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The Psychological Treatment of Obsessive-Compulsive Disorder
Abstract
The psychological treatment of obsessive-compulsive disorder (OCD) with exposure and response prevention (ERP) methods is one of the great success stories within the field of mental health. Within the span of about 20 years, the prognosis for individuals with OCD has changed from poor to very good as a result of the development of ERP. This success not with-standing, the procedures are far from perfect because a substantial minority of patients still either refuse treatment, drop out prematurely, or fail to benefit. I begin this article with a review of the development of ERP from early animal research on avoidance learning conducted during the 1950s. Next, I discuss the mechanisms of ERP. The bulk of the article reviews the treatment-outcome literature on ERP for OCD and includes comparisons with cognitive therapy--the "new kid on the block" with respect to psychological treatments for OCD.
... Cognitive behavioral therapy (CBT) focusing on exposure therapy with ritual prevention (ERP; [1]) is considered the treatment of choice for obsessive-compulsive disorder (OCD) [2,3]. ERP is regarded as efficacious [4], but studies have shown that up to 30% of patients drop out of the treatment program [5], 35-40% do not respond to the treatment [6,7], and more than 50% fail to achieve long-term recovery [8,9]. The search for enhanced OCD treatment has led to the development of various treatment formats, ranging from internet-based treatments to intensive and concentrated group treatments [10,11,12,13]. ...
Background
Treatment readiness factors, such as treatment credibility and expectancy, are postulated to be predictors of outcomes within the context of cognitive behavioral therapy (CBT). Concentrated exposure therapy (cET) is a form of short-term, intensive, exposure-based CBT that has shown promising results. This study investigated whether treatment expectancy and credibility predict cET treatment outcomes in patients with difficult-to-treat (nonresponders and patients with relapse following CBT) obsessive-compulsive disorder (OCD).
Methods
A total of 163 patients underwent 4 days of cET treatment. Treatment credibility and expectancy were measured using the Credibility/Expectancy Questionnaire (CEQ) prior to the start of treatment. OCD symptom severity was measured using the Yale-Brown Obsessive Compulsive Scale (Y-BOCS) at pretreatment, posttreatment, 3-month follow-up, and 1-year follow-up. Work- and social functioning were measured before treatment and at the 1-year follow-up.
Results
Higher CEQ scores were significantly associated with lower Y-BOCS score at posttreatment and follow-up after controlling for age, sex, and pretreatment OCD, anxiety, and depression levels. The CEQ scores were also significantly associated with work- and social functioning at the 1-year follow-up. A receiver operating characteristic analysis suggested a mean item cutoff point of 92.5 (0-100 scale) for the CEQ, and 87% of the patients classified as having high expectancy had a positive treatment response.
Conclusions
This study confirmed that treatment expectancy and credibility are predictors of cET outcomes in patients with OCD. Higher scores on the CEQ were linked to better treatment results, both immediately and up to one year later. These insights highlight the need to consider patients’ attitudes toward treatment in the early treatment phase.
Trial registration
ClinicalTrials.gov identifier: NCT02656342 (First registered: 2015-11-30).
... It has been reported that from the first development of symptoms to diagnosis and intervention among OCD cases, it often consumes up to 17 years. However, it is a common psychiatric disorder [27][28][29][30][31]. Furthermore, around 50% of OCD cases do not have considerable improvement with psychotherapy [32,33], and 25-50% of cases show poor adherence to pharmacological intervention [33][34][35]. OCD, when combined with other psychiatric disorders, e.g., MDD or bipolar disorder (BD), aggravates patient situation and it becomes more complex to manage these cases [36][37][38][39][40]. ...
Treatment of resistant obsessive-compulsive disorder (OCD) typically results in insufficient symptom
alleviation, and even long-term medication often fails to have the intended effect. Ketamine is a potent noncompetitive antagonist of the N-methyl-D-aspartate (NMDA) receptor. Studies have shown that low-dose
ketamine infusion results in a considerable reduction in obsessive-compulsive symptoms and a rapid
resolution of suicidal ideation. This is a case report on the effect of intravenous ketamine infusion on a
patient with resistant OCD and severe suicidal ideation. Intravenous (IV) ketamine was given once a week
over consecutive three weeks with necessary precautions. Psychometric tools such as the Yale-Brown
Obsessive Compulsive Scale (Y-BOCS), the Clinical Global Impressions Scale (CGI-S), the Beck Scale for
Suicidal Ideations (BSSI), and Depression Anxiety and Stress Scale 21 (DASS-21) were applied before and
after infusions. Obsessive-compulsive symptoms and suicidal severity started to decrease rapidly after the
first infusion. However, after a transient improvement, these symptoms again began to increase after a
stressful incident on the second day of the first infusion. All the symptoms measured by validated rating
scales showed continued improvement after the following two infusions. The improvement was sustained
until discharge (one week after the last infusion) and subsequent follow-up in the sixth and 12th weeks. The
role of ketamine in reducing suicidal thoughts and behavior is already established. Very few studies
emphasized its effectiveness in improving severe/resistant obsessive-compulsive symptoms. This pioneering
work may offer scope for similar research in the relevant field.
