In recent years evidence has accumulated to suggest a strong link between obsessive-compulsive disorder (OCD) or obsessive-compulsive symptoms (OCS) on one hand (henceforth OCD/S), and a tendency for dissociative experiences on the other hand, including episodes of depersonalization and derealization (sensations of detachment or estrangement from one’s self or the environment, respectively; American Psychiatric Association [APA], 2013), and “absorption and imaginative involvement” (AII; Carlson and Putnam, 1993), (i.e., a tendency for experiencing immersive attention toward an internal or external stimulus, accompanied by obliviousness to surroundings). Dissociative experiences seem to be a transdiagnostic construct relevant to several psychiatric disorders (Soffer-Dudek, 2014; Ellickson-Larew et al., 2020; Buchnik-Daniely et al., 2021; Lynn et al., 2022). It has been suggested that dissociative experiences may interact in specific ways with various disorders, and those specific interactive paths should be studied to advance the understanding of both dissociation and the respective disorders (Soffer-Dudek, 2014). Nevertheless, as dissociative experiences or symptoms have been mostly related to trauma and trauma-related disorders, the dissociation-OCD/S connection is not intuitive for many researchers and clinicians, most of whom naturally belong to only one of the respective fields (either trauma-dissociation or OCD/S). More importantly, the mechanisms governing this association are poorly understood. The present work is a theoretical formulation, aimed to outline suggested underlying mechanisms, and identify pertinent areas that warrant exploration through future empirical research and may be a focus for personalized interventions for high-dissociation individuals with OCD/S. Although most OCD/S researchers see dissociative episodes as an effect of OCD/S, the current formulation suggests that certain dissociative experiences may act as a cause as well; specifically, the present work will try to establish that AII may contribute to OCS as well as to the emergence of established cognitive risk factors for OCD.

The sections below will: (1) briefly define common dissociative experiences and discuss their etiology; (2) describe their strong, specific relationship with OCD/S; (3) suggest five different causal models with specific mechanisms that may underlie that relationship; and finally (4) remark on identified areas for future study and possible interventions. Better insight into the processes that generate the link between OCD/S and dissociative processes will advance clinical psychological science within both respective fields, and may also augment existing psychotherapies for OCD, which have proved to be less successful among clients reporting dissociative experiences (Rufer et al., 2006a; Prasko et al., 2009; Semiz et al., 2014).

Dissociation is defined in the Diagnostic and Statistical Manual of Mental Disorders (DSM, 5th ed.) as “the splitting off of clusters of mental contents from conscious awareness” (American Psychiatric Association [APA], 2013, p. 820). Dissociative disorders, accordingly, “…are characterized by a disruption of and/or discontinuity in the normal integration of consciousness, memory, identity, emotion, perception, body representation, motor control, and behavior” (p. 291). Alongside extreme or rare forms of dissociation (e.g., dissociative identity disorder; DID, in which one experiences oneself as having multiple identities), several types of experiences that are widely considered to be dissociative are quite common. For example, experiences of depersonalization and/or derealization (DEP/DER), are characterized by feeling detached or estranged from oneself, either one’s own mental processes, body, or actions (e.g., individuals may feel as if they were located outside of their body), or from the world (e.g., objects, actions, or events may be perceived as “dreamlike” or as moving in slow-motion). The prevalence of DEP/DER disorder is estimated at 1–2%, but transient DEP/DER sensations are very common, with lifetime estimations ranging between 26 and 74% (Hunter et al., 2004). A recent, integrative theoretical account of dissociative experiences maintains that whereas early, severe, or complex traumatic stress (e.g., childhood physical or sexual abuse) may result in extreme dissociative disorders (DID, dissociative amnesia), mild-to-moderate stress may result in mild-to-moderate dissociative experiences, such as DEP/DER (Buchnik-Daniely et al., 2021; Soffer-Dudek and Somer, 2022). Although DEP/DER may represent symptoms of post-traumatic stress disorder (PTSD; DSM-5, American Psychiatric Association [APA], 2013) or appear as a transient experience during trauma (a phenomenon labeled peritraumatic dissociation, e.g., Marmar et al., 1996), it is also characteristic of panic attacks or overwhelming anxiety that is not necessarily trauma-driven (DSM-5, American Psychiatric Association [APA], 2013; Soffer-Dudek, 2014). Moreover, DEP/DER experiences increased longitudinally following excessive rumination over a span of several months, in a sample of individuals with depression and anxiety but no PTSD, mixed with a community sample (Vannikov-Lugassi et al., 2021). In daily diary studies spanning non-clinical and clinical samples, state DEP/DER symptoms were predicted by daily stress and anxiety (Stiglmayr et al., 2008; Soffer-Dudek, 2017a). DEP/DER experiences also tend to increase following full or partial sleep deprivation (Giesbrecht et al., 2007; Selvi et al., 2015; van Heugten-van der Kloet et al., 2015; Soffer-Dudek et al., 2017) and to improve in accordance with the improvement of sleep (van der Kloet et al., 2012a). Finally, as a stand-alone disorder, DEP/DER disorder is not especially related to childhood trauma (e.g., Michal et al., 2016). To conclude, etiological factors for DEP/DER experiences are broad, ranging from traumatic to non-traumatic stress and from psychological to physiological effects.

