August 2006, Vol. XXIII, No. 9
Obsessive-compulsive disorder (OCD) is a common and debilitating condition. In many cases, it can come to dominate a person's behavior and cognitive processes, creating great anxiety. It typically affects all aspects of an individual's life, including school performance, occupational responsibilities, and family and social interactions.
In addition, our experience confirms that about 85% of persons with OCD report having some level of depression; Demal and associates1 found a similar rate, 79%, in their retrospective study. This is understandable, considering that persons with OCD tend to feel hopeless and helpless about controlling their obsessions and compulsions. Patients generally have insight into their illness and are aware that their actions and thoughts may be considered bizarre. As a result, they may hide their symptoms for fear of embarrassment. Some may not disclose their OCD symptoms even to their mental health provider for fear that they might be considered crazy, and as a result might lose their job or have their children taken away from them.
While medications can reduce symptoms of OCD by about one third,2 this is seldom sufficient to adequately control the disorder. Patients with OCD generally respond best to cognitive-behavioral therapy (CBT). While the term CBT is often used interchangeably with cognitive therapy and behavior therapy, there are distinctions between these interventions. The CBT programs used at my institution are composed of about 85% behavior therapy and 15% cognitive therapy. These percentages are adjusted slightly, according to an individual's profile and needs. Most patients we treat are already taking medication and have received whatever benefit medication can provide before they are admitted to one of our OCD programs.
At the core of the behavior therapy program is a technique known as exposure and ritual prevention (ERP).3 ERP is based on the process of habituation, in which individuals habituate to stimuli they don't like. We all experience this process in our daily lives. An example would be jumping into cold water. The water feels cold initially, but gradually feels warmer as our body becomes habituated to it. A person can become habituated to smells, sounds, physical sensations, and emotions. In persons with anxiety related to OCD, habituation is a decrease in anxiety that occurs with the simple passage of time. It is essential that nothing else, such as relaxation therapy, be added because other treatments could become compulsions in patients who have OCD. The elements of a behavior therapy program are outlined in Table 1.
To implement the ERP technique, the patient must be exposed to or placed in the feared situation. Simply doing this, however, does not guarantee that he or she is going to become habituated and experience relief from anxiety. For exposure to be effective, it must be prolonged, repetitive, and graduated.
Elements of a behavior therapy program
for obsessive-compulsive disorder
|• Exposure and ritual prevention is the key element3
Based on the principle of habituation
• Exposure: placing the patient in feared situations (targets the obsessions)
Needs to be prolonged enough to lead to within-trial habituation (at least 50% reduction in anxiety)
• Ritual prevention: blocking the typical response or ritual before, during, and after exposure so habituation can take place (targets compulsions)
Replace the ritual with habituation as a way of controlling anxiety
Continuing the water analogy, quickly jumping in and out of the water does not decrease your body's sensitivity to the cold. You must remain in the water long enough for your body to become habituated to it. The person who has a fear of contamination, for example, must touch the feared objects with all fingers of both hands, back and front. He should keep touching the object in this way until he reports his anxiety decreasing by at least half. You can use a scale of 0 (no anxiety) to 7 (greatest anxiety) to help in measuring this. The amount of time it takes a person to experience a 50% reduction in anxiety depends on many variables. However, if the exposure is done in a graduated fashion, this should be a matter of minutes, not hours. The time it takes for the patient's anxiety to halve is called an exposure trial. The quantitative reduction in anxiety—going from 4 to 2 on the scale, for example—is called within-trial habituation.
For the patient's anxiety to permanently diminish, exposure to the stimulus or situation must be repeated until it is no longer bothersome. Most patients will reach this goal within 8 to 12 exposure trials (each trial being a single exposure) as long as the exposure is being done in a prolonged, gradual fashion.
Graduating the exposure to the stimulus helps improve compliance with the exposure program. Graduation should be done in a hierarchic manner. I find that patients exposed to a challenging but manageable range of anxiety—a level of 3 on the 7-point scale—tolerate treatment better than those who are plunged into treatment at a potentially overwhelming anxiety level of 4 or higher. As a result, we experience a lower dropout and refusal rate than has been reported in the literature for behavior therapy. With ERP, a slow as you go approach ultimately takes the same time as (or even less time than) a higherintensity approach because the patient experiences more rapid within-trial and between-trial habituation.
In some cases, ERP can be supplemented with another technique called imaginable exposure. This is very helpful when the patient cannot physically repeat ERP often enough for it to be effective or cannot conduct an exposure in real life (eg, a person with obsessions about harming himself or others). You can ask the patient to imagine what it feels like to be in the feared situation. It is remarkable how anxious some OCD patients become just imagining their feared situations. Imaginal exposure can also play a key role in ensuring a graduated approach to the exposure. Many times imaginal scripts are used with endless loop audio tapes to provide prolonged, repetitive exposures.
The other essential component of ERP treatment is ritual prevention. This involves blocking the ritual that the patient typically performs before, during, and after exposure to feared objects/situations so that habituation can occur. The ritual is replaced with habituation as a way of controlling anxiety.3 In the case of a compulsive hand-washer, ritual prevention would involve not washing hands at all unless unwashed hands pose a health or safety hazard. Someone who wears contact lenses, for example, would be allowed to wash his hands just before inserting the lens, but not at any other time. He also would need to recontaminate his hands immediately after inserting his lenses. During ritual prevention, it is essential to take the patient beyond the normal limits (for instance, not washing hands after using the bathroom, or having him dry off after a shower with a towel that he had used previously and did not consider perfectly clean) to get him to ultimately arrive at normal behavior.