Mindfulness as a therapeutic option for obsessive-compulsive disorder

ABSTRACT

Introduction

Obsessive-compulsive disorder (OCD) is a prevalent mental health issue characterized by intrusive thoughts (obsessions) and repetitive behaviors (compulsions) that can cause significant life impairment. Despite cognitive-behavioral therapy (CBT) being the most effective treatment, some individuals experience insufficient symptom reduction or relapse.

Areas covered

This special report explores the potential of mindfulness-based interventions as complementary treatments for OCD, examining the specific techniques used and their practical application. In the initial section, the authors examine ten randomized control trial studies included in the meta-analysis conducted by Chien et al. (2022), demonstrating the effectiveness of mindfulness interventions. The authors focus on elucidating the specific mindfulness techniques used in these studies. Then, the authors discuss the integration of these mindfulness strategies into CBT, focusing on enhancing emotional regulation, cognitive flexibility, and acceptance of intrusive thoughts.

Expert opinion

While mindful based interventions (MBIs) show promise as adjunctive treatments for OCD, variability in OCD symptoms and treatment responses necessitate individualized therapeutic approaches. Further research is required to refine mindfulness-based techniques and optimize their effectiveness. Incorporating MBIs into standard CBT protocols may improve outcomes for patients with persistent OCD symptoms.

Plain Language Summary

Although obsessive-compulsive disorder (OCD) is a serious mental health problem, it can be effectively treated with psychotherapy. One such treatment is called mindfulness-based therapy. It teaches people to be aware of their thoughts without judging them. This can help reduce the obsessions and compulsions that come with OCD. Research shows that mindfulness therapy can be helpful for OCD, but there are many different ways to do it. We need to study more to understand how it works. OCD is different for everyone, so we suggest personalized treatments that fit each person’s needs. Instead of using one-size-fits-all approaches, we should focus on what works best for each person. This could make OCD treatment better and give hope to those dealing with this challenging condition.

KEYWORDS:

• Mindfulness
• OCD
• treatment
• intervention
• MBCT
• CBT

1. Introduction

Obsessive-compulsive disorder (OCD) is a highly prevalent and serious mental health problem. It is characterized by the presence of unwanted, intrusive thoughts (obsessions), which cause anxiety or distress. Additionally, people who suffer from OCD engage in repetitive and ritualistic behaviors (compulsions), as a means to alleviate distress, caused by the obsessions [1]. According to the diagnostic criteria of DSM 5, compulsions can manifest through repetitive behaviors (such as washing hands, organizing things, or checking) or through repetitive mental actions (such as counting, praying, or repeating words). Obsessions and compulsions are very time-consuming and often dominate a large part of the daily routine of those affected. Therefore, OCD is considered a mental disorder that leads to significant limitations in the personal as well as professional lives of individuals [2]. Fortunately, effective treatment techniques have been developed in recent decades to improve this condition. Particularly, cognitive-behavioral therapy (CBT) has been extensively researched and has emerged as the most effective treatment for OCD [3–5]. CBT aims to modify maladaptive thoughts and behaviors through various techniques, such as exposure and response prevention (ERP). Despite the effectiveness of CBT, a subset of individuals with OCD do not experience sufficient symptom reduction or may experience relapse [6]. This suggests that there may be factors influencing treatment response that are not yet fully understood.

A promising approach for patients who have already undergone CBT is the addition of mindfulness-based therapy. Mindfulness is purposefully engaging with the present moment and consciously observing present experiences, such as thoughts, feelings, and sensations, without evaluating or judging them [7,8]. It is based on the notion that a mindful and nonjudgmental attitude toward present experience can enhance regulation of emotions, behaviors, and cognitive processes, as an excessive focus on the past or future can lead to heightened experiences of depression or anxiety [8]. The concept of mindfulness has been adopted for psychotherapy by Kabat-Zinn and colleagues in the form of a stress reduction intervention for chronic pain disorders [9] and its modifications have been shown to be an effective treatment for various disorders, such as anxiety and depression [10].

As the intervention for promoting mindfulness involves adopting a non-judgmental attitude toward one’s thoughts, it is logical to apply these techniques to obsessive-compulsive disorder (OCD). This has been increasingly studied in recent years.

