Neuropsychoanalysis

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Separation Distress in Obsessive-Compulsive

Disorder

Michelle Jackson & Mark Solms

To cite this article: Michelle Jackson & Mark Solms (2013) Separation Distress
in Obsessive-Compulsive Disorder, Neuropsychoanalysis, 15:2, 117-125, DOI:
10.1080/15294145.2013.10799825

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 Neuropsychoanalysis, 2013, 15 (2) 117

Separation Distress in Obsessive-Compulsive Disorder

Michelle Jackson & Mark Solms (Cape Town)

Four iterative studies tested the hypothesis that separation distress is a significant component of obsessive-compulsive disorder
(OCD). Separation distress and separation trauma were measured in nonclinical undergraduate university participants who scored
at the high end of the spectrum of obsessionality and low mood; in patients clinically diagnosed with OCD and major depression dis-
order (MDD); and in control groups. The Meta-Cognitions Questionnaire, Padua Inventory, Major Depression Inventory, and Positive
and Negative Affect Scales were used to distribute participants on spectrums of obsessionality and low mood (Studies 1 and 2) and
classify them in terms of clinical OCD and MDD (Study 3). Participants were evaluated on measures of separation distress, using
the Separation Anxiety Symptom Inventory, the Structured Clinical Interview for Separation Anxiety Symptoms, the Adult Separation
Anxiety Checklist, and the Affective Neuroscience Personality Scales. To measure separation trauma, participants were asked to
indicate whether they had been physically separated from their primary caregiver during specific time frames based on widely es-
tablished work. Analyses confirmed that separation distress is strongly implicated in both OCD and MDD and that it accounts for the
well-established comorbidity of these disorders. Chi-square contingency analysis indicated that OCD and/or MDD in adulthood are
contingent upon early separation trauma.

Keywords:  anxiety; major depression disorder; obsessive-compulsive disorder; PANIC; separation distress; separation trauma

Converging lines of evidence suggest that obsessive-
compulsive disorder (OCD) may be linked with sepa-
ration distress. First, anterior cingulate cortex (ACC)
activation is highly correlated with symptom severity
in OCD (Baer, Wetter, Nichols, Greene & Berry, 1995;
Breiter & Rauch, 1996; Breiter et al., 1996; Gehring,
Himle, & Nisenson, 2000; Schwartz, Stoessel, Baxter,
Martin, & Phelps, 1996; van Veen & Carter, 2002).
ACC activation is strongly implicated in conflict-mon-
itoring, a cognitive function for detecting discrepan-
cies in information processing (Botvinick, Cohen, &
Carter, 2004; Bush, Luu, & Posner, 2000). Overactive
conflict-monitoring has been suggested as a putative
mechanism of OCD, and in this sense it could be con-
ceptualized as a disorder of error-detection (Gehring,
Himle, & Nisenson, 2000; Thorpe, Rolls & Maddison,
1983; Ursu, Stenger, Shear, Jones, & Carter, 2003;
Schwartz et al., 1996). However, OCD also has an af-
fective component and is classified in the DSM as an
anxiety disorder (APA, 1994).
Second, the ACC is strongly implicated in the ­basic
emotion of separation distress, where it forms the
rostral end of the so-called PANIC/GRIEF system,
the neural substrate for conscious feelings of separa-
tion distress (Panksepp, 1998, 2010). This emotional
system, and the feelings it generates, serves at the
most fundamental level to respond to being separated
from one’s primary source of care, shelter, and provi-
sion—principally one’s mother, in mammalian species
(Panksepp, 1998). Separation leads to distress vocal-
izations—crying—in young, dependent mammals, and
to a strong inbuilt need to reestablish nurturance (Pank-
sepp, 2010). The PANIC system is a distributed net-
work involving the midbrain periaqueductal grey, the
medial diencephalon (especially the dorsomedial thal-
amus), the ventral septal area, the preoptic area, sites
in the bed nucleus of the stria terminalis, the ACC, and
the hypothalamus (Panksepp, 1998, 2010). The system
is aroused by glutamate and corticotropin-releasing
factor (Panksepp, 2010). Conversely, it is inhibited by
endogenous opioids, oxytocin, and prolactin, which
constitute the neurochemistry of social attachment and

Michelle Jackson & Mark Solms: Department of Psychology, University of Cape Town, Cape Town, South Africa.
Correspondence to: Michelle Jackson: Department of Psychology, University of Cape Town, Private Bag, Rondebosch 7701, Cape Town, South Africa
(email: dr.m.l.jackson@gmail.com).

