Cognitive-Behavioral Therapy for Obsessive-Compulsive Disorder
Abstract
Cognitive-behavioral therapy (CBT) with exposure and response prevention is one of the most effective treatments available for obsessive-compulsive disorder (OCD). This treatment avoids side effects that are common to management of symptoms with psychotropic medication and has the added benefit of reducing the risk for relapse once medication is discontinued. Development of a treatment plan involves identification and ranking of stimuli that provoke obsessions, exposure to these stimuli while preventing compulsions through various techniques, and use of cognitive restructuring. The family of the OCD patient plays a significant role in treatment. The family’s accommodation and emotional response to a patient’s obsessions and compulsions may interfere with therapy and perpetuate symptoms. The same considerations apply to OCD in the pediatric population. However, the form of obsessions and compulsions differs according to age, and therapeutic techniques are modified to make them developmentally appropriate.
As mentioned in the introductory article, cognitive-behavioral therapy (CBT) remains one of the most effective treatments for obsessive-compulsive disorder (OCD). In this article, we define CBT; review the evidence for the efficacy of CBT for OCD; provide a case example and sample treatment plan; and discuss family factors that affect treatment outcome, group, and family-based modalities to administer CBT and special applications of CBT to children with OCD.
Defining CBT
Over the years, CBT has come to represent a blend of modifying cognitions and behavior. Traditionally, in cognitive therapy faulty thoughts and beliefs are the target of therapy (1–3). In behaviorally focused treatment, termed exposure and response prevention (ERP), patients engage in exposure to stimuli that trigger obsessions and are encouraged through various techniques to refrain from performing compulsions (4).
The APA guidelines support the use of cognitive therapy and ERP but note that there is more evidence for the efficacy of ERP. A recent meta-analysis found that ERP and cognitive therapy produced very similar effect sizes, although a larger amount of data exists in support of ERP (5–7). This finding led to the recommendation that ERP be considered as the first-line psychotherapeutic treatment for OCD. In practice, we recommend a combination of cognitive and behavioral techniques (8).
Efficacy of CBT monotherapy
The efficacy of CBT monotherapy has been established as superior in comparison to progressive muscle relaxation (9–11), anxiety management training (12), and systematic relaxation (13). A recent meta-analysis of 16 randomized-placebo or wait-list–controlled trials found that ERP and cognitive therapy resulted in symptom improvement, with no difference in efficacy between these two forms of psychotherapeutic treatment (14).
Head-to-head comparator trials of CBT versus medication are few. CBT-ERP was shown to be superior to clomipramine in one multisite trial, with fewer side effects (15). CBT-ERP was superior to fluvoxamine in another study, albeit at lower-than-maximum doses of fluvoxamine (16). Although comparison data are few, it is important to note that ERP may reduce the risk for relapse once medication is discontinued (15, 17–22).
CBT and pharmacotherapy: Augmentation and combination
The APA practice guidelines state that modest evidence exists to support the use of CBT in augmentation of selective serotonin reuptake inhibitors (SSRIs). One trial found that patients with partial response to SSRIs randomly assigned to CBT-ERP showed greater improvement than those randomly assigned to stress management training (23). A recent study found that in patients with some response to stable doses of SSRIs, greater improvement occurred when patients were randomly assigned to ERP in comparison to risperidone and pill-placebo (24). Data from a similar trial provide additional support (25). Further, albeit still limited, evidence comes from a study of patients with some response to SSRIs who were randomly assigned either to therapist-administered or self-administered ERP (26). This study found that both forms of ERP reduced OCD symptoms; however, the therapist-administered sessions resulted in greater improvement (26). Open trials have also provided support for CBT augmentation of medication (27–30).
CBT in combination with medication was found to have greater efficacy than medication or CBT alone in several studies (14, 31–33). Current APA treatment guidelines recommend combination therapy in situations of SRI-responsive co-occurring disorders or in severe cases of OCD symptoms and among patients who wish to limit the duration of pharmacotherapy (34). This latter instance is derived from the finding that CBT may reduce the risk for relapse once medication is discontinued, as noted earlier. The neurobiological mechanism of action in CBT is uncertain. However, data suggest that CBT does lead to changes in neurobiology in patients with anxiety disorders (35). In OCD patients specifically, decreased caudate positron emission tomographic activity (36, 37) and decreased functional magnetic resonance imaging frontal orbital cortex activity (38) have been found following CBT. The decrease in caudate activity following CBT was similar to that seen with successful treatment of OCD with fluoxetine (36).
Assessment of OCD
The assessment of OCD begins with accurate diagnosis. The DSM-5 diagnostic criteria for OCD have been covered in the introductory article in this issue of Focus. Once the diagnosis of OCD has been made, the treatment provider can begin to determine 1) the underlying behavior contingencies and 2) the underlying maladaptive cognitions, in order to develop a treatment plan.
Classical and operant conditioning principles can be used to characterize the obsessions and compulsions demonstrated by the patient as behavioral contingencies (39–41). In this model, previously neutral stimuli, such as countertops or doorknobs, lead to anxiety through repeated presentation with an event that leads to distress, such as thoughts about illness. The thoughts or images regarding illness are the obsession in this model. The patient with OCD, when presented with the obsession (a conditioned stimulus), engages in compulsive behaviors that neutralize the associated distress. The compulsive behaviors are strengthened through negative reinforcement (removal of a distressing stimulus, anxiety). This is important for case conceptualization and for development of a treatment plan, as will be discussed in a later portion of this article.
To the outside observer, the connection between the obsessions and compulsions may appear to be an unreasonable appraisal of the true likelihood of danger. This unrealistic appraisal is often the case but need not be present for the diagnosis of OCD. The degree to which the appraisal of threat is recognized by the patient as unreasonable is referred to as the degree of insight possessed by the patient (which is one of the newly included DSM-5 specifiers).
Regardless of the degree of insight, distorted cognitions are held by the OCD patient and are a second focus of treatment planning. Common cognitions may be “All countertops contain germs. If I touch them, I or my family will get sick.” A major model of the cognitive process in OCD posits that there are five dysfunctional assumptions held by the OCD patient:
•
thoughts are the same as actions,
•
directly causing harm is equivalent to failing to prevent harm,
•
responsibility is not attenuated by outside variables,
•
desire for the feared consequence to occur is equivalent to failure to perform a compulsion, and
The treatment provider can engage in techniques to elicit these distorted cognitions and subsequently engage in methods to modify these cognitions.
After conceptualizing the above stimulus parameters and associated cognitions, the provider is encouraged to begin ERP concurrently (42). Cognitive restructuring can be used after ERP is initiated, and techniques for this portion of therapy are presented later in the article.
A Case Example
Ms. H, a 21-year-old woman, presented for psychiatric evaluation of possible OCD. On presentation, the psychiatrist learned that Ms. H. had been discharged from the hospital 2 months ago, after admission for a severe skin infection. Ms. H described herself as being an anxious person since childhood. She noted that when she was younger, she worried at night that someone might come into the house and she made her parents check the doors and windows several times to make sure they were locked. Ms. H reports that her anxiety significantly increased following her hospitalization. She described severe concern regarding recontracting a skin infection or some other life-threatening illness. Prior to her hospitalization, Ms. H had been performing very well in school and had been nearing completion of an undergraduate degree. She reported having many friends and a good relationship with her family. Ms. H’s fear of contracting an illness had become so severe that she rarely ventured out of her apartment for fear of being around sick individuals or coming into contact with contaminated surfaces. She developed strict rituals for cleaning utensils and washing her hands. Food could only be eaten from freshly opened packages. Ms. H reported that these rituals and rules reduced her anxiety regarding fear of becoming ill. Ms. H presented at the urging of her roommate and family and required the presence of her sister in order to travel to her appointment. During the interview, the clinician noticed that Ms. H’s hands were red and abraded. During the interview, Ms. H frequently asked her sister nervously if she thought there were germs in the office and whether she might become ill. The clinician noticed that Ms. H’s sister would calm Ms. H by telling her “No-no, everything is fine. This is a doctor’s office, everything is cleaned daily. I’m sure you won’t get sick.” Ms. H would become calm for a few minutes before again asking similar questions of her sister.
Treatment plan
Initial Measurement of Symptoms
To fully characterize the obsessions and compulsions a patient may possess, the Yale-Brown Obsessive Compulsive Scale (YBOCS) checklist and severity rating (43, 44) is the gold standard assessment tool. The YBOCS checklist contains items designed to assess the presence of various forms of obsessions and compulsions. This checklist aids the clinician in fully characterizing the extent of the patient’s obsessions and compulsions. The checklist is followed by a measure of severity of obsessions and compulsions. A 10-item, 0–4 scale severity measure is commonly used, although longer forms are available. Generally, patients endorse multiple obsessions and compulsions, but we limit our discussion to the OCD symptoms presented in the case example (boxes). Measurements of depression and anxiety can also be obtained, such as the Beck Depression Inventory (45) or Beck Anxiety Inventory (46), as these are often comorbid with OCD. As discussed in the introductory article, the Brown Assessment of Belief Scale can be used as a measure of insight (47). All of these measures can be obtained periodically during treatment to track the patient’s progress.
Psychoeducation
In the first several sessions, and on an ongoing basis, psychoeducation is provided to the patient. Particular attention is given to the diagnostic criteria for OCD, explanation of the cognitive-behavioral model for the development and maintenance of OCD symptoms, and the rationale for CBT-ERP. Therapeutic interventions that will be used during sessions are defined, and treatment goals are identified by the patient. At this time, the role of family accommodation (FA) and expressed emotion (EE) (presented later in the article) can also be discussed with family members. Life events that may be crucial to the understanding of the patient’s symptoms are also discussed during the initial sessions, as they may be important in the development of a treatment plan.
ERP
Exposure is more readily titrated than response prevention, and it is recommended that a hierarchy of stimuli provoking anxiety be constructed with the first few sessions of therapy. The exposure hierarchy is constructed by asking the patient to identify and rank stimuli that would provoke obsessions. Subjective Units of Distress Scale (SUDS) ratings are numerical values provided by the patient for the level of distress each stimulus produces. The scale utilized is typically 1–10 or 1–100.
