D-cycloserine Augmentation of Cognitive Behavioral Therapy (CBT) for Pediatric Obsessive-compulsive Disorder (OCD)

Obsessive-compulsive disorder (OCD) affects 1-2% of children, runs a chronic course without
treatment, and is associated with considerable functional impairment and poor quality of
life. Although most patients with OCD respond to cognitive-behavioral therapy (CBT) or
pharmacotherapy with a serotonin reuptake inhibitor (SRI), a substantial number of youth
remain symptomatic after receiving these therapies. Pharmacological interventions with SRIs
are only moderately efficacious, rarely produce remission, may be accompanied by side
effects, and may not be an acceptable intervention to some parents. Medication augmentation
strategies such as atypical antipsychotics are often used in children with partial response
but have concerning metabolic effects and no systematic supporting efficacy or safety data.
Although CBT is the gold standard treatment for pediatric OCD, not all patients benefit and
the availability of skilled therapists is quite limited. Thus, there is a critical need for
interventions to optimize treatment outcome in pediatric OCD. The primary mechanism in CBT is
repeated and prolonged exposure to feared situations while abstaining from OCD rituals. This
treatment is based on animal models of extinction of conditioned fears. Basic research on the
neural circuitry underlying fear extinction led to the examination of d-cycloserine (DCS), a
partial agonist at the NMDA receptor in the amygdala, as an agent capable of enhancing
extinction learning. Following successful validation of this strategy in animals, six trials
in adult humans - and one study in youth with OCD - provide support for DCS dosing as
facilitating extinction learning that occurs during exposure-based psychotherapy. However,
experts and agencies responsible for regulating drug indications in the US, including the
FDA, recognize that safety and efficacy findings in adults should not be routinely
extrapolated to children. The present study furthers pilot work on DCS to augment the effects
of CBT in children with OCD. The investigators are conducting a double-blind randomized
controlled trial, conducted at two sites, to examine the relative benefit of 10 psychotherapy
sessions of which sessions 4-10 will be augmented with weight-adjusted doses of DCS (25/50mg)
compared to CBT augmented with placebo. 150 youth (ages 7-17) with OCD will be randomly and
evenly assigned to one of the two treatment conditions. The primary outcome will be change in
OCD symptom severity assessed by independent evaluators. The study recruitment sites are the
University of South Florida (USF) and Massachusetts General Hospital/Harvard Medical School
(MGH). This study extends the first report of DCS augmentation in youth with anxiety
disorder/OCD by conclusively investigating an innovative research approach that manipulates
glutamatergic pathways to mediate improved outcomes of exposure-based psychotherapy based
upon a translational model of the neurobiology of OCD.

Inclusion Criteria:

- Outpatient youth with obsessive-compulsive disorder between the ages 7-17 years.

- A Children's Yale-Brown Obsessive-Compulsive Scale score ≥ 16

- Child has a Full Scale IQ≥85 as assessed on the WASI (within 90% CI).

- English speaking

Exclusion Criteria:

- Receiving concurrent psychotherapy or a past adequate trial of CBT for OCD. Families
will have the option of discontinuing such services to enroll in the study.

- New Treatments: Initiation of an antidepressant within 12 weeks before study
enrollment or an antipsychotic 6 weeks before study enrollment. No new alternative
medications, nutritionals or therapeutic diets within 6 weeks of study enrollment.

- Established Treatment changes: Any change in established psychotropic medication
(e.g., antidepressants, anxioloytics, stimulant, alpha agonist) within 8 weeks before
study enrollment (6 weeks for antipsychotic). Alternative medications must be stable
for 6 weeks prior to baseline.

- Current clinically significant suicidality or individuals who have engaged in suicidal
behaviors within 6 months will be excluded.

- DSM-IV conduct disorder, autism, bipolar, schizophrenia or schizoaffective disorders;
or substance abuse in past 6 months using all available information.

- Youth with hoarding symptoms that are their primary form of OCD.

- Weight less than 25.0 kg.

- Epilepsy, renal insufficiency, and current/past history of alcohol abuse.

- Pregnant or having unprotected sex [in females] as the effects of d-cycloserine on
pregnancy are unknown.

- Presence of a significant and/or unstable medical illness that might lead to
hospitalization during the study.

- Known d-cycloserine allergy.