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 Table of Contents    
Year : 2019  |  Volume : 61  |  Issue : 7  |  Page : 104-113
New-wave behavioral therapies in obsessive-compulsive disorder: Moving toward integrated behavioral therapies

Department of Clinical Psychology, National Institute of Mental Health and Neuro Sciences, Bengaluru, Karnataka, India

Click here for correspondence address and email

Date of Web Publication9-Jan-2019


New-wave behavioral therapies in obsessive-compulsive disorders (OCDs) comprise of third-wave therapies and newer cognitive therapies (CTs). This review covers outcome studies published in English until December 2017. A total of forty articles on mindfulness-based CT, metacognitive therapy, acceptance and commitment therapy, and danger ideation reduction therapy in the form of single-case studies, case series, open-label trials, two-group comparison studies, and randomized controlled studies were included. Results show that studies on these therapies are limited in number. Methodological limitations including lack of active control groups, randomized controlled trials, small sample sizes, and short follow-up periods were also noted. However, the available literature demonstrates the feasibility and utility of these therapies in addressing the issues unresolved by exposure and response prevention (ERP) and cognitive behavior therapy (CBT). These therapies were often combined with traditional ERP and CBT based on the profile and response of the client; hence, it is unclear whether they can be used as standalone therapies in the larger segment of the OCD population. Supplementary use of these strategies alongside established therapies could provide better utilization of resources. In view of the need for such integration, further research is warranted. The use of sound methodologies and establishing the mechanism of action of these therapies would assist in choosing the techniques for integration.

Keywords: Cognitive therapies, integration, obsessive-compulsive disorder, third-wave therapies

How to cite this article:
Manjula M, Sudhir PM. New-wave behavioral therapies in obsessive-compulsive disorder: Moving toward integrated behavioral therapies. Indian J Psychiatry 2019;61, Suppl S1:104-13

How to cite this URL:
Manjula M, Sudhir PM. New-wave behavioral therapies in obsessive-compulsive disorder: Moving toward integrated behavioral therapies. Indian J Psychiatry [serial online] 2019 [cited 2021 Jan 15];61, Suppl S1:104-13. Available from:

   Introduction Top

Exposure and response prevention (ERP) remains the first-line intervention among the empirically advocated, nonpharmacological treatments for obsessive-compulsive (OC) disorder (OCD).[1],[2],[3] Cognitive interventions in combination with behavioral techniques are equally effective, and more than half of the participants have been reported to respond to cognitive behavior therapy (CBT).[3],[4],[5],[6] Cognitive therapy (CT), although not superior to ERP, may be more effective in a subset of patients where ERP is less effective (e.g., compulsive hoarders, primary obsessive slowness, and people with pure obsessions without compulsions and poor insight OCD).[7]

CBTs in OCD have gone through periodic changes which can be charted along three broad waves in therapy. The first wave is that of behavioral therapy, which is largely based on respondent and operant learning theories, derived from laboratory research. Meyer[8] further refined exposure therapy by including repeated exposures without permitting any neutralizing behaviors called ERP, based on the learning mechanism of habituation and extinction of anxiety.[9]

Second-wave therapies include CTs in which anxiety is conceptualized as a result of faulty appraisal of obsessional triggers through cognitive processes such as thought–action fusion (TAF), inflated sense of responsibility, and catastrophic misinterpretation. The anxiety/distress is maintained by specific unhealthy mechanisms employed to reduce distress, such as thought suppression, thought control, and threat monitoring and involving in motor rituals/neutralizing behaviors. Modifying dysfunctional cognitions by challenging and restructuring, using cognitive and behavioral strategies, is central to CT.[10],[11]

Third-wave therapies that came into practice aimed to address some of the limitations of CTs such as CBT not being acceptable to all patients, difficulties involved with ERP such as high dropout and treatment refusal rates (25%), partial treatment responses (50%–60% recovery), and nonresponse (at least 35% improvement). Those who responded continued to have persistent residual symptoms, and about 3%–12% relapsed. ERP has doubtful efficacy in pure obsessions without overt compulsions, hoarding, and those with poor motivation and noncompliance.[7],[12],[13]

