According to a team of Duke University-led psychiatrists, behavioral therapy (BT), cognitive behavioral therapy (CBT), and medications should be regarded as first-line treatments for OCD. Psychodynamic psychotherapy may help in managing some aspects of the disorder. The American Psychiatric Association notes a lack of controlled demonstrations that psychoanalysis or dynamic psychotherapy are effective "in dealing with the core symptoms of OCD."
The specific technique used in BT/CBT is called exposure and ritual prevention (also known as "exposure and response prevention") or ERP; this involves gradually learning to tolerate the anxiety associated with not performing the ritual behavior. At first, for example, someone might touch something only very mildly "contaminated" (such as a tissue that has been touched by another tissue that has been touched by the end of a toothpick that has touched a book that came from a "contaminated" location, such as a school.) That is the "exposure". The "ritual prevention" is not washing. Another example might be leaving the house and checking the lock only once (exposure) without going back and checking again (ritual prevention). The person fairly quickly habituates to the anxiety-producing situation and discovers that their anxiety level has dropped considerably; they can then progress to touching something more "contaminated" or not checking the lock at all—again, without performing the ritual behavior of washing or checking.
Exposure ritual/response prevention (ERP) has been demonstrated to be the most effective treatment for OCD. Using ERP alone, one can become completely symptom free. However, the individual must be highly motivated and consistent. It has generally been accepted that psychotherapy, in combination with psychotropic medication, is more effective than either option alone. However, more recent studies have shown no difference in outcomes for those treated with the combination of medicine and CBT versus CBT alone.
Association splitting is a new technique aimed at reducing obsessive thoughts. The method draws upon the “fan effect” of associative priming: The sprouting of new associations diminishes the strength of existing ones. As OCD patients show marked biases or restrictions in OCD-related semantic networks (e.g., cancer is only associated with “illness” or “death”, fire is only associated with “danger” or “destruction”), they are encouraged to imagine neutral or positive associations to OCD-related cognitions (cancer = zodiac sign, animal, lobster; fire = fireflies, fireworks, candlelight-dinner). First studies tentatively confirm the feasibility and effectiveness of the approach for a subgroup of patients.
Medications as treatment include selective serotonin reuptake inhibitors (SSRIs) such as paroxetine, sertraline, fluoxetine, escitalopram, and fluvoxamine and the tricyclic antidepressants, in particular clomipramine. SSRIs prevent excess serotonin from being pumped back into the original neuron that released it. Instead, serotonin can then bind to the receptor sites of nearby neurons and send chemical messages or signals that can help regulate the excessive anxiety and obsessive thoughts. In some treatment-resistant cases, a combination of clomipramine and an SSRI has shown to be effective even when neither drug on its own has been efficacious.
Treatment of obsessive–compulsive disorder is an area needing significant improvement in prescribing regimens. Benzodiazepines are sometimes used for obsessive compulsive disorder, although they are generally believed to be ineffective for this indication; however, effectiveness was found in one small study. Benzodiazepines can be considered as a treatment option in treatment resistant cases. Morphine and other less potent pain killers, which possess agonist actions at the μ-opioid receptor and inhibit the reuptake of norepinephrine and serotonin, have shown effectiveness in the treatment of OCD.
Serotonergic antidepressants typically take longer to show benefit in OCD than with most other disorders they are used to treat. It is common for 2–3 months to elapse before any tangible improvement is noticed. In addition to this, treatment usually requires high dosages. Fluoxetine, for example, is usually prescribed in dosages of 20 mg per day for clinical depression, whereas with OCD the dosage often ranges from 20 mg to 80 mg or higher, if necessary. In most cases antidepressant therapy alone provides only a partial reduction in symptoms, even in cases that are not deemed treatment resistant. Much current research is devoted to the therapeutic potential of the agents that affect the release of the neurotransmitter glutamate or the binding to its receptors. These include riluzole, memantine, gabapentin, N-Acetylcysteine, and lamotrigine. MDMA, which is a powerful and illicit serotonergic drug, has also been anecdotally reported to temporarily alleviate the symptoms of OCD.
Low dosages of the newer atypical antipsychotics olanzapine, quetiapine, ziprasidone, and risperidone have also been found to be useful as adjuncts in the treatment of OCD. The use of antipsychotics in OCD must be undertaken carefully, however, because although there is very strong evidence that at low dosages they are beneficial (probably because of their dopamine receptor antagonism), at high dosages these same antipsychotics have caused dramatic obsessive–compulsive symptoms even in patients who do not normally have OCD. This can be because the antagonism of 5-HT2A receptors becomes very prominent at these dosages and outweighs the benefits of dopamine antagonism. However, the antidepressant mirtazapine, which is a 5-HT2A antagonist, has been shown to benefit OCD patients. This could be explained partially by the fact that Clomipramine (often regarded as the most effective medication against OCD symptoms) and Mirtazapine share a similar potency with regard to antagonism at 5-HT2A and 5-HT2C receptors, with Ki values for the 5-HT2A receptor as 36nM and 69nM respectively, and for the 5-HT2C receptor as 65nM and 39nM respectively.
