Why Intensive Treatment for Obsessive-compulsive and Anxiety disorders works

There was a time when successful treatment of OCD was considered almost impossible. This is born out by a quote by the psychiatrist Charles Breitner (1960) who wrote “most of us are agreed that the treatment of obsessional states is one of the most difficult tasks confronting the psychiatrist and many of us consider it hopeless”.

The first published study using exposure and response prevention that I could find was a series of case studies by Victor Meyer (1966). He reported very positive results from two case studies with people who were admitted as inpatients to his psychiatric ward at Middlesex Hospital in London. Both cases involved daily treatment during their hospital stay. So it seems reasonable to say that the first successful case studies of behaviorally treating OCD were “intensive” treatments. Intensive referring to the frequency of treatment being daily or multiple times per week. The fact that Meyer was able to achieve treatment success and that these successes persisted over a year later was a remarkable achievement at the time.

Soon after Meyer, other the research labs led by Stanley Rachman, Paul Emmelkamp and Edna Foa all started publishing studies on what eventually became called exposure and response prevention (ERP). Behavioral scientists started to migrate treatment to outpatients, typically done in sessions once a week. But relatively quickly, it became clear that daily treatment for a short period of time was extremely effective and in addition, for some patients, once a week of ERP did not seem to be sufficient (Steketee, 1987).

So it’s clear that intensive treatment works and works fast. In as little as 3 weeks to as long as 8-10 weeks, patients can see reductions in symptoms of over 40-50%. Since those early days, intensive treatment has become a mainstay for treating OCD.

It seems likely that not only is it faster, but intensive treatment might be better than 1x a week outpatient therapy for OCD. A recent paper suggests that intensive treatment may produce stronger treatment effects than once a week treatment. Hjalti Jonsson and colleagues compared four studies that were head-to-head comparisons of intensive (5x a week) vs weekly treatment. Each of these studies standardized the number of treatment hours so that every patient got the same number of treatment hours. But some got them in an intensive/daily format, and some got them once or twice a week spread out over an extended number of weeks. Their findings show a significantly stronger treatment effect (also called effect size) for intensive treatment.

Why might this be? Perhaps practicing learning new skills (like how to manage overwhelming anxiety) is well suited for frequent “squeezed together” practice, rather than practicing in spread out sessions. Keep in mind that spaced, weekly sessions do help ALOT and do work. but working in a concentrated fashion might be even better.

References

Breitner, C. Drug therapy in obsessional states and other psychiatric problems. In Diseases of the Nervous System. 1960 Vol 21, pgs 31-35.

Emmelkamp P & Rabbie, DM. Psychological treatment of obsessive-compulsive disorder. Book Chapter in Biological Psychiatry. 1981

Foa, E. Steketee G., and Ozarow, BJ Behavior Therapy with Obsessive-Compulsives. In Obsessive-Compulsive Disorder. 1985, pgs 49-129.

Jónsson H. and colleagues. Intensive cognitive behavioural therapy for obsessive-compulsive disorder: A systematic review and meta-analysis. In Journla of Obsessive-Compulsive and Related Disorders. 2015 Vol 6, pgs 83-96.

Marks, IM, Hodgson, R, & Rachman, SJ. Treatment of Chronic Obsessive-Compulsive Neurosis by in-vivo Exposure A Two-Year Follow-up and Issues in Treatment. In The British Journal of Psychiatry. 1975 Volume 127, Issue 4, pgs 349-364.

Meyer V. Modification of expectations in cases with obsessional rituals. In Behaviour Research and Therapy. (also known as BRAT ;) 1966 Vol 4, 273–280.

Steketee G Behavioral Social Work with Obsessive-Compulsive Disorder. In Journal of Social Service Research. 1987 10:2-4, 53-72