How Are My Obsessions Related to My Identity? Findings from My Doctoral Thesis

The aim of my doctoral thesis was this: to explore the role that identity (the self), context and narratives (inner dialogue) play in the development and maintenance of obsessive-compulsive disorder. Cognitive models of OCD have considered these three elements, but mostly from a theoretical point of view, so there has been little research on them.

The Inference-Based Model regards these elements as three basic pillars in the origin, development and maintenance of OCD, which is why it is the model that has explored them in most depth so far.

The thesis contains five studies, three of which focus on these elements, and I’ll be summarising them in these articles. Today we’ll start with the study on the role of the self (identity) in OCD. I’m starting with this one because it’s the one I liked most and, of course, also the most complicated. I also find the results really interesting, and they open the door to a lot more research on the subject.

I’ll try to make it as enjoyable as possible, bearing in mind that we’re talking about presenting the results of a doctoral thesis, and we all know this kind of work isn’t exactly known for simple, approachable language… I’ll spare you the statistics and jargon and try to go straight to the conclusions of the studies and their therapeutic implications – in other words, how useful these results are in patients’ real lives.

First of all, a reminder that the inferential model proposes the following definitions when it comes to identity:

• Actual self (or real identity): the kind of person I believe I am; self-concept.
• Feared self (or feared identity): the kind of person I’d be afraid of becoming.

The inferential model’s view of identity and OCD: the general population will always give more credibility to the actual self and push the feared self into the background, whereas people with OCD will do the opposite.

Some of the questions we asked ourselves in the study on the self/identity in OCD were these:

1. Do patients with OCD tend to have a negative self-concept/actual self? How do patients with OCD most often describe themselves?
2. Is there a relationship between the actual self and OCD?
3. Are patients with OCD characterised by a stronger feared self than the rest of the population?
4. Is this feared self related to obsessions? And to intrusions? Is the feared self stronger or weaker depending on the content of the obsession?

So, regarding these questions, what did we observe in the results of this work? Let’s answer them one by one.

1. How patients with OCD see themselves

We found that patients with OCD are not characterised by a negative self-concept/actual self. It’s true, though, that insecurity is an attribute that stands out especially when they describe themselves, which in principle would increase their tendency to doubt, and so increase the chances of those doubts turning into clinical obsessions. It could also be the other way round: the patient may become a more insecure person over time as a result of living with obsessions for a long period. We can’t know which came first – that is, we can’t establish a causal relationship – because our study was cross-sectional (meaning it was carried out at one particular point in the patients’ lives; we didn’t follow the course of the disorder over the years). Good people and anxious were two other attributes that patients with OCD very frequently used to describe themselves.

So, according to the results of our study, patients with OCD usually see themselves as insecure, anxious and good people. And, in general, their self-concept/actual self is not a negative one.

2. Is there a relationship between the actual self and obsessions and intrusions?

Our results show that the actual self (especially insecurity) is related to obsessions more than to intrusions, but the difference isn’t significant. This means the difference isn’t large enough statistically, and we need more studies to conclude whether there really is a difference between how the actual self relates to intrusions and how it relates to OCD obsessions. In any case, our results indicate that the patient’s actual self and their obsessions are related in some way: there does seem to be a link between how I see myself and my obsessions, regardless of the type of obsessive content (what if I’m a paedophile, what if I want to slit my grandfather’s throat, what if I’ve caught HIV…).

3. What is the feared self of patients with OCD like?

We were able to confirm that patients with OCD report significantly higher levels of feared self than the general population, which is consistent with previous research on the subject. And what does that mean in practical terms? It means that, just as the Inference-Based Model holds, patients with OCD give more credibility to the kind of person they fear becoming than to the kind of person they really are. In other words, they believe more in a fictional identity (the feared self) than in their real identity.

