Obsessive-compulsive disorder (OCD) is one of the most difficult to understand of all psychiatric illnesses. It is a complex and difficult-to-treat condition if not treated correctly by a skilled professional.
Persons who have this condition find themselves repeating certain behaviors or thoughts again and again. They know the repetition is unnecessary, but are unable to stop themselves. Common forms of this are checking locks, stoves, and lights, or even recurrent intrusive thoughts of hurting oneself or one’s children. Afflicted individuals usually experience severe anxiety if unable to complete their rituals, though many therapies work by helping the individual understand that no catastrophe occurs when the behaviors do cease.
Research has shown that one of the most difficult problems in OCD is getting family members to understand that the patient is unable to simply stop the behavior. Many times relatives become angry and upset when they are forced to deal with the time-consuming and unrealistic repetitive behaviors. With this background, it is no wonder that many patients do not volunteer their symptoms and instead complain only of anxiety or depression.
Psychotherapy for OCD
For many years, obsessive-compulsive disorder (OCD) was seen as a purely psychological disorder, related to a desire to control one’s environment or to undo some perceived wrong action. Insight-oriented psychotherapy has been singularly unsuccessful in treating this group of disorders, however. Behavior therapies have had much more success, especially those with specific small steps geared towards the specific obsessions and compulsions involved in the individual case.
Recognized as one of the most effective treatments currently — and considered the “gold standard” for treating OCD — is Exposure and Response Prevention (EX/RP). It has received strong research support from numerous clinical trials evaluating its efficacy in OCD patients in both inpatient and outpatient settings. EX/RP involves two components: 1) provoking obsessions and having the patient experience their subsequent anxiety while 2) refraining from engaging in rituals.
Rooted from a cognitive-behavioral orientation, the purpose of this process is to gradually extinguish the patient’s obsession-related anxiety by having the patient “learn by doing.” When a patient repeatedly tests their predictions of their feared outcome (e.g., “I will get sick and die”) by exposing themselves to their anxiety triggers (e.g., dirt on their hands) and resisting the urge to perform rituals (e.g., hand washing 3 times), the paired association between the obsessions and compulsions becomes weakened. Crucially, by preventing rituals, the patient is able to learn that (1) despite their anxiety and compulsive urge, the feared outcome likely will not occur (or at least not nearly as bad as imagined), and (2) the anxiety itself will habituate on its own as long as compulsions are not performed. As a byproduct, many patients also feel a sense of control and empowerment over their anxiety for the first time, instead of remaining crippled by obsessions and compulsions.
Behavioral exposure occurs gradually and hierarchically, where the least feared stimuli is presented first. Exposure exercises can be done during-session (and assigned to patient for homework) through guided in-vivo (out in the world) or imaginal scripts in the therapy room.
In imaginal exposure, a patient will typically sit with their eyes closed and verbally perform a narrative of the occurrence of the feared consequences of their obsessions. For example, a woman who performs counting rituals to neutralize obsessions about accidentally killing her husband may be asked to vividly imagine killing her husband, while refraining from counting.
During, in-vivo exposure, the therapist will actually bring the patient “face-to-face” with their feared stimuli. For example, a patient with contamination fears may be asked to sit on the bathroom floor for a specified amount of time, without washing his/her hands or taking a shower.
Learn more: ERP Therapy: A Good Choice for Treating OCD
Cognitive therapy is often added during EX/RP so that the patient can process these behavioral experiences and “make sense” of them as treatment progresses. EX/RP typically lasts 12 to 16 sessions; although it is probably often provided on a once-weekly basis, it can be delivered more frequently (e.g., daily or twice-weekly).
Other forms of behavior therapy have been shown to be successful in treating OCD, though these are becoming increasingly replaced by EX/RP in the field. Two common and popular techniques are systematic desensitization and flooding, which are types of exposure accompanied with relaxation techniques. Systematic desensitization techniques involve gradually exposing the client to ever-increasing anxiety-provoking stimuli. It is important to note here, though, that such a technique should not be attempted until the client has successfully learned relaxation skills and can demonstrate these to the therapist. Exposing a patient to either of these techniques without increased coping skills can result in relapse and possible harm to the client.