© 2013 The International Neuropsychoanalysis Society  •  http://www.neuropsa.org

118 Michelle Jackson & Mark Solms
are thought to be necessary for the foundation of secure
attachments (Panksepp, 2010).
Between the ages of 15 and 30 months, behavior in
response to separation aligns closely with the neuro-
biological model of separation distress, consisting of
three stages—protest, despair, and separation/detach-
ment (Bowlby, 1973)—which reflect the biologically
primed separation-distress response to activation of
the PANIC substrate (Panksepp, 1998). This process
describes the predictable pattern of response when
infants are separated from their mothers: severe protest
and crying, giving way to quiet despair and finally to
detachment and apparent indifference (Bowlby, 1973).
Excessive activation or sensitivity of this system
would therefore lead to a depletion or dysregulation
of such neurochemicals and possibly interfere with the
formation of secure attachment, which has long been
well supported in psychological models as an underly-
ing factor in the development of depressive affect in
adulthood (Bowlby, 1960, 1973). A recent formulation
(Watt & Panksepp, 2009) hypothesizes that depres-
sion has evolved from a mechanism designed to shut
down ongoing separation distress (perhaps, at least in
part, through suppression of activity in the mesolimbic
dopaminergic circuitry). This model proposes that in
depression, this shut-down state is pathologically sus-
tained and can become easily activated in response to
chronic stressors.
Separation distress is more obviously associated
with mood than anxiety disorders (Solms & Pank-
sepp, 2010), but major depressive disorder (MDD) and
OCD share high comorbidity, as do MDD and panic
disorder (Basso, Bornstein, Carona, & Morton, 2001;
Bhattacharyya, Reddy, & Janardhan, 2005; Cavedini,
Ferri, Scarone, & Belodi, 1998; Moritz, Meier, Hand,
Schick, & Jahn, 2004; Moritz et al., 2001). Could it be
that separation distress (PANIC anxiety) is a common
denominator, the “missing link,” between OCD and
MDD?
Given the high comorbidity between OCD and
MDD, as well as the overlap in neurochemical and
neuroanatomical bases of disorders and emotion sub-
strates as described above, this study aims to further
explore the hypothesis that separation distress may
constitute an affective mechanism of both OCD and
MDD. It was hypothesized that a tendency toward
experiencing excessive feelings of separation distress,
which reflects sensitivity of the basic emotion sub-
strate, PANIC, will be associated both with the ten-
dency toward obsessiveness and low mood, which
indicate vulnerability to OCD and MDD, and with
OCD and MDD themselves.
Study 1
Aim:  To examine whether both conflict-monitoring
and separation distress increased in a nonclinical group
of participants who score high on measures of obses-
sionality.
Method
A large sample (N = 1,119) was recruited from un-
dergraduate students at the University of Cape Town
(UCT) in South Africa, which consists of a wide va-
riety of faculties. An online questionnaire site was
created, and students were invited to participate by
advising them of the study through departmental
emails and login alerts to on-campus computers. En-
try into a cash raffle prize was offered as reward.
Participants were administered the Meta-Cognitions
Questionnaire (MCQ; Cartwright-Hatton & Wells,
1997) and the Padua Inventory (PI; Sanavio, 1988)
via an online portal. The size of the sample was based
on an analysis of the development and norming of the
MCQ and PI, which indicated that an initial sample
of 1,000 participants was required, based largely on
the fact that OCD has a lifetime prevalence of 2% to
3% worldwide (Robins, Helzer, Weissman, & Orvas-
chel, 1984, in Maltby, Tolin, Worhunsky, O’Keefe,
& Kiehl, 2005; Weissman et al., 1994, in Whiteside,
Port, & Abramowitz, 2004). In order to obtain sig-
nificantly high- and low-scoring groups on the obses-
sionality spectrum, a sufficiently large enough sample
had to be tested. It was hoped that a score distribution
matching the percentage of clinical occurrence, as op-
posed to a clinical diagnosis of OCD—would provide
support for conclusions drawn from the research. Re-
spondents were asked to indicate whether they had
been diagnosed with OCD or MDD, and this was an
exclusion criterion.
The MCQ and PI were used in conjunction because
together they cover a broad spectrum of obsessive-
compulsive traits. The PI is a more conventional clini-
cally diagnostic tool for OCD assessment. The MCQ
has been shown to predict worry-proneness, proneness
to obsessional symptoms, and anxiety (Cartwright-Hat-
ton & Wells, 1997). It was included because its items
were derived not only from outpatients diagnosed with
OCD, generalized anxiety disorder, panic disorder, and
hypochondriasis, but also from a nonclinical under-
graduate sample. Using these two measures together
was considered best suited to assess obsessionality in
these nonclinical participants.
Separation Distress in Obsessive-Compulsive Disorder 119
In addition, participants were tested for separation
distress using the SADNESS scale of the Affective
Neuroscience Personality Scales (ANPS; Davis, Pank-
sepp, & Normansell, 2003), which includes items that
assess the respondent’s tendency toward activation of
the PANIC emotion substrate and its associated feel-
ings of separation distress. Finally, participants were
assessed on conflict-monitoring performance using the
Stroop test (Stroop, 1935); they were required to es-
timate the accuracy of their own performance on the
Stroop test, creating a “metacognitive” measure of
error-monitoring.
From the entire sample, scores on the MCQ and
PI were then averaged for each participant, placing
them on a continuum from lowest to highest degree of
obsessionality. High-obsessionality (N = 21) and low-
obsessionality (N = 20) groups were thus generated.
These numbers of participants were chosen because
they represent roughly the top and bottom 2% to 3%
of the overall study sample, which reflects the 2% to
