Skip to main content Accessibility help
×
Home
Hostname: page-component-78bd46657c-2pqp7 Total loading time: 0.286 Render date: 2021-05-09T23:35:43.749Z Has data issue: true Feature Flags: { "shouldUseShareProductTool": true, "shouldUseHypothesis": true, "isUnsiloEnabled": true, "metricsAbstractViews": false, "figures": false, "newCiteModal": false, "newCitedByModal": true }

Effectiveness of group-based cognitive–behavioural therapy in patients with obsessive–compulsive disorder

Published online by Cambridge University Press:  02 January 2018

Colette Kearns
Affiliation:
St Patrick's University Hospital, Dublin
Yvonne Tone
Affiliation:
St Patrick's University Hospital, Dublin
Gavin Rush
Affiliation:
St Patrick's University Hospital, Dublin
James V. Lucey
Affiliation:
St Patrick's University Hospital, Dublin Trinity College, Dublin
Corresponding
E-mail address:
Rights & Permissions[Opens in a new window]

Abstract

Aims and method

To establish whether cognitive-behavioural therapy (CBT) with response and exposure prevention (ERP) is effective in individuals with obsessive–compulsive disorder (OCD). Twenty-four patients with OCD, divided into four groups, participated in ten sessions of group CBT. All patients completed the Yale–Brown Obsessive–Compulsive Scale (Y-BOCS), the Maudsley Obsessive–Compulsive Inventory (MOCI), the Beck Depression Inventory (BDI) and the Beck Anxiety Inventory (BAI) pre- and post-treatment.

Results

The mean (s.d.) YBOC score post-treatment was 17.1 (5.8). This was significantly lower than the mean (s.d.) YBOC pre-treatment (24.7 (6.1); t = 8.4, d.f. = 23, P < 0.005). A significant reduction was also observed in relation to all other rating scales.

Clinical implications

Cognitive–behavioural therapy for OCD delivered in a group setting is a clinically effective and acceptable treatment for patients. The use of group-based CBT is an effective means to improve access to psychotherapy.

Type
Original Papers
Creative Commons
Creative Common License - CCCreative Common License - BY
This is an Open Access article, distributed under the terms of the Creative Commons Attribution (CC-BY) license (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted re-use, distribution, and reproduction in any medium, provided the original work is properly cited.
Copyright
Copyright © The Royal College of Psychiatrists, 2010

Exposure and response prevention (ERP) is the behavioural treatment of choice for obsessive-compulsive disorder (OCD). Reference Van Oppen, Steketee, Pato and Zohar1 Many early studies showed 70–75% improvement after 15 sessions of ERP, Reference Marks, Hodgson and Rachman2,Reference Emmelkamp and Kraaen3 but later studies showed positive gains from cognitive approaches aimed at reducing obsessions and rituals. Several cognitive models have been proposed for OCD, including those of Salkovskis Reference Salkovskis4 and Rachman. Reference Rachman5 Rachman suggests that obsessions are caused by catastrophic misinterpretation of the significance of one's thoughts as originating in normal intrusive thoughts which are interpreted in relation to responsibility beliefs, controllability of thoughts and beliefs concerning danger and threat. Danger ideation reduction therapy, for individuals with OCD with washing/contamination concerns, has been shown to be as useful as ERP. Reference Jones and Menzies6Reference Jones and Menzies8

Despite increasing interest in the role of cognitive therapy in the treatment of OCD, there is limited evidence to suggest that cognitive therapy is superior to ERP. In a study of three groups, one receiving cognitive therapy alone, one receiving ERP alone and one receiving ERP with cognitive therapy, there were no reported differences between the groups. Reference Krochmalik, Jones and Menzies9 Another study showed no difference between rational emotive therapy (analysing irrational thoughts) and exposure in vivo. Reference van Oppen, de Haan, van Balkom, Spinhoven, Hoogduin and van Dyck10

