Obsessive compulsive disorder - Treatment 

Treating obsessive compulsive disorder 

CBT expert

Professor David Clark explains how cognitive behavioural therapy (CBT) works and who could benefit from it.

Media last reviewed: 24/04/2013

Next review due: 24/04/2015

Step-wise approach to treating OCD

The level of treatment for OCD can be increased in steps until it is effective. It's important to remember it can take several months before a treatment has a noticeable effect.

Below is an example of treatment steps that may be followed if you have OCD:

  • You are likely to start with a course of cognitive behavioural therapy (CBT). Different types of CBT and longer sessions can be used if your initial course does not work.
  • You may then be prescribed a selective seretonin reuptake inhibitor (SSRI). Your dose may be increased if the medication is not effective, or there are several different SSRIs you can try.
  • As well as trying higher doses and different types of SSRI, you may also be prescribed another type of medication, such as an antipsychotic. Antipsychotics are used to treat a number of different mental health conditions.
  • CBT delivered by a highly specialised team can also be used in combination with any type of medication you are taking. 

If you have obsessive compulsive disorder (OCD), your treatment will depend on the how much the condition is affecting your ability to function.

As OCD develops, the unwelcome and obsessive fears that can be overwhelming vary from person to person. This is also the case for the compulsive behaviour people use to try to control their fears.

How much impact OCD has on a person's life depends on:

  • the amount of time spent on a compulsive behaviour or ritual
  • the intensity of the behaviour
  • how much of it happens in their mind, rather than in their actions

Your treatment plan

Your treatment programme is likely to involve:

  • behavioural therapy – to change the way you behave and reduce your anxiety 
  • medication – to control your symptoms 

Healthcare professionals refer to the disruption of daily function as functional impairment.

OCD that causes mild functional impairment is usually treated with a short course of cognitive behavioural therapy (CBT). CBT is a talking therapy that can help you manage your problems by changing the way you think and behave.

If you have OCD that causes moderate functional impairment, it may be recommended that you have a more intensive course of CBT, or a type of antidepressant medication known as selective seretonin reuptake inhibitors (SSRIs). You may also be referred to a specialist mental health service.

If your OCD causes severe functional impairment, you will be referred to a specialist mental health service for a combination of intensive CBT and a course of SSRIs.

Children with OCD are usually referred to a healthcare professional with experience of treating OCD in children.

Behavioural therapy 

CBT that involves graded exposure and response prevention (ERP) has been shown to be an effective treatment for OCD.

Exposure and response prevention (ERP)

ERP involves identifying a number of situations that cause you anxiety. These are placed in order from the situations that cause you the most to the least anxiety.

You and your therapist will identify tasks that will expose you to the situations that cause anxiety, but at a level you can cope with. You need to do the exposure tasks without carrying out your anxiety-relieving compulsions (the actions you usually take to help you cope with the situation).

Although this sounds frightening, people with OCD find that when they confront their anxiety without carrying out their compulsion, the anxiety disappears completely in one to two hours.

The same exposure task should be repeated two to three times a day. Each time, the anxiety is likely to be less and last for a shorter period of time. Once you have conquered one exposure task, you can move onto a more difficult task, until you have overcome all of the situations that make you anxious. 

People with mild to moderate OCD usually need about 10 hours of therapist treatment, combined with self-treatment exposure exercises between sessions. Those with moderate to severe OCD may need a more intensive course of CBT that lasts longer than 10 hours.

Medication

You may need medication if CBT fails to treat mild OCD, or if you have moderate or severe OCD. The different types of medication you may be prescribed are discussed below.

Selective serotonin reuptake inhibitors (SSRIs)

Selective serotonin reuptake inhibitors (SSRIs) are a type of antidepressant that increase the levels of a chemical called serotonin in your brain. Serotonin is a neurotransmitter that the brain uses to transmit information from one brain cell to another.

Possible SSRIs that you may be prescribed include: 

You will usually need to take an SSRI for 12 weeks before you notice any benefit. Most people with moderate to severe OCD need to take SSRIs for at least 12 months. After this time, your condition will be reviewed and if it causes few or no troublesome symptoms, you may be able to stop taking the medication.

Possible side effects of SSRIs include headaches and feeling sick. However, these should pass within a few weeks.

There is a small chance SSRIs will increase your anxiety, which may cause you to have suicidal thoughts or a desire to self-harm.

Contact your GP immediately or go to your nearest hospital if you are taking an SSRI and have suicidal thoughts or want to self-harm.

