Cognitive therapy for obsessive–compulsive disorder
Introduction
Although medication and exposure with response prevention (ERP) are efficacious treatments for obsessive–compulsive disorder (OCD; e.g., Abramowitz, 1998), side-effects, nonresponse, and treatment refusal suggest alternatives are needed. Cognitive therapy (CT) may be a viable alternative or adjunct. Although different versions of CT have outperformed wait list, results are mixed in comparison to ERP (Cottraux et al., 2001; Jones & Menzies, 1998; McLean et al., 2001; van Oppen et al., 1995). However, the versions of CT investigated in these studies differ somewhat from conventional forms of CT. Whereas conventional forms address a wide variety of distortions (Beck (1976), Beck (1995)), most of the CTs examined in the OCD literature were designed to target one or two themes stipulated by the protocol. The treatment manual (Wilhelm & Steketee, 2001) in the current study includes modules to address a wider array of specific themes and permits greater flexibility to tailor specific interventions to individual clients.
Further, none of these studies have used treatments that incorporate strategies to target core beliefs. To enhance the depth with which meaningful cognitive change can occur and to align the treatment with more current CT approaches (e.g., Beck, 1995), the manual followed here includes focus on schemas in addition to automatic thoughts. Finally, behavioral experiments were minimized to facilitate a purer test of cognitive restructuring. Prior studies have included these experiments as important elements, which leaves open debate on the utility of a purely cognitive intervention.
Section snippets
Method
A multiple-baseline across subjects design was used to test CT's efficacy in reducing symptoms. To show efficacy, symptoms should be stable during baseline and then drop once treatment is introduced. Baseline was staggered across subjects (never <4 time points) to test whether any symptom decline was attributable to CT rather than time, testing, and contact with the clinic (Kazdin, 1992). The design was quasi- and not fully experimental because baseline length was not determined randomly, but
Results
Efficacy of CT was examined by visual inspection of change in compulsions across six individuals with staggered baselines and by analysis of clinically significant change indices and effect sizes. See Table 1.
Diary data were plotted for visual inspection of the change in target ratings over time. The efficacy of CT is supported if, after a stable baseline, symptoms decline when the intervention is introduced but not before, while subjects still in baseline remain stable or worsen. See Fig. 1.
On
Discussion
Overall, CT may be an acceptable choice for some OCD patients. Treatment was well tolerated, with no one dropping out. For two to three of the six, change was observed during but not before treatment, suggesting that change was likely due to treatment. Effect sizes for OCD were large, whereas effect sizes for both depression and anxiety were moderate.
Results here are generally consistent with other trials that emerged while the current study was in progress (Krochmalik, Jones, & Menzies, 2001;
Acknowledgements
This work was partially supported by the Harriet L. Rheingold Award and Smith Graduate Research Fund, as well as a National Research Service Award from the National Institute of Mental Health. We thank Jake Godfrey for his work as therapist on the study; Gail Steketee and Sabine Wilhelm for their consultation on treatment; Katie Lee, Rachel Maid, Tracy Moore, Mayowa Obasaju, Janelle Perkins, Lindsay Thomas, Fabiula Unger, and Jason Vickers for their help with treatment integrity coding;
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Present address: Department of Psychology, University of Pennsylvania.