OCD Treatment – An Overview

Treatment should aim to help you understand yourself and your OCD patterns better over time. The goal is not to eliminate triggers or discomfort entirely, but to equip you to respond skillfully when challenges inevitably arise.

There are several treatment options for OCD, including cognitive behavioral therapy (CBT) with exposure response prevention (ERP), cognitive restructuring and inference-based therapy, acceptance commitment therapy (ACT) with mindfulness, self-help, and medication.

Complicating matters, there are many treatments, and the practitioners offering these interventions claim effectiveness, even when there is little research to support these claims. Be very cautious of self-help advice for OCD, and make sure it is supported with scientific evidence.

Obsessive-compulsive disorder (OCD) is an anxiety disorder characterized by repeated unwanted
thoughts (obsessions) and repetitive behaviors (compulsions) that are difficult to control.

OCD is a self-maintaining disorder, as the person with it naturally searches for ways to reduce anxiety as quickly as possible to minimize the chances of the perceived threat becoming a reality.

The OCD cycle has four repetitive steps:

1. Intrusive thought/urge triggers anxiety
2. You interpret this feeling as anxiety and feel compelled to neutralize it
3. You perform a compulsive ritual to relieve the anxiety temporarily
4. Seeing the ritual “worked,” your brain remembers to repeat the cycle next time an intrusion occurs

According to the National Institute for Health and Care Excellence, the main treatment recommended for OCD is a type of therapy called cognitive behavioral therapy (CBT) (NICE, 2005). This includes three parts:

Ask Questions
When seeking a provider who says they offer CBT, ask them how they will addresses OCD using exposure and response prevention (ERP). If they seem unwilling or unable to describe expertise with current gold-standard techniques, seek another provider to avoid the greater frustration of failed treatment.

If not done correctly, exposure therapy for OCD can make symptoms worse. 

1. Exposure and Response Prevention (ERP)

Exposure and Response Prevention (ERP) Therapy is a type of Cognitive Behavioral Therapy (CBT).

The idea behind ERP is to trigger your obsessive fears intentionally but not allow yourself to complete the usual compulsive behavior you would do to reduce anxiety. So you “expose” yourself to the scary situation but “prevent” the response or ritual.

ERP breaks the OCD cycle by deliberately triggering obsessive thoughts and anxiety through planned exposure. It allows anxiety to fully peak without escaping or neutralizing with compulsions. ERP shows that feared consequences don’t actually happen even without performing rituals. It teaches your brain that intrusive thoughts are not dangerous, so compulsions become unnecessary.

For example, if you have contamination OCD focused on door handles:

• Exposure would be deliberately touching dirty door handles that you normally avoid
• Response prevention would be stopping yourself from washing your hands afterwards

The goal is to learn that even if you don’t do the compulsion, the bad thing you fear does not actually happen.

By not doing the handwashing ritual, you learn that even though it makes your anxiety sky-high at first, nothing terrible actually happens – your anxiety will peak and then start coming down naturally.

Over many repetitions, your brain learns not to fear door handles anymore.

ERP is done in a structured way with support from the therapist:

• Start small with more manageable exposures
• Don’t try to eliminate all rituals straight away
• Go at your own pace, not too overwhelming
• Resist the urge to mentally “undo” an exposure after – let it sink in

The therapist helps you develop a fear hierarchy and graded exposure plan. They will guide you through initial ERP exercises in sessions, helping you stay with the exposure until your anxiety starts to decrease within each one.

It’s very tough at first, but gets easier in a belief-challenging way. Research shows ERP creates long-term improvement by targeting the underlying faulty associations between triggers, feared consequences and compulsions ((Antony & Swinson, 2000).

With OCD, it’s the ‘perceived threat’ that’s generating most of the anxiety. People cannot maintain an anxious state for a long period in the absence of a threat.

How long does ERP therapy take?

The length of treatment can vary based on the severity of symptoms and your therapy process.

