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Metacognitive therapy versus exposure and response prevention for obsessive-compulsive disorder – A non-inferiority randomized controlled trial
... MCT focuses on beliefs about rituals, thoughts and thought process instead of thought contents and does not include repeated or prolonged exposure exercises. At present, three randomized controlled trials (RCTs) are available which addressed the efficacy of MCT in OCD (Exner et al., 2024;Glombiewski et al., 2021;Melchior et al., 2023). The studies by Glombiewski et al. (2021) and Melchior et al. (2023) did not find statistically significant differences in efficacy between MCT and ERP, neither in symptom severity (Y-BOCS) nor in success rates (Glombiewski et al., 2021;Melchior et al., 2023). ...
... The studies by Glombiewski et al. (2021) and Melchior et al. (2023) did not find statistically significant differences in efficacy between MCT and ERP, neither in symptom severity (Y-BOCS) nor in success rates (Glombiewski et al., 2021;Melchior et al., 2023). Exner et al. (2024) reported MCT to be non-inferior to ERP, "especially at post-treatment". In the following, we will discuss these 3 RCTs with regard to the question whether the available evidence justifies to consider MCT as non-inferior to ERP. ...
... Thus, the efficacy of MCT has not been demonstrated in these RCTs. Pre-post changes or success rates are not sufficient for a strict proof of efficacy, since they lack a comparison condition The third study (Exner et al., 2024) planned to consider MCT as non-inferior to ERP if MCT showed less drop-outs and turned out to be non-inferior at both post-treatment and follow-up with regard to improvements in the Yale-Brown-Obsessive Compulsive Scale (Y-BOCS) (Exner et al., 2024, p. 2, 5). From their results, Exner et al. (2024) concluded that MCT is "non-inferior to ERP, especially at post-treatment". ...
There is evidence that exposure and response prevention (ERP) is efficacious in the treatment of obsessive-compulsive disorder (OCD). As an alternative to ERP metacognitive therapy (MCT) was developed. Two previous randomized controlled trials (RCTs) did not find significant differences between MCT and ERP. However, from non-significant results, non-inferiority of a treatment cannot be concluded. For this purpose, non-inferiority studies are required. Exner and colleagues carried out such a non-inferiority study whose results were recently published in this journal. The authors concluded from their results that MCT is a viable alternative treatment with efficacy similar to the standard ERP. However, this study raises several concerns, among them problems of transparency and of non-inferiority testing. These issues are critically discussed here in more detail. Taking all of these issues into account, the conclusions that can be drawn from the available studies are less clear. Further research is needed to decide whether MCT can really be considered as non-inferior to ERP or even as efficacious at all. Future studies need to fulfill the criteria of non-inferiority trials, that is (a) a priori define and (b) empirically justify a non-inferiority margin, (c) a preregistered sample size calculation ensuring a sufficient statistical power to confirm non-inferiority of the test treatment and (d) include a non-active control condition against which the standard and the test treatment are tested. Recommending a treatment prematurely as non-inferior to a standard treatment may prevent patients from receiving the most efficacious treatment.
... ERP, widely regarded as the gold standard in OCD treatment, involves gradual exposure to obsessional triggers while preventing the accompanying compulsive rituals, thereby helping individuals develop tolerance to anxiety and uncertainty over time [7,8]. This approach has shown efficacy in reducing obsessional severity, as evidenced by improvements on standardized scales like the Yale-Brown Obsessive Compulsive Scale (Y-BOCS) [9]. Nevertheless, ERP's intensive demands often result in high dropout rates, posing challenges to its implementation [9]. ...
... This approach has shown efficacy in reducing obsessional severity, as evidenced by improvements on standardized scales like the Yale-Brown Obsessive Compulsive Scale (Y-BOCS) [9]. Nevertheless, ERP's intensive demands often result in high dropout rates, posing challenges to its implementation [9]. CBT offers a complementary approach by focusing on modifying maladaptive thought patterns and reducing avoidance behaviors [10]. ...
The paper introduces the "Founder Mode Entrepreneurial Experience" (FMEE), a novel therapeutic framework rooted in transpersonal psychology that reimagines entrepreneurial engagement as exposure therapy for individuals with Moral Scrupulosity Obsessive-Compulsive Disorder (OCD). FMEE emphasizes confronting ethical dilemmas, embracing imperfection, and navigating moral ambiguities through mission-driven entrepreneurial activities. This approach not only facilitates desensitization to scrupulosity-related triggers but also fosters resilience, self-efficacy, and a purpose-driven mindset. Integrating transpersonal practices such as mindfulness, altruism, and intuitive decision-making, FMEE bridges personal healing with meaningful social impact. The manuscript underscores FMEE's transformative potential as a practical and spiritually grounded intervention for reducing moral rigidity and fostering holistic well-being. Implications for OCD therapy, transpersonal psychology, and social entrepreneurship are discussed, along with future research directions at the intersection of psychology and mission-driven innovation.
Background: Studies evaluating the efficacy of detached mindfulness (DM) as a stand-alone intervention for patients with panic disorder are lacking in the literature. In this con-text, the aim of this open study was to evaluate the efficacy of DM in patients with panic disorder. Methods: The study was conducted in 11 patients (7 females and 4 males). The DM ther-apy process was applied to the patients. The clinical course was followed using the Panic Disorder Severity Scale (PDSS), the Beck Anxiety Inventory (BAI), and the Beck Depression Inventory (BDI). Results: Patients’ attendance at therapy and completion of DM homework were found to be quite good. Patients’ PDSS scores decreased significantly at the end of treatment com-pared to baseline. A similar change was seen in the BAI and BDI scores. Conclusion: In conclusion, it can be stated that DM is an effective, easily applicable, and highly therapeutic method for the treatment of patients with panic disorder. However, the present study needs to be supported by future studies with larger samples.
O Transtorno Obsessivo Compulsivo (TOC) é um distúrbio neuropsicológico caracterizado por obsessões e/ou compulsões que causam grande prejuízo na vida do indivíduo. Seu diagnóstico é realizado por meio de critérios dispostos pelo Manual Diagnóstico e Estatístico de Transtornos Mentais (DSM-5). A fisiopatologia desse transtorno ainda não está totalmente elucidada, contudo diversos avanços no estudo da área têm mostrado novos circuitos neuronais envolvidos na fisiopatologia do TOC e, com isso, novas possibilidades de tratamento. Um desses tratamentos é a utilização do composto canabidiol (CBD), presente na Cannabis Sativa, como farmacoterapia, já que o circuito do Eistema Endocanabinoide (SEC), segundo os estudos, tem se mostrado presente na fisiopatologia do TOC. Com isso, essa revisão integrativa de literatura tem como objetivo analisar a efetividade do uso da cannabis no tratamento desse transtorno, bem como analisar os avanços na área e as questões éticas envolvidas.
