Treating Obsessive-Compulsive Disorder in Intimate Relationships: A Pilot Study of Couple-Based Cognitive-Behavior Therapy

Although cognitive-behavioral therapy (CBT) involving exposure and response prevention (ERP) is an established treatment for obsessive-compulsive disorder (OCD), not all patients respond optimally, and some show relapse upon discontinuation. Research suggests that for OCD patients in close relationships, targeting relationship dynamics enhances the effects of CBT. In the present study, we developed and pilot tested a 16-session couple-based CBT program for patients with OCD and their romantic partners. This program included (a) partner-assisted ERP, (b) techniques targeting maladaptive relationship patterns focal to OCD (e.g., symptom accommodation), and (c) techniques targeting non OCD-related relationship stressors. OCD, related symptoms, and relationship functioning were assessed at baseline, immediately following treatment (posttest), and at 6- and 12-month follow-up. At posttest, substantial improvements in OCD symptoms, relationship functioning, and depression were observed. Improvements in OCD symptoms were maintained up to 1 year. Results are compared to findings from studies of individual CBT for OCD and discussed in terms of the importance of addressing interpersonal processes that maintain OCD symptoms.     

Addressing Barriers to Change in the Treatment of Childhood Obsessive Compulsive Disorder

Although considerable evidence supports the use of cognitive behavior therapy (CBT) for the treatment of childhood obsessive compulsive disorder, large numbers of youth fail to respond and clinical remission is often elusive. Poor family functioning frequently is implicated as an obstacle for youth undergoing CBT, with features such as symptom accommodation, family conflict, and blame known to attenuate outcomes. These features are common in child and adolescent obsessive compulsive disorder (OCD) and they may pose particular challenges for exposure-based treatments. Nonetheless, interventions that focus specifically on family functioning have, to date, been limited. This paper reviews the literature on family features associated with childhood OCD and discusses their links to treatment outcome. It then describes the development of a brief family intervention tailored to address the needs of highly distressed families of youth with OCD in the service of improving individual child CBT outcomes. Preliminary pilot data are presented and clinical implications are discussed.     

Obsessive-Compulsive Disorder in Late Life

Although obsessive-compulsive disorder (OCD) has received increasing attention, the study and treatment of OCD in late life has been neglected. The obsessions and compulsions seen with older adults do not appear to differ from the symptoms experienced by other age groups, although developmental issues might influence symptom focus (e.g., memory functioning-related obsessions). Hoarding difficulties might be prevalent in late life, although additional studies are needed. Seniors with OCD can present with comorbid psychiatric disorders, multiple general medical problems, and impaired cognitive functioning, complicating evaluation. There have not been controlled clinical trials of cognitive-behavioral therapy (CBT) for late-life OCD, although initial reports suggest older adults respond to CBT that includes age-related treatment modifications. We illustrate the challenges to assessing and treating older adults with OCD with case examples involving memory-related obsessions and clinical hoarding. The successful strategies used for adapting CBT for the treatment of late-life generalized anxiety disorder might serve as a model for advancing the study and treatment of late-life OCD.     

Effect of treatments for depression on quality of life: a meta-analysis*

Cognitive-behavioral therapy (CBT) and selective serotonin reuptake inhibitors (SSRIs) are the two first-line treatments for depression, but little is known about their effects on quality of life (QOL). A meta-analysis was conducted to examine changes in QOL in adults with major depressive disorder who received CBT (24 studies examining 1969 patients) or SSRI treatment (13 studies examining 4286 patients) for their depression. Moderate improvements in QOL from pre to post-treatment were observed in both CBT (Hedges’ g = .63) and SSRI (Hedges’ g = .79) treatments. The effect size remained stable over the course of the follow-up period for CBT. No data were available to examine follow-ups in the SSRI group. QOL effect sizes decreased linearly with publication year, and greater improvements in depression were significantly associated with greater improvements in QOL for CBT, but not for SSRIs. CBT and SSRIs for depression were both associated with moderate improvements in QOL, but are possibly caused by different mechanisms.     

