Traditionally, it has been believed that 'neurotic' symptoms are experienced by the patient as egodystonic and that patients recognize the irrational character of their emotions or behaviour. Recent data show that this widely held idea needs to be qualified. The common way of gaining access to someone' beliefs is to ask the person. A number of studies have followed this approach and yielded findings that do not support the hypothesis of egodystonicity of neurotic problems. One could counter that when, for example, an obsessive-compulsive patient claims that she really believes that not washing her hands after turning a doorknob will result in catching a disease, this may be a rationalization. That is, confronted with her own irrational washing behaviour, the formulated belief may be a post hoc explanation intended to justify the behaviour to herself and/or to others. (1.01) However, it is far from obvious that it is socially more desirable to express beliefs that others regard as highly irrational (touching doorknobs results in disease) than to 'admit' that one endorses the view that the behaviour is irrational. (!0.2) Widely held impressions about egodystony, obtained in the consulting room, may be caused by patients denying beliefs that they expect the clinician to find untenable.
Irrational beliefs about the outside world are common in anxiety disorders. Especially interesting are people with monosymptomatic phobia who tend, in contrast to other anxiety patients, not to suffer from comorbid pathology and who present the clearest case of irrational emotions and behaviour in otherwise healthy people. While egodystony in specific phobias is even a diagnostic criterion of DSM-IV ('The person recognizes that the fear is excessive or unreasonable'), systematic questioning using a paper-and-pencil task, without the social pressure of an interviewer, reveals that spider phobics tend to endorse highly irrational beliefs about the dangerousness of spiders. The credibility of these frightening ideas is especially high in the presence of the phobic cue. (102) Social phobics appear to have negative beliefs about their own social performance and about others, whom they believe to be more critical and rejecting than they actually are. ^M0.4and 105) Furthermore, prominent other-centred problem-related convictions are found in patients suffering from borderline personality disorder who tend to believe that other people are malevolent, and will abuse, punish, or abandon the patient when the relationship becomes intimate. (106)
Apart from beliefs about the outside world and others, a number of psychiatric disorders appear to be characterized by problematic beliefs about the self in general or about specific internal events. Generalized beliefs about the self being worthless and vulnerable are found in depression and borderline personality disorder.(106) Panic patients firmly belief that specific benign bodily sensations such as palpitations predict imminent catastrophes (e.g. cardiac infarction). (108) Interestingly, the paroxysmal occurrence of the sensations feared by panic patients is highly prevalent in the general population. (10.9) The crucial difference between such non-clinical and clinical panic is that non-clinical panickers are far less inclined to believe, during the attacks, that they may die from suffocation, have a cardial arrest, lose consciousness, and so on/110) Remarkably, phobics appear to expect similar catastrophic consequences of experiencing fear and related bodily sensations during confrontation with the phobic object/102
Other internal events that can be subject to distorted beliefs are cognitive processes. Examples are the belief, found in many elderly people, that one' memory is failing although objective memory performance is, by all standards, normal. ^..l1) Just as the bodily sensations that panic patients fear are quite common, so are the types of intrusions that obsessive patients report. The content of the clinical intrusions is no different from that of non-clinical intrusions. The latter also circle around themes like sex, aggression, blasphemy, and illness. ^.J.2) What is different, however, is the appraisal of the intrusions. While obsessive-compulsive patients regard them as highly aversive and try to resist them,(1l2,ll3) healthy people do not. Relatedly, negative intrusions are common after loss and trauma. Post-trauma intrusions can be interpreted as normal and adaptive responses to extremely aversive events or, alternatively, as indications that one is losing control, that one can never concentrate or enjoy life anymore, etc. Victims suffering from post-traumatic stress disorder report far more negative ideas about intrusions than do victims without post-traumatic stress disorder/1.14) Worry is a hallmark of generalized anxiety disorder, in which patients appear to hold a wide range of beliefs about the pros and cons of worrying (so called 'meta-cognitions') which are hypothesized to fuel the worry process. (115) Hearing voices, curious as it may sound, is not a pathognomic sign of schizophrenia This phenomenon occurs in approximately 10 per cent of the general population and is related to conditions like sensory deprivation, sleep difficulties, intense imagery, and so on. How people cope with voices might be relevant when considering to what extent hallucinations might develop into pathological phenomena/1.16)
Thus there is good evidence that patients with a variety of disorders maintain problem-related beliefs that are highly unrealistic or dysfunctional. Two questions arise. First, given that there are no formal thought disorders, why do patients not give up such beliefs in the light of disconfirming evidence? Second, are there arguments that these beliefs are causally related to the problems? If so, what are the clinical implications?
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