1.OCD : A Hidden Epidemic

2. 30 years ago.. Being diagnosed with obsessive-compulsive disorder (OCD) was about the closest thing the psychiatric world had to being given a life sentence.. In addition to being seen as extremely rare, .prognosis for those with a diagnosis of OCD was very poor., ..with no effective truly pharmacological or psychological treatments 3. OCD OCD is characterized by intrusive, troubling thoughts (obsessions), and repetitive, ritualistic behaviors (compulsions) which are time consuming, significantly impair functioning and/or cause distress When an obsession occurs, it almost always corresponds with a massive increase in anxiety and distress. Subsequent compulsions serve to reduce this associated anxiety/distress. Lack CW, World J Psychiatry. 2012 Dec 22;2(6):86-90 4. Prevalence of OCD The lifetime prevalence rate of OCD is estimated at( USA) 2.3% in adults and around 1%-2.3% in children and adolescents under 18. Sub-clinical cases of OCD (around 5% of the population) Few epidemiological differences across different countries and even between European and Asian populations 1 Notably, 30-50% of patients develop OCD starting in childhood 2 1. Lack CW , World J Psychiatry. 2012 Dec 22;2(6):86- 2. Brian P. Brennan et al, Biol Psychiatry. 2013 Jan 1;73 5. OCD in children and adolescents Early-onset obsessive- compulsive disorder (OCD) is one of the more common mental illnesses of children and adolescents, with prevalence of 1% to 3%. Its manifestations often lead to severe impairment and to conflict in the family Walitza S et al, Dtsch Arztebl Int. 2011 Mar;108(11 6. OCD pathophysiology 7. The CSTC circuitry implicated in OCD Pittenger C et al, Pharmacol Ther. 2011 Dec;132(3):314 8. Wu et al. [16] summarized the prior literature on the pivotal role of glutamate in corticostriatal- thalamocortical (CSTC) models of OCD. One of the leading OCD models is based on the balance between direct and indirect pathways within CSTC circuits. According to this theory, reciprocal interaction between direct (ultimately leads to thalamic stimulation of the cortex) and indirect (ultimately leads to thalamic inhibition of the cortex) pathways normally resulted in a dynamic balance with no one pathway predominating. Hyperactivity of the direct pathway or hypoactivity of the indirect pathway would disinhibit CSTC circuits and promote consequent release of hardwired behaviors (compulsions) and cognitions (obsessions) that were normally held in check 9. Pathophysiology of OCD As yet Unknown Abnormalities in the orbital (OFC), ventromedial (vmPFC-subgenual cingulate and medial OFC), and dorsal anterior cingulate (dACC) cortical-basal ganglia circuits OCD-linked patterns of activity in these PFC regions are accentuated during provocation of symptoms They can predict treatment response They tend to normalize following successful treatment Haber SN et al, Neuropsychopharmacology. 2013 Ja 10. Neurotransmitter alterations in OCD?? Linkage of OCD risk with polymorphisms in the serotonin transporter Increased serotonin in peripheral blood has been reported in OCD Abnormalities in dopamine neurotransmission in OCD: A reduction in the dopamine D2 receptor Abnormalities in glutamate neurotransmission and homeostasis, especially in the CSTC circuitry Pittenger C et al, Pharmacol Ther. 2011 Dec;132(3):314 11. NeuroCircuitry Abnormalities in OCD Changes in vmPFC/OFC/dACC activity Overlap in the circuits Dysfunction of the vmPFC/OFC/dACC network PFC regions associated with OCD pathology Haber SN et al, Neuropsychopharmacology. 2013 J 12. Genetic factors and OCD Twin studies reveal a higher concordance of OCD in monozygotic twins (8087%) than in dizygotic twins (4750%) Genetic factors appear to have a substantial role in the etiology of early- onset OCD. Wu K et al, Pharmacol Biochem Behav. 2012 Feb;100(4):726-3 13. Glutamate Related Genes implicated in OCD Several glutamate-related genes have been associated with OCD risk. The glutamate transporter gene Slc1A1 The Sapap3 gene, is critical to the normal localization of ionotropic glutamate receptors The Grin2B gene may be associated with OCD transmission The Grik2 locus is involved in glutamate neurotransmission Pittenger C et al, Pharmacol Ther. 2011 Dec;132( 14. Disrupted neurotransmission of glutamate in OCD Disrupted neurotransmission of glutamate within corticalstriatal- thalamocortical (CSTC) circuitry Plays a role in OCD pathogenesis. Associations between variants for SLC1A1 Wu K et al, Pharmacol Biochem Behav. 