Practice recommendations
- Cognitive-behavioral therapy with exposure and response-prevention is effective for the treatment of obsessive-compulsive disorder (OCD) in both children and adults (A).
- Numerous medications are effective options for the treatment of OCD in adults, including serotonergic agents (clomipramine, citalopram, fluoxetine, sertraline, paroxetine, fluvoxamine) (A). Only clomipramine, fluoxetine, fluvoxamine, and sertraline have been approved by the Food and Drug Administration for use in youths (A).
Note: this article is a continuation of “Obsessive-compulsive disorder: Tools for recognizing its many expressions,” in the March 2006 issue of JFP.
Evidence supports 2 forms of treatment for adults and children with obsessive-compulsive disorder (OCD): cognitive-behavioral therapy (CBT) with exposure and response prevention (E/RP), and psychopharmacologic treatment with serotonin reuptake inhibitors (SRIs).
OCD Expert Consensus Guidelines strongly recommend exposure-based CBT, alone or with pharmacotherapy, as the first-line treatment.1 However, approximately 25% of persons with OCD wish not to participate in CBT for varying reasons (eg, limited insight, difficulty engaging in exposures), thus making medication alone the initial choice of treatment. In many cases, thankfully, patients whose symptoms decrease with medication become willing to participate in CBT.
Cognitive-behavioral therapy the preferred route
A large database supports the efficacy of CBT with E/RP in treating OCD. Methodologically rigorous controlled trials of CBT in adults and children have reported success rates reaching 85% (SOR: A).2,3 One qualifier of success: though most patients respond positively to CBT, symptoms often remain and true cure or complete remission is often not possible.
CBT is unlike other psychotherapies. Unfortunately, the number of qualified mental health professionals trained in CBT for OCD is limited,4 as is general knowledge about this approach. The Obsessive-Compulsive Foundation estimates that 5 million Americans with OCD lack access to behavioral therapy.5 Many of the patients we see in our clinic have participated in psychodynamic or traditional “talk therapies” that are supported by little evidence. Such approaches have a strength of recommendation (SOR) of C. As a result, many afflicted individuals receive only partial treatment that consists of either non-CBT psychotherapy or medication.
Preparing the way for your patient
Before referring a patient for CBT, ask about the practitioner’s level of training (PhD or PsyD are preferable), theoretical approach (cognitive behavioral vs others, such as psychodynamic or humanistic), and experience in working with OCD patients. Perhaps the most important question to ask a clinician is, “Will you expose the patient to situations that provoke rituals while having him/her refrain from engaging in them?”
What your patients can expect. CBT is a form of psychological treatment explicitly based on learning and cognitive principles. Twelve to 16 sessions are typical, though the function of each individual will determine the duration of treatment.2 Treatment may be stopped if significant symptom reduction has lasted for at least 4 consecutive weeks. Thereafter, periodic booster sessions are helpful to maintain gains and prevent relapse.1
The 3 central aspects of CBT therapy for OCD:
- Exposure—placing the patient in situations that elicit anxiety related to their obsessions
- Response prevention—deterring the ritualistic or compulsive behaviors that may serve to reduce or avoid anxiety
- Cognitive therapy—training the patient to identify and reframe anxiety-provoking cognitions.
Exposure—very simply, having the patient face their fear—reduces anxiety responses.
Response prevention involves encouraging the patient to refrain from engaging in repetitive, time-consuming compulsions. This component is based on the notion that rituals serve to reduce anxiety and are thus reinforcing. Naturally, E/RP is quite anxiety-provoking for patients. As a result, it may be useful to inform them that feared situations will be approached in a hierarchical manner, starting with easier items before moving to more difficult ones. Successful completion of E/RP tasks teaches patients that the feared consequences of not ritualizing are not going to occur.
Cognitive therapy takes into account that patients with OCD have characteristic thoughts believed to contribute to the development and maintenance of their condition. Specifically, common themes within this population include distorted appraisals of risk (eg, “The chance of burning the house down with an extinguished cigarette is 25%”), an inflated sense of responsibility for harm (eg, “If I do not touch this rock, my mother will get cancer”), and pathologic levels of self-doubt (eg, “I know the odds of contracting HIV from using a public toilet are slim, but I can’t be sure I will not”). OCD in adults has also been related to the concept of thought–action fusion, in which negative thoughts and actions are seen as synonymous.6 Such maladaptive cognitive processes often motivate compulsive behavior and make patients with OCD less able to cope with negative thoughts.7 The cognitive component of CBT addresses these issues and teaches patients ways to mend their thinking.