All in the Family

Optimizing Cognitive-Behaviorial Therapy for Childhood Psychiatric Disorders

ABSTRACTIntroduction: Pediatric obsessive-compulsive disorder (OCD) is a heterogeneous psychiatric condition that affects approximately 1–2% of youth. Exposure and response prevention (ERP), a behavioral intervention, is considered the first-line treatment for pediatric OCD. Although efficacious, a myriad of factors may complicate care for youth with OCD, suggesting the potential benefits of personalizing care for these youth.Areas covered: Factors such as comorbid psychopathology, familial factors (e.g., symptom accommodation, parental psychopathology), insight, developmental stage, and types of OCD symptom dimensions can each negatively affect treatment progress. Each of these factors are covered in length, with suggested clinical modifications provided in detail.Expert commentary: Youth with OCD will optimally benefit from mental health professionals that are appropriately trained in using the core components of ERP (i.e., exposure therapy). Adequate training and psychoeducation about factors that may complicate care are necessary to ensure that these youth receive targeted, personalized care that is efficacious.

The experience of obsessive-compulsive disorder (OCD) symptoms that have a religious theme is common. Recent research has found that religious participants with religious OCD symptoms frequently turn to religious advisors, such as imams or clergy, for help to understand and alleviate their symptoms. As such, the advice provided by imams or clergy may have an important impact on the response of the person seeking help. This study examined the attitudes, beliefs and experiences of 64 Muslim imams with mosque-goers who had religious OCD symptoms, particularly scrupulosity. This study also examined imams’ familiarity with first-line psychological treatments for OCD such as Exposure and Response Prevention (ERP). Sunni imams from Australia and Shia imams from Iran completed an online survey based on the research of Deacon, Vincent, and Zhang (2012), which was conducted with Christian clergy in the United States. Results showed that the majority of imams were unfamiliar with scrupulosity as a possible symptom of a mental health problem, such as OCD, and with ERP as a recognised treatment for OCD. While 37% of participants reported having been approached by mosque-goers for help with scrupulosity, only 9% referred mosque-goers to mental health professionals, and only one imam reported having referred a mosque-goer for ERP. Sunni imams located in Australia were more likely to provide advice inconsistent with the ERP approach and were also significantly less likely than Shia imams located in Iran to recommend referral to a mental health professional who was not affiliated with their own religious denomination. Finally, Sunni imams had significantly higher scores than Shia imams on Thought Action Fusion (TAF) subscales. Results of multiple regression analysis revealed that TAF explained a considerable amount of the variance related to ERP-inconsistent advice. Research implications and limitations are discussed.

Exposure and response prevention (ERP) constitutes the first-line treatment for obsessive-compulsive disorder (OCD). Despite robust empirical evidence supporting its efficacy, ERP has challenges, including high attrition rates and difficulty sustaining engagement. Research suggests that focusing on clients' strengths while addressing their difficulties can enhance therapy effectiveness. The present article details the case of a young adult with OCD characterized by sexual obsessions and mental compulsions, who initially underwent 12 sessions of cognitive-behavioral therapy (CBT) with limited progress. A subsequent transition to ERP throughout nine sessions resulted in positive treatment outcomes. The article illustrates how ERP may be coupled with a framework that capitalizes change using Innovative Moments (IMs)-changes in clients' discourse that reflect progress in therapy as manifested by new and adaptive ways of acting, feeling, or thinking. Therapists can be attentive, detect, and explore these moments to expand and promote further change. By attuning to and reinforcing IMs during ERP, the therapist assisted the client in disengaging from compulsions, increasing exposure tolerance, and consolidating therapeutic gains. This case underscores a practical strategy for clinicians: therapists can leverage naturally occurring change markers to enhance motivation and deepen learning in ERP rather than solely correcting dysfunctional patterns. The recognition and expansion of IMs have the potential to assist clients in maintaining engagement, tolerating distress, and cultivating more flexible responses to intrusive thoughts, which are all pivotal factors in the effective treatment of OCD.

