Management of Obsessive Compulsive Disorder
Authors: Martine A. Bouvard, Maud Milliery, Jean Cottraux
Journal: Psychotherapy and Psychosomatics (2004)

The patient is a 35-year-old married woman with an obsessive compulsive disorder. She had a 21-year history of obsessive thoughts and ritualistic behaviors including compulsive checking which had become persistent since the birth of her first child. There is no evidence of comorbidity, except for a mild generalized anxiety disorder. She wants to know which treatment is right for her at this point.Obsessive compulsive disorder (OCD) is a common chronic, and disabling disorder characterized by obsessions and/or compulsions. Obsessions are intrusive and distressing thoughts, images, or impulses. Compulsions are repetitive, intentional behaviors that the person feels compelled to perform, often with a desire to resist. Compulsions are typically intended to avert some fear event or to reduce distress. These symptoms are ego-dystonic and cause significant distress to patients and their families. OCD is among the most common anxiety disorders, with a lifetime prevalence of approximately 2.3% [1]. It is almost equally distributed between males and females.OCD often begins in adolescence or early adulthood usually with a gradual onset. However, a rapid onset of symptoms may occur, sometimes associated with a traumatic event, such as pregnancy or loss. Actually, recent literature suggests that pregnancy may precipitate OCD in individuals [2, 3], as in our case report. It appears that patients who reported the onset or worsening of OCD symptoms in pregnancy developed fear of harming the fetus or child [3, 4]. However, in our case report, the patient's preoccupations deal with responsibility for her child's health (e.g. 'my son will choke to death with his blanket if I don't check'): the patient does not fear being responsible for any harm coming to her son. Due to the secretive nature of the disorder, there is often a delay of more than 10 years before patients come to specialty settings [5]. The trouble is usually long, with most patients experiencing a chronic course, while others experience a fluctuating one [6].Patients with both obsessions and compulsions constitute a large proportion of affected patients. OCD can be expressed through many different symptoms. The classical presentation includes obsessive thoughts and ritualistic behaviors of washing and/or checking. Another pattern is one with merely intrusive obsessional thoughts, without compulsion (table 1).OCD can be severely incapacitating: depression is the most common complication and the symptoms can spread to interfere with the patient's social and occupational functioning, often involving the entire family.The case report thus highlights a common clinical problem faced by clinicians, whether in primary care or psychiatric unit. The patient meets the criteria for OCD according the DSM-IV [7].Until the early 1970s, OCD was considered a treatment refractory, chronic situation. Neither psychodynamic therapy nor a variety of pharmacological treatments, available at that time, led to significant improvement. Today, substantial evidence suggests that behavior therapy is effective in treating this chronic disorder [8]. Furthermore, recent advances in pharmacotherapy have led to a significant reduction in suffering and a return to productive living for many patients with OCD [9]. OCD is currently treated with pharmacological and/or psychological approaches. Our patient refused any pharmacological treatment; thus we recommended psychotherapy (20 sessions).Among the best established treatments are behavioral therapy, particularly those involving exposure and response prevention. Cognitive-behavioral therapy (CBT) involves the combination of behavior therapy (BT; exposure with response prevention, ERP) and cognitive therapy (CT). After more than a quarter century of research, ERP has become the gold standard to which other psychological treatments for OCD, such as CT, have been compared [10]. For CBT15–20 sessions are proposed for the treatment of an uncomplicated OCD patient. The format is individual weekly therapy sessions. A maintenance schedule is required (monthly booster sessions for 6–12 months).BT for OCD most specifically involves exposure and response or ritual prevention. The effectiveness of BT, in the form of ERP for OCD, has been demonstrated in controlled studies and meta-analyses [11, 12]. To date, the last meta-analysis [12]including 77 studies with 4,651 patients showed that BT was superior to selective serotonin reuptake inhibitor (SSRI) antidepressants. Exposure capitalizes on the fact that anxiety usually attenuates after a sufficient duration of contact with a feared stimulus. In order to achieve adequate exposure, it is usually necessary to help the patient block the rituals or avoidance behaviors, a process termed response or ritual prevention. In fact, the OCD patient is exposed to stimuli that provoke the obsessive response and helped to desist from avoidance and escape (compulsive) behavior. The rationale for treatment has to be outlined in the detail during the initial session for the patient and significant others, if present. This rationale uses a functional analysis to describe the patient's symptoms and to explain how the reduction of anxiety through compulsions maintains the behavior. It includes the theoretical and practical implications of ERP, focusing on the reduction of anxiety and rituals, and explains imaginary and in vivo exposure. Information