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David Baxter

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A fear of feeling guilty might be key to some forms of OCD
By Christian Jarrett, BPS Research Digest
February 3, 2017

There's increasing recognition that our vulnerability to mental health problems isn't just about how much we are prone to certain emotions such as anxiety and low mood, but also how we relate to those emotions. If we find them aversive and intolerable, we're more likely to develop problems. A new study in Clinical Psychology and Psychotherapy applies this principle to people's experience of guilt and their vulnerability to Obsessive Compulsive Disorder (OCD), helping make sense of why past research has been inconsistent on whether guilt-proneness is a risk factor for OCD or not. Gabriele Melli and his colleagues provide new evidence that the inconsistent results might be because the key factor is not how much guilt you suffer, but whether you're highly guilt-sensitive. They found that clients with OCD who said they found guilt unbearable were especially likely to have OCD symptoms related to compulsive checking, such as checking doors are locked and ovens switched off. Though preliminary, the results point to new ways to help clients with this kind of OCD.


Melli and his colleagues began by creating a new scale for measuring guilt sensitivity because no such questionnaire existed. The new scale had 20 items, such as 'Guilt is one of the most intolerable feelings' and 'The idea of feeling guilty because I was careless makes me very anxious'. Nearly 500 volunteers from a local community in central Italy rated their agreement or not with these items, and they completed other questionnaires tapping their tendency to experience guilt, and their levels of OCD, depression and anxiety symptoms. The results showed that guilt sensitivity is a separate concept from guilt proneness, and that it was more strongly related to checking-related OCD symptoms than depression or general anxiety.


Next, the researchers asked 61 clients diagnosed with OCD and 47 others diagnosed with general anxiety disorders to complete the new guilt-sensitivity questionnaire and other scales measuring their levels of anxiety and depression. The results showed there was a strong correlation between levels of guilt sensitivity and OCD symptoms related to compulsive checking, even after controlling for different levels of general anxiety and depression and obsessive beliefs, such as an irrational sense of responsibility. Moreover, guilt-sensitivity was especially high for OCD clients whose principle symptoms related to ritualistic checking.


'Guilt sensitivity may indeed cause individuals to be vigilant and sensitive to ways in which actions or inactions could potentially cause harm, performing checking compulsions in order to avoid, prevent, or neutralise the feared feeling of guilt,' the researchers said. This could have implications for therapy, they added, suggesting that in CBT, 'cognitive restructuring should target not only inflated responsibility beliefs, but also beliefs concerning the intolerability and dangerousness of experiencing guilt.' Note, however, that the new findings were purely correlational so it's not certain that guilt sensitivity causes OCD checking symptoms or if the symptoms lead to guilt sensitivity. It may be a bit of both. Or it's even possible some unknown factors contribute to the symptoms and the guilt-sensitivity.


Reference
The role of guilt sensitivity in OCD symptom dimensions
 
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Daniel

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Understanding fear of guilt key in better treating OCD
Waterloo News - University of Waterloo
May 3, 2018

Advances in our understanding of the development and persistence of Obsessive-Compulsive Disorder (OCD) have the potential to improve treatment according to a new study by the University of Waterloo.

The study found that fear of guilt evokes feelings of doubt in decision-making, with greater fear of guilt being associated with greater self-reported difficulty making decisions, less satisfaction with the decisions made, and less confidence in those decisions. A person’s fear of being guilty for something that they have done or haven’t done also results in them wanting more information before making a decision.

“People with OCD have generally been shown in research to have this inflated feeling of responsibility,” said Waterloo graduate student and lead researcher on the study, Brenda Chiang. “They often feel that they are going to be responsible for something bad that will happen or that if they fail to do something, they will be responsible for that harm too. So, they naturally have slightly higher levels of fear of guilt making them more susceptible to indecisiveness.

“This indecisiveness leads to difficulty terminating an action as well as evokes doubt as to whether an action was done properly, which leads to repetition of that action.”

