Obsessive-compulsive%20disorder Treatment
Principles of Therapy
- Both psychotherapy and pharmacotherapy are effective
Goals of Treatment
- Educate the patient and family about obsessive-compulsive disorder, the symptoms and its treatment
- Help patient develop coping strategies for stressors
- Decrease symptom frequency and severity
- Improve the patient’s functioning and quality of life
- Enhance patient’s ability to cooperate with care on the face of frightening cognitions caused by obsessive-compulsive disorder
- Reduce or minimize any drug’s adverse effects to improve treatment compliance
- Inform the patient about the likely side effects
- Schedule follow-up to monitor treatment compliance and response
Choice of Treatment
- Depends on the following factors:
- Patient’s preference
- Degree or nature of functional impairment, severity of symptoms
- Age
- Patient’s motivation and ability to comply with the treatment modality
- Presence of comorbidities
- Cost of treatment
Treatment Setting
- Provide the least restrictive setting which is safe and effective
Combination Therapy
- Considered in patients with an unsatisfactory response to monotherapy, with co-occurring psychiatric disorders for which pharmacological therapy are effective, those who want to shorten the duration of medication, and those who have severe obsessive-compulsive disorder
- Reviews showed that pharmacological therapy yields an early response to treatment, while psychotherapy may likely lead to maintained effects even after treatment discontinuation
Pharmacotherapy
- Pharmacological therapy is recommended in the following patients:
- Who are uncooperative with or who have inadequate response to cognitive-behavioral therapy
- Have moderate to severe functional impairment
- Have good response to a given drug
- Who prefer pharmacotherapy
- Symptoms are usually relieved but not completely eliminated
- There is usually an improvement in quality of life
- Substantial improvement is experienced 4-6 weeks after initiating therapy; some patients may respond after 10-12 weeks
- Successful pharmacotherapy should be continued for 1-2 years in adults and 6 months in children and adolescents
- Gradually taper by decrements of 10-25% every 1-2 months while observing for recurrence of symptoms or exacerbation
- Many patients relapse once medication is stopped
- Discontinuation of pharmacotherapy should be considered carefully
- Continued therapy of some form is recommended for most patients
Selective Serotonin Reuptake Inhibitors (SSRI)
- Eg Escitalopram, Fluoxetine, Fluvoxamine, Paroxetine, and Sertraline are recommended for obsessive-compulsive disorder patients
- Inhibit the reuptake of serotonin and normalize serotonergic imbalances
- Different selective serotonin reuptake inhibitors inhibit serotonin reuptake to different extents
- Provide obsessive-compulsive disorder symptom improvement
- Selective serotonin reuptake inhibitors are equally effective; however, patient may respond well to one medication and not to another
- Fluvoxamine and Sertraline are the recommended selective serotonin reuptake inhibitors for children and adolescents
- Fluoxetine may be used in children with comorbid depression
- Fluvoxamine, Paroxetine and Sertraline had similar efficacy but with better tolerability compared to Clomipramine
- May gradually increase dose to maximum if with inadequate response after 4-6 weeks and with no adverse effects
- Drug dosages used to treat obsessive-compulsive disorder are usually higher than those used to treat depression
- Monitor closely for adverse effects and suicidal tendencies/self-harm especially during the early phase of therapy and when increasing the dose
Clomipramine
- As effective as selective serotonin reuptake inhibitors, but the selective serotonin reuptake inhibitors are well or better tolerated
- It has shown benefits not only in adults but also in children and adolescents as well
- A tricyclic antidepressant; also blocks muscarinic cholinergic receptors, H1 histamine receptors, alpha1- adrenergic receptors and sodium channels
- Relieves symptoms of obsessive-compulsive disorder
- Side effects (particularly anticholinergic effects) and potential for fatal overdose may limit its use
Non-Pharmacological Therapy
Psychotherapy
- Obsessive-compulsive disorder is a chronic illness with a waxing and waning course
- Therapy is indicated when symptoms cause significant distress or interfere with functioning
- Individualize therapy according to the patient’s needs and capacities
- Establish and maintain a good therapeutic alliance between the physician and patient so that treatment will be more effectively planned and implemented
- Consider the patient’s feelings and acts toward the physician
- Consider the patient’s wants and expectations from treatment
- Provide the patient sufficient time to consider treatment options
