How are obsessions and compulsions treated?
Combining medication with cognitive-behavioural therapy is usually considered the most effective way to treat the obsessions and compulsions seen in clinical Obsessive-Compulsive Disorder, OCD.
Several medications are available to treat OCD. These medications are also often effective for treating other kinds of anxiety as well as depression, which are common among people with OCD. A psychiatrist or family doctor with experience with mental disorders is best qualified to help decide the correct type and course of medication for OCD.
With the help of a trained psychologist or other mental health professional, cognitive-behavioural therapy can also be used to treat OCD. The core feature of the treatment involves “facing your fears,” and the process is called “exposure with response prevention.” In this process, people face situations that cause or trigger their obsessions and anxiety. Then they are encouraged not to perform the rituals that usually help control their nervous feelings. For example, a person who is obsessed with germs might be encouraged to use a public toilet and wash his or her hands just once. This understandably produces considerable amounts of anxiety and the urge to perform rituals to reduce the anxiety (i.e., hand washing) obviously increase. To use this method, a person who has OCD must be able to tolerate the high levels of anxiety that can result from the experience. However, with experience, patients feel more comfortable with their ability to tolerate the anxiety and the urges to perform the rituals decreases with experience in the technique.
Cognitive-behavioural therapy for obsessions and compulsions
The cognitive-behavioural theory suggests that people with OCD associate certain objects or situations with fear, and that they learn to avoid the things they fear or to perform rituals that help reduce the fear. For example, a person who has always been able to use public toilets may, when under stress, make a connection between the toilet and a fear of catching an illness. Once a connection between an object and the feeling of fear becomes established, people may avoid the things they fear, rather than confront or tolerate the fear. For instance, the person who fears catching an illness from public toilets will avoid using them. When forced to use a public toilet, he or she will perform elaborate cleaning rituals, such as cleaning the toilet seat, cleaning the door handles of the cubicle or following a detailed washing procedure. Because these actions temporarily reduce the level of fear, the fear is never challenged and dealt with and the behaviour is reinforced. The association of fear may spread to other objects, such as public sinks and showers.
CBT treatment relies on “exposure.” The “exposure” part of CBT treatment involves direct or imagined confronting of the objects or situations that trigger obsessions that arouse anxiety. Over time, exposure to obsessional cues leads to less and less anxiety. Eventually, exposure to the obsessional cue arouses little anxiety at all. This process of getting used to obsessional cues is called “habituation.”
CBT treatment also uses “response prevention.” The “response” in “response prevention” refers to the ritual behaviours that people with OCD engage in to reduce anxiety. In treatment, patients learn to resist the compulsion to perform rituals and are eventually able to stop engaging in these behaviours. Before starting treatment, the therapist helps patients to make a list, or what is termed a “hierarchy” of situations that provoke obsessional fears. For example, a person with fears of contamination might create a list of obsessional cues that looks like this: 1) touching garbage 2) using the toilet 3) shaking hands. Treatment starts with exposure to situations that cause mild to moderate anxiety, and as the patient habituates to these situations, he or she gradually works up to situations that cause greater anxiety. The time it takes to progress in treatment depends on the patient’s ability to tolerate anxiety and to resist compulsive behaviours.
Exposure tasks are usually first performed with the therapist assisting. These sessions generally take between 45 minutes and three hours. Patients are also asked to practice exposure tasks between sessions for two to three hours per day. In some cases, direct, or “in vivo,” exposure to the obsessional fears is not possible in the therapist’s office. If, for example, a patient were being treated for an obsession about causing an accident while driving, the therapist would have to practice mental, or what is called “imaginal,” exposure. Imaginal exposure involves exposing the person to situations that trigger obsessions by imagining different scenes.
The main goal during both in vivo and imaginal exposure is for the person to stay in contact with the obsessional trigger without engaging in ritual behaviours. For example, if the person who fears contamination responds to the anxiety by engaging in handwashing or cleaning rituals, he or she would be required to increasingly resist such activities—first for hours, and then days following an exposure task. The therapy continues in this manner until the patient is able to abstain from ritual activities altogether.
To mark progress during exposure tasks with the therapist and in homework, patients are trained to be experts in rating their own anxiety levels. Once they have made progress in treatment, patients continue using the exposure techniques they have learned, and to apply them to new situations as they arise. A typical course of CBT treatment is between 14 and 16 weeks.
What is the outcome for people with obsessions and compulsions?
While cognitive-behavioural therapy and medication usually help to reduce the symptoms of OCD, the process of recovery, like the onset of the disorder, is gradual and ongoing. Continuing with treatment, even when symptoms have improved, can help maintain these gains and prevent relapse. People who are recovering from OCD may also benefit from individual, group or family therapy or a support group.
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