1
Alterations of Responsibility Beliefs Through Cognitive-Behavioural Group
Therapy for Obsessive-Compulsive Disorder
Tadashi Haraguchi1, Eiji Shimizu2, Hiroshi Ogura3, Goro Fukami1, Mihisa
Fujisaki1 and Masaomi Iyo1
1) Department of Psychiatry, Chiba University Graduate School of Medicine,
Chiba, Japan
2) Department of Integrative Neurophysiology, Chiba University Graduate
School of Medicine, Chiba, Japan
3) Asahi General Hospital, Chiba, Japan
Correspondence to: Eiji Shimizu, MD and PhD, Department of Integrative
Neurophysiology (C2), Chiba University Graduate School of Medicine,
Inohana 1-8-1, Chiba, 260-8670, Japan
TEL: +81-43-226-2027
FAX: +81-43-226-2028
E-mail: [email protected]
Abstract: 187 words, Text: 6113 words, 3 Tables
Running title: Group therapy for OCD.
2
Abstract
Background:
Inflated
responsibility
is
the
main
feature
of
cognitive-behavioural models of obsessive-compulsive disorder (OCD).
However, few studies have examined the effect of cognitive-behavioural
group therapy (CBGT) on inflated responsibility. Aim: The aim of this study
was to examine the effect of CBGT on OCD symptoms and responsibility
beliefs. Methods: The authors conducted CBGT that targeted inflated
responsibility in OCD patients. Thirty-six subjects meeting Diagnostic and
Statistical Manual of Mental Disorders, 4th edition, criteria for OCD were
recruited to CBGT, and 28 of them completed 12 sessions. The subjects were
assessed using the Yale-Brown Obsessive-Compulsive Scale (Y-BOCS), the
Responsibility Attitude Scale (RAS) and the Responsibility Interpretations
Questionnaire (RIQ) at pre- and post-treatment. Results: Y-BOCS, RAS and
RIQ (belief) scores were significantly improved at the end of the treatment.
The mean pre–post-treatment Y-BOCS score reduction was 7.8 (31.6%), and
the effect size (Cohen’s d) was 1.30. In contrast, the RIQ (frequency) score
was not significantly reduced. Conclusions: This study indicates that CBGT
improves not only obsessive-compulsive symptoms but also inflated
3
responsibility beliefs in patients with OCD. These results underscore the
potential efficacy of CBGT for OCD patients.
Key words: Cognitive-behavioural therapy, cognitive-behavioural model,
group
therapy,
inflated
responsibility,
intrusive
thought,
obsessive-compulsive disorder
Introduction
Obsessive-compulsive disorder (OCD) is characterized by persistent
intrusive thoughts (obsessions) and stereotyped repetitive behaviours
carried out in a ritualistic fashion (compulsions) (American Psychiatric
Association,
2000).
Epidemiological
studies
have estimated
lifetime
prevalence of OCD to be about 1–3% (Kessler, Chiu, Demler, Merikangas,
and Walters, 2005; Weissman et al., 1994).
Over the past few decades, a considerable number of studies have
examined
behavioural
therapy
(BT),
cognitive
therapy
(CT),
and
cognitive-behavioural therapy (CBT) for OCD patients. As a results, a large
body of research attesting to the success of BT and CBT for OCD now exists
4
(Clark, 2004; Eddy, Dutra, Bradley, and Westen, 2004; Foa et al., 2005).
Studies have evaluated the effects of behavioural interventions alone,
cognitive interventions alone and combinations of the two. The consensus is
that a combination of behavioural and cognitive techniques leads to
significant improvement in many patients (Anderson and Rees, 2007). The
National Institute of Clinical Excellence guideline concluded that CBT was
an efficacious treatment for OCD (The National Institute of Clinical
Excellence, 2005).
On the other hand, only a relatively small number of clinicians have
been trained in the specific behavioural and cognitive-behavioural
techniques that can be used to effectively treat OCD. Therefore, patients are
often forced to wait for long periods of time to consult an appropriately
trained clinician or may instead receive suboptimal treatment (Anderson
and Rees, 2007).
