Evidence-Based Reviews

Innovative and practical treatments for obsessive-compulsive disorder

Current Psychiatry. 2002 February;1(2):30-37

References

1. Goodman Wk, Price LH, et al. The Yale Brown Obsessive Compulsive Scale:1. Development, Use and Reliability. Arch Gen Psychiatry. 1989;46:1012-1016.

2. Catapano F, Sperandeo R, Perris F, Lanzaro M, Maj M. Insight and resistance in patients with obsessive compulsive disorder. Psychopathol. 2001;34(2):62-68.

3. Amir N, Freshman M, Foa EB. Family distress and involvement in relatives of obsessive-compulsive disorder patients. J Anxiety Disord. 2000;14(3):209-217.

4. Chambless DL, Steketee G. Expressed emotion and behavior therapy outcome: a prospective study with obsessive compulsive and agrophobic outpatients. J Consult Clin Psychol. 1999;67(5):658-665.

5. Black DW, Monahan P, Gable J, et al. Hoarding and treatment in 38 nondepressed subjects with OCD. J Clin Psychiatry. 1998;59(8):420-425.

6. Rosqvist J, Egan D, Manzo P, et al. Home-based behavior therapy for obsessive compulsive disorder: A case series with data. J Anxiety Disord. 2001;15(5):395-400.

7. Alonso P, Menchon JM, Pifarre J, et al. Long term follow up and predictors of clinical outcome in obsessive compulsive patients treated with serotonin reuptake inhibitors and behavioral therapy. J Clin Psychiatry. 2001;62(7):535-540.

8. Wewetzer C, Jans T, Muller B, et al. Long term outcome and prognosis of obsessive compulsive disorder with onset in childhood or adolescence. Eur Child Adoles Psychiatry. 2001;10(1):37-46.

9. Steketee G, Chambless DL, Tran GQ. Effects of axis I and axis II comorbidity on behavior therapy outcome for obsessive-compulsive disorder and agrophobia. Compr Psychiatry. 2001;42(1):76-86.

10. Piacentini J. Cognitive behavioral therapy in childhood OCD. Child Adolesc Psychiatr Clin N Am. 1999;8(3):599-616.

11. Himle JA, Rassi S, et al. Group behavioral therapy of obsessive Compulsive disorder: seven vs. twelve-week outcomes. Depress Anxiety. 2001;13(4):161-165.

12. Nakagawa A, Marks IM, Park JM, Bachofen M, Baer L, Dottl SL, Greist JH. Self treatment of obsessive compulsive disorder guided by manual and computer conducted telephone interview. J Telemed Telecare. 2001;6(1):22-26.

13. McLean PD, Whittal ML, et al. Cognitive verses behavior therapy in the group treatment of obsessive compulsive disorder. J Consult Clin Psychol. 2001;69(2):205-214.

14. van Balkom AJ, de Haan E, van Oppen P, et al. Cognitive and behavioral therapies alone versus in combination with fluvoxamine in the treatment of obsessive-compulsive disorder. J Nerv Ment Dis 1998;186:492-499.

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16. Pigott TA. Seay SM: A review of the efficacy of selective serotonin reuptake inhibitors in obsessive-compulsive disorders. J Clin Psychiatry. 1999;60:101-106.

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18. McDougle CJ, Barr LC, et al. Lack of efficacy of clozapine monotherapy in refractory obsessive-compulsive disorder. Am J Psychiatry. 1995;152(12):1812-1814.

19. Honagen F, et al. Combination of behaviour therapy with fluvoxamine in comparison with behaviour therapy and placebo. Br J Psychiatry. 1998;173(suppl 35):71-78.

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Treating patients whose OCD is associated with trauma

Exposure and response prevention therapy (ERP) may be contraindicated for OCD patients with comorbid posttraumatic stress disorder (PTSD). Patients with trauma histories, especially those for whom the trauma precipitated the onset of OCD symptoms, should receive trauma treatment before or in conjunction with ERP in order to be effective.

Patients with OCD and PTSD should receive adjunctive cognitive behavioral therapy (CBT) for their PTSD. Skills training modules, such as dialectical behavior therapy (DBT) and other CBT treatments, often provide the patient with the necessary skills to regulate the trauma-related stressors that are triggered during ERP and can cause premature termination of treatment.

