[CBT] with exposure and response prevention in the treatment of obsessive-compulsive disorder: A systematic review & meta-analysis.., Reid et al, 2021

Andy

Andy

Senior Member (Voting rights)
Full title: Cognitive behavioural therapy with exposure and response prevention in the treatment of obsessive-compulsive disorder: A systematic review and meta-analysis of randomised controlled trials
Background
Cognitive behavioural therapy (CBT), incorporating exposure and response prevention (ERP) is widely recognised as the psychological treatment of choice for obsessive-compulsive disorder (OCD). Uncertainty remains however about the magnitude of the effect of CBT with ERP and the impact of moderating factors in patients with OCD.

Method
This systematic review and meta-analysis assessed randomised-controlled trials of CBT with ERP in patients of all ages with OCD. The study was preregistered in PROSPERO (CRD42019122311). The primary outcome was end-of-trial OCD symptom scores. The moderating effects of patient-related and study-related factors including type of control intervention and risk of bias were examined. Additional exploratory analyses assessed the effects of treatment fidelity and impact of researcher allegiance.

Results
Thirty-six studies were included, involving 2020 patients (537 children/adolescents and 1483 adults) with 1005 assigned to CBT with ERP and 1015 to control conditions. When compared against all control conditions, a large pooled effect size (ES) emerged in favour of CBT with ERP (g = 0.74: 95% CI = 0.51 to 0.97 k = 36), which appeared to diminish with increasing age. While CBT with ERP was more effective than psychological placebo (g = 1.13 95% CI 0.71 to 1.55, k = 10), it was no more effective than other active forms of psychological therapy (g = −0.05: 95% CI -0.27 to 0.16, k = 8). Similarly, whereas CBT with ERP was significantly superior when compared to all forms of pharmacological treatment (g = 0.36: 95% CI 0.7 to 0.64, k = 7), the effect became marginal when compared with adequate dosages of pharmacotherapy for OCD (g = 0.32: 95% CI -0.00 to 0.64, k = 6).A minority of studies (k = 8) were deemed to be at low risk of bias. Moreover, three quarters of studies (k = 28) demonstrated suspected researcher allegiance and these studies reported a large ES (g = 0.95: 95% CI 0.69 to 1.2), while those without suspected researcher allegiance (k = 8) indicated that CBT with ERP was not efficacious (g = 0.02: 95% CI -0.29 to 0.33).

Conclusions
A large effect size was found for CBT with ERP in reducing the symptoms of OCD, but depends upon the choice of comparator control. This meta-analysis also highlights concerns about the methodological rigor and reporting of published studies of CBT with ERP in OCD. In particular, efficacy was strongly linked to researcher allegiance and this requires further future investigation.
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Open access, https://www.sciencedirect.com/science/article/pii/S0010440X21000018

Posted for this part from the conclusion, "This meta-analysis also highlights concerns about the methodological rigor and reporting of published studies of CBT with ERP in OCD. In particular, efficacy was strongly linked to researcher allegiance and this requires further future investigation.".
 
I have both OCD and ME/CFS, believe it or not. That exact technique, "exposure and response prevention", basically saved my life. I was afflicted by and extreme form of OCD, that appeared two years after the onset of my ME/CFS, to be precise, almost immediately after I started having memory issues. My hypothesis is that my OCD got triggered by the extreme anxiety and fear that I experienced due to experiencing cognitive decline at the tender age of 14, it really terrified me. Also, I think it's at least curious how my OCD started when my ME/CFS started generating cognitive issues, maybe both things are a result of ME/CFS "reaching my brain". In any case, I was able to overcome OCD thanks to the technique mentioned in this article. After my OCD resolved, my ME/CFS symptoms didn't improve at all, as expected. By the way, my ME is somewhat "confirmed" by a positive 48hs CPET, a tilt tablet test, etc. What I mean is that ME/CFS and psychiatric disorders can easily coexist, you sadly won't be protected by one of them from experiencing the other
 
In particular, efficacy was strongly linked to researcher allegiance
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This is universal to EBM. In fact EBM is mostly that, people pushing whatever they prefer until it sticks the old pre-science way of just arguing for one's opinion.

