Obsessive-compulsive%20disorder Treatment

• 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

• 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

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