Obsessingaboutintimate-relationships:Testingthedoublerelationship-vuln - PDF document

Obsessingaboutintimate-relationships:Testingthedoublerelationship-vulnerabilityhypothesisGuyDoron,OhadSzepsenwol,EinatKarp,NetaliGalSchoolofPsychology,InterdisciplinaryCenter(IDC)Herzliya,P.O.Box167,Herzliya,46150,IsraelarticleinfoArticlehistory:Received12February2013Receivedinrevisedform20May2013Accepted24May2013Keywords:CognitivetheoryObsessivecompulsivedisorderRelationshipsRelationship-centeredobsessionsBackgroundandObjectives:Obsessivepreoccupationanddoubtscenteringononesintimaterelationship Correspondingauthor.Tel.:97299602850.E-mailaddresses:gdoron1@gmail.com(G.Doron). ContentslistsavailableatSciVerseScienceDirectJournalofBehaviorTherapyandExperimentalPsychiatryjournalhomepage:www.elsevier.com/locate/jbtep 0005-7916/$seefrontmatter2013ElsevierLtd.Allrightsreserved.http://dx.doi.org/10.1016/j.jbtep.2013.05.003 J.Behav.Ther.&Exp.Psychiat.44(2013)433440 relationshipexperience(e.g.,IknowIloveher,butitdoesntfeel)andarethereforelessself-congruentthancommonrelationshipworries.Third,relationship-centeredintrusionsarefrequentlyperceivedasinterruptioninoneowofthoughtsandactions.Fourth,likeothertypesofobsessions,individualstendtojudgesuchintrusionsasexaggeratedorirrationalreactionstothectriggeringevent.Finally,relationship-centeredobsessionsoftenresultinextremeanxietyandrepetitiveneutralizingbehav-iourssuchascheckingandreassuranceseeking(Doronetal.,2012aClinicalexperiencesuggeststhatrelationship-centeredobses-sive-compulsivesymptomsoftenpertaintothreerelationaldi-mensions:onesfeelingstowardsarelationshippartner(e.g.,DoIreallylovehim?),thepartnersfeelingstowardsoneself(e.g.,Doesshereallyloveme?),andtheoftherelationshipIshetherightone?).TheRelationshipObsessive-CompulsiveInventory(ROCI;Doronetal.,2012a)wasspecicallydesignedtoassesssuchOCphenomena.Itemsweregeneratedtorepresentobsessions(i.e.,preoccupationanddoubts)andneutral-izingbehaviors(i.e.,checkingandreassuranceseeking)relatedtoeachofthethreerelationaldimensions.TheROCIshowedtheex-pectedpositiveassociationswithOCD,moodandrelationshipmeasures.Moreover,theROCIsignicantlypredicteddepressionandrelationshipsatisfactionover-and-abovemorecommonOCDsymptoms,relationshipambivalenceandothermentalhealthandrelationshipinsecuritymeasures(Doronetal.,2012a).TheseingssuggestthattheROCIcapturesarelativelydistincttheoreticalconstructthathasuniquepredictivevalue.2.Doublevulnerabilitytorelationship-centeredobsessionsAccordingtocognitive-behavioraltheoriesofobsessions,mostindividualsexperiencearangeofintrusivedoubts,thoughts,urges,andimages(Rachman&deSilva,1978).Thepersonalsigniattributedtotheoccurrenceorcontentofsuchintrusiveexperi-ences(e.g.,IambadforhavingsuchathoughtIamresponsibleforpreventingthisfromhappening),andtheirmismanagement(e.g.,compulsivechecking)eventuallyleadindividualstodevelopandmaintainobsessions(ObsessiveCompulsiveCognitionsWork-ingGroup[OCCWG],1997Rachman,1997Salkovskis,1985Indeed,severalcognitivebiasesfoundtobeassociatedwithOCD,suchasoverestimationofthreat,perfectionismandintoler-anceforuncertainty(OCCWG,19972005),werefoundtobelinkedwithrelationship-centeredOCsymptoms(Doronetal.,2012aSuchcognitivebiasesmayleadtothemisappraisalsofrelationship-relatedintrusionsandtherelationshipexperience.Forinstance,perfectionisttendenciesmayleadtoextremepreoccupationwithoftherelationship(i.e.,Isthisrelationshiptheright).Intoleranceforuncertainty(OCCWG,2005)mayincreasedoubtsandconcernsregardingonesfeelingstowardsthepartnerDoIreallylovemypartner?).OverestimationofthreatmaybiasindividualsinterpretationsofothersfeelingstowardthemDoesmypartnerreallyloveme?).LikeinotherformsofOCD,catastrophicinterpretationsofrelationshipintrusionsleadtoself-reinforcingneutralizingbehaviorssuchascheckingonefeelingstowardsthepartner,comparing,andreassuranceseeking.Thesebehaviorsmayactuallymaintaintheintrusionsthroughincreasingthesalienceofnegativethoughts.Recently,thetransformationofcommonintrusiveexperiencesintoobsessionswassuggestedtobemoderatedbytheextenttowhichsuchintrusionschallengecoreperceptionsoftheself(e.g.,Aardema&OConnor,2007Bhar&Kyrios,2007Clark&Purdon,1993García-Soriano,Clark,Belloch,delPalacio,&Castañeiras,2012).Preexistingself-vulnerabilitieswereproposedtointhespecicthemeofanindividualsobsession.Forinstance,DoronandKyrios(2005)proposedthatthoughtsoreventsthatchallengehighlyvaluedself-domains(e.g.,moralorrelationalself-domains)maythreatenapersonssenseofself-worthinthisdomain,andactivatecognitionsandbehavioraltendenciesaimedatcounter-actingthedamageandcompensatingfortheperceiveddeDoron,Sar-El,&Mikulincer,2012).Forsomeindividuals,suchasOCDsufferers,theseresponsesparadoxicallyincreasetheaccessibilityofnegativeself-cognitions(e.g.,mimmoralandunworthy)thattogetherwiththeactivationofotherdysfunctionalbeliefsassociatedwithobsessions(e.g.,inatedresponsibility,threatoverestimation;OCCWG,1997)canresultinthedevelop-mentofobsessionsandcompulsions.Mostindividuals,however,areabletoadaptivelyprotecttheirself-esteemfromunwantedintrusionsandrestoreemotionalequanimityfollowingchallengestosensitiveself-domains.Hence,theyareunlikelytobeoodedbynegativeself-evaluations,dysfunctionalbeliefs,andobsessionsfollowingsuchchallenges.Onepsychologicalmechanismproposedtohindersuchadaptiveregulatoryprocessesisattachmentinsecuritythatmayfostertheactivationofnegativeself-cognitionsandacascadeofdysfunc-tionalbeliefs(Doron,Moulding,Kyrios,Nedeljkovic,&Mikulincer,2009).Accordingtoattachmenttheory(Bowlby,19731982Mikulincer&Shaver,2007),interpersonalinteractionswithpro-tectiveothers(gures)earlyinlifeareinternalizedintheformofmentalrepresentationsofselfandothers(internalworkingmodels).Interactionswithattachmentguresthatareavailableandsupportiveintimesofneedfosterthedevelopmentofbothasenseofattachmentsecurityandpositiveinternalworkingmodelsofselfandothers.Whenattachmentguresarerejectingorunavailableintimesofneed,attachmentsecurityisundermined,negativemodelsofselfandothersareformed,andthelikelihoodofself-relateddoubtsandemotionalproblemsincreases(&Shaver,20032007).Parentsareoftenthemainattachmenturesduringchildhood.However,romanticpartnersoftentakeparentsplaceasmainattachmentgureslaterinlife(Mikulincer&Shaver,2007Attachmentorientationscanbeorganizedaroundtwoorthog-onaldimensions,representingthetwoinsecureattachmentpat-ternsofanxietyandavoidance(Brennan,Clark,&Shaver,1998reviewedbyMikulincer&Shaver,2007).Therstdimension,attachmentanxiety,reectsthedegreetowhichanindividualworriesthatasignicantotherwillnotbeavailableoradequatelyresponsiveintimesofneed,andtheextenttowhichtheindividualadoptshyperactivatingattachmentstrategies(i.e.,energetic,insistentattemptstoobtaincare,support,andlovefromrelation-shippartners)asameansofregulatingdistressandcopingwiththreatsandstressors.Theseconddimension,attachmentavoid-ance,reectstheextenttowhichapersondistrustsarelationshipsgoodwillandstrivestomaintainautonomyandemotionaldistancefromhimorher.Anavoidantlyattachedindi-vidualreliesondeactivatingstrategies,suchasdenialofattach-mentneedsandsuppressionofattachment-relatedthoughtsandemotions.Individualswhoscorelowonbothdimensionsaresaidtoholdastablesenseofattachmentsecurity(Mikulincer&Shaver,2003Amongindividualswhohavechronicorcontextuallyheight-enedmentalaccesstoattachmentinsecurities,aversiveexperi-encesandintrusionsofunwantedthoughtsmayresultintheactivationofdysfunctionaldistress-regulatingstrategiesandcognitivebiases,whichfurtherexacerbateanxietyandpromoteineffectiveresponses(Doronetal.,2009).Anxiouslyattachedin-dividualsinparticulartendtoreacttofailurebyexaggeratingthenegativeconsequencesoftheaversiveexperience,ruminatingonit,andexperiencingincreasedmentalactivationofattachment-relevantfearsandworries,suchasfearofbeingabandonedbyG.Doronetal./J.Behav.Ther.&Exp.Psychiat.44(2013)433 sattachmentgure(e.g.,relationshippartner)becauseofoneself(Mikulincer&Shaver,2003).Thus,inadditiontodis-ruptingfunctionalcopingwithexperiencesthatchallengesensitiveself-domains,thecopingstrategiesthatcharacterizeanxiouslyattachedindividualsmayrenderthemparticularlyvulnerabletorelationship-centeredobsessions.Indeed,attachmentanxietywasfoundtobeassociatedwithrelationship-centeredobsessionsDoronetal.,2012aWeproposethatvulnerabilityintherelationalself-domain(highdependenceofself-worthononesrelationships),whenaccompaniedbyattachmentanxiety,wouldbeassociatedwithrelationship-centeredobsessions.Suchdoublerelationship-vulnerabilitymayleadtoincreasedvigilancetorelationshipthreats,ontheonehand,andimpairedcapacityforadaptivecopingwithsuchchallengingexperiences,ontheotherhand.3.ThecurrentresearchThegoalofthecurrentresearchwastoconductasystematicexaminationofthelinkbetweenattachmentanxiety,relationship-contingentself-worth,andrelationship-centeredobsessionsandobsessive-compulsive(OC)tendencies.InStudy1,weassessedthecorrelationallinksbetweenrelationship-contingentself-worth,attachmentanxiety,andrelationship-centeredobsessive-compul-sive(OC)symptoms.InStudy2,weexaminedwhetherthreattotherelationalself-domainwouldincreaserelationship-centeredOCtendenciesamongindividualswithrelationship-contingentself-worthandattachmentanxiety