Elsevier

Behavior Therapy

Volume 47, Issue 4, July 2016, Pages 474-486
Behavior Therapy

Cognitive Mediation of Symptom Change in Exposure and Response Prevention for Obsessive-Compulsive Disorder

https://doi.org/10.1016/j.beth.2016.03.003Get rights and content

Highlights

  • We examined mechanisms of symptom change during EX/RP for OCD

  • We tested change in obsessive beliefs as a mediator of symptom improvement

  • Reductions in obsessive beliefs did not account for subsequent improvement in OCD

  • Results suggest that other mechanisms of change in OCD treatment should be examined

Abstract

This study examined cognitive mediators of symptom change during exposure and response prevention (EX/RP) for obsessive–compulsive disorder (OCD). Based on cognitive models of OCD, obsessive beliefs were hypothesized as a mediator of symptom change. Participants were 70 patients with primary OCD receiving EX/RP either as part of a randomized controlled trial (n = 38) or in open treatment following nonresponse to risperidone or placebo in the same trial (n = 32). Blinded evaluations of OCD severity and self-report assessments of three domains of obsessive beliefs (i.e., responsibility/threat of harm, importance/control of thoughts, and perfectionism/intolerance of uncertainty) were administered during acute (Weeks 0, 4 and 8) and maintenance treatment (Weeks 12 and 24). Study hypotheses were examined using cross-lagged multilevel modeling. Contrary to predictions, the obsessive beliefs domains investigated did not mediate subsequent OCD symptom reduction. In addition, OCD symptoms did not significantly mediate subsequent change in obsessive beliefs. The present study did not find evidence of cognitive mediation during EX/RP for OCD, highlighting the need to investigate other plausible mediators of symptom improvement.

Section snippets

Mechanisms of Change in OCD

A number of different types of cognitions have been theorized to play an important role in the reduction of OCD symptoms. Emotional processing theory (EPT; Foa & Kozak, 1986), which is the basis for EX/RP, emphasizes that exposure works by disconfirming beliefs about the likelihood of harm, the cost of that harm, and expectations that the feeling of anxiety will persist indefinitely (Foa, Huppert, & Cahill, 2006). Accordingly, erroneous beliefs related to a patient’s obsessions about the

Participants

Participants were 70 adults with OCD who were enrolled in an RCT evaluating the effectiveness of EX/RP vs. risperidone as a serotonin reuptake inhibitor (SRI) augmentation strategy (Simpson et al., 2013). Thus, all participants were on a stable dose of SRI throughout the trial. Participants included in the present study completed a pretreatment assessment and attended two introductory sessions and at least one EX/RP exposure session. All participants met the following inclusion criteria: (a)

Participation and Attrition Analyses

Of the 70 participants in our sample, 3 dropped out during the acute phase (i.e., completed fewer than five 90-minute EX/RP sessions) and another 9 dropped during the maintenance phase. The dropouts did not differ from the remaining participants on any demographics or pre-treatment measures (all ps > .05) and all assessment data collected prior to dropout was included in the current analyses. The mean number of 90-minute EX/RP sessions during the acute phase was 15.5 ± 3.1 for the total sample

Discussion

The present study used cross-lagged multilevel modeling to evaluate whether dysfunctional obsessive beliefs mediated OCD symptom improvement among 70 participants receiving EX/RP. Based on cognitive models of OCD, we specifically examined three central domains of obsessive beliefs (OCCWG, 2005) as possible cognitive mediators: inflated responsibility/threat of harm, perfectionism/intolerance of uncertainty, and importance and control of thoughts. Although obsessive beliefs decreased

Conclusions

The present study contributes to our knowledge of mechanisms of change in OCD during EX/RP by testing the cognitive mediation hypothesis within a manualized course of EX/RP. Using cross-lagged multi-level analyses, we replicated previous findings (Olatunji et al., 2013, Woody et al., 2011), showing that reductions in obsessive beliefs do not mediate OCD symptom improvement during CBT, suggesting that other mediators not examined in the present study may have an important role in OCD symptom

Conflict of Interest Statement

This study was funded by National Institute of Mental Health grants R01 MH45404 (Dr. Foa) and R01 MH045436 (Dr. Simpson). Medication was provided at no cost by Janssen Scientific Affairs LLC.

During this study, Dr. Simpson received research funds from Transcept Pharmaceuticals (2011-2013) and Neuropharm Ltd. (2009), served on a scientific advisory board for Pfizer (for Lyrica, 2009-2010) and Jazz Pharmaceuticals (for Luvox CR [controlled release], 2007-2008), and received royalties from

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