Prof. Joseph Levine

Obsessive-compulsive disorder in an intimate relationship [ROCD] in light of the self-model we develop

By Prof. Levine & Dr. Salganik

Greetings to our readers,

Obsessive-compulsive disorder in an intimate relationship (Relationship Obsessive-Compulsive Disorder or ROCD) is a subtype of obsessive-compulsive disorder (OCD) characterized by intrusive thoughts and compulsive behaviors centered on intimate relationships. We note that there is still no complete consensus as to whether such a type of OCD disorder exists or whether it can be included under the umbrella of the accepted diagnostic definition of OCD.

It is a chronic mental condition characterized as mentioned by intrusive thoughts (obsessions) and repetitive behaviors (compulsions) aimed at reducing anxiety (American Psychiatric Association [APA], 2013).

While traditional OCD symptoms often focus on contamination, symmetry, or harm, a subset of people experience obsessions and compulsions related to their romantic relationships, known as relationship obsessive-compulsive disorder (ROCD).

ROCD has received increasing attention in clinical research due to its significant impact on people's well-being and relationship satisfaction.

Definition and conceptualization of OCD in interpersonal relationships.

ROCD is characterized by persistent doubts and preoccupations about the quality of the relationship, the suitability of the partner, or feelings for the partner. These obsessions often lead to compulsive behaviors such as reassurance-seeking, testing, or mental rituals aimed at reducing uncertainty.

Two main themes are common in ROCD:

Obsessions focused on interpersonal relationships: doubts about the "righteousness" of relationships, compatibility or the presence of true love.

Partner-focused obsessions: Preoccupation with perceived flaws in the partner's appearance, personality, or other qualities.

Some cite a third type of ROCD focused on retroactive jealousy to previous partners of the intimate partner or this may be classified as a subtype of the partner-focused obsessions.

Prevalence and epidemiology

While exact prevalence rates of ROCD are not well established, studies show that relationship-related obsessions are relatively common among people with OCD. ROCD symptoms can appear at different stages of the relationship with the partner and are not limited to a specific demographic.

Etiology and risk factors

The development of ROCD is multifactorial, and involves biological, psychological and social factors:

Attachment styles: Insecure attachment patterns can cause people to develop ROCD symptoms.

Cognitive biases: Dysfunctional beliefs about relationships and perfectionism contribute to obsessive worries.

Emotional regulation: Difficulty managing negative emotions can worsen ROCD symptoms.

Clinical features and symptomatology

In people with ROCD it is found:

Obsessions: intrusive doubts about the authenticity of the relationship or the suitability of the partner.

Compulsions: repetitive behaviors such as seeking reassurance, comparing the partner to others or mental rituals.

Emotional distress: significant anxiety, guilt, or depression associated with the obsessive thoughts.

Differential diagnosis

ROCD involving specific OCD patterns must be distinguished from:

General relationship dissatisfaction: Doubts or normal conflicts in relationships.

Other mental states: such as generalized anxiety disorder or body dysmorphic disorder when focused on a partner, a depressive state with negative ruminations, and more.

Interpersonal communication disorders: as a result of personality disorders, Asperger's and more.

Impact on relationships and quality of life

ROCD can lead to:

Stress in relationships: frequent conflicts, reduced intimacy, repeated temporary separations or even the dissolution of a relationship.

Personal distress: decreased self-esteem, increased stress and dysfunction in other areas of life.

Assessment and diagnosis tools

The assessment includes:

Clinical interviews: to identify OCD patterns that focus on relationships

Self-report measures: such as the Obsessive-Compulsive Inventory (ROCI) and the Spouse-Related Obsessive-Compulsive Symptom Inventory (PROCSI).

Behavioral assessments: observing compulsive behaviors in relational contexts.

Treatment approaches:

Effective treatments for ROCD include:

Cognitive behavioral therapy (CBT)

Exposure and response prevention (ERP): gradual exposure to fearful thoughts without engaging and expressing the compulsions.

Cognitive restructuring: Challenging and changing dysfunctional beliefs about relationships.

drug treatment

Selective Serotonin Reuptake Inhibitors (SSRI): Drugs such as fluoxetine ciprofloxacin and others have been shown to be effective in reducing OCD symptoms.

Augmentation strategies: combining medication with psychotherapy for improved results.

