Obsessive compulsive disorder is a common anxiety disorder, thought to be chronic and impairing for the individual. OCD is characterized mainly by two features, obsessions and compulsions. The obsessions and the compulsions can occur separately, either the one of them, or most commonly both (Abramowitz, Taylor & McKay, 2009).
Obsessions are recurrent and intense thoughts, images, or impulses that can be intrusive and cause high anxiety to the individual (Abramowitz, Taylor & McKay, 2009; Doron & Moulding, 2009). These thoughts or images are not just normal worries about life problems (Abramowitz, Taylor & McKay, 2009). The individual recognize that these thoughts are products of his mind, that are excessive or unreasonable, and tries to suppress them, ignore them or disable them by doing some other thoughts or actions (Abramowitz, Taylor & McKay, 2009; Geffken, Storch, Gelfand, Adkins & Goodman, 2004). Some common examples of obsessive thoughts are thoughts or images of harming loved ones, doubts about not switching off the lights or other electrical equipment or not locked the doors, worries about being infected from viruses (contamination), somatic worries and aggressive or sexual thoughts (Abramowitz, Taylor & McKay, 2009; Geffken, Storch, Gelfand, Adkins & Goodman, 2004).
Compulsions are repetitive behaviors or mental acts, that the individual feel forced to do in order to prevent or reduce anxiety or prevent a dreadful event that is usually caused by the unwanted and intrusive obsession (Abramowitz, Taylor & McKay, 2009; Geffken, Storch, Gelfand, Adkins & Goodman, 2004). However, most of the time the compulsive acts are excessive or irrelevant to what they tend to prevent (Abramowitz, Taylor & McKay, 2009). Examples of compulsive behaviors are repetitive hand washing, ordering or checking and compulsive thoughts are repetitive praying, counting, or thinking good things to replace the bad thoughts (Abramowitz, Taylor & McKay, 2009). Sometimes compulsions occurr according to rigid rules, for example the individual has to check if the light switch is off by switching it on and off for three times (Abramowitz, Taylor & McKay, 2009). The compulsions that can be seen by others are called overt compulsions (e.g. checking if a door is locked), and the compulsions that are mental acts and cannot be seen (e.g. mentally repeating a phrase or praying) are called covert.
1.3. DSM – Criteria
Usually, the diagnosis of OCD is made through clinical interviews, where the therapist has to evaluate the symptoms of the client and decide if the disorder occurs or not based on the Diagnostic and Statistical Manual of Mental Disorders IV (DSM-IV-TR) criteria (Abramowitz, Taylor & McKay, 2009). The criteria in the DSM-IV-TR, fourth edition, text revision (APA, 2000) are the following:
A. Either obsessions or compulsions: Obsessions as defined by (1), (2), (3), and (4):
(1) recurrent and persistent thoughts, impulses, or images that are experienced, at some time during the disturbance, as intrusive and inappropriate and that cause marked anxiety or distress (2) the thoughts, impulses, or images are not simply excessive worries about real-life problems (3) the person attempts to ignore or suppress such thoughts, impulses, or images, or to neutralize them with some other thought or action (4) the person recognizes that the obsessional thoughts, impulses, or images are a product of his or her own mind (not imposed from without as in thought insertion). Compulsions as defined by (1) and (2): (1) repetitive behaviors (e.g., hand washing, ordering, checking) or mental acts (e.g., praying, counting, repeating words silently) that the person feels driven to perform in response to an obsession, or according to rules that must be applied rigidly (2) the behaviors or mental acts are aimed at preventing or reducing distress or preventing some dreaded event or situation; however, these behaviors or mental acts either are not connected in a realistic way with what they are designed to neutralize or prevent or are clearly excessive. B. At some point during the course of the disorder, the person has recognized that the obsessions or compulsions are excessive or unreasonable. Note: This does not apply to children. C. The obsessions or compulsions cause marked distress, are time consuming (take more than 1 hour a day), or significantly interfere with the person’s normal routine, occupational (or academic) functioning, or usual social activities or relationships. D. If another Axis I disorder is present, the content of the obsessions or compulsions is not restricted to it (e.g., preoccupation with food in the presence of an Eating Disorder; hair pulling in the presence of Trichotillomania; concern with appearance in the presence of Body Dysmorphic Disorder; preoccupation with drugs in the presence of a Substance Use Disorder; preoccupation with having a serious illness in the presence of Hypochondriasis; preoccupation with sexual urges or fantasies in the presence of a Paraphilia; or guilty ruminations in the presence of Major Depressive Disorder). E. The disturbance is not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition. Specify if: With Poor Insight: if, for most of the time during the current episode, the person does not recognize that the obsessions and compulsions are excessive or unreasonable. (p. 462-463).