Behavioural and cognitive-behavioural group therapy for OCD
Group therapy (GT) has several advantages compared to individual therapy.
One major advantage of GT is the reduction in therapist time; thus, GT can
5
reduce the cost and increase the efficiency of treatment (Anderson and Rees,
2007). GT is therefore a means by which more patients can access treatment
in a timely manner from highly skilled therapists.
Behavioural group therapy (BGT) and cognitive-behavioural group
therapy (CBGT) have received relatively little attention as potential
treatments for OCD. The large body of evidence on the efficacy of BT and
CBT for OCD is based almost entirely on experience with individual
treatment. However, a growing number of studies are focusing on the
effectiveness of BGT (Himle et al., 2001; Van Noppen, Steketee, McCorkle,
and Pato, 1997) and CBGT for OCD (Anderson and Rees, 2007; Asbahr et al.,
2005; Bouvard, 2002; Braga, Cordioli, Niederauer, and Manfro, 2005; Chacon
Pde, Motta, and Belloto, 2003; Jaurrieta et al., 2008; Jonsson and Hougaard,
2009; Martin and Thienemann, 2005; Schruers, 2007; Thienemann, Martin,
Cregger, Thompson, and Dyer-Friedman, 2001; Volpato Cordioli et al., 2003;
Whittal, Robichaud, Thordarson, and McLean, 2008). A qualitative review of
CBGT or group exposure and response prevention (ERP) by Himle et al.
(2001) concluded that there was some evidence of the effectiveness of CBGT
or group ERP. Recently, a meta-analysis of 13 studies conducted by Jonsson
6
et al. (2009) showed that CBGT or group ERP for OCD was effective. Though
evidence of the efficacy of CBGT for OCD has been increasing, data on the
effectiveness of CBGT including ERP for OCD are still insufficient.
Inflated responsibility of OCD patients
The study of distorted beliefs, attitudes and interpretations regarding
responsibility has become one of the central themes in cognitive models of
OCD (Rachman, 1998, 2002; Salkovskis, 1985). A landmark report by
Rachman and de Silva (1978) indicated that 80% of normal individuals
experience unwanted intrusive thoughts. Salkovskis (1985) later focused on
the differences between OCD patients and normal individuals in the
appraisal of intrusive thoughts. Intrusive thoughts are normal phenomena
that are universally experienced. Whereas most people simply ignore
intrusive thoughts, OCD patients pay attention to them and believe them to
be important. In OCD patients, beliefs about intrusive thoughts are
characterized by an exaggerated sense of responsibility for causing or failing
to prevent harm to oneself or others. As a result, the inflated sense of
responsibility experienced by OCD patients leads them to exercise excessive
7
control behaviour, resulting in a vicious cycle of obsession and compulsion.
Similarly, Rachman (1998) emphasized that interpretations of intrusive
thoughts related to responsibility for preventing harm are central to OCD
and that these intrusions persist as long as such misinterpretations are
exercised. The Obsessive Compulsive Cognitions Working Group (2005)
suggests that there are three factor analytically distinguishable types of
OC-related beliefs: (1) inflated personal responsibility and the tendency to
overestimate threat, (2) perfectionism and intolerance of uncertainty and (3)
overimportance and overcontrol of thoughts. In short, the key to the
cognitive-behavioural appraisal model of OCD lies not in an examination of
the characteristics of intrusive cognitions, but rather in the way in which
they, and their occurrence, are interpreted.
Experimental studies have linked inflated responsibility and OCD.
