Running head: OCD TREATMENT
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Treatments for Obsessive-Compulsive Disorder
Gerald Webb
Liberty University
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Abstract
Obsessive compulsive disorder (OCD) once thought to be very rare, is in fact quite common. It
often hides other disorders and can even be masked by comorbid disorders. This paper is a
collection of information on treatments for Obsessive-Compulsive disorder. Discussions will
consider Exposure and Response Prevention therapy which proposes a behaviorally oriented
solution for OCD. Cognitive Therapy looks at the disordered thoughts of the client with OCD
and seeks to give them new meaning. Acceptance and commitment therapy stresses that clients
sit with their distressing thoughts and develop mental flexibility. Other treatments for OCD
involve medications especially selective serotonin reuptake inhibitors. Best practices for helping
individuals diagnosed with OCD find hope are a combination of medications and expert led
therapies. A look at OCD from a spiritual perspective can provide great insight for counselors
and clients.
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Treatments for Obsessive-Compulsive Disorder
Obsessive-Compulsive Disorder (OCD) is a category of related anxiety provoking
disorders as defined in the Diagnostic and Statistics Manual 5th edition (DSM-V). These related
disorders include OCD, body dysmorphic disorder, hording disorder, trichotillomania,
excoriation disorder, OCD caused by medication, other specified OCD, and unspecified OCD
(American Psychiatric Association (APA), 2013). Obsession and compulsion definitions remain
consistent from the DSM-IV-TR to the DSM-5.
Obsessions are characterized by intrusive mental processes that cause agitation and stress.
Compulsions are performed to ease the tension created by the obsessions. The person believes
that by doing these actions he/she will relieve the stress caused by the obsessions or the actions
will prevent a feared event or situation (i.e. checking the stove multiple times to prevent a housefire). This belief can reinforce the obsession as the person with OCD perceives the house not
burning down is a result of the checking behavior. Typical forms of OCD include checking
behaviors, just-right behaviors (ordering & symmetry), cleaning behaviors, and fears related to
disease infection (Kopala, & Keitel, 2017).
Not so long ago mental health professionals believed OCD was a “a very rare and
untreatable condition” (Abramowitz, McKay, & Storch, 2017, p. 1). With the release of DSMIII-R in 1987, OCD began to be recognized as a commonly occurring mental disorder (James,
Farrell, & Zimmer‐Gembeck, 2017). Today, the DSM-V reports that at some time during a 12month period 1.2% of the U.S. population can be diagnosed as having OCD (APA, 2013).
Lifetime considerations yield different rates for men and women: women at 3.6% and men at
1.8% (Kopala, & Keitel, 2017). These prevalence rates indicate that OCD is quite common.
Women tend to have obsessions and compulsions related to cleaning and they tend to develop
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these behaviors in adulthood. While, men tend to develop OCD in adolescence in areas of
ordering and “forbidden thoughts” (Kopala, & Keitel, 2017, p. 457). Men often develop a tic
disorder in conjunction with their OCD diagnosis. Certain women diagnosed with OCD find that
symptoms began or are often made worse around events in the reproductive cycle such as the
premenstrual period, pregnancy, and postpartum (Guglielmi, et al., 2014).
Guglielmi, et al., (2014) conducted a study of 542 women in the United States and the
Netherlands diagnosed with OCD under DSM IV criteria. A small percentage of women
surveyed (3.7% to 5.1%) recalled onset of OCD symptoms during menopause, postpartum, and
pregnancy, while 13% of these women reported symptoms beginning within 12 months after
menarche. Significantly more women surveyed (32.7% to 46.6%) reported their OCD symptoms
getting worse during reproductive cycle events. The survey results led the researchers to
speculate about the release of estrogen and its possible interaction with serotonin regulation in
the body. Serotonin regulation is thought to be a key factor contributing to OCD.
Assessment
A quick word about assessment before we begin with treatment. There are many quality
assessment instruments for OCD. It is important for clinicians to realize that the total-scores on
these instruments do not necessarily reflect total dysfunction. Many of the OCD assessment
instruments look at a variety of obsessions and therefore total scores require a closer look. It is
important for clinicians to look closely at what the results are measuring. The Yale-Brown
Obsessive-Compulsive Scale (YBO-CS), a counselor administered instrument, is a quality
instrument. It calls attention to the obsession and then its severity. It first determines the area of
obsession and then seeks to determine the extent to which the obsession disrupts the client’s life.
