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Definition
By Mayo Clinic Staff

Cognitive behavioral therapy is a common type of mental health counseling (psychotherapy). With cognitive behavioral therapy, you work with a mental health counselor (psychotherapist or therapist) in a structured way, attending a limited number of sessions. Cognitive behavioral therapy helps you become aware of inaccurate or negative thinking, so you can view challenging situations more clearly and respond to them in a more effective way.

Cognitive behavioral therapy can be a very helpful tool in treating mental disorders or illnesses, such as anxiety or depression. But not everyone who benefits from cognitive behavioral therapy has a mental health condition. It can be an effective tool to help anyone learn how to better manage stressful life situations.

RISKS
In general, there’s little risk in getting cognitive behavioral therapy. Because it can explore painful feelings, emotions and experiences, you may feel emotionally uncomfortable at times. You may cry, get upset or feel angry during a challenging session, or you may also feel physically drained.

Some forms of cognitive behavioral therapy, such as exposure therapy, may require you to confront situations you’d rather avoid — such as airplanes if you have a fear of flying. This can lead to temporary stress or anxiety.

However, working with a skilled therapist will minimize any risks. The coping skills you learn can help you manage and conquer negative feelings and fears.

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Treatments and drugs
By Mayo Clinic Staff

Appointments & care

At Mayo Clinic, we take the time to listen, to find answers and to provide you the best care.
Learn more. Request an appointment.
Obsessive-compulsive disorder treatment may not result in a cure, but it can help you bring symptoms under control so they don’t rule your daily life. Some people need treatment for the rest of their lives.

The two main treatments for OCD are psychotherapy and medications. Often, treatment is most effective with a combination of these.

Psychotherapy

A type of therapy called exposure and response prevention (ERP) is the most effective treatment. This therapy involves gradually exposing you to a feared object or obsession, such as dirt, and having you learn healthy ways to cope with your anxiety. Exposure therapy takes effort and practice, but you may enjoy a better quality of life once you learn to manage your obsessions and compulsions.

Therapy may take place in individual, family or group sessions.

Medications

Certain psychiatric medications can help control the obsessions and compulsions of OCD. Most commonly, antidepressants are tried first.

Antidepressants that have been approved by the Food and Drug Administration (FDA) to treat OCD include:
•Clomipramine (Anafranil)
•Fluvoxamine (Luvox CR)
•Fluoxetine (Prozac)
•Paroxetine (Paxil, Pexeva)
•Sertraline (Zoloft)

However, other antidepressants and psychiatric medications used for other conditions may be prescribed off label to treat OCD.

Choosing a medication

With OCD, it’s not unusual to have to try several medications before finding one that works well to control your symptoms. It can take weeks to months after starting a medication to notice an improvement in your symptoms. Your doctor also might recommend combining medications, such as antidepressants and antipsychotic medications, to make them more effective in controlling your symptoms.

Don’t stop taking your medication without talking to your doctor, even if you’re feeling better — you may have a relapse of OCD symptoms. Antidepressants aren’t considered addictive, but sometimes physical dependence, which is different from addiction, can occur. So stopping treatment abruptly or missing several doses can cause withdrawal-like symptoms, sometimes called discontinuation syndrome. Work with your doctor to gradually and safely decrease your dose.

Medication side effects and risks

In general, the goal of OCD treatment with medications is to effectively control signs and symptoms at the lowest possible dosage. Here are some things to consider:
•Side effects. All psychiatric medications have potential side effects, which may include stomach upset, sleep disturbance, sweating and reduced interest in sexual activity. Talk to your doctor about possible side effects and about any health monitoring needed while taking psychiatric medications. And let your doctor know if you experience troubling side effects.
•Suicide risk. Most antidepressants are generally safe, but the FDA requires that all carry the strictest warnings for prescriptions. In some cases, children, teenagers and young adults under 25 may have an increase in suicidal thoughts or behavior when taking antidepressants, especially in the first few weeks after starting or when the dose is changed. If suicidal thoughts occur when taking an antidepressant, immediately contact your doctor or get emergency help. Keep in mind that antidepressants are more likely to reduce suicide risk in the long run by improving mood.
•Interactions with other substances. Some medications can have dangerous interactions with other medications, foods, alcohol or other substances. Tell your doctors about all medications and over-the-counter substances you take, including vitamins, minerals and herbal supplements.

