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Phenomenological Considerations of the World of the Obsessive Patient

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24 May 2023

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Abstract
Obsessive-compulsive disorder (OCD) remains, despite significant scientific progress, a pathological condition that is incomprehensible, due toits paradoxical psychological and behavioral symptoms. The presentwork aims at assessing current phenomenological understandings of this pathology. Among the cognitive models used today, post-rationalist cognitivism and cognitive neuropsychological psychotherapy, which both incorporate a phenomenological approach, seem most effective at grasping OCD patients’ experiences of the world, which are typically characterized by hyper-reflexivity, at the expense of "natural evidence." For OCD patients, the emotional sense of the world becomes a set of sterile rules that determine a suffering life.
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Subject: Public Health and Healthcare  -   Public Health and Health Services

1. Introduction

Obsessive-compulsive disorder (OCD) is a neuropsychiatric disorder characterized by the presence of obsessive (i.e., intrusive, repetitive, unwanted) thoughts and compulsive behaviors or mental acts [1]. The disorder has a global prevalence of 0.25–3.0% [2]. However, obsessive-compulsive symptoms (OCS), more generally, are widespread. Among children and adolescents, OCS prevalence is reported in the range of 7–35% [3], and 30–50% of adults with OCD experience symptoms before the age of 18 years [4]. OCD is a chronic life condition [5,6].
Obsessions and compulsions associated with OCD can be time-consuming (often involving more than 1 hour per day) and may significantly interfere with every day life habits, compromising quality of life [7,8]. In the DSM-5, OCD is recognized within the specific diagnostic category of obsessive compulsive disorders, which includes related disorders; this deviates from its previous classification within anxiety disorders [9], reflecting scientific advances [10–14[10–14[10–14[10,11,12,13,14]. However, OCD remains a complex disorder with paradoxical psychological and behavioral symptoms [15,16]. Thus, it requires further research into not only its clinical and behavioral aspects, but also its experiential aspects [17,18].

2. Research Objective

For a long time, clinicians have been curious about the main characteristics of patients suffering from OCD [17,18]. Studies have focused on the nature of their obsessions and the meaning of their anxiety, which they attempt to reduce via compulsions [19,20]; as well as the perception of disgust [21-23] and its pervasiveness in obsessive patients [7,8]. However, to date, research has not been able to grasp the true nature of OCD patients’ suffering, with respect to their experiences of and representations of the world.
The present work aims at assessing the current phenomenological reading of this pathology, focusing on the relationship between the obsessive patient and their world and its representations, in order to better understand the particular suffering of the OCD patient. Phenomenology, according to its founder, Edmund Husserl [24], is an approach to philosophy that assigns primary importance to intuitive experience. Thus, it takes phenomena (as presented in phenomenological reflections that are indissolubly associated with the subject’s perspective) as starting points and attempts to extract from them their essential experiential characteristics. More precisely, this approach is known as “transcendental phenomenology,” and it has had a profound influence on modern cognitive frameworks..

