In my last column, I explained what Obsessive-compulsive disorder is and what it is not.

Today, I will talk about how clinicians diagnose and treat OCD.

When OCD is diagnosed, your clinician (therapist or doctor) should follow the criteria in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), which states there needs to be a presence of obsessions, compulsions or both that take up more than an hour a day or “cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.”

Additionally, the symptoms cannot be attributed to another mental disorder or to a drug or medication. This is why it is important that your clinician do a full assessment, asking you questions to rule out anxiety disorders such as phobias and generalized anxiety disorder; disorders related to OCD such as hoarding, hair pulling and skin picking; post-traumatic stress disorder (PTSD); as well as depression, bipolar disorder, schizophrenia and eating disorders.

Treatment for OCD can be broken into two sorts: medication and therapy. Neither cures OCD, but alone or in combination, these can reduce symptoms enough for a person to live a regular life. Some people receive treatment and experience no more symptoms while others still have significant symptoms, which tells us there is a lot more work to be done to find treatments. If you are prescribed a medication, it is most likely to be a serotonin reuptake inhibitor (SSRI); however, medications of other types are also used instead of or in addition to SSRIs.

The therapy most used for OCD is called exposure and response prevention (ERP). This therapy was first developed and used in 1966 by Viktor Meyer, who based the treatment on theories about anxiety and avoidance proposed by O. H. Mowrer in the 1940s. The basic idea is that as people try to avoid anxiety by doing compulsions, they reinforce that there is something to be fearful of, thus experiencing more fear, which leads to doing more compulsions.

It is the compulsions, not the obsessions, that fuel the anxiety and the disorder, meaning the best focus of treatment is to have a person stop doing compulsions.

In ERP, a client is asked to rank feared situations from least to most difficult, and then treatment begins with fears at the lower end. For example, if a person fears they may harm someone and the compulsion is to check for sharp objects and avoid them, the exposure would be to sit in a room that might have sharp objects while the response prevention is to not do the compulsions of checking and avoiding.

A next-level exposure may be to hold a pair of scissors, and then to use the scissors while sitting next to a loved one. During the exposures, the person with OCD experiences anxiety and fear. As the exposure is repeated, the anxiety and fear should begin to go down as long as the person is not performing some type of compulsion, sometimes called a “safety behavior."

The goal of ERP is reduced anxiety, but we also want the person to learn that they can tolerate anxiety without doing anything to get rid of it. Anxiety always goes down in the absence of new triggers and efforts to stop or control the anxiety. One of the most important things people learn through ERP is how to trust themselves because OCD often robs people of self-trust.

ERP is primarily a behavioral therapy because it focuses on behavior, but there are other therapies based on a therapeutic approach called cognitive-behavioral therapy (CBT). CBT has grown into a family of many therapies which all rely on the principle that thoughts, not events, lead to the way we feel and behave. This type of therapy is used with many different mental disorders, including depression, anger issues, anxiety, PTSD and more. When applied to OCD, the focus is often on the process of thinking which comes before and after an obsession.

A newer therapy called inference-based CBT (ICBT) posits that a person has a pre-existing narrative which is reactivated when an obsessive doubt comes to mind. In this narrative, the brain creates evidence and conclusions which are not based in reality. These faulty conclusions lead to anxiety, fear and the urge to do compulsions. ICBT helps those with OCD better understand the OCD reasoning process and replace that with a process similar to how others reason.

For more information about ERP, visit www.iocdf.org. For more information about ICBT, visit www.icbt.online.

Nora Sinclair is a licensed professional counselor and national certified counselor based in Lexington, S.C.