TCPR: Dr. Hyman, most of your day-to-day work is with OCD patients. What therapeutic techniques are best for these patients?
Dr. Hyman: Exposure and response prevention (ERP) is an extremely effective therapy. Of course, the individual response varies from patient to patient, but we know that this is an effective treatment regimen. Patients are not used to therapists saying: “This will work.” Usually we say: “Well there is a chance it will work. We will give this a shot,” and so on. But you can say with conviction that if a patient commits to this therapy, it really has a good chance of reducing suffering.
TCPR: What is ERP?
Dr. Hyman: Basically, it is exposing a patient to the thing or things that cause anxiety or avoidance, and then helping him or her learn appropriate alternative responses to those situations. The art of this is in how you get patients to do things that are uncomfortable. But if you can enroll the patient in the possibility of significant relief with full participation in the therapy process, we see some really good outcomes.
TCPR: It must be a real challenge, though, getting people to sign on to expose themselves to something they are obsessed with avoiding.
Dr. Hyman: There is an inbred kind of resistance to the whole notion of exposure therapy among a fairly sizeable proportion of OCD patients. A lot of them have seen television shows and documentaries on ERP, and the first thing they say to themselves is, “No way am I doing that!” The other problem is the availability of these treatments. You can’t just pick a therapist out of your provider panel from your insurance company and think he or she will be familiar with this.
TCPR: So how do you “sell” this treatment to a patient?
Dr. Hyman: Well, I start with the overall theories of how the symptoms are maintained from a cognitive behavioral perspective. For example, I will explain to the patient the process by which obsessions and compulsions are initiated and maintained. Typically it starts with a situation that causes anxiety or concern, which can happen completely by accident, like standing in line at the checkout counter at the grocery store, and noticing an oozing cut on the arm of the cashier. Then the thought occurs, “What if that person bleeds all over my groceries?! I’ll surely get AIDS and die!” But you don’t want to appear rude so you tough it out, buy your groceries, then leave. But over the course of days and weeks, the patient starts developing avoidance strategies to situations involving blood and bodily fluids for the purpose of preventing some potential danger or harm to themselves or to someone they care about. So it starts with a thought, and that fearful thought is fueled by the behaviors or compulsions that are performed to neutralize the anxiety of that thought.
TCPR: And this is where people get into avoidant behavior.
Dr. Hyman: Yes, so I talk about what avoidance is and that by avoiding a situation or a thought, they actually increase the prevalence and intensity of that thought. I compare it to the familiar Chinese finger trap—the harder you pull to get out of the trap, the tighter it gets. I often tell patients that the OCD is mislabeled. It really should be compulsive-obsessive disorder because as much as the obsessions leads to the compulsions, the compulsions lead to the obsessions. What I try to get across to the patient is that as much as we try, we do not have control over our thoughts; what we do have control over is our response to those thoughts. So we are going to gear efforts in treatment to changing our relationship to those thoughts and not the thoughts themselves. Acting directly to change thoughts is not nearly as helpful as learning to change our responses to those thoughts.
TCPR: And how do you do that?
Dr. Hyman: We do it by purposefully activating our fears in a number of different situations that we typically avoid. In the course of the evaluation process I will ask for a list of situations that trigger anxiety and those avoidance responses. I explain to the patient that if we can activate your fear in these myriad situations, and at the same time try to control, manage, or change your response to those situations repeatedly over time, our experience is that the obsessions will decrease, the anxiety will go down, and the urge to do the compulsions actually diminishes as well.
TCPR: Let’s say we as psychiatrists want to start doing this with some of our patients. Can you give us a typical patient scenario?
Dr. Hyman: Let’s say someone has anxiety about touching a napkin in a public place. I create a set of exposure exercises where she actually comes into direct contact with what she considers a contaminated napkin. You can do this physically in your session or encourage her to go to the food court at the mall and take the first napkin on the top of the pile, which a lot of people with OCD won’t do. So a psychiatrist can encourage the patient to take a chance to do some of things that she avoids, because that avoidance is keeping the OCD problem active and frequent and intense.
TCPR: Is it possible for a psychiatrist to successfully do this kind of therapy if he or she sees a patient no more than every month or so?
Dr. Hyman: The dose of treatment has to be in proportion to the severity of the symptoms. So more severe patients need more frequent exposure sessions, and more monitoring of their exposures between sessions. But you can check in with them over the phone or via email to make sure they’re keeping up with their exposures when you don’t get to see them in person. Patients who are really severe need more guidance and oversight and accountability to do things that they are really afraid of. If you tell these people to go to the mall and touch a toilet seat, they’re just not going to do it. But for more mild to moderate cases, they will more likely do some self-directed exposure.
TCPR: Tell us about treating intrusive thoughts in OCD.
Dr. Hyman: There is a technique called imaginal exposure that we do specifically with patients who have intrusive thoughts. Imaginal exposure narratives are three to five minute long first-person accounts of a situation where a person’s anxiety is activated and his or her worst fear actually comes true. I have the patients actually write these out and then we go over them together.
TCPR: For example?
Dr. Hyman: Let’s say a female patient has the thought: “What if I lose control and stab my child?” I would have her write an imaginal exposure narrative describing the scene where she has a knife; she’s in the kitchen; she loses control; she plunges it into the child’s heart. This is a gruesome kind of scene, but the idea here is to activate the patient’s fear by making her think these thoughts. And in doing this imaginative exposure narrative over and over, she will see that she is not going to act on these thoughts, that she is still in control of herself despite what her thoughts say or what she believes her thoughts tell her to do.
TCPR: Are many of your patients also being treated with an SSRI when you see them?
Dr. Hyman: I would go so far as to say 90% to 100% of my patients have been through the gamut of SSRIs. In many cases they are non-responders or partial responders. I always get a complete medication history, because especially in the more severe and disabling cases, you would like to see at least a modicum of symptom relief from medication as it will make the cognitive behavioral therapy go more smoothly.
TCPR: Thank you, Dr. Hyman.