Mindfulness-based cognitive therapy (MBCT) in patients with obsessive-compulsive disorder (OCD) and residual symptoms after cognitive behavioral therapy (CBT): a randomized controlled trial.

Up to one-third of individuals with obsessive-compulsive disorder (OCD) do not benefit from evidence-based psychotherapy. We examined the efficacy of mindfulness-based cognitive therapy (MBCT) as a complementary treatment option. In a prospective, bicentric, assessor-blinded, randomized, and actively controlled clinical trial, 125 patients with OCD and residual symptoms after cognitive behavioral therapy (CBT) were randomized to either an MBCT group (n = 61) or to a psychoeducational group (OCD-EP; n = 64) as an active control condition. At post-treatment, there was no significant benefit of MBCT over OCD-EP with the Yale-Brown-Obsessive-Compulsive Scale (Y-BOCS) as the primary outcome measure, but with the Obsessive-Compulsive Inventory [OCI-R; F(1, 101) = 5.679, p = .036, effect size η2partial = 0.053]. Moreover, the response rate and the improvement on secondary outcomes such as obsessive beliefs and quality of life was significantly larger in the MBCT group. Non-completion rates were below 10%. At the 6-month follow-up, OC symptoms were further improved in both groups; group differences were no longer significant. Our findings suggest that MBCT, compared to a psychoeducational program, leads to accelerated improvement of self-reported OC symptoms and secondary outcomes, but not of clinician-rated OC symptoms. In the midterm, both interventions yield similar and stable, but small improvements, suggesting that additional treatment options may be necessary.

No talking, just writing! Efficacy of an Internet-based cognitive behavioral therapy with exposure and response prevention in obsessive compulsive disorder.

BACKGROUND: Many patients with obsessive-compulsive disorder (OCD) do not receive first-line treatment according to the current guidelines (cognitive behavioral therapy with exposure and response prevention, CBT with ERP) due to barriers to treatment. Internet-based therapy is designed to overcome these barriers. The present study evaluates the efficacy of an Internet-based writing therapy with therapeutic interaction based on the concept of CBT with ERP for patients with OCD. METHODS: Thirty-four volunteers with OCD according to DSM-IV-criteria were included in the trial and randomized according to a waiting-list control design with follow-up measures at 8 weeks and 6 months. The intervention consisted of 14 sessions, either starting directly after randomization or with an 8-week delay. Main outcome measure was the change in the severity of OCD symptoms (Yale-Brown Obsessive Compulsive Scale Self-Rating, Y-BOCS SR, and Obsessive-Compulsive Inventory-Revised, OCI-R). RESULTS: Obsessive-compulsive symptoms were significantly improved in the treatment group compared to the waiting-list control group with large effect sizes of Cohen's d = 0.82 (Y-BOCS SR) and d = 0.87 (OCI-R), using an intention-to-treat analysis. This effect remained stable at 6-month follow-up. Only 4 participants (12%) dropped out prematurely from the study. Of the 30 completers, 90% rated their condition as improved and would recommend the program to their friends. CONCLUSIONS: Internet-based writing therapy led to a significant improvement of obsessive-compulsive symptoms. Even though replications with larger sample sizes are needed, the results support the notion that Internet-based approaches have the potential for improving the treatment situation for patients with OCD.

Mindfulness-based cognitive therapy in obsessive-compulsive disorder: protocol of a randomized controlled trial.

