Relationshipobsessivecompulsivedisorder(ROCD):AconceptualframeworkGuyD - PDF document

Relationshipobsessivecompulsivedisorder(ROCD):AconceptualframeworkGuyDoron,DannyS.Derby,OhadSzepsenwolSchoolofPsychology,InterdisciplinaryCenter(IDC)Herzliya,P.O.Box167,Herzliya46150,IsraelTheIsraeliCenterforCognitiveBehavioralTherapy,TelAviv,IsraelarticleinfoArticlehistory:Received11July2013Receivedinrevisedform21November2013Accepted3December2013 Contentslistsavailableatjournalhomepage:JournalofObsessive-CompulsiveandRelatedDisorders Correspondingauthor.Tel.:97299602850.E-mailaddress:(G.Doron). JournalofObsessive-CompulsiveandRelatedDisorders3(2014)169180 broaderunderstandingofthedevelopmentandmaintenanceofOCD,especiallywithinarelationalcontext.Relationship-relatedobsessivecompulsivesymptomsmayoccurinvarioustypesofrelationshipsincludingpeoplesrelationshipwiththeirparents,children,mentors,oreventheirGod.Inthispaper,however,wewillrefertoROCDwithinthecontextofromanticrelationships.ConsistentwithpriorOCD-relatedtheoreticalwork(e.g.Doron&Kyrios,2005;Rachman,1997;OCCWG,1997),weproposeseveralprocessesinvolvedinthedevelopmentandmaintenanceofROCDandreviewinitialevidencefortheirroleinrelationshipobsessivecompulsivephenomena.Wealsoarguethatsocio-culturalfactors,earlychildhoodenvironments,andparentchildrelationships,inencethedevelopmentofdysfunctionalcognitivebiases,self-percep-tions,andattachmentrepresentationsrelevanttoROCD.Thus,thispaperaimstoextendthefocusofcurrentOCDresearchbyexploringpotentialdistalandproximalvulnerabilityfactorsthatmightcon-tributetothedevelopmentandmaintenanceofROCD-relateddysfunctionalbeliefsandsymptoms.2.Relationshipobsessivecompulsivedisorder(ROCD):ROCDismanifestedinobsessivedoubtsandpreoccupationsregardingromanticrelationshipsandcompulsivebehaviorsper-formedinordertoalleviatethedistressassociatedwiththepresenceand/orcontentoftheobsessions.Relationshipobsessionsoftencomeintheformofthoughts(e.g.,ishetherightone?andimagesoftherelationshippartner,butcanalsooccurintheformofurges(e.g.,toleaveonescurrentpartner).CompulsivebehaviorsinROCDinclude,butarenotlimitedto,repeatedcheckingofonesownfeelingsandthoughtstowardthepartnerortherelationship,comparingpartnerscharacteristicsorbeha-viorstoothers,visualizingorrecallingpositiveexperiencesorfeelings,reassuranceseekingandself-reassurance(seeTable1Relationship-relatedintrusionsareoftenego-dystonicastheycontradicttheindividualssubjectiveexperienceoftherelation-ship(e.g.,Iloveher,butIcantstopquestioningmyfeelings)orhisorherpersonalvalues(e.g.,appearanceshouldnotbeimportantinselectingarelationshippartner).Suchintrusionsareperceivedasunacceptableandunwanted,andoftenbringaboutfeelingsofguiltandshameregardingtheiroccurrenceand/orcontent.Forinstance,individualsmayfeelshameabouthavingcriticalthoughtsabouttheirpartnersintelligence,looks,orsocialcompetencies.Guiltandshamemayalsobeassociatedwithneutralizingbehaviors,suchascomparingonespartnerwithotherpotentialpartners.TheageofonsetofROCDisunknown.Inourclinic,clientspresentingwithROCDoftenreporttheonsetofsymptomsinearlyadulthood.Insuchcases,ROCDsymptomsseemtopersistthroughouttheindividualshistoryofromanticrelationships.Someindividuals,however,tracebacktheonsetoftheirROCDsymptomstothersttimetheyfacedcommitment-relatedromanticdecisions(e.g.,gettingmarried,havingchildren).AlthoughROCDsymptomscanoccuroutsideofanongoingromanticrelationship(e.g.,obsessingaboutpastorfuturerelation-ships),suchsymptomsseemtobemostdistressinganddebilitat-ingwhenexperiencedinthecourseofanongoingromanticrelationship.Incommunitysamples,ROCDsymptomswerenotfoundtosignicantlyrelatetorelationshiplengthorgenderDoronetal.,2012a,2012b;Doron,Szepsenwol,Karp,&Gal.,2013Thedyadiccontextprovidesabundanttriggersofrelationship-centeredandpartner-focusedOCphenomena.Nevertheless,forsomeindividuals,ROCDsymptomsmaybeactivatedbytheterminationofaromanticrelationship.Inthiscase,peoplemayreportbeingobsessivelypreoccupiedwiththeirpreviouspartnerbeingtherightonemissingtheONE.Suchcasesarefrequentlyassociatedwithextremefearofanticipatedregretandarecommonlyaccompaniedbyself-reassuringbehaviors(e.g.,recallingthereasonsforrelationshiptermination),compulsivecomparisons(i.e.,withcurrentpartners),andcompulsiverecollec-tionofpreviousexperiences(e.g.,relationshipconicts).Otherpeoplereportavoidingromanticrelationshipsaltogetherfordreadofhurtingothers(e.g.,IwilldrivehercrazyItwillbealie)orfearofre-experiencingROCDsymptoms.Forinstance,clientsmayreportavoidingseconddatesforyearsforfearofobsessingaboutawsoftheirpartnersortheirpartnersbecomingoverlyattachedtothem.3.MeasuresofrelationshipobsessivecompulsivesymptomsAquicksearchonGooglewouldshowthetermROCDhasbeenfrequentlyusedinthelastseveralyearsmainlyonpeer-supportOCDforums.Systematicresearch,however,requiresprecisedenitionsandvalidmeasurementtools.Recently,twomeasuresweredevelopedandvalidatedforthispurpose:therelationshipobses-sivecompulsiveinventory(ROCI),assessingrelationship-centeredOCsymptoms(Doronetal.,2012a),andthepartner-relatedobsessivecompulsivesymptomsinventory(PROCSI),assessingpartner-focusedOCsymptoms(Doronetal.,2012b).InaccordancewithrecentevidencethatOCDsymptomsarebetterconceptua-lizedintermsofdimensionsratherthancategories(e.g.,Williams,Kyrios,McKay,&Taylor,2005;Olatunji,Williams,Haslam,Abramowitz,&Tolin,2008),wedesignedtheROCIand Table1Examplesoftypicaltriggers,intrusions,appraisalsandresponsesinROCD.TypicaltriggersIntrusionAppraisalTypicalresponsesContextualRomanticcuesRelationship-centered(e.g.,romanticmovies,othercouplesinteractingetc.)IdonotfeelanythingIhavetomakesureIloveher/himEmotionalresponsesExposuretootherswithdesirableattributes(e.g.,workcolleagues,Facebooketc.)wearenotashappyastheyareOrGuiltImaybemissingtheONE.ShameUrgetoleaveCognitive-behavioralresponsesPhysicalattraction(orlackthereof)TalkofcommitmentPartner-focusedReassuranceseeking,monitoringfeelings,comparisonsavoidance(e.g.,romanticcuesandattractiveothers)SheisunattractiveIwillregretthisforeverthatisastupidthingtosay(bythethiswomanisinterestingIwillneverbehappywithmyApathyG.Doronetal./JournalofObsessive-CompulsiveandRelatedDisorders3(2014)169180170 