It may be helpful to tell a close friend or relative you are taking SSRIs. Ask them to tell you if they notice changes in your behaviour, or if they are worried about the way you are acting.

You may also have side effects when you stop taking SSRIs, so you shouldn't stop taking your medicine suddenly. If you no longer need the medicine, your GP will gradually reduce your dose. 

To find out more about possible side effects, see the patient information leaflet that comes with your medicine or the medicines information tab above.

Some people respond better to one SSRI than another. If you have been taking full recommended doses of an SSRI for three months without any benefit, you may be prescribed a different type of SSRI.

The doses of SSRI recommended for OCD are higher than those usually used for depression. There is evidence that low doses of SSRIs are ineffective.

Clomipramine

Clomipramine is a tricyclic antidepressant (TCA) that can be used as an alternative to SSRIs for treating OCD. TCAs are not as commonly used as SSRIs because they cause more side effects. However, they can be effective in treating people with OCD who cannot tolerate SSRIs.

Possible side effects of clomipramine include:

Clomipramine is not suitable for people who have:

If you are at risk of cardiovascular disease (conditions that affect the heart or blood vessels), your GP may recommend you have a blood pressure test and an electrocardiogram (ECG) before starting your treatment. An ECG measures the electrical activity of your heart.

As with SSRIs, a 12-month course of clomipramine is usually recommended, after which time your symptoms will be reviewed.

To find out more about the possible side effects, see the patient information leaflet that comes with your medicine or the medicines information tab above.

If SSRIs or clomipramine prove ineffective, you will be referred to a specialist mental health service.

Support groups

Many people with OCD find support groups helpful, as they can:

  • give you reassurance 
  • reduce feelings of isolation you may have 
  • give you a chance to socialise with others

Support groups can also provide information and advice for family members and friends who may be affected by your condition.

OCD Action and OCD-UK are both national charities for OCD that can provide information about support groups in your area. You can find information on their websites at the links below:

Surgery

Surgery is the very last resort for treating severe OCD when all other forms of treatment have failed. It should not be considered at all until someone has:

  • received at least two full trials of different SSRIs or clomipramine at recommended doses
  • had treatment for refractory OCD (OCD that does not respond to treatment) as well as antipsychotic medication or higher doses of SSRIs or mood stabilisers
  • received unsuccessful CBT treatments both in a clinic and at home, as well as having been treated by the National Service for Refractory OCD 

National Service for Refractory OCD

After the National Institute for Health and Clinical Excellence (NICE) published guidelines in 2005, the Department of Health (DH) commissioned a centre to treat people with severe, long-term refractory OCD. The National Service for Refractory OCD has been funded by the DH since April 2007 to treat people with the most severe form of the condition.

The National Service offers assessment and treatment to people with OCD who have not responded to treatments provided by their local and regional OCD speciality services. To be eligible for the National Service, you must have had a number of previous treatments and meet the severity criteria.

Most people improve after receiving treatment from the National Service. Very few people, perhaps one to two a year, may be considered for neurosurgery.

Read more about the NICE guidelines for OCD and the National Service for Refractory OCD.

Ablation neurosurgery

A very small number of people with OCD will need neurosurgery. During ablation neurosurgery, a neurosurgeon (a surgeon who specialises in surgery of the brain and nervous system) uses an electric current or a pulse of radiation to burn away a small part of the limbic system. The limbic system is a structure in the brain responsible for some of the most important brain functions, such as higher emotions, memory and behaviour.

Neurosurgery for OCD has never been subjected to controlled clinical trials. However, a survey conducted by the Royal College of Psychiatrists found that out of 478 people who had surgery for OCD, more than half felt they had improved. However, up to 15% felt unchanged or worse.

In addition, surgery for OCD carries the risks of both short- and long-term side effects, such as memory loss and mental confusion, which can be serious and irreversible.

Deep brain stimulation

Deep brain stimulation is an alternative surgical technique that may be used more frequently to treat OCD in the future. Currently, it is only used as part of medical research.

Deep brain stimulation involves implanting an electrical generator into your chest and electrodes (small metal discs) into your brain. An electrical signal is sent from the device in your chest to the electrodes in your brain.

Some small studies looking at deep brain stimulation for OCD have reported an improvement in symptoms. However, there are some possible serious side effects associated with the technique, including infection and bleeding inside the brain.

Page last reviewed: 05/10/2012

Next review due: 05/10/2014

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