Treatment of Patients With Obsessive-Compulsive Disorder

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PRA CT ICE GU IDEL INE FO R TH E
Treatment of Patients With
Obsessive-Compulsive Disorder
WORK GROUP ON OBSESSIVE-COMPULSIVE DISORDER
Lorrin M. Koran, M.D., Chair
Gregory L. Hanna, M.D.
Eric Hollander, M.D.
Gerald Nestadt, M.D.
Helen Blair Simpson, M.D., Ph.D.
This practice guideline was approved in October 2006 and 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 American Psychiatric Association (APA) Web site at
www.psych.org.
Dr. Koran has received research grants from Forest Pharmaceuticals, Pfizer, Eli Lilly, Ortho-McNeil, Somaxon, and
Jazz Pharmaceuticals. He has received honoraria from the Forest Pharmaceuticals Speakers Bureau and the Pfizer
Speakers Bureau. He has received consultant fees from Cypress Bioscience. Dr. Hanna reports no competing interests.
Dr. Hollander has received research grants from the National Institute of Mental Health, the National Institute of
Neurological Disorders and Stroke, the National Institute on Drug Abuse, the Office of Orphan Products Development
of the U.S. Food and Drug Administration, Pfizer, GlaxoSmithKline, Wyeth, Eli Lilly, Janssen, and Abbott. He has
served on advisory boards for Forest Pharmaceuticals, Abbott, and Somaxon. Dr. Nestadt reports no competing interests. Dr. Simpson reports no competing interests. The Executive Committee on Practice Guidelines has reviewed this
guideline and found no evidence of influence from these relationships.
Suggested citation: American Psychiatric Association. Practice guideline for the treatment of patients with obsessive-compulsive
disorder. Arlington, VA: American Psychiatric Association, 2007. Available online at http//www.psych.org/psych_pract/treatg/pg/
prac_ guide.cfm.
AMERICAN PSYCHIATRIC ASSOCIATION
STEERING COMMITTEE ON PRACTICE GUIDELINES
John S. McIntyre, M.D., Chair
Sara C. Charles, M.D., Vice-Chair
Daniel J. Anzia, M.D.
Ian A. Cook, M.D.
Molly T. Finnerty, M.D.
Bradley R. Johnson, M.D.
James E. Nininger, M.D.
Paul Summergrad, M.D.
Sherwyn M. Woods, M.D., Ph.D.
Joel Yager, M.D.
AREA AND COMPONENT LIAISONS
Joseph Berger, M.D. (Area I)
C. Deborah Cross, M.D. (Area II)
Harry A. Brandt, M.D. (Area III)
Philip M. Margolis, M.D. (Area IV)
John P.D. Shemo, M.D. (Area V)
Barton J. Blinder, M.D. (Area VI)
David L. Duncan, M.D. (Area VII)
Mary Ann Barnovitz, M.D.
Sheila Hafter Gray, M.D.
Sunil Saxena, M.D.
Tina Tonnu, M.D.
STAFF
Robert Kunkle, M.A., Senior Program Manager
Amy B. Albert, B.A., Project Manager
Thomas J. Craig, M.D., M.P.H., Director, Department of Quality Improvement and Psychiatric
Services
Darrel A. Regier, M.D., M.P.H., Director, Division of Research
MEDICAL EDITOR
Laura J. Fochtmann, M.D.
CONTENTS
STATEMENT OF INTENT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
GUIDE TO USING THIS PRACTICE GUIDELINE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
DEVELOPMENT PROCESS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
PART A: TREATMENT RECOMMENDATIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
I. EXECUTIVE SUMMARY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
A. Coding System . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
B. Executive Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
1. Psychiatric Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
a. Establishing a Therapeutic Alliance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
b. Assessing the Patient’s Symptoms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
c. Using Rating Scales . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
d. Enhancing the Safety of the Patient and Others . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
e. Completing the Psychiatric Assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
f. Establishing Goals for Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
g. Establishing the Appropriate Setting for Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
h. Enhancing Treatment Adherence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
2. Choosing an Initial Treatment Modality . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
3. Choosing a Specific Pharmacological Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
4. Choosing a Specific Form of Psychotherapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
5. Implementing a Treatment Plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
a. Implementing Pharmacotherapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
b. Implementing Cognitive-Behavioral Therapies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
c. Changing Treatments and Pursuing Sequential Treatment Trials . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
6. Discontinuing Active Treatment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
II. FORMULATION AND IMPLEMENTATION OF A TREATMENT PLAN . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
A. Psychiatric Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
1. Establish a Therapeutic Alliance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
2. Assess the Patient’s Symptoms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
3. Consider Rating the Severity of OCD and Co-occurring Symptoms and Their Effects on the Patient’s Functioning . . 16
4. Evaluate the Safety of the Patient and Others. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
5. Complete the Psychiatric Assessment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
6. Establish Goals for Treatment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
7. Establish the Appropriate Setting for Treatment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
8. Enhance Treatment Adherence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
9. Provide Education to the Patient and, When Appropriate, to the Family . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
10. Coordinate the Patient’s Care With Other Providers of Care and Social Agencies. . . . . . . . . . . . . . . . . . . . . . . . 22
B. Acute Phase . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .23
1. Choosing an Initial Treatment Modality . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
2. Choosing a Specific Pharmacologic Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
a. Implementing Pharmacotherapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24
b. Managing Medication Side Effects . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25
3. Choosing a Specific Form of Psychotherapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26
4. Implementing Cognitive-Behavioral Therapies. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26
5. Monitoring the Patient’s Psychiatric Status . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27
6. Determining When and Whether to Change Treatments. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27
7. Pursuing Sequential Treatment Trials . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28
C. Discontinuation of Active Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .30
III. SPECIFIC CLINICAL FEATURES INFLUENCING THE TREATMENT PLAN . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .31
A. Psychiatric Features . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .31
1. Chronic Motor Tics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31
2. Tourette’s Disorder . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32
3. Major Depression . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32
4. Bipolar Disorder . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32
5. Panic Disorder. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32
6. Social Phobia (Social Anxiety Disorder). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32
7. Schizophrenia. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32
8. Substance Use Disorders. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33
9. Autism and Asperger’s Syndrome. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33
10. Personality Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33
11. Neurological Conditions Inducing OCD. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33
B. Demographic and Psychosocial Factors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .34
1. Gender . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34
2. Ethnicity. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34
3. Pregnancy and Breast-Feeding. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34
4. Children and Adolescents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35
5. The Elderly . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35
C. Treatment Implications of Concurrent General Medical Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .36
PART B: BACKGROUND INFORMATION AND REVIEW OF AVAILABLE EVIDENCE . . . . . . . . . . . . . . . 36
IV. DISEASE DEFINITION, EPIDEMIOLOGY, NATURAL HISTORY, COURSE, AND GENETICS . . . . . . . . . . . . . . . . . . . . . .36
A. Disease Definition . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .36
B. Epidemiology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .37
C. Natural History and Course . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .38
D. Genetics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .38
1. Twin and Family Studies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38
2. Genetic Linkage and Candidate Gene Studies. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39
V. REVIEW AND SYNTHESIS OF AVAILABLE EVIDENCE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .39
A. Medications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .39
1. Efficacy of Clomipramine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40
a. Intravenous Clomipramine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41
b. Clomipramine as an Augmentation Agent . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42
B.
C.
D.
E.
2. Efficacy of SSRIs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42
a. Fluvoxamine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42
b. Fluoxetine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44
c. Paroxetine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45
d. Sertraline . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45
e. Citalopram . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46
f. Venlafaxine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47
3. Implementation of SRIs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47
4. Other Antidepressants . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48
a. Monoamine Oxidase Inhibitors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48
b. Tricyclic Antidepressants . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49
c. Trazodone . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49
5. Antipsychotics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50
a. Monotherapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50
b. Augmentation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50
c. Haloperidol . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51
d. Risperidone . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51
e. Olanzapine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52
f. Quetiapine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52
g. Other Antipsychotic Agents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53
6. Other Agents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53
a. Adrenergic Agents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53
b. Benzodiazepines . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53
c. Buspirone . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53
d. Inositol . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54
e. Lithium . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54
f. Mirtazapine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54
g. Other Medications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54
Other Somatic Therapies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .55
1. Transcranial Magnetic Stimulation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55
2. Electroconvulsive Therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56
3. Deep Brain Stimulation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56
4. Neurosurgical Stereotactic Lesion Procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57
Psychotherapies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .58
1. Exposure and Response Prevention . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58
a. Randomized Controlled Trials Comparing ERP With a Nonactive Treatment . . . . . . . . . . . . . . . . . . . . . . . 58
b. Factors That Affect Outcome From ERP . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60
c. Long-Term Outcome From ERP . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60
d. Cognitive-Behavioral Therapy as an Augmentor of SRI Response . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61
2. Cognitive Therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61
a. Efficacy of Cognitive Therapy Without ERP . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61
b. Efficacy of Cognitive Therapy Versus ERP . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61
c. Adding Cognitive Therapy to ERP . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63
3. Group and Multifamily Behavioral Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63
4. Kundalini Yoga . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 64
Combined Therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .64
Discontinuation of Active Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .66
PART C: FUTURE RESEARCH NEEDS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67
APPENDIX: EDUCATIONAL RESOURCES FOR PATIENTS AND FAMILIES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .69
ACKNOWLEDGMENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .73
INDIVIDUALS AND ORGANIZATIONS THAT SUBMITTED COMMENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .74
REFERENCES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .75
Practice Guideline for the Treatment of Patients With Obsessive-Compulsive Disorder
STATEMENT OF INTENT
The APA Practice Guidelines are not intended to be construed or to serve as a standard of medical care. Standards of
medical care are determined on the basis of all clinical data
available for an individual patient and are subject to change
as scientific knowledge and technology advance and practice
patterns evolve. These parameters of practice should be
considered guidelines only. Adherence to them will not ensure a successful outcome for every individual, nor should
they be interpreted as including all proper methods of care
or excluding other acceptable methods of care aimed at the
same results. The ultimate judgment regarding a particular
clinical procedure or treatment plan must be made by the
psychiatrist in light of the clinical data presented by the patient and the diagnostic and treatment options available.
This practice guideline has been developed by psychiatrists who are in active clinical practice. In addition, some
contributors are primarily involved in research or other academic endeavors. It is possible that through such activities
some contributors, including work group members and
reviewers, have received income related to treatments
discussed in this guideline. A number of mechanisms are
in place to minimize the potential for producing biased
recommendations due to conflicts of interest. Work group
members are selected on the basis of their expertise and integrity. Any work group member or reviewer who has a potential conflict of interest that may bias (or appear to bias)
his or her work is asked to disclose this to the Steering Committee on Practice Guidelines and the work group. Iterative
guideline drafts are reviewed by the Steering Committee,
other experts, allied organizations, APA members, and the
APA Assembly and Board of Trustees; substantial revisions
address or integrate the comments of these multiple reviewers. The development of the APA practice guidelines is not
financially supported by any commercial organization.
More detail about mechanisms in place to minimize bias
is provided in a document available from the APA Department of Quality Improvement and Psychiatric Services,
“APA Guideline Development Process.”
This practice guideline was approved in October 2006
and published in July 2007.
7
GUIDE TO USING THIS
PRACTICE GUIDELINE
The Practice Guideline for the Treatment of Patients With
Obsessive-Compulsive Disorder consists of three parts (Parts
A, B, and C) and many sections, not all of which will be
equally useful for all readers. The following guide is designed to help readers find the sections that will be most
useful to them.
Part A, “Treatment Recommendations,” is published as
a supplement to the American Journal of Psychiatry and contains general and specific treatment recommendations.
Section I summarizes the key recommendations of the
guideline and codes each recommendation according to
the degree of clinical confidence with which the recommendation is made. Section II is a guide to the formulation and implementation of a treatment plan for the individual patient. Section III, “Specific Clinical Features
Influencing the Treatment Plan,” discusses a range of clinical considerations that could alter the general recommendations discussed in Section I.
Part B, “Background Information and Review of Available Evidence,” and Part C, “Future Research Needs,” are
not included in the American Journal of Psychiatry supplement but are provided with Part A in the complete
guideline, which is available in print format from American Psychiatric Publishing, Inc., and online through the
American Psychiatric Association (http://www.psych.
org). Part B provides an overview of obsessive-compulsive
disorder (OCD), including general information on natural history, course, and epidemiology. It also provides a
structured review and synthesis of the evidence that underlies the recommendations made in Part A. Part C draws from
the previous sections and summarizes areas for which
more research data are needed to guide clinical decisions.
To share feedback on this or other published APA practice guidelines, a form is available at http://www.psych.
org/psych_pract/pg/reviewform.cfm.
8
DEVELOPMENT PROCESS
This practice guideline was developed under the auspices
of the Steering Committee on Practice Guidelines. The
development process is detailed in “APA Guideline Development Process,” which is available from the APA Department of Quality Improvement and Psychiatric Services.
The key features of this process with regard to this document include the following:
• A comprehensive literature review to identify all relevant randomized clinical trials as well as less rigorously
designed clinical trials and case series when evidence
from randomized trials was unavailable
• The development of evidence tables that summarized
the key features of each identified study, including
funding source, study design, sample sizes, subject characteristics, treatment characteristics, and treatment
outcomes
• Initial drafting of the guideline by a work group that
included psychiatrists with clinical and research expertise in obsessive-compulsive disorder
• The production of multiple revised drafts with widespread review (11 organizations and 68 individuals submitted significant comments)
APA PRACTICE GUIDELINES
• Approval by the APA Assembly and Board of Trustees
• Planned revisions at regular intervals
Relevant literature was identified through a MEDLINE
literature search using PubMed for articles published between 1966 and December 2004, using the keywords
(“Obsessive-Compulsive Disorder”[MeSH] OR “Compulsive Behavior”[MeSH]) OR (“obsession”[All Fields]
OR “obsessional”[All Fields] OR “obsessions”[All Fields]
OR “obsessive”[All Fields]) OR (“compulsion”[All Fields]
OR “compulsions”[All Fields] OR “compulsive”[All
Fields]). This search yielded 13,182 references, of which
10,756 were in the English language and had abstracts. Additional, less formal literature searches were conducted by
APA staff and individual members of the Work Group on
Obsessive-Compulsive Disorder. The Cochrane databases
were also searched for relevant meta-analyses.
The summary of treatment recommendations is keyed
according to the level of confidence with which each recommendation is made (indicated by a bracketed Roman
numeral). In addition, each reference is followed by a
bracketed letter that indicates the nature of the supporting evidence.
Part A
TREATMENT RECOMMENDATIONS
I.
EXECUTIVE SUMMARY
A. CODING SYSTEM
a. Establishing a Therapeutic Alliance
Establishing and maintaining a strong therapeutic alliance
is important so that treatment may be jointly, and therefore more effectively, planned and implemented [I]. Steps
toward this end include tailoring one’s communication
style to the patient’s needs and capacities, explaining symptoms in understandable terms, and being both encouraging and comforting [I]. The excessive doubting that is
characteristic of OCD may require special approaches to
building the alliance, including allowing the patient extra
time to consider treatment decisions and repeating explanations (a limited number of times) [I]. In building the
therapeutic alliance, the psychiatrist should also consider
how the patient feels and acts toward him or her as well as
what the patient wants and expects from treatment [I].
Each recommendation is identified as meriting one of
three categories of endorsement, based on the level of clinical confidence regarding the recommendation, as indicated
by a bracketed Roman numeral following the statement.
The three categories are as follows:
[I] Recommended with substantial clinical confidence
[II] Recommended with moderate clinical confidence
[III] May be recommended on the basis of individual circumstances
B. EXECUTIVE SUMMARY
1. Psychiatric Management
Obsessive-compulsive disorder (OCD) seen in clinical
practice is usually a chronic illness with a waxing and waning course. Treatment is indicated when OCD symptoms
interfere with functioning or cause significant distress [I].
Psychiatric management consists of an array of therapeutic actions that may be offered to all patients with OCD during the course of their illness at an intensity consistent with
the individual patient’s needs, capacities, and desires [I]. It is
important to coordinate the patient’s care with physicians
treating co-occurring medical conditions, other clinicians,
and social agencies such as schools and vocational rehabilitation programs [I]. When OCD is of disabling severity, the
psychiatrist may need to write on the patient’s behalf to government agencies that control access to disability income,
publicly financed health care, or government-supported
housing; or to tax authorities, courts, schools, or employers [I]. OCD patients who are parents of young children
may want advice regarding the genetic risk of OCD. It is
important for clinicians to explain to such patients that
the available data indicate an increased but modest risk
of OCD in the children of affected individuals; patients
wanting more information may be referred to a genetic
counselor [I].
b. Assessing the Patient’s Symptoms
In assessing the patient’s symptoms with the aim of establishing a diagnosis using DSM-IV-TR criteria, it is important to differentiate the obsessions, compulsions, and
rituals of OCD from similar symptoms found in other
disorders, including depressive ruminations, the worries
of generalized anxiety disorder, the intrusive thoughts and
images of posttraumatic stress disorder, and schizophrenic
and manic delusions [I].
c. Using Rating Scales
The psychiatrist should consider rating the baseline severity of OCD symptoms and co-occurring conditions
and their effects on the patient’s functioning, using a scale
such as the 10-item Yale-Brown Obsessive Compulsive Scale
(Y-BOCS), since this provides a way to measure response
to treatment [I]. If a rating scale is not used, it is helpful to
document the patient’s estimate of the number of hours
per day spent obsessing and performing compulsive behaviors, and the degree of effort applied to trying to escape
the obsessions and to resisting the behaviors [I]. Recording actively avoided items or situations also provides a
useful baseline against which change can be measured [I].
9
10
Scales may also be utilized to rate other symptoms, such as
depression or degree of disability.
d. Enhancing the Safety of the Patient and Others
The psychiatrist should evaluate the safety of the patient
and others [I]. This entails assessing the patient’s potential
for self-injury or suicide, since individuals with OCD
alone or with a lifetime history of any co-occurring disorder have a higher suicide attempt rate than do individuals in
the general population. Although acting on aggressive impulses or thoughts has not been reported in OCD, and patients rarely resort to violence when others interfere with
their performing their compulsive rituals, it remains important to inquire about past aggressive behavior. OCD patients who fear loss of control may engage in extensive
avoidance rituals in an effort to contain their symptoms.
The psychiatrist should understand that individuals with
OCD are not immune to co-occurring disorders that may
increase the likelihood of suicidal or aggressive behavior.
When such co-occurring conditions are present, it is important to arrange treatments that will enhance the safety of the
patient and others [I].
Because OCD symptoms can also interfere with parenting, the clinician may have to work with the unaffected
parent or social agencies to mitigate the effects of OCD
symptoms on the patient’s children [II].
e. Completing the Psychiatric Assessment
In completing the psychiatric assessment, the psychiatrist
will usually consider all the elements of the traditional
medical evaluation [I]. With regard to co-occurring conditions, the psychiatrist should pay particular attention to
past or current evidence of depression, given its frequency
and association with suicidal ideation and behaviors [I].
Exploration for co-occurring bipolar disorder and family
history of bipolar disorder is also important in view of the
risk of precipitating hypomania or mania with anti-OCD
medications [I]. Other anxiety disorders are common
in OCD patients, as are tic disorders, and may complicate
treatment planning. Other disorders that may be more
common and may complicate treatment planning include
impulse-control disorders, anorexia nervosa, bulimia
nervosa, alcohol use disorders, and attention-deficit/ hyperactivity disorder. Past histories of panic attacks, mood
swings, and substance abuse or dependence are also relevant [I].
It is important to document the patient’s course of symptoms and treatment history, including psychiatric hospitalizations and trials of medications (with details on treatment adequacy, dose, duration, response, and side effects)
and psychotherapies (with details on the nature, extent, and
response to all trials) [I].
APA PRACTICE GUIDELINES
The psychiatrist should also assess the patient’s developmental, psychosocial, and sociocultural history, including his or her primary support group and sociocultural
supports, potential psychosocial stressors, educational
and occupational history (including military history), sexual history, and capacity to navigate developmental transitions and achieve stable and gratifying familial and social
relationships [I]. In addition, the psychiatrist should evaluate how OCD has interfered with academic and vocational
achievement as well as familial, social, and sexual relationships [I]. Having evaluated the symptoms and their effects
on well-being, functioning, and quality of life, the psychiatrist should assess the role of the patient’s social supports
in facilitating treatment and in maintaining or exacerbating symptoms [I].
The psychiatrist should consider whether the OCD is a
manifestation of a general medical condition [I]; document
current medical conditions, relevant hospitalizations, and
any history of head trauma, loss of consciousness, or seizures [I]; and record the presence and severity of somatic
or psychological symptoms that could be confused with
medication side effects [I]. Current medications and doses,
including hormonal therapies, herbal or “natural” remedies, vitamins, and other over-the-counter medications,
should be reviewed to assess the potential for pharmacokinetic and pharmacodynamic interactions with psychotropic drugs [I]. Allergies or sensitivities to medications
should be recorded [I]. A mental status examination, including an evaluation of insight and judgment, should be
performed to systematically collect and record data related
to the patient’s signs and symptoms of illness during the
interview [I].
f. Establishing Goals for Treatment
Clinical recovery and full remission, if they occur, do not
occur rapidly. Thus, ongoing goals of treatment include
decreasing symptom frequency and severity, improving
the patient’s functioning, and helping the patient to improve his or her quality of life [I]. Treatment goals also include enhancing the patient’s ability to cooperate with
care despite the frightening cognitions generated by OCD,
minimizing any adverse effects of treatment (e.g., medication side effects), helping the patient develop coping strategies for stressors, and educating the patient and family
regarding the disorder and its treatment [I].
g. Establishing the Appropriate Setting for Treatment
The appropriate treatment setting may be the hospital,
a residential treatment or partial hospitalization program, home-based treatment, or outpatient care. Treatment should generally be provided in the least restrictive
setting that is both safe and effective [I].
Practice Guideline for the Treatment of Patients With Obsessive-Compulsive Disorder
h. Enhancing Treatment Adherence
To enhance treatment adherence, the psychiatrist should
consider factors related to the illness, the patient, the physician, the patient-physician relationship, the treatment,
and the social or environmental milieu [I]. Because the patient’s beliefs about the nature of the illness and its treatments will influence adherence, providing patient and
family education may enhance adherence [II]. Many patients with OCD benefit from educational materials and
access to support groups provided by the Obsessive Compulsive Foundation (www.ocfoundation.org). When a patient has insufficient motivation to participate effectively
in treatment, motivational interviewing or other psychosocial interventions designed to enhance readiness for
change may be helpful [II]. Because medications used to
treat OCD have side effects, particularly at high doses, adherence may be enhanced by informing the patient about
any likely side effects, responding quickly to side effect
concerns, and scheduling follow-up appointments soon
after starting or changing medications [I]. In describing
cognitive-behavioral therapy (CBT), it is helpful to advise
that it involves confronting feared thoughts and situations, though at a tolerable rate [I]. Practical issues such as
treatment cost, insurance coverage, and transportation
may need to be addressed. When a patient with OCD refuses or prematurely discontinues treatment, the clinician
may wish to recommend that family members and others
negatively affected by the OCD seek therapy to help develop strategies to mitigate the effect of the patient’s OCD
on their lives and to encourage the patient to obtain treatment [II].
2. Choosing an Initial Treatment Modality
In choosing a treatment approach, the clinician should
consider the patient’s motivation and ability to comply
with pharmacotherapy and psychotherapy [I]. CBT and
serotonin reuptake inhibitors (SRIs) are recommended as
safe and effective first-line treatments for OCD [I]. Whether
to utilize CBT, an SRI, or combined treatment will depend on factors that include the nature and severity of the
patient’s symptoms, the nature of any co-occurring psychiatric and medical conditions and their treatments, the
availability of CBT, and the patient’s past treatment history, current medications, capacities, and preferences.
CBT alone, consisting of exposure and response prevention, is recommended as initial treatment 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 and is willing to do the work that CBT
requires [II]. An SRI alone is recommended for a patient
who is not able to cooperate with CBT, has previously responded well to a given drug, or prefers treatment with an
11
SRI alone [II]. Combined treatment should be considered
for patients with an unsatisfactory response to monotherapy [II], for those with co-occurring psychiatric conditions for which SRIs are effective [I], and for those who
wish to limit the duration of SRI treatment [II]. In the latter instance, uncontrolled follow-up studies suggest that
CBT may delay or mitigate relapse when SRI treatment is
discontinued [II]. Combined treatment or treatment with
an SRI alone may also be considered in patients with severe
OCD, since the medication may diminish symptom severity sufficiently to allow the patient to engage in CBT [II].
Deciding whether to start or stop a psychotropic drug
during pregnancy or breast-feeding requires making a
risk-benefit calculation with the patient and her significant other; this process may be enhanced by providing
clear information, seeking consultation from an obstetrician, and providing counseling over several sessions to
help the patient come to terms with the uncertainty of the
risks [I].
3. Choosing a Specific Pharmacological Treatment
Clomipramine, fluoxetine, fluvoxamine, paroxetine, and
sertraline, which are approved by the U.S. Food and Drug
Administration (FDA) for treatment of OCD, are recommended pharmacological agents [I]. Although meta-analyses
of placebo-controlled trials suggest greater efficacy for
clomipramine than for fluoxetine, fluvoxamine, and sertraline, the results of head-to-head trials comparing clomipramine and selective serotonin reuptake inhibitors
(SSRIs) directly do not support this impression. Because
the SSRIs have a less troublesome side-effect profile than
clomipramine, an SSRI is preferred for a first medication
trial [I]. Although all SSRIs (including citalopram and
escitalopram) appear to be equally effective, individual patients may respond well to one medication and not to another. In choosing among the SSRIs, the psychiatrist should
consider the safety and acceptability of particular side effects for the patient, including any applicable FDA warnings, potential drug interactions, past treatment response,
and the presence of co-occurring general medical conditions [I].
4. Choosing a Specific Form of Psychotherapy
CBT that relies primarily on behavioral techniques such
as exposure and response prevention (ERP) is recommended because it has the best evidentiary support [I].
Some data support the use of CBT that focuses on cognitive techniques [II]. There are no controlled studies that
demonstrate effectiveness of dynamic psychotherapy or
psychoanalysis in dealing with the core symptoms of
OCD. Psychodynamic psychotherapy may still be useful
in helping patients overcome their resistance to accepting
12
a recommended treatment by illuminating their reasons for
wanting to stay as they are (e.g., best adaptation, secondary gains) [III]. It may also be useful in addressing the interpersonal consequences of the OCD symptoms [II]. Motivational interviewing may also help overcome resistance
to treatment [III]. Family therapy may reduce inter-family
tensions that are exacerbating the patient’s symptoms or
ameliorate the family’s collusion with symptoms [III].
5. Implementing a Treatment Plan
When treatment is initiated, the patient’s motivation and
adherence may be challenged by factors such as treatment
cost and medication side effects. It is essential for the psychiatrist to employ strategies to enhance adherence, as described above in Section I.B.1.h [I].
a. Implementing Pharmacotherapy
For most patients, the starting dose is that recommended by
the manufacturer [I]. Patients who are worried about medication side effects can have their medication started at
lower doses, since many SSRIs are available in liquid form
or in pills that can be split [I]. Most patients will not experience substantial improvement until 4–6 weeks after
starting medication, and some who will ultimately respond
will experience little improvement for as many as 10–12
weeks. Medication doses may be titrated up weekly in increments recommended by the manufacturer during the
first month of treatment [II], or when little or no symptom
improvement is seen within 4 weeks of starting medication, the dose may be increased weekly or biweekly to the
maximum dose comfortably tolerated and indicated [II].
This maximum dose may exceed the manufacturer’s recommended maximum dose in some cases [III]. The treatment trial is then continued at this dosage for at least 6 weeks
[II]. Since available trial data suggest that higher SSRI doses
produce a somewhat higher response rate and a somewhat
greater magnitude of symptom relief, such doses should
be considered when treatment response is inadequate [II].
Higher doses may also be appropriate for patients who
have had little response to treatment and are tolerating a
medication well [I]. If higher doses are prescribed, the patient should be closely monitored for side effects, including the serotonin syndrome [I]. Experience with pharmacotherapy in the elderly indicates that lower starting doses
of medication and a more gradual approach to dose increase are often advisable [I]. Medication side effects should
be inquired about and actively managed [I]. Useful strategies to manage medication side effects include gradual
initial dose titration to minimize gastrointestinal distress
[I], addition of a sleep-promoting agent to minimize insomnia [I], modest doses of modafinil to minimize fatigue
or sleepiness [III], and use of a low-dose anticholinergic
APA PRACTICE GUIDELINES
agent to minimize sweating [III]. Sexual side effects may
be minimized by reducing the dose [II], waiting for symptoms to remit [II], trying a once-weekly, one-day “drug
holiday” before sexual activity [II], switching to another
SSRI [II], or adding a pharmacological agent such as bupropion [II].
The frequency of follow-up visits after a new pharmacotherapy is initiated may vary from a few days to two weeks.
The indicated frequency will depend on the severity of the
patient’s symptoms, the complexities introduced by cooccurring conditions, whether suicidal ideation is present,
and the likelihood of troubling side effects [I].
b. Implementing Cognitive-Behavioral Therapies
Cognitive-behavioral therapies have been delivered in individual, group, and family therapy sessions, with session
length varying from less than 1 hour to 2 hours. One group
has explored a computer-based approach coupled with a
touch-tone telephone system accessible 24 hours a day.
CBT sessions should be scheduled at least once weekly [I].
Five ERP sessions per week may be more effective than
once-weekly sessions but are not necessarily more effective than twice-weekly sessions [II]. The number of treatment sessions, their length, and the duration of an adequate trial have not been established, but expert consensus
recommends 13–20 weekly sessions for most patients [I].
Clinicians should consider booster sessions for more severely ill patients, for patients who have relapsed in the past,
and for patients who show signs of early relapse [II]. When
resources for CBT are not available, the psychiatrist can
suggest and supervise the use of self-help treatment
guides and recommend support groups such as those accessible through the Obsessive Compulsive Foundation [III]
(see Appendix).
c. Changing Treatments and Pursuing Sequential Treatment Trials
First treatments rarely produce freedom from all OCD
symptoms. When a good response is not achieved after
13–20 weeks of weekly outpatient CBT, 3 weeks of daily
CBT, or 8–12 weeks of SRI treatment (including 4–6 weeks
at the highest comfortably tolerated dose), the psychiatrist should decide with the patient when, whether, and
how to alter the treatment [I]. This decision will depend
on the degree of suffering and disability the patient wishes
to accept. However, it is important to consider that illness
can bring secondary gains and that depressed mood can
diminish hopefulness; the psychiatrist may have to address
issues such as these when patients are not well motivated to
pursue further treatments despite limited improvement [I].
When initial treatment is unsatisfactory, the psychiatrist should first consider the possible contribution of
several factors: interference by co-occurring conditions,
Practice Guideline for the Treatment of Patients With Obsessive-Compulsive Disorder
inadequate patient adherence to treatment, the presence
of psychosocial stressors, the level of family members’ accommodation to the obsessive-compulsive symptoms,
and an inability to tolerate an adequate trial of psychotherapy or the maximum recommended drug doses [I].
When no interfering factor can be identified, augmentation strategies may be preferred to switching strategies
in patients who have a partial response to the initial treatment [II]. The psychiatrist should first consider augmentation of SRIs with trials of different antipsychotic medications or with CBT consisting of ERP, or augmentation
of CBT with an SRI [II]. Combined SRI and CBT treatment may be provided when the patient has a co-occurring
disorder that is SRI-responsive [I] or has a partial response
to monotherapy [II]. Combined SRI and CBT treatment
may also reduce the chance of relapse when medication is
discontinued [II]. Another option in the case of partial
response to ERP therapy is to increase the intensity of
treatment (e.g., from weekly to daily sessions) [III]. Some
evidence suggests that adding cognitive therapy to ERP
may enhance the results, but this remains to be established
[III].
Patients who do not respond to their first SRI may have
their medication switched to a different SRI [I]. A switch
to venlafaxine is less likely to produce an adequate response
[II]. For patients who have not benefitted from their first
SSRI trial, a switch to mirtazapine can also be considered
[III]. The available evidence does not allow one to predict
the chance of response to switching medications. SRI nonresponders, like partial responders, have responded to
augmentation with antipsychotic medications [II] or CBT
[II].
After first- and second-line treatments and well-supported augmentation strategies have been exhausted, less
well-supported treatment strategies may be considered
[III]. These include augmenting SSRIs with clomipramine,
II.
13
buspirone, pindolol, riluzole, or once-weekly oral morphine sulfate [III]. However, morphine sulfate should be
avoided in patients with contraindications to opiate administration, and appropriate precautions and documentation should occur. If clomipramine is added, appropriate
precautions should be utilized with regard to preventing
potential cardiac and central nervous system side effects
[I]. Less well-supported monotherapies to consider include D-amphetamine [III], tramadol [III], monoamine
oxidase inhibitors (MAOIs) [III], ondansetron [III], transcranial magnetic stimulation (TMS) [III], and deep brain
stimulation (DBS) [III]. Intensive residential treatment or
partial hospitalization may be helpful for patients with severe treatment-resistant OCD [II]. 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 and
these treatment approaches [III].
6. Discontinuing Active Treatment
Successful medication treatment should be continued 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 [I]. Successful ERP should be
followed by monthly booster sessions for 3–6 months, or
more intensively if response has been only partial [II]. In
medication discontinuation trials, rates of relapse or trial
discontinuation for insufficient clinical response are substantial but vary widely because of major methodological
differences across studies. Thus, discontinuation of pharmacotherapy should be carefully considered, and for most
patients, continued treatment of some form is recommended [II]. The data suggest that CBT consisting of ERP
may have more durable effects than some SRIs after discontinuation, but the observed differences in relapse rates
could be explained by other factors.
FORMULATION AND IMPLEMENTATION OF
A TREATMENT PLAN
The essential features of OCD identified in DSM-IV-TR
are “recurrent obsessions or compulsions (Criterion A)
that are severe enough to be time consuming (i.e., they
take more than 1 hour a day) or cause marked distress or
significant impairment (Criterion C)” (1, pp. 456–457).
Obsessions are intrusive, persistent, unwanted thoughts,
impulses, or images that give rise to marked anxiety or
distress. Compulsions are physical or mental acts that the
patient feels driven to perform in order to magically prevent some feared event, to undo some thought, or to reduce anxiety or distress.
Compulsive acts—also known as rituals—are carried out
repetitively, excessively, and usually according to rules or
in a rigid manner. Obsessions may occur spontaneously or
be evoked by a feared environmental stimulus or event.
Mental compulsions such as counting, praying, or reviewing
14
actions, conversations, or lists are initiated by the patient
willfully, with the aim of feeling safer or reducing anxiety
or distress.
The most common obsessional themes are fears of being contaminated or spreading contamination, accidentally
or purposely harming others, making a significant mistake, committing a religious offense or moral infraction,
contracting a disease, and being considered homosexual or
committing homosexual or pedophilic acts.
Hoarding, when a symptom of OCD, is not usually
feared, though it may be regretted. Individuals with OCD
may also obsess about orderliness or symmetry, lucky or
unlucky numbers or colors, needing to know or remember, heterosexual acts, or bodily health. Obsessions are often accompanied by a feeling of doubt, uncertainty, or incompleteness that drives repetitive thought or action and
are often colored by an inflated estimate of danger, an increased sense of responsibility, or a need for certainty or
perfection.
A. PSYCHIATRIC MANAGEMENT
Psychiatric management of OCD is indicated when symptoms interfere with functioning or cause significant distress. Although transient OCD is found in community
surveys, OCD seen in clinical practice is usually a chronic
illness with a waxing and waning course. With appropriate
treatment, OCD symptoms usually improve over weeks or
months and may become mild or even subside into remission over months or years. Thus, treatment planning and
psychiatric management will be iterative processes adapted
to the patient’s current status and response to previous interventions.
Psychiatric management encompasses a broad collection of professional actions and interventions designed to
benefit the patient. These actions and interventions include providing the following:
• Pharmacotherapy and psychotherapy in the appropriate setting, as indicated by patient preference and clinical judgment;
• Guidance to the patient and involved family members
about educational materials that are available in published form and on the Web (see Appendix); and
• Information about local support groups (see Appendix).
Psychiatric management should be offered throughout
the course of illness at an intensity consistent with the patient’s needs, capacities, and desires. The components of
psychiatric management across the stages of illness are described in more detail below.
APA PRACTICE GUIDELINES
1. Establish a Therapeutic Alliance
As in all of medicine, the physician first attempts to establish and then to maintain a therapeutic alliance so that the
patient’s care is a joint endeavor. The therapeutic alliance
allows the psychiatrist to obtain the information needed
to plan effective treatment. The alliance allows the patient
to trust the physician and helps motivate adherence to collaboratively planned treatments. It is important to tailor
one’s communication style to the patient’s needs and capacities, along continua from detailed to general, from biologically to psychosocially framed, and from warm to neutral. Explaining symptoms in understandable terms is both
encouraging and comforting to patients. The excessive
doubting that is characteristic of OCD may require special approaches to building the alliance. For example, the
clinician may need to allow the patient more time to consider treatment decisions and may need to repeat explanations (a limited number of times) and at several visits. Increased attention to excessive worry about medication side
effects, perfectionism, or checking behaviors may be needed.
Treatment of patients with OCD has a potential for transference and/or countertransference issues that may disrupt adherence and the therapeutic alliance. In building
the alliance, the psychiatrist should also consider the patient’s feelings and actions toward him or her, as well as why
the patient has come to him or her specifically, and why at
this point in time. What does the patient want and expect?
How are these desires and expectations affected by the patient’s cultural background, religious background, beliefs
about the illness (its cause, effects, and mechanisms), and
experience with past treatments?
2. Assess the Patient’s Symptoms
The psychiatrist should assess the patient for symptoms of
OCD, guided by the diagnostic criteria of DSM-IV-TR
(Table 1).
OCD is likely to be underdiagnosed unless specific
screening occurs (2). Screening questions might include
some of the following: 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, or
wash your hands, or check things over and over? Do you
worry a lot about whether you performed religious rituals
correctly or have been immoral? 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 family, or in social activities?
