Each recommendation is identified as meriting one of three
categories of endorsement, based on the level of clinical confidence
regarding the recommendation, as indicated by a bracketed Roman numeral
following the statement. The three categories are as follows:
[I] Recommended with substantial clinical
confidence
[II] Recommended with moderate clinical
confidence
[III] May be recommended on the basis of
individual circumstances
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1. Psychiatric Management
Obsessive-compulsive disorder (OCD) seen in clinical practice
is usually a chronic illness with a waxing and waning course. Treatment
is indicated when OCD symptoms interfere with functioning or cause
significant distress [I]. Psychiatric management
consists of an array of therapeutic actions that may be offered
to all patients with OCD during the course of their illness at an
intensity consistent with the individual patient's needs,
capacities, and desires [I]. It is important to coordinate
the patient's care with physicians treating co-occurring
medical conditions, other clinicians, and social agencies such as
schools and vocational rehabilitation programs [I].
When OCD is of disabling severity, the psychiatrist may need to
write on the patient's behalf to government agencies that
control access to disability income, publicly financed health care,
or government-supported housing; or to tax authorities, courts,
schools, or employers [I]. OCD patients who are parents
of young children may want advice regarding the genetic risk of
OCD. It is important for clinicians to explain to such patients
that the available data indicate an increased but modest risk of OCD
in the children of affected individuals; patients wanting more information
may be referred to a genetic counselor [I].
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a. Establishing a Therapeutic Alliance
Establishing and maintaining a strong therapeutic alliance
is important so that treatment may be jointly, and therefore more
effectively, planned and implemented [I]. Steps
toward this end include tailoring one's communication style
to the patient's needs and capacities, explaining symptoms
in understandable terms, and being both encouraging and comforting [I].
The excessive doubting that is characteristic of OCD may require
special approaches to building the alliance, including allowing
the patient extra time to consider treatment decisions and repeating explanations
(a limited number of times) [I]. In building the
therapeutic alliance, the psychiatrist should also consider how
the patient feels and acts toward him or her as well as what the
patient wants and expects from treatment [I].
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b. Assessing the Patient's
Symptoms
In assessing the patient's symptoms with the aim
of establishing a diagnosis using DSM-IV-TR criteria, it is important
to differentiate the obsessions, compulsions, and rituals of OCD
from similar symptoms found in other disorders, including depressive
ruminations, the worries of generalized anxiety disorder, the intrusive
thoughts and images of posttraumatic stress disorder, and schizophrenic
and manic delusions [I].
The psychiatrist should consider rating the baseline severity
of OCD symptoms and co-occurring conditions and their effects on
the patient's functioning, using a scale such as the 10-item
Yale-Brown Obsessive Compulsive Scale (Y-BOCS), since this provides
a way to measure response to treatment [I]. If
a rating scale is not used, it is helpful to document the patient's
estimate of the number of hours per day spent obsessing and performing
compulsive behaviors, and the degree of effort applied to trying
to escape the obsessions and to resisting the behaviors [I].
Recording actively avoided items or situations also provides a useful
baseline against which change can be measured [I].
Scales may also be utilized to rate other symptoms, such as depression
or degree of disability.
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d. Enhancing the Safety of the Patient
and Others
The psychiatrist should evaluate the safety of the patient
and others [I]. This entails assessing the patient's
potential for self-injury or suicide, since individuals with OCD
alone or with a lifetime history of any co-occurring disorder have
a higher suicide attempt rate than do individuals in the general
population. Although acting on aggressive impulses or thoughts has
not been reported in OCD, and patients rarely resort to violence
when others interfere with their performing their compulsive rituals,
it remains important to inquire about past aggressive behavior.
OCD patients who fear loss of control may engage in extensive avoidance
rituals in an effort to contain their symptoms.
The psychiatrist should understand that individuals with OCD
are not immune to co-occurring disorders that may increase the likelihood
of suicidal or aggressive behavior. When such co-occurring conditions
are present, it is important to arrange treatments that will enhance
the safety of the patient and others [I].
Because OCD symptoms can also interfere with parenting, the
clinician may have to work with the unaffected parent or social
agencies to mitigate the effects of OCD symptoms on the patient's children [II].
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e. Completing the Psychiatric Assessment
In completing the psychiatric assessment, the psychiatrist
will usually consider all the elements of the traditional medical
evaluation [I]. With regard to co-occurring conditions,
the psychiatrist should pay particular attention to past or current
evidence of depression, given its frequency and association with
suicidal ideation and behaviors [I]. Exploration
for co-occurring bipolar disorder and family history of bipolar
disorder is also important in view of the risk of precipitating
hypomania or mania with anti-OCD medications [I].
Other anxiety disorders are common in OCD patients, as
are tic disorders, and may complicate treatment planning. Other
disorders that may be more common and may complicate treatment planning
include impulse-control disorders, anorexia nervosa, bulimia nervosa,
alcohol use disorders, and attention-deficit/hyperactivity
disorder. Past histories of panic attacks, mood swings, and substance
abuse or dependence are also relevant [I].
It is important to document the patient's course
of symptoms and treatment history, including psychiatric hospitalizations
and trials of medications (with details on treatment adequacy, dose,
duration, response, and side effects) and psychotherapies (with
details on the nature, extent, and response to all trials) [I].
The psychiatrist should also assess the patient's
developmental, psychosocial, and sociocultural history, including
his or her primary support group and sociocultural supports, potential
psychosocial stressors, educational and occupational history (including
military history), sexual history, and capacity to navigate developmental
transitions and achieve stable and gratifying familial and social
relationships [I]. In addition, the psychiatrist
should evaluate how OCD has interfered with academic and vocational
achievement as well as familial, social, and sexual relationships [I]. Having
evaluated the symptoms and their effects on well-being, functioning,
and quality of life, the psychiatrist should assess the role of
the patient's social supports in facilitating treatment
and in maintaining or exacerbating symptoms [I].
The psychiatrist should consider whether the OCD is a manifestation
of a general medical condition [I]; document current
medical conditions, relevant hospitalizations, and any history of
head trauma, loss of consciousness, or seizures [I];
and record the presence and severity of somatic or psychological
symptoms that could be confused with medication side effects [I].
Current medications and doses, including hormonal therapies, herbal
or "natural" remedies, vitamins, and other over-the-counter
medications, should be reviewed to assess the potential for pharmacokinetic
and pharmacodynamic interactions with psychotropic drugs [I].
Allergies or sensitivities to medications should be recorded [I].
A mental status examination, including an evaluation of insight
and judgment, should be performed to systematically collect and
record data related to the patient's signs and symptoms
of illness during the interview [I].
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f. Establishing Goals for Treatment
Clinical recovery and full remission, if they occur, do not
occur rapidly. Thus, ongoing goals of treatment include decreasing
symptom frequency and severity, improving the patient's
functioning, and helping the patient to improve his or her quality
of life [I]. Treatment goals also include enhancing
the patient's ability to cooperate with care despite the
frightening cognitions generated by OCD, minimizing any adverse
effects of treatment (e.g., medication side effects), helping the patient
develop coping strategies for stressors, and educating the patient
and family regarding the disorder and its treatment [I].
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g. Establishing the Appropriate Setting
for Treatment
The appropriate treatment setting may be the hospital, a residential
treatment or partial hospitalization program, home-based treatment,
or outpatient care. Treatment should generally be provided in the
least restrictive setting that is both safe and effective [I].
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h. Enhancing Treatment Adherence
To enhance treatment adherence, the psychiatrist should consider
factors related to the illness, the patient, the physician, the
patient-physician relationship, the treatment, and the social or
environmental milieu [I]. Because the patient's
beliefs about the nature of the illness and its treatments will
influence adherence, providing patient and family education may
enhance adherence [II]. Many patients with OCD
benefit from educational materials and access to support groups
provided by the Obsessive Compulsive Foundation (www.ocfoundation.org).
When a patient has insufficient motivation to participate effectively
in treatment, motivational interviewing or other psychosocial interventions
designed to enhance readiness for change may be helpful [II].
Because medications used to treat OCD have side effects, particularly
at high doses, adherence may be enhanced by informing the patient
about any likely side effects, responding quickly to side effect concerns,
and scheduling follow-up appointments soon after starting or changing
medications [I]. In describing cognitive-behavioral
therapy (CBT), it is helpful to advise that it involves confronting
feared thoughts and situations, though at a tolerable rate [I].
Practical issues such as treatment cost, insurance coverage, and
transportation may need to be addressed. When a patient with OCD refuses
or prematurely discontinues treatment, the clinician may wish to
recommend that family members and others negatively affected by
the OCD seek therapy to help develop strategies to mitigate the
effect of the patient's OCD on their lives and to encourage
the patient to obtain treatment [II].
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2. Choosing an Initial Treatment
Modality
In choosing a treatment approach, the clinician should consider
the patient's motivation and ability to comply with pharmacotherapy
and psychotherapy [I]. CBT and serotonin reuptake
inhibitors (SRIs) are recommended as safe and effective first-line
treatments for OCD [I]. Whether to utilize CBT,
an SRI, or combined treatment will depend on factors that include
the nature and severity of the patient's symptoms, the
nature of any co-occurring psychiatric and medical conditions and
their treatments, the availability of CBT, and the patient's
past treatment history, current medications, capacities, and preferences.
CBT alone, consisting of exposure and response prevention, is recommended
as initial treatment for a patient who is not too depressed, anxious,
or severely ill to cooperate with this treatment modality, or who
prefers not to take medications and is willing to do the work that
CBT requires [II]. An SRI alone is recommended
for a patient who is not able to cooperate with CBT, has previously
responded well to a given drug, or prefers treatment with an SRI
alone [II]. Combined treatment should be considered
for patients with an unsatisfactory response to monotherapy [II],
for those with co-occurring psychiatric conditions for which SRIs
are effective [I], and for those who wish to limit
the duration of SRI treatment [II]. In the latter
instance, uncontrolled follow-up studies suggest that CBT may delay
or mitigate relapse when SRI treatment is discontinued [II].
Combined treatment or treatment with an SRI alone may also be considered
in patients with severe OCD, since the medication may diminish symptom severity
sufficiently to allow the patient to engage in CBT [II].
Deciding whether to start or stop a psychotropic drug during
pregnancy or breast-feeding requires making a risk-benefit calculation
with the patient and her significant other; this process may be enhanced
by providing clear information, seeking consultation from an obstetrician,
and providing counseling over several sessions to help the patient
come to terms with the uncertainty of the risks [I].
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3. Choosing a Specific Pharmacological
Treatment
Clomipramine, fluoxetine, fluvoxamine, paroxetine, and sertraline,
which are approved by the U.S. Food and Drug Administration (FDA)
for treatment of OCD, are recommended pharmacological agents [I].
Although meta-analyses of placebo-controlled trials suggest greater
efficacy for clomipramine than for fluoxetine, fluvoxamine, and
sertraline, the results of head-to-head trials comparing clomipramine
and selective serotonin reuptake inhibitors (SSRIs) directly do
not support this impression. Because the SSRIs have a less troublesome
side-effect profile than clomipramine, an SSRI is preferred for
a first medication trial [I]. Although all SSRIs
(including citalopram and escitalopram) appear to be equally effective,
individual patients may respond well to one medication and not to
another. In choosing among the SSRIs, the psychiatrist should consider
the safety and acceptability of particular side effects for the
patient, including any applicable FDA warnings, potential drug interactions,
past treatment response, and the presence of co-occurring general
medical conditions [I].
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4. Choosing a Specific Form of Psychotherapy
CBT that relies primarily on behavioral techniques
such as exposure and response prevention (ERP) is recommended because
it has the best evidentiary support [I]. Some
data support the use of CBT that focuses on cognitive techniques [II].
There are no controlled studies that demonstrate effectiveness of
dynamic psychotherapy or psychoanalysis in dealing with the core
symptoms of OCD. Psychodynamic psychotherapy may still be useful
in helping patients overcome their resistance to accepting a recommended
treatment by illuminating their reasons for wanting to stay as they
are (e.g., best adaptation, secondary gains) [III].
It may also be useful in addressing the interpersonal consequences
of the OCD symptoms [II]. Motivational interviewing
may also help overcome resistance to treatment [III]. Family
therapy may reduce inter-family tensions that are exacerbating the
patient's symptoms or ameliorate the family's
collusion with symptoms [III].
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5. Implementing a Treatment Plan
When treatment is initiated, the patient's motivation
and adherence may be challenged by factors such as treatment cost
and medication side effects. It is essential for the psychiatrist
to employ strategies to enhance adherence, as described above in
Section I.B.1.h [I].
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a. Implementing Pharmacotherapy
For most patients, the starting dose is that recommended by
the manufacturer [I]. Patients who are worried
about medication side effects can have their medication started
at lower doses, since many SSRIs are available in liquid form or
in pills that can be split [I]. Most patients
will not experience substantial improvement until 4–6 weeks
after starting medication, and some who will ultimately respond
will experience little improvement for as many as 10–12
weeks. Medication doses may be titrated up weekly in increments
recommended by the manufacturer during the first month of treatment [II],
or when little or no symptom improvement is seen within 4 weeks
of starting medication, the dose may be increased weekly or biweekly
to the maximum dose comfortably tolerated and indicated [II].
