Obsessive-compulsive disorder medical therapy: Difference between revisions

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__NOTOC__
__NOTOC__
{{Obsessive-compulsive disorder}}
{{Obsessive-compulsive disorder}}
{{CMG}}; {{AE}}{{USAMA}}
{{CMG}}; {{AE}}{{Priyanka}}{{Sonya}}, {{USAMA}}


== Overview ==
== Overview ==
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==Treatment==
==Treatment==
===Medical Therapy===
===Medical Therapy===
One may be referred by their doctor to a mental health specialist, such as a psychiatrist, psychologist, social worker, or counselor for evaluation of treatment, however OCD is usually medically managed by psychological and pharmacological interventions.<ref name="pmid28384832">{{cite journal| author=Hirschtritt ME, Bloch MH, Mathews CA| title=Obsessive-Compulsive Disorder: Advances in Diagnosis and Treatment. | journal=JAMA | year= 2017 | volume= 317 | issue= 13 | pages= 1358-1367 | pmid=28384832 | doi=10.1001/jama.2017.2200 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=28384832  }} </ref>
One may be referred by their doctor to a mental health specialist, such as a psychiatrist, psychologist, social worker, or counselor for evaluation of treatment, however OCD is usually medically managed by [[psychological]] and [[pharmacological]] interventions.<ref name="pmid28384832">{{cite journal| author=Hirschtritt ME, Bloch MH, Mathews CA| title=Obsessive-Compulsive Disorder: Advances in Diagnosis and Treatment. | journal=JAMA | year= 2017 | volume= 317 | issue= 13 | pages= 1358-1367 | pmid=28384832 | doi=10.1001/jama.2017.2200 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=28384832  }} </ref>
 
====Behavioral Therapy ====
*Cognitive therapy teaches patients alternative ways to think, behave, and react to their obsessions and compulsions. <ref name="pmid28384832">{{cite journal| author=Hirschtritt ME, Bloch MH, Mathews CA| title=Obsessive-Compulsive Disorder: Advances in Diagnosis and Treatment. | journal=JAMA | year= 2017 | volume= 317 | issue= 13 | pages= 1358-1367 | pmid=28384832 | doi=10.1001/jama.2017.2200 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=28384832  }} </ref>
*Cognitive beahvioral therapy (CBT) is a highly effective psychological treatment strategy for OCD patients. It is helpful both when used in group sessions or individually.<ref name="pmid28384832">{{cite journal| author=Hirschtritt ME, Bloch MH, Mathews CA| title=Obsessive-Compulsive Disorder: Advances in Diagnosis and Treatment. | journal=JAMA | year= 2017 | volume= 317 | issue= 13 | pages= 1358-1367 | pmid=28384832 | doi=10.1001/jama.2017.2200 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=28384832  }} </ref>
*CBT consists of two componenets either used together or individually:<ref name="pmid28384832">{{cite journal| author=Hirschtritt ME, Bloch MH, Mathews CA| title=Obsessive-Compulsive Disorder: Advances in Diagnosis and Treatment. | journal=JAMA | year= 2017 | volume= 317 | issue= 13 | pages= 1358-1367 | pmid=28384832 | doi=10.1001/jama.2017.2200 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=28384832  }} </ref>
:*Behavioral techniques and
:*Congnitive restructuring
*The specific technique used in the behavioral  therapy (BT/CBT) is called [[Exposure and response|exposure and ritual prevention]] (also known as "[[exposure and response prevention]]") or ERP; this involves gradually learning to tolerate the anxiety associated with not performing the ritual behavior. At first, for example, someone might touch something only very mildly "contaminated" (such as a tissue that has been touched by another tissue that has been touched by the end of a toothpick that has touched a book that came from a "contaminated" location, such as a school.) That is the "exposure". The "ritual prevention" is not washing. Another example might be leaving the house and checking the lock only once (exposure) without going back and checking again (ritual prevention). The person fairly quickly [[habituation|habituates]] to the anxiety-producing situation and discovers that their anxiety level has dropped considerably; they can then progress to touching something more "contaminated" or not checking the lock at all — again, without performing the ritual behavior of washing or checking.
:*This can consist of 13-20 weekly sessions or 3 weeks of daily session on week days. Reinforcement sessions can be offered periodically within 3 to 6 months following initial treatment.
:*This has been demonstrated to be the most effective treatment for OCD.