3% lifetime prevalence of OCD worldwide (Robins et
al., 1984, in Maltby et al., 2005). The scores of these
groups on the SADNESS scale of the ANPS and the
Stroop test were then compared with independent t-
tests to assess whether obsessionality was related to
separation distress or to conflict-monitoring.
Results
Conflict-monitoring scores (represented only by mea-
sures of estimation of accuracy on the metacogni-
tive Stroop) did not differ significantly between the
low- and high-obsessionality groups [X̄1 = 21.21, X̄2 =
26.08; t = 1.16, p = .13; Levene (.98, 39) = .34]. In con-
trast, the high-obsessionality group demonstrated sig-
nificantly higher separation-distress scores [X̄1 = 30.90,
X̄2 = 40.55; t = –6.59, p < .01; Levene (3.17, 39) = .08].
Conclusion
Separation distress (but not conflict-monitoring, as
measured here) is associated with obsessionality in a
nonclinical group. This is noteworthy because, as dis-
cussed in the rationale at the beginning of this study,
the proposed significance of conflict-monitoring in
OCD provided the impetus for investigating separation
distress in the same disorder. The lack of correlation
between conflict-monitoring and high scores on obses-
sionality in this sample may be due to the nonclinical
nature of the sample, since the significant results relat-
ing to conflict-monitoring and OCD cited in the litera-
ture were found in clinical participants. These findings
also raise the possibility that conflict-monitoring sub-
serves a different set of processes from those of separa-
tion distress, and this dissociation should be explored
in further work.
Study 2
Aim:  To examine whether separation anxiety predicts
both nonclinical obsessionality and low mood.
Method
A new sample of 1,077 undergraduate UCT students
were recruited by the same methods as in Study 1, via
a new online site. In addition to the MCQ and PI (de-
scribed in Study 1), participants completed two depres-
sion measures: the Major Depression Inventory (MDI;
WHO, 1993; Olsen, Jensen, Noerholm, Martiny, &
Bech, 2003) and the Positive and Negative Affect
Scales (PANAS; Watson, Clark, & Tellegen, 1988).
A subset of participants (N = 49) was drawn from this
new sample. The subset consisted of the 25 highest-
scoring and 24 lowest-scoring participants on com-
bined measures of obsessionality and low mood. The
number of participants were chosen based on the same
rationale as described in Study 1. They completed
four separation-distress scales—the Separation Anxi-
ety Symptom Inventory (SASI; Silove et al., 1993),
the Structured Clinical Interview for Separation Anxi-
ety Symptoms (SCI-SAS; Cyranowski et al., 2002),
the Adult Separation Anxiety Checklist (ASA-CL27;
Manicavasagar, Silove, Wagner, & Drobny, 2003), and
the ANPS (the SADNESS subscale of this was used to
measure separation distress, as in Study 1)—in addi-
tion to providing information on their early separation-
trauma experiences (Bowlby, 1960, 1973; Burlingham
& Freud, 1944; Heinecke, 1956; Robertson, 1953;
Spitz & Wolf, 1946).
The SASI is a 15-item self-report measure devel-
oped to address some of the difficulties traditionally
encountered when trying to assess the impact of early
separation anxiety on the development of adult psy-
chopathology (Silove et al., 1993). Importantly, re-
spondents’ scores appear to remain stable over time,
immune to fluctuations in emotional state such as
current levels of anxiety and depression (Silove et al.,
1993, in Manicavasagar, Silove, & Hadzi-Pavlovic,
1998).
120 Michelle Jackson & Mark Solms
The SCI-SAS incorporates the nine separation-anx-
iety-disorder criteria from the DSM-III-R (APA, 1987)
and obtains a rating of each for both an adult and a
childhood time frame (Cyranowski et al., 2002).
The ASA-CL27 is a self-report assessment consist-
ing of 27 checklist items derived from the lengthier
Separation Distress
Adult Separation Anxiety Structured Interview (ASA-
SI). It was chosen for its brevity since a number of as-
sessments are already employed.
Separation trauma:  Time frames established through
previous and widely established work to be critical in
terms of the adverse effects of separation (Burlingham
& Freud, 1942, 1944; Heinecke, 1956; Robertson,
1953) were used to assess whether and to what extent
participants had experienced early separation trauma.
The time frames were 0–6 months, 0–12 months, and
0–18 months—all applied to (1) under the age of 3
years, (2) under the age of 6 years, and (3) under the
age of 12 years.
Results
Independent t-tests confirmed that high- and low-ob-
sessionality groups were significantly different on ob-
sessionality measures (X̄1 = 54.57, X̄2 = 33.87, t = 7.84,
p < .01, F = 5.69 with p < .01) as were the groups with
high and low scores of low mood, on measures of low
mood (X̄1 = 29.92, X̄2 = 60.88, t = 11.59, p < .01, F =
1.51 with p = .33).
The above two groups showed notable differences:
t values indicated that participants in the high vs.
low groups scored an average of almost 8 standard
deviations (SD) higher on measures of obsessional-
ity and more than 11½ SD higher on measures of low
mood.
Separation-distress scores (as averaged across all
four measures of separation distress: SASI, SCI-SAS,
ASA-CL27, and the SADNESS component of the
ANPS scale) fell into distinct populations when di-
vided according to the high and low scores on obses-
sionality (r = –.13, X̄1 = 45.85, X̄2 = 27.20; t = –4.74,
p < .01, F = 4.54 with p < .01), as well as on low
mood (r = –.04, X̄1 = 44.64, X̄2 = 28.64; t = –3.86, p
< .01, F = 2.38 with p = .04). Therefore, separation
distress was significantly higher both in participants
who scored higher on obsessionality and in those who
scored higher on low mood (Figure 1). Dependent t-
test analysis showed that low mood and obsessionality
were not significantly different (X̄Obsessionality = 44.01,
X̄Low_mood = 45.08, diff = 1.08, SDdiff = 6.34, t = 1.19, p
= .0241) and were thus comorbid in this sample. Chi-
70
Highest scorers
Lowest scorers
60
50
40
30
20
10
0
Obsessionality Low Mood
Subjects Grouped by Obsessionality and Low Mood Scores