Both adults and children with OCD demonstrate inflated responsibility
(Salkovskis, 1989; van Oppen et al., 1995) and endorse responsibility beliefs
more than do other anxious patients (Foa, Amir, Bogert, Molnar, and
Przeworski, 2001) or matched controls (Barrett and Healy, 2003; Foa et al.,
2001; Rheaume, Freeston, Dugas, Letarte, and Ladouceur, 1995). Several
8
studies support the specificity of responsibility cognitions in OCD
(Salkovskis et al., 2000). In addition, some studies have reported the
relationship between responsibility beliefs and OCD symptoms in both
clinical and nonclinical samples (Freeston and Ladouceur, 1993; Salkovskis
et al., 2000) and have shown that responsibility attitudes mediate the
relationship between intrusive thoughts and OCD symptoms. Finally,
manipulation of responsibility beliefs has changed the perceived severity of
outcomes (Ladouceur et al., 1995): experimentally increasing inflated
responsibility beliefs has been shown to increase checking behaviours in
nonclinical samples (Bouchard, Rheaume, and Ladouceur, 1999; Ladouceur,
Rheaume and Aublet, 1997; Ladouceur et al., 1995).
On the other hand, other models of OCD do not regard dysfunctional
beliefs as an important factor (Taylor et al., 2006). Several research
investigations have suggested that OCD is a heterogeneous disorder rather
than a unitary syndrome (McKay et al., 2004). Another study indicated that
dysfunctional beliefs might play a role in only some types of OCD (Taylor et
al., 2006). Therefore, there is an ongoing discussion about dysfunctional
beliefs, including inflated responsibility, of all OCD patients.
9
Compared to the vast amount of research on inflated responsibility in
OCD patients, surprisingly few studies have examined the effects of
treatment on inflated responsibility. A report on a small sample of OCD
patients (N = 4) suggested that CT reduced the inflated responsibility of
patients with OCD (Ladouceur et al., 1997). Lopatka and Rachman (1995)
reported that they were able to manipulate the perceived responsibility for
feared consequences among compulsive checkers (N = 30). McLean et al.
(2001) reported that Responsibility Appraisal Scale scores declined
significantly after CBGT as well as after group ERP therapy. To date,
however, the evidence with regard to the effects of cognitive and/or
behavioural treatment on inflated responsibility is sorely lacking. As a result,
it is still not clear whether the inflated responsibility of OCD patients can be
improved by CBT. Moreover, to the best of our knowledge, there have been
few clinical trials examining the efficacy of CBGT on the inflated
responsibility beliefs of OCD patients.
Aims
The first aim of this study was to examine the effectiveness of CBGT on
10
OCD patients. The second aim was to examine whether CBGT could reduce
the inflated responsibility beliefs of OCD patients.
Methods
Subjects
Our subjects were 36 patients with the diagnosis of OCD who were recruited
through the Department of Psychiatry of Chiba University Hospital. They
were drawn from a population of patients with OCD and represent those
study-eligible patients who expressed an interest in participating in CBGT
and who were available during the scheduled group time.
The diagnostic criteria for the selection of the patients were in line
with the Diagnostic and Statistical Manual of Mental Disorders, 4 th edition
(DSM-IV) (American Psychiatric Association, 2000). All subjects were
evaluated using the Structured Clinical Interview for DSM-IV (SCID-IV)
(First, Spitzer, Gibbon and Williams, 1996), which defines comprehensive
diagnostic interviews designed to assess the disorders in DSM-IV. The
exclusion criteria were: major depression with suicidal risk, bipolar disorder,
severe personality disorder, mental retardation, substance abuse and severe
11
physical illness.
The subjects’ demographic data are shown in Table 1. Subjects
consisted of 36 subjects (8 male, 28 female) who fulfilled the DSM-IV criteria
for OCD. The mean age of all subjects was 30.9 years (standard deviation
[SD] = 10.3), and the mean duration of illness was 8.9 years (SD = 7.8). All
subjects were receiving or had previously received pharmacological
treatment. Eight of the subjects (22.2%) withdrew before completing all 12
sessions. The mean age of the completers was 32.6 years (SD = 10.7), and the
mean duration of illness was 9.3 years (SD = 8.3). Twenty-two of the
completers (78.6%) were already being administered antidepressant agents
such as paroxetine, fluvoxamine, sertraline, or clomipramine. Six of the
completers were medication-free. The dosages were kept constant for all of
the subjects who were receiving drug therapy. According to the Y-BOCS
symptom-based checklist, the OCD subjects included washing types (N = 8),
checking types (N = 3) and mixed types (N = 17). Eight of the completers
(28.6%) had comorbid major depression by Axis I diagnosis.