In summary, we provide the field with empirically derived Y-BOCS severity benchmarks across the lifespan which will be useful in research and clinical settings (subclinical OCD: 0-13 points; mild OCD: 14-21 points; moderate OCD: 22-29 points; severe OCD: 30-40 points). However, due to the modest accuracy of the classifications, we caution against the exclusive use of these benchmarks to guide important clinical decisions regarding individual patients, such as offering access to specialist treatment. Other relevant variables should be used, together with Y-BOCS scores, to guide clinical decision making and resource allocation, such as duration of the disorder, time without adequate treatment, psychiatric and somatic comorbidities, family accommodation, socioeconomic circumstances, and personal treatment history.
Importance:
Cognitive behavioral therapy (CBT) for obsessive-compulsive disorder (OCD) is a highly specialized treatment that is in short supply worldwide.
Objectives:
To investigate whether both therapist-guided and unguided internet-based CBT (ICBT) are noninferior to face-to-face CBT for adults with OCD, to conduct a health economic evaluation, and to determine whether treatment effects were moderated by source of participant referral.
Design, setting, and participants:
This study is a single-blinded, noninferiority, randomized clinical trial, with a full health economic evaluation, conducted between September 2015 and January 2020, comparing therapist-guided ICBT, unguided ICBT, and individual face-to-face CBT for adults with OCD. Follow-up data were collected up to 12 months after treatment. The study was conducted at 2 specialist outpatient OCD clinics in Stockholm, Sweden. Participants included a consecutive sample of adults with a primary diagnosis of OCD, either self-referred or referred by a clinician. Data analysis was performed from June 2019 to January 2022.
Interventions:
Guided ICBT, unguided ICBT, and face-to-face CBT delivered over 14 weeks.
Main outcomes and measures:
The primary end point was the change in OCD symptom severity from baseline to 3-month follow-up. The noninferiority margin was 3 points on the masked assessor-rated Yale-Brown Obsessive Compulsive Scale.
Results:
A total of 120 participants were enrolled (80 women [67%]; mean [SD] age, 32.24 [9.64] years); 38 were randomized to the face-to-face CBT group, 42 were randomized to the guided ICBT group, and 40 were randomized to the unguided ICBT group. The mean difference between therapist-guided ICBT and face-to-face CBT at the primary end point was 2.10 points on the Yale-Brown Obsessive Compulsive Scale (90% CI, -0.41 to 4.61 points; P = .17), favoring face-to-face CBT, meaning that the primary noninferiority results were inconclusive. The difference between unguided ICBT and face-to-face CBT was 5.35 points (90% CI, 2.76 to 7.94 points; P < .001), favoring face-to-face CBT. The health economic analysis showed that both guided and unguided ICBT were cost-effective compared with face-to-face CBT. Source of referral did not moderate treatment outcome. The most common adverse events were anxiety (30 participants [25%]), depressive symptoms (20 participants [17%]), and stress (11 participants [9%]).
Conclusions and relevance:
The findings of this randomized clinical trial of ICBT vs face-to-face CBT for adults with OCD do not conclusively demonstrate noninferiority. Therapist-guided ICBT could be a cost-effective alternative to in-clinic CBT for adults with OCD in scenarios where traditional CBT is not readily available; unguided ICBT is probably less efficacious but could be an alternative when providing remote clinician support is not feasible.
Trial registration:
ClinicalTrials.gov Identifier: NCT02541968.
Cognitive-behavior therapy (CBT), delivered in an individual or group format, is the recommended treatment of choice for Obsessive-Compulsive Disorder (OCD), but no studies have benchmarked the outcomes for group CBT in real-world clinical settings. The first aim of this evaluation was to benchmark the outcomes for group CBT in a sample of 125 patients who attended a routine clinical service for OCD. The results showed that the outcomes for the group CBT were comparable to those reported in previous treatment studies. However, consistent with the CBT for OCD literature, 28% of patients receiving CBT reported minimal improvement. The second aim of this evaluation was to carry out a benchmarking analysis for group metacognitive therapy (MCT) to determine if this could provide any advantages in a sample of 95 patients who also attended this clinical service over a subsequent period. The clinically significant results obtained for group MCT improved upon or equaled those obtained for group CBT and those typically found in treatment studies. The group MCT cohort improved significantly more than the group CBT cohort even after controlling for important pre-treatment variables including age, gender, number of diagnoses, symptoms of depression, and psychotropic medication. MCT had significantly higher clinical response rates. Based on international expert consensus criteria, 86.3% of patients in the MCT cohort responded compared with 64% in CBT. The implications of these findings are discussed.
Exposure-based interventions are a core ingredient of evidence-based cognitive-behavioral treatment (CBT) for anxiety disorders, posttraumatic stress disorder (PTSD), and obsessive-compulsive disorder (OCD). However, previous research has documented that exposure is rarely utilized in routine care, highlighting an ongoing lack of dissemination. The present study examined barriers for the dissemination of exposure from the perspective of behavioral psychotherapists working in outpatient routine care (N = 684). A postal survey assessed three categories of barriers: i) practicability of exposure-based intervention in an outpatient private practice setting, ii) negative beliefs about exposure, and iii) therapist distress related to the use of exposure. In addition, self-reported competence to conduct exposure for different anxiety disorders, PTSD, and OCD was assessed. High rates of agreement were found for single barriers within each of the three categories (e.g., unpredictable time management, risk of uncompensated absence of the patient, risk of decompensation of the patient, superficial effectiveness, or exposure being very strenuous for the therapist). Separately, average agreement to each category negatively correlated with self-reported utilization of exposure to a moderate degree ( -.35 ≤ r ≤ -.27). In a multiple regression model, only average agreement to barriers of practicability and negative beliefs were significantly associated with utilization rates. Findings illustrate that a multi-level approach targeting individual, practical, and systemic barriers is necessary to optimize the dissemination of exposure-based interventions. Dissemination efforts may therefore benefit from incorporating strategies such as modifying negative beliefs, adaptive stress management for therapists, or increasing practicability of exposure-based interventions.
