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Co-occurring psychiatric conditions are very common in tic disorders and Tourette syndrome. These additional symptoms are often detrimental to quality of life and may impact upon the implementation and efficacy of evidence-based behavioural therapies (BT) for tics. Combining a review of the available literature, relevant theory, and expert clinical practice, we present a guideline for implementing behavioural and psychosocial interventions when common comorbidities are present. These include attention-deficit hyperactivity disorder (ADHD), obsessive-compulsive disorder (OCD), anxiety, disruptive behaviour, autism spectrum disorder (ASD) and depression. Practical recommendations are provided for assessment, formulation and management of specific and multiple comorbidities in BT for both children and adults. Despite comorbidities being common in tic disorders, few studies have comprehensively addressed how they may influence the efficacy or implementation of existing therapies or how such treatments may need to be modified or sequenced. We outline recommendations for future research, including randomised control trials of BT for those with specific or multiple comorbidities, as well as adequately powered sub-group analyses within larger scale trials or naturalistic study designs. Transdiagnostic models of psychiatric disorders and treatment, including modular cross-diagnostic therapies, which recognise the dimensionality of psychiatric disorders are also highlighted as an important focus in treatment development in tic disorders., (© 2022. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany.)

Obsessive-compulsive disorder (OCD) with poor insight can contribute to the refusal to receive treatment, leaving the burden of care on parents or other caregivers. The case presented here involved a young adult with OCD with delusional levels of insight paired with extreme family-accommodating behaviors that had resulted in impaired quality of life and functioning for the young adult and his parents. A parent-led behavioral intervention [The Supportive Parenting for Anxious Childhood Emotions (SPACE)] that was developed for children with anxiety was adapted and utilized for a young adult with severe OCD. The case presents a treatment option for parents and caregivers of individuals with OCD who refuse treatment.

For those who suffer with chronic and disruptive obsessive-compulsive disorder (OCD), who have not been sufficiently helped by outpatient treatments or medications, intensive residential treatment (IRT) is often the next best treatment option. To date, research of the predictors of treatment outcome in IRT for OCD are mixed and sometimes contradictory. Additionally, although comorbidity is common for patients in this setting, the inclusion of comorbidity as a potential predictor of outcome has been mostly lacking in research to date. The current study aimed to address these issues by utilizing optimal indices of treatment outcomes, while incorporating comorbidity into our analyses, in order to identify the predictors of treatment outcomes in the IRT for OCD setting. To this end, we analysed outcome data from 379 patients receiving IRT for OCD at the Rogers Memorial OCD Center between August 2012, and December 2017. Results indicated that the most important predictor of treatment outcome was obsession severity at admission. Specifically, higher obsession severity at admission predicted poorer treatment outcomes at discharge. Clinical implications and suggestions for future research were discussed in the manuscript., (© 2019 John Wiley & Sons, Ltd.)

Contamination fear and washing compulsions are among the most common symptoms of obsessive compulsive disorder (OCD). Though these symptoms have traditionally been viewed as being driven by a desire to avoid harm, recent research has highlighted the importance of feelings of incompleteness (INC) or not-just right experiences (NJREs) in this symptom dimension. However, no study to date has examined the extent to which INC/NJREs may be associated with treatment response for contamination symptoms. The current study used a multi-method approach to examine the role of INC/NJREs in treatment of contamination symptoms. Participants (n = 88) with elevated contamination symptoms, half of whom met for an OCD diagnosis, engaged in three sessions of exposure and response prevention (ERP) targeting contamination fears, and completed self-report and in vivo measures of INC/NJRES and contamination symptoms. ERP was associated with significant reductions in INC/NJREs. Further, changes in INC were associated with changes in contamination symptoms, independent of changes in harm avoidance. Greater discomfort in response to an in vivo NJRE task at pre-treatment predicted poor treatment response, though a self-report measure of INC did not predict response. These findings provide novel evidence for the importance of INC/NJREs in contamination-based OCD and its treatment., (Copyright © 2018 Elsevier Ltd. All rights reserved.)

This case report describes a nursing experience caring for a patient with schizophrenia and obsessive-compulsive symptoms. This patient suffered from symptoms of being controlled, obsessive thoughts, and compulsive behaviors. In addition, the patient showed no interest in implementing strategies for dealing with anxiety, no motivation for changing this suffering, and an inability to receive a higher level of rehabilitative job training in daycare. These problems impeded this patient's reintegration into the community. Therefore, the authors employed a five-dimension assessment (physical, emotional, cognitive, social, and spiritual) in order to address the two major nursing problems. The period of nursing care was from October 21, 2016 to January 10, 2017. The two nursing problems addressed included: 1) altered thought processes and 2) ineffective coping. The author provided potentially helpful nursing processes based on the theory of Rational-Emotive Behavior Therapy in order to help the patient cope with symptoms, including being controlled and obsessive-compulsive behaviors. Meanwhile, a relaxation technique was applied to reduce the patient's feelings of discomfort during the nursing processes. As a result, the patient's coping skills to deal with symptoms of being controlled, obsession, and compulsion were improved through refutation of irrational beliefs. In addition to showing rational emotions and appropriate behavior to handle pressures, the patient was also able to apply the relaxation technique to relieve the discomfort from anxiety and pain as needed. This case report suggests that nurses may implement the irrational beliefs refutation training regimen under Rational-Emotive Behavior Therapy for similar cases at the beginning of nursing-patients relationships. Furthermore, providing relaxation techniques in the nursing process may assist patients to deal with stressful life events. The results of this nursing experience are expected to help nursing colleagues apply the above theory and skills with schizophrenia patients with obsessive-compulsive symptoms.

Current evidence-based treatments for obsessive-compulsive disorder in children and adolescents include cognitive-behavioral therapy, specifically exposure and response prevention, and psychopharmacological treatments. Despite the established efficacy of these treatments, many youth do not benefit from them, and barriers, including lack of motivation and resistance to treatment, prevent many youth from even attempting them. Parent-based treatments offer an alternative approach to child-based therapy. SPACE (Supportive Parenting for Anxious Childhood Emotions) is a parent-based treatment that focuses on systematically reducing family accommodation, or the changes that parents make to their own behavior to help a child avoid or alleviate distress related to the disorder, while increasing supportive responses to the child's symptoms. This article presents the theoretical background for SPACE and illustrates its implementation through a case description. Conclusions and knowledge to be gained from the case are discussed.

