Cognitive Therapy of Cognitive Compulsions

Intro

While many are familiar with the overt behavioral compulsions of moderate to severe Obsessive Compulsive Disorder (OCD), the subtler cognitive compulsions of OCD, Obsessive Compulsive Personality Disorder (OCPD) or a sub-clinical presentation that we might refer to simple as an over-controlled (OC) or compulsive cognitive or neurotic style is often misdiagnosed as Generalized Anxiety Disorder (GAD). (3)

I don't personally consider myself an OCD specialist, yet as a psychologist, I naturally come across OCD and OC-spectrum presentations regularly in my practice. I'll often refer to the OCD IOP for more severe presentations, which provides highly successful Exposure and Response Prevention (ERP) (described below). A few years ago, to better assist my clients in the outpatient setting, I bought a book called Overcoming Unwanted Intrusive Thoughts: A CBT-Based Guide to Getting Over Frightening, Obsessive, or Disturbing Thoughts (5), which influenced my approach described in this article that I shaped over the last few years.

Prevalence

Prevalence rate estimates of OCPD varies widely. One estimate was 8% in the general population (1). It may range from 8.7-26% in the outpatient setting and around 23.3% in the inpatient setting (2). In my practice's location, we have many high-functioning young adults (a Northeast metropolitan city), pushing the prevalence into the upper ranges, with sub-clinical OC styles likely or often comprising greater than 50% of the caseload (the remainder typically being dysregulated coping styles and a small portion of individuals with potentially psychotic cognitive styles, leaning on denial as a primary coping mechanism).

ERP for OCD

ERP is the gold standard of treatment for behavioral compulsions (4). ERP, the compulsive behavior is extinguished by introducing a trigger (the conditioned stimuli) and then preventing the over-learned compulsive behavior (conditioned response). This usually occurs in a series of increasingly intense or anxiety provoking exposures rather than flooding. A process of habituation occurs, when anxiety reduces as the person sits with the trigger without engaging in the conditioned response - the length of time is key for this. Therapy itself can be looked at as habituation to anxiety provoking stimuli, namely the topics discussed in therapy!

Cognitive Compulsions (vs. Obsessive Thoughts)

Cognitive compulsions are a) often less overt than behavioral compulsions, and consequently overlooked including by trained mental health professionals, and b) often confused with obsessive thoughts.

Obsessive thoughts

Obsessive thoughts are involuntary - we can imagine if I say "don't think of the pink pony," you cannot help but see one in you're mind's eye (unless you have aphantasia).

Cognitive compulsions

Cognitive compulsions, like other compulsions, may feel impossible not to engage in, but are in fact voluntary. They are a set of mental acts or behaviors that serve a three functions: 1) to reduce immediate anxiety, 2) ostensibly to prevent some future aversive experience but often does not have a measurable impact on the intended outcome and 3) thereby assauge guilt or regret. We must attend to an internal self-part rationalizing engaging in the compulsion ("it is too risky not to" or "I simply have to, it is too hard not to, the urge is too strong, I just need to feel better").

Cognitive Compulsions and Anxiety

Cognitive compulsions reduce immediate anxiety in multiple ways.

• A psychodynamic defense-mechanism perspective of OCD is that the true fear or worry is pushed into the unconscious, and masked by a surface level expression of the anxiety (displacement via intellectualization or isolation of affect). In other words, the obsessive thoughts are not actually related to the fear and thereby briefly distract from it.

• The cognitive compulsion also promises (a rationalization) to somehow address the immediate worry such as "thinking through it just one more time will prevent the negative outcomes."

• It may feel reckless or out of control not to think through it. There is a carrot and a stick here: the compulsive checking reducing immediate anxiety and assauges the risk of future guilt for not double-checking.

• Thinking through it gives a false or perceived sense of control, but this reduction in anxiety is self-reinforcing and consequently we become beholden to the exact thing that is supposed to give us control: we lose (perceived) control over the compulsion itself. The result is worsened anxiety over time: we implicitly train ourselves that this thing - the fear - is dangerous and unmanageable otherwise.

Stop Thought Stopping

Thought stopping was an old, but now widely considered debunked, approach to obsessive thoughts and cognitive compulsions. This involves forcibly stopping, such as by verbally or mentally imploring ones mind to stop the thought process. You may have heard the recommendation to put a rubber band on your wrist and "snap" it against your skin when you have the intrusive thought. Literature indicates this does not work and may even backfire. So how does cognitive therapy of cognitive compulsions differ?

Cognitive Therapy

Thought-Fact Bias

Winston and Seif describe cognitive compulsions as fueled by a "thought-fact bias." People who engage in cognitive compulsion implicitly take (or mistake) thoughts as facts. This is analogous to individuals with OCD reacting to thoughts as if they are actions. For example, having an intrusive thought or mental image about hurting someone or someone getting hurt is met with guilt as if they actually performed the action. Conversely, the general population may be disturbed by the thought, we let it go simply as an odd thing our brain threw out there into our consciousness. We can think of this as a form of black-and-white thinking or rigidity.

