OCD and Cognitive-Behavioral Therapy

Our guest,Dr. Michael Gallo says a combination of Cognitive-Behavioral Therapy (CBT) and medications is the best treatment for OCD (Obsessive-Compulsive Disorder). Cognitive Behavioral Therapy is a type of therapy where you identify and challenge your irrational thoughts and modify your behavior accordingly.

David Roberts is the HealthyPlace.com moderator.

The people in blue are audience members.

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David: Good Evening. I'm David Roberts. I'm the moderator for tonight's conference. I want to welcome everyone to HealthyPlace.com.

Our topic tonight is "OCD and Cognitive-Behavioral Therapy". Our guest is Michael Gallo, PSY.D. Dr. Gallo has trained and served as a psychotherapist and researcher at several major OCD treatment centers, including Harvard Medical School/Massachusetts General Hospital and The Emory Clinic. Dr. Gallo practices in Atlanta, Georgia.

Good evening Dr. Gallo and welcome to HealthyPlace.com. Thank you for being our guest tonight. So everyone knows, can you please define Cognitive-Behavioral Therapy (CBT)?

Dr. Gallo: Cognitive Behavioral Therapy is a very concrete, goal-oriented type of therapy. It focuses on helping people learn to identify, analyze and challenge irrational thoughts (i.e., the "cognitive" portion).

The behavioral portion of the therapy teaches people to change counter-productive behaviors which may be instigating or contributing to their problems.

David: Can you give us an example of CBT and how it would be used in relation to Obsessive-Compulsive Disorder?

Dr. Gallo: Well, that is a big question, but let me take a crack at it.

A person with OCD may feel compelled to engage in a less than rational, compulsive behavior. For example, excessive checking of door and window locks. CBT would help the person understand that by resisting the compulsive urge to check the locks, over-and-over again, they can eventually "wait out" their anxiety until the anxiety level dissipates over time. This is a technique known in CBT as Exposure and Response Prevention.

Cognitive therapy would work by helping the person rationally challenge the practical necessity for checking the locks multiple times.

David: What would you consider the optimum treatment for OCD (Obsessive-Compulsive Disorder)?

Dr. Gallo: Clinical research has clearly demonstrated that most people with moderate to severe OCD will respond best to a combination of OCD medications and Cognitive Behavioral Therapy. However, if one had to choose either OCD medications or CBT, I think the clear choice should be CBT. This is because CBT gives a person the tools to effectively manage their OCD for their entire life.

David: I realize that every person is different, but is there any general statistic you can give us, regarding the effectiveness of CBT alone. Can a person expect, let's say, a 50% relief of their OCD symptoms using CBT?

Dr. Gallo: In general, research has suggested that approximately 75-80% of people who diligently participate in CBT will achieve substantial relief from their OCD symptoms. I have personally had patients who, after suffering for years with severe OCD, have experienced as much as 80-90% reduction in symptoms and anxiety.

David: That's amazing. Is this a significant problem -- people with OCD become frustrated and give up before completing the therapy, getting all the tools they need to deal with the OCD symptoms?

Dr. Gallo: Yes, unfortunately one of the biggest problems encountered in CBT for OCD is resistance to full-fledged engagement in the therapy process. CBT is first and foremost...hard work! It requires persistence and high motivation on the part of the patient. In fact, ultimate success is highly correlated with the patient's level of motivation.

You see, engaging in CBT for OCD will require that a person "face their fears" (however, in a highly structured and supportive environment.

In CBT for OCD, a person can expect to "feel worse" before they ultimately feel better.

Cognitive Behavioral Therapy is akin to a highly effective, but bitter tasting medicine. However, if a person diligently participates in CBT for OCD it is virtually impossible for them NOT to experience at least some substantial improvement.

David: We have a lot of audience questions, Dr. Gallo. Here we go:

teddygirl: Do OCD and depression always go together?

Dr. Gallo: Not necessarily. However, having a severe problem with Obsessive-Compulsive Disorder often causes a person to become depressed in a "reactive", secondary way. It is only normal to feel depressed when you have such a problem with disturbing thoughts and compulsive rituals. Sometimes, however, OCD and depression are mutually exclusive and truly unrelated per se.

Hope20: Will that type of CBT ( Exposure and Response Prevention) also work for Trichotillomania sufferers?

