Uncertainty, feedback, goal-directedness and habit: toward a theory of obsessive-compulsive disorder

What is it about?

Fradkin et al. (2020: doi.org/10.1037/rev0000188) published a theory of obsessive-compulsive disorder (OCD), approaching it from a Bayesian view of the brain, with uncertainty as a central concept. Extreme uncertainty was thought to underlie the core symptoms of several OCD dimensions, in interaction with other psychological constructs, especially the amount and quality of feedback from action results, and the strained relation between goal-directedness and habit in coping with difficult situations. I admired the enterprise of the authors but judged that the theory needed further elaboration and clarification, some revision, and a more detailed connection with clinical cases. That was a reason for me to write the present critical analysis of it. In this summary, the innovating elements of my exercise are highlighted. I first argued that it is necessary to distinguish between uncertainty as a personality feature with a broad impact (an impaired ability to predict causal behavior-environment and within-environment relations) and the pathological uncertainty as a core symptom of OCD dimensions. The latter probably ensues somehow from the former, but is not identical with it. Additionally, a distinction must be made between uncertainty as a personality feature and uncertainty as a more or less emotional reaction to situations that may be difficult to control. This distinction is analogous to the one between anxiety as a trait and as a state, made by Spielberger. The personality feature implies that one readily reacts with emotional uncertainty to certain situations and events. To keep the treatise focused, I confined the remainder of the analysis to three obsessive-compulsive symptom clusters, each exemplified with a case vignette: 1) contamination anxiety leading to washing compulsion, 2) compulsively checking the results of simple routines, and 3) habitual domestic activity having gotten out of hand. 1) The difficulty to terminate washing and cleaning in contamination anxiety is due to the lack of (directly relevant) sensory feedback from these activities. If the patient really has a fear of becoming infected with germs or infecting others with it, the lack of direct feedback is due to the imperceptibility of germs. If the feared contamination is an emotionally loaded one rather than a literal one, e.g., after unwanted sexual approaches, or when feeling guilty about an immoral action, then washing it away cannot be literal either. In that case, any sensory feedback is irrelevant. The lack of feedback deprives the subjects involved of a basis to keep their cleaning within limits. The stronger the fear or disgust involved, the more serious the stopping problems. 2) The pathological uncertainty about the results of simple routines, such as locking the front door, turning off the gas, water tap, heating etc., leading to repeated checking which is not helpful either, cannot be due to a lack of sensory feedback. I propose the following alternative interpretation: The occasions on which this pathological uncertainty occurs are moments of relinquishing control of one’s home or working place for a longer time, e.g., when leaving home for one’s job, or for a prolonged leave; or before going to bed for the night; or when leaving one’s car or other precious possessions unobserved for a longer time. In trait-uncertain persons such moments arouse more emotional uncertainty than in self-assured persons, and the former try to remedy this by putting more effort, carefulness, concentration in these concluding routines, and by checking these a few times. However, the routines are only marginally relevant to what the subjects involved are really aiming it: feeling completely reassured about relinquishing control for a longer time. The additions to the routines cannot improve their already perfect results and their marginal relevance. On the contrary, the more certainty the subjects try to “squeeze” out of the routines, the less relevant they become and the less the reassurance they can provide. This continual negative feedback loop leads to a full-blown checking compulsion. 3) The simple (concluding) routines are habitual behavior in which the subjects discussed above seek refuge on moments of uncertainty. Their uncertainty pertains to regular instances of diminished control. However, when such subjects are confronted with more dramatic and complex situations, which would demand a complex coping behavior involving painful decisions, they may seek refuge in a more extensive kind of habitual and familiar behavior, i.e., their job, parts of their professional activity, or their domestic activities as part of their social role. These are only marginally relevant to what their problems need at best, and hence the behavior involved leaves the subjects unconvinced at dissatisfied. However, these activities leave more room for improvement than door-locking etc., so the fruitlessness of clinging to them is less obvious and may assume absurd proportions more easily.

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Photo by Benjamin Elliott on Unsplash

Photo by Benjamin Elliott on Unsplash

Why is it important?

Full-blown psychological theories about OCD are still scarce. As a consequence, much the research of it is fragmented, not cumulative, not relevant to a broadly adhered to view on OCD. Therefore, the enterprise of Fradkin et al. (2020) merits close attention and critical discussion. My article is meant as an innovative contribution to this aim.

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