Enhancing treatment outcome in cognitive behavioral therapy for obsessive compulsive disorder: The importance of cognitive factors

Abstract

Bedre behandlingsutfall ved kognitiv atferdsterapi for tvangslidelser: betydningen av kognitive faktorer

Bakgrunn: Tvangslidelser er en av de mest utbredte psykiske lidelsene og forbundet med betydelig redusert livskvalitet og funksjonsnivå. Hensikten med denne avhandlingen var å undersøke betydningen av komorbiditet, terapeutiske fellesfaktorer og kognitive antakelser for utfallet av kognitiv atferdsterapi for tvangslidelser.

Metode: I Paper I ble det benyttet data fra 35 pasienter med tvangslidelse som fullførte eksponering med responsprevensjon. Hierarkiske multiple regresjonsanalyser ble utført for å måle effekten av komorbide lidelser for behandlingsutfall. Data fra de samme 35 pasientene i tillegg til to pasienter som ikke fullførte behandlingen, ble inkludert i Paper II. Multiple regresjonsanalyser ble utført for å undersøke effekten av behandlingsmotivasjon, behandlingsforventning og behandlingsallianse for behandlingsutfall. I Paper III ble data fra 83 pasienter som fullførte kognitiv atferdsterapi inkludert. Regresjonsanalyser ble utført for å sammenlikne betydningen av kognitive- og metakognitive faktorer for å predikere symptomreduksjon og bedring. En litteraturgjennomgang ble gjennomført i Paper IV for å evaluere betydningen av kognitive- og metakognitive faktorer for behandlingen av tvangslidelser.

Resultater: I Paper I ble det rapportert at komorbide tilstander som GAD og/eller panikklidelse og personlighetsforstyrrelser predikerte utfall i eksponering med responsprevensjon ved tvangslidelser. Behandlingsallianse predikerte behandlingsutfall i Paper II. I Paper III ble det rapportert at behandlingsutfall var signifikant relatert til reduksjon i metakognitive antakelser selv etter at det ble kontrollert for andre antakelser. I Paper IV ble det rapportert at kognitiv- og metakognitiv terapi enda ikke er etablert som mer effektiv enn eksponering med responsprevensjon, men at metakognitive faktorer ser ut til å være av betydning for opprettholdelse av tvangslidelse.

Konklusjon: I denne avhandlingen ble det funnet at komorbid GAD og/eller panikklidelse, personlighetsforstyrrelser, positiv behandlingsallianse og metakognitive antakelser predikerer behandlingsutfall. Det gjenstår å se om kognitiv atferdsterapi kan forbedres ved at intervensjoner som er rettet mot disse faktorene blir benyttet

Introduction

Obsessive–compulsive disorder (OCD) is among the most common mental disorders in the population. When the disorder is untreated it is associated with high levels of personal distress, functional disability and represents a significant mental health problem. The general aim of the present study was to investigate if factors like comorbidity, treatment expectancy, the therapeutic alliance, treatment motivation and cognitive- and metacognitive beliefs predict treatment outcome in cognitive behavioral therapy for OCD, and if such treatment can be enhanced by integrating interventions based on such knowledge.

Method

In Paper I data from 35 patients diagnosed with OCD who completed individual exposure and response prevention treatment (ERP) were included. Hierarchical multiple regression analyses were performed to assess the effects of comorbid disorders on treatment outcome. Data from the same 35 patients together with data from two patients who dropped out of treatment was included in Paper II. Multiple regression analyses were performed to investigate the effect of treatment motivation, treatment expectancy, and helping alliance on treatment outcome. In Paper III data from 83 patients who completed cognitive behavior therapy was included. Regression analyses were performed to compare the importance of cognitive- and metacognitive factors in predicting symptom improvement and recovery. A comprehensive review of literature was performed in Paper IV in order to evaluate the importance of cognitive- and metacognitive factors in the treatment of OCD.

Results

In Paper I it was reported that comorbid conditions of GAD and/or panic disorder and personality disorders predict outcome in exposure and response prevention treatment (ERP) of OCD. Helping alliance was found to be significantly predictive of post-treatment Y-BOCS in Paper II. Response to ERP-treatment was significantly associated with reduction in metacognitive beliefs; even when other beliefs are controlled for in Paper III. In Paper IV it was reported that cognitive- or metacognitive therapy targeting dysfunctional beliefs, assumed to underlie the disorder, have yet to be established as more effective than ERR. However, the role of metacognitive factors in the maintenance of OCD seemed to be of importance.

Conclusion

In this work study several factors such as comorbid GAD and/or panic disorder and personality disorders, positive helping alliance and metacognitive beliefs were found to predict treatment outcome in cognitive behavior therapy for OCD. It remains to be seen if cognitive behavior therapy can be enhanced by adding interventions targeting these factors.