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March 13, 2008 (Savannah, Georgia) — In an exploratory study of 37 inpatients treated for obsessive-compulsive disorder (OCD) with a cognitive behavioral therapy (CBT) that is largely focused on exposure and response prevention, improvement in anger expression predicted decreased OCD severity and depression.
These findings, from a study of patients treated at the Menninger Clinic OCD Program, which is affiliated with Baylor College of Medicine, in Houston, Texas, were presented as a poster here at the Anxiety Disorders Association of America 28th Annual Meeting.

The results suggest that during the exposure and response prevention treatment for OCD, the patients experienced strong negative emotions and constructed more adaptive responses to them, the study authors write.

"Through exposure response prevention . . . without targeting anger symptoms directly, anger levels [especially anger suppression], reduced with treatment," John Hart, the poster's lead author, told Medscape Psychiatry.

This fits with the speculation that people with OCD suppress thoughts and strong emotions, and through exposure therapy — in which they experience strong emotions such as anxiety and anger — they learn more adaptive and better ways to cope with negative emotions, he added. This change occurred even though the CBT did not specifically target these symptoms, he noted.

Previous research has suggested that OCD symptoms might be associated with anger levels. A recent study reported that individuals with checking compulsions had significantly higher scores in measures of trait anger (a personality disposition to perceive situations as annoying), which might be due to frustration related to OCD symptoms (Radomsky AS et al. Behav Res Ther. 2007;45:2712-2725).

The current study aimed to examine anger in OCD patients, before and after an intensive CBT treatment program, and see how anger was related to OCD intensity and depression.

The researchers hypothesized that scores of measures of trait anger and anger expression would be significantly lower following treatment.

The study subjects comprised 37 adults (19 men and 18 women) with an average age of 33 ± 11 years who participated in an in-patient OCD treatment program during an average clinic stay of 6.8 weeks.
The participants completed various assessments at admission and discharge, including the State Trait Anger Expression Inventory-2 (STAXI-2), a 57-item self-report inventory that measures experience, expression, and control of anger.

For this study, the researchers looked at results from 2 STAXI-2 subscales:
The Anger Expression Index-In (AX-I), a measure of the tendency to suppress angry feelings and experiences.
The Anger Expression Index (AX Index), a measure of anger experience, which can be either expressed or suppressed anger.

The Yale-Brown Obsessive Compulsive Scale (Y-BOCS) was used to determine OCD severity, and the Beck Depression Inventory (BDI) was used to assess depression symptoms.
OCD severity, depression, and anger-expression scores improved with treatment.

Outcomes Following Intensive CBT for OCD Measure n Admission Mean ± SD Discharge Mean ± SD P
Y-BOCS 37 27.0 ± 5.0 19.0 ± 7.2 < .001
BDI 31 23.2 ± 9.0 14.1 ± 9.5 < .001
AX-I 37 57.7 ± 11.6 55.4 ± 9.2 .129
AX Index 37 56.1 ± 8.7 51.4 ± 8.7 < .001
Y-BOCS = Yale-Brown Obsessive Compulsive Scale
BDI = Beck Depression Inventory
AX-I = Anger Expression Index-In
AX Index = Anger Expression Index
CBT = cognitive behavioral therapy
OCD = obsessive-compulsive disorder

Regression analysis showed that changes in anger (AX-I and AX Index) scores explained 32.6% of the change in depression scores and 18.2% of the change in OCD-severity scores.

"I think it is interesting that the anger levels actually predicted the depression and the OCD severity, as opposed to the other way around," said Dr. Hart. "Further statistical analysis will show that, hopefully, people experiencing negative emotion more adaptively is actually what is improving the Y-BOCS and the anger-expression scores."


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