28-12-2012, 01:31 PM
Obsessive compulsive disorder (OCD)
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Introduction:-
Obsessive compulsive disorder (OCD) is a disabling condition which is having large burden on health care system. Cognitive behavioral therapy (CBT) that includes Exposure and Response Prevention (ERP) and Cognitive Restructuring is the recommended First-line treatment, either by itself or in combination with selective serotonin reuptake inhibitor (SSRI) medication (American Psychiatric Association, 2007). However many people do not respond to either treatment, many drop out or refuse therapy, and others respond minimally (Freeman et al., 2009; Thienemann, Martin, Cregger, Thompson, & Dyer-friedman, 2001). As 30 percent of patients with OCD do not respond with both the treatment or remain symptomatic despite adequate trial of CBT or SSRI.
Acceptance and commitment therapy (ACT; Hayes, Strosahl, & Wilson, 1999) is an empirically-based psychological intervention that is showing promise in the treatment of OCD instead of focusing on first-order change of internal experience (i.e., reduction in obsessions and anxiety). ACT focuses on second-order changes through targeting the function of these internal experience (i.e., reduction in obsessions and anxiety and promotes behavior change in service of increasing individuals’ quality of life (Twohig, 2009). ACT utilizes processes such as acceptance, values, and mindfulness in treatment to foster willingness to experience obsessions and related anxiety (Hayes etal., 1999). Whereas traditional CBT treatments focus on controlling or regulating thoughts and emotions, ACT encourages individuals to accept private events and to act in ways consistent with chosen values (Hannan & Tolin, 2005).
Trials using ACT for adult OCD have shown high levels of effectiveness and acceptability (Twohig, Hayes, & Masuda, 2006; Twohig et al., 2010). Acceptance condition, while individuals in the suppression condition experienced significant increases in distress (Najmi, Riemann, & Wegner, 2009). The dysfunctional beliefs thought to underlie OCD according to a CBT model (inflated responsibility, over-importance of thoughts, cognitive control, perfectionism, intolerance for uncertainty; OCCWG, 1997) can potentially be well addressed with acceptance and mindfulness approaches (Hannan & Tolin, 2005; Tolin,2009). Practices such as acceptance, defusion, and being present-focused promote contact with, not avoidance of, obsessions and associated distress. Instead of addressing maladaptive cognitions head-on, acceptance and mindfulness approaches aim to alter the function of these inner experiences rather than their form, frequency, or how likely they are to occur in certain situations. ACT teaches a way to continue to experience these internal experiences, but not be overly affected by them (Twohig, 2009).
Efficacy of Acceptance and Commitment therapy OCD:-
There is growing support for the use of act for OCD in the form of a multiple baseline design (Twohig et al., 2006) and a recently completed NIMH-funded randomized clinical trial (n = 79) comparing 8 one hour sessions of ACT (without in session exposure) to Progressive Relaxation Training ( Twohig et al., 2010). Intent to treat analyses showed that ACT was more effective than PRT(Progressive relaxation technique) on the Y-BOCS at post and follow-up (ACT Y-BOCS scores pre = 24, post = 13, follow-up = 12; prt YBOCS scores pre = 25, post = 19, follow-up = 16). Clinical response rates were 46-66% at follow-up for the ACT condition compared to 1616-18% for the PRT condition. One participant refused ACT and 5 of 41 (12%) of the ACT condition dropped out of the study. Additionally, all participants in the ACT condition rated the treatment acceptability as a 4 or greater on a 5-point scale, with 5 being the most positive score (m= 4.38 in the ACT condition compared to m = 3.68 in the PRT condition). Further, exposure with response prevention was not present in any session, based on coding with a scoring manual (Twohig et al., 2010). There is also evidence supporting act plus habit reversal for OC-Spectrum disorders such as Trichotillomania (Twohig & Woods, 2004; Woods et al., 2006), ACT alone for Chronic skin Picking (Twohig et al., 2006) and Compulsive Pornography use (Twohig & Crosby, 2010).
Rational for the study:
Significant number of patients with OCD shows resistant with the conventional treatment approaches. Growing number of studies show support for the ACT in the treatment of OCD. Therefore, ACT could be plausible and potential treatment modality for patients with OCD. ACT minimize experiential avoidance (Kashdan, Barrios, Forsyth, & Steger, 2006), improve psychological flexibility (Hayes et al., 2006), reduce cognitive defusion (Marcks & Woods, 2005, 2007; Masuda et al., 2009), improve acceptance (Eifert & Heffner, 2004; Hofmann, Heering, Sawyer, & Asnaani, 2009; Levitt, Brown, Orsillo, & Barlow, 2004), improve capacity of being in the present moment (Arch & Craske, 2006), and values (Dahl, Wilson, & Nilsson, 2004). These all capacities or attributes are anti-obsessive in nature. Henceforth, the present study is an effort to examine the efficacy of ACT in patient with OCD.
OPERATIONAL DEFINITIONS :
Obsessive Compulsive Disorder: According to the DSM-IV-TR (APA, 2000) the essential features of OCD are recurrent obsessions or compulsions that are severe enough to be time consuming (more than 1 hour a day), cause marked distress or significantly interfere with the person’s normal routine, occupational (or academic) functioning, or usual social activities or relationships. At some point of time, during the course of the disorder, the person has recognized that the obsessions or compulsions are intrusive, excessive or unreasonable. If any other Axis I Disorder is present, the content of the content of obsessions or compulsions is not restricted to it. The disturbance is not due to direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition.
Obsessions: Obsessions are defined as recurrent and persistent thoughts, impulses, or images that are experienced at some point as intrusive causing distress or anxiety, the person attempts to suppress such thoughts unsuccessfully. They are recognized as the product of his or her own mind (not imposed from outside as in thought intrusion) (APA, 2000).
Compulsions: Compulsions are repetitive behaviors or mental acts; the goal of which is to prevent or reduce anxiety or distress, not to provide pleasure or gratification. In most cases the person feels driven to perform the compulsion to reduce the distress that accompanies an obsession or to prevent some dreaded event or situation; however, these behaviors or mental acts either are not connected in a realistic way with what they are designed to neutralize or prevent or are clearly excessive (APA, 2000).
Completers: Patients will be considered treatment completers if they attend at least 8-10 sessions and assessment complete for all fall up time points.