2012 Feb;1 15. Proinflammatory cytokines in OCD Significant reduction in IL-1 levels Lower plasma IL-6 levels. Elevated TNF- levels in individuals with comorbid depression. Gray SM et al, Curr Psychiatry Rep. 2012 Jun;14(3) 16. Diagnosis of OCD 17. ICD-10 criteria for obsessive-compulsive disorder (age-independent)* For a definite diagnosis, obsessional symptoms or compulsive acts, or both, must be present on most days for at least 2 successive weeks and be a source of distress or interference with activities. 18. ICD-10 criteria for obsessive-compulsive disorder (age-independent)* The obsessional symptoms should have the following characteristics: They are acknowledged as originating in the mind of the patient, and are not imposed by outside persons or influences. At least one obsession or compulsion must be present which is unsuccessfully resisted. Carrying out the obsessive thought or compulsive act is not in itself pleasurable. The thoughts, images, or impulses must be unpleasantly repetitive 19. ICD-10 criteria for obsessive-compulsive disorder (age-independent)* The patient must suffer from obsessions and/or compulsions, i.e., thoughts and/or behavioral impulses. At least one of these obsessions and/or compulsions must be resisted. The patient does not perceive the manifestations of the disorder as being pleasurable. The obsessions and/or compulsions occur repetitively; the patient is troubled by them and is markedly impaired by them. 20. DSM V and OCD changes : Unnecessay but harmless? The APA is considering changing the name of this category to Anxiety and Obsessive-Compulsive Spectrum Disorders. Obsessive-Compulsive Disorder removed from the Anxiety Disorders category, and reclassified in its own category. Reason : OCD has a neurological basis. 21. DSM V and OCD changes The DSM-IV focus was not on the cause of the but rather on the presenting symptoms that define the conditions. One of the primary defining characteristics of OCD is anxiety. The one common factor - they are highly anxious about their obsessive and compulsive symptoms. 22. OCD and DSM-V: Taking the anxiety out of OCD Psychiatrists and psychologists debate whether or not OCD should continue to be classified as an anxiety disorder. In some ways, OCD overlaps with other anxiety-related conditions, such as panic disorder Phobias social anxiety disorder generalized anxiety disorder, and post-traumatic stress disorder (PTSD). 23. DSM V and OCD The new Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5) Has a number of changes to obsessive-compulsive and related disorders, such as hoarding and body dysmorphic disorder. A separate chapter for OCD and related disorders They are no longer considered anxiety disorders. Disorders in this chapter include obsessive-compulsive disorder, body dysmorphic disorder and trichotillomania (hair-pulling disorder), as well as two new disorders: hoarding disorder and excoriation (skin-picking) disorder. 24. DSM-5 Obsessive-compulsive and related disorders can include body-focused repetitive behavior disorder and obsessional jealousy, or unspecified obsessive- compulsive and related disorder. Body-focused repetitive behavior disorder, is characterized by recurrent behaviors other than hair pulling and skin picking (e.g., nail biting, lip biting, cheek chewing) and repeated attempts to decrease or stop the behaviors. Obsessional jealousy is characterized by nondelusional preoccupation with a partners perceived infidelity. 25. Diagnosis with the Y-BOCS Define the range and severity of OCD symptoms The Yale-Brown Obsessive Compulsive Scale (Y-BOCS) is a good tool Complete Mental Status Examination Look for comorbid symptoms and 26. Imaging studies Functional MRI and PET scanning demosntrate increase in blood flow and metabolic activity in the orbitofrontal cortex, limbic structures, caudate, and thalamus with a trend toward right-sided predominance. Areas of overactivity have been shown to normalize following successful treatment with either SSRIs or CBT. These imaging modalities, are of value for research They are not indicated for normal workups. 27. OCD Presenting Features 28. Common obsessions Contamination fears Worries about harm to self or others The need for symmetry, exactness and order, Religious/moralistic concerns Forbidden thoughts (e.g., sexual or aggressive), or A need to seek reassurance or confess Lack CW , World J Psychiatry. 