Obsessive-Compulsive Disorder (OCD) Treatment
Living with obsessive-compulsive disorder (OCD) can be exhausting and overwhelming. Intrusive, upsetting thoughts, images, or urges regularly bombard you. You also might find yourself repeating certain behaviors over and over and over—even though you likely know they’re unnecessary. But you can’t stop.
Maybe you repeatedly check locks, lights, and the stove. Maybe you have to repeat certain reassuring phrases, or keep driving around the block to make sure you haven’t hit anything or anyone.
And if you can’t complete your rituals, you experience severe, off-the-charts anxiety. Which leaves you feeling hopeless.
Or maybe your child is struggling with OCD, and experiencing similar symptoms.
Fortunately, OCD is highly treatable for both adults and kids. The first-line treatment is a type of cognitive behavioral therapy called exposure and response prevention (EX/RP). Medication, particularly selective serotonin reuptake inhibitors (SSRIs), also might be an initial treatment, if you prefer medication or EX/RP isn’t available.
However, once medication is stopped, symptoms can return, while EX/RP treats OCD long term.
For kids and teens, medication is typically reserved for moderate to severe symptoms of OCD, or if EX/RP hasn’t worked. Often, the best approach for moderate to severe symptoms is a combination of EX/RP and an SSRI (which can be helpful for adults, as well).
Overall, your treatment (or your child’s treatment) will depend on various factors, such as the severity of symptoms, presence of co-occurring conditions, availability of EX/RP, treatment history, current medication, and preference.
Psychotherapy for OCD
Exposure and response prevention (EX/RP) is considered the “gold standard” for treating obsessive-compulsive disorder (OCD). It has received strong research support from numerous clinical trials evaluating its efficacy in individuals with OCD in both inpatient and outpatient settings. EX/RP involves two components: 1) provoking obsessions and experiencing subsequent anxiety while 2) refraining from engaging in rituals.
The purpose of this process is to gradually extinguish your obsession-related anxiety by having you “learn by doing.” When you repeatedly test your predictions of your feared outcome (e.g., “I will get sick and die”) by exposing yourself to your anxiety triggers (e.g., dirt on your hands) and resisting the urge to perform rituals (e.g., washing your hands 3 times), the paired association between the obsessions and compulsions gets weaker.
Crucially, by preventing rituals, you learn that (1) despite your anxiety and compulsive urge, the feared outcome likely will not occur (or at least not nearly as bad as you imagined); and (2) the anxiety itself will habituate on its own as long as compulsions aren’t performed. Plus, as a byproduct, many people also feel a sense of control and empowerment over their anxiety for the first time, instead of remaining crippled by obsessions and compulsions.
The actual exposure occurs gradually and systematically, so you start with the least feared situation and move onto the most feared. These exercises can be done during session (and assigned to you as homework) through guided in-vivo (out in the world) or imaginal scripts at your therapist’s office.
In imaginal exposure, you’ll typically sit with your eyes closed and verbally perform a narrative of your feared consequences. For example, if you keep thinking about accidently killing your spouse and perform counting rituals to counteract these obsessions, your therapist will ask you to imagine killing your spouse without counting.
During, in-vivo exposure, you’ll come “face-to-face” with your fear. For example, if your fear centers around contamination, your therapist will ask you to sit on the bathroom floor for a certain amount of time without washing your hands or taking a shower. Or, at first, the therapist will ask you to delay washing your hands for a certain amount of time. The next time you do this, they’ll ask you to wait longer to wash your hands, and so on.
This, of course, sounds scary and hard and maybe even impossible. But EX/RP should be done at your own pace—without the therapist forcing you to do anything you don’t want to do. You’re in charge of the process, and can go as slowly as you need.
Cognitive therapy is often added during EX/RP so you can process these behavioral experiences and “make sense” of them as treatment progresses. Cognitive therapy also is critical because it helps to correct strongly held (mistaken) beliefs. And it helps you realize that your intrusive thoughts aren’t powerful tell-tale truths, but simply normally occurring, meaningless thoughts.
EX/RP typically lasts 12 to 16 sessions, and is provided once a week. But it can be delivered more frequently, if necessary (e.g., daily or twice-weekly).
Because therapy can be costly, and a therapist who specializes in CBT can be tough to find, research has explored remote options. A recent review found remote CBT for OCD to be effective. It included various interventions with and without a therapist: vCBT (video-conferencing with a therapist); tCBT (talking over the phone with a therapist); cCBT (an over-the-phone computerized program you do on your own); iCBT (an internet clinician-directed or self-directed program); and bCBT (a print workbook to conduct your own treatment).
EX/RP is also highly effective for kids and teens with OCD. Specifically, family involvement can be invaluable. In family-based CBT, parents learn about OCD and its treatment, along with how they might maintain OCD symptoms.
The therapist coaches parents on effective ways to handle requests from their kids, so they’re not accommodating their obsessions or compulsions. Which is very common. Well-intentioned parents regularly try to protect their children from triggers, participating in their child’s rituals, offering reassurance, and generally letting OCD take over (e.g., no longer going to restaurants or on vacation).