Other interventions:

Mindfulness-based treatments: These include promoting acceptance of thoughts and reducing emotional reactivity.

Couple therapy: treatment of the relational dynamics of the spouses to each other and the improvement of communication.

In general, further research is needed to:

Understanding the underlying mechanisms: exploring neurobiological and cognitive processes specific to ROCD.

Develop specialized interventions: tailoring treatments that address unique aspects of ROCD.

Act to increase awareness: Educate clinicians and the public about ROCD to promote early detection and intervention.

ROCD is thus a mentally debilitating condition that significantly affects people and their intimate relationships. Comprehensive understanding and effective treatment are essential to mitigate its impact.

We will now move on to understanding obsessive-compulsive disorder in relationships (ROCD) using the psychobiological model of the self that is the basis of the RGFT treatment: the integration of the components of the self, the Individual Sensitivity Channels (ISC) and the groups of internalized characters.

The psychobiological model of the self that is the basis of the RGFT treatment:

Our model of the self includes the elements of the human soul. The model first assumes the existence of a "primary self", which is actually the basic biological nucleus consisting of several innate structures and subject to increasing development during life, this self includes the instinctive emotional and cognitive parts of the person. The primary self uses the reservoirs and mechanisms of emotion, memory and cognitive abilities and it contains primary nuclei for the future development of other mental structures.

The psychobiological model we propose for Self.

Let's first refer to the primary self (Biological Predestined Core):

As mentioned, the primary self consists of innate biological structures and instincts that form the innate basis of the parts of the personality and it also includes the cognitive processes and the emotional processes.

This primary self has its own dynamics during a person's life and is subject to changes with age, following diseases, traumas, drug consumption, addiction, etc.

Both the instincts and the basic needs in each and every person change according to different periods of development and aging – (hence their effect on behavior) and may change through drugs, trauma, diseases and more. Within the primary self there is the potential for instrumental abilities that are innate, but they can also be promoted, or on the contrary, suppressed through the influence of the reference groups.

The primary self also has cognitive abilities that are partly innate and partly dependent on interactions with the environment especially during the first years of life.

In addition, it includes the temperament and emotional intelligence that are partly innate and partly dependent on interactions with the environment in the first years of life. And finally, it includes an energy charge that is mostly innate but can be suppressed through the influence of the reference groups, as well as through various situational factors.

The primary self also includes the six personal sensitivity channels: Individual Sensitivity Channels (ISC) which reflect our individual reactivity in response to stressors (both external and internal). So far we have identified six channels of sensitivity:

1. Sensitivity regarding a person's status and location (the status channel)

2. Sensitivity to changes in norms (norm channel)

3. Sensitivity regarding emotional attachment to others (attachment channel)

4. Sensitivity to threat (the threat channel)

5. Sensitivity to routine changes (the routine channel)

6. Sensitivity to a decrease in energy level and the ability to act derived from it (the energy channel)

From the primary self, a number of superstructures are developed from innate nuclei that constitute a crucial basis for development during the interaction of the baby and later the person during his life with the figures around him:

A) The Experience Coordinating Agency (ECA)

B] Three structures that together make up the secondary self or the social self and include:

1] The group of the internalized characters that we will metaphorically call the board or directorate of internalized characters.

2] Enemies group.

3] A group of Self-representations.

The Experience coordinating Agency:

Now we will note that from the primary self a structure arises and is built from a potential nucleus at birth that we will call the Experience coordinating Agency (ECA) and it comprises 3 brain networks:

The emotional salience network that assesses the external flux of events on the one hand and the internal mental flow on the other hand and directs further reference to the other two networks:

The cognitive execution network regarding events in the external world

The brain default network that deals with aspects of the events of the mind internally in the absence of action focused on tasks in the external world.

The role of this ECA is therefore to review and observe the systems of the inner mind and the systems of external reality. This mechanism has the function of evaluation and is also related to the interpretation of the events of reality and the events of the inner mind. We will note that emotions and their strength play a role in the activity of the ECA.

The psychobiological model we propose for the Self

The internalized characters’ group

The group of the internalized characters that we metaphorically call the board or directorate of internalized characters consists of the internalizations of influential figures in a person’s life, arranged in a hierarchical order.