====Medication====
====Medication====


Medications as treatment include the following:  
*Medications as treatment include the following:  
:*[[Selective serotonin reuptake inhibitor]]s (SSRIs) such as [[Paxil|paroxetine (Seroxat, Paxil)]], [[Zoloft|sertraline (Zoloft)]], [[Prozac|fluoxetine (Prozac)]], [[escitalopram]] (Lexapro), and [[Luvox|fluvoxamine (Luvox)]]  
:*[[Selective serotonin reuptake inhibitor]]s ([[SSRI]]s) such as [[Paxil|paroxetine (Seroxat, Paxil)]], [[Zoloft|sertraline (Zoloft)]], [[Prozac|fluoxetine (Prozac)]], [[escitalopram]] (Lexapro), and [[Luvox|fluvoxamine (Luvox)]]  
:*[[Tricyclic antidepressant]]s, in particular [[clomipramine|clomipramine (Anafranil)]].  
:*[[Tricyclic antidepressant]]s, in particular [[clomipramine|clomipramine (Anafranil)]].  
*SSRIs prevent excess [[serotonin]] from being pumped back into the original [[neuron]] that released it. Serotonin can then bind to the [[receptor (biochemistry)|receptor]] sites of nearby neurons and send chemical messages or signals that can help regulate the excessive [[anxiety]] and obsessive-compulsive thoughts.  
*[[SSRI]]s prevent excess [[serotonin]] from being pumped back into the original [[neuron]] that released it. [[Serotonin]] can then bind to the [[receptor (biochemistry)|receptor]] sites of nearby [[neuron]]s and send chemical messages or signals that can help regulate the excessive [[anxiety]] and obsessive-compulsive thoughts.  
*In some treatment-resistant cases, a combination of [[clomipramine]] and an SSRI has shown to be effective even when neither drug on its own has been efficacious. [[Serotonergic]] [[antidepressant]]s typically take longer to show benefit in OCD than with most other disorders which they are used to treat, as it is common for 2–3 months to elapse before any tangible improvement is noticed.  
*In some treatment-resistant cases, a combination of [[clomipramine]] and an [[SSRI]] has shown to be effective even when neither drug on its own has been efficacious. [[Serotonergic]] [[antidepressant]]s typically take longer to show benefit in OCD than with most other disorders which they are used to treat, as it is common for 2–3 months to elapse before any tangible improvement is noticed.  
*In addition, the treatment usually requires high doses. [[Fluoxetine]], for example, is usually prescribed in doses of 20&nbsp;mg per day for clinical depression, whereas with OCD the dose will often range from 20&nbsp;mg to 80&nbsp;mg or higher, if necessary.  
*In addition, the treatment usually requires high doses. [[Fluoxetine]], for example, is usually prescribed in doses of 20&nbsp;mg per day for clinical [[depression]], whereas with OCD the dose will often range from 20&nbsp;mg to 80&nbsp;mg or higher, if necessary.  
*In most cases antidepressant therapy alone will only provide a partial reduction in symptoms, even in cases that are not deemed treatment-resistant. Other medications such as [[riluzole]], [[memantine]], [[gabapentin|gabapentin (Neurontin)]], [[lamotrigine|lamotrigine (Lamictal)]], and low doses of the newer [[atypical antipsychotic]]s [[olanzapine|olanzapine (Zyprexa)]], [[quetiapine|quetiapine (Seroquel)]] and [[risperidone|risperidone (Risperdal)]] have also been found to be useful as adjuncts in the treatment of OCD. The use of [[antipsychotic]]s in OCD must be undertaken carefully, however, since, although there is very strong evidence that at low doses they are beneficial (most likely due to their [[dopamine receptor]] [[antagonism]]), at high doses these same antipsychotics have proven to cause dramatic obsessive-compulsive symptoms even in those patients who do not normally have OCD. This is most likely due to the [[antagonism]] of 5-HT2A receptors becoming very prominent at these doses and outweighing the benefits of [[dopamine]] antagonism.  
*In most cases antidepressant therapy alone will only provide a partial reduction in [[symptoms]], even in cases that are not deemed treatment-resistant. Other medications such as [[riluzole]], [[memantine]], [[gabapentin|gabapentin (Neurontin)]], [[lamotrigine|lamotrigine (Lamictal)]], and low doses of the newer [[atypical antipsychotic]]s [[olanzapine|olanzapine (Zyprexa)]], [[quetiapine|quetiapine (Seroquel)]] and [[risperidone|risperidone (Risperdal)]] have also been found to be useful as adjuncts in the treatment of OCD. The use of [[antipsychotic]]s in OCD must be undertaken carefully, however, since, although there is very strong evidence that at low doses they are beneficial (most likely due to their [[dopamine receptor]] [[antagonism]]), at high doses these same [[antipsychotic]]s have proven to cause dramatic obsessive-compulsive [[symptoms]] even in those patients who do not normally have OCD. This is most likely due to the [[antagonism]] of 5-HT2A receptors becoming very prominent at these doses and outweighing the benefits of [[dopamine]] antagonism.  
*Another point that must be noted with antipsychotic treatment is that SSRIs inhibit the chief [[enzyme]] that is responsible for [[metabolising]] antipsychotics &mdash; [[CYP2D6]] &mdash; so the dose will be effectively higher than expected when these are combined with SSRIs.
*Another point that must be noted with [[antipsychotic]] treatment is that [[SSRI]]s inhibit the chief [[enzyme]] that is responsible for [[metabolising]] [[antipsychotic]]s &mdash; [[CYP2D6]] &mdash; so the dose will be effectively higher than expected when these are combined with [[SSRI]]s.
*The naturally occurring sugar [[inositol]] may be an effective treatment for OCD. Inositol appears to modulate the actions of serotonin and has been found to reverse [[desensitisation]] of the [[neurotransmitter]]'s receptors.<ref>{{cite web |url=http://www.biopsychiatry.com/inositol.htm |title=Inositol in psychiatry |accessdate=2007-06-28 |format= |work=}}</ref>
*The naturally occurring sugar [[inositol]] may be an effective treatment for OCD. [[Inositol]] appears to modulate the actions of [[serotonin]] and has been found to reverse desensitisation of the [[neurotransmitter]]'s receptors.<ref>{{cite web |url=http://www.biopsychiatry.com/inositol.htm |title=Inositol in psychiatry |accessdate=2007-06-28 |format= |work=}}</ref>
*[[St John's Wort]] has been claimed to be of benefit due to its (non-selective) serotonin re-uptake inhibiting qualities, and studies have emerged that have shown positive results. However, a double-blind study, using a flexible-dose schedule(600-1800 mg/day), found no difference between St John's Wort and the placebo.<ref>{{cite journal |author=Kobak KA, ''et al'' |title=St John's wort versus placebo in obsessive-compulsive disorder: results from a double-blind study.
*[[St John's Wort]] has been claimed to be of benefit due to its (non-selective) [[serotonin]] re-uptake inhibiting qualities, and studies have emerged that have shown positive results. However, a double-blind study, using a flexible-dose schedule(600-1800 mg/day), found no difference between [[St John's Wort]] and the placebo.<ref>{{cite journal |author=Kobak KA, ''et al'' |title=St John's wort versus placebo in obsessive-compulsive disorder: results from a double-blind study.
|journal=Int Clin Psychopharmacol. |volume=20 |issue=6 |pages=299-304 |year=2005 |pmid=16192837 |doi= |url=http://www.ncbi.nlm.nih.gov/pubmed/16192837?ordinalpos=1&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVDocSum | doi = 10.1097/00004850-200511000-00003 <!--Retrieved from CrossRef by DOI bot-->