Measures
12
Yale-Brown Obsessive Compulsive Scale (Y-BOCS) (Goodman, Price,
Rasmussen, Mazure, Delgado et al., 1989; Goodman, Price, Rasmussen,
Mazure, Fleischmann et al., 1989).
This symptom checklist includes more
than 60 symptoms organized according to 15 separate categories of
obsessions and compulsions. It is divided into three major sections: a
symptom inventory organized by category, a target symptom list, and a
10-item severity rating scale (Likert scale: 0, none; 4, extreme). There are
five items for the evaluation of obsessions and five for the evaluation of
compulsions; in both cases, the five items assess distress, frequency of
distress, and its interference in everyday life; resistance to symptoms; and
control over symptoms. The Japanese version of the self-report Y-BOCS has
been validated (Hamagaki, Takagi, Urushihara, Ishisaka and Matsumoto,
1999).
Responsibility Attitude Scale (RAS) (Salkovskis et al., 2000). This
scale consists of 26 items designed to assess general beliefs about
responsibility. Ratings are on a 7-point Likert scale (1, totally disagree; 7,
totally agree). The score is obtained by calculating the mean rating for these
26 items. Salkovskis et al. (2000) found RAS to be a reliable and valid
13
measure.
Responsibility Interpretations Questionnaire (RIQ) (Salkovskis et al.,
2000).
This questionnaire is designed to assess the frequency of and belief
in specific interpretations of intrusive thoughts about possible harm. Ratings
of frequency of intrusive thoughts are on a 5-point Likert scale (0, never
occurred; 4, always occurring). The score is obtained by calculating the mean
rating for these items. Having rated the frequency for each of the items,
subjects are asked to rate the extent to which they presently believe this
particular interpretation (i.e. their belief at the time of testing). Ratings of
extent of belief range from 0 to 100. The score is obtained by calculating the
mean rating for these items. Salkovskis et al. (2000) found RIQ to be a
reliable and valid measure. We developed Japanese versions of the RAS and
RIQ with Prof. Salkovskis’ permission.
Beck Depression Inventory-Second Edition (BDI-II) (Beck, 1996).
This inventory consists of 21 items designed to assess depressive symptoms.
Ratings are on a 4-point Likert scale (from 0 to 3), and the possible
maximum total score is 63. The Japanese version has been validated (Kojima
et al., 2002).
14
Treatment protocol
We prepared a manual of CBGT for OCD by consulting previous studies of
GT for OCD (Anderson and Rees, 2007; Braga et al., 2005; Chacon Pde et al.,
2003; Himle et al., 2001; Schruers, 2007; Sousa, Isolan, Oliveira, Manfro,
and Cordioli, 2006; Volpato Cordioli et al., 2003). For the present study, we
considered that modification of inflated responsibility was important based
on the cognitive-behavioural model of Salkovskis and others (Foa et al.,
2001; Rachman, Thordarson, Shafran, and Woody, 1995; Salkovskis, Shafran,
Rachman and Freeston, 1999; Salkovskis, 1985; Salkovskis et al., 2000). The
treatment sessions were based on the manual. Treatment programs
consisted of 12 weekly sessions; all sessions lasted 1.5 hours and were
facilitated by three psychiatrists.
This treatment protocol represents a blend of cognitive and
behavioural techniques. Table 2 describes each session of the treatment
protocol. The treatment program integrates cognitive restructuring based on
Beck’s model (Beck, 1976) of logical analysis and hypothesis testing into
exposure exercises. The treatment protocol includes specific homework
15
exercises attached to each component of the treatment. All homework
activities were carefully monitored by one or more of the participating
therapists. A family member was allowed to attend the sessions.
