'I wash until it feels right': the phenomenology of stopping criteria in obsessive-compulsive washing

Recent elaborations of cognitive behavioral theory in OCD suggest that difficulties in deciding when to stop a compulsive action may be related to the use of counter-productive termination criteria by obsessional patients [Salkovskis, P. M. (1999). Understanding and treating obsessive-compulsive disorder. Behaviour Research and Therapy, 37, s29-s52]. Such criteria are characterized by their subjective nature, i.e. a primarily internal reference point (e.g. 'just right' feelings), and are conceptualized as the "top level" of a general strategy involving elevated evidence requirements. Thirty-eight obsessional washers, 41 obsessionals with other problems and 43 healthy controls were interviewed about and rated two situations varying in the degree of urgency to wash; they also washed their hands in a behavioral test. Washers reported using subjective criteria more frequently and rated them as more important for the termination of the washes than the other groups in questionnaire, interview and laboratory data. Both obsessional groups considered more criteria before stopping than the healthy controls, suggesting that using multiple criteria is a general strategy. The data are consistent with the predictions of the elaborated cognitive-behavioral model of OCD. They indicate that the use of subjective criteria and elevated evidence requirements is affected by the perceived significance of the situation in a similar way for obsessional and non-obsessional individuals.