One of the ongoing debates in the field of mental health and psychology treatment involves making a definitive determination about the best course of treatment for patients with diagnosed mental illnesses, which include clinical depression and other disorders. Arriving at such a determination, however, is challenging for almost all known psychiatric disorders; while some clinicians contend that psychotherapy is most effective at symptom control and reduction, others argue that pharmacological intervention holds greater promise for patient stability and recovery.
Empirical evidence is available to support both arguments for most illnesses. In the case of obsessive compulsive disorder (OCD), however, little research attention has been devoted to determining which treatment is best, even though OCD is the fourth most common mental illness in the United States (Valente, 2002). What the existing literature does seem to suggest, though, is that OCD is treated most effectively with therapeutic intervention, particularly with cognitive behavioral therapy (CBT); despite etiological organicity, the symptoms and expressions of OCD are behaviorally based, indicating that non-pharmacological interventions can help reshape maladaptive response patterns.
Obsessive compulsive disorder is a mental illness that is classified as one of the Axis I anxiety disorders (Valente, 2002). According to Valente (2002), the history of OCD can be traced back many years, and the earliest cases of the disorder were observed among individuals who had suffered some form of physical trauma, usually cerebral or neurological in nature. Although there are researchers who argue against several theories in psychology, including theory of biological etiology, most contemporary researchers studying OCD agree that there is compelling evidence to substantiate the physiological roots of the disorder as opposed to any psychosocial precursors or precipitants (Valente, 2002). In fact, Valente (2002) claims that the “pattern of OCD following a neurological disorder suggests that OCD is related to neuroanatomical deviations” (p. 125). Clinical research supports such a claim; medical researchers have determined that individuals who have been diagnosed with OCD tend to present with “low orbitofrontal activity” (Fineberg, Marazitti, & Stein, 2001, p. 168).
Given the apparent biological roots of OCD, one might expect that the disorder would respond best to medication. Before jumping to that conclusion, however, the typical symptom picture of OCD must be taken into consideration. The two parts of the name of this disorder—obsessions and compulsions—help one to understand the primary characteristics of the illness. Valente (2002) defines obsessions as “recurrent, inappropriate, persistent thoughts, impulses, or images that cause marked anxiety or distress. These images are time-consuming and interfere with normal routines at school or work, social and occupational activities” (p. 125). She defines compulsions as the “behaviors or mental acts that one feels driven to perform in response to an obsession…. [These] are performed according to rigidly applied rules” (Valente, 2002, p. 125). While the thoughts may be neurocognitive in origin, the actions based on the psychological profile are behavioral. In fact, some clinicians and scholars are calling for OCD to be declassified as an anxiety disorder and to be reclassified as a behavioral disorder in the next edition of the DSM (Mataix-Cols, Pertusa, & Leckman, 2007). Their rationale is that “obsessions and compulsions are the basic features of the disorder, instead of anxiety” (Mataix-Cols et al., 2007, p. 1313).
If the anxiety caused by thoughts is not the core feature of the OCD diagnosis, then, it follows that the intervention should be at a behavioral level. There are several ways to explain and defend this idea. First, some researchers point out that the typical trajectory of OCD is that the illness and its attendant symptoms emerge afterneurological damage is sustained (Fineberg et al., 2001). The basic structure of the brain has been altered, and importantly, it has been altered irrevocably. Once damaged, the structure of the brain is not able to repaired, whether through surgery or through medication (Fineberg et al., 2001). Fineberg et al. (2001) report “[t]he finding that OCD patients with low orbitofrontal activity prior to treatment are less likely to respond to medication” (p. 168). In short, the disruptive obsessive thoughts are not eliminated, nor are their maladaptive behaviors contained (Fineberg et al., 2001). Fineberg et al. (2001) explain this argument by observing, “It is as if there is not enough capacity in the system for adequate compensation to be achieved” (p. 168).
The second way to defend the claim that psychotherapy is likely to be more effective than pharmacological intervention is to examine the literature that reports the treatment success rates of each approach. As Fineberg et al. (2001) point out, the most commonly prescribed medication in the field of psychology for OCD—selective serotonin reuptake inhibitors (SSRIs)—simply do not demonstrate impressive rates of success, whether in the short-term or over the course of long-term treatment. These researchers also criticize the existing studies on the efficacy of pharmacological intervention for OCD patients, noting that the value of the research is inhibited by poorly constituted samples, small sample sizes, and the lack of control groups (Fineberg et al., 2001). While it would be rash to dismiss the possibility that SSRIs and other pharmacological treatments could have some benefits for OCD patients, the fact of the matter is that it would be irresponsible to treat patients without having a reasonable sense of efficacy. Furthermore, the clinician and the patient alike must also consider the unwelcome side effects of psychiatric medications, which may control some symptoms while creating untenable physiological side effects, as well as an abrupt relapse if medications are discontinued (Cartwright & Hollander, 1998).