2012 Dec 22;2 29. Common obsessions Safety Doubting one's memory or perception Scrupulosity (need to do the right thing, fear of committing a transgression, often religious) Need for order or symmetry Unwanted, intrusive sexual/aggressive thought 30. Common compulsions Cleaning/washing Checking Counting Repeating Straightening Routinized behaviors Confessing Praying Seeking reassurance Touching Tapping or rubbing, and Avoidance Lack CW , World J Psychiatry. 2012 Dec 22;2 31. Common compulsions Checking (eg, locks, stove, iron, safety of children) Counting/repeating actions a certain number of times or until it "feels right" Arranging objects Touching/tapping objects Hoarding Confessing/seeking reassurance List making 32. Gender differences More common in males in pediatric patients. There are some differences in comorbidity as well. Among men, hoarding symptoms are most often associated with GAD and tic disorders. In women social anxiety, PTSD, body dysmorphic disorder, nail biting, and skin picking are more often observed Lack CW , World J Psychiatry. 2012 Dec 22;2 33. Cultural influences on symptom expression Bali: Heavy emphasis on somatic symptoms and need to know about members of their social network Jews: Emphasis on cleanliness and order Muslims : Religious obsessions in Muslim communities South America : Aggressive aggressions USA : Dirt and contamination worries Lack CW , World J Psychiatry. 2012 Dec 22;2 34. OCD in children 35. OCD in children Presentation of OCD symptoms is similar in children and adults. Younger children will not be able to recognize that their obsessions and compulsions are both unnecessary In young children, compulsions often occur without the patient being able to report their obsessions Adolescents are often able to report multiple obsessions and compulsions. Lack CW , World J Psychiatry. 2012 Dec 22;2 36. OCD in children Children and adolescents are also more likely to include family members in their rituals Can be highly demanding of adherence to rituals and rules, leading to disruptive and oppositional behavior and even episodes of rage. Youth with OCD are generally more impaired than adults with the same type of symptoms Lack CW , World J Psychiatry. 2012 Dec 22;2 37. OCD and comorbid disorders 38. Comorbid disorders with OCD Up to 75% of persons with OCD present with comorbid disorders. In pediatric cases : ADHD, disruptive behavior disorders, major depression, and other anxiety disorders. In adults: Social anxiety, major depression, and alcohol abuse. Lack CW , World J Psychiatry. 2012 Dec 22;2 39. Comorbid disorders with OCD Primary symmetry/ordering symptoms are often seen with comorbid tics bipolar disorder obsessive-compulsive personality disorder panic disorder, and agoraphobia Those with contamination/cleaning symptoms are more likely to be diagnosed with an eating disorder. Those with hoarding cluster symptoms, are likely to be diagnosed with personality disorders, particularly Cluster C disorders Lack CW , World J Psychiatry. 2012 Dec 22;2 40. OCD and schizophrenia The mean OCD prevalence is 13.6% The prevalence rate of OCS, defined as any obsession or compulsion is 30.7% The prevalence of OCS and OCD in schizophrenia is substantial, specifically in more chronic patient populations It is influenced by the method of assessment Swets M, Schizophr Res. 2013 Dec 19. pii: S0920-9964(13)00 41. Prevalence estimations of OCS and OCD within different samples of patients Schirmbeck F, Front Pharmacol. 2013 Aug 9;4:99. 42. Onset of OCS First onset of OCS has been described at different stages during the course of psychotic illness: Before psychosis as independent, co-existing symptoms or diagnosed OCD. Prior to psychotic manifestation as part of the at risk mental state (ARMS). Simultaneously with the first manifestation of psychosis. After the first psychotic episode during the course of chronic schizophrenia. As de novo OCS after initiation of antipsychotic treatment. Schirmbeck F, Front Pharmacol. 2013 Aug 9;4:99. 43. OCS might manifest at different time points during the course of schizophrenia illness (A) Pre-existing and persistent OCS. (B) Intermittent OCS during ARMS or later in the clinical course. (C) OCS-onset during ARMS and persistent course, strongly associated to the psychotic symptoms (schizo-obsessive concept). (D) Fluctuating course of OCS. (E) Second-onset OCS during antipsychotic treatment Schirmbeck F, Front Pharmacol. 