Journal of Obsessive-Compulsive and Related Disorders 2 (2013) 91–98

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Journal of Obsessive-Compulsive and Related Disorders

2211-36

http://d

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authors

journal homepage: www.elsevier.com/locate/jocrd

Further evidence for the efficacy of association splittingin obsessive-compulsive disorder. An internet studyin a Russian-speaking sample

Steffen Moritz n,1, Rada Russu 1

Department of Psychiatry and Psychotherapy, University Medical Center Hamburg-Eppendorf, Martinistr. 52, D-20246 Hamburg, Germany

a r t i c l e i n f o

Article history:

Received 10 October 2012

Received in revised form

5 December 2012

Accepted 10 December 2012Available online 21 December 2012

Keywords:

Obsessive-compulsive disorder

Therapy

Self-help

Association splitting

Cognition

49/$ - see front matter & 2012 Elsevier Inc. A

x.doi.org/10.1016/j.jocrd.2012.12.002

esponding author. Tel.: þ49 40 7410 56565;

ail address: moritz@uke.uni-hamburg.de (S. M

e authors have equally contributed to the

hip.

a b s t r a c t

Notwithstanding its undisputed efficacy for most psychological disorders, the dissemination of CBT-

oriented techniques remains suboptimal. Many patients cannot afford treatment, have no access to

specialized facilities or are reluctant to seek face-to-face treatment. The situation is especially grave in

developing countries and countries where CBT is less accepted. The present study investigated the

efficacy of ‘‘association splitting’’ (AS), a self-help intervention for obsessive-compulsive disorder

(OCD), in a Russian-speaking population with a probable diagnosis of OCD. A total of 72 participants

with self-reported OCD were recruited via online resources. Subsequent to a baseline survey,

participants were randomly allocated to either AS or a wait list group. After four weeks participants

were re-assessed. Per protocol as well as intention to treat analyses suggest that AS is superior to a

waitlist control condition for the improvement of obsessions and depression. Differences were

confirmed even if data of noncompleters were considered as unchanged. The present study demon-

strates the feasibility and effectiveness of AS in Russian-speaking subjects who in half of the cases had

not received any treatment before. Prior experience with CBT does not seem to represent a prerequisite

for self-help. To conclude, CBT-oriented self-help may represent an alternative when therapies are

either not available (e.g., rural areas) or affordable to patients.

& 2012 Elsevier Inc. All rights reserved.

1. Introduction

Obsessive-compulsive disorder (OCD) is a severe psychologicaldisorder. In most cases, obsessions (i.e., intrusive, repetitive andbothersome thoughts, for example, fears about committing a severecrime or transmitting an infection) and compulsions (i.e., ritualizedbehaviors, for example, washing and checking) coexist and arefunctionally interwoven (Summerfeldt, Richter, Antony, & Swinson,1999). Recent epidemiological results suggest that OCD is morefrequent than previously thought: while the full clinical pictureaffects up to 3% of the world population, subclinical forms areobserved in approximately 8% of the people (Adam, Meinlschmidt,Gloster, & Lieb, 2012). Recent years have witnessed advances in thetreatment of OCD: cognitive-behavioral therapy (CBT) and medica-tion treatment promise effective treatment in 50–60% of patients ifdrop-out and noncompletion is considered (Abramowitz, 2006a).Overall, CBT exerts a large effect size (Gava et al., 2007). Still, only aminority of OCD patients receives evidence-based interventions and40–60% do not get treatment at all (Kohn, Saxena, Levav, &

ll rights reserved.

fax: þ49 40 7410 57566.

oritz).

study and thus split first

Saraceno, 2004; Marques et al., 2010). If a competent therapy iseventually initiated, many years have usually elapsed (Blanco et al.,2006; Hollander et al., 1996; Pinto, Mancebo, Eisen, Pagano, &Rasmussen, 2006). A multitude of factors relating both to ‘‘demandand supply’’ represent barriers to treatment. Patients abstain fromhelp for several reasons (for a review Moritz, Timpano, Wittekind,& Knaevelsrud, in press): apart from financial problems andinsufficient insurance coverage, stigma/shame, irrational fears tobe regarded as a (potential) offender because of aggressive obses-sions (Marques et al., 2010), as well as rejection of exposuretreatment (Kozak & Foa, 1997) play a role. With respect to supply,problems particularly relate to a dearth of (skilled) therapists(especially in rural areas), including countries that have incorpo-rated CBT into their treatment guidelines (Shafran et al., 2009). Inaddition, even if CBT is (allegedly) performed, guidelines are notalways fully translated into practice. Studies conducted in Ger-many found that many therapists trained in CBT do not practiceexposure and response prevention (ERP), a core and efficientcomponent of (cognitive-)behavioral therapy (Bohm, Forstner,Kulz, & Voderholzer, 2008; Kulz et al., 2009). Finally, manyclinicians do not feel competent to treat OCD, a situation that alsoapplies to other patient groups such as borderline personalitydisorder or psychosis. Moreover, OCD patients are often judgedas ‘‘difficult customers’’ by therapists due to, for example,

S. Moritz, R. Russu / Journal of Obsessive-Compulsive and Related Disorders 2 (2013) 91–9892

occasional latent aggression (Hand, 1991) and some therapistseven refuse therapy, thus further prolonging the already longwaitlist periods for OCD.

