Exploring the role of external criticism in Obsessive Compulsive Disorder: A narrative review

Clinical Psychology Review 31 (2011) 361–370

Contents lists available at ScienceDirect

Clinical Psychology Review

Exploring the role of external criticism in Obsessive Compulsive Disorder: A narrative review Sonia M. Pace a,⁎, Richard Thwaites b, Mark H. Freeston c a b c

Gateshead Primary Care Mental Health Team, The Croft, Wrekenton, Gateshead, Tyne and Wear, NE9 7BJ, United Kingdom Cumbria Partnerships NHS Foundation Trust, First Step, Elmwood, 2a Tynefield Drive, Penrith Cumbria, CA11 8JA, United Kingdom Newcastle University, Institute of Neuroscience, Newcastle upon Tyne, NE1 7RU, United Kingdom

a r t i c l e

i n f o

Article history: Received 19 August 2010 Received in revised form 15 January 2011 Accepted 18 January 2011 Available online 26 January 2011 Keywords: Obsessive Compulsive Disorder Criticism Cognitive model

a b s t r a c t The concept of external criticism has been associated with different aspects of Obsessive Compulsive phenomena. The various threads of evidence highlight the potential role of criticism within different areas of the cognitive model of Obsessive Compulsive Disorder (OCD) with often overlapping ideas. However, the fragmented nature of the findings makes it difficult to identify how or why criticism impacts on OCD. This review collates the existing findings and maps these onto the cognitive model of OCD to provide a better understanding of the potential role of criticism. It proposes criticism could play a role in OCD as a vulnerability factor, but also as a perpetuating factor. Furthermore potential research questions have been generated which could help inform future understanding. Future research should consider the complexity of the concept when defining criticism as well as developing methodological designs which could answer questions of causality. © 2011 Elsevier Ltd. All rights reserved.

Contents 1.

2.

3.

4. 5.

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1.1. Defining constructs . . . . . . . . . . . . . . . . . . . . . . 1.1.1. Obsessive Compulsive Disorder . . . . . . . . . . . . 1.1.2. Criticism . . . . . . . . . . . . . . . . . . . . . . . 1.1.3. Difficulties in defining criticism . . . . . . . . . . . . 1.2. Subtypes of criticism . . . . . . . . . . . . . . . . . . . . . 1.3. Criticism in the mental health literature . . . . . . . . . . . . 1.4. Cognitive models of OCD. . . . . . . . . . . . . . . . . . . . 1.5. Criticism and OCD . . . . . . . . . . . . . . . . . . . . . . . 1.6. Methodology . . . . . . . . . . . . . . . . . . . . . . . . . Developmental factors and familial influences . . . . . . . . . . . . . 2.1. Parenting styles . . . . . . . . . . . . . . . . . . . . . . . . 2.2. Familial factors . . . . . . . . . . . . . . . . . . . . . . . . Belief domains within OCD . . . . . . . . . . . . . . . . . . . . . . 3.1. Perfectionism . . . . . . . . . . . . . . . . . . . . . . . . . 3.2. Self-worth . . . . . . . . . . . . . . . . . . . . . . . . . . 3.3. Self-domains . . . . . . . . . . . . . . . . . . . . . . . . . 3.4. Responsibility . . . . . . . . . . . . . . . . . . . . . . . . . Compulsive behaviors . . . . . . . . . . . . . . . . . . . . . . . . Criticism and treatment outcome . . . . . . . . . . . . . . . . . . . 5.1. Expressed Emotion (EE) and Perceived Criticism (PC) . . . . . . 5.2. Why does PC or criticism and hostility by relatives predict poorer 5.2.1. Criticism and hostility . . . . . . . . . . . . . . . . . 5.2.2. EE as a stressor . . . . . . . . . . . . . . . . . . . . 5.2.3. Attributional style. . . . . . . . . . . . . . . . . . . 5.3. Limitations of treatment outcome research . . . . . . . . . . .

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . treatment . . . . . . . . . . . . . . . . . . . .

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . outcome? . . . . . . . . . . . . . . . . . . . .

. . . . . . . . . . . . . . . . . . . . . . . . . .

. . . . . . . . . . . . . . . . . . . . . . . . . .

. . . . . . . . . . . . . . . . . . . . . . . . . .

. . . . . . . . . . . . . . . . . . . . . . . . . .

. . . . . . . . . . . . . . . . . . . . . . . . . .

. . . . . . . . . . . . . . . . . . . . . . . . . .

. . . . . . . . . . . . . . . . . . . . . . . . . .

. . . . . . . . . . . . . . . . . . . . . . . . . .

. . . . . . . . . . . . . . . . . . . . . . . . . .

. . . . . . . . . . . . . . . . . . . . . . . . . .

. . . . . . . . . . . . . . . . . . . . . . . . . .

. . . . . . . . . . . . . . . . . . . . . . . . . .

. . . . . . . . . . . . . . . . . . . . . . . . . .

. . . . . . . . . . . . . . . . . . . . . . . . . .

. . . . . . . . . . . . . . . . . . . . . . . . . .

. . . . . . . . . . . . . . . . . . . . . . . . . .

. . . . . . . . . . . . . . . . . . . . . . . . . .

. . . . . . . . . . . . . . . . . . . . . . . . . .

. . . . . . . . . . . . . . . . . . . . . . . . . .

. . . . . . . . . . . . . . . . . . . . . . . . . .

. . . . . . . . . . . . . . . . . . . . . . . . . .

. . . . . . . . . . . . . . . . . . . . . . . . . .

. . . . . . . . . . . . . . . . . . . . . . . . . .

362 362 362 362 362 362 362 362 363 363 363 364 364 365 365 365 365 365 366 367 367 367 367 367 367 368

⁎ Corresponding author. Tel.: +44 1912832541. E-mail addresses: [email protected], [email protected] (S.M. Pace), [email protected] (R. Thwaites), [email protected] (M.H. Freeston). 0272-7358/$ – see front matter © 2011 Elsevier Ltd. All rights reserved. doi:10.1016/j.cpr.2011.01.007

362

S.M. Pace et al. / Clinical Psychology Review 31 (2011) 361–370

6.

Discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6.1. How can the findings be understood within the cognitive model 6.2. Methodological issues and implications for future research . . . 6.3. Limitations . . . . . . . . . . . . . . . . . . . . . . . . . 6.4. Clinical implications . . . . . . . . . . . . . . . . . . . . . 6.5. Conclusion. . . . . . . . . . . . . . . . . . . . . . . . . . Acknowledgement . . . . . . . . . . . . . . . . . . . . . . . . . . . . References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1. Introduction 1.1. Defining constructs 1.1.1. Obsessive Compulsive Disorder Obsessive Compulsive Disorder (OCD) is considered a heterogeneous disorder (Calamari, Weigartz, & Janeck 1999) and a disabling condition that can significantly impair quality of life (Eisen et al. 2006). The worldwide prevalence rate of OCD is estimated at 2% of the general population (Sasson, Zohar, Chopra, Lustig, & Iancu 1994). The key features of OCD are intrusive recurrent distressing thoughts (obsessions) and compulsive behaviors (ICD-10, WHO, 2007). Such unwanted thoughts can include those of harm to oneself or to others and are common in approximately 90% of the population (Rachman & de Silva 1978). In individuals with OCD the occurrence of obsessions is distinguished by the degree of distress experienced. Compulsions can involve washing, cleaning, checking, ordering, seeking reassurance, repetitive actions, and covert compulsions, such as mental rituals (ICD-10, WHO, 2007) and are generally performed to prevent a feared consequence or event, or to relieve distress provoked by the obsession. 1.1.2. Criticism Criticism is derived from the Greek word 'Kritikos' meaning discernment therefore criticism originally referred to making a judgment (Baron, 1993). However, Baron (1993) claims the modern day recognition of the meaning of criticism is associated with terms such as unpleasant, inconsiderate, or harsh. In support of this a number of definitions broadly cast criticism as a negative concept. For example, Neapolitan (1988) defined criticism as a “negative reinforcement which produces feelings of failure and has been identified as a poor way to encourage better performance” (p. 223). More recently Smith and Peterson (2008) describe it as “a generic stressor because it has been linked to medical and psychiatric problems as well as marital discord” (p. 301). A critique common across these definitions is that they fail to elaborate on the definition or justify the terms in relation to the wider literature on criticism which suggests that criticism is a complex construct and therefore difficult to define narrowly. 1.1.3. Difficulties in defining criticism Abbott and Lyter (1998) highlight the difficulty and lack of clarity in defining criticism. They state that criticism can mean different things to different people; it can simply mean “an act of analysis” (p. 44) or it can have quite negative connotations. Meyer, Reisenzein, and Dickhauser (2004) further confound the concept of criticism by discussing it interchangeably with blame without attempting to define either concept and so imply that they are synonymous. 1.2. Subtypes of criticism The lack of agreed definition may stem from different subtypes of criticism. The most detailed descriptions and definitions are found in attempts to develop sub-categories of criticism, largely in the non-

. . . . . of OCD? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

. . . . . . . .

