The best treatment for OCD is a type of cognitive behavioral therapy called Exposure and Response Prevention (ERP). According to Corboy, in the past 15 to 20 years, controlled research studies have found that ERP (with or without medication) is superior to all other types of treatments for OCD.
Specifically, with ERP, “individuals with OCD gradually expose themselves to events, situations, or objects that cause anxiety, without doing their customary compulsive response,” Corboy said. Over time, he noted, people become less obsessive and anxious.
Exposure is conducted in a graduated fashion by creating a hierarchy of distressing situations, Chapman said. The therapist helps the client list these situations in order, typically from zero to 100 (100 being the most distressing). Then they work on this list, moving from the lowest anxiety-provoking situation to the highest. “[M]any clinicians begin at about 50 — sometimes lower, sometimes higher — which represents ‘moderate distress.’”
Chapman shared this example of a hierarchy for a client who has contamination obsessions:
50 = touching doorknobs at work (not washing hands)
60 = using ink pens of my “consumers” at work
65 = eating cracker off the table
75 = touching dirty floor
100 = sitting on toilet seat (no paper on seat)
In some cases people have what is sometimes called “Pure O,” in which their compulsions are less obvious. But Corboy cautioned that the term “Pure O” is misleading. “Every person I have treated with so-called ‘Pure O’ has exhibited numerous compulsive behaviors,” Corboy said. When treating Pure O, “imaginal exposure,” a type of exposure, is especially effective, he said.
This involves writing a short story about your obsessive fear, and reading it repeatedly until it becomes less anxiety provoking, he said. “It is the same process as standard exposure, except that the exposure is to the upsetting thought, rather than to an external event, situation, or thing.”
CBT also involves learning to practice flexible thinking, tolerate distressing emotions and cope adaptively, Umbach said.
People with OCD tend to get stuck in rigid thought patterns, she said. One example is “My writing must be perfect or I will be fired.” Clinicians help clients “move away from extremes, be open to other possibilities, and explore assumptions rather than taking them at face value.” They may work on revising the writing thought to this thought: “My writing is legible and neat, I will still have my job even if the lines are not perfectly straight.”
They also work on developing effective coping skills, such as breathing, imagery and soothing techniques, which might include exercising or listening to music, Umbach said. Clients may create a list of coping statements to navigate tough times, such as “I am strong, and I can do this.” Another coping strategy, she said, is seeing OCD as a character outside yourself that you’re defeating.
Because exposing yourself to anxiety-provoking situations triggers negative emotions, CBT also teaches clients to successfully tolerate distress. “Rather than avoiding, people learn they are able to tolerate low levels of distress and get through it without escaping. We are able to ride out our emotions because we know they are temporary and will dissipate over time.” As clients are successful in tolerating distress in smaller situations, they move on to more difficult ones, she said.
Corboy suggested visiting the International OCD Foundation, which features a database of therapists you can search who specialize in treating OCD.
Medication for OCD
“Medications can provide much needed relief from the crippling effects of OCD,” said Brian Briscoe, MD, founding partner and CEO of Kentucky Psychiatric and Mental Health Services, PLLC.
They can reduce the frequency and intensity of obsessions, he said. They also help to treat depressive symptoms, which often accompany OCD.
Commonly prescribed medications include selective serotonin reuptake inhibitors (SSRIs) and serotonin and norepinephrine reuptake inhibitors (SNRIs). In some cases, physicians prescribe other medications to augment the effects of SSRIs or SNRIs, he said. (Some supplements, such as N-Acetyl Cystiene (NAC) have also been shown to boost the effects of an SSRIs or SNRIs, according to Briscoe.)
However, Dr. Briscoe strongly recommends that all his patients engage in exposure and response prevention (ERP) with a skilled therapist. Some of his patients don’t take medication and have achieved full remission from OCD with ERP alone. Others do well with both ERP and medication.
If you’re considering taking medication, Briscoe stressed the importance of seeking a board-certified psychiatrist or a psychiatric nurse practitioner, who’s experienced in treating OCD.
He also noted that having a collaborative relationship with your provider is essential for optimal treatment. That is, it’s key for the “the patient and doctor [to] work together to find a medication that is effective with minimal to no side effects,” and to “mutually work together to achieve goals that the patient has laid out for himself or herself.”
Mindfulness and OCD
Corboy has found that individuals with OCD have benefited tremendously when ERP is combined with mindfulness. He defined mindfulness for OCD as “the awareness and acceptance of the unwanted thoughts, feelings, and sensations being experienced.”
It involves accepting that the thoughts exist in your consciousness (not that the thoughts are true), he said. “By accepting the thoughts, rather than trying to eliminate them, the person learns that they are able to experience them without doing compulsions.”
You can learn more in The Mindfulness Workbook for OCD: A Guide to Overcoming Obsessions and Compulsions Using Mindfulness and Cognitive Behavioral Therapy, which Corboy co-wrote with Jon Hershfield, MFT.
Learn everything you can about OCD. “The more you understand about OCD, the more you will gain insight into your own personal patterns,” Umbach said. And the more you comprehend your patterns, the easier it will be to break them, she said.
Corboy most frequently recommends these books: Getting Control and The Imp of the Mind by Lee Baer, Ph.D; and The OCD Workbook by Bruce Hyman, Ph.D, and Cherry Pedrick, RN. Umbach’s website includes a list of recommended resources on OCD. And, again, the International OCD Foundation has excellent information.
Be open to change. What can help you be more open is to consider how OCD has influenced your life, and all the reasons why you want to make a change, Umbach said. “Carrying your motivation with you will help during the challenging times.”
Understand that treatment is a process. “Even though people want to get better quickly and easily, understanding that change takes time will make the process more tolerable,” Umbach said. She also stressed the importance of practicing the skills you’re learning in therapy.
Connect with others who have OCD by joining online support groups. The best online support group is http://groups.yahoo.com/group/OCD-Support, Corboy said. “This group has been online since 2001 and has almost 5,000 members.”
Also, keep engaging in “mini exposures” as distressing situations arise in your life. According to Chapman, “Once treatment has been completed, individuals with symptoms of OCD should remain proactive in approaching distressing situations since avoidance backfires and intensifies the very distress that the individual is trying to eliminate.” For instance, if a person becomes distressed about a sermon on eternal damnation, they can engage in “imaginal exposure” of “entering the gates of hell, focus on their uncertainty of going to heaven, and the feelings associated with this uncertainty [such as] ‘I feel distressed because I’m uncertain of my salvation),’” he said.
OCD is a debilitating illness. The good news is that it’s highly treatable, and you can recover. Please don’t hesitate to seek professional help.