CBT helps people change their thoughts and feelings by first changing their behavior. Behavior therapy for OCD involves Exposure and Response Prevention. Exposure is based on the fact that anxiety usually goes down after repeated contact with a feared object. For exposure to be of the most help, it needs to be combined with response or ritual prevention. In the latter, the person's rituals or avoidance behaviors are blocked. For example, a person with OCD may be asked to touch a toilet seat that he considers contaminated (exposure) and then resist washing his hands afterwards (ritual prevention). As therapy progresses, the patient is asked to resist the compulsion for longer and longer periods of time. "Homework" assignments are given so that the patient can practice with real-life situations that he or she encounters at home and on the job.

Cognitive Therapy, the other component of CBT, is often added to Exposure and Response Prevention to help reduce the catastrophic thinking and exaggerated sense of responsibility typical of OCD. "People with OCD 'jump to conclusions' about what is going to happen. For example, a mother might assume that simply having a thought about hurting her child means that she will do it, but in fact it is only a thought and actually a pretty common one," says Steketee. "In cognitive therapy, the patient is asked to pay attention to her thoughts and beliefs and to evaluate how rational or logical that 'conclusion' really is."

Steketee uses several exercises to help patients correct their faulty thinking. "For example, for any given scenario, we ask what the patient would think if a friend argued that such-and-such would happen. If someone believes they'll cause harm to their family, we ask them to play judge and jury and logically think about whether their case would stand up in a court of law."

In milder OCD, CBT alone is often the initial choice, but medication may also be needed if CBT is not effective enough. Individuals with severe OCD or complicating conditions that may interfere with CBT (e.g., panic disorder, depression) often need to start with medication, adding CBT once the medicine has provided some relief. SSRIs are the type of medication most often prescribed initially for OCD. "Research shows that a combination of these two types of treatment results in the best outcome," says Hollander. However, the doctor may start with one or the other treatment first, and add the second one later. Whichever route you and your doctor decide on, experts advise that you:

• Give medication a fair trial. A substantial body of evidence shows drugs are highly effective in OCD. However, patients need patience. "It may take up to three months to see the effect of an SSRI," warns Hollander. "Waiting is difficult but you need to give the medicine time to work before giving up on it." It's also important to follow your doctor's orders on how much medication to take and when to take it. If you are not happy with your initial experience, your doctor can try changing the dose, switching to a different drug, or combining drugs. Do not reduce or increase the amount you take without specific instructions from your doctor.
• Manage expectations about treatment. Knowing what to expect during treatment makes going through it easier. For example, anxiety often increases during exposure therapy, and learning that you can get through it OK takes a few trials. Medication may take a while to kick in. "Although family members may assume that their loved one's irrational thinking and behaviors should just stop, recovery is in reality a step-by-step process that takes time," says Steketee.
• Take advantage of support networks. Keeping motivated throughout treatment is always a challenge. Participating in self-help groups, finding a buddy for exposure "homework," seeking out books or Internet sites on OCD, and going to family therapy are some of the many ways to gain insight the recovery process.
• Report changes in symptoms. Symptoms may arise or increase in intensity for a number of reasons and may require adjusting treatment. Medications, although safe, do have side effects (be sure to report any to your doctor). Depression and other anxiety disorders may co-exist with OCD. Talk to your doctor if you begin to eat or sleep too much or too little, feel constantly lethargic or hopeless or have suicidal thoughts. Stress can also exacerbate OCD symptoms.

What Family Members Can (and Shouldn't) Say

SOURCE: Adapted from When Once is Not Enough: Help for Obsessive Compulsives by Gail Steketee, Ph.D. and Kerrin White, M.D. (New Harbinger Publications, Oakland, CA, 1990), p. 129-130

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