obsessive-compulsive%20disorder
OBSESSIVE-COMPULSIVE DISORDER
Obsessive-compulsive disorder is characterized by the presence of either obsessions or compulsions, but more commonly by both symptoms that can cause marked impairment or distress.
Obsession is a recurrent, persistent, intrusive, unwanted thought, image or urge that cause distressing emotions (eg anxiety and disgust).
Compulsion is a repetitive behavior or mental act that the person feels driven to perform, in order to lessen the distress caused by the obsession.
Anxiety is the central feature of obsessive-compulsive disorder.

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
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