Cognitive Behavioural Therapy with Exposure and Response Prevention in the treatment of Obsessive-Compulsive Disorder: A systematic review and meta-analysis of randomised controlled trials

© 2021 Published by Elsevier Inc. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).Background: Cognitive behavioural therapy (CBT), incorporating exposure and response prevention (ERP) is widely recognised as the psychological treatment of choice for obsessive-compulsive disorder (OCD). Uncertainty remains however about the magnitude of the effect of CBT with ERP and the impact of moderating factors in patients with OCD. Method: This systematic review and meta-analysis assessed randomised-controlled trials of CBT with ERP in patients of all ages with OCD. The study was preregistered in PROSPERO (CRD42019122311). The primary outcome was end-of-trial OCD symptom scores. The moderating effects of patient-related and study-related factors including type of control intervention and risk of bias were examined. Additional exploratory analyses assessed the effects of treatment fidelity and impact of researcher allegiance. Results: Thirty-six studies were included, involving 2020 patients (537 children/adolescents and 1483 adults) with 1005 assigned to CBT with ERP and 1015 to control conditions. When compared against all control conditions, a large pooled effect size (ES) emerged in favour of CBT with ERP (g = 0.74: 95% CI = 0.51 to 0.97 k = 36), which appeared to diminish with increasing age. While CBT with ERP was more effective than psychological placebo (g = 1.13 95% CI 0.71 to 1.55, k = 10), it was no more effective than other active forms of psychological therapy (g = −0.05: 95% CI -0.27 to 0.16, k = 8). Similarly, whereas CBT with ERP was significantly superior when compared to all forms of pharmacological treatment (g = 0.36: 95% CI 0.7 to 0.64, k = 7), the effect became marginal when compared with adequate dosages of pharmacotherapy for OCD (g = 0.32: 95% CI -0.00 to 0.64, k = 6).A minority of studies (k = 8) were deemed to be at low risk of bias. Moreover, three quarters of studies (k = 28) demonstrated suspected researcher allegiance and these studies reported a large ES (g = 0.95: 95% CI 0.69 to 1.2), while those without suspected researcher allegiance (k = 8) indicated that CBT with ERP was not efficacious (g = 0.02: 95% CI -0.29 to 0.33). Conclusions: A large effect size was found for CBT with ERP in reducing the symptoms of OCD, but depends upon the choice of comparator control. This meta-analysis also highlights concerns about the methodological rigor and reporting of published studies of CBT with ERP in OCD. In particular, efficacy was strongly linked to researcher allegiance and this requires further future investigation.Peer reviewe

Functional Interventions as Augmentation Strategies for Obsessive-Compulsive Disorder (OCD) : Scoping Review and Expert Survey from the International College of Obsessive-Compulsive Spectrum Disorders (ICOCS)

© 2021 Taylor & Francis. This is an Accepted Manuscript of an article published by Taylor & Francis in International Journal of Psychiatry in Clinical Practice on 27/01/2021, available online: https://dx.doi.org/10.1080/13651501.2021.1872646.Background. Patients with obsessive-compulsive disorder (OCD) commonly exhibit a range of functional difficulties, presumed linked to neurocognitive changes. Evidence-based first-line treatments have limited effect on improving these cognitive-functional problems. Candidate interventions could be used to augment evidence-based treatments by the multi-professional mental health team. Methods. A scoping review was performed to identify any intervention with at least one peer-reviewed report of clinical improvement in any of the 13 functional domains of the Cognitive Assessment Instrument of Obsessions and Compulsions (CAIOC-13). Next, an online survey of experts of the International College of Obsessive-Compulsive Spectrum Disorders was conducted.Results. Forty-four studies were identified reporting a positive outcome for 27 different kinds of intervention. Twenty-six experts from 12 different countries, including at least one expert from each continent, completed the opinion survey. Five interventions were identified as ‘highly promising’, none of which was moderated by rater-related factors, suggesting global applicability. Conclusion. Patients with OCD may benefit from a detailed functional assessment, to identify areas of unmet need. A variety of interventions show theoretical promise for treating the complex functional difficulties in OCD as adjuncts to first-line treatments, but the published evidence is weak. Randomised controlled trials are needed to determine the clinical effectiveness of these interventions.Peer reviewe

Habit reversal therapy in obsessive compulsive related disorders : A systematic review of the evidence and consort evaluation of randomized controlled trials

