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American Journal of Applied Psychology. 2014, 2(5), 114-122
DOI: 10.12691/ajap-2-5-3
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“Tackling Trauma to Overcome OCD Resistance” (The TTOOR Florence trial) Efficacy of EMDR plus CBT versus CBT Alone for Inpatients with Resistant Obsessive Compulsive Disorder. Protocol for a Randomized Comparative Outcome Trial

Andrea Pozza1, 2, , Gian Paolo Mazzoni3, 4, Maria Tiziana Neri3, Rossano Bisciglia2, 3, Carmelo La Mela5, 6, Isabel Fernandez7 and Davide Dèttore2, 8

1Department of Experimental and Clinical Medicine, University of Florence, Italy

2Miller Institute for Behavioural and Cognitive Psychotherapy, Genoa, Italy

3Unit for the Treatment of Resistant OCD, Poggio Sereno Clinic, Fiesole, Florence, Italy

4“Studi Cognitivi” Cognitive Psychotherapy and Research Center, Florence, Italy;“Studi Cognitivi” Postgraduate Program on Cognitive Psychotherapy, Florence, Italy

5“Studi Cognitivi” Cognitive Psychotherapy and Research Center, Florence, Italy

6“Studi Cognitivi” Postgraduate Program on Cognitive Psychotherapy, Florence, Italy

7Psychotraumatology Research Center, Milan, Italy

8Department of Health Sciences, University of Florence, Italy

Pub. Date: November 11, 2014

Cite this paper:
Andrea Pozza, Gian Paolo Mazzoni, Maria Tiziana Neri, Rossano Bisciglia, Carmelo La Mela, Isabel Fernandez and Davide Dèttore. “Tackling Trauma to Overcome OCD Resistance” (The TTOOR Florence trial) Efficacy of EMDR plus CBT versus CBT Alone for Inpatients with Resistant Obsessive Compulsive Disorder. Protocol for a Randomized Comparative Outcome Trial. American Journal of Applied Psychology. 2014; 2(5):114-122. doi: 10.12691/ajap-2-5-3


Researchers and clinicians have recently highlighted the usefulness of integrating additional therapeutic approaches into standard intensive cognitive behavioural treatments (CBT) with the aim to improve clinical outcomes for patients with severe resistant OCD. To date, there is still a limited amount of knowledge on the effectiveness of third-wave CBT techniques for OCD, despite such techniques seemed to be effective for a wide range of mental disorders. The Eyes Movement Desensitization Reprocessing (EMDR) is a treatment approach, based on the Adaptive Information Processing model, which conceptualizes psychological disorders as manifestations of unresolved traumatic or distressing memories. EMDR has been conceived as an integrative approach, aimed at facilitating resolution of memories, desensitizing stimuli that trigger present distress as a consequence of second-order conditioning, and incorporating adaptive attitudes and behaviours for better functioning. The present paper describes a research protocol for a randomized comparative outcome trial on inpatients with treatment-resistant OCD in a tertiary inpatient clinic in Italy. The study will aim to: (a) examine the effectiveness of EMDR with intensive brief CBT (EMDR+CBT) compared to intensive brief CBT alone on primary outcomes (OCD symptoms, obsessive beliefs, depression, and anxiety) at immediate post-treatment, one-, six-month-, and one-year-follow-up; (b) compare feasibility and acceptability of EMDR+CBT protocol versus intensive brief CBT alone (in terms of attrition and treatment satisfaction); (c) examine the effectiveness of EMDR+CBT versus intensive brief CBT alone on secondary outcomes (disgust propensity and sensitivity, emotion dysregulation, and dissociative experiences and symptoms). Inclusion/exclusion criteria of participants, outcomes, time scheduling, rationale, and therapeutic components of the treatments will be presented.

Obsessive Compulsive Disorder Eyes Movement Desensitization Reprocessing cognitive behavioural therapy inpatients randomized controlled trial