Third-wave therapies largely include concepts such as mindfulness, emotions, acceptance, relationships, values, goals, and metacognition. Here, the focus is on modifying the relationship one has with one's inner experiences (thoughts and emotions) and not the content of that experience. Distancing oneself from the thoughts without attaching too much importance, mindful awareness, acceptance of the distress, addressing experiential avoidance, and developing psychological flexibility are the important components of these therapies.[14],[15] The assumptions of third-wave therapies are as follows: psychological pain and distress are an inevitable part of life and they cannot be completely avoided or eliminated. Efforts to control, minimize, or avoid discomfort can result in temporary relief, and those efforts are negatively reinforced. Active acceptance of psychological discomfort (problems in the first- and second-generation terms) will reduce the distress. Thus, changing the way people respond to the painful aspects of their thoughts, memories, feelings, and physical sensations will help them in doing what they care about.[16]

Only a few third-wave therapies have been tried in OCD. In addition to the third-wave therapies, newer CTs such as metacognitive therapy (MCT) and danger ideation reduction therapy have also been tried in OCD. Thus, the new wave in OCD therapy includes some of the third-wave therapies as well as newer CTs.

The current review is an attempt to provide an overview of the third-wave and newer CTs, the efficacy of which has been examined in OCD. The therapeutic interventions covered here include mindfulness-based CTs (MBCTs), acceptance and commitment therapy (ACT), MCT, and danger ideation reduction therapy (DIRT).

   Methods Top

The present review includes all published outcome studies in English until December 2017. New-wave therapies in OCD have only been recently examined, limiting the total number of studies in this area. The search engines used included EBSCOhost, Karger, PsychINFO, Medline, Google search, and Google Scholar. The search terms used were “Third wave behaviour therapies in OCD,” “New wave therapies in OCD,” “Metacognitive therapy in OCD,” “Mindfulness in OCD,” “Danger ideation reduction therapy in OCD,” and “Acceptance and commitment therapy in OCD.” A total of forty studies were found to be relevant for review. The review included single-case studies, open-label trials, two-group comparison studies, and randomized controlled studies. The control groups included those receiving treatment as usual; nonspecific therapies such as relaxation, expressive writing, psychoeducation, and stress management training; as well as active control groups receiving ERP, CT, and CBT. Review articles including expert reviews have also been used to discuss the results of outcome studies. The review is organized under each of the newer behavioral therapies applied in OCD.

Acceptance and commitment therapy

ACT is a method of behavioral therapy based on functional contextualism and the relational frame theory (RFT). RFT states that language naturally creates psychological suffering.[17] According to the conceptualization of RFT, human beings understand “Problems” as something unwanted and try to find solutions and the solution is often to figure out how to get rid of it or avoid it. According to ACT, the primary source of problems is psychological inflexibility – a narrowing of options for behaving, which leaves a person feeling “stuck.” The strategies (narrow options) which maintain the problems are avoidance, escape, efforts to reduce, change, suppress, and experiential avoidance. Thus, control itself is considered as a problem and not the solution.

The two major goals of ACT are: (1) acceptance of unwanted thoughts and feelings whose occurrence or disappearance is not under one's control (to function with them) and (2) commitment and action toward living a valued life (increase the quality of life).[16]

Therapy is generally conducted over eight sessions. The important components of ACT for OCD include the following: (1) Examining the success of previous attempts to regulate obsessions in the short- and long-term (usefulness of compulsions and neutralizing behaviors) aimed at making the individual understand the futility of the methods used to reduce distress/discomfort. Exercises and metaphors are used to illustrate the futility of resisting, fighting, or trying to control unwanted internal experiences to help foster willingness to engage with obsessions and anxiety without challenging or resisting them.[14],[16],[18] (2) A discussion of how obsessions cannot be controlled. (3) Accepting obsessions and the associated anxiety as a part of the illness. (4) Training in psychological defusion (perceiving inner experiences as only thoughts, feelings, and bodily sensations and nothing more) so that the person does not identify himself or herself with the experiences and can distance them. (5) Training in self as a construct that is more permanent than one's experiences (identifying self to be different from obsessions). (6) Training in mindfulness and being present with inner experiences without attempting to regulate them. (7) Clarifying values (areas of life that are important to the client); identifying and listing out the values in various domains of the individual's life and (8) Increasing behavioral commitments to engage in value-based activities.