. . . . . . . .

. . . . . . . .

. . . . . . . .

. . . . . . . .

. . . . . . . .

. . . . . . . .

. . . . . . . .

. . . . . . . .

. . . . . . . .

. . . . . . . .

. . . . . . . .

. . . . . . . .

. . . . . . . .

. . . . . . . .

. . . . . . . .

. . . . . . . .

. . . . . . . .

. . . . . . . .

. . . . . . . .

. . . . . . . .

. . . . . . . .

. . . . . . . .

. . . . . . . .

. . . . . . . .

. . . . . . . .

. . . . . . . .

. . . . . . . .

. . . . . . . .

368 368 368 369 369 369 369 369

clinical literature. The subtypes provide useful descriptions of criticism and suggest possible effects, which could help explore the role of criticism in OCD and are therefore briefly outlined in Table 1.

1.3. Criticism in the mental health literature Criticism within the clinical literature typically uses terms, such as expressed emotion, hostile and non-hostile criticism, perceived criticism and blame. These concepts fit the modern day recognition suggested by Baron (1993) of criticism as negative or punitive. The exception to this is hostile and non-hostile criticism, which has been differentiated within the clinical literature. However, recent research has found ratings of general perceptions of criticism are driven by perceived hostile criticism, therefore, when people are asked about criticism they consider it to be negative or hostile (Renshaw, Blais, & Caska 2010). Self-criticism has also been investigated in relation to mental health (e.g., Blatt, 2004); however, self-criticism involves a negative self-judgment (Ongen, 2006) and is defined as “a harsh punitive evaluation of the self often accompanied by guilt, feelings of unworthiness, and self-recrimination” (Powers, Zuroff, & Topciu 2004, p.61). Therefore, self-criticism is not solely dependent on feedback from others and is deemed distinct from experiences of external criticism and will therefore not be considered in this review.

1.4. Cognitive models of OCD Maintenance and origins of OCD can be understood through cognitive theory, where clinical and research data from the last thirty years provide support to a well-founded account of obsessional difficulties (Salkovskis, 1985). Central to the cognitive model of OCD is the role of appraisals. The distress experienced in OCD comes in part from a dysfunctional responsibility appraisal, which may involve beliefs around responsibility for causing or preventing harm to oneself or others (Salkovskis, 1985). According to this account it is the appraisal of the obsessions in terms of personal responsibility that links the intrusion with distress and the urge to neutralize (Salkovskis, Forrester, & Richards 1998; Rheaume, Ladouceur, Freeston, & Letarte 1995). Beliefs related to inflated responsibility have been proposed as one of six cognitive variables that play an important role in OCD (Obsessive Compulsive Cognitions Working Group (OCCWG), 1997). The remaining five belief domains are: overimportance of thoughts (which includes the concept of Thought Action Fusion (TAF, Rachman, 1993)), excessive concern about the importance of controlling one's thoughts, overestimation of threat, intolerance of uncertainty and perfectionism (OCCWG, 1997). The belief domains of responsibility and perfectionism will be explored within this review as there are some studies linking them to the construct of criticism. The other four belief domains will not be considered because literature searches on these terms found no studies to date that linked them to criticism in OCD.

S.M. Pace et al. / Clinical Psychology Review 31 (2011) 361–370

363

Table 1 a Subtypes of criticism. Author

Subtypes of criticism

Features

Tracy, Van Dusen, and Robinson (1987)

Good

° ° ° ° °

Bad

Baron (1993)

Constructive

Destructive

Kamins and Dweck (1999)

Process Outcome Person

Neapolitan (1988)

Specific product General actor

a

Assistance to make the desired change was provided. Positive reasons for changing a behaviour were given. Feedback was specific. Criticism was part of a bigger more positive message. Negative language and a harsh manner, raised in volume or reflective of negative. labels (e.g. stupid). ° Emphasis focused on the awful consequences of not making change. ° Specificity of content. ° Delivery via a considerate tone and in an appropriate setting. ° Causal attributions of performance are not made. ° Non-specific and inconsiderate without consideration of the feelings of the recipient. ° It can be harsh, and contain threats without guidance on how the recipient could improve their performance. ° It is inappropriate in terms of time and method. ° It implies internal attributions, which can create a sense of blame on the part of the recipient. ° Process criticism focused on the strategy used and not the individual performing. ° Outcome criticism, where criticism was focused on the behaviour itself and not the individual participant. ° Person criticism, which was described as harsher criticism, this feedback involved an evaluation directed to the individual participant based on his or her performance. ° Focuses on what the individual has done and the role they have played. ° It is specific and therefore outlines what is good and bad about the performance. ° No specific information is delivered to the individual. ° The criticism is not related to what the individual has done but more towards the individual themselves.

Table 1 description of specific subtypes of criticism.

1.5. Criticism and OCD A wide range of literature links the concept of external criticism to various aspects of OC phenomena, ranging from theoretical discussions to clinical case evidence to empirical investigations. The literature is quite fragmented and criticism is often not the explicit focus of the research. The review therefore aims to explore roles of external criticism in OCD. The review will be broadly structured around the cognitive model of OCD. It begins with an examination of the role of criticism in the context of developmental and familial factors; this considers aspects of the cognitive model which focus on the early experiences which could predispose an individual to develop OCD. Next, belief domains within OCD are discussed in relation to criticism, namely perfectionism and responsibility. Self worth and the specific belief domain of social acceptability are also reviewed in this section as research has investigated the role of these concepts in relation to criticism and OCD. Then, neutralizing behaviors are considered with a focus on the compulsive behaviors of checking and cleaning. Last, the role of criticism in relation to treatment outcome is considered, including research which has investigated measures of perceived criticism and expressed emotion (which includes criticism) and their impact on treatment outcome in OCD.

sociological, where key terms were derived from the mental health literature and the broader non-clinical literature (i.e., criticism, negative feedback, and blame). The review included: peer reviewed journals, books, and grey literature including unpublished theses. The search was not limited by date and all study types were included. Clinical and non-clinical populations were included as aspects of OC behaviors have often usefully investigated within non-clinical samples. Sources which could not be accessed in the English language were not used. Searches included terms which did not explicitly mention criticism per se but referred to overlapping constructs, therefore additional narrower searches were also used. For example, the term Expressed Emotion (EE) is broader construct made of three components including criticism so it was used as a search term to ensure all of the literature investigating EE in OCD was accessed. Further searches were also conducted on names of authors whose work was identified throughout the search process and who appeared to be key researchers in the field of interest. Further articles were indentified through systematic examination of reference lists from articles found in each of the earlier searches. Following these threads through the literature increased likelihood of adequate coverage of the field.

1.6. Methodology

2. Developmental factors and familial influences

The review used a mixed method employing systematic search techniques with a narrative method. The disjointed nature of the literature warrants a narrative style without a heavy methodological focus where quite different areas of knowledge are scoped and synthesized to develop a better understanding of the area. As a purely systematic search is unlikely to successfully access the rather fragmentary literature, where key terms may not appear in titles, abstracts or words, a range of additional search strategies were therefore employed and are described below. A range of electronic databases (Web of knowledge, Medline via OVID, Applied Social Sciences Index, and Abstracts via CSA ILLUMINA and PsycINFO via APA PsycNET) was used in the review to encompass a wide range of sources, which include medical, psychological, and

The cognitive model of OCD identifies types of early experiences that may predispose an individual to develop OCD. This builds on early theoretical discussions and empirical investigations that consider the role of critical and demanding child-rearing styles as a vulnerability factor in the development of OCD beliefs and behaviors. For example, OC behaviors may develop as techniques to gain parental approval and avoid criticism (Cameron, 1947). Dollard and Miller (1950) proposed OC behaviors to be the result of social training; as parental criticism increases anxiety, methods (such as OC behaviors) for reducing anxiety are learned. Broader family studies have further identified heightened levels of criticism in families of children and adults with OCD (e.g., Tynes, Salins, & Winstead, 1990; Leonard et al., 1993).