An even more common dissociative experience is an empirically derived subscale of the Dissociative Experiences Scale (DES; Carlson and Putnam, 1993), labeled AII, considered by many as a personality tendency representing mild or “non-pathological” dissociation (Butler, 2006). AII represents the disintegration of consciousness in everyday behaviors and contexts; it refers to a tendency to be totally immersed in a stimulus, which often will be one’s imagination or daydreaming, which is especially immersive and vivid (Bregman-Hai et al., 2018), but may also be external such as a movie or a book. It is the narrowing of one’s attention to a fragment of experience, to the point where one is oblivious to surroundings (Soffer-Dudek et al., 2015), at times failing to notice substantial occurrences, or registering them unconsciously (resulting in dissociative amnesia, a compartmentalization or inaccessibility of autobiographical memories). AII could be argued to represent an inclination for often experiencing moments where a person functions in a less integrative way, with a decreased sense of an overarching observer self (Soffer-Dudek and Somer, 2022). Normative dissociation may be manifested, for example, in realizing you are unsure of what you had said to someone, as your mind was “someplace else” during the conversation. Another common dissociative experience is “highway hypnosis,” characterized by driving somewhere yet suddenly realizing that you have no memory for parts of the trip (Williams, 1963). Interestingly, researchers have shown that driving while listening to unrelated auditory content relies on the parallel activation of two separate neural systems, supporting the notion that in certain conditions of normal daily life, our mental functioning is indeed divided (Sasai et al., 2016). Absorbers tend to act on “auto-pilot”; their awareness is focused elsewhere while they are performing routine tasks. This may lead to mistakes (e.g., putting the flour in the freezer instead of in the pantry) or to miscommunication (e.g., answering someone absent-mindedly). Automaticity is a complex concept with many definitions (Moors and De Houwer, 2006); a full review of automaticity is outside the scope of the current work. However, automatic processes are commonly seen as self-regulated actions that run to completion without conscious guidance (Bargh, 1989, 1992, 1997), conscious monitoring (Tzelgov, 1999), or meta-consciousness (Schooler, 2002). The disintegration between awareness or conscious guidance, and performing complex behavior, exemplifies how AII is the common or normative manifestation of the “splitting” of awareness occurring in clinical-level dissociation (Bregman-Hai et al., 2020). Indeed, Butler (2006) has suggested that pathological and “non-pathological” dissociation “…both involve a telescoping of the attentional field to concentrate on a narrow range of experience and the concomitant exclusion of other material (internal or external) from awareness and, to some degree, from accessibility” (p. 45). In line with the idea that AII is characterized by mental disintegration, healthy high AII individuals show decreased neural connectivity (lower EEG coherence) at resting state compared to low AII individuals; The observed decreased coherence in relation to high AII was in the long (frontal-occipital) range, and in the central-parietal short-range pair, both mostly in the left hemisphere (Soffer-Dudek et al., 2019).¹ This supports the notion of a stable and meaningful personality trait. Indeed, despite the commonness of such experiences, some individuals tend to have them more than others. Below, it will be established that not only are individual differences in AII relevant to psychopathology, but also, that they are relevant specifically to OCD/S. But before, two important caveats on AII and common dissociation in general should be noted.