Trichotillomania (TTM) is a poorly understood condition that causes significant impairment, but effective behavioral management strategies exist. The phenomenology of TTM is complex and requires an individualized treatment approach, and there are some important facets of TTM that have only recently been recognized. Specifically, contemporary research indicates that hair pulling is often performed to regulate aversive sensations and provide somatosensory reward. In this article, we describe the complex phenomenology of TTM, evidence-based treatment options, and illustrate a case of sensory-based TTM treated effectively with a comprehensive behavioral intervention.

Objective: We examined outcomes from a residential treatment program emphasizing exposure and response prevention (ERP) to determine if the typically robust response to this treatment in outpatient settings extends to patients treated in this unique context., Method: One hundred and seventy-two adolescents with primary Obsessive-compulsive disorder (OCD) completed measures at admission and discharge. Almost all (92.4%) participants had at least two diagnoses and nearly half (44.2%) had three or more. Treatment consisted of intensive ERP (i.e., approximately 26.5 hr per week), additional cognitive behavioral therapy interventions, and medication management within a residential setting. In contrast to the samples reported on in the vast majority of other pediatric OCD trials, participants in the current study were living apart from their families and were immersed within the treatment setting, with staff members available at all times., Results: Paired sample t-tests revealed significant decreases in OCD and depression severity., Conclusions: Results suggest that residential treatment for adolescents with OCD using a multimodal approach emphasizing ERP can be effective for complex cases with significant comorbidity. Results were comparable with several randomized controlled trials.

Harm-related, or "aggressive," obsessions are a symptom subtype in obsessive-compulsive disorder (OCD). Given the violent nature of these thoughts, the stark contrast between the child's character and the content of these obsessions often results in high levels of distress for not only the patient but also the family. This case report illustrates the application of family-based exposure and response prevention (ERP) for a 15-year-old male presenting with harm-related obsessions and mild depressive symptoms secondary to the OCD. The obsessions primarily revolved around the fear of acting on unwanted impulses (e.g., stabbing a family member, pushing a friend onto oncoming traffic), and the compulsions entailed avoidance (both mental and physical), excessive reassurance seeking, and ritualistic confessions. The client underwent a 14-week course of ERP involving repeated imaginal and in vivo exposures and behavioral activation to alleviate depressive symptoms. Significant improvements in obsessive-compulsive symptom severity and depressive symptoms were observed posttreatment, elucidating the efficacy of treating harm-related obsessions with a course of ERP., (© 2016 Wiley Periodicals, Inc.)

Contamination fear is one of the most common symptoms of obsessive-compulsive disorder (OCD). Exposure and response prevention (ERP) is effective for OCD, but a significant minority of treatment-seeking individuals refuse ERP entirely or drop out prematurely. Research suggests that safety behaviour (SB) may enhance the acceptability of ERP; however, questions remain about how to incorporate SB into existing treatments. Clinical participants with OCD and contamination fear (N = 57) were randomized to receive an exposure session with no SB (ERP), a routinely used SB (RU), or a never-used SB (NU). Significant reductions in contamination fear severity were observed in all conditions. Although omnibus comparisons were only marginally significant, pairwise comparisons revealed some condition differences. NU demonstrated significantly lower self-reported contamination fear severity at post-exposure, as well as marginally higher treatment acceptability ratings. Findings suggest that exposure with SB may be effective and acceptable, and are discussed in terms of cognitive-behavioural theory and treatment of anxiety and related disorders.

This study examined cognitive mediators of symptom change during exposure and response prevention (EX/RP) for obsessive-compulsive disorder (OCD). Based on cognitive models of OCD, obsessive beliefs were hypothesized as a mediator of symptom change. Participants were 70 patients with primary OCD receiving EX/RP either as part of a randomized controlled trial (n=38) or in open treatment following nonresponse to risperidone or placebo in the same trial (n=32). Blinded evaluations of OCD severity and self-report assessments of three domains of obsessive beliefs (i.e., responsibility/threat of harm, importance/control of thoughts, and perfectionism/intolerance of uncertainty) were administered during acute (Weeks 0, 4 and 8) and maintenance treatment (Weeks 12 and 24). Study hypotheses were examined using cross-lagged multilevel modeling. Contrary to predictions, the obsessive beliefs domains investigated did not mediate subsequent OCD symptom reduction. In addition, OCD symptoms did not significantly mediate subsequent change in obsessive beliefs. The present study did not find evidence of cognitive mediation during EX/RP for OCD, highlighting the need to investigate other plausible mediators of symptom improvement., (Copyright © 2016. Published by Elsevier Ltd.)

Background: Obsessive-compulsive disorder (OCD) is a relatively common and disabling condition., Objectives: To determine the clinical effectiveness, acceptability and cost-effectiveness of pharmacological and psychological interventions for the treatment of OCD in children, adolescents and adults., Data Sources: We searched the Cochrane Collaboration Depression, Anxiety and Neurosis Trials Registers, which includes trials from routine searches of all the major databases. Searches were conducted from inception to 31 December 2014., Review Methods: We undertook a systematic review and network meta-analysis (NMA) of the clinical effectiveness and acceptability of available treatments. Outcomes for effectiveness included mean differences in the total scores of the Yale-Brown Obsessive-Compulsive Scale or its children's version and total dropouts for acceptability. For the cost-effectiveness analysis, we developed a probabilistic model informed by the results of the NMA. All analyses were performed using OpenBUGS version 3.2.3 (members of OpenBUGS Project Management Group; see www.openbugs.net )., Results: We included 86 randomised controlled trials (RCTs) in our systematic review. In the NMA we included 71 RCTs (54 in adults and 17 in children and adolescents) for effectiveness and 71 for acceptability (53 in adults and 18 in children and adolescents), comprising 7643 and 7942 randomised patients available for analysis, respectively. In general, the studies were of medium quality. The results of the NMA showed that in adults all selective serotonin reuptake inhibitors (SSRIs) and clomipramine had greater effects than drug placebo. There were no differences between SSRIs, and a trend for clomipramine to be more effective did not reach statistical significance. All active psychological therapies had greater effects than drug placebo. Behavioural therapy (BT) and cognitive therapy (CT) had greater effects than psychological placebo, but cognitive-behavioural therapy (CBT) did not. BT and CT, but not CBT, had greater effects than medications, but there are considerable uncertainty and methodological limitations that should be taken into account. In children and adolescents, CBT and BT had greater effects than drug placebo, but differences compared with psychological placebo did not reach statistical significance. SSRIs as a class showed a trend for superiority over drug placebo, but the difference did not reach statistical significance. However, the superiority of some individual drugs (fluoxetine, sertraline) was marginally statistically significant. Regarding acceptability, all interventions except clomipramine had good tolerability. In adults, CT and BT had the highest probability of being most cost-effective at conventional National Institute for Health and Care Excellence thresholds. In children and adolescents, CBT or CBT combined with a SSRI were more likely to be cost-effective. The results are uncertain and sensitive to assumptions about treatment effect and the exclusion of trials at high risk of bias., Limitations: The majority of psychological trials included patients who were taking medications. There were few studies in children and adolescents., Conclusions: In adults, psychological interventions, clomipramine, SSRIs or combinations of these are all effective, whereas in children and adolescents, psychological interventions, either as monotherapy or combined with specific SSRIs, were more likely to be effective. Future RCTs should improve their design, in particular for psychotherapy or combined interventions., Study Registration: The study is registered as PROSPERO CRD42012002441., Funding Details: The National Institute for Health Research Health Technology Assessment programme.

