Can Obsessive Compulsive Disorder be Considered a Disorder of Imagination? A Psychological Perspective

Search methodology

This comprehensive review of OCD and the role of imagination was conducted using major databases, including Google Scholar, PubMed, Scopus, PsycINFO, Web of Science, MEDLINE, Cochrane Library, Embase, DOAJ (Directory of Open Access Journals) and Science Direct. The search keywords included terms such as OCD, imagination, cognitive perspective, default mode network (DMN), neurobiological perspective, and treatment.

Role of imagination in symptomatology

Association between imagination and intrusive images in OCD

Research demonstrates that both intrusive images and imagination within OCD share equivalent brain and cognitive processes, although they remain distinct concepts in the disorder. Research has revealed that both brain and mental functions exhibit overlap. The DMN, together with visual imagery processing systems, operates during both imagination and intrusive imagery experiences. Results from some research^[19] show that OCD patients experiencing intrusive ideas present hyperactivity patterns in the precuneus and posterior cingulate cortex areas, which process imagined scenes. During OCD-related imagery studies, scientists found that the hippocampus, which plays a central role in imagination and memory formation, became active according to functional magnetic resonance imaging (fMRI) results.^[20]

The DMN model and origin of negative imagery:

When a resting state occurs, the DMN is activated, engaging several brain regions that are involved in daydreaming, self-reflection, and imaginative processes. Studies utilising neuroimaging techniques have shown abnormalities within the DMN structures in patients suffering from OCD that might be responsible for the significant symptoms of this disorder. Research has identified that OCD patients reveal elevated DMN network connections through large brain nodes, which indicates that more self-centred mental processing reduces their capacity for typical sensory input.^[25] People with hyperactive DMN networks get caught in mental loops that produce obsessive mental activity, leading to recurrent compulsive actions. Research conducted by some researchers^[26] confirmed that creative skills lead individuals to display enhanced functional connectivity between the DMN and inferior prefrontal cortex, indicating better control of the area and imagination-area coordination. In one study,^[27] discovered that imagination requires executive control networks to work together with the DMN during creative task performance. The research studies^[28] demonstrated that imaginative thinking activated the DN throughout its length. The DN is activated uniformly in the absence of external demands on the task, a state that has mainly been explained as being due to mind-wandering or the spontaneous occurrence of thought independent of sensory input^[29-31], which further indicates its possible implication in obsessive-compulsive disorder as the mind is always on a lookout for a dangerous outcome in the absence of any apparent trigger stimuli in the environment in OCD. Spreng^[32] suggested, based on his research data, that the DN is not only a task-negative network but is instead a reflection of active internal processing involved in goal-directed task performance^[33-35]. The DN shows high activity when a person retrieves episodic memories, which consist of reconstructing past experiences rather than simply recalling them as static records.^[20] For example, let’s say one is asked to remember their last birthday party. The brain of the individual will not just replay an exact video of the event. Still, instead, it will reconstruct details like who was there, the cake’s taste, and the music playing by piecing together stored episodic information.^[36] The DN helps in this reconstruction process. Not just this, but the DN is also activated when individuals imagine future scenarios, using past experiences to predict what might happen.^[37] For example, if one individual is planning a vacation to the mountains, they might visualise hiking, the cold air, and the beautiful views, even if they have never been there before. The brain in humans relies on past experiences to construct an imagined future. In view of these research findings, it is strongly implied that the same process underpins OCD brain functioning. In OCD, the mind becomes prone to cognitive distortions like catastrophizing, black-and-white thinking, and inferential confusion.^[38] Given the activation of these cognitive distortions, the default network gives rise to negative-toned futuristic thinking in combination with constructing and tunnelling episodic memory to the negative spectrum mostly. In combination with cognitive distortions like intolerance of uncertainty,^[39] the default network produces a row of intrusive thoughts accompanied by compulsion in many cases, and this phenomena clearly indicate how imagery works inside the brain, along with a few dominant cognitive errors, giving birth to a doubtful orientation of the decision-making process in the form of OCD. Furthermore, studies have shown decreased functional connectivity in some DMN subsystems in patients with OCD, which can act as a possible biomarker of obsession severity.^[40] These results suggest the multifaceted function of the DMN in OCD, where increased global connectivity and decreased connectivity in particular subsystems could be involved in the pathology of the disorder. In addition, disruptions in the DMN have been associated with abnormal self-referential processing in OCD patients, indicating that these changes in the brain could be responsible for the intrusive and repetitive thoughts of the disorder.^[41] Together, these studies indicate that hyperactivity and connectivity changes in the DMN could be a key factor in the development and maintenance of OCD symptoms, where imagery work is distorted and causes abnormalities in self-referential thoughts.

