Potentials and Limitations of Cognitive Treatments for Obsessive‐Compulsive Disorder

Exposure and response prevention (ERP) is a well‐established treatment for obsessive‐compulsive disorder (OCD). However, it is not completely effective for many patients, and some do not benefit from or tolerate this treatment. Over the past 3 decades there has been growing interest in using cognitive interventions, either as adjuncts or alternatives to exposure‐based treatments such as ERP, to address these shortcomings. Cognitive therapy and cognitive behavior therapy for OCD have both demonstrated greater efficacy than no treatment at all, and appear to have a lower incidence of dropout than ERP. Unfortunately, however, for the average OCD patient, cognitive interventions have not improved treatment efficacy; that is, cognitive interventions, either alone or combined with ERP, are no more effective than ERP alone. Reasons for this disappointing result are considered, and indications for the use of cognitive interventions are discussed. Future research directions are suggested in order to evaluate more fully the merits of, and indications for, cognitive methods for treating OCD.     

Potentials and limitations of cognitive treatments for obsessive-compulsive disorder

Exposure and response prevention (ERP) is a well-established treatment for obsessive-compulsive disorder (OCD). However, it is not completely effective for many patients, and some do not benefit from or tolerate this treatment. Over the past 3 decades there has been growing interest in using cognitive interventions, either as adjuncts or alternatives to exposure-based treatments such as ERP, to address these shortcomings. Cognitive therapy and cognitive behavior therapy for OCD have both demonstrated greater efficacy than no treatment at all, and appear to have a lower incidence of dropout than ERP. Unfortunately, however, for the average OCD patient, cognitive interventions have not improved treatment efficacy; that is, cognitive interventions, either alone or combined with ERP, are no more effective than ERP alone. Reasons for this disappointing result are considered, and indications for the use of cognitive interventions are discussed. Future research directions are suggested in order to evaluate more fully the merits of, and indications for, cognitive methods for treating OCD.     

Need for speed: Evaluating slopes of OCD recovery in behavior therapy enhanced with d-cycloserine

Evidence suggests that the antibiotic d-cycloserine (DCS) enhances the treatment effects of exposure and response prevention (ERP) for Obsessive-Compulsive Disorder (OCD). Further, evidence suggests that the effects of DCS diminish partway through treatment, but it is unclear to what extent. In an effort to evaluate these issues, the current study re-analyzes data from a 10-session randomized controlled trial of ERP + DCS versus ERP + placebo in a sample of 22 adults with OCD. We analyzed repeated-measures mixed models with random slopes and intercepts across different intervals: sessions 1-10, 1-5, and 6-10. The results indicate that the course of ERP was 2.3 times faster over the full 10 sessions for the DCS compared to the placebo group, and nearly six times quicker in the first half of ERP. Further interpretation of the results suggests that DCS does not amplify the effects of ERP, but instead initiates treatment effects sooner in treatment. In addition, DCS does not necessarily lose its effect over repeated use, but instead may exhaust its maximum utility after effectively jump-starting ERP. Ultimately, DCS may provide a means for curtailing treatment costs, decreasing treatment dropout and refusal rates, and enhancing access to care.     

Does d-Cycloserine Augmentation of CBT Improve Therapeutic Homework Compliance for Pediatric Obsessive–Compulsive Disorder?

Clinical studies in adults and children with obsessive–compulsive disorder (OCD) have shown that d-cycloserine (DCS) can improve treatment response by enhancing fear extinction learning during exposure-based psychotherapy. Some have hypothesized that improved treatment response is a function of increased compliance and engagement in therapeutic homework tasks, a core component of behavioral treatment. The present study examined the relationship between DCS augmented cognitive-behavioral therapy (CBT) and homework compliance in a double-blind, placebo controlled trial with 30 youth with OCD. All children received 10 CBT sessions, the last seven of which included exposure and response prevention paired with DCS or placebo dosed 1 h before the session started. Results suggested that DCS augmented CBT did not predict improved homework compliance over the course of treatment, relative to the placebo augmented CBT group. However, when groups were collapsed, homework compliance was directly associated with treatment outcome. These findings suggest that while DCS may not increase homework compliance over time, more generally, homework compliance is an integral part of pediatric OCD treatment outcome.     

