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Exposure therapy and cognitive-behavioral therapy are the two therapies which have shown the most benefit for OCD difficulties.

Cognitive Behavioral Therapy:  The main domains of thinking that tend to predispose certain individuals to the distorted thinking commonly found in OCD include an inflated sense of responsibility for harm, overestimation of threat, perfectionism, intolerance of uncertainty, a tendency to overestimate the importance of thoughts, and the need to control thoughts. Several studies have suggested that cognitive therapy for OCD is as effective as exposure plus response prevention. 

The first set of data consisted of pilot data from a trial of pure cognitive therapy with no additional exposure plus response prevention. Patients were 15 individuals with OCD who received 14 sessions of cognitive therapy. By the end of treatment, Y-BOCS scores were reduced, on average, from the mid 20s to 14, and the therapy appeared to work particularly well for harming, sexual, and religious obsessions. However, the data suggested that the therapy was not particularly helpful for individuals who had contamination obsessions or those who had previously failed exposure plus response prevention. For instance, there was a 64% drop in Y-BOCS scores for the patients who had not received exposure plus response prevention previously, compared with a 0% drop among those who had received it but had not responded to it.

Dr. Steketee then presented preliminary data from a current National Institute of Mental Health-funded study in which cognitive therapy was compared with a waitlist control condition for OCD. Specifically, she and her colleagues were interested in the following questions: Can cognitive therapy focused on belief domains reduce OCD symptoms? Does cognitive therapy reduce OCD-related beliefs, in addition to OCD symptoms? Does the reduction in beliefs predict reduction in symptoms? (That is, with respect to the last question, is the reduction in beliefs the mediating mechanism through which cognitive therapy is believed to exert its effects?)

The cognitive therapy techniques in this study all employed Socratic dialogue[8] in an attempt to identify and subsequently help modify cognitive errors. An example of such a technique includes calculating the probability that a patient with harm-related obsessions could actually bring about a feared outcome. This involves estimating the individual probabilities of occurrence of each step required in a sequence of steps and then multiplying those probabilities together to arrive at the final estimate. This estimate is then compared with the probability that the patient originally estimated.

Case Illustration

For a patient who fears that he or she will cause a building to burn down with a cigarette, one would separately estimate the probabilities that a particular cigarette was not extinguished, a spark landed on the floor, the spark caught fire, and people did not notice the spark or noticed it too late, and then multiply all the probabilities together. This would result in a 1/10,000,000 probability of the feared outcome occurring. The individual would also then have to take into account how many cigarettes would have to be smoked in order for any one of them to cause a spark to catch fire. Typically, once patients compare this more empirically derived estimate with their own estimate, they experience a decrease in their anxiety.

In a 22 session preliminary study of 13 patients by Gail Steketee of Boston University, the Y-BOCS scores of patients who received cognitive therapy dropped from an average of 26 to 11 (58% reduction), which is similar to what one would expect with exposure plus response prevention. This pattern held across symptoms. The researchers also observed substantial decreases on the Beck Depression Inventory (BDI), even though the sample was not particularly depressed at baseline.

The investigators also observed that cognitive therapy was associated with 30% to 50% decreases in inflated responsibility, threat overestimation, perfectionism, intolerance of uncertainty, the importance of thoughts, and the need to control thoughts.

Cognitive Behavior Therapy As Good for OCD as Combination: In a random assignment study, 37 OCD patients were treated with Cognitive Behavior Therapy (CBT) alone, and 37 with combined CBT and SRI treatment. Of the latter, 17 discontinued SRI treatment during follow-up (1 and 2 years after inpatient treatment). During the initial treatment, scores for Y-BOCS (p < 0.001), HDRS (p < 0.001) and the Global Assessment of Functioning Scale (GAF) (p < 0.001) improved significantly in all groups. Two years later, OCD symptom severity and depression scores were similar between the groups and discontinuation of SRI did not prompt by a recurrence. Clinical outcome in patients with obsessive-compulsive disorder after discontinuation of SRI treatment: results from a two-year follow-up. Kordon A, Kahl KG, et al. Universitaetsklinikum Schleswig-Holstein, Luebeck, Germany. Eur Arch Psychiatry Clin Neurosci. 2004 Nov 12

CBT Helps Even Some Multiple Medication Non-Responders: 20 OCD adults with inadequate response to multiple medications received 15 sessions of outpatient CBT incorporating exposure and ritual prevention.  OCD severity decreased significantly (p <.05) after treatment, and improvement was maintained over a 6-month follow-up period. Significant benefit was found in 40% at 6-month follow-up. Cognitive-behavioral therapy for medication nonresponders with obsessive-compulsive disorder: a wait-list-controlled open trial. Tolin DF, Maltby N, et al. The Institute of Living/Hartford Hospital, CT. J Clin Psychiatry. 2004 Jul;65(7):922-31

Exposure and Response Prevention May Be Key in Behavioral Treatments: Incompleteness-the troubling and irremediable sense that one's actions or experiences are not "just right"--appears to underlie many of the symptoms of obsessive-compulsive disorder (OCD). Behavioral methods aimed at habituation (e.g., exposure and ritual prevention [ERP]) are probably more applicable than conventional cognitive techniques. However, even these may result in modest long-term gains; relapse is a probability if they are not actively practiced after treatment cessation. Understanding and treating incompleteness in obsessive-compulsive disorder. Summerfeldt LJ. Trent University, Peterborough, Ontario. J Clin Psychol. 2004 Nov;60(11):1155-68

SSRI Plus Cognitive Behavior Therapy Best Results for Child OCD: In a 12-week DB PC study of 112 OCD children ages 7-17 with Children's Yale-Brown Obsessive-Compulsive Scale (CY-BOCS) scores of 16 or higher given CBT alone, sertraline (Zoloft) alone, combined CBT and sertraline, or pill placebo, an intent-to-treat analyses indicated a statistically significant advantage for CBT alone (P = .003), sertraline alone (P = .007), and combined treatment (P = .001) over placebo. Combined treatment proved superior to CBT alone (P = .008) and to sertraline alone (P = .006), which did not differ from each other. Clinical remission for combined treatment was 54%; for CBT alone, 39%; for sertraline alone, 21%; and for placebo, 4%. Cognitive-behavior therapy, sertraline, and their combination for children and adolescents with obsessive-compulsive disorder: the Pediatric OCD Treatment Study (POTS) randomized controlled trial.  JAMA. 2004 Oct 27;292(16):1969-76

Thomas E. Radecki, M.D., J.D.

Email: [email protected]