Background: Habit Reversal Therapy (HRT) has long been used in the treatment of Tourette Syndrome and Tic Disorders. It has more recently been used to treat Trichotillomania and skin picking behaviors, both considered as Obsessive Compulsive Related Disorders (OCRD). Objectives: This literature review sought to establish and quality assess the existing randomized controlled trial evidence supporting the use of HRT in the DSM-5 family of OCRDs. Search Methods: EMBASE, PsycINFO, PubMed, and Cochrane databases were searched for key terms relating to each OCRD (as classified in the DSM-5), and HRT. Selection Criteria: Titles and abstracts were screened, and any literature matching pre-specified criteria were then selected to be reviewed further. Of these, 8 Randomized Controlled Trials (RCT) relating to Trichotillomania, and 2 RCTs relating to Excoriation Disorder, were extracted and reviewed against the 2010 Consolidating Standards of Reporting Trials (CONSORT) statement. Results: The review identified 10 RCTs of HRT, but these were limited to patients with a primary diagnosis of Trichotillomania or “excoriation behavior,” only. There were some reports of the use of HRT in Tourette Syndrome or Tic Disorder with secondary OCD, but the OCD symptoms were not reliably reported on. Conclusion: There is a gap in the current literature regarding the use of HRT in the DSM-5 OCRDs. In those RCTs that have been reported, the quality of study methodology was questionable as evaluated by CONSORT criteria. The implications of these findings are discussed, and suggestions are made for future research.Peer reviewe

Standards of care for obsessive–compulsive disorder centres

In recent years, many assessment and care units for obsessive–compulsive disorder (OCD) have been set up in order to detect, diagnose and to properly manage this complex disorder, but there is no consensus regarding the key functions that these units should perform. The International College of Obsessive- Compulsive Spectrum Disorders (ICOCS) together with the Obsessive Compulsive and Related Disorders Network (OCRN) of the European College of Neuropsychopharmacology (ECNP) and the Anxiety and Obsessive Compulsive Disorders Section of the World Psychiaric Association (WPA) has developed a stand- ards of care programme for OCD centres. The goals of this collaborative initiative are promoting basic standards, improving the quality of clinical care and enhance the validity and reliability of research results provided by different facilities and countries

Imagery rescripting therapy, a pilot study : reducing shame and cognitive inflexibility in obsessive compulsive disorder.

Background: Symptoms of Obsessive–Compulsive Disorder (OCD) sometimes do not improve despite being competently treated with known effective pharmacological and/or cognitive behavioural therapy with exposure and response prevention interventions. OCD symptoms that are particularly difficult to treat are related to harm /aggressive, sexually taboo and religious/blasphemous intrusive obsessional thoughts/images. Factors such as the vividness of the intrusive imagery, guilt, shame, cognitive inflexibility and inhibitory control deficits, are known to impact on OCD. Therefore it is important to further improve treatment given that the quality of life of patients with untreated OCD symptoms can be as equally poor as that of patients diagnosed with schizophrenia and in some cases worse. Imagery rescripting therapy is effective in reducing shame, guilt and the intensity of imagery vividness in trauma-based disorders such as Post-Traumatic Stress Disorder (PTSD). The ameliorative qualities of imagery rescripting may be of therapeutic benefit in OCD. Aim: This study explored the therapeutic utility of one-session imagery rescripting with homework practice in reducing image vividness, guilt, shame, cognitive inflexibility and impairment in motor inhibitory control linked to OCD related to harm/aggressive, sexually taboo and religious/blasphemous intrusive images. Methodology: A multiple baseline single-case experimental design was utilised with 6 adult participants recruited. One participant withdrew after the initial baseline phase and the visual graphed data analysis for 5 participants was conducted on scores on measures of vividness, shame, guilt and anxiety, with the Tau-U test utilised to assess trends between baseline and intervention phases. Clinical significance (CS) and reliable change index (RCI) calculations were used to assess changes in scores on global measures of OCD, depression and cognitive flexibilities before and after the intervention and at follow-up. A favourable ethical opinion was obtained from appropriate research ethics committees before data collection commenced. The study was conducted in accord with research ethics and governance requirements. Results: This study found that changes in intrusive imagery vividness, was only reported in one of the two patients whose intrusive imageries were associated with memories of past adverse experiences. It was also found that patients with intrusive imageries that did not have an association with an adverse memory also reported improvement in shame, guilt and OCD following imagery rescripting. The study also found that the OCD patients performed worse on the CANTAB – SSRT and ED tasks compared to the healthy normal group but similar to the OCD clinical controls, however, the improvements in set-shifting deficits and or in motor inhibitory impairment following imagery rescripting could not be established. Instead it was found that the impairments improved following repeated measurements at the baseline phase in the absence of treatment. Conclusion and Implications: Although only one patient supplied evidence consistent with imagery rescripting having therapeutic potential for OCD images, however from a broader view point the study demonstrated replication failure of this result across the participants. Furthermore, there was also no conclusive evidence to suggest imagery rescripting had significantly changed set-shifting and motor inhibitory impairments. Further investigation is required, taking into account of the study limitations and implications before one could comment for definite how the findings contribute to the current knowledge. Single case experimental design might not be particularly suitable for investigating neurocognitive improvement in treatment trials due to the nature of repeated measurements

