Obsessive-compulsive disorder: Evidence-based treatments and future directions for research

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Abstract
Over the past three decades, obsessive-compulsive disorder (OCD) has moved from an almost untreatable, life-long psychiatric disorder to a highly manageable one. This is a very welcome change to the 1%-3% of children and adults with this disorder as, thanks to advances in both pharmacological and psychological therapies, prognosis for those afflicted with OCD is quite good in the long term, even though most have comorbid disorders that are also problematic. We still have far to go, however, until OCD can be described as either easily treatable or the effective treatments are widely known about among clinicians. This review focuses on the current state of the art in treatment for OCD and where we still are coming up short in our work as a scientific community. For example, while the impact of medications is quite strong for adults in reducing OCD symptoms, current drugs are only somewhat effective for children. In addition, there are unacceptably high relapse rates across both populations when treated with pharmacological alone. Even in the cognitive-behavioral treatments, which show higher effect sizes and lower relapse rates than drug therapies, drop-out rates are at a quarter of those who begin treatment. This means a sizable portion of the OCD population who do obtain effective treatments (which appears to be only a portion of the overall population) are not effectively treated. Suggestions for future avenues of research are also presented. These are primarily focused on (1) increased dissemination of effective therapies; (2) augmentation of treatments for those with residual symptoms, both for psychotherapy and pharmacotherapy; and (3) the impact of comorbid disorders on treatment outcome.
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doi:10.5498/wjp.v2.i6.86
World J Psychiatr 2012 December 22; 2(6): 86-90
ISSN 2220-3206 (online)
© 2012 Baishideng. All rights reserved.
World Journal of
Psychiatry
W J P
Obsessive-compulsive disorder: Evidence-based treatments
and future directions for research
Caleb W Lack
Caleb W Lack,
Department of Psychology, University of Central
Oklahoma, Edmond, OK 73034, United States
Author contributions:
Caleb W Lack solely contributed to this
paper.
Correspondence to: Caleb W Lack, PhD, Assistant Profes-
sor,
Department of Psychology, University of Central Oklahoma,
Edmond, OK 73034, United States. clack@uco.edu
Telephone:
+1-405-9745456
Fax:
+1-405-974851
Received:
February 17, 2012
Revised:
September 14, 2012
Accepted:
September 21, 2012
Published online:
December 22, 2012
Abstract
Over the past three decades, obsessive-compulsive
disorder (OCD) has moved from an almost untreatable,
life-long psychiatric disorder to a highly manageable
one. This is a very welcome change to the 1%-3% of
children and adults with this disorder as, thanks to ad-
vances in both pharmacological and psychological ther-
apies, prognosis for those afflicted with OCD is quite
good in the long term, even though most have comor-
bid disorders that are also problematic. We still have far
to go, however, until OCD can be described as either
easily treatable or the effective treatments are widely
known about among clinicians. This review focuses on
the current state of the art in treatment for OCD and
where we still are coming up short in our work as a
scientific community. For example, while the impact of
medications is quite strong for adults in reducing OCD
symptoms, current drugs are only somewhat effective
for children. In addition, there are unacceptably high
relapse rates across both populations when treated with
pharmacological alone. Even in the cognitive-behavioral
treatments, which show higher effect sizes and lower
relapse rates than drug therapies, drop-out rates are at
a quarter of those who begin treatment. This means a
sizable portion of the OCD population who do obtain ef-
fective treatments (which appears to be only a portion
of the overall population) are not effectively treated.
Suggestions for future avenues of research are also
presented. These are primarily focused on (1) increased
dissemination of effective therapies; (2) augmentation
of treatments for those with residual symptoms, both
for psychotherapy and pharmacotherapy; and (3) the
impact of comorbid disorders on treatment outcome.
© 2012 Baishideng. All rights reserved.
Key words:
Obsessive-compulsive disorder; Evidence-
based psychological practice; Cognitive-behavioral
therapy; Psychopharmacology
Peer reviewer:
Feryal Cam Celikel, MD, Associate Professor
of Psychiatry, Gaziosmanpasa University School of Medicine,
60100 Tokat, Turkey
Lack CW. Obsessive-compulsive disorder: Evidence-based
treatments and future directions for research. World J Psychiatr
2012; 2(6): 86-90 Available from: URL: http://www.wjg-
net.com/2220-3206/full/v2/i6/86.htm DOI: http://dx.doi.
org/10.5498/wjp.v2.i6.86
INTRODUCTION
Thirty years ago, being diagnosed with obsessive-compul-
sive disorder (OCD) was about the closest thing the psy-
chiatric world had to being given a life sentence. In addi-
tion to being seen as extremely rare, prognosis for those
with a diagnosis of OCD was very poor, with no effec-
tive truly pharmacological or psychological treatments
available
[1]
. Today, however, a diagnosis of OCD does not
carry this loss of hope for the future and poor treatment
outcomes. Instead, clinicians now have at their disposal
both pharmacological and psychological treatments that
are remarkably effective for the majority of patients
[2]
.