As part of the assessment, the psychiatrist must differentiate obsessions, compulsions, and rituals from similar
symptoms found in other disorders. Unlike obsessions, de-
Practice Guideline for the Treatment of Patients With Obsessive-Compulsive Disorder
TA B LE 1 .
15
DSM-IV-TR Diagnostic Criteria for 300.3 Obsessive-Compulsive Disorder
A. Either obsessions or compulsions:
Obsessions as defined by (1), (2), (3), and (4):
(1) recurrent and persistent thoughts, impulses, or images that are experienced, at some time during the
disturbance, as intrusive and inappropriate and that cause marked anxiety or distress
(2) the thoughts, impulses, or images are not simply excessive worries about real-life problems
(3) the person attempts to ignore or suppress such thoughts, impulses, or images, or to neutralize them with some
other thought or action
(4) the person recognizes that the obsessional thoughts, impulses, or images are a product of his or her own mind
(not imposed from without as in thought insertion)
Compulsions as defined by (1) and (2):
(1) repetitive behaviors (e.g., hand washing, ordering, checking) or mental acts (e.g., praying, counting, repeating
words silently) that the person feels driven to perform in response to an obsession, or according to rules that
must be applied rigidly
(2) the behaviors or mental acts are aimed at preventing or reducing distress or preventing some dreaded event or
situation; however, these behaviors or mental acts either are not connected in a realistic way with what they
are designed to neutralize or prevent or are clearly excessive
B. At some point during the course of the disorder, the person has recognized that the obsessions or compulsions are
excessive or unreasonable. Note: This does not apply to children.
C. The obsessions or compulsions cause marked distress, are time consuming (take more than 1 hour a day), or
significantly interfere with the person’s normal routine, occupational (or academic) functioning, or usual social
activities or relationships.
D. If another Axis I disorder is present, the content of the obsessions or compulsions is not restricted to it (e.g.,
preoccupation with food in the presence of an Eating Disorder; hair pulling in the presence of Trichotillomania;
concern with appearance in the presence of Body Dysmorphic Disorder; preoccupation with drugs in the presence
of a Substance Use Disorder; preoccupation with having a serious illness in the presence of Hypochondriasis;
preoccupation with sexual urges or fantasies in the presence of a Paraphilia; or guilty ruminations in the presence
of Major Depressive Disorder).
E. The disturbance is not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or
a general medical condition.
Specify if:
With Poor Insight: if, for most of the time during the current episode, the person does not recognize that the
obsessions and compulsions are excessive or unreasonable.
Source. Reprinted from Diagnostic and Statistical Manual of Mental Disorders, 4th Edition, Text Revision. Washington, DC, American
Psychiatric Association, 2000. Copyright © 2000, American Psychiatric Association.
pressive ruminations are experienced as consistent with
one’s self-image or values. They often focus on past events
but, like obsessions, may concern possible current or future
negative events or anticipated failures. The subject matter
of depressive ruminations usually concerns self-criticism,
failures, guilt, regret, or pessimism regarding the future.
Depressive ruminations do not elicit compulsive rituals.
The worries of generalized anxiety disorder focus on real
life problems and usually do not lead to compulsive rituals, although, as in OCD, the sufferer may try to convince
himself or herself that the fear is groundless or may check
on the safety of loved ones. Generalized anxiety disorder
may also present as a vague but troubling feeling of fore-
boding, whereas the obsessions of OCD always have clear
content. The intrusive thoughts and images of posttraumatic stress disorder are replays of actual events, not
anticipations of future events. Obsessions held with delusional conviction can be distinguished from schizophrenic and manic delusions by the absence of other signs
and symptoms of these disorders. Moreover, delusional obsessions will have typical OCD content rather than content
related to persecution, grandiosity, passivity experiences,
or ideas of reference.
OCD can be differentiated from hypochondriasis by
noting that the hypochondriacal fear or belief regarding
serious disease arises from misinterpretation of ordinary
16
bodily signs and symptoms. In OCD such fears arise from
external stimuli—for example, a patient fearing he has contracted AIDS because he was served by a waiter wearing a
bandage, possibly exposing him to blood. In addition, an
individual with hypochondriasis does not have insight into
the irrationality of his or her fears and behaviors, whereas
some insight is usually present in OCD. In body dysmorphic disorder, the recurrent and intrusive preoccupations
are limited to the fear or belief that one has a disturbing
physical defect, when in reality the defect is nonexistent or
slight. In anorexia nervosa and bulimia nervosa, the intrusive thoughts and irrational behaviors center on weight
and its effects on self-evaluation. In contrast to the thoughts
and urges of paraphilias, OCD-related sexual obsessions
or images (e.g., fears of homosexuality, images of having
sex with a child) lead to avoidance behaviors, are morally
abhorrent, and are resisted. Similarly, in OCD, obsessions
regarding a sexual partner are experienced as alien to the self
and are not accompanied by stalking behavior.
Differentiating urges to harm an infant that occur as
postpartum symptoms of OCD from superficially similar
symptoms of postpartum depression is critical. The OCD
urges are not accompanied by depressed mood and are experienced as inconsistent with one’s self, are resisted, or
induce efforts to neutralize the urges through other behaviors. Although OCD rituals aimed at avoiding harming the infant may interfere with attachment or normal
maternal behaviors and may require treatment, there is
little risk of direct harm to the infant. In contrast, the impulses or ideas that arise in postpartum depression may be
experienced as justified, may not be strongly resisted, and
emerge from depressed mood and other signs and symptoms of major depression. In postpartum depression, taking steps to protect the infant may be necessary (3).
Differentiating compulsions from the complex vocal or
motor tics sometimes seen in Tourette’s disorder can be
difficult. Tics, unlike compulsions, are neither preceded by
thoughts nor aimed at relieving anxiety or preventing
or undoing an external, undesired event (4). DSM-IV-TR
(1, p. 108) defines a tic as “a sudden, rapid, recurrent, nonrhythmic, [and] stereotyped motor movement or vocalization.” Tics are often preceded by premonitory sensations such as muscular tension and may involve repeating
an action until an unpleasant, localized, physical tension
or a sense of incompleteness is relieved (5, 6). Complex
motor tics can take the form of arranging, ordering, touching, or making objects symmetrical (5). Repeating an action until “it feels right” (e.g., repeatedly closing a door
until the right sound or sensation of closure is achieved)
may be a complex tic or a compulsion, or reflect elements
of both. Complex tics may be more likely in individuals
with a personal or family history of motor or phonic tics;
APA PRACTICE GUIDELINES
individuals with a history of hypersensitivity to sensations
associated with scratchy fabrics, the touch of clothing labels, or to uneven shoelaces or socks; and individuals with
co-occurring diagnoses of attention-deficit disorder or
learning disorder (5).
Differentiating OCD from obsessive-compulsive personality disorder (OCPD) may also be difficult. In addition,
OCD and OCPD may co-occur (7, 8). In fact, the greater
prevalence of OCPD in first-degree relatives of OCD patients than of control subjects suggests the possibility of a
genetic relationship between the two disorders (9). Although hoarding, scrupulosity, perfectionism, and preoccupation with rules, order, and lists may occur in both disorders, a number of factors may help distinguish OCD
and OCPD. For example, in OCD, anxiety about feared
consequences of forgoing compulsive behaviors is prominent, whereas in OCPD, the focus is on “doing things my
way, the right way” (i.e., on the need for control). In OCD,
perfectionism and preoccupation with rules is usually focal
and limited to feared events; in OCPD these traits globally color the individual’s attitudes and behavior. Fundamentally, the person with OCPD experiences the concerns
and behaviors as part of the normal self and does not resist
them but, to the contrary, considers them valued attributes.
Despite the fact that OCPD traits often irritate companions or associates, the individual with OCPD has no desire to change these traits.
3. Consider Rating the Severity of OCD and Co-occurring
Symptoms and Their Effects on the Patient’s Functioning
Use of the Y-BOCS Symptom Checklist (10), which allows
the recording of current and past symptoms, or the 18item Obsessive-Compulsive Inventory (11) may be helpful. These scales may help document both the variety and
the clustering of the patient’s symptoms. The Y-BOCS
Symptom Checklist lists 40 obsessions, 15 behavioral
compulsions, 5 mental compulsions, and 9 miscellaneous
compulsions.
The psychiatrist should consider using a rating scale
such as the 10-item Y-BOCS scale (10, 12) to record baseline severity since this provides a way to measure response
to treatment. The Y-BOCS rating can also be compared
with the patient’s and the family’s impressions of severity.
The Y-BOCS scale evaluates obsessions and compulsions
separately and, for each of these two symptom dimensions, measures the time spent and the degrees of distress,
interference with functioning, resistance to the symptoms, and success in resisting. The Y-BOCS may be found
at the following Web sites: http://healthnet.umassmed.edu/
mhealth/YBOCRatingScale.pdf or www.peaceofmind.com/
YBOCS.pdf. The Obsessive-Compulsive Inventory (11),
a self-rated scale, may also be considered. A simpler measure
Practice Guideline for the Treatment of Patients With Obsessive-Compulsive Disorder
is a visual analog scale in the form of a thermometer with
the bottom labeled “no OCD symptoms” and the top labeled “incapacitating OCD symptoms.” Encouraging the
patient to use a self-rated scale will help him or her become a better self-observer and may aid in identifying factors that aggravate or ameliorate symptoms. If a rating scale
is not used, the psychiatrist should document the patient’s
estimate of the number of hours per day spent in obsessing and in performing compulsive behaviors, and the degree of effort applied to trying to escape the obsessions (by
distraction or accepting passive awareness, not by counterargument) and to resisting the behaviors. Recording items
or situations that the patient actively avoids because of
OCD also provides a useful baseline against which change
can be measured.
The psychiatrist should consider recording co-occurring conditions and their effects on the patient’s functioning. For monitoring depression, which is commonly present and may aggravate OCD symptoms, the clinician might
also consider self-rated scales. These can be as simple as
visual analog scales or scales measuring symptoms of interest using a “0 to 10” severity rating. Formal self-rated
scales that may be useful include the Patient Health Questionnaire (PHQ-9) (13, 14), Beck Depression Inventory–II
(BDI-II) (15), Zung Depression Scale (16), and the patient
versions of the Inventory of Depressive Symptomatology
(IDS) or the shorter 16-item Quick-IDS (QIDS) (17).
OCD symptoms may seriously impair self-care, interpersonal relationships, vocational ability, marital and family relationships, child-rearing capacities, and use of leisure time. Thus, it may be useful to include a rating of
disability—for example, the self-rated, three-item Sheehan
Disability Scale (SDS) (18, 19), which records disability in
the domains of work, family, and social relationships. Some
patients, however, may not accurately recognize the degree of their disability until after successful treatment. For
most patients, OCD seriously impairs quality of life (20).
A rating of the patient’s quality of life, using a scale such as
the Quality of Life Enjoyment and Satisfaction Questionnaire (Q-LES-Q) (21) or the more detailed World Health
Organization Quality of Life Survey (WHOQOL-100)
(22), can provide a broader measure of disease impact and
of the results of treatment.
4. Evaluate the Safety of the Patient and Others
In individuals with OCD, as with all psychiatric patients,
assessing the risk for suicide and self-injurious behavior, as
well as the risk for harm to others, is crucial. Collateral
information from family members or others can be helpful in assessing such risks. When these risks are present, it
is important to arrange treatments that will enhance the
17
safety of the patient and others. Although accurate prediction of dangerousness to self or others is not possible in a
given individual at a given point in time, many factors
have been associated with increased risk in groups of individuals and are, therefore, important to determine.
In assessing and estimating the patient’s potential for
self-injury or suicide, a number of factors should be taken
into consideration. Individuals with OCD alone or with a
lifetime history of any co-occurring disorder have a
higher suicide attempt rate than do individuals in the general population (23, 24). In rare instances, self-injury can
also be directly or indirectly associated with compulsive
behaviors. Because increased risk of suicide attempts and
suicide has been associated with specific psychiatric symptoms and disorders, the psychiatrist will also want to assess
for hopelessness, agitation, psychosis, anxiety, or panic attacks, as well as the presence of mood or substance use disorders, schizophrenia, borderline personality disorder, or
other disorders associated with heightened risk. Risk for
suicide and for suicide attempts is also increased by a history of previous suicide attempts, including aborted attempts. Thus, if a patient has this history, the nature of those
attempts and their potential lethality should be determined.
It is also essential to determine whether the patient has
had thoughts of death, self-harm, or suicide and the degree
to which the patient intends to act on any such thoughts. If a
patient has considered suicide, the extent of planning or
preparation and the relative lethality of any planned suicide methods should be considered. The availability of the
means for suicide, including firearms, should also be explored. Also relevant is any family history of suicide, recent exposure to suicide or suicide attempts by others, real
or perceived lack of social supports, and recent losses, including impairments resulting from medical conditions.
Cultural, religious, and ethnic factors can also modify suicide risk. Further information is available in APA’s Practice
Guideline for the Assessment and Treatment of Patients With
Suicidal Behaviors (25).
The psychiatrist should also evaluate the patient’s potential for harming others. This evaluation will include
inquiring about whether the patient has had thoughts or
urges to harm others and when these thoughts and urges
have led to aggression toward others in the past. Such questioning should be sensitive to the fact that patients may fear
thoughts, impulses, urges, or images related to harming others or to sexually abusing a child, even though these are
experienced as alien to the self and true desires. Although
acting on such impulses or thoughts has not been reported
in OCD, the patient may fear loss of control and engage in
extensive avoidance rituals. OCD symptoms can occasionally be associated with direct or indirect potential for
18
harm to others. For example, OCD symptoms can interfere with parenting, leading the patient, for example, to
avoid or neglect his or her children, to “clean” them inappropriately with bleach or other harmful substances, or to
insist on inappropriate neatness. In such cases, the psychiatrist may have to work with the unaffected parent or social agencies to mitigate the effects of OCD symptoms on
the patient’s children. On rare occasions, individuals with
OCD have become distressed and aggressive when others
interfered with the performance of compulsive rituals.
Finally, in assessing the potential for harm to others, the
psychiatrist should consider the possibility that aggressive
behavior can be associated with co-occurring disorders such
as substance use, impulse control, and personality disorders.
5. Complete the Psychiatric Assessment
In completing the psychiatric assessment, the psychiatrist
will usually include the elements of the adult general psychiatric evaluation as described in APA’s Practice Guideline
for the Psychiatric Evaluation of Adults, 2nd edition (26). Facets of the assessment that are of particular relevance to individuals with OCD are highlighted in Table 2.
At all phases of subsequent assessment, the psychiatrist
should be alert for signs, symptoms, and history suggesting the possibility of co-occurring conditions. Particular
attention should be given to mood disorders, since depressive disorders (27, 28) and bipolar disorder (29, 30) are more
common in patients with OCD than in the general population. Careful exploration for family history for bipolar
disorder is also important in view of the risk of precipitating hypomania or mania with anti-OCD medications.
Other anxiety disorders (panic disorder, generalized
anxiety disorder, social phobia) are common in OCD patients (24, 31, 32) and may complicate treatment planning
as described later in this guideline (Sections III.A.5 and
III.A.6).
Tics are common in individuals with OCD. Conversely,
OCD has been diagnosed in 28%–62% of individuals
with Tourette’s disorder (33). In patients with co-occurring
OCD and Tourette’s disorder, use of a rating scale such as
the Yale Global Tic Severity Scale (YGTSS) (34) may be
helpful. This scale provides anchor points for rating the
number, frequency, intensity, complexity, interference,
and impairment associated with motor and phonic tics.
Anorexia nervosa and bulimia nervosa may be more
common in men and women with OCD than in the general population (24, 35). The prevalence of OCD appears
to be elevated in patients with either anorexia nervosa or
bulimia nervosa (36–38).
Evaluation should also include screening for alcohol or
substance abuse or dependence. In some (31, 39) but not
all studies (24), an increased risk of alcohol abuse and de-
APA PRACTICE GUIDELINES
pendence has been noted. In addition, the presence of a
substance use disorder will influence treatment planning
(Section III.A.8).
Other disorders with elevated prevalence in OCD include certain impulse-control disorders, such as skin picking and trichotillomania. In children and adolescents with
OCD, the prevalence of attention-deficit/hyperactivity
disorder (ADHD) and of oppositional defiant disorder
(ODD) is elevated (40). Since structured interview instruments lack modules for developmental disorders, the absence of prevalence data regarding ADHD in adult OCD
patients may represent an error of omission. Given that
about half of early-onset OCD patients with co-occurring
ADHD will continue to have clinically significant ADHD
symptoms in adulthood, assessing adult OCD patients for
ADHD may be helpful. Assessment instruments include
the Conners Adult ADHD Rating Scales (CAARS) (41)
and the Wender Utah Rating Scale (WURS) (42), among
others (e.g., see reference 43).
In assessing the past psychiatric history, a chronological history should be obtained of past psychiatric illnesses,
including substance use disorders and treatment, and of
hospitalizations. More specifically, the psychiatrist should
attempt to document the longitudinal course of the patient’s symptoms and their relationship to aggravating or
ameliorating factors, including treatment. Details of the
patient’s past medication trials should be obtained to ensure that drug doses and trial durations have been adequate, to understand side effects and other factors influencing adherence, and to evaluate the degree of response.
The nature, extent, and response to all trials of psychotherapy, including cognitive-behavioral therapy, should
also be documented. When past medical records are accessible, these can be helpful in augmenting the treatment
history provided by the patient. Past histories of psychiatric symptoms or co-occurring disorders will influence
treatment planning and should also be elicited, such as alcohol or substance abuse or dependence (Section III.A.8),
prominent fluctuations in mood (Section III.A.4), or panic
attacks (Section III.A.5).
The general medical history should document any
current general medical conditions, recent or relevant
hospitalizations, and any history of head trauma, loss of
consciousness, or seizures. The psychiatrist should also
consider whether the OCD is a rare manifestation of a
general medical condition (e.g., brain trauma, stimulant
abuse, carbon monoxide poisoning, parkinsonism). Evaluation of such potential etiologies does not require screening with imaging studies (44), as these disorders are usually obvious from history and examination (33). Current
medications and doses should be reviewed to determine
potential pharmacokinetic and pharmacodynamic inter-
Practice Guideline for the Treatment of Patients With Obsessive-Compulsive Disorder
TA B LE 2 .
19
Highlights of the Psychiatric Evaluation in Obsessive-Compulsive Disorder (OCD)
Assess the patient’s current symptoms
Consider rating symptom severity
Evaluate the effects of symptoms on well-being, functioning, and quality of life
Evaluate the safety of the patient and others
Be alert to the presence of co-occurring conditions, especially
Depressive disorders
Bipolar disorder
Other anxiety disorders
Tics or Tourette’s disorder
Eating disorders
Alcohol or substance abuse or dependence
Impulse-control disorders such as skin-picking, trichotillomania
Attention-deficit/hyperactivity disorder
Record the past psychiatric history, especially
Course of symptoms
Treatment history, including hospitalizations and trials of medications and psychotherapies, with details of
treatment adequacy, duration, response, and side effects
Past histories of co-occurring disorders that may influence treatment (e.g., mood or substance use disorders; panic
attacks)
Record the general medical history, especially
Current general medical conditions
Hospitalizations
History of head trauma, loss of consciousness, or seizures
Current medications, including hormonal therapies, herbal remedies, vitamins, other over-the-counter
medications, and other alternative or complementary therapies
Allergies or drug sensitivities
Elicit a review of systems, especially
Symptoms that could be confused with medication side effects
Record the developmental, psychosocial, and sociocultural history, especially
Developmental transitions in childhood and adulthood
Capacity to achieve stable and gratifying familial and social relationships
Sexual history, including baseline dysfunction, nature of relationships, and impulsive or high-risk sexual behaviors
Educational and occupational history (including military history)
Primary support group and sociocultural supports (e.g., spouse/partner, children, other family and friends,
community or faith-based organizations)
Potential psychosocial stressors (e.g., housing, finances, transportation, health care access, involvement with social
agencies or the justice system)
Effects of OCD on schooling, work, and relationships
Role of social supports in facilitating treatment or in maintaining or exacerbating symptoms
Record the family history, especially
OCD
Other psychiatric disorders (e.g., major depression, bipolar disorder, panic disorder, generalized or social anxiety
disorder, substance use disorders)
Tics and/or Tourette’s disorder
20
APA PRACTICE GUIDELINES
TA B LE 2 .
Highlights of the Psychiatric Evaluation in Obsessive-Compulsive Disorder (OCD) (continued)
Perform a mental status examination, especially
Appearance and general behavior, including degree of cooperation
Psychomotor abnormalities (e.g., tics, mannerisms, rituals, abnormal involuntary movements)
Thought process (e.g., circumstantiality)
Thought content (e.g., obsessions, compulsions, phobias, overvalued ideas, ideas of reference, delusions, suicidal
or homicidal ideas)
Perceptual disturbances (e.g., illusions, hallucinations)
Sensorium and cognition
Insight (e.g., understanding of the irrationality of OCD symptoms; motivation and expectations for treatment)
Judgment, especially effects of OCD symptoms in day-to-day decision making
actions with psychotropic drugs. Herbal or “natural” remedies must also be inquired about, along with hormonal
therapies, vitamins, other over-the-counter medications,
and other alternative or complementary treatments. Allergies and sensitivities to medications, including the nature of
the patient’s reaction, should be recorded. On careful exploration, reactions the patient describes as “allergies” will
sometimes turn out to be unpleasant but manageable side
effects. In performing the review of systems, the psychiatrist should record the presence and severity of somatic or
psychological symptoms that could be confused with medication side effects.
In assessing the patient’s developmental, psychosocial,
and sociocultural history, the psychiatrist should review
the stages of the patient’s life, with attention to developmental transitions in childhood and adulthood and the patient’s capacity to achieve stable and gratifying familial
and social relationships. A sexual history will identify the
nature of the patient’s sexual relationships, including impulsive or high-risk sexual behaviors. It will also provide
baseline information on patient concerns or sexual dysfunctions from which to judge potential side effects of
psychotropic medications. An educational and occupational history (including military history) will help in evaluating the extent to which OCD symptoms have interfered
with academic or vocational achievement. The psychiatrist should also assess the patient’s primary support group
and sociocultural supports (e.g., spouse/partner, children,
other family or friends, community or faith-based organizations), as well as their possible role in facilitating treatment and in maintaining or exacerbating symptoms. Assessing the family’s understanding of the patient’s illness
and of potential treatments is similarly important for treatment planning. Other specific information that may be
relevant to the assessment of psychosocial stressors includes living arrangements; sources of income, insurance,
or prescription coverage; access to transportation and health
care; and past or current involvement with social agencies
or the justice system.
In assessing the family history, the presence of OCD
among family members is of interest for how it may affect
the patient’s expectations about the illness and its treatment. Although OCD is associated with genetic risk, the
clinician should not expect concordance of specific OCD
symptoms among siblings or across generations, with the
possible exception of hoarding and ordering symptoms
(45). A family history of other psychiatric disorders (e.g., major depression, bipolar disorder, panic disorder, generalized anxiety disorder, social phobia, substance use disorders)
is also relevant, since it contributes to an increased risk of
co-occurring disorders that may influence treatment choice.
A family history of tics or Tourette’s disorder suggests a
need for careful exploration of these disorders in the patient,
as their presence could influence treatment response.
The mental status examination involves the systematic
collection and recording of data related to the patient’s
signs and symptoms of illness during the interview. The
examination includes consideration of the patient’s appearance and general behavior, including the patient’s
degree of cooperativeness. Psychomotor abnormalities
(e.g., tics, mannerisms, rituals, abnormal involuntary
movements) are also noted. The patient’s mood should be
assessed, since the presence of mood symptoms may alter cooperation with treatment or suggest a co-occurring mood
disorder. In addition to specific obsessions and compulsions, other abnormalities in thought content (e.g., phobias, overvalued ideas, ideas of reference, delusions, suicidal
or homicidal ideas) or thought process (e.g., circumstantiality) may be present. Perceptual disturbances (e.g., illusions, hallucinations) or disturbances in sensorium or cognition are less commonly observed and suggest the presence
of a co-occurring disorder. Assessing the patient’s degree
of insight into the irrationality of the OCD symptoms and
motivation and expectations of treatment is essential to
treatment planning. Also crucial is the degree to which
OCD is affecting judgment, as measured by OCD’s effects
on the patient’s management of the ordinary decisions of
daily life.
Practice Guideline for the Treatment of Patients With Obsessive-Compulsive Disorder
6. Establish Goals for Treatment
Marked clinical improvement, recovery, and full remission, if they occur, do not occur rapidly (46). Thus, persistent goals of treatment include decreasing symptom
frequency and severity, improving the patient’s functioning, and helping the patient to improve his or her quality
of life (in family, social, work/school, home, parental, and
leisure domains). Treatment goals also include enhancing
the patient’s ability to cooperate with care despite the frightening cognitions that are typical of OCD; anticipating stressors likely to exacerbate the condition and helping the patient develop coping strategies; providing assistance and
support in dealing with stresses; monitoring the patient’s
psychiatric status and intervening as indicated; minimizing any adverse effects of treatment (e.g., medication side
effects); and educating the patient and family regarding the
disorder and its treatment. Reasonable treatment outcome targets include less than 1 hour per day spent obsessing and performing compulsive behaviors; no more than
mild OCD-related anxiety; an ability to live with uncertainty; and little or no interference of OCD with the tasks
of ordinary living. However, some patients will be unable to
reach these targets, despite the psychiatrist’s and the patient’s best efforts.
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. Consequently, the appropriate treatment
setting will depend on a number of factors:
a.
Hospital treatment (47) may be indicated by suicide
risk, an inability to provide adequate self-care, danger
to others, need for constant supervision or support, an
inability to tolerate outpatient medication trials because of side effects, need for intensive CBT, the presence of medical conditions that necessitate hospital
observation while medications are initiated, or by cooccurring conditions that themselves require hospital
treatment, such as severe or suicidal depression, schizophrenia, or mania.
b. Residential treatment (48) may be indicated in individuals with severe treatment-resistant OCD, who require multidisciplinary treatment in a highly structured
setting that permits intensive individual and group
CBT as well as psychopharmacologic management with
close monitoring of treatment adherence over a period of several months.
c. Partial hospitalization (49) may be indicated by a need
for daily CBT and monitoring of behavior or medications or a supportive milieu with other adjunctive
psychosocial interventions, or to stabilize and increase
21
the gains made during a period of full hospitalization.
Goals of treatment include restoring the patient’s
ability to function in daily life without intensive monitoring; reduction of symptoms to a level consistent
with outpatient treatment; prevention of relapse; and
maintenance and improvement of social functioning.
d. Home-based treatment may be necessary for patients
with hoarding or, initially, for those with contamination fears or other symptoms so impairing that they
cannot come to the office or clinic. Home-based treatment may also be indicated for individuals who experience symptoms primarily or exclusively at home.
e. Outpatient treatment is usually sufficient for the treatment of OCD, but the intensity may vary from daily
psychotherapy, such as intensive CBT, to treatment
less than once a week (after achieving substantial symptom reduction and stabilization).
8. Enhance Treatment Adherence
Factors influencing adherence can be thought of as related to the illness, the patient, the physician, the patientphysician relationship, the treatment, and the social or environmental milieu (50). The fears, doubting, and need
for certainty that are characteristic of OCD can influence the
patient’s willingness and ability to cooperate and can challenge the physician’s patience. Patients may, for example,
obsess about possible medication side effects and, as a result, refuse pharmacotherapy. Cognitive and motivational
effects of co-occurring conditions such as major depression must also be taken into account. Thus, it is useful to
determine what the treatment will require of the patient
and the way in which these requirements match his or her
skills, resources, coping methods, priorities, and goals.
Providing the patient and family with education (see Appendix) can be beneficial, because the patient’s beliefs about
the nature of the illness and its treatments will influence
adherence. For example, it is important to inform patients
about the delay between starting medication and experiencing substantial symptom relief, and the need for extended periods of medication taking (51).
Medication side effects can influence adherence. The
patient’s culture, however, may limit his or her willingness
to report them (e.g., sexual side effects) or how discomfiting they are. Since effective medications differ both in sideeffect profiles and in their adverse effects on a given patient,
the psychiatrist has many options for responding to the
patient’s concerns and preferences. Informing the patient
about any likely side effects, responding quickly to side effect concerns, and scheduling follow-up appointments
soon after starting or changing medications will enhance
adherence.
22
In describing CBT, the clinician should note that it involves confronting feared thoughts and situations, but at a
tolerable rate. The therapist is a supportive coach, not a
disciplinarian, and encourages behavior change and praises
successes while validating the difficulty of confronting the
OCD symptoms.
As with all psychotherapies, how the patient thinks, feels,
and acts toward the clinician can decrease cooperation
with CBT, the only psychotherapy with documented efficacy for OCD. For example, patients may seek excessive
reassurance or have difficulty committing to treatment
options. These reactions can often be dealt with in the
course of CBT. At other times, improving the patient’s degree of cooperation may be best accomplished with another form of psychotherapy. Motivational interviewing
(52) and other psychosocial interventions designed to enhance readiness for change may help to improve a patient’s
motivation for treatment. Clinician-related issues in the
therapeutic alliance may also interfere with adherence and
therapeutic success. Use of consultation can sometimes be
helpful in resolving such impediments.
The psychiatrist should also consider the role of the patient’s family and social support system in treatment adherence. Family members may be important allies in the treatment efforts (53). By contrast, family members may provide
repeated inappropriate reassurance in efforts to reduce the
patient’s anxiety or inappropriately offer to do the patient’s
checking rituals so the patient can get more rest. The family or significant others may not understand that OCD is an
illness that gives rise to the patient’s compulsive behaviors.
They may accuse the patient of being weak or “crazy” or
may react to symptomatic behavior with inappropriate anger. They may also be adversely affected by rituals, such as
excessive cleaning, or by the patient’s insistence on avoiding
“contaminated” places. Family therapy may be indicated to
deal with hostility, dependency, or other family system issues. When a patient with OCD refuses or prematurely discontinues treatment, family members and others negatively
affected by the OCD may benefit from therapy. Under these
conditions, the goals of therapy may be to reduce the OCD’s
impact on the rest of the family and to teach family members how to support recovery from OCD.
Finally, practical issues such as treatment cost, insurance coverage, and transportation may need to be addressed. Pharmaceutical companies may provide free
medications for patients with severe financial limitations, with the exact criteria differing from company to
company. Information on patient assistance programs
is available from the pharmaceutical company Web sites,
from the Web site of the Partnership for Prescription Assistance (www.helpingpatients.org), and from Rx Assist
(www.rxassist.org).
APA PRACTICE GUIDELINES
9. Provide Education to the Patient and, When Appropriate,
to the Family
Patients often have little knowledge of the nature, biology,
course, and treatment of their disorders. Those with
childhood onset of OCD may confuse symptoms with aspects of their innate selves. All patients with OCD should
be provided with information and access to educational
materials explaining the nature of the disorder and the range
of available treatments. Education will help destigmatize
the illness and allow the patient to make more fully informed decisions about treatments. Education may also
increase the patient’s motivation and ability to cooperate
in care. When appropriate, education should also be offered to involved family members. The appendix to this
guideline contains lists of self-help books for patients with
OCD and co-occurring OCD spectrum disorders (see also
references 33, 54, 55), patient advocacy group Web sites
that provide scientifically reliable information, Web sites
that provide information on the use of medications in
pregnancy and during breastfeeding, and scientifically reliable, broader mental health Web sites. All OCD patients
should be made aware of the Obsessive Compulsive Foundation (www.ocfoundation.org), which provides both educational materials and access to support groups.
10. Coordinate the Patient’s Care With Other Providers of
Care and Social Agencies
The psychiatrist should coordinate the patient’s care with
physicians treating co-occurring medical conditions, with
other clinicians, and with social agencies such as schools
and vocational rehabilitation programs. For patients whose
OCD symptoms or medications impair dental health, coordination with the patient’s dentist will also be useful.
OCD-related functional impairments may involve
family, social, academic, or occupational roles or financial
problems. Consequently, under some circumstances, the
psychiatrist may need to provide government agencies,
schools, employers, and others with written documentation on the patient’s behalf. For example, the psychiatrist
may have to write to the federal Internal Revenue Service
and state tax authorities to explain that a patient’s hoarding or procrastination has prevented timely filing of income tax returns. A letter regarding special provisions for
participation in or excuse from jury duty may also be appropriate. Students may need letters explaining the need
for special dormitory living situations or academic accommodations. Employers may need help in understanding
what accommodations are appropriate in light of the Americans With Disabilities Act (56), and referral to a state vocational rehabilitation agency or an occupational therapist
may be indicated. For OCD of disabling severity, the psychiatrist must be willing to write to government agencies
Practice Guideline for the Treatment of Patients With Obsessive-Compulsive Disorder
that control access to disability income, publicly financed
health care, or government-supported housing.
OCD patients who are parents of young children may
want advice regarding the genetic risk of OCD. The clinician may wish to refer these parents to a genetic counselor,
but should be aware of the available data (Section IV.D).
The psychiatrist should help patients concerned about the
possibility of OCD in their children find clinicians who
can conduct an appropriate evaluation. (Educational materials for parents of children with OCD are included in
the Appendix.)
B. ACUTE PHASE
1. Choosing an Initial Treatment Modality
CBT and SRIs are recommended on the basis of clinical
trial results as safe and effective first-line treatments for
OCD. SRIs include clomipramine and all of the SSRIs.
Whether to recommend a form of CBT, an SRI, or combined treatment will depend on a number of factors. These
include the nature and severity of the patient’s symptoms,
the nature of any co-occurring psychiatric and medical
conditions and their treatments, the availability of CBT,
and the patient’s past treatment history, current medications, and preferences. Because most treatment studies
have been of 3–4 months’ duration, only limited data are
available to guide long-term treatment decisions (Section
II.C).
The evidence base for the form of CBT that relies primarily on behavioral techniques, such as ERP (57), is the
strongest (58–60). Data also support the use of CBT that
focuses on cognitive techniques aimed at identifying, challenging, and modifying dysfunctional beliefs (61–64) if
these techniques are combined with behavioral experiments. However, some data suggest, and many clinical experts believe, that the most effective form of CBT for
OCD integrates exposure, response prevention (behavior
that results in not performing rituals), discussion of feared
consequences and dysfunctional beliefs, and relapse prevention. There are few data from controlled trials to support cognitive therapy without ERP or behavioral experiments.
CBT alone, consisting of ERP, is recommended as initial
treatment 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. The patient must
be willing to do the work that CBT requires (e.g., regular
behavioral homework).
An SRI alone is recommended for a patient who has
previously responded well to a given drug or prefers treatment with an SRI alone. Starting with an SRI alone may
23
enhance cooperation with treatment by diminishing symptom severity. Thus, an SRI alone may also be considered
in patients who have severe OCD or are not otherwise able
to cooperate with the demands of CBT. An SRI alone may
also be necessary if CBT is not accessible or available.
The available data suggest that combining an SRI and
CBT consisting of ERP is more effective than monotherapy in some patients but is not necessary for all (65). Combined treatment should be considered for patients with an
unsatisfactory response to monotherapy, for those with
co-occurring psychiatric conditions for which SRIs are effective, and for those who wish to limit the duration of
treatment with medication. In the latter instance, uncontrolled follow-up studies suggest that CBT consisting of
ERP may delay or mitigate relapse when SRI treatment is
discontinued (66–68). Combined treatment may also be
considered in patients with severe OCD, since the medication may diminish symptom severity sufficiently to allow the patient to engage in CBT.
2. Choosing a Specific Pharmacological Treatment
Clomipramine, fluoxetine, fluvoxamine, paroxetine, and
sertraline, which are approved by the FDA for treatment
of OCD, are recommended pharmacological agents. Although meta-analyses (59, 69, 70) of placebo-controlled
trials suggest greater efficacy for clomipramine than for
fluoxetine, fluvoxamine, and sertraline, the results of headto-head trials comparing clomipramine and SSRIs directly do not support this impression (Section V.A.1). Because the SSRIs have a less troublesome side-effect profile
than clomipramine (see Section II.B.2.b), an SSRI is preferred for a first medication trial. Although all SSRIs
(including citalopram and escitalopram) appear to be equally
effective, individual patients may respond well to one and
not to another. The reasons for this patient-specific response are unknown, and no demographic or clinical variables are sufficiently accurate predictors of treatment outcome to permit their use in selecting medications (71).
In choosing among the SSRIs, the psychiatrist should
consider the safety and acceptability of particular side
effects for the patient, including any applicable FDA
warnings, potential drug interactions, past treatment response, and the presence of co-occurring general medical
conditions. For example, paroxetine, the SSRI most associated with weight gain (72) and the most anticholinergic SSRI, would not be the first choice for patients with
obesity, diabetes mellitus, constipation, or urinary hesitancy.
Another factor in choosing among medications is the
degree to which they alter metabolism through the hepatic
cytochrome P450 enzyme system or uridine 5′-diphosphate
glucuronosyltransferases (UGTs), act at the P-glycoprotein
24
APA PRACTICE GUIDELINES
TA B LE 3 .
Dosing of Serotonin Reuptake Inhibitors (SRIs) in Obsessive-Compulsive Disorder (OCD)
Starting Dose and
Incremental Dose
a
(mg/day)
Usual
Target Dose
(mg/day)
Usual
Maximum Dose
(mg/day)
Citalopram
20
40–60
80
120
Clomipramine
25
100–250
250
Escitalopram
10
20
40
—
60
Fluoxetine
20
40–60
80
120
Fluvoxamine
50
200
300
450
Paroxetine
20
40–60
60
100
50
200
200
400
SRI
Sertraline
d
Occasionally Prescribed
Maximum Dose
b
(mg/day)
c
a
Some patients may need to start at half this dose or less to minimize undesired side effects such as nausea 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 and inadequate therapeutic response after 8 weeks or more at the usual maximum dose.
c
Combined plasma levels of clomipramine plus desmethylclomipramine 12 hours after the dose should be kept below 500 ng/mL to
minimize risk of seizures and cardiac conduction delay.
d
Sertraline, alone among the SSRIs, is better absorbed with food.
transporter, or displace drugs tightly bound to plasma proteins (e.g., see references 73–76). Many interactions, however, reflect only in vitro data, and their clinical importance
is not established. Citalopram, escitalopram, and sertraline (along with venlafaxine and mirtazapine) have few or
no important known drug interactions. Web sites providing
data on potential drug interactions include http://medicine.
iupui.edu/flockhart and http://mhc.com/Cytochromes.
