CBT for OCD

For many sufferers of Obsessive-Compulsive Disorder (OCD) and other types of anxiety, deciding to seek help can be a difficult decision to make. Once that decision is made, another choice is required: what kind of help is best for me? Two of the most researched treatment options available are pharmacological treatment (medication) and cognitive-behavioral therapy. Many people will prefer one or the other, saying, “Oh, I would never want to take medication unless I had to,” or alternatively, “Just give me the pill, what’s the big deal?” This is a very personal choice that each person must make individually. For those that wonder how effective each option may be for them, good news – there is a good deal of research on exactly how effective each of these two treatment options can be.

Much of the research on the effectiveness of various medications for OCD focuses on the class of medications known as the SSRIs (selective serotonin reuptake inhibitors). This class of medications is relatively new, having been first used in the late 1980’s. Medications like Celexa, Lexapro, Prozac, Zoloft, Luvox, and Paxil belong to this class. They are widely used, partially because their side effect profiles are favorable. Some possible side effects are difficulties with sexual arousal, lowered interest in sex, headache, and changes in appetite. However each medication will have a different set of potential side effects, and of course you should consult your prescriber before deciding which medication might be best for you.

Much of the research on the effectiveness of psychotherapy for OCD and anxiety disorders focuses on different types of cognitive-behavioral therapy (CBT). For OCD, a form of cognitive-behavioral therapy known as Exposure and Ritual Prevention (ExRP) has been shown to be effective in treatment. ExRP is the updated form of Exposure and Response Prevention (ERP), and it focuses on changing the strategies used by the OCD sufferer to cope with anxiety. For more on ExRP, click here.

Both SSRI and CBT are considered first-line treatments for simple OCD, meaning that one of the two will typically be the first thing recommended for someone with OCD. Research has generally not shown either one to be more effective than the other; both are considered effective in reducing symptoms of COD. Occasionally there is research that compares these two types of OCD treatment, and a study was published in July 2006 that did just that. Some researchers in Brazil compared Zoloft to a CBT group therapy. CBT group therapy for OCD has been shown to be comparably effective to individual CBT for OCD. In the Brazilian study, a summary of which is included below, the CBT that was studied included “techniques of ERP” as well as some classic elements of CBT. While details were not explicit in the article, the therapy used may be best understood as a hybrid of ERP and conventional CBT.

Here is the summary, as reported in 2006 by Reuters:

OCD Responds Better to Cognitive-Behavioral Therapy Than to Sertraline

NEW YORK (Reuters Health) Aug 28 - Combination treatment withcognitive-behavioral group therapy plus sertraline (Zoloft) is effective for the treatment of obsessive-compulsive disorder (OCD), but when each treatment is given alone, cognitive-behavioral therapy is superior to sertraline. Although OCD is responsive to the combination of these two therapeutic approaches, Dr. Aristides V. Cordioli and colleagues from Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil, wrote, "there is no consensus about which of these forms of treatment is more effective" when used alone.

In the current study, published in the July issue of the Journal of Clinical Psychiatry, the researchers compared the efficacy of cognitive behavioral therapy versus sertraline in reducing symptoms of OCD. They evaluated 50 OCD outpatients randomized to 100 mg/day sertraline or cognitive behavioral group therapy for 12 weeks. The patients were assessed at baseline and weeks 4, 8, and 12.

While the patients responded to both treatments, "the reduction of symptoms for cognitive behavioral group therapy patients was 44.07% while in the sertraline group it was 27.78% (p = 0.033)," Dr. Cordioli's team reports.

Patients who received cognitive behavioral group therapy also experienced asignificantly greater reduction in the intensity of compulsions (p = 0.030).

Complete remission of OCD symptoms was observed in eight patients in the cognitive behavioral therapy group compared with only one patient in the sertraline group.

No significant reductions in the intensity of anxiety and depression symptoms were seen with either treatment.

This study showed that the group receiving CBT experienced greater reduction in symptoms than the group receiving Zoloft. The authors point out that the study was conducted on patients suffering from OCD but not from any other psychological problems (e.g., depression, social anxiety), and that the results obtained in the study may not apply to people with other difficulties in addition to OCD. This study can be interpreted as confirmation of the effectiveness of both CBT and Zoloft in treatment of OCD, and also as showing some newer results about the superiority of CBT in the “intensity of compulsions, the rate of symptom reduction, and in complete remission.”

Some people with OCD wonder about the advisability of taking medication while in therapy. There are advantages and disadvantages to this. One advantage to not taking any psychoactive medication while in CBT is that you will learn new skills to cope with your OCD, anxiety, depression, etc., while you are experiencing those symptoms. If you began CBT while on medication, and then later came off the medication, your symptoms may overwhelm your ability to use the tools you had learned in CBT. Some people report that while medication is helpful for them, it is not helpful anymore after they stop taking it, and they are vulnerable to feeling that they are “back at square one.”

There has been other recent research on the neurophysiology of OCD that shows differences in brain activity patterns in people with OCD compared to people without OCD. Research has also found that these patterns change after successful CBT or SSRI treatment. While some sufferers of OCD may be alarmed at the notion that their brains are different than anyone else’s, it is important to remember that the brain is a remarkable, dynamic, constantly changing organ. Every time we learn something new, nerve cells in our brains form new and different connections that were not there before. Patterns of activity in the brain change when we perform seemingly simple tasks: every time we open our eyes in the morning, a complex wave of electrical activity makes its way from our optic nerve to various parts of our cerebral cortex. Given the sensitivity of the brain to new information and new habits (both mental and physical), it should not be a surprise, nor undue cause for alarm, that patterns of activity in the brain should be different in people with OCD. Some interpret research studies on the effects of CBT and medication on the brain as simply complementary to other studies showing the effectiveness of these treatment options.

In conclusion, the choice of whether to pursue CBT, medication, or both can be a difficult one. Fortunately, sufferers of OCD today can take some comfort in the fact that both of these treatments have been shown to be effective, as neither was available just a few decades ago.