What strategies are used to treat OCD in psychotherapy?

Obsessive-Compulsive Disorder is a very complex psychiatric condition, in which ideas are presented obsessives of all kinds whose anxiety is calmed by all kinds of compulsions and behaviors ritualists.

Focused on treating anxiety and avoiding compulsive behavior in patients with this disorder, There are several strategies used to treat OCD in psychotherapy; let's delve into them.

• Related article: "Obsessive-Compulsive Disorder (OCD): what is it and how does it manifest itself?"

Characteristics of OCD

Obsessive Compulsive Disorder (OCD) is a mental disorder characterized by the patient having intrusive ideas in the form of obsessions that cause anxiety, and that to reduce the associated symptoms you need to perform certain rituals or compulsions. These compulsions help you reduce anxiety and gain the feeling of security that nothing bad is going to happen.

For example, we have a patient with the obsessive idea that he may choke to death while he eats. When he has to eat he feels very anxious and cannot stop thinking at any time about the possibility of choking (obsession). To make sure that he does not choke, he does not eat any solid food and makes sure that everything he eats is well crushed, checking it before putting it in the mouth and, once there, chewing it ten times (compulsion).

OCD is a fairly complex disorder, with many different types of obsessive ideas, ritualistic behaviors, and compulsions, with varying degrees of anxiety and fear.

Fortunately, there are different therapeutic strategies, both psychological and pharmacological that serve to improve the quality of life of patients and even eliminate their symptoms. However, the effectiveness of treatment depends on how quickly and early the disorder has been diagnosed. Without a diagnosis of the disorder, there can be no good treatment.

It is considered that the most appropriate tool to treat OCD is psychotherapy, with some consensus that it offers a greater short-term benefit and has longer lasting positive results than pharmacology. It is for this reason that, as a general rule, in mild-moderate cases it is recommended to start with psychotherapy and, depending on how the patient responds to the treatment, it would be chosen to combine it or not with medication. The combination of psychotherapy with psychotropic drugs is often used in severe cases of OCD.

Throughout the following points, we are going to find out what strategies are used to treat OCD in psychotherapy, in addition to giving some brushstrokes on what psychopharmacological treatments exist, along with brain stimulation and the importance of psychoeducation.

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Psychotherapy

The psychotherapeutic approach to OCD focuses on intervening on rituals and avoidance behaviors (compulsions) that lead to performed by the patient to reduce anxiety associated with the presentation of a stimulus or the intrusion of an unpleasant idea (obsessions).

In most situations, the goal is ensure that the patient does not perform rituals associated with the obsessive ideas and that he / she becomes accustomed to them or controls them in such a way that they do not involve too much disruption in your life.

Now we are going to see a few strategies used to treat OCD in psychotherapy, some of them typical of the strategic psychological therapy, one of the psychotherapeutic approaches considered effective for the management of this disorder.

1. Exposure with response prevention

This therapy is based on the idea that, when we expose a person to what causes anxiety or phobia, progressively and controlled, he will get used to it and, as time goes by, the anxiety levels that such a stimulus can produce will be increasingly minors.

In the specific case of OCD, exposure and response prevention it implies making the patient expose himself to that object that she fears or that every time he thinks of an obsessive idea, such as dirt, order, contamination, is exposed to them, but resisting the urge to make their compulsive rituals, those she did to make sure she was in control of the situation or served to calm down.

Exposure and response prevention takes a lot of effort and practice, but it is possible that the patient achieves a better quality of life once he learns to manage her obsessions and compulsions.

• Related article: "Exposure therapy with response prevention: what it is and how it is used"

2. Counter-rituals

Let's imagine a patient with OCD who always, before leaving home, has to check that absolutely everything is closed or in a certain way. Check the gas, check that all the lights are off, the door is tightly closed, that the tap does not leak... but, despite having done it, just when he is already on the street the doubt comes to him and he has to go home to check everything again.

One of the strategies used to deal with this behavior is what psychologists call "counter-ritual", make her compulsive ritual become more tedious and time consuming, something that over time ends up being unsustainable to maintain.

For this specific case, the patient could be asked that, every time he feels the urge to have to check again what he has done and does it, he does not check it once, but five. He will do everything five times, going in and out of your house each time he has done it, but only if he has had to recheck it after checking everything the first time.

By having to apply this new ritual, the patient is much more likely to dispense with rechecking everything the first time, for the simple reason that he does not want to waste any more time and knows that a new review would mean rechecking everything five more times.

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3. The violation of the ritual

There are cases of patients with OCD who have many rituals, so many and so varied that it is difficult to classify them. In these cases the strategy of the violation of the ritual can be applied, asking the patient to choose one of her many rituals each day and make an effort not to carry it out, while she has total freedom to continue doing others.

