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Obsessive-Compulsive Disorder: an Overview for Pharmacists by Jennifer P

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Obsessive-Compulsive Disorder: an Overview for Pharmacists by Jennifer P CONTINUING EDUCATION Obsessive-Compulsive Disorder: An Overview for Pharmacists By Jennifer P. Askew, BS, PharmD, CPP and Emily L. Heil pon successful completion of this article, the in response to obsessions. (See Table 1, below.) pharmacist should be able to: The most common obsessions involve 1. Describe the symptoms of OCD based on thoughts about contamination, repeated doubts, DSM IV diagnostic criteria. a need to have things in a particular order, ag- 2. Differentiate the symptoms of OCD from gressive or horrific impulses, and sexual imagery. other psychiatric disorders. Individuals with obsessions tend to ignore or U3. Analyze the pharmacologic and non-pharmacologic suppress the thoughts or attempt to neutralize treatment options for OCD. them through an action (compulsion). Individuals 4. Understand how to implement pharmacotherapy and feel driven to perform the compulsion to reduce manage medication side effects. the distress that accompanies an obsession. The 5. Recognize possible confounders to the treatment plan. most common compulsions involve washing, cleaning, counting, checking, repeating actions, OBSESSIVE-COMPULSIVE DISORDER and ordering. For example, a person obsessed Obsessive-Compulsive Disorder (OCD) is an anxiety disor- with contamination fears may wash their hands re- der marked by recurrent obsessions or compulsions. The peatedly and bathe multiple times a day. Patients American Psychiatric Association’s: Diagnostic and Statisti- with repeated doubts worry about causing harm to cal Manual of Mental Disorders, 4th ed, revised (DSM IV TR) themselves or others and may compulsively check identifies the essential features of OCD as “recurrent obses- to make sure they’ve turned the stove off or they sions or compulsions (Criterion A) that are severe enough to have not injured someone with their car. Patients be time consuming (they take more than one hour a day) or with “bad thoughts” such as sexual obsessions, cause marked distress or significant impairment (Criterion often a fear of being a homosexual or a pedo- C)”. Obsessions are defined as intrusive and inappropriate phile, will use compulsions to “cancel out” the bad ideas, thoughts, impulses or images that cause marked thoughts with good thoughts. anxiety and distress. Compulsions are physical or mental Patients with OCD can also be obsessed with acts a patient believes driven to perform to reduce anxiety, numbers or symmetry. For example, the person not to provide pleasure. Compulsions are usually performed might be obsessed with odd numbers but even Table 1: Types of Obsessions and Examples of Compulsions Obsession Example Compulsion Fear of contamination Repetitive hand washing and showering Repeated Doubts Checking that the door is locked 20 times before going to bed Need to have things in a particular order Organizing and alphabetizing Praying, counting, repeating words silently to cancel out the bad thoughts. Aggressive or horrific impulses For example counting to 10 backwards and forwards 100 times Fear of needing something that they throw away Hoarding behavior, never throwing anything away 36 america’s PHARMACIST |December 2007 www.americaspharmacist.net Table 2: DSM IV TR Diagnostic Criteria for 300.3 Obsessive Compulsive Disorder A. Either obsessions or compulsions: Obsessions as defined by (1), (2), (3), and (4): (1) recurrent and persistent thoughts, impulses, or images that are experienced, at some time during the disturbance, as intrusive and inappropriate and that cause marked anxiety or distress (2) the thoughts, impulses, or images are not simply excessive worries about real life problems (3) the person attempts to ignore or suppress such thoughts, impulses, or images, or to neutralize them with some other thought or action (4) the person recognizes that the obsessional thoughts, impulses, or images are a product of his or her own mind (not imposed from without as in thought insertion) Compulsions as defined by (1) and (2): (1) repetitive behaviors (e.g., hand washing, ordering, checking) or mental acts (e.g., praying, counting, repeating words silently) that the person feels driven to perform in response to an obsession, or according to rules that must be applied rigidly (2) the behaviors or mental acts are aimed at preventing or reducing distress or preventing some dreaded event or situation; however, these behaviors or mental acts either are not connected in a realistic way with what they are designed to neutralize or prevent or are clearly excessive B. At some point during the course of the disorder, the person has recognized that the obsessions or compulsions are excessive or