The International Journal of Indian Psychology

ISSN 2348-5396 (e) | ISSN: 2349-3429 (p)

Volume 4, Issue 2, No. 86, DIP: 18.01.039/20170402
ISBN: 978-1-365-68609-2
http://www.ijip.in | January-March, 2017

Comparative Study on Efficacy of Various Types of Exposure

Response Prevention Therapies on OCD

Mihir Ranjan Nayak 1, Narendra nath Samantaray2*, Preeti Singh 3

ABSTRACT
Objective: The heterogeneity of OCD has various mixed findings related to the treatment
procedures, psychological and pharmacological treatment. Consistent research has shown mixed
findings regarding which form of ERP, ERP as Habituation tool or ERP as restructuring tool, is
more efficacious. Hence this study is done to examine efficacies of various treatment procedures
but importantly to propose a possible treatment choices based on efficacy and acceptability in
Indian settings for OCD management. Method: Participants were adult outpatients (N=22) with
primary OCD selected from OPD level and randomly assessed to two treatment groups; a)
ERP(Habituation only) with SSRI b) ERP (ERP as restructuring tool) with SSRI. Participants
received 12-14 exposure sessions, Result and Conclusions: ERP when used as a process of
“habituation” is more efficacious in terms of treatment outcomes but when ERP used as both
habituation and cognitive restructuring tool is more tolerable and acceptable by patients and also
not prone to dropouts.

Keywords: Obsessive Compulsive Disorder, ERP, Behavior Therapy, Cognitive Therapy, CBT,
SSRI, Y-BOCS

Obsessive Compulsive Disorder (OCD) is marked by three components (Mc Kay, 2004). One
component, obsessions, has been defined as intrusive and unwanted thoughts, images or ideas, as
well as doubts about actions. The second component, compulsions, has been defined as specific
behavioral actions, including covert mental rituals, intended to neutralize the obsessions, or to
verify behaviors that are the subject of doubts. In addition to these two primary components,
individuals with the disorder engage in extensive avoidance to prevent the provocation of
obsessions and their associated compulsions. And these avoidance and compulsions are
maintaining factors of this disorder (Hawton, 1989). Interest in the treatment of obsessive-

1
Associate Professor, Dept of Psychiatry, MHI, SCB Medical College, Cuttack, India
2
Clinical Psychologist, Dept of Clinical Psychology, MHI, SCB Medical College, Cuttack, India
3
Assistant Professor, Dept of Clinical Psychology, IMHH, Agra, India
*Responding Author
Received: December 30, 2016; Revision Received: January 20, 2017; Accepted: January 30, 2017
© 2017 Nayak M, Samantaray N, Singh P; licensee IJIP. This is an Open Access Research distributed under the
terms of the Creative Commons Attribution License (www.creativecommons.org/licenses/by/2.0), which permits
unrestricted use, distribution, and reproduction in any Medium, provided the original work is properly cited.
 Comparative Study on Efficacy of Various Types of Exposure Response Prevention Therapies on OCD

compulsive disorder has increased with novel approaches to understanding and managing this
often complex and debilitating disorder. Serotonin reuptake inhibitors (SRIs) (e.g., clomipramine
and various selective serotonin reuptake inhibitors [SSRIs]) and cognitive and behavioural
therapy involving exposure and ritual prevention have been found to be efficacious in
randomized, controlled trials (APA, 2006).

In clinical practice, SRIs are used most frequently (Blanco, 2006), but because they typically
yield only a 20%–40% reduction in OCD symptoms (Pigott, 1999), many SRI responders
continue to have clinically significant symptoms. The heterogeneity of this disorder has various
mixed findings related to the treatment procedures and choices hence this study is done not to
only examine efficacies of various treatment procedures but importantly to propose a possible
treatment hierarchy and choices based on efficacy and acceptability in Indian settings.

Exposure and response prevention (ERP):

For the past 35 years, the psychosocial treatment of choice has been exposure and response
prevention. Treatment using this approach involves developing a hierarchy of presenting
symptoms, from least fear producing to most, and then guiding the client through exposure to
items on the hierarchy until the highest level items are readily tolerated at the same time response
prevention is included, whereby the client is asked to refrain from completing the compulsions
that would otherwise eliminate the anxiety or distressing emotional reaction (Rowa et al., 2007).
Some data suggest that ERP is more effective if it includes not only habituation but also
discussion of feared consequences and dysfunctional beliefs (Freeston, 1997). Over the past
several decades, considerable research work has accumulated to show that ERP is an efficacious
intervention for OCD (Foa & Kozak, 1996). The method of delivery is important with in vivo
therapist– assisted ERP, in conjunction with imagery, reported to produce the greatest change in
symptom severity.

