Exposure And Response Prevention Research Articles

Inference-Based Cognitive Behavioral Therapy versus Cognitive Behavioral Therapy for Obsessive-Compulsive Disorder: A Multisite Randomized Controlled Non-Inferiority Trial

Introduction: Although cognitive behavioral therapy (CBT) effectively treats obsessive-compulsive disorder (OCD), many patients refuse CBT or drop out prematurely, partly because of anxiety regarding exposure and response prevention (ERP) exercises. Inference-based cognitive behavioral therapy (I-CBT) focuses on correcting distorted inferential thinking patterns, enhancing reality-based reasoning, and addressing obsessional doubt by targeting underlying dysfunctional reasoning, without incorporating an ERP component. We hypothesized that I-CBT would be non-inferior to CBT. Additionally, we hypothesized that I-CBT would be more tolerable than CBT. Methods: 197 participants were randomly assigned to 20 sessions CBT or I-CBT and assessed at baseline, posttreatment, and 6 and 12 months’ follow-up. The primary outcome was OCD symptom severity measured using the Yale-Brown Obsessive-Compulsive Scale (Y-BOCS; non-inferiority margin: 2 points). The secondary outcome, treatment tolerability, was assessed using the Treatment Acceptability/Adherence Scale (TAAS). A linear mixed-effects model was used to assess the non-inferiority of the primary outcome and superiority of secondary outcomes. Results: Statistically significant within-group improvements in the primary and secondary outcomes were observed in both treatments. No statistically significant between-group differences in Y-BOCS were found at any assessment point, but the confidence intervals exceeded the non-inferiority threshold, making the results inconclusive. The estimated mean posttreatment TAAS score was significantly higher in the I-CBT group than in the CBT group. Conclusion: While both CBT and I-CBT are effective for OCD, whether I-CBT is non-inferior to CBT in terms of OCD symptom severity remains inconclusive. Nevertheless, I-CBT offers better tolerability and warrants consideration as an alternative treatment for OCD.

Implementation of Cognitive Behavioral Therapy in a Child with Obsessive - Compulsive Disorder: A Case Study

Obsessive-Compulsive Disorder (OCD) is a prevalent child and adolescent psychiatric condition characterized by substantial functional impairments. Cognitive Behavioral Therapy (CBT) has emerged as the primary therapeutic approach for managing mild to moderate cases of OCD in children and adolescents. Significant advancements have been made in applying CBT specifically to this age group in the past decade. Exposure and response prevention (ERP) is a core therapeutic technique grounded in the principle that anxiety tends to diminish through repeated exposure to anxiety-inducing stimuli, leading to a gradual reduction in anxiety response. In the present study, we present the case of a 9-year-old boy with OCD who was treated with CBT. Τhe evaluation of this case highlights the necessity for rigorous behavior analysis to precisely implement exposure therapy and the significance of multidisciplinary intervention in the child's daily life. In the discussion that follows the analysis of the case, parameters such as the differentiation of ERP in children compared to adults, the control of OCD over the rest of the family members and the OCD phenomenology of parents have been discussed. Additionally, the effect of the patient's comorbidity on the treatment outcome and his compliance with homework were also addressed.

Treatment for OCD and Their Effectiveness

This research looks at a variety of aspects related to obsessive-compulsive disorder (OCD), such as symptoms, possible factors diagnosis, and treatment methods. OCD's distinctive ritualistic compulsions, which frequently manifest as uncontrollable thought and behavior patterns, are brought on by distressing obsessions. According to this study neurotransmitter and Corticostriatal circuits abnormalities have been linked to this disorder, although the exact cause is still unknown. Increased susceptibility among blood relations of sick individuals suggests a role for genetics. Obsessions and compulsions are diagnosed based on predetermined criteria that highlight their irrationality and disruptive nature. The connection between obsessive thoughts and anxiety can be broken by a number of treatments, the foundation of which is behavioral therapy. By gradually confronting anxiety-inducing circumstances, exposure and response prevention (ERP) has proven successful. According to this paper the main objectives of cognitive therapy are to address dysfunctional thought processes, such as overestimating threats or taking on excessive responsibility. This paper contends that by cognitive-behavioral therapy (CBT) combining behavioral and cognitive elements is both economical and efficient. The studies under review in this paper demonstrate differences in treatment effectiveness, accentuating the necessity for more studies with larger sample sizes in making definitive judgments on treatment outcomes.

