THE CONTRIBUTION OF COGNITIVE- BEHAVIORAL THERAPY TO THE TREATMENT OF OBSESSIVE-COMPULSIVE DISORDER
By the nature of specific clinical manifestations, obsessive-compulsive disorder is a unique psychiatric nosology, requiring a distinct approach to treatment. The currently existing debate in the psychiatric and psychotherapeutic medical environment refers to the type of treatment and the existing scientific validity at the moment. Cognitive-behavioral psychotherapy has a strong scientific support that recommends it as a stand- alone intervention or along with medication to treat the obsessive pathology.
As with many other psychiatric nosologies, the OCD etiopatogy is mostly made up of bio-psycho-social dysfunctions. Neuroimaging has found that the OCD involves a dysfunction located in the cortico-striatal- thalamic-cortical, with extensions in the amygdala, hippocampus, the anterior cingulate cortex and dorsolateral prefrontal cortex (4) (5) (6) (7) (8). At the level of neurotransmitters, a mutation was discovered in the hSERT gene, called I425V, resulting in a decrease in the level of serotonin in the neuronal synapse (9). Another biological aspect of TOC, consists of a specific increase in the intensity of symptoms of OCD or tics, in infants with a neuropsychiatric disorders, infections related to the presence of beta-hemolytic streptococci of group A (10) (11).
The theory of cognitive behavioral therapy (CBT), advances the idea that intrusive thoughts would be perceived by the patient as hazardous / catastrophic, resulting in the emergence of anxiety / depression. After all, everyone presents intrusive thoughts, but patients with OCD gives them a much greater significance and interprets them in a different sense. Social factors that contribute to the triggering / amplification of specific symptoms of this disorder are correlated with adverse life events, ie the distress caused by these events (12) (13).
CBT EFFICIENCY IN OCD AND THE REPRESENTATION BY NEUROIMAGING
Two meta-analyzes, first taking into account 19 studies conducted between 1980 to 2006, and the second taking into account 37 studies conducted between
1993 and 2014, measured the effect technique Exposition Prevention Response (ERP) compared to the overall effect of CBT. The results of the two meta-analyzes, and other studies indicate that CBT is effective in the treatment of OCD, thus revealing that the ERP and the Restructuring Cognitive (CR) technique are the most effective in addressing the TOC (14) (15) (16). Both the standard and the intensive CBT are effective in addressing the obsessive pathology. However, a more recent meta-analysis that includes 17 clinical studies shows that the CBT intensive therapeutic effect is installed faster compared to the CBT standard, but after three months of treatment this difference disappears, both forms being equally effective (17).
However, if there is a drug-resistant OCD, several factors contribute to achievement of the positive therapeutic results through the use of psychotropic medication combined with CBT (18). Getting an effective therapeutic response may be adversely affected by the presence of a serious OCD symptomatology, comorbidity of depression, somatoform disorders of high intensity or low levels of insight (19). Psychotherapeutic cognitive behavioral intervention combined with antidepressant medication / antipsychotic contribute in such cases to decrease anxiety / depression, and not least of symptoms caused by OCD (20) (21) (22).
It is known that a combination of psychiatric medication with psychotherapy determines significant changes in the patient’s brain (23). This is true, however, in the separate evaluation of the two therapeutic forms (24) (25) (26). Through direct influence on the brain caused by changes produced in the neuronal circuits with direct / indirect field of epigenetic effect of cognitive-behavioral therapy (CBT) on the brain, it may be considered in some cases, similar to psychotropic medication, more accurately, identical to a ,, epigenetic action drug „(27).
When referring to anxiety disorders, it appears that cognitive therapy (CT) acts mainly by gains in ventral and dorsal anterior cingulate cortex (ACC), the PFC median (mPFC), and not least the right cortex ventrolateral. Simultaneously, there is a decline in activity in the amygdala, hippocampus and medial temporal cortex. The cause of these neurophysiological changes, is attributed to the use of CBT techniques that have direct impact on higher executive functions such as problem solving, self-referential thinking or cognitive spectrum re- evaluations (28) (29). In OCD, short cognitive-behavioral therapy (CBTs) had as a direct effect on brain, neuro- anatomical changes consisting of a decrease in thalamic activation correlated with increases in activity of the dorsal anterior cingulate cortex (Dhaka), all these changes are related to a decrease in the symptoms of OCD-specific (30) (31) (32) (33).
