Treating OCD

General obsessive compulsive disorder treatment plan. What follows is a general description of exposure and response prevention for treating ocd. For more details on treating specific sets of symptoms, see Foa & Wilson (1991), an excellent self-help book to get rid of ocd, and Steketee (1993), an excellent treatment manual. Several case studies are presented by Minichiello (1990).

Assessment. A thorough behavioral assessment is the first step in treating OCD. It is necessary not only to uncover the patient's obsessions and compulsions, but the context in which they occur as well, because patients avoid contexts that act as triggers for their obsessive thoughts and rituals. Diaries of obsessive thoughts and rituals are useful in this regard (Greist, 1994). The nature of obsessive-compulsive disorder should be explained to the patient, who also should be informed about the behavioral techniques to be used and why they are effective. Patients should also be told that while some exercises can be accomplished during sessions with the therapist, most of them will have to be carried out at home. The therapist should point out that treatments for ocd to be effective, patients must engage in self-directed exposure and response prevention treatment. Patients need to know that the most important aspect of treatment is successful completion of homework assignments. They must be told that the exercises will make them uncomfortable, but that the discomfort is a necessary part of the treatment. They should also be told why this is so. Munford et al. (1994) have pointed out that assessment and treatment should be integrated.

Using standardized interview techniques demonstrates to patients that you understand what they are going through, including the hidden aspects. This helps to gain their trust and makes self disclosure more likely. At the very least, assessment should include an OCD symptom checklist and a rating scale that measures frequency and severity of symptoms. The Yale-Brown Obsessive Compulsive Scale (Y-BOCS) is the instrument of choice for both initial assessment and treatment outcome at this time. The Y-BOCS is useful in assessing improvement during therapy, since it is difficult to measure progress on a qualitative basis. Recently, Woody et al. (1995) have examined the reliability and validity of the Y-BOCS and have recommended that the resistance items be deleted and that an item reflecting avoidance be included. Finally, it is important that the therapist's attitude be supportive and nonjudgmental.

Listing the symptoms. Patients should keep a diary and make a list of their ocd symptoms, along with the situations in which they occur and any situations that they avoid. There are two reasons for this. First, patients may not have provided a complete list during the assessment interview. Second, this list will provide the basis for the procedures that follow. A self-help text, such as that of Foa & Wilson (1991) can be useful in helping the patient to organize this information.

Treatments hierarchies. For most obsessions (e.g. contamination), there are many situations that cause discomfort and are avoided when possible. When avoidance is not possible, the patient engages in compulsive rituals (e.g. hand washing) to reduce the anxiety and feel safe again. All of these situations require direct exposure and response (ritual) prevention treatment. However, some of these situations are much more disturbing to the ocd sufferer than others. Thus, with the therapist's help, patients create a treatment hierarchy in which the disturbing situations are ranked from least to most distressing. When this is finished, patients rate each situation on a scale from 0 (not disturbing at all) to 100 (maximum distress). These hierarchies are then used for the exposure exercises that follow.