OBSESSIVE-COMPULSIVE DISORDER

Treatment of Obsessive-Compulsive Disorder: Literature Review

Samantha Zaitz

Wake Forest University

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Abstract

Obsessive-Compulsive Disorder (OCD) is a prevalent disorder that effects people of all

ages from around the world. The DSM-5 describes Obsessive-Compulsive Disorder as having

obsessions and/or compulsions that are considered excessive and persistent. Obsessions are

characterized by recurrent and repeated thoughts, urges or images that are found to be invasive

and unwanted. Compulsions are characterized as repetitive acts either mental or physical that

someone is compelled to perform in response to an obsession and are aimed at reducing the

anxiety or dread induced by the obsession (American Psychiatric Association, 2013). Aside from

Obsessive-Compulsive disorder, other OCD disorders include body dysmorphic disorder,

hoarding disorder, trichotillomania or excoriation. In terms of treatment “OCD is typically

treated with medication, psychotherapy, or a combination of the two. Although most patients

with OCD respond to treatment, some patients continue to experience symptoms” (U.S.

Department of Health and Human Services, 2019). The intention of this literature review is to

assess the current evidence-based treatments currently available to treat obsessive-compulsive

disorder and provide an overview of the research behind these treatments. First, the methodology

utilized to find the articles assessed in this literature review is presented. Afterward, there is an

overview of the DSM-5 criteria that is used to diagnose obsessive-compulsive disorder as well as

an outline of the existent and most utilized evidence-based treatments and the current research

behind them. This literature review concludes with suggestions of future research on treatment

for obsessive-compulsive disorder based off the identification of the gaps and doubt in the

research explored.
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Introduction

Obsessive-Compulsive Disorder (OCD) 300.3 (F42.2) is a debilitating disease that is

associated with significant interruptions in activity across work, home and social life settings and

impairs these critical parts of daily life and functioning. Per the American Psychiatric

Association, 2013 an individual must have the presence of either obsessions (i.e. persistent

thoughts, images, or urges) or compulsions (actions, behaviors, mental acts to neutralize said

obsessions) or both to be diagnosed with OCD. Examinations looking into the burden of OCD on

quality of life found that OCD symptoms severely impact overall functioning across the board.

(Asnaani et al., 2017 p.7). Obsessive-Compulsive Disorder is the fourth most prevalent mental

health disorder in the world (De Putter and Koster, 2017 as cited in Fisher et al., 2020 p. 94). In

addition to substantially reducing a person’s quality of life, OCD increases the risk of suicide

with accounts being 10 times higher than patients without in matched controlled settings (de la

Cruz et al., 2017 as cited in Fisher et al., 2020 p. 95).

The current and most widely used evidence-based therapeutic treatments for Obsessive

Compulsive Disorder include Acceptance and Commitment Therapy (ACT), Cognitive

Behavioral Therapy (CBT) and Exposure Response (or ritual) Prevention (ERP) (Twohig et al.,

2010 p. 67). The two most recommended pharmacological interventions for OCD are Serotonin

Reuptake Inhibitors (SSRIs) and SRI Clomipramine (Fineberg et al., 2012). However, according

to Külz et al., 2018 “Up to one-third of individuals with obsessive-compulsive disorder (OCD)

do not benefit from evidence-based psychotherapy” (p.223). A newer alternative therapy that is

gaining momentum is Transcranial Magnetic Stimulation, discussed later on. There is a

significant amount of research available on the various treatment methods for Obsessive-
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Compulsive Disorder, but with such a vast amount of information available, a closer look at the

current research is needed to determine which treatment proves to be most effective among

individuals. A review of these treatments can be found in the results segment that follows in this

literature review.

Method

I conducted this research through the Wake Forest University Z. Smith Reynolds Library

website. I utilized the two databases PsychINFO and PubMed the most. Before entering my

search criteria, I selected the option to filter my results to only peer reviewed items. I also

changed the time window from 2007 to present to only see timely resources. To find relevant

literature I searched for keywords “Obsessive-Compulsive Disorder” AND “Treatment”.

