Understanding the cognitive behavior of obsessive thinking

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Xu Guiyun translationUntil recently, forced rumination (no apparent behavioral rituals) was a form of OCD that was particularly ineffective.


Xu Guiyun translation

Until recently, forced rumination (no apparent behavioral rituals) was a form of OCD that was particularly ineffective. This situation has now changed, and the results of the study by the OCD research group in Oxford and colleagues in other centres, in particular Quebec, led to two results. First, from the behavioral point of view (obsessional ruminations) re analysis reveals that the theory can not be fully developed behavior. Second, the development of cognitive behavioral theory has added new dimensions, including the general understanding and treatment of obsessive compulsive problems, especially obsessive thinking. In this paper, will describe the basic force psychopathology problem, then outline the behavior theory and thinking of the treatment of forced maintenance. It is the first time that cognitive theory is extended to the general cognitive theory of anxiety, and it is especially suitable for obsessive compulsive problem. Finally, the cognitive behavioral therapy of OCD is described.

A.OCD: basic phenomena

Obsessive thinking is involuntary and intrusive thoughts, images, and impulses. They are often perceived as inconsistent, unconscious, unacceptable, and difficult to eliminate. In general, a specific trigger stimulus can evoke obsessive thinking. Once it is generated, it is accompanied by a feeling of discomfort (often a mixture of depression / fear and anxiety), and the impulse to resist (correct) the obsessive (or perceived) outcome. The overwhelming majority of compulsive behavior (e.g. cleaning or inspection). The act of forcing or resisting is often in a fixed manner, or in accordance with the "rules" of a particular definition, and is accompanied by a brief reduction in anxiety, or it is expected that the anxiety of the act will not be increased if no rituals occur. Acts of resistance including mental activity changes, or intend to adapt to the different thinking of forced thinking. Patients may also develop avoidance behavior, especially when avoidance triggers a compulsive thinking.

Obsessive compulsive symptoms are often divided into compulsive thinking (forced rumination) with no apparent compulsive behavior, and obsessive compulsive behavior associated with obsessive compulsive behavior (Hodgson) (Ranchmen and, 1980). The classification of symptoms that are simply divided into obvious and covert manifestations may omit important functional indicators. The psychological model of obsessive compulsive thinking (Ranchmen 1978) emphasizes the functional significance of overt and covert compulsions (known as ritual acts). Accordingly, obsessive thinking, imagery, intruding and impulsive, involuntary and automatic, and accompanied by an increase in anxiety, and ritual behavior (explicit and covert compulsive behavior) is voluntary, restrained behavior, is to reduce the anxiety of patients (or risk of injury) caused by behavior. From my point of view, covert ritual behavior is the same as obsessive thinking. One example is "forced thinking a stranger might attack his" patients; if this kind of thinking, in order to feel better, he would have to make himself appear again this kind of thinking (for example, even many times). This may lead to long-term results, intrusion resistance intrusion - resistance - intrusion...... And so on, resulting in a different function of the thinking chain, rather than its content.

Two.OCD behavior theory

The basis of the behavior pattern is that the compulsive thinking is the intrinsic stimulation. And then the experience of traumatic conditioning, which is expected to be alleviated when the mind is forced to produce again, unless the person who is forced to think about the use of avoidance behavior (for example, washing hands, checking behavior).

According to this theory, it is of great importance to maintain compulsive thinking. By definition, forced rumination is an obsessive compulsion to act without apparent compulsion. Salkovskis and Westbrook (1989) highlights the incidence and importance of covert compulsions. This covert compulsion exists in a certain way in forced rumination. Obsessive compulsive behavior is not considered a subtype of OCD, which is almost completely hidden and forced, so it is particularly difficult to access and control. The term 'forced rumination' is confusing because it is used selectively to describe forced thinking and mental resistance. For example, one patient reported that she had obsessive thoughts and images about the death of her family. Well, she would think about these ideas for 3 hours at a time. Careful questioning that thinking has two functions of different thinking. First of all, she had an intrusive thought, 'my son is dead'. If she had such a thought, she would be able to resist these thoughts by letting herself think that my son was not dead, and form a representation of the normal movement of her son.

As a result, the behavioral model of obsessive-compulsive symptoms only needs to be expanded to recognize the role of mental resistance and avoidance behavior, which is difficult to detect and control. Anxiety can be repeatedly exposed to the basic principles of mitigation of fear thought still exist, if there is no termination or avoidance of exposure, explicit and covert response.

A further special consideration is that rapid and persistent anxiety relief is best done by encouraging patients to expose as much as possible to stimuli. For forced thinking without overt compulsions, exposure is thought, and it is more difficult to predict than the exposure of forced thinking to overt compulsions. Variables such as obsessive thinking activity, onset time, attack speed, intensity, duration, frequency, and the details of the actual, are beyond the control of the patient and therapist, and often change from the expression to report. Although the irregular expression of thinking will eventually adapt, but not obvious to patients, patients may therefore continue to resist or even give up treatment.

