Moral judgments in obsessive-compulsive disorder: a narrative mini-review
Keywords:moral judgments, moral decision making, obsessive-compulsive disorder, executive functions, dual-process theory
Obsessive-compulsive disorder (OCD) is a prevalent mental disorder characterized by intrusive thoughts (obsessions) and ensuing rituals (compulsions). Although OC patients exhibit various cognitive and behavioral problems, rigid and hypersensitive moral judgments are known to be one of the most striking problems in these patients. There is evidence indicating that OC patients often tend to make deontological judgments in moral dilemmas, significantly more than the healthy population. Therefore, numerous studies are dedicated to understanding the underlying cognitive processes responsible for such variation of moral judgments in OCD, which are reviewed and discussed in the current paper. First, it is previously discussed that abnormal moral judgments in OCD are due to executive dysfunctions. These dysfunctions include impaired cognitive control resulting in the domination of strong, uncontrolled emotional responses, impaired cognitive flexibility resulting in the inability to switch between aspects of a scenario, and decreased capacity and overload of working memory and its inability to resist the interfering information. The dual-process theory also emphasizes and acknowledges the role of executive functions in moral judgments. Second, it is thought that disobeying moral norms results in the abnormal feeling of deontological guilt in OC patients, to which these patients are highly sensitive. Feeling of guilt is also thought to be correlated with OCD symptomatology. The third impairment contributing to abnormal moral judgments in OCD is known to be the abnormal feeling of disgust for moral violations and immoral unwanted intrusive thoughts, which is regarded as one of the major causes of OCD symptoms. Finally, the abnormal fear of responsibility and being criticized due to not acting morally is regarded as one of the primary impairments contributing to the abnormal moral judgments in OCD. In conclusion, this review sheds light on the most striking cognitive and affective impairments contributing to abnormal moral judgments in OCD.
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (DSM-5®): American Psychiatric Pub.
Arntz, A., Voncken, M., & Goosen, A. C. (2007). Responsibility and obsessive-compulsive disorder: An experimental test. Behaviour Research and Therapy, 45(3), 425-435. https://doi.org/10.1016/j.brat.2006.03.016
Baddeley, A. D. (1986). Working memory Oxford. England: Oxford Uni.
Baddeley, A. D., & Hitch, G. (1974). Working memory. In Psychology of learning and motivation (Vol. 8, pp. 47-89): Elsevier.
Barkley, R. A. (1997). Behavioral inhibition, sustained attention, and executive functions: constructing a unifying theory of ADHD. Psychological Bulletin, 121(1), 65. Retrieved from https://doi.org/10.1037/0033-2909.121.1.65
Basile, B., & Mancini, F. (2011). Eliciting guilty feelings: A preliminary study differentiating deontological and altruistic guilt. Psychology, 2(2), 98-102. https://doi.org/10.4236/psych.2011.22016
Basile, B., Mancini, F., Macaluso, E., Caltagirone, C., & Bozzali, M. (2014). Abnormal processing of deontological guilt in obsessive-compulsive disorder. Brain Structure and Function, 219(4), 1321-1331. https://doi.org/10.1007/s00429-013-0570-2
Benzina, N., N'Diaye, K., Pelissolo, A., Mallet, L., & Burguière, E. (2019). A cross-species assessment of cognitive flexibility in compulsive disorders. bioRxiv, 542100. https://doi.org/10.1101/542100
Besiroglu, L., Sozen, M., Ozbebit, Ö., Avcu, S., Selvi, Y., Bora, A., Atli, A., Unal, O., & Bulut, M. (2011). The involvement of distinct neural systems in patients with obsessive-compulsive disorder with autogenous and reactive obsessions. Acta Psychiatrica Scandinavica, 124(2), 141-151. https://doi.org/10.1111/j.1600-0447.2011.01726.x
Bhikram, T., Abi-Jaoude, E., & Sandor, P. (2017). OCD: obsessive-compulsive… disgust? The role of disgust in obsessive-compulsive disorder. Journal of Psychiatry & Neuroscience: JPN, 42(5), 300-306. https://dx.doi.org/10.1503%2Fjpn.160079
Bigdeli, I., Badin, M., & Sabahi, P. (2017). The comparison of Cognitive Flexibility, theory of mind and working memory in students with symptoms of obsessive-compulsive disorder and normal group. Advances in Cognitive Sciences, 18(4), 24-37.