These characters maintain a continuous dialogue among them and sometimes even conflicts, while one or more internalized characters have the greatest influence on the individual's attitudes, feelings and behavior, which we called the "leader self" [a character formerly also called the "dictator self", see previous conversations].

The attitudes of the inner leader play a central role in making decisions about the internalization of information and characters. He decides whether to reject the internalization or, if accepted, in what form it will be internalized.

In other words, in a way, we assume that this influential figure is also a form of internal censorship. It should be emphasized that these are not concrete hypotheses regarding the presence of internalized figures in the inner world of the individual as a kind of "little people inside the brain", but rather in their representation in different brain areas whose nature and manner of representation still requires further research.

AI- assisted illustration for the internalized characters’ board

We note that the events and figures in the external world maintain a kind of dialogue through the mediation of the ECA that we will detail later with the internalized figures in the “directors’ board”, or with the “enemies group”, or with the representations of the self and may affect the expression and sometimes even the hierarchy of the figures in these groups.

In addition, it is possible that, similar to short-term memory, parts of which are transferred to long-term memory, also when it comes to the internalization of characters, there is a short-term internalization that, depending on the circumstances, the importance and duration of the character's influence, will eventually be transferred to a long-term internalization in the set of internalized characters.

The structure of the directors’ board of the internalized figures:

This board consists of "secondary characters" which include the following types:

1] Representations of internalized characters that originate from the significant characters that the person was exposed to during his life, but as mentioned, there may also be imaginary characters represented in books, movies, etc. that greatly influenced the person.

2] internalized representations of "subculture" [subculture refers to social influences in the environment in which a person lives and are not necessarily related to a specific person].

We note that the individual is usually not aware that his actions, feelings and attitudes are caused by the dynamic relationships between these structured characters.

We will add that internalized key figures in the board of directors [usually human], usually refer to the significant people in a person's life who played central roles in shaping his beliefs, values and self-concept. These figures may include family members, friends, mentors, teachers, or any other influential person who has left a lasting impression on the person's psyche. Sometimes, these will also include historical, literary and other figures that left a noticeable mark on the person and were internalized by him.

The term "internalized" implies that the influence of these key figures has been absorbed and integrated into the individual's thoughts, attitudes, and behaviors. This internalization occurs through the process of observing, interacting with, and learning from these important people. As a result, the individual may adopt certain values, perspectives, and approaches to life that mirror those of the influential figures.

These internalized characters can serve as guiding forces in decision-making, moral thinking and emotional regulation.

Enemies’ Group

Now we will note in addition that from the primary self there arises and is built from a potential nucleus at birth a structure that we will call the “enemies’ group”. Thus, in addition to the board of characters, in the social self there is also the "enemies’ group" and more precisely the "group of internalized enemies" this is the place where the characters that threaten the person in a significant way are internalized and which the dominant characters in the board of characters prevent them from entering and being internalized in the “directors’ board”.[We assumed the existence of this group in the last year in light of thinking about the evolutionary need of the higher animals and up to man in creating such a group for their survival].

The characters in the "enemies’ group" are characters with negative emotional value and are represented more schematically than the characters within the board of internalized characters. We note that usually the transition between the board group and the enemies’ group is not common and even rare and usually happens following a traumatic or threatening event for a person.

A group of Self-representations

In addition, from the initial self, as mentioned, a group of Self-representations develops in the different periods of life [for example, the self-representation as a child, as a teenager, as an adult, etc.], including the representation of the body.

Representations of the self include cognitive attitudes and feelings towards the self. In a certain sense, the ego representations are also a kind of containers for the flow of information of emotional attitudes and behaviors from the dynamics in the board of internalized characters and other structures in the model.

According to our model, the development of ROCD can be understood through the lens of the biological and psychological components of the self. All of these starting from the "primary self", which includes innate biological and cognitive structures along with its development into more complex psychological superstructures, such as the groups of internalized characters, the enemies and the representations of the self, play a role in understanding the psychological dynamics of ROCD.

In order to fully understand ROCD, this article examines the disorder using a new psychobiological model that assumes a multi-layered conception of the self. This model is rooted in the primary self, which consists of innate biological and cognitive structures and maintains, through the mediation of the various superstructures that develop from it, an interaction with the internal and external reality as detailed above.

