The first-line treatments for OCD and related disorders include cognitive-behavioral therapy (CBT), pharmacological / medication management usually with serotonin reuptake inhibitors (SRIs), or a combination of CBT and medication. Recommended therapies and/or medications vary depending on the individual’s symptoms and the presence of any co-occurring conditions (co-morbidities). Each patient needs to be assessed to determine the appropriate treatment. Below is a general description of cognitive behavioral therapy (CBT) and medication treatment.
Cognitive-behavioral therapy (CBT)
Cognitive-behavioral therapy (CBT) is a time-limited, skills-based treatment aimed at helping individuals to identify and change maladaptive thought, emotion, and behavior patterns. CBT for OCD and related disorders often primarily consists of exposure and response prevention (ERP) to help individuals approach anxiety-provoking or previously avoided situations (exposure), without the use of rituals (response prevention). Treatment also includes strategies to help patients let go of distressing thoughts and/or challenge unhelpful, negative beliefs. CBT is designed to provide patients with a set of skills they can continue to use long after the therapy has ended. With continued skills practice, patients can experience long-term reductions in their anxiety/distress, reduce time spent performing rituals, and re-engage with the people, places, and activities they value.
Serotonin Reuptake Inhibitors (SRIs) are the most effective medications for most OCD and related disorders. SRIs are antidepressants commonly used to treat depression, but which also reduce symptoms of OCD and related disorders. These medications include fluoxetine (Prozac), escitalopram (Lexapro), fluvoxamine (Luvox), sertraline (Zoloft), paroxetine (Paxil), and citalopram (Celexa). Clomipramine (Anafranil) is another antidepressant medication used to treat OCD and related disorder. The SRI doses used for treating OCD and related disorders are typically higher than those needed for treating depression.
Other Treatment Options
Transcranial magnetic stimulation (TMS)
Transcranial magnetic stimulation (TMS), is a painless, noninvasive form of brain stimulation that involves applying electromagnetic currents on the skull and directing them to specific brain regions.
During a TMS session, patients are awake and sit in a comfortable chair while the stimulation is delivered. Through a coil placed on the head, electromagnetic pulses are applied that travel through hair, skin, muscle, and bone until they reach the brain. The amount of stimulation and target of stimulation is specific to each patient based on an initial brain assessment. A typical TMS session lasts from 20 to 40 minutes, and most treatments require daily sessions Monday to Friday for six or more weeks. Because there are no side effects, patients can return immediately to regular activity. In 2018, the FDA approved the use of TMS for the treatment of OCD.
Deep Brain Stimulation (DBS)
Deep Brain Stimulation (DBS) is only for individuals who do not respond well to cognitive behavior therapy or medication. DBS involves implanting electrodes in targeted areas of the brain. The electrodes are connected by wires under the skin to a pulse generator, a pacemaker-like device under the skin used to control the amount of stimulation. The FDA recently approved DBS for treatment-resistant OCD under a Humanitarian Device Exemption (HDE). The HDE approval assumes a relatively small number of patients will receive the treatment. The placement of the electrodes, and the decision about how much stimulation is given, is crucial. Because DBS for treatment-resistant OCD is a very specialized procedure, it is recommended that treatment be given at institutions that have previous DBS experience.
Gamma knife is a noninvasive technique that uses highly focused radiation to lesion targeted brain tissue. Gamma knife should only be considered for individuals who do not respond to cognitive behavior therapy or medication.
Brain surgery for OCD involves drilling through the skull and using a heated probe to burn an area within the anterior cingulate cortex (cingulotomy) or the anterior limb of the internal capsule (capsulotomy).