To ocd ή ιδεοψυχαναγκαστικη νευρωση δεν εχει καμια σχεση με την ψυχωση και ουτε μπορει να καταληξει εκει. Μιλαμε για αγχωδη διαταραχη, διαφορετικη παθοφυσιολογια. Ωστοσο αυτα που κανουνε οι ψυχαναγκαστικοι οντως μοιαζουν απο λιγο εως πολυ " τρελά".
Ειναι ενδιαφερον να δειτε πανω κατω τι γινεται στο μυαλο ενος πασχοντα απο ιδεοψυχαναγκαστικη διαταραχη! Ενω δεν ειναι τρελος, οι μεταγνωσιακες πεποιθησεις που εχει για τις ιδες του τις σκεψεις ειναι καπως "τρελες" . Η γενετικη προδιαθεση παιζει σιγουρα ρολο.
1. Thought-event fusion (TEF):
Thinking about an event means it has happened or it will happen.
My thoughts become reality-if I think something it will come true.
Thinking something is contaminated means it is contaminated.
Thinking bad thoughts can make bad things happen.
2. Thought-action fusion (TAF):
If I think of harming someone, I probably will harm them.
If I have thoughts about harming myself, I will act on them.
If I have (unwanted) thoughts, it must mean I want to have them.
Objects can become contaminated with memories.
3. Thought-object fusion (TOF):
Objects can become contaminated with thoughts/feelings.
If things look old and used, they are contaminated with other
peopleʼs experience (and I could catch it).
Αside from beliefs about thoughts and feelings, instrumental beliefs
about the commission of rituals and neutralising responses are also relev-
ant to the metacognitive formulation. The role of this category of beliefs
has been largely ignored by previous cognitive approaches. However,
appraisals of the success/failure or meaning of events linked to rituals is
an important influence on distress and continued maladaptive coping
efforts. Beliefs about these strategies fall into two broad categories:
Positive beliefs:
If I keep my mind in check, bad things wonʼt happen.
Performing my rituals keeps me safe.
If I check my memory for actions, I can know Iʼve done no harm.
If I can remember everything, I can know Iʼve not committed
unwanted acts.
0 I need to do this.
If I donʽt perform my rituals, my emotions will overwhelm me/
become permanent.
Ruminating/dwelling makes things turn out OK.
I could lose control/go crazy.
0 My rituals could make me ill.
0 I have no control over my rituals.
0 My rituals will take me over.Negative beliefs:
Metacognitive beliefs characterised by inverse inference, a belief simi-
lar to TEF, and beliefs about the consequences of thoughts are pre-
dictive of obsessional rumination and impulses, even when
depression is controlled (Emmelkamp & Aardema, 1999).
Inverse inference and TAF are significant independent predictors of
compulsive checking (Emmelkamp & Aardema, 1999).
Experimental manipulation producing an increase in TAF leads to an
increase in the frequency of intrusive thoughts and discomfort
(Rassin, Merckelbach, Muris & Spaan, 1999).
Negative metacognitive beliefs concerning the uncontrollability and
danger associated with thoughts are positively associated with obses-
sional symptoms, and this relationship is independent of general
worry-proneness (Wells & Papageorgiou, 1998a).
ELICITING DYSFUNCTIONAL BELIEFS AND APPRAISALS
Therapists should aim to explore different categories of appraisals of,
and beliefs about, intrusions. In assessing appraisals/beliefs, questions
should be directed at eliciting the meaning and dangers of intrusions.
Aside from direct questions about intrusions, an indirect strategy is to
question the consequences of not engaging in neutralising (coping) be-
haviour. Below are a series of examples of questions used to elicit meta-
cognitive beliefslappraisals and the nature of maladaptive criteria for
the control of rituals:
Useful questions:
1. Beliefs about obsessional thoughts
When you had obsessive thought (OT), how did you feel (e.g.
anxious, afraid, guilty)?
When you felt (e.g. anxious), what thoughts went through your
mind?
0 What does having this OT mean to you?
Could anything bad happen as a result of having the OT?
0 What could happen?
0 Does the OT mean something bad has happened?
0 What is that?
Whatʼs the worst that could happen if you have an OT?
What would happen if you couldnʼt get rid of these OTs?
Whatʼs the worst that could happen if you had an OT and did
nothing to deal with it?
2. Beliefs about ritualslcoping
Examples follow of questions that are useful for eliciting beliefs asso-
ciated with ritual behaviours. Note that for clinical purposes it is often
necessary to elicit material by questioning the worst consequences of
not engaging in a ritual behaviour, rather than only questioning about
the benefits of engaging in behaviour:
0 Do you do anything to prevent (catastrophe associated with intru-
sion) from happening? What do you do?
