Treating Obsessive-Compulsive Disorder (OCD)

Exposure and behavioral therapies have proven to be the most effective therapies for OCD. These therapies fall under the umbrella of cognitive behavioral therapy (CBT). They’re provided by licensed mental health professionals who work in the mental health field.

You will find therapy providers working in various fields of practice. They also have different backgrounds and training. Some may have doctoral degrees (such as PhD, PsyD, EdD) or master’s degrees (such as MSW, MA, MS). A therapist may be a:

• psychologist
• social worker
• clinical counselor
• marriage and family therapist

Not all therapists are trained in ERP or skilled in providing it, especially for OCD. Before engaging a therapist, be sure to ask about their background in ERP for OCD, and how they would provide it for you.

IOCDF reminds people that anyone has the right to ask questions of a prospective therapist. They recommend you ask questions like these:

• How do you treat OCD? Be sure your therapist mentions CBT or ERP. If they don’t, you’ll want to be cautious about going forward.
• Do you use exposure and response prevention techniques? If they say “no” or they’re vague, they may not be the therapist for you. Be wary if they say they use CBT but do not explain further.
• What kind of training and experience do you have in treating OCD? Here’s where you want to hear about their background and success in treating OCD. If you don’t, you’ll want to reconsider your choice. You want a therapist who is experienced with OCD.

To find an ERP therapist, consider asking your doctor for a recommendation or searching in the IOCDF resource directory. The therapists in the directory have all indicated that they use ERP therapy to treat OCD.

Cognitive behavioral therapy (CBT)

Cognitive behavioral therapy (CBT) for treating OCD involves evaluating and modifying mistaken beliefs about intrusive thoughts. Your therapist will also help you reconsider how useful or necessary it is to engage in compulsions.

Your therapist will also help you explore internal experiences and situations that lead to intrusive thoughts and compulsions. You’ll practice sitting with the uncertainty that the thoughts may or may not be true, and that you can never know for sure.

By sitting with this uncertainty and avoiding doing your usual compulsion, you’ll have the opportunity to see that feared consequences don’t come true. Over time, your anxiety will go down. This is called habituation. As you habituate to the feelings that your obsessions bring up, you’ll be able to reduce your dependence on compulsions.

CBT is a large umbrella encompassing a variety of behavioral therapies. Two therapies most commonly used for OCD are exposure and response prevention (ERP) therapy and acceptance and commitment therapy (ACT).

Exposure and response prevention (ERP)

Exposure and response prevention (ERP) therapy is the first-line therapy for OCD. A therapist guides you through situations in which you face your most feared obsessions but don’t act out any compulsions. You do this in a therapist’s office or in real life.

ERP usually worsens anxiety in the short term but leads to less anxiety over time as you learn to tolerate your obsessions. This process is called habituation. Over time in ERP, your anxiety about obsessions goes down on its own without your needing to do compulsions.

Research shows that 50% to 60% of people with OCD improve after completing a course of exposure therapy. However, it can be a challenging therapy. About 50% of patients don’t experience significant improvement, and 25% to 30% don’t finish treatment.

These statistics underscore the need to choose a provider who is skilled in ERP and can collaborate with you in identifying and solving problems. ERP is a gradual process that functions best when performed at a challenging but manageable pace, with you remaining squarely in the driver’s seat.

Acceptance and commitment therapy (ACT)

Acceptance and commitment therapy (ACT) is a mindfulness-based therapy in what is called the “third wave” of behavioral therapies. It focuses on creating a meaningful life by learning not to be overwhelmed by your thoughts and feelings. You learn to solve life’s problems and move forward in your life, even while experiencing your obsessions.

You gain the flexibility to carry on in daily life and other activities while letting your obsessions and anxiety come and go. You become able to choose actions that advance your life, even though your thoughts and feelings are not within your control.

The benefit of this approach is that you can change your actions without having to confront your obsessions and anxiety, as you do in ERP.

Imaginal exposure (IE)

If the idea of confronting your obsessions in the real world through CBT or ERP makes you too uncomfortable, you may ask your therapist to start with imaginal exposure (IE). In IE therapy, you face your obsessions and anxiety in your imagination.