... [1] Today, there is no doubt that OCD is one of the most debilitating mental disorders that severely reduces the quality of life of patients. [2] Studies have shown that people with OCD have many deficiencies in various aspects of cognitive processes such as cognitive flexibility, [3] which reduces emotional distress by creating the ability to use cognitive restructuring, [4] organizing changes, attention, memory, [5,6] and information processing speed. [7,8] Among all cognitive impairments, it is noteworthy that the deficits in cognitive information processing and executive functioning greatly limit the patient's abilities to maintain, acquire, and relearn the skills required for proper functioning. ...
BACKGROUND
In recent studies, the deficit in the cognitive process has been investigated as one of the etiological hypotheses in a wide range of obsessive–compulsive disorders (OCD). This study aimed to compare the effectiveness of acceptance and commitment therapy (ACT) and metacognitive therapy (MCT) on objective cognitive information processing style in obsessive–compulsive patients.
MATERIALS AND METHODS
This quasi-experimental study with a pre-test and post-test plan and a control group was conducted on 45 patients with OCD, matched with gender, age, and educational and marital status. The samples in three groups were selected using the convenience sampling method. Finally, the study participants were randomly divided into two experimental groups and one control group and assessed using Pacini and Epstein's rational experimental Inventory (REI) in two stages, pre-test, and post-test. The experimental groups received ACT and MCT weekly during eight and seven sessions and in a group.
RESULTS
The results showed that ACT and MCT are effective at a significant level in the objective cognitive information processing style of obsessive–compulsive patients (P < 0.05). The post-test results showed that the effect of ACT in changing rational processing style is more effective than MCT treatment. Also, the effect of ACT on intuitive processing style changes was greater than on MCT treatment.
CONCLUSION
The findings of this study indicate that ACT and MCT cause a significant change in intuitive style to rationalism in the thematic processing of cognitive information of obsessive–compulsive patients. According to the results, both methods of treatment improve the research variables in these patients.
... er universalitetsoplevelser og gruppeidenti kation på ingen måde tilstraekkelige til at fremme den enkeltes motivation for forandring -men de giver deltagerne mulighed for at vedgå sig egne behov og omsaette dem aktivt, hvorfor de er vaerd at fremme. Imidlertid peger mine analyser på, at symptomheterogeniteten, som kendetegner OCD (Taylor et al., 2007), kan forhindre disse oplevelser. Et oplagt tiltag forekommer derfor at vaere, at OCD-ramte personer, hvis symptomer i høj grad divergerer, ikke placeres i samme gruppe. ...
OCD er en alvorlig lidelse med vidt- rækkende konsekvenser, hvorfor behovet for motiverende behandling er stort. Kognitiv ad- færdsterapeutisk gruppebehandling (G-CBT) benyttes ofte i behandlingen af OCD. Imid- lertid har få studier fokuseret på deltagernes subjektive perspektiver. For at råde bod på dette – og for at finde måder, hvorpå nuværende praksis evt. kan forbedres – udførte jeg i 2011 en kritisk psykologisk undersøgelse i forbindelse med mit speciale. Undersøgel- sen udforskede, hvordan OCD-ramte voksne forholdt sig til G-CBT. Formålet var at un- dersøge, hvordan modsætninger relateret til behandlingen kunne hhv. fremme og begrænse deltagernes motivation for forandring. I denne artikel identificeres og analyseres 9 modsætningspar på baggrund af 3 kvali- tative interviews med OCD-ramte voksne. I forlængelse heraf bliver det diskuteret, hvilke forandringer, der kan implementeres mhp. at støtte deltagerne i at udvide deres handlemu- ligheder – bl.a. bliver det foreslået, at delta- gere skal have indflydelse på den terapeutiske dagsorden, at succes bør tilfalde deltagerne, mens nederlag skal deles, samt at individuel terapi skal tilbydes som supplement. Endelig bliver det pointeret, at mere gennemgribende ændringer er nødvendige, fx på arbejdsmarkedet, dersom OCD-ramte mennesker skal opleve reelle forbedringer.