364

S.M. Pace et al. / Clinical Psychology Review 31 (2011) 361–370

2.1. Parenting styles A core feature of the cognitive model of OCD is the role of responsibility. Salkovskis, Shafran, Rachman, and Freeston (1999) considered a number of pathways that could lead to an inflated sense of responsibility. Overprotective and critical parenting was proposed to lead to inflated responsibility as protecting the child from responsibility could result in increasing sensitivity to responsibility. Coles, Schofield, and Pietrefesa (2006) found overprotective parenting moderated the relationship between behavioral inhibition and OCD symptoms; potentially overprotective parenting could involve intrusive and critical parenting. Salkovskis et al. (1999) theorized that experiences of recurrent criticism may increase the “subjective cost of being responsible” (Salkovskis et al., 1999 p.1065). Such theoretical discussions are useful as they propose how criticism could contribute to the development of OC beliefs. However, it is difficult to determine whether criticism or blame is the construct under discussion as the concepts are discussed interchangeably without a clear definition of either. Despite this, a recent descriptive study of the proposed pathways to developing OCD highlighted the role of criticism. Five out of twenty participants reported an event through which either failure to do something or actually doing something led to the experience of harm. In four out of these five examples individuals conceptualized harm as excessive criticism from their parents (Davies, 2005). In considering how such incidents may be influential in the development of inflated responsibility, Davies (2005) proposed that the costs of making a mistake for some in the OCD sample appeared to be the risk of criticism. One participant described setting higher standards to avoid criticism, while another felt that concern over criticism drove feelings of responsibility where the main concern was not for others but concern over being criticized. Appraisals of responsibility are proposed to influence subsequent compulsive behaviors; therefore could critical parenting also provoke OC behaviors? Rachman and Hodgson (1980) proposed how different parenting styles could differentially influence OC behaviors. Overprotective families may result in fearful dependent children while rejecting and overcritical parents may increase the subjective costs of making mistakes leading to children who attempt to keep things right and avoid errors, resulting in checking behaviors (Rachman & Hodgson, 1980). Partial support for the differential controlling parenting styles was found in a clinical study where half of the participants in the checker group identified their mother as meticulous and 68% described their mother as demanding, compared with 29% of washers (Steketee, Grayson, & Foa, 1985). Although a hyper-critical style was not explicitly measured, it is possible that terms such as demanding and meticulous would relate to a parent who is perceived as, or is critical. Further, in a non-clinical sample a highly critical and demanding parenting style was associated with OC traits and symptoms as well as other anxiety disorders (Aycicegi, Harris, & Dinn, 2002). This small number of studies highlights the potential role of critical parenting styles in the development of OC phenomena. Despite this, limitations common across these studies must be acknowledged. Due to the lack of comparison and control groups it is not clear whether individuals with other psychiatric problems would report similar experiences. The studies utilize retrospective self-reports which rely on participants memory rather than actual objective accounts of events and are therefore subject to bias. For example, Bhar (2004) found that empirical literature can fail to differentiate what are memories of childhood experiences from what are actual experiences. A further limitation is the lack of clear differential definitions of criticism and other similar concepts in these studies. Terms describing parenting styles such as demanding or meticulous may suggest a critical style but do not measure criticism directly. Analysis of speech samples could be used to consider the number of critical comments a parent makes towards their child (e.g., Challacombe & Salkovskis,

2009), this would need to be applied to families with children with OCD or prospective studies. Furthermore, where incidents of criticism have been explicitly investigated there is a reliance on the participants' perceptions of criticism and not an objective report of the incident. Perceptions of criticism in a patient relative dyad have only shown moderate correlations with objective measures of criticism (Chambless, Bryan, Aiken, Steketee, & Hooley, 1999). However, Hooley and Teasdale (1989) argued that perceived criticism is more important than objective reports as perceptions of criticism relate to the criticism that is “getting through to the patient” (p. 234). A study which partially resolved this latter limitation used a group of non-clinical participants (undergraduate and graduate students) who reported obsessive and compulsive symptoms (subclinical OC group), a group who did not (control group), and their parents, specifically to investigate whether parents of the subclinical OC group are characterized by perfectionism, high levels of criticism and riskaversion (Frost, Steketee, Cohn, & Griess, 1994). Participants' perceptions of parental criticism (PC) and parents' self-reports of delivering criticism were measured. The subclinical OC group reported significantly higher scores on measures of perceived criticism of their mothers compared to the control group. There was no significant difference in relation to perceived criticism from the father. Fathers in the OC group self-reported more criticism towards their daughters than the fathers in the control group did. Support for the role of criticism from both received and delivered perspectives is evident, although the relationship between the two positions is inconsistent; higher received from the mother, higher delivered by the father. Further, ratings of criticism from both parties only reached significance in the group rated higher in OC behaviors; therefore, an actual clinical sample may show a stronger association. 2.2. Familial factors The role of criticism in OCD has also been investigated using the construct of Expressed Emotion (EE). EE refers to the feelings displayed by a relative towards a patient with psychological difficulties and is usually measured with the Camberwell Family Interview (CFI) (Vaughn & Leff, 1976). EE is made up of CFI-rated Criticism, Hostility and Emotional Over Involvement (EOI). Relatives identified as low EE have shown tolerant and sensitive characteristics (Wearden, Tarrier, Barrowclough, Zastowny, & Armstrong Rahill, 2000), whereas, high EE is scored if one or more relatives are rated as critical, hostile, or emotionally over involved. Parents of children with OCD have exhibited higher levels of EE compared to parents of nonpsychiatric controls (Hibbs, Hamburger, Kruesi, & Lenane, 1993). Hibbs et al. (1991) found a high percentage of children in their OCD sample had one relative who was rated high in EE, while similar findings have been replicated across more than one culture (Shanmugiah, Verghese, & Khanna, 2002). Although the high EE categorization usually results from a rating of criticism (Chambless, 1998), as three components are grouped to make up EE it is unclear which element is the most important. In consideration of this more recent research has investigated the three components separately; the majority of this line of research focuses on the impact of EE on treatment outcome and will be discussed in the latter part of the review. While parental and familial criticism has been clearly identified in some cases; causality is unclear. For example, it is not clear whether experiences of critical parenting are a vulnerability factor for OCD, or does the behavior of the patient lead a stressed parent or relative to express critical attitudes? Alternatively does living with a highly critical relative affect the patient in a way which contributes to relapse (Wearden et al., 2000) and therefore maintains the disorder? Waters and Barrett (2000) argue that causal interpretations cannot be made and a reciprocal relationship between relatives' and patients'