Still, though, there are further advances that need to be
made, to continue improving treatment effectiveness and
patient outcomes.
EDITORIAL
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Lack CW. Research and treatments in OCD
OCD is characterized by intrusive, troubling thoughts
(obsessions), and repetitive, ritualistic behaviors (com-
pulsions) which are time consuming, signicantly impair
functioning and/or cause distress
[3,4]
. When an obsession
occurs, it almost always corresponds with a massive in-
crease in anxiety and distress. Subsequent compulsions
serve to reduce this associated anxiety/distress. Com-
mon obsessions include contamination fears, worries
about harm to self or others, the need for symmetry,
exactness and order, religious/moralistic concerns, for-
bidden thoughts (e.g., sexual or aggressive), or a need to
seek reassurance or confess
[5]
. Common compulsions
include: cleaning/washing, checking, counting, repeating,
straightening, routinized behaviors, confessing, praying,
seeking reassurance, touching, tapping or rubbing, and
avoidance
[6]
. Unlike in adults, children need not view their
symptoms as nonsensical to meet diagnostic criteria
[7]
.
In the United States, the lifetime prevalence rate of
OCD is estimated at 2.3% in adults
[8]
and around 1%-2.3%
in children and adolescents under 18
[9]
. There are also a
fairly substantial number of “sub-clinical” cases of OCD
(around 5% of the population
[10]
), where symptoms are
either not disturbing or not disruptive enough to meet full
criteria and yet are still impairing to some degree. There
is strong evidence that cultural differences do not play a
prominent role in presence of OCD
[11,12]
, with research
showing few epidemiological differences across differ-
ent countries
[13-15]
and even between European and Asian
populations
[16]
. There are, however, cultural inuences on
symptom expression. In Bali, for example, heavy emphasis
on somatic symptoms and need to know about members
of their social network is found
[17]
, while type of religious
upbringing has been related to different types of primary
obsessions, such as emphasis on cleanliness and order in
Judaism, religious obsessions in Muslim communities, ag-
gressive aggressions in South American samples, and dirt
and contamination worries in the United States
[13,18-20]
.
While OCD is equally present in males and females
in adulthood, the disorder is heavily male in pediatric
patients
[21]
. There are some differences in comorbidity as
well
[22]
. Among men, hoarding symptoms are most often
associated with GAD and tic disorders, but in women so-
cial anxiety, PTSD, body dysmorphic disorder, nail biting,
and skin picking are more often observed
[8,23]
.
Presentation of OCD symptoms is generally the same
in children and adults
[24]
. Unlike many adults, though,
younger children will not be able to recognize that their
obsessions and compulsions are both unnecessary (e.g.,
you don’t really need to wash your hands) and extreme
(e.g., washing hands for 15-20 s is ne, but 5 min in scald-
ing water is too much) in nature. In young children, com-
pulsions often occur without the patient being able to
report their obsessions, while adolescents are often able
to report multiple obsessions and compulsions. Children
and adolescents are also more likely to include family
members in their rituals and can be highly demanding of
adherence to rituals and rules, leading to disruptive and
oppositional behavior and even episodes of rage
[25]
. As
such, youth with OCD are generally more impaired than
adults with the same type of symptoms
[26]
.
Up to 75% of persons with OCD also present with
comorbid disorders
[8]
. The most common in pediatric
cases are ADHD, disruptive behavior disorders, major
depression, and other anxiety disorders
[27]
. In adults, the
most prevalent comorbids are social anxiety, major depres-
sion, and alcohol abuse
[10]
. Interestingly, the presence of
comorbid diagnoses predict quality of life (QoL) more so
than OCD severity itself in both children
[28]
and adults
[29]
.
Different primary O/C are also associated with certain
patterns of comorbidity, in both adults and youth
[30]
. Pri-
mary symmetry/ordering symptoms are often seen with
comorbid tics, bipolar disorder, obsessive-compulsive
personality disorder, panic disorder, and agoraphobia,
while those with contamination/cleaning symptoms are
more likely to be diagnosed with an eating disorder. Those
with hoarding cluster symptoms, on the other hand are
especially likely to be diagnosed with personality disorders,
particularly Cluster C disorders.
Almost all adults and children with OCD report that
their obsessions cause them signicant distress and anxi-
ety and that they are more frequent as opposed to similar,
intrusive thoughts in persons without OCD
[31]
. In terms
of QoL, persons with OCD report a pervasive decrease
compared to controls
[28]
. Youth show problematic peer
relations, academic difculties, sleep problems, and partici-
pate in fewer recreational activities than matched peers
[32,33]
.
Overall, there is a lower QoL in pediatric females than
males
[28]
, but in adults similar disruptions are reported
[29]
.
