Innovative and practical treatments for obsessive-compulsive disorder
How can you differentiate obsessive-compulsive disorder from psychosis? And once the diagnosis is made, how do you determine a course of treatment or predict whether it will be successful? This article will help you answer those questions.
When you suspect a patient has obsessive-compulsive disorder (OCD) (Box 1), how can you differentiate OCD from psychosis? Once you have made the diagnosis, what critical factors suggest treatment will be successful—or unsuccessful? Is behavioral therapy more effective than medication? Which medications are most likely to be effective? The answers to these questions can help you improve the well-being of your patients with OCD.
Unfortunately, many patients with severe OCD are misdiagnosed with psychosis or schizophrenia spectrum disorder and spend many years suffering without proper treatment.3 Despite many similarities between patients with severe OCD and psychosis—including rigid belief systems, unrealistic concerns, magical thinking, and odd behaviors—patients with OCD can recognize the irrational nature of their beliefs when they are not in the throes of anxiety.
Patients with OCD also will usually respond to behavioral interventions within a few weeks while patients who are psychotic usually get progressively worse. Treatment must be given time as both cohorts will get anxious or increase their negative symptoms initially, but patients with OCD should soon habituate and find symptom relief.
Some patients have OCD with psychotic features and tend to have more difficulty responding to behavior therapy without medication. Patients with both OCD and schizotypal personalities respond poorly to both behavior therapy and psychotropic medications.4
Meeting the criteria for OCD
Obsessions are intrusive and unwanted thoughts, images, or impulses that produce anxiety. They commonly consist of obsessive fears involving causing harm to others, contamination, safety, religiosity, incompletion, pathological doubt, magical thinking, and the need for certainty, and symmetry.
Usually, obsessions will be accompanied by compulsions, which are behaviors or thoughts performed to reduce the anxiety caused by the obsessions. Compulsions typically consist of excessive washing, checking until it “feels right,” and mental retracing. In rare cases, patients present with only obsessions, which are more difficult to treat than compulsions. Most patients will have several types of symptoms.
To meet the criteria for OCD, patients must be preoccupied by obsessive thoughts and engage in compulsions, which will be frequent, intense, of long duration (more than 2 hours/day), and interfere with the individual’s ability to function. The Yale-Brown Obsessive Compulsive Symptoms Checklist and Scale1 are reliable assessment tools to identify types of symptoms and degree of severity.
‘All I can eat is milk ’ and one brand of peanut butter’
Anne is a 53-year-old widow whose OCD symptoms consisted of not letting anything pass her lips that she considered contaminated, lest she become ill with cancer. Her symptoms became so severe that she restricted her diet to a specific brand of peanut butter and milk. The manner in which she ate the peanut butter was rife with checking rituals. If she thought that there might be something wrong with the jar, she threw it away. If she thought the jar was “safe,” she poured the peanut butter directly into her mouth, avoiding the risk of dirty utensils. She drank milk out of the carton. By the time she began treatment, she was malnourished and slightly dehydrated.
Anne’s restrictive diet was also a product of obsessive label checking. Her label reading inevitably resulted in her seeing ordinary household items that she considered risky and would then avoid. Other avoidance behaviors included spitting out saliva and not licking her lips due to fear of what might be ingested, and avoidance of medication, toothpaste, eye drops, skin lotion, and food she feared others had touched.
The good intentions of people in Anne’s community had the effect of enabling her OCD. For example, the local grocer made sure to keep a few cases of Anne's preferred brand of peanut butter in stock for when she needed it. She bought in bulk, but returned unopened jars that she thought were contaminated. As is common with obsessions, no real evidence is needed to legitimize avoidance.
To help Anne break the OCD cycle of avoidance, a meal plan was devised. Although she looked anorexic, but was not, this approach succeeded because she greatly missed the experience of eating and tasting a variety of foods. She also agreed to drink daily nutritional supplements until her diet was more enriching, and had weekly weigh-ins to track her weight gain.
Anne also began a regimen of fluoxetine, which ultimately improved her ability to use the behavior therapy techniques. She was started at 5 mg/d in liquid form. The dosage was increased to 40 mg/d across 1 month, then changed to pill form and titrated to 80 mg/d, which was maintained at discharge.
Exposure and response prevention therapy (ERP) was also administered in twice-daily, 2-hour sessions for about 3 months. Exposure therapy consisted of accompanying Anne to the local supermarket and having her purchase any kind of food that she wanted, regardless of its nutritional value. Her initial purchases consisted of cheesecake, doughnuts, juice, herbal tea, canned ravioli, cereal, lasagna, and snacks.
For response prevention related to food purchases, Anne was prevented from reading labels and examining individual items for imperfections. She was encouraged to buy the first item on the shelf and put it in her basket.
The next step in exposure therapy was to supervise her eating habits. While she looked forward to tasting the food she bought, she was apprehensive because of the obsessive doubt about their purity. Firm but kind encouragement helped her take one bite after another, and this success built on itself. She was excited to be finally confronting her obsessive fears, tasting the foods she restricted herself from for so long, and taking better care of herself. Her complexion improved, and her weight increased.
At times she was highly anxious and looked for ways to avoid the exposure, but with redirection was able to stay on track. She eventually was able to eat community food, eat at a restaurant, use beauty and hygiene products, and have contact with artificial or chemical substances.