gathering includes current OCD symptoms and general functioning, administration of the Yale-Brown Obsessive Compulsive Scale, course and history of OCD, previous treatment and response, general psychosocial and family history. Information gathering usually requires three sessions. Treatment planning has to be completed in the session preceding the first exposure session, focusing on the construction of a hierarchy (which includes items that the patient either currently avoids or performs only with rituals). The patient is asked to rate each item on a rating scale in which 0 indicates no anxiety and 100 indicates maximum anxiety. After the situations are ranked from lowest to highest anxiety rating, exposure therapy proceeds upward on the hierarchy, beginning with the lower-rated items to maximize compliance of the patient. The techniques which have to be used are therapist-aided ERP in imagination and/or in vivo, exposure in vivo with response prevention through homework and family intervention whenever the family is involved in rituals [13, 14]. The patients have to record homework completion. Behavioral homework is discussed and set with the therapist.To date less attention has been paid to CT, which may be added to ERP, to address such things as faulty estimation of danger or the exaggerated sense of personal responsibility often seen in OCD patients. The first step in CT for OCD consists of informing the patient that his/her intrusive thoughts are an abnormal phenomenon and provides him or her with a list of intrusive thoughts that commonly occur in the general population [15]. The patient learns that the difference between normal and dysfunctional intrusive thoughts lies in the significance attached to these thoughts. The interpretation of these intrusive thoughts made by people with obsession affects the occurrence and/or the content of these thoughts [16]. An important general cognitive technique used by the therapist to challenge the automatic thoughts is Socratic Dialogue [17]. The patient is encouraged to question the catastrophic significance of the intrusive thought and to construct alternative less catastrophic interpretations. Behavioral experiments are also commonly used to test the empirical basis of the patient's new interpretation in order to challenge or evaluate the beliefs. Two controlled trials compared CT based on Beck's model and ERP. Van Oppen et al. [10]demonstrated that CT was better than ERP at the post-test phase, but to date no follow-up of this study has been published. In a randomized controlled trial [18]CT and intensive BT were equally effective on OCD, but at post-test CT had specific effects on depression which were stronger than those of BT. Findings for the 1-year follow-up study are presently in preparation. The principal finding is that benefits are maintained and both treatments produced equivalent results: at week 26 and 52, improvement was retained in both groups without between-group difference. Cognitive measures of obsessions changed equally in the 2 groups.In our case, the first 3 sessions were assigned to the behavioral analysis, the therapeutic goals, and evaluation. We then started the CT from session 3 to 12. We first explained the OCD cognitive model to the patient, and then we taught her to point out and modify her automatic thoughts and cognitive biases. Automatic thoughts dealt with disasters and her responsibility for these ('if I haven't closed the window, someone will enter and take my son away'). During the 13th session, we started the behavioral therapy (ERP) for 8 sessions. After having explained the OCD behavioral model and the habituation principle to the patient, we set up a hierarchy in order to expose the patient (imaginary and in vivo exposure).The predominant hypothesis about OCD pathophysiology implicates abnormal serotonergic function regulation. Research clearly shows that the serotonin reuptake inhibitors (SRIs) are the only effective treatments for OCD. These medications increase the concentration of serotonin. Six SRIs are currently available: clomipramine, fluoxetine, fluvoxamine, paroxetine, sertraline, and citalopram. Fluoxetine, fluvoxamine, paroxetine, sertraline, and citalopram are SSRIs because they primarily affect only serotonin. Clomipramine is a nonselective SRI: it affects many other neurotransmitters besides serotonin.In most cases, treatment should be initiated with a SSRI because of the superior safety tolerability, and equivalent efficacy of this class of drug compared with clomipramine [19]. Actually, there have been relatively few comparative studies between the SSRIs in the treatment of OCD [20, 21, 22]. The studies comparing SSRI and clomipramine have shown that they all demonstrated efficacy [23, 24]. However, clomipramine is also associated with an increased incidence of adverse effects [25, 26, 27, 28, 29]. In a flexible dose trial of paroxetine compared with clomipramine in 406 patients with OCD [26], paroxetine and clomipramine were more effective than placebo. In terms of efficacy, no significant difference between paroxetine and clomipramine were noted beginning at week 6, and the response was nearly equivalent at week 12. However, significantly more patients treated with clomipramine withdrew from the study because of adverse effects. In a review of the efficacy of SRIs in OCD [30], the authors reported that SSRIs possess efficacy similar to that of clomipramine, but have a superior side effect profile. This suggestion may have important implications for patients with OCD who require