THREE SPECIAL CLiNICAL CONSIDERATIONS
Special Issues in Treatment
Treatment Resistant Cases
A number of patients with OCD and related disorders do not show adequate response to usual first-line psychological and pharmacological interventions.
As a broad rule we would recommend that "treatment resistance" be defined as a failure to respond to at least two adequate courses of evidence-based pharmacotherapies and at least one adequate course of evidence-based psychotherapy. Failure to respond can be operationalized as less than 25-35% reduction in total symptom severity scores as compared to the pre-treatment baseline. By way of example, for Obsessive Compulsive Disorder (OCD), treatment resistance would be less than 25-35% reduction in total Yale-Brown Obsessive Compulsive Scale (YBOCS) scores (versus pre-treatment baseline) following a course of two Serotonin Reuptake Inhibitors (SRIs) (each of at least 6 week duration at a therapeutic doses), and a minimum 12 session (12 hour) course of manualized validated Cognitive Behavioral Therapy (CBT) with Exposure and Response Prevention (ERP).
In possible treatment-resistant cases, the following steps can be very useful:
- 1. Re-evaluate the symptom history and presentation to confirm not only that any diagnoses are correct, but also that other diagnoses (including personality disorders) have not been overlooked. In considering this, do not forget to ask about Substance Use Disorders (alcohol, smoking, illicit substances), and medical conditions. See the individual disorder chapters for lists of common differential diagnoses and co-morbidities for each OC Family Disorder.
- 2. Take a detailed history of treatments received to date, wherever possible in conjunction with case note review. If medications were received, were they titrated to therapeutic doses? Did patients receive therapeutic doses for a reasonable treatment duration (such as minimum six weeks for SRI treatment of OCD)? Check with patients about any side effects they noticed and sensitively ask whether they were compliant with a given medication consistently over the course of the intervention. For psychotherapy, check about attendance, content, length of each session, number of sessions received, and who conducted the therapy. Were there any difficulties that stopped the patient being able to engage with a given therapy? Again, the clinician should look to evaluate whether any psychological treatments received were adequate in order to conclude that a given modality was ineffective.
- 3. Assess for any predisposing, precipitating, and perpetuating factors. Exploring perpetuating factors in particular could help to identify reasons for treatment non-response and identify modifiable contributing factors. For example, there may be psychosocial stressors (difficult family dynamics or a stressful job situation). It can be helpful to ask about any first-degree relatives with psychiatric conditions and what treatments worked for them. For example, there may have been a parent with OCD who responded well to a given medication: if so, has this medication been tried in the patient?
- 4. In light of the above, consider:
a. Pharmacological and psychological augmentation strategies (see disorder specific chapters for lists of treatment options in refractory cases where known)
b. Use of inpatient management (see section later in this chapter on Hospitalization, Day Treatments, and Residential Treatments) c. Referring the patient to more specialized services for consideration of other treatment strategies including the use of psychosurgery or deep brain stimulation where indicated and an evidence base exists (see section later in this chapter on Neurosurgery for OCD)
d. Suggesting to patients that they try alternative treatments in addition to evidence based treatments (see Alternative Treatments section later in this chapter)
- • Abudy A, Juven-Wetzler A, Zohar J. Pharmacological management of treatment-resistant obsessive compulsive disorder. CNS Drugs. 2011 Jul;25(7):585-96.
- • Boschen MJ, Drummond LM, Pillay A, Morton K. Predicting outcome of treatment for severe, treatment resistant OCD in inpatient and community settings. J Behav Ther Exp Psychiatry. 2010 Jun;41(2):90-5.
- • Dold M, Aigner M, Lanzenberger R, Kasper S. Antipsychotic augmentation of serotonin reuptake inhibitors in treatment-resistant obsessive compulsive disorder: a meta-analysis of double-blind, randomized, placebo-controlled trials. Int J Neuropsychopharmacol. 2013 Apr;16(3):557-74.