Adding motivational interviewing to exposure and ritual prevention for obsessive-compulsive disorder: an open pilot trial

Psychotherapies and digital interventions for OCD in adults: What do we know, what do we need still to explore?

BACKGROUND

Despite significant advances in the understanding and treatment of obsessive compulsive disorder (OCD), current treatment options are limited in terms of efficacy for symptom remission. Thus, assessing the potential role of iterative or alternate psychotherapies is important. Also, the potential role of digital technologies to enhance the accessibility of these therapies, should not be underestimated. We also need to embrace the idea of a more personalized treatment choice, being cognisant of clinical, genetic and neuroimaging predictors of treatment response.

PROCEDURES

Non-systematic review of current literature on emerging psychological and digital therapies for OCD, as well as of potential biomarkers of treatment response.

FINDINGS

A number of 'third wave' therapies (e.g., Acceptance and Commitment Therapy, Mindfulness-Based Cognitive Therapy) have an emerging and encouraging evidence base in OCD. Other approaches entail employment of elements of other psychotherapies such as Dialectical Behaviour Therapy; or trauma-focussed therapies such as Eye Movement Desensitisation and Reprocessing, and Imagery Rescripting and Narrative Therapy. Further strategies include Danger Ideation Reduction Therapy and Habit Reversal. For these latter approaches, large-scale randomised controlled trials are largely lacking, and the precise role of these therapies in treating people with OCD, remains to be clarified. A concentrated 4-day program (the Bergen program) has shown promising short- and long-term results. Exercise, music, and art therapy have not been adequately tested in people with OCD, but may have an adjunctive role. Digital technologies are being actively investigated for enhancing reach and efficacy of psychological therapies for OCD. Biomarkers, including genetic and neuroimaging, are starting to point to a future with more 'personalised medicine informed' treatment strategizing for OCD.

CONCLUSIONS

There are a number of potential psychological options for the treatment of people with OCD who do not respond adequately to exposure/response prevention or cognitive behaviour therapy. Adjunctive exercise, music, and art therapy might be useful, albeit the evidence base for these is very small. Consideration should be given to different ways of delivering such interventions, including group-based, concentrated, inpatient, or with outreach, where appropriate. Digital technologies are an emerging field with a number of potential applications for aiding the treatment of OCD. Biomarkers for treatment response determination have much potential capacity and deserve further empirical testing.

Neural correlates of emotional reactivity predict response to cognitive-behavioral therapy in obsessive-compulsive disorder

BACKGROUND

Examining predictive biomarkers to identify individuals who will likely benefit from a specific treatment is important for the development of targeted interventions. The late positive potential (LPP) is a neural marker of attention and elaborated stimulus processing, and increased LPP responses to negative stimuli are characteristic of pathological anxiety. The present study investigated whether LPP reactivity would prospectively predict response to cognitive-behavioral therapy (CBT), the first-line treatment for obsessive-compulsive disorder (OCD).

METHODS

To this end, the LPP in response to negative as compared to neutral pictures was examined in 45 patients with OCD, who underwent CBT in a naturalistic outpatient setting. LPP amplitudes were used as predictors of symptom reduction after CBT.

RESULTS

We found that higher LPP amplitudes to negative relative to neutral stimuli were predictive of lower self-reported OCD symptoms after completion of CBT, controlling for pre-treatment symptoms. Further, LPP reactivity was negatively correlated with self-reported habitual use of suppression in everyday life.

LIMITATIONS

Some participants had already begun treatment at the time of study participation. Overall, results need further replication in larger samples and standardized therapy settings.

CONCLUSIONS

The current findings suggest that patients with increased emotional reactivity benefit more from CBT, possibly through less avoidance of anxiety-provoking stimuli during exposure with response prevention, a crucial component in CBT for OCD. Although its clinical utility still needs to be evaluated further, the LPP constitutes a promising candidate as a prognostic marker for CBT response in OCD.