For up-to-date clinical reports of interactions between
specific SRIs and other medications, psychiatrists can
consult the federal National Library of Medicine database
at http://www.ncbi. nlm.nih.gov/entrez/query.fcgi?DB=
pubmed, which is also accessible by entering the term
“pubmed” in a search engine. Since there are very few serious risks associated with treatment with SSRIs (e.g., the
risk of serotonin syndrome from adding an SSRI to an
MAOI, tramadol, meperidine, or dextromethorphan [77,
78]), the psychiatrist will much more often have to consider the relative potential for specific SSRIs to interact
with the patient’s other medications, particularly given
the higher doses of SSRIs that are often used in treating
OCD.
Although no definitive data are available, the response
of first-degree relatives to particular medications may be
predictive of the patient’s response because of genetic
similarity. This is a subject, however, for future research.
a. Implementing Pharmacotherapy
The need to educate the patient about any medication recommended has been emphasized earlier. Table 3 displays
suggested starting doses, known effective doses, maximum recommended doses, and maximum doses occasionally prescribed for each SRI. For most patients, the
starting dose is that recommended by the manufacturer.
For patients who are worried about side effects, the medication can be started at half the listed dose or less, since
many SSRIs (e.g., citalopram, escitalopram, fluoxetine,
paroxetine, and sertraline) are available in liquid form or in
pills that can be split. Lower initial medication starting
doses and more gradual dose titration may also be needed
in patients with co-occurring anxiety disorders, who may
experience a transient worsening of anxiety symptoms.
Experience with pharmacotherapy in the elderly indicates
that lower starting doses of medication and a more gradual
approach to dose increase are often advisable. Most patients will not experience substantial improvement until
4–6 weeks after starting medication, and some who will ultimately respond will experience little improvement for as
many as 10–12 weeks. Available trial data suggest that higher
SSRI doses produce a somewhat higher response rate and
somewhat greater magnitude of symptom relief (79–82).
Some patients, such as those who have had little response
to previous treatments and are tolerating the medication
well, may benefit from even higher doses than those shown
in the last column of Table 3. In these instances, the patient should be closely monitored for side effects, including the serotonin syndrome. Moreover, patients who have
not responded to a known effective dose after 10–12 weeks
may respond at higher doses (83, 84). For this reason, some
clinicians prefer to titrate doses more rapidly (in weekly
Practice Guideline for the Treatment of Patients With Obsessive-Compulsive Disorder
increments to the maximum recommended dose if this is
comfortably tolerated), rather than waiting for 1–2 months
before each dose increment to evaluate results.
No evidence suggests that OCD treatment outcome is
related to plasma levels of clomipramine (85), fluoxetine
(86), fluvoxamine (87), or sertraline (82). However, these
studies were not designed to identify whether rapid or ultrarapid metabolizers of these medications were more likely
to be nonresponders.
b.
Managing Medication Side Effects
Unlike the SSRIs, clomipramine also blocks norepinephrine reuptake, muscarinic cholinergic receptors, H 1 histamine receptors, and α1-adrenergic receptors, as well as sodium channels in the heart and brain. Thus, clomipramine
is more likely to induce anticholinergic effects such as
tachycardia, dry mouth, constipation, and blurred vision,
although these typically diminish over time. Clomipramine
is also more likely to induce delayed urination or, uncommonly, urinary retention. Histaminic blockade is associated with weight gain and sedation. Adrenergic blockade
may lead to orthostatic hypotension and postural dizziness. Sodium channel blockade can induce cardiac arrhythmias or seizures (estimated to occur in 0.7% of patients
treated with clomipramine at a dose of up to 300 mg/day
for as many as 6 years [88]). In view of clomipramine’s less
favorable side-effect profile, expert opinion favors one or
more SSRI trials before trying clomipramine (89). Starting
clomipramine at a dose of 25 mg/day or less will increase
its early tolerability (90).
The most common side effects of the SSRIs include
gastrointestinal distress (especially in the first weeks of treatment), agitation, insomnia or somnolence, increased tendency to sweat, and sexual side effects, including diminished libido and difficulty with erection and orgasm. A first
step in managing any side effect is to consider whether lowering the drug dose may alleviate the side effect without
loss of therapeutic effect. When this is not possible, specific interventions may be considered. Gastrointestinal distress can be minimized by starting with low doses; if mild
queasiness or nausea occurs, it will usually disappear within
1–2 weeks at a constant dose. Insomnia may respond to
the patient’s taking the medication in the morning or to
standard sleep hygiene measures, or may require addition
of a sleep-promoting agent. Fatigue or sleepiness may respond to the addition of modest doses of modafinil (91).
Cases of successful treatment of sweating have been reported with low doses of anticholinergic agents such as
benztropine (92, 93), and with clonidine (94), cyproheptadine (95), and mirtazapine (96).
Few controlled trials have been published regarding the
management of sexual side effects, which may affect one-
25
third or more of patients (97). Management approaches
include reducing the dose to the minimal effective dose;
waiting for the symptom to remit (which clinical impression suggests may occur within 2 months in about 10% of
patients); trying a once-weekly, one-day “drug holiday”
before engaging in sexual activity; switching to another
SSRI (which may relieve the sexual dysfunction but not
control the patient’s OCD); or adding a counteracting pharmacologic agent. The drug holiday approach may alleviate
difficulties with erection or orgasm but not with libido. It
is not effective for fluoxetine because of its long half-life
(98) and may induce withdrawal symptoms if attempted
with paroxetine or venlafaxine. Taking drug holidays more
than once weekly risks a return of OCD symptoms. Case
series and primarily uncontrolled studies report modest
success in restoring libido, erection, and orgasm by addition of amantadine, bupropion, buspirone, yohimbine,
Ginkgo biloba extract (99), ropinirole (100), or stimulants
such as methylphenidate or dextroamphetamine. Adding
bupropion has the best evidence base (101), but even this
literature is mixed (102). Case series and uncontrolled studies report modest success in restoring erection or orgasm,
but not libido, with cyproheptadine or mirtazapine (99).
Controlled trials support the use of sildenafil, tadalafil, and
vardenafil (103, 104) to restore erection and, in men (105)
and women (106), to restore orgasmic ability.
Primarily on the basis of data in children and adolescents
(Section III.B.4), concerns have been raised about the potential for increases in self-harming or suicidal behaviors
in individuals treated with antidepressant medications, including SRIs. A meta-analysis in adults treated with SSRIs
did not demonstrate increases in rates of suicide or suicidal thoughts, although there was weak evidence for an
increase in self-harming behavior (107). A second metaanalysis noted an increase in the odds ratio for suicide
attempts but did not report on the risk of other suicidal
behaviors (108). However, interpretation of these results
is difficult because of the confounds involved in calculating risks of suicide and other suicidal behaviors from
meta-analyses (109). This is particularly true with regard
to the use of antidepressants to treat OCD, because the
majority of SSRI clinical trials involve depressed subjects,
not subjects with OCD. In addition, studies using other
methodologies, including a nested case–control study
(110), a retrospective analysis of a large sample of computerized health plan records (111), and a large prospective
effectiveness study in adult subjects with bipolar disorder
(112), showed no increases in the likelihood of suicide
or suicide attempts with antidepressant treatment. An additional nested case–control study also showed no increase in the risk of suicide but did note a small increase in
the likelihood of self-harm (113). Although antidepressant
26
treatment in adults does not appear to be associated with
an increase in suicide, it is conceivable that side effects
(e.g., anxiety, agitation, insomnia, irritability) may increase the chance of self-harming behaviors in some individuals (109). Thus, careful monitoring for such side
effects, as well as for evidence of self-harming or suicidal
thoughts or behaviors, is important, particularly in the
early phases of treatment and after increases in antidepressant dose. Against these small risks, the benefits of
antidepressant treatment must always be considered (114,
115).
SSRIs may be associated with increased intra-operative
blood loss in patients also taking nonsteroidal anti-inflammatory drugs (116) and, along with clomipramine, may interact with anesthetics and opiate pain relievers. Patients
should inform their surgeon and anesthesiologist if they
are taking an SRI.
A drug discontinuation syndrome consisting most often of dizziness, nausea/vomiting, headache, and lethargy,
but also including agitation, insomnia, myoclonic jerks,
and paresthesias (117, 118), may occur if medication is suddenly stopped. The syndrome may occur after stopping
any SRI but is most often seen after rapid discontinuation
of paroxetine or the serotonin-norepinephrine reuptake
inhibitor (SNRI) venlafaxine (117). Particularly for these
latter medications, a slow taper over several weeks or more
will minimize the likelihood of discontinuation symptoms. If symptoms do occur, raising the medication dose
and slowing the taper may bring relief.
3. Choosing a Specific Form of Psychotherapy
CBT is the only form of psychotherapy for OCD whose
effectiveness is supported by controlled trials. There are
no controlled studies that demonstrate effectiveness of
dynamic psychotherapy or psychoanalysis in dealing with
the core symptoms of OCD. Psychodynamic psychotherapy may still be useful in helping patients overcome their
resistance to accepting a recommended treatment by illuminating their reasons for wanting to stay as they are (e.g.,
best adaptation, secondary gains). It may also be useful
in addressing the interpersonal consequences of the OCD
symptoms (119). Motivational interviewing may also help
overcome resistance to treatment. As noted in Section II.B.1,
the CBT variant that relies primarily on behavioral techniques such as ERP has the strongest evidence base (59, 60).
Some data suggest that ERP is more effective if it integrates habituation with discussions of feared consequences
and dysfunctional beliefs (120, 121) and with relapse prevention (122–125). For OCD patients without co-occurring depression, data from one large (N =122) randomized
controlled trial suggest that intensive CBT consisting
of ERP may be superior to clomipramine monotherapy
(123, 126).
APA PRACTICE GUIDELINES
Data also support CBT that primarily utilizes cognitive
techniques such as identifying, challenging, and modifying dysfunctional beliefs when these techniques are combined with behavioral experiments (64, 121, 127–129),
which can resemble ERP depending on how they are done.
In direct comparisons, CBT utilizing cognitive techniques
and behavioral experiments had efficacy similar to CBT consisting of ERP that focused only on habituation. Whether
incorporating cognitive techniques with ERP is more effective than either treatment alone is under investigation
(122). Only case reports support attempting to treat OCD
with cognitive therapy alone, without exposure or behavioral experiments (129, 130). No controlled trials have evaluated other psychosocial methods for treating OCD that
have been used in clinical practice (e.g., the “brain-lock
technique” [131], other mindfulness approaches, acceptance
and commitment therapy).
4. Implementing Cognitive-Behavioral Therapies
Cognitive-behavioral therapies have been delivered in individual, group (132–134), and family therapy sessions,
with session length varying from less than 1 hour to 2 hours
(135, 136) (for a summary of group and family therapy
studies, see references 136, 137). One group has explored
the delivery of behavior therapy by means of a self-instructional workbook that allows the patient to design and implement an individualized treatment plan. The patient couples the plan with a voice-activated telephone-response
system accessible 24 hours a day to monitor and report
progress (138, 139). The literature and expert opinion suggest that CBT sessions should be scheduled at least once
weekly (63, 140). One study suggests that five sessions per
week of CBT consisting of ERP may be more effective than
once-weekly ERP sessions, but are not necessarily more effective than twice-weekly ERP sessions (141). The number
of treatment sessions, their length, and the duration of an
adequate trial have not been established, but expert consensus recommends 13–20 weekly sessions for most patients (140). More severely ill patients may require longer
treatment and/or more frequent sessions. On the basis of
clinical experience, clinicians should also consider booster
sessions for more severely ill patients, patients who have
relapsed in the past, and patients who show signs of early
relapse. Finally, because the majority of treatment trials
have been only 8–16 weeks long, the long-term persistence
of treatment effects and the utility of periodic “booster
sessions” require further study.
The psychiatrist may elect to conduct CBT or to refer
the patient for this or another adjunctive psychotherapy.
Psychiatrists wishing to utilize various forms of CBT are
encouraged to pursue training through workshops, conferences, and other training programs. In addition, they
can consult a number of treatment manuals (128, 142–
Practice Guideline for the Treatment of Patients With Obsessive-Compulsive Disorder
146) or other publications (33, 147–149) or obtain consultation from a clinician specializing in the use of CBT. The
psychiatrist initiating CBT should explain to the patient
the nature of the treatment, including its here-and-now
focus, the rationale underlying treatment procedures, and
what the patient will be required to do. When resources
for CBT are not available, the psychiatrist can suggest and
supervise the use of self-help treatment guides (Appendix)
and recommend support groups such as those accessible
through the Obsessive Compulsive Foundation (Appendix), although these interventions have not been subjected
to controlled study.
At the start of therapy, the psychiatrist can use the
Y-BOCS Symptom Checklist (10) to help the patient create a list of target symptoms, including obsessions, compulsions, and items or situations that are avoided because
of OCD concerns. The patient ranks the listed items from
least to most anxiety-provoking.
In CBT consisting of ERP, patients are taught to confront feared situations and objects (i.e., exposure) and to
refrain from performing rituals (i.e., response prevention).
Exposures may include in vivo confrontations (e.g.,
touching objects in public bathrooms) and imaginal confrontations of feared consequences (e.g., imagining becoming “dirty” from “contamination”). Exposures that
provoke moderate anxiety are prescribed first, followed as
quickly as tolerable by exposures of increasing difficulty.
Moving at too slow a pace can diminish faith in the treatment and motivation to continue. Patients must face their
fears for a prolonged period without ritualizing, allowing
the anxiety or discomfort to dissipate on its own (“habituation”). The goal is to weaken the connections between
feared stimuli and distress and between carrying out rituals and relief from distress.
As noted earlier, ERP can be combined with formal
cognitive techniques aimed at dysfunctional beliefs (122).
Dysfunctional beliefs in OCD include magical thinking
(e.g., contamination by proximity), an inflated sense of
responsibility for unwanted events, overestimations of
the probability of feared events, the assumption that
thoughts are morally equivalent to actions or inevitably
lead to action (“thought-action fusion”), perfectionism,
the belief that anxiety/ discomfort will persist forever,
and the need for control. Whether ERP with cognitive
therapy is superior to ERP alone is currently under investigation. However, many experts believe that integrating
exposures (or behavioral experiments) with discussions of
dysfunctional beliefs and feared consequences is likely to
be the most effective treatment (120). Modifications of
ERP that include formal cognitive techniques as well as
other interventions have been suggested for OCD patients
with certain symptoms (e.g., hoarding [150]) and those
without overt rituals (e.g., see references 59, 149, 151).
27
5. Monitoring the Patient’s Psychiatric Status
The frequency of follow-up visits after a new pharmacotherapy is initiated may vary from a few days to 2 weeks.
The indicated frequency of visits will depend on the severity of the patient’s symptoms, the complexities introduced by co-occurring conditions, whether suicidal
ideation is present, and the likelihood of troubling side
effects. Patients should be seen as often as necessary for
psychiatric management. They should be encouraged to
telephone between visits if medication questions arise. If
telephone calls become reassurance rituals, the physician
should work with the patient and the patient’s family to
limit call frequency, using exposure (e.g., to the anxiety
that prompts the urge to call) and response prevention
(e.g., limiting calls), just as in treating any other ritual.
As noted earlier, symptom rating scales can sometimes be
helpful for monitoring the response of OCD, co-occurring
depression, or co-occurring anxiety disorders, or for
keeping an objective record over time in those patients
whose symptoms do not respond to initial treatments. Although use of scales is not expected in routine practice,
keeping an objective record over time for patients who do
not respond to initial treatments may be helpful.
6. Determining When and Whether to Change Treatments
The physician’s goals are always to reduce suffering and
disability while minimizing the adverse effects of treatment. First treatments rarely produce freedom from all
OCD symptoms. In clinical trials, OCD “responders” are
variously defined as those whose Y-BOCS scores decrease
by at least 25%–35% from baseline or who are rated much
improved or very much improved on the Clinical Global
Impressions–Improvement scale (CGI-I) (152). But even
these degrees of improvement leave much room for additional gains. Thus, the psychiatrist must decide with the
patient when, whether, and how to alter the treatment approach.
Deciding whether to alter the treatment approach will
depend on the degree of suffering and disability the patient wishes to accept. Because illness can bring secondary
gains (familial attention and caring and freedom from responsibilities), and because depressed mood can diminish
hopefulness, the psychiatrist may have to address these issues when the patient is not well motivated to pursue further treatments despite limited improvement in his or her
OCD. In the opinion of CBT experts, 13–20 sessions of
weekly outpatient CBT with daily homework or weekday
daily CBT for 3 weeks (about 50 hours, half therapistguided, half homework) is an adequate dose after which
next steps can be considered (140). With regard to SRIs,
expert opinion supports changing medication strategy
(switching or augmenting) after a trial of 8–12 weeks,
with at least 4–6 weeks at the highest comfortably tolerated
28
TA B LE 4 .
APA PRACTICE GUIDELINES
Factors to Consider at Each Treatment Step
Patient’s motivation and ability to comply
Nature and severity of OCD symptoms
Co-occurring psychiatric disorders and their treatment
Presence/absence of suicide risk
Co-occurring medical disorders and their treatment
Likely drug side effects
If patient is a woman of childbearing age or is elderly
Patient’s past treatment history
Stressors
Family or caregivers’ involvement in symptoms
Cultural issues
Patient’s preferences regarding treatment modality,
acceptable risks, and expected benefits
dose (140). However, some patients may respond simply
to a longer period of continued treatment with the same
medication (84). There is no apparent relationship between OCD treatment outcome and plasma levels of SRIs
(82, 85–87).
When the outcome of initial treatment has been unsatisfactory, the psychiatrist should first consider the possible
contribution of several factors: problems in the therapeutic alliance; interference by co-occurring conditions such
as panic disorder, major depression, alcohol or substance
use disorders, or severe personality disorder; inadequate
patient adherence to treatment; the presence of psychosocial stressors; the level of family members’ accommodation to the obsessive-compulsive symptoms (153); and an
inability to tolerate an adequate trial of psychotherapy or
the maximum recommended drug doses. The psychiatrist
should next consider extending or intensifying the psychotherapeutic or pharmacotherapeutic intervention.
Figure 1 displays a treatment algorithm outlining potential next steps; Table 4 lists factors to be considered at each
treatment step.
7. Pursuing Sequential Treatment Trials
When the patient has an inadequate response to the initial
treatment and no interfering factor can be identified, the
psychiatrist and patient must decide on next treatment
steps without the benefit of data from controlled trials
comparing all the possibilities. The sequence of treatment
trials shown in Figure 1 is based on expert opinion (e.g.,
reference 140 and contributors to this guideline).
Given the absence of definitive trial data, augmentation strategies might be preferred to switching strategies
in patients who have had a partial response to the initial
treatment. Modest evidence supports augmentation of SRIs
with antipsychotic medications, including haloperidol (154),
risperidone (155–157), quetiapine (158), or olanzapine
(159). These trials report response rates in the range of
40% to 55%. Patients who do not respond to one antipsychotic augmenting agent may respond to another. A chart
review study found that discontinuing successful augmentation after 1–12 months resulted in relapse for more than
80% (15/18) of patients, most within 2 months of discontinuation (160). Despite these promising data regarding
antipsychotic augmentation in OCD, many questions
about this treatment strategy remain unanswered, including the optimal dose for each drug, long-term tolerability,
when and how to discontinue treatment, the drugs’ relative augmentation efficacy, and the reasons that only some
patients benefit. Further data are also needed on subsets
of patients who may respond preferentially to specific
augmentation strategies. For example, one study (154) suggests that augmentation with haloperidol helps only those
patients with co-occurring tic disorders.
Modest evidence supports augmentation of SRIs with
CBT (specifically, ERP) (161–163) and augmentation of
CBT with SRIs (164, 165). Some studies have demonstrated no added benefit from combining SRIs and CBT
(61, 123), but these findings are limited by high refusal
and dropout rates and uncertainty about levels of treatment resistance (166, 167). Some evidence suggests that
adding cognitive therapy to ERP may enhance the results,
but this remains to be established. In the absence of definitive data, combination treatment is provided in clinical
situations that include efforts to treat a co-occurring disorder that is SRI responsive, to augment a partial response
to monotherapy (163), and to reduce the chance of relapse
when medication is discontinued (67).
For patients who do not respond to their first SRI, expert opinion and clinical trial data support switching to a
different SRI (85, 87, 168–171). However, the evidence
does not allow one to predict the patient’s chance of response
to the new SRI. Clinical experience suggests that response
rates to a second SRI trial are close to 50% but may diminish as the number of failed adequate trials increases. A
switch to venlafaxine at doses ranging from 225 mg/day to
350 mg/day is supported by active comparator trials and
open-label studies suggesting its effectiveness in treating
OCD (171–173). A switch to mirtazapine is supported by
one open pilot study and a double-blind discontinuation
trial (174).
If the strategies described above are not effective, augmentation with other pharmacotherapies may also be considered. Expert opinion (140, 175) and three open-label
studies (176–178) support clomipramine augmentation
of SSRIs. If clomipramine is added, plasma levels of clomipramine and desmethylclomipramine should be assayed
2–3 weeks after reaching a dose of 50 mg/day, and the total
29
Practice Guideline for the Treatment of Patients With Obsessive-Compulsive Disorder
First-line
treatments
CBT (ERP)
Is the response
adequate after 13–20
weekly sessions of CBT?
SSRI + CBT
(ERP)
SSRI
No
Is the response adequate after
8–12 total weeks of SSRI
(4–6 weeks at maximal tolerable dose)
or 13–20 weekly sessions of CBT or
weekday daily CBT for 3 weeks?
Yes
Yes
No
For medication: continue for 1–2 years, then consider gradual taper over
several months or more.
For CBT: provide periodic booster sessions for 3–6 months after acute
treatment.
Strategies for Moderate Response
• Augment with a second-generation antipsychotic
or with CBT (ERP) if not already provided.
• Add cognitive therapy to ERP.*
Yes
Adequate
response?
No
Strategies for Little or No Response
• Switch to a different SSRI (may try more than one trial).
• Switch to clomipramine.
• Augment with a second-generation antipsychotic.
• Switch to venlafaxine.
• Switch to mirtazapine.*
Strategies for Moderate and for Little or No Response
• Switch to a different augmenting second-generation antipsychotic.
• Switch to a different SRI.
• Augment with clomipramine.*
• Augment with buspirone,* pindolol,* morphine sulfate,* inositol,*
or a glutamate antagonist (e.g., riluzole, topiramate).*
Strategies Only for Little or No Response
• Switch to D-amphetamine monotherapy.*
• Switch to tramadol monotherapy.*
• Switch to ondansetron monotherapy.*
• Switch to an MAOI.*
After first- and second-line strategies have been exhausted, other options
that may be considered include transcranial magnetic stimulation,* deep
brain stimulation,* and ablative neurosurgery.
FI G U R E 1 .
Algorithm for the Treatment of Obsessive-Compulsive Disorder (OCD)
Note. “Moderate response” means clinically significant but inadequate response.
*Treatment with little supporting evidence (e.g., one or few small trials or case reports or uncontrolled case series).
CBT =cognitive-behavioral therapy; ERP= exposure and response prevention; MAOI=monoamine oxidase inhibitor; SRI= serotonin
reuptake inhibitor; SSRI= selective serotonin reuptake inhibitor.
30
plasma concentration should be kept below 500 ng/mL to
avoid cardiac and central nervous system toxicity. Fluvoxamine most increases plasma clomipramine levels (178),
but substantial increases may occur with fluoxetine and
paroxetine. A screening electrocardiogram may be advisable in patients suspected of having heart disease or in
patients over the age of 40. Pulse rate and blood pressure
should be monitored as the dose of clomipramine is increased.
Positive case reports exist for lithium augmentation,
and positive case series have been reported for buspirone
augmentation. However, small controlled but methodologically limited trials of lithium and buspirone augmentation
have been negative. Adding pindolol 2.5 mg three times
daily was effective in one small, double-blind, placebocontrolled trial (179) but not in another (180). A small, 12week, open-label study reported that augmentation of SRIs
with riluzole 50 mg two times daily was often helpful, but
methodological limitations prevent confidence that the benefit was due to riluzole itself (501). Small controlled augmentation trials with L-triiodothyronine and desipramine
have produced generally negative results, and a doubleblind, placebo-controlled trial found St. John’s wort to be
no better than placebo (181).
Adding once-weekly oral morphine sulfate 30–45 mg
to various SSRIs with or without other augmenting agents
was superior to placebo in a double-blind crossover study
(182). However, morphine sulfate should be avoided in
patients with contraindications to opiate administration,
including a history of substance or prescription medication abuse, psychosis, mania, antisocial personality disorder, chronic obstructive pulmonary disease, or cardiovascular compromise. In addition, the psychiatrist should
consider what precautions and documentation may be
needed—for example, those described by the American
Academy of Pain Medicine (www.painmed.org). In addition, positive case reports exist, along with a positive case
series, for monotherapy with the weak narcotic agonist
tramadol (183). And two small, double-blind, placebocontrolled, single-dose studies reported positive results
for D-amphetamine 30 mg in unmedicated OCD subjects
(184, 185). However, these drugs should be avoided in
some patients (e.g., those with a history of alcohol or
other substance abuse or dependence).
Other treatment strategies that are supported only by
case series, case reports, or small open trials—literatures
that are less likely to include negative experiences—include anticonvulsants, MAOIs, ondansetron, L -tryptophan, nicotine delivered via transdermal patch or chewing gum (186), and Kundalini yoga. For patients with
severe treatment-resistant OCD, partial hospitalization
APA PRACTICE GUIDELINES
(49, 187) and intensive residential treatment (48, 188,189)
have been used.
Other somatic therapies should be considered only after first- and second-line treatments and well-supported
augmentation strategies have been exhausted. With treatments such as these for which efficacy is uncertain, it is especially important to weigh the potential benefits against
the side effects and other risks of therapy. For example,
evidence for the use of electroconvulsive therapy (ECT) in
OCD is limited to a single case series using a nonstandard
form of ECT administration (190). In addition, ECT carries the risks of anesthesia and has side effects such as memory impairment. As a result, ECT cannot be recommended
for the treatment of OCD but may be considered for
treating co-occurring conditions for which it may be indicated (e.g., major depression, uncontrollable mania, and
schizophrenia) (191–194). Transcranial magnetic stimulation (TMS) is associated with less potential for side effects,
but evidence for its efficacy is limited. Deep brain stimulation (DBS), a reversible and adjustable neurosurgical intervention, has been reported to show efficacy in a few case series of individuals with severe, highly treatment-resistant
OCD (195) but also has potential side effects.
The efficacy of ablative neurosurgery (anterior capsulotomy, limbic leucotomy, cingulotomy, and gamma-knife
radiosurgery) in patients with severe, treatment-refractory,
or intractable OCD has been evaluated in case reports and
unblinded studies. Improvement rates have ranged from
35% to 50% (196–198). Although some studies report
relatively high rates of improvement, the unblinded nature of these studies and the ongoing treatment of many
patients limit interpretation of these results. In addition,
potential adverse events range from personality changes,
seizures, and hydrocephalus to transient mania and mild
transient side effects such as urinary dysfunction. The recent
development of less invasive (DBS) and non-invasive (TMS)
procedures makes it harder to consider ablative neurosurgery as an alternative for highly treatment-resistant or intractable OCD. For the time being, DBS and ablative neurosurgical treatment for OCD should be performed only
at sites with expertise in both OCD and these treatment
approaches.
C. DISCONTINUATION OF ACTIVE TREATMENT
Successful medication treatment should be continued 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. Successful ERP should be followed by monthly booster sessions for 3–6 months, or
more intensively if response has been only partial.
Practice Guideline for the Treatment of Patients With Obsessive-Compulsive Disorder
Four double-blind SRI discontinuation studies studied
different SRIs, used different designs (e.g., length of observation and method of placebo substitution), and had
different relapse definitions. These methodological differences have been associated with widely varying reported rates of relapse or discontinuation for insufficient
clinical response after double-blind switch to placebo,
ranging from 89% within 7 weeks to 24% within 28 weeks
(80, 199–201). An open discontinuation study also reported
significantly higher 6-month, 1-year, and 2-year relapse
rates for the patients whose SRI treatment was discontinued
(177). Thus, rates of relapse appear to be increased after
discontinuation of SRI treatment but cannot be precisely
specified. Given these observations, discontinuation of
pharmacotherapy should be carefully considered, and for
most patients, continued treatment of some form is recommended.
A review of CBT studies consisting of ERP (202) concluded that about three-quarters of patients receiving ERP
(with and without concomitant medication) were doing
well at a mean follow-up of a little more than 2 years after
III.
31
the index treatment course. The studies’ methodological
limitations make this finding inconclusive. In addition,
the relapse definition utilized in this review differs from
those used in the SRI studies, precluding comparison of relapse rates.
A multi-site study (123) found that responders to intensive ERP (with or without concomitant clomipramine)
had a significantly lower relapse rate and longer time to
relapse after treatment discontinuation than responders
to clomipramine alone (67). Post hoc analyses generally
supported these findings, albeit with substantial variability in observed relapse rates (203), depending on the specific definition of relapse.
Together, these data suggest that the response to CBT
consisting of ERP may be more durable, at least in the
short run, than response to some SRIs after these treatments are discontinued. However, the observed differences could be explained by other factors, including
differences in the intensity of treatment before discontinuation, the rate of medication taper, the subjects studied,
the length of follow-up, and the relapse criteria.
SPECIFIC CLINICAL FEATURES INFLUENCING
THE TREATMENT PLAN
Many of the clinical features that will influence the treatment plan have been mentioned in describing the choice
of a treatment setting and methods of enhancing adherence. Additional features are described below.
A. PSYCHIATRIC FEATURES
In suggesting treatments for adults, the clinician should
consider the patient’s response to past treatments, including the benefits and side effects, and the patient’s motivation and ability to adhere to pharmacotherapy and psychotherapy. As noted, educational efforts are a standard
treatment element and enhance treatment motivation. An
unstable or stressful living situation diminishes the chances
of successful treatment and may require concomitant interventions such as family therapy.
Assessing the patient’s degree of insight is useful because it may influence willingness to cooperate with treatment. The Brown Assessment of Beliefs Scale (204) and
the Overvalued Ideas Scale (OVIS) (205) provide quantitative measures. Poor insight is associated with poorer response to SRIs in most studies (71, 206) but not all (207),
and poorer response to CBT in some studies (208) but not
others (209–211).
Patients appear to be less likely to benefit from medications, CBT, or combined treatment (212) if their predominant or only OCD symptom is hoarding (i.e., acquiring or accumulating items such as newspapers, magazines,
books, packaging, old clothing, notes, and lists that are
beyond reasonable need or of little objective value). Such
individuals may be less responsive to treatment than patients with other symptom patterns because they usually
demonstrate less insight, less distress, and therefore less
motivation for change (45, 213–217). A recent study, however, found that OCD patients who hoard responded as
well to pharmacotherapy as did OCD patients with other
symptom types (218). Differences in the underlying neurobiology (219) or OCD-related genetics (220) of hoarding patients compared with nonhoarding patients may
also play a role. Specific treatment programs that achieve
benefit with hoarding patients have been described (33,
150, 221, 222) but not tested in controlled trials. The Appendix includes a helpful Web site (San Francisco Bay
Area Resource & Internet Guide for Extreme Hoarding
Behavior, Clutterers Syndrome, or Pack Rat Syndrome).
1. Chronic Motor Tics
Co-occurring chronic motor tics in the absence of Tourette’s disorder have been shown to decrease the likeli-
32
hood of response to fluvoxamine (154, 223) but not to clomipramine (224). Patients with OCD who do not respond
to an SRI and have co-occurring tics may benefit from the
addition of an antipsychotic drug (154, 225). Although tic
onset or exacerbation during SSRI treatment is reported
in isolated cases (226, 227), trials of SSRIs should not be
withheld from OCD patients with co-occurring motor tics.
2. Tourette’s Disorder
OCD co-occurring with Tourette’s disorder can be treated
with SRIs, which usually have little effect, either positive
or negative, on the tic symptoms (225). When the OCD fails
to respond after one or two adequate SRI trials, adding a
first-generation (typical) or second-generation (atypical)
antipsychotic drug in a low to modest dose may ameliorate
both disorders (225).
3. Major Depression
Co-occurring major depression does not adversely affect
the response of OCD to SRIs (71, 228). When the OCD
responds well and the major depression does not, the clinician has many choices, none of which have been studied
in large double-blind trials. As a result, it is reasonable to
apply the treatment strategies outlined in APA’s Practice
Guideline for the Treatment of Patients With Major Depressive
Disorder (192). These include using psychotherapies that
are effective in treating depression (i.e., interpersonal
psychotherapy, CBT, or short-term psychodynamic therapy), increasing the SRI dose, adding an antidepressant
from another class, adding an augmenting agent, or, in patients with severe, treatment-resistant, or suicidal depression, utilizing ECT (191). In many trials of CBT (229–231),
but not all (232), co-occurring major depression has been
associated with a poorer OCD outcome. Severe depression clearly interferes with CBT (233). Thus, it may be
useful to utilize antidepressant medication, and particularly
SRIs, to treat co-occurring major depression before or during a trial of CBT.
4. Bipolar Disorder
Treatment of patients with both OCD and bipolar disorder should include measures to achieve mood stabilization
before initiating treatment with agents, such as SRIs, that
may induce or exacerbate hypomania or mania. Stabilizing
the bipolar disorder may require a combination of medications, including lithium, anticonvulsants, and secondgeneration antipsychotic drugs (193). In bipolar OCD
patients, SSRIs appear to be less likely than clomipramine
to precipitate hypomania or mania (29). Potential drug
interactions should be carefully considered when clomipramine, fluoxetine, fluvoxamine, paroxetine, or sertraline are considered for use in combination with these
agents.
APA PRACTICE GUIDELINES
Episodic OCD, characterized by periods of markedly
different symptom severity independent of OCD treatment, appears to be considerably more common in OCD
patients with bipolar disorder (29). Thus, a history of episodic OCD should raise the psychiatrist’s suspicion that
co-occurring bipolar disorder may be present. Perhaps as
a result of co-occurring bipolar disorder, patients with episodic OCD appear to be more likely to suffer from alcohol
abuse or dependence, panic disorder, and agoraphobia
(29), which will also require treatment.
5. Panic Disorder
Co-occurring panic disorder may respond to the SRI utilized to treat the patient’s OCD (234) or to CBT for panic
(235). When co-occurring panic disorder or a history of
panic attacks is present, SRI treatment should be initiated
at low doses, and the dose should be slowly titrated upward over a period of weeks, in order to avoid initiating
or exacerbating panic attacks (234). Alternatively, the clinician can start an SRI at usual doses combined with a benzodiazepine at antipanic doses for the first month or so and
then try tapering the benzodiazepine over a period of weeks
(234).
6. Social Phobia (Social Anxiety Disorder)
Co-occurring social phobia may respond to the SRI utilized to treat the patient’s OCD (236). However, in one
small study, OCD patients with co-occurring social anxiety disorder experienced a poorer response to SSRI treatment than those without this condition (237). Large,
double-blind, placebo-controlled studies support the effectiveness of escitalopram (238), fluoxetine (239), fluvoxamine (240), paroxetine (241), and sertraline (242), as well
as venlafaxine (243) and clonazepam (244), in treating social phobia. Phenelzine, while effective, cannot be combined with SRIs because the combination is likely to cause
the serotonin syndrome. Controlled trials suggest that social phobia also responds to cognitive-behavioral therapies (245).
7. Schizophrenia
The point and lifetime prevalences of obsessive-compulsive symptoms and of OCD in patients with schizophrenia
are elevated (246–248). In patients with co-occurring
schizophrenia, OCD or obsessive-compulsive symptoms
may be present independently or may be precipitated or
exacerbated by second-generation antipsychotic medications (249, 250). Clozapine is the second-generation antipsychotic most often reported to exacerbate obsessivecompulsive symptoms. However, case reports also describe
this effect with risperidone (251), quetiapine (252), and
olanzapine (253). Some patients with schizophrenia have
insight into the irrationality of their obsessions and com-
Practice Guideline for the Treatment of Patients With Obsessive-Compulsive Disorder
pulsions while lacking insight into their schizophrenic delusions. In other patients, the obsessions and delusions become illogically linked, as for example when the patient
believes that obsessions have been inserted into his mind
by an external force or that his compulsive rituals control
world events. When clinically significant OCD or obsessivecompulsive symptoms are present independently, the psychiatrist must rely on clinical judgment in formulating a
treatment plan, since no large, controlled trials have been
conducted.
The patient’s antipsychotic regimen should first be stabilized. A review of the treatment literature (254) suggests
that SRIs are usually well tolerated and can be beneficial,
but isolated reports of psychotic exacerbation exist. As with
all use of combination pharmacotherapies, potential drug
interactions must be borne in mind. Olanzapine monotherapy has been beneficial in two case series. Adding fluvoxamine has been helpful in two open trials, as has adding fluoxetine, paroxetine, or sertraline in individual cases.
Case reports suggest that low doses of fluvoxamine (75–
300 mg/day) and slow upward titration are indicated (254).
When a second-generation antipsychotic drug induces
obsessive-compulsive symptoms, they may disappear within
a few weeks. If not, treatment options include adding an
SRI, switching to another second-generation antipsychotic, or attempting a trial of CBT. No controlled trials
exist to guide treatment planning, but reviewing the results of published cases (249, 254) may be helpful.
8. Substance Use Disorders
Because co-occurring alcohol or substance abuse or dependence can interfere with treatment adherence and response and bring risks of drug interactions, these disorders
must be treated either before or while treating the patient’s OCD. Several organizations have published guidelines to aid in treatment planning (255–257).
9. Autism and Asperger’s Syndrome
Repetitive thoughts and behaviors are common in children and adults with autism or Asperger’s syndrome. In a
recent study that carefully distinguished stereotypic behaviors and idiosyncratic interests from obsessions and
compulsions, only somatic obsessions and repetition rituals were more common in adults with OCD than in adults
with high-functioning autistic spectrum disorders (258).
