Presentation and Treatment of Complicated Obsessive-Compulsive Disorder

Charles F. Brady, PhD, ABPP

Lindner Center of HOPE and Lindner Center Professional Associates, Mason, Ohio, and the Department of Psychiatry, University of Cincinnati and University of Cincinnati Physicians, Cincinnati, Ohio

OCD is a potentially disabling condition that strikes both children and adults. The lifetime prevalence of OCD is 2.3%,1 with men and women affected equally.2 OCD delivers a staggering toll for the individual and society, as about 40% of individuals with OCD are unable to work.3 In addition, the cost of OCD has been estimated to be nearly 6% of the total annual cost of mental health disorders in America.4

AV 1. Response Rates for Patients With OCD (N=149) (00:31)

Data from Foa et al5
P<.05 for all groups vs placebo; response = CGI score of 1 or 2
Abbreviations are defined before the References

With an arsenal of treatment approaches, including pharmacotherapy, ERP-based CBT, and pioneering psychosurgical procedures such as deep brain stimulation, OCD is no longer considered an untreatable condition. More than 80% of patients who participate fully in treatment see significant reductions in their symptoms (AV 1),5 with accompanying gains in their quality of life.6 Further, relapse rates after ERP therapy are low.7

Even with available treatments, clinicians will encounter obstacles that can hinder the recovery of patients with OCD. For example, many individuals with OCD harbor strong fears about medications and hesitate to consent to adequate medication management. Patients who receive pharmacotherapy as their sole treatment risk relapse if they discontinue the medication.7 Some patients do not respond to ERP, while others decline to participate or terminate treatment prematurely.8 Some of the most common complicating factors for clinicians treating patients with OCD include suicidal obsessions, compulsions associated with self-harm, and the presence of overvalued ideation (ie, limited insight) and low motivation.

Suicidal Obsessions

Many people with OCD struggle with periods of suicidal ideation that are fueled by feelings of shame, hopelessness, and helplessness. A 6-year longitudinal study9 of patients in a specialty OCD clinic noted that 8% of the subjects reported suicidal ideation and 5% attempted suicide during the study. A cross-sectional study10 reported a 36% lifetime rate of suicidal thoughts and a 10% rate of current suicidal thoughts, with 11% of participants having attempted suicide.

Suicidal ideation may be consistent with patients’ feelings and desires, ie, ego-syntonic, but some patients with OCD experience ego-dystonic obsessions of suicide.10 These intrusive thoughts of killing oneself are unwanted and terrifying. Patients with ego-dystonic obsessions of suicide pose a challenge to the clinician when they present in the emergency department or outpatient clinic. Their presentation to medical professionals is often a compulsion through which they are either seeking reassurance that they are not a danger to themselves or hoping that being in the hospital will help them stop having the thoughts or will prevent them from acting on them. When clinicians fail to assess whether these thoughts and urges are ego-dystonic and admit the patient too quickly to an acute care hospital unit due to “dangerousness,” they run the risk of reinforcing the patient’s belief in the credibility of these unwanted thoughts, making the OCD more difficult to treat.

AV 2. Risk Assessment of Suicidal Thoughts (00:29)

Based on author’s clinical experiences

When assessing patients for the risk of imminent self-harm or suicide, clinicians should evaluate whether the thoughts are ego-dystonic or ego-syntonic. Clues that the suicidal thoughts may be obsessions—which reduces the potential for imminent harm—include a history devoid of any suicidal or self-harming behaviors, the presence of other obsessive-compulsive symptoms, and the absence of a major depressive episode (AV 2). Instead of suicide prevention measures and hospitalization, patients with ego-dystonic obsessions of suicide would benefit from psychoeducation about the nature of their obsessions and from ERP.10

Self-Harming Compulsions

Typically, a compulsion is annoying and time-consuming, but at times it can produce harm, as demonstrated in the following cases.

Case example. Mr A, a 30-year-old man, presented to the clinic with diagnoses of bipolar disorder and OCD. He experienced intrusive thoughts that tragedies may befall his children. When he experienced such thoughts, he found that he could neutralize them by striking himself. Often, slapping himself lightly was sufficient, but at times the hitting escalated if he doubted that he had neutralized the thought sufficiently.