Knowledge and competency standards for specialized cognitive behavior therapy for adult obsessive-compulsive disorder

Obsessive-Compulsive Disorder (OCD) is a leading cause of disability world-wide (World Health Organization, 2008). Treatment of OCD is a specialized field whose aim is recovery from illness for as many patients as possible. The evidence-based psychotherapeutic treatment for OCD is specialized cognitive behavior therapy (CBT, NICE, 2005, Koran and Simpson, 2013). However, these treatments are not accessible to many sufferers around the world. Currently available guidelines for care are deemed to be essential but insufficient because of highly variable clinician knowledge and competencies specific to OCD. The phase two mandate of the 14 nation International OCD Accreditation Task Force (ATF) created by the Canadian Institute for Obsessive Compulsive Disorders is development of knowledge and competency standards for specialized treatments for OCD through the lifespan deemed by experts to be foundational to transformative change in this field. This paper presents knowledge and competency standards for specialized CBT for adult OCD developed to inform, advance, and offer a model for clinical practice and training for OCD. During upcoming ATF phases three and four criteria and processes for training in specialized treatments for OCD through the lifespan for certification (individuals) and accreditation (sites) will be developed based on the ATF standards.

Cognitive Behavioral Intervention for Youth at Risk for Conduct Problems: Future Directions

This article briefly overviews the history of cognitive behavioral intervention (CBI) for children displaying early signs, or actual diagnoses, of conduct disorders. A series of randomized control trials have identified evidence-based CBI programs for children with these behavior problems at various developmental stages from preschool through adolescence. Although it is critically important for the field to disseminate these existing programs as developed, we argue that it is important to also move beyond the existing evidence-based programs. Research should continue to test new comprehensive, multicomponent interventions, fueled by our evolving understanding of active mechanisms that contribute to children's externalizing behavior problems. The future of research in this area can also benefit from a focus on four central issues. First, research can address how single interventions can have meaningful impact on a range of transdiagnostic outcomes because the intervention mechanisms may affect those various outcomes. Second, rooted in implementation science, we are beginning to understand better how evidence-based programs can be disseminated in the real world, examining key issues such as the adequacy of training approaches and the role of therapist and organizational characteristics. Third, a major focus of research can be on how to optimize intervention outcomes, including a focus on microtrials, on tailoring of interventions, on examining rigorously how interventions are delivered, and on the integration of technology and of other approaches such as mindfulness training into CBI. Fourth, research can explore how the therapeutic relationship and the therapists' characteristics can play substantial roles in effective CBI with conduct problem children.

Does Motivation Impact OCD Symptom Severity? An Exploration of Longitudinal Effects

Understanding the role of patient motivation in OCD treatment is of clinical importance given the requisite autonomous role of patients in Exposure and Response Prevention. The present study investigated state- and trait-like relations between three variables: two previously established motivational constructs, readiness to change (RTC) and committed action (CA), derived from the University of Rhode Island Change Assessment, and OCD symptom severity as measured by the self-report Yale-Brown Obsessive Compulsive Scale (Y-BOCS-SR). Utilizing a random-intercept cross-lagged panel model (RI-CLPM) design, we assessed autoregressive, within-time correlations, and cross-lagged effects of RTC, CA, and Y-BOCS-SR scores at admission, month 1 of treatment, and discharge from an intensive/residential treatment program for OCD. Results revealed significant autoregressive (i.e., state-like) effects for CA and Y-BOCS-SR, negative within-time correlations between state CA and Y-BOCS-SR across all time points, a positive within-time correlation between state CA and RTC at admission, and a cross-lagged effect between state Y-BOCS-SR at month 1 of treatment and state RTC at discharge. Results also demonstrated that the stability of the RTC variable was attributable to trait-like factors in the present sample. This study is novel in its use of RI-CLPM in an OCD sample and represents an important addition to the literature on the longitudinal impacts of dynamic constructs of motivation. Our findings may provide future researchers with strategies to supplement ERP with CA-driven motivational interviewing.

Predictors of treatment outcome and attrition in adults with hoarding disorder

While a number of hoarding disorder-specific therapeutic interventions have been developed over recent years, hoarding disorder (HD) remains difficult to treat. The purpose of this investigation is to inform HD treatment efforts by examining factors that influence treatment attrition and treatment response. Secondary data analysis of baseline and post-treatment data from two previously published psychotherapy treatment studies for hoarding were performed to identify predictors of hoarding symptom improvement and treatment attrition in 106 adults with HD. No demographic variables were associated with symptom improvement or treatment attrition. However, higher levels of avoidant coping (i.e., self-distraction combined with behavioral disengagement) significantly predicted symptom improvement. The maintenance stage of change along with high readiness for change also significantly predicted symptom improvement. Participants who dropped from treatment had significantly higher baseline levels of denial and clutter, both of which independently predicted treatment attrition. The findings from this study suggest that emotion-related constructs, such as managing stress and motivation for change, may play an important role in patients' response to and participation in HD treatment.