Disgust is an understudied but important emotion in various psychological disorders. Over the last decade, increasing evidence suggests that disgust is also present in various subtypes of obsessive-compulsive disorder (OCD), especially in contamination-related OCD (C-OCD). The treatment of choice for C-OCD is exposure with response prevention, originally designed to reduce fear-associated emotions thought to be acquired through Pavlovian conditioning (PC). However, disgust has been proposed to be acquired through evaluative conditioning (EC) and according to the referential model of this form of learning, there are functional differences between PC and EC that need to be considered in the treatment of disgust-related responses. Alternative strategies suggested by EC-based models include counterconditioning (contingent presentation of the CS with a US of opposite valence) and US revaluation (contingent presentation of the US with US of opposite valence). Drawing on the referential model, this paper reviews evidence for the effectiveness of each strategy to identify the most theoretically sound and empirically valid intervention to reduce disgust in C-OCD., (Copyright © 2015 Elsevier Ltd. All rights reserved.)

Objective: The objective of this article is to provide an update on current psychological treatment for obsessive compulsive disorder (OCD)., Conclusions: Cognitive behaviour therapy (CBT), incorporating exposure and response prevention, remains the non-pharmacological treatment of choice for OCD. Recent developments highlight the importance of family involvement in adult OCD treatment, and the use of alternative 'third-wave' interventions. Internet-delivered CBT may provide an opportunity to overcome barriers to effective treatment, such as distance and lack of trained clinicians., (© The Royal Australian and New Zealand College of Psychiatrists 2015.)

Obsessive-compulsive disorder (OCD) is difficult to treat, and more so when comorbid with major depressive disorder (MDD). The aim of the present case study was to examine effects of behavioral activation (BA) and pharmacotherapy with an adult with chronic comorbid OCD and MDD. BA aimed at increasing approach behaviors in life activities and decreasing avoidant and inactive behaviors. After 21 months of treatment at a community mental health clinic, OCD and MDD symptoms, including compulsive checking behaviors, were no longer at clinical levels. Symptom alleviation and psychological health improved in line with increases in activities of living such as self-care, domestic, social, and studying, and decreases in medications from a regimen of mood stabilizers and anxiolytics to a sole antidepressant. The participant was satisfied with treatment procedures and outcome. The results add to growing evidence of effective BA treatments for comorbid disorders that include depression., ((c) 2015 APA, all rights reserved).)

Objective: To evaluate the overall effect of D-cycloserine (DCS) augmentation on exposure and response prevention (ERP) therapy for obsessive-compulsive disorder (OCD)., Methods: Clinical studies on the effect of DCS augmentation on ERP therapy for OCD compared to placebo were included for meta analysis. The primary outcome was the Yale-Brown Obsessive-Compulsive Scale (Y-BOCS). Meta-analyses were performed with a random-effect model or a fixed-effect model using the Cochrane Review Manager (RevMan, version 5.2) to calculate the odds ratio and the mean difference, with their corresponding 95% confidence intervals., Results: A total of six studies was included in the current meta-analyses, and their data were extracted. Among them, four were for analyses of DCS and Y-BOCS at midtreatment, six for analysis at posttreatment, and four at 3-month follow-up. Besides, three of the six eligible studies were included in the meta-analysis of the DCS and Clinical Global Impression-Severity Scale at posttreatment, and three in the meta-analysis of DCS and proportions of treatment responders and of subjects attaining clinical remission status criteria at posttreatment. Our meta-analyses do not reveal a significant effect of DCS augmentation in ERP therapy for OCD patients, except when measured at midtreatment. Compared to the placebo group, DCS augmentation did show a trend toward significantly lower/decreased Y-BOCS; when measured at posttreatment and in the subpopulation of DCS taken before some of the ERP sessions, DCS augmentation showed a trend toward significantly lower/decreased Y-BOCS., Conclusion: Our result suggested that with the careful optimization of DCS-augmented ERP therapy by fine-tuning timing and dosing of DCS administration and number and frequency of ERP sessions, DCS may enhance the efficacy of ERP therapy in reducing the symptomatic severity of OCD patients, especially at early stage of the treatment; therefore, DCS augmentation could possibly reduce treatment cost, reduce treatment drop and refusal rate, and help to improve access to the limited number of experienced therapists.

Accommodation consists of changes in family members' behavior to prevent or reduce patients' obsessive-compulsive disorder (OCD) rituals or distress. High levels of family accommodation are associated with more severe symptoms and functional impairment in patients, and may also interfere with exposure-based treatment. The purpose of this study was to develop and test an intervention to reduce accommodation in the family members of adult OCD patients. Patients (N=18, mean age=35.44, 33% male, 94% Caucasian) received a course of standard individual exposure and ritual prevention (ERP) for OCD. Family members (N=18, mean age=41.72, 56% male, 94% Caucasian) were randomized to either receive or not receive the adjunctive intervention, consisting of two sessions of psychoeducation and skills training in reducing accommodation. Results revealed that the intervention successfully reduced scores on the clinician-rated Family Accommodation Scale (Week 8: d=1.05). Patients whose family members received the intervention showed greater reductions in Yale-Brown Obsessive-Compulsive Scale scores across treatment than patients whose family members had not (Week 8: d=1.27), and hierarchical regression analyses revealed that change in family accommodation from baseline accounted for a significant amount of variance in later OCD symptoms (β=.45, p=.02). Results from this preliminary study suggest that adjunctive intervention produces more rapid treatment response compared with traditional ERP alone. Accommodation is a potentially important target for improving treatment in OCD and other diagnostic groups where accommodation is likely to occur., (Copyright © 2014. Published by Elsevier Ltd.)