Another search I conducted was “Obsessive-Compulsive Disorder” AND “Medication” as well

as “Obsessive-Compulsive Disorder Treatment” AND “Therapy”. Once I started narrowing

down my search criteria I also searched “Obsessive-Compulsive Disorder with the following:

AND “CBT”, AND “ACT”, “SSRI”, AND “Pharmacological.” I had the most luck with

PsychINFO as this database provided the greatest number of relevant and quality results. The

majority of the results that came up had direct links available to the full text. I chose articles

based off of topic relevance, date of the study or publication and made note of who wrote and/or

published the article. In picking my resources, I wanted to make sure I selected articles from

reputable authors and publications. Additional resources were also identified through the sources

cited in journals I had already selected.

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Results

Diagnosis

According to the American Psychiatric Association the benchmarks that need to be met

in order to diagnose Obsessive-Compulsive Disorder are Criterion A: Having obsessions and/or

compulsions and Criterion B, which states that the obsessions and compulsions must take up 1

hour or longer per day and/or cause significant distress to the individual (American Psychiatric

Association, 2013). Other criteria that must be met includes that OCD symptoms are not

associated with the physiological effects of a drug, medication or another medical condition and

must also not be attributed to another psychological disorder such as generalized anxiety disorder

or addition disorder (American Psychiatric Association, 2013). The criterion used to diagnose

OCD helps separate those suffering from the disorder from those who practice common

repetitive behaviors or habits (i.e. checking a door is locked) (American Psychiatric Association,

2013). The content of obsessions and compulsions varies from person to person. However, there

are common compulsions seen across many OCD patients including: excessive cleaning (fear of

contamination obsessions), symmetry, perfectionism and counting (just-right obsessions),

forbidden thoughts (sacrilegious and/or unseemly obsessions), and harm and/or checking (fear of

harm to self or others) (American Psychiatric Association, 2013). These compulsions are

considered acts that “an individual feels driven to perform in response to an obsession according

to rules that must be applied rigidly” (American Psychiatric Association, 2013). Up to 30% of

individuals with OCD have compulsions that last can last a lifetime (Leckman et al., 2010 as

cited in American Psychiatric Association, 2013).

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The Yale Brown Obsessive Compulsive Scale (Y-BOCS) is considered “the gold

standard” of OCD symptom evaluation and is the most utilized and validated clinician

administered measurement of OCD diagnosis (Storch et al., 2010, Asnaani et al., 2017). This

scale consists of two parts: a checklist of obsessions and compulsions and a scale of severity of

the symptoms over the course of the week prior to taking the test. The Y-BOCS typically takes

approximately 1-hour to administer to patients and must be administered by a trained practitioner

(Asnaani et al., p. 8). Another commonly used symptom evaluation is called The Obsessive-

Compulsive Inventory, Revised (OCI-R), which is done through patient self-reporting. This test

is easier to administer due to the self-reporting nature and takes much less time to complete

(approx.10 minutes). An advantage to using this over the Y-BOCS is that it measures 6 common

specific obsessions and compulsions, where Y-BOCS is much more generalized in regard to

symptom severity (Asnaani et al., 2017 p. 8). Y-BOCS and OCI-R may be 2 of the most

commonly used instruments to measure symptoms, but others include the Structured Clinical

Interview (SCDID-I), the Beck Depression Inventory-II (BDI-II) and the Ruminative Response

Scale (RRS) (Rohani et al., 2018 p. 8). There are also are other less quantitative ways to

diagnose and determine severity of symptoms. Although obsessive-compulsive disorder effects

individuals of all ages and backgrounds, “Most people are diagnosed by about age 19, typically

with an earlier age of onset in boys than in girls, but onset after age 35 does happen” (U.S.

Department of Health and Human Services, 2019).

Treatments & Findings

Cognitive Behavioral Therapy. Cognitive Behavioral therapy (CBT) “aims to reduce the

frequency of unwanted obsessions by directly altering the appraisals through cognitively

challenging and experiential exercises” (Woody et al., 2011 p. 654). In other words, those with
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OCD appraise intrusive, obsessive thoughts as important, true and meaningful and CBT teaches

them not to give meaning or importance to these thoughts, which in turn reduces distress.

Cognitive theories suggest that adequate symptom reduction is achieved through changing the

cognition (Woody et al., 2011 p. 656). Through CBT “Alternative nonthreatening and neutral

interpretations are developed in treatment and evidence for them is collected through a variety of

strategies including piecharting, surveys, and cognitive challenging (Twohig et al., 2010 p. 71).