Three. The difference between thinking and thinking of the resistance force

Forced thinking and thinking in the cognitive aspects of resistance mixed together, their differences of treatment is the key. Intrusive, involuntary, involuntary thinking that must be distinguished from a patient's deliberate, voluntary effort to try to reduce anxiety or danger. It may also be a covert avoidance behavior, such as trying not to think. Avoidance (Avoidance) is not based on how successful it is to define anxiety, but rather to define what behavior to do. Avoidance and resistance, assessed by asking the patient for any mental effort due to obsessive thought.

Although not by anxiety disorders such as pathological view of OCD, but the cognitive hypothesis assumes the existence of other normal cognitive process can become 'sticky' (stuck), leading to excessive and disability level of anxiety, this anxiety is anxiety disorder patients experience. The factors involved in the occurrence of more serious and persistent anxiety can be divided into two categories: (1) factors that lead to higher levels of anxiety; and (2) factors that can maintain a high level of anxiety.

1 increase the degree of anxiety factors

Based on the cognitive theory of the development of mood disorders (Beck, 1976), it is more likely that people will be more likely to explain the real situation than they encounter, because of the particular assumptions or beliefs that they have learned in their early life. This belief may be useful in the early years of its life, but the problem arises when a new and different situation is required. This example is the belief, "keep perfectly calm is important", "if I can't control myself, I have lost control of the dangerous", "I can't express my feeling ',' if I don't have to worry about, then what will be a mess.". In addition to the general assumptions about anxiety, there are other specific types of disorders, such as panic disorder, social phobia, OCD, hypochondria, and so on. Life events, or other critical events, can intensify such assumptions, leading to a certain scenario, or an explanation of the excessive threat of long or short duration (Beck, 1976).

Second, the factors related to excessive anxiety are related to the special evaluation of the threat itself. In the most general case, cognitive models are considered in detail, and anxiety disorders tend to be too high to assess the likelihood of threats. However, Beck et al. (1985) describes the concept of a broader and more useful, anxious cognitive structure. This can be summarized as the following equation:

Perceived threat of the possibility of X perceived value of the danger / dignity

Perceived coping ability + perceived 'rescue factor'

According to this view, an increase in perceived risk may lead to an increase in anxiety. However, the perceived probability (or probability) must be combined with the special meaning of the patient's risk. For example, a person may believe it is likely that they have left without lock the door, but did not feel excessive anxiety, unless they feel that no door is very bad or dangerous things (for example, lead them to its home stolen responsible or blame). These two factors are considered multiplication and synergism. The conceptualization of the cognitive factors of this anxiety also illustrates the general scenario of the event, and the patient is believed to be unlikely to produce a particular negative outcome in such a scenario, unless there is still extreme fear. Although unlikely, this pattern is especially likely when patients believe that the threat is too dangerous. This association is evident in many instances, including serious health anxiety and obsessive thinking. Patients are aware that their concerns are likely to be unconscious, but if this is not possible, it can be devastating. For the vast majority of patients, it is impossible for them to always be sure that the outcome of their fear or attempt to transfer will not occur, even if they do not appear to be an assessor.

The combination of risk and cost is further perceived by patients as they can or cannot cope with the degree of risk adjustment. Will it materialize? Should be related to the external factors (e.g., the help of others) in relation to their own coping. Clinical and research evidence suggests that patients with anxiety disorders can exhibit a single or combined distortion of the factors involved. There are different combinations of different individuals and different obstacles. For example, patients with panic disorder may show improvement in all areas. Patients with OCD and patients often report a relatively low risk, but there is a very high level of perceived cost or dignity. The combination of OCD is more clear about the concept of responsibility, crime and shame. The evaluation of anxiety disorders should focus on all the components described.

2 factors to maintain anxiety

An excessive and persistent negative interpretation of stimuli, events, or situations is thought to be critical to understanding anxiety disorders. According to cognitive theory, there are at least three major components (Beck; 1986b; Clark; & Clark; Beck; 1988) for maintaining negative thinking and anxiety. Figure 1 illustrates the main types of vicious cycles that are thought to be involved in maintaining anxiety.

Potentially threatening stimuli

(situations, sensation, thoughts)

(Selective attention)

Theat appraisal

Probability x Awfulness

Coping + rescue

(prevent disconfirmation, increase symptoms)

Safety - seeking behaviours

(avoidance, escape, within-situation behaviours, neutralizing, checking, reassurance seeking)


Physiological and

Biological changes

Fig. 1 An illustration the in which factors can perpetrate threat cognitions and therefore maintain anxiety way problems. psychological (of)

(1) selective attention

Those who believe that they are in danger will become sensitive to the stimuli that they notice (consistent with the perceived danger). Although it seems to a certain extent, this is an unconscious reaction (very similar to that found their partner pregnant people begin to pay attention to other pregnant women, but at least some of the same) selective anxiety observed when attention produces to the risk of intentional gaze. Therefore, forced to wash their hands deliberately looking for their clothes or be rumination attention, intrusive thinking harassment body. Note that the more dangerous signals will then be incorrectly interpreted as a signal that the danger has actually increased, thus increasing its attention and further strengthening its interpretation.

