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Cognitive Therapy for Obsessive-Compulsive and Related Disorders

Matthew D. Jacofsky, Psy.D., Melanie T. Santos, Psy.D., Sony Khemlani-Patel, Ph.D. & Fugen Neziroglu, Ph.D. of the Bio Behavioral Institute, edited by C. E. Zupanick, Psy.D.

As mentioned, cognitive-behavioral therapy is the gold standard for obsessive-compulsive and related disorders (OCRDs). The behavioral component, called exposure and response prevention, was discussed in the section above. In this section, we discuss the cognitive component of therapy.

woman deep in thoughtSpecifically, the cognitive portion of therapy addresses two basic types of problematic beliefs common in OCRDs. These are: 1) irrational beliefs, and 2) distorted beliefs. Cognitive therapy also seeks to improve motivation for treatment and increase insight.

In the diagnosis chapter, we discussed the similarities and differences between the obsessive-compulsive and related disorders (OCRDs). One such difference is the different types of problematic beliefs. In addition, people who have the same disorder will have varying degrees of insight about the validity of their beliefs. In some disorders, such as obsessive-compulsive disorder (OCD), the beliefs tend to be more of the irrational type. For instance, it is irrational to believe that you will positively get sick unless you wash your hands every time you touch a doorknob. Some people with OCD have good insight. They readily acknowledge this is an irrational belief. Others lack this insight. In general, the greater the insight, the better the prognosis for successful recovery.

In some OCRDs, such as body dysmorphic and hoarding disorders, distorted types of beliefs are more common. To illustrate distorted types of beliefs, let's consider body dysmorphic disorder. It is perfectly sensible and rational to believe one's personal appearance is important. However, it is a distortion of that belief if one believes their entire value and worth is determined by some small flaw or defect. Another example of distorted beliefs is hoarding disorder. It is perfectly fine to value being thrifty and avoiding waste. However, it is a distortion of that value to believe that everything has equal value and nothing should ever be discarded (hoarding disorder).

The specific therapeutic techniques may vary depending upon whether beliefs are the irrational or distorted type. Likewise, the treatment approach will need to take into account the degree of insight a person has about those beliefs, and the motivation for treatment.

Irrational beliefs are somewhat simpler to treat than distorted beliefs. This is because it is possible to refute (disprove) irrational beliefs. It is more difficult to challenge distorted beliefs. This is because they are usually extreme interpretations of an otherwise normal, acceptable belief or value. For instance, imagine trying to argue with someone that being thrifty is a bad idea. It only becomes problematic when taken to the extreme. Nonetheless, whether the beliefs are irrational, distorted, or lack insight, they are all considered dysfunctional when they limit someone's ability to function well in society and/or cause significant distress.

According to cognitive theory, irrational or distorted beliefs lead to a pattern of dysfunctional thoughts. These thoughts lead to extreme emotions, which in turn, lead to unhealthy behaviors. To illustrate this powerful chain of events, consider the following example: Suppose I am preparing to take a difficult test. While doing so, I think to myself, "I can't do anything right, I will probably fail this test." This thought will likely cause me to feel apprehensive, hopeless, depressed, or anxious when I eventually take the test. This will affect my ability to concentrate and earn a good grade. In addition, these negative thoughts will affect the amount of effort I put forth when studying for the test. When I incorrectly believe that I will certainly fail, it seems rather futile to invest a great deal of energy in attempting to succeed. As a result, I may indeed fail, simply because I didn't invest much time and energy in preparation for the exam.

Ironically, my test failure serves to strengthen my faulty belief. In other words, my poor test score "proves" my belief is correct. My belief becomes a 'fact': I am a failure. However, the true reason for my failure was due to my lack of effort and preparation, and not because I am inherently a failure. Note, since my belief has now become a 'fact,' it is even more likely that I will not study and prepare for my next exam.

Quite a different outcome would occur if I were to think to myself, "Yes, this test is going to be quite difficult but I have succeeded before. I will need to study hard and put forth my best effort. Besides, I am just as competent as any of the other students in the class." These thoughts would cause me to feel confident and ready to face the challenge. I would be willing to put forth the extra effort needed to succeed.

Clearly, these two different ways to think about the same event originate from very different beliefs. For instance, in the first example my thought "I'll probably fail this test" may stem from a core belief "I must always achieve complete success or else I am a complete failure." In general, people are usually not aware of the beliefs that prompt certain thoughts. However, people can learn to become aware of their thoughts. Once people become aware of their thoughts, they gain the ability to uncover the underlying dysfunctional beliefs supporting those thoughts.