This maximum dose may exceed the manufacturer's recommended
maximum dose in some cases [III]. The treatment
trial is then continued at this dosage for at least 6 weeks [II].
Since available trial data suggest that higher SSRI doses produce
a somewhat higher response rate and a somewhat greater magnitude
of symptom relief, such doses should be considered when treatment
response is inadequate [II]. Higher doses may
also be appropriate for patients who have had little response to
treatment and are tolerating a medication well [I].
If higher doses are prescribed, the patient should be closely monitored
for side effects, including the serotonin syndrome [I].
Experience with pharmacotherapy in the elderly indicates that lower
starting doses of medication and a more gradual approach to dose
increase are often advisable [I]. Medication side
effects should be inquired about and actively managed [I].
Useful strategies to manage medication side effects include gradual
initial dose titration to minimize gastrointestinal distress [I],
addition of a sleep-promoting agent to minimize insomnia [I],
modest doses of modafinil to minimize fatigue or sleepiness [III],
and use of a low-dose anticholinergic agent to minimize sweating [III].
Sexual side effects may be minimized by reducing the dose [II],
waiting for symptoms to remit [II], trying a once-weekly,
one-day "drug holiday" before sexual activity [II],
switching to another SSRI [II], or adding a pharmacological
agent such as bupropion [II].
The frequency of follow-up visits after a new pharmacotherapy
is initiated may vary from a few days to two weeks. The indicated
frequency will depend on the severity of the patient's
symptoms, the complexities introduced by co-occurring conditions,
whether suicidal ideation is present, and the likelihood of troubling
side effects [I].
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b. Implementing Cognitive-Behavioral
Therapies
Cognitive-behavioral therapies have been delivered in individual,
group, and family therapy sessions, with session length varying
from less than 1 hour to 2 hours. One group has explored a computer-based
approach coupled with a touch-tone telephone system accessible 24
hours a day. CBT sessions should be scheduled at least
once weekly [I]. Five ERP sessions per week may
be more effective than once-weekly sessions but are not necessarily
more effective than twice-weekly sessions [II].
The number of treatment sessions, their length, and the duration
of an adequate trial have not been established, but expert consensus
recommends 13–20 weekly sessions for most patients [I].
Clinicians should consider booster sessions for more severely ill
patients, for patients who have relapsed in the past, and for patients
who show signs of early relapse [II]. When resources
for CBT are not available, the psychiatrist can suggest and supervise
the use of self-help treatment guides and recommend support groups
such as those accessible through the Obsessive Compulsive Foundation [III] (see Appendix).
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c. Changing Treatments and Pursuing
Sequential Treatment Trials
First treatments rarely produce freedom from all OCD symptoms.
When a good response is not achieved after 13–20 weeks
of weekly outpatient CBT, 3 weeks of daily CBT, or 8–12
weeks of SRI treatment (including 4–6 weeks at the highest
comfortably tolerated dose), the psychiatrist should decide with
the patient when, whether, and how to alter the treatment [I].
This decision will depend on the degree of suffering and disability
the patient wishes to accept. However, it is important to consider
that illness can bring secondary gains and that depressed mood can
diminish hopefulness; the psychiatrist may have to address issues
such as these when patients are not well motivated to pursue further
treatments despite limited improvement [I].
When initial treatment is unsatisfactory, the psychiatrist
should first consider the possible contribution of several factors:
interference by co-occurring conditions, inadequate patient adherence
to treatment, the presence of psychosocial stressors, the level
of family members' accommodation to the obsessive-compulsive
symptoms, and an inability to tolerate an adequate trial of psychotherapy
or the maximum recommended drug doses [I].
When no interfering factor can be identified, augmentation
strategies may be preferred to switching strategies in patients
who have a partial response to the initial treatment [II].
The psychiatrist should first consider augmentation of SRIs with
trials of different antipsychotic medications or with CBT consisting
of ERP, or augmentation of CBT with an SRI [II].
Combined SRI and CBT treatment may be provided when the patient
has a co-occurring disorder that is SRI-responsive [I] or
has a partial response to monotherapy [II]. Combined
SRI and CBT treatment may also reduce the chance of relapse when
medication is discontinued [II]. Another option
in the case of partial response to ERP therapy is to increase the
intensity of treatment (e.g., from weekly to daily sessions) [III].
Some evidence suggests that adding cognitive therapy to ERP may
enhance the results, but this remains to be established [III].
Patients who do not respond to their first SRI may have their
medication switched to a different SRI [I]. A
switch to venlafaxine is less likely to produce an adequate response [II].
For patients who have not benefitted from their first SSRI trial,
a switch to mirtazapine can also be considered [III].
The available evidence does not allow one to predict the chance
of response to switching medications. SRI nonresponders, like partial
responders, have responded to augmentation with antipsychotic medications [II] or
CBT [II].
After first- and second-line treatments and well-supported
augmentation strategies have been exhausted, less well-supported
treatment strategies may be considered [III].
These include augmenting SSRIs with clomipramine, buspirone, pindolol,
riluzole, or once-weekly oral morphine sulfate [III].
However, morphine sulfate should be avoided in patients with contraindications
to opiate administration, and appropriate precautions and documentation
should occur. If clomipramine is added, appropriate precautions
should be utilized with regard to preventing potential cardiac and
central nervous system side effects [I]. Less
well-supported monotherapies to consider include d-amphetamine [III],
tramadol [III], monoamine oxidase inhibitors (MAOIs) [III],
ondansetron [III], transcranial magnetic stimulation
(TMS) [III], and deep brain stimulation (DBS) [III].
Intensive residential treatment or partial hospitalization may be
helpful for patients with severe treatment-resistant OCD [II].
Ablative neurosurgery for severe and very treatment-refractory OCD
is rarely indicated and, along with deep brain stimulation, should
be performed only at sites with expertise in both OCD and these
treatment approaches [III].
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6. Discontinuing Active Treatment
Successful medication treatment should be continued for 1–2
years before considering a gradual taper by decrements of 10%–25% every
1–2 months while observing for symptom return or exacerbation [I].
Successful ERP should be followed by monthly booster sessions for
3–6 months, or more intensively if response has been only
partial [II]. In medication discontinuation trials,
rates of relapse or trial discontinuation for insufficient clinical
response are substantial but vary widely because of major methodological
differences across studies. Thus, discontinuation of pharmacotherapy
should be carefully considered, and for most patients, continued
treatment of some form is recommended [II]. The
data suggest that CBT consisting of ERP may have more durable effects than
some SRIs after discontinuation, but the observed differences in
relapse rates could be explained by other factors.
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II. Formulation and Implementation
of a Treatment Plan
The essential features of OCD identified in
DSM-IV-TR are "recurrent obsessions or compulsions (Criterion
A) that are severe enough to be time consuming (i.e., they take
more than 1 hour a day) or cause marked distress or significant
impairment (Criterion C)" (1, pp. 456–457). Obsessions are
intrusive, persistent, unwanted thoughts, impulses, or images that
give rise to marked anxiety or distress. Compulsions are physical
or mental acts that the patient feels driven to perform in order
to magically prevent some feared event, to undo some thought, or
to reduce anxiety or distress.
Compulsive actsalso known as ritualsare
carried out repetitively, excessively, and usually according to
rules or in a rigid manner. Obsessions may occur spontaneously or
be evoked by a feared environmental stimulus or event. Mental compulsions
such as counting, praying, or reviewing actions, conversations,
or lists are initiated by the patient willfully, with the aim of
feeling safer or reducing anxiety or distress.
The most common obsessional themes are fears of being contaminated
or spreading contamination, accidentally or purposely harming others,
making a significant mistake, committing a religious offense or
moral infraction, contracting a disease, and being considered homosexual
or committing homosexual or pedophilic acts.
Hoarding, when a symptom of OCD, is not usually feared, though
it may be regretted. Individuals with OCD may also obsess about
orderliness or symmetry, lucky or unlucky numbers or colors, needing
to know or remember, heterosexual acts, or bodily health. Obsessions
are often accompanied by a feeling of doubt, uncertainty, or incompleteness
that drives repetitive thought or action and are often colored by
an inflated estimate of danger, an increased sense of responsibility,
or a need for certainty or perfection.
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A. Psychiatric Management
Psychiatric management of OCD is indicated when symptoms interfere
with functioning or cause significant distress. Although transient
OCD is found in community surveys, OCD seen in clinical practice
is usually a chronic illness with a waxing and waning course. With
appropriate treatment, OCD symptoms usually improve over weeks or
months and may become mild or even subside into remission over months
or years. Thus, treatment planning and psychiatric management will be
iterative processes adapted to the patient's current status
and response to previous interventions.
Psychiatric management encompasses a broad collection of professional
actions and interventions designed to benefit the patient. These
actions and interventions include providing the following:
Pharmacotherapy and psychotherapy
in the appropriate setting, as indicated by patient preference and
clinical judgment;
Guidance to the patient and involved family members
about educational materials that are available in published form
and on the Web (see Appendix); and
Information about local support groups (see Appendix).
Psychiatric management should be offered throughout the course
of illness at an intensity consistent with the patient's
needs, capacities, and desires. The components of psychiatric management across
the stages of illness are described in more detail below.
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1. Establish a Therapeutic Alliance
As in all of medicine, the physician first attempts to establish
and then to maintain a therapeutic alliance so that the patient's
care is a joint endeavor. The therapeutic alliance allows the psychiatrist
to obtain the information needed to plan effective treatment. The
alliance allows the patient to trust the physician and helps motivate
adherence to collaboratively planned treatments. It is important
to tailor one's communication style to the patient's
needs and capacities, along continua from detailed to general, from
biologically to psychosocially framed, and from warm to neutral. Explaining
symptoms in understandable terms is both encouraging and comforting
to patients. The excessive doubting that is characteristic of OCD
may require special approaches to building the alliance. For example,
the clinician may need to allow the patient more time to consider
treatment decisions and may need to repeat explanations (a limited
number of times) and at several visits. Increased attention to excessive
worry about medication side effects, perfectionism, or checking
behaviors may be needed. Treatment of patients with OCD has a potential
for transference and/or countertransference issues that
may disrupt adherence and the therapeutic alliance. In building
the alliance, the psychiatrist should also consider the patient's
feelings and actions toward him or her, as well as why the patient
has come to him or her specifically, and why at this point in time.
What does the patient want and expect? How are these desires and
expectations affected by the patient's cultural background,
religious background, beliefs about the illness (its cause, effects,
and mechanisms), and experience with past treatments?
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2. Assess the Patient's
Symptoms
The psychiatrist should assess the patient for symptoms of
OCD, guided by the diagnostic criteria of DSM-IV-TR (Table 1).
OCD is likely to be underdiagnosed unless specific screening
occurs (2). Screening questions might include some
of the following: Do you have unpleasant thoughts you can't
get rid of? Do you worry that you might impulsively harm someone?
Do you have to count things, or wash your hands, or check things
over and over? Do you worry a lot about whether you performed religious
rituals correctly or have been immoral? Do you have troubling thoughts about
sexual matters? Do you need things arranged symmetrically or in
a very exact order? Do you have trouble discarding things, so that
your house is quite cluttered? Do these worries and behaviors interfere
with your functioning at work, with your family, or in social activities?
As part of the assessment, the psychiatrist must differentiate
obsessions, compulsions, and rituals from similar symptoms found
in other disorders. Unlike obsessions, depressive ruminations are experienced
as consistent with one's self-image or values. They often
focus on past events but, like obsessions, may concern possible
current or future negative events or anticipated failures. The subject
matter of depressive ruminations usually concerns self-criticism,
failures, guilt, regret, or pessimism regarding the future. Depressive
ruminations do not elicit compulsive rituals. The worries of generalized
anxiety disorder focus on real life problems and usually do not
lead to compulsive rituals, although, as in OCD, the sufferer may
try to convince himself or herself that the fear is groundless or
may check on the safety of loved ones. Generalized anxiety disorder
may also present as a vague but troubling feeling of foreboding,
whereas the obsessions of OCD always have clear content. The intrusive
thoughts and images of posttraumatic stress disorder are replays
of actual events, not anticipations of future events. Obsessions
held with delusional conviction can be distinguished from schizophrenic
and manic delusions by the absence of other signs and symptoms of
these disorders. Moreover, delusional obsessions will have typical
OCD content rather than content related to persecution, grandiosity,
passivity experiences, or ideas of reference.
OCD can be differentiated from hypochondriasis by noting that
the hypochondriacal fear or belief regarding serious disease arises
from misinterpretation of ordinary bodily signs and symptoms. In OCD
such fears arise from external stimulifor example, a patient
fearing he has contracted AIDS because he was served by a waiter
wearing a bandage, possibly exposing him to blood. In addition,
an individual with hypochondriasis does not have insight into the
irrationality of his or her fears and behaviors, whereas some insight
is usually present in OCD. In body dysmorphic disorder, the recurrent
and intrusive preoccupations are limited to the fear or belief that
one has a disturbing physical defect, when in reality the defect
is nonexistent or slight. In anorexia nervosa and bulimia nervosa,
the intrusive thoughts and irrational behaviors center on weight
and its effects on self-evaluation. In contrast to the thoughts
and urges of paraphilias, OCD-related sexual obsessions or images
(e.g., fears of homosexuality, images of having sex with a child)
lead to avoidance behaviors, are morally abhorrent, and are resisted.