In face of low availability of competent treatment in parallel withthe reluctance of many patients to undergo face-to-face treatment,self-help via bibliotherapy (e.g., Abramowitz, 2009) and onlinetreatment (for example BT-Steps/OC Fighter; Mataix-Cols & Marks,2006; Tumur, Kaltenthaler, Ferriter, Beverley, & Parry, 2007) isincreasingly utilized by both patients and therapists to address thelarge treatment gap. According to a recent survey, three out of fourOCD patients have read at least one self-help book on OCD (Moritz,Wess, Treszl, & Jelinek, 2011). While comparison of face-to-facetreatment to unguided self-help usually favors the former (Tolinet al., 2007), a number of studies assert that unguided interventionsare both feasible and effective.

The present study is concerned with a cognitive techniqueentitled association splitting (AS), which is available as a self-helpresource in German, English, Italian, Montenegrin and mostrecently Russian language. The manual can be downloaded atno cost via www.uke.de/assoziationsspaltung (Moritz & Jelinek,2007; Moritz, Jelinek, Klinge, & Naber, 2007). The concept drawsupon well-founded principles of cognitive psychology, particu-larly the assumption that associations are organized in semanticnetworks (for a comprehensive introduction see Reisberg, 2007),AS rests on the hypothesis that patients with OCD share a biasedprocessing of OCD-relevant material, favoring negative associa-tions (for evidence see Jelinek, Hottenrott, & Moritz, 2009). Toillustrate, while a nonclinical subject would associate multiplemeanings and associations to words like for example ‘‘cancer’’(e.g., phonetic association like dancer, cancel, enhancer, Lancia (carbrand); semantic associations like illness, zodiac, animal), in mostOCD washers only the illness-relevant association becomes sali-ent. In short, AS teaches patients to create new or augment thestrength of existing neutral or positive associations for fear-related OCD themes (e.g., cancer, death, AIDS, robbery). This isdone by rehearsing neutral and positive associations that areunrelated to OCD concerns. For example, a patient who despitegood illness insight is preoccupied with ‘‘HIV’’ may exercise with‘‘High Five’’, ‘‘Henry the Fourth‘‘ (Henry IV) or ‘‘HSV’’ (Germansoccer club) ideally using visual material that can be collected, forexample, via search engines (for other examples, please see theappendix of the manual). Exercises should be performed inobsession-free intervals to prevent covered avoidance or meredistraction. In other words, patients are explicitly discouragedfrom using the technique as a ritual or neutralizing behaviorduring obsessions.

Once the semantic network of these themes has been enlargedto incorporate neutral or positive concepts, confrontation with athreat cue is hoped to coactivate a range of OCD-unrelatedassociations so that the patient is not stuck with negativeassociations alone. AS conveys patients a cognitive model thatthere is no evil inner self in their minds but that OCD-related fearsare based on learning principles that can be altered, thuschallenging the alleged omnipotence of the OCD thoughts andcompulsive urges.

So far, three studies have investigated the feasibility andefficacy of AS. The first study adopted an uncontrolled design(Moritz et al., 2007). Assessments were made over the internetfour weeks apart using the Yale-Brown Obsessive-CompulsiveScale (Y-BOCS self-rating version), Maudsley Obsessive Compul-sive Inventory (MOCI) and the Beck Depression Inventory (BDI).Symptom decline on the Y-BOCS was approximately 4 points.A primary effect was seen for obsessions and depression while noeffect was noted for compulsions. Marked improvement was seenin 1/3 of patients as defined by a 35% decline on the Y-BOCS totalscore. While OCD patients are usually not prone to placebo

effects, the lack of clinical control participants precludes anymonocausal attribution of the effects to AS.

To control for confounding effects such as motivation tochange or elapse of time, a recent investigation studied 46participants with OCD symptoms who were randomly allocatedto either AS or a waitlist control (Moritz & Jelinek, 2011). Again,assessments were made over the internet. Symptom decline onthe Y-BOCS was approximately 25% on the Y-BOCS (Mtotal change¼

5.6). Similar to the forerunner study, effects were seen forobsessions and depression but not for compulsions.

An independent study conducted in Cuba (Rodriguez-Martin,Moritz, Molerio-Perez, & Gil-Perez, in press) examined if sub-clinical subjects with unwanted intrusive thoughts (UIT; e.g.,cheating of partner, worries about work) but without OCD orother disorders would benefit from AS. Unlike the forerunnerstudies, subjects were seen by physicians. Comparisons to awaitlist control group suggested that after intervention, the ASgroups showed marked improvements on UITs at a largeeffect size.

