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Psychiatry Research xxx (2010) xxx–xxx

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Psychiatry Research
j o u r n a l h o m e p a g e : w w w. e l s ev i e r. c o m / l o c a t e / p s yc h r e s

Group versus individual cognitive treatment for Obsessive-Compulsive Disorder:


Changes in non-OCD symptoms and cognitions at post-treatment and
one-year follow-up
Amparo Belloch a,⁎, Elena Cabedo b, Carmen Carrió c, Héctor Fernández-Alvarez d,
Fernando García d, Christina Larsson e
a
Departmento de Psicologia de la Personalidad, Facultad de Psicologia, Universidad de Valencia, Valencia, Spain
b
Mental Health Outpatient Clinic, Agencia Valenciana de Salud, Foios, Valencia, Spain
c
Mental Health Outpatient Clinic, Agencia Valenciana de Salud, Burjassot Valencia, Spain
d
Aiglé Institute, Buenos Aires, Argentina
e
Mental Health Outpatient Clinic, Agencia Valenciana de Salud, Vinaroz, Valencia, Spain

a r t i c l e i n f o a b s t r a c t

Article history: Current cognitive approaches postulate that obsessions and compulsions are caused and/or maintained by
Received 15 February 2010 misinterpretations about their meaning. This assumption has led to the development of cognitive therapeutic
Received in revised form 5 August 2010 (CT) procedures designed to challenge the dysfunctional appraisals and beliefs patients have about their
Accepted 19 October 2010
obsessions. Nonetheless, few studies have compared the efficacy of individual and group CT in changing the
Available online xxxx
dysfunctional cognitions that hypothetically underlie Obsessive-Compulsive Disorder (OCD). In this study, 44
Keywords:
OCD patients were assigned to individual (n = 18) or group (n = 24) CT. Sixteen completed the individual CT,
Cognitive treatment and 22 completed the group CT. The effects of the two CT conditions on depression and worry tendencies were
Group treatment comparable. Individual treatment was more effective than group treatment in decreasing scores on
Dysfunctional beliefs dysfunctional beliefs (responsibility, overestimation of threat, and intolerance to uncertainty) and the use of
Thought control strategies suppression as a thought control strategy. The post-treatment changes were maintained one year later. The
Metacognitions correlations between symptom improvement (OCD severity change) and belief changes were moderate: in
the individual treatment the greatest associations were with beliefs about thoughts (importance and control),
whereas in the group treatment the greatest associations were with beliefs related to anxiety in general
(threat overestimation and intolerance to uncertainty).
© 2010 Elsevier Ireland Ltd. All rights reserved.

1. Introduction least as effective as individual ERP in changing symptoms and


dysfunctional cognitions, both short and long term. Regarding the
Current cognitive approaches that view obsessions as being caused effectiveness of group CT, the results also support its validity for OCD
by misinterpretations about their meanings have led to the develop- in terms of both statistically and clinically significant outcomes (Braga
ment of cognitive therapeutic procedures specifically designed to et al., 2005; Fineberg et al., 2005; Meier et al., 2006; Sousa et al., 2006;
challenge patients' dysfunctional appraisals and beliefs about their Rees and van Koesveld, 2008; Whittal et al., 2008).
obsessions (Rachman, 1997, 1998; Salkovskis, 1999; Clark, 2004). As for studies comparing group and individual CT for OCD,
The efficacy of individual cognitive therapy (CT) for the treatment Anderson and Rees (2007) report the first controlled study showing
of Obsessive-Compulsive Disorder (OCD) has been well established. that the group CT condition can be as effective as the individual one.
Several controlled studies have compared the effectiveness of Nevertheless, the follow-up period in this study was only one month,
individual CT versus Exposure and Response Prevention (ERP), the which limits the conclusions that can be drawn about the stability of
most firmly established behavioural therapy for OCD to date (e.g., the obtained changes over time. Jaurrieta et al. (2008a) conducted a
Cottraux et al., 2001; van Oppen et al., 2005; Whittal et al., 2005; randomized open trial comparing the effectiveness of individual and
Belloch et al., 2008). The general conclusion is that individual CT is at group CT at 6-month and one-year follow-ups. They did not observe
significant differences between the two conditions in clinical out-
comes (severity, depression, and anxiety) or in the dropout rates
during the two follow-up periods. In a second study (Jaurrieta et al.,
⁎ Corresponding author. Departamento de Personalidad, Evaluación y Tratamientos
Psicológicos, Facultad de Psicología, Avenida Blasco Ibáñez, 21. Valencia 46010, Spain.
2008b), the authors found that regardless of the treatment modality,
Tel.: +34 963983439; fax: +34 963864669. patients with contamination obsessions showed the least improve-
E-mail address: amparo.belloch@uv.es (A. Belloch). ment on depression and anxiety measures at post-treatment.

