Cognitive and Metacognitive Changes in Exposure and Response Prevention Treatment for Obsessive –Compulsive Disorder:Empirical Support for a Metacognitive Model

Abstract

Exposure and response prevention (ERP) treatment for obsessive-compulsive disorder (OCD) has repeatedly been demonstrated as an efficient treatment for OCD and can be learned relatively easy by inexperienced student therapists (paper I). ERP was developed based on behavioral principles and the mechanisms of change have been suggested to involve reciprocal inhibition, counter-conditioning, habituation, extinction, or informal network-based emotional processing. More recent theories suggest cognitive and metacognitive beliefs as essential in the maintenance of OCD and that improvement following treatment could be mediated by changes in these beliefs. In paper II the validity of cognitive models of OCD and the metacognitive model of OCD was empirically tested. Support for the role of thought fusion beliefs, beliefs about rituals, and stop signals as predictors of obsessive-compulsive symptoms was documented. These metacognitive variables predicted more variance in obsessive compulsive symptoms than ordinary cognitions. Paper III documented further support for the metacognitive model by demonstrating empirically that change in metacognitions was a better predictor of treatment outcome than cognitive constructs such as perfectionism/certainty and responsibility/harm. The results suggested that modification of metacognitions could mediate reductions in symptoms when delivering ERP for OCD. However, the metacognitive model needs further investigation with more rigorous studies and analyses. Moreover, although the thesis suggests that changes in metacognition may be essential in ERP treatment of OCD it did not evaluate metacognitive therapy. In addition, the relationship between change in metacognition and change in specific obsessive-compulsive symptoms was not specified. This can now be tested using the Norwegian adaptation of the Obsessive Compulsive Inventory-Revised which seems to posses adequate psychometric properties allowing for dimensional assessment of obsessive-compulsive subtypes (Paper IV).