Metacognitive Training for Obsessive-Compulsive Disorder: A randomized controlled trial

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Highlights

  • The Metacognitive Training for OCD (MCT-OCD) reduced patients' OC symptoms.

  • The MCT-OCD showed good acceptability.

  • The MCT-OCD is a highly standardized intervention, which may narrow treatment gap.

Abstract

Objective

Less than half of help-seeking individuals with obsessive-compulsive disorder (OCD) receive evidence-based treatment recommended by guidelines. Metacognitive Group Training for OCD (MCT-OCD) aims to fill the treatment gap, until evidence-based treatment is available as it is easy to administer even by less trained personnel and highly standardized, which facilitates preparation and thus, dissemination.

Method

An assessor-blind randomized controlled trial comparing the MCT-OCD (n = 39) to a care as usual control condition (n = 40) was conducted. The Yale-Brown Obsessive Compulsive Scale (Y-BOCS) represented the primary outcome. Secondary outcomes targeted treatment processes. Patients were reassessed eight weeks (post) after baseline and three months (follow-up) after post.

Results

In the MCT-OCD group, OC symptoms declined more than in the control group from baseline to post with a moderate effect (ηp2 = 0.078) in the complete cases sample. Decrease in compulsions and dysfunctional metacognitions was larger in the MCT-OCD than the control group from baseline to post and from baseline to follow-up (compulsions only). Acceptability of the MCT-OCD was good.

Conclusions

The results demonstrate that the MCT-OCD is a promising add-on treatment for reducing OC symptoms and dysfunctional metacognitions. Its easy dissemination enables a large number of patients with OCD to be treated.

Introduction

According to the cognitive model (McFall & Wollersheim, 1979), the emotional processing theory (Foa & Kozak, 1986), and Wells' metacognitive model (Wells, 1997, 2000; Wells, Myers, Simons, & Fisher, 2017), dysfunctional (metacognitive) beliefs and/or cognitive biases play an important role in the development and maintenance of obsessive-compulsive disorder (OCD). However, the boundaries between the concepts of dysfunctional beliefs, metacognitive beliefs, and cognitive biases are blurry (Moritz & Lysaker, 2018; Moritz, Lysaker, Hofmann, & Hautzinger, 2018). For heuristic reasons, it is important to differentiate among these concepts. A belief can be conceptualized as a permanent organization of cognitions (Krech & Crutchfield, 1948), as, for example, the OCD-specific belief overestimation of threat (Obsessive Compulsive Cognitions Working Group, 1997, Obsessive Compulsive Cognitions Working Group, 2003, Obsessive Compulsive Cognitions Working Group, 2005). Metacognitions are is conceptualized as thinking about thinking (Moritz & Lysaker, 2018). An OCD specific dysfunctional metacognitive belief is thought-action fusion (TAF; the conviction that a mere thought is able to cause an action; Wells, 1997, 2000). Biases are automatic distortions of perceptions and interpretations of information (Moritz & Lysaker, 2018), such as unrealistic pessimism (i.e., patients with OCD tend to overestimate their personal threat; Moritz & Jelinek, 2009). Apart from this theoretical conceptualization, recent studies highlight the need to target (meta)cognitive beliefs in the treatment of OCD by investigating mechanisms of change in different therapies (e.g., cognitive therapy, CT; see Solem, Håland, Vogel, Hansen, & Wells, 2009; Wilhelm, Berman, Keshaviah, Schwartz, & Steketee, 2015). Solem et al. (2009) investigated whether metacognitions change in patients with OCD after treatment. The authors found that metacognitions explained 22% of the variance in symptoms at post-treatment, highlighting the relevance of metacognitions in the treatment of patients with OCD.