(2) physiological changes

Anxiety has both direct and indirect physiological responses. Those who feel they are in danger may experience the release of adrenaline. If the source of danger is perceived to be associated with the physical sensation, then the feeling of danger increases and the spiral rises to panic attacks (Clark, 1986a). Obsessive compulsive patients who have repeatedly washed their hands, but began to sweat more and experience the hands or dirty feeling. In fact, this may be due to dry hands, but also because of the reaction to anxiety and sweat wet. In each case, a vicious circle leads to increased risk.

(3) behavioral change

Risk perception is thought to increase avoidance behavior. Avoidance behavior increases the urgency of the threat (because it increases the patient's attention to the avoidance of things), according to the cognitive model, thus forming a vicious cycle involving the maintenance of anxiety third. Improperly seeking safety can also prevent anxiety patients from finding their fears unfounded. An attack, has established a fear of consequences did not occur, and actively seek safe behavior of patients may believe that they are lucky to escape the threat, because they made efforts to prevent the disaster occurred without fear. From this point of view, there have been thousands of times the wrong thinking has not led to the injury forced patients, as well as thousands of times feel that they have prevented the occurrence of disasters. (side note: however, perceived risk is generally considered to occur in the distant future, then covering the safety behavior problems, and caused refute special difficulties). Seek safe behavior may be general behavior such as avoidance and escape avoidance behavior, or more subtle forms, in some cases feel patients to prevent risks such as trying to rule out a special type of thinking. Seeking safe behavior can not only prevent the rebuttal, but in some cases, it can also increase the initial symptoms of false interpretation of the symptoms, therefore, increase anxiety (Salkovskis, 1 996c).

According to the definition, forcing patients to experience intrusive thinking, "they are trying to suppress or resist (DSM-IV:American, Psychiatric, 1994) with some other thought or action. Consciously attempting to suppress the intrusive nature of the intrusive thinking does increase the emergence of these thoughts (Salkovkis & Campbell, 1994; Trinder & Salkovkis, 1994). If a patient wants to reject the giraffe of (thoughts giraffes) in his mind, then in the whole process of trying to suppress, it is inevitable that this kind of thinking or representation will be more frequent. This may be due to the exclusion of this thinking, pay attention to the general concept of giraffe. It goes without saying that it is in itself, why in the process of trying to rule out this kind of thinking, this kind of 'unwanted' thinking will appear. However, a case of a forced with hate into thinking trying to exclude obsessive thinking (such as the experience of blasphemy or violence, thinking of patients) with no apparent connection between safety behavior and increase the frequency of forced thinking. As a matter of fact, the patients often think that this annoying thought is taking place at a high frequency of worrying, although trying not to think about them. Therefore, it is concluded that if he or she wants to suppress the termination, these thoughts will still appear in a higher frequency and in a more controlled manner.

Six. Applied cognitive theory of obsessive thinking

The general cognitive theory of emotional and emotional problems emphasizes the role of thinking in the production of mood disorders. According to this view, the treatment needs to correct the distorted thinking mode, which can produce less sadness and shorter duration. This approach first requires the identification of specific patient specific evaluation centers, and subsequent maintenance reactions. In so doing, it may be the beginning of attempts to correct this distortion as well as the maintenance factor. Different types of disorders are characterized by different, specific types of distorted thinking (although, in any individual, the expression of a particular difference involves very specific factors). For example, the negative thinking feature of panic disorder in order to focus on catastrophic errors on somatosensory interpretation, social phobia with negative interpersonal situations, personal appearance and social function, performance etc. explanation for the characteristics.

1 'normal' and 'abnormal' intrusion

Although, at first glance, intrusive thinking seems to be the key component of the symptoms of obsessive-compulsive disorder, but this view can not stand scrutiny. Almost all of the normal people (non-clinical subjects) have experienced this in thinking, according to the original content and not forced thinking phase difference (Rachman & de Salkovskis & Silva, 1978; Harrison, 1984). Moreover, the vast majority of patients believe that forced thinking is unconscious or extremely unlikely. These factors suggest that forced thinking as the primary goal of cognitive intervention is inappropriate.

OCD's theory of cognitive behavior suggests that forced thinking does not differ from normal intrusive thinking. Like forced thinking, the normal intrusion is the idea, thought, image, or impulse that breaks into the current flow of consciousness. The difference between normal intrusive cognition and compulsive intrusive cognition is not in its original production, but in the interpretation of the emergence and / or intrusion of such intrusive cognition. According to this hypothesis, when the intrusion of cognition is interpreted as a hint, namely (may, be) patients may have (may have been), or may be (may come to be) to prevent injury or damage for 1985, 1989 (Salkovskis, 1993; Salkovskis et; Rachman, Al, 1995). According to the patients on their own or other people harm, in patients believe thinking and uncomfortable experience and resistance (forced) behavior - whether between explicit or hidden behavior - there is a link, which is a special interpretation for the occurrence and content into the thinking of. Acts of resistance, avoidance behavior, a tendency of excessive attention with their mental content and negative mood, in general cognitive theory to maintain the negative concept of responsible because of the occurrence and thinking of the content into the category, can interaction the above way. Figure 2 summarizes the manner in which such factors are hypothesized to interact in the onset and maintenance of obsessive-compulsive symptoms. This description of these factors, the patient 's common understanding of the occurrence of help.