Figure 1.  High- and low-scoring groups distinguishable by separa-
tion-distress scores.
square contingency-table analysis indicated that sepa-
ration trauma was not significant in predicting whether
nonclinical participants would fall into the high- or
low-obsessionality and low-mood groups as adults [l2
= .91 and at α = .05, k = 1, l2.05(1) = 3.84; l2 = 3.19 and
at α = .05, k = 1, l2.05(1) = 3.84]. The four separation-
distress measures demonstrated good internal consis-
tency (inter-item correlation and split-half reliability)
and adequate convergent validity in the nonclinical
sample. The ANPS showed some divergence from the
other three scales.
Obsessionality, low mood, and separation distress
were moderately correlated in the nonclinical sample:
obsessionality and separation distress most strongly (r
= 0.526, p < .01), followed by separation distress and
low mood (r = 0 .476, p < .01) and obsessionality and
low mood (r = 0.454, p < .01).
The following individual factors were the most pre-
dictive of separation-distress scores: MCQ4 (Themes
of superstition, punishment, & responsibility, t = 3.643,
p < .01); MCQ2 (Uncontrollability & danger, t =
3.587, p < .01); PI1 (Impaired control over mental abil-
ities, t = 2.928, p < .01); and negative affect (t = 4.301,
p < .01).
Conclusion
Separation distress was significantly implicated in both
obsessionality and low mood. High scores on measures
Separation Distress in Obsessive-Compulsive Disorder 121
of obsessionality and low mood were not contingent on
separation trauma.
Study 3
Aim:  The final study tested the hypothesis that
separation distress and separation trauma are signifi-
cantly and comparably heightened in both OCD and
MDD.
Method
A large clinical sample of participants who had been
diagnosed with OCD and/or MDD (N = 84) and a
well-matched control group (N = 75) were recruited.
Clinical participants were those who reported hav-
ing received a diagnosis of OCD and/or MDD from a
mental health professional. Participants were recruited
mainly via the South African Depression and Anxi-
ety Group (SADAG), by placing information about
the study on its website. In addition, patient database
lists were sourced from hospitals and from a research
facility. These patients had previously participated in
research and had given their consent to be contacted
regarding future studies. A brief description was also
placed in a newspaper, as well as in an article on a
health-related website. Lastly, the leader of an OCD
support group invited the group members to partici-
pate. A clinical evaluative measure, the Yale–Brown
Obsessive-Compulsive Scale (Y-BOCS; Goodman et
al., 1989a, 1989b), was added to the collection of
questionnaires administered in Study 2.
Participants (see Table 1) were well matched on age
(t = .928, p = .355), years of education (t = 1.859, p =
.065), gender groupings [l2 = .498; l2.05(1) = 3.84],
and occupation [skilled/unskilled; l2 = .905, l2.05(1)
= 3.84]. Distribution into clinical vs. control groups
was highly contingent on participants’ reported use of
psychotropic medication [l2 = 96.51; l2.005(1) = 7.88],
as well as on current or previous psychiatric or psycho-
logical treatment/therapy [l2 = 83.75; l2.005(1) = 7.88].
Separation-trauma experiences also affected distribu-
tion.
Results
Groups were clearly and significantly dissociable in
terms of clinical and control OCD and MDD scores.
The t-tests for independent groups revealed that the
clinical and control participants differed significantly
in the hypothesized direction, in terms of separation-
distress results: X̄1 = 53.21 (19.29); X̄2 = 32.84 (13.49);
t(155) = 7.58, p < .01; t = 7.73 (separation variance
estimate), p < .01, 2-tailed; F = 2.04; Levene (1, 155) =
13.04, p < .01.
Chi-square contingency analysis showed that the
distribution of OCD and MDD scores into clinical
and control groups was highly contingent on early
separation trauma (l2 = 6.74; l2.05(1) = 6.63, p < .01).
Scale-validation analyses indicated good convergent
and divergent validity, as well as internal consistency
for all four separation-distress scales in clinical and
control groups. The ANPS again diverged from the
other three scales.
Mediation analysis showed a strongly significant
indirect effect relating the comorbidity of OCD and
depression to separation distress (the latter represented
by scores on the SADNESS subscale of the ANPS in
Study 3) (see Table 2). Various mediation models were
tested, including that (1) separation distress mediates
the relationship between OCD and MDD; (2) OCD
mediates the relationship between separation distress
and MDD; and (3) MDD mediates the relationship
between separation distress and OCD. In all cases, the
mediating variable is the one that significantly influ-
ences the effect of one variable in the model on the
other. The most significant model was that positioning
separation distress as a significant mediator of the rela-
tionship between OCD and MDD—that is, separation
distress is a variable through which OCD and MDD are
strongly related [with a mean direct effect (ab) = .092;
Z = 5.244 at p < .05]. Findings were confirmed by the
Test of Joint Significance (TJS; MacKinnon, Lock-
wood, Hoffman, West, & Sheets, 2002), a technique
that exhibits the best relative balance of Type I error
and statistical power (MacKinnon et al., 2002). This
statistical model shows that the indirect relationship
between OCD and MDD, when mediated by separa-
tion distress, is stronger than the direct relationship
between OCD and MDD.
Conclusion
Separation distress was consistently linked with a self-
reported history of a diagnosis of OCD and MDD and
may therefore represent a feature of OCD and MDD.
Furthermore, a reported clinical diagnosis of OCD and/
or MDD in adulthood in this sample was highly con-
tingent on the experience of separation trauma during
critical early periods in childhood. Further work should
investigate whether these findings can be replicated
with subjects assessed directly by the investigators.
122 Michelle Jackson & Mark Solms