Background: Effective treatments for obsessive-compulsive disorder (OCD) include behavioral therapy (exposure and response/ritual prevention and cognitive behavioral therapy) and serotonin-reuptake inhibitors (SRIs); however, the relative efficacy of these treatments is not well established. We sought to review evidence from head-to-head randomized-controlled trials (RCTs) of behavioral therapy and SRIs in the treatment of OCD., Methods: A systematic search of multiple databases was conducted from first available date to June 30, 2012, for RCTs in the treatment of OCD among outpatients, comparing behavioral therapy and SRIs, alone or combined. Two independent reviewers evaluated studies for eligibility and risk of bias. The main outcome measure was posttreatment mean Yale-Brown Obsessive-Compulsive Scale (YBOCS) score., Results: We identified 2,186 unique articles. Fifteen articles were included, describing 13 RCTs. Pooled standardized mean difference (SMD; 95% confidence intervals) in YBOCS score significantly favored behavioral therapy over SRIs (0.37; 0.10, 0.64; P = .007), but not in a subset of trials that used selective SRIs (0.22; -0.02, 0.47; P = .070). Within individual trials, effect sizes significantly favored the combination of behavioral therapy plus an SRI over an SRI, but not behavioral therapy, alone., Conclusions: This review provides evidence that, among outpatients with OCD, behavioral therapy is more effective than SRIs, overall, but not selective SRIs. Furthermore, the combination of behavioral therapy plus an SRI is more effective than an SRI alone. These data may be used to inform the development of evidence-based treatment guidelines; however, more studies are also needed to further evaluate the relative efficacy of these interventions., (© 2014 Wiley Periodicals, Inc.)

Translating findings from basic science, several compounds have been identified that may enhance therapeutic outcomes and/or expedite treatment gains when administered alongside exposure-based treatments. Four of these compounds (referred to as cognitive enhancers) have been evaluated in the context of randomized controlled trials for anxiety disorders (e.g., specific phobias, panic disorder, social anxiety disorder), obsessive-compulsive disorder and post-traumatic stress disorder. These cognitive enhancers include D-cycloserine, yohimbine hydrochloride, glucocorticoids and cortisol and brain-derived neurotrophic factor. There is consistent evidence that cognitive enhancers can enhance therapeutic outcomes and/or expedite treatment gains across anxiety disorders, obsessive-compulsive disorder and post-traumatic stress disorder. Emerging evidence has highlighted the importance of within-session fear habituation and between-session fear learning, which can either enhance fear extinction or reconsolidate of fear responses. Although findings from these trials are promising, there are several considerations that warrant further evaluation prior to widespread use of cognitive enhancers in exposure-based treatments. Consistent trial design and large sample sizes are important in future studies of cognitive enhancers.

Aims: To examine the feasibility, acceptability and preliminary efficacy of family-based exposure/response prevention therapy (E/RP) versus treatment as usual (TAU) in a cohort of very young children with early onset obsessive-compulsive disorder (OCD)., Methods: Thirty-one children ages 3-8 years (M = 5.8 years) with a primary diagnosis of OCD were randomized to E/RP or TAU. The E/RP condition received 12 sessions of family-based E/RP twice weekly over 6 weeks. Families were assessed at baseline, post-treatment, 1-month and 3-month follow up. The Children's Yale Brown Obsessive Compulsive Scale and Clinical Global Impression served as primary outcome measures., Results: A large group effect emerged in favor of the E/RP group (d = 1.69). Sixty-five percent of the E/RP group was considered treatment responders as compared to 7% in the TAU group. Symptom remission was achieved in 35.2% of the E/RP group and 0% of the TAU group. There was no attrition and satisfaction was high; gains were maintained at 3 months., Conclusions: Even amongst children as young as 3 years, developmentally tailored E/RP is efficacious and well-tolerated in reducing OCD symptoms. Key adaptations for younger children include extensive parent involvement, targeting family accommodation, and frequent meetings while delivering a full course of E/RP., Clinicaltrialsgov Identifier: NCT01447966 http://clinicaltrials.gov/ct2/show/NCT01447966?term=ocd+and+st+petersburg&rank=1., (Copyright © 2014 Elsevier Ltd. All rights reserved.)

We report the case of a patient requiring gamma ventral capsulotomy (GVC), a neurosurgical intervention to address severe refractory obsessive-compulsive disorder (OCD). GVC involves stereotactic lesions in the ventral anterior limb of the internal capsule and adjacent ventral striatum. This study details the course of an extinction-based behavioral therapy, namely exposure and response prevention (ERP). The patient experienced significant changes in motivation and ability to tolerate ERP post-surgery. Furthermore, he was better able to absorb and remember exposure sessions. GVC surgery may affect the neural mechanisms involved in the extinction learning process, the same process implicated in ERP treatment.

Objective: To examine symptom change over time, the effect of attrition on treatment outcome, and the putative mediators of cognitive therapy (CT) versus behavior therapy (BT) for obsessive-compulsive disorder (OCD) using archival data., Method: Sixty-two adults with OCD were randomized to 20 sessions of CT (N = 30) or BT (N = 32) that consisted of 4 weeks of intensive treatment (16 hr total) and 12 weeks of maintenance sessions (4 hr). Independent evaluators assessed OCD severity using the Yale-Brown Obsessive Compulsive Scale (Y-BOCS) at baseline and at Weeks 4, 16 (posttreatment), 26, and 52 (follow-up). Behavioral avoidance, depressive symptoms, and dysfunctional beliefs regarding responsibility were also measured at each assessment. Study hypotheses were tested using multilevel modeling., Results: The slope of change in Y-BOCS scores was significantly greater in BT than in CT (d = 0.69), and those receiving BT had lower Y-BOCS scores at the final assessment than those receiving CT (d = 1.17). The greater slope of change in BT versus CT did not differ for dropouts versus completers. Reduction in depressed mood mediated changes in Y-BOCS across the 2 treatments, but a reduction in sense of responsibility and a decrease in avoidance did not. Instead, Y-BOCS improvements appeared to precede a decrease in avoidance., Conclusions: BT may have some therapeutic advantage over CT in the treatment of OCD, and this advantage does not appear to be due to a differential pattern of responding for treatment dropouts versus completers. Further, inconsistent with hypotheses, improvements in OCD symptoms were mediated by reductions in depressed mood instead of decreases in avoidance and responsibility. Theoretical, methodological, and clinical implications are discussed.

