Obsessive Compulsive Disorder (OCD) is a prevailing mental illness that prevents an individual from achieving an optimal, quality of life. An individual diagnosed with OCD experiences uncontrollable obsessions or irrational intrusive thoughts, which is associated with high levels of anxiety. In order to get rid of their distress, this requires an OCD sufferer to perform ritualistic behaviors that will alleviate their distress. Although an OCD sufferer is able to eliminate their distress, it is only a matter of time until their distress arises again. The inability for the OCD-diagnosed individual to overcome this type of mental illness is due to fear extinction being compromised. Fear extinction is defined as the decrease in conditioned fear response due to repeated exposure of the stimulus that is not reinforced (Milad and Quirk, 2012). This is linked to impaired neural circuity and abnormal levels of activity within certain areas (ventromedial prefrontal cortex, amygdala, anterior cingulate cortex, hippocampus, and other areas associated with fear extinction) found within individual’s brain (Falkenstein et al., 2013). Falkenstein et al. (2013) defines OCD as a disorder as a behavioral inhibition and prevents the individual from being able to self-regulate their thoughts, feelings, and actions. By being diagnosed with OCD, the Institute for Quality and Efficiency in Health Care (2014) asserts that having the mental illness interrupts the individual’s daily life, jeopardizes their relationship with themselves, their relationships with others, and all other affiliations they are involved with. As of right now, there is no treatment that can eradicate individuals suffering from OCD. However, there are treatments that are able to effectively reduce the severity of OCD symptoms (Institute for Quality and Efficiency in Health Care, 2014).
The most effective first-line treatment for lessening the severity of OCD symptoms are pharmacotherapy with Selective Serotonin Reuptake Inhibitors (SSRIs) and psychotherapy, specifically Cognitive Behavioral Therapy (CBT). SSRI pharmacotherapy has shown profound results in patients suffering from OCD. OCD patients are recommended to consistently take SSRIs for up to 12 weeks to determine its effectiveness, and to keep on taking them up until 12 months for desirable results. (Brakoulias, 2015). CBT is the most utilized psychotherapeutic approach towards patients suffering from OCD because it is an extinction-based therapy. This makes CBT the ideal choice for treating OCD because OCD-diagnosed individuals have deficient fear extinction (Falkenstein et al., 2013). OCD sufferers have structural and functional abnormalities within areas associated with fear extinction. This gives rise to OCD sufferers’ inability to go back and forth between safety learning and fear learning because their associative learning is compromised (Falkenstein et al., 2013.) Due to this inflexibility, OCD sufferers will avoid situations that may provoke their fears or distress instead of facing them in order to overcome them. (Milad, M.R. & Rauch, 2012). CBT is centralized on the idea that an individual’s internal thoughts drive their feelings and behavior. This enables highly-trained therapists to work with their clients by helping them overcome their fears or the things that distresses them (Institute for Quality and Efficiency in Health Care, 2014). The Exposure and Response Prevention (ERP) method is the most common approach to use when treating patients with OCD. The purpose of ERP is to trigger the exposure of a client’s uncontrollable obsessions, and have the client learn to prevent themselves from making the compulsions they routinely do to lessen their distress. (Institute for Quality and Efficiency in Health Care, 2014). The therapist is responsible for evoking the OCD sufferer’s distress to help them overcome their fears while maintaining a safe environment. This makes CBT an ideal choice for treating individuals with OCD since they will be exposed to the things or situations that triggers their distress instead of trying to avoid them.
