Treatment Refractory Obsessive-Compulsive Disorder

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OCD that Doesn't Respond to Treatment

Very few patients with obsessive-compulsive disorder (OCD) ever experience a complete remission of symptoms. Often a clinician stops working with the patient, or the patient stops working with the clinician, once symptoms have been reduced to tolerable levels. Although symptoms may have only reduced by a third, if the person is able to function, this may be considered "good enough."

When is OCD truly treatment-refractory?

There is a difference between treatment resistant OCD and treatment refractory OCD, although the two terms are often used interchangeably. Treatment resistant OCD is generally defined by two adequate attempts with SRIs. SRIs stand for a class of medication called antidepressants. They include tricyclic antidepressants (TCAs) and selective serotonin reuptake inhibitors (SSRIs).

True treatment-refractory OCD can only be determined if a person has tried, at a minimum, three different SSRIs at a maximum dosage for at least 3 to 6 months each (with the TCA clomipramine being one of them). They must have also undergone behavioral therapy while on a therapeutic dose of an SSRI, and lastly, have received at least two atypical anti-psychotics as augmenters while receiving behavioral therapy and taking the SSRIs. The "failure" is determined by a less than 25 percent reduction of their Y-BOCS score, or the improvements are greater than 25 percent but the individual still experiences significant OCD-caused impairment.

Before being deemed treatment-refractory, a clinician must first re-evaluate the diagnosis of OCD, look at any other comorbid disorders (e.g. psychosis or depression) and confirm that the patient has undergone full-length trials of each treatment, multiple times. One problem in determining treatment-refractory OCD is that most people have not received an adequate trial of behavior therapy, meaning that few people can actually be labeled treatment-refractory. Determining that a patient has received an adequate trial of behavioral therapy is thus one of the most important steps before a clinician can label a patient treatment-refractory and refer them for more extreme procedures, e.g. psycho-surgery.

Treatment Refractory Checklist

Ready to give up on your stubborn OCD? Before your disorder can be considered "refractory" you should have tried all the following.

  • Two attempts at an SSRI (e.g. Prozac or Zoloft) at the maximum dosage for 3 to 6 months. (Maximum dosage for OCD can be double the dose used for depression.)
  • One attempt of the TCA clomipramine at maximum dosage for 3 to 6 months.
  • Six months of behavioral therapy under the supervision of a clinical psychologist trained in behavioral techniques.
  • At least two atypical antipsychotic augmenters used in conjunction with an SSRI.

What type of OCD is most resistant?

Research seems to indicate that some factors will make it less likely that an individual will respond well to treatment. One study that appeared in the Journal of Affective Disorders noted that some patients with obsessive-compulsive disorder experience an unsatisfactory reduction in symptom severity despite being treated with all the available treatment options. To investigate factors associated with treatment-refractory OCD, they conducted a case-control study, comparing patients with treatment-refractory OCD to patients with treatment-responding OCD.

The researchers found that the factors associated with refractoriness of OCD were more severe of symptoms, chronic course of illness, lack of a partner, being unemployed, low economic status, presence of obsessive-compulsive symptoms of sexual or religious content, and greater family accommodation of the OC symptoms. However, this was but one small study, and future studies are warranted to verify these findings.

What options are there for treatment-refractory OCD?

Medication management: Many people try one or two medications for a few weeks, and then give up when their symptoms don't improve. Be patient -- it can take up to 3 months to see improvement when using the most common medications for OCD. Although family doctors are a great first-line for most medical issues, make sure you are seeing a bona fide psychiatrist. Don't let embarrassing side-effects (like sexual dysfunction) keep you from taking medications. Usually these can be managed in consultation with your psychiatrist. More about medications for OCD...

If you've tried garden-variety SSRIs with no luck, read on.

Medication augmentation: Many different drugs can be used to augment traditional SSRIs. This means that in combination, you will experience greater relief of symptoms.

  • Antipsychotics: OCD and tic disorders appear to be closely related, with some studies showing a 35 percent prevalency of tic disorders in OCD patients. More about OCD related disorders... Antipsychotics are the general treatment for Tourette's disorder, thus it was theorized that patients with both disorders would respond to antispychotics and SSRIs administered together. One study showed greater improvement in patients with both disorders when an antipsychotic (haloperidol) and SSRI (fluvoxamine / Luvox) were combined concurrently rather than treatment with an SSRI alone. Initially the belief was that this form of treatment would only be beneficial to people with both disorders, but subsequent studies have shown significant improvement in those without tic disorders. This has lead to many questions being raised about antipsychotics in the treatment of OCD and the implementation of many new studies. Therefore, when SSRIs alone are not working an antipsychotic augmentation must always be explored before being deemed "refractory."
  • Atypical Antipsychotics: These drugs are better tolerated than regular antipsychotics, and have shown some potential in treating OCD when combined with SSRIs. Some of the atypical antipsychotics shown to be effective when combined with an SRI include: risperidone, olanzapine, quetiapine. A few studies have shown an increase of obsessive-compulsive symptoms when using atypical antidepressants, but that was only in patients with a primary diagnosis of psychosis.
  • Other augmenters: Atypical antidepressants have been used to augment an SRI or even used alone to successfully treat OCD.
  • More about OCD and medication augmentation...