The present study aimed to replicate and extend prior findingson AS. Similar to the two aforementioned clinical studies wecollected data over the internet on a sample with a probablediagnosis of OCD. The present study investigated a Russian-speaking population with a target population of approximately144 million native-speaking people (8th most spoken language inthe world by native speakers and 4th by total number of speakers).We chose a Russian-speaking sample for the following majorreasons: (1) the two forerunner studies on OCD targeted nationswith a long tradition of CBT treatment and strong coverage of CBT inthe media (e.g., USA, England, Germany, Austria). In contrast, inRussian-speaking countries CBT is less well-known and not widelyavailable to sufferers due to a low population density, a differentpsychology tradition and a shortage of skilled therapists (Jenkinset al., 2007). While the number of psychiatric beds is equivalent oreven higher relative to Western countries (Russia: 11.5; USA: 7.7;Germany: 7.5 per 10.000 inhabitants; data from World HealthOrganization, 2005), there are few psychologists (psychologists per10.000 inhabitants, Russia: 1.9; USA: 31.1, Germany: 51.5; WorldHealth Organization, 2005) and community-based treatment as wellas care facilities are very limited (McDaid et al., 2006), althoughthere has been an increase in outpatient treatment facilities over theyears (Sakharova, Gurovich, & Wahlbeck, 2007). According to astudy by Angermeyer, Breier, Dietrich, Kenzine, and Matschinger(2005) there is a willingness to seek help from medical sourcesoutside the mental health sector which in their view may indicate atendency towards avoiding psychiatric treatment, which duringSoviet times was connected with numerous negative consequences,such as obligatory documentation in the psychiatric registry. Itdeserves to be tested whether the encouraging findings of the firststudies are replicable in an environment that is less experiencedwith CBT. (2) We expected a higher degree of participants in thispopulation without any prior treatment allowing us to explore ifefficacy in this subgroup is lower or higher.

2. Methods

2.1. Recruitment

The study was set up as an online study. Invitations for participation were

posted on several Russian-speaking internet services and discussion fora (e.g., ww

w.vk.com/obsessive_compulsive). Consent was sought from webmasters before

posts were published. Similar to our prior studies, fora with a broader scope

beyond OCD were avoided as these might have attracted patients with other

disorders. In our invitation the following inclusion criteria were explicitly named:

age between 18 and 65, self-reported presence of obsessive thoughts (a definition

was provided), self-reported (partial) insight into the exaggerated nature of the

disorder, consent to participate in two anonymous (internet-based) surveys that

S. Moritz, R. Russu / Journal of Obsessive-Compulsive and Related Disorders 2 (2013) 91–98 93

were four weeks apart and sufficient time to perform exercises in the meantime.

Participants who did not fulfill these criteria or did not approve the procedure

were excluded. Participants were made aware that half of them were to receive a

self-help manual as a pdf-formatted ebook immediately and the other half at the

end of the post-assessment.

No compensation for participation was offered except for the immediate or

delayed cost-free delivery of an electronic self-help book (pdf-converted ebook)

along with an English-speaking self-help manual for OCD at the end of the

post-assessment (so-called mymct, see www.uke.de/mymct).

Interested individuals were then directed to the online baseline survey which

consisted of the following parts: welcome and summary of the study

rationale, electronic informed consent (no name or address was requested,

not even optionally), demographic variables (age, gender, school education),

medical history (e.g., time when OCD symptoms had started, profession of the

person who had diagnosed OCD), assessment of psychopathology (see question-

naires section for details), request of email address (and a code word) to send the

manual if a patient was allocated to the experimental group (the email address

was also used to match pre and post survey data). The online software that was

used to set up the survey did not store IP addresses.

Upon completion of the baseline survey, participants were randomly allocated

to either the experimental (AS) or control group (pseudo-random consecutive

allocation according to date of registration) with no further stratification applied.

The treatment manual was then sent to participants in the experimental group via

email attachment. The other half was informed via email that they were allocated

to the control group and would receive the manual subsequent to post-assessment

four weeks later. For questions, participants could turn to the second author. No

guided self-help was implemented.

Four weeks after the pre-assessment, all participants were asked by email to

take part in the post-assessment. The email contained the respective code word of

the participant. To allow identification, participants were requested to first enter

either their code word or email address when starting the survey. Up to three

reminders were sent in case subjects failed to participate in the post-assessment.

The questionnaire proceeded with the same questionnaires already administered

in the baseline phase. If subjects endorsed that they had read (at least parts of) the

manual (experimental group only), they were posed several questions on, for

example, the subjective effectiveness of the technique, comprehensibility of the

manual and motivation to use the technique in the future; these items closely

followed the questionnaires of the forerunner studies (see Table 2). This part was

skipped for all subjects in the control group and those in the experimental group

who acknowledged that they had not read the manual at all. At the end of the

assessment, gratitude was expressed to participants and a link was provided to the

English translation of a self-help book for OCD (myMCT; Moritz & Hauschildt,

2012; Moritz, Jelinek, Hauschildt, & Naber, 2010).

