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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."

Example: "I’ve got to do everything perfectly."

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

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!

What keeps OCD going?

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.


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.


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.

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."

OCDers, like normal neurotics, often then construct secondary disturbances about their cognitive distortions and about the poor emotional and behavioral results which accompany such irrational Beliefs. Thus, they may think, "I must not be anxious about my OCD! I must not demand that I be free of OCD! I must not have low frustration tolerance about my OCD!" In this manner OCDers can easily create self-downing about their self-downing and LFT [low frustration tolerance] about their LFT--all related to their OCD.

In addition, OCDers can have regular self-denigration and regular LFT about other aspects of their lives. Thus, they can put themselves down for any failures or inability to achieve their ideal goals; and they can define as "unbearable" any hassles, mild or serious. Their tendency to castigate themselves for their "poor" performances and their tendency to make "utter horrors" out of normal hassles may, once again, be partly innate. I suspect this but have no hard evidence to back it up. An alternate hypothesis is that they have so many and so profound difficulties and failures because of their OCD, that they easily develop self-downing and LFT when non-OCD-related problems are added to their OCD-related difficulties.

OCDers, then, frequently have ego anxiety and depression (self-downing) and discomfort anxiety and depression (LFT) about (a) their OCD difficulties, about (b) their other regular life problems, and about (c) their self-downing and their LFT that often--probably, usually!--accompany their OCD and their non-OCD difficulties.

Journal of Rational-Emotive & Cognitive-Behavior Therapy

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)


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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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)...



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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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.

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1600+ citing articles


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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

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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