However, ERP is reported to be a difficult treatment to tolerate. Drop-out and refusal rates range
20%–30% (Stanley & Turner, 1996), and many people leave with residual symptoms.

The concerns with classical ERP led to the development of alternate theories that would more
directly address the changes that were thought to account for a decrease in the severity of OCD
symptoms. It was consensually proposed that OCD patients attach a threatening meaning to the
intrusions, whereas those without OCD appraise similar thoughts in a more neutral fashion
(Carr;1974, Mc Fall 1979, Salkovskis, 1985). It is the appraisal that produces the emotional
distress and the urge to neutralize the intrusive thought and these faulty appraisals are distributed
in six domains: tendency to overestimate the risk and the responsibility; the importance and the
power of thoughts and the need of controlling them; the need of certainty; and perfectionism
(Salkovskis, 1985).

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 Comparative Study on Efficacy of Various Types of Exposure Response Prevention Therapies on OCD

A number of recent randomized controlled trials have investigated the efficacy of contemporary
cognitive strategies in comparison to individual ERP (Cottraux et al., 2001; van Oppen et al.,
1995) and group ERP (McLean et al., 2001) and with a subgroup of primary obsessionals
(Freeston et al., 1997). These studies collectively reported that cognitively focused treatment is
effective in significantly reducing the severity of obsessions and compulsions and that the
treatment gains appear to be maintained through short-term follow- up. Although there were no
significant differences between CBT and ERP, van Oppen (1995) reported trends in favor of
CBT. Alternatively, McLean et al. (2001) reported that group ERP was marginally better than
group CBT at post treatment and 3-month follow-up and that significantly more ERP participants
had attained clinically significant improvement compared to CBT participants.

Fluoxetine and Fluvoxamine (SSRI):

Double-blind, placebo-controlled, and active-comparator studies indicate that fluoxetine and
fluvoxamine is significantly more effective than placebo and equal in efficacy to clomipramine
and certain SSRIs (citalopram, paroxetine). In addition, double-blind active-comparator studies
suggest fluoxetine and fluvoxamine is comparable in efficacy to clomipramine and sertraline and
superior in efficacy to phenelzine. Compared with clomipramine, both SSRI exhibited fewer side
effects in many studies

METHOD
This study was conducted at Mental Health Institute (Centre of Excellence), SCB Medical
College, Cuttack. Patients were selected at OPD level on the basis of their consent and inclusion
criteria which are: a) Participants meeting ICD 10 criteria of OCD, b) Ages between 18-35 years
old, and c) Participants having minimum education of matriculation. Exclusion criteria are; a)
Participants having comorbid psychiatry diagnosis, b) Participants having predominantly
obsessions type. Initially 26 participants (16 males and 10 females) were selected and were
randomly assigned to the TWO TREATMENT GROUPS which are:
a) ERP(Habituation only) with SSRI
b) ERP (ERP as restructuring tool) with SSRI.

However, total number of four participants dropped out from the study (4 from group a).

Treatment
Following treatments versions are used:
1. Exposure and ritual prevention (Classical “Habituation” Version)
Two versions of ERP are used in the present study. For Category 1 (Group 1), the classical
version of ERP is used as a part of Behaviour Therapy procedure where habituation is given
emphasis where further discussion of feared consequences and dysfunctional beliefs related to
ERP procedures (ERP as tool for cognitive restructuring) is not used.

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 Comparative Study on Efficacy of Various Types of Exposure Response Prevention Therapies on OCD

2. Exposure and ritual prevention ( As Cognitive Restructuring tool)

But in second category, Group 2, the protocol for exposure and ritual prevention followed the
procedures of Kozak and Foa (1997) which emphasized on both use of habituation and cognitive
restructuring in ERP. Along with habituation further discussion of feared consequences and
dysfunctional beliefs related to ERP procedures (ERP as tool for cognitive restructuring) are
done.

Exposure exercises were arranged hierarchically, beginning with moderately distressing ones. It
included 12-14 exposure sessions each. Both in vivo and imaginable exposures were conducted.
Patients were encouraged to persist with each exposure until the distress decreased noticeably.
As homework, patients were asked to record any rituals and spend at least 1 hour per day
conducting self-guided exposures. To ensure this a family member of the participants are
involved in one session where they were told the rationale, method and guidelines for practice
sessions of ERP.

1. SSRI (Fluoxetine and Fluvoxamine)

In both group doses of fluoxetine for first month is 40-60mg per day and fluvoxamine 50 mg per
day and later homogeneously modified upon the subsequent consultation with psychiatrist.
Assessments
Independent evaluators, those who are not attached with this project, evaluated patients at
baseline (week 0) and but after completion of treatments (after week 16). Symptom severity was
evaluated using the Yale-Brown Obsessive Compulsive Scale (Goodman, 1989) for OCD.