In a recent meta-analysis [11] with 10 included studies MBIs were found to have significant small to medium effects on reducing clinical outcomes such as OCD and depression symptoms as well as improvements in mindfulness skills. Not only did the studies include patients suffering from OCD without therapy for at least 12 months, but they also investigated groups of patients who had previously undergone traditional CBT and were still experiencing symptoms. These studies also have shown positive outcomes [12–14]. This points to the potential of mindfulness-based therapy as a complementary treatment for patients suffering from persistent OCD.

A closer examination of the ten studies included in the meta-analysis reveals that there is variability in the types and application of mindfulness-based techniques. It is evident that there is no one manual treatment technique called ‘mindful based cognitive therapy (MBCT)’ for OCD. Therefore, it is necessary to examine the various techniques and interventions used for treating OCD with mindfulness techniques. We have contacted all the authors of the ten reviewed papers in the meta-analysis of [11] to obtain as accurate information as possible. Fortunately, more than half of them have provided us with detailed materials, which we will summarize and discuss in this article. In the next step, we explored the advantages of incorporating mindfulness-based strategies into CBT treatments and suggest a more personalized therapeutic strategy, for which mindfulness-based interventions appear to be well-suited.

2. Qualitative analysis of 10 reviewed paper

The main focus of the mindfulness-based interventions (MBIs) in the studies was to establish and preserve an overall non-judgmental state of awareness toward intrusive urges. Several intervention techniques have been addressed and adjusted in order to find empirical support for improvements in obsessions and/or compulsions. The intervention studies were RCTs and mostly followed the original guidelines of MBCT [15,16] or other related versions of it (e.g. mindfulness-based exposure and response prevention, see [17]). As described in the detailed MBCT manual by Segal et al. [15,16] individuals received in total eight weekly sessions with a mean duration of 120 minutes (i.e. double session of 60–90 min. each) in a group setting, which mirrors the standard for group treatments [15]. However, in some studies participants practiced mindfulness exclusively in the form of an online course. In these courses they reported a higher number of sessions and a denser intervention frequency but the time range of individual exercise units were much shorter [18,19]. To the best of our knowledge, effects of additional follow-up booster sessions after three and six months were discussed in only two publications [13,14].

Among the variety of experimental studies, an integral part of MBIs was psychoeducation (i.e. knowledge acquisition of factors that increase and maintain OCD symptoms as well as disorder-specific benefits of mindfulness). The program structure was either comprehensively or briefly described [17,20,21] and in some completely omitted [19,22]. A constantly reported goal was to teach participants that instead of suppressing intrusive thoughts they were encouraged to accept recurring cognitive distortions such as thought-action fusion through attentional focus to the present moment [13,21]. Participants were invited to internalize the role of a neutral observer in order to distinguish between obsessions, thoughts and fantasies leaving out any form of judgment. Other approaches included individual decision making in executing or avoiding the compulsions to cultivate a sustaining attitude of acceptance.

In general, attention and self-awareness in MBIs were practiced using techniques relying on perceptive experience validation [23]. Typical implementations of such methods include body scan [18], breathing meditation [17], raisin exercise [14,24], acoustic sensing [12] or observing moving objects [20]. Although MBIs were mostly driven by body and sensory perception, patients in other adaptations were taught to practice mindfulness during non-OCD related moments and across different daily activities (e.g. walking, eating, brushing teeth; see [21,25]). In order to facilitate comprehension of abstract concepts (i.e. letting go, letting flow or being aware) different didactic approaches have been addressed. Clinicians and experienced practitioners of MBCT often use methods such as Socratic questioning (e.g. metacognitive restructuring [25], verbal guidance (e.g. audio recordings [17]), imaginative picturing via illustrative metaphors and analogies (e.g. observing passing train wagons [20]) and even verbal distancing (i.e. sense of self ≠ OCD thoughts [21]). Mindfulness of breath and meditation exercise were conducted in a sitting position. The intervention sessions were mostly in group format, however, studies addressing mindfulness remotely used an individual approach [18,19]. Overall, a wide range of interventions was used, predominantly focusing on active meditative techniques in group settings but also including everyday mindfulness-based tasks.

