Disorders - Obsessive Compulsive Disorder
ONeill, J., Piacentini, J., Chang, S., Ly, R., Lai, T. M., Armstrong, C. C., Bergman, L., Rozenman, M., Peris, T., Vreeland, A., Mudgway, R., Levitt, J. G., Salamon, N., Posse, S., Hellemann, G. S., Alger, J. R., McCracken, J. T., Nurmi, E. L.
Cognitive-behavioral therapy (CBT) is effective for pediatric obsessive-compulsive disorder (OCD), but non-response is common. Brain glutamate (Glu) signaling may contribute to OCD pathophysiology and moderate CBT outcomes. We assessed whether Glu measured with magnetic resonance spectroscopy (MRS) was associated with OCD and/or CBT response. Youths aged 7-17 years with DSM-IV OCD and typically developing controls underwent 3 T proton echo-planar spectroscopic imaging (PEPSI) MRS scans of pregenual anterior cingulate cortex (pACC) and ventral posterior cingulate cortex (vPCC)-regions possibly affected by OCD-at baseline. Controls returned for re-scan after 8 weeks. OCD youth-in a randomized rater-blinded trial-were re-scanned after 12-14 weeks of CBT or after 8 weeks of minimal-contact waitlist; waitlist participants underwent a third scan after crossover to 12-14 weeks of CBT. Forty-nine children with OCD (mean age 12.2+/- 2.9 years) and 29 controls (13.2+/-2.2 years) provided at least one MRS scan. At baseline, Glu did not differ significantly between OCD and controls in pACC or vPCC. Within controls, Glu was stable from scan-to-scan. Within OCD subjects, a treatment-by-scan interaction (p=0.034) was observed, driven by pACC Glu dropping 19.5% from scan-to-scan for patients randomized to CBT, with minor increases (3.8%) for waitlist participants. The combined OCD participants (CBT-only plus waitlist-CBT) also showed a 16.2% (p= 0.004) post-CBT decrease in pACC Glu. In the combined OCD group, within vPCC, lower pre-CBT Glu predicted greater post-CBT improvement in symptoms (CY-BOCS; r= 0.81, p= 0.00025). Glu may be involved in the pathophysiology of OCD and may moderate response to CBT. Copyright © 2017 American College of Neuropsychopharmacology.
Neuropsychopharmacology, 42(12) : 2414-2422
- Year: 2017
- Problem: Obsessive Compulsive Disorder
- Type: Randomised controlled trials
-
Stage: Disorder established (diagnosed disorder)
-
Treatment and intervention: Psychological Interventions (any)
, Cognitive & behavioural therapies (CBT)
, Exposure therapy, Exposure and response prevention
Conelea, C. A., Selles, R. R., Benito, K. G., Walther, M. M., Machan, J. T., Garcia, A. M., Sapyta, J., Morris, S., Franklin, M., Freeman, J. B.
The Pediatric Obsessive-Compulsive Disorder Treatment Study II (POTS II) investigated the benefit of serotonin reuptake inhibitor (SRI) augmentation with cognitive behavioral therapy (CBT). Primary outcomes focused on OCD symptom change and indicated benefit associated with a full course of CBT. Given that the majority of youth with OCD suffer from significant comorbid symptoms and impaired quality of life, the current study examined POTS II data for effects on secondary outcomes. Participants were 124 youth ages 7-17 years with a primary diagnosis of OCD who were partial responders to an adequate SRI trial. Participants were randomized to medication management, medication management plus instructions in cognitive behavioral therapy (CBT), or medication management plus full CBT. Acute effects on non-OCD anxiety, depression, inattention, hyperactivity, and quality of life were examined across treatment conditions. Improvement across treatment was observed for non-OCD anxiety, inattention, hyperactivity, and quality of life. Changes were generally significantly greater in the group receiving full CBT. Child-rated depression was not found to change. OCD-focused treatment lead to improvement in other areas of psychopathology and functioning. For youth who are partial responders to SRI monotherapy, augmentation with full CBT may yield the greatest benefit on these secondary outcomes. Clinical trials registration Treatment of Pediatric OCD for SRI Partial Responders, Clinicaltrials.gov Identifier: NCT00074815, http://clinicaltrials.gov/show/NCT00074815. Copyright © 2017 Elsevier Ltd
Journal of Psychiatric Research, 92 : 94-100
- Year: 2017
- Problem: Obsessive Compulsive Disorder
- Type: Randomised controlled trials
-
Stage: Disorder established (diagnosed disorder)
-
Treatment and intervention: Biological Interventions (any)
, Selective serotonin reuptake inhibitors (SSRIs), Service Delivery & Improvement, Psychological Interventions (any)
, Cognitive & behavioural therapies (CBT)
, Other service delivery and improvement interventions
Ghanizadeh, A., Mohammadi, M. R., Bahraini, S., Keshavarzi, Z., Firoozabadi, A., Shoshtari, A. A.
