Treating obsessive compulsive disorder
If you have obsessive compulsive disorder (OCD), your recommended treatment plan will depend on how much your OCD is affecting your ability to function. Treatment is likely to involve:
- behavioural therapy to change the way you behave and reduce your anxiety
- medication to control your symptoms
Treatment plan
OCD that causes mild functional impairment is usually treated using a short course of cognitive behavioural therapy (CBT).
OCD that causes moderate functional impairment can be treated with a more intensive course of CBT, or antidepressants known as selective seretonin reuptake inhibitors (SSRIs). Such cases may also require referral to a specialist mental health service.
OCD that causes severe functional impairment will require referral 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 who has experience of treating OCD in children.
See the box (right) for an example of the steps that may be followed when treating OCD.
Behavioural therapy
Cognitive behavioural therapy involving graded exposure and response prevention has repeatedly proved to be an effective treatment for OCD.
Exposure and response prevention
Exposure and response prevention (ERP) is a treatment that involves identifying a number of situations that cause you anxiety. These are then placed in order, depending on which situation causes the most anxiety.
You and your therapist will identify tasks that will expose you to the situation that cause anxiety, but at a level that 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 their compulsion, the anxiety disappears completely in one to two hours.
This same exposure task should be repeated two or three times a day. Each time, the anxiety is likely to be less, and last for a shorter period of time. Once one step has been conquered you can move onto a more difficult exposure 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 for more than 10 hours.
Medication
You may be prescribed medication if CBT fails to treat mild OCD or if you have moderate or severe OCD. The different types of medication that you may be prescribed are discussed below.
Selective serotonin reuptake inhibitors (SSRIs)
Selective serotonin reuptake inhibitors (SSRIs) are a type of antidepressant that boost levels of a substance called serotonin in the brain. Serotonin is a neurotransmitter, which is a chemical that the brain uses to transmit information from one brain cell to another. See the Health A-Z topic about SSRIs for more information about this type of medication.
Possible SSRIs that you may be prescribed include:
- fluoxetine
- fluvoxamine
- paroxetine
- sertaline
- citalopram
- escitalopram
You normally need to take an SSRI for 12 weeks before you notice any benefit. Most people with moderate to severe OCD are required to take SSRIs for at least 12 months. After that time, your condition will be reviewed. If the condition is causing you very few or no troublesome symptoms, you may be able to stop taking SSRIs.
Side effects of SSRIs include:
- headaches
- feeling sick
These side effects should pass within a few weeks.
There is a small chance that 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 you have suicidal thoughts or want to self-harm.
It may be helpful to tell a close friend or relative that 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 do not suddenly stop taking your medicine. If you no longer need the medicine, your GP will gradually reduce your dose.
See the patient information leaflet of your medicine to find out more about the possible side effects. Or see the Medicines information tab above.
Some people respond better to one SSRI rather than another. If you have been taking full recommended doses of an SSRI for three months without benefit, you may be prescribed a different type of SSRI.
The doses of SSRI recommended for OCD are higher than those generally used for depression. There is evidence that low doses of SSRIs are ineffective.
Clomipramine
Clomipramine is a tricyclic antidepressant (TCA), which 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.
Side effects of clomipramine include:
- a dry mouth
- constipation
- diarrhoea
- blurred vision
- dizziness
- fatigue (extreme tiredness)
Clomipramine is not suitable for people who have:
- low blood pressure
- arrhythmia (an irregular heartbeat)
- recently had a heart attack
For adults at risk of cardiovascular disease (conditions that affect the heart or blood vessels), your GP may recommend a blood pressure test and an electrocardiogram (ECG) before starting your treatment. An electrocardiograph (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.
See the patient information leaflet that comes with your medicine to find out more about the possible side effects. Or see the Clomipramine medicines information above.
If SSRIs or clomipramine prove to be ineffective, you will be referred to a specialist mental health service.
Support groups
Many people with OCD find support groups helpful. Support groups can:
- reassure you
- reduce any feelings of isolation
- 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 OCD.
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 for OCD 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) with the addition of antipsychotic medication or the recommended 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 OCD (see below)
National Service for Refractory OCD
After guidelines published by the National Institute for Health and Clinical Excellence (NICE) in 2005, the Department of Health commissioned a centre to treat people with severe, long-term refractory OCD. Since April 2007, the Department of Health has funded the National Service for Refractory OCD to fulfill this aim.
The National Service offers assessment and treatment to people with OCD who have not responded to treatments in their local and regional OCD speciality services. To be eligible for the National Service, you must have had a number of previous treatments and you must meet the severity criteria.
Most people improve after receiving treatment from the National Service. Very few people, perhaps one or two a year, may be considered for neurosurgery.
Ablation neurosurgery
A very small number of people with OCD will need neurosurgery. During ablation neurosurgery, a neurosurgeon (a surgeon who specialises in surgery involving the brain and nervous system) will use 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 that is responsible for some of the most important brain functions, such as the higher emotions, memory and behaviour.
Neurosurgery 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 that they had improved. But as many as 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 have reported an improvement in symptoms. But some possible serious side effects are associated with the technique, including:
- infection
- bleeding inside the brain
Possible treatment plan
If your treatment does not appear to be successful, there are other options. The level of treatment you are receiving can increase in steps until it is effective. You should also remember that treatments can take several months before they have a noticeable effect.
Below is an example of the treatment steps that may be followed if you have OCD.
- You are likely to start with a course of CBT. Different types of CBT and longer sessions can be used if your initial course of CBT does not work.
- You may then be prescribed a SSRI.
- If your SSRI is not effective, your dose may be increased.
- If this does not work, there are several different SSRIs that you can try.
- If this still proves to be ineffective, you may be prescribed higher doses of SSRIs or you may be given another medication to take with your SSRI. One of the most common additional types of medication is antipsychotic medicine. Antipsychotics are used to treat a number of different mental health conditions.
- CBT delivered by a highly specialised team can also be used with any type of medication that you are taking.
