A process that can throw light on the so-called ‘fear of self’
in obsessive-compulsive disorder: the Retrospective Identification
of Motivations and Inclinations

Un processo che può gettare luce sulla cosiddetta ‘paura di sé’ nel disturbo
ossessivo-compulsivo: l’Identificazione Retrospettiva delle Motivazioni
e delle Inclinazioni

GHERARDO MANNINO1, ROSSELLA GUERINI2
E-mail: gherardo.mannino@libero.it

1Department of Mental Health, Azienda Sanitaria Locale RM-1, Rome, Italy
2University of Rome “Roma Tre”, Italy


SUMMARY. In recent years, to better understand the psychopathology of Obsessive-Compulsive Disorder (OCD), increasing attention has been paid to the so-called ‘fear of self’, that is the fear of people with OCD of housing in their inner unacceptable aspects of Self. However, the exact dynamics of the phenomenon is still unclear: to better clarify it, a specific psychological process, termed Retrospective Identification of Motivations and Inclinations (RIMI), will be described here. When a patient with OCD evaluates his/her inner experience (thought, emotion, imagery, etc.) or own behavior in some way as unacceptable, he/she will identify in a retrospective way the alleged negative motivations/inclinations which would have been the source of that experience or behavior. RIMI, not only helps to better understand ‘Fear of Self’, but has also important implications for the therapy.

KEY WORDS: OCD, fear of self, Retrospective Identification of Motivations and Inclinations, RIMI.


RIASSUNTO. Al fine di comprendere meglio la psicopatologia del disturbo ossessivo-compulsivo (DOC), in anni recenti è stata prestata una crescente attenzione alla cosiddetta “paura di sé” (fear of self), vale a dire la paura che le persone con DOC nutrono di ospitare dentro di sé aspetti inaccettabili. Tuttavia, l’esatta dinamica di questo fenomeno ancora non è chiara: di conseguenza, allo scopo di delucidarla meglio, sarà qui descritto uno specifico processo psicologico denominato Identificazione Retrospettiva delle Motivazioni e delle Inclinazioni (IRMI). Quando un paziente con DOC valuta in qualche modo come inaccettabile una propria esperienza interna (pensieri, emozioni, immagini mentali, ecc.) o un proprio comportamento, identificherà retrospettivamente le presunte motivazioni/inclinazioni negative che sarebbero state all’origine di quell’esperienza o comportamento. L’IRMI non solo aiuta a comprendere meglio il fenomeno della “paura di sé”, ma possiede anche importanti implicazioni per la terapia.

PAROLE CHIAVE: DOC, paura di sé, Identificazione Retrospettiva delle Motivazioni e delle Inclinazioni, IRMI.

