Kabul ve Kararlılık Terapisi Perspektifinden Obsesif Kompulsif Bozuklukta Yaşantısal Kaçınma

Öz

Obsesif kompulsif bozukluk (OKB), obsesyon ve kompulsiyonlarla süregiden ve işlevselliği olumsuz yönde etkileyen, tedavi edilmediğinde kronikleşebilen psikiyatrik bir rahatsızlıktır. OKB’de ilaç tedavisi ve maruz bırakma-tepki önleme tekniklerini içeren Bilişsel Davranışçı Terapinin etkililiği kanıtlanmış görünse de tedavi bırakma oranları ve takip sonrası kalıntı belirtilerin görülmesi, araştırmacıları farklı tedavi yaklaşımlarına yöneltmiştir. Bu bağlamda ortaya çıkan üçüncü kuşak terapi yaklaşımlarından biri olan Kabul ve Kararlılık Terapisi (KKT), OKB tedavisinde yenilikçi ve etkili bir yaklaşım olarak giderek daha fazla ilgi görmektedir. KKT, temelde hayatın doğal akışı içerisinde var olan acılardan kaçınmak yerine onları kabul ederek kişinin yaşamını kendi seçtiği değerler doğrultusunda yönlendirmesini amaçlamaktadır. KKT yaklaşımı ile OKB tedavisinde, bireylerin psikolojik esneklik seviyelerini artırmaya yönelik müdahalelerle hastalığın prognozuna olumlu katkı sağlanabildiği görülmektedir. OKB hastalarında obsesyonların yarattığı kaygıdan kaçınmak için kompulsiyonlara girişmenin yanı sıra çok çeşitli yaşantısal kaçınma stratejileri izlenebilmektedir. KKT yaklaşımı ile, bu stratejilerinin azaltılarak olumsuz içsel yaşantıların kabulü yoluyla obsesyonların yarattığı kaygının giderilmesi ve kompulsiyonların ortadan kaldırılması sağlanabilmektedir. Bu derleme makalesi, OKB’de yaşantısal kaçınmayı KKT çerçevesinde ele almaktadır. Son yıllarda yayımlanan güncel çalışmalar ekseninde, KKT’nin OKB tedavisinde yaşantısal kaçınmayı nasıl hedef aldığı ve yapılan müdahalelerin OKB semptom şiddeti ve psikolojik esneklik arasındaki ilişkiye etkileri tartışılmaktadır.

Anahtar Kelimeler

• Obsesif kompulsif bozukluk
• kabul ve kararlılık terapisi
• yaşantısal kaçınma

Experiential Avoidance in Obsessive-Compulsive Disorder from the Perspective of Acceptance and Commitment Therapy

Abstract

Obsessive compulsive disorder (OCD) is a psychiatric disorder characterized by the persistence of obsessions and compulsions, which negatively impact functionality and may become chronic if left untreated. Although the efficacy of pharmacological treatment and Cognitive Behavioral Therapy (CBT) involving exposure and response prevention techniques has been proven in OCD, treatment discontinuation rates and residual symptoms following treatment have led researchers to explore different therapeutic approaches. One such approach gaining increasing interest is Acceptance and Commitment Therapy (ACT), a third-generation therapeutic model, which is proving to be an innovative and effective treatment for OCD. ACT primarily aims to guide individuals toward leading a life aligned with their chosen values, by accepting the pains that exist in the natural flow of life instead of avoiding them. In the treatment of OCD, with the ACT approach, interventions aimed at enhancing psychological flexibility have been shown to positively impact the prognosis of the disorder. In addition to engaging in compulsions to avoid the anxiety caused by obsessions, OCD patients may follow a wide variety of experiential avoidance strategies. With the ACT approach, these strategies can be reduced and the anxiety caused by obsessions and compulsions can be eliminated through the acceptance of negative internal experiences. This review article addresses experiential avoidance in OCD within the framework of ACT. Based on recent publications, the article discusses how ACT targets experiential avoidance in OCD treatment and the effects of interventions on the relationship between OCD symptom severity and psychological flexibility.