It requires more than investigation, it requires overhauling the entire system to remove this state of double standards where lesser evidence with no validity is used to block research into better evidence.
 
glennthefrog said:
I have both OCD and ME/CFS, believe it or not. That exact technique, "exposure and response prevention", basically saved my life. I was afflicted by and extreme form of OCD, that appeared two years after the onset of my ME/CFS, to be precise, almost immediately after I started having memory issues. My hypothesis is that my OCD got triggered by the extreme anxiety and fear that I experienced due to experiencing cognitive decline at the tender age of 14, it really terrified me. Also, I think it's at least curious how my OCD started when my ME/CFS started generating cognitive issues, maybe both things are a result of ME/CFS "reaching my brain". In any case, I was able to overcome OCD thanks to the technique mentioned in this article. After my OCD resolved, my ME/CFS symptoms didn't improve at all, as expected. By the way, my ME is somewhat "confirmed" by a positive 48hs CPET, a tilt tablet test, etc. What I mean is that ME/CFS and psychiatric disorders can easily coexist, you sadly won't be protected by one of them from experiencing the other
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You're not alone. A friend of mine, who had ME since age of 10, also developed OCD a couple of years later (which she says was started by fears about her ME). I think developing ME is exactly the sort of terrifying life event which can lead to some people developing OCD (though doubtless there's also a biological predisposition to it at play - in my friend's case, her brother also had OCD for a time).

I've had OCD on-and-off (mostly on) throughout my life, and developing ME certainly gave rise to some new obsessions and compulsions for me. I consider myself to currently be in remission from OCD, but I imagine it could pop back up in the right (or rather wrong) circumstances.

I did have some formal CBT for it, but that wasn't very helpful as the therapist was a bit useless. But I definitely think that CBT and ERP techniques (which I basically ended up self-teaching*) helped me to cope and to get into remission.

*Self-teaching would probably not be possible for people with severe OCD.

Perversely, I think my ME becoming severe also helped to get the OCD into remission. I would be thinking about an obsession, but then my brain fog would make me forget what I was thinking about. And it forced me to stop doing some compulsions because I simply didn't have the energy.

Now I just have plain old Anxiety to deal with. I find that CBT techniques help me to cope with that, but I don't think that will ever be cured for me.
 
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But, the results of this study are interesting. I'm surprised to read that efficacy was strongly linked to researcher allegiance, because I've never encountered a person with OCD saying that ERP with a good therapist didn't help them (and I have been around the block quite a bit online with reading about this). @Joan Crawford I'm curious what you make of this?
 
Sarah94 said:
But, the results of this study are interesting. I'm surprised to read that efficacy was strongly linked to researcher allegiance, because I've never encountered a person with OCD saying that ERP with a good therapist didn't help them (and I have been around the block quite a bit online with reading about this). @Joan Crawford I'm curious what you make of this?
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Hi, I suspect that clinical trials for all sorts of treatments and conditions will largely be carried out by those or by colleagues of those who develop the basic science, theory, model of therapy and so forth. The therapists in the trials perhaps understand and maybe trained more in the work. I suspect that might make a difference. Leaves lots of scope for overt and covert biases to creep in. Even if trials are blinded (trials of pills) patients talk about side effects and so forth that clinicans can sometimes guess who is on the active treatment and so on. Also, bias creeps in with choice of measures used to assess effectiveness and on it goes. Lots that can be done to mitigate and minimise too. Depending on the trial design and what is being studied.

Where CBT does often really help is with patients with anxiety conditions like PTSD, ocd, generalised anxiety and so forth when the therapist generally follows the principles (frequently this is poor), can develop a respectful, collaborative working relationship (variable....) and the client understands the underlying theory (and agree with it and is not humouring the therapist ) and is open to working in detail on thinking and feelings along with approaching feared situations and feeling states in a hierarchical manner. There is a lot that can go wrong here. And there is often a great deal to be gained for the client if they can get into it, feel supported and have the resources (time, cognitive etc) to do the work. A side effect of untreated anxiety can be low mood and in time often depression as people feel incompetent managing their emotions, relationships and so forth.
 
'The primary outcome was end-of-trial OCD symptom scores.'

It'd be more helpful if outcome was whether the patients met or not OCD criteria (independently and blind to treatment assessed using structured, clinical interviews) post treatment.

Plus other real world measures like ability to work (or equivalent such as accomplish caring responsibilities etc) and so forth.
 
I think that CBT is effective at changing thoughts and behaviours if the changes are beneficial to the patient. My mother was always a bit obsessive but after my father died she found herself unable to get to bed because she kept checking the doors were locked. We discussed it and came up with moving her watch from one wrist to the other when she did her first check, though she allowed herself one last round.

I would hope that therapists have enough experience to come up with things that help. They can also help clients come to terms with what is happening. In our family we talk about taking the emotion out of things so it leaves you free to deal with the real problem in a practical manner.