Some people experience benefits and changes in just a few weeks after starting ERP, whereas for others, it can take months to see an impact.

On average, ERP will require around 12-16 weeks of treatment. Each session typically lasts from 90 to 120 min and they are typically carried out weekly.

You will know you’re getting close to the end of ERP therapy when you can do exposures at the top of your hierarchy, manage the thoughts that arise, and allow your anxiety to naturally decrease.

Can ERP therapy make OCD worse?

During ERP, you will feel an initial increase in anxiety, uncertainty, and obsessional thoughts. However, this increase in symptoms is only short-term.

Overtime, you will learn that while these feelings and thoughts are distressing, they can’t hurt you.

Eventually, you will find that when you stop fighting the obsessions and anxiety, these feelings will begin to subside.

Over the last 30 years, several investigations of ERP for treating OCD have been conducted worldwide. These studies, with over 500 patients and numerous therapists, have affirmed the success and generalizability of ERP’s beneficial effects on OCD treatment (Abramowitz, 2006).

How can I prepare myself to do exposure and response prevention (ERP) for my OCD?

Rather than worrying about “preparing” for ERP, ask yourself – how badly is my OCD impacting my life right now, and am I willing to feel some discomfort to live a more meaningful life?

You will face anxiety by going after your goals and living intentionally. ERP has been shown to help OCD through research over time. Be willing to feel discomfort to get your life back rather than waiting until your OCD gets severe.

ERP is considered the gold standard treatment, but it can also become a compulsion if not practiced carefully. Any treatment approach may potentially be used compulsively.

2. Cognitive Restructuring In CBT

In CBT, cognitive restructuring involves looking at how you interpret intrusive thoughts, questioning whether your thoughts are realistic, and challenging your beliefs about responsibility, threat, importance of thoughts, need for control, etc.

Some common thoughts that fuel OCD include:

• Overestimating how likely or severe perceived threats are (e.g., “If I don’t check, there is a 90% chance the house will burn down”)
• Believing you are personally responsible for preventing harm or disasters, even highly unlikely ones
• Thinking that “just right” feelings or certainty are necessary before you can stop a compulsion
• Black and white thinking (e.g. “If I have this thought, I must be a terrible person”)

Cognitive restructuring uses techniques

Cognitive restructuring uses techniques like examining the evidence for and against the dysfunctional thought, weighing up the odds of feared outcomes actually happening, and putting things in perspective (Salkovskis, 1999).

For example, if you think, “If I don’t check the stove five times, the house will burn down,” you can challenge this by checking just once and seeing that the house does not actually burn down. Over time, this changes how you think about your obsessions.

Over time, building up these new balanced thought patterns helps reduce distress around intrusions and reliance on compulsions. Cognitive work can be combined with ERP for best results.

Research shows that ERP on its own or combined with cognitive restructuring therapy is the most effective psychological treatment for OCD (Öst et al., 2015). Doing ERP every day between sessions boosts improvement, too (Antony & Swinson, 2000). Sometimes, medication is combined with CBT as well.

3. Inference-Based CBT

Traditional CBT for OCD focuses on identifying irrational or exaggerated thoughts and beliefs related to your obsessions, like “If I don’t wash my hands repeatedly, I’ll get sick.”

It then uses tools like logical disputation to challenge those thoughts, replace them with more rational ones, and gradually face feared situations to show that the feared outcome doesn’t happen.

Inference-Based Cognitive-Behavioral Therapy (I-CBT) takes a different approach. It sees OCD not as an anxiety disorder driven by exaggerated fears, but primarily as a “doubting disorder.”

The key idea is that OCD doesn’t come out of the blue. It starts with an intense feeling of doubt popping into someone’s head – doubt that something bad might happen or that something is dangerously contaminated.

This doubt feels real and urgent even though there is no actual evidence for it. The person can’t just ignore it. Where does this feeling come from then?

The Inference-Based Approach says it comes from a glitch in how someone is thinking. Their brain tricks itself by overvaluing “what if” possibilities compared to what they are actually seeing or experiencing in that moment.