1 Liability (Responsibility) is used in a special way. Appraisal (responsibility) is assumed to be defined as "the conviction of specific obsessive-compulsive symptoms as" the belief that a person has the ability to produce or subjectively prevent critical negative outcomes. These results may be true, that is, the results produced in the real world, and / or the evaluation of the moral level (Salkovskis, 19960).

2 the conceptualization of the problem (Conceptualizing the Problem)

The conceptualization of the overall structure is consistent with the cognitive approach to other types of anxiety disorders, in which special non threatening scenarios become the focus of attention, as a result of danger or threat. Thus, the way in which anxiety is expressed depends on the perception of threat perception and its consequences, which produce a subsequent response. For example, in the cognitive hypothesis of panic disorder (Clark, 1986a; Salkovskis, 1988), has been described as panic attacks, explain on normal body to feel wrong results, especially the normal body feel anxiety. The vast majority of normal people have experienced this feeling, but only those who have long been able to explain these feelings in a catastrophic way will experience repeated panic attacks. This may be due to the disaster focused anxiety (catastrophe- focused anxiety) the tendency of the results: (a) lead to the increase of symptom perception of the initial focus of the center's (b) to seek safe behavior, this behavior is to prevent individuals found that they fear will not happen, and sometimes increase in symptoms (Clark, 1986a; Salkovskis 1991). For the same reason, into thinking, impulse, representation and doubt, is a part of everyday experience, but only has its own mental activity is interpreted as a personal "responsibility" (personal 'responsibility') the persistent tendency of people to experience the OCD uncomfortable and resist pattern. The effect of this emotional arousal and security seeking behavior will maintain and strengthen the relevant model.

For example, forcing patients may believe that the emergence of a forced thinking such as "I can kill or tease my children" means there is danger she would succumb to action, unless she take some ways to prevent, avoid alone with her children. Not only will the child be hurt, but she and others are clearly responsible for their actions. In order to offset (counteract) of these fears, she must seek to let the people around at ease, and trying to prevent the escape or into thinking, or try to think positive thoughts to balance the negative thinking (resistance into thinking). Therefore, marked increase in forced liability, resulting in a large number of important and associated effects: (a) increased discomfort and anxiety and depression; (b) to increase the intrusion of thinking; (c) are prone to break into the original thinking and other thinking; and (d) positive to reduce this kind of thinking, and to reduce or remove the perceived related responsibilities, including acts of resistance and cognitive 'resistance' response, but usually not up to the expected goal. These may include situations such as obsessive compulsive behavior, avoidance of obsessive compulsive thinking, reassurance (resulting in dilution or sharing of responsibility), and attempts to get rid of or reject the thought from the mind.

Each of these effects not only blocks anxiety relief, but also increases attention and increases the vicious cycle of intrusive thinking that leads to an inappropriate emotional, cognitive, and behavioral response. In some cases, when the outcome of fear is approaching, behavioral responses can have an additional effect to prevent the rejection of the patient's negative beliefs (Salkovskis, 1996b, C). For example, a patient may believe that a person who has a strong heart for 15 minutes without washing his hands will suffer serious illness on the same day or at least second. Washing hands in this way, the family did not have a disease, so as to make sure that the initial belief, and later when the pollution of the mind to re emergence of the original belief (or even strengthen).

3 Responsibility Evaluation

The cognitive hypothesis suggests that exaggerated responsibility evaluation can focus attention on the occurrence or the content of intrusive cognition, or both (Salkovskis et al, 1995). The meaning of emotion is a result of a special and unique evaluation model. If this is the case, it is possible that the first thought of intrusive thinking is the initial emotional resistance. However, as other potential emotional stimuli, they may show a positive, negative or no emotional meaning, according to their previous experience and thinking into what happened (Edwards & Durkerson, 1987; England & Dickerson, 1988). As described above, a critical part of the evaluation of intrusive thinking involves the meaning of an intrusion and the need for action in the future. If the intrusion is evaluated as having no meaning, the priority of the process is cancelled.

The assessment of responsibility for the occurrence and content of the intrusion may be at least partially independent, although often connected. One can't get rid of a singular and dislike thinking and appearance of the patients, resist the obvious explanation for this effort to control, is a sign he is in danger of losing control of the unpredictable behavior and violence.

He became absorbed in deliberate efforts to prevent the victory from the mind, extra thinking, the thinking of marshalling. In this case, the occurrence of an intrusion that he mistakenly interpreted is the initial manifestation. In another case, the patient experienced repeated and vivid appearances, and she lay dead in front of her local shop, surrounded by her family around her coffin. She explains that the emergence of these special images is a prediction of the future. She is particularly concerned by the images of real places and people, as well as the vivid and detailed images of them. Here, the contents of the intrusion is more important.

Although the evaluation of these two aspects are the most common problems associated with force ("the thinking means of my family is in danger"), but not in every case these are obviously some evaluation. For example, a happy and sad thinking if the scene (such as the funeral procession produce sex thinking) is not consistent, it may have a negative evaluation. However, when considering the meaning of the unique thought, the connection between the emergence of thought and its content is usually obvious.