Objective: Glutamate is considered a target for treating obsessive-compulsive disorder (OCD). The efficacy and safety of the nutritional supplement of N-Acetylcysteine (NAC) as an adjuvant to serotonin reuptake inhibitor (SSRI) for treating children and adolescents with OCD has never been examined. Methods: This was a 10-week randomized double-blind placebo-controlled clinical trial with 34 OCD outpatients. The patients received citalopram plus NAC or placebo. Yale-Brown Obsessive-Compulsive Scale (YBOCS) and Pediatric Quality of Life Inventory (PedsQLTM) were used. Adverse effects were monitored. Results: YBOCS score was not different between the two groups at baseline, but the score was different between the two groups at the end of this trial (P < 0.02). The YBOCS score of NAC group significantly decreased from 21.0(8.2) to 11.3(5.7) during this study. However, no statistically significant decrease of YBOCS was found in the placebo group. The Cohen's d effect size was 0.83. The mean change of score of resistance/control to obsessions in the NAC and placebo groups was 1.8(2.3) and 0.8(2.1), respectively (P = 0.2). However, the mean score of change for resistance/control to compulsion in the NAC and placebo groups was 2.3(1.8) and 0.9(2.3), respectively. Cohen's d effect size was 0.42. The score of three domains of quality of life significantly decreased in N-Acetylcysteine group during this trial. However, no statistically significant decrease was detected in the placebo group. No serious adverse effect was found in the two groups. Conclusion: This trial suggests that NAC adds to the effect of citalopram in improving resistance/control to compulsions in OCD children and adolescents. In addition, it is well tolerated.
Iranian Journal of Psychiatry, 12(2) : 134-141
- Year: 2017
- Problem: Obsessive Compulsive Disorder
- Type: Randomised controlled trials
-
Stage: Disorder established (diagnosed disorder)
-
Treatment and intervention: Biological Interventions (any)
, Selective serotonin reuptake inhibitors (SSRIs), Antidepressants (any)
, Other biological interventions
Iniesta-Sepulveda, M., Rosa-Alcazar, A. I., Sanchez-Meca, J., Parada, Navas, J. L., Rosa-Alcazar, A.
A meta-analysis on the efficacy of cognitive-behavior-family treatment (CBFT) on children and adolescents with obsessive-compulsive disorder (OCD) was accomplished. The purposes of the study were: (a) to estimate the effect magnitude of CBFT in ameliorating obsessive-compulsive symptoms and reducing family accommodation on pediatric OCD and (b) to identify potential moderator variables of the effect sizes. A literature search enabled us to identify 27 studies that fulfilled our selection criteria. The effect size index was the standardized pretest-postest mean change index. For obsessive-compulsive symptoms, the adjusted mean effect size for CBFT was clinically relevant and statistically significant in the posttest (dadj = 1.464). For family accommodation the adjusted mean effect size was also positive and statistically significant, but in a lesser extent than for obsessive-compulsive symptoms (dadj = 0.511). Publication bias was discarded as a threat against the validity of the meta-analytic results. Large heterogeneity among effect sizes was found. Better results were found when CBFT was individually applied than in group (d+ = 2.429 and 1.409, respectively). CBFT is effective to reduce obsessive-compulsive symptoms, but offers a limited effect for family accommodation. Additional modules must be included in CBFT to improve its effectiveness on family accommodation. Copyright © 2017 Elsevier Ltd
Journal of Anxiety Disorders, 49 : 53-64
- Year: 2017
- Problem: Obsessive Compulsive Disorder
- Type: Systematic reviews
-
Stage: Disorder established (diagnosed disorder)
-
Treatment and intervention: Psychological Interventions (any)
, Cognitive & behavioural therapies (CBT)
, Family therapy, Other Psychological Interventions
Lenhard, F., Andersson, E., Mataix-Cols, D., Ruck, C., Vigerland, S., Hogstrom, J., Hillborg, M., Brander, G., Ljungstrom, M., Ljotsson, B., Serlachius, E.