Intravenous medication: One option that appears to be very effective in the treatment of refractory OCD is intravenous medication. Clomipramine, when taken orally is first converted into a less potent form by the metabolism in the liver. Therefore it is theorized that when administered intravenously it is able to bypass the metabolism and flood the patient with a more potent dose. Several studies have shown intravenous drugs to be very effective in patients who have lacked success with oral medications.

Opiates: Researchers have postulated that the opiod system in the brain plays some role in the OCD circuitry. Several research studies indicate that opiates (like morphine) may be promising treatment for OCD alone or combined with SSRIs.

Novel medications: Included in this category are tramadol, inositol, mirtazapine and new medications that continually are being tested by researchers. Each of these medications works in novel ways not normally used in the treatment of OCD. You may consider participating in a research study to gain free access to these novel treatments.

Cognitive-behavioral therapy: It is imperative that proper behavior therapy is attempted before being labeled treatment refractory. As stated, most OCD sufferers have not received an adequate trial of behavioral therapy, which is ultimately the most effective way to beat OCD long-term. While behavioral therapy and medication both have very similar results, up to 80 percent of OCD sufferers relapse when off medication. More about behavioral therapy...

Inpatient treatment programs: For severe OCD an inpatient treatment program may be warranted. This involves several weeks of residence in a hospital where the patient can receive intensive behavior therapy under a team of specially trained physicians, psychologists and psychiatric nurses. Medication can also be increased more quickly for optimal response in this type of setting. This is a good option for people with OCD who have trouble leaving their homes or making it in on time for appointments.

Neurosurgery: Psychosurgery is basically the destruction of a small amount of brain tissue. It has been used for decades to treat many types of severe mental illnesses. As medications have become more effective in recent years, this type of surgery has become less necessary. However, if medication and therapy are not effective, surgery continues to be a viable option, with fairly high rates of success in treatment refractory OCD. People with treatment refractory OCD usually realize how disabled they have become and are desperate for any kind of effective treatment -- which makes the risks of surgery seem acceptable. Many of these surgeries involve the use of radiofrequency waves to destroy small amount of tissue in the brain. These surgeries can all be done without cutting open the skull. For more about this visit our psychosurgery page...

Vagus nerve stimulation (VNS): This technique is based on the common belief of the effect that the tenth cranial nerve has on the limbic system. VNS involves the implantation of a pulse generator in the wall of the left chest. This generator then stimulates the vegas nerve. VNS has shown promise in the treatment of refractory OCD, but more research is needed to determine how effective.

Deep brain stimulation (DBS): DBS is a treatment accepted in the use of movement disorders such as Parkinson's disease. DBS involves an implanted electrode beneath the skin in the brain, which delivers a current via the implant. Abnormal neuronal activity can then be suppressed by chronic electrical stimulation or lesioning. It is not entirely understood how DBS works but it is hypothesized to be disrupting neural firing, in a sense "neural jamming" -- which leads to enhanced information flow. Traditional surgical procedures are irreversible, but DBS is reversible and the intensity of electrode stimulation can be adjusted. This makes for a flexible treatment that can be modified according to a patients needs and based on the way they are handling the side effects. More research needs to be done, but DBS has shown to be very effective thus far despite limited use, and is more reversible than brain surgery.

Transcranial magnetic stimulation (TMS): This technique was first introduced in 1985 by Baker, and is the least invasive of all physical OCD treatments. It involves a magnetic field being inducted over the scalp by passing an electrical current through a coil. This form of therapy has shown some potential in relieving compulsions, but no studies so far have shown any effect on obsessions. TMS has shown to be somewhat effective in the treatment of depression, leading some to call for more studies of its effectiveness in treating OCD. One thought is that the ineffectiveness of TMS thus far in the treatment of OCD is related to the inadequate range of the magnet in reaching the parts of the central nervous system believed to be the cause of OCD. Because of encouraging results and the small risk of side effects compared to other more invasive physical procedures more research appears likely.

Summary

If first-line treatments such as SRIs and behavior therapy have failed, there are still many options for treatment refractory OCD. Options include atypical antipsychotics, proper psychotherapy, novel medications, intravenous medications, brain surgery and various forms of brain simulations and other alternative techniques. All of these options have shown varying degrees of success, leaving hope for those suffering from a seemingly incurable disorder.

It must also be restated that full-length trials of SRIs and behavioral therapy must be attempted before being deemed treatment refractory — something that many people have not adequately received. While a family doctor can be a great start, one must make sure to seek a properly trained mental health clinician for optimal results. Another thing to keep in mind is that a comorbid disorder that is often the real problem and needs to be treated first.

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