Acceptance and commitment therapy as an add-on treatment for the management of patients with obsessive-compulsive disorder

Abstract

Background:

Obsessive compulsive disorder (OCD) is a chronic and long-lasting illness affecting approximately 2% of the population. Up to 40%–60% of patients with OCD do not have satisfactory outcomes, thereby leading to disability in performing daily routine activities. Acceptance and commitment therapy (ACT) provides a substitute for old-fashioned psychotherapies, as it involves the client directly experiencing the problematic emotion, that is, anxiety and obsessions in the case of OCD.

Aim:

To observe the effect of ACT on patients with OCD and compare its effect on obsessive compulsive symptoms, thought control, thought and action fusion, acceptance and action, and depression.

Materials and Methods:

A total of 62 patients diagnosed with OCD as per Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) in the age range between 18 and 60 years, having duration of illness less than two years, both male and female, literate and illiterate, hailing from rural and urban background, were included in the study. For pre- and post-assessment Yale-Brown Obsessive and Compulsive Scale (Y-BOCS), Hamilton Depression Rating Scale (HDRS), acceptance and commitment questionnaire, thought control questionnaire, and thought and action fusion questionnaire were used in this study, and ACT was used for management of OCD.

Results:

There is a significant difference between the groups treated with ACT and those treated as usual, on every domain of thought control questionnaire (TCQ) -- distraction (t = 9.07), social control (t = 11.13), worry (t = 11.93), punishment (t = 16.78), and re-appraisal (t = 16.47). Significance is also seen in the thought and action fusion in the moral domain (t = 16.22), the likelihood domain (t = 16.49), and others (t = 9.23). On Y-BOCS, HDRS, and acceptance and action questionnaire (AAQ) both groups show a significant difference between each other.

Conclusion:

The findings of the present study indicate that ACT is a productive method for patients with OCD as it encourages the patient to accept and integrate their lived experiences, challenges effective responses, and recognizes and eliminates the controlling dimensions.

Up to 40%–60% of patients with obsessive compulsive disorder (OCD) do not have satisfactory outcomes causing disability in performing daily routine activities.[1] It is the sixth most disabling psychiatric illness.[2] Some people in the general population do not fulfill the criteria of OCD, but up to one-fourth of the population faces obsessive compulsive symptoms in their lifetime.[2] This condition is comorbid with other psychiatric conditions, mostly depression and anxiety disorders. This leads to an increase in the suicidality associated with OCD. Hence, nonpharmacological management along with pharmacological management plays an important role in OCD. Obsessions have been termed as a “deficiency of mindfulness,” “narrow-mindedness,” and reflections and the overuse of social intelligence.[3] People with OCD who have comorbid depression, lead the poorest quality of life and have high disability compared to those suffering from only OCD.[4] Individuals living with OCD face occupational distress as they spend countless hours with their obsessions and compulsions.

Homework completion and homework quality are significantly related to treatment outcome and compliance.[5] Different treatment methods show different efficacy for patients. Psychotherapeutic management of OCD creates neurological changes in patients' brains, even though the mechanism behind these changes is unclear.[6] From the results of neuroimaging in psychotherapy, the idea behind psychotherapy may radically change. It provides insight into how psychotherapy could be used to create changes in patients' behavior.[7]

Acceptance and commitment therapy is the “third wave” in behavioral and cognitive therapy.[8] Mindfulness, acceptance, and value-based living are the three important techniques of ACT. In OCD, when patients feel anxious, it becomes unbearable, and striving to avoid this anxiety, only worsens the situation.[9]

Acceptance and commitment therapy not only addresses disorders like OCD, but also addresses other related issues, for example, dysfunction in occupational areas, interpersonal relationships, aggression, etc., By providing interventions of ACT, psychological flexibility increases which makes it more amenable to deal with obsessions.[10] Psychological flexibility can be defined as an individual's ability to be in sync with the present situation without any restraints, in a way to continue value-driven action. Psychological inflexibility is challenging because it creates repetitive behavior, which is one of the core symptoms of OCD. It also restricts the individual's chances of external fortification of behavior and results in a lower quality of life for people with OCD.[11] Experiential avoidance plays a crucial part in the maintenance of OCD, which necessitates its reduction by way of cognitive diffusion. In ACT, the patient is made to understand that obsessions like fear of contamination are merely thoughts and the associated anxiety is an emotion that can be managed through relaxation. In addition to reducing obsessions and anxiety, ACT promotes value-based living, which provides a meaningful direction in life.[12] For several conceptual and framework reasons, implementing ACT on patients with OCD would be of great benefit.[13] Given the paucity of Indian studies in this area, this study was conducted to assess the efficacy of ACT in OCD patients.