4 the persistence of intrusive thinking

When prompted to evaluate the occurrence and content into a special purpose (including reaction time, or to avoid the press tried to resist the intrusion, or even carefully monitoring its occurrence), will give priority to, and then broke the frequency almost inevitably increase. In patients for its interpretation of the responsibility, and therefore will tend to continue, and further into thinking and behavior into the center; may also be as independent thought, but it will not follow further thinking or behavior. However, sometimes unpleasant and annoying cognition can not be solved, it will become more persistent, such as depression, anxiety and worry. When a particular type of thought is judged as an experience that will harm to oneself or others, the occurrence and content of the mind becomes a source of discomfort and compulsion. This compulsion is intended to be used to combat this obsessive thinking and to bring potentially harmful results in order to prevent or control its further occurrence. Then, the occurrence and content of the thinking has become a source of discomfort and force signals, the forced behavior is intentional resistance to forced thinking, and it has potential harm results, and prevent and control the occurrence of further.

In order to prevent the occurrence of intrusion, and / or prevent the meaning of knowing and limiting liability, it is often necessary for the patient to pay close attention to his / her mental activity. The need for hard work and attention, tend to control mental activity, including a variety of symptoms and maintenance of obsessive-compulsive symptoms. These may include, for example, to determine the accuracy of his memory, considering all the factors, their decision to prevent the unwilling things happen, when the subtle difference reached and did not reach between the (such as, in order to remove pollution, after washing their hands to determine completely clean, ensure results). Strategies (precise), by the impact of such strategies, the patient's specific beliefs determine. The choice of strategy is best understood as the safety of patients. The patient will respond in the way he / she believes, which is considered to be the most effective way to reduce the threat of injury. Thus, behaviours (Safety) is directed by the patient to prevent injury or prevent injury. However, if the patient has the potential to prevent or even potentially harm, then his perceived responsibility may be increased by this awareness. If someone can influence an event, he assumes certain responsibilities for the possible outcome. Therefore, the short-term "evasive" or the transfer of responsibility, is also without effect, enhance more lasting faith, which increased in the first place and is responsible for what happens in the future scope of faith.

5 the role of hypothesis

The cognitive theory hypothesis, because from childhood through long-term learning since the formation of hypotheses, or as an unusual or extreme event and environment as a result of the formation of the assumption that people tend to make special evaluation. Some assumptions about the characteristics of patients presenting with OCD have been described by Salkovskis (1985), including:

"If there is a thought about an action, it is possible to perform this action"

"If you do not prevent (or do not try to prevent) harm to yourself or others, it will also be the first to do harm"

"Responsibility will not be reduced by other factors, such as something impossible"

"When an intrusion has occurred, does not resist the harm that is similar to or equivalent to the search or need for injury, which occurs when an intrusion occurs"

"One should (and can) train to control his mind."

If someone is very stubborn to adhere to these attitudes, then the patients with overt and covert covert behavior may occur naturally.

The effects of these types of assumptions are often described in terms of 'thinking errors' (Beck, 1976). Thinking errors affect the level of the content of the response in the future. Thinking errors are not pathological in themselves; in fact, most people are judged by some 'inspiration', and many of them may not be reliable (Nisbett & Ross, 1980).

The cognitive hypothesis suggests that OCD patients exhibit a large number of characteristic difficulties (thinking errors), which are associated with their obsessive compulsive disorder (obsessional). It is possible that the most typical and most important of these is the idea that "any effect is equivalent to a result.".

A particularly interesting possibility is that the relationship between behavior (action) relative to the non performance (inaction) responsibility. As outlined above, Salkovskis (1985) proposed that faith "failed to prevent (or failure to try to prevent) on their own or other people's injuries will also cause harm, the first" may be the key assumptions in obsessive-compulsive disorder. Spranca et al. (1991) demonstrate that there is a "neglect preference" (omission bias) in sub clinical individuals (nonclinical subjects). They show that the responsibility of a normal individual to determine negative outcomes is reduced when a omission is involved in the negative outcomes associated with some particular behavior. This is true in the normal person, even when the intent element (e.g., the scope of the individual's desire for 'negative' results) is controlled. Therefore, the vast majority of people are concerned about themselves, more responsible for what they do, rather than do not do what is responsible. Clinical experience (and our recent preliminary trial) suggests that compulsive patients do not show evidence of this type of neglect preference. If this observation is confirmed by experiments, a new range of possibilities for understanding compulsive behavior is developed. (see Salkovskis et al., 1995; Salkovskis 1996a: a further discussion of the problem and how it relates to perceived responsibility.)

Eight. Cognitive behavioral therapy of obsessive thinking

As described here, the cognitive hypothesis allows a clear understanding of the generation and maintenance of anxiety symptoms. A particularly important part of the treatment, which involves techniques for risk mitigation (Salkovskis, 1991). However, in this regard, OCD poses some special difficulties. Pay attention to the details of the obsessive belief, clarify where the difficulties are and how best to solve them. In the case of coercion, it is common that the risk of fear is judged by the patient and is likely to occur in some relatively distant future. For example, forcing a patient may believe that he is unable to control his blasphemous thoughts, which means that he will suffer permanent torture after his death. Strategies intended to show the patient's fear that it will not occur are likely to fail. It has long been known that these problems have no effect on Assurance (Marks, 1981).

