Emphasizing the Need for Post-Treatment Maintenance in the Treatment of Obsessive Compulsive Disorder

By Eda Gorbis, Ph.D., M.F.C.C.

Eda Gorbis, Ph.D., M.F.C.C., is in private practice, an Assistant Clinical Professor at the UCLA School of Medicine, Consultant for the Center for Cognitive Therapy’s OCD Program in Beverly Hills, and Vice-President of OCSDA. Dr. Gorbis is also a member of the International OCD Foundation’s Scientific Advisory Board.

This article was initially published in the Fall 2009 edition of the OCD Newsletter

Obsessive Compulsive Disorder (OCD) is not as rare as previously thought.  A conservative estimate is that as many as four million Americans of every sex, age, and culture experience debilitating OCD symptoms.  This number grows exceedingly when considering world-wide prevalence rates.   Behavioral treatment of OCD has yielded impressive results even with the most intractable of cases, including those with poor insight and “pure obsessionals.”  Following the extensive empirical research of Drs. Foa and Kozak, when done properly, behavioral therapy can alleviate symptoms for up to six years.  This is especially true if treatment is followed with a structured relapse prevention program (Foa, 1994).

It is now well known that the nature of OCD is one of continual waxing and waning, with exacerbation under conditions of stress.  However, this is equally true of many chronic medical conditions.  More recently it was discovered that OCD fluctuates and exacerbates in response to hormonal conditions, imbalances, or changes (like puberty, pregnancy, menstruation, and menopause).  In this short case study I would like to bring to the reader’s attention the importance of attending and prevention relapse.  Perseverance, consistency, persistence, and commitment: these double PCs appear to be the key to long-term, complete remission (9 to 11 years) of OCD.

Eleven years ago I treated a very complicated case.  Sheila was then 28 years old and had experienced OCD since she was a teenager.  As in many OCD cases, she was affected by a number of fears, each of which was further complicated by poor insight.  Sheila’s OCD began with contamination obsessions that exacerbated when her doctor diagnosed her with venereal disease (V.D.).  This led to contamination compulsions including 3-5 hours of hand washing, repetitive body cleaning, and unwarranted returns to her doctor requesting tests for contagious conditions.  This continued for a year after full recovery from her V.D.

During our initial meeting I had asked her to fill out some questionnaires about her OCD symptoms and her scores had indicated severe levels of symptomatology and beliefs in her obsessions.  She feared that her loved ones would be stricken by disastrous conditions/circumstances, which caused her to worry incessantly.  She also had a number of major doubting behaviors and some reassurance seeking behaviors.  Doubt, the hallmark of OCD, had paralyzed her to the point that she was unable to make small decisions, leaving her life in stalemate.  Following a 5 day hospitalization, Sheila responded well to three weeks of Exposure and Response Prevention therapy (ERP).  At the termination of her therapy with me, her symptoms were in full remission.

It was not until 11 years later that I received a call from Sheila.   She was crying and reported having a “breakdown.”  She was experiencing severe OCD symptoms, poor appetite, weight loss, crying spells, and depression.  She also expressed suicidal ideation, without a plan or intention.  I immediately scheduled an appointment with her.  I knew Sheila had responded well to treatment 11 years ago and it sounded like she was eager to begin again.

During the treatment of her relapse, the content of Sheila’s fears centered on the possibility that certain foods would interact with her medication and diminish their efficacy, particularly foods containing citrus.  I administered the entire battery of tests including the MINI, a short form general diagnostic tool for Axis I and II disorders.  I wanted to do a thorough assessment in order to start Sheila on her path to relief as soon as possible.  From the onset, her obsessions did not seem to be bizarre, complicated, or especially difficult.  However, within two days I realized that, without medication, progress would not be possible.  This was because Sheila’s insight was becoming increasingly impaired.

Sheila was referred to Dr. Lee Y. Sadja who specializes in intractable cases, and someone I’ve worked with many times in the past few years.  I worked with Sheila 8 hours a day, three times a week; however, not only was she non-responsive, but her symptoms worsened.  She continued to experience crying spells, sleeplessness, lack of appetite, weight loss, and failed to habituate outside of session.  Sheila often called me from home seeking reassurance and reporting an increase in OCD behaviors.  After a month of intensive treatment Sheila was hospitalized for medication management.  Because one of her medications seemed to worsen her symptoms, her prescription was changed to another OCD medication, which seemed to decrease her symptoms.  Her food intake increased and she was able to sleep better.