The treatment then identifies these reasoning tricks underlying patients’ obsessive doubts. It helps them recognize when their brain is favoring remote “maybes” instead of realistic information.

Rather than only saying “Tolerate the uncertainty,” it shows how the doubt itself was unreasonable to begin with. The goal is to prevent the obsessive doubt from arising, rather than mainly managing anxiety after it arises.

I-CBT aims to:

• Identify the nature of the obsessional doubt and the faulty reasoning behind it
• Unravel the subjective reasoning “story” used to justify the doubt
• Illustrate how this doubt contradicts sensory information about reality

Once these doubt thought patterns are corrected, the extreme anxiety, repetitive rituals and other OCD symptoms should improve or even go away. The key is catching that initial spark of obsessional doubt where something feels dangerously uncertain or contaminated. By changing reasoning here, the later fire of full-blown OCD can be prevented.

Acceptance Commitment Therapy

Acceptance and Commitment Therapy (ACT) takes a different approach to treating obsessive-compulsive disorder (OCD) than traditional methods. Accepting means not judging the thoughts as good or bad, and understanding that we cannot control thoughts that arise. Here’s a basic explanation of what happens:

1. Focusing less on stopping or fighting OCD symptoms. Unlike some therapies that aim to reduce OCD rituals and compulsions directly, ACT says trying to control or eliminate obsessions and compulsions can often paradoxically make them stronger and more distressing.
   
   Instead, ACT teaches acceptance of unwanted thoughts and feelings while committing action to values and life goals.
2. Understanding how language and thinking impact symptoms. ACT looks at how we use language, analyze situations, and buy into thoughts that contribute to suffering.
   
   For example, telling yourself that having an intrusive thought means you’re terrible. The goal is to step back and gain distance from unhelpful ways of thinking.
3. Letting go of control and avoidance behaviors. Trying excessively to control thoughts and feelings linked to OCD, or constantly avoiding triggers tends to worsen problems long-term.
   
   ACT guides people to practice willingness to experience obsessions, realize control itself is part of the problem, and move in valued life directions regardless of whatever thoughts show up.
4. Clarifying personal values and committing to action. Obsessions, mental rituals, and avoidance behavior can narrow one’s life. So ACT helps identify what really matters to the individual – core values like family relationships, health, and career goals.
   
   Then, make behavioral commitments aligned with those values, rather than avoid OCD triggers. This expands life despite intrusive thoughts still occurring sometimes.

The ultimate goal of ACT for OCD is to live a meaningful life even with obsessions continuing to arise at times. It’s about accepting what is out of one’s control, and focusing energy on what can be controlled – chosen values and actions.

Mindfulness

Mindfulness interventions emphasize present-moment awareness with an attitude of non-judgment. They have shown promise for improving both physical and mental health across disorders.

The mindfulness skill of non-reactivity, or allowing thoughts and feelings to come and go without reacting, may be particularly helpful for managing intrusive thoughts in OCD.

One mindfulness skill that could be especially useful for managing intrusive thoughts in OCD is called non-reactivity. This means noticing intrusive thoughts and urges come into your mind, but allowing them to pass by again without reacting, engaging with them, or being critical of yourself.

So rather than doing compulsions when obsessions occur, non-reactivity mindfulness teaches people to observe their thoughts non-judgmentally and let them fade away naturally.

This calmer, more detached response style may reduce OCD symptoms over time.

Mindfulness is a core component of Acceptance and Commitment Therapy (ACT). Here are some of the key ways mindfulness is incorporated into ACT:

1. Promoting awareness of thoughts, feelings, and sensations. Mindfulness exercises like noticing or labeling help clients gain perspective and distance from difficult private experiences like obsessions or anxiety. This decreases their believability and impact.
2. Fostering willingness and acceptance. Mindfulness teaches clients to allow and let be troubling thoughts, emotions, and physical feelings rather than fighting against them or avoiding them. Reducing unhelpful control behaviors can reduce suffering.
3. Living in the present moment. Mindfulness helps clients anchor themselves in the here-and-now rather than getting caught up in regrets, future worries, or abstract verbal rules. Connecting to the present moment facilitates valued action.
4. Clarifying the observing self. Mindfulness of self as context exercises create separation between someone’s sense of the permanent “I” and passing experiences. This provides perspective – “I am having the thought not I am the thought”.

