PPRNet Clinical summary: Short-term Psychodynamic Therapy of Obsessive-Compulsive Disorder

Obsessive-compulsive disorder (OCD) is often a chronic mental health problem characterized by recurrent obsessions and uncontrolled compulsions. The lifetime prevalence rate is 2.7%, and OCD is often associated with depression and anxiety. Evidence suggests that CBT with exposure and response prevention (ERP) and selective serotonin-reuptake inhibitors (SSRIs) are efficacious treatments for OCD. However, many studies of these treatments have significant limitations, including small sample sizes and a high risk of bias. Treatments for OCD tend to have modest response rates – patients receiving CBT and/or ERP have between 38% and 43% response to treatment (i.e., 50% reduction in symptoms). Most CBT studies include patients on medication, and response rates for CBT plus medications are only slightly better. Leichsenring and colleagues argued that none of the existing treatments work for most patients with OCD, and developing new efficacious treatments is necessary. The authors conducted the first randomized controlled trial of short-term psychodynamic therapy (STPP) for OCD. Exposure to feared and avoided feelings, thoughts, and objects has a long history in psychodynamic therapy dating back to Freud’s early conceptualization of obsessions and compulsions. The manual of STPP for OCD tested in Leichsenring’s and colleagues’ study gradually encourages the patient to self-expose to the situation they fear, refrain from their defensive procedures (compulsions), and face the anxiety. The experiences the patient discusses during therapy serve as material to help the patient work through core conflictual relationship themes (unconscious wishes, others' reactions, responses of self) that confer vulnerabilities to symptoms. This differs from the CBT focus on the conscious fear associated with OCD symptoms. 67 unmedicated patients were randomly assigned to receive STPP or a waitlist control condition. Only 10% dropped out of STPP, which is lower than typically seen in treatments for OCD. Therapists scored high on the use of psychodynamic techniques and low on CBT interventions, indicating that STPP therapists predominantly used STPP rather than CBT. STPP achieved significantly lower OCD symptom scores on the Y-BOCS (a standard measure of OCD symptoms) at the end of treatment than the waiting list condition (t = -4.24, p < 0.0001). The between-group effect size was large (d = 1.04). The reduction in OCD symptom severity, measured with the Y-BOCS, was -11.94 points, which is almost twice the minimal clinically important difference of -6 points for the Y-BOCS. The response to STPP (at least 50% reduction in symptoms), was 53% of patients vs 16% of patients in the control condition (OR = 0.11, 95% CI 0.03, 0.42, p = 0.003), similar to those reported in studies of CBT and ERP interventions. 

Practice Implications 

The results of this first study of a manual-guided STPP indicated that a psychodynamically-oriented therapy is probably efficacious in the treatment of OCD. This provides clinicians and patients with additional treatment options. Most patients achieved clinically meaningful reductions in OCD symptoms. Since all patients were unmedicated, this is one of the few studies of OCD that tested a psychological therapy independent of the effects of medications (e.g., SSRIs).  

Leichsenring, F., Steinert, C., Biskup, J., Feix, L.A., Heim, N., Nimis, B., Kreische, R., Nöske, F., Ruckes, C., Weiss, H., Reich, G., & Starck, A. (2026). Short-term psychodynamic therapy of obsessive-compulsive disorder: A randomized controlled trial of unmedicated patients. Psychotherapy and Psychosomatics, https://doi.org/10.1159/000550421.