Where CBT fails is that many things it aims to treat, including OCD, have a strong biological component and no amount of psychological help will make that go away. Too often that last, unreachable bit is seen as the patient's fault or moral weakness.
 
glennthefrog said:
I have both OCD and ME/CFS, believe it or not. That exact technique, "exposure and response prevention", basically saved my life. I was afflicted by and extreme form of OCD, that appeared two years after the onset of my ME/CFS, to be precise, almost immediately after I started having memory issues. My hypothesis is that my OCD got triggered by the extreme anxiety and fear that I experienced due to experiencing cognitive decline at the tender age of 14, it really terrified me. Also, I think it's at least curious how my OCD started when my ME/CFS started generating cognitive issues, maybe both things are a result of ME/CFS "reaching my brain". In any case, I was able to overcome OCD thanks to the technique mentioned in this article. After my OCD resolved, my ME/CFS symptoms didn't improve at all, as expected. By the way, my ME is somewhat "confirmed" by a positive 48hs CPET, a tilt tablet test, etc. What I mean is that ME/CFS and psychiatric disorders can easily coexist, you sadly won't be protected by one of them from experiencing the other
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Same here, I was in a really bad downward spiral with my OCD, I’m not sure if I’d be alive anymore without exposure and response therapy. It’s horribly difficult but it was very effective for me.
 
Sarah94 said:
But, the results of this study are interesting. I'm surprised to read that efficacy was strongly linked to researcher allegiance, because I've never encountered a person with OCD saying that ERP with a good therapist didn't help them (and I have been around the block quite a bit online with reading about this). @Joan Crawford I'm curious what you make of this?
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thank you for this reply... is the first time I hear about an experience like mine. I think that's the exact issue, developing ME is such a terrifying experience that it can be the perfect trigger for OCD and other anxiety related illnesses, for me it's something very easy to understand, but no doctor I ever visited was able to understand it. It's unbelievable how close your experience matches mine, as brain fog is also one of the key elements that allowed me to recover, I'm 100% sure that if I didn't suffered from memory impairment due to ME, it would have been impossible for me to forget my obsessions as I did. My individual obsessions popped out in my mind in a repetitive manner during years and were clearly stored as memories, memories that have now been destroyed, making it impossible for the obsessions to come back. Also, thanks to ERP, I have now such control over my mind that I can consciously refrain from recalling any memory about my past obsessions, I simply can choose to "not go in there", where before ERP, that was completely impossible, I simply wasn't able to decide what to think or not think about , OCD was in charge :-(
By the way I also "self taught" ERP, which is extremely common, as most psychologists and psychiatrist don't know about it or aren't willing to do the effort required to apply it to their patients. For me, it was so effective that I saw clearly positive results in just one week, when everything else I tried for 10 years, including drugs and psychotherapy, had completely failed, not providing even the smaller amount of relief
 
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Sarah94 said:
You're not alone. A friend of mine, who had ME since age of 10, also developed OCD a couple of years later (which she says was started by fears about her ME). I think developing ME is exactly the sort of terrifying life event which can lead to some people developing OCD (though doubtless there's also a biological predisposition to it at play - in my friend's case, her brother also had OCD for a time).

I've had OCD on-and-off (mostly on) throughout my life, and developing ME certainly gave rise to some new obsessions and compulsions for me. I consider myself to currently be in remission from OCD, but I imagine it could pop back up in the right (or rather wrong) circumstances.

I did have some formal CBT for it, but that wasn't very helpful as the therapist was a bit useless. But I definitely think that CBT and ERP techniques (which I basically ended up self-teaching*) helped me to cope and to get into remission.

*Self-teaching would probably not be possible for people with severe OCD.

Perversely, I think my ME becoming severe also helped to get the OCD into remission. I would be thinking about an obsession, but then my brain fog would make me forget what I was thinking about. And it forced me to stop doing some compulsions because I simply didn't have the energy.

Now I just have plain old Anxiety to deal with. I find that CBT techniques help me to cope with that, but I don't think that will ever be cured for me.
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Sarah94 said:
Of course, if it doesn't work for some people, that's not their fault (just as it's not somebody's fault if a medication doesn't help their health condition). Probably means that either it's not the right approach for them, or the therapist isn't good enough.
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there's also the fact that probably many of the participants didn't even have OCD to begin with. OCD is notable for being extremely difficult to diagnose, the average time for diagnosis is 10 years...
 
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