Philosophy and Obsessive–Compulsive Disorder

The paper “Obsessive-Compulsive Disorder, Free Will, and Control” (Meynen 2012) makes a number of interesting points. In particular, it notes that free will has been characterized in terms of retaining control, whereas mental disorders have been characterized in terms of decreased control. It also makes the more specific argument that obsessive–compulsive disorder (OCD) is characterized only by illusory control and in fact involves a loss of control, and that this has implications for psychotherapy. I begin by commenting on the issue of OCD and control, and I then briefly discuss two other issues, namely (a) loss of freedom and lack of free will in compulsive and impulsive disorders, and (b) the relationship between philosophical and scientific work on psychopathology.

OCD and Control

The article argues on the basis of philosophical premises that OCD is characterized by a loss of control, and that psychotherapists should tell patients with OCD that their control is illusory. The idea that OCD is characterized by loss of control is, however, already well-established in the OCD literature. Early on, psychoanalytic authors emphasized that the control in OCD was illusory (Stein and Stone 1997). More recent cognitive theories note that OCD involves an attempt to gain control, rather than actual control (Moore and Abramowitz 2007). And the neurobiological literature emphasizes dyscontrol in OCD (Fineberg et al. 2010). Thus, in contrast with the view put forward in the paper that different methodological approaches may lead to different views of control in OCD, there is perhaps some agreement, whether or not the focus is on the experience of symptoms or on underlying psychobiological mechanisms.

It is true that reference to increased control can also be found in the OCD literature. Phenomenological and psychobiological contrasts have been drawn between compulsivity in OCD and impulsivity in impulse control disorders, for example, with behavioral inhibition and increased frontal activity in the former versus behavioral disinhibition and decreased frontal activity in the latter (Fineberg et al. 2010; Stein and Hollander 1993). However, typically authors immediately note that the situation is more complex than such a heuristic contrast suggests; with impulse dyscontrol in OCD, and with compulsive aspects in impulse control disorders (Fineberg et al. 2010; Stein and Hollander 1993). The complexity that is exemplified by the term ‘dyscontrol’ has been described in both the clinical literature (where, for example, Tourette’s disorder has been shown to have both compulsive and impulsive aspects) and the basic literature (where, for example, substance use has been shown to be characterized by both impulsive and compulsive neurobiological mechanisms; Fineberg et al. 2010; Stein and Hollander 1993).

Indeed, OCD is arguably best depicted when the precise nature of the characteristic and complex dyscontrol is described. From a symptomatic point of view, patients describe simultaneously being aware that their concerns about a particular issue (e.g., that they are dirty) are absurd, while at the same time feeling responsible for having to respond to these issues in a particular way (e.g., washing repeatedly). From a psychobiological point of view, OCD is characterized both by evidence of disinhibition (e.g., on particular neuropsychological measures), and at the same time by evidence of mechanisms that appear to be involved in responding to such inhibition (e.g., activation of particular corticostriatal regions on brain imaging). Thus, although the author avers that some OCD literature refers to extra control, a closer reading suggests that any increased control is typically described in relation to aspects of diminished control, so that a more accurate view of the literature might be that the focus is on dyscontrol (Fineberg et al. 2010; Stein and Hollander 1993).

It is an empirical question as to whether providing information about control to an individual with OCD in a specific way (as advocated in the paper) would be particularly effective. However, it can be argued that cognitive–behavioral therapy (CBT) for OCD already provides a sophisticated approach to discussing control that goes beyond simply taking away control (the view of CBT outlined in the paper). For example, in his relevantly named volume Getting Control, Baer (1991...