3. Conclusion

The studies reported in the meta-analysis by Chien et al. [11] utilize a variety of techniques to challenge OCD symptoms. As in other MBCT treatments for anxiety and depression [26], breathing meditation and body scan were core aspects of the OCD treatment. The effect sizes in the meta-analysis fall within a moderate range. Considering that analysis included even studies in which patients continued to experience significant limitations despite intensive cognitive-behavioral therapy (CBT) treatment, the positive results offer hope for future OCD treatment. However, it is important to acknowledge the significant variability in symptoms of OCD and the overlap with other mental disorders, as highlighted by Hirschtritt et al. [27]. Furthermore, the lack of consensus in defining symptom improvements among researchers, as noted by Kühne et al. [28], underscores the necessity for well-defined hypotheses regarding the specific OCD symptoms targeted by interventions. It is noteworthy that most studies included in the analysis primarily focused on the effect of interventions on general OCD criteria, such as overall obsessions and compulsions. Consequently, the impact of different mindfulness techniques on therapeutic outcomes remains uncertain. This becomes more evident when looking into a subgroup analysis by Chien et al. [11]. They showed that improvements in OCD symptoms remained only significant for self-report assessments (i.e. OCI-R = Obsessive-Compulsive Scale Revised [29]) but they were no longer significant for assessor-rated instruments (i.e, Y-BOCS = Yale-Brown Obsessive Compulsive Scale [30]). Chien et al. [11] noted that a major reason for these differences may be explained by the weak correlation between the OCI-R and the Y-BOCS (i.e. r = .30). This is not surprising given the fact that both instruments use different approaches for measuring OCD symptoms. However, when it comes to understanding the individual processes of change in OCD symptoms, the OCI-R might have some limitations, because of its limited set of items. For instance, a patient with no checking behaviors might have experienced extreme impairment due to excessive hand washing, but might have a relatively lower OCI-R score than a less impaired person with moderate washing and checking. Therefore, items unrelated to a person’s OCD symptoms may not be critical for understanding the course of symptoms over time during therapy. Items that focus more on the severity of individuals’ most relevant problems could provide greater insight into the underlying processes and the functional relationship between specific problems (e.g. Hayes et al. [31]). Therefore, individualized assessments are more promising to understand the change processes mindfulness can induce for OCD patients.

In conclusion, the diverse range of interventions employed in these studies, and the varying manifestations of OCD, caution should be exercised when interpreting the results of the meta-analysis, particularly with respect to the comparability of their effects.

4. Expert opinion

The transfer of mindfulness techniques to the treatment of OCD seems to be a meaningful and effective method for improving symptoms and quality of life for many patients. However, it remains uncertain whether MBCT should be part of the first-line treatment for OCD. Instead, we suggest that MBCT is considered as an adjunct to traditional CBT, especially for patients who experience no or only partial response to initial CBT, as shown in studies by Chien et al. [11]. MBCT is a promising adjunctive treatment because it encourages acceptance and cognitive flexibility, which can be particularly effective for targeting repetitive negative cognitive processes resulting in intrusive thoughts. This is consistent with the literature on OCD suggesting that it is not only important to target intrusive thoughts per se, but also the metacognitive belief about the need to control one’s thoughts [2,32]. However, additional research on this issue and other aspects of the OCD is necessary before incorporating mindfulness-based strategies into the first-line treatment for OCD.

In recent decades, the question of whether a therapy is effective has been dominated by an approach that involves contrasting the effectiveness of disorder-specific therapy manuals for the treatment of OCD (e.g [33]). These conventional therapy manuals predominantly address symptoms indicative of latent diseases, such as intrusive thoughts, anxiety, and stress within the context of OCD. However, contemporary clinical psychology has shifted its focus from assessing whether a therapy is effective to understanding why a therapy works. The ‘why-question’ emphasizes a deeper exploration and understanding of the mechanisms responsible for dysfunctional processes (for a brief discussion, see [34]), as opposed to solely focusing on concrete content (i.e. symptoms).

Consequently, there is an increasing prominence placed on the treatment of mechanisms underlying psychopathology. In this context, the term ‘mechanisms’ denotes fundamental processes that are responsible for therapeutic changes, such as cognitions, affect, and attention [35]. Some of these processes may be considered transdiagnostic in nature, but not all mechanisms of change share this characteristic. Transdiagnostic mechanisms are those that are not specific to specific disorders. For example, the overvaluation of intrusive thoughts might contribute to conditions, like depression, social phobia, and even OCD. In this context, MBCT can be regarded as a transdiagnostic therapeutic approach (e.g [36]), as the mechanisms through which MBCT operates transcend specific disorders as well, rendering mindfulness suitable for a diverse range of disorders, including OCD. Notably, mindfulness has demonstrated effectiveness in treating diverse psychiatric disorders within standard clinical practice [37].

