Comparing the Effectiveness of Acceptance and Commitment Therapy with Exposure and Schema Therapy with Exposure on Depression, Anxiety and Stress in Patients with Obsessive-Compulsive Disorder

Articles in Press

Document Type : Original Article

Authors

• mahnaz Ghatreh Samani ¹
• Mahmoud Najafi ²

¹ Ph.D student in psychology, Department of clinical Psychology, Faculty of Psychology and Educational Sciences, Semnan University, Semnan, Iran

² Associate Professor, Department of Clinical Psychology, Faculty of Psychology and Educational Sciences, Semnan University, Semnan, Iran.

10.22067/tpccp.2025.92212.1764

Abstract

Introduction
Obsessive-Compulsive Disorder (OCD) is characterized by the presence of obsessions and compulsions. The majority of patients diagnosed with this disorder have been observed to demonstrate a higher degree of self-control over their compulsions (Stein et al., 2019). Depression frequently co-occurs with this disorder, leading to the intensification of obsessive-compulsive thoughts (Jones et al., 2018). Conversely, obsessive-compulsive disorder (OCD) frequently co-occurs with anxiety symptoms. Intolerance of ambiguity in these individuals has been shown to cause anxiety, prompting the person to engage in compulsions to reduce ambiguity (Sharma et al., 2021). In this regard, stress in this disorder is significantly related to the severity of obsessive symptoms but not to the severity of compulsions. In fact, while obsessions are stressful, compulsions act as a stress-reducing mechanism (Sousa-Lima et al., 2019). For this purpose, acceptance and commitment therapy with exposure utilizes three primary processes: acceptance, thought defusion, and values, for the treatment of this disorder (Twohig et al., 2015). Conversely, schemas cause psychological distress through cognitive distortions, destructive life patterns, and maladaptive coping styles. Schema therapy involves the substitution of healthy coping responses with the modification of schemas (Thiel et al., 2014). Consequently, the examination and comparison of these two integrated approaches can yield novel evidence in an efficient field and contribute to a more profound understanding of the factors that influence the persistence of OCD symptoms by focusing on variables such as anxiety, stress, and depression. The objective of this study is to compare the effectiveness of acceptance and commitment therapy with exposure and schema therapy with exposure on depression, anxiety, and stress in patients with OCD.
Method
This study employed a quasi-experimental pretest-posttest design with both experimental and control groups. Participants were selected through convenience sampling. Using GPower software, we determined a required sample size of 54 participants (18 per group). To account for potential attrition, we initially enrolled 20 participants in each group, resulting in a total sample of 60 individuals. The inclusion criteria for the groups encompassed the following: a diagnosis of obsessive-compulsive disorder, a minimum age of 18 years, and a minimum education level equivalent to middle school. The exclusion criteria encompassed the presence of psychotic disorders, other comorbid disorders, concurrent psychiatric treatments, and absence of more than three sessions. In this study, the Lovibond Depression Anxiety and Stress Scale (DASS-21) (1995) was utilized to assess three scales of depression, anxiety, and stress. The first experimental group engaged in acceptance and commitment therapy with exposure sessions, as outlined by Lee et al. (2018). The second experimental group participated in schema therapy with exposure sessions, as described by Thiel et al. (2016). The control group did not receive any therapeutic interventions. These treatments were administered on a weekly basis, with each session lasting for a duration of 60 minutes.
Findings
The findings of multivariate covariance analysis demonstrated that there was a significant discrepancy between the groups with respect to the components of depression, anxiety, and stress (F=30.133 and P=0.001), anxiety (F=37.557 and P=0.001), and stress (F=25.044 and P=0.001) in the two experimental and control groups. The post hoc test results indicated that both treatments had a significant and equal effect on depression in patients with obsessive-compulsive disorder (p > 0.05). A significant body of research has demonstrated that schema therapy with exposure has a greater effect on reducing anxiety (p < 0.05). Similarly, acceptance and commitment therapy with exposure has been shown to have a greater effect on reducing stress in participants (p < 0.05).
Discussion & Conclusion
The objective of this study was to compare the effectiveness of acceptance and commitment therapy with exposure therapy in reducing depression, anxiety, and stress in patients diagnosed with OCD. The findings of the study demonstrate the efficacy of acceptance and commitment therapy with exposure in addressing depression, anxiety, and stress in patients diagnosed with OCD. This finding aligns with the observations reported by Han and Kim (2022), and previous studies have demonstrated the efficacy of this therapeutic approach in enhancing psychological flexibility and alleviating symptoms of stress (Brinkborg et al., 2011) and depression (Twohig & Levin, 2017). This therapeutic modality aims to mitigate negative emotions by modifying the patient's relationship with their thoughts, cognitive processes, and their perception of suffering and harm in life. It assists patients in acknowledging the harm caused by their suffering while facilitating the adoption of steps towards their life values. The study's findings indicate that schema therapy with exposure is effective in addressing depression, anxiety, and stress in patients diagnosed with OCD. This hypothesis aligns with the findings reported by Priemer et al. (2015) and Ansari et al. (2020). Schema therapy demonstrates efficacy in alleviating depression, anxiety, and stress symptoms by targeting and modifying maladaptive schemas. This therapeutic approach proves particularly relevant for individuals with OCD, as their characteristic schemas often maintain depressive cognitions, anxiety patterns, and stress responses. Through schema restructuring, patients develop more adaptive cognitive frameworks that reduce pathological symptoms. A potential pivotal mechanism for the alteration of symptoms within the framework of schemas is the modification in distinctive negative core beliefs. That is to say, when symptoms demonstrate improvement, core beliefs concomitantly exhibit enhancement.
The present study was subject to several limitations, including use of a convenience sampling method and the absence of subsequent follow-up. It is recommended that a random sampling method be employed in subsequent research to generalize the results. Additionally, a six-month follow-up period should be incorporated to ascertain the stability of the results over time.