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[1]  Sánchez-Meca, J., Rosa-Alcázar, A. I., Iniesta-Sepúlveda, M., & Rosa-Alcázar, Á. (2014). Differential efficacy of cognitive-behavioral therapy and pharmacological treatments for pediatric obsessive–compulsive disorder: A meta-analysis. Journal of Anxiety Disorders, 28, 31-44.
[2]  Fisher, P. L., & Wells, A. (2005). How effective are cognitive and behavioral treatments for obsessive–compulsive disorder? A clinical significance analysis. Behaviour Research and Therapy, 43, 1543-1558.
[3]  Taylor, S., Abramowitz, J. S., & McKay, D. (2012). Non-adherence and non-response in the treatment of anxiety disorders. Journal of Anxiety Disorders, 26, 583-589.
[4]  Pollard, C.A. (2007). Treatment Readiness, Ambivalence, and Resistance. In M.M. Anthony, C. Purdon, & L. Summerfeldt (eds.), Psychological treatment of OCD: fundamentals and beyond. Washington DC: APA books.
[5]  Stewart, S. E., Stack, D. E., Farrell, C., Pauls, D. L., & Jenike, M. A. (2005). Effectiveness of intensive residential treatment (IRT) for severe, refractory obsessive-compulsive disorder. Journal of psychiatric research, 39(6), 603-609.
[6]  Pinto, A., Pinto, A. M., Neziroglu, F., & Yaryura-Tobias, J. A. (2007). Motivation to change as a predictor of treatment response in obsessive compulsive disorder. Annals of Clinical Psychiatry, 19, 83-87.
[7]  Sookman, D., & Steketee, G. (2010). Specialized cognitive behaviour therapy for treatment resistant obsessive compulsive disorder. In D. Sookman, & R. L. Leahy (Eds.). Treatment resistant anxiety disorders. Resolving impasses to symptom remission (pp. 31-74). New York, London: Routledge, Taylor & Francis Group.
[8]  Vogel, P. A., Hansen, B., Stiles, T. C., & Götestam, K. G. (2006). Treatment motivation, treatment expectancy, and helping alliance as predictors of outcome in cognitive behavioral treatment of OCD. Journal of Behavior Therapy and Experimental Psychiatry, 37, 247-255.
[9]  Sookman, D., & Pinard, G. (1999). Integrative cognitive therapy for obsessive-compulsive disorder: A focus on multiple schemas. Cognitive and Behavioral Practice, 6, 351-362.
[10]  Sookman, D., & Pinard, G. (2007). Specialized Cognitive Behavior Therapy for Resistant Obsessive-Compulsive Disorder: Elaboration of a Schema-Based Model. In Riso, Lawrence P., du Toit, Pieter L., Stein, Dan J., Young, Jeffrey E. (eds.) Cognitive schemas and core beliefs in psychological problems: A scientist-practitioner guide (pp. 93-109). Washington, DC, US: American Psychological Association,
[11]  Shapiro, F., & Forrest, M. S. (2001). EMDR: Eye movement desensitization and reprocessing. New York: Guilford.
[12]  Shapiro, F., & Solomon, R. M. (1995). Eye movement desensitization and reprocessing. Chichester: John Wiley & Sons.
[13]  Neborsky, R., & Solomon, M. F. (2001). Attachment bonds and intimacy: Can the primary imprint of love change. Short-term therapy for long-term change, 155-185.
[14]  Fensterheim, H. (1996). Eye movement desensitization and reprocessing with complex personality pathology: An integrative therapy. Journal of Psychotherapy Integration, 6, 27-38.
[15]  Bohart, A. C., & Greenberg, L. (2002). EMDR and experiential psychotherapy. Experts of diverse orientations explore the paradigm prism (pp. 239-261). Washington, DC, US: American Psychological Association,
[16]  Shapiro, F. (2001). The challenges of treatment evolution and integration. American Journal of Clinical Hypnosis, 43(3-4), 183-186.
[17]  Bisson, J., & Andrew, M. (2007). Psychological Treatment of Post-traumatic Stress Disorder (PTSD) (Review). Chichester: Wiley & Sons.
[18]  Zabukovec, J., Lazrove, S., & Shapiro, F. (2000). Self-healing aspects of EMDR: The therapeutic change process and perspectives of integrated psychotherapies. Journal of Psychotherapy Integration, 10, 189-206.
[19]  Marr, J. (2012). EMDR Treatment of obsessive-compulsive disorder: Preliminary research. Journal of EMDR Practice and Research, 6, 2-15.
[20]  Baer, H., Kim, D., & Ahn, J. (2006). A case series of post-traumatic obsessive compulsive disorder: a six month follow-up evaluation. Journal of Korean Neuropsychiatric Association, 45, 476-480.
[21]  Parnell, L. (2007). A therapist’s guide to EMDR. New York: Norton & Company.
[22]  Böhm, K., & Voderholzer, U. (2010). Use of EMDR in the treatment of obsessive-compulsive disorders: A case series. Verhaltenstherapie, 20, 175-181.
