|Year : 2019 | Volume
| Issue : 1 | Page : 80-87
Cognitive behavioral therapy and functional impairment in obsessive–Compulsive disorder
Laxmi Narayan Rathore1, Jai Prakash2
1 Department of Clinical Psychology, Gwalior Mansik Arogyashala (Govt. Mental Hospital), Gwalior, Madhya Pradesh, India
2 Department of Clinical Psychology, RINPAS, Kanke, Ranchi, Jharkhand, India
|Date of Submission||24-Sep-2017|
|Date of Decision||30-Jul-2018|
|Date of Acceptance||08-Oct-2018|
|Date of Web Publication||27-Mar-2019|
Prof. Jai Prakash
Department of Clinical Psychology, RINPAS, Kanke, Ranchi, Jharkhand
Source of Support: None, Conflict of Interest: None
Background: Obsessive–compulsive disorder (OCD) is characterized by the presence of obsessions and compulsions and has a lifetime prevalence of around 2%–3%. Increase in symptoms severity in OCD is associated with noticeable impairment in daily psychosocial functioning of the patient, that further add-on to the stress level of the individual and increases burden on the family and society. Therefore, effective and timely management is required. Literature favors cognitive behavioral therapy (CBT) intervention in managing symptoms severity in OCD. The present study attempts to look its role on functional impairment of such patients. Methods: Pre- and post-intervention with a control group design were made to conduct this study involving 20 patients with OCD. Patients were equally divided in two groups where one group was given intervention with CBT sessions for 10 weeks. Pre- and post-intervention assessment was done using Yale–Brown Obsessive–Compulsive Scale (YBOCS) and dysfunctional analysis questionnaire (DAQ) and results were compared. Results: Obtained data indicate significant decrease in composite score on YBOCS and significant increase in composite and domain-wise scores for DAQ assessment at postintervention assessment, in the group which has been given intervention with CBT as compared to the other group. Conclusion: Finding reveals that CBT has an impact in improving the functional ability along with remission of primary obsessive–compulsive symptoms in patients with OCD.
Keywords: Cognitive behavioral therapy, compulsions, dysfunctional analysis questionnaire, functional impairment, obsessions, obsessive–compulsive disorder
|How to cite this article:|
Rathore LN, Prakash J. Cognitive behavioral therapy and functional impairment in obsessive–Compulsive disorder. Indian J Soc Psychiatry 2019;35:80-7
|How to cite this URL:|
Rathore LN, Prakash J. Cognitive behavioral therapy and functional impairment in obsessive–Compulsive disorder. Indian J Soc Psychiatry [serial online] 2019 [cited 2019 Apr 24];35:80-7. Available from: http://www.indjsp.org/text.asp?2019/35/1/80/255002
| Introduction|| |
Obsessive–compulsive disorder (OCD) is characterized by the presence of obsessions and compulsions. It is one of the major psychiatric conditions observed in patients coming to mental health settings. According to the World Health Organization, OCD is the fourth major diagnosis made in outpatient departments (OPD). OCD studies have suggested a lifetime prevalence rate in general population to the tune of 2%–3%., This disorder is known to express mainly in the adolescent period with men typically having an earlier age of onset than women, who have slightly greater incidence of this condition.,,, OCD shares high rate of diagnostic comorbidity with depressive episode, ranging from 30% to 50%., OCD is associated with functional disability and is known to cause debilitating effect in patient's day-to-day normal functioning to great extent. This illness has been reported to have a significant negative impact on a person's ability to function normally at home, social, and occupational domains, especially in more severe cases., Studies have reported a diminished quality of overall functional capacity in such patients and this increases with chronicity of illness and with emergence of further comorbid psychopathology. Therefore, effective and timely intervention is required. Previous studies,, have used cognitive and behavioral techniques on OCD patients and do conclude the effectiveness of cognitive and behavioral measures in decreasing the severity of obsessive–compulsive symptoms. However, these studies did not comment on the status of patient's functional ability after cognitive behavioral intervention. The present study aims to see the role of cognitive behavioral therapy (CBT) on functional ability in life of patients with OCD.