Objective: This article describes the long-term effects of augmenting serotonin reuptake inhibitors (SRIs) with exposure and ritual prevention or stress management training in patients with DSM-IV obsessive-compulsive disorder (OCD)., Method: Between November 2000 and November 2006, 111 OCD patients from 2 academic outpatient centers with partial SRI response were randomized to the addition of exposure and ritual prevention or stress management training, delivered twice weekly for 8 weeks (acute phase); 108 began treatment. Responders (38 of 52 in the exposure and ritual prevention condition, 11 of 52 in the stress management training condition) entered a 24-week maintenance phase. The Yale-Brown Obsessive Compulsive Scale (YBOCS) was the primary outcome measure., Results: After 24 weeks, patients randomized to and receiving exposure and ritual prevention versus stress management training had significantly better outcomes (mean YBOCS scores of 14.69 and 21.37, respectively; t = 2.88, P = .005), higher response rates (decrease in YBOCS scores ≥ 25%: 40.7% vs 9.3%, Fisher exact test P < .001), and higher rates of excellent response (YBOCS score ≤ 12: 24.1% vs 5.6%, Fisher exact test P = .01). During the maintenance phase, the slope of change in YBOCS scores was not significant in either condition (all P values ≥ .55), with no difference between exposure and ritual prevention and stress management training (P > .74). Better outcome was associated with baseline variables: lower YBOCS scores, higher quality of life, fewer comorbid Axis I diagnoses, and male sex., Conclusions: Augmenting SRIs with exposure and ritual prevention versus stress management training leads to better outcome after acute treatment and 24 weeks later. Maintenance outcome, however, was primarily a function of OCD severity at entrance. Greater improvement during the acute phase influences how well patients maintain their gains, regardless of treatment condition., (© Copyright 2013 Physicians Postgraduate Press, Inc.)

Objective: This pilot study investigates the effects of habit reversal training in a German-speaking population of children and young adults with chronic tic disorders on comorbid symptoms and subjective interference., Methods: 16 children were treated using a manualized program. Comorbid-symptoms (ADHD, anxiety and OCD, depression) were assessed using parent and self-ratings. Additionally, the correlation of tic symptoms with comorbid symptoms at the beginning of the therapy was analyzed., Results: We obtained positive results in reducing comorbid symptoms during a primary treatment of tic symptoms. We further found a correlation of tic symptoms and comorbid symptoms especially in parent ratings., Conclusions: These first findings show that a primary treatment of tics may be indicated in patients with comorbid symptoms, because a therapy of tic symptoms has also positive effects on comorbid symptoms.

The current study used magnetic resonance spectroscopy (MRS) to investigate differences in absolute levels of neurochemicals in the head of the caudate nucleus (HOC) and anterior cingulate cortex (ACC) between 15 children with obsessive-compulsive disorder (OCD) and a matched control group, as well as the effects of behavior therapy on these chemicals. At baseline, absolute levels of N-acetyl-l-aspartate (NAA) in the left HOC were significantly lower in non-medicated patients (N=8) with OCD compared to medicated patients (N=5) and compared to matched controls (N=9). Exploratory analyses provided preliminary data suggesting that behavior therapy is associated with a decrease in Glx (glutamate+glutamine) in the right HOC (N=7). The baseline differences in NAA replicate previous finding from the adult literature and show a relationship between NAA in OCD across the lifespan. The changes in Glx raise the possibility that behavior therapy and medication treat OCD symptoms through similar pathways., (Copyright © 2012 Elsevier Ireland Ltd. All rights reserved.)

Despite the existence of effective psychological and pharmacological interventions for obsessive-compulsive disorder (OCD), there are a large proportion of individuals for whom intervention is not effective. The study reports on the results of a community treatment service for individuals with treatment-refractory OCD who have not benefitted from previous cognitive behavioural or pharmacological treatment by community mental health services. A total of 205 individuals accepted for treatment by a specialist community OCD treatment service in London were provided with a combination of behavioural, cognitive, and pharmacological treatment within a specialist OCD service, with 158 completing treatment. Treatment was associated with significant reduction in clinician-rated and self-reported OCD symptoms after 12 weeks, with further reductions in OCD symptoms over a subsequent 12-week period. A significant reduction in symptoms of depression was also observed after 12 and 24 weeks. Approximately 40% of individuals treated experienced clinically significant improvement in their symptoms, with approximately 10% deemed to have recovered by the end of treatment. Our results add to previous research into refractory OCD, and provide support for the existence of specialist community treatment services which may provide assistance to individuals who have not responded to previous treatment., (Copyright © 2012 Elsevier Ltd. All rights reserved.)

Previous studies suggest that baseline differences in neuronal markers between patients with obsessive-compulsive disorder (OCD) and healthy controls no longer exist following successful pharmacotherapy. The current study used proton magnetic resonance spectroscopy (MRS) to investigate differences in absolute concentrations of neurochemicals (i.e., N-acetyl-l-aspartic; NAA) in the head of the caudate nucleus (HOC) and orbital frontal white matter (OFWM) between 15 adults with OCD and a sex- and age-matched control group, as well as the effects of behavior therapy on these chemicals. Behavior therapy was associated with a significant increase in left HOC NAA. When the analyses were restricted to only pairings with complete data (OCD patient, control, post-treatment), the levels of left HOC NAA were significantly lower in patients compared to controls, and increased significantly with treatment. Exploratory analyses suggested that levels of NAA and Cr (creatine) in the right OFWM may be significantly lower in the OCD group than the control group. The results raise the possibility that successful behavioral treatment may be associated with increases in markers of neuronal viability, although other associations found in the literature were not replicated., (Copyright © 2011 Elsevier Ireland Ltd. All rights reserved.)

Purpose of Review: In spite of advances in the understanding and treatment of obsessive-compulsive disorder (OCD), for most patients some symptoms persist even after therapeutic intervention. Another large subgroup does not seek treatment at all, particularly due to shame or fear of stigma. The treatment gap in OCD is large and self-help is increasingly seen as a low-threshold form of intervention for individuals with minor symptoms or who are currently treatment-reluctant. Our review summarizes the expanding but still small literature on self-help and Internet interventions for OCD and provides advice on how to conduct (Internet) studies on self-help. Strategies to deal with methodological problems that notoriously plague Internet research are discussed., Recent Findings: Despite methodological limitations inherent in most studies considered for the current review, as well as the unreplicated nature of some of the more recent findings, self-help tools hold some promise. In particular, self-help interventions that are rooted in evidence-based concepts may be helpful as an add-on to standard interventions and as (initial) therapeutic strategies for those who are presently reluctant to participate in face-to-face treatment., Summary: The current review identifies self-help, which is based on evidence-based concepts, as a promising clinical tool for the treatment of OCD. The current literature suggests that self-help can be a facilitator and aid to standard face-to-face interventions, rather than a rival.