Delayed Sleep Timing in Obsessive-Compulsive Disorder Is Associated With Diminished Response to Exposure and Ritual Prevention

Exposure and ritual prevention (ERP) and pharmacotherapy are typically associated with significant symptom reductions for individuals with obsessive-compulsive disorder (OCD). However, many patients are left with residual symptoms and other patients do not respond. There is increasing evidence that delays in sleep timing/circadian rhythms are associated with OCD but the potential effects of delays in sleep timing on ERP warrant attention. This paper presents data from 31 outpatients with OCD who participated in ERP. Results showed that delayed sleep timing was common and that individuals with delayed bedtimes benefited significantly less from treatment and were significantly more likely to be nonresponders compared to individuals with earlier bedtimes. Further, the effects of sleep timing remained statistically significant even after controlling for global sleep quality, negative affect, and several other variables. These findings add to a growing literature suggesting the utility of better understanding the role of disruptions in the timing of sleep in OCD.     

A Brief Motivational Intervention for Treatment‐Refusing OCD Patients

Cognitive behavioral therapy involving exposure and response prevention (ERP) is the psychosocial treatment of choice for obsessive‐compulsive disorder (OCD). Despite this, ERP is not widely used by mental health practitioners, and so dissemination of ERP and other empirically supported treatment (ESTs) has become a priority. Even so, utilization of ESTs such as ERP remains below 50% even among therapists who self‐identify as having a cognitive behavioral orientation. Barriers to the acceptance of ERP include practical obstacles such as lack of training and the cost of treatment, but also patient variables such as treatment refusal. It has been estimated that approximately 25% of OCD patients refuse ERP. This paper describes a brief, 4‐session readiness intervention (RI) designed to decrease ERP refusal among patients with OCD. In this study, 12 patients with OCD who had refused ERP were randomized to RI or wait‐list (WL). 86% of participants in the RI condition and 20% of participants in WL condition agreed to begin ERP following the 4‐week period. ERP following RI, but not WL, was associated with a decrease in OCD symptoms comparable to that observed in OCD patients who did not refuse ERP. However, ERP following RI was associated with a high drop‐out rate (50%), a figure that exceeds that typically seen in OCD treatment studies. Techniques to reduce drop‐out as well as directions for future research are discussed.     

A brief motivational intervention for treatment-refusing OCD patients

Cognitive behavioral therapy involving exposure and response prevention (ERP) is the psychosocial treatment of choice for obsessive-compulsive disorder (OCD). Despite this, ERP is not widely used by mental health practitioners, and so dissemination of ERP and other empirically supported treatment (ESTs) has become a priority. Even so, utilization of ESTs such as ERP remains below 50% even among therapists who self-identify as having a cognitive behavioral orientation. Barriers to the acceptance of ERP include practical obstacles such as lack of training and the cost of treatment, but also patient variables such as treatment refusal. It has been estimated that approximately 25% of OCD patients refuse ERP. This paper describes a brief, 4-session readiness intervention (RI) designed to decrease ERP refusal among patients with OCD. In this study, 12 patients with OCD who had refused ERP were randomized to RI or wait-list (WL). 86% of participants in the RI condition and 20% of participants in WL condition agreed to begin ERP following the 4-week period. ERP following RI, but not WL, was associated with a decrease in OCD symptoms comparable to that observed in OCD patients who did not refuse ERP. However, ERP following RI was associated with a high drop-out rate (50%), a figure that exceeds that typically seen in OCD treatment studies. Techniques to reduce drop-out as well as directions for future research are discussed.     

