روابط بین خشم، علائم و عوامل شناختی در چکرز OCD

The purpose of this study was to examine whether individuals diagnosed with obsessive–compulsive disorder (OCD) with primary checking compulsions report higher levels of trait anger and anger expression compared with a student control group, and whether trait anger and anger expression are correlated with specific beliefs and interpretations that are common among individuals who compulsively check. A group of individuals with OCD reporting significant checking compulsions (n=33) and a group of undergraduate students (n=143) completed a questionnaire package that included measures of trait anger and anger expression, as well as measures of obsessive–compulsive symptoms and beliefs. The compulsive checking group reported greater trait anger, though not greater anger expression, than the student control group. Furthermore, beliefs concerning perfectionism and intolerance of uncertainty were positively correlated with anger expression and trait anger among compulsive checkers but not among the student control group. The implications of these findings are discussed in terms of cognitive–behavioural treatments for and models of compulsive checking in OCD.

Although obsessive–compulsive disorder (OCD) is currently classified as an anxiety disorder (APA, 2000), there has been much recent interest in research on the experience of other emotions associated with OCD such as disgust (Berle & Phillips, 2006; Mancini, Gragnani, & D’Olimpio, 2001; Rachman, 2004) and shame/guilt (Mancini & Gangemi, 2004; Rachman, 1993; Shafran, Watkins, & Charman, 1996). We sought to build upon recent work on anger in OCD (Whiteside & Abramowitz (2004) and Whiteside & Abramowitz (2005)) as it applies to those who engage in compulsive checking behaviour. We chose this particular symptom of OCD as a focus for this work on anger for a number of different reasons. A 36-year-old married female with OCD, characterized primarily by checking compulsions and aggressive obsessions, said during a therapy session, I hope you don’t take this the wrong way, but I’m worried that I might be full of rage. I get so angry sometimes because I have to keep repeating and checking things; but then I worry that maybe the anger makes me dangerous so I try to shut it down. I’d never do anything harmful to anyone, but sometimes my anger and frustration make me wonder about how safe a person I might be. These emotions sometimes make me think that I’m really a dangerous person and I know that if I could stop checking so much, I wouldn’t be so angry and maybe I wouldn’t worry so much about this anger getting out of control. This quote suggests that this patient's feelings of anger and rage are intimately linked to her compulsive checking, and it is typical of the anger and frustration sometimes expressed by individuals with checking compulsions in therapy. Consistent with clinical observations, several studies have noted that individuals with both clinical and subclinical levels of OCD report elevated levels of anger compared with individuals without an anxiety disorder (Rubenstein, Altemus, Pigott, Hess, & Murphy, 1995; Spinella, 2005; Whiteside & Abramowitz, 2005). Relative to other manifestations of OCD, compulsive checking—characterized by doubts and repetitive attempts to verify whether an action has been completed properly—may be associated with greater anger (Rachman & Hodgson, 1980). Rachman and Hodgson suggested that checkers may report higher levels of anger due to the frustration that their doubts are rarely resolved by checking. In other words, because the act of checking rarely results in clear confirmation that harm has been prevented, an individual may experience increased frustration at having to check over time. There are a number of characteristics and beliefs prevalent in OCD, such as intolerance of uncertainty and perfectionism, which may influence doubt and the ability of those who compulsively check to verify whether something has been done properly (OCCWG, 1997). These may well be related to increased anger, as these beliefs are frequently elevated in individuals with OCD (Obsessive Compulsive Cognitions Working Group (1997) and Obsessive Compulsive Cognitions Working Group (2005)). Not only might individuals with compulsive checking in particular experience more anger than individuals without OCD, it may also be the case that they express anger differently from other individuals with OCD (Rachman, 1993; Whiteside & Abramowitz, 2004). Rachman (1993) suggested that the difficulty individuals with OCD have in expressing their anger may stem from the fact that they feel excessively responsible for the prevention of harm. This inflated sense of responsibility has been associated with a number of different forms of OCD (Salkovskis, 1985), but is often most strongly related to compulsive checking (e.g., Lopatka & Rachman, 1995). Rachman (1993) suggested that such excessive responsibility may lead individuals with OCD to express anger internally rather than externally. Recent research also suggests that individuals with OCD not only feel more responsible to prevent harm, but may also believe that other people are less responsible than they are for preventing harm (Ashbaugh, Gelfand, & Radomsky, 2006). Believing that other people are irresponsible and that one must take full responsibility to prevent harm may further contribute to feelings of anger. This is also consistent with clinical observations. For example, a 21-year-old female with primarily checking compulsions stated in therapy, “I get very angry at people when they try to make me hurry; all of my checking takes time and people [who do not check] don’t seem to understand it.” Two recent studies have examined whether individuals with OCD express anger differently compared with individuals without OCD. Whiteside and Abramowitz (2004) found that individuals with subclinical symptoms of OCD report greater anger expression, as assessed by the Spielberger State Trait Anger Expression