Sophie Robillard

Evaluation of a cognitive-behavioural program for the management of chronic tic and habit disorders

The aim was to evaluate the efficacy of a manualized cognitive-behavioural program based on habit reversal for the management of chronic tic disorder (CTD) and habit disorder (HD). Forty-seven CTD and 43 HD received a 4-month treatment program. Thirty-eight (22 CTD, 16 HD) were placed on a waitlist control group, which subsequently received treatment. The treatment approach combined awareness training, relaxation (including modification of a tension-producing style of action), and habit-reversal training, with more general cognitive restructuring of anticipations linked to ticcing. Sixty-five percent of completers reported between 75 and 100% control over the tic. At 2-year follow-up, 52% rated 75-100% control. There were also significant changes post-treatment in measures of self-esteem, anxiety, depression and style of planning action. Successful tic/habit modification was associated in CTD and HD groups with successful change in style of planning action. There were no consistent differences in any outcome measures between CTD and HD groups.

Cognitive-behaviour therapy and medication in the treatment of obsessive-compulsive disorder: a controlled study.

Objective: To evaluate the effect of combining cognitive-behaviour therapy (CBT) and medication in the treatment of obsessive-compulsive disorder (OCD). Method: Twenty-nine subjects diagnosed with OCD according to Diagnostic and Statistical Manual of Mental Disorders (DSM-III-R) criteria were recruited through the Anxiety Clinic of Louis-H Lafontaine Hospital. They were evaluated at baseline and after treatment on the Yale-Brown Obsessive Compulsive Scale (Y-BOCS) by a psychiatrist who was blind to treatment modality. Subjects rated their degree of resistance to their rituals and the strength of their obsessional beliefs. Subjects then received 1 of 4 treatments: medication and CBT simultaneously (n = 9), CBT only (n = 6), medication while on a wait-list for CBT (n = 6), or no treatment while on a wait-list for CBT (n = 5). Results: Multivariate analysis revealed that Y-BOCS scores and clinical ratings significantly improved posttreatment in all groups except the nontreatment wait-list control group. Subjects in the 2 active treatment groups receiving CBT showed reduced strength in their obsessional beliefs. The subsequent administration of CBT to those groups on the wait-list also decreased the strength of their primary obsessional beliefs and beliefs about the consequences of not performing the rituals. Conclusions: Our results suggest that either CBT or medication alone is more effective than no treatment. The combination of CBT and medication seems to potentiate treatment efficacy, and we found it more clinically beneficial to introduce CBT after a period of medication rather than to start both therapies simultaneously.

Inference processes in Obsessive-Compulsive Disorder: Some clinical observations

In this paper we outline a cognitive model of Obsessive-Compulsive Disorder (OCD) which proposes that the core belief of OCD evolves through a series of illogical inferences. These faulty inference processes involve inferring the plausibility of events on the basis of irrelevant associations, dismissing actual evidence on the grounds of going beyond surface reality to a deeper reality, and finally inferring that a completely fictional narrative is a remote probability. A therapy aimed specifically at changing these inference processes is illustrated with case examples of OCD clients who had not benefited from conventional behavior therapy. The inference based approach (IBA) complements existing cognitive-behavioral therapy but suggests that in certain cases, the conventional cognitive therapy view of OCD beliefs as exaggerated fears of remote possibilities may actually reinforce the obsessional belief since even remote events are real. The IBA on the contrary suggests that an important goal in therapy is to highlight this confusion found in OCD between imagination and reality and illuminate for the OCD client how their compulsions, far from reassuring them about a remote possibility, actually take them further away from reality and reinforce their imaginary doubt.

Evaluation of an Inference‐Based Approach to Treating Obsessive‐Compulsive Disorder

This study evaluated an inference‐based approach (IBA) to the treatment of obsessive‐compulsive disorder (OCD) by comparing its efficacy with a treatment based on the cognitive appraisal model (CAM) and exposure and response prevention (ERP). IBA considers initial intrusions in OCD (e.g. “Maybe the door is open”, “My hands could be dirty”) as idiosyncratic inferences about possible states of affairs arrived at through inductive reasoning. In IBA such primary inferences represent the starting point of obsessional doubt, and the reasoning maintaining the doubt forms the focus for therapy. This is unlike CAM, which regards appraisals of intrusions as the maintaining factors in OCD. Fifty‐four OCD participants, of whom 44 completed, were randomly allocated to CAM, ERP or IBA. After 20 weeks of treatment all groups showed a significant reduction in scores on the Yale‐Brown Obsessive Compulsive Scale (Y‐BOCS) and the Padua Inventory. Participants with high levels of obsessional conviction showed greater benefit from IBA than CAM. Appraisals of intrusions changed in all treatment conditions. Strength of primary inference was not correlated with symptom measures except in the case of strong obsessional conviction. Strength of primary inference correlated significantly with the Y‐BOCS insight item. Treatment matching for high and low conviction levels to IBA and CAM, respectively, may optimize therapy outcome.

