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Group CBT for OCD Group CBT for OCD Professor Karina Lovell Professor Karina Lovell

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OCD Action Group Therapy presentation by Karina Lovell

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Group CBT for OCDGroup CBT for OCD

Professor Karina LovellProfessor Karina Lovell

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Aims of the workshopAims of the workshop

Identify the recommended treatments for OCD Identify the recommended treatments for OCD (NICE guidelines) (NICE guidelines)

Identify how and where group treatment for OCD Identify how and where group treatment for OCD is incorporated into the NICE guidelineis incorporated into the NICE guideline

Examine the evidence base for group CBT for Examine the evidence base for group CBT for OCDOCD

Examine the advantages and disadvantages for Examine the advantages and disadvantages for group CBT for OCDgroup CBT for OCD

Examine how group therapy for OCD works in Examine how group therapy for OCD works in practicepractice

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The prevalence of OCD is estimated at:The prevalence of OCD is estimated at:

AA

1-3%1-3%

BB

4-7%4-7%

CC

8-11%8-11%

DD

12-15%12-15%

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NICE Guidelines do not recommend NICE Guidelines do not recommend which treatment for OCD?which treatment for OCD?

AA

CBT (with exposure and CBT (with exposure and response prevention)response prevention)

BB

SSRI’sSSRI’s

CC

Psychodynamic Psychodynamic psychotherapypsychotherapy

DD

Group CBTGroup CBT

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Which of the following modes of delivery have been Which of the following modes of delivery have been tested with OCD:tested with OCD:1) Bibliotherapy1) Bibliotherapy2) cCBT2) cCBT3) Group CBT3) Group CBT4) Telephone4) Telephone

AA

1,2,3 & 4 1,2,3 & 4

BB

1,3 & 41,3 & 4

CC

1& 41& 4

DD

2,3 & 42,3 & 4

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Which of the following low intensity interventions do NICE Which of the following low intensity interventions do NICE recommend:recommend:1) cCBT 1) cCBT 2) Brief individual CBT 2) Brief individual CBT 3) Group CBT3) Group CBT4) CBT delivered by telephone4) CBT delivered by telephone

AA

1, 2, 3 & 4 1, 2, 3 & 4

BB

1 & 21 & 2

CC

2, 3 & 42, 3 & 4

DD

2 & 42 & 4

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Nice guidelines determine low intensity Nice guidelines determine low intensity treatments as less than how many treatments as less than how many

therapist hours?therapist hours?AA

55

BB

1010

CC

1515

DD

2020

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The most common outcome measure used in The most common outcome measure used in

treatment studies is the ?treatment studies is the ?

AA

BDIBDI

BB

OCCOCC

CC

CORE-OMCORE-OM

DD

YBOC’sYBOC’s

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In 1996 OCD was ranked as the ?th leading In 1996 OCD was ranked as the ?th leading cause of disabilitycause of disability

AA

8th8th

BB

9th9th

CC

10th10th

DD

11th11th

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Obsessive compulsive disorderObsessive compulsive disorder

OCD is a major disorder is and under OCD is a major disorder is and under recognized public health problem. recognized public health problem.

10th leading cause of disability by 10th leading cause of disability by WHOWHO

Lifetime prevalence (1.9-3.0%)Lifetime prevalence (1.9-3.0%) There is evidence that without There is evidence that without

adequate treatment the disorder adequate treatment the disorder tends to have a chronic fluctuating tends to have a chronic fluctuating course course

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ObsessionsObsessionsObsessionsObsessions are repetitive, recurring thoughts, are repetitive, recurring thoughts,

ideas, images or impulses that are experienced ideas, images or impulses that are experienced as intrusive and are usually distressing or as intrusive and are usually distressing or anxiety provoking. Such thoughts are often anxiety provoking. Such thoughts are often centered on dirt and contamination, accidental centered on dirt and contamination, accidental harm, illness, aggression, sex, orderliness and harm, illness, aggression, sex, orderliness and perfection.perfection.

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CompulsionsCompulsions

CompulsionsCompulsions (rituals) are repetitive and (rituals) are repetitive and intentional acts and serve to reduce anxiety the intentional acts and serve to reduce anxiety the thoughts provoke. The person recognizes that thoughts provoke. The person recognizes that their behavior is excessive or unreasonable.their behavior is excessive or unreasonable.