S.M. Pace et al. / Clinical Psychology Review 31 (2011) 361–370

behaviors and/or temperament is likely. The actual OC behaviors themselves could evoke critical reactions, which can have a reciprocal effect as the impact of punishment or criticism could result in distress and/or increased symptoms (Renshaw, Steketee, & Chambless, 2005), however this does not rule out the possibility that early experiences of criticism could be a vulnerability factor for developing OCD. Therefore, a critical parent or high EE relative could both trigger and perpetuate OC behaviors or develop and strengthen OC beliefs; longitudinal or experimental designs may be needed to build the case. 3. Belief domains within OCD A range of beliefs based on assumptions about self, world, and others has been identified in OCD. Specifically six beliefs domains have been recognized as important (OCCWG, 1997), although there is much debate about the distinctiveness of these and the degree to which they overlap (e.g., OCWG, 2003; Wu & Carter, 2008). It of course remains possible that beliefs about threat, certainty or thoughts (and their controllability) as indicators of possible harm may also contribute to the perception of negative events or outcomes that if they were to occur, whether caused or not prevented by the individual concerned, could lead to criticism by others. To date, the role of criticism has been investigated in relation to two belief domains, perfectionism and responsibility. Bhar (2004) proposed these belief domains function to maintain a sense of selfworth, for example by maintaining a sense of responsibility and perfectionism the individual strives to maintain approval from others (and so avoids criticism and disapproval). Therefore, the role of criticism in relation to self-worth will also be considered. 3.1. Perfectionism McFall and Wollersheim (1979) first proposed that perfectionistic strategies in OCD aim to avoid criticism or disapproval from others. Other authors have also suggested perfectionism develops to gain approval from hyper-critical parents (Frost, Marten, Lahart, & Rosenblate, 1990). For the purpose of this review, a sub-type of perfectionism will be considered. Socially Prescribed Perfectionism (SPP) involves concerns over meeting other people's standards and avoiding disapproval from others, therefore, those exhibiting SPP would be expected to have a greater fear of criticism (Hewitt & Flett, 1991). In line with this proposal, SPP was associated with measures of Fear of Negative Evaluation (Hewitt & Flett, 1991). Furthermore, SPP has been linked to EE and an individual's perceptions of critical others (Hewitt & Flett, 1991). Thus, it appears justifiable to consider this construct as similar to concern over, or perception of criticism and therefore a relationship between SPP and OCD could provide indirect support for the role of criticism in OCD. Bhar and Kyrios (1999) showed that OC phenomena were significantly related to sociotropy and SPP after controlling for gender and depression, this relationship was not found for autonomy. If criticism signals disapproval of either the behavior or of the person, a desire for approval may also indicate a reluctance to be criticized. The relationship between OC phenomena, sociotropy, and SPP could then provide indirect evidence for the role of criticism in OCD. Bhar and Kyrios (1999) suggest depression or OCD could be seen as different reactions to personality styles where compulsions found in OCD demonstrate a reaction which attempts to meet social approval (and therefore avoid criticism). This is in line with Guidiano and Liotti's (1983) proposal that OC behaviors or beliefs may be perfectionistic strategies to gain or retain the social approval of others (and therefore avoid criticism). Although the study controlled for depression the lack of control for other anxiety-related features limits the specificity of the findings as the same factors identified by this study may also be important in other anxiety disorders. For example, SPP was found not to be specific to OCD symptoms but was also correlated with measures

365

of symptoms of other disorders including phobias and anxiety (Hewitt & Flett, 1991). 3.2. Self-worth This proposed need for the social approval of others and the importance of avoiding disapproval or criticism could be related to an individual's perception of their self-worth (Ehntholt, Salkovskis, & Rimes, 1999). Individuals with OCD may be unsure about their selfworth due to receiving contradictory messages from a dominant parent during childhood (Guidiano & Liotti, 1983). Compulsive behaviors may then emerge as unhelpful strategies to regain a positive sense of self or to retain social approval, and therefore a positive personal identity (Guidiano & Liotti, 1983). In support of this, dysfunctional responsibility beliefs and perfectionistic strategies were related to an ambivalent sense of self in those with OCD (Bhar, 2004). The cognitive model of OCD proposes that an individual fears harm coming to self or being responsible and blamed for causing harm (Ehntholt et al., 1999). Therefore, OC behaviors, such as avoidance or approval seeking, may serve to protect the individual and help maintain a sense of self-worth (Bhar, 2004). An investigation with a primary focus on the link between selfesteem and obsessional problems found that when compared to anxious control and non clinical groups, those with OCD were more sensitive to potential criticism or blame from others (Ehntholt et al., 1999). They argued that this finding is consistent with cognitive theories of an inflated sense of responsibility (Ehntholt et al., 1999). Therefore, responsibility for preventing harm may be maintained by a fear of criticism. Despite this, criticism was not defined, furthermore sensitivity to blame and criticism are used simultaneously so it is unclear whether the self-referent component refers to a fear over being criticized or blamed, or both. Participants did describe concern that others would “loathe” or “despise” them (Ehntholt et al., 1999, p. 778) which seems more related to criticism of the person without a consequence and less relevant to being blamed for behavior or for an action. 3.3. Self-domains Recent research has investigated the self-concept as multidimensional where a number of specific self-domains have been associated with the cognitive theory of OCD (Doron & Kyrios, 2005). The domain of social acceptability, which refers to concerns over negative evaluation from others, seems most relevant to the role of criticism in OCD. Research on non-clinical participants found high social acceptability was related specifically to beliefs about perfectionism/intolerance of uncertainty; however this did not remain after controlling for self-worth (Doron & Kyrios, 2005). The relationship between social acceptability and OCD cognitions was not replicated among people with OCD (Doron, Moulding, Kyrios, & Nedeljkovic, 2008), although there may be restricted range effects in a clinical group. The lack of consistent findings makes it difficult to draw firm conclusions. The research on self-worth, self-domains and socially prescribed perfectionism is limited and due to its cross-sectional nature inferences about causality cannot be made. It is therefore unclear whether perfectionist styles or a low sense of self-worth develops in response to criticism or is maintained by experiences of criticism. Furthermore the research to date in this area fails to consider subtypes of OC phenomena, which may be more or less related to social approval and/or avoidance of criticism. 3.4. Responsibility The belief domain of responsibility plays a central role in the cognitive model of OCD (Salkovskis, 1999) and is supported by

366

S.M. Pace et al. / Clinical Psychology Review 31 (2011) 361–370

evidence that has shown OC patients and those with OCD-like symptoms score higher on measures of responsibility (e.g., Myers & Wells, 2004; Salkovskis et al., 2000; Steketee, Frost, & Cohen, 1998; Rheaume, Freeston, Dugas, Letarte, & Ladouceur, 1995). Responsibility and criticism could also be linked as the actions that someone is responsible for are also the ones that are likely to produce criticism or guilt (Rachman, 1976). It is possible that as responsibility for an action decreases so may the likelihood of being criticized for that action (Rachman, 1976). An experimental investigation of the role of criticism and responsibility in OCD found manipulations of higher and lower responsibility led to significant increases and decreases in perceptions of the likelihood of anticipated criticism, as rated by participants with OCD (Lopatka & Rachman, 1995). There was also a trend in a high responsibility condition for the severity of anticipated criticism to be enhanced and for increases in perceived responsibility to be followed by increases in the severity of anticipated criticism. Severity of anticipated criticism decreased after perceptions of responsibility decreased (Lopatka & Rachman, 1995). Interestingly, in this study, the manipulation of responsibility included a manipulation of blame, participants in the high responsibility condition were told "you will be to blame if anything happens" (Lopatka & Rachman, 1995, p. 676). Therefore, were increases in perceptions of criticism related to expectations of blame or is the threat of being blamed another way of manipulating responsibility? This study is useful as it is one of the few experimental studies which directly examine a link between a core feature of OCD and the role of criticism. Despite this, the study fails to define criticism (although the focus was not primarily on criticism); it is not clear if anticipation of criticism is related to criticism directed at the person, their behavior or both, and whether there was an overlap with perceptions of blame. Furthermore, as criticism is not clearly defined and based on an individual's understanding of the term criticism, it is difficult to measure. Finally, the wider literature has highlighted that criticism can be construed differently between individuals. Although a sense of responsibility has been shown to influence the likelihood of anticipated criticism, the opposite position that criticism influences responsibility has not yet been specifically investigated. However, recent research has considered the relationship between negative feedback on a task, OC behaviors and responsibility (Mancini, D'Olimipio, & Cieri, 2004). An increased “expectation of failure” (Mancini et al., 2004 p. 451), was manipulated by informing participants they obtained very low scores because they were inattentive, which could also be construed as delivering negative feedback or criticism. In the ‘expectation of failure’ (or negative feedback) plus responsibility condition participants performed more compulsive type behaviors than in the responsibility only and control conditions. Although these results are interpreted as indicating the role of reduced coping abilities in OC phenomena (Mancini et al., 2004) they may provide evidence for the effect of criticism on OC behaviors where the person is held responsible. Furthermore, due to the experimental design it could be concluded receipt of criticism under conditions of responsibility increases OC–type behaviors above responsibility alone. However, the findings are limited as power was not reported, though a small sample was used (n = 12 in each group) and a number of statistical tests were conducted without acknowledging the possibility of a type 1 error. 4. Compulsive behaviors Compulsive behaviors or neutralizing strategies are also defining features of OCD (ICD-10, WHO, 2007) and therefore must be considered in this review. As mentioned previously compulsions are generally performed to prevent a feared consequence or event or to ease distress provoked by the obsession. As noted from the developmental section, distress can be conceptualized at least in

