Obsessive-compulsive disorder
BMJ 2006; 333 doi: https://doi.org/10.1136/bmj.333.7565.424 (Published 24 August 2006) Cite this as: BMJ 2006;333:424All rapid responses
Rapid responses are electronic comments to the editor. They enable our users to debate issues raised in articles published on bmj.com. A rapid response is first posted online. If you need the URL (web address) of an individual response, simply click on the response headline and copy the URL from the browser window. A proportion of responses will, after editing, be published online and in the print journal as letters, which are indexed in PubMed. Rapid responses are not indexed in PubMed and they are not journal articles. The BMJ reserves the right to remove responses which are being wilfully misrepresented as published articles or when it is brought to our attention that a response spreads misinformation.
From March 2022, the word limit for rapid responses will be 600 words not including references and author details. We will no longer post responses that exceed this limit.
The word limit for letters selected from posted responses remains 300 words.
OCD which is like the proverbial Old seaman-Zindbad of the Arabian
stories, can be a penalty to pay for enjoying superior intelligence and
these workaholics are the main pillars of an establishment, taking less
and giving more to the society. The renowned 18th century English writer
Dr Samuel Johnson had to touch every post while walking, going back if he
happened to miss one. Very little attention has been paid to this disorder
in recent times and the paper of Heyman, Mataix-Cols and Fineberg (1) has
been thought provoking.
OCD may have a biological substratum. Psychological and environmental
factors can push the individuals predisposed to OCD into the right gear.
Fluctuations of thoughts in the obsessional individual are sometimes
confused for the mood swings of the affective disorder and over treated.
OCD is a heterogeneous disorder and so the response to one set of
treatment could be idiosyncratic. From a psychopharmacological point of
view, combination and augmentation treatments appear justifiable in the
management of difficult to treat patients. Clomipramine/SSRIs are more
effective than non-serotnergic drugs (2). Whether Clomipramine or SSRIs
should be the first choice in the treatment of OCD is debatable. Even
though SSRIs and clomipramine help OCD, depression and OCD do not have a
shared aetiology.
Most data suggest that OCD is a life –long disease (3). There are
treatment resistant and treatment refractory cases of OCD although the
terms “resistant and refractory” are used interchangeably. When a patient
has failed both adequate trials of an SSRI and psychotherapy, it is
considered as treatment resistant. An “adequate trial” is defined as 10-
12 weeks of continuos trial at maximum tolerated dose of SSRI or
clomipramine and adequate psychotherapy is at least 30 hours of
behavioural therapy with no improvement (3). Treatment refractory OCD can
be determined if a person has tried, at a minimum three different SSRIs
(Clomipramine one among them) at a maximum dosage for at least 3-6 months
along with the behavioural therapy together in conjunction with a trial of
two atypical antipsychotics individually.
Multicentre studies suggest that 20 percent of patients who fail to
respond to an initial SSRI will go on to respond to a second trial of
another SSRI. Thereafter pharmacological augmentation is justifiable.
Options of DA receptor antagonist such as risperidone, Olanzapine are
worth considering in treatment resistant OCD but these drugs on its own
has minimal effect. The addition of TCA s to SSRI s has been proven to be
effective where neither of the two drugs were individually unsuccessful.
(4)
The clinical data so far do not support the routine use of lithium
augmentation in the management of patients with OCD. My experience in
three cases of refractory OCD with the addition of lithium to SSRI/
Clomipramine produced favourable results (as described at routine clinical
follow up, rather than by formal rating scales). The decision to add
lithium which has undesirable long term side effects, would depend upon
how desperate is the patient or the therapist.
References:
1.I Heyman, D Mataix-Cols,Fineberg N A. Obsessive –compulsive
disorder. British Medical Journal 2006; 333: 424-9
2. M Piccinelli, S Pini, C B ellaetuopv, G Wilkinson. Effectiveness
of drug treatment in OCD: A metanalytic review. B.J.P. 1995, 166: 424-43
3 Rasmussen SA, Eisen JL, Treatment strategies for chronic and refractory
OCD. J. Clin Psychiatry 1997, 58(suppl 13):9-13
4.Simeon TG, Thatte S, Wiggins D, Treatment of adolescent OCD with
clomipramine-fluoxetine combination. Psychopharmacology bulletin 1990; 26:
285-290.
