Treatment of Obsessive-Compulsive Disorder Overview
by Leslie E. Packer, PhD
Last Updated January 2009
Article Table of Contents:
Medical Management (Pharmacological and Surgical)
Combining Medication and Psychotherapy
The Role of the Family
They come on so strong
They stay for a while
They never leave me alone
I have the power to stop them
They interfere with my daily life
They stop me from enjoying myself
They keep me isolated from my loved ones
I have the power to stop them
They disrupt my sleep
They change the person that I am
They are my thoughts
I have the power to stop them
When it comes to the treatment of OCD, patients will find that unlike some conditions where only medication seems to be really effective, there are nonmedication treatments for OCD that are just as — or more — effective than medication. In the remainder of this article, we will summarize some of the research on these treatments and talk a bit about what else is available if the “first line” treatments either do not work or the individual cannot or does not comply with the treatment regimen.
We will also consider the role of the family, because although family always makes a difference, when it comes to OCD, well-meaning family members often inadvertently enable the problematic behavior and patterns.
MEDICATION MANAGEMENT OVERVIEW
The class of medications known as SSRIs (Selective Serotonin Reuptake Inhibitors) appear to be the first-line treatments pharmacologically. In the U.S., available SSRIs include fluoxetine hydrochloride (Prozac®), paroxetine hydrochloride (Paxil®), sertraline hydrochloride (Zoloft®), fluvoxamine maleate (formerly marketed as Luvox®), citalopram (Celexa®), and escitalopram oxalate (Lexapro®). Not all are approved by the FDA for treatment of OCD.
Research on the SSRIs suggest that they are effective in treating OCD in adults, children, and adolescents. About 60 – 70% of OCD sufferers benefit from medication treatment. Some patients report feeling some improvement within days of starting an SSRI, but it may take 2-3 months before the levels build up in the system sufficiently to give the individual any noticeable relief. A meta-analysis of research studies investigating SSRIs in the treatment of OCD found that there were no significant differences among the SSRIs in terms of their effectiveness (Meth & Reddy, 2007). There are conflicting data as to whether any beneficial effects persist after medication is discontinued.
The other 30 – 40% of patients generally do not respond well to SSRIs or do not achieve satisfactory results with SSRIs. Patients with OCD who have poor insight (as to the irrationality of their obsessions and compulsions) do not respond as well to SSRIs as those with good insight. The presence of comorbid conditions may also predict a poorer response to medication: children with OCD who have comorbid ADHD, Oppositional Defiant Disorder or Conduct Disorder do not benefit as much from SSRIs (Grados & Riddle, 2008).
Although SSRIs are generally accepted as first line of treatment, they are not the most effective medication for OCD. An older medication that is not serotonergic-selective, clomipramine hydrochloride (Anafranil®), has been shown to be more effective than the SSRIs and is approved for treatment of OCD in children and adults. Physician reluctance to prescribe it may be due more to its side effect profile: it can produce gastric discomfort, flatulence, weight gain and other problems.
As suggested above, any benefits of medication may not persist when medication is discontinued. Maina et al. (2001) investigated the effects of reintroducing an SSRI if a patient relapsed after discontinuing SSRI treatment. They found that patients who were responders during the intial treatment did respond again when SSRIs were re-introduced, but they got less benefit with the re-introduction. Their data have important implications for treatment in terms of whether medications should be discontinued.
MEDICATIONS – ADVERSE EFFECTS
The SSRIs do have side effects that may be problematic in some cases. Insomnia or somnolence, nausea, diarrhea, sweating or tremor, activation or hypomania, and delayed ejaculation or impotence are just some of the adverse side effects that have been reported in the literature. Some patients have also reported unpleasant withdrawal-emergent effects associated with stopping SSRIs. Perhaps the most contentious side effect has been whether SSRIs induce suicidality. In 2004, the FDA required a “black box warning” for the use of SSRIs with youth; the warning went into effect in 2005. In the years since the warning was mandated, prescriptions for SSRIs decreased significantly. Of concern, suicides increased. A discussion of the history of the FDA warning and the data it was based on can be found in an article by Kyle and Cortes in Pharmacy Times.
