Cognitive Aspects of Obsessive Compulsive Disorder

• Report from AABT by Jim Pretzer, 11/30/96
  
  

Report on the International Obsessive Compulsive Disorder Cognitions Working Group Conference (R.O.Frost & D. Clark)

An international group of OCD researchers are pooling their efforts to come up with better ways to measure the cognitive aspects of OCD. They've decided to focus initially on self-report measures of (1) beliefs relevant to OCD and (2) interpretations of intrusive thoughts. The consensus thus far is that the most important beliefs related to OCD are:

• Overimportance of thoughts - The belief that presence of a thought automatically means that the thought is important.
• Responsibility - the belief that one has the power that is critical to bring about or prevent (subjectively) crucial outcomes
• Tolerance for ambiguity - beliefs about the necessity of being certain, one's capacity to cope with unpredictability...
• Need for control over thoughts - a belief that one can and must exercise complete control over intrusive thoughts.
• Overestimation of threat-an exaggerated estimate if risk (likelihood or severity)
• Perfectionism - belief that one should/must perform tasks perfectly
• Consequences of anxiety - belief that anxiety itself has serious consequences.

This work is still under way, the next stage is to refine measures of these beliefs and to validate them.

Overvalued Ideas in OCD (F. Neziroglu)

Overvalued ideas are different from the intrusive thoughts characteristic of obsessions in that they are not intrusive and are not resisted. Rather they are extreme beliefs which are understandable, are not delusional, and are strongly held. They also play an important role in Body Dysmorphic Disorder and Hypochondriasis.

The more fixed the beliefs are (the more confident the client is that harm will occur if they do not maintain their belief, the less willing the client is to modify their belief, the less they recognize the belief as bizarre, the less they recognize it as idiosyncratic, ...) the worse the prognosis.

Behavioral Tasks and Cognitions in OCD (R. Safran and S. Rachman)

For a number of years Rachman and his colleagues have been investigating the use of behavioral experiments in the treatment of OCD. These are tasks which create the opportunity to test the client1s convictions. Clinically, these are typically used to test the client1s beliefs re the effects of relinquishing their obsessions or compulsions. In research, they also can be used to collect data and test the validity of theory.

These investigators find that anxiety and the urge to check are higher in situations where the client has responsibility (or believes they have responsibility). Clients who believe that having a bad thought is as bad as committing the action or that having a thought of a feared event makes an event more likely, are more likely to engage in some action to neutralize the thought.

For behavioral experiments to work you must get the belief clearly stated and derive testable predictions. You and the client can then work to find a practical way to test whether the belief is true. Real-life tests of the obsessive-compulsives beliefs are usually much more powerful that purely verbal interventions. (For example, one of my clients held a strong conviction that there was a high risk of contracting food poisoning if one ate at major hamburger chains. This conviction had resisted years of persuasive efforts of her husband and friends. We derived a testable hypothesis - People who eat fast-food hamburgers regularly will get food poisoning frequently. and tested it, first by collecting data on the frequency with which her friends and relatives contracted food poisoning, and later by having her eat fast food hamburgers herself. This experiment quickly disconfirmed her belief and was fairly easy to generalize to pizza and a variety of restuarants.) With experience it becomes easier to design good behavioral experiments. They recommend keeping the experiment simple and straightforward.

The Treatment Utility of Cognitive Assessment in Obsessive Compulsive Disorder (M.H. Freeston, E. Leger, J. Rheaume & R. Ladouceur)

This group is working to develop a standardized approach in treating clients who have obsessions which are not accompanied by compulsions. The standard approach to OCD with compulsions (exposure and response prevention) is difficult to apply when there is no overt compulsive behavior and many clinicians report that obsessions which are not accompanied by compulsions are difficult to treat.

The key cognitions which they find to be important are:

• Overimportance of thoughts
• Responsibility
• Perfect control, completeness, and control are possible
• Overestimation of severity and likelihood of consequences
• Anxiety caused by thoughts is unacceptable and dangerous

The intervention approach they tested consisted of Cognitive Therapy which began with a detailed assessment and then targeting the specific cognitions relevant for each individual. Preliminary results are encouraging even though exposure and response prevention was not used. However, they only have outcome data from a handful of clients so far and the assessment methods are still being refined.

Discussion (S. Taylor)

The current work is very encouraging. Maybe we can develop as effective a treatment approach for OCD which is as effective as Cognitive Therapy for Panic Disorder. We need to make sure we1re not overlooking important aspects of cognition. It can be hard to develop conclusive behavioral experiments with some obsessions and we need to find better ways to deal with this. We often encounter state-dependent effects, the client1s thinking and beliefs change under the influence of anxiety. We need to improve our assessment methods. We may need to do our assessment and intervention while the client is anxious in order to identify and modify the relevant cognitions. Assessing level of relevant beliefs at the close of treatment should predict likelihood of relapse. We need to test this and if this holds up in real life, it would provide a useful way to determine if the client is ready to terminate treatment.

• Addn Info about the Report from the Intnl OCD Committee by Larry Needleman, Ph.D., 6/13/97