Yaghoob Vakili 1,* ; Banafsheh Gharaee 2 ; Mojtaba Habibi Background

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1 Irn J Psychitry Behv Sci June; 9(2):e845. Published online 2015 June 1. DOI: /ijpbs845 Originl Article Acceptnce nd Commitment Therpy, Selective Serotonin Reuptke Inhibitors, nd Their Combintion in the Improvement of Obsessive Compulsive Symptoms nd Experientil Avoidnce in Ptients With Obsessive Compulsive Disorder Yghoob Vkili 1,* ; Bnfsheh Ghree 2 ; Mojtb Hbibi 3 1 Deprtment of Clinicl Psychology, School of Medicine, North Khorsn University of Medicl Sciences, Bojnord, IR Irn 2 Deprtment of Clinicl Psychology, Tehrn Psychitric Institute, Irn University of Medicl Sciences, Tehrn, IR Irn 3 Deprtments of Fmily Therpy, Fmily Reserch Institute, University of Shhid Beheshty, Tehrn, IR Irn *Corresponding uthor: Yghoob Vkili, Deprtment of Clinicl Psychology, School of Medicine, North Khorsn University of Medicl Sciences, Bojnord, IR Irn. Tel: , Fx: , E-mil: yghoobvkili@yhoo.com Received: December 20, 2013; Revised: June 20, 2014; Accepted: September 5, 2014 Bckground: Selective serotonin reuptke inhibitors (SSRIs) nd exposure with response prevention for tretment of obsessivecompulsive disorder (OCD) hve demonstrted empiricl support; however, substntil number of ptients remin with cliniclly significnt OCD symptoms fter such tretments. Objectives: The im of this study ws to compre the effectiveness of cceptnce nd commitment therpy (ACT), selective serotonin reuptke inhibitors (SSRIs) nd combintion of ACT nd SSRIs in the tretment of dults with obsessive-compulsive disorder (OCD). Ptients nd Methods: Thirty-two outptients meeting Dignostic nd Sttisticl Mnul of Mentl Disorders, Fourth Edition, Text Revision criteri for OCD were rndomly ssigned to one of the three tretment conditions: ACT, SSRIs nd combined tretment. The Yle- Brown Obsessive-Compulsive Scle nd Acceptnce nd Action Questionnire were dministered t pre-tretment nd post-tretment. Twenty-seven ptients completed the study. Dt ws nlyzed using one-wy nlysis of vrince (ANOVA) nd one-wy nlysis of covrince (ANCOVA), cliniclly significnt chnge (CSC) nd complete remission sttus. Results: ANCOVA reveled tht ptients treted with ACT nd combined tretment experienced significntly greter improvement in obsessive-compulsive (OC) symptoms nd experientil voidnce (EA) t post-tretment compred to those treted with SSRIs lone. However, there were no significnt differences between ACT nd combined tretment on OC symptoms nd EA. CSC nd complete remission sttus results showed tht unlike SSRI, ACT nd combined tretment led to more improvement in OC symptoms. Conclusions: ACT nd combined tretment re more effective thn SSRIs lone in treting OC symptoms nd EA. However, it ppers tht dding SSRIs to ACT does not increse the effectiveness of ACT in the tretment of dults with OCD in the short-term. Keywords: Acceptnce nd Commitment Therpy; Obsessive-Compulsive Disorder; Selective Serotonin Reuptke Inhibitors 1. Bckground Selective serotonin reuptke inhibitors (SSRIs) nd exposure with response prevention for tretment of obsessive-compulsive disorder (OCD) hve demonstrted empiricl support; however, substntil number of ptients remin with cliniclly significnt OCD symptoms fter these tretments (1-6). In recent yers, one of the promising novel tretment strtegies developed to improve the efficcy of tretment for ptients with OCD is cceptnce nd commitment therpy (ACT) (7, 8). ACT is third-wve behvior therpy, which specificlly focuses on decresing experientil voidnce (EA), incresing ctivity in the chosen vlued life direction nd incresing psychologicl flexibility. The gol of ACT is not symptom reduction per se, but helping ptients to ccept versive inner experiences (e.g. thoughts, imges, emotions nd bodily senstions) in the service of engging in vluesguided behvior (9). EA is defined s unwillingness to remin in contct or experience versive privte thoughts or experiences to void or escpe from these experiences (7). EA hs been suggested to ply n importnt role in the development nd mintennce of OCD (10). EA hs been hypothesized to mnifest s compulsions in OCD (10). In EA perspective, ptients with OCD engge in compulsions to control or reduce their unwnted obsessionl thoughts, becuse they wnt to reduce negtive ffect ssocited with them (10). In support of this perspective, correltionl studies hve found tht high levels of EA were positively ssocited with high levels obsessive-compulsive (OC) symptoms (11-13). In treting OCD, ACT trgets EA nd cognitive fusion through defusion nd cceptnce techniques. ACT teches ptients to crete new reltionship with obsessive thoughts nd nxious emotions, for exmple, helping ptients notice tht thought is just thought nd nxiety is n emotion to be felt. ACT lso helps ptients commit to ct in the service of their vlued life Copyright 2015, Mzndrn University of Medicl Sciences. This is n open-ccess rticle distributed under the terms of the Cretive Commons Attribution-Non- Commercil 4.0 Interntionl License ( which permits copy nd redistribute the mteril just in noncommercil usges, provided the originl work is properly cited.

