Imagery rescripting for patients with obsessieve compulsive disorder not responding to outpatient cognitive behavioral therapy (CBT).

Obsessive-compulsive disorder (OCD) is a severe disorder that causes
limitations for patients in multiple areas of life. When not treated, this
disorder takes on a chronic nature. Effective forms of treatment for OCS
include Exposure and Response Prevention (ERP) and Cognitive Therapy (CT).
However, research shows that 40% of patients do not benefit sufficiently from
these first choice treatments. Scaling up therapy to clinical treatment is
drastic for the patient and his/her environment and is socially costly. There
is a need to explore alternative forms of treatment for OCS that act on other
working mechanisms than exposure in vivo (which includes ERP) to increase the
response to psychological treatments. One of these alternative treatments is
Imaginary Rescripting (ImRs). ImRs is a technique by which past memories are
edited through mental imagination, creating different meaning. Research shows
that past events may be related to the onset and severity of OCS symptoms. It
also appears that 80% of patients with OCS have mental images of a direct or
associated memory of aversive past events. When these negative events are
worked on, a decrease in compulsive symptoms may be possible. Meanwhile, some
small studies have been done in patients with OCS and a (partial) treatment
with ImRs and the results are encouraging.

The purpose of this study is to expand the so far limited research on the
effectiveness of ImRs in the treatment of OCS. The primary objective is to
investigate whether the application of ImRs, after previous outpatient ERP
treatment, leads to symptom reduction in patients who have not benefited, or
have benefited too little, from ERP treatment (Y-bocs score of 16 or higher).
If positive results are obtained, another study may be conducted in the form of
an RCT, which will provide more insight into the effectiveness of this
treatment intervention in OCS. Also, two process measures will be included in
the study (Mastery and Core Cognitions) to gain more insight into the working
mechanisms of ImRs in OCD.

This is an efficacy study in the form of a randomized single case design with
repeated measurements (within-subject time-series design). This study is an
experimental study that is suitable for research into the effects of treatment
in which the chance of spontaneous recovery is small. This is the case with
non-responders to previous outpatient CBT for OCS.
Patients all receive the same intervention, but are randomly assigned to
different time periods before and after treatment, during which symptoms are
monitored 2-weekly. By measuring the change in symptoms over time weekly, the
causal relationship between intervention and treatment outcome can be
established. The 11-week study period will be divided into four phases:

T0: Screening
T1: Baseline 2.5-5.5 weeks
T2: Active intervention (3 weeks, pretreatment session + 2x ImRs per week)
T3: Post-treatment phase 2.5-5.5
T4: Follow-up (after 3 months)

The intervention used is ImRs. ImRs is a technique from schema therapy that
rewrites images and changes events in a more desirable direction. The aversive
memories from childhood are rewritten, therefore changing the meaning of the
original memory or forming an alternative, more competitive memory. ImRs is an
effective therapeutic technique that is becoming more widely used and
increasingly researched. A recent meta-analysis shows that ImRs is effective
for treating negative memories in various mental disorders such as depressive
disorder, post-traumatic stress disorder, social phobia and also OCS.

Patients in this study will receive a preteratment session and six sessions of
ImRs (two sessions per week). The affect bridge will be used to select the
memory that will be worked on with ImRs. A recent situation related to the
obsessive-compulsive disorder will serve as a gateway to original meaningful
experiences.

In the first two ImRs sessions, the therapist will rescript the situation. In
the following sessions, the patient will step into the picture as an adult and
rescript the situation. If necessary, the therapist can assist or possibly
rescript himself again (if the patient's capabilities do not allow it).

In this study, the ImRs is described as a stand-alone intervention, without the
addition of other treatment methods such as cognitive restructuring.

The therapists conducting the ImRs sessions have already been trained in the
application of ImRs and will also receive supervision. Also, the ImRs sessions
will be recorded (audio) and scored using a compliance checklist.

The burden will consist of the completion of questionnaires and the
administration of interviews. Interviews will be conducted twice a week with an
average duration of 15-30 minutes. Also, four measurement moments will take
place throughout the study and a measurement will last approximately 60-90
minutes.