Treatment - Obsessive-Compulsive Disorder
Table of Contents
Obsessive-Compulsive Disorder is one of the most difficult to understand of all psychiatric illnesses. Persons who have this condition find themselves repeating certain behaviors or thoughts again and again and 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 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 learn that no catastrophe occurs when the behaviors do cease.
Research has shown that one of the most difficult problems in OCD is in 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.
For many years, 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 to the exact obsessions.compulsions involved in the individual case.
Behavior therapy has a lot to offer individuals with this disorder. Two common and popular techniques are systematic desensitization and flooding. 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 their use 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. It is important for the client to find a relaxation technique which works best for them, before attempting something like systematic desensitization or flooding. Flooding allows the patient to face the most anxiety-provoking situation, while using the relaxation skills learned. 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 (e.g., traumatizing the individual further).
Additional behavior and cognitive-behavioral techniques which may have some effectiveness for people who suffer from this disorder include saturation and thought-stopping. Through saturation, the client is directed to do nothing but think of one obsessional 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), and then encouraged to transplant this behavior to the privacy of their home. They can also often use other incompatible stimuli, such as tweaking a rubber-band which is around their wrist whenever they have a thought. The latter technique would be more effective in public, for example.
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 anti-depressants that act selectively on the re-uptake of serotonin, a neurotransmitter. In the last few years, neuro-imaging 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 tick disorders such as Tourette's Syndrome and to Attention Deficit Disorder. It now seems that variable amounts of dysfunction produce clinical symptoms that may be virtually all 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 Sydinham's Chorea have a significantly increased risk of OCD. Therefore treatment with antibiotics early in an infectious illness may reduce the chances of future obsessive thinking.
Imaging studies have also demonstrated that both medications and behavior therapy alter brain metabolism in the direction of normalcy. This then is one of the few areas in all 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 usual amount. Behavioral therapy with medications seems to offer the best long term improvement. Virtually no treatment is curative for OCD. Most treatment can be expected to reduce symptoms by 50-80% or more, however. The illness is cyclic, and worsens when the individual is under stress.
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Parts of this article were written by James F. Hooper, M.D., while other sections were written by John M. Grohol, Psy.D. for .