Day # 95: Treatment of Obsessive Compulsive Disorder (OCD)

Today we will discuss the treatment of obsessive compulsive disorder (OCD). We will summarize pharmacological and non-pharmacological options and provide a framework for when to consider specific treatments.

Today's Content Level: Intermediate

INTRODUCTION

•Treatment options for OCD includes psychotherapy, pharmacotherapy, and other alternative treatments. Therapy and medications are both effective separately and together in OCD. The most effective treatment is a combination of these approaches.

•Discuss patient’s preference for psychotherapy and/or pharmacotherapy, as studies show that patient choice is one of the most important factors for recovery.

•Medications can reduce symptoms enough so that a patient can participate in therapy and address any psychosocial contributors of their symptoms and train themselves to resist acting out their compulsions. Therapy can help prevent relapse if medications are no longer prescribed.

Goals of treatment include:

• Decrease the frequency and severity of symptoms. Significant treatment response is typically defined as reduction in Y-BOCS score by at least 25%–35%.

• It is helpful to set measurable goals such as spending less than 1 hour per day obsessing or performing compulsive behaviors.

• Improved functioning and quality of life.

• Once symptoms have improved, a shift in focus to preventing relapse is important. For example, continued medication management for 1-2 years before a slow taper may be recommended and/or periodic therapy sessions to reinforce skills.

PSYCHOTHERAPY

•There are a number of different modalities of psychotherapy that are helpful for patients suffering from OCD. This post will describe some of the most commonly used techniques.

Exposure and Response Prevention Therapy (ERP) 1

• ERP is a specialized form of CBT and is first-line psychotherapy for mild/moderate OCD with minimal co-morbidities.

• As the name implies, it includes repeated and prolonged exposures to the thoughts, images, objects, and situations that make them anxious and/or start obsessions. It also includes response prevention training in order to help them not perform compulsive behaviors.

• Sessions typically occur weekly and have weekly homework assignments.

• Results vary, but randomized control trials have shown improvement in 55-85% of patients and improvement is maintained after completion of treatment.

• If poor response after course of ERP alone then add pharmacotherapy.

Cognitive Behavioral Therapy (CBT)

• Technically, ERP is a form of CBT, so including it here may be a bit redundant, but we will include it here to be thorough.

• CBT examines the relationship between anxiety-driven thoughts, emotions, and behaviors. The general approach is exposure (not reassurance) and cognitive restructuring.

• May be a more appropriate starting place than ERP alone if the patient has other significant co-morbidities (MDD, GAD, etc.).

• Again, results vary between trials, but studies show a similar response and effect size compared to ERP and has both short-term and long-term efficacy.

• If poor response after course of CBT then add pharmacotherapy.

Psychodynamic Psychotherapy

• "There is a long history of understanding obsessive-compulsive symptoms from a psychodynamic perspective. However, there is no rigorous evidence that a psychodynamic approach is useful in the treatment of OCD." 3

Non-Pharm / Non-Therapy

• Psychoeducation: understand the patient and families preconceptions about OCD, teach basic facts about the disorder, build a collaborative approach to care, and instill hope. Provide resources to advocacy organizations such as the Obsessive-Compulsive Foundation.

• Encourage patients to engage in regular physical exercise. Exercise has been shown to significantly reduce anxiety. 4

• Evaluate for "stimulants" such as caffeine (coffee, tea, energy drinks), workout supplements ("pre-workout), or herbal remedies with stimulant properties. Recommend significant reduction or elimination as these may worsen the anxiety associated with OCD.

MEDICATIONS

•There are a number of medications that can be helpful in OCD. SSRIs are typically first-line treatment of OCD, but other medications are also used as augmentation or as second-line options.

•One review of the research has suggested that approximately 40% to 60% of patients respond to treatment with SSRIs or clomipramine with a 20% to 40% reduction in OCD symptoms on average. 5

Selective Serotonin Reuptake Inhibitors (SSRIs)

• First-line medications for OCD.

• First-line over clomipramine (see below) due to better adverse effect profile.

• Effective but takes weeks to see treatment effect. 4-6 weeks for initial response and 10-12 weeks for max benefit

• Often requires titrating to the higher dose range to achieve symptom remission when compared to treating depression. Higher doses are often required as compared to treatment for MDD and above standard treatment guidelines are sometimes given (eg, sertraline >200 mg).

• Most effective when combined with psychotherapy.

• No specific drug has been shown to have significantly higher efficacy than any other. The choice is often based on the side effect profile, drug-drug interactions, patient preference, or providers clinical experience.

• Fluvoxamine is unique among SSRIs in that it only has FDA approval for OCD.

• SNRIs not considered first-line (less evidence for adrenergic involvement in OCD), but have been used as second-line agent with some efficacy.

• See earlier post on SSRIs for more details on this class of meds.

Tricyclic Antidepressants (TCAs) 6, 7

• First-line alternative for OCD if SSRIs are not effective.

• In head-to-head comparisons of clomipramine and SSRIs, there is equal efficacy, but SSRIs are better tolerated (less side effects). Monitor for anticholinergic side effects in particular.

• Clomipramine is preferred among TCAs since it is the most potent serotonin reuptake inhibitor (SRI) among the TCAs. In fact, clomipramine is more potent as an SRI than any of the SSRIs. Typical dose range effective for OCD 50-250 mg.

• See earlier posts on TCAs for more details on this class of meds.

Antipsychotics 8

• Second-line option for OCD. Consider if partial response with SSRI/clomipramine.

• Most often used in low to moderate doses as augmentation to SSRI/clomipramine.

• Risperidone and aripiprazole have the most data. There is some evidence for haloperidol.

Third-Line Options / Experimental

• SSRI + clomipramine: Consider combination of SSRI and clomipramine. Inform of risk of serotonin syndrome and monitor closely. The combination of citalopram and clomipramine (9) has been studied specifically and is recommended by NICE.

• There are a number of other medications that have either initial positive data or mixed results.

  • Options include augmentation with buspirone, acetylcysteine (GI effects may be problematic), lamotrigine (slow up-titration), topiramate (for compulsions specifically), memantine, riluzole, pindolol, and ketamine.

Other Interventions

• Residential Treatment: for severe cases of OCD you may consider placing a referral for a higher level of care such as a residential program. Patients may benefit from an interdisciplinary approach for cases that have proven difficult to treat using standard therapies. For more details view this article.

• ECT or TMS: TMS received FDA approval for treating OCD in 2018. ECT can be considered in severe refractory cases, particularly if comorbid depression is present. 10

• Surgical options: OCD is one of the few mental health disorders where surgical interventions can be effective in treatment-resistant, severely debilitating cases. Options include anterior cingulotomy, capsulotomy, and deep brain stimulation.

CONCLUSION

I hope you enjoyed this overview of the treatment of OCD. Feel free to comment below if there is something I missed or if there was anything in particular that you learned. During our next lesson we will discuss body dysmorphic disorder.

Resources for today's post include Pocket Psychiatry, Kaplan and Saddocks Comprehensive Psychiatry, and the Maudsley Prescribers Guide.

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