Although CBT is considered the treatment of choice for those suffering from OCD

approximately 50% of patients do not experience remission following treatment (Leeuwerik et

al., 2019 p. 1).

In a study conducted by Woody et al. (2011), a randomized, controlled study was

conducted on 73 individuals with OCD where their primary obsessions involve unwanted sexual,

violent or blasphemous intrusions with about 52% of the participants on stable medication at the

start. The study conducted was to determine the efficacy of CBT compared to Stress

Management Training (SMT), which does not aim to change cognitions, but to regulate

emotions, in treating OCD symptoms. Woody et al. (2011) utilized the YBOCS for diagnostic

assessments and to identify the participants specific obsessions and used it at the initial

evaluation and posttreatment evaluation sessions. Obsessional Activity Questionnaire (OAQ) and

Obsessive Belief Questionnaires (OBQ) were also used throughout the study for participant self-

assessment. The results of the suggest that CBT is more effective than SMT for patients with

severe OCD symptoms. However, SMT proved to be more beneficial for those with mild-to-

moderate obsessions. The study suggests that although CBT is an effective treatment for

symptom reduction, further research needs to be done on introducing additional strategies in

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combination with CBT that could address symptoms, but also contribute to basic life skills and

emotional regulation.

In another study conducted by Anand et al., (2010), the efficacy of CBT was examined in

31 adults with OCD who had not responded to at least two SRI trials. The participants received

20-25 sessions of CBT over the course of the 2 months. The main measure of improvement was

response to treatment and was measured using YBOCS. Participants were assessed initially

(baseline), during and post treatment as well as 1 year after treatment was completed. 23 out of

the 31 patients (74%) were considered to have positively responded to the CBT treatment.

Furthermore, the 12-month follow up proved to have a high retention rate of symptom

improvement. This is an effective study in showing why CBT is considered to be such an

effective evidence-based intervention.

Acceptance Commitment Therapy. Studies have shown that Cognitive Behavioral

Therapy (CBT) and/or exposure response prevention (ERP) to be the most effective therapeutic

treatments for OCD (Külz et al., 2018 p.223). However, Acceptance and Commitment Therapy

(ACT) is also a beneficial psychotherapeutic technique that is very effective in patients suffering

from OCD. Acceptance and Commitment therapy in regard to the treatment of OCD involves

looking at whether or not attempts to regulate obsessions in the short and long-term were

successful, accepting obsessions and the feelings of anxiety that follow, learning psychological

diffusion, (experiencing thoughts, feelings and body sensations as just that and nothing else )

learning about the self-separate from obsessions, training in mindfulness (being present),

identifying personal values and participating in activities that are value-based. (Twohig et al.,

2010 p. 71). ACT “generally focuses on the function of cognitions and other inner experiences to

decrease their impact on overt behavior without targeting the content of these inner experiences.
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Overt behavior is addressed through values work (e.g., future directed motivational

enhancement) and commitments to behavior change” (Twohig et al., 2010 P. 67, 68).

Rohani et al., (2018) conducted a study on 46 women with OCD who were already on a

stable dose of Selective Serotonin Reuptake Inhibitor (SSRI) medication. The participants were

randomly selected to be in two groups. The study examined the effect of ACT in combination

with SSRIs compared to the efficacy of SSRIs alone. The medication dose of the participants

involved stayed the same throughout the 16-week study. Assessment was conducted on

participants pre and post study as well as at the 2-month follow up using measures such as

YBOCS, RRS and BDI-II. Sessions in the ACT + SSRI group “included: creative hopelessness,

control as the problem and introduction to acceptance, acceptance, defusion, self as context, con-

tact with present moment, values, and committed action” (Rohani et al. 2018). According to the

study, group comparisons showed a huge difference in symptom improvement for the ACT +

SSRI group from before and after treatment to follow up at 71.3% improvement. However, there

were also significant differences for the just SSRI group as well at 31.2% improvement. The

findings show that although both treatments proved to have a considerable difference in terms of

reducing OCD symptoms over the study period, the ACT + SSRI group proved to be more

successful. However, because the sample group was limited to females, the generalization of the

findings are restricted. Another limitation of this study is that follow-ups were only completed 2-

months after the study, which provides us with limited data (Rohani et al., 2018 p.12).