How does (checking, ruminating, neutralising) help?
How much control do you have over your (checking, neutralising,
rumination)?
Whatʼs the worst that could happen if you donʼt stop it?
Does your (checking, ruminating, neutralising) keep you safe in
some way? How does that work?
Have you tried to stop (specific ritual)?
Is there a reason for not trying to stop?
What happens to your feelings/thoughts when you are prevented
from (neutralising, checking, ruminating)?
3. Eliciting stop signals for rituals
When you start (specific ritual), what it is that tells you it is safe to
What is the goal of (specific ritual); what are you aiming to achieve?
How do you know your ritual is working?
What is another way of determining whether you need to act
(what would your best friend do?)-useful for exploring replace-
ment strategies in treatment.
stop?
What is the goal of (specific ritual); what are you aiming to achieve?
How do you know your ritual is working?
What is another way of determining whether you need to act
(what would your best friend do?)-useful for exploring replace-
ment strategies in treatment.
Are you acting on the absence of a memory or the presence of a
memory (can an absence tell you that you have done
something?)-useful for cognitive restructuring in treatment.
The following extract of a dialogue with a patient suffering from OCD
illustrates the use of some of the questions outlined above to elicit infor-
mation for building the idiosyncratic case conceptualisation in Figure
11.1.
TP:
T:
P:
T
P:
T:
P:
T:
P:
T:
P:
T:
P:
T:
P:
T:
P:
T:
P:
T:
p:
When was the last time you were bothered by these thoughts?
Yesterday I became really scared. My daughter was getting on my
nerves and I had an image of the Devil jumping on her.
It sounds as if that was frightening. What were you afraid of?
Wouldnʼt you be scared if you kept getting thoughts like that?
I suppose it isnʼt a nice thought, but I donʼt think it would scare me.
Did you think anything bad could happen as a result of thinking
that?
I donʼt know why I thought it. Do you see many people who have
thoughts like that?
Yes. People troubled by obsessional thoughts are usually bothered by
blasphemous thoughts, or thoughts of a sexual or violent nature. But
that doesnʼt mean they are bad people. Whatʼs the worst that could
happen if you think about the Devil jumping on your daughter?
Itʼs too scary to think about (becomes tearful).
It sounds like something bad could happen.
It means I might want it to happen-but I know I donʼt.
Could it make anything bad happen?
Yes, it could make the Devil appear.
So the thought is distressing because of what it means, or what it
might cause. You seem to be concerned that having the thought will
make the Devil appear. Is that right?
Yes.
When you had that thought, did you do anything to prevent the
Devil appearing?
I tried to imagine Jesus with his arms around us protecting us.
Did you do anything else for protection?
I said the Lordʼs Prayer.
Did you have to do that in any special way?
I had to say it without getting an image of the Devil.
How did you do that?
I concentrated on every word as if I really meant it.
T:
P:
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P:
How did you know when to stop your ritual?
I repeated it until I could say the prayer without getting any bad
thoughts, and whilst having a perfect clear image of Jesus.
Is it easy to do that?
No. I can spend hours trying to get it right. If I canʼt get it right, I
worry about it and get into a panic.
T:
P:
T:
P:
T:
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What would happen if you didnʼt engage in your ritual or get it
right?
I couldnʼt do that. Iʼd be panicking all day.
Whatʼs the worst that could happen?
Iʼd be worried that something bad would happen. The Devil would
harm us.
So it sounds as if you believe your rituals keep evil away. Is that
right?
Yes. God will protect us.
It sounds as if you are trying hard to control your thoughts and
prevent bad thoughts.
Yes.
Do you think there are any problems with trying to get perfect im-
ages and avoid all distractions when praying?
It doesnʼt work always, and now sometimes when I try to see Jesus
he can have horns growing out of his head.
Note that this material can also be represented as an A-M-C (reformu-
lated A-B-C) analysis (see Figure 11.2).
SOCIALISATION
Socialisation proceeds by sharing the conceptualisation with the patient.
Socialisation begins in communicating the concept that negative beliefs
about intrusions along with behavioural responses and worry about in-
trusions, are the main problem, rather than the occurrence of the intru-
sion alone.
Socialisation is facilitated by the use of questions like those in the therapy
extract presented earlier. In particular, questions should be directed at
determining the consequences in emotional terms of having intrusions if
the individual no longer believed that they were harmful, indicative of
negative events, or characterologically meaningful.
