Introduction
Obsessive-compulsive Disorder (OCD) is defined by repetitive and disturbing images, thoughts, and impulses that cause significant distress (for example, obsessions) and are followed by actions or behaviors (for example, compulsions) aimed at reducing distress [1]. OCD is a chronic condition that affects 1% to 3% of the general population [2, 3, 4]. The annual prevalence of OCD in different cultures is estimated to be 1.1%-1.8% [5]. Over the last 20 to 30 years, the prevalence of psychological interventions in the treatment of OCD has been significant, and various studies have shown the effectiveness of such interventions in the treatment and improvement of symptoms in OCD patients [12, 13, 14, 15]. By using cognitive-behavioral techniques, the prognosis of people with OCD changes from weak to excellent [13, 14]. However, despite the relative success of patients who have completed these therapies, there is no significant improvement in the percentage of treated patients and there are very limited findings of long-term therapeutic achievement because of treatment discontinuations and relapses [12].
Therefore, it is necessary to create and expand new strategies and effective treatment approaches to prevent the lack of response to treatment and to further improve the condition of patients with OCD. The emotional schema therapy model (EST) is a metacognitive or meta-experiential model in which emotions are a part of social cognition [28]. EST emphasizes that people with maladaptive emotional schemas are likely to resist certain emotions and use avoidant strategies [29]. In this treatment model, the focus is on clarifying, modifying, and changing the patient’s specific theory of emotion. The emphasis is that emotion itself is not a problem, but a type of evaluation of people’s problems. Every individual may have unreasonable fears of infection, but only some people get OCD. The ability to confirm painful and difficult emotions, accept them as part of a full life experience, evaluate them in a non-judgmental way, avoid emotional catastrophe, and recognize the transience of emotions are among the goals of this treatment in OCD patients [28]. Patients with OCD may have beliefs about anxiety and other emotions that lead to non-acceptance or continuation of ERP. Similar to the belief that since anxiety persists indefinitely and leads to psychological damage, anxiety should always be avoided or reduced as soon as possible [20].
Therefore, given the limited history of research on the effectiveness of treatment based on emotional schemas and to improve patients’ symptoms as much as possible along with considering the above-mentioned measures, the main question is whether there are significant differences between ESTERP compared to ERP and pharmacotherapy in improving the symptoms in patients with OCD.
Methods
After the necessary coordination with the target centers, the patients were referred based on psychiatric diagnosis. Then, these patients were evaluated based on the structured clinical interview for diagnostic and statistical manual of mental disorders, 5th Edition (DSM-5), the clinician version (SCID-5-CV) (for screening clinical disorders), and the structured clinical interview for DSM-5 personality disorders (SCID-5-PD) (for screening personality disorders). The criteria for the entry of 45 patients with OCD were selected by the targeted sampling method. Of this population, 15 patients were randomly assigned to the combined drug and ESTERP, 15 patients were included in the combined drug and ERP, and 15 patients received only the drug treatment. After randomly placing the patients in the three groups, all patients completed the Yale-Brown obsessive–compulsive scale-2nd edition (Y-BOCS-II), the four systems anxiety questionnaire (FSAQ), and the Beck depression inventory-2nd edition (BDI-II) questionnaires before, in the end, and 2 months after the treatment.
Then, the data were analyzed using descriptive statistics (description of demographic data, Mean±SD), inferential statistics, given the lack of assumptions of parametric statistics, nonparametric statistics, and clinical significance by the Reliable change index (RCI).
Results
There was a significant difference between ESTERP with ERP and pharmacotherapy in the symptoms and severity of OCD and anxiety (except for the depression variable) in patients with OCD. In addition, the findings of the clinical significance of ESTERP compared to the other two treatments showed more significant changes in symptoms and severity of OCD, depression (except for the anxiety variable) (Tables 1, 2, and 3).






Discussion
Based on the results of this study and given the effectiveness of ESTERP in patients with OCD, clinical specialists can use this protocol along with other pharmacological and psychotherapeutic interventions. 

Ethical Considerations
Compliance with ethical guidelines
The present study was designed based on the principles of the Declaration of Helsinki and was approved by Iran University of Medical Sciences (Code: IR.IUMS.REC.1397.175).

Funding
This article is taken from the dissertation of the Samira Masoumian PhD thesis in clinical psychology of Iran University of Medical Sciences.

Authors contributions
Conceptualization: Samira Masoumian, Mohammad Reza Shaeiri and Banafsheh Gharraee; Research and review: Samira Masoumian and Mohammad Reza Shaeiri; Editing and finalization: Samira Masoumian, Banafsheh Gharraee, Mohammad Reza Shaeiri, Abbas Ramezani Farani and Ali Asghar Asgharnejadfarid; Supervision:  Mohammad Reza Shaeiri and Ali Asghar Asgharnejadfarid

Conflicts of interest
The authors declare no conflict of interest.

Acknowledgements
We would like to thank the Faculty of Behavioral Sciences and Mental Health of Iran University of Medical Sciences for their financial assistance, as well as all the patients who participated in the study. 


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