What is the best approach to plan a CBT session for a young to middle-aged adult patient with a diagnosis of OCD, potentially with a history of anxiety or depression?

Planning a CBT Session for OCD

Begin with psychoeducation and exposure and response prevention (ERP) as the core intervention, structuring 10-20 sessions with gradual exposure to fear-provoking stimuli while instructing the patient to abstain from all compulsive behaviors. 1, 2

Session Structure and Initial Components

First Session: Foundation Building

• Establish therapeutic alliance with both patient and family members, explaining that OCD is a biologically-based disorder with effective treatments that can substantially reduce symptoms and improve quality of life. 1, 2
• Provide psychoeducation addressing:
  • The nature and prevalence of OCD 2
  • Biological and psychological underpinnings 2
  • How compulsions temporarily reduce anxiety but maintain the disorder long-term 1
  • The role of family accommodation behaviors that maintain symptoms 1, 2
• Address stigma and correct misconceptions about OCD 1, 2
• Introduce the Yale-Brown Obsessive Compulsive Scale (YBOCS) to establish baseline symptom severity 1

Core ERP Protocol (Sessions 2-18)

ERP involves gradual and prolonged exposure to fear-provoking stimuli combined with instructions to abstain from compulsive behaviors—this is the gold-standard intervention with a number needed to treat of 3 compared to 5 for SSRIs. 1, 3

Exposure Component

• Create a hierarchy of feared situations ranked by distress level (0-100 scale) 3
• Begin with moderately distressing exposures (not the easiest or hardest) 3
• Conduct exposures that are:
  • Gradual but prolonged (typically 60-90 minutes per exposure until anxiety decreases by at least 50%) 1, 3
  • Repeated frequently (daily homework is essential) 1
  • Progressively more challenging as habituation occurs 3

Response Prevention Component

• Instruct the patient to actively abstain from ALL forms of compulsive behaviors during and after exposure, including: 2
  • Overt rituals (washing, checking, ordering) 2
  • Mental compulsions (counting, praying, reviewing) 2
  • Reassurance-seeking from others 2
  • Self-reassurance through mental review 2
  • Internet searching for confirmation 2
  • Confessing to others 2

Between-Session Homework

Patient adherence to between-session homework is the strongest predictor of both short-term and long-term treatment success—this must be emphasized repeatedly. 1, 4

• Assign daily ERP exercises matching in-session exposures 1, 3
• Use self-monitoring forms to track exposures, anxiety levels, and urges to ritualize 3
• Review homework completion at the start of each session 3

Cognitive Interventions to Integrate

While ERP is primary, incorporate cognitive techniques to enhance treatment:

• Challenge the belief that compulsions provide lasting relief 2
• Build tolerance for uncertainty, recognizing that absolute certainty is impossible 2
• Address misinterpretation of anxiety by teaching that physical sensations are normal anxiety responses, not evidence confirming fears 2
• Identify and challenge inflated responsibility, thought-action fusion, and overestimation of threat 3

Monitoring Progress Throughout Treatment

• Administer YBOCS every 2-4 sessions to track symptom severity objectively 1
• Monitor for:
  • Reduction in time spent on obsessions and compulsions 1
  • Decreased distress and interference in daily functioning 1
  • Improved quality of life 1
• Expect full therapeutic effect may be delayed until 4-5 weeks or longer 1, 3

When to Consider Pharmacotherapy Augmentation

Recommend combining CBT with SSRI treatment from the outset if the patient has moderate-to-severe OCD, as this approach yields larger effect sizes than either monotherapy. 1, 2

Initiate SSRI when:

• Symptoms are severe enough to prevent engagement with CBT 1
• Patient has comorbid major depression 5
• Patient prefers medication 1
• Partial response to CBT alone after 8-10 sessions 1

Sertraline and fluoxetine have FDA approval specifically for OCD and should be considered first-line SSRIs, with doses higher than typically prescribed for depression (fluoxetine 20-80 mg/day for OCD). 1, 6

Intensive Treatment Format for Severe or Treatment-Resistant Cases

For patients with severe symptoms or those who have not responded to standard weekly treatment, consider intensive CBT protocols with multiple sessions over condensed timeframes (days to weeks). 1, 7

Intensive format involves:

• Daily sessions (sometimes multiple per day) over 2-4 weeks 7, 8
• Longer session duration (90-180 minutes) 7, 9
• More rapid progression through exposure hierarchy 7
• Evidence shows intensive treatment is equally effective as weekly treatment and may produce faster results 8

Alternative Delivery Methods

Computer-assisted self-help CBT interventions that include ERP components and last more than 4 weeks can be effective alternatives when in-person therapy is not available. 1, 2

These should include:

• Interactive elements with personalized feedback 1
• Self-monitoring and assignments 1
• Psychoeducation, cognitive elements, and ERP components 1

Maintenance Phase (Sessions 19-20 and Beyond)

• Plan monthly booster sessions for 3-6 months after initial treatment to maintain gains. 10, 2
• Review relapse prevention strategies:
  • Recognizing early warning signs 3
  • Continuing self-directed ERP exercises 3
  • Avoiding gradual return to accommodation 3
• Emphasize that OCD is often chronic and long-term vigilance is necessary 2

Critical Pitfalls to Avoid

• Never allow partial response prevention—patients must abstain from ALL compulsions, not just reduce them. 2, 3
• Do not progress too slowly through the hierarchy; this reduces treatment efficacy 3, 9
• Avoid reassuring the patient during exposures that "nothing bad will happen"—this undermines the learning process 2
• Do not neglect family involvement and psychoeducation, as family accommodation maintains symptoms 1, 2
• Ensure exposures are long enough (60-90 minutes minimum) for habituation to occur; brief exposures may sensitize rather than desensitize. 3, 9

Special Considerations for Comorbidities

If comorbid major depression is present:

• Consider initiating SSRI treatment first, potentially combined with CBT 5
• Monitor closely for suicidal ideation, particularly in first weeks of SSRI treatment 5
• Address depressive symptoms that may interfere with ERP engagement 5

If comorbid anxiety disorders are present:

• Tailor exposures to address both OCD and other anxiety symptoms 2
• May require longer treatment duration 2