1.4. Prevalence and other statistics
OCD has a lifetime prevalence of 2-3% in the general population (Abramowitz, Taylor & McKay, 2009; Foa et al., 2005). There is no difference in the disorder distribution between men and women, although the typical age of onset tends to be younger for men in comparison to women and in children the disorder is most commonly found in boys than girls (Abramowitz, Taylor & McKay, 2009; Geffken, Storch, Gelfand, Adkins & Goodman, 2004). In contrast, Doron & Moulding (2009) reported a slight predominance of prevalence in women. OCD symptoms are associated with severe occupational, social and family dysfunction where people with OCD are less possible to be married and be employed (Abramowitz, Taylor & McKay, 2009; Storch et al., 2008). The onset is usually gradual, appears in early life and tends to be chronic (Abramowitz, Taylor & McKay, 2009; Geffken, Storch, Gelfand, Adkins & Goodman, 2004). The common age of onset is during adolescent or early adulthood, although there is evidence that OCD can be occurred earlier in childhood, even at age 4 or in late adulthood (Abramowitz, Taylor & McKay, 2009; Geffken, Storch, Gelfand, Adkins & Goodman, 2004). The clinical presentation of the disorder is similar between adults and children (Abramowitz, Taylor & McKay, 2009). Most of the OCD patients, around 50%, present comorbid disorders and the most common comorbid disorder is major depression (Doron & Moulding, 2009). Other common disorders in people with OCD are comorbid anxiety disorders and alcohol abuse or dependence (Abramowitz, Taylor & McKay, 2009).
2. Cognitive Behavioral Therapy
2.1. Conceptualization of the disorder
The most empirical supported model of OCD is the cognitive behavioral approach (CBT) (Abramowitz, Taylor & McKay, 2009). CBT supports that the obsessions and the compulsions are born from specific dysfunctional beliefs, which the strength of them influences the possibility of developing these obsessions and compulsions (Abramowitz, Taylor & McKay, 2009). Specifically, the dysfunctional beliefs, underlying negative appraisals of harmful thoughts, have an important role in maintaining the OCD, because they lead in discomfort and to the developing of control strategies, like compulsions (Jonsson, Hougaard & Bennedsen, 2011).
The baseline of CBT is that most of the people experience unwanted thoughts and unpleasant images or impulses (Abramowitz, Taylor & McKay, 2009; Veale, 2007). The content of the above is similar to the content of clinical obsessions, so the difference is in the frequency, intensity and discomfort caused by the thoughts (Abramowitz, Taylor & McKay, 2009; Doron & Moulding, 2009). An example, given by Abramowitz, Taylor & McKay (2009), is the disturbing image of stabbing one’s child with a knife. Commonly, if people experienced such an image, would think of it as an unpleasant but meaningful event, with no harmful consequences. However, a person who develops an obsession will think of it as highly important and threatening, for example that the fact that he is having these images will lead him to lose control and kill his child in reality (Abramowitz, Taylor & McKay, 2009). Thus, the misconception of those normal thoughts causes anxiety to the individual and motivates him to suppress or remove the unwanted thought (Abramowitz, Taylor & McKay, 2009; Doron & Moulding, 2009). This may happen by replacing the bad image with a good one or prevent the occurrence of a harmful event associated with the bad thought (Abramowitz, Taylor & McKay, 2009). In Abramowitz, Taylor & McKay (2009) example, the person may be avoiding knifes and repeatedly checking the safety of the child (Abramowitz, Taylor & McKay, 2009). That’s how the compulsive rituals develop. This fusion between thoughts/images and reality, i.e. the fact that the person thinks that he will act on the thought or that he may be acted on it in the past, is called “thought-action fusion” or “magical thinking” (Veale, 2007). According to CBT, the reason why compulsions become persistent and excessive is because they are reinforced by the direct reduction of anxiety and removal of the distressing thought (Abramowitz, Taylor & McKay, 2009). These compulsions, also, prevent the person from understanding that his estimate is unrealistic, meaning that nothing wrong will happen if he thinks of something bad (Abramowitz, Taylor & McKay, 2009).
