# Key Cognitive Errors in OCD



## Daniel (Sep 10, 2010)

CBT (cognitive behavior therapy) involves actively challenging and confronting the distorted thinking and beliefs that drive and maintain obsessions and compulsions. Below are the key cognitive errors of people with OCD.

*Black-and-White or All-or Nothing Thinking*
_Example:_ "If I’m not completely safe, then I’m in overwhelming danger."

*Magical Thinking*
_Example:_ "If I think bad thoughts, bad things will happen."

*Overestimating Risk and Danger*
_Example:_ "If I take even a slight risk, I will come to great harm."

*Perfectionism*
_Example:_ "I’ve got to do everything perfectly."

*Hypermorality*
_Example:_ "I’ll be punished for every mistake."

*Overresponsibility for Others*
_Example:_ "I must always guard against making mistakes that even remotely harm an innocent person."

*Thought-Action Fusion (similar to Magical Thinking)*
_Example:_ "If I have a bad, even horrible thought about harming someone, it feels just as if I've actually done it or that it is highly likely to happen in the future."

*Overimportance of Thought*
_Example:_ "If I think about a terrible event occurring, it is much more likely to happen."

*Exclusivity Error*
_Example:_ "Bad things are much more likely to happen to me than to other people."

*Martyr Complex*
_Example:_ "Suffering and sacrificing my life by doing endless rituals is a small price to pay to protect those I love. Since no harm has come to them, I must be doing something right."

*“What If” Thinking*
_Example:_ "In the future, what if I...

do it wrong?"
make a mistake?"
get AIDS?"
am responsible for causing harm to someone?"

*Intolerance of uncertainty*
_Example:_ "I can’t relax until I am 100% certain of everything and know everything will be OK."

Adapted from: *The OCD Workbook: Your guide to breaking free from obsessive-compulsive disorder*

Preview at: *The OCD Workbook: Your guide to breaking free from obsessive-compulsive disorder*


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## Daniel (Sep 10, 2010)

_Info by Deb Osgood-Hynes, PsyD. (Harvard Medical School) on common OCD thought patterns:_

1) *Over importance of thoughts.* Does the OCD influence you to  put too much importance or significance on the mere presence of a  thought? Many OCD sufferers believe that just because a thought is  present, it must carry some importance. This is not necessarily true.  Try this experiment. Allow yourself to be aware of all thoughts entering  into your mind over the next three minutes. Some thoughts could be  important and some may be totally random or nonsensical and not have any  significant meaning. OCD makes a sufferer believe that all thoughts  have equal importance. Related to this is the belief that thinking a  thought is the same as doing an action; or the mere presence of a  thought will result in an unwanted action or will cause an event to  happen.

2) *Over estimation of threat/all-or-nothing thinking.* Do you tend  to overestimate the actual probability or level of threat associated  with a particular event? Do you catastrophize a situation, immediately  conjuring up as a probability the worst-case scenario? Are you  considering only information the OCD is trying to emphasize; magnifying  this out of proportion while minimizing or disqualifying other evidence  to the contrary? Do you think in terms of black-and-white or  all-or-nothing without considering the grey area or steps in between?

3) *Difficulty with doubt and uncertainty.* Do you have a difficult  time tolerating uncertainty? Doubt is a common symptom of OCD and  frequently generates a great deal of distress when the OCD won’t allow a  situation to “feel right” or won’t allow you to feel a comfortable  degree of certainty about a particular thought or event. Observe your  internal self-talk about having to sit with the discomfort of doubt and  uncertainty. Do you wish for this discomfort to go away immediately?

4) *Over responsibility.* Does the OCD influence your thinking by  telling you to take complete responsibility for situations in which  anyone else would not consider you responsible? Do you believe you have  the power to prevent negative or catastrophic events from happening by  doing mental or physical rituals? Do you excessively concern yourself  with, or blame yourself for, a negative event which may or did happen?

