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Achieving Wellness from Obsessive Compulsive Disorder is a treatment study sponsored by NIMH.

Getting Well

OCD is a Serious Illness

Obsessive-compulsive disorder (OCD) can be a severe and disabling illness. According to a World Health Organization study, OCD is the tenth leading cause of disability worldwide, with a total cost in the US estimated at more than $8 billion annually. People with OCD usually spend years suffering before beginning effective treatment. The situation is complicated by the fact that many health professionals are not educated about the best treatments available to OCD patients.

The Limitations of Medication for OCD

The first-line treatment for obsessive-compulsive disorder is typically a course of anti-depressant medications, specifically serotonin reuptake inhibitors (SRIs). This term includes the well-known "selective" serotonin reuptake inhibitors (SSRIs) such as fluoxetine (Prozac), fluvoxamine (Luvox), sertraline (Zoloft), paroxetine (Paxil), citalopram (Celexa) and escitalopram (Lexapro), as well as the older tricyclic medication clomipramine (Anafranil). SSRIs are very safe medications for most people, which is one reason physicians are quick to prescribe these to patients with OCD symptoms.

Most people who try SRIs will experience some improvement in their OCD, but research has shown that on average people with OCD will experience only about a 30% reduction in symptoms. Historically, people who tried one medication without success would then be switched to a different SRI until an effective one could be found. However, this strategy of switching to a different medication is not well-supported by research. Considering the long period SRIs may take to be effective, often 4-8 weeks, the waiting and switching process can be frustrating to patients, and patients who benefited only partially from one SRI may not benefit from other SRIs. For this reason it is increasingly common to augment SRI medication with a type of psychotherapy specifically for OCD.

Augmenting Your SRI with Cognitive-Behavioral Therapy

  Augmenting medication with cognitive-behavioral therapy (CBT) may be an especially good choice, as a high percentage of patients treated with drugs alone will experience a return of their symptoms after they stop medication. CBT is a term used to describe a type of evidence-based treatment that focuses on changing a patients thoughts, emotions and behaviors. The cognitive and emotional parts involve helping patients change unhelpful and unrealistic thoughts and unwarranted negative emotions. In the behavioral part, the therapist helps the patients overcome the compulsive behaviors.  This is not the same as therapies that focus on childhood issues, relationships, or unconscious conflicts; such "insight-oriented" psychotherapies are not effective treatments for OCD. CBT treatments have been found to be helpful for a variety of mental disorders, particularly anxiety disorders like OCD.

The most effective CBT techniques for OCD include Exposure and Response prevention (EX/RP). EX/RP involves approaching anxiety-provoking situations or objects that trigger OCD related distress (exposure) combined with intentionally refraining from doing compulsions. Over time such exposure reduces the distress in situations that previously lead to compulsions, allowing patients to refrain from ritualizing behaviors and to function more normally.

EX/RP is the only proven augmentation therapy for people taking SRIs. In one recent study, EX/RP was tested against stress management training (SMT), a treatment involving the use of relaxation techniques and problem-solving strategies, but without direct confrontation of the OCD symptoms. In this study, all patients stayed on their SRI medicine and were randomly assigned to receive EX/RP or SMT. The majority of patients receiving EXRP improved and one-third were left with minimal OCD symptoms at the end of the 8-week treatment period, compared to those in the SMT group who mostly showed very little improvement. Thus EX/RP appears to be a very effective augmentation strategy for those with SRI-resistant OCD.