Keywords

• : obsessive-compulsive disorder
• acceptance and commitment therapy
• experiental avoidance

Kaynakça

1. Abramowitz JS (2006) The psychological treatment of obsessive-compulsive disorder. Can J Psychiatry, 51:407-416.
2. Abramowitz JS, Lackey GR, Wheaton MG (2009) Obsessive-compulsive symptoms: the contribution of obsessional beliefs and experiential avoidance. J Anxiety Disord, 23:160-166.
3. Abramowitz JS, McKay D, Taylor S (2008) Clinical Handbook of Obsessive-Compulsive Disorder and Related Problems. Baltimore, Johns Hopkins University Press.
4. Akhouri D, Hamza, Kumar S, Reyazuddin M (2023) Acceptance and commitment therapy as an add-on treatment for the management of patients with obsessive-compulsive disorder. Ind Psychiatry J, 32(Suppl 1):179-185.
5. Allen LB, Barlow DH (2009) Relationship of exposure to clinically irrelevant emotion cues and obsessive-compulsive symptoms. Behav Modif, 33:743-762.
6. American Psychiatric Association (2013) Diagnostic and Statistical Manual of Mental Disorders, 5th ed. Arlington, VA, American Psychiatric Publishing.
7. Angelakis I, Gooding P (2020) Obsessive-compulsive disorder and suicidal experiences: the role of experiential avoidance. Suicide Life Threat Behav, 50:359-371.
8. Angelakis I, Pseftogianni F (2021) Association between obsessive-compulsive and related disorders and experiential avoidance: a systematic review and meta-analysis. J Psychiatr Res, 138:228-239.

