Comparing Exposure and Response Prevention and Emotion-Focused Therapy on Experiential Avoidance, Intolerance of Uncertainty, and Emotion Regulation in Patients with Obsessive-Compulsive Disorder
Downloads
Objective: Obsessive-Compulsive Disorder (OCD) is characterized by intrusive thoughts and repetitive behaviors often maintained by experiential avoidance (EA), intolerance of uncertainty (IU), and emotional dysregulation. This study aimed to compare the effectiveness of Exposure and Response Prevention (ERP) and Emotion-Focused Therapy (EFT) in reducing EA and IU and improving cognitive emotion regulation (CER) in patients with OCD.
Methods and Materials: In this quasi-experimental study, 45 patients with clinically diagnosed OCD were randomly assigned to three groups: ERP (n=15), EFT (n=15), and a control group (n=15). Participants completed the Acceptance and Action Questionnaire-II (AAQ-II), Intolerance of Uncertainty Scale (IUS-27), and the Cognitive Emotion Regulation Questionnaire (CERQ) at pretest, posttest, and 2-month follow-up. ERP was delivered over 10 sessions, and EFT over 8 sessions. Data were analyzed using repeated measures ANOVA with Bonferroni post hoc tests.
Findings: Both ERP and EFT significantly reduced experiential avoidance and intolerance of uncertainty compared to the control group (p < 0.01). ERP was more effective in reducing IU, while EFT led to greater improvements in adaptive CER strategies. Both therapies equally reduced maladaptive emotion regulation. Therapeutic gains were sustained at follow-up.
Conclusion: ERP and EFT are both effective interventions for addressing emotional and cognitive vulnerabilities in OCD. ERP appears more suitable for addressing intolerance of uncertainty, while EFT is more effective for enhancing adaptive emotional processing. Treatment plans tailored to individual emotional and cognitive profiles may optimize clinical outcomes.
Downloads
Amanloo, L., Ranjbar, M., & Alavi, K. (2024). Mindfulness-based therapy versus emotion-focused therapy in patients with peptic ulcer: A comparative study. Journal of Clinical Psychology, 80(1), 45-58. https://doi.org/10.1002/jclp.22503
Angelakis, I., & Gooding, P. (2020). Obsessive–compulsive disorder and suicidal experiences: The role of experiential avoidance. Suicide and Life‐threatening Behavior, 50(2), 359-371.
Angelakis, I., & Pseftogianni, F. (2021). Association between obsessive-compulsive and related disorders and experiential avoidance: A systematic review and meta-analysis. Journal of psychiatric research, 138, 228-239.
Askari, S., Sotoudeh Asl, N., Sabahi, P., & Ghorbani, R. (2022). Comparison of the effectiveness of behavioral activation and mindfulness-based cognitive therapy on cognitive emotion regulation and executive functions in individuals with obsessive-compulsive disorder. Health and Care, 24(4), 342–354. [In Persian]
Brakoulias, V., Starcevic, V., Belloch, A., Brown, C., Ferrao, Y. A., Fontenelle, L. F., ... & Viswasam, K. (2017). Comorbidity, age of onset and suicidality in obsessive–compulsive disorder (OCD): an international collaboration. Comprehensive psychiatry, 76, 79-86.
Buher K., Dugas MJ. (2006). Inves ga the construct validity pf intolerance uncertainty and its unique rela onship with worry. Anxiety disord 20:222-236.
D’Mello RJ and Kumar A. (2022). Experience of Disgust and Symptom Severity in Contamination Subtype of Obsessive-Compulsive Disorder: Role of Experiential Avoidance. Indian J Psychol Med. 2022;44(6):580–585.
del-Valle, M. V., Zamora, E. V., Urquijo, S., Olsen, C., López-Morales, H., & Andrés, M. L. (2022). Emotional Regulation Difficulties, Distress Tolerance and Psychopathological Symptoms. Annals of Psychology.309-325.
Eichholz, A., Schwartz, C., Meule, A., Heese, J., Neumüller, J., & Voderholzer, U. (2020). Self‐compassion and emotion regulation difficulties in obsessive–compulsive disorder. Clinical psychology & psychotherapy, 27(5), 630-639.
Einstein, D. A. (2014). Extension of the transdiagnostic model to focus on intolerance of uncertainty: A review of the literature and implications for treatment. Clinical Psychology: Science and Practice, 21(3), 280–300.
