Treating Obsessive Compulsive Disorder

Treatment of pure obsessionals. Response prevention techniques are effective when the compulsive rituals are overt behaviors, but blocking techniques, such as thought stopping or snapping a rubber band placed around the wrist, are required when the rituals are covert.  

Pure obsessions are best treated with imaginal exposure in a technique called revised habituation. After the therapist explains the rationale for imaginal exposure, a loop tape is made by the patient that includes obsessive thoughts but not the covert neutralizing rituals. For example, a patient may spend several hours a day ruminating about death and the dying process, or of killing her child (when this really has no possibility of happening).

These are the kinds of thoughts that would be recorded on the loop tape. Neutralizing rituals might consist of arguments to herself that she could never kill her child, or that death was not close by and that it would probably be quite different than imagined when it did occur. While these reactions seem at first to be reasonable, in reality they function as covert rituals that reduce the distress caused by the obsessive thoughts. Successful treatment of the obsessive thoughts requires sustained exposure, along with prevention of the neutralizing rituals.

Response prevention of covert rituals allows habituation of obsessive ruminations in the same manner as that of obsessive thoughts associated with overt behavioral rituals. To accomplish this, the patient is instructed to listen to the loop tape without engaging in the reassuring (neutralizing) thoughts.

Neutralizing thoughts are generally voluntary, whereas the intrusive thoughts are not. Making patients aware of this can help them to create a more effective loop tape. Once a loop tape is made that does not contain any neutralizing rituals, there is still a high probability that the patient will engage in these responses while listening to the tape.

Some ocd techniques that may be helpful in correcting this are distraction and thought stopping. It is important, however, to make sure that these techniques are used only for the neutralizing, and not for the obsessive, ruminations. In working with pure obsessions and covert rituals, Roth and Church (1994) point out the importance of exploring the intrusive images and their associations, in order to reduce the complexity and sheer number of intrusive images that would make treatment of each on an individual basis impractical.

It is important to identify the relatively few specific underlying thoughts that function as triggers for the intrusive images. This results in useful clarification for the patient as well. Further details of this approach are discussed by Salkovskis and Westbrook (1989).

Therapist-aided versus self-exposure. Current evidence suggests that self-exposure is just as effect as therapist-aided exposure. This again underlines the importance of engaging in exposure and response prevention at home and also indicates that self-help books can be very important adjuncts to therapy.

Relapse prevention. What is an adequate trial to determine whether behavior therapy is going to work? This is a difficult question to answer because individual patients can differ enormously in severity and complexity of symptoms. Baer (1993) has suggested that at least 15-30 hours of exposure and response prevention be tried. Following treatment, however, one must do what is possible to prevent relapse. As discussed above, the long-term treatment gains achieved with behavior therapy are encouraging.

However, there is always room for improvement. Hiss et al. (1994) reported a relapse prevention program consisting of four 90-minute sessions of self-exposure training, cognitive restructuring and planning lifestyle changes, all conducted over a one-week period. This procedure resulted in maintenance of treatment gains at six-month follow up. Of course, anything that the therapist can do to prepare the patient for relapses and self-help will be useful. For additional discussion, see Foa and Wilson (1991).
Cognitive therapy in the treatment of OCD