Obsessive Compulsive Disorder
LEARNING OBJECTIVES
The reader will be able to:
 Ms. V |
Ms. V is a 28-year-old, single female, living with her parents and 9-year-old child. she presented with an intense fear of contamination combined with multiple rituals that interfered with her functioning and met diagnostic criteria for obsessive compulsive disorder (OCD). Although treated with fluvoxamine (250 mg per day), she continued to experience significant anxiety and compulsive behaviors and her psychiatrist referred her for integrated treatment. Ms. V has been treated for the last 10 years after being hospitalized at age 18 because her anxiety and ritual
behaviors were overwhelming. At the initial psychological evaluation she stated that she “did not want to touch a toilet.” In the past, she typically stopped attending individual therapy sessions after a few months.
behaviors were overwhelming. At the initial psychological evaluation she stated that she “did not want to touch a toilet.” In the past, she typically stopped attending individual therapy sessions after a few months.
According to the National Institute of Mental Health (NIMH) Epidemiologic Catchment Area Study, the lifetime prevalence of OCD is approximately 2.5%. Onset occurs before age 21 in 50% of patients and symptoms fluctuate in severity but typically persist throughout life. Psychological problems postulated to underlie OCD include an abnormality in risk assessment, pathological doubt, and the need for certainty or perfection.
OCD consists of obsessions (i.e., persistent ideas, thoughts, impulses, or images) that originate internally and are perceived as intrusive and senseless. Typical themes include:
Contamination
Aggression
Safety or harm
Sex
Religious scruples
Physical concerns
Need for symmetry or exactness
To neutralize these experiences, compulsive behaviors are performed usually in a stereotypical manner as per a set of rules. Typical behaviors include:
Cleaning
Washing
Checking
Excessive ordering and arranging
Counting
Repeating
Collecting
In addition, hoarding may represent a distinct OCD subtype.1,2 For example, there is genetic data to support biological differences between patients having OCD with or without hoarding.3,4 Further, these patients may have a more severe form of
the illness (e.g., poorer insight, greater indecisiveness, greater prevalence of social phobia, and generalized anxiety disorder, more severe compulsions, greater impairment, and dysphoria). Finally, although some data indicate a poorer response to treatment, this is yet to be adequately resolved.5
the illness (e.g., poorer insight, greater indecisiveness, greater prevalence of social phobia, and generalized anxiety disorder, more severe compulsions, greater impairment, and dysphoria). Finally, although some data indicate a poorer response to treatment, this is yet to be adequately resolved.5
To meet diagnostic levels, these experiences should cause distress, consume significant time, and interfere with normal daily activities. Presently, there is ongoing debate as to the classification of OCD as separate from other anxiety disorders.
Ms. V experienced intense fears of being contaminated which caused her to conduct several washing rituals in the shower. Many times her showers took >2 hours. Throughout the day she continued to fear contamination, was careful about what she touched and where she sat, and washed her hands repeatedly throughout the day. Sometimes she required her family’s assistance in child care when unable to withstand the anxiety about being dirty.DIFFERENTIAL DIAGNOSIS
Comorbid conditions are frequent with as many as 50% of patients with OCD also experiencing a major depression. Phobias, panic disorder, and alcohol abuse are also more frequent with OCD in comparison with the general population. The strong association with Gilles de la Tourette syndrome is notable given the likely genetic basis of this condition. Finally, a variety of conditions manifest symptoms that are reminiscent of OCD, have familial patterns, and often respond to similar treatments. These include:
Body dysmorphic disorder
Trichotillomania
Tic disorders
Hypochondriasis
Obsessive compulsive personality disorder
This has given rise to the concept of obsessive compulsive spectrum disorder (OCSD).
NEUROBIOLOGY OF OBSESSIVE COMPULSIVE DISORDER
The biology of OCD has been considered from several perspectives including:
Familial/genetic studies that find a higher prevalence in first-degree relatives
Imaging studies that implicate the anterior cingulate-basal ganglia-thalamocortical circuit
For example, basal ganglia dysfunction often manifests OCD symptoms (e.g., Huntington disease)
TREATMENT OF OBSESSIVE COMPULSIVE DISORDER
Both pharmacotherapy and psychotherapy have demonstrated efficacy in the management of OCD. The choice of either approach or their combination is dictated by such factors as:
Level of insight
Symptom severity
Level of disability
Good prior response to a specific approach
Level of response to initial monotherapy
Chronicity
Comorbid disorders
Patient preference
Treatment availability
We first describe the evidence to support each approach as a monotherapy and then discuss their sequencing and combination. In this context, data suggest that the combination of therapies is more effective in some but not all patients.