In this light, MBCT aligns with the growing emphasis in clinical psychology toward prioritizing transdiagnostic processes (e.g [38]). Key components through which mindfulness operates encompass attention regulation, body awareness, emotion regulation, and change of perspective on the self. These components interact synergistically to establish an augmented process of increased self-regulation (for a brief discussion, see [39]). Furthermore, a coherent body of evidence supports cognitive and emotional reactivity as foundational mechanisms underlying MBCT. Mindfulness, rumination, and worry emerge as mediators affecting the relationship between interventions and their impact on mental health outcomes [40]. The mechanisms targeted by MBCT partially overlap with those mechanisms underlying OCD, involving negative interpretations of obsessive thoughts [41], impairments in the process of extinction learning [42], increased concerns about harm, impaired control of unwanted responses, and excessive preoccupation with the regulation of thoughts (for a brief discussion, see [2]). The transdiagnostic and process-driven nature of MBCT, coupled with the confluence of mechanisms addressed by MBCT with the fundamental components of OCD, contributes to the rationale behind employing MBCT for OCD treatment, as substantiated by empirical investigations. However, despite the efficacy, effect sizes of MBCT remain small to medium [11], necessitating consideration of refining this treatment approach to enhance its effectiveness.

A potential solution involves moving beyond the concept that the effectiveness of a treatment solely depends on the incorporation of established treatment components targeting scientifically relevant mechanisms. Instead, it is significantly influenced by the correct sequencing of chosen procedures [34]. The order in which therapeutic procedures are applied is central given the progressive nature of psychological processes. These processes must be arranged in a particular order to reach desired treatment goals [34,43]. For example, consider an obsessive-compulsive patient whose intrusive thoughts evoke strong emotions, which in turn are neutralized by actions [41]. Understanding the temporal sequences and associations of these cognitive, affective, and behavioral processes guides therapists in determining which processes should be addressed at particular points in time. Therapies should be designed to address the most influential processes and consider causal links [44]. The mere integration of scientifically validated mechanisms into a therapeutic program is insufficient.

A central question thus arises: are the components utilized in therapy, such as in MBCT, logically interconnected to effectively target the individual’s underlying maintaining mechanisms? Enhancing the MBCT program may necessitate aligning the order and structure of sessions more closely with the functional structure of underlying disorders’ processes.

In the case of MBCT, it may be relevant for example to develop a certain degree of emotion regulation or cognitive openness in advance, as these may be necessary for mindfulness and attention regulation. Without these skills, patients may become more immersed and entangled in their negative thoughts and emotions. Functional analyses of the patient’s underlying processes, for example with the help of idiographic networks (e.g [45]), could therefore identify negative thoughts and emotions as relevant precursors of mindful behavior, which could consequently be addressed first. An understanding of the functional relationships of relevant processes therefore provides information about which procedures should be arranged in chronological order (for clinical examples, see [43,46]).

However, it is crucial to acknowledge that the most appropriate sequence may vary on an individual basis [31], given that processes may influence each other in different temporal order even when individuals share similar combinations of symptoms [47]. Therefore, these mechanisms should be arranged in a sequence tailored to the individual rather than a one-size-fits-all approach [31]. While the individualization of therapy is highly significant (e.g [31,43,48]), it is important to recognize that the enhanced efficacy resulting from the adaptation of mindfulness-based intervention components to the individual needs to be empirically examined in the coming years.

It is essential to note that individualization is not inherently feasible in group therapies like MBCT programs, since these are designed on a group-level. Nonetheless, therapies, including MBCT, obviously aim to enhance individuals’ mental health and there have been developed MB programs specific for individuals in recent years (e.g [49,50]). Thus, therapies should integrate principles developed based on individuals and subsequently adapted to the group (for a brief discussion, see [51]). Consequently, a next step would involve employing techniques that enable the identification of group-level structures concerning symptom associations using idiographic data (e.g [52]). Subsequently, these generalizations can be used to best match therapy components.