Fortunately, the practice of cognitive therapy is the basis for the therapist to work with patients to achieve a common understanding of the patient's problem. The most effective way to change the interpretation of errors (whether it is a symptom, a scene, or a thought) is to help a group of patients to come up with a threat to change and reduce their experience. The next treatment (including the discussion, the refutation of the behavioral tests and exercises) is a complete alignment to help the patient to distinguish between its various interpretations. In each instance, the selective interpretation, based on the particular patterns of interpretation and symptoms of each person, is likely to be highly specific. Cognitive hypothesis also shows that different types of psychological problems in different species will show some degree of widespread agreement. Therefore, the experience of repeated panic attacks in patients with concerns, especially in the patient may be able to explain the physical and mental sense of the way, this physical and mental feeling is an imminent disaster. The problems of social phobia patients are obviously concentrated on the idea of being humiliated, ridiculed and rejected. Such concerns are relatively easy to refute, as they occur in 'here and now'. However, since the disaster of fear in OCD tends to happen in the future, it is seldom used as a strategy. This increases the importance of understanding the patient and therapist's non threatening interpretation of their symptoms. That is to say, the cognitive model is specific to the patient's symptoms and situations. The cognitive interpretation of OCD is important and will be described below.

Eight. Overall strategy for OCD treatment

Following the discussion above, there is a consistent understanding of the psychological basis for the treatment of obsessive compulsive symptoms. This is crucial because, at the start of treatment, these patients believe that their symptoms are that they are in some terrible disaster unless they take preventive measures. If this belief is so strong, it is unlikely that the patient will receive appropriate psychological (or psychiatric) treatment. For example, obsessive compulsive patients believe that their thinking means that he is a child molestation, a potential murderer, a god of blasphemy, and so on. In the face of this belief, do not be surprised that he seeks to deal with this situation by fighting his mind and resisting any attempt to ensure that he is not responsible for any harm or other humiliation. Therefore, in the early stages of treatment, it is necessary to help patients understand that the difficulties they experience may have an alternative explanation. To introduce a specific basic cognitive model to patients, providing a completely different and less threatening explanation of their symptoms. Use the same situation, they are not a child molester, but they fear and believe that they may be the child molester, which is true in the thinking of torture, because of fear they want to exclude the intrusion, but failed (and against product). In order to be effective, it may be concluded that it is necessary to allow patients to agree to treatment strategies to reduce this anxiety, rather than to try to reduce the risk (which may also lead to increased anxiety).

At this stage of treatment (protocol, engagement), two possible explanations for the patient's problems are needed, rather than mutually exclusive. Ask the patient to consider how these two alternative views fit in with the experience. Once the therapist and the patient agree to choose between the two, the benefits of treatment are used to evaluate the strengths and weaknesses of these two perspectives. Review evidence of support and opposition, and discuss in detail. Use charts to illustrate, with reference to figure 2, to help patients understand the psychology of choice. The particular form and content of a chart, determined by the particular pattern determined by the evaluation process.

Often, discussions are needed to find further information that is currently not available to patients. This is the practice of information gathering exercises to help patients clean up their beliefs. Patients may be forced to understand that trying not to think a thought may increase the frequency of such thinking. However, she also takes into account that it is possible that she will hurt her child's thinking not to follow this pattern, perhaps she simply by pushing away their children to try to hug them, thus transferring her. To test this, patient diary records the frequency of the occurrence of forced thinking these days, and now she tried to transfer as much as possible but the compulsive thinking is very difficult, and some future time allowed into thinking without resistance. In doing so, she will find that when the choice to resist forced thinking, forced thinking occurs more frequently and make her more trouble. In this process, the mutual influence between the lasting cognitive behavior structure is a sketch of the patient and therapist, discuss how patients experience adapt to the structure, and the use of behavioral experiments to further elucidate the mode and structure of the new information and experience. Cognitive and behavioral factors are intertwined, but the guiding principle is always to promote patients to recognize and accept more helpful and no fear of faith, rather than they have previously accepted beliefs.

Nine. Special elements of cognitive behavior therapy

Once the patient is involved in a therapeutic partnership, the main therapeutic factors are:

(a) to negotiate with patients and develop and achieve a comprehensive, cognitive behavior model that maintains their obsessive problems. This includes the identification of the core of the distorted belief, and the joint construction of a non threatening, optional interpretation of its forced experience, allowing patients to clearly test their responsibility.

(b) with the identification and evaluation of the self monitoring force, thinking and patients with practice, designed to help patients to amend its responsibility, depending on the method of a minute (e.g., through the use of diary dysfunction thinking).

(c) techniques for discussing challenging evaluation and underlying assumptions. The aim was to revise the patient's negative beliefs about his personal responsibility (for example, to allow the patient to describe all the factors that contribute to the outcome of the fear, and to classify them with statistical charts).