Competing interests:
None declared
Competing interests: No competing interests
We read with interest the extremely helpful article by Heyman,Mataix-
Cols and Fineberg. The reference to the stepped-care model outlined in the
NICE Guidelines was particularly informative and easy to read. However, we
thought it may be useful to make people aware that there is a dearth of
services for the most severely ill patients with OCD. Indeed, for those
patients who require inpatient treatment as listed under Step 6 of the
NICE guidelines (www.nice.org.uk), there is only one 24-hour staffed NHS
facility who can deal with patients who are unable to cope with less
intensive support. This has been reported elsewhere (Drummond, 1993;
Drummond,Pillay,Kolb and Rani, 2006). Full details of the service can be
accessed via http://www.swlstg-
tr.nhs.uk/services/behavioural_and_cognitive_psychotherapy_unit_national.asp
References:-
Drummond,L.M. (1993) The treatment of severe, chronic, resistant Obsessive
-Compulsive Disorder.An evaluation of an Inpatient Programme using
Behavioural Psychotherapy in combination with other treatments. British
Journal of Psychiatry, 163, 223-229.
Drummond,LM, Pillay,A.,Kolb,PJ and Rani,RS (2006) Specialised
Inpatient Treatment for Severe, Chronic, Resistant Obsessive-Compulsive
Disorder. Psychiatric Bulletin, 30, in press.
Competing interests:
None declared
Competing interests: No competing interests
Obsessive-compulsive disorder: a review
EDITOR - We will discuss the article by Heyman et al1 with related reports
published recently on obsessive compulsive disorder (OCD).
The results of genetic studies in family have demonstrated
significantly higher rates of OCD in parents and siblings of OCD probands
with an age-corrected morbid risk ranging from approximately 10% to 35% in
first-degree relatives2. In a case series, Sutor et al3 reported four
cases of patients with Down syndrome with symptoms consistent with OCD.
Grant et al4 examined sexual obsessions and clinical correlates in adults
with OCD and reported that subjects with sexual obsessions had an earlier
age of onset of OCD than subjects without these symptoms, and subjects
with current sexual obsessions were significantly more likely to report
current aggressive (P <.001) and religious (P = .001) obsessions, as
compared to those without these symptoms.
The long-term efficacy and adverse cognitive effects of stereotactic
bilateral anterior cingulotomy was investigated as a treatment option for
refractory OCD patients, and was found effective, and no significant
adverse cognitive effects on long-term follow-up were found5.
References:
1.Heyman I, Mataix-Cols D, Fineberg NA. Obsessive-compulsive
disorder. BMJ 2006; 333:424-429. (26 August.)
2.Eapen V, Pauls DL, Robertson MM. The role of clinical phenotypes in
understanding the genetics of obsessive- compulsive disorder. J Psychosom
Res 2006; 61:359-64.
3.Sutor B, Hansen MR, Black JL. Obsessive compulsive disorder
treatment in patients with Down syndrome: a case series. Downs Syndr Res
Pract 2006; 10:1-3.
4.Grant JE, Pinto A, Gunnip M, Mancebo MC, Eisen JL, Rasmussen SA.
Sexual obsessions and clinical correlates in adults with obsessive-
compulsive disorder. Compr Psychiatry 2006; 47:325-9.
5.Jung HH, Kim CH, Chang JH, Park YG, Chung SS, Chang JW. Bilateral
Anterior Cingulotomy for Refractory Obsessive-Compulsive Disorder: Long-
Term Follow-Up Results. Stereotact Funct Neurosurg 2006; 84:184-189.
Competing interests:
None declared
Competing interests: No competing interests
Heyman and colleagues (BMJ 2006;333:424-9) present the case for
cognitive-behaviour therapy and medication in the treatment of obsessive-
compulsive disorder. However, their search methodology was based on the
term ‘obsessive compulsive disorder’. This will fail to identify
treatments such as solution-focused brief therapy, which does not link
treatment to diagnostic categories in this way. A number of studies of
solution-focused therapy have included patients with compulsive behaviours
who have responded successfully to this approach, which requires less
resources than cognitive behaviour therapy.
Competing interests:
I teach and use solution focused therapy in general psychiatric practice.
Competing interests: No competing interests
In Pakistan, we conducted a study in a fishermen community living on
Manora island and found 3% of the population suffering from Obsessive-
compulsive disorder which is much higher than the 0.8% determined from
recent epidemiological studies. It was asssumed that this order was of
serious magnitude based on the afore-mentioned community-based study.Even
in general practice, many cases would come across which deserve attention.
The current turbulent scenario in Pakistan has an important role to play
in increasing the incidence and prevalence of mental disorder. General
practitioners play a pivotal role in identifying mental illness in
Pakistan and further training on this issue with emphasis on using the
symptom questionnaire can help identifying such cases.Education through
media can create insight among masses who would in turn seek appropriate
treatment. The general trend in Pakistan is for drug prescription and
CBT/ERP is used by only a few centres. Following 'NICE' guideline can also
help the practitioners in management of this disorder which is probably
becoming the second commonest disorder after major depression.
