Founder, OCD Institute at McLean Hospital Professor of Psychiatry, Harvard Medical School
Christopher Pittenger, MD, PhD
Director, Yale OCD Research Clinic Associate Professor of Psychiatry and in the Child Study Center, Yale School of Medicine
Treatment types available today for OCD mostly fall under two categories: therapy and medication. There are different types within each of these two categories, and there are new forms of treatment in development as we speak. But, for now, let’s look at what seems to work best for many people.
As a broad generalization, a combination of therapy and medication can be the best option for helping people get better and avoid relapse. So you don’t need to see it as therapy versus medication, because many people end up wanting or needing both. The cost and availability of each, and the approach your clinician takes, will also help determine your treatment path.
Many people see medication as a more direct response to the underlying cause of their OCD. Although a cause hasn’t been established, many different ideas have circulated in the past few decades; a couple, most notably the suggestion that serotonin imbalance is responsible for OCD and other mental health conditions, have stuck. While the reason that certain psychiatric drugs seem to help isn’t always clear, people have had enough success with them that it makes sense to at least discuss medication with your clinician. But a lot of research suggests therapy can alter the way our brains function too, so don’t count it out because it seems less “direct,” or even less scientific, at first.
It’s also worth mentioning that the presence of other conditions in addition to OCD– what we call comorbid disorders– can make the need for medication clearer. This is true in part because that other condition needs to be treated (and sometimes even more urgently than the OCD), and medication might be a good fit. It’s also true because almost all of the medications used for OCD are antidepressants. In other words, there’s a chance your OCD will start to improve as you take medication anyways.
On the other hand, comorbid disorders can make taking medication for OCD a bit more complicated. For instance, medication that acts on serotonin might not be an option for people with both OCD and bipolar or mixed mood disorders because those drugs can make moods more unstable over time. The common drugs for bipolar and mixed mood disorders, like lithium, don’t seem to do anything about OCD. And so therapy might be a better first option for these people (in addition to any medication that helps the comorbid disorder but not the OCD).
What’s the deal with therapy?
Therapy is one of those things that are really hard to understand until you’ve tried it. Some people swear by it, others have sworn it off. It’s impossible to say everyone should try therapy because in most cases it gets very expensive, but if it’s accessible to you and you think you might benefit from it, therapy is worth a try. Especially if you have OCD.
There are many types of therapy, but the stuff that works for OCD is pretty specific, and not every therapist knows how to do it. Traditional counseling–the kind you see on television where the therapist works with the patient to figure out why they’re feeling bad and what might be causing it–can be very helpful for improving other aspects of your mental health, but usually won’t help with OCD symptoms. If the therapist doesn’t recognize the OCD symptoms for what they are, they can make things worse, as patient and therapist may enter a cycle of compulsions and reassurance.
Let’s use a quick example. A patient comes in and says “Every single time I’m in a doctor’s office I’m struck by all these thoughts about how I’ve definitely just caught a deadly illness but won’t know until I’m dying from it.”
The therapist says, “Let’s challenge those thoughts and see if they stand to reason. What makes you think you’ve caught a deadly illness? Are there deadly illnesses in the doctor’s office? How might you know they’re there?” Now the therapist is asking the patient to engage in the same behavior that has become problematic: trying to figure out whether or not they might’ve contracted a deadly illness.
Alternatively, the therapist might say: “People are in doctor’s offices all the time and they don’t get sick. I think you’ll be just fine.” In this case, the therapist has filled the patient’s compulsive need for reassurance.
In either case, the OCD symptoms are not going to improve. A better response to this OCD patient, even though it might sound brutal at first, is something like: “You’re absolutely right. You might have caught a deadly illness while you were in the doctor’s office.” Of course, this is fundamentally true, and it’s this kind of uncertainty in our lives that people with OCD find it so hard to tolerate.
This acknowledgement of uncertainty is central to a treatment process called Exposure and Response Prevention (ERP). ERP is a specific form of Cognitive Behavioral Therapy (CBT) that has two components: exposure and response prevention.
The basic idea of ERP is this: you expose yourself to anxiety, obsessions, and distress; then you prevent the compulsions you’d normally perform in response. Over time, you habituate to the difficult thoughts and sensations– meaning they don’t bother you anymore. You have to prevent your compulsions or this habituation cannot occur.
The exposure part means you work with your therapist to put yourself, little by little, into situations that bring on your obsessions. Whatever you’ve been avoiding because of your obsessions and the distress they cause, your therapist will help you work toward not avoiding it. This has to be carefully planned to ensure it’s effective, and so that you’re gradually building toward your goal rather than moving too quickly and getting completely overwhelmed.
Exposure can be really uncomfortable, but it’s worth it if you’re tired of feeling so anxious and afraid. Sometimes exposures are just about imagining yourself doing something, and other times they involve actually going out and putting yourself in the stressful situation.
The response prevention part is probably even more important. The repetitive responses, or compulsions, that you’ve been performing have to stop in order for you to spend less time and energy on your OCD symptoms.
A lot of people will say that it’s about learning to “just sit with your anxiety,” but this is kind of unclear. Are you really supposed to just sit there resisting your compulsions until you feel less anxious? In some cases, yes. In other cases, response prevention has to be done on the fly. For instance, if you’re exposing yourself to anxiety at work or around friends, you usually aren’t able to just quietly sit there doing nothing for an extended period of time.