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NICE GuidelinesNICE Guidelines

Obsessive compulsive disorder: Obsessive compulsive disorder: core core interventions in the treatment of obsessive compulsive interventions in the treatment of obsessive compulsive disorder and body dysmorphic disorderdisorder and body dysmorphic disorder

Published 2005Published 2005

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What is NICE?What is NICE?

National Institute for Health and Clinical National Institute for Health and Clinical ExcellenceExcellence

Part of the NHSPart of the NHS Established 1999Established 1999 Produces Clinical Guidelines for the Produces Clinical Guidelines for the

“appropriate treatment and care of people “appropriate treatment and care of people with specific diseases and conditions with specific diseases and conditions within the NHS in England and Wales”within the NHS in England and Wales”

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What does the NICE OCD/BDD What does the NICE OCD/BDD guideline coverguideline cover

Children, young people and adults with OCD/BDD – Children, young people and adults with OCD/BDD – mild, moderate and severe functional impairmentmild, moderate and severe functional impairment

A stepped-care approach to recognition, assessment, A stepped-care approach to recognition, assessment, treatment interventions, intensive treatment and inpatient treatment interventions, intensive treatment and inpatient services, discharge and re-referralservices, discharge and re-referral

Who is it aimed at?Who is it aimed at? Healthcare professionals who share in the treatment and Healthcare professionals who share in the treatment and

care of people with OCD/BDD care of people with OCD/BDD Commissioners of servicesCommissioners of services Service users, families/carersService users, families/carers

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NICE recommendations NICE recommendations identified as key prioritiesidentified as key priorities

All people with OCD should have All people with OCD should have access to evidence-based treatments: access to evidence-based treatments: CBT including exposure and CBT including exposure and response prevention (ERP) and/or response prevention (ERP) and/or pharmacologypharmacology

CBT (including ERP) should be CBT (including ERP) should be offered in a variety of formatsoffered in a variety of formats

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Treatment options for adults with OCD

Mild functional Moderate functional Severe functional impairment impairment impairment

Brief CBT (+ERP)< 10 therapist hours

(individual or groupformats)

Offer choice of:more intensive CBT

(+ERP)>10 therapist hours

orcourse of an SSRI

Patient cannot engage in/CBT (+ERP) is inadequate

Offer combinedtreatment ofCBT (+ERP)and an SSRI

Inadequate response at 12 weeks

Multidisciplinary review

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Interventions for OCDInterventions for OCD Cognitive Behaviour Therapy (exposure and Cognitive Behaviour Therapy (exposure and

response prevention)response prevention) Pharmacological (SSRI’s)Pharmacological (SSRI’s)

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Low intensity interventionsLow intensity interventions

Brief individual CBT (including ERP) Brief individual CBT (including ERP) using structured self help using structured self help

Brief individual CBT (including ERP) by Brief individual CBT (including ERP) by telephonetelephone

Group CBT (including ERP)Group CBT (including ERP)

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Exposure and response Exposure and response preventionprevention

Exposure is the therapeutic confrontation to a Exposure is the therapeutic confrontation to a feared stimulus in imagination or in vivo until feared stimulus in imagination or in vivo until fear subsides (process known as habituation).fear subsides (process known as habituation).

Response prevention Response prevention is resisting carrying out is resisting carrying out the ritual. the ritual.

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Small group workSmall group work

In small groups discuss for 10 minutes the In small groups discuss for 10 minutes the advantages and disadvantages of group advantages and disadvantages of group treatment for people with OCDtreatment for people with OCD

Identify a scribe to feedback to the large Identify a scribe to feedback to the large groupgroup

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Advantages of group treatmentAdvantages of group treatment

Cost effective Cost effective ‘‘sharing’ of experiences between sharing’ of experiences between

participantsparticipants Possibly more motivating for participants Possibly more motivating for participants

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Disadvantages of group Disadvantages of group treatmenttreatment