Objective: Cognitive-behavioral therapy (CBT) is the first-line treatment for young people with obsessive-compulsive disorder (OCD), but most patients do not have access to this treatment. Thus, innovative ways to increase the accessibility of CBT are needed. The objective of this trial was to evaluate the efficacy of therapist-guided internet-based CBT (ICBT) for adolescents with OCD. Method: Sixty-seven adolescents (12-17 years old) with OCD were randomly assigned to a 12-week clinician- and parent-supported ICBT program (BiP OCD) or a waitlist condition. The primary outcome was the Children Yale-Brown Obsessive Compulsive Scale (CY-BOCS) administered by blinded assessors before and after the intervention. All patients were followed up 3 months after the intervention. Results: In intention-to-treat analyses, BiP OCD was superior to waitlist on the CY-BOCS (time-by-group interaction, B = -4.53, z = -3.74, p < .001; Cohen's d = 0.69; 95% CI 0.19-1.18) and on most secondary outcome measurements. Patients randomized to BiP OCD also showed further improvement from post-treatment to 3-month follow-up, with a within-group pretreatment to follow-up effect size (Cohen's d) equal to 1.68 (95% CI 1.00-2.36). Patient satisfaction with BiP OCD was high. There were no relevant adverse events. Average clinician support time was 17.5 minutes per patient per week. Conclusion: Therapist-guided ICBT is a promising low-intensity intervention for adolescents with OCD and has the potential to increase access to CBT. It might be particularly useful in a stepped-care approach, in which a large proportion of patients with moderately severe OCD could first be offered ICBT, thus freeing limited resources for more complex cases. (PsycINFO Database Record (c) 2017 APA, all rights reserved)
Journal of the American Academy of Child & Adolescent Psychiatry, 56(1) : 10-19
- Year: 2017
- Problem: Obsessive Compulsive Disorder
- Type: Randomised controlled trials
-
Stage: Disorder established (diagnosed disorder)
-
Treatment and intervention: Service Delivery & Improvement, Psychological Interventions (any)
, Cognitive & behavioural therapies (CBT)
, Technology, interventions delivered using technology (e.g. online, SMS)
Aboujaoude, E.
Background The use of telemedicine in obsessive-compulsive disorder (OCD) represents some of the earliest technology-enabled interventions in mental health. A review of telemedicine efficacy data in OCD provides a window into the telemental revolution and informs us on the best-supported technology tools in OCD treatment. Methods A PubMed database search of efficacy studies was conducted across telemental health platforms-computerized, internet, mobile, and virtual reality based. Results Eleven randomized controlled trials (RCTs) were identified covering computerized cognitive behavioral therapy (CBT), online CBT and virtual reality exposure therapy. Studies included children, adolescents and adults, and represented various levels of clinician involvement (therapist-free, limited or full), as well as non-therapist support ("coach", technician or parent). Discussion The best-supported modality represents CBT interventions in mild to moderate OCD, delivered over computerized, online or virtual reality platforms. No controlled data were retrieved on non-CBT psychotherapies, psychopharmacology, or mobile interventions. Overall, the hypothesis that adequate care can be delivered with minimal clinician involvement has motivated much research; while this could increase access and diminish cost, it might turn away some providers and patients. Conclusion Several platforms as well as psychotherapeutic and psychopharmacological treatments remain untested. Meanwhile, a case can be made for using technology-mediated CBT in mild to moderate OCD, then escalated to interventions with more clinician involvement and a broader evidence base. Copyright © 2017 Elsevier Ltd
Journal of Obsessive-Compulsive and Related Disorders, 14 : 65-70
- Year: 2017
- Problem: Obsessive Compulsive Disorder
- Type: Systematic reviews
-
Stage: Disorder established (diagnosed disorder)
-
Treatment and intervention: Service Delivery & Improvement, Technology, interventions delivered using technology (e.g. online, SMS)
Stech, E. P., Grisham, J. R.