The role of the amygdala, fear processing, and visual perspective in intrusive imagery of OCD:

Considerably more focus on the function of negative verbal thoughts than on the function of visual intrusions has been given in mental disorders.^[42] On the other hand, a growing body of empirical data indicates that intrusive visual memories and visions are a common component of many disorders and are recognised as a trans-diagnostic process.^[43,44] Experimental research suggests that imagery may elicit stronger emotional responses than do corresponding verbal cognitions.^[45,46] In line with this, the significance of intrusive imagery in understanding emotional distress has been noted many times in literature.^[47,48] In contrast to merely linguistic or abstract “contents of consciousness,” images are “contents of consciousness that possess sensory qualities” .^[49] According to some studies, images are perceived “on a continuum from the near accurate reconstruction in the mind of a real event to the construction of an entirely hypothetical situation. Vibrantness is a crucial aspect of imaging from a clinical standpoint.^[50] Although it can vary greatly in intensity, reliving is a common characteristic of autobiographical memory and is consistent with Tulving’s ^[51] concept of autonoetic awareness, which is a particularly vivid type of imagery. The higher frequency, more frequent adoption of a field viewpoint, and lower degree of linkage with memories of intrusive pictures in OCD set them apart from those in other anxiety disorders. ‘Unacceptable concepts of damage’ and a ‘hazardous self ’ were frequently mentioned in their content. These results imply that imagery rescripting might be helpful and have implications for the application of therapeutic therapies in OCD. Patients with OCD have been found to have a hyperactive amygdala, a crucial part of the brain involved in processing fear and identifying threats.^[52] According to some studies, this hyperactivity makes intrusive thoughts seem more vivid, genuine, and upsetting by increasing their emotional significance.^[53] According to many research studies, this heightened fear response is connected to the cortico-striato-thalamo-cortical circuit’s maladaptive activation, which is linked to OCD symptoms.^[54] Therefore, intrusive visions cause a strong emotional response, which reinforces how upsetting they are and results in compulsive actions meant to counteract perceived dangers.^[2]

This effect is consistent with the evolutionary “fight or flight” reaction, which occurs when the brain increases visual and sensory awareness in response to possible danger.^[55] This increased threat awareness in OCD, however, is diverted toward imagined rather than real threats, leading people to believe that their intrusive pictures are real and imminent threats.^[56] For example, a person suffering from contamination OCD may not only think about germs but also vividly “see” them spreading across their hands. This overwhelming sensation of impending danger drives them to engage in compulsive washing rituals.^[57] In addition to making suffering worse, this merging of mental images and observed reality emphasises how neurobiological dysfunction contributes to the recurrence of OCD symptoms.

The study by some researchers^[58] aimed to investigate the behavioural and subjective effects of altering visual perspective, either for the field or the observer, on intrusive pictures associated with worries about contamination and doubt. One hundred and twelve undergraduates with severe OCD symptoms were instructed to visualise and identify an intrusive image associated with contamination or questioning worries. They were then given the task of revisualising their image from either a field (first-person) or observer (third-person) perspective at random. In contrast to those who adopted a “field perspective,” those who adopted an “observer perspective” felt that the image was “less likely to happen,” had “fewer urges to suppress it,” and experienced “a greater reduction” in distress from the image. Intrusive images are experienced by OCD sufferers from a “first-person (field) perspective” because they give the thoughts a “more vivid, real, and emotionally intense” dimension. By elevating “self-relevance”, this viewpoint exacerbates anxiety and distress. Fear is processed by the “amygdala”, which is “hyperactive in OCD” and intensifies the emotional reaction.^[51] OCD sufferers struggle to leave intrusive thoughts because they lack the skill of “cognitive distancing”.^[58] The sensation of being directly involved in the threatening experience depends on first-person imagery to make obsessions feel urgent, leading people to engage in compulsive behaviours. The Revised Dual Representation Theory helps understand intrusive imagery in OCD According to some studies, the theory distinguishes between the abstract temporal Contextual Representations (C-Reps), which carry meaning, and the Sensation-Based Representations (S-Reps) that maintain specific sensory and emotional quality. The reason OCD-related intrusive thoughts remain both emotionally powerful and unfading is that “weak C-Reps” cause the mind to lose its ability to dismiss them rationally. OCD patients experience difficulties due to their unreasonable fears, as indicated by this explanation.^[59]