5) *Reasoning-Logic based on emotions.* Are your conclusions about a  situation based more on your strong emotions and less on actual fact?  Are you confusing a feeling as evidence of a fact because that’s what  the OCD is telling you? Do you say to yourself “I’m feeling anxious;  therefore, this situation must be dangerous” or “I’m feeling guilt;  therefore, I must have done something bad?”

_excerpted from the article _Cognitive Therapy for OCD: What It is, When to Use It  and When Not!


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## Daniel (Sep 10, 2010)

*What keeps OCD going?*
_Overcoming.co.uk
_ 
 Whatever the factors that might have caused your OCD, it is more helpful to address the mechanisms that _maintain_  it, because this is the key to overcoming the problem. OCD is kept  going by a vicious circle of obsession, anxiety and response to anxiety.

 One of the first things to understand in what keeps OCD going is the  role of avoidance and compulsions in fear. Each time you avoid a  situation or activity the behaviour is 'reinforced' because you have  escaped the harm that you think might have happened. 

This reinforcing  means that you're more likely to act the same way next time. Compulsions  are also reinforced:  if you feel less anxious after you check that a  light switch is off, you are more likely to act the same way in future.  Avoidance and compulsions seem at first to 'work' - you _think_ that you have prevented harm and this stops you feeling anxious. But in the long term they make you _more_ anxious and fearful, because they feed the obsession.

 The next thing to understand about OCD is the _meaning_ that you attach to normal experiences. This applies to a various different ways of thinking.
*
Inflated responsibility and magical thinking*
If you have OCD you have an inflated sense of responsibility. This  means that you believe you have the power to either cause or prevent bad  events that are personally important to you. 'Magical' thinking -  performing special actions to prevent something happening (an extreme  form of superstitious thinking) - is closely related to this. It makes  you feel more comfortable, as if you had more influence and control over  what happens.
*
The over-importance of thoughts*
This means the degree of importance that you attach to intrusive thoughts or images. It's crucial to understand here that _everyone_  experiences intrusive thoughts and doubts - that are usually absurd and  are the opposite of what they want to do or think. In the 1970s  researchers carried out experiments where they asked some people with  OCD and some people without OCD to list their intrusive thoughts. _They could find no difference in the types of thought reported by those with and those without OCD_. The difference is that people with OCD have more frequent and distressing thoughts than others because of the _meaning_  they attach to the thoughts and the way they respond to them. OCD is  maintained when you interpret intrusive thoughts as a sign that is there  a serious risk of harm to yourself or others (over-importance of  thoughts), and also believe that you can prevent the harm by what you do  or don't do (overinflated responsibility).

 The actual content of intrusive thoughts comes from your values - the  things that are most important to you. The thoughts represent your  deepest fears. So, for example, a mother might have intrusive thoughts  about stabbing her baby, because he is the most precious thing in the  world to her and she would be devastated if anything happened to him.
*
Overestimation of danger*
Another aspect of the meaning you attach to things if you have OCD is  that you overestimate the threat of a situation and underestimate your  ability to cope with it. So, for example, if you have a fear of  contamination from HIV and see something red, you immediately think it  must be blood that contains HIV and that you can't protect yourself from  the risk of infection.
*
Intolerance of uncertainty*
Many people with OCD believe that they need to know for certain that  something bad won't happen. For them, OCD is the ultimate insurance  policy - it means thinking that if you try hard enough and do more  rituals and get more reassurance then you can be more certain. In fact,  however, trying harder usually increases doubts and the feeling of  uncertainty.
*
Perfectionism*
Some types of OCD involve the belief that there is a perfect solution  to everything - that it is possible and necessary to do something  perfectly, and that even minor mistakes have serious consequences. This  is common in people with OCD who have a desire for order, and especially  common in those who also have anorexia nervosa.
*
Attention*
If you have OCD you are likely to focus on situations that you think  may be dangerous. This has the effect of magnifying the situation and  making you more aware of it. This is actually a normal phenomenon in  everyday life, but it creates another vicious circle: the more you pay  attention to your intrusive thoughts, the more you are aware of them,  and the worse they seem.