Cognitive models of obsessive-compulsive disorder propose that beliefs about the importance of and need to control thoughts (ICT) are central to the maintenance of the disorder. Cognitive Bias Modification for Interpretation (CBM-I) can be used to experimentally test this theory and may also have clinical utility as an adjunct therapeutic tool. The current study extended previous research to investigate whether two CBM-I sessions (one within and one outside the laboratory) would augment effects on obsessive-compulsive beliefs and behavior. We randomly allocated undergraduate participants high in ICT beliefs to a Positive (n = 30) or Control (n = 36) CBM-I condition and conducted multi-modal assessments immediately following the first training and at one-week follow-up. As predicted, participants in the Positive condition reported a reduction in obsessive-compulsive beliefs from baseline to follow-up (partial eta2 = .42), whereas those in the Control condition did not. Participants responded more adaptively to the ICT relevant stressor task at follow-up compared to post-intervention, but there was no significant difference between conditions. Likewise, participants reported a reduction in obsessive symptoms over time that did not differ between conditions. The findings are considered in light of cognitive models of OCD, and clinical implications are discussed. Copyright © 2017 Springer Science+Business Media New York
Journal of Psychopathology and Behavioral Assessment, : 1-12
- Year: 2017
- Problem: Obsessive Compulsive Disorder
- Type: Randomised controlled trials
-
Stage: At risk (indicated or selected prevention)
-
Treatment and intervention: Psychological Interventions (any)
, Attention/cognitive bias modification
Siwiec, S. G., Davine, T. P., Kresser, R. C., Rohde, M. M., Lee, H. J.
Thought-action fusion (TAF) is an important cognitive bias in various emotional disorders, especially, obsessive-compulsive disorder (OCD). TAF leads individuals to interpret the presence of unwanted mental intrusions as morally equivalent to acting on them, and/or increasing the likelihood of the feared consequence. We sought to test the feasibility of a brief computerized cognitive bias modification for interpretations (CBM-I) as a potential intervention to reduce TAF among undergraduates who reported obsessional intrusions. We also examined if the TAF-focused CBM-I can decrease participants' emotional reactions towards a variety of obsessional thoughts, including personally-relevant intrusions. Participants were randomized to (a) the TAF-incongruent condition (TAF-INC), designed to decrease TAF linked to obsessional thoughts, or (b) the TAF-congruent condition (TAF-CON), designed to render TAF-like interpretation of obsessional thoughts unchallenged. Results indicate the TAF-INC group displayed a significantly greater reduction in the severity of total TAF and TAF moral than the TAF-CON group. Reductions on TAF likelihood did not differ by group. Emotional reaction to personally-relevant obsessional intrusions was also shown to be lower after training in the TAF-INC group. Overall, this study presents preliminary data supporting the feasibility of CBM-I to be used as an effective intervention for TAF. Copyright © 2016 Elsevier Ltd
Journal of Obsessive-Compulsive and Related Disorders, 12 : 15-22
- Year: 2017
- Problem: Obsessive Compulsive Disorder
- Type: Randomised controlled trials
-
Stage: At risk (indicated or selected prevention)
-
Treatment and intervention: Psychological Interventions (any)
, Attention/cognitive bias modification
Skarphedinsson, G. A., Weidle, B., Thomsen, P. H., Dahl, K., Torp, N. C., Nissen, J. B., Melin, K. A., Hybel, K. A., Valderhaug, R., Hojgaard, D. R. M. A., Ivarsson, T.
Objectives: Expert guidelines recommend CBT as a first-line treatment in pediatric OCD and the addition of SSRI when CBT is not effective. However, the weaknesses of these guidelines are the meager and partly conflicting evidence of the long-term outcome of these treatments both in terms of the durability of the CBT effect and the benefits vs. the cost of switching or augmenting with medication. In a previous paper, we reported the results of a randomized controlled trial on CBT and Sertraline (SRT) for CBT non-responders showing no significant differences between the treatments at the post-treatment assessment. The objective of the current research is to report on the 1, 2, and, 3-year-follow-up data. Methods: The youth participated in a randomized controlled trial conducted in five sites in Denmark, Sweden and Norway. Fifty-four participants, 7-17 years, with DSM-IV primary OCD (non-responders after initial 14 weekly sessions of CBT) were randomized to SRT or continued CBT for 16 weeks. Primary outcomes were the CY-BOCS total score and clinical response (CYBOCS <16). The study was a part of the Nordic Long-Term OCD Treatment Study. The intent-to-treat sample included 50 participants, mean age 14.0 (SD = 2.7) and 48 percent (n = 24) males. Results: Statistical analysis with linear mixed effects showed significant reduction on the CYBOCS total score over time across treatments. Planned pairwise comparison did not reveal a significant difference between the treatments at 12, 24, or 36 month-follow-up. The response rate (CY BOCS<16) and the remission rate (CY-BOCS<11) was 92 percent and 77 percent respectively across both groups at the 3-year follow-up with no significant differences between groups. Conclusions: The results suggest that both continued CBT and SSRI for CBT non-responders is effective 3 years after post-treatment with no significant differences between groups.
