What You'll Learn
- Why does avoiding anxiety triggers make anxiety worse?
- How does “exposure with response prevention” work?
- What is the treatment for severe OCD?
The gold standard treatment for OCD (obsessive-compulsive disorder) is a kind of CBT (cognitive behavioral therapy) called “exposure with response prevention.”
When children experience anxiety they often try to avoid the things that trigger it. Avoiding anxiety temporarily makes them feel better, but it actually makes their fear worse in the long run. Instead of avoiding the situation, exposure with response prevention helps children learn to face their fears in a very structured and safe way. In the process children find that they get used to the anxiety and it fades over time.
During treatment, the child and the therapist work together to come up with a list of the child’s OCD triggers. Then they rank the fears on a scale from 1 to 10. Next, the child is exposed to their fear in its mildest possible form. The therapist supports the child until their anxiety fades. As their anxiety lessens, children feel more in control.
Children with more severe OCD are often also treated with medication called SSRIs (selective serotonin reuptake inhibitors). This medication can help reduce a child’s anxiety. Some children may also need more intensive treatment where they have therapy sessions several times a week.
The gold standard treatment we have for OCD (and OC spectrum disorders) is a kind of cognitive behavioral therapy called “exposure with response prevention,” where essentially we help children overcome their fears by having them face their fears directly head-on. Anxiety disorders, in general, are maintained through avoidance. So if someone’s afraid of something or it causes them anxiety, they’re going to want to avoid it. And avoiding it temporarily eases their anxiety or prevents their anxiety from coming, but it actually builds and maintains their anxiety over time.
So exposure with response prevention says instead of avoiding the situation, since that’s making you worse over the long run, what you should do is face your fear in the moments, in a very structured and systematic way. In the process children with OCD find that they get used to the anxiety and it actually fades.
Getting used to anxiety triggers
Exposure with response prevention (which is also sometimes called exposure therapy) works through a phenomenon called “habituation,” where your body basically adapts to whatever it is that it was fearing or it was having a hard time adjusting to. We see the same thing with all the different senses. For example, on a hot day if you jump into a cold pool, your body will feel the temperature of the water. But if you stay in the water, over time, eventually your body gets used to it. The temperature stayed the same, but your body adapted.
The same thing happens with OCD. When we systematically and slowly introduce kids to the things that they’re afraid of, they feel the anxiety, but then they learn how to get used to it, they learn how to adapt without resorting to compulsions, and it doesn’t bother them anymore.
How does exposure therapy work?
The first step is identifying triggers. We design a “hierarchy of fears” — a series of incremental challenges, each of which is tolerable, and which together build to significant progress. Instead of thinking in black and white terms — I can’t touch something dirty — kids are asked to consider degrees of difficulty. We might ask a child with contamination fears, for example, “On a scale of 1 to 10, how difficult would it be to touch the door handle with one finger? To touch and open the door?” By rating these different fears, kids come to see that some are less extreme, and more manageable, than they had thought.
Next, we expose the child to the trigger in its mildest possible form. For a child with a germ obsession, they might start with a low-level trigger, such as touching clean towels, and build to more difficult triggers, such as holding something from the trash. This allows them to experience anxiety and distress without resorting to compulsions, with the support of the therapist. Through facing their triggers children learn to tolerate their anxiety and, over time, they discover that their anxiety has actually decreased.
Treatment for severe OCD
While the primary treatment for OCD is exposure therapy, children with more severe cases are often also treated with medication. A class of antidepressant medication called SSRIs, or selective serotonin reuptake inhibitors, can be used to help reduce a child’s anxiety. This can help the child to be more responsive to therapy.
Some children may also need more intensive treatment. Weekly or even twice-weekly therapy sessions might not be effective enough. Intensive OCD treatment programs allow children to be seen several times a week, compressing treatment and helping children make more gains faster. These programs can have a transformative effect on children struggling with severe OCD, and can many times prevent hospitalization.