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Randomized Controlled Trial
. 2024;93(6):397-411.
doi: 10.1159/000541508. Epub 2024 Oct 18.

Inference-Based Cognitive Behavioral Therapy versus Cognitive Behavioral Therapy for Obsessive-Compulsive Disorder: A Multisite Randomized Controlled Non-Inferiority Trial

Nadja Wolf  1   2   3 , Patricia van Oppen  1   2 , Adriaan W Hoogendoorn  1   4 , Odile A van den Heuvel  1   5   6 , Harold J G M van Megen  3 , Aniek Broekhuizen  1   3   5   6 , Mirjam Kampman  7   8 , Daniëlle C Cath  9 , Koen R J Schruers  10   11 , Saskia M van Es  12 , Tamara Opdam  13 , Anton J L M van Balkom  1   2 , Henny A D Visser  3   14
Affiliations
Randomized Controlled Trial

Inference-Based Cognitive Behavioral Therapy versus Cognitive Behavioral Therapy for Obsessive-Compulsive Disorder: A Multisite Randomized Controlled Non-Inferiority Trial

Nadja Wolf et al. Psychother Psychosom. 2024.

Abstract

Introduction: Although cognitive behavioral therapy (CBT) effectively treats obsessive-compulsive disorder (OCD), many patients refuse CBT or drop out prematurely, partly because of anxiety regarding exposure and response prevention (ERP) exercises. Inference-based cognitive behavioral therapy (I-CBT) focuses on correcting distorted inferential thinking patterns, enhancing reality-based reasoning, and addressing obsessional doubt by targeting underlying dysfunctional reasoning, without incorporating an ERP component. We hypothesized that I-CBT would be non-inferior to CBT. Additionally, we hypothesized that I-CBT would be more tolerable than CBT.

Methods: 197 participants were randomly assigned to 20 sessions CBT or I-CBT and assessed at baseline, posttreatment, and 6 and 12 months' follow-up. The primary outcome was OCD symptom severity measured using the Yale-Brown Obsessive-Compulsive Scale (Y-BOCS; non-inferiority margin: 2 points). The secondary outcome, treatment tolerability, was assessed using the Treatment Acceptability/Adherence Scale (TAAS). A linear mixed-effects model was used to assess the non-inferiority of the primary outcome and superiority of secondary outcomes.

Results: Statistically significant within-group improvements in the primary and secondary outcomes were observed in both treatments. No statistically significant between-group differences in Y-BOCS were found at any assessment point, but the confidence intervals exceeded the non-inferiority threshold, making the results inconclusive. The estimated mean posttreatment TAAS score was significantly higher in the I-CBT group than in the CBT group.

Conclusion: While both CBT and I-CBT are effective for OCD, whether I-CBT is non-inferior to CBT in terms of OCD symptom severity remains inconclusive. Nevertheless, I-CBT offers better tolerability and warrants consideration as an alternative treatment for OCD.

Keywords: Cognitive behavioral therapy; Inference-based cognitive behavioral therapy; Obsessive-compulsive disorder; Psychiatric disorders; Treatment outcome.

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Conflict of interest statement

The authors have no conflicts of interest to declare.

Figures

Fig. 1.
Fig. 1.
Schematic representation of the difference between I-CBT and CBT.
Fig. 2.
Fig. 2.
Flow diagram of a randomized controlled trial comparing I-CBT and CBT. *These participants discontinued therapy within 12 sessions in consultation with their therapist due to rapid response. However, at the posttreatment assessment, it was found that they did not meet criteria for remission.
Fig. 3.
Fig. 3.
Estimated mean Y-BOCS scores of the ITT sample from LMM correcting for pretreatment differences by treatment group at pretreatment (T0), posttreatment (T1) and 6 months’ (T2), and 12 months’ (T3) follow-up using standard deviation error bars.
Fig. 4.
Fig. 4.
Plotted non-inferiority analyses of the ITT sample with differences (Cohen’s d) and 95% CIs between CBT and I-CBT conditions at posttreatment (T1), 6 months’ (T2) and 12 months’ (T3) follow-up.
See this image and copyright information in PMC

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