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Psychotherapy for OCD

impulses from conscious awareness. To mediate this conflict, the ego develops defenses such as doubting, indecision, and magical thinking to mediate the struggle between id and superego.24 For example, contamination fears may relate to wishes to alleviate displaced feelings of shame, fears of one’s house being destroyed are representation of one’s destructive wishes, and obsessions of hurting one’s children may be a redirection of anger toward one’s spouse.25 There is no known empirical support for the efficacy of psychodynamic therapy forOCD*controlled-trials of psychodynamic therapy forOCD are nonexistent,26,27 and consequently a psychodynamic approach is not recommended for the treatment of OCD.

Cognitive-behavioral therapy (CBT)

CBT is an empirically supported psychosocial treatment premised on the theory that an individual experiences significant distress in the presence of a previously neutral thought or stimulus that has become classically conditioned to signal distress. The individual engages in compulsions to reduce obsessional distress. Exposure and response preven- tion (ERP) is a behavioral component of CBT that directs the individual to confront the aversive stimulus (ie, thought, item, situation), and experience the associated distress with- out engaging in rituals. Such distress will naturally habituate over time in the absence of ritual engagement.

Pragmatically, CBT for OCD is a multicomponential approach, conducted in a sequential manner. First, indivi- duals are provided with psychoeducation regarding OCD, its behavioral, cognitive, and neurobiological underpinnings, and the treatment regimen. Obsessive-compulsive disorder may be described to patients as a ‘‘brain hiccup’’ or ‘‘odd wiring’’ that causes individuals to experience anxiety when certain thoughts or actions arise. It is then explained that engaging in compulsions triggered by obsessions reinforces this relationship by reducing distress, thereby increasing the likelihood of engaging in rituals whenever an anxiety inducing stimulus is encountered. Thus, treatment focuses on eliciting anxiety by presenting an obsessional trigger and prohibiting compulsions. By doing so, the obsessive-com- pulsive cycle is broken and eventually extinguished, as the individual learns the feared event does not occur if the compulsion is not performed, and in turn the aversive trigger no longer elicits distress at original levels. Second, a stimulus hierarchy is created to rank order the degree of distress the patient anticipates experiencing with being exposed to an obsessional trigger while refraining from ritual engagement. The exposure itself consists of having an individual confront the trigger*starting with less anxiety provoking stimuli first*without engaging in compulsions. The individual remains in the feared situation until anxiety habituation (ie, reduction in anxiety to a negligible level) occurs. A single exposure is typically repeated until it no longer elicits a significantly anxious response, or at least until the associated anxiety falls considerably below pre-exposure levels. Follow- ing successful completion of an exposure, progressively more difficult exposures are conducted in a gradual manner according to the individual’s hierarchy.28 Homework based 39

on the session content is a critical component of treatment with patients typically being assigned up to 60 min or more of homework daily. Third, cognitive strategies are developed to highlight and confront irrational and dysfunctional thoughts. As previously mentioned, individuals with OCD tend to overestimate the likelihood of feared events occurring, as well as overestimating their individual responsibility in such an occurrence. Cognitive strategies focus on helping the patient identify and correct anxiogenic cognitions that are conceptually related to obsessive-compulsive symptoms. By doing so, individuals further cultivate nonattachment to OCD-related thoughts and come to rely on more realistic perceptions of stimuli. In addition, strategies that enhance constructive self-talk (ie, ‘‘this is hard but I can do it’’) may enhance motivation and engagement in treatment proce- dures. Finally, relapse prevention training is a critical component of CBT with an emphasis of teaching the patient skills to maintain gains and deal with any reemergence of symptoms.

Although CBT has demonstrated efficacy, attrition rates

during treatment are problematic, ranging from 3% to 39%.13 and as many as 25% of patients refuse to participate in psychosocial treatment.29 Attrition may be related to a series of factors including lack of motivation or insight, low tolerance for discomfort related to treatment strategies, severe symptom presentation, or comorbid psychopathology that interferes with treatment seeking behavior (eg, avoidant personality disorder, severe major depression). For those with OCD of mild to moderate severity, practice guidelines recommend initiating treatment with CBT alone.30 If an adequate response is not achieved, multimodal treatment may be appropriate. Similarly, for those with severe OCD symp- toms, pharmacotherapy either in conjunction or sequentially provided before CBT initiation is most appropriate. Through sequential pharmacological intervention, it may be possible to reduce baseline anxiety levels or to mitigate symptoms of comorbid disorders (eg, depression), reducing rates of attrition and fostering improved treatment outcome.

CBT OUTCOME DATA IN ADULTS WITH OCD CBT has been rigorously studied as a treatment for adult

OCD. Studies have varied some in terms of number of sessions provided, session format (group vs individual, intensive vs weekly), reliance on cognitive restructuring, and in combination with pharmacotherapy. A review of 12 CBT outcome studies for adults with OCD revealed that 83% of adults had a clinically meaningful response, and were able to maintain gains at extended follow-up durations.31 Effect sizes of CBT for adult OCD are robust (d1.301.86), compared to SRIs (d0.951.63) or a placebo (d0.200.5915). Perhaps best illustrating this, Foa and colleagues,14 examined the relative efficacy of CBT, clomipramine, and combined therapy over 12 weeks of intervention in OCD symptom reduction. Overall, CBT was as efficacious as CBT with concurrent clomipramine, and both treatments were significantly more effective than clomipramine monotherapy or a placebo (clomipramine was superior to placebo).

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

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