A randomized controlled trial of self-directed versus therapist-directed cognitive-behavioral therapy for obsessive-compulsive disorder patients with prior medication trials

Cognitive-behavioral therapy incorporating exposure and response prevention (ERP) is widely considered a first-line psychosocial treatment for patients with obsessive-compulsive disorder (OCD). However, a number of obstacles prevent many patients from receiving this treatment, and self-administered ERP may be a useful alternative or adjunct. Forty-one adult outpatients with a primary diagnosis of OCD, who reported at least 1 current or previous adequate medication trial, were randomly assigned to self-administered or therapist-administered ERP. Patients in both treatment conditions showed statistically and clinically significant symptom reduction. However, patients receiving therapist-administered ERP showed a superior response in terms of OCD symptoms and self-reported functional impairment. We discuss several potential reasons for the superiority of therapist-administered treatment, and propose a stepped-care integration of self-administered and therapist-administered interventions for OCD.     

Irritability in Children and Adolescents With OCD

Irritability is a common, impairing transdiagnostic symptom in childhood psychopathology, though it has not been comprehensively studied in pediatric obsessive-compulsive disorder (OCD). Further, the central cognitive behavioral treatment component for OCD, exposure and response prevention therapy (ERP), has been recently proposed as a treatment for irritability. This study aimed to evaluate whether certain clinical characteristics are associated with irritability in pediatric OCD and whether irritability reduces following ERP. Participants were 161 youth (ages 7–17) with OCD and a caregiver participating in a randomized controlled trial of D-cycloserine or pill placebo augmented ERP. Participants completed validated assessments during treatment. Irritability was significantly and positively associated with depressive symptoms, defiance, functional impairment, and family accommodation, but was not associated with pretreatment OCD severity, symptom dimensions, obsessive beliefs. Irritability significantly declined following treatment, with over half of youth with any pretreatment irritability experiencing clinically significant change, though this change was not related to OCD improvement. Results suggest that irritability may be a marker of psychiatric comorbidity, parental accommodation, and impairment in youth with OCD. Implications for the exposure-based treatment of irritability are discussed.     

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.     

Safety Behaviour Enhances the Acceptability of Exposure

Compulsive washing and contamination fears are among the most common symptoms of obsessive-compulsive disorder (OCD). Research suggests that exposure and response prevention (ERP) is effective for OCD. However, ERP is prone to dropouts and refusals, and a substantial proportion of clients therefore do not receive the care they need. A proposed solution involves the judicious use of safety behaviour to enhance the acceptability of exposure-based interventions. The current study aimed to test this proposed solution. Participants were 70 undergraduate students who completed two exposure exercises for contamination fear, one with safety behaviour and one without. Participants then rated the acceptability of the two exercises. Exposure with safety behaviour (ESB) was rated as significantly more acceptable than ERP. Furthermore, subjective fear ratings were lower and behavioural approach to a series of contaminants was greater in the ESB condition. Results demonstrated the acceptability-enhancing potential of safety behaviour in exposure, and are discussed in terms of both theoretical and practical aspects of safety behaviour, exposure, and evidence-based interventions for anxiety disorders.     

The Treatment of Mental Contamination: A Case Series

The recommended treatment for obsessive-compulsive disorder (OCD) is cognitive behavior therapy (CBT) incorporating exposure and response prevention (ERP), which is effective for approximately 50% of patients. However, there has been little advance in treatment outcomes since the introduction of ERP in 1979. It has been suggested that some progress can be made in treating contamination obsessions and washing compulsions by addressing feelings of dirtiness and contamination that arise without physical contact with a tangible contaminant. To date, the treatment of these “mental contamination” fears in OCD has not been systematically explored. This paper reports on a case series of 12 participants with OCD who received 10 to 20 sessions of a CBT-based treatment for mental contamination. At the end of treatment, 7 participants no longer met the diagnostic criteria for OCD and mental contamination and these gains were maintained at 6-month follow-up. The clinical implications of these findings are discussed.     

Cognitive Behavior Therapy for Obsessions and Compulsions: New Applications and Emerging Trends

This paper describes recent developments in the cognitive behavioral treatment (CBT) of obsessive compulsive disorder (OCD). Although behavioral treatment of OCD consisting of exposure and response prevention (ERP) has been shown to be clinically effective, certain limitations with ERP have led clinical researchers to propose that treatment should be augmented with direct cognitive interventions. Modification of dysfunctional beliefs and faulty appraisals or interpretations of the obsession are now considered a crucial component of CBT for obsessions and compulsions. This paper discusses the conceptual basis of the new CBT for OCD and reviews its limited empirical status. A case example is provided in which CBT is used to treat obsessional ruminations of becoming sick. The article concludes with a discussion of the challenges and pitfalls involved in offering CBT for obsessions and compulsions.     

