Wednesday, September 06, 2006

Obsessive-Compulsive Disorder

A good summary of psychotherapy for OCD, written by Bradley Riemann, appeared in the Psychiatric Times last month. The article opens with this observation:

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.
Although the television show "Monk" strives for laughs about it, there is no humor OCD. It can be absolutely debilitating. The worst thing about it is that the client knows his or her behavior is irrational, but can't stop doing it.

The heart of treatment for OCD is exposure and ritual prevention. There is typically a feared situation, which is followed by some form of ritual to reduce the fear. For example, a client may go to the bathroom and then compulsively wash his hands for the next 20 minutes. Treatment is straightforward.

First, the client begins with a mildly anxiety-provoking response. For example, he might go into a public bathroom and touch the sink. This exposure creates anxiety. Normally, the client would reduce the anxiety by hand washing. Instead, the handwashing response is prevented. The client waits for the anxiety to drop, which it always does. The procedure is repeated until there is no more anxiety. Then, the client moves on to a more anxiety-producing stimulus, such as a toilet seat.

This procedure has two effects. First, the anxiety is extinguished by a process called habituation. Recall learning to drive. At first, you were quite anxious. As you drove repeatedly, you became less anxious. Through repeated exposure, you habituated to driving.

Second, the client learns an important lesson. Anxiety always goes away. If you tolerate anxiety for a period of time, it always goes away. This gives the client tools for dealing with other compulsive behaviors.

Psychotherapy for OCD is critical. Riemann cites research indicating that antidepressant medications can reduce symptoms of OCD by about 1/3, so medication alone won't provide full relief. Unfortunately, our office procedures are not always sufficient for good treatment. For exposure and response prevention to be truly effective, a person with OCD needs intensive treatment, usually outside the office. Treatment centers are being established in order to meet this need.

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