Pharmacotherapy for Obsessive Compulsive Disorder
The preponderance of evidence supports the role of agents that block 5-HT reuptake into presynaptic neurons.6
In this context, an important observation is the unique benefit of clomipramine in comparison to other tricyclic antidepressants (TCAs) and monoamine oxidase inhibitors (MAOIs).7 Although this agent involves both NE and 5-HT reuptake inhibition, it is singularly more potent in its 5-HT actions relative to other agents in its class. This action, coupled with the known efficacy of selective serotonin reuptake inhibitors (SSRIs) for OCD, identifies this neurotransmitter as a critical target for therapeutic effects. Although earlier data supported a preferential benefit for clomipramine over other SSRIs, subsequent comparison trials have not proved the same.8 Given the more significant adverse effects and similar efficacy of clomipramine, an SSRI is the recommended first-line medication approach. Although not all SSRIs have a U.S. Food and Drug Administration (FDA)-approved indication for OCD, it is likely that they all would be effective. An adequate trial may involve higher doses (e.g., sertraline 400 mg per day) for a more extended duration (e.g., 12 weeks). An unsuccessful or partially beneficial trial dictates trying another SSRI because there is ample evidence that insufficient response to one agent in class does not mean that a second SSRI would also fail. Choice of specific SSRIs should be guided by factors such as:
Prior history of responsiveness
Presence of comorbid psychiatric and/or medical disorders
Safety/tolerability profile
Potential for drug interactions
Dose titration schedules may require a conservative (i.e., lower doses, less frequent increments) approach to insure tolerability and the ultimate achievement of an adequate trial. The downside of this approach is the more extended time frame to achieve adequate treatment levels (see Table 3-1).
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If adequate symptom control remains elusive, adding psychotherapy or switching to clomipramine is indicated. The combined approach is discussed later in this chapter. As noted earlier, the potential efficacy of clomipramine is muted by its adverse effect profile, which is similar to other TCAs. These include:
Anticholinergic effects (e.g., dry mouth, constipation, cognitive effects)
Antihistaminic effects (e.g., sedation, weight gain)
α-Adrenergic effects (e.g., hypotension)
Sodium channel effects (e.g., cardiac rhythm disturbance)
Starting at low doses (≤25 mg per day) and gradually titrating up may allow for acclimation to these effects in many patients.
With lack of adequate response after the steps mentioned earlier, the evidence base is much less robust in dictating the next strategies. Pharmacologic approaches include selective serotonin
and norepinephrine reuptake inhibitors (SNRIs) such as venlafaxine, mirtazapine; SSRI augmentation with one or more trials of different first-generation antipsychotics (FGAs) or second-generation antipsychotics (SGAs); or buspirone.
and norepinephrine reuptake inhibitors (SNRIs) such as venlafaxine, mirtazapine; SSRI augmentation with one or more trials of different first-generation antipsychotics (FGAs) or second-generation antipsychotics (SGAs); or buspirone.
Discontinuing successful acute treatment is a complicated decision. Most experts agree that aminimum maintenance period of 1 to 2 years should elapse before considering a cessation of therapy. Relapse rates and time to relapse in discontinuation trials vary widely but generally indicate that a substantial number of patients will experience a recurrence. Therefore, indefinite pharmacotherapy should be considered in all patients. If attempted, tapering of treatment should be slow (i.e., 10% to 25% decrease monthly) with careful monitoring for symptom worsening.
Device-Based Therapies for Obsessive Compulsive Disorder
In more severe unremitting courses, device-based, neuromodulatory therapies and psychoses general procedures have been studied or utilized, including the following:
Psychotherapy for Obsessive Compulsive Disorder
OCD is a complicated illness with a high rate of treatment avoidance. It is estimated that up to 30% of patients who initiate psychotherapy drop out of treatment.10 The only empirically supported psychotherapeutic treatment for OCD is cognitive behavioral therapy (CBT). There are currently no studies examining the success of other psychotherapeutic interventions (e.g., psychodynamic, interpersonal).
The development of psychotherapy for OCD illustrates the evolution of psychotherapy in general. The early treatments in
this specialty concentrated on psychodynamic interpretations but were not very successful. In the late 1960s the focus on behavioral interventions and learning theory formed a new psychotherapeutic paradigm. Over time, criticisms of behaviorism and its possible limitations led to a focus on cognitive interventions. The treatment for OCD has mirrored that evolution. Exposure and response prevention (ERP) became the treatment of choice because this behavioralmodelwas very successful. Many patients, however, did not respond or could not tolerate ERP. As a result, cognitive therapy (CT) techniques were then used to treat OCD due to their success with other anxiety disorders. CT focuses less on exposure and more on cognitive restructuring. In our estimation the distinction is subtle. In this chapter, the terms ERP and CBT are used interchangeably and emphasize the behavioral intervention component.
this specialty concentrated on psychodynamic interpretations but were not very successful. In the late 1960s the focus on behavioral interventions and learning theory formed a new psychotherapeutic paradigm. Over time, criticisms of behaviorism and its possible limitations led to a focus on cognitive interventions. The treatment for OCD has mirrored that evolution. Exposure and response prevention (ERP) became the treatment of choice because this behavioralmodelwas very successful. Many patients, however, did not respond or could not tolerate ERP. As a result, cognitive therapy (CT) techniques were then used to treat OCD due to their success with other anxiety disorders. CT focuses less on exposure and more on cognitive restructuring. In our estimation the distinction is subtle. In this chapter, the terms ERP and CBT are used interchangeably and emphasize the behavioral intervention component.
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