Patients with OCD respond well to individual therapy combining behavioural and cognitive approaches (cognitive–behavioural therapy, CBT) when delivered by a trained therapist. Reference Emmelkemp and Beens11 Unfortunately, the supply of trained CBT therapists is limited, leading to long waiting lists for this essential psychotherapy. Despite this, few studies have examined the effectiveness of group therapy for OCD. Krone et al Reference van Oppen, van Balkom, de Haan and van Dyck12 used psychoeducation about cognitive therapy and ERP approaches with 36 patients in weekly groups for 7 weeks. Yale–Brown Obsessive–Compulsive Scale (Y-BOCS) scores changed significantly from moderately severe before treatment to below clinical levels at 3-month follow-up. A further study compared three groups: group one received ERP, group two received individual ERP and group three received individual sessions of progressive muscle relaxation. This study demonstrated that, after 2 h once-weekly sessions, both individual and group ERP showed significant post-treatment improvement in OCD symptoms, depression and anxiety scores. Reference Krone, Himle and Nesse13 Bouvard et al Reference Fals-Stewart, Marks and Shafer14 reported that 19 patients treated with six sessions of cognitive therapy followed by six sessions of ERP had a significant improvement following the cognitive therapy, but the addition of the ERP did not improve the patients further. The study was uncontrolled and non-randomised, but the clinical impression was that cognitive therapy helped to maintain the results in the long term.

Method

As a result of the limited data available on group CBT for patients with OCD, we undertook this naturalistic study in the Department of Cognitive Behavioural Therapy, St Patrick's University Hospital, Dublin, Ireland. St Patrick's is a 300-bed facility affiliated to the University of Dublin, Trinity College, and a national referral centre for the management of mental illness. The CBT department has a particular interest in individuals with OCD.

Twenty-seven patients with OCD consecutively referred for CBT were invited to participate in group CBT as an alternative to individual treatment. Three patients declined, preferring to remain on the waiting list for individual therapy. Three of the 24 patients dropped out of the study during the course of the programme. All were out-patients and each met the DSM–IV criteria for OCD. Reference Bouvard15 They were referred by general practitioners and reviewed by consultant psychiatrists. The therapists worked under the supervision of a consultant psychiatrist.

We divided the participants into four groups (five, four, eight and seven patients). Each patient underwent an initial screen for diagnosis using DSM–IV criteria and suitability for CBT (e.g. motivation for change, behavioural goals, willingness to participate in a group). Ten men and fourteen women participated.

Seventeen patients were established on a selective serotonin reuptake inhibitor prior to participation in the group. The remaining seven patients were drug-free. The patients did not have any changes to their pharmacological treatment or participate in an alternative psychotherapeutic intervention during the course of the group therapy.

All participants completed pre- and post-treatment questionnaires. The rating scales used were the Yale–Brown Obsessive–Compulsive Scale (Y-BOCS), 16 the Maudsley Obsessive–Compulsive Inventory (MOCI), Reference Goodman, Price, Rasmussen, Mazure, Delgado and Heniger17 the Life Adjustment Questionnaire and Visual Analogue Problems and Goals Measure, Reference Sternberger and Burns18 the Beck Depression Inventory (BDI), Reference Marks and Matthew19 and the Beck Anxiety Inventory (BAI). Reference Beck, Steer and Garbin20

Each group completed ten 90-minute CBT sessions, facilitated by a trained CBT therapist (YT or CK); the first and last group were facilitated by both therapists. A consultant psychiatrist (JVL) co-facilitated one session per group. Generally, each session began with feedback from the previous session, followed by a review of the previous week, a teaching part on a planned topic, discussion within the group, a key learning point and homework. The group format is presented in Table 1.