Other treatment

Sometimes, medications and psychotherapy aren’t effective enough to control OCD symptoms. Research continues on the potential effectiveness of deep brain stimulation (DBS) for treating OCD that doesn’t respond to traditional treatment approaches.

Because DBS hasn’t been thoroughly tested for use in treating OCD, make sure you understand all the pros and cons and possible health risks.

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Tests and diagnosis
By Mayo Clinic Staff

Appointments & care

At Mayo Clinic, we take the time to listen, to find answers and to provide you the best care.
Learn more. Request an appointment.
To help diagnose OCD, your doctor or mental health provider may do exams and tests, including:
•Physical exam. This may be done to help rule out other problems that could be causing your symptoms and to check for any related complications.
•Lab tests. These may include, for example, a complete blood count (CBC), screening for alcohol and drugs, and a check of your thyroid function.
•Psychological evaluation. A doctor or mental health provider asks about your thoughts, feelings, symptoms and behavior patterns. Your doctor may also want to talk to your family or friends, with your permission.

Diagnostic criteria for OCD

To be diagnosed with OCD, you must meet the criteria in the Diagnostic and Statistical Manual of Mental Disorders (DSM) published by the American Psychiatric Association. This manual is used by mental health professionals to diagnose mental illnesses and by insurance companies to reimburse for treatment.

General criteria required for a diagnosis of OCD include:
•You must have either obsessions or compulsions or both.
•You may or may not realize that your obsessions and compulsions are excessive or unreasonable.
•Obsessions and compulsions are significantly time-consuming and interfere with your daily routine and social or work functioning.

Your obsessions must meet these criteria:
•Recurrent, persistent and unwelcome thoughts, impulses or images are intrusive and cause distress.
•You try to ignore these thoughts, images or impulses or to suppress them with compulsive behaviors.

Compulsions must meet these criteria:
•Repetitive behavior that you feel driven to perform, such as hand-washing, or repetitive mental acts, such as counting silently.
•You try to neutralize obsessions with another thought or action.
•These behaviors or mental acts are meant to prevent or reduce distress, but they are excessive or not realistically related to the problem they’re intended to fix.

Diagnostic challenges

It’s sometimes difficult to diagnose OCD because symptoms can be similar to those of obsessive-compulsive personality disorder, anxiety disorders, depression, schizophrenia or other mental illnesses. Someone with true obsessions and compulsions has OCD, although it’s possible to have both OCD and obsessive-compulsive personality disorder. Be sure to stick with the diagnostic process so you can get appropriate diagnosis and treatment.

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Preparing for your appointment
By Mayo Clinic Staff

You may start by seeing your primary doctor. Because obsessive-compulsive disorder often requires specialized care, you may be referred to a mental health provider, such as a psychiatrist or psychologist, for evaluation and treatment.

What you can do

To prepare for your appointment, think about your needs and goals for treatment.
•Make a list of any symptoms you’ve noticed, including any that may seem unrelated to the reason for the appointment.
•Make a note of key personal information, including any major stresses or recent life changes.
•Take a list of all medications, vitamins, herbal remedies or other supplements, as well as the dosages.
•Make a list of questions you’d like to ask to make the most of your appointment time.

For OCD, basic questions to ask may include:
•Do you think I have OCD?
•How do you treat OCD?
•How can treatment help me?
•Are there medications that might help?
•Will talk therapy (psychotherapy) help?
•How long will treatment take?
•What can I do to help myself?
•Are there any brochures or other printed material that I can have? Can you recommend websites?

Don’t hesitate to ask questions anytime you don’t understand something.

What to expect from your doctor

Your doctor is likely to ask you a number of questions. Being ready to answer them may reserve time to go over any points you want to spend more time on. Your doctor may ask:
•Do certain thoughts go through your mind over and over despite your attempts to ignore them?
•Do you have to have things arranged in a certain way?
•Do you have to wash your hands, count things or check things over and over?
•When did your symptoms start?
•Have symptoms been continuous or occasional?
•What, if anything, seems to improve the symptoms?
•What, if anything, appears to worsen the symptoms?
•How do the symptoms affect your daily life?
•In a typical day, how much time do you spend on obsessive thoughts and compulsive behavior?
•Have any of your relatives had a mental illness?
•Have you experienced any trauma or major stress?