Intensive Family-Based Cognitive-Behavioral Therapy for Pediatric Obsessive-Compulsive Disorder: Applications for Treatment of Medication Partial- or Nonresponders

Serotonin reuptake inhibitor medications and cognitive-behavioral therapy (CBT) are both effective treatments for pediatric obsessive-compulsive disorder (OCD). Despite recommendations that youth with OCD be treated with CBT alone or together with serotonin reuptake inhibitor medication, many youth are treated with medication alone or with non-CBT psychotherapy initially. Although effective, symptom remission with medication alone is rare (e.g., only 21.4% of youth achieved remission with sertraline in the Pediatric OCD Treatment Study, 2004) and residual symptoms often remain (e.g., 58% of subjects in the March et al. [1998] sertraline trial were not considered treatment responders). This paper reviews the literature on the efficacy of CBT for pediatric OCD, particularly as it relates to the treatment of youth with prior inadequate response to medication. It also describes an intensive, family-based CBT program for children and adolescents with OCD and support for its efficacy among those with prior partial- or nonresponse to medication. Finally, we present a case study of an adolescent girl with OCD who participated in the intensive treatment program after having limited benefit from medication and non-CBT psychotherapy and experienced a favorable response.     

Subtypes of obsessive-compulsive disorder: Implications for specialized cognitive behavior therapy

Although obsessive-compulsive disorder (OCD) is a heterogeneous condition, OCD subtypes have received limited attention in trials of cognitive behavior therapy (CBT). Because many patients with OCD do not respond optimally to CBT, it is important for clinicians to consider whether variability in treatment response is related to symptom presentation. Treatment modifications for patients without overt compulsions or with hoarding symptoms show promise. In this article we discuss the available research addressing the treatment of OCD subtypes, review the clinical characteristics and treatment recommendations for prominent OCD subtypes, raise the prospect of using dysfunctional beliefs as a potentially helpful conceptual approach to subtyping OCD and matching treatment to subtypes, and consider future directions in the treatment of OCD subtypes.     

An open clinical trial of cognitive-behaviour therapy in children and adolescents with obsessive-compulsive disorder administered in regular outpatient clinics

The aim of the present study was to examine the effectiveness of manual-guided cognitive-behaviour therapy (CBT) for childhood obsessive-compulsive disorder (OCD) administered within three regular, i.e., non-academic, Norwegian outpatient child psychiatric clinics. METHODS: A total of 28 youngsters, aged 8-17 with primary OCD entered the study. Assessment at intake included Norwegian versions of the K-SADS-PL, Children's Yale-Brown Obsessive Compulsive Scale (CY-BOCS), and a measure of OCD-specific functional impairment (Child OCD Impact Scale (COIS)). Therapy consisted of 12 manual-guided sessions with combined individual and family CBT-based interventions and was conducted by psychologists and physicians under training and supervision. Outcome was assessed after treatment and at 3- and 6-month follow-ups by means of the CY-BOCS, the Clinical Global Impression (CGI) and the CGI-Improvement scales, and the COIS. RESULTS: Twenty-four youngsters (86%) completed treatment and were available for the follow-up assessments. Significant improvements were found on all outcome measures after treatment, including a mean symptom reduction on the CY-BOCS of 60.6%, increasing to 68.8% at the 6-month follow-up. Estimates of within-group effect sizes showed strong effects of treatment. CONCLUSION: The results of the present study suggest that manual-guided CBT for childhood OCD can be successfully implemented in non-academic community child psychiatric settings with outcomes in accordance with previous findings from highly specialised university clinics.     

