During the past 30 years, the treatment protocols for obsessive-compulsive and related disorders (OCRDs) have rapidly advanced and improved. Newer medications are more effective, with fewer side-effects. Cognitive behavioral psychotherapy is the treatment of choice for OCRDs, backed by years of research demonstrating its effectiveness. Despite this progress, there are certain factors that predict poorer treatment outcomes. Nonetheless, when these factors are identified and addressed by a qualified clinician, the negative influence can be mitigated. Let's review some of the more common obstacles to successful treatment of obsessive-compulsive disorders.
Treatment complication: Limited insight and overvalued ideation (OVI)
One factor that complicates the treatment of obsessive-compulsive and related disorders (OCRDs) is called overvalued ideation (OVI). OVI refers to a person's insight; the sensibility of their beliefs; and the tendency to cling to their beliefs despite evidence to the contrary. For example, a person with obsessive-compulsive disorder and low OVI may enter treatment saying, "I realize I can't really get AIDS from touching a doorknob or a toilet seat. I know it doesn't make any sense, but I still don't want to touch them. Logically, I understand that these worries are symptoms of my disorder. Even so, the anxiety is just too much for me to tolerate." This indicates a low degree of belief in the validity of their obsessional thoughts. This low OVI helps the person to more readily participate in the uncomfortable, but highly effective, exposure and response prevention exercises (ERP). In contrast, people with high OVI are uncertain if their beliefs are illogical or untrue. This uncertainty decreases motivation for treatment and leads to a reluctance to participate in ERP therapy. Therefore, high OVI predicts a poorer response to treatment (Basoglu Lax, Kasvikis, & Marks, 1988; Neziroglu, et al., 2000).
Certain disorders are more likely to have higher OVI than others. Hoarding disorder and body dysmorphic disorders are associated with higher OVI than obsessive-compulsive disorder (Neziroglu, Weissman, Allen, & McKay, 2012; Phillips, et al., 2012; Eisen, Phillips, Coles, & Rasmussen, 2004; McKay, Neziroglu, Yaryura-Tobias, 1997).
Therapy for people with high OVI involves more steps; and at a slower, more gradual pace. Oftentimes, motivation for therapy must be increased before proceeding. A helpful therapeutic technique is called motivational interviewing. It is specifically designed to increase motivation in persons who are ambivalent about participating in therapy. Additional cognitive therapy is also needed to modify high OVI. Therapeutic exercises are designed to test and restructure inaccurate beliefs. However, this can take longer and can be a more challenging task for therapists and therapy participants alike. When people with high OVI are ready for ERP, they may once again need to proceed more slowly and gradually.
Treatment complication: Other psychiatric conditions combined with obsessive-compulsive disorder
People with obsessive-compulsive and related disorders (OCRDs) frequently have other psychiatric conditions as well. For example, more than 80 percent of people with body dysmorphic disorder (BDD) also have a depressive disorder. Another 30% have obsessive-compulsive disorder along with their BDD. Similarly, up to 30% of people with obsessive-compulsive disorder also have a depressive disorder at the time of their evaluation (Tukel et al., 2002).
Having more than one disorder at the same time is called comorbidity. Quite sensibly, comorbidity complicates treatment. Comorbidity may be associated with a poorer treatment response in obsessive-compulsive disorders (Pallanti & Quercioli, 2006). Although comorbidity makes treatment more complex, people with more than one disorder can still benefit from treatment. It requires a thoughtful and systematic treatment plan. Symptoms of some conditions may need to be treated before others. For example, if a person is depressed and suicidal, therapy would prioritize the stabilization of these conditions before attempting exposure and response prevention therapy for obsessive-compulsive disorder.
Treatment complication: Family dynamics
As mentioned in the section on family therapy, a family's response to obsessive-compulsive symptoms can affect treatment outcome. One study found that family members' hostility and criticism of the recovering person symptoms had a negative impact on treatment response (Chambless, Floyd, Rodebaugh, & Steketee, 2007). Family therapy can be a valuable and necessary adjunct to improve treatment response. Family therapy provides needed education, strengthens family relationships, delivers emotional support, reduces symptoms, and predicts whether the person with an obsessive-compulsive disorder will remain in treatment.