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MIND & BRAIN, THE JOURNAL OF PSYCHIATRY


REVIEW ARTICLE


A Review of Psychotherapy for Obsessive-Compulsive Disorder


Lindsay Brauer1, Adam B Lewin2 and Eric A Storch2 Affiliations: 1Department of Psychology, University of South Florida, Tampa, Florida, USA and 2Department of Pediatrics, Rothman Center for Neuropsychiatry, University of South Florida, St. Petersburg, Florida, USA


ABSTRACT


Cognitive-behavioral therapy (CBT) is a first-line treatment for obsessive-compulsive disorder (OCD) in adults and children due to its efficacy, maintenance of therapeutic gains after treatment withdrawal, safety, and tolerability. The current article reviews research regarding the theoretical underpinnings of CBT, pragmatics regarding CBT implementation, and efficacy findings, while also highlighting barriers to efficacious treatment (ie, age, comorbidity, geography), methods of addressing such issues, and areas in need of further study.


Keywords: cognitive-behavioral therapy, obsessive-compulsive disorder, treatment, psychotherapy


Correspondence: Eric A Storch, All Children’s Hospital guild Endowed Chair, Departments of Pediatrics and Psychiatry, Rothman Center for Neuropsychiatry, University of South Florida, 880 6th Street South, 4th Floor North, Box 7523, St. Petersburg, FL 33701, USA. Tel:1 727 767 8230. Fax: 1 727 767 7786; e-mail: estorch@health.usf.edu


INTRODUCTION Obsessive-compulsive disorder (OCD) has a point-preva-


OCD is beyond the scope of this review and thus, the reader is referred to comprehensive reviews on this topic.1215


lence of approximately 1%2% across children and adults13 and a lifetime prevalence of approximately 2%.4 Obsessive- compulsive disorder is characterized by the presence of distressing and difficult to control thoughts, impulses, or images that evoke considerable distress (obsessions). Indivi- duals with OCD tend to engage in overt or covert behaviors aimed to reduce or neutralize distress (compulsions). Problematically, this cycle of compulsion engagement in response to obsessional triggers creates a negative reinforce- ment loop (ie, rituals reduce anxiety in the short-term), which maintains and/or exacerbates symptom severity.5


The scope of impairment associated with OCD is unique


from other anxiety disorders.6 Relative to those with other anxiety disorders, adults with OCD are more likely to report unemployment, sleep loss, interpersonal or relationship conflict, hospitalization, chronic personal distress, and impairment in activities of daily living.6 Children with OCD experience problematic family relations, considerable aca- demic difficulties, and marked social dysfunction, which can further disrupt normative development.3,710 The extreme functional impairment that accompanies OCD is often directly due to the excessive time occupied by symptoms, nature of the obsessions, rituals and avoidance, and psychia- tric comorbidity.11


The available evidence suggests that cognitive-behavioral therapy (CBT) is among the most efficacious treatments for adult and childhood OCD. Serotonin reuptake inhibitors (SRI) have also demonstrated efficacy in the reduction of symptom severity in children and adults with OCD.12,13 A full review of efficacy and safety data pertaining to pharmacotherapy for


M&B 2011; 2:(1). July 2011 38


Over the past several decades, a substantial literature has demonstrated the efficacy of CBT for adults and children with OCD.16,17 Response rates extend upward to 85% among adults and children alike,14,18 with approximately 40%50% of patients achieving clinical remission. Treatment gains are generally stable, with effects being maintained over periods up to 7 years.19,20 Pooled effects suggest that CBT may have some advantage in efficacy over SRI treatment alone.21 leading to the suggestion that patients with OCD receive CBT alone or together with SRI therapy.14,22 The determina- tion of which individuals receive CBT alone or concomitant with SRI medication is multifaceted and may be a function of illness severity, comorbidity, and ancillary features (eg, insight, anxiety sensitivity, etc.23). To explain the nature, efficacy, and limitations of OCD treatment, we review the available research on psychotherapy for OCD, individual factors (ie, comorbidity, insight) that may attenuate treatment response, and alternative approaches that may aid in improving response and remission rates for OCD.


PSYCHOTHERAPY


Psychodynamic therapy While there is some variance in theory, generally psychody- namic interpretations of OCD posit that obsessions and compulsions arise due to a conflict between an impulsive id and a rigid superego battling for control over the expression of unresolved fixations from the anal stage of development. Specifically, the id pushes for aggressive and sexual impulses to be fulfilled, while the rigid superego attempts to rid such


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