Obsessive-Compulsive Disorder: Issues in the Physician–Patient Relationship

Issues in the Physician–Patient Relationship

Treatment for OCD is often effective, leading to at least some response in a majority of patients. However, treatment adherence is difficult for some patients, which may interfere with treatment efficacy. Short- and long-term compliance with treatment can be greatly facilitated by considering how the nature of the illness affects the treatment modalities used.

At the core of OCD are the concepts of obsessional doubt, risk aversion and a need to feel in control of one’s environment. These three concepts affect behavioral and pharmacological treatment. In the initial phases of behavioral treatment, it may be difficult to engage the patient in treatment because of his or her doubt that the treatment will be effective and an unwillingness to experience the anxiety that results from exposure to feared stimuli. Extra time must often be spent convincing patients of the potential efficacy of treatment and lack of serious side effects from behavioral treatment. Unlike pharmacological treatment, in which the side effects can be quantified in medical terms, the side effects that patients fear from behavioral treatment are related to their cognitive distortions. For instance, those with contamina-tion fears may be thoroughly convinced that simply walking by an AIDS clinic will put them at risk of contracting AIDS or that simply using a public bathroom will give them a communicable disease. Thus, reassurance that this is not the case and that it is safe to engage in behavioral treatment may first involve playing out the catastrophic consequences in their mind or role-playing and discussing the irrational nature of the fear to the fullest ex-tent possible.

When behavioral treatment is started, it is customary to develop a hierarchy of subjective units of distress, which rate par-ticular events according to how much anxiety they produce. Forsome patients, the ability to develop this hierarchy and thereby obtain a sense of control over their fears, and the ability to begin with the least stressful challenges, can allow them to engage in behavioral treatment.

Similar concerns related to doubt, risk aversion and con-trol must also be addressed when pharmacological treatment is undertaken. In the initial treatment phases, the major task is get-ting the patient to engage in treatment. Patients with OCD, par-ticularly those with contamination and somatic obsessions, often have numerous questions about medication safety and may be hesitant to take them. Patients with contamination and somatic obsessions may be more likely to engage in behavioral treatment initially.

Although it is important that patients have a thorough un-derstanding of side effects, the psychiatrist should not be thor-ough to an obsessional degree. Many patients with OCD want a detailed understanding of every side effect and have difficulty differentiating which side effects are of concern and which are not. Thus, it is critical when discussing side effects to present an objective assessment of the relative frequency and severity of various side effects. It is important to emphasize that even though some of the rare side effects are more serious than the more com-mon side effects, they are unlikely to occur. It is also worth keep-ing in mind that the patient’s concerns about a particular side effect may be different from the psychiatrist’s. Again, it may help to elicit the catastrophic fears that the patient has and address the irrational obsessional qualities of those fears.

The initial phase of treatment is often the most difficult. This has to do with both risk aversion and a need to be in con-trol. With pharmacologic treatment, patients may occasionally experience an initial worsening of symptoms in addition to side effects. This can be terrifying to the patient and can lead to an abrupt discontinuation of the medication. Warning the patient be-fore treatment that this might occur increases the patient’s sense of control. Similarly, the antiobsessional effects of treatment of-ten take 6 to 10 weeks to be seen and are often gradual in onset. This gradual response is usually delayed until after the patient experiences side effects. Thus, the early phase of treatment may need to focus on encouraging the patient to stay on medication despite side effects and no improvement. Side effects can often be framed as a good sign that the medication is being actively absorbed by the body. Again, preparing patients in advance helps them feel in control and able to continue treatment. The gradual onset of improvement, although in some cases frustrating, is also reassuring to patients who might feel out of control if improve-ment occurred too rapidly.

Unlike many patients with mood disorders, most pa-tients with OCD do not have full recovery from their symptoms. Although the majority of patients, perhaps as many as 85%, ex-perience some improvement, most tend to remain symptomatic to some degree. Nonetheless, symptom improvement of even 10 to 15% can have a dramatic effect on their lives.