Internet-Delivered Exposure and Response Prevention for Pediatric Tourette Syndrome

Behavior therapy is a recommended intervention for Tourette syndrome (TS) and chronic tic disorder (CTD), but availability is limited and long-term effects are uncertain. To investigate the long-term efficacy and cost-effectiveness of therapist-supported, internet-delivered exposure and response prevention (ERP) vs psychoeducation for youths with TS or CTD. This 12-month controlled follow-up of a parallel group, superiority randomized clinical trial was conducted at a research clinic in Stockholm, Sweden, with nationwide recruitment. In total, 221 participants aged 9 to 17 years with TS or CTD were enrolled between April 26, 2019, and April 9, 2021, of whom 208 (94%) provided 12-month follow-up data. Final follow-up data were collected on June 29, 2022. Outcome assessors were masked to treatment allocation throughout the study. A total of 111 participants were originally randomly allocated to 10 weeks of therapist-supported, internet-delivered ERP and 110 participants to therapist-supported, internet-delivered psychoeducation. The primary outcome was within-group change in tic severity, measured by the Total Tic Severity Score of the Yale Global Tic Severity Scale (YGTSS-TTSS), from the 3-month follow-up to the 12-month follow-up. Treatment response was defined as 1 (very much improved) or 2 (much improved) on the Clinical Global Impression-Improvement scale. Analyses were intention-to-treat and followed the plan prespecified in the published study protocol. A health economic evaluation was performed from 3 perspectives: health care organization (including direct costs for treatment provided in the study), health care sector (additionally including health care resource use outside of the study), and societal (additionally including costs beyond health care [eg, parent's absenteeism from work]). In total, 221 participants were recruited (mean [SD] age, 12.1 [2.3] years; 152 [69%] male). According to the YGTSS-TTSS, there were no statistically significant changes in tic severity from the 3-month to the 12-month follow-up in either group (ERP coefficient, -0.52 [95% CI, -1.26 to 0.21]; P = .16; psychoeducation coefficient, 0.00 [95% CI, -0.78 to 0.78]; P > .99). A secondary analysis including all assessment points (baseline to 12-month follow-up) showed no statistically significant between-group difference in tic severity from baseline to the 12-month follow-up (coefficient, -0.38 [95% CI, -1.11 to 0.35]; P = .30). Treatment response rates were similar in both groups (55% in ERP and 50% in psychoeducation; odds ratio, 1.25 [95% CI, 0.73-2.16]; P = .42) at the 12-month follow-up. The health economic evaluation showed that, from a health care sector perspective, ERP produced more quality-adjusted life years (0.01 [95% CI, -0.01 to 0.03]) and lower costs (adjusted mean difference -$84.48 [95% CI, -$440.20 to $977.60]) than psychoeducation at the 12-month follow-up. From the health care organization and societal perspectives, ERP produced more quality-adjusted life years at higher costs, with 65% to 78% probability of ERP being cost-effective compared with psychoeducation when using a willingness-to-pay threshold of US $79 000. There were no statistically significant changes in tic severity from the 3-month through to the 12-month follow-up in either group. The ERP intervention was not superior to psychoeducation at any time point. While ERP was not superior to psychoeducation alone in reducing tic severity at the end of the follow-up period, ERP is recommended for clinical implementation due to its likely cost-effectiveness and support from previous literature. ClinicalTrials.gov Identifier: NCT03916055.