MATERIALS AND METHODS

This longitudinal study was undertaken at the Psychiatry Department of a tertiary care hospital attached to a Medical College in Uttar Pradesh after obtaining permission from the Institutional Ethical Committee. All the participants gave written informed consent.

Sample

A total of 62 patients with OCD, meeting the inclusion and exclusion criteria were recruited from the Department of Psychiatry through purposive sampling, from the outpatients and inpatients of the Department of Psychiatry.

Inclusion criteria

Patients diagnosed with OCD as per Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) criteria[14] in the age range of 18–60 years, both genders, both illiterate and literate, belonging to the urban and rural population, with the duration of illness less than 2 years, and those who provided informed oral consent, were included in the study.

Exclusion criteria

People who do not fall under the age range of 18–60 years, who have comorbid medical conditions, presence of psychotic symptoms, illness duration of more than two years, people with intellectual disability, visual and hearing impairment, and patients who do not provide informed consent, were excluded from the present study.

Tools

Semi-structured sociodemographic datasheet: - This semi-structured Performa was developed by researchers to collect the details of the subject regarding sociodemographic details. This Performa includes details like their name, age, gender, address, type of family, education, marital status, domicile, profession, present illness, etc.

Thought control questionnaire (TCQ): - It is a 30-item questionnaire developed by Adrian Wells and Mark I. Davies (1994). This scale is applied to ascertain the efficacy of approaches used for controlling unpleasant and unwanted thoughts. It has 0.8 internal consistency. The scoring ranges from 30 as minimum to 120 as maximum.[15]

Thought Action Fusion Scale-Revised (TAFS-R): - It is a 19-item questionnaire. It plays an important role in measuring the effectiveness of cognitive components over time. The thought process of OCD patients includes magical thinking, that is, bad thought leads to bad action and thinking of certain thoughts will come to fruition. It has three subscales -- TAF other, TAF-Likelihood other, and TAF-Likelihood self. It has Cronbach's alphas from 0.85 to 0.96.[16,17]

The Acceptance and Action Questionnaire (AAQ-2): - This tool is used to measure psychological flexibility. It is a seven-point Likert-type scale and has seven items. A higher score on this scale shows less flexibility while a lower score shows high flexibility. It has Cronbach's alpha 0.9.[18,19]

Yale-Brown Obsessive Compulsive Scale (Y-BOCS): - It is a 10-item scale designed by Wayne K. It has five items to assess the severity of obsessive thoughts and five to assess the severity of compulsive behavior.[20]

Hamilton Depression Rating Scale (HDRS): - It is a 17-item scale developed by Dr. Max. Hamilton. It is a test used for measuring the severity of depressive symptoms in individuals. It has a score range of 0–72.[21]

Procedure

A total of 62 patients with OCD who met inclusion and exclusion criteria were included in the study. Among the patients with OCD, 31 were randomly selected for the experimental group and 31 for the control group or treatment as usual (TAU). After explaining the purpose of the study and taking consent, semi-structured sociodemographic details were filled and pre-assessment was carried out by different psychological tools, TCQ, Thought and Action fusion scale revised (TAFS-R), Hamilton Depression Rating Scale (HDRS), and Acceptance and Action Questionnaire-2 (AAQ-2) of both the groups [Figure 1]. Experimental group patients were taken for ACT.[22] Figure 1 (flow chart) and Table 1 (module) explain the procedure in detail.

Figure 1.

Flow chart

Table 1.