thePROCSItoassessrelationship-centeredandpartner-focusedsymptomsonacontinuum,frommildpreoccupationtosevereanddebilitatingdisorder.OurreferencestoROCDsymptomsthrough-outthispapercorrespondtothisdimensionalview.TheROCIwasconstructedtomeasuretheseverityofobses-sions(i.e.,preoccupationanddoubts)andcompulsions(i.e.,checkingandreassuranceseeking)onthreerelationaldimensions:sfeelingstowardsarelationshippartner(e.g.,IcontinuouslyreassesswhetherIreallylovemypartner),thepartnersfeelingstowardsoneself(e.g.,Icontinuouslydoubtmypartnerslovefor),andtheoftherelationship(e.g.,Icheckandrecheckwhethermyrelationshipfeelsright).Findingssupportedthisthree-factorstructureaboveandbeyondtwoalternativemeasurementmodels,butalsosuggestedtheexistenceofahigher-ordergeneralfactorforrelationship-centeredOCsymp-toms.TheROCIperformedwellonmostgoodnessoftindices,andthetotalandsubscalescoreswerehighlyreliable(Doronetal.,2012aThePROCSIwasdesignedtomeasureobsessions(i.e.,preoccu-pationsanddoubts)andneutralizingbehaviors(i.e.,checking)focusedontheperceivedawsofonesrelationshippartnerinsixcharacterdomains:physicalappearance,sociability,morality,emotionalstability,intelligence,andcompetence.Findingsforthismeasuresupportedasix-factorstructureaboveandbeyondalternativemeasurementmodels,butagainsuggestedtheexis-tenceofahigher-ordergeneralfactorforpartner-focusedOCsymptoms.ThePROCSIstotalandsubscalesscoreswerefoundtobeinternallyconsistentandhadgoodtestretestreliabilityDoronetal.,2012bROCIandPROCSIscoresseemtodiscriminatebetweenROCDandotherOCDsymptoms.Inanongoingstudy,wecomparedtheROCIandPROCSIscoresof17clientspresentingwithROCDtothescoresof18clientspresentingwithotherOCDthemes.WealsousedtheMiniInternationalNeuropsychiatricInterview(MINI;Sheehanetal.,1998)toattainclinicaldiagnosis.FindingssofarshowsignicantdifferencesbetweenthetwogroupsontheROCI,(1,33)10.28,.003,.24,andthePROCSI,(1,33).14.ROCDclientsmeanROCIscores(ona0to4scale)werehigher(2.10,.67)thanthoseofclientspresentingotherOCDsymptoms(1.16,1.02).ThisdifferenceremainedsignicantwhencontrollingforseverityofOCDanddepressionsymptoms.Similarly,ROCDclientsmeanPROCSIscoreswerehigher(1.33,.56)thanclientspresentingotherOCDsymptoms(.79).Again,thisdifferenceremainedsignicantwhencontrollingforseverityofOCDanddepressionsymptoms.Thus,ROCDsymptoms,asmeasuredbytheROCIandthePROCSI,seemtobeconceptuallyandempiricallydifferentiatedfromotherOCDsymptomdimensions.Nevertheless,astheROCIandPROCSIaredesignedtoassessobsessivecompulsivephenomena,smalltomoderatecorrelationsareexpectedbetweenthesemeasuresandtoolsassessingotherOCDsymptoms.Indeed,wehavefoundmoderatecorrelationsbetweentheROCIandtheObsessiveCompulsiveInventory-Revised(OCI-R;Foaetal.,2002).Specically,theROCItotalscorewasmoderatelycorrelatedwiththeOCI-Rtotalscore(.45)andsubscalescores(srangedfrom.28forneutralizingto.47forDoronetal.,2012a).Similarly,smalltomoderatecorrelationswerefoundbetweenthePROCSItotalscoreandtheOCI-Rtotalscore(.44)andsubscalescores(srangedfrom.28fororderingto.40forobsessions;Doronetal.,2012b4.DevelopmentandmaintenancemechanismsinROCDTheetiologyandmaintenanceofROCDsymptomsismostlikelymulti-facetedandinvolvingacombinationoffactors.Inthissection,weexploretheroleofOCDrelatedbeliefs,processesrelatedtodysfunctionalmonitoringofinternalstates,andperceptionsofrelationalcommitmentinthedevelopmentandmaintenanceofROCD.FollowingrecentmodelsofOCD,wethensuggestthatpre-existingself-vulnerabilitiesandattachmentinsecuritiesmaybeimplicatedintheexacerbationofintrusionsintoobsessions.Finally,weevaluatethepotentialroleofotherpersonalityfactors,societaluences,andparentingandfamilyenvironmentfactorsintheetiologyandpreservationofROCDsymptoms.4.1.ROCDandcognitivemodelsofOC-relateddisordersCognitivebehavioralmodelsofOC-relateddisordersgiveacentralroletomaladaptiveappraisalsofinternalorexternalstimuliinthedevelopmentandmaintenanceofthesedisorders.Accordingtosuchmodels(e.g.,Rachman,1997;Storch,Abramowitz,&Goodman,2008;Wilhelm,Buhlmann,Cook,Greenberg,&Dimaite,2010;Wihlem&Neziroglu,2002),obsessivepreoccupationisaresultofcatastrophicmisinterpretationsofcommonphenomena.InthecaseofOCD,individualscatastrophicallyinterpretthepresenceorconsequenceofnaturallyoccurringintrusivethoughtsasindicatingimminentdangertoselforothers(Rachman,1997;Salkovskis,1985).Similarly,inthecaseofBodyDysmorphicDisorder(BDD),individualscatastrophicallymisinterpretthesignicanceandsocialconsequencesofestheticfeaturesandminorawsintheirownappearance(e.g.,peoplewillbedisgustedofmeWilhelmetal.,2010;Veale,2004Cognitivebeliefsandbiases,suchasthreatoverestimation,perfec-tionism,intoleranceofuncertainty,importanceofthoughtsandtheircontrol,andinatedresponsibilityincreasethelikelihoodofcata-strophicappraisalsinOC-relateddisorders(OCCWG,2005;Storchetal.,2008).Theseappraisals,inturn,promoteselectiveattentiontowardspotentiallydistressingstimuli(OCCWG,1997Veal,2004)Moreover,ineffectivestrategiesfordealingwithsuchstimuli,suchasrepeatedcheckingandreassuranceseeking,paradoxicallyexacerbatethefrequencyandemotionalimpactofsuchpreoccupations.ROCDsymptomsmayinvolvecognitivebeliefsandbiasessimilartothoseunderlyingotherOCphenomena(Doron,Szepsenwol,Derby,&Nahaloni,2012).SomedysfunctionalOCDrelatedprocesses,however,maybemorepertinenttotherelationalOCDtheme.Inthefollowingparagraphs,werstdescribethewaybeliefspreviouslyidentiedasimportantinOCDmayplayaroleinROCD.WethenrefertoprocessesthatmaybespecicallygermanetoROCDsymptoms.4.2.ROCDandOCD-relatedmaladaptivebeliefsBeliefspreviouslylinkedwithOCDhavealsobeenfoundtobelinkedwithROCD(Doronetal.,2012a,2012b).OC-relatedbeliefsmayinuenceinterpretationsofintrusivethoughtspertainingtotherelationshipsortherelationshippartner.Forinstance,over-estimationofthreatmaybiasindividualsinterpretationsofothersfeelingstowardsthem(e.g.,Hedidntcallforhours,hetreallyloveme)andtheseverityandconsequencesofthesperceiveddecits(e.g.,heisextremelyunstable,hencehewillneverbeabletoprovideforourfamily).Perfectionisttendenciesmaypromotepreoccupationwiththeoftherelationship(e.g.,IdontfeelperfectwithhimallthetimesomaybeheisnotTHEONE)andother-orientedperfectionismHewitt&Flett,1991)mayresultinextremepreoccupationwithcfeaturesofaromanticpartnerspersonalityorappearancesheisnotmoralenoughhernoseistoobig).Thebeliefthatonecanandshouldcontrolonesthoughtsmaypromotesuppressioneffortsofrelationshipdoubtsornegativethoughtsaboutthepartner,therebyincreasingtheiroccurrence.IntoleranceforuncertaintymayplayaparticularlyimportantroleinROCDasitpertainstooneofitscoreelementsaboutbeingintherightrelationship.Moreover,ROCDsymptomsG.Doronetal./JournalofObsessive-CompulsiveandRelatedDisorders3(2014)169180171 oftenconcernvague,intangibleinternalstates(e.g.,love)thatinherentlyinvolveuncertainty.Difcultywithuncertaintymayincreasedistressandmaladaptivemanagementofcommonlyoccurringrelationshipdoubts.Webelievethateffectivetreatmentrequirespostponingofanyrelationaldecisionsattheinitialstagesoftherapy,makingsuchtoleranceanimportanttargetfortreat-mentinterventions(seeSection84.3.ROCDandmonitoringofinternalstatesLibermanandDar(2009)haverecentlyproposedaninnovativemodelofOCD.TheysuggestedthatindividualswithOCDdoubttheirinternalstatesandshowdecreasedcapacitytoaccessthesestates.Inanattempttodecreasedoubtsregardingtheirinnerfeelingsandstates,OCDclientsover-monitorandtendtorelyonexternalfeedbackforassessingthem.Insupportofthesehypoth-eses,studieshavefoundthat,ascomparedtoparticipantswithlowobsessivecompulsivetendencies,participantswithhighobsessivecompulsivetendenciesare(a)lessaccurateinassessinginternalstates,suchastheirownlevelofrelaxationormuscletension,and(b)relymoreonexternalfeedbackinassessingtheseinternalstates(Lazarov,Dar,Oded,&Liberman,2010,Lazarov,Dar,Liberman,&Oded,2012).Moreover,Shapira,Gundar-Goshen,Liberman,andDar(2013)haverecentlyfoundthatintensemonitoringofonesfeelingsofemotionalclosenessinanintimateconversationhampersachievingthesefeelings,asmeasuredbysittingdistancebetweenpairmembers.Increasedmonitoringmayindeedreduceaccesstointernalstatesandfeelings.Relationship-centeredOCsymptoms,bydenition,involvepreoccupationwithinternalstates(e.g.,loveforapartnerorfeelingright).Inordertoassessorreduceuncertaintyregardingtheirownfeelings,ROCDclientsofteninvesttimeandeffortinmonitoringtheirfeelingsandemotions.Weoftenhearclientsdescribecontinuousmonitoringoftheirfeelingstowardstheirpartner(e.g.,DoIfeelloverightnow?Doesthisfeelright?Insuchinstances,monitoringofinternalstatesisusedasadeliberateattempttoreassureoneselfaboutthestrengthandqualityofonesownfeelings.ROCDclientsalsodescribeusingwhattheyperceiveastivesignsinordertojudgetheirfeelings.Forinstance,oneclientquantiedherpartnersloveforherbycompulsivelycomparingthetimehespentwithhertothetimehespentwithothers(e.g.,hismother).Anotherclientreportedtimespentcryingarelationshipbreakupasaretrospectiveindicatorofhisfeelings.Moreoften,however,clientsgagerelationshipqualityorrightnessbyreferringtothecognitive(e.g.,doubtsandpreoccupations)andbehavioral(e.g.,lookingatotherwomen)featuresofROCDsymptoms.Forinstance,clientsmayidentifyexperiencingdoubtsasanegativeindicatorofrelationshiporoftheirfeelingstowardstheirpartner.Accordingly,clientsmaytreatthoughtsaboutpartnersdecienciesasnegativeindicatorsoftheirownfeelings(e.g.,ifIseesomanyaws,Idonotlovehimseebelowforfurtherdiscussionofthislink).Increasedmonitoringofinternalstatesandreferringtoexter-nalfeedbackfortheevaluationofsuchstatesmayalleviatedistressintheshortterm.Likeothercompulsivebehaviors,however,repetitiveuseofsuchstrategiesresultsinROCDsymptomsexacerbation.4.4.ROCDandrelationship-relatedbeliefsRecently,Doronetal.(2012a)proposedthatmaladaptiverelationalbeliefscanuniquelycontributetothedevelopmentandmaintenanceofROCD.FollowingRachmansmodel(1997,1998),theysuggestedseveralbiasesimplyingcatastrophiccon-sequencesofrelationship-relatedthoughts,images,andurges.Thesemayincludebeliefsfocusingonthedisastrousconsequencesofleavingarelationship(e.g.,IfIleave,Iwillhurtmypartnerandthecatastrophicconsequencesofremaininginalessthanperfectrelationship(e.g.,IfImaintainarelationshipIamnotsureabout,IwillbemiserableforeverInthiscontext,researchonrelationalcommitmentmaybeparticularlyrelevant.AdamsandJones(1997)proposedathree-dimensionalconceptualizationofrelationalcommitment,includ-ing(a)apersonalcommitmentdimension(feelingsofaffection,intimacy,andlovetowardapartner);(b)amoral-normativedimension(onesmoralobligationtotherelationshipandthepartner);and(c)aconstrainingdimension(social,nancialandemotionalnegativecostsofrelationshipdissolution).Studieshavefoundthathighlevelsofpersonalcommitmenthelpromanticallyinvolvedpeopletoappreciatethegoodqualitiesofapartnerandshieldthemfromthetemptationofattractivealternatives(seeLydon,2010forareview).InthecaseofclientswithROCD,lowlevelsofpersonalcommitmentmayintensifyobsessionaldoubtsconcerningtherightnessoftheirrelationshipandtheattractive-nessoftheirpartner.Moreover,thesedoubtsmayfurtherreducepersonalcommitment,which,inturn,maydecreasetheeffective-nessoftemptation-shieldingmechanismsandthenintensifytheseverityofROCDsymptoms.Thenormativeandconstrainingdimensionsofrelationalcom-mitmentmaybeheavilyinuencedbyonescultureandreligionAdams&Jones,1997;Allgood,Harris,Skogrand,&Lee,2008alsoseeSection4.7).Inourview,thesetwodimensionsreectthepresenceofcatastrophicnegativebeliefsregardingthemoral(e.g.,IfIleaveherIwillbeanimmoralperson)andpractical(e.g.,IwillhavetomoveoutofmyhomeIwillbeexcommunicatedbymychurch)consequencesofrelationshipterminationthatmayexacerbateROCDsymptoms.Indeed,itisnotuncommonforclientswithROCDtoexpressstrongcommitment-relatedmoralbeliefs(e.g.,youshouldonlymarryonce).Suchbeliefsseemtoamplifytheneedforcertaintyabouttherelationshiporthepartner,therebyincreasingROCDclientstendencytouseneutra-lizingbehaviors(e.g.,monitoringofinternalstates,monitoringofsbehaviors).Similarly,focusingonthesocial,emotionalnancialnegativeconsequencesofrelationshipdissolutionmaymagnifyfearsofmakingthewrongdecision,leadingtocatastrophicinterpretationsofrelationaldoubtsandevenencouragingavoidanceofrelationshipsalltogether.Anadditionalrelationship-relatedfactorthatmaybeinvolvedinthemaintenanceofROCDsymptomsisanticipatedregret.Regretisexperiencedwhenwerealizethatourcurrentsituationcouldhavebeenmoresatisfyinghadwemadeadifferentchoice.Anticipatedregretreferstoregretthatweanticipateexperiencinginthefuture(Zeelenberg,1999).Fearofanticipatedregretmaycantlyheightenreactivitytorelationalintrusions.Forinstance,oneofourclientsexpressingstrongfearsofanticipatedregretdescribedanextremelydistressingsituation:WhileonFacebook,thethoughtthathispartnerisnotintelligentenoughintohishead.Hereportedthefollowingthoughtsequence:Therearesomanywomenoutthere,ifIstaywithonethatmaynotbesmartenoughIwillregretitforever,butifIleave,ImayrealizethatImissedtheloveofmylife.Indeed,onecorefeatureofROCDisextremefearofmakingthewrongrelationship-relateddecision.Clientsalternatebetweenbeingterrorizedbythoughtsofseparation(e.g.,IwillalwaysthinkthatImayhavemissedTHEONE)andbeingtrappedinthewrongrelationship(e.g.,IwillalwaysfeelthatIhavecompromised4.5.ROCDandself-relatedprocessesPre-existingself-vulnerabilitiesmayalsoplayasignicantroleinthedevelopmentandmaintenanceofROCD.Rachman(1997,G.Doronetal./JournalofObsessive-CompulsiveandRelatedDisorders3(2014)169180172 1998)hasarguedthatintrusionschallengingapersonssystemofvaluesaremorelikelytoescalateintoobsessionsthanintrusionsnotchallengingsuchvalues.Followingthisidea,severalscholarshaveproposedthatpre-existingself-vulnerabilitiescontributetothespecicthemeofanindividualsobsession(e.g.,Aardema&Connor,2007;Aardema,Molding,Radomsky,Doron,&Allamby,inpress;Bhar&Kyrios,2007;Clark&Purdon,1993;García-Soriano,Clark,Belloch,delPalacio,&Castañeiras,2012).Inthiscontext,DoronandKyrios(2005)havearguedthatthoughtsoreventsthatchallengehighlyvaluedself-domains(e.g.,moralself-domain)maythreatenapersonssenseofself-worthinthisdomain,andactivatecognitionsandbehavioraltendenciesaimedatcounteractingthedamageandcompensatingfortheperceivedcits(e.g.,Doron,Sar-El,&Mikulincer,2012).Forsomeindivi-duals,suchasOCDsufferers,theseresponsesparadoxicallyincreasetheaccessibilityofnegativeself-cognitions(e.g.,immoralandunworthy)thattogetherwiththeactivationofotherdysfunctionalbeliefsassociatedwithobsessions(e.g.,inatedresponsibility,threatoverestimation;OCCWG,1997)canresultinthedevelopmentofOCD.Inourview,vulnerabilityintherelationalself-domainmayleadtotheescalationofrelationship-centeredintrusionsintoobsession(Doronetal.,2013).Thatis,sensitivitytointrusionschallengingself-perceptionsintherelationshipdomain(e.g.,Idonotfeelrightwithmypartneratthemoment)maytriggercatastrophicrelationshipappraisals(e.g.,beinginarelationshipIamnotsureaboutwillmakememiserableforever)andothermaladaptiveappraisals(e.g.,Ishouldnthavesuchdoubtsregard-ingmypartner),followedbyneutralizingbehaviors(e.g.,con-stantlyseekingreassurancethattherelationshipisgoingright).Similarly,whenonesself-worthiscontingentontheperceivedvalueofarelationshippartner(i.e.,partner-contingentself-worth),everythoughtoreventrelatedtothispartnerawscanintensifypartner-focusedOCsymptoms.Hence,individualsperceivingtheirsfailuresorawsasreectingontheirownself-worthareexpectedtobemoresensitivetothoughtsoreventspertainingtotheirpartnersqualitiesandcharacteristics.Suchintrusionsmaytriggercatastrophicappraisals(e.g.,Heisnotintelligentenough.Wewillneverbeabletosupportourfamily)andneutralizingbehaviors(e.g.,increasedmonitoringofthepartnersgrammaticalAlthoughrelationalchallengesanddoubtsofthekindsdescribedabovearefairlyfrequent,mostindividualsmanagetoadaptivelyrespondtosuchself-challengesandarethereforelesslikelytobeoodedbynegativeself-evaluationsfollowingthem.Onepsychologicalmechanismsuggestedtothwartsuchadaptiveregulatoryprocessesisattachmentinsecurity(Doron,Moulding,Kyrios,Nedeljkovic,&Mikulincer,20094.6.ROCDandattachmentrepresentationsInhisseminalwork,Bowlby(1973,1982)proposedthatinter-personalinteractionswithprimarycaregivers()earlyinlifeareinternalizedintheformofmentalrepresentationsofselfandothers(internalworkingmodelsWhenattachmentguresareabsent,inconsistentlyavailable,orrejectingintimesofneed,onessenseofattachmentsecurity(asensethattheworldisgenerallyasafeplace,othersarehelpfulwhencalledupon,anditispossibletoexploretheenvironmentcuriouslyandcondentlyandengagerewardinglywithotherpeople)isunderminedandnegativemodelsofselfandothersaredeveloped.Suchmodelsincreasethelikelihoodofself-relateddoubtsandemotionaldifcultieslaterinlife(Mikulincer&Shaver,2007).Parentsaremostfrequentlythemainattachmentduringchildhood.Inadulthood,however,romanticpartnersoftentakeparentsplaceasmainattachmentResearchhassupportedatwo-dimensionalrepresentationofindividualdifferencesinattachmentinsecuritiesinadulthood,organizedaroundtwoorthogonaldimensionsofanxietyandavoidance(Brennan,Clark,&Shaver,1998;Mikulincer&Shaver,2007).Attachmentanxietyinvolvesworriesregardingtheavail-abilityofsignicantotherstoadequatelyrespondintimesofneed,andtheadoptionofhyperactivatingattachmentstrategies(i.e.,energetic,insistentattemptstoobtaincare,support,andlovefromgures)asameansofregulatingdistress.Attachmentavoidanceinvolvesdistrustinsignicantothersandastrivingtomaintainautonomyandemotionaldistancefromthem.Avoidantlyattachedindividualscommonlyendorsedeactivatingstrategies,suchasdenialofattachmentneedsandsuppressionofattachment-relatedthoughtsandemotions.Individualswhoscorelowonbothinsecuritydimensionsaresaidtoholdastablesenseofattachmentsecurity(Mikulincer&Shaver,2007Attachmentinsecuritiesmayhinderadaptivecopingwithself-relatedchallengesbyactivatingdysfunctionaldistress-regulatingstrategies,furtherexacerbatinganxietyandineffectiveresponsesDoronetal.,2009).Forinstance,anxiouslyattachedindividualstendtoreacttoself-relevantfailuresbyamplifyingthenegativeconsequencesoftheaversiveexperience,ruminatingonit,andincreasingmentalactivationofattachment-relevantfearssuchasfearofbeingabandonedbecauseofoneself(Mikulincer&Shaver,2003).Thus,inadditiontodisruptingfunctionalcopingwithexperiencesthatchallengesensitiveself-domains,anxiouslyattachedpeoplescopingstrategiesmayrenderthemparticularlyvulnerabletorelationship-centeredobsessions.Recentndingsclearlyindicatethatself-sensitivityintherela-tionaldomainandattachmentanxietyjointlycontribute(i.e.,double-relationshipvulnerability)tothedevelopmentandmain-tenanceofROCDsymptoms(Doronetal.,2013).Inonestudy,attachmentanxietywaslinkedwithmoresevereROCDsymptomsmainlyamongindividualswhoseself-worthwasstronglydepen-dentontheirrelationship.Inasecondstudy,subtlehintsofincompetenceintherelationalself-domain(i.e.,mildlynegativefeedbackregardingthecapacitytomaintainlong-termintimate-relationships)ledtoincreasedROCDtendenciesmainlyamongindividualshighinbothattachmentanxietyandrelationship-contingentself-worth.Thus,jointlywithsensitivityintherelationalself-domain,attachmentanxietymayresultinincreasedsuscept-ibilitytorelationship-relatedobsessivedoubtsandworries.4.7.ROCDandotherpersonalityandsocietalfactorsPersonalfactorsmayinteractwithsocietalinuencestoaffectsabilitytofeelsecurewithoneschoiceofpartner.Inrecentyears,wehaveseenasignicantincreaseinexposuretootherpeople,theirbehaviors,andtheirpersonallives.Suchincreasedexposureisparticularlyevidentindigitalsocialnetworks(e.g.,Facebook,Google)anddatingwebsites/applications,thuscreat-inganillusionofavailability.ManyclientswithROCDdescribesuchextensiveexposuretopotentialpartnersasapowerfultriggeroftheirrelationshipdoubtsandpreoccupations.Inthiscontext,itisimporttonotethatreligiousviews,culturalnormsandsocio-economicstatusmaysignicantlyimpactbothactual(e.g.,abilitytoworkoutsidethefamilyhomeoracceptabilityofdivorce)andperceivedavailabilityofalternativepartners(e.g.,havingaccesstosocialmedia).Studiesinbehavioraleconomicshavelongsupportedtheroleofperceivedavailabilityofbetteroptionsinindecisivenessanddifferingchoices(e.g.,Tversky&Shar,1992).Withintherelationshipsetting,recentstudieslookingatdecisionmakinginonlinedatingsitesshowthatmoresearchoptions(i.e.,increasedperceivedavailability)resultinexcessivesearching,poorerdecisionmakingandreducedselectivityinndingpotentialpartners(themore-means-worseeffectWu&G.Doronetal./JournalofObsessive-CompulsiveandRelatedDisorders3(2014)169180173 Chiou,2009).Morerecently,YangandChiou(2010)examinedthemoderatingeffectofpersonalitytendenciesondecisionmakinginthecontextofchoiceproliferation.Findingsindicatedthatthemore-means-worseeffectisaccentuatedamongindividualswithmaximiz-decisionmakingtendencies.Maximizingstrategiesareaimedatachievingthebestpossibleoptionandrequireanexhaustivesearchofallpossibilities(Simon,1956;Schwartzetal.,2002).Incontrary,satisfyingstrategiesstriveforagoodenoughchoice,searchinguntilmeetinganacceptableoption.Indeed,individualdifferencesinmaximizingdecision-makingstrategieswerelinkedwithpoorermentalhealth(e.g.,depressionsymptoms),increasedmaladaptivebeliefs(e.g.,perfectionism),moreregret,andhigherlikelihoodofengaginginupwardsocialcomparisons(Schwartzetal.,2002Maximizerswerealsofoundtospendmoretimereviewingoptionswhenmakingachoicethandosatisers,arguablyincreasingmax-uncertaintyregardingthebestchoice(Dar-Nimrod,Rawn,Lehman,&Schwartz,2009;Iyengar,Wells,&Schwartz,2006).More-over,recentndingssuggestthatmaximizerstendtoavoidcommit-menttotheirdecisionsinawaythatcontributestoreducedsatisfaction(Sparks,Ehrlinger,&Eibach,2012).Thus,increasedper-ceivedavailabilityofalternativestogetherwithamaximizingdecisionmakingstrategymayincreasedoubtsregardingonesrelational4.8.ROCD,parenting,andfamilyenvironmentParentsarearguablytherstandmostdominantmodelofromanticrelationshipsapersonisexposedtoduringchildhood.Itisreasonabletohypothesize,therefore,thatthequalityofasparentsromanticrelationshipwouldimpactherorhisrelationalbeliefs,emotions,andbehaviors.Indeed,earlyexperi-ences,particularlyparentalconict,havebeentheoreticallyandempiricallylinkedwithpeoplesrelationalattitudes,valuesandbehaviors(SeeAmato,2000,forreview).Moreover,parentalicthasbeentheoreticallyandempiricallyassociatedwithotherROCD-relatedfactors,suchasattachmentinsecurities,dysfunctionalself-views,andmentalhealthproblems(e.g.,Amato,2001Davies&Cummings,1994Jekielek,1998;Mikulincer&Shaver,2007).Finally,manyclientswithROCDrecallalongstandinghistoryofintenseandovertparentalconict.Thus,weproposethatanegativefamilyenvironmentduringchildhood,particularlycomprisingofintenseandlongstandingparentalict,canbeadistalvulnerabilityfactorofROCD.5.RelationalandpersonalconsequencesofROCDResearchhasshownthatOCDcancarrynegativeconsequencesforrelationalfunctioning(e.g.,Angstetal.,2004).Forexample,thecontinuouspressurethatpeoplewithOCDexertontheirrelation-shippartnerstoparticipateincompulsiveritualshasbeenfoundtobeasourceofrelationaltensionandconictandtoimpairrelationshipquality(Koran,2000).Accordingly,partnersaccom-modationtoOCDsymptoms(e.g.,takingpartinritualsorinavoidanceofanxiety-provokingsituations)hasalsobeenlinkedwithsymptomseverity,treatmentoutcomes,andlowerrelation-shipsatisfactionoftheindividualwithOCD(Boedingetal.,2013)Furthermore,OCDseverityhasbeenassociatedwithdecreasedfamily,work,andsocialfunctioning(Ruscio,Stein,Chiu,&Kessler,2008),highercaregiverburdenanddistress(Cerqueira,Torres,Torresan,Negreiros,&Vitorino,2008;Vikas,Avasthi,&Sharan,2011)andincreasedmaritaldistress(Emmelkamp,DeHaan,&Hoogduin1990;Rasmussen&Eisen,1992;Riggs,Hiss,&Foa,1992).Onlyrecently,researchhasbeguntoexplorethecontributionofROCDsymptomstopoorrelationalandpersonal5.1.ROCDandrelationshipsatisfactionROCDsymptomsmaybeparticularlydetrimentaltointimaterelationships.SimilartocommonOCDsymptoms,ROCDsymp-tomsmaybringaboutnegativeresponsesfromtherelationshippartnerandbeasourceofrelationshipconict.ThismaybeevenmoreprominentinROCD,becausethefocusofthepreoccupationistherelationshipitselfortherelationshippartner.Constantrelationalconictmayseriouslyunderminerelationshipsatisfac-tionandendangertherelationshipsstability(Amato,2000Yet,ROCDsymptomsmayimpactrelationshipsatisfactioninadditionalways.Repeatedlydoubtingonesrelationshiporrela-tionshippartnermayseriouslyunderminecorerelationshippro-cessesanddirectlydestabilizetherelationship.Forinstance,positiveidealsaboutonesrelationshipandromanticpartnerwereedasbenecialcognitivebiasesofindividualsinsuccessfulromanticrelationships(e.g.,Fletcher,Simpson,&Thomas,2000;Overall,Fletcher,&Simpson,2006).Idealizedrelationshipandpartnerperceptionshavebeenlinkedtopositiverelationalout-comes,suchasgreatersatisfaction,lessconict,andmorestablerelationships(e.g.,Barelds&Dijkstra,2011;Murrayetal.,2011;Murray,Holmes,&Grifn,1996;Rusbult,VanLange,Wildschut,Yovetich,&Verette,2000),whereasthefadingofsuchidealizedperceptionshasbeenlinkedtorelationshipbreakup(Caughlin&Huston,2006).IndividualswithROCDarelikelytonditdiftomaintainidealizedrelationshipandpartnerperceptions,orevenpositiveones,inthefaceofrepeatedintrusions,andarehencemorelikelytoexperiencepoorrelationshipsatisfaction.TwostudiesconductedinnonclinicalsampleshavefoundtheexpectedrelationshipbetweenROCDsymptomsandpoorrela-tionshipsatisfaction.Inonestudy,relationship-centeredOCsymp-toms,asmeasuredbytheROCI,weresignicantlyassociatedwithrelationshipdissatisfaction,evenwhencontrollingforcommonOCDsymptoms,moodsymptoms,lowself-esteem,attachmentanxietyandavoidance,andrelationshipambivalence(Doronetal.,2012a).Thisndingwasreplicatedinasubsequentstudywithsimilarcontrols(Doronetal.,2012b).Partner-focusedOCsymp-toms,asmeasuredbythePROCSI,werealsofoundtobesig-cantlyassociatedwithrelationshipdissatisfaction,evenwhencontrollingforrelationship-centeredsymptomsinadditiontoalltheothercontrolsmentionedabove.Infact,bothpartner-focusedandrelationship-centeredOCsymptomshadtheirownuniquestatisticalcontributiontorelationshipdissatisfaction,suggestingsomewhatdivergentcausalpaths(Doronetal.,2012b).Itshouldbenoted,however,thattherelationshipbetweenrelationshipsatisfactionandROCDislikelytobebidirectional.Thatis,poorrelationshipsatisfactionrootedinotherfactorsmaypromoterelationship-centeredandpartner-focuseddoubts,justlikeendo-genousrelationship-centeredandpartner-focuseddoubtsmaypromotepoorrelationshipsatisfaction.5.2.ROCDandwell-beingROCDsymptomsmayleadtoextremedistress,anxiety,anddisability.Clientsfrequentlyreportfeelingsofshameandguiltabouttheirdoubtsandpreoccupations.Thesefeelingsencourageself-criticismandmaylowerpsychologicalwell-being.Inaddition,neutralizingbehaviorsinvolvedinROCDareexperiencedasuncontrollableandirrational,therebypromotingnegativeself-perceptions.Thetimeandenergydedicatedtopreoccupationswitharelationshipoftencomesattheexpenseofworkandacademicfunctioning.Indeed,individualswithROCDreportdis-tressduetotheirsymptoms,therelateddisabilitystemmingforthesesymptoms,andtheanguishtheybelievetheyarecausingcloseothers.G.Doronetal./JournalofObsessive-CompulsiveandRelatedDisorders3(2014)169180174 Recentndingsfromstudiesconductedinnon-clinicalsamplessupportsuchclientreports.Inonestudy,relationship-centeredOCsymptoms,asmeasuredbytheROCI,weresignicantlyassociatedwithdepression,evenwhencontrollingforcommonOCDsymp-toms,relationshipambivalence,attachmentanxietyandavoid-ance,andlowself-esteem(Doronetal.,2012a).Thisndingwasreplicatedinasubsequentstudy,inwhichanxietyandstresswerestatisticallycontrolledinadditiontoself-esteemandcommonOCDsymptoms(Doronetal.,2012bDoronetal.(2012b)foundthatpartner-focusedOCsymptoms,asmeasuredbythePROCSI,weresignicantlyassociatedwithdepression,evenwhenrelationship-centeredOCsymptomswereaddedtoalltheabove-mentionedcontrols.Infact,partner-focusedOCsymptomswerefoundtobemoreconsequentialtodepressionthanrelationship-centeredOCsymptoms.Whereaspartner-focusedsymptomspredicteddepressionoverandaboverelationship-centeredsymp-toms,theoppositewasnottrue.6.Theassociationbetweenrelationship-centeredandpartner-focusedOCsymptomsROCDcaninvolverelationship-centeredandpartner-focusedsymptoms.Inthefollowingsection,weexplorethereciprocalassociationsbetweenthesetwopresentationsofROCDphenomena.Webeginbydiscussingthewithin-personinterplaybetweenrelationship-centeredandpartner-focusedsymptoms.WethenconsidertheimpactofROCDsymptomsontherelationshippartner.6.1.Within-personbidirectionalinltrationofROCDsymptomsClinicalexperienceandempiricalndingsindicatethatrelationship-centeredandpartner-focusedOCsymptomsoftenco-occur.Indeed,thetotalscoresofthePROCSIandROCIwerefoundtobestronglycorrelated(e.g.,Doronetal.,2012b).TworecentlongitudinalstudiessuggestthatthesetwopresentationsofROCDsymptomsmayfueleachotherovertime.Inonelong-itudinalstudy,partner-focusedOCsymptomspredictedanincreaseinrelationship-centeredOCsymptomstwomonthslaterandviceversa(Doronetal.,2012b).Morerecently,thesewerereplicatedinaone-yearlongitudinalstudy(Szepsenwol,Doron,&Shahar,submittedforpublicationPartner-focusedOCsymptomsmayexacerbaterelationship-centeredOCsymptomsbyincreasingdoubtsregardingtherela-tionshipandtherelationshipquality.Asdiscussedearlier,relation-shipsatisfactionishamperedbypartner-focusedOCsymptomsDoronetal.,2012b).ROCDclientstendtointerprettheoccurrenceofintrusionsregardingthepartnerawsasevidencethatsome