Chiang, B., & Purdon, C. (2019). Have I done enough to avoid blame? Fear of guilt evokes OCD-like indecisiveness. Journal of Obsessive-Compulsive and Related Disorders, 20, 13-20. https://doi.org/10.1016/j.jocrd.2018.02.001
Cosentino, T., D’Olimpio, F., Perdighe, C., Romano, G., Saliani, A., & Mancini, F. (2012). Acceptance of being guilty in the treatment of obsessive-compulsive disorder. Psicoterapia Cognitiva e Comportamentale, 18(3), 39-56.
D'Olimpio, F., Cosentino, T., Basile, B., Tenore, K., Gragnani, A., & Mancini, F. (2013). Obsessive-compulsive disorder and propensity to guilt feelings and to disgust. Clinical Neuropsychiatry, 10(3 Suppl.1), 20-29.
D’Olimpio, F., & Mancini, F. (2014). Role of deontological guilt in obsessive-compulsive disorder-like checking and washing behaviors. Clinical Psychological Science, 2(6), 727-739. https://doi.org/10.1177%2F2167702614529549
de Wilde, A., Koot, H. M., & van Lier, P. A. C. (2016). Developmental links between children’s working memory and their social relations with teachers and peers in the early school years. Journal of Abnormal Child Psychology, 44(1), 19-30. https://doi.org/10.1007/s10802-015-0053-4
Deckersbach, T., Savage, C. R., Curran, T., Bohne, A., Wilhelm, S., Baer, L., Jenike, M. A., &. Rauch, S. L. (2002). A study of parallel implicit and explicit information processing in patients with obsessive-compulsive disorder. American Journal of Psychiatry, 159(10), 1780-1782. https://doi.org/10.1176/appi.ajp.159.10.1780
Frankenstein, A. (2016). To Kill or Not to Kill: Exploring the Roles of Empathy and Working Memory in Moral Decision Making. UNF Graduate Theses and Dissertations. 625. https://digitalcommons.unf.edu/etd/625
Franklin, S. A., McNally, R. J., & Riemann, B. C. (2009). Moral reasoning in obsessive-compulsive disorder. Journal of Anxiety Disorders, 23(5), 575-577. https://doi.org/10.1016/j.janxdis.2008.11.005
Freeston, M. H., Rhéaume, J., & Ladouceur, R. (1996). Correcting faulty appraisals of obsessional thoughts. Behaviour Research and Therapy, 34(5-6), 433-446. https://doi.org/10.1016/0005-7967(95)00076-3
Gaikwad, U. (2014). Pathophysiology of obsessive-compulsive disorder: affected brain regions and challenge towards discovery of novel drug treatment. In Obsessive-Compulsive Disorder-The Old and the New Problems: IntechOpen. https://doi.org/10.5772/56999
Garrigan, B., Adlam, A. L., & Langdon, P. E. (2018). Moral decision-making and moral development: Toward an integrative framework. Developmental Review, 49, 80-100. https://doi.org/10.1016/j.dr.2018.06.001
Gibbs, J. C. (2019). Moral development and reality: Beyond the theories of Kohlberg, Hoffman, and Haidt: Oxford University Press.