OCD APPROACH BY THE CBT STANDARD
At the moment, there are a number of scientifically validated techniques specific to CBT, and that are effective in addressing the TOC, but not only. However it requires a greater influx of research in this area, given the complexity of clinical cases; it is important to correlate science with clinical practice and to find new ways, including the involvement of technology in the psychotherapeutic process (34) (35) (36) (37).
So the emergence of interactive platforms / websites to patients with OCD, contributes to the management of individual self-monitoring techniques such as obsessions and rituals, motivation, behavioral exposure, completing questionnaires / psychological test, etc. When this process involves a therapist, the effectiveness of these programs is evident (38). Involving technology in some psychiatric disorders, including OCD, is especially beneficial, not only in terms of efficiency but also economically, CBT being a viable choice in the field of psychopathology (39) (40). However in severe cases of OCD, standard CBT is recommended along with weekly meetings within the practice with direct applications in the patient’s life.
Because OCD is a complex psychiatric nosology, involving obsessive rituals, compulsive behavior and also anxiety or depression behaviors in the treatment of severe cases is recommended a combined between SSRI augmented with cognitive behavioral therapy (41). The combination of CBT and SSRI is superior in therapeutic efficacy and in the TOC, or CBT monotherapy consisting of SSRI (42).
Simpson et. al (2013) show that augmentation of SSRIs and cognitive behavioral therapy consisting of exposure and prevention rituals (EX / RP) is superior in terms of therapeutic augmentation to SSRIs with Risperidone, the two forms of treatment being superior augmentation of SSRIs and placebo in OCD. SSRI efficacy and EX / RP consisted of a statistically significant reduction in anxiety, depression and OCD specific symptoms compared to SSRI and Risperidone, SSRI and placebo respectively. One of the conclusions of this study indicates that augmentation of SSRIs before the TOC and an antipsychotic is recommended by the CBT intervention consisting of EX / RP (43) (44). Exposure with response prevention (ERP) can be considered as first-line intervention in the TOC (45), so it is used in a large proportion of the cognitive-behavioral therapists (46).
However, unfortunately 20% of patients with OCD do not accept ERP, and another 25% give up this technique after the first meeting of exposure, so it is necessary to add antidepressant medication or more cognitive therapy interventions (47). Using specific techniques Cognitive Therapy (CT) / Rational Emotional B eh av io r al Th er ap y ( R EB T) , p r o d u ce clin ical improvement within tolerance uncertainty / decrease in response to stimuli anxiogenic, a change in the scope of dysfunctional beliefs / irrational faiths and more compliance to treatment in these patients (48) (49). Lastly, the role of cognitive techniques is to prepare the patient for behavioral exposures that will be performed within therapy (50).
Thiel et al. (2016) in a pilot study, applied a combination therapy of the Scheme Centered Cognitive Therapy (ST), and ERP which they called a STERP, with OCD patients resistant to standard CBT intervention. The results of this study showed that after 12 weeks of treatment, there was a significant remission of the symptom of the TOC in the patients included in the study. These results remained stable after six months from the end of the intervention, a period in which the applied intervention CBT and ERP, indicating that the ST in combination CBT and ERP can be an alternative to the TOC resistant to intervention with CBT standard (51).
