When the Pros become Cons in people with obsessive-compulsive disorder

Gherardo Mannino1

1Dipartimento di Salute Mentale, ASL Roma 1.

Summary. Although descriptive psychopathology of obsessive-compulsive disorder (OCD) is well-established, this disorder still presents very enigmatic and puzzling aspects. Hence the usefulness for further contributions to better clarify the picture. For example, one of the most problematic manifestations of OCD consists in pathological doubt, whose origin, however, remains unclear. For this purpose, a psychopathological analysis of several cases of OCD, in which decisional uncertainty is involved, is conducted, as well as a rereading of a famous case by Freud. As a result, the existence of a new psychological phenomenon observable in OCD people is suggested. It is proposed to call it: “incompatibility perceived between unbiased commitment and satisfaction for an unexpected and effortless personal benefit” (ICB). In fact, when an OCD subject experiences a sense of commitment, be it interpersonal or impersonal, he/she will experience the satisfaction for an unexpected and effortless benefit that results from the commitment, as incompatible with the commitment itself. As result, the subject will consider the satisfaction for the benefit as true but inacceptable, whereas he/she will consider the sense of commitment as desirable but as false. This phenomenon not only seems to explain at least some cases of indecision typical of OCD, but sheds new light on some important explanatory concepts, such as ‘ambivalence’, ‘self-ambivalence’ and ‘fear of oneself’, called into question over time precisely to explain the varied psychopathology of OCD. Finally, it also seems to have important implications for psychotherapy.

Key words. Ambivalence, indecisiveness, fear of self, obsessive-compulsive disorder, ICB, incompatibility perceived between unbiased commitment and satisfaction for a personal benefit, OCD, pathological doubt, self-ambivalence.

Quando i pro diventano contro nelle persone con disturbo ossessivo-compulsivo.

Riassunto. Sebbene la psicopatologia descrittiva del disturbo ossessivo-compulsivo (DOC) sia ben consolidata, questo disturbo presenta ancora aspetti molto enigmatici e sconcertanti; da qui l’utilità di ulteriori contributi per chiarire ulteriormente il quadro. Per esempio, una delle manifestazioni più problematiche del disturbo ossessivo compulsivo consiste nel dubbio patologico, la cui origine però resta ancora poco chiara. A questo scopo viene condotta un’analisi psicopatologica di diversi casi di disturbo ossessivo compulsivo, in cui è coinvolta l’incertezza decisionale, nonché la rilettura di un famoso caso di Freud. Come risultato, viene suggerita l’esistenza di un nuovo fenomeno psicologico osservabile nelle persone con disturbo ossessivo compulsivo, che si propone di chiamare: “incompatibilità percepita tra impegno disinteressato e soddisfazione per un vantaggio personale inaspettato e senza sforzo” (ICB). Infatti, quando un soggetto con disturbo ossessivo compulsivo sperimenta un senso di impegno, sia esso interpersonale o impersonale, vivrà la soddisfazione per un beneficio inaspettato e senza sforzo che deriva dall’impegno, come incompatibile con l’impegno stesso. Di conseguenza, il soggetto considererà la soddisfazione per il beneficio come vera, ma inaccettabile, mentre considererà il senso di impegno come desiderabile, ma falso. Questo fenomeno non solo sembra spiegare almeno alcuni casi di indecisione tipici del DOC, ma getta nuova luce su alcuni importanti concetti esplicativi, quali ‘l’ambivalenza’, ‘l’ambivalenza del sé’ e ‘la paura di sé stessi’, chiamati nel tempo in causa proprio per spiegare la variegata psicopatologia del disturbo ossessivo compulsivo. Infine, il fenomeno discusso sembra avere importanti implicazioni anche per la psicoterapia.

Parole chiave. Ambivalenza, ambivalenza del sé, disturbo ossessivo-compulsivo, DOC, dubbio patologico, incompatibilità percepita tra impegno disinteressato e soddisfazione per un vantaggio personale, indecisione, ICB, paura di sé.

Introduction

Even today, obsessive-compulsive disorder (OCD) is often a disabling condition1, that responds well to psychotherapy only in a modest percentage of cases2 and that, even with pharmacotherapy, rarely goes into complete remission3-5.

