Group Cognitive-Behavior Therapy or Group Metacognitive Therapy for Obsessive-Compulsive Disorder? Benchmarking and Comparative Effectiveness in a Routine Clinical Service

Metacognitive therapy versus exposure and response prevention for obsessive-compulsive disorder - A non-inferiority randomized controlled trial

OBJECTIVE

Exposure with response prevention (ERP) is the first-line treatment for obsessive-compulsive disorder (OCD). However, refusals, dropouts and the required high time and logistic effort constitute barriers to the use of ERP. In a non-inferiority randomized controlled trial, we compared metacognitive therapy (MCT) to exposure with response prevention (ERP) as treatments for OCD.

METHOD

74 outpatients received 12 weekly sessions of either manualized MCT or ERP, with primary outcomes assessed by blinded assessors using the Yale-Brown Obsessive Compulsive Scale (Y-BOCS) at pre-treatment, mid-treatment, post-treatment, and 6-month follow-up. Secondary outcomes included measures of depression and anxiety. Non-inferiority margin was specified at no less than d = 0.38 below the improvement reached by ERP, corresponding to a difference of about 3 points on the Y-BOCS.

RESULTS

Drop-out rates were low (<14%) and similar in both groups. Linear models indicated non-inferiority of MCT to ERP at post-treatment, but not at 6-month follow-up. While both groups showed comparable Y-BOCS improvements, the MCT group demonstrated a significantly greater reduction in state anxiety scores at post-treatment and follow-up.

CONCLUSIONS

Overall, MCT was not inferior to ERP, especially at post-treatment, suggesting it could be a treatment alternative. However, further research is needed to explore differential treatment indications.

The relationship between sleep disturbance and obsessive- compulsive symptoms: the mediation of repetitive negative thinking and the moderation of experiential avoidance

Background

Studies have found that sleep disturbance is associated with obsessive-compulsive symptoms. This study aimed to elaborate on the mediating and moderating mechanisms between these two variables. We hypothesized that repetitive negative thinking plays a mediating role in the relationship between sleep disturbance and obsessive-compulsive symptoms, and experiential avoidance plays a moderating role.

Method

This study included 639 Chinese adults. A questionnaire survey was used to assess sleep quality, obsessive-compulsive symptoms, experiential avoidance, repetitive negative thinking, and depression symptoms. A moderated mediation model was established.

Results

After controlling for depressive symptoms, repetitive negative thinking partially mediated the positive correlation between sleep disturbance and obsessive-compulsive symptoms. This indirect relationship was significant in individuals with lower experiential avoidance levels. Particularly, the relationship between sleep disturbance and repetitive negative thinking was significant among individuals with lower experiential avoidance levels, but not among individuals with higher experiential avoidance levels.

Conclusion

This study demonstrated that repetitive negative thinking partially mediated the impact of sleep disturbance on obsessive-compulsive symptoms. The findings suggest that when providing support to individuals with sleep disturbance and obsessive-compulsive symptoms, assessing their level of experiential avoidance is necessary for performing targeted interventions. Individuals with low experiential avoidance may benefit from a clinical intervention targeting repetitive negative thinking to improve sleep quality and obsessive-compulsive symptoms.

Psychotherapies and digital interventions for OCD in adults: What do we know, what do we need still to explore?

BACKGROUND

Despite significant advances in the understanding and treatment of obsessive compulsive disorder (OCD), current treatment options are limited in terms of efficacy for symptom remission. Thus, assessing the potential role of iterative or alternate psychotherapies is important. Also, the potential role of digital technologies to enhance the accessibility of these therapies, should not be underestimated. We also need to embrace the idea of a more personalized treatment choice, being cognisant of clinical, genetic and neuroimaging predictors of treatment response.

PROCEDURES

Non-systematic review of current literature on emerging psychological and digital therapies for OCD, as well as of potential biomarkers of treatment response.

FINDINGS

A number of 'third wave' therapies (e.g., Acceptance and Commitment Therapy, Mindfulness-Based Cognitive Therapy) have an emerging and encouraging evidence base in OCD. Other approaches entail employment of elements of other psychotherapies such as Dialectical Behaviour Therapy; or trauma-focussed therapies such as Eye Movement Desensitisation and Reprocessing, and Imagery Rescripting and Narrative Therapy. Further strategies include Danger Ideation Reduction Therapy and Habit Reversal. For these latter approaches, large-scale randomised controlled trials are largely lacking, and the precise role of these therapies in treating people with OCD, remains to be clarified. A concentrated 4-day program (the Bergen program) has shown promising short- and long-term results. Exercise, music, and art therapy have not been adequately tested in people with OCD, but may have an adjunctive role. Digital technologies are being actively investigated for enhancing reach and efficacy of psychological therapies for OCD. Biomarkers, including genetic and neuroimaging, are starting to point to a future with more 'personalised medicine informed' treatment strategizing for OCD.