-thingiswronginthisrelationship.Inthisway,preoccupationswiththepartnersperceivedawsmayincreasethelikelihoodofdevelopingdoubtsregardingtherelationshipsfeelingstowardsthepartner.ClinicalexperiencealsoshowsthatROCDclientswithpartner-focusedsymptomsoftendevoteincreasedattentiontoromanticalternativesandcompulsivelycomparetheircurrentromanticpartnerstothesealternatives.Increasedattentiontoalternatives,whencoupledwithlowrela-tionshipsatisfaction,islikelytolowerrelationshipcommitmentRusbult,1980)andfosterrelationshipdoubts.Relationship-centeredOCsymptomsmaypromotepartner-focusedOCsymptomswhenidentifyingpartnersdecienciesisusedasameansforassessingtherightnessoftherelationshiporsfeelingstowardsthepartner.Asarguedabove,relationship-centeredOCsymptomsincreasemonitoringofinternalstatesandrelianceonexternalobjectivefeedbackforevaluatingonesownfeelings(Liberman&Dar,2009).Forsomeclients,identicationofcienciesinapartnerisusedasaproxyforassessingonesownfeelingstowardsthispartnerortherelationship.Inthisway,theirdoubtsandworriesbyreferringtotheirobjectiveaws.6.2.Between-personinltrationofROCDsymptomsInadditiontobeingself-enhancedwithinthesamepersonovertime,ROCDsymptomsmayalsospreadfromonepersontothenext,especiallywithinromanticrelationships.Thatis,apersonROCDsymptomsmayovertimehisorherrelationshippartner,leadingtomoreROCDsymptomsamongthispartner.Forinstance,duringacouples-therapysession,awomandescribedhersrepeatedquestioningofherfeelingstowardshimasatriggerforsuchdoubts.Initialndingsfromanongoinglong-itudinalstudyofdatingpartnersindicatethatwithinaone-monthperiod,relationship-centeredsymptomsinonedyadmemberincreasedrelationship-centeredsymptomsintheotherdyadmember.Atthesametime,partner-focusedsymptomsinonedyadmemberincreasepartner-focusedsymptomsintheotherdyadmember.ThesedyadiceffectsmayresultfromseveralROCD-relatedprocesses.Forexample,havingonepartnerconstantlyquestiontherelationshipmaycausetheotherpartnertodothesame(e.g.,sunsureaboutthisrelationship.AmIsureaboutit?).ROCDsymptomssuchasrepeatedreassuranceseeking(e.g.,Doyoulove)mayleadtoanincreaseinpartnersmonitoringoftheirowninternalstates(i.e.,doIfeellovetowardshim?)inresponsetorepeatedquestioning.Similarly,compulsivecomparisonsofonepartnermayincreasethelikelihoodoftheotherpartnerdoingthesame(e.g.,shekeepscomparingmetoherformerboyfriend,buthowdoesshecomparetomyformergirlfriend?).Moregenerally,however,theemotionalburdenlaidbyonepartnerconstantlyquestioningtheotherpartnerscharacter,appearance,orsuitabil-itymayleadtoincreasedpersonalstressandhigherthreatappraisalsinthetargetedpartner,which,inturn,mayleadtomoreROCDsymptomsinthispartner.Finally,onepartnercontinuousdoubtingoftherelationshipmayactivatepreexistingattachmentinsecuritiesintheotherpartner,therebycontributingtothedevelopmentofROCDsymptomsinthispartner.7.ROCDandrelatedconstructsWehavearguedthatROCDinvolvesfeaturesthatareuniquetotherelationaldomainaswellasfeaturesthatarecommonwithotherOCDsymptoms.Yet,ifROCDistobeunderstoodasadistinctphenomenon,itisessentialtodifferentiateitfromotherrelatedconstructs.Inthissection,wereviewtheconceptualandempiricallinksbetweenrelationship-centeredOCsymptomsandrelatedconstructs,suchasworryandsocialanxiety.Wealsodealwiththepotentiallinksbetweenpartner-focusedOCphenomenaandbody-dysmorphicsymptoms.7.1.Relationship-centeredOCsymptomsandworriesTraditionally,relationshipsareconsideredtofallwithintherealmofgeneralworries(Clark,2004).Itisimportant,therefore,todifferentiatebetweenrelationship-centeredOCphenomenaandworry.Clinicalexperienceandinitialempiricalndingssuggestthatrelationship-centeredobsessionscanbedifferentiatedfromgeneralworriesinbothcontentandform.Relationship-centeredobsessions,bydenition,focusononescurrentfeelingstowardsapartner,apartnersfeelingstowardsoneself,andtherightnessofacurrentorpastrelationship.Incontrast,worryoftenrelatestofutureconsequencesrealsituationsClark,2004;e.g.,whatwillIdoifIbreakupwithmygirlfriend?).LikeotherformsofG.Doronetal./JournalofObsessive-CompulsiveandRelatedDisorders3(2014)169180175 obsessions,relationship-centeredobsessionsareexperiencedasmoreunwanted,intrusive,andunacceptablethannormalworriesandappeartobemorestronglyresisted.Clientsoftendescribethoughts,questions,anddoubtsspringingupintotheirmindTheseintrusionsareperceivedasexaggerated,havingslightornorealisticbasis,andascontradictingapersonsstrongfeelingstowardsapartner.Relationship-centeredobsessionsarethereforelessself-congruent,morelikelytobeassociatedwithneutralizingefforts,andareperceivedaslessrationalthanworries.Further-more,whereasworriescommonlyappearinverbalformat,relationship-centeredobsessionscomeinavarietyofforms,includingimages,thoughtsandurges.Thereisinitialempiricalevidencesupportingthedifferentiationbetweenrelationship-centeredobsessionsandgeneralworries.Inarecentstudy,Doronetal.(2013)showedonlyasmallcorrelation.21)betweentheROCIandoneofthemostcommonlyusedmeasuresofgeneralworrythePennStateWorryQuestionnaire(PSWQ;Meyer,Miller,Metzger,&Borkovec19907.2.Relationship-centeredOCsymptomsandsocialanxietyBothrelationship-centeredobsessionsandsocialanxietymayrelatetoindividualscloserelationshipsandaffectinterpersonalinteractions.However,whereasrelationship-centeredobsessionsconcernapersonsrelationalappraisals,feelings,andexperiences,socialanxietyconcernapersonsperceivedfunctioningininter-personalsituations.Forinstance,apersonwithrelationship-centeredobsessionislikelytobepreoccupiedwithhis/herownfeelingstowardsapartnerduringorfollowingaromanticencoun-ter.Incontrast,apersonwithsocialanxietyismorelikelytofearhis/herperceivedincompetenceinafutureromanticencounter(i.e.,anticipatedanxiety),duringtheromanticencounter(amIsweating?)orfollowingtheromanticencounter(howdidIlook?DidIblush?).Socialanxietysymptomsaremorelikelytoincludephysicalsymptoms(e.g.,blushingandsweating)thanrelationship-centeredOCsymptomsandtendtobeassociatedwithmoreself-congruentnegativeself-talk.Indeed,inayetunpublishedstudywithacommunitycohort(218),theROCIshowedonlyasmallcorrelation(.22)withsocialanxietysymptoms,asmeasuredbytheSocialInteractionAnxietyScale(SIAS;Mattick&Clarke,1998).7.3.Relationship-centeredOCsymptomsandobsessionaljealousyRelationship-centeredobsessionsandobsessionaljealousymayrelatetoromanticrelationships.Obsessionaljealousy,however,focusesononespartnerallegedunfaithfulbehaviorsandindelity,ratherthantherelationshipexperience.Unlikeobsessivejealousy,relationship-centeredobsessionsdonotassumetheexistenceofapotentialrivalandarelesslikelytoinvolvemonitoringandcheckingofpartnersbehaviorsforcuesofindelity.Nevertheless,increasedROCDsymptoms(e.g.,doubtsregard-ingthepartnerslove)maybeassociatedwithmoreobsessionaljealousysymptoms(e.g.,Ihavetocheckwhetherhelovesmeandnotsomeoneelse).Moreover,ROCDandobsessionaljealousymaysharesomevulnerabilityandmaintenancefactorssuchasself-sensitivityintherelationaldomain.Consistentwiththis,unpub-lishedcorrelationaldata(218)showedamoderatecorrelation.41)betweentheROCIandjealousydrivencheckingbehaviors,asmeasuredbythecheckingsubscaleofthequestionnaireofaffectiverelationships(QAR;Marazzitietal.,20037.4.Partner-focusedOCsymptomsandBDDPartner-focusedOCsymptomsaredenedbymarkedpreoccu-pationandneutralizingbehaviorconcerningperceivedpartnercitsoraws.Likeinbodydysmorphicdisorder(BDD),partner-focusedOCsymptomsmayfocusonphysicalappearance.BDD,however,isdenedbyexcessivepreoccupationwithonesown,ratherthanothersperceivedphysicalaws.Furthermore,althoughpartner-focusedOCsymptomsmayrelatetothepartnersphysicalfeatures(alsotermedBDDbyProxy,seeJosephson&Hollander,1997Greenbergetal.,2013),theyoftenrelatetoothercharacter-istics,suchassocialqualities(e.g.,sociability)orpersonalityattributes(e.g.,morality).Finally,likeotherROCDsymptoms,partner-focusedobsessivesymptomsmayoccurinavarietyofcloserelationships(parentchild;person-Godetc.).Nonetheless,bothBDDandpartner-focusedsymptomsinvolvehypervigilancetoperceiveddefectsorawsandcatastrophicinterpretationsoftheconsequencesofsuchaws.Estheticsensi-tivitymayalsobecommontobothdisorders(Lambrou,Veale,&Wilson,2011).Therefore,moderatecorrelationsbetweenBDDandpartner-focusedOCsymptomsshouldbeexpected.Consistentwiththeseexpectations,Doronetal.(2012b)havefoundamoderatecorrelationbetweenBDDsymptomsandthePROCSItotalscore(.39).Furthermore,besidestheROCIscore,BDDsymptomsweretheonlysignicantpredictorofchangesinPROCSIscoresinaonemonthfollow-upanalysis.Importantly,BDDsymptomsdidnotshowastrongercorrelationwiththePROCSIappearancesubscale(.32)thanwiththeotherPROCSIsubscales,supportingamoregeneralizedunderlyingcommonpredisposition(Doronetal.,2012b7.5.Relationship-relatedobsessionsandsexualorientationobsessions(HOCD)Forsomeindividuals,relationaldoubtsmaybestronglylinkedwithsexualorientationobsessions(i.e.,doubtaboutonessexualorientationorfearsofbecominghomosexual;e.g.,Williams&Farris,2011Moulding,Aardema,&Oconnor,thisissue).Forinstance,oneclientdescribedthetransformationofhisROCDsymptomstosexualorientationobsessionasfollows:Itstartedwithdoubtsabouttherelationship.IcontinuouslyaskedmyselfwhetherIamintherightrelationship.IwouldcheckandrecheckwhetherIamattractedtoher.Afterawhile,Istartedthinkingmaybeitisnotabouther.MaybeImnotattractedtowomen.Sincethen,IcantstopcheckingwhetherImarousedbywomanand/ormenandIreallyfearndingoutImhomosexual.AdifferentclientdescribeherHOCDsymptomsleadingtoROCDsymptoms:Istartedhavingobsessionsaboutmysexualpreferenceasanadolescent.AsIgrewoldertheyabated.Now,however,whenIaminaseriousrelationship,IcontinuouslydoubtmyfeelingsformypartnerandwhetherIamintherightrelationship.MaybeIlesbianandImmisleadinghimandmyselfPreoccupationsinROCDcenterontherelationshipexperience.HOCDinvolvesfearscenteringontheself.Asseenabove,increasedmonitoringofinternalstatesmayplayacrucialroleintherelationshipbetweenROCDandHOCD.Monitoringofinternalstatessuchasphysicalattractionandsexualdesiremaymakesuchstateslessaccessibletherebyfuelingrelationalandself-relateddoubts.Futureresearchmayshadefurtherlightonthislinkanditstherapeuticimplications.8.AssessmentandtreatmentWorrying,havingdoubtsorevenbeingpreoccupiedwithaparticularrelationshipdoesnotautomaticallysuggestadiag-nosisofROCD.LikeotherOCDsymptoms,relationship-relatedOCsymptomsrequirepsychologicalinterventiononlywhentheyarecausingsignicantdistressandareincapacitating.DiagnosingROCDisfurthercomplicatedbythefactthatsuchexperiences,G.Doronetal./JournalofObsessive-CompulsiveandRelatedDisorders3(2014)169180176 evenifdistressing,maystillbeapartofthenormalcourseofastilldevelopingrelationship,mainlyduringtheirtinganddatingstages,orreectreallifeproblems.Furthermore,treatmentisfrequentlysoughtonlyduringrelationalinstability(e.g.,increasingpressurefromapartner,lowrelationshipsatisfaction)andROCDisoftencomorbidwithotherdisorders,suchasdepression,otheranxietydisorders,andotherOCDsymptoms.EstablishingthatapersonissufferingfromROCD;therefore,requiresparticularcare.8.1.AssessmentRelationalobsessionsusuallybeginintheearlystagesofarelationshipandexacerbateastherelationshipprogressesorreachdecisionpoints(e.g.,cohabitation,marriage).Cliniciansshouldkeepinmindthatrelationshipobsessionsexistandpersistregardlessofrelationshipconict.WhensuspectingROCD,initialevaluationshouldincludeaclinicalinterviewtoascertainthediagnosisofOCDandcoexistingdisordersormedicalconditions.Itisstronglyrecommendedtousestructuredinterviews,suchastheMiniInternationalNeuropsychiatricInterview(MINI;etal.,1998)ortheSCID(First,Spitzer,Gibbon,&Williams,1997),toascertaindisabilityanddiagnosisofOCD.AdditionalinstrumentsshouldbeusedtoquantifyROCDsymptomseverity(e.g.,theROCIandthePROCSI),otherOCDsymptoms(e.g.,OCI-R,YaleBrownObsessiveCompulsiveScale),OCD-relatedcognitions(e.g.,Obses-siveBeliefsQuestionnaire;Moldingetal.,2011),depression,anxiety,andBodyDysmorphicsymptoms.Athoroughhistorywouldincludethepresentingproblem(s),backgroundoftheproblem(s),andpersonalhistorywithspeciemphasisonrelationalhistory,familyhistoryandenvironmentandcurrentrelationshipassessment.Itisofoutmostimportancetogainaclearunderstandingofthenature,pattern,anddurationofclientssymptomswithinthecurrentrelationshipcontextandinpreviousrelationships.Level,frequencyandthemesofcurrentrelationalconict,strategiesofresolvingsuchconicts,sexualfunctioningandsatisfactionaswellasperceptionsofcommitmentandrelationshipexpectationsshouldbenoted.Therapistsshouldcollectdetailedinformationabouttriggersofobsessions,theirfrequencyandduration,theexpectedfearedoutcomeorworryabouttheobsessions,andtheresponsestotheseintrusions.Responsesincludeemotions(e.g.,anxiety,guilt),overtcompul-sions(e.g.,checking,comparing,reassuranceseeking),covertcompulsions(e.g.,thoughtsuppression,monitoringofinternalstates,self-reassurance),andavoidanceorsafetybehaviors.8.2.PharmacotherapyTherearenoknownstudiesastotheeffectivenessofpharma-cotherapytoROCDsymptoms.Ourclinicalexperienceshows,however,thathighdosesofSSRIsasacceptedinthetreatmentofOCD(e.g.,Montgomery,Kasper,Stein,Hedegaard,&Lemming,2001)mayleadtoareductionofROCDsymptomsforsomeindividuals.8.3.PsychosocialtreatmentsTheeffectivenessofpsychosocialtreatmentforROCDhasyettobetested.Asuccessfultherapeuticintervention,however,shouldbebasedonatheoreticalunderstandingofthevulnerabilityfactorsandmaintenanceprocessesdescribedabove.WearecurrentlydevelopingatreatmentmanualthatwilladdressthemaintainingprocessesandvulnerabilityfactorsofROCD.FollowingcurrentcognitivebehavioralinterventionsforOCD,webelievesuchtreat-mentshouldincludeassessmentandinformationgathering,psycho-educationandidenticationandchallengingofdysfunc-tionalthinkingpatterns,self-perceptions,andattachment-relatedfearsanddefenses.ExposureResponsePrevention(ERP)andotherbehavioralexperimentsarebelievedtobeveryusefulinthistherapeuticprocess.Psycho-educationsetsthetonefortherestoftherapy.Thepsycho-educationcomponentshouldcoverthecognitivemodelofOCDandROCD(seeFig.1).Itisimportanttoprovidetheclientwiththerationaleforthetherapeuticprocessanddiscussthecourseoftherapy.TheinuenceofROCDsymptomsondecisionmakingshouldthenbeaddressedandthedifferencebetweenobsessivethinkingandproblemsolvingclaried.Inthiscontext, Fig.1.TheROCDmaintenancecycle.G.Doronetal./JournalofObsessive-CompulsiveandRelatedDisorders3(2014)169180177 