PRACTICE GUIDELINE FOR THE Treatment of Patients With Obsessive-Compulsive Disorder WORK GROUP ON OBSESSIVE-COMPULSIVE DISORDER Lorrin M. Koran, M.D., Chair Gregory L. Hanna, M.D. Eric Hollander, M.D. Gerald Nestadt, M.D. Helen Blair Simpson, M.D., Ph.D. This practice guideline was approved in October 2006 and published in July 2007. A guideline watch, summarizing significant developments in the scientific literature since publication of this guide- line, may be available in the Psychiatric Practice section of the American Psychiatric Association (APA) Web site at www.psych.org. Dr. Koran has received research grants from Forest Pharmaceuticals, Pfizer, Eli Lilly, Ortho-McNeil, Somaxon, and Jazz Pharmaceuticals. He has received honoraria from the Forest Pharmaceuticals Speakers Bureau and the Pfizer Speakers Bureau. He has received consultant fees from Cypress Bioscience. Dr. Hanna reports no competing interests. Dr. Hollander has received research grants from the National Institute of Mental Health, the National Institute of Neurological Disorders and Stroke, the National Institute on Drug Abuse, the Office of Orphan Products Development of the U.S. Food and Drug Administration, Pfizer, GlaxoSmithKline, Wyeth, Eli Lilly, Janssen, and Abbott. He has served on advisory boards for Forest Pharmaceuticals, Abbott, and Somaxon. Dr. Nestadt reports no competing inter- ests. Dr. Simpson reports no competing interests. The Executive Committee on Practice Guidelines has reviewed this guideline and found no evidence of influence from these relationships. Suggested citation: American Psychiatric Association. Practice guideline for the treatment of patients with obsessive-compulsive disorder. Arlington, VA: American Psychiatric Association, 2007. Available online at http//www.psych.org/psych_pract/treatg/pg/ prac_ guide.cfm. Copyright 2010, American Psychiatric Association. APA makes this practice guideline freely available to promote its dissemination and use; however, copyright protections are enforced in full. No part of this guideline may be reproduced except as permitted under Sections 107 and 108 of U.S. Copyright Act. For permission for reuse, visit APPI Permissions & Licensing Center at http://www.appi.org/CustomerService/Pages/Permissions.aspx. AMERICAN PSYCHIATRIC ASSOCIATION STEERING COMMITTEE ON PRACTICE GUIDELINES John S. McIntyre, M.D., Chair Sara C. Charles, M.D., Vice-Chair Daniel J. Anzia, M.D. Ian A. Cook, M.D. Molly T. Finnerty, M.D. Bradley R. Johnson, M.D. James E. Nininger, M.D. Paul Summergrad, M.D. Sherwyn M. Woods, M.D., Ph.D. Joel Yager, M.D. AREA AND COMPONENT LIAISONS Joseph Berger, M.D. (Area I) C. Deborah Cross, M.D. (Area II) Harry A. Brandt, M.D. (Area III) Philip M. Margolis, M.D. (Area IV) John P.D. Shemo, M.D. (Area V) Barton J. Blinder, M.D. (Area VI) David L. Duncan, M.D. (Area VII) Mary Ann Barnovitz, M.D. Sheila Hafter Gray, M.D. Sunil Saxena, M.D. Tina Tonnu, M.D. STAFF Robert Kunkle, M.A., Senior Program Manager Amy B. Albert, B.A., Project Manager Thomas J. Craig, M.D., M.P.H., Director, Department of Quality Improvement and Psychiatric Services Darrel A. Regier, M.D., M.P.H., Director, Division of Research MEDICAL EDITOR Laura J. Fochtmann, M.D. Copyright 2010, American Psychiatric Association. APA makes this practice guideline freely available to promote its dissemination and use; however, copyright protections are enforced in full. No part of this guideline may be reproduced except as permitted under Sections 107 and 108 of U.S. Copyright Act. For permission for reuse, visit APPI Permissions & Licensing Center at http://www.appi.org/CustomerService/Pages/Permissions.aspx. CONTENTS STATEMENT OF INTENT . .7 GUIDE TO USING THIS PRACTICE GUIDELINE . .7 DEVELOPMENT PROCESS . .8 PART A: TREATMENT RECOMMENDATIONS . 9 I. EXECUTIVE SUMMARY . .9 A. Coding System. .9 B. Executive Summary . .9 1. Psychiatric Management . 9 a. Establishing a Therapeutic Alliance . 9 b. Assessing the Patient’s Symptoms . 9 c. Using Rating Scales . 9 d. Enhancing the Safety of the Patient and Others . 10 e. Completing the Psychiatric Assessment . 10 f. Establishing Goals for Treatment . 10 g. Establishing the Appropriate Setting for Treatment . 10 h. Enhancing Treatment Adherence . 11 2. Choosing an Initial Treatment Modality . 11 3. Choosing a Specific Pharmacological Treatment . 11 4. Choosing a Specific Form of Psychotherapy . 11 5. Implementing a Treatment Plan . 12 a. Implementing Pharmacotherapy . 12 b. Implementing Cognitive-Behavioral Therapies . 12 c. Changing Treatments and Pursuing Sequential Treatment Trials . 12 6. Discontinuing Active Treatment. 13 II. FORMULATION AND IMPLEMENTATION OF A TREATMENT PLAN . .13 A. Psychiatric Management . .14 1. Establish a Therapeutic Alliance . 14 2. Assess the Patient’s Symptoms . 14 3. Consider Rating the Severity of OCD and Co-occurring Symptoms and Their Effects on the Patient’s Functioning . 16 4. Evaluate the Safety of the Patient and Others. 17 5. Complete the Psychiatric Assessment. 18 6. Establish Goals for Treatment. 21 7. Establish the Appropriate Setting for Treatment. 21 8. Enhance Treatment Adherence . 21 9. Provide Education to the Patient and, When Appropriate, to the Family . 22 10. Coordinate the Patient’s Care With Other Providers of Care and Social Agencies. 22 Copyright 2010, American Psychiatric Association. APA makes this practice guideline freely available to promote its dissemination and use; however, copyright protections are enforced in full. No part of this guideline may be reproduced except as permitted under Sections 107 and 108 of U.S. Copyright Act. For permission for reuse, visit APPI Permissions & Licensing Center at http://www.appi.org/CustomerService/Pages/Permissions.aspx. B. Acute Phase. .23 1. Choosing an Initial Treatment Modality. .23 2. Choosing a Specific Pharmacologic Treatment . .23 a. Implementing Pharmacotherapy . .24 b. Managing Medication Side Effects . .25 3. Choosing a Specific Form of Psychotherapy . .26 4. Implementing Cognitive-Behavioral Therapies. .26 5. Monitoring the Patient’s Psychiatric Status . .27 6. Determining When and Whether to Change Treatments. .27 7. Pursuing Sequential Treatment Trials . 28 C. Discontinuation of Active Treatment . .30 III. SPECIFIC CLINICAL FEATURES INFLUENCING THE TREATMENT PLAN . .31 A. Psychiatric Features. .31 1. Chronic Motor Tics . .31 2. Tourette’s Disorder . .32 3. Major Depression . 32 4. Bipolar Disorder . 32 5. Panic Disorder. ..