Obsessive-Compulsive Disorder Treatment & Management

OCD is a chronic illness that usually can be treated in an outpatient setting. The mainstays of treatment of OCD include the use of serotoninergic antidepressant medications, particular forms of behavior therapy (exposure and response prevention and some forms of CBT), education and family interventions, and, in extremely refractory cases, neurosurgery.

Patients who have achieved remission of symptoms with behavior therapy alone may never require medication and may instead need only 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.

Consider hospitalization for a patient with OCD if a suicide risk exists or if the individual’s symptoms are sufficiently severe to impair the patient's ability to care for himself/herself safely at home. If inpatient care is necessary, admitting the patient to a psychiatric unit whose staff is familiar with OCD and behavioral therapy is preferable.

First-line pharmacologic treatments consist of 5-HT reuptake inhibitors, such as the SSRIs (fluoxetine, fluvoxamine, sertraline, paroxetine, citalopram, escitalopram), and clomipramine (Anafranil), a tricyclic antidepressant [TCA] with 5-HT and NE reuptake inhibition. Possible alternatives include venlafaxine, a serotonin norepinephrine reuptake inhibitor (SNRI). All of these are commonly used to treat OCD, although not all have received an indication from the US Food and Drug Administration (FDA) for this disorder.

Unlike in the case of major depression, complete or near-complete remission of OCD symptoms is rare with only serotonergic antidepressant treatment. More typically, perhaps half of patients may experience symptom reductions of 30-50%, as measured by the Y-BOCS, with many other patients failing to achieve even this degree of relief.

Doses above those needed for treatment of depression may be more effective for some patients. A therapeutic dose for 6-10 weeks may be required to observe a clinical response. Response tends to be slow and continue for at least 12 weeks (the common duration of OCD pharmacologic clinical trials), unlike the use of these same antidepressants in the treatment of major depressive episodes, where responses are more often seen somewhat earlier.

Several treatment studies suggest a possible role for norepinephrine (NE) in cases of OCD. A subset of patients reportedly shows greater clinical improvement with a combination of 5-HT and NE reuptake inhibition as compared with treatment with SSRIs alone. These have included patients treated with clomipramine and patients whose SSRI treatment was augmented with an NE reuptake inhibitor, such as desipramine. (See Treatment-Resistance Strategies.)

Preclinical studies and several case reports and small clinical trials have provided some preliminary support for the therapeutic use of specific glutamatergic agents. ^{[6, 7]} However, these agents (eg, memantine, N -acetylcysteine, riluzole, topiramate, glycine) have varied glutamatergic and other pharmacologic effects, so if they are demonstrated to be effective, clarifying any therapeutic mechanism of action will be important.

The first double-blind, placebo-controlled trial conducted by Berlin et al suggests topiramate augmentation for treatment-resistant OCD may be beneficial for compulsions but not obsessions. ^[33] The modification of glutamatergic function may be partly responsible for the improved response in compulsions seen with topiramate.

Behavior therapy is a first-line treatment that should be undertaken with a psychotherapist who has specific training and experience in such treatment (most commonly a behaviorally trained psychologist). Some patients will not undertake this therapy, with perhaps 25% rejecting it and 25% dropping out of behavioral therapy, but it should definitely be encouraged if a competent behavioral therapist is available.

Exposure and response (or ritual) prevention (ERP) is the important and specific core element in behavior therapy for OCD. The patient rank orders OCD situations he or she perceives as threatening, and then the patient is systematically exposed to symptom triggers of gradually increasing intensity, while the individual is to suppress his or her usual ritualized response. This is generally challenging and often quite distressing for the patient, but when effectively done, it promotes unlearning of the strong link that has existed between having an urge and giving into the urge.

When a patient does not respond in the face of a potent trigger, extinction of the response can take place. The patient’s significant others should be involved when possible, and they may have to be willing to change their responses to the patient (eg, not provide requested reassurance to irrational doubts).

Simpson et al reported on a multimodal residential treatment program that integrated ERP treatment for OCD with ERP treatment that targeted eating pathology. Patients also received a supervised eating plan, medication management, and social support. The results were significant decreases in OCD severity, eating disorder severity, and depression in the 56 patients with both disorders. Greater improvement was seen in patients with bulimia nervosa than in those with anorexia nervosa. ^[34]

ERP is now usually administered as part of a broader program of CBT specifically designed for OCD. Other elements of CBT that are used include identifying and challenging the cognitive distortions of OCD symptoms (eg, intolerance of uncertainty, black-and-white thinking, focusing on unlikely extreme possibilities instead of viewing the future in a balanced manner, ascribing overimportance to thoughts, excessive concern about the importance of one's thoughts, inflated sense of responsibility). After making the patient aware of his or her irrational thoughts, the therapist works to have the patient counter them with more rational thoughts and do cost/benefit analyses regarding performing his or her rituals.