Similarly, in OCD, obsessions regarding a sexual partner are experienced
as alien to the self and are not accompanied by stalking behavior.
Differentiating urges to harm an infant that occur as postpartum
symptoms of OCD from superficially similar symptoms of postpartum
depression is critical. The OCD urges are not accompanied by depressed
mood and are experienced as inconsistent with one's self,
are resisted, or induce efforts to neutralize the urges through
other behaviors. Although OCD rituals aimed at avoiding harming
the infant may interfere with attachment or normal maternal behaviors
and may require treatment, there is little risk of direct harm to
the infant. In contrast, the impulses or ideas that arise in postpartum
depression may be experienced as justified, may not be strongly
resisted, and emerge from depressed mood and other signs and symptoms
of major depression. In postpartum depression, taking steps to protect
the infant may be necessary (3).
Differentiating compulsions from the complex vocal or motor
tics sometimes seen in Tourette's disorder can be difficult.
Tics, unlike compulsions, are neither preceded by thoughts nor aimed
at relieving anxiety or preventing or undoing an external,
undesired event (4). DSM-IV-TR (1, p. 108) defines
a tic as "a sudden, rapid, recurrent, nonrhythmic, [and] stereotyped
motor movement or vocalization." Tics are often preceded
by premonitory sensations such as muscular tension and may involve
repeating an action until an unpleasant, localized, physical tension
or a sense of incompleteness is relieved (5, 6).
Complex motor tics can take the form of arranging, ordering, touching,
or making objects symmetrical (5). Repeating an action
until "it feels right" (e.g., repeatedly closing
a door until the right sound or sensation of closure is achieved)
may be a complex tic or a compulsion, or reflect elements of both.
Complex tics may be more likely in individuals with a personal or
family history of motor or phonic tics; individuals with a history
of hypersensitivity to sensations associated with scratchy fabrics,
the touch of clothing labels, or to uneven shoelaces or socks; and
individuals with co-occurring diagnoses of attention-deficit disorder
or learning disorder (5).
Differentiating OCD from obsessive-compulsive personality
disorder (OCPD) may also be difficult. In addition, OCD and OCPD
may co-occur (7, 8). In fact, the greater
prevalence of OCPD in first-degree relatives of OCD patients than
of control subjects suggests the possibility of a genetic relationship
between the two disorders (9). Although hoarding, scrupulosity,
perfectionism, and preoccupation with rules, order, and lists may
occur in both disorders, a number of factors may help distinguish
OCD and OCPD. For example, in OCD, anxiety about feared consequences
of forgoing compulsive behaviors is prominent, whereas in OCPD,
the focus is on "doing things my way, the right way" (i.e.,
on the need for control). In OCD, perfectionism and preoccupation
with rules is usually focal and limited to feared events; in OCPD
these traits globally color the individual's attitudes
and behavior. Fundamentally, the person with OCPD experiences the
concerns and behaviors as part of the normal self and does not resist
them but, to the contrary, considers them valued attributes. Despite
the fact that OCPD traits often irritate companions or associates,
the individual with OCPD has no desire to change these traits.
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3. Consider Rating the Severity of
OCD and Co-occurring Symptoms and Their Effects on the Patient's
Functioning
Use of the Y-BOCS Symptom Checklist (10),
which allows the recording of current and past symptoms, or the
18-item Obsessive-Compulsive Inventory (11) may be
helpful. These scales may help document both the variety and the
clustering of the patient's symptoms. The Y-BOCS Symptom
Checklist lists 40 obsessions, 15 behavioral compulsions, 5 mental
compulsions, and 9 miscellaneous compulsions.
The psychiatrist should consider using a rating scale such
as the 10-item Y-BOCS scale (10, 12) to
record baseline severity since this provides a way to measure response
to treatment. The Y-BOCS rating can also be compared with the patient's
and the family's impressions of severity. The Y-BOCS scale
evaluates obsessions and compulsions separately and, for each of
these two symptom dimensions, measures the time spent and the degrees
of distress, interference with functioning, resistance to the symptoms,
and success in resisting. The Y-BOCS may be found at the following
Web sites: http://healthnet.umassmed.edu/mhealth/YBOCRatingScale.pdf
or www.peaceofmind.com/YBOCS.pdf. The Obsessive-Compulsive
Inventory 11, a self-rated scale, may also be considered. A simpler
measure is a visual analog scale in the form of a thermometer with
the bottom labeled "no OCD symptoms" and the top
labeled "incapacitating OCD symptoms." Encouraging
the patient to use a self-rated scale will help him or her become
a better self-observer and may aid in identifying factors that aggravate
or ameliorate symptoms. If a rating scale is not used, the psychiatrist
should document the patient's estimate of the number of
hours per day spent in obsessing and in performing compulsive behaviors,
and the degree of effort applied to trying to escape the obsessions
(by distraction or accepting passive awareness, not by counter-argument)
and to resisting the behaviors. Recording items or situations that
the patient actively avoids because of OCD also provides a useful
baseline against which change can be measured.
The psychiatrist should consider recording co-occurring conditions
and their effects on the patient's functioning. For monitoring
depression, which is commonly present and may aggravate OCD symptoms,
the clinician might also consider self-rated scales. These can be
as simple as visual analog scales or scales measuring symptoms of
interest using a "0 to 10" severity rating. Formal
self-rated scales that may be useful include the Patient Health
Questionnaire (PHQ-9) (13, 14), Beck Depression
Inventory–II (BDI-II) (15), Zung Depression
Scale (16), and the patient versions of the Inventory
of Depressive Symptomatology (IDS) or the shorter 16-item Quick-IDS
(QIDS) (17).
OCD symptoms may seriously impair self-care, interpersonal
relationships, vocational ability, marital and family relationships,
child-rearing capacities, and use of leisure time. Thus, it may
be useful to include a rating of disabilityfor example,
the self-rated, three-item Sheehan Disability Scale (SDS) (18, 19),
which records disability in the domains of work, family, and social
relationships. Some patients, however, may not accurately recognize
the degree of their disability until after successful treatment.
For most patients, OCD seriously impairs quality of life (20).
A rating of the patient's quality of life, using a scale
such as the Quality of Life Enjoyment and Satisfaction Questionnaire
(Q-LES-Q) (21) or the more detailed World Health Organization
Quality of Life Survey (WHOQOL-100) (22), can provide
a broader measure of disease impact and of the results of treatment.
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4. Evaluate the Safety of the Patient
and Others
In individuals with OCD, as with all psychiatric patients,
assessing the risk for suicide and self-injurious behavior, as well
as the risk for harm to others, is crucial. Collateral information
from family members or others can be helpful in assessing such risks.
When these risks are present, it is important to arrange treatments
that will enhance the safety of the patient and others. Although accurate
prediction of dangerousness to self or others is not possible in
a given individual at a given point in time, many factors have been
associated with increased risk in groups of individuals and are,
therefore, important to determine.
In assessing and estimating the patient's potential
for self-injury or suicide, a number of factors should be taken
into consideration. Individuals with OCD alone or with a lifetime
history of any co-occurring disorder have a higher suicide attempt
rate than do individuals in the general population (23, 24).
In rare instances, self-injury can also be directly or indirectly
associated with compulsive behaviors. Because increased risk of
suicide attempts and suicide has been associated with specific psychiatric
symptoms and disorders, the psychiatrist will also want to assess
for hopelessness, agitation, psychosis, anxiety, or panic attacks,
as well as the presence of mood or substance use disorders, schizophrenia,
borderline personality disorder, or other disorders associated with heightened
risk. Risk for suicide and for suicide attempts is also increased
by a history of previous suicide attempts, including aborted attempts.
Thus, if a patient has this history, the nature of those attempts
and their potential lethality should be determined. It is also essential
to determine whether the patient has had thoughts of death, self-harm,
or suicide and the degree to which the patient intends to act on
any such thoughts. If a patient has considered suicide, the extent
of planning or preparation and the relative lethality of any planned
suicide methods should be considered. The availability of the means
for suicide, including firearms, should also be explored. Also relevant
is any family history of suicide, recent exposure to suicide or
suicide attempts by others, real or perceived lack of social supports,
and recent losses, including impairments resulting from medical
conditions. Cultural, religious, and ethnic factors can also modify
suicide risk. Further information is available in APA's Practice
Guideline for the Assessment and Treatment of Patients With Suicidal
Behaviors (25).
The psychiatrist should also evaluate the patient's
potential for harming others. This evaluation will include inquiring
about whether the patient has had thoughts or urges to harm others
and when these thoughts and urges have led to aggression toward
others in the past. Such questioning should be sensitive to the
fact that patients may fear thoughts, impulses, urges, or images
related to harming others or to sexually abusing a child, even though
these are experienced as alien to the self and true desires. Although
acting on such impulses or thoughts has not been reported in OCD, the
patient may fear loss of control and engage in extensive avoidance
rituals. OCD symptoms can occasionally be associated with direct
or indirect potential for harm to others. For example, OCD symptoms
can interfere with parenting, leading the patient, for example,
to avoid or neglect his or her children, to "clean" them
inappropriately with bleach or other harmful substances, or to insist
on inappropriate neatness. In such cases, the psychiatrist may have
to work with the unaffected parent or social agencies to mitigate
the effects of OCD symptoms on the patient's children.
On rare occasions, individuals with OCD have become distressed and
aggressive when others interfered with the performance of compulsive
rituals. Finally, in assessing the potential for harm to others,
the psychiatrist should consider the possibility that aggressive
behavior can be associated with co-occurring disorders such as substance
use, impulse control, and personality disorders.
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5. Complete the Psychiatric Assessment
In completing the psychiatric assessment, the psychiatrist
will usually include the elements of the adult general psychiatric
evaluation as described in APA's Practice
Guideline for the Psychiatric Evaluation of Adults, 2nd
edition (26). Facets of the assessment that are of
particular relevance to individuals with OCD are highlighted in
Table 2.
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At all phases of subsequent assessment, the psychiatrist should
be alert for signs, symptoms, and history suggesting the possibility
of co-occurring conditions. Particular attention should be given to
mood disorders, since depressive disorders (27, 28)
and bipolar disorder (29, 30) are more
common in patients with OCD than in the general population. Careful
exploration for family history for bipolar disorder is also important
in view of the risk of precipitating hypomania or mania with anti-OCD
medications.
Other anxiety disorders (panic disorder, generalized anxiety
disorder, social phobia) are common in OCD patients (24, 31, 32)
and may complicate treatment planning as described later in this
guideline (Sections III.A.5 and III.A.6).
Tics are common in individuals with OCD. Conversely, OCD has
been diagnosed in 28%–62% of individuals
with Tourette's disorder (33). In patients
with co-occurring OCD and Tourette's disorder, use of a
rating scale such as the Yale Global Tic Severity Scale (YGTSS)
(34) may be helpful. This scale provides anchor points
for rating the number, frequency, intensity, complexity, interference,
and impairment associated with motor and phonic tics.
Anorexia nervosa and bulimia nervosa may be more common in
men and women with OCD than in the general population (24, 35).
The prevalence of OCD appears to be elevated in patients with either
anorexia nervosa or bulimia nervosa (36–38).
Evaluation should also include screening for alcohol or substance
abuse or dependence. In some (31, 39)
but not all studies (24), an increased risk of alcohol
abuse and dependence has been noted. In addition, the presence of
a substance use disorder will influence treatment planning (Section
III.A.8).
Other disorders with elevated prevalence in OCD include certain
impulse-control disorders, such as skin picking and trichotillomania.
In children and adolescents with OCD, the prevalence of attention-deficit/hyperactivity
disorder (ADHD) and of oppositional defiant disorder (ODD) is elevated
(40). Since structured interview instruments lack modules
for developmental disorders, the absence of prevalence data regarding
ADHD in adult OCD patients may represent an error of omission. Given
that about half of early-onset OCD patients with co-occurring ADHD
will continue to have clinically significant ADHD symptoms in adulthood,
assessing adult OCD patients for ADHD may be helpful. Assessment
instruments include the Conners Adult ADHD Rating Scales (CAARS)
(41) and the Wender Utah Rating Scale (WURS) (42),
among others (e.g., see reference 43).
In assessing the past psychiatric history, a chronological
history should be obtained of past psychiatric illnesses, including
substance use disorders and treatment, and of hospitalizations.
More specifically, the psychiatrist should attempt to document the
longitudinal course of the patient's symptoms and their
relationship to aggravating or ameliorating factors, including treatment. Details
of the patient's past medication trials should be obtained
to ensure that drug doses and trial durations have been adequate,
to understand side effects and other factors influencing adherence, and
to evaluate the degree of response. The nature, extent, and response
to all trials of psychotherapy, including cognitive-behavioral therapy,
should also be documented. When past medical records are accessible,
these can be helpful in augmenting the treatment history provided
by the patient. Past histories of psychiatric symptoms or co-occurring
disorders will influence treatment planning and should also be elicited,
such as alcohol or substance abuse or dependence (Section III.A.8),
prominent fluctuations in mood (Section III.A.4), or panic attacks
(Section III.A.5).
