OCD Facts: Evidence-Based Treatments for OCD
Evidence-Based Treatments for OCD
Within the body of research on Obsessive Compulsive Disorder, a number of treatments for OCD in children and adolescents have been reported. However, clinical studies using randomized, controlled methodology (the "gold standard" for conducting research) have consistently supported only two treatments as being effective: (1) Cognitive Behavior Therapy (CBT), and (2) medications known as serotonin reuptake inhibitors. Each of these treatments is discussed below.
Cognitive Behavior Therapy
Cognitive Behavior Therapy (CBT) is the only scientifically-supported behavioral treatment for OCD. It is recommended by leading national authorities, including the Mayo Clinic, the National Institutes of Health, Harvard Medical School and the American Academy of Child and Adolescent Psychiatry.
Treatment guidelines developed in 1997 by consensus among OCD experts indicated that, for children who have not yet reached puberty, CBT is the first treatment of choice, whether the OCD is mild or more severe. For adolescents, CBT is the initial choice when OCD is milder. If the OCD is more serious, CBT is still the first choice but, if that doesn’t work well, a medication is often added. In some cases, CBT and medication are used from the beginning if the child or adolescent is very sick -- for example, if he or she has severe depression in addition to OCD. Medication would be prescribed in that instance and, once the child began to experience some relief from the OCD and depression, he or she would start CBT.
In 2004, the results of the first, large-scale study to compare the effects of CBT alone, medication alone (Zoloft, which belongs to a class of medications known as selective serotonin reuptake inhibitors, or SSRIs), or the combination of CBT and Zoloft, were released. The results of this study, known as the Pediatric OCD Treatment Study (POTS), indicated that children and adolescents with OCD should begin treatment with CBT alone or CBT plus a medication like Zoloft.
Similarly, new guidelines by the American Academy of Child and Adolescent Psychiatry (AACAP) for the treatment of pediatric OCD recommend CBT as the first line of treatment for children and adolescents with mild to moderate cases of OCD; a combination of CBT and medications is recommended for severe cases of OCD.
The results of the 1997 treatment guidelines, the 2004 POTS study and the AACAP recommendations clearly support the effectiveness of Cognitive Behavior Therapy. CBT makes use of two techniques: Exposure and Response Prevention (ERP) -- sometimes called "ritual prevention" -- and Cognitive Therapy. Not every psychologist or psychiatrist is trained in the use of CBT, and not every doctor or mental health professional trained in CBT has experience treating children or young adults. Sometimes finding a cognitive behavior therapist with this experience is challenging.
In Exposure and Response Prevention therapy, the therapist develops, together with the child, a hierarchy of all the child’s fears and rituals (from least to most disruptive) as well as situations in which these symptoms are likely to be triggered. The therapist then conducts a series of controlled ERP sessions, beginning with tasks that are lower on the list (i.e., they produce less fear). The child is systematically placed into feared situations (exposure) and instructed to refrain from performing his or her usual compulsions or rituals for a period of time (response prevention). During repeated exposure exercises, the child may be asked to delay the rituals for increasingly greater periods of time.
For example, if a child has an obsessive fear of germs, a therapist conducting ERP therapy may encourage the child to touch a pencil that he or she believes is contaminated. The child will then be coached to refrain from washing his or her hands (the ritual typically performed in response to contamination fears) for a specific amount of time. In subsequent exposures, the child will be asked to refrain from the handwashing behavior for longer periods of time.
How It Works
When therapeutic exposures are repeated over time, the associated anxiety decreases until it is barely noticeable or even fades entirely. There is no way to predict exactly how long it will take for the child to gain control over the persistent thoughts or fears that must be overcome. But ERP works because of “habituation” -- a process in which the anxiety created by the exposures gradually decreases on its own, even without performing rituals.
Habituation has been compared to what happens when an individual jumps into a swimming pool with cold water; while uncomfortable at first, the body adapts to the temperature of the water and, over time, the individual feels better -- even though the temperature of the water has not changed. When habituation occurs within the context of ERP, situations that previously triggered OCD symptoms produce less anxiety and a reduced urge to ritualize. Through a series of sessions, the therapist guides the child to take on more challenging exposures until even the most difficult obsessions and compulsions become manageable.
Every child is different, so the therapist will design a program that fits the symptoms and circumstances of the child and the family. In most cases, children and adolescents are scheduled for outpatient sessions once or twice a week with “homework” that must be completed each day at home between sessions. Recent research suggests that CBT conducted in group settings or on an intensive basis (e.g., 14 sessions over 3 weeks) also shows promise.
Another important component of CBT is Cognitive Therapy. The therapist may help the child learn certain new ways of thinking through Cognitive Therapy. It helps children understand that the brain is “playing a trick” on them, so they come to understand that their fears are not real and learn to manage the urges to engage in compulsive acts. For example, a child may fear that, by touching a pencil, he will become ill and cause his family members to become ill, as well. Using Cognitive Therapy, this child might be asked to challenge his thoughts (which involve an exaggerated sense of responsibility for harm) and taught a more suitable alternative to his or her current way of thinking. Strategies such as self-talk, learning to separate oneself from the disorder, and analyzing the realistic chances or probability of a catastrophe's occurrence are part of Cognitive Therapy.