Specific cognitive strategies are incorporated into this program to
challenge faulty estimations of danger (e.g. probability testing) (van Oppen
and Arntz, 1994), inflated responsibility (Salkovskis, Forrester and Richards,
1998) and thought-action fusion beliefs. Based on a previous report
(Obsessive Compulsive Cognitions Working Group, 1997), six faulty
appraisals were identified and discussed during treatment: (a) inflated
responsibility, (b) overimportance of thought, (c) overestimation of threat, (d)
importance of controlling thoughts, (e) intolerance of uncertainty and (f)
perfectionism. Methods to challenge these faulty appraisals were introduced.
Appraisal change exercises were demonstrated during sessions and were
assigned weekly as homework. Exposure exercises were developed to suit the
idiosyncratic obsessions and rituals specific to each case. Exposure exercises
were introduced both as an opportunity to test beliefs as well as a way to
learn to habituate to anxiety.
16
Procedure
The protocol was performed during five successive periods from January
2008 to May 2009 with five to seven (mean = 6) subjects. All patients were
attending the psychiatric outpatient service at Chiba University Hospital,
Chiba,
Japan.
Subjects
were
evaluated
using
the
aforementioned
instruments at the start (week 0) and end (week 12) of treatment. This study
was carried out using an open-trial design. Data were compiled using a
prospective cohort follow-up design. The investigation was carried out in
accordance with the latest version of the Declaration of Helsinki.
Statistics
Differences between means of Y-BOCS, RAS, RIQ and BDI-II pre- and
post-treatment were assessed with Student’s paired t-test. All statistical
tests were two-sided, and significance was defined as P < 0.05. To enable
comparisons with prior studies, the effect size (Cohen’s d) was calculated for
treatment completers only. A responder to treatment was defined as having a
decrease of ≧35% in the Y-BOCS score at the end of the study (Sousa et al.,
2006). Patients who responded to treatment were also classified as having
17
complete remission if the Y-BOCS scores were ≦8 after treatment (Sousa et
al., 2006).
Results
The results of treatment completer analyses and intention-to-treat (ITT)
analyses are shown in Table 3.
Treatment completer analyses
The treatment completer sample consisted of 28 subjects. A significant
reduction in the Y-BOCS total score was observed (P < .001). The mean
pre–post-treatment Y-BOCS score reduction was 7.8 (31.6%), and the effect
size (Cohen’s d) was 1.30. The reductions in the scores for obsession and
compulsion were 2.9 (24.8%) and 4.4 (35.2%), respectively. Ten patients
(35.7%) met the criterion for improvement (a reduction of ≧35% in the
Y-BOCS score). Regarding the criterion for complete remission of OCD
symptoms (Y-BOCS score ≦ 8), two
subjects (7.1%) reached this
improvement level.
A significant reduction in the intensity of the responsibility attitude
18
measured by the RAS was observed (P = 0.004). In addition, a significant
reduction was observed in the intensity of the responsibility interpretation
measured by RIQ (belief) (P = 0.033). In contrast, there was no significant
difference in the frequency of intrusive thought as measured by the RIQ
(frequency) (P = 0.881). There were no significant differences in the severity
of depressive symptoms measured by the BDI-II (P = 0.21).
ITT analyses
The ITT sample consisted of 36 subjects. In the case of treatment dropouts,
the last observation carried forward method was used as a conservative
estimate of symptomatology for those individuals without outcome measure
scores following treatment. Using this method, individuals with missing data
following treatment were assigned the score from the last measurement
taken from them. This resulted in an additional eight subjects in the
analyses.
A significant reduction in the Y-BOCS total score was observed (P <
0.001) (Table 3). The mean pre–post-treatment Y-BOCS score reduction was
6.2 (24.7%). The reductions in the scores for obsession and compulsion were
19
2.3 (18.9%) and 3.6 (28.2%), respectively. Eleven patients (30.6%) met the
criterion for improvement (a reduction of ≧35% in the Y-BOCS score). Two
subjects (7.1%) reached the improvement criterion for complete remission of
OCD symptoms (Y-BOCS score ≤ 8).