One other potential adverse effect is something called “amotivational syndrome,” a frontal lobe syndrome associated with the use of SSRIs that is characterized by apathy and lack of motivation. Garland and Baerg (2001) reported on four children and one adolescent who experienced this syndrome while on SSRIs; one of the children also experienced behavioral disinhibition. The authors note that the symptoms were dose-related and reversible, but that the lack of insight in patients and delayed onset indicate that clinicians need to inform patients and families of the potential symptoms. A subsequent literature review by Barnhart, Makela, and Latocha (2004) confirmed their findings and recommendations.
As with every prescription medication, patients taking SSRIs need to be educated about what to watch out for and potentially dangerous medication combinations, including combinations with over-the-counter compounds. If you’re not sot sure what to ask your doctor when medications are being considered for any of the conditions discussed on this web site, see my suggestions in “Questions to Ask About Medications.”
If SSRIs ameliorate symptoms but provide inadequate relief, the physician may recommend switching to clomipramine (mentioned above), or the physician may recommend augmenting the SSRI with either a second medication or cognitive-behavior therapy. To date, only atypical neuroleptics (such as Risperdone®) have been been empirically validated as effective augmenters (Math & Reddy, 2007).
Research demonstrating a relationship between glutamate and OCD [cf, Yücel, Wood, et al., (2008); Starck, Ljunberg, et al., (2008); Sjigart, Wang et al., (2009)] offer another possibility for treatment or augmentation. Preliminary studies using memantine (Namenda®) and riluzole (Rilutek®) which are glutamate antagonists, and glycine, a glutamate receptor agonist, found that a significant percentage of non-responders to SSRIs or SSRI plus atypical neuroleptic responded well to the treatment [Aboujaoude, Barry, & Gamel (2009); Greenberg, Benedict, et al., (2008); Grant, Lougee, et al. (2007)].
SURGERY FOR OCD AND ALTERNATIVE TREATMENTS
Psychosurgery may also be an option for some people with severe treatment-resistant OCD. The topic is too complex to discuss on a web site of this type, but there are some data suggesting that in severe OCD that has not responded to medication and therapy, certain Anterior cingulotomy and deep brain stimulation may be of benefit.
There is no adequately controlled research indicating that any alternative or complementary treatments such as herbals would be of benefit in treating OCD. Initial reports of Inositol as an effective treatment were not replicated. St. John’s Wort (Hypercin/Hypercium) is similar to the SSRIs in that it affects the serotonin system, but the one study investigating its effectiveness in treating OCD found that it did not produce any benefit over and above a placebo (Kobak, Taylor, et al., 2005).
Although no alternative treatments have met scientific standards for demonstrated efficacy, that does not seem to stop many places and professionals from using them or selling them. If you want to explore alternative treatments that have not passed the usual standards for demonstrating efficacy, be an informed consumer: ask questions about success rate, ask how long it will take before effects are noted, ask what the risks are, and ask to see copies of all research reports supporting the use of the herbal or treatment. Then check with your regular physician to see if the physician has any concerns about potential side effects or interactions.
COGNITIVE BEHAVIOR THERAPY OVERVIEW
One of the most clinically effective approaches to treating OCD is a nonmedication approach, Cognitive Behavior Therapy (CBT). The term “CBT” refers to a broad class of therapeutic interventions that involve changing both the individual’s cognitions (thoughts) and behavior. Of particular relevance is the type of CBT known as Exposure-Response Prevention therapy (ERP). In ERP, the client and therapist may construct a hierarchy of situations that are progressively more difficult in terms of resisting the need to engage in the targeted compulsive behavior. The client is taught how to relax, and then starting with the least intense item on the hierarchy, the client intentionally exposes him/herself to the ‘trigger’ for the compulsive behavior while resisting the performance of the behavior itself.
The “exposure” can be done in the patient’s imagination and/or in “real life.” The logic of the technique is fairly straightforward. In the presence of the ‘trigger’ or the obsessive thought, the individual’s anxiety will rise. Prior to therapy, the individual would engage in the compulsive ritual and thereby reduce the anxiety. The problem with that, however, is that the performance of the ritual was actually reinforced (“rewarded”) by reduction in anxiety, thereby strengthening the likelihood that the individual will engage in the compulsive behavior again in the presence of the anxiety-producing obsessive thought.