Background: Despite improved treatment options, many people with obsessive-compulsive disorder (OCD) do not seek or even actively avoid therapy due to shame or fear of stigmatization. Self-help treatment is increasingly acknowledged as a means to "treat the untreated" and to motivate patients for face-to-face psychotherapy. Our group has gathered preliminary evidence for the efficacy of a novel self-help approach entitled association splitting (AS) aimed at the reduction of obsessions., Methods: For this study, a total of 46 participants with a likely diagnosis of OCD were randomly allocated to either AS or a waitlist control (WL). Treatment consisted of the self-study of a manual sent via e-mail. At baseline and four weeks later symptoms were assessed online using the self-report version of the Yale-Brown Obsessive-Compulsive Scale (Y-BOCS), the Obsessive-Compulsive Inventory-Revised (OCI-R), and the Beck Depression Inventory (BDI)., Results: A total of 74% of the initial sample took part in the re-assessment. Results were in accordance with prior uncontrolled data indicating that AS is a feasible approach leading to a symptom decline of approximately 25% on the Y-BOCS. The technique also exerted a positive effect on depression (BDI) and the OCI-R subscale obsessive thoughts., Conclusions: The study confirms the feasibility and efficacy of AS for a subgroup of patients with OCD. Ongoing studies explore whether short-term effects are maintained over time and whether therapist-guided therapy may enhance the efficacy of AS., (© 2011 Wiley-Liss, Inc.)

Obsessive-compulsive disorder (OCD) is a heterogeneous disease in terms of manner of onset, dimension of symptoms, and responses to psychological or pharmacological treatments. This paper groups cases of OCD into "effective" and "ineffective" types, based on their responses to exposure and response prevention (ERP). In the next phase, cases in the "effective" category were further broken down into Type A, characterized as readily responding to ERP, and Type B, characterized as not readily responding to ERP. Factors associated with Type B include: 1) below-average intelligence, 2) co-morbidity of other mental disorders, 3) insufficient recognition of irrationality of OCD symptoms, 4) significant difficulties in daily life, 5) insufficient motivation to follow through with ERP, and 6) other personal problems. This paper discusses possible strategies for addressing these factors, and thereby increasing the potential effectiveness of ERP. Next, this paper describes the characteristics and treatment of obsessional slowness as a typical type for which ERP is ineffective. Finally, this paper examines the process of distinguishing between OCD and other mental disorders that do not respond to ERP in spite of showing OC symptoms.

Background: The importance of the therapist's education and experience for the successful behavior treatment of obsessive-compulsive disorder (OCD) has not been investigated. Data on the relative effectiveness of self-controlled versus therapist-controlled in vivo exposure with response or ritual prevention (ERP) have yielded conflicting results. The present study compared the effectiveness of 4 different modes of delivery of ERP in a referred sample of OCD patients., Method: Of the 146 eligible OCD outpatients, 118 patients enrolled in this randomized controlled trial and were randomly assigned to (1) therapist-controlled ERP performed by experienced behavior therapists; (2) therapist-controlled ERP performed by master's students of clinical psychology; (3) self-controlled ERP performed by experienced behavior therapists; and (4) self-controlled ERP performed by master's students of clinical psychology. This trial was performed from January 1999 to January 2005., Results: Our analyses revealed no significant differences in clinical outcome between any of the different modes of delivery of ERP at posttreatment. The different ERP modes of delivery were associated with significant pretreatment to posttreatment improvement on all measurements, with large effect sizes on the primary outcome measure, the Yale-Brown Obsessive Compulsive Scale., Conclusions: Our results indicate that clinically inexperienced master's students with no postgraduate training can be as capable as experienced and certified behavior therapists in treating OCD patients, as long as therapists adhere to a standardized treatment manual and adequate training and supervision is provided. In contrast to other studies, we did not find a supposed benefit of therapist-controlled ERP versus self-controlled ERP in patients with OCD., Trial Registration: www.trialregister.nl Identifier: NTR1444., (© Copyright 2010 Physicians Postgraduate Press, Inc.)

Evidence suggests that the antibiotic d-cycloserine (DCS) enhances the treatment effects of exposure and response prevention (ERP) for Obsessive-Compulsive Disorder (OCD). Further, evidence suggests that the effects of DCS diminish partway through treatment, but it is unclear to what extent. In an effort to evaluate these issues, the current study re-analyzes data from a 10-session randomized controlled trial of ERP+DCS versus ERP+placebo in a sample of 22 adults with OCD. We analyzed repeated-measures mixed models with random slopes and intercepts across different intervals: sessions 1-10, 1-5, and 6-10. The results indicate that the course of ERP was 2.3 times faster over the full 10 sessions for the DCS compared to the placebo group, and nearly six times quicker in the first half of ERP. Further interpretation of the results suggests that DCS does not amplify the effects of ERP, but instead initiates treatment effects sooner in treatment. In addition, DCS does not necessarily lose its effect over repeated use, but instead may exhaust its maximum utility after effectively jump-starting ERP. Ultimately, DCS may provide a means for curtailing treatment costs, decreasing treatment dropout and refusal rates, and enhancing access to care., (Copyright 2010 Elsevier Ltd. All rights reserved.)

The highly stressful conditions of a war zone may exacerbate or trigger a wide variety of symptoms including Obsessive Compulsive Disorder (OCD) once a service member returns home. Service members and new veterans of the Iraq and Afghanistan wars present to treatment with multiple psychosocial concerns and co-morbid psychiatric conditions. Evidence-based treatments including exposure based therapies are commonly recommended for use with returning veterans. Although studies support the efficacy of Exposure Response Prevention (ERP) therapy for treating OCD, eligibility for these studies limits participation to subjects who self-report a well-defined, circumscribed complaint. This approach is not typical of clinic clients who, more often than not, report multiple psychological issues. The following individual case study demonstrates how integrating hypnosis facilitated the cognitive-behavioral ERP therapy and treatment for a patient suffering from OCD.

The aim of the current study was to test the effectiveness of ERP-based 12 weeks group therapy for OCD patients in a community-based, general Norwegian outpatient clinic. The sample consisted of 54 patients diagnosed with OCD. The Yale-Brown Obsessive-Compulsive Scale (Y-BOCS), the Beck Depression Inventory (BDI) and the Spielberger State Anxiety Inventory (STAI-S) were administered before treatment, after treatment and at 3- and 12-month follow-ups. Analyses with mixed models for repeated measurements showed that group behavioural therapy offered to OCD patients significantly improved ratings of obsessive-compulsive symptoms, depression and anxiety. These improvements were maintained at 3- and 12-month follow-ups and an additional reduction in obsessive-compulsive symptoms was observed from post-treatment to 3-month follow-up. However, the delayed effect of therapy was no longer present at 12-month follow-up. The results also revealed that the patients had a lower chance for an increased outcome category (e.g. from unchanged to improved or recovered) with high scores on STAI-S at the given observation times (post-treatment, 3- and 12-months follow-ups). Depressive symptoms (BDI) at post-treatment and follow-ups had no significant influences on the three categories of outcome for OCD. In conclusion, the results indicate that behavioural group therapy can successfully be delivered to patients with considerable comorbidity in a real world setting conducted by therapists with limited training in the CBT., (Copyright (c) 2010 Elsevier Ltd. All rights reserved.)

