Martin E. Franklin

Symptom Presentation and Outcome of Cognitive-Behavioral Therapy for Obsessive-Compulsive Disorder

Previous researchers have classified obsessive-compulsive disorder (OCD) patients by the themes of their obsessions and compulsions (e.g., washing, checking); however, mental compulsions have not been adequately assessed in these studies. The authors conducted 2 studies using a large sample of OCD patients (N=132). In the 1st study, they categorized patients on the basis of symptom presentation, giving adequate consideration to mental compulsions. Five patient clusters were identified: harming, contamination, hoarding, unacceptable thoughts, and symmetry. Mental compulsions were most prevalent among patients with intrusive, upsetting religious, violent, or sexual thoughts. In the 2nd study, they compared response to cognitive-behavioral therapy across symptom categories, finding poorer outcomes among patients with hoarding symptoms compared with those with other symptom themes.

Predictors and Moderators of Treatment Outcome in the Pediatric Obsessive Compulsive Treatment Study (POTS I)

OBJECTIVE To identify predictors and moderators of outcome in the first Pediatric OCD Treatment Study (POTS I) among youth (N = 112) randomly assigned to sertraline, cognitive behavioral therapy (CBT), both sertraline and CBT (COMB), or a pill placebo. METHOD Potential baseline predictors and moderators were identified by literature review. The outcome measure was an adjusted week 12 predicted score for the Childrens Yale Brown Obsessive Compulsive Scale (CY-BOCS). Main and interactive effects of treatment condition and each candidate predictor or moderator variable were examined using a general linear model on the adjusted predicted week 12 CY-BOCS scores. RESULTS Youth with lower obsessive-compulsive disorder (OCD) severity, less OCD-related functional impairment, greater insight, fewer comorbid externalizing symptoms, and lower levels of family accommodation showed greater improvement across treatment conditions than their counterparts after acute POTS treatment. Those with a family history of OCD had more than a sixfold decrease in effect size in CBT monotherapy relative to their counterparts in CBT without a family history of OCD. CONCLUSIONS Greater attention is needed to build optimized intervention strategies for more complex youth with OCD. Youth with a family history of OCD are not likely to benefit from CBT unless offered in combination with an SSRI. CLINICAL TRIALS REGISTRATION INFORMATION Treatment of Obsessive Compulsive Disorder (OCD) in Children, http://www.clinicaltrials.gov, NCT00000384.

Treatment of obsessive compulsive disorder.

Obsessive compulsive disorder (OCD) is characterized by the presence of intrusive, anxiety-provoking thoughts, images, or impulses along with repetitive behaviors or mental acts designed to reduce obsessional distress. OCD is associated with significant functional impairment, psychiatric comorbidity, and compromised quality of life. Fortunately, substantive progress has been made in the past several decades in the development and empirical evaluation of treatments for OCD across the developmental spectrum. The current review begins with a discussion of the clinical presentation of OCD and psychological theories regarding its etiology and maintenance. A detailed discussion follows of exposure plus response prevention, the psychosocial treatment that has garnered the most evidence for its efficacy. A summary of the extant treatment outcome literature related to exposure plus response prevention as well as cognitive therapies, pharmacotherapies, and combined approaches is then presented. Recommendations for future clinical and research directions are then provided.

Context in the clinic: how well do cognitive-behavioral therapies and medications work in combination?

Cognitive-behavioral therapy (CBT) and pharmacotherapy demonstrate efficacy across the anxiety disorders, but recognition of their limitations has sparked interest in combining modalities to maximize benefit. This article reviews the empirical literature to examine whether combining treatments influences efficacy of either monotherapy. We conducted a comprehensive literature search of published randomized trials that compared combined treatment with pharmacologic or CBT monotherapies. Ten studies that met our inclusion criteria were reviewed in detail, and within-subjects effect sizes were calculated to compare treatment conditions within and across studies. At posttreatment and follow-up, effect size and percentage responder data failed to clearly demonstrate an advantage or disadvantage of combined treatment over CBT alone for obsessive-compulsive disorder, social phobia, and generalized anxiety disorder. Some advantage of combined treatment over pharmacotherapy alone emerged from the few studies that allowed for such a direct comparison. In contrast, combined treatment for panic disorder seems to provide an advantage over CBT alone at posttreatment, but is associated with greater relapse after treatment discontinuation. The advantage of combined treatment may vary across the anxiety disorders. The potential differences in usefulness of combined treatment are discussed, directions for future research are suggested, and implications for clinical practice are considered.

