Why context matters in OCD (findings from my PhD thesis)

Today I want to talk about another important part of my PhD findings: the role of context in the onset and maintenance of obsessive-compulsive disorder. As with the other articles on the results of this research, I’ll try to explain it as accessibly as I can, without forgetting that it’s a complicated subject. To follow this article, you first need to distinguish between two key concepts in the inference-based model of OCD:

Appropriate context: a doubt (of any kind, normal or obsessional) occurs in an appropriate context when the information we perceive in our here and now through our senses justifies that doubt arising. In other words, given the context I’m perceiving at that moment, it makes sense that I’d wonder about “x”. Examples: my period is late and I start wondering whether I might be pregnant; I get an erection while looking at a photo of a 12-year-old girl and I ask myself whether I might be a paedophile; “What if I’ve caught HIV?” after having unprotected sex with a stranger; my father has been diagnosed with an illness and I wonder whether this will be his last year; I’ve been in contact with someone who tested positive for COVID and I wonder whether I might be infected.

Inappropriate context: a doubt (of any kind, normal or obsessional) occurs in an inappropriate context when the information we perceive in our here and now through our senses does not justify that doubt arising. In other words, there’s no direct link between the information I’m picking up from the context and the doubt that appears. Examples: my period has just started and I keep wondering whether I’m pregnant; I’m watching a film with a child in it whom I find very cute and I think, “What if I’m a paedophile?”; “What if I’ve caught HIV?” because I drank from someone else’s glass; I see a man in the street who looks like my father and seems ill, and I think, “What if my father dies?”; my credit card brushed against the plastic wrapping of the box of chocolates I’ve just bought and I start doubting whether the card is carrying the virus and whether I’ll end up responsible for the COVID death of whoever receives the chocolates.

In the research, we set out to analyse the context in which both the intrusions and the obsessions of the same patient appeared. According to the hypothesis of the inference-based model of OCD, context could be what distinguishes intrusions from obsessions, defining them as two different cognitive phenomena rather than one phenomenon on a continuum of severity (note: the “continuum of severity” refers to the fact that current cognitive models of OCD suggest intrusions and obsessions are the same phenomenon to different degrees, the intrusion being the seed and the obsession the fully grown weed). According to the inference-based model, obsessions arise more often in inappropriate contexts, while intrusions (normal doubts) tend to arise more often in appropriate contexts.

Until now, context in OCD has received very little attention, but the few studies carried out so far suggest that it may play an important role in the onset and maintenance of OCD. One of the aims of this thesis was to look more deeply at the role of context, to find out whether it really could be a distinguishing factor between obsessions and intrusions, as the inference-based model proposes. We felt this research was highly relevant because, if the model’s hypothesis were confirmed, it would imply that intrusions and obsessions might not be part of the same continuum, calling into question one of the fundamental pillars on which appraisal-based models rest. This could also be part of the reason why current OCD-specific treatments don’t help a moderate proportion of the clinical population: they don’t take context into account in their protocols.

What do our findings tell us?

The results suggest that, initially, there are no differences in the type of context in which intrusions and obsessions are born (that is, first appear). This is contrary to what the inference-based model predicted, and to the results of some previous research in the field. What’s more, the data suggest that both cognitive phenomena arise in similar contexts, characterised by a negative emotional state and high levels of stress, linked to stressful experiences and, in most cases, to some kind of environmental or contextual trigger. So, according to our results, the context in which obsessions arise does not seem to be any more inappropriate than the one in which intrusions arise. That said, when we look at the timeline, obsessions are more likely than intrusions to appear spontaneously, that is, in an inappropriate context. So context does seem to play a key role, not the first time intrusions and obsessions appear, but once the obsession has taken hold. Our results support the idea that there is indeed an intrusion-obsession continuum and that, although context may be a factor worth considering in OCD, as the inference-based model suggests, it doesn’t seem to be a crucial distinguishing element between intrusions and obsessions. Overall, the research indicates that obsessions do appear in inappropriate contexts, so focusing on context to discredit obsessions can be a useful strategy when working with patients with OCD.

As with any study, we need to be cautious with these results, since they need to be replicated in further research before more definitive conclusions can be drawn. As I mentioned above, earlier studies on the subject did find results supporting the hypothesis that context distinguishes obsessions from intrusions. The difference between studies could be down to a number of variables. For example, in our research each patient was interviewed and some of the data collected referred to the past (a description of the first time the obsession and the intrusion appeared…), so the data are shaped both by memory and by each participant’s subjective interpretation of events.

Speaking personally, since I don’t work full-time in research but in clinical practice, I can allow myself to add my own point of view: in my professional experience with OCD patients, when they come to therapy and describe the different contexts in which their obsessions arise (whatever their content), the context is always inappropriate according to the definition given by the inference-based model. Always. This fits with part of the thesis findings, since by the time a patient comes to therapy the obsession is usually well entrenched. I look forward to future research on this topic because, honestly, by working on context (among other things), my patients and I have achieved very significant improvements. Obviously it’s no panacea, but I do believe it’s an important element in the cognitive therapy of this disorder and that it deserves more attention than it currently gets.

If for any reason you’d like to read the original paper, it was published in the Journal of Clinical Psychology under the title Is context a crucial factor in distinguishing between intrusions and obsessions in patients with obsessive-compulsive disorder? and you can access it here: http://dx.doi.org/10.1002/jclp.23060

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