A significant reduction in the intensity of the responsibility attitude
measured by the RAS was observed (P = 0.005). In addition, a significant
reduction was observed in the intensity of the responsibility interpretation
measured by the RIQ (belief) (P = 0.035). In contrast, there was no
significant difference in the frequency of intrusive thoughts as measured by
the RIQ (frequency) (P = 0.880). There were no significant differences in the
severity of depressive symptoms measured by the BDI-II (P = 0.103).
Discussion
Obsessive-compulsive symptoms
The first aim of this study was to examine the effectiveness of CBGT in a
sample of patients with OCD. To our knowledge, this is the first study
conducted in Japan in which the effectiveness of CBGT for OCD was
examined.
20
A significant reduction in the Y-BOCS total score was observed in both
the treatment completer analyses and ITT analyses (Table 3). The
improvement rate (31.6%) of the present study was comparable to the
outcomes of previous GT studies (approximately 20–40%) (Jonsson and
Hougaard, 2009). Next, the pre-post effect size of this study (1.30) was
comparable to the sizes (1.18 for four randomized controlled trials [RCTs],
four non-RCTs and five open trials; 1.25 for the five open trials) in the
previously reported meta-analysis of GT for OCD (Jonsson and Hougaard,
2009) as well as to the pre-post effect size (1.48) in the previously reported
meta-analysis of individual CBT in 13 RCTs (Eddy et al., 2004). As
previously mentioned, evidence of the effectiveness of CBGT has been
limited in comparison with that for the effectiveness of individual CBT
(Jonsson and Hougaard, 2009). Thus, the results of this study provide
additional support for the effectiveness of CBGT for OCD patients. Further
comparative studies of group versus individual therapy will be needed to
clarify the relative effectiveness of the two treatment formats.
GT has several advantages in comparison with individual therapy.
First, GT makes it possible to treat a larger number of patients at a lower
21
cost and with similar efficacy to that of individualized care (Anderson and
Rees, 2007; Fals-Stewart, Marks, and Schafer, 1993; Sousa et al., 2006;
Volpato Cordioli et al., 2003). In the present study, with three therapists
treating six subjects per group 1.5 hours per week over 12 weeks, a total of 9
hours were needed to treat one patient compared with 18 hours per patient
in individualized treatment. A considerable amount of time was therefore
saved by using a group format. Second, the mutual support of the group
environment may increase patients’ motivation for facing avoided situations
and the increased anxiety levels inherent in ERP (Sousa et al., 2006). This
kind of support could bring about a reduction in the dropout rate for CBT
sessions. The dropout rate in this study (22.2%) was approximately
equivalent to the dropout rates in previous studies, which ranged from 4 to
25% (Anderson and Rees, 2007; Jonsson and Hougaard, 2009; Krone, Himle,
and Nesse, 1991; McLean et al., 2001; Sousa et al., 2006; Van Noppen et al.,
1997; Van Noppen, Pato, Marsland, and Rasmussen, 1998; Volpato Cordioli
et al., 2003). Thus, CBGT for OCD not only provides an opportunity for more
patients to receive high-quality treatment, but also heightens their
motivation to continue treatment.
22
Nevertheless,
GT
has
several
disadvantages.
A standardized
treatment protocol for GT has not been established (e.g. content of sessions
and number of subjects). Compared with individual therapy, it is more
difficult in GT to deal with idiosyncratic symptoms and variations in the
severity of individual cases. Further studies will be needed to elucidate the
advantages and disadvantages of CBGT for OCD and to develop an optimally
effective CBGT program.
Inflated responsibility
The second aim of this study was to examine the effect of CBT on the inflated
responsibility beliefs of OCD patients. To the best of our knowledge, this
study is the first to investigate the effect of CBGT on inflated responsibility
beliefs in OCD as measured by the RAS and RIQ.