|journal=Int Clin Psychopharmacol. |volume=20 |issue=6 |pages=299-304 |year=2005 |pmid=16192837 |doi= |url=http://www.ncbi.nlm.nih.gov/pubmed/16192837?ordinalpos=1&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVDocSum | doi = 10.1097/00004850-200511000-00003 <!--Retrieved from CrossRef by DOI bot-->
}}</ref>
}}</ref>
*Recent research has found increasing evidence that [[opioid]]s may significantly reduce OCD symptoms, though the addictive property of these drugs likely stands as an obstacle to their sanctioned approval for OCD treatment. Anecdotal reports suggest that some OCD sufferers have successfully self-medicated with opioids such as [[Ultram]] and [[hydrocodone|Vicodin]], though the off-label use of such [[painkiller]]s is not widely accepted, again because of their addictive qualities. [[Tramadol]] is an atypical opioid that may be a viable option as it has a low potential for abuse and addiction, mild side effects, and shows signs of rapid efficacy in OCD. Tramadol not only provides the anti-OCD effects of an [[opiate]], but also inhibits the [[re-uptake]] of serotonin (in addition to [[norepinephrine]]). This may provide additional benefits, but should not be taken in combination with [[antidepressant]] medication unless under careful medical supervision due to potential [[serotonin syndrome]].<ref>{{cite journal |author=Goldsmith TB, Shapira NA, Keck PE |title=Rapid remission of OCD with tramadol hydrochloride |journal=The American journal of psychiatry |volume=156 |issue=4 |pages=660-1 |year=1999 |pmid=10200754 |doi= |url=http://ajp.psychiatryonline.org/cgi/content/full/156/4/660a}}</ref>
*Recent research has found increasing evidence that [[opioid]]s may significantly reduce OCD [[symptoms]], though the [[drug addiction|addictive]] property of these drugs likely stands as an obstacle to their sanctioned approval for OCD treatment. Anecdotal reports suggest that some OCD sufferers have successfully self-medicated with [[opioid]]s such as [[Ultram]] and [[hydrocodone|Vicodin]], though the off-label use of such [[painkiller]]s is not widely accepted, again because of their addictive qualities. [[Tramadol]] is an atypical [[opioid]] that may be a viable option as it has a low potential for [[abuse]] and [[addiction]], mild side effects, and shows signs of rapid efficacy in OCD. Tramadol not only provides the anti-OCD effects of an [[opiate]], but also inhibits the [[re-uptake]] of [[serotonin]] (in addition to [[norepinephrine]]). This may provide additional benefits, but should not be taken in combination with [[antidepressant]] medication unless under careful medical supervision due to potential [[serotonin syndrome]].<ref>{{cite journal |author=Goldsmith TB, Shapira NA, Keck PE |title=Rapid remission of OCD with tramadol hydrochloride |journal=The American journal of psychiatry |volume=156 |issue=4 |pages=660-1 |year=1999 |pmid=10200754 |doi= |url=http://ajp.psychiatryonline.org/cgi/content/full/156/4/660a}}</ref>
*Studies have also been done that show nutrition deficiencies may also contribute to OCD and other [[mental disorder]]s. Certain [[vitamin]] and [[mineral supplements]] may aid in such disorders and provide the [[nutrients]] necessary for proper mental functioning. [http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=2248201]
*Studies have also been done that show nutrition deficiencies may also contribute to OCD and other [[mental disorder]]s. Certain [[vitamin]] and [[mineral supplements]] may aid in such disorders and provide the [[nutrients]] necessary for proper mental functioning. [http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=2248201]
*Research has generally shown that [[psychotherapy]], in combination with [[psychotropic medication]], is more effective than either option alone.
*Research has generally shown that [[psychotherapy]], in combination with [[psychotropic medication]], is more effective than either option alone.
*Recent studies at the University of Arizona using the [[tryptamine]] [[alkaloid]] [[psilocybin]] have shown promising results.<ref>{{cite web |url=http://www.maps.org/research/psilo/azproto.html |title=Psilocybin in the Treatment of Obsessive Compulsive Disorder |accessdate=2007-06-28 |format= |work=}}</ref> There are reports that other [[hallucinogen]]s such as [[LSD]] and [[peyote]] have produced similar benefits. It has been hypothesised that this effect may be due to stimulation of [[5-HT2A receptor]]s and, less importantly, [[Serotonin receptor|5-HT2C receptors]]. This causes, among many other effects, an inhibitory effect on the [[orbitofrontal cortex]], an area of the brain in which [[hyperactivity]] has been strongly associated with OCD.<ref>{{cite web |url=http://www.ajp.psychiatryonline.org/cgi/content/full/156/7/1123 |title=Hallucinogens and Obsessive-Compulsive Disorder -- PERRINE 156 (7): 1123 -- Am J Psychiatry |accessdate=2007-06-28 |format= |work=}}</ref>
*Recent studies at the University of Arizona using the [[tryptamine]] [[alkaloid]] [[psilocybin]] have shown promising results. There are reports that other [[hallucinogen]]s such as [[LSD]] and [[peyote]] have produced similar benefits. It has been hypothesised that this effect may be due to stimulation of [[5-HT2A receptor]]s and, less importantly, [[Serotonin receptor|5-HT2C receptors]]. This causes, among many other effects, an inhibitory effect on the [[orbitofrontal cortex]], an area of the brain in which [[hyperactivity]] has been strongly associated with OCD.<ref>{{cite web |url=http://www.ajp.psychiatryonline.org/cgi/content/full/156/7/1123 |title=Hallucinogens and Obsessive-Compulsive Disorder -- PERRINE 156 (7): 1123 -- Am J Psychiatry |accessdate=2007-06-28 |format= |work=}}</ref><ref>{{cite web |url=http://www.maps.org/research/psilo/azproto.html |title=Psilocybin in the Treatment of Obsessive Compulsive Disorder |accessdate=2007-06-28 |format= |work=}}</ref>
*Emerging evidence has suggested that regular [[nicotine]] treatment may be helpful in improving symptoms of OCD, although the [[pharmacodynamics|pharmacodynamical]] mechanism by which this improvement is achieved is not yet known, and more detailed studies are needed to fully confirm this hypothesis. Anecdotal reports suggest OCD can worsen when cigarettes are smoked.<ref>{{cite journal |author=Lundberg S, Carlsson A, Norfeldt P, Carlsson ML |title=Nicotine treatment of obsessive-compulsive disorder |journal=Prog. Neuropsychopharmacol. Biol. Psychiatry |volume=28 |issue=7 |pages=1195-9 |year=2004 |pmid=15610934 |doi=10.1016/j.pnpbp.2004.06.014}}</ref>
*Emerging evidence has suggested that regular [[nicotine]] treatment may be helpful in improving [[symptoms]] of OCD, although the [[pharmacodynamics|pharmacodynamical]] mechanism by which this improvement is achieved is not yet known, and more detailed studies are needed to fully confirm this hypothesis. Anecdotal reports suggest OCD can worsen when cigarettes are smoked.<ref>{{cite journal |author=Lundberg S, Carlsson A, Norfeldt P, Carlsson ML |title=Nicotine treatment of obsessive-compulsive disorder |journal=Prog. Neuropsychopharmacol. Biol. Psychiatry |volume=28 |issue=7 |pages=1195-9 |year=2004 |pmid=15610934 |doi=10.1016/j.pnpbp.2004.06.014}}</ref>