Similarly, the compulsive act reminds to the individual the harmful thoughts and thus it causes their reoccurrence (Abramowitz, Taylor & McKay, 2009; Doron & Moulding, 2009). For example, a person that repeatedly washing his hands, he keeps reminding himself that he may be contaminated (Abramowitz, Taylor & McKay, 2009).
Also, it must be considered that an effort to distract someone from his harmful thought can increase the frequency of them, mainly because the distracter is used as a reminder of the thought (Abramowitz, Taylor & McKay, 2009). Also, compulsions increase the person’s responsibility, meaning that when after the compulsive act the person sees that indeed no harmful event has happened, he feels responsible for removing the threat, and thus he feels that he must keep doing the compulsive act (Abramowitz, Taylor & McKay, 2009; Veale, 2007). OCD individuals think that the harm, that may occur in the self, loved-ones or other person, will occur due to what they might do or fail to do (Veale, 2007). So, this belief that they can and should prevent the harm is what leads to compulsions and avoidance behaviors (Veale, 2007).
2.2. CBT techniques
The most common techniques of CBT, in order to break the dysfunctional response cycle of OCD (intrusions, negative appraisals, anxiety, dysfunctional responses (compulsions), increase frequency of intrusions and over again), are exposure and response prevention (EX/RP) (Doron & Moulding, 2009). These techniques are shown to be effective in the treatment of OCD (Geffken, Storch, Gelfand, Adkins & Goodman, 2004). Briefly, the EX/RP techniques direct the person to face the feared stimulus and experience the anxiety without performing any rituals (Brauer, Lewin & Storch, 2011).
In exposure techniques the individual has to simply face his fear, by repeatedly and gradually exposing to increasingly feared stimuli, in order to decrease his anxiety (Doron & Moulding, 2009; Geffken, Storch, Gelfand, Adkins & Goodman, 2004). An example of this, according to Doron & Moulding (2009), is a person, who worries about causing harm by putting fire at his house, and he is gradually exposed to the feared stimuli, e.g. toaster, heater, iron etc.
The exposure method involves the “situational exposure” or “exposure in vivo”, where the individual faces actual feared stimuli (exposure in real life), like knifes, cemeteries, or touching the water faucets in a restaurant (germs obsession) (Abramowitz, Taylor & McKay, 2009; Foa, 2010). The stimuli are presented in an order, beginning with the less distressing and progressing to more distressing stimuli (Foa, 2010).
The other exposure method is the “imaginal exposure”, where the individuals are asked to imagine the feared stimuli (Foa, 2010). Thus, they encounters obsessional images, thoughts and doubts that provoke anxiety, like a loved-one’s death, the idea of hurting someone by mistake (Abramowitz, Taylor & McKay, 2009). It is used, primarily, to help people face the harmful consequences that they fear will happen, if they don’t do the rituals (Foa, 2010). If we thing of an example, like someone imaging that got a disease by not washing his hands, it is obvious that these consequences cannot be created in reality (Foa, 2010).
