Obsessive-Compulsive Disorder

OCD involves:

Obsessions, which are unwanted and bothersome thoughts, ideas, or images.

Compulsions, which are repetitive behaviors or rituals which seem to decrease the anxiety that a person is feeling. Common compulsions include frequent hand-washing and checking of doors/locks.

People with OCD usually report that the obsessions and compulsions are embarrassing and disruptive to their lives. One study found that 36% of those with OCD report job troubles and 23% report relationship problems (Hollander, Greenwald, & Neville, 1996/1997). Individuals with OCD commonly note associated problems including depression, sleep disturbance, other anxiety disorders, and sometimes anorexia or bulimia. Physical problems can occur; for example, someone who engages in excessive hand-washing may develop skin problems.

Typical Chain of Events in OCD:

Various triggers cause intrusive, obsessive thoughts.

This in turn triggers the individual to experience higher anxiety.

This in turn leads the individual to engage in some ritual such as hand-washing, checking, doing something in even numbers, only entering a room by leading with the left or the right leg, etc.

The ritual or compulsion reduces the anxiety, which feels good, thereby providing positive reinforcement of the whole cycle. The cycle is strengthened.

Treatment:
The usual treatment for OCD is a procedure called Exposure & Response Prevention (ERP). Basically, this involves gradually and systematically exposing an individual to the triggers that stimulate obsessions or compulsions. The client and the psychologist develop a hierarchy of situations and gradually progress from easy to difficult. At the individual's pace, he/she gradually places himself/herself in situations that trigger rituals or compulsions (exposure). The individual then purposely does not engage in the compulsion or habitual response prevention -- the individual is exposed to the trigger and then prevents himself/herself from responding. What happens is that the anxiety goes up at first, but after a while, the anxiety goes back down thereby weakening the need to engage in the compulsion or ritual. After a while, being exposed to the trigger no longer drives the person to engage in the ritual or compulsion.

CBT Outcome for OCD: Outcome studies indicate that approximately 83% of individuals who complete this type of treatment show long-term improvement based on a review of 12 outcome studies (Foa & Franklin, 2001). This is a low relapse problem.

Medication outcome for OCD: Stahl (2000) notes that the average response rate for medications with OCD is a 35% reduction in symptoms, and, there is a relapse problem -- when people stop the medications, they often relapse or have a return of symptoms.

If medications are utilized, serotonergic medications are usually chosen. These include the selective serotonin reuptake inhibitors (SSRI's): fluoxetine (Prozac), sertraline (Zoloft), fluvoxamine (Luvox), citalopram (Celexa), escitalopram (Lexapro), and paroxetine (Paxil). Another serotonergic medication that is sometimes chosen is clomipramine (Anafranil).

Whether or not a combination of serotonergic medications plus CBT is advantageous is not clear but probably needs to be evaluated on a case-by-case basis.

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