Changes in the daily life experience of patients with obsessive-compulsive disorder following mindfulness-based cognitive therapy: Looking beyond symptom reduction using ecological momentary assessment

Highlights

• MBCT participation did not result in significant changes of daily life experienced positive and negative affect, distress associated with OC symptoms, or acceptance of momentary emotions.

• Results indicate decreased insight into the unreasonableness of OC symptoms in the MBCT group at post-treatment. However, momentary OC symptoms at post-treatment predicted higher insight in the MBCT group.

• The finding concerning changes of insight post MBCT warrants further investigation.

• Future research should explore if longer and/or more intense guidance is needed for this patient group.

Abstract

The current study examines changes in daily life experiences following mindfulness-based cognitive therapy (MBCT) in a sample of 38 patients with obsessive-compulsive disorder (OCD) and residual symptoms following cognitive behavioral therapy (CBT). Participants were randomized to either an MBCT group (n = 17), or to a psychoeducational group (OCD-EP; n = 21) as an active control condition. Both groups underwent ecological momentary assessment (EMA) six times a day for a period of six consecutive days pre- and posttreatment. Contrary to hypotheses, MBCT participation did not, when compared to OCD-EP, result in significant changes of positive affect, negative affect, acceptance of momentary emotions, or distress associated with obsessive-compulsive (OC) symptoms. In fact, insight into the unreasonableness of OC symptoms improved significantly more in the OCD-EP group compared to MBCT. However, in the MBCT group, the presence of momentary OC symptoms at post assessment predicted increased insight, which indicates an improved ability to detach from OC symptoms in the moments in which they occur. All in all, however, results do not indicate favorable changes in everyday life experiences of OCD patients following MBCT. Owing to the modest sample size, results must be considered preliminary. Implications and directions for future research are discussed.

Introduction

Obsessive-compulsive disorder (OCD) is characterized by repetitive and intrusive thoughts, images, or impulses, and/or overt repetitive behaviors or mental acts performed in order to reduce distress or prevent perceived harm (American Psychiatric Association, 2013). OCD has a lifetime prevalence of 1–3% (Hirschtritt et al., 2017) and is associated with substantial functional impairment and a diminished quality of life (Jacoby et al., 2014; Jahangard et al., 2018; Koran et al., 1996). Cognitive behavioral therapy (CBT) with exposure and response prevention yields large effect sizes in randomized, placebo-controlled clinical trials (Carpenter et al., 2018; McKay et al., 2015; Ost et al., 2015). On this basis, CBT is recommended in clinical practice guidelines as the psychotherapeutic treatment of first choice for OCD (American Psychiatric Association, 2007; National Institute for Health and Clinical Excellence, 2006). However, given the substantial proportion of patients who do not respond sufficiently to treatment (Fisher & Wells, 2005; Foa et al., 2013; Foa et al., 2015; Simpson et al., 2008; Simpson et al., 2013; Simpson et al., 2006), researchers have sought to find ways to improve treatment response (for a review, see Abramowitz et al., 2018).

In the last decade, increasing attention has been paid to mindfulness-based approaches in the treatment of OCD as one possibility for enhancing treatment effects (e.g., Didonna, 2009; Hertenstein et al., 2012; Key et al., 2017; Külz et al., 2014; Strauss et al., 2018). Mindfulness originates from Buddhist meditation traditions and is characterized by observing, nonjudgmentally, one's ongoing stream of consciousness in an attitude of openness and curiosity (Bishop et al., 2004). In the last two decades, mindfulness has become increasingly popular in western psychotherapy, where it has established its role, both in individual therapy settings (Mander et al., 2019; Michalak et al., 2019), and in structured group programs such as mindfulness-based stress reduction (MBSR, Kabat-Zinn, 2013) and mindfulness-based cognitive therapy (MBCT, Segal et al., 2013). MBCT has found to be efficacious for preventing relapse in patients with three or more previous episodes of major depressive disorder (Galante et al. 2013; Kuyken et al., 2016). Furthermore, a recent meta-analysis has found mindfulness-based interventions (MBIs) to be equivalent to evidence-based therapies at post-treatment for reducing symptoms of anxiety and depression (Goldberg et al., 2018). For mental disorders in the acute phase, however, MBIs have not proven superior compared to placebo or other active control conditions; yet, their inferiority compared to evidence-based treatment has also not been clearly demonstrated (Hedman-Lagerlöf et al., 2018). Specific to OCD, although only a few studies with comparison groups exist (for a review, see Manjula and Sudhir, 2019), there is preliminary evidence supporting the effectiveness of MBIs for treating OCD (e.g., Key et al., 2017; Hertenstein et al., 2012; however, see Strauss et al. (2018), for contrary results).