2.2. Participants

The first page of the survey was accessed by 116 individuals. After 72 subjects

(62%) had completed the baseline survey, the enrollment phase was terminated

and no further participants were accepted. Of these, 48 participants (67% of the

baseline sample) completed the post-assessment approximately four weeks later.

The following persons confirmed a diagnosis of OCD: psychiatrist (n¼30),

psychologist (n¼16), psychotherapist not further specified (n¼10), neuropathol-

ogist (n¼4). In 12 cases OCD was self-diagnosed.

2.3. Association splitting manual

The experimental group received the 18-page manual on association splitting

which is also available at no cost via www.uke.de/assoziationsspaltung in several

languages. In brief, subjects are familiarized with the concept of semantic

networks and how distortions in the processing of semantic information may

contribute to OCD. Typically, the range of associations for OCD-relevant informa-

tion is constricted to illness-relevant cognitions in patients (e.g., the word

‘‘cancer’’ will elicit associations about the illness but not, for example, the zodiac

sign). Participants are instructed how to extend the meaning repertoire of OCD-

relevant cognitions by building up new associations or strengthening weak

associations that are both meaningful and neutral. Many examples are provided

how this can be achieved through both verbal and visual information. For

example, patients who are fearful of burglaries and preoccupied with, for example,

the word ‘‘lock’’ or images hereof may think of ‘‘Heather Locklear’’ (American

actress), the jeans brand L.O.G.G., the company foot locker or Lockheed enterprise.

Exercises should be made in obsession-free intervals and are not meant as a ritual

or compulsion when obsessions arise. The aim is to reduce obsessive thoughts by

diffusing associations across a range of associations, thus attenuating the strength

of core obsessive associations and related compulsive urges. The manual also

teaches subjects about dysfunctional coping styles.

2.4. Questionnaires

Subjects were required to fill out three questionnaires (see below) both at baseline

and reassessment. The survey only proceeded if all items were answered.

Yale-Brown Obsessive Compulsive Scale (Y-BOCS; Baer, Brown-Beasley, Sorce, &

Henriques, 1993; Goodman et al., 1989). We adopted the Russian translation of

the Y-BOCS (Mironova & Jenski, 2006). The Y-BOCS assesses the severity of

obsessions and compulsions, irrespective of content. At the beginning of the Y-

BOCS section, examples for obsessions and compulsions are presented to avoid

potential misunderstandings (e.g., cognitive compulsions such as counting are

sometimes confused with obsessive thoughts; Federici et al., 2010). Items were

worded in the original item format except that the time-frame was restricted to

the last week. In addition to the 10 items computed for the total score, items on

insight (item 11), avoidance (item 12) as well as symptom change (item 13) were

posed. The self-report version of the scale has shown strong convergent validity

with the original interview version (Schaible, Armbrust, & Nutzinger, 2001;

Steketee, Frost, & Bogart, 1996). The present study used a subscale algorithm

proposed by Kim, Dysken, Pheley, and Hoover (1994) and Moritz et al. (2002):

severity of obsessions (items 1–3), severity of compulsions (items 6–8) as well as

resistance (items 4 and 9). The obsession subscale served as the primary outcome,

while the total score represented a secondary outcome.

Obsessive-Compulsive Inventory-Revised (OCI-R) (Foa et al., 2002). The OCI-R is a

self-report scale measuring the severity of specific OC subtypes. To the best of our

knowledge, the scale was not available in Russia before and was therefore translated

by the second author (RR). Several studies have confirmed the good to excellent

psychometric properties for the original version (Abramowitz & Deacon, 2006; Foa

et al., 2002; Huppert et al., 2007). Internet administration of the OCI (Coles, Cook, &

Blake, 2007) has been established to be equivalent to paper-and-pencil administra-

tion and both the test re-test reliability and validity of the online version of the

subscale were recently confirmed (Moritz et al., 2010). The instruction of the post-

assessment survey asked for symptoms experienced during the last seven days. The

OCI-R total score and the obsessions subscore served as secondary outcome

measures.

Beck Depression Inventory (BDI; Beck & Steer, 1993). The BDI was administered in

its Russian version (Iljin, 2001) to cover depressive symptoms. The BDI is often

regarded as the gold standard for depression. It contains good concurrent validity in

medical inpatients (Beck & Steer, 1993). Internet administration of the BDI

(Schulenberg & Yutrzenka, 2001) has been found to be equivalent to paper-and-

pencil administration. For the present study we used the short version of the BDI which

was validated for internet research in an OCD sample before (Moritz et al., 2010).