2 gols rther thn spending lrge mounts of time trying to decrese the obsession or void nxious feelings. ACT helps ptients to ccept their obsessionl thoughts nd negtive feelings nd commit to cting in service of their vlued life directions whether obsessions were occurring. Thus, these constructs would increse psychologicl flexibility, which is the bility to ct inconsistent with ptient s meningful life directions regrdless of unplesnt inner experiences (14, 15). ACT hs demonstrted lrge nd cliniclly significnt improvements in OCD symptoms in dults (14-17) nd dolescent (18). However, ccording to the best of our knowledge, there re no rndomized controlled studies directly compring the reltive effectiveness of ACT with SSRIs nd combintion of ACT nd SSRIs in the tretment of OCD. 2. Objectives Therefore, the im of this study ws to compre ACT with SSRIs nd combintion of ACT nd SSRIs in improvement of OC symptoms nd EA. 3. Mterils nd Methods In n experimentl design using convenience smpling, dults with OCD were recruited from outptients of clinics in Tehrn, Irn, from Februry 2012 to Mrch The study ws pproved by the Ethics Committee of Tehrn University of Medicl Sciences. A written informed consent ws obtined from ptients nd received complete descriptions regrding the study procedures. Inclusion criteri for the smple were: ) primry dignosis of OCD ccording to the Dignostic nd Sttisticl Mnul of Mentl Disorders, Fourth Edition, Text Revision (DSM-IV-TR) (19); b) ge between 18 nd 50 yers; nd c) OC symptoms durtion of t lest one yer. Ptients were excluded from the study if they: ) hd current or pst psychotic disorder; b) hd suicidl tendencies; c) hd medicl illness; d) hd substnce buse disorder; e) hd personlity disorder nd f) hd been treted with either phrmcotherpy or psychotherpy in the lst one month. Forty-four ptients were referred for tretment, of which 40 met the DSM-IV-TR criteri for OCD. They were interviewed by structured clinicl interview for DSM-IV xis I disorders, ptient edition (SCID-I/P version 2) (20) nd structured clinicl interview for DSM-IV xis II disorders (SCID-II) (21) to verify the dignosis by n independent evlutor (PhD level clinicl psychologist). Two ptients with bipolr disorder, two ptients with psychotic disorder, one ptient with voidnt personlity disorder, two ptients with OC personlity disorder nd one ptient with borderline personlity disorder were excluded from the study. In ll, 32 ptients fitted the inclusion/exclusion criteri nd were rndomly ssigned to receive ACT (n = 10), SSRIs (n = 11) or combintion of ACT nd SSRIs (n = 11). Five ptients did not complete the study. Three ptients dropped out the drug group; one becuse of not tolerting dverse effects of sertrline nd two for irregulr use of fluoxetine. One ptient bndoned the ACT group for needing SSRI during the tretment phse. One ptient dropped out of the combintion group for unknown resons. The men ge of the finl smple (n = 27) ws ± 6.83 yers; 55.6% (n = 15) of the ptients were men nd 44.4% (n = 12) women. Durtion of OC symptoms rnged between 1 nd 16 yers. The Yle-Brown Obsessive-Compulsive Scle (Y-BOCS) totl nd Acceptnce nd Action Questionnire (AAQ) scores (men ± stndrd devition) for the smple were ± 3.07 nd ± 6.08, respectively. All ptients met the criteri for OCD s their primry dignosis with 33.3% receiving one dditionl dignosis. The frequency of comorbidities in ech tretment condition ws s follows; mjor depressive disorder nd dysthymi, two ACT, two SSRIs, two ACT plus SSRIs; nxiety disorders, one ACT, one SSRI, one ACT plus SSRIs. OCD subtypes for the smple were wshing, checking, ordering, religious/sexul/ggressive thoughts nd hording. ACT ws bsed on n ACT mnul for OCD developed by Twohig (14). A PhD clinicl psychologist (the first