Knowledge and competency standards for specialized cognitive behavior therapy for adult obsessive-compulsive disorder

The relationship between Obsessive Compulsive Disorder (OCD) and Obsessive Compulsive Personality Disorder (OCPD) has been the subject of interest for some time due to the historical assumption that OCPD causes OCD. This study systematically examined the association between OCD and OCPD in terms of prevalence and clinical presentation. The specificity of the association between OCD and OCPD was investigated relative to another axis I anxiety disorder (Panic disorder). Data for this study were drawn from measures taken at initial assessment at a specialist treatment centre for anxiety disorders. Of the 359 participants included in this study, 189 had a principal diagnosis of OCD, while 170 had a principal diagnosis of Panic disorder. Measures included SCID I and II interview modules and self-report measures of anxiety, depression, and OCD syptomatology. Significantly elevated rates of OCPD were found in OCD relative to Panic disorder. Regardless of axis I disorder, individuals with comorbid OCPD reported more severe depression relative to those without. Participants with both OCD and OCPD had greater self-reported OCD symptom severity, doubting, ordering, and hoarding symptoms at assessment relative to those without OCPD. Participants with OCD and comorbid OCPD also reported significantly higher levels of alcohol consumption. There appears to be a significant and specific association between OCD and OCPD. Co-occurring OCD and OCPD is associated with greater severity of impairment in terms of certain OCD symptoms. The significant and specific association between OCD and OCPD suggests that OCPD occurs more frequently with OCD than previously suggested. A comorbid OCPD diagnosis is associated with a greater degree of depression, regardless of axis I disorder, either OCD or Panic disorder. This is an important consideration, as depression can interfere with therapeutic progress (Foa, 1979). Participants with OCD and OCPD had greater self-reported OCD severity, along with doubting, ordering, and hoarding symptoms, relative to those without OCPD. In clinical practice, where OCD symptoms are severe, and the primary OCD symptoms include doubting, ordering, and hoarding, this may indicate a need to assess for comorbid OCPD. This may be useful in terms of including relevant information in formulation with the patient, and in addressing these issues in treatment. There may have been a sampling issue, as the study compared patients from a specialist clinic for the treatment of OCD and Panic disorder. Furthermore, OCD referrals were primary, secondary, or tertiary, whereas Panic disorder referrals were primary or secondary from the immediate catchment area only. This suggests the possibility of greater severity of the OCD sample relative to Panic disorder patients. All participants who met criteria for OCD were assessed for OCPD regardless of whether or not this was indicated by the SCID II screener self-report measure, while participants with Panic disorder were interviewed for OCPD only if indicated by the SCID-II screener. Had participants with Panic disorder been assessed for OCPD regardless of whether or not this was indicated by the SCID-II screener, there is a possibility that a higher rate of OCPD in the Panic disorder sample may have been found.

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.

Reversal Learning as a Neuropsychological Indicator for the Neuropathology of Obsessive Compulsive Disorder? A Behavioral Study

Patients with obsessive-compulsive disorder (OCD) face multiple barriers when accessing treatment and rarely receive best-practice cognitive behaviour therapy (CBT) when they seek help. Remote treatments, such as internet-delivered CBT (ICBT), enhance access to evidence-based treatments. To date, no known studies have examined the reasons individuals seek remote treatment over traditional in-person treatment for OCD. Thus, the aim of the current study was to examine the treatment histories of individuals who completed ICBT for OCD and their reasons for seeking ICBT. One hundred and sixty-six participants (Mage = 33.88; SD = 13.41, 71.7% female) were included in the study. Almost three-quarters of the sample had previously spoken to a health professional about their OCD symptoms. General practitioners were the most frequently consulted health professionals initially (41.7%), while psychologists were the most frequently consulted overall (81.7%). Supportive counselling (74.2%) and medication (72.5%) were the most common forms of treatment ever received. Of those who had received CBT for OCD, only 20.0% (12.5% of the overall sample) likely received best-practice CBT. The most frequently endorsed reasons for seeking ICBT over in-person treatment related to having no access to face-to-face treatment in the community (25.9%) and having found previous face-to-face treatment unhelpful (24.1%). Group differences in reasons for seeking ICBT over face-to-face treatment emerged based on geographical location, OCD severity and presence of comorbid depressive symptoms. Evidence-based treatment for OCD is underutilized in the community highlighting the need to develop and disseminate evidence-based remote treatments for OCD.

