1. Recent Developments and Mechanisms of Change
An Inference Based Approach (IBA) to the treatment of OCD across symptom subtypes
Recent Developments and Mechanisms of Change

2. Symposium Presentations
Review of the Inference Based Approach to Treatment of OCD
Kieron O'Connor, Frederick Aardema
Results of an Open Trial Investigating an Inference-Based Approach to OCD across Symptom Subtypes and Treatment Resistant Cases
Frederick Aardema, Kieron O'Connor
Inference-Based Therapy (IBT) and Cognitive-Behavioural Therapy (CBT) for OCD - Integrative and Synergetic Potential
Jan Van Niekerk
The Role of Fear of Self-Concerns in OCD
Gabriele Melli, Frederick Aardema ,Richard Moulding

3. Frederick Aardema, Kieron O`Connor, Marie-Eve Delorme and
The Inference Based Approach to the treatment of Obsessive-Compulsive Disorder
Frederick Aardema, Kieron O`Connor, Marie-Eve Delorme and
Jean-Sebastien Audet
1 Institut universitaire en santé mentale de Montréal
2 University of Montreal
EABCT, Jerusalem, September, 2015

4. Obsessive-Compulsive Disorder
Obsessions…repetitive and persistent thoughts, images, or impulses that are considered intrusive and inappropriate and cause marked distress.
Compulsions…repetitive behaviors or mental acts that the person feels compelled to perform in response to an obsession.
DSM-5 changes
- OCD is no longer considered an anxiety disorder
- The old DSM-IV specifier with poor insight has been changed to varying levels of insight, including delusional-like OCD.
the major change for obsessive-compulsive disor
considering the obsessions as completely reasonable and realistic)der is the fact that it and related disorders now have their own chapter.

5. Standard Cognitive-behavioral Therapy for OCD
CBT-as-usual involves principally the administration of exposure and response prevention (ERP), but also focuses on pre-existing beliefs a person may hold which sensitize them to react adversely to intrusive thoughts.
This cognitive model is termed the ‘appraisal model’ and claims that the causal and maintaining cognitive factor of OCD is not the initial doubt or ‘intrusion’.
It primarily addresses obsessional beliefs guiding the appraisal of intrusive cognitions, including overestimation of threat, over-importance given to thoughts, inflated responsibility, control of thoughts, need for certainty and perfectionism.

6. Treatment target of CBT-as-usual
Intrusive
thought
Appraisal
Distress
Compulsion
Obsession
Standard CBT primarily targets the interpretations of intrusive cognitions and not the initial obsession or belief itself.
However, in OCD with overvalued ideation addressing the initial obsessional beliefs is important exactly because they are firmly held beliefs, and not because they are “normal” thought intrusions that are only later evaluated as important.

7. Lack of insight and overvalued Ideation in OCD
The treatment resistance of those OCD patients with limited insight and abnormal obsessional conviction to behavioural treatments was noted early on in clinical trials (Foa, Steketee, Gayson, & Doppelt, 1983; Rachman, 1983)
This treatment-resistant subgroup has been classified as a separate category of overvalued ideation (OVI) (Veale, 2002).
“..as patients experience their obsessions as more realistic, insight gets poorer and level of overvalued ideation increases until it becomes delusional in quality” (Neziroglu, McKay, Yaryura-Tobias, Stevens, Todaro, 1999).

8. An Inference Based Approach to OCD
The inference-based approach (IBA) was developed with the central notion that obsessions can be held at varying levels degrees of belief and realism by the patient with OCD.
In particular, if obsessions are held to be highly valid and realistic then these obsessions often resemble overvalued ideation or delusional-like beliefs.
The treatment target of IBA is the initial obsessional doubt or belief rather than its appraisal.

9. Doubt and beliefs in OCD
‘Maybe my hands are dirty….’
‘What if the door is not locked…’
‘Perhaps this picture is not straight…’
‘It might be that I inadvertently ran over someone…’
‘What if I am sexually aroused by children…’
‘I could be contaminated…’
‘I could make a mistake….’