Aims and objectives
The aim of this study has been to see the impact of cognitive behavior therapy on functional impairment of patients with OCD.
| Methods|| |
The study has been a pre- and post-intervention-based study with control group design, which was conducted at Ranchi Institute of Neuropsychiatry and Allied Sciences.
A total of twenty patients diagnosed with OCD as per the International Classification of Disease-10 Diagnostic Criteria for Research (ICD-10-DCR) criteria were enrolled for this study using purposive sampling procedure. Patients were divided into experimental and control group using draw of lots method with replacement. Both groups were having equal number of 10 patients.
- Inclusion criteria for both groups:
- Patients diagnosed with OCD as per ICD-10-DCR criteria
- Age ranges between 25 and 40 years
- Duration of illness between 2 and 5 years
- Patients who have attained education of at least primary level
- Patients who are able to understand Hindi.
Exclusion criteria for both groups:
- Patients having comorbid psychiatric conditions except secondary depression, having brain or neurological disorders
- Patients having mental retardation
- Patients with any substance or drug dependence except nicotine dependence.
- Sociodemographic and clinical data sheet –For the present study, a sociodemographic and clinical data sheet has been prepared and used to collect information regarding various sociodemographic and clinical variables such as age, domicile, socioeconomic status, religion, education, marital status, family type and onset of illness, duration of illness, presence of precipitating factor, and treatment undertaken.
- Yale–Brown Obsessive–Compulsive Scale (YBOCS) – This rating scale was originally developed by Goodman et al. (1989). It is a widely used instrument to rate the severity of obsessive and compulsive symptoms and to monitor the improvement in OCD patients. This scale measures obsessions and compulsions separately. It is a clinician-rated 10 items scale. Each item is rated from 0 (no symptoms) to 4 (severe symptoms). The scale includes item about the amount of time spent on obsessions, impairment or distress experienced, and resistance or control patients have over such thoughts. The cutoff point for the presence of obsession and compulsions is 7, that is, a score of 7 or less indicates no obsessions and/or compulsion. A score of 8–15 indicates mild, 16–23 indicates moderate, a score of 24–31 indicates severe, and a score of 32–40 indicates extreme obsessions and/or compulsion. The internal consistency of YBOCS was found to be of acceptable level and the inter-rater reliability has been found to be excellent, that is, correlation coefficients is r = 0.85 for the total YBOCS score
- Dysfunctional analysis questionnaire (DAQ) – DAQ is a fifty-item questionnaire developed and standardized in India by Pershad et al. (1985). This measures dysfunction in five areas of activity, mainly social, vocational, personal, familial, and cognitive. The instrument can be either self-administered or administered in a structured clinical interview. There are ten items each for the abovementioned five areas of activity. Each item is rated on a 5-point scale (1-5), comparing the present level of functioning to that before the onset of illness. A raw score of 1 indicates functioning better than that before the onset of illness, 2 indicating no impairment, and 3, 4, and 5 indicating mild, moderate, and severe impairment, respectively. The total raw score for each of the activity areas is converted to a percentage score, which has a range of 20–100. A percentage score of 20–39 indicates better functioning than premorbid level, percentage score of 40 indicates no change, and a percentage score of more than 40 is an indication of dysfunction. DAQ has been used in various previous researches. The test–retest reliability of this scale ranges from 0.76 to 0.92 and the spilt-half reliability was also found to be significant
- Intervention package – In this study, intervention was done using cognitive behavior therapy. Along with psychoeducation, following cognitive and behavioral components were used in Hindi language for the present study:
- Psychoeducation: It is the educative component of the cognitive behavioral intervention. Initial phase of psychoeducation is essential for the success of intervention package
- Cognitive restructuring techniques: This is one of the main therapeutic components of CBT intervention. Available literature suggests that the precondition for cognitive restructuring process is patient's ability to distinguish their appraisals from obsessions. It is recommended to use these techniques after initial sessions of psychoeducation. In the present study, downward arrow and socratic questioning techniques were used
- Behavioral intervention: For success of CBT, these are significant. Depending on the nature of symptoms presentation, exposure and response prevention and thought stopping method were used in this study.