- Assess patient’s symptoms
- Differentiate the obsessions, compulsions, and rituals of obsessive-compulsive disorder from similar symptoms found in other disorders (eg depression, generalized anxiety disorder, post-traumatic stress disorder, schizophrenia, mania)
- Perform a complete psychiatric assessment including medical evaluation
- Use rating scales
- Perform baseline severity rating of obsessive-compulsive disorder symptoms, comorbidities and their effects on patient’s functioning
- Ensure safety of the patient and others
- Guided self-help with support and information for the family members is used for children and adolescents with mild functional impairment
- Dynamic psychotherapy or psychoanalysis
- No controlled studies to show the efficacy in dealing with obsessive-compulsive disorder symptoms
- May still be helpful in patients to overcome their resistance in accepting a recommended therapy by enlightening them on the reasons for wanting to stay as they are
- Address interpersonal consequences of obsessive-compulsive disorder symptoms
- Motivational interview
- May also be useful to overcome resistance to therapy
Cognitive-Behavioral Therapy (CBT)
- Recommended as 1st-line therapy for children, adolescents and adults with obsessive-compulsive disorder
- Most widely used psychological therapy
- Indicated in patients who are not too anxious, depressed, severely ill to cooperate, or who do not prefer pharmacological therapy
- Used in children and adolescents who have moderate to severe functional impairment and those with mild functional impairment for whom guided self-help has been ineffective or refused
- Exposure may result in normalization of corticostriatal-thalamic-cortical circuitry
- Various studies show that behavioral therapy is successful in 50-90% of the patients with obsessive-compulsive disorder
- The only form of psychotherapy for obsessive-compulsive disorder whose effectiveness is supported by clinical trials
- Cognitive interventions incorporated into behavioral therapy
- Eliminates risk of medication side effects and produces results that may be better maintained after medical treatment is terminated
- Low intensity cognitive-behavioral therapy
- Used in adult patients with mild functional impairment
- Includes brief individual cognitive-behavioral therapy using structured self-help materials, brief individual cognitive-behavioral therapy by phone, and group cognitive-behavioral therapy
- Also includes exposure and response prevention (ERP)
- Up to 10 therapist hours per patient
- Intensive Cognitive-Behavioral Therapy
- Used in adult patients with moderate to severe functional impairment and those who have inadequate response to low intensity cognitive-behavioral therapy
- Includes exposure and response prevention
- >10 therapist hours per patient
- Brief treatment (eg 13-20 weekly sessions)
- May use daily treatments if speed is of the essence or in severe obsessive-compulsive disorder
- More severe patients may need longer therapy and/or more frequent sessions
- Include family members in the treatment process as patient’s behavior may affect the family system, or when family members can support patient treatment, especially if the patient is a child or a young adult
- Individualize intensity and length of sessions
Exposure and Response Prevention (ERP)
- Considered the 1st-line psychological treatment approach in obsessive-compulsive disorder
- Involves gradually exposing patients to stimuli that elicit obsessive fear (eg “contaminated” objects) while simultaneously preventing them from performing any of their compulsive rituals (eg hand washing)
- Situations that provoke moderate anxiety are done first, followed as quickly as tolerable by exposures of increasing difficulty
- Patients must confront their fears for a prolonged period without ritualizing to allow the anxiety to dissipate on its own (“habituation”)
- Aims to weaken the connections between feared stimuli and distress, and between doing the rituals and relief from distress
- Some data has shown that exposure and response prevention may be more effective when habituation is integrated with discussions of feared consequences and with relapse prevention
- Successful exposure and response prevention should be followed by monthly booster sessions for 3-6 months, or more intensively if there is only partial response to treatment
- Efficacy has been demonstrated in children and adolescents, although the literature is smaller compared to adults
Cognitive Therapy
- Helps patients identify and modify thought patterns that cause anxiety, distress, or negative behavior
Combination of Exposure and Response Behavioral and Cognitive Therapy
- Integration of exposures with discussions of dysfunctional beliefs and feared consequences is likely to be the most effective psychotherapy