The general medical history should document any current general
medical conditions, recent or relevant hospitalizations, and any
history of head trauma, loss of consciousness, or seizures. The psychiatrist
should also consider whether the OCD is a rare manifestation of
a general medical condition (e.g., brain trauma, stimulant abuse,
carbon monoxide poisoning, parkinsonism). Evaluation of such potential
etiologies does not require screening with imaging studies (44),
as these disorders are usually obvious from history and examination
(33). Current medications and doses should be reviewed
to determine potential pharmacokinetic and pharmacodynamic interactions
with psychotropic drugs. Herbal or "natural" remedies
must also be inquired about, along with hormonal therapies, vitamins,
other over-the-counter medications, and other alternative or complementary
treatments. Allergies and sensitivities to medications, including
the nature of the patient's reaction, should be recorded.
On careful exploration, reactions the patient describes as "allergies" will
sometimes turn out to be unpleasant but manageable side effects.
In performing the review of systems, the psychiatrist should record
the presence and severity of somatic or psychological symptoms that
could be confused with medication side effects.
In assessing the patient's developmental, psychosocial,
and sociocultural history, the psychiatrist should review the stages
of the patient's life, with attention to developmental
transitions in childhood and adulthood and the patient's
capacity to achieve stable and gratifying familial and social relationships.
A sexual history will identify the nature of the patient's
sexual relationships, including impulsive or high-risk sexual behaviors.
It will also provide baseline information on patient concerns or
sexual dysfunctions from which to judge potential side effects of
psychotropic medications. An educational and occupational history
(including military history) will help in evaluating the extent
to which OCD symptoms have interfered with academic or vocational
achievement. The psychiatrist should also assess the patient's
primary support group and sociocultural supports (e.g., spouse/partner,
children, other family or friends, community or faith-based organizations), as
well as their possible role in facilitating treatment and in maintaining
or exacerbating symptoms. Assessing the family's understanding
of the patient's illness and of potential treatments is similarly
important for treatment planning. Other specific information that
may be relevant to the assessment of psychosocial stressors includes
living arrangements; sources of income, insurance, or prescription
coverage; access to transportation and health care; and past or
current involvement with social agencies or the justice system.
In assessing the family history, the presence
of OCD among family members is of interest for how it may affect
the patient's expectations about the illness and its treatment.
Although OCD is associated with genetic risk, the clinician should
not expect concordance of specific OCD symptoms among siblings or
across generations, with the possible exception of hoarding and
ordering symptoms (45). A family history of other psychiatric
disorders (e.g., major depression, bipolar disorder, panic disorder,
generalized anxiety disorder, social phobia, substance use disorders)
is also relevant, since it contributes to an increased risk of co-occurring
disorders that may influence treatment choice. A family history
of tics or Tourette's disorder suggests a need for careful
exploration of these disorders in the patient, as their presence
could influence treatment response.
The mental status examination involves the systematic collection
and recording of data related to the patient's signs and
symptoms of illness during the interview. The examination includes
consideration of the patient's appearance and general behavior,
including the patient's degree of cooperativeness. Psychomotor
abnormalities (e.g., tics, mannerisms, rituals, abnormal involuntary
movements) are also noted. The patient's mood should be
assessed, since the presence of mood symptoms may alter cooperation
with treatment or suggest a co-occurring mood disorder. In addition
to specific obsessions and compulsions, other abnormalities in thought
content (e.g., phobias, overvalued ideas, ideas of reference, delusions,
suicidal or homicidal ideas) or thought process (e.g., circumstantiality)
may be present. Perceptual disturbances (e.g., illusions, hallucinations)
or disturbances in sensorium or cognition are less commonly observed
and suggest the presence of a co-occurring disorder. Assessing the
patient's degree of insight into the irrationality of the
OCD symptoms and motivation and expectations of treatment is essential
to treatment planning. Also crucial is the degree to which OCD is
affecting judgment, as measured by OCD's effects on the
patient's management of the ordinary decisions of daily
life.
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6. Establish Goals for Treatment
Marked clinical improvement, recovery, and full remission,
if they occur, do not occur rapidly (46). Thus, persistent
goals of treatment include decreasing symptom frequency and severity, improving
the patient's functioning, and helping the patient to improve
his or her quality of life (in family, social, work/school,
home, parental, and leisure domains). Treatment goals also include
enhancing the patient's ability to cooperate with care
despite the frightening cognitions that are typical of OCD; anticipating
stressors likely to exacerbate the condition and helping the patient
develop coping strategies; providing assistance and support in dealing
with stresses; monitoring the patient's psychiatric status
and intervening as indicated; minimizing any adverse effects of
treatment (e.g., medication side effects); and educating the patient
and family regarding the disorder and its treatment. Reasonable
treatment outcome targets include less than 1 hour per day spent
obsessing and performing compulsive behaviors; no more than mild
OCD-related anxiety; an ability to live with uncertainty; and little
or no interference of OCD with the tasks of ordinary living. However,
some patients will be unable to reach these targets, despite the
psychiatrist's and the patient's best efforts.
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7. Establish the Appropriate Setting
for Treatment
In general, patients should be cared for in the least restrictive
setting that is likely to be safe and to allow for effective treatment.
Consequently, the appropriate treatment setting will depend on a number
of factors:
Hospital treatment (47)
may be indicated by suicide risk, an inability to provide adequate
self-care, danger to others, need for constant supervision or support,
an inability to tolerate outpatient medication trials because of
side effects, need for intensive CBT, the presence of medical conditions
that necessitate hospital observation while medications are initiated,
or by co-occurring conditions that themselves require hospital treatment,
such as severe or suicidal depression, schizophrenia, or mania.
Residential treatment (48) may be indicated
in individuals with severe treatment-resistant OCD, who require
multidisciplinary treatment in a highly structured setting that
permits intensive individual and group CBT as well as psychopharmacologic
management with close monitoring of treatment adherence over a period
of several months.
Partial hospitalization (49) may be indicated
by a need for daily CBT and monitoring of behavior or medications
or a supportive milieu with other adjunctive psychosocial interventions,
or to stabilize and increase the gains made during a period of full
hospitalization. Goals of treatment include restoring the patient's
ability to function in daily life without intensive monitoring;
reduction of symptoms to a level consistent with outpatient treatment;
prevention of relapse; and maintenance and improvement of social
functioning.
Home-based treatment may be necessary for patients with
hoarding or, initially, for those with contamination fears or other
symptoms so impairing that they cannot come to the office or clinic. Home-based
treatment may also be indicated for individuals who experience symptoms
primarily or exclusively at home.
Outpatient treatment is usually sufficient for the treatment
of OCD, but the intensity may vary from daily psychotherapy, such
as intensive CBT, to treatment less than once a week (after achieving
substantial symptom reduction and stabilization).
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8. Enhance Treatment Adherence
Factors influencing adherence can be thought of as related
to the illness, the patient, the physician, the patient-physician
relationship, the treatment, and the social or environmental milieu
(50). The fears, doubting, and need for certainty that
are characteristic of OCD can influence the patient's willingness
and ability to cooperate and can challenge the physician's
patience. Patients may, for example, obsess about possible medication
side effects and, as a result, refuse pharmacotherapy. Cognitive
and motivational effects of co-occurring conditions such as major
depression must also be taken into account. Thus, it is useful to
determine what the treatment will require of the patient and the
way in which these requirements match his or her skills, resources,
coping methods, priorities, and goals. Providing the patient and
family with education (see Appendix) can be beneficial, because
the patient's beliefs about the nature of the illness and
its treatments will influence adherence. For example, it is important
to inform patients about the delay between starting medication and
experiencing substantial symptom relief, and the need for extended
periods of medication taking (51).
Medication side effects can influence adherence. The patient's
culture, however, may limit his or her willingness to report them
(e.g., sexual side effects) or how discomfiting they are. Since
effective medications differ both in side-effect profiles and in
their adverse effects on a given patient, the psychiatrist has many
options for responding to the patient's concerns and preferences. Informing
the patient about any likely side effects, responding quickly to
side effect concerns, and scheduling follow-up appointments soon
after starting or changing medications will enhance adherence.
In describing CBT, the clinician should note that it involves
confronting feared thoughts and situations, but at a tolerable rate.
The therapist is a supportive coach, not a disciplinarian, and encourages
behavior change and praises successes while validating the difficulty
of confronting the OCD symptoms.
As with all psychotherapies, how the patient thinks, feels,
and acts toward the clinician can decrease cooperation with CBT,
the only psychotherapy with documented efficacy for OCD. For example,
patients may seek excessive reassurance or have difficulty committing
to treatment options. These reactions can often be dealt with in
the course of CBT. At other times, improving the patient's
degree of cooperation may be best accomplished with another form
of psychotherapy. Motivational interviewing (52) and
other psychosocial interventions designed to enhance readiness for
change may help to improve a patient's motivation for treatment.
Clinician-related issues in the therapeutic alliance may also interfere
with adherence and therapeutic success. Use of consultation can
sometimes be helpful in resolving such impediments.
The psychiatrist should also consider the role of the patient's
family and social support system in treatment adherence. Family
members may be important allies in the treatment efforts (53).
By contrast, family members may provide repeated inappropriate reassurance
in efforts to reduce the patient's anxiety or inappropriately
offer to do the patient's checking rituals so the patient
can get more rest. The family or significant others may not understand
that OCD is an illness that gives rise to the patient's
compulsive behaviors. They may accuse the patient of being weak
or "crazy" or may react to symptomatic behavior
with inappropriate anger. They may also be adversely affected by
rituals, such as excessive cleaning, or by the patient's
insistence on avoiding "contaminated" places.
Family therapy may be indicated to deal with hostility, dependency,
or other family system issues. When a patient with OCD refuses or
prematurely discontinues treatment, family members and others negatively
affected by the OCD may benefit from therapy. Under these conditions,
the goals of therapy may be to reduce the OCD's impact
on the rest of the family and to teach family members how to support
recovery from OCD.
Finally, practical issues such as treatment cost, insurance
coverage, and transportation may need to be addressed. Pharmaceutical
companies may provide free medications for patients with severe financial
limitations, with the exact criteria differing from company to company.
Information on patient assistance programs is available
from the pharmaceutical company Web sites, from the Web site of
the Partnership for Prescription Assistance (www.helpingpatients.org),
and from Rx Assist (www.rxassist.org).
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9. Provide Education to the Patient
and, When Appropriate, to the Family
Patients often have little knowledge of the nature, biology,
course, and treatment of their disorders. Those with childhood onset
of OCD may confuse symptoms with aspects of their innate selves.
All patients with OCD should be provided with information and access
to educational materials explaining the nature of the disorder and
the range of available treatments. Education will help destigmatize
the illness and allow the patient to make more fully informed decisions about
treatments. Education may also increase the patient's motivation
and ability to cooperate in care. When appropriate, education should
also be offered to involved family members. The appendix to this
guideline contains lists of self-help books for patients with OCD
and co-occurring OCD spectrum disorders (see also references 33, 54, 55),
patient advocacy group Web sites that provide scientifically reliable
information, Web sites that provide information on the use of medications
in pregnancy and during breastfeeding, and scientifically reliable,
broader mental health Web sites. All OCD patients should be made
aware of the Obsessive Compulsive Foundation (www.ocfoundation.org),
which provides both educational materials and access to support
groups.
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10. Coordinate the Patient's
Care With Other Providers of Care and Social Agencies
The psychiatrist should coordinate the patient's
care with physicians treating co-occurring medical conditions, with
other clinicians, and with social agencies such as schools and vocational
rehabilitation programs. For patients whose OCD symptoms or medications
impair dental health, coordination with the patient's dentist
will also be useful.
OCD-related functional impairments may involve family, social,
academic, or occupational roles or financial problems. Consequently,
under some circumstances, the psychiatrist may need to provide government
agencies, schools, employers, and others with written documentation
on the patient's behalf. For example, the psychiatrist
may have to write to the federal Internal Revenue Service and state
tax authorities to explain that a patient's hoarding or
procrastination has prevented timely filing of income tax returns.
A letter regarding special provisions for participation in or excuse
from jury duty may also be appropriate. Students may need letters
explaining the need for special dormitory living situations or academic
accommodations. Employers may need help in understanding what accommodations
are appropriate in light of the Americans With Disabilities Act
(56), and referral to a state vocational rehabilitation
agency or an occupational therapist may be indicated. For OCD of
disabling severity, the psychiatrist must be willing to write to
government agencies that control access to disability income, publicly
financed health care, or government-supported housing.
OCD patients who are parents of young children may want advice
regarding the genetic risk of OCD. The clinician may wish to refer
these parents to a genetic counselor, but should be aware of the
available data (Section IV.D). The psychiatrist should help patients
concerned about the possibility of OCD in their children find clinicians
who can conduct an appropriate evaluation. (Educational materials
for parents of children with OCD are included in the Appendix.)
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1. Choosing an Initial Treatment
Modality
CBT and SRIs are recommended on the basis of clinical trial
results as safe and effective first-line treatments for OCD. SRIs
include clomipramine and all of the SSRIs. Whether to recommend
a form of CBT, an SRI, or combined treatment will depend on a number
of factors. These include the nature and severity of the patient's
symptoms, the nature of any co-occurring psychiatric and medical
conditions and their treatments, the availability of CBT, and the
patient's past treatment history, current medications,
and preferences. Because most treatment studies have been of 3–4 months' duration,
only limited data are available to guide long-term treatment decisions
(Section II.C).