9. Arabatzoudis T, Rehm IC, Nedeljkovic M, Moulding R (2017) Emotional regulation in individual with and without trichotillomania. J Obsessive Compuls Relat Disord, 12:87–94.
10. Armstrong AB, Morrison KL, Twohig MP (2013) A preliminary investigation of acceptance and commitment therapy for adolescent obsessive–compulsive disorder. J Cogn Psychother, 27:175-190.
11. Aydın G (2017) Assessing a model of cognitive test anxiety: The role of rumination, selfforgiveness, perfectionism cognitions and cognitive defusion through the indirect effect of psychological flexibility (Doktora Tezi). Ankara, Orta Doğu Teknik Üniversitesi.
12. Bach P, Hayes SC (2002) The use of acceptance and commitment therapy to prevent the rehospitalization of psychotic patients: a randomized controlled trial. J Consult Clin Psychol, 70:1129-1139.
13. Barnes-Holmes Y, Hayes SC, Barnes-Holmes D, Roche B (2001) Relational frame theory: a post-Skinnerian account of human language and cognition. In Advances in Child Development and Behavior (Eds HW Reese, R Kail):101-138. New York, Academic Press.
14. Bennet R, Oliver JE (2019) Acceptance and Commitment Therapy. New York, Routledge.
15. Beşiroğlu L (2014) Obsesif kompulsif bozuklukta fenomenoloji: tedavi yanıtı için önemli mi? Psikiyatride Güncel, 4:221-229.
16. Blackledge JT (2003) An introduction to relational frame theory: basics and appli¬cations. Behav Anal Today, 3:421–433.
17. Blackledge JT, Hayes SC (2001). Emotion regulation in acceptance and commitment therapy. J Clin Psychol, 57:243-255.
18. Blakey SM, Reuman L, Buchholz JL, Abramowitz JS (2017) Experiential avoidance and dysfunctional beliefs in the prediction of body image disturbance in a nonclinical sample of women. Body Image, 22:72-77.
19. Bluett EJ, Homan KJ, Morrison KL, Levin ME, Twohig MP (2014) Acceptance and commitment therapy for anxiety and OCD spectrum disorders: an empirical review. J Anxiety Disord, 28:612-624.
20. Bond FW, Hayes SC, Baer RA, Carpenter KM, Guenole N, Orcutt HK et al. (2011) Preliminary psychometric properties of the Acceptance and Action Questionnaire-II: a revised measure of psychological inflexibility and experiential avoidance. Behav Ther, 42:676-688.
21. Chacin M, Chacin J, Suarez-Roca H (2019) Addicted to compulsions: a complex case study of obsessive and compulsive disorder treated with acceptance and commitment therapy (ACT) and exposure therapy (ERP). Drug Dependence and Addiction, 1:1–7.
22. Chawla N, Ostafin B (2007) Experiential avoidance as a functional dimensional approach to psychopathology: an empirical review. J Clin Psychol, 63:871-890.
23. Clark DA (2004) Cognitive-Behavioral Therapy for OCD. New York, Guilford Press.
24. Davazdahemami MH, Bayrami A, Petersen JM, Twohig MP, Bakhtiyari M, Noori M et al. (2020) Preliminary evidence of the effectiveness of acceptance and commitment therapy for death anxiety in Iranian clients diagnosed with obsessive-compulsive disorder. Bull Menninger Clin, 84(Suppl A):1-11.
25. Dehlin JP, Morrison KL, Twohig MP (2013) Acceptance and commitment therapy as a treatment for scrupulosity in obsessive compulsive disorder. Behav Modif, 37:409–430.
26. Demet MM, Deveci A, Deniz F, Taşkın EO, Şimşek E, Yurtsever F (2005) Obsesif kompulsif bozuklukta sosyodemografik özellikler ve fenomenoloji. Anadolu Psikiyatri Derg, 6:133-144.
27. Didonna F, Lanfredi M, Xodo E, Ferrari C, Rossi R, Pedrini L (2019) Mindfulness-based cognitive therapy for obsessive-compulsive disorder: a pilot study. J Psychiatr Pract, 25:156-170.
28. Dougherty DD, Rauch SL, Jenike MA (2004) Pharmacotherapy for obsessive-compulsive disorder. J Clin Psychol, 60:1195-1202.
29. Eifert G, Forsyth J (2005) Acceptance & Commitment Therapy for Anxiety Disorders: A Practitioner’s Treatment Guide to Using Mindfulness, Acceptance, and Values-Based Behavior Change Strategies. Oakland, CA, New Harbinger.
30. Eisen JL, Sibrava NJ, Boisseau CL, Mancebo MC, Stout RL, Pinto A et al. (2013) Five-year course of obsessive-compulsive disorder: predictors of remission and relapse. J Clin Psychiatry, 74:233-239.
31. Evey KJ, Steinman SA (2023) A systematic review of the use of acceptance and commitment therapy to treat adult obsessive-compulsive disorder. Behav Ther, 54:1006-1019.
32. Fineberg NA, Baldwin DS, Drummond LM, Wyatt S, Hanson J, Gopi S et al. (2018) Optimal treatment for obsessive compulsive disorder: a randomized controlled feasibility study of the clinical-effectiveness and cost-effectiveness of cognitive-behavioural therapy, selective serotonin reuptake inhibitors and their combination in the management of obsessive compulsive disorder. Int Clin Psychopharmacol, 33:334-348.