Efficacy of acceptance and commitment therapy

The application of ACT in OCD (eight sessions) is illustrated in many case studies. These studies report reductions in symptoms of OCD, depression, and anxiety, with gains being maintained at follow-ups of 3 and 6 months.[19],[20],[21] Case series involving both adults and children with OCD have demonstrated the efficacy of ACT. A 9-session ACT program resulted in reduced frequency of obsessions and Children's Yale–Brown Obsessive Compulsive Scale (Y–BOCS) scores in two of three children aged <12 years.[22] A brief ACT delivered by the school psychologist and facilitated by parents in three children aged 10–11 years was also found to be effective.[23] An 8-session ACT was found to effect 81% improvement in anxiety, depression, experiential avoidance, believability, and need to respond to obsessions and 68% reduction in obsessions and compulsions at 3 months of follow-up in four adult patients.[24] In three adolescents of 12–13 years, it was found that 8–10 sessions of ACT without in-session exposure could bring about 40% mean reduction in compulsions posttreatment. The gains were maintained for up to 3 months, and the procedure was rated as highly acceptable.[25] ACT has been compared with other cognitive and behavioral techniques such as CT and progressive relaxation training and expressive training. There were no significant differences when ACT was compared with ERP and CT [Table 1].
Table 1: Efficacy of acceptance and commitment therapy in obsessive-compulsive disorder

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The studies using ACT in OCD largely involved nonclinical samples (found to have OCD symptoms on screening); those with clinical samples had small sample sizes (case studies and case series), indicating the need for studies with larger samples having active control groups. Changes in dysfunctional assumptions and psychological flexibility and extinction were reported as contributors of symptom reduction across ACT, CT, and exposure-based techniques.[26],[27],[28]

Mindfulness-based cognitive therapy

Mindfulness is defined as “paying attention in a particular way: on purpose, in the present moment, and nonjudgmentally.”[29],[30] Mindfulness-based stress reduction (MBSR) program that combines mindfulness and the principles of yoga is an 8-week program which is extensively used in both medical and psychological problems.[31] MBCT has variously been called mindfulness-integrated CBT, mindfulness-integrated CT, mindfulness-based CBT, mindfulness-based behavioral therapy, etc., MBCT was developed by incorporating the basic structure of MBSR with CBT techniques to address relapse in depression.[31] Cognitive restructuring is used in varying degrees across these therapies. The common component across these therapies is the practice of mindfulness in an 8-week format. They target the attitude toward thoughts and not their content. Patients are taught to carefully observe every arising thought, label it as a thought, try not to judge it, accept it, and refrain from acting on it compulsively.[32],[33] MBCT has been tailored to address the residual symptoms of OCD following CBT. It has preliminary evidence as an augmentative strategy following CBT to optimize the treatment.[34]

Components of MBCT include (1) psychoeducation about OCD symptoms (thoughts as false messages), experiential avoidance, thought suppression, and impermanence of thoughts; (2) developing awareness and acceptance of obsessions, reducing the significance given to obsessions, and errors in thinking (practice of being mode); (3) friendly attitude toward self (self-compassion), exposure to the triggers, and use of mindfulness instead of compulsions; and (4) attention retraining, reduction of avoidance, validating one's perceptual experiences, and distancing from thoughts and emotions.

Strategies used in MBCT include the practice of mindfulness, use of metaphors, defusion and disidentification from thoughts, exposure to anxiogenic stimuli (in vitro and client-planned exposures to demonstrate nondangerous nature of obsessions), and self-regulation of attention.[35]

Mechanism of action in mindfulness-based cognitive therapy

MBCT as compared to ERP is less anxiety provoking and thus may be useful in managing processes such as TAF and thought suppression.[36] Mindfulness is also likely to reduce the experiential avoidance,[37] attentional bias for threat,[38] secondary elaborative processing,[39] rumination,[40] and selfinvalidation of private experience[41] that are involved in the phenomenology of obsessions. Habituation, tolerance of uncertainty, and affective tolerance may owe their development to the absence of neutralizing behaviors. All these possibly reduce distress and psychophysiological activation,[42] eventually enabling the client to learn to stay in the being mode and not in doing mode.