In the present study, RAS, RIQ (frequency) and RIQ (belief) scores
were 4.12, 1.66 and 50.4, respectively, at pre-treatment. In a report by
Salkovskis et al. (2000), mean RAS, RIQ (frequency) and RIQ (belief) scores
were 3.48, 0.67 and 15.8 in normal controls and 4.69, 1.94 and 49.46 in OCD
patients, respectively. Thus, our patients’ scores were closer to the scores of
23
OCD patients than to those of normal controls in the report by Salkovskis.
This observation suggests that the intensity of distorted responsibility
attitudes and beliefs are higher in OCD patients than in healthy individuals
and that OCD patients have a higher frequency of belief in their
interpretation of intrusive thoughts than do healthy individuals.
As measured by the RAS and RIQ (belief), significant reductions were
observed in the intensity of responsibility attitudes and in the interpretation
of intrusive thoughts at post-treatment in the treatment completer as well as
ITT analyses (Table 3). In contrast, no significant reduction in RIQ
(frequency) was observed at post-treatment. The present results suggest that
CBGT improved responsibility attitudes and beliefs, but did not improve the
frequency of belief in intrusive thoughts. As described in the Methods section,
we conducted CBGT that targeted inflated responsibility, which plays a key
role in the cognitive appraisal model of OCD (Rachman, 1998; Rachman et
al., 1995; Salkovskis et al., 1999; Salkovskis, 1985). Appraisals involving
responsibility for causing or preventing harm are important because it is
hypothesized that these appraisals, rather than the intrusions per se, are
distressing and that they motivate attempts to neutralize intrusions.
24
Although our results did not necessarily clarify whether the severity of
obsessive-compulsive symptoms was correlated with the frequency of
intrusive thoughts, one possible interpretation of these results is that OCD
patients gradually learned to ignore or cope with intrusive thoughts more
constructively as their treatment progressed. However, this implication
cannot be generalized to all OCD patients because the sample size of the
present study was small.
Our results document that CBGT improved not only the Y-BOCS
scores, but also the RAS and RIQ (belief) scores, suggesting that
reconstruction of responsibility beliefs may play an important role in
reducing OCD symptoms through CBGT. Clinicians should note the effect of
cognitive intervention, as well as that of ERP based on BT, on inflated
responsibility beliefs in the treatment of OCD patients. We also believe that
changing beliefs will lead to better long-term outcomes after treatment is
discontinued and plan to collect data regarding this aspect in the near
future.
On the other hand, other models of OCD do not regard dysfunctional
beliefs as playing an important role (Taylor et al., 2006). In these models,
25
OCD is a heterogeneous disorder rather than a unitary syndrome (McKay et
al., 2004). Taylor et al. (2006) indicated that dysfunctional beliefs might play
a role in only some types of OCD. As only three subjects were of the checking
type in the present study, we could not examine the relation between
subtypes and inflated responsibility. Therefore, it remains unclear whether
subtypes relate to the severity of inflated responsibility. Additional studies
are needed to examine how CBGT affects inflated responsibility in different
subtypes of OCD.
Study limitations
Limitations of this study include (a) the lack of a control group, (b) the small
sample size, (c) concurrent medication and (d) presence of comorbidities such
as major depression. These circumstances may affect the generalizability of
the results. Moreover, as this trial was not controlled, it is difficult to draw
conclusions based on the data. We hope to increase the sample size in future
studies. Thus, further RCTs with larger samples and follow-up data are
required.
26
Conclusion
This article examined the effect of CBGT for OCD on obsessive-compulsive
symptoms and inflated responsibility beliefs in OCD patients. There were
two main results: we showed that CBGT improved obsessive-compulsive
symptoms and inflated responsibility belief scores in OCD patients. The
present study adds support to previous studies that suggest that CBGT is
effective for OCD. This article is the first to report that CBGT improves
inflated responsibility beliefs in OCD patients as measured by the RAS and
RIQ. These results underscore the potential efficacy of CBGT for OCD
patients. Because the number of subjects was small, it will be necessary to
replicate
these
results
before
concluding
that
these
findings
are
generalizable. A further study using CBGT in a larger sample of OCD
patients is therefore necessary.