Following a review of extant reporting standards for scientific publication, and reviewing 10 years of experience since publication of the first set of reporting standards by the American Psychological Association (APA; APA Publications and Communications Board Working Group on Journal Article Reporting Standards, 2008), the APA Working Group on Quantitative Research Reporting Standards recommended some modifications to the original standards. Examples of modifications include division of hypotheses, analyses, and conclusions into 3 groupings (primary, secondary, and exploratory) and some changes to the section on meta-analysis. Several new modules are included that report standards for observational studies, clinical trials, longitudinal studies, replication studies, and N-of-1 studies. In addition, standards for analytic methods with unique characteristics and output (structural equation modeling and Bayesian analysis) are included. These proposals were accepted by the Publications and Communications Board of APA and supersede the standards included in the 6th edition of the Publication Manual of the American Psychological Association (APA, 2010).
Obsessive–compulsive disorder (OCD) is a relatively common and disabling condition.
Objectives
To determine the clinical effectiveness, acceptability and cost-effectiveness of pharmacological and psychological interventions for the treatment of OCD in children, adolescents and adults.
Data sources
We searched the Cochrane Collaboration Depression, Anxiety and Neurosis Trials Registers, which includes trials from routine searches of all the major databases. Searches were conducted from inception to 31 December 2014.
Review methods
We undertook a systematic review and network meta-analysis (NMA) of the clinical effectiveness and acceptability of available treatments. Outcomes for effectiveness included mean differences in the total scores of the Yale–Brown Obsessive–Compulsive Scale or its children’s version and total dropouts for acceptability. For the cost-effectiveness analysis, we developed a probabilistic model informed by the results of the NMA. All analyses were performed using OpenBUGS version 3.2.3 (members of OpenBUGS Project Management Group; see
www.openbugs.net
).
Results
We included 86 randomised controlled trials (RCTs) in our systematic review. In the NMA we included 71 RCTs (54 in adults and 17 in children and adolescents) for effectiveness and 71 for acceptability (53 in adults and 18 in children and adolescents), comprising 7643 and 7942 randomised patients available for analysis, respectively. In general, the studies were of medium quality. The results of the NMA showed that in adults all selective serotonin reuptake inhibitors (SSRIs) and clomipramine had greater effects than drug placebo. There were no differences between SSRIs, and a trend for clomipramine to be more effective did not reach statistical significance. All active psychological therapies had greater effects than drug placebo. Behavioural therapy (BT) and cognitive therapy (CT) had greater effects than psychological placebo, but cognitive–behavioural therapy (CBT) did not. BT and CT, but not CBT, had greater effects than medications, but there are considerable uncertainty and methodological limitations that should be taken into account. In children and adolescents, CBT and BT had greater effects than drug placebo, but differences compared with psychological placebo did not reach statistical significance. SSRIs as a class showed a trend for superiority over drug placebo, but the difference did not reach statistical significance. However, the superiority of some individual drugs (fluoxetine, sertraline) was marginally statistically significant. Regarding acceptability, all interventions except clomipramine had good tolerability. In adults, CT and BT had the highest probability of being most cost-effective at conventional National Institute for Health and Care Excellence thresholds. In children and adolescents, CBT or CBT combined with a SSRI were more likely to be cost-effective. The results are uncertain and sensitive to assumptions about treatment effect and the exclusion of trials at high risk of bias.
Limitations
The majority of psychological trials included patients who were taking medications. There were few studies in children and adolescents.
Conclusions
In adults, psychological interventions, clomipramine, SSRIs or combinations of these are all effective, whereas in children and adolescents, psychological interventions, either as monotherapy or combined with specific SSRIs, were more likely to be effective. Future RCTs should improve their design, in particular for psychotherapy or combined interventions.
Study registration
The study is registered as PROSPERO CRD42012002441.
Funding details
The National Institute for Health Research Health Technology Assessment programme.
- SUPPLEMENTARY RESOURCES ARE ATTACHED: Full Report and Quick Reference Guide -
Marked inconsistencies exist in how terms such as treatment response, remission, recovery, and relapse are defined in clinical trials of Obsessive-Compulsive Disorder (OCD). This severely impairs the comparability of results across these trials and communication in the field. The aim of this study was to reach an international expert consensus on the conceptual and operational definitions of treatment response, remission, recovery, and relapse in clinical trials of OCD. First, second, last, and corresponding authors of international peer-reviewed papers on OCD published between 2007 and 2013 were invited to participate in a multi-stage Delphi survey. The responses obtained in Round 1 were analyzed and a summary returned to the participants. In Round 2, a new set of questions was designed to facilitate consensus on any remaining issues. For each definition, consensus was defined as ≥ 80% agreement. Consistent with the literature, the results of Round 1 illustrated that, while there was broad consensus regarding the conceptual definitions, lack of agreement was the norm regarding the operationalization of these constructs. At the end of Round 2, broad consensus (> 82% agreement) was achieved for all definitions except for the duration requirement for treatment response and remission. Based on the results, we propose consensus definitions for treatment response, remission, recovery, and relapse. Use of these definitions will improve the comparability across treatment studies and the communication between researchers, clinicians, and patients.
This article summarizes and scrutinizes the growth of the development of clinically relevant and psychometrically sound approaches for determining the clinical significance of treatment effects in mental health research by tracing its evolution, by examining modifications in the method, and by discussing representative applications. Future directions for this methodology are proposed.
Objective: Although treatments with demonstrated efficacy exist for Obsessive-compulsive disorder (OCD); researches on the effectiveness of combined treatment versus psychotherapy or drug treatment are controversial. The aim of this study was to compare the efficacy of Metacognitive therapy (MCT), fluvoxamine and the combination of MCT with fluvoxamine treatment in treating patients with OCD. Methods: Twenty-one outpatients meeting DSM-IV-TR criteria for OCD without any other axis I and II disorder were randomly assigned to one of three treatment conditions for 10 weeks of treatment: MCT, fluvoxamine, and combined treatment group. The Yale-Brown Obsessive-compulsive scale (Y-BOCS), Beck depression inventory-II-second edition (BDI-II), and Beck anxiety inventory (BAI) were administered at pretreatment and post-treatment. Group differences were examined using chi-square (for gender and marital status), one-way analysis of variance (ANOVAs) and one-way analysis of covariance (ANCOVAs) statistical procedures on each of the outcome measures using the SPSS-16 statistical package. Results: Nineteen patients completed this study. All patients in MCT and combined treatment groups showed significant improvement at post-treatment. ANCOVA results showed that MCT and combined treatment lead to a more significant improvement in the severity of OCD symptoms (p<0.001), depression (p<0.001), and anxiety (p<0.001) than fluvoxamine treatment. There were no significant differences between MCT and combined therapy (all p>0.05). Conclusion: It seems that adding drugs to treatment does not increase the efficacy of metacognitive therapy.