*Maintaining the cycle*
As is so often the case with emotions, the harder we resist anxiety,  the worse it seems to get. There are some particular ways of thinking  about anxiety that make the situation worse.


'_awfulizing_' means tending to describe something as  'awful', 'horrible', or 'the end of the world'. This only makes it seem  more frightening.
'_catastrophizing_' means anticipating disaster as the only  outcome - thinking that something catastrophic will happen unless you do  something to stop it.
_'low frustration tolerance_' (LFT) means regarding anxiety  as 'intolerable' or 'unbearable'. Unfortunately this makes it more  likely that you will use short-term ways of dealing with it.
 The vicious circle that maintains OCD is completed by using  safety-seeking behaviours in situations that make you anxious. When you  think you are in danger and feel extremely anxious, the natural response  is to escape. In this sense, safety-seeking behaviour is a natural way  to try to reduce your anxiety. However, as we have seen, intrusive  thoughts themselves are not the problem, and dealing with them by  safety-seeking behaviours - such as trying to suppress the thoughts or  performing compulsions - actually increases their frequency and feeds  back into the obsession.

*Management and treatment of OCD*
For most people, OCD can be successfully overcome. There are two main  ways of treating it: cognitive behaviour therapy (CBT) and medication,  and these can be used separately or together. However, CBT is generally  preferred because it lasts longer and tends to have fewer side-effects.  Medication may be recommended as an additional treatment if your OCD is  severe, or as a short-term measure while you are waiting for CBT.

The first effective psychological treatment for OCD was _exposure and response prevention_.  This means deliberately and repeatedly facing your fears or obsessions,  and not responding to them. In this way you gradually become used to  them, and your fear begins to subside. But not everyone feels able to go  through with this treatment. The technique has been refined by CBT,  which focuses on changing the _meaning_ of intrusive thoughts and urges (the 'cognitive' part) as well as altering the way you _respond_  to the obsessions (the 'behaviour' part). The CBT approach is about  breaking out of the cycle of obsession, anxiety and response described  above. It involves thinking about the meaning you attach to thoughts and  events, and developing alternative responses to them.


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## David Baxter PhD (Sep 10, 2010)

Excellent posts!


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## Daniel (Jul 23, 2011)

Albert Ellis, 1994:



> OCDers, because of their somewhat bizarre behavior, engender many  more frustrations and criticisms than the rest of us "nice neurotics"  do. They therefore easily develop great low frustration tolerance (LFT) by irrationally believing, "_I absolutely should not, must not be  so severely frustrated by my OCD and the disadvantages to which it  leads. Such great frustration and such severe handicaps must not afflict me! It's awful [completely or more than bad] when they do. I  can't stand it and will never be able to conquer it. How horrible!_"
> 
> At the same time, because of social disapproval of their  dysfunctional behavior, and of themselves for having it, OCDers  frequently put themselves down, depress themselves; and make themselves  anxious about other failures and disapproval. This self-denigration and  feelings of worthlessness stem from irrational Beliefs (iB's), such as  "_I must not be as disapproved as I am being! I'm no good for bringing on  this disapproval! If I can't function better than I do function, I'm a  worthless person_."
> 
> ...


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## Daniel (Apr 25, 2013)

*Mindless Traps
*excerpted from MBCT for OCD 

1. Relying rigidly on information from the past


Overestimation of harm, responsibility and risk -- relying heavy on assumptions from the past and not taking the present moment into account.
Past rules are imposed as the ‘right or proper’ thing to do and not taking into account a possibility of change in the environment or circumstances.
Unable to attend to new information due to reliance on past rules.

2. Automatic behaviour


Doubting, ‘what if...’, magical thinking, thought/action fusion becomes very automatic.
Reacting to obsessions, feared consequences, negative emotions and physical reactions -- performing rituals, compulsions habitually.
The inability to inhibit automatic responses to the above.
Being mindful helps you to catch thoughts and rituals before you engage in them and enable you to respond differently.