INTRODUCTION
In recent years, to better understand the psychopathology of Obsessive-Compulsive Disorder (OCD), increasing attention has been paid to the so-called ‘fear of self’, that is the fear of people with OCD of housing unacceptable aspects in their inner Self1-4. Indeed, current psychopathological models of OCD hypothesize that obsessions arise from intrusive phenomena per se normal, that become extremely upsetting because negatively appraised by subjects with OCD5. This would happen because people with OCD would interpret the content of intrusions as revealing hidden and negative aspects of their own selves6.
However, why is the content of these intrusions felt as so negative? The most convincing answer is that it appears threating to the subject, because in contrast to the current self-image or, anyway, to the accepted self-image7. Then this arises a new question: why OCD persons feel such a so strong contrast between current feelings and their accepted image? Is because they really have more negative inner aspects than other people? This really does not seem to be the case as these subjects, as well-known, have often high moral principles: for example, people with aggressive obsessions not only fellow often a severe morality but also feel often a deep and a sincere respect toward others. Said that, it is difficult to believe that OCD subjects present ‘Fear of Self’ simply because they are worse than others.
On the other hand, however, it is necessary to recognize, as some authors have done since Freud8, the possible importance of some degree of ambivalence in the feelings of people with OCD7,9. For example, a man with OCD could recognize that, besides his love to his father, he feels also a great anger to him. However, strictly speaking, some degree of ambivalence is an ubiquitous phenomenon: indeed, many people experience varied feelings toward other people and, in most cases, they are not very upset by this. So, why are precisely these people so disturbed by these feelings?
In addition, it should be mentioned that people with OCD do no fear an eventual and hypothetical self but rather a self, which is felt as real and current in all respects. In other terms, extremely negative aspects of self are not for them a mere possibility but rather a certainty. Therefore, we can ask: “Why, unlike normal people with intrusive phenomena, only OCD subjects feel the certainty of personal negativity?”.
To answer to these questions a specific psychological process termed Retrospective Identification of Motivations and Inclinations (RIMI), already outlined in Mannino10,11, will be described in this paper. In the next paragraph we will illustrate what happens when RIMI has a stake in the case of relatively clear feelings, whereas in the two following sections we will examine RIMI in the case of more complex and varied feelings.
THE RIMI IN THE CASE OF RELATIVELY CLEAR FEELINGS
RIMI deals with the characteristic way through which people with OCD come to feel that the ‘fear of self’ has a real base. In fact, the psychopathological analysis of OCD subjects’ experience highlights that these individuals are characterized by the marked tendency to identify in a retrospective way the motivations of those personal experiences whose consequences they evaluate as unacceptable, for example, because they perceive a supposed violation of their moral principles
It is obvious that the motivations identified in this way are inevitably only the presumed ones and not the true motivations, that means those which really gave rise to those mental phenomena.
A clinical case, already reported elsewhere11, will help to illustrate the concept.
Clinical case 1
A 25-year-old female student exhibited a pattern of doubts, ruminations and controls which, among other things, had led to a significant decrease in academic success. Once, while studying a book, she was upset by the sense of satisfaction for the ease with which she had understood a difficult paragraph. In fact, since her conception of the study was inspired by principles of commitment and sacrifice, the satisfaction she had felt looked incongruous to her and a sign of her hidden desire to avoid effort. From here she began a long rumination.


In this case a sequence can be easily outlined as represented in Figure 1.
Here the patient initially interprets her feeling of satisfaction as ‘unacceptable’, since it seems to her incompatible with her concept of study in terms of commitment and effort, values that often characterize OCD subjects12. Then, from this appraisal, she retrospectively identifies as presumed motivation of her ‘ease in reading’ the existence of a concealed will to avoid effort, now considered as the ‘true’ cause of the deceptive breeziness.



RIMI IN THE CASE OF APPARENT AMBIVALENCE
Naturally, there other cases in which one could thought at first glance that some ambivalence could really exist. However, a better look allows to find that ambivalence in most cases is only apparent.
A clinical example is useful to illustrate the concept.
Clinical case 2
A 22-years-old boy, who for several years suffered from OCD, was extremely upset by having greatly admired at a country festival a boy he knew only of sight. At once, he thought he might be gay. Here-hence a new obsession began: in fact, the simple reminder of the episode as well as feeling similar emotions in other situations were whenever extremely upsetting because they were seen from him as a clue of his unacceptable orientation. Furthermore, the doubt itself of being gay as well as the content of intrusive mental images were regarded from him as further proof of his latent inclination.


RIMI is at stake here on several levels. At a first level, for example, it is obvious that another boy, being more confident of his true sexual inclination, could have smiled at himself with this thought: instead the patient, from the admiration felt for the boy, soon draws retrospectively the existence of his presumed deviance. At a second level, also the idea itself that had crossed his mind (the doubt of being gay) was seen from the patient as a clue of a pre-existent orientation seen from him as unacceptable.
It is important underline that this retrospective mechanism is not, at least in most cases, the consequence of an explicit reasoning, namely a genuine a posteriori deduction. Instead it is the product of a process that takes place at a largely unconscious level. In other words, it is a characteristic mode of processing one’s own experience: the patient tends to identify retrospectively his or her motivational states rather than recognizing them in direct contact10,11.
If one wants to put a largely implicit and procedural sequence into words, it is as if the patient said to himself: “If a feeling, a thought or an image X, which I consider as unacceptable, occurs to me now, this means that I always had inside me a latent tendency toward X”11 (Figure 2).