10. Distribution of Level of Conviction in Obsessional Doubt
Grenier et al. (2009). BJCP

11. Obsessional sequence in IBA

12. Obsessional sequence in IBA

13. How OCD Trumps the Senses and Reality
Example 1:
Sense and Reality based information: The door looks firmly closed… but…
Narrative/reasoning: …There may be dust inside the lock which I can ’t see which makes it not shut properly and I remember reading about a person who thought the door was locked but then got robbed, so I better go back and check because…
Obsessional doubt: …Maybe the door isn ’t shut, even if I know I closed it.
Example 2:
Sense and Reality Based information: I know I never hurt anyone ...but..
Narrative/reasoning: …I dreamt of stabbbing someone and enjoying it, which means I have the hidden desire to actually stab someone. The dream felt so real that I might be able to do this in real life also. Even though I read about similar obsessions of other people and I know that people with OCD are not dangerous, their obsessions were never totally the same, which means I still might be dangerous….
Obsessional doubt: …Maybe I am a dangerous person.

14. Reasoning Errors that Characterize the Inductive Idiosyncratic Narrative of Obsessional Thought (``Inferential Confusion``)
Category errors - Confusing two logical or ontically distinct properties or objects (ex. if this white table is dirty, it means the other white table could need cleaning).
Apparently comparable events - Confusing two distinct events separated by time, place and/or causal agency (ex. my friend often drives off and leaves his garage door open, so mine could be left open).
Selective use of out-of-context facts or 'misplaced concreteness‘ - Abstract facts are inappropriately applied to specific personal contexts (ex. microbes do exist so therefore there might be microbes infecting my hands).
Purely imaginary sequences - Making up convincing stories and living them (ex. I can imagine the waves entering my head so they could be infecting my brain).
Inverse inference - Inferences about reality precede rather than follow observation of reality (ex. a lot of people must have walked on this floor, therefore it could be dirty).
Distrust of normal perception... Disregarding the senses in favour of going deeper into reality (ex. even though my senses tell me there's nothing there, I know by my intelligence that there might be more than I can see).

15. Example of an inductive narrative with reasoning errors
 …my kids were playing outside and like I know it ’s dirty (selective use of fact). I ’ve seen the dirt on the pavement and I think they may have touched something dirty (category error), like picked up something from the street, dirty paper or something else, and then I say well if they ’re dirty then I ’m going to be dirty (apparently comparable events) and I ’m going to make the house dirty, and I imagine the house dirty and me with my dirty hands, so I start to feel dirty (imaginary sequence). So I go in and wash and I can ’t stop, you know, it ’s like a voice in my head, saying over and over again, you ’re dirty, even though you ’re washing and you see nothing (distrust of normal senses), you could still be dirty (inverse inference). 

16. Inferential Confusion
The reasoning process by which the person crosses over from reality into the imagination, and which results in the belief that ‘maybe’ something is probable despite contradictory evidence from the senses.
The person with OCD creates doubt on the basis of a purely subjectively generated narrative then acts ‘as if ’ this is true in the absence of any visible proof.
However, since the person tries to remove an imaginary constructed doubt or belief with real actions they can never really succeed.

17. Empirical Evidence for an inference based approach to OCD
Psychometric, Experimental and Clinical Research

18. The Inferential Confusion Questionnaire (Aardema et al, 2005; BRAT)
The Inferential Confusion Questionnaire (15 item and 30-item expanded version) was developed to measure common reasoning errors in OCD.
Strongly related to symptoms of OCD (r=0.50 to 0.74) in clinical and non-clinical samples. Aardema,et al.,, 2010; Yorulmaz et al. 2010, 2010; Goods et al, 2014
Inferential confusion is uniquely related to symptoms of OCD independent from obsessive belief domains and negative mood states. Aardema, Radomsky et al., 2008; Aardema, Moulding et al, 2013; Wu et al, 2009.

