Anxiety Disorder and OCD

Although progress is being made in the application of cognitive therapy to obsessive-compulsive disorder (OCD), behavior therapy, especially exposure and response prevention, is currently the nonpharmacological treatment of choice. The behavioral model of OCD states that obsessive fears give rise to anxiety.

Anxiety is then reduced by compulsive behaviors, which are thus maintained by negative reinforcement. While the model falls short of explaining the acquisition of obsessions, it does give an adequate account of the maintenance of compulsive behaviors. For the most part, behavior therapy has been at least as effective as medication and shows lasting benefits at follow up. Impediments to progress in treatment include noncompliance, severe depression, personality disorders and overvalued ideas.

Treatment guidelines for behavior therapy are presented. In the cognitive model of OCD, automatic thoughts involving overestimated perceived personal responsibility and exaggerated perceived threat lead to anxiety; compulsive rituals function to reduce this anxiety. The effectiveness of cognitive therapy in the treatment of OCD is assessed and some treatment guidelines are provided. Although behavior therapy is the treatment of choice for OCD, patients can benefit from the addition of antidepressant medication or cognitive therapy, at least during the initial stages of treatment.

For many years, obsessive-compulsive disorder (OCD) was thought to be extremely difficult, if not impossible, to treat. However, with the advent of serotonin reuptake inhibitors, and recent advances in psychosocial treatment, especially behavior therapy, the outlook is much brighter. In this paper, I shall be discussing some of the ways in which psychosocial treatment can be used to reduce the frequency and severity of obsessive-compulsive symptoms, as well as eliminating them in many cases.

When Black wrote his paper on the natural history of obsessional neurosis in 1974, he reviewed several studies  and found that no approaches extant at the time were effective in the long-term treatment of `obsessional illness' (Black, 1974). Even Freud, whose descriptions of OCD symptoms were referred to by Greist as being `as good as any we have' (Greist, 1990a), could not find a successful treatment for OCD, his treatment of the `Rat Man' (Freud, 1959) notwithstanding.

Modern versions of psychoanalytic therapy have not fared any better. Munford et al. (1994) have informed us that experienced psychoanalysts have admitted that OCD continues to be refractory to their efforts, and Greist (1992) has stated that: `Attempts to treat symptomatic OCD with psychoanalysis should be abandoned until and unless analysts provide evidence from controlled research that this technique is effective'.

Although the role of cognitive therapy in the treatment of OCD has been growing recently, the current psychosocial treatment of choice for OCD is behavior therapy.