Furthermore, the disorder still presents many puzzling and enigmatic aspects that require a variety of concepts to understand. In fact, the conceptualization of OCD psychopathology seems to include different levels. Precisely at its surface, we find a first level consisting in description and definition of the phenomena: the main clinical manifestations of OCD (i.e., obsessions and compulsions), the most frequent themes of obsessions (i.e. moral scrupulosity, contamination, etc.), the main kinds of compulsions (i.e., checking, washing, etc.) and so on.

At an intermediate level, instead, we can find more elaborated constructs as the ‘belief domains’ (‘responsibility/ threat estimation’, ‘perfectionism/certainty’ and ‘importance/control of thoughts’)6,7, that lie beyond the purely phenomenological level. These concepts are the result of an operation of abstraction performed by psychopathologists: in fact, they are tacit assumptions often not spontaneously identified by the patients themselves.

Eventually, at an even deeper level, there can be concepts involving higher-order constructs such as the concepts of ‘ambivalence’, ‘self-ambivalence’ and ‘fear of self’, in whose light some authors have tried to also reread obsessive-compulsive symptomatology.

These latter concepts are sufficient to explain all the still enigmatic aspects of OCD, or could it be worth trying to identify some other construct that could prove useful? To try to answer this question, let us think, for example, of one of the most exhausting and problematic manifestations of OCD: pathological doubt and indecisiveness, the nature of which remains unclear.

To try to understand this phenomenon, several researchers have understandably chosen to study decision-making processes in people with OCD. Recent research, i.e., has shown that OCD subjects, more frequently than controls, make suboptimal choices when the goal is to maximize gains rather than to minimize losses and that therefore they seem less able to identify options that should be clearly preferable8,9. How to explain these results? One possibility has to do with a primary deficit of executive function10. Another possibility stems from a simple consideration: tasks used in research do not consider the individual’s value system. Indeed, these tasks consider only values considered socially shared and therefore they tell us little about the different values of an individual and the way the latter faces them. For example, some subjects, for some reason, may not be interested in maximizing gains (at least in certain contexts) or, more importantly, might even upset about achieving such a goal. Could this be the case for OCD people? If so, empirical research presents the risk of considering a particular behavioral profile only as the result of a deficit, rather than the result of some particular and idiosyncratic functioning (characteristic of a specific diagnostic category).

Therefore, in addition to further studying – on an empirical level – decision-making process in OCD, it may be extremely helpful trying to better conceptualize potential idiosyncratic phenomena that can influence decision-making process in OCD. For example, what happens when an OCD subject finds himself/herself in everyday life in the opportunity to maximize own gains? Moreover, what happens, more precisely, when he/she – involved with unbiased and impartial commitment in a task – sees an unexpected and effortless personal benefit that could derive from that task?

Incompatibility perceived between unbiased commitment and satisfaction for an unexpected and effortless personal benefit (ICB)

In everyday life, it is constantly happening that someone perceives a sense of unbiased and disinterested commitment to someone or something: it can be a selfless concern about other people (as in the case of a physician who takes care of his/her patients) or a more impersonal concern (i.e., the observance and respect of certain principles). In both cases, the subject, following his/her commitment to something, can simultaneously also perceives with satisfaction some unexpected benefits which derive from his/her diligence and, usually, he/she does not feel these instances (commitment and personal benefit) as they were in conflict. For example, an architect who works hard on a project at the same time will be pleased to have found the easiest solution to a problem that allows him to return home first and he will not perceive any contradiction between the commitment to his job (and the search for the best solution to a technical problem) and the relief at having averted an evening of work.

Instead, the psychopathological analysis of the subjective experience of people with OCD and especially of the temporal course of this experience shows that things are very different for them. In fact, when an OCD person experiences an activity with a sense of unbiased and impartial commitment, he/she will experience the satisfaction with an unexpected and effortless personal benefit that could result from his/her activity as incompatible with the commitment itself. For simplicity, we can call this phenomenon “incompatibility perceived between unbiased commitment and satisfaction for an unexpected and effortless personal benefit” (ICB). To better illustrate this phenomenon, it is useful to present a clinical example.

Clinical example 1

A 25-year-old woman, suffering by obsessive doubts and ruminations for several years, had experienced – among other things – a significant decline in academic performance. This decline seemed to be due to the repeated occurrence of a phenomenon capable of significantly interfering with fluency in the study. Once, for example, while studying for an exam, she was very upset to notice the satisfaction she had felt by easily reading a difficult paragraph. In fact, considering her conception of the study based on principles of strict commitment, the pleasure she had felt seemed incongruous to her and a sign of her secret desire to avoid commitment.

