How Is Severe OCD Treated?
Medically reviewed by Michael MacIntyre, MD
Severe obsessive-compulsive disorder (OCD) is a debilitating mental health condition. It causes a person to have persistent, recurring, intrusive, and often upsetting thoughts (obsessions), along with repetitive behaviors or mental acts (compulsions). These acts are performed in an attempt to reduce anxiety caused by the obsessions.
OCD has a lifetime prevalence of approximately 2.3% among adults in the United States. Up to half of adults with OCD experience serious impairment, known as severe OCD.
Read on to learn how OCD can cause intrusive symptoms that interfere with daily functioning and how these symptoms can be managed.
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Symptoms of Severe OCD
Severe OCD is indicated based on the level of impairment the OCD symptoms cause. Symptoms may be considered severe if they are causing significant disruption and distress.
Persons with OCD have symptoms relating to obsessions, compulsions, or both.
Obsessions are repeated thoughts, urges, or mental images that trigger anxiety. Common obsessions include:
Fear of germs
Fear of misplacing or losing something
Worries about harming oneself or others
Unwanted forbidden thoughts involving sex or religion
Needing to have everything in a certain order
Compulsions are behaviors that one needs to do over and over to reduce anxiety or stop the obsessive thoughts. Common types of compulsive behavior include:
Excessive handwashing or cleaning
Repeated checking (such as checking that the door is locked or that the oven is off)
Counting things over and over
Ordering and arranging things in a certain way
Causes and Risk Factors of Severe OCD
OCD affects men and women equally. It can develop anytime from preschool to late in life, but begins most often during two peaks: between the ages of 9 to 11 and between the ages of 20 to 23. Up to 50% of cases have juvenile-onset, while less than 10% start after age 40.
Age of onset may play a role in severity. Early or middle childhood-onset has been associated with a better outcome and higher rate of spontaneous remission. Onset in adolescence or later in life may result in more persistent symptoms and course of the condition.
The exact cause of OCD isn't known, but a number of factors that may play a role have been identified.
Genetics
While no specific genes for OCD have been identified, it appears to run in families, suggesting it has a genetic component.
Some research shows that if a parent has OCD, their child has a slightly increased risk of developing some forms of OCD (such as childhood-onset OCD).
Brain Activity
Brain studies have noted differences in the brains of people with and without OCD.
People with OCD show an overactive neural circuit between the prefrontal cortex (involved in cognitive behavior, executive decision making, and personality), and the nucleus accumbens (part of the reward system).
Imaging techniques, such as positron emission tomography (PET) and magnetic resonance imaging (MRI), are being used to study the brains of people with OCD to better understand how brain differences affect OCD.
Serotonin is neurotransmitter (chemical messenger in the brain) that has been associated with the development and maintenance of OCD. Medications that target serotonin levels can help reduce OCD symptoms.
Psychological Factors
OCD may be influenced by:
How a person interprets events and pays attention to information
Their beliefs about obsessions
Certain personality traits (such as perfectionism)
Life Experiences
Stress, such as marital problems, school exams, or a new baby, can increase symptoms for people with OCD.
Other conditions like depression or other emotional problems can also cause a worsening of symptoms.
Associated Conditions
Comorbidities (co-occurring conditions) are common in people with OCD. Studies show rates as high as 90% of people with OCD meeting the criteria for at least one other mental health condition in their lifetime.
Conditions seen alongside OCD include:
Mood disorders (especially major depressive disorder)
Impulse control disorders
Many people with OCD also experience suicidal thoughts and actions.
Help Is Available
If you are having suicidal thoughts, contact the National Suicide Prevention Lifeline at 988 for support and assistance from a trained counselor. If you or a loved one are in immediate danger, call 911.
If you or a loved one is struggling with OCD, contact the Substance Abuse and Mental Health Services Administration (SAMHSA) National Helpline at 1-800-662-4357 for information on support and treatment facilities in your area. For more mental health resources, see our National Helpline Database.
Complications of OCD
OCD symptoms can be severe enough to greatly impact a person's ability to function in daily life, such as attending school, being employed, sustaining relationships, and performing tasks such as running errands or self-care. In fact, worldwide, OCD is counted among the top 10 causes of disability.
About 20% of people with OCD have severely debilitating symptoms that can result in isolation (including staying in their homes), reduced quality of life, and economic hardship.
About 10% of people with OCD have severe symptoms that are resistant to all therapies, leading to great functional impairment.
Related: How OCD Is Diagnosed
Treatment for Severe OCD
There is no cure for OCD, but symptoms can wax and wane in severity over time, and many people go into remission from OCD. Evidence-based therapies can help manage symptoms and may promote OCD remission.
Some research has found that prolonged treatment has lower relapse rates than short-term treatment, even after treatment is discontinued. This suggests that early intensive and long-term treatment may result in better outcomes for people with OCD.
There are several types of treatments available for OCD, which most commonly include medication and/or psychotherapy (talk therapy).