Keywords

• Stress
• depression
• anxiety
• acceptance and commitment therapy
• schema therapy
• obsessive-compulsive

Main Subjects

• Cognetive Psy

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References

Ansari, S., Asgari, P., Makvandi, B., Heidari, A., & Seraj Khorrami, N. (2020). Effectiveness of schema therapy in psychological distress, body image, and eating disorder beliefs in patients with anorexia nervosa. Avicenna Journal of Neuro Psycho Physiology, 7(3), 184-189. https://doi.org/10.32592/ajnpp.2020.7.3.107

Basile, B., Tenore, K., & Mancini, F. (2018). Investigating schema therapy constructs in individuals with depression. Journal of Psychology & Clinical Psychiatry, 9(2), 214-221. https://doi.org/10.15406/jpcpy.2018.09.00524.

Bohlmeijer, E. T., Fledderus, M., Rokx, T., & Pieterse, M. E. (2011). Efficacy of an early intervention based on acceptance and commitment therapy for adults with depressive symptomatology: Evaluation in a randomized controlled trial. Behaviour research and therapy, 49(1), 62-67. https://doi.org/10.1016/j.brat.2010.10.003.

Brinkborg, H., Michanek, J., Hesser, H., & Berglund, G. (2011). Acceptance and commitment therapy for the treatment of stress among social workers: A randomized controlled trial. Behaviour research and therapy, 49(6-7), 389-398. https://doi.org/10.1016/j.brat.2011.03.009.

Child, S. T., & Lawton, L. E. (2020). Personal networks and associations with psychological distress among young and older adults. Social Science & Medicine, 246, 112714. https://doi.org/10.1016/j.socscimed.2019.112714

Eghdampanah foumani, m. L., Asadi Mojreh S, & B., a. (2024). Comparison of the Effectiveness of Cognitive Hypnotherapy and Schema Therapy on Difficulty in Emotion Regulation in Substance-Dependent Individuals. Journal of Research on Addiction, 18(72), 145-168, Article (In Persian). https://doi.org/10.61186/etiadpajohi.18.72.7.

Han, A., & Kim, T. H. (2022). Efficacy of internet-based acceptance and commitment therapy for depressive symptoms, anxiety, stress, psychological distress, and quality of life: Systematic review and meta-analysis. Journal of Medical Internet Research, 24(12), e39727. https://doi.org/10.2196/39727

Jones, P. J., Mair, P., Riemann, B. C., Mugno, B. L., & McNally, R. J. (2018). A network perspective on comorbid depression in adolescents with obsessive-compulsive disorder. Journal of anxiety disorders, 53, 1-8. https://doi.org/10.1016/j.janxdis.2017.09.008.

Lee, E. B., Ong, C. W., An, W., & Twohig, M. P. (2018). Acceptance and commitment therapy for a case of scrupulosity-related obsessive-compulsive disorder. Bulletin of the Menninger Clinic, 82(4), 407-423. https://doi.org/10.1521/bumc.2018.82.4.407

Levin, M. E., MacLane, C., Daflos, S., Seeley, J. R., Hayes, S. C., Biglan, A., & Pistorello, J. (2014). Examining psychological inflexibility as a transdiagnostic process across psychological disorders. Journal of Contextual Behavioral Science, 3(3), 155-163. https://doi.org/10.1177/0145445515603707

Lovibond, P. F., & Lovibond, S. H. (1995). The structure of negative emotional states: Comparison of the Depression Anxiety Stress Scales (DASS) with the Beck Depression and Anxiety Inventories. Behaviour research and therapy, 33(3), 335-343. https://doi.org/10.1016/0005-7967(94)00075-u

Moritz, S., & Jaeger, A. (2018). Decreased memory confidence in obsessive–compulsive disorder for scenarios high and low on responsibility: is low still too high? European archives of psychiatry and clinical neuroscience, 268, 291-299. https://doi.org/https://doi.org/10.1007/s00406-017-0783-0

Ong, C. W., Blakey, S. M., Smith, B. M., Morrison, K. L., Bluett, E. J., Abramowitz, J. S., & Twohig, M. P. (2020). Moderators and processes of change in traditional exposure and response prevention (ERP) versus acceptance and commitment therapy-informed ERP for obsessive-compulsive disorder. Journal of Obsessive-Compulsive and Related Disorders, 24, 100499. https://doi.org/https://doi.org/10.1016/j.jocrd.2019.100499