THE RIMI IN THE CASE OF MORE COMPLEX AND VARIED FEELINGS
Of course, there are also cases with more complex and varied feelings where there really seems to be some degree of ambivalence. A clinical case example from the literature 12 may be useful to illustrate the concept.
Clinical case 3
A 25-year-old accountant, married for a year with his employer’s daughter, complained for several months of ‘bad thoughts’: for example, ‘presentiments’ of some serious illness that could affect his father-in-law, mental images of a sexual intercourse between his wife and her father and so on. Each of these thoughts made him feel immediately wicked and from any of them every time long ruminations were born12.


In this case, it seems obvious that the patient has at least some degree of hostility towards his wife and his father-in-law. So, one might think that in this case the ‘fear of self’ arises from the fact that he realizes that there are actually negative and unacceptable feelings within himself. So, one might conclude that ‘fear of self’, at least in some cases, is really the result of an objective ambivalence. However, if one goes to look at the emotions at the stake he will find that what happens is quite the opposite. That means, emotions that arouse fear because are felt at first glance as dangerous are poorly acknowledged and poorly processed; consequently, the subject cannot recognize himself in those and cannot integrate them within his image of himself 12. But why these emotions are immediately felt as dangerous? Here it is hypothesized that through the mechanism of RIMI the subject obtains the presumed proof of the existence of unacceptable motivations and inclinations upstream. In fact, these emotions are not dangerous at all; rather they are often unprecedented but potentially very significant feelings from an existential point of view13. As soon as the subject begins to better understand them in therapy, they lose their disturbing quality and instead begin to enrich the vision the patient has of himself/herself and of others.
In the above clinical case, for example, it became apparent that rage against the father-in-law originated from the fact that he felt relegated to work at secondary roles and that the anger towards his wife was born from the fact that she never took his part in the discussions between him and her father. As in therapy he became more skilled in recognizing these emotions, they gradually lost their disturbing quality and consequently their intrusive quality too, so that feeling ‘angry’ no longer meant to feel ‘bad’ 12. From all the cases discussed above, it is quite evident that ‘Fear of Self’ seems originate in many cases, not from the perception of objective ambivalence or genuinely negative feelings, but rather from the retrospective identification of just alleged motivations and inclinations, using as starting point emotions which are not only per se normal but also potentially meaningful from an existential point of view.
IMPLICATIONS FOR THERAPY
Finally, RIMI has important implications also for psychotherapy, whether conducted alone or in combination with drug therapy14,15. In fact, one of the major limitations of the current psychotherapeutic approaches to OCD, e.g. cognitive therapy, seems perhaps to be the fact of taking the content of obsessions to the letter11. This is a problem because it could take the therapist out of the way, since the patient tends to report the motivations and the affective states that preceded the obsessive phenomena, not for how they really were, but rather for how he/she identified retrospectively them. For example, if a patient has the obsessive fear of harming others, a standard intervention of cognitive therapy could consist in leading him/her to a more realistic risk assessment16. However, such an intervention could perhaps change explicit beliefs about the risk of the damage but not the implicit and emotional way of feeling himself/herself: as result, for example, the patient could now recognize that his/her fear is really exaggerated, but nevertheless will continue to feel a bad person. So, changing the way a subject tells himself/herself a disturbing emotion, can perhaps make that emotion more controllable, but does not really change its tonality 17.
Therefore, the therapist, keeping well in mind the concept of the RIMI, will have to reconstruct the motivations as the patient really experienced them.
In the case n. 2, for example, after the psychotherapist has patiently reconstructed the whole episode, it clearly turned out that the feeling that so deeply upset the patient was not a real attraction toward the boy he saw at the country festival, but only a sense of admiration toward him. Furthermore, it became clear as, also before that episode, he already admired that boy for the success he was believed to have with girls, especially because he, at that time, was alone and really wanted a relationship with a girl. So, in a sense, his attitude toward that boy proved to be the opposite of what he thought it was. Furthermore, it became clear that also the mental images, perceived as intrusive, were often volunteered images with which the patient tried to test his feelings and therefore his real sexual orientation . Therefore, also in this case, the affective state that preceded the images resulted the opposite of the feared one.
In this case, the patient was very relieved to find out that his true feelings and inclinations were quite different from the presumed ones and that in these now he easily recognized himself without no problem. Naturally, the therapist must repeat this intervention also with other episodes in which ‘fear of self’ is involved. At first, a ‘fear of self’ reduction will occur only in relation to the reconstructed episodes, but - as the patient becomes gradually more skilled to identify real motivations - it will happen in a more marked and generalized manner.