Despite the efficacy of cognitive-behavioural interventions in improving the experience of obsessions and compulsions, some people do not benefit from this approach. The present research uses a case series design to establish whether mindfulness-based therapy could benefit those experiencing obsessive-intrusive thoughts by targeting thought-action fusion and thought suppression. Three participants received a relaxation control intervention followed by a six-session mindfulness-based intervention which emphasized daily practice. Following therapy all participants demonstrated reductions in Yale-Brown Obsessive-Compulsive Scale scores to below clinical levels, with two participants maintaining this at follow-up. Qualitative analysis of post-therapy feedback suggested that mindfulness skills such as observation, awareness and acceptance were seen as helpful in managing thought-action fusion and suppression. Despite being limited by small participant numbers, these results suggest that mindfulness may be beneficial to some people experiencing intrusive unwanted thoughts and that further research could establish the possible efficacy of this approach in larger samples., (Copyright (c) 2009 John Wiley & Sons, Ltd.)

The Obsessive-Compulsive Beliefs Questionnaire-87 (OBQ-87) has been constructed by leading obsessive-compulsive disorder (OCD) experts to assess dysfunctional beliefs typical for OCD patients. The OBQ-87 has recently been revised (Obsessive-Compulsive Beliefs Questionnaire-44 [OBQ-44]) to improve its psychometric properties. The current investigation entailed two goals: (1) to assess the sensitivity of both Obsessive Beliefs Questionnaire (OBQ) versions to treatment change and other OCD measures; and (2) to assess relations between symptom subtypes, OBQ beliefs and changes in beliefs as a consequence of treatment. One hundred and four patients have completed the OBQ before and after 12 sessions of behaviour therapy. Results suggest that (1) both OBQ versions exhibit an identical medium effect size; (2) overlap between clinical and non-clinical populations limit the use of the OBQ as a primary measure of treatment change; and (3) the symptom dimension obsessions + checking was related to initial OBQ scores, but no symptom dimensions were related to OBQ pre-treatment to post-treatment changes.

Background: Compulsive buyers feel a continual urge to buy things, irrespective of their financial means. Interest in compulsive buying has increased in the last 30 to 40 years. Since excessive buying is a regularly occurring feature of various illnesses encountered in clinical practice, one wonders whether it should be regarded as a sign of the times, as a symptom of a psychiatric illness or as a distinct psychiatric syndrome., Aim: To gain insight into the concept of compulsive buying., Method: We searched the literature via Medline, PubMed and PsycInfo for the period from 1966 to August 2008. results Compulsive buying is a relatively unknown and poorly defined phenomenon, despite its high incidence and high comorbidity. It is characterised by chronic, repetetive behaviour; it occurs mainly among women and should be classified as an impulsive-control disorder nos. Current aetiological models lack explanatory power and, so far, the most successful treatment results seem to have been achieved with behavioural therapy., Conclusion: Compulsive buying should be considered from a neuroscientific perspective. Future research needs to have a neuropsychiatric focus and a contextual psychological and behavioural analytical approach in which inhibition, self-control and rule-governed behaviour play a central role.

Several patients with obsessive-compulsive disorder (OCD) who are refractory to adequate treatment with first-line treatments are considered treatment-resistant. Further surveys were to be implemented to explore the outcome predictors of the antiobsessional response. Such study was aimed at building a model suitable to predict the final outcome of a mixed OCD pharmacologic and nonpharmacologic treatment approaches. We studied 130 subjects with OCD who underwent pharmacologic (with selective serotonin reuptake inhibitors alone or with selective serotonin reuptake inhibitors and risperidone at low dosage) and/or behavioral therapy (using exposure and response prevention techniques). The following variables were used as predictors: symptoms dimension, as resulting from the Yale-Brown Obsessive-Compulsive Scale items factor analysis; neuropsychologic performances; and epidemiologic variables. The treatment response arising from 3 to 6 months of therapy was used as dependent variable. A conventional logistic regression was used to define a previsional model of treatment response and multilayer perceptrons and to supervise an artificial neural network technique. The 46.9% of the sample resulted to be refractory to treatment. Results obtained with the logistic regression model showed that the only predictors of treatment outcome are hoarding symptoms, repeating rituals, and counting compulsions. Furthermore, using all the variables considered in the models, multilayer perceptrons showed highly better predictive performance as compared with the logistic regression models (93.3% vs 61.5%, respectively, of correct classification of cases). Complex interactions between different clinical and neuropsychologic variables are involved in defining OCD treatment response profile, and nonlinear and interactive modeling strategies, that is, supervised artificial neural networks, seem to be more suitable to investigate this complexity than linear techniques.

Neuroimaging studies have suggested that behavior therapy (BT) might change abnormal activity in the frontal-subcortical circuits of the brain in patients with obsessive-compulsive disorder (OCD). However, the results of these studies have been rather inconsistent. The aim of the present study was to use statistical parametric mapping (SPM) analysis to explore the effects of successful BT on regional cerebral blood flow (rCBF) in patients with OCD. Forty-five OCD patients who were treatment-resistant to a single serotonin reuptake inhibitor (SRI) trial were examined. Single photon emission computed tomography (SPECT) using 99mTc-ECD was performed before and after the completion of 12 weeks of BT. Although no significant differences in pre-treatment rCBF were observed between responders and nonresponders to BT, the post-treatment rCBF values in the left medial prefrontal cortex (Brodmann area 10) and bilateral middle frontal gyri (Brodmann area 10) were significantly lower in the responders than in the nonresponders. Furthermore, the baseline rCBF in the bilateral orbitofrontal cortex (OFC) was significantly correlated with the change in the Y-BOCS score among the responders. Our results support the hypothesis that while the OFC may be associated with the BT response, BT may result in changes in rCBF in the medial and middle frontal cortex.