===Dosing of Medications for OCD treatment===
===Dosing of Medications for OCD treatment===
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<nowiki>*</nowiki>Adopted from JAMA<ref name="pmid283848322">{{cite journal| author=Hirschtritt ME, Bloch MH, Mathews CA| title=Obsessive-Compulsive Disorder: Advances in Diagnosis and Treatment. | journal=JAMA | year= 2017 | volume= 317 | issue= 13 | pages= 1358-1367 | pmid=28384832 | doi=10.1001/jama.2017.2200 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=28384832  }}</ref>
<nowiki>*</nowiki>Adopted from JAMA<ref name="pmid283848322">{{cite journal| author=Hirschtritt ME, Bloch MH, Mathews CA| title=Obsessive-Compulsive Disorder: Advances in Diagnosis and Treatment. | journal=JAMA | year= 2017 | volume= 317 | issue= 13 | pages= 1358-1367 | pmid=28384832 | doi=10.1001/jama.2017.2200 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=28384832  }}</ref>
==Overview==
There is no treatment for [disease name]; the mainstay of therapy is supportive care.
OR
Supportive therapy for [disease name] includes [therapy 1], [therapy 2], and [therapy 3].
OR
The majority of cases of [disease name] are self-limited and require only supportive care.
OR
[Disease name] is a medical emergency and requires prompt treatment.
OR
The mainstay of treatment for [disease name] is [therapy].
OR
 