long-term treatment. In a multicenter meta-analysis [31]placebo-controlled trials found clomipramine, fluoxetine, fluvoxamine, and sertraline to be superior to placebo. These authors also found that the 3 SSRIs were comparable to each other in efficacy and that clomipramine was more effective than the SSRIs. Stein et al. [32]presented a meta-analysis of pharmacotherapy trials for OCD. In placebo-controlled trials, SRIs (clomipramine, fluoxetine, fluvoxamine and sertraline) had a significant effect on medication effect size with clomipramine more effective than fluoxetine. Another meta- analytic review of the efficacy of drug treatments [33]found that SRIs (clomipramine, fluoxetine, fluvoxamine and sertraline) are effective in short-term treatments for patients suffering from OCD; although the increase in improvement rate over placebo was greater for clomipramine than for SSRIs, direct comparison between these drugs showed that they had similar therapeutic efficacy on obsessive-compulsive symptoms; concomitant high levels of depression at the outset did not seem necessary for clomipramine and for SSRIs to improve obsessive-compulsive symptoms. In a meta-analysis comparing pharmacological treatments of OCD (clomipramine, fluoxetine, fluvoxamine, paroxetine and sertraline) [34], clomipramine was not significantly better than fluoxetine or fluvoxamine; no significant difference was found between clomipramine and the other SRIs as a group in head to head trials; furthermore, no difference in drop-out rates was found. Clomipramine stands out from the other SRIs. The authors conclude that this difference is probably not clinically significant enough to warrant first choice treatment, given clomipramine's greater lethality in overdose.The backbone of pharmacological treatment for OCD is a 10- to 12- week trial with clomipramine or a SSRI in adequate doses before initiating alternative therapy. Actually, OCD appears to respond in a time interval of approximately 8–12 weeks. Clinical experience suggests the necessity of long-term, and in some case lifelong treatment. As far as pharmacologic treatment is concerned, a drug treatment should last at least 2 years after the remission of symptoms before considering medication withdrawal. This is motivated by the fact that preliminary evidence suggests that relapses after discontinuation of the drug are associated with increased resistance of treatment [35]. If the patient does not respond to an average dose of SSRI, the experts [36]recommend gradually increasing the dose to its maximum within 4–8 weeks from the start of the treatment. When a patient is having a partial response to an average dose of SSRI, the experts suggest gradually increasing the dose to its maximum within 5–9 weeks from the start of the treatment. They consider 8–13 weeks an adequate medication trial before changing medication or augmenting with another agent.Despite these significant advances in pharmacological treatment with SSRIs and clomipramine, as many as 40–60% of OCD patients are clinically unchanged after an adequate trial with these agents [37].Simos [38]reported that the efficacy of combined BT and pharmacotherapy for OCD is controversial. In a review of relevant studies, Steketee [39]concluded that this combination has shown little advantage over BT alone. Preliminary findings from a trial by Kozak et al. [40]also supported this conclusion. However, some controlled studies combining BT with antidepressants showed a better outcome on rituals and depression in the long term. In particular, Cottraux et al. [41]showed that SSRI + BT compared to placebo + BT gives better results at 3 months on rituals and at 6 months on depression with equivalent results at 12 and 18 months. Moreover, a more recent but small sample study comparing CBT and medication in the treatment of OCD provided evidence in favor of the combination [42]. OCD patients received 1 of 4 treatments: medication and CBT simultaneously; CBT only; medication while on a waiting list for CBT, or no treatment while on a waiting list for CBT. Multivariate analyses revealed that the Yale-Brown Obsessive Compulsive Scale scores and clinical ratings significantly improved after treatment in all groups except the non-treatment, waiting list, control group. Subjects in the 2 treatment groups receiving CBT showed reduced strength in their obsessional beliefs. The subsequent administration of CBT to those groups on the waiting list also decreased the strength of their primary obsessional beliefs and beliefs about the consequences of not performing the rituals. Results of this small sample study suggest that either CBT or medication alone is more effective than no treatment. The combination seems to potentiate treatment efficacy, and, according to the authors, it is more clinically beneficial to introduce CBT after a period of medication rather than to start both therapies simultaneously. This study is limited by the small number of subjects per condition (5–9 maximum), the duration of the treatment (5 months), and the absence of follow-up.Initial management of OCD relies on potent SRIs and CBT, used separately, sequentially or concurrently. 