Clinical Management of Obsessive-compulsive Disorder

Educational Objectives

The goal of this program is to improve diagnosis and management of obsessive-compulsive disorder (OCD). After hearing and assimilating this program, the clinician will be better able to:

1. Identify the symptoms of OCD as described in the Diagnostic and Statistical Manual of Mental Disorders (Fifth Edition).
2. Differentiate symptoms of OCD from obsessive compulsive personality disorder.
3. Manage symptoms of OCD using recommended treatments.

Summary

Obsessive-compulsive disorder (OCD): original term was obsessional reaction (1952); in the 1968 Diagnostic and Statistical Manual of Mental Disorders (Second Edition; DSM-2) it was termed obsessional neurosis; it was designated as OCD in DSM-3 in 1980, and is classified this way in DSM-5; in DSM-5, a new chapter was created entitled “Obsessive-compulsive and related disorders”; other conditions included in this chapter are body dysmorphic disorder, hoarding disorder, trichotillomania, and excoriation or skin-picking disorder; lifetime prevalence of OCD is estimated at 1.6% to 3%; clinically important OCD is prevalent in ≈1% of the population; included in top 10 causes of global disability by the World Health Organization (WHO); prevalence of OCD in the world population is ≈2%

Classification of OCD in DSM-5: includes presence of obsessions, compulsions, or both; this should be time consuming (ie, >1 hr/day), or cause clinically significant distress or impairment in social, occupational, or other important areas of functioning; it cannot be caused by effects of substance or other medical conditions or explained by another mental disorder; some patients demonstrate good or fair insight (person recognizes their OCD beliefs are not or may not be true); some patients demonstrate poor insight (person recognizes that their OCD beliefs are probably true)

Obsession: this is defined as recurrent or persistent thoughts, urges, or images experienced at some time as intrusive and unwanted; these cause anxiety and distress in most people; individuals attempt to ignore, suppress, or neutralize obsessional thoughts with some other action (eg, a compulsive ritual); there is a triad of obsessions; they are intrusive, unwanted, and resisted; types include eg, contamination obsessions, obsessions doubting their perceptions, and somatic obsessions; most patients have multiple obsessions

Compulsions: these are repetitive behaviors that a person feels driven to perform; behavior is not willed, purposeful or intentional; the clear motivation is to reduce or prevent anxiety or distress created by the obsessional thought; behaviors are not connected realistically to things they are designed to neutralize or they are excessive; compulsions include, eg, checking, washing, counting, confessing, symmetry, hoarding; most patients demonstrate multiple compulsions; obsessions produce anxiety and compulsions reduce anxiety

Diagnosing OCD: Yale-Brown Obsessive Compulsive Scale (Y-BOCS) is beneficial in assessment; it has 10 questions, 5 regarding obsessions and 5 for compulsions; it is scored from 0 to 40; it is used mainly in research, but occasionally used clinically; differential diagnosis includes, eg, anxiety disorders, psychosis, obsessive-compulsive personality disorder (OCPD), paraphilias, eating disorders, autism spectrum disorder; there is confusion between OCD vs OCPD is common; according to the DSM-5, OCPD is a pervasive pattern of preoccupation with orderliness, perfectionism, and mental and interpersonal control at expense of flexibility, openness, and efficiency; it is a lifelong style of relating to other people; mean age of onset of OCD is in the early 20s; it rarely starts after 30 yr of age; men tend to experience earlier onset; although it is a chronic disease, it has a waxing and waning course; the prognosis of OCD is worse when accompanied by depression or anxiety; OCD can be associated with low academic achievement, low career aspiration, disrupted family relationships, and attempted suicide

Comorbidity with OCD: associated with substantial psychiatric comorbidity; 90% OCD patients have some psychiatric disorder; in the National Comorbidity Survey Replication (NCS-R) anxiety disorders were found in 76% of patients with OCD, mood disorders in 63%, bipolar disorder in 23%, and substance abuse disorder in 39%; anecdotal evidence shows 90% of patients with OCD meet criteria of personality disorder (commonly cluster C); cluster A and B disorders are less commonly associated with OCD; studies have shown patients with OCD with comorbid personality disorder respond less well to pharmacotherapy; although cause of OCD is unknown, genetics have long been considered; 20% of first-degree relatives of patients appear to have OCD; studies have shown high monozygotic twin concordance; there appears to be greater genetic influence for early vs late onset; neurocircuitry alteration and disturbed neurotransmission in serotonin, dopamine, and glutamate systems are other potential causes of OCD; autoimmune process following Streptococcus A infections (ie, pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections [PANDAS] syndrome) are implicated in childhood onset of OCD

Management of OCD: it includes behavior therapy, cognitive therapy, pharmacotherapy, neurosurgery, and transcranial magnetic stimulation; most experts recommend behavior therapy with pharmacotherapy

Behavior therapy: this is considered first-line treatment; challenges include lack of trained therapists and low patient acceptance because of increased anxiety; patient education improves outcomes; it needs to be of sufficient frequency and duration (≥10 clinical hr) to be effective; response rates with effective behavior therapy is calculated at 76% to 83%; it is argued that skills taught in behavior therapy can last for a lifetime; outcomes are better in patients with prominent rituals that can be seen and counted and likely less effective in patients with mental rituals