Directions in Specialized Cognitive Behavior Therapy for Resistant Obsessive-Compulsive Disorder: Theory and Practice of Two Approaches

Obsessive-compulsive disorder (OCD) is a chronic and debilitating mental health condition characterized by persistent intrusive thoughts (obsessions) and repetitive behaviors (compulsions). While cognitive-behavioral therapy (CBT) involving exposure and response prevention (ERP) and pharmacotherapy with selective serotonin reuptake inhibitors are first-line treatments, many individuals continue to experience persistent symptoms or achieve only partial remission. Mindfulness-based interventions (MBIs), which aim to cultivate present-moment awareness and acceptance of internal experiences, have emerged as a promising adjunctive or alternative treatment approach for OCD. This review synthesizes the existing literature on the use of MBIs, such as mindfulness-based cognitive therapy (MBCT) and mindfulness-based stress reduction (MBSR), for OCD. Potential mechanisms by which MBIs may benefit individuals with OCD include improved attentional regulation, enhanced emotion regulation skills, reduced cognitive inflexibility through promoting cognitive defusion, and decreased experiential avoidance of intrusive thoughts and urges. Several studies have demonstrated the efficacy of MBIs in reducing OCD symptom severity, and providing insights into how MBIs can increase acceptance, improve emotion regulation, and foster a greater sense of control over symptoms.

Standard psychological treatment of obsessive‐compulsive disorder (OCD) typically involves the behavioural‐based therapy exposure and response prevention (ERP). This study compared the effectiveness of ERP with the recently developed cognitive therapy‐based treatment package, Danger Ideation Reduction Therapy for obsessive‐compulsive checkers (DIRT‐C) (Vaccaro, Jones, Menzies, and St Clare). Both treatments were delivered in 14 1‐hr individual weekly sessions. Post‐treatment intention‐to‐treat analysis revealed large statistically significant improvements for participants in both ERP (n = 22) and DIRT‐C (n = 28) conditions. However, treatment effect sizes for change in OCD symptom severity at post‐treatment were greater for DIRT‐C than for ERP (3.74 versus 2.89). In addition, at post‐treatment assessment, significantly more participants who received DIRT‐C were recovered compared with those who received ERP (43% versus 14%). Similarly, at 6‐month follow‐up, treatment effect sizes for change in OCD symptom severity were greater for DIRT‐C than for ERP (3.9 versus 2.76). This study provides further evidence of the usefulness of the DIRT‐C package for people with OCD checking subtype. Future research investigating DIRT‐C is warranted.

BackgroundExposure and response prevention, a type of cognitive-behavioral therapy, is an effective first-line treatment for obsessive-compulsive disorder (OCD). Despite extensive evidence of the efficacy of exposure and response prevention (ERP) from clinical studies and in real-world samples, it is still underused as a treatment. This is likely due to the limits to access to care that include the availability of adequately trained therapists, as well as geographical location, time, and cost barriers. To address these, NOCD created a digital behavioral health treatment for OCD using ERP delivered via video teletherapy and with technology-assisted elements including app-based therapy tools and between-session therapist messaging.ObjectiveWe examined treatment outcomes in a large naturalistic sample of 3552 adults with a primary OCD diagnosis who received NOCD treatment.MethodsThe treatment model consisted of twice-weekly, live, face-to-face video teletherapy ERP for 3 weeks, followed by 6 weeks of once-weekly brief video teletherapy check-ins for 30 minutes. Assessments were conducted at baseline, at midpoint after completion of 3 weeks of twice-weekly sessions, and at the end of 6 weeks of brief check-ins (endpoint). Longitudinal assessments were also obtained at 3, 6, 9, and 12 months after endpoint.ResultsTreatment resulted in clinically and statistically significant improvements, with a 43.4% mean reduction in obsessive-compulsive symptoms (g=1.0; 95% CI 0.93 to 1.03) and a 62.9% response rate. Treatment also resulted in a 44.2% mean reduction in depression, a 47.8% mean reduction in anxiety, and a 37.3% mean reduction in stress symptoms. Quality of life improved by a mean of 22.7%. Reduction in OCD symptoms and response rates were similar for those with mild, moderate, or severe symptoms. The mean duration of treatment was 11.5 (SD 4.0) weeks, and the mean total therapist time was 10.6 (SD 1.1) hours. Improvements were maintained at 3, 6, 9, and 12 months.ConclusionsIn this sample, representing the largest reported treated cohort of patients with OCD to date, video teletherapy treatment demonstrated effectiveness in reducing obsessive-compulsive and comorbid symptoms and improved quality of life. Further, it achieved meaningful results in less than half the total therapist time compared with standard once-weekly outpatient treatment, an efficiency that represents substantial monetary and time savings. The effect size was large and similar to studies of in-person ERP. This technology-assisted remote treatment is readily accessible for patients, offering an advancement in the field in the dissemination of effective evidence-based care for OCD.

