How does cognitive behavioral therapy work?

There are different types of psychological treatment. OCD is usually treated with cognitive behavioral therapy (CBT), which is commonly offered by behavioral therapists. It combines two therapeutic approaches: cognitive therapy and behavioral therapy.

Cognitive therapy is about learning to recognize and understand your own thought patterns. The aim is to identify the thoughts that are at the root of the compulsive behavior, and then change them. This may involve asking questions like: What can be gained from checking ten times whether the door is locked? Will my rituals really make me safer?

Behavioral therapy deals specifically with the compulsive behavior itself. One particular type of behavioral therapy that is commonly used for people with OCD is called “exposure and response prevention.” In this treatment, people are gradually confronted with the things that trigger their compulsive behavior (exposure). If, for instance, someone has a compulsion to constantly wash their hands, the therapist could ask the person to touch something perceived as dirty. After that, the client would try not to immediately wash their hands (response prevention). Over time, the confrontation teaches them that their feeling of fear and restlessness goes away even if they don't perform their compulsive behavior. Having a therapist for support is very important, especially when starting treatment or when the exercises get harder.

Cognitive behavioral therapy is offered as group or individual therapy. It usually involves a series of weekly sessions, each lasting about one hour. Some people already feel much better after ten sessions, while others may need several months before they notice a clear improvement. In order for the therapy to be successful, it is important that you feel comfortable with your therapist. It might take some time to find the right therapist.

Having family members involved in therapy can also help. For example, relatives can help people with OCD deal with their compulsions at home. This is especially important after the therapy, to help make the positive effects last.

What can I expect from cognitive behavioral therapy?

Cognitive behavioral therapy has been tested in a number of studies with children, teenagers and adults who have OCD. The studies show that this therapy is very effective. It can help people keep their symptoms under control, relieve their anxiety, and cope better in everyday life again.

This kind of therapy demands a great deal of commitment and patience: It can take a while to get the compulsions under control, and it takes a lot of courage to face your urges and fears. The therapy can be very demanding, especially at first. But many people say it was worth it because they were able to deal with their OCD much better afterwards.

Which medications can help?

Medications that are used to treat depression (antidepressants) can also be used for OCD. “Selective serotonin re-uptake inhibitors” (SSRIs) and the drug clomipramine are the most commonly used medications for OCD. These medications increase the concentration of serotonin, a neurotransmitter, in the brain.

A combined analysis of the studies on these drugs shows that they can relieve OCD symptoms in many people:

• Without SSRIs, the symptoms improved in 23 out of 100 people.
• With SSRIs, the symptoms improved in 43 out of 100 people.

In other words: medication improved the symptoms in 20 out of 100 people.

Many of the these studies lasted less than three months, so the long-term effects of SSRIs on OCD needs to be studied further. But the studies that lasted more than twelve months indicate that SSRIs do help over the long term as well.

They can have a variety of side effects, though. These include nausea, nervousness, and trouble sleeping. Sexual desire may be affected too. About 6 out of 100 participants stopped the treatment because of side effects.

The side effects mainly occur during the first few weeks of use. If a particular SSRI is poorly tolerated, a different one can be tried out. When stopping treatment with an SSRI, the dosage is gradually reduced over several weeks to prevent side effects like trouble sleeping and restlessness.

Several drug regulatory agencies, including the German Federal Institute for Drugs and Medical Devices (BfArM), have issued a safety warning for SSRIs in children, teenagers and young adults. They point out that these drugs have been associated with suicidal thoughts and self-harm in some people. So signs of unusual thoughts and behavior should be carefully monitored, especially when starting treatment, changing the dose or switching from one drug to another.

Which is more effective: Cognitive behavioral therapy or medication?

Several studies have looked into how cognitive behavioral therapy compares to medication in the treatment of OCD. They suggest that cognitive behavioral therapy is slightly more helpful than antidepressants are. For this reason, cognitive behavioral therapy is the preferred treatment for obsessive compulsive disorder.

But there may be good reasons for using medication, like having to wait a while before starting therapy. Cognitive behavioral therapy may also demand a great deal of commitment and strength. Some people's urges are so strong that they would hardly be able to make it through the therapy without medication. The medication can help relieve the symptoms enough to make it possible to do the therapy. Some people might prefer medication to psychological treatment for personal reasons.