Efficacy of mindfulness-based cognitive therapy

Single-case studies and case series employing 8–12 sessions have reported improvements in symptoms with medium-to-large effect sizes.[37] MBSR program was used in an individual with OCD who refused medication and ERP. After the 8-week program, there was clinically significant reduction in the symptoms of OCD as well as an increased capacity to evoke a state of mindfulness.[43] The gains of mindfulness-based therapies were maintained for up to 6 months.[44] In one refractory case, it was found that mindfulness-based therapy could reduce the symptoms and improve functioning.[45] Open-label trials and case series have demonstrated the effectiveness of MBCT in reducing symptoms, improving mindfulness skills, and functioning. In addition, the feasibility and acceptability of MBCT has been established in these studies. Studies with comparison groups are relatively less and most of them had small sample sizes. The comparison groups received components such as relaxation, bibliotherapy, and psycho-educative coaching [Table 2]. There has been no direct comparison with CBT or ERP.
Table 2: Efficacy of mindfulness-based cognitive therapy in obsessive-compulsive disorder

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Metacognitive therapy

MCT evolved from classical CT. Metacognition (knowing about knowing) is the aspect of cognition that controls mental processes and thinking. MCT is based on self-regulatory executive function (SERF) theory of psychological disorders.[52] According to SERF theory, “Cognitive Attentional Syndrome,” a psychopathological state consisting of inflexible self-focused attention, and repetitive cognitive processes (worrying, rumination, dysfunctional threat monitoring, and dysfunctional cognitive and behavioral coping) result in anxiety and mood symptoms.[53]

Metacognitions in obsessive-compulsive disorder

According to MCT, the two domains of beliefs in OCD are: (1) Metacognitive beliefs about the meaning and consequences of intrusive thoughts and emotions, further classified into three types: TAF, thought–event fusion, and thought–object fusion (TOF) and (2) Metacognitive beliefs concerning the necessity of performing rituals and the negative consequences of failure to carry out these rituals.[54],[55] Research has shown that people with OCD have more positive beliefs about rituals and stop signals and TAF beliefs.[56],[57],[58]

The metacognitive model of OCD posits that intrusive thoughts activate metacognitive beliefs (e.g., TAF, nonacceptance, and invalidation of own experiences) about the meaning of intrusions, resulting in feelings of fear, anxiety, distress, or guilt. The person involves in cognitive strategies such as thought suppression, neutralization, rumination, and threat monitoring (doing mode) to reduce the distress, thus maintaining the symptom cycle.[41]

Metacognitive therapy in obsessive-compulsive disorder

MCT involves helping clients to become aware of their own metacognitive processing and to learn to modify it (e.g., beliefs about the importance of thoughts).[59] It also includes developing new and flexible ways of experiencing obsessions that reduces their importance and the distress caused. Attention training techniques are used to develop skills in cognitive flexibility. A special form of mindfulness (detached mindfulness) is taught, and guided cognitive and behavioral experiments are performed to change metacognition.

Efficacy of metacognitive therapy in obsessive-compulsive disorder

Preliminary studies support the use of MCT, but controlled trials have not yet been conducted. Case series have shown that there were clinically significant changes in symptoms and the improvements were maintained at 6 months of follow-up.[60],[61] Group MCT (n = 22) was also found to be effective in decreasing the symptoms of OCD and depression. Furthermore, decrease in metacognitive beliefs significantly correlated with the decrease in OCD symptoms[62] and accounted for 22% of variance in symptoms at postassessment.[63] An open trial has also demonstrated the effectiveness of MCT [Table 3].
Table 3: Efficacy of metacognitive therapy in obsessive-compulsive disorder

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Danger ideation reduction therapy

Danger ideation reduction therapy (DIRT) for OCD was developed by Jones and Ross (1998).[67] It targets the faulty thinking that people with OCD have, about adverse events taking place if repeated washing was not done; later, it was extended to checking compulsions as well. Studies also show that participants who had high danger expectations regarding the likelihood and severity of a consequent disease showed increased avoidance behavior and increased washing behavior when exposed to disgusting stimuli.[68] DIRT is based on the rationale that, if the therapist provides as much factual information as possible to decrease the expectation that harmful events (such as the fear of illness or disease, fire, damage, theft, harm to others, and other physical losses) will follow any failure to check/wash, it could reduce the dropout rates seen in conventional ERP. The therapy consists of six discrete treatment components aimed at reducing the number of intrusive thoughts and change beliefs. The number of sessions range from 6 to 21 across studies.