CONCLUSIONS

There are a number of potential psychological options for the treatment of people with OCD who do not respond adequately to exposure/response prevention or cognitive behaviour therapy. Adjunctive exercise, music, and art therapy might be useful, albeit the evidence base for these is very small. Consideration should be given to different ways of delivering such interventions, including group-based, concentrated, inpatient, or with outreach, where appropriate. Digital technologies are an emerging field with a number of potential applications for aiding the treatment of OCD. Biomarkers for treatment response determination have much potential capacity and deserve further empirical testing.

Efficacy of group cognitive-behavioral therapy in adolescents with obsessive compulsive disorder: a systematic review and meta-analysis

OBJECTIVE

To evaluate the effectiveness of group cognitive-behavioral therapy (GCBT) for the treatment of adolescents with obsessive compulsive disorder (OCD).

METHODS

This review was registered in PROSPERO under number CRD42020158475. Five databases (PubMed, Virtual Health Library, Web of Science, Scopus, and PsycINFO) were searched. After applying the inclusion and exclusion criteria, 13 studies were analyzed in the qualitative synthesis (i.e., systematic review) and eight in the quantitative synthesis (i.e., meta-analysis). For the latter, fixed-effect modeling was used to assess the primary outcome (i.e., OCD symptoms).

RESULTS

The main findings suggest that GCBT is effective in reducing the symptoms of OCD in adolescents (d = -1.32). However, these results must be interpreted with caution, since all of the included studies showed some bias in their design.

CONCLUSIONS

GCBT is effective in reducing OCD symptoms in adolescents.

Group Metacognitive Therapy for Obsessive-Compulsive Disorder in a Routine Clinical Setting: An Open Trial

Obsessive-compulsive disorder (OCD) is often a chronic disorder characterised by uncontrollable, reoccurring thoughts (obsessions), and/or behaviours (compulsions). Accumulating evidence suggests that metacognitive beliefs may underlie many of the processes implicated in the formation and perpetuation of OCD. Metacognitive therapy (MCT) for OCD aims to modify these maladaptive metacognitive beliefs and processes to treat this debilitating disorder. The current study examines the outcome of a pilot trial of MCT for OCD in 26 (17 females; 9 males) adults (18–64 years) referred to a specialist outpatient service. Results were promising, with significant decreases in OCD and depression symptoms, which were maintained at the 3-month follow-up. The improvement in Yale-Brown Obsessive-Compulsive Scale scores between pre-treatment and follow-up in the completer sample (n=22) was large (d=1.29), and comparable to outcomes of well-established treatments. These encouraging results add to early empirical support for the effectiveness of group MCT as an OCD treatment alternative, as well as reinforcing the role of metacognitions contributing to this disorder.

The Scope of Metacognitive Therapy in the Treatment of Psychiatric Disorders

Metacognitive therapy (MCT) is a novel and promising transdiagnostic psychotherapy intervention based on the Self-Regulatory Executive Function model of conceptualizing emotional disorders. It was developed by Adrian Wells in 2009. Its therapeutic response occurs by reducing dysfunctional metacognitive beliefs regarding worry and rumination, often seen in patients with psychiatric disorders. Since its inception, it has been increasingly applied to a wide spectrum of psychiatric illnesses, but mainly focusing on mood and anxiety disorders. To our knowledge, no study has detailed its existing therapeutic scope in psychiatry. In this comprehensive narrative review, we describe the various psychiatric illnesses in which MCT has been used, the advantages of MCT, and the limitations of the MCT research. In addition, we propose some solutions to systematically examine its place in psychiatry. We encountered its potential role in treating trauma and stress-related disorders, obsessive-compulsive spectrum disorders, personality disorders, psychotic disorders, substance use disorders, and sexual disorders.

Metacognitive Change During Exposure and Metacognitive Therapy in Obsessive-Compulsive Disorder

Metacognitive therapy (MCT) has been shown to be a promising treatment approach for obsessive-compulsive disorder (OCD). The changeability of metacognitions by (metacognitive) treatment and its relevance to treatment outcome is, however, still unclear. The current study investigates, (1) if treatment with MCT or exposure and response prevention (ERP) in a randomized-controlled pilot trial (n = 24 patients with OCD) changes OCD-specific metacognitions of thought fusion beliefs, beliefs about rituals and stop signals, and (2) if these changes are relevant for the treatment outcome in terms of patient- and therapist-rated OCD symptoms. ANOVA with pretest, posttest and follow-up scores could show that all three metacognitions significantly decreased during both treatments. Regarding thought fusion beliefs, a significant interaction effect indicated a higher decrease after MCT than ERP treatment. In hierarchical regression analyses, changes in stop signals from pre- to post-treatment significantly predicted patient-rating OCD symptoms at post-treatment and follow-up at 3 months after treatment. These changes were even predictive of post-treatment outcome after controlling for general metacognitions and dysfunctional cognitive beliefs. These findings support the assumption that metacognitions can change during both treatments and that changes in stop signals might be relevant for the treatment outcome on the symptom level in OCD.