Greenberg, B. D., Altemus, M., & Murphy, D. L. (1997). The role of neurotransmitters and neurohormones in obsessive-compulsive disorder. International Review of Psychiatry, 9(1), 31-44. https://doi.org/10.1080/09540269775574
Greenberg, B. D., Rauch, S. L., & Haber, S. N. (2010). Invasive circuitry-based neurotherapeutics: stereotactic ablation and deep brain stimulation for OCD. Neuropsychopharmacology, 35(1), 317. https://doi.org/10.1038/npp.2009.128
Greene, J., & Haidt, J. (2002). How (and where) does moral judgment work? Trends in Cognitive Sciences, 6(12), 517-523. https://doi.org/10.1016/S1364-6613(02)02011-9
Greene, J. D. (2009). Dual-process morality and the personal/impersonal distinction: A reply to McGuire, Langdon, Coltheart, and Mackenzie. Journal of Experimental Social Psychology, 45(3), 581-584. https://doi.org/10.1016/j.jesp.2009.01.003
Greene, J. D., Morelli, S. A., Lowenberg, K., Nystrom, L. E., & Cohen, J. D. (2008). Cognitive load selectively interferes with utilitarian moral judgment. Cognition, 107(3), 1144-1154. https://doi.org/10.1016/j.cognition.2007.11.004
Greene, J. D., Nystrom, L. E., Engell, A. D., Darley, J. M., & Cohen, J. D. (2004). The neural bases of cognitive conflict and control in moral judgment. Neuron, 44(2), 389-400. https://doi.org/10.1016/j.neuron.2004.09.027
Greene, J. D., Sommerville, R. B., Nystrom, L. E., Darley, J. M., & Cohen, J. D. (2001). An fMRI investigation of emotional engagement in moral judgment. Science, 293(5537), 2105-2108. https://doi.org/10.1126/science.1062872
Guglielmo S. (2015). Moral judgment as information processing: an integrative review. Frontiers in Psychology, 6, 1637. doi:10.3389/fpsyg.2015.01637
Harrison, B. J., Pujol, J., Soriano-Mas, C., Hernández-Ribas, R., López-Solà, M., Ortiz, H., Alonso, P., Deus, J., Menchon, J. M., Real, E., Segalàs, C., Contreras-Rodríguez, O., Blanco-Hinojo, L., & Cardoner N. (2012). Neural correlates of moral sensitivity in obsessive-compulsive disorder. Archives of General Psychiatry, 69(7), 741-749. https://doi.org/10.1001/archgenpsychiatry.2011.2165
Hinson, J. M., Jameson, T. L., & Whitney, P. (2003). Impulsive decision making and working memory. Journal of Experimental Psychology: Learning, Memory, and Cognition, 29(2), 298-306. https://doi.org/10.1037/0278-73126.96.36.1998
Huey, E. D., Zahn, R., Krueger, F., Moll, J., Kapogiannis, D., Wassermann, E. M., & Grafman, J. (2008). A psychological and neuroanatomical model of obsessive-compulsive disorder. The Journal of Neuropsychiatry and Clinical Neurosciences, 20(4), 390-408. https://doi.org/10.1176/jnp.2008.20.4.390
Inchausti, F., Delgado, A. R., & Prieto, G. (2015). Obsessive-compulsive disorder and its relationship with disgust vulnerability and conscientiousness. Psicothema, 27(3), 254-260. https://doi.org/10.7334/psicothema2015.7
Jaafari, N., Frasca, M., Rigalleau, F., Rachid, F., Gil, R., Olié, J.-P., Guehl, D., Burbaud, P., Aouizerate, B., Rotgé, J. Y., & Vibert, N. (2013). Forgetting what you have checked: A link between working memory impairment and checking behaviors in obsessive-compulsive disorder. European Psychiatry, 28(2), 87-93. https://doi.org/10.1016/j.eurpsy.2011.07.001
Lieberman, M. D., Gaunt, R., Gilbert, D. T., & Trope, Y. (2002). Reflexion and reflection: A social cognitive neuroscience approach to attributional inference. Advances in Experimental Social Psychology, 34, 199-249. https://doi.org/10.1016/S0065-2601(02)80006-5
Lopatka, C., & Rachman, S. (1995). Perceived responsibility and compulsive checking: An experimental analysis. Behaviour Research and Therapy, 33(6), 673-684. https://doi.org/10.1016/0005-7967(94)00089-3
Maia, T. V., Cooney, R. E., & Peterson, B. S. (2008). The neural bases of obsessive-compulsive disorder in children and adults. Development and Psychopathology, 20(4), 1251-1283. https://doi.org/10.1017/S0954579408000606
Maia, T. V., & McClelland, J. L. (2012). A neurocomputational approach to obsessive-compulsive disorder. Trends in Cognitive Sciences, 16(1), 14-15. https://doi.org/10.1016/j.tics.2011.11.011
Mancini, F., & Gangemi, A. (2011). Fear of deontological guilt and fear of contamination in obsessive-compulsive disorder. Psicoterapia Cognitiva e Comportamentale, 17(3), 395-404.