uthor) provided ACT under the supervision of n experienced clinicl psychologist in treting OCD. The ACT progrm included evluting ptient s obsessions nd compulsions (session 1); The Mn in the hole metphor ws used to illustrte how ptient s efforts to regulte obsessions re ineffective (session 2); The Tow scles metphor ws used to illustrte possible benefits of cceptnce of obsessions nd nxiety rther thn ttempting to control or reduce them (sessions 3 nd 4); using defusion, contct with present or mindfulness, nd self s context exercises (sessions 5 nd 6); recognize his vlues; nd preventing relpse (sessions 7 nd 8). Ptients in drug group received different SSRI (sertrline = mg/d; fluoxetine = mg/d) for 10 weeks, which ws monitored by two psychitrists. The combintion group received both ACT nd different SSRI (sertrline = mg/d; fluoxetine = mg/d) for 10 weeks. Studies showed equivlent efficcy for different SS- RIs in OCD (2). In this study, we did not compre the efficcy of sertrline with fluoxetine on ech outcome mesure t the end of tretment. SCID-I/P nd SCID-II re widely used s gold stndrd instruments for dignosing xis I nd xis II disorders (22). All prticipnts were initilly ssessed using the SCID-I/P nd SCID-II. Clinicl symptoms were ssessed using the Y-BOCS (23, 24), AAQ (25) t the beginning nd end of tretment. Y-BOCS is 10-item clinicin dministered scle used for the ssessment of severity of OC symptoms. It hs good psychometric properties nd hs shown excellent tretment sensitivity (23, 24, 26, 27). AAQ is 9-item self-report scle, which ssesses EA. Ech item is rted on 7-point scle with higher scores indicting greter EA (rnge: 7-63). It hs demonstrted good internl consistency (α = 0.70) nd test-retest relibility over 4-month intervl (rs = 0.64) (24). The relibility nd vlidity of the Irnin version of the Y- BOCS (28), AAQ (29), SCID-I/P nd SCID-II (30) hve been evluted nd shown to be s good s their originl versions. 2

3 The criteri for cliniclly significnt chnge (CSC) considered Y-BOCS totl score reduction of eight scores or more from pre-tretment to post-tretment nd finl Y- BOCS totl score 14. Ptients who chieved CSC were defined s recovered. Ptients were clssified s improved if they chieved relible chnge tht is eight score or more, but scoring bove 14 on Y-BOCS totl. Ptients who did not chieve relible chnge on the Y-BOCS were defined s unchnged (6). Full remission ws defined s posttretment Y-BOCS totl score 8 (31). Group differences were evluted using chi-squre, onewy nlysis of vrince (ANOVA) nd one-wy nlysis of covrince (ANCOVA) sttisticl procedures on ech of the outcome mesures using SPSS for Windows (version 16.0, SPSS Inc., Chicgo, IL, USA) sttisticl pckge. 4. Results Using ANOVA nd chi-squre test, no significnt difference ws found between the groups regrding demogrphic chrcteristics nd pre-tretment mesures (Tbles 1 nd 2) CSC Ptients chieving CSC t post-tretment were 44.4%, 40.0% nd 12.5% for ACT, combined nd SSRIs groups, respectively. Two ptients (22.2%) in ACT nd two ptients (20.0%) in combined group nd two ptients (25.0%) in SS- RIs group met the criteri for relibility improved. Three ptients (33.3%) in ACT, four ptients (40.0%) in combined nd five ptients (62.5%) in SSRIs groups were clssified s unchnged. Tble 1. Demogrphic Chrcteristics, Anlysis of Vrince,b Mesure Group χ 2 nd F Sttistic Proportion men/ womn Proportion single/mrried 5/4 4/4 6/4 χ 2 = /5 4/4 5/5 χ 2 = 0.08 Age, y ± ± ±9.46 F = 0.17 Eduction, y ± ± ± 1.81 F = 1.10 OCD durtion, y 5.22 ± ± ± 4.44 F = 0.22 Abbrevitions: ACT, Acceptnce nd commitment therpy; OCD, Obsessive-compulsive disorder; nd SSRIs, Selective serotonin reuptke inhibitors. b Dt re presented s Men ± SD, nd ll P > Tble 2. Pre-Tretment Outcome Mesures, Anlysis of Vrince,b Mesure