.4.Study1OurhypothesisinStudy1wasthatattachmentanxietywouldpredicthigherrelationship-centeredOCsymptomsamongin-dividualswhoseself-worthisstronglydependentontheirrela-tionship(relationship-contingentself-worth).4.1.Method4.1.1.ParticipantsThesampleconsistedof171Israelisfromthegeneralpopulation(77women)whowererecruitedvia,anIsraelionlinesurveyplatform.Participantsagesrangedfrom19to6437).Allparticipantswereinanintimaterelationshipatthetimeofthestudy.Medianrelationshiplengthwas96months.ParticipantswereinformedoftheirrightsandcompletedanonlineinformedconsentforminaccordancewithuniversityIRBstan-dards.Theycompletedthesurveyinonesession(thewebsiteal-lowsoneentryperparticipant)andwerereimbursed20NIS(around$5)fortheirtime.4.1.2.MaterialsandprocedureThestudywasadministeredonlineusingtheweb-basedsurveywww.midgam.com.Responsesweresavedanonymouslyontheserveranddownloadedforanalysis.AllparticipantscompletedHebrewversionsoftheRelationshipObsessive-CompulsiveInventory(ROCI;Doronetal.,2012a),theExperiencesinCloseRelationshipsscale(ECR;Brennanetal.,1998),andfouritemsassessingrelationship-contingentself-worth.Inaddition,theycompletedtheshortformoftheObsessiveBeliefsQuestion-naire(OBQ-20;Mouldingetal.,2011),theshortformoftheDepressionAnxietyStressScales(DASS-21;Antony,Bieling,Cox,Enns,&Swinson,1998),theSingle-ItemSelf-EsteemScale(SISE;Robins,Hendin,&Trzesniewski,2001),andthePennsylvaniaStateWorryQuestionnaire(PSWQ;Meyer,Miller,Metzger,&Borkovec,1990).Thesemeasureswereusedascontrolsinouranalysis.Theorderofthequestionnaireswasrandomizedacrossparticipants.TheRelationshipObsessive-CompulsiveInventory(ROCI;etal.,2012a)isaself-reportmeasureofobsessionsandcompul-sionscenteredononesromanticrelationship.Thescaleincludes12itemsloadingonthreerelationaldimensions:feelingstowardsspartner(e.g.,IcontinuouslyreassesswhetherIreallylovemy),perceptionofonespartnersfeelings(e.g.,Icontinu-ouslydoubtmypartnersloveforme),andappraisaloftheoftherelationship(e.g.,Icheckandrecheckwhethermyrelationshipfeelsright).Participantsratedtheextenttowhichsuchthoughtsandbehaviorsdescribedtheirexperiencesininti-materelationshipsonascalerangingfrom0(notatall)to4(verymuch).ThethreesubscalesaswellasthetotalROCIscorehavebeenshowntorelatestronglytomeasuresofOCDsymptoms,measuresofanxiety,depressionandstress,andmeasuresofrelationshipquality(Doronetal.,2012a).Inthecurrentstudy,weusedthetotalROCIscore(Cronbach0.93)asthepredictedvariableintheregressionanalyses.TheExperiencesinCloseRelationshipsscaleBrennanetal.,1998)assessesattachmentanxietyandavoidance.Itin-cludes36items,18assessingattachmentanxiety(e.g.,mydesiretobeveryclosesometimesscarespeopleaway)and18assessingattachmentavoidance(e.g.,Iwanttogetclosetomypartner,butIkeeppullingaway).Participantsratedtheextenttowhicheachitemwasself-descriptiveoftheirthoughts,feelings,andbehaviorsinromanticrelationshipsonascalerangingfrom1(disagreestrongly)to7(agreestrongly).Cronbachsalphasinoursamplewere0.81foravoidanceand0.90foranxiety.Relationship-contingentself-worthwasassessedthroughfouritemswrittenspecicallyforthecurrentstudy(KnowingthatIhavearomanticpartnerwhocaresaboutmeisimportanttomyself-worthKnowingthatmyromanticpartnerlovesmemakesmefeelgoodaboutmyselfWhenmyromanticpartnerisproudofme,mysenseofself-worthincreases,andMyself-worthisnotinuencedbythequalityofmyrelationshipwithmyromanticpartnerreversedscale).TheseitemswerebasedontheContingenciesofSelf-WorthScale(Crocker,Luhtanen,Cooper,&Bouvrette,2003)andecttheextenttowhichrespondentsconsidertheintimate-relationshipdomainrelevanttotheirself-worth.Itemswereratedonascalerangingfrom1(stronglydisagree)to7(stronglyagreePrincipalcomponentsanalysisonthefouritemsyieldedasinglefactorexplaining59.5%ofthevariance(Cronbach0.70).TheshortformoftheObsessiveBeliefsQuestionnaire(etal.,2011)isanabbreviatedversionofthe44-itemObsessiveBeliefsQuestionnaire-Revised(OCCWG,2005).The20-itemOBQcoversfourbeliefdomainsrepresentedby5itemseach:(1)Inatedresponsibility(IfIdontactwhenIforeseedanger,thenIamtoblameforconsequences);(2)ThreatOverestimation(EvenwhenIamcareful,Ioftenthinkbadthingswillhappen);(3)Perfec-tionism/uncertainty(Forme,thingsarenotrightiftheyarenot);and(4)Importance/Controlofthoughts(HavingbadthoughtsmeansIamweirdorabnormal).Participantsratedallitemsonascalerangingfrom1(disagreeverymuch)to7(agreeverymuch).InthisstudyweusedthetotalOBQscore(averageofallitems,Cronbach0.91).TheshortversionoftheDepressionAnxietyStressScales(DASS,Antonyetal.,1998)isaself-reportquestionnairelistingnegativeemotionalsymptoms.Thescaleisdividedintothreesubscales:depression,anxiety,andstress.Participantsratedhowoftenaparticularsymptomwasexperiencedinthepastweek.Ratingsweremadeonascalerangingfrom1(didnotapplytomeatall)to4appliedtomemostofthetime).Asthethreescaleswerehighlycorrelatedinoursample,weusedonlythedepressionscale(CronbachG.Doronetal./J.Behav.Ther.