Abstract
Obsessive-compulsive disorder (OCD) is characterised by intrusive, distressing thoughts that an individual is unable to control. These thoughts keep recurring and cause imminent anxiety for an individual, which they try to control by associating certain actions which they consider neutralising in nature. The prevalence of OCD is estimated to be 1%–3% globally. Prevalence of OCD in the Indian subcontinent has shown an upward trend, with a lifetime prevalence of 0.6% and approximately 3% among the adult population.
OCD is not only characterised by a marked fall in social functioning, but the economic cost of the illness is also quite high worldwide. Recent studies have tried to look at the neurocognitive factors that lead to the epigenesis as well as the maintenance of OCD. Various deficits are noted in neuropsychological functioning, particularly in the domains of executive functions (response inhibition, cognitive flexibility, planning and decision-making) and non-verbal memory. 1 Cognitive flexibility, which is the ability to adapt and shift attention and perspective according to new rules, is highly implicated in OCD. This could be attributed to increased self-referential thinking and heightened attention to the thinking process, causing cognitive rigidity in the patients.
Social cognition, which encompasses the theory of mind, perspective taking, mentalising, emotional processing, social perception and attributional biases, 2 is also significantly affected among OCD patients. Social cognition was initially highly researched in psychotic conditions and led to the discovery of social brain evolution in humans. Research has shown that social cognition deficits (especially related to theory of mind) are found in disorders that implicate the basal ganglia, such as Huntington’s and Parkinson’s and thus, perhaps OCD. The aetiology of OCD explores the role of dysfunction in the fronto-striatal neural networks, which points towards deficits in social cognition and metacognition as well. 3 Deficits in the ‘advanced’ theory of mind and perspective taking were found to be prevalent in OCD patients. Theory of mind deficits were found to be significantly and positively correlated with the level of insight in the OCD patients. 4
Social Cognitive Intervention Training (SCIT) was initially developed as a group-based intervention for individuals with psychotic spectrum disorders. It comprises three phases: Phase I, Emotion Training; Phase II, Figuring Out Situations; and Phase III, Checking It Out. 5 It was conceptualised to be delivered by two psychotherapists across 20–24 weeks with each session spanning 1 hour.
The first phase allows participants to establish a relationship between emotions and different thoughts and situations and enables them to distinguish between justified and unjustified emotions. Due to significant differences in anger and disgust recognition, OCD patients show significant difficulties with emotional and facial expression recognition. 6 Thus, Phase I could help them overcome this misclassification of emotions and state-related emotional processing biases. The second phase teaches participants not to jump to conclusions and reduces their need for closure in social situations. It also teaches the participant the distinction between personal and situational attributions. Patients with OCD are hypothesised to have intolerance of uncertainty. This could lead to abnormal decision-making in uncertain situations and, in haste, jumping to conclusions to gain a semblance of greater certainty. 7 OCD is also characterised by an inflated sense of responsibility, which can lead to personal misattribution. This model explains the drive for compulsions in OCD, as the patients misinterpret the link between their actions and harm occurrence. 8 Phase II could thus help clarify this distinction between situational and personal attribution and reduce jumping to conclusions among OCD patients, potentially benefitting in the reduction of compulsive behaviours. The third phase collaboratively assesses the facts and guesses surrounding different situations. Cognitive illusions, that is, causal reasoning, illusion of control, confirmation bias and biases in deductive reasoning, as well as memory and judgement illusions, are common in OCD. 9 This model suggests that OCD is developed and maintained through the presence of such illusions. Phase III could help bridge the gap between these illusions and reality, making therapy aimed at response prevention more effective.
SCIT also improves an individual’s ability to interact with others as well as the quality and size of their social network. As OCD is often associated with feelings of loneliness and a sense of isolation from society, which ultimately leads to detrimental consequences for the patients this would help enrich their social network and help reduce the severity of the mood and obsessive symptoms among patients.
The current article thus highlights the role of social cognition in OCD and underscores the need for further work, especially on the lines of intervention application to overcome social cognition deficits in OCD patients.