Although either SSRI pharmacotherapy or CBT may be used to treat OCD, there have been a myriad of cases where OCD symptoms are exceedingly severe. These cases have reached to point that it interferes with therapeutic treatment because the OCD patient has developed a resistance to medical treatment (Brakoulias, 2015). This for an alternative treatment plan that will efficiently treat and lessen the severity of OCD symptoms and pharmacoresistant OCD patients. Several studies have shown that the combination of both CBT and pharmacotherapy with SSRIs has shown to be more effective towards patients with OCD versus either treatment alone (Brakoulias, 2015). One of the research studies that supports the combination of both treatments was performed by Prasko et al. (2016) on 66 OCD patients for six weeks. Each patient received 30 group and six individual CBT sessions and pharmacotherapy with SSRIs. The study produced results that demonstrated a significant decrease in the severity of OCD symptoms and an increase in improvement among OCD patients that are resistant to drug treatment. Another case that also provides support for combination therapy of CBT and pharmacotherapy with SSRIs was conducted by Iniesta-Sepúlveda et al. (2014), which focused on children and adolescents with OCD. The research team gathered 18 studies to assess the effectiveness of using CBT and pharmacotherapy together versus CBT and pharmacotherapy alone. The main finding was that a combination of CBT and SSRIs showed the most decrease in OCD symptoms, as well as other symptoms comorbid with OCD, such as depression, and anxiety (Iniesta-Sepúlveda et al, 2014).
Despite how effective the combination of both therapies may be for OCD patients, there are several limitations that prevent the combination of CBT and pharmacotherapy with SSRIs from being a first-line treatment choice. There are many patients with OCD who are either incapable of or disinclined to receiving therapeutic treatment that involves CBT. Patient-related factors that limit CBT access include the following: being reluctant to seek out treatment due to OCD stigma, inability to seek treatment due to a lack of belief that CBT is effective, the demanding amount of time and effort it takes when receiving therapeutic treatment, and having severe psychiatric comorbidities that prevents one from receiving CBT. CBT is highly more demanding than pharmacotherapy with SSRIs due to the amount of commitment, time, and effort it requires. Unlike SSRIs, which are able to relieve the severity of OCD symptoms, it takes time for one to notice results from attending CBT sessions. CBT sessions lasts for approximately one hour per session, and sessions may last for several months for their therapy to be completed. Attending CBT sessions also requires the individual to have a robust backbone and to be able to put in a substantial amount of effort during therapy sessions since they are required to confront their compulsions during CBT. Patient-external factors also limit OCD patients from receiving treatment. Several factors include the lack of therapists who are highly trained in CBT, the inability to schedule an appointment within the requested time frame due to long waiting times, and health insurances being unable to cover or only partially cover CBT sessions (Feusner and O’Neill, 2015).
In correlation to patient-related and patient-external factors preventing one from receiving CBT, a survey study was done by Dixon et al (2014) that focused on OCD patients and the number and type of visits they made in regards to their mental illness. Dixon et al. (2014) identified the types of treatments OCD patients sought out for when they visited their physicians and their mental health professionals. Based on the data that was collected, most of the doctor visits made by OCD patients were in regards to prescribed medications (psychotropic and other medications, as well as unspecified medications) and less than half of the doctor visits made by OCD patients pertained to seeking out psychotherapy that was not specified by the data (Dixon et al, 2014).
In correspondence the previous notion mentioned, it is supported with the following information obtained from the survey: those who self-pay for their treatments had a higher chance of receiving psychotherapy versus paying psychotherapy with an insurance company, and those who paid to see a psychiatrist were more than likely to receive psychotherapy as well (Dixon et al, 2014). This demonstrates that those who are able to pay out of pocket are the type of patients that are able to afford psychotherapy. Also, since the number of doctor visits were mostly OCD patients seeking medical treatment for their symptoms, it shows that most of them did not have the sufficient income or health insurance that can cover the costs for therapeutic treatments or other credible reasons. This observation further supports the study conducted by Feusner and O’Neill (2015) that financial income plays a huge factor in receiving CBT.
It is necessary to overcome these limiting factors and reprogram OCD sufferers’ neural circuitry in order for them to regain the ability to control their thoughts and extinguish their fears. There is profound evidence that administering both therapeutic approaches produce more promising results than either therapy alone. By treating OCD patients with the combination of CBT and SSRI pharmacotherapy, OCD sufferers’ will not have deficiencies in fear extinction and which will no longer be governed by their mental illness.