BACKGROUND: Obsessive-compulsive disorder (OCD) is a very disabling condition with a chronic course, if left untreated. Though cognitive behavioral treatment (CBT) with or without selective serotonin reuptake inhibitors (SSRI) is the method of choice, up to one third of individuals with obsessive-compulsive disorder (OCD) do not respond to treatment in terms of at least 35% improvement of symptoms. Mindfulness based cognitive therapy (MBCT) is an 8-week group program that could help OCD patients with no or only partial response to CBT to reduce OC symptoms and develop a helpful attitude towards obsessions and compulsive urges. METHODS/DESIGN: This study is a prospective, bicentric, assessor-blinded, randomized, actively-controlled clinical trial. 128 patients with primary diagnosis of OCD according to DSM-IV and no or only partial response to CBT will be recruited from in- and outpatient services as well as online forums and the media. Patients will be randomized to either an MBCT intervention group or to a psycho-educative coaching group (OCD-EP) as an active control condition. All participants will undergo eight weekly sessions with a length of 120 minutes each of a structured group program. We hypothesize that MBCT will be superior to OCD-EP in reducing obsessive-compulsive symptoms as measured by the Yale-Brown-Obsessive-Compulsive Scale (Y-BOCS) following the intervention and at 6- and 12-months-follow-up. Secondary outcome measures include depressive symptoms, quality of life, metacognitive beliefs, self-compassion, mindful awareness and approach-avoidance tendencies as measured by an approach avoidance task. DISCUSSION: The results of this study will elucidate the benefits of MBCT for OCD patients who did not sufficiently benefit from CBT. To our knowledge, this is the first randomized controlled study assessing the effects of MBCT on symptom severity and associated parameters in OCD. TRIAL REGISTRATION: German Clinical Trials Register DRKS00004525 . Registered 19 March 2013.

The prediction of treatment outcomes by early maladaptive schemas and schema modes in obsessive-compulsive disorder.

BACKGROUND: Higher levels of early maladaptive schemas (EMS) and schema modes according to schematherapy by Jeffrey Young are present in obsessive-compulsive disorder (OCD) compared to healthy controls. This study examines the relationship of EMS and schema modes to OC symptom severity and the predictive value of EMS and schema modes on treatment outcome in inpatients receiving Cognitive-Behavioral Therapy (CBT) with Exposure and Response Prevention (ERP). The main assumption was a negative association between the EMS of the domain 'disconnection' and dysfunctional coping and parent schema modes and the treatment outcome. METHODS: EMS, schema modes, depression and traumatic childhood experiences were measured in 70 patients with OCD. To analyze the predictors, two regression analyses were conducted considering multiple variables, such as depression, as covariates. RESULTS: Regression analyses demonstrated that higher scores on the EMS named failure and emotional inhibition and depressive symptom severity at pretreatment were significantly related to poor outcome and explained a high percentage of the variance in OC symptoms at posttreatment. No influence on the treatment outcome was observed for schema modes, other EMS or other covariates. CONCLUSIONS: The results support the approach to extend the CBT with ERP treatment with therapeutic elements focusing on maladaptive schemas, particularly in non-responders.

[Mindfulness based cognitive therapy (MBCT) in patients with obsessive-compulsive disorder--an adaptation of the original program]. / Achtsamkeitsbasierte kognitive Therapie (MBCT) für Patienten mit Zwangsstörung--Eine Adaptation des Originalkonzepts.

Mindfulness-based cognitive Therapy (MBCT) has shown to be effective in the relapse prevention and treatment of several psychiatric disorders. However, MBCT has not yet been applied in OCD (Obsessive-compulsive Disorder). This article proposes an adaptation of the eight-session group program for patients with residual symptoms after cognitive behavioural treatment (CBT) with exposure. It has proven feasible and was considered helpful by patients within the framework of a pilot study 1. Apart from an overview of the modified manual, OCD-specific elements are presented in detail and illustrated on the base of work sheets. The manual indicates that MBCT could be a useful supplement to CBT and is well applicable to the therapeutic needs of patients with OCD.

Quality of life changes following inpatient and outpatient treatment in obsessive-compulsive disorder: a study with 12 months follow-up.