90% of patients can be helped with one or combination of these therapies [43].Unfortunately some patients do not respond adequately or at all to the initial treatment plan of CBT or SSRI or a combination of the two. The experts [36]recommend adding an SSRI when patients have not responded well to CBT alone. When patients have not done well with medication management alone, the experts suggest either adding CBT or switching to another SSRI. Thus, combined CBT and medication is the experts' preference for most patients who have not responded to an initial trial of either CBT or medication alone. In patients who have shown no response to combined treatment, the experts recommend switching SSRIs and continuing CBT. In patients with a partial response to combination therapy, they suggest switching SSRIs, providing more CBT, and possibly augmenting with another medication.Some patients are treatment-refractory, defined by the experts [36]as those who fail to respond to 3 sequential well-delivered SRI trials combined with expert CBT. A thorough clinical assessment of patients with treatment-refractory OCD is the first step in planning possible intervention. All DSM-IV axes should be thoroughly evaluated. These aspects include assessment of complications: Axis I (e.g., comorbid disorders); Axis II (e.g., personality disorders); Axis III (e.g., underlying medical disorder), and Axis IV (e.g., psychosocial stressors). In addition, the OCD symptoms themselves should be carefully assessed. Actually, there is some evidence that hoarding is more likely than other OCD symptoms to fail to respond to treatment [44, 45].There are a growing number of management options, including both pharmacotherapy and psychotherapy augmentation, and alternative interventions for treatment-refractory OCD patients. The literature has somewhat less agreement about what to do in managing treatment-refractory patients. First-line recommendations are to add an augmenting medication, especially if the patient exhibits associated features (e.g., tics or a comorbid anxiety disorder) that might predict a positive response to augmentation. For example, it may be helpful to add an anxiety-reducing medication, such as clonazepam or alprazolam, in patients with high levels of anxiety; a high potency neuroleptic, such as haloperidol or risperidone, when tics or comorbid schizotypy are present. Second-line recommendations are to try a new CBT setting (e.g., using a partial hospital or inpatient behavioral unit to conduct therapist-assisted ERP), technique, intensity (additional CBT sessions or intensive CBT), or format (family or group therapy), or to switch to another SRI or a monoamine oxidase inhibitors (MAOIs). Pharmacotherapy augmentation included augmentation with serotoningeric agents, dopaminergic agents, and various other agents as well as alternative forms (e.g., increased doses) or routes (e.g., intravenous administration) of SRI administration.There are a variety of psychological factors, such as low motivation, negative expectancies for treatment success, procrastination, and noncompliance, that may interfere with response to ERP. In these cases, the cognitive component of OCD should be addressed more directly [46]. Obsessive-compulsive symptom dimensions were studied as predictors of compliance with and response to BT in a controlled trial [47]. High scores on the hoarding dimension were more likely to dropout prematurely from the study and tend to improve less. BT is specially indicated for OCD patients with aggressive/checking, contamination/cleaning and symmetry/ordering symptoms. OCD patients with comorbid personality disorder should be treated by integrative CT [48].To better understand the causes of obsessions and compulsions, further work needs to be done to identify cognitive domains (beliefs and appraisals) that are specific to OCD. Some of the beliefs and appraisals identified by the Obsessive Compulsive Working Group [49]may be nonspecific, playing a role in obsessions, compulsions, and in many other clinical problems such as depression and generalized anxiety. Further work also needs to be done to identify the causes of important beliefs and appraisals. Advances in understanding OCD are more likely to occur if we can integrate the various methods of assessment [50]. There are also several challenges to be met in the area of OC spectrum disorders. First, the boundaries of the OC spectrum need to be better defined. More systematic research is needed on the relationship between OCD and various spectrum disorders, especially with respect to etiology, treatment response, and other theoretical important features [51]. Notwithstanding the growing evidence for the efficacy of CT or CBT in treating OCD, there is still little evidence that cognitive components of treatment add to the effectiveness of behavioral therapy [18, 52]. Perhaps we do not yet know enough about cognition in OCD, especially how to measure and modify them. A number of researchers have demonstrated that CBT produces a change in measures of beliefs considered relevant and/or specific to OCD. However, these studies are preliminary at this point, but nonetheless promising [53].The development of new models of OCD should help to understand and improve actual treatments, such as the model of perceived impulsivity and compensatory compulsivity [54].The experts [36]usually prefer to begin the treatment of OCD with either CBT alone or with a combination of CBT and medication. The likelihood that medication will be included in the recommendation varies with the severity of the OCD and the age of the patient. In milder OCD, CBT alone is the initial choice. As severity increased, the experts are more likely to add medications to CBT as the initial treatment or to use medication alone. In younger patients, the experts are more likely to use CBT alone. The experts consider the combination of ERP as the optimal behavioral