(Wu, 2017). Unlike other instruments, the YBO-CS directs the counselor where to look.
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Treatment
Exposure with Response Prevention (ERP)
The effectiveness of ERP has been verified in several empirical studies of patients with
OCD (Goodman, Grice, Lapidus, & Coffey, 2014). ERP therapy has its roots in behavior theory.
In behavioral theory obsession come from average thoughts that were once treated with
indifference. These thoughts have become paired with anxiety. The anxiety increases each time
the thought occurs to the person. The thought occurs more often as worry fuels the anxiety.
Compulsions develop as the individual attempts to find relief from the anxiety. Performing the
compulsion provides the individual some relief from the tension created by the obsession. The
compulsion is reinforced when the fear is not realized. These rituals of intrusive thought,
obsession over the fear, and compulsion to avoid the fear prevent the individual from dismissing
the anxiety in a healthy manner (Berman, Schwartz, & Park, 2017).
ERP seeks to break the created association that bonds the obsession to the compulsion by
exposing the individual to fear gradually, while requiring that the individual sit with the anxiety.
In other words, the individual does not seek short-term relief for the anxiety by performing the
compulsive behavior. The counselor helps the client create a list of fears relating to the
obsession. The list is arranged from least to the most fearful. The individual is exposed to the
distressing situations, gradually. Exposure can be imagined or real exposure to situations
depending on the fear. Imaginary exposure to adverse stimuli has been found to be important
when helping individuals diagnosed with OCD. It is essential when fearful situations cannot be
duplicated in real life (i.e. fear of turning into something) or when the fear of any exposure is to
much for the person to handle (Franklin, & Foa, 2011). Results from programs that offer both
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imagination and direct exposure have been found to exceed results from direct exposure alone in
many studies (Berman, Schwartz, & Park, 2017).
Franklin and Foa (2011) reported that programs with daily sessions over a 30-day period
provide optimum results. They also pointed out that quality results have been achieved with a
more moderate meeting schedule. Clients “with mild-to-moderate OCD” (p. 234) and who are
inspired to change usually respond well to the more moderate meeting schedules. Several
sessions per week is better that one session per week according to Berman, Schwartz, and Park,
(2017).
Recent studies have brought to light important information about “inhibitory learning”
(Berman, Schwartz, & Park, 2017, p. 225) during the ERP process. Inhibitory learning is the
development of alternatives to the fears that do not produce anxiety. Alternatives are developed
during exposure exercises and then the goal of inhibitory learning is to “maximize the
likelihood” (p. 225) that the alternative thought will be associated with the fear. Progressively
moving toward the fear is not necessary, because alternatives, that do not produce anxiety, have
been developed.
Cognitive Therapy (CT)
CT has also received much empirical support and results are comparable to ERP
(Berman, Schwartz, & Park, 2017). CT has its roots in the cognitive model. Unwanted thoughts
are seen as normal and everyone has them. The problem then is not the thought but an
individual’s reaction to the thought. The individual believes that this unwanted thought is
extremely important and determines something about them or some situation. (i.e. I think this
thought therefore I am a bad person, or if I do not do something the result will be disastrous).
Then the individual attempts to silence the thought and only succeeds in increasing it. Emotions
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surrounding the thought produce anxiety. Compulsions develop to help the individual control the
anxiety. Wrong thinking does not get corrected because the compulsion reinforces the obsession.
Research has provided “three obsessive beliefs” (p. 230) that lead the individual into OCD
behaviors. An inflated sense of responsibility and/or threat estimation is the first. An individual
believes that they are responsible for disastrous consequences. Second is a feeling of certainty or
perfection seeking beliefs. The correct solution to every problem is available and must be found.
If this solution is not found, disaster will follow. A final obsessive belief is placing too much
importance on the unwanted thought or trying to control the thought. The individual believes that
just having the thought ensures that the they will act upon it or that the fear will become a reality
(Berman, Schwartz, & Park, 2017).
CT starts with an assessment of the individual’s thoughts with regard to the obsessions
and a complete examination of known symptoms. Psychoeducation is important to help the client
understand the cognitive perspective. When they understand the framework, clients are taught
how to find and identify what triggers their obsession and how they assign value to the trigger.