19. The Inferential Confusion Questionnaire (Aardema et al, 2005; BRAT)
Two studies have shown that changes in inferential confusion are significantly related to treatment outcome independent of change in negative mood states Aardema, Emmelkamp et al, 2005; Aardema, Wu et al., 2010
However, change in inferential confusion was not related to treatment outcome in a recently developed self-help adaptation of IBA. Moritz et al, 2015.
Those with OCD consistently score significantly higher on inferential confusion than those with an anxiety disorder. Aardema et al, 2005; Aardema, Wu et al, 2010;Yorulmaz et al. 2010

20. Inferential Confusion in clinical and non-clinical samples

21. Inferential confusion and dissociation in OC symptoms
Dissociative absorption refers to the tendency of people with OCD to get highly imaginatively involved into their obsessional narratives and thoughts.
Similar to the notion in IBA that the person crosses over from reality to non-reality when they engage in obsessions.
In particular, recent work suggests that dissociative absorption is most relevant to OCD, as well as a longitudinal predictor of OCD development (Soffer-Dudek et al. 2015)
Both inferential confusion and dissociation uniquely predict symptoms of OCD independent from negative mood states and appraisal domains in non-clinical and clinical samples (Aardema & Wu, 2011; Paradisis, Aardema & Wu, 2015)

22. Inferential confusion and dissociation in OCD symptoms
Study 1 in non-clinical sample (Aardema & Wu, 2011)
Inferential confusion and dissociative absorption significantly related.
Both inferential confusion and dissociation uniquely predict symptoms of OCD independent from negative mood states.
Study 2 in clinical OCD sample (Paradisis, Aardema & Wu, 2015)
Inferential confusion and dissociation are major predictors of symptoms of OCD independent from negative mood states and obsessive belief domains both as measured through self-report and clinician-rated symptom measures (YBOCS).

23. Operationalization of Doubt in OCD
The Inference Processes Task (IPT) is an experimental task measuring level of doubt during reasoning.
During the task, participants are presented with alternating pairs of reality and possibility based information negating reality.
Doubt is measured at each time-point as part of an ongoing reasoning process.

25. Main Findings with the IPT Task
Doubt can be successfully operationalized according to the dynamic interplay between reality based information and negating possibility based information.
The degree of doubting in OCD is significantly related to symptom severity and inferential confusion independent from anxiety.
IBA improves people`s ability to resolve doubt, which in turn is related to more positive treatment outcome.
Higher levels of OCD symptoms and feared-self beliefs significantly predict both higher baseline levels of doubt and greater fluctuation in levels of doubt. (Nikodijevic, Moulding et al, 2015)

26. IBA and Treatment OUTCOME

27. First Randomized Controlled Trial O`Connor, Aardema et al., 2006
Comparison between Inference Based Therapy, Standard CognitiveTherapy and Behavior Therapy.
Target of Inference Based Therapy: Primary inference of Doubt or Belief
Target of Standard Cognitive Therapy: Appraisals, Obsessive Belief domains, Reality Testing
Target of Behaviour Therapy: Exposure and Response prevention

28. RESULTS Pre and post treatment Y-BOCS scores

29. Treatment outcome among those with high obsessional conviction Pre and post treatment Y-BOCS scores

30. Second Randomized Controlled Trial (Visser et al., 2015)
Comparison of Inference Based Treatment with standard Cognitive-Behavioral Therapy among OCD patients with poor insight.
Patients assessed according DSM-IV criteria with poor insight and the first two items of the Overvalued Ideation Scale (Nezirogulu et al.1999).

31. Results (Visser et al., 2015) Pre and post treatment Y-BOCS scores

32. Results (Visser et al., 2015) Pre and post treatment Y-BOCS scores among those high on Overvalued Ideation

33. Conclusions
IBA performs equally to behavioral therapy and cognitive-behavioral therapy.
IBA and CBT-as-usual perform equally for those with limited insight.
However, IBA appears to be particularly beneficial to those with more severely compromised insight or very high levels of overvalued ideation “.. a belief in the sensibility of one`s own thinking” (Neziroglu et al, 1999).
Need for a large scale trial investigating IBA treatment across subtypes, including those with high levels of overvalued ideation.

