Evidence-Based Reviews

How to reduce distress and repetitive behaviors in patients with OCD

Current Psychiatry. 2009 August;8(8):19-24

Strategies help increase the effectiveness of CBT for obsessions and compulsions

References

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2. Diagnostic and statistical manual of mental disorders. 4th ed, text rev. Washington, DC: American Psychiatric Association; 2000.

3. Goodman WK, Price LH, Rasmussen SA, et al. The Yale-Brown Obsessive Compulsive Scale. I. Development, use, and reliability. Arch Gen Psychiatry. 1989;46(11):1006-1011.

4. Goodman WK, Price LH, Rasmussen SA, et al. The Yale-Brown Obsessive Compulsive Scale. II. Validity. Arch Gen Psychiatry. 1989;46(11):1012-1016.

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11. Franklin ME, Abramowitz JS, Kozak MJ, et al. Effectiveness of exposure and ritual prevention for obsessive-compulsive disorder: randomized compared with nonrandomized samples. J Consult Clin Psychol. 2000;68(4):594-602.

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Comment on this article

Exposure and response (or ritual) prevention has been shown to be effective in improving the therapeutic outlook for patients with obsessive-compulsive disorder (OCD). Yet barriers—including patient unwillingness to enter into the intensive therapy—prevent more persons with OCD from achieving an improved quality of life.

This article focuses on the clinical picture of OCD and the multifaceted cognitive-behavioral therapy (CBT) that has received the most empirical support. We also describe initiatives to make CBT more accessible to OCD patients, such as providing twice-weekly instead of daily treatment sessions.

OCD definition: Anxiety/distress

OCD is a relatively common, debilitating condition that often develops early in life (Box 1).^1,2 The obsessions of this disorder are not simply excessive worries about real-life problems. The compulsions are excessive or unreasonable and serve to reduce the discomfort associated with the obsessions. The Yale-Brown Obsessive Compulsive Scale (Y-BOCS) is the gold standard tool for quantifying OCD (Box 2).^3,4

Obsessions vs compulsions. When diagnosing and treating OCD, it is important to ascertain the functional relationship between a patient’s obsessions and compulsions and anxiety/distress:

Obsessions give rise to anxiety/distress.
Compulsions aim to reduce this anxiety/distress.

Box 1

OCD: A common, debilitating condition

The lifetime prevalence of obsessive-compulsive disorder (OCD) is 2% to 3%—approximately 2 to 3 times higher than that of schizophrenia. Onset of OCD often is in childhood or adolescence. OCD presents earlier in boys than girls, but by young adulthood the incidence is equally distributed in men and women.¹ Its course typically is chronic and is associated with substantial suffering and functional impairment.

According to DSM-IV-TR criteria, OCD is characterized by:

obsessions—persistent thoughts, impulses, or images that are experienced as intrusive, inappropriate, and distressing that an individual attempts to ignore, suppress, or neutralize with other thoughts or actions
compulsions—repetitive behaviors or mental acts that are aimed at reducing distress or preventing a dreaded consequence.²

This distinction is important because lay people routinely use the word “obsessing” to describe being consumed by an idea or an activity. This is not the same as the obsession of OCD. Similarly, repetitive behaviors often described as “compulsive” are not necessarily a symptom of OCD. “Compulsive” eating or gambling can be self-stimulating or positively reinforcing (mostly ego-syntonic). The compulsive behavior of OCD is often viewed by the individual as inappropriate or incompatible with the perception of self (mostly ego-dystonic).

Box 2

Assessing obsessive-compulsive disorder: Y-BOCS

The 10-item, clinician-rated Yale-Brown Obsessive Compulsive Scale (Y-BOCS)^3,4 has excellent psychometric properties. It is widely used in outcome studies and clinical practice to assess and monitor change and progress.

Y-BOCS consists of 5 questions about obsessions and 5 about compulsions; each symptom is rated on a scale of 0 (least severe) to 4 (most severe). Results are combined for a total score of 0 to 40, which is interpreted as:

0 to 7=subclinical
8 to 15=mild
16 to 23=moderate
24 to 31=severe
32 to 40=extreme.

OCD’s clinical picture

Classic vs nonclassic obsessions. Frequently reported obsessions in OCD include fears related to:

contamination (dirt, germs, bodily waste, chemicals)
making mistakes (locks, appliances, paperwork, decisions)
having unwanted impulses (violent, sexual, religious, embarrassing)
orderliness (neatness, symmetry, numbers).

Clinical Point

Many patients believe established OCD treatments won’t be effective because they do not have ‘classic’ symptoms

Many patients who seek treatment for OCD believe they do not have “classic” OCD symptoms. They think no one has seen or heard of their form of OCD and, therefore, they may not be good candidates for treatments shown to be effective for “classic” OCD. Examples of “non-classic” forms of OCD—which often are encountered at OCD specialty clinics and are less often described in mainstream literature or media—include:

intrusive, irrational, or excessive worries about loss of identity, essence, or intelligence, mostly seen in teenagers or young adults
contamination by “evil” or fear of becoming a “bad person”
fear of harm to a newborn child by new parents
fear of unintentionally performing socially inappropriate behaviors, such as shoplifting, molesting, or insulting someone.

Distressed by uncertainty. In assessing whether fears of inappropriate behaviors reflect OCD, first determine if the person has engaged in such behaviors. Clinical experience suggests that persons with OCD rarely act out their fears, and indeed are less likely to do so than those without the disorder.

A common theme among OCD patients is overwhelming distress associated with uncertainty. Patients with OCD often appraise low-probability events as extremely high-probability events, and as a result require reassurance and guarantees that dreaded outcomes will not occur. That reassurance can come in many forms:

searching the Internet for answers
asking family members, friends, or experts for confirmation or disconfirmation
mentally checking and reevaluating whether they had opportunity or propensity to perform any of those acts.