Medication
Medications that may be prescribed to treat OCD include:
Selective Serotonin Reuptake Inhibitors (SSRIs)
Prozac (fluoxetine)
Paxil (paroxetine)
Celexa (citalopram)
Luvox (fluvoxamine)
Zoloft (sertraline)
Lexapro (Escitalopram)
Serotonin-Norepinephrine Reuptake Inhibitors (SNRIs)
Pristiq (desvenlafaxine)
Effexor (venlafaxine)
Cymbalta (duloxetine)
Tricyclic Antidepressants
Anafranil (Clomipramine)
These medications all target serotonin, and some also target the neurotransmitter norepinephrine. In some cases, such as if a person does not respond to serotonin-targeting medications, a combination of medications may be tried. For example, an SSRI antidepressant may be combined with a medication such as risperidone (also used to treat psychotic symptoms such as hallucinations and delusions).
Psychotherapy
Cognitive behavioral therapy (CBT) is the most common psychotherapy used to treat OCD. It helps with:
Controlling compulsive rituals/avoidance
Reducing the anxiety surrounding obsessions, ultimately reducing their intensity and frequency
CBT for OCD has two major components.
Behavior therapy and exposure and ritual prevention (ERP) involves:
Gradually increasing exposure to and confrontation of anxiety-inducing triggers, such as obsessions, while resisting the urge to use compulsive behaviors in response
Regularly repeating (up to two-hour-long sessions, at least four to five times a week) until the situation or experience no longer triggers distress
Cognitive therapy involves:
Helping a person with OCD learn to recognize their anxious beliefs about the meaning of their obsessions and substitute them with more realistic ones
Learning to recognize that their obsession doesn't hurt anyone and does not have the power to, despite their anxious thoughts about it
Anxiety Management
A mindfulness-based program known as acceptance and commitment therapy (ACT) is emerging as a newer treatment for OCD. It's less researched than CBT, but it is showing promise as a treatment used alongside CBT or for people who have not responded well to ERP.
Characteristics of ACT include:
Less focused on reducing intrusive thoughts (obsessions) and more focused on changing the way they are experienced
Distinguishes between thoughts, feelings, and actions
Believes thoughts, feelings, and bodily sensations are not under a person's control, but how the person responds to them is
Aims to help a person with OCD experience anxious thoughts as neutral, letting them come and go without the need to respond, making them less intrusive
When to Seek Medical Attention
If you are experiencing symptoms that are disrupting your life, see a healthcare provider or mental health professional, particularly if they:
Impair functioning
Cause distress
Take up an hour or more each day
Interfere with your daily life
If symptoms are severe, a psychiatric consultation is recommended.
Residential Treatment
Increased intensity care is considered a last resort and may be needed for people with OCD who:
Have very severe symptoms
Have not responded effectively to less intensive treatments, such as medication and/or therapy
Are unable to have their needs met through typical treatment routes
Levels of therapy, from least to most intensive, include:
Traditional outpatient: Individual sessions with a therapist (generally 45 to 50-minute sessions, one or two times a week)
Intensive outpatient: May involve group sessions and one individual session per day, several days a week
Day program: Treatment sessions (typically group and individual therapy) are attended during the day (typically all day) at a mental health treatment center, up to five days a week
Partial hospitalization: Same as the day program, but treatment is received at a mental health hospital
Residential: Treatment is received while voluntarily living in an unlocked mental health treatment center or hospital
Inpatient: The highest level of care for a mental health condition, inpatient is used if a person poses harm to themselves or others or is unable to care for themselves. The person receives treatment in a locked unit in a mental health hospital (may be voluntary or involuntary).
Emerging Therapies
Research is being conducted on other ways to treat OCD, including some treatments that are beginning to be implemented. These treatments include:
Surgery: Involves a procedure known as deep brain stimulation (DBS), in which electrical leads are placed into specific areas of the brain and then connected to a neurostimulator (like a "pacemaker for the brain"). Surgery can also be used to create a lesion in the brain that interrupts the overactive circuit. Surgery is not a cure and is considered a last resort when other treatments have not been successful.
Electroconvulsive therapy (ECT): In ECT, controlled electrical currents are passed through the brain, inducing a controlled seizure. The person is under general anesthesia for the procedure (about five to 10 minutes). It may be suggested when first-line therapies have not been effective.
Summary
OCD is a mental health condition characterized by intrusive, recurrent thoughts (obsessions) and patterns of behaviors (compulsions) used to try to relieve anxiety caused by the obsessions. It is typically treated with medications, such as antidepressants, and psychotherapy, such as CBT.
Some people with OCD experience severe symptoms that cause debilitating disruptions to their level of functioning. More intensive treatments, such as programs within a mental health facility, may be needed for people with severe symptoms or who are unresponsive to conventional treatments. Emerging therapies that may be used as a "last resort" treatment for OCD include surgery and electroconvulsive therapy.
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