17.3 Obsessive–Compulsive and Related Disorders

Imaginal Exposure

Another CBT technique commonly used to treat OCD is called imaginal exposure, which involves mentally confronting and engaging with a feared situation, traumatic memory, or anxiety-provoking thought in a safe and controlled environment. This technique aims to help individuals process their fears, reduce anxiety, and learn effective coping strategies. For example, suppose a client with OCD has an intense fear of contamination from germs that she believes will cause a deadly illness to her family members. Her compulsions involve excessive washing and avoiding physical contact with her children. Direct exposure might be too overwhelming for her at the beginning of treatment.

In an imaginal exposure session, the therapist asks the client to imagine touching a doorknob without washing her hands and then hugging her children. They create a vivid description of the scene, involving all sensory details, and the therapist guides the client to visualize it repeatedly. The therapist encourages the client to experience anxiety and discomfort without engaging in compulsive washing behavior. They repeat the exposure several times during and in subsequent sessions until the anxiety associated with the imagined scenario diminishes. This technique allows the client to confront and gradually habituate to the fear in a controlled setting, thereby reducing the anxiety associated with the feared contamination (Peterson et al., 2019).

Habit Reversal Training

A behavioral therapy technique primarily used for treating tic disorders and body-focused repetitive behaviors (BFRBs), such as hair pulling (trichotillomania) and skin picking (excoriation disorder), is habit reversal training (HRT). Although HRT is not specifically designed for OCD, it can be adapted and used with other therapeutic approaches to manage some OCD symptoms, particularly those involving compulsive behaviors (Lee et al., 2019). HRT consists of several steps:

• Awareness training: This step involves helping the individual become more aware of their compulsive behavior, the triggers, and the situations in which they are most likely to engage. For example, a client with OCD who has a compulsive habit of repeatedly checking the stove to ensure it is off may be assisted to recognize the specific circumstances, feelings, and thoughts that trigger the compulsive stove checking.
• Competing response training: The individual learns a new, healthier behavior to replace the compulsive one. This competing response should be incompatible with the compulsive behavior and should be practiced whenever the urge to engage in the compulsive behavior arises. Together, the client and therapist develop a healthier response to the identified triggers. For instance, they might decide that the client will check the stove once, take a photograph with his phone, and then leave the house, using the photograph to reassure himself if he feels the urge to check again.
• Social support: It can be beneficial to enlist the help of friends, family, or a support group to provide encouragement and reinforcement for practicing the competing response. A family member or friend may be involved to support the client and remind them to use the new coping strategy if they notice them engaging in compulsive behavior.
• Motivation enhancement: Techniques to increase motivation for change, such as identifying the personal benefits of stopping the compulsive behavior, can help the individual stay committed to the habit reversal process. The therapist helps the client understand the negative impact of the compulsive checking and the benefits of the new behavior, reinforcing motivation to change.
• Generalization: The individual is encouraged to apply the competing response in different situations and environments to generalize their new behavior and reduce the likelihood of relapse (Azrin & Nunn, 1973). Strategies are discussed to prevent a return to the compulsive behavior, and the client is encouraged to use the newly learned techniques if the urge returns.

Traditional treatments for OCD usually involve a combination of medication and psychotherapy, with ERP being the most effective therapeutic approach. In cases where ERP is not entirely effective or when the compulsive behaviors are more habit-like, HRT may be an effective adjunctive intervention to help manage compulsive behaviors in OCD (Lee et al., 2019).

Medication

Medications are often used alongside psychotherapy for OCD. The most common medications for OCD are SSRIs, which are considered the first-line pharmacological treatment due to their efficacy and tolerability. Some common SSRIs used for OCD include:

• fluoxetine (Prozac)
• sertraline (Zoloft)
• fluvoxamine (Luvox)
• paroxetine (Paxil)
• citalopram (Celexa)
• escitalopram (Lexapro)

Benzodiazepines, such as diazepam (Valium) and lorazepam (Ativan), are sometimes used for short-term relief of anxiety associated with OCD. Tricyclic antidepressants (TCAs) are an older class of antidepressants that affect multiple neurotransmitters, including serotonin and norepinephrine. The TCA clomipramine (Anafranil) has been specifically approved for treating OCD and is often used when SSRIs are ineffective or not tolerated. TCAs do have more side effects than SSRIs, so they are not considered first-line treatment (International OCD Foundation, 2023).

Gamma Knife

Gamma knife treatment is a noninvasive surgical procedure that uses radiation to destroy targeted brain tissue. While it is typically used to treat tumors and other abnormalities, it has also been used as a treatment for severe cases of OCD that have not responded to other forms of treatment. The procedure involves using multiple beams of gamma radiation to precisely target the area of the brain that is responsible for OCD symptoms. It is thought to disrupt the abnormal neural circuitry contributing to OCD symptoms. While gamma knife treatment may be effective for some individuals with severe OCD, it is not a first-line treatment option and is typically reserved for cases that have not responded to other forms of treatment (International OCD Foundation, 2023).

Deep Brain Stimulation and Transcranial Magnetic Stimulation

Researchers are studying both deep brain stimulation (DBS) and transcranial magnetic stimulation (TMS) as potential treatments for OCD. DBS involves the surgical implantation of electrodes in specific areas of the brain that are believed to be involved in OCD, followed by electrical stimulation of those areas. Studies have shown that DBS can effectively reduce OCD symptoms in some clients. DBS is invasive though and there are many risks associated with brain surgery.

TMS is a noninvasive procedure that uses magnetic fields to stimulate specific brain areas; it is approved for treating conditions like depression and certain anxiety disorders (Perera et al., 2016). While results in treating OCD have been mixed, some studies have found TMS effective in reducing symptoms (Rapinesi et al., 2019). TMS has become more accessible and is available in various settings, including a physician’s office. Conducting TMS in a physician’s office allows for more convenient access to treatment for clients. It may also promote collaboration between the client’s existing health-care providers, fostering a more integrated approach to care (Dunner et al., 2014). The treatment involves multiple sessions, often over four to six weeks. TMS provides an additional option for clients who have not responded to traditional therapies (Maslenikov et al., 2017).

Self-Help for OCD

Regardless of their treatment, nurses should encourage clients to educate themselves about OCD to understand the disorder and how it affects daily life. Keeping a journal to identify situations or thoughts that trigger OCD symptoms is a helpful way to deal with the disorder by challenging negative thoughts with positive, realistic thoughts. Clients should also get adequate rest, a balanced diet, and adequate physical activity. Setting small goals and recognizing that the recovery process may be slow is important for the client to consider to prevent further negative thoughts about themselves (Jassi et al., 2020).