CBT

Title

Change in Obsessive Beliefs as Predictor and Mediator of Symptom Change During Treatment of Obsessive-Compulsive Disorder – A Process-Outcome Study

Authors

  • Alice Diedrich

  • Philipp Sckopke

  • Caroline Schwartz

  • Sandra Schlegl

  • Bernhard Osen

  • Christian Stierle

  • Ulrich Voderholzer

Abstract

  • Background: Cognitive models suggest changes in obsessive beliefs are crucial in treating obsessive-compulsive disorder (OCD).

  • Aim: To test if changes in obsessive beliefs predict treatment outcomes and mediate symptom changes.

  • Methods: 71 inpatients with OCD assessed using:

    • Yale-Brown Obsessive-Compulsive Scale (Y-BOCS)

    • Obsessive Beliefs Questionnaire (OBQ)

    • Beck Depression Inventory-II (BDI-II)

  • Results: Changes in beliefs predicted symptoms at discharge, mediating symptom changes over treatment.

  • Conclusions: Reducing obsessive beliefs may improve CBT approaches in inpatient settings.

Background

Definition of OCD

  • OCD is characterized by repetitive thoughts and compulsive behaviors aimed at reducing anxiety and fear.

  • Classified in ICD-10 into three subtypes:

    • Predominantly obsessional thoughts

    • Predominantly compulsive acts

    • Mixed types

Prevalence and Impact

  • Significant and chronic mental health issue, often comorbid, leading to reduced quality of life and functional impairment.

  • 10th leading cause of disability worldwide.

Treatment

  • Recommended Treatments:

    • Cognitive Behavioral Therapy (CBT)

    • Exposure and Response Prevention (ERP)

    • Selective Serotonin Reuptake Inhibitors (SSRIs)

  • Despite effectiveness, 30-50% do not significantly benefit from standard CBT.

Predictors and Mediators in OCD Treatment

Role of Dysfunctional Beliefs

  • Dysfunctional beliefs lead to negative appraisals of intrusive thoughts, driving compulsive behaviors to alleviate distress.

  • Identified belief domains (OCCWG):

    • Inflated sense of personal responsibility

    • Need for certainty

    • Perfectionism

    • Threat estimation

    • Importance of thoughts

    • Need to control thoughts

Hypothesis

  • Initial levels and changes in obsessive beliefs impact treatment outcomes.

Study Design

Participants

  • N = 156 admitted patients, reduced to N = 71 for analysis post-exclusions.

  • Inclusion Criteria:

    • Fluent in German

    • Aged 18-65

    • Meet DSM-IV criteria for OCD

  • Exclusions for high suicide risk and severe medical conditions.

Methodology

  • Assessments at treatment intake, six weeks, and discharge.

  • Multimodal inpatient treatment included:

    • Individual and group therapy

    • Psychoeducation

    • Individualized case formulation

    • In vivo ERP

Measures

Y-BOCS

  • Measures OCD symptom severity with good reliability (Cronbach’s α = .79 - .93).

BDI-II

  • Measures depressive symptoms with strong validity and reliability.

OBQ

  • 44-item measure of obsessive beliefs with demonstrated internal consistency (Cronbach’s α = .92 - .93).

Data Analysis

Analytical Techniques

  • Hierarchical regression analyses with changes in beliefs entered in model.

  • Mediation analysis using Baron and Kenny criteria:

    1. Predictor correlates with mediator.

    2. Predictor correlates with criterion.

    3. Mediator correlates with criterion when controlling for predictor.

    4. Predictor's correlation with criterion weakened when mediator controlled.

Results

Regression Findings

  • Changes in global obsessive beliefs significantly predicted discharge outcomes (R² = 0.06).

Mediation Findings

  • Significant paths indicating changes in beliefs reduced OCD symptoms during treatment (partial mediation confirmed by Sobel’s test).

Discussion

Conclusions from Findings

  • Changes in obsessive beliefs are significant for treatment outcomes in OCD.

  • Changes in the belief domains of importance and need to control are crucial predictors.

  • Clinical implication suggests that focusing on obsessive beliefs may enhance treatment effectiveness, especially for patients resistant to standard treatments.

Limitations

  • Inability to isolate the effects of specific treatment elements due to a lack of control groups.

  • Future studies should explore the precise contributions of treatment components in larger, controlled trials.

Recommendations for Future Research

  • Investigate the relationship between OCD subtype and belief domains.

  • Determine the effectiveness of cognitive versus behavioral interventions on obsessive beliefs.

Abbreviations

  • BDI-II: Beck Depression Inventory-II

  • CBT: Cognitive Behavioral Therapy

  • DSM-IV: Diagnostic and Statistical Manual of Mental Disorders - IV

  • ERP: Exposure and Response Prevention

  • ICD-10: International Classification of Diseases - 10

  • OBQ: Obsessive Beliefs Questionnaire

  • OCCWG: Obsessive-Compulsive Cognitions Working Group

  • OCD: Obsessive-Compulsive Disorder

  • Y-BOCS: Yale-Brown Obsessive-Compulsive Scale