Here it is quite evident that the girl experiences a sense of satisfaction for the unexpected and effortless benefit (the great ease in reading a difficult paragraph) that, per se, is perfectly compatible with her commitment to study and her disinterested thirst for knowledge. Instead, despite the lack of a real incompatibility, this patient perceives the two ingredients of her subjective experience as completely incompatible. In other terms, this case illustrates immediately the title of the present paper and, that is, the fact that a positive side of an activity (in this case, the ease in reading the paragraph) becomes, to the patient’s eye, even a disadvantage!

Importantly, both ingredients (the fact that the benefit is unexpected and that it is obtained effortlessly) appear to be necessary. That is to say, the subject should not foresee the benefit in advance but only glimpses it a moment later; and, in addition, the benefit must not come from extra effort.

Anyway, ICB seems so typical of OCD to be ubiquitous: to the point that it is easy to recognize it even during a psychotherapeutic treatment. Here too a clinical example is useful.

Clinical example 2

A 35-year-old woman, who has been suffering from OCD for many years, had undertaken psychotherapy with commitment. On one occasion, an understanding of why certain events in her life had caused her troublesome doubts had brought her great relief. A moment later, however, she had thought that “it was too good to be true”, and that perhaps the reading key, found during the therapy session, was misleading.

Even here, it is evident how the sudden appearance, even if after a laborious reconstruction of events, of an unexpected sense of relief has produced in the patient the suspicion of deceiving herself. Of course, there is no true incompatibility between her disinterested search for truth and the unexpected relief aroused by a guessed interpretation. Nevertheless, the patient feels deeply this presumed incompatibility and consequently looks at the unexpected advantage with suspicion and sees the relief as a proof that her commitment to therapy and her search for truth are only apparent.

That is not enough: in fact, the emotions involved in the presumed contrast are not simply perceived by patients as incompatible, but also undergo a process of double delegitimization, albeit in a different way for the two emotions. To understand this fact, it is useful for a moment to return to the first clinical example.

Here, in fact, the patient first feels the satisfaction felt with the ease with which she completed the reading of the difficult paragraph as incompatible with her conception of the study based on strict commitment. Then, through a process of ‘retrospective identification of motivations and inclinations’, described elsewhere11-13, the patient also ends up considering the satisfaction felt as the sign of her latent inclination to avoid the commitment. In fact, it is as if the patient were saying to herself “If I have felt this pleasure, which those who approach the study seriously should not feel, then it means that inside me there is an underlying superficiality and a tendency to avoid commitment and effort”13. Consequently, the patient considers the commitment to study a certainly desirable attitude but obviously false in her case; at the same time, she considers satisfaction (with ease of reading) as true, but completely unacceptable (that is, a feeling that should not be tried at all). In short, the subject with OCD manages to resolve the presumed contrast between the emotions perceived as incompatible only at the price of a heavy price: the delegitimization of both emotions.

ICB as a possible basis for at least some cases of indecisiveness in OCD

Phenomena like indecisiveness and pathological doubting about the decisions are well-known manifestations of OCD14. Usually, these phenomena are considered expression of some executive dysfunction10 or of some cognitive bias that would affect the decisional processes15, but the real problem that affects the decision-making in OCD is still unclear.

In everyday life, the decision-making process in OCD people tends often to be endless. Why? To understand this fact, we must keep in mind that a decision difficulty often manifests itself in the form of doubt between two options. Careful clinical observation allows us to discover that in OCD there is more than this: in fact, usually the difficulty in everyday life consists in a recursive oscillation between two branches of a doubt, where the subject feels both branches as impracticable. Each branch, in fact, leads to two instances perceived as incompatible, so the subject abandons it returning to explore, albeit with minimal variations, the other branch; but even this is impracticable, so the patient returns to the first branch and the process is repeated endlessly.

Here too, to exemplify the concept, it is useful to resort to a clinical example.