Case example. Ms B, a 35-year-old woman with OCD, spent several hours per day washing her hands with cleansing agents to prevent getting and spreading an STD. At times of intense fear, she used harmful, burn-producing bathroom cleaning chemicals to assuage her distress.

Dangerous compulsions affect the implementation of treatment. Before initiating ERP, clinicians must determine the risk of harm that patients’ compulsions pose. The use of ERP for OCD takes time because it is built upon a foundation of approaching feared stimuli in a gradual and progressive fashion while reducing and eliminating the compulsive responses.11 When compulsions are not dangerous, the clinician can work with patients to gradually wean them from the compulsive behaviors. However, when the compulsion is dangerous, the clinician will need to assess whether the person can be safely treated in standard outpatient treatment or if intensive outpatient or residential treatment is needed to reduce the risk of harm.

Overvalued Ideation and Low Motivation

Perhaps the most complicating, if not the most frustrating, factors in treating OCD occur when the patient either is unable to perceive the obsessions and compulsions as maladaptive or does not display sufficient motivation to participate actively in ERP or comply with medication recommendations.

Overvalued ideation. Individuals with overvalued ideation see their worrying and compulsions as rational and logical responses to potential danger.12 They rarely seek treatment on their own and typically arrive in the clinician’s office at the insistence of concerned family members. Education about the biopsychological nature of OCD and a motivational interviewing approach13 are sometimes useful in readying these individuals for treatment. If their compulsions create risk for imminent harm to themselves or others, involuntary hospitalization may be necessary.

Family members should also receive education about the nature of OCD. Often, the clinician is well advised to engage in a collaborative and supportive relationship with a patient’s family members to assist them in setting and maintaining appropriate behavioral limits for the patient.


Low motivation. Patients with low motivation understand the senseless nature of their worries but struggle to sustain the consistent effort needed to overcome the illness. These patients may begin therapy with high levels of motivation and make initial dramatic gains but then settle into complacency. With the highest levels of their distress ameliorated, they may find the remaining obsessions and compulsions tolerable and lose interest in applying persistent effort to their treatment regimen. Patients should be informed of the significant risk of maintaining the status quo when obsessive-compulsive symptoms are still present and interfering with their functioning. Clinical observations have shown that when a person ceases to push against his or her symptoms in a consistent and systematic fashion through ERP, then he or she is at risk for relapse to a significantly higher level of symptomatology and distress than was present before treatment started.

Whenever low motivation is present, the clinician should assess patients for other contributing factors, such as a mood disorder, sleep disorder, thyroid condition, substance use, or other medical condition that may cause excessive fatigue or low energy. When evidence of unhealthy diet or sedentary lifestyle is found, nutritional assessment and counseling as well as physical exercise may reduce the low energy that is often associated with low motivation. In psychotherapy, the therapist may employ motivational interviewing or strategies of acceptance and commitment therapy14 to help patients move toward building more rewarding, rich, and satisfying lives for themselves.


OCD is a potentially disabling condition but is highly treatable with pharmacotherapy and psychotherapy, especially ERP. Clinicians need to address complicating factors so that patients can fully benefit from treatment. Thoughts of suicide require clinical vigilance and readiness to respond if a true desire for death is present as well as prudence to not over-respond if they are ego-dystonic obsessions. Some patients’ compulsions may lead to self-harm, requiring intensive treatment rather than gradual therapy. The clinician must also be prepared for all-too-frequent instances when patients either are unable to recognize their obsessions as unrealistic or lack the willingness to engage in treatment. Clinicians may need to educate family members to help patients overcome limited insight and should assess for comorbid conditions or lifestyle behaviors that can contribute to low motivation. With vigilant care and appropriate strategies, clinicians can successfully manage factors that complicate the treatment of patients with OCD.

Clinical Points

  • Assess whether suicidal thoughts are ego-syntonic or ego-dystonic before selecting an intervention
  • Determine whether intensive outpatient or residential treatment is needed instead of standard care for patients whose compulsions are dangerous
  • Use a motivational interviewing approach and family education to help patients with overvalued ideation
  • Assess for health factors that may contribute to low motivation, and try employing motivational interviewing or strategies of acceptance and commitment therapy


CBT = cognitive-behavioral therapy, CGI = Clinical Global Impression improvement scale, ERP = exposure and response/ritual prevention, OCD = obsessive-compulsive disorder, STD = sexually transmitted disease

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