some case as harm in the form of criticism from others. A further function of OC behaviors is proposed to include the avoidance of criticism or guilt for having caused some kind of harm (Rachman, 1976). Neutralizing behaviors such as compulsions may result from attempts to prevent blame from others for failing to prevent some kind of harm (Salkovskis, 1985). Relatives’ critical comments were found to be related to patient's compulsive behaviors but not obsessions (Amir, Freshman, & Foa, 2000); however, intrusive thoughts could make the individual feel like a bad person and subsequent OC behaviors could be attempts to avoid any blame for having the intrusion (Salkovskis, 1985). In a single case study, McAndrew (1989) found attempts to control intrusive thoughts were related to the person's fear of negative evaluation, criticism and rejection. The thoughts were appraised by this person as evidence of being a bad person, and criticism validated the appraisal of the intrusive thoughts (McAndrew, 1989). The developmental theories discussed earlier propose a specific relationship between criticism and checking behaviors. Following this proposal, theoretical discussions and research have considered the role of criticism with regard to the type of compulsive behaviors. For example, Rachman (1976) proposed that checking behaviors may be attempts at prevention, whereas, the purpose of cleaning behaviors can be restorative (Rachman, 1976). A potential outcome from harm caused to others would be to experience criticism from others. Thus, checking behaviors could be seen as an attempt at active avoidance; actively doing something to prevent punishment in the form of criticism from others or the experience of guilt (Rachman, 1976). Therefore, if the focus is on prevention and an individual experiences criticism, would this increase checking behavior? A test of Rachman's (1976) hypothesis with a clinical sample compared OC washers and checkers (Turner, Steketee, & Foa, 1979). Six items from the Fear Survey Schedule (FSS; Wolpe & Lang, 1969) were used to measure fear of criticism. The mean scores for all six factors were higher in the OC group as opposed to the phobia and control groups but no difference was found between washers and checkers. However, an attempted replication of the study with additional anxious comparison groups found no differences between the OCD, social phobic, and agoraphobic group on measures of fear of criticism (Thyer, Curtis, & Fechner, 1984). Thus, there is inconsistent support for this position although the construct validity for the 6-item criticism scale is unclear. An indirect investigation relevant to this question was conducted by Van-Dijk and Kluger (2004) based on Higgins (1997) selfregulatory theory to consider how negative feedback can be used to increase or decrease motivation on a task. Higgins (1997) described two basic self-regulation systems. The first system regulates avoidance of punishment and focuses on a prevention goal. Through interactions with parents or significant carers children learn to regulate themselves. Criticism for mistakes or punishment for irresponsibility incites a concern with safety, responsibility and a prevention focus (Higgins, 1997). Those individuals who are prevention focused are sensitive to negative outcome and believed to watch for any errors, with the aim of avoiding/preventing mistakes. If the individual experiences a negative outcome, for example negative feedback that is compatible with their focus (preventing punishment), a preventative strategy is triggered (Higgins, 1997). Van-Dijk and Kluger (2004) found among individuals who were prevention focused, receiving negative feedback that is congruent with their regulation focus style increased motivation more than the receipt of positive feedback. Although this research is non-clinical and makes no links to the OCD literature, findings are in line with Rachman's (1976) proposals. If individuals displaying OC checking behaviors are focused on prevention, an actual experience of negative feedback could increase their motivation and therefore increase checking behaviors and perhaps hypervigilance to triggers or intrusive thoughts about harm and so lead to an increase in checking behaviors.

S.M. Pace et al. / Clinical Psychology Review 31 (2011) 361–370

Thus, the empirical research on specific OC behaviors is limited to checking behaviors and based on the predictions made by Rachman (1976), but these predictions are only partially supported. The measure used to assess the construct ‘fear of criticism’ is limited as it taps into guilt (self-criticism) as well as external criticism; therefore, it is not clear which type of criticism is most influential in differentiating the groups. Despite these limitations the role of criticism has been directly related to responsibility, while the hypothesized links between responsibility, criticism and checking behaviors have been indirectly assessed through examining the effects of negative feedback (Mancini et al., 2004). Given the link between responsibility and OC behaviors it seems reasonable to propose that criticism may impact on OC behaviors by inflating (further) a sense of responsibility, though this and other potential routes are yet to be directly investigated. 5. Criticism and treatment outcome Cognitive behavioral formulations of OCD have led to integrated treatment strategies. Cognitive elements of treatment aim to develop a less threatening explanation for and so appraisal of intrusive thoughts (Salkovskis, 1999), while behavioral elements include exposing the patient to the obsessions but preventing engagement in compulsions or other neutralizing strategies. The impact of criticism on treatment outcome is arguably the main area of empirical research to explicitly consider the role of criticism in OCD; with a focus on the constructs of Expressed Emotion (EE) and Perceived Criticism (PC) in relation to outcomes of behavioral treatment. Criticism has been found to predict poorer treatment outcome across a number of studies (e.g., Chambless & Steketee, 1999), which has been further supported by evidence demonstrating better treatment outcomes for interventions which address the role of criticism in the family (e.g., Grunes, Neziroglu, & McKay, 2001). The data set for a number of studies was derived from the same larger sample (i.e., Chambless & Steketee, 1999), which included a sample of participants with OCD and participants with panic disorder with agoraphobia, and was subsequently used to investigate further research questions (e.g., Renshaw, Chambless, & Steketee, 2001; Renshaw, Chambless, & Steketee, 2003; Renshaw, Steketee, & Chambless, 2006). The sample of participants recruited was on the basis that the patient allowed a relative to take part, which may have excluded patients with extremely critical relatives who may have refused to participate (Renshaw et al., 2003). Furthermore, most studies fail to investigate why or how criticism impacts on treatment outcome in OCD. Due to these limitations and the scope of this review, this broader literature will be reviewed briefly with discussion including four studies that have attempted to explain why perceptions or experiences of criticism predict poorer outcome, a more informative way of considering the role of criticism in OCD.

367

(PC) and how upset the patient is by that criticism (UC). Higher levels of CFI-rated relative's criticism were associated with better performance on an anxiety-provoking task, whereas, higher levels of PC predicted poorer treatment outcome and higher rates of relative's hostility predicted higher rates of drop out, though hostility was not a significant predictor of poorer outcome (Chambless & Steketee, 1999). 5.2. Why does PC or criticism and hostility by relatives predict poorer treatment outcome? 5.2.1. Criticism and hostility In attempting to understand this research it is useful to consider similarities and differences between the different concepts. Criticism and hostility are thought to be largely overlapping but independent constructs (Van Noppen & Steketee, 2009) where hostility is described as a more powerful form of criticism directed towards the person rather than the behaviors or both (Chambless, Floyd, Rodenbaugh, & Steketee, 2007). Perceived Criticism shows only a modest correlation with CFI measured critical comments, therefore, it seems that perceived criticism is different to objective criticism observed on the CFI, which in turn is different to hostility and has been termed non-hostile criticism (Chambless & Steketee, 1999). How can this information help interpret the findings that CFI-rated criticism leads to positive outcome and PC leads to a negative outcome? In laboratory tasks on healthy individuals negative feedback has been found to be less effective if the individual feels they have no influence over their performance (Ilgen & Davies, 2000). As ‘non-hostile’ criticism refers to comments directed at the individuals' behaviors this may actually motivate an individual and therefore be viewed positively. In contrast hostile comments, which are either more global or directed at a particular characteristic of the person, which may be more difficult to change (Chambless & Steketee, 1999). This distinction is of importance but the authors state causal explanations cannot be made due to the correlational nature of the data (Chambless & Steketee, 1999). 5.2.2. EE as a stressor Investigations into EE have described the construct as a stressor (Hooley & Gotlib, 2000) where an individual (for whatever reason) is predisposed to be vulnerable to particular disorders so that interactions with high EE relatives may lead to enhanced symptoms (Chambless, 1998). In line with this, patient and relative interactions on a problem solving task found relatives of patients with OCD were more likely to be hostile than interactions between relatives and patients with panic disorder and agoraphobia, where the relative focused on the negative outcome rather than on generating a positive solution (Chambless et al., 2007). Such results provide some evidence for the view that EE acts a stressor, which may then increase patients' symptoms.

