Obsessive Compulsive Disorder



Obsessive Compulsive Disorder







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

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.



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)


  • Neurotransmitter dysregulation (e.g., 5-hydoxytryptamine [5-HT] transporter, Dopamine [DA] receptor type 4, glutamate transporter, γ-aminobutyric acid [GABA] type B receptor 1)


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).









TABLE 3-1 Medications for Treatment of Obsessive Compulsive Disorder (OCD)9



















































Class/Generic Name


Common Trade Name


Usual Drug Dosage (mg/d)


Usual Maximum Dose (mg/d)


SSRIs


aCitalopram


Celexa


40-60


80


aEscitalopram


Lexapro


20


40


Fluoxetine


Prozac


40-60


80


Fluvoxamine


Luvox


200


300


Paroxetine


Paxil


40-60


60


Sertraline


Zoloft


200


200


TCAs


Clomipramine


Anafranil


100-250


250


a Not FDA approved for OCD.


SSRI, selective serotonin reuptake inhibitor; TCA, tricyclic antidepressant. (Adapted from Koran LM, Hanna GL, Hollander E, et al. Practice guideline for the treatment of patients with obsessive-compulsive disorder. Am J Psychiatry. 2007;164[Suppl 7]:22.)


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.

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:



  • Neurosurgery



    • Anterior capsulotomy


    • Limbic leukotomy


    • Cingulotomy


    • Gamma-knife radiosurgery


  • Deep brain stimulation (DBS)


  • Transcranial magnetic stimulation (TMS)


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.

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Jul 8, 2016 | Posted by in PSYCHOLOGY | Comments Off on Obsessive Compulsive Disorder

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