The components of DIRT include: (1) Attentional focusing (focused meditation, based on a counting and breathing repetition task), (2) Cognitive restructuring, (3) Microbial/double-checking experiments (series of microbiological experiments concerning contamination, e.g., door handles and money), (4) Corrective information (based on facts related to illness and death rates in various occupational groups), (5) Filmed interviews (series of l0-min filmed interviews with various workers who had regular contact with contamination-related stimuli), and (6) Probability of catastrophe task (calculating the probability of occurrence of each step required for the negative consequences and probability of all the steps taking place concurrently).

Efficacy of danger ideation reduction therapy

DIRT has proven beneficial for patients who continued to have intractable symptoms following standard treatments and those with poor insight. In a case study of a client with fear of infection and washing compulsions wherein the client did not cooperate for ERP, DIRT could reduce the fear as well as washing compulsions.[69] A 14-session weekly DIRT was effective in reducing the severity of OCD (severe to subclinical) on Y–BOCS in an older adult, and the gains were maintained for up to 6 months.[70] Another patient with long-standing OCD with washing compulsions, who had inadequate response to CBT, benefitted from self-administered DIRT with minimal contact with therapist (12 weeks) with reductions in the severity of OCD as well as depression.[71] A case study reported from India with untreated OC washing behavior showed improvements with symptoms of OCD, insight, and functioning, following 15 DIRT sessions over 2 months.[72] Similarly, a treatment-refractory adolescent (medications as well as ERP) with contamination fears, washing compulsions, and significant avoidance responded to 16 sessions of DIRT. There was substantial improvement in OCD symptoms, depression, and anxiety; these improvements were maintained at 12 months of follow-up.[73] A randomized controlled study comparing DIRT and ERP has shown equal effectiveness of both therapies; however, recovery rates at follow-up were better with DIRT [Table 4].
Table 4: Danger ideation reduction therapy in obsessive-compulsive disorder

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In clinical practice, clinicians often integrate components across the three waves to achieve better outcomes. Although this is technical eclecticism, there are no studies examining such attempts, and it currently remains the practitioners' choice.

   Discussion Top

The new-wave therapies covered in this review have been discussed with respect to methodological limitations, the possible mechanisms of action, integration with other therapies, and future directions.

There are a few studies that have explored the efficacy of new-wave behavioral therapies in OCD. The research is largely restricted to case studies, case series, and open-label trials with very few RCTs and meta-analytical studies.[79] A further limitation is that of small sample sizes; thus, the results from new-wave therapies can at best be considered preliminary. There is a relative inadequacy of comparisons of the new-wave therapies with empirically established interventions such as ERP and CBT. The inclusion of components of CT in varying proportions in mindfulness-based therapies makes it difficult to ascertain the contribution of the individual components toward outcome. In most studies using mindfulness and ACT, the nature of OCD symptoms was predominantly cognitive compulsions and not motor compulsions. The follow-up in these studies is limited to a maximum of 6 months. Hence, it is unclear whether these therapies are effective in all subtypes of OCD and over longer periods.

DIRT, which is largely based on cognitive restructuring using an educational method, appears to be effective in washing and checking compulsions which are refractory to pharmacotherapy and ERP-based CBT.[76],[78] However, these findings are preliminary and largely based on case studies. In addition, the therapy appears to be an elaborated version of psychoeducation along with behavioral experiments that are components of CBTs, with similar principles of learning.

It would be helpful to compare the efficacy of acceptance-based treatments with that of the existing treatments such as ERP and CT with respect to their mechanisms of action.