The present study has been carried out in three steps:
- Step 1: This step involved enrolment and baseline assessment of all patients on clinical tools, after the research protocol was passed by the ethics committee. Using purposive sampling method and based on inclusion criteria, OCD patients were enlisted from the OPD. Then, the purpose of the study was explained in Hindi language to the patients and only those patients were enrolled for the study who gave their written consent for participation in the study. All patients were divided into two groups using draw of lots method. Patients in both groups were asked to retain their psychiatric medications from their psychiatrist and were allowed to continue their visit to their psychiatrist, if they desire. Patients comfort and availability were kept in mind while giving appointments for intervention sessions. During the appointed day, patients were taken to the psychotherapy room of the hospital for their baseline assessment. The assessment procedure was started with an informal discussion to make the patients comfortable. After this, a semi-structured interview was conducted to list their current obsessive and compulsive symptoms and to understand other clinical aspects of illness such as presence of insight, avoidance behavior, and use of resistance against compulsive rituals. Baseline assessment of obsessive–compulsive symptoms of all patients in both groups has been done on YBOCS. Further assessment of the current functional ability of patients has been done using DAQ
- Step II: In this step, all OCD patients in the experimental group were given sessions of cognitive behavior therapy. Intervention of psychoeducation, cognitive restructuring, and behavioral methods was given. Twenty sessions of CBT were given with a frequency of two sessions per week and duration of 45 min per se ssions. Intervention started with psychoeducational phase followed by introduction of cognitive and behavioral strategies.
Plan of sessions
Twenty intervention sessions were given for OCD patients of experimental group. In the beginning, around three sessions were involved in psychoeducating the client about various aspects of OCD and to develop a positive therapeutic relationship with the patient. During psychoeducation, cognitive behavioral model of OCD and issues of normal and abnormal obsessions were discussed to normalize them with regard to their intrusive thoughts. The underlying idea during these sessions has been to develop an understanding that obsessions are as normal as any other intrusive thought and often their frequency is increased by (constantly) focusing on them, as we tend to make them significant for ourselves by our focus. Efforts were made during these sessions of psychoeducation, for the successful acceptance of cognitive behavioral explanations about their OC phenomenon. After initial sessions of psychoeducation, cognitive intervention involving restructuring strategies were introduced from fourth session onward. During these sessions, the patients were pointed towards their use of selective approach in dealing with their unwanted intrusive thoughts. Restructuring process focused on inculcating an understanding in the patients about their different ways of dealing with low-frequency intrusive thoughts (nonobsessive) and selective way of dealing with high-frequency intrusive thoughts (obsessive). In those patients who were having overestimated threat appraisals, Downward arrow technique has been used to challenge the excessive negative fear. A step-wise questioning (probing) has been used to reach the core fear about obsession and then to challenge overestimation/unrealistic fear related with “that particular obsession.” Socratic questioning method was also used for challenging other types of appraisals such as appraisal of inflated responsibility and perfectionism. On an average, five sessions of cognitive restructuring were introduced for all patients of experimental group. Efforts were made during these sessions of cognitive interventions to generate an alternative appraisal for their specific obsession which is readily accepted by them. After cognitive intervention sessions, behavioral interventions were given to the patients. Intervention techniques of exposure and response prevention or thought stopping were introduced to the patients. In this manner, intervention was given to all OCD patients of experimental group. Along with application of therapeutic components of cognitive behavioral intervention, all patients in experimental group were allowed to continue with their “treatment as usual” on the grounds of clinical and ethical management. However, no sessions of CBT were demonstrated to OCD patient of control group during this step, but they were allowed to continue with their “treatment as usual.”