Cognitive-behavioral therapy (CBT) is first-line treatment for patients with OCD and recommended by guidelines (Kordon, Lotz-Rambaldi, Muche-Borowski, Zurowski, & Hohagen, 2014; National Instituate for Health and Care Excellence (NICE), 2005). Besides modification of dysfunctional cognitions, CBT includes exposure and response prevention (ERP; Turner, O'Gorman, Nair, & O'Kearney, 2018) and has been evaluated as highly effective (Hedges' g = 1.31; see meta-analysis by Öst, Havnen, Hansen, & Kvale, 2015). Cognitive therapy (CT), which focuses on the cognitive elements of CBT, is also a recommended treatment for patients with OCD (NICE, 2005) and has a comparable efficacy to ERP as assessed by the Yale-Brown Obsessive Compulsive Scale (Ougrin, 2011).

Nevertheless, available therapies for OCD, especially ERP, are often not applied, not even by well-trained therapists (Böhm, Förstner, Külz, & Voderholzer, 2008; Külz et al., 2010; Stobie, Taylor, Quigley, Ewing, & Salkovskis, 2007). For example, Külz et al. (2010) found that less than half of therapists carried out ERP. There also exist other treatment barriers to the application of ERP on the patients' and therapists' side: (1) ERP often has high dropout rates (18.7%; Ong, Clyde, Bluett, Levin, & Twohig, 2016) because patients are afraid to face their feared stimulus or for other (Meyer, Farrell, Kemp, Blakey, & Deacon, 2014; Moritz et al., 2019). (2) Therapists lack training in conducting ERP (Külz et al., 2010). (3) Therapists' schedules often do not allow for block treatments (i.e., three exposure sessions per week; Moritz et al., 2019). (4) Therapists have difficulty designing ERP sessions in certain cases, such as when the patient fears the delayed consequences of an action (e.g., the fear that the patient's mother will die in the future if the patient does not say a prayer when he/she walks out a door; discussed in McKay, Taylor, & Abramowitz, 2010).

In addition to specific barriers to the implementation of ERP, other therapies (e.g., CT) are not carried out because of the low number of trained professionals. As a result, patients are currently waiting approximately five months before they receive therapy in Germany (Bundespsychotherapeutenkammer, 2018). An economic and low-threshold way to provide access to psychotherapy is group intervention, which has been shown to be effective for patients with OCD (Schwartze, Barkowski, Burlingame, Strauss, & Rosendahl, 2016). Besides CBT group treatment, metacognitive therapy by Wells may also be applied in a group setting (Fisher & Wells, 2008). Metacognitive group therapy primarily targets dysfunctional metacognitive beliefs (e.g., TAF), and there is preliminary evidence for its effectiveness in one single-arm study (Rees & van Koesveld, 2008). One problem with this approach is that it requires two years of training, which makes dissemination more difficult. In fact, there are only nine certified therapists in the United Kingdom (https://mct-institute.co.uk/mct-registered-therapists/united-kingdom/, accessed Nov. 9, 2019). In summary, there is an urgent need for the development and integration of treatments that address the aforementioned treatment barriers.

Metacognitive Training for Patients with OCD (MCT-OCD) aims to address the aforementioned treatment barriers in order to provide help to a larger number of patients. The MCT-OCD is derived from the metacognitive training for psychosis (MCT) by Moritz & Woodward (2007); for recent meta-analyses see Eichner & Berna, 2016; Liu, Tang, Hung, Tsai, & Lin, 2018; Philipp et al., 2018), which has recently been added to the treatment guidelines for psychosis (German Psychiatric Association, 2019). The MCT laid the foundation for the development of subsequent metacognitive trainings for patients with depression (Jelinek et al., 2016) and borderline personality disorder (Schilling, Moritz, Köther, & Nagel, 2015). All MCTs aim to raise patients’ awareness of disorder-specific cognitive biases by providing metacognitive experiences and subsequently changing them by means of functional strategies (Moritz & Lysaker, 2018). Other common features of the MCTs are (1) an open group format, which enables patients to join the group at any time and thus reduces the long waiting time for treatment, (2) highly standardized slide-based multimedia presentations, which facilitates preparation and thus, dissemination, and (3) practical exercises allowing patients to experience cognitive biases without having to talk about their own symptoms (thus, MCTs are also suitable for patients with fear of or doubts about psychotherapy). However, the MCT-OCD is not meant to replace CBT with ERP but is instead intended to (1) bridge waiting times due to its structural advantages (e.g., high standardization) or (2) serve as an add-on therapy in order to narrow the existing treatment gap.