When compared to other anxiety disorders and unipolar
mood disorders, a person with OCD is less likely to be
married, more likely to be unemployed, and more likely to
report impaired social and occupational functioning
[34]
.
EMPIRICALLY SUPPORTED TREATMENTS
There are both pharmacological and psychological
treatments for OCD that are supported by research evi-
dence
[35-38]
. Overall, pharmacology with serotonin reup-
take inhibitors (SRIs) shows large effect sizes in adults
(0.91
[39]
), but only moderate effect sizes in youth (0.46
[40]
).
Unfortunately, even with effective medication, most treat-
ment responders show residual symptoms and impair-
ments. There is also a very high relapse rate seen across
numerous studies (between 24%-89%
[41]
). SRIs can be
successfully supplemented with adjunctive antipsychotics,
but even then only a third of patients will show improve-
ments and there are serious health concerns with their
long-term usage
[42]
. Metanalyses and reviews have not
shown that the ve selective SRIs (including uoxetine,,
paroxetine, fluvoxamine, sertraline, and citalopram) or
the non-selective SRI clomipramine differ among each
other in terms of effectiveness in either adults or pediat-
ric patients
[39,40]
. Across subtypes of OCD, however, there
are medication differences seen (for a review see
[43]
). For
example, the presence of tics appears to decrease selec-
tive SRI effects in children
[44]
, but it is unclear if it has the
same effect in adults. Another known difference is that
patients who have OCD with comorbid tics respond bet-
87
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ter to neuroleptic drugs than those who have OCD with-
out tics
[43]
.
The psychological treatment of choice for OCD, in
both adults and children and backed by numerous clinical
trials, is cognitive-behavioral therapy (CBT), particularly
exposure with response prevention (EX/RP)
[45]
. It is
superior to medications alone, with effect sizes ranging
from 1.16-1.72
[46,47]
. While there is a lower relapse rate
than in medications (12%
vs
24%-89%), it is important
to note that up to 25% of patients will drop out prior
to completion of treatment due to the nature of treat-
ment
[48]
. The course of therapy generally lasts between
12-16 sessions, beginning with a thorough assessment of
the triggers of the obsession, the resultant compulsions,
and ratings of the distress caused by both the obsession
and if they are prevented from performing the compul-
sion. A series of exposures are then carefully planned
through collaboration between the therapist and client
and implemented both in session and as homework be-
tween sessions
[49-52]
.
As in the medication research, differences in response
to CBT have been found across populations. For in-
stance, it has been seen that those with hoarding cluster
symptoms respond less well to CBT, in part due to reluc-
tance to engage in exposures and poor insight
[53]
. Accom-
modation by family members in pediatric clients has been
found to be predictive of poorer treatment response as
well
[54]
. Intriguingly, group therapy that uses CBT and
EX/RP has been shown to be equally as effective as in-
dividual therapy in some studies
[55]
but less effective in
others
[56]
. For persons with mild OCD, computer-assisted
self-treatment has been shown to be very effective (see
for a review
[57,58]
).
FUTURE DIRECTIONS FOR RESEARCH
Although the treatment of OCD is remarkably advanced
compared to 30 years ago, there are a number of areas
where improvements can be made. First, treatment dis-
semination, particularly for CBT and EX/RP, remains an
issue
[59]
. While reasons for this are many, certain steps can
and should be undertaken to improve dissemination. For
instance, efforts have been made to incorporate technol-
ogy into the treatment of adult OCD with a number of
successes (for a review see
[57]
), and there are increasing ef-
forts to extend these ndings into the realm of pediatric
OCD. As educational efforts aimed at training new men-
tal health practitioners alone are not sufcient, dissemi-
nation of both the safety and effectiveness of exposure-
based therapies to both the general public and existing,
already licensed mental health clinicians (psychiatrists,
psychologists, counselors, and social workers) must be
made a priority.
Second, although many patients respond to rst-line
interventions to some degree, partial response is frequent
with many continuing to exhibit residual OCD symp-
toms, particularly to medication monotherapy. Pharma-
cological treatment augmentation options remain limited
and under-researched. One promising approach involves
targeting the extinction learning core to EX/RP with
d-cycloserine
[60]
, a partial agonist at the NMDA recep-
tor in the amygdala. Preliminary results in adults
[61,62]
and
youth with OCD
[63]
show promising results and suggest
the need for further trials and renement of methodolo-
gy and dosage. In terms of psychotherapy augmentation,
the primary issue in need of addressing would be the
high drop-out rate. Therapy may need to be augmented
with some sort of motivational enhancement module
for those unwilling or too distressed to engage in expo-
sures
[64]
, or new strategies for exposure-reluctant patients
may need to be developed.