0165-1781/$ – see front matter © 2010 Elsevier Ireland Ltd. All rights reserved.
doi:10.1016/j.psychres.2010.10.015

Please cite this article as: Belloch, A., et al., Group versus individual cognitive treatment for Obsessive-Compulsive Disorder: Changes in non-
OCD symptoms..., Psychiatry Research (2010), doi:10.1016/j.psychres.2010.10.015
2 A. Belloch et al. / Psychiatry Research xxx (2010) xxx–xxx

In sum, the efficacy of CT for OCD seems to be firmly established, Table 1


and although the individual delivery of treatment shows better results Participants' attrition.

than the group treatment, the latter is a promising tool that merits Spanish Argentinean
further research. In the majority of studies, the main reported
Individual Group Group
outcome is the change in OCD severity. In a previous study, we
Accepted treatment 18 15 11
provided the results of an open trial comparing the efficacy of group
Dropped out prior treatment 0 2 0
versus individual CT for OCD at post-treatment and one-year follow- Started treatment 18 13 11
up. We found that the two CT conditions were equally effective in Dropped out during treatment 2 1 1
reducing OCD severity, although the effect sizes were higher after Completed treatment 16 12 10
individual treatment at the two assessment periods, as were the rates Available at follow-up 16 10 10

of recovered participants, since 73.3% of the patients were recovered


at post-treatment in the individual treatment, compared to 40.91% of
those receiving group CT (Cabedo et al., 2010). However, we Beck Depression Inventory (BDI; Beck et al., 1979. Spanish version: Vázquez and
Sanz, 1999). This 21-item self-report instrument measures the intensity of depressive
wondered whether the differential efficacy of the two CT conditions symptoms, using a 4-point scale (from 0 = not present, to 3 = very intense).
in improving OCD symptoms would be comparable to a change in the Penn-State Worry Questionnaire (PSWQ; Meyer et al., 1990. Spanish version:
dysfunctional cognitions (i.e., beliefs and thought control strategies) Sandín et al., 2009). This 16-item self-report inventory assesses the generality,
which, from a cognitive perspective, underlie the genesis and excessiveness, and uncontrollability of worry. Each item is rated on a 5-point scale (1 =
“not at all typical of me” to 5 = “very typical of me”).
maintenance of OCD. In a review of published studies comparing
The White Bear Suppression Inventory (WBSI; Wegner and Zanakos, 1994. Spanish
individual and group cognitive-behavioural treatments (CBT) for version: Luciano et al., 2006). This 15-item self-report inventory measures the chronic
anxiety and depressive disorders, Tucker and Oei (2007) indicate that tendency to suppress negative and/or unwanted thoughts in general. The items are scored
individual CBT has some advantages over group CBT, as it is possible to on a 5-point Likert scale (from 1 = “Absolutely disagree” to 5 = “Absolutely agree”).
design the therapy around the patient's unique needs, and there is a Thought Control Questionnaire (TCQ; Wells and Davies, 1994. Spanish version:
Luciano et al., 2006). This 30-item self-report instrument assesses the frequency of the use
greater opportunity to focus on each patient's personal and emotional of different strategies to control negative unwanted thoughts. It includes five empirically
issues. Regarding CBT for OCD, Whittal et al. (2005) assert that a group derived subscales: distraction, punishment, reappraisal, social control and worry.
setting would probably make it difficult to adequately challenge all the Obsessive Beliefs Spanish Inventory—Revised (OBSI-R; Belloch et al., 2003, 2010;
relevant beliefs that each patient ascribes to his/her obsessions and/or Cabedo et al., 2004). This 50-item self-report questionnaire was designed to assess
dysfunctional beliefs hypothetically related to the maintenance and/or development of
compulsions.
OCD from a cognitive perspective. It was elaborated following the preliminary work by
From these perspectives and taking into account our previous the Obsessive-Compulsive Cognitions Working Group (1997, 2001). Participants were
results about the differential changes between the two treatment asked to rate whether or not they agreed (7-point Likert scales from 0 = “absolutely
formats in OCD severity, we hypothesize that individual CT will be more disagree” to 7 = “absolutely agree”) with statements corresponding to general
effective than group treatment in changing OCD-related dysfunctional dysfunctional beliefs. The OBSI-R contains eight subscales that showed good fit indexes
in a Confirmatory Factor Analysis: Over-importance of thoughts, Thought-Action
cognitions and associated comorbidity (depression), both at post- Fusion, Probability, Thought-Action Fusion, Morality, Inflated responsibility, Impor-
treatment and one year later. tance of thought control, Overestimation of threat, Intolerance of uncertainty, and
Perfectionism. The Cronbach's alpha for the eight subscales in a group of 75 OCD
2. Method patients ranged from 0.69 to 0.85 (Belloch et al., 2010).