[23]  Goodman, W. K., Price, L. H., Rasmussen, S. A., Mazure, C., Fleischmann, R. L., Hill, C. L., Heninger, G. R., & Charney, D. S. (1989). The Yale-Brown obsessive–compulsive scale, I: development, use and reliability. Archives of General Psychiatry, 40, 1006-1011.
[24]  Nazari, H., Momeni, N., Jariani, M., & Tarrahi, M. J. (2011). Comparison of eye movement desensitization and reprocessing with citalopram in treatment of obsessive-compulsive disorder. International journal of psychiatry in clinical practice, 15, 270-274.
[25]  Cisler, J. M., Olatunji, B. O., & Lohr, J. M. (2009). Disgust sensitivity and emotion regulation potentiate the effect of disgust propensity on spider fear, blood-injection-injury fear, and contamination fear. Journal of behavior therapy and experimental psychiatry, 40(2), 219-229.
[26]  David, B., Olatunji, B. O., Armstrong, T., Ciesielski, B. G., Bondy, C. L., & Broman-Fulks, J. (2009). Incremental specificity of disgust sensitivity in the prediction of obsessive-compulsive disorder symptoms: Cross-sectional and prospective approaches. Journal of behavior therapy and experimental psychiatry, 40(4), 533-543.
[27]  Olatunji, B. O., Cisler, J., McKay, D., & Phillips, M. L. (2010). Is disgust associated with psychopathology? Emerging research in the anxiety disorders.Psychiatry research, 175(1), 1-10.
[28]  Tolin, D. F., Woods, C. M., & Abramowitz, J. S. (2006). Disgust sensitivity and obsessive–compulsive symptoms in a non-clinical sample. Journal of behavior therapy and experimental psychiatry, 37(1), 30-40.
[29]  McKay, D. (2006). Treating disgust reactions in contamination-based obsessive–compulsive disorder. Journal of Behavior Therapy and Experimental Psychiatry, 37(1), 53-59.
[30]  Storch, E. A., Jones, A. M., Lack, C. W., Ale, C. M., Sulkowski, M. L., Lewin, A. B., & Murphy, T. K. (2012). Rage attacks in pediatric obsessive-compulsive disorder: phenomenology and clinical correlates. Journal of the American Academy of Child & Adolescent Psychiatry, 51(6), 582-592.
[31]  Rufer, M., Fricke, S., Held, D., Cremer, J., & Hand, I. (2006). Dissociation and symptom dimensions of obsessive–compulsive disorder. European Archives of Psychiatry and Clinical Neuroscience, 256, 146-150.
[32]  Semiz, U. B., Inanc, L., & Bezgin, C. H. (2013). Are trauma and dissociation related to treatment resistance in patients with obsessive–compulsive disorder?. Social Psychiatry and Psychiatric Epidemiology, 1-10.
[33]  Lochner, C., Seedat, S., Hemmings, S. M., Kinnear, C. J., Corfield, V. A., Niehaus, D. J., ... & Stein, D. J. (2004). Dissociative experiences in obsessive-compulsive disorder and trichotillomania: clinical and genetic findings.Comprehensive Psychiatry, 45, 384-391.
[34]  Rufer, M., Held, D., Cremer, J., Fricke, S., Moritz, S., Peter, H., & Hand, I. (2005). Dissociation as a predictor of cognitive behavior therapy outcome in patients with obsessive-compulsive disorder. Psychotherapy and Psychosomatics, 75, 40-46.
[35]  Chan, A. W., Tetzlaff, J. M., Altman, D. G., Laupacis, A., Gøtzsche, P. C., Krleža-Jerić, K., & Moher, D. (2013). SPIRIT 2013 statement: defining standard protocol items for clinical trials. Annals of Internal Medicine, 158, 200-207.
[36]  Rasmussen, S. A., & Eisen, J. L. (1997). Treatment strategies for chronic and refractory obsessive compulsive disorder. Journal of Clinical Psychiatry, 58, 9-13.
[37]  American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: American Psychiatric Association.
[38]  First, M. B., Spitzer, R. L., Gibbon, M., & Williams, J. B. (1995). Structured Clinical Interview for DSM-IV Axis I disorders-Patient edition (SCID-I/P, version 2.0). New York: Biometrics Research Department.
[39]  Mazzi, F., Morosini, P., De Girolamo, G., Lussetti, M., & Guaraldi, G. P. (2000). SCID-I—Structured Clinical Interview for DSM-IV Axis I Disorders (Italian Edition). Giunti OS: Firenze.
[40]  Cohen, J. (1992). Statistical power analysis. Current directions in psychological science, 1(3), 98-101.
[41]  First, M. B., Gibbon, M., Spitzer, R. L., Williams, J. B. W., & Benjamin, L. S. (1997). Structured Clinical Interview for DSM-IV Axis II personality disorders (SCID-II). Washington, DC: American Psychiatric Press.