&Exp.Psychiat.44(2013)433 TheSingle-ItemSelf-EsteemScale(SISE;Robinsetal.,2001requiredparticipantstoratetheextenttowhichthesentencehaveahighself-esteem"wasdescriptiveofthemona9-pointscale.TheSISEhasbeenfoundtohavehightestretestreliabilityandstrongcriterionvalidity(Robinsetal.,2001ThePennStateWorryQuestionnaire(PSWQ;Meyeretal.,1990isa16-itemself-reportscale(e.g.,MyworriesoverwhelmmeManysituationsmakemeworry)thatassessespathologicalworry.Participantsratedthedegreetowhicheachitemistypicalofthemonascalerangingfrom1(notatalltypicalofme)to5(verytypicalofme).Inthecurrentsample,Cronbachwas0.92fortheentirescale.5.ResultsanddiscussionPreliminaryanalysisshowedthatattachmentanxietywaspositivelycorrelatedwithrelationship-contingentself-worth,0.24,0.001.However,themodestsizeofthiscorrelationsuggeststhatattachmentanxietydoesnotnecessarilyinvolvehighrelationship-contingentself-worth.Itispossiblethatwhileanxiouslyattachedindividualsarevulnerabletorelationshipdifculties,theyndithardertousetherelationshipasapositiveself-worthresource.PreliminaryanalysisalsoshowedthatROCItotalscoreswerenotcorrelatedwithageorgender(Importantly,onlyasmallcorrelationwasfoundbetweentheROCIandthePSWQ,furthersupportingthedifferentiationbetweenrelationship-centeredOCphenomenaandgeneralworries(seeTable1Inordertoexamineourhypothesisthatattachmentanxietywouldpredictmorerelationship-centeredOCsymptomsamongindividualswhoseself-worthisstronglycontingentontheirrela-tionship,weconductedahierarchicalregressionanalysiswiththetotalROCIscoreasthepredictedvariable.Thepredictorswereattachmentanxiety,relationship-contingentself-worth,andtheirinteraction.Inaddition,wecontrolledforattachmentavoidance,depression,obsessivebeliefs,generalself-esteem,andpathologicalworries.Thismodelexplained35%ofthevarianceinthetotalROCIscore,(8,162)11.00,0.001.Attachmentanxietyhadasignicantmaineffectonrelationship-centeredOCsymptoms.However,thismaineffectwasqualiedbyasignicantinteractionbetweenattachmentanxietyandrelationship-contingentself-worth(seeTable1).Simpleslopesanalysisindicatedthat,asexpected,thepositiveassociationbetweenattachmentanxietyandrelationship-centeredOCsymp-tomsbecamestrongerasrelationship-contingentself-worthbecamehigher(seeFig.1).Amongindividualswithhighlyrelationship-contingentselfworth(1SD),theassociationbe-tweenattachmentanxietyandtheROCIscorewasstrongand0.001.Incontrast,amongindividualswhoseself-worthwaslesscontingentontheirrelationship(1SD),theassociationbetweenattachmentanxietyandtheROCIscorewasweakerandfailedtoreachsigni0.18.Inaddition,theassociationbetweenrelationship-contingentself-worthandtheROCIscoretendedtobepositiveamongindividualshighinattachmentanxiety(1SD;0.12),andnegativeamongin-dividualslowinattachmentanxiety(1SD;0.10).ndingssupportourhypothesisthatattachmentanxietyisasignicantpredictorofrelationship-centeredOCsymptoms,especiallywhenaccompaniedbystrongdependenceofself-worthontherelationaldomain.Thisremainedtrueaftercontrollingforobsessive-compulsivebeliefs,generalworry,depression,andself-esteem,suggestingauniquecontributionofsuchdoublerelation-shipvulnerabilitytorelationship-centeredobsessionalconcerns.Interestingly,relationship-contingentself-worthalonewasnotrelatedtorelationship-centeredOCsymptoms.Itseemsthatamongindividualswhofeelsecureintheirrelationship,asindividualslowinattachmentanxietyusuallydo,relianceonintimaterelationshipsasasourceofself-esteemdoesnotpromotevulnerabilitytoobsessivedoubtsandworriesconcerningrelationships.Incontrast,amongindividualswhoascribehighimportancetorelationshipswhilefeelinganxiousabouttheirownrelationships,relationship-centeredOCsymptomsseemmorelikelytoemerge.Study1ndingsimplicatebothselfandattachmentvulnera-bilitiesinthemaintenanceofrelationship-centeredobsessions.Onthisbasis,onecanhypothesizethateventschallengingtherela-tionalself-domainwouldincreaserelationship-centeredobses-sionsandcompulsionsonlyamongindividualswithsuchdoublevulnerability.Instudy2wetestedthecausalroleofthreatstotherelationalself-domainamongindividualswithselfandattachmentvulnerabilities.6.Study2InStudy2,participantswereassignedtoeitheramildlypositivefeedbackcondition(i.e.,controlcondition)oramildly-negativefeedbackconditionfollowingabogustaskthatwasallegedtoassesscompetenceinthemaintenanceofintimaterelationships.Then,relationship