Efficacy of treatment for obsessive-compulsive disorder

Obsessive-compulsive disorder (OCD) is a severe mental illness characterized by intrusive, repetitive, and bothersome thoughts (ie, obsessions) usually followed by ritualized behavior (ie, compulsions such as excessive hand-washing for fear of transmitting diseases) aimed at neutralizing the obsessive contents.¹ As a consequence of OCD, the majority of patients are confronted with vast economic and social problems; many patients are unable to work, and lack a stable social network. Quality of life is usually very low,^2,3 and comorbid depression is diagnosed in one to two thirds of all patients.³

Effective treatment strategies have been at hand for quite some time now. As a rule of thumb, cognitivebehavioral therapy (CBT) has a success rate of around 80% for those who complete treatment.^4,5 Recent reviews assert^6,7 that its core ingredients, behavioral and cognitive techniques, share roughly similar efficacy. The overall effect size for psychological interventions in adult samples is d=1.24 according to a Cochrane review.⁶ In adolescents, estimates are similar.⁸

However, several words of caution are necessary in view of studies that find less favorable results.^9,10 For example, when dropout rates are considered, response is typically only seen in every second patient.^1,11 While Pinard¹¹ concludes in his editorial introduction on Abramowitz' meta-analysis⁴ that “OCD therapeutic strategies are [ ...] less than satisfactory for the moment,” treatment reality beyond controlled trials, the latter usually being conducted with skilled, trained, and highly motivated therapists, may be even worse. The dropout rate seen under standard clinical conditions is likely to be higher relative to ideal study conditions. For example, a Spanish study¹² reports that of 203 patients (mainly anxiety disorders) seen in a cognitive-behavioral unit 43.8% dropped out mostly at early stages of the intervention.

Treatment gap of OCD: the need for improved interventions

It often takes up to 10 years until OCD patients seek professional help for their problems, and there is a lag of 6 or more years until the diagnosis is correctly determined and appropriate treatment is initiated.^13,14 The rate of untreated cases for OCD is 59.5% (so-called treatment gap) according to a large WHO study¹⁵ However, the few patients receiving psychiatric or psychological help often do not get optimal, evidence-based treatment. A recent study¹⁶ showed that 65% of adult patients with OCD were treated with an SSRI, whereas only 7.5% of the patients received CBT despite its effectiveness.⁷ A recent German study found that less than 50% of all interviewed psychotherapists (CBT and other) performed exposure and response prevention (ERP) mainly owing to lack of experience and insufficient training in this technique.¹⁷ According to patients' reports, the situation is even worse. Approximately 84% of the sample reported that they did not receive exposure and response prevention at all.^18,19

Importantly, treatment success is usually not defined as full symptom remission, but as a symptom decline of 30% to 35% at least on the Yale-Brown ObsessiveCompulsive Scale (Y-BOCS),²⁰ which has led to some criticism, for example by Pinard¹¹ who wrote: “as if reducing rituals from 6 to 4 hours were clinically meaningful.” Others²¹ have noted that outcome criteria are less strict for OCD than for other disorders for which a remission of 50% of symptoms is considered substantial. Thus, many patients remain severely disabled even after a clinically defined successful therapy. Furthermore, modest symptom decline does not necessarily translate into improved quality of life.³

Metacognitive training for OCD (myMCT)

Based on a cognitive tradition of psychotherapy, our group developed a self-help manual called Metacognitive Training for OCD (myMCT).²² Among other cognitive distortions, it deals with the six cognitive biases identified by the Obsessive-Compulsive Working Group^23-26: (i) inflated responsibility, (ii) overimportance of thoughts, (iii) excessive concern about the importance of controlling one's thoughts, (iv) overestimation of threat, (v) intolerance of uncertainty, and (vi) perfectionism (see Appendix) .

Some of its exercises have been derived from a metacognitive training program for schizophrenia first published in 2005.²⁷ The myMCT pursues three overarching aims: (i) knowledge translation/psychoeducation, that is, to teach patients about core features of OCD (ie, obsessions, compulsions, avoidance, and safety behaviors); (ii) help patients to detect cognitive biases, dysfunctional metacognitive beliefs as well as dysfunctional coping strategies that subserve, maintain, or fuel OCD symptoms; (iii) convey new strategies to reduce and cope with OCD symptoms, particularly obsessions.

The program is eclectic and encompasses theories and strategies derived from other “schools,” most notably cognitive-behavioral, metacognitive,²⁸ and to a lesser degree psychoanalytic accounts,²⁹ whose theoretical foundations are not mutually exclusive but may in part reflect different sides of the same coin. To illustrate, inflated responsibility plays a central role for most OCD theories. Whereas cognitive intervention would primarily target the content of the belief, dynamic approaches would ask how far responsibility reflects, for example, reaction formation, that is, overcompensation of latent aggression.³⁰ In a recent study, we indeed found evidence that these seemingly contradictory attitudes - inflated responsibility and high moral standards versus latent aggression and mistrust - coexist in patients.³¹ From Wells' metacognitive standpoint, exaggerated responsibility is an epiphenomenon related to fusion beliefs³²: Patients feel responsible as their thoughts are deemed toxic and potentially harmful to others.