Neuromodulation techniques have been proposed as add-on strategies for modulating brain areas involved in obsessive-compulsive disorder symptoms. Trigeminal nerve stimulation is a novel neuromodulation technique, which, to date, has not yet been explored for obsessive-compulsive disorder treatment. In this report, we describe a 52-year-old female patient suffering from major depressive disorderand obsessive-compulsive disorder for 18 and 32 years, respectively and successfully undergoing a trigeminal nerve stimulation intervention protocol (10 consecutive daily trigeminal nerve stimulation sessions), with amelioration of symptoms. Cognitive function was not obviously altered as assessed by the Montreal Cognitive Assessment. Major depressive disorder and obsessive-compulsive disorder symptoms assessed using the Yale-Brown Obsessive-Compulsive Scale and the 17-item Hamilton Depression Rating Scale substantially improved after the 10-day treatment course and remained stable after 1-month follow-up (30 days after final trigeminal nerve stimulation). The patient reported significant global clinical gains and mild diurnal sleepiness without severe adverse effects. Trigeminal nerve stimulation has been studied for the treatment of various neuropsychiatric disorders that share common functional alterations at the frontal cortex and subcortical areas, usually altered in obsessive-compulsive disorder. We present the first case report on trigeminal nerve stimulation for co-morbid obsessive-compulsive disorder and major depressive disorder. These encouraging results should be seen as hypothesis-driving for further controlled randomized trials exploring the impact of trigeminal nerve stimulation in the treatment of obsessive-compulsive disorder.doi: 10.4103/2542-3932.198962How to cite this article: Trevizol AP, Sato IA, Cordeiro Q (2017) Trigeminal nerve stimulation for the treatment of major depressive disorder and obsessive-compulsive disorder: a case study. Asia Pac J Clin Trials Nerv Syst Dis 2(1):30-32.

The initial treatment of obsessive-compulsive disorder (OCD) has generally been limited to serotonergic agents, cognitive-behavioral therapy (CBT), or a combination of the two. These findings were supported by the POTS study for OCD in children and adolescents. However, treatment with serotonergic agents or CBT can take several weeks before benefit is seen; severe cases of OCD may require more immediate treatment. The authors present a case of severe OCD in an adolescent that required immediate treatment due to her critical medical condition. The patient's symptoms included not eating or taking medications or fluids by mouth due to fears of contamination. A medical hospitalization was previously required due to dehydration. As treatment with an SSRI would not have quick enough onset and the patient was initially resistant to participating in CBT, the patient was psychiatrically hospitalized and first started on liquid risperidone. After several doses of risperidone, the patient was able to participate in CBT and start sertraline. The authors discuss the differential diagnosis of such a patient, including the continuum of OCD symptoms and psychotic symptoms. The authors discuss the different treatment options, including the utilization of inpatient psychiatric hospitalization. The authors discuss the potential risks and benefits of using atypical antipsychotics in lieu of benzodiazepines for the initial treatment of severe adolescent OCD. The authors also discuss other current treatment recommendations and rationale for the treatment that was pursued. This patient received benefit of her symptoms relatively quickly with psychiatric hospitalization and an atypical antipsychotic. The diagnosis of a psychotic disorder should be considered. These treatment options must be weighed against the risks of atypical antipsychotics, including extrapyramidal symptoms, weight gain, and metabolic syndrome; benzodiazepines also have their risks and benefits. Additionally, the cost of time and finances of inpatient hospitalization must be considered. More research is needed regarding the short- and long-term efficacy and safety of antipsychotics in the treatment of OCD in the child and adolescent population.

While serotonin reuptake inhibitors (SRIs) are first-line pharmacological agents in the treatment of obsessive-compulsive disorder (OCD), 40-60% of patients with the disorder do not respond to these agents. This suggests that other neurotransmitters may play a role in OCD. In this regard, there has been particular interest in the dopaminergic system, with various antipsychotic drugs having been used as adjunctive therapy for refractory OCD. The aim of this study was to compare the efficacy of quetiapine and ziprasidone as adjuncts for treatment-resistant OCD. A total of 24 OCD patients treated with either quetiapine (n = 15) or ziprasidone (n = 9) as adjunctive therapy to high-dose SRI treatment were included in this retrospective evaluation. Yale-Brown Obsessive-Compulsive Scale (Y-BOCS) and Clinical Global Impression (CGI) scale scores were used to evaluate baseline clinical status and clinical improvement at 1, 2, 3 and 6 months of follow-up. Clinical improvement was established in 80% of the quetiapine group and in 44.4% of the ziprasidone group with an overall mean improvement rate on the Y-BOCS scale of 66.7%. Both Y-BOCS and CGI mean scores were higher in the ziprasidone group at 2, 3 and 6 months follow-up than in the quetiapine group. In the first reported study of its role in this setting, ziprasidone was found to be less effective than quetiapine in the treatment of refractory OCD.