The optimal therapy for [malignancy name] depends on the stage at diagnosis.
OR
[Therapy] is recommended among all patients who develop [disease name].
OR
Pharmacologic medical therapy is recommended among patients with [disease subclass 1], [disease subclass 2], and [disease subclass 3].
OR
Pharmacologic medical therapies for [disease name] include (either) [therapy 1], [therapy 2], and/or [therapy 3].
OR
Empiric therapy for [disease name] depends on [disease factor 1] and [disease factor 2].
OR
Patients with [disease subclass 1] are treated with [therapy 1], whereas patients with [disease subclass 2] are treated with [therapy 2].
==Medical Therapy==
*Pharmacologic medical therapy is recommended among patients with [disease subclass 1], [disease subclass 2], and [disease subclass 3].
*Pharmacologic medical therapies for [disease name] include (either) [therapy 1], [therapy 2], and/or [therapy 3].
*Empiric therapy for [disease name] depends on [disease factor 1] and [disease factor 2].
*Patients with [disease subclass 1] are treated with [therapy 1], whereas patients with [disease subclass 2] are treated with [therapy 2].
===Disease Name===
* '''1 Stage 1 - Name of stage'''
** 1.1 '''Specific Organ system involved 1'''
*** 1.1.1 '''Adult'''
**** Preferred regimen (1): [[drug name]] 100 mg PO q12h for 10-21 days '''(Contraindications/specific instructions)''' 
**** Preferred regimen (2): [[drug name]] 500 mg PO q8h for 14-21 days
**** Preferred regimen (3): [[drug name]] 500 mg q12h for 14-21 days
**** Alternative regimen (1): [[drug name]] 500 mg PO q6h for 7–10 days 
**** Alternative regimen (2): [[drug name]] 500 mg PO q12h for 14–21 days
**** Alternative regimen (3): [[drug name]] 500 mg PO q6h for 14–21 days
*** 1.1.2 '''Pediatric'''
**** 1.1.2.1 (Specific population e.g. '''children < 8 years of age''')
***** Preferred regimen (1): [[drug name]] 50 mg/kg PO per day q8h (maximum, 500 mg per dose) 
***** Preferred regimen (2): [[drug name]] 30 mg/kg PO per day in 2 divided doses (maximum, 500 mg per dose)
***** Alternative regimen (1): [[drug name]]10 mg/kg PO q6h (maximum, 500 mg per day)
***** Alternative regimen (2): [[drug name]] 7.5 mg/kg PO q12h (maximum, 500 mg per dose)
***** Alternative regimen (3): [[drug name]] 12.5 mg/kg PO q6h (maximum, 500 mg per dose)
****1.1.2.2 (Specific population e.g. '<nowiki/>'''''children < 8 years of age'''''')
***** Preferred regimen (1): [[drug name]] 4 mg/kg/day PO q12h(maximum, 100 mg per dose)
***** Alternative regimen (1): [[drug name]] 10 mg/kg PO q6h (maximum, 500 mg per day)
***** Alternative regimen (2): [[drug name]] 7.5 mg/kg PO q12h (maximum, 500 mg per dose) 
***** Alternative regimen (3): [[drug name]] 12.5 mg/kg PO q6h (maximum, 500 mg per dose)
** 1.2 '''Specific Organ system involved 2'''
*** 1.2.1 '''Adult'''
**** Preferred regimen (1): [[drug name]] 500 mg PO q8h
*** 1.2.2  '''Pediatric'''
**** Preferred regimen (1): [[drug name]] 50 mg/kg/day PO q8h (maximum, 500 mg per dose)
* 2 '''Stage 2 - Name of stage'''
** 2.1 '''Specific Organ system involved 1 '''
**: '''Note (1):'''
**: '''Note (2)''':
**: '''Note (3):'''
*** 2.1.1 '''Adult'''
**** Parenteral regimen
***** Preferred regimen (1): [[drug name]] 2 g IV q24h for 14 (14–21) days
***** Alternative regimen (1): [[drug name]] 2 g IV q8h for 14 (14–21) days
***** Alternative regimen (2): [[drug name]] 18–24 MU/day IV q4h for 14 (14–21) days
**** Oral regimen
***** Preferred regimen (1): [[drug name]] 500 mg PO q8h for 14 (14–21) days
***** Preferred regimen (2): [[drug name]] 100 mg PO q12h for 14 (14–21) days
***** Preferred regimen (3): [[drug name]] 500 mg PO q12h for 14 (14–21) days
***** Alternative regimen (1): [[drug name]] 500 mg PO q6h for 7–10 days 
***** Alternative regimen (2): [[drug name]] 500 mg PO q12h for 14–21 days
***** Alternative regimen (3):[[drug name]] 500 mg PO q6h for 14–21 days
*** 2.1.2 '''Pediatric'''
**** Parenteral regimen
***** Preferred regimen (1): [[drug name]] 50–75 mg/kg IV q24h for 14 (14–21) days (maximum, 2 g)
***** Alternative regimen (1): [[drug name]] 150–200 mg/kg/day IV q6–8h for 14 (14–21) days (maximum, 6 g per day)
***** Alternative regimen (2):  [[drug name]] 200,000–400,000 U/kg/day IV q4h for 14 (14–21) days (maximum, 18–24 million U per day) '<nowiki/>'''''(Contraindications/specific instructions)''''''
**** Oral regimen
***** Preferred regimen (1):  [[drug name]] 50 mg/kg/day PO q8h for 14 (14–21) days  (maximum, 500 mg per dose)
***** Preferred regimen (2): [[drug name]] '''(for children aged ≥ 8 years)''' 4 mg/kg/day PO q12h for 14 (14–21) days (maximum, 100 mg per dose)
***** Preferred regimen (3): [[drug name]] 30 mg/kg/day PO q12h for 14 (14–21) days  (maximum, 500 mg per dose)
***** Alternative regimen (1):  [[drug name]] 10 mg/kg PO q6h 7–10 days  (maximum, 500 mg per day)
***** Alternative regimen (2): [[drug name]] 7.5 mg/kg PO q12h for 14–21 days  (maximum, 500 mg per dose)
***** Alternative regimen (3): [[drug name]] 12.5 mg/kg PO q6h for 14–21 days  (maximum,500 mg per dose)
** 2.2  '<nowiki/>'''''Other Organ system involved 2''''''
**: '''Note (1):'''
**: '''Note (2)''':
**: '''Note (3):'''
*** 2.2.1 '''Adult'''
**** Parenteral regimen
***** Preferred regimen (1): [[drug name]] 2 g IV q24h for 14 (14–21) days
***** Alternative regimen (1): [[drug name]] 2 g IV q8h for 14 (14–21) days
***** Alternative regimen (2): [[drug name]] 18–24 MU/day IV q4h for 14 (14–21) days
**** Oral regimen
***** Preferred regimen (1): [[drug name]] 500 mg PO q8h for 14 (14–21) days
***** Preferred regimen (2): [[drug name]] 100 mg PO q12h for 14 (14–21) days
***** Preferred regimen (3): [[drug name]] 500 mg PO q12h for 14 (14–21) days
***** Alternative regimen (1): [[drug name]] 500 mg PO q6h for 7–10 days 
***** Alternative regimen (2): [[drug name]] 500 mg PO q12h for 14–21 days
***** Alternative regimen (3):[[drug name]] 500 mg PO q6h for 14–21 days
*** 2.2.2 '''Pediatric'''
**** Parenteral regimen
***** Preferred regimen (1): [[drug name]] 50–75 mg/kg IV q24h for 14 (14–21) days (maximum, 2 g)
***** Alternative regimen (1): [[drug name]] 150–200 mg/kg/day IV q6–8h for 14 (14–21) days (maximum, 6 g per day)
***** Alternative regimen (2):  [[drug name]] 200,000–400,000 U/kg/day IV q4h for 14 (14–21) days (maximum, 18–24 million U per day)
**** Oral regimen
***** Preferred regimen (1):  [[drug name]] 50 mg/kg/day PO q8h for 14 (14–21) days  (maximum, 500 mg per dose)
***** Preferred regimen (2): [[drug name]] 4 mg/kg/day PO q12h for 14 (14–21) days (maximum, 100 mg per dose)
***** Preferred regimen (3): [[drug name]] 30 mg/kg/day PO q12h for 14 (14–21) days  (maximum, 500 mg per dose)
***** Alternative regimen (1):  [[drug name]] 10 mg/kg PO q6h 7–10 days  (maximum, 500 mg per day)
***** Alternative regimen (2): [[drug name]] 7.5 mg/kg PO q12h for 14–21 days  (maximum, 500 mg per dose)
***** Alternative regimen (3): [[drug name]] 12.5 mg/kg PO q6h for 14–21 days  (maximum,500 mg per dose)


