Obsessive-Compulsive Disorder (OCD): How to Find the Right Treatment

Having obsessive-compulsive disorder (OCD) is a lot more than the stereotypes people often associate it with, such as washing your hands raw or repeatedly checking to see if a door is locked.

It’s a complex condition that involves uncontrollable, intrusive thoughts (obsessions) that make people feel compelled to take actions (compulsions) to relieve an underlying anxiety. Whether this involves unusual behaviors to assuage a fear of unwittingly harming a loved one or a strong need for things to be symmetrical, OCD can range from mild to severe and interfere with a person’s work, school, or overall quality of life.

Fortunately, most people with OCD can be treated, and research is underway at Yale School of Medicine to identify new therapies that could more effectively relieve the condition’s most stubborn symptoms. This is good news for the estimated two to three million people in the United States living with OCD.

In the Q&A below, Christopher Pittenger, MD, PhD, a Yale Medicine psychiatrist and director of the Yale OCD Research Clinic, describes what is happening inside the brain of a person with OCD and discusses current treatments and research into new ones.

An OCD diagnosis means that you have obsessions and compulsions. Technically, you don't need both to be diagnosed with the condition, but almost everyone with OCD does have both. Obsessions are thoughts that come into your mind unbidden and seem foreign—or unlike your everyday train of thought. These obsessions may conflict with your values or who you think you are and, therefore, are distressing.

But everyone experiences unwanted thoughts to some degree. If you ask people if they sometimes get thoughts that bother them and don’t seem in line with who they think they are, 90% will say yes. For example, say you’re driving in a car, and you think, “Hey, I could steer off the side of the road here.” That is a common thought people occasionally have. A healthy reaction is to say, “That was weird,” and move on.

But in OCD, these thoughts take on a power, an urgency, and an importance. They are impossible to ignore. OCD is very diverse in that it can arise as almost anything, not just the commonly mentioned thoughts about germs or about death. It can include thoughts about anything that feels distressing or foreign.

Compulsions are behaviors that people engage in to manage the distress that comes with the obsession. For example, you may have an intrusive thought such as, “I’m contaminated. I’m going to die,” or “I'm going to start a plague,”—because, interestingly, it's often about responsibility and guilt—then a logical behavior would be to wash your hands.

When you do this behavior, your anxiety is somewhat relieved, and you think it worked. Compulsions do manage the distress, at least partially, sometimes. If you clean, pray, count, or do any of the countless other things people do to mitigate the distress associated with a particular thought, and it gets better, then you've treated that thought as powerful and important.

The pernicious fact is that, when they work, the things that people do to try to control the distress reinforce the process, and you get stuck in this feedback loop—and that’s what OCD is all about.

Sometimes, the relationship between an obsession and a compulsion is not rational. We call that magical or superstitious thinking. For example, someone might think knocking on wood three times will keep bad things from happening. People pick up these ideas from society, or perhaps they tried some behavior that made them feel better, so they are more likely to do it again.

Most—but not all—people with OCD have a perfectly clear understanding that these behaviors aren't necessary. I call this the curse of insight, which means that people's behaviors are controlled by obsessions they know are irrational, yet they feel compelled to do the behavior anyway. That's a particular kind of torture.

People’s obsessions and compulsions tend to fall into different patterns. These aren’t separate conditions—it’s all OCD—but they are recognizable enough that they’re sometimes useful to discuss separately. These include contamination, which leads to washing your hands a lot; fear of harm, which results in checking locks on doors and windows; taboo thoughts, which are usually blasphemous, sexual or violent; and symmetry, which is when things need to be in the right order.

These types capture roughly 70% of people with OCD, but the thoughts could be about almost anything. Some people will separate out “relationship OCD” as a subtype. This can include thoughts about unfaithfulness or, “Do they really like me?” These are normal thoughts in a relationship, but if they become excessive, irrational, and problematic, that can be OCD. There could also be thoughts about sexuality, such as “Am I gay?” or someone who is gay wondering, “Am I straight?”

The short answer is we don’t know. A slightly longer answer is that there are both genetic and environmental components, and we and others are working to better understand them.

We are studying the relationship between stress and OCD. OCD hasn't traditionally been considered a stress-related disorder in the way that depression and posttraumatic stress disorder are, but there's evidence that stress, either acute or cumulative, can lead to OCD. One possibility is that some people—because of their genetics or something about their early brain development—may develop OCD when they are under stress. But it's not well understood.

In women, OCD symptoms can fluctuate with hormones, including with their menstrual cycle, or onset around childbirth. But it's not well studied, and it’s less clear if there is a similar hormone-related phenomenon in men.