AIMTo review available evidence on the use of cognitive behavioural therapy (CBT) for treating obsessive compulsive disorder co-occurring with psychosis.METHODSIn this paper we present a detailed and comprehensive review of the current literature focusing on CBT treatment of obsessive compulsive disorder (OCD) co-occurring with schizophrenia or schizoaffective disorder. We identified relevant literature published between 2001 and May 2016 through MEDLINE/PubMed search using as search string (“obsessive compulsive disorders” or “obsessive compulsive symptoms”) and (“schizophrenia” or “schizoaffective disorder” or “psychosis”) and (“cognitive behavioural therapy”). Other citations of interest were further identified from references reported in the accessed articles. The search was limited to studies written in English and carried out in adult patients. A total of 9 studies, 8 case reports and 1 case series, were found.RESULTSThe reviewed evidence indicates that CBT is: (1) safe, i.e., does not worsen psychotic symptoms; (2) well accepted, with a discontinuation rate quite similar to that reported for patients with OCD without psychosis comorbidity; (3) effective, with a symptom reduction quite similar to that reported for patients with OCD without psychosis and for SRIs treatment of OCD co-occurring with psychosis; and (4) effective in patients with OCD induced by second-generation antipsychotic as well as in patients with OCD not induced by second-generation antipsychotic. Alcohol/substance use disorder comorbidity and OCD onset preceding that of SCH/SA was predictors of poor outcome. These results are derived only by additional studies with adequate sample size.CONCLUSIONOur results support the use of CBT for OCD in patients with psychosis.

LATA K. MCGINN & WILLIAM C. SANDERSON: Treatment of Obsessive-Compulsive Disorder. Northvale, NJ, Jason Aronson Inc. 1999, 296 pp., $40.00, ISBN 0-76-570-2118. Drs. Lata McGinn and William Sanderson have responded to the demands of the health care environment by producing an evidence-based cognitive-behavioral treatment (CBT) protocol for the Treatment of Obsessive-Compulsive Disorder Increasingly, clinicians are being required by managed care companies and other agencies to employ treatments that have empirical support. Unfortunately, few clinicians have formal training in these evidence-based treatments since limited numbers of doctoral programs in clinical psychology, psychiatry residency training programs, and psychology and social work internships employ faculty with expertise in these evidence-based treatment approaches. The age-old problem has been transporting these treatments developed in university laboratories to the real world. McGinn and Sanderson achieve this goal by presenting a detailed, session-by-session guide that helps clinicians carefully assess and systematically treat obsessive-compulsive disorder (OCD). These authors have developed a comprehensive treatment for OCD that creatively combines psychoeducation and cognitive restructuring, with traditional exposure and response prevention techniques. The techniques described in this book draw primarily from the previous work of Aaron Beck, Edna Foa, Gail Steketee, and Paul Salkovskis. McGinn and Sanderson describe a patient diagnosed with OCD and weave this clinical material throughout the book to highlight the specific techniques presented. The first chapter of the book offers a succinct review of a cognitive-behavioral model of OCD. The authors describe the integration of the recent advances in employing cognitive restructuring with the traditional behavioral strategies. Each of the remaining eight chapters in the book is considered a session. This structure helps clinicians organize their treatment around several content areas and stages. It is understood by the reader that this treatment is not actually completed in 8 sessions but rather each is typically extended over several visits. Each session has its goals outlined at the beginning of each chapter which, when used later as a reference, helps the reader quickly review the highlights. Session I involves the assessment of OCD which contains two primary components. First, the authors review how to establish the diagnosis and which common comorbid conditions to consider. Second, is a review of general elements of any initial assessment as well as key elements in the assessment of OCD. For example, onset and course of the disorder, prior treatments, degree of insight, are some of the general domains of any assessment, whereas anxiety triggers (internal and external), avoidance behaviors, and ritualized thoughts and behaviors, are specific assessment areas relevant to OCD. …

Until the late 1960s, obsessive compulsive disorder (OCD) was considered to be a relatively untreatable condition. Over the next several years, many advances were made in the psychological treatment of OCD as clinicians and researchers began to realize the value of behavioural treatments for this population. Isaac Marks and his colleagues played an instrumental role in the development and initial validation of exposure-based treatments for OCD. In addition to his other important research in the area of anxiety, Marks continued to study behavioural treatments for OCD, including the processes and predictors of treatment outcome. More recently, his work has focused on self-administered treatments for OCD and other anxiety disorders, including computerized and telephone-based treatments. This paper reviews research on the behavioural treatment of OCD, with an emphasis on the contributions of Isaac Marks.