Clinical example 3

A 30-year-old man, a computer technician, suffering from OCD for many years, on one occasion while at work, began a long rumination without being able to interrupt it. In fact, the end of the working hours was approaching, and the man had not yet completed the tasks scheduled for that day. Once decided in any case to complete the work, he asked himself whether to ask his head for authorization for overtime. However, as soon as he thought of asking for authorization (“after all it is my right”), he also felt a sense of satisfaction for the relative economic gratification and immediately saw himself as a decidedly negative person (“terribly attached to material things”). However, if he thought instead not to ask for the extraordinary (“after all I like the job anyway”), when he saw that this choice also had the advantage of avoiding the annoyance of talking with his head, immediately saw himself also in this case as a negative person (“a person false with oneself”).

In this case, both branches of doubt (“I ask/I don’t ask for the overtime”) turn out to be impassable. In fact, when he thinks that “after all it is my right to ask for overtime”, at that moment he feels in the foreground an instance marked by his impartial attitude, and this because he perceives – at least at that moment – the request for overtime as a practice governed by an impersonal juridical rule, which does not concern him in the first person; however, as soon as, a moment later, he also focuses on the implication of economic gratification, he instead sees the latter as a personal benefit, which, however, appears to him completely incompatible with the disinterest of his right. It is at this point that he sees himself “attached to material things” as he identifies satisfaction with economic gratification as the true element of his experience and his appeal to a right, instead, only as apparent and therefore false.

In other words, the OCD subject, as already pointed out by Shapiro16, tries to decide by following a rule, an impersonal principle; the fact, highlighted in this paper, is that as soon as he/she sees an unexpected personal advantage that derives from that choice, he/she feels the adherence to that principle as not sincere.

A substantially similar process occurs as soon as the patient enters the other branch of doubt. In fact, when the patient thinks that he could do without the overtime (“because after all I like my job anyway”) he feels at first his choice as completely unbiased and disinterested (that is, not influenced by the search for personal advantage); however, as soon as he foresees – also in this case – an advantageous personal aspect (avoid facing the office manager), he feels the latter as the true element of experience, while he perceives the selfless interest in the work as false and therefore only as a pretext. Therefore, the subject abandons this second branch returning to explore, albeit with minimal variations, the first one; but first branch, despite the changes, will be still impracticable, so that the process will repeat itself indefinitely.

To further illustrate this process, yet another example may be useful:

Clinical example 4

A 28-year-old man had recently begun to be tormented by a doubt, which was also the reason he had asked for a consultation. In fact, his girlfriend had recently told him she was expecting a baby. This had taken him completely by surprise, as he had always made it clear to his partner that he did not wish to have children. At this point, anyway, he was at a crossroads: to recognize the future child or not? On the one hand, he thought it was right to assume his responsibilities; but when it occurred to him that in this case the girl’s father would surely offer him a good job in his company, he immediately saw himself as an opportunist taking advantage of the situation. On the other hand, when he thought that he had every right not to recognize the child, given the clarity with which he had always expressed his intentions to the girl, as soon as it occurred to him that this also entailed the advantage of freedom and possibility of new affective relationships, he immediately saw himself as an unscrupulous egoist.

Also in this case, it is evident that both branches of the doubt appear impracticable to the subject and due to a dynamic, that can be completely superimposed on the case discussed above. In fact, when the patient thinks he must take on his responsibilities, he sees only his duty in the foreground; but as soon as, a moment later, he also glimpses the economic gratification for the very probable permanent position, only this appears to him as a true and genuine feeling while the initial sense of duty seems to him only a pretext. In other words, it is as if he were saying to himself: “Ah, then that’s the only reason I would do it; therefore, the fact of taking my responsibilities is not the real reason, but only a pretext”.

When, on the other hand, he considers that he is not strictly obliged to recognize the child, at first, he sees in the foreground only the fact of appealing to his right and of remaining consistent with his previous decision. However, as soon as here too he feels, because of the choice not to recognize the child, the satisfaction for a newfound affective freedom, he feels only the latter as a true feeling, while at that point he feels the coherence of his own choice only as fictitious and spurious.

Of course, also in this case the subject abandons the second branch of his doubt returning to explore, albeit with minimal variations, the first one; but as the first branch, despite the changes, is still impracticable, the process will repeat itself indefinitely.

ICB, ‘ambivalence’, ‘self-ambivalence’, and ‘fear of self’

ICB also seems to shed new light on several concepts widely debated in the OCD literature: the concepts of ‘ambivalence’, ‘self-ambivalence’, and ‘fear of self’. Strictly speaking, these terms do not refer to OCD symptoms, but rather to explanatory concepts called into question precisely to explain the various clinical manifestations of the disorder.

