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WJ P

World Journal of
Psychiatry
World J Psychiatr 2012 December 22; 2(6): 86-90
ISSN 2220-3206 (online)
© 2012 Baishideng. All rights reserved.

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doi:10.5498/wjp.v2.i6.86

EDITORIAL

Obsessive-compulsive disorder: Evidence-based treatments
and future directions for research
Caleb W Lack
Caleb W Lack, Department of Psychology, University of Central
Oklahoma, Edmond, OK 73034, United States
Author contributions: Caleb W Lack solely contributed to this
paper.
Correspondence to: Caleb W Lack, PhD, Assistant Professor, Department of Psychology, University of Central Oklahoma,
Edmond, OK 73034, United States. clack@uco.edu
Telephone: +1-405-9745456 Fax: +1-405-974851
Received: February 17, 2012 Revised: September 14, 2012
Accepted: September 21, 2012
Published online: December 22, 2012

Suggestions for future avenues of research are also
presented. These are primarily focused on (1) increased
dissemination of effective therapies; (2) augmentation
of treatments for those with residual symptoms, both
for psychotherapy and pharmacotherapy; and (3) the
impact of comorbid disorders on treatment outcome.

Abstract

Peer reviewer: Feryal Cam Celikel, MD, Associate Professor
of Psychiatry, Gaziosmanpasa University School of Medicine,
60100 Tokat, Turkey

© 2012 Baishideng. All rights reserved.

Key words: Obsessive-compulsive disorder; Evidencebased psychological practice; Cognitive-behavioral
therapy; Psychopharmacology

Over the past three decades, obsessive-compulsive
disorder (OCD) has moved from an almost untreatable,
life-long psychiatric disorder to a highly manageable
one. This is a very welcome change to the 1%-3% of
children and adults with this disorder as, thanks to advances in both pharmacological and psychological therapies, prognosis for those afflicted with OCD is quite
good in the long term, even though most have comorbid disorders that are also problematic. We still have far
to go, however, until OCD can be described as either
easily treatable or the effective treatments are widely
known about among clinicians. This review focuses on
the current state of the art in treatment for OCD and
where we still are coming up short in our work as a
scientific community. For example, while the impact of
medications is quite strong for adults in reducing OCD
symptoms, current drugs are only somewhat effective
for children. In addition, there are unacceptably high
relapse rates across both populations when treated with
pharmacological alone. Even in the cognitive-behavioral
treatments, which show higher effect sizes and lower
relapse rates than drug therapies, drop-out rates are at
a quarter of those who begin treatment. This means a
sizable portion of the OCD population who do obtain effective treatments (which appears to be only a portion
of the overall population) are not effectively treated.

WJP|www.wjgnet.com

Lack CW. Obsessive-compulsive disorder: Evidence-based
treatments and future directions for research. World J Psychiatr
2012; 2(6): 86-90 Available from: URL: http://www.wjgnet.com/2220-3206/full/v2/i6/86.htm DOI: http://dx.doi.
org/10.5498/wjp.v2.i6.86

INTRODUCTION
Thirty years ago, being diagnosed with obsessive-compulsive disorder (OCD) was about the closest thing the psychiatric world had to being given a life sentence. In addition to being seen as extremely rare, prognosis for those
with a diagnosis of OCD was very poor, with no effective truly pharmacological or psychological treatments
available[1]. Today, however, a diagnosis of OCD does not
carry this loss of hope for the future and poor treatment
outcomes. Instead, clinicians now have at their disposal
both pharmacological and psychological treatments that
are remarkably effective for the majority of patients[2].
Still, though, there are further advances that need to be
made, to continue improving treatment effectiveness and
patient outcomes.