BACKGROUND: Quality of life (QoL) is increasingly recognized as a critical outcome parameter in mental health studies. The aim of this study was to investigate different domains of the QoL in persons with obsessive-compulsive disorder (OCD) before and after a multimodal, disorder-specific in- and outpatient treatment. METHODS: Data of 73 persons with OCD treated in an inpatient setting followed by outpatient treatment were analyzed. The World Health Organization Quality of Life abbreviated (a multidimensional measure of the QoL) and the Beck Depression Inventory were administered prior to (baseline) and 12 months after the inpatient treatment (follow-up). RESULTS: At baseline, participants reported a significantly diminished psychological, social, physical, and global QoL compared to the German general population. Environmental QoL was not impaired in the present sample. The QoL was significantly improved at follow-up, except for social QoL, but remained below norm values. The QoL improvement was predicted by improvements of depressive symptoms. CONCLUSIONS: The results indicate that persons with OCD suffer from a very low QoL. The QoL was significantly improved after 12 months of intensive state-of-the-art treatment. However, the QoL indices remained considerably lower than population norm values, indicating the need for additional research into novel treatment options for persons with OCD.

Mindfulness-based cognitive therapy in obsessive-compulsive disorder - a qualitative study on patients' experiences.

BACKGROUND: Cognitive behavioral therapy (CBT) with exposure and response prevention (ERP) is the first-line treatment for patients with obsessive-compulsive disorder (OCD). However, not all of them achieve remission on a longterm basis. Mindfulness-based cognitive therapy (MBCT) represents a new 8-week group therapy program whose effectiveness has been demonstrated in various mental disorders, but has not yet been applied to patients with OCD. The present pilot study aimed to qualitatively assess the subjective experiences of patients with OCD who participated in MBCT. METHOD: Semi-structured interviews were conducted with 12 patients suffering from OCD directly after 8 sessions of a weekly MBCT group program. Data were analyzed using a qualitative content analysis. RESULTS: Participants valued the treatment as helpful in dealing with their OCD and OCD-related problems. Two thirds of the patients reported a decline in OCD symptoms. Benefits included an increased ability to let unpleasant emotions surface and to live more consciously in the present. However, participants also discussed several problems. CONCLUSION: The data provide preliminary evidence that patients with OCD find aspects of the current MBCT protocol acceptable and beneficial. The authors suggest to further explore MBCT as a complementary treatment strategy for OCD.

Direct and indirect assessment of perfectionism in patients with depression and obsessive-compulsive disorder.

According to the transdiagnostic perspective, psychological disorders share common cognitive processes involved in their pathogenesis. One dysfunctional belief that has been found to be associated with several psychological disorders, including major depressive disorder (MDD) and obsessive-compulsive disorder (OCD), is perfectionism. Perfectionism comprises two factors, namely, perfectionistic strivings and perfectionistic concerns. This study aims to replicate and extend previous research in several ways. We aimed to assess similarities between the two disorders using Bayesian statistics. Furthermore, as dysfunctional beliefs are assumed to not be fully accessible by introspection, we included an indirect measure (perfectionism single category implicit association task; SC-IAT). The SC-IAT and a self-report measure of perfectionism (FMPS) was used in patients with MDD (n = 55), OCD (n = 55), and in healthy controls (n = 64). In replication of previous findings, patients with MDD and OCD differed from healthy controls regarding self-reported perfectionism scores. Furthermore, Bayesian statistics showed that the two patient groups did not differ regarding perfectionistic strivings and only showed differences on perfectionistic concerns, when the doubts about actions subscale-which is also closely related to symptoms of OCD-was included. Contrary to our expectations, the SC-IAT did not discriminate groups. In conclusion, these results give further evidence that self-reported perfectionism may serve as a relevant transdiagnostic process. More studies are needed to assess implicit facets of perfectionism.

Rumination about obsessive symptoms and mood maintains obsessive-compulsive symptoms and depressed mood: An experimental study.