Clients are also taught to identify how the respond emotionally and what behaviors they use to
compensate for the triggers. Finally, individuals are taught cognitive strategies to address the
categories of obsessive beliefs (Berman, Schwartz, & Park, 2017).
One strategy is the “Continuum Technique” (p. 233) for black-or-white thinking. The
client rates themselves on a scale, 0-100, based on their unwanted thought (i.e. immorality).
They are asked to rate several other people based on what they have done (i.e. committed
murder). The belief is that the individual will develop a realistic picture of their thoughts.
Another strategy is the “Behavioral Experiment” (p. 233) in which the client tests a specific
conclusion. The counselor and the client work together. One example might be for an individual
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to test if the belief that the house will burn down if the stove is not checked fifteen times. Using
the scientific method, the counselor helps the client test the belief. A third strategy used in CT is
known as the “Courtroom Technique” (p. 233). This strategy sets up a courtroom role play in
which the client presents evidence supporting their faulty belief and the counselor acts as an
opposing attorney. A final strategy used in CT to combat OCD is “Advantages and
Disadvantages” (p. 233) in which the unwanted thoughts and their resulting beliefs are examined
for truth and resulting consequences.
Acceptance and Commitment Therapy (ACT)
ACT does not have the empirical support that ERP and CT have, but some studies have
shown that ACT is effective in reducing OCD symptoms. Bluett, Homan, Morrison, Levin, and
Twohig (2014) looked at the treatment of anxiety disorders and OCD with ACT by reviewing
several published studies. The review of the OCD studies showed a “94% and 95% reductions in
OCD symptoms (Y-BOCS) and significant increases in psychological flexibility from pre- to
post-treatment” (p. 619). ACT is rooted in the cognitive behavioral model. ACT proposes that
individuals function in the context of their environment. ACT expects individuals to operate their
lives consistent with their internal code of conduct. Like ERP, ACT challenges individuals to sit
with their distress producing thoughts and not become overcome with anxiety. ACT points the
client to six mental processes that will help them develop a more relaxed mental framework:
“acceptance, defusion, values, self as context, contact with the present moment, and committed
action” (Berman, Schwartz, & Park, 2017, p. 235). Acceptance and commitment therapy helps
clients find “ways of coping with uncomfortable thoughts and feelings” and helps them “to live
the life” they want “to live, according to their values” (Wheeler, 2017, p. 317).
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Clients are taught acceptance of one’s distressing thoughts by sitting with them and not
trying to control them. Cognitive defusion redefines anxiety producing thoughts as normal. When
thoughts are perceived as normal they lose their power. Counselors help their clients identify
their personal values. By identifying values individuals can see how their ruminative thoughts
disrupt their lives and they can decide to live according to these values. In a case study Wheeler
(2017) used mindfulness exercises to help the client “to access self as context” (Berman,
Schwartz, & Park, 2017, p. 236) by learning to observe themselves from the outside.
Mindfulness has also be used to help the individual stay in contact with the present moment.
Finally, committed action uses the values identified earlier to give the client’s life substance and
purpose. With more research ACT may prove to be a significant alternative for clients with
treatment resistant OCD.
Eye Movement Desensitization and Reprocessing (EMDR)
Empirical evidence for the use of EMDR with clients diagnosed with posttraumatic stress
disorder (PTSD) is strong, but recent evidence suggests that EMDR may be a viable option for
treating OCD (Marsden, 2016). Marr (2012) reported on the use of EMDR with four individuals.
Each received one of two adapted forms of EMDR one for phobias or one for anxiety. The
EMDR techniques used to address phobias and anxiety first addresses the “current triggers” by
looking at “images, emotions, and bodily sensations” (Marr, 2012, p. 12) related to those
triggers. Each individual saw significant reductions in their YBO-CS scores and significant
improvements in their OCD symptoms.
EMDR operates under two distinct principles “reliving” and “distancing” (Lee, 2008, p.
264). Reliving allows clients to freely gather mental information connected to a stressful event or
in this case a distressing thought. Distancing allows the client to be in-the-moment with the
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counselor, while looking at the distress from a distance. This processing of the distress
“desensitizes” the distress and a “positive cognition” can be associated with the distress (Marr,
2012, p. 12). The goal of EMDR in treating OCD is “eliminating fears and empowering the
client” (Marr, 2012, p. 12). More research will provide a clearer picture of the usefulness of
EMDR with clients diagnosed with OCD.