2.1. Participants 2.3. Procedure

The OCD patients came from two countries, Spain and Argentina. The Spaniards Before being included, all of the potential participants were individually screened
were recruited from three outpatient mental-health clinics included in the network of with a full history and examination by one of the authors. Intake assessment consisted
the public National Health System. The Argentinean patients were treated in a private of the Anxiety Disorders Interview Schedule for DSM-IV: Lifetime version (ADIS-IV-L;
mental-health outpatient clinic, and they were recruited via referrals from general Di Nardo et al., 1994) to determine diagnoses for current and past Axis I disorders, and
practitioners, mental-health professionals in the public National Health System or the Yale-Brown Obsessive-Compulsive Scale (Y-BOCS; Goodman et al., 1989a,b) to
private organizations, and self-referrals. determine the severity of the OCD symptoms. Information about demographic data
Inclusion criteria were a primary diagnosis of OCD (DSM-IV-TR criteria; APA, 2000), (age, gender, occupation, educational level, and socio-economic status), medical
an age range of 18–65 years, a minimum OCD symptom duration of one year, an conditions, and current/past psychological or pharmacological treatments was also
adequate level of reading ability, and absence of any organic mental disorder, mental recorded. If inclusion criteria were met during this initial interview, the evaluator
retardation, psychotic disorder, Cluster A personality disorder, current history of informed the patient about the purpose and assessment procedure of the study, and
substance abuse disorders, or concurrent psychological treatment. All of the patients asked for the patient's explicit consent to participate. After giving his or her explicit
who were undergoing pharmacotherapy had to have maintained stable doses for a consent, each patient was then given a questionnaire packet containing all the self-
period of at least 3 months before being included in the protocol treatment. report questionnaires described earlier, and randomly referred to a therapist (another
Medications could be reduced or removed during the follow-up period. one of the authors) for a second assessment one week later. This assessment session
Regarding the Spanish patients, of the 50 initially referred subjects, 14 (28%) did included a review of OCD symptomatology, identification of pre-disposing, precipitat-
not fit the inclusion criteria, and three patients (6%) refused to receive any form of ing, and maintaining factors, and an explanation of the model that was to guide their
psychological treatment. The remaining 33 patients were randomly assigned to the treatment. Following this second assessment, a case-based formulation was written
individual (18 patients) or group (15 patients in two groups) treatment. In Argentina, and later discussed in weekly team meetings.
of the 40 patients referred and assessed, 20 (50%) did not fit the inclusion criteria, and Once the treatments were completed, the same questionnaire packet as in the pre-
nine (22.5%) refused to receive the treatment offered. In all, 38 patients completed treatment was again administered, and then again at the 12-month follow-up. The
treatment, and 36 were available at follow-up. Table 1 shows a summary of participants' questionnaire packet was always given to the patient by the first evaluator, who met
attrition. with the patients individually and evaluated OCD severity on each occasion (Y-BOCS).
Fourteen patients who completed treatment had a comorbid Axis I disorder (7 in each
treatment condition), and five had a comorbid Axis II disorder. The comorbid Axis I 2.4. Therapists and treatment protocol
diagnoses were major depression (five patients in each treatment condition), generalized
anxiety disorder (two patients in the individual treatment), and hypochondriasis (two Doctoral level clinical psychologists experienced in treating anxiety disorders,
patients in the group treatment). Four patients had a comorbid dependent personality depression, and personality disorders from a cognitive-behavioural perspective (AB, EC,
disorder (two patients in each treatment condition), and one patient in the group CC, HFA, and FG) and a Licensed Clinical Psychologist (CL) conducted the treatments. The
treatment had comorbid obsessive-compulsive personality disorder. therapists' competence was not assessed.
The two treatment modalities (individual and group CT) were manualised by the
2.2. Measures authors before the treatments started, following the guidelines by Salkovskis (1999),
Freeston et al. (2001), Rachman (2003), and Clark (2004).
Yale-Brown Obsessive-Compulsive Scale (Y-BOCS; Goodman et al., 1989a,b. In the individual treatment condition, the CT consisted of 18 sessions over a 6-month
Spanish version: Nicolini et al., 1996). This interview is especially designed to measure period (18 h of treatment). The first two sessions were psycho-educational in order to
OCD severity (ranging from 0 to 40). familiarize patients with the cognitive model of OCD. The following 14 sessions were