Rumination is common in individuals diagnosed with obsessive-compulsive disorder (OCD). We sought to clarify the causal role of rumination in the immediate and intermediate maintenance of obsessive-compulsive symptoms and depressed mood. In total, 145 individuals diagnosed with OCD were asked to read aloud their most distressing obsessive thought (OT). OT activation was followed by a thought-monitoring phase in which frequency of the OT was assessed. Participants were randomly allocated to one of three experimental conditions: rumination about obsessive-compulsive symptoms, rumination about mood, or distraction. Ratings of distress, urge to neutralize, and depressed mood and frequency ratings of the OTs were taken before and after the experimental manipulation. Obsessive-compulsive symptom severity and affect were assessed 2, 4, and 24 hr after the laboratory experiment using ecological momentary assessment. Compared to distraction, both types of rumination resulted in an immediate reduced decline of distress, urge to neutralize, depressed mood, and frequency of OTs, with medium to large effect sizes. Rumination about obsessive-compulsive symptoms did not have a stronger immediate effect than rumination about mood. Rumination about obsessive-compulsive symptoms increased obsessive-compulsive symptom severity and reduced positive affect compared to rumination about mood 24 hr later. Regarding negative affect, there was no difference in effect between the two types of rumination in the intermediate term. To conclude, rumination in OCD has an immediate and intermediate maintaining effect on obsessive-compulsive symptoms and mood and may require additional psychological interventions that supplement cognitive behavioral therapy. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

[Psychotherapeutic care in OCD outpatients--results from an anonymous therapist survey]. / Ambulante psychotherapeutische Versorgung bei Zwangserkrankungen.

The aim of the present study was to investigate the actual psychotherapeutic care in OCD outpatients. All psychotherapeutic members of the Südbaden Association Of Statutory Health (n=386) were contacted to fill in an anonymous questionnaire regarding frequency of treatment and treatment strategies in OCD. Particularly, the application of exposure therapy was asked. Answers were analysed descriptively. 177 therapists (45%) took part in the study. In average, psychotherapists treated about 3 patients with OCD in 2006. 86.7% of the therapists estimated the treatment of OCD as being of no relevance or only of little relevance in their daily practice. Exposure treatment was used by less than half of the therapists. The most frequent reason for avoidance of exposure treatment was a lack of experience or insufficient training in this technique. Results suggest a need for optimization of OCD outpatient care, especially with regard to application of treatment strategies with scientific evidence.

Changes in the daily life experience of patients with obsessive-compulsive disorder following mindfulness-based cognitive therapy: Looking beyond symptom reduction using ecological momentary assessment.

The current study examines changes in daily life experiences following mindfulness-based cognitive therapy (MBCT) in a sample of 38 patients with obsessive-compulsive disorder (OCD) and residual symptoms following cognitive behavioral therapy (CBT). Participants were randomized to either an MBCT group (n = 17), or to a psychoeducational group (OCD-EP; n = 21) as an active control condition. Both groups underwent ecological momentary assessment (EMA) six times a day for a period of six consecutive days pre- and posttreatment. Contrary to hypotheses, MBCT participation did not, when compared to OCD-EP, result in significant changes of positive affect, negative affect, acceptance of momentary emotions, or distress associated with obsessive-compulsive (OC) symptoms. In fact, insight into the unreasonableness of OC symptoms improved significantly more in the OCD-EP group compared to MBCT. However, in the MBCT group, the presence of momentary OC symptoms at post assessment predicted increased insight, which indicates an improved ability to detach from OC symptoms in the moments in which they occur. All in all, however, results do not indicate favorable changes in everyday life experiences of OCD patients following MBCT. Owing to the modest sample size, results must be considered preliminary. Implications and directions for future research are discussed.

Long-Term Follow-up of Cognitive-Behavioral Therapy for Obsessive-Compulsive Disorder: Symptom Severity and the Role of Exposure 8-10 Years After Inpatient Treatment.

Obsessive-compulsive disorder (OCD) can be effectively treated by cognitive behavioral therapy (CBT) with exposure and response prevention (ERP). Yet, little is known about the long-term effects of inpatient CBT up to one decade after treatment. Thirty patients who had been treated with 12 weeks of intensive inpatient CBT with ERP were examined 8-10 years after their stay in hospital with regard to obsessive-compulsive symptoms, secondary outcomes, and use of healthcare services. Significant (p < .001) improvements in OC symptoms with medium and large effects compared to baseline on the Yale-Brown-Obsessive-Compulsive Scale (Y-BOCS) and on the Obsessive-Compulsive Inventory (OCI-R) could still be observed, with 20% of the patients reaching remission status. Continuation of exposure exercises after the inpatient stay was the sole significant factor for improved scores at follow-up. The results suggest that OCD does not necessarily take a chronic course. However, maintenance of exposure training seems to be crucial for sustained improvement.

