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Mind & Brain, the Journal of Psychiatry


results have yet to be published, the design may hold prospects for the dissemination of CBT strategies through psychiatrists, which may be more accessible to children than psychologists trained in CBT for OCD.


FUTURE DIRECTIONS


Tailored treatment Despite its efficacy, only 25%40% of individuals reach full


recovery with CBT78 and many treatment responders remain somewhat symptomatic. This review has addressed several of the reasons for this (eg, comorbidity, insight, access to trained professionals, etc.). To date, however, treatments have been developed for the ‘‘average’’ patient with limited attention to the considerable symptom heterogeneity asso- ciated with OCD that might impact treatment course. Individualized treatment approaches that are responsive to individual patient characteristics will improve clinical out- come and treatment efficiency.


Tailoring the intervention to dually address OCD and the


comorbid condition holds merit for maximizing treatment outcome and is consistent with the increased emphasis on individualized patient care. For example, individuals with comorbid depression for whom behavioral activation is an obstacle in OCD treatment (eg, unable to be motivated to engage in exposures) may benefit from a trial of an SRI prior to CBT implementation.79 Similarly, for those whose comor- bid anxiety interferes with adherence, CBT protocols may benefit from sequential pharmacotherapy. As impulsivity and inattention may limit an individual’s ability to refrain from ritual engagement, individuals with ADHD may benefit from concurrent pharmacotherapy.35,79 Future research is needed, however, to examine a wider array of comorbidities (eg, bipolar disorder, schizophrenia spectrum disorders, sub- stance abuse) across a range of severity to examine the impact of comorbidity on OCD treatment-response to better tailor treatments and enhance response.


D-cycloserine


A potentially significant translational success derived from animal research has shown that the N-methyl-D-aspartate (NMDA) receptor is critically involved in fear extinction, and that the NMDA partial agonist D-cycloserine (DCS) enhances extinction of learned fear.8084 Given that extinction of conditioned fear is central to CBT,85 DCS augmentation of exposure therapy has been tested in several adult anxiety disorders.8588 Studies that have examined the efficacy of DCS in CBT for OCD in adults have also been encouraging as individuals administered DCS experienced more rapid and enduring treatment gains compared to those given a pla- cebo.89,90 D-cycloserine has been suggested to make enga- ging in exposures more palatable, as quicker successes and learning increases confidence and motivation to engage in a wider variety of exposures, which in turn increases general- ization to other stimuli and may lead to better treatment outcomes. This effect may be particularly useful for children, who may have difficulty buying into ERP tasks. Storch et al91


M&B 2011; 2:(1). July 2011 42


recently compared the efficacy of DCS to placebo in children undergoing weekly CBT for OCD. Relative to the placebo augmentation arm, DCS augmentation was associated with reduced OCD symptom severity at posttreatment with effect sizes in the moderate range. Future work investigating DCS as an augmenting medication in CBT for OCD should examine its impact on participant attrition and durability of treatment gains.


CONCLUSION


Psychotherapy, namely CBT that heavily relies on ERP, is a highly effective intervention for OCD. Indeed, current practice parameters for OCD in adults and children recommend it as the first-line intervention in those with mild and moderate symptoms and together with SRI therapy in those with severe symptomology or clinical characteristics that may complicate illness course (eg, comorbid depression, poor insight). The safety and tolerability of CBT tend to be excellent as are the durability of gains. Yet, CBT is not without its limitations. Limited access to trained clinicians, financial barriers, time, and the ability of the patient to tolerate exposures, however, all interfere with accessing treatment. Research has partially addressed these issues by: (1) devel- oping various therapies that minimize these issues (eg, intensive treatment programs, manualized treatments, web- based ERP), (2) attempting to enhance CBT effects with pharmacological augmentation (eg, DCS), and (3) devising treatments tailored to address psychiatric comorbidity. These advances have afforded clinicians new tools to address the many complexities of OCD and enhance the availability of empirically supported treatment.


Disclosure: The authors declare no conflict of interest. Funding: Ms. Brauer has no financial disclosures to report.


Dr. Lewin receives research funding from NARSAD, the Interna- tional OCD Foundation, the Joseph Drown Foundation, and the Friends of the Semel Institute. Dr. Storch receives research support from the National Institutes of Health, Centers for Disease Control, All Children’s Hospital Research Foundation, Ortho-McNeil Janssen Pharmaceuticals, Foundation for Prader-Willi Research, Tourette Syndrome Association, and NARSAD. He receives royalties from Lawrence Erlbaum and Springer Publishers.


REFERENCES


1. Douglass HM, Moffitt TE, Dar R, McGee R, Silva P. Obsessive- compulsive disorder in a birth cohort of 18-year-olds: prevalence and predictors. J Am Acad Child Adolesc Psychiatry. 1995;34(11):14241431.


2. Zohar AH. The epidemiology of obsessive-compulsive disorder in children and adolescents. Child Adolesc Psychiatr Clin N Am. 1999;8:445 460.


3. Storch EA, Lewin AB, Farrel L, et al. Does cognitive-behavioral therapy response among adults with obsessive-compulsive disorder differ as a function of certain comorbidities? J Anxiety Disord. 2010;24:547552.


4. Ruscio AM, Stein DJ, Chiu WT, Kessler RC. The epidemiology of obsessive compulsive disorder in the National Comorbidity Survey Replication. Molec Biol. 2010;15:5363.


5. Storch EA. Pediatric obsessive-compulsive disorder: Guide to effective and complete treatment. Contemporary Pediatrics. 2005;22(11):5870.


6. Barlow DH. Anxiety and Its Disorders: The Nature and Treatment of Anxiety and Panic. New York: Guilford Press; 2002.


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