Use of an Augmented Exposure and Response Prevention Procedure in the Treatment of Obsessive-Compulsive Disorder: A Case Report

This case report describes the assessment and treatment of a 21-year-old male with obsessive-compulsive disorder (OCD) using an intensive exposure and response prevention (ERP) treatment program. The patient and his father received daily 2-hour ERP sessions delivered across 10 consecutive weekdays, and monthly follow-up appointments. In addition to the condensed treatment schedule, ERP procedures were augmented to address ongoing family conflict and depressive symptoms. To the best of the our knowledge, this is the first study to include such treatment adaptations within the context of intensive ERP for an adult with OCD. Results indicated target behaviors decreased over the 2-week intensive treatment phase and were maintained during 4 months of follow-up. Ancillary outcomes reported by the patient and his father included more frequent engagement in activities of daily living and improved family communication. Outcomes of this study provide an important step toward establishing recommendations regarding ERP session frequency, especially among patients with comorbid disorders.

Co-occurring PTSD in intensive OCD treatment: Impact on treatment trajectory vs. response.

Obsessive-compulsive disorder (OCD) and co-occurring posttraumatic stress disorder (PTSD) is associated with more severe and chronic OCD. However, findings regarding treatment effectiveness of cognitive behavioral treatment (CBT) with exposure and response prevention (ERP) with this comorbidity are mixed. Research aimed at understanding the precise barriers to OCD treatment effectiveness for individuals with co-occurring PTSD may help elucidate unique treatment needs. The current study used linear regression and latent growth curve analysis comparing treatment response and trajectory from patients with OCD (n=3083, 94.2%) and OCD+PTSD (n=191, 5.2%) who received CBT with ERP in two major intensive OCD treatment programs. Although patients with OCD+PTSD evidenced similar trajectories of overall severity change, patients at one site required nearly 11 additional treatment days to achieve comparable reduction in OCD severity. Further, at the dimensional level, those with OCD+PTSD had poorer treatment response for unacceptable thoughts and symmetry symptoms. The moderate effect for unacceptable thoughts, indicating the widest gap in treatment response, suggests these symptoms may be particularly relevant to PTSD. Findings are limited by a naturalistic treatment sample with variation in treatment provision. Findings emphasize caution in using a one-size-fits-all approach for patients with co-occurring OCD+PTSD within intensive OCD treatment programs, as broadly defined outcomes (e.g., reduction in overall severity) may not translate to reduction in the nuanced symptom dimensions likely to intersect with trauma. Unacceptable thoughts and symmetry symptoms, when co-occurring with PTSD, may require a trauma-focused treatment approach within intensive OCD treatment.

Psychotherapeutic Approach to the Treatment of a Youth with Schizophrenia and OCD: A Case Report

Schizophrenia and obsessive-compulsive disorder (OCD), which are often first detected during adolescence, commonly co-occur. Individually, they are some of the most complex and challenging psychiatric disorders to manage. This article reports on a case of an adolescent with co-morbid schizophrenia and OCD and the use of exposure and response prevention (ERP) for the treatment of OCD in the context of management of his schizophrenia and addressing developmental issues. This contributed to the overall stabilization of the youth’s condition.

Behavioral avoidance as a factor in concentrated exposure and response prevention for obsessive-compulsive disorder

Although exposure and response prevention (ERP) is recommended for adults with obsessive-compulsive disorder (OCD), some recipients do not fully respond while others improve and subsequently relapse. Identifying factors associated with poor outcomes is therefore highly important. We investigated behavioral avoidance as one potential factor. Data came from a large randomized controlled trial that delivered a concentrated ERP protocol over the course of four consecutive days in accord with the Bergen 4-Day Treatment (B4DT). Avoidance was assessed with the auxiliary item from the Yale-Brown Obsessive-Compulsive Scale (YBOCS). Although behavioral avoidance did not predict acute outcome at immediate post-treatment, patients with substantial avoidance behaviors prior to treatment had worse long term (12-month) outcomes (increased OCD severity and greater functional impairment), after controlling for OCD severity at baseline. Avoidance significantly decreased from pre-to post-treatment but increased from post-treatment to 3-month and 12-month follow-up. Change in avoidance from post-treatment to 3-month follow-up predicted subsequent OCD worsening at 12-months, after controlling for change in global OCD severity. Results suggest that avoidant patients can benefit from concentrated ERP but may be at increased risk of poorer long-term outcomes. Future work should investigate strategies to identify and ameliorate worsening avoidance to reduce relapse.