Exposure therapy is designed to prompt obsessions to occur. Through prolonged exposure to anxiety-provoking stimuli, and prevention of the associated compulsion, the patient habituates to the anxiety provoked by the obsessions. The patient learns to tolerate increasing increments of distress without engaging in compulsions. The therapist provides instructions and encouragement, which are essential to helping the patient resist performing compulsions (48). The therapist can also provide alternative behaviors to engage in when the patient desires to perform compulsions. For initial exposures, it is recommended that the stimuli be strong enough to induce obsessions and the desire to perform a compulsion yet weak enough that the patient is able to refrain from or delay performing the associated compulsion. Typically, this corresponds to an item on the exposure hierarchy with a SUDS rating of 4 on a 1–10 scale or 40 on a 1–100 scale.
Two forms of exposure may be used by the therapist treating OCD: in vivo and imaginal. In vivo exposure consists of stimuli that are used in real life. In imaginal exposure, the patient composes a very detailed script that consists of feared stimuli and outcomes that would occur if prevented from performing compulsions. This technique is very useful, as it is often difficult or not advised to expose a patient to some feared outcomes (i.e., aggressive, sexual obsessions). Imaginal exposure can be used in combination with in vivo exposure and has led to positive outcomes in several studies (49–53).
Gradual exposure is preferred by patients (54), and in our clinical experience, it would appear that rapid exposure leads to no better response. Flooding, also called implosion therapy (55) (these two terms are not synonymous, but the distinction is not necessary for the purposes of this discussion), which is rapid exposure to stimuli that are extremely high on the SUDS hierarchy, is often used in imaginal exposure. Imaginal exposure need not involve flooding, and the prudent therapist would be well advised to only engage in flooding exercises when a great deal of motivation and therapeutic rapport are present.
The frequency and number of ERP sessions for optimal outcome are unclear. It is possible that individual patient characteristics and aspects unique to each patient-therapist relationship moderate optimum frequency and treatment duration. Generally, treatment consisting of 90- to 120-minute sessions once or twice per week, for a total of 12–20 sessions, is effective (56). However, protocols of varying intensity have been used (15, 57, 58). In practice, the number, frequency, and duration of sessions should be considered in light of the patient’s availability, motivation, and degree of improvement during the course of treatment. In our own clinic, we have achieved excellent results with every-other-week sessions, provided the patient engages in between-session exposure exercises for “homework.”
Researchers hypothesize that ERP requires a strong therapeutic relationship. Similar to the findings in FA research (presented later in this article), in ERP therapists who are permissive and tolerant have poorer results than those who are respectful and encouraging to their patients, yet challenge them (9, 59).
Cognitive Restructuring
As discussed earlier, patients with OCD tend to hold maladaptive beliefs. Foremost among these beliefs is some form of “the world is a dangerous place.” Although more evidence exists for ERP, cognitive restructuring to address maladaptive beliefs may independently lead to additional benefits (60–65).
The most direct method of addressing maladaptive cognitions is through discussion before and after exposure exercises. These thoughts are directly tested during the exposure exercise, and after completion of the exposure, patients are asked to rate the degree of belief in their maladaptive cognition. The therapist should not aim for a goal of complete disbelief in a strongly held maladaptive cognition early in the treatment, as this would be too extreme a change for the patient. In cases of strongly held maladaptive cognitions, the therapist should have more modest aims of simply having the patient accept the existence of alternatives to the feared outcome (66).
Between sessions, patients can practice testing their thoughts when performing exposure exercises. The Thought Record, a very useful technique in cognitive therapy, can be given to patients. Patients are taught to challenge their maladaptive thoughts with more adaptive and helpful thoughts. In its most basic form, thought records involve writing maladaptive cognitions in one column and more balanced, adaptive, and helpful thoughts in a second column. This exercise forces patients to identify that alternatives to their obsessional thinking exist, which in itself reduces the degree of conviction of obsessions. In more complex forms, the thought record involves directly rating the degree of belief in obsessions, as well as the level of anxiety or happiness, before and after alternative thoughts are written.
Mental Compulsions
Special attention needs to be paid to mental compulsions of patients. Mental rituals can take the form of praying, repeating certain words or phrases, counting, and creating mental checklists. The treatment provider should inquire about the presence of such compulsions, as they may go otherwise unnoticed. Special techniques may be necessary to treat mental compulsions, once identified. Exposure follows the same procedure as previously described. Response prevention involves having the patient either say “stop” aloud or distract himself or herself by thinking about other compelling ideas (i.e., memorizing poems, planning dinner). Similar to the treatment of physical compulsions, in the case of mental compulsions therapists encourage patients to engage in repeated exposure to obsessive thoughts that trigger the mental compulsions at planned intervals to allow habituation to occur. Whittal et al. (67) examined primarily mental compulsions, finding efficacy for cognitive therapy.
The Treatment of Ms. H
Ms. H. elected to engage in CBT treatment. During the first several sessions, the clinician developed rapport with Ms. H, assisting her to identify the emotions, thoughts, and behaviors that developed and maintained her contamination obsessions and cleanliness compulsions. The therapist was supportive and empathic during this beginning period. Avoidance of obsession-provoking stimuli and seeking of reassurance from family members were discussed with the patient as common additional compulsions. The YBOCS checklist yielded no additional obsessions, but mental compulsions consisting of “cleanliness checklists” were uncovered. Ms. H.’s initial score on the YBOCS severity scale was 25 (moderate to severe OCD symptoms). Of particular importance was the patient’s insight that her recent skin infection played a central role in the development of her OCD symptoms.
With the assistance of the therapist, Ms. H. constructed an exposure hierarchy (Table 1). The therapist encouraged Ms. H. to discuss her thoughts that occurred when she was engaged in obsessions and compulsions. Primary among these thoughts was “If I don’t make sure to keep everything clean, I will get sick.”
After developing rapport with Ms. H., the therapist began to engage in exposure therapy. For the initial exposure session, briefly placing a hand on the countertop in one of the adjacent examination rooms was selected as a stimulus provoking a moderate level of obsessions. Initially, Ms. H. reported a SUDS rating of approximately 4 of 10 and had a strong desire to engage in compulsive hand washing. With gentle, yet firm, encouragement, Ms. H. was able to refrain from washing her hands. Ms. H. engaged in multiple trials of touching her hand to the countertop, with the duration of contact increasing during the course of the session. Her anxiety level gradually reduced during the course of the session to 2 of 10, and between therapy sessions she was encouraged to continue these exposure exercises at home.
Mental compulsions were addressed during later exposure sessions, as it appeared that Ms. H. was using these to reduce anxiety during the sessions with the clinician. Ms. H. was provided with psychoeducation regarding the importance of identifying her use of checklists to reduce anxiety. Ms. H. was taught the technique of dismissing the thoughts, agreeing to say aloud the words “Stop. This is a compulsion” whenever she had the urge to engage in her mental checklists. She reported finding this technique useful, and her desire to engage in mental checklists rapidly reduced.
After several exposure sessions, cognitive restructuring was provided. It should again be noted that subtle rephrasing of maladaptive cognitions is more readily accepted by the patient than are major contradictions. The clinician asked Ms. H. how strongly she believed her initial statement that “If I don’t make sure to keep everything clean, I will get sick,” and she responded that she held this cognition less strongly (from 90% conviction to 65%) than at the onset of treatment. She stated that she had not fallen ill, despite repeatedly touching “contaminated” items and refraining from engaging in ritualistic cleaning or avoidance. At this time, the clinician introduced the concept of the Thought Record (Table 2) and requested that she identify her automatic thoughts, such as “if I go near a sick person, I will get sick.” She was given instructions to challenge these maladaptive thoughts with more realistic thoughts, such as “I may get sick, but it likely won’t be so bad I end up in the hospital.”
After further developing rapport with Ms. H., the clinician discussed her deeper concerns about contamination. Ms. H. reported that her greatest fear was that she would again become ill, but rather than simply spend an extended period of time in the hospital, she would die, leaving behind her husband, sons, and parents. Ms. H. feared that without her presence, her children would become juvenile delinquents and perhaps felons. Meanwhile, her husband and parents would be left with extremely high hospital bills for medical expenses, which would lead them to bankruptcy. The clinician helped Ms. H. create a script for imaginal exposure, as an in vivo exposure obviously could not be designed. Ms. H. recorded on her cellular phone a script describing the feared consequence in great detail. She then spent the remainder of the session listening to this script several times. Initially, listening to a script describing the feared consequence of her becoming ill created severe anxiety (SUDS rating =9). The patient asked to leave the session to call family members for reassurance that she had not exhibited any recent signs of illness. The clinician encouraged Ms. H. to refrain from reassurance seeking, and the patient habituated slightly to the script during the course of the session (SUDS rating =7). For homework, she was assigned daily imaginal exposure using the script she had created. After engaging in imaginal exposure for 2 weeks, Ms. H. came to find the script more annoying than anxiety provoking (SUDS rating =2). Ms. H. stated that in the past the fears described in the script would cause her anxiety whenever they spontaneously arose in her mind. Now, however, she was able to quickly dismiss these fears when they arose, and she stated that they “they just don’t seem as important anymore.”
Family members were instructed to gradually reduce the frequency of reassurance provision and accommodation to the patient’s compulsions. The clinician, Ms. H., and family members constructed a plan for the identification of compulsive behaviors and the family members’ own accommodation to the compulsive behaviors. When Ms. H. was identified as seeking reassurance, family members were instructed to state, “I can see that you are anxious and seeking reassurance. Please use the techniques you learned in therapy.” Family members gradually reduced the time they spent waiting for the patient to complete ritualistic hand washing and accommodation to other compulsive behaviors.
The therapist and Ms. H. gradually moved up the exposure hierarchy they had created together. By the end of the 12th session, Ms. H.’s OCD severity was greatly reduced, with a YBOCS score of 5 (indicating remission). Family members described Ms. H as more social and outgoing than prior to therapy. Ms. H. reported that she was much more productive, as she no longer feared leaving her home and had returned to school part time.
| Stimulus | Ratinga |
|---|---|
| Touching toilet seat in public restroom | 10 |
| Touching faucet in public restroom | 9 |
| Drinking from public water fountain | 8 |
| Using utensils provided by public cafeteria | 7 |
| Touching table in public cafeteria | 6 |
| Shaking hands with acquaintance | 5 |
| Touching countertop in examination room | 4 |
| Petting family dog | 3 |
| Eating food prepared by family member | 2 |
| Eating food from sealed packaging | 1 |
a
Possible scores range from 1 to 10, with higher scores indicating greater distress.
| Stimulus | Automatic thought | Balanced alternative thought |
|---|---|---|
| Person sneezes near me | “If I go near a sick person, I will get sick.” | “I may get sick, but it likely won’t be so bad I end up in the hospital.” |
| I shook an acquaintance’s hand | “I need to wash my hands before I get sick.” | “Just because I think something doesn’t make it true. I can wait to wash my hands until a more appropriate time.” |
| I ate at a restaurant for a friend’s birthday | “I can’t watch my food being prepared. The food might be contaminated.” | “People eat at restaurants all the time and don’t get sick. I’ve done many rounds of exposure to “contaminated objects” while in therapy and did not get sick. The chances of my getting sick are low.” |
FA and EE in adults
Family responses, such as FA and EE, are gaining prominence in the literature as possible mediators in the course of OCD and treatment.
