[Spring/Summer 1998; Vol. 25 No. 1]
John M. Greist, M.D., a Distinguished Senior Scientist at the Dean Foundation for Health Research and Education and also Clinical Professor of Psychiatry at the University of Wisconsin Medical School discussed newer developments in the treatment of these disorders. (April 22, 1998, Sheppard Pratt)
The dual cornerstones of effective treatment for OCD, he began, are potent serotonin reuptake inhibitors and behavior therapy. He credited French psychiatrist, Pierre Janet, with a classic description of the phenomenology of OCD as well as for the earliest description of behavior therapy for this condition (1925). However, the term "behavior therapy" was unknown in Janet's time. Not until 1966, did the modern era of effective behavior therapy for OCD begin. The effective components of behavior therapy in OCD are exposure and ritual prevention. Some studies reported that 90 percent of patients who underwent behavior therapy had at least a 30 percent reduction in obsessions and compulsions. Long term results from 16 studies showed that, at a mean follow up of 29 months, 76 percent of patients were "very much" or "much" improved. He also reported studies showing improvements from behavior therapy greater than those obtained by potent SRIs (clomipramine, fluoxetine, fluvoxamine, paroxetine and sertraline).
He emphasized that pitting the therapeutic approaches of behavior therapy and pharmacotherapy against each other would be unwise and unnecessary. He stressed the value of combination approaches in which patients received both behavior therapy and pharmacotherapy. When successful, the effects of behavior therapy are said to last over extended periods of time after termination of treatment. In the case of pharmacotherapy, symptoms are likely to recur soon after medication is discontinued.
Behavioral assessment should also elicit information about involvement of family, friends and coworkers in the patientsµ rituals, as this is quite common. Specific techniques have been developed to guide those caught up in the patient's disorder to help the patient overcome the disorder by serving as co-therapists.
Therapist Involvement
There is no question, Dr. Greist said, that the therapist-intensive
approach to behavior therapy is quite effective, and that it remains a
standard against which other therapist involvement models can be compared.
He mentioned psychoanalytic psychotherapy and cognitive therapy as forms of treatment that are usually ineffective for this disorder. When Greist underwent his own psychoanalysis, his analyst advised him against using psychoanalysis to treat OCD.
Comorbidity and Behavioral Therapy
Marked depression can interfere with behavior therapy, as it does with
psychotherapy for all disorders. If depression is pronounced, a potent SRI
antidepressant often provides effective treatment for both the depression
and the OCD.
Some individuals have both OCD and schizophrenia. Even here the OCD may be responsive to behavior therapy. Schizophrenic delusions and hallucinations seldom change during behavior therapy.
Noncompliance
About 25 percent of patients either refuse behavior therapy outright or
undermine its effectiveness by poor adherence to important therapy
components. Even more troubling is clinician noncompliance. For three
decades behavior therapy has been known to be effective for OCD and
proponents have attempted to train clinicians. Despite this, behavior
therapy is not widely available. Greist said that many clinicians are
unwilling to learn or to practice the techniques of behavior therapy.
BT Steps
Because behavior therapy is an effective treatment for OCD and because it
is not widely available, Marks and colleagues have developed BT STEPS.
This is a comprehensive computer administered self-help behavioral
treatment program for OCD that utilizes interactive voice response
technology. It includes a workbook to guide the treatment process and
permits the patient to place 12 distinct telephone calls that contain over
one thousand phrases or frames with branching between them based on
responses in present and previous frames. The program helps patients
assess their OCD and then design and implement self-help treatment
programs.
Pharmacotherapy
He expanded his discussion of pharmacotherapy as a cornerstone of
treatment for OCD. Despite the widespread acceptance of pharmacotherapy
for OCD a non-response or partial response to these medications is "a
frustratingly common occurrence with OCD drug monotherapy." Dr.
Greist believes that OCD patients frequently receive excessively high
doses of these drugs. In most cases, the dose required to treat OCD is no
higher than that needed to treat depression. Adverse event dropouts were
about four to five times greater on the higher doses. Clomipramine is
seldom the first medication choice because of the higher rate of
unpleasant and sometimes serious side effects.
Comorbidity and Pharmacotherapy
Patients with OCD often have other conditions that also need
pharmacotherapy. For example a patient with bipolar disorder and OCD would
almost always require a mood stabilizer and an SRI. A patient with panic
disorder and OCD might do well on just an SRI because all the SRIs have
anti-panic activity. However, this patient might require a lower than
usual starting dose to avoid over stimulation. A patient with substance
abuse and OCD would probably do poorly with any OCD treatment unless the
substance abuse was controlled. Patients with comorbid tic spectrum
disorder or schizotypal personality disorder have been reported to respond
to neuroleptic augmentation.
Dr. Greist concluded the lecture with a lively question and answer period.
Gerald D. Klee, M.D.