Group F Sttistic Y-BOCS ± ± ± AAQ ± ± ± Abbrevitions: AAQ, Acceptnce nd Action Questionnire; ACT, Acceptnce nd commitment therpy; SSRIs, Selective serotonin reuptke inhibitors; nd Y-BOCS, Yle-Brown Obsessive-Compulsive Scle. b Dt re presented s Men ± SD, nd ll P > Full Remission Regrding the criteri for OC symptoms full remission (Y-BOCS score 8), two ptients (22.2%) in ACT nd two ptients (20.0%) in combined group chieved this improvement level, but none of the ptients in SSRIs group hd full remission ANCOVA Results Tble 3 displys the men scores, stndrd devition nd ANCOVA results on ech outcome mesure t the end of tretment. The ssumptions of homogeneity of vrince nd homogeneity of regression were met for ech of the comprisons. ANCOVA results reveled significnt differences between the groups on Y-BOCS nd AAQ. Pir-wise post-hoc comprisons of the mens of the groups showed significnt differences between ACT nd SSRIs s well s between combined tretment nd SSRIs on the Y-BOCS nd AAQ t post-tretment. However, there were no significnt differences between ACT nd combined tretment on the mesures. Effect sizes using Cohen s d (difference between djusted mens divided by the pooled stndrd devition (32) ws clculted to evlute the size of differences between the tretment groups. Lrge effect sizes were found for differences between the ACT group nd the SSRI group s well s between the combined group nd the SSRI group on the Y-BOCS nd AAQ. However, there were no significnt differences between ACT nd combined groups on OC symptoms nd EA t post-tretment (Tble 4). Tble 3. Post-Tretment Outcome Mesures, Anlysis of Covrince (Using the Pre-Tretment Scores s the Covrite),b Mesure Group F Sttistic Y-BOCS ± ± ± AAQ ± ± ± Abbrevitions: AAQ, Acceptnce nd Action Questionnire; ACT, Acceptnce nd commitment therpy; SSRIs, Selective serotonin reuptke inhibitors; nd Y-BOCS, Yle-Brown Obsessive-Compulsive Scle. b Dt re presented s Men ± SD, nd P < Tble 4. Effect Sizes for Pirwise Post-Hoc Comprisons,b Mesure ACT vs. SSRIs ACT vs. Combined Combined vs. SSRIs Y-BOCS 1.14 c c AAQ 1.18 c c Abbrevitions: AAQ, Acceptnce nd Action Questionnire; ACT, Acceptnce nd commitment therpy; SSRIs, Selective serotonin reuptke inhibitors; nd Y-BOCS, Yle-Brown Obsessive-Compulsive Scle. b d = Cohen s effect size (0.2 = smll effect, 0.5 = medium effect, 0.8 = lrge effect). c P <

4 5. Discussion All three tretments were effective in reducing totl scores in the Y-BOCS nd AAQ t post-tretment. Nevertheless, ACT nd combined tretment presented significntly greter improvements in severity of OC symptoms nd EA nd higher rte of complete remission of OC symptoms thn those resulting from SSRIs use. Furthermore, ACT nd combined tretment produced greter rtes of recovery in OC symptoms compred to SSRIs lone. Regrding OC symptoms improvement, our results were similr to those found in previous studies with ACT (14-18) nd SSRIs (1, 2). The rte of reduction in the Y-BOCS in the study of Twohig et l. (15), ws 47.3% t post-tretment, which is virtully the sme s 41.3% reduction t the end of ACT observed in the current study. A possible explntion for the effectiveness of ACT my be the fct tht reductions in EA nd cognitive fusion produce greter psychologicl flexibility. ACT imed t helping ptients to ccept their obsessionl thoughts nd negtive feelings nd commit to cting in service of their vlued life gols regrdless of obsessions were occurring. Incresing psychologicl flexibility nd vlues-bsed ction in the presence of obsessionl thoughts nd negtive emotions could be core process of chnge in OC symptoms (15). In support of this perspective, evidence (14-18) show tht reduction in OC symptoms is due to specific processes used in ACT (i.e. cceptnce nd cognitive defusion). ACT processes (e.g. reductions