Third, given the high comorbidity rates seen in per-
sons with OCD, it is important to examine what impact
that has on treatment
[65,66]
. Although a substantial body
of literature has shown that for most anxiety disorders
comorbidity does not diminish the impact of treatment
(see for a review
[67]
), research on OCD is mixed. Hav-
ing primary OCD with comorbid PTSD has been found
to decrease response rate
[68]
, while OCD and comorbid
GAD was shown to increase dropout rates and decrease
treatment response
[65]
. In contrast, others studies have
shown no negative impact on OCD treatment from co-
morbid anxiety problems in adults
[65]
or children
[66,69]
. As
such, both more research on how certain comorbidity
patterns impact treatment and the most optimal thera-
peutic methods to address the differential patterns should
be conducted
[70]
. Such methods could include novel com-
binations of pre-existing treatments (e.g., combining par-
ent management training with CBT for youth with OCD
and disruptive behavior
[71]
or the use of motivational
enhancement techniques
[72-74]
).
CONCLUSION
Although this may sound trite, there is truly not a better
time in history to have OCD than the present, given the
multiple effective pharmacological agents, the presence
of a very effective psychological therapy, and an ever-
increasing understanding of the disorder itself. This is
not, however, the time to sit back and pat our collective
backs in triumph. Instead, we must continue to advance
treatment for OCD in both adults and youth. Above, I
have outlined several potential avenues of research and
how they will benet those who continue to suffer from
OCD despite the advances of the last 30 years. With the
continued efforts of clinicians and researchers the world
over, the next 30 years should see a further explosion in
our ability to decrease symptomatology and increase the
QoL of those with this fascinating disorder.
REFERENCES
1
Franklin ME
, Foa EB. Obsessive-compulsive disorder. In: Bar-
low DH, editor. Clinical handbook of psychological disorders.
4th ed. New York, NY: Guilford Press, 2007: 164-215
2
Lack CW
, Storch EA, Murphy TK. More than just monsters
under the bed: Assessing and treating pediatric OCD. Psychi-
atric Times 2006;
23
: 54-57
3
American Psychiatric Association
. Diagnostic and statistical
88 December 22, 2012
|
Volume 2
|
Issue 6
|
WJP
|
www.wjgnet.com
Lack CW. Research and treatments in OCD
manual of mental disorders. 4th ed. Arlington, VA: Author,
2000
4
Foa EB
, Kozak MJ, Goodman WK, Hollander E, Jenike MA,
Rasmussen SA. DSM-IV eld trial: obsessive-compulsive dis-
order. Am J Psychiatry 1995;
152
: 90-96
5
Barrett PM
, Healy LJ. An examination of the cognitive pro-
cesses involved in childhood obsessive-compulsive disorder.
Behav Res Ther 2003;
41
: 285-299
6
Swedo SE
, Rapoport JL, Leonard H, Lenane M, Cheslow D.
Obsessive-compulsive disorder in children and adolescents.
Clinical phenomenology of 70 consecutive cases. Arch Gen
Psychiatry 1989;
46
: 335-341
7
Last CG
, Strauss CC. Obsessive-compulsive disorder in
childhood. J Anxiety Disord 1989;
3
: 295-302
8
Kessler RC
, Berglund P, Demler O, Jin R, Merikangas KR,
Walters EE. Lifetime prevalence and age-of-onset distribu-
tions of DSM-IV disorders in the National Comorbidity Sur-
vey Replication. Arch Gen Psychiatry 2005;
62
: 593-602
9
Zohar AH
. The epidemiology of obsessive-compulsive disor-
der in children and adolescents. Child Adolesc Psychiatr Clin N
Am 1999;
8
: 445-460
10
Ruscio AM
, Stein DJ, Chiu WT, Kessler RC. The epidemiol-
ogy of obsessive-compulsive disorder in the National Comor-
bidity Survey Replication. Mol Psychiatry 2010;
15
: 53-63
11
Okasha A
, Saad A, Khalil AH, el Dawla AS, Yehia N. Phe-
nomenology of obsessive-compulsive disorder: a transcultural
study. Compr Psychiatry 1994;
35
: 191-197
12
Fontenelle LF
, Mendlowicz MV, Marques C, Versiani M.