Another point that must be noted with antipsychotic treatment is that SSRIs inhibit the chief enzyme that is responsible for metabolising antipsychotics—CYP2D6—so the dosage will be effectively higher than expected when these are combined with SSRIs. Also, it must be noted that antipsychotic treatment should be considered as augmentation treatment when SSRI treatment does not bring positive results.
Alternative drug treatments
The naturally occurring sugar inositol has been suggested as a treatment for OCD, as it appears to modulate the actions of serotonin and reverse desensitisation of neurotransmitter receptors. St John's Wort has been claimed to be of benefit due to its (non-selective) serotonin re-uptake inhibiting qualities, although a double-blind study using a flexible-dose schedule (600–1800 mg/day) found no difference between St John's Wort and a placebo.
Nutrition deficiencies may also contribute to OCD and other mental disorders. Vitamin and mineral supplements may aid in such disorders and provide nutrients necessary for proper mental functioning.
Opioids may rapidly ameliorate OCD symptoms. Tramadol is an atypical opioid that appears to provide the anti-OCD effects of an opiate and inhibit the re-uptake of serotonin (in addition to norepinephrine). Oral morphine, administered once weekly, has been shown to reduce OCD symptoms in some treatment-resistant patients. The mechanism of therapeutic action is unknown.
Psychedelics such as LSD, peyote, and tryptamine alkaloid psilocybin have been proposed as treatment due to their observed effects on OCD symptoms. It has been hypothesised that hallucinogens may stimulate 5-HT2A receptors and, less significantly, 5-HT2C receptors, causing an inhibitory effect on the orbitofrontal cortex, an area of the brain strongly associated with hyperactivity and OCD.
Regular nicotine treatment may ameliorate symptoms of OCD, although the pharmacodynamical mechanism by which this is achieved is not yet known, and more detailed studies are needed to fully confirm this hypothesis.
Electroconvulsive therapy (ECT)
This has been found effective in severe and refractory cases.
For some, neither medication, support groups nor psychological treatments are helpful in alleviating obsessive–compulsive symptoms. These patients may choose to undergo psychosurgery as a last resort. In this procedure, a surgical lesion is made in an area of the brain (the cingulate cortex). In one study, 30% of participants benefited significantly from this procedure.
In the US, psychosurgery for OCD is a treatment of last resort and will not be performed until the patient has failed several attempts at medication (at the full dosage) with augmentation, and many months of intensive cognitive–behavioral therapy with exposure and ritual/response prevention. Likewise, in the UK, psychosurgery cannot be performed unless a course of treatment from a suitably qualified cognitive–behavioral therapist has been carried out.
Treatment in children and adolescents
Although the causes of OCD in younger age groups range from brain abnormalities to psychological preoccupations, life stress may also contribute to childhood cases of OCD—acknowledging these stressors plays an important role in treating the disorder. In her article “Factors Influencing the Onset of Childhood Obsessive Compulsive Disorder” Tina M. D’Alessandro reports that such stressors as bullying and traumatic familial deaths have caused anxiety and depression in children, conditions that have led to their development of OCD. In order to reduce suffering and prevent OCD-related mortality in adulthood, D’Alessandro emphasizes the importance of considering these stressors early-on so as to guide the child toward treatment as soon as possible.
As with adults, behavioral treatment has proven to be quite effective in reducing ritual behaviors of OCD. A key component to the success of such treatments in children and adolescents consists of family member involvement which can be established in a number of different ways. Dr. Judith L. Rapoport stresses the importance of familial participation during the child’s therapy sessions as well as outside the sessions, in the form of creating behavioral observations and reports. Additionally, parental intervention aids in providing positive reinforcement for the child when s/he exhibits appropriate behaviors as alternatives to his/her compulsive response. Therapy, in general, has proven very helpful to children and adolescents with OCD according to Dr. Paul L. Adams. Parents may expect the duration of weekly sessions to last one to two years, but the results are quite valuable. Adams reports such changes in his own patients as the acquisition of a larger circle of friends, the child exhibiting less shyness, and being far less self-critical after considering the true meaning behind his/her obsession and learning how to cope with it in therapy sessions.
For phasing out obsessive thoughts, Rapoport reports that the mental technique of “thought stopping” has been successful particularly among adolescents. In this procedure, whenever the individual has an obsessive thought, s/he is encouraged to either mentally or verbally pronounce “STOP” in mid-thought to interrupt the obsession. Additionally, Rapoport reports a modification of this process so as to prevent “STOP” for becoming a stimulus to the obsessive thoughts: the child is to call to mind the thought, interrupt by loudly counting backward from ten, and then evoke a pleasant scene—in one subject, this reduced the obsessive frequencies by 80% in just one week and eliminated them in four.
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