Our self-help manual starts with an introduction which defines core features of OCD symptomatology, demonstrates its most prevalent subtypes, and requests patients to identify their own core problems (obsessions, compulsions, avoidance, safety behavior) and dysfunctional coping strategies (eg, thought suppression, rumination). Then, the aims of the program are explicated. The myMCT consists of 14 sections dealing with prevalent cognitive biases in OCD. These are summarized in the Appendix.

The present study set out to explore the feasibility and effectiveness of the myMCT as a self-help approach for OCD. Although therapist-guided CBT remains the undisputed treatment of choice for OCD, a large group of patients, as mentioned before, does not actively seek professional help and specialized therapy is not widely available. So far, there is scarce evidence for the effectiveness of self-help programs (“bibliotherapy”). Most studies to date involved at least some contact to therapists.³³ In a recent study by Tolin and coworkers,³⁴ patients performed an exposure and response prevention, either self- or therapist-directed. This study demonstrated that bibliotherapy is an effective method, although direct treatment led to more favorable results. In this study, therapist contact was minimal (first session).

To reach patients outside the treatment system, for the present study, participants with OCD were recruited over the Internet for the present study. Assessments were also made online. Half of the patients were allocated to a waitlist group and the other half received the myMCT immediately after participation in the initial assessment. The post assessment was performed 1 month later. We expected myMCT to be superior to the waitlist group, especially for the reduction of obsessions. As exposure and response prevention was not included in the manual at that time (this aspect was incorporated later), a negligible improvement on compulsions was expected. However, in view of poor attention, motivation, and slowness in many patients, we expected that not all patients in the experimental (myMCT) arm would read the manual and perform the exercises.

Methods

Results

Discussion

The present trial asserts that myMCT is a feasible and effective self-help approach to treat patients with OCD. Medium to strong effect sizes in favor of myMCT were obtained for the Y-BOCS and OCI-R total scores. A fine-grained analysis showed that the decline was especially owing to a decrement on the Y-BOCS obsessions and the OCI-R obsessing subscales. Depression also declined significantly for those who read the e-book. Benefits for compulsions were small and nonsignificant (d=.20). Since the initial release we expanded the myMCT manual with a chapter on exposure which will likely positively impact on compulsions.

In retrospect, two thirds of the patients reported a symptom decline due to myMCT and the manual was deemed useful and comprehensive. The overwhelming majority (85%) found the myMCT more useful than other selfhelp books. While these findings are encouraging, they clearly fall behind the response rates obtained in formal clinician-administered psychotherapeutic studies,^5,6 which mirrors prior results on self- versus therapistdirected exposure and response prevention.³⁴ Patients in the myMCT group who refrained from reading the manual had fewer symptoms and possibly less leidensdruck.⁴⁶ Before turning to possible implications, some limitations need to be acknowledged. Firstly, myMCT addresses different cognitive and metacognitive distortions and illness models derived from cognitive therapy (eg, normalizing: demonstrating patients that obsessions are common in the population and not a sign of psychopathology per se⁴⁷), recent basic research on cognitive biases (eg, inflated responsibility, perfectionism), We lls' metacognitive therapy (eg, teaching patients that thoughts are not equivalent to actions and the dysfunctionality of rumination), analytic theorizing (especially latent aggression), and self-developed techniques (eg, association splitting^48,49). Therefore, it is impossible to identify the most potent and efficacious component of the myMCT. We think, however, that some differences, for example between Wells' metacognitive therapy and CBT, have been overemphasized in the past²⁸ and that overlaps exist between CBT and analytic approaches²⁹ as well as between cognitive therapy and behavioral-oriented approaches.⁵⁰ Because some views are compatible and possibly complementary, we felt the need to integrate different concepts into a comprehensive treatment program. The result may be considered messy relative to pure programs. However, from the patients' comments we are left with the impression that for different patients different domains and exercises were helpful in line with a multifactorial illness model of OCD claiming that different etiologies may cause similar symptoms.

Secondly, the data relied on self-report rendering its results preliminary. While we acknowledge that external validation is the gold standard, recent studies have shown the reliability of self-report instruments and the compatibility of results obtained with the Y-BOCS selfreport scale and the conventional expert rating.^44,45 In addition, the validity of internet relative to conventional research has been increasingly demonstrated,^51-54 even with severely impaired groups.^55,56 In line with these findings, the reliability (all scales r>.8) and validity (r=.56 between Y-BOCS and OCI-R) of the instruments were good in the present study.

MyMCT is not aimed to substitute standard psychotherapies but to reach patients unwilling or unable to undergo such therapies. As we have laid out in the introduction, the majority of patients does not receive (competent) help and if so, only at a very late stage. Low-threshold help and knowledge translation is thus extremely important at earlier stages, before symptoms become chronic, and psychosocial and work functioning deteriorate, which may further aggravate psychological problems. Presumably, many of the patients participating in the study would not have undergone a formal clinical study. However, in future studies, we will test the utility of myMCT as a complement or add-on of regular psychotherapies.

To conclude, myMCT is a promising novel program targeting common cognitive biases in OCD. Whereas those biases identified by the Obsessive Compulsive Cognitions Working Group^23-26 are at its core, the program additionally incorporates other techniques (association splitting, detached mindfulness). It may not only serve as a self-help e-book, but its exercises, diagrams, and illustrations could also facilitate planning and performing psychotherapies, especially in view of increasing reports about a large number of therapists not adhering to standard therapy guidelines.¹⁹.