... In the CT condition, treatment focused on "overestimation of danger and inflated personal responsibility," and after session 6, behavioral experiments were included to test the basis of unrealistic beliefs. The exposure condition consisted of EX/RP working up a hierarchy of feared and avoided situations, with no discussion of feared consequences until after session 6. 42 Clinical researchers should continue to refine CBT programs to maximize improvement and make treatment more palatable to those in need of help. It is difficult to determine the usefulness of psychological interventions other than EX/RP and CBT because of lack of control studies. ...
Until the mid-1960s, obsessive-compulsive disorder (OCD) was considered to be treatment-resistant, as both psychodynamic psychotherapy and medication had been unsuccessful in significantly reducing OCD symptoms. The first real breakthrough came in 1966 with the introduction of exposure and ritual prevention. This paper will discuss the cognitive behavioral conceptualizations that influenced the development of cognitive behavioral treatments for OCD. There will be a brief discussion of the use of psychodynamic psychotherapy and early behavioral therapy, neither of which produced successful outcomes with OCD. The main part of the paper will be devoted to current cognitive behavioral therapy (CBT) with an emphasis on variants of exposure and ritual or response prevention (EX/RP) treatments, the therapy that has shown the most empirical evidence of its efficacy.
Obsessive-compulsive disorder (OCD) is a severe and disabling psychiatric disorder that impacts people all around the world. OCD has several different phenotypes, with intrusive visual images being a presentation of the disease. In this paper, a case is presented of a patient who suffers from intrusive visual images of a large spider and octopus with visualization of the tentacle on her body. These visual images were identified as a symptom of OCD; therefore, this paper aims to present this unique presentation of the disease.
Background
Exposure and response prevention (ERP) is considered the first-line psychotherapy for obsessive-compulsive disorder (OCD). Substantial research supports the effectiveness of ERP, yet a notable portion of patients do not fully respond while others experience relapse. Understanding poor outcomes such as these necessitates further research. This study investigated the role of patient adherence to ERP tasks in concentrated exposure treatment (cET) in a sample who had previously not responded to treatment or relapsed.
Method
The present study included 163 adults with difficult-to-treat OCD. All patients received cET delivered during four consecutive days. Patients’ treatment adherence was assessed using the Patient EX/RP Adherence Scale (PEAS-P) after the second and third day of treatment. OCD severity was evaluated at post-treatment, 3-month follow-up, and 1-year follow-up by independent evaluators.
Results
PEAS-P scores during concentrated treatment were associated with OCD-severity at post-treatment, 3-month follow-up, and 1-year follow-up. Moreover, PEAS-P scores predicted 12-month OCD severity adjusting for relevant covariates. Adherence also predicted work- and social functioning at 1-year follow-up.
Conclusions
These results indicate that ERP adherence during the brief period of cET robustly relates to improvement in OCD symptoms and functioning in both the short and long term. Assessing adherence might identify patients at risk of poor outcomes, while improving adherence may enhance ERP for treatment resistant patients.
Trial Registration
ClinicalTrials.gov identifier: NCT02656342.
Background
Although cognitive behavioral therapy is a highly effective treatment for obsessive-compulsive disorder (OCD), yielding large symptom reductions on the group level, individual treatment response varies considerably. Identification of treatment response predictors may provide important information for maximizing individual treatment response and thus achieving efficient treatment resource allocation. Here, we investigated the predictive value of previously identified biomarkers of OCD, namely the error-related activity of the supplementary motor area (SMA) and the sensorimotor network (SMN, postcentral gyrus/precuneus).
Methods
Seventy-two participants with a primary diagnosis of OCD underwent functional magnetic resonance imaging (fMRI) scanning while performing a flanker task prior to receiving routine-care CBT.
Results
Error-related BOLD response of the SMN significantly contributed to the prediction of treatment response beyond the variance accounted for by clinical and sociodemographic variables. Stronger error-related SMN activity at baseline was associated with a higher likelihood of treatment response.
Conclusions
The present results illustrate that the inclusion of error-related SMN activity can significantly increase treatment response prediction quality in OCD. Stronger error-related activity of the SMN may reflect the ability to activate symptom-relevant processing networks and may thus facilitate response to exposure-based CBT interventions.