-centeredOCtendencieswereassessed.Previousresearchhasshowedthatevensubtlesuggestionsofincompetenceinsensitiveself-domainsmayleadtoheightenedobsessive-compulsivebehavioraltendencies(Doronetal.,2012).Wethere-forehypothesizedthatmildsuggestionsofincompetenceintherelationshipdomainwouldleadtohigherrelationship-centeredOCtendencies,particularlyamongindividualsshowinghighattach-mentanxietyandrelationship-contingentself-worth. Table1RegressionandcorrelationcoefcientsStudy1.rbtDepression0.38***0.142.15*PSWQ0.21**OBQ0.40***0.172.65**Avoidance0.18*0.030.47Anxiety0.53***0.294.07***RCSW0.090.010.17RCSW0.112.01*Note.tvaluesareprovidedfortheregressioncoefcients(s).Dependentvariable:RelationshipObsessive-CompulsiveInventorytotalscore;AnxietyECRanxietysubscale;AvoidanceECRavoidancesubscale;RCSWself-worth;DepressionDASSdepressionscale;SISESingle-ItemSelf-EsteemScale;PSWQPennStateWorryQuestionnaire;OBQObsessiveBeliefsQues-0.05,**0.01,*** RCSW HighRCSW Low Anxiety High Anxiety Low Fig.1.EstimatedvaluesofROCItotalscores(ontheaxis)asafunctionofrelationship-contingentselfworth(RCSW)andattachmentanxiety(high1SD;1SD).Errorbarsrepresentstandarderrors.***0.001.G.Doronetal./J.Behav.Ther.&Exp.Psychiat.44(2013)433 6.1.Method6.1.1.ParticipantsThesampleconsistedof80Israeliundergraduates(46women)ranginginagefrom20to29(24)whoparticipatedinthestudyforacademiccredit.Allparticipantswereinanintimaterelationshipatthetimeofthestudy.Medianrelationshiplengthwas18months.ParticipantswereinformedoftheirrightsandcompletedaninformedconsentforminaccordancewithuniversityIRBstandards.6.1.2.MaterialsandprocedureParticipantswereinvitedtothelabandtoldthattheywouldparticipateinastudyexaminingthelinkbetweenpersonalityandperformance.Theyrstcompletedabatteryofquestionnaires,includingtheExperiencesinCloseRelationshipsscaletappingattachmentanxietyandavoidance,thefouritemsassessingrelationship-contingentself-worththatweredescribedinStudy1,andtheDepressionscalefromtheshortformoftheDepression,AnxietyandStressScales.Cronbachsalphasinthecurrentsamplewerehigh(0.96,0.95,0.91,and0.77forattachmentanxiety,attachmentavoidance,relationship-contingentself-worth,anddepression,respectively).Uponcompletingthequestionnaires,participantsperformedabogusSingleCategoryImplicitAssociationTask(SC-IAT;&Steinman,2006).ThistaskisamodiedversionoftheIATGreenwald,McGhee,&Schwartz,1998)andassessesthestrengthofevaluativeassociationswithasingleattitudeobject(romanticrelationships,inourcase).Thetaskincludedtwoblocksof36trialseach,presentedinrandomorder.Withineachblock,participantswereaskedtocorrectlycategorize(i.e.,pressthecorrectresponsekey)positive,negative,orrelationshipwordspresentedinrandomorder.Atthebeginningofthetask,participantswererandomlydividedintotwoconditions.Intheexperimentalcondition(39),partic-ipantsreceivedamildly-negativeautomatedfeedbackuponcompletingthetask.Themessageinformedtheparticipantsthat,basedonastatisticalmodel,theirperformanceonthetasksuggestedthattheircapacityformaintainingalong-termrelationshipissomewhatbelowaverage.Inthemildpositivecondition(41),participantsreceivedamildly-positiveautomatedfeedbackuponcompletingthetask.Themessageinformedtheparticipantthat,basedonastatisticalmodel,theirperformanceonthetasksuggestedthattheircapacityformaintainingalong-termrelationshipissomewhataboveaverage.Thismanipulationwaspilotedon15undergraduateparticipants.Duringdebriengallreportedbelievingthatthetaskevaluatedrelationship-relatedvariablesandconrmedthatthemanipulationchallengedtheirrelationalself-views.Followingthecomputerizedtask,participantswereaskedtoimaginethemselvesin12hypotheticalscenariosdepictingactualrelationship-centeredOCconcerns(e.g.,Afteraphoneconversa-tionwithyourpartner,youbegintodoubtyourrelationshipYouareabouttomeetwithyourpartnerforlunch,suddenlythethoughtthatyoudontreallyloveyourpartnerpopsupYouareathomewithyourpartnerandfeeltheneedtocheckwhetheryourpartnerreallylovesyou;seeMenzies,Harris,Cumming,&Einstein,2000Moulding,Doron,Kyrios,&Nedeljkovic,2008Doronetal.,2012forsimilarmethodologies)andansweredthreequestionsabouteachscenario,assessingdistress(towhatextentdoyoufeeldiscomfortinthissituation?),urgetoact(Towhatextentdoyoufeelanurgetodosomethingaboutyourconcernsinthis)andthelikelihoodofacting(Howlikelyareyoutotakeactiontopreventthenegativeconsequencesofthissituationfrom).Participantswerethendebriefedregardingthegoalofthestudyandtherandomnatureofthefeedback.Ratingsofthehypotheticalscenariosweremadeonascalerangingfrom1(notatall)to9(verymuch).Inthecurrentsample,discomfort,urge-to-act,andlikelihood-of-actingitemswerehighlycorrelated(srangingfrom0.62to0.82).Moreover,discomfort,urge-to-act,andlikelihood-of-actingscoresloadedontoasinglefactorinaprincipalcomponentsanalysis(82.35%explainedvari-ance).Hence,weaveragedallitemstocreateatotalscore(Cron-0.97)thatwenamedrelationshipOCtendencies7.ResultsanddiscussionPreliminaryanalysisshowedthatthecorrelationbetweenattachmentanxietyandrelationship-contingentself-worthinStudy2,0.51,0.001,waslargerthanthesamecorrelationinStudy1.Yet,thiscorrelationwasstilllowenoughtosuggestthatattachmentanxietyandrelationship-contingentself-worthconstituteseparateriskfactorsforrelationship-centeredobses-sions.PreliminaryanalysisalsoshowedthatRelationshipOCten-dencieswerenotcorrelatedwithageorgender(0.12,InordertoexamineourhypothesisthatthreateningonessenseofrelationalcompetencewouldinducemorerelationshipOCten-denciesamongindividualshighinattachmentanxietyandrelationship-contingentself-worth,weconductedahierarchicalregressionanalysis.ThepredictedvariablewasthetotalscoreofrelationshipOCtendencies,andthepredictorswerefeedbacktype(adummyvariablecontrastingmildlynegative,1,tomildlypositive,1),attachmentanxiety,relationship-contingentself-worth,andtheirtwo-wayandthree-wayinteractions.Inaddition,wecontrolledforattachmentavoidance,depression,andrelationshiplength.Thismodelexplained53.34%ofthevariance,(10,69)7.89,0.001.Theregressionrevealedasignicantfeedbackrelationship-contingentself-worthinteraction,butthiseffectwasqualiedbyacantthree-wayinteractionforfeedback,attachmentanxiety,andrelationship-contingentself-worth(seeTable2).Simpleslopesanalysisindicatedthat,asexpected,mildnegativefeedbackaboutrelationalcompetenceincreasedrelationshipOCtendencies,butonlyamongindividualshighinbothattachmentanxietyandrelationship-contingentself-worth(1SD;1.38,0.001).Otherslopeswerenotsignicant(seeFig.2Study2representsareplicationandextensionofStudy1ndings.InStudy1wefoundthathighattachmentanxietytogetherwithoverrelianceonrelationshipsasaself-worth Table2RegressionandcorrelationcoefcientsStudy2.rbtR.LengthDepression0.080.120.040.17Condition0.190.010.05RCSW0.070.170.94RCSW0.362.04*Anxiety0.311.47RCSW0.010.05RCSW0.713.95***Note.tvaluesareprovidedforregressioncoefcients(s).Dependentvariable:RelationshipOCtendenciestotalscore;AnxietyECRanxietysubscale;ECRavoidancesubscale;RCSWRelationship-contingentself-worth;DASSdepressionscale;R.LengthRelationshiplengthinmonths.0.05,**0.01,*** Consistentwithself-enhancementbias(Taylor&Brown,1988),mildly-positivefeedbackwasusedasthecontrolgroup.G.Doronetal./J.Behav.Ther.&Exp.Psychiat.44(2013)433437 resourcepredisposesindividualstorelationship-centeredOCsymptoms.Study2revealedthatsuchdoublerelationship-vulnerabilitypredisposesindividualstostrongerreactivitytothreatstotherelationshipself-domain,asmanifestedinrelation-shipOCtendencies.8.GeneraldiscussionOneofthemainresourcesforindividualsresilienceandwell-beingissatisfactoryintimate-relationships.Obsessingaboutonefeelingstowardsonespartner,thepartnerfeelingstowardsone-self,andtheoftherelationshipmayseriouslyhinderrelationshipsatisfactionandrelationship-maintenancecapacitiesDoronetal.,2012a).Consistentwiththedoublerelationship-vulnerabilityhypothesis,ourndingsshowedthatwhenself-vulnerabilityintherelationaldomaincoincideswithattachmentanxiety,individualsbecomemoresusceptibletorelationship-relatedobsessivedoubtsandworries.InStudy1attachmentanx-ietywaslinkedwithhigherrelationship-centeredOCsymptomsamongindividualswhoseself-worthwasstronglydependentontheirrelationship.Study2showedthatasubtlehintofincompe-tenceintherelationalself-domaincanincreaserelationship-centeredOCtendenciesamongindividualshighinbothattach-mentanxietyandrelationship-contingentself-worth.ndingsareconsistentwithresearchandtheorylinkingattachmentinsecuritiesandself-vulnerabilitiestoOCsymptoms,cognitions,andbehavioraltendencies(e.g.,Aardema&OConnor,2007Aardema,Moulding,Radomsky,Doron&Allamby,inpressDoronetal.,2012García-Sorianoetal.,2012Myhr,Sookman&Pinard,2004Rowa,Purdon,Summerfeldt,&Antony,2005).Inparticular,thesendingsareconsistentwithpreviousaccountsofOCDdevelopmentandmaintenanceproposingthatthoughtsoreventsthatthreatenperceptionsofcompetenceinOCDrelevantself-domains(e.g.,morality)maythreatenself-worth,activateat-temptsatcompensatingfortheperceiveddecits,andleadtothedevelopmentofneutralizingbehaviors(Doron&Kyrios,2005Doronetal.,2012).Indeed,priorndingssuggestthatwhenself-worthiscontingentonaparticulardomain,successorfailureinthisdomain,evenifonlyhintedof,mayresultinemotionalupsanddownsandextremeinstabilitiesinself-esteemthatevaluationsoftheselfasgoodCrocker&Wolfe,2001Kneeetal.,2008).Ourndings,however,whileconcentratingonaparticularcategoryofobsessions,takeanextrastepinprovidingcorrelationalandexperimentalevidenceidentifyingwhichin-dividualsmaybemorevulnerabletothedevelopmentofsuchobsessions.Byemphasizingthecombinedroleofinherentself-sensitivityanddysfunctionalcoping,ourdoublerelationship-vulnerabilitymodelcanpotentiallybetranslatedtoaccountforotherobsessionalthemes.Ourresultspointtotheinvolvementofseveralfactors,somectorelationship-centeredOCsymptoms(i.e.,relationship-contingentself-worth)andsomecommonwithotherOCdi-mensions(i.e.,attachmentanxiety)inthedevelopmentofriskforthisparticularthemeofobsessive-compulsive(OC)symptoms.Additionalrelationship-relatedcognitivebiasesthatmayplayanimportantroleindevelopmentandmaintenanceofrelationship-centeredOCsymptomsarethetendencytocatastrophizeconsequencesofleavinganexistingrelationship(e.g.,frommypartnerwouldleadtoirreversibledamage)orofremaininginalessthanperfectrelationship(e.g.,ifIstayinarelationshipthatIamnotsureabout,IwillbemiserableforeverIndeed,relationshipself-sensitivityandrelationship-relatedcognitivebiasesmayunderlierelationship-relatedOCsymptoms,butnototherOCdimensions.Inthiscontext,however,itshouldbenotedthatwehavefoundmoderatecorrelationsbetweenrelationship-contingentself-worthandattachmentanxiety,whichindicatesthatwhiledistinct,thesetworiskfactorsarenotentirelyindependent.Attentionshouldbepaidtothedependencebetweenriskfactorswhenexaminingthedoublerelationship-vulnerabilitymodelinfuturestudiesorwhenconsideringadditionalfactorsorbiasesthatmightpromoterelationship-relatedOCphenomena.Althoughourndingswereoverallconsistentwiththepro-posedmodel,somelimitationsofthecurrentstudiesshouldbeaddressed.Onelimitationistheuseofnonclinicalcohorts.NonclinicalparticipantsexperienceOC-relatedbeliefsandsymp-toms(Haslam,Williams,Kyrios,McKay,&Taylor,2005).However,theymaydifferfromclinicalpatientsinthetypeandseverityofOCDsymptoms,aswellasinsymptom-relatedimpairment.Futureresearchwouldbenetfromexaminingtheproposedlinksinpar-ticipantspresentingwithOCDsymptomscenteredonrelationshipthemes.Futurestudiesonclinicalsampleswouldalsobenetfromassessingthelinksbetweengeneralworries,socialanxietysymp-toms,andrelationship-centeredOCphenomena.Thedistinctionbetweenrelationship-centeredOCsymptomsandworriesmaybeofspecialinterestinfutureresearch,asthesetwoconstructscaneasilybeconated,especiallywhenassessedinnonclinicalsamples.ThecurrentstudywasnotdesignedtoassessthediscriminantvalidityoftheROCDconstruct.Yet,whenconsideringthemoderatecorrelation(0.45)thatwasfoundinthepastinanonclinicalsamplebetweenrelationship-centeredOCsymptomsandOCDsymptoms(Doronetal.,2012a),themoremodestcorrelationbetweenrelationship-centeredOCsymptomsandgeneralworrythatwasfoundinstudy1lendsomesupporttoourviewthatrelationship-centeredOCsymptomssharemorefeatureswithOCDthanwithgeneralworry.Indeed,clinicalexpe-riencesuggeststhatrelationship-centeredOCsymptoms,likeotherOCDsymptoms,aremoreunacceptable,unwanted,egodystonicandintrusivethangeneralworries.Moretargetedresearchisneeded,however,toteaseapartthesetwoconstructs.Suchresearchmayfocusonthedistinctivefeaturesofrelationship-centeredOCsymptoms(e.g.,unacceptability,egodystonicity)inrelationtoregularrelationshipworries.InthecurrentstudieswedidnotcontrolformorecommonOCDsymptoms(e.g.,fearofcontamination).TherelationshipbetweencommonOCDsymptomsandrelationship-centeredOCsymptomswaspreviouslyfoundtobemoderate.Moreover,relationship-centeredOCsymptomswerefoundtopredictdepressionandrelationshipsatisfactionoverandabovecommonOCDsymptomDoronetal.,2012a).Futurestudies,however,mayconsiderrepli-catingourndingswhilecontrollingforOCDsymptoms. 123456789Anxiety HighRCSW HighAnxiety HighRCSW LowAnxiety LowRCSW HighAnxiety LowRCSW Low Mild negative Fig.2.EstimatedvaluesofROCIscenarioscoresasafunctionoffeedbacktype(mildnegativevs.mildpositive),relationship-contingentselfworth(RCSW)andattachmentanxiety(high1SD;Low1SD).Errorbarsrepresentstandarderrors.0.001.G.Doronetal./J.Behav.Ther.