FA
FA in OCD specifically refers to providing reassurance, participating in rituals, modifying personal and family routines, facilitating avoidance, and taking on the patient’s responsibilities (68). Intrusiveness, poor role definition, and a lack of boundaries are characteristic in families with a high degree of accommodation (68). Calvocoressi et al. (68) reported that FA was present for 88% of spouses or parents and correlated significantly with patient symptom severity and global functioning, family dysfunction, and relatives’ stress. Although accommodation to OCD symptoms may seem benevolent, relatives’ excessive accommodation to compulsions contradicts exposure-based therapy, may perpetuate and reinforce symptoms, and may increase relatives’ feelings of distress (69).
The only published measure for FA is the Family Accommodation Scale (FAS), validated in both interview (70) and self-rated (FAS-SR) (71) versions, and it measures the presence and level of accommodation for adult and pediatric OCD populations [for a full review, see Lebowitz et al. (72)]. Other versions of the FAS have been reported in the literature, although they have not been validated against this gold standard. The FAS-SR is a 19-item relative self-report. It is easy to administer (it may be administered to the OCD patient in the event a family member is not available) and yields valuable clinical information that can be useful to target reducing FA. Most OCD patients are unaware that FA interferes with ERP treatment.
In response to a questionnaire that assessed relatives’ motives for and beliefs regarding accommodation, 65% of relatives reported that their accommodation behaviors were attempts to attenuate patient distress or anger, and 63% reported that their behaviors were designed to decrease the time that the patient was spending on compulsions/rituals (68). Providing reassurance is the most commonly reported type of FA (70, 73). It is often unrecognized as a symptom of OCD by patients and relatives yet can be quite severe, time consuming, and impairing.
Amir et al. (74) noted the relationship of FA with treatment outcome, finding lower response rates to behavioral therapy when relatives modified their schedules to accommodate or participate in OCD patients’ ritualistic behaviors. Similar findings are evident in pediatric treatment outcome studies (see below).
In a path-analytic model, Van Noppen and Steketee (75) found that of all the family variables, FA made the largest contribution to predicting OCD symptom severity. FA is consistently indicated as correlating with OCD symptom severity (72, 76), although more investigation into directionality of this relationship is required.
EE
Expressed emotion (criticism, hostility, and emotional overinvolvement) is recognized as a robust factor for reliably mediating course or relapse in psychiatric illnesses [for a review, see Barrowclough et al. (77); Brown and Rutter (78); Hooley and Licht (79)]. EE may reflect the emotional quality of interactions that occur between relatives and a psychiatric patient, linking family reactions to patient functioning [for a review, see Steketee et al. (69)].
Emmelkamp et al. (80) demonstrated that EE predicted relapse, and Steketee (81) reported that patients who characterized family interactions as angry and critical experienced fewer gains. Chambless and Steketee (82) found the potential benefit in analyzing the components of criticism, hostility, and EOI separately and investigated the relationship of EE to behavior therapy outcome for OCD and panic disorder with agoraphobia. Controlling all other EE variables, they found that relatives’ hostility placed a patient at six times the risk for premature dropout from therapy (82). Contrary to expectation, nonhostile, but critical, comments were predictive of significantly better behavioral therapy outcome (82). When delivered without hostility toward the person as a whole, nonhostile criticism may be motivating for OCD patients who use avoidance to neutralize anxiety, an important ingredient in exposure-based behavioral therapy [for a review, see Steketee et al. (69)].
Chambless and Steketee (82) found that perceived criticism [rated by the Perceived Criticism Measure (83)] is a strong predictor of treatment outcome for OCD. Whether or not relatives objectively scored high, OCD adult patients who perceive relatives to be critical may interpret their behavior as nonsupportive, driving more anxiety. Reducing perceived criticism could be a target of CBT to improve outcome.
This finding was further examined by De Berardis et al. (84), who reported that poor insight is associated with higher perceived criticism, significantly higher OCD symptom severity, more compulsions, and depressive symptoms. These patients may be particularly sensitive to hostile criticism and would benefit from communication training to prevent resistance to treatment.
Chambless and Steketee (82) concluded that research directed at changing EE or the response to EE among patients with severe anxiety disorder may improve treatment outcome and patient functioning. In a similar vein, Bressi and Guggeri (85) suggested that interventions specifically aimed at improving strategies of families dealing with an adult diagnosed with OCD should target relatives’ perceptions of patient behavior and their emotional and behavioral responses to the behavior. A family-based approach to treatment underscores the fact that OCD is embedded in a family context, highlighting the important dynamic between relative responses and the patient’s anxiety level and functioning. The findings from studies on FA and EE indicate that these family responses are gaining attention as a predictor of outcome and can be targeted foci of family-based treatment.
Family and couple-based interventions
CBT and medication have been effective treatments of OCD; however, substantial dropout and refractory rates remain. Family members are often excluded from individually based CBT. Perhaps FA and EE are moderators for treatment outcome, and including family in order to target changing these responses could further improve symptom reduction and durability.
Family-based interventions for OCD have been more rigorously and recently investigated in pediatric samples (see below), although reports on the treatment of adults date back four decades. The APA practice guidelines indicate the importance of family factors in OCD treatment outcomes (86). Lebowitz et al. (72) searched PubMed and PsycINFO for studies on OCD and family-related terms between 1967 and 2011 and identified 641 articles.
Clearly, the importance of family in the course of the disorder and its treatment has been prominent but not that well developed in controlled studies [for a review, see Steketee and Van Noppen (87); Renshaw et al. (88)]. Perhaps the first group to recognize the benefits of including family in patients’ treatment was Marks et al. (9), who initiated a monthly open-ended educational and support group.
Tynes et al. (89), Black and Blum (90), and Cooper (91) used family psychoeducational groups in the treatment of OCD. In particular, patients with family involvement as a “co-therapist at home” experienced greater reduction in anxiety and improvement in social and occupational functioning (92).
In an uncontrolled inpatient study, Thornicroft et al. (93) reported on the use of a family component that focused on reducing relatives' involvement in rituals by training them to monitor patient behavior and encourage self-exposure in a noncritical manner. Findings indicated decreases in OCD symptoms at discharge, indicating good success for this severe inpatient population who scored in the extreme range on disability from OCD symptoms.
Grunes et al. (94) examined the benefits of a relative’s participation in an 8-week psychoeducation group designed to help reduce accommodation to OCD symptoms. Patients whose family member was involved in the group experienced greater reductions in OCD symptoms and depressed mood compared with patients whose relatives did not participate (YBOCS score decrease of 26% versus 9%). Overvalued ideation, also known as poor insight (95), and known to be a predictor of treatment outcome in OCD (poor insight), also was reduced to a greater degree in the family intervention group. Gains were maintained at a 1-month follow-up, suggesting that inclusion of family members in treatment is advantageous.
In an uncontrolled study of the effects of 10–12 weekly multifamily behavioral therapy (MFBT) treatments (96), family members and patients received education about OCD and in vivo ERP. They also were taught family contracting for behavioral change to reduce FA, hostile criticism, and emotional overinvolvement during the family group sessions. YBOCS scores dropped significantly from pretreatment to posttreatment, and gains were maintained at 1-year follow-up [for an abbreviated manual, see Van Noppen (97)]. MFBT offers distinct advantages by combining the therapeutic components of both family-based and group modalities. It may prove to be more cost effective than individual CBT as well.
In a 16-session couple-based CBT approach, Abramowitz et al. (98, 99) targeted relationship dynamics to “enhance” the effectiveness of traditional gold-standard CBT. Similar to the therapeutic components in MFBT, this intervention includes partner-assisted ERP, targets changing maladaptive relationship patterns focal to OCD (such as accommodation), and targets non–OCD-related stressors. At posttest, significant improvements in OCD symptoms as measured by the YBOCS, relationship functioning, insight, and depression were reported and were maintained at 1-year follow-up (99).
Controlled and replicated studies are needed, although findings support the efficacy of family and couple-based CBT for OCD and clinical wisdom suggests that including relatives can only further enhance ERP effects, maintain gains, and improve family functioning. In a recent meta-analysis (100), “family inclusive treatment (FIT)” for OCD that targeted FA was associated with greater improvement in patient functioning. The investigators stated that the findings “underscore the need for continued momentum in the development, evaluation and dissemination” of family-based treatment of OCD.
Patient-only group behavioral therapy (GBT)
Delivered in a group modality, CBT allows for efficient use of therapist time and potential cost containment. In the 1970s, Hand et al. (101), Teasdale et al. (102), and Hafner and Marks (103) reported, for anxious and phobic patients, not just a reduction in therapist time expenditures, but an increased benefit brought about by group processes such as cohesion and modeling (104). In a group format, CBT was demonstrated to be effective in a meta-analysis (105). A small meta-analysis found no difference in efficacy between group and individual formats, although dropout rates were much higher in the individual format in one study (106).
The first systematic report of behavioral groups for OCD patients (107) described an elaborate three-phase group process, and like Hand et al. (101) and Teasdale et al. (102), Jaurrieta et al. (106) found that group cohesion provided extra benefits for OCD patients.
With the aim of providing cost-effective treatment that also improves patient compliance, Espie (108) conducted a 10-session behavioral therapy and treatment focused on behavioral skills, homework, and follow-up group sessions scheduled after the end of intensive therapy. This study reported that the decrease in OCD symptoms was maintained at a 1-year follow-up. Krone et al. (109) provided a structured GBT, with results that support the assertion that behavioral treatment groups for OCD provide a savings of therapist time and money and are possibly as efficacious as individual treatment.
Fals-Stewart et al. (11) conducted a controlled trial for OCD, comparing group exposure (imaginal and/or in vivo) and response prevention with individual treatment and individual relaxation therapy (control). Participants in both group and individual treatment conditions showed significant improvement on measures of OCD symptoms, depression, and anxiety at posttest and follow-up, whereas the control condition produced change only on anxiety.
