How to reduce distress and repetitive behaviors in patients with OCD

Current Psychiatry. 2009 August;08(08):19-24

August 1, 2009|Psychiatry

Strategies help increase the effectiveness of CBT for obsessions and compulsions

Clinical Point

Phrases such as ‘just in case’ and ‘yes, but what if…?’ are telltale signs of an OCD obsession

Because guarantees often are impossible to secure, persons with OCD begin avoiding places and people where they may have an opportunity to encounter triggering stimuli. Phrases such as “just in case,” “yes, but what if…?” and “how do I know for sure?” are telltale signs of an OCD obsession.

A recent model of OCD may further advance our understanding of how obsessions and compulsions frequently appear together because of their functional link. This model clusters OCD symptoms into “symptom dimensions” that include:

symmetry/ordering
contamination/cleaning
sexual/religious/aggressive/checking
hoarding.^5–7

Varying insight. Patients differ greatly in their reports of the functional relationship between their compulsions and obsessions. Some patients clearly state that their compulsions are meant to prevent harm to others or dreaded consequences, whereas others note their compulsions are intended solely to reduce discomfort associated with obsessions. Some OCD sufferers report that they perform compulsions automatically, without an identified purpose; others are unclear about the relationship between their obsessions and compulsions.

Multifaceted CBT

OCD is conceptualized by both behavioral and cognitive theory (Box 3). Cognitive-behavioral treatment for OCD includes:

exposure in vivo—repeated, prolonged confrontation with anxiety-evoking stimuli
repeated, prolonged imaginal confrontation with feared disasters
ritual prevention—blocking or preventing compulsions
cognitive interventions—correcting erroneous cognitions about potential consequences if confrontation with feared situations is not followed by “ritualizing” (engaging in compulsive behavior).

Box 3

What causes OCD? Cognitive vs behavioral theories

The behavioral theory of obsessive-compulsive disorder (OCD) suggests that obsessions produce anxiety—and/or other forms of distress, such as disgust—and compulsions reduce obsessional anxiety. Compulsions are maintained because they are reinforced by briefly reducing obsessional anxiety; however, in the long term, they prevent the habituation of obsessional anxiety.

The cognitive theory of OCD maintains that the disorder is characterized by erroneous cognitions, including:

unrealistic estimates of threat, and exaggerated sense of personal responsibility for harm
the notion that absence of complete evidence of safety denotes danger
the notion that obsessional anxiety can be reduced only by compulsions or avoidance of the triggering stimuli.

In vivo exposure (EX) consists of confronting situations, objects, and thoughts that evoke anxiety or distress because they are associated with unrealistic danger. The patient first confronts exposures that provoke moderate anxiety/discomfort, followed by exposures of increasing difficulty. The aim is for patients to face obsessional fears for a prolonged period without ritualizing, which allows them to disconfirm their feared consequences and reduce anxiety/discomfort. The goal is to weaken the association between feared stimuli and distress and between ritualizing and relief from distress, and to disconfirm mistaken OCD beliefs.

Imaginal exposure involves repeated confrontation (in imagination) with the disastrous consequences the patient anticipates if the rituals are not performed (eg, a parent’s children will contract a disease many years from now because of failure to protect them from harmful toxins).

Clinical Point

Blocking avoidance of feared situations helps patients realize that obsessional fears are unrealistic or exaggerated

Response (or ritual) prevention (RP) is blocking avoidance of—or escape from—situations that give rise to obsessional distress. By strongly encouraging the patient to gradually approach the distressing situation and to remain in it without ritualizing, RP allows patients to realize that their obsessional fear is unrealistic or exaggerated and that anxiety or distress diminishes with time and repetition.

Cognitive interventions involve discussing the changes that take place during in vivo and imaginal exposure, such as:

the patient’s anxiety decreases with repeated exposure even without ritualistic behavior
the feared consequences often do not materialize
in some cases tolerance of uncertainty is what is being practiced.

Evidence supports EX/RP

Several randomized controlled trials (RCTs) have demonstrated the efficacy of EX/RP for reducing OCD symptoms.^8–10 To address the potential generalizability of these results to typical clinical practice, Franklin et al¹¹ compared findings from 4 RCTs of EX/RP with treatment outcome data from 110 outpatients receiving EX/RP. The outpatients had varying OCD severity, treatment histories, concomitant pharmacotherapy regimens, psychiatric comorbidity profiles, and ages. Following EX/RP, they achieved substantial and clinically meaningful reductions in their OCD and depressive symptoms that were comparable with those reported in the RCTs, which suggests the benefits of EX/RP are not limited to select patient samples.

Foa et al¹² compared the relative and combined efficacy of clomipramine (maximum dosage 250 mg/d) and EX/RP for treating OCD in adults. At week 12, all active treatments were more effective than placebo. EX/RP and EX/RP plus clomipramine were comparable, and both were more effective than clomipramine alone. The study also suggested that with regular supervision, treatment modalities could be successfully implemented in clinics with differing expertise.

References

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