2.2.2. Response prevention
Response prevention, or else ritual prevention, includes directing the person to refrain from the rituals that he believes prevent the feared consequences or reduce the anxiety caused by the obsession (Foa, 2010). These rituals or compulsive behaviors are performed to reduce the anxiety and so they are retained through negative reinforcement (Geffken, Storch, Gelfand, Adkins & Goodman, 2004). An example of ritual is washing the hands every time you touch a restaurant faucet fearing that you are going to be contaminated by a disease (Foa, 2010). This technique helps the person to realize that anxiety decreases without performing any ritual and that no harmful consequences will happen (Foa, 2010).
These commonly used techniques help the person learn that anxiety decreases naturally, that the harmful consequences are unlikely to happen and therefore challenge his dysfunctional belief system (Doron & Moulding, 2009). Finally, the main aim of EX/RP techniques is to make the individual understand that his “obsessional anxiety does not persist indefinitely” and that the rituals are not necessary for preventing any harm (Abramowitz, Taylor & McKay, 2009).
2.3. Effectiveness of CBT
CBT including EX/RP was found to be effective in a number of clinical trials in the treatment of OCD, and thus it’s generally recommended as the first treatment of choice (Jonsson, Hougaard & Bennedsen, 2011). Regards to the EX/RP techniques, the results from the Yale-Brown obsessive compulsive disorder scale (Y-BOCS) studies, which measures the severity of the OCD symptoms, showed that these techniques had the best outcomes in comparison with other forms of psychotherapy and placebos (Abramowitz, Taylor & McKay, 2009). Also, about 75% of the patients adhere to the therapy and according to the National Collaborating Centre of Mental Health (2005) these people have a significant improvement (as cited in Veale, 2007). The effects were found both in adults and children (Abramowitz, Taylor & McKay, 2009). For the individuals that undergo EX/RP, the outcomes of this treatment last even up to 2 years (Abramowitz, Taylor & McKay, 2009).
2.3.1. CBT compared with medication
CBT with exposure and response prevention is considered to be the most efficacious treatment of OCD (Foa et al., 2005). However a lot of researches have investigated the efficacy of medications against exposure and response prevention methods, like serotonin reuptake inhibitors (SRIs), clomipramine, selective reuptake inhibitors (SSRIs) etc (Foa et al., 2005). Some of them were also found efficacious, while others were found not so beneficial for some patients who continued to be symptomatic (Foa et al., 2005) In this paper, some significant findings of those studies are going to be discussed.
Generally, although both CBT and some forms of pharmacotherapy found to be effective treatments of OCD, the findings from a lot of studies show that CBT improve OCD symptoms more than pharmacotherapy, it has more durability after treatment withdrawal and provides more safety (Abramowitz, Taylor & McKay, 2009; Geffken, Storch, Gelfand, Adkins & Goodman, 2004; Storch et al., 2010).
According to Anand, Sudhir, Math, Thennarasu & Reddy (2011), the two most recommended treatments for OCD is the medication with Serotonin Reuptake Inhibitors (SRIs) and CBT including exposure (EX) and response prevention (RP). Both of them seem to be equal effective. However, some patients found to be unresponsive to the medication treatment or have a minimal response, so the alternative choice of those patients it’s the supplementation with CBT. In their study, Anand, Sudhir, Math, Thennarasu & Reddy (2011), reported some studies that invested the efficacy of CBT in those patients. In all of them, it was found that CBT was effective in reducing the symptom severity. However, those studies examined patients with two or more SRI trials. Therefore, Anand, Sudhir, Math, Thennarasu & Reddy (2011), run a study to examine the efficacy of CBT in adults, non-responders to multiple SRI trials (at least two), and also examined the outcome in periodic follow-up assessment up to 1 year post-treatment. The results of the study showed that CBT, including EX/RP is effective for OCD patients who were non-responsive to SRI trials, while the outcome of the treatment could be seen after a period of 1-year. Similar studies have shown that this kind of treatment reduces the symptoms of OCD and improves the socio-occupational functions of the individuals (Anand, Sudhir, Math, Thennarasu & Reddy, 2011).
