Many people believe that if they stop one bad habit it will be replaced with another bad habit. However, one of the key ideas of habit reversal is to replace the harmful habit with another harmless habit that makes the bad habit impossible. This new behaviour is known as a competing response.

A suitable competing response for skin-picking might be clenching one’s fist, as this is incompatible with skin-picking. Another important part of habit reversal training is practising a suitable method of relaxation such as meditation, abdominal breathing or progressive muscle relaxation.

Successful CBT will also involve stimulus control. Once the sufferer has identified the particular environmental factors or mood states that lead to picking, steps can be taken to deal with such triggers. For instance this might mean avoiding or covering mirrors or challenging automatic thoughts and emotions connected with picking and replacing them with less negative responses.

It basically involves breaking down each part of the behaviour and attempting to change it. Initially it focuses on developing habit awareness (may include keeping record of when, where and under what circumstances the CSP or TTM occurs. Then the harmful habit is replaced with another harmless habit that makes the bad habit impossible. This new behaviour is known as a competing response.

Although a person’s general practitioner can prescribe this medication, s/he may refer the person to a psychiatrist.

About 60% of patients with OCD improve with medication. In order for a person to know whether s/he responds, s/he may have to take a high dose of the drug for at least 12 weeks.

The newer selective serotonin reuptake inhibitor (SSRI) drugs are more widely prescribed. These include: Fluoxetine (trade name ‘Prozac’); Fluvoxamine (’Faverin’); Sertraline (’Lustral); Paroxetine (’Seroxat’); Escitalopram (’Cipralex’) and Citalopram (’Cipramil’). All these drugs can be effective but one person may get a better response to one than another. As a result, at least three are usually tried before concluding that they have no benefit.

Clomipramine (trade name ‘Anafranil’) was the first anti-obsessional drug available in the UK but this is less commonly prescribed now. The dose required may be quite high (250mg or more) and this can lead to some side effects including: dry mouth, blurred vision, constipation, drowsiness, dizziness on standing, and inability to reach orgasm.

In individuals who do not respond to anti-obsessional drugs, other medications may also be prescribed, such as Risperidone (trade name in UK ‘Risperidal’), Haloperidol (’Haldol’) or Sulpiride (’Dolmatil’). These drugs are probably only useful in a low dose in a few patients, as an additional treatment to anti-obsessional drugs, and after a number of anti-obsessional drugs have already been tried fully. They are not thought to be helpful if used alone. They have different side effects such as stiffness in the limbs or slurred speech that can be countered by other medication. In low doses the drugs may help to reduce anxiety. In more severe cases, there are other drugs that may be added to improve the response.

SSRIs tend to produce fewer side effects than clomipramine. With these drugs, a minority of people may experience nausea, diarrhoea, headache, difficulty in sleeping, restlessness or difficulties in reaching orgasm. Most people find the side effects are minor irritations that usually decrease after a few weeks. Although the patient may stop taking SSRIs whenever s/he wishes, it is sensible to reduce them under supervision.

If you have any concerns regarding your medication, please speak to your GP or whoever prescribed the treatment.

Behaviour therapy began in the late 1960s and is the most researched psychological treatment for OCD. It involves repeatedly confronting feared situations that are avoided (a process called ‘exposure’).

For the treatment to be successful, the exposure needs to be long enough for the anxiety to subside. The fear needs to be constant and the exposure should be repeated often. Exposure needs to be done without performing a compulsion (a process called ‘Response Prevention’) and in this way allow the person to tolerate the discomfort that occurs. If a compulsion is performed, then the exposure should be repeated in order to ‘undo’ the compulsion.

Each individual has a personal hierarchy. This means that each person starts by confronting relatively easy situations and then gradually works up to more difficult ones. Facing up to each fear becomes easier and easier and the anxiety gradually subsides. The short-term side effects consist of anxiety and distress, but these will gradually decrease and, in the long term, the fear will subside. No one is forced to confront their fears but the person with OCD is encouraged to take responsibility for devising their own programme. A therapist does not have to be present, although it may help some individuals at the start of their treatment programme. Tasks need to be challenging but not overwhelming. There are a number of excellent self-help books which explain such programmes in more detail.

In research trials, about 25% of patients either refuse to take part in a programme of Exposure and Response Prevention (ERP) or fail to adhere to a programme. Of those that do adhere, about 75% are helped significantly after 10-20 sessions as an outpatient. The risk of relapse after treatment is about 25%, when the person may require additional treatment. More severe cases (especially washers) may be helped by a more intensive programme as an inpatient or at home. Due to the high drop-out rate and partial success with ERP, research is being carried out to make this treatment better. One approach is adding cognitive therapy.

Cognitive therapy suggests that OCD results when an individual misinterprets intrusive thoughts or urges as a sign that not only will harm occur, but that they may be responsible for it through what they do or what they fail to do. Therapy seeks to help the individual understand that their problem is one of anxiety rather than danger and to react accordingly. Individuals with OCD are therefore trying too hard to prevent harm. The solution becomes the problem. For example, a mother may try to suppress or neutralise intrusive thoughts about stabbing her baby. This has the effect of increasing the frequency of intrusive thoughts. The problem is not the intrusive thoughts but the meaning the individual with OCD attaches to them; for example “having such thoughts means I might act upon them” or “I shouldn’t be having such thoughts”. This has the effect of increasing the degree of threat and responsibility felt, and will lead the person to avoid having knives around their kitchen or being alone with their baby. This will further maintain their fears and prevent the person from demonstrating that their fears are just ‘thoughts’.

Cognitive therapy will also try to help the person overcome the need for certainty and to alter the criteria they may use to terminate a compulsion (eg, when “I feel comfortable” or “just right” – beliefs that will tend to maintain a compulsion.).

When a person is receiving CBT, the most important ingredient is the homework that must be done between the sessions. The therapist can only act as a guide or teacher and the more patients practise on their own, the sooner they will get better. When patients have completed a successful course of treatment for OCD, most experts recommend follow-up visits for at least six months to a year.