Thought-Fact Bias leads to Cognitive Compulsions

If the thought is taken as a fact, then we also may be implored to act on it. Imagine having a thought or mental image of a negative pregnancy outcome. It would feel reckless and irresponsible not to plan in order to prevent this outcome or cope with it to mitigate it negative consequences. Consequently, the individual prone to cognitive compulsions goes down a rabbit's hole of anticipating what may happen and planning contingencies for each possibility. One can see how this is similar to checking the stove and locking the doors in the more familiar (but far less common) behavior compulsive presentation of OCD. Both cause distress, take up significant time and get in the way of other important behaviors for social-occupational functioning (this is part of the definition in diagnostic criteria) (3).

Psychoeducation and Cognitive Reframe

Educating patient's on this thought-fact bias helps them to start recognize the obsessive thoughts that trigger cognitive compulsions. Then they can challenge these automatic thoughts as simply thoughts, not facts. This opens the door to free-will: a decision whether or not to engage in the cognitive compulsion.

The decision

Should I go down the rabbit's hole or not? After recognize a thought-fact bias, the individual asks themselves if they want to engage in the compulsion. A reasonable question is whether I have already adequately addressed the concern? In other words, part of the thought-fact bias is that there is something unresolved: are yet undiscovered risks or solutions and behavior contingencies (what to do when this anticipated future aversive event occurs) that need to be determined. If this is true, then yes, go down the rabbit's hole! Is now the right time, or do we want to set aside a future time-limited and pre-allocated time-slot for this (again, indicating control or agency over the process).

If there is no reason to go down the rabbit's hole, we engage in response prevention (refer to ERP, above). We determine not to go down the rabbit's hole and utilize another set of skills.

Things to Say and Do

The Things to Say and Do is an eloquently simple way of describing two common components of successful coping or intervention: our self-talk and coping skills, borrowed from CBT-E for eating disorders (6).

Things to say

Common "things to say" that help my clients include:

• "This is a thought, not a fact."

• "I've seen this episode before." This is a highly syndicated show, I don't need to re-watch it, I know the outcome and like Larry David's Curb Your Enthusiasm cringe-comedy, I don't need to subject myself to this discomfort. "I don't need to live out this nightmare in my mind."

• "I've gone down this rabbit hole, I know where it takes me, I've already thought of all the important possibilities and contingencies."

• "Yes, it's hard, but I do, in fact, have agency over whether I go down this rabbit's hole. It gets easier each time I don't engage in the compulsion."

• "I'm not guilty or reckless for not torturing myself with this again. This isn't truly 'out of control' but only gives me a false sense of control."

• Remind self of the social-occupational functioning consequences: "This gets in the way of important things like [homework] and being able to be mindfully connected with others." We may pair this with psycho-education on polyvagal theory (7): without challenging the thought-fact bias, we permit an assumption of a threat that activates our sympathetic branch of our autonomic nervous system, resulting in a fight-or-flight anxious response. Self-soothing and activating our parasympathetic nervous system allows us to be in a state that permits socializing, and consequently social supports that further lessen anxiety.

Things to do

• Parasympathetic activation coping skills and tolerating the trigger and worry without engaging in the compulsion. Think of it as getting used to a hot tub.

• Schedule time to worry: this involves both things to say and do, including deciding if a worry requires time devoted to processing or a tangible solution. If so, we schedule a limited amount of time to "go down the rabbit's hole." Then we write down the result - a summary or the tangible solution. We might store this somewhere safe or put it in our pocket. If a trigger elicits an urge to engage in the cognitive compulsion, we determine if we need further time to resolve some tangible aspect (and schedule the time if so), and if not, remind ourselves we have already done diligence. We can remind our self the solution is written down, so we do not need to perseverate and rehearse this in our head (like when a friend says, "hey, remember this phone number!"), or we can review our written conclusion to short-circuit the need to engage in the cognitive compulsion (so long as we do not start to do this compulsively!).

  

  Scheduling Worry

• Social supports: talk to a friend or family, including about the worry with the caveat that you are working on not "going down the rabbit's hole."

• A healthy distracting pastime.

References

1. Grant JE, Mooney ME, Kushner MG. Prevalence, correlates, and comorbidity of DSM-IV obsessive-compulsive personality disorder: results from the National Epidemiologic Survey on Alcohol and Related Conditions. J Psychiatr Res. 2012 Apr;46(4):469-75. doi: 10.1016/j.jpsychires.2012.01.009. Epub 2012 Jan 16. PMID: 22257387.

2. Maciej Z ˙erdzin´ski1,2*, Marcin Burdzik1,3*, Paweł De˛bski4,5, Roksana Z ˙muda1, Magdalena Piegza5 and Piotr Gorczyca5. The impact of obsessive-compulsive personality disorder one obsessive-comprulsive disorder: clinical outcomes in the context of bipolarity. Frontiers in Psychiatry.

3. American Psychiatric Association. (2022). Diagnostic and statistical manual of mental disorders (5th ed., text rev.). doi.org

4. Foa, E. B., Yadin, E., & Lichner, T. K. (2012). Exposure and response (ritual) prevention for obsessive-compulsive disorder: Therapist guide (2nd ed.). Oxford University Press.

5. Winston, S. M., & Seif, M. N. (2017). Overcoming unwanted intrusive thoughts: A CBT-based guide to getting over frightening, obsessive, or disturbing thoughts. New Harbinger Publications.

6. Fairburn, C. G. (2008). Cognitive behavior therapy and eating disorders. Guilford Press. [1, 2, 3, 4]

7. Porges, S. W. (2011). The polyvagal theory: Neurophysiological foundations of emotions, attachment, communication, and self-regulation. W. W. Norton & Company.