Jonathan Lukas: Medication vs. No Medication for Treating Anxiety Disorders

I’m often asked if medication is necessary in the treatment of obsessive-compulsive disorder and related anxiety disorders. Because no two people are the same in terms of severity of symptoms, genetic makeup and tolerance to medication, there is no simple answer.

Some people come into therapy with a conviction that they will not take medication under any circumstances. I let them know that I support that decision with the caveat that it might be more difficult to achieve the same level of symptom reduction without medication. With medication and cognitive behavioral therapy, the treatment for OCD shows to be more effective vs. therapy alone or medication alone. This is because the medications used to treat anxiety disorders include Selective Serotonin Reuptake Inhibitors (SSRIs).

Anti-anxiety medications such as Ativan or Klonopin and, for more severe types of OCD, atypical antipsychotics might be necessary. These medications target certain areas of the brain and specific neurotransmitters that can be crucial in successfully reducing the debilitating symptoms of OCD.

Without medication, success can be more difficult to obtain because treatment for OCD involves actually increasing a patient’s anxiety to allow for habituation of anxiety without the use of compulsions or rituals. Therefore the initial spike in anxiety can be more difficult to tolerate without medications to aid and in effect give the patient breathing room to adjust to exposure and response prevention, a form of cognitive behavioral therapy.

When a patient is suffering from intense anxiety from obsessions, there is an overwhelming need to try to reduce that anxiety through the use of rituals or compulsions. They don’t work and only lead to more anxiety and thus more compulsions. This is the cycle of OCD. The more anxiety you feel, the more you feel a need to stop the anxiety through rituals.

With medication, a person can experience less intense anxiety spikes as a result of these medications. The result is a reduced need to engage in compulsive behaviors since the obsessions become less intrusive, frightening and overwhelming. It is as though the medications are allowing the person some leeway to gain insight into this disorder while engaging in cognitive behavioral therapy to understand anxiety in a new and more effective way.

If a client came to me with mild to moderate symptoms of OCD, I would want to look at the client’s motivation, level of insight and general functioning to help him or her make an educated decision as to whether medication is necessary. For example, if a client is functioning well, is maintaining a job and healthy relationships, and generally just wants to get the anxiety more under control, then medication might not be necessary. If, on the other hand, a client is generally not functioning, i.e., is isolating, engaging in OCD nonstop, is no longer taking care of his or her physical health and is experiencing depression along with anxiety, I would absolutely refer the client to a psychiatrist for a medication evaluation.

Without medication, this client most likely will struggle with exposure and response prevention because of the initial increased anxiety and will often refuse to do the work that is necessary to overcome the severe symptoms of OCD. My ethical duty is to provide the best information and the best treatment that I can. If I feel medication is necessary with the level of anxiety being experienced, then I will say so. If the client still refuses to consider medication, then the likelihood of successful treatment is limited. This doesn’t mean the client won’t make some gains, but medication could make the difference between moderate relief from symptoms vs. major relief from symptoms.

The complaints that I hear about medication are often the same. “What if I have to take these medications for the rest of my life?” “What if the medications make my symptoms worse?” “What if I become addicted to these medications and can’t get off of them when I want to?” These are all very important considerations.

Here is what I tell them: “When you are battling a brain disorder like OCD, it’s important to use every weapon available to you. For more difficult cases of OCD, medication will give you an ability to fight OCD more effectively in conjunction with CBT. Without medication, you are likely to find that the symptoms of OCD are just too difficult to fight on your own. OCD not only affects our emotional health but can also affect our physical health. If you were a diabetic, you most likely would need insulin to treat the diabetes and keep it in check. With OCD, a brain disorder, the medication would help to keep the symptoms in check. The medication would give you the added tools to truly help you fight this brain disorder. You could always choose to fight OCD without medication, but it will be a tougher fight.”

I have worked with clients who sometimes refuse medication even though they are at a level of severity that would merit medication. I often find that their opinion of the need for medication changes as we get further into treatment. Some clients refuse to consider medication, and they often don’t make significant gains. When I work with clients who are motivated, open to the possibility of medication and really just sick and tired of battling OCD, then greater success is absolutely possible and probable.

Finally, I would say keep an open mind about medication in conjunction with cognitive behavioral therapy if your symptoms from OCD are causing significant difficulty in general functioning. If the anxiety that you are facing is causing time-consuming compulsions and leading to depression, substance abuse (self-medicating) and isolation, then I would encourage a medication evaluation. On the other hand, if your anxiety is not significantly getting in the way of your enjoyment of life and you are motivated to beat OCD, then medication might not be as necessary. Either way, throughout the treatment process, it’s generally a good idea to keep an open mind should the symptoms become more difficult.

Medication might be the answer even if initially you didn’t consider it an option. Since OCD is a chronic brain disorder, there is a possibility that these medications will become long term. Remember that success is highly possible in the treatment of OCD, and if you or a loved one is ready to do the work necessary to put OCD in its place, then you are likely to see results. It’s tough work, but it can also be life-changing in all aspects of your life. You owe it to yourself to do whatever it takes to get your life back.

Lastly, I agree that side effects of medication can often be initially difficult and can sometimes be more trouble than they are worth. The good news is that if one doesn’t work then there are a number of medications to try these days. You are not limited to one SSRI or one anti-anxiety medication. Talk to your psychiatrist about your options.

What is more debilitating: The side effects of medication that often dissipate over time, or a lifetime of overwhelming symptoms caused my OCD and related anxiety disorders? It sometimes comes down to a choice between the lesser of two evils.

— Jonathan Lukas MFT is a psychotherapist specializing in cognitive behavioral therapy. He is in private practice and runs The OCD Treatment Center of Santa Barbara, working with adolescents and adults with anxiety disorders. Click here for more information or call 805.453.2347.