A naturalistic open trial of a time-limited behavioral group treatment with key elements of education, in vivo ERP, therapist and participant modeling, and cognitive restructuring is described by Van Noppen et al. (110). After 10 sessions of a weekly 90-minute manualized GBT, average YBOCS score dropped from 21.8 to 16.6, similar findings to Krone et al. (109) and Fals-Stewart et al. (11). The authors describe distinct therapeutic advantages of group therapy, stemming from Yalom’s (104) “curative factors of universality, imparting information, instillation of hope, imitative behavior, altruism,” and competition (not a curative factor but a motivator for patients treated in groups).
Benefits of GBT have gained international recognition. Results of GBT are durable and comparable to those of individual-based therapy (111–115), and GBT holds promising advantages over individually delivered CBT and may not only be preferable but also produce more robust outcomes for some difficult-to-treat patients. There is a need for further investigation using manualized controlled trials that consider medication effects with consistent study criteria and standard measures that allow comparison and generalizability.
A review of pediatric OCD: CBT, EE, and FA
OCD is estimated to affect approximately 2%−3% of children and adolescents (116–118). Pediatric OCD is characterized by a 3:2 male-to-female ratio, and in a National Institute of Mental Health sample, boys were more likely than girls to have an onset before puberty (119). The mean age of onset of pediatric OCD ranges from 7.5 to 12.5 years, with an average of 2.5 years between age at onset and treatment (120). Approximately 80% of adults with OCD have their onset during childhood (118, 121), suggesting the importance of early intervention.
Generally, the types of obsessions and compulsions that children have are similar to those of adults; however, the content differs because it is more developmentally appropriate. Children’s obsessions often center on a fear of a catastrophic family event. The most common obsessions for children are contamination, sexual and somatic obsessions, and excessive scruples (e.g., feeling guilty over small transgressions, whereas the most common compulsions are washing, repeating, checking, and ordering (122).
Pediatric OCD is associated with significant impairment in social and family functioning and academic difficulties that influence child development (123, 124). The most common OCD-related problem reported by parents and children is concentrating on schoolwork, with completing homework the second most common (123, 125). Storch et al. (126) found greater rates of peer victimization in youth with OCD and noted that peer victimization was positively related to loneliness, child-reported depression, parent-reported internalizing and externalizing symptoms, and clinician-rated OCD severity.
Similar to OCD of adults, with pediatric OCD evidence from meta-analyses indicates that CBT is effective (127–129), even for children as young as 3 years of age (130, 131). The 2004 Pediatric Obsessive-Compulsive Disorder Treatment Study (POTS) trial (118), using a randomized comparison of CBT, SSRIs, their combination, and a placebo control group, concluded that pediatric OCD benefits from CBT alone or in combination with an SSRI. Further research has supported and extended these findings and deems CBT an effective treatment of pediatric OCD with respect to its safety and durability of response (132–136). The results from POTS II (2011) (136) found that therapist-guided CBT-ERP is more effective than simply giving instructions on CBT (136, 137), relaxation strategies (138), or waitlist controls (139). Kircanski and Peris (140), in a pilot randomized controlled study of family-based CBT (FCBT) for youth, investigated the impact of variables such as self-reported distress during ERP and the quantity and quality of ERP tasks on treatment outcome. They found that when the variability of distress was greater (i.e., that the distress changes) during ERP tasks and when more than one obsessive-compulsive symptom was targeted, the treatment outcome was better, supporting the reduction of anxiety during ERP as a core ingredient of CBT.
An extension of the Nordic Long-Term OCD Treatment Study compared sertraline with continued CBT in a sample of children who were considered CBT nonresponders and found no difference between groups (141). For the interested reader, Ung et al. (142) outlined the optimal treatment of pediatric OCD, including a detailed description of the specific evidence for CBT and pharmacotherapy with SSRIs. Additionally, a section on pediatric acute-onset neuropsychiatric syndrome (PANS) is included.
PANS refers to a subgroup of children who experience OCD symptoms because of an infectious trigger, environmental factors, or other possible triggers (e.g., metabolic disorders) that affect the immune system and result in an inflammation of the child’s brain. Because of this inflammation, a sudden onset of severe OCD symptoms or severely restricted food intake occurs and does not follow the typical, more gradual onset of OCD symptoms seen in pediatric OCD. In addition, neuropsychiatric symptoms such as anxiety, mood disruptions, irritability, frequent urination, academic regressions, and more may be present (143). The interested reader is referred to Chang et al. (143) for a consensus statement (derived from the First PANS Consensus Conference) for a clinically distinct presentation of PANS criteria and for expert recommendations on evaluating PANS. These experts outlined the core components of a thorough diagnostic evaluation of suspected PANS cases.
Common assessment tools for pediatric OCD include the Children’s Yale-Brown Obsessive Compulsive Scale (CY-BOCS) (144), the Children’s Florida Obsessive-Compulsive Inventory (C-FOCI) (145), the Obsessive-Compulsive Inventory–Revised (OCI-R) (146), and the Child OCD Impact Scale–Revised (COIS-R) (147). However, because of space limitations, a review of assessment tools for pediatric OCD is beyond the scope of this article. Readers are referred to other sources for a more in-depth review of assessment measures (132, 148–150).
Kircanski et al. (148) outlined numerous developmental considerations that complicate treatment when working with children, such as 1) challenges on the part of the child in being able to describe specific obsessions and their role in triggering compulsions; 2) less insight; 3) present orientation that makes future symptom relief less of a motivating factor for the child; 4) lower frustration tolerance and attention sustainability; and 5) poorer coping abilities. Child-oriented CBT packages address these issues by incorporating age-appropriate metaphors (e.g., false alarms, “bossing back” OCD), naming OCD, using fear thermometers, and creating incentive programs. The study by Geller and March (132) provides practice parameters based on a thorough review of the literature, outlines best practices, discusses how treatment differs with children and adolescents with OCD, and provides references for therapists interested in mastering child-friendly techniques.
As with adult OCD, in pediatric OCD FA is a salient feature, with a large percentage of families engaging in modifying family routines and/or participating in a youth’s rituals (58, 124, 138, 151–153). FA is associated with poorer treatment outcome (153, 154). The most common FA behaviors with pediatric OCD are providing reassurance, participating in rituals, and assisting in avoidance of feared situations or objects (58). Research has found that FA is significantly related to parents’ reports of functional impairment at home, OCD symptom severity, and internalization and externalization of behaviors. Also, children reported greater impairment in school when families accommodated their symptoms. FA mediated the relationship between OCD symptom severity and parent-rated functional impairment of the child (58). Hence, FA is associated with increased obsessive-compulsive symptom severity because it causes greater family dysfunction and negative family dynamics (58, 124, 153, 154). For an in-depth review of FA, the interested reader is referred to Lebowitz et al. (72).
Numerous studies have investigated FA in pediatric samples and noted the following results: child internalizing symptoms mediated the relationship between parent anxiety and FA (151), family cohesion and externalizing symptoms predicted FA (155), coercive/disruptive behaviors often significantly contributed to increased levels of FA (156), and higher levels of accommodation were related to poorer results irrespective of modality (CBT or medication) (157). These results are consistent with POTS findings (118).
FA interferes with treatment goals of CBT-ERP by reinforcing the fear-and-avoidance behaviors; thus, FA is an important focus for intervention. Merlo et al. (153) examined the relationship between FA and treatment outcome by providing FCBT (which directly targets FA) for 14 sessions. They found that participation in FCBT was associated with a significant reduction in FA and that FA reduction was related to less symptom severity and better treatment outcome. Poor insight has predicted greater FA and severity of symptoms, and has been associated with diminished CBT response in children and adolescents (124, 158, 159). Low insight, higher levels of FA, and greater obsessive-compulsive symptom severity were linked to poorer in-session compliance and willingness to participate in treatment (160). Adelman and Lebowitz (161) outlined specific strategies to improve insight in pediatric OCD.
As with adults with OCD, when children have OCD, EE predicts poorer treatment outcome (162, 163) and is prevalent among the parents. Also, high EE results in poorer overall child adjustment, including increased anxiety. Studies looking at maternal EE and how well children were functioning after treatment found that high baseline EE was a significant predictor of poorer treatment outcome (164, 165). Studies have shown that mothers and fathers with OCD displayed higher rates of EE than controls (166,167). Przeworski et al. (165) found that mothers had higher EE (driven by criticism rather than emotional overinvolvement) when describing a child with OCD (16%) compared to her child’s sibling without OCD (2.6%), indicating that EE may be state dependent. Peris et al. (164) found that maternal criticism correlated with parental blame and the degree of responsibility of obsessive-compulsive symptoms attributed to the child but that maternal emotional overinvolvement correlated with parental anxiety, depression, and OCD. These studies underscore the high rate of blame, hostility, criticism, and emotional overinvolvement that correlates with OCD in children. Preliminary evidence that family emotional responses (e.g., conflict, blame, and low levels of support) are related to treatment outcome was found in a separate study by Peris et al. (154), suggesting the importance of targeting EE in treatment.
In a thorough review (2007–2012) of the psychosocial treatment literature, Freeman et al. (168), using an evidence-based, five-level evaluation criterion (see the article by Freeman et al. for definitions), evaluated the studies and classified the treatment methods as “well established,” “probably efficacious,” “possibly efficacious,” “experimental,” and “of questionable efficacy.” Using this rigorous methodological criterion, the authors reported that although no pediatric OCD treatment was designated as “well established,” both individually focused CBT and family-focused individual CBT (FCBT) are considered “probably efficacious” treatments. Group FCBT and group individual CBT, as well as alternative non–face-to-face deliveries (e.g., Internet), are now considered “possibly efficacious” treatments.
More recently, research has focused on investigating FCBT in a more systematic manner. Piacentini et al. (138) contrasted FCBT with psychoeducation and relaxation training (PRT), finding faster and greater decrease in OCD severity and functional impairment for the FCBT compared with the PRT group. The POTS Jr study (169), a multisite randomized controlled trial (RCT), found that FCBT was significantly more effective than relaxation therapy for young children (ages 5–8 years) with OCD. Consistent with these results, Lewin et al. (131) in a pilot RCT found that children as young as 3 years of age responded better to treatment with family-based ERP (65%) compared with continuing with previous treatment, as outlined by their providers (7%).
