Revised ocd_ qrg.qxd

TREATING
Based on Practice Guideline for the Treatment of Patients With Obsessive-Compulsive Disorder, originally published in July 2007. A guideline watch, summarizing significant developments in the scientific literature since publication of this guideline, may be available in the Psychiatric Practice section of the APA web site at www.psych.org.
American Psychiatric Association
Steering Committee on Practice Guidelines
Robert Kunkle, M.A., Senior Program Manager Thomas J. Craig, M.D., M.P.H., Director, Department of Quality Improvement Darrel A. Regier, M.D., M.P.H., Director, Division of Research TREATING OBSESSIVE-COMPULSIVE DISORDER • 3
Introduction
“Treating Obsessive-Compulsive Disorder: A Quick Reference Guide” is a synop-sis of the American Psychiatric Association’s Practice Guideline for the Treatmentof Patients With Obsessive-Compulsive Disorder, which was originally published inThe American Journal of Psychiatry in July 2007 and is available through AmericanPsychiatric Publishing, Inc. The psychiatrist using this Quick Reference Guide(QRG) should be familiar with the full-text practice guideline on which it is based.
The QRG is not designed to stand on its own and should be used in conjunctionwith the full-text practice guideline. For clarification of a recommendation or for areview of the evidence supporting a particular strategy, the psychiatrist will find ithelpful to return to the full-text practice guideline.
Statement of Intent
The Practice Guidelines and the Quick Reference Guides are not intended to beconstrued or to serve as a standard of medical care. Standards of medical careare determined on the basis of all clinical data available for an individual patientand are subject to change as scientific knowledge and technology advance andpractice patterns evolve. These parameters of practice should be considered guide-lines only. Adherence to them will not ensure a successful outcome for every indi-vidual, nor should they be construed as including all proper methods of care orexcluding other acceptable methods of care aimed at the same results. The ultimatejudgment regarding a particular clinical procedure or treatment plan must be madeby the psychiatrist in light of the clinical data presented by the patient and the diag-nostic and treatment options available. The development of the APA PracticeGuidelines and Quick Reference Guides has not been financially supported by anycommercial organization.
• TREATING OBSESSIVE-COMPULSIVE DISORDER
A. Psychiatric Management . . . . . . . . . . 5 2. Assess the patient’s symptoms.53. Consider rating the patient’s symptom 4. Enhance the safety of the patient and 5. Complete the psychiatric assesment.96. Establish goals for treatment.97. Establish the appropriate setting for TREATING OBSESSIVE-COMPULSIVE DISORDER • 5
A. Psychiatric Management
1. Establish and maintain a therapeutic alliance.
• Tailor communication style to the patient’s needs and abilities.
• Allow patients with excessive worry or doubting time to consider treatment decisions. Repeat explanations if necessary. • Attend to transference and countertransference, which may disrupt • Consider how the patient’s expectations are affected by his or her cultural and religious background, beliefs about the illness, andexperience with past treatments.
2. Assess the patient’s symptoms.
• Use DSM-IV-TR criteria for diagnosis.
• Consider using screening questions to detect commonly unrecog- • Differentiate OCD obsessions, compulsions, and rituals from similar symptoms found in other disorders (Table 2).
TABLE 1. Example Obsessive-Compulsive Disorder
Screening Questions
Do you have unpleasant thoughts you can’t get rid of?Do you worry that you might impulsively harm someone?Do you have to count things, wash your hands, or check things over and over?Do you worry a lot about whether you performed religious rituals correctly or have Do you have troubling thoughts about sexual matters?Do you need things arranged symmetrically or in a very exact order?Do you have trouble discarding things, so that your house is quite cluttered?Do these worries and behaviors interfere with your functioning at work, with your • TREATING OBSESSIVE-COMPULSIVE DISORDER
TABLE 2. Symptoms of Other Psychiatric Disorders to be
Differentiated From the Obsessions, Compulsions,
and Rituals of Obsessive-Compulsive Disorder (OCD)
How the Symptom Differs
Disorder
From Symptoms of OCD
The content of the delusions is usually related to grandiosity.
ruminations are experienced as con-sistent with one’s self-image and usually concern self-criticism, failures, guilt, regret, or pessimism about the future. Unlike obsessions, depressive ruminations do not lead to compulsive rituals.