How to Treat Compulsive Facets of Behavioural Addictions

© 2024, The Author(s), under exclusive licence to Springer Nature Switzerland AG. This is the accepted manuscript version of an article which has been published in final form at https://doi.org/10.1007/s40429-024-00596-6Purpose of Review: Treatment approaches to disorders of behavioural addiction are beginning to emerge. In this paper we provide a narrative review of the growing range of treatment approaches for the less well understood compulsive facets, including compulsions and the associated latent phenotypes, such as cognitive domains characterised by inflexible thinking or a preference for habitual responding. We aim to offer new insights and heuristics for treating compulsive forms of behavioural addiction, such as cyberchondria, compulsive hoarding, compulsive forms of gaming disorder, trichotillomania and skin picking (excoriation) disorder. Recent Findings: Emerging evidence of treatment approaches showing promise include novel forms of pharmacotherapy (extending beyond drugs acting on the serotonin system), psychotherapy (extending beyond conventional cognitive-behaviour therapy) and non-invasive neuromodulation. Summary: A broad approach to designing novel treatment strategies that includes careful characterisation of the phenotypic and latent cognitive profiles based on a growing understanding of the neurobiology of compulsivity is recommended.Peer reviewe

How to treat compulsive facets of behavioural addictions

Purpose of review: treatment approaches to disorders of behavioural addiction are beginning to emerge. In this paper we provide a narrative review of the growing range of treatment approaches for the less well understood compulsive facets, including compulsions and the associated latent phenotypes, such as cognitive domains characterised by inflexible thinking or a preference for habitual responding. We aim to offer new insights and heuristics for treating compulsive forms of behavioural addiction, such as cyberchondria, compulsive hoarding, compulsive forms of gaming disorder, trichotillomania and skin picking (excoriation) disorder. Recent findings: emerging evidence of treatment approaches showing promise include novel forms of pharmacotherapy (extending beyond drugs acting on the serotonin system), psychotherapy (extending beyond conventional cognitive-behaviour therapy) and non-invasive neuromodulation. Summary: a broad approach to designing novel treatment strategies that includes careful characterisation of the phenotypic and latent cognitive profiles based on a growing understanding of the neurobiology of compulsivity is recommended

Investigating adjustment to the easing of pandemic (COVID-19) restrictions

The UK Government response to the Covid-19 pandemic resulted in an enforced global ‘lockdown’ of citizens in their own homes, under conditions of extreme social avoidance with active encouragement of physical distancing, closure of almost all schools, business, venues, facilities, amenities and places of worship and repeated handwashing to reduce the risk of contamination. This period lasted roughly 3 months, from late March to early July 2020, during which these precautionary behaviours were repeatedly reinforced by multiple forms of media (TV, radio, online, newspapers), giving time for the behaviours to become habitual. This study is aimed at investigating adjustment to the easing of pandemic restrictions. We are interested in: - Exploring how difficult it is to readjust to normal life after 3 months of lockdown. - Assessing lifestyle, mood, anxiety and stress in the general population during this transition phase. - Assessing if inflexible (obsessive compulsive) personality traits can predict a poor ability to adjustment to the easing of lockdown. - Investigating if cognitive inflexibility as measured by a digital task can predict poor adjustment. The study will consist of an online-based questionnaire followed by an online thinking task, disseminated via social media, email and other channels

Functional interventions as augmentation strategies for obsessive-compulsive disorder (OCD): scoping review and expert survey from the international college of obsessive-compulsive spectrum disorders (ICOCS)

BACKGROUND Patients with obsessive-compulsive disorder (OCD) commonly exhibit a range of functional difficulties, presumed linked to neurocognitive changes. Evidence-based first-line treatments have limited effect on improving these cognitive-functional problems. Candidate interventions could be used to augment evidence-based treatments by the multi-professional mental health team. METHODS A scoping review was performed to identify any intervention with at least one peer-reviewed report of clinical improvement in any of the 13 functional domains of the Cognitive Assessment Instrument of Obsessions and Compulsions (CAIOC-13). Next, an online survey of experts of the International College of Obsessive-Compulsive Spectrum Disorders was conducted. RESULTS Forty-four studies were identified reporting a positive outcome for 27 different kinds of intervention. Twenty-six experts from 12 different countries, including at least one expert from each continent, completed the opinion survey. Five interventions were identified as 'highly promising', none of which was moderated by rater-related factors, suggesting global applicability. CONCLUSION Patients with OCD may benefit from a detailed functional assessment, to identify areas of unmet need. A variety of interventions show theoretical promise for treating the complex functional difficulties in OCD as adjuncts to first-line treatments, but the published evidence is weak. Randomised controlled trials are needed to determine the clinical effectiveness of these interventions. Highlights Functional-cognitive problems are common in patients with OCD. First-line evidence-based treatments have limited effect on these functionalcognitive difficulties. In our scoping review we found 44 studies reporting of improved clinical outcomes in any of the 13 functional domains of the Cognitive Assessment Instrument of Obsessions and Compulsions (CAIOC-13). An online survey of experts of the International College of Obsessive-Compulsive Spectrum Disorders (ICOCS) was conducted and identified five interventions as "highly promising" candidate treatments for functional-cognitive problems in OCD. Randomised controlled trials are needed to determine the clinical effectiveness of these interventions