A Randomized, Controlled Trial of Cognitive-Behavioral Therapy for Augmenting Pharmacotherapy in Obsessive-Compulsive Disorder

OBJECTIVE Although serotonin reuptake inhibitors (SRIs) are approved for the treatment of obsessive-compulsive disorder (OCD), most OCD patients who have received an adequate SRI trial continue to have clinically significant OCD symptoms. The purpose of this study was to examine the effects of augmenting SRIs with exposure and ritual prevention, an established cognitive-behavioral therapy (CBT) for OCD. METHOD A randomized, controlled trial was conducted at two academic outpatient clinics to compare the effects of augmenting SRIs with exposure and ritual prevention versus stress management training, another form of CBT. Participants were adult outpatients (N=108) with primary OCD and a Yale-Brown Obsessive Compulsive Scale total score > or = 16 despite a therapeutic SRI dose for at least 12 weeks prior to entry. Participants received 17 sessions of CBT (either exposure and ritual prevention or stress management training) twice a week while continuing SRI pharmacotherapy. RESULTS Exposure and ritual prevention was superior to stress management training in reducing OCD symptoms. At week 8, significantly more patients receiving exposure and ritual prevention than patients receiving stress management training had a decrease in symptom severity of at least 25% (based on Yale-Brown Obsessive Compulsive Scale scores) and achieved minimal symptoms (defined as a Yale-Brown Obsessive Compulsive Scale score < or = 12). CONCLUSIONS Augmentation of SRI pharmacotherapy with exposure and ritual prevention is an effective strategy for reducing OCD symptoms. However, 17 sessions were not sufficient to help most of these patients achieve minimal symptoms.

Exposure and Ritual Prevention for Obsessive-Compulsive Disorder: Effects of Intensive Versus Twice-Weekly Sessions

Exposure and ritual prevention (ERP) is the most effective treatment for obsessive-compulsive disorder (OCD), yet the intensive treatment schedule often described is not transportable to many settings. In the present study, the authors examined whether a twice-weekly (TW) ERP program reduced the effectiveness of intensive (IT) ERP. Forty OCD patients received 15 sessions of ERP: 20 received daily treatment over 3 weeks and 20 received twice weekly therapy over 8 weeks. Results indicated that both programs were effective. The effect of therapy schedule was moderate, with a trend toward more improvement in the intensive group at posttreatment. No differences were found at follow-up; some evidence of relapse was found with IT but not TW.

Body dysmorphic disorder and cosmetic surgery.

Learning Objectives: After studying this article, the participant should be able to: 1. Identify the diagnostic criteria and clinical features of body dysmorphic disorder. 2. Describe the prevalence of body dysmorphic disorder in cosmetic populations. 3. Identify appropriate treatment strategies for body dysmorphic disorder. Background: Body dysmorphic disorder is a relatively common psychiatric disorder among persons who seek cosmetic surgical and minimally invasive treatments. Methods: This article reviews the history of the diagnosis and the current diagnostic criteria. Etiologic theories, clinical and demographic characteristics, and comorbidity, including the relationship of body dysmorphic disorder to obsessive-compulsive spectrum and impulse control disorders, are discussed. The prevalence of body dysmorphic disorder in cosmetic populations is highlighted. Treatments for body dysmorphic disorder, including medical, psychiatric, and psychological interventions, are reviewed. Results: Body dysmorphic disorder is an often severe, impairing disorder. Among patients presenting for cosmetic treatments, 7 to 15 percent may suffer from the condition. Retrospective outcome studies suggest that persons with body dysmorphic disorder typically do not benefit from cosmetic procedures. Pharmacotherapy and cognitive-behavioral psychotherapy, in contrast, appear to be effective treatments for body dysmorphic disorder. Conclusions: Because of the frequency with which persons with body dysmorphic disorder pursue cosmetic procedures, providers of cosmetic surgical and minimally invasive treatments may be able to identify and refer these patients for appropriate mental health care. Directions for future research are suggested.

