3 AugOvercoming OCD: A Guide To The Best Evidence-Based Therapies by Dr. Victoria Wacha, PhD Have you ever wondered about OCD – its prevalence, how it manifests, or the therapeutic options available? This comprehensive guide dives deep into OCD, shedding light on its nuances and providing practical, evidence-based solutions. Understanding OCD Obsessive compulsive disorder is a brain-based disorder that is characterized by obsessions and compulsions. Obsessions are intrusive thoughts, images or impulses that are distressing, anxiety producing and make one feel very uncomfortable. They enter the mind unwanted, and they are hard to control. This discomfort prompts individuals to engage in avoidance and ritualized behaviors to get rid of them and the discomfort they produce. These ritualized behaviors are compulsions. Compulsions are repetitive behaviors or mental acts that the individual feels driven to do in an attempt to make themselves feel better and get rid of discomfort, anxiety and distress. These behaviors, when performed, give the brain a small dopamine hit which lowers the individual’s emotional pain, but only for the short term. The dopamine surge that one gets when performing the compulsions inevitably increases the need to do the behavior again and again and again. Prevalence and Consequences of OCD According to the National Institute of Health, it’s estimated 1.2% of U.S. adults have OCD. Past year prevalence of OCD was higher for females (1.8%) than for males (0.5%). Lifetime prevalence of OCD among U.S. adults was 2.5%. Obsessions and compulsions may take up many hours of a person’s day and can interfere with family and social relationships. They can also have a negative effect on education and employment. As OCD becomes more severe, individuals may engage in more and more avoidance which leads to their world becoming smaller and smaller. Some individuals can even become housebound. It is important to get help for OCD. When seeking help, it is necessary to engage in evidence-based therapy specific for OCD because traditional psychotherapy has been shown to be ineffective and even harmful in treating OCD. Diagnostic Criteria and OCD Subtypes According to the Diagnostic and Statistical Manual of Mental Disorders, fifth edition, text revision (DSM-5-TR), OCD is described as the presence of obsessions, compulsions, or both. Obsessions must be recurrent and persistent thoughts, images or urges that are experienced as intrusive, unwanted and cause significant anxiety and distress. The person attempts to ignore the obsessions or suppress them. Compulsions must be repetitive and aimed at preventing or reducing distress caused by the obsessions. The DSM-5-TR also includes excoriation disorder and hoarding disorder as obsessive-compulsive disorders. The International OCD Foundation (IOCDF) identifies the following subtypes of OCD: harm OCD, Just Right OCD, contamination OCD, scrupulosity OCD, postpartum & perinatal OCD. However, mental health therapists and individuals may hear or read about other subtypes of OCD such as pedophilia OCD, symmetry and order OCD, relationship OCD, hit and run OCD, homosexual OCD or Pure O (purely obsessional OCD). OCD often is comorbid with other mental health disorders. The common co-occurring disorders are depression, anxiety, eating disorders, ADHD, tic disorder, body dysmorphic disorder and hypochondriasis. Due to the likelihood of a co-occurring disorder, it is important to be screened for these during the initial intake session. Potential Causes of OCD The causes of OCD are not fully understood at this point in time. However, some factors that may contribute to the development of OCD are genetics, temperament, and environmental factors. There are also thought to be some neurobiological basis of OCD. Brain scans show that individuals with OCD may have a slightly different brain structure than individuals without OCD. Exposure Response Prevention (ERP) Therapy for OCD The evidence-based therapies for OCD are Cognitive Behavioral Therapy (CBT) and antidepressant medication either combined or separate. The gold standard of treatment is considered Exposure Response Prevention (ERP) due to decades of research showing its efficacy. Exposure Response Prevention is under the umbrella of CBT and is really the behavioral part of CBT. In short, CBT focuses on the influences that thoughts, behaviors, and emotions have on one another and seeks to modify and challenge faulty thoughts in order to improve functioning. With OCD, we don’t try to modify thoughts or challenge them at all. Instead, we encourage the individual with OCD to gradually approach their distressing and feared thoughts while preventing them from responding to these thoughts (ie. doing something to get rid of the thoughts or doing something to make themselves feel better), which is ERP in a nutshell. ERP therapy is a goal directed, guided therapy in which the individual is gradually exposed to situations designed to provoke their obsessions in a safe and strategic way while not engaging in their compulsions. ERP does not get rid of distressing thoughts or situations. It teaches individuals to tolerate the distress and uncertainty of what will happen when they don’t engage in their compulsions. It is equivalent to getting used to something that is uncomfortable or we don’t like, which is called habituation. An example of habituation is what happens when we first get into a pool of cold water. First it is cold and uncomfortable, but then the water starts to feel warmer. The water has not actually gotten warmer, our body has just gotten used to it, so it no longer feels uncomfortable. We didn’t do anything except let time pass so that our body adjusted to the temperature. This is the same with anxiety and distress from obsessions and/or fears. By staying in an exposure long enough and not doing anything, the individual experiences a decrease or reduction in anxiety with nothing but the passing of time. ERP also allows individuals to learn something new when they are exposed to their fears over and over and do not engage in compulsions. They learn that when they face their fear (obsession) and don’t engage in a ritual (compulsion), nothing happens. Their brain has created a new non-threatening association with the obsession or fear. This is called inhibitory learning. There are several steps involved in ERP. I have listed them below for ease of understanding. Gather a comprehensive history of symptoms, presentation, duration, and family history Screen for co-occurring disorders (I use the QuickSCID-5) Administer the Yale-Brown Obsessive-Compulsive Scale (YBOCS) Have the patient begin tracking their obsessions and compulsions Review the results of YBOCS and Explain the rationale for ERP and subjective units of distress (SUDS) Create exposure hierarchy with the patient Decide