Hypochondriasis Fear or belief regarding external stimuli (e.g., that causes con-tamination) rather than misinterpreta-tion of an ordinary bodily sign or symptom.
TREATING OBSESSIVE-COMPULSIVE DISORDER • 7
TABLE 2. Symptoms of Other Psychiatric Disorders to be
Differentiated From the Obsessions, Compulsions,
and Rituals of Obsessive-Compulsive Disorder (OCD)
(continued)
How the Symptom Differs
Disorder
From Symptoms of OCD
fectionism and preoccupation with rules.
morally abhorrent to the individual, and lead to avoidance.
emerge from depressed mood or psy-chosis and are resisted.
rather than anticipate future events as in OCD.
The content is usually bizarre or relat-ed to persecution, grandiosity, passivity experiences, or ideas of reference.
ceded by thoughts nor aimed at reliev-ing anxiety or preventing or undoing an event.
• TREATING OBSESSIVE-COMPULSIVE DISORDER
3. Consider rating the patient’s symptom severity and level of
functioning.
• Recording baseline severity provides a way to measure response to • A useful symptom scale is the Yale-Brown Obsessive Compulsive Scale (Y-BOCS), which is available on web sites such ashttp://healthnet.umassmed.edu/mhealth/YBOCRatingScale.pdf orhttp://www.peaceofmind.com/YBOCS.pdf.
• Useful self-rated depression scales include the Patient Health Questionnaire (PHQ-9), the Beck Depression Inventory–II (BDI-II),the Zung Depression Scale, and the patient versions of theInventory of Depressive Symptoms (IDS) or the Quick-IDS.
• A useful disability rating scale is the Sheehan Disability Scale • A useful quality-of-life scale is the Quality of Life Enjoyment and Satisfaction Questionnaire (Q-LES-Q) or the more detailed WorldHealth Organization Quality of Life Survey (WHOQOL-100).
4. Enhance the safety of the patient and others.
• Assess for risk of suicide, self-injurious behavior, and harm to others.
• Collateral information from family members and others can be • Take into consideration factors associated with increased risk of suicide, including specific psychiatric symptoms and disorders(e.g., hopelessness, agitation, psychosis, anxiety, panic attacks,mood or substance use disorders, schizophrenia, borderline per-sonality disorder) and previous suicide attempts. See APA’s PracticeGuideline for the Assessment and Treatment of Patients WithSuicidal Behaviors.
• Evaluate the patient’s potential for harming others, either directly or indirectly (e.g., when OCD symptoms interfere with parenting).
TREATING OBSESSIVE-COMPULSIVE DISORDER • 9
5. Complete the psychiatric assessment.
• See APA’s Practice Guideline for the Psychiatric Evaluation of Adults.
• Assess for common co-occuring disorders, including mood disor- ders, other anxiety disorders, eating disorders, substance use disorders, and personality disorders.
6. Establish goals for treatment.
• Goals of treatment include decreasing symptom frequency and severity, improving the patient's functioning, and helping thepatient to improve his or her quality of life.
• Reasonable treatment outcome targets include less than 1 hour per day spent obsessing and performing compulsive behaviors, nomore than mild OCD-related anxiety, an ability to live with OCD-associated uncertainty, and little or no interference of OCD with thetasks of daily living. Despite best efforts, some patients will beunable to reach these targets.
7. Establish the appropriate setting for treatment.
• In general, patients should be cared for in the least restrictive setting that is likely to be safe and to allow for effective treatment.
