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The effectiveness of acceptance and commitment therapy in treating a case of obsessive compulsive disorder.

Objective The aim of this study was to evaluate the effectiveness of acceptance and commitment therapy (ACT) in treating obsessive compulsive disorder (OCD). Method In a single-subject experiment trial, the treatment process was carried out on a 39-year old male subject. The patient satisfied the DSM-IV-TR criteria for OCD and was assessed for pre-duration and post treatment. The scales used in this study included: The Yale-Brown Obsessive Compulsive Scale(Y-BOCS), Beck Depression Inventory-II-second edition (BDI-II), and Beck Anxiety Inventory (BAI). In addition, all scales were again completed by the subject at 1-month, 3-months, and 6-months follow-ups. Results The treatment led to reductions in symptoms of OCD, depression and anxiety. Gains were maintained at follow-ups. Conclusion The treatment approach appears to be effective in the treatment of OCD.

While selective serotonin reuptake inhibitors (SSRIs) and exposure with response prevention (ERP) for treatment of obsessive compulsive disorder (OCD) have demonstrated empirical support, a substantial number of patients remain with clinically significant OCD symptoms after these treatments (1)(2)(3)(4). It is estimated that 30-40% of OCD patients show no improvement to SSRIs, and patients who do respond to this treatment suffer from residual symptoms (5). Also, despite the efficacy of cognitive-behavioral therapy, including ERP, all OCD patients do not respond to treatment, with as few as 25% experiencing full recovery (6). Recently, one of the promising novel treatment strategies which have been developed to improve the efficacy of treatment for patients with OCD is acceptance and commitment therapy (7)(8). ACT is a third-wave behavior therapy that specifically focuses on decreasing experiential avoidance (EA) and increasing psychological flexibility (9). EA is defined as an unwillingness to remain in contact or experience aversive private thoughts and to avoid or escape these experiences (7). EA has been suggested to play an important role in the development and maintenance of OCD (10). EA has been hypothesized to manifest as compulsions in OCD (10). In the EA perspective, OCD patients engage in compulsions to control or reduce their unwanted obsessional thoughts because they want to reduce the negative affect associated with them (10). In support of this perspective, correlational studies have found that high levels of EA were positively associated with high levels OC symptoms (11)(12)(13). In treating OCD, ACT targets particular constructs including: cognitive difusion and decreasing EA. ACT teaches patients to create a new relationship with obsessive thoughts and anxious emotions; for example, helping patients notice that a thought is just a thought and anxiety is an emotion to be felt. ACT also helps patients commit to act in the service of their valued life goals rather than spending large amounts of time trying to decrease the obsession or avoid anxious feelings. ACT helps patients to accept their obsessional thoughts and negative feelings and commit to act in the service of their valued life directions whether or not obsessions were occurring. Thus, these constructs will increase psychological flexibility, which is the ability to act in accordance with patient's meaningful life directions regardless of unpleasant inner experiences (14,15). This article reports a case of OCD that was resistant to pharmacological treatment, but responded well to ACT; and this therapeutic effect remained for a relatively long-time.

Case Presentation
The patient was a 39-year-old divorced male, with an educational level of high school diploma, who was admitted to Tehran Psychiatry Institute for resistant OCD and was referred for ACT by the attending psychiatrist. His problem started at the age of 23, and

Iran J Psychiatry 2014; 9:2: 115-117
the duration of his OCD symptoms was 16 years. The patient was evaluated by administering the SCID-I for Axis I disorders and SCID-II for Axis II disorders. The resulting evaluation confirmed the diagnosis of OCD; no psychiatric comorbidity was observed. His primary obsessions included harming others, intrusive thoughts (The belief that he was "damned to hell" by God because he had sex with a prostitute. Also, he believed that God may not forgive such sins, and these obsessions triggered feeling anger. Primary compulsions consisted of checking and washing rituals. The disorder had deteriorated his social and interpersonal relations. He underwent several different kinds of SSRIs, including full doses of sertraline and fluoxetine. The mentioned medications did not affect his obsessive compulsive symptoms. At the time, ACT was initiated for the patient and he received sertraline (100mg) daily. Sertraline continued during the assessment period. Although the mentioned medication indicated a positive outcome, the main effect was due to the ACT illustrated in the baseline treatment ( Figure  1).

Assessments
The present study has utilized the intensive time-series design (16). The patient was asked to complete the Y-BOCS, BDI-II and BAI before, during and after the treatment sessions and also at the follow-up sessions.

Treatment Procedures
The treatment procedures were planned based on the ACT manual for OCD (14). The ACT program included evaluating the patient's obsessions and compulsions (Session 1). The "Man in the hole" metaphor was used to illustrate how the patient's efforts to regulate obsessions are ineffective (Session 2). The "Tow scales" metaphor was used to illustrate the possible benefits of acceptance of obsessions and anxiety rather than attempting to control or reduce them (Sessions 3 and 4). By the use of defusion, the patient was helped to contact with the present or mindfulness and self as context exercises (Sessions 5 and 6). Helping the patient to recognize his values and to prevent relapse (Sessions 7 and 8). After 8 sessions, the treatment program was established, and the patient was then followed for 1, 3 and 6 months.

Result
As demonstrated by the below figure, the treatment led to reductions in symptoms of OCD, depression and anxiety. Gains were maintained at 1-month, 3 months and 6 months follow-ups.

Discussion
This case report illustrates the effectiveness of ACT for a patient with OCD that was resistant to pharmacological trials. The treatment of OCD improves as a result of increasing psychological flexibility and value-based actions in the presence of obsessional thoughts (15). In other words, increasing psychological flexibility and value based actions in the presence of obsessional thoughts and negative emotions could be a core process of change in OC symptoms (15). In support of this perspective, evidence (14, 15, 17&18) shows that reduction in OC symptoms is due to the specific processes used in ACT (i.e., acceptance and cognitive defusion). The results of this study must be interpreted cautiously. The study involved only one patient, who may not fully represent all OCD cases. Nevertheless, the present results imply that continuing evaluations of this new treatment are warranted.