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The Relative Impact of Cognitive and Behavioral Skill Comprehension and Use During CBT for Obsessive Compulsive Disorder

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Abstract

Background

During cognitive-behavioral therapy (CBT) for Obsessive Compulsive Disorder (OCD), individuals learn to utilize cognitive and behavioral skills to manage their symptoms. However, it is unclear whether these CBT skills have similar effects on symptom alleviation throughout treatment.

Method

This study examined the impact of CBT skill comprehension and CBT skill frequency on OCD symptom change during CBT for OCD. Participants experiencing a primary diagnosis of OCD (N = 101) completed self-report measures of OCD symptoms, skill comprehension (e.g., using the Skills of Cognitive Therapy Questionnaire (SoCT)), and skill frequency (i.e., comparing the thought record (TR) with exposure and response prevention (ERP)) during treatment.

Results

Structural equation modelling analyses involving an integration of growth curve analysis and cross-lagged regression analysis demonstrated that skill comprehension and skill frequency trajectories are associated with OCD symptom trajectories. There was a significant cross-lagged relationship between skill comprehension and OCD symptom change, in which higher levels of skill comprehension were associated with OCD symptom alleviation. Comparable analyses of skill frequency demonstrated that higher levels of both TR frequency and ERP frequency were associated with improvements in OCD symptoms.

Conclusions

These results demonstrate that higher levels of skill comprehension as well as skill frequency are associated with OCD symptom alleviation.

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References

  • Abramowitz, J. S., & Arch, J. J. (2014). Strategies for improving long-term outcomes in cognitive behavioral therapy for obsessive-compulsive disorder: Insights from learning theory. Cognitive and Behavioral Practice, 21(1), 20–31.

    Article  Google Scholar 

  • Abramowitz, J. S., Taylor, S., & McKay, D. (2009). Obsessive-compulsive disorder. The Lancet, 374(9688), 491–499.

    Article  Google Scholar 

  • Akaike, H. (1973). Information theory and an extension of the maximum likelihood principle. In B. N. Petrov & F. Csaki (Eds.), Proceedings of the 2nd international symposium on information theory (pp. 267–281). Budapest: Akademiai Kiado.

    Google Scholar 

  • American Psychiatric Association (APA). (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: American Psychiatric Association.

    Book  Google Scholar 

  • American Psychiatric Association. (2007). Practice guideline for the treatment of patients with obsessive-compulsive disorder. The American Journal of Psychiatry, 164(7 Suppl), 5–53.

    Google Scholar 

  • Arbuckle, J. L. (2016). Amos (Version 25.0) [Computer Program]. Chicago, IL: SPSS.

    Google Scholar 

  • Baer, L., Brown-Beasley, M. W., Sorce, J., & Henriques, A. I. (1993). Computer-assisted telephone administration of a structured interview for obsessive-compulsive disorder. The American Journal of Psychiatry. https://doi.org/10.1176/ajp.150.11.1737.

    Article  PubMed  Google Scholar 

  • Barber, J. P., & DeRubeis, R. J. (1989). On second thought: Where the action is in cognitive therapy for depression. Cognitive Therapy and Research, 13, 441–457. https://doi.org/10.1007/bf01173905.

    Article  Google Scholar 

  • Barber, J. P., & DeRubeis, R. J. (2001). Change in compensatory skills in cognitive therapy for depression. Journal of Psychotherapy Practice and Research, 10, 8–13.

    CAS  PubMed  PubMed Central  Google Scholar 

  • Beck, A. T., Rush, A. J., Shaw, B. F., & Emery, G. (1979). Cognitive therapy of depression. New York: Guilford Press.

    Google Scholar 

  • Bentler, P. M. (1990). Comparative fit indexes in structural models. Psychological Bulletin, 107(2), 238.

    Article  CAS  PubMed  Google Scholar 

  • Boswell, J. F., Anderson, L. M., & Barlow, D. H. (2014). An idiographic analysis of change processes in the unified transdiagnostic treatment of depression. Journal of Consulting and Clinical Psychology, 82(6), 1060–1071. https://doi.org/10.1037/a0037403.