Table 1.  Participant demographics

Clinical group (N = 84) Control group (N = 75)

Variables n SD % n SD % t p F

Age, in years 34.12 8.52 32.68 10.85  0.928 .355 1.621 (p = .035)
Education, years of 13.55 1.68 14.48  1.81  1.859 .065 1.163 (p = .505)

Critical λ2
2
λ (df = 1) p

Gender, females 59 70.24 57 76.00  0.498 3.84 .05 

Occupation, skilled 24 28.57 27 36.00  0.905 3.84 .05
Psychiatric treatment a 63 75.00  3  4.00 83.746 7.88  .005
Psychopharmacological 63 75.00  4  5.33 96.510 7.88  .005
treatment b
Separation trauma 33 39.29 16 21.33  6.251 3.84 .05

Did not meet exclusion criteria 24  4

a 
For the variables psychiatric/psychological treatment, psychopharmacological treatment, and separation trauma, the number of participants
who reported experience of these is given, with the corresponding percentage in parentheses.
b 
Psychopharmacological treatment included medication prescribed for clinical psychological and psychiatric disorders—e.g., benzodiazepines
(anti-anxiety medication, or tranquilizers) and antidepressants such as SSRIs (selective serotonin reuptake inhibitors).

Discussion ated with OCD and MDD—namely, obsessionality and

These studies aimed to explore whether PANIC/sepa-
ration distress is significantly associated with both
obsessionality and low mood, as well as with a history
of diagnosed OCD and MDD, and whether it could
therefore in part account for the comorbidity between
OCD and MDD.
Our results repeatedly indicated that those who score
high on measures of obsessionality and low mood, as
well as those with clinical OCD and MDD, exhibit
significantly higher degrees of separation distress, in-
dicating an inclination toward heightened activation
of the PANIC system. We therefore find evidence for
a relationship between both the characteristics associ-
low mood—and these characteristics and separation
distress, in all four of our studies. It may be that obses-
sionality represents the activated phase of separation
distress, in which the subject needs to respond to the
acute trigger of loss, and depressiveness represents the
energy-conserving “despair” phase of the reaction to
separation. We suggest that obsessionality, low mood,
OCD, MDD, and panic disorder exist on a spectrum.
Our findings indicate that this spectrum is grounded,
at least in part, in a disturbance of the PANIC circuits.
These studies establish that PANIC/separation dis-
tress is an important emotion system in obsessionality.
This is valuable since OCD is classified as an anxiety
disorder, and the new findings broaden the conceptu-