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Risk factors
By Mayo Clinic Staff

Factors that may increase the risk of developing or triggering obsessive-compulsive disorder include:
•Family history. Having parents or other family members with the disorder can increase your risk of developing OCD.
•Stressful life events. If you’ve experienced traumatic or stressful events or you tend to react strongly to stress, your risk may increase. This reaction may, for some reason, trigger the intrusive thoughts, rituals and emotional distress characteristic of OCD.

Complications
By Mayo Clinic Staff

Individuals with obsessive-compulsive disorder may have additional problems. Some of the problems below may be associated with OCD — others may exist in addition to OCD but not be caused by it.
•Inability to attend work, school or social activities
•Troubled relationships
•Overall poor quality of life
•Anxiety disorders
•Depression
•Eating disorders
•Suicidal thoughts and behavior
•Alcohol or other substance abuse
•Contact dermatitis from frequent hand-washing

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Symptoms
By Mayo Clinic Staff

Obsessive-compulsive disorder symptoms usually include both obsessions and compulsions. But it’s also possible to have only obsession symptoms or only compulsion symptoms. About one-third of people with OCD also have a disorder that includes sudden, brief, intermittent movements or sounds (tics).

Obsession symptoms

OCD obsessions are repeated, persistent and unwanted urges or images that cause distress or anxiety. You might try to get rid of them by performing a compulsion or ritual. These obsessions typically intrude when you’re trying to think of or do other things.

Obsessions often have themes to them, such as:
•Fear of contamination or dirt
•Having things orderly and symmetrical
•Aggressive or horrific thoughts about harming yourself or others
•Unwanted thoughts, including aggression, or sexual or religious subjects

Examples of obsession signs and symptoms include:
•Fear of being contaminated by shaking hands or by touching objects others have touched
•Doubts that you’ve locked the door or turned off the stove
•Intense stress when objects aren’t orderly or facing a certain way
•Images of hurting yourself or someone else
•Thoughts about shouting obscenities or acting inappropriately
•Avoidance of situations that can trigger obsessions, such as shaking hands
•Distress about unpleasant sexual images repeating in your mind

Compulsion symptoms

OCD compulsions are repetitive behaviors that you feel driven to perform. These repetitive behaviors are meant to prevent or reduce anxiety related to your obsessions or prevent something bad from happening. However, engaging in the compulsions brings no pleasure and may offer only a temporary relief from anxiety.

You may also make up rules or rituals to follow that help control your anxiety when you’re having obsessive thoughts. These compulsions are often not rationally connected to preventing the feared event.

As with obsessions, compulsions typically have themes, such as:
•Washing and cleaning
•Counting
•Checking
•Demanding reassurances
•Following a strict routine
•Orderliness

Examples of compulsion signs and symptoms include:
•Hand-washing until your skin becomes raw
•Checking doors repeatedly to make sure they’re locked
•Checking the stove repeatedly to make sure it’s off
•Counting in certain patterns
•Silently repeating a prayer, word or phrase
•Arranging your canned goods to face the same way

Symptoms usually begin gradually and tend to vary in severity throughout your life. Symptoms generally worsen when you’re experiencing more stress. OCD, considered a lifelong disorder, can be so severe and time-consuming that it becomes disabling.

Most adults recognize that their obsessions and compulsions don’t make sense, but that’s not always the case. Children may not understand what’s wrong.

When to see a doctor

There’s a difference between being a perfectionist and having OCD. OCD thoughts aren’t simply excessive worries about real problems in your life. Perhaps you keep the floors in your house so clean that you could eat off them. Or you like your knickknacks arranged just so. That doesn’t necessarily mean that you have OCD.

If your obsessions and compulsions are affecting your quality of life, see your doctor or mental health provider. People with OCD may be ashamed and embarrassed about the condition, but treatment can help.

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DEFINITION

Obsessive-compulsive disorder (OCD) is characterized by unreasonable thoughts and fears (obsessions) that lead you to do repetitive behaviors (compulsions). It’s also possible to have only obsessions or only compulsions and still have OCD.

With OCD, you may or may not realize that your obsessions aren’t reasonable, and you may try to ignore them or stop them. But that only increases your distress and anxiety. Ultimately, you feel driven to perform compulsive acts in an effort to ease your stressful feelings.