[42]  Maffei, C., Fossati, A., Agostoni, I., Barraco, A., Bagnato, M., Donati, D., Namia, C., Novella, L., & Petrachi, M. (1997). Interrater Reliability and Internal Consistency of the Structured Clinical Interview for DSM-IV Axis II Personality Disorders (SCID-II), Version 2.0. Journal of Personality Disorders, 11, 279-284.
[43]  Abramowitz, J. S., Deacon, B. J., Olatunji, B. O., Wheaton, M. G., Berman, N. C., Losardo, D., et al. (2010). Assessment of obsessive-compulsive symptom dimensions: development and evaluation of the Dimensional Obsessive-Compulsive Scale. Psychological Assessment, 22, 180–198.
[44]  Melli, G., Chiorri, C., Bulli, F., Carraresi, C., Stopani, E., & Abramowitz, J. (2014). Factor Congruence and Psychometric Properties of the Italian Version of the Dimensional Obsessive-Compulsive Scale (DOCS) Across Non-Clinical and Clinical Samples. Journal of Psychopathology and Behavioral Assessment, 1-11.
[45]  Beck, A.T., Steer, R.A., & Brown, G.K. (1996). Beck Depression Inventory-Second Edition Manual. San Antonio, TX: The Psychological Corporation Harcourt Brace & Company.
[46]  Ghisi, M., Flebus, G. B., Montano, A., Sanavio, E., & Sica, C. (2006). Beck Depression Inventory-Second Edition. Adattamento italiano: Manuale. Firenze: Organizzazioni Speciali.
[47]  Beck, A. T., Epstein, N., Brown, G., & Steer, R. A. (1988). An inventory for measuring clinical anxiety: psychometric properties. Journal of consulting and clinical psychology, 56(6), 893.
[48]  Sica, C., Coradeschi, D., Ghisi, M., & Sanavio, E. (2006). Beck anxiety inventory. Adattamento italiano: Manuale. Firenze: Organizzazioni Speciali. Cerca con Google.
[49]  Obsessive Compulsive Cognitions Working Group. (2005). Psychometricvalidation of the Obsessive Belief Questionnaire and Interpreta-tion of Intrusions Inventory–part 2: factor analyses and testing ofa brief version. Behaviour Research and Therapy, 43(11), 1527-1542.
[50]  Dorz, S., Novara, C., Pastore, M., Sica, C., & Sanavio, E. (2009). Presentazione della versione italiana dell’obsessive beliefs questionnaire (OBQ): Struttura fattoriale e analisi di attendibilità (parte 1). Psicoterapia Cognitiva e Comportamentale, 15, 139–170.
[51]  van Overveld, M., de Jong, P. J., Peters, M. L., Cavanagh, K., & Davey, G. C. L. (2006). Disgust propensity and disgust sensitivity: separate constructs that are differentially related to specific fears. Personality and Individual Differences, 41, 1241-1252.
[52]  Olatunji, B. O., Cisler, J., Deacon, B. J., Connolly, K., & Lohr, J. (2007). The Disgust Propensity and Sensitivity Scale-Revised: Psychometric properties and specificity in relation to anxiety disorder symptoms. Journal of Anxiety Disorders, 21, 918-930.
[53]  Gratz, K. L., & Roemer, L. (2004). Multidimensional assessment of emotion regulation and dysregulation: Development, factor structure, and initial validation of the difficulties in emotion regulation scale. Journal of Psychopathology and Behavioral Assessment, 26(1), 41-54.
[54]  Sighinolfi, C., Pala, A. N., Chiri, L. R., Marchetti, I., & Sica, C. (2010). Difficulties in Emotion Regulation Scale (DERS): Traduzione e adattamento Italiano. Psicoterapia cognitiva e comportamentale, 16, 141-170.
[55]  Bernstein, E. M., & Putnam, F. W. (1986). Development, reliability and validity of a dissociation scale. Journal of Nervous and Mental Disease, 174, 727-735.
[56]  Schimmenti A., Craparo G. Caretti V. (np), Reliability and validity of the Revised Dissociative Experience Scale (DES-II) in an Italian sample. Faculty of Human and Social Science, Kore University of Enna.
[57]  Moher, D., Schulz, K. F., & Altman, D. G. (2001). The CONSORT statement: revised recommendations for improving the quality of reports of parallel group randomized trials. BMC Medical Research Methodology, 1, 2.
[58]  Kozak, M. J., & Foa, E. B. (1997). Mastery of obsessive-compulsive disorder: A cognitive-behavioural approach. San Antonio, TX: The Psychological Corporation Hartcourt Brace Company.
[59]  Newell, D. J. (1992). Intention-to-treat analysis: implications for quantitative and qualitative research. International Journal of Epidemiology, 21, 837-841.
[60]  Hedges, L. V. (1982). Estimation of effect size from a series of independent experiments. Psychological Bulletin, 92, 490-499.
[61]  Jacobson, N. S., & Truax, P. (1991). Clinical significance: a statistical approach to defining meaningful change in psychotherapy research. Journal of Consulting and Clinical Psychology, 59, 12-19.