Summary
Background: Potential negative effects of psychotherapeutic
treatment have not been studied systematically to date. The current
report describes the development of a self-report instrument
for assessing negative effects of psychotherapy. Patients and
Methods: Items assessing negative effects of psychotherapy in
different areas of life (intrapersonal change, relationships, friendships,
family, malpractice, and stigmatization) were generated via
literature research and presented to a group of psychotherapy
experts. Items were created with a bipolar scale to avoid negative
priming. Additionally, patients’ attributions regarding the cause
of negative effects were assessed. Between November 2010 and
February 2011, 195 former psychotherapy patients (74.9% female,
age M = 38.4 years, SD = 11.8) took part in an online survey, also
reporting on treatment conditions during therapy. Results: Of
195 participants, 93.8% (n = 183) have reported to have experienced
negative effects in or after psychotherapy. The highest
rates of negative effects were reported for intrapersonal changes
(15.8%), stigmatization (14.9%), and relationships (12.0%). Reports
of malpractice were few, with 2.6% sexual harassment, or
1% physical violence. On the basis of item analysis and content
criteria, the Inventory for the Assessment of Negative Effects of
Psychotherapy (INEP) comprising 21 items was created (Cronbach’s
α = 0.86). Discussion: A significant number of negative
effects were reported within the therapeutic setting (e.g., feeling
offended by what the therapist said; stages of dejection). Additionally,
patients who described the therapeutic alliance as poor
also reported a high number of negative effects. Conclusion:
Negative effects of psychological treatment can be identified and
systematically assessed via patient survey and INEP. Further
evaluation in different clinical subpopulations is needed.
The present study aimed to identify mechanisms of change in individuals with moderately severe obsessive-compulsive disorder (OCD) receiving cognitive therapy (CT). Thirty-six adults with OCD received CT over 24 weeks. At weeks 0, 4/6, 12, 16/18, and 24, independent evaluators assessed OCD severity, along with obsessive beliefs and maladaptive schemas. To examine mechanisms of change, we utilized a time-varying lagged regression model with a random intercept and slope. Results indicated that perfectionism and certainty obsessive beliefs and maladaptive schemas related to dependency and incompetence significantly mediated (improved) treatment response. In conclusion, cognitive changes in perfectionism/certainty beliefs and maladaptive schemas related to dependency/incompetence precede behavioral symptom reduction for OCD patients. Targeting these mechanisms in future OCD treatment trials will emphasize the most relevant processes and facilitate maximum improvement.
Objective
Many adolescents with obsessive-compulsive disorder (OCD) do not have access to evidence-based treatment. A randomized controlled non-inferiority trial was conducted within a specialist OCD clinic to evaluate the effectiveness of telephone cognitive-behavioral therapy (TCBT) for adolescents with OCD compared to standard clinic-based face-to-face CBT.
Method
Seventy-two adolescents aged 11-18 years with primary OCD and their parents were randomized to receive specialist TCBT or CBT. The intervention provided differed only in the method of treatment delivery. All participants received up to 14 sessions of CBT, incorporating exposure with response prevention (E/RP), provided by experienced therapists. The primary outcome measure was the Children’s Yale-Brown Obsessive-Compulsive Scale (CY-BOCS). Blind assessor ratings were obtained at midtreatment, posttreatment, 3-month, 6-month, and 12-month follow-up.
Results
Intent-to-treat analyses indicated that TCBT was not inferior to face-to-face CBT at posttreatment, 3-month, and 6-month follow-up. At 12-month follow-up, there were no significant between-group differences on the CY-BOCS, but the confidence intervals exceeded the non-inferiority threshold. All secondary measures confirmed non-inferiority at all assessment points. Improvements made during treatment were maintained through to 12-month follow-up. Participants in each condition reported high levels of satisfaction with the intervention received.
Conclusion
TCBT is an effective treatment and is not inferior to standard clinic-based CBT, at least in the midterm. It provides a means of making a specialised treatment more accessible to many adolescents with OCD. Clinical trial registration information— Evaluation of telephone-administered cognitive-behaviour therapy (CBT) for young people with obsessive-compulsive disorder (OCD); http:// www.controlled-trials.com/isrctn/pf/27070832.
Maximum likelihood or restricted maximum likelihood (REML) estimates of the
parameters in linear mixed-effects models can be determined using the lmer
function in the lme4 package for R. As for most model-fitting functions in R,
the model is described in an lmer call by a formula, in this case including
both fixed- and random-effects terms. The formula and data together determine a
numerical representation of the model from which the profiled deviance or the
profiled REML criterion can be evaluated as a function of some of the model
parameters. The appropriate criterion is optimized, using one of the
constrained optimization functions in R, to provide the parameter estimates. We
describe the structure of the model, the steps in evaluating the profiled
deviance or REML criterion, and the structure of classes or types that
represents such a model. Sufficient detail is included to allow specialization
of these structures by users who wish to write functions to fit specialized
linear mixed models, such as models incorporating pedigrees or smoothing
splines, that are not easily expressible in the formula language used by lmer.
While many researchers have largely focused on principles of systematic desensitization and habituation
in explaining fear extinction, these processes have mixed evidence at best. In particular, these models
do not account for spontaneous recovery or reinstatement of fear, nor do they explain the context
dependency of extinction or rapid reacquisition. This may in part account for the significant number of
patients who fail to respond to our available treatments which rely on these principles in designing
exposure sessions. However, recent research is converging to suggest that an inhibitory model of fear
reduction, in which the original feared association (CS-US) remains but is inhibited by a newly formed
association (CS-noUS) representing safety, holds promise in explaining the long-term attenuation of fear
and anxiety. This paper reviews research in a number of areas, including neuroimaging,
psychophysiology, and psychopharmacology that all provide support for the inhibition model of anxiety.
Limitations to this body of research are discussed, along with recommendations for future research and
suggestions for improving exposure therapy for fear and anxiety disorders. Clinical implications
discussed in this paper include incorporating random and variable practice in exposure sessions,
multiple contexts, and pharmacological aides, among others.