First, a closely related construct is the similarly labeled trait of “absorption” as measured by the Tellegen absorption scale (TAS; Tellegen and Atkinson, 1974). However, the constructs are not identical: Tellegen’s absorption involves both a narrowing and an expansion of attention (Tellegen, 1982),² whereas AII refers mainly to the narrowing of the attentional span, which relegates the neglected—or dissociated—domains to the periphery of consciousness (Putnam, 1997; Leavitt, 2001). Tellegen’s absorption includes the inclination to experience mystical or enlightening experiences and a sense of elation or oneness with nature, all of which are not included in AII. Indeed, AII and the TAS are only moderately to strongly associated, but do not overlap (r = 0.42–0.52; Frischholz et al., 1991; Smyser and Baron, 1993; Levin and Spei, 2004). Moreover, in a factor analysis on N = 841 they were virtually discrete; AII was labeled “attentional dissociation” (Carleton et al., 2010). Finally, AII, but not the TAS, involves impairments specific to one’s sense of self and agency (Bregman-Hai et al., 2020), constructs that will be further discussed below.

Second, it is important to mention that structural dissociation theorists do not consider AII or DEP/DER to represent dissociation (e.g., van der Hart et al., 2004). These experiences are viewed by them as alterations in attention and awareness that should not be labeled “dissociative,” as they do not necessarily stem from trauma and do not represent a structural dissociation of the personality into independently functioning agentic parts. Indeed, AII and DEP/DER do not necessarily stem from trauma, and accordingly, have been suggested as transdiagnostic factors relevant for understanding several psychopathologies, including OCD/S (Soffer-Dudek, 2014); however, this does not automatically imply that they should not be considered as mild forms of dissociation. The definition of dissociation does not include etiology but rather describes specific symptoms or phenomena. The discussion of whether they should be labeled dissociative or not is outside the scope of the current work. In line with most of the literature on dissociation, including the DSM-5 (American Psychiatric Association [APA], 2013), The present work will refer to these processes as dissociative. Specifically, DEP/DER disorder appears in the dissociative disorders chapter in the DSM-5 and DEP/DER symptoms have been used in the DSM-5 to define the dissociative subtype of PTSD (American Psychiatric Association [APA], 2013). Thus, the current paper will adhere to this terminology. Regarding AII, it is the subscale carrying most of the variance of the DES (Stockdale et al., 2002; Soffer-Dudek et al., 2015), which is the most widely used measure in the literature aimed to assess dissociation. AII is also very high in the dissociative disorders, including DEP/DER disorder as well as DID (Ross et al., 1995; Leavitt, 1999, 2001; Simeon et al., 2009) and it is associated with a similar neural correlate of decreased coherence as severe dissociation (Soffer-Dudek et al., 2019). Theoretically, an extensive account on why AII is rightfully considered to represent dissociation has recently been published, referring to its properties of decreased agency, incoherent sense of self, increased automaticity, and temporarily compartmentalized behavior and thought, all of which render it a common and mild manifestation of multiplicity, that may represent a diathesis for the development of more extreme dissociative symptoms (Soffer-Dudek and Somer, 2022). The reader is referred to this source for the discussion of whether AII should be considered dissociative.