Can Cognitive‐Behavioral Therapy Be Optimized With Parent Psychoeducation? A Randomized Effectiveness Trial of Adolescents With Major Depression in Puerto Rico

This is a longitudinal randomized control trial on the impact of adding a parent psychoeducation intervention (TEPSI) as part of cognitive‐behavioral therapy (CBT) for adolescents with Major Depressive Disorder (MDD) in a Puerto Rican sample. We tested the efficacy of adding 8 group sessions of TEPSI to 12 sessions of individual CBT on reducing depressive symptoms, MDD diagnosis, and improving family functioning. Participants (n = 121) were randomized to individual CBT with or without TEPSI. No main group effects were found for most patient domains including depression symptoms, as well as presence of adolescent's MDD diagnosis at posttreatment. Results did show a main effect of CBT over time for depression symptoms, suicide ideation, family criticism, and the presence of MDD diagnosis decreasing from pre‐ to postintervention. A year post treatment, almost 70% of adolescents in both conditions (CBT and CBT + TEPSI) remained in remission. A main effect was obtained for treatment in the adolescent's perception of familism and family emotional involvement. The primary hypothesis that family psychoeducation would optimize CBT for depression in adolescents was not supported. Both conditions yielded similar clinical end points. The culturally adapted CBT was found effective with Latino/a adolescents showing clinically significant improvements from pretreatment to posttreatment and remained stable at a 1‐year follow‐up. Regarding family outcomes, adolescents in CBT + TEPSI remained stable from pretreatment to posttreatment on family emotional involvement, while adolescents in CBT‐alone showed an increase. The implication of these findings is discussed.     

Patient utilization of cognitive-behavioral therapy for OCD

The current study examined utilization of cognitive-behavioral therapy (CBT) by individuals receiving treatment for obsessive-compulsive disorder (OCD). Participants were 202 adults with primary DSM-IV OCD who enrolled in a longitudinal, observational study of the course of OCD and completed 2 years of annual follow-up interviews using the Longitudinal Interval Follow-Up Evaluation. One hundred twenty participants reported that a mental health professional recommended CBT for their OCD symptoms at some point during the 2-year follow-up period. One quarter (n = 31) of these participants did not initiate CBT despite receiving a treatment recommendation. Thirty-one percent of the 89 participants who entered CBT endorsed dropping out of CBT prematurely and less than one third received an adequate “dose” of CBT sessions. Self-reported CBT drop-out rates were significantly greater than attrition rates reported in clinical trials using intensive schedules of exposure and ritual prevention (EX/RP). Perceived environmental barriers and fears regarding treatment participation were the most frequently endorsed reasons for not participating or dropping out of CBT. Despite its efficacy for OCD, many individuals with clinically significant symptoms fail to initiate CBT when recommended by a mental health professional, receive treatments that are less intensive than those used in clinical trials, or drop out of treatment prematurely. Financial costs of CBT, difficulty attending sessions, and fears regarding treatment are significant barriers to initiating and completing therapy.     

Mood, personality disorder symptoms and disability in obsessive compulsive hoarders: a comparison with clinical and nonclinical controls

Hoarding is a symptom of obsessive compulsive disorder (OCD), as well as a diagnostic criterion for obsessive compulsive personality disorder (OCPD). One recent study suggests that people who suffer from compulsive hoarding report more general psychopathology than people who do not [Frost, R.O., Krause, M.S., & Steketee, G. (1996). Hoarding and obsessive compulsive symptoms. Behavior Modification, 20, 116-132]. The present study addressed whether persons with OCD hoarding exhibit more depression, anxiety, OCD and personality disorders symptoms than community controls, OCD nonhoarders, or other anxiety disorder patients. Disability was also examined. Hoarding subjects were older than the other three groups, but age did not account for any of the differences observed among the groups. Compared to controls, OCD hoarding, nonhoarding OCD and anxiety disorder patients showed elevated YBOCS scores, as well as higher scores on depression, anxiety, family and social disability. Compared to nonhoarding OCD and anxiety disorder patients, OCD hoarding patients scored higher on anxiety, depression, family and social disability. Hoarding subjects had greater personality disorder symptoms than controls. However, OCD hoarding subjects differed from OCD nonhoarding and anxiety disorder subjects only on dependent and schizotypal personality disorder symptoms. The findings suggest that hoarding is associated with significant comorbidity and impairment compared to nonhoarding OCD and other anxiety disorders.     