• Outpatient treatment is usually sufficient. More intensive settings (e.g., hospitalization, residential treatment, or partial hospitaliza-tion) may be needed by patients who have significant suicide risk,pose a danger to others, are unable to provide adequate self-care,have co-occurring psychiatric and general medical conditions, orneed intensive treatment or monitoring.
• Home-based treatment may be needed by patients who are unable to visit an office or clinic because of impairing fears or other symp-toms.
10 • TREATING OBSESSIVE-COMPULSIVE DISORDER
8. Enhance treatment adherence.
• Recognize that the patient’s fears, doubting, and need for certainty can influence his or her willingness and ability to cooperate withtreatment and can challenge the clinician’s patience.
• Provide education about the illness and its treatment, including expected outcomes and time and effort required.
• Inform the patient about likely side effects of medications, inquire about side effects the patient may be unwilling to report (e.g., sexual side effects), respond quickly to concerns about side effects,and schedule follow-up appointments soon after starting or chang-ing medications.
• Address breakdowns in the therapeutic alliance.
• Consider the role of the patient’s family and social support system.
• When possible, help the patient to address practical issues such as treatment cost, insurance coverage, and transportation.
B. Choice of Initial Treatment
First-line treatments for OCD are cognitive-behavioral therapy (CBT)
and serotonin reuptake inhibitors (SRIs).
• SRIs include clomipramine and all of the selective serotonin reup-
take inhibitors (SSRIs). Clomipramine, fluoxetine, fluvoxamine,paroxetine, and sertraline are approved by the U.S. Food andDrug Administration for treatment of OCD.
• Strong evidence, including from controlled trials, supports using CBT that relies primarily on the behavioral technique of exposureand response prevention (ERP).
TREATING OBSESSIVE-COMPULSIVE DISORDER • 11
Choice of initial treatment modality is individualized and depends on
factors including the following:
• The nature and severity of the patient’s symptoms.
• Co-occurring psychiatric and medical conditions.
• The availability of CBT.
• The patient’s past treatment history, current medications, capacities,
CBT alone is recommended for a patient who is not too depressed,
anxious, or severely ill to cooperate with this treatment modality, or
who prefers not to take medications.
• In ERP, patients are taught to confront feared situations and objects
(i.e., exposure) and to refrain from performing rituals (i.e.,response prevention). The goal is to weaken the connectionsbetween feared stimuli and distress and between carrying out ritu-als and relief from distress.
• Cognitive techniques such as identifying, challenging, and modify- ing dysfunctional beliefs (e.g., magical thinking, inflated sense ofresponsibility for unwanted events, overestimation of the probabilityof feared events, “thought-action fusion,” perfectionism, belief thatanxiety will persist forever, and need for control) may be effectivelycombined with ERP.
• The patient must be willing to do the work that CBT requires (e.g., • Psychodynamic psychotherapy may be useful in helping patients overcome their resistance to accepting a recommended treatmentand addressing the interpersonal consequences of OCD symptoms.
• Motivational interviewing may also help overcome resistance to 12 • TREATING OBSESSIVE-COMPULSIVE DISORDER
An SRI alone is recommended for a patient who has previously
responded well to a given drug or who prefers treatment with an SRI
alone.
• Starting with an SRI alone may enhance cooperation with treatment
by diminishing symptom severity. Thus, an SRI alone may also beconsidered in patients who have severe OCD or are not otherwiseable to cooperate with the demands of CBT.
• An SRI alone may also be necessary if CBT is not accessible or • Because the SSRIs have a less troublesome side effect profile than clomipramine, an SSRI is preferred for a first medication trial.
• Factors to consider when choosing among the SSRIs include safety, side effects and their acceptability to the patient, and potentialinteractions with other medications the patient may be taking.
Combined treatment (SRI and CBT) is more effective than
monotherapy for some patients but is not necessary for all patients.
• Combined treatment should be considered for patients who have
had an unsatisfactory response to monotherapy, who have co-occurring psychiatric conditions for which SRIs are effective, orwho wish to limit the duration of medication treatment.