The evidence base for the form of CBT that relies primarily
on behavioral techniques, such as ERP (57), is the
strongest (58–60). Data also support the use
of CBT that focuses on cognitive techniques aimed at identifying, challenging,
and modifying dysfunctional beliefs (61–64)
if these techniques are combined with behavioral experiments. However,
some data suggest, and many clinical experts believe, that the most
effective form of CBT for OCD integrates exposure, response prevention
(behavior that results in not performing rituals), discussion of
feared consequences and dysfunctional beliefs, and relapse prevention.
There are few data from controlled trials to support cognitive therapy
without ERP or behavioral experiments.
CBT alone, consisting of ERP, is recommended as initial treatment
for a patient who is not too depressed, anxious, or severely ill
to cooperate with this treatment modality, or who prefers not to take
medications. The patient must be willing to do the work that CBT
requires (e.g., regular behavioral homework).
An SRI alone is recommended for a patient who has previously
responded well to a given drug or prefers treatment with an SRI
alone. Starting with an SRI alone may enhance cooperation with treatment
by diminishing symptom severity. Thus, an SRI alone may also be
considered in patients who have severe OCD or are not otherwise
able to cooperate with the demands of CBT. An SRI alone may also
be necessary if CBT is not accessible or available.
The available data suggest that combining an SRI and CBT consisting
of ERP is more effective than monotherapy in some patients but is
not necessary for all (65). Combined treatment should
be considered for patients with an unsatisfactory response to monotherapy,
for those with co-occurring psychiatric conditions for which SRIs
are effective, and for those who wish to limit the duration of treatment
with medication. In the latter instance, uncontrolled follow-up
studies suggest that CBT consisting of ERP may delay or mitigate
relapse when SRI treatment is discontinued (66–68).
Combined treatment may also be considered in patients with severe
OCD, since the medication may diminish symptom severity sufficiently
to allow the patient to engage in CBT.
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2. Choosing a Specific Pharmacological
Treatment
Clomipramine, fluoxetine, fluvoxamine, paroxetine, and sertraline,
which are approved by the FDA for treatment of OCD, are recommended
pharmacological agents. Although meta-analyses (59, 69, 70)
of placebo-controlled trials suggest greater efficacy for clomipramine
than for fluoxetine, fluvoxamine, and sertraline, the results of
head-to-head trials comparing clomipramine and SSRIs directly do
not support this impression (Section V.A.1). Because the SSRIs have
a less troublesome side-effect profile than clomipramine (see Section II.B.2.b), an SSRI is preferred for a first medication trial. Although
all SSRIs (including citalopram and escitalopram) appear to be equally effective,
individual patients may respond well to one and not to another.
The reasons for this patient-specific response are unknown, and
no demographic or clinical variables are sufficiently accurate predictors
of treatment outcome to permit their use in selecting medications
(71).
In choosing among the SSRIs, the psychiatrist should consider
the safety and acceptability of particular side effects for the
patient, including any applicable FDA warnings, potential drug interactions,
past treatment response, and the presence of co-occurring general
medical conditions. For example, paroxetine, the SSRI most associated
with weight gain (72) and the most anticholinergic
SSRI, would not be the first choice for patients with obesity, diabetes
mellitus, constipation, or urinary hesitancy.
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Another factor in choosing among medications
is the degree to which they alter metabolism through the hepatic
cytochrome P450 enzyme system or uridine 5'-diphosphate
glucuronosyltransferases (UGTs), act at the P-glycoprotein transporter,
or displace drugs tightly bound to plasma proteins (e.g., see references
73–76). Many interactions, however, reflect only in vitro
data, and their clinical importance is not established. Citalopram,
escitalopram, and sertraline (along with venlafaxine and mirtazapine)
have few or no important known drug interactions. Web sites providing
data on potential drug interactions include http://medicine.iupui.edu/flockhart
and http://mhc.com/Cytochromes. For up-to-date
clinical reports of interactions between specific SRIs and other
medications, psychiatrists can consult the federal National Library
of Medicine database at http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?DB=pubmed, which
is also accessible by entering the term "pubmed" in
a search engine. Since there are very few serious risks associated
with treatment with SSRIs (e.g., the risk of serotonin syndrome
from adding an SSRI to an MAOI, tramadol, meperidine, or dextromethorphan [77,
78]), the psychiatrist will much more often have to consider
the relative potential for specific SSRIs to interact with the patient's
other medications, particularly given the higher doses of SSRIs
that are often used in treating OCD.
Although no definitive data are available, the response of
first-degree relatives to particular medications may be predictive
of the patient's response because of genetic similarity.
This is a subject, however, for future research.
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a. Implementing Pharmacotherapy
The need to educate the patient about any medication recommended
has been emphasized earlier. Table 3 displays suggested starting
doses, known effective doses, maximum recommended doses, and maximum
doses occasionally prescribed for each SRI. For most patients, the
starting dose is that recommended by the manufacturer.
For patients who are worried about side effects, the medication
can be started at half the listed dose or less, since many SSRIs
(e.g., citalopram, escitalopram, fluoxetine, paroxetine, and sertraline)
are available in liquid form or in pills that can be split. Lower
initial medication starting doses and more gradual dose titration
may also be needed in patients with co-occurring anxiety disorders,
who may experience a transient worsening of anxiety symptoms. Experience
with pharmacotherapy in the elderly indicates that lower starting
doses of medication and a more gradual approach to dose increase
are often advisable. Most patients will not experience substantial improvement
until 4–6 weeks after starting medication, and some who
will ultimately respond will experience little improvement for as
many as 10–12 weeks. Available trial data suggest that higher
SSRI doses produce a somewhat higher response rate and somewhat
greater magnitude of symptom relief (79–82).
Some patients, such as those who have had little response to previous
treatments and are tolerating the medication well, may benefit from
even higher doses than those shown in the last column of Table 3.
In these instances, the patient should be closely monitored for
side effects, including the serotonin syndrome. Moreover, patients
who have not responded to a known effective dose after 10–12
weeks may respond at higher doses (83, 84).
For this reason, some clinicians prefer to titrate doses more rapidly
(in weekly increments to the maximum recommended dose if this is
comfortably tolerated), rather than waiting for 1–2 months before
each dose increment to evaluate results.
No evidence suggests that OCD treatment outcome is related
to plasma levels of clomipramine (85), fluoxetine (86),
fluvoxamine (87), or sertraline (82).
However, these studies were not designed to identify whether rapid
or ultra-rapid metabolizers of these medications were more likely
to be nonresponders.
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b. Managing Medication Side Effects
Unlike the SSRIs, clomipramine also blocks norepinephrine
reuptake, muscarinic cholinergic receptors, H1 histamine
receptors, and 
1-adrenergic
receptors, as well as sodium channels in the heart and brain. Thus,
clomipramine is more likely to induce anticholinergic effects such
as tachycardia, dry mouth, constipation, and blurred vision, although
these typically diminish over time. Clomipramine is also more likely
to induce delayed urination or, uncommonly, urinary retention. Histaminic
blockade is associated with weight gain and sedation. Adrenergic
blockade may lead to orthostatic hypotension and postural dizziness.
Sodium channel blockade can induce cardiac arrhythmias or seizures
(estimated to occur in 0.7% of patients treated with clomipramine
at a dose of up to 300 mg/day for as many as 6 years [88]).
In view of clomipramine's less favorable side-effect profile,
expert opinion favors one or more SSRI trials before trying clomipramine
(89). Starting clomipramine at a dose of 25 mg/day
or less will increase its early tolerability (90).
The most common side effects of the SSRIs
include gastrointestinal distress (especially in the first weeks
of treatment), agitation, insomnia or somnolence, increased tendency
to sweat, and sexual side effects, including diminished libido and
difficulty with erection and orgasm. A first step in managing any
side effect is to consider whether lowering the drug dose may alleviate
the side effect without loss of therapeutic effect. When this is
not possible, specific interventions may be considered. Gastrointestinal
distress can be minimized by starting with low doses; if mild queasiness
or nausea occurs, it will usually disappear within 1–2
weeks at a constant dose. Insomnia may respond to the patient's
taking the medication in the morning or to standard sleep hygiene measures,
or may require addition of a sleep-promoting agent. Fatigue or sleepiness
may respond to the addition of modest doses of modafinil (91).
Cases of successful treatment of sweating have been reported with
low doses of anticholinergic agents such as benztropine (92, 93),
and with clonidine (94), cyproheptadine (95),
and mirtazapine (96).
Few controlled trials have been published regarding the management
of sexual side effects, which may affect one-third or more of patients
(97). Management approaches include reducing the dose
to the minimal effective dose; waiting for the symptom to remit
(which clinical impression suggests may occur within 2 months in
about 10% of patients); trying a once-weekly, one-day "drug
holiday" before engaging in sexual activity; switching
to another SSRI (which may relieve the sexual dysfunction but not
control the patient's OCD); or adding a counteracting pharmacologic
agent. The drug holiday approach may alleviate difficulties with
erection or orgasm but not with libido. It is not effective for
fluoxetine because of its long half-life (98) and may
induce withdrawal symptoms if attempted with paroxetine or venlafaxine.
Taking drug holidays more than once weekly risks a return of OCD
symptoms. Case series and primarily uncontrolled studies report
modest success in restoring libido, erection, and orgasm by addition
of amantadine, bupropion, buspirone, yohimbine, Ginkgo biloba extract
(99), ropinirole (100), or stimulants
such as methylphenidate or dextroamphetamine. Adding bupropion has
the best evidence base (101), but even this literature
is mixed (102). Case series and uncontrolled studies
report modest success in restoring erection or orgasm, but not libido,
with cyproheptadine or mirtazapine (99). Controlled
trials support the use of sildenafil, tadalafil, and vardenafil
(103, 104) to restore erection and, in
men (105) and women (106), to restore
orgasmic ability.
Primarily on the basis of data in children and adolescents
(Section III.B.4), concerns have been raised about the potential
for increases in self-harming or suicidal behaviors in individuals
treated with antidepressant medications, including SRIs. A meta-analysis
in adults treated with SSRIs did not demonstrate increases in rates
of suicide or suicidal thoughts, although there was weak evidence
for an increase in self-harming behavior (107). A second
meta-analysis noted an increase in the odds ratio for suicide attempts
but did not report on the risk of other suicidal behaviors (108).
However, interpretation of these results is difficult because of
the confounds involved in calculating risks of suicide and other
suicidal behaviors from meta-analyses (109). This is
particularly true with regard to the use of antidepressants to treat
OCD, because the majority of SSRI clinical trials involve depressed
subjects, not subjects with OCD. In addition, studies using other
methodologies, including a nested case–control study (110),
a retrospective analysis of a large sample of computerized health
plan records (111), and a large prospective effectiveness
study in adult subjects with bipolar disorder (112),
showed no increases in the likelihood of suicide or suicide
attempts with antidepressant treatment. An additional nested case–control
study also showed no increase in the risk of suicide but did note
a small increase in the likelihood of self-harm (113).
Although antidepressant treatment in adults does not appear to be
associated with an increase in suicide, it is conceivable that side
effects (e.g., anxiety, agitation, insomnia, irritability) may increase
the chance of self-harming behaviors in some individuals (109).
Thus, careful monitoring for such side effects, as well as for evidence
of self-harming or suicidal thoughts or behaviors, is important,
particularly in the early phases of treatment and after increases
in antidepressant dose. Against these small risks, the benefits
of antidepressant treatment must always be considered (114, 115).
SSRIs may be associated with increased intra-operative blood
loss in patients also taking nonsteroidal anti-inflammatory drugs
(116) and, along with clomipramine, may interact with
anesthetics and opiate pain relievers. Patients should inform their
surgeon and anesthesiologist if they are taking an SRI.
A drug discontinuation syndrome consisting most often of dizziness,
nausea/vomiting, headache, and lethargy, but also including
agitation, insomnia, myoclonic jerks, and paresthesias (117, 118),
may occur if medication is suddenly stopped. The syndrome may occur
after stopping any SRI but is most often seen after rapid discontinuation
of paroxetine or the serotonin-norepinephrine reuptake inhibitor
(SNRI) venlafaxine (117). Particularly for these latter
medications, a slow taper over several weeks or more will minimize the
likelihood of discontinuation symptoms. If symptoms do occur, raising
the medication dose and slowing the taper may bring relief.
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3. Choosing a Specific Form of Psychotherapy
CBT is the only form of psychotherapy for
OCD whose effectiveness is supported by controlled trials. There
are no controlled studies that demonstrate effectiveness of dynamic
psychotherapy or psychoanalysis in dealing with the core symptoms
of OCD. Psychodynamic psychotherapy may still be useful in helping
patients overcome their resistance to accepting a recommended treatment by
illuminating their reasons for wanting to stay as they are (e.g.,
best adaptation, secondary gains). It may also be useful in addressing
the interpersonal consequences of the OCD symptoms (119).
Motivational interviewing may also help overcome resistance to treatment.