==References==
==References==


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Latest revision as of 16:54, 23 April 2021

Obsessive-compulsive disorder Microchapters

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Priyanka Kumari, M.B.B.S[2]Sonya Gelfand, Usama Talib, BSc, MD [3]

Overview

According to the Expert Consensus Guidelines for the Treatment of obsessive-compulsive disorder, behavioral therapy (BT), cognitive therapy (CT), medications, or any combination of the three are first-line treatments for OCD. Psychodynamic psychotherapy may help in managing some aspects of the disorder, but there are no controlled studies that demonstrate effectiveness of psychoanalysis or dynamic psychotherapy in OCD.[1] Though there is no known treatment for full remission of OCD yet, there are a number of successful treatment options available to promote significant improvement.

Treatment

Medical Therapy

One may be referred by their doctor to a mental health specialist, such as a psychiatrist, psychologist, social worker, or counselor for evaluation of treatment, however OCD is usually medically managed by psychological and pharmacological interventions.[2]

Medication

  • Medications as treatment include the following:
  • SSRIs prevent excess serotonin from being pumped back into the original neuron that released it. Serotonin can then bind to the receptor sites of nearby neurons and send chemical messages or signals that can help regulate the excessive anxiety and obsessive-compulsive thoughts.
  • In some treatment-resistant cases, a combination of clomipramine and an SSRI has shown to be effective even when neither drug on its own has been efficacious. Serotonergic antidepressants typically take longer to show benefit in OCD than with most other disorders which they are used to treat, as it is common for 2–3 months to elapse before any tangible improvement is noticed.
  • In addition, the treatment usually requires high doses. Fluoxetine, for example, is usually prescribed in doses of 20 mg per day for clinical depression, whereas with OCD the dose will often range from 20 mg to 80 mg or higher, if necessary.
  • In most cases antidepressant therapy alone will only provide a partial reduction in symptoms, even in cases that are not deemed treatment-resistant. Other medications such as riluzole, memantine, gabapentin (Neurontin), lamotrigine (Lamictal), and low doses of the newer atypical antipsychotics olanzapine (Zyprexa), quetiapine (Seroquel) and risperidone (Risperdal) have also been found to be useful as adjuncts in the treatment of OCD. The use of antipsychotics in OCD must be undertaken carefully, however, since, although there is very strong evidence that at low doses they are beneficial (most likely due to their dopamine receptor antagonism), at high doses these same antipsychotics have proven to cause dramatic obsessive-compulsive symptoms even in those patients who do not normally have OCD. This is most likely due to the antagonism of 5-HT2A receptors becoming very prominent at these doses and outweighing the benefits of dopamine antagonism.
  • Another point that must be noted with antipsychotic treatment is that SSRIs inhibit the chief enzyme that is responsible for metabolising antipsychoticsCYP2D6 — so the dose will be effectively higher than expected when these are combined with SSRIs.
  • The naturally occurring sugar inositol may be an effective treatment for OCD. Inositol appears to modulate the actions of serotonin and has been found to reverse desensitisation of the neurotransmitter's receptors.[3]
  • St John's Wort has been claimed to be of benefit due to its (non-selective) serotonin re-uptake inhibiting qualities, and studies have emerged that have shown positive results. However, a double-blind study, using a flexible-dose schedule(600-1800 mg/day), found no difference between St John's Wort and the placebo.[4]
  • Recent research has found increasing evidence that opioids may significantly reduce OCD symptoms, though the addictive property of these drugs likely stands as an obstacle to their sanctioned approval for OCD treatment. Anecdotal reports suggest that some OCD sufferers have successfully self-medicated with opioids such as Ultram and Vicodin, though the off-label use of such painkillers is not widely accepted, again because of their addictive qualities. Tramadol is an atypical opioid that may be a viable option as it has a low potential for abuse and addiction, mild side effects, and shows signs of rapid efficacy in OCD. Tramadol not only provides the anti-OCD effects of an opiate, but also inhibits the re-uptake of serotonin (in addition to norepinephrine). This may provide additional benefits, but should not be taken in combination with antidepressant medication unless under careful medical supervision due to potential serotonin syndrome.[5]
  • Studies have also been done that show nutrition deficiencies may also contribute to OCD and other mental disorders. Certain vitamin and mineral supplements may aid in such disorders and provide the nutrients necessary for proper mental functioning. [4]
  • Research has generally shown that psychotherapy, in combination with psychotropic medication, is more effective than either option alone.
  • Recent studies at the University of Arizona using the tryptamine alkaloid psilocybin have shown promising results. There are reports that other hallucinogens such as LSD and peyote have produced similar benefits. It has been hypothesised that this effect may be due to stimulation of 5-HT2A receptors and, less importantly, 5-HT2C receptors. This causes, among many other effects, an inhibitory effect on the orbitofrontal cortex, an area of the brain in which hyperactivity has been strongly associated with OCD.[6][7]
  • Emerging evidence has suggested that regular nicotine treatment may be helpful in improving symptoms of OCD, although the pharmacodynamical mechanism by which this improvement is achieved is not yet known, and more detailed studies are needed to fully confirm this hypothesis. Anecdotal reports suggest OCD can worsen when cigarettes are smoked.[8]

