Cognitive Behavioral Therapy

Cognitive aspects of OCD, and the indication for cognitive therapy, can be traced back to the last century. Insel (1990) points out that, in 1878, Westphal suggested that the central feature of a syndrome that would today be recognized as OCD was the existence of irrational thoughts. 

Since then, several cognitive theories have emerged. Three important models are those of Carr (1974), who believed that a high subjective estimate of the probability of an undesired outcome led to anxiety, and that rituals were used to reduce the anxiety, McFall and Wollersheim (1979), who related catastrophic predictions to the patient's subjective assessment of his or her ability to cope with such outcomes, and Salkovskis (1985,1989), who integrated the Beck, Emery and Greenberg model of anxiety (Beck et al., 1985) with the idea of personal responsibility. Reviews of these models can be found in van Oppen and Amtz (1994).

Salkovskis (1985) has proposed that, in OCD patients, obsessional thoughts are associated with dysfunctional schema involving a sense of inflated responsibility for potential harm that may befall themselves or others. Thus, two important evaluative processes are present in OCD: perceived threat and perceived personal responsibility. Automatic thoughts involving personal responsibility are provoked by the intrusive obsessive thoughts and consist of blame, fault finding, guilt, etc. For example, a patient who repeatedly checks whether the stove is turned off when leaving the house has the intrusive thought, `I may not have turned the stove off'.

This is followed by the automatic thought, `because of my forgetfulness, the house may burn down'. The distress arising from the obsessive thought is actually brought on by the negative automatic thought. A ritual then follows, such as checking or self-assurance.

The belief that the patient has the power to cause or prevent disastrous outcomes is referred to as `pivotal power' or `pivotal influence' over negative outcomes. Rheaume et al. (1995) have provided data with non-clinical subjects in which pivotal power was found to be the best predictor of responsibility. They concluded that intrusive thoughts are thus evaluated on the basis of the impact a person believes he or she has on the outcome of ambiguous situations.

O'Connor and Robillard (1995) have argued that the core belief of OCD results from a series of illogical inferences. Therapy involves changing these inference processes. The therapist determines and draws patients' attention to the ways in which they confuse imagination and reality, what's real and what's not real but OCD. This is consistent with what I have found in some patients.

For example, one of my patients with severe contamination obsessions is very resistant to exposure and response prevention, especially after leaving the office or the ward. He reports that none of the training seems to `stick'. However, once he is convinced that something is `OCD' rather than real, he has no difficulty overcoming it.