Treatment Planning for Co-occurring Disorders

Depression: If the person has significant co-occurring depression with their OCD, both medication and psychotherapy would be appropriate. In that case, a therapeutic approach that includes exposure and response prevent (ERP) but also eclectic enough to include emotional regulation, social skill training, and interpersonal dynamics could be more beneficial than someone rigidly adhering to ERP only.

Substance Use Disorders: In the case of a patient with OCD and Substance Use Disorders, the person may first need detoxification from the substance with some abstinence prior to undergoing ERP for the OCD.

Bipolar Disorder: When bipolar disorder co-occurs with OCD, medications to stabilize mood (e.g., lithium, anti-epileptics) may be needed prior to treatment of the OCD. Given that some uncertainty exists around SRIs inducing hypomania or mania, the first-line of treatment after mood stabilization should be ERP.

Pathology

Description

Investigations

Potential interventions

Infections

Certain infections have been associated with OCD-like symptoms, notably HIV, and Group A beta-hemolytic streptococcal infection

Blood work-up including viral screen, bacteriology, immune status. Brain imaging for HIV

Treatment of underlying pathology with antiretroviral medications (HIV), or antibiotics (streptococcal infection). OCD symptoms can respond to SRIs. Plasmaphoresis and intravenous immunoglobulins are used for PANDAS (see PANDAS section)

Seizures

Partial complex, frontal, and tonic-clinic seizures have all been associated with OCD symptoms

Extensive blood workup including electrolytes, bone profile, liver function tests. Head imaging. Consider possible contribution of prescribed medications, use of alcohol, and illicit substances

Treatment approach unclear. May respond to anti-epileptic medications or SRIs, although clomipramine should be avoided due to lowering of the seizure threshold

(continued)

Pathology

Description

Investigations

Potential interventions

Head injury

Cases of OCD have been associated with head injury resulting in loss of consciousness

Diagnostic investigations are usually not very revealing

May respond to SRIs

Cerebrovascular

infarcts

Infarcts of the right frontal, caudate nuclei, and right putamen areas have all been associated with older age of OCD onset

Consider

cardiovascular risk factors that are modifiable (check fasting lipid profile). Brain imaging

The treatment of the OCD symptoms is unclear as some evidence suggests that SRIs may not be effective

Parkinson’s

Disease

Individuals with Parkinson’s disease who are taking dopamine agonists may develop punding behavior that mimics OCD symptoms

N/A

Decreasing or discontinuing the dopamine agonist may eliminate the punding behavior. Since the patient may need some dopamine agonist therapy, however, lowering the dose or changing the medication should be performed before stopping medication completely

Medications/

Drugs

Prescribed and illicit stimulants (e.g., cocaine, amphetamine) have been associated with stereotyped repetitive behaviors and appear to be associated with skin picking and worsening of Trichotillomania (Hair Pulling Disorder) in some people. There is not good evidence, however, that these substances result in obsessive thoughts or are associated with OCD

Detailed medication history and sensitive screening for illicit drug use (including urine toxicology)

Consider reducing prescribed dose of stimulant medication if clinically appropriate to do so. Support patients in reducing intake of illicit substances and treat these addictions rigorously

Severe OCD Cases

In severe cases of OCD, in-patient or partial hospitalization programs may be necessary, and rarely psychosurgery may be utilized. Please see the section on these interventions elsewhere.

Key References

  • • Benito K, Storch EA. Assessment of obsessive compulsive disorder: review and future directions. Expert Rev Neurother. 2011 Feb;11(2):287-98.
  • • Figee M, Wielaard I, Mazaheri A, Denys D. Neurosurgical targets for compulsivity: what can we learn from acquired brain lesions? Neurosci Biobehav Rev. 2013 Mar;37(3):328-39.
  • • Fineberg NA, Krishnaiah RB, Moberg J, O’Doherty C. Clinical screening for obsessive compulsive and related disorders. Isr J Psychiatry Relat Sci. 2008;45(3):151-63.
 
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