    Article  PubMed  Google Scholar 

  • Browne, M. W., & Cudeck, R. (1993). Alternative ways of assessing model fit. In K. A. Bollen & J. S. Long (Eds.), Testing structural equation models (pp. 136–162). Newbury Park, CA: Sage focus editions.

    Google Scholar 

  • Byrne, B. M. (2004). Testing for multigroup invariance using AMOS graphics: A road less traveled. Structural Equation Modeling, 11(2), 272–300.

    Article  Google Scholar 

  • Clark, D. A. (2004). Cognitive-behavioral therapy for OCD. New York, NY: Guilford Press.

    Google Scholar 

  • Clark, D. A., Beck, A. T., & Alford, B. A. (1999). Scientific foundations of cognitive theory and therapy of depression. New York: Wiley.

    Google Scholar 

  • Dimidjian, S., Hollon, S. D., Dobson, K. S., Schmaling, K. B., Kohlenberg, R. J., Addis, M. E., et al. (2006). Randomized trial of behavioral activation, cognitive therapy, and antidepressant medication in the acute treatment of adults with major depression. Journal of Consulting and Clinical Psychology, 74, 658–670. https://doi.org/10.1176/ajp.156.7.1007.

    Article  PubMed  Google Scholar 

  • Eddy, K. T., Dutra, L., Bradley, R., & Westen, D. (2004). A multidimensional meta-analysis of psychotherapy and pharmacotherapy for obsessive-compulsive disorder. Clinical Psychology Review, 24, 1011–1030. https://doi.org/10.1016/j.cpr.2004.08.004.

    Article  PubMed  Google Scholar 

  • Erekson, D. M., Lambert, M. J., & Eggett, D. L. (2015). The relationship between session frequency and psychotherapy outcome in a naturalistic setting. Journal of Consulting and Clinical Psychology, 83(6), 1097–1107. https://doi.org/10.1037/a0039774.

    Article  PubMed  Google Scholar 

  • First, M. B., Spitzer, R. L., Gibbon, M., & Williams, J. B. W. (1996). Structured Clinical Interview for Axis I DSM-IV Disorders-patient edition. New York, NY: New York State Psychiatric Institute Biometrics Research Department.

    Google Scholar 

  • First, M. B., Spitzer, R. L., Gibbon, M., & Williams, J. B. W. (2002). Structured clinical interview for DSM-IV-TR axis I disorders, research version, patient edition (SC1D-1/P). NY: Biometrics Research, State Psychiatric Institute.

    Google Scholar 

  • Foa, E. B., Yadin, E., & Lichner, T. K. (2012). Exposure and response (ritual) prevention for obsessive-compulsive disorder: Therapist guide. Oxford: Oxford University Press.

    Book  Google Scholar 

  • Hamagami, F., & McArdle, J. J. (2001). Advanced studies for individual differences linear dynamic models for longitudinal data analysis. In G. A. Marcoulides & R. E. Schumacker (Eds.), New developments and techniques in structural equation modeling (pp. 203–246). Mahwah, NJ: Erlbaum.

    Google Scholar 

  • Hawley, L. L., Ho, M. H. R., Zuroff, D. C., & Blatt, S. J. (2006). The relationship of perfectionism, depression, and therapeutic alliance during treatment for depression: Latent difference score analysis. Journal of Consulting and Clinical Psychology, 74(5), 930.

    Article  PubMed  Google Scholar 

  • Hawley, L. L., Padesky, C. A., Hollon, S. D., Mancuso, E., Laposa, J. M., Brozina, K., et al. (2017). Cognitive behavioral therapy for depression using mind over mood: CBT skill use and differential symptom alleviation. Behavior Therapy, 48, 29–44. https://doi.org/10.1016/j.beth.2016.09.003.

    Article  PubMed  Google Scholar 

  • Hawley, L. L., Rector, N. A., & Laposa, J. M. (2016). Examining the dynamic relationships between exposure tasks and cognitive restructuring in CBT for SAD: Outcomes and moderating influences. Journal of Anxiety Disorders, 39, 10–20. https://doi.org/10.1016/j.janxdis.2016.01.010.