Table 1 Summary of interventiona,

Session Planb
1 Introductions, purpose of group, ground rules
Definition of OCD, CBT rationale for treatment, handouts, ratings/measures done
Key learning points, homework for week
2 Goal-setting
Maintenance of OCD, exposure and response prevention
Key learning point and homework
3 Continued teaching on exposure and response prevention
Key learning point and homework
4 Obsessive thoughts diary
Work on responsibilities and appraisals
Key learning point and homework
5 Specific work on thoughts; meaning, gathering evidence, use of thought diary
Set behavioural experiment
6 Cognitive strategies: probability measures, ‘responsibility pie’ Reference Krochmalik, Jones and Menzies9
Set homework
7 Review of goals
Overview of CBT strategies so far
Key learning point and homework
8 Case formulation, developing own by looking at early experiences and beliefs and rules that maintain OCD
Key learning point and homework
9 Review of skills learned
Blueprint of recovery
Relapse prevention
10 Preparation for discharge
Feedback regarding group
Follow-up

The group initially focused on exploring the fear and avoidance model of OCD and how this contributes to maintaining OCD cycles. It then moved into evolving a formulation based on Salkovskis' Reference Salkovskis4 model. The group then focused on misinterpretation of thoughts and the rose of neutralisation, i.e. engaging in overt or covert impulsive rituals which maintain the illness. The group then moved on to look at appraisals that maintain OCD and challenged the meaning clients attribute to having the thoughts in the first place. We also explored patients' tendencies to overestimate dangers and their responsibility attached to events. Through the use of thought diaries we encouraged patients to watch out for misinterpretations of the significance of their thoughts and to identify and challenge them when possible. We then requested participants to identify a key learning point at the end of each session and from this the ERP homework task was collaboratively derived. Each participant was encouraged to see how their experience fits into Salkovskis' model. At the end of therapy, participants were encouraged to design a blueprint for recovery summarising what they have learnt during the group sessions and what they need to focus on to consolidate the progress made in managing their OCD.

Statistical analysis was carried out using SPSS version 12 for Windows. Paired student's t-tests were used to compare symptom levels, using an intention-to-treat analysis (due to three non-completers), pre-treatment and post-treatment. Pearson's product moment correlation examined relationships between clinical characteristics and symptom variables.

Ethical approval for this study was obtained from the research ethics committee, St Patrick's University Hospital.

Results

Participants

There were 10 men and 14 women in the participant sample. The mean (s.d.) age of the participants was 43 years (range 26–68 years). The mean (s.d.) age at illness onset was 20 years (range 6–62 years). The mean (s.d.) illness duration was 21.6 years (range 2–50 years).

Measures of illness severity pre- and post-treatment

There was a significant reduction in clinical symptom ratings on completion of group CBT for individuals with OCD (Table 1).

There were no significant correlations between age, age at onset, illness duration and clinical variables (e.g. severity of illness) in relation to treatment response (Table 2).

Table 2 Rating scales: baseline scores and outcomes

Pre-treatment score Mean (range) Post-treatment score Mean (range) Significance of changea
Yale—Brown Obsessive—Compulsive Scale 24.7 (12-38) 17.1 (6-28) t=8.4
Maudsley Obsessive—Compulsive Inventory 17 (5-26) 14.4 (5-20) t=3.3
Beck Depression Inventory 21.9 (3-45) 13.8 (0-31) t=5.88
Beck Anxiety Inventory 20.8 (7-43) 15.7 (3-34) t=4.9

Discussion

Without access to effective CBT/ERP, many individuals with OCD will remain symptomatic. This disorder is not amenable to other forms of psychotherapy and it has a very low rate of placebo response. Reference Beck, Epstein and Brown21 This fact alone distinguishes it therapeutically from many other psychiatric disorders.

Although it is generally accepted that this patient group needs access to CBT/ERP, Reference de Veaugh-Geiss, Landau and Katz22 many patients are denied this form of treatment because of the scarcity of trained CBT therapists. It has been suggested that CBT could be applied in groups, with results equivalent to those of individual treatment, particularly when the number of sessions is comparable with that usually provided for individual patients in controlled research (i.e. 12–20 sessions). Reference Van Oppen, Steketee, Pato and Zohar1 Individuals with OCD frequently postpone requests for therapeutic help for many years and when they do present to services they may be faced with a long waiting list for effective psychotherapy. Evidence confirming the effectiveness of group-based CBT/ERP is therefore welcome as an aid to increase the availability of therapy to patients without a necessary increase in resources.

