Treating a condition’s underlying cause through direct means may have waned in prevalence in recent years, given the surge of medicated cases of attention deficit hyperactivity disorder (ADHD) and attention deficit disorder (ADD). New evidence suggests treating obsessive compulsive disorder (OCD) with exposure therapy, in tandem with advancing medications, is a more effective combination than antidepressants and antipsychotics alone.

The Band-Aid Problem

When a person with OCD takes medications to quiet his or her symptoms, the brain’s propensity to ritualize certain behaviors doesn’t diminish. The compulsion still exists, much in the same way a scrape still exists even when it is covered with a bandage — only with OCD, the brain cannot heal itself like the skin simply with a protective veneer. The condition will resurface later and in potentially greater severity.

"Therapy specifically targets the underlying problem whereas the antipsychotic doesn't really target the problem — it just puts a Band-Aid over the symptoms," Dr. Kerry Ressler, from the Department of Psychiatry at Emory University in Atlanta, wrote in an editorial of a recent study published in JAMA.

The study, conducted by researchers from the University of Pennsylvania, sought to examine the efficacy of exposure therapy on patients with moderate to severe OCD and who were taking serotonin reuptake inhibitors (SRIs) to treat the disorder. SRIs are the only drug approved by the FDA for the treatment of OCD, and they work by keeping greater concentrations of the chemical serotonin in the brain, thereby increasing connections between brain cells.

One-hundred participants were assigned to one of three groups: eight weeks of exposure therapy, treatment with the antipsychotic drug risperidone, and a placebo. At the study’s start, researchers found that participants all fell around 26 or 27 on a scale of severity that ranged from 0 to 40, 40 being the worst possible symptoms. Typically, scores between 24 and 31 are considered severe.

Exposure therapy has been gaining legitimacy in recent decades as more and more people see long-lasting success from confronting the ritualistic behaviors unique to OCD, such as touching certain items a specific number of times or performing the same routine to a meticulous, unhealthy degree. While the method may induce more suffering in the patient, much in the same way direct exposure to phobias may create sensations of panic and anxiety, researchers suggest that the method forestalls significant chunks of time spent coping with the condition in the future.

As roughly one percent of the U.S. population, or over three million people, experiences OCD symptoms in their lifetime, the team advises healthcare professionals to begin with treatment that carries the greatest effectiveness. From their study, exposure therapy is the superior choice over antidepressants.

"This data strongly suggests that OCD patients on (antidepressants) with clinically meaningful symptoms should be first offered exposure and ritual prevention therapy to get better still," Dr. Helen Blair Simpson, the study's lead author from Columbia Psychiatry in New York, told Reuters Health.

The Results And Implications

After the eight-week period, participants in the placebo and antidepressant group saw modest decline in severity, falling from 26 or 27 on the scale to around 23. Meanwhile, exposure therapy subjects saw their symptoms subside dramatically, falling to an average of 13 out of 40. A case of OCD between 8 and 15 is considered mild.

The upshot to the study isn’t that antipsychotic and antidepressant drugs are of no use in treating OCD; many cases involve tics and other involuntary movements, and for these sufferers, the introduction of relief medication could greatly enhance their physiological response, more so than exposure therapy. In such instances, the condition is likely more chemical than psychological.

In any case, Ressler says that the combination of exposure therapy and medication should be seen as a viable alternative to treating a disorder that has long seen only one means of escape.

"Cognitive behavioral therapy or exposure and ritual prevention is skill-based treatment,” she said, adding that “what it's really about is a therapist teaching you a different way to handle your compulsions.”

Source: Simpson H, Foa E, Liebowitz M. Cognitive-Behavioral Therapy vs Risperidone for Augmenting Serotonin Reuptake Inhibitors in Obsessive-Compulsive Disorder. JAMA. 2013.