Exposure Therapy Helps Patients With OCD Who Don’t Benefit From Medication

When patients with obsessive-compulsive disorder (OCD) come to our clinic, they are almost always already on medication. Often, they have tried numerous doses and combinations of medications and have been taking medication for many years. Patients sometimes tell us that the medication they are taking has reduced their OCD symptoms, but rarely do we hear that it has made a really significant impact. Of course, many patients are helped a lot by OCD medication and don’t need additional treatment. We don’t see this group of patients at our clinic, so our sample is biased. But research backs up our clinical impression that OCD medications often fall short. Most patients who take serotonin reuptake inhibitors (SRIs), which are the most common medications prescribed for OCD, continue to have clinically significant symptoms that negatively affect their health, functioning, and quality of life. For these patients, adding an antipsychotic medication such as risperidone is the usual next step, but this strategy helps only a minority of patients, if any. So, how should we treat these patients? What can we do to help those who have already tried the first-line medication treatments for OCD and continue to have clinically significant symptoms?

This is the question that my colleagues aimed to answer in our recent study. Patients were 32 adults with OCD who were on a therapeutic dose of an SRI and completed an 8-week trial of augmentation with either risperidone or placebo. Basically, these were folks who had failed to achieve much benefit from either an SRI alone or an SRI with antipsychotic augmentation. In an open trial, we offered them a type of cognitive-behavioral therapy called exposure and response prevention, or EX/RP. EX/RP involves helping patients approach feared images and situations (ie, exposure) while simultaneously eliminating compulsive behaviors (ie, response prevention).

The results showed that EX/RP was effective in reducing OCD symptoms in these patients. After an average of 14 EX/RP sessions, 56% of patients were classified as treatment responders (≥ 25% reduction in symptoms), and 16% were classified as excellent responders, which means they had minimal symptoms. Excellent response is important because it is associated with long-term symptom remission, good quality of life, and a high-level of functioning. It means these patients are doing really well. While the effects of EX/RP in this study were good, they weren’t as strong as what we typically see for EX/RP as a stand-alone treatment. I think this is probably because the patients in our study were more treatment-resistant than patients in most other studies.

A large body of research supports the use of EX/RP for treating OCD. We already knew that this treatment works well. What makes the current findings important is that they tell us that EX/RP can help even when traditional medication treatments fail. Patients with OCD who have already tried standard medication treatments for OCD yet continue to suffer from symptoms (and this is not a small group) should take heart: we now have good reason to believe that our best psychotherapy, EX/RP, can help.

Financial disclosure:Dr McLean had no relevant personal financial relationships to report. ​