Motivational Interviewing as an Adjunct to Cognitive Behavior Therapy for Anxiety Disorders: A Critical Review of the Literature

Cognitive behavior therapy (CBT) is efficaciously and effectively used in the treatment of anxiety disorders; however, as CBT for anxiety routinely utilizes exposure components, clients often experience ambivalence about treatment and their clinicians often must deal with resistance. Motivational Interviewing (MI) is a therapeutic strategy that addresses ambivalence about change in clinical interventions. MI has been applied as an adjunct for treatments such as CBT in order to increase motivation for and commitment to the intervention, especially when components of the treatment may be challenging (e.g., exposure, cognitive restructuring). Though researchers have commented specifically on the use of MI as a supplement to CBT for anxiety disorders, no comprehensive review has systematically assessed the strengths and limitations of extant literature on the topic, nor across anxiety disorders. Findings are summarized from 6 case studies and uncontrolled trials and 11 randomized controlled trials published through March 2016. An integrated critique of this literature also is offered. Limitations and the preliminary nature of the work in this area notwithstanding, it appears that it is feasible to supplement or integrate CBT with MI and that doing so has the potential to improve treatment initiation and engagement, as well as clinical outcomes. A number of directions for future research are addressed, such as determining which MI approaches to implement, with whom, when, and in what contexts.

Patient adherence and treatment outcome with exposure and response prevention for OCD: Which components of adherence matter and who becomes well?

Exposure and response prevention (EX/RP) is an evidence-based treatment for obsessive-compulsive disorder (OCD), yet not all patients achieve wellness with EX/RP. The degree to which patients adhere to EX/RP procedures outside of sessions has been found to predict therapy outcomes, including who achieves post-treatment wellness. We sought to investigate which components of treatment adherence most relate to outcome and to develop adherence benchmarks to identify who does and does not become well to provide clinicians with prognostic tools. Adherence data came from 37 adult patients with DSM-IV OCD who received 17 sessions of EX/RP as part of a randomized controlled trial of augmentation strategies for incomplete response to serotonin reuptake inhibitors (SRIs). Therapists rated between-session patient adherence at each exposure session by quantifying: 1) the quantity of homework exposures attempted; 2) the quality of attempted exposures; and 3) the degree of success with response prevention. Each adherence item significantly correlated with post-treatment OCD severity. Success with response prevention proved particularly strongly linked to therapy outcome. Time course analysis of this item accurately identified, relatively early in treatment, who would achieve post-treatment wellness. These data provide an efficient method for differentiating between those patients who will and will not achieve wellness after EX/RP augmentation of SRIs. Limitations and clinical implications of the current findings are discussed.

Effect of motivational interviewing on quality of life in patients with epilepsy

OBJECTIVE

In this study, the effect of motivational interviewing on quality of life was evaluated in patients with epilepsy.

METHODS

Fifty-six patients with epilepsy in a clinical trial were randomly assigned to intervention and control groups. Motivational interviewing during 5 sessions was applied for the intervention group, and the control group received health-care services. Quality-of-life questionnaire in epilepsy (QOLIE-89) was applied as pre- and posttest for both groups. Before and two months after intervention, both groups were assessed. Data were analyzed by independent t-test, Chi-square test, and paired t-test.

RESULTS

The data analysis showed that mean score of the QOLIE-89 was 38.94±8.55 and 70.90±7.99 in the intervention group before and after the intervention, respectfully, and 44.59±12.27 and 36.52±7.16 in the control group sequentially. The intervention group showed a significant score increase in their quality of life (p<0.001), whereas the control group had a score decrease (p<0.001).

CONCLUSION

Motivational interviewing approach could be used as an effective intervention method for improving patients' quality of life.

Does d-Cycloserine Augmentation of CBT Improve Therapeutic Homework Compliance for Pediatric Obsessive-Compulsive Disorder?

