Understanding OCD: A Journey from Diagnosis to Hope (Part 2 of 3 in a New Series)

In the previous post we went through a brief overview of what OCD is by outlining key aspects of the disorder. Additionally, screening, diagnosis, and preventative measures were laid out. The post concluded with some personal thoughts regarding self-diagnosis. In part 2 of this series, my goal is to give you the state-of-the-art treatments, along with advice on what to do if you have resistance to treatment.

Management

This section reviews the role of psychoeducation for both the patient and their family or significant others. Psychotherapy and pharmacotherapy (medication) will also be reviewed. Treatment plans differ from patient to patient, but there are still some general principles that are useful to keep in mind.

Psychoeducation

Managing OCD symptoms doesn't only involve the patient's efforts in following prescribed procedures. Stigma, prejudice, and role of family and significant others in maintaining or promoting OCD should also be addressed. The latter is known as family accommodation and it occurs when a closed one facilitates or even participates in the patient's avoidance behaviors or rituals. Involving family in the treatment (if and whenever possible) is beneficial, especially when treating children or adolescents with OCD. This comes back to diminishing the impact of family accommodation on patients.

Patients may be hesitant to seek treatment or negatively impact the success of their treatment for a few reasons, including:

• lack of knowledge on the disorder
• feeling shame regarding their symptoms
• anxiety regarding exposure therapy as the patient faces feared stimuli.

These factors cause a greater impact if the patient has poor insight (check part 1 of the series to see definition). Motivational interviewing techniques have proved effective in aiding patients with poor insight. Such techniques may include exploring the benefits and costs of both OCD symptoms and their reduction and empathizing with the patient's experience. As you would expect, therapy alliance is essential for the success of these techniques, therefore the patient's compatibility with the therapist is an important factor.

Psychotherapy

Evidence from scientific literature puts cognitive-behavioral therapy (CBT) in first place for the best and most-researched form of psychotherapy for OCD, while also being a good initial treatment for OCD.

CBT involves both cognitive reappraisal and behavioral intervention. Within behavioral intervention, exposure behavioral therapy (ERP) is the favored psychological treatment for OCD. ERP involves consistent and gradual exposure to fear-provoking stimuli coupled with instructions to not follow through with the compulsive behavior. The combination of ERP with a discussion of the patient's feared consequences and dysfunctional beliefs may enhance ERP effectiveness as it makes the process of exposure less daunting, reducing treatment resistance. This is especially the case for patients with poor insight and individuals less tolerant to exposure.

Individual and group CBT (ERP with cognitive reappraisal) in person or online are effective in OCD treatment. Moreover, patient adherence to between-session homework has been shown to be the best predictor of good short-term and long-term outcome with CBT. Homework may include exposure exercises outside of the clinical setting.

Pharmacotherapy

SSRIs have proven to be the first-line pharmacological treatment for OCD. Evidenced by their efficacy, tolerability, safety and absence of abuse potential. Additionally, higher doses for OCD compared to the ones administers for other anxiety disorders or major depression are linked with greater treatment efficacy. However, higher rates of dropout due to adverse effects (initial gastrointestinal symptoms and sexual dysfunctional) has also been observed.

Treatment resistance

Unfortunately, around half of patients that undergo OCD pharmacological or therapy treatment do not experience good results. Predictors of poor response to first-line treatment can be seen in the lists bellow. They include clinical, socioedemographic and other characteristics.

A common way to address resistance to treatment is by coupling one treatment style with another, also known as combinational treatment. I have discussed this in the past with the use of CBT and SSRIs. However, CBT is not always readily available or tolerance to exposure may be limited. In this case, evidence advises switching to a different SSRI, taking more than the maximum recommended dose, or attempt to use serotonin-noradrenaline reuptake inhibitor. This is all decided together with your doctor.

If you want to know more about the pharmacological augmentation strategies, please check out this research paper and read through page 15 to page 16. Pharmacology is very beyond the subjects that I have studied and researched, so I will avoid delving into the available treatments. Hope you understand.

Neuromodulation and neurosurgery. I will also guide you towards the same research paper (pages 16, 17). A very quick summary of this section is that neuromodulation for OCD includes both invasive and noninvasive treatment approaches. With some options only being present for 1% of treatment-resistant individuals.

Alternative treatments

There are options for treatment outside the traditional options, but they need further evidence to be clinically recommended . Such treatments include yogic meditation techniques, mindful-based CBT, physical exercise, and acupuncture.

I can personally attest to some of these methods. In particular meditation, mindful-based CBT, and physical exercise. Give it a try and let me hear about your results.

Final Thoughts

I would like to reiterate the importance of choosing the right therapist for you. Therapy alliance is an essential part of your healing process and if you don't "click" with your current therapist, I would urge you to start looking for another one. Although I understand that resources may be limited . If this is the case, try to slowly introduce to your therapists some of the concepts here (if they aren't already introduced), such exposure therapy, homework, discussions about the cost and benefits of your symptoms. This way, you could potentially start to mold your therapy sessions to something that works for you. It won't be the same as having a therapist you connect with, but it will be an improvement and hopefully you will start seeing results faster.

Try as best as you can to do you between-sessions homework. Aside for being essential to improve your symptoms, especially if you want to speed up symptom reduction, it could ameliorate the effects of having a therapist you are not satisfied with. By taking your healing into your own hands but also cultivate a greater sense of empowerment. Be an active participant in your healing journey.

In the next post we will be discussing the impact of OCD on quality of life and the several factors that influence this association (education level, marital status, etc.) On top of this, I will wrap up these series by giving you tools that you can use in your OCD journey. These will be mostly checklists and treatment roadmaps that you can use as an extra aid throughout your treatment journey or you can send to someone you think would benefit of such tool.

Thank you for taking the time to read my post,

João Carvalho

Sources

[1] D. J. Stein et al., “Obsessive–compulsive disorder,” Nat Rev Dis Primers, vol. 5, no. 1, p. 52, Aug. 2019, doi: 10.1038/s41572-019-0102-3.

[2] A. Singh, V. P. Anjankar, and B. Sapkale, “Obsessive-Compulsive Disorder (OCD): A Comprehensive Review of Diagnosis, Comorbidities, and Treatment Approaches,” Cureus, Nov. 2023, doi: 10.7759/cureus.48960.

Disclaimer: Everything I share here comes from my own personal research and reflections. This isn't a substitute for professional advice—if you're struggling, I truly encourage you to reach out to a qualified mental health professional.