Clomipramine, Self-exposure and Therapist-aided Exposure for Obsessive–Compulsive Rituals

Abstract

A randomised treatment design for 49 chronically obsessive-compulsive ritualising patients was devised and three controlled comparisons were made. 1. During 7 weeks of self-exposure instructions, clomipramine treatment improved some measures of rituals and depression significantly more than did placebo medication; this effect was transient and disappeared as drug treatment and exposure were continued for a further 15 weeks. 2. During 11-16 weeks of clomipramine treatment, self-exposure instructions yielded highly significantly more patient improvement than did anti-exposure instructions on nearly all measures of rituals and some of social adjustment. 3. Adding therapist-aided exposure (1.3 hours) to self-exposure instructions (3 hours) after 8 weeks had a barely significant transient effect of dubious clinical value, which was lost by the end of exposure (at week 23) and during follow-up assessments to week 52. We conclude that of the three therapeutic factors tested, self-exposure was the most potent; clomipramine played a limited adjuvant role, and therapist-aided exposure a marginal one.

World Federation of Societies of Biological Psychiatry (WFSBP) Guidelines for the Pharmacological Treatment of Anxiety, Obsessive-Compulsive and Post-Traumatic Stress Disorders – First Revision

“…In another complex study involving self-exposure, clomipramine, and therapist-aided exposure, self-exposure was the most potent; clomipramine played a limited adjuvant role, and therapist-aided exposure a marginal one (Marks et al 1988). A comparison of fluvoxamine with antiexposure, fluvoxamine with exposure, or placebo with exposure was difficult to interpret.…”

Behaviour therapy and drug treatments for obsessive–compulsive disorder

“…Marks and colleagues compared clomipramine and exposure with exposure alone. They found that although clomip ramine initially enhanced the effect of exposure, this drug effect had disappeared at two years' follow-up (Marks et al, 1988).…”

“…The recruiting of an informant, such as a close family member, is often very useful in that the OCD sufferer may minimise his level of disability or omit crucial avoidances, and family members may need guidance in avoiding offering reassurance. This often involves explicit coaching, for example, encouraging the relative to respond to requests for reassurance with the same neutral and monotonous response -'the hospital has instructed me to say no answer' (Marks, 1986).…”

“…There are several instruments which give a quantitative assessment of OCD symptoms. As a routine package in the assessment of OCD, I would advise using the Self-Report Obsessive Compulsive Checklist, (Marks, 1986); the Fear Questionnaire (Marks & Matthews, 1979), and the Beck Depression Inventory (Beck et al, 1961).…”

Increased Maintenance of Obsessive-Compulsive Disorder Remission after Integrated Serotonergic Treatment and Cognitive Psychotherapy Compared with Medication Alone

“…This strategy might be warranted also with other psychotherapeutic approaches. Although only one trial reported superiority of combined treatment at the study endpoint [29], in most trials combined treatment was superior to medication or psychotherapy alone in the first weeks [30, 31, 32]. Also, many studies suggest that adding psychotherapy might lead to further improvement in patients who are already stabilised on medication [33, 34, 35, 36].…”