Learning Objectives
- Describe treatment options for OCD.
- Describe treatment options for body dysmorphic disorder.
- Describe treatment options for hoarding disorder.
OCD
9.5.1.1. Exposure and Response Prevention (ERP). Treatment of OCD has come a long way in recent years. Among the most effective treatment options is exposure and response prevention (March, Frances, Kahn, & Carpenter, 1997). First developed by psychiatrist Victor Meyer (1966), as you might infer from the name, individuals are repeatedly exposed to their obsession, thus causing anxiety/fears, while simultaneously prevented from engaging in their compulsive behaviors. Exposure sessions are often done in vivo (in real life), via videos, or even imaginary, depending on the type of obsession. For example, a fear that one’s house would burn down if their compulsion was not carried out would obviously be done via imaginary exposure, as it would not be ethical to have a person burn their house down.
Prior to beginning the exposure and response prevention exercises, the clinician must teach the patient relaxation techniques for them to engage in during the distress of being exposed to the obsession. Once relaxation techniques are taught, the clinician and patient will develop a hierarchy of obsessions. Treatment will start at those with the lowest amount of distress to ensure the patient has success with treatment, as well as preventing withdrawal of treatment.
Within the hierarchy of obsessions, the individual is also gradually exposed to their obsession. For example, an individual obsessed with germs, may first watch a person sneeze on the computer in session. Once anxiety is managed and compulsions refrain at this level of exposure, the individual would move on to being present in the same room as a sick individual, to eventually shaking hands with someone obviously sick, each time preventing them from engaging in their compulsive behavior. Once this level of their hierarchy was managed, they would move on to the next obsession and so forth until the entire list was complete.
Treatment outcome for exposure and response prevention is very effective in treating individuals with OCD. In fact, some studies suggest up to an 86% response rate when treatment is completed (Foa et al., 2005). Combination treatments such as ERP with family counseling (utilizing CBT techniques) may increase this response rate even higher (Bolleau, 2011; Krebs & Heyman, 2015). Like most OCD related treatments, the largest barrier to treatment is getting patients to commit to treatment, as the repeated exposures and prevention of compulsive behaviors can be extremely distressing to patients.
9.5.1.2. Psychopharmacology. There has been minimal support for the treatment of OCD with medication alone. This is likely due to the temporary resolution of symptoms during medication use. Among the most effective medications are those that inhibit the reuptake of serotonin, clomipramine and SSRIs. Reportedly, up to 60% of patients show improvement in symptoms while taking these medications; however, symptoms are quick to return when medications are discontinued (Dougherty, Rauch, & Jenike, 2002). While there has been some promise in a combined treatment option of exposure and response prevention and SSRIs, these findings were not superior to exposure and response prevention alone, suggesting that the inclusion of medication in treatment does not provide an added benefit (Foa et al., 2005).
Body Dysmorphic Disorder
Seeing as though there are strong similarities between OCD and body dysmorphic disorder, it should not come as a surprise that the only two effective treatments for body dysmorphic disorder are those that are effective in OCD. Exposure and response prevention has been successful in treating symptoms of body dysmorphic disorder, as patients are repeatedly exposed to their body imperfections/obsessions and prevented from engaging in compulsions used to reduce their anxiety. (Veale, Gournay, et al., 1996; Wilhelm, Otto, Lohr, & Deckersbach, 1999). The other treatment option, psychopharmacology, has also been shown to reduce symptoms in patients with body dysmorphic disorder. Similar to OCD, medications such as clomipramine and SSRIs are generally prescribed. While these are effective in reducing body dysmorphic disorder symptoms, once medication is discontinued, symptoms resume nearly immediately suggesting this is not an effective long-term treatment option for those with body dysmorphic disorder.
Treatment of body dysmorphic disorder appears to be difficult, with one study finding that only 9% of participants had full remission at a 1-year follow-up, and 21% reported partial remission (Phillips, Pagano, Menard & Stout, 2006). A more recent finding reported more promising findings, with 76% of participants reporting full remission over 8 years (Bjornsson, Dyck, et al., 2011).
9.5.2.1. Plastic surgery and medical treatments. Many individuals with body dysmorphic disorder seek out plastic surgery to attempt to correct their deficits. Phillips and colleagues (2001) evaluated treatments of patients with body dysmorphic disorder and found that 76.4% of the patients reported some form of plastic surgery or medical treatment, with dermatology treatment the most reported (45%) followed by plastic surgery (23%). The problem with this type of treatment is that the individual is rarely satisfied with the outcome of the procedure, thus leading them to seek out additional surgeries on the same defect (Phillips et al., 2001). Therefore, it is important that medical professionals thoroughly screen patients for psychological distress before completing any medical treatment.
Hoarding Disorder
Recent research has concluded that unlike OCD, many individuals with hoarding disorder do not experience intrusive thoughts, nor do they experience urges to perform rituals. Because of this difference, treatment for hoarding disorder has moved away from exposure and response prevention, and more toward a traditional cognitive-behavioral approach.
Frost and Hartl (1996) believed that individuals with hoarding disorder engage in complex decision-making processes, overanalyzing the value and worth of possessions, thus leading to hoarding the object as opposed to discarding it. Therefore, in addition to having the individual engage in exposure treatment, an added component of cognitive restructuring and motivational interviewing are added to address the complex-decision making that is involved in maintaining unnecessary possessions. By discussing motives for keeping items, as well as fears that may be associated with discarding items, clinicians can assist patients in their cognitive processes to ultimately determine the item’s actual worth (Williams & Viscusi, 2016). Unfortunately, due to the distressing nature of having to discard their possessions, many individuals in treatment for hoarding disorder prematurely end treatment, thus never reaching remission of symptoms (Mancebo, Eisen, Sibrava, Dyck, & Rasmussen, 2011).
Key Takeaways
You should have learned the following in this section:
- Treatment options for OCD include exposure and response prevention, as well as SSRIs though the drug does not provide an added benefit in treatment.
- Treatment options for body dysmorphic disorder include exposure and response prevention and drugs clomipramine and SSRIs.
- Treatment options for hoarding disorder include exposure treatment, cognitive restructuring, and motivational interviewing.
Review Questions
- Discuss the various types of treatments for OCD. Which treatment option has the best outcome?
- What are the different components of Exposure and Response Prevention? How do they work together to reduce OCD symptoms?
- What are the most effective treatment approaches for body dysmorphic disorder?
- According to Frost and Hartl (1996) what are the main components that contribute to the maintenance of hoarding disorder?
Module Recap
As in all modules past, we have discussed the clinical presentation, epidemiology, comorbidity, etiology, and treatment options for a specific class of disorders – obsessive compulsive and related disorders.