    Article  PubMed  Google Scholar 

  • Hopko, D. R., Lejuez, C., Le Page, J. P., Hopko, S. D., & McNeil, D. W. (2003). A brief Behavioral Activation treatment for depression: A randomized pilot trial within an inpatient psychiatric hospital. Behavior Modification, 27(4), 458–469. https://doi.org/10.1177/0145445503255489.

    Article  PubMed  Google Scholar 

  • Hundt, N. E., Mignogna, J., Underhill, C., & Cully, J. A. (2013). The relationship between use of CBT skills and depression treatment outcome: A theoretical and methodological review of the literature. Behavior Therapy, 44(1), 12–26. https://doi.org/10.1016/j.beth.2012.10.001.

    Article  PubMed  Google Scholar 

  • Jacobson, N. S., Dobson, K. S., Truax, P. A., Addis, M. E., Koerner, K., Gollan, J. K., et al. (1996). A component analysis of cognitive-behavioral treatment for depression. Journal of Consulting and Clinical Psychology, 64(2), 295–304. https://doi.org/10.1037/0022-006X.64.2.295.

    Article  CAS  PubMed  Google Scholar 

  • Jarrett, R. B., Vittengl, J. R., Clark, L. A., & Thase, M. E. (2011). Skills of Cognitive Therapy (SoCT): A new measure of patients’ comprehension and use. Psychological Assessment, 23(3), 578–586. https://doi.org/10.1037/a0022485.

    Article  PubMed  PubMed Central  Google Scholar 

  • Joreskog, K. G., Sorbom, D., & Magidson, J. (1979). Advances in factor analysis and structural equation models. Cambridge: Abt books.

    Google Scholar 

  • Katz, D., Laposa, J., Hawley, L. L., Quigley, L., & Rector, N. (2019). Cognitive moderation of CBT: Disorder-specific or transdiagnostic predictors of treatment response. Cognitive Therapy and Research, 43, 803–818. https://doi.org/10.1007/s10608-019-10009-y.

    Article  Google Scholar 

  • Katzman, M. A., Bleau, P., Blier, P., Chokka, P., Kjernisted, K., & Van Ameringen, M. (2014). Canadian clinical practice guidelines for the management of anxiety, posttraumatic stress and obsessive compulsive disorders. BMC Psychiatry, 14(1), S1. https://doi.org/10.1186/1471-244X-14-S1-S1.

    Article  PubMed  PubMed Central  Google Scholar 

  • Kazantzis, N., Deane, F., & Ronan, K. (2000). Homework assignments in cognitive and behavioral therapy: A meta-analysis. Clinical Psychology: Science and Practice., 7(2), 189–202. https://doi.org/10.1093/clipsy.7.2.189.

    Article  Google Scholar 

  • Kazantzis, N., Whittington, C., & Dattilio, F. (2010). Meta-analysis of homework effects in cognitive and behavioral therapy: A replication and extension. Clinical Psychology: Science and Practice., 17(2), 144–156. https://doi.org/10.1111/j.1468-2850.2010.01204.x.

    Article  Google Scholar 

  • Kozak, M. J., & Foa, E. B. (1997). Mastery of obsessive-compulsive disorder. A cognitive behavioural approach. Therapist guide. New York, NY: Graywind Publications.

    Google Scholar 

  • Lambert, M. J. (2017). Maximizing psychotherapy outcomes beyond evidence-based medicine. Psychotherapy and Psychosomatics, 86, 80–89. https://doi.org/10.1159/000455170.

    Article  PubMed  Google Scholar 

  • Laposa, J. M., Hawley, L. L., Grimm, K. J., Katz, D., & Rector, N. A. (2019). What drives OCD symptom change during CBT treatment? Temporal relationships among obsessions and compulsions. Behavior Therapy, 50(1), 87–100. https://doi.org/10.1016/j.beth.2018.03.012.