2013 Aug 44. Identification of obsessive-compulsive symptoms in schizophrenia. Insight-criterion Patients suffering from OCD typically fulfill three symptom characteristics: they attribute the obsessions, impulsive symptoms and compulsions to their own thinking, declare with insight their unreasonableness and show some degree of resistance against them. In particular the first two properties allow a differentiation from hallucinations and delusions. Ruminations or stereotypic ego-dystonic cognitions with direct relation to the contents to psychotic thinking should not be diagnosed as obsessions. OCS not solely related to the psychotic content Cleaning or checking behavior should be diagnosed as compulsions only if it is accompanied by typical obsessions and not, if the patient currently suffers from delusions of contamination, intoxication or infection. Re-evaluation of OCS after remission of psychotic symptoms If first manifestation of OCS occurs simultaneously with the first psychotic exacerbation, the final decision on a valid comorbid condition should be postponed until the remission of psychotic symptoms. Schirmbeck F, Front Pharmacol. 2013 Aug 9;4 45. Identification of obsessive-compulsive symptoms in schizophrenia. Differentiation from catatonic symptoms Repetitive behavior or stereotypic actions should carefully be discriminated from catatonic symptoms most importantly in patients with so- called manieristic catatonia. Obsessions presented as pseudohallucinations A subgroups of OCS patients, who experience their obsessions as extremely aversive and burdening may try to distance themselves by using expressions such as voices or foreign thought content, but in most cases these phenomena can be characterized as pseudohallucinations. SGA-induced OCS Patients without a previous history of OCS might develop these phenomena during antipsychotic treatment. This constellation hints toward the unfavorable effect of second-onset OCS induced by SGAs. Schirmbeck F, Front Pharmacol. 2013 Aug 9;4:99. 46. Factors for occurrence of OCS The additional occurrence of OCS is associated with high subjective burden of disease additional neurocognitive impairment poorer social and vocational functioning greater service utilization high levels of anxiety and depression. Schirmbeck F,Front Pharmacol. 2013 Aug 9;4 47. Hypothesis for OCD + Schizophrenia Patients with schizophrenia develop OCS as an attempt to reduce psychotic symptoms ?? The presence of OCS was proposed to have protective effects?? Negative correlations between specific OCS and the severity of psychotic disorganization in thinking and behavior, may be due to compensating mechanisms?? Schirmbeck F,Front Pharmacol. 2013 Aug 9;4 48. Schizotypic OCD Primary OCD-patients present beliefs, which can be classified on a spectrum between obsessions and delusions emphasizing the similarities as being irrational thoughts, the first with insight and the latter lacking insight. Schirmbeck F,Front Pharmacol. 2013 Aug 49. Neurobiological mechanisms in OCD and schzophrenia Pronounced cognitive deficits reflect an underlying neurobiological risk factor for schizophrenia patients to develop OCS and mirror at least partially overlapping neurobiological mechanisms with OCD Serotonergic dysfunctions, alterations in dopaminergic activity and in glutamatergic neurotransmission, have also been related to OCD Schirmbeck F,Front Pharmacol. 2013 Aug 50. Impact of OCD on QoL Almost all adults and children with OCD report that their obsessions cause them significant distress and anxiety A pervasive decrease in QOL Youth show problematic peer relations, academic difficulties, sleep problems, and participate in fewer recreational activities Lack CW , World J Psychiatry. 2012 Dec 22;2 51. OCD and bipolar disorder Obsessive compulsive features occurring in mania have been well documented. There are very few case reports and studies in India This is a complex comorbidity to treat as OCD requires high doses of SSRIs which precipitates mania. A sound knowledge of etiology and the pathology operating gives an insight into the comorbidity Annigeri B, Indian J Psychol Med. 2011 Jan;33(1):83-5 52. Treatment of OCD and bipolar disorder Treatment guidelines may differ as compared with that of pure cases. BPD also responds poorly to mood stabilizing antipsychotics like olanzapine in the presence of OCD. BPD receives preference with regards to treatment Annigeri B, Indian J Psychol Med. 2011 Jan;33(1):83-5 53. Treatment options for OCD 54. Cognitive-behavioral therapy (CBT) The psychological treatment of choice for OCD Effective in both adults and children Is backed by numerous clinical trials Particularly exposure with response prevention (EX/RP) Lack CW , World J Psychiatry. 