Dr. Gallo: Trichotillmania is a special subtype of OCD that has many complex components. There is a specialized type of Behavioral Therapy called Habit Reversal which can be helpful in remediating problems with hair pulling. In short, this involves switching the hair pulling behavior to another more benign type habit (e.g., rubbing a touch-stone) which is incompatible with pulling one's hair.

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jmass: What if a person does not respond to exposure therapy? Are drugs the only other alterative?

Dr. Gallo: It's important to remember that Exposure Therapy must work if it is conducted diligently and persistently. The human nervous system simply must desensitize eventually to any anxiety provoking stimuli. However, if the anxiety is too severe, then medication can help the person to begin learning to use exposure and response prevention.

Often times, a person can eventually taper off the medication after they become skilled at (and confident in) the ERP.

mrhappychap: I have OCD as well as other stuff, and I was wondering if homicidal thoughts are part of Obsessive-Compulsive Disorder?

Dr. Gallo: Sometimes, a person with OCD will have what we call "ego dystonic" thoughts. These are thoughts which the person recognizes are foreign to your true self, your true desires, but which none-the-less intrude into one's mind seemingly out of nowhere and with little instigation.

Often, a person will find these thoughts abhorrent, but find that they continue to pop into their minds. Homicidal thoughts and sexual thoughts are common forms of these ego dystonic thoughts, essentially "nonsense" thoughts.

David: Does a person with OCD ever have to worry about "acting" on those types of intrusive thoughts?

Dr. Gallo: A person who has true OCD (and not another type of disorder, such as an impulse control disorder or schizophrenia) in all likelihood, does not need to worry about acting upon ego dystonic thoughts. I have never heard of a case of a person with OCD acting upon their obsessive thoughts. Most people who have these thoughts know, deep down, that they truly have no desire to do such things. However, they "fear" that they "might" become capable. In essence, the true impulse to do these bad things is not really there...only the fear and doubt that one might become capable of doing so.

maggie29: Is CBT something that must be done with a therapist, or can it be done on our own?

Dr. Gallo: Generally, it's best to learn the ropes from an experienced therapist. Once one has had practice, you can, in essence, eventually become your own therapist. Actually, the majority of your therapy takes place when you leave your therapist's office and go out in the real world to practice what you have learned. The more practice in real life, the quicker you will improve.

David: Here's the link to the HealthyPlace.com OCD Community. You can sign up for the mail list at the top of the page, so you can keep up with events like this.

Here are some more audience questions:

mkl: I have Obsessive-Compulsive Disorder and take prozac. Is it okay to have a beer or 2 or marijuana (if legal-I know) once in a while or does it screw up all medications?

Dr. Gallo: As a psychologist who does not have a license to prescribe medication, I am afraid I can not comment on this question. I suggest you speak with the doctor who is prescribing your Prozac.

David: This person, Dr. Gallo, is using the beer or marijuana to occasionally relieve anxiety. What's your opinion about that?

Dr. Gallo: Well, this is a common occurrence. We refer to this use of substances as "self-medication". While alcohol and marijuana are both somewhat "effective" at temporarily reducing anxiety, they are indeed, not very good medicines. In fact, both of these substances tend to leave you with an increased overall level of anxiety, once their effect wears off.

Moreover, each of these drugs, comes with a host of other problems which make them poor substitutes for prescription medication.

paulbythebay: Is CBT preferable to a potent SSRI, such as Luvox?

Dr. Gallo: Not necessarily. Many people obtain significant relief from the SSRIs. However, SSRIs can usually work well only on the obsessions. A person must still teach themselves to resist the compulsive rituals.

Moreover, SSRIs and CBT complement each other and work very well together. In fact, most of my patients use both Cognitive Behavioral Thearpy and an anti-obsessional drug like Luvox, Anafranil, Prozac, Zoloft or Paxil.

Matt249: Is CBT equally effective in treating both obsessions and compulsions?

Dr. Gallo: It is indeed. In fact there is a special type of CBT designed for people who have only "pure obsessions" and/or mental compulsions.

stan.shura: Is behavior therapy an effective option for someone who has many different "smaller" rituals as opposed to one big one like hand-washing? My waking and "going to bed" routines -among others - are a frustrating series of rituals that take about 45 minutes in the A.M. and over an hour in the P.M. Some of these are repeated throughout the day - but I have "substituted" smaller rituals that seem to satisfy the need/anxiety.