An earlier study found that, compared with adults with
OCD, adults with autistic disorder had significantly more
ordering, hoarding, touching, and self-injurious behaviors (259). However, about half of the autistic individuals
in that study were either intellectually impaired, mute, or
both. Conversely, one study reported that about 20% of
OCD patients have autistic traits (260). One study found the
33
rate of OCD to be elevated in the parents of autistic children
with extensive rituals and restricted interests (261).
The SRIs have been effective in treating the repetitive
thoughts and behaviors associated with autism (262). In
two studies with autistic children, clomipramine was more
effective than either desipramine or placebo in reducing
repetitive and compulsive behaviors (263, 264). One controlled study found fluvoxamine to be significantly better
than placebo for decreasing repetitive behavior and aggression in adults with autistic disorder (265). In a randomized
controlled trial in children with Asperger’s syndrome, CBT
was effective in reducing obsessive-compulsive symptoms
and other forms of anxiety (266).
10. Personality Disorders
Although the majority of studies suggest that personality
disorders are common in patients with OCD (267), the literature is mixed with regard to their impact on the outcome
of pharmacotherapy and of CBT. Attempts to draw conclusions are hampered by methodological problems such as
small sample sizes, retrospective study design, poorly defined outcome criteria, difficulties in valid ascertainment of
these disorders (268), and differing diagnostic criteria and
lengths of follow-up. Some personality traits (e.g., passiveaggressive) and disorders (e.g., borderline personality disorder) have been reported to interfere with adherence to
treatment (269, 270). Other traits (e.g., the odd thinking
style in schizotypal personality disorder) or particular disorders (especially schizotypal personality disorder [271,
272]) have been associated with poor outcome for unclear
reasons in some, but not all, studies (269, 273). Thus, the
presence of a co-occurring personality disorder should not
prevent a trial of CBT and/or SRIs, but rather should alert
the clinician to consider whether to provide additional
treatments targeting the personality disorder. Obsessivecompulsive personality disorder, which may co-occur with
OCD, has, for example, been noted in case reports to respond to psychodynamic psychotherapy or individual psychotherapy with an expressive emphasis (274–276), to CBT
(277), and, in a case series, to SSRIs (278). Patients with
OCPD may feel threatened by a lack of control in therapy,
deny negative and painful feelings, intellectualize feelings,
or resist becoming “dependent” on medications or therapy.
Strategies to enhance the therapeutic work with these patients include respecting the patient’s defenses, helping the
patient accept his or her humanness, enlisting the patient’s
collaboration in treatment planning, and empathizing with
the patient’s feelings of shame and fear (119).
11. Neurological Conditions Inducing OCD
OCD or obsessive-compulsive symptoms not meeting
DSM-IV-TR diagnostic criteria can be manifestations
34
of a number of neurological conditions, including brain
trauma, stroke, encephalitis, temporal lobe epilepsy, PraderWilli syndrome, Sydenham’s chorea, carbon monoxide
poisoning, manganese poisoning, and neurodegenerative
diseases such as Parkinson’s disease and Huntington’s disease (33, 279, 280). Treatment is first directed to the underlying neurological condition when this is possible.
When OCD symptoms persist after treatment or stabilization of the underlying condition, isolated case reports
suggest that treatment with an SRI and/or CBT may be of
some benefit. No controlled treatment trials have been
conducted in patients with OCD induced by neurological
conditions.
B. DEMOGRAPHIC AND PSYCHOSOCIAL FACTORS
1. Gender
Gender does not appear to influence the likelihood of treatment response in OCD (71). However, men and women
may differ in their metabolism of psychotropic medications, including those used in treating OCD (281–283). In
addition, premenstrual worsening of OCD has been reported in from 20% (284) to 42% (285) of women and may
influence apparent treatment responses.
2. Ethnicity
Pharmacogenetic influences on the probability of therapeutic outcomes and adverse reactions to SRIs are beginning to be reported. Differences in neurotransmitter
transporter and receptor genotypes are beginning to be
implicated in predicting therapeutic response. In addition,
differences in the prevalence of cytochrome P450 (CYP)
slow, normal, extensive, and ultra-rapid metabolizers of
psychotropic medications, and hence in pharmacokinetic
contributions to rates of adverse events, are being associated with ethnicity (286). For example, data indicate that
13%–23% of Asians are CYP2C19 poor metabolizers
compared with 2%–5% of Caucasians, and thus should
receive about 60% of the average dose of clomipramine
(287). CYP2D6 poor metabolizers may require lower
doses of paroxetine, which is both an inhibitor and a substrate for this enzyme (287). In the future, identifying CYP
genotypes through approaches such as gene chips, may
help prevent adverse responses and metabolism-related
treatment failures. Although the data are too sparse to support guidelines at present, psychiatrists should remain alert
for helpful information.
3. Pregnancy and Breast-Feeding
For patients wishing to become pregnant, pregnant patients, and patients who are breast-feeding, CBT alone
should be considered. Deciding whether to start or stop a
APA PRACTICE GUIDELINES
psychotropic drug during pregnancy or breast-feeding requires making a risk-benefit assessment without having
complete information. Risks to the well-being of the fetus, the infant, and the mother occur whether medications
are started or stopped, since the mother’s health will influence the pregnancy outcome and postpartum infant
care. A model to integrate and weigh the decision-making
elements in this situation has been proposed (288). In counseling the patient and her concerned others, the physician
should provide clear summaries of the available data and,
if desired, aid in obtaining more detailed data (289) and
provide counseling over several sessions to help the patient
come to terms with the uncertainty of the risks. Two helpful Web sites are listed in the Appendix. Consultation with
the patient’s obstetrician-gynecologist should be offered.
Because OCD patients are often quite anxious, experience doubting, and can suffer from perfectionism or a
need for certainty, helping the patient and her significant
other reach an informed decision may take several sessions. Documentation of the information provided and
the clinical rationale for the chosen treatment approach is
advisable.
OCD symptom onset during pregnancy has been reported in 13% (285) to 39% (290) of women with OCD
who have been pregnant. The severity of pre-existing OCD
is usually unaffected by pregnancy but has been reported
to worsen in from 8% (284) to 17% (285) of women with
OCD who are pregnant and to improve in 14% (285).
The available data suggest that exposure to tricyclic
antidepressants (TCAs), fluoxetine, fluvoxamine, paroxetine, or sertraline does not increase rates of intrauterine
death (288, 291). Whether SRI exposure decreases birth
weight or increases rates of premature delivery is unclear;
the data are conflicting (292). Available data do not suggest increased rates of major malformations after in utero
exposure to citalopram (293) or escitalopram (294); fluoxetine, sertraline, or TCAs (288, 295); or fluvoxamine
(296). However, the FDA has determined that exposure to
paroxetine in the first trimester of pregnancy may increase the risk for congenital malformations, particularly
cardiac malformations (www.fda.gov/cder/drug/advisory/
paroxetine200512.htm; accessed December 13, 2005).
Consequently, at the FDA’s request, the manufacturer has
changed paroxetine’s pregnancy category from C (“Risk
cannot be ruled out”) to D (“Positive evidence of human
fetal risk”).
A neonatal behavioral syndrome that includes central
nervous system, motor, respiratory, and gastrointestinal
signs may occur in neonates exposed to SRIs in the third
trimester. Although monitoring of exposed neonates is
warranted, this behavioral syndrome is usually mild and
is manageable with supportive care, and disappears by
Practice Guideline for the Treatment of Patients With Obsessive-Compulsive Disorder
2 weeks of age (297). Some evidence also suggests an increase in the likelihood of persistent pulmonary hypertension of the newborn when the patient receives an SSRI
during the third trimester (298). Since the severity of OCD
symptoms may not rapidly increase when medication is
tapered, tapering the patient’s SRI dose during the last
weeks of pregnancy may be considered.
The very limited data regarding long-term effects of
exposure throughout pregnancy to TCAs or SSRIs do not
suggest an elevated risk of abnormalities in cognitive function, language, temperament, or general behavior between
ages 15 and 71 months (299). In addition, one study found
no evidence for developmental delay at up to 2 years of age
associated with in utero exposure to TCAs, fluoxetine, sertraline, or paroxetine at varying times and for varying durations (295).
The pharmacokinetic, pharmacodynamic, and safety
considerations in administering SRIs and other psychotropic drugs in pregnancy (and during breast-feeding) are
reviewed elsewhere (300, 301). Although there are no data
specific to OCD, increases in the SSRI dose have been
needed in the early third trimester to maintain remission
in major depression. The relative safety of administering
first-generation antipsychotics, especially trifluoperazine
and perphenazine, during pregnancy is supported by a
large database (300). The data regarding second-generation
antipsychotics consist only of case reports and case series
totaling fewer than 100 children for any individual drug
except clozapine, for which the total approaches 150 children. The FDA classifies all second-generation antipsychotics as pregnancy risk Category C (“Risk cannot be ruled
out”), except clozapine, which is classified as Category B
(“No evidence of risk in humans”). Benzodiazepines are
apparently not associated with a significant risk of somatic
teratogenesis, but the risk of neurobehavioral effects is unclear because of conflicting reports (300, 302). The reviewers
recommend tapering these drugs before delivery when
possible and using benzodiazepines in FDA Category C
(i.e., clonazepam) or those with less potential for fetal accumulation (i.e., lorazepam and oxazepam).
The available data concerning the effects on the infant
of maternal SRI ingestion during breast-feeding are derived
from only a few hundred infants. The data suggest that
the risk of contemporaneous, noticeable effects is quite
low (300, 303). Cases of respiratory depression, hypotonia, poor feeding, irritability, and uncontrollable crying
have been reported (303). There are no reports of longterm adverse effects of exposure, but in the absence of large,
controlled trials or observational studies, caution remains
in order. The American Academy of Pediatrics Committee on Drugs recommends that a nursing mother be informed that the infant will be exposed to maternal medi-
35
cations (304). No consensus exists regarding how best to
measure infant exposure (305), but sertraline and paroxetine appear least likely to produce detectable or elevated
infant plasma drug levels (303). Monitoring maternal or
breast milk antidepressant levels is not recommended (303).
Discarding the breast milk 8–9 hours after taking sertraline reduces infant exposure by a little more than 15% (305).
Data helpful in evaluating the risks and benefits of taking
other psychotropic drugs during breast-feeding are reviewed elsewhere (300, 306).
4. Children and Adolescents
In children and adolescents, treatment should often start
with CBT or with a combination of psychotherapy and an
SRI (307). Cognitive-behavioral approaches consisting
primarily of ERP have been shown to be efficacious in
children (308–310), and three SSRIs and clomipramine are
FDA-approved for use in treating OCD in children (308,
311–313). Caution and frequent clinical monitoring are
advisable when treating children and adolescents with SRIs
because of the possibility of an increase in suicidal thinking or behaviors (314). However, using SRIs in treating
children and adolescents with OCD or major depression
may be necessary and should not be avoided when clinically indicated (315–320). As further information on the
treatment of OCD in children and adolescents is beyond
the scope of this guideline, the reader is referred to the
practice parameter of the American Academy of Child
and Adolescent Psychiatry (321).
5. The Elderly
No studies of treatment of OCD in the elderly have been
published. Experience with pharmacotherapy of other
psychiatric disorders in the elderly indicates that lower
starting doses of medication and a more gradual approach
to dose increases are often advisable in this age group. Advanced age may affect drug absorption, free drug concentration in plasma, the volume of distribution of lipid-soluble
drugs (leading to an increased half-life), and renal excretion rates (322–324). Although hepatic CYP enzyme activity does not regularly diminish with age, decreases in liver
mass or blood flow can lead to diminished rates of drug
metabolism. For example, diminished hepatic blood flow
in the elderly is associated with slower clearance of drugs
metabolized by CYP3A4 (e.g., alprazolam, triazolam, sertraline, and mirtazapine). Older patients may also be more
sensitive to adverse drug effects. In particular, elderly patients are more sensitive to anticholinergic effects of tricyclics, such as clomipramine, and of antipsychotic drugs.
They are also more sensitive to the sedative, cardiac, autonomic, and weight-increasing side effects of these drugs.
Because elderly patients are more likely to be taking medications for general medical conditions, the physician pre-
36
APA PRACTICE GUIDELINES
scribing anti-OCD medications will more often have to
consider potential pharmacokinetic and pharmacodynamic
drug interactions in these patients (73, 76, 283) (Section
II.B.2).
C. TREATMENT IMPLICATIONS OF CONCURRENT
GENERAL MEDICAL DISORDERS
Co-occurring medical conditions and any medications
being used to treat them must be considered when the
psychiatrist is choosing pharmacotherapies for OCD. In
particular, the effects of kidney and liver disease on drug
metabolism and the potentials for pharmacokinetic and
pharmacodynamic drug interactions must be reviewed.
SSRIs would be preferred over clomipramine in a) patients
with epilepsy, because of lower seizure risk; b) patients
with cardiac arrythmias, congestive heart failure, or blood
pressure abnormalities, because of relative cardiovascular
safety; and c) patients who are overweight, because of a
lesser likelihood of stimulating appetite. The psychiatrist
should recall that SSRIs have been associated with cases of
bradycardia, hypertension, hyponatremia, bleeding (325),
easy bruising, nausea, diarrhea, constipation, changes in
urination, extrapyramidal symptoms, and other symptoms that can be confused with manifestations of co-occurring medical conditions or treatments (33). SSRIs may
be used in patients with migraine headaches who are taking triptans (326). Moreover, they may also be used in patients with Parkinson’s disease, although there are isolated
case reports of worsened motor functioning (327, 328). In
patients with diabetes mellitus, it is important to select
second-generation antipsychotics that are least likely to
affect glucose metabolism and appetite (e.g., aripiprazole
and ziprasidone) (194, 329). In all cases, the potential for
interactions between the patient’s medical and psychiatric
medications should be reviewed.
Part B
BACKGROUND INFORMATION AND
REVIEW OF AVAILABLE EVIDENCE
IV.
DISEASE DEFINITION, EPIDEMIOLOGY, NATURAL HISTORY,
COURSE, AND GENETICS
A. DISEASE DEFINITION
The conceptualization of OCD has changed over the last
two centuries (330). Obsessions, marked by preserved
insight, were gradually distinguished from delusions;
compulsions were distinguished from various paroxysmal,
stereotyped, and impulsive behaviors. DSM-IV-TR identifies the essential features of OCD as “recurrent obsessions or compulsions (Criterion A) that are severe enough
to be time consuming (i.e., they take more than 1 hour a
day) or cause marked distress or significant impairment
(Criterion C)” (1, pp. 456–457). The full criteria set is
shown in Table 1. DSM-IV-TR describes obsessions as
intrusive, persistent, unwanted thoughts, impulses, or
images that give rise to marked anxiety or distress. Compulsions are physical or mental acts that the patient feels
driven to perform in order to magically prevent some
feared event, undo some thought, or reduce anxiety or
distress. Compulsive acts—also known as rituals—are carried out repetitively, excessively, and usually according
to rules or in a rigid manner. Compulsions are distinguished from repetitive behaviors motivated by pleasure
or gratification.
The psychiatrist should differentiate between obsessions and mental rituals or compulsions, since the CBT
approaches to these symptoms differ. Obsessions occur
spontaneously or are evoked by a feared environmental
stimulus or event and generate anxiety or distress. Mental
compulsions such as counting, praying, or reviewing actions, conversations, or lists are initiated by the patient willfully, albeit sometimes reluctantly, with the aim of feeling
safer or reducing anxiety or distress.
Practice Guideline for the Treatment of Patients With Obsessive-Compulsive Disorder
The DSM-IV (and DSM-IV-TR) diagnostic criteria
differ from those in DSM-III-R in allowing a diagnosis of
OCD when insight into the irrationality or excessiveness
of obsessions or compulsions is severely compromised or
absent. The field trial of the DSM-IV criteria (331) reported that 8% of OCD patients currently lacked insight and 5% had never had insight. Thus, DSM-IV and
DSM-IV-TR incorporate a specifier, “with poor insight,”
and allow an additional diagnosis of delusional disorder
(297.1) or psychotic disorder not otherwise specified
(289.9) when obsessions are of delusional quality. The
DSM-IV and DSM-IV-TR criteria also clarify that the
“neutralizing thoughts” mentioned in DSM-III-R are
mental compulsions, not obsessions.
The DSM-IV field trial revealed that most patients with
OCD have both obsessions and compulsions (331). It was
found that 96% of OCD patients had obsessions and compulsions, 2% had predominantly obsessions, and 2% had
predominantly compulsions, as determined by the Y-BOCS
Symptom Checklist. Patients varied with regard to which
symptoms were most troubling. Clinicians rated about 49%
of patients as troubled equally by obsessions and compulsions, nearly 30% as troubled predominantly by obsessions, and about 21% as troubled predominantly by
compulsions.
The most common themes of obsessions are fears of
contamination, of accidentally or purposely harming others, of making a significant mistake (e.g., leaving a stove
on, a door unlocked, a bill incorrectly paid, throwing away
something important), of committing a religious offense
or moral infraction, of contracting a disease, and of being
considered homosexual or committing homosexual or
pedophilic acts. Hoarding, when a symptom of OCD, is
not usually feared, though it may be regretted. In addition, individuals with OCD may obsess about orderliness
or symmetry, lucky or unlucky numbers or colors, needing to know or to remember (e.g., everything in the news
or every word in a movie), heterosexual acts, or bodily
health. Obsessions are often accompanied by a feeling of
doubt, uncertainty, or incompleteness that drives repetitive thought or action. Obsessive thinking is often colored
by an inflated estimate of danger, an increased sense of
responsibility, or a need for certainty or perfection. Reinvestigating the nature and extent of symptoms after a
therapeutic alliance has been established may be helpful
since patients may not reveal embarrassing symptoms in a
first visit.
Because compulsions are usually performed in response
to obsessions, the common themes are similar: cleaning,
checking, harm avoidance, undoing, asking for reassurance
or confessing, accumulating (hoarding), arranging, repeating, praying, and counting.
37
B. EPIDEMIOLOGY
Clinically significant OCD is not uncommon. For DSMIV OCD, the 1-month prevalence in adults is estimated to
be 0.6% (332). A large British epidemiological study utilizing ICD-10 diagnostic criteria (333) found a 1-month
prevalence of 1.1%. Estimates of the 12-month prevalence in adults range from 0.6% to 1.0% for DSM-IV
OCD (334, 335) and 0.8% to 2.3% for DSM-III-R OCD
(336). The World Health Organization places OCD among
the 10 most disabling medical conditions worldwide
(337), and the National Comorbidity Survey Replication
indicates that OCD is the anxiety disorder with the highest percentage (50.6%) of serious cases (338). The prevalence of DSM-IV OCD in children and adolescents is
discussed elsewhere (339, 340). A meta-analysis of followup studies of childhood-onset OCD found that at follow-up
periods of varying durations, mean persistence rates were
41% for full OCD and 60% for full or subthreshold OCD
(341).
The lifetime prevalence of OCD in adults is estimated
to be 1.6% (338). In contrast to the prevalence rates of
DSM-IV OCD, the mean lifetime prevalence of DSM-III
OCD was 2.5% across five U.S. catchment areas (336). The
lifetime prevalence rates of DSM-III OCD in seven countries ranged from 0.7% (in Taiwan) to 2.5% (in Puerto Rico)
(342). The differences in OCD prevalence rates between
studies using DSM-III and DSM-IV criteria have been attributed to refinements in diagnostic interviews and to
changes in DSM-III-R and DSM-IV that better define obsessions and compulsions and emphasize the degree of distress and impairment required for diagnosis (334). Whereas
the prevalence of clinical OCD is less than 3%, up to 80%
of the general population may experience intrusive, unpleasant, or unwanted thoughts (343), and about 50% may
engage in ritualized behaviors (344).
The mean age at OCD onset ranges in epidemiological
studies between 22 and 35 years, with at least one-third
of cases beginning by 15 years (342, 345). The National
Comorbidity Survey Replication reported a median age at
onset of 19 years, with 21% of cases starting by age 10 (335).
A second incidence peak occurs in both males and females
in middle to late age in some studies (346). However, others report that onset of OCD after age 50 is unusual (280).
Males generally have earlier onset of the disorder than
females, possibly contributing to a preponderance of
males in most clinical samples of children and adolescents
with OCD and of adults with early-onset OCD (347–
349). However, several epidemiological studies of children and adolescents reported equal rates in boys and girls
(339, 350). A slight female predominance is reported
in epidemiological studies by age 18 years (351), a pattern
38
found in most adult samples (342, 345, 346). The disorder
is evenly distributed across socioeconomic strata in most
studies, although there tends to be a paucity of minority
subjects in epidemiological and clinical studies in the
United States (336).
Although the symptoms of OCD are virtually identical
in children and adults, there appear to be important clinical differences between early- and late-onset OCD. Earlyonset OCD has been associated with higher symptom severity ratings (347, 352), higher rates of compulsions without obsessions (348), and higher rates of clinically significant obsessive-compulsive symptoms (347, 353). It has
also been associated with higher rates of co-occurring tic
disorders (354, 355), ADHD, and multiple anxiety disorders (356). Childhood onset of OCD may also be associated with a somewhat greater chance of poor response to
SRI treatment in adulthood (71).
There are no established environmental risk factors for
OCD. The role of stressful life events (including pregnancy and childbirth) as potential risk factors for OCD
still warrants further studies. However, streptococcal infection may be associated with a form of early-onset OCD that
involves an abrupt onset of obsessive-compulsive symptoms
and co-occurring tics, often abbreviated PANDAS for pediatric autoimmune neuropsychiatric disorder associated
with streptococcal infection (357–363).
C. NATURAL HISTORY AND COURSE
The methodological limitations of available studies hinder
attempts to describe the natural history and course of
OCD. These limitations include differences in sampling
settings; criteria for diagnosis, inclusion, improvement, or
deterioration; reliance on subjects’ recall of distant histories; and varying intervening treatment histories. Retrospective studies with a mean follow-up of at least 10 years
and conducted before effective pharmacotherapies became
available reported improvement rates of 32% to 74% (cited
in reference 46). In a unique study, one psychiatrist twice
evaluated 144 adult patients aged 19–52 years who had
been admitted for inpatient treatment of OCD symptoms
in Göteborg, Sweden, between 1947 and 1953. The first
evaluations occurred between 1954 and 1956 and the second between 1989 and 1993, providing follow-ups after a
mean of 47 years (46). After varying histories of treatment
or no treatment, about two-thirds of the patients improved within a decade of OCD onset, and 83% by the
end of the study. Nearly half (48%) experienced a “clinical
recovery” (no clinically relevant symptoms for ≥5 years),
but only 20% achieved a full remission (no symptoms in
the previous 5 years). At the second evaluation, 80% had
clinical symptoms (52%) or subclinical symptoms (obvi-
APA PRACTICE GUIDELINES
ous symptoms without distress or interference) (28%),
9% showed no improvement, and 8% had experienced a
deteriorative course. Of those who were ill at the first
evaluation (n=125), 50% had a chronic course (≥5 years of
continuous symptoms of the same degree), 25% an intermittent course (≥2 episodes with symptom-free intervals),
12% an episodic course (one episode lasting <5 years), and
2% were unspecified. Relapses occurred after 20 years of
remission in 17% of subjects. However, of those in remission at the first evaluation, 46% remained in remission for
at least 30 years. Retrospective diagnostic evaluation indicated that 85% of the subjects met DSM-IV diagnostic
criteria.
Similar statistics regarding course were reported for a
cohort admitted to the University of Pisa, Italy, outpatient
treatment program who met DSM-III-R diagnostic criteria and were followed up after at least 10 years of illness:
27% had an intermittent course (≥6 months of full symptom remission) [termed “episodic” by the study’s authors],
and 73% had a chronic course (stable or fluctuating symptoms or deterioration) (364). A U.S. study of 200 OCD
outpatients meeting DSM-III-R criteria reported that
85% had a continuous course with waxing and waning
symptoms, 2% had an episodic course with full remissions
of ≥6 months, and 10% had a deteriorative course (365).
Only one study has involved a long-term follow-up of a
community sample of OCD subjects (24). The number of
OCD subjects was, unfortunately, small (n = 22). The investigators attempted six evaluations over a 20-year period of OCD cases first diagnosed when the patients were
ages 19 and 20 years in Zurich, Switzerland. The long-term
outcomes were favorable. After a mean follow-up period
of 12.9 years, 86% had no symptoms, 9% had symptoms
and moderate distress, and only 5% met DSM-IV diagnostic criteria. Only one-third had received treatment. An
epidemiological study (333) showed that individuals with
OCD and other co-occurring disorders are much more
likely to seek treatment than are individuals with “pure”
cases (56% vs. 14%, P<0.001).
These studies suggest that individuals whose OCD or
co-occurring disorders lead them into treatment experience a more chronic and troubling course than do
individuals in all cases occurring before age 20 and ascertained through community survey. Only larger community studies can confirm or refute this impression.
D. GENETICS
1. Twin and Family Studies
The genetic epidemiology of OCD has been examined
in twin and family studies but not in adoption studies
(366). Both twin and family studies provide evidence that
Practice Guideline for the Treatment of Patients With Obsessive-Compulsive Disorder
genetic factors are involved in the transmission and expression of OCD. In two of the larger twin studies, concordance
rates ranged from 80% to 87% for monozygotic twins and
from 47% to 50% for dizygotic twins (367, 368). In a
study with 419 twin pairs, the heritability estimate for obsessive-compulsive symptoms was 47%, suggesting that
just under half of the phenotypic variation was due to genetic factors (369). In a study with 527 female twin pairs,
the best-fit model suggested heritabilities of 33% and 26%,
respectively, for factors roughly corresponding to obsessions and compulsions (370). By way of comparison, the
heritability of panic disorder has been estimated to be approximately 43% (366, 371, 372).
Controlled family studies using adult probands have
found that the lifetime prevalence of OCD is significantly
higher in case compared with control relatives (10.3%–
11.7% vs. 1.9%–2.7%) (373, 374). A meta-analysis of data
from five family studies with adult probands found a fourfold increase in the likelihood of OCD in case versus control first-degree relatives (366).
In family studies utilizing adult probands, an early age at
onset of obsessive-compulsive symptoms has been strongly
associated with a more familial form of OCD (373–376).
Although family studies using pediatric probands have often lacked control groups and yielded divergent results, a
recent controlled family study utilizing pediatric probands
found that the lifetime prevalence of OCD was significantly
higher in case compared with control relatives (22.5% vs.
2.6%) (377). A second recent family study also found in
case relatives, compared with control relatives, a higher agecorrected risk of OCD (22.7% vs. 0.9%) and chronic tics
(11.6% vs. 1.7%) (376). In addition, first-degree relatives
of probands with ordering compulsions had a significantly
higher lifetime prevalence of definite and subthreshold
OCD than did relatives of case probands without ordering
V.
39
compulsions (45.4% vs. 18.8%) (377). A similar pattern
with symmetry and ordering symptoms was noted in a segregation analysis of family data (378, 379). These findings
suggest that ordering compulsions along with hoarding
(45) may characterize a more familial and possibly more
etiologically homogeneous form of OCD.
2. Genetic Linkage and Candidate Gene Studies
A genome scan has found suggestive evidence for linkage
on chromosome 9p24 (380), which has been replicated by
an independent research group (381). Association studies
examining candidate genes in the 9p24 region have produced mixed results, with one study finding modest association at two microsatellite markers flanking SLC1A1 (381)
and another finding no evidence of association at two single
nucleotide polymorphisms (SNPs) in SLC1A1 intron 3
(382). SLC1A1, which codes for the glutamate transporter
EAAC1 (EAAT3), is the most promising candidate gene
in the region shared by the 9p24 linkage findings and the
reported 9p monosomy.
Numerous other studies have shown mixed results in
examining genetic loci mainly associated with serotonergic,
dopaminergic, or glutamatergic pathways or immunological processes, as functional candidate genes for OCD (e.g.,
see references 383–388).
Subgroups of individuals with OCD have also been examined for evidence of genetic linkages or the presence of
candidate genes. For example, a genome scan focused on
hoarding in affected sibling pairs with Tourette’s disorder
found significant allele sharing for hoarding phenotypes
for markers at 4q34–35, 5q35.2–35.3, and 17q25 (220). In
addition, a missense mutation described in the serotonin
transporter gene appears to be associated with a complex
neurobehavioral syndrome that includes OCD, social phobia, and Asperger’s disorder (389).
REVIEW AND SYNTHESIS OF AVAILABLE EVIDENCE
A. MEDICATIONS
The following sections review evidence on the outcomes
of pharmacological treatments for OCD. Unless otherwise indicated, outcomes are given for the intent-to-treat
(ITT) sample with the last-observation-carried-forward
(LOCF) method. ITT results inform the clinician of what
outcome to expect when considering all patients exposed
to a treatment. Results reported for patients who completed the study, by contrast, indicate what to expect for
those exposed to completed durations of treatment. Fi-
nally, visitwise outcome results indicate likely outcomes
for patients exposed to those particular durations of treatment. In considering “responder” rates reported in OCD
pharmacotherapy studies, it may be helpful to keep in
mind the responder rates reported in subjects in the placebo arms of such studies. As noted previously in Section
II.B.6, “responders” are variously defined as subjects who
experience a ≥25% or ≥35% decrease in Y-BOCS score or
a CGI-I score of 1 (very much improved) or 2 (much improved), usually after 12 weeks of treatment. In one analysis of studies published before 1997, responder rates in
40
placebo subjects ranged from 0% to 35% (mean 15%),
with later studies generally reporting higher placebo response rates (70). In the interest of brevity, the responder
criteria specified above are symbolized in this section as
follows: YBOCS-25%, YBOCS-35%, and CGI-I:1,2.
1. Efficacy of Clomipramine
Clomipramine is a mixed serotonin and norepinephrine
reuptake inhibitor (and cholinergic and histaminic blocking agent) introduced in Europe in 1966 for treating depression. It was subsequently used for OCD and was approved by the FDA in 1989 for the treatment of OCD in
the United States.
Randomized controlled studies have found clomipramine significantly superior to placebo in the treatment of
OCD. However, no adequate studies have determined the
minimally effective or optimal clomipramine dose. Trials
directly comparing clomipramine with certain SSRIs (e.g.,
fluoxetine, fluvoxamine, and paroxetine) report equal effectiveness. However, in some studies the SSRIs appear to
have better tolerability. Sample sizes limited the power of
most of these studies to detect differences, and most studies did not include a placebo comparison group. Thus, although clomipramine is recommended for treating OCD,
safety and tolerability issues favor the SSRIs.
The Clomipramine Collaborative Study (390), the first
large, double-blind, placebo-controlled trial in the United
States of a pharmacotherapy for OCD, was a landmark for
the treatment of OCD in general, and clomipramine treatment specifically. This 10-week, double-blind, placebocontrolled, multicenter study included 260 subjects in
each group. Subjects who had not received prior CBT or
clomipramine and scored ≥16 on the Y-BOCS and ≥7 on the
National Institute of Mental Health Obsessive-Compulsive
Scale (NIMH-OC) were included. Subjects took clomipramine at a dose of at least 200 mg/day or matched placebo,
with the opportunity to increase the dose to 300 mg/day.
The mean Y-BOCS score in the clomipramine group decreased 40% compared with 4% in the placebo group.
The YBOCS-35% responder rate in the clomipramine
group (55%) far exceeded that in the placebo group (7%).
In a 1-year extension (391) in a subsample (n =134) of participants in the Clomipramine Collaborative Study, OCD
symptoms fell to the subclinical range in 50% of the clomipramine group, compared with 4% of the placebo group.
CGI-I:1,2 responder rates for clomipramine were 50%
versus 7% for placebo. Adverse reactions, however, led
17 of the 129 (13%) subjects taking clomipramine to drop
out of the study.
Many additional randomized, double-blind, placebocontrolled studies or active-comparator studies support
the effectiveness of clomipramine treatment of OCD (70,
APA PRACTICE GUIDELINES
392, 392b). Taken together with the findings of the Clomipramine Collaborative Study, these studies indicate that
clomipramine at doses of up to 250 mg/day is an effective
treatment for OCD. Adverse effects, especially anticholinergic and cardiovascular effects and weight gain, are
common; however, dropout rates are not high except in
one study (393). Clomipramine may elevate levels of liver
transaminases, and a potential for seizures exists at doses
exceeding 250 mg/day.
Several studies have compared clomipramine with other
medications (also see Section V.A.2). Pigott et al. (394)
compared clomipramine 250 mg/day (n =5) and fluoxetine
40 mg/day (n=6) in a small crossover trial of 10 weeks on
each drug with a 4-week washout period interposed. The
Y-BOCS score decreased significantly in both groups,
with no between-group significant difference. LopezIbor et al. (395) found no difference in Y-BOCS score decrease in an 8-week, double-blind comparison of clomipramine 150 mg/day (n =25) and fluoxetine 40 mg/day
(n=30). The YBOCS-25%, but not the YBOCS-35%, responder rate was significantly higher for clomipramine. The
drugs did not differ in dropout rates. This study was, however, small, had no placebo control arm, and used low doses
of both medications.
A 10-week, multicenter, randomized controlled trial
(396) compared clomipramine (n =34; maximum dose =
250 mg) and fluvoxamine (n=30; maximum dose=250 mg).
All patients had a Y-BOCS score ≥16 at baseline, and half
of the patients had had prior treatment. Improvement in
Y-BOCS score was equivalent (fluvoxamine mean Y-BOCS
score decrease =8.6; clomipramine decrease= 7.8). Both
medications were well tolerated, but the clomipramine
group experienced more sexual dysfunction. In a 10-week,
multicenter, randomized controlled trial, patients scoring
≥16 on the Y-BOCS were treated with clomipramine
(n=65; maximum dose=300 mg, mean=206 mg) or fluvoxamine (n= 37; maximum dose= 300 mg, mean = 212 mg).
The drugs were equally effective (YBOCS-25% responder
rates for clomipramine and fluvoxamine were 56% and
54%, respectively). Both medications were well tolerated,
with no difference in dropout rates due to adverse events
(397). Another 10-week, multicenter, randomized controlled trial enrolling patients scoring ≥16 on the Y-BOCS
compared clomipramine (n =42; maximum dose=250 mg,
mean =255 mg) with fluvoxamine (n=37; maximum dose=
300 mg, mean = 201 mg). The drugs were equally effective, but fluvoxamine was better tolerated; constipation
and dry mouth were problematic in the clomipramine group
(398).
In a 12-week, double-blind, flexible-dose trial that
included a placebo arm, clomipramine (n = 99; 150–250
mg/day, mean =113 mg/day) and paroxetine (n=201; 20–
Practice Guideline for the Treatment of Patients With Obsessive-Compulsive Disorder
60 mg/day, mean =37 mg/day) produced equal Y-BOCS25% responder rates (55%), which were significantly higher
than that associated with placebo (35%) (393). Paroxetine
was significantly better tolerated than clomipramine; withdrawal rates for treatment-emergent adverse events were
17% for clomipramine, 9% for paroxetine, and 6% for placebo. However, the placebo group had more subjects with
“serious” treatment-emergent adverse events (6.1%) than
did the clomipramine (2.5%) or placebo (2.0%) groups.
At least five meta-analyses have evaluated randomized,
double-blind, controlled studies comparing clomipramine with SSRIs. A meta-analysis of studies comparing
clomipramine and fluoxetine reported a greater effect size
(Cohen’s d) for clomipramine (1.84) than for fluoxetine
(1.34) (399), but with fewer adverse events for fluoxetine.
Dropout rates did not differ. A later meta-analysis (400)
found the effect size (Cohen’s d) for fluoxetine (3.45) in
seven studies to be greater than that for clomipramine
(3.24) in 12 studies, with a lower dropout rate for fluoxetine subjects. Using data on subjects who completed the
studies, Abramowitz (69) found a modestly greater effect
size (Cohen’s d) for clomipramine than for certain SSRIs
(effects sizes: clomipramine vs. placebo, 1.31/0.66 [clinician rating/patient rating], fluvoxamine vs. placebo,
1.28/0.37; sertraline vs. placebo, 0.37/ 1.09; fluoxetine vs.
placebo, 0.68/[no patient rating done]). When the difference in side-effect profiles between clomipramine and
placebo was statistically adjusted to zero, the superiority
of clomipramine over the SSRIs disappeared. Eddy et al.
(59) also found a greater effect size (Cohen’s d) for clomipramine in analyzing 32 randomized controlled studies
(18 involving clomipramine) published between 1980 and
2001, enrolling 3,500 subjects. The pre-post clomipramine effect size was 1.55; the sertraline effect size (largest
among the SSRIs) was 1.36. This result must be viewed
with caution because more subjects in the clomipramine
trials were treatment naive, one-third of potential subjects
were excluded from the studies, and only 80% completed
the trials. A meta-analysis using meta-regression (effectsize modeling using least-squares regression) applied to
25 randomized controlled trials published between 1989
and 1997 found that the superiority of clomipramine over
fluoxetine, fluvoxamine, and sertraline in placebo-controlled trials persisted after heterogeneity effects were
controlled for (70). There was no significant difference
among the SSRIs in comparisons with placebo-controlled
trial results.
Several explanations have been proposed for this disparity in results between placebo-controlled and clomipramine-SSRI direct comparison studies. Abramowitz (69)
suggested that clomipramine’s apparent superiority may
have resulted from its more obvious side effects, thus di-
41
minishing the integrity of the blind in placebo-controlled
studies. Further doubt is cast on the larger effect size of
clomipramine compared with the effects of the SSRIs by
the fact that double-blind trials directly comparing clomipramine with fluvoxamine, fluoxetine, and paroxetine
showed no difference (70), and a double-blind comparison
with sertraline found sertraline more effective (401). This
latter result was strongly influenced, however, by inappropriately high starting doses of clomipramine (50 mg/day),
which led to a high dropout rate, and by low maximum
clomipramine doses. A meta-analysis using meta-regression
(70) found that age at onset, pre-trial OCD severity, date of
publication, trial length, and length of single-blind prerandomization each affected the magnitude of the treatment
effect; but after these predictive factors were controlled
for, clomipramine still appeared superior in comparisons
across placebo-controlled trials.