Some people don’t like group treatmentSome people don’t like group treatment Difficult to organise at a convenient time Difficult to organise at a convenient time

for all group membersfor all group members It may be more difficult to involve It may be more difficult to involve

families/relativesfamilies/relatives

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Group CBT – The evidence baseGroup CBT – The evidence base Cordioli et al (2003) RCT: compared efficacy of group CBT with Cordioli et al (2003) RCT: compared efficacy of group CBT with

waiting list controlwaiting list control

McLean et al (2001) RCT: compared efficacy of two group McLean et al (2001) RCT: compared efficacy of two group treatment types (CBT or ERP) by two time frames (immediate or treatment types (CBT or ERP) by two time frames (immediate or delayed start)delayed start)

Jones & Menzies (1998) RCT compared efficacy of DIRT with a Jones & Menzies (1998) RCT compared efficacy of DIRT with a waiting list controlwaiting list control

Fals-Stewart et al (1993) RCT compared effectiveness of group Fals-Stewart et al (1993) RCT compared effectiveness of group behaviour therapy with individual behaviour therapybehaviour therapy with individual behaviour therapy

Emmelkamp et al (1988) RCT compared group cognitive therapy Emmelkamp et al (1988) RCT compared group cognitive therapy (RET) with group behaviour therapy (exposure in vivo)(RET) with group behaviour therapy (exposure in vivo)

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Systematic reviewSystematic review Reviewed 13 trials of group CBT treatment. Overall Reviewed 13 trials of group CBT treatment. Overall

  pre–post-ES of these trials of 1.18 and a between-group pre–post-ES of these trials of 1.18 and a between-group ES of 1.12 compared with waiting list control in three ES of 1.12 compared with waiting list control in three randomized controlled studies indicate that group randomized controlled studies indicate that group CBT/ERP is an effective treatment for OCD. Group CBT CBT/ERP is an effective treatment for OCD. Group CBT achieved better results than pharmacological treatment achieved better results than pharmacological treatment in two studies. One study found no significant differences in two studies. One study found no significant differences between individual and group CBT.between individual and group CBT.

Jónsson & Hougaard Group cognitive behavioural therapy for obsessive–Jónsson & Hougaard Group cognitive behavioural therapy for obsessive–compulsive disorder: a systematic review and meta-analysis (2009). Acta compulsive disorder: a systematic review and meta-analysis (2009). Acta Psychiatrica Scandinavica, Volume 119, Pages: 98-106Psychiatrica Scandinavica, Volume 119, Pages: 98-106

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What does this evidence meanWhat does this evidence mean

Post treatment, group CBT was found to be more effective than either no therapy or sertraline, but no different than ERP

There are no RCTs in adults with OCD comparing the effectiveness of group CBT with individual CBT.

Group CBT for OCD is effective Further research is needed to evaluate individual

versus group CBT for OCD.

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Group CBT - ApplicationGroup CBT - Application

Pre attendancePre attendance Detailed individual assessment of problemDetailed individual assessment of problem

Explanation of group process, expectations Explanation of group process, expectations and treatment model to enable the individual to and treatment model to enable the individual to make an informed decisionmake an informed decision

Willingness and commitment to participate in Willingness and commitment to participate in group CBT group CBT

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Group CBT - ApplicationGroup CBT - Application

Closed group formatClosed group format 5 – 12 participants5 – 12 participants 1 or 2 therapists1 or 2 therapists Weekly or twice weekly sessionsWeekly or twice weekly sessions 1 – 2.5 hours duration 1 – 2.5 hours duration 7 -12 sessions plus follow up7 -12 sessions plus follow up Pre, post and follow-up measuresPre, post and follow-up measures

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Group CBT - ApplicationGroup CBT - Application

Education regarding OCD and treatment Education regarding OCD and treatment modelmodel

CBT including ERP CBT including ERP Relapse preventionRelapse prevention Between session tasks tasksBetween session tasks tasks Monitoring progressMonitoring progress Telephone contact between sessions if Telephone contact between sessions if

requiredrequired

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Any questionsAny questions

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EvaluationEvaluation Was the workshop at the right levelWas the workshop at the right level Did it cover what you wantedDid it cover what you wanted What did you likeWhat did you like What would you want to change if we were to do What would you want to change if we were to do

the workshop againthe workshop again

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Thank you for listening Thank you for listening

[email protected]@manchester.ac.uk