Obsessive compulsive disorder (OCD) is one of the most frequently occurring psychiatric conditions in older adults. While exposure and response prevention (ERP) is considered the most effective psychological treatment for children and adults with OCD, research investigating its effectiveness for older adults is scarce. This clinical case study investigates the effectiveness of ERP in an 80-year-old man with a 65-year history of OCD. The client received 14 individual, 50-minute ERP treatment sessions. Clinician-based Y-BOCS scores reduced by 65% from 20 (moderate) at pretreatment to 7 (subclinical) at 7-month posttreatment followup. OCI-R total scores reduced by 45% from 38 at baseline to 21 at 7-month follow-up. Despite his long history of the disorder, ERP was effective and well tolerated. The application of ERP for older adults with OCD, including age-specific modifications that may be required for this treatment approach, is discussed.

Intervention cost-effectiveness for pediatric anxiety and OCD: A systematic review and integrated database model

Obsessive-compulsive disorder (OCD) is a chronic, severe and debilitating disorder, affecting over 3 million people in the United States. People afflicted with OCD have obsessions and compulsions that impair their functioning in life. According to the World Health Organization, OCD is among the ten most disabling medical conditions worldwide. The National Comorbidity Survey Replication, when examining anxiety disorders, found that OCD had the highest percentage of serious cases (50.6%) (Kessler et al., 2005). Lifetime prevalence estimates of OCD in pediatric and adult populations range from 1% to 3% (Kessler et al., 2005). The clinical presentation of OCD in childhood and adulthood is similar, making findings applicable across the age span. The mean age of onset for OCD in children is between 9 to 11 years in males and 11 to 13 years in females (Hanna, 1995). A more negative outcome is associated with an early age of onset. Furthermore, pediatric OCD was found to be chronic and unremitting in up to 87% of cases that failed to receive effective treatment (Stewart et al., 2004). Finally, an early diagnosis of OCD is associated with a higher risk for developing other psychiatric disorders into adulthood. THE CASE FOR NOVEL TREATMENTS OF OCD Serotonin reuptake inhibitors (SRI) are the only FDA approved medications for OCD. While considered effective in the clinical trial literature, treatment of OCD with SRI’s has proven limited in clinical practice. SRIs are only effective in 40 to 60% of patients (Jenike, 2004). Obviously, this leaves a considerable number still ill. Additionally, studies often define treatment response as a 20 to 40% reduction in symptoms. Hence, many subjects who are classed as “responders” still have marked symptoms after treatment (Jenike, 2004). OCD symptom severity scores, as calculated by the Children’s Yale-Brown Obsessive-Compulsive Scale (CY-BOCS), normally range from 15 to 20 post-treatment. A score in this range is still indicative of significant impairment. In addition to SRIs, cognitive behavioral therapy (CBT), alone or in combination with SRI, is also considered effective for treating OCD (POTS, 2004). Nonetheless, one-third of pediatric patients remain markedly ill even after receiving the combination of CBT and medication (POTS, 2004). What is more, data indicates that an earlier onset of OCD may be associated with the illness being more treatment refractory (POTS, 2004). Indeed, OCD is one of the few remaining psychiatric disorders for which there is a neurosurgical treatment indication. The persistence of symptoms and the limited nature of treatment response indicates that the serotonin paradigm of understanding OCD cannot fully account for the underlying neurobiology of the illness. Therefore, novel, evidence based approaches are needed to advance treatment of OCD. The glutamate hypothesis of OCD, first developed over a decade ago (Rosenberg & Keshavan, 1998), and resulting biological evidence has recently translated to the application of glutamate modulating agents for the treatment of pediatric OCD.

Treating Obsessive-Compulsive Disorder in Intimate Relationships: A Pilot Study of Couple-Based Cognitive-Behavior Therapy

