1. (1) Sexual obsessions are common in adolescent obsessive compulsive disorder (OCD).

2. (2) Little guidance is available on how to conduct exposure and response prevention sensitively for sexual obsessions in adolescent OCD.

3. (3) Imagery-based techniques can be used effectively for reducing sexual obsessions.

4. (4) Imagery-based techniques delivered by videoconferencing can be acceptable for young people.

1. (1) To describe the factors that might lead to a patient disengaging from exposure work in treatment for OCD.

2. (2) To identify the advantages and disadvantages of incorporating a period of extended formulation when working with patients who have not previously been able to tolerate exposure work.

3. (3) To describe ways of monitoring observable improvements in areas of functioning that matter to the patient in order to help them to celebrate their progress and boost their sense of self-efficacy.

Kleptomania is a disease that shares features with obsessive compulsive spectrum disorders (OCD) and with substance abuse disorders (SAD). This is underlined by therapeutic approaches in kleptomania ranging from cognitive behavioural therapy and selective serotonin reuptake inhibitors that are effective in OCD, and opioid antagonists that are currently being used in SAD. However, almost no literature exists about exposure and response prevention (ERP) therapy in kleptomania. Furthermore, there is a clear lack of objective markers that would allow a therapeutic monitoring.

To show the effectiveness of ERP therapy in kleptomania in a single case report.

An ERP therapy under real-world conditions and later augmentation with the opioid antagonist naltrexone is described. Continuous measurements of galvanic skin response (GSR) before, during and after therapy sessions are reported in association with changes of the Kleptomania Symptom Assessment Scale (KSAS) self-questionnaire.

While KSAS scores showed a clear treatment response to ERP sessions, the GSR was significantly lower during ERP treatment in comparison with baseline measures. However, during augmentation with naltrexone, GSR measures increased again and clinical severity did not further improve.

This case shows the possible usefulness of ERP-like approaches and therapy monitoring using electrophysiological markers of arousal for individualized treatment in kleptomania.

Preliminary studies have shown that the addition of the partial NMDA-agonist d-cycloserine (DCS) might be promising in enhancing the results of exposure therapy in obsessive-compulsive disorder (OCD). We examined the effect of DCS addition to exposure therapy in a somewhat larger sample of OCD patients with special attention to subgroups, because of the heterogeneity of OCD.

A randomized, double-blind, placebo controlled trial was conducted in 39 patients with OCD. Patients received 6 guided exposure sessions, once a week. One hour before each session 125 mg DCS or placebo was administered.

Scores on the Yale-Brown Obsessive-Compulsive Scale (Y-BOCS) declined more in the DCS group than in the placebo group, but the difference did not reach statistical significance (P = 0.076, partial η2 = 0.13). Response percentages also did not differ between the DCS and the placebo group (37% and 15% respectively). In the ‘cleaning/contamination’ subgroup a significant effect was found in favour of DCS (P = 0.033, partial η2 = 0.297).

The results of this study did not support the application of DCS to exposure therapy in OCD. Some specific aspects need further investigation: efficacy of DCS in a larger ‘cleaning/contamination’ (sub-)group, DCS addition only after successful sessions, interaction with antidepressants.

Deep brain stimulation (DBS) is a promising new treatment for patients with treatment-refractory obsessive–compulsive disorder (OCD). However, since most DBS patients only show a partial response, the treatment still needs to be improved. In this study we hypothesized that cognitive–behavioural therapy (CBT) could optimize the post-operative management in DBS and we evaluated the efficacy of CBT as augmentation to DBS targeted at the nucleus accumbens.

A total of 16 patients with treatment-refractory OCD were treated with DBS targeted at the nucleus accumbens. After stabilization of decline in OCD symptoms, a standardized 24-week CBT treatment programme was added to DBS in an open-phase trial of 8 months. Changes in obsessive–compulsive, anxiety and depressive symptoms were evaluated using the Yale–Brown Obsessive Compulsive Scale, Hamilton Anxiety Scale and Hamilton Rating Scale for Depression.

Following the addition of CBT to DBS, a significant decrease in obsessive–compulsive symptoms was observed, but not in anxiety and depressive symptoms. In a subsequent double-blind phase, in which stimulation was discontinued, OCD symptoms returned to baseline (relapse) and anxiety and depressive symptoms worsened (rebound) compared with baseline.

The results of this explorative study suggest that a combined treatment of accumbens DBS and CBT may be optimal for improving obsessive–compulsive symptoms in treatment-refractory OCD. However, a subsequent randomized controlled trial is necessary to draw firm conclusions. It seems that DBS results in affective changes that may be required to enable response prevention in CBT. This may indicate that DBS and CBT act as two complementary treatments.