Principles of Therapy
Both psychotherapy and pharmacotherapy are effective in the management of obsessive-compulsive disorder. In children and adolescents, combination therapy is more effective than drug treatment or cognitive-behavioral therapy alone.
Goals of Treatment
The goals of treatment are as follows: Educate the patient and family about obsessive-compulsive disorder, its symptoms, and treatment; help the patient develop coping strategies for stressors; decrease symptom frequency and severity; improve the patient’s functioning and quality of life; enhance the patient’s ability to cooperate with care on the face of frightening cognitions caused by obsessive-compulsive disorder; and reduce or minimize any drug’s adverse effects to improve treatment compliance. Inform the patient about the likely side effects and schedule follow-up to monitor treatment compliance and response.
Choice of Treatment
The 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; and cost of treatment.
Treatment Setting
Provide the least restrictive setting for the patient that is safe and effective.
Combination Therapy
Combination therapy is considered in patients with an unsatisfactory response to monotherapy, with co-occurring psychiatric disorders for which pharmacological therapy is 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.
Pharmacological therapy
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Pharmacological therapy is recommended in the following patients: Those who are uncooperative with or who have an inadequate response to cognitive-behavioral therapy; have moderate to severe functional impairment; have a good response to a given drug; and those 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 (SSRIs)
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Escitalopram, Fluoxetine, Fluvoxamine, Paroxetine, and Sertraline are recommended for obsessive-compulsive disorder patients. These drugs inhibit the reuptake of serotonin and normalize serotonergic imbalances. Different selective serotonin reuptake inhibitors inhibit serotonin reuptake to different extents and provide obsessive-compulsive disorder symptom improvement. Selective serotonin reuptake inhibitors are equally effective; however, patients may respond well to one medication and not to another.
Fluvoxamine and Sertraline are the recommended selective serotonin reuptake inhibitors for children and adolescents. Fluvoxamine may be considered to be added with psychotherapy in patients not responding to cognitive-behavioral therapy. Fluoxetine may be used in children with comorbid depression. Fluvoxamine, Paroxetine and Sertraline had similar efficacy but with better tolerability compared to Clomipramine. Gradually increase the dose to the maximum if there is an 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 or self-harm, especially during the early phase of therapy and when increasing the dose.
Clomipramine
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Clomipramine is as effective as selective serotonin reuptake inhibitors, but the SSRIs are well or better tolerated. It has shown benefits not only in adults but also in children and adolescents as well. Clomipramine is a tricyclic antidepressant that also blocks muscarinic cholinergic receptors, H1 histamine receptors, alpha1-adrenergic receptors, and sodium channels. This relieves symptoms of obsessive-compulsive disorder. Side effects (particularly anticholinergic effects) and potential for fatal overdose may limit its use.
Nonpharmacological
Psychotherapy
Obsessive Compulsive Disorder_Management 4Obsessive-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 the patient so that treatment will be more effectively planned and implemented, such as considering the patient’s feelings and acts toward the physician, considering the patient’s wants and expectations from treatment, and providing the patient sufficient time to consider treatment options.
Assess the 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, and mania). Perform a complete psychiatric assessment, including medical evaluation, and use rating scales. Perform a baseline severity rating of obsessive-compulsive disorder symptoms, comorbidities, and their effects on the patient's functioning. Ensure the 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.
For dynamic psychotherapy or psychoanalysis, there are no controlled studies to show the efficacy in dealing with obsessive-compulsive disorder symptoms, and it may still be helpful in patients to overcome their resistance to 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. A motivational interview may also be useful to overcome resistance to therapy.
Cognitive-Behavioral Therapy (CBT)
Obsessive Compulsive Disorder_Management 5Cognitive-behavioral therapy is recommended as first-line therapy for children, adolescents, and adults with obsessive-compulsive disorder. This is the most widely used psychological therapy. This is indicated in patients who are not too anxious, depressed, or severely ill to cooperate, or who do not prefer pharmacological therapy. Cognitive-behavioral therapy is 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. This is the only form of psychotherapy for obsessive-compulsive disorder whose effectiveness is supported by clinical trials. Cognitive interventions may be incorporated into behavioral therapy. This eliminates the risk of medication side effects and produces results that may be better maintained after medical treatment is terminated.
Low Intensity Cognitive-Behavioral Therapy
Low-intensity cognitive-behavioral therapy is used in adult patients with mild functional impairment. This includes brief individual cognitive-behavioral therapy using structured self-help materials, brief individual cognitive-behavioral therapy by phone, and group cognitive-behavioral therapy. This also includes exposure and response prevention (ERP) and up to 10 therapist hours per patient.
Intensive Cognitive-Behavioral Therapy
Intensive cognitive-behavioral therapy is used in adult patients with moderate to severe functional impairment and those who have an inadequate response to low-intensity cognitive-behavioral therapy. This includes exposure and response prevention and involves >10 therapist hours per patient.
Brief Treatment
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. This includes family members in the treatment process, as a 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 the intensity and length of sessions.
Exposure and Response Prevention (ERP)
Exposure and response prevention is considered the first-line psychological treatment approach in obsessive-compulsive disorder. This 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 handwashing). 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”). ERP 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
Cognitive therapy helps patients identify and modify thought patterns that cause anxiety, distress, or negative behavior.
Combination of Exposure and Response Prevention (ERP) and Cognitive Therapy
Integration of exposures with discussions of dysfunctional beliefs and feared consequences is likely to be the most effective psychotherapy.