Mediating Mechanisms in Cognitive Behavioral Therapy for Childhood OCD: The Role of Dysfunctional Beliefs

Reframing cognitions is assumed to play an important role in treatment for obsessive-compulsive disorder (OCD). However, there hardly is any empirical support for this assumption, especially for children. The aim of this study was to examine if changing dysfunctional beliefs is a mediating mechanism of cognitive behavioral therapy (CBT) for childhood OCD. Fifty-eight children (8-18 years) with OCD received CBT. Dysfunctional beliefs (OBQ-CV) and OCD severity (CY-BOCS) were measured pre-treatment, mid-treatment, post-treatment, and at 16-week follow-up. Results showed that OCD severity and dysfunctional beliefs decreased during CBT. Changes in severity predicted changes in beliefs within the same time interval. Our results did not support the hypothesis that changing dysfunctional beliefs mediates treatment effect. Future studies are needed to replicate these findings and shed more light on the role of explicit and implicit cognitions in treatment for childhood OCD.

What Drives OCD Symptom Change During CBT Treatment? Temporal Relationships Among Obsessions and Compulsions

Cognitive behavior therapy (CBT) is an effective treatment for obsessive-compulsive disorder (OCD). However, less is known about how obsessions and compulsions change during treatment, either in tandem, sequentially, or independently. The current study used latent difference score analysis to show path-analytic dynamic modeling of OCD symptom change during CBT. Four competing models of the temporal relationship between obsessions and compulsions were examined: no coupling (obsessions and compulsions are not dynamically related), goal directed (obsessions lead to subsequent changes in compulsions), habit driven (compulsions lead to subsequent changes in obsessions), and reciprocal. Treatment seeking participants (N = 84) with a principal diagnosis of OCD completed 12 weeks of CBT group therapy and completed measures assessing obsession and compulsion severity at pretreatment, Sessions 4 and 8, and end of treatment. Bivariate results supported the goal directed traditional CBT model, where obsession scores are temporally associated with subsequent changes in compulsion scores. These results have implications for theoretical and treatment modelling of obsessions and compulsions in OCD treatment.

Testing the Mediating Effects of Obsessive Beliefs in Internet-Based Cognitive Behaviour Therapy for Obsessive-Compulsive Disorder: Results from a Randomized Controlled Trial

Although cognitive interventions for obsessive-compulsive disorder (OCD) have been tested in randomized trials, there are few trials that have tested the specific mechanisms of cognitive interventions, i.e. how they achieve their effects. In this study, we aimed to investigate the mediating effects of a short cognitive intervention in the treatment of OCD and used data from a recently conducted randomized controlled trial where 101 participants were allocated to either Internet-based CBT (ICBT) or to a control condition. Obsessive beliefs were measured at pre-treatment, at the time they had received the cognitive intervention, and also at post-treatment. Weekly OCD symptoms were measured throughout the 10 weeks of treatment. We hypothesized that (1) the ICBT group would have greater reductions in obsessive beliefs (controlling for change in OCD symptoms) after completing the cognitive intervention, and that (2) this reduction would, in turn, predict greater OCD symptom reduction throughout the rest of the treatment period. Contrary to our expectations, the longitudinal mediation analysis indicated that (1) being randomized to ICBT actually increased the degree of obsessive beliefs after receiving the cognitive intervention at weeks 1-3, and (2) increase in obsessive beliefs predicted better outcome later in treatment. However, when repeating the analysis using cross-sectional data at post-treatment, the results were in line with the initial hypotheses. Results were replicated when the control condition received ICBT. We conclude that, although obsessive beliefs were significantly reduced at post-treatment for the ICBT group, early increase rather than decrease in obsessive beliefs predicted favourable outcome.

KEY PRACTITIONER MESSAGE

This study investigated the impact of cognitive interventions on obsessive beliefs for patients with obsessive-compulsive disorder. Results showed that a sudden increase in obsessive beliefs is not an indicator of worse treatment response. On the contrary, it is more likely that the patient is better off when having this sudden increase. Clinicians should not be alarmed if the patient has a sudden increase in obsessive beliefs, but we do recommend the clinician to investigate the reasons for this further.

Acceptance and commitment therapy as a treatment for problematic internet pornography viewing

Despite the prevalence of problematic Internet pornography viewing and the breadth of intervention approaches to potentially address it, no studies to address this problem have been reported to date. An emerging treatment approach, Acceptance and Commitment Therapy (ACT), holds promise as a treatment for Internet pornography viewing because of its focus on processes hypothesized to underlie this maladaptive behavior. In the first experiment on the treatment of problematic Internet pornography viewing, 6 adult males who reported that their Internet pornography viewing was affecting their quality of life were treated in eight 1.5-hour sessions of ACT for problematic pornography viewing. The effects of the intervention were assessed in a multiple-baseline-across-participants design with time viewing pornography as the dependent variable. Treatment resulted in an 85% reduction in viewing at posttreatment with results being maintained at 3-month follow-up (83% reduction). Increases were seen on measures of quality of life, and reductions were seen on measures of OCD and scrupulosity. Weekly measures of ACT-consistent processes showed reductions that corresponded with reductions in viewing. Large reductions were seen on a measure of psychological flexibility, and minor reductions were seen on measures of thought-action fusion and thought control. Overall, results suggest the promise of ACT as a treatment for problematic Internet pornography viewing and the value of future randomized trials of this approach.