Mechanism of change becomes an important aspect in ascertaining the utility and strength of any therapy. In the exploration of mechanisms predicting symptoms in emotional disorders, it was found that metacognition correlated strongly with the symptoms of depression, anxiety, and OCD, whereas mindfulness was a weaker predictor.[58] In addition, lower metacognition scores were associated with poor insight in people with OCD, indicating that patients with poor insight may benefit from methods aimed at belief modification.[80] New-wave therapies that employ mindfulness techniques are required to address metacognition in order to handle intrusive thoughts. Some of the recent experimental studies and experiential accounts indicate that acting with awareness and acceptance predicts less frequent and distressing experiences of obsessive intrusive thoughts. Mindfulness enabled people with OCD to experience an altered relationship with their symptoms and self.[81],[82] However, the differential contribution of various techniques employed in third-wave therapies is still unclear; dismantling studies may helpful in improving this understanding. A study that examined the components of ACT in OCD found a significant relationship between OCD severity and self-compassion, courage, and valued living.[83] However, the mediating role of mindfulness, and acceptance in OCD treatment, needs to be determined at an empirical level. Furthermore, the third-wave therapies seem to have more similarities than differences with respect to the mechanism of action.[14],[84] Researchers have opined that the mechanism of action is similar across CT, ERP, and third-wave therapies, thus emphasizing the need for further research.[18],[85],[86]

Clinical experts with experience in the area surmise that mindfulness and acceptance-based methods were often incorporated into ERP/CBT.[87] There have already been attempts in this direction to add components from third-wave therapies, in order to address specific symptom manifestations (e.g. integration of ACT and CT for depression).[88] Incorporation of strategies that increase inhibitory learning (e.g., the application of ACT concepts within ERP) has been suggested to enhance the treatment outcomes of ERP.[89] Integration of mindfulness with CBT (with exposure therapy) has been suggested to complement traditional CBT interventions, to increase their efficacy and possibly prevent relapse.[90] Researchers have opined that the components of third-wave therapies may be better used as complementary methods to individualize the treatment of OCD. Future research is warranted to establish the same.[91] There is increasing integration of mindfulness and acceptance strategies along with traditional/conventional CT/CBT in clinical practice. However, the manner of integration is based on several factors including the clinician's judgment.[92] It would be helpful to study whether the efficacy and acceptability (factors such as ease of use, tolerability, and attrition rate) of ERP can be augmented by new-wave therapies.[14]

The additional contribution of newer CTs (e.g., MCT) is yet to be established. Considering that pure cognitive methods have demonstrated efficacy in certain subtypes of OCD (pure obsession/OCD with cognitive compulsions), the feasibility and comparative efficacy with respect to ERP-based CBT needs to be established.[47],[65] It is also unclear as to which factors and symptoms should determine the choice of type of therapy. This needs to be addressed by studies that compare the different new-wave therapies across various categories of OCD.

Although the new-wave therapies claim to have a different mechanism of action than the CBTs, this needs further examination with respect to comparing mechanisms within third-wave therapies and across CBTs and third-wave therapies.[93] Integration of these therapies is becoming increasingly important in clinical applications. Thus, to understand the relative contribution of these techniques to the outcomes, the underlying mechanisms, and the principles of integration of various techniques (according to symptomatology, severity, distress, timing, and client characteristics), dismantling studies may be important. Furthermore, it may be parsimonious to identify key strategies in relation to the symptoms of OCD and work toward a common elements approach for both clinical application and training. However, achieving this would require a sound theoretical and practical evidence base which could be achieved through exploratory and outcome research on integrated therapies.

   Conclusions Top

There is preliminary evidence for the effectiveness of new-wave behavioral therapies based on a small number of outcome studies. However, none of these newer therapies have been compared sufficiently with alternative empirically established therapies such as CBT and ERP, and the methodologies adopted are not sound. The role of new forms of behavioral interventions needs to be further studied by analyzing the mechanisms contributing to change, contributions of the different components of these therapies, and specific indications for using these therapies (symptom profiles, course, severity, etc.). It is also important to alternatively examine if these may better serve as complementary methods along with the traditional CT combined with ERP.

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Conflicts of interest

There are no conflicts of interest.

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Correspondence Address:
Dr. M Manjula
Department of Clinical Psychology, National Institute of Mental Health and Neuro Sciences, Bengaluru - 560 029, Karnataka
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/psychiatry.IndianJPsychiatry_531_18

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  [Table 1], [Table 2], [Table 3], [Table 4]