unreasonable. Note: This does not apply to children. C. The obsessions or compulsions cause marked distress, are time consuming (take more than one hour a day), or significantly interfere with the person’s normal routine, occupational (or academic) functioning, or usual social activities or relationships. D. If another Axis I disorder is present, the content of the obsessions or compulsions is not restricted to it (e.g., preoccupation with food in the presence of an eating disorder; hair pulling in the presence of Trichotillomania; concern with appearance in the presence of body dysmorphic disorder; preoccupation with drugs in the presence of a substance use disorder; preoccupation with having a serious illness in the presence of Hypochondriasis; preoccupation with sexual urges or fantasies in the presence of a Paraphilia; or guilty ruminations in the presence of major depressive disorder). E. The disturbance is not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition. Specify if: with poor insight: if, for most of the time during the current episode, the person does not recognize that the obsessions and compulsions are excessive or unreasonable Source: Reprinted from Diagnostic and Statistical Manual of Mental Disorders, 4th Edition, Text Revision. Washington, D.C., American Psychiatric Association, 2000. Copyright © 2000, American Psychiatric Association. numbers make them anxious and angry. Patients interfere with their abilities to maintain employment. Patients obsessed with body evenness might step on a often avoid certain places and situations to avoid obsession crack on the sidewalk with their left foot, and then triggers. Some patients with untreated, extreme OCD are feel compelled to step on the crack with their unable to even leave their houses. right foot. Patients with OCD realize that their thoughts Table 3: Example Screening Questions From American and behaviors are irrational but continue to repeat Psychiatric Association (APA) Practice Guidelines the compulsive behaviors to help with the anxi- q Do you have unpleasant thoughts you can’t get rid of? ety and distress the obsessions cause. Unlike q Do you worry that you might impulsively harm someone? compulsive gamblers or other “addictive behav- q Do you have to count things, or wash your hands, or check iors”, OCD sufferers do not want to perform the things over and over? q Do you worry a lot about whether you performed religious compulsions and do not derive any pleasure from rituals correctly or have been immoral? these compulsive acts. OCD can be a debilitat- q Do you have troubling thoughts about sexual matters? ing disease depending on the severity. It can take q Do you need things arranged symmetrically or in a some patients hours just to prepare to leave their very exact order? q Do you have trouble discarding things, so that your houses due to all the rituals they have to perform. house is quite cluttered? Many OCD patients spend hours of their day q Do these worries and behaviors interfere with your functioning performing compulsive acts which can severely at work, with your family or social activities? www.americaspharmacist.net December 2007 | america’s PHARMACIST 37 Figure 1. Algorithm for the Treatment of Obsessive-Compulsive Disorder (OCD) First-line treatments CBT (ERP) SSRI SSRI + CBT (ERP) Is the response no Is the response adequate after 8–12 total weeks of SSRI adequate after 13–20 (4–6 weeks at maximal tolerable dose) or 13–20 weekly weekly sessioons of CBT? sessions of CBT or weekday daily CBT for 3 weeks? yes no For medication: continue for 1–2 years, then consider gradual taper over several months or more. For CBT: provide periodic booster sessions for 3–6 months after acute treatment. Strategies for Moderate Response • Augment with a second-generation antipsychotic or with CBT (ERP) if not yes already provided. Adequate yes • Add cognitive therapy to ERP.* response? Strategies for Little or No Response no • Switch to a different SSRI (may try more than one trial). • Switch to clomipramine. • Augment with a second-generation antipsychotic. • Switch to venlafaxine. • Switch to mirtazapine.* Strategies for Moderate and for Little or No Response • Switch to a different augmenting second-generation antipsychotic. • Switch to a different SRI. • Augment with clomipramine.* • Augment with buspirone,* pindolol,* morphine sulfate,* inositol,* or a glutamate antagonist (e.g., riluzole, topiramate).* Strategies Only for Little or No Response After first- and second-line strategies have been exhausted, other options • Switch to D-amphetamine monotherapy.* that may be considered include • Switch to tramadol monotherapy.* transcranial magnetic stimulation,* • Switch to ondansetron monotherapy.* deep brain stimulation,* and ablative • Switch to an MAOI.* neurosurgery. Source: American Psychiatric Association.
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