As noted in Section II.B.1, the CBT variant that relies primarily
on behavioral techniques such as ERP has the strongest evidence
base (59, 60). Some data suggest that
ERP is more effective if it integrates habituation with discussions
of feared consequences and dysfunctional beliefs (120, 121)
and with relapse prevention (122–125). For
OCD patients without co-occurring depression, data from one large
(N = 122) randomized controlled
trial suggest that intensive CBT consisting of ERP may
be superior to clomipramine monotherapy (123, 126).
Data also support CBT that primarily utilizes cognitive techniques
such as identifying, challenging, and modifying dysfunctional beliefs
when these techniques are combined with behavioral experiments (64, 121, 127–129),
which can resemble ERP depending on how they are done. In direct
comparisons, CBT utilizing cognitive techniques and behavioral experiments
had efficacy similar to CBT consisting of ERP that focused only
on habituation. Whether incorporating cognitive techniques with
ERP is more effective than either treatment alone is under
investigation (122). Only case reports support attempting
to treat OCD with cognitive therapy alone, without exposure or behavioral
experiments (129, 130). No controlled
trials have evaluated other psychosocial methods for treating OCD
that have been used in clinical practice (e.g., the "brain-lock
technique" [131], other
mindfulness approaches, acceptance and commitment therapy).
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4. Implementing Cognitive-Behavioral
Therapies
Cognitive-behavioral therapies have been delivered in individual,
group (132–134), and family therapy sessions,
with session length varying from less than 1 hour to 2 hours (135, 136)
(for a summary of group and family therapy studies, see references 136, 137).
One group has explored the delivery of behavior therapy by means
of a self-instructional workbook that allows the patient to design
and implement an individualized treatment plan. The patient couples
the plan with a voice-activated telephone-response system accessible
24 hours a day to monitor and report progress (138, 139).
The literature and expert opinion suggest that CBT sessions should
be scheduled at least once weekly (63, 140).
One study suggests that five sessions per week of CBT consisting
of ERP may be more effective than once-weekly ERP sessions, but
are not necessarily more effective than twice-weekly ERP sessions
(141). The number of treatment sessions, their length, and the duration
of an adequate trial have not been established, but expert consensus
recommends 13–20 weekly sessions for most patients (140).
More severely ill patients may require longer treatment and/or
more frequent sessions. On the basis of clinical experience, clinicians
should also consider booster sessions for more severely ill patients,
patients who have relapsed in the past, and patients who show signs
of early relapse. Finally, because the majority of treatment trials
have been only 8–16 weeks long, the long-term persistence
of treatment effects and the utility of periodic "booster
sessions" require further study.
The psychiatrist may elect to conduct CBT or to refer the
patient for this or another adjunctive psychotherapy. Psychiatrists
wishing to utilize various forms of CBT are encouraged to pursue training
through workshops, conferences, and other training programs. In
addition, they can consult a number of treatment manuals (128, 142–146)
or other publications (33, 147–149)
or obtain consultation from a clinician specializing in the use
of CBT. The psychiatrist initiating CBT should explain to the patient
the nature of the treatment, including its here-and-now focus, the
rationale underlying treatment procedures, and what the patient
will be required to do. When resources for CBT are not available,
the psychiatrist can suggest and supervise the use of self-help treatment
guides (Appendix) and recommend support groups such as those accessible
through the Obsessive Compulsive Foundation (Appendix), although
these interventions have not been subjected to controlled study.
At the start of therapy, the psychiatrist can use the Y-BOCS
Symptom Checklist (10) to help the patient create a
list of target symptoms, including obsessions, compulsions, and
items or situations that are avoided because of OCD concerns. The
patient ranks the listed items from least to most anxiety-provoking.
In CBT consisting of ERP, patients are taught
to confront feared situations and objects (i.e., exposure) and to
refrain from performing rituals (i.e., response prevention). Exposures
may include in vivo confrontations (e.g., touching objects in public
bathrooms) and imaginal confrontations of feared consequences (e.g.,
imagining becoming "dirty" from "contamination").
Exposures that provoke moderate anxiety are prescribed first, followed
as quickly as tolerable by exposures of increasing difficulty. Moving
at too slow a pace can diminish faith in the treatment and motivation to
continue. Patients must face their fears for a prolonged period
without ritualizing, allowing the anxiety or discomfort to dissipate
on its own ("habituation"). The goal is to weaken
the connections between feared stimuli and distress and between
carrying out rituals and relief from distress.
As noted earlier, ERP can be combined with formal cognitive
techniques aimed at dysfunctional beliefs (122). Dysfunctional
beliefs in OCD include magical thinking (e.g., contamination by
proximity), an inflated sense of responsibility for unwanted events,
overestimations of the probability of feared events, the assumption
that thoughts are morally equivalent to actions or inevitably lead
to action ("thought-action fusion"), perfectionism,
the belief that anxiety/ discomfort will persist forever, and
the need for control. Whether ERP with cognitive therapy is superior
to ERP alone is currently under investigation. However, many experts
believe that integrating exposures (or behavioral experiments) with
discussions of dysfunctional beliefs and feared consequences is
likely to be the most effective treatment (120). Modifications
of ERP that include formal cognitive techniques as well as other
interventions have been suggested for OCD patients with certain
symptoms (e.g., hoarding [150]) and
those without overt rituals (e.g., see references 59, 149, 151).
+
5. Monitoring the Patient's
Psychiatric Status
The frequency of follow-up visits after a new pharmacotherapy
is initiated may vary from a few days to 2 weeks. The indicated
frequency of visits will depend on the severity of the patient's symptoms,
the complexities introduced by co-occurring conditions, whether
suicidal ideation is present, and the likelihood of troubling side
effects. Patients should be seen as often as necessary for psychiatric
management. They should be encouraged to telephone between visits
if medication questions arise. If telephone calls become reassurance
rituals, the physician should work with the patient and the patient's
family to limit call frequency, using exposure (e.g., to the anxiety
that prompts the urge to call) and response prevention (e.g., limiting
calls), just as in treating any other ritual.
As noted earlier, symptom rating scales can sometimes be helpful
for monitoring the response of OCD, co-occurring depression, or
co-occurring anxiety disorders, or for keeping an objective record
over time in those patients whose symptoms do not respond to initial
treatments. Although use of scales is not expected in routine practice,
keeping an objective record over time for patients who do not respond
to initial treatments may be helpful.
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6. Determining When and Whether to
Change Treatments
The physician's goals are always to reduce suffering
and disability while minimizing the adverse effects of treatment.
First treatments rarely produce freedom from all OCD symptoms. In
clinical trials, OCD "responders" are variously
defined as those whose Y-BOCS scores decrease by at least 25%–35% from
baseline or who are rated much improved or very much improved on
the Clinical Global Impressions–Improvement scale (CGI-I)
(152). But even these degrees of improvement leave
much room for additional gains. Thus, the psychiatrist must decide
with the patient when, whether, and how to alter the treatment approach.
+
Deciding whether to alter the treatment approach
will depend on the degree of suffering and disability the patient
wishes to accept. Because illness can bring secondary gains (familial
attention and caring and freedom from responsibilities), and because
depressed mood can diminish hopefulness, the psychiatrist may have
to address these issues when the patient is not well motivated to pursue
further treatments despite limited improvement in his or her OCD.
In the opinion of CBT experts, 13–20 sessions of weekly
outpatient CBT with daily homework or weekday daily CBT for 3 weeks
(about 50 hours, half therapist-guided, half homework) is an adequate
dose after which next steps can be considered (140).
With regard to SRIs, expert opinion supports changing medication
strategy (switching or augmenting) after a trial of 8–12
weeks, with at least 4–6 weeks at the highest comfortably
tolerated dose (140). However, some patients may respond
simply to a longer period of continued treatment with the same medication
(84). There is no apparent relationship between OCD
treatment outcome and plasma levels of SRIs (82, 85–87).
When the outcome of initial treatment has been unsatisfactory,
the psychiatrist should first consider the possible contribution
of several factors: problems in the therapeutic alliance; interference
by co-occurring conditions such as panic disorder, major depression,
alcohol or substance use disorders, or severe personality disorder;
inadequate patient adherence to treatment; the presence of psychosocial
stressors; the level of family members' accommodation to
the obsessive-compulsive symptoms (153); and an inability
to tolerate an adequate trial of psychotherapy or the maximum recommended drug
doses. The psychiatrist should next consider extending or intensifying
the psychotherapeutic or pharmacotherapeutic intervention. Figure
1 displays a treatment algorithm outlining potential next steps;
Table 4 lists factors to be considered at each treatment step.
+
+
7. Pursuing Sequential Treatment
Trials
When the patient has an inadequate response to the initial
treatment and no interfering factor can be identified, the psychiatrist
and patient must decide on next treatment steps without the benefit of
data from controlled trials comparing all the possibilities. The
sequence of treatment trials shown in Figure 1 is based on expert
opinion (e.g., reference 140 and contributors to this guideline).
Given the absence of definitive trial data, augmentation strategies
might be preferred to switching strategies in patients who have
had a partial response to the initial treatment. Modest evidence supports
augmentation of SRIs with antipsychotic medications, including haloperidol
(154), risperidone (155–157),
quetiapine (158), or olanzapine (159).
These trials report response rates in the range of 40% to
55%. Patients who do not respond to one antipsychotic augmenting
agent may respond to another. A chart review study found that discontinuing
successful augmentation after 1–12 months resulted in relapse
for more than 80% (15/18) of patients, most within
2 months of discontinuation (160). Despite these promising
data regarding antipsychotic augmentation in OCD, many questions about
this treatment strategy remain unanswered, including the optimal
dose for each drug, long-term tolerability, when and how to discontinue
treatment, the drugs' relative augmentation efficacy, and
the reasons that only some patients benefit. Further data are also
needed on subsets of patients who may respond preferentially to
specific augmentation strategies. For example, one study (154)
suggests that augmentation with haloperidol helps only those patients
with co-occurring tic disorders.
Modest evidence supports augmentation of SRIs with CBT (specifically,
ERP) (161–163) and augmentation
of CBT with SRIs (164, 165). Some studies
have demonstrated no added benefit from combining SRIs and CBT (61, 123),
but these findings are limited by high refusal and dropout rates
and uncertainty about levels of treatment resistance (166, 167).
Some evidence suggests that adding cognitive therapy to ERP may
enhance the results, but this remains to be established. In the
absence of definitive data, combination treatment is provided in clinical
situations that include efforts to treat a co-occurring disorder
that is SRI responsive, to augment a partial response to monotherapy
(163), and to reduce the chance of relapse when medication
is discontinued (67).
For patients who do not respond to their first SRI, expert
opinion and clinical trial data support switching to a different
SRI (85, 87, 168–171).
However, the evidence does not allow one to predict the patient's
chance of response to the new SRI. Clinical experience suggests
that response rates to a second SRI trial are close to 50% but may
diminish as the number of failed adequate trials increases. A switch
to venlafaxine at doses ranging from 225 mg/day to 350
mg/day is supported by active comparator trials and open-label studies
suggesting its effectiveness in treating OCD (171–173).
A switch to mirtazapine is supported by one open pilot study and
a double-blind discontinuation trial (174).
If the strategies described above are not effective, augmentation
with other pharmacotherapies may also be considered. Expert opinion
(140, 175) and three open-label studies
(176–178) support clomipramine
augmentation of SSRIs. If clomipramine is added, plasma
levels of clomipramine and desmethylclomipramine should be assayed
2–3 weeks after reaching a dose of 50 mg/day,
and the total plasma concentration should be kept below 500 ng/mL
to avoid cardiac and central nervous system toxicity. Fluvoxamine
most increases plasma clomipramine levels (178), but
substantial increases may occur with fluoxetine and paroxetine.
A screening electrocardiogram may be advisable in patients suspected
of having heart disease or in patients over the age of 40. Pulse
rate and blood pressure should be monitored as the dose of clomipramine
is increased.
Positive case reports exist for lithium augmentation, and
positive case series have been reported for buspirone augmentation.
However, small controlled but methodologically limited trials of
lithium and buspirone augmentation have been negative. Adding pindolol
2.5 mg three times daily was effective in one small, double-blind,
placebo-controlled trial (179) but not in another (180).
A small, 12-week, open-label study reported that augmentation of
SRIs with riluzole 50 mg two times daily was often helpful, but
methodological limitations prevent confidence that the benefit was
due to riluzole itself (501). Small controlled augmentation
trials with l-triiodothyronine and
desipramine have produced generally negative results, and a double-blind, placebo-controlled
trial found St. John's wort to be no better than placebo
(181).
Adding once-weekly oral morphine sulfate 30–45 mg
to various SSRIs with or without other augmenting agents was superior
to placebo in a double-blind crossover study (182).
However, morphine sulfate should be avoided in patients with contraindications
to opiate administration, including a history of substance or prescription
medication abuse, psychosis, mania, antisocial personality disorder,
chronic obstructive pulmonary disease, or cardiovascular compromise.
In addition, the psychiatrist should consider what precautions and
documentation may be neededfor example, those described
by the American Academy of Pain Medicine (www.painmed.org). In addition,
positive case reports exist, along with a positive case series,
for monotherapy with the weak narcotic agonist tramadol (183).
And two small, double-blind, placebo-controlled, single-dose studies
reported positive results for d-amphetamine
30 mg in unmedicated OCD subjects (184, 185).
However, these drugs should be avoided in some patients (e.g., those
with a history of alcohol or other substance abuse or dependence).