Background
The COVID-19 pandemic has been suggested to constitute a broad base stressor with severe mental health consequences. mHealth applications are accessible self-help tools that can be used to reduce psychological distress during the pandemic. This randomized controlled trial evaluated the effects of mobile-based cognitive training exercises on COVID-19 related distress and maladaptive cognitions.
Methods
Following initial screening (n = 924), participants scoring 1 standard deviations above the mean of the COVID-19 Distress Scale were randomized into two groups. Participants in the immediate-app group (iApp; n = 25) started using the application at baseline (T0) for 12 days (from T0 to T1). Participants in the delayed-app group (dApp; n = 22) started using the mobile application at T1 (crossover) and used it for the following 12 days (T1 to T2).
Results
Intention to treat analyses indicated that the iApp group exhibited lower COVID-19 distress, lower depression, fewer intolerance of uncertainty and obsessive beliefs than the dApp group at T1. In addition, using the app for 12 consecutive days was associated with large effect-size reductions (Cohen's d ranging from 0.81 to 2.35) in COVID-19 distress and related maladaptive cognitions in the iApp group (from T0 to T1) and the dApp group (from T1 to T2). Moreover, these reductions were maintained at the follow-up.
Limitations
This study was a crossover trial with a relatively limited sample size and mainly female participants.
Conclusion
Our findings underscore the usefulness of brief, low-intensity, portable interventions in alleviating the negative effects of the pandemic on mental health.
The authors compared obsessive-compulsive symptoms in 150 patients with obsessive-compulsive disorder (OCD) who had never experienced a mood disorder, who had once experienced a mood disorder, and who had a current mood disorder. All patients were administered the Structured Clinical Interview for DSM-III-R, the Yale-Brown Obsessive-Compulsive Scale, and the Beck Depression Inventory. Patients with comorbid mood disorder showed more severe obsessional symptoms, but not more severe compulsive symptoms, than did patients without mood disorder. In patients free of mood disorder, severity of subclinical dysphoria was correlated with severity of obsessions as well, but not with severity of compulsions. That is, mood disorders seem selectively associated with worsening of obsessions.
Cognitive-behavioral therapy (CBT) and pharmacotherapy with serotonin reuptake inhibitors (SRIs) are established monotherapies for obsessive-compulsive disorder (OCD), yet research on their combined efficacy is lacking. Practicing psychologists who treat OCD are thus unable to say definitively whether exposure and ritual prevention would be more successful with concomitant SRI pharmacotherapy. The authors explored this issue in a clinical sample of 56 outpatients who received fee-for-service CBT; 31 (55%) received CBT alone, and 25 (45%) received CBT plus SRI. Both groups made clinically significant and comparable posttreatment gains, suggesting that CBT is effective with or without concomitant pharmacotherapy. Clinical implications are discussed. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
We present a meta-analytic review of 16 controlled treatment studies of cognitive behavioral therapy for obsessive-compulsive disorder (OCD). Specifically, we examined the efficacy of exposure-based therapy, cognitive therapy, and their combination; and we investigated the relative efficacy of exposure and cognitive treatment programs. Consistent with previous research, our results revealed that exposure therapy was significantly more effective than control (effect size = 1.50; percent symptom reduction = 48.32). Although, cognitive and combined treatments were also superior to controls, effect sizes did not differ reliably from zero, probably due to the small number of studies. Results of direct comparisons between exposure and cognitive therapy are difficult to interpret due to 1) the use of behavioral experiments (which are similar to elements of exposure) in several cognitive treatment programs; and 2) the absence of therapist supervision in many exposure programs. The use of cognitive and exposure procedures in both types of treatment is discussed. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
Studies that have examined the effects of comorbid depression on response to treatment in obsessive-compulsive disorder (OCD) have yielded inconsistent results. We examined treatment outcome for 15 OCD patients with comorbid major depressive disorder (MDD) and 33 OCD patients without MDD. All patients received intensive cognitive-behavioral therapy by exposure and response (ritual) prevention. Improvement in OCD symptoms was observed in both patient groups, and treatment gains were maintained at follow-up. Whereas the presence of a comorbid MDD diagnosis in OCD was not related to treatment failure, nondepressed patients had significantly lower posttreatment and follow-up OCD severity scores.