Thought control experiments can be used to demonstrate how be-
havioural responses are rarely fully effective and may exacerbate intru-
sions (feedback cycle “a” in Figure 11.0). For instance, patients can be
asked to try and suppress a thought of a “white bear” for a period of 1
minute, and the effects of this strategy are then discussed in terms of the
model. The impact of emotional reactions on intrusions (triggers) can be
demonstrated by reviewing the effects of mood (feedback cycle ”b” in
Figure 11.0) on the frequency of intrusions and doubts.
COGNITIVE DE-FUSION
Treatment strategies should be directed at challenging fusion beliefs. This
can be done with verbal reattribution strategies and with behavioural
experiments
Irutially, de-fusion aims to challenge beliefs about the validity of appraisals of
intrusions and to teach patients alternative strategies for behaving in re-
sponse to intrusions. The first step requires establishing the mental frame-
work in which to build an alternative belief system. It is therefore necessary
to socialise patients in the role of metacognitive beliefs. This is accomplished
through guided discovery. Many patients are operating at the level of how
catastrophic it would be, or how responsible they would feel, if their ap-
praisal of an obsession were valid. However, this is operating in object mode
and not in metacogrutive mode. The therapist should shift the patient to
working at the metacognitive level. That is, focus on challenging the validity
of the appraisal of the intrusion, coupled with the abandonment of counter-
productive ritual and coping strategies. Some useful questions for establish-
ing the metacognitive mode include the following:
0 What prompts you to engage in your (overt/covert) ritual behaviour?
0 If you didnʼt believe your thought (appraisal of obsession) was realis-
tic, would you need to engage in rituals?
0 How would you feel if you knew your fears and beliefs about your
thought were unrealistic?
0 How does your checking behaviour/avoidance affect your confidence
in your memory?
0 How does your checking behaviour/avoidance affect your ability to
discriminate between imagined and real events?
The last two questions should be modified to incorporate the patientʼs
idiosyncratic behaviours (checking, ruminating, neutralising, rituals,
avoidance, reassurance seeking, etc.). Through use of this form of ques-
tioning, the therapist should help the patient to acquire a metacognitive
model of his/her problem. The unhelpful nature of behavioural strategies
for the long-term resolution of the obsessional problem should be
highlighted.
Once the basic framework is established, the next step consists of chal-
lenging metacognitive fusion beliefs. This can be accomplished by verbal
strategies and behavioural experiments.
Verbal strategies include:
1.
2.
Questioning the mechanism of fusion: how does thinking a thought
cause an event/action? What is the mechanism?
Inducing dissonance: the incompatibility of appraisals of obsessions
with general self-beliefs should be highlighted and questioned. Ex-
ample questions are:
0 What sort of person is likely to worry about having thoughts of
harming someone-is it the kind of person who is likely to act on
the thought?
0 What kind of person are you? The kind that always acts on his/
her thoughts?
0 Where's the evidence you will act on your obsessional thoughts?
The historical review: a review of occasions on which the patient experi-
enced an obsessional thought but was unable to neutralise it or other-
wise prevent feared outcomes should be undertaken. The
identification of these episodes can be used as evidence that thoughts
do not lead to action or catastrophe.
3.
Rational responses that invalidate belief about intrusions should be for-
mulated (e.g. "This is just a thought, not a reality"; "I don't need to
reason with fantasy-let it go").
Behavioural experiments
Behavioural experiments should be used to test belief in fusion. Patients
who believe that thoughts can influence events (TEF) can be asked to try
and increase the frequency of positive and negative events by changing
thinking patterns. For example, a patient may be asked to cause his/her
car to break down by thinking about this, or asked to think about winning
the lottery to see if this happens.
Beliefs in thought-action fusion (TAF) can be challenged by running
experiments in which patients are exposed to feared situations whilst
deliberately eliciting obsessional thoughts. For example, a patient was
worried that if he had thoughts about stabbing someone when in the
vicinity of sharp objects, he would carry out the action. Behavioural
experiments consisted of holding a sharp pen and repeatedly thinking
about stabbing the therapist during a session. As a homework task, the
patient was asked to leave a knife on the kitchen work-top at home
whilst having thoughts of stabbing his wife when they were at home
together.
Belief in thought-object fusion (TOF) can be tested by asking patients to
touch and examine particular objects, and guess the history of the objects
and the characteristics of people that owned them. The therapist should
write out a brief summary of these details before the experiment so that
the patient's description can be compared against the predocumented
facts.
Exposure and response prevention experiments