Although AII is usually referred to as “non-pathological dissociation,” several studies have demonstrated its linear association with psychopathology in general (Leavitt, 2001; Levin and Spei, 2004; Armour et al., 2014; Soffer-Dudek et al., 2015; Humpston et al., 2016), and specifically, with OCS (Soffer-Dudek et al., 2015; Soffer-Dudek, 2017a,2019; Tapancı et al., 2018; Boysan et al., 2022). More generally, dissociative experiences, as measured with the DES as well as with other scales, have been associated with OCD/S in several studies (for a review see Soffer-Dudek, 2014, although additional studies have been published since). Specifically, clinical-sample studies showed that the presence or severity of several OCS in adults or adolescents diagnosed with OCD were associated with dissociative symptoms (Goff et al., 1992; Grabe et al., 1999; Merckelbach and Wessel, 2000; Lochner et al., 2004; Rufer et al., 2006b; Fontenelle et al., 2007; Belli et al., 2012; Tatlı et al., 2018; Meral et al., 2021). In one study, out of 78 patients diagnosed with OCD, 11 (14.1%) were also diagnosed with a comorbid dissociative disorder, and the general mean score of dissociation symptoms in the sample was close to the clinical cutoff score for suspected dissociative disorders (Belli et al., 2012). Similarly, clinical OCD patients are higher in dissociation scales than healthy controls (e.g., Merckelbach and Wessel, 2000; Tapancı et al., 2018; Tatlı et al., 2018). For example, in one study (Tatlı et al., 2018), controls had a mean DES score of 4.87, whereas OCD patients scored a significantly higher 20.58. In another, it was similarly 8.89 vs. 19.36, also a statistically significant difference (Tapancı et al., 2018). Finally, non-clinical or mixed sample studies repeatedly show that OCS and dissociation are associated (Norton et al., 1990; Watson et al., 2004; Zermatten et al., 2006; Aardema and Wu, 2011; Soffer-Dudek et al., 2015; Soffer-Dudek, 2017a,2019; Vannikov-Lugassi and Soffer-Dudek, 2018a; Ellickson-Larew et al., 2020). Moreover, several studies have demonstrated the specificity of the dissociation-OCD/S link, as it could not be accounted for by general neuroticism, psychopathological comorbidities, depression levels, psychotropic medication, attention deficit symptoms, or mind-wandering (Watson et al., 2004; Rufer et al., 2006a; Soffer-Dudek et al., 2015; Soffer-Dudek, 2019). There has even been a measure of “obsessional dissociation” developed, merging the two constructs into a single theoretical dimension (Boysan et al., 2018; Yıldırım and Boysan, 2019).

Obsessive-compulsive disorder is characterized by intrusive, unwanted, repeated, and uncontrollable thoughts, feelings, impulses, or images, and/or repetitive behaviors, usually aimed at reducing the associated anxiety. Some OCD/S researchers have discussed or shown that OCD/S may bring about dissociative and absorptive states due to immersion in obsessions or engaging total attention in compulsive rituals. In other words, they have viewed dissociation as an outcome of OCD/S. For example, O’Connor and Aardema (2012) have described how during obsessional thinking, individuals experience the world as if “in a bubble,” in an immersive and dissociative consciousness state. Possibly, the narrowing of attention, which is an inherent element in obsessions and in many compulsions (that need to be performed “just right” or memorized) alters the sense of reality and induces DEP/DER. Indeed, in a very relevant analog study, van den Hout et al. (2009) showed how compulsive-like staring brought about DEP/DER in a non-clinical sample. Specifically, they demonstrated how even relatively short intervals (e.g., 30 s) of concentrated staring at a gas stove (participants were asked not to avert their gaze or blink) paradoxically decreased certainty about perception and increased dissociative experiences. This result joined a series of seminal works by van den Hout et al. (2009) showing that compulsions were not only a result of obsessions/anxiety in OCD but also a driving force or causal factor contributing to the maintenance of the inefficient cycle of uncertainty and checking in the disorder. In this respect, dissociation or the disintegration of experience is viewed as an outcome of compulsive acts.