RESULTS
Examination of Treatment Effects
Table -1:Y-BOCS Pre Post Test Scores
Group N Mean Std. Deviation
Group1Pre 11 28.4000 2.40832
Group1Post 11 10.4000 2.07364
Group2Pre 11 28.1429 2.03540
Group2Post 11 13.0000 .81650

As mentioned in Table 1, the mean score of Y-BOCS on post test measures (graphically shown
in Figure 1) on two treatment categories, are 10.4 and 13 respectively. In comparison to the pre-
test measures on these two categories of treatment combinations, 28.4 and 28.14, respectively,
the post test measures of each treatment group suggest that participants in all groups made
statistical and clinical gains following treatments.

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 Comparative Study on Efficacy of Various Types of Exposure Response Prevention Therapies on OCD

However, the result indicates Category 1(ERP as “Habituation” Version with SSRI) have the
best treatment outcome post test scores followed by Category 2 (ERP as Restructuring Tool with
SSRI), Category 2 (SSRI with CT) and Category 4 (SSRI alone) respectively.

DISCUSSION AND IMPLICATIONS

As described above, our results suggest, the mean score of Y-BOCS on post test measures on
two treatment categories showed that all groups made statistical and clinically significant gains
following treatment. However, it is important to place these findings in the context of what has
been reported with EX/RP in other settings and with other samples. Comparing the percentage of
reduction on the Y-BOCS observed here with those found across other EX/RP outcome studies
that have used this outcome measure would be one alternative, yet these calculations do not take
sample variances into account. Instead, we calculated within subject effect sizes based on the Y-
BOCS for each of our treated groups, as recommended by Cohen (1988), and compared them
with those derived from other recent EX/RP studies.

In the present study the effects of ERP (used as Habituation Tool) along with SSRI medications
emerged as the best possible combination of treatment for OCD.

But the disadvantages in ERP when used as “Habituation tool” as noticed in present study bears
synonymous with many other findings mentioned in literature. 4 participants dropped from
Category 1 treatment group in between the ERP sessions and when asked reason he found
subjectively difficult to resist ERP sessions along with other reasons. But in group 2 when ERP
is used as cognitive restructuring no such incidence were there. And further it is not associated
with any drop outs; it may be suggestible that ERP when used as element of cognitive
restructuring might result in better adherence and tolerance than ERP only used as a method of
“habituation”. But those who completed yielded the best outcome in means.

But on the basis of the present study it can be said that ERP when used as CBT is more tolerable
and acceptable to patients than ERP when used as “habituation” only. This finding that ERP
when executed using as both principles is more acceptable to patients and may lessen the
dropouts is a major implication of our research.

As mentioned above and in almost all literature that avoidance to triggering stimuli of OC
symptoms are fuelling the disorder and is one of the basic maintain features of OC symptoms.
In the absence of long-term outcome data, our findings cannot be used to help answer questions
about whether patients who received combined treatment will later be able to withdraw from
SSRI without experiencing a significant return of OCD symptoms.

To a certain extent, examination of the question of CBT treatment outcome with and without
SSRI in a naturalistic study comes at the expense of internal validity. For example, we cannot

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 Comparative Study on Efficacy of Various Types of Exposure Response Prevention Therapies on OCD

determine the influence of patient choice (e.g., choosing CBT only over combined treatment) on
treatment response. Nevertheless, it could well be said that our findings ought to be replicated
with larger samples using more carefully controlled designs.

CONCLUSIONS
Major conclusions that can be derived from the present studies can be summed up in following
ways: A) ERP (as “Habituation”), ERP (as Restructuring Tool), and SSRI all are effective
treatment modules in OCD. B) The most efficacious treatment procedures in order of hierarchy
are ERP (as Habituation) with SSRI. C) But when ERP used as a process of “habituation” is
more efficacious in terms of treatment outcomes than any other and marginally superior version
than other ERP procedures but D) when ERP used as cognitive restructuring tool is more
tolerable and acceptable by patients and also not prone to dropouts as compared to ERP when
used as habituation only, hence it is recommended to implement and use ERP as a common
denominator to both BT and CT to patients. F) ERP is very highly and effectively decreases
avoidance of fearful triggering stimuli in OCD patients.

Acknowledgments
The author appreciates all those who participated in the study and helped to facilitate the
research process.

Conflict of Interests: The author declared no conflict of interests.

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How to cite this article: Nayak M, Samantaray N, Singh P (2017), Comparative Study on
Efficacy of Various Types of Exposure Response Prevention Therapies on OCD, International
Journal of Indian Psychology, Volume 4, Issue 2, No. 86, ISSN:2348-5396 (e), ISSN:2349-3429
(p), DIP:18.01.039/20170402, ISBN:978-1-365-68609-2

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