Originally obsessive-compulsive disorder was considered extremely difficult, if not impossible, to treat. Psychoanalytic thought, based on Freud's theories of unconscious drives and wishes, produced many theories and interesting case studies, but no treatment approaches that could be shown to be effective.
Several cognitive and behavioral approaches, based on learning theory, were developed for OCD, with varying degrees of success. The goal of these was to reduce fear by exposing the patient to the very thing that was feared or avoided until the patient adapted, or habituated, to the situation.
The first real breakthrough occurred in the 1960's, with a scientific report of two patients successfully treated with a behavioral therapy program that included prolonged exposure to distressing objects and situations, coupled with strict prevention of rituals. This account was followed by many more research studies that supported these findings, and subsequent studies were conducted to separate the effects of the treatment components.
Overview of CBT for OCD
Cognitive-behavior researchers tested a number of techniques that have since been refined into what is now called exposure and ritual prevention (EXRP) — an effective psychological strategy for the treatment of OCD. (The word "ritual" in EXRP is often replaced by "response," but the word "response" is too broad as not all responses are compulsions.) Though behaviorally-based, EXRP includes both behavioral and cognitive techniques. Strict cognitive therapy (CT) is advocated by some and may be appropriate for patients who are not responsive to behavioral strategies. However, EXRP and CT both typically include behavioral and cognitive elements. EXRP has been used in a variety of formats, including individual and group treatment, family based treatment, computer based treatment, self-help techniques, and intensive programs. The remainder of this article will describe the important components of EXRP and CT for OCD.
Because avoidance is a central feature of OCD, exposure is the cornerstone of EXRP treatment. Pure in-vivo (real life) exposure has been shown to reduce obsessions and the related distress. This technique involves repeated and prolonged confrontation with situations that cause anxiety. Individual exposure sessions may last anywhere from 45 minutes to two hours. The immediate goal is for the patient to remain in the situation long enough to experience some reduction in anxiety. With repeated exposures, subsequent sessions will result in less distress. Thus, the patient habituates to feared items in two ways, within the session and between sessions.
Typically, exposure is gradual and the patient begins by facing objects and situations that result in only moderate levels of anxiety. Constructed in collaboration with the patient, an ordered list of avoided items are placed on a hierarchy. A simple rating scale of 0-100 (often called a SUDS scale for Subjective Units of Distress/Discomfort Scale) is used to rate the expected amount of anxiety associated with each item, with the most distressing item at the top of the hierarchy. After an item from the hierarchy is faced in session with a therapist, the patient then practices self-exposure of the same exposure as daily homework. Once mastered, the patient faces the next progressively more distressing object or situation to produce higher levels of anxiety. The patient learns (1) that the feared consequence will not occur, (2) to better tolerate anxiety, and (3) that anxiety naturally diminishes over time.
The ritual or response prevention component involves instructions for the patient not to engage in compulsions or rituals of any sort. This is important because patients feel that the rituals prevent the occurrence of a feared outcome. Only by stopping the rituals do patients learn that rituals do not protect them from their obsessional concerns. Rituals are usually connected to the obsessional thought in a logical way (i.e. "If I keep washing I will be safe from getting germs and disease,") but at times the ritual is more magically connected (i.e. "If I tie my shoes 4 times the right way, my children will be safe from harm.") Sometimes there is no feared event that the patient can articulate, rather performance of the ritual "just feels right," therefore the feared consequence is simply ongoing anxiety and discomfort.
The implementation of ritual prevention involves a detailed analysis of all compulsions or rituals performed by the patient. Typically patients are asked to keep daily logs of all rituals performed. The therapist uses these logs initially to identify rituals to be stopped and, as treatment progresses, areas of difficulty that need more therapeutic attention.