Research has extended the efficacy of FCBT to intensive programs. Storch et al. (58) compared intensive (daily for 3 weeks) and weekly (once per week) FCBT and found high remission rates for both groups (75% versus 50%, respectively). In an open trial of intensive FCBT, for children who were either medication partial responders or nonresponders, Storch et al. (170) found that FCBT was successful, with 80% improved after treatment, including significant reductions in obsessive-compulsive–related impairment and FA. Rudy et al. (171) found that 14 FCBT sessions at 3 weeks had 88.5% children as treatment responders. Whiteside and Jacobsen (172) found that, even in a 5-day intensive program, FCBT significantly improved symptoms.
In a series of five case studies, Comer et al. (173) found that after a full treatment course of Internet-delivered FCBT (including ERP), 60% of children no longer met the diagnosis for OCD. These results were consistent with the preliminary findings of Storch et al. (174) with webcam-delivered FCBT. O’Leary et al. (175) examined group versus individual FCBT and found a significant remission rate for both forms of FCBT (95% for group based and 79% for individual based) at 7-year follow-up. A pilot study by Farrell et al. (176) in 2012 found that group FCBT was effective for youth with OCD and comorbid diagnosis.
In conclusion, exposure-based CBT, with the proper developmental considerations and adaptations, is highly effective as treatment of pediatric OCD. FA is prevalent in pediatric OCD and affects symptom severity, treatment outcomes, and functional impairment. The emotional climate in a home, including EE, also affects treatment outcome. Given these findings, treatment with children increasingly involves addressing these behaviors through the use of FCBT, and research increasingly supports its effectiveness. Future research should use the more methodologically rigorous RCT design in order to continue to address and compare the effectiveness of these various treatment modalities for pediatric OCD.
Enhancing the efficacy of CBT
Retention appears to be a significant issue in CBT. Recently, the use of motivational interviewing to aid with retention and encourage participation in exposure activities has been examined. Mixed results have been found; some studies have reported enhanced efficacy (177–179), whereas another study found no benefit of motivational interviewing (180).
Recently, there has been interest in memory consolidation during or after exposure sessions. d-cycloserine, a modulator of the N-methyl-d-aspartic acid receptor (and available as the antibiotic Seromycin), has been found to increase the rate of response with exposure therapy in OCD (181–184). The efficacy of d-cycloserine remains less than fully clear, and important moderating variables, such as the correct timing of administration and duration of effects, continue to be studied (185).
Conclusion
In conclusion, CBT with an emphasis on ERP is a robust and effective treatment of OCD with or without medication. Some individuals benefit from combined treatment. To speed treatment response or to treat treatment-resistant patients, it may be necessary to consider combined treatment with medication or the use of techniques to enhance the efficacy of CBT-ERP. FA and EE are important topics for the clinician to be aware of in pediatric and adult populations, and evidence suggests that attention to these topics results in improvement of OCD symptoms.
Footnote
The authors report no competing interests.
References
1.
Beck AT: Cognitive Therapy and the Emotional Disorders. New York, NY, International Universities Press, 1976
2.
Salkovskis PM: Obsessional-compulsive problems: a cognitive-behavioural analysis. Behav Res Ther 1985; 23:571–583
3.
Wilhelm S, Steketee G, Fama JM, et al: Modular cognitive therapy for obsessive-compulsive disorder: a wait-list controlled trial. J Cogn Psychother 2009; 23:294–305
4.
Meyer V: Modification of expectations in cases with obsessional rituals. Behav Res Ther 1966; 4:273–280
5.
Rosa-Alcázar AI, Sánchez-Meca J, Gómez-Conesa A, et al: Psychological treatment of obsessive-compulsive disorder: a meta-analysis. Clin Psychol Rev 2008; 28:1310–1325
6.
Eddy KT, Dutra L, Bradley R, et al: A multidimensional meta-analysis of psychotherapy and pharmacotherapy for obsessive-compulsive disorder. Clin Psychol Rev 2004; 24:1011–1030
7.
Fisher PL, Wells A: How effective are cognitive and behavioral treatments for obsessive-compulsive disorder? A clinical significance analysis. Behav Res Ther 2005; 43:1543–1558
8.
Foa EB, Kozak MJ: Emotional processing of fear: exposure to corrective information. Psychol Bull 1986; 99:20–35
9.
Marks IM, Hodgson R, Rachman S: Treatment of chronic obsessive-compulsive neurosis by in-vivo exposure. A two-year follow-up and issues in treatment. Br J Psychiatry 1975; 127:349–364
10.
Röper G, Rachman S, Marks I: Passive and participant modelling in exposure treatment of obsessive-compulsive neurotics. Behav Res Ther 1975; 13:271–279
11.
Fals-Stewart W, Marks AP, Schafer J: A comparison of behavioral group therapy and individual behavior therapy in treating obsessive-compulsive disorder. J Nerv Ment Dis 1993; 181:189–193
12.
Lindsay M, Crino R, Andrews G: Controlled trial of exposure and response prevention in obsessive-compulsive disorder. Br J Psychiatry 1997; 171:135–139
13.
Greist JH, Marks IM, Baer L, et al: Behavior therapy for obsessive-compulsive disorder guided by a computer or by a clinician compared with relaxation as a control. J Clin Psychiatry 2002; 63:138–145
14.
Olatunji BO, Davis ML, Powers MB, et al: Cognitive-behavioral therapy for obsessive-compulsive disorder: a meta-analysis of treatment outcome and moderators. J Psychiatr Res 2013; 47:33–41
15.
Foa EB, Liebowitz MR, Kozak MJ, et al: Randomized, placebo-controlled trial of exposure and ritual prevention, clomipramine, and their combination in the treatment of obsessive-compulsive disorder. Am J Psychiatry 2005; 162:151–161
16.
Nakatani E, Nakagawa A, Nakao T, et al: A randomized controlled trial of Japanese patients with obsessive-compulsive disorder—effectiveness of behavior therapy and fluvoxamine. Psychother Psychosom 2005; 74:269–276
17.
Hembree EA, Riggs DS, Kozak MJ, et al: Long-term efficacy of exposure and ritual prevention therapy and serotonergic medications for obsessive-compulsive disorder. CNS Spectr 2003; 8:363–371, 381
18.
Simpson HB, Liebowitz MR, Foa EB, et al: Post-treatment effects of exposure therapy and clomipramine in obsessive-compulsive disorder. Depress Anxiety 2004; 19:225–233
19.
Kordon A, Kahl KG, Broocks A, et al: Clinical outcome in patients with obsessive-compulsive disorder after discontinuation of SRI treatment: results from a two-year follow-up. Eur Arch Psychiatry Clin Neurosci 2005; 255:48–50
20.
Kasvikis Y, Marks IM: Clomipramine, self-exposure and therapist-accompanied exposure in obsessive-compulsive ritualizers: two-year follow-up. J Anxiety Disord 1998; 2:291–298
21.
O’Sullivan G, Marks I: Follow-up studies of behavioral treatments for obsessive-compulsive disorder: literature review. Psychiatr Ann 1991; 21:368–373
22.
Pato MT, Zohar-Kadouch R, Zohar J, et al: Return of symptoms after discontinuation of clomipramine in patients with obsessive-compulsive disorder. Am J Psychiatry 1988; 145:1521–1525
23.
Simpson HB, Foa EB, Liebowitz MR, et al: A randomized, controlled trial of cognitive-behavioral therapy for augmenting pharmacotherapy in obsessive-compulsive disorder. Am J Psychiatry 2008; 165:621–630
24.
Simpson HB, Foa EB, Liebowitz MR, et al: Cognitive-behavioral therapy vs risperidone for augmenting serotonin reuptake inhibitors in obsessive-compulsive disorder: a randomized clinical trial. JAMA Psychiatry 2013; 70:1190–1199
25.
Tenneij NH, van Megen HJ, Denys DA, et al: Behavior therapy augments response of patients with obsessive-compulsive disorder responding to drug treatment. J Clin Psychiatry 2005; 66:1169–1175
26.
Tolin DF, Hannan S, Maltby N, et al: A randomized controlled trial of self-directed versus therapist-directed cognitive-behavioral therapy for obsessive-compulsive disorder patients with prior medication trials. Behav Ther 2007; 38:179–191
27.
Tundo A, Salvati L, Busto G, et al: Addition of cognitive-behavioral therapy for nonresponders to medication for obsessive-compulsive disorder: a naturalistic study. J Clin Psychiatry 2007; 68:1552–1556
28.
Simpson HB, Gorfinkle KS, Liebowitz MR: Cognitive-behavioral therapy as an adjunct to serotonin reuptake inhibitors in obsessive-compulsive disorder: an open trial. J Clin Psychiatry 1999; 60:584–590
29.
Tolin DF, Maltby N, Diefenbach GJ, et al: Cognitive-behavioral therapy for medication nonresponders with obsessive-compulsive disorder: a wait-list-controlled open trial. J Clin Psychiatry 2004; 65:922–931
30.
Kampman M, Keijsers GP, Hoogduin CA, et al: Addition of cognitive-behaviour therapy for obsessive-compulsive disorder patients non-responding to fluoxetine. Acta Psychiatr Scand 2002; 106:314–319
31.
Hohagen F, Winkelmann G, Rasche-Rüchle H, et al: Combination of behaviour therapy with fluvoxamine in comparison with behaviour therapy and placebo. Results of a multicentre study. Br J Psychiatry Suppl 1998; 35:71–78
32.
Marks IM, Lelliott P, Basoglu M, et al: Clomipramine, self-exposure and therapist-aided exposure for obsessive-compulsive rituals. Br J Psychiatry 1988; 152:522–534
33.
Cottraux J, Mollard E, Bouvard M, et al: A controlled study of fluvoxamine and exposure in obsessive-compulsive disorder. Int Clin Psychopharmacol 1990; 5:17–30
34.
Koran L, Simpson H: American Psychiatric Association. Guideline Watch (March 2013): Practice Guideline for the Treatment of Patients With Obsessive-Compulsive Disorder. Arlington, Va, American Psychiatric Association, 2013
35.
Porto PR, Oliveira L, Mari J, et al: Does cognitive behavioral therapy change the brain? A systematic review of neuroimaging in anxiety disorders. J Neuropsychiatry Clin Neurosci 2009; 21:114–125
36.
Schwartz JM, Stoessel PW, Baxter LR Jr, et al: Systematic changes in cerebral glucose metabolic rate after successful behavior modification treatment of obsessive-compulsive disorder. Arch Gen Psychiatry 1996; 53:109–113
37.