Clinical studies in adults and children with obsessive-compulsive disorder (OCD) have shown that d-cycloserine (DCS) can improve treatment response by enhancing fear extinction learning during exposure-based psychotherapy. Some have hypothesized that improved treatment response is a function of increased compliance and engagement in therapeutic homework tasks, a core component of behavioral treatment. The present study examined the relationship between DCS augmented cognitive-behavioral therapy (CBT) and homework compliance in a double-blind, placebo controlled trial with 30 youth with OCD. All children received 10 CBT sessions, the last seven of which included exposure and response prevention paired with DCS or placebo dosed 1 h before the session started. Results suggested that DCS augmented CBT did not predict improved homework compliance over the course of treatment, relative to the placebo augmented CBT group. However, when groups were collapsed, homework compliance was directly associated with treatment outcome. These findings suggest that while DCS may not increase homework compliance over time, more generally, homework compliance is an integral part of pediatric OCD treatment outcome.

Treatment fears in anxiety disorders: development and validation of the treatment ambivalence questionnaire

OBJECTIVES

There are a number of effective psychological interventions for anxiety disorders. Anecdotal and empirical evidence indicates that clients are often highly apprehensive about commencing therapy. However, to date, there have been no empirical studies of the content of individuals' fears about beginning a psychological treatment for anxiety problems. Here we describe the development and initial validation of the Treatment Ambivalence Questionnaire (TAQ), a 30-item self-report measure of concerns about commencing psychological treatment for anxiety.

METHODS

Participants were a large group of individuals with a principal diagnosis of an anxiety disorder who were referred to a specialty anxiety disorders clinic. Participants completed the TAQ as well as several general self-report instruments before commencing treatment.

RESULTS

The TAQ exhibited good internal consistency and, based on exploratory factor analyses, the items yielded three subscales: (a) fears of the personal consequences of engaging in treatment (e.g., personality change), (b) fears of negative or adverse reactions to treatment (e.g., not getting better), and (c) concerns about the inconvenience of engaging in treatment (e.g., treatment will be time-consuming). Confirmatory factor analysis supported this factor structure. Scores on the TAQ did not simply represent general symptom severity or distress. Preliminary data on the relation of TAQ scores to treatment outcome suggested either no relationship or a small relationship.

CONCLUSION

The TAQ may be a useful means of normalizing treatment fears, identifying and addressing specific fears, and identifying people who may benefit from treatment readiness interventions.

Motivational Interviewing for adolescent substance use: a review of the literature

Motivational Interviewing (MI) is a widely-used approach for addressing adolescent substance use. Recent meta-analytic findings show small but consistent effect sizes. However, differences in intervention format and intervention design, as well as possible mediators of change, have never been reviewed. This review of the literature summarizes the most up-to-date MI interventions with adolescents, looks at differences between intervention format and design, and discusses possible theory-based mechanisms of change. Of the 39 studies included in this review, 67% reported statistically significant improved substance use outcomes. Chi square results show no significant difference between interventions using feedback or not, or interventions combined with other treatment versus MI alone. The need for systematic investigation in theory-based mechanisms of change is presented.

Extending motivational interviewing to the treatment of major mental health problems: current directions and evidence

Motivational interviewing (MI) was originally developed for the treatment of substance abuse but is rapidly expanding to other major mental health populations beyond addictions. This brief review considers the use of MI and related motivational enhancement therapies (METs) in the treatment of anxiety, depression, and eating disorders, and concurrent psychosis and substance use disorders. MI-MET has been added and (or) integrated into treatment for these problems in a wide variety of ways, most commonly as a pretreatment to other therapies (psychosocial treatments and pharmacotherapy) or integrated into standard assessment procedures. In each problem domain, the bulk of the current evidence supports the value of adding MI to existing therapies in increasing engagement with treatment and in improving clinical outcomes. This is particularly encouraging in that many of the populations included in these investigations represent severe and treatment-recalcitrant populations. However, research on the application of MI to other major mental health problems beyond addictions is in the early stages, with existing studies having numerous limitations (for example, small uncontrolled studies or lack of adequate control groups, and failure to establish both MI treatment integrity and the unique contribution of MI in integrated treatments). In short, the substantial body of promising preliminary findings strongly support the continued investigation of MI and related methods for these populations in well-designed clinical trials that examine not only the additive value of MI but also mechanisms underlying these effects and individual differences (moderators) indicating the need for MI.