• Combined treatment may also be considered for patients with severe OCD, since the medication may diminish symptom severityand allow the patient to engage in CBT.
TREATING OBSESSIVE-COMPULSIVE DISORDER • 13
C. Implementation of Treatment
Initiate pharmacotherapy at the dose recommended by the manufac-
turer (for most patients) and titrate to a maximally tolerable dose
(Table 3).
• Patients who are worried about side effects can be started at
• Lower doses and more gradual titration may be needed for patients with co-occurring anxiety disorders and for elderlypatients.
• Evidence suggests that higher SSRI doses produce a somewhat higher response rate and somewhat greater magnitude of symptomrelief.
• Some patients may benefit from even higher doses than those shown in the last column of Table 3. Monitor such patients closelyfor side effects including serotonin syndrome.
• There is no apparent relationship between OCD treatment outcome Continue pharmacotherapy for 8–12 weeks, including 4–6 weeks at
a maximally tolerable dose.
• Most patients will not experience substantial improvement until
4–6 weeks after starting medication, and some who will ultimatelyrespond will experience little improvement for as many as 10–12 weeks.
• Patients who have not responded to a known effective dose after 10–12 weeks may respond at higher doses. • Some clinicians prefer to titrate doses more rapidly (in weekly increments to the maximum recommended dose if this is comfort-ably tolerated) rather than waiting for 1–2 months before eachdose increment.
14 • TREATING OBSESSIVE-COMPULSIVE DISORDER
TABLE 3. Dosing of Serotonin Reuptake Inhibitors (SRIs) in
Obsessive-Compulsive Disorder
Starting Dose
Occasionally
Prescribed
Incremental
Usual Target
(mg/day)a
(mg/day)
(mg/day)
(mg/day)b
aSome patients may need to start at half this dose or less to minimize undesired side effects such as nau-sea or to accommodate anxiety about taking medications. b These doses are sometimes used for rapid metabolizers or for patients with no or mild side effects andinadequate therapeutic response after 8 weeks or more at the usual maximum dose.
cCombined plasma levels of clomipramine plus desmethylclomipramine 12 hours after the dose should bekept below 500 ng/mL to minimize risk of seizures and cardiac conduction delay.
dSertraline, alone among the selective serotonin reuptake inhibitors, is better absorbed with food.
Manage medication side effects.
• A first step is to consider if lowering the drug dose may alleviate
the side effect without loss of therapeutic effect.
• Clomipramine is likely to induce anticholinergic effects, although these typically diminish over time. Side effects may include delayedurination, weight gain and sedation, orthostatic hypotension andpostural dizziness, and cardiac arrhythmias and seizures. Startingat a dose of 25 mg/day or less will increase early tolerability.
• Common side effects of SSRIs and management strategies are described in Table 4. Sexual side effects may affect one-third ormore of patients taking SSRIs.
TREATING OBSESSIVE-COMPULSIVE DISORDER • 15
• Carefully monitor patients taking SSRIs for suicidal thoughts and suici- dal or other self-harming behaviors, particularly during the earlyphases of treatment and after dosage increases.
• A discontinuation syndrome consisting of dizziness, nausea/vomiting, headache, and lethargy but also agitation, insomnia, myoclonic jerks,and paresthesias may occur if medication is suddenly stopped. Thesyndrome may occur with any SRI but is most often seen with paroxe-tine or the serotonin-norepinephrine reuptake inhibitor venlafaxine. Aslow taper over several weeks or more will minimize the likelihood ofdiscontinuation symptoms.
TABLE 4. Management Strategies for Common Side Effects of
Selective Serotonin Reuptake Inhibitors (SSRIs)
Side Effect
Management Strategies
• Advise that mild queasiness or nausea will usually disappear within 1–2 weeks at a constant dose.
• Recommend taking the medication in the morning.
• Recommend sleep hygiene measures.
• Reduce the dose to that which is minimally effective.