Theoretical framework: the self and its development

As mentioned according to our model, the primary self (which is actually the person’s biological predestined core) serves as the basis for the entire personality and consists of innate biological, emotional and cognitive components. It includes instincts, emotional regulation systems and cognitive processes, which develop throughout life in response to external experiences, such as trauma or environmental changes.

In people with ROCD, the structures of the primary self, especially the ECA and within it the emotional salience network, and the brain's default network become hyperactive in response to pressures in relationships with the intimate partner. This leads to an overestimation of concerns related to interpersonal relationships, manifested in persistent doubts and intrusive thoughts about one's romantic relationship.

These intrusive thoughts engage the Experience Coordination Agency (ECA).

The ECA which monitors internal and external stimuli and within it, the default network that deals with the internal world is involved in this disorder in particular. In the context of ROCD, the ECA focuses excessively on relationship-related anxieties and misinterprets neutral or everyday events as threats to the relationship. This focus on the inner world of anxieties and romances is associated with an overactivity of the default network.

On the one hand, a body of research links the default network (DMN), a brain network associated with ruminative self-referential thinking in one of the mental disorders: depression. On the other hand, generally ruminative thought processes are observed in OCD and ROCD.

We believe that the role of the default network in internal rumination and ruminative thoughts contributes to the three subtypes of ROCD: partner-focused ROCD, relationship-focused ROCD, and retroactive jealousy ROCD.

The DMN consists of several brain regions, including the middle prefrontal cortex (mPFC), the posterior cingulate gyrus (PCC), and the angular gyrus. This network is very active during periods of rest, introspection and when people engage in self-centered thinking. For people with ROCD, activation of this network can lead to repetitive and intrusive thoughts (ruminations) about their relationships or their partner.

These rumination processes, mediated by the default network, contribute to the persistent doubts and preoccupations that characterize ROCD. When activated, the default network fosters a self-referential loop that increases anxieties about relationships, thereby driving the need for compulsive behaviors aimed at reducing uncertainty.

We assume that there is also an involvement of emotion processing that might be impaired in ROSD (and in regular OCD by the way). The importance of the emotion processing network in decision making is well documented and ambivalence, difficulty in taking decisions is one of the prominent symptoms of both ROCD and OCD. We will devote a particular article elaborating on this topic.

The primary self and the sensitivity channels

As mentioned, the primary self contains six emotional sensitivity channels (Individual Sensitivity Channels – ISC), which affect the way people react to external stimuli, including those related to relationships. These include sensitivities to status, attachment, threat, norms, routine changes, and energy levels. In ROCD, the attachment channel, routine channel, and the threat channel become especially hyperactive, leading people to perceive threats where none exist or to intensify normal conflicts in relationships. We presume that it is the hypersensitivity of the attachment channel in ROCD which differentiates between this condition and a regular OCD. As opposed to that, in regular OCD attachment channel doesn’t seem to be especially involved.

For example, a minor disagreement with a partner may activate the attachment channel, causing the person to question the overall validity of the relationship. Similarly, marginal changes in a partner's behavior, such as a missed text message, can activate the threat channel, leading to an overwhelming sense of anxiety about the stability of the relationship.

Development of secondary structures: the internalized characters

The secondary self, which consists of internalized images of others (ie, representations of past important relationships) and the self, also influences the individual's response to ROCD-related stress. The internalized figures in the figures’ board influence the cognitive and emotional processing of the individual. For people with ROCD, the attitudes of these figures and especially the internalized leaders can contribute to rigid expectations about what constitutes a "perfect" relationship, thus perpetuating the cycle of obsessive doubt and compulsive behavior.

For example, if an individual has internalized a parental figure who holds idealistic or perfectionistic views of love, this internalized figure may continually challenge the individual's perception of their current romantic relationship, exacerbate feelings of doubt, and drive the compulsions associated with ROCD.

In addition, people with ROCD may also have internalized enemies, representing past relationship traumas or figures that contributed to feelings of rejection or inadequacy. These characters are sometimes relegated by the inner leaders from the internal board group to the "enemies’ group" in the individual's psyche. In people with ROCD, a slight similarity in a certain parameter of the intimate partner to a figure in the enemy group will be met with harsh criticism by the leaders in the board group, which will further strengthen obsessive thoughts.

Cognitive and behavioral mechanisms in ROCD.