Please cite this article as: Belloch, A., et al., Group versus individual cognitive treatment for Obsessive-Compulsive Disorder: Changes in non-
OCD symptoms..., Psychiatry Research (2010), doi:10.1016/j.psychres.2010.10.015
A. Belloch et al. / Psychiatry Research xxx (2010) xxx–xxx 3

carried out over a five-month period: ten weekly 60-minute sessions followed by four 60- were observed between the individual and group treatment conditions
minute sessions held every two weeks. The purpose of the sessions was to help the
on most of the socio-demographic variables studied, except for age: the
patients challenge the catastrophic and dysfunctional interpretations of their obsessions
and compulsions. All the dysfunctional evaluative appraisals and beliefs maintained by the patients in the group CT were significantly older. There were no
patients about their obsessions and compulsions were analysed and then corrected. significant differences in the clinically relevant variables, with the
Behavioural experiments were also employed as a complementary way to provide exception of duration of the disorder, which was significantly higher for
relevant evidence contradicting the patients' dysfunctional beliefs about their fears, once the group treatment participants. The patients in the two treatment
these beliefs had been discussed in the same treatment session. The last two 60-minute
biweekly sessions were devoted to relapse prevention.
conditions were also comparable with regard to OCD severity (Y-BOCS
The group CT took place during 16 sessions over a four and a half month period (32 h scores), OCD-relevant beliefs (OBSI-R), and the general strategy of
of treatment). All the sessions lasted 2 h, and the initial 14 were held weekly, whereas the suppressing thoughts (WBSI). However, the patients assigned to the
last two were held every two weeks. As in the individual treatment condition, the first two group treatment were more depressed than the subjects in the
sessions were psycho-educational. The following 12 sessions, designed to help the patients
individual treatment condition.
challenge their catastrophic and dysfunctional interpretations of their obsessions, were
strictly scheduled in order to ensure that each treatment group followed the same Taking into account that the group CT was delivered in Spain and
sequence of contents. The techniques applied were the same as in the individual treatment Argentina, we compared the patients at pre-treatment on all the study
condition, including the behavioural experiments. variables. The only difference obtained was for marital status (chi
All the treatment sessions in the group condition, and nearly 50% of those in the square = 6.779; p = 0.03): 75% of the patients from Spain were married,
individual treatment, were video-recorded or audio-taped to ensure that the therapists
followed the same procedures. A randomly selected number of therapeutic sessions
whereas only 30% of the patients from Argentina were married.
were rated on adherence to the treatment protocol in the weekly team meetings, but no
formal records of these ratings were kept. 3.2. Comparative effects of the two treatment conditions at post-treatment
and at follow-up
2.5. Statistical analyses
The effects of the two treatment conditions on depression (BDI)
A 2 (treatment type: individual versus group) × 2 (time: post-treatment versus
follow-up) design was used to compare the results obtained in each therapeutic format.
and worry tendencies (PSWQ) were comparable (see Table 3).
We compared the two CT conditions using univariate analysis of covariance Compared with the Group CT, the subjects included in the Individual
(ANCOVAs) of posttest scores (post-treatment or follow-up) with pre-treatment CT showed a greater decrease in their ascription to three dysfunc-