Inventory (STAXI; Spielberger, 1988), compared with individuals without symptoms of OCD. However, this greater anger expression was not due to their greater outward expression of anger, such as verbal or physical aggression; rather, it was due to greater control of anger and inner expression (or suppression) of anger. Additionally, Whiteside and Abramowitz found that the OCD symptoms of washing, checking, and doubting were those most strongly related to anger expression and control. However, after controlling for symptoms of depression, many of these relationships between anger expression and OCD disappeared, though the correlations between anger expression and anger control and checking did remain significant. This last finding complicated matters, as it was therefore unclear whether anger control and the inner expression (suppression) of anger were related to OCD or to depressive symptomatology. In a follow-up study, using a sample of individuals diagnosed with OCD, Whiteside and Abramowitz (2005) did not find that the STAXI measures of anger expression were elevated relative to a community control group or relative to the normative data reported by Spielberger (1988), though measures of trait anger were significantly higher in the clinical group. Correlations between OCD symptoms and anger expression revealed no relationship between compulsive checking and anger expression. The authors (Whiteside & Abramowitz, 2005) also examined whether thought–action fusion (TAF), defined as the beliefs that having a negative thought about a bad action/event is morally equivalent to acting on that thought, and/or that it makes the bad event/action more likely to occur (Shafran, Thordarson & Rachman, 1996), is related to anger expression. They found that only the tendency to report TAF beliefs related to the self were related to anger expression, particularly the inward expression of anger. However, TAF beliefs about others and moral TAF beliefs, which are forms of TAF most related to OCD (Shafran, Thordarson, et al., 1996; Shafran, Watkins et al., 1996), were unrelated to overall anger expression, though moral TAF was also significantly correlated with the inward expression of anger. Although it is possible that OCD is completely unrelated to anger (though this would conflict with anecdotal clinical reports), it may be that the inability to clearly detect differences in anger expression between individuals with OCD and individuals without OCD were due to methodological issues in these two studies. In their first study on anger and OCD symptoms, Whiteside and Abramowitz (2004) relied on a non-clinical sample and used the Maudsley Obsessional Compulsive Inventory (MOCI; Hodgson & Rachman, 1977) to assess symptoms of OCD. One of the limitations of the MOCI is the fact that items are answered on a true–false basis. Limited response options reduce respondents’ ability to discriminate their responses and this may result in a loss of information (Streiner & Norman, 1995). This may have obscured potential differences between the high and low OCD symptom participants. Recently, a number of new scales have attempted to address this problem by both expanding the scale and using a Likert-type response format, including a revised version of the MOCI, the Vancouver Obsessional Compulsive Inventory (VOCI; Thordarson et al., 2004). This updated scale may help improve our ability to detect differences between correlates and mechanisms associated with the various symptoms of OCD in anger and anger expression. Though Whiteside and Abramowitz (2005) attempted to address the first limitation of their earlier paper by examining anger expression among a group of individuals diagnosed with OCD, the fact that their OCD sample was heterogeneous may have reduced their ability to detect differences in anger expression among compulsive checkers. Additionally, in their second study, though they did attempt to examine the relationships between anger expression and OCD-related cognitions, this was only limited to TAF beliefs, which conceptually may not be particularly related to anger or to its expression. This study attempts to address some of these limitations and to more broadly examine trait anger and anger expression among individuals who compulsively check. Trait anger can be defined as “individual differences in the disposition to perceive a wide range of situations as annoying or frustrating and by the tendency to respond to such situations with elevations in state anger” (Spielberger, 1999, p. 1), whereas anger expression has four major components and generally measures the way in which an individual expresses anger (Spielberger, 1999, p. 1). The four components of anger expression include inward- (suppression) and outward-based aspects of anger expression and anger control. We predicted that individuals diagnosed with OCD, who report checking compulsions as a primary problem, would have higher levels of trait anger and anger expression, especially inward expression and outward control of anger, compared with individuals without OCD. Additionally, we examined the degree to which OCD symptoms and beliefs relate to trait anger and anger expression. We predicted that beliefs concerning perfectionism and intolerance of uncertainty as well as compulsive checking behaviour would be related to measures of trait anger, whereas inflated responsibility and compulsive checking symptoms would be related to measures of anger expression. As described above, clinicians have observed that individuals with OCD who compulsively check report elevated levels of anger; however, without clearly understanding how these phenomena are related to one another, it is difficult to assess the degree to which they will respond to the same treatment strategies. If certain beliefs characteristic of compulsive checking are found to be related to anger and its expression, this would suggest that targeting such beliefs will not only reduce OCD symptomatology, but may be effective in targeting anger as well.