86

December 22, 2012|Volume 2|Issue 6|

In Bali. Different primary O/C are also associated with certain patterns of comorbidity. younger children will not be able to recognize that their obsessions and compulsions are both unnecessary (e.46[40]). In terms of QoL. on the other hand are especially likely to be diagnosed with personality disorders. For example.g. academic difficulties. repeating. Those with hoarding cluster symptoms.g. checking. and agoraphobia. or a need to seek reassurance or confess[5]. and dirt and contamination worries in the United States[13. the presence of comorbid diagnoses predict quality of life (QoL) more so than OCD severity itself in both children[28] and adults[29]. cultural influences on symptom expression. As such. sleep problems. there are medication differences seen (for a review see[43]). Overall. hoarding symptoms are most often associated with GAD and tic disorders. Children and adolescents are also more likely to include family members in their rituals and can be highly demanding of adherence to rituals and rules. routinized behaviors. while adolescents are often able to report multiple obsessions and compulsions. There are also a fairly substantial number of “sub-clinical” cases of OCD (around 5% of the population[10]).12]. significantly impair functioning and/or cause distress[3. Almost all adults and children with OCD report that their obsessions cause them significant distress and anxiety and that they are more frequent as opposed to similar. While OCD is equally present in males and females in adulthood. and citalopram) or the non-selective SRI clomipramine differ among each other in terms of effectiveness in either adults or pediatric patients[39. ritualistic behaviors (compulsions) which are time consuming. There is also a very high relapse rate seen across numerous studies (between 24%-89%[41]). disruptive behavior disorders. where symptoms are either not disturbing or not disruptive enough to meet full criteria and yet are still impairing to some degree. a person with OCD is less likely to be married. but 5 min in scalding water is too much) in nature. while those with contamination/cleaning symptoms are more likely to be diagnosed with an eating disorder. while type of religious upbringing has been related to different types of primary obsessions. Youth show problematic peer relations. Another known difference is that patients who have OCD with comorbid tics respond bet- 87 December 22. in both adults and youth[30]. Across subtypes of OCD. troubling thoughts (obsessions). there is a lower QoL in pediatric females than males[28]. compulsions often occur without the patient being able to report their obsessions. major depression. Common obsessions include contamination fears. persons with OCD report a pervasive decrease compared to controls[28].40]. washing hands for 15-20 s is fine. particularly Cluster C disorders.. however. Among men. straightening. paroxetine. for example. Unlike many adults. but it is unclear if it has the same effect in adults. most treatment responders show residual symptoms and impairments.. and participate in fewer recreational activities than matched peers[32. Subsequent compulsions serve to reduce this associated anxiety/distress. Interestingly. obsessive-compulsive personality disorder. even with effective medication.g.com EMPIRICALLY SUPPORTED TREATMENTS There are both pharmacological and psychological treatments for OCD that are supported by research evidence[35-38]. the need for symmetry. the presence of tics appears to decrease selective SRI effects in children[44]. you don’t really need to wash your hands) and extreme (e. religious obsessions in Muslim communities. forbidden thoughts (e. Overall. In adults. seeking reassurance. Unlike in adults. PTSD. and more likely to report impaired social and occupational functioning[34]. tapping or rubbing.91[39]). Up to 75% of persons with OCD also present with comorbid disorders[8]. SRIs can be successfully supplemented with adjunctive antipsychotics. more likely to be unemployed. praying. but in adults similar disruptions are reported[29].wjgnet. Metanalyses and reviews have not shown that the five selective SRIs (including fluoxetine. OCD is characterized by intrusive.. and avoidance[6]. though. panic disorder. children need not view their symptoms as nonsensical to meet diagnostic criteria[7]. body dysmorphic disorder. Unfortunately. bipolar disorder. fluvoxamine. aggressive aggressions in South American samples. When compared to other anxiety disorders and unipolar mood disorders. In the United States. counting. the lifetime prevalence rate of OCD is estimated at 2. youth with OCD are generally more impaired than WJP|www. leading to disruptive and oppositional behavior and even episodes of rage[25]. it almost always corresponds with a massive increase in anxiety and distress. and repetitive. heavy emphasis on somatic symptoms and need to know about members of their social network is found[17].18-20]. however. with research showing few epidemiological differences across different countries[13-15] and even between European and Asian populations[16].23]. Presentation of OCD symptoms is generally the same in children and adults[24]. and other anxiety disorders[27]. When an obsession occurs.Lack CW. intrusive thoughts in persons without OCD[31]. exactness and order.3% in adults[8] and around 1%-2. Common compulsions include: cleaning/washing. touching. religious/moralistic concerns. major depression. but even then only a third of patients will show improvements and there are serious health concerns with their long-term usage[42]. There are. There are some differences in comorbidity as well[22]. 2012|Volume 2|Issue 6| . sexual or aggressive). worries about harm to self or others. the most prevalent comorbids are social anxiety. but only moderate effect sizes in youth (0. In young children. Research and treatments in OCD adults with the same type of symptoms[26].3% in children and adolescents under 18[9]. The most common in pediatric cases are ADHD. the disorder is heavily male in pediatric patients[21]. and alcohol abuse[10]. and skin picking are more often observed[8. pharmacology with serotonin reuptake inhibitors (SRIs) shows large effect sizes in adults (0. There is strong evidence that cultural differences do not play a prominent role in presence of OCD[11. nail biting.4].33]. sertraline. but in women social anxiety. confessing. such as emphasis on cleanliness and order in Judaism.. Primary symmetry/ordering symptoms are often seen with comorbid tics.