34. Open Trial Investigating Inference Based Treatment
A study across subtypes and treatment resistant cases

35. Aims and Hypotheses
Aim of the open trial: To establish the efficacy of cognitive therapy based on the inference-based approach in a large sample of OCD patients across all major subtypes, including those with high levels of overvalued ideation.
Hypothesis 1: Cognitive treatment based on the IBA is an efficacious treatment significantly reducing symptoms in OCD across all major symptom subtypes
Hypothesis 2: Treatment based on the IBA is effective for both those with low and high levels overvalued ideation
Hypothesis 3: Change in inferential confusion is a major predictor of successful treatment outcome independent from change in other cognitive domains and negative mood states.

36. Entry criteria Entry criteria were:
(a) primary diagnosis of OCD as evaluated by an independent evaluator using the using the Structured clinical interview for DSM-IV (SCID-I) and the Yale-Brown Obsessive Compulsive Scale (Y-BOCS)
(b) age between 18-65,
(c) no change in medication type or dose during the 12 weeks before treatment for antidepressants (4 weeks for anxiolytics),
(d) willingness to keep medication stable while participating in the study,
(e) no evidence of suicidal intent,
(f) no evidence of current substance abuse,
(g) no evidence of current or past schizophrenia, bipolar disorder or organic mental disorder,
(h) a willingness to undergo active psychological treatment,

37. Treatment protocol
24-week treatment program based on the Inference Based Approach for OCD delivered in a stepwise format utilizing worksheets, exercise sheets and training cards in accordance with published guidelines (O`Connor & Aardema, 2012)
Participants were seen individually by a licensed psychologist for four evaluation sessions, followed by 20 treatment sessions.
In the course of the study, there were a total of six therapists who delivered treatment based on the IBA to clients. All therapists were licensed psychologists trained in IBA and supervised by a senior psychologist during weekly meetings.

38. Participants
A total of 213 potential participants that expressed interest in the study were screened by telephone with a total of 180 proceeding to formal assessment.
Following formal assessment, 34 were excluded due to not meeting entry criteria, while another 23 refused treatment.
During treatment, a total of 23 participants dropped out of treatment (18.4%)
102 participants who completed treatment.
Mean age: 38.3 years old
54 females (52.9%) and 48 males (47.1%).
Education level: 13.2% elementary school, 25.3% high school, 22% college and 39.6% university.
Marital status: 45.1% single, 32.3% married/cohabiting, 5.9% s eparated or divorced and 4.9% widowed.

39. Subgroup allocation
<
Participants were allocated to different subtypes of OCD based on their main obsessional preoccupation in the Y-BOCS as assessed by the independent evaluator.
(1) unacceptable thoughts and impulses (n=23)
(2) checking (n=22)
(3) contamination (n=22)
(4) hoarding (n=15)
(5) other (n=20).

40. Natural wait-list control group
A natural wait-list group acted as a control group (n=22) .
Average amount of time that had passed between the first and second evaluation before treatment was 8.14 months.
Mean age of the wait-list control group was years, 57.9% of the participants were women, 63.2% had higher than high school education, 52.6% were working either part of full time and 52.6% were single.
No significant differences in age, gender, and level of education between the natural wait-list control group and the main sample of 102 participants under investigation in the current study.

41. Main Measures
The Yale-Brown Obsessive-Compulsive Scale (Y-BOCS) - the instrument of choice for clinician assessment of OC symptoms and severity and served as the principal outcome measure .
The Over-Valued Ideas Scale (OVIS)- a 11-item clinician-rated scale measuring severity of overvalued ideation on a number of different dimensions, including:
strength of belief
reasonability of the belief
shared by others or not
perceived effectiveness of compulsions
resistance to the belief.
Main Self Report Measures: Beck Anxiety Inventory, Beck Depression Inventory, the Inferential Confusion Questionnaire, The Obsessive Beliefs Questionnaire

42. YBOCS Pre and Post Treatment (Total Sample)SD
Post
Effect size (95% CI) t p
Total Sample (n=102)
-Total Score
-Obsessions
-Compulsions
26.58
13.24
13.34
6.11
3.26
4.00
14.28
7.21
7.09
7.50
3.94
4.23
1.80 [ ]
1.67 [ ]
1.52 [ ]
15.59
13.56
13.88
< .001