Peeters, N., Stappenbelt, S., Burk, W. J., van Passel, B., & Krans, J. (2021). Schema therapy with exposure and response prevention for the treatment of chronic anxiety with comorbid personality disorder. British Journal of Clinical Psychology, 60(1), 68-76. https://doi.org/https://doi.org/10.1111/bjc.12271

Petersen, J., Ona, P. Z., Blythe, M., Möller, C. M., & Twohig, M. (2022). Intensive outpatient acceptance and commitment therapy with exposure and response prevention for adolescents. Journal of Contextual Behavioral Science, 23, 75-84. https://doi.org/https://doi.org/10.1016/j.jcbs.2021.12.004

Priemer, M., Talbot, F., & French, D. J. (2015). Impact of self-help schema therapy on psychological distress and early maladaptive schemas: A randomised controlled trial. Behaviour Change, 32(1), 59-73. https://doi.org/10.1017/bec.2014.30

Remmerswaal, K. C., Cnossen, T. E., van Balkom, A. J., & Batelaan, N. M. (2023). Schema therapy with cognitive behaviour day-treatment in patients with treatment-resistant anxiety disorders and obsessive-compulsive disorder: an uncontrolled pilot study. Behavioural and Cognitive Psychotherapy, 51(2), 174-179. https://doi.org/https://doi.org/10.1017/S1352465822000625

Renner, F., DeRubeis, R., Arntz, A., Peeters, F., Lobbestael, J., & Huibers, M. J. (2018). Exploring mechanisms of change in schema therapy for chronic depression. Journal of behavior therapy and experimental psychiatry, 58, 97-105. https://doi.org/10.1016/j.jbtep.2017.10.002.

Russell, E. J., Fawcett, J. M., & Mazmanian, D. (2013). Risk of obsessive-compulsive disorder in pregnant and postpartum women: a meta-analysis. The Journal of clinical psychiatry, 74(4), 18438. https://doi.org/10.4088/JCP.12r07917.

Samani, S., & Joukar, B. (2007). A study on the reliability and validity of the short form of the depression anxiety stress scale (DASS-21). Social Science and Humanties of Shiraz University, 26(52), 65-77, Article (In Persian). https://www.sid.ir/paper/391033/fa

Sharma, P., Rosário, M. C., Ferrão, Y. A., Albertella, L., Miguel, E. C., & Fontenelle, L. F. (2021). The impact of generalized anxiety disorder in obsessive-compulsive disorder patients. Psychiatry Research, 300, 113898. https://doi.org/https://doi.org/10.1016/j.psychres.2021.113898

Sousa-Lima, J., Moreira, P. S., Raposo-Lima, C., Sousa, N., & Morgado, P. (2019). Relationship between obsessive compulsive disorder and cortisol: Systematic review and meta-analysis. European Neuropsychopharmacology, 29(11), 1185-1198. https://doi.org/10.1016/j.euroneuro.2019.09.001

Stein, D. J., Costa, D. L., Lochner, C., Miguel, E. C., Reddy, Y. J., Shavitt, R. G., van den Heuvel, O. A., & Simpson, H. B. (2019). Obsessive–compulsive disorder. Nature reviews Disease primers, 5(1), 52. https://doi.org/10.1038/s41572-019-0102-3.

Sun, J., Li, Z., Buys, N., & Storch, E. A. (2015). Correlates of comorbid depression, anxiety and helplessness with obsessive–compulsive disorder in Chinese adolescents. Journal of Affective Disorders, 174, 31-37. https://doi.org/10.1016/j.jad.2014.11.004

Thiel, N., Jacob, G. A., Tuschen-Caffier, B., Herbst, N., Kuelz, A. K., Hertenstein, E., Nissen, C., & Voderholzer, U. (2016). Schema therapy augmented exposure and response prevention in patients with obsessive–compulsive disorder: Feasibility and efficacy of a pilot study. Journal of behavior therapy and experimental psychiatry, 52, 59-67. https://doi.org/10.1016/j.jbtep.2016.03.006

Thiel, N., Tuschen-Caffier, B., Herbst, N., Külz, A. K., Nissen, C., Hertenstein, E., Gross, E., & Voderholzer, U. (2014). The prediction of treatment outcomes by early maladaptive schemas and schema modes in obsessive-compulsive disorder. BMC psychiatry, 14, 1-13. https://doi.org/10.1186/s12888-014-0362-0

Twohig, M. P., & Levin, M. E. (2017). Acceptance and commitment therapy as a treatment for anxiety and depression: a review. Psychiatric clinics, 40(4), 751-770. https://doi.org/10.1016/j.psc.2017.08.009

Twohig, M. P., Vilardaga, J. C. P., Levin, M. E., & Hayes, S. C. (2015). Changes in psychological flexibility during acceptance and commitment therapy for obsessive compulsive disorder. Journal of Contextual Behavioral Science, 4(3), 196-202. https://doi.org/10.1016/j.jcbs.2015.07.001.