3. The world of the Obsessive Patient: Phenomenological Considerations

Since the earliest descriptions of OCD, researchers have debated how the phenomenology of the disorder should be understood [25].
Erwin Straus [26], one of the leading exponents of phenomenological psychiatry in the 20th century, noted that, in every day life, obsessive patients are blocked by obstacles and impediments that do not constitute problems for “healthy” individuals.This simple statement leads to a fundamental question that may help us to broaden our understanding of OCD: Why are“healthy”individuals able to tolerate uncertainty, while such uncertainty seems towear out patients with OCD?
In attempting to answer this question, we will consider the traditional cognitive vision model [27], the post-rationalist cognitive model [28], and neuropsychological cognitive psychotherapy approach [29,30].
More specifically, we will attempt to determine which of these models—all of which are influenced by phenomenological thought—can most effectively grasp the world that is experienced by OCD patients. According to the traditional cognitive model [31,32,33], individuals know the world through mental functions such as perception, attention, memory, and thought. Mental processes allow individuals to transform, reduce, store, and retrieve the information that reaches their sensory systems. Behavior is conceived of as a series of acts guided by cognitive processes to solve a problem, with continuous adjustment to ensure the best solution. The mind is therefore an apparatus with a fixed sequential organization, which regulates behavior according to its momentary objectives and reduces the discrepancy between subjective representations and facts in “reality.
For obsessive patients, the discrepancy between subjective experience and reality is so great that it leads to obsessions—that is, to incorrect assessments of the “truthfulness” of facts. OCS stem from patients’ incorrect thoughts and evaluations of themselves and external reality, as compulsions and rituals are introduced to reduce the negative emotions that arise from these dysfunctional assessments [34]. Several studies [35,36,37,38,39] have provided support for these cognitive hypotheses and helped to outline two fundamental concepts that may, from this perspective, contribute to OCD: feelings of guilt and inflated responsibility.
For obsessive patients,the possibility that one may be guilty of something is experienced as not only demeaning and negative (as for healthy people) but, above all, as an unforgivable catastrophe that cannot be overcome [40,41,42]. This self-consideration goes hand in hand with OCD patients’exaggerated sense of responsibility [43,44], which Salkovskis and Forrester [45] defined as the belief that one has a fundamental role in determining outcomes and reducing negative consequences (i.e., through rituals or superstitious gestures).
According to cognitivism, uncertainty and doubt [46,47,48,49] are ill-tolerated by OCD patients, because an excessive sense of responsibility and guilt imprisons them in a vicious circle of thoughts (i.e., obsessions) and does not allow them to accept the situation as is. Their exaggerated and dysfunctional belief that they play a central role in determining consequences leads to an incorrect assessment of reality. Therefore, false, exaggerated, and wrong beliefs lie at the root of their condition.
Now, is it possible to understand a pathology as something that “happens” only in the mind? If one considers humans thinking machines, then this cognitive perspective is correct. However, this perspective, while contributinga meticulous and systematic analysis of the characteristics of obsessive thought, limits its observations to the functioning of the individual’s mind, while overlooking the fundamental sense and meaning of the world in which OCD patients are trapped.Straus’s methodology of structural analysis [26] aims at tracing the constitutive essence and structure of psychic disorders. This involves comparing the characteristic elements of a given disorder with their correspondences in “normal” psychology. Straus claimed that, in psychiatric work, more attention should be paid to the standard modalities of phenomena, since it is only through comparison with “normality” that it is possible to achieve an adequate understanding of psychopathological manifestations. More specifically, he wrote [50] that “only after coming to understand the world in which the obsessive patient lives can one hope to know the genesis of the pathology.”
Straus’s phenomenology introduced a new vision of the individual, sensitive to the phenomenological approach—one in which the individual was no longer understood as an isolated subject, but as an inhabitant of the human world. This made different experiences understandable in the light of every day life. The object of Straus’s phenomenology was individuals’ experienced consciousness, be it “normal” or pathological.
According to Straus [26], pathology is an interruption of the “normal” subject–world relationship, since existence takes shape in relationship with the other. Therefore, for OCD patients, something is broken in their relationship with the world; what is lacking, precisely, is the sense of continuity and form that should characterize worldly objects (i.e., the physiognomy of the world). Existence, for OCD patients, is experienced as a shapeless whole (i.e., as aneidos, as opposed to the eidos, representing a harmonious articulation) of objects, moments, and sensations. Without a sense of outer organization, objects and the world lose their pleasantness. For this reason, Straus [26] described that disgust is the central and fundamental character of obsessive pathology.
