CBT

The earliest cognitive therapies were in many ways “insight therapies,” in that the therapy used
largely introspective techniques designed to change a patient's overt “personality” (Beck, 1967; Ellis,
1962).

Beck, Ellis, and their colleagues were among the first to use a wide range of behavioral treatment
techniques, including structured in vivo homework. They have consistently emphasized the impact of
cognitive and behavioral techniques not only on symptoms but also on the cognitive “schemas” or
controlling beliefs. Schemas provide the instructions to guide the focus, direction, and qualities of
daily life and special contingencies.

it is usually more productive to identify and modify “core” problems in treating personality disorders.

The two perspectives differ in their views of the nature of this core structure, the difference being
that the psychoanalytic perspective sees these structures as unconscious and not easily available to
the patient. The cognitive perspective holds that the products of this process are largely in the realm
of awareness (Ingram & Hollon, 1986) and with special strategies may be even more accessible to
consciousness.

Dysfunctional feelings and conduct (according to the cognitive therapy theory) are largely due to the
function of certain schemas that produce consistently biased judgments and a concomitant tendency
to make cognitive errors in certain types of situations. The basic premise of the cognitive therapy
model is that attributional bias, rather than motivational or response bias, is the main source of
dysfunctional affect and conduct in adults (Hollon, Kendall, & Lumry, 1986; Zwemer & Deffenbacher,
1984).

It is rare that personality problems are the chief complaint of a patient presenting for treatment.
Instead, difficulties with depression, anxiety, or external situations compel the patient into
treatment.

Heuristic signs that may point to the possibility of Axis II problems

include the following scenarios:

1. A patient or significant other reports, “Oh, he (she) has always

done that since he (she) was a little boy (girl),” or the patient

may report, “I’ve always been this way.”

2. The patient is not compliant with the therapeutic regimen. Al

though noncompliance is common in many problems, for many

reasons, persistent noncompliance should be used as a signal for

further exploration of Axis II features.

3. Therapy seems to have come to a sudden stop for no apparent

reason. The clinician working with this patient can often help
the patient to reduce problems of anxiety or depression, only to

be blocked in further therapeutic work by the personality disor

der.

4. The patient seems entirely unaware of the effect of his or her

behavior on others. Such patients report the responses of others

but fail to address any provocation or dysfunctional behavior

that they might contribute.

5. The patient gives “lip service” to the tasks of therapy by ex

pressing interest and intention to change but fails to follow

through on agreed actions. The importance of change is ac

knowledged, but the patient manages to avoid making any ac

tual changes.

6. The patient’s personality problems appear to be acceptable and

natural for him or her. The patient sees the problems as a funda

mental aspect of his or her “self” and makes statements such as,

“This is who I am; this is how I have always been. I can’t imagine being any other way.

OCD

If it’s worth doing, it’s worth doing well.

A stitch in time saves nine.

A place for everything, and everything in its place.

The obsessive–compulsive personality style is common. This may be partially due to the high value
that society places on certain characteristics of this style. These qualities include at tention to detail,
self-discipline, emotional control, perseverance, reliability, and politeness.

However, some individuals possess these qualities in such an extreme form that they lead to either
functional impairment or subjective distress. Thus, the individual who develops obsessive compulsive
personality disorder (OCPD) becomes rigid, perfectionistic, dogmatic, ruminative, moralistic,
inflexible, indecisive, and emotionally and cognitively blocked
The most common presenting problem of persons with OCPD is some form of anxiety. Compulsives’
perfectionism, rigidity, and rule governed behavior predispose them to the chronic anxiety that is
characteristic of generalized anxiety disorder.

Basic belief/ attitude

“I must not err.”

Strategy /overt behaviour

Perfectionism

Individuals with a personality disorder tend to show certain patterns of behavior that are
hypertrophied, or overdeveloped, and other patterns that are underdeveloped. The obsessive–
compulsive disorder, for example, may be characterized by an excessive emphasis on control,
responsibility, and systematization and a relative deficiency in spontaneity and playfulness

The deficient features are frequently the counterparts of the strong features. It is as though when
one interpersonal strategy is overdeveloped, the balancing strategy fails to develop properly. One
can speculate that as a child becomes overinvested in a predominant type of behavior, it
overshadows and perhaps weakens the development of other adaptive behaviors.

overdeveloped strategies may be a derivative from or compensation for a particular type of self-
concept and a response to particular developmental experiences. Also, as indicated previously,
genetic predisposition may favor the development of a particular type of pattern in preference to
other possible patterns.

