Obsessive-compulsive disorder: Under-recognized and responsive to treatment

,; ,; ,

Behavioral Health

Obsessive-compulsive disorder: Under-recognized and responsive to treatment

J Fam Pract. 2017 August;66(8):503-506

PDF Download

References

1. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. Washington, DC: American Psychiatric Association; 2013.

2. Deacon B, Lickel J, Abramowitz JS. Medical utilization across the anxiety disorders. J Anxiety Disord. 2008;22:344-350.

3. Glazier K, Calizte RM, Rothschild R, et al. High rates of OCD symptom misidentification by mental health professionals. Ann Clin Psychiatry. 2013;25:201-209.

4. Schwartz C, Schlegl S, Kuelz AK, et al. Treatment-seeking in OCD community cases and psychological treatment actually provided to treatment-seeking patients: a systematic review. J Obsessive Compuls Relat Disord. 2013;2:448-456.

5. Marciniak M, Lage MJ, Landbloom RP, et al. Medical and productivity costs of anxiety disorders: case control study. Depress Anxiety. 2004;19:112-120.

6. Forray A, Focseneanu M, Pittman B, et al. Onset and exacerbation of obsessive-compulsive disorder in pregnancy and the postpartum period. J Clin Psychiatry. 2010;71:1061-1068.

7. Purdon C, Clark DA. Obsessive intrusive thoughts in nonclinical subjects. Part I. Content and relation with depressive, anxious and obsessional symptoms. Behav Res Ther. 1993;31:713-720.

8. Clark DA. Cognitive-Behavioral Therapy for OCD. New York: The Guilford Press; 2002.

9. Glazier K, Swing M, McGinn LK. Half of obsessive-compulsive disorder cases misdiagnosed: vignette-based survey of primary care physicians. J Clin Psychiatry. 2015;26:e761-e767.

10. Fineberg NA, Reghunandanan S, Simpson HB, et al. Obsessive-compulsive disorder (OCD): practical strategies for pharmacological and somatic treatment in adults. Psych Res. 2015;227:114-125.

11. Goodman WK, Price LH, Rasmussen SA, et al. The Yale-Brown Obsessive Compulsive Scale. I. Development, use, and reliability. Arch Gen Psychiatry. 1989;46:1006-1011.

12. Storch EA, Larson MJ, Goodman WK, et al. Development and psychometric evaluation of the Yale-Brown Obsessive-Compulsive Scale—second edition. Psychol Assess. 2010;22:223-232.

13. Katzman MA, Bleau P, et al. Canadian clinical practice guidelines for the management of anxiety, posttraumatic stress and obsessive-compulsive disorders. BMC Psychiatry. 2014;14(Suppl 1):S1.

14. Bandelow B, Sher L, Bunevicius R, et al. Guidelines for the pharmacological treatment of anxiety disorders, obsessive-compulsive disorder, and posttraumatic stress disorder in primary care. Int J Psychiatry Clin. 2012;16:77-84.

15. Foa FB, Liebowitz MR, Kozak MJ, et al. Randomized, placebo-controlled trial of exposure and response prevention, clomipramine, and their combination in the treatment of obsessive-compulsive disorder. Am J Psychiatry. 2005;162:151-161.

16. Abramowitz JS. The psychological treatment of obsessive compulsive disorder. Can J Psychiatry. 2006;51:407-416.

How to make the diagnosis

A clinical interview is an essential component of assessing OCD in primary care. Ask patients who have mood or anxiety concerns about OCD symptoms, due to the high comorbidity rates of these entities.¹ If a family history of OCD is known, assess the patient for this disorder, as higher rates exist among family members.¹⁰ Although primary care providers should indeed screen for OCD and provide provisional diagnoses as warranted, additional assessment by a behavioral health practitioner is recommended, given their specialty training in this area.

Patients with OCD are often reluctant to disclose intrusive thoughts due to perceiving them as shameful or unacceptable. Consider asking direct questions to facilitate the evaluation:

“Do you ever feel bothered by unwanted or unusual thoughts that you cannot get out of your mind even though you try to?”
“Do you feel that you have to do anything to get rid of these thoughts or prevent something bad from happening?”
“Will you feel very uncomfortable if you don’t do something a specific way?”

Evidence-based self-report measures are also available. The Yale-Brown Obsessive Compulsive Scale (Y-BOCS)¹¹ has become the gold standard psychometric measure for OCD. The updated version (Y-BOCS-II)¹² and child/adolescent version (CY-BOCS)¹¹ are also available.

Treatment: A tandem approach is most effective

Offer patients with OCD both medication options and cognitive-behavioral therapy (CBT). Selective serotonin reuptake inhibitor (SSRI) medications are effective first-line treatments.¹³ Treatment with clomipramine has yielded treatment outcomes similar to those seen with SSRIs; however, SSRIs are generally better tolerated.¹⁰ For treating OCD, evidence is lacking to support use of one SSRI over another.¹⁰ Medium- to upper-dose ranges are recommended for all SSRIs.¹⁴

Patient characteristics (eg, comorbid depression, level of adherence to treatment) may also help guide prescribing choices.¹⁰ For patients not responding to pharmacologic treatment in 8 to 12 weeks, consider referral to a psychiatrist.¹⁴

Research suggests that CBT with ERP (exposure with response prevention) produces outcomes equivalent to those achieved with pharmacotherapy.

For OCD, CBT provided by a trained specialist typically involves exposure with response prevention (ERP). This entails confronting difficult thoughts and feared situations through exposure therapy and learning to reduce compulsive and excessive safety behaviors (eg, thinking about being contaminated by germs and then refraining from washing hands). Research suggests that CBT with ERP produces outcomes equivalent or superior to those achieved with pharmacotherapy.¹³ In addition to finding large effect sizes, clinical trials have demonstrated a treatment response of 86% in those completing CBT with ERP, compared with 48% of those receiving clomipramine.¹⁵ And Y-BOCS symptom scores have been reduced by 50% to 60% with CBT and ERP.¹⁶

How best to navigate coordination-of-care issues

When selecting a psychotherapy treatment provider for a patient with OCD, ask whether they are trained in ERP. If a trained psychotherapist is not available in the local health care system, you may refer to the International OCD Foundation (iocdf.org), which maintains an online directory of psychotherapists specializing in OCD.

Primary care physicians can also work with psychiatrists or psychotherapy providers to develop shared treatment plans. Part of this plan may involve reducing excess medical utilization and checking/reassurance (eg, requesting repeat medical tests). When there is concern about safety issues (eg, intrusive homicidal or suicidal thoughts), a risk assessment is strongly recommended.

CASE

An on-site psychologist evaluated Ms. L and diagnosed OCD. Ms. L had talked to the doctor about the possibility of medication, but she preferred to try behavioral treatment first. Ms. L agreed to participate in CBT with ERP. Treatment included imaginal and situational exposure exercises to decrease emotional reactivity associated with the thoughts, and to challenge beliefs that the thoughts are meaningful (eg, that having the thought means that she may act on it or that she is an unfit mother).

For example, Ms. L practiced repeating the thoughts aloud and going into feared situations (eg, being alone with her child). This was paired with response prevention, meaning that Ms. L was instructed to avoid checking with, or seeking, reassurance from others. She engaged in 4 ERP sessions in the primary care setting, and treatment led to significant symptom improvement that was maintained at follow-up with her primary care provider 6 and 12 months later.

CORRESPONDENCE
Jared L. Skillings, PhD, ABPP, Division of Psychiatry and Behavioral Medicine, Spectrum Health System, 2750 East Beltline NE, Grand Rapids, MI 49525; jared.skillings@spectrumhealth.org.