It is important to note that children will proceed through the CBT process at their own pace. It is not unusual for symptoms to subside within weeks. Even when a student’s behavior improves, there may be setbacks, as it is often difficult to consistently sustain improvement. When treatment is completed, additional sessions may either be planned or scheduled, as needed, when the child is under stress or during challenging times. These “booster” sessions may contribute to keeping children well.
Rarely, and only in special circumstances, is hospitalization needed. Hospitalization may be required, for example, in the most severe cases of OCD, if a child tries to harm himself (such as a suicide attempt), when multiple coexisting anxiety disorders are present that require extended observation and treatment, or when medication reactions need to be closely monitored.
Medication
Several studies have shown that CBT is more effective than medication alone in treating OCD in children and adolescents. CBT has also been shown to be more durable than medications in that the positive effects of CBT last longer. In addition, because drugs always have the potential for side effects, CBT is safer than medications. Unfortunately, a large number of individuals with OCD are unable to access CBT because of location (e.g., individuals in rural areas may have to travel long distances to find a qualified CBT therapist), financial issues (e.g., an insurance company may not cover the cost of CBT and families cannot afford to pay for it out of pocket), and a lack of professionals who are trained to implement CBT. Moreover, some children and adolescents are unwilling to participate in, or don't respond to, CBT. In these cases, medications may need to be prescribed to treat OCD. Of note is that many individuals are more willing and able to participate in CBT after being on medication for a period of time.
Medications Used to Treat OCD in Children and Adolescents
Because students with OCD may be taking medication, it is important for school personnel to have a working knowledge of the medications typically prescribed for OCD. Following is a discussion of the major drugs used to treat OCD and some of their most common side effects. It is important to note that school personnel should always discuss any possible side effects of medication with parents.
Anafranil (generic name, clomipramine) is one of the older medications that has been used for many years to treat young people (and adults) with OCD. A serotonin reuptake inhibitor (SRI), Anafranil belongs to a class of medications known as tricyclic antidepressants and has been approved for use with children 10 years of age and above. Although it has been shown to be effective in treating OCD, Anafranil has been associated with many potentially harmful side effects, including a risk for seizures, weight gain, and a negative impact on the cardiovascular system.
Because of Anafranil's side effects, physicians frequently treat OCD with drugs belonging to a different class of medications: the selective serotonin reuptake inhibitors, or SSRIs. Five SSRIs have been used to treat children and adolescents with OCD, including Zoloft (sertraline), Prozac (fluoxetine), Luvox (fluvoxamine), Paxil (paroxetine), and Celexa (citalopram). Of these drugs, three have been approved by the FDA for use with children: Zoloft, for use with children 6 years of age and above, Prozac, for children 7 and over, and Luvox, for children 8 and above.
In some cases, a medication is used "off-label" when it is prescribed to treat a condition or an age group not specifically listed on its prescribing label as an FDA-approved use. Thus, although certain SSRIs, e.g., Paxil (paroxetine) and Celexa (citalopram) -- as well as non-SSRI medications such as Effexor (venlafaxine) -- are not FDA approved for treating childhood OCD, physicians do prescribe these drugs for that purpose.
Although the SSRIs typically have fewer side effects than Anafranil, they do carry the potential for side effects such as nausea, diarrhea, increased anxiety, jitteriness and insomnia. Although side effects frequently subside after a period of time, some young people experience difficulties throughout treatment.
One potential side effect of antidepressants in children and adolescents is something known as behavioral activation. Behavioral activation includes a variety of symptoms, including agitation, aggression, irritability, impulsivity, hyperactivity, increased depression or anxiety and, among a small fraction of youth, an increased risk for suicidality -- suicidal thinking and behavior. In fact, in October of 2004, the Federal Drug Administration issued a black box warning (i.e., a warning that appears on the package insert of prescription drugs) alerting health care providers to the potential risk of increased suicidality among young people taking antidepressants. This is a risk not only for children and adolescents with depression but also for those with OCD and other anxiety disorders. Multiple studies have indicated, however, that the benefits of using SSRIs to treat children and adolescents with OCD generally outweigh the risks. Whenever a student is taking an antidepressant, the prescribing physician should closely monitor its effects. In addition, school personnel should be extremely alert to any evidence of suicidal behavior or other troubling behaviors and discuss them with parents immediately. In general, potential safety concerns associated with medication support the idea of treating OCD in children and adolescents with CBT prior to medication whenever possible.
Unfortunately, a considerable number of people experience an increase in OCD symptoms once medication is stopped. It has been estimated that medication reduces symptoms by only about 30-40%, leaving the majority of people with residual symptoms. Many experts believe that adding CBT to medication, whenever possible, is the best way to improve the results of treatment outcome.