As she did during her initial treatment, Sheila wrote diligently and was continually exposed to stimuli.  Exposure consisted of drinking juices (cranberry, orange, grapefruit) with sugar pills that looked very similar to her medication, beginning with the least anxiety provoking stimuli and working towards the most anxiety provoking.  During exposure, Sheila’s eyes were bloodshot and filled with horror and she was extremely tearful.  She was certain that the juice would dissolve her meds and diminish or destroy their efficacy.

While hospitalized she improved, but on release she worsened.  Continuing to doubt and give in to her now delusional beliefs, she repeatedly sought reassurance despite my discouraging her from doing so.  On the other hand, her depression was better, she had fewer crying spells, her appetite had increased, and she was sleeping better.  She also reported fewer thoughts of suicide.  However, an additional complication arose:  Sheila had developed symptoms of Body Dysmorphic Disorder (BDD).  Rather than seeing and feeling her actual size (6-8), she perceived herself as being a size 14.  A part of her BDD exposure therapy involved excursions to nearby boutiques where Sheila was required to try on clothing that was clearly oversized.

Sheila was fortunate to have strong support from her family and her boyfriend, yet was progressively unhappy.  One of her obsessions involved thoughts/fears that her family was far

happier about her sister’s engagement and upcoming marriage than they would have been about her own.  These feelings brought immense guilt and shame for Sheila, since she saw herself as being a bad sister for feeling left out and envious.

Today, Sheila has a 60% improvement rate, but we still have a long way to go and neither

Sheila nor I have plans of giving up.  I still recall that time 11 years ago when Sheila was able to accomplish 100% remission of intractable OCD.  Her case provides a clear illustration of the need for vigilant post-treatment maintenance.  Another case occurred early last July; following successful treatment, the client experienced 9.5 years of remission before calling to report a return of OCD symptoms.  Yet another case occurred three years ago when a client who had experienced 6 years of remission returned for treatment.  The relapse improvement rate for both cases was significantly (nearly 50%) lower than their rates of improvement during initial treatment.

The OCD client must not neglect him/herself.  Much like a person diagnosed with a chronic medical condition such as diabetes or high blood pressure, treatment does not suddenly end once the symptoms diminish.  Occasional check-ups, systemic life changes, and regular monitoring of and attending to one’s condition are a must.  Most importantly, the regular practice of ERP is the key to getting – and remaining – on the road to success.  The importance of maintenance and relapse prevention cannot be overstated.  The progress gained in treatment must be constantly reinforced and strengthened.  Otherwise, old fears and their maladaptive behaviors can reappear, become reinforced, and be re-strengthened. OCD cannot be set on a back burner.  To aid in avoiding relapse, the gains of treatment must be continually reinforced, examined, and exercised through use of repeated exposure.  As Drs. Foa and Kovacs put forward, treatment eliminates fear “structures” and symptoms, but it does not eradicate the blueprints for these fear behaviors.  It is these blueprints that give rise to the possibility of relapse. This is why I repeatedly remind the members of my weekly OCD group, “It is not good to feel good!”  Feeling good is a trap that tricks you into believing that you are cured, and no longer within the treacherous grasp of OCD!

Relapse treatment of OCD is not easy, but through the double PCs (perseverance, consistency, persistence, and commitment) you can avoid the excruciating pain of not succeeding, or succeeding to a much lesser degree than that of your treatment and work your way to long-term, complete remission.  In short, my theory is this:

  1. OCD  is never to be neglected
  2. OCD is never cured – it is only in remission
  3. Short-term success is not enough
  4. Long-term, habitual life changes are required
  5. Ongoing exposure to feared stimuli is a must
  6. You can either have growth or excuses, but not both

Fortunately, we know a lot about OCD; unfortunately, we know far less about its causes.   Yet one thing is very clear: those who accept the fact that OCD is an enduring part of their lives, rather than seeking impulsive, short-term, “feel good” behaviors or remedies, will experience the greatest success in eliminating symptoms long-term. People who suffer from OCD will have no choice but to be constantly vigilant and mindful of their ever changing, ever pervasive, and ever intrusive symptoms. Again, no cure for OCD exists, but through prolonged and repeated exposures to those events, places, people, and objects that provoke anxiety, one may gain long-term control over his or her condition.