Other treatment strategies that are supported only by case
series, case reports, or small open trialsliteratures
that are less likely to include negative experiencesinclude
anticonvulsants, MAOIs, ondansetron, l-tryptophan,
nicotine delivered via transdermal patch or chewing gum (186),
and Kundalini yoga. For patients with severe treatment-resistant
OCD, partial hospitalization (49, 187)
and intensive residential treatment (48, 188,189)
have been used.
Other somatic therapies should be considered only after first-
and second-line treatments and well-supported augmentation strategies
have been exhausted. With treatments such as these for which efficacy
is uncertain, it is especially important to weigh the potential
benefits against the side effects and other risks of therapy. For
example, evidence for the use of electroconvulsive therapy (ECT)
in OCD is limited to a single case series using a nonstandard form
of ECT administration (190). In addition, ECT carries
the risks of anesthesia and has side effects such as memory impairment.
As a result, ECT cannot be recommended for the treatment of OCD
but may be considered for treating co-occurring conditions for which
it may be indicated (e.g., major depression, uncontrollable mania,
and schizophrenia) (191–194).
Transcranial magnetic stimulation (TMS) is associated with less
potential for side effects, but evidence for its efficacy is limited.
Deep brain stimulation (DBS), a reversible and adjustable neurosurgical
intervention, has been reported to show efficacy in a few case series
of individuals with severe, highly treatment-resistant OCD (195)
but also has potential side effects.
The efficacy of ablative neurosurgery (anterior capsulotomy,
limbic leucotomy, cingulotomy, and gamma-knife radiosurgery) in
patients with severe, treatment-refractory, or intractable OCD has been
evaluated in case reports and unblinded studies. Improvement rates
have ranged from 35% to 50% (196–198).
Although some studies report relatively high rates of improvement,
the unblinded nature of these studies and the ongoing treatment
of many patients limit interpretation of these results. In addition,
potential adverse events range from personality changes, seizures,
and hydrocephalus to transient mania and mild transient side effects
such as urinary dysfunction. The recent development of less invasive
(DBS) and non-invasive (TMS) procedures makes it harder to consider
ablative neurosurgery as an alternative for highly treatment-resistant
or intractable OCD. For the time being, DBS and ablative neurosurgical
treatment for OCD should be performed only at sites with expertise
in both OCD and these treatment approaches.
+
C. Discontinuation of Active Treatment
Successful medication treatment should be continued for 1–2
years before considering a gradual taper by decrements of 10%–25% every
1–2 months while observing for symptom return or exacerbation.
Successful ERP should be followed by monthly booster sessions for
3–6 months, or more intensively if response has been only
partial.
Four double-blind SRI discontinuation studies studied different
SRIs, used different designs (e.g., length of observation and method
of placebo substitution), and had different relapse definitions. These
methodological differences have been associated with widely varying
reported rates of relapse or discontinuation for insufficient clinical
response after double-blind switch to placebo, ranging from 89% within
7 weeks to 24% within 28 weeks (80, 199–201).
An open discontinuation study also reported significantly higher
6-month, 1-year, and 2-year relapse rates for the patients whose
SRI treatment was discontinued (177). Thus, rates of
relapse appear to be increased after discontinuation of SRI treatment
but cannot be precisely specified. Given these observations, discontinuation
of pharmacotherapy should be carefully considered, and for most
patients, continued treatment of some form is recommended.
A review of CBT studies consisting of ERP (202)
concluded that about three-quarters of patients receiving ERP (with
and without concomitant medication) were doing well at a mean follow-up
of a little more than 2 years after the index treatment course.
The studies' methodological limitations make this finding
inconclusive. In addition, the relapse definition utilized in this
review differs from those used in the SRI studies, precluding comparison
of relapse rates.
A multi-site study (123) found that responders
to intensive ERP (with or without concomitant clomipramine) had
a significantly lower relapse rate and longer time to relapse after
treatment discontinuation than responders to clomipramine alone
(67). Post hoc analyses generally supported these findings,
albeit with substantial variability in observed relapse rates (203),
depending on the specific definition of relapse.
Together, these data suggest that the response to CBT consisting
of ERP may be more durable, at least in the short run, than response
to some SRIs after these treatments are discontinued. However, the
observed differences could be explained by other factors, including
differences in the intensity of treatment before discontinuation,
the rate of medication taper, the subjects studied, the length of
follow-up, and the relapse criteria.
+
III. Specific Clinical Features Influencing
the Treatment Plan
Many of the clinical features that will influence the treatment
plan have been mentioned in describing the choice of a treatment
setting and methods of enhancing adherence. Additional features
are described below.
+
A. Psychiatric Features
In suggesting treatments for adults, the clinician should
consider the patient's response to past treatments, including
the benefits and side effects, and the patient's motivation
and ability to adhere to pharmacotherapy and psychotherapy. As noted,
educational efforts are a standard treatment element and enhance
treatment motivation. An unstable or stressful living situation
diminishes the chances of successful treatment and may require concomitant
interventions such as family therapy.
Assessing the patient's degree of insight is useful
because it may influence willingness to cooperate with treatment.
The Brown Assessment of Beliefs Scale (204) and the
Overvalued Ideas Scale (OVIS) (205) provide quantitative
measures. Poor insight is associated with poorer response to SRIs
in most studies (71, 206) but not all
(207), and poorer response to CBT in some studies (208)
but not others (209–211).
Patients appear to be less likely to benefit
from medications, CBT, or combined treatment (212)
if their predominant or only OCD symptom is hoarding (i.e., acquiring
or accumulating items such as newspapers, magazines, books, packaging,
old clothing, notes, and lists that are beyond reasonable need or
of little objective value). Such individuals may be less responsive
to treatment than patients with other symptom patterns because they
usually demonstrate less insight, less distress, and therefore less
motivation for change (45, 213–217).
A recent study, however, found that OCD patients who hoard responded
as well to pharmacotherapy as did OCD patients with other symptom
types (218). Differences in the underlying neurobiology
(219) or OCD-related genetics (220) of
hoarding patients compared with nonhoarding patients may also play
a role. Specific treatment programs that achieve benefit with hoarding
patients have been described (33, 150, 221, 222)
but not tested in controlled trials. The Appendix includes a helpful
Web site (San Francisco Bay Area Resource & Internet Guide for
Extreme Hoarding Behavior, Clutterers Syndrome, or Pack Rat Syndrome).
Co-occurring chronic motor tics in the absence of Tourette's
disorder have been shown to decrease the likelihood of response
to fluvoxamine (154, 223) but not to clomipramine
(224). Patients with OCD who do not respond to an SRI
and have co-occurring tics may benefit from the addition of an antipsychotic
drug (154, 225). Although tic onset or
exacerbation during SSRI treatment is reported in isolated cases
(226, 227), trials of SSRIs should not
be withheld from OCD patients with co-occurring motor tics.
OCD co-occurring with Tourette's disorder can be
treated with SRIs, which usually have little effect, either positive
or negative, on the tic symptoms (225). When the OCD
fails to respond after one or two adequate SRI trials, adding a
first-generation (typical) or second-generation (atypical) antipsychotic
drug in a low to modest dose may ameliorate both disorders (225).
Co-occurring major depression does not adversely affect the
response of OCD to SRIs (71, 228). When
the OCD responds well and the major depression does not, the clinician
has many choices, none of which have been studied in large double-blind
trials. As a result, it is reasonable to apply the treatment strategies
outlined in APA's Practice Guideline for
the Treatment of Patients With Major Depressive Disorder (192).
These include using psychotherapies that are effective in treating
depression (i.e., interpersonal psychotherapy, CBT, or short-term
psychodynamic therapy), increasing the SRI dose, adding an antidepressant
from another class, adding an augmenting agent, or, in patients
with severe, treatment-resistant, or suicidal depression, utilizing
ECT (191). In many trials of CBT (229–231),
but not all (232), co-occurring major depression has
been associated with a poorer OCD outcome. Severe depression clearly
interferes with CBT (233). Thus, it may be useful to
utilize antidepressant medication, and particularly SRIs, to treat
co-occurring major depression before or during a trial of CBT.
Treatment of patients with both OCD and bipolar disorder should
include measures to achieve mood stabilization before initiating
treatment with agents, such as SRIs, that may induce or exacerbate
hypomania or mania. Stabilizing the bipolar disorder may require
a combination of medications, including lithium, anticonvulsants,
and second-generation antipsychotic drugs (193). In
bipolar OCD patients, SSRIs appear to be less likely than clomipramine
to precipitate hypomania or mania (29). Potential
drug interactions should be carefully considered when clomipramine,
fluoxetine, fluvoxamine, paroxetine, or sertraline are considered
for use in combination with these agents.
Episodic OCD, characterized by periods of markedly different
symptom severity independent of OCD treatment, appears to be considerably
more common in OCD patients with bipolar disorder (29).
Thus, a history of episodic OCD should raise the psychiatrist's
suspicion that co-occurring bipolar disorder may be present. Perhaps
as a result of co-occurring bipolar disorder, patients with episodic
OCD appear to be more likely to suffer from alcohol abuse or dependence,
panic disorder, and agoraphobia (29), which will also
require treatment.
Co-occurring panic disorder may respond to the SRI utilized
to treat the patient's OCD (234) or to CBT
for panic (235). When co-occurring panic disorder or
a history of panic attacks is present, SRI treatment should be initiated
at low doses, and the dose should be slowly titrated upward over
a period of weeks, in order to avoid initiating or exacerbating
panic attacks (234). Alternatively, the clinician can
start an SRI at usual doses combined with a benzodiazepine at antipanic
doses for the first month or so and then try tapering the benzodiazepine
over a period of weeks (234).
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6. Social Phobia (Social Anxiety
Disorder)
Co-occurring social phobia may respond to the SRI utilized
to treat the patient's OCD (236). However,
in one small study, OCD patients with co-occurring social anxiety
disorder experienced a poorer response to SSRI treatment than those
without this condition (237). Large, double-blind,
placebo-controlled studies support the effectiveness of escitalopram
(238), fluoxetine (239), fluvoxamine (240),
paroxetine (241), and sertraline (242),
as well as venlafaxine (243) and clonazepam (244),
in treating social phobia. Phenelzine, while effective, cannot be
combined with SRIs because the combination is likely to cause the
serotonin syndrome. Controlled trials suggest that social phobia
also responds to cognitive-behavioral therapies (245).
The point and lifetime prevalences of obsessive-compulsive
symptoms and of OCD in patients with schizophrenia are elevated
(246–248). In patients with co-occurring
schizophrenia, OCD or obsessive-compulsive symptoms may be present
independently or may be precipitated or exacerbated by second-generation
antipsychotic medications (249, 250).
Clozapine is the second-generation antipsychotic most often reported
to exacerbate obsessive-compulsive symptoms. However, case reports
also describe this effect with risperidone (251), quetiapine
(252), and olanzapine (253). Some patients
with schizophrenia have insight into the irrationality of their
obsessions and compulsions while lacking insight into their schizophrenic
delusions. In other patients, the obsessions and delusions become
illogically linked, as for example when the patient believes that
obsessions have been inserted into his mind by an external force
or that his compulsive rituals control world events. When clinically
significant OCD or obsessive-compulsive symptoms are present independently,
the psychiatrist must rely on clinical judgment in formulating a
treatment plan, since no large, controlled trials have been conducted.
The patient's antipsychotic regimen should first
be stabilized. A review of the treatment literature (254)
suggests that SRIs are usually well tolerated and can be beneficial,
but isolated reports of psychotic exacerbation exist. As with all
use of combination pharmacotherapies, potential drug interactions
must be borne in mind. Olanzapine monotherapy has been beneficial
in two case series. Adding fluvoxamine has been helpful in two open
trials, as has adding fluoxetine, paroxetine, or sertraline in individual
cases. Case reports suggest that low doses of fluvoxamine (75–300
mg/day) and slow upward titration are indicated (254).
When a second-generation antipsychotic drug induces obsessive-compulsive
symptoms, they may disappear within a few weeks. If not, treatment
options include adding an SRI, switching to another second-generation
antipsychotic, or attempting a trial of CBT. No controlled trials
exist to guide treatment planning, but reviewing the results of
published cases (249, 254) may be helpful.
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8. Substance Use Disorders
Because co-occurring alcohol or substance abuse or dependence
can interfere with treatment adherence and response and bring risks
of drug interactions, these disorders must be treated either before
or while treating the patient's OCD. Several organizations
have published guidelines to aid in treatment planning (255–257).
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9. Autism and Asperger's
Syndrome
Repetitive thoughts and behaviors are common in children and
adults with autism or Asperger's syndrome. In a recent
study that carefully distinguished stereotypic behaviors and idiosyncratic interests
from obsessions and compulsions, only somatic obsessions and repetition
rituals were more common in adults with OCD than in adults with
high-functioning autistic spectrum disorders (258).
An earlier study found that, compared with adults with OCD, adults
with autistic disorder had significantly more ordering, hoarding,
touching, and self-injurious behaviors (259). However,
about half of the autistic individuals in that study were either
intellectually impaired, mute, or both. Conversely, one study reported
that about 20% of OCD patients have autistic traits (260).