Dysfunctional Metacognitive Beliefs in Patients With Obsessive-Compulsive Disorder and Pattern of Their Changes Following a 3-Month Treatment

Introduction: Metacognitions are considered to be crucial factors for the development and maintenance of pathologic anxiety. The present case-control study aimed to examine how metacognitive beliefs are associated with the diagnostic status and subtypes of obsessive-compulsive disorder (OCD). In addition, we examined the pattern of changes in metacognitive beliefs after a 3-month pharmacological treatment in patients with OCD. Methods: A total of 562 cases with OCD and 236 healthy controls were assessed with the Metacognitions Questionnaire (MCQ) and various measures of OC symptom severity. Multivariate analyses of variance (MANOVAs) with covariates were conducted to explore the relationship between subdimensions of metacognitive beliefs and OCD disease status. In addition, for the OCD patients, Pearson's correlation was performed between baseline MCQ subdimensions and Obsessive-Compulsive Inventory-Revised-Korean subscales (OCI-R-K). Finally, in a subset of drug-free OCD patients (n = 144), the MCQ was reassessed after 3 months of treatment and patterns of changes in subdimensions of the MCQ were examined. Results: Patients with OCD scored significantly higher on the four dimensions of the MCQ. There were significant associations between all MCQ subdimensions and OCI-R-K subscales. In the repeated-measure MANOVA, a significant group (non-responders vs. responders)-by-time interaction effect was found only for the negative beliefs about the uncontrollability and danger of worry (NB) subdimension (F = 10.75; η² = 0.072; p = 0.001). Conclusion: The presence of dysfunctional metacognitive beliefs in OCD subjects and their association with OCD characteristics suggest that dysfunctional metacognitions may play a crucial role in the pathophysiology of OCD. Improvement of metacognitive beliefs in the NB dimension may be a clinically meaningful correlate of good treatment response in the pharmacological treatment of OCD.

Metacognitive Training for Obsessive-Compulsive Disorder: a study protocol for a randomized controlled trial

BACKGROUND

A high number of patients with obsessive-compulsive disorder (OCD) do not receive cognitive-behavioral therapy with exposure and response prevention, which is the most effective treatment for OCD. Therefore, Metacognitive Training for OCD (MCT-OCD) was developed, which is a structured group therapy aiming at the modification of dysfunctional (meta-)cognitive biases, beliefs and coping styles. It can be administered by less trained personnel, thus may reach a higher number of patients. An uncontrolled pilot study (MCT-OCD pilot version) provided first evidence that the training is highly accepted by patients; OC symptoms decreased with a high effect size (η2partial = 0.50). The aim of the present study is to address the shortcomings of the pilot study (e.g., no control group) and to assess the efficacy of the revised version of the MCT-OCD in the framework of a randomized controlled trial.

METHODS

Eighty patients with OCD will be recruited. After a blinded assessment at baseline (-t1), patients will be randomly assigned either to the intervention group (MCT-OCD; n = 40) or to a care as usual control group (n = 40). The MCT-OCD aims to enhance patients' metacognitive competence in eight modules by addressing dysfunctional (meta-)cognitive biases and beliefs associated with OCD (e.g., intolerance of uncertainty). After 8 weeks, patients will be invited to a post assessment (t1), and then they will receive a follow-up online questionnaire 3 months following t1 (t2). The primary outcome is the Y-BOCS total score, and the secondary outcomes include the HDRS, OCI-R, OBQ-44, MCQ-30, WHOQOL-BREF, BDI-II, and subjective appraisal ratings of the MCT-OCD. We expect that OC symptoms will decrease more in the intervention group compared with the care as usual control group from -t1 to t1 and that treatment gains will be maintained until t2.

DISCUSSION

The planned study is the first to investigate the MCT-OCD, a promising new treatment, in a randomized controlled trial. The MCT-OCD may help to overcome existing treatment barriers for patients with OCD.

TRIAL REGISTRATION

German Registry for Clinical Studies ( DRKS00013539 ), 22.02.2018.

Establishing the Feasibility of Group Metacognitive Therapy for Anxiety and Depression in Cardiac Rehabilitation: A Single-Blind Randomized Pilot Study

BACKGROUND

Anxiety and depression are common in cardiac rehabilitation (CR) patients. However, CR programs which incorporate psychological techniques achieve modest reductions in emotional distress. More efficacious interventions that can be easily integrated within services are required. A promising alternative to current psychological interventions is metacognitive therapy (MCT). The aim was to evaluate the acceptability and feasibility of delivering Group-MCT to CR patients experiencing symptoms of anxiety and depression.