Background: Work on potential negative effects of psychotherapeutic treatment has been limited so far. The current report describes the development of a self-report instrument accessing negative effects of psychotherapy. Patients and Method: Items accessing negative effects of psychotherapy in different areas of life (intrapersonal change, relationships, friendships, family, malpractice and stigmatization) were chosen via literature research and presented to a group of psychotherapy experts. Items were created with a bipolar scale to avoid negative priming. Additionally, patients´ attributions regarding the cause of negative effects were assessed. Between 11/2010 and 02/2011 n=195 former psychotherapy patients (74,9% female, age M=38,4 years, SD=11,8) took part in the online questionnaire. Information on the conditions of the reported treatment was given by the patients. Results 93,8% (n=183) of 195 participants reported negative effects because of their psychotherapy. The highest frequencies of negative effects were reported for the following areas: intrapersonal changes (15,8%), stigmatization (14,9%) and relationships (12,0%). Reports of malpractice were few: sexual harassment (2,6%) or physical force (1%). A consistent scale for the assessment of negative effects of psychotherapy (INEP) was constructed, k = 21 items (cronbach’s α=0,86).
Discussion: A significant number of negative effects were reported within the therapeutic setting (e.g., feeling offended by what the therapist said, feeling down since the end of treatment). Additionally patients who reported a high number of negative effects described a poor therapeutic alliance. Conclusions: Negative effects occur after psychological treatment and can be systematically accessed with the INEP. Further evaluation for different clinical settings is needed.
Background
The Beck Depression Inventory (BDI) underwent revision in 1996 (BDI-II) with the goal of addressing DSM-IV depression criteria. The present study assessed psychometric properties of the German version of the BDI-II.
Patients and methods
The BDI-II was translated into German and evaluated in a series of studies with clinical and nonclinical samples.
Results
The content validity of the BDI-II has improved by following DSM-IV symptom criteria. Internal consistency was satisfactorily high (α≥0.84), and retest reliability exceeded r≥0.75 in nonclinical samples. Associations with construct-related scales (depression, dysfunctional cognitive constructs) were high, while those with nonsymptomatic personality assessment (NEO-FFI) were lower. The BDI-II differentiated well between different grades of depression and was sensitive to change.
Conclusion
The German BDI-II demonstrates good reliability and validity in clinical and nonclinical samples. It may now replace the older version of the BDI for assessing self-rated severity of depression and course of depressed symptoms under treatment.
The present study aimed to examine the efficacy of metacognitive therapy in treatment of patients with pure obsession.
Six patients suffering from pure obsession were selected using purposeful sampling method and were included after meeting the inclusion criteria of the study. Patients were assessed using the structured clinical interview for DSM- IV Axis I disorder - patient edition (SCID- I/P). The patients' main obsessions were present including sexual, aggressive and blasphemous thoughts. In response to these obsessions, all patients used covert rituals and compulsive behaviors. In this study, multiple baseline, a major type of single- subject empirical design, was employed. During the baseline (3-7 weeks) and treatment (14 weekly sessions) and follow-up (3 months) patients filled out the Obsessive Compulsive Inventory (Revised form) (OCI-R), Yale-Brown Obsessive-Compulsive Scale (Y-BOCS), Metacognitive Questionnaire (MCQ), Thought Fusion Inventory (TFI) and Beck Depression Inventory- II (BDI-II). To implement metacognitive therapy, Well's theraputicimstruction for OCD was used.
The results indicated that Metacognitive Therapy (MCT) is effective in reducing obsessive - compulsive symptoms and in modifying metacognitive beliefs and thought-fusion beliefs.
Metacognitive therapy is effective in treatment of pure obsession.
The benefits of cognitive–behavioral treatment for obsessive–compulsive disorder (OCD) have been evidenced by several meta-analyses. However, the differential effectiveness of behavioral and cognitive approaches has shown inconclusive results. In this paper a meta-analysis on the effectiveness of psychological treatment for OCD is presented by applying random- and mixed-effects models. The literature search enabled us to identify 19 studies published between 1980 and 2006 that fulfilled our selection criteria, giving a total of 24 independent comparisons between a treated and a control group. The effect size index was the standardized mean difference in the posttest. The effect estimates for exposure with response prevention (ERP) alone (d+ = 1.127), cognitive restructuring (CR) alone (d+ = 1.090), and ERP plus CR (d+ = 0.998) were very similar, although the effect estimate for CR alone was based on only three comparisons. Therapist-guided exposure was better than therapist-assisted self-exposure, and exposure in vivo combined with exposure in imagination was better than exposure in vivo alone. The relationships of subject, methodological and extrinsic variables with effect size were also examined, and an analysis of publication bias was carried out. Finally, the implications of the results for clinical practice and for future research in this field were discussed.
The purpose of the present study was to examine the psychometric properties, factorial structure, and validity of the Padua Inventory—Washington State University Revision and of the Padua Inventory—Revised in a large sample of patients with obsessive—compulsive disorder (n = 228) and with anxiety disorders and/or depression (n = 213). The five-factor structures of both revisions were not replicated. A 24-item revision, referred to as the Padua Inventory—Palatine Revision (PI-PR), was developed on the basis of both theoretical and statistical considerations. The PI-PR assesses six subscales: Contamination and Washing, Checking, Numbers, Dressing and Grooming, Rumination, and Harming Obsessions and Impulses. The results demonstrate that the PI-PR is a brief, psychometrically sound, and valid measure for the assessment of a broad range of obsessive—compulsive symptoms, which has important advantages over both previous revisions.
Despite significant advances in the study of obsessive-compulsive disorder (OCD), important questions remain about the disorder's public health significance, appropriate diagnostic classification, and clinical heterogeneity. These issues were explored using data from the National Comorbidity Survey Replication, a nationally representative survey of US adults. A subsample of 2073 respondents was assessed for lifetime Diagnostic and Statistical Manual of Mental Disorders, 4th edn (DSM-IV) OCD. More than one quarter of respondents reported experiencing obsessions or compulsions at some time in their lives. While conditional probability of OCD was strongly associated with the number of obsessions and compulsions reported, only small proportions of respondents met full DSM-IV criteria for lifetime (2.3%) or 12-month (1.2%) OCD. OCD is associated with substantial comorbidity, not only with anxiety and mood disorders but also with impulse-control and substance use disorders. Severity of OCD, assessed by an adapted version of the Yale-Brown Obsessive Compulsive Scale, is associated with poor insight, high comorbidity, high role impairment, and high probability of seeking treatment. The high prevalence of subthreshold OCD symptoms may help explain past inconsistencies in prevalence estimates across surveys and suggests that the public health burden of OCD may be greater than its low prevalence implies. Evidence of a preponderance of early onset cases in men, high comorbidity with a wide range of disorders, and reliable associations between disorder severity and key outcomes may have implications for how OCD is classified in DSM-V.