Sometimes doing response prevention means finding other ways to cope with the distress, besides performing your compulsions. But you don’t want to be doing anything that decreases your anxiety, or it won’t have the opportunity to come down on its own. So you’ll have to work closely with your therapist to make a plan. The first step is to become aware of what you normally do, because sometimes we do compulsions without even knowing it. Then you can try to do something else. But response prevention, like exposure, is highly individualized– it has to be done on a case-by-case basis.
Without the response prevention part, doing exposures is just unnecessary pain and won’t help you get any better. In order to give yourself a chance to habituate to the distress– that’s when the horrible feelings you’ve been dealing with finally grow weaker– you have to avoid doing anything to get rid of that distress.
A quick example: a therapist gets a new patient who’s so afraid of hitting someone while driving that she finds herself looping back whenever she goes over any kind of bump. The therapist might decide that, for an exposure, the patient will repeat out loud while driving, “I just hit someone, I seriously hurt someone back there.” As response prevention, the patient agrees not to loop back and check at any point during her drive. If this is too much right away, she’ll agree not to loop back for five minutes, then ten minutes, then thirty minutes, and finally the whole drive.
It’s important to be honest when starting response prevention about whether or not you might be able to fully resist your compulsions. Sometimes you’ll need to start with a smaller goal, like delaying them for a minute. Then you build up to five minutes, ten minutes, and so on. If you’ve been doing a compulsion very frequently for a long time, it’s unrealistic to expect that you can suddenly stop.
While it can be exhausting and difficult, ERP is currently the most effective form of therapy for people with OCD. With a good ERP plan and a bit of motivation to stick with it, people can see drastic improvement in the amount of time they spend each day on compulsions and the way they feel about their life.
Lastly, there’s another form of therapy that can be helpful when combined with CBT and ERP. It’s called Acceptance and Commitment Therapy, or ACT, because it teaches people how to accept the way things are and the way they feel while also identifying their values and acting in line with them. Together, these two things give a person psychological flexibility, or the ability to enter a situation completely open to whatever it will bring and change your behavior as needed in response to what’s happening.
ACT can be helpful for people with OCD in a number of ways. First of all, knowing your values is very important when ERP treatment gets tough. You might ask yourself, “What in the world am I going through all this pain for?” If you know what you want in life, you know what you’re working hard for. The mindfulness techniques taught in ACT are also helpful during exposures, so you can try noticing things around you and accepting whatever feelings arise in you. Lastly, psychological flexibility can vanish when obsessive-compulsive symptoms begin: you’re not capable of openness to thoughts and feelings because there’s so much fear and anxiety built up around them.
There isn’t a single form of therapy that works for everyone, but there’s a good chance one of these might help you. It’s impossible to say everyone should try therapy, because in many cases it’s really expensive, but if it’s accessible to you and you think you might benefit from it, therapy is worth a try.
What is the best medication for OCD?
We have to give you a familiar but not terribly satisfying answer here: some types of medication work well for some people and not well for others, and in most cases nobody really knows why. The brain is extremely complex, and there’s no simple fix. The success rates for certain medications is high enough, however, that it might be worth trying them out if therapy isn’t quite doing enough for you.
By far the most commonly prescribed type of medication for OCD is the SRIs, or serotonin reuptake inhibitors; these are also one of the most commonly prescribed medications for depression. These drugs are usually given in much higher doses for OCD than for depression. Some common ones, and their generic forms, are: Prozac (fluoxetine), Paxil (paroxetine), Zoloft (sertraline), Lexapro (escitalopram), and Celexa (citalopram).
Also commonly used is the older drug Anafranil (clomipramine), one of the tricyclic antidepressants. Other people are prescribed Effexor (venlafaxine), one of the selective norepinephrine reuptake inhibitors, though it’s not yet clear whether it works as well as the others. It’s not generally clear at the outset which of these might work best for you, so work with your doctor to make a decision and try them as appropriate.
If you decide to try medication, you’ll need to take it exactly as prescribed. A lot of people think they can stop as soon as they feel better, but this will land you right back where you started. And suddenly stopping any of these medications can give you really unpleasant withdrawal effects, like dizziness and shakiness.
All doctors can prescribe medication for OCD, but if you’re able to see a psychiatrist, this is preferable. Psychiatrists are doctors who specialize in these conditions, so they have the most experience making treatment decisions for OCD and other mental disorders.
In some cases, OCD symptoms can become so severe that people consider suicide. If you ever consider suicide, please call your local emergency number or go directly to a hospital. In the United States, you can also call the Suicide Hotline at 1-800-273-8255.
How It Feels To Have OCD? Why OCD Thoughts Feel Real?
Every day, from the time I wake up to the time I finally go to bed, I’m overwhelmed by disturbing thoughts that I don’t want to have. They’re usually about things that matter a lot to me, and I’ve started doing specific things (sometimes over and over) just to make sure the thoughts won’t come true. I’ve also been avoiding situations that might bring the thoughts back. Why do I feel like this all the time?
Sarah gets a lot of obsessive thoughts around kids, so she skips family events whenever her nephew will be there. Matt is so comfortable around kids that he works at a daycare center, but the idea of taking out the trash causes him so much anxiety that his wife always ends up doing it. Sarah avoids kids, and Matt avoids the trash. Do they have the same condition? Should they be treated similarly?