5.1. Expressed Emotion (EE) and Perceived Criticism (PC) A number of older studies demonstrate that high EE predicts poorer treatment outcome in OCD (Emmelkamp, Kloek, & Blaauw, 1992; Steketee, 1993; Leonard et al., 1993) however some studies fail to use the gold standard CFI measure of EE, instead relying on self-reports of family interactions instead of observational data. Furthermore, in analyzing EE a number of components including criticism are combined making it difficult to determine which component is the strongest predictor of treatment outcome or relapse. More recent research (e.g., Chambless & Steketee, 1999) has considered the utility of components of EE separately and has also used an additional measure of patient's perceptions of criticism, the Perceived Criticism Measure (PCM) (Hooley & Teasdale, 1989). This measure assesses two conceptually related aspects of the receipt of Expressed Emotion, how critical a patient perceives a relative to be

5.2.3. Attributional style An attributional style involves communicating a causal belief about an event (Renshaw et al., 2006). High levels of relative's hostility were related to high levels of responsibility attributions (where relatives viewed patient's symptom behaviors as internal and controllable) (Renshaw et al., 2006). This relationship was not moderated by patient diagnosis (i.e., OCD vs. Panic Disorder with Agoraphobia). There was a trend for a relationship between responsibility attributions and criticism; however, this did not reach significance. Illness attributions (views that behaviors are associated with the disorder) were not associated with any EE component (Renshaw et al., 2006). Further research has found higher levels of perceived criticism were related to relative's attributions of patient control (Van Noppen & Steketee, 2009). Although causality has not been demonstrated the research provides useful insight into why a

368

S.M. Pace et al. / Clinical Psychology Review 31 (2011) 361–370

Experiences of criticism in childhood

relative may react with hostility or criticism. If a relative's attribution of responsibility for the behavior leads to hostility toward the patient, could this inadvertently feed into the patients already inflated sense of responsibility and so potentially increase OC behaviors? 5.3. Limitations of treatment outcome research Although more recent research has attempted to explore why criticism may have such a negative impact, there remain a number of threats to construct validity. The key constructs are not always explicitly defined. Although CFI is coded for inter-rater reliability, the PCM relies on self-reports from the patients' perspective. Therefore criticism that is rated rather than observed may include the patient's or relative's perceptions of criticism, hostility, and blame. 6. Discussion The aim of the review was to explore the potential roles of criticism in OCD and attempt to integrate the findings around the cognitive model of OCD. The findings suggest criticism could play various roles in OCD. First, there is some evidence supporting the notion that past experiences of criticism could be a vulnerability factor in developing OCD. Second, research has suggested that OC belief domains may develop in reaction to criticism and OC behaviors may work as strategies to avoid future criticism. However, only certain subtypes of OC beliefs and behaviors have been investigated in relation to criticism. Third, perceptions of criticism have predicted poor treatment outcome across a number of studies though causal interpretations have not been possible. 6.1. How can the findings be understood within the cognitive model of OCD? Although the importance of criticism is evident, it is less clear how these findings can be integrated. Where in the OCD model is criticism most influential and how does it impact on OCD? Fig. 1 attempts to integrate the different strands of literature reviewed so far, alongside the following summary: Experiences of regular and/or significant criticism in childhood from either a parent or a family member may be distressing for the individual; the individual could fear further criticism, which could lead to strategies to prevent this form of punishment. Therefore, the individual adopts a prevention focus and a strategy of avoidance (Rachman, 1976). A prevention focus increases sensitivity to signs of external criticism, which could lead to sensitivity in particular belief domains. Active avoidance strategies could involve becoming responsible for preventing hazards that could evoke criticism (Salkovskis et al., 1999). Additionally, a perfectionistic style may develop in an attempt to gain approval as opposed to criticism from others (Guidiano & Liotti, 1983). Such strategies could then lead to OC behaviors, such as checking to avoid potential dangers and avoid criticism (Rachman, 1976). These OC type behaviors may either maintain to avoid the criticism or develop into more repetitive stereotypical behaviors that no longer function in terms of those original reasons (Rachman, 1976). However, OC behavior itself engenders further criticism, which could act as a stressor to maintain behaviors (Renshaw et al., 2005), while criticism based on responsibility attributions (Renshaw et al., 2006) could inadvertently feed into an already inflated sense of responsibility and so potentially increase OC behaviors. This is of course a hypothetical proposition, which pulls together the various theoretical propositions and limited empirical findings of the review. It is important to acknowledge these ideas assume, for

Stress / distressed

Increased sensitivity to criticism Aim to prevent further criticism Responsibility

Perfectionism

Checking behaviours

Criticised by others for checking

Stress distress Fig. 1. Proposed roles of external criticism in the development and maintenance of OCD.

example, distress in response to criticism, sensitivity to criticism, and may also be restricted to specific subtypes of OC behaviors and belief domains. However, this also suggests useful research questions. If criticism could heighten responsibility beliefs could this then impact on OC behaviors? Given the relationship found between responsibility and OC behaviors it seems plausible that for criticism to impact on OC behaviors it may do so through inflating a sense of responsibility. Furthermore, criticism based on responsibility attributions could reinforce responsibility appraisals and so maintain OC behavior. Similarly, various factors could make an individual more vulnerable to the effects of criticism. This could include a low sense of self-worth, such individuals may depend more on the approval of others and criticism would signify a failure to acquire approval. Individuals with a perfectionistic style based on the opinions of others would also be sensitive to external criticism and perhaps strive to avoid it; therefore OC behaviors may develop to prevent criticism that threatens sense of self.

6.2. Methodological issues and implications for future research The current literature has highlighted the difficulties in conducting research in criticism; therefore, future research would have to consider a number of factors. First, given the complexity of the concept of criticism and the inconsistency in the use of terms it would be important to define criticism. The non-clinical literature has managed this more successfully than the clinical literature to date. The importance of definitions can be seen in one example in the OCD literature where non-hostile criticism was shown to have a positive effect, and hostile criticism a negative effect on treatment outcome (Chambless & Steketee, 1999).

S.M. Pace et al. / Clinical Psychology Review 31 (2011) 361–370

Future research should attempt to define the type of criticism and where it is directed (e.g., to the person, their behavior or both). Second, research in social psychology beyond the scope of this review has highlighted numerous factors which may affect how someone responds to criticism. These include causal attributions, perceived control over the situation, and a belief that the criticism is valid (for reviews see Ilgen & Davies, 2000; Liden & Mitchell, 1985). Therefore, research should consider such factors when measuring reactions to criticism. A measure of perception of criticism, namely the PCM (Hooley & Teasdale, 1989), has usefully predicted treatment outcome. However little is known about the underlying construct measured (Renshaw, 2008). Initially, more idiographic methods in relation to measuring individual perceptions of criticism could provide valuable information and so further understanding of how and why criticism may have an effect. Third, currently it is not entirely clear whether criticism is the construct under investigation. Blame has also been connected to the OCD literature in a similar manner to criticism; perhaps experiences of blame inflate responsibility and increase OC type behaviors. Or it may be that attributions of blame are secondary to criticism. Drawing from the wider literature some key definitional features should guide research and measurement of criticism. Definitions of criticism should consider: ° Who delivers criticism? ° How it is delivered (tone, manner, situation) ° Where it is directed (at the person, their behavior, the outcome of an event) ° How does the recipient perceive the feedback? ° Is it followed by a consequence or punishment? If so, does this imply it could overlap with blame? Finally, the previous research on criticism and OCD largely uses correlational and known-group or case–control designs and so are unable to make causal interpretations. Therefore future research could usefully employ experimental designs to investigate whether the manipulation of criticism leads to an increase in specific belief domains or OC behaviors such as checking. 6.3. Limitations Difficulties in defining the concept of criticism have been highlighted, while the inconsistent use of terms and often the lack of definition of the constructs became evident throughout the review. These problems also limit the review, as without an agreed definition it is difficult to draw firm conclusions about the construct under investigation. This, as well as the fragmented nature of the literature led to a variety of search strategies, which although had systematic elements were not wholly so. As a consequence the search strategies may have introduced bias or left gaps. The review does not claim to be exhaustive. However, reliance on a systematic search strategy alone may equally have missed a number of key pieces of research. Due to the fragmentary literature on criticism and negative feedback in OCD compared to the vast amount of literature in other fields (e.g., social psychology), it is likely that some relevant articles about potential mechanisms have been missed. Other areas were excluded a priori. For example, self-criticism was not included as it is considered a separate concept, however future research may consider self-criticism as those who are more selfcritical may also be more sensitive to external or other criticism. 6.4. Clinical implications Concern over criticism could impact on adherence to and success of treatment and risk of relapse if patients are in a critical environment, or if they perceive criticism. Techniques such as cognitive restructuring could be used to reframe biased perceptions