Exposure Response Therapy. Exposure Response Therapy (ERP) is focused on symptom

extinction and challenging the threat and overestimation of danger caused by symptoms (Twohig

et al. 2010 p. 76). ERP as a treatment for OCD is based on habituating the patient to the

obsessional stimuli (Twhohig et al., 2010 p. 71). When a patient is repeatedly exposed to the
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thing or thought that causes distress (and consequently compulsions), the patient slowly becomes

acclimated and desensitized to the obsession and thus less compelled to perform the compulsion.

In a study conducted by Twohig et al. (2010) ACT, CT and ERP were compared all as

effective treatments for OCD. In the study 6 adults with OCD were treated with one of the 3

treatments to distinguish the differences (and similarities) between these treatments.

Psychological flexibility, cognitive reappraisal and compulsion extinction of participants were

measured. Symptom severity was measured using YBOCS. The study proved that although all

treatments are effective in different ways, participants who received ERP has the most consistent

results with compulsion extinction being the biggest marker of change. Although this is different

among each individual, symptom extinction is the most pivotal change a patient can have from a

clinical standpoint. However, some known issues with ERP are increased treatment drop-out and

treatment refusal (Twohig et al., 2010 p. 67). One limitation of the study is due to the fact that

there are no existing, quantifiable measurements of psychological flexibility, cognitive

reappraisal or extinction within the treatment of OCD (Twohig et al., 2010 p. 69). As a result,

Twohig et al. (2010) had to create these instruments, which leaves room for error in their final

assessments.

Pharmacological Treatments

Serotonin Reuptake Inhibitors. Serotonin Reuptake Inhibitors (SSRIs) are the most

commonly used pharmacological treatment for OCD symptoms. “SSRIs inhibit activity of the

serotonin transporter protein (SERT), thus decreasing presynaptic reuptake of the neuro-

transmitter 5-Hydroxytryptamine (5-HT) i.e. serotonin, and increasing serotonin signaling in the

brain. Serotonin signaling is implicated in effecting many physiological processes including:

autonomic function, cognition, affection, emotion and reward-based symptoms” (Montanez et

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al., 2003, Sangkuhl et al., 2009 as cited in Miller et al., 2019 p. 1). There are currently 6 SSRI’s

that are commonly prescribed to treat OCD (Miller et al., 2019 p.1). In a real world and meta-

analysis study conducted by Miller et al. (2019) a survey was designed and administered to

practicing psychiatrists in North America with patients that are suffering from OCD. Meta-

analysis was conducted on existing double-blind, randomized controlled clinical trials. The

results show that the real-world and clinical trial efficacy agree that SSRIs are significantly

superior in treating symptoms when compared to placebo. The study also found that there is not

a significant difference between SRRI’s effectiveness compared to clomipramine, which is

contradictory to other studies mentioned later.

In another study conducted by Meng et al. (2019), 167 patients in China were recruited to

participate in a randomized study looking at CBT alone as a treatment for OCD compared to

CBT + SSRIs and SSRIs alone for a 24-week period. Participant symptoms were measured using

YBOCS among other scales that also measured social functioning. According to Meng et al.,

2019 the results show us that combined therapy of both SSRI and CBT was the most beneficial

among participants. Although this study does provide evidence that CBT with SSRIs are an

effective intervention, the study did not have a CBT only group. Due to this flaw in design, they

are unable to determine if the improved numbers are due to CBT alone or the combination of

CBT with SSRIs (Meng et al., 2019 p. 190).

Clomipramine. Clomipramine is a tricyclic antidepressant that is commonly prescribed to

treat OCD patients. Similarly, to SSRI dugs, clomipramine inhibits the reuptake of serotonin in

the brain, which is beneficial for patients with OCD. Clomipramine also has an active metabolite

that has substantial noradrenergic properties. (Fineberg et al., 2012 p. 1174). In a study

conducted by Skapinakis et al., 2016 a systematic review and meta-analysis was done to examine
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both psychotherapeutic and pharmacological interventions for OCD in adults. Skapinakis et al.,

2016 found that all pharmacological treatments had substantially better outcomes than placebo

treatments. However, there was no evidence to support that Clomipramine was more effective

than SSRIs in terms of efficacy. Aside from studies showing the improved performance of SSRIs

compared to Clomipramine in treating symptoms, Clomipramine is also less tolerated than most

SSRI medications “SSRIs should usually be considered the treatment of choice, with

clomipramine reserved for those who cannot tolerate or who have failed to respond to them

(Fineberg et al., 2012 p. 1176).

