Obsessive-Compulsive Disorder (OCD)
Finding The Right Treatment
Treatment
OCD is typically treated with a combination of therapy and medications. Therapists use cognitive behavioral therapy (CBT) to help individuals overcome their irrational behaviors and obsessions. For example, exposure and response prevention (ERP) is a form of CBT in which the therapist helps clients safely engage in the situation which triggers them.
Exposure and response prevention (ERP)
This technique replaces avoidance of a feared trigger with approaching it. For instance, a person who fears contamination may be instructed to touch a dirty item. Then the therapist prevents their patient from handwashing to reinforce learning that nothing terrible happens if they do not immediately wash their hands.
Several rules for successful exposure therapy:
Exposure exercises should be performed on a hierarchy from least difficult to most difficult. It is important to begin with a less threatening exercise so an individual with OCD feels mastery of the assignment before approaching more difficult challenges.
Exercises to desensitize an individual should be performed frequently, at least 3-4 times a week. This helps dilute the challenge of a possible negative trial one or two of the days, with more favorable results the other days.
It is also important that sustained effort, at least 5-10 minutes, is devoted to each exercise session. The goal for the person with OCD is to notice that they are uncomfortable but to persevere. This also reinforces the sense of mastery.
End on a good note. If an exercise is difficult, it is best to try to sustain the exposure rather than run from it. Wait until the anxiety has died down before abandoning the exercise.
It is best for the person with OCD to monitor and keep record of their level of anxiety for each exposure on a scale of 1-10. This allows the individual to see growth or decline and determine if they are ready for the next challenging exercise.
Cognitive therapy
Treatment will help the individual with OCD recognize that their unpleasant thoughts are consistent with their diagnosis. Therefore, extensive psychoeducation explaining the diagnosis is important to treatment. Learning to identify the thought as “my OCD” helps diminish the substance of the thought and instead focus on the process. Treatment involves learning a new narrative: “I am thinking this way because my OCD makes me think this way, rather than facing an actual threat.”
Cognitive therapy does not consist of talking the person with OCD out of their fear.
Most people with OCD already are aware that their thoughts and subsequent behaviors are irrational. Because of this awareness, cognitive therapy focuses on helping the person identify when they are going down the OCD rabbit hole, and redirecting their thoughts to more productive or pleasant ones. The therapy may include “go to” strategies to invoke when an intrusive thought occurs: removing oneself from the current setting, even switching rooms in one's house; taking a walk and listening to a podcast, calling a friend and engaging in conversation unrelated to the distressing cognition.
CBT does NOT look to the root of the intrusive thoughts and behavior. It focuses not on the WHY (do I do this) and instead concentrates on the HOW (do I fix it). While the therapy can look at events which may precede this condition, it will not devote much attention to causation.
Finding a therapist
Therapy has been proven to yield major improvements in the lives of those with OCD. Most therapists have experience working with adults with OCD.
There are different kinds of professionals who can provide effective therapy for OCD:
- Clinical psychologists (PhD)
- Licensed social workers (LSW)
- Licensed professional counselors (LPC)
- Licensed clinical professional counselors (LCPC)
- Licensed Marriage and Family Therapists (LMFT)
The decision to start therapy
Many people try to cope with their distress on their own, and then feel disappointed when they find that this is very difficult to do. Deciding to start therapy can be hard; it takes courage.
For some people, it can take time to warm up to the idea of sharing one’s intimate thoughts or disclosing details of one’s life, especially for those who grew up in a culture where seeking psychological help was frowned upon.
Psychotherapy is increasingly accepted as not only a way to improve mental health symptoms, but also a means for self exploration and personal growth. No problem is too small for a trained therapist: an individual need not worry that others may have it worse. The willingness to reach out for help is increasing: in 2020, one out of every six Americans (men and women) reported seeing a therapist.
Seeing a therapist with whom one feels comfortable, and a sense of connection, and who also participates in their insurance network, is essential. It may take a couple tries to find a therapist who feels like the right fit. If therapy didn't help the first time around, it can be helpful to give another therapist a try because therapeutic styles vary so much from therapist to therapist.
Where to start
Asking one’s physician to make a referral is often a good place to start. Many health insurance cards have websites or 1-800 numbers to call for a list of in-network providers.
To find a therapist who takes your insurance, the National Institute of Mental Health offers a comprehensive list of resources.
Psychology Today also lists therapists by type, location and insurance.
Determining whether medications will play a role in treatment
Medications to treat OCD can often be helpful.
Antidepressants
The most commonly used medications are antidepressants called Selective Serotonin Reuptake Inhibitors (SSRIs) or Selective Serotonin and Norepinephrine Reuptake Inhibitors (SNRIs). Even though these medications are called antidepressants and can be used for treating depression, they are also studied and approved for use in individuals who struggle with OCD.
This class of medications take 4-6 weeks before they start working. Medications have been proven to decrease the emotional burden associated with obsessive thoughts and compulsive actions and they lower the generalized anxiety that accompanies OCD. While these medications are used to treat a number of mental health conditions, including depression, OCD, and some pain conditions, the dosing and the use of concomitant medications differs across conditions.
Considering TMS or deep brain stimulation
Some individuals with severe OCD who are resistant to treatment may be candidates for transcranial magnetic stimulation (TMS) treatments, available at some major medical centers.
TMS is an FDA approved treatment for OCD. The Brainsway Deep Transcranial Magnetic Stimulation device is one such device that is used to treat individuals who are not responsive to therapy or medication. The special magnet delivers a magnet pulse to the brain from an electromagnetic coil. There are a number of other companies that have competing TMS technologies and treatment networks.
Deep brain stimulation (DBS) is surgical treatment for adults with OCD who have not responded to therapy and medications. This is a complex and invasive brain surgery that involves the implantation of an electrical pacemaker in the chest which transmits impulses to electrodes in the brain. DBS is performed only in a few major medical centers and is reserved for the most severe cases of OCD.
Healthcare providers that can prescribe medications
Psychiatrists, psychiatric nurse practitioners, and physician assistants are practitioners who are trained to diagnose and treat mental health conditions by prescribing medications. Sometimes it's hard to find a psychiatric provider because there are so many people who need them. So, individuals often choose to see a different kind of provider who can prescribe. This could be a doctor they already see, like a primary care doctor, family doctor or OB/GYN, or a new primary doctor.
FDA warning about suicide risk with antidepressants
Some research exists that, occasionally, newly initiated anti-depressants may increase the risk of suicide. If an individual begins to have these thoughts after starting an anti-depressant, please stop this medicine and contact a prescriber immediately. This risk is more evident in children, adolescents, and young adults.