Sara Schenkelberg, PharmD: PGY-1 Walgreens Community Resident-Kansas City, MO
Chad Cadwell, PharmD, AAHIVP: Walgreens Health System-Truman Medical Center-Kansas City, MO
Program Number: 2018-03-01
Approval Dates: 4/4/18-7/6/18
Approved Contact Hours: One (1) CE(s) per LIVE session.
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IntroductionObsessive Compulsive Disorder, also known as OCD, is an anxiety disorder in which people have recurring, unwanted thoughts and behaviors that one feels the need to repeat repetitively. Many people have intrusive thoughts, and/or repetitive behaviors, but usually do not act on them. People with OCD have thoughts that are persistent, undesirable, and cause unwanted distress. Behaviors are visible or mental and interact with one’s daily activities and social interactions.
Current estimates state this condition affects approximately 1 in 40 adults in the United States, affecting roughly 2.2 million adults or 1.0% of the adult population, and 1 in 100 children.22 It equally affects men, women, and children of all races and socioeconomic status.20,22 The average age of onset is 19, with 25% of cases occurring before age 14. OCD is not only common in the United States, but also worldwide. The World Health Organization ranks OCD as one of the top 20 causes of illness-related disability worldwide between ages 15-44.11 Despite OCD being a common mental illness, most only seek treatment after several years of suffering. Those who suffer from OCD tend to be secretive about their symptoms and suffer from shame and embarrassment, which can lead to a delay in treatment. Less than one-third of OCD sufferers receive appropriate pharmacotherapy and even less receive evidence-based psychotherapy.11
Obsessions vs. CompulsionsObsessions are repeated, persistent, unwanted thoughts and urges that are intrusive and cause distress or anxiety. These thoughts are hard to ignore and typically intrude on daily thoughts. Obsessions often have themes to them, such as, fear of contamination, needing things orderly and symmetrical, aggressive or horrific thoughts about harming yourself or others.15,16
Compulsions are repetitive behaviors that one feels driven to perform. These repetitive behaviors or mental acts are meant to prevent or reduce anxiety related to the obsessions. However, engaging in the compulsions brings no pleasure and may offer only a temporary relief from anxiety. As with obsessions, compulsions typically have themes. Examples of these themes include constantly washing and cleaning, checking, counting, following a strict routine, and demanding reassurance.15, 16
DiagnosisMany people experience intrusive thoughts and exhibit repetitive behaviors. A diagnosis of OCD is made only if symptoms are time consuming (i.e. more than an hour per day), distressing and cause significant interference in functioning.14 Unlike physical diseases and illnesses, no specific laboratory tests are available to diagnose mental illness. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) acts as a manual for mental health professionals in giving an OCD diagnosis. Although not all experts agree on the definitions and criteria set forth in the DSM-5, it is considered the gold standard by most mental health professionals in the United States.2,3 In order to determine if a patient meets DSM-5 diagnostic criteria for OCD, the patient must experience the presence of recurrent, unwanted, and intrusive thoughts and/or repetitive behaviors or rituals intended to relieve the fear, anxiety, and/or distress associated with obsessions. Additionally, obsessions and compulsions must cause significant distress and impairment in social, academic, and/or family functioning. The exclusion clause is that the obsessions or compulsions are not best explained by another mental disorder (table 1).12 Further diagnostic criteria include the addition of a “with tics” specifier and specifier distinguishing one’s insight: “with good or fair insight,” “with poor insight,” or “with absent insight/delusional beliefs.”2,3
In the early 1990s, investigators identified a subgroup of children who developed a sudden onset of OCD symptoms following an active infection with beta-hemolytic Streptococcus.21 This was later identified as PANDAS, an acronym for “pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections.” Newer research has shown that strep is not the only infection that can cause these sudden-onset symptoms. In a condition known as Pediatric Acute-Onset Neuropsychiatric Syndrome (PANS), similar OCD symptoms are observed following a wide variety of infections, such as mycoplasma, mononucleosis, Lyme disease, influenza, and auto-inflammatory diseases.21,23 PANDAS/PANS is a rare condition that affects roughly 1 in 2,000 children.2,3 Both conditions should be managed with antibiotic treatment followed by standard OCD treatments for continued symptoms.
Risk FactorsThere are no clearly established environmental risk factors for OCD. However, some patients describe the onset of symptoms after a biologically or emotionally stressful event.1 There have been components of genetic factors contributing to an increased risk for developing OCD. Twin and family studies have shown that people with first-degree relatives who have OCD are at a higher risk for developing OCD themselves. The risk is higher if the first-degree relative developed OCD as a child or a teen.22 Ongoing research continues to explore the connection between genetics and OCD, which may help improve OCD diagnosis and treatment.
