Cognitive Therapy Plus Exposure and Response Prevention Effective in OCD

The treatment led to significantly greater symptom relief and belief reduction compared with exposure and response prevention.

The addition of cognitive therapy to exposure and response prevention (ERP) resulted in improved outcomes in patients with obsessive-compulsive disorder (OCD), according to the results of a study published in the British Journal of Clinical Psychology.

The use of ERP in patients with OCD is considered an effective first-line therapy and is recommended by major guidelines. ERP therapy results in effective and lasting change in OCD, regardless of symptom presentation and severity and the presence of comorbidities. Both intensive and outpatient therapies are effective. Cognitive therapy is less well established in the treatment of OCD, although it is effective as well. Most studies have compared ERP with cognitive therapy (CT) and both have shown significant and equivalent efficacy. However, the integration of ERP and CT has been proposed in treatment guidelines such as those from the National Institute for Health and Care Excellence (NICE). This is the first randomized controlled study to directly test whether integrated manualized CT offers a therapeutic benefit greater than ERP alone.

Neil A. Rector, PhD, C.Psych, of the Frederick W. Thompson Anxiety Disorders Centre, Sunnybrook Health Sciences Centre, and the Department of Psychiatry, University of Toronto, Canada, and colleagues conducted a longitudinal randomized controlled trial to compare treatment that integrated CT with ERP (ERP + CT) with ERP alone. The investigators measured obsessive-compulsive symptoms before treatment, post-treatment, and at 6-month follow-up.

The investigators randomized 127 patients with OCD to receive individual outpatient ERP or ERP + CT. ERP + CT led to significantly greater symptom relief and belief reduction compared with ERP. The added benefit was equivalent to a medium to large treatment effect. More participants in the ERP + CT group were judged to be recovered than patients in the ERP group. Benefits were found in the main OCD dimensions, including contamination/washing, doubting-harming/checking, order-symmetry/repeating and pure obsession (harming, sexual, somatic, and religious).

Limitations of the study included the failure to examine the differential effects of ERP or ERP + C vs another form of psychotherapy, and given the high rates of depression in individuals with OCD, that a diagnosable mood disorder was the basis for exclusion from the trial. Nonetheless, the investigators argued that these findings support NICE treatment guidelines that recommend the integration of ERP and cognitive therapy for OCD.


Rector NA, Richter MA, Katz D, Leybman M. Does the addition of cognitive therapy to exposure and response prevention for obsessive compulsive disorder enhance clinical efficacy? A randomized controlled trial in a community setting [published online July 8, 2018]. Br J Clin Psychol. doi:10.1111/bjc.12188