Cognitive behavior therapy in treatment-naive children and adolescents with obsessive-compulsive disorder: an open trial

This work aims is to evaluate the therapeutic efficacy of cognitive behavior therapy (CBT) in pediatric patients with obsessive-compulsive disorder (OCD) who had not previously been treated with either pharmacotherapy or psychotherapy and who remained medication-free during CBT. Sixteen OCD outpatients, 8-17 years of age, were treated in a 12-week open trial with manualized CBT. Target symptoms were rated at two-week intervals with the Children's Yale-Brown Obsessive Compulsive Scale (CY-BOCS), the National Institute of Mental Health Global Obsessive-Compulsive Scale (NIMH Global), the Clinical Global Impression Scale (CGI), and the Hamilton Anxiety Rating Scale (Ham-A). Statistical analyses showed a significant benefit for treatment. Ten patients experienced at least a 50% reduction in symptoms on the CY-BOCS; seven were asymptomatic on the NIMH Global. These results build on previous reports that CBT may be effective in the acute treatment of pediatric OCD. Further, the results of this study suggest that CBT can be efficacious in alleviating OCD symptoms in the absence of pharmacotherapy. These results must be considered preliminary, given the small sample size and open administration of treatment.     

Behavioural group therapy for obsessive-compulsive disorder in Norway. An open community-based trial

The aim of the current study was to test the effectiveness of ERP-based 12 weeks group therapy for OCD patients in a community-based, general Norwegian outpatient clinic. The sample consisted of 54 patients diagnosed with OCD. The Yale-Brown Obsessive-Compulsive Scale (Y-BOCS), the Beck Depression Inventory (BDI) and the Spielberger State Anxiety Inventory (STAI-S) were administered before treatment, after treatment and at 3- and 12-month follow-ups. Analyses with mixed models for repeated measurements showed that group behavioural therapy offered to OCD patients significantly improved ratings of obsessive-compulsive symptoms, depression and anxiety. These improvements were maintained at 3- and 12-month follow-ups and an additional reduction in obsessive-compulsive symptoms was observed from post-treatment to 3-month follow-up. However, the delayed effect of therapy was no longer present at 12-month follow-up. The results also revealed that the patients had a lower chance for an increased outcome category (e.g. from unchanged to improved or recovered) with high scores on STAI-S at the given observation times (post-treatment, 3- and 12-months follow-ups). Depressive symptoms (BDI) at post-treatment and follow-ups had no significant influences on the three categories of outcome for OCD. In conclusion, the results indicate that behavioural group therapy can successfully be delivered to patients with considerable comorbidity in a real world setting conducted by therapists with limited training in the CBT.     

What Do People Really Think of Me? Evaluating Bias in Interpersonal Predictions Over the Course of Cognitive-Behavioral Therapy of Depression

Cognitive behavioral therapy (CBT) of depression is hypothesized to achieve its effects by correcting negative biases. However, little research has tested how biases change over the course of CBT. We focus on biases in interpersonal judgments and examine whether changes in biases occur in CBT and are associated with symptom improvements. A sample of 126 adults (60% women, mean age 31.7, 83% White) participated in CBT of depression. Observers provided ratings of patients participating in two interpersonal tasks on three occasions. Patients were asked to predict observers’ ratings. In a thin slice (TS) task, observers evaluated how patients came across in a brief segment in which patients talked about themselves. In a Standard Interaction Task (SIT), observers rated the social skills patients displayed in challenging role plays. The difference between patient predictions and observer ratings provided measures of bias in these interpersonal judgments. TS and SIT bias became significantly less pessimistic and more realistic over the course of CBT. Improvements in TS bias were associated with a faster reduction in symptoms, whereas there was a non-significant trend for improvement in SIT bias being associated with faster symptom reduction. Consistent with the CBT model, negative interpersonal biases became more realistic throughout a course of CBT for depression and at least some of the changes in bias were related to therapeutic outcomes. We encourage future researchers to continue examining for whom and under which conditions correcting such biases produces the greatest benefits.     