A network analysis of mechanisms of change during exposures over the course of intensive OCD treatment

Exposure and response prevention (ERP) is an evidence-based treatment for obsessive-compulsive disorder (OCD). Theories for how it works vary in their emphasis on active mechanisms of change. The current study aimed to clarify mechanisms of change in ERP for OCD using network analysis, comparing ERP networks at the start and end of intensive treatment (partial hospital and residential). In our sample of 182 patients, the most central node in both networks was engagement with exposure, which was consistently related to greater understanding of ERP rationale, higher willingness, and less ritualization, accounting for all other variables in the network. There were no significant differences in networks between the start and end of treatment. These results suggest that nonspecific parameters like facilitating engagement in exposures without ritualizing and providing a clear rationale to clients may be key to effective treatment. As such, it may be useful for clinicians to spend adequate time underscoring the need to eliminate rituals to fully engage in exposure tasks and explaining the rationale for ERP prior to doing exposures, regardless of theoretical orientation. Nonetheless, findings represent group-level statistics and more fine-grained idiographic analyses may reveal individual-level differences with respect to central mechanisms of change. Other limitations include demographic homogeneity of our sample.

Effectiveness of One Videoconference-Based Exposure and Response Prevention Session at Home in Adjunction to Inpatient Treatment in Persons With Obsessive-Compulsive Disorder: Nonrandomized Study.

Therapist-guided exposure and response prevention (ERP) for the treatment of obsessive-compulsive disorder (OCD) is frequently conducted within clinical settings but rarely at places where patients are usually confronted with OCD symptom-provoking situations in daily life (eg, at home). This study aimed to investigate patients' views on 1 ERP session at home via videoconference and its impact on treatment outcome. A total of 64 inpatients with OCD received 1 session of therapist-guided videoconference-based ERP at home in adjunction to a multimodal inpatient treatment between 2015 and 2020. Compared with 64 age- and sex-matched controls who received a multimodal inpatient treatment without 1 session of videoconference-based ERP at home, patients who received 1 session of videoconference-based ERP in adjunction to a multimodal inpatient treatment showed stronger reductions in OCD symptom severity from admission to discharge. Before the videoconference-based ERP session, patients reported high rationale credibility and treatment expectancy. After the videoconference-based ERP session, patients reported medium-to-high positive mood as well as depth and smoothness of the session, and they perceived the working alliance as high. Results highlight the importance of administering therapist-guided ERP sessions in patients' natural environment to enhance treatment response in OCD. Videoconference-based ERP as add-on to treatment as usual is, therefore, a promising approach to facilitate the application of ERP in patients' natural environment and foster the generalization of ERP conducted in clinical settings.

Cognitive-Behavioral Therapy for Obsessive-Compulsive Disorder: A Brief Review

Treatment for obsessive-compulsive disorder (OCD) has drastically improved since behavioral models emerged over 60 years ago. Exposure and response prevention (ERP), the “gold standard” psychotherapy for OCD, is highly efficacious, yet a significant portion of patients either cannot access it or continue to experience residual symptoms following treatment. A growing body of research suggests other cognitive-behavioral approaches, particularly cognitive therapy, demonstrate comparable treatment effects to ERP. This brief review outlines research-supported cognitive-behavioral therapies for OCD including behavioral, cognitive, and “third wave” approaches such as metacognitive therapy and acceptance and commitment therapy. The theoretical foundations as well as an overview of research findings for each therapy are summarized. Recommendations for improving outcomes and access to treatment are also provided. [ Psychiatr Ann . 2024;54(3):e75–e79.]