(d) test, evaluation, test assumptions, and direct patients in forced patients involved in (for example, assume that the program that attempts to suppress a thinking lead to the increase in the frequency of occurrence, or beliefs such as "if I want it then I wish it was wrong). Each behavior test is specially designed, in order to help patients and therapists rely on new, come to a common (non threatening), to test its previous experience, the (threatening) interpretation.

(E) to help patients identify and correct fundamental assumptions (such as, "if you do not try to prevent injury, that is to say, to make it happen"), which causes them to distort their mental activity.

Treatment of the overall idea to guide the rehabilitation of patients. Although through questioning (questioning) and discussion, the nature of the problems encountered by patients and therapists is consistent. On the basis of this common understanding and discussion, a special behavioral test is designed to expand the understanding of the problem and to evaluate the predictions that are generated from the same understanding and the predictions of the graphs that have been drawn. Behavioral tests will be described in detail below, but include the various strategies listed below:

(a) design behavior tests to assess the extent to which a particular procedure may play a role in maintaining the patient's fear.

(b) the design of other trials, which may lead to the addition of symptoms (such as intrusive thinking), or to increase the fear and pain associated with these symptoms.

(c) (Exposure exercises), exposure practice (rumination, usually using cyclic tape), give patients the opportunity to discover, which broke into thinking or related stimuli (hopefully, with negative evaluation of responsibility to reduce the level of repetition) will make uncomfortable experience to reduce.

In the treatment of obsessive rumination, although repeatedly stressed that the cycle of effective tape as the excitation strategy, but this particular technology must go deep into the overall framework of cognitive behavioral approach in. It is important to remember that the fundamental basis of the problem is the way in which the patient is able to interpret or evaluate intrusive thinking and related phenomena of value. Special attention is needed, although in many anxiety disorders, may through the production process and results refute the fear of helping patients change their beliefs (Salkovskis, 1991), but rarely achieves this result of forced problems (Salkovskis, 1996b). Assume so, reduce the patient's belief distorted interpretation (classic, explanation and content into thinking is harm to individual responsibility in a sign) the best way is to provide alternative explanation for a less threat to patients. The alternative explanation is, of course, based on the framework of cognitive behavior. Therefore, patients are constantly reminded of the problem forced to experience does have two possible explanations: it is possible, they are really in danger caused by injury or cannot prevent injuries, so they must do everything possible to transfer this damage; or it may have some worry, the hurt, the problem due to this particular anxiety, and care about far more than any real harm. In every opportunity to emphasize what is beneficial to the patient, the two different perspectives have produced the opposite predictions. In particular, the continuing efforts to prevent some of the concerns of patients, will inevitably have increased the effect of worry.

Nine. Treatment overview

1 phase 1: assessment and goal setting (Stagel: Assessment and goal-setting)

During the evaluation phase, the therapist focused on obtaining a patient's description of the recent onset of rumination and identifying the specific outcome of the attack. It is worth emphasizing that the identification of patients into interpretation thinking (or other intrusive cognition) way, according to the influence on the responsibility and then trying to resist oppression or other control into this thinking. The effect of this attempt on the control of the occurrence of an intrusion has become prominent. To the end of the stage, to achieve two goals. First, the framework of the problem or the common understanding of the need to achieve consistency; second, to discuss the treatment objectives. These goals should include short, medium and long term goals. It is important to emphasize that patients who are forced to swallow are not completely removed by the type of thinking that is considered.

2 stage 2

This includes further clarifying the patient's problems and helping patients understand the mechanism of their intrusion into the mind. At this stage, to use several strategies, including: (a) to discuss the normal function into thinking; (b) to discuss who it is who will experience a special type in thinking, and the people what it means; and (c) to solve the problem of recognition in / out between creation and thinking into contact and if they are positive, negative or neutral. This latter strategy also includes the identification of the effectiveness of negative intrusive thinking in very situations, and the manner in which aggressive aggressive thinking may be negatively evaluated in an appropriate environment.

At the end of this phase, it is important to help patients understand that intrusive thinking is not only normal, but also a crucial part of everyday life.

3 stage 3

Ask the patient directly, comparing two views on their problems. To highlight the differences and similarities, and discuss in detail the need to feel the need for this painful experience. Explain the use of tape recording procedures, as well as the importance of explaining the concept of corrective liability and preventing any resistance.

4 phase 4: tape exposure and belief revision

As described above, the loop tape is used to stimulate the patient's intrusion. Stresses the importance of correcting patient responsibility and how they relate to the promotion of resistance at this point. The reaction begins with the basic principles of cognition, and usually helps patients to challenge their assessment of intrusion. In the treatment, the adaptation (habituation) begins with an uncomfortable assessment, the first tape playback, any difficulties identified in the prevention of the reaction and the need for repeated treatment and discomfort. The treatment procedure needs to be repeated until both patients and therapists agree that the treatment procedure has been completed, and that anxiety / discomfort or resistance to the impulse at least begins to show signs of reduction. The homework is provided to the patient in a graphical and detailed manner. At this stage, every opportunity to continue to correct the patient's beliefs. Ask the patient how to deal with any changes that occur, and how to adapt to two choices. Each subsequent treatment changes the different compulsive thinking, and changes the habit from the time specified in the patient's home to regulate the treatment of the transition to the tape in any possible treatment.

