OCD Recovery Center (Obsessive Compulsive Disorder): OCD: Comprehensive Treatment for Primarily Obsessional OCD

Comprehensive Treatment for Primarily Obsessional OCD

By Dr. Christian R. Komor
OCD Recovery Center

Part 2: Exposure and Response Prevention for Obsessions

When treating most forms of OCD the procedure used is a gradual one. The therapist assists the individual in developing a hierarchy of feared items and then begins assisting the individual in exposing their self to the items starting in the mid-range of the scale. When dealing with primarily obsessional OCD this can be counterproductive. It is usually necessary to jump right into the worst of the obsessions with both feet - challenging the obsessions head on and giving them no quarter to escape and regroup. Defensive strategies, attempts to gain reassurance, or seeking comfort from the obsessions invariably causes them to escalate.

A good way to think of Exposure and Response Prevention (ERP) behavioral treatment is like an immunization. While doing the ERP work one's anxiety is likely to increase rather than decrease and this is normal. Regarding the anxiety like energy or electrical current that is simply passing through one's mind and body is a productive conceptualization. During ERP work it is best not to try to eliminate the anxiety through relaxation techniques, but rather just feel it and go on with daily activities.

At the OCD Recovery Center we have defined four critical elements that produce success in Exposure and Response Prevention (ERP) behavior therapy. When OC sufferers have not achieved success in prior ERP-based treatment it is most likely due to inattention to one or more of these variables: (1) Intensity - keeping anxiety levels between the SUB levels of 25-75, (2) Saturation - making the exposure constantly present in the individual's environment, (3) Duration - holding the exposure for as long as it takes to habituate, (4) Neutralization - making sure the OC sufferer does not "undue" the exposure with rituals or compulsions. (Sometimes OC sufferers have been known to "hold out" for weeks or months before performing a compulsion or ritual to "make it better" and thus neutralize the ERP work!)

The difficulty with O-OCD is that it is difficult to observe and control for these four variables. Many people with primarily obsessional OCD have come to feel discouraged and even hopeless because of many failed treatment experiences. It can be greatly reassuring to realize that the causes of "failure" in treatment can be defined, localized and corrected simply by attending to the four variables above. As we proceed further with a discussion of practices and procedures please keep in mind these four critical elements and how they would be applied in the situation at hand.

It is also crucial to remember that: (1) Obsession-based OCD takes six to twelve months or more to neutralize to any significant degree and (2) The number of "hits" or attacks by the obsession (e.g. the frequency with which the obsession presents itself into consciousness) will almost always increase during the first weeks and months of treatment. What we are looking for in treatment is not a decrease in hits, but rather a decrease in the amount of time and intensity with which the individual dwells on, or gets stuck in the obsession. Thus, successful treatment will look like an increase in obsessional hits and a increasing ability to say (in effect) "Oh that is just my brain giving me an erroneous message again."

Massed Imaginal Exposure (ME)

This is the primary and, usually, most powerful technique for working through primarily obsessive OCD. (ME should not be used where psychosis or antisocial features are present.) The first step in ME is to carefully develop a personalized script of the worst of the individuals obsessional fears. The key here is exposure to the content of the thoughts. The script should be made in short powerful statements in the (immediate) future tense ("Soon I will kill all of my relative in a bloody rampage!") rather than a lengthy description of one event ("I walked in the kitchen and got the knife out of the drawer. Then I..."). Because of the form of the script is essential, this is often best done during a counseling session with the psychotherapist typing to the individuals dictation and adding embellishments and refinements as the process goes along. It is important to develop several paragraphs of the individuals most horrific fears - sparing nothing and even exaggerating the intensity of the fearful thoughts. After this has been accomplished the individual reads the script onto an audiotape. Following this the individual collects a small number of items that trigger or represent the obsession (knife, picture of a murder scene, nude pictures of someone the same sex, etc.).

Once the script, tape and materials have all been collected, the individual sits down facing the feared objects and begins reading the script out loud for 20 minutes. Next the individual spends 20 minutes listening to the audio tape. Finally they spend another 20 minute reading the script silently or retyping it over and over. It is important to note the anxiety level when commencing and at the conclusion and every ten minutes after the exercise. The task is to simply experience the anxiety generated by the material without avoiding it or (later) undoing it. The ME exercise is expected to become monotonous and this is actually the goal. This can be compared to watching a scary movie over and over and over at the theater. Eventually the movie is not only no longer scary, but one begins to "pick apart" the movie - looking behind the acting, noticing the scripting, lighting, directing - seeing the movie for the pretend play that it is rather than being captivated by it.

The ME exercise can be altered for Intrusive Obsessions by doing a loop tape of sticky songs, words, etc.

If time is limited one option is for the individual to alternate days for practicing Attention Training (ATT) and Massed Exposure (ME). This way in one hour a day the individual is able to develop both the mental control to detach from obsessive thoughts and habituate to the current major obsessive theme.

(Detailed instructions for conducting a Massed Exposure exercise are included in Appendix 1.

Obsessions must be countered during ERP in their original medium to be most effective. This means that if the obsession is an image an image should be used to counter it. If the obsession is a thought a thought should be used in ERP. If it is a sound then a sound is called for, etc.
Encouraging the Obsession. Make the obsession bigger than it presents itself as. (Instead of "I might stab my spouse with this knife." "I am going to slash and gore my spouse with this knife and watch the blood splatter all over the floor." Other methods of encouraging the obsession include: Writing out or saying the feared thoughts, acts, statements or sentences. Reading books watching a video or making a scrapbook about the obsession; Deliberately going places where one will encounter the obsession; Taking part in feared activities; Resisting doing things the obsession says one must do; Making a card, t-shirt or other expression of the obsession. Remember that this must be done primarily in the original medium of the obsession. If the obsession is a thought - thinking and even worse thought will be more effective than looking at an image of an even worse thought.
Discontinue as much as possible reassurance seeking. This is crucial and some OC sufferers have reported significant reductions in obsessions simply by discontinuing reassurance seeking behavior. The counselor or loved ones should give one reassurance statement ("No, I don't think the individual's eyes were damaged when one looked at the sun for that instant.") and then offer no more - no matter how often, hard or pleadingly the individual asks. Instead, as response such as "One have OCD and one are seeking reassurance again." Can serve as a non-committal reminder to the individual that reassurance seeking is destructive to the treatment process.
- Note that reassurance seeking and neutralizing behaviors can be very subtle. For example, a OC sufferer suffering with obsessions of harming her children walks into the kitchen and sees a knife. Simply leaning back away form the knife can, for some, be reinforcing to the OCD.
Break the rules. The individual may find creative ways to challenge the obsessive thought. For example, they may change the obsessive thought by adding an element in the middle or they may cut the thought off half-way. Other options include delaying the obsessive thought or acting it out in pantomime very, very slowly. The important feature here is to break out of the groove that the obsession has established for itself.
Include the family. Having a loved one participate in the treatment process (without providing unhealthy reassurance or enmeshing with the individual) increases the chances of treatment success significantly.

Part 3: Obsession Innoculation (Cognitive and Pysiologic Approaches) >>