Other studies, examining pharmacotherapy with SRIs and CBT with EX/RP found that CBT has greater effects than SRIs alone (Storch et al., 2008). A meta-analysis investigating the differences between combined treatments of EX/RP and SRIs and monotherapies of both, found no benefit of combination over monotherapies (Abramowitz, Taylor & McKay, 2009). Additionally, CBT combined with SRIs was found to be as effective as CBT alone (Geffken, Storch, Gelfand, Adkins & Goodman, 2004). Another study, conducted by Franklin, Abramowitz, Bux Jr., Zoellner & Feeny (2002), explored 56 patients, of whom 55% received CBT alone and the other 45% received CBT with SRIs. The results indicated that CBT was helpful whether or not patients were receiving pharmacotherapy. Thus, Franklin, Abramowitz, Bux Jr., Zoellner & Feeny (2002) suggested that patients who don’t already taking medication prior to CBT initiation, they don’t need to begin, to benefit from treatment.
The reason why SRIs cannot work in combination with CBT is because they differ in their form of action. While this medication inhibits serotonin levels, CBT tries to provoke anxiety in the individuals by exposing them to the feared stimuli and make them remain in the situation until the anxiety decreases (Geffken, Storch, Gelfand, Adkins & Goodman, 2004). This kind of medication, as benzodiazepines too, prevents the individuals from reaching a high level of anxiety and thus they decrease the effectiveness of CBT (Geffken, Storch, Gelfand, Adkins & Goodman, 2004). Other medications, such as SSRIs that reduce anxiety but they allow to the person to feel some form of arousal, do not interfere with CBT model and thus its effectiveness (Geffken, Storch, Gelfand, Adkins & Goodman, 2004).
A well-known study is Foa’s and his colleagues’ (Foa et al., 2005), where they compared EX/RP with clomipramine, the combination of EX/RP and clomipramine, and placebo. The results showed that EX/RP alone and EX/RP with clomipramine had no difference in reducing symptoms, but both of them had greater results than clomipramine alone (Foa et al., 2005). Placebo had the lowest scores (Foa et al., 2005).
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Another form of pharmacotherapy is the use of agents that accommodate fear extinction. Research found that N-methyl-D-aspartate (NMDA) glutamate receptors are important for conditioned fear extinction (Abramowitz, Taylor & McKay, 2009). A NMDA agonist is D-cycloserine which was found to facilitate fear extinction (Abramowitz, Taylor & McKay, 2009). According to Abramowitz, Taylor & McKay (2009) three studies had examined the differences between EX/RP with C-cycloserine and EX/RP with placebo in reducing OCD symptoms. The first one hadn’t showed difference between the two, but in the other two studies was found that D-cycloserine had better and more rabid outcomes than placebo with combination with EX/RP (Abramowitz, Taylor & McKay, 2009). This result show that although other forms of medication have poor outcomes or even negative outcomes when combined with EX/RP, this form of medication can be useful in EX/RP treatment, in order to accelerate the outcomes of it, especially in the early stages of therapy (Abramowitz, Taylor & McKay, 2009).
2.3.2. CBT compared with other psychotherapies and techniques
The view that EX/RP are the most efficacious and best available techniques for treating OCD, was partly formed by several studies that had examined the differences of EX/RP and other forms of therapy.
Lindsay, Crino & Andrews (1997), examined 18 adults with OCD, when they were receiving EX/RP or anxiety management and found that EX/RP were related with significantly greater reductions of OCD symptoms (as cited in Storch et al., 2008). Additionally, in the study of Simpson et al. (2008), it was found that EX/RP reduced OCD symptoms more than stress management training, which is another form of treatment. This study was consistent with previous studies, and indicates that the use of EX/RP is the best treatment solution in OCD (Simpson et al., 2008).
However, other forms of CBT found to have a good effectiveness in reducing OCD symptoms. One of them is group cognitive behavioral therapy (GCBT), which seems to have equal effects as individual CBT (Raffin, Fachel, Ferrao, Pasquoto de Souza & Cordioli, 2009).
There is evidence that the effectiveness of EX/RP in symptom reduction is due to the specific techniques used in therapy (e.g. exposed to feared stimuli), while other characteristics, like expectation and attention are found in all psychological treatments (Abramowitz, Taylor & McKay, 2009).