Mancini, F., & Gangemi, A. (2015). Deontological guilt and obsessive compulsive disorder. Journal of Behavior Therapy and Experimental Psychiatry, 49, 157-163. https://doi.org/10.1016/j.jbtep.2015.05.003
Melli, G., Aardema, F., & Moulding, R. (2016). Fear of self and unacceptable thoughts in obsessive-compulsive disorder. Clinical Psychology and Psychotherapy, 23(3), 226-235. https://doi.org/10.1002/cpp.1950
Melli, G., Chiorri, C., Carraresi, C., Stopani, E., & Bulli, F. (2015). The role of disgust propensity and trait guilt in OCD symptoms: A multiple regression model in a clinical sample. Journal of Obsessive-Compulsive and Related Disorders, 5, 43-48. https://doi.org/10.1016/j.jocrd.2015.01.007
Moore, A. B., Clark, B. A., & Kane, M. J. (2008). Who shalt not kill? Individual differences in working memory capacity, executive control, and moral judgment. Psychological Science, 19(6), 549-557. https://doi.org/10.1111/j.1467-9280.2008.02122.x
Nakamura, K. (2012). The Footbridge Dilemma Reflects More Utilitarian Thinking Than The Trolley Dilemma: Effect Of Number Of Victims In Moral Dilemmas. Paper presented at the Proceedings of the Annual Meeting of the Cognitive Science Society. 803-808.
Nestadt, G., Grados, M., & Samuels, J. F. (2010). Genetics of obsessive-compulsive disorder. The Psychiatric Clinics of North America, 33(1), 141-158. https://doi.org/10.1016/j.psc.2009.11.001
Neubauer, A. C., & Fink, A. (2009). Intelligence and neural efficiency. Neuroscience & Biobehavioral Reviews, 33(7), 1004-1023. https://doi.org/10.1016/j.neubiorev.2009.04.001
Obsessive Compulsive Cognition Working Group. (1997). Cognitive assessment of obsessive-compulsive disorder. Behaviour Research and Therapy, 35(7), 667-681. https://doi.org/10.1016/S0005-7967(97)00017-X
Olatunji, B. O., Ebesutani, C., David, B., Fan, Q., & McGrath, P. B. (2011). Disgust proneness and obsessive-compulsive symptoms in a clinical sample: Structural differentiation from negative affect. Journal of Anxiety Disorders, 25(7), 932-938. https://doi.org/10.1016/j.janxdis.2011.05.006
Olatunji, B. O., Tolin, D. F., Huppert, J. D., & Lohr, J. M. (2005). The relation between fearfulness, disgust sensitivity and religious obsessions in a non-clinical sample. Personality and Individual Differences, 38(4), 891-902. https://doi.org/10.1016/j.paid.2004.06.012
Piacentini, J., Bergman, R. L., Keller, M., McCracken, J. (2003). Functional impairment in children and adolescents with obsessive-compulsive disorder. Journal of Child and Adolescent Psychopharmacology, 13(Supplement 1), S61-69. https://doi.org/10.1089/104454603322126359