Clomipramine has been compared, albeit in methodologically limited studies, with the MAOIs clorgyline and
phenelzine. A small crossover study with 6-week drug
treatment periods found a significant effect for clomipramine but not for clorgyline (402). A 12-week randomized
trial comparing clomipramine 225 mg/day (n = 16) with
phenelzine 75 mg/day (n=14) found no difference, but the
study was very underpowered and used nonstandard outcome measures (403).
Foa et al. (123) compared clomipramine (n=36), intensive CBT consisting of ERP (n = 29), clomipramine plus
intensive ERP (n = 31), and placebo (n = 26). In this 12week randomized trial enrolling subjects with Y-BOCS ≥
16, no major depression, and no prior adequate treatment with clomipramine or ERP, clomipramine was
more effective than placebo. Intensive ERP combined
with clomipramine was more effective than clomipramine
alone but was not more effective than intensive ERP
alone.
a.
Intravenous Clomipramine
A few investigators have studied the effects of intravenously administered clomipramine, which produces higher
immediate plasma levels by avoiding first-pass liver metabolism. However, this treatment is not available in the
United States. In controlled trials, intravenous clomipramine has been shown to be superior to placebo in treatment-resistant patients (404). Pulse-loaded intravenous
clomipramine was more rapidly effective than identical oral
doses in a double-blind pilot study (405), but a larger study
did not confirm this finding (85). Both studies reported
therapeutic effects in some patients with very treatmentresistant OCD, suggesting that rapid escalation of oral
doses may help such patients. Pulse-loaded intravenous
clomipramine was more effective than gradually increased
42
intravenous clomipramine, and more rapidly so in a study
in which intravenous treatment was followed by treatment
with orally administered clomipramine (406).
b. Clomipramine as an Augmentation Agent
The strategy of adding clomipramine to an SSRI or vice
versa is supported by expert opinion (140, 175) and several
open-label trials. In a randomized, open-label, 90-day
trial that compared adding clomipramine or nothing to
citalopram in patients who had failed to benefit from adequate 16-week trials of both clomipramine and fluoxetine,
nine of nine patients in the clomipramine augmentation
group were YBOCS-35% responders, versus only one of
seven patients assigned to citalopram alone (176). In patients
with an inadequate response to 6 months of clomipramine
150 mg/day, Ravizza et al. (407) reported a better response
and fewer side effects when sertraline 50 mg/day was added
to clomipramine 150 mg/day than when the clomipramine
dose was raised to 250 mg/day.
2. Efficacy of SSRIs
a. Fluvoxamine
Double-blind, placebo-controlled, and active-comparator
studies indicate that fluvoxamine is significantly more effective than placebo and equal in efficacy to clomipramine
and certain SSRIs (citalopram, paroxetine), although the
sample size for the latter comparison was small. Compared with clomipramine, fluvoxamine showed fewer anticholinergic side effects and better tolerability. Whether
the combination of fluvoxamine and CBT (particularly
ERP) is more effective than CBT alone is uncertain because of methodological shortcomings in available studies.
An early double-blind, placebo-controlled trial (408)
reported positive findings when 42 OCD patients—half
of whom also had depressive symptoms—were randomly
assigned to receive fluvoxamine (up to 300 mg/day, mean
final dose=255 mg/day) or placebo for 6–8 weeks. Nine of
21 fluvoxamine patients were CGI-I:1,2 responders (mean
Y-BOCS score decrease from baseline= 42%) versus none
in the placebo group. The majority of week 6 partial responders became full responders at week 8 of fluvoxamine
treatment, suggesting that at least 8 weeks of treatment
are needed to detect a full clinical response.
A 10-week, double-blind trial (409) randomly assigned
40 OCD subjects to receive fluvoxamine (up to 300 mg/day,
mean maximum dose = 294 mg/day) or placebo and reported a statistically significant greater improvement for
fluvoxamine than for placebo on Y-BOCS and NIMHOC but not CGI measures.
Two pivotal 10-week, multicenter, double-blind, placebocontrolled studies with identical study protocols provide
convincing evidence for the therapeutic efficacy of fluvox-
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amine in OCD (410, 411). Subjects met DSM-III-R criteria for OCD of at least 12 months’ duration and had an
NIMH-OC scale score of ≥7 and a 17-item Hamilton Depression Rating Scale (Ham-D) score of ≤19. Seventy-nine
(410) and 78 (411) fluvoxamine-treated subjects and 78 (410)
and 80 (411) placebo-treated subjects completed the studies. Fluvoxamine was flexibly titrated to 100–300 mg/day.
At week 10, the mean fluvoxamine doses were 245 and 251
mg/day, at which time the mean Y-BOCS score had fallen
21% in the fluvoxamine groups compared with 7% in the
placebo groups (among patients who received at least one
postbaseline rating). A statistically significant difference
between the two groups was first observed at week 6.
CGI-I:1,2 response (ITT) was achieved in 33% and 38% of
fluvoxamine subjects compared with 9% and 15% of placebo subjects.
In the largest double-blind, placebo-controlled fluvoxamine trial (412), 253 OCD subjects were randomly assigned
to receive fluvoxamine controlled release or placebo (efficacy analyses: n= 237, 117 fluvoxamine controlled release,
120 placebo). After 12 weeks, fluvoxamine was significantly more effective than placebo on all efficacy measures,
including the Y-BOCS and CGI scales. YBOCS-25% and
YBOCS-35% response rates were significantly higher in
the fluvoxamine group, as were remission rates (44% vs.
31% and 18% vs. 8%, with Y-BOCS score definitions of
≤16 and ≤8, respectively). Therapeutic effects were evident at week 2, which is earlier than reported in other fluvoxamine versus placebo studies, with the earlier onset of
effects perhaps attributable to the higher starting dose
(100 mg/day). Fluvoxamine, although having more side
effects (e.g., insomnia, nausea, somnolence) than placebo,
was safe and generally well tolerated.
In double-blind, active-comparator studies, fluvoxamine
was superior to desipramine and as efficacious as other
SRIs (clomipramine and some SSRIs); however, the lack
of placebo control groups prevents calculating the net
drug effect (i.e., active drug effect minus placebo effect).
In an 8-week trial (413), OCD subjects were randomly
assigned to receive fluvoxamine (up to 300 mg/day, mean
final dose=214 mg/day) or desipramine (up to 300 mg/day,
mean final dose= 223 mg/day). Forty subjects completed
at least 2 weeks of treatment and were included in the efficacy analysis. The mean Y-BOCS score decreased 29%
from baseline in the fluvoxamine group and was virtually
unchanged in the desipramine group.
In a 12-week trial (414), 12 OCD subjects were randomly assigned to receive fluvoxamine or clomipramine
(both up to 200 mg/day). For the 10 subjects who completed the study, the Y-BOCS score decreases were similar
in the treatment groups; however, the small number of
subjects limits the power to detect differences.
Practice Guideline for the Treatment of Patients With Obsessive-Compulsive Disorder
In a 10-week multicenter trial (396), fluvoxamine (up
to 250 mg/day, mean final dose=200 mg/day) was as effective as clomipramine (up to 250 mg/day, mean final dose=
200 mg/day). Endpoint Y-BOCS scores among the 64
randomly assigned subjects with at least one postbaseline
rating did not significantly differ between the two treatment groups. Fluvoxamine produced fewer anticholinergic side effects and less sexual dysfunction than clomipramine. These findings were replicated in a subsequent
10-week study (397) that involved 79 OCD subjects randomly assigned to receive fluvoxamine (up to 300 mg/day,
mean final dose = 225 mg/day) or clomipramine (up to
300 mg/day, mean final dose= 201 mg/day). Among the
73 subjects with at least one postbaseline rating, the percentage of Y-BOCS-25% responders in the two groups
showed no difference at any time. The mean Y-BOCS score
decrease was 30% in both treatment groups. The fluvoxamine group experienced fewer anticholinergic side effects.
In a large, 10-week, multicenter, double-blind trial,
227 OCD subjects were randomly assigned to receive
fluvoxamine (up to 300 mg/day) or clomipramine (up to
300 mg/day) (415). Both groups experienced a marked
improvement in OCD as evidenced by Y-BOCS, NIMHOC, and CGI scores. Fluvoxamine was better tolerated
primarily because troubling anticholinergic side effects
were more common in the clomipramine group. In a small,
10-week, single-blind trial, 30 OCD patients were randomly assigned to receive fluvoxamine (up to 300 mg/day,
mean final dose=290 mg/day), paroxetine (up to 60 mg/day,
mean final dose = 53.3 mg/day), or citalopram (up to
60 mg/day, mean final dose = 50.9 mg/day); all patients
completed the study (416). At trial endpoint the percentage of responders (with response defined as YBOCS-35%
and a CGI-I score ≤3 [minimally improved]) showed no statistically significant differences, suggesting similar effectiveness. However, the small number of subjects in each
group severely limited the power to detect differences between the drugs.
Two double-blind studies compared the efficacy of fluvoxamine combined with different forms of CBT to the
efficacy of CBT alone or of CBT combined with placebo.
In a combined single- and double-blind trial, 60 patients
were randomly assigned to receive fluvoxamine and antiexposure therapy, fluvoxamine and ERP, or placebo and ERP
(165). Pharmacotherapy (fluvoxamine up to 300 mg/day,
mean dose=282 mg/day) lasted for 24 weeks. The medication was then tapered over a 4-week period and discontinued, and patients were then free to seek treatment as
desired. Evaluations were conducted after 2 months of
active treatment (n=50) and at the end of active treatment
(6 months, n=44). Follow-up evaluations by a blinded rater
were done at 1 year (n= 37) and 18 months (n= 33). Flu-
43
voxamine with ERP and fluvoxamine with antiexposure
therapy yielded greater reduction in rituals at week 8 than
placebo with ERP, but this superiority disappeared at
1 year. By week 24, all treatments had reduced OCD symptoms, with no significant between-group differences.
Fluvoxamine plus antiexposure and fluvoxamine plus
ERP had more effect on depressive measures than did
ERP plus placebo. However, the lack of a standard response measure (Y-BOCS), the small number of subjects
in each treatment group, and varying treatments subjects received during follow-up limit interpretation of the
results.
Hohagen et al. (164) randomly assigned 60 OCD inpatients to receive 10 weeks of either fluvoxamine (up
to 300 mg/day, mean dose=288 mg/day) plus CBT or placebo plus CBT. The CBT consisted of therapist-aided ERP
plus cognitive restructuring. In the 49 patients who completed the study, both treatments significantly reduced
OCD symptoms. However, there were significantly more
YBOCS-35% responders in the fluvoxamine plus CBT
group (87.5%) than in the placebo plus CBT group (60%).
Post hoc analyses suggested that patients with OCD and
depression benefited more from fluvoxamine plus CBT
than from placebo plus CBT. However, this conclusion
must be viewed cautiously, as no information was given on
the two groups’ degree of response to prior treatments,
and the analyses excluded nine subjects in order to equalize
the two groups’ baseline Y-BOCS scores.
Van Balkom et al. (61) randomly assigned 117 outpatients to five treatment conditions: fluvoxamine plus cognitive therapy, fluvoxamine plus self-guided ERP, cognitive therapy alone, self-guided ERP alone, or an 8-week
wait-list control. Fluvoxamine was titrated to 300 mg/day,
with a mean endpoint dose in the two drug groups of 197
mg/day. Pharmacotherapy lasted 16 weeks, and a naturalistic follow-up measurement was made at 6 months. Completer and ITT analyses posttreatment revealed no differences in effects (Y-BOCS, SCL-90, BDI) between the
four active treatment conditions; however, this result may
be due to inadequate power. Overall, 36% of subjects who
completed the study were responders (Y-BOCS score ≤12
and ≥6-point improvement). No evidence was found that
the combination of fluvoxamine with cognitive therapy or
ERP was superior to the cognitive therapy or ERP alone.
However, neither the ERP nor the fluvoxamine dosing
was optimized. Moreover, because of the absence of a
group treated with fluvoxamine alone and of a control
group for the duration of the study, the differential efficacy of fluvoxamine, cognitive therapy, or self-guided ERP
at week 16 cannot be determined.
A recent follow-up study (66) assessed 62 OCD subjects who completed controlled trials (23 treated with CBT
44
consisting of ERP alone, 24 with SRI alone [fluvoxamine
or clomipramine], 15 with ERP plus medication) and found
that most subjects showed long-term improvement following either ERP or medication treatment. The small
number of patients in each group, however, limited the
power to detect differences between the groups.
One fluvoxamine study supports the hypothesis that
OCD with co-occurring chronic tic disorders may be a
clinically meaningful subtype. An 8-week open-label trial
(223) assessed the efficacy of fluvoxamine in 66 OCD patients, of whom 33 had tic disorders. Of the OCD patients
with co-occurring chronic tic disorders, 21% were fluvoxamine YBOCS-35% and CGI-I:1,2 responders compared with 52% of the OCD patients without co-occurring chronic tics. The authors concluded that fluvoxamine
monotherapy may be less efficacious in OCD patients
with tics than in those free of this condition. A clomipramine study, however, found no reduction in effectiveness
in OCD patients with tics (224).
b. Fluoxetine
Three randomized, double-blind, placebo-controlled studies show that fluoxetine is significantly more effective than
placebo. In addition, double-blind active-comparator studies suggest fluoxetine is comparable in efficacy to clomipramine and sertraline and superior in efficacy to phenelzine.
Compared with clomipramine, fluoxetine exhibited fewer
side effects in one study. In other studies, fluoxetine was
well tolerated, with side effects comparable to those of the
comparator drugs.
Two large, randomized, double-blind, placebo-controlled studies demonstrated the effectiveness of fluoxetine in the treatment of adults with DSM-III-R OCD.
In an 8-week double-blind study (417), 214 subjects were
randomly assigned to receive fluoxetine 20, 40, or 60 mg/day
or placebo. Fluoxetine response (defined as YBOCS-25%
and CGI-I:1,2) rates were significantly higher in the
40 mg/day and 60 mg/day groups (48% and 47%, respectively) than in the placebo group (26%), but the response
rate in the 20 mg/day group (36%) was not. In a 16-week
extension, subjects who had not responded to 20 mg/day
or 40 mg/day and who took fluoxetine 60 mg/day experienced a highly significant decrease in Y-BOCS scores.
Fluoxetine and placebo dropout rates did not differ significantly.
A 13-week, randomized, double-blind trial (83) assessed
the effects of fluoxetine 20, 40, or 60 mg/day versus placebo in 355 outpatients with OCD. At each dose, fluoxetine was significantly superior to placebo on the Y-BOCS
and other efficacy measures, with statistical significance
reached by week 5. The fluoxetine groups had YBOCS35% response rates of 32%, 32%, and 35%, respectively,
APA PRACTICE GUIDELINES
with a trend for greater improvement in the 60 mg/day
group. The YBOCS-35% response rate in the placebo
group was 8.5%. The safety and efficacy of fluoxetine in the
acute treatment of OCD are further supported by open trials (418–421).
Two studies compared fluoxetine with clomipramine in
the treatment of DSM-III-R OCD without using a placebo control group (394, 395). In the first study, involving
crossover designs with 10 weeks of treatment, 4 weeks of
drug washout, and samples of 6 and 20 subjects, fluoxetine
up to 80 mg/day was as effective as clomipramine up to
250 mg/day (394). Both drugs produced a significant decrease in the Y-BOCS score, although clomipramine was
associated with more adverse events. The second study, an
8-week, double-blind, randomized trial, compared fluoxetine 40 mg/day (n=30) with clomipramine 150 mg/day
(n= 25) (395). The two drugs appeared equally effective
over this short treatment period. The YBOCS-25% responder rate, but not the YBOCS-35% responder rate, was
higher with clomipramine. The discontinuation rates for
adverse events were 3% for fluoxetine and 4% for clomipramine.
A 24-week, randomized, double-blind trial compared
the efficacy and tolerability of fluoxetine (mean dose= 57±
23 mg/day) and sertraline (mean dose =140± 59 mg/day)
in outpatients with DSM-IV OCD (422). Equivalent and
significant improvement was found at week 24 in Y-BOCS
and NIMH-OC scale scores. Remission rates (defined as
Y-BOCS score ≤11 and CGI-I:1,2) at weeks 12 and 24 were
significantly higher for sertraline (36% vs. 22% at week
24). Subjects treated with sertraline showed an earlier improvement on some, but not all, efficacy measures. Both
medications were well tolerated; rates of discontinuation
due to adverse events were 14% for fluoxetine and 19% for
sertraline.
A 10-week randomized trial compared fluoxetine
80 mg/day, phenelzine 60 mg/day (both doses achieved
by the end of week 3), and placebo in 64 adults with
DMS-III-R OCD (423). Fluoxetine was superior to placebo at weeks 6 and 10 as well as to phenelzine at week 10.
Symmetry obsessions and lower baseline Y-BOCS scores
were significantly more common in phenelzine responders than in fluoxetine responders; however, this post hoc
analysis provides only weak evidence for a phenelzine effect in this subgroup.
The long-term treatment of OCD with fluoxetine has
been examined to a limited extent. In a continuation of the
13-week, double-blind, placebo-controlled, fixed-dose
fluoxetine study (83), treatment responders continued
their blinded treatment, whereas nonresponders began a
24-week open-label trial of maximally tolerated doses up
to 80 mg/day (81). Among acute-phase responders, all
Practice Guideline for the Treatment of Patients With Obsessive-Compulsive Disorder
three doses of fluoxetine (20, 40, and 60 mg/day) were associated with further Y-BOCS improvement. The acutephase nonresponders benefited from upward dose titration, with two-thirds achieving a YBOCS-35% response.
Another study assessed the efficacy and safety of 52 weeks
of fluoxetine or placebo treatment in patients with DSMIV OCD who had responded to single-blind fluoxetine
for 20 weeks (201). Patients who received fluoxetine had
numerically lower relapse rates compared with those who
received placebo, although the difference was not significant (see Section V.E for details).
c. Paroxetine
Three double-blind placebo-controlled trials show paroxetine to be more effective than placebo acutely; an additional double-blind study shows the superiority of
paroxetine relative to placebo in maintaining response
over 6 months of continuation treatment. A double-blind
active-comparator study suggests that paroxetine is comparable in efficacy to clomipramine. Compared with venlafaxine, the relative efficacy of paroxetine is less clear, as
findings vary with the definition of treatment response.
Paroxetine’s tolerability is comparable to that of other
SSRIs. Some evidence (424), but not all (80), suggests paroxetine is more likely to be associated with significant
weight gain. Paroxetine is more likely to induce anticholinergic side effects than are other SSRIs (118, 425). It
also carries a greater risk of an unpleasant withdrawal syndrome, comparable to the risk associated with venlafaxine
(426).
In a 12-week double-blind trial (80), OCD patients
without co-occurring major depression, tics, or Tourette’s
disorder were randomly assigned to receive paroxetine
20 mg/day (n=88), 40 mg/day (n=86), 60 mg/day (n=85),
or placebo (n=89). A little more than half of subjects had
had a prior SRI trial. Endpoint response rates (defined as
YBOCS-25% or Clinical Global Impression–Severity
[CGI-S] score decrease of ≥ 2 points) for paroxetine
40 mg/day (25%) and 60 mg/day (29%), but not 20 mg/day
(16%), were significantly greater than for placebo (13%).
In a 12-week, double-blind, flexible-dose study (427), 191
subjects were randomly assigned to receive placebo or
paroxetine, with the dose increasing from 20 mg/day to
40 mg/day by week 3 and up to 50 mg/day from week 8
onward. The CGI-I:1,2 response rate was significantly
greater in the paroxetine (50%) than in the placebo group
(24%). A significantly greater response rate was similarly
observed in subjects randomly assigned to receive 12 weeks
of flexibly dosed paroxetine 20–60 mg/day (mean dose=
37 mg/day) (n=201) or placebo (n=99) (393). More than
half (55%) of the paroxetine subjects were YBOCS-25% responders compared with 35% of placebo subjects. The ac-
45
tive comparator, flexibly dosed clomipramine (150–250
mg/day, mean dose= 113 mg/day), produced the same responder rate as paroxetine.
A 12-week, randomized, double-blind, flexible-dose
study (172) comparing paroxetine with venlafaxine found
no significant difference in YBOCS-35% responder rates
for paroxetine at doses up to 60 mg/day (44%) (n=76) and
venlafaxine at doses up to 300 mg/day (37%) (n=75), although the YBOCS-25% responder rate was higher for
paroxetine (66%) than for venlafaxine (49%). When the
medication for nonresponders in this study was switched
to the alternative medication in a double-blind fashion, a
higher YBOCS-25% responder rate was observed for paroxetine (56% [15/27]) than for venlafaxine (19% [3/19])
(171).
Long-term effectiveness of paroxetine has been observed in one study. Responders to paroxetine in a 12-week
double-blind study and its 6-month open-label, flexibledose extension phase (N = 105) were randomly assigned
to receive 6 months of double-blind paroxetine or placebo (80). Relapse was defined as a return to the baseline
Y-BOCS score or an increase of ≥1 point in the CGI-S
score for more than one visit. Subjects assigned to placebo
had a significantly higher relapse rate (59%) than those
assigned to paroxetine (38%). The mean time to relapse
was 29 days in the placebo group and 63 days in the paroxetine group.
d. Sertraline
Two double-blind, placebo-controlled trials demonstrated
the efficacy of sertraline in treating OCD. In double-blind
active-comparator studies, sertraline appeared comparable in efficacy to fluoxetine. Sertraline was superior in efficacy to clomipramine (although methodological shortcomings influenced the latter comparison) and, in subjects
with co-occurring depression, was superior to desipramine.
Finally, in an open-label trial, subjects who responded to
1 year of treatment with sertraline experienced further
small but noticeable decreases in symptoms when treatment was extended to 2 years.
In a 12-week, randomized, fixed-dose trial (82), subjects were assigned to sertraline 50 mg/day (n= 80), 100
mg/day (n= 81), 200 mg/day (n= 80), or placebo (n = 84).
Sertraline at doses of 50 mg/day and 200 mg/day was
significantly superior to placebo with regard to change
in Y-BOCS, NIMH-OC, CGI-S, and CGI-I scores, but
at 100 mg/day sertraline was only superior in terms of the
NIMH-OC, probably because of the high dropout rate
(33%) in this group. At endpoint, CGI:1,2 responder rates
were 39% for sertraline and 30% for placebo. A 12-week,
double-blind, randomized study of flexibly-dosed sertraline 50–200 mg/day (mean maximum dose at endpoint =
46
165±55 mg/day) found the drug (n=86) more effective than
placebo (n=81) with regard to change in Y-BOCS, NIMHOC, and CGI-S scores (428). The CGI-I:1,2 responder rate
was numerically but not significantly higher for sertraline
(41%) than for placebo (23%).
In a 24-week, double-blind, randomized, flexible-dose
comparison of sertraline 50–200 mg/day (mean endpoint
dose= 140 ± 59 mg/day) (n = 77) versus fluoxetine 20–80
mg/day (mean endpoint dose=57±23 mg/day), the differences in CGI-I:1,2 responder rates (60% and 60%) and
remission (defined as CGI-I:1,2 plus Y-BOCS <12) rates
(36% vs. 22%) were not significant (422).
A 16-week double-blind study compared sertraline and
clomipramine 50 mg/day for 4 weeks followed by flexible increases in dose to 200 mg/day (mean final dose =
132 mg/day for sertraline and 101 mg/day for clomipramine) (401). The sertraline group had significantly greater
improvement as measured by the Y-BOCS, NIMH-OC,
and CGI-S. Inappropriately high starting doses of clomipramine (50 mg/day), producing a high dropout rate
and low maximum clomipramine dose, strongly influenced the comparative result. Among subjects treated for
at least 4 weeks, the two drugs produced equal results, but
the mean final clomipramine dose was relatively low. The
Y-BOCS-35% responder rates were 72% for sertraline and
65% for clomipramine.
In another double-blind, flexible-dose study (429),
OCD patients with co-occurring depression were randomly assigned to receive sertraline 50–200 mg/day (mean
endpoint dose=160± 50 mg/day) or desipramine 50–300
mg/day (mean endpoint dose= 194 ±90 mg/day). Sertraline (n=79) was more effective than desipramine (n=85) in
bringing about “robust improvement in OCD symptoms”
(Y-BOCS score decrease ≥40%).
A second completed year of continued treatment with
open-label sertraline flexibly dosed from 50 mg/day to
200 mg/day was associated with a mean decrease in Y-BOCS
scores from about 12 to about 9 in 38 subjects (430) who
had been CGI-I:1,2 responders in a 1-year, fixed-dose,
double-blind study (431).
Finally, after 1 year of single-blind treatment, sertraline responders rarely relapsed over 28 weeks regardless
of whether they were maintained on flexibly dosed sertraline (50–200 mg/day) (3/108, or 3%) or switched over
2 weeks to placebo (5/113, or 4%) (200) (see Section V.E.
for details).
e. Citalopram
A double-blind, placebo-controlled trial showed citalopram to be more effective than placebo, with a trend for
greater efficacy and more rapid response at a higher dose.
Several open trials suggest efficacy for citalopram in individuals whose OCD has not responded to other SRIs. In
APA PRACTICE GUIDELINES
addition, several open-label trials suggest comparable
efficacy to other SRIs. The active isomer in citalopram,
escitalopram, is now marketed as a separate SSRI in the
United States.
In the only double-blind, placebo-controlled, randomized trial, 12 weeks of treatment with fixed-dose citalopram
20 mg/day (n=102), 40 mg/day (n=98), or 60 mg/day (n=
100) produced higher YBOCS-25% response rates (57%,
52%, and 65%, respectively) than did placebo (n = 101)
(37%) (432). There were trends for the highest dose to be
associated with a more rapid response.
A small open-label trial suggests that citalopram (n=11;
mean dose=51 mg/day) and paroxetine (n =9; mean dose=
53 mg/day) bring about similar YBOCS-35% responder
rates (40% and 45%, respectively) in inpatients (416). The
response rate to fluvoxamine (n=10; mean dose=290 mg/
day) (60%) was numerically but not statistically significantly higher. An open-label, random-assignment, flexible-dose study utilizing a blinded rater found no significant difference in YBOCS-35% responder rates to 12 weeks
of citalopram 40–60 mg/day (n =23) (48%), fluvoxamine
200–300 mg/day (n=83) (55%), clomipramine 150–250 mg/
day (n= 37) (48%), or paroxetine 40–60 mg/day (n = 16)
(50%) (433).
An open-label trial of citalopram flexibly dosed from
20 mg/day to 60 mg/day (mean final dose=46 mg/day) reported that 22 of 29 (76%) patients who completed
24 weeks of treatment experienced a ≥ 50% decrease in
Y-BOCS score (434). Among 18 patients who completed
16 weeks of citalopram (20 mg/day for 2 weeks, then
40 mg/day) after nonresponse to two or three adequate,
6-month SRI trials (Y-BOCS decrease < 25% and score
≥21), 14 (78%) were CGI-I:1 responders (435). A shorter
12-week trial (176), using the YBOCS-35% definition, reported a lower responder rate: only one of seven (14%)
subjects who had failed to benefit (Y-BOCS score decrease
< 35%) from fluoxetine (≥20 mg/day for ≥12 weeks) and
from clomipramine (≥ 150 mg/day for ≥ 12 weeks) responded to citalopram (20 mg/day for 2 weeks, then
40 mg/day).
A single case report described a patient whose OCD
was unresponsive after 3 months of citalopram 80 mg/day
but subsequently responded to 160 mg/day, which was
well tolerated over several months (436). Intravenous citalopram (unavailable in the United States) was well tolerated in one study at doses of 20–80 mg/day and may have
a faster onset of action than oral citalopram (437).
Escitalopram was as effective as paroxetine for OCD in
a European multicenter double-blind, active-comparator
trial (437a) and was superior to placebo in preventing OCD
relapse in a second large European double-blind trial
(437b).
Practice Guideline for the Treatment of Patients With Obsessive-Compulsive Disorder
f. Venlafaxine
Venlafaxine is a serotonin-norepinephrine reuptake inhibitor (SNRI) that does not have an FDA indication for
OCD. A small, double-blind, placebo-controlled trial
with venlafaxine was negative, but several open-label trials
showed robust responses in OCD symptoms at doses of at
least 225 mg/day. In addition, double-blind active-comparator studies suggest venlafaxine is comparable in efficacy to clomipramine and perhaps to paroxetine. Venlafaxine has been generally well tolerated.
In the only double-blind, placebo-controlled trial (438),
30 OCD patients were randomly assigned to receive placebo or venlafaxine (up to 225 mg/day) for 8 weeks. At endpoint, there were no statistically significant differences in
response, although there was a trend for greater response
in the venlafaxine group. The study’s small sample size,
short trial length, low venlafaxine dose, and lack of standard outcome measures (Clinical Global Impression, ratings of avoidance) severely constrain interpretation.
In a 12-week, double-blind, active-comparator study
(172), 150 OCD patients were randomly assigned to receive venlafaxine XR (up to 300 mg/day) or paroxetine (up
to 60 mg/day). Full response was defined as a Y-BOCS
score decrease of ≥50% and partial response as a decrease
of ≥35%. An ITT LOCF analysis demonstrated no significant differences in responder rates (full response: 24%
venlafaxine vs. 22% paroxetine; partial response: 37%
venlafaxine vs. 44% paroxetine). Only a small percentage
of patients (5%) dropped out because of adverse effects.
The study’s methodological limitations include the absence of a placebo control group and venlafaxine doses not
exceeding 300 mg/day. In addition, the venlafaxine group
had undergone more unsuccessful medication trials.
Nonresponders (Y-BOCS decrease <25%) in this study
(n =43) were treated for 12 additional weeks with the alternative medication (171). A significantly higher proportion of those whose medication was switched to paroxetine
(56%, 15/27) were YBOCS-25% responders compared
with those whose medication was switched to venlafaxine
XR (19%, 3/16). However, the small sample size, the lack
of a placebo control group, and a less stringent response
criterion are methodological limitations in this second
study.
In a 12-week double-blind trial (173), 73 OCD subjects
were randomly assigned to receive venlafaxine (225–350
mg/day, mean dose=265 mg/day) or clomipramine (150–
225 mg/day, mean dose=168 mg/day). Visitwise and LOCF
analyses at study end revealed no statistically significant
difference between the groups in YBOCS-35% and CGII:1,2 responder rates (visitwise responder rates: venlafaxine 36% vs. clomipramine 50%; LOCF responder rates:
47
venlafaxine 35% vs. clomipramine 43%). The investigators concluded that venlafaxine at these doses may be as
effective acutely as clomipramine, with fewer side effects.
However, confidence in these results is again limited by
the lack of a placebo control group, the small size of the
study, and by the relatively low mean clomipramine dose.
An open, naturalistic, retrospective study examined
treatment results for 39 OCD patients (29 who were “nonresponders” [undefined] to one or more SRI trials) after
treatment for a mean of 18 months (range 1–56 months)
with venlafaxine up to 450 mg/day (mean final dose=230
mg/day) (439). At study end, 69% of subjects entering the
study were CGI-I:1,2 responders. Of note, 76% of the
“nonresponders” to one or more SRI trials, and 82% of
the “nonresponders” to two or more SRI trials were sustained responders. Venlafaxine even at the higher end of
the dosing range was well tolerated.
An 8-week open-label trial in which 12 OCD patients
were treated with venlafaxine 150–300 mg/day reported
responder rates of 75% (YBOCS-35%) and 35% (CGII:1,2) (440) without substantial side effects. A 12-week
open-label trial utilizing venlafaxine 150–350 mg/day
in 10 OCD patients reported responder rates of 30%
(YBOCS-35%) and 40% (CGI–I:1,2), with a more robust response in treatment-naive patients (441). Marazziti
(442) reported five patients whose OCD was resistant
to SSRIs who improved (Y-BOCS, Ham-D, and other
clinical evaluations) for at least 1 year with venlafaxine
150–225 mg/day.
3. Implementation of SRIs
Available trial data suggest that higher SSRI doses produce a somewhat higher response rate and somewhat
greater magnitude of symptom relief (79–82) (Table 5).
Among nonresponders, raising the dose of an SSRI is
associated with enhanced response (Table 6). The literature does not allow specification of the chance of response
as a function of the number of previously failed adequate
SRI trials. Attempts to interpret the clinical trial data are
limited by differences in the number of failed trials in patients included in a given study, by absence of information
about the number of failed adequate trials, by differences
in the definition of “failed,” and by the small, highly selected samples. However, clinical experience suggests that
patients who do not respond to one SRI may still respond
well to another (Table 7). With SRIs, response rates to a
second trial are close to 50% but may fall off as the number of failed adequate trials increases. A switch to venlafaxine at doses of 225–350 mg/day is also supported by active-comparator trials and open-label studies that suggest
its effectiveness in treating OCD.
48
APA PRACTICE GUIDELINES
TA B LE 5 .
Effects of Higher Selective Serotonin Reuptake Inhibitor (SSRI) Doses in Fixed-Dose Trials on Obsessive-Compulsive Disorder (OCD)
Drug
Study
Response Definition
Response
Achieved
Fluoxetine
Tollefson et al.
1994 (83)
YBOCS ↓
≥35% (mean ↓)
Citalopram
Montgomery et al.
2001 (432)
Sertraline
Paroxetine
Note.
Dose 1
Dose 2
Dose 3
Week 13
LOCF
20 mg
32%
(3.4 points)
40 mg
32%
(4.6 points)
60 mg
35%
(5.9 points)
YBOCS ↓
≥25% (mean ↓)
Week 12
LOCF
20 mg
57%
(8.4 points)
40 mg
52%
(8.9 points)
60 mg
65%
(10.4 points)
Greist et al.
1995 (431)
YBOCS
↓ in mean score
Week 12
LOCF
50 mg
~6.8 points
100 mg
~5.7 points
200 mg
~7.5 points
Hollander et al.
2003 (80)
YBOCS
↓ in mean score
Week 12
LOCF
20 mg
4.1 points
40 mg
6.4 points
60 mg
7.3 points
LOCF=last observation carried forward; YBOCS=Yale-Brown Obsessive Compulsive Scale.
4. Other Antidepressants
a. Monoamine Oxidase Inhibitors
There is only very weak support for the use of MAOIs in
OCD. In one small, double-blind, placebo- and fluoxetinecontrolled study, the Y-BOCS score decrease for subjects
completing a 10-week trial of phenelzine 60 mg/day (n=
17) was not significantly greater than for those completing placebo treatment (n=18), in contrast to the Y-BOCS
score decrease produced by fluoxetine 80 mg/day (n=19)
(423). In a post hoc analysis, the authors suggested that
symmetry obsessions might be a strong predictor of
phenelzine “response” (undefined). In a blinded, 12-
week, random-assignment, open-label comparison of
phenelzine 75 mg/day (n = 12 completers) and clomipramine 225 mg/day (n = 14 completers), with both doses
reached by week 5, no significant difference was found on
either the Maudsley Obsessional-Compulsive Inventory
(MOCI) or a nonstandard scale (403). The absence of a
placebo group, use of nonstandard rating scales, and small
sample size limit this study’s evidentiary weight. A case series (443) and isolated case reports add only minimal evidence of the effectiveness of MAOIs. The presence of severe anxiety or panic attacks or of symmetry obsessions
has been a positive predictor in some case reports.
Effects of Raising the Dose of Selected SSRIs in Nonresponders
T A BL E 6 .
Initial Phase
Drug
Fluoxetine
b
Continuation Phase
Duration
Dose
Duration
Dose
Responder
a
Rate (n)
13 weeks
20 mg
26 weeks
60 mg
80% (8/10)
80 mg
46% (15/33)
60 mg
20%c (1/5)
80 mg
53% (17/32)
80 mg
50% (15/30)
200 mg
34% (10/29)
377 mg
52% (11/21)
40 mg
60 mg
Sertraline
a
d
16 weeks
200 mg
12 weeks
c
c
c
c
e
Response defined as a decrease of ≥ 25% on the Yale-Brown Obsessive Compulsive Scale.
Tollefson et al. 1994 (83).
c
Last observation carried forward.
d
Ninan et al. 2006 (84).
e
Completers.
b
e
49
Practice Guideline for the Treatment of Patients With Obsessive-Compulsive Disorder
TA B LE 7 .
Chance of Responding to the Next Serotonin Reuptake Inhibitor (SRI) After Failure to Benefit From the Previous SRI
Responders
Drug Switched to
and Dose
Outcome
Measurement
Response
Definition
Rasmussen et al. 1997
(168)
Sertraline
50–200 mg
Week 12
Goodman et al. 1997
(87)
Fluvoxamine
50–300 mg
Ackerman et al. 1998
(169)
Study
Drug Naive
Drug Experienced
CGI-I=1,2
53%
(N=293)
33%
(N =172)
Week 10
CGI-I=1,2
50%
(N=126)
19%
(N=31)
Fluoxetine
20, 40, 60 mg
Week 13
YBOCS ↓
≥35%
42%
(N =83)
11%–27%
(N=19, 59)
Ravizza, cited in
Hollander et al.
2002 (170)
Venlafaxine
225–350 mg
Clomipramine
150–225 mg
Citalopram
40–60 mg
Week 12
YBOCS ↓
≥35%
—
38%
(N =8)
27%
(N=11)
11%
(N =9)
Koran et al. 2006
(85)
Clomipramine
100–250 mg
Week 13
YBOCS ↓
≥35%
—
34%
(N=32)
Denys et al. 2004
(171)
Paroxetine (P)
60 mg
Venlafaxine (V)
300 mg
Week 12
YBOCS ↓
≥25%
—
V →P 56%
(N=27)
P → V 19%
(N=16)
a
Note. CGI-I= Clinical Global Impression–Improvement; YBOCS=Yale-Brown Obsessive Compulsive Scale.
a
Eleven percent if previously treated with SRIs alone; 27% if previously also treated with CBT.
The side-effect burden of MAOIs can be significant and
includes cardiovascular problems and weight gain, as well
as potentially severe drug-drug interactions and dietary
restrictions associated with nonselective MAOIs or highdose selective MAOIs (444, 445). This burden, combined
with the relative lack of evidence for MAOI efficacy, argues against the use of these medications except in severely
ill OCD patients who have failed most or all first-line treatments and most second-line treatments.
b. Tricyclic Antidepressants
Limited investigations of TCAs other than clomipramine
have found no evidence for their efficacy in treating
OCD.