Table 2.  Analysis of magnitude and statistical significance of indirect effects

Independent Mediator Dependent Mean Indirect

variable variable variable β a effect (ab) SEab b Z c 95% CI d
OCD Separation distress Depression (.775) × (.625) .4844 .092 5.244 .465 ≤ µ ≤ .504
a 
Standardized path coefficient and product.
b 
Where sβaβb = √(βa2sb2 + βb2sa2 – sa2sb2).
c 
The Z statistic is judged against tables of the normal distribution and therefore is significant at the level of α = .05 when Z > ±1.96.
d 
CI = confidence interval for mean indirect effect (this 95% CI excludes zero and therefore is significant at p < .05).
Separation Distress in Obsessive-Compulsive Disorder 123
alization of the disorder, which may lead to new ways
of understanding and treating it. The evidence that
separation distress is also an important underlying af-
fective mechanism in clinical depression strengthens
the finding that OCD is characterized by a panic type
of anxiety.
This proposal is supported by a mediation analysis,
which shows that these variables are strongly and sig-
nificantly linked via a generative mechanism. The fact
that the indirect relationship between OCD and depres-
sion, when mediated by separation distress, is stronger
than the direct relationship between OCD and depres-
sion, provides strong evidence for the hypothesis that
separation distress is integrally involved in how these
two disorders are associated.
Separation trauma in early childhood was highly
associated with whether the participants in this study
were diagnosed with OCD and/or MDD in adult life,
suggesting that incidence of separation trauma during
critical periods could prove useful as a predictive fac-
tor in the adult development of these disorders.
Our findings suggest that separation distress in some
way mediates the relationship between OCD and the
mood disorder, MDD. This invites a new conceptu-
alization of this anxiety disorder. Our findings show
that separation distress plays a similar role in OCD
and MDD. This appears to account in part for the high
comorbidity between OCD and MDD.
Limitations of the study include the difficulties with
self-reported data. There are well-documented flaws
involved in asking people to give an accurate report of
their own symptoms and psychological experiences.
Apart from the difficulties in recalling emotions and
experiences accurately, there are also the dangers of
response sets, susceptibility to suggestions by item
phrasing or instructions, and social desirability bias. In
addition, a larger sample would have been preferable
for Study 2, but the large number of questionnaires
that had to be completed within a certain time frame
limited the number of participants. It is also possible
that volunteer participants represent a certain subset of
the population, thus limiting the generalizability of the
sample. The undergraduate university sample is also
limited in its generalizability. Finally, psychopharma-
cotherapeautic effects on patients in Study 3 may have
affected their responses.
Psychoanalytic relevance
These findings provide supporting evidence that OCD
and MDD both arise in part from a disturbance in the
PANIC/separation-distress system, which resonates
with models offered by a number of psychoanalytic
thinkers (e.g., Freud, 1917 [1915]; Kernberg, 1992;
Klein, 1940) and the cognitive behavioral therapy mod-
el linking depression with loss (Beck, 1983). As such,
they would reasonably be assumed to have a similar
underlying affective process. As discussed at the start
of this article, MDD appears to encompass the process
of withdrawal and grief that follows separation. Obses-
sions and compulsions could be seen as manifestations
of the acute psychological pain and protest that come
prior to the chronic despair, and then detachment, of
MDD. The protest and despair phase is an attempt to
reestablish the security and nurturance that is lost in
separation—this could be manifested as obsessions
and compulsions—and is a possible psychoanalytic
perspective on why OCD may precede depression.
Together, our findings indicate that further research
into the role of the PANIC system in OCD and MDD
will be richly rewarded.
REFERENCES
APA (1987). Diagnostic and Statistical Manual of Mental Dis-
orders, Third Edition (DSM–III-R). Washington, DC: Amer-
ican Psychiatric Association.
APA (1994). Diagnostic and Statistical Manual of Mental Dis-