Post-rationalist cognitivism developed the cognitive model further, in harmony with the phenomenological approach. This model does not consider psychological reality objective and objectively definable, but it instead regards it asthe product of the interaction between the observer and the environment [51]. In this framework, the mind is not a simple passive computer of information. Rather, it builds (based on cognitive schemes that organizepersonal meaning) reality actively through interaction with—and the interpretation and classification of—the surrounding environment [28].
Self-consciousness, worldviews, and existential temporality, in narrative form, follow verbal, unconscious rules (i.e., tacit knowledge) [52]. The continuous assimilation of experience over time progressively increases the inner complexity of the self, taking the individual to more integrated levels of self and world knowledge [53]. These are the epistemological criteria on which the post-rationalist psychotherapy of psychopathological disorders such as OCD are based [54].
Cognitive neuropsychological psychotherapy represents a natural evolution of cognitive psychotherapy. This approach combines recent developments in neuroscience, developmental psychology, and psychopathology into a unitary theoretical framework [55]. Through this rigorous and interdisciplinary perspective (referring to the phenomenological and hermeneutic traditions) [56], the individual represents an inseparable unity of mental processes, body, history, and planning. This allows for psychotherapeutic interventions that are scientifically reliable and formalizable, yet not reduced to technical protocol. The framework attempts to integrate the concepts of bio and psi to promote a science of the person that does not sacrifice anything of the human being who acts and suffers [30].
This model seems better able to grasp the meaning of the world of OCD patients, in alignment with Straus’s thesis that obsessive patients, defending themselves from the world and its “ugliness,” do nothing but isolate themselves and close themselves in their own reality, thus breaking the original relationships that characterize human beings. Through this lens, disgust is the meaning grasped at the world’s opening [30]. Therefore, the only conceivable mode of an obsessive relationship with the world is defense from it and its formless shape.
The phenomenological perspective, alongside the post-cognitive rationalist framework and neuropsychological cognitive psychotherapy, contribute significant insights into obsessive pathology by reflecting on the meanings of the world, as experienced by OCD patients.
The cognitive neuropsychological approach builds on Blankenburg’s [57] concept of natural evidence, related to the study of pauci symptomatic psychosis. Natural evidence represents the background of pre-reflexive obviousness that gives continuity to experience (thematic consciousness), a sense of self, and temporality. It is altered in psychopathological situations, creating a feeling of detachment and unfamiliarity [58]. For OCD patients, the emotional sense of the world is insufficient. Therefore, their relationship to the environment must be managed and regulated rigorously and systematically, in reference to an external and abstract set of rules (undergoing continuous improvement). This allows them to maintain an adequate sense of personal stability [30]. OCD patients therefore meet the other and the world through a mediation of the reference system. OCS emerge from an alteration (i.e., “insecurity”) of personal identity due to a mismatch between the experience and the set of rules through which OCD patients perceive themselves [30,59]. Whenever an inconsistency occurs—that is, when experience can no longer be reconfigured through the set of rules—the subjective sensation is that of disintegration, since the sense of personal stability is shaken. Obsessions are the consequence of the interruption between experience and the reference system, and compulsions represent an attempt to reconnect these aspects through an immediate re-positioning [30].

4. Conclusions

The models of traditional cognitivism [27], post-rationalist cognitivism [28], and neuropsychological cognitive psychotherapy [29,30] contribute different understandings of OCD: all provide a descriptive picture of the pathology, but only the latter two, which integrate a phenomenological approach, focus on the particular relationship betweenOCD patients and their world, characterized by hyper-reflexivity at the expense of natural evidence [57,58]. For these patients, the emotional feelings that normally direct individuals pre-reflexively become a set of sterile rules that determine suffering in the world.

Author Contributions

Conceptualization, F.D. and M.P.; investigation, writing—original draft preparation, M.P., C.D.V. and D.B..; writing—review and editing, F.D., M.P. and S.V.; supervision, F.D. and S.V. All authors have read and agreed to the published version of the manuscript.

Funding

This work was supported also by the Italian Ministry of Health with Current Research 194 funds.

Institutional Review Board Statement

Not applicable

Informed Consent Statement

Not applicable

Data Availability Statement

Not applicable

Conflicts of Interest

The authors declare no conflict of interest.

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