both more research on how certain comorbidity patterns impact treatment and the most optimal therapeutic methods to address the differential patterns should be conducted[70]. particularly for CBT and EX/RP. certain steps can and should be undertaken to improve dissemination.. the time to sit back and pat our collective backs in triumph. Diagnostic and statistical December 22. A series of exposures are then carefully planned through collaboration between the therapist and client and implemented both in session and as homework between sessions[49-52]. is cognitive-behavioral therapy (CBT). the resultant compulsions. Accommodation by family members in pediatric clients has been found to be predictive of poorer treatment response as well[54]. Although a substantial body of literature has shown that for most anxiety disorders comorbidity does not diminish the impact of treatment (see for a review[67]). remains an issue[59]. Research and treatments in OCD ter to neuroleptic drugs than those who have OCD without tics[43].62] and youth with OCD[63] show promising results and suggest the need for further trials and refinement of methodology and dosage. Murphy TK. CONCLUSION FUTURE DIRECTIONS FOR RESEARCH Although this may sound trite. 4th ed. Preliminary results in adults[61. As educational efforts aimed at training new mental health practitioners alone are not sufficient. New York. One promising approach involves WJP|www. while OCD and comorbid GAD was shown to increase dropout rates and decrease treatment response[65]. Storch EA. NY: Guilford Press. or new strategies for exposure-reluctant patients may need to be developed. group therapy that uses CBT and EX/RP has been shown to be equally as effective as individual therapy in some studies[55] but less effective in others[56]. treatment dissemination. In contrast. The course of therapy generally lasts between 12-16 sessions. This is not. While reasons for this are many.47]. dissemination of both the safety and effectiveness of exposurebased therapies to both the general public and existing. already licensed mental health clinicians (psychiatrists. 2007: 164-215 Lack CW. Having primary OCD with comorbid PTSD has been found to decrease response rate[68].66]. partial response is frequent with many continuing to exhibit residual OCD symptoms. efforts have been made to incorporate technology into the treatment of adult OCD with a number of successes (for a review see[57]). differences in response to CBT have been found across populations. particularly to medication monotherapy. and social workers) must be made a priority. As such. More than just monsters under the bed: Assessing and treating pediatric OCD. In terms of psychotherapy augmentation. For instance. Although the treatment of OCD is remarkably advanced compared to 30 years ago. there is truly not a better time in history to have OCD than the present. given the multiple effective pharmacological agents. with effect sizes ranging from 1. I have outlined several potential avenues of research and how they will benefit those who continue to suffer from OCD despite the advances of the last 30 years. Therapy may need to be augmented with some sort of motivational enhancement module for those unwilling or too distressed to engage in exposures[64]. the primary issue in need of addressing would be the high drop-out rate.72[46. there are a number of areas where improvements can be made. and an everincreasing understanding of the disorder itself. With the continued efforts of clinicians and researchers the world over. and ratings of the distress caused by both the obsession and if they are prevented from performing the compulsion. Intriguingly. Clinical handbook of psychological disorders. It is superior to medications alone. it is important to examine what impact that has on treatment[65. the next 30 years should see a further explosion in our ability to decrease symptomatology and increase the QoL of those with this fascinating disorder. While there is a lower relapse rate than in medications (12% vs 24%-89%). and there are increasing efforts to extend these findings into the realm of pediatric OCD. Obsessive-compulsive disorder. in part due to reluctance to engage in exposures and poor insight[53]. others studies have shown no negative impact on OCD treatment from comorbid anxiety problems in adults[65] or children[66. it is important to note that up to 25% of patients will drop out prior to completion of treatment due to the nature of treatment[48].69]. Pharmacological treatment augmentation options remain limited and under-researched. the presence of a very effective psychological therapy. psychologists. we must continue to advance treatment for OCD in both adults and youth. Instead. research on OCD is mixed. although many patients respond to first-line interventions to some degree.Lack CW. Such methods could include novel combinations of pre-existing treatments (e.g. particularly exposure with response prevention (EX/RP)[45]. As in the medication research.com REFERENCES 1 2 3 88 Franklin ME. given the high comorbidity rates seen in persons with OCD. targeting the extinction learning core to EX/RP with d-cycloserine[60]. counselors. a partial agonist at the NMDA receptor in the amygdala. beginning with a thorough assessment of the triggers of the obsession. Third.wjgnet. In: Barlow DH. Second. First. Foa EB. For persons with mild OCD. For instance. computer-assisted self-treatment has been shown to be very effective (see for a review[57. Above. 2012|Volume 2|Issue 6| . however. it has been seen that those with hoarding cluster symptoms respond less well to CBT. in both adults and children and backed by numerous clinical trials.16-1. 23: 54-57 American Psychiatric Association. The psychological treatment of choice for OCD. Psychiatric Times 2006. editor.58]). combining parent management training with CBT for youth with OCD and disruptive behavior[71] or the use of motivational enhancement techniques[72-74]).

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