369

of criticism perhaps using the questions laid out for the definition above to “unpack” perceived criticism into a more nuanced understanding. In some cases exploration of past experience of criticism may be useful when working toward an understanding of and more adaptive levels of responsibility and perfectionism. Links between current experience of criticism and activation of OC beliefs and behaviors could be explored, particularly in the context of relapse prevention. Alternatively, therapy could focus on accepting/managing actual criticism when it is accurate and directed toward appropriate targets. Finally, if clients are in unsupportive environments, therapeutic work could involve working with families or significant others who are the source of criticism; such work has shown beneficial results (Grunes et al., 2001). 6.5. Conclusion The findings, although speculative and tentative, provide prima facie evidence to conclude that criticism can play a role in OCD. On account of the potentially different areas where criticism could impact on OCD, further research examining potential mechanisms is warranted. Due to lack of designs allowing causal interpretation of findings it seems important to use experimental designs to investigate how experiences of criticism increase OC behavior and OC-related beliefs. Acknowledgement This review is based on a dissertation by the first author submitted in part fulfillment of a Doctorate in Clinical Psychology at Newcastle University. References Abbott, A. A., & Lyter, S. C. (1998). The use of constructive criticism in field supervision. The Clinical Supervisor, 17, 43−57. Amir, N., Freshman, M., & Foa, E. B. (2000). Family distress and involvement in relatives of obsessive–compulsive disorder patients. Journal of Anxiety Disorders, 14, 209−217. Aycicegi, A., Harris, C. L., & Dinn, W. M. (2002). Parenting style and obsessive–compulsive symptoms and personality traits in a student sample. Clinical Psychology & Psychotherapy, 9, 406−417. Baron, R. A. (1993). Criticism (Informal negative feedback) as a source of perceived unfairness in organizations: Effects, mechanisms and countermeasures. In R. Cropanzano (Ed.), Justice in the workplace (pp. 155−169). New Jersey, NJ: L. Erlbaum Associates. Bhar, S. S. (2004). Self-ambivalence in obsessive–compulsive disorder. (Unpublished doctoral dissertation). University of Melbourne, Melbourne, Australia. Bhar, S. S., & Kyrios, M. (1999). Cognitive personality styles associated with depressive and obsessive compulsive phenomena in a non-clinical sample. Behavioural and Cognitive Psychotherapy, 27, 329−343. Blatt, S. (2004). Experiences of depression: Theoretical, clinical and research perspectives. Washington DC, WA: American Psychological Association. Calamari, J. E., Weigartz, P. S., & Janeck, A. S. (1999). Obsessive–compulsive disorder subgroups: A symptom-based clustering approach. Behaviour Research and Therapy, 37, 113−125. Cameron, N. A. (1947). The psychology of behavior disorders. Boston, MA: Houghton Mifflin Company. Challacombe, F., & Salkovskis, P. (2009). A preliminary investigation of the impact of maternal obsessive–compulsive disorder and panic disorder on parenting and children. Journal of Anxiety Disorders, 23, 848−857. Chambless, D. L. (1998). Family overinvolvement and criticism: An introduction to expressed emotion. In session: Psychotherapy in Practice, 4(3), 1−5. Chambless, D. L., Bryan, A. D., Aiken, L. S., Steketee, G., & Hooley, J. M. (1999). The structure of expressed emotion: A three-construct representation. Psychological Assessment, 11, 67−76. Chambless, D. L., Floyd, F. J., Rodenbaugh, T. L., & Steketee, G. (2007). Expressed Emotion and familial interaction: A study with agoraphobic and obsessive–compulsive patients and their relatives. Journal of Abnormal Psychology, 116, 754−761. Chambless, D. L., & Steketee, G. (1999). Expressed emotion and behavior therapy outcome: A prospective study with obsessive–compulsive and agoraphobic outpatients. Journal of Consulting and Clinical Psychology, 67, 658−665. Coles, M. E., Schofield, C. A., & Pietrefesa, A. S. (2006). Behavioral inhibition and obsessive compulsive disorder. Anxiety Disorder, 20, 118−1132. Davies, A. (2005). Developing our understanding in inflated responsibility in OCD. (Unpublished doctoral dissertation). University of Newcastle upon Tyne, Newcastle upon Tyne, UK.

370

S.M. Pace et al. / Clinical Psychology Review 31 (2011) 361–370

Dollard, J., & Miller, N. E. (1950). Personality and psychotherapy. New York, NY: McGrawHill Book Company inc. Doron, G., & Kyrios, M. (2005). Obsessive compulsive disorder: A review of possible specific internal representations within a broader cognitive theory. Clinical Psychology Review, 25, 415−432. Doron, G., Moulding, R., Kyrios, M., & Nedeljkovic, M. (2008). Sensitivity of self-beliefs in obsessive compulsive disorder. Depression and Anxiety, 25, 874−884. Ehntholt, K. A., Salkovskis, P. M., & Rimes, K. A. (1999). Obsessive–compulsive disorder, anxiety disorders, and self-esteem: An exploratory study. Behaviour Research and Therapy, 37, 771−781. Eisen, M., Mancebo, A., Pinto, M., Coles, M., Pagano, R., Stout, S., et al. (2006). Impact of obsessive–compulsive disorder on quality of life. Comprehensive Psychiatry, 47, 270−275. Emmelkamp, P. M. G., Kloek, J., & Blaauw, E. (1992). Obsessive–compulsive disorders. In P. H. Wilson (Ed.), Principles and practice of relapse prevention. New York, NY: Guilford Press. Frost, R. O., Marten, P., Lahart, C., & Rosenblate, R. (1990). The dimensions of perfectionism. Cognitive Therapy and Research, 14, 1573−2819. Frost, R. O., Steketee, G., Cohn, L., & Griess, K. (1994). Personality traits in subclinical and non-obsessive compulsive volunteers and their parents. Behaviour Research and Therapy, 32, 47−56. Grunes, M. S., Neziroglu, F., & McKay, D. (2001). Family involvement in the behavioral treatment of obsessive–compulsive disorder: A preliminary investigation. Behavior Therapy, 32, 803−820. Guidiano, V. F., & Liotti, G. (1983). Cognitive processes and emotional disorders. New York, NY: The Guilford Press. Hewitt, P. L., & Flett, G. L. (1991). Perfectionism in the self and social contexts: Conceptualization, assessment and association with psychopathology. Journal of Personality and Social Psychology, 60, 456−470. Hibbs, E. D., Hamburger, S. D., Kruesi, M. J. P., & Lenane, M. (1993). Factors affecting expressed emotion in parents of ill and normal children. The American Journal of Orthopsychiatry, 63, 103−112. Hibbs, E. D., Hamburger, S. D., Lenane, M., Rapoport, J. L., Markus, J. P., Kruesi, C. S., et al. (1991). Determinants of expressed emotion in families of disturbed and normal children. Journal of Child Psychology and Psychiatry, 32, 757−770. Higgins, E. T. (1997). Beyond pleasure and pain. The American Psychologist, 52, 1280−1300. Hooley, J. M., & Gotlib, I. H. (2000). A diathesis-stress conceptualization of expressed emotion and clinical outcome. Applied and Preventive Psychology, 9, 135−151. Hooley, J. M., & Teasdale, J. D. (1989). Predictors of relapse in unipolar depressives: Expressed emotion, marital distress, and perceived criticism. Journal of Abnormal Psychology, 98, 229−235. Ilgen, D. R., & Davies, C. A. (2000). Bearing bad news: Reactions to negative performance feedback. Applied Psychology: An international Review, 49, 550−565. Kamins, M. L., & Dweck, C. S. (1999). Person versus process praise and criticism: Implications for contingent self-worth and coping. Developmental Psychology, 35, 835−847. Leonard, H. L., Swedo, S. E., Lenane, M. C., Rettew, D. C., Hamburger, S. D., Bartko, J. J., et al. (1993). A two to seven year follow up study of 54 obsessive compulsive children and adolescents. Archives of General Psychiatry, 50, 429−439. Liden, R. C., & Mitchell, T. R. (1985). Reactions to feedback: The role of attributions. Academy of Management Journal, 28, 291−308. Lopatka, C., & Rachman, S. (1995). Perceived responsibility and compulsive checking: An experimental analysis. Behaviour Research and Therapy, 33, 673−684. Mancini, F., D'Olimipio, F., & Cieri, L. (2004). Manipulation of responsibility in nonclinical subjects: Does expectation of failure exacerbate obsessive–compulsive behaviours? Behaviour Research and Therapy, 42, 449−457. McAndrew, J. F. (1989). Obsessive–compulsive disorder: A behavioral case formulation. Journal of Behavior Therapy and Experimental Psychiatry, 20, 311−318. McFall, M. E., & Wollersheim, J. P. (1979). Obsessive–compulsive neurosis: A cognitivebehavioral formulation and approach to treatment. Cognitive Therapy and Research, 3, 333−348. Meyer, W. U., Reisenzein, R., & Dickhauser, O. (2004). Inferring ability from blame: Effects of effort-versus liking-orientated cognitive schemata. Psychology Science, 46, 281−293. Myers, S. G., & Wells, A. (2004). Obsessive–compulsive symptoms: The contribution of metacognitions and responsibility. Journal of Anxiety Disorders, 19, 806−817. Neapolitan, J. (1988). The effects of different types of praise and criticism on performance. Sociological focus, 21, 223−231. Obsessive Compulsive Cognitions Working Group (OCCWG) (1997). Cognitive assessment of obsessive–compulsive disorder. Behaviour Research and Therapy, 35, 667−681. Obsessive Compulsive Cognitions Working Group (OCCWG) (2003). Psychometric validation of the obsessive beliefs questionnaire and the interpretation of intrusions inventory: Part I. Behaviour Research and Therapy, 41, 863−878. Ongen, D. E. (2006). The relationships between self-criticism, submissive behavior and depression among Turkish adolescents. Personality and Individual Differences, 41, 793−800. Powers, T. A., Zuroff, D. C., & Topciu, R. A. (2004). Covert and overt expressions of selfcriticism and perfectionism and their relation to depression. European Journal of Personality, 18, 61−72. Rachman, S. (1976). Obsessional–compulsive checking. Behaviour Research and Therapy, 14, 269−277. Rachman, S. (1993). Obsessions, responsibility and guilt. Behaviour Research and Therapy, 33, 779−784.