2.5. Strategy of data analysis

We expected that AS would yield a medium-to-strong effect on the primary

outcome parameter (Y-BOCS obsession subscore) at b of 0.8 and a of 0.05 requiring

approximately 70 participants. ANCOVA models were performed with the pre-post

difference score as dependent variable and the baseline score as covariate. Unlike

mixed models, this type of analysis adjusts for baseline differences as well as possible

regression to the mean. Moreover, this type of analysis usually requires smaller sample

sizes (Borm, Fransen, & Lemmens, 2007). Both per protocol (PP) analyses (considering

completers and participants from the experimental group who had read the manual) as

well as intention-to-treat analyses (ITT; data of all subjects initially enrolled in the

study) were conducted. For ITT, we decided to analyze data with multiple imputation

(MI) as well as last observation carried forward (LOCF). While LOCF is increasingly

regarded as obsolete it provides conservative estimates for the method under

investigation as it implies that noncompleters have not improved at all. This

assumption may not always be valid (however, see Hilvert-Bruce, Rossouw, Wong,

Sunderland, & Andrews, 2012). For example, patients may have well improved but did

not participate again for non-availability, low motivation or little gain from participa-

tion in the reassessment which is a potential motive in our experimental group as

participants have already received the treatment at this point. MI was conducted using

SAS PROC MI (SAS 9.22): 5000 iterations were performed before the first imputation

and 5000 iterations were performed between successive imputations. Group compar-

isons at single points in time (pre or post) were conducted using either t-tests (for

dimensional variables) or cross tables (for nominal data).

Effect sizes for ANOVA results were expressed as Z2partial, whereby 0.01 represents

a weak effect (equivalent to d¼0.2), .06 represents a medium effect (equivalent to

d¼0.5) and 0.14 a strong effect (equivalent to d¼0.8). As an estimate of response, we

also calculated the reliable change index (Jacobson & Truax, 1991).

3. Results

3.1. Baseline differences

As can be derived from Table 1, the two groups did notsignificantly differ on any demographic or psychopathological

Table 1Background and psychopathological differences at baseline. Means and standard deviations (in brackets).

Variable Waitlist (n¼36) Association splitting (n¼36) Statistics (df for t-tests¼70) Significance

Gender (female/male) 23/13 16/20 w2(1)¼2.74 p¼0.09

Age in years 23.36 (4.09) 24.18 (6.99) 0.60 p40.5

Education (frequency for eligibility for university) 24 – 24 – w2(1)¼0.00 p40.9

Length of illness in years (N¼67) 11.78 (6.00) 9.26 (7.07) 1.59 p40.1

OCI-R total 32.78 (13.72) 35.31 (15.40) 0.74 p40.4

BDI total score 10.69 (7.60) 10.33 (4.83) 0.24 p40.8

Y-BOCS

Obsessions 7.39 (2.28) 7.44 (2.22) 0.11 p40.9

Compulsions 5.61 (3.00) 5.03 (2.87) 0.84 p40.4

Resistance 4.44 (1.78) 4.00 (1.69) 1.09 p40.2

Total 21.64 (7.80) 20.58 (6.70) 0.62 p40.5

0

0.5

1

1.5

2

2.5

3

3.5

4

4.5

resistance

chan

ge s

core

waitlistassociation splitting

**

*

total obsessions compulsions

Fig. 1. Participants in the AS group improved by approximately 4 points on the

Y-BOCS total score (item 1–10), predominantly reflecting strong improvement on

the obsessions subscore (items 1–3; per protocol data). npr0.05; nnpr0.001.

S. Moritz, R. Russu / Journal of Obsessive-Compulsive and Related Disorders 2 (2013) 91–9894

baseline characteristics. The Y-BOCS total score was in the rangeof prior online studies but below the mean score of most clinicalstudies (range 23–26 points). A total of 25% of the sample werecurrently taking medication and only 47% had received any kindof treatment for OCD before.

Seven participants from the control group and 17 participantsfrom the AS group did not take part in the post-assessment, thedifference was significant, w2(1)¼6.25, p¼0.01. Completers andnoncompleters did not differ on any single demographic orpsychopathological variable (all ps40.1).

Only one subject in the experimental group responded that heor she had not read the manual. Three subjects read at least halfbut not the entire manual and one person endorsed that themanual was read multiple times.

3.2. Per protocol analyses

At a medium-to-strong effect size, the AS group improvedmore strongly on the Y-BOCS total score across time relative tothe control group, F(1,45)¼4.50, p¼0.04, Z2

partial¼0.09, wherebylarge differences emerged for the primary outcome, obsessions(p¼0.001, Z2

partial¼0.21). In contrast, neither the difference forcompulsions (p40.4, Z2

partial¼0.01), nor resistance (p40.1,Z2

partial¼0.05), achieved significance (see Fig. 1). For the AS group,within-subject comparisons using the one-sample t-test against 0(¼unchanged) were significant for obsessions, resistance, and thetotal score (at least po0.05), suggesting improvement beyondchance. For the wait-list control group, none of the within-subjectcomparisons was significant (p40.1). We also examined items oninsight and avoidance which are not counted to the total score(see above). For insight (Y-BOCS item 11) no significant groupdifferences occurred (p40.1, Z2

partial¼0.04). For avoidance (Y-BOCSitem 12) a trend emerged in favor of AS (p¼0.07, Z2

partial¼0.07).As can be seen in Fig. 2, the AS group improved markedly on

the OCI-R total score (secondary outcome), whereas the controlgroup showed a slight but nonsignificant deterioration. Thedifference achieved a large effect size, F(1,46)¼9.32, p¼0.004,Z2