The study assessed 63 undergraduate students from the University of Waterloo, who were previously identified as having a wide range of trait levels of fear of guilt; from low to high.

“The next step would be to examine this in people who have OCD,” said Professor Christine Purdon, co-author of the study. “The current gold standard for treating OCD is Cognitive Behavioral Therapy, which has about a 50 to 60 per cent success rate if you include people who drop out because they can’t tolerate it or people who decline the treatment because they anticipate that they can’t do it.

“We’re only getting about half of the people with OCD treated properly, so once we have a better understanding of factors that cause repetition and doubt, we can develop treatment that addresses a greater number of persons.”

The study was recently published in the Journal of Obsessive-Compulsive and Related Disorders.
 

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Why Do I Feel Bad? | hitched
By Dr. Neil Fiore

Guilt can be healthy when it reminds us that we're deviating from our values. Some forms of guilt, however, spring from the belief that we should be able to save and protect others. While we have a duty to protect those under our care, we are human and, therefore, have limited power and authority over the lives and fortunes of others. Yet, as children, we often feel guilty because we think we should be able to keep our parents happy, just as we did when we were infants. When as adults, we continue to hold onto the child’s "illusion of unlimited power," we can evoke feelings of guilt and self-blame.

Tip: Accepting yourself as human, that is, not a god or a magical child, with limited powers will help remove much of your irrational guilt. I’m sorry to tell you, but you’re not so powerful that you can control the feelings and actions of your spouse. Even when they tell you, "You make me happy. You make me sad." Don’t fall into the trap of assuming you’re that powerful. Do take responsibility for your actions and your attitude, but understand that, if you don't have the power and authority, you don't have the responsibility or the guilt.
 

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Many people experience these feelings because of past events:
  • regret
  • shame
  • stress
That’s typical. But what isn’t typical is an inability to stop thinking about those feelings.

People with real event OCD cannot always manage their obsessive thoughts and compulsive actions. They often seek to clarify what happened and find a “resolution.” But that’s not always possible.

However, with treatment and continuing mental health exercises, people with real event OCD can find relief from their obsessive thoughts.
 

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(2016; 17 citations)

Screen Shot 2022-01-07 at 8.33.32 AM.jpg

Highlights

• OCD individuals fear feeling guilty for harm and try to prevent or atone for guilt.

• The Fear of Guilt Scale consists of Punishment and Harm Prevention factors.

• FOGS demonstrated good internal consistency and convergent and divergent validity.

• FOGS Punishment predicts OCD severity over OCD responsibility beliefs.

• FOGS predicts OCD symptomatology over guilt, anxiety, depression, and neuroticism.


Abstract

Although people with obsessive-compulsive disorder (OCD) often report devastating feelings of guilt, to date, a clear link between guilt and OCD symptoms has not been established. Researchers are currently exploring the extent to which individuals with OCD fear the feeling of guilt (e.g., for harm they might have caused, averted, or minimised) and behave compulsively in consequence. However, no self-report measures of the fear of guilt construct exist, which limits our ability to examine its role in OCD. We therefore developed a 17-item Fear of Guilt Scale (FOGS), culled from a larger, 49-item pool following exploratory and confirmatory factor analyses, to measure fear of guilt in OCD.

Psychometric analyses were conducted across three large, nonclinical undergraduate samples and suggest the FOGS consists of two factors: Punishment (drive to punish oneself for feelings of guilt) and Harm Prevention (drive to proactively prevent guilt). The FOGS demonstrated strong internal consistency and convergent and divergent validity. It also significantly predicted OCD symptom severity over measures of neuroticism, depression, trait guilt, and inflated responsibility beliefs. Thus, fear of guilt, as measured by the FOGS, is an important and distinct construct in understanding OCD. Implications for future use of the scale are discussed.