Rachman, S. J., & de Silva, P. (1978). Normal and abnormal obsessions. Behaviour Research and Therapy, 16, 233−248. Rachman, S. J., & Hodgson, R. J. (1980). Obsessions and compulsions. New Jersey, NJ: Prentice-Hall, Inc. Renshaw, K. D. (2008). The predictive, convergent, and discriminant validity of perceived criticism: A review. Clinical Psychology Review, 28, 521−534. Renshaw, K. D., Blais, R. K., & Caska, C. M. (2010). Distinctions between hostile and nonhostile forms of perceived criticism from others. Behavior Therapy, 41, 364−374. Renshaw, K. D., Chambless, D. L., & Steketee, G. (2001). Co morbidity fails to account for the relationship of expressed emotion and perceived criticism to treatment outcome in patients with anxiety disorders. Journal of Behavior Therapy and Experimental Psychiatry, 32, 145−158. Renshaw, K. D., Chambless, D. L., & Steketee, G. (2003). Perceived criticism predicts severity of anxiety symptoms after behavioral treatment in patients with obsessive compulsive disorder and panic disorder with agoraphobia. Journal of Clinical Psychology, 59, 411−421. Renshaw, K. D., Steketee, G., & Chambless, D. L. (2005). Involving family members in the treatment of OCD. Cognitive Behaviour Therapy, 34, 164−175. Renshaw, K. D., Steketee, G., & Chambless, D. L. (2006). The relationship of relatives attributions to their expressed emotion and to patients' improvement in treatment for anxiety disorders. Behavior Therapy, 37, 159−169. Rheaume, J., Freeston, M. H., Dugas, M. J., Letarte, H., & Ladouceur, R. (1995). Perfectionism, responsibility and obsessive–compulsive symptoms. Behaviour Research and Therapy, 33, 785−794. Rheaume, J., Ladouceur, R., Freeston, M. H., & Letarte, H. (1995). Inflated responsibility in obsessive–compulsive disorder: Validation of an operational definition. Behaviour Research and Therapy, 33, 159−169. Salkovskis, P. M. (1985). Obsessional–compulsive problems: A cognitive-behavioural analysis. Behaviour Research and Therapy, 23, 571−583. Salkovskis, P. M. (1999). Understanding and treating obsessive–compulsive disorder. Behaviour Research and Therapy, 37, S29−S52. Salkovskis, P. M., Forrester, E., & Richards, C. (1998). Cognitive-behavioural approach to understanding obsessional thinking. British Journal of Psychiatry, 173(35), 53−63. Salkovskis, P. M., Shafran, R., Rachman, S., & Freeston, M. H. (1999). Multiple pathways to inflated responsibility beliefs in obsessional problems: Possible origins and implications for therapy and research. Behaviour Research and Therapy, 37, 1055−1072. Salkovskis, P. M., Wroe, A. L., Gledhill, A., Morrison, N., Forrester, E., Richards, C., et al. (2000). Responsibility attitudes and interpretations are characteristic of obsessive– compulsive disorder. Behaviour Research and Therapy, 38, 347−372. Sasson, Y., Zohar, M., Chopra, R., Lustig, I., & Iancu, J. (1994). Obsessive–compulsive disorder: Diagnostic considerations and an epidemiological update. In E. J. L. Griez, C. Faravelli, D. Nutt, & J. Zohar (Eds.), Anxiety Disorders (pp. 157−168). New York, NY: John Wiley & Sons Ltd.. Shanmugiah, A., Verghese, M., & Khanna, S. (2002). Expressed emotion in obsessive compulsive disorder. Indian Journal of psychiatry, 44, 14−18. Smith, D. A., & Peterson, K. M. (2008). Over perception of spousal criticism in dysphoria and marital discord. Behavior Therapy, 39, 300−312. Steketee, G. (1993). Social support and treatment outcome of obsessive–compulsive disorder at 9 month follow up. Behavioural Psychotherapy, 21, 81−95. Steketee, G., Frost, R., & Cohen, I. (1998). Beliefs in obsessive compulsive disorder. Journal of Anxiety Disorders, 12, 525−537. Steketee, G., Grayson, J. B., & Foa, E. B. (1985). Obsessive–compulsive disorder: Differences between washers and checkers. Behaviour Research and Therapy, 23, 197−201. Thyer, B. A., Curtis, G. C., & Fechner, S. L. (1984). Fear of criticism is not specific to obsessive–compulsive disorder. Behaviour Research and Therapy, 22, 77−80. Tracy, K., Van Dusen, D., & Robinson, S. (1987). “Good” and “bad” criticism: A descriptive analysis. Journal of communication, 37, 46−59. Turner, R. M., Steketee, G. S., & Foa, E. B. (1979). Fear of criticism in washers and checkers and phobias. Behaviour Research and Therapy, 17, 79−81. Tynes, L. L., Salins, C., & Winstead, D. K. (1990). Obsessive compulsive patients: Familial frustration and criticism. Journal of Louisiana State Medical Society, 142, 24−26. Van Noppen, B., & Steketee, G. (2009). Testing a conceptual model of patient and family predictors of obsessive compulsive disorder (OCD) symptoms. Behaviour Research and Therapy, 47, 18−25. Van-Dijk, D., & Kluger, A. N. (2004). Feedback sign effect on motivation: Is it moderated by regulatory focus? Applied Psychology: An International Review, 53, 113−135. Vaughn, C. E., & Leff, J. P. (1976). The influence of family and social factors on the course of psychiatric illness: A comparison of schizophrenic and depressed neurotic patients. British Journal of Psychiatry, 129, 125−137. Waters, T. L., & Barrett, P. M. (2000). The role of the family in childhood obsessive– compulsive disorder. Clinical Child and family Psychology Review, 3, 173−184. Wearden, A. J., Tarrier, N., Barrowclough, C., Zastowny, T. R., & Armstrong Rahill, A. (2000). A review of expressed emotion research in health care. Clinical Psychology Review, 20, 633−666. Wolpe, J. & Lang, P.J. (1969). Fear Survey Schedule. Educational Industrial Testing Service. San Diego. California. World Health Organisation (2007). International Classification of diseases ((10th Revision)). Germany: WHO. Wu, K. D., & Carter, S. A. (2008). Further investigation of the obsessive beliefs questionnaire: Factor structure and specificity of relations with OCD symptoms. Journal of Anxiety Disorders, 22, 824−836.