This strategy is based on the idea that, first, the patient manages to violate her own routine, although she does it in a different way every day. The simple fact of having to deprive yourself of making a compulsion when having an obsessive idea or a stimulus that generates fear is already a breakthrough, which can help her understand that compulsions are not necessary to reduce her anxiety if she gets used to what provokes.

As the months go by, the patient will dare to do without more rituals, arriving at the moment when she completely violates her initial ritualistic pattern. That is, it goes from a progressive violation to a total violation of the entire list of rituals and compulsions that she used to calm herself.

• Related article: "Obsessive Compulsive Personality Disorder: What is it?"

4. Delay the compulsion

Another strategy used to treat OCD in the context of strategic psychological therapy is to delay the compulsion. For example, the patient may be asked each day to try to avoid what the obsession asks him to do and to delay the compulsion..

If she is a patient who needs to wash her hands every time she touches a wooden table, what she may be asked to do is wash her hands, but after about five minutes. The idea behind this technique is that sooner or later, as time goes by, postponing the ritual will turn into dispensing with it, perhaps even without realizing it.

5. Ritualize the compulsion

This technique is used in cases where, for example, the patient repeats formulas, lists of words and numbers or He pulls hair out throughout the day after performing a certain action or a certain idea comes to mind. Ritualizing the compulsion implies turning it into something more orderly, making it have to be done at a certain time and following a much more complex ritual.

For example, a patient might be asked to repeat the multiplication tables every two times while she thinks about how poorly she was at math. small (intrusive thinking) that does just this, repeat the multiplication tables, but only when the clock strikes an even hour (10, 12, 14...). When this condition occurs, the patient should go to the nearest bathroom, look in the mirror and, for 3 minutes, repeat the multiplication tables without rest.

This strategy makes the patient, while still carrying out the compulsion, now has control over it. Before, he did it at any time of the day, being able to intrude on his work schedule or while doing a leisure activity. Now, By having a schedule where you specify when you allow that compulsion to take place, you are turning it into a controlled habit and, with the passage of time, you will be able to dispense with its use.

Psychopharmacology

The first psychotropic drug that showed great utility in the treatment of OCD was marketed in Switzerland in 1966: the clomipramine.

Since then, no drug treatment has been discovered that has been more effective than this tricyclic antidepressant. but safer drugs have been discovered, with fewer side effects and with a lower risk of interaction with others drugs. The most used are the SSRIs which, together with clomipramine, constitute a group of antidepressants with antiobsesive properties.

The drugs approved to treat OCD are:

• Citalopram (Prisdal ®)
• Clomipramine (Anafranil ®)
• Escitalopram (Esertia ®)
• Fluoxetine (Prozac ®)
• Fluvoxamine (Dumirox ®)
• Paroxetine (Seroxat ®)
• Sertraline (Besitran ®)

There are other drugs that, despite not having been approved by government agencies, contain principles active ingredients that could be useful for the treatment of OCD, one of them being Venlafaxine (Vandral ® or Dubupal ®).

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Brain stimulation

There are two techniques used as treatment for OCD that we cannot include in psychotherapy or psychopharmacology: two forms of brain stimulation. These techniques are unorthodox methods, used as alternative therapy when drugs and psychotherapy have not been shown to be useful, especially in the most severe cases.

1. Deep brain stimulation

Deep brain stimulation is a therapeutic strategy approved in the United States by the FDA (Food and Drug Administration). Drug Administration) to treat OCD in adults 18 years of age and older who have not responded to further treatment traditional. This procedure involves implanting electrodes in certain areas of the brain., which produce electrical impulses that can help regulate obsessions and, above all, compulsions.

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2. Transcranial magnetic stimulation

Also approved in the United States by the FDA, transcranial magnetic stimulation is used in adults with OCD ranging in age from 22 to 68 years. This procedure is non-invasive, and involves using magnetic fields to stimulate nerve cells in the brain. and improve the symptoms associated with the disorder. During a transcranial magnetic stimulation session, an electromagnetic coil is placed on the scalp, near the forehead. This electromagnet produces a magnetic pulse that stimulates nerve cells in the brain.

Psychoeducation

As a final point, we want to highlight the importance of psychoeducation before applying psychotherapeutic and psychopharmacological tools in the patient. It is essential that the patient has a correct understanding of their disorder before starting treatment and beginning the road to recovery..

It is preferable that the information that the patient receives about OCD comes directly from their psychotherapist, but in the practice this is complicated given that we live in a world where ICT has conquered all the vital aspects of the persons. It is very likely that the patient has already documented himself previously, and it is possible that she has done so by finding information that does not correspond to reality or is reliable.

For this reason, one of the tasks of the psychologist during the psychoeducation phase and before starting therapy is to see what misconceptions or myths the patient can believe, try to counter them with real and truthful information and explain what the fundamental features of her psychopathology are. This part can help a lot in their recovery, since the patient can understand that this The problem does not only happen to him or her, in addition there are proven therapies to improve their state of Health.