2012 Dec 22;2 55. CBT It is superior to medications alone, with effect sizes ranging from 1.16-1.72 There is a lower relapse rate than in medications (12% vs 24%-89%) Up to 25% of patients will drop out prior to completion of treatment due to the nature of treatment. The course of therapy generally lasts between 12-16 sessions Lack CW , World J Psychiatry. 2012 Dec 22;2 56. Differing responses to CBT Those with hoarding cluster symptoms respond less well to CBT Accommodation by family members in pediatric clients is predictive of poorer treatment response as well. Intriguingly, group therapy that uses CBT and EX/RP has been shown to be equally as effective as individual therapy For persons with mild OCD, computer-assisted self-treatment has been shown to be very effective Lack CW , World J Psychiatry. 2012 Dec 22;2 57. Pharmacological treatment Treatment is targeted primarily at monoaminergic neurotransmission, particularly at the serotonin and dopamine systems. The SSRIs are the mainstay of pharmacotherapy The SSRIs are of benefit in 5060% of patients Pittenger C et al, Pharmacol Ther. 2011 Dec;132 58. Drug therapy First-line pharmacologic treatments consist of 5-HT reuptake inhibitors, such as the SSRIs (fluoxetine, fluvoxamine, sertraline, paroxetine, citalopram, escitalopram), Clomipramine TCA with 5-HT and NE reuptake inhibition. Venlafaxine (SNRI). 59. SSRIs SRIs can be successfully supplemented with adjunctive antipsychotics Only a third of patients will show improvements and there are serious health concerns with their long-term usage. Lack CW, World J Psychiatry. 2012 Dec 22;2(6):86-90 60. Indian experience with SSRIs in OCD The study examined the 5-year course prospectively in 115 OCD outpatients who were mostly treated with serotonin reuptake inhibitors (SRIs). The outcome of OCD seems to be better than generally assumed, at least in moderately ill outpatients. Regular treatment over extended period may enhance likelihood of remission. Full remission should be the goal of treatment since it is associated with lesser propensity for relapse. Most patients remit in the first 2 years of treatment; therefore, early detection and intervention may improve the outcome. Cherian AV et al, J Affect Disord. 2014 Jan;152- 154:387-94 61. Clinical Pearls Adding ERP to SRIs was superior to both risperidone and pill placebo. Patients with OCD receiving SRIs who continue to have clinically significant symptoms should be offered ERP before antipsychotics given its superior efficacy and less negative adverse effect profile. Simpson HB JAMA Psychiatry. 2013 Nov;70(11):1190 62. Clinical Pearls Augmenting SRIs with exposure and ritual prevention versus stress management training leads to better outcome after acute treatment and 24 weeks later The response in combination group was significantly higher starting from 9th week, continuing up to 13th week. Mean symptom reduction and mean percentage reduction of symptoms were also higher in the case of combination group. Foa EB, J Clin Psychiatry. 2013 May;74(5):464-9 Giasuddin NA, Pak J Pharm Sci. 2013 Jan;26(1):95-8 63. Clinical Pearls About one-third of SRI-resistant OCD patients benefited from an augmentation strategy with antipsychotics. Based on the favourable risk:benefit ratio, risperidone can be considered as the agent of first choice and should be preferred to quetiapine and olanzapine. Dold M, Int J Neuropsychopharmacol. 2013 Apr;16(3):5 64. Sertraline for non responders of OCD Greater symptom improvement was seen in the high-dose sertraline group compared to the 200- mg/day dose group during continuation treatment. Both dosages have similar safety profiles. Administration of higher than labeled doses of selective serotonin reuptake inhibitors may be a treatment option for certain OCD patients who fail to respond to standard acute treatment Ninan PT, J Clin Psychiatry. 