Alternative Treatments

Transcranial Magnetic Stimulation. Among patients with OCD about 40-60% of patients

do not sufficiently respond to pharmacological treatment and CBT (Roth et al., 2020 p.1). In

2018 the FDA approved Transcranial Magnetic Stimulation (TMS) as a new addition for

treatment of OCD in adults (U.S. Department of Health and Human Services, 2019). Up to 6

weeks of transcranial magnetic stimulation is proven to be a safe and effective treatment for

OCD (Roth et al., 2020 p. 1). Carmi et al., 2019 conducted a study to examine the effects of deep

transcranial magnetic stimulation (dTMS) in a multicenter double-blind controlled study. At 11

different centers, 99 patients with OCD were selected at random and allocated to two different

treatment groups: one with high-frequency and the other with fake dTMS (placebo). The 2

groups received treatment daily following deliberate provoking of symptoms for 6 weeks.

Response to treatment from baseline was measured mainly using the Yale-Brown Obsessive

Compulsive Scale at the posttreatment assessment and again one month after. Results showed

that high-frequency dTMS significantly improved OCD symptoms. For patients who did not

find enough benefit from SSRIs and CBT, this can be a good alternative intervention. However,
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as mentioned in the study, due the fact that treatment history of each patient for the study was not

validated, and symptom provocation measures were not fully defined, further research would be

beneficial (Carmi et al., 2019 p. 937).

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Discussion

In examining the various treatments identified in this paper it is evident that although

there are effective treatments available, more research needs to be done for a number of reasons.

One limitation in the research presently available is the fact that therapeutic treatments for CBT,

ACT, ERP and medications can vary so much in their implementation. For example, what CBT

tools are specifically taught to the study participants and what dosage of medication they are on

and for how long. Unfortunately, there is no uniform way of testing each theoretical treatment as

a whole and each individual’s drug dosage can depend on their height, weight and duration of

treatment etc. The issues of not being able to directly compare each intervention in a uniform

matter is problematic. One suggestion for future research would be to come up with and test

various instruments that could uniformly present each intervention to test in a study.

Another issue with directly comparing treatments such as CBT, ACT and ERP is the fact

that these different treatments are essentially one in the same. ACT is a derivative of CBT and

ERP is a specific tool within the umbrella of CBT. With these various treatments being so

intertwined, this would be a good explanation as to why the differences in testing them are so

marginal. Future research should better specify and outline the connections of each theory before

identifying each as a separate entity entirely.

Lastly, a gap in the current research is that most studies are done using participants that

are only adults or only young children. However, there was not much available on young adults

specifically, which is a crucial demographic. Finally, with the exception of one study, there were

not many current articles available that specifically focused on adult women or adult men. As

women and men differ so much in their thought patterns this seems like an obvious place to start

for future studies.

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Reference List

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental

disorders (5th ed.). Washington, DC: Author

Anand, N., Sudhir, P. M., Math, S. B., Thennarasu, K., & Janardhan Reddy, Y. C. (2011).

Cognitive behavior therapy in medication non-responders with obsessive–compulsive

disorder: A prospective 1-year follow-up study. Journal of Anxiety Disorders, 25(7),

939–945. https://doi.org/10.1016/j.janxdis.2011.05.007

Asnaani, A., Kaczkurkin, A. N., Alpert, E., McLean, C. P., Simpson, H. B., & Foa, E. B. (2017).

The effect of treatment on quality of life and functioning in OCD. Comprehensive

psychiatry, 73, 7–14.

https://doi-org.go.libproxy.wakehealth.edu/10.1016/j.comppsych.2016.10.004

Carmi, L., Tendler, A., Bystritsky, A., Hollander, E., Blumberger, D. M., Daskalakis, J., …

Zohar, J. (2019). Efficacy and safety of Deep transcranial magnetic stimulation for

obsessive-compulsive Disorder: A Prospective Multicenter randomized double-blind

placebo-controlled trial. American Journal of Psychiatry, 176(11), 931–938.

https://doi.org/10.1176/appi.ajp.2019.18101180

Fineberg, N. A., Brown, A., Pampaloni, I., & Reghunandanan, S. (2012). Evidence-based

pharmacotherapy of obsessive–compulsive disorder. International Journal of

Neuropsychopharmacology, 15, 1173–1191.

https://doi.org/doi:10.1017/S1461145711001829

Fisher, P. L., Cherry, M. G., Stuart, T., Rigby, J. W., & Temple, J. (2020). People with

obsessive-compulsive disorder often remain symptomatic following psychological

15
OBSESSIVE-COMPULSIVE DISORDER

treatment: A clinical significance analysis of manualised psychological interventions.

