For a disorder marked by recurrent, intrusive thoughts (obsessions) and repetitive behaviors performed to reduce them (compulsions); ERP-based psychotherapy is combined with high-dose SSRIs when appropriate.
Indication
- Recurrent, intrusive, distressing thoughts (obsessions) — about contamination, symmetry, religion, sexuality, or harm
- Repetitive behaviors performed to reduce obsessions (compulsions) — handwashing, checking, counting, ordering
- Obsessions and compulsions taking more than 1 hour per day or significantly impairing functioning
- Continuous rituals adversely affecting daily life, work, school, or relationships
- OCD with tics or pediatric-onset OCD (including evaluation for PANDAS / streptococcus-related forms)
- Comorbid depression, anxiety disorder, or eating disorder
- Inability to control obsessions/compulsions despite recognizing them as irrational
Preparation
- Noting age of onset, course, and triggers of symptoms
- Keeping a diary to categorize obsession-compulsion types (contamination, checking, symmetry, hoarding, etc.)
- Sharing family history of OCD, tic disorder, or Tourette syndrome
- Reporting current medications and side-effect history to the physician
How it's performed
- Detailed psychiatric evaluation; severity grading using Y-BOCS (Yale-Brown Obsessive Compulsive Scale)
- First-line psychotherapy with ERP (exposure and response prevention) — the patient is gradually exposed to obsession-triggering situations and prevented from performing the compulsion
- Cognitive interventions — restructuring incorrect beliefs underlying obsessions, such as excessive responsibility and perfectionism
- SSRIs are first-line medications; OCD generally requires higher doses than depression (e.g., fluoxetine 60-80 mg, sertraline 200 mg)
- In treatment-resistant cases, clomipramine (tricyclic) or low-dose atypical antipsychotic augmentation (risperidone, aripiprazole) may be added to an SSRI
- Response to effective treatment becomes apparent in 8-12 weeks; patience and continuity are important
Post-procedure
- Regular weekly or biweekly psychiatric follow-up for the first 3 months; weekly ERP sessions
- Drug therapy is continued for at least 1-2 years after full response is achieved
- Very gradual tapering (over weeks) when discontinuation is needed — abrupt stopping triggers relapse
- Including family members in treatment (relatives are taught not to participate in compulsions)
- Educating the patient and family for early intervention if symptoms return
Risks
- Sleep, sexual function, and gastrointestinal side effects with high-dose SSRIs
- Transient anxiety increase during ERP therapy — managed with the therapist; avoidance is critical to prevent
- Cardiac rhythm disturbances, constipation, dry mouth, and weight gain with clomipramine
- Metabolic effects (weight gain, lipid-glucose changes) when atypical antipsychotics are added
- Treatment non-response or partial response — full remission is not achieved in approximately 30-40% of cases, requiring ongoing monitoring
FAQ
Does OCD fully recover?
OCD is a chronic condition; however, with proper treatment, symptoms can be greatly reduced and daily life restored. Some patients may require long-term maintenance therapy.
Is exposure therapy (ERP) difficult?
ERP can initially provoke anxiety because the patient is consciously exposed to feared situations. With the therapist's guidance, progress is gradual and anxiety markedly decreases over time.
My obsessions are about causing harm — am I dangerous?
No. Harm-related obsessions in OCD are intrusive, unwanted thoughts the person genuinely does not want. People with OCD experience intense guilt because of these thoughts, and the rate of acting on them is lower than in the general population.
What should I do if my child shows OCD symptoms?
Consulting a child and adolescent psychiatrist is important. ERP-based therapy is also effective in childhood OCD, with SSRIs added when necessary. Family involvement supports treatment.
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