ACCEPTANCE AND COMMITMENT THERAPY IN OCD
Acceptance and Commitment Therapy (ACT) CBT is a psychotherapy belonging to the next generation (the third wave). By using philosophical pragmatism called functional contextualism (52) (53), ACT can be effective in addressing obsessional pathology, particularly due to increasing psychological flexibility (54). Psychological interventions consist of acceptance exercises or use of metaphors by the therapist in order to increase psychological flexibility of these patients. Other techniques consist in confronting mental obsessions and the awareness of emotions associated with these obsessions. Cognitive diffusion techniques serve to help the patient understand that obsessions and anxiety are directly connected more with his subjective experiences than the events of real life and that ultimately a thought is nothing more than a thought, in other words there is a big difference between thought and action (55). Beliefs / thoughts are not good or bad innately, but the interaction with stimuli and not least the significance attached to these stimuli lead to the division between positive or negative. If the patient with OCD responds to unexpected stimuli (intrusive thoughts / obsessions) as if they were real or would come from the real world, in other words map and territory are parts of a whole, the thought then becomes synonymous with the act / behavior (56). Another important aspect of the relational context (RFT), refers to the appearance of psychological discomfort by organizing the reports in a manner which causes irrational dysfunctional behavior. For example a patient may have the following intrusive / obsessive thought,, if I do not follow the same route every day to go to college, my mother will die „, this thought is followed by a sense that the patient attaches to the thought ,, if mom is going to die because I did not follow the same route every morning, it is a catastrophe and it is all happening just because of me. ” Thought the fusion between action and through the patient sees the situation as it would have happened already or would be about to happen, meaning ,, hot cognition „is ,, is awful and it would be a tragedy / disaster if mother would die because of me „, this thought is followed by mental neutralization ,, will follow the same route every day to avoid this to happen to me , so that I do not feel guilty and accountable ” (57), this thought generating anxiety, the final consequence is the emergence of rituals / compulsion. For this reason, before starting behavioral exposure techniques, the intolerance to uncertainty should be addressed directly and the thought-action fusion, through specific cognitive ACT diffusion techniques (58).
Perfectionism is a cognitive distortion that occurs generally because of the central beliefs or personality traits, which makes the patient using repetitive and contextual phrase must (59) (60). This must has an imperative connotation that contributes to increasing psychological inflexibility, including in patients with OCD. For instance if a person says ,, if you want to be a good student, you must go to class, „then must has a positive valence. Conversely if the same person says ,, I must be the best in all the examinations which I will sit in college, „then must has a negative value. The reason relates to the fact that nobody can be perfect and can not always succeed in all conditions. In fact, behind this must is the fear of failure, in other words the fear of liability (61) (62). Especially in obsessive pathology, the approach to perfectionism is by using cognitive restructuring techniques, the use of metaphors and not least using catastrophe avoidance techniques. Meanwhile, these techniques can be complemented with specific ACT techniques such as accepting, this resulting in reducing suppression of thought, and not activating the vicious circle of negative automatic thoughts / obsessions. Unconditional acceptance of oneself is an unevaluated system, uncritical and only refers to the highlighting of errors through isolated / contextual behaviors and acceptance of the fallible nature of the individual (63) (64).
Mindfulness site used as a therapeutic technique is a viable choice only when it is practiced in a practice, by a therapist, self-applied techniques of mindfulness do not have the desired effect in OCD (65).
Due to the complexity and bio-psycho-social deficits present in OCD, this approach requires a medical- psychological type multidisciplinary clinical pathology. Depending on the severity of symptoms, the psychiatrist may choose as mono-therapeutic treatment option, which may consist in medication / CBT or a combination of both methods of treatment. Due to the fact that the effect of CBT on brain / neuro-transmitters is similar to the SSRIs, it can be used as a means of increasing and can replace large doses of medication / augmentation with another medication. This way the occurrence of specific side effects is avoided. In terms of CBT’s the combination of ERP and cognitive restructuring, is the first-line intervention in the TOC, and in some cases they may be supplemented by ACT techniques such as cognitive acceptance and diffusion. Lastly, psychotherapeutic interventions may be supplemented by programs / web sites that contribute to facilitate the therapeutic process.
OCD = Obsessive-Compulsive Disorder
CBT = Cognitive-Behavioral Therapy
ERP =Exposure with Response Prevention
CR = Cognitive Restructuring
ACT = Acceptance and Commitment Therapy
EX / RP = Exposure and Ritual Prevention
1. American Psychiatric Association. Diagnostic and statistical manual of mental disorders.5th, DSM – 5.Arlington : American Psychiatric Association, 2013.
2. Lăzărescu, M and Ile, L. Tulburarea obsesiv-compulsiva. Circumscriere, modele si interventii.Iaşi : Polirom, 2007.
3. Ruscio, AM, Stein, DJ, Chiu, WT, Kessler, RC. The epidemiology of obsessive-compulsive disorder in the National Comorbidity Survey Replication.Molecular Psychiatry.2010; 15:53–63.
4. Milad, MR, Quirk, GJ. Fear extinction as a model for translational neuroscience: ten years of progress. A Revi of Psychol. 2012; 63:129–151.