Discussion

...Importantly, the FOGS’ Punishment factor significantly predicted severity of OCD symptoms after controlling for depression, anxiety, stress, and OCD responsibility beliefs. Thus, fear of guilt, as measured by the FOGS’ Punishment factor, significantly adds to our understanding of OCD beyond what might be explained by an inflated sense of responsibility, itself a well-recognised predictor variable in OCD literature. Indeed, it appears that both responsibility and fear of guilt may be distinct constructs relevant to OCD symptomatology...

These study findings have many implications for our understanding and treatment of OCD. Theoretically, these results highlight the need to attend to guilt in current models of OCD and the role of excessive fear of guilt in the development and persistence of OCD. In particular, fear of guilt may raise the stakes for the individual with OCD, making it difficult to know that it is safe to terminate compulsive behaviours (thus driving perseveration) and heightening obsessive preoccupation with ways in which they have or might be guilty of some moral wrongdoing. This may be especially true for heterogeneous repugnant obsessions (e.g., unwanted sexual or aggressive thoughts) or experiences of mental contamination (arising in the absence of physical contact with a contaminant) reported in OCD; the threat of guilt for individuals particularly sensitive to guilt may be sufficiently distressing that they feel motivated to neutralise such obsessional content with overt or covert compulsions. This construct also offers a framework for understanding why responsibility is particularly toxic among individuals with OCD, as excessive fear of guilt may interact with responsibility beliefs, such that any responsibility for wrongdoing – let alone inflated sense of responsibility – is intolerable.

Clinically, it will be important to assess the extent to which guilt informs compensatory or preventative efforts (compulsions) and vigilance toward possible wrongdoings (obsessions) in case formulations for each individual. It is possible that individuals are unaware of the extent to which they experience guilt or fear guilt, and therapy can facilitate insight into the contributions of guilt. Thoughtful exploration of moral self-concept may also be informative. Treatment can then address and detoxify maladaptive beliefs about guilt, making exposures more palatable for clients and reducing treatment ambivalence or mitigating other impediments to change. Therapeutic approaches that focus on self-compassion and acceptance may also be beneficial in helping individuals tolerate guilty feelings and respond more adaptively to their fear of guilt.

The creation of the FOGS also makes it possible to empirically test other elements put forth by Mancini and Gangemi, such as whether fear of guilt drives individuals to be particularly concerned about the quality of their conduct rather than the negative outcome itself. Future research can also further elucidate the extent to which individuals might be aware of their fear of guilt and clarify the mechanisms by which fear of guilt might drive perseveration. For example, does fear of guilt raise the threshold for subjective criteria that individuals use to determine they have done enough to terminate compulsions?

The development of the FOGS also opens avenues for exploring possible relations between fear of guilt and other constructs capturing fear and avoidance of internal states or cues (e.g., emotions, distress, etc.) in individuals with OCD. Studies have typically found that OCD is associated with poor emotional awareness (alexithymia) compared to healthy controls, but no different from clinically anxious individuals (Robinson & Freeston, 2014); this appears to be an experiential deficit, as individuals with greater OC tendencies show attenuated access to internally experienced emotions but demonstrate appropriate semantic knowledge of emotions (i.e., theoretical understanding of how one should feel; Dar, Lazarov, & Liberman, 2016). Given that they have difficulty identifying and accessing internal experiences, individuals with OCD may not have developed appropriate regulatory strategies for feelings, making it especially difficult to regulate emotions such as guilt and, given their preoccupation with morality, rendering the experience of guilt a particularly feared or aversive state.

Indeed, poor distress tolerance (feeling that upsetting emotions are threatening or unmanageable) has been associated with obsessions and is elevated in OCD compared to healthy controls. Moreover, anxiety sensitivity – the fear of sensations associated with the experience of anxiety – is elevated in OCD (Robinson & Freeston, 2014), possibly making even low-level arousal from feared guilt highly unpleasant. Individuals with OCD have also been observed to be sensitive to other feelings, such as disgust (Moretz and McKay, 2008, Tolin et al., 2006), with disgust sensitivity but not disgust propensity predicting avoidance behaviour on behavioural approach tasks involving contamination concerns (Nicholson & Barnes-Holmes, 2012). It is then possible that fear of guilt is borne out of poor access to internal states and difficulty regulating guilt, which individuals with OCD have difficulty tolerating and to which they become increasingly sensitive.

