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Treatment Strategies for OCD (obsessive-compulsive disorder)

Behavioural and cognitive behavioural approaches Behavioural treatment of OCD typically involves exposure and response prevention. In this, the individual is exposed to their feared stimulus, frequently in a graded manner, and then helped to prevent avoidance through their use of escape rituals: ‘contaminating’ hands and not washing them, and so on. This is thought to extinguish the fear response as the individual learns the lack of association between the occurrence of harm-related thoughts and any expected negative consequences. Relaxation may also be taught to help people cope with the high levels of physiological arousal associated with the fear response.

Many clinical studies using this approach achieved moderate success, although complete remission was achieved by less than half of those who engaged in such programmes (Salkovskis and Kirk 1997). Behavioural treatments were also diffi cult to apply to people who ruminated or who had no ritualistic behaviour, and treatment refusals and drop-outs were relatively common. Accordingly, as models of the disorder have evolved, so have the treatment programmes, which now focus increasingly on the cognitive factors that maintain the disorder. The cognitive approach still involves exposure to a feared stimulus and response prevention. However, these procedures are augmented by a number of cognitive strategies, including:

challenging inappropriate thoughts

mind experiments

behavioural hypothesis testing.

Mind experiments allow the individual to test the validity of their expectations, particularly focusing on the threat associated with their thoughts. Someone who is frightened that their thoughts may kill someone, for example, may be encouraged to test the reality of this assumption by a mind experiment in which the therapist and then client test out this assumption by thinking the feared thoughts – hopefully with no negative effects! Although cognitive behavioural interventions are consistently better than no intervention or treatment as usual (Gava et al. 2007), comparisons between behavioural and cognitive approaches have failed to consistently identify either one as the superior approach (Siev and Chambless 2007) – indeed, one study found a cognitive intervention to be less effective than a behavioural one. McLean et al. (2001) compared the effectiveness of a purely behavioural intervention (exposure and response prevention) and a cognitive intervention involving challenging cognitions thought to underpin the disorder, with a particular focus on infl ated responsibility, overestimation of threat, and intolerance of uncertainty. By the end of therapy, 16 and 38 per cent of participants in the cognitive and behavioural groups respectively had made ‘signifi cant’ recoveries. At threemonth follow-up, the fi gures were 13 and 45 per cent respectively. Unfortunately, the method of cognitive therapy used in the study may not have been optimal. In the behavioural programme, participants were exposed to their feared stimuli on several occasions and remained with them without responding with safety behaviours until their anxiety had signifi cantly diminished, facilitating the extinction of their anxiety response. In the cognitive intervention, participants were similarly exposed to the feared stimuli, but only to practise their cognitive skills. They did not remain with the feared stimulus until their fear had diminished. Participants may have left the presence of the feared stimulus while still highly anxious. This procedure may therefore have maintained or even exacerbated their initial levels of anxiety and obsessional behaviour. The relative failure of the cognitive approach may therefore be of no surprise. No difference in effectiveness between cognitive and behavioural therapy was reported by Cottraux et al. (2001) when cognitive therapy involved challenging assumptions underlying the obsessional behaviour, but did not use exposure and response prevention methods. Finally, Van Oppen et al. (1995) found cognitive therapy combined with exposure and response prevention to be superior to behaviour therapy. It seems that ‘pure’ cognitive interventions without exposure/response prevention are less effective than exposure/response prevention alone. However, a combination of both approaches may be most effective.

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