Patient utilization of cognitive-behavioral therapy for OCD

The current study examined utilization of cognitive-behavioral therapy (CBT) by individuals receiving treatment for obsessive-compulsive disorder (OCD). Participants were 202 adults with primary DSM-IV OCD who enrolled in a longitudinal, observational study of the course of OCD and completed 2 years of annual follow-up interviews using the Longitudinal Interval Follow-Up Evaluation. One hundred twenty participants reported that a mental health professional recommended CBT for their OCD symptoms at some point during the 2-year follow-up period. One quarter (n = 31) of these participants did not initiate CBT despite receiving a treatment recommendation. Thirty-one percent of the 89 participants who entered CBT endorsed dropping out of CBT prematurely and less than one third received an adequate "dose" of CBT sessions. Self-reported CBT drop-out rates were significantly greater than attrition rates reported in clinical trials using intensive schedules of exposure and ritual prevention (EX/RP). Perceived environmental barriers and fears regarding treatment participation were the most frequently endorsed reasons for not participating or dropping out of CBT. Despite its efficacy for OCD, many individuals with clinically significant symptoms fail to initiate CBT when recommended by a mental health professional, receive treatments that are less intensive than those used in clinical trials, or drop out of treatment prematurely. Financial costs of CBT, difficulty attending sessions, and fears regarding treatment are significant barriers to initiating and completing therapy.

The role of treatment expectancy in youth receiving exposure-based CBT for obsessive compulsive disorder

The purpose of this investigation was to examine correlates of parent, child, and therapist treatment expectations and their role in the exposure-based treatment of childhood obsessive compulsive disorder (OCD). Treatment expectations were assessed among 49 youth with primary OCD, their parents, and therapists as part of the baseline evaluation and post-treatment clinical outcomes were determined by blind evaluators. Baseline depressive symptoms, child/parent-rated functional impairment, externalizing behavior problems, number of comorbid psychiatric disorders, and a lower perception of control were associated with lower pre-treatment expectations. Parent expectation was associated with parental OCD symptoms, child depressive symptoms and child-reported impairment. Therapist expectations inversely correlated with child depressive symptoms, externalizing problems, and child-rated impairment. Pre-treatment OCD severity and prior treatment history were not linked to expectancy. Finally, higher treatment expectations were linked to better treatment response, lower attrition, better homework compliance, and reduced impairment.

Overcoming barriers to disseminating exposure therapies for anxiety disorders: a pilot randomized controlled trial of training methods

The present study evaluated methods for training mental health providers (N=46) in exposure therapies (ETs) for anxiety disorders. A pilot randomized controlled trial compared: (1) an interactive, multimedia online training (ET OLT), (2) the ET OLT plus a brief Motivational Interviewing-based intervention (ET OLT+MI), and (3) a placebo control OLT. Assessments were completed at baseline, post-training, and one-week following training. Both ET OLT and ET OLT+MI received high satisfaction ratings and were comparably effective at increasing knowledge of ETs as well as clinicians' overt efforts to learn and use the treatment. ET OLT+MI was the most effective method for improving clinicians' attitudes toward ETs. Results indicate that OLT is effective for disseminating knowledge about ETs to clinicians, and suggest that supplementing OLT with a brief MI-based intervention may be a promising direction to address potential attitudinal barriers to adopting these highly efficacious treatments.

Using Motivational Interviewing to Enhance Treatment Outcome in People With Obsessive-Compulsive Disorder

Obsessive-compulsive disorder (OCD) is a leading cause of health-related disability. There are two evidence-based treatments for OCD, pharmacotherapy and cognitive-behavioral therapy consisting of exposure and response prevention (EX/RP). Although effective, outcome from both treatments is often limited by patient lack of adherence to the treatment procedures. In this article, we present the rationale for using motivational interviewing (MI) to increase EX/RP adherence. We then review two published studies that used MI in different ways to foster EX/RP participation. Finally, we describe 6 cases in which we explored whether MI could help ready OCD patients who had refused or failed prior evidence-based treatment of any kind. Together, these data illustrate the promise and obstacles of employing MI to promote treatment adherence in OCD. We conclude by discussing future directions for researchers and for clinicians when using MI in this population.

