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Doubt Therapy Changes Thinking Patterns in People with OCD

New manual helps people with contamination worries and compulsive washing.

Washing is a common form of OCD
Compulsive washing in OCD is driven by unrelenting doubt.
purchased from istockphoto
Metacognitive training for OCD

A recent study conducted at the University Medical Center Hamburg-Eppendorf by Dr. Steffan Moritz and Chantal Friese examined the effect of “metacognitive training” on patients suffering from Obsessive-compulsive Disorder (OCD). Based on doubt therapy, metacognitive training is a new angle on an old problem—how to get people with OCD to tolerate uncertainty.

The German study focused on people with washing compulsions. People with OCD who repeatedly wash don’t do it because they enjoy washing. Rather, they are not completely sure that they are clean enough, and keep washing just to be certain. In other words, they doubt.

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Researchers develop a reference manual

The researchers provided a metacognitive training for OCD (myMCT) manual to a study group of 25 initial participants with OCD, and another 25 participants had to wait four weeks before receiving copies of the manual. The waiters became the comparison group in an attempt to measure the effects of having a reference guide to dealing with obsessions. The manual encourages people with OCD to reflect on their thinking, particularly on those thought styles or distortions that contribute to the development and maintenance of the disorder. The manual not only examines the distorted thinking, but offers strategies to deal with these troublesome thoughts at home.  

Traditional treatment for OCD makes use of medication or a specialized type of cognitive-behavioral therapy (CBT) called exposure and ritual prevention. On average, medication results in only a 30 percent reduction in symptoms, and may involve side-effects.  Conversely, CBT can be costly and hard to find, as few therapist know how to conduct exposure and ritual prevention.  What is so remarkable about the study is that by using a free manual, participants showed real results. 

Major improvement post-study

The study showed that, well past any reasonable doubt of chance, using the myMCT manual lead to significant improvements in OCD symptoms.  The participants engaged in fewer compulsions and fewer rituals. 

The study used two measurements to determine the effectiveness of metacognitive training. This included the Yale-Brown Obsessive-Compulsive Scale (Y-BOCS) and the Obsessive-Compulsive Inventory-Revised (OCI-R). Both methods of diagnosing obsessive thoughts showed a significant reduction during the post study evaluations using just the doubt therapy handbook. The decline in obsessions (as measured with Y-BOCS) was 23.25 percent in the treatment group versus 9.02 percent in the waitlist group.  The decline in obsessions (as measured with OCI-R) was 25 percent in the treatment group versus 2 percent in the waitlist group.

The post-treatment testing showed that these methods can reduce the obsessions, at least in the short term, but also a significant reduction in the incidents of obsessive washing. The decline of obsessive washing (as measured with OCI-R) was 46.1 percent in the treatment group versus 14.6 percent in the waitlist group.

Thinking about thinking

The study handbook used extensive examination of what is considered “normal” thinking versus “abnormal” thinking caused by OCD. In many cases, the obsessive thoughts are focused on something horrible happening if the compulsion isn’t carried out, i.e. “If I don’t wash my hands, my child will get sick and die from AIDS.”

These thoughts can lead to avoidance behavior, such as wearing gloves or refusing to touch door handles and railings in public.  It can also lead to extremes such as agoraphobic behavior (refusing to leave the home), or even cutting off loved ones to avoid guilt. 

Researchers had participants answer questions on what might be considered abnormal thoughts: Anyone who has malicious thoughts is also a malicious person; I hoard things that I know are actually useless, etc.

They showed the percentages of “normal” people that had the same type of thoughts. The numbers showed that these types of thoughts truly aren’t abnormal. But in people without OCD, they are fleeting thoughts, or minor obsessions in the moment and nothing more. In people with OCD they become obsessive, a constant loop of thought running their mind causing them to feel high levels of anxiety leading to compulsive behavior.

Wooden man thinks
Thinking about thinking.
Examining the thought process

The handbook encourages participants to start their process of change slowly.  For example, if you have a compulsion that leads to hoarding, instead of having a television crew show up and begin tossing away everything in sight, instead slowly deal with the over-accumulation of items; learn that someone won’t die or you won’t have caused an emergency by discarding 20-year-old TV guides, for example.  This process can help to show that catastrophic fall out will not occur, despite the anxiety-producing obsessive thoughts. 

Where to find the metacognitive training handbook

The authors of the study have made the 130-page handbook available free of charge on their website, and it can be found at the following link: www.uke.de/mymct.

But if you have OCD, don't discard your mental health provier just yet. Further studies are planned to see if use of the handbook has long-term benefits, or rather if participants maintain their gains or simply slip back into old habits.

Metacognitive training may be useful for other forms of OCD or other disorders. The study to date has only measured immediate impact on obsessive thoughts and compulsions surrounding washing in OCD, but researchers plan to study the use of the therapy to help people with other types of difficulties as well.

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Monnica Williams, Ph.D., is an Assistant Professor in the Department of Psychological & Brain Sciences at the University of Louisville.

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