Treatment Update of OCD

Current trends in the treatment of Obsessive-Compulsive Disorder

Lisa Bonavita

  The Pennsylvania State University – College of Medicine

November 2004

 

DSM-IV Diagnosis of Obsessive-Compulsive Disorder

• Either Obsessions or Compulsions:

• Obsessions defined as all of the following:
  • Recurrent and persistent thoughts, impulses, or images that are experienced, at some time during the disturbance, as intrusive and inappropriate and that cause marked anxiety or distress
  • The thoughts, impulses, or images are not simply excessive worries about real-life problems
  • The person attempts to ignore or suppress such thoughts, impulses, or images or to neutralize them with some other thought or action
  • The person recognizes that the obsessional thoughts, impulses, or images are a product of his or her own mind (not imposed from without as in thought insertion)
• Compulsions defined as all of the following:
  • Repetitive behaviors (ex. hand washing, checking) or mental acts (ex. praying, counting) that the person feels driven to perform in response to an obsession, or according to rules that must be applied rigidly
  • The behaviors or mental acts are aimed at preventing or reducing distress of preventing some dreaded event or situation; however, these behaviors or mental acts either are not connected in a realistic way with what they are designed to neutralize or prevent or are clearly excessive

• At some point during the course of the disorder, the person has recognized that the obsessions are excessive or unreasonable (this does not apply in children)
• The obsessions or compulsions cause marked distress, are time consuming (take more than 1 hour/day), or significantly interfere with the person’s normal routine, occupational (or academic) functioning, or usual social activities or relationships.
• If another Axis I disorder is present, the content of the obsessions or compulsions is not restricted to it (ex- the preoccupation with food in a patient with an eating disorder)
• The disturbance is not due to the direct physiological effects of a substance or a general medical condition.

Assessing the Severity of Obsessive-Compulsive Disorder

• CY-BOCS
• CGI-S (clinical global impressions-severity of illness scale)

Treatment Options

• Cognitive Behavioral Therapy (CBT)
  • Psychoeducation
  • Cognitive training: cognitive therapy teaches patients to identify maladaptive thoughts and replace them with positive ones
  • Mapping OCD target symptoms
  • Exposure and Response (ritual) Prevention

 

• Pharmacotherapy
  • SSRIs: Luvox (fluvoxamine), Zoloft (sertraline), Prozac (fluoxetine), Paxil (paroxetine)
  • SRIs: Effexor (venlafaxine-inhibits serotonin, norepinephrine, dopamine reuptake)
  • Atypical anti-psychotics: Seroquel (quetiapine-block dopamine receptors)

 

Evidence Based Recommendations on treatment  [Editors note: the first study is the only one limited to children]

 

• Cognitive-Behavior Therapy, Sertraline, and their Combination for Children and Adolescents with Obsessive Compulsive Disorder – Pediatric OCD Treatment Study (POTS)
  • o Objective: Look at the clinical efficacy of treatment options in the treatment of OCD (CBT alone, SRI alone, combo, or placebo)
  • o Methods: Masked, randomized (computer generated randomized groupings)
    • 112 patients aged 7-17 y/o, 28 randomized to each subgroup
    • Subjects had DSM-IV diagnosis and CY-BOCS score ³16
    • 12 week study of 4 arms by a single masked investigator
    • 89% of subjects had co-morbid psychiatric disorders (affective disorders, anxiety disorders, ADHD, ODD, conduct disorder)
      • this was considered an advantage to simulate clinical practice because many pts with OCD have co-morbid psych disorders
    • CBT regimen (14 visits): psychoeducation, cognitive training, mapping OCD target symptoms, exposure & response (ritual) prevention
    • Analyzed by “intention-to-treat”
  • o Main Outcome Measure: change in CY-BOCS score (look for linear time regression or remission defined as £10)
  • o Results:
    • Statistically significant advantage for CBT (p=.003), SSRI (p=.007) and combo (p=.001) versus placebo
    • Clinical remission rates for CBT (39.3%), SSRI (21.4%), and combo (53.5%)
    • Treatments were safe and well tolerated: no mania, hypomania, depression or suicidal thoughts/attempts)
      • Even with current talks of suicide with SSRIs, sertraline for OCD treatment is thought to have a favorable risk-to-benefit ratio
    • o Conclusions:
      • Any treatment of OCD should include CBT and if one must make a choice between CBT and pharmacotherapy, CBT has been shown to be statistically superior
        • Despite the wide availability of an OCD treatment protocol, many children are solely treated with an SSRI or an SSRI plus an atypical anti-psychotic

 

Literature Cited

Pediatric OCD Treatment Study (POTS) Team. Cognitive-Behavior Therapy, Sertraline, and their combination for children and adolescents with Obsessive-Compulsive Disorder. Journal of the American Medical Association. 2004 Oct 27; 292 (16): 1969-76.