Esfahani, Z., Ghorbani, M., & Esfahani, M. (2023). Comparison of the effectiveness of exposure and response prevention and narrative therapy on reducing symptoms of obsessive-compulsive disorder. Clinical Psychology, 15(2), 59–72. [In Persian]
Eslami, H. (2024). New etiological perspectives on obsessive-compulsive disorder: A single-case study. New Ideas in Psychology Quarterly, 20(24), 1–12. [In Persian]
Fawcett J, Wakeham-Lewis R., Garland, Sh., & Fawcett, E. (2020). Obsessive compulsive disorder prevalence may not increase with latitude: A re-analysis and extension of Coles et al. Journal of Obsessive-Compulsive and Related Disorders, 2020; 25: 100527.
Fergus, T. A., & Bardeen, J. R. (2014). Emotion regulation and obsessive–compulsive symptoms: A further examination of associations. Journal of Obsessive-Compulsive and Related Disorders, 3(3), 243-248.
Ferrando, C., & Selai, C. (2021). A systematic review and meta-analysis on the effectiveness of exposure and response prevention therapy in the treatment of obsessive-compulsive disorder. Journal of Obsessive-Compulsive and Related Disorders, 31, 100684.
Ferreira, S., Couto, B., Sousa, M., Vieira, R., Sousa, N., Pico-Perez, M., & Morgado, P. (2021). Stress influences the effect of obsessive-compulsive symptoms on emotion regulation. Frontiers in psychiatry, 11, 594541.
Gross, J. J. (2015). Handbook of emotion regulation. California: Guilford Publications.
Hayes SC, Wilson KG, Gifford EV, et al. (1996). Emotional avoidance and behavioral disorders: A functional dimensional approach to diagnosis and treatment. J Consult Clin Psychol 1996; 64: 1152–1168.
Hebert, E. A., & Dugas, M. J. (2019). Behavioral experiments for intolerance of uncertainty: Challenging the unknown in the treatment of generalized anxiety disorder. Cognitive and Behavioral Practice, 26(2), 421-436.
Huang, Y., Wang, Y., Wang, H., Liu, Z., Yu, X., Yan, J., et al. (2019). Prevalence of mental disorders in China: a cross-sectional epidemiological study. Lancet Psychiatr. 6, 211–224.
Jani, S., Hajloo, N., & Narimani, M. (2023). Comparing the Effectiveness of Internet-Based Cognitive-Behavioral Therapy and Emotion-Focused Therapy on Ambiguity Tolerance and Threat Sensitivity in Married Women with Obsessive-Compulsive Disorder. Clinical Psychology and Personality, 20(2), 77-89.
Knowles, K. A., Cole, D. A., Cox, R. C., & Olatunji, B. O. (2022). Time-Varying and Time-Invariant Dimensions in Intolerance of Uncertainty: Specificity in the Prediction of Obsessive-Compulsive Symptoms. Behavior Therapy, 53(4), 686-700.
Nazari, F., Gharaei, B., & Zahedi Tajrishi, K. (2022). The mediating role of emotion dysregulation, experiential avoidance, and rumination in the relationship between emotional schemas and obsessive-compulsive symptoms. Iranian Journal of Psychiatry and Clinical Psychology (Andisheh va Raftar), 28(4), 466–479. [In Persian]
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.
Pascual-Vera, B., Belloch, A., Ghisi, M., Sica, C., & Bottesi, G. (2021). To achieve a sense of rightness: The joint role of Not Just Right Experiences and Intolerance of Uncertainty in Obsessive-Compulsive Disorder. Journal of Obsessive-Compulsive and Related Disorders, 29, 100627.
Pinciotti, C. M., Riemann, B. C., & Abramowitz, J. S. (2021). Intolerance of uncertainty and obsessive-compulsive disorder dimensions. Journal of Anxiety Disorders, 81, 102417.
Reed, G. F. (1985). Obsessional experience and compulsive behaviour: A cognitive-structural approach. Personality, psychopathology, and psychotherapy, 34.
Saberizadeh, M., & Zare Nistanak, M. (2023). Effectiveness of mindfulness-based cognitive therapy on intolerance of uncertainty, inflated responsibility, and thought-action fusion in women with obsessive-compulsive disorder in Arak. Journal of Clinical Psychology and Counseling Research, 13(2), 81–102. [In Persian]
Sadeh, N., & Bredemeier, K. (2021). Engaging in risky and impulsive behaviors to alleviate distress mediates associations between intolerance of uncertainty and externalizing psychopathology. Journal of personality disorders, 35(3), 393-408.
