As a psychiatrist who specializes in both the psychopharmacology and cognitive-behavioral therapy of obsessive-compulsive disorder (OCD) and related conditions, I couldn’t be more excited to serve as guest editor of this edition of Psychiatric Annals. The amount of suffering and disability from this condition is often under-recognized. In fact, it is one of the top 20 causes of illness-related disability worldwide for individuals between the ages of 18 and 44 years.1 In addition, individuals with OCD tend to experience a tremendous amount of shame related to their symptomatology, which often leads them to suffer in silence. Even in the context where an individual with OCD decides to seek treatment, it often takes many years before proper treatment is obtained. Finding a psychiatrist with an understanding of the basic best practice principles in OCD treatment is often a challenge for patients. This issue is devoted to furthering psychiatrists’ knowledge of OCD and provides a much-needed resource that describes the best practice approaches in OCD and also discusses treatments that are still under study.
In the article “Obsessive-Compulsive Disorder: Overview and Standard Treatment Strategies,” I had an opportunity to collaborate with a pioneer in OCD research, Dr. Eric Hollander, and Dr. Rebecca J. Hamblin in creating a discussion of the basics in OCD. The epidemiology, pathophysiology, and assessment and treatment approaches for OCD are reviewed. Importantly, assessment tools and exposure and response prevention (ERP) are discussed. We also included a discussion on reassurance-seeking behavior in OCD, which is often a subtle symptom that goes unrecognized in treatment. We also review standard as well as more complex medication approaches, including use of clomipramine/fluvoxamine combination and various augmentation strategies. Rationale behind minimum 12-week trials of at least moderate doses of serotonin reuptake inhibitors is also provided.
The issue then transitions to a more detailed discussion of ERP in an article by Dr. H. Blair Simpson’s group entitled “Cognitive-Behavior Therapy Outcomes for Obsessive-Compulsive Disorder: Exposure and Response Prevention.” Dr. H. Blair Simpson is one of the world’s leading experts in OCD and ERP and has published much seminal work in this area. The article gives an excellent overview of the ERP process and should be a prime resource for psychiatrists who have not been trained in this approach, which is the gold-standard form of cognitive-behavioral therapy in OCD. The authors discuss the development of ERP and the data to support its use. There is a discussion of predicting and enhancing ERP outcomes, as well as issues regarding access to ERP. The mechanism of action is discussed, as are directions for future research.
Dr. Christopher Pittenger, a leading expert in the area of glutamate-modulating approaches in OCD, then gives an overview of the glutamate system and how it relates to the pathophysiology of OCD. He also describes studies of agents that have been examined for the treatment of OCD, including memantine, riluzole, ketamine, D-cycloserine, glycine, N-acetylcysteine, topiramate, and lamotrigine, and discusses the need for further research in this area.
Finally, Dr. Stefano Pallanti (a leading expert in neuromodulatory approaches for OCD) and colleagues discuss the use of deep-brain stimulation in the treatment of severe, treatment-refractory OCD. The authors also describe repetitive and deep transcranial magnetic stimulation and discuss the use of this approach in OCD. They conclude with a discussion of unanswered questions and directions for future research.
Please enjoy this issue of Psychiatric Annals on OCD and please do not hesitate to contact me if you have any questions.
- World Health Organization. The World Health Report 2001–Mental Health: New Understanding, New Hope. Geneva, Switzerland: World Health Organization; 2001.