33. Fisher PL, Wells A (2005) How effective are cognitive and behavioral treatments for obsessive-compulsive disorder? A clinical significance analysis. Behav Res Ther, 43:1543-1558.
34. Fletcher L, Hayes SC (2006) Relational frame theory, acceptance and commitment therapy, and a functional analytic definition of mindfulness. J Ration Emot Cogn Behav Ther, 23:315–336.
35. Freud S (1926) Ketlemeler, semptomlar ve kaygı. In Psikopatoloji Üzerine (Çeviri Ed. S Budak):229-329. Ankara, Öteki yayınları.
36. Gaudiano BA, Herbert JD (2006) Acute treatment of inpatients with psychotic symptoms using acceptance and commitment therapy: pilot results. Behav Res Ther, 44:415-437.
37. Gururaj GP, Math SB, Reddy JY, Chandrashekar CR (2008) Family burden, quality of life and disability in obsessive compulsive disorder: an Indian perspective. J Postgrad Med, 54:91-97.
38. Hayes SC, Wilson KG, Gifford EV, Follette VM, Strosahl K (1996) Experiential avoidance and behavioral disorders: a functional dimensional approach to diagnosis and treatment. J Consult Clin Psychol, 64:1152–1168.
39. Hayes SC (2004) Acceptance and commitment therapy, relational frame theory, and the third wave of behavioral and cognitive therapies. Behav Ther, 35:639– 665.
40. Hayes SC, Luoma JB, Bond FW, Masuda A, Lillis J (2006) Acceptance and commitment therapy: model, processes and outcomes. Behav Res Ther, 44:1-25.
41. Hayes SC, Pistorello J, Levin M (2012) Acceptance and commitment therapy as a unified model of behavior change. Couns Psychol, 40:976-1002.
42. Hayes SC, Strosahl KD, Wilson KG (2011) Acceptance and Commitment Therapy: The Process and Practice of Mindful Change. New York, Guilford Press.
43. Hayes SC, Strosahl KD, Wilson KG (2012) Acceptance and Commitment Therapy: The Process and Practice of Mindful Change, 2nd ed. New York, Guilford Press.
44. Hofmann SG, Smits JA (2008) Cognitive-behavioral therapy for adult anxiety disorders: a meta-analysis of randomized placebo-controlled trials. J Clin Psychiatry, 69:621-632.
45. Kashdan TB, Barrios V, Forsyth JP, Steger MF (2006) Experiential avoidance as a generalized psychological vulnerability: comparisons with coping and emotion regulation strategies. Behav Res Ther. 44:1301-1320.
46. Leeuwerik T, Cavanagh K, Strauss C (2019) Patient adherence to cognitive behavioural therapy for obsessive-compulsive disorder: a systematic review and meta-analysis. J Anxiety Disord, 68:e102135.
47. Manjula M, Sudhir PM (2019) New-wave behavioral therapies in obsessive-compulsive disorder: moving toward integrated behavioral therapies. Indian J Psychiatry, 61(Suppl 1):104-113.
48. Manlick CF, Cochran SV, Koon J (2013) Acceptance and commitment therapy for eating disorders: rationale and literature review. J Contemp Psychother, 43:115-122.
49. Manos RC, Cahill SP, Wetterneck CT, Conelea CA, Ross AR, Riemann BC (2010) The impact of experiential avoidance and obsessive beliefs on obsessive-compulsive symptoms in a severe clinical sample. J Anxiety Disord, 24:700-708.
50. Marx BP, Sloan DM (2005) Peritraumatic dissociation and experiential avoidance as predictors of posttraumatic stress symptomatology. Behav Res Ther, 43:569-583.
51. McKay D, Sookman D, Neziroglu F, Wilhelm S, Stein DJ, Kyrios M et al. (2015) Efficacy of cognitive-behavioral therapy for obsessive-compulsive disorder. Psychiatry Res, 225:236-246.
52. Morrison J (2016) DSM-5’i Kolaylaştıran Klinisyenler için Tanı Rehberi (Çeviri Ed. HU Kural). Ankara, Nobel Akademik Yayıncılık.
53. MOWRER OH (1951) Two-factor learning theory: summary and comment. Psychol Rev, 58:350-354.
54. Norton PJ, Price EC (2007) A meta-analytic review of adult cognitive-behavioral treatment outcome across the anxiety disorders. J Nerv Ment Dis, 195:521-531.
55. Obsessive Compulsive Cognitions Working Group (1997) Cognitive assessment of obsessive-compulsive disorder. Behav Res Ther, 35:667-681.
56. Obsessive Compulsive Cognitions Working Group (2001) Development and initial validation of the Obsessional Beliefs Questionnaire and the Interpretation of Intrusions Inventory. Behav Res Ther, 39:987−1006.
57. Okasha A, Saad A, Khalil AH, el Dawla AS, Yehia N (1994) Phenomenology of obsessive-compulsive disorder: a transcultural study. Compr Psychiatry, 35:191-197.
58. Ong CW, Clyde JW, Bluett EJ, Levin ME, Twohig MP (2016) Dropout rates in exposure with response prevention for obsessive-compulsive disorder: what do the data really say? J Anxiety Disord, 40:8-17.
59. Osland S, Arnold PD, Pringsheim T (2018) The prevalence of diagnosed obsessive compulsive disorder and associated comorbidities: a population-based Canadian study. Psychiatry Res, 268:137-142.