Dosing of Medications for OCD treatment

Medication Starting Dose

(mg/d)

Target Dose

(mg/d)

SSRIs Fluoxetine 20 80
Fluvoxamine 50 300
Sertraline 50 200
Paroxetine 20 60
Citalopram 20 40
Escitalopram 10 40
Tricyclic

Antidepressants

Clomipramine 25 250

*Adopted from JAMA[9]

Overview

There is no treatment for [disease name]; the mainstay of therapy is supportive care.

OR

Supportive therapy for [disease name] includes [therapy 1], [therapy 2], and [therapy 3].

OR

The majority of cases of [disease name] are self-limited and require only supportive care.

OR

[Disease name] is a medical emergency and requires prompt treatment.

OR

The mainstay of treatment for [disease name] is [therapy].

OR   The optimal therapy for [malignancy name] depends on the stage at diagnosis.

OR

[Therapy] is recommended among all patients who develop [disease name].

OR

Pharmacologic medical therapy is recommended among patients with [disease subclass 1], [disease subclass 2], and [disease subclass 3].

OR

Pharmacologic medical therapies for [disease name] include (either) [therapy 1], [therapy 2], and/or [therapy 3].

OR

Empiric therapy for [disease name] depends on [disease factor 1] and [disease factor 2].

OR

Patients with [disease subclass 1] are treated with [therapy 1], whereas patients with [disease subclass 2] are treated with [therapy 2].

Medical Therapy

  • Pharmacologic medical therapy is recommended among patients with [disease subclass 1], [disease subclass 2], and [disease subclass 3].
  • Pharmacologic medical therapies for [disease name] include (either) [therapy 1], [therapy 2], and/or [therapy 3].
  • Empiric therapy for [disease name] depends on [disease factor 1] and [disease factor 2].
  • Patients with [disease subclass 1] are treated with [therapy 1], whereas patients with [disease subclass 2] are treated with [therapy 2].