Furthermore, OCD is a complex disorder characterized by a heterogeneous spectrum of symptoms (e.g [53]) and various empirically supported dimensions pertaining to OCD symptoms [54]. In fact, an increasing body of network analyses highlights the relevant influence of comorbidity between OCD and other disorder-specific symptoms [55,56]. Consequently, the mechanisms responsible for perpetuating the disorder can exhibit substantial variations, even among people sharing the same diagnostic label. The diversity of perpetuating mechanisms implies that MBCT is not equally effective across all mechanisms and, consequently, all patients. Any intervention, including MBCT, can be associated with side effects. For instance, it is conceivable that mindfulness exercises focusing on breathing and other internal states might guide the patient’s attention toward the body and could, therefore, trigger anxiety in vulnerable individuals, such as those with high anxiety sensitivity. Although this was not evident in the existing meta-analysis, this cannot be ruled out. Therefore, it is important to track intraindividual changes on a regular basis and move beyond simple pre-post comparison tests. Mindfulness training rarely leads to immediate and linear improvements. Much more common are delayed, slow, and inconsistent and non-linear changes with some patients improving more than others.

Despite these challenges, additional treatment options are particularly important because we still have the situation that many people suffering from mental disorders receive treatment late or not but also the metacognitive belief about the need to control one’s thoughtsat all due to long waiting lists [57]. It is quite conceivable that the emotional burden for patients who do not respond well to a treatment that has already been carried out is particularly strong and that further treatment is required quickly. We believe that the meta-analysis and its studies show that MBCT is a helpful and valuable method, which can be applied quickly. MBCT should be viewed as an adjunctive or complementary treatment, particularly for patients who did not or only partially responded to traditional CBT. In our view, more emphasis should be placed on examining individual processes. Suffering from OCD can mean something very different for each individual. Our qualitative analysis reveals a significant degree of heterogeneity in mindfulness interventions for the treatment of OCD residuals. This diversity presents empirical challenges, yet also offers an opportunity to harness this variety for the development of individualized, mindfulness-based therapies.

Article highlights

• Obsessive-compulsive disorder (OCD) is a prevalent mental health problem characterized by intrusive thoughts (obsessions) and repetitive, ritualistic behaviors (compulsions) aimed at alleviating distress.

• Cognitive-behavioral therapy, particularly exposure and response prevention, is the most effective psychological treatment for OCD. However, some individuals do not experience sufficient symptom reduction or experience relapse.

• Mindfulness-based interventions are emerging as promising complementary treatments for OCD. They involve non-judgmental awareness of present experiences and have shown small to medium effects on reducing OCD.

• There is considerable variability in the application of mindfulness-based techniques for treating OCD. They include psychoeducation, body scan, breathing meditation, and various sensory and perceptive exercises.

• Incorporating mindfulness-based techniques into CBT treatments may enhance emotional regulation, cognitive flexibility, and acceptance of intrusive thoughts, potentially improving treatment outcomes for patients with persistent OCD symptoms.

• Given the heterogeneity of OCD symptoms and responses to treatment, individualized assessment and tailored therapeutic strategies are essential for optimizing the effectiveness of mindfulness-based interventions.

This box summarizes key points contained in the article.

Declaration of interest

SG Hofmann receives financial support by the Alexander von Humboldt Foundation, the Hessische Ministerium für Wissenschaft und Kunst, the National Institutes of Health/National Institute of Mental Health (NIH/NIMH) via grant nos. R01MH128377 and NIH/NIMHU01MH108168, the Broderick Foundation/MIT, and the James S. McDonnell Foundation 21st Century Science Initiative in Understanding Human Cognition – Special Initiative. He also receives compensation for his work as editor from SpringerNature and receives royalties and payments for his work from various publishers. The authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed.

Reviewer disclosures

Peer reviewers on this manuscript have no relevant financial or other relationships to disclose.

Acknowledgments

In compliance with the International Committee of Medical Journal Editors (ICMJE) recommendations, the authors provide the following disclosure regarding the utilization of AI services in this work: the authors of this article used the Large Language Model GPT-3.5 by OpenAI exclusively for minor translations and grammatical corrections in this work. All sentences revised by GPT-3.5 were reviewed and verified by the authors. No content was generated by the GPT-3.5 or any other AI service.

Additional information

Funding

Dr. Hofmann receives financial support by the Alexander von Humboldt Foundation (as part of the Alexander von Humboldt Professur), the Hessische Ministerium für Wissenschaft und Kunst (as part of the LOEWE Spitzenprofessur), and the DYNAMIC center, funded by the LOEWE program of the Hessian Ministry of Science and Arts (Grant Number: LOEWE1/16/519/03/09.001(0009)/98). He also receives compensation for his work as editor from SpringerNature and royalties and payments for his work from various publishers.