According to other psychotherapies, like psychodynamic therapy, there are no controlled trials of this therapy for OCD, and thus no evidence to support its efficacy. NICE does not recommend this approach for the treatment of OCD (Brauer, Lewin & Storch, 2011)
2.3.3. Effectiveness in Adults
A lot of studies have been made about CBT as a treatment in adults, regarding the number of sessions, the session format, the effectiveness of cognitive restructuring and the combination with medication (Brauer, Lewin & Storch, 2011). A review study of 12 CBT studies with adults found that 83% of the adults had a significant response in treatment and the benefits gained lasted in a long follow-up period (Brauer, Lewin & Storch, 2011).
A study examining the differences between intensive (daily) and weekly session of CBT in adults with OCD, found that intensive CBT had an advantage of efficacy at post-treatment (Storch et al., 2008). Additionally, intensive CBT found to improve 60-80% of OCD adults and 50-80% of their symptoms (Saxena et al., 2009). Also, intensive CBT was found to cause significant changes in their brain function after 4 weeks of treatment, which is considered a very rapid outcome compared to SRIs or weekly CBT (Saxena et al., 2009).
About 75% of adults with OCD have at least one comorbid disorder (Brauer, Lewin & Storch, 2011). Some findings reported that some comorbidities affect negatively the CBT outcome in adults (Brauer, Lewin & Storch, 2011). The most common comorbid disorder is depression and the studies showed that high rates of depression are related with poorer outcome (Keeley, Storch, Merlo & Geffken, 2008; Storch et a., 2010). That’s because depression affects the level of motivation and active engagement in treatment techniques (causes amotivation and pessimism), some things that are necessary in CBT method, including the exposure and response prevention tasks (Franklin, Abramowitz, Bux Jr., Zoellner & Feeny, 2002). However, the results are mixed and this is maybe due to the type and severity of comorbid disorders in clinical trials (Brauer, Lewin & Storch, 2011).
2.3.4. Effectiveness in Children & Adolescents
As in adults, CBT has shown to be high effective in the treatment of OCD in children and in adolescents and more effective than other modes of treatment, such as relaxation training (Brauer, Lewin & Storch, 2011).
A study in 2004 examined the effects of CBT, SSRIs and the combination of these in children and in adolescents and found that children with OCD should receive treatment with CBT alone, or CBT with SSRIs (Barton & Heyman, 2012). Additionally, in 2006, the National Institute of Health and Clinical Excellence (NICE), summarized the evidenced-based treatments for children with OCD, and psychoeducation and CBT were recommended as treatments of the first choice, while CBT with SSRIs was recommended for more severe cases (Barton & Heyman, 2012).
An important factor, found to increase the positive outcomes of CBT, is the participation of families in therapy (Brauer, Lewin & Storch, 2011). There are a numerous of reasons why family has an important role in enchasing symptoms’ reduction or contributing to symptoms severity. Poor insight in children has shown to cause limited treatment response in children (Brauer, Lewin & Storch, 2011). However, the family can help the child by increasing his motivation level to face obsessional triggers and reduce compulsions (Brauer, Lewin & Storch, 2011). Parents can take the role of co-therapists, encourage and reward the children for their progress (Barton & Heyman, 2012). On the other hand, family may contribute to the maintaining of symptoms severity by trying to help the child with avoiding the feared stimuli and making a “safe” environment without distressing stimuli, in order to avoid child’s anxiety (Brauer, Lewin & Storch, 2011). Obviously, by doing that, they contribute negatively to the CBT outcome (Brauer, Lewin & Storch, 2011). In order to eliminated and identify the effect of family on treatment outcome, the family-based cognitive behavioral therapy was developed.
A study examining 40 children and adolescents who received intensive or weekly family-based CBT, found that similarly with adults, intensive CBT had greater efficacy at post-treatment and in 3-months follow-up (Storch et al., 2008).