A randomized controlled trial comparing nortriptyline, clomipramine, and placebo with eight subjects in
each treatment group found that clomipramine, but not
nortriptyline, was superior to placebo in reducing interview-based ratings of OCD severity (446). However,
there was no significant difference in effectiveness between clomipramine and nortriptyline.
In a placebo-controlled trial that divided OCD subjects
into a “high depression” group (Beck Depression Inventory
[BDI] score ≥ 21) and a “low depression” group (BDI score
≤20), imipramine (mean dose= 233/mg/day) reduced depression over 6 weeks in the highly depressed patients
(n=37) but did not affect the obsessive-compulsive symptoms in either depressed group (447).
In another study, 38 patients were divided into moderately and mildly depressed groups according to their Beck
Depression Inventory scores (232). One half of each group
received imipramine and the other half received placebo
for 6 weeks followed by 3 weeks of daily CBT consisting
of ERP and then 12 weekly sessions of supportive psychotherapy. Although imipramine improved depressive
symptoms in the depressed patients, it did not affect obsessive-compulsive symptom severity. ERP reduced OCD
symptom severity, but imipramine did not potentiate ERP
effects. Response of OCD to therapy did not differ in
moderately depressed versus mildly depressed patients.
c. Trazodone
Case reports and case series (448) suggest that trazodone
at doses of at least 250 mg/day may warrant a trial in OCD
patients who have not responded to first- and second-line
treatments. In one case series (N = 5), augmentation of
an SSRI with trazodone 300–600 mg/day was helpful in
alleviating OCD and anxiety as well as sleep disturbance,
50
APA PRACTICE GUIDELINES
TA B LE 8 .
Results of Second-Generation Antipsychotic Augmentation in Treatment-Resistant Obsessive-Compulsive Disorder (Double-Blind,
Placebo-Controlled Trials)
Medication
Carey et al. 2005 (458)
b
Fineberg et al. 2005 (459)
Denys et al. 2004 (158)
Mean
Final Dose
(mg/day)
Quetiapine
169
Quetiapine
215
Quetiapine
c
—
Final
Dose Range
(mg/day)
Active Drug:
a
Responders /Total
(N)
Percentage of
Responders,
Drug/Placebo
25–300
8/20
40%/48%
50–400
3/11
27%/10%
200–300
8/20
40%/10%
d
50%/20%
Erzegovesi et al. 2005 (157)
Risperidone
0.5
0.5
5/10
McDougle et al. 2000 (155)
Risperidone
2.2
1–4
9/20
45%/0%
Hollander et al. 2003 (156)
Risperidone
2.3
NA
4/10
40%/0%
Bystritsky et al. 2004 (159)
Olanzapine
11.2
5–20
6/13
46%/0%
Olanzapine
6.1
5–10
9/22
41%/41%
Shapira et al. 2004 (460)
b
a
Unless noted otherwise, responder is defined as patient having ≥ 25% decrease in Y-BOCS score from baseline to endpoint.
Short prior SRI trial prior to antipsychotic augmentation.
c
No mean final dose provided.
d
Responder is defined as patient with ≥ 35% decrease in Y-BOCS score.
b
gastrointestinal distress, and sexual dysfunction (449). However, a 10-week, double-blind, placebo-controlled trial with
11 patients who completed the trazodone trial (mean dose=
235 mg/day) and 6 patients who completed the placebo
trial found no evidence of efficacy (450). Nevertheless, the
trial may have been too short (6 weeks at ≥250 mg/day)
with too small a sample to allow definitive conclusions. If
trazodone is used, sedation is likely to be a limiting side
effect, and torsades de pointes has been reported on rare
occasions (451). Males must be warned of the risk of priapism, which may occur in from 1/1,000 to 1/10,000 men
(451).
5. Antipsychotics
a.
Monotherapy
Few studies have examined the efficacy of antipsychotics
as monotherapy for OCD, and the available evidence does
not support such use. An early study (452) examined chlorpromazine in a mixed population of patients (those with
“psychoneuroses or personality disorders with some symptoms of an obsessive or compulsive type”) and did not use
standardized assessment instruments. Case studies using
haloperidol were inconclusive (e.g., references 453 and
454), although a case report described an OCD patient
who responded well to loxapine (455).
An open 10-week trial involving 12 OCD patients examined the possible efficacy of clozapine 300–600 mg/day
(456). The patients had not responded (Y-BOCS score decrease ≥35% or score <16 and a CGI-I:1,2) to prior SRI
trials. Two patients dropped out because of side effects
(i.e., sedation and hypotension). Among the 10 patients
who completed the study, none had a response to the trial;
the mean Y-BOCS reduction was 10%. The authors concluded that clozapine is ineffective as monotherapy in patients who have not responded to prior SRI treatment.
Most recently, Connor et al. (457) examined the efficacy of aripiprazole in eight OCD patients over 8 weeks.
Seven patients took aripiprazole at a dose of 10–30
mg/day, but two dropped out due to side effects (i.e.,
akathisia, nausea). Among the five completers, three experienced a Y-BOCS decrease of ≥30%; two subjects were
rated much or very much improved. The authors concluded that some patients may benefit from aripiprazole
monotherapy. However, the small sample and open-label
design preclude strong conclusions.
b. Augmentation
In the many OCD patients who have either no response
or a partial response to SRI treatment, antipsychotic medication has been used to augment treatment with an SRI.
Randomized, placebo-controlled augmentation trials of
both first-generation (haloperidol) and second-generation (risperidone, olanzapine, quetiapine) antipsychotic
medications have yielded response rates in the range of
40% to 55% within 4–6 weeks (Table 8).
Other controlled trials did not find significant differences between antipsychotic and placebo augmentation
(458–460); however, methodological limitations in these
studies likely contributed to the negative findings. In two
of these studies (458, 460), in which SSRI monotherapy
was limited to 8 weeks, the failure of active drug to sepa-
Practice Guideline for the Treatment of Patients With Obsessive-Compulsive Disorder
rate from placebo was probably due to a high rate of response to continued SSRI monotherapy in the placebo
augmentation group. One 16-week, double-blind, placebo-controlled trial (459) found no significant difference
between quetiapine (mean final dose= 50–400 mg/day)
and placebo. Again, the dosing may have been low.
The long-term effects of antipsychotic augmentation
have not been systematically studied. A retrospective chart
review (160) found that 15 of 18 patients (83%) who responded to antipsychotic augmentation relapsed within
1 year after the antipsychotic was discontinued. Thirteen
of the 15 who relapsed did so by the eighth week after discontinuation.
Many questions about antipsychotic augmentation in
OCD remain unanswered, including the optimal dose for
each of the agents, their long-term tolerability, and the
reasons some patients benefit but others do not. In addition, the relative efficacy of the different agents remains to
be examined.
c. Haloperidol
In the first double-blind, placebo-controlled study of antipsychotic augmentation (154), 34 patients with OCD
resistant to 8 weeks of fluvoxamine (defined as less than
a YBOCS-35% decrease or a score ≥ 16 and not having
a CGI-I:1,2) were randomly assigned to receive 4 weeks
of adjunctive haloperidol (n=17) or placebo (n=17). Adjunctive haloperidol (initiated at 2 mg and increased to a
maximum of 10 mg/day) was significantly more effective
than placebo. Eleven of the 17 haloperidol patients responded versus none of the patients receiving placebo, but
akathisia requiring propranolol treatment was common.
Response was defined as 1) YBOCS-35% and score <16;
2) CGI-I:1,2; and 3) consensus of the treating clinician
and two of the primary investigators. Of the 11 responders, 7 met all three criteria, and 4 met two criteria. All 8
subjects with co-occurring tics responded to haloperidol,
versus 3 of 9 without tics. No subject with tics responded
to placebo. The authors concluded that OCD patients
with a chronic tic disorder might benefit from adjunctive
haloperidol but that it should not be used indiscriminately
because of the risk of tardive dyskinesia.
A 9-week, double-blind, placebo-controlled, crossover
study compared 2 weeks of adjunctive treatments with risperidone 1 mg/day, haloperidol 2 mg/day, or placebo in
16 patients with Y-BOCS scores of ≥16 after at least 12
weeks of therapeutic SRI doses (461). Haloperidol augmentation, but not risperidone augmentation, reduced
the Y-BOCS score significantly more than did placebo
augmentation. Both drugs were significantly better than
placebo at reducing Y-BOCS obsession scores. Four subjects dropped out of the study before receiving neurolep-
51
tic treatment. Of the 12 subjects (75%) who completed
the risperidone arm, 5 (42%) discontinued haloperidol for
adverse events. The low dose of risperidone that was used
constrains interpretation of the study results (see Section
V.A.5.d).
d. Risperidone
Three double-blind, placebo-controlled studies, albeit of
modest size, and several open-label studies support the
safety and effectiveness of risperidone augmentation of
SRI treatment of OCD. McDougle et al. (155) randomly
assigned 36 patients whose OCD was resistant to 12 weeks
of SRI treatment (<YBOCS-35% decrease or a score ≥16
and CGI-I:1,2) to 6 weeks of adjunctive risperidone (n =
20) or placebo (n=16). Risperidone was initiated at 1 mg/day,
and the dose was increased by 1 mg weekly. The mean final
risperidone dose was only 2.2 mg/day (SD =0.7 mg/day;
range=1–4). Among patients who completed the trial (risperidone, n =18; placebo, n =15), risperidone was significantly superior to placebo (Y-BOCS reduction: 32% for
risperidone; 9% for placebo). Nine (50%) of the 18 patients
who completed the risperidone trial were responders
compared with none of the 15 patients who completed the
placebo trial. Response was defined as 1) YBOCS-35% and
score <16; 2) CGI-I:1,2; and 3) consensus of the treating
clinician and two of the primary investigators. There was
no difference in outcome between OCD patients with and
without co-occurring tic disorder or schizotypal personality disorder. Risperidone was well tolerated, with mild transient sedation being the most prominent adverse effect;
one risperidone patient dropped out in the first week because of intolerable insomnia.
In a smaller controlled study (156), 16 OCD patients
who had “failed” (i.e., no more than minimally improved)
at least two 12-week SRI trials were randomly assigned to
receive 8 weeks of adjunctive risperidone (n =10) or placebo (n = 6). Risperidone was started at 0.5 mg/day, and
the dose was increased by 0.5 mg weekly to a maximum of
3 mg/day; the mean risperidone dose was 2.25 mg/day
(SD = 0.86), with no difference between responders and
nonresponders. In the ITT sample, the risperidone group
had a numerically larger mean Y-BOCS score decrease
(25%) than the placebo group (5%). Four of 10 (40%) risperidone patients and none of six (0%) placebo patients
were YBOCS-25% responders. Three subjects discontinued (risperidone, n = 1; placebo, n=2) because of unsatisfactory clinical response. Risperidone was generally well
tolerated; only four risperidone patients experienced side
effects (i.e., sedation, dizziness, dry mouth).
A randomized controlled trial (157) examined the efficacy of adding risperidone 0.5 mg/day versus placebo
in OCD patients who had either responded or not re-
52
sponded to their first SRI trial (12 weeks of fluvoxamine,
maximum dose= 300 mg/day, final doses not provided).
Responders (defined as those with YBOCS-35% and
CGI-I:1,2) and “nonresponders” were then randomly assigned to receive added risperidone 0.5 mg/day or placebo
for 6 weeks. Among the 39 patients completing the trial,
added risperidone significantly reduced OCD symptoms in
the 10 fluvoxamine nonresponders but not in the 9 fluvoxamine responders (Y-BOCS reduction for fluvoxamine
nonresponders: risperidone 26%, placebo 7%; Y-BOCS
reduction for fluvoxamine responders: risperidone 4%,
placebo 28%). Among the fluvoxamine nonresponders, 5 of
10 (50%) risperidone patients and 2 of 10 (20%) placebo
patients became YBOCS-35% responders. The study’s
limitations include the small sample size, the potential for
ceiling effects in the fluvoxamine responders, the low dose
of risperidone, and the lack of information about whether
the treatment groups received similar fluvoxamine doses
prior to augmentation.
e. Olanzapine
The safety and effectiveness of adjunctive olanzapine in
OCD have been examined in two randomized, placebocontrolled trials and several open-label trials. Bystritsky et
al. (159) randomly assigned 26 OCD patients who had not
“improved” (undefined) after at least two 12-week SRI trials and at least one ERP trial to 6 weeks of adjunctive
olanzapine (n=13) or placebo (n=13). OCD patients with
current co-occurring Axis I disorders were excluded. The
mean olanzapine dose was 11.2 mg/day (SD= 6.5; range:
5–20 mg/day). In the ITT sample, adjunctive olanzapine
was significantly superior (Y-BOCS reductions: olanzapine 17%; placebo 2%). Six (46%) of 13 olanzapine patients were YBOCS-25% responders compared with none
in the placebo group. Two olanzapine patients (15%) discontinued because of the side effects (sedation: n=1; weight
gain: n=1).
Shapira et al. (460) randomly assigned OCD nonresponders (<25% decrease) or partial responders (YBOCS25% but score ≥16) after 8 weeks of fluoxetine (40 mg/day
in 42 subjects, 20 mg/day in 1 subject), to 6 weeks of adjunctive olanzapine (n = 22), or placebo (n= 22). Olanzapine was started at 5 mg/day, and the dose was increased to
a maximum of 10 mg/day. Both treatment groups improved
significantly, with no significant difference between them;
the proportions of responders were similar (YBOCS25%= 41% for both groups; YBOCS-35%= 23% for olanzapine, 18% for placebo). The authors concluded that
adding olanzapine was not superior to extending the 8-week
fluoxetine monotherapy trial. However, as they noted, the
patients were unlikely to have attained full benefit from
the SSRI before the olanzapine trial began, thus obscur-
APA PRACTICE GUIDELINES
ing any olanzapine effect. Olanzapine patients gained a
mean of 2.8 (±3.1) kg compared with 0.5 (±1.8) kg for placebo patients.
f. Quetiapine
The safety and effectiveness of quetiapine augmentation
of SRI treatment in OCD have been evaluated in three
randomized, double-blind, placebo-controlled trials; one
randomized, single blind, placebo-controlled trial; and
several open-label studies.
Denys et al. (158) randomly assigned 40 OCD patients
without co-occurring diagnoses who were unresponsive
(Y-BOCS decrease<25%) after at least two SRI trials (at
maximum tolerated dose for 8 weeks) to receive adjunctive quetiapine (n = 20) or placebo (n = 20) for 8 weeks.
Quetiapine was started at 50 mg/day, and the dose was increased, following a fixed dosing schedule, to a maximum
of 300 mg/day. In the ITT sample, adjunctive quetiapine
was significantly superior to placebo (Y-BOCS reduction:
quetiapine 32%; placebo 7%). Eight (40%) quetiapine
patients were responders (defined as YBOCS-35% and
CGI-I:1,2), compared with only two (10%) placebo patients. The most common side effects of quetiapine were
somnolence (95%), dry mouth (55%), weight gain (30%),
and dizziness (30%).
Carey et al. (458) randomly assigned 41 patients who
had not responded (defined as not CGI-I:1,2 or not
YBOCS-25%) after 12 weeks of SRI treatment to 6 weeks
of flexibly dosed adjunctive quetiapine (n=20) or placebo
(n=21). The mean final quetiapine dose was 169 (±121)
mg/day. Both quetiapine and placebo led to a significant
reduction in mean Y-BOCS scores (Y-BOCS reduction:
quetiapine 27%; placebo 26%). Responder (defined as
CGI-I:1, 2 and YBOCS-25%) rates were 40% and 48% for
quetiapine and placebo, respectively. Two quetiapine patients dropped out because of severe sedation, and 75% complained of sedation (vs. 33% of placebo patients). Quetiapine augmentation was no more effective than placebo, but
the study was limited in that patients had received their
maximum SRI dose for only 6 weeks before randomization.
Fineberg et al. (459) randomly assigned 21 adult OCD
patients with minimal response (defined as <25% Y-BOCS
decrease) after 12 weeks of an SRI at the maximum tolerated dose, to receive either adjunctive quetiapine (n = 11;
mean final dose= 215 mg/day, range=50–400 mg/day) or
placebo (n=10). After 16 weeks of augmentation, there was
no difference in the ITT sample between the two groups
(Y-BOCS reduction: quetiapine 14%; placebo 6%). Three
of 11 quetiapine-treated patients were YBOCS-25% responders compared with 1 of 10 placebo patients. The authors suggested that exclusion of co-occurring Axis I disorders and tic disorders may have led to their negative findings.
Practice Guideline for the Treatment of Patients With Obsessive-Compulsive Disorder
In a single-blind placebo-controlled study (462), 27
OCD patients with no response to at least one 12-week
SRI trial (defined as no more than minimal improvement,
a Y-BOCS score of ≥18, and agreement of three of the authors) were randomly assigned to receive adjunctive quetiapine (n= 14) or placebo (n=13) for 8 weeks. Of the 14
patients randomly assigned to 50–200 mg/day of quetiapine, 10 (71%) experienced improvement (defined as
Y-BOCS decrease ≥30%), in comparison to none of the
placebo patients. Nine quetiapine-treated patients reported
side effects (nausea, n=6; sedation, n =3; dizziness, n=1).
The study’s main limitation was the single-blind design.
53
1.0 mg/day) ineffective in 28 patients with DSM-III-R
OCD (467).
6. Other Agents
b. Benzodiazepines
Evidence for beneficial effects of benzodiazepines as
monotherapy for OCD is primarily limited to case reports
with clonazepam and alprazolam. For clonazepam, negative results from a double-blind, placebo-controlled trial
(468) and an open trial (469) cast serious doubt on the
positive results of a double-blind, multiple-crossover trial
(467). In the latter study, effectiveness seems to have necessitated doses that were poorly tolerated and produced
serious adverse events. Modest doses of benzodiazepines
may relieve anxiety and distress in OCD without directly
diminishing the frequency or duration of obsessions or
compulsions. However, case reports have noted an onset
of action within 1–3 weeks. Among patients with histories
of substance abuse or dependence, benzodiazepine use
may aggravate symptoms and should be prescribed cautiously (234, 255). Thus, given their limited evidence for efficacy, benzodiazepines cannot be recommended as monotherapy for OCD, except in those rare individuals who are
unable or unwilling to take standard anti-OCD medications.
a. Adrenergic Agents
Pindolol, a beta-blocker and serotonin 1A (5-HT1A) presynaptic receptor antagonist, increases serotonergic transmission through its effect on the presynaptic 5-HT1A receptor. It has been suggested that pindolol can be given
once or twice daily for augmentation in the treatment of
psychiatric disorders (464). In OCD, small studies have
produced mixed results regarding its possible efficacy as
an augmentation agent. An 8-week, double-blind, placebo-controlled trial examined pindolol augmentation of
fluvoxamine in 15 patients (180). No differences between
the two treatment groups were noted either in symptomatic response or in the latency of response to fluvoxamine.
A double-blind, placebo-controlled trial enrolled 14 patients with DSM-IV OCD who had not responded to paroxetine and at least two other SRIs (179). Augmentation
with pindolol 2.5 mg three times daily was associated with
significant decrease in the Y-BOCS score after the fourth
week of treatment. The greatest improvement was noted
in the ability to resist compulsions. No group differences
were found in pulse rate or blood pressure. An open-label
study found beneficial therapeutic effects from combining
pindolol and a serotonergic antidepressant, but only after
tryptophan was added (465). Another open-label study
found that one of eight patients with treatment-resistant
OCD responded to pindolol augmentation (466).
A double-blind crossover comparison trial with 6week drug periods found clonidine (maximum dose =
c. Buspirone
Small and methodologically limited studies provide inconsistent results regarding the possible effectiveness of
buspirone 60 mg/day as monotherapy and no substantial
evidence of its effectiveness as an augmenting agent.
A 6-week double-blind comparison of buspirone titrated to 60 mg/day (n=10) and clomipramine titrated to
250 mg/day (n=10) suggested equal effectiveness (470). In
a 4-week, double-blind, placebo-controlled, crossover
trial (n= 13), however, buspirone was no better than placebo (471). In addition, an 8-week open trial of buspirone
at a dose of 60 mg/day for the last 5 weeks of the trial resulted in virtually no decrease in the mean Y-BOCS score
of the 10 subjects who completed the study (472). However, these trial durations were too short to allow a robust
test of buspirone’s possible effectiveness.
In a small (n = 14), 10-week, double-blind, placebocontrolled trial, which involved a 2-week placebo lead-in
followed by 10 weeks of buspirone augmentation, buspirone did not differ from placebo, although 29% (4/14)
of buspirone subjects experienced a YBOCS-25% response (473). A 6-week, double-blind, placebo-controlled
trial of buspirone 60 mg/day as an augmentation of fluvoxamine was negative, but this study assessed the efficacy
of buspirone augmentation in patients with treatmentresistant OCD (<35% decrease in Y-BOCS score and rated
“unimproved” by the investigators) rather than in partial responders for whom further improvement was sought (474).
g. Other Antipsychotic Agents
Double-blind, placebo-controlled studies are not available for ziprasidone or aripiprazole. Published case reports
weakly suggest that ziprasidone augmentation of SRI pharmacotherapy may be effective (463). A small (n=8), openlabel, 8-week, flexible-dose study of aripiprazole (10–30
mg/day) monotherapy reported that three subjects (38%)
experienced a 30% or greater decrease in Y-BOCS score
(457).
54
d. Inositol
Inositol, a precursor in the phosphatidylinositol cycle, has
been studied in two double-blind, placebo-controlled,
crossover studies (as monotherapy in one and as an augmenting agent in the other) and an open augmentation
trial. Inositol appears to be well tolerated. In addition, the
data weakly suggest that inositol may benefit a minority of
OCD patients but do not support a recommendation that
it be routinely tried.
In a double-blind, crossover study, inositol (18 gm/day)
and placebo were administered for 6 weeks in each condition in 13 subjects free of major depression and with variable responses to SSRIs (475). There was a small but significantly greater decrease in the Y-BOCS score in the
inositol condition (5.9 points) compared with the placebo
condition (2.8 points). A double-blind, placebo-controlled,
crossover augmentation study with 6 weeks in each condition and no washout between conditions found no difference in Y-BOCS score decrease between inositol and
placebo in the first drug condition, but the study groups
were small (six inositol and four placebo) (476). Subjects
had been taking a stable SRI dose for at least 8 weeks before
randomization but showed greater improvement in the
study’s first 6 weeks than in its second 6 weeks, regardless
of which blinded drug was administered first. In an open
study (477), inositol (18 gm/day) was added for 6 weeks in
10 subjects who had been rated minimally improved on the
CGI-I after 12 weeks or more of stable SSRI treatment.
Mean Y-BOCS scores fell significantly from 23.6 (± 4.4) to
17.6 (±4.6), but only three subjects (30%) achieved CGI-I
scores of much improved.
e. Lithium
Case reports suggest that lithium monotherapy may deserve further study in trials that utilize an adequate serum
level (≥0.6 mEq/L) and an adequate duration of treatment
(≥10 weeks). However, findings from an 8-week, doubleblind, crossover augmentation study (n=16) with a mean
serum level of 0.54 mEq/L (478) and a 4-week, doubleblind, placebo-controlled, augmentation trial (n=10) with
a mean serum level of 0.77 mEq/L (479) were negative.
The 4-week lithium treatment period in these studies may
have been too short to fully evaluate lithium’s potential
utility as an augmentation agent in OCD. The utility of
lithium in the treatment of co-occurring bipolar disorder
is clearly established (193).
f. Mirtazapine
A study combining an open-label first phase with a doubleblind discontinuation phase suggests that mirtazapine
may be effective for OCD in patients who have not received SRI treatment or have not responded to only one
APA PRACTICE GUIDELINES
adequate SRI trial (174). However, the small sample size
(15 treatment-naive patients and 15 not responding to exactly one adequate SRI trial) makes these results suggestive rather than strong evidence for mirtazapine’s effectiveness. Significant weight gain was observed in more
than 30% of patients in the first 12 weeks of treatment. A
small pilot study provides slight additional support (480).
Additional double-blind, placebo-controlled trials utilizing a parallel groups design are indicated.
g. Other Medications
A case series (481) and a double-blind, placebo-controlled
crossover study (182) suggest that once-weekly oral morphine sulphate 30–45 mg may be useful as an augmentation strategy for resistant OCD. In the double-blind study,
7 of 23 subjects (30%) experienced a YBOCS-25% response to morphine versus none in the placebo condition.
In addition, a small (n=8), 6-week, open-label study found
evidence for the effectiveness of tramadol monotherapy
254±119 mg/day in the six patients who completed at least
2 weeks of treatment (183). The dose-limiting side effect
was sedation.
Some anticonvulsants (valproate, oxcarbazapine, carbamazepine, gabapentin, topiramate) have been reported
to help individual patients either as monotherapy or as
augmentation agents. A small (n =9), 8-week, open-label
carbamazepine trial (482) and a small case series (n = 5)
(483) each reported only one positive response. A 6-week
open-label study of gabapentin augmentation (mean dose=
2520 mg/day) in five patients who had a partial response
to fluoxetine suggested some benefit (484), but a 6-week,
double-blind, placebo-controlled, crossover trial of gabapentin 3600 mg/day added to fluoxetine found no benefit
(485). An open case series reviewing at least 14 weeks of
topiramate augmentation (mean daily dose=253 mg) in 16
patients who had a partial response or no response to SRI
treatment reported 11 of 16 (68.8%) CGI-I:1,2 responders. The mean time to response was 9 weeks (486).
L -Tryptophan 3–9 gm/day combined with nicotinic
acid 1 gm two times daily and pyridoxine 200 mg two
times daily was reported to be beneficial in early case reports that predated modern diagnostic criteria and measurement instruments (487, 488). However, some patients
became violent. Adding L-tryptophan at doses exceeding
1–2 gm/day to an SRI can induce the serotonin syndrome.
D-Amphetamine 30 mg, studied in a single-dose, double-blind, placebo-controlled trial, was associated with a
significant decrease in self-rated symptoms about 6 hours
after the dose, independently of effects on mood (184). DAmphetamine had an acute anti-OCD effect in 11 of 12
subjects (92%). With placebo, neither the self-ratings nor
the blinded observer’s ratings decreased significantly. Two
Practice Guideline for the Treatment of Patients With Obsessive-Compulsive Disorder
patients continued D -amphetamine at a dose of 10–20
mg/day for “several weeks” with continued response. In a
small (n=11), double-blind, placebo-controlled, crossover
study of single doses of methylphenidate 40 mg and Damphetamine 30 mg, both taken orally, the latter drug was
associated with a significantly greater reduction in OCD
symptom rating than was placebo (185). Five of the 11
subjects (45%) had a ≥50% decrease in their OCD scores
after D-amphetamine, two (18%) after methylphenidate,
and only one (9%) after placebo. In both studies, the decrease in OCD symptoms was independent of mood effects. Open-label methylphenidate, 40 mg once orally,
produced no significant effect on OCD or mood 4 hours
later in a small study (n=13), although four patients had a
50% decrease in an OCD rating scale score (489). Case
reports exist of OCD benefit after treating co-occurring
attention-deficit disorder with stimulants. The presence
of tics or Tourette’s disorder does not contraindicate the
use of stimulants to treat ADHD co-occurring with OCD,
although methylphenidate appears to be better tolerated
in this situation than D-amphetamine (490).
Hallucinogens have been reported to alleviate OCD in
individual cases (491, 492). Since hallucinogens are not a
practical treatment modality or recommended, studies of
safer serotonin2A,C (5-HT2A,C) receptor agonists may be
warranted.
Ondansetron 1 mg three times daily was associated with a
significant decrease in Y-BOCS scores in a small (n = 8),
8-week, open-label study (493).
St. John’s wort (450 mg of 0.3% hypericum two times
daily), a weak serotonin-reuptake inhibitor, was associated
with CGI-I:1,2 response in 5 of 12 (42%) subjects in a
12-week open-label trial (494). However, a 12-week, flexible-dose, placebo-controlled trial enrolling 60 subjects
found St. John’s wort to be no better than placebo (181).
In addition, St. John’s wort predisposes to photosensitivity and interacts with anti-HIV medications (495), cyclosporin (496, 497), and birth control pills (498), among
other medications (499).
Bupropion titrated from 150 mg/day to 300 mg/day after 2 weeks had no mean effect on Y-BOCS scores in an
open trial involving 12 patients (500). However, 2 patients
were YBOCS-25% responders; 4 patients “improved,”
with a mean Y-BOCS decrease of 31%, but 8 patients experienced a worsening of symptoms, with a mean Y-BOCS
increase of 21%.
A 12-week open-label study adding riluzole 50 mg two
times a day to SSRIs and other augmenting medications
reported that 7 of 13 (54%) patients with treatmentresistant OCD were YBOCS-35% responders (501).
However, these results must be viewed cautiously because
ratings were not blinded, other augmenting medications
55
were present, and prior treatment regimens were stable
for only 4 weeks before riluzole was added. Riluzole was
well tolerated, although one patient experienced an
asymptomatic increase in liver enzyme (ALT) to a level
more than nine times normal, which decreased despite
continued treatment.
B. OTHER SOMATIC THERAPIES
Somatic therapies used in the treatment of OCD include
deep brain stimulation and other forms of neurosurgery,
transcranial magnetic stimulation, and electroconvulsive
therapy. Plasmapheresis has been investigated only in childhood OCD. None of these therapies are considered firstline treatments for OCD, and their use is limited to patients with treatment-resistant OCD.
Specific descriptions of the criteria used to establish
treatment resistance and to determine eligibility for surgical treatments (stereotactic lesion procedures and DBS)
in OCD patients have been published elsewhere (152,
502–504).
Data regarding treatment of OCD with these somatic
therapies are quite limited, and there is an understandable
absence or paucity of double-blind trials; as a result, no definitive conclusions can be drawn. The majority of available
reports are case series and open-label trials. Although
stereotactic lesion procedures have a more abundant database (197) than the other somatic therapies in patients
with treatment-resistant or intractable OCD, the cost, irreversibility, and lack of a clear relationship between specific anatomic lesions and successful outcomes continue
to limit their use.
1. Transcranial Magnetic Stimulation
Findings of the four published trials of repetitive TMS
(rTMS) are inconsistent, perhaps because the studies differed in design, stimulation sites, duration, and stimulation parameters. The available results and the technique’s
non-invasiveness and good tolerability should encourage
future research, but the need for daily treatment may limit
the use of TMS in practice.
In a TMS study of possible frontal lobe involvement in
OCD (505), 12 OCD patients (6 patients with past or current major depression) were randomly assigned to receive
one session of active right-side or left-side or sham (occipital) rTMS. Blinded raters made ratings during the stimulation and 30 minutes and 8 hours after the session. Compulsive urges, but not obsessions, decreased significantly,
and positive mood increased moderately, with right lateral
prefrontal rTMS (during stimulation and 30 minutes and
8 hours after stimulation), but not after left rTMS or occipital rTMS. Stimulation was well tolerated, with two
56
patients reporting mild headache after stimulation. Although the report was not intended as a treatment study
(only one administration per anatomical site was used),
methodological limitations include the treatment duration, lack of Y-BOCS outcome measures, small sample
size, and the lack of a control group. Another non-treatment TMS study reported altered cortical excitability in
subjects with OCD compared with controls (506).
A 6-week trial (three sessions per week) (507) found no
advantage for low-frequency right rTMS (n = 10) over
sham stimulation (n=8). No dropouts were reported, and
side effects, consisting of headache and cognitive difficulties, were modest and transient. The use of a relatively
nonfocal, teardrop-shaped coil limits the interpretation of
the results.
In a 10-session, single-blind, 2-week trial (508), 12 patients with treatment-resistant OCD were randomly assigned to receive active right-side or left-side rTMS. Ten
subjects taking medications were maintained on a constant dose for 8 weeks prior to and during the study. Evaluations after 2 weeks of stimulation and 4 weeks later
showed significant reduction in obsessions and compulsions in both groups, with no significant difference between right and left stimulation. Four patients (two receiving left and two receiving right rTMS) had a clinically
significant improvement (Y-BOCS reduction >40%); one
patient relapsed but responded somewhat to repeat treatment. No dropouts were reported, and stimulation was
well tolerated, with three patients reporting headache.
However, interpretation is limited by the absence of a placebo control group and the presence of concurrent pharmacotherapy.
In an open-label trial (509), 10 treatment-resistant patients (5 with OCD, 3 with Tourette’s syndrome, and two
with both) received low-frequency rTMS for 2 weeks.
Medication doses were stable for at least 12 weeks before
and throughout rTMS and the follow-up period. Eight
patients completed the study; no dropouts due to side effects were reported. CGI scores decreased significantly at
the end of the first and second weeks of treatment, with
benefit maintained at the 1-month and 3-month followups. Three of the five patients with pure OCD had a clinically significant improvement, with a >40% reduction in
Y-BOCS scores, and two Tourette’s patients had a complete remission at the second week. Six subjects (60%) had
clinical improvement that persisted at 3-month followup. The study was limited by the open design and small
sample size.
2. Electroconvulsive Therapy
The literature on ECT in treatment-resistant OCD includes a case series and several individual cases, with some
APA PRACTICE GUIDELINES
reported degree of effectiveness. However, the frequent
Axis I comorbidity among subjects, lack of standard outcome measures, absence of blinded trials, need for repeated anesthesia, and the side effects of ECT preclude it
from being considered for treatment-resistant OCD uncomplicated by co-occurring conditions (191).
The case series (190) describes a retrospective study of
32 patients with DSM-III-R treatment-resistant OCD
(19 not depressed and 13 depressed; 14 with primarily
checking rituals, 13 with primarily cleaning rituals, and four
with both) who received ECT between 1979 and 1991.
The patients were treated with bilateral frontotemporal
ECT (average three to five seizures per session over 2–3
weeks) and were evaluated 2 days before treatment and at
5 days and 6 and 12 months after the end of treatment.
Comparison of baseline scores (Beck Hopelessness Scale,
Maudsley Obsessional-Compulsive Inventory) with data
5 days after treatment yielded highly significant pre-post
paired t test results (P<0.001) that were still significant at
6 months posttreatment. However, by 12 months only the
MOCI scores remained significantly different from those
prior to ECT. In addition, methodological limitations include the absence of blinded ratings and standard outcome
measures, the use of medications during the long-term
follow-up, and the presence of co-occurring depression in
a significant proportion of patients (13/32). Furthermore,
the number of seizures per session is not considered standard ECT treatment (191).
In addition, several single case reports (510–514) suggest possible efficacy of ECT in treatment-resistant OCD.
However, the unblinded ratings, frequent Axis I comorbidity (schizophrenia, depression, Tourette’s disorder),
and differing ECT parameters limit the confidence that
can be placed in the findings.
3. Deep Brain Stimulation
Two small, double-blind trials and several case reports
have investigated the efficacy of DBS in OCD. Given the
preliminary promising results in treatment-resistant OCD,
the procedure’s reversibility and adjustability in comparison with ablative neurosurgery, and the absence to date of
serious adverse events, DBS deserves investigation in severe, treatment-resistant OCD. Nonetheless, DBS is an
invasive procedure, and the risks of brain hemorrhage,
infection, and new onset of seizures must be kept in mind
(195).
The first report (515, 516) concerns six subjects with
OCD refractory to various antiobsessional treatments and
to CBT (Y-BOCS ≥ 30, GAF ≤ 45, both for a minimum of
5 years) who were treated with DBS. Quadripolar electrodes were implanted bilaterally in the anterior limbs of
the internal capsules with a double-blind stimulation-off
Practice Guideline for the Treatment of Patients With Obsessive-Compulsive Disorder
condition representing the placebo condition throughout
the 21 months of evaluation. Four patients completed a
blinded crossover trial (i.e., stimulator on for 3 months
and stimulator off for 3 months, or vice versa, in random
order). Three were YBOCS-35% responders during the
stimulation-on condition, with CGI-I scores much improved. Responders reported clinically meaningful improvement in the first week of stimulation. Side effects
included fatigue and memory disturbances. The persistence of the effect for at least 21 months argues against a
placebo effect. Patient 5 received a different electrode
placement, one in each dorsomedial thalamic nucleus and
one in each internal capsule (517). The dorsomedial thalamic nucleus did not seem as effective a target for this
patient, who was also considered a nonresponder with
longer-term internal capsule stimulation. Patient 6 experienced a major improvement (more than 50% decrease in
postoperative tests) in his aggressive, intrusive thoughts
and mood when stimulation was turned on.
One small trial enrolled four subjects with DSM-IV
OCD who did not respond to at least four antiobsessional
medications and CBT (Y-BOCS ≥ 25; GAF ≤ 44) (518). The
patients, who had been following stable medication regimens for at least 6 weeks before surgery and during the
blinded phase of the study, received DBS with quadripolar
electrodes placed stereotactically in the anterior limb of
each internal capsule; stimulation-off was the control. The
double-blind study consisted of four consecutive 3-week
periods (in an alternating on-off design), followed by an
open phase in which stimulation, medication, and CBT
were adjusted to optimize response for up to 1 year. During the double-blind phase, two of the four patients showed
clinically meaningful responses but one of these patients
also responded during periods without stimulation. One
subject experienced mood elevation in response to stimulation. Positron emission tomography (PET) scans showed
orbitofrontal deactivation only in the two patients with a
positive clinical response. Side effects included tingling,
nausea, and diarrhea. Beneficial effects appeared over variable times, ranging from 3 weeks to several months.
In addition, four recent case reports of open-label DBS
(519–522) suggest the efficacy of DBS in treatmentresistant patients with OCD. In a recent case-series report
(523), three of four patients with severe OCD and anxiety
disorders who received DBS in the shell of the right nucleus accumbens experienced significant reduction in severity of symptoms.
4. Neurosurgical Stereotactic Lesion Procedures
Neurosurgical treatment for psychiatric disorders has a long
and controversial history. Today this approach—including
cingulotomy, capsulotomy (also performed via radiosur-
57
gery and known as “gamma-knife” capsulotomy), subcaudate tractotomy, limbic leucotomy, central lateral thalamotomy/anterior medial pallidotomy—is a highly
selective treatment performed for relatively few patients
with severe, treatment-refractory affective, anxiety, or
obsessive-compulsive disorders (197). The availability of
reversible and adjustable DBS may lead to a decrease in
the use of ablative neurosurgical procedures. However,
these procedures still represent a potentially efficacious
alternative for a few carefully selected patients with very
severe OCD.
