Moral Foundations for OCD
Does it matter what OCD is about?
Some stories stick with you:
A middle-aged atheist prays nightly to a unicorn figurine for his parent’s health.
A grad student circles the block fifteen times to ensure he didn’t hit-and-run a pedestrian.
Weeks after a dinner party, a young woman can’t shake the worry that other guests thought she was masturbating under the table.
A man avoids divine punishment by eating breakfast in a particular sequence.
The mother of a newborn checks envelopes over and over, worried that her daughter will accidentally get sent out in the mail.
Obsessive-Compulsive Disorder isn’t too common, but the experience of such disturbing thoughts is ubiquitous. Leaving for an overnight trip, I squash the urge to drive home and check the stove, door, or faucet. After my daughter was born, I had a brief but bizarre fear that the wooden corner of the mantel might extend across the living room and jab her head.
Obsessions (recurrent, unwanted thoughts) and compulsions (repetitive, ritualized behaviors) often go together, such as washing hands after a thought of being dirty. They don’t have to. People with OCD tend to worry a lot, so the DSM previously lumped it in with anxiety disorders. But there’s clearly a role for guilt, doubt, and disgust.
Working with OCD, you quickly pick up on a common thread. Obsessive thoughts tend toward variations on a theme like “What if I did a terrible thing?” or “If a terrible thing happens, it’ll be my fault” or “I can’t be sure I haven’t done a terrible thing” or “Something just seems wrong” or perhaps “I feel gross and impure.” Unsurprisingly, many theories of OCD place morality in a central role.
Morality and OCD
Psychoanalytic doctrine saw OCD as “a distorted private religion.” Unconscious sexual or aggressive impulses conflict with the strictures of society; the pressure generates anxiety, doubt, and flawed defenses like undoing and reaction formation.
Modern psychological models tend to emphasize a cognitive process. A thought occurs; if sufficiently upsetting it creates negative emotions, followed by an action to neutralize the bad thought. Transitory relief creates positive feedback via negative reinforcement. It looks something like this:
But why are these thoughts so upsetting? What separates OCD from the generic worries of GAD or Social Anxiety?
In OCD, the theory goes, intrusive thoughts are "threats to a positive view of the self because they defy internalized standards of moral purity and social approval” (Clark 2004). But again, everybody has random disturbing ideas. People who develop OCD must have “sensitive morality,” meaning they strongly value yet feel lacking in morality, due to higher attributes like perfectionism and inflated responsibility. Ultimately, compulsive behaviors occur “in part, as direct attempts to reduce feelings of moral violation” (Harrison et al, 2012).
Morality is such a broad concept, though.
Moral Foundations and OCD
The highly successful Moral Foundations Theory argues that human moral intuition rests on a handful of distinct pillars - “innate and universally available psychological systems.” MFT extends morality beyond consequentialist calculations, to include:
Care/harm: Suffering is bad, and we should avoid hurting others.
Fairness/cheating: Cheating is wrong; people should “get what they deserve” in both good and bad senses.
Loyalty/betrayal: You have special obligations to your kin or “team.” Group needs may swamp the individual.
Authority/subversion: Social hierarchy and traditions are valuable. Respect for authority.
Sanctity/degradation: Striving for bodily and spiritual purity is admirable. On display at church, Youtube fitness channels, and Whole Foods.
MFT also grounds morality in evolution. While the prominence of each foundation varies across cultures and individuals, they are supposedly universal. Each system emerged from adaptive traits such as mammalian attachment to kin (Care/Harm), tribal ingroup/outgroup dynamics (Loyalty/Betrayal) and parasite avoidance (Sanctity/Degradation).
For OCD, the Yale-Brown Obsessive Compulsive Scale (Y-BOCS) is the gold standard assessment tool. It includes a symptom checklist helpfully organized by theme:
Aggressive Obsessions: fear of harming self or others, intrusive violent images, fear of inadvertently harming others. Often linked to Checking Compulsions, e.g. repeatedly checking the stove to prevent a house fire.
Contamination Obsessions: excessive concern with bodily secretions, dirt, germs, environmental contaminants, sticky substances. Related to Cleaning/Washing Compulsions such as repetitive hand-washing.
