Dad for their unconditional love and support – you help me to feel that I am doing good work, not matter how hopeless it can seem at times. Last, but not least to my partner, Ned - for being generally awesome. Your emotional and practical support is always unwavering, and was crucial to the completion of this thesis. I doubt I would be at this point without you. It has been a rewarding experience working closely with you all. Thumbs up and cheers for the help. vii
 TABLE OF CONTENTS ABSTRACT.…………………………………………………………………………….ii DECLARATION.………………………………………………………………………..v ACKNOWLEDGMENTS.……………………………………………………………...vi TABLE OF CONTENTS.……………………………………………………………...vii LIST OF TABLES.……………………………………………………………………..xi LIST OF FIGURES...………………………………………………………………….xii LIST OF APPENDICES.……………………………………………………………..xiii PART I – INTRODUCTION AND LITERATURE REVIEW………………………...14 Chapter 1: Thesis Overview.……………………………………………………...........14 Chapter 2: The Phenomenology and Epidemiology of Obsessive-Compulsive Disorder……………………………………………………..………………………….17 2.1 Introduction to Obsessive-Compulsive Disorder (OCD)…………………..17 2.2 Definition and Phenomenology……………..……………………………...17 2.2.1 Definition……………..………………………………………......17 2.2.2 Differentiation from ICD definition..……………..……………...19 2.2.3 Obsessions..……………..………………………………………..20 2.2.4 Compulsions..……………..……………………………..……….22 2.2.5 Cultural context. ……………..…………………………..………24 2.2.6 Non-clinical obsessions and compulsions………………..………25 2.2.7 Subtypes/Dimensions of OCD………………………….….……..28 2.3 Epidemiology…………………………………………………….…….…...31 2.3.1 Prevalence..…………………………………………….…….…...31 2.3.2 Demographics..……………………………………….……….….32 2.3.3 Course………………………………………………………….....33 2.4 Comorbidity……………………………………………………….………..34 2.4.1 Axis I..…………………………………………………….……...34 2.4.2 Axis II..…………………………………………………….….…36 2.5 Disability……………………………………………………………….…..37 2.6 Summary……………………………………………………………………39 Chapter 3: Aetiological theories of OCD…………………………………………..…..41 3.1 Introduction……………………………………………………………..….41 3.2 Biological, Neuroscientific and Genetic Theories of OCD……………..….41 3.3 Psychodynamic Model…………………………………………………..…44 3.4 Behavioural Model………………………………………………………....45 3.5 Cognitive Model……………………………………………..……………..47 3.5.1 Unwanted intrusions..………………………………..…………...47 3.5.2 Appraisal of intrusions………………………………..…………..48 3.5.3 Neutralisation.…………………………………………..………...49 viii
 3.5.4 Beliefs……………………………………………………..……...52 3.5.5 Cognitive-Behavioural Therapy (CBT) for OCD…………..…….58 3.5.6 Limitations of cognitive theory for OCD……………………..….61 3.6 Summary…………………………………………………………………....63 Chapter 4: The Self………………………………………………………..……………65 4.1 Introduction ……………………………………………………..…………65 4.2 What is The Self? ………………………………………………..………...66 4.3 Theories of Self……………………………………………………..……...67 4.3.1 Psychodynamic models……………..……………………………67 4.3.2 Cognitive views of the self…………..…………………………...69 4.3.3 Social models of the self……………..…………………………...71 4.3.4 Social-Cognitive paradigm……………..………………………...73 4.4 Nature of self………………………………………..……………………...75 4.4.1 Multiplicity of self…………………………..……………………75 4.4.2 Structure of the self…………………………..…………………...76 4.4.3 Self-esteem……………………………………..………………...78 4.5 Dual process theories……………………………………..………………...82 4.5.1 Two modes of experience………………………..……………….82 4.5.2 Implicit and explicit self cognitions………………..…………….83 4.5.3 Measurement of implicit and explicit self. …………..…………..87 4.5.4 Relationship between implicit and explicit self………..…………91 4.5.5 Discrepancy between implicit and explicit self…………..………93 4.6 Summary……………………………………………………………..……..97 Chapter 5: Self-processes in OCD………………………………………..…………….98 5.1 Introduction……………………………………………………..………….98 5.2 Theoretical discourse about self processes in OCD……………..…………98 5.2.1 Cognitive theory………………………………………..………...98 5.2.2 Guidano and Liotti’s (1983) theory of self-ambivalence……….100 5.3 Empirical support for self processes in OCD……………………………..105 5.3.1 Self-ambivalence in OCD……………………………………….105 5.3.2 Self-esteem………...……………………………………………108 5.3.3 Self-concept……………………………………………………..109 5.3.3.1 Obsessions as ego-dystonic……………………………….109 5.3.3.2 Moral self in OCD…………………………...