These two treatment approaches can also be combined. This may be particularly suitable for people with OCD who also have depression.

Sources

• Bundesinstitut für Arzneimittel und Medizinprodukte (BfArM). Antidepressiva: Wissenschaftliche Neubewertung der SSRI / SNRI abgeschlossen - Neue Warnhinweise auf suizidales Verhalten bei Kindern und Jugendlichen. July 12, 2005.
• Deutsche Gesellschaft für Psychiatrie und Psychotherapie, Psychosomatik und Nervenheilkunde (DGPPN). S3-Leitlinie Zwangsstörungen. AWMF-Registernr.: 038-017. May 14, 2013.
• Gava I, Barbui C, Aguglia E, Carlino D, Churchill R, De Vanna M et al. Psychological treatments versus treatment as usual for obsessive compulsive disorder (OCD). Cochrane Database Syst Rev 2007; (2): CD005333. [PubMed: 17443583]
• Ivarsson T, Skarphedinsson G, Kornor H, Axelsdottir B, Biedilae S, Heyman I et al. The place of and evidence for serotonin reuptake inhibitors (SRIs) for obsessive compulsive disorder (OCD) in children and adolescents: Views based on a systematic review and meta-analysis. Psychiatry Res 2015; 227(1): 93-103. [PubMed: 25769521]
• Lee YH, Rees CS. Is exposure and response prevention treatment for obsessive-compulsive disorder as aversive as we think? Clin Psychol 2011; 15(1): 17-21.
• National Institute for Health and Clinical Excellence (NICE). Obsessive-compulsive disorder: core interventions in the treatment of obsessive-compulsive disorder and body dysmorphic disorder. NICE Clinical Guidelines; Volume 31. Rushden: The British Psychological Society and The Royal College of Psychiatrists; 2006.
• O'Kearney RT, Anstey K, von Sanden C, Hunt A. Behavioural and cognitive behavioural therapy for obsessive compulsive disorder in children and adolescents. Cochrane Database Syst Rev 2006; (4): CD004856. [PMC free article: PMC8855344] [PubMed: 17054218]
• Romanelli RJ, Wu FM, Gamba R, Mojtabai R, Segal JB. Behavioral Therapy and Serotonin Reuptake Inhibitor Pharmacotherapy in the Treatment of Obsessive-Compulsive Disorder: A Systematic Review and Meta-Analysis of Head-to-Head Randomized Controlled Trials. Depress Anxiety 2014; 31(8): 641-652. [PubMed: 24390912]
• Skapinakis P, Caldwell D, Hollingworth W, Bryden P, Fineberg N, Salkovskis P et al. A systematic review of the clinical effectiveness and cost-effectiveness of pharmacological and psychological interventions for the management of obsessive-compulsive disorder in children/adolescents and adults. Health Technol Assess 2016; 20(43): 1-392. [PMC free article: PMC4921795] [PubMed: 27306503]
• Skarphedinsson G, Hanssen-Bauer K, Kornor H, Heiervang ER, Landro NI, Axelsdottir B et al. Standard individual cognitive behaviour therapy for paediatric obsessive-compulsive disorder: a systematic review of effect estimates across comparisons. Nord J Psychiatry 2015; 69(2): 81-92. [PubMed: 25142430]
• Soomro GM, Altman D, Rajagopal S, Oakley-Browne M. Selective serotonin re-uptake inhibitors (SSRIs) versus placebo for obsessive compulsive disorder (OCD). Cochrane Database Syst Rev 2008; (1): CD001765. [PMC free article: PMC7025764] [PubMed: 18253995]

• IQWiG health information is written with the aim of helping people understand the advantages and disadvantages of the main treatment options and health care services.

  Because IQWiG is a German institute, some of the information provided here is specific to the German health care system. The suitability of any of the described options in an individual case can be determined by talking to a doctor. We do not offer individual consultations.

  Our information is based on the results of good-quality studies. It is written by a team of health care professionals, scientists and editors, and reviewed by external experts. You can find a detailed description of how our health information is produced and updated in our methods.