    Article  PubMed  Google Scholar 

  • Martell, C. R., Addis, M. E., & Jacobson, N. S. (2001). Depression in context: Strategies for guided action. New York, NY: Norton.

    Google Scholar 

  • McArdle, J. J. (2001). A latent difference score approach to longitudinal dynamic analysis. In R. Cudeck, S. Du Toit, & D. Sörbum (Eds.), Structural equation modeling: Present and future (pp. 341–380). Lincolnwood, IL: Scientific Software International.

    Google Scholar 

  • McArdle, J. J., & Hamagami, F. (2001). Latent difference score structural models for linear dynamic analyses with incomplete longitudinal data. In L. M. Collins & A. G. Sayer (Eds.), Decade of behavior. New methods for the analysis of change (pp. 139–175). Washington: American Psychological Association.

    Chapter  Google Scholar 

  • McKay, D., Sookman, D., Neziroglu, F., Wilhelm, S., Stein, D. J., Kyrios, M., et al. (2015). Efficacy of cognitive-behavioral therapy for obsessive–compulsive disorder. Psychiatry Research, 225(3), 236–246.

    Article  PubMed  Google Scholar 

  • Meredith, W., & Tisak, J. (1990). Latent curve analysis. Psychometrika, 55(1), 107–122.

    Article  Google Scholar 

  • NICE. (2005). Obsessive-compulsive disorder and body dysmorphic disorder: Treatment. Nice guideline (CG31). Retrieved from https://www.nice.org.uk/guidance/cg31.

  • Obsessive Compulsive Cognitions Working Group. (1997). Cognitive assessment of obsessive compulsive disorder. Behaviour Research and Therapy, 35, 667–681. https://doi.org/10.1016/S0005-7967(97)00017-X.

    Article  Google Scholar 

  • Obsessive Compulsive Cognitions Working Group. (2001). Development and initial validation of the obsessive beliefs questionnaire and the interpretation of intrusions inventory. Behaviour Research and Therapy, 39, 987–1006. https://doi.org/10.1016/S0005-7967(00)00085-1.

    Article  Google Scholar 

  • Olatunji, B. O., Davis, M. L., Powers, M. B., & Smits, J. A. J. (2013). Cognitive-behavioral therapy for obsessive-compulsive disorder: A meta-analysis of treatment outcome and moderators. Journal of Psychiatric Research, 47(1), 33–41.

    Article  PubMed  Google Scholar 

  • Öst, L.-G., Havnen, A., Hansen, B., & Kvale, G. (2015). Cognitive behavioral treatments of obsessive–compulsive disorder. A systematic review and meta-analysis of studies published 1993–2014. Clinical Psychology Review, 40, 156–169.

    Article  PubMed  Google Scholar 

  • Rachman, S. (1978). An anatomy of obsessions. Behaviour Analysis and Modification, 2, 253–278.

    Google Scholar 

  • Rachman, S. (1997). A cognitive theory of obsessions. Behaviour Research and Therapy, 35, 793–802. https://doi.org/10.1016/S0005-7967(97)00040-5.

    Article  CAS  PubMed  Google Scholar 

  • Rachman, S., & Hodgson, R. J. (1980). Obsessions and compulsions. Englewood Cliffs, NJ: Prentice-Hall.

    Google Scholar 

  • Rector, N. A., Richter, M. A., Katz, D., & Leybman, M. (2018). Does the addition of cognitive therapy to exposure and response prevention for obsessive compulsive disorder enhance clinical efficacy? A randomized controlled trial in a community setting. British Journal of Clinical Psychology, 58(1), 1–18. https://doi.org/10.1111/bjc.12188.

    Article  PubMed  Google Scholar 

  • Rosa-Alcázar, A. I., Sánchez-Meca, J., Gómez-Conesa, A., & Marín-Martínez, F. (2008). Psychological treatment of obsessive–compulsive disorder: A meta-analysis. Clinical Psychology Review, 28(8), 1310–1325.

    Article  PubMed  Google Scholar 

  • Salkovskis, P. M. (1985). Obsessional-compulsive problems: A cognitive-behavioural analysis. Behaviour Research and Therapy, 23, 571–583. https://doi.org/10.1016/0005-7967(85)90105-6.

