Self-Ambivalence in Obsessive-Compulsive Disorder Sunil S Bhar Submitted in total fulfilment of the requirements of the degree of Doctor of Philosophy July, 2004 Produced on acid-free paper Department of Psychology University of Melbourne ii iii Abstract According to the cognitive model, Obsessive-compulsive disorder (OCD) is maintained by various belief factors such as an inflated sense of responsibility, perfectionism and an overestimation about the importance of thoughts. Despite much support for this hypothesis, there is a lack of understanding about the role of self-concept in the maintenance or treatment of OCD. Guidano and Liotti (1983) suggest that individuals who are ambivalent about their self-worth, personal morality and lovability use perfectionistic and obsessive compulsive behaviours to continuously restore self- esteem. This thesis develops a model of OCD that integrates self-ambivalence in the cognitive model of OCD. Specifically, it explored the hypothesis that the OCD symptoms and the belief factors related to the vulnerability of OCD are mechanisms that provide relief from self- ambivalence. It addressed three questions. First, is self-ambivalence related to OCD symptoms and OCD-related beliefs? Second, to what extent is self-ambivalence specific to OCD, compared to other anxiety disorders? Third, to what extent is self-ambivalence important in accounting for response and relapse of OCD to psychological interventions? In order to explore these questions, a questionnaire measuring self- ambivalence was first developed and evaluated. Non clinical and clinical participants were recruited for research. Non-clinical participants (N = 269) comprised undergraduate students (N = 226: mean age = 19.55; SD = 3.27) and community controls (N = 43; mean age = 43.78; SD = 3.92). Clinical participants (N = 130) included 73 with OCD as the primary diagnosis (mean age = 36.16; SD = 11.24) and 50 individuals with another anxiety disorder (mean age = 36.45; SD = 11.42). To measure various cognitive, mood and behavioural factors associated with OCD, questionnaires were administered to the participants. Three studies were conducted. In the first study, a 19-item questionnaire, the Self- Ambivalence Measure (SAM) was developed to measure self-ambivalence. Following iv data reduction analyses, a unifactorial solution was found. This factor was stable across the non-clinical and clinical cohorts. Satisfactory psychometric properties were demonstrated, as indicated by reliability and validity indices, including internal consistency, test-retest reliability, content validity, criterion validity, convergent validity and discriminant validity. The second study examined the associations between self-ambivalence, OCD symptoms, OCD-related beliefs and anxiety disorders. This study found that self- ambivalence related significantly to OCD symptoms and distinguished individuals with OCD from normal controls. However, it found no difference in self-ambivalence between the OCD cohort and anxious controls. Finally, it found that self-ambivalence related significantly to OCD-related beliefs and accounted for a significant portion of their co-variation. The third study investigated the relationship between self-ambivalence and treatment outcomes in a sample of 51 participants with OCD (mean age = 35.61, SD = 11.96) undergoing 16 weeks of cognitive behavioural treatment (CBT). The participants were assessed before, during, and six months after treatment for changes in self-ambivalence, OCD symptoms and OCD-related beliefs. The study found that improvement in OCD symptoms was associated with an improvement in self-ambivalence. Further, it found that improvement in self-ambivalence during CBT protected against the deterioration of OCD compulsions in the six month period following treatment. In conclusion, these studies collectively showed that self-ambivalence relates to OCD symptoms, and to the various beliefs implicated in vulnerability for OCD. In integrating self-ambivalence within the cognitive model of OCD, we suggest that self-ambivalence may act with environmental and other developmental influences to render individuals vulnerable to the development of OCD-related beliefs and, hence, OCD. Perfectionism, inflated responsibility and excessive importance placed on controlling thoughts may develop as defences against negative self-perceptions. Self-ambivalence may also be an important vulnerability factor in other anxiety disorders, depending on their idiosyncratic, developmental, experiential and cognitive profiles. Nonetheless, it v appears to account for why some OCD patients have poor treatment outcomes. Patients who are extremely ambivalent about self-worth may be reluctant to relinquish cognitive and behavioural patterns that protect against negative definitions of self. Overall, self- ambivalence is important to the vulnerability for, and treatment of OCD. vi Declaration This is to certify that the thesis comprises only my original work towards the PhD except where indicated in the Preface, 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. __________________________ Sunil Singh Bhar July, 2004 vii Acknowledgment I am indebted to colleagues, teachers and friends who have helped me complete this dissertation. I am grateful to many who have sharpened my methodology and helped me think more clearly about the research. These individuals have been fundamental to the development of my ideas. I owe a debt of gratitude to Henry Jackson, Chris Mackey, Mark Kraemer, Jenny Boldero, Paul Gilbert, David Harder, Paul Hyler, and Loretta Bell for introducing me to resources and instruments, and in some cases for permitting me to use their measures. I am also grateful to Pip Pattison and Paul Dudgeon for giving up their time to help me with statistical conundrums. Numerous individuals have reassured me along the way that my ideas were not "crazy" and for that I am grateful. Thank you Di Bretherton , Mary Ainley, Glen Bates, Angelo Piccardo, Christine Purdon, Susie O'Neill. I am very thankful for the thoughtful feedback given by Celia Hordern and Kathryn I’Anson. Also, to the research team at the University of Melbourne Psychology Clinic who provided a sounding board for musings, thank you. Associate Professor Michael Kyrios who has been supervising this research has been a stabilising force in my career. He has been supportive and directive in all aspects of the PhD, and has had a powerful impact on my development as a researcher and professional. I am profoundly grateful to him for his attention to detail, dedication, care and nurturing manner. To my mother, who has supported me patiently and with reassurance and wisdom, having completed her own PhD some years back, I am most thankful. I am also grateful to her for sub-editing this thesis. And, to my wife, Kanwaljit, who has had to arrange her life around my studies and to endure years of obsessionality from me in writing this dissertation, I will be very much in her debt for much time to come. viii Finally, I am deeply appreciative to the hundreds of people who participated in this research. For many, their involvement meant disclosing personal information, and paying for travel expenditure. Then, there was the effort required to complete numerous questionnaires. The Anxiety Recovery Centre of Victoria (ARCVIC) has been tireless in supporting this research. Many of the participants in this research were members of ARCVIC. Thank you for your trust and for your belief in the research. ix Table of Contents Abstract............................................................................................................................ iii Declaration....................................................................................................................... vi Acknowledgment............................................................................................................ vii Table of Contents............................................................................................................. ix List of Tables................................................................................................................. xiv List of Appendices......................................................................................................... xvi Chapter 1 Introduction.................................................................................................... 19 1.1 Background To The Research ........................................................................ 19 1.2 Research Problem and Hypotheses................................................................. 21 1.3 Justification For The Research ....................................................................... 22 1.4 Methodology................................................................................................... 23 1.5 Outline Of The Thesis .................................................................................... 24 1.6 Delimitations of Scope and Key Assumptions............................................... 26 1.7 Terminology ................................................................................................... 26 1.8 Summary......................................................................................................... 27 Chapter 2 Obsessive-Compulsive Disorder: Phenomenology.......................................