People who experience obsessive-compulsive disorder (OCD) often turn to medications first for treatment (since they often turn to their primary care physician first for a diagnosis as well). However, decades’ worth of research actually suggests a “best practice” treatment for OCD that doesn’t involve the prescription of any medications.
The treatment is a cognitive behavioral approach for OCD that combines exposure and ritual (or response) prevention, known as EX/RP. According to a recent Monitor article on this topic, University of Pennsylvania researchers have conducted research studies to identify the active ingredients of EX/RP. In one set of studies, the team compared separate components of EX/RP and found that exposure only and ritual prevention only were not as effective as the combination of the two. In another line of research, they compared the efficacy of the tricyclic antidepressant clomipramine with EX/RP. They found that EX/RP reduced symptoms more than clomipramine and that EX/RP improved the effects of clomipramine, but the reverse was not the case.
The results of these studies “show that EX/RP is the treatment of choice for OCD, both as a treatment by itself and as an augmentation to medication,” say the researchers. They have found similar results with children and adolescents, although a related study on young people at Duke University did find an optimal effect by combining the selective serotonin reuptake inhibitor (SSRI) Zoloft (sertraline) and EX/RP.
How Does Exposure/Ritual Prevention Work?
In this form of behavior therapy, the patient is deliberately and voluntarily exposed to the feared object or idea, either directly or by imagination, and then is discouraged or prevented from carrying out the usual compulsive response.
For example, a compulsive hand washer may be urged to touch an object believed to be contaminated, and then may be denied the opportunity to wash for several hours. When the treatment works well, the patient gradually experiences less anxiety from the obsessive thoughts and becomes able to do without the compulsive actions for extended periods of time.
Studies of behavior therapy for OCD have found it to produce long-lasting benefits. To achieve the best results, a combination of factors is necessary: The therapist should be well-trained in the specific method developed; the patient must be highly motivated; and the patient’s family must be cooperative. In addition to visits to the therapist, the patient must be faithful in fulfilling weekly homework assigned by the therapist. For those patients who complete the course of treatment, the improvements can be significant.
Clinical trials in recent years have shown that drugs that affect the neurotransmitter serotonin can also help decrease the symptoms of OCD. These drugs include fluvoxamine, paroxetine, sertraline, clomipramine and fluoxetine. All these selective serotonin reuptake inhibitors (SSRIs) have proved effective in treatment of OCD.
If a patient does not respond well to one SSRI, another SSRI may give a better response. For patients who are only partially responsive to these medications, research is being conducted on the use of an SRI as the primary medication and one of a variety of medications as an additional drug (an augmenter). Medications are of great help in controlling the symptoms of OCD, but often, if the medication is discontinued, relapse will follow. Most patients can benefit from a combination of medication and behavioral therapy.
Most people will benefit from trying the EX/RP behavior therapy first, before trying a medication. Medications will generally take longer and have more unpleasant, daily side effects than the EX/RP technique in most people. With a combination of EX/RP and, when necessary, medications, the majority of OCD patients will be able to function well in both their work and social lives.