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When Exposures Go Right: Effective Exposure-Based Treatment for Obsessive–Compulsive Disorder

March 2017
Journal of Contemporary Psychotherapy 47(1)

DOI:10.1007/s10879-016-9339-2

Authors:

Cary Jordan

Adam Reid

Harvard Medical School

Andrew Giles Guzick

University of Pennsylvania

Show all 5 authorsHide

Cognitive behavioral therapy with exposure and response prevention (CBT-E/RP) is the first-line treatment for obsessive–compulsive disorder (OCD). Several CBT-E/RP treatment manuals exist, yet clinicians still struggle to implement this evidence-based form of therapy. This article aims to help clinicians implement exposure-based treatment for OCD by providing practical treatment-enhancing strategies. In particular, literature and treatment recommendations related to effective hierarchy formation, strategic exposure design, and optimal exposure implementation is reviewed. Clinical case examples are provided throughout the paper to illustrate important principles, concepts, and recommendations. This paper aims to enhance the delivery of CBT-E/RP and address common questions and concerns that both new and advanced clinicians encounter when learning and applying this form of psychotherapy. Improving the integrity of CBT-E/RP delivery can improve therapeutic outcomes, patient compliance, and successful treatment completion.

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ORIGINAL PAPER

When Exposures Go Right: Effective Exposure-Based Treatment

for Obsessive–Compulsive Disorder

Cary Jordan

1,2

•Adam M. Reid

3,4

•Andrew G. Guzick

•Jessica Simmons

•

Michael L. Sulkowski

Published online: 27 July 2016

ÓSpringer Science+Business Media New York 2016

Abstract Cognitive behavioral therapy with exposure and

response prevention (CBT-E/RP) is the ﬁrst-line treatment

for obsessive–compulsive disorder (OCD). Several CBT-E/

RP treatment manuals exist, yet clinicians still struggle to

implement this evidence-based form of therapy. This arti-

cle aims to help clinicians implement exposure-based

treatment for OCD by providing practical treatment-en-

hancing strategies. In particular, literature and treatment

recommendations related to effective hierarchy formation,

strategic exposure design, and optimal exposure imple-

mentation is reviewed. Clinical case examples are provided

throughout the paper to illustrate important principles,

concepts, and recommendations. This paper aims to

enhance the delivery of CBT-E/RP and address common

questions and concerns that both new and advanced clini-

cians encounter when learning and applying this form of

psychotherapy. Improving the integrity of CBT-E/RP

delivery can improve therapeutic outcomes, patient com-

pliance, and successful treatment completion.

Keywords Exposure-based therapy Psychotherapy 

Evidence-based treatment OCD Clinical

recommendations

Introduction

Obsessive–compulsive disorder (OCD) treatment presents

many challenges for clinicians, but research demonstrates

that obsessive–compulsive symptoms respond well through

comprehensive use of cognitive-behavioral therapy with

exposure and response prevention (CBT-E/RP). Meta-an-

alytic research indicates that CBT-E/RP signiﬁcantly

reduces OCD symptoms in adults (O

¨st et al. 2015) and

youth (McGuire et al. 2015) and is considered the ﬁrst-line

treatment for individuals with OCD (Jordan et al. 2012).

While estimates vary due to methodological differences,

research suggests that typically 62–68 % of individuals

with OCD respond to CBT-E/RP, 57 % achieve clinical

&Cary Jordan

CJordan@mercy.com

Adam M. Reid

amreid@partners.org

Andrew G. Guzick

guzick@phhp.uﬂ.edu

Jessica Simmons

Jessica.Simmons@rogersbh.org

Michael L. Sulkowski

sulkowski@email.arizona.edu

St. Elizabeth Boardman Hospital, Family Health Center,

8423 Market St. Ste. 101, Boardman, OH 44512, USA

Family and Community Medicine, Northeast Ohio Medical

University, Rootstown, OH, USA

Department of Psychiatry, Harvard Medical School, Boston,

MA, USA

Division of Medical Psychology, Department of Psychiatry,

University of Florida, 8491 NW 39th Ave, Gainesville,

FL 32606, USA

Rogers Behavioral Health-Nashville, 4230 Harding Pike,

Nashville, TN 37205, USA

Department of Disability and Psychoeducational Studies,

College of Education, University of Arizona, 1430 East 2nd

St., Tuscon, AZ 85721-0069, USA

123

J Contemp Psychother (2017) 47:31–39

DOI 10.1007/s10879-016-9339-2

Content courtesy of Springer Nature, terms of use apply. Rights reserved.