Baxter LR Jr, Schwartz JM, Bergman KS, et al: Caudate glucose metabolic rate changes with both drug and behavior therapy for obsessive-compulsive disorder. JAMA Psychiatry 1992; 49:681–689
38.
Nakao T, Nakagawa A, Yoshiura T, et al: Brain activation of patients with obsessive-compulsive disorder during neuropsychological and symptom provocation tasks before and after symptom improvement: a functional magnetic resonance imaging study. Biol Psychiatry 2005; 57:901–910
39.
Dollard J, Miller N: Personality and Psychotherapy: An Analysis in Terms of Learning, Thinking, and Culture. New York, McGraw-Hill, 1950
40.
Mowrer OH: A stimulus-response analysis of anxiety and its role as a reinforcing agent. Psychol Rev 1939; 46:553–565
41.
Mowrer OH: Learning Theory and Behavior. New York, Wiley, 1960
42.
Foa EB, Steketee G, Grayson JB, et al: Deliberate exposure and blocking of obsessive-compulsive rituals: immediate and long-term effects. Behav Ther 1984; 15:450–472
43.
Goodman WK, Price LH, Rasmussen SA, et al: The Yale-Brown Obsessive Compulsive Scale. II. Validity. Arch Gen Psychiatry 1989; 46:1012–1016
44.
Goodman WK, Price LH, Rasmussen SA, et al: The Yale-Brown Obsessive-Compulsive Scale. I. Development, use, and reliability. Arch Gen Psychiatry 1989; 46:1006–1011
45.
Beck AT, Ward CH, Mendelson M, et al: An inventory for measuring depression. Arch Gen Psychiatry 1961; 4:561–571
46.
Beck AT, Epstein N, Brown G, et al: An inventory for measuring clinical anxiety: psychometric properties. J Consult Clin Psychol 1988; 56:893–897
47.
Eisen JL, Phillips KA, Baer L, et al: The Brown assessment of beliefs scale: reliability and validity. Am J Psychiatry 1998; 155:102–108
48.
Foa EB, Franklin ME, Moser J: Context in the clinic: how well do CBT and medications work in combination? Biol Psychiatry 2002; 51:989–997
49.
Boulougouris JC, Bassiakos L: Prolonged flooding in cases with obsessive-compulsive neurosis. Behav Res Ther 1973; 11:227–231
50.
Rabavilas AD, Boulogouris JC, Stefanis C: Duration of flooding sessions in the treatment of obsessive-compulsive disorder. Behav Res Ther 1976; 14:349–355
51.
Foa EB, Steketee G, Turner RM, et al: Effects of imaginal exposure to feared disasters in obsessive-compulsive checkers. Behav Res Ther 1980; 18:449–455
52.
Foa EB, Goldstein AJ: Continuous exposure and complete response prevention in the treatment of obsessive-compulsive neurosis. Behav Ther 1978; 9:821–829
53.
Steketee G, Foa EB, Grayson JB: Recent advances in the behavioral treatment of obsessive-compulsives. Arch Gen Psychiatry 1982; 39:1365–1371
54.
Hodgson R, Rachman S, Marks IM: The treatment of chronic obsessive-compulsive neurosis: follow-up and further findings. Behav Res Ther 1972; 10:181–189
55.
Stampfl TG, Levis DJ: Essentials of implosive therapy: a learning-theory-based psychodynamic behavioral therapy. J Abnorm Psychol 1967; 72:496–503
56.
Franklin ME, Foa EB: Treatment of obsessive compulsive disorder. Annu Rev Clin Psychol 2011; 7:229–243
57.
Abramowitz JS, Foa EB, Franklin ME: Exposure and ritual prevention for obsessive-compulsive disorder: effects of intensive versus twice-weekly sessions. J Consult Clin Psychol 2003; 71:394–398
58.
Storch EA, Geffken GR, Merlo LJ, et al: Family-based cognitive-behavioral therapy for pediatric obsessive-compulsive disorder: comparison of intensive and weekly approaches. J Am Acad Child Adolesc Psychiatry 2007; 46:469–478
59.
Rabavilas A, Boulougouris JC, Perissaki C: Therapist qualities related to outcome with exposure to in vivo in neurotic patients. J Behav Ther Exp Psy 1979; 10:293–294
60.
van Balkom AJ, de Haan E, van Oppen P, et al: Cognitive and behavioral therapies alone versus in combination with fluvoxamine in the treatment of obsessive-compulsive disorder. J Nerve Ment Dis 1998; 186:492–499
61.
Cottraux J, Note I, Yao SN, et al: A randomized controlled trial of cognitive therapy versus intensive behavior therapy in obsessive compulsive disorder. Psychother Psychosom 2001; 70:288–297
62.
McLean PD, Whittal ML, Thordarson DS, et al: Cognitive versus behavior therapy in the group treatment of obsessive-compulsive disorder. J Consult Clin Psychol 2001; 69:205–214
63.
Whittal ML, Thordarson DS, McLean PD: Treatment of obsessive-compulsive disorder: cognitive behavior therapy vs. exposure and response prevention. Behav Res Ther 2005; 43:1559–1576
64.
Whittal ML, Robichaud M, Thordarson DS, et al: Group and individual treatment of obsessive-compulsive disorder using cognitive therapy and exposure plus response prevention: a 2-year follow-up of two randomized trials. J Consult Clin Psychol 2008; 76:1003–1014
65.
Vogel PA, Stiles TC, Gotestam KG: Adding cognitive therapy elements to exposure therapy for obsessive compulsive disorder: a controlled study. Behav Cogn Psychother 2004; 32:275–290
66.
Beck J: Cognitive Behavior Therapy: Basics and Beyond, 2nd ed. New York, Guilford Press, 2011
67.
Whittal ML, Woody SR, McLean PD, et al: Treatment of obsessions: a randomized controlled trial. Behav Res Ther 2010; 48:295–303
68.
Calvocoressi L, Lewis B, Harris M, et al: Family accommodation in obsessive-compulsive disorder. Am J Psychiatry 1995; 152:441–443
69.
Steketee G, Van Noppen B, Lam J, et al: Expressed emotion in families and the treatment of OCD. In Session: Psychotherapy in Practice, 1998;4:73–91
70.
Calvocoressi L, Mazure CM, Kasl SV, et al: Family accommodation of obsessive-compulsive symptoms: instrument development and assessment of family behavior. J Nerv Ment Dis 1999; 187:636–642
71.
Pinto A, Van Noppen B, Calvocoressi L: Development and preliminary psychometric evaluation of a self-rated version of the Family Accommodation Scale for Obsessive-Compulsive Disorder. Journal of Obsessive-Compulsive and Related Disorders. J Obsessive-Compulsive Relat Disord 2013; 2:457–465
72.
Lebowitz ER, Panza KE, Su J, et al: Family accommodation in obsessive-compulsive disorder. Expert Rev Neurother 2012; 12:229–238
73.
Stewart SE, Beresin C, Haddad S, et al: Predictors of family accommodation in obsessive-compulsive disorder. Ann Clin Psychiatry 2008; 20:65–70
74.
Amir N, Freshman M, Foa EB: Family distress and involvement in relatives of obsessive-compulsive disorder patients. J Anxiety Disord 2000; 14:209–217
75.
Van Noppen B, Steketee G: Testing a conceptual model of patient and family predictors of obsessive compulsive disorder (OCD) symptoms. Behav Res Ther 2009; 47:18–25
76.
Vikas A, Avasthi A, Sharan P: Psychosocial impact of obsessive-compulsive disorder on patients and their caregivers: a comparative study with depressive disorder. Int J Soc Psychiatry 2011; 57:45–56
77.
Barrowclough C, Tarrier N, Johnston M: Attributions, expressed emotion and patient relapse: an attributional model of relatives’ response to schizophrenia illness. Behav Ther 1994; 25:67–88
78.
Brown GW, Rutter M: The measurement of family activities and relationships: a methodological study. Hum Relat 1966; 19:241–263
79.
Hooley JM, Licht DM: Expressed emotion and causal attributions in the spouses of depressed patients. J Abnorm Psychol 1997; 106:298–306
80.
Emmelkamp PM, Kloek J, Blaauw E: Obsessive-compulsive disorders, in Principles and Practice of Relapse Prevention. Edited by Wilson PH. New York, NY, Guilford Press, 1992, pp 213–234
81.
Steketee G: Social support and treatment outcome of obsessive-compulsive disorder at 9-month follow-up. Behav Psychother 1993; 21:81–95
82.
Chambless DL, Steketee G: Expressed emotion and behavior therapy outcome: a prospective study with obsessive-compulsive and agoraphobic outpatients. J Consult Clin Psychol 1999; 67:658–665
83.
Hooley JM, Teasdale JD: Predictors of relapse in unipolar depressives: expressed emotion, marital distress, and perceived criticism. J Abnorm Psychol 1989; 98:229–235
84.
De Berardis D, Campanella D, Serront N, et al: Insight and perceived expressed emotion among adult outpatients with obsessive-compulsive disorder. J Psychiatr Pract 2008; 14:154–159
85.
Bressi C, Guggeri G: Obsessive-compulsive disorder and the family emotional environment. New Trends in Experimental and Clinical Psychiatry 1996; 12:265–269
86.
American Psychiatric Association Practice Guidelines for the Treatment of Psychiatric Disorders. Compendium 2006. Arlington, Va, American Psychiatric Association, 2006
87.
Steketee G, Van Noppen B: Family approaches to treatment for obsessive compulsive disorder. Rev Bras Psiquiatr 2003; 25:43–50
88.
Renshaw KD, Steketee G, Chambless DL: Involving family members in the treatment of OCD. Cogn Behav Ther 2005; 34:164–175
89.
Tynes LL, Salins C, Skiba W, et al: A psychoeducational and support group for obsessive-compulsive disorder patients and their significant others. Compr Psychiatry 1992; 33:197–201
90.
Black DW, Blum NS: Obsessive-compulsive disorder support groups: the Iowa model. Compr Psychiatry 1992; 33:65–71
91.
Cooper M: A group for families of obsessive-compulsive persons. Fam Soc 1993; (May):301–307
92.
Mehta M: A comparative study of family-based and patient-based behavioural management in obsessive-compulsive disorder. Br J Psychiatry 1990; 157:133–135
93.