In 1984, Jacobson, Follette, and Revenstorf defined clinically significant change as the extent to which therapy moves someone outside the range of the dysfunctional population or within the range of the functional population. In the present article, ways of operationalizing this definition are described, and examples are used to show how clients can be categorized on the basis of this definition. A reliable change index (RC) is also proposed to determine whether the magnitude of change for a given client is statistically reliable. The inclusion of the RC leads to a twofold criterion for clinically significant change.
Importance
In most countries, young people with obsessive-compulsive disorder have limited access to specialist cognitive behavioral therapy (CBT), a first-line treatment.
Objective
To investigate whether internet-delivered CBT implemented in a stepped-care model is noninferior to in-person CBT for pediatric obsessive-compulsive disorder.
Design, Setting and Participants
A randomized clinical noninferiority trial conducted at 2 specialist child and adolescent mental health clinics in Sweden. Participants included 152 individuals aged 8 to 17 years with obsessive-compulsive disorder. Enrollment began in October 2017 and ended in May 2019. Follow-up ended in April 2020.
Interventions
Participants randomized to the stepped-care group (n = 74) received internet-delivered CBT for 16 weeks. Nonresponders at the 3-month follow-up were then offered a course of traditional face-to-face treatment. Participants randomized to the control group (n = 78) immediately received in-person CBT for 16 weeks. Nonresponders at the 3-month follow-up received additional face-to-face treatment.
Main Outcomes and Measures
The primary outcome was the masked assessor–rated Children’s Yale-Brown Obsessive-Compulsive Scale (CY-BOCS) score at the 6-month follow-up. The scale includes 10 items rated from 0 (no symptoms) to 4 (extreme symptoms), yielding a total score range of 0 to 40, with higher scores indicating greater severity. Assessors were masked to treatment allocation at pretreatment, posttreatment, 3-month follow-up, and 6-month follow-up assessments. The predefined noninferiority margin was 4 points on the CY-BOCS.
Results
Among the 152 randomized participants (mean age, 13.4 years; 94 [62%] females), 151 (99%) completed the trial. At the 3-month follow-up, 34 participants (46%) in the stepped-care group and 23 (30%) in the in-person CBT group were nonresponders. At the 6-month follow-up, the CY-BOCS score was 11.57 points in the stepped-care group vs 10.57 points in the face-to-face treatment group, corresponding to an estimated mean difference of 0.91 points ([1-sided 97.5% CI, −∞ to 3.28]; P for noninferiority = .02). Increased anxiety (30%-36%) and depressive symptoms (20%-28%) were the most frequently reported adverse events in both groups. There were 2 unrelated serious adverse events (1 in each group).
Conclusions and Relevance
Among children and adolescents with obsessive-compulsive disorder, treatment with an internet-delivered CBT program followed by in-person CBT if necessary compared with in-person CBT alone resulted in a noninferior difference in symptoms at the 6-month follow-up. Further research is needed to understand the durability and generalizability of these findings.
Trial Registration
ClinicalTrials.gov Identifier: NCT03263546
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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 represented the primary outcome. Secondary outcomes targeted treatment processes. Patients were reassessed eight weeks (post) and three months (follow-up) after baseline.
Results
In the MCT-OCD group, OC symptoms declined more than in the control group from baseline to post with a moderate effect (ηp² = .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.
Cognitive behaviour therapy, especially exposure and response prevention (ERP) is the treatment of choice for obsessive-compulsive disorder (OCD). However, a substantial number of patients refuse this method or fail to benefit enough. Metacognitive therapy (MCT) claims to successfully treat OCD without prolonged exposures. However, only case series and small, mostly uncontrolled trials have been published so far.
The efficacy and feasibility of MCT for OCD compared to ERP were investigated in a pilot randomized trial. Thirty-seven outpatients with OCD according to DSM-IV criteria were randomly allocated to individual, weekly 14-sessions of therapy with either MCT or ERP. Analyses focused on treatment efficacy at post-treatment and 3-months follow-up, treatment fidelity and credibility.
Participants showed a significant reduction in OCD symptoms in both treatment conditions and with no differences between MCT and ERP. Participants in the MCT condition required less face-to-face time with a therapist than those in the ERP condition.
MCT and ERP were both effective with large effect sizes. There was no evidence that the two treatments lead to statistically different outcomes. Larger controlled trials are justified.
Whilst cognitive behavioural therapy (CBT) is the treatment of choice for obsessive-compulsive disorder (OCD), around half of the participants do not experience remission following treatment. As yet, there is no comprehensive systematic review of the extent to which patient non-adherence presents a challenge to the overall benefit of CBT for OCD. The aim of this systematic review and meta-analysis was to identify the magnitude, moderators and reasons for poor patient adherence to CBT for OCD in terms of: (1) treatment refusal, (2) treatment dropout, (3) session attendance/module completion, and (4) between-session CBT task adherence. Sociodemographic and clinical variables, treatment and study design characteristics were examined as moderators of adherence. The systematic search identified 123 studies including 5627 participants taking part in CBT or control conditions. A pooled rate of 15.6% of eligible patients refused CBT and a further 15.9% of treatment starters dropped out from treatment. Group CBT had significantly lower dropout rates than individually-delivered CBT. No other significant moderators were found. Most studies reported moderate to good adherence to between-session CBT tasks, which had a significant medium to large association with post-treatment OCD symptom reduction. Recommendations for enhanced measurement and reporting of patient adherence to CBT for OCD are made along with clinical implications of findings.
Meta-analyses suggest that exposure with response prevention (ERP) is the most efficacious treatment for obsessive–compulsive disorder (OCD) and treatment guidelines for the disorder accordingly recommend ERP. Despite this, many therapists, including those with a cognitive-behavioral therapeutic background, do not perform ERP in patients with OCD. The present study aimed to elucidate the reasons why. German therapists (N = 216) completed an anonymous online survey, the newly developed Reasons for Not Performing Exposure in OCD Scale (REPEX), that inquired whether, to what extent, and how they perform ERP in the treatment of OCD. We also asked their reasons for not applying ERP in the past. Most therapists considered ERP an efficient treatment for OCD. Marked differences emerged between physicians and psychologists, however. The former used exposure less often and for a shorter period, preferred in sensu to in vivo exposure, and conducted exposure less often in the personal environment of the patient than did psychologists. Both groups were familiar with clinical guidelines to a similar extent. A factor analysis of the REPEX scale revealed five factors. Patient lack of motivation, preference for exposure to be self-help as well as alleged organizational difficulties were endorsed most often. The latter was correlated with the age of the therapist and was far more often affirmed by physicians. Fear of side effects was named by a subgroup of clinicians; in the context of patient ambivalence, this may foster “phobie à deux”. Unlike prior research, lack of expertise was rarely identified as a reason not to use ERP. Recommendations for improving adherence to guidelines are discussed.