The module on acceptance and commitment therapy

Sessions	ACT technique	Details of Intervention
1.	Detailed assessment	Psycho-education was given, rapport was built, the purpose of the intervention was explained, Assessment of psychosocial elements.
2.	Confronting the system	Assisting the patients to examine the strategies they have adopted, challenging their linguistic sets that define their problem and solution
3.	Recognizing control	Helping the patients recognize that their thought control strategies may aggravate their problems
4.	Experiential avoidance	Method of circumventing one’s own experiences (thoughts, memories, etc.)
5.	Cognitive diffusion and mindfulness	Through this technique the aim is to create psychological flexibility in the patients, it helps patients to make tolerable the negative impact of thought
6.	Promoting acceptance	Implementing their experiences in the present moment
7.	Value-based living	Assisting the patients to take control of their lives, meaningful directions in one’s life
8.	Creating commitment	Behavioral responses that are congruent with one’s identified value-based living for serving empowerment and post-assessment were done

The techniques mentioned in the module [Table 1] of ACT were provided in weekly sessions (a total of eight) to the experimental group and TAU to the control group. Patients were treated by psychiatrists with different selective serotonin reuptake inhibitors (SSRIs) (fluoxetine, sertraline, escitalopram, fluvoxamine). Drugs were selected on an individual basis. In the case of nonresponders, dosages of drugs were increased/decreased after assessment of 8 and 12 weeks. Maximum used dosages of SSRIs are fluoxetine 80 mg, escitalopram 30 mg, sertraline 200 mg, and fluvoxamine 200 mg. After reaching the maximum dose of SSRI, therapy was augmented with Clomipramine (average dosage of 50 mg) in nonresponders. Three patients did not respond to SSRI + Clomipramine therapy (TAU group). In these patients, atypical antipsychotics (Risperidone and Aripiprazole) were also used. The average dose of risperidone was 4 mg and that of aripiprazole was 10 mg. Subsequently, post-assessment with the above-mentioned tools was performed for both groups, and ascertaining the maintenance level of the experimental group at three-month follow-up assessments was also carried out.

Statistical analysis

Using IBM SPSS 26 (IBM Corp. Armonk, NY), an independent sample t-test was applied to compare experimental and control groups at baseline, after the intervention, and at follow-up maintenance. Paired sample t-test was performed to compare the effect of ACT in the experimental group pre- and post-intervention.

RESULTS

Demographic characteristics of the OCD patients is given in Table 2. Table 3 indicates that there is no significant difference between the experimental group and the control group at the baseline level. Table 4 indicates that there is a significant difference between the experimental and control groups after providing the intervention of ACT to the experimental group, while the control group was on TAU. There is a significant difference between both groups on every domain of TCQ on distraction (t = 9.07), social control (t = 11.13), worry (t = 11.93), punishment (t = 16.78), and re-appraisal (t = 16.47). On Y-BOCS, Ham-D, and AAQ both groups show a significant difference between each other. Table 5 indicates the reduction in the severity of OCD after the intervention of ACT. In preintervention, the assessment level of OCD was: mean = 3.03, standard deviation = 0.70, while it reduced to mean = 1.82, standard deviation = 0.78 postintervention. In the TAFS, at preintervention, the mean = 36.85, SD = 4.64 on the moral domain while at postintervention it was mean = 4.64, SD = 11.98; with a significant difference in the likelihood (t = 9.42) and other (t = 9.30) domains of TAFS. On Thought control, there is a significant difference in each domain: distraction (t = 8.34), social control (t = 9.53), worry (t = 8.48), punishment (t = 8.79), and re-appraisal (t = 9.62) with a P value of significance at 0.05 level. On Ham-D (t = 6.75) and AAQ (t = 10.56) with a significant difference in pre-and post-assessment after providing intervention. Table 6 indicates that there is no significant difference in the level of the experimental group on post-assessment and three-month follow-up assessment.

Table 2.

Sociodemographic details of the OCD patients

Variables	Frequency (n=62)	Percentage
Groups
Experimental	31	50
Control	31	50
Gender
Male	40	64.5
Female	22	35.5
Education
Illiterate	6	9.7
Primary or Literate	12	19.4
Middle School certificate	22	35.5
High school Certificate	16	25.8
Intermediate/Post-High school diploma	6	9.7
Marital Status
Married	26	41.9
Divorced	24	38.7
Widow/Widower	8	12.9
Unmarried	4	6.5
Area of Residing
Urban	28	45.2
Sub-urban	11	17.7
Rural	23	37.1
Socioeconomic Status
Upper	16	25.8
Middle	27	43.5
Lower	19	30.6

Table 3.

