The psychological treatment of obsessive-compulsive disorder
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The psychological treatment of obsessive–compulsive disorder (OCD) with exposure and response prevention (ERP) methods is one of the great success stories within the field of mental health. Within the span of about 20 years, the prognosis for individuals with OCD has changed from poor to very good as a result of the development of ERP. This success not withstanding, the procedures are far from perfect because a substantial minority of patients still either refuse treatment, drop out prematurely, or fail to benefit. I begin this article with a review of the development of ERP from early animal research on avoidance learning conducted during the 1950s. Next, I discuss the mechanisms of ERP. The bulk of the article reviews the treatment-outcome literature on ERP for OCD and includes comparisons with cognitive therapy—the “new kid on the block” with respect to psychological treatments for OCD.
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CBT treatments that include CT interventions appear to be more tolerated by patients and to reduce dropout, compared to ERP alone.
“Cognitive therapy (CT) is effective, too, in treating OCD, both alone and in combination with ERP, and CBT treatments that include CT interventions appear to be more tolerated by patients and to reduce dropout, compared to ERP alone (Abramowitz, 2006; Fisher & Wells, 2005; Rector et al., 2019; Rosa-Alcázar et al., 2008; Whittal et al., 2008).”
From TREATING GUILT-INDUCING SELF-TALK IN OCD WITH DRAMATIZED SOCRATIC DIALOGUE: A STEP BY STEP INTERVENTION (2024) · cites this paper as Abramowitz, 2006
The “Adding CT to ERP” section reports that including CT reduced dropout and says cognitive interventions can help patients comply with ERP. It does not establish that CT-containing treatment is better tolerated, and the dropout comparison was ERP plus relaxation therapy, not ERP alone. Page numbers were not available in our copy. (LLM, conf=0.85)
Experimental — accuracy not yet measuredCBT is only about 50% effective when treatment refusal, drop-out, and non-response are considered.
“However, treatment success remains around 50% when refusal and dropout are considered.”
From A preliminary investigation of the relationships between attachment insecurity, fear of compassion, and <scp>OCD</scp> severity (2025) · cites this paper as Abramowitz, 2006
The Predictors of Improvement section (page unavailable) says about 50% of patients referred with OCD are not significantly improved with ERP, accounting for dropout and non-response. It does not say that treatment refusal was included in that figure, and its estimate concerns ERP specifically rather than CBT generally. (LLM, conf=0.87)
Experimental — accuracy not yet measuredMany ERP trials used the Yale-Brown Obsessive-Compulsive Scale as an outcome measure, which is viewed as the gold standard for OCD symptom severity.
“A strength of many ERP trials was the use of the Yale-Brown Obsessive-Compulsive Scale (YBOCS; Goodman, Price et al, 1989 a; b) as an outcome measure. This clinician-administered tool is viewed as the gold standard for ascertaining OCD symptom severity (Abramowitz, 2006; Summerfeldt, 2001).”
From An update on the efficacy of psychological treatments for obsessive-compulsive disorder in adults (2013) · cites this paper as Abramowitz, 2006
According to cognitive models, faulty beliefs give rise to obsessional anxiety, and compulsive acts are performed to ameliorate intrusive thoughts and anxiety.
“according to cognitive models, faulty beliefs give rise to obsessional anxiety. Compulsive acts are then performed to ameliorate intrusive thoughts and anxiety”
From Obsessive-compulsive disorder: Etiology, neuropathology, and cognitive dysfunction (2023) · cites this paper as Abramowitz, 2006
Cognitive therapy was developed to target these cognitive biases and involves teaching patients about the implausibility and maladaptive nature of these cognitions.
“To target these cognitive biases, “cognitive therapy” was developed (Rosa‐Alcázar et al., 2008). Cognitive therapy typically involves teaching patients about the implausibility and maladaptive nature of these cognitions”
From Obsessive-compulsive disorder: Etiology, neuropathology, and cognitive dysfunction (2023) · cites this paper as Abramowitz, 2006
Exposure and response prevention (ERP) is the first-line treatment for obsessive-compulsive disorder (OCD).
“While exposure and response prevention (ERP) is the first-line treatment for obsessive-compulsive disorder (OCD), up to half of patients do not effectively respond.”
From 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 (2024) · cites this paper as Abramowitz, 2006
CT is effective in treating OCD, both alone and in combination with ERP.