Picó‐Pérez, M., Ipser, J., Taylor, P., Alonso, P., López‐Solà, C., Real, E., Segalàs, C., Roos, A., Menchón, J. M., Stein, D. J., & Soriano-Mas, C. (2019). Intrinsic functional and structural connectivity of emotion regulation networks in obsessive‐compulsive disorder. Depression and Anxiety, 36(2), 110-120. https://doi.org/10.1002/da.22845
Pittenger, C., Bloch, M. H., & Williams, K. (2011). Glutamate abnormalities in obsessive compulsive disorder: neurobiology, pathophysiology, and treatment. Pharmacology & Therapeutics, 132(3), 314-332. https://doi.org/10.1016/j.pharmthera.2011.09.006
Purcell, R., Maruff, P., Kyrios, M., & Pantelis, C. (1998). Cognitive deficits in obsessive-compulsive disorder on tests of frontal-striatal function. Biological Psychiatry, 43(5), 348-357. https://doi.org/10.1016/S0006-3223(97)00201-1
Radua, J., van den Heuvel, O. A., Surguladze, S., & Mataix-Cols, D. (2010). Meta-analytical comparison of voxel-based morphometry studies in obsessive-compulsive disorder vs other anxiety disorders. Archives of General Psychiatry, 67(7), 701-711. https://doi.org/10.1001/archgenpsychiatry.2010.70
Reuven, O., Liberman, N., & Dar, R. (2014). The effect of physical cleaning on threatened morality in individuals with obsessive-compulsive disorder. Clinical Psychological Science, 2(2), 224-229. https://doi.org/10.1177%2F2167702613485565
Rickelt, J., de Wit, S. J., van der Werf, Y. D., Schruers, K. R., Marcelis, M., de Vries, F. E., & van den Heuvel, O. A. (2019). Emotional processing and disgust sensitivity in OCD patients with and without contamination-type obsessive-compulsive symptoms-An fMRI study. Journal of Obsessive-Compulsive and Related Disorders, 22, 100443. https://doi.org/10.1016/j.jocrd.2019.100443
Robinson, J. S., Xu, X., & Plaks, J. E. (2019). Disgust and deontology: Trait sensitivity to contamination promotes a preference for order, hierarchy, and rule-based moral judgment. Social Psychological and Personality Science, 10(1), 3-14. https://doi.org/10.1177%2F1948550617732609
Şahin, H., Köşger, F., EşSizoğlu, A., & Aksaray, G. (2018). The Relationship Between Obsessive Belief Level and Cognitive Flexibility in Patients with Obsessive Compulsive Disorder. Archives of Neuropsychiatry, 55(4), 376-379. https://dx.doi.org/10.5152%2Fnpa.2017.21648
Salkovskis, P. M., Wroe, A., Gledhill, A., Morrison, N., Forrester, E., Richards, C., Reynolds, M., & Thorpe, S. (2000). Responsibility attitudes and interpretations are characteristic of obsessive compulsive disorder. Behaviour Research and Therapy, 38(4), 347-372. https://doi.org/10.1016/S0005-7967(99)00071-6
Saxena, S., Brody, A. L., Schwartz, J. M., & Baxter, L. R. (1998). Neuroimaging and frontal-subcortical circuitry in obsessive-compulsive disorder. The British Journal of Psychiatry, 173(S35), 26-37.
