Page 1 of 16http://spider.apa.org/ftdocs/ccp/1997/february/ccp65144.html 10/12/2000Effectiveness of Psychological and Pharmacological Treatments for Obsessive —Compulsive Disorder A Quantitative Review Jonathan S AbramowitzThe University of Memphis ABSTRACTQuantitative review of the controlled treatment outcome literature for obsessive—compulsive disorder (OCD) showed that exposure with response prevention was highly effective in reducing OCD symptoms. Cognitive approaches were also found to be at least as effective as exposure procedures. It appears that both cognitive and exposure interventions involve some overlapping procedures and capitalize on similar mechanisms of change. Serotonergic medication, particularly clomipramine, also substantially reduced OCD symptoms. However, clomipramine may not be particularly superior to other serotonergic medication. The relationship between side effects and effect size in medication trials was explored. I thank the following people for their assistance and helpful suggestions during various stages of this research: Leslie Robinson, Guy Mittleman, John Richter, Will Shadish, Gail Steketee, Fugen Neziroglu, and John Greist. I also express special thanks and appreciation to Art Houts for his invaluable support. Correspondence may be addressed to Jonathan S Abramowitz, Department of Psychology, The University of Memphis, Memphis, Tennessee, 38152. Electronic mail may be sent to [email protected] Received: September 11, 1995 Revised: December 19, 1995 Accepted: March 21, 1996 Obsessive—compulsive disorder (OCD) involves (a) intrusive and unwanted thoughts, ideas, or images (obsessions) that lead to increased anxiety; and (b) repetitious, intentional rituals (compulsions) performed to neutralize the anxiety. Because people who show this behavior pattern spend excessive amounts of time obsessing and ritualizing, they typically experience significant impairment in occupational and social functioning. Ritualizing often involves friends or family members who may devote considerable time to care for the person. In severe cases, ritualizing can dominate the entire day and sometimes involve self-injury, such as skin damage from excessive hand washing. Usually, OCD symptoms wax and wane throughout the course of the disorder ( AmericanPsychiatric Association, 1994 ; Rachman & Hodgson, 1980 ; Rasmussen & Tsuang, 1986 ; Riggs &Foa, 1993 ). Until a decade ago, OCD was thought to be a rare condition with a poor prognosis. Recently, the Epidemiological Catchment Area survey estimated that the lifetime prevalence rate could be as high Journal of Consulting and Clinical Psychology © 1997 by the American Psychological Association February 1997 Vol. 65, No. 1, 44 -52 For personal use only--not for distribution.Page 2 of 16http://spider.apa.org/ftdocs/ccp/1997/february/ccp65144.html 10/12/2000as 2.5% in the United States ( Karno, Golding, Sorenson, & Burnam, 1988 ). Because they fear embarrassment, individuals with OCD often attempt to hide their symptoms from others. As a result, it is common for people to suffer with obsessions and compulsions for several years before seeking treatment ( Steketee, 1993 ). Consistent findings show the average age of onset to be in the early twenties ( Minichiello, Baer, Jenike, & Holland, 1990 ). Considering the personal cost and prevalence, OCD is a significant public health concern, and identifying effective interventions for this disorder is important. Current treatments for OCD can be divided into psychological and pharmacological approaches. Psychological interventions have included exposure-based procedures ( Riggs & Foa, 1993 ; Steketee, 1993 ) and cognitively oriented strategies such as Ellis's rational emotive behavior therapy (REBT; Ellis, 1994 ), 1 a cognitive treatment based on Beck's (1976) cognitive therapy for depression ( van Oppen & Arntz, 1994 ), and thought stopping ( Hackman & McLean, 1975 ). Pharmacotherapy has been dominated by the use of antidepressants, particularly the serotonin reuptake inhibitors (SRIs; Jenike, Baer, & Greist, 1990 ). Although clomipramine, an SRI, has received more research attention than any other single medication to date, newer SRIs such as fluoxetine, fluvoxamine, and sertraline have become the focus of recent controlled clinical trials. Behavior therapy and medication have also been used in combination, most often in cases of severe OCD or when patients failed to respond to behavior therapy alone. Previous reviews of this outcome literature have generally concluded that the behavioral, cognitive, and pharmacological treatments developed over the past 3 decades were more effective than the psychoanalytically oriented therapies used previously (e.g., Stanley & Turner,1995 ). One procedure, exposure with response prevention (ERP), is often considered the psychological treatment of choice for OCD ( Riggs & Foa, 1993 ; Steketee, 1993 ). Conclusions that ERP is more effective than other psychological treatments have been based on research studies that represent a variety of methodological designs and patient characteristics. Many have been single-case reports and uncontrolled trials rather than the methodologically preferable comparisons between patients randomly assigned to treatment and control groups. Uncontrolled trials should be interpreted with caution because they merely reflect within-group changes over time (pre- to posttest) without taking into account the effects of nonspecific factors on treatment. For example, there are natural fluctuations in symptom severity that occur throughout the course of OCD. Because people are inclined to seek treatment when their symptoms are more severe, changes in the direction of improvement would be expected from normal fluctuations of symptoms. In the present review, I avoid these problems by focusing exclusively on studies that contained direct comparisons between randomly assigned groups. In the late 1970s and early 1980s, studies of pharmacological treatments for OCD mainly concerned tricyclic antidepressants (e.g., Mavissakalian, Turner, Michelson, & Jacob, 1985 ). Although case studies and open trials provided preliminary evidence that some of these medications were effective, well-executed randomized comparisons usually demonstrated the superiority of clomipramine ( Perse, 1988 ). Because clomipramine (a tricyclic antidepressant and SRI) increased levels of available serotonin, hypotheses about a relationship between
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