In ERP, the trigger is present and the individual’s anxiety is generated, but now the compulsive behavior is not performed. What will happen? The first thing that happens is that anxiety levels will probably rise. And rise. And rise. If the individual is able to employ any relaxation or distraction techniques and is able to successfully stop herself from performing the ritual/compulsive behavior, eventually (and “naturally”), the anxiety will start to subside. This part of the process is known as “extinction” — the anxiety response is not followed by any consequences, and so extinguishes or dies out. The next time the individual is exposed to the trigger/stimulus, their anxiety will rise again, but again, if they don’t perform the compulsive behavior, their anxiety will extinguish. Over sessions and weeks, the individual’s anxiety will diminish to a point where the trigger/stimulus no longer produces an anxiety response. At that point, the therapist and client may go to a more challenging item from the hierarchy.
Participating in CBT is hard work. Young children often lack insight into the irrationality of their obsessive thoughts and/or may not be motivated to address what the adults in their lives see as a significant problem. And even adults who do have insight may find the anxiety so overwhelming that they are unable to even get started in such therapy. For those who have very severe OCD, a combination of medication and therapy may be indicated, with the medication serving to bring the OCD symptoms down to a manageable level so that the individual can benefit from the therapy, but even that is controversial, because if you reduce the person’s symptoms via medication, you may also reduce their motivation to do the cognitive-behavioral work.
Piacentini and his colleagues at UCLA conducted open trials on CBT with children with OCD (2002). The 42 children (approximately half of whom were on medication at baseline) were given a treatment protocol based on ERP. For the sample, there was a clinically significant response to treatment. The investigators note that for this sample, poorer outcome was associated with more severe obsessions and greater OCD-related academic impairment prior to treatment.
There are many variations on CBT and the preceding was meant simply to give you an idea of the kind of approach that might be used. A number of intriguing research reports have appeared in the literature, with some investigators comparing in vivo exposure to the ‘trigger’ to purely cognitive strategies. Some studies suggest suggested that cognitive interventions alone or behavior therapy alone may be as effective as cognitive-behavior therapy.
At the present time, both CBT and medication are considered first line treatments for OCD. A study by Dr. John March and his colleagues (2004) (pdf) directly investigated whether CBT alone (in this case, Exposure-Response Prevention), SSRI medication alone, or CBT and SSRI therapy combined were most effective in treating OCD in children and adolescents. In their multi-center study, sertraline was the SSRI used for the SSRI condition. The SSRI-alone, CBT-alone, and SSRI-CBT combination were all significantly more effective than the placebo condition. Additional analyses of their data indicated that combined treatment and CBT-alone did not differ from each other significantly, but both were significantly better than medication-alone the remission rate outcome. Based on their findings, they recommended that children and teens with OCD should begin treatment with a combination of CBT plus an SSRI or just start with CBT alone.
The current practice guideline (pdf) for psychiatrists advises:
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].
The guideline reflects findings that benefits of medication may not continue once medication is stopped, that CBT can reduce the need for medication [cf, Cottraux et al. (1993)], and that incorporating CBT can help prevent regression to pre-treatment symptom levels. The value of CBT is also demonstrated by brain imaging studies that indicate that therapy — even without medication — normalizes brain function [cf, Nakatani et al. (2003); Linden (2006); Nabayema et al. (2008); and Saxena et al. (2009)].
ROLE OF THE FAMILY
Regardless of whether OCD is inherited or nonfamilial, it impacts the entire family. Parents or family members are often at a loss as to whether to accommodate the relative’s symptoms and possibly enable them, or “hang tough” or take some other course.
Amir et al. (2000) looked at: (1) the family’s reactions to OCD as a function of the severity of the patient’s symptoms and (2) the effects of family accommodation and rejection on treatment outcome. Prior to treatment, the family’s accommodations and responses affected the family’s functioning but were not related to the severity of the child’s OCD. Following treatment, family accommodation was related to the severity of patients’ OCD. From a correlational study of this kind, it is not clear whether the parental accommodations contributed to the severity of the child’s symptoms or were merely a reflection of the possibility that the more severe symptoms required more accommodations by the family.
Their findings received partial support in a subsequent study by Peris, Bergman et al. (2008). These investigators found parents commonly made accommodations for their children’s OCD. Parental involvement in rituals correlated positively with higher levels of child OCD severity and negatively with levels of family organization.
Getting the family involved in treatment is obviously an important component in planning any treatment regimen. Training the family how to respond to the child or family member, and interventions oriented towards training family members to use techniques that foster problem-solving, independence, and greater self-confidence may all improve the child’s functioning.
“My Thoughts,” © 2001, Loren Packer-Hopke. All rights reserved.