Políptico Nº2: productos, objetos y mujeres 71

4.1. Summary of key findings

This review has investigated the affective profiles of individuals with different obsessive-compulsive presentations; five key conclusions are discussed.

4.1.1. Washing affective profile

Disgust was consistently associated with washing presentations. The relationship between disgust and contamination-related OCE has also been recognised in the wider evidence base (Athey et al, 2015; Brady, Adams, & Lohr, 2010; Cisler, Olatunji, & Lohr, 2009). It is theorised that elevated levels of disgust sensitivity drive compensatory washing behaviours in attempts to reduce the potential threat from contagious sources (Berle &

Phillips, 2006). This fits with paradigms regarding the adaptive evolutionary function of disgust (Cisler, et al., 2009). Although one study in the review did not find significantly higher disgust in washing groups than checking groups, this may have been due to the mixed histories of participants in their sample, as the authors noted the history of checking

behaviours in their sample of “washers” and washing behaviours in their sample of “checkers” (d'Olimpio et al., 2013). As such, it may be helpful for future research – if grouping participants by compulsive difficulties – to ensure discrete groups are achieved.

Two studies reported raised anxiety in contamination and washing groups during exposure to disgusting stimuli (García-Soriano et al., 2016; Phillips et al., 2000). This highlights a potential mediating role of anxiety in the relationship between disgust and washing behaviours. As such, it is plausible that when individuals with contamination- related OCE experience elevated disgust, it makes them feel anxious about the potential threat of disease, which in turn, drives washing compulsions. Indeed, research has

highlighted that when disgust towards a stimulus is experienced, anxiety and fear towards that stimulus becomes elevated (Davey, MacDonald, & Brierley, 2008; Davey, 2011). Future research may benefit from using a mediation analysis to explore the interactions between disgust, anxiety, and washing compulsions. Additionally, future studies must ensure affective confounds are appropriately controlled to generate conclusions about specific affective variables.

4.1.2. Checking affective profile

Findings suggested that individuals with checking compulsions experience greater guilt than individuals with washing compulsions. This result could be explained in terms of underlying obsessional thoughts which may lead to checking behaviours. It is widely

understood that checking compulsions are related to thoughts about being responsible for the cause or prevention of harm and, therefore, the safety of self and others (OCD-UK, 2013). Such feelings of inflated responsibility are thought to be related to the emotion of guilt

(Rachman, 1993), which could explain the current findings in terms of guilt-emotions driving checking-behaviours. Equally, it may be possible that the completion of checking rituals leads individuals to feel guilty afterwards, either due to failed attempts to resist checking urges or due to concerns about not “checking” to their necessary standards.

4.1.3. Hoarding affective profile

Findings suggest that individuals with hoarding difficulties may experience lower levels of undesirable affective phenomena than those with other compulsive difficulties. However, this finding may be due to the designs of the included studies, as hoarding groups were often compared to those with multiple difficulties, which have also been suggested to be more distressing to experience (see below). Furthermore, the results may not suggest that individuals with hoarding behaviours experience lower levels of negative affective

phenomena initially, but rather that hoarding is a more effective strategy for avoiding distress (Frost & Hartl, 1996). This may be explained by the evolutionary psychology view of hoarding as a universally adaptive trait used functionally and effectively in humans and animals (Andrews-McClymont, Lilienfeld, & Duke, 2013).

However, the findings may also be representative of a distinct difference between compulsive-hoarding presentations and those characterised by other compulsions. While hoarding has long-since been recognised as an obsessive-compulsive experience (WHO, 1992), the most recently published diagnostic manual has also listed “hoarding disorder” as a distinct difficulty (APA, 2015a). While an international meta-analysis comprising 21 studies confirmed that hoarding is an independent factor of the “obsessive-compulsive disorder” diagnosis (Bloch, Landeros-Weisenberger, Rosario, Pittenger, & Leckman, 2008), several arguments have also been made as to why hoarding is conceptually different from other OCE. Not only has research suggested that hoarding urges are not experienced as intrusive

obsessions (Steketee, Frost, & Kyrios, 2003), but evidence also suggests that they do not often share the repetitive and distressing properties of typical OCE (Kyrios, Frost, &

Steketee, 2004). These differences offer an evidence-based explanation as to why the

affective profile of compulsive-hoarding may be characterised by fewer undesirable affective phenomena.

4.1.4. Affective profile of mixed presentations

Individuals who present with more than one compulsive difficulty may be prone to experiencing less positive affect and more anxiety, worry, negative affect, and anxiety sensitivity than individuals presenting with a single compulsion (Grisham et al., 2005; Neziroglu et al., 2012). However, this conclusion is based on consistent findings from a small number of studies (n = 4) out of only six studies that had groups with mixed or multiple compulsions.

While it is reasonable to assume that more compulsions may elicit more undesirable affective phenomena, there appears to be mixed evidence regarding this finding in the wider evidence base. In accordance with the current suggestion, Shetti et al. (2005) found that mixed OCE, as opposed to single compulsive-difficulties, were significantly associated with nonresponse to pharmacological treatment using serotonin reuptake inhibitors. However, Math and Janardhan Reddy (2007) found no significant difference between the course of presentation over a duration of five to six years in individuals with mixed and “predominantly obsessive” compulsive difficulties. With limited evidence available in this field, further research into the impact of experiencing multiple compulsions on mental health and recovery may increase understanding around mixed presentations.

