Why Some Don't Recover from OCD
OCDChicago.org
Getting appropriate treatment for OCD and committing to a treatment plan are key to realizing relief from OCD. Even when treatment gains are made, it can be difficult to sustain improvement. When this occurs, it means a person who might have looked forward to a better life is stuck in a life of uncertainty and distress with OCD.
This can happen because of physician under-diagnosis, under-treatment or treatment resistance on the part of the person who has OCD.
Under-Diagnosis and Under-Treatment
Even though OCD is a relatively common illness and effective treatment is available, OCD is often under-diagnosed and under-treated. There are a number of reasons why:
Hiding symptoms:
Some people hide their symptoms and do not seek help. Many do not know that OCD is a treatable disorder. Some are reluctant to admit that they need help. Some are so ashamed of their obsessions and compulsions they never seek treatment.
Avoidance:
Avoidance is not always recognized as a symptom of OCD. Some people with OCD avoid places, events, objects and even people because of uncontrollable, irrational fears. For example, a person with contamination obsessions may avoid public restrooms or refuse to borrow a pen from someone else. In these cases, avoidance is a compulsive behavior. Continued avoidance strengthens obsessions and worsens the disorder.
Another kind of avoidance is recovery avoidance. If someone who has OCD avoids getting treatment, or doesn’t fully commit to treatment sessions and the accompanying homework, they derail the treatment process.
Discomfort:
OCD can involve unwanted disturbing thoughts, including violence, sexuality, blasphemy and contamination. Some people with OCD are uncomfortable discussing disturbing thoughts, even with a treatment provider.
Fear of Change:
Change can be difficult, particularly if the obsessions and compulsions have existed for many years. Some people with OCD are afraid to begin treatment or believe they don’t have the courage or stamina to confront their fears. But living with untreated OCD is vastly more painful than any discomfort associated with treatment.
Physician Diagnosis:
Not all physicians know how to diagnose and treat OCD. At routine check-ups, some doctors do not ask questions about a patient’s mental health. Some doctors—even psychiatrists—have not been trained to recognize symptoms of OCD. Others may prescribe only medications because they aren’t aware that Cognitive Behavior Therapy (CBT) is the treatment of choice.
Treatment Provider Education:
Some psychologists and psychiatrists still rely on unproven, ineffective theories about treating OCD. Psychoanalytic therapy and therapy that focuses on family dynamics, early childhood trauma or issues of self-esteem are not effective treatments for OCD. While other forms of therapy such as marriage and family counseling can help with some of the difficulties that can accompany OCD, only CBT can reduce symptoms of the disorder.
Misdiagnosis:
Common but less familiar symptoms may not be understood as forms of OCD. The disorder can take many forms and is not limited to familiar or obvious symptoms such as compulsive washing or checking door locks. Examples of compulsive behavior that can go unrecognized as OCD in adults or children include:
Treatment Resistance
Most people who undergo a course of Cognitive Behavior Therapy for OCD will experience a significant reduction in symptoms. However, some people don’t do well in treatment. Here are some possible obstacles to success:
Comorbid Disorders:
When OCD is accompanied by another anxiety disorder, those disorders are considered to be “comorbid”. A mood disorder such as major depression or bipolar disorder, alcoholism or substance abuse, or another anxiety disorder can interfere with success in therapy and may require separate treatment.
Poor Communication with Therapist:
Open and honest communication about the exact nature and frequency of obsessions and compulsions is a must so that the therapist can design effective exposure exercises. When people fear revealing all of their obsessions (either because they feel ashamed of their thoughts or because they believe that therapy could not help particular obsessions or compulsions that seem the most difficult) they can unknowingly prevent a therapist from helping them. Keeping certain aspects of OCD secret will impair the therapist’s ability to help them overcome their OCD.
Insufficient Exposures:
Exercises must be sufficiently challenging, and “homework” of daily exposures must be completed between therapy sessions.
Infrequent Sessions:
Therapy sessions are generally scheduled weekly, but in some cases may need to be more frequent—even daily. In the most severe cases of OCD, therapy, it’s possible that a person may need to be treated in a residential facility.
Improper Session Location:
Therapy sessions may be more effective if they are held in locations that trigger obsessions and compulsions—for example, in a person’s home, car or outdoors. Some therapists will conduct sessions out of the office, or by telephone.
Family Interference:
Family members who participate in an individual’s compulsive rituals, provide reassurance or enable avoidance behavior can actually sabotage success in therapy. Sometimes a family member can be trained to act as a “coach” to keep track of exposures and discourage behavior by others that enable the rituals.
Wrong Choice of Therapist:
Someone who does not succeed with one therapist may enjoy excellent results with another. The personality fit may not be right, or that therapist may not design challenging, appropriate exposures. The therapist may also be inexperienced. You can recommend that they try a different therapist or at least consult a different therapist for a second opinion.
Inappropriate Therapy:
Cognitive Behavior Therapy, sometimes accompanied by medication, is the only behavioral treatment for OCD that is supported by scientific evidence. Research does not support the use of treatments such as hypnosis, herbal or homeopathic remedies, psychoanalysis, relaxation therapy, nutrition supplements, eye movement desensitization reprocessing (EMDR) or dietary changes.
Lack of Support:
Talking to others who have learned to master their symptoms can encourage a person with OCD to undertake the challenge of therapy and boost the likelihood of success. Joining a local support group, participating in an online support group or contacting OCD Chicago or the International OCD Foundation are good ways to find people with similar experiences. Note: support groups should not be considered a substitute for CBT therapy.