Journal of Affective Disorders, 275, 94–108. https://doi.org/10.1016/j.jad.2020.06.019

Leeuwerik, T., Cavanagh, K., & Strauss, C. (2019). Patient adherence to cognitive behavioural

therapy for obsessive-compulsive disorder: A systematic review and meta-

analysis. Journal of anxiety disorders, 68, 102135.

https://doi.org/10.1016/j.janxdis.2019.102135

Meng, F.-Q., Han, H.-Y., Luo, J., Liu, J., Liu, Z.-R., Tang, Y., Hou, X., Wei, J., Shi, L.-L., Tang,

M.-N., Yan, Y.-P., Huang, Y.-Q., Sun, J., & Li, Z.-J. (2019). Efficacy of cognitive

behavioural therapy with medication for patients with obsessive-compulsive disorder: A

multicentre randomised controlled trial in China. Journal of Affective Disorders, 253,

184–192. https://doi-org.go.libproxy.wakehealth.edu/10.1016/j.jad.2019.04.090

Miller, E. W., Shoup, D. S., & Recktenwald, E. W. (2019). Real-world and clinical trial efficacy

of selective serotonin-reuptake inhibitors in the treatment of obsessive-compulsive

disorder measured by survey and meta-analysis. Journal of Obsessive-Compulsive and

Related Disorders, 23, 100456. https://doi.org/10.1016/j.jocrd.2019.100456

Rohani, F., Rasouli-Azad, M., Twohig, M. P., Ghoreishi, F. S., Lee, E. B., & Akbari, H. (2018).

Preliminary test of group acceptance and commitment therapy on obsessive-compulsive

disorder for patients on optimal dose of selective serotonin reuptake inhibitors. Journal

of Obsessive-Compulsive and Related Disorders, 16, 8–13.

https://doi.org/10.1016/j.jocrd.2017.10.002

Roth, Y., Barnea-Ygael, N., Carmi, L., Storch, E. A., Tendler, A., & Zangen, A. (2020). Deep

transcranial magnetic stimulation for obsessive-compulsive disorder is efficacious even

16
OBSESSIVE-COMPULSIVE DISORDER

in patients who failed multiple medications and CBT. Psychiatry Research, 290, 113179.

https://doi.org/10.1016/j.psychres.2020.113179

Skapinakis, P., Caldwell, D. M., Hollingworth, W., Bryden, P., Fineberg, N. A., Salkovskis, P.,

… Lewis, G. (2016). Pharmacological and psychotherapeutic interventions for

management of obsessive-compulsive disorder in adults: a systematic review and

network meta-analysis. The Lancet Psychiatry, 3(8), 730–739.

https://doi.org/10.1016/s2215-0366(16)30069-4

Storch, E. A., Rasmussen, S. A., Price, L. H., Larson, M. J., Murphy, T. K., & Goodman, W. K.

(2010). Development and psychometric evaluation of the Yale–Brown Obsessive-

Compulsive Scale—Second Edition. Psychological Assessment, 22(2), 223–232.

https://doi.org/10.1037/a0018492

Twohig, M. P., Whittal, M. L., Cox, J. M., & Gunter, R. (2010). An initial investigation into the

processes of change in ACT, CT, and ERP for OCD. International Journal of Behavioral

Consultation and Therapy, 6(1), 67–83. https://doi.org/10.1037/h0100898

U.S. Department of Health and Human Services. (2019, October). Obsessive-Compulsive

Disorder. National Institute of Mental Health.

https://www.nimh.nih.gov/health/topics/obsessive-compulsive-disorder-ocd/index.shtml

Woody, S. R., Whittal, M. L., & McLean, P. D. (2011). Mechanisms of symptom reduction in

treatment for obsessions. Journal of Consulting and Clinical Psychology, 79(5), 653–664.

https://doi.org/10.1037/a0024827