Parents also learn how to encourage their kids to engage in exposure exercises, along with effective communication and problem solving skills. Since anxiety tends to run in families, parents may additionally learn how to manage their own anxiety.
Recent research supports the use of acceptance and commitment therapy (ACT) in treating OCD. ACT is a behavioral, mindfulness-based 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, ACT involves paying attention to and enduring your obsession-related anxiety while resisting the urge to react (i.e., perform compulsive action or ritual).
However, different from EX/RP, ACT focuses on values and acceptance. People are taught to focus on the present moment and act in line with their goals and life values—instead of being pushed around by their obsessions. Rituals are only effective at reducing short-term distress, but they preserve your long-term suffering. As such, you begin to act out of awareness towards values (e.g., family, job, health) regardless of the distress.
More research supporting ACT is needed. Also, ACT may be most effective for people with greater insight (who recognize that their obsessions and compulsions are problematic).
When searching for a therapist, look for keywords such as “cognitive behavioral therapy” and “exposure and response prevention” in a therapist’s description.
Learn more: ERP Therapy: A Good Choice for Treating OCD
Medications for OCD
The medication of choice for obsessive-compulsive disorder (OCD) is a selective serotonin reuptake inhibitor (SSRI). The following have been approved by the U.S. Food and Drug Administration (FDA) for treating OCD and appear to be equally as effective: fluoxetine (Prozac), fluvoxamine (Luvox), paroxetine (Paxil), and sertraline (Zoloft).
Your doctor might prescribe one of those SSRIs or escitalopram or citalopram, which haven’t been FDA-approved but also are effective in reducing OCD symptoms.
If your child has OCD, your doctor might prescribe an FDA-approved SSRI or an SSRI “off label.” Fluoxetine (Prozac), fluvoxamine (Luvox) and sertraline (Zoloft) have been FDA approved for use in kids.
Individuals with OCD typically benefit from higher doses of SSRIs (than other conditions such as depression or anxiety). This is true for kids, as well, who might need adult-sized doses. (But the doctor will likely start out with a low dose—lower than adolescents.) According to clinical practice guidelines, it’s best to try an SSRI (at the max tolerable dose) for at least 8 to 12 weeks.
SSRIs treat other conditions, including depression and some anxiety disorders. This is important because OCD commonly co-occurs with these disorders.
Side effects of SSRIs include nausea, diarrhea, agitation, insomnia, vivid dreams, excessive sweating, and sexual side effects (e.g., decreased sexual desire, delayed orgasm).
If the first SSRI you try doesn’t work or you can’t tolerate the side effects, your doctor will likely prescribe a different SSRI. Which is also the process for kids and teens.
Don’t abruptly stop taking an SSRI, because stopping can trigger “discontinuation syndrome” or “withdrawal syndrome” (some researchers prefer the latter term). These symptoms start within days of stopping medication and can last up to 3 weeks (though it can be longer). Symptoms include insomnia, nausea, dizziness, and visual disturbances, along with flu-like sensations.
It’s best to talk to your doctor about stopping, so you can gradually and systematically taper off a medication—and even then, many people still experience these symptoms.
Many people don’t respond to first-line treatments. When this happens, your doctor might prescribe clomipramine (Anafranil), a tricyclic antidepressant that’s FDA approved for OCD (in both kids and adults). Clomipramine has been around for almost five decades, and is actually just as effective as SSRIs but it’s less tolerated. That’s because of its side effects, which include dry mouth, blurred vision, constipation, fatigue, tremor, orthostatic hypotension (severe drop in blood pressure), and excessive sweating. Clomipramine also has an increased risk of arrhythmia and seizures at doses greater than 200 mg per day.
This is why clomipramine is typically used as a second-line treatment when SSRIs haven’t worked. Another treatment approach is to add clomipramine to an SSRI (however, this hasn’t been studied).
Doctors also might add an antipsychotic, such as risperidone or aripiprazole, to an SSRI or clomipramine to boost its effects. This tends to help about 30 percent of people with treatment-refractory OCD. However, antipsychotics do come with significant side effects, such as increased risk for diabetes, weight gain, and tardive dyskinesia (uncontrollable movement of your face and body). For this reason, if you don’t get better after 6 to 10 weeks of treatment, your doctor will likely have you discontinue the antipsychotic medication.
When meeting with your doctor, talk about your concerns, and ask any questions you might have. Ask about the specific side effects of your medication, and how you might minimize those side effects. Ask when you should expect to feel better, and what that might look like. Remember the medication you try should be a collaborative decision that honors your preferences and concerns.
Learn more: Medications for Obsessive-Compulsive Disorder (OCD)
Sometimes, once-a-week therapy and medication aren’t enough for individuals with OCD. They need more frequent or more intensive treatment. The International OCD Foundation includes information on more intensive treatment options. You’ll also find additional insights in this piece written by a mom whose son struggled with severe OCD.