Sexual Obsessions: perverse and taboo thoughts or impulses
Hoarding/Saving Behaviors (DSM 5 moved this to a separate Hoarding Disorder)
Religious Obsessions: excessive concern with sacrilege, blasphemy, and right/wrong
Need for Symmetry or Exactness, related to Ordering/Arranging Compulsions
Somatic Obsessions: excessive concern with a particular illness; fears that a body part is dysfunctional or malformed
Repeating and Counting Rituals: rereading text multiple times, recounting objects
Miscellaneous: need to tell/ask/confess; fear of certain phrases, bothered by certain sounds, superstitions such as lucky numbers or colors
Similar themes appear in the Dimensional Obsessive-Compulsive Scale (DOCS), which explicitly groups symptoms into categories of Contamination, Responsibility for Harm, Unacceptable Thoughts, and Concerns about Symmetry or “Just Rightness.”
I don’t think it’s a stretch to see connections here!
Aggressive obsessions and checking behaviors link to Care/Harm: the individual has recurrent fears about harm to others and develops rituals to prevent it. Contamination fears, compulsive cleaning, and somatic obsessions relate to Sanctity/Degradation: a preoccupation with being infected, impure or warped in some way. Concern over unacceptable thoughts such as blasphemy, offensive statements, and sexual taboos can be viewed as a fear of subversive behavior.
Links for the Loyalty/Betrayal domain are less clear, though the construct of “relationship OCD” does involve obsessive doubt and repetitive reassurance-seeking about relationship status. Finally, and this is rank speculation, but I could see a brain system that originates as an interpersonal cheater-detection module, evolves to include abstractions like fairness and justice, and occasionally rigidifies into obsessions with evenness, order, and just-rightness.
I’m not the first to notice this
A 2016 study investigated whether higher ratings on a moral foundation linked to greater OCD symptoms. Researchers at Baylor University gave Mechanical Turk surveys, including the Moral Foundations Questionnaire and Dimensional Obsessive-Compulsive Scale, to 577 adults.
The moral foundation of harm/care unexpectedly generally did not relate to obsessive-compulsive symptoms, whereas ingroup/loyalty and authority/respect both unexpectedly shared associations with obsessive-compulsive symptoms. As hypothesized, purity/sanctity tended to cluster with contamination and unacceptable thoughts. Purity/sanctity appeared particularly relevant to scrupulosity (fear of sin and fear of God) as well. Importantly, purity/sanctity was the only moral foundation to share an association with obsessive-compulsive symptoms after statistically accounting for religiosity, negative affect, obsessive beliefs, and the other moral domains…Overall, Study 1 findings suggest that purity/sanctity is the moral domain most relevant to obsessive-compulsive symptoms.
The authors speculate that purity/sanctity may “contribute to obsessive-compulsive symptoms…by increasing misappraisals of intrusive thoughts (e.g., as immoral).”
This is a mixed bag, but overall a little disappointing. It would certainly be neat for moral foundation scores to correspond 1:1 with similar OC symptoms. And no association on the Care/Harm domain? That’s very surprising. Of course, the participants in this study don’t have OCD; it’s a non-clinical sample of Internet users. Also, I question the underlying model.
As always, Dimensions vs Categories
The authors are working in a cognitive theory, as described above. But they don’t really specify a relationship between moral beliefs and obsessive thoughts. The implicit premise seems to be that OCD emerges from unusually intense convictions. There is indeed evidence that OC symptoms are continuously distributed in the general population, consistent with stronger moral beliefs leading to marginally more symptoms.
But I don’t think the “extreme trait” view explains a core feature of the illness, namely that sufferers recognize the symptoms as irrational. People with OCD don’t wash their hands 24 times a day due to a considered faith in the importance of personal hygiene; repeated urges drive them to clean despite knowing it doesn’t entirely make sense. Moreover, the behaviors are often idiosyncratic - somebody who flips a light switch 8 times until it feels “just right” can otherwise be a disheveled mess.