Control and experimental group at baseline

Variable	Experimental group (n=31)		Control group (n=31)		t	P
	Mean	SD	Mean	SD
TCQ
Distraction	19.73	2.01	17.81	2.84	3.04	2.52
Social Control	28.83	7.78	31.00	7.11	4.22	1.94
Worry	22.4	1.91	23.55	2.11	3.99	1.25
Punishment	18.96	1.99	19.28	1.54	0.69	2.42
Re-Appraisal	18.80	1.88	19.06	1.74	0.57	1.65
TAFS
Moral	38.43	4.20	35.37	4.59	2.72	1.9
Likelihood	13.30	1.31	13.2	1.29	0.25	0.80
Other	9.03	1.29	7.9	2.25	2.26	0.97
YBOCS	3.46	0.571	2.62	0.55	5.81	0.81
HAM-D	3.03	0.72	2.59	0.71	2.49	0.19
AAQ	38.93	5.46	37.00	5.46	1.3	0.21

¹TCQ=Thought control questionnaire, ²TAFS=thought Action Fusion Scale, ³YBOCS=Yale-Brown Obsessive Compulsive Scale, ⁴HAM-D=Hamilton Depression Rating Scale, ⁵AAQ=Acceptance and Action questionnaire

Table 4.

Post-intervention difference between the experimental and control group

Variable (Post)	Experimental group (n=31)		Control group (n=31)		t	P
	Mean	SD	Mean	SD
TCQ
Distraction	9.3	1.53	16.68	3.31	9.07	0.000*
Social Control	2.66	1.31	7.50	1.58	11.13	0.000*
Worry	9.23	2.04	18.0	2.06	11.93	0.001*
Punishment	8.90	2.60	17.96	1.65	16.78	0.000*
Re-Appraisal	9.13	1.45	17.65	1.96	16.47	0.001*
TAFS
Moral	11.06	3.66	35.53	6.31	16.22	0.000*
Likelihood	11.60	1.24	11.87	2.13	16.49	0.001*
Other	2.66	1.21	6.84	2.23	9.23	0.000*
Y-BOCS	1.26	0.44	2.34	0.65	7.51	0.000*
HAM-D	1.27	0.45	2.56	0.65	7.60	0.001*
AAQ	32.25	7.51	11.96	6.52	11.32	0.001*

*Significant 0.05 level. SD=Standard deviation, TCQ=Thought control questionnaire, TAFS=thought Action Fusion Scale, YBOCS=Yale-Brown Obsessive Compulsive Scale, HAM-D=Hamilton Depression Rating Scale, AAQ=Acceptance and Action questionnaire

Table 5.

Pre and post-comparison of the experimental group after the intervention of ACT

Variable	Intervention	Mean	SD	t	Sig value
Y-BOCS	Pre-ACT	3.03	0.70	8.202	0.000*
	Post-ACT	1.82	0.78
TAFS
Moral	Pre-ACT	36.85	4.64	8.75	0.000*
	Post-ACT	22.14	11.98
Likelihood	Pre-ACT	13.25	1.26	9.42	0.000*
	Post-ACT	8.35	4.06
Other	Pre-ACT	8.48	1.91	9.30	0.000*
	Post-ACT	4.82	2.76
TCQ
Distraction	Pre-ACT	18.74	2.64	8.34	0.000*
	Post-ACT	13.11	4.53
Social control	Pre-ACT	9.40	1.95	9.53	0.000*
	Post-ACT	5.16	2.90
Worry	Pre-ACT	19.43	1.62	8.48	0.000*
	Post-ACT	13.75	4.86
Punishment	Pre-ACT	19.12	1.76	8.79	0.002*
	Post-ACT	13.58	5.04
Re-Appraisal	Pre-ACT	19.93	1.80	9.62	0.000*
	Post-ACT	13.53	4.62
HAM-D	Pre-ACT	2.80	0.74	6.75	0.001*
	Post-ACT	1.93	0.86
AAQ	Pre-ACT	38.00	5.86	10.56	0.001*
	Post-ACT	22.43	12.38

*Significant 0.05 level. SD=Standard deviation, TCQ=Thought control questionnaire, TAFS=thought Action Fusion Scale, YBOCS=Yale-Brown Obsessive Compulsive Scale, HAM-D=Hamilton Depression Rating Scale, AAQ=Acceptance and Action questionnaire

Table 6.