psychotherapy for OCD, while CT may provide additional benefit by directly targeting distorted 'OCD beliefs' and/or by improving compliance with ERP.In managing treatment-refractory patients, the experts suggest a variety of augmentation strategies that can be tried in OCD, including clomipramine, clonazepam, conventional neuroleptics, buspirone, risperidone, and a second SSRI added to the first. The choice of augmentation medications would have to be tailor made for each patient. Clomipramine may be useful in boosting the response of a patient treated with an SSRI who is not having an adequate response. Neuroleptics may be helpful for patients who have not had an adequate response to an SRI and who have a comorbid tic disorder, OCD symptoms such as compulsive touching that resembles tics, or a comorbid schizotypy. Second-line recommendations are to try a new CBT setting, technique, or intensity, or to switch to another SRI or an MAOI. Finally, in patients with extremely severe and non-remitting OCD, intravenous clomipramine, neurosurgery, or electro-convulsive therapy (if the patient is also depressed) may sometimes be considered.The case illustrated in here represents a typical obsessive compulsive patient. We offered her a CBT effective in 20 sessions. The Yates-Brown Obsessive Compulsive Scale score dropped from 29 at the beginning of therapy to 13 at the end of the treatment. This decrease represents a 55% efficacy. Results were stable for the 1-year follow-up. The overall strategies for treatment of OCD are presented in figure 1. On the basis of the evidence available, the following approach is outlined.The first step in treating OCD is educating the patient and family about OCD and its treatment as a medical illness. During the last 20 years, two effective treatments have been developed: CBT and medication with a SSRI. Education is crucial in helping the patients and their families learn how to best manage OCD and prevent complications. CBT is the key element of treatment for most patients with OCD. Medication with SSRI is helpful for many patients, especially for patients with depression. The BT (ERP) involved systematic exposure to the obsessions as well as prevention of any compulsive or neutralizing behaviors that might be used to reduce anxiety. ERP did prove to be a very successful form of treatment for OCD, especially for those with washing and, to a lesser extent, checking rituals. Outcome studies of ERP indicate that approximated 70–80% of OCD patients who complete treatment show significant symptom improvement [55]. CT, which may be added to BT, addresses such dysfunctional beliefs as faulty estimation of the importance of thoughts, exaggerated sense of personal responsibility and perfectionism often seen in OCD patients. CT may also provide additional benefits by improving compliance with ERP. CT may also be of value for the substantial number of refusers and potential drop-outs of BT. Because of well-proven efficacy and safety profiles, the SSRIs are first-line pharmacotherapy for the management of patients with OCD. Patients who initially do not respond to SSRI therapy may benefit from switching to another SSRI or combining another medication or CBT with SSRI. There is evidence that addition of a neuroleptic may improve response to SSRI in some patients.Once OCD symptoms are eliminated or much reduced – a goal which is practical for the majority of those with OCD – then maintenance of treatment gains becomes the goal. When patients have completed a successful course of treatment for OCD, most experts recommend monthly follow-up visits for at least 6 months and continued treatment for at least 2 years before trying to stop medication or CBT. Relapse is very common when medication is withdrawn, particularly if the person has not felt the benefit of CBT. Therefore, many experts recommend continuing medication if the patients do not have access to CBT. Individuals with repeated episodes of OCD may need to receive long-term or even life-long prophylactic medication. The experts recommend such long-term treatment after 2–4 severe relapses or 3–4 milder relapses.The efficacy, acceptance and cost-effectiveness of short-term interventions for patients with OCD should certainly be further improved. The identification of factors which predict treatment response is a major goal. To effectively address the needs of individuals with severe and refractory OCD, current treatment strategies may need to be modified and supplemented. A promising area of research is the role of cognitive factors in OCD. Only the reports by Sookman and Pinard [48]have specifically examined the use of cognitive intervention with a difficult-to-treat sample of OCD patients. The apparent success of their cognitive treatment suggests that cognitive mechanisms could be involved in determining the severity or resilience of OCD. However, firm conclusions regarding the specific effects on cognitive intervention on severe or refractory OCD must await controlled studies.The authors wish to thank Emilie Aurouer for the English translation.'Case management' is a section which addresses biopsychosocial management of cases in clinical medicine. It integrates research evidence with clinical experience. Full disclosure of conflict of interest is required. However, clinicians with substantial conflicts of interest (owing a patent, being a stockholder or executive or serving in the board of directors or being a regular consultant in a company with commercial interests tied to the research discussed) cannot contribute.