Research has not yet clarified the origins of excessive fear of guilt in OCD, but it may be that parental psychological control plays a significant role (see Ballash, Leyfer, Buckley, & Woodruff-Borden, 2006; Barber, 1996). Rakow et al. (2009) found that guilt induction (one type of psychological control) was associated with internalizing problems in children. Heightened fear of guilt may thus develop in response to autobiographical events in which one was inappropriately held responsible for matters one could not control, or in response to consistent exposure to influential people who are highly critical. In both cases, people may feel terribly guilty for not having done enough, or for having done the wrong thing, and suffered important consequences (e.g., withdrawal of love, support, and validation), becoming increasingly fearful of guilt and motivated to atone for it. Indeed, retrospective report of childhood experiences of guilt induction significantly predicted self-reported feelings of mental contamination and washing rituals performed in response to mental pollution in nonclinical individuals (Berman, Wheaton, Fabricant, & Abramowitz, 2012).

An obvious limitation of our findings is that nonclinical samples were used, and fear of guilt may manifest differently in a clinical sample of people with OCD. For example, it is possible that failure of pre-emptive strategies is a hallmark of vulnerability to OCD; if this were the case, then high scores on both subscales would be associated with greater symptomatology. It is essential that the psychometric properties of the FOGS be examined in sizeable clinical samples of people with and without OCD. Further research is also needed to determine the test-retest reliability of the scale and to replicate the convergent and divergent validity of the FOGS with more specific measures than those administered in this study to control for anxiety, depression, guilt, and neuroticism. Regardless, the results of this study suggest that fear of guilt is an important construct in OCD, and the FOGS is a viable tool that is worthy of continued development. Once its reliability and validity have been established in clinical samples it could prove a useful tool for elucidating the role of guilt in the development and persistence of OCD.

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“If I let these thoughts and emotions determine what I do in the next few minutes or an hour, will it get me closer to the person I want to be or will it move me even further away?”
 

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(2005; 138 citations)

We tested predictions from cognitive-behavioural theory that people with obsessive–compulsive disorder (OCD) regard their intrusions as revealing unacceptable aspects of their character. We compared an OCD sample with anxious controls (AC) and non-anxious controls (NAC) on a measure of the extent to which intrusions led to negative inferences about the self, assessed the discrepancy between their actual and feared self, and recorded the traits making up the feared self.

The OCD sample did not differ from AC on self-discrepancies, but did differ from both control groups on the measure of negative inferences about the self. In addition, the feared self of the OCD sample was significantly more likely to consist of bad and immoral traits...

Cognitive therapy may have in some cases to address deep-rooted beliefs about the self, rather than simply targeting people's beliefs about their intrusions. Negative interpretations of intrusions...may sometimes be not so much the primary problem as a manifestation of an underlying disturbance in identity...

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(2004; 140 citations)

Abstract

Previous cognitive models of obsessive–compulsive disorder (OCD) propose that inflated responsibility plays a key role in the maintenance of symptoms (Behav.Res.Ther. 28 (1985) 571). In this manuscript, we propose that this thesis may be improved by emphasizing that instead, OCD may be characterized by a fear of guilt that would result from behaving irresponsibly and/or from not behaving responsibly. We believe that this concept provides a better explanation for the anxious and fearful nature of OCD than do more traditional conceptualizations of inflated responsibility. We support this idea with empirical evidence and propose that OCD symptoms are consistent with patients acting in a prudential mode because of their fears of guilt.


General conclusions

In this article it is argued that the cognitive core of OCD is characterized by fear of guilt from having acted irresponsibly.