Research into the efficacy of psychotherapy, and in particular, cognitive behavioral therapy (CBT) is much more promising when compared to the research results of pharmacological intervention for the treatment of obsessive compulsive disorder (Storch, Gelfand, Geffken, & Goodman, 2003). Storch et al. (2003) have even reported that cognitive behavioral therapy has particular promise for patients who have been treatment resistant or non-responsive to pharmacological intervention. Cognitive behavioral therapy (CBT) is an intensive and highly focused form of therapy that focuses not on the patient’s past, but on his or her present, honing in on behaviors that are problematic for the patient and which detract from his or her quality of life (Storch et al., 2003). The goal of cognitive behavioral therapy is to help patients recognize maladaptive thoughts and the behaviors that they choose to express as a result (Storch et al., 2003). In the specific treatment of obsessive compulsive disorder, the CBT modality is delivered in two distinct phases (Storch et al., 2003). In the first phase, referred to as exposure and response prevention, a patient is exposed to situations that typically provoke their obsessions, and are then assisted in preventing themselves from engaging in their usual response patterns (Storch et al., 2003). Exposure and response achieves two functions; first, it helps a patient habituate to the reality of stress, and second, it helps the patient contest—through reality testing—their worst fears related to their obsessions (Storch et al., 2003). In the second phase of treatment, patients are taught to identify and reframe situations and to practice new and more adaptive behaviors and response patterns (Storch et al., 2003).
The theory behind cognitive behavioral therapy in the treatment of individuals with obsessive compulsive disorder is that the competencies instilled in the patient through CBT techniques will help interrupt and then begin to reprogram their habituated patterns of thought and response to provocative stimuli (Storch et al., 2003). While CBT will obviously not help a damaged brain repair itself, it can help the individual learn to live with neurocognitive impairments and to adapt to those impairments in order to achieve healthier functioning. Cognitive behavioral therapy will also provide patients with valuable life skills that will help them confront many situations in life that are stressful and challenging. Compared to pharmacological intervention, cognitive behavioral therapy has no known negative side effects, and the success rate of CBT is certainly higher than is the case for pharmacological intervention for this disorder (Storch et al. 2003).
Although the writer advocates cognitive behavioral therapy as the preferred method of treatment for individuals who have been diagnosed with obsessive compulsive disorder, an important caveat must be made. Despite impressive improvements reported by researchers with respect to cognitive behavioral therapy intervention, the literature also cautions that treatment needs must be assessed for each client by the treating clinician or team, as some symptom pictures may warrant pharmacological intervention to some degree, possibly in combination with psychotherapeutic approaches. As Fineberg et al. (2001) note, “Particular symptoms in OCD (such as tics) and comorbid disorders (such as depression) may well influence the choice of intervention” (p. 172). Researchers should continue to examine the various interventions that are available for the treatment of all mental illnesses, including obsessive compulsive disorder. Patients with this diagnosis will benefit from more empirical substantiation of initial studies’ claims about the efficacy of psychotherapy when compared to pharmacological intervention. Initial evidence seems to suggest that cognitive behavioral therapy is the best approach at present for treating obsessive compulsive disorder, and best practices are currently in the process of being developed. Clinicians should always remember to examine each patient’s needs individually and plan treatment accordingly.
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References
Cartwright, C., & Hollander, E. (1998). SSRIs in the treatment of obsessive compulsive disorder. Depression and Anxiety, 8(S1), 105-113.
Fineberg, N., Marazitti, D., & Stein, D.J. (2001). Obsessive compulsive disorder: A practical guide. London: Martin Dunitz.
Mataix-Cols, D., Pertusa, A., & Leckman, J.F. (2007). Issues for DSM-IV: How should obsessive-compulsive and related disorders be classified? American Journal of Psychiatry, 164(9), 1313-1314.
Storch, E.A., Gelfand, K.M., Geffken, G.R., & Goodman, W.K. (2003). An intensive outpatient approach to the treatment of obsessive compulsive disorders: Case exemplars. Annals of the American Psychotherapy Association, 6(4), 14.
Valente, S. (2002). Obsessive compulsive disorder. Perspectives in Psychiatric Care, 38(4), 125.
