Predictors for successful treatment
Insight Researchers3 found that about 52% of patients with insight into the reasonableness of their obsessions responded to medications, while none who lacked insight responded. Therefore, it pays to assess patients’ insight and ability to recognize the long-term consequences of OCD to themselves and those around them.
Some patients who have suffered with treatment-refractory OCD for most of their lives lack a premorbid high level of functioning to serve as a reference for normalized behavior. Educating these patients to see the advantages of living without certain negative behaviors improves their receptivity to treatment.
Patients who lack insight often refuse to acknowledge that many of their behaviors are manifestations of OCD. Such patients, however, are usually more amenable to giving up or modifying their dysfunctional behaviors—and the clinician more likely to avoid confrontations—if they are shown how certain behaviors undermine their goals.
Cost-benefit analysis Because of the aversive nature of exposure and response prevention therapy (ERP) and the negative side effects of many medications, some patients may find it easier to live with their symptoms, as painful as they are, rather than undergo the discomfort of behavior therapy. Because the prognosis is poor in such cases, patients need to be convinced that the discomfort of treatment is merely short-term, while the discomfort of the illness could last forever if left untreated.
Motivation In our experience, motivation has played a crucial role in determining treatment outcome for severe refractory OCD. And regardless of the severity of their symptoms, patients who are fed up with their symptoms, or are tired of living a life controlled by their obsessions, usually are excellent candidates for treatment.
Conversely, those who enter treatment as a result of external pressure from spouses or family face a less positive prognosis. High emotional expressiveness, overinvolvement, and hostility by relatives is related to higher attrition rates in treatment.3 Because ERP is so aversive, these patients will find ways to dilute the treatment’s effectiveness. In many cases, they do the minimal amount of work required to stay in treatment to avoid whatever consequences their families would impose for not adhering to treatment.
One marker to assess compliance is whether the clinician feels he or she is investing more time and effort into the patient’s treatment than the patient is. If so, this should be addressed in a timely manner. Also, sporadic attendance at sessions and noncompliance with medications, homework, and behavior therapy assignments may also portend a poor outcome. Remember, though, that noncompliance and lack of motivation are fluid states; many previously noncompliant patients later return to treatment better motivated and more compliant.
Predictors for a lower success rate
Secondary gain Researchers4 found that patients who were enabled by their families had more severe symptoms than those who were not. These relational and environmental factors should be discussed openly. If the patient finds that many of his or her life needs are being met secondary to the illness, that patient might not agree to an aversive treatment.
To overcome this, urge family members or other individuals who provide dysfunctional reinforcers to remove them from the environment. Meet with the patient and family/friends and frankly point out dysfunctional gains and the ways in which family members unknowingly allow the gains to continue (e.g., giving the patient more money after he or she overspent his or her allowance). A family behavioral contract should be devised to address how these gains will be reasonably eliminated.
Recognize, too, that a patient may find it difficult to give up the secondary gains, detrimental as they may be, without adequate skills or coping mechanisms to fill the void. So in some cases, it is best not to remove all the secondary gains at once; this can cause many patients to terminate treatment prematurely.
Trauma or abuse history Many patients with treatment refractory OCD have trauma histories and cannot habituate to the behavioral tasks because of dissociation, emotional numbing, or some form of distraction that mediates their anxiety and prevents proper habituation. If the patient is adequately complying with the exposures, yet still is unable to confront every feared stimulus, inquire about a trauma or abuse history (Box 2).
Substance abuse The stress that is inherent to ERP can cause many patients to relapse or abuse illicit substances to manage their anxiety. Therefore, patients with severe substance abuse problems often have great difficulty handling ERP, as they are asked to experience the very discomfort that initially caused them to abuse drugs and alcohol.