Cognitive-Behavioral Therapy for Obsessive-Compulsive Disorder

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:

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.

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.

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.