Information Section: Conditions
Condition: OCD
Article: Treatment of Obsessive-Compulsive Disorder Overview
Source: Leslie E. Packer, PhD  
File Last Updated: December 2004  

Page 1 of 1

Article Table of Contents

"MY THOUGHTS"*
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

PREFACE

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 maleate1, citalopram (Celexa®), and escitalopram oxalate (Lexapro®), although the only ones that are actually FDA-approved for treatment of OCD are fluoxetine, sertraline, and fluvoxamine. 

Research on the SSRIs suggest that they are effective in treating OCD in adults, children, and adolescents, and that they produce changes in the brain that may persist after treatment is discontinued. While the symptoms of OCD may be disabling for some, the good news is that about 60 - 70% of OCD sufferers benefit from treatment. Some patients report feeling some improvement within days of starting an SSRI, but it may take weeks before the levels build up in the system sufficiently to give the individual any noticeable relief. The other 30 - 40% 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.  

Another non-SSRI medication, clomipramine hydrochloride (Anafranil®) is approved for treatment of OCD, and while it has a somewhat stronger side effect profile than the SSRIs, it appears to be more effective than the SSRIs in treating OCD in both adults and children. Because of its stronger side effect profile, however, it is generally not considered a "first line" treatment.  

As suggested above, some patients do not achieve adequate results with medication. Others achieve some results, but relapse when treatment is discontinued. Maina et al. (2001) looked at what happens when someone who relapses is put back on the SSRI that had helped them before to investigate whether putting the individual back on the SSRI would produce the same benefits as it originally produced. The results indicated that response was poorer when the SSRIs were reinstated, regardless of type of SSRI used. Their data suggest that if someone relapses and goes back on the same SSRI that helped them before, they will get some benefit, but not as much as they got before. For that reason, the patient and clinician need to carefully consider whether to discontinue medication if the patient is doing well or whether to continue the patient on a maintenance schedule.

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 a withdrawal-emergent effects associated with stopping SSRIs. As with other medications, patients taking SSRIs need to be educated about potentially dangerous medication combinations, including combinations with over-the-counter compounds.  

The activation or hypomania adverse effect is one that has drawn particular attention because it raises the question of whether the use of SSRIs in children or teenagers might "trip" a child into Bipolar Disorder. At the present time, available research suggests that hypomania may be a genuine side effect of SSRIs and that it may trigger a "switch" in those who already have a bipolar disorder or are vulnerable to one.  

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.  

Use of SSRIs in children with OCD has recently been called into question by other research on suicidality related to the use of SSRIs in treating major depression in children. In 2004, the UK and US both issued statements stating that SSRIs should not be prescribed for children with Major Depressive Disorder and the safety issues continue to be debated in the professional literature. Since many children and teens with OCD also have depression, parents need to have a serious discussion with their child's prescribing physician about any risks that might exist in prescribing SSRIs for OCD in the presence of a history of depression or current depressive symptoms.  

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."

SURGERY FOR OCD

Surgery 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 surgical procedures may be of benefit.

SUPPLEMENTS AS ALTERNATIVE TREATMENT FOR OCD

A number of alternative treatments involving supplements or other approaches have had some anecdotal support for effectiveness, but to date, none have really demonstrated significant effectiveness in controlled experiments. If you are considering alternative approaches, you can research them on the alternative treatment databases and resources listed elsewhere on this site. I did receive email from a site visitor urging me to mention the use of Inositol as a complementary or alternative treatment. Unfortunately, in my zeal to protect site visitor confidentiality, I deleted his correspondence and I don't have it available to go back to now, other than my recollection that he reported that Inositol was of significant benefit to him above and beyond any prescribed OCD medications. As with all complementary supplements, it is important to note that they often lack controlled research demonstrating their efficacy over and above any placebo effects, but it doesn't mean that it might not help any one individual. Inositol is a good example of this, as some preliminary research had suggested it might be effective, but further research did not really demonstrate any significant benefit over and above placebo when both were added to an SSRI treatment program. The use of Inositol has somewhat stronger support for its use in Panic Disorder, but for OCD itself, there isn't a lot of compelling research to suggest it should be a first-line treatment. The March 2006 Supplement Watch newsletter is an interesting discussion and commentary on the state of research on supplements that site visitors may wish to read.

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 investigators have suggested that cognitive therapy alone (without the actual exposure) may be as effective as ERP.

COMBINING MEDICATION AND PSYCHOTHERAPY

A recent report by Dr. John March and his colleagues (October, 2004 JAMA) directly investigated whether CBT alone, 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 suggested that children and teens with OCD should begin treatment with a combination of CBT plus an SSRI or just start with CBT alone.

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. Their results indicated that family distress, accommodation, and rejection were related to depression and anxiety in the family members, but not to severity of the patients' OCD. At post treatment, family accommodation was related to the severity of patients' OCD, i.e., if the family "made allowances" or "accommodations," the patient was more likely to have more severe symptoms. Thus, family factors can predispose a child to OCD, maintain the symptoms, or actually enable them. 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.

NOTE

"My Thoughts," © 2001, Loren Packer-Hopke. All rights reserved.

Information Section: Conditions
Condition: OCD
Article: Treatment of Obsessive-Compulsive Disorder Overview
Source: Leslie E. Packer, PhD  
File Last Updated: December 2004  

Page 1 of 1

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