Part 7. Pathogenic beliefs

To the list of common pathogens—like bacteria, viruses, and fungi—we must add another: cognitions. I define a pathogenic belief—or cognogen for short—as a belief that contributes to psychological or physical pathology.

Cognopathology

Each distinct psychopathology has fairly characteristic upstream cognogens. Cognitive specificity refers to causative links between specific cognogens and their specific psychopathologies. Here are some examples:

COGNOGEN*	COGNOTYPE	PSYCHOPATHOLOGY
I can’t cope with attacks away from home	Agoraphobogenic	Agoraphobia
I can never be too thin	Anorexogenic	Anorexia nervosa
It’s hopeless	Depressogenic	Depression
I can’t cope	Anxiogenic	Generalized anxiety disorder
I can’t cope at all if I don’t sleep well	Insomnogenic	Insomnia
A panic attack could kill me	Panicogenic	Panic disorder
I must push away these intrusive images	Obsessogenic	Obsessive compulsive disorder
All dogs are very dangerous	Phobogenic	Simple phobia
If people knew me, they’d reject me	Sociophobogenic	Social anxiety disorder
I’m a burden to everyone	Suicidogenic	Suicidality

^*Most patients with a given diagnosis have more than 1 cognogen.

Identifying cognogens

The 3 basic methods for identifying cognogens are listening, asking, and guessing.

Listening

Pt: I’ve gotta make up for lost time. (Manicogenic cognogen)

Pt: I’m the fattest and ugliest ever. (Body dysmorphogenic cognogen)

Pt: There’s no such thing as too many tests. (Hypochondrogenic cognogen)

Asking

Dr: What was going through your mind before you picked up the razor?

Pt: I was scared the empty feeling would never end. (Borderline personality disorder cognogen)

Dr: What were you thinking before you punched him?

Pt: Doc, life is dog-eat-dog …. You’ve gotta hit them or they’ll hit you. (Antisocial cognogen)

Dr: What were you thinking just before you used?

Pt: A little bit can’t hurt. (Substance abuse cognogen)

Guessing (“empathic conjectures”)

Dr: [To the truant child] Billy, are you worried you’ll never make friends at your new school? (School-refusal cognogen)

Dr: [To the angry patient] Were you feeling you had to settle the score right there and then? (Intermittent explosive disorder cognogen)

Dr: [To the tearful widow] Jan, are you frightened that you’ll never find happiness again now that Pete is gone? (Complicated grief cognogen)

These methods are admittedly inexact. Unfortunately, precision in assessing almost every posited mediator of psychopathology remains a serious challenge for psychiatry. Biological approaches are, if anything, blinder than cognitive approaches, with no tools whatsoever for measuring putative mediators in the clinical setting—FPs continue to await psychiatry’s neurotransmitter laboratory tests.

Tips

1. In the real world it is neither practical nor desirable to treat all cognogens. Some are of low pathogenicity, and the severity of symptoms must be the guide.

2. Efforts to identify the most virulent cognogen are to be encouraged—to a point. In many cases the sweetest spot is simply not knowable—“close enough” will do.

3. Cognogens rarely work alone. If you’ve identified one, odds are its brother, uncle, and second cousin are lurking around, and they should be treated as well.

4. Although cognogens are often treated with “cognitive restructuring tools” (ie, persuasion), in many situations other interventions (eg, medications) are preferred.

5. The extent to which one charts cognogens varies with the context. Although orthodox cognitive behavioural therapy necessitates compulsive documentation, if you predict only 5 to 6 loosely structured 20-minute sessions over a few months, much rougher documentation (eg, half a dozen cognogens recorded) is more appropriate. If the “therapy” is likely only a single session (eg, for noncompliance), then any cognogen documentation might be a relatively poor use of resources.

The cognogen concept opens the door to more effective mental health interventions. Cognogen assessment should be a part of many clinical encounters.