Feeling more confident to encounter negative emotions: The mediating role of distress tolerance on the relationship between self-efficacy and outcomes of exposure and response prevention for OCD

BackgroundWhile exposure and response prevention (ERP) is the first-line treatment for obsessive-compulsive disorder (OCD), up to half of patients do not effectively respond. In an effort to better understand the mechanisms behind ERP, the inhibitory learning model emphasizes the roles of increasing perceived self-efficacy and distress tolerance. While self-efficacy and distress tolerance have separately been shown to predict OCD symptoms and treatment outcomes, no studies have assessed their joint effects in ERP. The current study examined distress tolerance as a mediator of the relationship between self-efficacy and ERP outcomes. MethodsPatients in an intensive ERP-based treatment program (N = 116) completed weekly self-report measures. ResultsOver the course of treatment, as OCD symptoms reduced, self-efficacy and distress tolerance both significantly increased. Importantly, increases in self-efficacy and distress tolerance mediated each other in explaining symptom reduction, suggesting a possible bi-directional effect. LimitationsThe temporal relationship between changes in self-efficacy and distress tolerance is worthy of further investigation. In addition, the current sample had limited racial diversity and might not be representative of patients receiving lower levels of care. Findings merit replication to be ascertained of their reliability. ConclusionsFindings suggest that during ERP, patients gain confidence in their abilities both to cope with general challenges and to withstand distress, potentially helping them engage with exposures and overcome initial fears. These findings provide support for the inhibitory learning model and highlight the mechanistic roles of self-efficacy and distress tolerance in ERP. Clinical implications to target both in treatment are discussed.

Family-Based Exposure and Response Prevention for Obsessive-Compulsive Disorder: A Case Study

Pediatric obsessive-compulsive disorder (OCD) affects approximately .25%–3% of children and if left untreated, can cause significant impairment for the child and family. Cognitive behavioral therapy with exposure and response prevention (ERP) is the gold-standard treatment for pediatric OCD. When using ERP with children and adolescents, it is essential to assess and target family factors in treatment in order to help the youth make therapeutic progress. The following case study illustrates the successful implementation of family-based ERP in a young female with contamination OCD. It further highlights strategies for targeting family accommodation and family conflict within the course of treatment.

Improvement in Distress Tolerance as a Mechanism of Symptom Reduction During Intensive Exposure and Response Prevention–Based Treatment for OCD

Exposure and Response Prevention (ERP) is an effective treatment for obsessive-compulsive disorder (OCD), yet the specific underlying mechanisms by which ERP improves symptoms remain unclear. Initial theories suggested that habituation to triggering events and stimuli was the key therapeutic factor in ERP, while other theories highlight the role of developing the ability to tolerate distress, rather than reduction of distress. The current study examined improvements in distress tolerance as a mechanism of OCD, anxiety, and depressive symptom reductions during an ERP-based intensive program. Participants (N = 180) completed weekly measures of distress intolerance, and symptom severity of OCD, anxiety, and depression. Using Multi-Level Structural Equation Modeling, we found that participants experienced significant weekly decreases in OCD, anxiety, and depressive symptom severity across the course of their ERP-based treatment. Weekly reductions in OCD symptom severity were partially accounted for by weekly improvements in participants’ ability to tolerate distress, particularly for obsession symptoms. This effect was also significant for anxiety and depressive symptom severity, above and beyond the effects of weekly reductions in OCD symptom severity. The current study suggests improving the ability to tolerate distress represents a transdiagnostic mechanism of symptom severity reduction in OCD, anxiety, and depressive psychopathology via intensive ERP-based psychotherapy programming. Limitations and future directions for improving treatments for OCD, anxiety, and depressive symptoms are discussed.

