eMedicine Specialties > Psychiatry > Adult

Obsessive-Compulsive Disorder: Follow-up

Author: William M Greenberg, MD, Associate Director, Clinical Development, Forest Research Institute, Forest Laboratories, Inc; Visiting Scientist, Nathan S Kline Institute for Psychiatric Research; Private Practice
Contributor Information and Disclosures

Updated: May 31, 2009

Follow-up

Further Inpatient Care

  • Obsessive-compulsive disorder (OCD) typically is treated in an outpatient setting.
  • Consider hospitalization if symptoms are sufficiently severe to impair a patient's ability to care for himself/herself safely at home or if a risk of suicide exists. If admission is necessary, admitting the patient to an inpatient unit whose staff is familiar with OCD and behavioral therapy is preferable.

Further Outpatient Care

  • OCD is a chronic illness that usually can be treated in an outpatient setting. The mainstays of treatment are behavior therapy and use of serotoninergic antidepressant medications.
  • Patients who have achieved remission of symptoms with behavior therapy alone may never require medication and may only need to return to therapy if they have an exacerbation of their illness. Also, a subset of patients has been treated with a combined approach; these patients can discontinue medication, maintaining a remission with behavioral interventions alone. However, many patients require ongoing medication to prevent relapse.

Inpatient & Outpatient Medications

  • SSRIs or clomipramine should be advanced as tolerated to a therapeutic dose. Clinical response may take 6-10 weeks to become apparent. The clinician should review adequacy of dose, duration of therapy, and compliance before deciding that a medication is ineffective.
  • Antipsychotics, such as haloperidol, olanzapine, and risperidone, have been used with some success in augmenting SSRIs in patients with OCD, particularly in those with comorbid Tourette disorder or other tic disorders.7

Transfer

If a patient has symptoms of sufficient severity to warrant hospitalization, consider transfer to a psychiatric unit with expertise in treating OCD.

Prognosis

  • OCD is an illness with a wide range of potential severity.
    • Overall, close to 70% of patients entering treatment experience a significant improvement in their symptoms. However, OCD remains a chronic illness, with symptoms that may wax and wane during the life of the patient.
    • Roughly 15% of patients can show a progressive worsening of symptoms or deterioration in functioning over time.
    • Approximately 5% of patients have a complete remission of symptoms between episodes of exacerbation.
    • Pharmacological treatment is often prescribed on a continuing basis; if a successfully treated individual discontinues their medication regimen, relapse is not uncommon. However, patients who successfully complete a course of CBT (perhaps as few as 12-20 sessions) may experience enduring relief even after the treatment, although some evidence shows that having CBT continue in some extended but less frequent fashion may further decrease the risk of relapse.
  • A certain percentage of patients may have disabling, treatment-resistant symptoms.
    • These patients may require multiple medication trials and/or referral to a research center.
    • A small subgroup of these patients may be candidates for neurosurgical intervention.

Patient Education

  • Education about the nature and treatment of OCD is essential. As with many psychiatric disorders, patients and their families often have misconceptions about the illness and its management. Information should be provided about the neuropsychiatric source of the symptoms, as opposed to having families unnecessarily blame themselves for causing the disorder.
  • Some of the limited experience the public has with modestly accurate portrayals of OCD come from the visual media (eg, Jack Nicholson in As Good As It Gets, Nicolas Cage in Matchstick Men, Leonardo DiCaprio in The Aviator —the screen saga of Howard Hughes' life, and Tony Shalhoub in the television series Monk). A more helpful and very well-written book for the public, which became a national best-seller, is Dr. Judith Rapoport's The Boy Who Couldn't Stop Washing30 , telling the story of the recognition and identification of effective treatments for individuals with OCD.
  • More usefully, patients and their families should be provided information on support groups and have opportunities to discuss the impact the illness has had on their self-experience and on their relationships. The Obsessive-Compulsive Foundation (203-401-2070) is a self-help and family organization founded in 1986 that offers information and resources regarding OCD and related disorders (including contact information for various types of affiliated support groups, contact information listing psychiatrists and therapists who are experienced in the treatment of OCD, research opportunities, book reviews, etc).
  • Some other organizations offer more specialized resources, (eg, San Francisco Bay Area Internet Guide for Extreme Hoarding Behavior), the Madison Institute of Medicine's Obsessive Compulsive Information Center, which provides information and a monthly newsletter for individuals with OCD symptoms of scrupulosity about religious/moral issues.
  • A more complete listing of OCD resources appears as an appendix in the APA Practice Guideline for OCD.22
  • Several self-help books are also available, including Drs. Edna Foa and Reid Wilson's book23 , which can add CBT-style self-treatment to the educational experience they provide.
  • Other useful Web sites include the following:

Miscellaneous

Medicolegal Pitfalls

  • The most common medical pitfall in the treatment of OCD is the failure to make the diagnosis. Clinicians should be familiar with the diagnostic criteria and consider OCD in their differential when evaluating tics, mood and anxiety disorders, or other compulsive behaviors such as trichotillomania or neurodermatitis.
  • Another common pitfall is the failure to identify the comorbid diagnoses frequently encountered in patients with OCD. These can include the following:
    • Major depressive disorder (30-70%)
    • Panic disorder (14%, 35% lifetime incidence)
    • Body dysmorphic disorder (14.5%)
    • Generalized anxiety disorder (20%)
    • Social phobia and simple phobia (24%)
    • ADHD
    • Tourette syndrome (5-7%)
    • Other tic disorders (20-30%)
    • Trichotillomania
    • Neurodermatitis
    • Idiopathic torticollis
    • Substance abuse
    • Eating disorders
  • Identification of these diagnoses guides treatment interventions as well as identifies those patients who are at higher risk for suicide or self-harm. Not surprisingly, patients with OCD have a significant risk for suicide, which increases with the severity of symptoms and the number of concurrent psychiatric diagnoses.
 
Acknowledgments

The authors and editors of eMedicine gratefully acknowledge the contributions of previous author Sarah C Aronson, MD to the development and writing of this article.



More on Obsessive-Compulsive Disorder

Overview: Obsessive-Compulsive Disorder
Differential Diagnoses & Workup: Obsessive-Compulsive Disorder
Treatment & Medication: Obsessive-Compulsive Disorder
Follow-up: Obsessive-Compulsive Disorder
References
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Further Reading

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Keywords

OCD, obsessive-compulsive disorder, obsessions, anxiety, obsessive compulsive disorder treatment, symptoms, cognitive-behavioral therapy, CBT, anxiety, behavior therapy, exposure and response prevention

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Contributor Information and Disclosures

Author

William M Greenberg, MD, Associate Director, Clinical Development, Forest Research Institute, Forest Laboratories, Inc; Visiting Scientist, Nathan S Kline Institute for Psychiatric Research; Private Practice
William M Greenberg, MD is a member of the following medical societies: American Orthopsychiatric Association and American Psychiatric Association
Disclosure: Forest Laboratories, Inc. Salary Employment

Medical Editor

Mohammed A Memon, MD, Medical Director of Geriatric Psychiatry, Department of Psychiatry, Spartanburg Regional Hospital System
Mohammed A Memon, MD is a member of the following medical societies: American Association for Geriatric Psychiatry, American Medical Association, and American Psychiatric Association
Disclosure: Nothing to disclose.

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Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

David Bienenfeld, MD, Vice-Chair, Program Director, Professor, Department of Psychiatry, Wright State University School of Medicine
David Bienenfeld, MD is a member of the following medical societies: American Medical Association, American Psychiatric Association, and Association for Academic Psychiatry
Disclosure: Nothing to disclose.

CME Editor

Harold H Harsch, MD, Program Director of Geropsychiatry, Department of Geriatrics/Gerontology, Associate Professor, Department of Psychiatry and Department of Medicine, Froedtert Hospital, Medical College of Wisconsin
Harold H Harsch, MD is a member of the following medical societies: American Psychiatric Association
Disclosure: lilly Honoraria Speaking and teaching; Forest Labs Honoraria Speaking and teaching; AstraZeneca Honoraria Speaking and teaching; Pfizer Grant/research funds Speaking and teaching; Northstar Grant/research funds Research; Novartis Grant/research funds research; Pfizer  Speaking and teaching; Sanofi-avetis Grant/research funds research; Otsuke Grant/research funds reseach; GlaxoSmithKline Grant/research funds research

Chief Editor

Stephen Soreff, MD, President of Education Initiatives, Nottingham, NH; Faculty, Metropolitan College of Boston University, Boston, MA
Stephen Soreff, MD is a member of the following medical societies: American College of Mental Health Administration and American Psychosomatic Society
Disclosure: Nothing to disclose.

 
 
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