Key takeaways: CBT that includes an exposure response prevention (E-RP) component remains the non-pharmacological treatment of choice for obsessive-compulsive disorder (OCD); research advances highlight the importance of family for the treatment of OCD in adults; ‘third wave’ interventions including acceptance and commitment therapy (ACT) offer new options for patients Internet CBT helps cross barriers to achieving effective treatment, including geographic distance and lack of physician resources In addition to pharmacotherapy, psychotherapy plays an equally important role in the treatment of obsessive-compulsive disorder (OCD). In a new study published in Psychiatry Australia, researchers update the evidence on psychological treatment approaches for OCD. CBT has an unassailable status Cognitive behavioral therapy is a structured, cognitively oriented, short-course psychotherapy approach used to address psychological disorders such as depression and anxiety, as well as psychological problems caused by irrational cognitions. It focuses on the patient’s irrational cognition and eliminates undesirable emotions and behaviors by changing the patient’s thinking and behavior. CBT with an exposure response blocking (E-RP) component remains the preferred non-pharmacological treatment for OCD, and Meta-analyses have confirmed the efficacy of this treatment for OCD, with evidence consistently showing superiority over wait-list and placebo treatments. The development of a cognitive model of OCD has extended the therapeutic principles of E-RP. A meta-analysis evaluating the efficacy of E-RP therapy, cognitive therapy (CT), and E-RP combined with CT for OCD showed similar effect sizes for all three therapies, and moderate improvements in secondary outcome indicators such as depression and social adjustment. Since these instruments technically overlap in the treatment of OCD, the absence of significant differences between cognitive and behavioral treatments is not unexpected. There is previous evidence that the introduction of CT may reduce treatment dropout rates; however, a recent study comparing E-RP and CT did not support this finding: treatment effects and dropout rates were comparable for both therapies. However, after a one-year follow-up, patients treated with E-RP had significantly lower scores on the Yale-Brown Obsessive Compulsive Scale (Y-BOCS) than the CT group. There are few studies in this area with follow-up beyond 12 months, and one study showed no significant change in patients’ Y-BOCS scores during the 2-year follow-up period, but subjects in the E-RP group generally had lower scores than those in the CT group. Importantly, 50% of the patients were rated as recovered (recovered) during the 2-year follow-up period, which supports the long-term efficacy of CBT. Clearly, there is strong empirical support for the efficacy of CBT for OCD. However, as with pharmacotherapy, not all patients respond positively to CBT; even when they do, the degree of symptom reduction is inconsistent. An analysis sought to assess the ameliorative effect of cognitive or behavioral treatments on OCD symptoms, with five studies meeting inclusion criteria involving 300 individuals and a Y-BOCS score of 14 as the threshold. The studies showed an overall recovery rate of 50%, with an additional 11% of subjects rated as having improved symptoms and 38% having no significant change in symptoms. Using the more stringent criterion of asymptomatic recovery, a Y-BOCS score of <7, the percentage of subjects who met this criterion was 27%. Although more than 60% of subjects who completed treatment showed clinically meaningful symptom change, a proportion sufficient to support the efficacy of CBT, the results also showed clinically meaningful response variability, and some studies also assessed predictors and moderators of response variability. A systematic review highlighted a range of factors associated with poor outcome, including hoarding disorder, higher levels of anxiety, higher OCD symptoms, negative personal emotional status, and unemployment. Although co-morbidities were not associated with poor CBT regression overall, some researchers have noted that specific co-morbid disorders may have a negative impact on treatment regression. The significance of family in treatment In recent years, there has been increasing interest in "family accommodation" for adults with OCD as an important factor influencing treatment outcome. The importance of family accommodation in the treatment of children and adolescents with OCD is widely accepted, and CBT has made extensive use of family members in the treatment of children with OCD. family accommodation is also present in a high proportion of adults with OCD. In a study that included 97 adult OCD patients and their families, family members reported that they provided daily psychological validation for patients (47%), participated in rituals (35%), and helped them avoid sources of anxiety (43%). In a naturalistic study, 72% of families reported the presence of family reconciliation, and of those families, 46% reported that it occurred at least daily. For patients with OCD who received medication, higher levels of family reconciliation were associated with poor regression at 12 months of follow-up. Partners of the 20 adults with OCD seeking treatment also had some degree of family reconciliation, a condition associated with higher symptom severity and functional impairment, as well as poorer relationship satisfaction and higher levels of perceived criticism. Importantly, family reconciliation was associated with higher symptom severity after treatment. Other than the above findings, there are few studies on CBT using family members to treat adults with OCD. Given the apparent ceiling effect in the current treatment of OCD with CBT, it is surprising that family factors were not included when exploring treatment regression. Uncontrolled and controlled studies have consistently shown that family-based interventions are superior to individual-specific treatment alone. A recent open-label study enrolling a total of 21 patients treated with CBT for OCD showed that approximately 68% of patients achieved good functional status after treatment and that these gains were maintained at months 6 and 12 of follow-up. Calculations showed that 94% of patients showed reliable improvement after treatment, and 81% were rated as reliably improved at months 6 and 12 of follow-up. Although the results have yet to be replicated and expanded, it is worth noting that the involvement of family members will further enhance the efficacy of CBT for OCD. "The development of alternative interventions to CBT and the rise of the 'third wave' of interventions is a major problem in the treatment of OCD with E-RP: the large number of patients who experience anxiety due to the impending fearful stimuli and who refuse treatment or shed prematurely. ' interventions have risen to provide patients with a more acceptable alternative to traditional therapies. Among these, Acceptance and Commitment Therapy (ACT) has shown therapeutic potential. In a recent study, patients with OCD were randomized to either the ACT group or the progressive relaxation training group. Subjects in both groups showed significant improvement after treatment and at three months of follow-up; however, subjects in the ACT group showed greater improvement in OCD symptoms and secondary indicators of depression. no patients in the ACT treatment group explicitly refused treatment. In contrast to the traditional reliance on stimulus exposure, ACT focuses on "increasing psychological resilience and values-based action in the face of difficult emotions and thoughts". From a behavioral perspective, ACT does not differ significantly from E-RP, except for a different emphasis. iCBT: Overcoming Geographic and Resource Constraints CBT remains the most effective psychological intervention for OCD. However, for rural and remote areas, it is often difficult for patients to access effective treatment due to geographic location or lack of trained therapists. Recent advances in the treatment of OCD include CBT programs delivered via the Internet (iCBT), which often provide patients with access to clinician support or contact. Significant efficacy of iCBT and similar clinical improvement rates across guided programs have been reported; however, for patients with co-morbid depression, iCBT has not been significantly more effective than controls. Current evidence suggests that iCBT is a viable option for patients who are unable to access treatment due to distance or lack of trained physicians. In conclusion, CBT that includes an E-RP component remains the first choice for non-pharmacological treatment of OCD. Its efficacy has been consistently reliable and significant over time and across different treatment modalities. Recent advances highlight the importance of including others of importance to patients, such as family members, in the treatment of OCD, while providing preliminary evidence to support CBT programs delivered via the Internet. A "third wave" of CBT interventions, including ACT, is flourishing, making CBT more accessible to patients who find traditional interventions too anxiety-provoking.