In IE, you create a story about yourself in a situation involving your obsession, which ends in the worst possible outcome. You write the story down, record it, or tell it to your therapist. You read, listen, or tell it to yourself many times each day until it becomes less frightening.

As you habituate to the anxiety of repeatedly facing your worst scenario, the anxiety around your obsession gradually decreases.

Skilled therapists may start off with imaginal exposures as part of OCD therapy. This allows you to indirectly face particular obsessions for which you have overwhelming fear or anxiety. Writing a story about your obsessional thought in IE offers a way you can begin to face your fear.

IE is especially helpful for people with OCD who struggle the most with inner distressing thoughts, images, and impulses, and not so much with observable rituals. This type of OCD is sometimes called pure obsessional OCD.

IE also allows you to be exposed to obsessional thoughts that cannot legally or morally be acted on in real life, such as killing someone. You can’t kill someone in real life, but you can write a story about it and face the obsession indirectly.

IE should always be undertaken as a part of therapy under the guidance of a therapist. Strong emotions may result from writing such a powerful story. You’ll want a therapist who can assist you in dealing with the any reactions you may have.

Antidepressants are the primary medications for treating OCD. They’re very effective when used in conjunction with therapy. Sometimes, CBT and ERP therapy are tried first without medication, especially with younger children.

Antidepressants called serotonin reuptake inhibitors (SRIs) are the most often prescribed to treat OCD. They’re available only from licensed medical professionals, such as your personal care physician (PCP) or a psychiatrist.

Seven SRIs are available in the United States. Six of these are called selective serotonin reuptake inhibitors (SSRIs) because they regulate only one neurotransmitter called serotonin in the brain.

Side effects sometimes occur with SSRIs. They often go away as your body gets used to the medication. Side effects of SSRIs may include:

• weight gain
• nervousness and restlessness
• insomnia
• nausea
• sexual dysfunction
• diarrhea

The seventh drug, clomipramine, is a nonselective SRI, meaning it affects neurotransmitters other than serotonin. Although clomipramine has been used the longest to treat OCD and has been studied the most, it can have more serious side effects than SSRIs. These include blood pressure problems and irregular heartbeat.

For this reason, SSRIs are usually tried before clomipramine. For severe OCD, clomipramine is sometimes used in combination with an SSRI. If SRIs don’t work for you, your doctor can prescribe stronger psychiatric medications. Since SRIs can interact with other medications, it’s important to tell your doctor all the medications you take.

The FDA has approved five SRIs for treating OCD in adults, and some for children. They include:

• Clomipramine (Anafranil): approved for adults and children 10 years and older
• Fluoxetine (Prozac): approved for adults and children 7 years and older
• Fluvoxamine: approved for adults and children 8 years and older
• Paroxetine (Paxil, Pexeva): approved only for adults
• Sertraline (Zoloft): approved for adults and children 6 years and older

Some medications are used successfully in treating OCD even though their label doesn’t indicate FDA approval for that use, or for a particular age group. This is called off-label use. For example, these three SSRIs are sometimes used off-label to treat OCD:

• Paxil: commonly used to treat OCD in children, though not approved by FDA for that purpose
• Citalopram (Celexa): commonly used by adults to treat OCD, though not approved by FDA for that purpose
• Escitalopram (Lexapro): commonly used by adults to treat OCD, but not approved by FDA or that purpose

It’s important to tell your doctor about any difficulties you experience with medication. They can change your medication or your dosage to help. Medication doesn’t help everyone with OCD, but many people do benefit. For those who do benefit from medication, research shows that their OCD symptoms reduce by 40% to 60%.

OCD can occur during childhood as well as adulthood. OCD can be difficult to notice in childhood because kids often hide the symptoms out of shame or embarrassment. Also, parents and guardians sometimes regard the symptoms as just a phase of childhood. Every kid is a picky eater or fussy dresser at some point, right?

Well, yes. But OCD is not the same thing as being picky or fussy. Children’s obsessions do not focus just on clothing or food. Kids’ obsessions may focus on the same themes as those of adults, such as

• contamination
• perfectionism
• harming oneself or others
• unwanted sexual thoughts
• morality or religion

If your child’s obsessions and compulsions become time-consuming and disturbing enough to disrupt school, hygiene, and social interactions, OCD may be considered. Typically, OCD symptoms come on gradually over several weeks or months.