Dr. Gallo: Behavior therapy is ideal for dealing with all rituals, large or small. The same techniques, when applied creatively, can be used on an ongoing basis throughout the day to help you combat a variety of rituals.

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Dan3: Are there any foods, for example fruits, that help treat OCD?

Dr. Gallo: While it is very important to pay attention to what I call the basics of good health" (e.g., proper nutrition, sleep, exercise and recreation) there is no substantive evidence that any particular foods have a therapeutic effect on OCD. I cannot, though, over-emphasize attention to the important basics.

pinky444: I was wondering if I have OCD. I think I show signs of it, but I'm not sure. I obsess over people I know, and I, in a sense "stalk them". Could I have Obsessive Compulsive Disorder?

Dr. Gallo: While it is not possible, or ethical, for me to attempt to make a diagnosis over the internet (without a thorough personal evaluation) this does not, at first glance, seem like classic OCD. This type of "obsessive" thinking and "compulsive" behavior falls into a different category of problems.

David: I'm sure Dr. Gallo would agree, if you believe you have a problem or psychological issue, it would be important to see a psychologist to be evaluated.

Dr. Gallo: Absolutely. All of my answers are meant to inform. If you are experiencing significant problems or distress in your life, please do consult with a professional psychologist or psychiatrist.

annie1973: I am in CBT, as well as on OCD medications. They are both working well for me. Skin picking, I am told, is part of my OCD. This, I cannot seem to control, even though my other symptoms are getting better. My therapist says it will get easier when I start applying my tools more often, but I try to and they are of no help. Any suggestion?

Dr. Gallo: You might ask you therapist to research the technique called habit reversal. It also works for skin picking.

obiwan27: Could helping somebody out with their OCD, actually make my OCD worse?

Dr. Gallo: By trying to "help" a person engage in their rituals, you can actually reinforce the obsessive-compulsive problem. The best way to help someone with OCD is to remind them that what they are experiencing is truly OCD and that they should practice the CBT techniques that their therapist has taught them. Above all, resist enabling the person or you will only make things worse (despite your pure intentions).

4mylyfe: Dr. Gallo, I am wondering how the patient and doctor can best identify the irrational thoughts and fears which come into play in Obsessive-Compulsive Disorder? Also, how long does CBT generally need to last?

Dr. Gallo: It is essential that a person see a doctor who is VERY experienced in OCD, otherwise they will miss many of the more subtle obsessive cues. Many people are misdiagnosed for years.

Cognitive-Behavioral Therapy essentially lasts a life time, but the actual time with the therapist can be relatively brief. Ten to fifteen sessions can work wonders, if the person diligently practices the techniques in their everyday life. However, the patient in essence becomes his/her own therapist and continues to utilize CBT throughout their lives. OCD is an illness which can be effectively managed if a person practices what they learn in therapy throughout their life.

pstet55: Is working with obsessive thoughts tougher than say, just having compulsions. I'm talking about disturbing, tormenting thoughts.

Dr. Gallo: Yes, I am afraid it does tend to be harder. However, a skilled cognitive therapist can help you learn how to rationally challenge and restructure these thoughts.

samantha3245: Do they try this treatment on young children? I'm 11 years old.

Dr. Gallo: Oh yes, Samantha! Young children are capable of a lot more than we give them credit for. However, the child must be motivated to work with the therapist. Sometimes parents can get involved also, and help the child with his/her therapy exercises. As an 11 year old, you can definitely benefit from CBT! Go for it and start living a happier life!

We B 100: I feel so frustrated because I have to color code everything and alphabetize everything. Just to do my homework I have to use 4 different colors of ink (pink, purple, blue, green). I feel like such a weirdo and hate this feeling of craziness. Is there anything that I can do at home to stop this without uprooting my whole life?

Dr. Gallo: First and foremost, a person with OCD is not crazy or weird. The very fact that you recognize the irrationality of your actions shows how lucid and sane you actually are. I would suggest seeking a skilled CBT therapist in your area. There are two very fine organizations which can help you locate someone. Anxiety Disorders Association of America and the Obsessive Compulsive Foundation.

MeKaren: I used to be a checker, but over the years my compulsions have changed. I'd have to resist this ridiculous thing I do of always taking 3 steps before doing anything. It is quite time consuming and frustrating. What can I do?