Ironically, Anne’s vocational interest was in cooking and after discharge from the program, she investigated employment in hotel/restaurant work and studies at culinary school.
Predictors for successful treatment
Insight Researchers3 found that about 52% of patients with insight into the reasonableness of their obsessions responded to medications, while none who lacked insight responded. Therefore, it pays to assess patients’ insight and ability to recognize the long-term consequences of OCD to themselves and those around them.
Some patients who have suffered with treatment-refractory OCD for most of their lives lack a premorbid high level of functioning to serve as a reference for normalized behavior. Educating these patients to see the advantages of living without certain negative behaviors improves their receptivity to treatment.
Patients who lack insight often refuse to acknowledge that many of their behaviors are manifestations of OCD. Such patients, however, are usually more amenable to giving up or modifying their dysfunctional behaviors—and the clinician more likely to avoid confrontations—if they are shown how certain behaviors undermine their goals.
Cost-benefit analysis Because of the aversive nature of exposure and response prevention therapy (ERP) and the negative side effects of many medications, some patients may find it easier to live with their symptoms, as painful as they are, rather than undergo the discomfort of behavior therapy. Because the prognosis is poor in such cases, patients need to be convinced that the discomfort of treatment is merely short-term, while the discomfort of the illness could last forever if left untreated.
Motivation In our experience, motivation has played a crucial role in determining treatment outcome for severe refractory OCD. And regardless of the severity of their symptoms, patients who are fed up with their symptoms, or are tired of living a life controlled by their obsessions, usually are excellent candidates for treatment.
Conversely, those who enter treatment as a result of external pressure from spouses or family face a less positive prognosis. High emotional expressiveness, overinvolvement, and hostility by relatives is related to higher attrition rates in treatment.3 Because ERP is so aversive, these patients will find ways to dilute the treatment’s effectiveness. In many cases, they do the minimal amount of work required to stay in treatment to avoid whatever consequences their families would impose for not adhering to treatment.
One marker to assess compliance is whether the clinician feels he or she is investing more time and effort into the patient’s treatment than the patient is. If so, this should be addressed in a timely manner. Also, sporadic attendance at sessions and noncompliance with medications, homework, and behavior therapy assignments may also portend a poor outcome. Remember, though, that noncompliance and lack of motivation are fluid states; many previously noncompliant patients later return to treatment better motivated and more compliant.
Predictors for a lower success rate
Secondary gain Researchers4 found that patients who were enabled by their families had more severe symptoms than those who were not. These relational and environmental factors should be discussed openly. If the patient finds that many of his or her life needs are being met secondary to the illness, that patient might not agree to an aversive treatment.
To overcome this, urge family members or other individuals who provide dysfunctional reinforcers to remove them from the environment. Meet with the patient and family/friends and frankly point out dysfunctional gains and the ways in which family members unknowingly allow the gains to continue (e.g., giving the patient more money after he or she overspent his or her allowance). A family behavioral contract should be devised to address how these gains will be reasonably eliminated.
Recognize, too, that a patient may find it difficult to give up the secondary gains, detrimental as they may be, without adequate skills or coping mechanisms to fill the void. So in some cases, it is best not to remove all the secondary gains at once; this can cause many patients to terminate treatment prematurely.
Trauma or abuse history Many patients with treatment refractory OCD have trauma histories and cannot habituate to the behavioral tasks because of dissociation, emotional numbing, or some form of distraction that mediates their anxiety and prevents proper habituation. If the patient is adequately complying with the exposures, yet still is unable to confront every feared stimulus, inquire about a trauma or abuse history (Box 2).
Substance abuse The stress that is inherent to ERP can cause many patients to relapse or abuse illicit substances to manage their anxiety. Therefore, patients with severe substance abuse problems often have great difficulty handling ERP, as they are asked to experience the very discomfort that initially caused them to abuse drugs and alcohol.
Treating patients whose OCD is associated with trauma
Exposure and response prevention therapy (ERP) may be contraindicated for OCD patients with comorbid posttraumatic stress disorder (PTSD). Patients with trauma histories, especially those for whom the trauma precipitated the onset of OCD symptoms, should receive trauma treatment before or in conjunction with ERP in order to be effective.
Patients with OCD and PTSD should receive adjunctive cognitive behavioral therapy (CBT) for their PTSD. Skills training modules, such as dialectical behavior therapy (DBT) and other CBT treatments, often provide the patient with the necessary skills to regulate the trauma-related stressors that are triggered during ERP and can cause premature termination of treatment.
If habituation is not occurring in the absence of trauma, ask whether the patient is dissociating, daydreaming, numbing, or distracting, as these avoidances will jeopardize his or her ability to benefit from ERP. Teaching the patient grounding techniques and alternate coping mechanisms, such as those found in the mindfulness and distress tolerance module of DBT, can help some patients tolerate their anxiety.
For trauma patients whose dissociation, numbing, or distraction is severe, home-based or residential treatment may be required. There, they can be coached during ERP to bring their attention back to the feared stimuli and deal with the negative fallout of their trauma..
In such cases, a patient cannot realistically be asked to give up a coping mechanism, faulty as it may be, until a more functional reinforcer takes its place. Hence, skills training is a crucial part of treatment for this group.