This study examined the effects of cognitive- behavior therapy (CBT) compared with traditional behavior therapy (exposure and response prevention [ERP]) in the group treatment of obsessive-compulsive disorder. Of the 76 participants who started treatment, 38 were wait-listed for 3 months before treatment to assess possible course effects. Both treatments were superior to the control condition in symptom reduction, with ERP being marginally more effective than CBT by end of treatment and again at 3-month follow-up. In terms of clinically significant improvement, treatment groups were equivalent on the conclusion of treatment, but 3 months later significantly more ERP participants met criteria for recovered status. Only 1 of 7 belief measures changed with treatment improvement, and the extent of this cognitive change was similar between CBT and ERP groups. Discussion includes consideration of optimal formats for the delivery of different types of treatment.
The efficacy of exposure and ritual prevention (EX/RP) for reducing symptoms of obsessive-compulsive disorder (OCD) has been demonstrated in several randomized controlled trials (RCTs). However, procedures used in these studies to maximize experimental control may have limited their generalizability to typical clinical practice. Treatment outcome data from 110 clinical patients receiving EX/RP on an outpatient fee-for-service basis were compared with findings from 4 RCTs of EX/RP. Adult patients in the clinical sample were not excluded because of treatment history, concomitant pharmacotherapy, psychiatric comorbidity, age, or OCD severity. Clinical patients achieved substantial and clinically meaningful reductions in their OCD and depressive symptoms following EX/RP, which were comparable with those reported in the RCTs. Findings indicate that EX/RP is a potent treatment for OCD, and its benefits are not limited to select patient samples. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
• Reviews the book, Understanding and Treating Obsessive-Compulsive Disorder: A Cognitive-Behavioral Approach by Jonathan S. Abramowitz (see record 2005-13001-000 ). Cognitive-behavioral therapy (CBT) incorporating exposure and response prevention (ERP) is the psychosocial treatment of choice for obsessive-compulsive disorder (OCD). Despite the demonstrated efficacy of ERP, this treatment is not widely used by mental health practitioners who treat OCD in the community. This book aims to disseminate the theory and technique of ERP to mental health clinicians who might otherwise not be familiar with this approach. The book is divided into two sections. The first section, "What We Know About OCD," presents a cognitive-behavioral model that will provide the theoretical underpinning for the treatment. The next section, "How to Conduct Consultation and Treatment for OCD," gets into the nuts and bolts of the treatment itself. Abramowitz provides detailed diagnostic and assessment-related information, and selected assessment measures are reprinted in an Appendix of the book. This book is a thorough, readable guide for clinicians treating patients with OCD. Although Abramowitz outlines a cognitive-behavioral model of OCD, therapists unfamiliar with this treatment modality may benefit from some background reading to make the most effective use of this book. The treatment descriptions are clear and easy to follow, without resorting to a "cookbook" style that leaves little room for creativity and flexibility on the part of the therapist. The book will likely become a "must read" for students and clinicians learning about this powerful approach to treatment. (PsycINFO Database Record (c) 2016 APA, all rights reserved)
• Reviews the book, Understanding and Treating Obsessive-Compulsive Disorder: A Cognitive-Behavioral Approach by Jonathan S. Abramowitz (see record 2005-13001-000 ). Cognitive-behavioral therapy (CBT) incorporating exposure and response prevention (ERP) is the psychosocial treatment of choice for obsessive-compulsive disorder (OCD). Despite the demonstrated efficacy of ERP, this treatment is not widely used by mental health practitioners who treat OCD in the community. This book aims to disseminate the theory and technique of ERP to mental health clinicians who might otherwise not be familiar with this approach. The book is divided into two sections. The first section, "What We Know About OCD," presents a cognitive-behavioral model that will provide the theoretical underpinning for the treatment. The next section, "How to Conduct Consultation and Treatment for OCD," gets into the nuts and bolts of the treatment itself. Abramowitz provides detailed diagnostic and assessment-related information, and selected assessment measures are reprinted in an Appendix of the book. This book is a thorough, readable guide for clinicians treating patients with OCD. Although Abramowitz outlines a cognitive-behavioral model of OCD, therapists unfamiliar with this treatment modality may benefit from some background reading to make the most effective use of this book. The treatment descriptions are clear and easy to follow, without resorting to a "cookbook" style that leaves little room for creativity and flexibility on the part of the therapist. The book will likely become a "must read" for students and clinicians learning about this powerful approach to treatment. (PsycINFO Database Record (c) 2016 APA, all rights reserved)