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Purpose of Review Pediatric OCD is associated with substantive symptoms, impairment across multiple domains and, if left untreated, clinically significant dysfunction extending into adulthood. Fortunately, the efficacy and effectiveness of several forms of treatment have now been established, the most studied of which is cognitive behavioral therapy (CBT) involving exposure plus response prevention (ERP). Our review describes this literature in detail, and also covers the search for predictors and moderators of outcome which may help identify patient subgroups at risk for partial or non-response (treatment-resistant). Recent Findings ERP is efficacious both alone and in combination with pharmacotherapy with serotonin reuptake inhibitors (SRIs) and appears to retain its benefits beyond the context of the academic medical centers where the protocols were developed and tested initially. However, there are still some patients who do not respond fully to the first-line interventions. Data on several potential candidates for prediction and moderation is reviewed, factors that limit the utility of the extant literature are described, and new initiatives are discussed which may allow the field to move forward in informing the development of the algorithms necessary for the application of the principles of precision medicine in pediatric OCD. Summary Efficacious treatments for pediatric OCD have been identified, but response to these first-line interventions is neither universal nor complete. Issues in play that limit access to efficacious forms of care including ERP at present are described, and potential solutions are offered to address current barriers to improving empirically supported interventions and increasing treatment access.

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Written by internationally recognized experts, this comprehensive CBT clinician's manual provides disorder-specific chapters and accessible pedagogical features. The cutting-edge research, advanced theory, and attention to special adaptations make this an appropriate reference text for qualified CBT practitioners, students in post-graduate CBT courses, and clinical psychology doctorate students. The case examples demonstrate clinical applications of specific interventions and explain how to adapt CBT protocols for a range of diverse populations. It strikes a balance between core, theoretical principles and protocol-based interventions, simulating the experience of private supervision from a top expert in the field.

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Treatment of specific fears and phobias is sometimes followed by a return of fear. Work with rats has provided evidence that a greater return of fear occurs when a conditioned stimulus extinguished in 1 context is later presented in a different context than if presented in the same context in which it was originally extinguished. In the present study, 36 human participants who were highly afraid of spiders received 1 session of exposure therapy (with participant modeling) and were then tested for return of fear 1 week later in either the same or a different context. It was hypothesized that there would be a greater return of fear in those participants treated and followed up in different contexts than in those treated and followed up in the same context. Participants tested in a novel context at follow-up showed a greater return of fear than participants tested in the same context. Limitations and areas for future study are discussed.

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While exposure therapy is effective in treating anxiety, fear can return after exposure. Return of fear can be understood through mechanisms of extinction learning. One form of return of fear is reinstatement, or, the fear that results from an unsignaled unconditional stimulus (US) presentation after extinction. Though the conditional response (CR; e.g., fear) typically reduces during extinction, the excitatory conditional stimulus (CS+) valence remains negative. The more negative the CS+ valence after the end of extinction, the greater the fear at reinstatement. The current study evaluated the degree to which positive mood induction (positive imagery training; PIT) compared to control (positive verbal training; PVT) before extinction a) decreased CS+ negative valence during extinction and b) reduced reinstatement fear. Compared to PVT, PIT a) increased positive affect, b) decreased post-extinction CS+ negative valence, and c) reduced reinstatement responding as measured by eye blink startle reflex (when shock was used at reinstatement) and self-report fear (regardless of reinstatement US type). Results suggest that increasing positive affect prior to exposure therapy could reduce relapse through reinstatement. Copyright © 2015 The Authors. Published by Elsevier Ltd.. All rights reserved.