5. Milad, MR, Furtak, SC, Greenberg, J L, Keshaviah, A, Im, JJ, Falkenstein, MJ, et al. Deficits in conditioned fear extinction in obsessive–compulsive disorder and neurobiological changes in the fear circuit. JAMA Psychiatry. 2013; 70(6):608–618.
6. A bramovitch, A , A bramow itz, J S , M ittelman, A , The neuropsychology of adult obsessive-compulsive disorder: a meta- analysis. Clinical Psychology Review. 2013; 33(8):1163–1171.
7. Abramovitch, A, Cooperman, A. The cognitive neuropsychology of obsessive-compulsive disorder: A critical review. Journal of Obsessive- Compulsive and Related Disorders.2015; 5:24-36.
8. Milad, MR, Rauch, SR. Obsessive-compulsive disorder: beyond segregated cortico-striatal pathways. Trends in Cognitive Sciences. 2012; 16(1): 43-51.
9. Kilic, F, Murphy, DL, Rudnick, G. A human serotonin transporter mutation causes constitutive activation of transport activity. Molecular Psychopharmacology. 2003; 64(2):440–446.
10. Kurlan, R, Johnson, D, Kaplan, EL. Streptococcal Infection and Exacerbations of Childhood Tics and Obsessive-Compulsive Symptoms: A Prospective Blinded Cohort Study. Pediatrics. 2008; 121(6):1188-1197.
11. Swedo, S, Leonard, H, Garvey, M, et al. Pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections: clinical description of the first 50 cases. Am J Psychiatry. 1997; 155(2):264–271.
12. Clark, DA, Beck, AT. Cognitive Therapy of Anxiety Disorders: Science and Practice. New York : The Guilford Press, 2010.
13. Clark, D. Cognitive-Behavioral Therapy for OCD. New York : The Guilford Press, 2004.
14. Rosa-Alcázar, A, Sánchez-Meca, J, Gómez-Conesa, A, Marín- Martínez, F. Psychological treatment of obsessive–compulsive disorder: A meta-analysis. Clinical Psychology Review. 2008; 28(8):1310–1325.
15. Houghton, S, Saxon, D, Bradburn, M, Ricketts, T, Hardy, G. The effectiveness of routinely delivered cognitive behavioural therapy for obsessive-compulsive disorder: A benchmarking study. British Journal of Clinical Psychology.2010; 49:473–489.
16. Ponniah, K, Magiati, I, Hollon, SV. An update on the efficacy of psychological treatments for obsessive–compulsive disorder in adults.Journal of Obsessive-Compulsive and Related Disorders. 2013; 2(2):207-218.
17. Jónsson, H, Kristensen, M, Arendt, M. Intensive cognitive behavioural therapy for obsessive-compulsive disorder: A systematic review and meta-analysis., Journal of Obsessive-Compulsive and Related Disorders, 2015; 6:83–96.
18. Krebs, G, Isomura, K, Lang, K, Jassi, A, Diamond, H. et al. How resistant is ‘treatment-resistant’ obsessive-compulsive disorder in youth? British Journal of Clinical Psychology. 2015. 54:63–75.
19. Vyskocilova, J, Prasko, J, Sipek, J. Cognitive behavioral therapy in pharmacoresistant obsessive–compulsive disorder., Neuropsych disease and treatment. 2016; 12:625—639.
20. Foa, EB. Cognitive behavioral therapy of obsessive-compulsive disorder.Dialogues in Clinical Neuroscience. 2010; 12(2):199–207.
2 1 . M a , J i a n – D o n g e t a l . C o g n i t i v e – c o p i n g t h e r a p y f o r obsessive–compulsive disorder: A randomized controlled trial. Journal of Psychiatric Research. 47(11):1785 – 1790.
22. Bunmi, OO, et al. Cognitive-behavioral therapy for obsessive- compulsive disorder: A meta-analysis of treatment outcome and moderators. Journal of Psychiatric Research. 2013; 47(1):33–41.
23. Porto, PR, et al. Does Cognitive Behavioral Therapy Change the Brain? A Systematic.The Journal of Neuropsychiatry and Clinical Neurosciences. 2009. 21(2):114-125.
24. Sudak, DM. Combining CBT and medication:an evidence-based approach. Hoboken : John Wiley & Sons, 2011.
25. Linden, DEJ. How psychotherapy changes the brain – the contribution of functional neuroimaging. Molecular Psychiatry.2006; 11:528–538.