orders, Fourth Edition (DSM–IV). Washington, DC: Ameri-
can Psychiatric Association.
Baer, R. A., Wetter, M. W., Nichols, D. S., Greene, R., & Berry,
D. T. R. (1995). Sensitivity of MMPI-2 validity scales to
underreporting of symptoms. Psychological Assessment, 7
(4): 419–423.
Basso, M. R., Bornstein, R. A., Carona, F., & Morton, R.
(2001). Depression accounts for executive function deficits
in OCD. Neuropsychiatry, Neuropsychology, and Behav-
ioural Neurology, 14 (4): 241–245.
Beck, A. T. (1983). Cognitive therapy of depression: New per-
spectives. In: Treatment of Depression: Old Controversies
and New Approaches, ed. P. J. Clayton & J. E. Barrett. New
York: Raven Press, pp. 265–290.
Bhattacharyya, S., Reddy, Y. C., & Janardhan, K. S. (2005).
Depressive and anxiety disorder comorbidity in OCD. Psy-
chopathology, 38 (6): 315–319.
Botvinick, M., Cohen, J. D., & Carter, C. S. (2004). Conflict
monitoring and anterior cingulate cortex: An update. Trends
in Cognitive Sciences, 8: 539–546.
Bowlby, J. (1960). Separation anxiety. International Journal of
Psychoanalysis, 41: 89–113.
Bowlby, J. (1973). Attachment and Loss, Vol. 2: Separation,
Anxiety and Anger. London: Hogarth Press and the Institute
of Psycho-Analysis.
Breiter, H. C., & Rauch, S. L. (1996). Functional MRI and the
study of OCD: From symptom provocation to cognitive-
behavioural probes of cortico-striatal systems and the amyg-
dala. NeuroImage, 4 (3): S127–S138.
124 Michelle Jackson & Mark Solms
Breiter, H. C., Rauch, S. L., Kwong, K. K., Baker, J. R.,
Weisskoff, R. M., Kennedy, D. N., et al. (1996). Functional
magnetic resonance imaging of symptom provocation in
obsessive-compulsive disorder. Archives of General Psy-
chiatry, 53: 595–606.
Burlingham, D., & Freud, A. (1942). Young Children in War-
time. London: Allen & Unwin.
Burlingham, D., & Freud, A. (1944). Infants without Families.
London: Allen & Unwin.
Bush, G., Luu, P., & Posner, M. I. (2000). Cognitive and emo-
tional influences in the anterior cingulate cortex. Trends in
Cognitive Sciences, 4 (6): 215–222.
Cartwright-Hatton, S., & Wells, A. (1997). Beliefs about worry
and intrusions: The Meta-cognitions Questionnaire and its
correlates [Electronic version]. Journal of Anxiety Disor-
ders, 11 (3): 279–296.
Cavedini, P., Ferri, S., Scarone, S., & Belodi, L. (1998). Frontal
lobe dysfunction in OCD and major depression: A clinical-
neuropsychological study. Psychiatry Research, 78: 21–28.
Cyranowski, J. M., Shear, M. K., Rucci, P., Fagiolini, A., Frank,
E., Grochocinski, V. J., et al. (2002). Adult separation anxi-
ety: Psychometric properties of a new structured clinical in-
terview. Journal of Psychiatric Research, 36: 77–86.
Davis, K. L., Panksepp, J., & Normansell, L. (2003). The Affec-
tive Neuroscience Personality Scales: Normative data and
implications. Neuropsychoanalysis, 5: 21–29.
Freud, S. (1917 [1915]). Mourning and melancholia. Standard
Edition, 14.
Gehring, W. J., Himle, J., & Nisenson, L. G. (2000). Action-
monitoring dysfunction in obsessive-compulsive disorder.
Psychological Science, 11 (1): 1–6.
Goodman, W. K., Price, L. H., Rasmussen, S. A., Mazure, C.,
Fleischmann, R. L., Hill, C. L., et al. (1989a). The Yale-
Brown Obsessive-Compulsive Scale. I. Development, use,
and reliability. Archives of General Psychiatry, 46 (11):
1006–1011.
Goodman, W. K., Price, L. H., Rasmussen, S. A., Mazure, C.,
Delgado, P., Heninger, G. R., et al. (1989b). The Yale-Brown
Obsessive-Compulsive Scale. II. Validity. Archives of Gen-
eral Psychiatry, 46 (11): 1012–1016.
Heinecke, C. M. (1956). Some effects of separating two-year-
old children from their parents. Human Relations, 9: 105.
Kernberg, O. (1992). Aggression in Personality Disorders and
Perversion. New Haven, CT: Yale University Press.
Klein, M. (1940). Mourning and its relation to manic-depres-
sive states. In: Writings, Vol. 1: Love, Guilt and Reparation
and Other Works, 1921–1945. London: Hogarth Press, 1985,
pp. 344–369.
MacKinnon, D. P., Lockwood, C. M., Hoffman, J. M., West,
S. G., & Sheets, V. (2002). A comparison of methods to test
mediation and other intervening variables effects. Psycho-
logical Methods, 7 (1): 83–104.
Maltby, N., Tolin, D. F., Worhunsky, P., O’Keefe, T. M., &
Kiehl, K. A. (2005). Dysfunctional action monitoring hy-
peractivates frontal-striatal circuits in obsessive-compulsive
disorder: An event-related MRI study. NeuroImage, 24 (2):