Thornicroft G, Colson L, Marks I: An in-patient behavioural psychotherapy unit. Description and audit. Br J Psychiatry 1991; 158:362–367
94.
Grunes MS, Neziroglu F, McKay D: Family involvement in the behavioral treatment of obsessive-compulsive disorder: a preliminary investigation. Behav Ther 2001; 32:803–820
95.
Neziroglu F, McKay D, Yaryura-Tobias JA, et al: The Overvalued Ideas Scale: development, reliability and validity in obsessive-compulsive disorder. Behav Res Ther 1999; 37:881–902
96.
Van Noppen B, Steketee G, McCorkle B, Pato M: Group and Multifamily Behavioral Treatments for OCD, in OCD: Diagnosis, Etiology, Treatment. Edited by Hollander E. and Stein D. New York, Marcel Dekker, 1997, p 331–366
97.
Van Noppen B: Multifamily behavioral treatment (MFBT) for OCD. Crisis Intervention 1999; 5:3–24
98.
Abramowitz JS, Baucom DH, Wheaton MG, et al: Enhancing exposure and response prevention for OCD: a couple-based approach. Behav Modif 2013; 37:189–210
99.
Abramowitz JS, Baucom DH, Boeding S, et al: Treating obsessive-compulsive disorder in intimate relationships: a pilot study of couple-based cognitive-behavior therapy. Behav Ther 2013; 44:395–407
100.
Thompson-Hollands J, Edson A, Tompson MC, et al: Family involvement in the psychological treatment of obsessive-compulsive disorder: a meta-analysis. J Fam Psychol 2014; 28:287–298
101.
Hand I, Lamontagne Y, Marks IM: Group exposure (flooding) in vivo for agoraphobics. Br J Psychiatry 1974; 124:588–602
102.
Teasdale JD, Walsh PA, Lancashire M, et al: Group exposure for agoraphobics: a replication study. Br J Psychiatry 1977; 130:186–193
103.
Hafner J, Marks I: Exposure in vivo of agoraphobics: contributions of diazepam, group exposure, and anxiety evocation. Psychol Med 1976; 6:71–88
104.
Yalom I: The Theory and Practice of Group Psychotherapy. New York, Basic Books, 1975
105.
Jónsson H, Hougaard E: Group cognitive behavioural therapy for obsessive-compulsive disorder: a systematic review and meta-analysis. Acta Psychiatr Scand 2009; 119:98–106
106.
Jaurrieta N, Jiménez-Murcia S, Alonso P, et al: Individual versus group cognitive behavioral treatment for obsessive-compulsive disorder: follow up. Psychiatry Clin Neurosci 2008; 62:697–704
107.
Hand I, Tichatzky M: Behavioral group therapy for obsessions and compulsions: First results of a pilot study, in Trends in Behavior Therapy. Edited by Sjoden PO, Bates D, Dockens WS. New York, Academic Press, 1979, pp 269–297
108.
Espie CA: The group treatment of obsessive-compulsive ritualizers: behavioral management of identified patterns of relapse. Behav Psychother 1986; 14:21–33
109.
Krone KP, Himle JA, Nesse RM: A standardized behavioral group treatment program for obsessive-compulsive disorder: preliminary outcomes. Behav Res Ther 1991; 29:627–631
110.
Van Noppen BL, Pato MT, Marsland R, et al: A time-limited behavioral group for treatment of obsessive-compulsive disorder. J Psychother Pract Res 1998; 7:272–280
111.
Cabedo E, Belloch A, Carrió C, et al: Group versus individual cognitive treatment for obsessive-compulsive disorder: changes in severity at post-treatment and one-year follow-up. Behav Cogn Psychother 2010; 38:227–232
112.
Haraguchi T, Shimizu E, Ogura H, et al: Alterations of responsibility beliefs through cognitive-behavioural group therapy for obsessive-compulsive disorder. Behav Cogn Psychother 2011; 39:481–486
113.
Håland AT, Vogel PA, Lie B, et al: Behavioural group therapy for obsessive-compulsive disorder in Norway. An open community-based trial. Behav Res Ther 2010; 48:547–554
114.
Jónsson H, Hougaard E, Bennedsen BE: Randomized comparative study of group versus individual cognitive behavioural therapy for obsessive compulsive disorder. Acta Psychiatr Scand 2011; 123:387–397
115.
Reese CS, van Koesveld KE: An open trial of group metacognitive therapy for obsessive-compulsive disorder. J Behav Ther Exp Psy 2008; 39:451–458
116.
Valleni-Basile LA, Garrison CZ, Jackson KL, et al: Frequency of obsessive-compulsive disorder in a community sample of young adolescents. J Am Acad Child Adolesc Psychiatry 1994; 33:782–791
117.
Flament MF, Whitaker A, Rapoport JL, et al: Obsessive compulsive disorder in adolescence: an epidemiological study. J Am Acad Child Adolesc Psychiatry 1988; 27:764–771
118.
Pediatric OCD Treatment Study (POTS) Team: Cognitive-behavior therapy, sertraline, and their combination for children and adolescents with obsessive-compulsive disorder: the Pediatric OCD Treatment Study (POTS) randomized controlled trial. JAMA 2004; 292:1969–1976
119.
Swedo SE, Rapoport JL, Leonard H, et al: Obsessive-compulsive disorder in children and adolescents. Clinical phenomenology of 70 consecutive cases. Arch Gen Psychiatry 1989; 46:335–341
120.
Geller D, Biederman J, Jones J, et al: Is juvenile obsessive-compulsive disorder a developmental subtype of the disorder? A review of the pediatric literature. J Am Acad Child Adolesc Psychiatry 1998; 37:420–427
121.
Rasmussen SA, Eisen JL: The epidemiology and differential diagnosis of obsessive compulsive disorder. J Clin Psychiatry 1992; 53(Suppl):4–10
122.
Geller DA, Biederman J, Faraone S, et al: Developmental aspects of obsessive compulsive disorder: findings in children, adolescents, and adults. J Nerv Ment Dis 2001; 189:471–477
123.
Piacentini J, Bergman RL, Keller M, et al: Functional impairment in children and adolescents with obsessive-compulsive disorder. J Child Adolesc Psychopharmacol 2003; 13(Suppl 1):S61–S69
124.
Storch EA, Larson MJ, Muroff J, et al: Predictors of functional impairment in pediatric obsessive-compulsive disorder. J Anxiety Disord 2010; 24:275–283
125.
Valderhaug R, Ivarsson T: Functional impairment in clinical samples of Norwegian and Swedish children and adolescents with obsessive-compulsive disorder. Eur Child Adolesc Psychiatry 2005; 14:164–173
126.
Storch EA, Ledley DR, Lewin AB, et al: Peer victimization in children with obsessive-compulsive disorder: relations with symptoms of psychopathology. J Clin Child Adolesc Psychol 2006; 35:446–455
127.
Abramowitz J, Whiteside S, Deacon B: The effectiveness of treatment for pediatric obsessive-compulsive disorder: a meta-analysis. Behav Ther 2005; 36:55–63
128.
Sánchez-Meca J, Rosa-Alcázar AI, Iniesta-Sepúlveda M, et al: Differential efficacy of cognitive-behavioral therapy and pharmacological treatments for pediatric obsessive-compulsive disorder: a meta-analysis. J Anxiety Disord 2014; 28:31–44
129.
Watson HJ, Rees CS: Meta-analysis of randomized, controlled treatment trials for pediatric obsessive-compulsive disorder. J Child Psychol Psychiatry 2008; 49:489–498
130.
Freeman J, Sapyta J, Garcia A, et al: Family-based treatment of early childhood obsessive-compulsive disorder: the Pediatric Obsessive-Compulsive Disorder Treatment Study for Young Children (POTS Jr)—a randomized clinical trial. JAMA Psychiatry 2014; 71:689–698
131.
Lewin AB, Park JM, Jones AM, et al: Family-based exposure and response prevention therapy for preschool-aged children with obsessive-compulsive disorder: a pilot randomized controlled trial. Behav Res Ther 2014; 56:30–38
132.
Geller D, March J: Practice parameter for the assessment and treatment of children and adolescents with obsessive-compulsive disorder. J Am Acad Child Adolesc Psychiatry 2012; 51:98–113
133.
Treatment of obsessive-compulsive disorder. The Expert Consensus Panel for obsessive-compulsive disorder. J Clin Psychiatry 1997; 58(Suppl 4):2–72
134.
Jordan C, Reid A, Mariaskin A, et al: First-line treatment for Pediatric Obsessive-compulsive disorder. J Contemp Psychother 2012; 42:243–248
135.
Barrett P, Farrell L, Pina A, et al: Evidence-based psychosocial treatments for child and adolescent OCD. J Clin Child Adolesc 2008; 37:131–155
136.
Franklin ME, Sapyta J, Freeman JB, et al; Pediatric OCD Treatment Study Team: Cognitive behavior therapy augmentation of pharmacotherapy in pediatric obsessive-compulsive disorder: the Pediatric OCD Treatment Study II (POTS II) randomized controlled trial. JAMA 2011; 306:1224–1232
137.
Freeman JB, Garcia AM: Family-Based Treatment for Young Children With OCD Workbook. New York, Oxford University Press, 2009
138.
Piacentini J, Bergman RL, Chang S, et al: Controlled comparison of family cognitive behavioral therapy and psychoeducation/relaxation training for child obsessive-compulsive disorder. J Am Acad Child Adolesc Psychiatry 2011; 50:1149–1161
139.
Barrett P, Healy-Farrell L, March JS: Cognitive-behavioral family treatment of childhood obsessive-compulsive disorder: a controlled trial. J Am Acad Child Adolesc Psychiatry 2004; 43:46–62
140.
Kircanski K., Peris T: Exposure and response prevention process predicts treatment outcome in youth with OCD. J Abnorm Child Psych 2014 Jul 23. [Epub ahead of print]
141.
Skarphedinsson G, Weidle B, Thomsen P, et al: Continued cognitive-behavior therapy versus sertraline for children and adolescents with obsessive–compulsive disorder that were non-responders to cognitive-behavior therapy: a randomized controlled trial. Eur Child Adolesc Psychiatry. 2014 Sep 20 [Epub ahead of print]
142.
Ung D, Ale C, Storch E: Optimal management of pediatric obsessive-compulsive disorder. Pediatric Health. Medicine and Therapeutics 2012; 3:9–18
143.