If indeed dissociation is merely an outcome of OCD/S, it should not necessarily be of significant interest to OCD/S clinicians and researchers. Importantly, however, whereas DEP/DER is indeed likely to represent a consequence or by-product of OCD/S, AII may represent a risk factor or augmenting factor in generating or maintaining OCD/S (Soffer-Dudek, 2014, 2019). This proposition is based on the idea that individuals with the tendency to become absorbed, “spaced out,” or dissociated may experience anxiety and confusion following such episodes, which may propel them to perform checking or act out other alleged safety measures. In other words, the narrow attentional spotlight and dissociated/automatic behavior characterizing high AII individuals are not continuously present; occasionally, their awareness returns to an integrated state (Butler, 2006), whereupon they may wonder what just transpired, even regarding their own actions. This uncertainty may cause anxiety, obsessing, and checking in an attempt to substantiate reality (Soffer-Dudek, 2014, 2019). Others have also recently noted that dissociation may be the factor that turns “normal” obsessions into abnormal ones, i.e., into OCD (Boysan et al., 2018), and that dissociative amnesia or lack of confidence in one’s own actions may enhance obsessional doubts (Pozza and Dèttore, 2019). Accordingly, AII demonstrates specificity in predicting OCS, in several ways: (1) AII was the only dissociative factor that predicted a longitudinal increase in OCS (Soffer-Dudek et al., 2015); (2) the relationship of AII and OCS cannot be explained by the association of OCS with attention-deficit symptoms or with mind-wandering (Soffer-Dudek, 2019); and finally, and (3) in a daily diary study, with constructs measured as daily states, time-lag analysis indicated that both AII and DEP/DER were elevated on days in which OCS were elevated; however, only AII proved to also be elevated on the previous day (Soffer-Dudek, 2017a). It is important to note that such a design cannot establish initial causality/etiology, but it can shed light on present-day dynamics. To conclude, OCD/S, DEP/DER, and AII may enhance each other reciprocally, meaning that it is important to better understand the role of dissociation in OCD/S.

This importance is also exemplified in several studies showing that high baseline levels of dissociation in individuals with OCD predict poorer treatment response, or in other words, more treatment-resistant OCD (Rufer et al., 2006a; Prasko et al., 2009; Semiz et al., 2014). In one of these studies, an exploration of subscales revealed that the effect stemmed from AII; Specifically, individuals scoring high on AII at baseline were less successful in their cognitive-behavioral therapy for OCD and were more inclined to drop out, even after controlling for psychopathology and medication use (Rufer et al., 2006a). It has been suggested that the reason that highly dissociative individuals with anxiety disorders are less responsive to treatment is because perhaps they detach from negative emotions that arise during exposure therapy sessions, or because of poor attachment following childhood trauma, which hampers the development of a therapeutic alliance (Spitzer et al., 2007; Semiz et al., 2014). Moreover, traumatic-dissociative flashbacks have been suggested to be indistinguishable at times from obsessional phenomena (Lipinski and Pope, 1994; Semiz et al., 2014). However, detachment following negative emotions could be said about any other disorder as well, and thus does not explain the specificity demonstrated for the OCS-dissociation relationship. In addition, it does not explain the specific relation with AII. As for trauma and flashbacks, although the relation of traumatic stress with dissociation is well-documented, the correlation effect size in most samples is medium (r = 0.32 in a meta-analysis; Dalenberg et al., 2012), indicating that the proportion of explained variance is only slightly over 10%, pointing to the need to better understand additional sources of variance in accounting for dissociation. This claim is augmented by the fact that whereas several studies found trauma to be related to OCD/S (Mathews et al., 2008; Lafleur et al., 2011; Berman et al., 2013; Khosravani et al., 2017; Miller and Brock, 2017; Ay and Erbay, 2018), several others did not (Fontenelle et al., 2007; Grabe et al., 2008; Selvi et al., 2012; Visser et al., 2014; Ivarsson et al., 2016). Moreover, in a study exploring both dissociation and trauma as potential predictors of treatment non-response in OCD, only the former was a significant predictor (Semiz et al., 2014). In another study, trauma could not explain the effect of dissociation on OCD (Tatlı et al., 2018). Additional explaining factors that have been mentioned regarding dissociation predicting treatment non-response in OCD are high levels of affect during exposure, inhibiting reality testing, regulation of emotional arousal, and habituation (Rufer et al., 2006a; Semiz et al., 2014). It has also been mentioned that the presence of dissociation could be a marker of more severe obsessive–compulsive symptoms (Goff et al., 1992; Semiz et al., 2014). Yet, most of these mechanisms and explanations are non-specific and vague, leaving a gap in our theoretical understanding of dissociation in OCD.