partial¼0.17. Within-subject comparisons, again using the one-sample t-test against 0, showed a significant decline in the ASgroup only (p¼0.02). Fine-grained analyses revealed that groupdifferences were significant for obsessions (secondary outcome;p¼0.003, Z2

partial¼0.18), washing (p¼0.01, Z2partial¼0.12), and

neutralizing (p¼0.04, Z2partial¼0.08). The latter two effects are

partly owing to symptom worsening in the waitlist group, as forthe AS group the within-subject comparisons were significantonly for the obsessions subscale (po0.001). No significant groupdifferences emerged for hoarding (p40.1, Z2

partial¼0.04) andchecking (p40.1, Z2

partial¼0.04), while for ordering a trendemerged in favor of AS (p¼0.07, Z2

partial¼0.07). For the waitlistcontrol group, none of the within-subject comparisons yieldedsignificant differences across time (all ps40.05). The BDI score

declined significantly more strongly in the AS group yielding astrong effect size, F(1,45)¼7.76, p¼0.008, Z2

partial¼0.15, see Fig. 2.

3.3. Intention to treat analyses

As described before, we computed two ITT models based onLOCF and multiple imputation. Using multiple imputation, groupdifferences achieved significance for the Y-BOCS obsessions(p¼0.006, Z2

partial¼0.13), resistance (p¼0.03, Z2partial¼0.11) and

total score (p¼0.02, Z2partial¼0.13). With respect to the OCI-R,

the subscores for neutralizing (p¼0.05, Z2partial¼0.10), obsessions

(p¼0.005, Z2partial¼0.18), washing (p¼0.01, Z2

partial¼0.15) as wellas the total score (p¼0.003, Z2

partial¼0.19) achieved significance.For ordering, a trend was obtained favoring AS (p¼0.09,Z2

partial¼0.07). Likewise, depression improved more strongly inthe AS group (p¼0.01, Z2

partial¼0.16).LOCF assumes that noncompleters have not improved at all.

This type of analyses clearly disadvantaged the AS condition asnoncompletion was elevated for this group. Still, results remainedsignificant for Y-BOCS obsessions (p¼0.01, Z2

partial¼0.09) and atrend was seen for the Y-BOCS total score, (p¼0.08, Z2

partial¼0.04).For resistance and compulsions the analyses were insignificantmirroring results obtained in the PP analyses. The OCI-R totalscore (p¼0.01, Z2

partial¼0.09) as well as the obsessions (p¼0.01,Z2

partial¼0.09), washing (p¼0.01, Z2partial¼0.09), and neutralizing

subscales (p¼0.05, Z2partial¼0.05) again achieved significance. The

nonsignificant PP analyses for the other OCI-R subscales wereconfirmed for the LOCF analyses. For the BDI, the conservativeLOCF analyses also revealed a significant difference across time infavor of the AS (p¼0.03, Z2

partial¼0.07).

Table 2Subjective assessment of association splitting (n¼18). Percentage endorsement (agree fully—somewhat).

Item Present study

(Russian sample) (%)

Moritz and Jelinek (2011)

(English sample) (%)

Moritz et al., 2007

(German sample) (%)

Association splitting is appropriate for self-administration 100 92 77

My OCD symptoms have decreased due to association splitting 83 42 n.a.

The manual was written comprehensively 100 100 93

I found the manual useful 89 83 80

I was able to regularly perform the exercises 67 75 n.a.

I did not find the time to study the manual intensively 44 58 80

I would find association splitting more helpful in combination with a direct psychotherapy 72 83 43

The manual was written in an appealing way. 94 92 n.a.

Others have helped me with the exercises 17 n.a. 40

I found association splitting more helpful than other self-help approaches 83 67 n.a.

I will use association splitting in the future. 69 82 86

Note. n.a.¼not assessed

-3

-2

-1

0

1

2

3

4

5

6

7

8

OCI-Rwashing

OCI-Robsessions

OCI-Rhoarding

OCI-Rordering

OCI-Rchecking

OCI-Rneutralizing

OCI-R total

chan

ge s

core

waitlistassociation splitting

***

***

***

***

BDI

Fig. 2. Participants in the AS group improved more strongly on the OCI-R obsessions subscale and the BDI relative to the waitlist group. For washing and neutralizing

significant differences emerged as well but were partly owing to slight symptom worsening in the control group rather than improvements in the AS group. npr0.05;nnpr0.01; nnnpr0.005.

S. Moritz, R. Russu / Journal of Obsessive-Compulsive and Related Disorders 2 (2013) 91–98 95

3.4. Subjective appraisal

Table 2 provides data on the subjective evaluation of AS andcontrasts results of the present study with that of the twoforerunner investigations. Eighteen out of 20 participants pro-vided responses. All found the manual written comprehensivelyand appropriate for self-administration. Four out of five partici-pants judged the technique as superior to other approaches and asimilar number experienced subjective symptom decline becauseof AS. Approximately two-thirds intended to continue using AS inthe future.