- Step III: This is the final phase of data collection. For the experimental group, this phase comes after administration of minimum 20 intervention sessions (10 weeks) of CBT and for the control group, this phase comes after 10 weeks of their baseline assessment. During this phase, patients of both groups were again assessed using same clinical tools, that is, YBOCS and DAQ which were used for baseline assessment. After the reassessment, control group of OCD patients was also given therapeutic sessions of CBT on moral and ethical grounds.
The obtained data have been analyzed using the Statistical Package for the Social Sciences version 16.0 of windows (SPSS 16.0 was developed by IBM Corporation, USA). As the study sample was small, nonparametric test measures were used for analysis of the data. Chi-square and Mann–Whitney U-test has been used to see the difference between two groups for categorical and continuous variables, respectively. Wilcoxon signed-rank test was used to compare pre- and post-intervention phase scores in case of experimental group subjects.
[Table 1] indicates that both the compared groups did not differ significantly with regard to various sociodemographic variables. The groups were found alike on marital status, education, occupation, sex, and type of family domains.
|Table 1: Comparison between experimental group and control group of obsessive-compulsive disorder patients on sociodemographic variables|
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[Table 2] revealed that both the groups did not differ significantly on various clinical variables such as age, age of onset, and duration of OCD.
|Table 2: Comparison of age and clinical variables between experimental group and control group of obsessive-compulsive disorder patients|
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[Table 3] depicts that there is no significant statistical difference between OCD patients of both compared groups at baseline with regard to their obsessive and compulsive symptoms independently and compositely. Data indicate that both groups exhibited similar level of impairment in their obsessive and compulsive symptoms at baseline level.
|Table 3: Baseline assessment of obsessive-compulsive disorder patients of experimental group and control on Yale-Brown Obsessive-Compulsive Scale|
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[Table 4] indicates that experimental and control group of OCD patients did not differ significantly at baseline for their assessment on DAQ. Obtained data suggest that both groups were alike with regard to their impairment on cognitive, family, personal, vocational, and social adjustment domains. Similar findings were also noticed for composite adjustment scores.
|Table 4: Baseline assessment of experimental group and control group of obsessive-compulsive disorder patients on dysfunctional analysis questionnaire|
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[Table 5] suggests that OCD patients of both compared groups differ statistically significantly (P < 0.01) at postintervention phase assessment on YBOCS. The experimental group exhibited reduced obsessive and compulsive symptoms, both independently and compositely after intervention.
|Table 5: Postintervention assessment of experimental group and control group of obsessive-compulsive disorder patients on Yale-Brown Obsessive-Compulsive Scale|
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Findings in [Table 6] suggests that there is significant difference between OCD patients of experimental and control group (P < 0.01) at postintervention phase assessment on DAQ. Reduced scores indicating improvement were observed in cognitive, familial, personal, vocational, and social functioning as well as for composite functioning in patients of experimental group at postintervention.
|Table 6: Postintervention assessment of experimental group and control group of obsessive-compulsive disorder patients on dysfunctional analysis questionnaire|
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[Table 7] indicates significant difference between pre- and post-intervention phase assessment of OCD patients of experimental group on DAQ. Difference was noticed for social, cognitive, personal, familial, and vocational functioning as well as for overall functioning at postintervention phase from their preintervention phase performance.
|Table 7: Pre- and post-intervention analysis of experimental group of obsessive-compulsive disorder patients on dysfunctional analysis questionnaire|
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| Discussion|| |
The present research work looked into the role of CBT on the functional impairment in daily living of patients with OCD. Due to the severe debilitating effect, this illness has on such patient's overall daily functional capacity, the onus is to look for such treatment strategies, which are not only effective in managing the severity of primary symptoms of the disorder per se but would also help in improving their functional capacity in various areas of day-to-day life situations. As it has been well documented that following the increase in symptoms severity, OCD patient more or less, exhibit poorer or diminished daily functioning,,,, therefore, the point of interest in this study has been to see what role does cognitive and behavioral strategies have on functional capacity in different areas of daily living of patients having OCD. With such aim in mind, the present research has been planned with twenty patients having primary diagnosis of OCD.
