Category: Blog

By Angela Couch, RN, MSN, PMHNP-BC,
Psychiatric Nurse Practitioner, Lindner Center of Hope

The goal of treatment for OCD is not to get rid of the thoughts but to learn to tolerate uncertainty. For someone who struggles with OCD, the idea of this, of tolerating uncertainty, can create a lot of discomfort.  Medications will not get rid of the thoughts, unfortunately.  This is because we cannot “control” our thoughts or prevent them.  Thoughts come into our brains, often unbidden, and sometimes contain content we didn’t ask for or want, which may be scary or upsetting.  For someone who has OCD, this occurrence creates a more intense feeling of distress, which often leads to various compulsions, in an effort to relieve the distress and the uncertainty.

Medication is recommended for the treatment of OCD any time someone has a moderate to severe case of OCD. Appropriate psychotherapy is very important; generally, this is a sub-type of CBT (Cognitive Behavioral Therapy) called ERP (Exposure and Response Prevention), or sometimes ACT (Acceptance and Commitment Therapy). The combination of medication and psychotherapy is the most powerful between medication alone, psychotherapy alone or both together. Those who have completed appropriate psychotherapy also, have a lower risk of significant relapse if medication treatment is stopped.

Medication can help make the thoughts less “sticky” in the brain. It also can slow the thoughts down and somewhat reduce the level of distress caused by the thoughts. This can make it easier for someone to participate in the appropriate psychotherapy to manage the OCD.  Medication can help someone ride the waves of OCD/uncertainty more effectively. There are many treatment options, which should be individualized to the patient.

The frontline treatments for OCD are typically the SSRI (Selective Serotonin Reuptake Inhibitors) or the TCA (Tri-cyclic antidepressant) clomipramine, or sometimes an SNRI (Serotonin Norepinephrine Reuptake Inhibitors). These medications slowly build in the patient’s system after repeated administration to a steady state at which the medications begin to assert their effects. Dose increases are common because OCD typically requires higher dosing than when treating depression or anxiety disorders such as Generalized Anxiety Disorder, Panic Disorder, etc.
Sometimes, this may include “off-label” dosing (dosing higher than the FDA label for the drug). Typically, we don’t call a drug trial a true failure until the patient has taken the highest dose for up to twelve weeks because it often takes longer for the medications to impact OCD than the other disorders listed above.

Sometimes, an augmentation strategy is used in conjunction with the primary treatment. Augmentation strategies may more commonly include SDA’s (Serotonin Dopamine Antagonists, also called second-generation antipsychotics), or drugs that may impact the neurotransmitter glutamate such as NMDA receptor antagonists, certain mood stabilizers, or acetylcysteine. SDA’s or mood stabilizers are also commonly used when a patient has a concurrent bipolar spectrum illness, because treatment with an SSRI, SNRI, or TCA alone may cause mood switching.
Sometimes, when a patient has a diagnosis of OCD alone, they may very slowly taper off the medication after having a longer period of stability on the medication and psychotherapy. Sometimes this is successful for some period of time, but sometimes an individual’s brain simply needs the support to keep symptoms manageable, and that is okay, too. Patients who also have a mood or other type of disorder may need to take the medication longer term. These treatment decisions need to be tailored to the individual’s circumstances.

In conclusion, psychotherapy is a critical piece of the treatment plan, there are many medications that may provide benefit in the treatment of OCD, and treatment decisions should be individualized.