Cognitive (CT) and behavioral treatments (BT) for OCD are efficacious separately and in combination. Tailoring treatment to patient-level predictors and moderators of outcome has the potential to improve outcomes. The present study combined data from eight treatment clinics to examine the benefits of BT (n = 125), CT (n = 108) and CBT (n = 126), and study predictors across all treatments and moderators of outcome by treatment type. All three methods led to large benefits for OCD and depression symptoms. Residual gain scores for OCD symptoms were marginally smaller for BT compared to treatments containing CT. For depression, significantly more gains were evident for CBT than BT, and CT did not differ from either. Significantly fewer BT participants (36%) achieved clinically significant improvement compared to CT (56%), and this was marginally evident for CBT (48%). For all treatments combined, no predictors were identified in residual gain analyses, but clinically improved patients had lower baseline depression and stronger beliefs about responsibility/threat and importance/control of thoughts. Moderator analyses indicated that higher baseline scores on depression adversely affected outcomes for BT but not CT or CBT, and lower OCD severity and more education were associated with positive outcomes for CT only. A trend was evident for higher responsibility/threat beliefs to moderate clinical improvement outcomes for those receiving cognitive (CT and CBT), but not behavioral (BT) treatment. Medication status and comorbidity did not predict or moderate outcomes. Findings are discussed in light of models underlying behavioral and cognitive treatments for OCD.
The beneficial effects of cognitive-behavioral interventions (particularly exposure and response prevention) for OCD are among the most consistent research findings in the mental health literature. Nevertheless, even after an adequate trial, many individuals experience residual symptoms, and others never receive adequate treatment due to limited access. These and other issues have prompted clinicians and researchers to search for ways to improve the conceptual and practical aspects of existing treatment approaches, as well as look for augmentation strategies. In the present article, we review a number of recent developments and new directions in the psychological treatment of OCD, including (a) the application of inhibitory learning approaches to exposure therapy, (b) the development of acceptance-based approaches, (c) involvement of caregivers (partners and parents) in treatment, (d) pharmacological cognitive enhancement of exposure therapy, and (e) the use of technology to disseminate effective treatment. We focus on both the conceptual/scientific and practical aspects of these topics so that clinicians and researchers alike can assess their relative merits and disadvantages.
Obsessive-compulsive disorder is ranked by the WHO as among the 10 most debilitating disorders and tends to be chronic without adequate treatment. The only psychological treatment that has been found effective is cognitive behavior therapy (CBT). This meta-analysis includes all RCTs (N=37) of CBT for OCD using the interview-based Yale-Brown Obsessive Compulsive Scale, published 1993 to 2014. The effect sizes for comparisons of CBT with waiting-list (1.31), and placebo conditions (1.33) were very large, whereas those for comparisons between individual and group treatment (0.17), and exposure and response prevention vs. cognitive therapy (0.07) were small and non-significant. CBT was significantly better than antidepressant medication (0.55), but the combination of CBT and medication was not significantly better than CBT plus placebo (0.25). The RCTs have a number of methodological problems and recommendations for improving the methodological rigor are discussed as well as clinical implications of the findings.
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The Dodo bird hypothesis asserts that when bona fide treatments are compared they yield similar outcomes and is consistent with a common factors or contextual model of psychotherapy. Wampold et al. (1997) the most recent comprehensive meta-analysis to test the Dodo bird hypothesis, yielded consistent evidence of treatment equivalence. However, some of Wampold et al.’s analytic strategies, such as using multiple effect sizes from the same study and prioritizing long-term follow-up, may have obscured treatment differences. The current meta-analysis updated Wampold et al. by analyzing studies published in the subsequent 16 years (k = 51). Separate effect sizes were calculated for primary outcomes versus secondary outcomes, at termination and follow-up. Contrary to the Dodo bird hypothesis, there was evidence of treatment differences for primary outcomes at termination. Furthermore, cognitive-behavioral treatments may be incrementally more effective than alternative treatments for primary outcomes. Consistent with the Dodo bird hypothesis, there was little evidence of treatment differences for the secondary outcomes at termination and follow-up. There are small, statistically significant differences between bona-fide treatments when the specific targets of those treatments are assessed, but not when secondary outcomes are assessed, providing mixed support for both specific factors and contextual models of psychotherapy.
Therapy of Anxiety and Obsessive-Compulsive Disorder in Behavior Therapy PracticeIntroduction: The importance of exposure in the treatment of anxiety and obsessive-compulsive disorders is widely accepted. The present study investigates how therapists in German ambulatory care actually treat patients with anxiety disorders or obsessive-compulsive disorders. Material and Methods: For this purpose 138 medical and psychological psychotherapists (behavior therapy) were investigated by use of a self-constructed questionnaire. The questionnaire contained 85 closeended and half-open questions on the concrete proceeding in therapies for anxiety and obsessive-compulsive disorder especially regarding exposure. Data were analyzed descriptively. Results: 83.3% of the therapists used exposure therapy in the treatment of anxiety disorders, 79% used it in the treatment of obsessive-compulsive disorders. Mostly, therapists choose gradual exposure. Only sometimes they use exposure in vivo. Only a minority allows 2 hours or more for an exposure session or leaves their private practice for the exposure training.
Obsessive-compulsive disorder (OCD) is a heterogeneous and disabling condition; however, no studies have examined symptom categories or subtypes as predictors of long-term clinical course in adults with primary OCD.
A total of 213 adults with DSM-IV OCD were recruited from several mental health treatment sites between July 2001 and February 2006 as part of the Brown Longitudinal Obsessive Compulsive Study, a prospective, naturalistic study of treatment-seeking adults with primary OCD. OCD symptoms were assessed annually over the 5-year follow-up period using the Longitudinal Interval Follow-Up Evaluation.