2006 Jan;67(1):15 65. Fluvoxamine Vs Clomipramine in OCD 67 66. Fluvoxamine Vs Clomipramine in OCD Presentation Title Date 68 Study objective: To directly compare the efficacy and safety of fluvoxamine and clomipramine in patients with OCD Study Design: Double-blind, randomised, multicentre study Patient population: 227 patients with a primary diagnosis of OCD Evaluation parameters: Yale-Brown Obsessive-Compulsive Scale (Y-BOCS) National Institute of Mental Health Obsessive-Compulsive (NIMH-OC) scale Global Improvement item of the Clinical Global Impression (CGI) scale Mundo E. Hum Psychopharmacol. 2001 Aug;16(6):461-468. 67. Fluvoxamine Vs Clomipramine in OCD 69 Fluvoxamine and clomipramine were equally effective, both resulting in clinically significant improvement Mundo E. Hum Psychopharmacol. 2001 Aug;16(6):461-468. 68. Fluvoxamine Vs Clomipramine in OCD 70 Mundo E. Hum Psychopharmacol. 2001 Aug;16(6):461-468. Fluvoxamine and clomipramine were equally effective on secondary endpoints variable 69. Fluvoxamine Vs Clomipramine in OCD 71 Mundo E. Hum Psychopharmacol. 2001 Aug;16(6):461-468. Fluvoxamine was better tolerated than clomipramine The overall incidence of premature withdrawal due to adverse events was twice as high as with clomipramine than with fluvoxamine (16% Vs 8%) 70. Cognitive therapy versus fluvoxamine as a second- step treatment in obsessive-compulsive disorder nonresponsive to first-step behavior therapy OCD patients who are nonresponsive to ERP (exposure in vivo with response prevention) may benefit more from a switch to treatment with an antidepressant instead of switching to CT In clinical practice, it may be important to motivate this subgroup of patients to undergo psychopharmacological treatment, as this may improve their outcome considerably van Balkom AJ, Psychother Psychosom. 2012;81(6):366- 71. Weight gain with SSRIs Clomipramine,, citalopram, fluoxetine, fluvoxamine, paroxetine, or sertraline At the end of the 2.5-years patients had gained a mean of 2.5% of their body weight with respect to baseline (1.58 kg) Higher proportion of clomipramine-treated patients (34.8%) gained > or = 7% in weight as compared with sertraline and fluoxetine Sertraline and fluoxetine had the lowest percentage of patients with a significant weight gain (4.5% and 8.7%, respectively),Maina G, J Clin Psychiatry. 2004 Oct;65(10):1365-71. 72. Clinical Pearls : Treatment predictors for fluvoxamine Pre-treatment activation in the right cerebellum (Z-score=5.10, x,y,z=22,-84,- 18) and the left STG (Z-score=4.95, x,y,z=-62,-22,0) was positively correlated with the improvement in the Y-BOCS score. Pre-treatment activation in the right cerebellum and in the left STG predict subsequent reduction in OCD symptom severity. There is every possibility that fMRI can be used as a tool to predict treatment response. Sanematsu H et al, J Psychiatr Res. 2010 Mar;44(4):193-20 73. Major sites of action of glutamate- modulating drugs Pittenger C et al, Pharmacol Ther. 2011 Dec;132 74. Differing responses The presence of tics appears to decrease selective SRI effects in children, but it is unclear if it has the same effect in adults. Another known difference is that patients who have OCD with comorbid tics respond better to neuroleptic drugs than those who have OCD without tics Lack CW, World J Psychiatry. 2012 Dec 22;2(6):86-90 75. Clinical Pearls Unlike in the case of major depression, complete or near-complete remission of OCD symptoms is rare with only serotonergic antidepressant treatment. More typically, perhaps half of patients may experience symptom reductions of 30-50%, with many other patients failing to achieve even this degree of relief. Doses above those needed for treatment of depression may be more effective for some patients. A therapeutic dose for 6-10 weeks may be required to observe a clinical response. Response tends to be slow and continues for at least 12 weeks 76. Clinical Pearls For reasons that remain unclear, higher doses than those used for depression are often required for OCD In disease refractory to these agents, pharmacological augmentation with neuroleptic drugs, which antagonize the D2 dopamine receptor, can be efficacious Pittenger C et al, Pharmacol Ther. 2011 Dec;132 77. Clinical Pearls Role of life events in obsessive compulsive disorder. Life events are significantly more frequent in OCD patients The severity of OC symptoms is directly proportional to the number of stressful life events experienced in the last six months prior to onset. Sarkhel S et al, Isr J Psychiatry Relat Sci. 2011;48(3):182-5. 