Acknowledgements
We would like to thank Ms. Mio Yoshida for her assistance.
27
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Figure legends
Table 1. Demographics and clinical characteristics
Total (N = 36)
Completers (N = 28)
30.9 (10.3)
32.6 (10.7)
8 (22.2%)/28 (77.8%)
5 (17.9%)/23 (82.1%)
22.1 (9.5)
23.4 (9.7)
8.9 (7.8)
9.3 (8.3)
29 (80.6%)
22 (78.6)
Washing
11(30.6%)
8 (28.6%)
Checking
3 (8.3%)
3 (10.7%)
22 (61.1%)
17 (60.7%)
Age Mean (SD)
Man/Woman N (%)
Age of onset Mean
(SD)
Duration Mean (SD)
Using medications N
(%)
Subtype N (%)
Mixed
39
Table 2. The protocol of cognitive-behavioural group therapy for obsessive-compulsive
disorder (OCD): session outline
Session Theme
Contents
Overview of course; explanation of basic pathophysiology and
1
Guidance
CBT of OCD.
Introduction
2
to
cognitive
therapy;
intrusive
thought,
Thoughts
obsession and compulsion
3
Emotion
Introduction to behaviour therapy; subjective units of distress
Ritual behaviour, neutralization, ERP, development of
4
Behaviours
experimental hierarchies
5
Cognition 1
Interpretation of intrusive thought, thought-action fusion
Responsibility
6
attitude
and
interpretation,
Inflated
Cognition 2
responsibility
Imagined
7
Ritual behaviour in mind
exposure
In-session ERP incorporating cognitive therapy component;
8-11
ERP
continuous review and trouble shooting
40
Review and trouble shooting, discussion of strategies for
12
Review
maintaining goals
CBT = cognitive-behavioural therapy; ERP = exposure and response
prevention
Table 3. Treatment outcome
P
Pre-treatment Post-treatment t value d.f.
Improvement Effect
value
rates (%)
sizes
Mean ± SD
Mean ± SD
Total
24.7
± 6.0
16.9
± 6.3
6.09
25
<0.001 31.6
1.30
Obsession
11.7
± 3.9
8.8
± 3.4
5.24
25
<0.001 24.8
0.75
Compulsion 12.5
± 3.3
8.1
± 3.1
6.15
25
<0.001 35.2
1.33
± 1.3
3.6
± 1.5
3.22
21
0.004
27.5
0.36
± 1.13
-0.15
18
0.881
-1.2
-0.02
Y-BOCS
Completer
analyses
RAS
4.1
RIQ
Frequency 1.66
± 1.05 1.68
41
Belief
50.4
± 26.5 42.4
± 27.3
2.31
17
0.033
15.9
0.30
18.3
± 15.4 15.2
± 14.1
1.71
19
0.103
15.8
0.20
Total
25.3
± 6.5
19.0
± 7.6
5.35
32
<0.001 24.7
0.96
Obsession
12.2
± 4.0
9.9
± 4.0
4.74
32
<0.001 18.9
0.57
Compulsion 12.7
± 3.4
9.1
± 3.7
5.37
32
<0.001 28.2
1.04
± 1.4
3.7
± 1.5
3.04
29
0.005
8.6
0.25
BDI-II
Y-BOCS
Intention-to-treat
RAS
4.1
analyses
RIQ
Frequency 1.55
± 1.05 1.56
± 1.11
-0.15
27
0.88
-0.8
-0.01
Belief
42.7
± 27.8 37.2
± 27.0
2.23
25
0.035
12.9
0.20
22.1
± 16.9 20.1
± 16.8
1.68
30
0.103
9.04
0.12
BDI-II
Y-BOCS = Yale-Brown Obsessive Compulsive Scale; RAS = Responsibility
Attitude Scale; RIQ = Responsibility Interpretations Questionnaire; BDI-II =
Beck Depression Inventory, Second Edition