Trans-cultural aspects of obsessive-compulsive disorder: a
description of a Brazilian sample and a systematic review of
international clinical studies. J Psychiatr Res 2004;
38
: 403-411
13
Chavira DA
, Garrido H, Bagnarello M, Azzam A, Reus VI,
Mathews CA. A comparative study of obsessive-compulsive
disorder in Costa Rica and the United States. Depress Anxiety
2008;
25
: 609-619
14
Himle JA
, Muroff JR, Taylor RJ, Baser RE, Abelson JM, Hanna
GL, Abelson JL, Jackson JS. Obsessive-compulsive disorder
among African Americans and blacks of Caribbean descent:
results from the National Survey of American Life. Depress
Anxiety 2008;
25
: 993-1005
15
Weissman MM
, Bland RC, Canino GJ, Greenwald S, Hwu
HG, Lee CK, Newman SC, Oakley-Browne MA, Rubio-Stipec
M, Wickramaratne PJ. The cross national epidemiology of
obsessive compulsive disorder. The Cross National Collabora-
tive Group. J Clin Psychiatry 1994;
55
Suppl: 5-10
16
Matsunaga H
, Maebayashi K, Hayashida K, Okino K, Matsui
T, Iketani T, Kiriike N, Stein DJ. Symptom structure in Japa-
nese patients with obsessive-compulsive disorder. Am J Psy-
chiatry 2008;
165
: 251-253
17
Lemelson R
. Obsessive-compulsive disorder in Bali: the
cultural shaping of a neuropsychiatric disorder. Transcult Psy-
chiatry 2003;
40
: 377-408
18
Greenberg D
. Cultural aspects of obsessive compulsive dis-
order. In: Hollander E, editor. Current insights in obsessive
compulsive disorder. New York: Wiley, 1994: 11-21
19
Abramowitz JS
, Deacon BJ, Woods CM, Tolin DF. Associa-
tion between Protestant religiosity and obsessive-compulsive
symptoms and cognitions. Depress Anxiety 2004;
20
: 70-76
20
Rosmarin DH
, Pirutinsky S, Siev J. Recognition of scrupulosity
and non-religious OCD by Orthodox and non-Orthodox Jews.
J Soc Clin Psychol 2010;
29
: 930-944
21
Geller DA
. Obsessive-compulsive and spectrum disorders
in children and adolescents. Psychiatr Clin North Am 2006;
29
:
353-370
22
Labad J
, Menchon JM, Alonso P, Segalas C, Jimenez S, Jaurrie-
ta N, Leckman JF, Vallejo J. Gender differences in obsessive-
compulsive symptom dimensions. Depress Anxiety 2008;
25
:
832-838
23
Torres AR
, Prince MJ, Bebbington PE, Bhugra D, Brugha TS,
Farrell M, Jenkins R, Lewis G, Meltzer H, Singleton N. Obses-
sive-compulsive disorder: prevalence, comorbidity, impact,
and help-seeking in the British National Psychiatric Morbidity
Survey of 2000. Am J Psychiatry 2006;
163
: 1978-1985
24
Stewart SE
, Rosario MC, Baer L, Carter AS, Brown TA, Scharf
JM, Illmann C, Leckman JF, Sukhodolsky D, Katsovich L,
Rasmussen S, Goodman W, Delorme R, Leboyer M, Chabane
N, Jenike MA, Geller DA, Pauls DL. Four-factor structure of
obsessive-compulsive disorder symptoms in children, adoles-
cents, and adults. J Am Acad Child Adolesc Psychiatry 2008;
47
:
763-772
25
Storch EA
, Jones AM, Lack CW, Ale CM, Sulkowski ML,
Lewin AB, De Nadai AS, Murphy TK. Rage attacks in pedi-
atric obsessive-compulsive disorder: phenomenology and
clinical correlates. J Am Acad Child Adolesc Psychiatry 2012;
51
:
582-592
26
Piacentini J
, Peris TS, Bergman RL, Chang S, Jaffer M. Func-
tional impairment in childhood OCD: development and
psychometrics properties of the Child Obsessive-Compulsive
Impact Scale-Revised (COIS-R). J Clin Child Adolesc Psychol
2007;
36
: 645-653
27
Geller DA
, Biederman J, Grifn S, Jones J, Lefkowitz TR. Co-
morbidity of juvenile obsessive-compulsive disorder with dis-
ruptive behavior disorders. J Am Acad Child Adolesc Psychiatry
1996;
35
: 1637-1646
28
Lack CW
, Storch EA, Keeley ML, Geffken GR, Ricketts ED,
Murphy TK, Goodman WK. Quality of life in children and
adolescents with obsessive-compulsive disorder: base rates,
parent-child agreement, and clinical correlates. Soc Psychiatry
Psychiatr Epidemiol 2009;
44
: 935-942
29
Fontenelle IS
, Fontenelle LF, Borges MC, Prazeres AM,
Rangé BP, Mendlowicz MV, Versiani M. Quality of life and
symptom dimensions of patients with obsessive-compulsive
disorder. Psychiatry Res 2010;
179
: 198-203
30
de Mathis MA
, Diniz JB, do Rosário MC, Torres AR, Hoexter
M, Hasler G, Miguel EC. What is the optimal way to subdi-
vide obsessive-compulsive disorder? CNS Spectr 2006;
11
:
762-768, 771-774, 776-779
31
Julien D
, O’Connor KP, Aardema F. Intrusions related to ob-
sessive-compulsive disorder: a question of content or context?