We raised a number of objections to Salkovskis (1985), Salkovskis (1996) and Salkovskis and Forrester (2002) definition of inflated responsibility, arguing that this definition is insufficient to describe the obsessive mind. On the contrary, the obsessive person's mind can be better defined by the fear of behaving guiltily. Here, the individual who is fearful of guilt regarding his/her perceived responsibility assumes the existence of a causal relationship between his/her own action/inaction and the unjust outcome. In addition, this individual assumes that she/he is free from constraints, in that their choice to act/not act is not a forced one, and that they have a goal to act according to their perceived duty. Finally, the individual who is fearful of guilt foresees that she/he will not behave in accordance with his/her moral standards.

The results of several empirical studies show that having a fear of guilt regarding one's potential to act irresponsibly increases obsessive-like behaviours, and that the individuals’ hypothesis-testing process might account for this effect. In particular, it is hypothesized that both responsibility and fear of guilt, but particularly the latter, influence subjects’ hypotheses-testing process in a prudential mode. This prudential mode entails focusing on and confirming the worst case, and then reiterating the testing process. We suggest that the prudential mode may contribute in such a way as to explain the frequency, repetitiveness and persistence of obsessive–compulsive symptoms.
 

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(Excerpt below is also in OCD Coping Tips).


(2020; 2 citations)

Abnormal moral judgments in OCD are due to executive dysfunctions. These dysfunctions include impaired cognitive control resulting in the domination of strong, uncontrolled emotional responses, impaired cognitive flexibility resulting in the inability to switch between aspects of a scenario, and decreased capacity and overload of working memory and its inability to resist the interfering information...

Disobeying moral norms results in the abnormal feeling of deontological guilt ["guilt originating from the violation of a rule"] in OC patients, to which these patients are highly sensitive...

Contributing to abnormal moral judgments in OCD is known to be the abnormal feeling of disgust for moral violations and immoral unwanted intrusive thoughts, which is regarded as one of the major causes of OCD symptoms. Finally, the abnormal fear of responsibility and being criticized due to not acting morally is regarded as one of the primary impairments contributing to the abnormal moral judgments in OCD.
-consequences-of-Obsessive-Compulsive-Disorder-OCD.jpg
 
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High levels of guilt and OC symptoms have a particular sensitivity to NJREs [“Not Just Right Experiences”] corroborating centrality of guilt in OC symptoms.

------------------


Cognitive-behavioral conceptualizations of obsessive compulsive disorder (OCD) have predominantly viewed compulsions as being motivated by harm avoidance. However, sensations of things being incomplete or not "just right" may also underlie compulsions in OCD. Preliminary research suggests that distinguishing between harm avoidance and incompleteness in OCD may have practical utility, but the research on this topic is very limited to date.

The current study further addressed the role of incompleteness in OCD. A confirmatory factor analysis provided evidence for harm avoidance and incompleteness as separate constructs in a student sample. Supporting the benefits of considering incompleteness in addition to harm avoidance, self-reported levels of both constructs were significantly correlated with all domains of OCD symptoms and perfectionism assessed. Further, some evidence for unique relationships was found (e.g., incompleteness with ordering and personally prescribed perfectionism; harm avoidance with obsessing). The role of incompleteness in OCD warrants greater attention...

An increased understanding of NJREs holds great promise for elucidating the phenomenology and treatment of OCD.
 
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More generally, guilt as a symptom of stress/anxiety/trauma:


In the aftermath of a traumatic event, such as a fire or an air-crash, the mysterious onset of survivor guilt used to baffle friends, families and colleagues so much that it was classified as a mental disorder...

In a more muted form, it can affect people who have been spared a 'slow motion' trauma like redundancy. But the effects are similar. Always the over-heated conscience is at work. "Why wasn't it me?" or "Could I have done more?" The guilt is nearly always completely unfounded.

  • Survivors of traumatic incidents often blame themselves over nothing.
  • This irrational behaviour is officially classified as a symptom of PTSD.
  • Specialist therapy and co-counselling can largely defuse the problem
 
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"You did then what you knew how to do. And when you knew better, you did better."

~ Maya Angelou
 

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