Obsessive-compulsive disorder (OCD) is a neuropsychiatric disorder with a lifetime prevalence of 2 to 3 % and is estimated to be the 10th leading cause of disability in the world. National health surveys in Australia estimate it to be around 2%.
Patients with OCD experience recurrent, intrusive thoughts (obsessions) and/or repetitive, stereotyped behaviours (compulsions) that last for at least one hour per day and significantly interfere with the individual’s normal level of functioning.
Psychological treatment of Obsessive-compulsive disorder (OCD)
Cognitive-behavioural therapy (CBT) is the psychological approach of choice for OCD.
The most effective component of CBT has been shown to be a prolonged graded exposure to the feared situation with self-imposed ‘response prevention’ (ERP).
Graded exposure encourages prolonged periods of contact with the anxiety-provoking triggers until anxiety levels reduce by a process called habituation. It usually takes couple of hours to achieve this result.
As it can be really distressing to do it at once, a graded approach based on the comfort levels of the patient is usually adopted. This followed by self-imposed response prevention. For instance trying not to engage in compulsion such as washing hands.
Up to three quarters of patients experience symptom reduction by half at the end of ERP. These beneficial effects can last for a number of years. Sometimes ERP is combined with cognitive therapy to change unhelpful thinking patterns. Psychiatrists at Mindoc are OCD specialists located in Melbourne who can give you advice on the appropriate form of treatment.
Pharmacotherapy (Medicines for OCD)
OCD responds well to drugs that inhibit the synaptic reuptake of serotonin such as selective serotonin reuptake inhibitors (SSRIs), SNRI’s. Among SSRI’s Fluvoxamine has established superiority over its SSRI counterparts and Tricyclics apart from Clomipramine.. Because of their more benign side effect profile, SSRIs are now considered first-line pharmacotherapy for OCD.
The tricyclic antidepressant Clomipramine is considered as the gold standard due to its properties and its potent serotonin reuptake inhibition. It has decades of safety and efficacy data, which is replicated in multiple controlled trials. Experience from clinical practice support its use in those with comorbid skin picking disorder and Narcolepsy.
The use of SSRIs and Clomipramine in the treatment of OCD differs from the treatment of depression and other anxiety disorders in two important ways: First, higher doses of SRI medications are typically required before clinical improvement is seen. Second, improvement in OCD tends to be gradual, and an adequate medication trial is considered to be at least 10 -12 weeks in duration.
Common reasons for treatment failure are:
- Inadequate dosage of medication,
- Less than a 12-week period of treatment
- Inappropriately applied CBT/ERP techniques,
- Failure to use SRI and CBT treatments together.
A consultation with OCD specialists in Melbourne would be useful to clarify these issues professionally. Psychiatrists specialising on OCD will be able to provide advice on both medical and psychological treatments of OCD.
Treatment resistant Obsessive-compulsive Disorder (OCD)
Although CBT and pharmacotherapy with SRIs are effective treatments for many patients, Around 30% of patients continue to experience troublesome residual symptoms despite prolonged treatment. Treatment-resistant OCD generally refers to individuals who have failed at least two adequate trials of SRIs.
Second layer of treatment in OCD
A psychiatrist specialising in the treatment of obsessive-compulsive disorder provides advanced treatments in OCD. The guidelines suggest that if OCD did not respond to one or 2 SSRIs, monotherapy with Venlafaxine may be tried. Mirtazapine can be effective by itself or in combination with paroxetine.The idea of the second layer of treatments is to target both the serotonin and Noradrenergic systems at the same time. Clomipramine targets more than one such chemical systems and should be considered if the above steps fail.Intravenous treatment with Clomipramine or Citalopram may be required in refractory cases.
Augmentation of existing treatments for OCD.
If the existing treatment with SSRI, SNRI or clomipramine is partially effective, consider augmentation. By doing so, we are trying to target an addition chemical systems-Dopamine, Glutamate or opioid.
OCD is comorbid with Tourette syndrome in children. Children with or without co-morbid Tourette improve with Dopamine blockers, commonly known as anti-psychotics. Haloperidol, Risperidone and Olanzapine and Quetiapine has evidence as Augmentation agents. You might want to discuss with a psychiatrist for OCD to consider such strategies.
Two other chemical systems of interest are the Glutamate and opioid systems. Anti-glutaminergic agent Riluzole was found to be useful in the treatment of obsessive-compulsive disorder (OCD). Medications acting through the opioid system such as Morphine given once weekly has shown efficacy in treatment-resistant OCD, similarly administration of the opioid agonist tramadol hydrochloride has also been show to diminish OCD symptoms. It is likely that opioids may inhibit glutamate release in cortex via disinhibition of serotonergic neurons. Anti-glutaminergics may also have a similar effect on the serotoninergic system. More interestingly Studies on Ketamine’s mechanism of action on depression have pointed towards the opioid system as the “middle man”.
Surgical options in the treatment of obsessive-compulsive disorder (OCD)
Neuroimaging studies have localised the anatomy of OCD to the orbitofrontal cortex, striatum, and thalamus. These brain regions are components of the cortico-striato-thalamo-cortical (CSTC) circuitry. This circuitry consists of parallel pathways that receive cortical information, process it, and project it back to the cortex by way of the thalamus. There are 2 such pathways that counterbalance our behavioural responses, thus keeping our behaviour in check. Hence OCD can be seen as the imbalance in these circuits that can be surgically corrected.
Some of such procedures are namely, Anterior cingulotomy, Anterior capsulotomy , Limbic leucotomy .
Deep brain stimulation (DBS) techniques offer a reversible alternative to specifically modify neuronal circuitry. Access to such treatments is limited. You may want to discuss this with a psychiatrist specialising in OCD (OCD specialist Melbourne) and get a second opinion from a neuro-psychiatrist to assess its suitability.
Non-surgical brain stimulation options for treatment of OCD
Finally, the uses of electroconvulsive therapy (ECT), transcranial magnetic stimulation (TMS) are alternatives, but none of these therapies have demonstrated marked efficacy in the treatment of OCD. Psychiatrists in a hospital setting offer these treatments.
To conclude, there are a number of options available for treatment of OCD. Psychiatrists for OCD at Mindoc clinic, Glen Waverley has the expertise to undertake a comprehensive assessment to look at the reasons behind treatment resistance and to prepare a complex management plan, which would assist in getting you back to your feet at the earliest. Psychiatrists OCD treatment may differ from those offered by psychologists.Moreover, Mindoc runs OCD clinics educating and treating those with difficult to treat OCD. Call us to know more or book online.