Relaxation techniques may include imagery, breathing skills, and muscle relaxation. The aim is for patients to learn to habituate to their anxiety. It is important for the client to find a relaxation technique that works best for them, before attempting something like systematic desensitization or flooding. Systematic desensitization is the preferred technique of the two; flooding is not recommended except in rare uses. Flooding’s potential harm usually outweighs its potential benefits if not done correctly by a highly skilled professional (e.g., traumatizing the individual further). Flooding allows the patient to face the most anxiety-provoking situation, while using the relaxation skills learned.
Additional cognitive-behavioral techniques, which may have some effectiveness for people who suffer from OCD, include saturation and thought-stopping. Through saturation, the client is directed to do nothing but think of one obsessive thought which they have complained about. After a period of time of concentration on this one thought (e.g., 10-15 minutes at a time) over a number of days (3-5 days), the obsession can lose some of its strength.
Through thought-stopping, the individual learns how to halt obsessive thoughts through proper identification of the obsessional thoughts, and then averting it by doing an opposite, incompatible response. A common incompatible response to an obsessive thought is simply by yelling the word “Stop!” loudly. The client can be encouraged to practice this in therapy (with the clinician’s help and modeling, if necessary), then they are encouraged to continue this behavior at home. They can often use other incompatible stimuli, such as snapping a rubber band which is around their wrist whenever they have a thought. The latter technique would be more effective in public.
Recent research supports mindfulness-based treatments for OCD, and specifically Acceptance and Commitment Therapy (ACT). ACT is a behavioral therapy that aims to change the relationship individuals have with their own thoughts and physical sensations that are feared or avoided. Similar to EX/RP, patients are led by paying-attention-to and enduring their states of obsession-related anxiety while resisting the urge to react (i.e., perform compulsive action/ritual).
Different from EX/RP, ACT focuses on values and acceptance whereby promoting acceptance of distressing states, people are taught to more-effectively focus on the present moment and act in line with their goals and life values — instead of being pushed around by their obsessions. Once the patient can acknowledge that rituals are only effective at reducing short-term distress, while preserving their long-term struggle, they can begin to act out of awareness towards values (e.g., family, job, health) regardless of distress. More research supporting this treatment is needed, and this therapy may be most effective in OCD-patients with greater insight.
Learn more: OCD and Insight
Medications for OCD
In the last 25 years, medications have been found to be fairly successful in the treatment of OCD. First was the tricyclic antidepressant clomipramine (Anafranil). This has been followed by several of the newer SSRI class antidepressants that act selectively on the reuptake of serotonin, a neurotransmitter.
In the last few years, neuroimaging studies have begun to disclose the underlying pathophysiology of OCD. The area of the brain that functions abnormally is directly next to those areas that relate to tic disorders such as Tourette’s syndrome and to attention deficit disorder. It now seems that variable amounts of dysfunction produce clinical symptoms that may all be found in one of these areas, or may be overlapping. Many people with ADD also have tics, as do many people with OCD.
Most unexpected is the finding that children who have rheumatic fever and develop Sydenham’s chorea have a significantly increased risk of OCD. Therefore treatment with antibiotics early in an infectious illness may reduce the chance of future obsessive thinking.
Learn more: Medications for Obsessive-Compulsive Disorder (OCD)
Summary of Treatment Options for OCD
Imaging studies have also demonstrated that both medications and behavior therapy alter brain metabolism in the direction of normalcy. This is one of the few areas of mental health where clear proof exists for the efficacy of multiple types of treatment.
With medications, generally the dose used to treat depression is not enough to control OCD symptoms. Patients often will take 2-4 times the that amount. Exposure with Response Prevention or other forms of behavioral therapy with medications seems to offer the best long term improvement.
Virtually no treatment is curative for OCD. However, most treatment can be expected to reduce symptoms by 50-80% or more. The illness is cyclic, and worsens when the individual is under stress.
As a final note, it is crucial when looking for a therapist, that they have specialized training in OCD treatment. Because not all treatment providers (e.g., psychologists, social-workers, and counselors) are apt to treat OCD, it may be more difficult to find an effective OCD therapist than a therapist for other disorders. Patients should be wary of treatments not mentioned in this article and should look for buzzwords, such as “cognitive-behavioral therapy” and “Exposure and Response Prevention” in a therapist’s description.
Learn more: Residential Treatment for OCD
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders, Fifth edition. Arlington, VA.
van Niekerk, J. (2018). A Clinician’s Guide to Treating OCD: The Most Effective CBT Approaches for Obsessive-Compulsive Disorder. New Harbinger.