Cognitive Mediation of Symptom Change in Exposure and Response Prevention for Obsessive-Compulsive Disorder
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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2020, Journal of Affective DisordersCitation Excerpt :In other words, a mechanism of treatment may not be captured at baseline but rather, may emerge at another point of assessment during treatment. Indeed, mediators that are analyzed with time as a covariate often fail to show significance, and the statistical requirement that a mediator must be assessed before a clinically significant outcome does not account for the fact that change is incremental (Kraemer et al., 2002; Su et al., 2016). As such, if change has not occurred in the sample yet and the network inherently considers time (e.g., baseline), it is plausible that metacognitions may play a more substantial role in affecting other nodes given a different time period of assessment (e.g., mid- or post-treatment).
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2019, Behavior TherapyCitation Excerpt :Thus, the design of the current study does not illuminate how selected interventions impacted temporal change in obsessions and compulsions. While the findings of the current study stand in contrast to those reporting that cognitive belief domains do not mediate treatment outcome (Olatunji et al., 2013; Su, Carpenter, Zandberg, Simpson, & Foa, 2016), the current study design cannot speak to direct implications for psychotherapy practice guidelines. Conclusions from this study are tempered by the study’s limitations.