Cognitive-behavioral therapy (CBT) consisting of exposure and response prevention (EX/RP) is efficacious as a treatment for obsessive-compulsive disorder (OCD). However, about half of patients have a partial or poor response to EX/RP treatment. This study examined potential predictors and moderators of CBT augmentation of pharmacotherapy, to identify variables associated with a poorer response to OCD treatment. Data were drawn from a large randomized controlled trial that compared the augmenting effects of EX/RP to stress management training (SMT; an active CBT control) among 108 participants receiving a therapeutic dose of a serotonin reuptake inhibitor (SRI). Stepwise regression was used to determine the model specification. Pretreatment OCD severity and gender were significant moderators of outcome: severity affected SMT (but not EX/RP) outcome; and gender affected EX/RP (but not SMT) outcome. Adjusting for treatment type and pretreatment severity, significant predictors included greater co-morbidity, number of past SRI trials, and lower quality of life (QoL). Significant moderators, including their main-effects, and predictors accounted for 37.2% of the total variance in outcome, comparable to the impact of treatment type alone (R2=30.5%). These findings were replicated in the subgroup analysis of EX/RP alone (R2=55.2%). This is the first randomized controlled study to examine moderators and predictors of CBT augmentation of SRI pharmacotherapy. Although effect sizes for individual predictors tended to be small, their combined effect was comparable to that of treatment. Thus, future research should examine whether monitoring for a combination of these risk factors and targeting them with multi-modular strategies can improve EX/RP outcome.

Obsessive-compulsive disorder (OCD) is a debilitating psychiatric condition characterized by recurrent and unwanted obsessions and compulsions. Obsessions are persistent, unwanted thoughts or impulses that cause anxiety. Compulsions are repetitive behaviors performed to reduce the experienced anxiety. OCD has four distinct symptom dimensions: 1) fear of contamination and cleaning compulsions, 2) symmetry, ordering, and counting, 3) aggressive, sexual, and blasphemous obsessions, and 4) hoarding and checking. OCD often co-occurs with other disorders, such as depression and anxiety. Treatment options include psychotherapy and pharmacotherapy, with cognitive behavioral therapy (CBT) with exposure and response prevention (ERP) being the most effective psychotherapy. Selective serotonin reuptake inhibitors (SSRIs) are the first choice for medication. However, these treatment strategies are not equally effective for everyone. A better understanding of the underlying neurobiological processes of OCD may help improve treatment. Although much imaging research has been conducted on the structure and function of the brains of people with OCD, significant questions remain unanswered due to the limitations of previous studies, including the confounding effects of medication use and small sample sizes. Additionally, relatively little research has been done on changes in neurotransmitters in the brains of people with OCD. There is suspicion that important neurotransmitters, such as glutamate and gamma-aminobutyric acid (GABA), differ in the brains of individuals with OCD. One reason for the limited research on neurotransmitters is the technical limitations of current measurement methods. Therefore, two important approaches are needed to better understand the underlying neurobiology of OCD. First, large-scale, harmonized research with large participant groups and detailed clinical characterization is required. Second, there is a need for technically advanced studies that investigate potential differences in neurotransmitters between individuals with and without OCD. The goal of the studies in this dissertation was therefore twofold. The first aim was to reliably identify structural brain differences between medication-free OCD patients and healthy controls by using larger sample sizes. By also collecting detailed clinical information from this large group of participants, we aimed to better understand the relationships between these findings and clinical variables such as disease duration, comorbid anxiety, and depression. These analyses are based on data collected in the Global OCD study, a worldwide consortium where data collection and processing were harmonized. The second aim was to better understand whether there are consistent differences in neurotransmitter concentrations between individuals with and without OCD, and how these neurotransmitters relate to clinical features or change after undergoing psychotherapy. We also sought to map how neurotransmitters change during exposure to OCD-related images in an MRI scanner by using technologically innovative imaging techniques. This dissertation includes five studies that utilize various imaging techniques to gain a deeper insight into the neurobiological mechanisms of OCD and potentially contribute to the development of more effective treatments in the future.

Exposure and response prevention (ERP) is a well‐established treatment for obsessive‐compulsive disorder (OCD). However, it is not completely effective for many patients, and some do not benefit from or tolerate this treatment. Over the past 3 decades there has been growing interest in using cognitive interventions, either as adjuncts or alternatives to exposure‐based treatments such as ERP, to address these shortcomings. Cognitive therapy and cognitive behavior therapy for OCD have both demonstrated greater efficacy than no treatment at all, and appear to have a lower incidence of dropout than ERP. Unfortunately, however, for the average OCD patient, cognitive interventions have not improved treatment efficacy; that is, cognitive interventions, either alone or combined with ERP, are no more effective than ERP alone. Reasons for this disappointing result are considered, and indications for the use of cognitive interventions are discussed. Future research directions are suggested in order to evaluate more fully the merits of, and indications for, cognitive methods for treating OCD.