Welcome to PsyDactic - Residency Edition - Your podcast resource to survive and thrive in your psych residency.
I am Dr. O, and as of this recording I am a 2nd Year Resident in the National Capital Consortium Psychiatry Residency Program. However, make no mistake, I do not speak for this program, nor do I speak for the Department of Defense or the Federal Government or anyone else for that matter. What I say is my opinion, and I reserve the right to be wrong, so trust me at your own risk. It’s a risk some are willing to take.
References and recommended readings can be found at the end of the show transcript, located at psydactic.buzzsprout.com.
In the previous episode, we took an imaginary train ride through some of the circuits in the brain that are thought to play major roles in the pathogenesis of obsessive compulsive disorder. In this episode, I will quickly explore how to treat patients with OCD. Choosing first-line treatment is relatively straight-forward, but I found less clarity on how to proceed if my patient does not respond. It is imperative, then, to make sure that I understand my patient’s symptoms and their goals very well.
It may go without saying that we need to establish some kind of partnership with our patients. We can’t assume that because a patient is sitting in front of us, desperate for some relief, that they will be willing to partner with anyone who gives them some advice. Establishing a therapeutic alliance is more involved. A therapeutic alliance is not a process where I tell the patient what to do and then they comply or not. It is a process of developing a relationship.
The patient needs to understand two important things. The first is that I as the provider have at least a decent understanding of what is happening to them. OCD can have a broad range of symptoms. I may have given them a symptom rating scale, like the Y-BOCS, but that doesn’t mean that I have a good grasp of their symptoms or that I understand exactly how their symptoms are affecting their life. That cannot be captured on a form. That is a result of a continuing conversation, and needs to be updated regularly. The patient needs to understand that I don’t just understand their disease, I understand them. I understand what their understanding of their disorder is. I understand how it affects their life. I understand the factors in their interpersonal and cultural interactions that create distress or provide comfort and support for them.
But for therapeutic alliance, the patient needs also to know that I can do something for them. They may know that I have a great understanding of what is going on, but if they don’t believe that I can offer them something to relieve their suffering, then why would they align with me?
To do something for someone, I have to understand their goals. Goal setting is a compromise just like anything else. If the patient comes to me and says, “I want all my symptoms to go away and never come back,” I’ll have to find an effective way to steer them toward something more realistic like, “How about we make some achievable short term goals, and see what we can do to improve your daily functioning. What is the thing that most interrupts your day?”
Once we have goals, then we can start talking treatments. The treatments I will outline below are primarily based on the American Psychiatric Association Practice Guidelines for OCD.
You probably know that first line pharmacologic treatments for OCD are the serotonin reuptake inhibitors, especially the selective variety such as fluoxetine, fluvoxamine, paroxetine, and sertraline which have FDA approval. The APA does not recommend any particular SSRI over another, so it is reasonable to use citalopram, escitalopram or others. Clomipramine, a tricyclic serotonin and norepinephrine reuptake inhibitor, is also FDA approved. There does not seem to be any good evidence that any one of these is much better than any other, but risks and side effect profiles differ substantially.
I am going to apologize now. In the last episode, I discussed how the brain makes decisions about what to do, and talked about the cortico-striatal-thalamo-cortical tract in excruciating detail. If you remember, the neurons involved were glutamatergic and GABAergic, and the GABAergic ones were heavily modulated by dopamine. How do serotonergic agents modulate this system? The best answer is I don’t know. So I am sorry that I can’t actually take that previous knowledge and connect it to our treatment plan. SSRIs work because that is what we have the best evidence for, not because we have an a priori reason to explain their action.
To get back to SSRIs, when choosing the first one, efficacy is not really a part of the decision. Look at your patient as a whole, consider side effect profile, comorbid conditions, likelihood of pregnancy, etc when deciding, and let the patient know exactly why you chose a specific medication. Also, don’t forget to set realistic expectations for the 4-6 weeks a medication may take to be at least partially effective, and the 8-12 weeks needed to assess its maximum efficacy, along with the high likelihood that the dose of any medication will have to be increased beyond the usual maximum dosage. Also, don’t let your patient be surprised to find out that more than one medication may need to be trialed, sometimes by adding on an additional medicine.
If a patient is amenable to also do CBT, then combining this with pharmacologic agents may help enhance the effect and might make relief more durable for patients who want or need to discontinue medications. Not surprisingly CBT such as Exposure and Response Prevention Therapy (or ERT), that has a focus on behaviors is what is initially recommended. A patient may have very good insight already into their disease, and so enhancing their cognitive abilities may do little for them. For those with limited or poor insight, depending on why this insight is limited, adding on cognitive components may be necessary. However, any CBT seems to be better than no CBT.