On the basis of the aforementioned MCTs, our research group developed a metacognitive self-help manual called My Metacognitive Training (myMCT) for patients with OCD (Moritz, Jelinek, Hauschildt, & Naber, 2010) that helps patients to identify their personal dysfunctional (meta)cognitive beliefs and provides new coping strategies. The myMCT reduced patients' OC symptoms compared to wait-list as well as psychoeducation groups in three randomized controlled trials (Hauschildt, Schröder, & Moritz, 2016; Moritz et al., 2010, 2016) and demonstrated a small to moderate effect size of SMD = 0.40 in a recent meta-analysis (Philipp et al., 2018). Because many patients pa asked for a face-to-face version of the myMCT (Hauschildt et al., 2016; Moritz et al., 2010), we transformed the self-help manual into a group training, which can be applied as a standalone or add-on treatment. The content of the myMCT was modified in order to match the general format and length of the metacognitive trainings developed by our working group. However, although its name might suggest otherwise, the MCT-OCD does not exclusively address metacognitive beliefs; it also addresses cognitive biases. Since it is similar to the other MCTs in terms of structure and setup (presentation based, open group, etc.), the name reflects this proximity and the tradition in which the training was developed. The pilot version of the MCT-OCD is comprised of four modules and, in contrast to the more “eclectic” myMCT (i.e., the latter includes strategies from different therapies), focuses primarily on dysfunctional (meta)cognitive beliefs. Notably, in an uncontrolled pilot study evaluating the four-module version of the MCT-OCD with an inpatient sample, objective measurements of symptom reduction after treatment with the MCT-OCD was correlated with patients' subjective evaluation that their OC symptoms were reduced due to the MCT-OCD (Miegel et al., 2020). Additionally, the finding that the control of thoughts specifically improved after the relevant session underlines one of the assumed mechanisms of the MCT-OCD pilot version (Miegel et al., 2019). This finding was replicated in a subsequent session-specific analysis including patients of the MCT-OCD group of the current sample (Miegel, Cludius, Hottenrott, Demiralay, & Jelinek, 2020). Furthermore, whereas particular modules improved the patients' mood, others worsened it, so this aspect of the pilot version needed to be revised (Miegel et al., 2019). According to patients’ feedback, acceptability of the MCT-OCD was high (Jelinek et al., 2018), but patients did make suggestions for its improvement (e.g., reducing the amount of information given in each module).

Based on these findings, we revised the MCT-OCD. The revision of the MCT-OCD included (1) an expansion from four to eight modules to allow more time for each session, (2) an additional module (module #1) giving basic information about OCD (due to the inclusion of an outpatient sample, which might encompass patients without prior therapy experience and thus less knowledge about the disorder), (3) additional slides on comorbid depressive thought patterns (e.g., rumination) because OCD and major depression frequently co-occur (Rickelt et al., 2016), and (4) newly designed slides in order to address the aforementioned finding that mood did not improve (Miegel et al., 2019) and to help the participants be more comfortable with the treatment. Some of the (meta)cognitive beliefs that are targeted in the MCT-OCD are also part of CT and the metacognitive therapy by Wells. However, the MCT-OCD reduces the patient's dysfunctional (meta)cognitive beliefs, for example, by corrective experiences (“aha moments”) and humorous exercises (e.g., to try to influence someone to perform a certain gesture in order to illustrate thought-action-fusion). In contrast to the metacognitive therapy by Wells, the MCT-OCD addresses various cognitive and metacognitive beliefs. Furthermore, the MCT-OCD addresses the above-mentioned treatment barriers by providing a treatment that is not expected to evoke much fear (or to a lesser degree compared to ERP) and is highly structured and thus can be administered by less experienced professionals. Thus, the format of the MCT-OCD (i.e., the slide supported presentation) is unique and a major advantage in comparison to the other described treatments.

