Cognitive Behavior Therapy for Obsessive-Compulsive and Related Disorders

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Key points

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    Behavioral therapies constitute a high-efficacy, minimal risk treatment of obsessive-compulsive disorder (OCD) and related disorders for individuals of all ages.

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    Based primarily on the principles of extinction learning, cognitive behavior therapy (CBT) and related therapies (eg, habit reversal training) produce equivalent or superior outcomes to pharmacotherapy for OCD and obsessive-compulsive spectrum disorders with few associated adverse side effects.

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    Although flexible in dosing (weekly vs

Overview of cognitive behavior treatment of obsessive-compulsive and related disorders

Cognitive behavior therapy (CBT) with exposure and response prevention (ERP) for obsessive-compulsive disorder (OCD) is a well-established treatment, supported by randomized clinical trials among adults and youth. CBT is a durable, side effect–free intervention that consistently produces improvement in 60% to 83% of patients.1, 2 Studies consistently identify the efficacy of CBT with ERP, with response rates equivalent to or greater than multimodal treatment with pharmacotherapy.3 With relapse

Patient evaluation overview for OCD

Before initiating CBT, a clinical assessment should be conducted to assess for diagnosis, symptom presentation and severity, illness course, functioning/impairment, comorbidity, treatment history, individual strengths, and social support.6, 38 It is important to differentiate obsessions and compulsions associated with OCD from similar symptoms associated with other neuropsychiatric illnesses that may present with ruminations, worries, ritualized behavior, or repetitive intrusive thoughts (eg,

CBT for OCD

CBT has garnered much attention and empirical support for the treatment of OCD.3, 51, 52, 53, 54, 55, 56 Although numerous treatment manuals are available,57, 58, 59, 60, 61, 62, 63, 64 CBT for OCD typically includes the following core therapeutic elements:

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    Psychoeducation

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    Symptom hierarchy development

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    Cognitive training

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    The core therapeutic component, ERP

Psychoeducation (central to CBT for any disorder) provides patients and/or families information about OCD, discusses the cognitive behavioral

Combination therapies: CBT and pharmacotherapy

There are several studies of CBT in combination with pharmacotherapy (or as an augmenting agent). As described earlier, in a double-blind RCT, Foa and colleagues91 examined the relative efficacy of ERP, clomipramine, their combination, and a pill placebo in 122 adults. ERP alone and ERP with clomipramine were both superior to clomipramine alone, with no differences between ERP alone and ERP with clomipramine. In other trials directly comparing CBT and pharmacotherapy, results have been mixed,

OCD

Despite the efficacy of CBT for OCD, at least 30% of individuals do not achieve significant symptom improvement or complete remission.143, 144 Several clinical factors have been implicated in explaining treatment-refractory cases.43, 46 First, comorbid disorders have been associated with poorer treatment response in both pediatric and adult populations; specifically, depressive, schizotypal personality, and disruptive behavior, and attention-deficit/hyperactivity disorders (ADHDs) have shown

Summary

CBT with ERP is an effective and well-tolerated first-line treatment of OCD and spectrum disorders. Compared with medication, CBT with ERP has consistently produced equivalent or superior outcomes. CBT is a highly acceptable treatment and therapeutic gains are more durable following discontinuation of treatment. Nevertheless, accessibility and dissemination remain barriers. Too few practitioners specialize in exposure-based therapies, with an even greater disparity for patients seeking

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    • Cited by (0)

    Dr A.B. Lewin has received research support from the International OCD Foundation, Joseph Drown Foundation, and NARSAD, has an agreement for a publishing honorarium from Springer Publishing, speakers honorarium from the Tourette Syndrome Association, reviewer honorarium from Children’s Tumor Foundation, travel support from Rogers Memorial Hospital, National Institute of Mental Health, and American Academy of Child and Adolescent Psychiatry, and consulting fees from Prophase LLC. Dr E.A. Storch has received research support from the National Institutes of Health (1R01MH093381-01A1) and Agency for Healthcare Research and Quality (1R18HS018665-01A1), author honorarium from Springer Publishing, American Psychological Association, Wiley Incorporated, travel and salary support from Rogers Memorial Hospital, and consulting fees from Prophase LLC. Mr J.F. McGuire and Ms M.S. Wu have no potential conflicts of interest to report.

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