Disease Name

  • 1 Stage 1 - Name of stage
    • 1.1 Specific Organ system involved 1
      • 1.1.1 Adult
        • Preferred regimen (1): drug name 100 mg PO q12h for 10-21 days (Contraindications/specific instructions)
        • Preferred regimen (2): drug name 500 mg PO q8h for 14-21 days
        • Preferred regimen (3): drug name 500 mg q12h for 14-21 days
        • Alternative regimen (1): drug name 500 mg PO q6h for 7–10 days
        • Alternative regimen (2): drug name 500 mg PO q12h for 14–21 days
        • Alternative regimen (3): drug name 500 mg PO q6h for 14–21 days
      • 1.1.2 Pediatric
        • 1.1.2.1 (Specific population e.g. children < 8 years of age)
          • Preferred regimen (1): drug name 50 mg/kg PO per day q8h (maximum, 500 mg per dose)
          • Preferred regimen (2): drug name 30 mg/kg PO per day in 2 divided doses (maximum, 500 mg per dose)
          • Alternative regimen (1): drug name10 mg/kg PO q6h (maximum, 500 mg per day)
          • Alternative regimen (2): drug name 7.5 mg/kg PO q12h (maximum, 500 mg per dose)
          • Alternative regimen (3): drug name 12.5 mg/kg PO q6h (maximum, 500 mg per dose)
        • 1.1.2.2 (Specific population e.g. 'children < 8 years of age')
          • Preferred regimen (1): drug name 4 mg/kg/day PO q12h(maximum, 100 mg per dose)
          • Alternative regimen (1): drug name 10 mg/kg PO q6h (maximum, 500 mg per day)
          • Alternative regimen (2): drug name 7.5 mg/kg PO q12h (maximum, 500 mg per dose)
          • Alternative regimen (3): drug name 12.5 mg/kg PO q6h (maximum, 500 mg per dose)
    • 1.2 Specific Organ system involved 2
      • 1.2.1 Adult
        • Preferred regimen (1): drug name 500 mg PO q8h
      • 1.2.2 Pediatric
        • Preferred regimen (1): drug name 50 mg/kg/day PO q8h (maximum, 500 mg per dose)
  • 2 Stage 2 - Name of stage
    • 2.1 Specific Organ system involved 1
      Note (1):
      Note (2):
      Note (3):
      • 2.1.1 Adult
        • Parenteral regimen
          • Preferred regimen (1): drug name 2 g IV q24h for 14 (14–21) days
          • Alternative regimen (1): drug name 2 g IV q8h for 14 (14–21) days
          • Alternative regimen (2): drug name 18–24 MU/day IV q4h for 14 (14–21) days
        • Oral regimen
          • Preferred regimen (1): drug name 500 mg PO q8h for 14 (14–21) days
          • Preferred regimen (2): drug name 100 mg PO q12h for 14 (14–21) days
          • Preferred regimen (3): drug name 500 mg PO q12h for 14 (14–21) days
          • Alternative regimen (1): drug name 500 mg PO q6h for 7–10 days
          • Alternative regimen (2): drug name 500 mg PO q12h for 14–21 days
          • Alternative regimen (3):drug name 500 mg PO q6h for 14–21 days
      • 2.1.2 Pediatric
        • Parenteral regimen
          • Preferred regimen (1): drug name 50–75 mg/kg IV q24h for 14 (14–21) days (maximum, 2 g)
          • Alternative regimen (1): drug name 150–200 mg/kg/day IV q6–8h for 14 (14–21) days (maximum, 6 g per day)
          • Alternative regimen (2):  drug name 200,000–400,000 U/kg/day IV q4h for 14 (14–21) days (maximum, 18–24 million U per day) '(Contraindications/specific instructions)'
        • Oral regimen
          • Preferred regimen (1): drug name 50 mg/kg/day PO q8h for 14 (14–21) days (maximum, 500 mg per dose)
          • Preferred regimen (2): drug name (for children aged ≥ 8 years) 4 mg/kg/day PO q12h for 14 (14–21) days (maximum, 100 mg per dose)
          • Preferred regimen (3): drug name 30 mg/kg/day PO q12h for 14 (14–21) days (maximum, 500 mg per dose)
          • Alternative regimen (1): drug name 10 mg/kg PO q6h 7–10 days (maximum, 500 mg per day)
          • Alternative regimen (2): drug name 7.5 mg/kg PO q12h for 14–21 days (maximum, 500 mg per dose)
          • Alternative regimen (3): drug name 12.5 mg/kg PO q6h for 14–21 days (maximum,500 mg per dose)
    • 2.2 'Other Organ system involved 2'
      Note (1):
      Note (2):
      Note (3):
      • 2.2.1 Adult
        • Parenteral regimen
          • Preferred regimen (1): drug name 2 g IV q24h for 14 (14–21) days
          • Alternative regimen (1): drug name 2 g IV q8h for 14 (14–21) days
          • Alternative regimen (2): drug name 18–24 MU/day IV q4h for 14 (14–21) days
        • Oral regimen
          • Preferred regimen (1): drug name 500 mg PO q8h for 14 (14–21) days
          • Preferred regimen (2): drug name 100 mg PO q12h for 14 (14–21) days
          • Preferred regimen (3): drug name 500 mg PO q12h for 14 (14–21) days
          • Alternative regimen (1): drug name 500 mg PO q6h for 7–10 days
          • Alternative regimen (2): drug name 500 mg PO q12h for 14–21 days
          • Alternative regimen (3):drug name 500 mg PO q6h for 14–21 days
      • 2.2.2 Pediatric
        • Parenteral regimen
          • Preferred regimen (1): drug name 50–75 mg/kg IV q24h for 14 (14–21) days (maximum, 2 g)
          • Alternative regimen (1): drug name 150–200 mg/kg/day IV q6–8h for 14 (14–21) days (maximum, 6 g per day)
          • Alternative regimen (2):  drug name 200,000–400,000 U/kg/day IV q4h for 14 (14–21) days (maximum, 18–24 million U per day)
        • Oral regimen
          • Preferred regimen (1): drug name 50 mg/kg/day PO q8h for 14 (14–21) days (maximum, 500 mg per dose)
          • Preferred regimen (2): drug name 4 mg/kg/day PO q12h for 14 (14–21) days (maximum, 100 mg per dose)
          • Preferred regimen (3): drug name 30 mg/kg/day PO q12h for 14 (14–21) days (maximum, 500 mg per dose)
          • Alternative regimen (1): drug name 10 mg/kg PO q6h 7–10 days (maximum, 500 mg per day)
          • Alternative regimen (2): drug name 7.5 mg/kg PO q12h for 14–21 days (maximum, 500 mg per dose)
          • Alternative regimen (3): drug name 12.5 mg/kg PO q6h for 14–21 days (maximum,500 mg per dose)

References

  1. Koran LM, Hanna GL, Hollander E, Nestadt G, Simpson HB; American Psychiatric Association. Template:PDFlink Am J Psychiatry 2007; 164(7 Suppl): 5-53. PMID 17849776.
  2. Hirschtritt ME, Bloch MH, Mathews CA (2017). "Obsessive-Compulsive Disorder: Advances in Diagnosis and Treatment". JAMA. 317 (13): 1358–1367. doi:10.1001/jama.2017.2200. PMID 28384832.
  3. "Inositol in psychiatry". Retrieved 2007-06-28.
  4. Kobak KA; et al. (2005). "St John's wort versus placebo in obsessive-compulsive disorder: results from a double-blind study". Int Clin Psychopharmacol. 20 (6): 299–304. doi:10.1097/00004850-200511000-00003. PMID 16192837.
  5. Goldsmith TB, Shapira NA, Keck PE (1999). "Rapid remission of OCD with tramadol hydrochloride". The American journal of psychiatry. 156 (4): 660–1. PMID 10200754.
  6. "Hallucinogens and Obsessive-Compulsive Disorder -- PERRINE 156 (7): 1123 -- Am J Psychiatry". Retrieved 2007-06-28.
  7. "Psilocybin in the Treatment of Obsessive Compulsive Disorder". Retrieved 2007-06-28.
  8. Lundberg S, Carlsson A, Norfeldt P, Carlsson ML (2004). "Nicotine treatment of obsessive-compulsive disorder". Prog. Neuropsychopharmacol. Biol. Psychiatry. 28 (7): 1195–9. doi:10.1016/j.pnpbp.2004.06.014. PMID 15610934.
  9. Hirschtritt ME, Bloch MH, Mathews CA (2017). "Obsessive-Compulsive Disorder: Advances in Diagnosis and Treatment". JAMA. 317 (13): 1358–1367. doi:10.1001/jama.2017.2200. PMID 28384832.

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