3.5. Test re-test reliability and validity

The test re-test reliabilities of the total scores were as follows:BDI: r¼0.73 (po0.001), OCI-R: r¼0.77 (po0.001), and Y-BOCS: r¼

0.73 (po0.001). OCI-R and Y-BOCS total scores were correlated atr¼0.49 (po0.001). If the analyses were confined to the morehomogenous waitlist control group test re-test reliabilities rose toat least r¼0.85.

3.6. Reliable change

The reliable change methodology aims to provide an index ofchange that is relevant and unlikely due to chance. To compute theindex, the standard error of the difference (Sdiff) is used to create aconfidence interval (i.e., a prediction interval) for the test-retestdifference score. Essentially, this confidence interval represents theprobable range of measurement error for the distribution ofdifference scores. In keeping with the literature, we used the formula

proposed by Jacobson and Truax (1991). The Y-BOCS total score(difference) served as the dependent variable. As expected, reliablechange (tested at 5% in each tail) was significantly higher in the ASgroup (53%) compared to the waitlist control group (17%;w2(1)¼6.69, p¼0.01).

3.7. Moderator analyses

We conducted several subsidiary analyses exploring possiblemoderators and confounds of symptomatic outcome. For theseanalyses we ran two-way ANCOVA models. Condition (AS versuswaitlist control) always served as the first between-subject factor,while the respective moderator served as the second between-factor.The difference score of the Y-BOCS total scores was thedependent variable and the Y-BOCS baseline total score was enteredas covariate. When entering baseline symptom severity (at least 16points on the Y-BOCS versus lower than 16 points) as a secondbetween-subject factor, no main effect or interaction with samplewas seen (p40.1). However, for a similar analysis with priorpsychological or psychiatric treatment (yes, no) the main effect oftreatment was significant, F(1,43)¼5.74, p¼0.02, Z2

partial¼0.12,reflecting a stronger symptom decline in the group without any priortreatment (M¼4.74) than that which had received treatment before(M¼0.38). Although the two-way interaction failed to reach signifi-cance, we would like to report that this effect was numerically moremarked in the AS group (M¼6.52) than in the control group(M¼2.67). For current medication a similar response patternemerged, F(1,43)¼2.68, p¼0.11, Z2

partial¼0.06. Those without currentdrug treatment showed a stronger decline (M¼3.28) than thosereceiving medication (M¼�0.14) and this effect was more marked in

S. Moritz, R. Russu / Journal of Obsessive-Compulsive and Related Disorders 2 (2013) 91–9896

the AS group (M¼5.80) than in the control group (M¼0.76) receivingno medication. Finally, we calculated if patients with an externallyverified diagnoses achieved better outcome (i.e., defined as reliablechange) than self-diagnosed patients, which, however, was not thecase, w2(1)¼0.04, p40.8.

4. Discussion

In accordance with prior trials we found that participants withprobable OCD in the AS condition improved substantially relativeto participants in the waitlist control arm. The magnitude of thedifference was 4 points on the Y-BOCS total score which wassimilar to a pilot study (Moritz et al., 2007) but somewhat lowerthan in a more recent study (Moritz & Jelinek, 2011). Reliablechange was seen in 53% of the participants in the AS groupcompared to only 17% in the waitlist control group. The magni-tude of change in the OCI-R was even somewhat higher in thepresent study compared to the forerunner study (Moritz & Jelinek,2011). Per protocol and ITT analyses using multiple imputationsuggested medium-to-large or even large effect sizes for all totalscores (Y-BOCS, OCI-R, BDI) for the AS relative to the waitlistcondition.

As expected, symptom decline emerged for the Y-BOCS andOCI-R obsessions subscales at a large effect size but not for the Y-BOCS compulsions subscale. The ITT analysis with MI alsoindicated an effect for the resistance subscale (items 4 and 9).The present study also confirms the reliability and validity of theRussian version of the OCI-R which showed a satisfactory test re-test reliability and validity.

The noncompletion rate was much higher in the AS conditionthan in the control group. As there are various motives why subjectsdecide against participation, we cannot rule out that (partial)subjective treatment failure or disappointment about small or evenno change was one of them, although a recent online study showedthat noncompleters derive benefit before dropping out comparable tothat seen by completers (Hilvert-Bruce et al., 2012). However, eventhe very conservative LOCF analyses resting on the assumption thatnoncompleters have remained unchanged confirmed that AS ishelpful relative to a waitlist control beyond chance level in reducingobsessions as well as depression. At this point we can only speculatewhy noncompletion was much higher in the experimental group. Forexample, the incentive (download of an English self-help book) mightnot have been very attractive as some participants may not havesufficient command of the English language (in other studies addi-tional self-help material was provided in the language spoken by thetarget population). Interestingly, unlike prior studies noncompleterswere neither more often male nor showed fewer symptoms(Besiroglu, Cilli, & Askin, 2004; Moritz et al., 2010).

