ABSTRACT
Introduction ...................................................................................................... 32 Outcome literature relevant to treatment resistance ................................... 34 Compliance with specialized ERP for OCD ................................................. 37
Meanings of and reasons for resistance to cognitive therapy and ERP ............................................................... 38
Applying CT without formal ERP ................................................................. 40 Description of CT methods ........................................................................ 40 Evidence for success of CT methods ........................................................ 42
A schema-based model .................................................................................... 44 The model in theory .................................................................................... 45 The model in practice: CBT for resistant OCD ........................................ 47 Clinical example of CBT without schema-based interventions ............ 49 The model in practice: schema-based assessment and treatment
interventions for resistant OCD ........................................................... 57 Treatment efcacy for resistant OCD ............................................................ 61
Implications for future research of CBT resistance in OCD .................. 61 Intervention criteria for CBT resistance in OCD ..................................... 62 Criteria for remission/recovery following CBT for OCD ..................... 64 Criteria for CBT resistance in OCD .......................................................... 64
References .......................................................................................................... 66
Obsessive compulsive disorder (OCD) is a heterogeneous, frequently incapacitating disorder that is distinct from other anxiety disorders in terms of psychopathology and treatment requirements (Frost & Steketee, 2002). Cognitive behavior therapy (CBT), with the essential interventions of exposure and response prevention (ERP), is the empirically established psychotherapy of choice (American Psychiatric Association, 2007). Several controlled studies have found that CBT combined with pharmacological treatment is no more effective than CBT alone for OCD symptoms (Foa et al., 2005; O’Connor et al., 2006; Rufer, Grothusen, Mab, Peter, & Hand, 2005). Improvement is more sustained with ERP compared with medication, and adding ERP to medication substantially improves response rate and reduces susceptibility to relapse compared with medication alone (Kordan et al., 2005; Simpson, Franklin, Cheng, Foa, & Liebowitz, 2005; Simpson et al., 2008). Indications for combined treatment include presence of severe comorbid mood disorder or other disorders or symptoms that require medication (e.g., Hohagen et al., 1998). Thus, it can be concluded from available empirical evidence that the rst-line treatment of choice for OCD is CBT and that pharmacotherapy, where indicated, should be administered in combination with CBT for optimal and sustained results. Unfortunately, many individuals with OCD do not receive CBT (Goodwin, Koenen, Hellman, Guardino, & Struening, 2002), and fewer still receive specialized CBT for OCD delivered or supervised by a therapist experienced with this disorder.