OCD often centers around themes, such as a fear of getting contaminated by germs. To ease your contamination fears, you may compulsively wash your hands until they’re sore and chapped. Despite efforts to ignore or get rid of bothersome thoughts, the thoughts or urges keep coming back. This leads to more ritualistic behavior — and a vicious cycle that’s characteristic of OCD.

CAUSES

The cause of obsessive-compulsive disorder isn’t fully understood. Main theories include:
•Biology. OCD may be a result of changes in your body’s own natural chemistry or brain functions. OCD may also have a genetic component, but specific genes have yet to be identified.
•Environment. Some environmental factors such as infections are suggested as a trigger for OCD, but more research is needed to be sure.

Many people begin to notice an improvement in their symptoms after two or three treatments with electroconvulsive therapy. Full improvement may take longer. Response to antidepressant medications, in comparison, can take several weeks or more.

No one knows for certain how ECT helps treat severe depression and other mental illnesses. What is known, though, is that many chemical aspects of brain function are changed during and after seizure activity. These chemical changes may build upon one another, somehow reducing symptoms of severe depression or other mental illnesses. That’s why ECT is most effective in people who receive a full course of multiple treatments.

Even after your symptoms improve, you’ll still need ongoing treatment to prevent a recurrence. Known as maintenance therapy, that ongoing treatment doesn’t have to be ECT, but it can be. More often, it includes antidepressants or other medications, or psychological counseling (psychotherapy).

The ECT procedure takes about five to 10 minutes, with added time for preparation and recovery. ECT can be done while you’re hospitalized or as an outpatient procedure.

Before the procedure

To get ready for the ECT procedure:
•You’ll have general anesthesia, which means you may have dietary restrictions before the procedure. Your health care team will tell you how long to avoid food and drinks before ECT treatment. Typically, this might mean no food or water after midnight and only a sip of water to take any morning medications.
•You may have a brief physical exam to check your heart and lungs.
•You’ll have an intravenous (IV) line inserted. Your nurse or another health care team member inserts an IV tube into your arm or hand through which medications or fluids can be given.
•Your nurse places electrode pads on your head. Each pad is about the size of a silver dollar. ECT can be unilateral, in which electrical currents focus on only one side of the brain, or bilateral, in which both sides of the brain receive focused electrical currents.

Anesthesia and medications

At the start of the procedure, you’ll receive these medications through your IV:
•An anesthetic to make you unconscious and unaware of the procedure
•A muscle relaxant to help minimize the seizure and prevent injury

You also may receive other medications, depending on any health conditions you have or your previous reactions to ECT.

A blood pressure cuff placed around your ankle stops the muscle relaxant medication from entering the foot and affecting the muscles there. When the procedure begins, your doctor can monitor seizure activity by watching for movement in that foot.

During the procedure, monitors constantly check your heart, blood pressure and oxygen use. You may be given oxygen through an oxygen mask. You may also be given a mouth guard to help protect your teeth and tongue from injury

Inducing a seizure

When you’re asleep from the anesthetic and your muscles are relaxed, the doctor presses a button on the ECT machine. This causes a small amount of electrical current to pass through the electrodes to your brain, producing a seizure that usually lasts less than 60 seconds.

Because of the anesthetic and muscle relaxant, you remain relaxed and unaware of the seizure. The only outward indication that you’re having a seizure may be a rhythmic movement of your foot if there’s a blood pressure cuff around your ankle. But internally, activity in your brain increases dramatically. A test called an electroencephalogram (EEG) records the electrical activity in your brain. Sudden, increased activity on the EEG signals the beginning of a seizure, followed by a leveling off that shows the seizure is over.

A few minutes later, the effects of the short-acting anesthetic and muscle relaxant begin to wear off. You’re taken to a recovery area, where you’re monitored for problems. When you wake up, you may experience a period of confusion lasting from a few minutes to a few hours or more.

Series of treatments

In the United States, ECT treatments are generally given two to three times weekly for three to four weeks — for a total of six to 12 treatments. The number of treatments you’ll need depends on the severity of your symptoms and how rapidly they improve.

Some people may be advised not to return to work until one to two weeks after the last ECT in a series or for at least 24 hours after the last treatment.

Before having your first ECT treatment, you’ll need a full evaluation, which usually includes:
•A medical history
•A complete physical exam
•A psychiatric assessment
•Basic blood tests
•An electrocardiogram (ECG) to check your heart health

These exams help make sure that ECT is safe for you. You may also see an anesthesiologist to go over the risks of anesthesia.