Three Types of OCD Cases: Integrating Malan’s Model of OCD with the Core Fear Model
As discussed here, an individual’s OCD symptoms are aimed at avoiding a specific form of emotional distress, or Core Fear. And as discussed here, OCD symptoms are aimed at preventing a loss of attachment.
So is the Core Fear always a loss of attachment? The answer is that while the fear of losing attachment is always in the background, loss of attachment is not always the form of emotional distress around which symptoms are organized.
This article discusses three types of cases, or three different ways in which symptoms may be organized:
- Cases in which loss of attachment is the Core Fear (meaning symptoms are organized around avoiding the pain that would come from being without attachment)
- Cases in which vulnerability to loss of attachment is the Core Fear (meaning symptoms are organized around avoiding the the distress of feeling vulnerable to losing attachment)
- Cases in which the feeling of the symptom itself is the Core Fear (meaning symptoms are organized around avoiding the distressing feeling associated with a symptom)
Type 1: When Loss of Attachment Is the Core Fear
In many cases, the Core Fear is indeed some individual version of loss of attachment. This means a person’s symptoms are organized around avoiding the pain of being without attachment. Because this is a highly individual, subjective experience, we cannot simply say that the Core Fear is loss of attachment and leave it at that. Rather, as discussed here, we have to elicit the patient’s personal version of this feeling.
Type 2: When Vulnerability to Loss of Attachment Is the Core Fear
In other cases, the Core Fear isn’t loss of attachment, but rather vulnerability to loss of attachment.
In these cases, the person prioritizes stability over attachment. If there’s a chance of losing attachment, they’d rather just get it over with. For these people, the most distressing feeling is, metaphorically, lying in bed with the front door open, or walking around waiting for something to knock you down.
It’s important to understand what is going on in these cases because otherwise the person’s behavior may sometimes seem completely irrational. For example, they may fear being alone, but then avoid relationships; or if they are attached, they may do things to sabotage that attachment, or reject themselves before they can be rejected. They may even do things that could actively get them into trouble or put them in harm’s way. Once it is understood that the person would rather ‘get it over with’ than feel unstable and unsafe, their counterphobic behaviors begin to make sense.
It’s also important to note that in these cases, a person may feel unsafe when they are not anxious, because they feel as if they are letting their guard down and are therefore going to be caught off guard. They may therefore try to avoid this feeling of vulnerability by identifying specific threats, from which they can then try to protect themselves (e.g., by ruminating about them). In other words, feeling anxious feels safe, and not feeling anxious feels unsafe. When this is the case, it is important to help the person become aware of this conflict regarding letting go of rumination, as well as how they may unconsciously search for something to worry about. It is also important, in working with these patients, to distinguish between pathological anxiety and the discomfort of vulnerability.
Based on my clinical experience, I believe this presentation may be more common among people who grew up with caregivers who were unpredictable in some way, such that as a child they were constantly afraid of being caught off guard by a loss of attachment, and/or among people who were made to feel that they were fundamentally bad or unlovable (for whom seeking love feels like a venture that will inevitably fail).*
Notably, Type 1 and Type 2 are two sides of the same coin.** Type 1’s also want stability, and Type 2’s also want attachment. To illustrate this, consider the person who is afraid they’re in the ‘wrong’ relationship. They are terrified to lose the relationship, but then they also wonder if they should just get it over with and break up. Or the person who is afraid they’re a pedophile. They are terrified to believe this, but then they also wonder if they should just accept it as true and plan accordingly. Thus, the difference between these two types of cases seems to come down to which is more distressing – being alone or being afraid – and it seems likely that there could be a continuum between the two.
Thinking in terms of Malan’s conflict model of OCD, Type 2’s experience the same conflict as Type 1’s but resolve it differently.
Type 3: When the Feeling of the Symptom Itself Is the Core Fear
Finally, in some cases the Core Fear is the distress associated with the symptom itself. These people often say they aren’t afraid of any external consequence, they’re just afraid of being trapped in the symptom forever. This is often the case in sensorimotor cases, certain types of contamination, and ‘just right’/random ritual/compulsive behavior cases, as well as many emetophobia cases.
I believe that cases like this may result when a person has experienced their symptoms as posing a threat to attachment; for example, if a person is rejected, shamed, or invalidated for their symptoms. I think of these as ‘double conflict’ cases, because there is an underlying conflict that produces the symptom, and then there is another layer of conflict associated with the symptom itself. Here’s just one example of what this might look like:
Conflict 1: A child has very controlling parents, but if the child expresses anger about being controlled, then the child is shamed and invalidated. This conflict manifests as OCD symptoms.
Conflict 2: When they engage in an OCD symptom, they are shamed and invalidated again, so they are anxious about having these symptoms.
An upsetting but common example of this is when parents react to a child’s symptoms by blaming the child for not working on their anxiety, not wanting to get better, or not doing their exposure homework. This reaction to symptoms can collude with the dynamics driving the symptoms, and make things even worse. This is also an example of what can go wrong when a therapist intervenes behaviorally without attending to the emotional and relational factors that are causing the symptoms to begin with.
If a person says they aren’t afraid of any external consequence, just of the feeling of the symptom itself, this is sufficient to proceed with RF-ERP treatment, since the focal point of the symptoms (i.e., Core Fear) has been identified. Of course, it is worth keeping an eye out for the underlying conflict as treatment progresses. The person may not initially be conscious of this original conflict or fear, but may later become conscious of it.
Notably, because there are two layers of conflict in these cases, a person may have some symptoms that are organized around avoiding the feeling of the symptom itself, and others that are aimed at avoiding vulnerability or a loss of attachment.
I believe that understanding how symptoms are organized is an essential part of conceptualizing an OCD case. It helps restore a person’s sense of agency by helping them to understand why they are doing what they are doing, helps in designing a more effective behavioral intervention, and helps identify underlying emotional and relational factors to be addressed as part of treatment.
* Thank you to my associate Dr. Suzie Long, who helped me refine the Type 2 profile, and its connection to the Type 1 profile, over the course of many conversations.
** This presentation may correlate with an avoidant attachment style, whereas Type 1 may correlate with an anxious attachment style. I also wonder whether there might sometimes be a connection between the impulse to ‘get it over with’ and impulsive behaviors (e.g., in ADHD or impulse control disorders).