• Recommend a once-weekly, one-day “drug holiday” before engaging in sexual activity (not effective for fluoxetine). • Add a counteracting pharmacological agent • Add a low-dose anticholinergic agent such as • Add clonidine, cyproheptadine, or mirtazapine.
16 • TREATING OBSESSIVE-COMPULSIVE DISORDER
Provide CBT at least once weekly for 13–20 weeks.
• The literature and expert opinion suggest that 13–20 weekly
sessions with daily homework (or 3 weeks of weekday daily CBT) is an adequate trial for most patients. More severely ill patients may require longer treatment and/or more frequent sessions.
• Consider booster sessions for more severely ill patients, patients who have relapsed in the past, and those who show signs of early relapse.
• The psychiatrist may conduct the CBT or refer the patient for this or Monitor the patient’s psychiatric status in follow-up visits.
• The frequency of follow-up visits may vary from a few days to
2 weeks. The indicated frequency will depend on the severity of the patient's symptoms, the complexities introduced by co-occur-ring conditions, whether suicidal ideation is present, and the likeli-hood of troublesome side effects.
• The patient should be encouraged to telephone between visits if medication questions arise. If telephone calls become reassurance rituals, work with the patient and the patient's family to limit call frequency, using treatment as for any other ritual.
D. Changing Treatment
Decide when, whether, and how to alter the therapeutic plan for
patients who have continued OCD symptoms despite treatment.
• First treatments rarely produce freedom from all OCD symptoms,
and there is typically opportunity for improvement.
TREATING OBSESSIVE-COMPULSIVE DISORDER • 17
• Decisions about altering treatment may depend on the degree of residual symptoms that a patient is willing to accept.
• When patients are not motivated to pursue further treatments despite limited improvement, consider if depressed mood is dimin-ishing hopefulness or if illness is associated with secondary gain.
Consider whether other factors are contributing to limited improve-
ment and address them:
• Problems in the therapeutic alliance
• Interference of co-occurring conditions such as panic disorder,
major depression, a substance use disorder, or severe personalitydisorder • Inadequate adherence to treatment or failure to tolerate an ade- quate trial of psychotherapy or medication at the recommendeddose • Psychosocial stressors• Family accommodation to symptoms Consider extending or intensifying the psychotherapeutic or pharma-
cological intervention.
If the patient continues to have an inadequate response to treatment,
consider the following alternatives:
• Providing combined treatment (SRI and CBT)
• Augmenting an SRI with an antipsychotic medication
• Switching to a different SRI
• Switching to venlafaxine
18 • TREATING OBSESSIVE-COMPULSIVE DISORDER
After the above treatments and augmentation strategies have been
exhausted, consider less well supported strategies.
• Augmentation of SSRIs with clomipramine, buspirone, pindolol,
riluzole, or once-weekly morphine sulfate may be helpful for somepatients. However, morphine sulfate should be avoided in patientswith contraindications to opiate administration, and appropriateprecautions and documentation should occur. If clomipramine isadded, appropriate precautions should be used to prevent potentialcardiac and central nervous system side effects. • Monotherapy with D-amphetamine, tramadol, monoamine oxidase inhibitors, ondansetron, transcranial magnetic stimulation, or deepbrain stimulation may be considered in selected circumstances.
• Intensive residential treatment or partial hospitalization may be helpful for patients with severe treatment-resistant OCD.
• Ablative neurosurgery for severe and very treatment-refractory OCD is rarely indicated and, along with deep brain stimulation,should be performed only at sites with expertise in both OCD andthese treatment approaches.
E. Discontinuing Treatment
Because relapse appears to be common, continue treatment of some
form for most patients.
• Continue successful medication treatment for 1–2 years before
considering a gradual taper by decrements of 10%–25% every 1–2 months while observing for symptom return or exacerbation.
• Follow successful CBT consisting of ERP by monthly booster sessions for 3–6 months, or more intensively if response has been only partial.

Source: http://mads.eu/ekstern/FINALOCD_%20QRG_06-21-07.pdf