Dr. Gallo: While it is hard for me to give specific individual therapeutic advice, you can try resisting the impulse to do so, tolerate the anxiety until it hits a peak, starts to plateau and then eventually declines. Also, there is an excellent guide by Dr Edna Foa on CBT for OCD that you can read to get you started if you cannot find a good therapist.

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bruin:What kind of an approach to CBT would you use for someone whose anxiety-reducing "rituals" are almost exclusively based on religious beliefs and religious rituals? (i.e. saying a certain amount of prayers before bedtime or before I go to church on Sunday).

Dr. Gallo: Cognitive therapy combined with good spiritual counseling from a clergy member who you respect can help with these types of obsessions and compulsions.

tiger007: I fear something bad may happen to me by other people. Is it Obsessive Compulsive Disorder or paranoia? What is the best way to cure this?

Dr. Gallo: From the info provided, it is hard to make an definitive diagnosis. It could be OCD or another type of anxiety disorder called Generalized Anxiety Disorder. Unless you really believe that other people are trying to hurt you, you most likely are not suffering from paranoia.

Brenda1: What about the type of OCD where you constantly fidget or count things. My doctor says this is a way of distraction, but I do it without thinking. How can I stop this?

Dr. Gallo: If you feel you need to count in order to reduce anxiety, or because you fear that something "bad" will happen if you don't count, then this may be OCD. However, it could also simply be a plain old habit behavior, which many of us possess.

neuro11111: Dr. Gallo, I have done a little reading on CBT (Jeff Schwartz). I can understand how actively refraining from certain compulsions can eventually lead to creating less of an importance in carrying them out. I can sort of relate to that, as throughout the years, I have established at least some kind of control over excessive washing (hands & arms). Since acts like washing and checking are tangible, they are somewhat easier in some cases. However, when it comes to controlling those darn thoughts! What can I do?

Dr. Gallo: One technique for banishing thoughts is to use something we call "mental-exposure therapy". I suggest you do this with the help of a skilled therapist, because it involves exposing yourself mentally to the anxiety-provoking thoughts in a systematic and gradual way. It is important that you have professional therapeutic help and support while doing this. Mental exposure does eventually lead to desensitization to the anxiety.

Also, a good cognitive therapist can help you learn to do what we call cognitive restructuring, whereby you identify, analyze, challenge, and restructure your obsessive, irrational thoughts.

paulbythebay: I am 38 now, but have endured parental abuse, verbal badgering and serious losses (employment, relationships), due to OCD. What is being done to promote understanding of this, as a treatable disorder?

Dr. Gallo: The two organizations I mentioned, as well as the National Institute of Mental Health are actively and aggressively involved in promoting rational understanding of this rather common disorder. You might consider becoming an active member of one of these organizations.

stan.shura: Is it appropriate and/or beneficial for a person to disclose something like Obsessive-Compulsive Disorder to his/her supervisor or company? Are there any specific accommodations that can be made - or is OCD fundamentally different in that any such accommodations would be enabling instead of helpful?

Dr. Gallo: This is a good question. While opinions may differ, I believe that it would be better not to disclose or ask for accommodations for one's OCD. Accommodations, in essence, feed into, and reinforce the ritualistic behavior. Compulsions must be aggressively challenged, if they are to be beaten. They are like a monkey on one's back, that must be tossed off. Ultimately, the person who produces the cure is the patient him or herself.

espee: How is the category of "obsessive thoughts" and "compulsive behavior" different from classical OCD?

Dr. Gallo: Classical OCD consists of two primary symptoms. Intrusive, Disturbing, Anxiety-Provoking, Obsessive thoughts, coupled with compulsive rituals which are physical or mental actions intended to neutralize the anxiety caused by obsessions.

David: I know it's getting late. I want to thank Dr. Gallo for being our guest and staying to answer many of the audience questions. We appreciate that. I also want to thank everyone in the audience for coming and participating. I hope you found it helpful. Please feel free to continue chatting in our OCD chatroom or any other chatroom here. Thank you again, Dr. Gallo.

Dr. Gallo: Thank you, and good night for having me here tonight. I hope I've answered your questions well.

David: You did, and we appreciate it. Good night everyone.

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Disclaimer: We are not recommending or endorsing any of the suggestions of our guest. In fact, we strongly encourage you to talk over any therapies, remedies or suggestions with your doctor BEFORE you implement them or make any changes in your treatment.

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