BOSTON — , a new analysis shows.
Although avoidant patients with OCD reported symptom improvement immediately after treatment, baseline avoidance was associated with significantly worse outcomes 1 year later.
“Avoidance is often overlooked in OCD,” said lead investigator Michael Wheaton, PhD, an assistant professor of psychology at Barnard College in New York. “It’s really important clinically to focus on that.”
The findings were presented at the Anxiety and Depression Association of America (ADAA) annual conference and published online in the Journal of Obsessive-Compulsive and Related Disorders.
The Avoidance Question
Although ERP is often included in treatment for OCD, between 38% and 60% of patients have residual symptoms after treatment and as many as a quarter don’t respond at all, Dr. Wheaton said.
Severe pretreatment avoidance could affect the efficacy of ERP, which involves exposing patients to situations and stimuli they may usually avoid. But prior research to identify predictors of ERP outcomes have largely excluded severity of pretreatment avoidance as a factor.
The new study analyzed data from 161 Norwegian adults with treatment-resistant OCD who participated in a concentrated ERP therapy called the Bergen 4-day Exposure and Response Prevention (B4DT) treatment. This method delivers intensive treatment over 4 consecutive days in small groups with a 1:1 ratio of therapists to patients.
B4DT is common throughout Norway, with the treatment offered at 55 clinics, and has been trialed in other countries including the United States, Nepal, Ecuador, and Kenya.
Symptom severity was measured using the Yale-Brown Obsessive Compulsive Scale (YBOCS) at baseline, immediately after treatment, and 3 and 12 months later. Functional impairment was measured 12 months after treatment using the Work and Social Adjustment Scale.
Although the formal scoring of the YBOCS does not include any questions about avoidance, one question in the auxiliary items does: “Have you been avoiding doing anything, going anyplace or being with anyone because of obsessional thoughts or out of a need to perform compulsions?”
Dr. Wheaton used this response, which is rated on a five-point scale, to measure avoidance. Overall, 18.8% of participants had no deliberate avoidance, 15% were rated as having mild avoidance, 36% moderate, 23% severe, and 6.8% extreme.
Long-Term Outcomes
Overall, 84% of participants responded to treatment, with a change in mean YBOCS scores from 26.98 at baseline to 12.28 immediately after treatment. Acute outcomes were similar between avoidant and nonavoidant patients.
But at 12-month follow-up, even after controlling for pretreatment OCD severity, patients with more extensive avoidance at baseline had worse long-term outcomes — both more severe OCD symptoms (P = .031) and greater functional impairment (P = .002).
Across all patients, average avoidance decreased significantly immediately after the concentrated ERP treatment. Average avoidance increased somewhat at 3- and 12-month follow-up but remained significantly improved from pretreatment.
Interestingly, patients’ change in avoidance immediately post-treatment to 3 months post-treatment predicted worsening of OCD severity at 12 months. This change could potentially identify people at risk of relapse, Dr. Wheaton said.
Previous research has shown that pretreatment OCD severity, measured using the YBOCS, does not significantly predict ERP outcomes, and this study found the same.