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To compare exposure and response prevention with general anxiety management in patients with obsessive compulsive disorder (OCD).
Randomised controlled trial with a 3 week intervention period.
Outpatient clinic in New South Wales, Australia.
18 patients (mean age 33 y, 67% women) who met the Diagnostic and Statistical Manual of Mental Disorders, 4th edition diagnosis of OCD and had a mean duration of OCD of 11 years (range 1 to 26 y).
Patients were allocated to exposure and response prevention (n=9) or a control group involving general anxiety management (n=9). Exposure and response prevention consisted of graded exposure to situations that were previously associated with obsessional thoughts or impulses. Patients then implemented self imposed prevention of compulsive rituals. The treatment programme included outpatient clinic sessions and daily homework exposure tasks. General anxiety management consisted of learning breathing techniques in response to hyperventilation, muscle relaxation, and problem solving about non-OCD life stressors. No instruction was given about exposure to triggers or prevention of rituals. Patients in both groups received about 15 hours of face to face therapy sessions over the 3 week intervention period.
Main outcome measures
Change in severity of obsessions, compulsions, anxiety, and depression using the following scales: Padua Inventory, Maudsley Obsessional-Compulsive Inventory (MOCI), Yale-Brown Obsessive-Compulsive Scale, State-Trait Anxiety Inventory, and an interference rating scale.
Patients in both groups rated their therapists as supportive and understanding. A principal components analysis yielded 2 components, the first accounting for 62.6% of the variance in scores on individual measures and the second accounting for 16.7% of the variance. The first component gave a combined measure of OCD symptom severity, and the second a general measure of anxiety and depression. After treatment, when scores on the first principal component were combined, an overall reduction in scores occurred in patients in the exposure and response prevention group whereas no change in scores occurred in patients in the anxiety management group (p<0.006). No differences existed between the groups on the second principal component, but when pretreatment and post-treatment scores were combined differences between the groups in favour of the exposure group were seen on the MOCI (p<0.006) and interference ratings (p<0.006).
A reduction in obsessional symptoms in obsessive compulsive disorder occurred after a 3 week programme of exposure and response prevention techniques. No improvement was seen after a programme of general anxiety management.
Barlow has described generalised anxiety disorder as being the “basic anxiety disorder” characterised by intense, uncontrollable worry.1 The relation of OCD to other anxiety disorders has been in question for many years. In North America, OCD is included as one of the anxiety disorders whereas OCD is categorised separately in the International Classification of Disease, 10th edition.
The study by Lindsay et al compares 2 treatments, each of which has been found to be effective in various specific anxiety disorders. Exposure plus response prevention has become the standard treatment for OCD with consistent evidence for the efficacy of the total package but not for the individual parts. Anxiety management has been shown to be effective in generalised anxiety disorder.
The study addresses the issue of whether anxiety management, an active anxiety treatment, is as effective in reducing the severity of symptoms in one of the anxiety disorders as exposure and response prevention which has usually been compared with inert psychological placebos. The outcome of the study is quite clear in this small sample. Exposure plus response prevention reduces the symptoms of OCD whereas anxiety management does not.
The findings are of considerable relevance for clinical practice. Many patients with OCD are still treated primarily with attempts to reduce anxiety rather than with techniques that directly target the major symptoms and behaviours of the disorder. This study confirms the need for the application of exposure and response prevention in the optimal management of OCD.
Source of funding: no external funding.
For article reprint: Dr R Crino, Clinical Research Unit for Anxiety Disorders, 299 Forbes Street, Darlinghurst, New South Wales 2010, Australia. Fax +61 2 9332 4316.
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