TreatmentFirst-line treatments for OCD are cognitive-behavioral therapy (CBT) and selective serotonin reuptake inhibitors (SSRIs).2 The U.S. Food and Drug Administration approved clomipramine, fluoxetine, fluvoxamine, paroxetine, and sertraline for treatment of OCD in adults. Sertraline, fluoxetine, and fluvoxamine have also been approved for use in children six, seven, and eight years of age and above, respectively.5,6,7,12 Although meta-analyses of placebo-controlled trials suggest greater efficacy and superiority for clomipramine than for fluoxetine, fluvoxamine, paroxetine and sertraline, the results of head-to-head trials comparing clomipramine and SSRIs does not support clomipramine as a first line agent.14,16 SSRIs are considered first line because the agents have less side effects and are better tolerated than clomipramine (table 2).12 Unlike the SSRIs, clomipramine also blocks norepinephrine reuptake, muscarinic cholinergic receptors, H1 histamine receptors, and alpha1-adrenergic receptors. Thus, clomipramine is more likely to induce anticholinergic effects, weight gain, sedation, orthostatic hypotension, and cardiac arrhythmias.16 In choosing among the SSRIs, the prescriber 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.
Cognitive Behavioral Therapy (CBT) alone is recommended for a patient who is not too depressed, anxious, or severely ill to cooperate with this treatment modality, or who prefers not to take medications. CBT is the only form of psychotherapy for OCD whose effectiveness is supported by controlled trials.16 Compared to traditional psychotherapy, in which sessions are spent merely discussing the client’s problems, CBT treatment for OCD is far more proactive.8 Yale-Brown Obsessive Compulsive Scale (Y-BOCS) is a common assessment tool therapists use to help the client create a detailed list of his or her symptoms.18 Y-BOCS is considered the gold standard assessment tool for OCD symptom severity. Y-BOCS is a 10-item, clinician-administered scale designed to rate symptom severity, not to establish a diagnosis.18
This list of symptoms is then used as the primary tool in a form of CBT treatment called Exposure and Response Prevention (ERP). The CBT variant that relies primarily on behavioral techniques, such as Exposure and Response Prevention (ERP), has the strongest evidence base. 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). Literature and expert opinion suggest providing CBT at least once weekly for 13-20 weeks.16
An SSRI alone is recommended for a patient who has previously responded well to a given drug, prefers treatment with an SSRI alone, or when CBT is not accessible. Starting with an SSRI alone may enhance cooperation with treatment by diminishing symptom severity.1,16 Combined treatment with SSRI and CBT is more effective than monotherapy for some patients, but is not always necessary. Combined treatment should be considered for patients who have had an unsatisfactory response to monotherapy, who have occurring psychiatric conditions for which SSRIs are effective, or have severe OCD. 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.1,16
Changing TreatmentInitial treatments rarely produce freedom from all OCD symptoms and there is typically opportunity for improvement.2 If the patient continues to have an inadequate response to treatment, there are second-line options to consider. Examples include augmenting an SSRI with an antipsychotic medication, switching to a different SSRI, or switching to venlafaxine. Venlafaxine, a serotonin-norepinephrine reuptake inhibitor with preferential serotonergic action, has been studied in comparison to paroxetine in a double blinded study and clomipramine in a single blinded study.1,16 The studies found no difference in the efficacy between venlafaxine and the comparator agents in acute control of OCD. Given the absence of evidence from placebo-controlled trials, venlafaxine is not the first-line treatment for OCD.2 Hence, the guidelines consider venlafaxine as a second-line monotherapy agent in the treatment of OCD. In 2006, the National Institute of Clinical and Health Excellence (NICE) guidelines for Obsessive Compulsive Disorder (OCD) recommended anti-psychotics as a class for SSRI treatment resistant OCD.2 The article aimed to systematically review a meta-analysis on the clinical effectiveness of atypical anti-psychotics augmenting an SSRI. Risperidone and aripiprazole can be used cautiously at a low dose as an augmentation agent in non-responders to SSRIs and CBT. However, these agents should be monitored at four weeks to determine efficacy.2
If those options have been exhausted, consider less well supported strategies such as augmentation of SSRIs with clomipramine, buspirone, pindolol, or once-weekly morphine sulfate.2,12 Morphine sulfate should be avoided in patients with contraindications to opiate administration. Last resort therapies include monotherapy with dextroamphetamine, tramadol, monoamine oxidase inhibitors, ondansetron, transcranial magnetic stimulation, or deep brain stimulation.2,12 These options may be considered in selected circumstances.