with patient what the first exposure will be and conduct the exposure next session Begin Exposures (4 to 9 months of treatment) Always assign exposure homework between sessions Begin wrapping up treatment – re-rate hierarchy Re-administer the symptom severity scale on the YBOCS Develop relapse prevention/maintenance plan Taper sessions to once per month, then every 3 months, or you can end after you have done the relapse prevention plan Tips for Implementing ERP Some tips for implementing ERP are to be structured and stick with the exposure until the anxiety decreases by half or the predicted outcome doesn’t happen (ex. I said over and over that I am going to die from touching this surface while touching the doorknob and not washing my hands after and I didn’t die). Some more tips are to vary the exposures (do them in different places), be prepared to induce anxiety and not reassure, be prepared for much repetition because repetition is what makes the exposures stick and creates new learning. Repetition is medicine. Understand that ERP doesn’t have to be linear. If the patient wants to move to harder exposures, be open and willing to let them. Make sure patients do exposures on their own between sessions as this will develop confidence and keep the momentum going. Choosing the Right Therapist for OCD Treatment When seeking professional help, it is important to choose a qualified therapist (psychologist, social worker or Licensed Professional Counselor). So how do you know who is qualified to treat OCD? In order to get the best care, find a therapist who specializes in OCD and is trained in ERP. Better yet, find a therapist who is certified in ERP. This means that they have gone through advanced training in which they received consultation from an expert trainer and demonstrated solid knowledge of OCD and competency in implementing ERP. ERP Therapy Sessions ERP therapy sessions are usually 60 to 90 minutes in length. They are structured and goal directed sessions. The therapist is more like a coach in these sessions than a traditional therapist. They are guiding you, encouraging you, and facilitating new learning. A typical session begins with a review of the exposure homework (what went well, what problems arose, what did they learn, did their feared consequence happen). Then the therapist validates the patient’s feelings (not the same as reassurance), supports their efforts and encourages them. This encouragement, validation and coaching builds and strengthens the therapeutic alliance. Next the client does either an imaginal or in vivo exposure from their hierarchy of feared thoughts or situations that trigger obsessions and compulsions. The therapist assesses their distress level throughout the exposure. Typically, the patient stays in the exposure until their distress drops by half of its peak. However, newer research shows that habituation is not necessary for successful exposure. Rather inhibitory learning is as effective in reducing obsessions and compulsions because your brain is learning something new each time you do the exposure. Self-Help Strategies for Living with OCD Some self-help strategies for living with OCD include building a support network of friends and family who know that you have OCD and will provide encouragement during OCD flare ups, as well as, tracking obsessions and self-monitoring. I like to tell individuals to be an OCD detective because OCD is sneaky and tries to trick the owners of OCD brains into doing compulsions. One of my golden rules for patients is to do the opposite of what their OCD brain is telling them to do and if an intrusive thought comes into their head and sticks around, consider it an obsession. It is also important to understand that avoidance maintains OCD, so an important lifestyle change for someone managing OCD is to lean into their fears, let their distressing thoughts be by not responding to them in any way. Learning to practice mindfulness on a daily basis will help with letting thoughts be in the mind without doing anything to get rid of or neutralize them. Mindfulness is also a great stress management technique for all individuals, not just individuals with OCD. Staying Vigilant and Managing Setbacks It is important to remain vigilant and steadfast in your OCD recovery. Challenges may arise, such as setbacks and relapses. These can occur during life transitions, times of stress or with a lapse in following your relapse prevention plan. A long-term maintenance strategy for OCD is to do a monthly check in where you write down your thoughts, evaluate whether or not they are reasonable, see if you have done any compulsions, rate your thoughts with SUDs, and determine whether you need to do an exposure. Some more maintenance strategies include doing the opposite of what your OCD tells you to do, recognize intrusive thoughts as simply that – intrusions, understand that OCD can randomly shift, and that OCD feeds on fears and values and creates self-doubt. It is also very important to recognize that if you can’t manage, seek ERP treatment. Resources for Understanding and Managing OCD Some additional resources on OCD are: The International OCD Foundation website YouTube videos on OCD (look for videos by Reid Wilson, Jonathan Grayson and Patrick McGrath). Some books that might help an individual understand OCD are: Freedom from Obsessive Compulsive Disorder: A Personalized Recovery Program for Living with Uncertainty – by Jonathan Grayson Stuff That’s Loud: A Teen’s Guide to Unspiraling When OCD Gets Noisy – by Ben Sedley and Lisa W. Coyne Support groups and online communities: NOCD has online support groups Remember, obsessive compulsive disorder is a brain-based disorder that can be serious and debilitating, but with the help of a trained mental health professional, recovery and remission is very possible. Exposure response prevention is the cornerstone treatment for OCD. Antidepressant (SSRI) medication is also effective in treating and managing OCD, especially when combined with ERP. ERP treatment is short-term (4-9 months) with large gains. Most recent research shows an 80% success rate. ERP can make a dramatic difference in the lives and relationships of people with OCD. Some may experience a complete remission of OCD symptoms and live a life that is fulfilling and complete without compulsions. Frequently Asked Questions What is the most evidence-based treatment for OCD? Exposure Response Prevention and antidepressant medication. What kind of therapy is most effective in treating OCD? Exposure Response Prevention. What is the coping mechanism of OCD? People with OCD cope with their obsessions by avoiding and engaging in compulsions. Therefore, therapy focuses on learning to tolerate uncertainty, gradually facing fears, and eliminating compulsions. What is the root cause of OCD? There is no known cause for OCD.