For example, you might check yourself into a residential treatment center for OCD. Or you might attend an outpatient program that involves group and individual therapy at a mental health treatment center from 9 a.m. to 5 p.m. during the week.
The International OCD Foundation also has a resource directory where it lists these programs and other resources in your area.
Self-Help Strategies for OCD
Learn to effectively navigate stress. Stress can exacerbate your OCD. Which is why it can help to minimize stressors and anticipate the ones you can’t reduce. This can include two approaches: relaxation and self-care techniques that honor your emotional, physical, and mental health; and problem solving strategies.
The former might consist of regularly listening to guided meditation, getting enough sleep, and taking walks in nature. For the latter, Anxiety Canada provides a specific 6-step-process to follow in this PDF.
Remind yourself what obsessions really are. Everyone has strange, upsetting, and even violent thoughts from time to time. The difference is that when you have OCD, you view these thoughts as gospel. You think they’re dangerous, and somehow reflect who you really are deep down. Which is why exploring and revising the interpretation of your thoughts can be powerful. Remind yourself that these are harmless, weird thoughts. You can even think of them as brain glitches.
Importantly, what doesn’t work is telling yourself to stop thinking these thoughts (equally unhelpful is an outdated strategy of snapping a rubber band against your wrist any time obsessions arise).
Avoid accommodating your child’s fears. As a parent, you want to protect your child. You want to help them feel safe and comfortable. However, when applied to OCD, this well-meaning approach only feeds the disorder. Many parents change their routines and habits to accommodate OCD, and participate in their kids’ compulsions. What can help instead is to encourage your child to practice the skills and techniques they’re learning in therapy—to face their fears. It’s also helpful to separate their OCD from them by naming it (e.g., “The Bully”).
The Child Mind Institute, an independent non-profit organization that helps kids and families with mental health and learning disorders, has excellent expert-written articles on exactly how you can help, along with stories from families. For instance, check out this article, and this video.
The International OCD Foundation has a helpful article on how to specifically help your teen.
There are also books for kids and teens, including: Freeing Your Child from Obsessive-Compulsive Disorder; The OCD Workbook for Kids; Helping Your Child with OCD; and OCD: A Workbook for Clinicians, Children, and Teens.
Learn more: Residential Treatment for OCD
Abramowitz, J. (2019, March 13). Psychotherapy for obsessive-compulsive disorder in adults. UpToDate.com. Retrieved from https://www.uptodate.com/contents/psychotherapy-for-obsessive-compulsive-disorder-in-adults.
Abramowitz, J., Blakey, S.M., Reuman, L., Buchholz, J.L. (2018). New directions in the cognitive-behavioral treatment of OCD: Theory, research, and practice. Behavior Therapy, 49, 311-322. DOI: 10.1016/j.beth.2017.09.002.
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Publishing.
Fava, G., Gatti, A., Belaise, C., Guidi, J., Offidani, E. (2015). Withdrawal Symptoms after Selective Serotonin Reuptake Inhibitor Discontinuation: A Systematic Review. Psychotherapy and Psychosomatics, 84, 2, 72-81. DOI: 10.1159/000370338.
Hirschtritt, M.E., Bloch, M.H., Mathews, C.A. (2017). Obsessive-Compulsive Disorder Advances in Diagnosis and Treatment. JAMA, 317, 13, 1358-1367. DOI: 10.1001/jama.2017.2200.
Katzman MA, Bleau P, Blier P, Chokka P.., Kjernisted, Van Ameringen, M., … Walker, J.R. (2014) Canadian clinical practice guidelines for the management of anxiety, posttraumatic stress and obsessive-compulsive disorders. BMC Psychiatry 14(Suppl. 1): 1-83. DOI: 10.1186/1471-244X-14-S1-S1.
Koran L.M., Simpson H.B. (2013). Guideline Watch (March 2013): Practice Guideline for the Treatment of Patients with Obsessive-Compulsive Disorder. Arlington, VA: American Psychiatric Association.
OCD Clinical Practice Review Task Force. (2015) Clinical Practice Review for OCD. Silver Spring, MD: Anxiety and Depression Association of America. Retrieved from https://www.adaa.org/resources-professionals/practice-guidelines-ocd.
Simpson, H.B. (2017, June 22). Pharmacotherapy for obsessive-compulsive disorder in adults. UpToDate.com. Retrieved from https://www.uptodate.com/contents/pharmacotherapy-for-obsessive-compulsive-disorder-in-adults.
van Niekerk, J. (2018). A Clinician’s Guide to Treating OCD: The Most Effective CBT Approaches for Obsessive-Compulsive Disorder. Oakland, CA: New Harbinger.
Wootton BM. (2016). Remote cognitive-behavior therapy for obsessive-compulsive symptoms: a meta-analysis. Clinical Psychology Review, 43, 103-113. DOI: 10.1016/j.cpr.2015.10.001
Tartakovsky, M. (2020). Obsessive-Compulsive Disorder (OCD) Treatment. Psych Central. Retrieved on July 13, 2020, from https://psychcentral.com/ocd/obsessive-compulsive-disorder-ocd-treatment/