5 phase 5: further behavioral testing

At this stage, the spontaneous nature of the intrusion is used as a cue to use the tape. Initiate self - directed exposure and response to other thoughts and keep records. During the course of the reaction, the patient must continue to record the intrusive thoughts and other intrusion. The reaction prevents a portion of the tape from picking up a particular belief and accelerating its correction. Through this period, the use of responsibility and the interpretation of the questionnaire to monitor the special beliefs may need to deal with.

Expression of the patient's obsessive thoughts and beliefs of the patient at this stage should be very clear and guide further treatment. The discussion and behavioral tests should be combined with the idea of an alternative explanation ("my question is really annoying"), and behavioral test design to reinforce the idea. Examples can be metaphors or thought reconstruction, disaster metaphors, or language exercises, as a demonstration of the ways in which these concepts increase discomfort and distress. A circular chart dealing with the concept of responsibility; a test of thought; a patient tries to produce an event that they fear and what they want to be responsible for; a positive and a negative aspect of coercion and non coercion; a cumulative probability.

Factors that trigger anxiety and discomfort may continue to occur in the treatment of obsessive thinking. However, the treatment has been effective, correcting the significance of intrusive thinking for the vast majority of other people (non compulsive patients) feel this level of anxiety. Do not attempt to directly reduce the number of experiences of invasive thinking, and some of the patient's intention to produce this reduction is a challenge to the basic beliefs that drive it. However, the lucky and desirable side effects of cognitive behavioral therapy are that the intrusion is usually reduced because the patient is no longer considered to be important, so it is no longer a priority. Note that the 'normal' person does not often seek to control the mind; the control tends to be indirect, since the absence of symptoms does not produce serious negative consequences.

6 final stage: prevention of recurrence

The potential difficulty of the future is to identify the "blocked bag" edited by the patient. Throughout the treatment, patients were asked to keep an eye on the knowledge they had learned in each treatment, to promote the patient 's becoming their own therapist, and to summarize the key points.

Ten. Therapeutic effect

A large number of case reports and case studies have been published to describe the efficacy of this type of CBT in obsessive compulsive thinking (Salkovskis, 1983; Salkovskis & Westbrook;; & Roth; Church, 1994). Recently, Freeston (1994) reported the results of a controlled trial that compared with in situ (waiting list control) groups using a complete CBT (including repeated assessment strategies and revised adaptive training). As a result, obsessive-compulsive symptoms were significantly reduced, both in terms of self-evaluation and therapist evaluation. It is particularly encouraging that the treatment effect lasts until 6 months of follow-up, and no recurrence after cessation of treatment. Our team is currently comparing the CBT with the in situ control and high confidence stress management package (high -credibility stress-management package).

Eleven. Conclusions and recommendations for further research

The application of cognitive behavior theory to the treatment of obsessive thoughts is now supported by evidence. As for the CBT, which is very prominent in the ritual behavior, there is evidence that the long-term outcome is very good and the recurrence rate is low.

Future research may focus on the popularization of CBT, and how treatment affects the psychological and biological processes of obsessive compulsive problems. What is urgently needed is the development of more rigorous and accurate evaluation procedures. Measurements such as Y-BOCS (the Obsessive- Compulsive Scale, Y-BOCS; Goodman et al, 1989) are designed to evaluate drug treatment, and reflect a wide range of changes in the treatment of Yale-Brown. A reanalysis of this scale showed that the presence of resistance to the project and the need to include avoidance assessment (Woody et al., 1995). Forced ruminant in the assessment of the treatment effect, Freeston (1994) stressed the need to separate assessment of explicit and covert resistance, suggesting that "Y-BOCS compulsion 'need all compulsion and covert resistance evaluation. These are prompted through the entire field. In addition, in the Y-BOCS's' obsessive compulsive thinking 'scale, there is a problem with the design of the evaluation of the ability to control the obsessive thinking, if used to assess the efficacy of CBT. When the patient was completely in control of his obsessive thinking, the project scored lower, and when the patient did not want to control the project would be a pathological. This is a problem, because the CBT's specific purpose is to help patients end up trying to control their obsessive thoughts, in order to help patients find that this is the best way to 'control' their obsessive thoughts.

Also need to change research assessment in the course of treatment to heart process; these may include such as break frequency, acceptability evaluation, responsibility evaluation, overall beliefs, thinking about responsibility and effect, to suppress the danger / threat possibility, perceived cost, etc.. This assessment may promote psychological and pharmacological treatment, according to the treatment plan and the model of residual problems once the treatment is completed, the need to determine the therapeutic effect. There is preliminary evidence to show that the treatment of compulsive thinking is effective. Further research should seek to repeat the findings and improve the efficacy of this treatment, and better understand the mechanisms of change.

(Salkovskis: Paul M., Elizabeth Forrester, Candida Cognitive-behavioural approach understanding thinking. British J Psychiatry 1998173 (Suppl 35): 53-63) in,



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