Obsessive-compulsive disorder (OCD) is a debilitating neuropsychiatric condition estimated to afflict 1-3% of the world population. The estimated financial impact in the treatment and management of OCD is in the billions of dollars annually in the US alone. At present there is a marked lack of evidence on the specific causes of OCD. Current hypotheses largely focus on the serotonin (5-HT) system on the basis of the effectiveness of selective serotonin reuptake inhibitors (SSRIs) in alleviating symptoms of patients with OCD, yet a considerable fraction of patients are non-responsive or minimally responsive to these agents. Despite this fact, SSRIs have remained the primary pharmacological treatment avenue for OCD. In recent years, multiple lines of evidence have implicated glutamatergic synaptic dysfunction within the cortico-striatal-thalamo-cortical (CSTC) brain circuit in the etiology of OCD and related disorders, thereby prompting intensified effort in the development and evaluation of agents that modulate glutamatergic neurotransmission for the treatment of OCD. With this in mind, here we review the following topics with respect to synaptic dysfunction and the neural circuitry underlying OCD: (1) evidence supporting the critical involvement of the CSTC circuit, (2) genetic studies supporting the involvement of glutamatergic dysfunction, (3) insights from genetic animal models of OCD, and (4) preliminary findings with glutamatergic neurotransmission-modulating agents in the treatment of OCD. Given the putative mechanistic overlap between OCD and the broader OC-spectrum of disorders, unraveling the synaptic basis of OCD has potential to translate into more effective treatments for an array of poorly understood human disorders.

The development of empirically based treatments for obsessive compulsive disorder (OCD) has gone through many phases and has been informed by several practices. Initial applications of behavioral treatments for anxiety disorders were directly linked to laboratory research on conditioning (e.g., Jones 1924; Wolpe, 1958). Meyer (1966) refined these procedures for the treatment of OCD into what we now know as exposure and ritual prevention (ERP). Behavioral processes such as respondent conditioning and operant avoidance (e.g., Mower, 1960) were proposed as the processes through which the effects were produced in ERP (Eyseneck & Rachman, 1965; Rachman & Hodgson, 1980). ERP has been well-researched and its effectiveness demonstrated (Abramowitz, Franklin, & Foa, 2002), and remains a first line intervention for adult and childhood OCD. However, secondary to the difficulties associated with ERP including high drop-out and treatment refusal rates, and partial treatment response, cognitive approaches to OCD have increased in popularity (e.g., Rachman, 1997, 1998; Salkovskis, 1985; Wilhelm & Steketee, 2006). Original cognitive conceptualizations of anxiety disorders focused on the role of inaccurate cognitions as proposed by Beck (1976) and Ellis (Ellis, 1962). Carr (1974) and McFall and Wollersheim (1979) put forward initial cognitive conceptualizations of OCD. Since that time, cognitive conceptualizations of OCD evolved (Rachman, 1997, 1998; Salkovskis, 1985) to incorporate the detrimental effects of thought control (Clark, Ball, & Pape, 1991; Tolin, Abramowitz, Przeworski, & Foa, 2002), thought action fusion (Shafran, Thordarson, & Rachman, 1996), and inflated responsibility (Salkovskis et al., 2000), as well as other concepts (e.g., Wilhelm & Steketee, 2006). Nevertheless, cognitive theorists postulated that belief change at least partially mediates changes in behavior (e.g., Rachman, 1997, 1998; Salkovskis, 1985). At the same time that CT was developing, a separate line of research grew out of behavior analysis that focused on language and cognition as explicated in relational frame theory (Hayes, Barnes-Holmes, & Roche, 2001). Based on this line of research and a functional contextual approach to science, another version of CBT, acceptance and commitment therapy (ACT) (Hayes, Strosahl, & Wilson, 1999), developed. ACT generally focuses on the function of cognitions and other inner experiences to decrease their impact on overt behavior without targeting the content of these inner experiences. Overt behavior is addressed through values work (e.g., future directed motivational enhancement) and commitments to behavior change. The data on ACT as a treatment for OCD is limited to a time-series design and one randomized clinical trial comparing ACT to Progressive Muscle Relaxation (Twohig, Hayes, & Masuda, 2006, Twohig et al., 2010). The addition of ACT and other third generation therapies has led to a noticeable amount of theoretical discussion on the similarities and differences of these treatments. Special issues on this topic have occurred in Clinical Psychology Review (Longmore & Worrell, 2007; Hofmann, 2008a; Worrell & Longmore, 2008), the Behavior Therapist (DiGuiseppe, 2008; Hayes, 2008a; Leahy, 2008; Moran, 2008; O'Brien, 2008; Salzinger, 2008) one review dealing with the treatment of anxiety disorders in Clinical Psychology Science and Practice (Arche & Craske, 2008; Hoffman, 2008b; Hayes, 2008b; Heimberg & Ritter, 2008) and one issue on OCD specifically Cognitive and Behavioral Practice (Chosak, Marques, Fama, Renaud, & Wilhelm, 2009, Himle & Franklin, 2009; Tolin, 2009; Twohig, 2009; Twohig & Whittal, 2009); these are in addition to individual reviews and replies that exist (DiGiuseppe, 2006; Hayes, Luoma, Bond, Masuda, & Lillis, 2006; Hoffman & Asmundson, 2008; Levin & Hayes, 2009; Ost, 2008; Powers, Zum Vorde Sive Vording, & Emmelkamp, 2009). …