60. Öst LG, Havnen A, Hansen B, Kvale G (2015) Cognitive behavioral treatments of obsessive-compulsive disorder: a systematic review and meta-analysis of studies published 1993-2014. Clin Psychol Rev, 40:156-169.
61. Philip J, Cherian V (2021) Acceptance and commitment therapy in the treatment of obsessive-compulsive disorder: A systematic review. J Obsessive Compuls Relat Disord, 28:1-9.
62. Pittenger C, Bloch MH (2014) Pharmacological treatment of obsessive-compulsive disorder. Psychiatr Clin North Am, 37:375-391.
63. Porgalı-Zayman E (2016) DSM-5'te obsesif kompulsif bozukluk. Çukurova Üniversitesi Tıp Fakültesi Dergisi, 41:360-362.
64. Rachman S (1997) A cognitive theory of obsessions. Behav Res Ther, 35:793-802.
65. Rachman S (1998) A cognitive theory of obsessions: elaborations. Behav Res Ther, 36:385-401.
66. Rachman S, De Silva P (2009) Obsessive-Compulsive Disorder: The Facts, 4th ed. New York, Oxford University Press.
67. Roemer L, Salters K, Raffa S, Orsillo SM (2005) Fear and avoidance of internal experiences in GAD: preliminary tests of a conceptual model. Cognit Ther Res, 29:71–88.
68. Rohani F, Rasouli-Azad M, Twohig MP, Ghoreishi FS, Lee EB, Akbari H (2018) Preliminary test of group acceptance and commitment therapy on obsessive-compulsive disorder for patients on optimal dose of selective serotonin reuptake inhibitors. J Obsessive Compuls Relat Disord, 16:8–13.
69. Ruiz FJ (2010) A review of acceptance and commitment therapy (ACT) empirical evidence: correlational, experimental psychopathology, component and outcome studies. Rev Int Psicol Ter Psicol, 10:125–162.
70. Ruscio AM, Stein DJ, Chiu WT, Kessler RC (2010) The epidemiology of obsessive-compulsive disorder in the National Comorbidity Survey Replication. Mol Psychiatry, 15:53-63.
71. Russ H, Hayes M (2007) ACT Made Simple: An Easy-to-read Primer on Acceptance and Commitment Therapy. Oakland, CA, New Harbinger.
72. Salkovskis PM. (1999) Understanding and treating obsessive-compulsive disorder. Behav Res Ther, 37(Suppl 1):S29-52.
73. Sayar K, Uğurad IK, Acar B (1999) Obsesif kompulsif bozuklukta fenomenoloji. Klinik Psikofarmakol Bulteni, 9:142-147.
74. Stockton D, Kellett S, Berrios R, Sirois F, Wilkinson N, Miles G (2019) 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.
75. Thompson BL, Twohig MP, Luoma JB (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. Behav Ther, 52:286-297.
76. Tezcan AE, Ülkeroğlu F, Kuloğlu M, Atmaca M (1991) Elazığ bölgesindeki obsesif kompulsif bozukluklu hastalarda psikososyal özellikler. Dusunen Adam, 10:22-27.
77. Tolin DF (2010) Is cognitive-behavioral therapy more effective than other therapies? a meta-analytic review. Clin Psychol Rev, 30:710-720.
78. Topçuoğlu V (2003) Obsesif kompulsif bozuklukta psikanalitik görüşler. Turkish J Clin Psy, 6:46-50.
79. Tükel MR (2009) Anksiyete bozuklukları. In Psikiyatri (Eds Baral-Kulaksızoğlu MI, Tükel MR, Üçok VA, Yargıç Lİ, Olcay):57-89. İstanbul, İstanbul Üniversitesi Basın ve Yayınevi.
80. Twohig MP, Hayes SC, Masuda A (2006). Increasing willingness to experience obsessions: acceptance and commitment therapy as a treatment for obsessive-compulsive disorder. Behav Ther, 37:3–13.
81. Twohig MP, Whittal ML, Cox JM, Gunter R (2010). An initial investigation into the processes of change in ACT, CT, and ERP for OCD. Int J Behav Consult Ther, 6:67–83.
82. Vakili Y, Gharaee B, Habibi M (2015). Acceptance and commitment therapy, selective serotonin reuptake inhibitors and their combination in the improvement of obsessive-compulsive symptoms and experiential avoidance in patients with obsessive-compulsive disorder. Iran J Psychiatry Behav Sci, 9:845.
83. Wersebe H, Lieb R, Meyer AH, Hofer P, Gloster AT (2018) The link between stress, well-being, and psychological flexibility during an acceptance and commitment therapy self-help intervention. Int J Clin Health Psychol, 18:60-68.
84. Wetterneck CT, Steinberg DS, Hart J (2014) Experiential avoidance in symptom dimensions of OCD. Bull Menninger Clin, 78:253-269.
85. Xiong A, Lai X, Wu S, Yuan X, Tang J, Chen J et al. (2021) Relationship between cognitive fusion, experiential avoidance, and obsessive-compulsive symptoms in patients with obsessive-compulsive disorder. Front Psychol, 12:e655154.
86. Yavuz KF (2015). Kabul ve kararlılık terapisi (ACT): genel bir bakış. Turkiye Klinikleri J Psychiatry-Special Topics, 8:21-27.
87. Yektaş Ç (2020). Kabul ve kararlılık terapisi (ACT). In Çocuk ve Ergen Psikiyatrisi Güncel Yaklaşımlar ve Temel Kavramlar Cilt II (Eds. ES Ercan, Ö Bilaç, I Perçinel-Yazıcı, MÖ Kütük, AG Kılıçoğlu, FS Durak):1231–1240. Ankara, Akademisyen Kitabevi.
88. Zettle RD (2005) The evolution of a contextual approach to therapy: From comprehensive distancing to ACT. Int J Behav Consult Ther, 1:77-79.