Relapse is common in OCD patients, so it’s important to continue some form of treatment. Patients should continue successful medication treatment for 1-2 years before considering a gradual taper by decrements of 10%-25% every 1-2 months while observing for symptom return or exacerbation.10
ConclusionObsessive Compulsive Disorder is an anxiety disorder that traps people in endless cycles of repetitive thoughts and behaviors. There has been research done that suggests genetics are a factor for developing OCD. However, more research needs to be conducted on the environmental reasons a person has OCD. Studies show OCD affects gender, race, and socioeconomic status equally. DSM-V is the current diagnostic tool used by clinicians. If a patient is diagnosed, there are treatment options with CBT and/or pharmacologic options. Choice of initial treatment modality is individualized and depends on factors such as the nature and severity of the patient’s symptoms, co-occurring psychiatric and medical conditions, availability of CBT, the patient’s past treatment history, current medications, and preferences.
1. Abramowitz, J. Effectiveness of psychological and pharmacological treatments for obsessive-compulsive disorder: a quantitative review. Journal of Consult Clinical Psychology. 1997; 65(1): 44-52.
2. American Psychiatric Association: Clinical Guidance on Obsessive Compulsive Disorder. Arlington, VA, American Psychiatric Association, 2013.
3. American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, 5th Edition. Arlington, VA, American Psychiatric Association, 2013.
4. Bokor, G., Anderson, PD. Obsessive-Compulsive Disorder. Journal of Pharmacy Practice. 2014 April; 27 (2): 116-130.
5. Clomipramine [package insert]. Hazelwood, MO: Mallinckrodt Inc.; Revised October 2012. Accessed 14 January 2018.
6. Fluoxetine [package insert]. Indianapolis, IN: Eli Lilly and Company Inc.; 1987. Accessed 15 Jan 2018.
7. Fluvoxamine [package insert]. Palo Alto, CA: Jazz Pharmaceuticals Inc.; 2008. Accessed 15 Jan 2018.
8. Goodman, W, Lydiard, R. Recognition and Treatment of Obsessive-Compulsive Disorder. Journal of Clinical Psychiatry. 2007 December; 68 (12): e38.
9. Keeley, M., Storch, E., Dhungana, P., et al. Pediatric Obsessive-Compulsive Disorder: A Guide to Assessment and Treatment. 2007 June; 28(6): 555-74.
10. Koran, Lorrin M., M.D.; Simpson, Blair H., M.D., Ph.D. Guideline Watch (March 2013): Practice Guideline for the Treatment of Patients with Obsessive-Compulsive Disorder. www.psychiatryonline.org. March 2013.
11. Lexi-Comp, Inc. (Lexi-DrugsTM). Accessed 12 Jan 2018.
12. Mcintrye, John S., M.D.; Charles, Sara C.; et al. Treating Obsessive-Compulsive Disorder: A Quick Reference Guide. American Psychiatric Association. July 2007.
13. Paroxetine [package insert]. Research Triangle Park, NC: GlaxoSmithKline Inc.; December 2012. Accessed 15 Jan 2018.
14. Reddy, J., Sundar, A., Narayanaswamy, J.; et al. Clinical practice guidelines for Obsessive-Compulsive Disorder. 2017. 59(5): 74-90.
15. Seibell, Phillip J.; Hollander, Eric. Management of Obsessive-Compulsive Disorder. 2014; 6: 68.
16. Sousa, MB, et al. A randomized clinical trial of cognitive-behavioral therapy and sertraline in the treatment of obsessive-compulsive disorder. Journal of Clinical Psychiatry. 2006; 67 (7): 1133.
17. Stewart, Evelyn S. Obsessive Compulsive Disorder. Psychiatric Neurotherapeutics. 2016; 2: 23-50.
18. Storch E., Larson M., Price L., et al. Development and psychometric evaluation of the Yale-Brown Obsessive-Compulsive Scale-Second Edition. Psychological Assess 2010a; 22(2): 223-232.
19. Sertraline [package insert]. New York, New York: Pfizer Inc.; Revised January 2018. Accessed 14 January 2018.
20. Swedo S., Leckman J., Rose N. From research subgroup to clinical syndrome: Modifying the PANDAS criteria to describe PANS (Pediatric Acute-onset Neuropsychiatric Syndrome). Pediatric Therapeutics 2012, 2:2.
21. Swedo SE, Leonard HL, Garvey M.; et al. Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal Infections: Clinical description of the first 50 cases. American Journal of Psychiatry 144:2, February 1998; pp 265-271.
22. UpToDate Inc. Accessed 14 Jan 2018.
23. What are PANS/PANDAS? American Psychiatric Association. September 7, 2017.
Table 2. Dosing of Serotonin Reuptake Inhibitors (SSRIs) in Obsessive-Compulsive Disorder.12
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