Pharmacological Treatments
The biology of OCD is complicated at best. It includes the intersection of brain circuitry,
neurochemistry, inherited genetics, the autoimmune system, and other conditions that affect the
entire body (Stewart & Loh, 2017). Understanding these complex interactions provides a basis
for understanding pharmacological treatments for OCD.
Selective serotonin reuptake inhibitors (SSRIs) are widely recognized as the front-line of
defense for OCD (Fineberg, et al. 2015). It is believed that the roots of OCD stem from a
dysregulation of the serotonin system. Serotonin is an important neurotransmitter that has been
linked to depression, as well. Depression is typically treated with low doses of SSRIs, while
OCD may require much higher doses of these medications. Meta-analyses have demonstrated
that higher doses of SSRIs are beneficial (Pittenger & Bloch 2014). SSRIs do not normally
produce adverse side effects. Some risk for irregular heartbeat and suicidality in youth exists for
prolonged use. Increased suicidality is not seen in Adults being treated for disorders not
involving mood (Stewart & Loh, 2017). Fluvoxamine was the first to be used effectively to treat
OCD. While it is still considered the first choice in treating OCD, no definitive studies have
shown it to be more affective than other SSRIs in treating OCD (Pittenger & Bloch 2014,
Fineberg, et al. 2015). For this reason, different SSRIs are chosen based on client toleration and
side effects (Pittenger & Bloch 2014).
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Clomipramine (CMI) is another antidepressant used in the treatment of OCD. Comparing
meta-analyses of CMI and SSRIs, CMI has a greater effect size, however rate of improvement,
40% - 60%, is consistent with the use of both (Stewart & Loh, 2017). Adverse side effects
include digestive issues and arrhythmias. Because of these issues Stewart & Loh (2017)
recommend using CMI only in conjunction with fluvoxamine. Fluvoxamine, an SSRI, inhibits
the digestive enzyme that metabolizes CMI. This has two effects. The first is to limit the enzyme,
because it is believed to be the cause of the digestive issues. The second is to allow for higher
levels of CMI with lower doses, thus minimize the cardiac related side effects as well as
increasing CMI’s effect on the serotonin system. Fineberg, et al. (2015) indicate that regardless
of medication or amount realization of symptom improvement can take weeks or months.
Twelve weeks of a maximum dose is typical.
Combination Treatments and Other Considerations
Clients not responding adequately to SSRI therapy may respond to CT combined with
ERP. Some studies have shown that CT and ERP combined with SSRI therapy to be better than
SSRI combined with relaxation techniques for stress reduction (Fineberg, et al. 2015).
OCD is a highly comorbid condition. Up to 76% of clients diagnosed with OCD have a
variety of other conditions; anxiety disorders, depressive disorders, obsessive-compulsive
personality disorder, tic disorders, attention deficit/hyperactivity disorder, schizoaffective
disorder, bipolar disorder, and eating disorders (APA, 2013).
Chronic OCD that seems to be treatment resistant has been treated in a number of ways.
Experimental procedures include electroconvulsive therapy and repetitive transcranial magnetic
stimulation. Neither of these procedures are approved for use due to the potential risk. Deep
brain stimulation, another experimental procedure, shows some promise. This involves placing
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electrodes in the brain surgically and stimulating the neurocircuits believed to be involved in
OCD. Some evidence, based on individual cases, does exist for the efficacy of this procedure. It
remains in the experimental stage. Neurosurgery is a final consideration for clients with
“incapacitating OCD who have failed” (Fineberg, 2015, p.122) to achieve relief even with
expertly delivered therapy. This process called “lesioning” (Atmaca, 2016, p. 130) involves
damaging the brain along the pathway involved in OCD neurocircuitry. While that sounds
gruesome, it has resulted in up to a 35% reduction in OCD symptoms as evidenced by YBO-CS
scores (Atmaca, 2016). While these options are clearly a last resort, the superior effect of SSRIs
and some type of cognitively based therapy appear to be the best option for most clients
diagnosed with OCD.