Thirty-nine percent of participants experienced either a partial (22.1%) or a full (16.9%) remission. Two OCD symptom dimensions impacted remission. Participants with primary obsessions regarding overresponsibility for harm were nearly twice as likely to experience a remission (P < .05), whereas only 2 of 21 participants (9.5%) with primary hoarding achieved remission. Other predictors of increased remission were lower OCD severity (P < .0001) and shorter duration of illness (P < .0001). Fifty-nine percent of participants who remitted subsequently relapsed. Participants with obsessive-compulsive personality disorder were more than twice as likely to relapse (P < .005). Participants were also particularly vulnerable to relapse if they experienced partial remission versus full remission (70% vs 45%; P < .05).
The contributions of OCD symptom categories and comorbid obsessive-compulsive personality disorder are critically important to advancing our understanding of the prognosis and ultimately the successful treatment of OCD. Longer duration of illness was also found to be a significant predictor of course, highlighting the critical importance of early detection and treatment of OCD. Furthermore, having full remission as a treatment target is an important consideration for the prevention of relapse in this disorder.
Numerous clinical trials have supported the efficacy of cognitive behavioral therapy (CBT) for the treatment of anxiety disorders. Accordingly, CBT has been formally recognized as an empirically supported treatment for anxiety-related conditions. This article reviews the evidence supporting the efficacy of CBT for anxiety disorders. Specifically, contemporary meta-analytic studies on the treatment of anxiety disorders are reviewed and the efficacy of CBT is examined. Although the specific components of CBT differ depending on the study design and the anxiety disorder treated, meta-analyses suggest that CBT procedures (particularly exposure-based approaches) are highly efficacious. CBT generally outperforms wait-list and placebo controls. Thus, CBT provides incremental efficacy above and beyond nonspecific factors. For some anxiety disorders, CBT also tends to outperform other psychosocial treatment modalities. The implications of available meta-analytic findings in further delineating the efficacy and dissemination of CBT for anxiety disorders are discussed.
Several studies have demonstrated that obsessive-compulsive disorder (OCD) is associated with interference in quality of life (QOL) and functional impairment. However, these studies did not compare individuals in remission to individuals who continue to have the disorder, predominantly used comparisons with norms and not with a matched normal sample, and did not always consider the impact of comorbidity.
We administered multiple measures that assess QOL and functional impairment to 66 OCD patients who had previously consented for a clinical trial and to 36 age and sex matched individuals who denied any psychiatric history.
Results confirm that OCD was associated with significantly lower QOL and functional impairment compared to healthy controls (HCs) in areas of work, social life, and family life. Individuals with OCD and other comorbid psychiatric diagnoses showed the poorest QOL and functioning, with comorbid depression accounting for much of the variance. The levels of QOL and functioning in individuals in remission tended to lie in between HCs and individuals with current OCD: their QOL or functioning did not differ significantly from HCs nor did they consistently differ significantly from those who had current OCD.
These results suggest that individuals who are in remission have improved levels of QOL and functioning, whereas individuals with OCD are significantly impaired, and individuals with OCD and comorbid disorders are the most impaired. Treatment strategies should be focused on achieving remission of all symptoms to have the greatest impact on functioning and QOL.
Treatment outcome studies ought to assess the fidelity of their treatments, including treatment delivery, but practical guidelines and examples for this are lacking. Based on general recommendations in available literature, this study proposes and illustrates the design and application of a Method of Assessing Treatment Delivery (MATD) in a behavioral medicine trial comparing two treatments for chronic low back pain.
In designing MATD, two experts identified several feasible treatment elements. Agreement between the experts in classifying these elements into five categories (essential and unique, essential but not unique, unique but not essential, compatible, prohibited) was assessed. In applying MATD, treatment recordings were evaluated by two independent raters, who coded the (non)-occurrence of MATD elements and who categorized each session as belonging to one of the two treatments.
MATDs content validity was supported by adequate agreement between the experts' classifications of the treatment elements. MATDs interrater reliability was good.
Comprehensive illustrations of designing and applying MATD may encourage the verification of treatment delivery as a partial reflection of treatment fidelity in forthcoming treatment outcome studies.
This paper presents a general statistical methodology for the analysis of multivariate categorical data arising from observer reliability studies. The procedure essentially involves the construction of functions of the observed proportions which are directed at the extent to which the observers agree among themselves and the construction of test statistics for hypotheses involving these functions. Tests for interobserver bias are presented in terms of first-order marginal homogeneity and measures of interobserver agreement are developed as generalized kappa-type statistics. These procedures are illustrated with a clinical diagnosis example from the epidemiological literature.
Is obsessive-compulsive disorder (OCD) a discrete disorder? Three hundred thirty-four individuals with OCD were interviewed using the Structured Clinical Interview for DSM (SCID). Results demonstrate that OCD is highly comorbid with other neuropsychiatric disorders, with 92% of OCD study participants receiving one or more additional Axis I DSM diagnoses. Among these additional diagnoses, lifetime mood disorders (81%) and anxiety disorders (53%) were the most prevalent. With the exception of substance-related disorders and specific phobias, all disorders assessed were found in considerably higher frequency than in the general population, indicating that OCD is associated with highly complex comorbidity. These data have implications for genetic studies of OCD and disorders related to OCD, as well as for specific psychotherapeutic and psychopharmacologic interventions.
This article gives an overview of sample size calculations for parallel group and cross-over studies with Normal data. Sample size derivation is given for trials where the objective is to demonstrate: superiority, equivalence, non-inferiority, bioequivalence and estimation to a given precision, for different types I and II errors. It is demonstrated how the different trial objectives influence the null and alternative hypotheses of the trials and how these hypotheses influence the calculations. Sample size tables for the different types of trials and worked examples are given.
A number of qualitative and meta-analytic reviews point to the efficacy of psychotherapeutic and pharmacological interventions for obsessive-compulsive disorder (OCD). In this article, we report a multidimensional meta-analysis of psychological and pharmacological treatment studies for OCD published between 1980 and 2001, examining a range of variables not previously meta-analyzed, including exclusion rates and exclusion criteria, percent of patients improved or recovered post-treatment, mean post-treatment symptomatology, and long-term outcome. These additional metrics provide a more nuanced view of the strengths and limitations of the existing data and their implications for clinical practice. Behavioral and cognitive-behavioral therapy, and a range of pharmacological interventions, lead to substantial improvement for the average patient, with individual psychotherapies and clomipramine and other Serotonin reuptake inhibitors faring best across multiple metrics. However, OCD symptoms persist at moderate levels even following adequate treatment course, and no replicable data are available on maintenance of gains for either form of treatment at 1 year or beyond. Future research should track recruitment and exclusion of study participants, include more comorbid patients, and focus on longer-term follow-up using multiple indices of outcome. More research on combined pharmacological and psychotherapeutic interventions is also indicated.