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In 1966, Meyer reported the successful behavioral treatment of two patients with severe compulsive ritualizing through around-the-clock response (or ritual) prevention. A series of elegant studies by other investigators (Foa et al. 1998; Marks et al. 1975; Rachman et al. 1973; Steketee et al. 1982) confirmed that approximately 75% of OCD patients will engage in behavior therapy and that most who do so faithfully show both acute (Foa et al. 1998) and sustained (O'Sullivan et al. 1991) improvement. Unsuccessful treatment is most often a result of noncompliance, which may take the form of unrecognized mental rituals. Comorbid severe depression, misdiagnosis (e.g., when psychotic delusions are misinterpreted as obsessions), and state-dependent learning (usually associated with high doses of central nervous system [CNS] depressant substances such as alcohol, barbiturates, carbamates, or benzodiazepines) also interfere with response to behavior therapy. Wolpe's (1958) systematic desensitization was found to have weak efficacy for patients with OCD (Cooper et al. 1965). Relaxation did not increase the benefit of effective exposure and ritual prevention, and exposure in fantasy or imagination was not as effective as exposure in vivo (Steketee et al. 1982).

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Figure 31–1. Sample rates of change with behavior therapy of an obsessive-compulsive disorder ritual.Source. Reprinted from Baer L: Getting Control: Overcoming Your Obsessions and Compulsions, Revised Edition. Boston, MA, Little, Brown, 2000, p. 53. Copyright 2000. Used with permission.

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