However, one type of pediatric OCD brings on OCD symptoms suddenly, seemingly overnight. It is associated with an infection, usually strep throat, and is called pediatric autoimmune neuropsychiatric disorder associated with streptococcus (PANDAS). A related condition, pediatric acute-onset neuropsychiatric syndrome (PANS), causes similar symptoms but follows a different infection, such as flu virus or mononucleosis.

Both ERP and medication are effective in treating OCD in children and adolescents. This treatment is approved by the American Academy of Child and Adolescent Psychiatry .

Some doctors prefer to try therapy alone for children before adding in medication. However, sometimes the reverse is true, as medication can help lessen a child’s anxiety enough to try ERP.

Researchers estimate that 40% of people treated for OCD don’t respond to standard treatment options. Read on to learn about other treatment options that may help.

Transcranial magnetic stimulation (TMS)

Transcranial magnetic stimulation (TMS) is a noninvasive process that can change brain activity, potentially lessening OCD symptoms. TMS is also called rTMS (the “r” standing for “repetitive”), to distinguish it from dTMS, or the deep version. TMS was approved by the FDA for treatment of OCD in 2018.

During a TMS session, you are awake in a treatment chair. The technician places a coil over an area of your head, and electromagnetic pulses are applied, which affects brain activity. Sessions last from 20 to 40 minutes. You are usually treated daily for 2 to 6 weeks.

TMS is painless, safe, and usually well-tolerated. TMS is most often used for people who are resistant to the standard treatment of therapy and medication. Research shows it can often lessen anxiety and symptoms enough for people with OCD to try ERP therapy.

Deep transcranial magnetic stimulation (dTMS)

Deep transcranial magnetic stimulation (dTMS) is similar to rTMS, except a different coil is used that allows the stimulation to go deeper into the brain and reach a larger area. Some medical professionals believe that it can be more effective than rTMS for OCD, but more research is needed.

Teletherapy

Many doctors are available for teletherapy sessions conducted over the internet. If you already see a therapist or psychiatrist, they may have suggested that you do this during the COVID-19 pandemic. One Japanese trial reported significant improvement of OCD through videoconferencing with a real-time therapist.

Research from the American Psychiatric Association shows that OCD sometimes goes untreated, or treatment is delayed, because of factors like stigma, availability of therapists, or distant location of treatment facilities. A variety of digital technologies can often overcome these obstacles. These include:

• videoconferencing
• online platforms
• websites
• mobile apps

IOCDF confirms that teleconferencing can be an effective way for both children and adults to undertake ERP therapy as part of their OCD treatment.

Day treatment

Day treatment is a step up in intensity from the usual structure of outpatient treatment where you meet with a therapist for an appointment on a regular schedule.

In day treatment, you participate in a program for full days and then return home in the evenings. It is a voluntary program. You’ll find it most useful if you’re stable and can maintain a regular schedule. Day treatment is sometimes referred to as intensive outpatient treatment or partial hospital treatment.

Intensive residential treatment (IRT)

If you don’t notice progress in outpatient or day treatment, intensive residential treatment (IRT) may provide a step up to further help. You participate in a structured treatment program with therapists and psychiatrists who specialize in the treatment of severe OCD.

In IRT, you live in a hospital unit and usually stay from 1 to 3 months. Care is available 24 hours a day, but the program is voluntary. You’re not restricted to a locked unit as you are during inpatient treatment.

Inpatient treatment

Inpatient treatment is the most intensive treatment for OCD. You’re admitted to a locked, secure hospital unit for treatment and are closely monitored. Inpatient care is needed only if you’re at risk of harming yourself or others, or if you’re unable to care for yourself or carry out daily activities.

Self-care treatment for OCD is a controversial topic. Some experts warn against it, especially when used in place of standard ERP and medication treatment. Others feel it can be a useful addition to ERP and medications. One clinical trial found yoga and meditation to be beneficial for people with OCD who did not respond to standard treatment.