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The current paper outlines the habituation model of exposure process, which is a behavioral model emphasizing use of individually tailored functional analysis during exposures. This is a model of therapeutic process rather than one meant to explain the mechanism of change underlying exposure-based treatments. Habitation, or a natural decrease in anxiety level in the absence of anxiety-reducing behavior, might be best understood as an intermediate treatment outcome that informs therapeutic process, rather than as a mechanism of change. The habituation model purports that three conditions are necessary for optimal benefit from exposures: 1) fear activation, 2) minimization of anxiety-reducing behaviors, and 3) habituation. We describe prescribed therapist and client behaviors as those that increase or maintain anxiety level during an exposure (and therefore, facilitate habituation), and proscribed therapist and client behaviors as those that decrease anxiety during an exposure (and therefore, impede habituation). We illustrate model-consistent behaviors in the case of Monica, as well as outline the existing research support and call for additional research to further test the tenets of the habituation model as described in this paper.

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Context: The empirical literature on treatment of obsessive-compulsive disorder (OCD) in children and adolescents supports the efficacy of short-term OCD-specific cognitive-behavior therapy (CBT) or medical management with selective serotonin reuptake inhibitors. However, little is known about their relative and combined efficacy. Objective: To evaluate the efficacy of CBT alone and medical management with the selective serotonin reuptake inhibitor sertraline alone, or CBT and sertraline combined, as initial treatment for children and adolescents with OCD. Design, setting, and participants: The Pediatric OCD Treatment Study, a balanced, masked randomized controlled trial conducted in 3 academic centers in the United States and enrolling a volunteer outpatient sample of 112 patients aged 7 through 17 years with a primary Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition diagnosis of OCD and a Children's Yale-Brown Obsessive-Compulsive Scale (CY-BOCS) score of 16 or higher. Patients were recruited between September 1997 and December 2002. Interventions: Participants were randomly assigned to receive CBT alone, sertraline alone, combined CBT and sertraline, or pill placebo for 12 weeks. Main outcome measures: Change in CY-BOCS score over 12 weeks as rated by an independent evaluator masked to treatment status; rate of clinical remission defined as a CY-BOCS score less than or equal to 10. Results: Ninety-seven of 112 patients (87%) completed the full 12 weeks of treatment. Intent-to-treat random regression analyses indicated a statistically significant advantage for CBT alone (P = .003), sertraline alone (P = .007), and combined treatment (P = .001) compared with placebo. Combined treatment also proved superior to CBT alone (P = .008) and to sertraline alone (P = .006), which did not differ from each other. Site differences emerged for CBT and sertraline but not for combined treatment, suggesting that combined treatment is less susceptible to setting-specific variations. The rate of clinical remission for combined treatment was 53.6% (95% confidence interval [CI], 36%-70%); for CBT alone, 39.3% (95% CI, 24%-58%); for sertraline alone, 21.4% (95% CI, 10%-40%); and for placebo, 3.6% (95% CI, 0%-19%). The remission rate for combined treatment did not differ from that for CBT alone (P = .42) but did differ from sertraline alone (P = .03) and from placebo (P<.001). CBT alone did not differ from sertraline alone (P = .24) but did differ from placebo (P = .002), whereas sertraline alone did not (P = .10). The 3 active treatments proved acceptable and well tolerated, with no evidence of treatment-emergent harm to self or to others. Conclusion: Children and adolescents with OCD should begin treatment with the combination of CBT plus a selective serotonin reuptake inhibitor or CBT alone.

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Cognitive behavioral treatments of obsessive-compulsive disorder. A systematic review and meta-analysis of studies published 1993–2014

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Obsessive-compulsive disorder is ranked by the WHO as among the 10 most debilitating disorders and tends to be chronic without adequate treatment. The only psychological treatment that has been found effective is cognitive behavior therapy (CBT). This meta-analysis includes all RCTs (N=37) of CBT for OCD using the interview-based Yale-Brown Obsessive Compulsive Scale, published 1993 to 2014. The effect sizes for comparisons of CBT with waiting-list (1.31), and placebo conditions (1.33) were very large, whereas those for comparisons between individual and group treatment (0.17), and exposure and response prevention vs. cognitive therapy (0.07) were small and non-significant. CBT was significantly better than antidepressant medication (0.55), but the combination of CBT and medication was not significantly better than CBT plus placebo (0.25). The RCTs have a number of methodological problems and recommendations for improving the methodological rigor are discussed as well as clinical implications of the findings. Copyright © 2015 Elsevier Ltd. All rights reserved.

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