If you can remember back two episodes, I mentioned that people with OCD most often are able to identify that their obsessions are probably unreasonable or exaggerated and that their compulsions likely do little to change the real world, but there are a minority (less than 5%) that have delusional beliefs surrounding their symptoms. If a patient is amenable, including trusted family members in a treatment plan may help to provide a patient with the greatest chance of improved functioning.
Many patients have only a partial response to their initial therapies. By partial, I mean that they have improved, but haven’t met their goals and are still living with some kind of intolerable dysfunction. You may use the Clinical Global Impressions Improvement scale, the Florida Obsessive-Compulsive Inventory, or the Y-BOCs scale to track symptoms, but don’t forget to ask the patient themselves whether they want to try for more relief or not. Don’t just say, “Your scores aren’t low enough, we should add more medication.” Find out if that is consistent with the patient’s goals. If the patient says “Let’s do more,” then the APA recommends that augmentation strategies be tried instead of switching to another SSRI, which you would do if there is no response. If all the patient has tried are serotonergic agents, then this is a good time to tag on ERT. If they have already tried this, then try increasing the intensity of ERT.
Once you have established that a patient has had an adequate trial of first line medications and/or CBT and they have only partially responded, then it's time to think about augmentation. First, consider augmentation of SSRIs with low doses of second generation antipsychotic medications including aripiprazole, risperidone, olanzapine, and quetiapine, or low dose haloperidol. There is not much evidence to help you choose between them as far as efficacy is concerned, but side-effect profiles can help you make a choice. As you can probably guess, there are serious questions about the tradeoffs of using antipsychotics for the long-term (such as extra pyramidal symptoms, metabolic syndrome, amenorrhea, gynecomastia, etc) and you should take substantial time building alliances with your patient around acceptable risks, costs, and benefits of antipsychotic treatment.
If antipsychotics fail, there are soooo many other potential strategies that I am reminded of a proverb that a surgeon once told me while repairing a pilonidal cyst. He said, “If there are a bunch of treatments for the same thing, it means that none of them really work.” Other strategies to treat OCD include changing from an SSRI to venlafaxine, augmentation with clomipramine, buspirone, mirtazapine, lithium, D-amphetamine, topiramate, lamotrigine, N-acetylcysteine, and even memantine.
You can also try rTMS, deep brain stimulation, or neurosurgery. In my TMS series I mention the use of rTMS in OCD, but unfortunately, the evidence of efficacy does not warrant a recommendation of “Do this.” It can be tried for treatment resistant OCD, but unless your patient is completely against trials of both medications and psychotherapy, this is not something to try first or even second. TMS is attractive because it is impressive to patients, is less invasive, and has fewer systemic side effects than other treatments, but in its current form, it is just not likely to get the job done.
According to a 2019 systematic review of brain stimulation techniques published in Current Neuropharmacology, DBS showed good results when targeting the connections between the nucleus accumbens and the ventral capsule or the subthalamic nucleus. You might suggest this before suggesting something like cingulotomy. DBS and surgery are reserved for severe and intractable OCD. Surgery involves cutting or ablating tracts during procedures such as capsulotomy,
limbic leucotomy, and cingulotomy. Gamma-knife radiosurgery has also been used. Surgery is so infrequently used that the evidence for it is limited primarily to case reports, but improvements can be substantial. However, side effects can be substantial as well. If OCD symptoms remit because the patient is made intractably apathetic, then the benefit may not be worth the cost.
This episode included a wild romp through the possible treatments for OCD. I spent time harping on building a therapeutic alliance with your patient, because for disorders that are chronic and as difficult to treat as OCD, lack of adherence to a treatment plan is the easiest way to guarantee that it won’t work. The first step is easy. Start an SSRI and recommend CBT based therapy, but it gets very fuzzy after that.
I am Dr. O, and this has been an episode of PsyDactic Residency Edition.
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Bibliography
1. Koran L, Simpson B, Ph. GUIDELINE WATCH (MARCH 2013): PRACTICE GUIDELINE FOR THE TREATMENT OF PATIENTS WITH OBSESSIVE-COMPULSIVE DISORDER.
2. Koran LM, Hanna GL, Hollander E, Nestadt G, Simpson HB, American Psychiatric Association. Practice guideline for the treatment of patients with obsessive-compulsive disorder. Am J Psychiatry. 2007;164(7 Suppl):5-53.
3. Grant JE, Chamberlain SR. Exploring the neurobiology of OCD: clinical implications. Psychiatr Times. 2020;2020.
4. Leckman JF, Grice DE, Boardman J, et al. Symptoms of obsessive-compulsive disorder. Am J Psychiatry. 1997;154(7):911-917. doi:10.1176/ajp.154.7.911
5. Rapinesi C, Kotzalidis GD, Ferracuti S, Sani G, Girardi P, Del Casale A. Brain Stimulation in Obsessive-Compulsive Disorder (OCD): A Systematic Review. Curr Neuropharmacol. 2019;17(8):787-807. doi:10.2174/1570159X17666190409142555