Freud (1909) was the first to speak of ‘ambivalence’ regarding the OCD in a case that later became famous as the ‘Rat Man’17. The patient was a well-educated young man who had suffered from obsessions since his childhood, but with great intensity for the last four years before contacting the famous neurologist. The main feature of his disorder was an obsessive fear that something might happen to two people of whom he was very fond: his father and a woman he was in love with. The point we are interested in here refers to a period that precedes of several years the beginning of therapy and to illustrate the concept it seems useful to resort directly to Freud’s words.

Clinical example 5

“At that time, he had already been in love with his lady, but financial obstacles made it impossible to think of an alliance with her. The idea had then occurred to him that his father’s death might make him rich enough to marry her. In defending himself against this idea he had gone to the length of wishing that his father might leave him nothing at all, so that he might have no compensation for his terrible loss”17.

As Freud illustrates from the beginning of his writing, the patient was bound to his father by a great and disinterested affection. Nevertheless, the simple idea that at the death of the latter he would be rich enough to marry his beloved woman, was at once considered by him so unacceptable that he came to desire to be even disinherited in order not to find any personal advantage from his death. From this, Freud derives the idea that the patient, even if only on an unconscious level, desired the death of his father.

From Freud onwards, the psychodynamic theories of the OCD are still today based on the concept of ‘ambivalence’, that is a sort of conflict between feelings of love and hate or in any case between emotions of opposite polarity 18. Consequently, statements of selfless affection on the part of the patient towards the loved one are interpreted as an altruistic façade that, at least in part, works as a defense against latent aggression toward the latter.

More recently, this concept has been also empirically investigated by contemporary authors19-21. However, to evaluate – among other dimensions – also latent aggression, this research has made use of questionnaires, which inevitably appeal to a subjective evaluation of their own experiences by the patient; but this evaluation, precisely for phenomena such as ICB, could easily lead to misleading conclusions (which may overestimate the extent of aggressive emotions).

But is there any alternative explanation to ‘ambivalence’? According to what has been said so far, it is possible that the patient reads his thought, through a process of retrospective identification of motivations described elsewhere13, as a sign of a pre-existing desire, albeit hidden, for the death of his father, even though he does not really feel it. That means, it is as if the patient had said to himself “if I have done this thought, it means that at least a part of me really desires it!”13. However, it is important to underline that this conclusion is the result of a kind of tacit deduction and that this desire is not real at all, but only presumed starting from the perceived incompatibility between the gratification for the inheritance and the love for the father: two ingredients which are perfectly compatible. Therefore, there is an important difference with the Freud view: in fact, for the latter, the patient in question really had, even if only at the unconscious level, the desire that his father died; instead, according to the point of view discussed in this paper, the patient would not really have had this desire; rather, this would have been only a presumed wish.

Of course, this does not mean that some degree of true ambivalence is not involved in other cases. For example, clinical experience shows that usually at the basis of intrusive images with aggressive content there are unrecognized aggressive emotions that the patient can gradually identify only later, during the therapy. This means that authentic cases of ambivalence can coexist in the same patient alongside situations where a phenomenon like ICB is at stake.

While ‘ambivalence’ has an interpersonal nature, so-called ‘self-ambivalence’ – proposed by Guidano e Liotti22 – instead, refers to an ambivalent view of oneself. In fact, according to these authors, OCD people could have a double image of themselves, consisting of conflicting or even contradictory views: i.e., a good person versus a bad one, an upright individual versus a dishonest one. Anyway, to recover a sense of certainty about himself/herself, the subject temporally dislocates these antithetical images in such a way that the current negative self is combined with a positive potential self, felt as achievable in future22-24.

Recent studies seem to confirm that ‘self-ambivalence’ is indeed more frequent in OCD people than in general population25 and that, during an effective psychotherapeutic treatment, the improvement of symptoms appears to be accompanied by a reduction in self-ambivalence itself26.

Now, it is evident that ICB helps us to better understand what maintains – at least in some cases – ‘self-ambivalence’ over time: in fact, every time the patient ‘discovers’ that, behind an apparent disinterested involvement, there is a presumed hidden goal, a double image of himself/herself will renew to his/her eyes: a surface positivity, behind which hides a core of negativity to keep at bay.