D-cycloserine, the medication found to enhance extinction of feared learning and therefore cause more rabid and enduring treatment benefits, could be also useful to children, who have difficulties engaging in EX/RP tasks (Brauer, Lewin & Storch, 2011). Storch et al. made a study where they examined the efficacy of DCS over placebo in children receiving CBT for OCD (as cited in Brauer, Lewin & Storch, 2011). They found that DCS was responsible for reduced symptoms severity (Brauer, Lewin & Storch, 2011). Generally, for children who have severe OCD or have shown limited response to CBT including the EX/RP tasks, there is evidence suggesting their treatment with medication, like SSRIs, in order to reduce their symptoms and improve their general functioning (Barton & Heyman, 2012). In conclusion, medication in children have been used in cases that there was unavailability of CBT. It is not acceptable to use medication in children with OCD, unless they are unable or unwilling to receive psychological treatment (Barton & Heyman, 2012).
As in adults, comorbid disorders in children affect negatively the effectiveness of CBT. The prevalence is similar to adults, meaning around 75% of the OCD children have a comorbid disorder (Brauer, Lewin & Storch, 2011). Comorbid disorders in children have been linked with poor CBT and pharmacotherapy response and high relapse rates. Specifically, similar to adults, depression has linked with attenuated CBT and disruptive behavior with low response and remission rates (Brauer, Lewin & Storch, 2011).
Although exposure and response prevention techniques are often effective, they often provoke anxiety to the individuals and therefore about 25% of them drop out of treatment or refuse it (Abramowitz, Taylor & McKay, 2009; Veale, 2007; Storch et al., 2010). From the other 75%, who continue receiving treatment, only 25-40% reach full recovery, while most of the receivers remain somewhat symptomatic (Brauer, Lewin & Storch, 2011; Storch et al., 2010). A meta-analytic review study of 16 studies with EX/RP in OCD patients, showed that 48% of them had symptom reduction but the majority of them remain symptomatic after treatment (Keeley, Storch, Merlo & Geffken, 2008). Similarly, in another review study, examining the CBT for pediatric OCD, found that although there were significant reductions of OCD symptoms, 50-75% of the patients remained symptomatic even after the full treatment course (Keeley, Storch, Merlo & Geffken, 2008).
Reasons of failure of CBT include lack of motivation, poor insight, low tolerance for discomfort caused by the strategies, not doing the homework, few hours on the exposure, assess to trained professionals and the presence of a comorbid disorder that affects the treatment seeking behavior, like major depression or avoidant personality disorder (Brauer, Lewin & Storch, 2011; Geffken, Storch, Gelfand, Adkins & Goodman, 2004). Patients with OCD that have depression as a comorbid disorder and they have low motivation to reduce their rituals, have poor outcomes in CBT treatment (Geffken, Storch, Gelfand, Adkins & Goodman, 2004; Veale, 2007). Thus, although CBT was found to be more effective than pharmacotherapy, in case of depression, medication for depression prior CBT treatment, it may be more beneficial (Geffken, Storch, Gelfand, Adkins & Goodman, 2004). Additionally, medication prior CBT initiation is more appropriate for patients with severe symptoms (Brauer, Lewin & Storch, 2011). Thus, symptom great severity may be a predictor for poor prognosis in treatment (Doron & Moulding, 2009). Also, patients with a personality disorder, such as schizotypal personality disorder, may have problems in therapy (Geffken, Storch, Gelfand, Adkins & Goodman, 2004; Veale, 2007). In case of motivation, patients who have poor insight and are convinced that their concerns are real, have poorer outcome in CBT (Geffken, Storch, Gelfand, Adkins & Goodman, 2004). Another factor that implicates in treatment outcome and predicts poorer outcome, is family factor (family dysfunction and accommodation), and that’s why modified treatments have been developed, like cognitive behavioral family therapy (Doron & Moulding, 2009; Keeley, Storch, Merlo & Geffken, 2008).
Some researchers reported that patients with more obsessions than compulsions may confront difficulties in CBT, while CBT techniques, like thought restructuring, can maintain the obsessions by turning the attention of the patient to the obsessive thought (Geffken, Storch, Gelfand, Adkins &