METHOD AND RESULTS

Fifty-two CR patients with elevated anxiety and/or depression were recruited to a single-blind randomized feasibility trial across three UK National Health Service Trusts and randomized to usual CR or usual CR plus six weekly sessions of group-MCT. Acceptability and feasibility of adding group-MCT to CR was based on recruitment rates, withdrawal, and drop-out by the primary end-point of 4 months; number of MCT and CR sessions attended; completion of follow-up questionnaires; and ability of the outcome measures to discriminate between patients. The study was also used to re-estimate the required sample size for a full-scale trial. We also examined the extent by which non-specialists adhered to the Group-MCT protocol. Group-MCT was found to be feasible and acceptable for CR patients with anxiety and depression. Recruitment and retention of participants was high, and attendance rates at CR were similar for both groups.

CONCLUSION

The results suggest the addition of MCT to CR did not have a negative impact on retention and support a full-scale trial of Group-MCT for cardiac patients.

Breaking the Cybernetic Code: Understanding and Treating the Human Metacognitive Control System to Enhance Mental Health

The self-regulatory executive function (S-REF) model explains the role of strategic processes and metacognition in psychological disorder and was a major influence on the development of metacognitive therapy. The model identifies a universal style of perseverative negative processing termed the cognitive attentional syndrome (CAS), comprised of worry, rumination, and threat monitoring in the development of disorder. The CAS is linked to dysfunctional metacognitions that include beliefs and plans for regulating cognition. In this paper, I extend the theoretical foundations necessary to support further research on mechanisms linking metacognition to cognitive regulation and effective treatment. I propose a metacognitive control system (MCS) of the S-REF that can be usefully distinguished from cognition and is comprised of multiple structures, information, and processes. The MCS monitors and controls activity of the cognitive system and regulates the behavior of neural networks whose activities bias the way cognition is experienced. Metacognitive information involved in the regulation of on-line processing includes metacognitive beliefs, metacognitive procedural commands, and more transient cybernetic code. Separation of the cognitive and metacognitive systems and modeling their relationship presents major implications concerning what should be done in therapy and how it should be done. The paper concludes with an in-depth consideration of methods that strengthen the psychological basis of psychotherapy and aid in understanding and applying metacognitive therapy in particular. Finally, limitations of the model and implications for future research on self-awareness, self-regulation, and metacognition are discussed.

Group Metacognitive Therapy for Generalized Anxiety Disorder: A Pilot Feasibility Trial

Background: Individual metacognitive therapy (MCT) for generalized anxiety disorder (GAD) is well established, but only one study has investigated the effectiveness of Group MCT (g-MCT) for GAD. The aim of the current study was therefore to evaluate the feasibility and effectiveness of g-MCT for GAD within a community mental health setting whilst addressing limitations evident in the previous study.

Methods: The study used an open trial design, and 23 consecutively referred adults with GAD completed 10 sessions (90 min) of g-MCT, delivered by two therapists trained in MCT. Diagnoses were assessed by trained raters using the Anxiety Disorder Interview Schedule-IV. All patients but one had previous psychosocial treatment, and 17 (73.9%) had at least one comorbid axis-I disorder. Self-reported symptoms were assessed using the Penn State Worry Questionnaire, the Generalized Anxiety Disorder-7, and the Patient Health Questionnaire-9 at pre- and post-treatment as well as 3-month follow-up. Feasibility was assessed using rates of patients who declined group treatment in favor of individual treatment, patients not able to attend due to pre-scheduled dates for sessions, and drop-out rate.

Results: Of 32 eligible participants, six patients (19%) declined g-MCT in favor of individual MCT, and three (9%) were unable to attend due to scheduling conflicts. No patients dropped out during treatment, but two patients did not complete the self-report questionnaires at 3-month follow-up. g-MCT was associated with significant reductions in worry, anxiety, depression, metacognitive beliefs, and maladaptive coping. According to the standardized Jacobson criteria for recovery, 65.3% were recovered at post-treatment, whereas 30.4% were improved and 4.3% showed no change. At 3-month follow-up, the recovery rate increased to 78.3%. Moreover, recovery rates were comparable for patients with- and without comorbidity. Number of therapist hours per patient was 6.5 and the treatment has now been implemented as a standard treatment option at the clinic.

Conclusion: g-MCT for GAD is an acceptable treatment which may offer a cost-effective alternative approach to individual MCT. Recovery rates and effect sizes suggested that g-MCT could be just as efficient as individual MCT and cognitive behavioral therapy.