In order to provide broader empirical evidence, we recently conducted a bicentric randomized controlled clinical trial on 125 OCD patients in which an adaptation of the original 8-week MBCT program for OCD was compared with a psychoeducational group program as active control condition (Külz et al., 2019). Although a significantly higher benefit was found for the MBCT group in secondary outcome measures including self-rated OC symptoms, depressive symptoms, quality of life and obsessive beliefs, the groups did not differ with respect to a reduction of clinician-rated OC symptoms. An important consideration, however, is that whereas CBT focuses primarily on changing cognition and behavior (Dobson and Block, 2001), MBIs aim at enhancing emotional well-being by changing the way in which individuals relate to their experiences (Bishop et al., 2004). Thus, when evaluating MBCT, changes that go beyond symptom reduction are of crucial interest. Evidence suggests that being more aware of present-moment experiences and acting less automatically is associated with increases in positive affect (Schroevers and Brandsma, 2010). A possible explanation for this finding is that a heightened moment-to-moment awareness of experiences – a stated goal of MBCT – may lead to heightened awareness of pleasant emotions and situations (Geschwind et al., 2011). An increase of positive affect through MBIs has been demonstrated in several randomized-controlled trials in both clinical (Batink et al., 2013; Garland et al., 2015; Geschwind et al., 2011; Strege et al., 2018) and non-clinical samples (Nyklicek and Kuijpers, 2008; Schroevers and Brandsma, 2010).

Apart from this, mindfulness is assumed to have positive effects on how OCD patients relate to their experiences (Didonna, 2009; Külz et al., 2014). Noticing internal and external stimuli as they arise within one's stream of consciousness in an attitude of curiosity and openness fosters a stance of acceptance, which, in turn, increases tolerance towards unpleasant feelings and reduces distress (Bishop et al., 2004). By actively deciding to allow thoughts, feelings and bodily sensations to occur, patients may cease struggling with their obsessive thoughts and difficult emotions and may also stop engaging in dysfunctional experiential avoidance strategies (Didonna, 2009; Key et al., 2017). Interestingly, an increased ability to accept unpleasant feelings was one of the main benefits of MBCT as demonstrated in a pilot study of twelve OCD patients who had previously not responded to CBT (Hertenstein et al., 2012). Furthermore, mindfulness can help to view thoughts and feelings as transient mental events rather than as inherent aspects of the self or as accurate reflections of reality (Teasdale et al., 2002). This metacognitive awareness may also increase insight into the unreasonableness and senselessness of OC symptoms (Didonna, 2009). A recent study conducted by our working group notably revealed that “letting go” of obsessive thoughts is associated with increased insight in daily life (Landmann et al., 2019).

To sum up, the aforementioned theoretical considerations when coupled with preliminary research results strongly suggest that MBCT may have effects extending beyond symptom reduction and may manifest both in how patients relate to their experiences and in their general well-being. However, existing studies on the effectiveness of MBCT for OCD have employed retrospective self-report questionnaires (e.g., Key et al., 2017) or interviews (see study by Hertenstein et al., 2012). Since it has been recommended that mindfulness should be conceptualized as a mode, or to put it differently, as a state-like phenomenon (Bishop et al., 2004), a repeated collection of participants’ momentary experiences might represent a suitable complementary methodology. In this light, we sought to make use of ecological momentary assessment (EMA; Stone and Shiffman, 1994) as a tool to explore post-MBCT changes in subjective everyday life experiences of OCD patients. EMA is defined as the repeated collection of real-time data of participants’ momentary experiences in their natural environments (Stone et al., 2007). Compared to retrospective techniques of data collection, EMA is less prone to memory distortions such as recall biases, and furthermore, exhibits more ecological validity (Shiffman et al., 2008). In addition, the repeated and dense sampling of momentary states provides a high temporal resolution enabling the analysis of dynamic processes and their temporal correlates (Trull and Ebner-Priemer, 2013). As a consequence, moderator effect of momentary symptom experience on the outcome variables can be accounted for in the analysis. Hence, EMA is a powerful research tool which has already been successfully used in a variety of clinical studies (Trull and Ebner-Priemer, 2009).

We hypothesized that MBCT, in comparison to the psychoeducational control group, would lead to (1) more experience of positive affect, (2) decreased negative affect, (3) an increased level of insight, (4) less distress associated with the occurrence of OC symptoms, and (5) increased acceptance of momentary emotions from pre- to post- treatment as measured by EMA. Furthermore, we hypothesized that these changes would become especially apparent in the presence of OC symptoms, since MBCT is primarily aimed at changing the way in which individuals relate to their symptoms rather than at reducing them. Thus, we expect higher changes in the subjective experience in the MBCT group to be moderated by momentary symptom experience.