Long-term effects of mindfulness-based cognitive therapy in patients with obsessive-compulsive disorder and residual symptoms after cognitive behavioral therapy: Twelve-month follow-up of a randomized controlled trial.

We examined the long-term efficacy of mindfulness-based cognitive therapy (MBCT) compared to a psychoeducation group as an active control condition in patients with obsessive-compulsive disorder (OCD) with residual symptoms of OCD after cognitive behavioral therapy. A total of 125 patients were included in a bicentric, interviewer-blind, randomized, and actively controlled trial and were assigned to either an MBCT group (n = 61) or a psychoeducation group (n = 64). Patients' demographic characteristics and the results from our previous assessments have already been reported (Külz et al., 2019). At the 12-month follow-up the completion rate was 80%. OCD symptoms were reduced from baseline to follow-up assessment with a large effect, but no difference was found between groups. Exploratory analyses showed that a composite score of time occupied by obsessive thoughts, distress associated with obsessive thoughts, and interference due to obsessive thoughts differed between groups in the per-protocol analysis, with a stronger reduction in the MBCT group. At the 12-month follow-up, the two groups showed a similar reduction of symptoms. However, preliminary evidence indicates that MBCT has a superior effect on some aspects of OCD. This should be replicated in future studies.

Mindfulness predicts insight in obsessive-compulsive disorder over and above OC symptoms: An experience-sampling study.

Insight in obsessive-compulsive disorder (OCD) is assumed to fluctuate over time. However, temporal variations of insight and its correlates in OCD have never been empirically studied. We used ecological momentary assessment (EMA) to analyze the temporal variation of insight into the unreasonableness of the threat-related core belief (1), into the senselessness of compulsions to prevent this belief from occurring (2), and into the belief, itself, as being due to OCD (3). Furthermore, we analyzed whether worry, self-punishment and mindfulness are associated with these aspects of insight. A total of 50 OCD patients underwent EMA 10 times a day over 6 consecutive days. Data were analyzed using multilevel modelling. Results revealed that multiple time-points within individuals accounted for up to 51.4% of insight variance, indicating a substantial fluctuation of insight over time. Root mean square successive difference (rMSSD) scores indicated significantly higher fluctuation patterns in the doubt/checking dimension as compared to taboo thoughts throughout all aspects of insight. As hypothesized, self-punishment and mindfulness significantly predicted insight into the unreasonableness of the threat-related belief and the senselessness of compulsions to prevent this belief from occurring. Mindfulness demonstrated the greatest predictive value and remained significant after controlling for OC symptoms. Contrary to expectation, worry, as it was measured in our study, was not associated with insight. Besides providing evidence for insight fluctuation, our results indicate that mindfulness-based strategies might be beneficial for increasing insight in OCD.

Effects of tryptophan depletion on cognitive functioning, obsessive-compulsive symptoms and mood in obsessive-compulsive disorder: preliminary results.

BACKGROUND: Previous studies suggest that obsessive-compulsive disorder (OCD) is associated with moderate cognitive deficits. There is also evidence for altered serotonergic transmission in OCD. The aim of this study was to evaluate the impact of rapid plasma tryptophan depletion on cognitive functioning in OCD. METHODS: A double-blind crossover study was conducted to explore the effects of tryptophan depletion on cognitive functioning, obsessive or compulsive (OC) symptoms and mood in OCD patients treated with selective serotonin reuptake inhibitors. RESULTS: After 5 h of tryptophan depletion, 6 out of 7 patients reported worsening of mood (placebo condition: 3 patients). No effect was found regarding OC symptoms. There was a small and nonsignificant improvement of nonverbal memory and fluency. Problem solving ability and verbal memory, in contrast, were slightly impaired after tryptophan depletion. The results, however, represented only tendencies without reaching significance. CONCLUSION: The results suggest that OC symptoms may not depend on the short-time availability of serotonin. As some critical cognitive functions improved following tryptophan depletion, there is no evidence from our study that neuropsychological impairment in OCD can be reduced to a lowered level of serotonin. Future studies are needed to further clarify these findings by use of larger samples.