Journal of the American Academy of Child and Adolescent Psychiatry, 55 (10 Supplement 1) : S240-S241
- Year: 2016
- Problem: Obsessive Compulsive Disorder
- Type: Randomised controlled trials
-
Stage: Disorder established (diagnosed disorder)
-
Treatment and intervention: Biological Interventions (any)
, Selective serotonin reuptake inhibitors (SSRIs), Antidepressants (any)
, Psychological Interventions (any)
, Cognitive & behavioural therapies (CBT)
Storch, E. A., Wilhelm, S., Sprich, S., Henin, A., Micco, J., Small, B. J., McGuire, J., Mutch, J., Lewin, A. B., Murphy, T. K., Geller, D. A.
Importance: Cognitive behavior therapy (CBT) among youth with obsessive-compulsive disorder (OCD) is effective, but many patients remain symptomatic after intervention. D-cycloserine, a partial agonist at the N-methyl-D-aspartate receptor in the amygdala, has been associated with enhanced CBT outcome for OCD among adults but requires evaluation among youth. Objectives: To examine the relative efficacy of weight-adjusted D-cycloserine (25 or 50 mg) vs placebo augmentation of CBT for youth with OCD and to assess if concomitant antidepressant medication moderated effects. Design, Setting, and Participants: In a placebo-controlled randomized clinical trial, 142 youths (age range, 7-17 years) enrolled between June 1, 2011, and January 30, 2015, at 2 academic health science centers (University of South Florida and Massachusetts General Hospital) with a primary diagnosis of OCD were randomized in a double-blind fashion to D-cycloserine plus CBT or placebo plus CBT. Intent-to-treat analysis was performed. Interventions: Patients were randomly assigned in a 1:1 ratio to either 10 sessions of D-cycloserine plus CBT or placebo plus CBT. D-cycloserine (25 or 50 mg) or placebo was taken 1 hour before sessions 4 through 10. Main Outcomes and Measures: Children's Yale-Brown Obsessive Compulsive Scale at randomization, biweekly, midtreatment, and posttreatment. Secondary outcomes included the Clinical Global Impressions-Severity or Clinical Global Impressions-Improvement, remission status, Children's Depression Rating Scale, Multidimensional Anxiety Scale for Children, and Children's Obsessive-Compulsive Impact Scale-Parent Version. Results: The study cohort comprised 142 participants. Their mean (SD) age was 12.7 (2.9) years, and 53.5%(76 of 142) were female. A mixed-effects model using all available data indicated significant declines in the Children's Yale-Brown Obsessive Compulsive Scale total score and Clinical Global Impressions-Severity. No significant interaction between treatment group and changes in the Children's Yale-Brown Obsessive Compulsive Scale and Clinical Global Impressions-Severity indicated that the D-cycloserine plus CBT group and the placebo plus CBT group declined at similar rates per assessment point on the Children's Yale-Brown Obsessive Compulsive Scale total score (estimate, -2.31, 95%CI, -2.79 to -1.83 and estimate, -2.03, 95%CI, -2.47 to -1.58, respectively) and Clinical Global Impressions-Severity (estimate, -0.29, 95%CI, -0.35 to -0.22 and estimate, -0.23, 95%CI, -0.29 to -0.17, respectively). No group differences in secondary outcomes were present. Antidepressant medication use at baseline did not moderate changes for either group. Conclusions and Relevance: D-cycloserine augmentation of CBT did not confer additional benefit relative to placebo among youth with OCD. Other augmentation approaches should be examined to enhance outcome. (PsycINFO Database Record (c) 2017 APA, all rights reserved)
JAMA Psychiatry, 73(8) : 779-788
- Year: 2016
- Problem: Obsessive Compulsive Disorder
- Type: Randomised controlled trials
-
Stage: Disorder established (diagnosed disorder)
-
Treatment and intervention: Biological Interventions (any)
, Psychological Interventions (any)
, Cognitive & behavioural therapies (CBT)
, D-cycloserine (DCS)
Varigonda, A. L., Jakubovski, E., Bloch, M. H.