    Article  CAS  PubMed  Google Scholar 

  • Segal, Z. V., Bieling, P. J., Young, T., MacQueen, G., Cooke, R., Martin, L., et al. (2010). Antidepressant monotherapy versus sequential pharmacotherapy and mindfulness-based cognitive therapy, or placebo, for relapse prophylaxis in recurrent depression. Archives of General Psychiatry, 67(12), 1256–1264. https://doi.org/10.1001/archgenpsychiatry.2010.168.

    Article  PubMed  PubMed Central  Google Scholar 

  • Steiger, J. H. (1998). A note on multiple sample extensions of the RMSEA fit index. Milton Park: Taylor & Francis.

    Book  Google Scholar 

  • Steketee, G., Frost, R., & Bogart, K. (1996). The yale-brown obsessive compulsive scale: Interview versus self-report. Behaviour Research and Therapy, 34(8), 675–684.

    Article  CAS  PubMed  Google Scholar 

  • Steketee, G. S., Frost, R. A., Rheaume, J., & Wilhelm, S. (1998). Cognitive theory and treatment of obsessive compulsive disorder. In M. A. Jenike, L. Baer, & W. E. Minichiello (Eds.), Obsessive compulsive disorders: Practical management (3rd ed., pp. 368–399). St. Louis, MO: Mosby.

    Google Scholar 

  • Steketee, G. S., Siev, J., Yovel, I., Lit, K., & Wilhelm, S. (2019). Predictors and moderators of cognitive and behavioral therapy outcomes for OCD: A patient-level mega-analysis of eight sites. Behavior Therapy, 50, 165–176. https://doi.org/10.1016/j.beth.2018.04.004.

    Article  PubMed  Google Scholar 

  • Strunk, D. R., Hollars, S. N., Adler, A. D., Goldstein, L. A., & Braun, J. D. (2014). Assessing patient’s cognitive therapy skills: Initial evaluation of the competencies of Cognitive Therapy Scale. Cognitive Therapy and Research, 38(5), 559–569. https://doi.org/10.1007/s10608-014-9617-9.

    Article  PubMed  PubMed Central  Google Scholar 

  • Taylor, S., Abramowitz, J. S., & McKay, D. (2007). Cognitive-behavioral models of obsessive-compulsive disorder. In M. M. Antony, C. Purdon, & L. J. Summerfeldt (Eds.), Psychological treatment of obsessive-compulsive disorder: Fundamentals and beyond (pp. 9–29). Washington, DC: American Psychological Association.

    Chapter  Google Scholar 

  • Wilhelm, S., & Steketee, G. (2006). Cognitive therapy for obsessive-compulsive disorder: A guide for professionals. Oakland: New Harbinger Publications Inc.

    Google Scholar 

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Acknowledgements

We thank Dr. Emilee Burgess for her feedback during the preparation of this manuscript.

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Authors and Affiliations

  1. Frederick W. Thompson Anxiety Disorders Centre, Sunnybrook Health Sciences Centre, 2075 Bayview Avenue, Toronto, ON, M4N 3M5, Canada

    Lance L. Hawley & Neil A. Rector

  2. Department of Psychiatry, University of Toronto, Toronto, ON, Canada

    Lance L. Hawley, Neil A. Rector & Zindel V. Segal

  3. Department of Psychological Clinical Science, University of Toronto - Scarborough, Scarborough, ON, Canada

    Lance L. Hawley, Neil A. Rector & Zindel V. Segal

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  1. Lance L. Hawley
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  2. Neil A. Rector
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Correspondence to Lance L. Hawley.

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L. Hawley, A. Rector, V. Segal have no competing interests to declare.

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All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

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Hawley, L.L., Rector, N.A. & Segal, Z.V. The Relative Impact of Cognitive and Behavioral Skill Comprehension and Use During CBT for Obsessive Compulsive Disorder. Cogn Ther Res 45, 439–449 (2021). https://doi.org/10.1007/s10608-020-10117-0

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