We have previously reported that individuals with OCD frequently refuse to participate in individual behavioural therapy. Reference Braga, Cordioli, Niederauer and Manfro23 However, the low level of drop-out from the CBT groups supports the impression that group therapy is an acceptable way of delivering CBT.

Limitations of the study

Our study is limited in scale and the participants were not randomised but selected consecutively from the waiting list for individual CBT. On completion of the treatment, patients were referred back to their treating clinician for ongoing care. We therefore have not collected data on longer-term outcomes or further management.

In summary, this study was performed in a naturalistic setting reflecting practice in a busy CBT department. Further study is warranted, such as a randomised control study comparing group, individual and biological therapies. However, our study confirms the prima facie case for including group-delivered CBT in any such comparison study. The provision of group CBT would allow this effective therapy to be available on a wider scale than currently.

Footnotes

Declaration of interest

None.

References

1 Van Oppen, BL, Steketee, G. Individual, group and multifamily cognitive-behavioural treatments. In Current Treatments of Obsessive-Compulsive Disorder (eds Pato, MT, Zohar, J): 133–72. American Psychiatric Press, 1991.Google Scholar
2 Marks, IM, Hodgson, R, Rachman, S. Treatment of chronic obsessive–compulsive neurosis by in vivo exposure: a two-year follow-up and issues in treatment. Br J Psychiatry 1975; 127: 349–64.CrossRefGoogle ScholarPubMed
3 Emmelkamp, PM, Kraaen, J. Therapist-controlled exposure in vivo versus self-controlled exposure in vivo: a comparison with obsessive–compulsive patients. Behav Res Ther 1977; 15: 491–5.CrossRefGoogle ScholarPubMed
4 Salkovskis, PM. Obsessional-compulsive problems: a cognitive–behavioural analysis. Behav Res Ther 1985; 23: 571–83.CrossRefGoogle ScholarPubMed
5 Rachman, S. A critique of cognitive therapy for anxiety disorders. J Behav Ther Exp Psych 1993; 24: 279–88.CrossRefGoogle ScholarPubMed
6 Jones, MK, Menzies, RG. Danger ideation reduction therapy (DIRT): preliminary findings with three obsessive-compulsive washers. Behav Res Ther 1997; 35: 955–60.CrossRefGoogle ScholarPubMed
7 Jones, MK, Menzies, RG. Danger ideation reduction therapy (DIRT) for obsessive–compulsive washers. A controlled trial. Behav Res Ther 1998; 36: 959–70.CrossRefGoogle ScholarPubMed
8 Krochmalik, A, Jones, MK, Menzies, RG. Danger ideation reduction therapy (DIRT) for treatment-resistant compulsive washing. Behav Res Ther 2001; 39: 897912.CrossRefGoogle ScholarPubMed
9 van Oppen, P, de Haan, E, van Balkom, AJLM, Spinhoven, P, Hoogduin, K, van Dyck, R. Cognitive therapy and exposure in vivo in the treatment of obsessive–compulsive disorder. Behav Res Ther 1995; 33: 379–90.CrossRefGoogle ScholarPubMed
10 Emmelkemp, PM, Beens, H. Cognitive therapy with obsessive–compulsive disorder: a comparative evaluation. Behav Res Ther 1991; 29: 293300.CrossRefGoogle Scholar
11 van Oppen, P, van Balkom, AJLM, de Haan, E, van Dyck, R. Cognitive therapy and exposure in vivo alone and in combination with fluvoxamine in obsessive–compulsive disorder: a 5-year follow-up. J Clin Psychiatry 2005; 66: 1415–22.CrossRefGoogle ScholarPubMed
12 Krone, K, Himle, J, Nesse, R. A standardised behaviour group treatment program for obsessive-compulsive disorder: preliminary outcomes. Behav Res Ther 1991; 23: 627–31.Google Scholar
13 Fals-Stewart, W, Marks, AP, Shafer, J. A comparison of behavioural group therapy and individual behaviour therapy in treating obsessive–compulsive disorder. J Nerv Ment Dis 1993; 181: 189–93.CrossRefGoogle ScholarPubMed
14 Bouvard, M. A standardised cognitive-behavioural group treatment for obsessive–compulsive disorder: preliminary outcomes. Encephale 2002; 28: 439–46.Google Scholar
15 American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders (4th edn) (DSM–IV). APA, 2000.Google Scholar
16 Goodman, WK, Price, LH, Rasmussen, SA, Mazure, C, Delgado, P, Heniger, GR, et al. The Yale–Brown Obsessive–Compulsive Scale. 1. Development use and reliability. Arch Gen Psych 1989; 46: 1006–11.Google Scholar
17 Sternberger, LG, Burns, GL. Maudsley Obsessional–Compulsive Inventory: obsessions and compulsions in a non-clinical sample. Behav Res Ther 1990; 28: 337–40.CrossRefGoogle Scholar
18 Marks, IM, Matthew, AM. Brief standard rating for phobic patients. Behav Res Ther 1979; 17: 263–7.CrossRefGoogle ScholarPubMed
19 Beck, AT, Steer, RA, Garbin, MG. Psychometric properties of the Beck Depression Inventory: twenty five years of evaluation. Clin Psychol Rev 1988; 8: 77100.CrossRefGoogle Scholar
20 Beck, AT, Epstein, N, Brown, G. An inventory for measuring anxiety: psychometric properties. J Consult Clin Psychol 1988; 56: 893–7.CrossRefGoogle ScholarPubMed
21 de Veaugh-Geiss, J, Landau, P, Katz, R. Preliminary results from a multicentre trial of clomipramine in obsessive-compulsive disorder. Psychopharmac Bull 1989; 25: 3640.Google Scholar
22 Braga, DT, Cordioli, AV, Niederauer, K, Manfro, GG. Cognitive–behavioral group therapy for obsessive–compulsive disorder: a 1 year follow-up. Act Psych Scand 2005; 112: 180–6.Google ScholarPubMed
23 Lucey, JV, Butcher, G, Clare, AW, Dinan, TG, et al. The clinical characteristics of patients with obsessive compulsive disorder. A descriptive study of an Irish sample. Ir J Psychol Med 1994; 11: 11–4.CrossRefGoogle Scholar
Submit a response