OCDChicago.org
Getting appropriate treatment for OCD and committing to a treatment plan are key to realizing relief from OCD. Even when treatment gains are made, it can be difficult to sustain improvement. When this occurs, it means a person who might have looked forward to a better life is stuck in a life of uncertainty and distress with OCD.
This can happen because of physician under-diagnosis, under-treatment or treatment resistance on the part of the person who has OCD.
Under-Diagnosis and Under-Treatment
Even though OCD is a relatively common illness and effective treatment is available, OCD is often under-diagnosed and under-treated. There are a number of reasons why:
Hiding symptoms:
Some people hide their symptoms and do not seek help. Many do not know that OCD is a treatable disorder. Some are reluctant to admit that they need help. Some are so ashamed of their obsessions and compulsions they never seek treatment.
Avoidance:
Avoidance is not always recognized as a symptom of OCD. Some people with OCD avoid places, events, objects and even people because of uncontrollable, irrational fears. For example, a person with contamination obsessions may avoid public restrooms or refuse to borrow a pen from someone else. In these cases, avoidance is a compulsive behavior. Continued avoidance strengthens obsessions and worsens the disorder.
Another kind of avoidance is recovery avoidance. If someone who has OCD avoids getting treatment, or doesn’t fully commit to treatment sessions and the accompanying homework, they derail the treatment process.
Discomfort:
OCD can involve unwanted disturbing thoughts, including violence, sexuality, blasphemy and contamination. Some people with OCD are uncomfortable discussing disturbing thoughts, even with a treatment provider.
Fear of Change:
Change can be difficult, particularly if the obsessions and compulsions have existed for many years. Some people with OCD are afraid to begin treatment or believe they don’t have the courage or stamina to confront their fears. But living with untreated OCD is vastly more painful than any discomfort associated with treatment.
Physician Diagnosis:
Not all physicians know how to diagnose and treat OCD. At routine check-ups, some doctors do not ask questions about a patient’s mental health. Some doctors—even psychiatrists—have not been trained to recognize symptoms of OCD. Others may prescribe only medications because they aren’t aware that Cognitive Behavior Therapy (CBT) is the treatment of choice.
Treatment Provider Education:
Some psychologists and psychiatrists still rely on unproven, ineffective theories about treating OCD. Psychoanalytic therapy and therapy that focuses on family dynamics, early childhood trauma or issues of self-esteem are not effective treatments for OCD. While other forms of therapy such as marriage and family counseling can help with some of the difficulties that can accompany OCD, only CBT can reduce symptoms of the disorder.
Misdiagnosis:
Common but less familiar symptoms may not be understood as forms of OCD. The disorder can take many forms and is not limited to familiar or obvious symptoms such as compulsive washing or checking door locks. Examples of compulsive behavior that can go unrecognized as OCD in adults or children include:
- Chronic procrastination
- Difficulty making decisions or inability to make decisions
- Asking repetitive questions
- Constant reassurance-seeking
- Avoidance of people, places, objects or events
Treatment Resistance
Most people who undergo a course of Cognitive Behavior Therapy for OCD will experience a significant reduction in symptoms. However, some people don’t do well in treatment. Here are some possible obstacles to success:
Comorbid Disorders:
When OCD is accompanied by another anxiety disorder, those disorders are considered to be “comorbid”. A mood disorder such as major depression or bipolar disorder, alcoholism or substance abuse, or another anxiety disorder can interfere with success in therapy and may require separate treatment.
Poor Communication with Therapist:
Open and honest communication about the exact nature and frequency of obsessions and compulsions is a must so that the therapist can design effective exposure exercises. When people fear revealing all of their obsessions (either because they feel ashamed of their thoughts or because they believe that therapy could not help particular obsessions or compulsions that seem the most difficult) they can unknowingly prevent a therapist from helping them. Keeping certain aspects of OCD secret will impair the therapist’s ability to help them overcome their OCD.
Insufficient Exposures:
Exercises must be sufficiently challenging, and “homework” of daily exposures must be completed between therapy sessions.
Infrequent Sessions:
Therapy sessions are generally scheduled weekly, but in some cases may need to be more frequent—even daily. In the most severe cases of OCD, therapy, it’s possible that a person may need to be treated in a residential facility.
Improper Session Location:
Therapy sessions may be more effective if they are held in locations that trigger obsessions and compulsions—for example, in a person’s home, car or outdoors. Some therapists will conduct sessions out of the office, or by telephone.
Family Interference:
Family members who participate in an individual’s compulsive rituals, provide reassurance or enable avoidance behavior can actually sabotage success in therapy. Sometimes a family member can be trained to act as a “coach” to keep track of exposures and discourage behavior by others that enable the rituals.
Wrong Choice of Therapist:
Someone who does not succeed with one therapist may enjoy excellent results with another. The personality fit may not be right, or that therapist may not design challenging, appropriate exposures. The therapist may also be inexperienced. You can recommend that they try a different therapist or at least consult a different therapist for a second opinion.
Inappropriate Therapy:
Cognitive Behavior Therapy, sometimes accompanied by medication, is the only behavioral treatment for OCD that is supported by scientific evidence. Research does not support the use of treatments such as hypnosis, herbal or homeopathic remedies, psychoanalysis, relaxation therapy, nutrition supplements, eye movement desensitization reprocessing (EMDR) or dietary changes.
Lack of Support:
Talking to others who have learned to master their symptoms can encourage a person with OCD to undertake the challenge of therapy and boost the likelihood of success. Joining a local support group, participating in an online support group or contacting OCD Chicago or the International OCD Foundation are good ways to find people with similar experiences. Note: support groups should not be considered a substitute for CBT therapy.