Stein, D. J., Fineberg, N. A., Bienvenu, O. J., Denys, D., Lochner, C., Nestadt, G., Leckman, J. F., Rauch, S. L., & Phillips, K. A. (2010). Should OCD be classified as an anxiety disorder in DSM‐V? Depression and Anxiety, 27(6), 495-506. https://doi.org/10.1002/da.20699
Sunstein, C. R. (2005). Moral heuristics. Behavioral and Brain Sciences, 28(4), 531-542. https://doi.org/10.1017/S0140525X05000099
Tomiyama, H., Nakao, T., Murayama, K., Nemoto, K., Ikari, K., Yamada, S., Kuwano, M., Hasuzawa, S., Togao, O., Hiwatashi, A., & Kanba S. (2019). Dysfunction between dorsal caudate and salience network associated with impaired cognitive flexibility in obsessive-compulsive disorder: A resting-state fMRI study. NeuroImage: Clinical, 24, 102004. https://doi.org/10.1016/j.nicl.2019.102004
Trafford, A. A., Wroe, A. L., Brown, G., & Luzon, O. (2018). What you see is what you do: Imagery and the moral judgements of individuals with OCD. Journal of Obsessive-Compulsive and Related Disorders, 16, 50-55. https://doi.org/10.1016/j.jocrd.2017.12.002
Twohig, M. P., Hayes, S. C., & Masuda, A. (2006). Increasing willingness to experience obsessions: Acceptance and commitment therapy as a treatment for obsessive-compulsive disorder. Behavior Therapy, 37(1), 3-13. https://doi.org/10.1016/j.beth.2005.02.001
Verduzco-Flores, S., Bodner, M., Ermentrout, B., Fuster, J. M., & Zhou, Y. (2009). Working memory cells' behavior may be explained by cross-regional networks with synaptic facilitation. PloS one, 4(8), e6399. https://doi.org/10.1371/journal.pone.0006399
Vicario, C. M. (2013). Morality and disgust: insights from obsessive compulsive disorder. Frontiers in Psychiatry, 3, 113. https://doi.org/10.3389/fpsyt.2012.00113
Viol, K., Aas, B., Kastinger, A., Kronbichler, M., Schöller, H. J., Reiter, E.-M., Said-Yürekli, S., Kronbichler, L., Kravanja-Spannberger, B., Stöger-Schmidinger, B., Aichhorn, W., & Schiepek, G. K. (2019). Erroneously disgusted: fMRI study supports disgust-related neural reuse in Obsessive-Compulsive Disorder (OCD). Frontiers in Behavioral Neuroscience, 13, 81. https://dx.doi.org/10.3389%2Ffnbeh.2019.00081
Voiklis, J., & Malle, B. F. (2018). Moral cognition and its basis in social cognition and social regulation. In K. Gray & J. Graham (Eds.), Atlas of moral psychology (p. 108–120). The Guilford Press.
Vos, S. P., Huibers, M. J., & Arntz, A. (2012). Experimental investigation of targeting responsibility versus danger in cognitive therapy of obsessive‐compulsive disorder. Depression and Anxiety, 29(7), 629-637. https://doi.org/10.1002/da.21915
Waldmann, M. R., & Dieterich, J. H. (2007). Throwing a bomb on a person versus throwing a person on a bomb: Intervention myopia in moral intuitions. Psychological Science, 18(3), 247-253. https://doi.org/10.1111%2Fj.1467-9280.2007.01884.x
Whitton, A. E., Henry, J. D., & Grisham, J. R. (2014). Moral rigidity in obsessive-compulsive disorder: Do abnormalities in inhibitory control, cognitive flexibility and disgust play a role? Journal of Behavior Therapy and Experimental Psychiatry, 45(1), 152-159. https://doi.org/10.1016/j.jbtep.2013.10.001
Wilhelm, S., Steketee, G., Reilly-Harrington, N. A., & Deckersbach, T., Buhlmann, U., & Baer, L. (2005). Effectiveness of cognitive therapy for obsessive-compulsive disorder: An open trial. Journal of Cognitive Psychotherapy, 19(2), 173-179. https://psycnet.apa.org/doi/10.1891/jcop.188.8.131.52792
Yoder, K. J., Decety, J. (2018). The neuroscience of morality and social decision-making. Psychology, Crime & Law, 24(3), 279-295. https://doi.org/10.1080/1068316X.2017.1414817
How to Cite
The observations and associated materials published or posted by NeurosciRN are licensed by the authors for use and distribution in accord with the Creative Commons Attribution license CC BY-NC 4.0 international, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.