Abramowitz et al (2007) performed a very interesting study in OCD and comorbid depression. They knew their literature, and saw that there was a gap to be filled (seriously keeping up with publications in your field is very important). There was a dearth of knowledge about cognitive factors in OCD combined with MDD.
Cognition derives from the latin verb ‘cognoscere’, and that means: to know, to conceptualize, to recognize. It refers to the processing of information in a person’s individual psychological functions. Hence, ‘cognitive’ is about how we form a representation of some thing, or a process, or another person. We use our senses, and our inner faculties (thought, fantasy, associative powers, and so on), and we use our private language and imagination to build a construct of something; and we can add value, weight to that something, i.e. determine what importance it has in the scheme of our own life.
Abramowitz et al made their own estimate of the frequency in which MDD can occur in patients that have OCD; and as others found, this centers around 1 in 4 to 1 in 2 patients (so: the same order of magnitude). OCD plus MDD often occurs together with generalized anxiety disorder (GAD), other severe anxieties, and unemployment through practical disabilitiy may be the result. This comorbidity mostly has sexual and religious obsessions as the core of its OCD part; precisely these obsessions are known to be more distressing than numerous others. The condition is aggravated by the experiential fact that so-called ‘exposure and response prevention’ (ERP), which works well in some OCD conditions, is much less effective in comorbid OCD/MDD; the patient’s progress is simply attenuated by the depressive symptoms.
In cognitive models of psychopathology, it is emphasized that dysfunctional beliefs and appraisals about internal and external stimuli and states are at the heart of the disorder. In OCD for instance, thought-action fusion can occur: ‘I have terrible thoughts about a disaster, and these may cause that disaster in reality’. In MDD, it can be: ‘I am a person that is unlovable, I am a social loser, I will never find a partner in life’. According to Rachman et al (1993), serious OCD cases can have an extended version of this thought-action fusion mechanism: ‘I have terrible thoughts about that disaster, and therefore I am a terrible person’. We see now that OCD and MDD potentially share cognitive processes: self-blame and self-deprecation are present and on the daily menu. A certain feature of OCD, TAF, can have a core characteristic of MDD, very low self-esteem, as the end result. This is a credible concept about how cognition such as in MDD can bring about depressive symptoms in an OCD patient.
The questions put forward in this study by Abramowitz thus are:
- do OCD patients that also have MDD have more misinterpretation of negative intrusive thoughts than patients with only OCD?
- are these misinterpretations uniquely related to the comorbid depressive symptoms of OCD? (so: not to other, confounding factors)
- is it true that OCD patients with MDD show poorer insight into their own OCD than do patients with solely OCD? (in terms of the senselessness of those OCD symptoms)
- in comorbid OCD/MDD, the OCD symptoms are more severe than in OCD alone
- in comorbid OCD/MDD, functional disability is more severe than in OCD alone
- in comorbid OCD/MDD, there is more grave misinterpretation of intrusive thoughts
- in comorbid OCD/MDD, insight into OCD symptoms as being senseless is poorer
Now I must introduce two new difficult words (impress others! read this blog!): nomothetic and idiographic.
In psychology, idiographic describes the study of the individual, who is seen as an entity, with properties setting him/her apart from other individuals (see idiographic image).
Nomothetic is more the study of a cohort of individuals. Here the subject is seen as representing a class or population and their corresponding personality traits and behaviours. The terms idiographic and nomothetic were introduced to American psychology by Gordon Allport in 1937, who borrowed them from the German philosopher Wilhelm Windelband.
So: nomothetic: look at a (the) group. Look at averages. Apply general theories and methods of classification. Build a conclusion from there. Idiographic: look closely at an individual. Notice his/her personal characteristics. Don’t average these out with elements from another one’s profile.
Abramowitz and his group concluded that if a nomothetic method was applied, their hypotheses could not be confirmed unequivocally. The answers turned out to be a mixed bag. However, an idiographic (in fact: semi-idiographic, for some general results had to be the outcome) approach confirmed their assumptions. This they ascribe to the fact that OCD is an idiosyncratic and highly heterogeneous disorder. Individual traits and habits may nicely fit into a coherent picture; but in assessing a large group of subjects, this coherence gets lost; and individual differences that are contrary may even cancel each other out in the proces of averaging. Therefore it is only logical that the idiographic method was successful – in practice this meant: using tailor-made measuring scales to assess personal characteristics and symptoms of OCD and MDD.
Functional disability and wrong appraisals of intrusive thoughts were uniquely associated with features of depression in OCD. The directionality of this relationship could not be established (which causes which?).
The authors finally discuss their own results critically. Again, they cite Rachman et al (1993): in OCD, the misinterpretation of intrusions eventually gets highly personalized. Self-blame and self-depreciation about bad thoughts are the result. Depression may ensue. Depression increases the vulnerability to negative intrusive thoughts. And thus, a vicious circle is the result, all the more grave because a method like exposure and response prevention does hardly work in such patients. The authors hence propose the application of advanced cognitive therapy, and also behavioural activation; the latter is not meant for changing mental strategies, but in general, physical efforts alleviate depression. Some limitations of the present study are mentioned, and also ideas for future research are provided: (i) one may look at OCD symptoms other than appraisal of intrusive thoughts, such as inflated responsibility, intolerance of uncertainty, perfectionism, and the need for ‘just right’ feelings; and (ii) something is brought to our attention that we already saw before, in the work of Besiroglu’s group: there is a strong indication that in many comorbid patients, depression cannot be attributed to the negative impact of OCD on life alone. MDD here can be said to be ‘autonomous’. Abramowitz et al advise to compare this type of patient with another type, that may really have developed MDD because OCD ruined so much in their personal life. The question then is: are there noticeable differences between illness characteristics in these two groups?
I know I made this description of the work of Abramowitz exceptionally long; and that is because it is an exceptionally good article. Tackling such difficult and heterogeneous disorders, and then asking various problematic questions simultaneously; and choosing the right assessment instruments (the scales); and performing those nomothetic and idiographic descriptions both – that is classy.
The complete literature references will follow shortly. Please stay tuned and give feedback if you feel like it!