J Clin Psychol 2009;
65
: 709-722
32
Valderhaug R
, Ivarsson T. Functional impairment in clinical
samples of Norwegian and Swedish children and adolescents
with obsessive-compulsive disorder. Eur Child Adolesc Psychia-
try 2005;
14
: 164-173
33
Storch EA
, Murphy TK, Lack CW, Geffken GR, Jacob ML,
Goodman WK. Sleep-related problems in pediatric obsessive-
compulsive disorder. J Anxiety Disord 2008;
22
: 877-885
34
Eisen JL
, Mancebo MA, Pinto A, Coles ME, Pagano ME, Stout
R, Rasmussen SA. Impact of obsessive-compulsive disorder
on quality of life. Compr Psychiatry 2006;
47
: 270-275
35
Mancuso E
, Faro A, Joshi G, Geller DA. Treatment of pedi-
atric obsessive-compulsive disorder: a review. J Child Adolesc
Psychopharmacol 2010;
20
: 299-308
36
March JS
. Cognitive-behavioral psychotherapy for children
and adolescents with OCD: a review and recommendations
for treatment. J Am Acad Child Adolesc Psychiatry 1995;
34
: 7-18
37
Watson HJ
, Rees CS. Meta-analysis of randomized, controlled
treatment trials for pediatric obsessive-compulsive disorder. J
Child Psychol Psychiatry 2008;
49
: 489-498
38
Foa EB
, Liebowitz MR, Kozak MJ, Davies S, Campeas R,
Franklin ME, Huppert JD, Kjernisted K, Rowan V, Schmidt
AB, Simpson HB, Tu X. Randomized, placebo-controlled trial
of exposure and ritual prevention, clomipramine, and their
combination in the treatment of obsessive-compulsive disor-
der. Am J Psychiatry 2005;
162
: 151-161
39
Eddy KT
, Dutra L, Bradley R, Westen D. A multidimensional
meta-analysis of psychotherapy and pharmacotherapy for
obsessive-compulsive disorder. Clin Psychol Rev 2004;
24
:
1011-1030
40
Geller DA
, Biederman J, Stewart SE, Mullin B, Martin A,
Spencer T, Faraone SV. Which SSRI? A meta-analysis of phar-
macotherapy trials in pediatric obsessive-compulsive disor-
89 December 22, 2012
|
Volume 2
|
Issue 6
|
WJP
|
www.wjgnet.com
Lack CW. Research and treatments in OCD
der. Am J Psychiatry 2003;
160
: 1919-1928
41
Abramowitz JS
, Taylor S, McKay D. Obsessive-compulsive
disorder. Lancet 2009;
374
: 491-499
42
Matsunaga H
, Nagata T, Hayashida K, Ohya K, Kiriike N,
Stein DJ. A long-term trial of the effectiveness and safety of
atypical antipsychotic agents in augmenting SSRI-refractory
obsessive-compulsive disorder. J Clin Psychiatry 2009;
70
:
863-868
43
Abudy A
, Juven-Wetzler A, Zohar J. Pharmacological man-
agement of treatment-resistant obsessive-compulsive disor-
der. CNS Drugs 2011;
25
: 585-596
44
March JS
, Franklin ME, Leonard H, Garcia A, Moore P,
Freeman J, Foa E. Tics moderate treatment outcome with
sertraline but not cognitive-behavior therapy in pediatric ob-
sessive-compulsive disorder. Biol Psychiatry 2007;
61
: 344-347
45
Foa EB
, Steketee G, Grayson JB, Turner RM, Latimer PR.
Deliberate exposure and blocking of obsessive-compulsive
rituals: Immediate and long-term effects. Behav Ther 1984;
15
:
450-472
46
Abramowitz J
, Franklin M, Foa E. Empirical status of cogni-
tive-behavioral therapy for obsessive-compulsive disorder:
a meta-analytic review. Rom J Cogn Behav Psychother 2002;
2
:
89-104
47
The Pediatric OCD Treatment Study (POTS) Team
.
Cognitive-Behavior Therapy, Sertraline, and Their
Combination for Children and Adolescents With Obsessive-
Compulsive Disorder: The Pediatric OCD Treatment Study
(POTS) Randomized Controlled Trial. JAMA 2004;
292
:
1969-1976
48
Simpson HB
, Liebowitz MR, Foa EB, Kozak MJ, Schmidt
AB, Rowan V, Petkova E, Kjernisted K, Huppert JD, Franklin
ME, Davies SO, Campeas R. Post-treatment effects of expo-
sure therapy and clomipramine in obsessive-compulsive
disorder. Depress Anxiety 2004;
19
: 225-233
49
Lewin AB
, Storch EA, Merlo LJ, Adkins JW, Murphy T, Gef-
fken GA. Intensive cognitive behavioral therapy for pediatric
obsessive compulsive disorder: A treatment protocol for
mental health providers. Psychol Serv 2005;
2
: 91-104
50
Abramowitz JS
, Whiteside SP, Deacon BJ. The effectiveness
of treatment for pediatric obsessive-compulsive disorder: A
meta-analysis. Behav Ther 2005;
36
: 55-63
51
Barrett P
, Healy-Farrell L, March JS. Cognitive-behavioral
family treatment of childhood obsessive-compulsive dis-
order: a controlled trial. J Am Acad Child Adolesc Psychiatry
2004;
43
: 46-62
52
Ginsburg GS
, Burstein M, Becker KD, Drake KL. Treatment
of obsessive compulsive disorder in young children: An in-
tervention model and case series. Child Fam Behav Ther 2011;
32
: 97-122
53
Keeley ML
, Storch EA, Merlo LJ, Geffken GR. Clinical
predictors of response to cognitive-behavioral therapy for
obsessive-compulsive disorder. Clin Psychol Rev 2008;
28
:
118-130
54
Merlo LJ
, Lehmkuhl HD, Geffken GR, Storch EA. Decreased
family accommodation associated with improved therapy
outcome in pediatric obsessive-compulsive disorder. J Con-
sult Clin Psychol 2009;
77
: 355-360
55
Zampetaki C
, Delimpalta C, Varouchaki E, Zampogiannis A.