In fact, we have a term for people whose intense morality leads to personal dysfunction: Obsessive-Compulsive Personality Disorder. No, this is not the same as OCD. Yes, the names are confusing and dumb. OC Personality refers to the people with traits like
“preoccupation with orderliness, perfectionism, and mental and interpersonal control”
excessive attention to “details, rules, lists, order, organization, and schedules”
“overconscientious, scrupulous, and inflexible about matters of morality”
People with OC Personality view their own high standards and scruples as obviously correct; the problem is everyone else who can’t keep up. They’re often professionally successful but struggle in relationships, due to being anal-retentive killjoys. Examples include Felix Unger, your cousin the twice-divorced accountant, and much of the Marine Corps.
So I propose that Obsessive-Compulsive Personality describes people whose persistent moral beliefs - need for order, doing things the right way, cleanliness - fall a few standard deviations to the right. Their moral system setpoints are high. What, then, is Obsessive-Compulsive Disorder?
This Year’s Model
OCD involves repetitive thought–feeling–behavior sequences (you might call these emotions). This is often referred to as “looping.” They’re short-lived but initiate numerous times per day. Quantifying the activity might yield something like this:
This distribution doesn’t suggest a system with an abnormally high set-point. It’s more like a short-cycling furnace that ineffectively rouses every few minutes. There’s no true temperature disturbance; the system is oscillating due to a clogged filter, dirty sensor, or poorly tuned thermostat.
For OCD, prevailing neuroscientific explanations indeed rely on dysregulated feedback loops:
The neural “infinite loop” model emphasizes deep brain structures like the basal ganglia, suggesting that the process doesn’t have to kick off with conscious thought. Instead, OCD sequences could result from repeated activation of primitive grooming and checking behaviors seen in other mammals. OCD is of course associated with motor tics and repetitive behaviors such as hair-pulling, and skin-picking. In this bottom-up view, the cortex fails to exert “voluntary control over habits stored in the basal ganglia” (Shapiro 2020) then scrambles to elaborate a post-hoc justification of the behavior.
Conclusions
I think Moral Foundations Theory sheds some light on the nature of OCD. Humans have “innate and universally available psychological systems” tuned to purity, minimizing harm, respecting social rules, etc. These systems presumably exist as neural networks that are at least somewhat separable and modular. Their evolutionary lineage and strong emotional valence means involvement of deep, conserved brain structures.
Moral systems can malfunction in many ways: not just extreme “setpoints” but also high (or low!) responsiveness, responding to inappropriate stimuli, or activity that’s independent of cues altogether. Obsessive-Compulsive Disorder results not from a high setpoint, but from repeated erroneous activation in one or more of these moral systems, analogous to a furnace cycling on/off all day.
As a psychiatrist, I can’t help but see other themes in psychopathology. There’s a strong case for attachment, which seems to go awry in various personality and mood disorders. The brain expends tremendous effort just monitoring and regulating the body; malfunction here could tie together everything from somatization to somatic obsessions to somatic delusions to dissociation. Otherwise, we’re mostly devoted to making other people like us, so networks for governing social status seem useful.
Physicians already think in terms of organ systems, so this is conceptually familiar ground. In keeping with this blog’s title - Affective Medicine - I think it’s worth applying such approaches to the confusing territory of mental illness.
Thank you for this analysis, I really like the connections it makes with morality related processes, though of we accept that disgust is a very basic emotion that's only secondarily about moral purity, the contamination subtype might be separate from morality? As in many humans with contamination focused OCD might not subscribe to purity ethics either personally or culturally.
It also reinforces my belief that intrusive thoughts themselves OCD don't make, but there still probably is a connection.
I've always wondered about one thing though, re notions of elevated responsibility. That for some people the idea that the world is dangerous, unpredictably and randomly so, is so unbearable and distressing (not consciously even, but in some emotional layer) that their minds create what I'd call provisionally an "emotional delusion of control" (emotional because acute awareness* of the irrationality / dysfunction is a feature of OCD) because painful as that is in effect, it's preferable to accepting that we can't save anyone, ever.
* that said, in my interactions with people with OCD (wether clinical or subclinical or just hinted at), it's very very rare to find people who don't "buy" into some mild version of their "irrational" loops: whether their emotional process influences values ("I am scared of infection so I think people with coughs going to work are evil bastards") or their values get monstrously/disastrously magnified into the process ("I think CSA is the most evil thing ever, and that's why my OCD manifests as intrusive thoughts of my harming children") is hard to determine.