“Cognitive therapy (CT) is effective, too, in treating OCD, both alone and in combination with ERP, and CBT treatments that include CT interventions appear to be more tolerated by patients and to reduce dropout, compared to ERP alone (Abramowitz, 2006; Fisher & Wells, 2005; Rector et al., 2019; Rosa-Alcázar et al., 2008; Whittal et al., 2008).”
From TREATING GUILT-INDUCING SELF-TALK IN OCD WITH DRAMATIZED SOCRATIC DIALOGUE: A STEP BY STEP INTERVENTION (2024) · cites this paper as Abramowitz, 2006
There is a substantial average gap of up to 17 years between symptom onset and receipt of treatment, together with high rates of disengagement from efficacious treatments such as psychological therapy.
“There is a substantial average gap of up to 17 years between symptom onset and receipt of treatment [10, 11], together with high rates of disengagement from efficacious treatments such as psychological therapy [12].”
From Testing the psychometric properties of the illness perceptions questionnaire for OCD (IPQ-O) (2019) · cites this paper as [12]
Approximately 20-30% of patients drop out of ERP prematurely.
“Approximately 20–30% of patients drop out of ERP prematurely,[11]”
From Exposure and response prevention for obsessive-compulsive disorder: A review and new directions (2019) · cites this paper as [11]
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- [45]45. Address for correspondence: Dr J Abramowitz, OCD/Anxiety Disorders Program, Department of Psychiatry and Psychology, Mayo Clinic, 200 First St, SW, Rochester, MN, 55905; abramowitz.jonathan@mayo.edu. W Can J Psychiatry, Vol 51, No 7, June 2006 416 The Canadian Journal of Psychiatry-In Review Résumé : Le traitement psychologique du trouble obsessionnel-compulsif Le traitement psychologique du trouble obsessionnel-compulsif (TOC) à l'aide de méthodes d'exposition avec prévention de la réponse (EPR) est une des grandes réussites du domaine de la santé mentale. En l'espace de quelque 20 ans, le pronostic des personnes souffrant de TOC est passé de médiocre à très bon, par suite de la mise au point de l'EPR. Nonobstant ce succès, les interventions sont loin d'être parfaites, car une minorité substantielle de patients soit refusent le traitement, soit abandonnent prématurément, soit n'en retirent aucun bénéfice. Cet article commence par un sommaire de l'élaboration de l'EPR, depuis les premières recherches zootechniques sur l'apprentissage de l'évitement, menées dans les années 1950. Ensuite, je présente les mécanismes de l'EPR. La majorité de l'article passe en revue la documentation des résultats du traitement par l'EPR pour le TOC et comprend des comparaisons avec la thérapie cognitive, la « nouvelle venue » au sein des traitements psychologiques du TOC.
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- Authors
- Abramowitz, J. S.
- Affiliations
- Mayo Clinic (US)
- Corresponding author
- Abramowitz, Jonathan S
- Venue
- The Canadian Journal of Psychiatry
- Publisher
- SAGE Publications
- Published
- 2006-06
- Volume
- 51
- Issue
- 7
- Pages
- 407-416
- ISSN
- 0706-7437 (ISSN-L)
- 1497-0015
- OpenAlex
- W2131506339
- Cited by
- 371
- References
- 44
- Citations by year
- 2026: 18 · 2025: 22 · 2024: 22 · 2023: 17 · 2022: 27 · 2021: 22 · 2020: 26 · 2019: 18 · 2018: 12 · 2017: 12 · 2016: 12 · 2015: 22 · 2014: 29 · 2013: 25 · 2012: 23
- FWCI
- 1.49
- Type
- journal article
- Language
- en
- Open access
- bronze
- doi.org
- Locations
- The Canadian Journal of Psychiatry (publishedVersion)
- PubMed (publishedVersion)
- Topics
- Social Sciences › Psychology › Clinical Psychology › Obsessive-Compulsive Spectrum Disorders
- Social Sciences › Psychology › Experimental and Cognitive Psychology › Anxiety, Depression, Psychometrics, Treatment, Cognitive Processes
- Social Sciences › Psychology › Clinical Psychology › Psychoanalysis and Psychopathology Research
- Keywords
- obsessive-compulsive disorder, exposure and response prevention, cognitive therapy, avoidance learning, treatment outcomes, treatment discontinuation, treatment resistance
- MeSH terms
- Combined Modality Therapy, Desensitization, Psychologic, Humans, Inhibition, Psychological, Obsessive-Compulsive Disorder, Cognitive Behavioral Therapy, Randomized Controlled Trials as Topic, Treatment Outcome
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