Cognitive Behavior Therapy Augmentation of Pharmacotherapy in Pediatric Obsessive-Compulsive Disorder The Pediatric OCD Treatment Study II (POTS II) Randomized Controlled Trial

CONTEXT The extant literature on the treatment of pediatric obsessive-compulsive disorder (OCD) indicates that partial response to serotonin reuptake inhibitors (SRIs) is the norm and that augmentation with short-term OCD-specific cognitive behavior therapy (CBT) may provide additional benefit. OBJECTIVE To examine the effects of augmenting SRIs with CBT or a brief form of CBT, instructions in CBT delivered in the context of medication management. DESIGN, SETTING, AND PARTICIPANTS A 12-week randomized controlled trial conducted at 3 academic medical centers between 2004 and 2009, involving 124 pediatric outpatients between the ages of 7 and 17 years with OCD as a primary diagnosis and a Childrens Yale-Brown Obsessive Compulsive Scale score of 16 or higher despite an adequate SRI trial. INTERVENTIONS Participants were randomly assigned to 1 of 3 treatment strategies that included 7 sessions over 12 weeks: 42 in the medication management only, 42 in the medication management plus instructions in CBT, and 42 in the medication management plus CBT; the last included 14 concurrent CBT sessions. MAIN OUTCOME MEASURES Whether patients responded positively to treatment by improving their baseline obsessive-compulsive scale score by 30% or more and demonstrating a change in their continuous scores over 12 weeks. RESULTS The medication management plus CBT strategy was superior to the other 2 strategies on all outcome measures. In the primary intention-to-treat analysis, 68.6% (95% CI, 53.9%-83.3%) in the plus CBT group were considered responders, which was significantly better than the 34.0% (95% CI, 18.0%-50.0%) in the plus instructions in CBT group, and 30.0% (95% CI, 14.9%-45.1%) in the medication management only group. The results were similar in pairwise comparisons with the plus CBT strategy being superior to the other 2 strategies (P < .01 for both). The plus instructions in CBT strategy was not statistically superior to medication management only (P = .72). The number needed-to-treat analysis with the plus CBT vs medication management only in order to see 1 additional patient at week 12, on average, was estimated as 3; for the plus CBT vs the plus instructions in CBT strategy, the number needed to treat was also estimated as 3; for the plus instructions in CBT vs medication management only the number needed to treat was estimated as 25. CONCLUSIONS Among patients aged 7 to 17 years with OCD and partial response to SRI use, the addition of CBT to medication management compared with medication management alone resulted in a significantly greater response rate, whereas augmentation of medication management with the addition of instructions in CBT did not. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT00074815.

Tics Moderate Treatment Outcome with Sertraline but not Cognitive-Behavior Therapy in Pediatric Obsessive-Compulsive Disorder

BACKGROUND The presence of a comorbid tic disorder may predict a poorer outcome in the acute treatment of pediatric obsessive-compulsive disorder (OCD). METHODS Using data from the National Institute of Mental Health (NIMH)-funded Pediatric OCD Treatment Study (POTS) that compared cognitive-behavior therapy (CBT), medical management with sertraline (SER), and the combination of CBT and SER (COMB), to pill placebo (PBO) in children and adolescents with OCD, we asked whether the presence of a comorbid tic disorder influenced symptom reduction on the Childrens Yale-Brown Obsessive Compulsive Scale (CY-BOCS) after 12 weeks of treatment. RESULTS Fifteen percent (17 of 112) of patients exhibited a comorbid tic disorder. In patients without tics, results replicated previously published intent-to-treat outcomes: COMB > CBT > SER > PBO. In patients with a comorbid tic disorder, SER did not differ from PBO, while COMB remained superior to CBT and CBT remained superior to PBO. CONCLUSIONS In contrast to CBT outcomes, which are not differentially impacted, tic disorders appear to adversely impact the outcome of medication management of pediatric OCD. Children and adolescents with obsessive-compulsive disorder and a comorbid tic disorder should begin treatment with cognitive-behavior therapy alone or the combination of cognitive-behavior therapy plus a serotonin reuptake inhibitor.

Effects of comorbid Depression on response to treatment for obsessive-compulsive disorder

We examined the effects of comorbid depression on response to treatment for obsessive-compulsive disorder (OCD) using cognitive-behavioral therapy with and without medication. Eighty-seven OCD patients were divided into nondepressed and mildly, moderately, and severely depressed groups on the basis of their pretreatment Beck Depression Inventory (BDI) scores. Each received an intensive cognitive-behavioral treatment program involving exposure with response prevention (EX/RP); 59 (68%) were also taking medication for OCD. Patients with severe initial depression (BDI ≥30) showed significantly less improvement compared to those less depressed or nondepressed; yet, even highly depressed patients showed moderate treatment gains. Failure to habituate to anxiety-evoking stimuli during exposure and a lack of motivation for therapy are considered possible causes of attenuated outcome.