Improvements were somewhat stronger in participants whohad not seen a specialist before (53% of the sample) and thosewithout medication treatment, although the former result did notreach significance. If replicated, this may indicate one or twothings: a. AS is applicable even in patients without prior experi-ence in CBT and/or b. that effective psychotherapy may absorb/cover some of the effects exerted by AS, thus attenuating thebenefit in this population.

As can be derived from Table 2, the subjective efficacy of ASwas appraised superior relative to a previous trial (83% vs. 42%;Moritz & Jelinek, 2011), although participants in the present studydevoted less time to the exercises and the study of the manual. Allparticipants found the manual comprehensible, while the techni-que was regarded as useful and written in an appealing way bythe vast majority. Yet, a fewer number than in the two previousstudies would apply the technique in the future (69% versus 82–86%).

Outcome data in self-help trials is usually worse in comparisonto clinician-administered psychotherapy (Abramowitz, 2006b;Gava et al., 2007), thus emphasizing that self-help and bibliother-apy should not be promoted as a substitute for standard psy-chotherapy but rather to reach patients unwilling or presentlyunable to undergo proper treatment, for example, when living inremote areas as in many parts of Russia or Australia where thenext available therapist may be hundreds of miles away. As laiddown by Mataix-Cols and Marks (2006), self-help books may helpmaking treatment time more efficient (Marks et al., 2003) bydelegating psychoeducation or certain exercises to homework andrestrict face-to-face intervention to aspects where it is irreplace-able (e.g., elaboration of an illness model and treatment plan). Weendorse a stepped care approach of OCD (see for example Mataix-Cols & Marks, 2006) which recommends (1) (guided) self-help forless severe cases, (2) brief face-to-face sessions (i.e., with atherapist) in an outpatient setting for medium symptom severity,and (3) ultimately intensive comprehensive treatment in a specialisedhospital setting for severe cases. Evidence suggests that the first stepinvolving self-help is more easily accessed than steps 2 or 3. Goodself-help books may eventually smoothen the way to treatment byreducing stigma and raising confidence in the effectiveness ofpsychotherapy (for a discussion see Moritz, Schroder, Meyer, &Hauschildt, in press).

We would like to acknowledge several critical points of ourstudy before we turn to the implications. Firstly, data wasobtained online and none of the information was externallyverified. As mentioned before, an online study is without alter-native if one tries to reach ‘‘the untreated’’ as expert interviews ina clinical environment will ward off many potential participants(Moritz et al., in press), especially those with aggressive obses-sions and low illness insight who fear they could be judged as a(potential) criminal. In line with recent studies demonstrating thereliability of self-report instruments and the compatibility ofresults obtained with the Y-BOCS self-report scale and theconventional expert rating (Schaible et al., 2001; Steketee et al.,1996), the psychometric properties of our scales were very good.It was recently shown that online studies are less easy to deceivethan often thought: scores of experts (e.g., clinicians as well aspsychology and medical students) who pretended having OCDmarkedly differed from real patients particularly with respect totest re-test reliability (Moritz, Van Quaquebeke, Hauschildt,Jelinek, & Gonner, in press). Secondly, our study is silent to thesustainability of the effect of AS. While a study by Tolin et al.(2007), for example, found that improvements through ERP self-help are maintained six months later, we cannot generalize thisfinding to AS. Thirdly and in line with a prior study (Moritz &Jelinek, 2011), far more participants in the experimental groupdid not participate in the post-assessment. As mentioned before,the AS group had the least to gain from the reassessment as theyhad already received the AS. However, steps should be under-taken to raise adherence in the experimental group (e.g.,vouchers).

4.1. Clinical implications

We regard AS as a promising self-help technique for OCD thatmay represent an initial treatment (step) for those OCD patientsyet not sufficiently motivated for treatment or on waitlists. Whilethe application of AS was somewhat attenuated (but not abol-ished) in those receiving concurrent treatment, AS has beensuccessfully incorporated as an adjunct to face-to-face CBT treat-ment (Hottenrott, Jelinek, Kellner, & Moritz, 2011). Furthermore,AS may serve as an alternative for CBT, the undisputed first-linetreatment of OCD, in cases where techniques such as ERP andbehavioral challenges such as reality testing are hard to

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implement (e.g., fears about consequences of negative acts that liein the far future, fears about past misbehavior that cannot bereliably tracked back and verified). Randomized controlled trialsare needed to assess the efficacy and also safety of AS in the longrun. Future studies should also examine the mechanisms ofaction. While we think that the technique indeed reduces thestrength and ‘‘black hole’’ properties (i.e., associations are biasedtowards negative OCD-related meanings) of obsessive cognitions,another route of action could be that it imparts patients with alearning model of OCD emphasizing the changeability of cogni-tions and that bad thoughts are normal and not necessarily thereflection of an ‘‘evil’’ personality.

Acknowledgments

The authors would like to thank Dr. Andras Treszl for helpingwith the multiple imputation of the missing data as well asKatharina Kolbeck for her valuable comments on an earlierversion of the mansucript.

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