Behavioral activity associated with onset in chronic tic and habit disorder

Seventy-six people (aged 18-62 years) diagnosed with either a chronic tic disorder or a habit disorder, entering a treatment study, kept a baseline daily diary for at least ten days, noting tic frequency and activity at time of onset. Together with an evaluator, participants completed a form ranking three high-risk activities where the tic or habit was likely to appear, and three low-risk activities where the tic was absent or barely present. Subjective appraisals distinguishing the two types of activities were also elicited and their relevance to the tic was measured on a seven-point scale using an adaptation of Kellys repertory grid technique. Overall, the most frequent high-risk and low-risk activities were, respectively, passive attendance and physical activity. There were, however, significant differences in types of high-risk activities amongst the tic and habit disorders. Conversely, appraisals of the high-risk activities seemed to center on negative evaluations of tenseness, boredom, dissatisfaction, and disinterest.

Cognitive behaviour therapy and medication in the treatment of obsessive–compulsive disorder

Objective:  To compare cognitive behaviour therapy (CBT) with CBT plus medication; medication alone; and placebo in the treatment of adult obsessive–compulsive disorder (OCD).

Treating Delusional Disorder: A Comparison of Cognitive-Behavioural Therapy and Attention Placebo Control

Objective: Cognitive-behavioural therapy (CBT) has proved effective in treating delusions, both in schizophrenia and delusional disorder (DD). Clinical trials of DD have mostly compared CBT with either treatment as usual, no treatment, or a wait-list control. This current study aimed to assess patients with DD who received CBT, compared with an attention placebo control (APC) group. Method: Twenty-four individuals with DD were randomly allocated into either CBT or APC groups for a 24-week treatment period. Patients were diagnosed on the basis of structured clinical interviews for mental disorders and the Maudsley Assessment of Delusion Schedule (MADS). Results: Completers in both groups (n = 11 for CBT; n = 6 for APC) showed clinical improvement on the MADS dimensions of Strength of Conviction, Insight, Preoccupation, Systematization, Affect Relating to Belief, Belief Maintenance Factors, and Idiosyncrasy of Belief. Conclusion: When compared with APC, CBT produced more impact on the MADS dimensions for Affect Relating to Belief, Strength of Conviction, and Positive Actions on Beliefs.

Cognitive-behavioural, pharmacological and psychosocial predictors of outcome during tapered discontinuation of benzodiazepine.

Eighty-six participants wishing to stop benzodiazepine and who met DSM-IV (Diagnostic and Statistical Manual of Mental Disorders, 4th ed. American Psychological Association, 1994) criteria for anxiety disorder or insomnia were assessed pre- and post-taper on clinical, pharmacological and psychosocial measures. An initial cohort of 41 participants received treatment as usual (taper only) plus physician counselling in the same clinic setting. A second cohort of 45 participants were randomly allocated to group cognitive-behavioural therapy (CBT) plus taper, or group support (GS) plus taper. At 3 months follow-up, the outcomes in both the CBT and the GS subgroups were equivalent. Intention to treat analysis revealed a slight advantage to the CBT over the GS group and the CBT group showed higher self-efficacy post-taper.Over all 86 participants, a high-baseline level of psychological distress, anxiety and dosage predicted a poor outcome, but increase in self-efficacy contributed to a successful outcome particularly in those with initially poor baseline predictors. Although there was a decrease in positive affect during preliminary stages of tapered discontinuation compared to baseline, there was no significant overall increase in negative affect.

A Cognitive Approach to the Treatment of Primary Inferences in Obsessive-Compulsive Disorder

In this article, it is argued that obsessive-compulsive disorder (OCD) with overt compulsions, where there is overvalued ideation, is primarily a disorder of the imagination and hence, by implication, psychological therapy should principally address the client’s imagination, rather than other cognitive processes. According to this model, the OCD client imagines a state of affairs which is then taken ‘as if it were a reality and does so because of the persuasive influence of an imaginary narrative fiction. This narrative is replayed, often in condensed form, in the OCD context and leads the client into a chain of maladaptive inferences about a possible state of affairs. The client then acts in accordance with what might be present rather than what is actually present. An inference-based approach (IBA) which directly addresses and challenges the imaginary narrative of the client is outlined, with clinical illustrations. The IBA approach complements other cognitive-behavioral therapy (CBT) and can be used in conjunction with existing CBT methods which focus more on modifying the interpretations and secondary appraisals subsequent to primary inferences.