Objective: We conducted a meta-analysis to examine the following: the time course of response to selective serotonin reuptake inhibitors (SSRIs) and clomipramine in pediatric obsessive-compulsive disorder (OCD); whether higher doses of SSRIs are associated with an improved response in pediatric OCD; differences in efficacy among SSRI agents; differences in efficacy between SSRIs and clomipramine; and whether the time course and magnitude of response to SSRIs are different in pediatric and adult patients with OCD. Method: We searched PubMed and CENTRAL for randomized controlled trials comparing SSRIs (or clomipramine) to placebo for the treatment of pediatric OCD and using the Children's Yale-Brown Obsessive-Compulsive Scale as an outcome. We extracted weekly symptom data from trials to characterize the trajectory of pharmacological response to SSRIs. Pooled estimates of treatment effect were calculated based on weighted mean differences between the treatment and placebo groups. Results: Nine trials involving 801 children with OCD were included in this meta-analysis. A logarithmic model indicating that the greatest benefits occurred early in treatment best fit the longitudinal data for both clomipramine and SSRIs. Clomipramine was associated with a greater measured benefit compared to placebo than SSRIs. There was no evidence for a relationship between SSRI dosing and treatment effect, although data were limited. Adults and children with OCD demonstrated a similar degree and time course of response to SSRIs in OCD. Conclusion: These results suggest that the greatest incremental treatment gains in pediatric OCD occur early in SSRI treatment (similar to adults with OCD and children and adults with major depression). (PsycINFO Database Record (c) 2017 APA, all rights reserved)
Journal of the American Academy of Child & Adolescent Psychiatry, 55(10) : 851-859
- Year: 2016
- Problem: Obsessive Compulsive Disorder
- Type: Systematic reviews
-
Stage: Disorder established (diagnosed disorder)
-
Treatment and intervention: Biological Interventions (any)
, Selective serotonin reuptake inhibitors (SSRIs), Tricyclic antidepressants, Antidepressants (any)
Ost, L.-G., Riise, E.N., Wergeland, G. J., Hansen, B., Kvale, G.
Obsessive-compulsive disorder (OCD) is ranked by the World Health Organization (WHO) among the 10 most debilitating disorders. The treatments which have been found effective are cognitive behavior therapy (CBT) and serotonin reuptake inhibitors (SRI). This meta-analysis includes all RCTs of CBT (25) and SRI (9) for OCD in youth using the Children's Yale-Brown Obsessive Compulsive Scale (C-YBOCS). CBT yielded significantly lower attrition (12.7%) than SRI (23.5%) and placebo (24.7%). The effect sizes for comparisons of CBT with waiting-list (1.53), placebo (0.93), and SRI with placebo (0.51) were significant, whereas CBT vs. SRI (0.22) and Combo (CBT+SRI) vs. CBT (0.14) were not. Regarding response rate CBT (70%) and Combo (66%) were significantly higher than SRI (49%), which was higher than placebo (29%) and WLC (13%). As for remission CBT (53%) and Combo (49%) were significantly higher than SRI (24%), placebo (15%), and WLC (10%), which did not differ from each other. Combo was not more effective than CBT alone irrespective of initial severity of the samples. The randomized controlled trials (RCTs) have a number of methodological problems and recommendations for improving research methodology are discussed as well as clinical implications of the findings. (PsycINFO Database Record (c) 2017 APA, all rights reserved)
Journal of Anxiety Disorders, 43 : 58-69
- Year: 2016
- Problem: Obsessive Compulsive Disorder
- Type: Systematic reviews
-
Stage: Disorder established (diagnosed disorder)
-
Treatment and intervention: Biological Interventions (any)
, Selective serotonin reuptake inhibitors (SSRIs), Antidepressants (any)
, Psychological Interventions (any)
, Cognitive & behavioural therapies (CBT)