Pharmacotherapy: selective serotonin reuptake inhibitors (SSRIs) are first-line treatment; response rate is 40% to 60%; experts say doses of SSRIs administered in OCD should be higher than standard-of-care doses in depression; there should be extended trials of medication lasting 10 to 12 wk vs 4 to 6 wk for depression; a study showed venlafaxine could be effective; there is a lack of follow-up data; another drug with activity in OCD is clomipramine (Anafranil), a tricyclic antidepressant; maximum dose is 250 mg/day; higher doses may lead to seizure; maximum doses of fluoxetine (60-80 mg/day), paroxetine (60 mg/day), sertraline (200 mg/day), fluvoxamine (300 mg/day), citalopram (40 mg/day), and escitalopram (30 mg/day) are higher vs treatment of depression; clomipramine was the first drug approved by the Food and Drug Administration (FDA) for OCD; according to the Clomipramine Collaborative Treatment Study Group, there was an improvement from baseline Y-BOCS scores of 26 to 27 to scores of 16 to 18 after treatment; research suggests antipsychotic agents may be useful in patients with OCD with tic disorders or comorbid schizotypal personality disorder; other drugs with possible benefits in OCD include dextroamphetamine, topiramate, lamotrigine, pregabalin, N-acetylcysteine, and morphine

Electroconvulsive therapy (ECT): has no role in treatment of OCD in the absence of severe major depressive disorder; likely only ≈33% of patients respond to pharmacotherapy; reasons for poor response rates include incorrect diagnosis, inadequate treatment, poor adherence, presence of comorbid conditions, and poor understanding of the treatment plan

Neurosurgery: the most popular procedure currently is deep-brain stimulation; other neurosurgical procedures include anterior cingulotomy, subcaudate tractotomy, limbic leucotomy, and anterior capsulotomy; challenges include lack of coverage by insurance companies and lack of availability of procedure; reserved for patients who are treatment resistant or whose lives are severely affected by OCD

Conclusion: patients with OCD should read about their disorder and become educated about it

Readings

Bear RE et al. Neurosurgery for obsessive-compulsive disorder: contemporary approaches. J Clin Neurosci. 2010;17:1-5; doi: 10.1016/j.jocn.2009.02.043; Bloch MH et al. Meta-analysis of the dose-response relationship of SSRI in obsessive-compulsive disorder. Mol Psychiatry. 2010;15:850-855; doi: 10.1038/mp.2009.50; Borders C et al. Deep brain stimulation for obsessive compulsive disorder: a review of results by anatomical target. Ment Illn. 2018;10:7900; doi: 10.4081/mi.2018.7900; DeVeaugh-Geiss J et al. Clomipramine in the treatment of patients with obsessive-compulsive disorder. The Clomipramine Collaborative Study Group. Arch Gen Psychiatry. 1991;48;730-738; doi: 10.1001/archpsyc.1991.01810320054008; Fenske JN, Petersen K. Obsessive-compulsive disorder: diagnosis and management. Am Fam Physician. 2015;92:896-903; Goodman WK et al. The Yale-Brown Obsessive Compulsive Scale. I. Development, use, and reliability. Arch Gen Psychiatry. 1989;46:1006-1011; doi: 10.1001/archpsyc.1989.01810110048007; Pittenger C, Bloch MH. Pharmacological treatment of obsessive-compulsive disorder. Psychiatr Clin North Am. 2015;37:375-391; doi: 10.1016/j.psc.2014.05.006; Ruscio AM et al. The epidemiology of obsessive-compulsive disorder in the National Comorbidity Survey Replication. Mol Psychiatry. 2010;15:53-63; doi: 10.1038/mp.2008.94; Snider LA, Swedo SE. PANDAS: current status and directions for research. Mol Psychiatry. 2004;9:900-907; doi: 10.1038/sj.mp.4001542; Williams MT et al. Symptom dimensions in obsessive-compulsive disorder: phenomenology and treatment outcomes with exposure and ritual prevention. Psychopathology. 2013;46:365-376; doi: 10.1159/000348582.

Disclosures

In adherence to ACCME Standards for Commercial Support, Audio Digest requires all faculty and members of the planning committee to disclose relevant financial relationships within the past 12 months that might create any personal conflicts of interest. Any identified conflicts were resolved to ensure that this educational activity promotes quality in health care and not a proprietary business or commercial interest. For this program, members of the faculty and planning committee reported nothing to disclose. In his lecture, Dr. Black presents information related to the off-label or investigational use of a therapy, product, or device.

Acknowledgements

Dr. Black was recorded exclusively for Audio Digest using virtual teleconference software, in compliance with current social-distancing guidelines during the COVID-19 pandemic. Audio Digest thanks the speakers for their cooperation in the production of this program.

CME/CE INFO

Accreditation:

The Audio- Digest Foundation is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

The Audio- Digest Foundation designates this enduring material for a maximum of 0 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Audio Digest Foundation is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's (ANCC's) Commission on Accreditation. Audio Digest Foundation designates this activity for 0 CE contact hours.

Lecture ID:

PS501901

Expiration:

This CME course qualifies for AMA PRA Category 1 Credits™ for 3 years from the date of publication.

Instructions:

To earn CME/CE credit for this course, you must complete all the following components in the order recommended: (1) Review introductory course content, including Educational Objectives and Faculty/Planner Disclosures; (2) Listen to the audio program and review accompanying learning materials; (3) Complete posttest (only after completing Step 2) and earn a passing score of at least 80%. Taking the course Pretest and completing the Evaluation Survey are strongly recommended (but not mandatory) components of completing this CME/CE course.

Estimated time to complete this CME/CE course:

Approximately 2x the length of the recorded lecture to account for time spent studying accompanying learning materials and completing tests.