A Short Review on Practice of Mindfulness as Treatment in Obsessive– Compulsive Disorder

ABSTRACT This article reviews the present research regarding the practice of mindfulness as a treatment for obsessivecompulsive disorder (OCD) which has been an area of growing interest for more than a decade. Mindfulness has been practiced in the treatment of OCD as mindfulness-based stress reduction, and mindfulness-based cognitive therapy in other different forms. This article aims to evaluate the effectiveness of mindfulness as an independent intervention and integrative treatments incorporating mindfulness. There is satisfactory evidence to support mindfulness in the treatment of OCD, specifically for those who have not benefited from traditional innervations. It can be used with other forms of psychotherapy such as cognitive behavioral therapy and exposure and response prevention (ERP), which might help in the prevention of relapse and espousing the individual to the stimulus during ERP. However, there is no sufficient evidence for it to be believed a stand-alone treatment. The current literature recommends that mindfulness may be best considered as adjunctive treatment within an existing treatment framework, but further research is required to further examine its effect and clarify its contribution toward change. Further, this review suggested a wide-ranged extensive review of the effectiveness of mindfulness in OCD by ruling out the existent limitations.

Effectiveness of Mindfulness-Based Interventions in the Treatment of Obsessive-Compulsive Disorder

Obsessive-compulsive disorder (OCD) is a chronic and debilitating mental health condition characterized by persistent intrusive thoughts (obsessions) and repetitive behaviors (compulsions). While cognitive-behavioral therapy (CBT) involving exposure and response prevention (ERP) and pharmacotherapy with selective serotonin reuptake inhibitors are first-line treatments, many individuals continue to experience persistent symptoms or achieve only partial remission. Mindfulness-based interventions (MBIs), which aim to cultivate present-moment awareness and acceptance of internal experiences, have emerged as a promising adjunctive or alternative treatment approach for OCD. This review synthesizes the existing literature on the use of MBIs, such as mindfulness-based cognitive therapy (MBCT) and mindfulness-based stress reduction (MBSR), for OCD. Potential mechanisms by which MBIs may benefit individuals with OCD include improved attentional regulation, enhanced emotion regulation skills, reduced cognitive inflexibility through promoting cognitive defusion, and decreased experiential avoidance of intrusive thoughts and urges. Several studies have demonstrated the efficacy of MBIs in reducing OCD symptom severity, and providing insights into how MBIs can increase acceptance, improve emotion regulation, and foster a greater sense of control over symptoms.

Intensive Exposure Therapy for an Individual With History of Self-Harm and Suicidality

Practitioners may hesitate to treat patients with a history of nonsuicidal self-injury (NSSI) and suicidal thoughts and behaviors (STBs) using exposure therapy due to concerns that exposures will increase these risk-related behaviors. However, when NSSI/STBs are exacerbated by distress associated with anxiety disorders or obsessive-compulsive disorder (OCD), lack of treatment can worsen disability. This case report describes the treatment of a 14-year-old gender-fluid individual with symptoms of multiple anxiety disorders, OCD, and borderline personality disorder (including emotion dysregulation, chronic suicidality, and NSSI). Treatment involved dialectical behavioral therapy (DBT) for “stage one” of treatment, including maintaining behavioral control over self-harm and suicidal behaviors, followed by intensive exposure and response prevention (ERP) during “stage two” of treatment. Upon discharge, the client had maintained an absence of NSSI/STBs, demonstrated reductions in anxiety and OC symptoms, observed further decreased familial accommodation, and improved daily functioning. In addition, the client’s parents exhibited an improved capacity to regulate their own emotions (before responding to the client), more validating responses, and reduction in familial accommodation. This case report supports the feasibility, efficacy, and safety of exposure therapy for individuals in “stage two” of DBT and highlights the role of exposure as an important emotion regulation strategy to reduce OCD and anxiety symptoms in patients with a history of self-harm and suicidality. Challenges, successes, and future directions are discussed.

Obsessive-Compulsive Disorder in Children and Adolescents.

Obsessive-compulsive disorder (OCD) in children and adolescents is a neurobehavioral condition that can lead to functional impairment in multiple domains and decreased quality of life. We review the clinical presentation, diagnostic considerations, and common comorbidities of pediatric OCD. An overview of the biological and psychological models of OCD is provided along with a discussion of developmental considerations in youth. We also describe evidence-based treatments for OCD in childhood and adolescence, including cognitive behavioral therapy (CBT) with exposure and response prevention (ERP) and pharmacotherapy. Finally, research evaluating the delivery of CBT in different formats and modalities is discussed, and we conclude with suggestions for future research directions.