Analysis of the result obtained indicates similar characteristics in both groups. Analysis further revealed that there has been no significant difference between both groups in terms of age, onset of illness, and duration of illness; factors that might affect the outcome of intervention. Baseline analysis of patients of both groups on YBOCS indicates no overall difference in composite scores for obsession and compulsions. Experimental group of OCD patients obtained composite score in the range of 29–30, whereas control group patients' exhibit a range of 28 to 31 for their OC symptoms. Findings revealed that statistically both groups were similar with regard to severity of OC symptoms at baseline. Review of the related literature suggests, a positive relation between severity of obsessive–compulsive symptoms and diminished functional ability of patients in long term for such disorder. Further, assessment on DAQ at baseline phase revealed dysfunctions in cognitive, family, personal, vocational, and social areas by patients of both groups in their daily functioning. Our present findings were consistent with previous researches, that had reported functional impairment with respect to different domains of daily living in patients having OCD. Calvocoressi et al. (1995) suggested that, in most of the cases of OCD, the patient finds it difficult to function effectively in various aspects of life and were unable to perform their roles and responsibilities in different areas such as personal, social, and vocational.
At the postintervention phase, the findings revealed decrease in severity of obsessive–compulsive symptoms along with improvement in dysfunctional level in that group of OCD patients which has been given intervention with cognitive behavioral therapeutic measures. However, similar level of improvement in obsessive–compulsive features and dysfunction in life were not observed in OCD patients of control group. Therefore, it suggests that with decrease in obsessive–compulsive features, such patient does exhibit improvement in functional ability in terms of different life areas such as cognitive, social, personal, and vocational. This, in turn, points toward the effective role of CBT in decreasing the functional impairment and increasing the functional ability in day-to-day life of OCD patient. Analysis of pre- and post-intervention phase scores of OCD patients of experimental group also revealed significant change (improvement) after intervention with CBT in experimental group. Thus, overall, it has been demonstrated that OCD patients who were given intervention with CBT exhibited features of reduced dysfunction in different areas of daily living such as social, vocational, personal, familial, and cognitive functioning. Our findings are in line with the previous researches.,,,, They have also observed improvement in functioning level of OCD patients following reduction in severity of primary obsessive and compulsive symptoms after application of CBT. Findings of similar nature were reported by Neill and Feusner (2015). Obtained findings could be understood with such observation that the amount of time consumed by the patient in dealing with his obsessions and compulsions is gradually increased with the progress in OCD and subsequently these patients have been found to indulge in their own thought matrix, either cognitively or behaviorally, which affects their functioning ability. However, with use of cognitive behavior therapy, patients with OCD experience change in cognitive style with respect to handling their obsessive thoughts, which is followed with change in their response pattern, and subsequently, they tend to carry out their responsibilities in different spheres of daily living more adaptively and effectively.
However, in the present study, patients were not controlled for their psychiatric medications and the sample studied was not large. Furthermore, the long-term impact of CBT on functional ability of patients has not been considered and the individual effect of cognitive or behavioral strategies have not been studied in this study, which could be done in future research protocols.
| Conclusion|| |
Findings of the present study do suggest that CBT intervention have an impact on decreasing the functional impairment and improving the daily functional ability of patients having OCD along with remission of primary obsessions and compulsions. Thus, the study calls for incorporating CBT strategies in treatment of patients with OCD to improve their functional ability in daily living. However, in future research protocols, patients could be followed up one more time to see the long-term effect of CBT and the study sample could be matched for medications also.
The authors wish to acknowledge all the cooperation extended in the form of active participation by all the patients who were a part of this study.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7]