Shapiro, D. (1965). Neurotic styles. Basic Books.
Sharbanee, J. M., & Greenberg, L. S. (2023). Emotion-focused therapy for grief and bereavement. Person-Centered & Experiential Psychotherapies, 22(1), 1-22.
Shaw, A. M., Halliday, E. R., & Ehrenreich-May, J. (2020). The effect of transdiagnostic emotion-focused treatment on obsessive-compulsive symptoms in children and adolescents. Journal of obsessive-compulsive and related disorders, 26, 100552.
Sperling, J. (2022). The Role of Intolerance of Uncertainty in Treatment for Pediatric Anxiety Disorders and Obsessive-Compulsive Disorder. Evidence-Based Practice in Child and Adolescent Mental Health, 1-10.
Stockton, D., Kellett, S., Berrios, R., Sirois, F., Wilkinson, N., and Miles, G. (2018). Identifying the underlying mechanisms of change during acceptance and commitment therapy (ACT): a systematic review of contemporary mediation studies. Behav. Cogn. Psychother. 47, 332–362.
Thomas, K. N., and Bardeen, J. R. (2020). The buffering effect of attentional control on the relationship between cognitive fusion and anxiety. Behav. Res. Ther. 132:103653.
Thompson, B. L., Twohig, M. P., & Luoma, J. B. (2021). Psychological flexibility as shared process of change in acceptance and commitment therapy and exposure and response prevention for obsessive-compulsive disorder: a single case design study. Behavior Therapy, 52(2), 286-297.
Timulak L, Keogh D, McElvaney J, Schmitt S, Hession N, Timulakova K, Jennings C, Ward F. (2020). Emotion-focused therapy as a transdiagnostic treatment for depression, anxiety and related disorders: Protocol for an initial feasibility randomised control trial. HRB Open Res. 2020 Feb 13;3:7
Toffolo, M. B., van den Hout, M. A., Engelhard, I. M., Hooge, I. T., & Cath, D. C. (2014). Uncertainty, checking, and intolerance of uncertainty in subclinical obsessive compulsive disorder: An extended replication. Journal of Obsessive-Compulsive and Related Disorders, 3(4), 338-344.
Twohig, MP, Hayes SC, and Masuda A. (2006). Increasing willingness to experience obsessions: Acceptance and commitment therapy as treatment for obsessive compulsive disorder. Behav Ther 2006; 37: 3–13.
Veale, D. (2007). Cognitive-behavioural therapy for obsessive-compulsive disorder. *Advances in Psychiat
Wang, Q. Q., Fang, Y. Y., Huang, H. L., Lv, W. J., Wang, X. X., Yang, T. T., ... & Zhang, Y. H. (2021). Anxiety, depression and cognitive emotion regulation strategies in Chinese nurses during the COVID‐19 outbreak. Journal of Nursing Management, 29(5), 1263-1274.
Wheaton, M. G., Messner, G. R., & Marks, J. B. (2021). Intolerance of uncertainty as a factor linking obsessive-compulsive symptoms, health anxiety and concerns about the spread of the novel coronavirus (COVID-19) in the United States. Journal of obsessive-compulsive and related disorders, 28, 100605.
Xiong, A., Lai, X., Wu, S., Yuan, X., Tang, J., Chen, J., ... & Hu, M. (2021). Relationship between cognitive fusion, experiential avoidance, and obsessive–compulsive symptoms in patients with obsessive–compulsive disorder. Frontiers in Psychology, 12, 655154.
Yap, K., Mogan, C., Moriarty, A., Dowling, N., Blair-West, S., Gelgec, C., & Moulding, R. (2018). Emotion regulation difficulties in obsessive compulsive disorder. Journal of Clinical Psychology, 74(4), 695–709.
Zwack, J., & Greenberg, L. (2020). Where Are the Emotions? How Emotion-Focused Therapy Could Inspire Systemic Practice. In Systemic Research in Individual, Couple, and Family Therapy and Counseling (pp. 249-264).
Copyright (c) 2025 International Journal of Body, Mind and Culture
This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License.
