A cognitive model of obsessive-compulsive disorder (Mancini)

Theory of change

The person changes when they can revise the fear of being guilty, tolerate uncertainty and moral risk, abandon compulsive preventive strategies and accept that being wrong does not destroy their personal worth.

Core ideas

1. Compulsions try to prevent guilt, not only harm

   The model holds that obsessive activity is organised around a specific fear: being guilty of having caused, allowed or failed to prevent an unjust harm, or of having transgressed a moral norm. The feared harm matters because it could turn the person into someone responsible, negligent, dangerous or morally defective. This formulation extends the inflated responsibility models by explaining why the person needs to prevent not only the negative outcome but also the moral condemnation they anticipate. Reference: Mancini, F. (2001). Un modello cognitivo del disturbo ossessivo-compulsivo; Mancini, F., & Gangemi, A. (2004). Fear of guilt from behaving irresponsibly in obsessive-compulsive disorder.

2. Feared guilt requires a specific cognitive structure

   For fear of guilt through irresponsibility to appear, the person must anticipate a harm or transgression, attribute a relevant causal link to their conduct, believe that they could have acted otherwise and hold a moral norm prescribing that the outcome be avoided. The model makes it possible to formulate these variables clinically instead of treating the obsession as undifferentiated fear. Reference: Mancini, F. (2001). Un modello cognitivo del disturbo ossessivo-compulsivo.

3. The prudential-guilt mode maintains repetition and persistence

   Fear of guilt favours a mode of testing that privileges the worst hypothesis, demands far more evidence to rule it out than to accept it, and resists reassuring information. The person goes on checking because they answer negatively to questions such as whether they have done enough or whether they can be completely sure of having averted the harm. This logic explains the repetition of rituals, ruminations and preventive behaviours. Reference: Mancini, F., & Gangemi, A. (2006). The role of responsibility and fear of guilt in hypothesis-testing.

4. Obsessive activity has a protective purpose

   Obsessions and compulsions are understood as purposive activities that seek to prevent, neutralise or repair a threat of guilt. This reading does not validate the obsessive content, but makes it possible to understand why the symptom persists despite being costly: the patient regards it as a defence against a morally intolerable possibility. The therapy works on that protective function and on the price of sustaining it through impossible certainty. Reference: Mancini, F. (2001). Un modello cognitivo del disturbo ossessivo-compulsivo.

5. Ego-dystonicity can feed a second maintaining cycle

   The patient usually considers their obsessions and compulsions excessive, irrational, shameful or destructive. This negative appraisal generates further attempts to suppress thoughts, to stop compulsions by force, to ruminate in order to convince themselves or to punish themselves for having symptoms. These second-order attempted solutions increase vigilance and the salience of the problem, helping to maintain obsessive activity. Reference: Mancini, F. (2001). Un modello cognitivo del disturbo ossessivo-compulsivo; Mancini, F. (2005). Il disturbo ossessivo-compulsivo.

6. Accepting possible guilt is different from accepting obsessive thoughts

   The later developments of the model propose that the patient can improve when they learn to regard the possibility of being guilty as painful but acceptable, reparable and compatible with maintaining personal dignity. The focus is not on accepting the obsessive content as true or on resigning oneself to acting irresponsibly, but on ceasing to organise one's life around eliminating every possibility of error, reproach or moral imperfection. Reference: Cosentino, T., D'Olimpio, F., Perdighe, C., Romano, G., Saliani, A. M., & Mancini, F. (2012). Acceptance of being guilty in the treatment of obsessive-compulsive disorder.

7. Deontological guilt provides a moral reading of OCD

   The later research of Mancini and colleagues has emphasised deontological guilt, associated with the perception of having transgressed a rule, failed in a duty or deserved moral reproach. This formulation helps to explain why symptoms of contamination, checking, scrupulosity, order or intrusive thoughts can be experienced as a threat to the person's purity, rectitude, responsibility or moral worth. Reference: Mancini, F., & Gangemi, A. (2015). Deontological guilt and obsessive-compulsive disorder; D'Olimpio, F., & Mancini, F. (2014). Role of deontological guilt in obsessive-compulsive disorder-like checking and washing behaviors.