In view of the changes in neurosurgical techniques in
the last decade, only trials using these advanced techniques
with adequate numbers of patients and specified inclusion
criteria and outcome measures are reviewed.
A prospective unblinded study of bilateral anterior capsulotomy in 15 subjects with treatment-refractory OCD
(mean duration = 18.1 ± 5.6 years; mean total Y-BOCS
score= 29.7) observed positive results at 1 and 12 months
postsurgery: at 12 months, the mean Y-BOCS score decrease was 39%, with 53%, 29%, and 17% of the patients
experiencing a 33% decrease, 50% decrease, and 66% decrease in Y-BOCS score, respectively (524). No cognitive
deficit was evident in neuropsychological screening tests.
Complications were observed in three case subjects: one
with transitory hallucinations, one with a single epileptic
seizure, and one who developed a progressive behavior
disorder (not further specified) that became permanent.
In an unblinded study (525) enrolling 44 subjects with
DSM-III-R OCD refractory to at least three SRIs trials,
at least one SRI augmentation trial, and a trial of CBT
(Y-BOCS ≥ 25, GAF ≤ 60, both for ≥5 years), one or more
cingulotomies (electrodes positioned in each cingulate
gyrus with magnetic resonance imaging [MRI] stereotactic guidance) were performed. Follow-up evaluations
were carried out a mean of 32 months after neurosurgery.
At the first follow-up (a mean of 6.7 months after the first
cingulotomy), the mean Y-BOCS score decrease was 20%; 5
patients (11%) met full responder criteria (YBOCS-35%
and CGI-I:1,2), and 4 patients (9%) met partial responder
criteria (either YBOCS-35% or CGI-I:1,2 or this degree
of improvement not attributed to cingulotomy). At the
32-month follow-up, the mean Y-BOCS score decrease
was 29%, with 32% of patients classified as responders
and 14% as partial responders. At the most recent followup for the 18 patients who received multiple cingulotomies, 5 (28%) were responders and 2 (11%) were partial
responders. These results suggest that cingulotomy may
benefit some patients with severe treatment-refractory
OCD. Although 20% of patients reported at least one
adverse effect after cingulotomy (e.g., memory disturbances, apathy, urinary disturbances), only 2 patients (5%)
58
reported enduring sequelae (i.e., seizure disorder and hydrocephalus).
Fourteen subjects with treatment-refractory and medically intractable OCD were evaluated up to 12 months
after bilateral anterior cingulotomy (526). At the 6- and
12-month follow-ups, the mean Y-BOCS scores decreased
29% and 36%, respectively, with 4 of 14 (29%) and 6 of 14
(43%) having a response (defined as YBOCS-35% and
CGI-I:1,2). No significant changes in cognitive functions
or memory were reported at the 12-month evaluation
compared with preoperative scores. Adverse effects (headache, insomnia, weight-gain/loss) persisted no more than
3 months after cingulotomy.
In a retrospective unblinded study, 15 subjects with
treatment-refractory OCD were followed up for approximately 1 year after bilateral cingulotomy (527). Four of
the 15 patients were YBOCS-35% responders. However,
only one had sustained benefit lasting more than 1 year. Minor postoperative symptoms included headache, nausea/
vomiting, and urinary incontinence, which resolved after
several months. Postoperative MRIs revealed no clear relationship between lesion location and significant clinical
improvement.
The efficacy of limbic leucotomy was evaluated in a
small unblinded study of 21 subjects, of whom 15 had
treatment-refractory OCD and 6 had refractory major
depression (528). Patients were evaluated after a mean of
26 months. Five of 12 OCD patients (42%) with physician
ratings were rated responders (defined as physician-rated
CGI-I:1,2), and 8 of the 13 (62%) OCD patients with selfratings rated themselves as responders (defined as PGII:1,2). One OCD patient, who had a history of a suicide
attempt, died by suicide after the surgical procedure. Minor
postoperative symptoms of headache, low-grade fever, and
nausea/vomiting were common but generally lasted less
than 48 hours. Among the 21 subjects, transient postoperative somnolence and apathy were noted in 29% and 24% of
patients, respectively. These results are comparable to
those in the limited previous reports regarding limbic leucotomy in intractable OCD (529).
C. PSYCHOTHERAPIES
1. Exposure and Response Prevention
Historically, CBT for OCD has been divided into two
forms: 1) CBT that relies primarily on behavioral techniques, such as ERP (57), and 2) CBT that relies primarily
on cognitive therapy techniques, such as identifying, challenging, and modifying faulty beliefs (530, 531). Certain
variants of exposure therapy routinely include some informal cognitive therapy techniques (e.g., a discussion of
fear-related thoughts and beliefs), and many variants of
APA PRACTICE GUIDELINES
cognitive therapy include behavioral experiments, which
can be similar to exposure techniques. Therefore, these
two forms of CBT, as administered in treatment trials, often overlap. In clinical practice, these two forms are often
combined.
Studies that have examined CBT consisting of ERP for
adults with OCD are reviewed in this section (see also reference 532).
a.
Randomized Controlled Trials Comparing ERP
With a Nonactive Treatment
Several randomized controlled trials have examined whether
ERP is superior to a nonactive treatment. Although the
studies used different variants of ERP (e.g., therapistsupervised or self-controlled exposures), different formats
(e.g., individual sessions vs. group therapy), different intensity (e.g., frequency and length of sessions per week),
and different control groups, all studies concluded that
ERP is efficacious for the treatment of adults with OCD.
Several early controlled studies reported that ERP was
superior to progressive muscle relaxation (PMR) (e.g., see
references 533, 534). These studies were limited by their
small samples and the lack of standard diagnostic and outcome measures.
A 12-week trial compared the effectiveness of randomassignment individual ERP (n =31), group ERP (n=30), or
PMR (n=32), which was included as an attention control
condition (132). Subjects were free of major depression
and Axis II disorders and were treatment naive. Individual
ERP was delivered in 1-hour sessions two times a week;
group ERP consisted of 2-hour sessions two times a week
delivered in groups of 10. In both cases, treatment consisted of exposure (imaginal and in vivo) and response prevention. In those subjects who completed treatment, both
individual and group ERP were superior to PMR but not
to each other in reducing OCD and depressive symptoms (Y-BOCS score reduction in subjects who completed the study: 40% for individual; 46% for group; 9%
for PMR). However, group ERP took much less staff
time. Patients receiving either individual or group treatment maintained their gains at 6-month follow-up; however, whether patients received additional treatment during follow-up is unclear.
In a 3-week trial in which all patients completed the
study, 18 patients were randomly assigned to receive either ERP (n=9) or anxiety management (n=9) (535). Both
treatments involved about 15 hours of therapy. ERP consisted of graded exposure to feared situations and ritual
prevention both in sessions and as homework. Anxiety
management consisted of breathing retraining, PMR, and
problem solving. ERP was significantly superior to anxiety management for both OCD and depressive symptoms
Practice Guideline for the Treatment of Patients With Obsessive-Compulsive Disorder
(e.g., Y-BOCS: 62% reduction for ERP; 6% increase for
anxiety management). During the study, five patients continued SRIs that had brought “no improvement” for at
least 12 months. Study limitations include the small sample, lack of independent raters, and very short-term duration of observation.
In a large multisite trial (139), 218 patients were randomly assigned to 10 weeks of ERP guided by a therapist
(n=69), ERP guided by a computer and workbook (n=74),
or systematic relaxation guided by an audiotape and manual (n = 75). ERP guided by a therapist consisted of 11
weekly 1-hour sessions in which therapists told patients
how to conduct exposures at home but did not supervise
in-session exposures. ERP guided by computer used BT
STEPS, a nine-step computer-driven interactive voice response system that allows patients to telephone from
home at any time of day or night and progress through a
self-paced workbook that allows the patient to design and
implement an individualized plan of behavior therapy.
Relaxation therapy consisted of an audiotape and manual
that directed the patient to practice PMR 1 hour daily. Of
those who entered, 55 (80%) completed ERP, 55 (74%)
completed BT STEPS, and 66 (88%) completed PMR. In
ITT analyses, ERP was superior to BT STEPS, and both
were superior to PMR (Y-BOCS reduction: 32% for ERP;
23% for BT STEPS; 7% for PMR). Significantly more
patients receiving ERP were CGI-I:1,2 responders (60%),
compared with patients receiving either BT STEPS
(38%) or PMR (14%). Patients who adhered to ERP (either guided by clinician or computer) had a larger mean
decrease in their symptoms than the overall mean decrease
for that condition. Patients were followed for an additional 14 weeks. However, the groups received different
follow-up treatment, so overall group comparisons were
confounded. Of note, nonresponders to BT STEPS who
were switched to clinician-guided ERP had a significant
decrease in OCD severity, whereas nonresponders to ERP
who were switched to BT STEPS did not. The authors
concluded that minimal ERP (i.e., 11 weekly 1-hour sessions
in which a therapist provides instructions only) is superior
to BT STEPS and that PMR is ineffective for OCD.
However, the reduction in OCD symptoms was substantially less than that seen in other studies in which therapists supervised in-session exposures (e.g., compare ITT
results in Lindsay et al. [535] and Foa et al. [123]).
In a Brazilian controlled trial of group ERP (134),
OCD patients were randomly assigned to 12 weeks of either group ERP (n = 23) or wait-list control (n = 24). Although 45% of patients were taking medications at the
time of therapy, they had been taking the medication at a
stable dose for at least 3 months. The group ERP was conducted in weekly 2-hour sessions in groups of seven or
59
eight; it included in-session exposure, ritual prevention,
and cognitive restructuring. In ITT analyses, group ERP
was significantly superior to the wait-list condition (Y-BOCS
reduction: group ERP 43%; wait-list 6%); 70% of group
ERP patients were YBOCS-35% responders. Twentytwo ERP patients reevaluated after 3 months had maintained their gains. However, whether patients received
additional treatment during follow-up was not stated.
A multisite trial (123) compared the efficacy of 12 weeks
of ERP, clomipramine, their combination, and pill placebo in adults with OCD and without co-occurring depression. Of 122 entering randomly assigned treatment,
87 (71%) completed the study. ERP was delivered intensively for the first 4 weeks (i.e., five 2-hour sessions per
week); it consisted of exposure (imaginal and in vivo),
ritual prevention, and relapse prevention. During exposures, feared consequences and dysfunctional beliefs were
discussed. For the remaining 8 weeks, patients received
45-minute maintenance sessions in which no in-session
exposures were conducted. Patients randomly assigned
to receive clomipramine or placebo were seen for 30 minutes weekly by a research psychiatrist. They received clomipramine titrated up to 200 mg/day or placebo in the
first 5 weeks, with an optional increase to 250 mg/day if
needed. In ITT and completer analyses, all active treatments were superior to placebo. ITT and completer response rates (CGI-I:1,2) were, respectively, 62% and 86%
for intensive ERP, 42% and 48% for clomipramine, 70%
and 79% for combination treatment, and 8% and 10% for
placebo. Post hoc analyses (126) demonstrated that intensive ERP with or without clomipramine produced a significantly higher proportion of patients (> 50%) with minimal symptoms (i.e., Y-BOCS ≤12) than either placebo
(0%) or clomipramine alone (25%). However, high study
refusal rates (71% of those meeting entry criteria refused
to participate) and dropout rates (18% at randomization
and an additional 23% before completion) may limit the
widespread applicability of this study’s findings.
In a Japanese study (536), 31 OCD outpatients were
randomly assigned to 12 weeks of single-blind ERP plus
pill placebo; fluvoxamine 150–200 mg/day (dose reached
no later than week 5) plus autogenic training (psychotherapy placebo); or autogenic training and placebo. Among
the 28 patients (90%) who completed treatment, ERP was
significantly more effective than fluvoxamine in reducing
Y-BOCS scores. Ten of 10 (100%) patients receiving ERP
were Y-BOCS-35% and CGI:1,2 responders compared
with 3 of 10 (30%) fluvoxamine patients and 0 of 8 (0%)
placebo patients. The study is limited by small sample
size, lack of double-blind ratings, and low doses of fluvoxamine.
60
APA PRACTICE GUIDELINES
In addition to these randomized controlled trials, several controlled trials compared ERP and different variants
of cognitive therapy with and without SRI medication.
These studies are reviewed in the section on cognitive
therapy for OCD (Section V.C.2). Overall, these studies
also found that ERP significantly reduced OCD symptoms, further supporting its efficacy for OCD. However,
most of these studies lacked a placebo or nonactive control condition. Two used a wait-list control, with one (61)
reporting that gradual self-controlled ERP was significantly
superior to 8 weeks of wait-list control, and the other (133)
finding that group ERP was superior to wait-list control.
Open trials of ERP (totaling hundreds of patients) also
support the efficacy of ERP for OCD (e.g., see references
229, 537–539).
b.
Factors That Affect Outcome From ERP
Several factors appear to affect the outcome of ERP.
These include patient adherence to the ERP procedures
(540, 541), the patient’s degree of insight into the irrationality of his or her fears (with poor insight leading to worse
outcome in some [208, 542, 543], but not all [209], studies),
and certain co-occurring conditions. For example, severe
depression and some co-occurring anxiety disorders (e.g.,
posttraumatic stress disorder, generalized anxiety disorder)
(233, 544, 545) may negatively impact outcome. Other
predictors of treatment outcome have also been reported,
but none is sufficiently accurate to apply in the individual
case (532, 546). Because some data suggest that certain
subtypes of OCD patients (e.g., patients with severe hoarding behavior, patients without overt compulsions) may not
benefit as much from ERP, modifications of standard ERP
for these subtypes are being investigated (e.g., see references 121, 150). Whether the addition of formal cognitive
therapy elements can improve the outcome from ERP
(either for all OCD patients or for patients with co-occurring conditions such as depression) is also under investigation (Sections II.B.1, II.B.3, II.B.4, and V.C.2).
Some data suggest that ERP is most effective when delivered intensively (e.g., five sessions per week [547, 548]).
On the other hand, one study found that twice-weekly
ERP was comparable to intensive treatment (141), and good
results have been achieved with weekly, 1-hour sessions
(63). To date, no study has compared once- or twice-weekly
treatment with intensive treatment in a randomized controlled design.
Whether the effects of ERP achieved in randomized
controlled trials can be reproduced in routine clinical practice remains unclear. However, several large case series
found that ERP (even when delivered weekly) can produce robust effects in fee-for-service settings, as long as the
therapists are skilled (or supervised by those skilled) in
ERP for OCD (537, 539).
c. Long-Term Outcome From ERP
Studies examining the long-term outcome of adult OCD
patients after ERP have generally concluded that most patients remain treatment responders at follow-up (67, 132–
134, 165, 202, 549–552). However, these findings are inconclusive for reasons that include design limitations in
some studies (e.g., uncontrolled studies and/or naturalistic follow-up), methodological limitations in others (e.g.,
lack of standardized assessment instruments and/or blind
ratings), and/or inconsistencies in whether additional treatment was received during follow-up. Recently, Simpson et
al. (67) examined the posttreatment effects of intensive
ERP with relapse prevention after sustained treatment
discontinuation, using evaluators blind to original treatment assignment. Twelve weeks after treatment discontinuation, the relapse rate was significantly lower, and the
time to relapse was significantly longer, for ERP responders (with or without concomitant clomipramine; n= 33;
12% relapse rate) than for responders to clomipramine
alone (n= 11; 45% relapse rate). Limitations include the
small sample size and short period of observation after
treatment discontinuation.
Incorporating relapse prevention procedures into exposure therapy appears to improve the long-term outcome of
ERP. A small randomized trial (124) examined whether
ERP with (n= 10) or without (n=10) relapse prevention
produced different outcomes. Both groups received 3 weeks
of intensive ERP (i.e., 15 daily sessions with 45 minutes devoted to imaginal exposure and 45 minutes to in vivo exposure sessions) followed by four 90-minute sessions of either
relapse prevention (i.e., discussion of stressors likely to trigger OCD, meeting with a significant other to discuss maintenance of gains, and cognitive restructuring) or associative
therapy (i.e., free association about OCD symptoms) combined with progressive muscle relaxation (AT-PMR).
Those subjects receiving relapse prevention also received
nine 15-minute phone calls over 12 weeks of follow-up.
Outcome was evaluated after intensive ERP with relapse
prevention and after 6 months of follow-up. Both groups
had dramatic decreases in OCD symptoms after intensive
ERP, without a significant difference (Y-BOCS decreases in
subjects who completed the study: 66% for relapse prevention; 60% for AT-PMR). However, at 6-month follow-up
the relapse prevention group showed significantly lower relapse rates than the AT-PMR group on most measures and
a trend in this direction on the Y-BOCS. The authors concluded that relapse prevention helps patients maintain
gains from ERP. Relapse prevention techniques are part of
some standard ERP protocols (142).
Practice Guideline for the Treatment of Patients With Obsessive-Compulsive Disorder
d.
Cognitive-Behavioral Therapy as an Augmentor of
SRI Response
Data from open trials (i.e., Simpson et al. [161] [n=6], Tolin et al. [162] [n=20]) and a completed randomized trial
(i.e., Tenneij et al. [163] [n=96]) indicate that CBT consisting of ERP can successfully augment a partial response
to an adequate SRI trial. A small (n= 14) open trial (553)
also suggests that the addition of CBT consisting of exposure, response prevention, and cognitive therapy can help
SRI nonresponders, although this trial lacked a control
group continuing on medication alone. No data are available regarding the effect of adding cognitive therapy elements alone in attempts to augment medication response.
2. Cognitive Therapy
This section reviews studies that have examined the efficacy of cognitive therapy (CT) in the treatment of adults
with OCD. For the purposes of this review, CT includes
those variants of CBT that rely primarily on cognitive
therapy techniques as described in Section V.C.1. The
studies address three issues: whether CT without ERP is
effective, whether CT is as effective as ERP and/or medication, and whether the addition of cognitive procedures
to ERP leads to a better outcome.
a.
Efficacy of Cognitive Therapy Without ERP
A small randomized trial involving patients who had previously failed to respond to CBT consisting of ERP compared the efficacy of group cognitive therapy to a wait-list
control for OCD patients with contamination concerns
(554). Eleven patients received 9 weeks of Danger Ideation Reduction Therapy (DIRT), which consisted of
eight 1-hour group therapy sessions and included cognitive restructuring, expert testimony and corrective information, attentional focusing, DIRT proscribed exposure,
response prevention, and behavioral experiments. Although DIRT led to significant greater changes than the
wait-list control on several self-report OCD and depression measures, the effects were small (e.g., a 20% mean
reduction in OCD symptoms on the MOCI). Study limitations include the small sample size, self-report measures,
and use of a wait-list control.
An open trial enrolling 15 patients (555) found that individual CT in the absence of prolonged exposure led
to significant improvement on several self-report OCD
and depression measures (including the Y-BOCS, Obsessional Beliefs Questionnaire, and BDI). CT consisted of
14 weekly 60-minute sessions and included psychoeducation, CT procedures following Beck’s method, and relapse
prevention. Behavioral experiments were used to test and
correct a patient’s belief but did not involve prolonged exposure.
61
In sum, there is limited evidence to support the efficacy
of pure CT (i.e., cognitive restructuring without exposure
or “behavioral experiments”) in the treatment of OCD.
b. Efficacy of Cognitive Therapy Versus ERP
Most direct comparisons of CT and ERP have found that
these treatments produce similar results. However, strong
conclusions are difficult to reach for a number of reasons.
First, some variants of ERP include informal cognitive techniques (e.g., relapse prevention, cognitive restructuring
during exposures) and some forms of cognitive therapy
include informal exposures (i.e., behavioral experiments
[behaviors that test the validity of the patient’s obsessional
beliefs, e.g., “If I think about a disease, my daughter will
get it.”]), blurring the distinction between these treatments. Second, the published studies have differed in their
designs and treatment procedures (e.g., duration and frequency of treatment sessions). Third, only some studies
formally monitored therapist adherence to the treatment
protocols. Fourth, some studies had limited power to detect differences. Fifth, no study included a placebo group
other than a wait-list control. Therefore, the treatment recommendations gleaned from these studies are necessarily
specific to the procedures used and limited by these methodological weaknesses. Together, the data suggest that
CT that includes behavioral experiments has similar efficacy to ERP based solely on habituation (i.e., without discussion of feared consequences or dysfunctional beliefs).
Two early studies (556, 557) examined the efficacy of
rational-emotive therapy (RET) based on the work of
Ellis (558); this CT program included the identification
and challenge of irrational beliefs but no behavioral experiments. Both studies found that therapist-administered
RET helped OCD patients and was similar in efficacy to
self-controlled ERP. One study (557) concluded that RET
followed by self-controlled ERP was no better than selfcontrolled ERP alone. However, both studies had small
samples (i.e., n≤11 per condition) and used a less than optimal ERP format (e.g., self-controlled as opposed to therapist-guided exposure). Another small open trial in six
subjects compared RET with ERP and thought stopping
and found that RET was more effective than ERP for purely
obsessional patients who had no covert rituals, and that
thought stopping was not helpful at all (151).
A larger randomized study by van Oppen et al. (559)
compared outcomes in 28 patients who received 16 weeks
of CT based on the model of Beck (530) and Salkovskis
(531), and 29 patients who received self-controlled ERP.
This CT program targeted dysfunctional beliefs considered to be central to OCD (i.e., the overestimation of danger and inflated personal responsibility), and specifically
included behavioral experiments. For both conditions,
62
therapy was delivered weekly in 45-minute sessions. Among
the subjects who completed the trial, both treatments led
to significant and clinically meaningful improvement in
OCD. Although there were no significant group differences, CT appeared somewhat superior (Y-BOCS reduction: 45% for CT; 32% for ERP). However, a less than
optimal ERP format (i.e., self-controlled exposure) was utilized, and the CT program used behavioral experiments.
Half the patients in this study participated in a multicenter trial comparing fluvoxamine, ERP, and CT, described below.
Van Balkom et al. (61) randomly assigned 117 patients
to one of five conditions: fluvoxamine plus ERP, ERP, CT,
fluvoxamine plus CT, or wait-list control. At baseline,
patients on average had mild depressive symptoms. Full
results are presented for the 70 patients who completed
16 weeks of active treatment and the 16 patients who
completed the 8-week wait-list condition. The mean dose
at week 16 in both fluvoxamine conditions was 197 (±82)
mg/day. All therapy sessions were 45 minutes long. CT
and ERP were delivered as in the van Oppen study (559)
described above. CT targeted dysfunctional OCD beliefs
and included behavioral experiments. ERP consisted of
gradual self-controlled exposure in vivo with gradual selfimposed response prevention. At week 16, all active treatments led to a significant decrease on all OCD measures,
with no significant differences between the treatment groups
(Y-BOCS reduction for subjects who completed the trial:
46% for CT [n =19]; 32% for ERP [n= 19]; 43% for fluvoxamine plus CT [n=14]; 49% for fluvoxamine plus ERP
[n= 18]). The authors concluded there was no reason to
combine SRIs and CBT (either CT or ERP) in OCD adults
without severe co-occurring mood disorder. However,
neither the ERP nor the fluvoxamine treatments were optimized. Moreover, the combination groups received only
10 therapy sessions that started after 8 weeks of fluvoxamine treatment, whereas the groups receiving ERP or CT
alone received 16 therapy sessions. Some of these patients
were followed naturalistically for 6 months, but the fact
that they received varied treatment during this follow-up
period precludes strong conclusions (549).
A French multisite randomized trial (62) compared the
outcome of patients who received 20 hours of either CT
(n=32) or ERP (n=33) over 16 weeks. CT treatment consisted of twenty 1-hour individual sessions following the
Beck and Salkovskis model (i.e., challenging of dysfunctional beliefs); behavioral experiments to “confront feared
situations to modify thoughts” were also used. ERP consisting of therapist-aided exposure with response prevention was delivered in an intensive phase (4 weeks of
two 2-hour individual sessions per week) and a maintenance phase (12 weeks of one 40-minute booster session
APA PRACTICE GUIDELINES
every 2 weeks). In those patients who completed treatment,
both treatments led to significant and substantial reductions in OCD symptoms (Y-BOCS reduction: 44% for
CT; 42% for ERP), and many patients were YBOCS-25%
responders (77% for CT; 70% for ERP). There were no
significant group differences. Patients were followed after
treatment to week 52, but 26% of the patients were lost to
follow-up, and whether those followed received additional
treatment is unclear.
In a Canadian randomized trial (133), OCD patients
(48% who were taking a stable dose of medication and 50%
of whom had a co-occurring Axis I disorder) were randomly assigned to 12 weeks of CT (n =18), ERP (n= 16),
or wait-list control (n=33). Patients in the wait-list condition were randomly assigned to receive CT or ERP after
the 12-week delay, and their data were pooled with the
data from those who received active treatment initially.
Treatment was delivered in groups and consisted of 2.5hour sessions delivered once per week. Based on the work
of Salkovskis (560), Freeston et al. (64), and van Oppen
and Arntz (561), the CT focused on challenging appraisals
of intrusive thoughts; behavioral experiments were used
to collect evidence for and against alternative appraisals.
ERP consisted of in-session and between-session exposure and ritual prevention focused on producing habituation, and relapse prevention; discussion of cognitive beliefs was proscribed. In those patients who completed
treatment, both treatments were superior to wait-list control; however, group ERP was superior to group CT in
the pooled sample (Y-BOCS decrease: 26% for CT; 39%
for ERP). Of the 63 patients who completed treatment,
16% of CT patients and 38% of ERP patients recovered
(defined as a Y-BOCS score decrease ≥6 points and a total
score <12). Of note, 12 of 49 CT and 2 of 44 ERP patients
dropped out of the study after learning of their randomization and before starting treatment. Moreover, nearly
twice as many patients taking medication received ERP
than received CT. At 3-month follow-up, there was still a
significant advantage for ERP over CT. However, these
data are limited by the fact that patients were not prohibited from obtaining treatment during follow-up.
In another Canadian controlled trial (63), patients were
randomly assigned to receive individual CT (n = 37) or
ERP (n =34). Both treatments consisted of 12 weekly 60minute sessions and followed the same format as in the
study of McLean et al. (133) described above. Specifically,
the CT focused on challenging dysfunctional beliefs but
included behavioral experiments; the ERP included relapse prevention but no cognitive restructuring. In those
who completed treatment (n = 59, 83%), OCD severity
improved significantly in both treatment groups, with no
significant group differences (Y-BOCS score reduction:
Practice Guideline for the Treatment of Patients With Obsessive-Compulsive Disorder
56% for CT; 52% for ERP). Of those patients who completed the study, 67% of CT and 59% of ERP patients
recovered (defined as a Y-BOCS score decrease ≥6 points
and a total score < 12). Both groups also had a significant
decrease in depressive symptoms and in dysfunctional beliefs. The authors concluded that individual ERP utilizing
only habituation was similar in efficacy to individual CT
that included behavioral experiments, and that both treatments reduce OCD symptoms. Additional CT techniques
without exposure are described in case reports (129, 130).
c. Adding Cognitive Therapy to ERP
Some data suggest that ERP is more effective if it includes
not only habituation but also discussion of feared consequences and dysfunctional beliefs (120, 121). One small
study suggests that the addition of relapse prevention
helps patients maintain their gains (124). Whether CT
added to ERP helps OCD patients with co-occurring
conditions (e.g., depression) is under investigation.
An early study (562) found that both ERP and ERP
plus “self-instructional” talk (i.e., emitting more positive
statements after imagining being exposed to some feared
stimulus) led to clinically significant improvement. However, the small sample (n=8 vs. n=7) and the uncertain diagnostic validity of the sample (given the lack of standard
criteria at that time) preclude strong conclusions.
A Norwegian randomized trial (122) examined whether
the ERP protocol of Kozak and Foa (142), which includes
discussion of feared consequences and dysfunctional beliefs during exposures, could be improved by the addition
of formal CT elements based on Beck’s work (530). Patients were randomly assigned to receive ERP plus CT, ERP
plus relaxation training, or wait-list control for 6 weeks.
After 6 weeks, those assigned to the wait-list control were
randomly assigned to receive one of the active treatments.
The final sample consisted of 16 patients who received
ERP plus CT and 19 patients who received ERP plus relaxation training; 34% were taking a stable dose of medication during the trial. Therapy consisted of 2-hour sessions twice weekly, for a total of 12 sessions. Each session
consisted of 1.5 hours of ERP and 30 minutes of either
CT (based on the Beck model and focused on either cooccurring conditions or faulty OCD beliefs) or relaxation
training (progressive muscle relaxation). ITT analysis indicated that both active groups did significantly better
than wait-list controls, with no differences between the
two active conditions (Y-BOCS reduction: 33% for ERP
plus CT; 28% for ERP plus relaxation training). However, more patients completed ERP plus CT (15/16) than
ERP plus relaxation (12/19). The authors concluded that
the addition of CT to ERP (delivered as outlined in Kozak
and Foa [142]) may reduce the dropout rate but does not
63
necessarily enhance efficacy. However, the sample was relatively small, and there were other methodological limitations (e.g., wait-list design, many ratings done by the therapist, more exposure time for patients who received ERP
plus relaxation training).
Recent studies have also examined whether CT added
to ERP can improve outcome (120, 122).
3. Group and Multifamily Behavioral Treatment
A limited number of studies have investigated group and
multifamily behavioral treatments for OCD.
A 12-week unblinded random-allocation study (132)
compared group (n=30) and individual ERP (n = 31) with
an active control (progressive muscle relaxation; n =32).
Patients with major depression or Axis II disorders were
excluded. Both active treatments were superior to the
control treatment, as reflected in changes in Y-BOCS, BDI,
and Social Adjustment Scale scores. However, response to
treatment was faster with individual behavior therapy. The
authors concluded that group therapy ERP was useful for
less severe OCD. From an efficiency standpoint, the individual treatment consumed 720 staff hours compared with
48 hours in the group therapy condition.
A randomized trial (133) (consisting of 12 weeks of weekly
2.5-hour groups) compared group CT with behavioral experiments (n=33) and group ERP (n=40) against a wait-list
control. The control subjects were later randomly assigned
to either active treatment. Subjects were diagnosed with
DSM-IV OCD of greater than 1 year’s duration and had
been taking medication on a stable regimen for ≥3 months.
Ninety-three subjects entered the trial, 76 (82%) began
treatment, and 63 (68%) completed treatment. Both active
treatments were significantly superior to the control condition as reflected in change in Y-BOCS scores. The effect
sizes (Cohen’s d) were 1.62 for ERP (n=16), and 0.98 for
CT (n =18). For those completing treatment, the difference in the proportions of “recovered” subjects (defined
as Y-BOCS score decrease ≥6 points and final score <12)
was not significant: ERP (38%, n=32) and CBT (16%, n=
31). At 3-month follow-up, ERP was associated with a significantly greater recovery rate among subjects who completed the treatment: ERP (45%) and CBT (13%). The
ERP group included more subjects using medication, but
in the analyses this did not affect improvement. This study
suggested that group ERP was marginally superior to group
CT. Caution in interpreting these results is warranted, because more subjects in the ERP group were taking medication, and because CT was characterized by a higher refusal rate among subjects accepted for treatment.
A single-blind, randomized trial compared 12 weeks of
weekly 2-hour group therapy sessions combining ERP
with cognitive therapy and homework assignments (group
64
CBT) (n=23) against a wait-list control (n=24) (134). The
group CBT included exposure, ritual prevention, and cognitive restructuring. Seventy percent of those in group CBT
were YBOCS-35% responders compared with 4% of controls. The Y-BOCS score effect sizes (not Cohen’s d) in the
ITT groups were 1.33 for the group CBT group and 0.43
for the controls. The therapeutic gains were maintained at
3-month follow-up. Group CBT was associated with a significant improvement in the quality of life as measured by
the Abbreviated WHOQOL. Nearly half the subjects were
maintained on stable medication regimens, but this did
not appear to influence the effect of active treatment. These
and other reports suggest the utility of group behavioral
therapies in the treatment of OCD; however, additional
study is warranted.
An uncontrolled, double-blind study without random
assignment compared group CBT (including ERP) (n =
17) and multifamily CBT (n =19) (136). In each treatment
there were ten to twelve 2-hour sessions monthly. This
small study found that both modalities were effective, with
a significant decrement in the Y-BOCS score in both components, and a significant decrease in the Sheehan Disability Inventory in the group CBT component. This study
provides support for both group approaches. There are
too few studies of multifamily CBT to provide sufficient
evidence to recommend its use.
In an unblended, random allocation study in India,
patients who had had no prior CBT but who had failed
pharmacological treatment were assigned to either a treatment in which family members functioned as co-therapists
conducting desensitization and ERP (n=15) or the same
treatment without a family member co-therapist (n = 15)
(135). The treatment group with a family member co-therapist showed significantly greater improvement at 12 weeks
and at 1-month follow-up on the MOCI and the Global
Assessment of Severity scale. This small study suggests
the utility of family co-therapists, but the results may not
be generalizable to other cultures and are limited by the
absence of a control group and the variability to be expected among families.
4. Kundalini Yoga
In a 12-week study (563), subjects with a primary DSMIII-R diagnosis of OCD, a minimum Y-BOCS score of 15,
and no medical contraindications to yoga were randomly
assigned to 12 weekly 2-hour group sessions of Kundalini
yoga (n= 12) or 1-hour group sessions of mental mindfulness and relaxation response management (n =10). Both
groups were instructed to practice at home daily. Seven
subjects completed each treatment arm. The subjects in
the yoga group who completed the trial experienced a mean
Y-BOCS score decrease of 38% (9.4 points), compared with
APA PRACTICE GUIDELINES
a 14% decrease (2.9 points) for the control group. In the
ITT analyses, the yoga group’s mean decrease in Y-BOCS
score was significant (5.5 points), but the mean decrease
for the control group (2.0 points) was not. In both groups,
an unspecified but equal number of subjects had been taking stable doses of anti-OCD medications for at least 3
months before randomization. Yoga was apparently well
tolerated, but the reasons for dropout are not given. This
small study requires replication by an independent group
before any conclusion about the effectiveness of yoga can
be drawn.
D. COMBINED THERAPY
Only six randomized trials have directly addressed whether
the combination of an SRI and CBT consisting of ERP is
superior to either treatment alone in adults with OCD,
and limitations in their designs and/or procedures prevent
definitive conclusions. Some studies also compared SRI
monotherapy with ERP monotherapy. Few studies had
adequate sample sizes to detect small differences between
treatments, even if such differences did exist. Moreover,
some studies excluded patients with significant comorbidity even though comorbidity is common in OCD and such
patients may be those who would benefit most from combination treatment. Finally, certain design decisions (e.g.,
how the treatments were delivered) may have prevented
the detection of important differences between combination treatment and monotherapy.
Despite these problems, the available data support the
idea that combination therapy can be superior to monotherapy in some OCD patients but that it is not necessary
for all OCD patients (166, 167). In particular, one study
found that combination therapy is superior to ERP
monotherapy in OCD patients with co-occurring depression (164). In OCD patients without co-occurring depression, another study found that combination therapy and
intensive ERP therapy alone were each superior to SRI
monotherapy (123).
Marks et al. (564) compared the outcome of 40 OCD
patients randomly assigned to receive oral clomipramine
or pill placebo plus 30 sessions of CBT consisting of ERP.
The study design was complex: during weeks 0–4, patients
received either clomipramine or placebo; during weeks 4–
10, patients also received either 30 sessions of ERP or 15
sessions of relaxation training followed by 15 sessions of
ERP. A direct comparison of the effects of clomipramine
plus ERP, ERP plus placebo, clomipramine plus relaxation training, and placebo plus relaxation training could
only be made at week 7. At that time, patients receiving
clomipramine plus ERP (n= 10) had more improvement
Practice Guideline for the Treatment of Patients With Obsessive-Compulsive Disorder
in rituals than patients receiving ERP plus placebo (n=10)
or clomipramine plus relaxation training (n = 10); however, there was no significant interaction of clomipramine
and ERP. The complex design, small sample, lack of standard OCD measures, and treatment procedures (e.g., the
effects of clomipramine were likely underestimated at
week 7) preclude strong conclusions.
A separate study (565) compared the outcome of 49
patients randomly assigned to receive one of four treatments: 6 months of clomipramine and 23 weeks of antiexposure instructions (clomipramine plus antiexposure); 6
months of clomipramine and 23 weeks of self-controlled
ERP (clomipramine plus ERP [self]); 6 months of clomipramine and 8 weeks of self-controlled ERP, followed
by therapist-aided ERP from weeks 8 to 23 (clomipramine plus ERP [self and therapist]); or 6 months of
placebo and 8 weeks of self-controlled ERP, followed by
therapist-aided ERP from weeks 8 to 23 (placebo plus
ERP [self and therapist]). At week 8, clomipramine plus
ERP (self, n= 25) produced significantly more improvement in rituals and depression than placebo plus ERP
(self, n = 12). However, at week 23, clomipramine plus
ERP (self and therapist, n=10) showed no superiority over
placebo plus ERP (self and therapist) plus placebo (n=8).
At week 8, clomipramine plus ERP (self, n=13) also produced significantly more improvement than clomipramine plus antiexposure (n=12) in rituals and depression.
Only three of the subjects in the clomipramine plus antiexposure group improved enough to continue, precluding further comparisons. The authors concluded that
the combination of clomipramine and ERP therapy had
a small transitory additive effect compared with placebo
plus ERP therapy. However, the complex design, small
sample, lack of standard OCD measures, and treatment
procedures (e.g., the clomipramine groups only achieved
doses ranging from 127–157 mg/day) preclude strong
conclusions.