Behavioral group treatment for obsessive-compulsive disorder in adolescence: a pilot study

This pilot study is a preliminary evaluation of the effectiveness of a cognitive-behavioral outpatient group treatment (CBT) protocol for adolescents with Obsessive-Compulsive Disorder (OCD). Seven adolescents were treated in a 10-session group CBT program with weekly 2-hour sessions. The treatment protocol was an adaptation of approaches with established effectiveness and emphasized three main components: externalizing the OCD by cultivating mindful detachment; exposure and response prevention (ERP); and refocusing on alternative, constructive behaviors following exposure. An occupational therapy component played a significant role in designing creative exposure and refocusing challenges. Self-report measures at pre, post, and 12-month follow-up suggested clinical improvements for 5 of the 7 patients, thus partially supporting a group treatment format for adolescents with mild to moderate OCD.     

Treatment of obsessions: A randomized controlled trial

This study tested Rachman's cognitive behavioral method for treating obsessions not accompanied by prominent overt compulsions. The cognitive behavioral treatment was compared to waitlist control and an active and credible comparison of stress management training (SMT). Of the 73 adults who were randomized, 67 completed treatment, and 58 were available for one-year follow-up. The active treatments, compared to waitlist, resulted in substantially lower YBOCS scores, OCD-related cognitions and depression as well as improved social functioning. Overall, CBT and SMT showed large and similar reductions in symptoms. Pre-post effect sizes on YBOCS Obsessions for CBT and SMT completers was d = 2.34 and 1.90, respectively. Although CBT showed small advantages over SMT on some symptom measures immediately after treatment, these differences were no longer apparent in the follow-up period. CBT resulted in larger changes on most OCD-related cognitions compared to SMT. The cognitive changes were stable at 12 months follow-up, but the differences in the cognitive measures faded. The robust and enduring effects of both treatments contradict the long-standing belief that obsessions are resistant to treatment.     

Measuring Change in OCD: Sensitivity of the Obsessive-Compulsive Inventory-Revised

This study examined the sensitivity to change and specificity of response of the Obsessive-Compulsive Inventory-Revised (OCI-R), an 18-item self-report measure of obsessive-compulsive disorder (OCD) severity. Seventy-seven OCD patients received cognitive-behavioral therapy incorporating exposure and response prevention (ERP). Change from pre- to posttest on the OCI-R was compared to changes as assessed by the Yale-Brown Obsessive Compulsive Scale (Y-BOCS) and other measures of OCD and related symptoms. Results suggest the OCI-R is sensitive to treatment effects and that pre- to posttest change on this instrument reflects improvement in OCD and related symptoms of depression, anxiety, and global functioning. The OCI-R was not sensitive to improvement in patients’ insight into the senselessness of their OCD symptoms. The OCI-R appears suitable for use in clinical settings and naturalistic outcome studies where time and resources do not permit administration of lengthy symptom interviews.     

Grief and trauma intervention for children after disaster: exploring coping skills versus trauma narration

This study evaluated the differential effects of the Grief and Trauma Intervention (GTI) with coping skills and trauma narrative processing (CN) and coping skills only (C). Seventy African American children (6-12 years old) were randomly assigned to GTI-CN or GTI-C. Both treatments consisted of a manualized 11-session intervention and a parent meeting. Measures of trauma exposure, posttraumatic stress symptoms, depression, traumatic grief, global distress, social support, and parent reported behavioral problems were administered at pre, post, 3 and 12 months post intervention. In general, children in both treatment groups demonstrated significant improvements in distress related symptoms and social support, which, with the exception of externalizing symptoms for GTI-C, were maintained up to 12 months post intervention. Results suggest that building coping skills without the structured trauma narrative may be a viable intervention to achieve symptom relief in children experiencing trauma-related distress. However, it may be that highly distressed children experience more symptom relief with coping skills plus narrative processing than with coping skills alone. More research on the differential effects of coping skills and trauma narration on child distress and adaptive functioning outcomes is needed.     

