Improving outcomes for obsessive compulsive disorder

Stages in developing a new psychological treatment

1. is there a need for a new/better/more effective treatment

2. is there a coherent theory that underpins the treatment

3. stages of treatment evaluation

obsessions

Recurrent & persistent thoughts, images or   urges  that are experienced as intrusive and   unwanted and cause marked anxiety or distress.

compulsions

Repetitive behaviours (e.g. hand washing,   checking) or mental acts (e.g. praying, counting)   that the person feels driven to perform in   response to an obsession to reduce distress or   preventing some dreaded event or situation.

current treatments for OCD- are they effective?

• CBT or ERP - recommended psychological approaches for OCD (NICE, 2006)

• Multiple meta-analyses conclude that CBT or ERP are effective interventions

BUT

• Meta-analyses focused on statistical significance (effect sizes) not the clinical significance

• We need to know if psychological interventions produce clinically meaningful change- if the sample is large you will get statistical significance regardless

• we need to know what magnitude of change is required to be effective

clinical significance analysis of Psychological Interventions for OCD

• To determine the efficacy treatment for OCD

• Applied Jacobson criteria to individual patient data on the “Gold Standard” outcome measure i.e. Yale Brown Obsessive Compulsive Scale (Y-BOCS)

• Found a 1 in 5 chance of full recovery/ 60% continue to experience symptoms

• Suggests a need for better treatments

Yale Brown Obsessive Compulsive Scale (Y-BOCS)

• Two fold criterion for recovery on Y-BOCS

a) Statistically significant improvement following Tx

b) Post-treatment score closer to a functional rather than dysfunctional population

• Asymptomatic criterion: 7 points or less on Y-BOCS

other issues to consider when interpreting results

• Therapist competency

• Inclusion/exclusion criteria of the RCTs

• Treatment Adherence

• 15% of eligible people refused

• 16% of treatment starters dropped out

metacognitive model of OCD- Wells, 1997

OCD is maintained by metacognitive beliefs

Not the thoughts themselves, but beliefs about thoughts produce distress and compulsions.

1. Trigger: Something triggers an intrusive thought/mental image/urge (did I lock the door)

2. Activation of Fusion Metacognitive Beliefs : “Thought-fusion” beliefs get activated (Not preventing harm makes me responsible)

3. Appraisal of Intrusion: The intrusive thought is seen as dangerous, meaningful, and important causing anxiety, guilt or disgust

4. Beliefs About Rituals: The person develops beliefs such as: If I check repeatedly, I can prevent danger.” (justifying compulsions)

5. Behaviour (Compulsions): Rituals and safety behaviours are used to feel safe

Compulsions → temporary relief → reinforces OCD cycle.

Emotion + thoughts + compulsions = feedback loop

metacognitive beliefs about obsessions 

• Thought-Action Fusion (TAF): “Imaging a knife in his chest  means I am going   to stab my psychologist”

• Thought-Event Fusion (TEF): “Thinking that I committed a murder means I did”

• Thought-Object Fusion (TOF): “Negative feelings can be passed into my possessions

metacognitive beliefs about rituals

• “My rituals give me peace of mind by getting the bad thoughts out of my head”

• “I must wash until I remove the thoughts from my mind and then I feel calmer”

• “ Checking that the door is locked stops me worrying”

• “ Rituals prevent anxiety from overwhelming me”

Belief domains and OCD symptoms- Myers, Fisher, & Wells (2008)

• Cognitive Beliefs

  • Perfectionism / Certainty

  • Responsibility

• Metacognitive Beliefs

  • Importance and control of thoughts

• General Constructs

  • Worry

  • Overestimation of threat

• Found cognitive domains are non-significant

• suggest metacognitive beliefs are more important- these prospectively and independently predict OCD symptoms

• BUT, cross-sectional study so cannot suggest causality

Modifying Metacognitive Beliefs in OCD: An Experimental Study- Fisher & Wells, 2005

• Compare the effects of brief exposure presented with a metacognitive rationale (ERP-E) with the effects of brief ERP presented with a habituation rationale (ERP)

• Dependent variables (DVs)

  i) Anxiety/distress (1-10)

  ii) Strength of metacognitive belief (1-10)

  iii) Urge to neutralise/perform rituals (1-10)

• participants 8 consecutive referrals with diagnosis of OCD for at least 1yr

• findings: 

  • metacognitive rationale produced greater changes than habituation rationale in fusion related beliefs, the urge to neutralise and levels of anxiety

  • Prolonged exposure is not necessary to modify the main symptoms of OCD.

  • Thus modification of metacognitive beliefs may result in a more time efficient and effective treatment.