Competing interests:
None declared
Competing interests: No competing interests
Comorbidities and treatment resistant OCD
I was interested to read that PTSD was not listed as a potentially
salient comorbidity factor in OCD in Heyman, Mataix-Cols, and Fineberg's
review.I thought it may be of interest to clinicians that there is a line
of research into comorbidity in OCD which has led to investigations into
the characteristics of people who have been unable or unwilling to benefit
from CBT and E/RP for OCD. I have outlined some of these findings
regarding PTSD and OCD below:
Gershuny, Baer, Parker, Gentes, Infield and Jenike (2008) found that
that 82% of their particpants (people receiving treatment in an OCD
specialist treatment centre over one year) reported a history of trauma
and 50% of these met criteria for a diagnosis of PTSD. Gershuny et al
(2002) also demonstrated that a diagnosis of comorbid Post Traumatic
Stress Disorder (PTSD) in individuals seeking treatment for resistant OCD
led to poorer treatment outcome (i.e., no change or a worsening of
symptoms) than for individuals without comorbid PTSD (Gershuny, Baer,
Jenike, Minichiello, and Wilhelm 2002).
A further case series (Gershuny, Baer, Wilson, Radomsky, and Jenike,
2003) revealed that for at least some patients with comorbid OCD and PTSD,
there appeared to be a important relationship between symptoms of both
disorders: when symptoms of OCD lessened, symptoms of PTSD increased; when
symptoms of OCD increased, symptoms of PTSD lessened. They concluded that
given this seemingly dynamic connection targeting OCD (and perhaps PTSD)
in isolation could impede therapy effectiveness (Gershuny et al., 2002;
Gershuny, et al., 2003) and described how habituation to the cue would not
occur if the psychological trauma consequences behind obsessions had not
been processed.
Interestingly, Cromer, Schmidt and Murphy (2007) found that 54% of a
general sample of 265 people with OCD, endorsed having experienced at
least one traumatic life event (TLE) in their lifetime, and that the
presence of one or more TLEs was associated with increased OCD symptom
severity. This relationship remained significant despite controlling for
key variables including age, OCD age-of-onset, comorbidity, and depressive
symptoms. This figure fits well with the finding that upto 40% of people
with OCD offered CBT with E/RP refuse treatment or drop out citing the
demands of exposure and response prevention (Steketee, 1993).
Another study recently found a direct and important role for trauma
in outcomes in OCD (Speckens, Hackmann, Ehlers, and Cuthbert, 2007). They
too found that 80% of their sample (a group of thirty seven people
receiving specialist inpatient treatment for OCD) experienced intrusive
mental imagery, and for two-thirds of these, the images were memories of
earlier adverse events or were associated with them. They also found that
the vividness and the extent to which the image was experienced as
happening right now was similar to those of intrusive memories in post
traumatic stress disorder (Hackmann in Speckens et al., 2007: 419) and the
distress was reported to be even higher.
It may be useful to ascertain the presence of overlooked trauma when
thinking about interventions for people presenting with OCD (treatment
resistant or not)?
Cromer, K. R., Schmidt, N. B. and Murphy, D. L. (2007) An
investigation of traumatic life events and obsessive-compulsive disorder,
in Behaviour Research and Therapy, 4 (7), pp. 1683-1691.
Gershuny, B S, Baer, L, Jenike, M A, Minichiello, W.E. and Wilhelm S.
(2002), Comorbid posttraumatic stress disorder: Impact on treatment
outcome for obsessive-compulsive disorder. The American journal of
psychiatry, 159(5), 852- 854.
Gershuny, B.S., Baer, L., Wilson, K.A., Radomsky, A.S. and Jenike,
M.A., (2003), Connection between symptoms of obsessive–compulsive disorder
and posttraumatic stress disorder: a case series, in Behaviour Research
and Therapy, 41, pp. 1029–1041.
Gershuny, B. S., Baer, L., Parker, H., Gentes, E.L., Infield, A.L.
and Jenike, M. A (2008), Trauma and Posttraumatic Stress Disorder in
Treatment-Resistant
Obsessive-Compulsive Disorder, Depression and Anxiety, 25, pp. 69–71
Hackmann, A., Ehlers, A. Speckens, A. and Clark, D.M. (2004)
Characteristics and content of intrusive memories in PTSD and their
changes with treatment, Journal of Traumatic Stress, 17, p.p. 231–240.
Steketee, G. (1993) Treatment of obsessive compulsive disorder. New
York: Guilford Press.
Speckens, A. E. M., Hackmann, A., Ehlers, A. and Cuthbert, B. (2007)
Imagery special issue: Intrusive images and memories of earlier adverse
events in patients with obsessive compulsive disorder, in Journal of
Behavior Therapy and Experimental Psychiatry, 38, (4) , pp. 411-422.
Competing interests:
None declared
Competing interests: No competing interests