308 CHAPTER 7
Treating Obsessive Compulsive Disorder
The primary targets of treatment for OCD are usually either neurological or psy-
chological factors. In Hughes’s case, there was no one in his life with the clout and
concern who could tell the powerful man that he needed help. As biographers Barlett
and Steele (1979) note, his living situation was like a mental institution, but it was
run by the patient, and no one was telling him that he had problems. His aides car-
ried out whatever compulsive demands Hughes made, never challenging him about
the irrationality of his orders.Targeting Neurological Factors: Medication
An SSRI is usually the type of medication used fi rst to treat OCD: paroxetine (Paxil),
sertraline (Zoloft), fl uoxetine (Prozac), fl uvoxamine (Luvox), or citalopram (Celexa)
(Soomro et al., 2008). OCD can also be treated effectively with the TCA clomi-
pramine (Anafranil), although a higher dose is required than that prescribed for de-
pression or other anxiety disorders (Rosenbaum et al., 2005). People who develop
OCD in childhood are less likely to respond well to clomiprimine or to other anti-
depressants (Rosario-Campos et al., 2001). Hughes’s use of codeine and Valium did
not appear to diminish his obsessions and compulsions in any signifi cant way; in
fact, such medications are not routinely prescribed for OCD. However, medication
alone is not as effective as medication combined with behavioral treatment, such as
exposure and response prevention (discussed in Chapter 4 and in the next section).
As with other anxiety disorders, when the medication is discontinued, OCD symp-
toms usually return (Foa et al., 2005).
If medication and behavioral treatments don’t help a person who has severe
OCD, he or she may receive transcranial magnetic stimulation (TMS) or neurosur-
gery (see Chapter 4). TMS involves delivering a series of very fast pulses of a very
strong magnetic fi eld to part of the brain, which disrupts neural activity. However,
the jury is still out on the value of this treatment for this disorder. Neurosurgery,
used as a last resort for cases that do not respond to less drastic treatment, is
aimed at disrupting the circuit (involving the frontal lobe and the basal ganglia,
described earlier) that apparently underlies the obsessions and compulsions that
characterize OCD (Greenberg, Murphy, & Rasmussen, 2003; Husted & Shapira,
2004; Mantovani et al., 2006; Pallanti, Hollander, & Goodman, 2004).Targeting Psychological Factors
Treatment that targets psychological factors focuses on decreasing the compulsive
behaviors and the obsessional nature of the thoughts. Both behavioral and cogni-
tive methods are effective (Cottraux et al., 2001), and treatment may combine both
types of methods (Franklin et al., 2002).Behavioral Methods: Exposure With Response Prevention
Patients with OCD often undertake exposure with response prevention (see Chap-
ter 4) as a behavioral treatment. The patient is exposed to the feared stimulus (such
as touching dirt) or the obsessive thought (such as the idea that the stove was left
on) and is prevented from engaging in the usual compulsion or ritual. For instance,
if someone were afraid of touching dirt, she would touch dirt but would not then
wash her hands. Through exposure with response prevention, patients learn that
nothing bad happens if they don’t perform their compulsive behavior; the anxiety
is lessened without resorting to the compulsion, their fear and arousal subside, and
they experience mastery. They survived the anxiety and exerted control over the
compulsion. When patients successfully respond differently to a feared stimulus,
this mastery over the compulsion gives them hope and motivates them to continue
to perform the new behaviors.
Although exposure treatment for OCD can be very helpful, not everyone is will-
ing to use this form of treatment. Confronting a feared stimulus is, well, frightening!
Medication may help such people when beginning exposure treatment—it can help
them tolerate the anxiety that arises. Then, as the exposure treatment progresses,P SN