43. Norms, reliable and clinically significant change
At pre-treatment, 62.7% of participants scored in the severe to extreme range (24-30) on the Y-BOCS. At post-treatment, only 14.7% scored in the severe to extreme range (24-40).
A percentage of 71.7 % of participants achieved reliable improvement as the result of treatment.
A percentage of 59.8% achieved clinically significant change where there no longer is statistical difference between YBOCS scores of OCD patients at post treatment and non-clinical comparison groups

44. YBOCS Pre and Post Treatment (Unacceptable thoughts/Impulses)
Subtype
Pre SD
Post
Effect size (95% CI) t p
Unacceptable thoughts and impulses (n=23)
- Total Score
-Obsessions
-Compulsions
26.04
13.39
12.65
5.91
3.56
7.45
14.87
7.52
7.74
7.73
4.45
4.55
1.62 [ ]
1.45 [ ]
0.79 [ ,64]
8.27
6.42
5.33
< .001

45. YBOCS Pre and Post Treatment (Contamination)
Subtype
Pre SD
Post
Effect size (95% CI) t p
Contamination (n=22)
- Total Score
-Obsessions
-Compulsions
26.73
12.86
13.86
6.06
3.78
3.12
15.23
7.05
7.86
7.30
3.26
4.41
1.71 [ ]
1.64 [ ]
1.57 [ ]
6.93
5.70
7.26
< .001

46. YBOCS Pre and Post Treatment (Checking)
Subtype
Pre SD
Post
Effect size (95% CI) t p
Checking (n=22)
- Total Score
-Obsessions
-Compulsions
27.59
13.05
14.55
5.78
3.15
3.14
11.46
5.73
6.86
3.56
3.48
2.53 [ ]
2.17 [ ]
2.65 [ ]
8.27
7.14
8.68
< .001

47. YBOCS Pre and Post Treatment (Hoarding)
Subtype
Pre SD
Post
Effect size (95% CI) t p
Hoarding (n=15)
- Total Score
-Obsessions
-Compulsions
26.40
12.80
13.60
5.25
2.78
2.85
17.06
8.47
8.60
7.12
3.46
3.87
1.49 [ ]
1.38 [ ]
1.47 [ ]
4.75
4.26
4.49
< .001
.001

48. YBOCS Pre and Post Treatment (Other)
Subtype
Pre SD
Post
Effect size (95% CI) t p
Other (n=20)
- Total Score
-Obsessions
-Compulsions
26.05
14.70
12.05
7.65
2.85
6.07
13.55
7.70
5.85
8.01
4.54
4.32
1.59 [ ]
1.84 [ ]
1.17 [ ]
7.20
6.58
6.06
< .001

49. Difference in treatment outcome between the subgroups
Those whose primary obsessional preoccupation revolved around checking appeared to benefit the most, while those with hoarding the least.
However, repeated measures of variance did not show a significant group by interaction effect; only a trend towards significance (F[4,97] =2.05; p=0.09).

50. Comparison with natural-wait list control group

51. Overvalued Ideation and Treatment Outcome
Obtained range on the OVIS was from 2.3 to 8.4 (M=5.23, SD=1.45).
Using the same cut-off points as three earlier independent studies those with a score higher than 6 were allocated to the high OVI group and those with score of 6 or lower to the low OVI group.
This procedure resulted in a total of 54 participants in the low OVI group (67.5%) and a total of 26 participants in the high OVI group (32.5%). .

52. Treatment outcome for high and low levels of overvalued ideation

53. Predictors of Treatment Outcome

54. Conclusion
Treatment based on the IBA is an effective treatment with effect sizes similar to standard CBT and BT.
Effective for all major subtypes, and potentially particularly effective for checking compulsions.
Main predictors of treatment outcome with IBA treatment were changes in inferential confusion, but also change in beliefs about threat and responsibility.
Treatment appears to be particularly promising for those with high levels of overvalued ideation.

55. Limitations Use of natural wait-list control group.
Need for large scale randomized trials to other treatments.
While IBA seems promising for OCD with OVI there is a need for a priori allocation of those with high levels of overvalued ideation in a randomized controlled trial.
Specific benefits of IBA in comparison to standard CBT deserve further exploration.

56. Thank you!
QUESTIONS?