The development of evidence-based treatments for anxiety disorders is a major achievement of clinical psychology, and cognitive behavior therapy is the best-established and most widely used method. The first form of this therapy, behavior therapy, was a combination of Pavlovian and Behavioristic ideas and methods and was particularly successful in reducing fears. The infusion of cognitive ideas in the late 1970s generated the wider and more flexible cognitive behavior therapy that independent agencies in the United States and United Kingdom now recommend as the treatment of choice for most of the anxiety disorders. Remaining theoretical problems and clinical limitations need to be tackled.

There is increasing evidence that obsessive-compulsive disorder (OCD) is associated with a dysfunction of cortico-striato-thalamo-cortical neuronal circuits. In order to examine treatment-related changes in neuronal processes, a drug-naive female patient with OCD (subtype: washing/contamination fear) and an age- and gender-matched healthy control were repeatedly tested using functional magnetic resonance imaging (MRI) during the presentation of a symptom provocation task. Patient-specific visual stimuli of symptom provoking situations were compared with disgust provoking and neutral pictures. FMRI scanning was conducted at the beginning, during and upon completion of an inpatient treatment. During the treatment period of more than eight weeks (combined behavioural and systemic couple therapy) the patient filled out a therapy process questionnaire (TPQ) which was administered daily. Results show a phase transition-like change characterized by a sudden reduction of clinical symptoms as assessed by the Yale-Brown Obsessive Compulsive Scale (Y-BOCS) in the middle of the treatment period. Before the discontinuous symptom reduction occurred, the dynamic complexity of the TPQ-time series increased which might be indicative for a critical instability of the system. The fMRI results at the beginning of the treatment suggest strong activities in various brain regions, especially in the anterior cingulate cortex. The results of the second and third acquisition revealed comparably smaller OCD-related neuronal responses. The results may indicate that important clinical changes are taking place during the psychotherapy process which correspond to changing patterns of brain activation as well as to critical instabilities and phase-transition like phenomena in the time-series of the patient's daily self-report data.

The benefits of cognitive-behavioral treatment for obsessive-compulsive disorder (OCD) have been evidenced by several meta-analyses. However, the differential effectiveness of behavioral and cognitive approaches has shown inconclusive results. In this paper a meta-analysis on the effectiveness of psychological treatment for OCD is presented by applying random- and mixed-effects models. The literature search enabled us to identify 19 studies published between 1980 and 2006 that fulfilled our selection criteria, giving a total of 24 independent comparisons between a treated and a control group. The effect size index was the standardized mean difference in the posttest. The effect estimates for exposure with response prevention (ERP) alone (d(+)=1.127), cognitive restructuring (CR) alone (d(+)=1.090), and ERP plus CR (d(+)=0.998) were very similar, although the effect estimate for CR alone was based on only three comparisons. Therapist-guided exposure was better than therapist-assisted self-exposure, and exposure in vivo combined with exposure in imagination was better than exposure in vivo alone. The relationships of subject, methodological and extrinsic variables with effect size were also examined, and an analysis of publication bias was carried out. Finally, the implications of the results for clinical practice and for future research in this field were discussed.

Background: Obsessional slowness is a rare psychiatric disorder with few treatment options and limited research to date. Some suggest that targeted behavioural interventions may reduce the time taken for functional daily activities., Purpose: To examine whether a behavioural intervention would reduce the amount of time taken for an adolescent with obsessional slowness to walk to class., Methods: A single-subject A-B-A withdrawal design was incorporated into this case study. The treatment involved one-to-one pacing and prompting during the subject's walk to gym class. Walking times to gym class were measured during a baseline phase, during a one-month treatment phase, and during a post-treatment follow-up phase., Findings: The subject's walking times decreased during the treatment phase. Post-treatment walking times suggested a carry-over effect., Implications: This study adds to the sparse evidence on treatments for obsessional slowness and suggests occupation-based treatment options.

The present study was undertaken to estimate the effect of exposure plus response-prevention (E/RP), delivered alone intensively over 5-weeks and without concomitant pharmacotherapy, for children and adolescents with OCD. Twenty children and adolescents with OCD, not receiving medication for this condition, were randomized to E/RP or a wait-list condition. Statistically and clinically significant symptomatic improvement was found in the E/RP group compared with controls, with improvement maintained at follow-up an average of 14 weeks later. Effect size in the main intention-to-treat analysis was 1.23 and in the secondary per protocol analysis was 1.64. This study lends further support to the view that E/RP is an effective treatment for childhood OCD.

Objective: This study examined whether d-cycloserine, a partial agonist at the N-methyl-D-aspartate (NMDA) glutamatergic receptor, enhances the efficacy of behavior therapy for obsessive-compulsive disorder (OCD)., Method: A randomized, double-blind, placebo-controlled trial investigating D-cycloserine versus placebo augmentation of behavior therapy was conducted in 23 OCD patients. Patients first underwent a diagnostic interview and pretreatment evaluation, followed by a psychoeducational/treatment planning session. Then they received 10 behavior therapy sessions. Treatment sessions were conducted twice per week. One hour before each of the behavior therapy sessions, the participants received either D-cycloserine, 100 mg, or a placebo., Results: Relative to the placebo group, the D-cycloserine group's OCD symptoms were significantly more improved at mid-treatment, and the D-cycloserine group's depressive symptoms were significantly more improved at posttreatment., Conclusions: These data provide support for the use of D-cycloserine as an augmentation of behavior therapy for OCD and extend findings in animals and other human disorders suggesting that behavior therapy acts by way of long-term potentiation of glutamatergic pathways and that the effects of behavior therapy are potentiated by an NMDA agonist.

Background: Behavior therapy [exposure and response prevention (ERP)] and cognitive therapy (CT) have proven effective in the treatment of obsessive-compulsive disorder. Direct comparisons between these treatment modalities have exposed no differences in efficacy. However, very little research has been conducted into the differences between the change processes in ERP and CT. This investigation is a first attempt to study change by measuring scores on a weekly basis rather than at specific stages in the treatment and follow-up., Methods: We used the Yale-Brown Obsessive-Compulsive Scale (Y-BOCS) at weekly intervals to rate and compare the severity of the obsessions and compulsions of 61 completers of either CT or ERP. The aim was to ascertain whether the process of change in CT is different from the process of change in ERP. We expected that ERP would primarily affect behavior, thus reducing compulsions first, while CT would primarily affect thought, thus reducing obsessions first., Results: Firstly, no differences were found between ERP and CT with respect to the change process for obsessions and compulsions. Secondly, it emerged that changes in compulsions predicted all treatment effects better than changes in obsessions., Conclusions: These results suggest that reduction of compulsions is the process through which both ERP and CT affect change., (2008 S. Karger AG, Basel)