Post ACT and follow up the comparison of the experimental group

Variable	Intervention	Mean	SD	t	Sig value
Y-BOCS	Post-ACT	1.32	0.54	1.43	0.16
	Follow-up	1.38	0.56
TAFS
Moral	Post-ACT	11.00	3.62	0.52	0.60
	Follow-ACT	12.00	3.8
Likelihood	Post-ACT	4.58	1.23	0.98	0.21
	Follow-ACT	5.09	1.19
Other	Post-ACT	2.74	1.09	0.98	0.35
	Follow-ACT	3.29	0.91
TCQ
Distraction	Post-ACT	9.25	1.52	1.48	0.19
	Follow-ACT	9.61	1.64
Social control	Post-ACT	2.71	1.21	1.16	0.32
	Follow-ACT	3.21	1.67
Worry	Post-ACT	9.19	2.02	2.03	0.42
	Follow-ACT	10.2	2.13
Punishment	Post-ACT	9.12	2.71	1.51	0.24
	Follow-ACT	9.58	2.74
Re-Appraisal	Post-ACT	9.22	1.52	1.44	0.28
	Follow-ACT	10.5	1.39
HAM-D	Post-ACT	1.29	0.46	0.32	0.74
	Follow-ACT	1.32	0.47
AAQ	Post-ACT	13.41	3.52	0.47	0.64
	Follow-ACT	13.29	4.08

*Significant 0.05 level. SD=Standard deviation; TCQ=Thought control questionnaire, TAFS-thought Action Fusion Scale; Y-BOCS=Yale-Brown Obsessive Compulsive Scale, HAM-D=Hamilton Depression Rating Scale, AAQ=Acceptance and Action questionnaire

DISCUSSION

Obsessions and compulsions cause anxiety and lead to co-morbid depression. Hence, through ACT, the patient is taught acceptance of their problematic behavior. The present study used the techniques of ACT to bring about mindfulness of the problematic behavior, which leads to value-based living. The primary outcome of the study is the reduction in obsessive compulsive symptoms and the secondary outcome is the reduction of the comorbid depression.

In the present study, Table 3 shows that there is no difference between experimental and control groups on a baseline level. The results of the present study showed a significant effect of ACT [Tables 4 and 5], supporting the previous study.[23] Our study also supports the conclusions of an earlier study that techniques of ACT like cognitive fusion and experiential avoidance create a significant drop in the score of depression and obsessive compulsive symptoms, and an increment in the score of acceptance and action.[21]

When a comparison was performed among patients who received ACT intervention with the control group, it was found ACT with pharmacological therapy significantly reduced depression scores and reduced to no depression or mild depression. Our study supports an earlier study which concluded that ACT reduces the symptoms of anxiety and depression in patients with OCD,[12] while it contradicts the findings of another study which reported that ACT reduces the symptoms of depression and also suggests some of the techniques of cognitive behavioral therapy (CBT) should be used to increase the efficacy of ACT.[24]

Assessing patients of the experimental group after three months of providing intervention of ACT, we found that there is no significant difference in their scores on obsessive compulsive symptoms, thought and action fusion, thought control, depression, and acceptance and action [Table 5]. It indicates that after getting the intervention of ACT with pharmacological management, patients remain in the maintenance phase for a long time. Our study supports the findings of an earlier study that patients remain symptom-free for up to three months and they also find ACT is more efficacious with exposure and response prevention (ERP).[10]

Limitations

The sample size was modest. This was a hospital-based study, hence the result cannot be generalized. Other psychosocial variables were not assessed such as quality of life, life satisfaction, etc.

CONCLUSION

Acceptance and commitment therapy is an effective mode of treatment in patients with OCD as it promotes psychological flexibility, decreases depression, and enhances value-based living in patients with OCD and patients remain in the maintenance phase for a long period, that is, three months in our study.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.