………..110 5.3.4 Implicit self and OCD….………………………………………..113 5.3.5 Self-discrepancy and OCD….…………………………………..115 5.4 Conclusion………………….……………………………………………..117 Chapter 6: This Thesis………………….……………………………………………..119 PART II – EMPIRICAL ANALYSES………………………………………………..128 Chapter 7: Study 1 Self-profiles and their relationship to OC phenomena…..……….128 7.1 Introduction……………………………………………………………….128 7.1.1 Self-processes in OCD….………………...……………………..131 7.1.2 Implicit self-processes….……………………………………….134 7.1.3 This study….……………………………………………………136 7.2 Method…………………………………………………………………….139 ix
 7.2.1 Participants….…………………………………………………..139 7.2.2 Measures..….……………………………………………………142 7.2.2.1 GNAT..….……………………………………………..142 7.2.2.2 NLPT..….……………………………………………...145 7.2.2.3 OSSI..….………………………………………………146 7.2.2.4 SAM..….………………………………………………146 7.2.2.5 RSES..….……………………………………………...147 7.2.2.6 OBQ..….………………………………………………147 7.2.2.7 OCI..….……………………………………………….148 7.2.2.8 BDI..….………………………………………………..148 7.2.3 Procedure……...….……………………………………………..149 7.3 Results…………………………………………………………………….150 7.3.1 Descriptive statistics and correlations…………………………..150 7.3.2 Preliminary data screening…………………………….………..150 7.3.3 Regression analysis……………………………………………...152 7.3.4 Mediational analyses………………………………..…………..154 7.3.5 Regression analysis with self-ambivalence as the dependent variable …………………………………………………………156 7.3.6 Correlational analyses…………………………………………...157 7.3.7 Analysis of covariance analyses………………………………...158 7.4 Discussion…………………………………………………………………163 7.4.1 Implicit self-processes and OC-phenomena…………………….163 7.4.2 Explicit self-processes in OC phenomena………………………………165 7.4.3 Implications……………………………………………………..167 7.4.4 Limitations and directions for future research…………………..168 7.4.5 Conclusion…………………………………………....................169 Chapter 8: Study 2 Exposure to unwanted intrusions, neutralising and their effects…170 8. 1 Introduction………………………………………………………….…...170 8.2 Method……….……………………………………………………….…...175 8.2.1 Participants……………………………………………………...175 8.2.2 Design. ………………………………………………………….175 8.2.2.1 NRAT…………………………………………………175 8.2.3 Procedure………………………………………………………..177 8.3 Results……………….……………………………………………….…...181 8.3.1 Preliminary data screening and descriptives……………………181 8.3.2 Analyses…………………………………………………………181 8.3.2.1 Discomfort. …………………………………………...181 8.3.2.2 Urge to neutralise……………………………………...182 8.3.2.3 Self-worth……………………………………………..183 8.3.2.4 Self-confidence………………………………………..184 8.3.2.5 Relationships between variables………………………187 8.4 Discussion…………………………………………………………….…...189 Chapter 9: Study 3 Self-vulnerabilities to experiencing OC phenomena……………..196 9.1 Introduction……….………………………………………………….…...196 9.2 Method………….…………………………………………………….…...204 9.2.1 Participants, materials, procedure……………………………….204 9.2.2 Statistical methods………………………………………………205 9.3 Results………….…………………………………………………….…...206 x
 9.3.1 Descriptive statistics…………………………………………….206 9.3.2 Preliminary analyses…………………………………………….207 9.3.3 Intercorrelations…………………………………………………208 9.3.4 Structural equation modeling analyses………………………….210 9.3.5 Post-hoc analyses………………………………………………..212 9.4 Discussion…………………………………………………………….…...213 9.4.1 Pathways shared by the different models……………………….213 9.4.2 Unique pathways of Model 1……………………………………215 9.4.3 Comparison with Model 2………………………………………215 PART III – GENERAL DISCUSSION AND CONCLUSION………………………218 Chapter 10: General Discussion ……………………………………………………...218 10.1 Introduction………………….……………………………………….….218 10.2 Summary of findings....…….……………………………………………221 10.2.1 Implicit self-processes in OCD……………………...………....221 10.2.2 Self-ambivalence……………………...……………………….222 10.2.3 Relationship of self-ambivalence to OC-phenomena…………223 10.3 Theoretical implications………….……………………………………...227 10.4 Practical implications………….…………………………………….......229 10.5 Limitations and directions for future research………….………………..232 10.6 Conclusion………….……………………………………………………235 REFERENCES……...………………………………………………..…...…………..237 APPENDICES…..………………………………………………..…...………………305