The aim of the present study was to overcome the methodological limitations of the pilot study (i.e., lack of control group, including inpatients that received a comprehensive treatment) and compare the revised MCT-OCD to a care as usual control condition in an assessor-blinded randomized controlled trial for an outpatient sample with OCD in order to evaluate the efficacy of the MCT-OCD as an add-on treatment. We expected a significantly higher reduction of OC symptoms in the MCT-OCD group compared to the control group from baseline to post assessment (primary outcome: Y-BOCS total score) and from baseline to three-month follow-up. For secondary outcomes, we expected obsessions (Y-BOCS), compulsions (Y-BOCS), depressive symptoms (Hamilton Depression Rating Scale, Beck Depression Inventory-II), metacognitions (Metacognitions Questionnaire), dysfunctional beliefs (Obsessive Beliefs Questionnaire), and the frequency and distress of OC symptoms (Obsessive Compulsive Inventory-Revised) to show a stronger reduction in the intervention group compared to the control group. In accordance with the pilot study (Jelinek et al., 2018), we expected a positive subjective appraisal of the MCT-OCD by participants.

Section snippets

Design

The present randomized controlled trial compared the Metacognitive Group Training for Patients with OCD (MCT-OCD) to a care as usual control condition. All patients were assessed at three points of time: baseline (t0), post (8 weeks), and follow-up (3 months after post). After t0, patients were randomly assigned to one of the two groups. The randomization was conducted by the principle investigator (FM), and the randomization plan was developed by a statistician (1:1 allocation rule). Patients

Results

Eighty-seven patients with OCD were fully screened. Based on the final inclusion and exclusion criteria, eight patients were excluded, resulting in a final sample of 79 (see Fig. 1). If only the patients who met the originally registered inclusion and exclusion criteria were included in the analyses (n = 76), the results on the main outcome variables would be the same.

Participants in the two groups did not differ in sociodemographic characteristics (see Table 1 for a detailed description).

Discussion

The present randomized controlled trial evaluated the efficacy and acceptance of metacognitive group training for patients with OCD (MCT-OCD) in an outpatient sample. We expected that OC symptoms (Y-BOCS total score: primary outcome) would decrease more in the intervention group from baseline to post and from baseline to follow-up assessment compared to the care as usual control condition. We also assumed a larger decrease in secondary outcomes (i.e., obsessions, compulsions, (meta)cognitive

Conclusions

To summarize, the revision of the MCT-OCD can be regarded as successful because the intervention was able to reduce patients' symptom severity (Y-BOCS total and Y-BOCS compulsions score) more compared to the care as usual control group with a medium effect size. Notably, patients evaluated the MCT-OCD as highly acceptable, which may be especially important for treatment adherence. However, results on the secondary outcomes (i.e., OBQ-44, MCQ-30, BDI-II) were mixed with only significant results

Role of funding sources

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Contributors

FM wrote the draft of the manuscript. LJ and SM designed the study and edited the manuscript. CD and BH edited the manuscript and created the framework conditions (e.g., helping to recruit patients, providing rooms). All authors reviewed the final manuscript.

Conflicts of interest

The authors declare that they have no conflict of interest.

Data availability

The data that support the findings of this study are available from the corresponding author upon reasonable request.

Statement of ethics

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Declaration of Helsinki and its later amendments or comparable ethical standards. Informed consent was obtained from all individual participants included in the study. This article does not contain any studies with animals performed by any of the authors. The study was preregistered at the German Clinical Trials

Acknowledgments

We thank Twyla Michnevich, Christopher Lau, Frederike Wagener, and Janina Wirtz for their help with the data collection and preparation of the study.

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