What do you do with obsessive thoughts

Use these five questions to help you identify obsessive-compulsive disorder

MAINZ. Obsessive-compulsive disorder is one of the more common mental disorders, with a twelve-month prevalence of 3 to 4 percent, but it is also among those with the lowest treatment rate. This is also due to the fact that they are often not recognized even by neurologists and psychiatrists, said Professor Ulrich Voderholzer from the Clinic for Psychosomatics in Prien am Chiemsee.

The problem: Patients try to hide their compulsions and deny them for as long as possible. They usually seek medical help for other reasons. If doctors don't ask about it explicitly, they will often go unaware of the disorder.

Investigations have shown that as a result, the majority of the resident therapists rarely treat patients with obsessive-compulsive disorder. "Given the frequency of obsessive-compulsive disorder, there are too few who specialize in it or like to treat such patients," explained Voderholzer.

In the "Psychiatry Update" in Mainz, the psychiatrist referred to the current S3 guideline on obsessive-compulsive disorder. According to this, doctors should always explicitly ask patients with mental disorders about compulsions.

With five questions about diagnostics

Such a screening can be done with five simple questions:

- Do you wash and clean a lot?

- Do you control a lot?

- Do you have tormenting thoughts that you want to get rid of but cannot?

- Do you need a long time for everyday activities?

- Are you concerned about order and symmetry?

If at least one of the questions is answered with "yes" and the compulsive actions affect everyday life, then a disorder is likely. In studies, these five questions were able to capture obsessive-compulsive disorder with a sensitivity of 94 percent and a specificity of 85 percent; in German-speaking countries, the values ​​are apparently somewhat worse, write the guideline authors.

However, they still see a great benefit in screening, since a delayed diagnosis favors chronification. If the screening is positive, doctors can use specific tools to corroborate the diagnosis.

Rapid diagnostics required

Voderholzer believes that rapid diagnosis and specific treatment are also very important because otherwise the patient's quality of life is often severely impaired and the life span is shortened. According to Danish registry data, the probability of dying within a certain period of time with OCD alone is around 1.9 times higher than in the general population (JAMA Psychiatry 2016; 73: 268-74).

With frequent concomitant illnesses such as anxiety, depression and substance abuse, the risk multiplies, especially that of unnatural death. The risk of dying from accidents or acts of violence in the case of an accompanying depression or anxiety disorder is seven times higher; if there is an addiction problem, it increases by 25 times. For Voderholzer, therefore, the rebuilding of positive and social activities is an important aspect of therapy.

The guideline primarily recommends psychotherapy for treatment. The authors of a meta-analysis of 53 studies come to a similar conclusion (Health Technol Assess 2016; 20: 1-392). According to this, psychotherapies have a much stronger therapeutic effect than drugs.

With behavioral therapies and cognitive therapies, the value on the Yale-Brown Obsessive Compulsive Scale (Y-BOCS) only fell by an average of around 3.5 points, with psychotherapies it fell by 8 to 10 points in the individual studies. As a reminder, patients with clinically relevant obsessive-compulsive disorder have between 16 and 30 Y-BOCS points.

Combination therapy has an advantage

The combination of SSRIs and psychotherapy seems to be somewhat more effective than monotherapy, at least for severe obsessive-compulsive disorder, says Voderholzer. However, a problem with all of these studies is their short duration. It is difficult to say which therapies work best in the long term.

Currently, however, cognitive behavioral therapy (CBT) with exposure and reaction management is best validated and is therefore the method of choice for obsessive-compulsive disorder. The expert considers pharmacotherapy to be an option especially if CBT is rejected, is not available, or if it increases willingness for CBT.

At the event, Voderholzer recalled some important statements in the guidelines on CBT. After that, exposure accompanied by a therapist is more effective than without. The exposure should also take place outside of the therapy room in the patient's home environment, especially if the compulsive actions cannot be reproduced in the clinical setting. At least two hours should be planned for exposure, and relatives can also be involved so that they do not support the compulsive acts.

In the opinion of the expert, it is particularly relevant for the success of the therapy that the patient should avoid any kind of compulsive action between exposures. Key date agreements with patients could help here.

Do online therapies help?

Since not all those affected can receive psychotherapy in a timely manner, online offers are also being tried out. They could be more important in the future, explained Voderholzer. Procedures such as metacognitive training involve, for example, the re-evaluation of obsessive-compulsive thoughts, the defusion of thoughts and events and the fusion of thoughts and actions or the correct assessment of dangers.

In the study, compulsions could be significantly reduced compared to control groups, but the effect was not too great. According to the psychiatrist, such methods are particularly suitable for very motivated patients.

Update seminars

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