Treatments for OCD
If you have OCD, there are four options you should know about: Behavior therapy (BT) or cognitive behavior therapy (CBT), medication, psychosurgery, and no treatment.
Experts agree (Expert Consensus Guidelines for the Treatment of OCD, Journal of Clinical Psychiatry, vol 58, supplement 4, 1997; also available online at http://www.psychguides.com/ocgl.html) that the best treatment for OCD is BT or CBT.
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If OCD is a biological disorder, then shouldn't it be treated with drugs?
Not necessarily. Someone who can't sleep because of psychological reasons (e.g., stress, anger, or worry) can be helped by medication, and someone who can't sleep for "biochemical" reasons (e.g., too much coffee) can be helped by psychological techniques. Interestingly, PET (positron emission tomography) scan research has shown that successful behavioral treatment of OCD results in the same kinds of changes in brain biochemistry that medication causes. |
E&RP involves two steps, exposure (to obsessional thoughts) and, not surprisingly, ritual prevention. Exposure means allowing yourself to be in situations that trigger your obsessions. Depending on your specific OCD symptoms, examples might be getting your hands slightly dirty, locking the front door, driving down a bumpy street, or being in the kitchen with a sharp knife and your child. If this is done correctly, this "exposure" would trigger obsessions about dirt or germs, whether you really locked the door or not, whether or not you hit a pedestrian, or whether you might harm your child.
Ritual prevention in these examples would consist of NOT washing your hands, NOT checking the lock, NOT looking in the rear-view mirror, and NOT putting the knife away or telling your child to leave the kitchen. Just as performing your compulsive rituals would reassure you and thus lower your anxiety, refraining from these behaviors will result in your anxiety going up. This can be quite unpleasant, but it is not harmful. A good therapist will work closely with you to come up with specific exposures that will make you anxious but not too anxious, so that you will be successful at resisting your compulsions. After your anxiety level goes up, it will level off, and then (this is the therapeutic part) drop. It typically goes up quickly and comes down slowly. It is important not to perform the ritual behavior to reduce your anxiety. The therapy will work if you let it.
As E&RP treatment continues, you can expect your obsessive thoughts to become less frequent and less intense. If this does not happen, you and your therapist need to do something differently. Often the problem is that your exposures are too mild or that you are not doing them often enough. Another problem is that you might be performing some other anxiety-reducing ritual behavior.
| How do antiobsessional medications work?
We don't know the full answer, but we know that it's much more complicated than "not having enough serotonin." For one thing, increasing serotonin levels can actually increase OCD symptoms initially in some patients. Only after weeks of treatment does the body respond to these higher levels by shutting down a significant number of postsynaptic receptors. This process is called downregulation. For reasons we don't yet understand, clinical improvement appears to be correlated with downregulation. So if you start (or increase the dosage of) an antiobsessional medication and your symptoms get worse, this can actually be a good sign that the medication will eventually work for you, and you should try to "tough it out" for the next week or two. |
The first choice of medications to treat OCD are the serotonin reuptake inhibitors (SRIs); all but one of these affect primarily the serotonin system and are thus called selective serotonin reuptake inhibitors (SSRIs). The SSRIs, with their American brand names in parentheses, are fluoxetine (Prozac, Sarifem), fluvoxamine (Luvox), sertraline (Zoloft), paroxetine (Paxil), citalopram (Celexa), and escitalopram (Lexapro). The lone SRI is clomipramine (Anafranil). You may see them all referred to as SSRIs.
These drugs have an excellent safety profile, but they can have side effects. Common side effects are decreased sexual drive and performance, headache, nausea, insomnia, and drowsiness. Not everyone gets side effects, so fear of side effects is usually not a good reason not to try them. If you do have side effects, they will go away after you stop the medication.
Venlafaxine (Effexor), mirtazepine (Remeron), and the class of drugs known as MAO inhibitors are also sometimes used to treat OCD, but these are not considered first-line treatments. Other medications, such as risperidone (Risperdal), are sometimes used in small doses to "augment" the effects of SRIs.
Evidence for benefit from "natural" pharmacological remedies such as herbs is scant, and recent reports suggest that there may be significant risks associated with these preparations, so they are not recommended at this time.
Psychosurgery, or the physical destruction of small amounts of brain tissue, is extremely rare. It is used only in severe cases of OCD when several trials of CBT and thorough trials of all antiobsessional medication have been tried. Nevertheless, it has been successful and is an option to be considered, if only as a last resort.
Not all OCD symptoms need to be treated! Someone who cannot go to bed until she touches all four dials on her stove while saying, "Off, off, off, off" is exhibiting a classic type of OCD symptom, but she may not need to change anything if this behavior doesn't interfere with her life. Our quirks, our ways of doing things, are what make us us. Similarly, successful OCD treatment rarely eliminates obsessions and compulsions completely, so just because you may have some OC tendencies left doesn't mean you should stay in treatment forever.
Psychodynamic psychotherapy, based on psychoanalytic principles, is a valid and valuable form for therapy for many problems, but not for OCD. The same is true for other forms of "insight-oriented" or "talking" therapies. There is virtually no evidence that symptoms of OCD result from unresolved or unconscious conflicts, or that they serve as a "defense" against more serious problems.