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Obsessive-Compulsive Disorder: Diagnosis and Management

Obsessive-Compulsive Disorder: Diagnosis and Management

Table 4. Screening

Table 4. Screening Questions for Obsessive-Compulsive DisorderDo you have thoughts or images that keep coming back toyou and are difficult to put out of your head? For example,being contaminated by something, having somethingterrible happen to you or someone you care about, or doingsomething terrible?Do you ever feel the need to perform certain actions that don’tmake sense or that you don’t want to do, such as washing,cleaning, counting, or checking things over and over?Adapted with permission from Canadian Psychiatric Association. Clinicalpractice guidelines. Management of anxiety disorders [publishedcorrection appears in Can J Psychiatry. 2006;51(10):623]. Can J Psychiatry.2006;51(8 suppl 2):44S.may be done with standardized rating scales or by apatient estimate of the time spent each day engaging inobsessive-compulsive thoughts or behaviors. The Yale-Brown Obsessive Compulsive Scale (Y-BOCS) is a reliabletool for measuring OCD symptom severity. 20 It isalso important to monitor the effect of OCD symptomson relationships, work, self-care, and recreational time.Treatment is indicated when OCD symptoms causeimpairment in functioning or significant distressfor the patient. Reasonable treatment goals wouldbe spending less than one hour per day on obsessivecompulsivebehaviors, with minimal interference withdaily tasks. 21 A treatment strategy algorithm is providedin Figure 1. 16,21Psychiatric consultation is recommended for patientswith severe OCD, as measured by the Y-BOCS. Forpatients with mild or subclinical symptoms, educationand support may be sufficient. High-qualityself-help materials are available that explain the natureof the disorder, its manifestations, and available treatments(see online patient handout).PSYCHOLOGICAL TREATMENTSPsychological treatments are effective for OCD. 22 Thesetreatments should be administered by a properly trainedhealth care professional, most commonly a psychologistTreatment of Obsessive-Compulsive DisorderAssess severity of OCDMild to moderateSevereOptionOptionInitiate psychiatric referralCBT with exposure andresponse preventionUnsatisfactoryimprovementSSRI with or without CBT withexposure and response preventionSatisfactory improvementSatisfactory improvementUnsatisfactory improvementComplete initial treatment courseConsider periodic “booster”sessions of CBT with exposureand response preventionContinue medication for one totwo years before attemptingto taperConsider periodic “booster”sessions of CBT with exposureand response preventionSatisfactoryimprovementAdd CBT to SSRI monotherapySwitch to new SSRIUnsatisfactory improvementSwitch to clomipramine (Anafranil), venlafaxine(Effexor), or mirtazapine (Remeron)Augment with atypical antipsychoticFigure 1. Treatment algorithm for patients with obsessive-compulsive disorder. (CBT = cognitive behavior therapy;OCD = obsessive-compulsive disorder; SSRI = selective serotonin reuptake inhibitor.)Information from references 16 and 21.242 American Family Physician Volume 80, Number 3 ◆ August 1, 2009

Obsessive-Compulsive Disorderor social worker. Cognitive behavior therapy (CBT) isthe method of psychotherapy most often used; there isno evidence for the use of psychodynamic psychotherapyor “talk therapy” for treatment of OCD. Exposureand response prevention is a key element of CBT thathas been proven effective in the treatment of OCD. 23Patients are taught to confront situations that createfear related to their obsessions, and to avoid performingcompulsive behaviors in response. The feared situationsmay be confronted directly (e.g., touching objectsin a public restroom), or through imagined encounters(e.g., imagining shaking hands with another person).Patients refrain from performing rituals until the levelof anxiety dissipates. Exposure and response preventionis usually performed in 13 to 20 weekly sessions, witheach session lasting one to two hours. 21PHARMACOTHERAPYOCD exhibits a highly selective response to serotonergicmedications. Clomipramine (Anafranil), a tricyclicantidepressant with a strong serotonergic effect, washistorically the first-line pharmacologic treatment forOCD. However, because of concerns about the safetyand adverse effects of tricyclic agents, SSRIs have becomefirst-line pharmacologic treatments for OCD. Fluoxetine(Prozac), fluvoxamine, paroxetine (Paxil), and sertraline(Zoloft) have been approved by the U.S. Food and DrugAdministration for the treatment of OCD. Citalopram(Celexa) and escitalopram (Lexapro) are also commonlyused. Approximately 60 to 70 percent of patients experiencesome degree of improvement in OCD symptomswith SSRI treatment. 24 A recent Cochranereview confirmed the effectiveness of SSRIsfor the treatment of OCD (absolute riskreduction = 8 to 17 percent; number neededto treat = 6 to 12). 25The dosage of SSRI required to achievetreatment effect for OCD is often higherthan the recommended dosages for otherindications (Table 5). 21 The dosage shouldbe increased over four to six weeks until themaximal dosage is achieved, or until furtherincrease is limited by adverse effects. 21Higher-than-maximal dosages are sometimesused, with careful monitoring forserotonin syndrome. Early signs of serotoninsyndrome include anxiety, tremor, tachycardia,and sweating. 26 The patient should continuetaking the SSRI for eight to 12 weeks,with at least four to six weeks at the maximaltolerable dosage. 21 It usually takes atleast four to six weeks for patients to note any significantimprovement in symptoms; for some, it may take 10 to12 weeks or longer.If medical therapy is successful, it should be continuedfor at least one to two years. 21 If the patient choosesto discontinue pharmacotherapy, the dosage should begradually tapered over several months. If symptomsworsen during this time, the original dosage should beresumed, and further attempts at discontinuing medicationshould be approached with reservation. Somepatients require lifelong medical therapy.Initial data suggest that the response to psychologicaltreatments may be more durable than medication. 27Periodic exposure and response prevention “booster”sessions are recommended to lower the risk of relapsewhen psychological therapy is discontinued. 21 Initiatingpsychological treatments before a trial of medicationdiscontinuation may also be an effective strategy tolower the risk of relapse.If an adequate trial of an SSRI or psychological therapydoes not result in a satisfactory response, one option isto initiate combined treatment. If the patient prefers tocontinue with medical therapy alone, a trial of a differentSSRI is indicated. 21 If there is no response to trials ofat least two SSRIs, clomipramine may be considered. 21Clomipramine can cause anticholinergic adverse effectsand, rarely, arrhythmia or seizures. It should be startedat a low dose (25 mg) with gradual titration to minimizeadverse reactions. Venlafaxine (Effexor) is anotheroption for second-line treatment; the extended-releaseform was shown in a randomized controlled trial to beTable 5. Typical SSRI Dosages in Patients withObsessive-Compulsive DisorderSSRIStarting dosage(mg per day)Target dosage(mg per day)Citalopram (Celexa) 20 40 to 60 80Escitalopram (Lexapro) 10 20 40Fluoxetine (Prozac)* 20 40 to 60 80Fluvoxamine* 50 200 300Paroxetine (Paxil)* 20 40 to 60 60Sertraline (Zoloft)* 50 200 200SSRI = selective serotonin reuptake inhibitor.Maximal dosage(mg per day)*—Approved by the U.S. Food and Drug Administration for treatment of obsessivecompulsivedisorder.Adapted with permission from Koran LM, Hanna GL, Hollander E, Nestadt G, SimpsonHB, for the American Psychiatric Association. Practice guideline for the treatment ofpatients with obsessive-compulsive disorder. Am J Psychiatry. 2007;164(7 suppl):22.August 1, 2009 ◆ Volume 80, Number 3 American Family Physician 243

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