OCD Treatment of Choice by Severity of Illness and by Age
According to participants in a recent NIMH consensus conference on OCD, participants in the International Obsessive Compulsive Disorders Conference (IOCDC), members of the Obsessive-Compulsive Foundation Scientific Advisory Board, and other published clinical researchers, the treatment of OCD patients with either CBT alone or with a combination of CBT and SRI or SSRI medication is the most likely to succeed. The likelihood that medication will be included in the recommendation varies with the severity of the OCD and the age of the patient. In milder OCD, CBT alone is the recommended initial choice. As severity increases, the experts are more likely to add medications to CBT as the initial treatment or to use medication alone. In younger patients, the experts are more likely to recommend treatment with CBT alone.
According to the expert's definition, Mild OCD (Yale-Brown Obsessive-Compulsive Scale 10-18) causes distress but not necessarily dysfunction; help from others is usually not required to get through the day. Moderate OCD (YBOCS 18 -29) causes both distress and functional impairment. Severe OCD (YBOCS = 30 or above) causes serious functional impairment requiring significant help from others.
OCD Treatment with CBT: Frequency and Duration
Cognitive Behavioral Therapy involves the combination of Behavior Therapy (E/RP) and Cognitive Therapy (CT). Behavior therapy for OCD (BT in CBT) most specifically involves Exposure (E) and Response or Ritual Prevention (RP). Exposure (E) capitalizes on the fact that anxiety usually attenuates after sufficient duration of contact with a feared stimulus. Thus, patients with obsessions related to germs must remain in contact with "germy" objects until their anxiety is extinguished. Repeated exposure is associated with decreased anxiety until, after multiple trials, the patient no longer fears contact with the specifically targeted stimulus. In order to achieve adequate exposure, it is usually necessary to help the patient block the rituals or avoidance behaviors, a process termed response or ritual prevention (RP). For example, patients with germ worries must not only touch "germy things," but must also refrain from ritualized washing until their anxiety diminishes, a process termed exposure and response prevention (E/RP). Cognitive therapy (CT), which may be added to E/RP, addresses such things as faulty estimation of danger or the exaggerated sense of personal responsibility often seen in OCD patients. Other techniques such as thought stopping and distraction (which involve suppressing or "switching off" OCD symptoms) and contingency management (which emphasizes rewards and costs as incentives for ritual prevention) are generally thought to be less effective than standard CBT.
The recommended treatment protocol includesweekly, individual CBT sessions and homework assignments or therapist assisted out-of-office (in vivo) exposure and response prevention. Group CBT or behavioral family therapy are second line alternatives. A dosage of 13-20 sessions is the appropriate number of CBT treatments for the typical patient. When speed is of the essence or OCD is particularly severe in adults, intensive CBT (daily CBT for 3 weeks) may be preferable.