What is well established is that there’s hyperactivity in a particular set of brain regions in people with OCD. And that hyperactivity gets worse when symptoms worsen, and it gets better with treatment.

There are theories that the neurotransmitter serotonin might be out of balance in OCD, based on the fact that medications that affect levels of serotonin are helpful. But there's little evidence there's anything wrong with the serotonin system in OCD. There has also been a lot of interest in imbalance of glutamate, which is an amino acid that functions as a neurotransmitter. We've been studying this for 20 years, but it's also not clear.

It's believed that there are different causes of OCD, and it’s not one single genetic, molecular, or neurobiological cause that everyone has in common, but rather a panoply of such factors.

We have good treatments that are proven to work. There's a form of cognitive behavioral therapy called ERP, which stands for exposure and response prevention, that is probably the best treatment if someone is motivated, has a good therapist, and can really do it. It's hard work.

It’s not about developing insight into your stresses, because most people with OCD have good insight into the nature of their symptoms, but that doesn't help. ERP is a set of exercises that are analogous to physical exercise, and your therapist is like your personal trainer.

In ERP, you trigger the thoughts that are bothering you, experience the anxiety, and sit with it. You don't engage in the behaviors that could lead to relief. This is difficult. But if you sit with the anxiety, it peaks, plateaus, and then goes down. This is an experience that many people with OCD have never had on their own. When something is painful or unpleasant, someone with OCD knows how to make it better. This is like putting your hand on the hot stove and leaving it there.

But this therapy makes you better at tolerating anxiety. It also reduces the anxiety, because ERP shows you that you can get anxious, but nothing bad happens. Next time, you're not quite so anxious. Most importantly, it breaks the feedback loop.

Ultimately, the goal isn't to control our thoughts because, ironically, the very act of trying to control our thoughts tends to make them come back. The goal is to make those thoughts boring, so if the thought comes, you say, “There’s that intrusive thought again. I know how to deal with that.”

SSRI medications, or selective serotonin reuptake inhibitors, can help. When treatment includes medication and therapy, it’s effective in 60% to 70% of people with OCD.

If SSRIs and therapy aren’t working, we might add another medication. This is where we might use glutamatergic medications or neuroleptic medications, also known as antipsychotics, that were developed to treat other mental health conditions but can sometimes help OCD. These medications aren’t as well proven as the SSRIs for the treatment of OCD, but we can try them.

In ideal circumstances, ERP usually works better than medication. and some people may be able to forgo medication. But in the real world, you may have other medical issues, find it hard to stay motivated, or may not have the right therapist. If that’s the case, there’s often a benefit from the combination of medication and therapy. In people whose OCD symptoms are severe, I usually suggest using both because I want to help people as quickly as possible.

If done properly, transcranial magnetic stimulation treatment (TMS) can help. Researchers at Yale and elsewhere are also looking at different psychotherapies, such as ones that focus on trauma. These would be for people who don’t respond to other core forms of psychotherapy.

There are also new potential treatments on the horizon. We're studying the psychedelic drug psilocybin to treat OCD. Early data suggests that it might be a useful tool. Here at Yale, we’re working on a paper reporting on the results of the first placebo-controlled trial of psilocybin for OCD. We find that about two-thirds of people who are treated with psilocybin, together with structured psychological support, get better, often for months. However, it’s early days yet; these are highly selected participants being treated in an intensive setting. We don’t yet know whether psilocybin will be useful at a larger scale.

Another way to improve treatment, which others are investigating, is to develop tests or assessments to see who will respond to which treatment. Currently, treatment choice can depend on the options available. For example, a psychiatrist or mental health specialist who has access to a TMS machine may offer that form of treatment, while another provider may suggest ERP. I’m hopeful we can develop evidence-based algorithms to help us decide which treatment is most likely to benefit each patient.

A huge challenge is that people with OCD often hide their symptoms. And this goes back to the curse of insight. When people think, “If I tell my doctor I'm having these intrusive thoughts that make no sense, they're going to lock me up,” they are less likely to talk to someone about it.

Likewise, I think OCD is underrepresented in training for both psychologists and psychiatrists, which means that mental health professionals may be less likely to ask patients the right questions. If no one is asking you about your symptoms, you get stuck in this cycle of withdrawal and hiding.

But this has gotten better over time. I serve on the scientific advisory board for the International OCD Foundation, and organizations such as these have done a great job of increasing public awareness about OCD. People are more likely to recognize this is not rare. It's about one in 40 adults in the U.S. A good resource for people to find help is www.iocdf.org.