One study found the rate of OCD to be elevated in the parents of
autistic children with extensive rituals and restricted interests
(261).
The SRIs have been effective in treating the repetitive thoughts
and behaviors associated with autism (262). In two
studies with autistic children, clomipramine was more effective
than either desipramine or placebo in reducing repetitive and compulsive
behaviors (263, 264). One controlled study
found fluvoxamine to be significantly better than placebo for decreasing repetitive
behavior and aggression in adults with autistic disorder (265).
In a randomized controlled trial in children with Asperger's
syndrome, CBT was effective in reducing obsessive-compulsive symptoms
and other forms of anxiety (266).
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10. Personality Disorders
Although the majority of studies suggest that personality
disorders are common in patients with OCD (267), the
literature is mixed with regard to their impact on the outcome of
pharmacotherapy and of CBT. Attempts to draw conclusions are hampered
by methodological problems such as small sample sizes, retrospective
study design, poorly defined outcome criteria, difficulties in valid ascertainment
of these disorders (268), and differing diagnostic
criteria and lengths of follow-up. Some personality traits (e.g.,
passive-aggressive) and disorders (e.g., borderline personality
disorder) have been reported to interfere with adherence to treatment
(269, 270). Other traits (e.g., the odd
thinking style in schizotypal personality disorder) or particular
disorders (especially schizotypal personality disorder [271, 272])
have been associated with poor outcome for unclear reasons in some,
but not all, studies (269, 273). Thus,
the presence of a co-occurring personality disorder should not prevent
a trial of CBT and/or SRIs, but rather should alert the
clinician to consider whether to provide additional treatments targeting
the personality disorder. Obsessive-compulsive personality disorder,
which may co-occur with OCD, has, for example, been noted in case
reports to respond to psychodynamic psychotherapy or individual
psychotherapy with an expressive emphasis (274–276),
to CBT (277), and, in a case series, to SSRIs (278).
Patients with OCPD may feel threatened by a lack of control in therapy,
deny negative and painful feelings, intellectualize feelings, or
resist becoming "dependent" on medications or
therapy. Strategies to enhance the therapeutic work with these patients
include respecting the patient's defenses, helping the
patient accept his or her humanness, enlisting the patient's
collaboration in treatment planning, and empathizing with the patient's
feelings of shame and fear (119).
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11. Neurological Conditions Inducing
OCD
OCD or obsessive-compulsive symptoms not meeting DSM-IV-TR
diagnostic criteria can be manifestations of a number of
neurological conditions, including brain trauma, stroke, encephalitis,
temporal lobe epilepsy, Prader-Willi syndrome, Sydenham's
chorea, carbon monoxide poisoning, manganese poisoning, and neurodegenerative
diseases such as Parkinson's disease and Huntington's
disease (33, 279, 280). Treatment
is first directed to the underlying neurological condition when
this is possible. When OCD symptoms persist after treatment or stabilization
of the underlying condition, isolated case reports suggest that
treatment with an SRI and/or CBT may be of some benefit.
No controlled treatment trials have been conducted in patients with
OCD induced by neurological conditions.
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B. Demographic and Psychosocial Factors
Gender does not appear to influence the likelihood of treatment
response in OCD (71). However, men and women may differ
in their metabolism of psychotropic medications, including those
used in treating OCD (281–283).
In addition, premenstrual worsening of OCD has been reported in
from 20% (284) to 42% (285)
of women and may influence apparent treatment responses.
Pharmacogenetic influences on the probability of therapeutic
outcomes and adverse reactions to SRIs are beginning to be reported.
Differences in neurotransmitter transporter and receptor genotypes
are beginning to be implicated in predicting therapeutic response.
In addition, differences in the prevalence of cytochrome P450 (CYP)
slow, normal, extensive, and ultra-rapid metabolizers of psychotropic
medications, and hence in pharmacokinetic contributions to rates
of adverse events, are being associated with ethnicity (286).
For example, data indicate that 13%–23% of
Asians are CYP2C19 poor metabolizers compared with 2%–5% of
Caucasians, and thus should receive about 60% of the average
dose of clomipramine (287). CYP2D6 poor metabolizers
may require lower doses of paroxetine, which is both an inhibitor and
a substrate for this enzyme (287). In the future, identifying
CYP genotypes through approaches such as gene chips, may help prevent
adverse responses and metabolism-related treatment failures. Although
the data are too sparse to support guidelines at present, psychiatrists
should remain alert for helpful information.
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3. Pregnancy and Breast-Feeding
For patients wishing to become pregnant, pregnant patients,
and patients who are breast-feeding, CBT alone should be considered.
Deciding whether to start or stop a psychotropic drug during pregnancy
or breast-feeding requires making a risk-benefit assessment without
having complete information. Risks to the well-being of the fetus,
the infant, and the mother occur whether medications are started
or stopped, since the mother's health will influence the
pregnancy outcome and postpartum infant care. A model to integrate
and weigh the decision-making elements in this situation has been
proposed (288). In counseling the patient and her concerned
others, the physician should provide clear summaries of the available
data and, if desired, aid in obtaining more detailed data (289)
and provide counseling over several sessions to help the patient
come to terms with the uncertainty of the risks. Two helpful Web
sites are listed in the Appendix. Consultation with the patient's
obstetrician-gynecologist should be offered. Because OCD patients
are often quite anxious, experience doubting, and can suffer from
perfectionism or a need for certainty, helping the patient and her
significant other reach an informed decision may take several sessions.
Documentation of the information provided and the clinical rationale
for the chosen treatment approach is advisable.
OCD symptom onset during pregnancy has been reported in 13% (285)
to 39% (290) of women with OCD who have been
pregnant. The severity of pre-existing OCD is usually unaffected
by pregnancy but has been reported to worsen in from 8% (284)
to 17% (285) of women with OCD who are pregnant
and to improve in 14% (285).
The available data suggest that exposure to tricyclic antidepressants
(TCAs), fluoxetine, fluvoxamine, paroxetine, or sertraline does
not increase rates of intrauterine death (288, 291).
Whether SRI exposure decreases birth weight or increases rates of
premature delivery is unclear; the data are conflicting (292).
Available data do not suggest increased rates of major malformations
after in utero exposure to citalopram (293) or escitalopram
(294); fluoxetine, sertraline, or TCAs (288, 295);
or fluvoxamine (296). However, the FDA has determined
that exposure to paroxetine in the first trimester of pregnancy
may increase the risk for congenital malformations, particularly
cardiac malformations (www.fda.gov/cder/drug/advisory/paroxetine200512.htm;
accessed December 13, 2005). Consequently, at the FDA's
request, the manufacturer has changed paroxetine's pregnancy
category from C ("Risk cannot be ruled out") to
D ("Positive evidence of human fetal risk").
A neonatal behavioral syndrome that includes central nervous
system, motor, respiratory, and gastrointestinal signs may occur
in neonates exposed to SRIs in the third trimester. Although monitoring
of exposed neonates is warranted, this behavioral syndrome is usually
mild and is manageable with supportive care, and disappears
by 2 weeks of age (297). Some evidence also
suggests an increase in the likelihood of persistent pulmonary hypertension of
the newborn when the patient receives an SSRI during the third trimester
(298). Since the severity of OCD symptoms may not rapidly
increase when medication is tapered, tapering the patient's
SRI dose during the last weeks of pregnancy may be considered.
The very limited data regarding long-term effects of exposure
throughout pregnancy to TCAs or SSRIs do not suggest an elevated
risk of abnormalities in cognitive function, language, temperament,
or general behavior between ages 15 and 71 months (299).
In addition, one study found no evidence for developmental delay
at up to 2 years of age associated with in utero exposure to TCAs,
fluoxetine, sertraline, or paroxetine at varying times and for varying
durations (295).
The pharmacokinetic, pharmacodynamic, and safety considerations
in administering SRIs and other psychotropic drugs in pregnancy
(and during breast-feeding) are reviewed elsewhere (300, 301).
Although there are no data specific to OCD, increases in the SSRI
dose have been needed in the early third trimester to maintain remission
in major depression. The relative safety of administering first-generation
antipsychotics, especially trifluoperazine and perphenazine, during
pregnancy is supported by a large database (300). The
data regarding second-generation antipsychotics consist only of
case reports and case series totaling fewer than 100 children for
any individual drug except clozapine, for which the total approaches
150 children. The FDA classifies all second-generation antipsychotics
as pregnancy risk Category C ("Risk cannot be ruled out"),
except clozapine, which is classified as Category B ("No
evidence of risk in humans"). Benzodiazepines are apparently
not associated with a significant risk of somatic teratogenesis,
but the risk of neurobehavioral effects is unclear because of conflicting
reports (300, 302). The reviewers recommend
tapering these drugs before delivery when possible and using benzodiazepines
in FDA Category C (i.e., clonazepam) or those with less potential
for fetal accumulation (i.e., lorazepam and oxazepam).
The available data concerning the effects on the infant of
maternal SRI ingestion during breast-feeding are derived from only
a few hundred infants. The data suggest that the risk of contemporaneous,
noticeable effects is quite low (300, 303).
Cases of respiratory depression, hypotonia, poor feeding, irritability,
and uncontrollable crying have been reported (303).
There are no reports of long-term adverse effects of exposure, but
in the absence of large, controlled trials or observational studies,
caution remains in order. The American Academy of Pediatrics Committee
on Drugs recommends that a nursing mother be informed that the infant
will be exposed to maternal medications (304). No consensus
exists regarding how best to measure infant exposure (305),
but sertraline and paroxetine appear least likely to produce detectable
or elevated infant plasma drug levels (303). Monitoring
maternal or breast milk antidepressant levels is not recommended
(303). Discarding the breast milk 8–9 hours
after taking sertraline reduces infant exposure by a little more
than 15% (305). Data helpful in evaluating
the risks and benefits of taking other psychotropic drugs during breast-feeding
are reviewed elsewhere (300, 306).
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4. Children and Adolescents
In children and adolescents, treatment should
often start with CBT or with a combination of psychotherapy and
an SRI (307). Cognitive-behavioral approaches consisting
primarily of ERP have been shown to be efficacious in children (308–310),
and three SSRIs and clomipramine are FDA-approved for use in treating
OCD in children (308, 311–313).
Caution and frequent clinical monitoring are advisable when treating
children and adolescents with SRIs because of the possibility of
an increase in suicidal thinking or behaviors (314).
However, using SRIs in treating children and adolescents with OCD
or major depression may be necessary and should not be avoided when
clinically indicated (315–320). As
further information on the treatment of OCD in children and adolescents
is beyond the scope of this guideline, the reader is referred to
the practice parameter of the American Academy of Child and Adolescent
Psychiatry (321).
No studies of treatment of OCD in the elderly have been published.
Experience with pharmacotherapy of other psychiatric disorders in
the elderly indicates that lower starting doses of medication and
a more gradual approach to dose increases are often advisable in
this age group. Advanced age may affect drug absorption, free drug
concentration in plasma, the volume of distribution of lipid-soluble
drugs (leading to an increased half-life), and renal excretion rates
(322–324). Although hepatic CYP
enzyme activity does not regularly diminish with age, decreases
in liver mass or blood flow can lead to diminished rates of drug
metabolism. For example, diminished hepatic blood flow in the elderly
is associated with slower clearance of drugs metabolized by CYP3A4
(e.g., alprazolam, triazolam, sertraline, and mirtazapine). Older
patients may also be more sensitive to adverse drug effects. In
particular, elderly patients are more sensitive to anticholinergic
effects of tricyclics, such as clomipramine, and of antipsychotic
drugs. They are also more sensitive to the sedative, cardiac, autonomic,
and weight-increasing side effects of these drugs. Because elderly
patients are more likely to be taking medications for general medical
conditions, the physician prescribing anti-OCD medications will
more often have to consider potential pharmacokinetic and pharmacodynamic
drug interactions in these patients (73, 76, 283)
(Section II.B.2).
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C. Treatment Implications of Concurrent
General Medical Disorders
Co-occurring medical conditions and any medications being
used to treat them must be considered when the psychiatrist is choosing
pharmacotherapies for OCD. In particular, the effects of kidney
and liver disease on drug metabolism and the potentials for pharmacokinetic
and pharmacodynamic drug interactions must be reviewed. SSRIs would
be preferred over clomipramine in a) patients with epilepsy, because
of lower seizure risk; b) patients with cardiac arrythmias, congestive
heart failure, or blood pressure abnormalities, because of relative
cardiovascular safety; and c) patients who are overweight, because
of a lesser likelihood of stimulating appetite. The psychiatrist
should recall that SSRIs have been associated with cases of bradycardia,
hypertension, hyponatremia, bleeding (325), easy bruising,
nausea, diarrhea, constipation, changes in urination, extrapyramidal
symptoms, and other symptoms that can be confused with manifestations
of co-occurring medical conditions or treatments (33).
SSRIs may be used in patients with migraine headaches who are taking
triptans (326). Moreover, they may also be used in
patients with Parkinson's disease, although there are isolated
case reports of worsened motor functioning (327, 328).
In patients with diabetes mellitus, it is important to select second-generation
antipsychotics that are least likely to affect glucose metabolism
and appetite (e.g., aripiprazole and ziprasidone) (194, 329).
In all cases, the potential for interactions between the patient's
medical and psychiatric medications should be reviewed.