scores as a covariate, once the equivalence of the pre-treatment standard deviations tional beliefs (Responsibility, Overestimation of threat, and Intoler-
had been verified. Additionally, BDI, duration of the disorder, and age were introduced
ance to uncertainty), as well as in their use of the strategy of
as covariate variables to control the effects of the differences at pre-treatment. This
analysis was chosen over multivariate analysis of covariance in order to avoid suppressing distressing thoughts (WBSI). The effects of the two
difficulties in interpretation resulting from the simultaneous use of four covariates. treatment modalities on the decrease in the remaining dysfunctional
Given the small sample of subjects, scores were subjected to a square root beliefs and thought control strategies (TCQ) were similar.
transformation in order to standardize the data before computing ANCOVAs. However, The correlations between symptom improvement (Y-BOCS
as the pattern of results was the same as the one obtained with non-transformed
scores, the latter were used in the analyses. Zero-order correlations between symptom
change) and belief changes (OBSI) at follow-up were moderate. In
improvement (Y-BOCS change) and pre- versus post-treatment changes in the study the individual treatment condition, the greatest associations were
measures (OBSI-R, TCQ, and WBSI) were computed. Effect sizes (ES) (Cohen's d) were between Y-BOCS change and Thought importance change (r = 0.45),
calculated for the variables studied in each therapeutic condition at post-treatment and and between Y-BOCS change and Thought control change (r = 0.45).
follow-up, taking into consideration the treatment completers for whom only follow-
In the group treatment condition, the greatest associations were
up data was available. The Cohen (1988) formula (M pre-treatment − M post-
treatment / S.D. pre-treatment), with the changes suggested by Becker (1988) for between Y-BOCS change and Threat overestimation change (r = 0.60),
small samples: d = g (1 − (3 / (4 (n − 1) − 1)), was also applied. Power analyses were and between Y-BOCS change and Intolerance to uncertainty change
conducted separately for the group and individual treatments on the basis of observed (r = 0.46).
sample size. Correlation coefficients between residual gain scores for the thought
control strategies and the Y-BOCS scores at follow-up indicated that
3. Results the change in the thought suppression strategy (WBSI) was highly
associated (p b 0.01) with symptom improvement in the individual
3.1. Preliminary analyses treatment condition only (r = 0.76). However, the correlation between
the Y-BOCS change and the TCQ-subscales change was significant for
The homogeneity of the patients in the two treatment conditions Punishment in the two treatment conditions (Individual: r = 0.48;
at pre-treatment was first examined (Table 2). No significant differences p b 0.01; Group: r = 0.66; p b 0.05).

Table 2
Demographic data and symptom measures for patients who completed the treatment.

Variables Individual (N = 16) Group (N = 22) t/χ2

Age (Mean ± S.D.) 30.44 ± 5.70 37.14 ± 10.48 − 2.53⁎


Women (%) 62.5 50 0.58
Married (%) 50 54.5 2.99
Educational level (%) Low 37.5 22.7 0.98
Medium 25 31.8
Higher 37.5 45.5
Years of OCD duration (Mean ± S.D.) 6.81 ± 3.55 13.1 ± 12.71 − 2.54⁎
Comorbidity—Axis I 7 (43.8%) 7 (31.8%) 0.56
Comorbidity—Axis II 2 (12.5%) 3 (13.6%) 0.01
Receiving pharmacotherapy 13 (81.3%) 18 (81.8%) 0.01
OCD subtype Pure obsessions 6 (37.5%) 8 (36.4%) 0.02
Obsessions and compulsions 10 (62.5%) 14 (63.6%)
Yale-Brown Obsessive-Compulsive Scale (severity) 25.81 ± 4.86 25.00 ± 5.97 0.44
Beck Depression Inventory 12.94 ± 10.98 24.05 ± 14.18 − 2.61⁎
Obsessional Beliefs Spanish Inventory—Revised (total) 208.31 ± 54.56 209.67 ± 41.57 − 0.09
White Bear Suppression Inventory 61.65 ± 8.63 56.73 ± 9.62 1.32
⁎ p b 0.05.