Spiritual Considerations
Osborn (2008) explores the idea of a spiritual cure for OCD. He examines the lives of
Martin Luther, John Bunyan, and Saint Thérèse of Lisieux. Each one appears to have had OCD
issues related to spiritual issues. They lived centuries apart and surprisingly each one reached the
same spiritual conclusion. Martin Luther lived in Germany in the 1500’s. He was plagued by his
need to confess the tiniest details of every misstep no matter how small. He would often be in the
confessional for hours driven by the fear of his sure sentence to hell. John Bunyan lived in
England in the 1600’s. Osborn (2008) says that John Bunyan’s reports of his obsessions and
compulsions are the best historical example of OCD. John speaks of his mind being tormented
by blasphemous thoughts. He, like Luther, was sure he was consigned to hell because of these
uncontrollable and unwanted thoughts. Saint Thérèse of Lisieux lived in France in the late
1700’s. Saint Thérèse lived in mortal fear of offending God. The life of a nun offered Thérèse
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structure and purpose for her obsessions and compulsions. She would often torture herself while
she slept in order to find some relief from her obsessions through the self-imposed punishment.
Each of these visionaries of the Christian faith lived years apart and each one was rooted
in a different religious culture. They all suffered from a deep belief that they were personally
responsible for their faith. Yet they each came to realize that it was necessary for them to give
the “responsibility for all obsessional fears completely and absolutely to God” (Osborne, 2008, p.
147). Faith alone worked for Luther and helped him transfer responsibility to God. God the
Father in particular, as the author of the faith alone plan, was essential to Luther. Jesus, God’s
Son, was the essential person of the Godhead for John Bunyan. The picture of Him sitting on the
Judgement Seat was essential to Bunyan. ‘My grace is sufficient for thee’ (2 Cor. 12:9, KJV) and
‘Him that cometh to me I will in no way cast out’ (John 6:37, KJV), became important verses for
him as he transferred responsibility to God. Saint Thérèse developed a different road to travel in
her transfer of responsibility to God. She claims God instructed her in the intimate ways of His
love. She called this the Little Way, “a way of trust and absolute surrender” (Osborne, 2008, p.
154). Each of these individuals thought radically different from their peers when it came to
spiritual matters. Could it be that the OCD, seemingly caused by the spirituality they practiced,
also be the source of great spiritual revelation?
Faith that cures OCD is faith in a person. Not faith that bad things will not happen, but
instead faith that, in spite of what happens, God has me and will not let me go. “For I am
convinced that neither death, nor life, nor angels, nor principalities, nor things present, nor things
to come, nor powers, nor height, nor depth, nor any other created thing, will be able to separate
us from the love of God, which is in Christ Jesus our Lord” (Romans 8:38-39, NASB).
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Based on Faith, Osborne (2008) proposes a three-step method for helping Christians
suffering with OCD. 1) Recognize obsessions when they strike. 2) Transfer responsibility to
God. 3) Prove your trust; resist compulsions. Bible reading, and prayer are important
assignments for Christians battling OCD. Osborne (2008) brings everything together when he
acknowledges that these assignments can easily become obsessions. He states that this Faith has
been a sort of restructuring of cognitive thought, a form of cognitive therapy for Christians. But
he says something else is needed, planned exposure and response-prevention exercises. These
exercises help to normalize the obsessions and eventually will rob them of their power to require
compulsions.
Exposure with Response Prevention therapy and Acceptance and Commitment therapy
asks clients to sit with their anxiety and stress. Sitting with the distress robs it of its power to
compel. God designs people to sit with their anxiety and give those burdens to Him. “And not
only this, but we also exult in our tribulations, knowing that tribulation brings about
perseverance;” (Romans 5:3, NASB). Many other passages talk about sitting with one’s anxiety
and how that produces something good in the believer. People were designed to sit with their
anxiety.
“Come to Me, all who are weary and heavy-laden, and I will give you rest. Take My
yoke upon you and learn from Me, for I am gentle and humble in heart, and you will find rest for
your souls. For My yoke is easy and My burden is light.” (Matthew 11:28-30, NASB). Christians
give their burdens to God.
Cognitive therapy asks clients to change the way they think about their obsessive
thoughts. The Bible asks the Christian “but be transformed by the renewing of your mind,”
(Romans 12:2, NASB), “yet our inner man is being renewed day by day” (2 Corinthians 4:16
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NASB), and “and that you be renewed in the spirit of your mind” (Ephesians 4:23 NASB).
Changing wrong thinking is essential to Christianity and counseling. And finally, it is important
to know where medications fit into this picture and how God has designed the world around as
something to discover. Our creative spirits can be used to help one another (i.e. the development
of medications). Medications can help clients access their potential to change the way they think
and allow the to be able to sit with their anxiety.
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