Dysfunctional beliefs in the process of change of cognitive treatment in obsessive compulsive checkers

Cognitive behaviour therapy (CBT) is considered to be effective in the reduction of obsessive compulsive symptoms. However, questions remain as to how CBT works. Cognitive-behavioural models postulate that negative appraisals of intrusive thoughts and dysfunctional beliefs that give rise to them underlie the development and maintenance of obsessive-compulsive disorder (OCD). The current study aimed to study this hypothesis by investigating the processes of change over the course of cognitive treatment for OCD. Furthermore, a new theoretical approach and method for studying processes of change was presented. The participants were seven patients suffering from OCD with predominantly checking symptoms. Process variables (beliefs, anxiety and compulsions) were measured using idiosyncratic diaries and were analysed on an intra- and inter-individual level using dynamic systems methods. Results showed significant decreases in credibility of dysfunctional beliefs in six out of the seven participants, which is in line with the cognitive-behavioural model. Associations between process variables were in general medium to high. However, the actual patterns of change showed important intra- and interpersonal differences. Results indicated that different paths can lead to clinical recovery, and it was concluded that process studies that focus on individual trajectories of change can contribute to our understanding of OCD and its treatment. Furthermore, dynamic systems methods provide insight into intra-individual processes and shed a new light on variability.

Processes of change in cognitive-behavioural treatment of obsessive-compulsive disorder: Current status and some future directions

The present paper discusses theoretical and methodological issues involved in the processes of change in cognitive-behavioural treatment (CBT) of obsessive-compulsive disorder (OCD). Treatment outcome studies showed that CBT is effective in reducing obsessive-compulsive symptoms. However, why and how CBT works cannot be corroborated by comparing pre- and post-assessment. Recently, there has been a resurgence of interest in theory driven process studies. By showing patterns of change over time, process studies can contribute to our insight into the actual mechanisms of change during treatment. We review process research in the field of OCD and discuss methodological issues involved in process studies for this particular disorder. It is concluded that studying the processes of change harbours promising possibilities for bridging the gap between theory and clinical practice.

Evaluation of an Inference‐Based Approach to Treating Obsessive‐Compulsive Disorder

This study evaluated an inference-based approach (IBA) to the treatment of obsessive-compulsive disorder (OCD) by comparing its efficacy with a treatment based on the cognitive appraisal model (CAM) and exposure and response prevention (ERP). IBA considers initial intrusions in OCD (e.g. "Maybe the door is open", "My hands could be dirty") as idiosyncratic inferences about possible states of affairs arrived at through inductive reasoning. In IBA such primary inferences represent the starting point of obsessional doubt, and the reasoning maintaining the doubt forms the focus for therapy. This is unlike CAM, which regards appraisals of intrusions as the maintaining factors in OCD. Fifty-four OCD participants, of whom 44 completed, were randomly allocated to CAM, ERP or IBA. After 20 weeks of treatment all groups showed a significant reduction in scores on the Yale-Brown Obsessive Compulsive Scale (Y-BOCS) and the Padua Inventory. Participants with high levels of obsessional conviction showed greater benefit from IBA than CAM. Appraisals of intrusions changed in all treatment conditions. Strength of primary inference was not correlated with symptom measures except in the case of strong obsessional conviction. Strength of primary inference correlated significantly with the Y-BOCS insight item. Treatment matching for high and low conviction levels to IBA and CAM, respectively, may optimize therapy outcome.

Seeing White Bears That Are Not There: Inference Processes in Obsessions

Meta-cognition refers to the notion of thoughts about one’s own thoughts and has been defined as knowledge and cognition about cognitive phenomena (Flavell, 1979). In recent years, meta-cognitive models have provided accounts of the maintenance of anxiety disorders (e.g., Wells, 2000). Meta-cognitive models would argue that the thoughts about the appearance and utility of otherwise normal thoughts generate anxiety. In this article we apply a meta-cognitive approach to understanding obsessions but, rather than thoughts about thoughts, we suggest that the ruminations in obsessive-compulsive disorder (OCD) without overt compulsions result largely from thoughts about thoughts that do not actually occur. Persons with obsessions thinks they might have or might have had the thoughts, and through a meta-cognitive process termed “inferential confusion,” confuse these imagined thoughts with actual thoughts. This account would explain the repetitive, compulsive yet ego-dystonic nature of obsessions. The justification, provided by patients with OCD, for treating imaginary thoughts as actual thoughts appears to be an imaginary narrative, which produces and maintains the obsessional preoccupation, and seems imposed on reality by a distorted inductive reasoning process.