In a new article published in Behavioral and Cognitive Psychotherapy, Rachel Verin and her colleagues explore the relationships between obsessive-compulsive disorder (OCD), death anxiety, and attachment style. The authors use interview data from 48 participants diagnosed with and seeking treatment for OCD.
The present research finds, in line with previous studies on this topic, that death anxiety strongly predicts OCD severity. However, contrary to the authors’ hypothesis, the results suggest that anxious and avoidant attachment styles do not correlate to OCD severity.
Previous research has found death anxiety to be a strong predictor of mental illness in terms of a number of lifetime diagnoses, medications, hospitalizations, distress/impairment, depression, anxiety, and stress. Some authors have suggested that by not treating death anxiety directly, we may doom service users to a “revolving door” of diagnoses where once we get a set of symptoms under control, a new set emerges.
OCD has been notoriously difficult to treat. One of the most effective therapies is called Exposure and Response Prevention (ERP). ERP is similar to exposure therapy in that it directs the service user to experience their obsession without repeatedly engaging in compulsion. For example, people with obsessive thoughts about germs that manifest in compulsive grooming behaviors may be asked to dirty their hands without washing them.
Unfortunately, there are few therapists trained in ERP. This can severely limit access to therapy for people that do not have significant financial resources. The authors have estimated that due to the limited number of practitioners familiar with ERP, it typically takes OCD sufferers about 17 years to find proper treatment.
While ERP does show great promise in treating OCD, most patients prefer other kinds of psychotherapy over both ERP and medications. This preference is likely due to the immense discomfort service users experience in the first stages of ERP. While service users report preferences for other treatments besides ERP, the attrition rates for ERP are similar to that of different treatments for OCD.
Attachment theory states that we form specific attachments with our primary caregivers in our early childhood. If we are provided with our basic necessities and nurtured, we form secure attachments that allow us to feel safe exploring the world around us. However, if we are neglected, we form an insecure attachment, vastly limiting our ability to interact with our world. However, new research has suggested that these attachments and their supposed consequences are far from a universal truth. They argue that rather than describing an objective, universal fact, attachment theory outlines a cultural construct that is only relevant (decreasingly so) to the culture that created it.
The present research explains that death anxiety has been highly correlated to OCD. Previous research has also shown this correlation to be causal, meaning that things in the world that remind OCD sufferers of death may also trigger their compulsive behaviors. Previous research has also found that secure attachment mitigates death anxiety. However, little to no research exists exploring this relationship in people diagnosed with OCD. The present study is designed to fill this gap in knowledge.
The present research utilizes the Multidimensional Fear of Death Scale, the Vancouver Obsessive-Compulsive Inventory, and the Experiences in Close Relationships-Revised interview tools to access the relationship between death anxiety, OCD, and attachment.
The researchers recruited 48 participants from a clinical psychology practice in Sydney, Australia. They were over 18 years old, had a current diagnosis of OCD, and had ODC as their principal diagnosis if more than one diagnosis was present. The participants were overwhelmingly Caucasian (93.8% or 45 of 48) and educated (with an average of 15.95 years of education).
First, the authors compared death anxiety scores to OCD severity. Consistent with previous research, they found a strong positive correlation between death anxiety and OCD severity in their participants. The authors also note that their sample of participants scored significantly higher in measures of death anxiety than the general population, further suggesting a link between death anxiety and OCD.
Next, the authors investigated the link between attachment styles and OCD severity in their sample. Contrary to their hypothesis, anxious and avoidant (therefore insecure) attachment styles did not significantly predict OCD severity. The authors note that although insecure attachment does not seem to correlate to OCD severity in their participants, their sample does demonstrate considerably higher rates of insecure attachment than the average population.
These findings indicate that secure attachment as a buffer for death anxiety may only hold in non-clinical populations. In other words, secure attachment likely protects “psychologically robust” individuals from death anxiety but provides no such benefit with clinically significant levels of distress.
The authors acknowledge several limitations to the current research. First, this study is correlational, meaning it is impossible to draw causal conclusions (for example, that death anxiety causes OCD severity or that insecure attachment causes more death anxiety).
Second, this research was done during the Covid-19 pandemic, which means participants were likely exposed to increased daily death reminders. Last, the small sample size makes an exploration of OCD sub-types impossible and generalization to larger populations shaky at best. The authors conclude:
“The present findings, while correlational, are consistent with experimental findings that suggest the central role of death anxiety in OCD. Based on this mounting evidence, the current clinical recommendations include directly targeting death anxiety using evidence-based approaches, such as exposure therapy. Current treatment approaches for OCD typically focus on disproving the client’s estimates of threat (e.g., the probability of contracting an illness) rather than directly targeting the underlying cause. However, by failing to target death anxiety, such treatments may contribute to the ‘revolving door’ of mental health, in which an individual may receive effective treatment for one condition, only to later return to treatment later in life with a different disorder, given that the underlying cause has not been resolved.”
Verin, R. E., Menzies, R. E., Menzies, R. G. (2021). OCD, death anxiety, and attachment: what’s love got to do with it? Behavioural and Cognitive Psychotherapy, 50(2), 131–141. https://doi.org/10.1017/s135246582100045x (Link)