78. Alternative agents Use of specific glutamatergic agents (eg, memantine, N -acetylcysteine, riluzole, topiramate, glycine) Sarkhel S et al, Isr J Psychiatry Relat Sci. 2011;48(3):182-5. 79. ERP treatment ERP is now usually administered as part of a broader program of CBT specifically designed for OCD. After making the patient aware of his or her irrational thoughts, the therapist works to have the patient counter them with more rational thoughts and do cost/benefit analyses regarding performing his or her rituals. 80. Treatment resistance strategies Strategies should always include an assessment of complicating diagnoses medication compliance drug dose, and duration of therapy. Comorbid diagnosis such as depression or panic disorder, can interfere with clinical recovery, and identification may guide the choice of interventions. William M Greenberg, Obsessive-Compulsive Disorder Treatment & Management.www.medscape.com 81. Treatment resistance strategies Interventions for patients with treatment resistance include Change or increase in medication More intensive CBT Other interventions, which have not received an FDA indication for OCD include the following: Addition of an NE reuptake inhibitor, such as desipramine, to an SSRI, or a trial of venlafaxine Addition of a typical or atypical antipsychotic, especially in patients with a history of tics William M Greenberg, Obsessive-Compulsive Disorder Treatment & Management.www.medscape.com 82. Treatment resistance strategies Interventions for patients with treatment resistance include Augmentation with buspirone Addition of inositol Sole or augmented use of selected glutamatergic agents Deep brain stimulation or cingulotomy neurosurgery or severe and intractable cases Some clinicians feel that individuals with comorbid Tourette disorder or with hoarding as their principal OCD symptom may be more likely to be treatment resistant, although there is significant variation in treatment response, regardless of the particular presenting symptomatology. William M Greenberg, Obsessive-Compulsive Disorder Treatment & Management.www.medscape.com 83. Low-frequency rTMS over the SMA for treatment-refractory patients of OCD Novel treatment strategies like repetitive transcranial magnetic stimulation (rTMS) have been proposed for OCD refractory to standard treatments Low-frequency rTMS over the SMA appears a promising treatment strategy as an add-on treatment in treatment-refractory patients of OCD. Kumar N et al,Indian J Psychiatry. 2011 Oct;5 84. Neurosurgical treatment of OCD Neurosurgical treatment of OCD is reserved for patients with severe and refractory symptoms. The most common small series use a specific small lesion (eg, cingulotomy) or deep brain stimulation. Current clinical trials are also exploring the application of transcranial magnetic stimulation (TMS), a noninvasive treatment, for OCD. William M Greenberg, Obsessive-Compulsive Disorder Treatment & Management.www.medscape.com 85. Neurosurgical treatment of OCD Stereotactic placement of bilateral lesions in the anterior cingulate cortex: 28% response rate, with an additional 17% showing a partial response. A deep brain stimulation technique consists of implanting a device to electrically stimulate the subthalamic nucleus William M Greenberg, Obsessive-Compulsive Disorder Treatment & Management.www.medscape.com 86. FUTURE DIRECTIONS FOR RESEARCH Treatment dissemination, particularly for CBT and EX/RP, remains an issue Steps can and should be undertaken to improve dissemination of CBT Dissemination of both the safety and effectiveness of exposure-based therapies to both the general public and mental health clinicians More research on how certain comorbidity patterns impact treatment 87. Study further New Promising approaches Targeting the extinction learning core to EX/RP with d-cycloserine , a partial agonist at the NMDA receptor in the amygdala Novel combinations of pre-existing treatments 88. End Note There is truly not a better time in history to have OCD than the present,. . given the multiple effective pharmacological agents, psychological therapy, and .an ever- increasing understanding of the disorder itself. This is not, however, the time to sit back and pat our collective backs in triumph.