Cottraux et al. (165) randomly assigned 60 adult patients with OCD to 24 weeks of fluvoxamine with ERP
(fluvoxamine plus ERP), fluvoxamine with instructions
not to engage in ERP (fluvoxamine plus antiexposure), or
placebo plus ERP. Of the 60 patients who entered, 44 (73%)
completed all 24 weeks (n=16, 13, and 15, respectively); of
these 44, 19 (43%) entered with a major depressive or dysthymic disorder (mean 17-item Ham-D score= 19). ERP
therapy consisted of eight weekly sessions that included
imaginal ERP during sessions and self-controlled ERP, followed by 16 weeks of therapist-guided ERP. Among those
patients who completed treatment, all groups improved
on some measures of rituals and depression, but only the
fluvoxamine plus ERP group improved on all measures at
week 24. The combined fluvoxamine treatment groups
had the largest percent reduction in the duration of rituals
65
per day (fluvoxamine plus ERP = 46%; fluvoxamine plus
antiexposure = 42%; placebo plus ERP = 25%) and the
largest percentage of patients who, by self-report, had
more than a 30% reduction in rituals per day (fluvoxamine plus ERP = 69%; fluvoxamine plus antiexposure =
54%; placebo plus ERP =40%); however, these group differences were not statistically significant. Study limitations include the small sample, the lack of standard OCD
measures, and the limited information about the treatment procedures (e.g., the ERP protocol consisted of
weekly sessions of an unspecified duration, and other psychosocial interventions were provided “as needed”).
Hohagen et al. (164) randomly assigned 60 adults with
OCD to receive fluvoxamine plus CBT or placebo plus
CBT. Many patients had co-occurring mood, anxiety, and
personality disorders (mean 21-item Ham-D score= 19),
and many (92%) had received prior treatment (84% had
taken medication, 35% had prior CBT). The mean dose of
fluvoxamine was 288 mg/day (range= 250–300 mg/day).
CBT was conducted weekly for at least 3 hours and included
therapist-aided exposure as well as cognitive restructuring.
After 9 weeks of treatment, both groups showed significant
reductions in OCD severity. However, there were significantly more YBOCS-35% responders in the fluvoxamine
plus CBT group (87.5%) than in the placebo plus CBT
group (60%). Post hoc analyses revealed that 1) both groups
improved significantly and comparably on compulsions,
but the fluvoxamine plus CBT group improved significantly more on obsessions; and 2) patients with co-occurring depression fared better if they received fluvoxamine
plus CBT. The authors concluded that combination therapy should be used when obsessions dominate the clinical
picture or when a secondary depression is present. Limitations include the lack of data on whether the two groups
differed in their response to prior treatment, the fact that
only 49 patients entered the final analysis because 9 were
removed to equate baseline Y-BOCS scores in the two
groups, and the fact that two patients dropped out for clinical reasons.
Van Balkom et al. (61) randomly assigned 117 patients
to receive one of five conditions: fluvoxamine plus ERP,
ERP, CT, fluvoxamine plus CT, or wait-list control. At
baseline, patients on average had mild depressive symptoms. Full results are presented for the 70 patients who
completed 16 weeks of active treatment and the 16 patients who completed the 8-week wait-list condition. The
mean fluvoxamine dose at week 16 in both fluvoxamine
conditions was 197 (± 82) mg/day. All therapy sessions
were 45 minutes long. ERP consisted of gradual self-controlled exposure in vivo with gradual self-imposed response prevention. At week 16, all active treatments led
to a significant decrease on all OCD measures, with no
significant differences between the treatment groups.
66
The authors concluded there was no reason to combine
SRIs and CBT (either ERP or CT) in OCD adults without severe co-occurring mood disorder. However, neither
the ERP nor the fluvoxamine dosing was optimized. Moreover, the combination group received only 10 ERP sessions, whereas the group receiving ERP alone received 16
sessions.
Foa et al. (123) compared treatment outcome in 122 adult
OCD patients randomly assigned to receive intensive ERP,
clomipramine, clomipramine plus intensive ERP, or
placebo. Patients with major depressive disorder (and a
Ham-D ≥ 18) were excluded. Mean daily doses of clomipramine during the last study week for all who entered
and all who completed the trial, respectively, were 196 and
235 mg/day for clomipramine patients and 163 and 194 mg/
day for clomipramine plus intensive ERP patients. ERP
was delivered intensively for the first 4 weeks (i.e., two information-gathering sessions, fifteen 2-hour sessions conducted over 3 weeks, two home visits); this intensive phase
was followed by eight 45-minute weekly maintenance sessions over the next 8 weeks. Patients receiving clomipramine plus intensive ERP began both treatments simultaneously. At week 12, all active treatments were superior
to placebo at reducing OCD symptoms. In addition, clomipramine plus intensive ERP and ERP did not significantly differ from each other, but each was superior to clomipramine alone. For all who entered treatment and all
who completed the 12-week trial, the CGI-I:1,2 response
rates were, respectively, 70% and 79% for clomipramine
plus intensive ERP, 42% and 48% for clomipramine, 62%
and 86% for ERP, and 8% and 10% for placebo. The authors concluded that clomipramine, intensive ERP, and
their combination are all efficacious treatments for OCD.
In addition, in OCD patients without co-occurring depression, intensive ERP was superior to clomipramine.
The authors noted several factors that may have limited
their ability to detect a superiority of combination treatment over intensive ERP monotherapy (e.g., the exclusion of patients with co-occurring depression, the potency
of intensive ERP, the fact that the combination group did
not achieve maximum clomipramine doses). Study limitations include the lack of data on patients who dropped out
after randomization but before treatment started and the
lack of systematic data on subjects’ prior treatment history. Interpretation of these results (123, 126) is also limited by uncertainty as to whether the treatment groups
were equally treatment resistant at baseline and by high
study refusal rates and dropout rates.
In the absence of definitive data, combination treatment (SRI medication plus CBT consisting of ERP) is
appropriate in clinical situations in which there are cooccurring disorders that are SRI responsive or there has
APA PRACTICE GUIDELINES
been a partial response to monotherapy (163), and in efforts to reduce the chance of relapse when medication is
discontinued (67).
E. DISCONTINUATION OF ACTIVE TREATMENT
Four double-blind SRI discontinuation studies in adults
with OCD have been published. Each concerned a different SRI and used a different design (e.g., length of observation and method of placebo substitution) and a different
relapse definition. Each produced different results.
Pato et al. (199) found that 89% of the 18 patients who
had responded to clomipramine had “substantial recurrence” (not further defined) of OCD 7 weeks after they
were blindly switched (over 4 days) to placebo. Romano et
al. (201) found no significant differences in 1-year estimates of relapse rates among patients who had responded
after 5 months of fluoxetine treatment between 36 patients who continued to take fluoxetine (21%) and 35 patients who were switched to placebo (32%); relapse was
defined as a ≥50% loss of improvement on the Y-BOCS, a
Y-BOCS score of ≥19, and a CGI-I rating of much or very
much worse relative to the end of treatment. Koran et al.
(200) found that it was uncommon for patients who responded to sertraline to discontinue the medication because of relapse or insufficient response over 28 weeks,
regardless of whether they continued to take sertraline
(3% [3/108]) or were switched over 2 weeks to placebo
(4% [5/113]); relapse was defined as a Y-BOCS increase of
≥5 points, a total Y-BOCS score of ≥20, and a ≥1-point
increase in CGI-I score relative to the end of acute treatment at three consecutive visits at 2-week intervals. Rates
of relapse or discontinuation because of insufficient response were 9% for sertraline and 24% for placebo, a significant difference. Finally, Hollander et al. (80) found that
patients who had responded to 9 months of paroxetine
treatment who continued to take paroxetine for 6 months
had a significantly lower relapse rate (37.7%) than those
switched immediately to placebo (58.8%) and a longer
time to relapse (62.9 days vs. 28.5 days); relapse was defined as a return to the pretreatment Y-BOCS score or a
≥1-point increase on the CGI-severity (CGI-S) scale (566)
relative to the end of treatment. In summary, using different SRIs, different study designs, and different relapse criteria, double-blind discontinuation studies reported SRI
relapse rates ranging from a low of 4% over 28 weeks
(200) to a high of 89% over 7 weeks (199).
An unblinded study of 130 OCD patients (177), in
which drug discontinuation was instituted after response
to 6 months of open treatment, reported significantly
higher 6-month relapse rates for the patients whose medication was discontinued: 8% (clomipramine 150 mg/day) ver-
Practice Guideline for the Treatment of Patients With Obsessive-Compulsive Disorder
sus 46% (no drug), 0% (fluoxetine 40 mg/day) versus 40%
(no drug), and 8% (fluvoxamine 300 mg/day) versus 62% (no
drug) (177). Equally large or larger disparities were present
after 1 and 2 years of treatment versus no treatment, and relapse rates were higher. Relapse was defined as a Y-BOCS
increase of ≥25% plus a CGI-I score indicating much or
very much worse relative to the end of treatment. These data
suggest both that SRIs may not fundamentally differ in the
long-term durability of treatment response after treatment
discontinuation and that most patients will eventually relapse after stopping SRI treatment.
In a review of 16 CBT studies that used ERP, Foa and
Kozak (202) concluded that patients receiving ERP (with
and without concomitant medication) did well long-term.
Of 376 treated patients, 76% were responders at follow-up
(mean=29 months; range=6–72 months). Of responders to
acute ERP treatment (with or without medication), the
proportion losing their response during follow-up was 20%
or less in most studies. While suggestive, these findings are
inconclusive because of 1) design limitations in some studies (e.g., uncontrolled studies with naturalistic follow-up);
2) methodological limitations in others (e.g., lack of evaluators blind to original treatment assignment); 3) differences
in determining “response”; 4) inconsistencies in whether
treatment during follow-up was permitted (and reported);
and 5) differences in length of follow-up. Further complicating any comparison with SRI relapse rates is the fact that
the relapse definition employed in this review (i.e., loss of
response) differs from that used in the SRI studies.
67
A multi-site study that compared the effects of clomipramine and intensive ERP after 12 weeks of treatment
(123) and again 12 weeks after treatment discontinuation
(67) found that subjects who responded to intensive ERP
(with or without concomitant clomipramine) had a significantly lower relapse rate (12%) and longer time to relapse
after treatment discontinuation than did subjects who
responded to clomipramine alone (45%); relapse was defined as a return to baseline severity on the CGI-S scale.
Post hoc analyses of these data generally supported these
findings, since most of the relapse criteria examined produced the same outcome—albeit with substantial variability—depending on the specific criteria used for relapse (203).
However, high study refusal rates (71% of those meeting
entry criteria refused to participate) and dropout rates
(18% at randomization and an additional 23% before completion) may limit the widespread applicability of this
study’s findings.
Together, these data suggest that ERP treatment response may be more durable, at least in the short run, than
response to some SRIs after they are discontinued. However, the observed differences could be explained by other
factors, including clinical characteristics of the subjects
studied, differences in the length of follow-up, the intensity of treatment prior to treatment discontinuation, the
rate of medication taper, and the relapse criteria. Because
of these differences, no definitive conclusions about the
relative durability of SRI and ERP treatment effects can
be drawn from these studies.
Part C
FUTURE RESEARCH NEEDS
Although current therapeutic approaches can alleviate
symptoms of OCD, additional research is needed to enhance existing treatments and develop additional therapeutic options. More specifically, studies are needed to
determine whether modifications in treatment regimens
can improve the proportion of responders and the degree,
rapidity, and permanence of response. For example, studies
could show whether higher doses or more rapid titration
of SRIs results in faster treatment response and greater
symptom relief. A number of medications (e.g., mirtazapine, pindolol, stimulants, opiate-receptor agonists,
glutamate-modulating agents, inositol, ondansetron, some
anticonvulsants, lithium) have shown some efficacy in preliminary research either alone or as augmentation strategies; however, these agents and related approaches require
further study in larger randomized trials. The use of adjunctive antipsychotic medications and other promising
somatic treatments (i.e., transcranial magnetic stimulation, deep brain stimulation) also need additional investigation. The recent introduction of a monoamine oxidase
inhibitor administered by skin patch, which at initial doses
does not require dietary restrictions, allows a re-investigation of the possible utility of this class of medication in
treating OCD.
68
Further studies of psychosocial therapies are also necessary. For example, with CBT, it will be important to determine the relative efficacies of different CBT treatment
elements and the optimal schedule (e.g., treatment session
length and frequency, number of sessions) for administering CBT in the acute, continuation, and maintenance
phases of treatment. In designing such research, the treatment schedules investigated will likely differ with the goals
of treatment (e.g., induce or maintain response or remission, reduce risk of relapse). Because CBT can be administered using a variety of formats (e.g., individual, group,
supplementary self-help manuals), it will be important to
compare the efficacies of these approaches. Other psychosocial therapies, such as therapies that involve the family in
the patient’s CBT, also require further study.
In terms of approaches to combining medications and
psychosocial therapies, more studies are needed to determine optimal methods to achieve the fastest onset of therapeutic action, the greatest degree of response, and the least
likelihood of relapse during active treatment and following
treatment discontinuation. It is also crucial to develop and
test strategies for relapse prevention as well as to identify
the necessary length of psychotherapy and of pharmacotherapy before treatment can be safely discontinued.
In addition to further investigating existing treatments
for OCD, it is equally important to develop new therapeutic approaches to initial treatment or new augmentation strategies for patients who have an inadequate response to first-line medications. Such approaches might
involve new psychosocial treatments, including psychotherapies, or new somatic treatments, including pharmacotherapies. Rehabilitation methods for those who have
been disabled also require study.
Development of new therapeutic modalities would be
aided by an improved understanding of the neurobiological alterations associated with OCD and with response to
OCD treatments. For example, identifying susceptibility
genes for OCD could provide insight into the pathogenesis of the disorder, establish a means to identifying individuals at high risk, and perhaps lead to the development
of more rational and effective therapies. Advances in pharmacogenetics, including gene chip techniques, could help
identify new neurochemical targets for pharmacotherapy
and predict response or side effects to particular medications
or to classes of medications. Other markers (e.g., blood,
electroencephalogram, neurocognitive measures, neuroimaging results or other neurobiological signs) may also
be useful in understanding the neurobiological bases of
OCD and in identifying early effects of medications or psy-
APA PRACTICE GUIDELINES
chotherapy that predict treatment outcomes for individual
patients. For example, several small studies (567, 568) using PET show correlations between rates of glucose metabolism in specific brain regions and response of OCD
symptoms to medications or behavioral therapy. Developing a valid animal model for OCD would also enhance our
knowledge of the underlying pathophysiologic basis of
the disorder and aid in identifying and developing new
treatment options.
With all therapeutic approaches to OCD, studies of
effectiveness will be required to supplement the findings
of efficacy studies. In addition, studies need to provide
more information that will help target specific treatment
approaches to individual patients. For example, individuals with specific subtypes of OCD (e.g., hoarding, contamination, mental compulsions) or those with specific co-occurring symptoms or disorders (e.g., co-occurring tics or
co-occurring schizotypal personality disorder) may exhibit better responses to specific treatments or combinations of treatments. The optimal schedule and the effective
elements of treatment may also differ by OCD symptom
type or co-occurring condition.
Interpretation and dissemination of future research
would be aided by more consistent use of the CONSORT
recommendations in designing and reporting randomized
treatment trials (569, 570) and by including details on
study power and effect sizes. Utilizing a reliable and valid
written self-rating scale to measure OCD symptom intensity may be useful in future studies. Standardizing the definitions of degrees of treatment response, resistance,
remission, and relapse following the models of the International Treatment Refractory OCD Consortium (152)
and Simpson et al. (126, 203) would also be helpful.
In order to make the advances in treatments for OCD
available to more individuals with the disorder, health services research on OCD and its treatment is needed. Such
research might help find ways to increase the availability
of effective treatments such as CBT or of OCD treatment
in general (e.g., across states and payers). Given the typical delays between OCD onset and initiation of treatment, there is a need for a sensitive and specific self-rated
OCD screening questionnaire for use in primary care settings. An improved understanding of the public health
impact of OCD (e.g., direct and indirect costs of OCD via
health care, premature death, co-occurring illnesses, lost
productivity of OCD patients, and lost work time of relatives caring for an OCD patient) is also important and
could lead to specific approaches to reducing disability
and improving patients’ quality of life.
Practice Guideline for the Treatment of Patients With Obsessive-Compulsive Disorder
69
APPENDIX: EDUCATIONAL RESOURCES FOR PATIENTS AND FAMILIES
The American Psychiatric Association does not vouch for
or endorse the accuracy of the information contained in
any of the publications or Web sites listed in this appendix
at the time of writing or in the future, although they are
believed to be generally trustworthy at the time of writing. The clinician should review a book or visit a Web site
before recommending it to a patient.
RESOURCES FOR OCD
1. Baer L: Getting Control: Overcoming Your Obsessions and Compulsions. New York, Plume Books,
2000.
2. Baer L: The Imp of the Mind: Exploring the Silent
Epidemic of Obsessive Bad Thoughts. New York,
Plume Books, 2001.
3. Chansky RE: Freeing Your Child From ObsessiveCompulsive Disorder. New York, Crown, 2000.
4. Ciarrocchi JW: The Doubting Disease: Help for
Scrupulosity and Religious Compulsions. Mahwah,
NJ, Paulist Press, 1998.
5. Foa EB, Kozak MJ: Mastery of Obsessive-Compulsive Disorder: A Cognitive-Behavioral Approach:
Client Kit. New York, Oxford University Press,
1997.
6. Foa EB, Wilson R: Stop Obsessing! How to Overcome Your Obsessions and Compulsions, 2nd ed.
New York, Bantam, 2001.
7. Gravitz HL: Obsessive Compulsive Disorder: New
Help for the Family. Santa Barbara, CA, Healing
Visions Press, 1998.
8. Grayson J: Freedom From Obsessive Compulsive
Disorder: A Personalized Recovery Program for Living With Uncertainty. New York, Penguin (Tarcher),
2003.
9. Greist JH: Obsessive-Compulsive Disorder: A Guide.
Madison, WI, Obsessive-Compulsive Information
Center, Madison Institute of Medicine, 2000.
10. Hyman BM, Pedrick C: The OCD Workbook: Your
Guide to Breaking Free From Obsessive Compulsive Disorder, 2nd ed. Oakland, CA, New Harbinger Publications, 2005.
11. Munford PR: Overcoming Obsessive Checking. Oakland, CA, New Harbinger Publications, 2004.
12. Munford PR: Overcoming Obsessive Washing.
Oakland, CA, New Harbinger Publications, 2005.
13. Neziroglu F, Bubrick J, Yaryura-Tobias JA. Overcoming Compulsive Hoarding: Why You Save and
How You Can Stop. Oakland, CA, New Harbinger,
2004.
14. Neziroglu F, Yaryura-Tobias JA: Over and Over
Again: Understanding Obsessive-Compulsive Disorder. San Francisco, Jossey-Bass, 1997.
15. Osborn I: Tormenting Thoughts and Secret Rituals.
New York, Dell, 1999.
16. Penzel F: Obsessive-Compulsive Disorders: A
Complete Guide to Getting Well and Staying Well.
New York, Oxford University Press, 2000.
17. Purdon C, Clark DA: Overcoming Obsessive
Thoughts: How to Gain Control of Your OCD.
Oakland, CA, New Harbinger Publications, 2005.
18. Santa TM: Understanding Scrupulosity: Helpful
Answers for Those Who Experience Nagging
Questions and Doubts. Ligouri, MI, Ligouri Publications, 1999.
19. Schwartz JM: Brain Lock: Free Yourself From
Obsessive Compulsive Disorder. New York, Harper
Collins, 1996.
20. Steketee GS: Overcoming Obsessive-Compulsive
Disorder: Client Manual. Oakland, CA, New Harbinger Publications, 1999.
21. Summers M (with Hollander E): Everything in Its
Place: My Trials and Triumphs With ObsessiveCompulsive Disorder. New York, Penguin Putnam,
1999.
22. van Noppen B, Pato M, Rasmussen S: Learning to
Live With OCD. New Haven, CT, Obsessive Compulsive Foundation, 2003.
23. Waltz M: Obsessive-Compulsive Disorder: Help for
Children and Adolescents. Sebastopol, CA, O’Reilly
Press, 2000.
Obsessive Compulsive Foundation
676 State St.
New Haven, CT 06511
Tel: 203-401-2070
www.ocfoundation.org
Obsessive-Compulsive Information Center
Information Centers
Madison Institute of Medicine
7617 Mineral Point Rd.
Suite 300
Madison, WI 53717
Tel: 608-827-2470
www.miminc.org/aboutocic.html
Scrupulous Anonymous
Offers a monthly newsletter for those with the religious/
moral questioning form of OCD.
http://mission.liguori.org/newsletters/scrupanon.htm
70
San Francisco Bay Area Resource & Internet Guide for
Extreme Hoarding Behavior, Clutterers Syndrome, or
Pack Rat Syndrome
www.hoarders.org
American Academy of Child and Adolescent Psychiatry
Provides “fact sheets” for families about OCD, Tourette’s
disorder, anxiety disorders, and other disorders, as well as
information about locating treating clinicians.
3615 Wisconsin Ave., NW
Washington, DC 20016-3007
Tel: 202-966-7300
Facts for Families database:
www.aacap.org/page.ww?section=Facts+for+
Families&name=Facts+for+Families
RESOURCE FOR TIC DISORDERS
Tourette Syndrome Association, Inc.
42-40 Bell Blvd.
Bayside, NY 11361
Tel: 718-224-2999
www.tsa-usa.org
RESOURCES FOR PANIC DISORDER AND
SOCIAL ANXIETY DISORDER
1. Antony MM, McCabe RE: 10 Simple Solutions to
Panic: How to Overcome Panic Attacks, Calm Physical Symptoms, and Reclaim Your Life. Oakland, CA,
New Harbinger Publications, 2004.
2. Barlow DH, Craske MG: Mastery of Your Anxiety and
Panic (MAP-3): Client Workbook for Anxiety and
Panic, 3rd ed. New York, Oxford University Press, 2000.
3. Bassett L: From Panic to Power: Proven Techniques
to Calm Your Anxieties, Conquer Your Fears, and Put
You in Control of Your Life. New York, HarperCollins, 1997.
4. Bourne EJ: The Anxiety and Phobia Workbook, 3rd
ed. Oakland, CA, New Harbinger Publications, 2000.
5. Craske MG, Barlow DH: Mastery of Your Anxiety
and Worry: Client Workbook, 2nd ed. New York, Oxford University Press, 2006.
6. Marks IM: Living With Fear: Understanding and
Coping With Anxiety, 2nd ed. New York, McGrawHill, 2001.
7. Pollard CA, Zuercher-White E: The Agoraphobia
Workbook: A Comprehensive Program to End Your
Fear of Symptom Attacks. Oakland, CA, New Harbinger Publications, 2003.
8. Rachman S, De Silva P: Panic Disorder: The Facts,
2nd ed. New York, Oxford University Press, 2004.
APA PRACTICE GUIDELINES
9. White JR: Overcoming Generalized Anxiety Disorder: A Relaxation, Cognitive Restructuring, and
Exposure-Based Protocol for the Treatment of
GAD: Client Workbook. Oakland, CA, New Harbinger Publications, 1999.
10. Wilson RR: Don’t Panic: Taking Control of Anxiety
Attacks, revised ed. New York, HarperCollins, 1996.
11. Zuercher-White E: Overcoming Panic Disorder and
Agoraphobia: Client Manual. Oakland, CA, New
Harbinger Publications, 1999.
12. Antony MM, Swinson RP: The Shyness and Social
Anxiety Workbook: Proven Techniques for Overcoming Your Fears. Oakland, CA, New Harbinger Publications, 2000.
13. Butler G: Overcoming Social Anxiety and Shyness: A
Self-Help Guide Using Cognitive-Behavioral Techniques. New York, New York University Press, 2001.
14. Hollander E, Bakalar N: Coping With Social Anxiety:
The Definitive Guide to Effective Treatment Options.
New York, Henry Holt, 2005.
15. Hope DA, Heimberg RG, Juster HA, Turk CL: Managing Social Anxiety: A Cognitive-Behavioral Therapy Approach: Client Workbook. New York, Oxford
University Press, 2000.
16. Rapee RM: Overcoming Shyness and Social Phobia:
A Step-by-Step Guide. Lanham, MD, Jason Aronson,
1998.
17. Schneier F, Welkowitz L: The Hidden Face of Shyness. New York, Avon Books, 1996.
18. Stein MB, Walker JR: Triumph Over Shyness: Conquering Shyness and Social Anxiety. Columbus, OH,
McGraw Hill, 2002.
19. Zimbardo PG. Shyness: What It Is and What To Do
About It. New York, Addison-Wesley, 1999.
Anxiety Disorders Association of America
8730 Georgia Ave.
Suite 600
Silver Spring, MD 20910
Tel: 240-485-1001
www.adaa.org
Anxiety Treatment and Research Centre
6th Floor, Fontbonne Building
St. Joseph’s Healthcare, Hamilton
50 Charlton Ave., East
Hamilton, ON L8N 4A6
Canada
Tel: 905-522-1155
www.anxietytreatment.ca
SocialAnxietySupport.com
www.socialanxietysupport.com
Practice Guideline for the Treatment of Patients With Obsessive-Compulsive Disorder
RESOURCES FOR POSTTRAUMATIC STRESS
DISORDER (PTSD)
1. Armstrong K, Best S, Domenci P: Courage After
Fire: Coping Strategies for Returning Soldiers and
Their Families. Berkeley, CA, Ulysses Press, 2005.
2. Matsakis A: I Can’t Get Over It: A Handbook for
Trauma Survivors, 2nd ed. Oakland, CA, New Harbinger Publications, 1996.
3. Rothbaum BO, Foa EB: Reclaiming Your Life After
Rape: A Cognitive-Behavioral Therapy for PTSD.
San Antonio, TX, Psychological Corporation, 2000.
U.S. Department of Veterans Affairs, National Center for
Posttraumatic Stress Disorder
www.ncptsd.va.gov
RESOURCES FOR SPECIFIC PHOBIAS
1. Antony MM, Craske MG, Barlow DH: Mastery of
Your Specific Phobia: Client Kit. New York, Oxford
University Press, 1995.
2. Bourne EJ: Overcoming Specific Phobia: A Hierarchy and Exposure-Based Protocol for the Treatment
of All Specific Phobias: Client Manual. Oakland, CA,
New Harbinger Publications, 1998.
3. Brown D: Flying Without Fear. Oakland, CA, New
Harbinger Publications, 1996.
4. Marks IM: Living With Fear: Understanding and
Coping With Anxiety, 2nd ed. New York, McGrawHill, 2002.
RESOURCE FOR PERFECTIONISM
1. Antony MM, Swinson RP: When Perfect Isn’t Good
Enough: Strategies for Coping With Perfectionism.
Oakland, CA, New Harbinger Publications, 1998.
RESOURCES FOR AUTISM
1. Ghaziuddin M: Mental Health Aspects of Autism and
Asperger Syndrome. London, UK, Jessica Kingsley
Publishers, 2005.
2. Hollander E: Autism Spectrum Disorders. New York,
Marcel Dekker, 2003.
3. Keenan M, Kerr KP, Dillenburger K: Parents’ Education as Autism Therapists: Applied Behaviour Analysis in Context. London, UK, Jessica Kingsley Publishers, 2000.
4. Siegel B: The World of the Autistic Child: Understanding and Treating Autistic Spectrum Disorders.
New York, Oxford University Press, 1998.
71
5. Volkmar FR, Paul R, Klin A, Cohen DJ: Handbook
of Autism and Pervasive Developmental Disorders,
2 Vols. New York, John Wiley & Sons, 2005.
Autism Society of America
7910 Woodmont Ave.
Suite 300
Bethesda, MD 20814-3067
Tel: 1-800-3AUTISM
301-657-0881
www.autism-society.org
RESOURCES FOR ASPERGER’S SYNDROME
1. Sohn A, Grayson C: Parenting Your Asperger’s Child:
Individualized Solutions for Teaching Your Child
Practical Skills. New York, Perigee, 2005.
2. DuCharme RW, Gullotta TP: Asperger Syndrome:
A Guide for Professionals and Families. New York,
Springer, 2003.
3. Ozonoff S, Dawson G, McPartland J: A Parent’s
Guide to Asperger Syndrome and High-Functioning
Autism: How to Meet the Challenges and Help Your
Child Thrive. New York, Guilford, 2002.
RESOURCES FOR BODY DYSMORPHIC DISORDER
1. Claiborn J, Pedrick C: The BDD Workbook: Overcoming Body Dysmorphic Disorder and End Body
Obsessions. Oakland, CA, New Harbinger Publications, 2002.
2. Phillips KA: The Broken Mirror: Understanding and
Treating Body Dysmorphic Disorder. New York,
Oxford University Press, 2005.
3. Pope HG, Phillips KA, Olivardia R: The Adonis
Complex: How to Identify, Treat and Prevent Body
Obsession in Men and Boys. New York, Touchstone,
2002.
4. Wilhelm S: Feeling Good About the Way You Look:
A Program for Overcoming Body Image Problems.
New York, Guilford, 2006.
RESOURCES FOR COMPULSIVE BUYING
1. Mellan O, Christie S: Overcoming Overspending: A
Winning Plan for Spenders and Their Partners. New
York, Barnes & Noble Books, 2004.
2. Wesson C: Women Who Shop Too Much: Overcoming the Urge to Splurge. New York, St Martin’s Press,
1990.
72
APA PRACTICE GUIDELINES
Debtors Anonymous
Council on Compulsive Gambling of New Jersey
General Service Office
P.O. Box 920888
Needham, MA 02492-0009
Tel: 781-453-2743
www.debtorsanonymous.org
Provides articles for the public, a directory of other state
Councils on Compulsive Gambling, and links to related
sites.
RESOURCES FOR KLEPTOMANIA
Cleptomaniacs & Shoplifters Anonymous (CASA)
Terry S. / C.A.S.A.
P.O. Box 250008
Franklin, MI 48205
Tel: 248-358-8508
www.shopliftersanonymous.com
National Association for Shoplifting Prevention
380 N. Broadway
Suite 306
Jericho, NY 11753
Tel: 1-800-848-9595
www.shopliftingprevention.org
RESOURCES FOR PATHOLOGICAL GAMBLING
3635 Quakerbridge Rd.
Suite 7
Hamilton, NJ 08619
Tel: 1-800-GAMBLER
609-588-5515
www.800gambler.org
RESOURCES FOR NONPARAPHILIC
SEXUAL DISORDERS
Sexaholics Anonymous
Provides publications and access to meetings across the
United States, which are modeled on the 12-step program
of Alcoholics Anonymous.
P.O. Box 3565
Brentwood, TN 37024
Tel: 1-866-424-8777
615-370-6062
www.sa.org
1. Blaszczynski A: Overcoming Compulsive Gambling:
A Self-Help Guide Using Cognitive Behavioral Techniques. London, UK, Robinson, 1998.
2. Grant JE, Kim SW: Stop Me Because I Can’t Stop
Myself: Taking Control of Impulsive Behavior. New
York, McGraw-Hill, 2003.
3. National Council on Problem Gambling and National Endowment for Financial Education: Personal
Financial Strategies for the Loved Ones of Problem
Gamblers. Greenwood Village, CO, National Endowment for Financial Educations, 2000.
Sexual Addicts Anonymous
Gamblers Anonymous
P.O. Box 1585
Old Chelsea Station
New York, NY 10011
Tel: 1-800-977-HEAL
212-606-3778
www.sca-recovery.org
Provides limited information on problematic gambling
and access to local meetings, which are modeled on the
12-step methods of Alcoholics Anonymous.
P.O. Box 17173
Los Angeles, CA 90017
Tel: 213-386-8789
www.gamblersanonymous.org
Provides access to publications and local chapter meetings.
P.O. Box 70949
Houston, TX 77270
Tel: 1-800-477-8191
713-869-4902
www.sexaa.org
Sexual Compulsives Anonymous (SCA)
Provides a list of meetings and a pen pal program controlled by SCA.
Society for the Advancement of Sexual Health
Provides information about sexual compulsions, addresses of
12-step programs, and recommended readings.
P.O. Box 725544
Atlanta, GA 31139
Tel: 770-541-9912
www.ncsac.org/general/index.aspx
Practice Guideline for the Treatment of Patients With Obsessive-Compulsive Disorder
RESOURCES FOR TRICHOTILLOMANIA
1. Keuthen NJ, Stein DJ, Christenson GA: Help for
Hair Pullers: Understanding and Coping With Trichotillomania. Oakland, CA, New Harbinger Publications, 2001.
2. Penzel F: The Hair-Pulling Problem: A Complete
Guide to Trichotillomana. New York, Oxford University Press, 2003.
Trichotillomania Learning Center
207 McPherson St.
Suite H
Santa Cruz, CA 95060-5863
Tel: 831-457-1004
www.trich.org
INFORMATION ON THE USE OF MEDICATION
DURING PREGNANCY AND BREASTFEEDING
California Teratogen Information Service and Clinical Research
Tel: 1-800-532-3749 (CA only)
610-543-2131
www.otispregnancy.org/ctis.html
Massachusetts General Hospital Women’s Mental Health
Program
www.womensmentalhealth.com
Motherisk.com
Database maintained by the Toronto Hospital for Sick
Children
www.motherisk.com
73
National Alliance on Mental Illness
Colonial Place Three
2107 Wilson Blvd.
Suite 300
Arlington, VA 22201
Tel: 1-800-950-6264
703-524-7600
www.nami.org
Mental Health America
2000 N. Beauregard St.
6th Floor
Alexandria, VA 22311
Tel: 1-800-969-6642
703-684-7722
www.nmha.org
National Library of Medicine
U.S. government online repository of articles published
in peer-reviewed medical journals.
www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed
National Center for Complementary and Alternative Medicine
(NCCAM), National Institutes of Health
Access to abstracts of peer-reviewed articles concerning
complementary medicine.
NCCAM Clearinghouse
P.O. Box 7923
Gaithersburg, MD 20898
Tel: 1-888-644-6226
301-519-3153
www.nlm.nih.gov/nccam/camonpubmed.html
ConsumerLab.com
Tests herbal and vitamin products for purity and posts the
results on the Web.
RESOURCES FOR GENERAL INFORMATION ON
MENTAL DISORDERS AND MEDICATIONS
www.consumerlab.com
National Institute of Mental Health (NIMH)
Features thousands of resources on the Internet.
Public Information and Communications Branch
6001 Executive Blvd.
Room 8184, MSC 9663
Bethesda, MD 20892
Tel:1-866-615-6464
www.nimh.nih.gov/publicat/index.cfm
www.mhnet.org
Mental Health Net
Kids Health
Features physician-approved health information about
children.
www.kidshealth.org
ACKNOWLEDGMENTS
Andrea Allen, Ph.D., and Bernardo Dell’Osso, M.D., assisted in the research and development of this guideline.
74
APA PRACTICE GUIDELINES
INDIVIDUALS AND ORGANIZATIONS THAT SUBMITTED
COMMENTS
Jonathan S. Abramowitz, Ph.D.
Gavin Andrews, M.D., F.R.A.N.C.Z.P.
Paul S. Appelbaum, M.D.
Kamal H. Artin, M.D.
Lee Baer, Ph.D.
Donald W. Black, M.D.
Michael H. Bloch, M.D.
Maria Cristina Cavallini, M.D.
Mirean Coleman, M.S.W., L.I.C.S.W., C.T.
Aristides Cordioli, M.D., Ph.D.
Jean Cottraux, M.D., Ph.D.
Greg Crosby, M.A., L.P.C., C.G.P.
Juliana Diniz, M.D.
Valsamma Eapen, Ph.D., F.R.C.Psych.
Jane L. Eisen, M.D.
Ygor A. Ferrão, M.D., Ph.D.
Naomi Fineberg, M.A., M.B.B.S., M.R.C.Psych.
Lois T. Flaherty, M.D.
Edna B. Foa, Ph.D.
Leonardo Fontenelle, M.D., Ph.D.
Mark Freeston, Ph.D.
Randy O. Frost, Ph.D.
Daniel A. Geller, M.D.
Cristina Gonzalez, M.D., Ph.D.
Wayne K. Goodman, M.D.
Marco Grados, M.D., M.P.H.
Jonathan Grayson, Ph.D.
Benjamin D. Greenberg, M.D., Ph.D.
John H. Greist, M.D.
Jessica R. Grisham, Ph.D.
Fritz Hohagen, M.D.
Jonathan Huppert, Ph.D.
Nancy Keuthen, Ph.D.
Michael J. Kozak, Ph.D.
James F. Leckman, M.D.
Antônio Carlos Lopes, M.D., Ph.D.
Henry Mallard, M.D.
Gail Mears, Psy.D., L.C.M.H.C., N.C.C.
Euripedes Miguel, M.D., Ph.D.
William R. Morris, O.M.D., MS.Ed., L.Ac.
Fugen A. Neziroglu, Ph.D., A.B.B.P., A.B.P.P.
Marvin Nierenberg, M.D.
Michele Pato, M.D.
Fred Penzel, Ph.D.
James M. Perrin, M.D., F.A.A.P.
Katia Petribu, M.D., Ph.D.
Katharine A. Phillips, M.D.
C. Alec Pollard, Ph.D.
Amir Qaseem, M.D., Ph.D., M.H.A.
Judith L. Rapoport, M.D.
Scott L. Rauch, M.D.
C. Ted Reveley, M.D.
Maria Conceição do Rosario, M.D., Ph.D.
Barbara R. Rosenfeld, M.D.
M. David Rudd, Ph.D., A.B.P.P.
Sanjaya Saxena, M.D.
Warren Seides, M.D.
Roseli Gedanke Shavitt, M.D., Ph.D.
Debbie Sookman, Ph.D.
Dan J. Stein, M.D., Ph.D.
Robert Stern, M.D., Ph.D.
S. Evelyn Stewart, M.D., F.R.C.P.C.
Richard P. Swinson, M.D., F.R.C.P.C., F.R.C.Psych.
David F. Tolin, Ph.D.
Albina R. Torres, M.D., Ph.D.
Barbara Van Noppen, Ph.D.
Maureen L. Whittal, Ph.D.
Sabine Wilhelm, Ph.D.
American Academy of Psychoanalysis and Dynamic Psychiatry
American Association of Oriental Medicine
American Association of Suicidology
American College of Physicians
American Group Psychotherapy Association
American Mental Health Counselors Association
American Psychoanalytic Association
Anxiety Disorders Association of America
Association for Academic Psychiatry
Brazilian Research Consortium on OCD Spectrum Disorders
National Association of Social Workers
Practice Guideline for the Treatment of Patients With Obsessive-Compulsive Disorder
75
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[A–] Randomized clinical trial. Same as above but not double-blind.
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