in EA) chnged prior to chnges in OCD severity. In the present study, EA decresed in ACT nd combined tretment groups, without significnt difference between the groups. These results re inconsistent with studies of Twohig (14), Twohig et l. (15, 16) nd Armstrong (18), which demonstrted reductions in EA in ptients with OCD following ACT. From n ACT perspective, incresing one s willingness to experience obsessionl thoughts nd negtive feelings nd not engge in behviors to decrese them produces reductions in EA nd compulsions (15). The finding tht ACT is more effective in improving OC symptoms thn SSRIs is consistent with previous findings by Fo et l. (33), Sous et l. (31), Abrmowitz et l. (34) nd Shreh et l. (35) who found the superiority of psychotherpy over nti-obsessive drugs lone in the tretment of dults with OCD. Similrly, Fo et l. (33), Shreh et l. (35) nd Gisuddin et l. (36) observed tht the combintion of psychotherpy nd phrmcotherpy reched better results thn phrmcotherpy lone. Eddy et l. (3) by reviewing 18 rndomized controlled trils found tht the combintion tretment is more effective in reducing OC symptoms thn either psychotherpy or mediction lone. However, in the present study, the combined tretment ws only more effective in reducing totl scores in the Y-BOCS thn mediction lone. In this study, no significnt differences were found between ACT nd combined tretment regrding the OC symptoms improvement. These findings support the results of two studies (37, 38), which found no dvntges of combining mediction nd psychotherpy compred to psychotherpy lone in treting ptients with OCD, lthough, unlike the present study, these studies found no significnt differences between combined tretment nd mediction lone. The results of the present study demonstrted tht combining SSRIs with ACT does not increse the effectiveness of ACT in improving OC symptoms nd EA in ptients with OCD in short-time. Moreover, ptients treted with ACT nd combined tretment experienced further improvement in OC symptoms nd EA t post-tretment compred to those treted with SSRIs lone. This study hd severl limittions. The smple size ws smll, nd thus, these findings should be considered preliminry until replicted in lrger smple sizes. Further reserches re necessry to exmine whether our results re pplicble to ptients with OCD nd other comorbid conditions excluded from this study. The present study did not hve follow-up ssessment. Therefore, future reserch is needed to evlute long-term effects of ll three mentioned tretments for OCD. It is recommended to perform further studies to compre the effectiveness of ACT with other empiriclly supported tretments nd combintion of these tretments with SSRIs for OCD. Despite these limittions, our results provided supporting evidence for effectiveness of ACT in helping ptients with OCD to experience significnt improvements in EA nd OC symptoms, s well highlighted the importnce nd need for dditionl studies in this re. Acknowledgements The study ws pproved by the Ethics Committee of Tehrn University of Medicl Sciences (The code of ethics: ). We lso thnk Dr. Mehrir Ndr- Mohmmdi for evluting ptients. Authors Contributions Yghoob Vkili conceived nd designed the evlution, collected clinicl dt, interpreted them, performed sttisticl nlysis, drfted the mnuscript nd revised it. Bnfsheh Ghree prticipted in designing the evlution nd helped to drft nd revised the mnuscript. Mojtb Hbibi prticipted in designing the evlution, interprettion of clinicl dt, sttisticl nlysis, drfting nd revising the mnuscript. All uthors red nd pproved the finl mnuscript. Clinicl Tril Registrtion Code N1. Ethics Committee Code Funding/Support We thnk the Medicl Reserch Council of Tehrn Uni- 4

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