Please cite this article as: Belloch, A., et al., Group versus individual cognitive treatment for Obsessive-Compulsive Disorder: Changes in non-
OCD symptoms..., Psychiatry Research (2010), doi:10.1016/j.psychres.2010.10.015
4 A. Belloch et al. / Psychiatry Research xxx (2010) xxx–xxx

Table 3
Comparative effects of the two treatment conditions at post-treatment and at follow-up.

Measures Pre-treatment Post-treatment Follow-up F

Individual (n = 18) Group (n = 24) Individual (n = 16) Group (n = 22) Individual (n = 16) Group (n = 20)

BDI 12.60 21.80 5.67 4.50 4.47 10.60 3.55*


(11.28) (5.65) (4.88) (4.80) (4.84) (7.78)
PSWQ 59.13 66.90 50.73 54.10 47.07 59.00 2.02
(11.67) (6.37) (13.08) (9.88) (11.56) (7.87)

Obsessional Beliefs Spanish Inventory—Revised


Responsibility 32.33 32.20 23.47 21.10 20.67 24.60 3.31*
(10.5) (6.92) (11.62) (7.94) (12.65) (8.15)
Thought importance 12.20 12.2 9.00 7.80 8.40 7.90 0.58
(4.93) (6.41) (6.14) (3.31) (5.75) (3.90)
TAF—Probability 14.67 16.55 8.80 12.20 8.53 10.30 0.28
(8.12) (7.33) (5.92) (6.33) (5.99) (5.92)
TAF—Moral 25.27 28.85 13.80 13.85 13.67 14.55 1.22
(8.92) (9.42) (9.91) (7.15) (10.2) (6.34)
Thought control 25.53 26.20 12.20 14.65 10.60 17.05 1.73
(4.80) (5.96) (7.87) (7.97) (8.16) (7.41)
Threat overestimation 33.53 34.25 22.60 24.10 21.73 29.30 4.60*
(11.81) (10.10) (10.91) (11.14) (10.30) (9.27)
Intolerance uncertainty 29.73 30.95 20.20 18.90 16.93 22.85 6.13**
(6.48) (6.29) (10.10) (9.30) (11.25) (6.51)
Perfectionism 29.67 28.60 19.73 18.65 16.40 20.45 2.54
(11.76) (8.92) (10.63) (10.28) (9.82) (9.60)
WBSI 61.07 56.45 47.60 47.60 38.60 50.49 4.64*
(8.69) (9.09) (13.39) (12.72) (16.10) (10.93)

Thought Control Questionnaire


Distraction 9.53 8.37 7.60 7.68 6.33 9.05 1.36
(13.29) (3.35) (2.58) (3.64) (2.16) (3.04)
Social control 7.07 7.63 5.60 6.94 5.93 7.94 0.82
(2.96) (3.50) (1.68) (2.57) (1.75) (3.64)
Worry 3.20 3.32 3.27 3.31 2.87 3.79 0.71
(1.15) (1.29) (1.10) (1.25) (0.99) (1.40)
Punishment 6.60 7.21 5.69 3.95 4.93 5.10 2.54
(2.90) (2.94) (2.82) (1.27) (3.13) (2.58)
Reappraisal 7.20 7.42 6.47 6.16 6.07 6.32 0.64
(1.93) (2.48) (2.65) (2.34) (1.90) (2.06)

Data are Mean (S.D.). BDI: Beck Depression Inventory; PSWQ: Penn-State Worry Questionnaire; TAF: Thought-Action Fusion; WBSI: White Bear Suppression Inventory. *pb0.05; **pb0.01.

