Treating obsessive-compulsive disorder

Obsessive-compulsive disorder (OCD), which affects 2% to 3% of people worldwide, often causes suffering for years before it is treated correctly — both because of delays in diagnosis and because patients may be reluctant to seek help.
Although OCD tends to be a chronic condition, with symptoms that flare up and subside over a patient's lifetime, effective help is available. Only about 10% of patients recover completely, but 50% improve with treatment.

OCD diagnosis

As the name implies, OCD is characterized by two hallmark symptoms. Obsessions are recurring and disturbing thoughts, impulses, or images that cause significant anxiety or distress. Compulsions are feelings of being driven to repeat behaviors, usually following rigid rules (such as washing hands multiple times after each meal). When these symptoms interfere with work, social activities, and personal relationships, it is time to consider treatment.

Initial treatments

For initial treatment of OCD, the APA recommends cognitive behavioral therapy, drug therapy with selective serotonin reuptake inhibitors (SSRIs), or a combination of the two.

Behavioral treatment. The most effective behavioral treatment for OCD is exposure and response prevention. In this therapy, patients encounter the source of their obsession repeatedly and learn ways to stop performing associated rituals until they are able to resist these compulsions.

Behavioral treatment alone may be an option for patients with mild symptoms of OCD or for those who don't want to take medications. It may take three to five months of weekly sessions to achieve results. The goal is to gradually extinguish a conditioned behavior pattern.

SSRIs. Drug treatment may be tried first if behavioral therapy isn't available or convenient, or if the patient's symptoms are severe.

All of the SSRIs are equally effective, although individual patients may respond better to one than another, and it may take some trial and error to determine which one is best. Generally 40% to 60% of patients with OCD will experience at least a partial reduction in symptoms after treatment with an SSRI. However, many continue to have residual symptoms.

To treat OCD, SSRI doses are usually higher than those used for depression. It also takes longer for these medications to alleviate symptoms of OCD. While patients with major depression might take two to six weeks to respond to an SSRI, patients with OCD typically take 10 to 12 weeks to respond.

The most common side effects of SSRIs are gastrointestinal distress, restlessness, insomnia, and sexual dysfunction (such as reduced libido, erectile dysfunction, and inability to reach orgasm).

Maintenance therapy. Many patients successfully treated for OCD will benefit from continuing medication indefinitely. A few medication discontinuation trials have been conducted in OCD patients, and most have found high relapse rates after SSRI withdrawal. It's possible that lower doses can be used during maintenance treatment, but this is not clear.

Additional treatment strategies

For patients whose symptoms have only been partially relieved by a first treatment, augmenting that treatment may be more effective than switching to a new one. Augmenting an SSRI with some other medication can produce effects within four weeks.

Augmentation options. One option is augmenting an SSRI with a major tranquilizer. Drug choices include first- or second-generation major tranquilizers, but the evidence is stronger for the newer drugs. Studies indicate that 40% to 55% of patients with OCD, after failing to respond to a first treatment, do improve when a major tranquilizer is added to an SSRI — although residual symptoms may remain.

Switching to a new drug. If treatment with an SSRI does not work, consider switching to another SSRI or another type of drug. The APA estimates that 50% of patients with OCD who do not respond to one SSRI will respond to another one.

Neurosurgery or brain stimulation

Roughly 10% of patients with OCD will get worse in spite of treatment. Patients who suffer severe and incapacitating symptoms despite multiple medication trials may be eligible for brain surgery or deep brain stimulation.

Both surgery and deep brain stimulation are usually held in reserve for patients with the most treatment-resistant OCD. Typically patients who opt for these strategies have debilitating symptoms and have tried other treatments for 10 years without success.

As researchers learn more about the brain basis of OCD, they hope to target brain regions more precisely, to achieve better results.

April 2009 update

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