&Exp.Psychiat.44(2013)433 Itisalsonoteworthythatoursamplesincludedonlyparticipantsthatwereinintimate-relationshipsatthetime.Wechosepartici-pantsinongoingrelationshipstominimizebiasesassociatedwithretrospectivereportsandallowforaclearreferencepointduringthetask.Futurestudies,however,maybenetfromexaminingtheprevalenceofdoublerelationship-vulnerabilityamongindividualsavoidingromanticrelationships,possiblyduetonegativepastrelationshipexperiences.Finally,theROCIassessesobsessive-compulsivesymptomsrelatedtoonesromanticrelationship.However,suchobsessivedoubtsandworriesarelikelytooccurinothertypesofclosere-lationshipssuchaschild-parentrelationships.Indeed,attachmentrepresentationsaretypicallyfoundedoninteractionswithprimarycaregiversduringchildhood(Mikulincer&Shaver,2007).Re-searchersmayconsideradaptingtheROCItoassessobsessive-compulsivesymptomsrevolvingaroundonesrelationshipwiththeirparentorchild.Researchhasonlybeguntoexplorerelationship-centeredOCsymptoms.Oneimportantdirectionforfutureinvestigationsmaybewhetherrelationship-centeredsymptomsarebetterconceptu-alizedasanadditionaldimensionofOCDoranewsubtype.Indeed,recenttaxometricanalysesshowthatOCsymptomsarebestconceptualizedintermsofdimensionsratherthancategories(e.g.,Haslametal.,2005).Thisdimensionalaccountissomewhatsup-portedbythecorrelationbetweenrelationship-centeredsymp-tomsandotherOCDsymptomsthatwasfoundinpreviousstudiesDoronetal.,2012aDespitethepotentiallimitationsandpendingreplicationoftheresultswithaclinicalcohort,ourndingshaveimportanttheo-reticalandclinicalimplications.Toourknowledge,thesearetherststudiesexploringtheinteractionbetweenself-vulnerabilitiesandattachmentinsecuritiesinthepredictionofrelationship-centeredOCsymptoms.Thesearealsotherststudiesassessingtheroleofdouble-relationshipvulnerabilityusinganexperimentaldesign.Suchinvestigationsoftheroleofself-vulnerabilitiesandattachmentinsecuritiesmayenhanceawarenessof,andclinicalattentionto,suchvulnerabilitieswhendealingwithrelationship-relatedobsessions.EvidencebasedOCDtreatmentconsistsofcognitiveandbehavioralcomponents.Similarly,OCDwithrelationalthemes(ROCD)wouldbenetfromsuchinterventionsadaptedtotherelationshipcontext.Examplesmayincludeincreasingrelationshiprelatedtoleranceofuncertainty(e.g.,acceptingonecannotknowhowtherelationshipwillbelikeinmanyyearstocome)andimportanceandcontrolofthoughtsbeliefs(e.g.,negativethoughtsaboutthepartnernecessarilyimplytherelationshiphastobereconsidered).Behavioralexperimentsmayincludeexposureandresponsepreventionforcheckingofthepartnerbehaviors,moni-toringofonesownemotions,orreassuranceseeking.ndingssuggestthatwhentreatingrelationship-centeredsymptomsparticularemphasisshouldbegiventorestructuringofattachmentinsecurities(e.g.,fearofabandonment,distrust),self-contingenciesandmaladaptiverelationshipdynamics(seeDoron&Moulding,2009fordescriptionofAttachment-basedCBT).Helpfulstrategiesmayincludechallengingthelinkbe-tweenOCDrelatedbeliefsandabandonmentfears(e.g.,over-vigilantwilldecreasethelikelihoodofbeingabandoned),usingbehavioralexperimentstoincreasetoleranceforabandonmentrelatedfears(e.g.,e.g.,writing/thinkingdoesmypartnerreallylovemewithoutaskingthepartnerforreassurance)andaddressingbeliefsassociatingabandonmentwithlowpercep-tionsofself-worth(e.g.,Iamnotworthanythingandwillthereforebeabandoned).Relationshipcontingencyofself-worthshouldbeexplicitlyexplored,suchthattheclientunderstandsthelinksbetweendistressandperceptionsoffailureinthisself-domain.Effortshouldbegiventoidentifyandexpandtherulesofcompetencyandboundariesofthisself-domain.Indeed,treat-mentsfocusingonovervaluationofparticularaspectsoftheself(e.g.,shapeandweight)havebeenusefulinthetreatmentofotherOCrelateddisorderseatingdisorders(Wilson,Grilo,&Vitousek,2007Inconclusion,thisresearchistherstsystematicattempttoassessthedoublerelationship-vulnerabilityhypothesisasasig-cantvulnerabilityfactorinthedevelopmentofrelationship-relatedOCphenomena.AuthorsG.D.developedthestudyconceptanddesign.DatacollectionwasperformedbyE.K.andN.G.,whiledataanalysisandinterpre-tationwasperformedbyG.D.andO.S.Thepaperwasdraftedbyallauthors.AllauthorsapprovedthenalversionofthepaperforDeclarationofconictinginterestsTheauthorsdeclaredthattheyhadnoconictsofinterestwithrespecttotheirauthorshiporthepublicationofthisarticle.ReferencesAardema,F.,Moulding,R.,Radomsky,A.S,Doron,G.,&Allamby,J.Fearofselfandobsessionality:developmentandvalidationofthefearofselfquestionnaire.JournalofObsessive-CompulsiveandRelatedDisordersinpressAardema,F.,&OConnor,K.(2007).Themenacewithin:obsessionsandtheself.JournalofCognitivePsychotherapy,21,182197Abramowitz,J.S.,McKay,D.,&Taylor,S.(2008).Obsessive-compulsivedisorder:Subtypesandspectrumconditions.Amsterdam:ElsevierAntony,M.M.,Bieling,P.J.,Cox,B.J.,Enns,M.W.,&Swinson,R.P.(1998).Psy-chometricpropertiesofthe42-itemand21-itemversionsoftheDepressionAnxietyStressScalesinclinicalgroupsandacommunitysample.PsychologicalAssessment,10,176181Baumeister,R.F.,&Leary,M.R.(1995).Theneedtobelong:desireforinterpersonalattachmentsasafundamentalhumanmotivation.Psych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