The role of group treatment for obsessive-compulsive disor-
der. Eur Psychiat 2011;
26
: 185
56
Belloch A
, Cabedo E, Carrió C, Fernández-Alvarez H, García
F, Larsson C. Group versus individual cognitive treatment
for Obsessive-Compulsive Disorder: changes in non-OCD
symptoms and cognitions at post-treatment and one-year
follow-up. Psychiatry Res 2011;
187
: 174-179
57
Morgan J
, Lack C, Storch EA. The utilization of technol-
ogy in the treatment of obsessive compulsive disorder. In:
Berhardt LV, editor. Advances in Medicine and Biology.
Hauppauge, NY: Nova Science Publishers, 2010: 161-176
58
Lack CW
, Storch EA. The use of computers in the assess-
ment and treatment of obsessive-compulsive disorder. Com-
put Hum Behav 2008;
24
: 917-929
59
Gunter RW
, Whittal ML. Dissemination of cognitive-behav-
ioral treatments for anxiety disorders: Overcoming barriers
and improving patient access. Clin Psychol Rev 2010;
30
:
194-202
60
Norberg MM
, Krystal JH, Tolin DF. A meta-analysis of
D-cycloserine and the facilitation of fear extinction and expo-
sure therapy. Biol Psychiatry 2008;
63
: 1118-1126
61
Kushner MG
, Kim SW, Donahue C, Thuras P, Adson D,
Kotlyar M, McCabe J, Peterson J, Foa EB. D-cycloserine aug-
mented exposure therapy for obsessive-compulsive disorder.
Biol Psychiatry 2007;
62
: 835-838
62
Wilhelm S
, Buhlmann U, Tolin DF, Meunier SA, Pearlson
GD, Reese HE, Cannistraro P, Jenike MA, Rauch SL. Aug-
mentation of behavior therapy with D-cycloserine for obses-
sive-compulsive disorder. Am J Psychiatry 2008;
165
: 335-341;
quiz 409
63
Storch EA
, Murphy TK, Goodman WK, Geffken GR, Lewin
AB, Henin A, Micco JA, Sprich S, Wilhelm S, Bengtson M,
Geller DA. A preliminary study of D-cycloserine augmenta-
tion of cognitive-behavioral therapy in pediatric obsessive-
compulsive disorder. Biol Psychiatry 2010;
68
: 1073-1076
64
Westra HA
, Dozois DJA. Preparing clients for cognitive be-
havioral therapy: A randomized pilot study of motivational
interviewing for anxiety. Cognit Ther Res 2006;
30
: 481-498
65
Steketee G
, Chambless DL, Tran GQ. Effects of axis I and
II comorbidity on behavior therapy outcome for obsessive-
compulsive disorder and agoraphobia. Compr Psychiatry
2001;
42
: 76-86
66
Storch EA
, Merlo LJ, Larson MJ, Geffken GR, Lehmkuhl HD,
Jacob ML, Murphy TK, Goodman WK. Impact of comorbid-
ity on cognitive-behavioral therapy response in pediatric
obsessive-compulsive disorder. J Am Acad Child Adolesc Psy-
chiatry 2008;
47
: 583-592
67
Lack CW
, Lehmkuhl-Yardley H, Dalaya A. Treatment of co-
morbid anxiety disorders across the lifespan. In: Storch EA,
McKay D, editors. Handbook of treating variants and com-
plications in anxiety disorders. New York: Springer, 2013: In
press
68
Gershuny BS
, Baer L, Jenike MA, Minichiello WE, Wilhelm
S. Comorbid posttraumatic stress disorder: impact on treat-
ment outcome for obsessive-compulsive disorder. Am J Psy-
chiatry 2002;
159
: 852-854
69
Storch EA
, Lack CW, Merlo LJ, Geffken GR, Jacob ML, Mur-
phy TK, Goodman WK. Clinical features of children and
adolescents with obsessive-compulsive disorder and hoard-
ing symptoms. Compr Psychiatry 2007;
48
: 313-318
70
Steketee G
, Eisen J, Dyck I, Warshaw M, Rasmussen S. Pre-
dictors of course in obsessive-compulsive disorder. Psychia-
try Res 1999;
89
: 229-238
71
Lehmkuhl HD
, Storch EA, Rahman O, Freeman J, Geffken
GR, Murphy TK. Just say no: Sequential parent management
training and cognitive-behavioral therapy for a child with
comorbid disruptive behavior and obsessive-compulsive
disorder. Clin Case Stud 2007;
8
: 48-58
72
Merlo LJ
, Storch EA, Lehmkuhl HD, Jacob ML, Murphy TK,
Goodman WK, Geffken GR. Cognitive behavioral therapy
plus motivational interviewing improves outcome for pe-
diatric obsessive-compulsive disorder: a preliminary study.
