Evidence-Based Reviews

Innovative and practical treatments for obsessive-compulsive disorder

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How can you differentiate obsessive-compulsive disorder from psychosis? And once the diagnosis is made, how do you determine a course of treatment or predict whether it will be successful? This article will help you answer those questions.


 

References

When you suspect a patient has obsessive-compulsive disorder (OCD) (Box 1), how can you differentiate OCD from psychosis? Once you have made the diagnosis, what critical factors suggest treatment will be successful—or unsuccessful? Is behavioral therapy more effective than medication? Which medications are most likely to be effective? The answers to these questions can help you improve the well-being of your patients with OCD.

Differential diagnosis

Unfortunately, many patients with severe OCD are misdiagnosed with psychosis or schizophrenia spectrum disorder and spend many years suffering without proper treatment.3 Despite many similarities between patients with severe OCD and psychosis—including rigid belief systems, unrealistic concerns, magical thinking, and odd behaviors—patients with OCD can recognize the irrational nature of their beliefs when they are not in the throes of anxiety.

Patients with OCD also will usually respond to behavioral interventions within a few weeks while patients who are psychotic usually get progressively worse. Treatment must be given time as both cohorts will get anxious or increase their negative symptoms initially, but patients with OCD should soon habituate and find symptom relief.

Some patients have OCD with psychotic features and tend to have more difficulty responding to behavior therapy without medication. Patients with both OCD and schizotypal personalities respond poorly to both behavior therapy and psychotropic medications.4

Box 1

Meeting the criteria for OCD

Obsessions are intrusive and unwanted thoughts, images, or impulses that produce anxiety. They commonly consist of obsessive fears involving causing harm to others, contamination, safety, religiosity, incompletion, pathological doubt, magical thinking, and the need for certainty, and symmetry.

Usually, obsessions will be accompanied by compulsions, which are behaviors or thoughts performed to reduce the anxiety caused by the obsessions. Compulsions typically consist of excessive washing, checking until it “feels right,” and mental retracing. In rare cases, patients present with only obsessions, which are more difficult to treat than compulsions. Most patients will have several types of symptoms.

To meet the criteria for OCD, patients must be preoccupied by obsessive thoughts and engage in compulsions, which will be frequent, intense, of long duration (more than 2 hours/day), and interfere with the individual’s ability to function. The Yale-Brown Obsessive Compulsive Symptoms Checklist and Scale1 are reliable assessment tools to identify types of symptoms and degree of severity.

‘All I can eat is milk ’ and one brand of peanut butter’

Anne is a 53-year-old widow whose OCD symptoms consisted of not letting anything pass her lips that she considered contaminated, lest she become ill with cancer. Her symptoms became so severe that she restricted her diet to a specific brand of peanut butter and milk. The manner in which she ate the peanut butter was rife with checking rituals. If she thought that there might be something wrong with the jar, she threw it away. If she thought the jar was “safe,” she poured the peanut butter directly into her mouth, avoiding the risk of dirty utensils. She drank milk out of the carton. By the time she began treatment, she was malnourished and slightly dehydrated.

Anne’s restrictive diet was also a product of obsessive label checking. Her label reading inevitably resulted in her seeing ordinary household items that she considered risky and would then avoid. Other avoidance behaviors included spitting out saliva and not licking her lips due to fear of what might be ingested, and avoidance of medication, toothpaste, eye drops, skin lotion, and food she feared others had touched.

The good intentions of people in Anne’s community had the effect of enabling her OCD. For example, the local grocer made sure to keep a few cases of Anne's preferred brand of peanut butter in stock for when she needed it. She bought in bulk, but returned unopened jars that she thought were contaminated. As is common with obsessions, no real evidence is needed to legitimize avoidance.

To help Anne break the OCD cycle of avoidance, a meal plan was devised. Although she looked anorexic, but was not, this approach succeeded because she greatly missed the experience of eating and tasting a variety of foods. She also agreed to drink daily nutritional supplements until her diet was more enriching, and had weekly weigh-ins to track her weight gain.

Anne also began a regimen of fluoxetine, which ultimately improved her ability to use the behavior therapy techniques. She was started at 5 mg/d in liquid form. The dosage was increased to 40 mg/d across 1 month, then changed to pill form and titrated to 80 mg/d, which was maintained at discharge.

Exposure and response prevention therapy (ERP) was also administered in twice-daily, 2-hour sessions for about 3 months. Exposure therapy consisted of accompanying Anne to the local supermarket and having her purchase any kind of food that she wanted, regardless of its nutritional value. Her initial purchases consisted of cheesecake, doughnuts, juice, herbal tea, canned ravioli, cereal, lasagna, and snacks.

For response prevention related to food purchases, Anne was prevented from reading labels and examining individual items for imperfections. She was encouraged to buy the first item on the shelf and put it in her basket.

The next step in exposure therapy was to supervise her eating habits. While she looked forward to tasting the food she bought, she was apprehensive because of the obsessive doubt about their purity. Firm but kind encouragement helped her take one bite after another, and this success built on itself. She was excited to be finally confronting her obsessive fears, tasting the foods she restricted herself from for so long, and taking better care of herself. Her complexion improved, and her weight increased.

At times she was highly anxious and looked for ways to avoid the exposure, but with redirection was able to stay on track. She eventually was able to eat community food, eat at a restaurant, use beauty and hygiene products, and have contact with artificial or chemical substances.

Ironically, Anne’s vocational interest was in cooking and after discharge from the program, she investigated employment in hotel/restaurant work and studies at culinary school.

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