Chang K., Frankovich J, Cooperstock M, et al: Clinical Evaluation of Youth with Pediatric Acute Onset Neuropsychiatric Syndrome (PANS): recommendations from the 2013 PANS Consensus Conference. J Child Adol Psychop 2014 [Epub ahead of print]
144.
Goodman W, Price L, Rasmussen S, et al: Children’s Yale-Brown Obsessive Compulsive Scale (CY-BOCS). Providence, RI, Department of Psychiatry Brown University School of Medicine, 1991
145.
Storch EA, Khanna M, Merlo LJ, et al: Children’s Florida Obsessive Compulsive Inventory: psychometric properties and feasibility of a self-report measure of obsessive-compulsive symptoms in youth. Child Psychiatry Hum Dev 2009; 40:467–483
146.
Foa EB, Huppert JD, Leiberg S, et al: The Obsessive-Compulsive Inventory: development and validation of a short version. Psychol Assess 2002; 14:485–496
147.
Piacentini J, Peris TS, Bergman RL, et al: Functional impairment in childhood OCD: development and psychometrics properties of the Child Obsessive-Compulsive Impact Scale-Revised (COIS-R). J Clin Child Adolesc Psychol 2007; 36:645–653
148.
Kircanski K, Peris TS, Piacentini JC: Cognitive-behavioral therapy for obsessive-compulsive disorder in children and adolescents. Child Adolesc Psychiatr Clin N Am 2011; 20:239–254
149.
Lewin AB, Piacentini J: Evidence-based assessment of child obsessive compulsive disorder: recommendations for clinical practice and treatment research. Child Youth Care Forum 2010; 39:73–89
150.
Merlo LJ, Storch EA, Adkins JW, et al: Assessment of pediatric obsessive-compulsive disorder, in Handbook of Child and Adolescent Obsessive-Compulsive Disorder. Edited by Storch E, Gefken G, Murphy T. Mahwah, NJ, Lawrence Erlbaum Associates Publishers, 2007, pp 67–107
151.
Caporino NE, Morgan J, Beckstead J, et al: A structural equation analysis of family accommodation in pediatric obsessive-compulsive disorder. J Abnorm Child Psychol 2012; 40:133–143
152.
Futh A, Simonds LM, Micali N: Obsessive-compulsive disorder in children and adolescents: parental understanding, accommodation, coping and distress. J Anxiety Disord 2012; 26:624–632
153.
Merlo LJ, Lehmkuhl HD, Geffken GR, et al: Decreased family accommodation associated with improved therapy outcome in pediatric obsessive-compulsive disorder. J Consult Clin Psychol 2009; 77:355–360
154.
Peris TS, Sugar CA, Bergman RL, et al: Family factors predict treatment outcome for pediatric obsessive-compulsive disorder. J Consult Clin Psychol 2012; 80:255–263
155.
Wu M, Lewin A, Murphy T, et al: Phenomenological considerations of family accommodation: related clinical characteristics and family factors in pediatric obsessive–compulsive disorder. J Obsessive-Compulsive Relat Disord 2014; 3:228–235
156.
Lebowitz ER, Vitulano LA, Mataix-Cols D, et al: Editorial perspective: when OCD takes over…the family! Coercive and disruptive behaviours in paediatric obsessive compulsive disorder. J Child Psychol Psychiatry 2011; 52:1249–1250
157.
Garcia AM, Sapyta JJ, Moore PS, et al: Predictors and moderators of treatment outcome in the Pediatric Obsessive Compulsive Treatment Study (POTS I). J Am Acad Child Adolesc Psychiatry 2010; 49:1024–1033, quiz 1086
158.
Bipeta R, Yerramilli SS, Pingali S, et al: A cross-sectional study of insight and family accommodation in pediatric obsessive-compulsive disorder. Child Adolesc Psychiatry Ment Health 2013; 7:20
159.
Lewin AB, Bergman RL, Peris TS, et al: Correlates of insight among youth with obsessive-compulsive disorder. J Child Psychol Psychiatry 2010; 51:603–611
160.
Morgan J, Caporino N, De Nadai A, et al: Preliminary predictors of within-session adherence to exposure and response prevention in pediatric obsessive-compulsive disorder. Child Youth Care Forum 2013; 42:181–191
161.
Adelman C, Lebowitz E: Poor insight in pediatric obsessive compulsive disorder: developmental considerations, treatment implications, and potential strategies for improving insight. J Obsessive-Compulsive Relat Disord 2012; 1:119–124
162.
Hibbs ED, Hamburger SD, Lenane M, et al: Determinants of expressed emotion in families of disturbed and normal children. J Child Psychol Psychiatry 1991; 32:757–770
163.
Leonard HL, Swedo SE, Lenane MC, et al: A 2- to 7-year follow-up study of 54 obsessive-compulsive children and adolescents. Arch Gen Psychiatry 1993; 50:429–439
164.
Peris T, Yadegar M, Asarnow J, et al: Pediatric obsessive compulsive disorder: Family climate as a predictor of treatment outcome. J Obsessive-Compulsive Relat Disord 2012; 1:267–273
165.
Przeworski A, Zoellner LA, Franklin ME, et al: Maternal and child expressed emotion as predictors of treatment response in pediatric obsessive-compulsive disorder. Child Psychiatry Hum Dev 2012; 43:337–353
166.
Challacombe F, Salkovskis P: A preliminary investigation of the impact of maternal obsessive-compulsive disorder and panic disorder on parenting and children. J Anxiety Disord 2009; 23:848–857
167.
Chilvers R: Different for Dads? The association between paternal OCD, parenting and child functioning. 2013. Electronic thesis downloaded from the King’s Research Portal at https://kclpure.kcl.ac.uk/portal/
168.
Freeman J, Garcia A, Frank H, et al: Evidence base update for psychosocial treatments for pediatric obsessive-compulsive disorder. J Clin Child Adolesc Psychol 2014; 43:7–26
169.
Freeman J, Garcia A, Benito K, et al: The Pediatric Obsessive Compulsive Disorder Treatment Study for Young Children (POTS Jr): developmental considerations in the rationale, design, and methods. J Obsessive-Compulsive Relat Disord 2012; 1:294–300
170.
Storch EA, Lehmkuhl HD, Ricketts E, et al: An open trial of intensive family based cognitive-behavioral therapy in youth with obsessive-compulsive disorder who are medication partial responders or nonresponders. J Clin Child Adolesc Psychol 2010; 39:260–268
171.
Rudy BM, Lewin AB, Geffken GR, et al: Predictors of treatment response to intensive cognitive-behavioral therapy for pediatric obsessive-compulsive disorder. Psychiatry Res 2014; 220:433–440
172.
Whiteside SP, Jacobsen AB: An uncontrolled examination of a 5-day intensive treatment for pediatric OCD. Behav Ther 2010; 41:414–422
173.
Comer JS, Furr JM, Cooper-Vince CE, et al: Internet-delivered, family-based treatment for early-onset OCD: a preliminary case series. J Clin Child Adolesc Psychol 2014; 43:74–87
174.
Storch EA, Caporino NE, Morgan JR, et al: Preliminary investigation of web-camera delivered cognitive-behavioral therapy for youth with obsessive-compulsive disorder. Psychiatry Res 2011; 189:407–412
175.
O’Leary EM, Barrett P, Fjermestad KW: Cognitive-behavioral family treatment for childhood obsessive-compulsive disorder: a 7-year follow-up study. J Anxiety Disord 2009; 23:973–978
176.
Farrell L, Waters A, Milliner E, et al: Comorbidity and treatment response in pediatric obsessive-compulsive disorder: a pilot study of group cognitive-behavioral treatment. Psychiatry Res 2012; 199:115–123
177.
Meyer E, Shavitt RG, Leukefeld C, et al: Adding motivational interviewing and thought mapping to cognitive-behavioral group therapy: results from a randomized clinical trial. Rev Bras Psiquiatr 2010; 32:20–29
178.
Maltby N, Tolin DF: A brief motivational intervention for treatment-refusing OCD patients. Cogn Behav Ther 2005; 34:176–184
179.
Merlo LJ, Storch EA, Lehmkuhl HD, et al: Cognitive behavioral therapy plus motivational interviewing improves outcome for pediatric obsessive-compulsive disorder: a preliminary study. Cogn Behav Ther 2010; 39:24–27
180.
Simpson HB, Zuckoff AM, Maher MJ, et al: Challenges using motivational interviewing as an adjunct to exposure therapy for obsessive-compulsive disorder. Behav Res Ther 2010; 48:941–948
181.
Kushner MG, Kim SW, Donahue C, et al: D-cycloserine augmented exposure therapy for obsessive-compulsive disorder. Biol Psychiatry 2007; 62:835–838
182.
Wilhelm S, Buhlmann U, Tolin DF, et al: Augmentation of behavior therapy with D-cycloserine for obsessive-compulsive disorder. Am J Psychiatry 2008; 165:335–341, quiz 409
183.
Chasson GS, Buhlmann U, Tolin DF, et al: Need for speed: evaluating slopes of OCD recovery in behavior therapy enhanced with d-cycloserine. Behav Res Ther 2010; 48:675–679
184.
Storch EA, Murphy TK, Goodman WK, et al: A preliminary study of D-cycloserine augmentation of cognitive-behavioral therapy in pediatric obsessive-compulsive disorder. Biol Psychiatry 2010; 68:1073–1076
185.
Storch EA, Merlo LJ, Bengtson M,et al: D-cycloserine does not enhance exposure-response prevention therapy in obsessive-compulsive disorder. Int Clin Psychopharmacol 2007; 22:230–237
Information & Authors
Information
Published In
History
Published in print: Spring 2015
Published online: 15 April 2015
Authors
Metrics & Citations
Metrics
Citations
Export Citations
If you have the appropriate software installed, you can download article citation data to the citation manager of your choice. Simply select your manager software from the list below and click Download.
For more information or tips please see 'Downloading to a citation manager' in the Help menu.
View Options
View options
PDF/EPUB
View PDF/EPUBLogin options
Already a subscriber? Access your subscription through your login credentials or your institution for full access to this article.
Personal login Institutional Login Open Athens loginNot a subscriber?
PsychiatryOnline subscription options offer access to the DSM-5-TR® library, books, journals, CME, and patient resources. This all-in-one virtual library provides psychiatrists and mental health professionals with key resources for diagnosis, treatment, research, and professional development.
Need more help? PsychiatryOnline Customer Service may be reached by emailing [email protected] or by calling 800-368-5777 (in the U.S.) or 703-907-7322 (outside the U.S.).