How to reduce distress and repetitive behaviors in patients with OCD

Current Psychiatry. 2009 August;08(08):19-24

August 1, 2009|Psychiatry

Strategies help increase the effectiveness of CBT for obsessions and compulsions

Most OCD patients who receive an adequate selective serotonin reuptake inhibitor (SSRI) trial (Table) continue to have clinically significant OCD symptoms. Simpson et al¹³ studied 108 outpatients with OCD and found that augmenting SSRIs with EX/RP further reduces OCD symptoms and is more effective than stress management training. However, the now-standard 17 sessions of EX/RP were not sufficient to help most patients achieve minimal symptoms, defined as a Y-BOCS score ≤12. Ongoing augmentation studies are examining ways to increase OCD remission rates and achieve greater palatability, accessibility, and duration of effects.

Table

SSRIs for OCD: Recommended dosages

Medication	Recommended dosage
Citalopram*	20 to 80 mg/d
Fluoxetine	20 to 80 mg/d
Fluvoxamine	100 to 300 mg/d
Paroxetine	40 to 60 mg/d
Sertraline	50 to 200 mg/d
*Not FDA-approved for OCD
SSRI: selective serotonin reuptake inhibitor; OCD: obsessive-compulsive disorder

Using EX/RP in practice

When EX/RP was developed and studied in the 1960s and ‘70s, it was conducted daily. However, intensive OCD treatments are not always practical or readily available. This consideration prompted us to examine—in a nonrandomized study—the efficacy of a twice-weekly EX/RP program that is otherwise identical to the intensive treatment program at 3-month follow-up. Results indicated that this less intensive program was as effective as the intensive treatment.¹⁴

Less-intensive, once- or twice-weekly programs may be suitable for most OCD patients. Consider intensive EX/RP for:

patients who wish to complete their treatment in a short period at expert centers
patients for whom less intensive treatment fails to produce the desired outcome.

Although EX/RP is an efficacious treatment for OCD, factors such as patient unwillingness to enter into treatment or inadequate adherence to the program can limit its effectiveness. In a preliminary study that integrated a motivational interviewing module with EX/RP, 5 of the 6 patients experienced decreased Y-BOCS scores and increased quality of life.¹⁵

In addition to lack of adherence, other predictors of poorer outcome include:

poor insight by the patient that the feared consequences were unrealistic¹⁶
comorbid severe depression that interferes with utilization of EX/RP¹⁷
family members’ expressed emotion (mainly hostility).¹⁸

OCD treatment in the general clinical setting often has included prescribing an SSRI as an initial step in the care of patients of all ages. However, a published expert consensus opinion—based on a survey of a wide range of clinicians and researchers in the OCD field—recommended beginning treatment with CBT alone, particularly in younger patients and those with milder cases, and adding an approved medication when symptoms worsen or if the patient has comorbidities.¹⁹

Clinical Point

Barriers to effective OCD treatment include nonadherence, poor insight, and comorbid severe depression

To help patients and clinicians overcome barriers to effective OCD treatment, researchers are evaluating the cost-effectiveness and feasibility of a stepped-care model,²⁰ in which effective treatment components are offered in phases, depending on need and availability. Phases include self-directed EX/RP, therapist-assisted EX/RP, intensifying frequency of sessions, and augmenting EX/RP with SSRIs.

Despite major improvements in OCD identification, treatment, and dissemination of knowledge to clinicians, the situation is far from ideal. Future research will help uncover additional factors for improving treatment outcome and portability.

Related resources

Foa EB, Wilson R. Stop obsessing! New York, NY: Bantam Books; 2001.
Abramowitz JS, Houts AC, eds. Concepts and controversies in obsessive-compulsive disorder. New York, NY: Springer; 2005.
The Obsessive-Compulsive Foundation. www.ocfoundation.org

Drug brand names

Citalopram • Celexa
Clomipramine • Anafranil
Fluoxetine • Prozac
Fluvoxamine • Luvox
Paroxetine • Paxil
Sertraline • Zoloft

Disclosures

Dr. Yadin reports no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.

Dr. Foa receives research support from the American Psychiatric Association, BASF (formerly Ciba Geigy), Bristol-Myers Squibb, Cephalon, Eli Lilly and Company, Forest Pharmaceuticals, GlaxoSmithKline, Kali-Duphar, Pfizer Inc., and Solvay. She has been a speaker for the American Psychiatric Association, Forest Pharmaceuticals, GlaxoSmithKline, Jazz Pharmaceuticals, and Pfizer Inc. and a consultant to Actelion Pharmaceuticals.

References

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