According to some authors, there are four types of feared self: the anxious/depressed, the imperfect, the moral and the rejected. According to our results, patients with OCD particularly fear an imperfect self or an “imperfect identity” (negative personality traits). This would include, for example, the fear of being a “liar” (an adjective mentioned by a large number of patients when describing their feared identity). The fact that being a liar is so feared by people with OCD could be because many patients hide their obsessions from those close to them, and from the world in general, for fear of being judged. Hiding from the world what they consider to be “their true identity” – supposedly the one their obsessions tell them they have – would partly explain this fear of seeing themselves as liars.

4. Is there a relationship between the feared self and obsessions and intrusions?

We observed that most patients found a link between that feared self and the content of their obsessions, but much less so with intrusions, and this time the difference was significant. Our results suggest that patients with OCD believe their obsessions bring them closer to their feared self, and this relationship also seems to be independent of the content of the obsession (although the tendency was stronger for aggressive, sexual and religious obsessions). This wouldn’t happen with intrusive thoughts or intrusions, and this could be one of the most important reasons why certain thoughts become obsessions while others remain simple intrusive thoughts.

The most global and central thing a human being has is their identity. If anything at all threatens our identity, it’s attacking our very core. So it’s no surprise that, if a person with OCD feels their obsessions are drawing them closer to an identity they reject, they will do everything they possibly can to get rid of those obsessions.

And now for the most important part, and the reason any kind of research exists.

What are the therapeutic implications of these results?

In other words, what’s the point of knowing all this?

Our results suggest that it’s important and useful to change how the patient with OCD perceives their feared self. That is, it would be helpful for professionals to devote part of therapy to analysing and changing the patient’s perceptions of their real identity and, above all, their feared identity – helping them to tell a real identity apart from a fictional one. By adding this work to the therapy protocol, we may reduce the chance of relapse in the future… Inference-Based Cognitive Behavioral Therapy (I-CBT) includes this part in its protocol, as it considers the self a key factor in the disorder that therefore needs to be addressed in therapy.

On the other hand, if future research shows that the feared self is also significantly related to other obsessive-compulsive spectrum disorders (something that has already begun to be studied), a protocol of strategies common to all of them could be developed.

And that’s the end of the first part. I hope I’ve been direct and concise enough, and got the results across in a clear and interesting way… I’ll alternate the thesis results with other content to avoid an OCD overdose. Needless to say, I’ve summarised the study a lot (!!), and I’ll do the same with all of them, because what interests me most here is sharing the key conclusions of the research. Even so, if you’d like to explore the subject in depth, you’ll find the thesis and the publications that came out of it at the end of this article.

The thesis and related publications

• Llorens Aguilar, S. (2020). Contexto, sí mismo y narrativas en el trastorno obsesivo compulsivo: cuando lo que podría ser importa más que lo que es [Doctoral thesis, Universitat de València]. https://hdl.handle.net/10550/74905
• Llorens-Aguilar, S., García-Soriano, G., Roncero, M., Barrada, J. R., Aardema, F. & O’Connor, K. (2019). Validation of the Spanish version of the Fear of Self Questionnaire. Journal of Obsessive-Compulsive and Related Disorders, 21, 69-74. https://doi.org/10.1016/j.jocrd.2018.12.006
• Llorens-Aguilar, S., García-Soriano, G., Roncero, M., Barrada, J. R., Aardema, F. & O’Connor, K. (2020). Spanish version of the Inferential Confusion Questionnaire-Expanded Version: Further support for the role of inferential confusion in obsessive–compulsive symptoms. Clinical Psychology & Psychotherapy, 27(4), 515-527. https://doi.org/10.1002/cpp.2435
• Llorens-Aguilar, S., García-Soriano, G., Arnáez, S., Aardema, F. & O’Connor, K. (2021). Is context a crucial factor in distinguishing between intrusions and obsessions in patients with obsessive-compulsive disorder? Journal of Clinical Psychology, 77(3), 804-817. https://doi.org/10.1002/jclp.23060
• Llorens-Aguilar, S., Arnáez, S., Aardema, F. & García-Soriano, G. (2022). The relationship between obsessions and the self: Feared and actual self-descriptions in a clinical obsessive–compulsive disorder sample. Clinical Psychology & Psychotherapy, 29(2), 642-651. https://doi.org/10.1002/cpp.2656