theimpactofROCDsymptomsononesabilitytoexperiencefeelingsshouldbeexplored.Basedontheseunderstandings,itisbesttoreachanagreementtopostponedecisionsregardingtherelationshipuntilROCDsymptomsaresignicantlyreduced.Contingentontheclientsapproval,oneshouldconsiderinvol-vingthepartnerinthetherapeuticprocess.Insuchcases,partnersymptomaccommodationshouldbeassessed,ROCDpsycho-educationprovided,andstrategiesforreducingdyadicinsuggested.Monitoringofobsessionsandcompulsionsshouldassisttheclientandthetherapisttomanagethereductionofcompulsionsandavoidancebehaviors.ThecognitivecomponentofROCDtreatmentmayincludeidenticationandchallengingofOCD-relatedmaladaptivebeliefs(e.g.,importanceofthoughts,intoler-anceforuncertainty).Itisalsoimportanttochallengecatastrophicbeliefsaboutrelationships(e.g.,IfIstayinarelationshipIamnotsureabout,IwillalwaysbemiserableIfIcommittothisrelationship,IwillneverbeabletogetoutofitifIleavethisrelationship,Iwillalwaysregretit).Inthiscontext,ERPtaskssuchasscriptsrelatedtofearofregret(e.g.,ndingyourselfmiserablewithyourpartnerinafewyearsand/orndingyourselfmiserablewithoutthesamepartner),otherfearedscenarios(e.g.,weddings)andinvivoexposuretositesormovies(e.g.,romanticcomedies)maybeuseful.ManyclientswithROCDdescribefearsofreenactingtheirparentalrelationship.Whenapplicable,thisinformationshouldbeintegratedintotheexpo-surescripts.Aneffectiveinterventionmayalsoaddressthemean-ingandconsequencesofincreasedmonitoringofinternalstates.Suitablebehavioralexperimentsforexemplifyingtheeffectsofexcessmonitoringmayincludein-sessionrepetitivemonitoringofinternalstates(e.g.,feelingsoftothetherapist).Contingenciesofself-worthonparticularrelationalaspects(e.g.,relationships,partnervalue)shouldbeexplicitlyexplored,suchthattheclientunderstandstheassociationbetweendistressandperceivedfailureintheserelationalaspects.Effortshouldbegiventoidentifyingandexpandingtherulesofcompetenceandboundariesoftheserelationalsourcesofself-worthaswellastoincreasethedominanceofothersourcesofself-worth(e.g.,academic,physical).Particularemphasisshouldbegiventosofteningattachmentworriesandanxieties,mainlyfearofabandonment(seeDoron&Molding,2009,foradescriptionofAttachment-basedCBT).Help-fulstrategiesmayincludechallengingthelinkbetweenOCD-relatedbeliefsandabandonmentfears(e.g.,over-vigilancewilldecreasethelikelihoodofbeingabandoned),usingbehavioralexperimentstoincreasetoleranceforabandonment-relatedfears(e.g.,writing/thinkingdoesmypartnerreallylovemeaskingthepartnerforreassurance),andaddressingbeliefsasso-ciatingabandonmentwithlowperceptionsofself-worth(e.g.,IamnotworthanythingandwillthereforebeabandonedManyclientswithROCDpreferavoidingrelationalconTryingtoavoidconict,however,mayexacerbatefearsoffutureentrapment.Furthermore,conictmaybearesultofROCDsymptoms,butalsoatriggerofrelationalobsessions.ThelinkbetweenROCDsymptomsandrelationalconictshouldbeassessedandaddressed.Appropriatecommunicationandconresolutionskillsshouldbetaughtandpracticedusingroleplayingforfearedsituations(i.e.,potentialconictualinteractionwithapartner).Thegoaloftherapyisnottosavetherelationship,buttohelptheclientreduceROCDsymptoms.ROCDsymptomreductionisoftenassociatedwithbetterunderstandingofonesownfeelingsandwithimproveddecisionmakingcapacity.Incaseofneed,however,problemsolvingtechnicsanddecisionmakingstrategiesmaybeintroducedtohelptheclientwithimportantrelational9.SummaryOCDisadebilitatingdisorderwithawidearrayofobsessionalthemes.WhilesomeOCDthemeshavebeenthesubjectofintenseinvestigationsleadingtosignicanttheoreticalandclinicaladvancements,researchonrelationship-relatedobsessivepulsivephenomenahasonlyrecentlybegun.Inthispaper,wepresentedrelationshipobsessivecompulsivedisorder(ROCD),neditsmainfeatures,anddescribeditsphenomenology.MeasuresofROCDsymptomseveritywerepresentedandtheirassociationswithotherOCDthemesdiscussed.Drawingonrecentcognitive-behavioralmodelsofOCD,socialpsychologyandattachmentresearch,wediscussedtheroleofOCD-relatedbeliefs,processesrelatedtodysfunctionalmonitoringofinternalstates,andperceptionsofrelationalcommitmentinthedevelopmentandmaintenanceofROCD.Wethenimplicatedpre-existingself-vulnerabilitiesandattachmentinsecuritiesintheexacerbationofcommonrelationshipworriesintoobsessionsandevaluatedthepotentialroleofpersonalityfactors,societaluences,parenting,andfamilyenvironmentsintheetiologyandmaintenanceofROCDsymptoms.TherelationalandpersonalimpactofROCDsymptomsandthereciprocalassociationsbetweenrelationship-centeredandpartner-focusedOCsymptomswerealsodiscussed.Finally,wereviewedtheconceptualandempiricallinksbetweenROCDsymptomsandrelatedconstructsandsuggestedtheoreticallydrivenassessmentandinterventionsprocedures.Althoughconsistentwithourtheoreticalmodel,thisnewbodyofresearchhasseverallimitations.ManyoftheproposedfactorshypothesizedtobeinvolvedinROCDareyettobeempiricallyevaluated.Furthermore,manystudieshavebeenconductedwithnon-clinicalsamples.Althoughnon-clinicalindividualsexperienceOCD-relatedbeliefsandsymptoms,theymaydifferfromclinicalpatientsinthetypeandseverityofsymptomsandtheresultingdegreeofimpairment.FutureROCDresearchshouldincludeclinicalsamples.Examiningdifferentclinicalgroupswouldfacil-itatetheidenticationofbothgeneralandspecicfactorsasso-ciatedwithROCDsymptoms.Laboratoryandlongitudinalstudiesshouldfurtherexaminethehypothesizedcausalandcorrelationalrelationshipsproposedinthispaper.ThisconceptualframeworkhasfocusedonarelativelynewareaofOCDrelatedresearch.Ouraimistoenhanceourunder-standingofOCDphenomenabydrawingattentiontowhatwebelieveisanimportantOCDtheme-relationships.Wealsoidenti-edpossiblefactorsthatmayleadtothedevelopmentofROCD.This,wehope,willenableabetterunderstandingoftheetiologyofROCD,itsdevelopment,treatment,andevenprevention.ReferencesAardema,F.,&OConnor,K.(2007).Themenacewithin:obsessionsandtheself.JournalofCognitivePsychotherapy,182197.AardemaF.,Moulding.R.,Radomsky.A.S,Doron.G,Allamby.J..(2013).Fearofselfandobsessionality:developmentandvalidationofthefearofselfquestion-naire.JournalofObsessive-CompulsiveandRelatedDisordersinpress.Abramowitz,J.S.,McKay,D.,&Taylor,S.(2008).Obsessivecompulsivedisorder:Subtypesandspectrumconditions.Amsterdam:ElsevierAdams,J.M.,&Jones,W.H.(1997).Theconceptualizationofmaritalcommitment:Anintegrativeanalysis.JournalofPersonalityandSocialPsychology11771196.Allgood,S.M.,Harris,S.,Skogrand,L.,&Lee,T.R.(2008).Maritalcommitmentandreligiosityinareligiouslyhomogenouspopulation.Marriage&FamilyReview(1),52Amato,P.R.(2000).Theconsequencesofdivorceforadultsandchildren.JournalofMarriageandFamily(4),12691287.Amato,P.R.(2001).Childrenofdivorceinthe1990s:AnupdateoftheAmatoandKeith(1991)meta-analysis.JournalofFamilyPsychology(3),355.Angst,J.,Gamma,A.,Endrass,J.,Goodwin,R.,Ajdacic,V.,Eich,D.,&Rössler,W.(2004).Obsessivecompulsiveseverityspectruminthecommunity:G.Doronetal./JournalofObsessive-CompulsiveandRelatedDisorders3(2014)169180178 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