Conflict of interest: the authors have no conflict of interest.
references
 1. Ferrier S, Brewin CR. Feared identity and obsessive-compulsive disorder. Behav Res Ther 2005; 43: 1363-74.
 2. Aardema F, Moulding R, Radomsky AS, Doron G, Allamby J, Souki E. Fear of self and obsessionality: development and validation of the Fear of Self Questionnaire. J Obsessive Compuls Relat Disord 2013; 2: 306-15.
 3. Melli G, Aardema F, Moulding R. Fear of Self and unacceptable thoughts in Obsessive-Compulsive Disorder. Clin Psychol Psychother 2016; 23: 226-35.
 4. Aardema F, Moulding R, Melli G, et al. The role of feared possible selves in obsessive-compulsive and related disorders: a comparative analysis of a core cognitive self-construct in clinical samples. Clin Psychol Psychother 2018; 25: e19-e29.
 5. Salkovskis PM. Obsessional-compulsive problems: a cognitive-behavioural analysis. Behav Res Ther 1985; 25: 571-83.
 6. Rachman S. A cognitive theory of obsessions. Behav Res Ther 1997; 35: 793-802.
 7. Bhar SS, Kirios M. An investigation of self-ambivalence in obsessive-compulsive disorder. Behav Res Ther 2007; 45: 1845-57.
 8. Freud S (1909). Notes upon a Case of Obsessional Neurosis. In: Strachey J (ed). The standard edition of the complete psychological works of Sigmund Freud: Vol. 10. London: Vintage, 2001.
 9. Moritz S, Kempke S, Luyten P, Ranjbar S, Jelinek L. Was Freud partly right on obsessive-compulsive disorder (OCD)? Investigation of latent aggression in OCD. Psychiatry Res 2011; 187: 180-4.
10. Mannino G. Psicopatologia e psicoterapia del disturbo ossessivo-compulsivo: tra continuità e cambiamento. In: Reda MA, Canestri L (eds). Continuità, cambiamento, coerenza sistemica e complessità. Atti del XV Convegno di Psicologia e Psicopatologia Post-razionalista. Siena: Università di Siena, 2014.
11. Mannino G. Vecchi problemi, nuove soluzioni. Proposta di un nuovo meccanismo patogenetico per il Disturbo Ossessivo-Compulsivo. In: Puzella A, Serino M, Ranfone S (a cura di). La psicopatologia nel mondo che cambia. Roma: Associazione Crossing Dialogues, 2016.
12. Guidano VF. The Self in Process. Toward a post-rationalist cognitive therapy. New York: Guilford Press, 1991.
13. Mannino G. Psicopatologia esplicativa del Disturbo Ossessivo-Compulsivo: una veduta post-razionalista. Riv Psichiatr 2011; 46: 343-8.
14. Berardelli I, Moretti G, Pasquini M, Biondi M. DOC refrattario: dalla fisiopatologia alle strategie terapeutiche farmacologiche. Riv Psichiatr 2008; 43: 208-19.
15. Albert U, Bogetto F. Il trattamento del disturbo ossessivo-compulsivo: farmaci, psicoterapia o trattamento integrato? Riv Psichiatr 2015; 50: 153-4.
16. Van Oppen P, Arntz A. Cognitive therapy for obsessive compulsive disorder. Behav Res Ther 1994; 32: 79-87.
17. Guidano VF. Complexity of the Self. A developmental approach to psychopathology and therapy. New York: Guilford Press, 1987.