Challenges using motivational interviewing as an adjunct to exposure therapy for obsessive-compulsive disorder

Exposure and response prevention (EX/RP) is an efficacious treatment for obsessive-compulsive disorder (OCD). However, patients often do not adhere fully to EX/RP procedures. Motivational interviewing (MI) has been shown to improve treatment adherence in other disorders. This pilot study used a randomized controlled design to examine whether MI can be successfully added to EX/RP and whether this intervention (EX/RP+MI) could improve patient adherence to between-session EX/RP procedures relative to EX/RP alone. Thirty adults with OCD were randomized to 18 sessions of EX/RP or EX/RP+MI. Therapists rated patient adherence at each exposure session. Independent evaluators assessed change in OCD and depressive symptoms, and patients completed self-report measures of readiness for change and quality of life. The two treatment conditions differed in degree of congruence with MI but not in conduct of EX/RP procedures. Both groups experienced clinically significant improvement in OCD symptoms, without significant group differences in patient adherence. There are several possible reasons why EX/RP+MI had no effect on patient adherence compared to standard EX/RP, each of which has important implications for the design of future MI studies in OCD. We recommend that MI be further evaluated in OCD by exploring alternative modes of delivery and by focusing on patients less ready for change than the current sample.

The future and promise of cognitive behavioral therapy: a commentary

The Academy for Psychological Clinical Science and the independent accrediting entity it created, the Psychological Clinical Science Accreditation system, have recently launched a movement aimed at reforming all of clinical psychology. If this movement is successful, it will result in a greater emphasis on empirical science in the practice of clinical psychology. As cognitive behavioral therapy (CBT) is the approach that currently has the greatest number of controlled scientific studies supporting it, this should be an impetus for CBT to grow. The very same scientific evidence that supports the efficacy of CBT, however, also shows that CBT is far from fully efficacious. Several recent trends that hold great promise to enhance the effectiveness of CBT are discussed, such as greater integration of CBT with biological approaches, cognitive science, systemic approaches, motivational interviewing, and strengths-based approaches.

Cognitive behavioral therapy for substance use disorders

Cognitive behavioral therapy (CBT) for substance use disorders has shown efficacy as a monotherapy and as part of combination treatment strategies. This article provides a review of the evidence supporting the use of CBT, clinical elements of its application, novel treatment strategies for improving treatment response, and dissemination efforts. Although CBT for substance abuse is characterized by heterogeneous treatment elements such as operant learning strategies, cognitive and motivational elements, and skills-building interventions, across protocols several core elements emerge that focus on overcoming the powerfully reinforcing effects of psychoactive substances. These elements, and support for their efficacy, are discussed.

Treatment-resistant Obsessive-compulsive Disorder in Young People: Assessment and Treatment Strategies

Cognitive behaviour therapy (CBT) and selective serotonin reuptake inhibitors have both been established as effective interventions for paediatric obsessive-compulsive disorder (OCD), with CBT being the recommended first-line treatment in most cases. While the majority of young people respond well to these treatments, a significant proportion remain symptomatic. Although the research on treatment-resistant OCD remains limited, increasing empirical attention is being paid to predictors of treatment outcome in young people with OCD, and efforts are being made to identify the factors that hinder recovery. This article outlines potential barriers in treatment and highlights strategies for optimising outcome, with particular focus on cognitive behavioural techniques.

Adding a motivational interviewing pretreatment to cognitive behavioral therapy for generalized anxiety disorder: a preliminary randomized controlled trial

Seventy-six individuals with a principal diagnosis of generalized anxiety disorder (GAD) were randomly assigned to receive either an MI pretreatment or no pretreatment (NPT), prior to receiving CBT. Significant group differences favoring the MI-CBT group were observed on the hallmark GAD symptom of worry and on therapist-rated homework compliance, which mediated the impact of treatment group on worry reduction. Adding MI pretreatment to CBT was specifically and substantively beneficial for individuals with high worry severity at baseline. There was evidence of relapse at 6-month follow-up for high severity individuals who received MI-CBT, but significant moderator effects favoring the high severity MI-CBT group were again apparent at 12-months post-treatment. Pending replication in a more controlled test, these findings suggest that MI may be a promising adjunct to CBT for GAD for those of high severity, a group which has been less responsive to CBT in past research.

Psychotherapy for obsessive-compulsive disorder

Cognitive-behavioral therapy (CBT) with exposure and response prevention is a first-line intervention for adult and childhood obsessive-compulsive disorder. Methodologically rigorous controlled trials have suggested that benefits from CBT exceed those from placebo and attention-control conditions and have similar or greater efficacy than serotonergic monotherapy. This article reviews the nature of CBT and associated outcome data, highlighting recent empiric findings in the treatment literature.