Medication

Medications that increase serotonin, a brain chemical that helps regulate mood, are usually the first treatment doctors try for OCD.

Antidepressants, specifically SSRIs, which are considered the most tolerable and are, therefore, the most prescribed, are generally safe to take long-term.

The most commonly prescribed drugs are antidepressants like Prozac, Zoloft, and Luvox. Another medication called clomipramine also helps control OCD symptoms.

These medicines ease OCD symptoms in many patients. Treatment response is dose-related, with
better clinical responses associated with higher dosages, although lower doses.

• Fluoxetine: Multiple placebo-controlled studies associate fluoxetine administration with positive treatment response. It has shown effectiveness in improving different types of OCD symptoms.
• Fluvoxamine: Several placebo-controlled studies link fluvoxamine administration with positive treatment response, though there have been some exceptions showing a lack of effectiveness.
• Paroxetine: Multiple studies consistently associate paroxetine treatment with significant symptom improvement and treatment response.
• Citalopram: Multiple trials demonstrate citalopram is effective for OCD treatment and leads to reductions in symptoms.
• Escitalopram: Several placebo-controlled studies show escitalopram treatment is associated with OCD treatment response and remission of symptoms.
• Sertraline: Numerous placebo-controlled studies consistently demonstrate sertraline-related treatment response. High doses have also shown effectiveness for refractory OCD.

The choice of medication regimen is still based on trial and error. In the future, genetic testing may allow doctors to predict the best drug for each patient. But those personalized tests aren’t ready for routine medical use yet.

But 40-60% of people don’t respond well enough to the medications alone. In these cases, doctors might add other drugs like risperidone or aripiprazole, which are normally used to treat schizophrenia. Adding these medications often helps control OCD when the antidepressant drugs haven’t worked.

Family Involvement

Family and friends often shape our views about our mental health difficulties and whether we should pursue treatment.

Family members who criticize you or your symptoms may unintentionally be making your OCD worse. Criticism is linked to more severe OCD symptoms.

Critical family members often think you have more control over your obsessions and compulsions than you do. They may believe you could stop the OCD if you tried harder. This could lead them to have more negative attitudes about you seeking treatment.

It’s also common for family members to accommodate your OCD symptoms, like participating in compulsions or modifying family routines. They may do this to reduce your distress or their own anxiety. However, high levels of accommodation can increase family stress.

Family members who accommodate a lot may think exposure therapy will be too hard for you. The high stress may also motivate them to encourage you to get treatment.

The critical and accommodating behaviors that family members show, while often well-intentioned, can fuel OCD and create concerns about treatment.

If you choose to include family in your treatment, addressing these behaviors and treatment worries early on will be important. This can create a more supportive environment and improve your treatment success.

What If OCD Is Not Treated? 

Here’s a quick summary of what can happen if OCD goes untreated:

• Symptoms often get worse over time. Fears can spread to new topics and rituals can take up more and more time.
• Quality of life and functioning continues to deteriorate as OCD starts impacting work, school, relationships and mental/physical health.
• A significant minority of sufferers develop major depression or suicidal thoughts due to the distress caused by uncontrolled OCD.
• For young people especially, leaving OCD untreated can cause major disruption to development and education.
• Physical health can also be affected if rituals involve things like excessive cleaning/handwashing.
• Heavy reliance on alcohol or other drugs to numb the anxiety caused by OCD sometimes occurs.
• OCD often co-occurs with other mental health conditions like eating disorders or body dysmorphic disorder, which can emerge or worsen without OCD treatment.

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