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.     

Does Exposure and Response Prevention Behaviorally Activate Patients With Obsessive-Compulsive Disorder? A Preliminary Test

Exposure and response prevention (ERP) and behavioral activation (BA) are effective treatments for obsessive-compulsive disorder (OCD) and depression, respectively. Patients with OCD often exhibit depression; furthermore, ERP for OCD is associated with reduced depressive symptoms. To our knowledge, no study has examined whether ERP itself functions to behaviorally activate patients with concurrent OCD and depressive symptoms. This prospective study was designed to test the hypotheses that (a) OCD exposure hierarchy completion, increased BA, and depressive symptom reduction would all be related, and (b) pre- to posttreatment changes in BA would mediate the direct effect of OCD hierarchy completion on posttreatment depressive symptoms, even after controlling for pretreatment depressive symptoms, pretreatment BA, pre- to posttreatment reductions in OCD symptoms, treatment duration, and antidepressant medication use. Patients (N = 90) with a primary diagnosis of OCD who received residential ERP for OCD completed a self-report battery at pre- and posttreatment. Exposure hierarchy completion, increases in BA, and decreases in depression were all significantly correlated (rs ranged .33 to .44). The effect of hierarchy completion on posttreatment depressive symptoms was fully mediated by pre- to posttreatment changes in BA. Findings highlight the potential for ERP to exert antidepressant effects by behaviorally activating patients. Limitations, clinical implications, and future directions are discussed.     

“Phobie à deux” and other reasons why clinicians do not apply exposure with response prevention in patients with obsessive–compulsive disorder

Meta-analyses suggest that exposure with response prevention (ERP) is the most efficacious treatment for obsessive–compulsive disorder (OCD) and treatment guidelines for the disorder accordingly recommend ERP. Despite this, many therapists, including those with a cognitive-behavioral therapeutic background, do not perform ERP in patients with OCD. The present study aimed to elucidate the reasons why. German therapists (N = 216) completed an anonymous online survey, the newly developed Reasons for Not Performing Exposure in OCD Scale (REPEX), that inquired whether, to what extent, and how they perform ERP in the treatment of OCD. We also asked their reasons for not applying ERP in the past. Most therapists considered ERP an efficient treatment for OCD. Marked differences emerged between physicians and psychologists, however. The former used exposure less often and for a shorter period, preferred in sensu to in vivo exposure, and conducted exposure less often in the personal environment of the patient than did psychologists. Both groups were familiar with clinical guidelines to a similar extent. A factor analysis of the REPEX scale revealed five factors. Patient lack of motivation, preference for exposure to be self-help as well as alleged organizational difficulties were endorsed most often. The latter was correlated with the age of the therapist and was far more often affirmed by physicians. Fear of side effects was named by a subgroup of clinicians; in the context of patient ambivalence, this may foster “phobie à deux”. Unlike prior research, lack of expertise was rarely identified as a reason not to use ERP. Recommendations for improving adherence to guidelines are discussed.     

Directions in Specialized Cognitive Behavior Therapy for Resistant Obsessive-Compulsive Disorder: Theory and Practice of Two Approaches