3. Acting from single perspective


Lots of attention biases in OCD -- by focussing on threat relevant cues they are unable to attend to information that will disconﬁrm their fears.
Usually we are attached to a single perspective and trying to control it -- instead of allowing life to unfold.  (Watching the closed door instead of seeing the one that opened).
Bound to thinking by rules, should’s, have to.
Being mindful is to question these rules, break the rules and doing things differently.
Changing the way we perceive OCD and anxiety, questioning the importance of thoughts -- thoughts are not facts but mind events.

(Didonna:2009) (Langer:1990)


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## Daniel (Oct 23, 2021)

OCD and Perceived Catastrophe
					


Incorrect threat estimation is a core feature of obsessive compulsive disorder.





					www.psychologytoday.com
				




A variety of common OCD presentations involve concerns with improbable catastrophic consequences and further implicate a more general sensitivity toward improbable threat...

Virtually all common consequences associated with the major OCD subtypes possess two striking commonalities. First, the most feared consequences in OCD are objectively catastrophic: the loss of one’s home, health, loved ones, or soul is among the costliest consequences imaginable. Second, the scenarios surrounding these catastrophic outcomes are often highly improbable.


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## Daniel (Jan 7, 2022)

Just to be certain: Confirming the factor structure of the Intolerance of Uncertainty Scale in patients with obsessive-compulsive disorder
					


Intolerance of Uncertainty (IU) is a cognitive construct in obsessive-compulsive disorder (OCD); yet no studies exist confirming the factor structure …





					www.sciencedirect.com
				




_Intolerance of uncertainty_ (IU) refers to “beliefs about the necessity of being certain, about the capacity to cope with unpredictable change, and about adequate functioning in situations which are inherently ambiguous” (Obsessive, Compulsive Cognitions Working Group [OCCWG], 1997, p.678) and is considered an important domain of dysfunctional cognition associated with anxiety disorders such as obsessive-compulsive disorder (OCD; OCCWG, 1997) and generalized anxiety disorder (GAD; Dugas, Buhr, & Ladouceur, 2004).

Individuals who are high in IU have a lower perceptual threshold of ambiguity, find uncertainty to be stressful and upsetting, believe that uncertainty reflects poorly on a person and should be avoided, and have difficulty functioning in uncertain or ambiguous situations (Buhr and Dugas, 2002, Krohne, 1993)...


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## Daniel (Aug 4, 2022)

Cognitive Processes and Biases in Obsessive-Compulsive Disorder​
The theories and data described throughout this chapter indicate that there is substantial room for cognitive components to make a significant contribution to OCD case conceptualization and treatment. *Rachman’s theory* implies that psychoeducation about OCD should begin with presentation of the idea that obsessions are cued by stimuli in the environment [2]. Given that the environment is ripe with cues, clients can expect and should be prepared to expect that the obsessive thought will be cued. If clients are more distressed by obsessions than they are by compulsions, cognitive bias training modification could be employed at this point in the treatment. Modification training would be expected to decrease the obsessions because clients should be less likely to attend to and interpret environmental cues as being related to their obsessions. This would prevent the obsessions from being cued.

If cued, clients can be taught that it is the actions that they now take when the obsession is present that are key.  Clients should be taught to first, identify when the obsession has come to mind. It is at this point that the client needs to employ mechanisms to cope with the obsession, including cognitive restructuring. The therapist is advised to administer a measure of *thought-action fusion* such as the Thought-Action Fusion scale [8]. If scores are elevated in the clinical range, the clinician can introduce the idea of thought-action fusion and review each statement endorsed on the TAF as indicating that thoughts equal actions. In order to ward off inferential confusion, clients can be taught inferential reasoning skills that would be expected to reduce the tendency to make reasoning errors. In addition, clients can be taught reality monitoring skills to help remind themselves that a thought is not equal to an action. That is, clients can be taught to ask themselves, “Did I think X thought or did I perform X action?” [adapted from 48]. The therapist can then work with the client to restructure cognitions regarding the probability of events and responsibility for events. Given that the client has likely had a similar thought many times and not acted on it, what is the evidence that they will do so now? With regard to compulsions, clients should be taught about memory norms. First, repeated routine events tend not to be recalled [49]. Therefore, the fact that one cannot remember if one has turned off the stove is normal given the large number of checks performed; therefore, one’s memory does not need to be confirmed.