Additional mechanisms must be responsible for the OCD/S-dissociation link, and the idea presented in this paper is that they are specific to the nature of dissociation as an interruption to an integrated sense of self. Indeed, it is being increasingly acknowledged in the OCD literature that one element characterizing OCD is an incoherent, unstable, or ambivalent sense of self (Guidano and Liotti, 1983; Bhar and Kyrios, 2007; Godwin et al., 2020; Aardema et al., 2021; Llorens-Aguilar et al., 2022). For example, a young adult male with OCD stated to the author of this paper that most of the time, he feels as if he is lying, even though he does not intend to lie, thus describing his continuous subjective experience of unfamiliarity and detachment from who he is and his bafflement as to his own identity. This distance from the spontaneous sense of knowing who you are, what you want, or what you mean, is closely related to dissociation and specifically depersonalization experiences, and may be a core feature of OCD/S, as it is closely associated with doubt and uncertainty. Below, specific constructs that may be at play in the OCD/S-dissociation relationship will be highlighted, each denoting a different causal pattern between the respective constructs. Table 1 presents a summary of the specific mechanisms and models suggested in this paper.

In the present work, five different theoretical causal models were presented, explaining the strong and specific relationship of dissociative experiences and OCD/S, none of which rely on general constructs such as trauma or detaching from negative emotion–constructs that are usually considered as the immediate etiological factors of dissociation, but are not specific to OCD/S. The five models do not negate one another but may be complementary, in other words, may all be true; they are presented separately for the sake of theoretical clarity. However, dissociation and OCD/S may reciprocally affect each other as well as stem from several common mechanisms.

Indeed, although the models were presented as separate, they are closely related. For example, both Models 2 (SoA) and 3 (Embodiment) focus on impaired binding or integration of sensory and/or motor systems; and both Models 4 (Sleepiness) and 5 (Imagery) imply enhanced salience of visual thought during waking. All five models probably work together in contributing to the anatomical-functional-psychological infrastructure generating and/or maintaining OCD/S. For example, attention overly focused inward (Model 1) may reciprocally affect and be affected by, decreased sensory integration (Models 2, 3), and that internal attentional spotlight may be directed toward salient, uncontrolled images (Models 4, 5), which further demand their share of attention, leaving the individual in a vicious cycle of fixation on fantastical possibilities.

More research is needed concerning self-concept clarity, identity, and automaticity in OCD/S. Additionally, AII, SoA, embodiment, sleep-wake boundaries, and imagination activity all seem to be worthwhile avenues for further investigation regarding OCD/S etiological and maintaining factors. In particular, there is a need for experimental work on dissociation and OCD/S, exploring the possibility of dissociative experiences as a causal factor. For example, experiments could explore whether manipulating individuals into an immersed and absorbed state while they perform a task with little awareness may bring about anxiety and uncertainty regarding their automatic actions. Also, experience-sampling and prospective-longitudinal designs are scarce in the OCD/S field; those could shed light on the day-to-day temporal dynamics of the OCD/S–dissociation relationship, as well as the long-term effects of personality. Specifically, large-scale longitudinal developmental studies may reveal whether experiential inclinations such as trait AII may, over time, engender cognitive schema risk factors for OCD/S, such as TAF.

The present work builds upon previous etiological knowledge accumulated on OCD/S, such as inferential confusion, TAF, and the SPIS model. However, considering dissociation adds important insights with incremental value for understanding OCD/S. For example, adding an experiential and sensory perspective helps shed light on the development of cognitive risk factors such as inferential confusion and TAF. Notably, the SPIS model suggests that TAF stems from lack of access to one’s feelings and motivations, and therefore trying to compensate by assigning excessive importance to one’s own thoughts and images (Dar et al., 2021). The current theoretical formulation postulates that considering dissociation is crucial to understanding how it may be that a person may feel diminished access to their own feelings and motivations, and offers a somewhat more specific explanation for TAF, which is characterized by magical thinking. Again, it does not contradict or negate the explanation suggested previously but enriches its nuances.