The obsessive–compulsive personality may develop in response to chaotic conditions in childhood—

as a way of bringing order to a disordered environment.

Overdeveloped strategies

Control

Responsibility

Systematization

Underdeveloped strategies

Spontaneity

Playfulness

SPECIFIC COGNITIVE PROFILES

The key words for obsessive–compulsives are “control” and “should.” These individuals make a virtue
of justifying the means to achieve the end to such an extent that the means becomes an end in itself.
To them, “orderliness is godliness.”

Self-view: They see themselves as responsible for themselves and others. They believe they have to
depend on themselves to see that things get done. They are accountable to their own perfectionistic
conscience. They are driven by the “shoulds.” Many of the people with this disorder have a core
image of themselves as inept or helpless. The deep concern

about being helpless is linked to a fear of being overwhelmed, unable to function. In these cases,
their overemphasis on systems is a compensation for their perception of defectiveness and
helplessness.

View of others: They perceive others as too casual, often irresponsible, self-indulgent, or
incompetent. They liberally apply the “shoulds” to others in an attempt to shore up their own
weaknesses.

Beliefs: In the serious obsessive–compulsive disorder, the core be liefs are “I could be
overwhelmed,” “I am basically disorganized or dis oriented,” “I need order, systems, and rules in
order to survive.” Their conditional beliefs are “If I don’t have systems, everything will fall apart,”
“Any flaw or defect in performance will produce a landslide,” “If I or others don’t perform at the
highest standards, we will fail,” “If I fail in this, I am a failure as a person,” “If I have a perfect system, I
will be successful/happy.” Their instrumental beliefs are imperative: “I must be in control,” “I must do
virtually anything just right,” “I know what’s best,” “You have to do it my way,” “Details are crucial,”
“People should do better and try harder,” “I have to push myself (and others) all the time,” “People
should be criticized in order to prevent future mistakes.” Frequent automatic thoughts tinged with
criticalness are “Why can’t they do it right?” or “Why do I always slip up?”

Threats: The main threats are flaws, mistakes, disorganization, or imperfections. They tend to
“catastrophize” that “things will get out of control” or that they “won’t be able to get things done.”
Strategy: Their strategy revolves around a system of rules, standards, and “shoulds.” In applying
rules, they evaluate and rate other people’s performance as well as their own. In order to reach their
goals, they try to exert maximum control over their own behavior and that of others involved in
carrying out their goals. They attempt to assert control over their own behavior by “shoulds” and
self-reproaches, and over other people’s behavior by overly directing, or disapproving and punishing
them. This instrumental behavior amounts to coercing and slave driving themselves or others. Affect:
Because of their perfectionistic standards, these individuals are particularly prone to experience
regrets, disappointment, and anger toward themselves and others. The affective response to their
anticipation of substandard performance is anxiety or anger. When serious “failure” does occur, they
may become depressed.

THINKING STYLES

“miss the forest for the trees.”

These persons focus so much on details that they miss the overall pattern; for example, a person
with this disorder may decide on the basis of a few flaws in another person’s performance that the
other person has failed, even though the flaws may have simply represented some variations in an
overall successful performance. Further, in contrast to histrionics, people with obsessive–compulsive
personality disorder tend to minimize subjective experiences. Thus, they deprive themselves of some
of the richness of life and of access to feelings as a source of information that enhances the
significance of important events.
OSD cases

 a perfectionistic computer programmer worked diligently at her job, but with little
satisfaction from the work. She was under pressure at work due to late completion of tasks,
and generally isolated from others because of working late into the evening and on
weekends, trying to get work done according to her “standards.” Her compulsive personality
traits had previously been rewarded in school, as teachers gave her the best grades, the most
attention, and the highest awards for outstanding performance based on her neat, perfect
work.

 Another patient, a 66-year-old military veteran with both obsessive–compulsive and

dependent personality disorders, stated, “The best time of my life was in the army. I didn’t
have to worry about what to wear, what to do, where to go, or what to eat.” His rule
orientation and compliance with orders facilitated a successful career in military service but
made civilian adjustment more challenging.