Obsessive Compulsive Disorder

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Acceptance and Commitment Therapy in combination with Exposure and Ritual Prevention for Obsessive Compulsive Disorder via Videoconference. - PowerPoint PPT Presentation

Transcript of Obsessive Compulsive Disorder

Crossing the Line: Interstate Delivery of Remote Psychological Services

Acceptance and Commitment Therapy in combination with Exposure and Ritual Prevention for Obsessive Compulsive Disorder via VideoconferenceElizabeth M. Goetter, Ph.D.1,2, James D. Herbert1, Ph.D., Evan M. Forman, Ph.D. 1, Erica K. Yuen, Ph.D. 3,4, Marina Gershkovich1, Stephanie Goldstein1

Drexel UniversityMassachusetts General HospitalMedical University of South CarolinaRalph H. Johnson VAMC

Obsessive Compulsive Disorder

Increased AnxietyCOMPULSIONOBSESSIONReduced Anxiety2Treating OCD: Current SituationResearch: Exposure and ritual prevention is the gold standard treatment for OCD.Practice: Specialist providers are in short supply.Gap: Most individuals with OCD do not receive adequate (if any) treatment.


Videoconference-mediated treatments show promise, butResearch is preliminaryVideoconference technology can be expensiveOCD is difficulty to treat and typically relies on active, therapist involvement

4The Current Study: AimsIs delivery of ERP through Skype feasible and acceptable?Is remote delivery of ERP effective?Is it advantageous to supplement ERP with acceptance and commitment therapy?


Adults with OCDLiving in eligible stateYBOCS 16Access to Skype via computer and broadband connectionEnglish fluency


Comorbid psychotic disorderHoarding subtypeAcute suicide potentialSeeking additional therapy for OCDNot on a stable medication regimen for prior 3 months

Participants15 adults87% femaleMean age=30.247% had a college degree47% employed full-time67% lived in nonmetropolitan areas, 40% lived >45 mins away from a specialist47% were extremely or fairly familiar with Skype67% had been in therapy before

InterventionStandard ERP (n=8)ERP + ACT (n=7)# Sessions 16 (90 min sessions)18 (90 min sessions)Presenting a definition of OCD, psychoeducation==Rationale for ExposureHabituationWillingness in service of valuesPrimary goal of treatment (extending from theory)Break link between (1) obsessions-anxiety; (2) ritualsanxiety reductionIncreased psychological flexibilityTime spent doing exposure==Out of session exposure==Phone check-ins==Supplemental coping strategies/supportStandard, therapist support, encouragementDefusion, mindfulness, metaphors, etc.

Assessment Schedule

Clinical Evaluation + Self Report Questionnaires administered at each Assessment PointData AnalysisMultiple imputation used for missing valuesITT and Completer Analyses were equivalentEffect sizes are emphasized given small sample sizeFormal between group analyses not conducted due to low power

Feasibility and Acceptability (both groups)

Attrition rate = 23% 82% mostly or completely satisfied with tx/therapist91% reported receiving tx was very or fairly easyTherapists reported tx very or fairly easy in 73% of casesHomework adherence (M = 4.43) was comparable to in-person study (M = 5.17)Most agreed (95% indicated > 70% agreement) that the videoconference environment was natural

12No technical problems for over half (57%) of all sessionsSevere or major technological problems were rare (3.5% of sessions)

Feasibility and Acceptability (both groups)

Treatment Outcome Trends by Group (YBOCS)

Treatment Outcome Across All ParticipantsPre Tx MeanPost Tx MeantpEffect Size (d)YBOCS26.1513.236.51< .0012.31OCI-R31.4611.854.46< .012.07OBQ-44180.54106.314.58< .011.62TAF24.6210.922.74< .051.03ROII-Emotions24.2317.002.02= .0670.89ROII-Intensity29.2315.853.61< .011.43CGI-Severity5.002.856.06< .0012.14BDI15.0810.311.17= .2640.45ASI28.3112.153.95< .011.34QLESQ51.5166.23-2.12= .0560.76SDS21.469.694.04< .011.75

- 33% no longer met criteria for OCD at post-treatment 61% were rated very much or much improved15Effect Sizes

*Videoconference studyChange in ACT Process Variables Across All Participants

Pre Tx MeanPost Tx MeantpEffect Size (d)AAQ-II

46.6033.312.94< .051.09DDS

24.9229.00-2.16= .050.43PHLMS-Acceptance

24.1630.31-2.55< .050.86PHLMS-Awareness

38.6933.852.76< .050.7317Defusion (DDS)

18Psychological Inflexibility/Exp Avoidance (AAQ)

19Mindful Acceptance (PHLMS)

20Mindful Awareness (PHLMS)


.20 (p = .52) .19 (p = .53).44 (p = .13)DDS

-.35 (p = .23)-.08 (p = .81)-.30 (p = .31)PHLMS-Acceptance-.12 (p = .71)-.44 (p = .13).30 (p = .33)PHLMS-Awareness-.05 (p = .87).01 (p = .98).21 (p = .49)

Correlations between Process Variables and OCD Symptoms Across All Participants22Advantages ChallengesConvenient and cost effectiveFlexibilityEasy access to home and familyTechnological difficultiesMore difficult to assess subtletiesReduced commitment?

Strengths and LimitationsStrengths Largest videoconference trial of ERP to date (and larger than the only other 2 trials combined)First known study of ACT+ERP for OCD via videoconferenceInnovative methodologyLow cost burden for participantsLimitationsSmall sampleNo comparison groupTherapists had relatively limited experiencePotential recruitment bias

RecommendationsMobile devices can aid as supplementsModel exposures as you would in face-to-face treatmentMinimize distractionsProvide tutorial in use of videoconference platformSame ethical considerations apply

Future DirectionsRandomized controlled trials (ACT vs. Standard ERP; Face-to-face vs. remote treatment settings)Smartphone applications Increasing adherence to treatmentIncreasing access21% of American adults do not use the Internet34% of Americans do not have broadband InternetDemographic disparities

ConclusionsERP delivered through Skype is feasible and acceptable

Treatment was effective in reducing OCD symptoms and effect sizes were commensurate with in-person treatments

Defusion and psychological flexibility are relevant targets in the treatment of OCD



Sheet1ERPERP+ACTSeries 3Pre25.526.72Mid1822.72Post14.3317.1433 mo F/U16.414.65To resize chart data range, drag lower right corner of range.


Series 1Pre- to post- Effect Sizes (YBOCS) for Treatment Completers Across Conditions

Sheet1Series 1Series 2Series 3*Current study (n=10)3.82.42*Vogel et al. (2012) (n=6)5.24.42Kozak et al. (2000) (n=13)2.31.83Fals-Stewart et al. (1993) (n=31)0.932.85Lindsay et al. (1997) (n=9)3.88van Balkom et al. (1998) (n=19)1UPenn Outpatients (n=100)3.26Twohig et al. 20102.39



Sheet1ERPERP+ACTSeries 3Pre28.820.42Mid26.628.42Post312733 mo35335To resize chart data range, drag lower right corner of range.



Sheet1ERPERP+ACTSeries 3Pre49.443.82Mid4437.82Post39.834.233 mo41.4375To resize chart data range, drag lower right corner of range.



Sheet1ERPERP+ACTSeries 3Pre27.424.62Mid28.227.22Post28.633.83F/U28.427.45To resize chart data range, drag lower right corner of range.



Sheet1ERPERP+ACTSeries 3Pre39.2372Mid3634.62Post35.831.83F/U37.836.65To resize chart data range, drag lower right corner of range.