26. Zurowski, B, et al. Relevance of orbitofrontal neurochemistry for the outcome of cognitive-behavioural therapy in patients with obsessive–compulsive disorder. Eur Arch Psychiatry Clin Neurosci.2012; 262:617-624.
27. Stahl, SM. Psychotherapy as an epigenetic ‘drug’: psychiatric therapeutics target symptoms linked to malfunctioning brain circuits with psychotherapy as well as with drugs. Jour of Clinical Pharmacy and Therapeutics. 2012; Vol. 37;249–253.
28. Northoff, G, et al. Self-referentialial processing in our brain- A meta- analysis of imaging studies on the self. NeuroImage, 2006; 31:440–457.
29. Clark DA, Beck, AT. Cognitive theory and therapy of anxiety and depression:
Convergence with neurobiological findings.Trend in cogn scien. 2010; 14:418–424.
30. Saxena, S, et al. Rapid effects of brief intensive cognitive-behavioral therapy on brain glucose metabolism in obsessive-compulsive disorder. Molecular Psychiatry.2009; 14:197–205.
31. Hoexter, MQ, et al. Gray Matter Volumes in Obsessive-Compulsive Disorder Before and After Fluoxetine or Cognitive-Behavior Therapy: A Randomized Clinical Trial. 2012, Neuropsychopharmacology, Vol. 37(3):734–745.
32. Dunlop K, et al. Reductions in Cortico-Striatal Hyperconnectivity Accompany Successful Treatment of Obsessive-Compulsive Disorder with Dorsomedial Prefrontal rTMS. Neuropsychopharmacology. 2016; 41(5):1395–1403.
33. Radua J, et al. Meta-analytical Comparison of Voxel-Based Morphometry Studies in Obsessive-Compulsive Disorder vs Other Anxiety Disorders. Arch Gen Psych. 2010; 67(7):701 – 711.
34. David, D, Matu, SA, David, OA. New Directions in Virtual Reality- Based Therapy for Anxiety Disorders.
International Journal of Cognitive Therapy. 2013; 6(2):114 – 137.
35.Persons, JB. Science in Practice in Cognitive Behavior T h e r a p y . C o g n i t i v e a n d B e h a v i o r a l P r a c t i c e . 2 0 1 6 ; doi.org/10.1016/j.cbpra.2016.01.003.
36. Craighead, WE. ABCT at 50 Years: Reflections, Changes, and F u t u r e . , C o g n i t i v e a n d B e h a v i o r a l P r a c t i c e , 2 0 1 6 ; doi:10.1016/j.cbpra.2015.12.004.
37. Tulbure, BS, David, O, Stefan, S, Månsson, K, David, D, et al. Internet-delivered cognitive-behavioral therapy for social anxiety disorder in Romania: A randomized controlled trial. PLoS One. 2015;
38. McIngvale, E, et al. Technology and Obsessive Compulsive Disorder: An Interactive Self-Help Website for OCD.
Journal of Technology in Human Services. 2012; 30(2): 128-136.
39. Sava, FA, Yates, BT, Lupu, V, Szentagotai, A, David, D. Cost- effectiveness and cost-utility of cognitive therapy, rational emotive behavioral therapy, and fluoxetine (prozac) in treating depression: a randomized clinical trial. J. Clin. Psychol. 2009; Vol. 65(1):36–52.
40. Warmerdam, L, et al. Cost-Utility and Cost-Effectiveness of Internet- Based Treatment for Adults With Depressive Symptoms: Randomized Trial.
J Med Internet Res. 2010; 12(5):e53.
41. (NICE), National Institute for Health and Care Excellence. Obsessive-compulsive disorder and body dysmorphic disorder: treatment. National Institute for Health and Care Excellence.[Online]
2 0 0 5 . h t t p s : / / w w w. n i c e . o r g . u k / g u i d a n c e / c g 3 1 / c h a p t e r / 1 –
42. O’Connor, KP, et al. Cognitive behaviour therapy and medication in the treatment of obsessive–compulsive disorder.
Acta Psychiatrica Scandinavica.2006; 113:408–419.
43. Simpson, HB, et al. Cognitive-Behavioral Therapy vs Risperidone for Augmenting Serotonin Reuptake Inhibitors in Obsessive- Compulsive Disorder. JAMA Psychiatry. 2013; 70(11):1190-1199.