4.1.5. Global affective profile

Finally, the results of the review found inconclusive results regarding anxiety and depression. Aside from the apparent reduction of these phenomena in hoarding presentations, as compared to other compulsions, no clear associations with specific compulsive-behaviours were identified. As such, it may be appropriate to conclude that all OCE are likely to feature degrees of elevated anxiety and depression. This finding is supported by research which

recognises the considerable overlaps between anxiety, depression, and OCE (Antony, Bieling, Cox, Enns, & Swinson, 1998; Goodwin, 2015). Additionally, research has reported significant correlations between measures of depression and anxiety and the OCI-R total score in a clinical sample (Gönner, Leonhart, & Ecker, 2008). As such, clinicians may benefit from recognising the likelihood of such difficulties co-occurring and the need to consider this when formulating and supporting clients. Furthermore, future research projects investigating the roles of affective phenomena in OCE should ensure that these overlapping factors are controlled in order to account for any confounding effects.

4.2. Quality appraisals

As reported, all included studies were rated either “fair” or “good” using the UK NIH quality assessment tools (2014a; 2014b). The process of quality appraisal facilitated the critical analysis of the studies’ findings. Upon closer consideration, it is evident that all studies rated “good” have contributed findings which directly support one or more of the five key conclusions; this suggests conclusions are robust and well-evidenced.

Berle et al. (2012), d’Olimpio et al. (2013), Lawrence et al. (2007), and García- Soriano et al. (2016) all found evidence to suggest a relationship between disgust and

washing presentations, be this a correlation between disgust measures and washing subscales, or a between-groups comparison. Although d’Olimpio et al. did not find between group differences regarding disgust in “washers” and “checkers”, they were able to explain this unexpected finding in terms of the possible overlaps in their groups; additionally, their

correlation analysis still evidenced a relationship between disgust and washing. Shafran et al. (1996) and d’Olimpio et al. (2013) both reported moderate to strong correlations between measures of guilt and checking, while Frost et al. evidenced that multiple presentations may lead to more undesirable affective phenomena. García-Soriano et al., d’Olimpio et al., and Lawrence et al., all also presented evidence of anxiety and low mood presenting consistently

across the different compulsions. As such, it is reasonable to suggest that the inconsistent findings within the review may have stemmed from studies with poorer methodological quality.

4.3. Clinical implications

Several clinical recommendations can be made from this review. First, there is value in assessing and supporting discrete OCE individually, as affective differences exist between the various compulsive behaviours. Clients with multiple presentations may experience greater affective distress, and require a series of bespoke interventions and additional support. Second, it is advised that clients’ co-occurring anxiety and low mood are always considered, as these may be contributing to, or resulting from, their OCE; providing an effective and holistic service requires awareness of the wider picture.

Third, clinicians are advised to consider important differences in underlying affective phenomena when supporting people with OCE, which could be contributing to, or resulting from, compulsions and contributing to reduced psychological wellbeing. This review suggests that feelings of disgust should be assessed and formulated when working with clients with washing or contamination-related presentations, as this may be driving an unhelpful pattern of obsessive thoughts and compulsive behaviours. Similarly, it may be beneficial to be mindful of guilt when working with individuals who experience checking compulsions. When working with these affective phenomena, it may be helpful to use interventions that focus on affect, for example compassion-focused therapy, (Gilbert, 2009), emotion-focused cognitive therapy (Power, 2010) or emotion-focused therapy (Greenberg, 2015). Finally, clinicians are encouraged to consider the similarities and differences between discrete hoarding presentations and obsessive-compulsive hoarding difficulties before

4.4. Strengths and limitations

4.4.1. Criticisms of the present review

The present review has several strengths. First, it has drawn upon studies with a breadth of methodologies and analyses, allowing for evidence to be assimilated from a range of sources. Second, the review has used a rigorous, systematic method to screen and select papers, and extract data. This, and the process of inter-rating the quality of the studies, seeks to reduce the influence of any researcher bias on the review findings. The review also contains papers from a variety of countries and cultures, making it potentially generalizable to an international population. Finally, the present review is the first of its kind to

systematically consider the roles of a range of affective phenomena in a variety of OCE. However, the review also had limitations. First, difficulties arose when attempting to compare and assimilate findings from papers that had used different measurement tools, designs, and analyses. This limitation was compounded by the volume of data available, which was difficult to organise and evaluate in a structured and meaningful way. While the use of multiple measures and designs added breadth to the review, it also limited the ability to succinctly summarise information across different studies. As such, the current review has only considered, in depth, a small proportion of the data it generated. While this was necessary for both clarity and brevity, this meant that only the most relevant and conclusive findings have been summarised.

Additionally, although multiple countries were represented in the review, the majority of reviewed papers considered westernised samples. While evidence suggests that “basic emotions”, such as disgust, are expressed and recognised cross-culturally (Ekman, 1992), consideration must also be given to the cultural contexts in which these emotions are likely to be first, evoked, and second, deemed appropriate or acceptable. The way in which different cultures understand emotions – and presentations such as OCE – must therefore be

considered when attempting to generalise the present findings to non-westernised populations.

4.4.2. Criticisms of the included papers

Although all included studies were rated “fair” or “good” using the NIH quality assessment tools (NIH, 2014a; 2014b), some of their designs limited the scope to draw confident conclusions; this included a lack of control over confounding affective influences. As no study used a longitudinal design which preceded the onset of OCE, the capacity to infer causality from the recognised relationships and associations was limited. This inhibits the review’s ability to clarify the direction of the relationship between affective phenomena and obsessive-compulsive behaviours. Nevertheless, due to the bidirectional relationship between affective phenomena and OCE, exploring directional effects was beyond the scope of the review.

A second limitation of the reviewed papers regards the affective variables and compulsive behaviours they considered. As some of the affective and compulsive variables have only been considered in a small number of studies, conclusions regarding factors such as shame and ordering could not be given the same in-depth consideration as factors which were investigated in several studies. This lack of evidence highlights the potential scope for more scientific research in this area.