Experts generally agree ERP and medication should be the first-line treatment, with self-care added on. Some common health practices such as eating a balanced diet, getting sufficient sleep, and limiting caffeine and alcohol can go a long way toward improving OCD symptoms. Read on to explore other self-care options.

Support groups

Support groups are especially useful if you have OCD. You can talk with others who have similar issues and begin to heal within a supportive community. You can either attend a support group in person or find an online or telephone group.

To find an in-person support group near you, try searching in the IOCDF OCD support groups list. For online or telephone groups, try looking in the IOCDF online or telephone support groups list.

Exercise

We all know that exercise can often help boost our spirits and distract us from our troubles. With the right approach, exercise can help reduce OCD symptoms.

One study found both short- and long-term reductions in obsessive-compulsive symptoms and positive changes in mood following 6 to 12 weeks in an exercise program. Researchers said more research was needed with larger samples to confirm their findings.

Another study showed that 30% of participants reduced their OCD symptoms by 35% with a program of aerobic exercise. Researchers said that the trial showed promise for exercise becoming a contributing treatment to the standard ERP and medication regimen, but that more research is needed.

With OCD, exercise must be done with care. Some people with OCD may use exercise as an avoidance strategy to escape or get rid of obsessive thoughts. If you find that you are using exercise this way, it can lead to increased obsessive thought. Be sure to discuss it with your therapist or doctor.

Mindfulness

Research shows evidence to support the use of mindfulness in treating OCD, particularly for those who have not benefited from traditional treatment. But there is not enough evidence for it to be considered a treatment by itself. It has been most successful as an add-on treatment to supplement an existing ERP or ACT therapy program and medication regimen.

Research also reported that participants with OCD found mindfulness useful in reducing OCD symptoms when combined with ERP therapy. The researchers do warn that people with OCD could potentially use the calming effect of mindfulness practice to distract themselves from intrusive thoughts.

The researchers concluded that people with OCD can best use mindfulness practice to develop a welcoming and accepting attitude toward intrusive thoughts and their accompanying feelings and bodily sensations.

If you do use mindfulness as part of your treatment for OCD, be sure to use it to practice accepting and sitting with intrusive thoughts and feelings, rather than trying to escape them.

The standard treatment recommended for OCD is a combination of medication with exposure and response prevention (ERP) therapy, which is a form of cognitive behavioral therapy (CBT). The most successful medications for treating OCD are selective serotonin reuptake inhibitors (SSRIs).

If medication and therapy don’t bring substantial improvement, transcranial magnetic stimulation (rTMS) or deep transcranial magnetic stimulation (dTMS) may be options. In these procedures, magnetic waves are used to alter brain activity to improve OCD symptoms.

Self-care can sometimes help improve your OCD symptoms, especially when used in conjunction with ERP and medication. Some self-care options include support groups, mindfulness meditation practice, and exercise programs.

It’s always best to coordinate your OCD services with your medical team. You may also search for services in these resources:

• Find an ERP therapist. To find one near you, try searching in the IOCDF resource directory. All therapists that come up in the search have reported that they use ERP to treat OCD.
• Find an in-person OCD support group. Try searching in the IOCDF OCD support groups list.
• Find online or telephone support groups. You can one in your area in the IOCDF online or telephone support groups list.
• Try teletherapy. Find a therapist in your area who offers videoconferencing in the IOCDF teletherapy providers list.
• Consider NOCD therapy. This is a for-profit service that offers face-to-face online therapy consultations that can be scheduled quickly, usually within several days. Their licensed therapists specialize in ERP therapy and are available in the United States, Australia, Ontario, and the United Kingdom. To inquire, visit the NOCD website and book a free 15-minute telephone call to start.
• Try an app. Apps provide tools to help you manage OCD symptoms. They are best used in conjunction with standard treatment. You can start by looking at the IOCDF OCD Apps list, and look for reviews on One Mind PsyberGuide.
• Educate yourself and your family. The IOCDF maintains a list of books and multimedia where you can find a variety of resources to learn about OCD. You’ll see books, DVDs, multimedia kits, and self-help workbooks for both you and your family.