44. O’Neill, J. Augmentation with cognitive behavioural therapy has superior efficacy to augmentation with risperidone for treating adults with treatment-resistant OCD. Evid Based Mental Health. 2014; 17(2):58-59.
45. Eisen, JL, et al. A 2-Year prospective follow-up study of the course of obsessive-compulsive disorder.The Journal of Clinical Psychiatry. 2010;
46. Scherr, SR, Herbert, JD, Forman, EM. The role of therapist experiential avoidance in predicting therapist preference for exposure treatment for OCD.Journal of Contextual Behavioral Science. 2015; 4(1):21–29.
47. Schruers, K, et al. Obsessive-compulsive disorder: a critical review of therapeutic perspectives. Acta Psychiatr Scand. 2005; 111(4):261-71.
48. McKay, D, et al. Efficacy of cognitive-behavioral therapy for obsessive–compulsive disorder. Psychiatry Research. 2015; 225(3):236–246.
49. Chosak, A, et al. Cognitive Therapy for Obsessive-Compulsive Disorder: a Case Example. Cognitive and Behavioral Practice.2009; 16:7-17.
50. Berman, NC, et al. Cognitive-based therapy for OCD: Role of behavior experiments and exposure processes. Journal of Obsessive- Compulsive and Related Disorders, 2015; 6:158-166.
51. Thiela, N, et al. Schema therapy augmented exposure and response prevention in patients with obsessive–compulsive disorder: Feasibility and efficacy of a pilot study. Journal of Behavior Therapy and Experimental Psychiatry. 2016;52:59–67.
52. Hayes, SC, Barnes-Holmes, D, Wilson, KG. Contextual Behavioral Science: Creating a science more adequate to the challenge of the human condition. Journal of Contextual Behavioral Science.2012; 1:1-16.
53. David, D, and Mogoase, C. Acceptance and commitment therapy’s philosophical foundation under scrutiny: an In-depth discussion of A- ontology. Jounr.of E.B.P. 2015; 15(22):169-177.
54. Bluett, EJ, et al. Acceptance and commitment therapy for anxiety and OCD spectrum disorders:
An empirical review. Journal of Anxiety Disorders.2014; 28:612–624.
55. Twohig, MP, et al. Changes in psychological flexibility during acceptance and commitment therapy for obsessive compulsive disorder. Journal of Contextual Behavioral Science, 2015; 4:196–202.
56. Twohig, MP. The Application of Acceptance and Commitment Therapy to Obsessive-Compulsive Disorder. Cognitive and Behavioral Practice, 2009; 18(1):18–28.
57. David, D, Szentagotai, A. Cognitions in cognitive-behavioral psychotherapies; toward an integrative model. Clinic Psycho Rev, 2006; 26:284 –298.
58. Baileya, BE, et al. Thought–action fusion: Structure and specificity to OCD.
Journal of Obsessive-Compulsive and Related Disorders. 2014;
59. Wetternecka, CT, et al. Obsessive–compulsive personality traits:
How are they related to OCD severity? Journal of Anxiety Disorders, 2011; 25(8):1024–1031.
60. Alford, B, Beck, A. Puterea integratoare a psihoterapiei cognitive. Bucureşti : Trei, 2011.
61. Ellis, A, David, D, Lynn, S. Rational and Irrational Beliefs: A Historical and Conceptual Perspective. Rational and Irrational Beliefs. New York : Oxford University Press, Inc. 2010, pp. 3-22.
62. David, D. Tratat de psihoterapii cognitiv-comportamentale. Iași : Polirom, 2012.
63. Hayes, SC, et al. Acceptance and Commitment Therapy and Contextual Behavioral Science: Examining the Progress of a Distinctive Model of Behavioral and Cognitive Therapy. Behavior Therapy. 2013; 44(2):180–198.
64. David, D, et al. Philosophical versus psychological unconditional acceptance: Implications for constructing the. Unconditional Acceptance Questionnaire.Journal of Cognitive and Behavioral Psychotherapies. 2013; 13(2A):445-464.
65. Cludius, B. et al. Mindfulness for OCD? No evidence for a direct effect of a self-help treatment approach. Journal of Obsessive- Compulsive and Related Disorders.2015; 6:59–65.