The Experience Coordinating Agency (ECA), which combines the emotional salience network, the executive cognitive control network and the brain's default states network, plays a central role in ROCD. This agency is responsible for scanning internal situations and external reality, assessing threats and interpreting emotional stimuli.

In ROCD the ECA becomes hypersensitive or dysregulated and overemphasizes relationship-related concerns and magnifies normal relationship problems into sources of obsession. For example, a neutral comment from a partner may be interpreted as evidence of a fundamental flaw in the relationship, leading the individual to engage in compulsive behavior seeking reassurance.

Treatment and interventions:

Given the complexity of ROCD and its interaction with the biological and psychological components of the self, treatment requires a multifaceted approach. Cognitive-behavioral therapy (CBT), especially exposure and response prevention (ERP), remains the gold standard for the treatment of ROCD. ERP involves exposing the individual to relationship-related anxieties without allowing them to engage in compulsive behaviors, thereby breaking the vicious cycle of obsession and compulsion.

In addition, reference group-focused therapy (RGFT), a therapeutic technique rooted in dealing with the influence of internalized figures and enemies, may be particularly helpful for individuals with ROCD. By identifying and addressing the internalized characters that contribute to obsessive relationship doubts, people can gain insight into how past relationships influence their current anxiety.

Conclusion:

ROCD is a complex manifestation of OCD involving obsessive doubts and compulsive behaviors focused on intimate relationships. By understanding ROCD through our psychobiological model, which integrates the primary self and the channels of sensitivity, the Experience Coordinating Agency, and the internalized character sets [the characters’ directorate, the enemies’ set, and the self-representations] clinicians can perhaps better address the underlying dynamics of the disorder.

We therefore emphasize here the importance of treatments that address both cognitive and emotional processes, such as CBT and RGFT.

References:

Abramowitz, J. S., McKay, D., & Taylor, S. (2014). Obsessive-Compulsive Disorder: Subtypes and Spectrum Conditions. Elsevier.

American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). American Psychiatric Publishing.

Buckner, R. L., Andrews-Hanna, J. R., & Schacter, D. L. (2008). The brain's default network: Anatomy, function, and relevance to disease. Annals of the New York Academy of Sciences, 1124(1), 1-38.

Didonna, F. (2009). Clinical Handbook of Mindfulness. Springer.

Doron, G., & Derby, D. S. (2017). Relationship Obsessive-Compulsive Disorder (ROCD): A Conceptual Framework. Journal of Obsessive-Compulsive and Related Disorders, 14, 33-41.

Doron, G., & Szepsenwol, O. (2015). Partner-Focused Obsessive-Compulsive Symptoms: A Framework for Understanding Relationship-Related Obsessions and Compulsions. Journal of Obsessive-Compulsive and Related Disorders, 5, 84-92.

Doron, G., Derby, D. S., & Szepsenwol, O. (2014). Relationship Obsessive-Compulsive Disorder (ROCD): A Rigorous Examination of the Boundaries Between Romantic Love and Pathological Doubt and Preoccupation. Personality and Individual Differences, 70, 170-180.

Doron, G., Derby, D. S., Szepsenwol, O., & Talmor, D. (2012b). Tainted Love: Exploring Relationship-Centered Obsessions in Two Non-Clinical Samples. Journal of Obsessive-Compulsive and Related Disorders, 1(1), 16-24.

Doron, G., Sar-El, D., & Mikulincer, M. (2012a). Obsessive-Compulsive Disorder (OCD) Comorbidity: Clinical Implications. Frontiers in Psychiatry, 3, 124.

Fineberg, N. A., Reghunandanan, S., Brown, A., & Pampaloni, I. (2015). Pharmacotherapy of Obsessive-Compulsive Disorder: Evidence-Based Treatment and Beyond. Australian & New Zealand Journal of Psychiatry, 49(9), 869-887.

Fischer, M., Ferreira, G. M., & Mikulincer, M. (2016). How Do Self-Critical Perfectionism and Dependency Relate to OCD Symptoms? The Role of Anger, Guilt, and Disgust. Journal of Obsessive-Compulsive and Related Disorders, 10, 71-81.

Pittenger, C., & Bloch, M. H. (2014). Pharmacological Treatment of Obsessive-Compulsive Disorder. Psychiatric Clinics, 37(3), 375-391.

That’s for now,

Yours,

Dr. Igor Salganik and Prof. Joseph Levine