Skills from other therapies can be borrowed, such as distress tolerance skills from *Dialetical Behavior Therapy* [50]. That is, it is OK to feel distress in response to an obsession; one does not need to act on the distress by engaging in compulsions. Distress tolerance skills should be used as opposed to thought suppression skills because research shows that thought suppression can increase rather than decrease unwanted thoughts [51]. Similarly, *behavioral activation* can be employed so that the client engages in other activities besides rumination.

Clients should receive psychoeducation about the normative progression of OCD symptoms. That is, they should expect that new compulsions may occur [52]. They can expect that the OCD will be worse in times of stress and can coincide with negative affect [2]. Consistent with behavioral theory, clients should be taught exposure and response prevention skills; family members that have become part of the OCD rituals should be participants in the therapy [53]. As in many empirically-supported treatments, relapse prevention skills should be taught and clinicians should be sure their clients are able to generalize these skills in order to deal with multiple obsessions and compulsions.


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## Daniel (Aug 4, 2022)

A cognitive theory of obsessions (1997)​S Rachman

It is proposed that obsessions are caused by catastrophic misinterpretations of the significance of one's thoughts (images, impulses). The obsessions persist as long as these misinterpretations continue and diminish when the misinterpretations are weakened. Evidence and arguments in support of the theory are presented, and the questions of vulnerability and the origins of the thoughts are addressed. A firmly focused treatment strategy is deduced from the theory.



1600+ citing articles


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## Daniel (Aug 4, 2022)

Fusion or Confusion in Obsessive-Compulsive Disorder​
Inferential confusion occurs when a person mistakes an imagined possibility for a real probability and might account for some types of thought-action and other fusions reported in obsessive-compulsive disorder. Inferential confusion could account for the ego-dystonic nature of obsessions and their recurrent nature, since the person acts “as if” an imagined aversive inference is probable and tries unsuccessfully to modify this imaginary probability in reality. The clinical implications of the inferential confusion model focus primarily on the role of the imagination in obsessive-compulsive disorder rather than on cognitive beliefs.



Citing articles


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## Daniel (Aug 4, 2022)

The Role of Fear of Self and Responsibility in Obsessional Doubt Processes: A Bayesian Hierarchical Model​
These findings provide additional support for the argument that individuals higher in OCD symptoms favor speculative possibilities above sensory-based information, and that greater endorsement of feared-self beliefs partially underlies this tendency.

Citing articles


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## Daniel (Aug 15, 2022)

Fear of Self and Unacceptable Thoughts in Obsessive–Compulsive Disorder (Citing articles)

"Even when considered with obsessive beliefs, anxiety and depression, the feared self was the only unique predictor of obsessionality, providing support for the notion that self-themes could explain why some intrusions convert into obsessions, whereas others do not."


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## Daniel (Oct 3, 2022)

Treatment of obsessive-compulsive disorder
					







					www.bmj.com
				



24 August 2006

Heyman and colleagues (BMJ 2006;333:424-9) present the case for
cognitive-behaviour therapy and medication in the treatment of obsessive-compulsive disorder. However, their search methodology was based on the term ‘obsessive compulsive disorder’. This will fail to identify treatments such as solution-focused brief therapy, which does not link treatment to diagnostic categories in this way. A number of studies of solution-focused therapy have included patients with compulsive behaviours who have responded successfully to this approach, which requires less resources than cognitive behaviour therapy.


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