Meditation and relaxation techniques may be useful, but not during active ERP, as the effectiveness of these exercises requires that the patient experience a significant level of discomfort and then not respond with his or her characteristic rituals. A patient may benefit from a self-help book in conducting ERP (eg, Foa and Reid, 2001 ^[31] ), and workbooks are available for CBT as well. When recommending such a book, the treating physician should be familiar with its content.

A related approach, described by Dr. Jonathan Grayson, focuses on getting the patient to accept living with uncertainty as it relates to his or her obsessional ideas, and to prepare an individualized script to reinforce this attitude. ^[35]

Psychodynamic psychotherapy alone has generally not been found to be helpful in ameliorating OCD symptoms. It may, however, be useful in working on a patient's resistance to accepting recommended treatments or in helping the patient to appreciate the interpersonal effects that his or her OCD symptoms are having on others. ^[30]

Strategies should always include an assessment of complicating diagnoses, medication compliance, drug dose, and duration of therapy.

The presence of a comorbid diagnosis that has not been addressed, such as depression or panic disorder, can interfere with clinical recovery, and identification may guide the choice of interventions. Targeted interventions might include, for example, lithium or antipsychotic augmentation or ECT for depression.

Interventions for patients with treatment resistance include the following:

• Change or increase in medication (eg, increase dose or prescribe different SSRI or clomipramine)

• More intensive CBT

Other interventions, which have not received an FDA indication for OCD include the following:

• Addition of an NE reuptake inhibitor, such as desipramine, to an SSRI, or a trial of venlafaxine

• Addition of a typical or atypical antipsychotic, especially in patients with a history of tics

• Augmentation with buspirone

• Addition of inositol

• Sole or augmented use of selected glutamatergic agents ^{[6, 7]}

• Deep brain stimulation ^{[11, 12]} or cingulotomy neurosurgery ^[13] for severe and intractable cases (see Surgical Care)

Some clinicians feel that individuals with comorbid Tourette disorder or with hoarding as their principal OCD symptom may be more likely to be treatment resistant, although there is significant variation in treatment response, regardless of the particular presenting symptomatology.

Neurosurgical treatment of OCD is performed at a limited number of centers and is reserved for patients with severe and refractory symptoms. The most common small series use a specific small lesion (eg, cingulotomy) or deep brain stimulation. Current clinical trials are also exploring the application of transcranial magnetic stimulation (TMS), a noninvasive treatment, for OCD.

One surgical technique involves the stereotactic placement of bilateral lesions in the anterior cingulate cortex. A case series of 18 patients showed a 28% response rate, with an additional 17% showing a partial response. No significant adverse neurologic or cognitive sequelae were noted.

A deep brain stimulation technique consists of implanting a device to electrically stimulate the subthalamic nucleus. A crossover study in 17 patients with severe, refractory OCD in which patients received 3 months of active stimulation and 3 months of sham stimulation in randomized order, found that there was significantly more improvement during the active stimulation periods. However, serious adverse events were substantial and included intracerebral hemorrhage and infection. ^[12]

In February 2009, the FDA approved the use of Reclaim Deep Brain Stimulation Therapy for individuals with chronic, severe OCD. This device is an implanted medical device that is designed to target a region called the ventral capsule/ventral striatum, which is in the anterior limb of the internal capsule of the brain.

The Obsessive Compulsive Foundation can provide a list of centers with experience in neurosurgical OCD treatment.

While treatment approaches for OCD are now well described in the literature, many clinicians remain unfamiliar with the features and management of this disorder. Consultation should be sought if the treating physician is unfamiliar or uncomfortable with the diagnosis, or if they feel they have exhausted the interventions with which they feel comfortable.

Consultations should be sought if the clinician is not experienced in treating patients with OCD with cognitive-behavioral therapy, including exposure and ritual prevention, if the patient might possibly cooperate with this treatment. For extreme, unremitting cases, consultation may be sought for neurosurgical interventions.

OCD is a disorder that may involve remissions and relapses, but it usually does not entirely remit without definitive behavioral therapy. Patients in continuing treatment should be monitored for the presence or worsening of comorbid disorders, which may include substance use disorders and major depression, and any risk of suicidal ideation or behavior.