Efficacy of Cognitive Therapy for Body Dysmorphic Disorder: A Randomized Controlled Pilot Trial

Dysfunctional cognitive processes and maladaptive interpersonal patterns have been postulated to maintain body dysmorphic disorder (BDD). The present trial evaluated CT for BDD (CT-BDD), which includes modules targeting maladaptive cognitive processing in BDD, as well as elements of schema therapy related to interpersonal problems. We investigated whether (a) CT-BDD is effective, as compared with a wait-list (WL) group at Week 12; (b) outcome of CT-BDD is maintained at posttreatment and 3- and 6-months follow-up; and (c) whether changes in shame and insight mediate changes in BDD symptom severity. Forty adults with BDD were randomized to 36 weeks immediate CT-BDD (n = 21), or to 12-week WL (n = 19). At Week 12, immediate CT-BDD was significantly superior to WL in clinician-rated BDD symptom severity, insight, self-reported BDD symptoms, shame, depression, general symptomatology, and life satisfaction. Changes in outcomes were associated with moderate to large effect sizes at Week 12. Reductions in shame and increase in insight separately mediated changes in BDD symptom severity during treatment at Week 12. From baseline to posttreatment, significant improvements occurred within CT-BDD in clinician-rated symptom severity, insight, depression, global functioning, self-reported BDD symptoms, shame, depression, general symptomatology, and life satisfaction. At posttreatment, improvements were associated with large effect sizes and were maintained at 3- and 6-month follow-up. Preliminary results support the efficacy of CT-BDD. Addressing interpersonal problems in addition to cognitive dysfunctions may increase the benefit of CBT for BDD patients.     

First-Line Treatment for Pediatric Obsessive–Compulsive Disorder

Pediatric obsessive–compulsive disorder (OCD) is a common psychiatric disorder that impairs children’s functioning in home, school, and community settings. Once thought to be an untreatable or treatment refractory disorder, evidence-based treatments now exist for pediatric OCD. Various psychological treatment approaches for pediatric OCD have been investigated and research supports the use of cognitive-behavioral therapy (CBT) with exposure and response prevention (E/RP) and combined CBT/E/RP with serotonin reuptake inhibitor pharmacotherapy. This paper reviews these approaches and highlights the prominent role of CBT/E/RP as a first-line treatment for pediatric OCD.     

Associations between miscellaneous symptoms and symptom dimensions: an examination of pediatric obsessive-compulsive disorder

Obsessive-compulsive disorder (OCD) in children and adults is a heterogeneous disorder associated with significant psychosocial impairment. Although factor analytic studies have identified symptom dimensions, these analyses do not capture the varied miscellaneous symptoms that fail to load on a specific dimension despite being functionally related. The present study sought to extend the findings of previous research in adults to a sample of youth with OCD (n=131). Logistic regression analyses were used to examine the predictive value of each of the four symptom factors (contamination symptoms, obsessions and checking, symmetry and ordering, and hoarding) to the miscellaneous OCD symptoms. The vast majority of miscellaneous symptoms (17 of the 18 symptoms) were associated with one or more symptoms factors (i.e., contamination symptoms, obsessions and checking, symmetry, and ordering). Hoarding was not related to any miscellaneous symptom. In addition to improving our understanding about the clinical presentation of pediatric OCD, findings also have important assessment (e.g., understanding which miscellaneous symptoms relate to certain dimensions) and treatment implications (e.g., hierarchy development).