Exposure and response prevention versus stress management training for adults and adolescents with obsessive compulsive disorder: A randomized clinical trial

ObjectiveThough exposure and response prevention (ERP) is a well-proven treatment for OCD across the lifespan, prior RCTs have not studied adolescent and adult patients with the same ERP protocol relative to an active comparator that controls for non-specific effects of treatment. This approach assesses differences in the effect of OCD-specific exposures in affected adolescents and adults and in response to ERP compared to a stress-management control therapy (SMT). MethodsThis assessor-blinded, parallel, 2-arm, randomized, ambulatory clinical superiority trial randomized adolescents (aged 12–18) and adults (24–46) with OCD (N = 126) to 12 weekly sessions of ERP or SMT. OCD severity was measured before, during and after treatment using the child or adult version of the Yale-Brown Obsessive Compulsive Scale (C/Y-BOCS), depending on participant age. We predicted that ERP would produce greater improvement in OCD symptoms than SMT and that there would be no significant post-treatment differences across age groups. ResultsERP (n = 63) produced significantly greater improvements on C/Y-BOCS scores at post-treatment than SMT (n = 63) (Effect size = −0.72, CI = −0.52 to −0.91, p < .001). ERP also produced more treatment responders (ERP = 86%, SMT = 32%; χ2 = 46.37, p < .001) and remitters than SMT (ERP = 39%, SMT = 7%; χ2 = 16.14, p < .001). Finally, there were no statistically significant post-treatment differences in C/Y-BOCS scores between adolescents and adults assigned to ERP. ConclusionA single ERP protocol is superior to SMT in treating both adolescents and adults with OCD. OCD-specific therapy is necessary across the lifespan for optimal outcomes in this highly disabling disorder, though non-specific treatments like SMT are still all-too-commonly provided.

Remission and Relapse Across Three Years in Pediatric Obsessive-Compulsive Disorder Following Evidence-Based Treatments

To examine relapse rates following remission in a 3-year follow-up study in pediatric patients with obsessive-compulsive disorder (OCD) treated with cognitive-behavioral therapy (CBT) in a first step, and either continued CBT or sertraline (randomized selection) in a second step. Participants (N= 269) fulfilled DSM-IV OCD criteria with a mean severity on the Children's Yale-Brown Obsessive Compulsive Scale (CY-BOCS) of 24.6 (SD= 5.1) and were included in analyses according to intent-to-treat principles. CBT used manualized exposure and response prevention (ERP) during both steps 1 and 2, and step 2 sertraline medication used flexible dosing. The follow-up schedules were timed to 6, 12, 24, and 36 months following step 1 CBT. Remission was defined as a CY-BOCS score≤10 and relapse as an elevated CY-BOCS score≥16 in those who had remitted. A good third of our patients were in stable and full remission at all examinations (n= 98, 36.4%). Further, some in remission following treatment (n= 36, 13.4%) had mild OCD at some examinations. Relapses during follow-up were not uncommon (n= 28, 10.4%), but in many patients these improved again (n= 10, 3.7%) and were in remission at the final 3-year follow-up. Furthermore, a considerable proportion (n= 50, 18.6%) of the patients were initial non-remitters to the treatment but achieved remission at some point during the follow-up. In addition, 11.5% (n= 31) had persistent OCD but reached remission by the last follow-up. Finally, a smaller segment of our sample (9.7%, n= 26), did not attain remission at any point during the study. Our outcome paints a more promising picture of pediatric OCD long-term outcome than previous studies have done. However, both relapse rates and the presence ofinitial non-remitters andpersistent OCD show that treatments need improvement, particularly for those who respond slowly, partially, or not at all. The lack of a general psychiatric interview at follow-up is a marked limitation. Nordic Long-term Obsessive compulsive disorder (OCD) Treatment Study; https://www.isrctn.com; ISRCTN66385119.