In some cases it is not possible to construct an in-vivo exposure to a patient's fear, and in these instances an exposure can be done in the imagination. Situations especially appropriate for an imaginal exposure are those in which the patient fears he may change in a fundamental way (i.e. shifting in sexual orientation or becoming a serial killer), cause a distal catastrophe (i.e. starting a chain of events that results in harm coming to unknown people), or that the outcome of failing to do a ritual is far in the future (i.e. going to hell or dying from cancer).
Previously termed "flooding in imagination," the technique is based on behavioral theories that were found to be effective in clinical studies. To conduct an imaginal exposure, the therapist and patient develop a detailed scene together based on the patient's worst fear. The story will describe a catastrophe befalling the patient and/or loved ones as a direct result of the patient's failure to perform rituals. The therapist might first recount the story aloud and then have the patient do the same, ideally in the present tense to make the events seem more real. SUDS levels are taken at various points throughout the narrative to assure that the story is evoking enough anxiety to be productive. The exposure is typically recorded and the patient repeatedly listens to the recording as homework.
OCD patients are anxious about their thoughts, or obsessions, because they interpret them as warnings of events that are dangerous and likely to occur. Cognitive therapy is designed to help patients identify these automatic unrealistic thoughts and change their interpretations of the meaning of the thoughts, resulting in decreased anxiety and decreased compulsions.
In the first stage of CT, patients are taught to develop an awareness of their worries as obsessions and their rituals as compulsions. The patient keeps a daily diary of obsessions, called a thought record. In the thought record, patients write down their obsessions and the interpretations associated with the obsessions. Important details to record may include what the patient was doing when the obsession began, the content of the obsession, the meaning attributed to the obsession, and what the patient did in response to the obsession (usually a compulsion).
The therapist will review the thought record with the patient and how the obsession was interpreted. Using gentle reasoning and Socratic questioning, the therapist will verbally challenge an unrealistic belief. This helps the patient to identify the cognitive distortion, typically a faulty assessment of danger, an exaggerated sense of responsibility, or fears that thinking something negative will make it come true (thought-action fusion).
In the past, thought-stopping was used to help increase awareness of obsessions and as a form of aversive therapy (punishment). This involves interrupting obsessional ruminations by using a cue word, such as "Stop!" Patients are taught to use the cue word when they experience distress from an obsession, and may be instructed to imagine something pleasant immediately after saying the cue word. Thought-stopping can also be conducted by having the patient snap his wrist with a rubber band when he finds himself obsessing, resulting in a sharp pain; thus the pain and obsession become connected. Thought-stopping techniques are used less frequently than in the past as they have not been shown to be very effective.
Once patients are able to quickly identify their obsessions and compulsions as symptoms of OCD, the therapist will initiate a few behavioral experiments to disprove errors in thinking about cause and effect. For example if a patient believes that smoking four cigarettes will prevent her family from being harmed in an auto accident, the therapist may instruct the patient to smoke only three cigarettes and then wait to see if family members are actually harmed that day in an auto accident. The therapist may then use the results of this experiment as material for discussion about other types of magical thinking. Over time, patients learn to identify and re-evaluate beliefs about the potential consequences of engaging in or refraining from compulsive behaviors and subsequently begin to eliminate compulsions.
Evidence-Based Psychological Treatment for OCD
Over 40 years of published research has led to the wide consensus among researchers and clinicians that cognitive-behavior therapy is an effective treatment for OCD.
Exposure-based treatments have the largest evidence-base to support their use for OCD. EXRP which includes elements of CT appears to be most effective, with over 80% of patients experiencing significant improvements with treatment. EXRP is recommended as the first-line treatment for OCD, with pure CT as a second choice alternative.
People interested in alternative approaches (i.e. yogic meditation, hypnosis, virtual reality therapy, homeopathy, or an integrated psychological approach) should understand that there is not yet any evidence base to support these treatments for OCD.
Adapted from M Williams, MB Powers, & EB Foa,"Obsessive Compulsive Disorder,"
Chapter 16, In
Handbook of Evidence-Based Practice in Clinical Psychology, Vol. 2.
Edited by P Sturmey & M Hersen, 2009.