According to other findings, multiple cognitive enhancement strategies may also warrant further exploration in OCD treatment, such as: cognitive remediation therapy, which emphasizes the development of cognitive flexibility; the inference-based approach, a new approach for OCD with poor insight in which patients are taught to rely on momentary sensory information vs obsessive reasoning in order to more accurately assess reality; and habit reversal therapy, which helps to increase patients’ awareness of premonitory urges preceding compulsive actions and to engage in competing responses instead.4 “I think that OCD is a consequence of habit formation in many patients,” said psychiatrist Danielle Cath, MD, PhD, a psychology professor at Utrecht University in the Netherlands and one of the authors of the 2016 review. “Habits are lower-energy repetitions that tend to easily generalize, and they must be replaced by more goal-directed behaviors that cost more energy and require constant effort and attention in daily life,” she told Psychiatry Advisor.

When all other treatment options fail, more invasive techniques may prove to be appropriate. Findings show that ablative surgery could improve symptoms in 30% to 60% of patients with treatment-refractory OCD, and increasing evidence supports the relative safety and efficacy of deep brain stimulation, a less invasive approach that “functionally overrides and modulates pathological hyperactivity in disturbed networks, reducing the hyperconnectivity” of the cortico-striato-thalamo-cortical loops.4 Though deep brain stimulation has been associated with a 50% treatment response rate, researchers will need to elucidate “which characteristics of OCD patients determine which treatment option is the best,” said Dr Cath.

 

In some cases, the issues lie not with treatment efficacy but with clinician competency to appropriately deliver OCD-specific treatment. For example, though “medication is widely available, many professionals may not understand the most effective way to use these drugs, as it is different from how they are used for other disorders,” explained Dr Claiborne. The majority of patients require high doses over a period of 10 to 12 weeks in order to experience notable improvement, and some “experience exacerbation of symptoms early in a trial of SSRI medication, which may lead to discontinuation. This is unfortunate as this early increase in symptoms may predict a positive longer-term response,” he said.

As for CBT, patients are often unable to access a therapist adequately trained to treat OCD, which “requires very intensive treatments that we often do not offer, or they are suboptimally delivered,” according to Dr Cath. Providing effective treatment as early as possible may offer the best chance of recovery. Patients who remain partially symptomatic after treatment have an especially high risk of relapse in response to stressful life events, which becomes even more pronounced over time and with lower-impact events. “So there is a window of opportunity in first-onset OCD where we clinicians should do all we can to help patients become symptom-free,” she said. 

References

1. National Institutes of Health: National Institute of Mental Health. Obsessive compulsive disorder among adults. Available at: http://www.nimh.nih.gov/health/statistics/prevalence/obsessive-compulsive-disorder-among-adults.shtml. Accessed 8/7/16.

2. Subramaniam M, Research Division, Institute of Mental Health, Singapore;Soh P, Research Division, Institute of Mental Health, Singapore;Ong C, et al. Patient-reported outcomes in obsessive-compulsive disorder. Dialogues Clin Neurosci. 2014;16(2):239-254.

3. Hertenstein E, Thiel N, Herbst N, et al. Quality of life changes following inpatient and outpatient treatment in obsessive-compulsive disorder: a study with 12 months follow-up. Ann Gen Psychiatry. 2013;12(1):4. 

4. Grant JE, Fineberg N, van Ameringen M, et al. New treatment models for compulsive disorders. Eur Neuropsychopharmacol. 2016;26(5):877-884. 

5. Fineberg NA, Reghunandanan S, Simpson HB, et al. Obsessive-compulsive disorder (OCD): practical strategies for pharmacological and somatic treatment in adults. Psychiatry Res. 2015; 227(1):114-125. 

6. Veale D, Miles S, Smallcombe N, Ghezai H, Goldacre B, Hodsoll J. Atypical antipsychotic augmentation in SSRI treatment refractory obsessive-compulsive disorder: a systematic review and meta-analysis. BMC Psychiatry. 2014;14:317.

7. Bloch MH, Wasylink S, Landeros-Weisenberger A, et al. Effects of ketamine in treatment-refractory obsessive-compulsive disorder. Biol Psychiatry. 2012; 72(11):964-970. 

8. Rodriguez CI, Kegeles LS, Levinson A, et al. Randomized controlled crossover trial of ketamine in obsessive-compulsive disorder: proof-of-concept. Neuropsychopharmacology. 2013;38(12):2475-2483.

9. Ammar G, Naja WJ, Pelissolo A. Treatment-resistant anxiety disorders: a literature review of drug therapy strategies. Encephale. 2015;41(3):260-265.

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