Finally, we come to the last aspect: the ‘fear of self’27,28. The premises for this concept originate from Rachman’s work29: in fact, according to this author, intrusive thoughts were so stressful for OCD people because in their eyes they revealed hidden and unacceptable aspects of their true selves. According to the point of view of more recent authors30, ‘feared possible self’ refers to a set of qualities that the person fears or worries being part of oneself, currently or in the future. In other terms, ‘fear of self’ refers to the idea, not only of a possible actual ‘self’, but also of a ‘self’ that an individual is afraid of becoming.

However, when a process such as ICB intervenes, we see that it is not a question whether feared self is the current self or the self that one is afraid of becoming; rather a dynamic occurs whereby the subject, starting from the self he/she believes to be, each time instead ‘discovers’ a self that he/she fears to be. Moreover, it is immediately evident why a dynamic of this type can be one of the main factors contributing to the maintenance of ‘fear of self’.

Conclusions

This paper describes a phenomenon that appears to be crucial in OCD. In fact, OCD subjects seem to consider as incompatible with each other two experiential ingredients, which are in themselves perfectly compatible: on the one hand, the unbiased and disinterested commitment with which they undertake an activity, on the other, the satisfaction for an unexpected and effortless personal benefit that derives or could derive from that activity.

Anyway, because of this presumed incompatibility, the subject comes to delegitimize both experiential ingredients: the unbiased commitment, as the subject at this point considers it not real but only apparent, and the satisfaction for the effortless and unexpected personal benefit, as the subject considers it a true feeling but completely unacceptable in the light of his/her principles.

A delegitimization of this kind seems to be at the basis of at least some cases of indecisiveness in everyday life. In fact, if a subject perceives both options of a choice as impassable, he/she will continue to oscillate from one to the other and the decision-making process will not end.

But we can ask ourselves what kind of concept ICB is? If we keep in mind the distinction, formulated in the introduction, between the different types of concepts necessary to understand OCD, it seems that ICB can be related to high-order constructs such as ambivalence, self-ambivalence and fear of self; naturally, there is a difference; while the latter are constructs in a strict sense, ICB is a psychological process that unfolds over time. However, the differences are less pronounced than they seem at first glance if only one considers that ICB appears to shed new light on these constructs and helps understand what fuels and sustains them over time. For example, it helps us to better understand what maintains ‘self-ambivalence’ over time at least in certain cases: in fact, every time the patient discovers, behind an apparently disinterested involvement, a presumed hidden motive, a double image of himself/herself will be renewed in his eyes and that is, a surface positivity, behind which a core of negativity to keep at bay lies.

Moreover, besides directly explaining at least some cases of pathological doubt, ICB might also be involved in many other manifestations of OCD. It must be considered, indeed, that especially at the onset of the disorder, obsessions do not suddenly appear out of the blue, as Freud’s case illustrates well. Therefore, it is possible that at the root of many intrusive thoughts, there is originally a process like ICB, which then ends up going unnoticed over time.

Naturally, a limitation of the present study is that it is exclusively theoretical in nature; therefore, further research will be necessary to assess the extent of ICB and the role it plays in OCD.

Anyway, the identification of ICB in OCD of course has not only a theoretical value, but it also has important clinical implications. In fact, it is evident that the way a clinical problem is conceptualized also suggests the treatment for it. In this case, the fact of identifying – as an important phenomenon underlying OCD – a process that renders emotions incompatible with each other, even when in fact they are not, also suggests therapeutic intervention. In fact, it is a question of helping the patient to recognize that this incompatibility between disinterestedness and satisfaction with an effortless personal advantage does not really exist.

To illustrate this procedure, let us think again of the first clinical example. In this case, in fact, the therapist reconstructed together with the patient the attitude and the emotional state that the latter had before the upsetting emotion emerged (the satisfaction with the ease of reading the difficult paragraph). It has become clear that the attitude of diligence and seriousness towards the study were also present in that circumstance. Furthermore, from the reconstruction it emerged that the ease in understanding the paragraph in question probably arose both from her natural predisposition for the subject and from the fact that she was finally achieving a mastery of a topic, for which - moreover - she felt a growing passion. In this case, she was very relieved to discover her true feelings. At the same time, she finally recognized that there was no incompatibility between her disinterested commitment to study and the gratification felt in that circumstance. In fact, she now discovered with great relief a richer self-image, in which instances previously perceived as completely irreconcilable are now not at all.

Conflict of interests: the author has no conflict of interests to declare.

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