A client obsesses about catching AIDS. He’s consumed with avoiding contact with anyone and anything that can even remotely ‘give me AIDS’. When doubts arise in his mind, as they do when he leaves his apartment, he repeatedly washes his hands. He purchases at-home AIDS tests at various pharmacies nearly every day, performs the tests and anxiously waits for the results. When he receives the results in the mail, he breathes a sigh of relief. 

Until the worries start again.

Western psychological tradition has two approaches to obsessions. Simply put: what’s the cart and what’s the horse. Is the target worry, getting AIDS, the horse and from that emerge the obsessions and compulsions. Or is the obsessive worried occupation the horse, and the target worry, for instance, getting AIDS, which becomes the cart. The DSM V takes the second approach. It makes little difference what the client worries about; all that’s required is that he worries and that worry gives rise to compulsive behaviors. (You can read the diagnostic criteria here.)

This approach however was not always the case nor is it universal to this day. Researchers often group manifestations of OCD by target worries:

Concerns about germs and contamination

Concerns about being responsible for harm injury of self or others

Concerns about bad luck

Concerns about unacceptable thoughts

Concerns about symmetry, completeness, and the demand that things to be “just right” 

For us, as cognitive therapists, both dimensions are important. The target worry, whether it’s about illness or symmetry, usually generates too much power to ignore. That’s why tuning into the client’s self talk and implicit cognition is important: we want to get the beliefs, assumptions, expectations, and fears out onto the table so that we can reduce their valence.

Still simply helping the client dispute his own beliefs is not enough. We must also focus on the loop of obsessive thought. 

So stay tuned!