495–503.
Manicavasagar, V., Silove, D., & Hadzi-Pavlovic, D. (1998).
Subpopulations of early separation anxiety: Relevance to
risk of adult anxiety disorders. Journal of Affective Disor-
ders, 48: 181–190.
Manicavasagar, V., Silove, D., Wagner, R., & Drobny, J. (2003).
A self-report questionnaire for measuring separation anxiety
in adulthood. Comprehensive Psychiatry, 44 (2): 146–153.
Moritz, S., Birkner, C., Kloss, M., Jacobsen, D., Fricke, S.,
Bothern, A., et al. (2001). Impact of comorbid depressive
symptoms on neuropsychological performance in OCD.
Journal of Abnormal Psychiatry, 110 (4): 653–657.
Moritz, S., Meier, B., Hand, I., Schick, M., & Jahn, H. (2004).
Dimensional structure of the Hamilton Depression Rating
Scale (HDRS) in patients with obsessive-compulsive disor-
der. Psychiatry Research, 125 (2): 171–180.
Olsen, L. R., Jensen, D. V., Noerholm, V., Martiny, K., & Bech,
P. (2003). The internal and external validity of the Major
Depression Inventory in measuring severity of depressive
states. Psychological Medicine, 33: 351–356.
Panksepp, J. (1998). Affective Neuroscience: The Foundations
of Human and Animal Emotions. New York: Oxford Univer-
sity Press.
Panksepp, J. (2010). Affective neuroscience of the emotional
MindBrain: evolutionary perspectives and implications for
understanding depression. Dialogues in Clinical Neurosci-
ence, 12 (4): 533–545.
Robertson, J. (1953). A Two-Year-Old Goes to Hospital. Lon-
don: Robertson Centre; Ipswich: Concord Films Council.
Robins, L. N., Helzer, J. E., Weissman, M. M., & Orvaschel, H.
(1984). Lifetime prevalence of specific psychiatric disorders
in three sites. Archives of General Psychiatry, 41: 949–958.
Sanavio, E. (1988). Obsessions and compulsions: The Padua
inventory. Behaviour Research & Therapy, 26 (2): 169–
177.
Schwartz, J. M., Stoessel, P. A., Baxter, L. R., Martin, K. M.,
& Phelps, M. E. (1996). Systematic changes in cerebral
glucose metabolic rate after successful behaviour modifica-
tion treatment of obsessive-compulsive disorder. Archives of
General Psychiatry, 53 (2): 109–113.
Silove, D., Manicavasagar, V., O’Connell, D., Blaszczynski,
A., Wagner, R., & Henry, J. (1993). The development of the
Separation Anxiety Symptom Inventory (SASI). Australian
& New Zealand Journal of Psychiatry, 27: 477–488.
Solms, M., & Panksepp, J. (2010). Why depression feels bad.
In: The Neuroscience of Conscious/Nonconscious Interac-
tions, ed. C. H. Ashton & E. K. Perry. Amsterdam: John
Benjamins.
Spitz, R. A., & Wolfe, K. M. (1946). Anaclitic depression: An
inquiry into the genesis of psychiatric conditions in early
childhood. Psychoanalytic Study of the Child, 2: 313–322.
Stroop, J. (1935). Studies of interference in serial verbal reac-
tions. Journal of Experimental Psychology, 18: 643–662.
Thorpe, S. J., Rolls, E. T., & Maddison, S. (1983). The orbito-
frontal cortex: Neuronal activity in the behaving monkey.
Experimental Brain Research, 4: 93–115.
Ursu, S., Stenger, V. A., Shear, M. K., Jones, M. R., & Carter,
C. S. (2003). Overactive action monitoring in obsessive-
compulsive disorder: Evidence from functional magnetic
resonance imaging. Psychological Science, 14 (4): 347–353.
Separation Distress in Obsessive-Compulsive Disorder 125
van Veen, V., & Carter, C. S. (2002). The anterior cingulate as
a conflict monitor: fMRI and ERP studies. Physiology and
Behaviour, 77 (4–5): 477–482.
Watson, D., Clark, L. A., & Tellegen, A. (1988). Development
and validation of brief measures of positive and negative
affect: The PANAS scales. Journal of Personality & Social
Psychology, 54 (6): 1063–1070.
Watt, D., & Panksepp, J. (2009). Depression: An evolutionarily
conserved mechanism to terminate separation distress? A
review of aminergic, peptidergic, and neural network per-
spectives. Neuropsychoanalysis, 11 (1): 7–51.
Weissman, M. M., Bland, R. C., Canino, G. J., Greenwald, S.,
Hwu, H. G., Lee, C. K., et al. (1994). The cross-national
epidemiology of obsessive-compulsive disorder. The Cross
National Collaborative Group. Journal of Clinical Psychia-
try 55 (Suppl.): 5–10.
Whiteside, S. P., Port, J. D., & Abramowitz, J. S. (2004). A me-
ta-analysis of functional imaging in obsessive-compulsive
disorder. Psychiatry Research: Neuroimaging, 132: 69–79.
WHO (1993). The ICD-10 Classification of Mental and Behav-
ioural Disorders: Diagnostic Criteria for Research. Geneva:
World Health Organization.