Beyond Exposure: A New Path to Treating OCD Without Fear

Wolf, N., van Oppen, P., Hoogendoorn, A. W., van den Heuvel, O. A., van Megen, H. J. G. M., Broekhuizen, A., Kampman, M., Cath, D. C., Schruers, K. R. J., van Es, S. M., Opdam, T., van Balkom, A. J. L. M., & Visser, H. A. D. (2024). Inference-based cognitive behavioral therapy versus cognitive behavioral therapy for obsessive-compulsive disorder: A multisite randomized controlled non-inferiority trial. Psychotherapy and Psychosomatics, 93(6), 397–411. https://doi.org/10.1159/000541508

Summary by: Levente Szovák Brack

For clinicians and patients, the treatment of Obsessive-Compulsive Disorder (OCD) can be very difficult because the nature of treatment often involves exposure to highly anxiety-provoking stimuli related to the obsessions of the patient which is how the current “gold standard”: Cognitive Behavioural Therapy (CBT) with Exposure and Response Prevention (ERP) essentially works. While it is effective, it can be extremely difficult. It requires the patients to deliberately expose themselves to their fears and at the same time resist the urge to perform compulsions which generates significant anxiety and distress.

This intense anxiety may contribute to approximately 15% of OCD patients refusing treatment or dropping out before completing it. This leaves a room for another approach to helping those with OCD that does not require patients to face their fears so aggressively. The recent randomized controlled trial by Wolf et al. (2024) suggests that Inference-Based Cognitive Behavioural Therapy (I-CBT) could be a viable alternative for OCD patients, potentially including those unwilling or unable to complete ERP therapy due to the anxiety and distress it can cause.

In standard ERP, the goal is habituation which means getting the patient used to the trigger so the anxiety decreases over time. In contrast, I-CBT focuses on the time before anxiety spikes described as “inferential confusion”. According to the I-CBT method, OCD is not just a fear problem, it is a reasoning problem. Patients confuse "possibility" (e.g., “It’s possible there are germs on this handle”) with reality (e.g., “There are germs on this handle”).

I-CBT aims to help patients identify the flawed reasoning behind their obsessions and fears, trust their common sense, and resolve their doubts logically, making the compulsion unnecessary. The main crucial difference between I-CBT and ERP is that I-CBT does not have an exposure complement. This means there is no deliberate activation of the fear/obsession and the patient learns to tolerate anxiety and trust reality.

This study recruited 197 participants with moderate-to-severe OCD, as measured by the Yale-Brown Obsessive Compulsive Scale (Y-BOCS), and randomly assigned them to receive 20 sessions of either standard CBT (with ERP) or I-CBT. The main question was “Is I-CBT as effective as standard CBT? (Non-inferiority)".

The results showed that both treatments were highly effective. Participants in both the CBT and I-CBT groups saw statistically significant improvement in their OCD symptoms, as measured by the Y-BOCS. These improvements were long lasting at both 6-month and 12-month follow-ups.

The non-inferiority cut-off point was 2 points. At post-treatment, CBT improved OCD symptoms by 10.02 points on the Y-BOCS, while I-CBT improved symptoms by 7.97 points. The difference between the two groups was 2.05 points in favour of traditional CBT with ERP. However, the 95% confidence interval for this difference ranged from −0.11 to 4.22 points, exceeding the non-inferiority margin of 2 points. Therefore, I-CBT could not be conclusively considered non-inferior to CBT. At the same time, the difference between the treatments was not statistically significant (p = 0.06), meaning that CBT's superiority was not established either. Therefore, the results were inconclusive. I-CBT still showed a large effect size however and was also significantly more tolerable at mid and post treatment compared to CBT showing it is still a valid and viable option.

A limitation is that the CBT therapists had an average of 7.5 years of experience while the I-CBT therapists had just 0.9 years on average experience with I-CBT as most of them were trained in the technique specifically for this study. A future study where experience is more equal in both may yield different results.

The findings of Wolf et al. (2024) suggest that deliberately confronting feared situations is not the only way to reduce OCD symptoms and severity.

While standard CBT with ERP will remain a strong therapy, it is not a perfect technique for all OCD sufferers. For those who are hesitant to start the therapy because they are terrified of exposure exercises, I-CBT offers an effective alternative.