Implicit approach and avoidance in patients with obsessive-compulsive disorder.

Avoidance is regarded as an important feature for the development and maintenance of obsessive-compulsive disorder (OCD) and is usually assessed using explicit measures such as self-report scales. However, some behavioral schemata are unavailable to introspection, making them partially inaccessible by explicit measures. We used an approach-avoidance task (AAT) as an implicit measure to examine behavioral tendencies in patients with OCD, including patients with checking- and contamination-related symptoms (n = 63), compared with a healthy control group (n = 30). Participants were asked to respond to the color of a stimulus or stimulus frame by pulling a joystick toward themselves or by pushing it away. The stimuli were comprised of checking-related, contamination-related, and neutral pictures and words. Patients with contamination-related symptoms were slower when responding to OCD-related stimuli, independent of approach or avoidance. Unexpectedly, patients with checking-related symptoms were faster at pulling (approaching) and slower at pushing (avoiding) checking-related material compared with neutral stimuli. The slower pushing (avoiding) of checking-related compared with neutral material correlated positively with explicit ratings of avoidance. These results suggest a biased approach-avoidance tendency in patients with checking-related symptoms of OCD, but not in those with contamination-related symptoms of OCD. Future studies are necessary to assess whether the AAT might be useful in the assessment of treatment gains as well as whether it might be a training tool to enhance psychotherapeutic changes in OCD. (PsycINFO Database Record

Schema therapy augmented exposure and response prevention in patients with obsessive-compulsive disorder: Feasibility and efficacy of a pilot study.

BACKGROUND: In spite of the availability of effective treatments for obsessive-compulsive disorder (OCD), many patients do not respond sufficiently or relapse. Treatments using other potentially effective methods such as experiential techniques need to be investigated. We developed a 12-week inpatient treatment augmenting exposure and response prevention (ERP) with schema therapy (ST) called STERP. The feasibility and effectiveness of STERP was tested.. METHODS: In a pilot study, 10 inpatients with OCD who failed to respond to Cognitive Behavioral Therapy (CBT) with ERP received STERP. The Yale-Brown Obsessive Compulsive Scale (Y-BOCS) served as primary outcome. Secondary outcome measures were the Obsessive Compulsive Inventory-revised (OCI-R) and the Beck Depression Inventory (BDI-II). Treatment effects were assessed with t-tests for paired samples. RESULTS: Significant reductions of the Y-BOCS, OCI-R and the BDI-II were found, with very large effect sizes (Cohen's d = 1.48-2.25). Results remained stable at 6 months follow-up. Five prior non-responders responded according to the 35% Y-BOCS symptom reduction criterion.. LIMITATIONS: Lack of control group, small sample size and lack of repeated outcome measures during baseline. CONCLUSIONS: STERP may be a feasible and potentially effective treatment for prior non-responders among OCD patients and thus worth further investigation in randomized controlled trials..

The effect of personality disorders on treatment outcomes in patients with obsessive-compulsive disorders.

The effect of comorbid personality disorders (PD) on treatment outcomes in obsessive-compulsive disorder (OCD) is unclear. The authors systematically review results from investigations of therapy outcomes in adult patients with OCD and a comorbid PD. PsycINFO and MEDLINE were searched for original articles. Twenty-three studies assessing PDs through interviews were selected. Cluster A PDs, particularly schizotypal PD, narcissistic PD, and the presence of two or more comorbid PDs, were associated with poorer treatment outcomes in patients with OCD. With regard to other PDs and clusters, the results are inconsistent or the sample sizes are too small to reach a conclusion. OCD patients with different comorbid PDs differ in their therapeutic response to treatment. To optimize the treatment of OCD, the predictive value of PDs on the treatment outcome should be further investigated, and treatment of Axis I and II comorbidity requires more attention.