This paper discusses specialized approaches developed for patients with obsessive-compulsive disorder (OCD) who are resistant to cognitive behavior therapy (CBT). Following a review of theoretical and outcome research, two approaches developed to resolve persistent OCD are described and illustrated. Cognitive therapy (CT) designed to address characteristic dysfunctional beliefs has shown promising results (Wilhelm et al., 2005; Wilhelm & Steketee, 2006). CT modules focus on understanding and correcting OCD-related beliefs (e.g., inflated responsibility, need for certainty, perfectionism) pertinent to each patient’s symptoms, using specialized strategies and behavioral experiments to test and modify maladaptive hypotheses and related negative emotions. CT appears to be acceptable to many patients and may reduce refusal rates and improve collaboration during exposure and response prevention (ERP). It is not yet clear whether this method improves outcomes for patients who have not responded to previous ERP. A schema-based CBT approach developed by Sookman and Pinard (1999, 2007) for resistant OCD of different subtypes aims to broaden the scope of CT, to improve patients’ capacity to fully engage in ERP, and to reduce susceptibility to relapse. Available results with previously CBT-resistant patients suggest this approach may improve learning during CT and collaboration in ERP, resulting in recovery for some patients. Criteria are outlined for defining CBT resistance and assessing treatment response using various outcome measures and stringent criteria. The ultimate goal of expert intervention for OCD is remission. The authors propose theory, practice, and research directions to help ameliorate symptoms and related difficulties in resistant OCD.     

Are all safety behaviours created equal? A comparison of novel and routinely used safety behaviours in obsessive-compulsive disorder

Contamination fear is one of the most common symptoms of obsessive-compulsive disorder (OCD). Exposure and response prevention (ERP) is effective for OCD, but a significant minority of treatment-seeking individuals refuse ERP entirely or drop out prematurely. Research suggests that safety behaviour (SB) may enhance the acceptability of ERP; however, questions remain about how to incorporate SB into existing treatments. Clinical participants with OCD and contamination fear (N = 57) were randomized to receive an exposure session with no SB (ERP), a routinely used SB (RU), or a never-used SB (NU). Significant reductions in contamination fear severity were observed in all conditions. Although omnibus comparisons were only marginally significant, pairwise comparisons revealed some condition differences. NU demonstrated significantly lower self-reported contamination fear severity at post-exposure, as well as marginally higher treatment acceptability ratings. Findings suggest that exposure with SB may be effective and acceptable, and are discussed in terms of cognitive-behavioural theory and treatment of anxiety and related disorders.     

Therapists’ Thought-Action Fusion Beliefs Predict Utilization of Exposure in Obsessive-Compulsive Disorder

Although exposure and response prevention (ERP) is considered the gold standard for the treatment of obsessive-compulsive disorder (OCD), it is rarely used in clinical practice. Therapists’ beliefs about ERP affect its utilization, as previous research suggests, but the role of therapists’ cognitive biases is unclear. In particular, susceptibility to thought-action fusion (TAF) may be related to the underutilization of ERP in OCD.Therapists (N = 353) were divided into those recommending (ERP+, n = 228) and not recommending ERP (ERP−, n = 125) as treatment for an OCD case example. TAF in therapists was assessed using behavioral and self-report measures (TAFS).TAF was higher in the ERP− than the ERP+ group, with a small to moderate effect size (0.2 ≤ d ≤ 0.4). ERP− therapists showed more avoidance and neutralizing behavior and a stronger emotional response than the ERP+ therapists during the experimental task. Moreover, higher TAF as measured by the TAFS was associated at a small magnitude with lower likelihood of using ERP in the therapists’ actual clinical practices.Therapists’ cognitive biases should be addressed in their training in order to increase the dissemination of evidence-based treatment (i.e., ERP) and thus improve the treatment of OCD.     

How effective are cognitive and behavioral treatments for obsessive-compulsive disorder? A clinical significance analysis

Controlled outcome studies investigating the efficacy of psychological treatments for obsessive-compulsive disorder (OCD) have employed different methods of determining the clinical significance of treatment effects. This makes it difficult to draw conclusions regarding the absolute and relative efficacy of psychological treatments for OCD. To address this issue, standardized Jacobson methodology for defining clinically significant change was applied to recent psychological outcome trials for OCD. The proportion of asymptomatic patients following treatment was also calculated. When recovery is defined by Jacobson methodology, exposure and response prevention (ERP) appears the most effective treatment currently available (50-60% recovered). However, when the asymptomatic criterion is used as the index of outcome, ERP and cognitive therapy have low and equivalent recovery rates (approximately 25%).