3.3. Effect sizes


Table 4
Effect sizes following individual and group CT for participants who completed
Regarding depressive symptoms (BDI scores), the ES were large in treatment and follow-up.
the group condition at post-treatment, and only medium at follow-up,
Measures d pre- versus post- d pre-treatment versus
whereas in the individual CT condition they were medium at post-
treatment follow-up
treatment and at follow-up (Table 4). The ES for the change in worry
Individual Group Individual Group
(PSWQ) was medium in the individual intervention at post-treatment
(n = 16) (n = 22) (n = 16) (n = 20)
and large at follow-up, whereas in the group CT, large effects were
observed at both times. Beck Depression 0.58 1.01 0.68 0.65
Inventory
The majority of the ES observed for the two treatment conditions Penn-State Worry 0.68 1.83 0.98 1.13
and assessment times for the dysfunctional beliefs (OBSI-R) were Questionnaire
large, with the following exceptions: over-importance of thoughts (all
the ES were medium), TAF-Likelihood (ES large at follow-up only in Obsessional Beliefs Spanish Inventory—Revised
Responsibility 0.80 1.68 1.10 1.05
the group condition), and overestimation of threat (only medium in
Thoughts importance 0.62 0.66 0.73 0.64
the group format at follow-up). In sum, a general pattern of increasing TAF—Probability 0.69 0.57 0.72 0.82
ES values between post-treatment and follow-up was observed in the TAF—Moral 1.22 1.53 1.24 1.46
individual treatment for all the dysfunctional beliefs, whereas in the Thought control 2.64 1.86 2.95 1.47
group treatment a general pattern of decreasing ES values between Threat overestimation 0.94 0.96 0.95 0.47
Intolerance uncertainty 1.40 1.84 1.88 1.24
post-treatment and follow-up was obtained, with the only exception Perfectionism 0.80 1.07 1.07 0.88
of TAF-probability. Total score 1.47 1.75 1.70 1.40
Most of the observed effects for the thought control strategies White Bear Suppression 1.47 0.93 2.46 0.63
(TCQ) at post-treatment and follow-up were small in both treatments, Inventory
with several exceptions: at post-treatment, the ES for punishment was
Thought Control Questionnaire
small in the individual intervention and large in the group condition, Distraction 0.14 0.20 0.23 0.19
whereas at follow-up the effects were medium for both treatment Social control 0.47 0.19 0.37 0.09
modalities. In the reappraisal strategy, the ES was large for the Worry 0.06 0.01 0.27 0.35
individual treatment only. A similar result was observed for thought Punishment 0.30 1.06 0.55 0.69
Reappraisal 0.38 0.49 0.56 0.43
suppression (WBSI), as large effects were observed in the individual

Please cite this article as: Belloch, A., et al., Group versus individual cognitive treatment for Obsessive-Compulsive Disorder: Changes in non-
OCD symptoms..., Psychiatry Research (2010), doi:10.1016/j.psychres.2010.10.015
A. Belloch et al. / Psychiatry Research xxx (2010) xxx–xxx 5