If habituation is not occurring in the absence of trauma, ask whether the patient is dissociating, daydreaming, numbing, or distracting, as these avoidances will jeopardize his or her ability to benefit from ERP. Teaching the patient grounding techniques and alternate coping mechanisms, such as those found in the mindfulness and distress tolerance module of DBT, can help some patients tolerate their anxiety.

For trauma patients whose dissociation, numbing, or distraction is severe, home-based or residential treatment may be required. There, they can be coached during ERP to bring their attention back to the feared stimuli and deal with the negative fallout of their trauma..

In such cases, a patient cannot realistically be asked to give up a coping mechanism, faulty as it may be, until a more functional reinforcer takes its place. Hence, skills training is a crucial part of treatment for this group.

Residential treatment for OCD patients with comorbid substance abuse in remission may be necessary to ensure a positive outcome. Patients should continue recovery work concurrent to behavior therapy to prevent relapse.

High-risk OCD symptoms Patients who have more traditional OCD symptoms usually have a good prognosis. Unfortunately some symptoms do not respond to ERP treatment. These include:

Repeating, hoarding, and symmetry. Though evidence suggests that hoarding is predictive of poor outcomes,⁵ treatment carried out in the home can be effective over a 24-week trial.⁶
Incompletion, or the need for things to feel right.
Rigid and overvalued belief systems.
Sexual and religious obsessions. These appear to be more resistant to behavior therapy and selective serotonin reuptake inhibitors (SSRIs).⁷

More research needs to be conducted to offer patients with these symptoms better respite.

Researchers also found that patients with childhood and adolescent onset of symptoms, tics, history of hospitalization, and terminated treatment against medical advice are more likely than other OCD patients to develop more severe symptoms in adulthood.⁸ Patients with OCD who also suffer from generalized anxiety disorders are more likely than those without GAD to drop out of treatment.⁹

Behavior therapy: first choice

ERP is considered the premier treatment for OCD and is suitable for both adults and children.¹⁰ Exposure forces patients to confront their feared stimuli. Response prevention blocks patients from engaging in compulsions or avoidance behaviors intended to reduce their discomfort. Patients are asked to identify situations that trigger their obsession and compulsions and rank them along a fear hierarchy. Patients confront a moderately rated situation and, once they become habituated to it, move up the fear hierarchy to the next situation.

ERP has been proven effective for OCD not only as an individual behavior treatment, but also when done in a group setting¹¹ or when delivered online or by telephone.¹²

Table 1

Dosage levels for SRIs in OCD

Clomipramine	150-200 mg/d
Fluoxetine	40-80 mg/d
Sertraline	50-200 mg/d
Fluvoxamine	200-300 mg/d
Paroxetine	40-60 mg/d
Citalopram	40-60 mg/d
The higher end of the dosage ranges shown above is preferred if tolerated. All clinical trials with SRIs for OCD should last at least 10 weeks.

Some clinicians prefer cognitive behavioral therapy (CBT) to ERP because it is less aversive. Researchers found that patients who were treated with either CBT or ERP improved. Patients treated with ERP, however, were more likely to maintain their gains in recovery 3 months after treatment concluded.¹³ Evidence suggests that ERP or CBT when implemented alone, or when applied in conjunction with fluvoxamine,¹⁴ are equally effective.

ERP should be managed only by clinicians specially trained in this modality. Several treatment centers across the country provide specialized care for OCD patients. For the nearest treatment center in your community that accepts referrals for ERP, contact the OC Foundation in North Branford, Conn. (See Related Resources.)

Medication for OCD: SRIs as first-line therapy

Experts agree that first-line somatic treatments for OCD include not only behavior therapy but also serotonin reuptake inhibitors (SRIs),¹⁵ that is, clomipramine or selective serotonin reuptake inhibitors, (SSRIs) (Table 1).

Caution: Many patients who “respond” to treatment in clinical studies remain symptomatic and meaningfully affected by their residual illness. Therefore, it is critical that you inform patients at the outset that 100% reduction in symptoms is rare.