Cognitive-behavioral therapy for OCD encompasses three treatment types: (1) exposure and response prevention (ERP), (2) cognitive therapy, and (3) relaxation training. Of the three, only ERP has been shown to be consistently effective in reducing OCD symptom severity (Shafron, 1998; Baer and Greist, 1997; Marks, 1997). Cognitive therapy is the changing of false beliefs regarding risk and responsibility, thereby challenging the reality of obsessions and the necessity for compulsions (Emmelkamp and Beens, 1991). It is generally viewed as ineffective if used as the sole treatment for OCD (Neziroglu et al., 2000) but may be helpful in facilitating participation in ERP (Shafron and Somers, 1998). Relaxation therapy is used mainly to manage anxiety during exposure but has not been shown to have direct benefits for the obsessive-compulsive symptoms (March, 1995).
Exposure and response prevention for OCD involves (1) daily exposure to cues avoided because of their inducing discomfort and compulsive rituals and (2) maintaining exposure and not ritualizing for at least an hour or until the discomfort slowly subsides (Greist, 1996; March, 1995). A minimal trial of ERP consists of 10 to 20 hours of treatment with both exposure and response prevention (Baer and Greist, 1997), with in vivo exposure being preferred over imaginal exposure (Foa et al., 1985). The strategies employed must be tailored to the patient's specific symptoms. Contamination fears, symmetry rituals, counting/repeating, hoarding, and aggressive urges are amenable to ERP, but the technique is not generally appropriate for pathological doubting, or pure obsessions, such as scrupulosity or violent images. Of note, obsessional slowness and hoarding symptoms are difficult to treat with either behavioral therapy or medications (Wolff and Rapoport, 1988). Exposure with response prevention has been reported to produce long-lasting benefits, particularly when booster sessions are utilized to address migration of symptoms and relapses brought on by stress (Greist, 1996).
Therapist-directed ERP has been shown to be the most effective means of treating OCD (Abramowitz, 1998). However, the shortage of trained therapists and expense of therapist-directed ERP mandated the development of alternative strategies. Several self-help programs for behavior therapy have been developed, including computer-and telephone-administered programs (Baer and Greist, 1997; Clark et al., 1998). Self-administered workbooks have also proven successful for both adults (Van Noppen et al., 1997) and pediatric patients (March et al., 1994; March and Mulle, 1998). In general, ERP appears to confer similar benefits in the pediatric population as it does for adults (March et al., 2001). The child must be old enough to understand fully the goals and requirements of treatment and to tolerate the discomforts inherent to exposure.
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