Cogn Behav Ther 2010;
39
: 24-27
73
Maltby N
, Tolin DF. A brief motivational intervention for
treatment-refusing OCD patients. Cogn Behav Ther 2005;
34
:
176-184
74
Simpson HB
, Zuckoff AM, Maher MJ, Page JR, Franklin ME,
Foa EB, Schmidt AB, Wang Y. Challenges using motivational
interviewing as an adjunct to exposure therapy for obses-
sive-compulsive disorder. Behav Res Ther 2010;
48
: 941-948
S- Editor
Wang JL
L- Editor
A
E- Editor
Zheng XM
90 December 22, 2012
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Volume 2
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Lack CW. Research and treatments in OCD
    • "& ERP is similar to traditional exposure therapy, except that special attention is paid to the prevention of escape responses. & Therapy employs in vivo and imaginal exposure and is most efficacious when patients remain in the exposure situation until the compulsive rituals and the obsessional distress reduce spontaneously [44, 45]. & Cognitive therapy (CT) techniques can augment ERP by assisting patients to confront maladaptive thought patterns or mistaken beliefs. "
    [Show abstract] [Hide abstract] ABSTRACT: Anxiety disorders are prevalent and represent an important focus of treatment within the field of psychiatry as well as within medicine more broadly. First-line pharmacotherapy treatment for anxiety disorders is serotonin selective reuptake inhibitors (SSRIs) or serotonin norepinephrine reuptake inhibitors (SNRIs). For patients who do not responsd to an initial first-line treatment, clinicians should ensure that there has been adequate exposure to the medication by assessing compliance and optimizing the prescribed dose. Non-response to a treatment trial should also prompt a re-evaluation of the diagnosis and a search for occult psychiatric, substance, or general medical disorders. Laboratory tests and other components of a diagnostic work-up should be considered if they have not already been completed. Following confirmation of the diagnosis, the clinician should consider a switch to an agent from a different class, for example a tricyclic antidepressant or monoamine oxidase inhibitor. Combination treatments with an antidepressant plus a benzodiazepine, second-generation antipsychotic, anticonvulsant, β-blocker, or other medication may be considered but data is limited. Psychotherapy is an important treatment component for anxiety disorders and should be implemented whenever feasible. Variants of cognitive behavioral therapy (CBT) in particular are effective in reducing anxiety symptoms, and data suggest that the combination for CBT plus medication may be particularly beneficial for patients. Obsessive-compulsive disorder (OCD), while sharing many clinical features with anxiety disorders, represents its own unique clinical challenge and has been removed from the category of anxiety disorders in the 5th edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-V). SSRIs are first-line therapy for OCD and higher doses are often required compared with anxiety disorders or major depressive disorder. Exposure and response prevention may be a particularly helpful form of psychotherapy for this patient population. For severe, intractable OCD, deep brain stimulation may be an appropriate therapeutic option.
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  • [Show abstract] [Hide abstract] ABSTRACT: The European Union Free Movement Directive gives professionals the opportunity to work and live within the European Union, but does not give specific requirements regarding how the specialists in medicine have to be trained, with the exception of a required minimum of 4 years of education. Efforts have been undertaken to harmonize post-graduate training in psychiatry in Europe since the Treaty of Rome 1957, with the founding of the European Union of Medical Specialists (UEMS) and establishment of a charter outlining how psychiatrists should be trained. However, the different curricula for post-graduate training were only compared by surveys, never through a systematic review of the official national requirements. The published survey data still shows great differences between European countries and unlike other UEMS Boards, the Board of Psychiatry did not introduce a certification for specialists willing to practice in a foreign country within Europe. Such a European certification could help to keep a high qualification level for post-graduate training in psychiatry all over Europe. Moreover, it would make it easier for employers to assess the educational level of European psychiatrists applying for a job in their field.
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  • Full-text · Chapter · Feb 2015 · European Psychiatry
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