8. Exposure works when it is oriented towards accepting uncertainty and moral risk

   Exposure with response prevention allows the patient to remain in the presence of the trigger without carrying out behaviours of prevention, neutralisation or reassurance seeking. On this formulation, its function does not consist solely in reducing anxiety through habituation, but in practising the acceptance that risk, doubt or possible guilt may exist without it being necessary to resolve them compulsively. Reference: Mancini, F., & Gragnani, A. (2005). L'esposizione con prevenzione della risposta come pratica dell'accettazione.

9. Moral self-criticism can be a direct clinical target

   Recent formulations of the model describe how many people with OCD respond to doubt with accusatory internal statements that increase guilt, anxiety and the need to neutralise. Identifying and transforming this dialogue is not the same as offering reassurance, but the building of an internal voice able to acknowledge proportional responsibility, human limits and the possibility of forgiveness. Reference: Saliani, A. M., Perdighe, C., Zaccari, V., Luppino, O. I., Mancini, A., Tenore, K., & Mancini, F. (2024). Treating guilt-inducing self-talk in OCD with dramatized Socratic dialogue.

Influences

• Cognitive psychology
• Cognitive-behavioural therapy
• The theory of emotional appraisal
• Salkovskis's cognitive model of OCD
• Rachman's cognitive theory of obsessions
• The theory of responsibility
• The theory of guilt
• Research on hypothesis testing

Key references

• Mancini, F. (2001). Un modello cognitivo del disturbo ossessivo-compulsivo. Psicoterapia, 22-23, 43-60.
• Mancini, F. (2005). Il disturbo ossessivo-compulsivo. In B. Bara (Ed.), Il manuale di terapia cognitiva. Torino: Bollati Boringhieri.
• Mancini, F. (Ed.). (2016). La mente ossessiva: Curare il disturbo ossessivo-compulsivo. Milano: Raffaello Cortina Editore.
• Mancini, F., & Gangemi, A. (2004). Fear of guilt from behaving irresponsibly in obsessive-compulsive disorder. Journal of Behavior Therapy and Experimental Psychiatry, 35, 109-120. https://doi.org/10.1016/j.jbtep.2004.04.003
• Mancini, F., & Gangemi, A. (2006). The role of responsibility and fear of guilt in hypothesis-testing. Journal of Behavior Therapy and Experimental Psychiatry, 37(4), 333-346. https://doi.org/10.1016/j.jbtep.2006.03.004
• Mancini, F., D’Olimpio, F., & Cieri, L. (2004). Manipulation of responsibility in non-clinical subjects: Does expectation of failure exacerbate obsessive-compulsive behaviours? Behaviour Research and Therapy, 42, 449-457.
• Gragnani, A., Toro, B., De Luca, L., Cavagnoli, M., & Mancini, F. (2003). L’efficacia delle tecniche cognitive nella riattribuzione della stima della probabilità. Psicoterapia Cognitivo Comportamentale, 9(2), 91-108.
• Mancini, F., & Gragnani, A. (2005). L’esposizione con prevenzione della risposta come pratica dell’accettazione. Cognitivismo Clinico, 2, 38-58.
• Cosentino, T., D’Olimpio, F., Perdighe, C., Romano, G., Saliani, A. M., & Mancini, F. (2012). Acceptance of being guilty in the treatment of obsessive-compulsive disorder. Psicoterapia Cognitiva e Comportamentale, Monograph Supplement, 39-56.
• Mancini, F., Gangemi, A., Perdighe, C., & Marini, C. (2008). Not just right experience: Is it influenced by feelings of guilt? Journal of Behavior Therapy and Experimental Psychiatry, 39, 162-176.
• Mancini, F., & Gangemi, A. (2015). Deontological guilt and obsessive-compulsive disorder. Journal of Behavior Therapy and Experimental Psychiatry, 49, 157-163.
• D’Olimpio, F., & Mancini, F. (2014). Role of deontological guilt in obsessive-compulsive disorder-like checking and washing behaviors. Clinical Psychological Science, 2(6), 727-739. https://doi.org/10.1177/2167702614529549
• Saliani, A. M., Perdighe, C., Zaccari, V., Luppino, O. I., Mancini, A., Tenore, K., & Mancini, F. (2024). Treating guilt-inducing self-talk in OCD with dramatized Socratic dialogue: A step by step intervention. Clinical Neuropsychiatry, 21(1), 63-78. https://doi.org/10.36131/cnfioritieditore2023060104
• Cosentino, T., & Mancini, F. (2020). L’integrazione dell’EMDR nel trattamento del DOC. Cognitivismo Clinico, 17(2).