Introduction: Alexithymia levels have generally been found high in patients with obsessive compulsive disorder (OCD). It is thought that there is a correlation between alexithymia and the severity of OCD symptoms. One of the factors influencing alexithymia is temperament-character traits. In this study, it was aimed to investigate the temperament-character traits in OCD patients and the correlation of these traits with alexithymia. Methods: This study included 43 OCD patients who applied to Atatürk University Psychiatry Outpatient Clinic and 33 healthy individuals as the control group. Structured Clinical Interview for DSM-IV Axis I Disorders (SCID-IV), Sociodemographic and clinical data form, and Temperament and Character Inventory (TCI), Toronto Alexithymia Scale (TAS-20) were applied to participants whereas Yale-Brown Obsessive-Compulsive Scale (Y-BOCS) was additionally applied to the patient group.Results: No difference was detected between both groups in terms of age and gender. In the OCD group, harm avoidance (HA) and self-transcendence (ST) scores were found high, and self-directedness (SD), cooperativeness (C) and novelty seeking (NS) were found low when compared to the control group. In the OCD group, difficulty in expressing feelings (TAS-B), extroverted thinking (TAS-C) and TAS-20 scores were found to be higher than the control group. In the alexithymic OCD group, the mean disorderliness and persistence(P) scores were found to be lower compared to the non-alexithymic group. A positive correlation was discovered between Y-BOCS scores and TAS-C scores in OCD patients.Conclusion: Alexithymia is observed at a high rate in OCD. The extroverted thinking sub-dimension of alexithymia is correlated with the severity of OCD symptoms. Some temperament-personality traits differ in alexithymic-OCD patients compared to those who are not alexithymic. The evaluation of alexithymia and the factors influencing alexithymia has the potential to offer a new approach to understand the etiology and treatment of OCD.

Obsessive-Compulsive Disorder in Children and Adolescents: A Review of the Past 10 Years

This study aims to investigate the application of Cognitive Behavioral Therapy (CBT) to individuals with Obsessive Compulsive Disorder (OCD). The study was conducted using the systematic review method. No field work was conducted and no scale was used. The studies examined in Turkish and English were conducted between 2017 and 2023. This review was conducted in two stages in March 2025 and May 2025. The results obtained show that OCD symptoms are significantly reduced and in some cases completely eliminated with CBT. It was also determined that CBT reduces individuals' anxiety levels, increases their functionality, and improves their ability to cope with obsessive thoughts. The reviewed sources show that CBT applied both individually and in groups yields positive results in the treatment of OCD. As a result, CBT stands out as an effective psychotherapy method that is widely used in the treatment of OCD, is based on scientific foundations, and can provide permanent improvement in the long term. This review strengthens the role of CBT in the treatment of OCD and provides a basis for future clinical research.