treatment at both post-treatment and follow-up, whereas for the thought control strategies suggests that the two treatment settings
group condition the effect was only medium at follow-up (Table 4). could have differential effects on patients.
The different associations that the two treatment modalities show
with the changes in OCD severity support this conclusion. In
4. Discussion individual CT, the greatest relationships were for the two dysfunc-
tional beliefs associated with the thoughts' meaning (i.e., thought
In a previous study we found that individual CT was more effective importance and the need to maintain the thoughts under control),
than group CT in improving OCD symptoms (Cabedo et al., 2010). whereas in the group CT condition, the changes in OCD severity were
However, it remained to be explored whether the two CT conditions associated, above all, with changes in two anxiety-related beliefs,
would also have differential effects in changing dysfunctional threat overestimation and intolerance to uncertainty, which are not
cognitions which, from a cognitive perspective, are determinant OCD specific. Regarding the thought control strategies, the decrease in
factors in the genesis and/or maintenance of OCD. The purpose of this the use of thought suppression was highly associated with OCD
study was to examine the comparative effectiveness of group and improvement only in individual CT, whereas the decrease in self-
individual cognitive therapy in modifying OCD associated symptoms punishment for having obsessions and/or compulsions was associated
(depression and worry proneness), dysfunctional beliefs, and thought with OCD improvement in both treatment modalities.
control strategies, and to measure the stability of the changes over one One limitation of this study is the sample size, with the subsequent
year. low observed power for the expected results. Another limitation has
The admission criteria meant the non-inclusion of a similar rate of to do with the heterogeneity of OCD, which has not been considered
patients to the 52.62% reported in the meta-analysis by Eddy et al. in the design, given the limited number of participants in each
(2004). Consequently, we are reasonably confident that our study has treatment condition. It is possible that each of the two CT formats
an adequate balance between external and internal validity. The rate of would be more or less appropriate depending on the obsession and/or
patients who abandoned the treatments once they started was lower compulsion modalities experienced by patients. This limitation is
than the 12.11% reported in the above-mentioned meta-analysis. common to most of the studies on the effects of therapies for OCD, and
The two treatment conditions had comparable effects on depres- must be carefully addressed in future studies. The different duration of
sive and worrying symptoms, and these results are similar to those the two treatments (18 and 16 sessions in the individual and group
reported by Anderson and Rees (2007). However, significant conditions, respectively) could be an additional limitation. Neverthe-
differences between the two CT conditions emerged for the assessed less, it should be kept in mind that the sessions lasted 1 h in the
cognitions. Individual CT produced greater decreases in the patients' individual treatment, whereas in the group treatment all the sessions
ascription to responsibility, overestimation of threat, and intolerance were 2 h long. Moreover, as the group therapy modality is commonly
to uncertainty beliefs than the group treatment did. There is some associated with additional benefits that are not usually provided by
evidence that individual CT reduces the attachment to OCD-related the individual treatment (Burlingame et al., 2004), we can assume
beliefs and appraisals (Cottraux et al., 2001; Whittal et al., 2005; that two more sessions in the individual treatment are not sufficiently
Belloch et al., 2008), and from this perspective, our data add support conclusive to explain the differences observed between the two CT
to the efficacy of cognitive techniques in decreasing the intensity with formats. The fact that the therapists were in two different countries,
which OCD patients assess their obsessions as having a threatening Argentina and Spain, and working in different settings, could be a
meaning. The magnitude of the change for most of these variables in further limitation. From the beginning of the study, we tried to
our study was large for the two treatment formats, but a clear overcome this possibility by strictly manualising the two treatment
advantage was observed for individual CT compared to group CT. conditions, and then recording and examining a greater number of
Regarding thought control strategies, the individual treatment was therapy sessions than is customary. However, as we do not apply
more effective in reducing the use of actively suppressing the any statistical analyses to these records, we cannot ensure that the
obsessions, although the magnitude of the change decreased adherence of the different therapists to the treatment protocol was
significantly at the follow-up in the group treatment condition. This comparable across settings. Finally, the role of medication in the
result supports the cognitive assumptions about the pathogenic role changes observed at follow-up has not been controlled. Patients
of suppression in the maintenance of OCD (Salkovskis, 1989; Rach- maintained the same medication regimen throughout the treatments,
man, 1997, 1998; Purdon and Clark, 1999), as it has been shown to be but after that it was the psychiatrist who made the decision about the
a thought control strategy specific to OCD patients, in contrast to best medication regimen for each patient, as is common in our
Depressed and other Anxiety non-OCD patients (Belloch et al., 2009). context. Future studies should be designed to adequately address the
Nevertheless, there were no differences between treatment effect of pharmacotherapy on the stability of changes produced by CT
conditions on the other thought control strategies (TCQ), although in OCD patients.
the magnitude of the change for punishment was high in the group CT
at post-treatment. This result suggests that there could be a group
effect for that particular thought control strategy, as sharing Acknowledgement

embarrassing and ego-dystonic thoughts with others, and realizing This study was supported by the Spanish Ministerio de Ciencia e Innovación
that these thoughts are also experienced by other people, could have a (SEJ2006/03893-PSIC, and PSI2010-18340).
beneficial effect on the tendency to punish oneself for having the
thoughts.
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Please cite this article as: Belloch, A., et al., Group versus individual cognitive treatment for Obsessive-Compulsive Disorder: Changes in non-
OCD symptoms..., Psychiatry Research (2010), doi:10.1016/j.psychres.2010.10.015