What are the evidence‑based psychotherapeutic interventions for obsessive‑compulsive disorder in adults and adolescents, including first‑line treatment and alternative options?

Psychotherapeutic Interventions in OCD

First-Line Treatment

Cognitive-behavioral therapy (CBT) with exposure and response prevention (ERP) is the first-line psychotherapeutic treatment for obsessive-compulsive disorder in both adults and adolescents. 1, 2, 3

• CBT with ERP demonstrates superior efficacy compared to pharmacotherapy, with a number needed to treat of 3 for CBT versus 5 for SSRIs. 1, 2
• ERP involves gradual and prolonged exposure to fear-provoking stimuli combined with instructions to abstain from compulsive behaviors, targeting threat learning through habituation (fear extinction) and inhibitory learning processes. 3, 4
• Patient adherence to between-session homework (ERP exercises) is the strongest predictor of good outcomes with CBT. 1, 3

Treatment Delivery Formats

Multiple delivery formats are effective for CBT/ERP:

• Individual face-to-face CBT is prioritized over group therapy due to superior clinical and health-economic effectiveness, though both formats demonstrate efficacy. 1
• Internet-based and video teletherapy CBT protocols are effective alternatives when in-person therapy is unavailable, particularly when interventions include ERP components and last more than 4 weeks. 1, 5
• Video teletherapy ERP in children and adolescents resulted in a median 38.46% decrease in OCD symptoms at 13-17 weeks, with 53.4% meeting full response criteria in real-world settings. 5
• Family-based CBT approaches are crucial, especially for children and adolescents, with family involvement being essential for treatment success. 1, 2, 3

Treatment Initiation and Structure

Begin treatment with psychoeducation that establishes a therapeutic alliance with both patient and family members, explaining that OCD is a common disorder with available treatments that can bring symptom reduction and improved quality of life. 1

• Address stigma, prejudice, and family accommodation behaviors that may maintain OCD symptoms. 1
• For mild to moderate OCD without comorbid major depression, initiate CBT with ERP as monotherapy. 1, 2
• For severe OCD or cases with comorbid major depression, combine CBT with SSRI treatment from the outset. 1, 2

High-Intensity ERP Approaches

For treatment-resistant cases or patients requiring rapid symptom improvement, intensive CBT protocols delivered through more and/or longer sessions in a condensed manner are beneficial. 1, 4

• High-intensity ERP involves multiple sessions over a few days, sometimes in inpatient settings, and has demonstrated efficacy for adults and youth with OCD who have not responded to standard weekly or twice-weekly outpatient ERP. 4
• This approach may be particularly useful for patients who have not responded to standard ERP or require rapid symptom improvement. 4

Treatment Duration and Maintenance

Continue CBT treatment with monthly booster sessions for 3-6 months after initial treatment to maintain therapeutic gains. 6, 1

• Long-term treatment is typically necessary as OCD is often a chronic condition. 1
• Treatment should be maintained for at least 12-24 months after symptom improvement to reduce relapse risk. 2, 3

Augmentation Strategies

When CBT alone is insufficient:

• Combine CBT with SSRI pharmacotherapy for severe cases, those with partial response to monotherapy, and cases with significant comorbidities. 1, 2, 3
• For extremely treatment-resistant cases after adequate trials of CBT and multiple SRIs (including clomipramine), consider neuromodulation approaches such as repetitive transcranial magnetic stimulation or deep brain stimulation. 6, 1

Common Pitfalls to Avoid

Critical errors that compromise treatment outcomes:

• Failing to address mental or covert rituals during ERP, which can interfere with treatment effectiveness. 7
• Neglecting family involvement in treatment, particularly for children and adolescents. 2, 3
• Premature discontinuation of treatment before adequate duration (minimum 12-24 months). 2, 3
• Not recognizing that clients may fail to habituate to anxiety during exposures, requiring troubleshooting and adjustment of ERP tasks. 7
• Failing to address comorbid conditions that may complicate treatment response. 1, 2

Specific CBT Techniques for Reassurance-Seeking Behaviors

Response prevention requires patients to actively abstain from all forms of reassurance-seeking, including asking others for confirmation, self-reassurance through mental review, confessing to others, and compulsively searching the internet. 1

• Teach patients to challenge the belief that reassurance provides lasting relief and instead build tolerance for uncertainty, recognizing that absolute certainty is impossible. 1
• Address misinterpretation of anxiety by teaching patients that physical sensations of anxiety are not evidence confirming their fears, but rather normal anxiety responses. 1

Enhancing Treatment Engagement

Therapists can leverage naturally occurring change markers (Innovative Moments) during ERP to enhance motivation and deepen learning, rather than solely correcting dysfunctional patterns. 8

• By attuning to and reinforcing moments of progress in therapy—manifested by new and adaptive ways of acting, feeling, or thinking—therapists can assist clients in disengaging from compulsions, increasing exposure tolerance, and consolidating therapeutic gains. 8