High-dissociation individuals are known to gain less from ordinary treatment for OCD (Rufer et al., 2006a; Prasko et al., 2009; Semiz et al., 2014), which is why the current formulations may be important in inspiring the development of clinical interventions for such individuals. The models suggested in this work harbor practical clinical significance in several domains. First, future studies could examine whether individuals with OCD may benefit from the use of grounding techniques, usually associated with treating dissociation, to focus their attention outward and ground their sense of bodily self when getting caught up in obsessions or negative emotion. This was briefly mentioned as a useful aid in two independent case reports of clients with OCD (Proescher, 2010; Cheli et al., 2020). Second, the idea that AII may contribute to OCD/S (Models 2 and 4) means that understanding dissociative-absorptive qualities in OCD may impact interventions. For example, one study aimed to enhance attentional abilities in OCD patients by training them at selective attention, but that did not decrease their symptoms (Haug et al., 2013). The present conceptualization, according to which individuals with OCD have a tendency for an absorptive, narrow attentional spotlight, in the form of AII, explains why training them to attend selectively to a single stimulus was unlikely to alleviate their symptoms. In contrast, the training of patients with OCD for attentional control should perhaps focus on the development of the ability to integrate mental states and multitask. Moreover, empathically addressing clients’ sensory experiences of increased automaticity, decreased agency, and resulting reality-fantasy confusion may help them feel better understood by the therapist, which may facilitate their motivation to correct their cognitive oversights.

Third, future studies should explore whether alterations in automatic processing and integration of bodily cues (Model 3), perhaps due to temporo-parietal abnormalities, may also be of importance as a possible focus of intervention. Such a neuropsychological intervention has been attempted in the field of dissociation (Mantovani et al., 2011). Fourth, the idea that sleepiness and mixed sleep-wake states may be involved in the etiology or maintenance of OCD/S (Model 4) means that at the beginning of treatment, an OCD client should be assessed not only with dissociation scales, but also pertaining to sleep quality and sleep-wake boundary phenomena. Sleep-wake boundaries are important to consider, rather than merely focusing on traditional sleep quality measures (Soffer-Dudek, 2017b). For example, a client may off-handedly report that they have no problems falling asleep and indeed, report that they drink coffee every evening and still fall asleep within minutes. This may suggest an inclination for experiencing mixed states, that may manifest in both nighttime aroused dreaming and daytime dissociative experiences, that may possibly exacerbate their OCD symptoms. While this suggestion is speculative and in need of further study, it should be considered as it is quite easy to implement sleep hygiene interventions in addition to treatment as usual. Finally, a hyperactive imagery system (Model 5) may suggest the existence of comorbid maladaptive daydreaming. If the client experiences elaborate, narrative, absorbing fantasies, which they engage in compulsively, treatment should address that, for example by monitoring the imagination activity and its triggers (Herscu et al., 2023). Maladaptive daydreaming often involves an idealized version of the self (Somer, 2002) and experimenting with different personalities (Soffer-Dudek and Somer, 2022), meaning that addressing self-image, self-coherency, or other underlying self-related issues may also be relevant.

The present work has several limitations. Specifically, knowledge of the neuropsychological underpinnings of dissociative experiences is quite scant and preliminary, which makes it difficult to identify the functional source of dissociative impairments in OCD/S. Second, the definitions of dissociative experiences may be at times quite hazy and controversial (e.g., see van der Hart et al., 2004), with points of overlap with other existing constructs such as negative SoA, for DEP/DER, and deficits in attention, for AII (e.g., see Carleton et al., 2010, who defined AII as “attentional dissociation”). Importantly, though, attention deficit and mind-wandering have been shown to be separate factors from AII, and the latter had significant incremental value over them in predicting OCD/S (Soffer-Dudek, 2019). Still, overlapping or ambiguous definitions hinder scientific clarity. Finally, a lack of specific intervention protocols for mild dissociative states limits the ability to tailor treatments differently for individuals with OCD who are high in dissociation. Nevertheless, the use of grounding techniques and the implementation of sleep hygiene seem to be promising avenues.

Hopefully, the present work may encourage further empirical research into the dissociative aspects of OCD/S, as well as establish dissociation as a transdiagnostic factor relevant to additional psychopathologies rather than trauma alone. These novelties carry theoretical significance for the understanding of a link between clinical symptoms which is currently poorly understood and under-researched. Such explorations will enrich both respective fields.

The original contributions presented in this study are included in the article/supplementary material, further inquiries can be directed to the corresponding author.

NS-D was solely responsible for the literature review, conceptualization, writing, reviewing and editing, and any other work associated with this manuscript.