eLetters

No eLetters have been published for this article.
You have Access
Open access

Send article to Kindle

To send this article to your Kindle, first ensure no-reply@cambridge.org is added to your Approved Personal Document E-mail List under your Personal Document Settings on the Manage Your Content and Devices page of your Amazon account. Then enter the ‘name’ part of your Kindle email address below. Find out more about sending to your Kindle. Find out more about sending to your Kindle.

Note you can select to send to either the @free.kindle.com or @kindle.com variations. ‘@free.kindle.com’ emails are free but can only be sent to your device when it is connected to wi-fi. ‘@kindle.com’ emails can be delivered even when you are not connected to wi-fi, but note that service fees apply.

Find out more about the Kindle Personal Document Service.

Effectiveness of group-based cognitive–behavioural therapy in patients with obsessive–compulsive disorder
Available formats
×

Send article to Dropbox

To send this article to your Dropbox account, please select one or more formats and confirm that you agree to abide by our usage policies. If this is the first time you use this feature, you will be asked to authorise Cambridge Core to connect with your <service> account. Find out more about sending content to Dropbox.

Effectiveness of group-based cognitive–behavioural therapy in patients with obsessive–compulsive disorder
Available formats
×

Send article to Google Drive

To send this article to your Google Drive account, please select one or more formats and confirm that you agree to abide by our usage policies. If this is the first time you use this feature, you will be asked to authorise Cambridge Core to connect with your <service> account. Find out more about sending content to Google Drive.

Effectiveness of group-based cognitive–behavioural therapy in patients with obsessive–compulsive disorder
Available formats
×
×

Reply to: Submit a response


Your details


Conflicting interests

Do you have any conflicting interests? *