Obsessive-compulsive disorder therapy can work without medication

Psychiatry, Psychosomatics & Psychotherapy

A certain psychotherapy procedure, cognitive behavioral therapy with exposure and reaction management, and drug therapy with certain antidepressants (serotonin reuptake inhibitors) have proven to be primarily effective. Early therapy is important to prevent the numerous consequences of the disease. But even if the disease has been around for decades, the right therapy can still be very successful. The symptoms only disappear completely in some of the patients, but for many patients the quality of life often increases enormously when the obsessive-compulsive thoughts and actions decrease in intensity.

psychotherapy

The method of choice today is cognitive behavioral therapy, including exposure-response management. In exposure reaction management, the person concerned, accompanied by his therapist, gradually exposes himself to the compulsive stimuli and learns to deal with the unpleasant feelings that arise without performing compulsive acts. If possible, the confrontation with the compulsory triggering situation should take place in the patient's everyday situation (e.g. in the home environment). The patient experiences that the compulsive fears associated with the situation do not materialize and that he can cope with the unpleasant feelings, i.e. that fear, disgust or tension subside after a certain time, even if he does not perform any compulsive acts.

In order to do justice to the complexity of the disorder, multimodal cognitive-behavioral therapeutic concepts are generally used, at least in the case of moderate and severe obsessive-compulsive disorders. These include - in addition to symptom therapy by means of exposure-reaction management - further cognitive-behavioral therapeutic methods and often also systemic, psychodynamic and / or mindfulness-based elements. Possible functionalities of the obsessive-compulsive symptoms are also included in the treatment. For example, compulsions can have the function of compensating for strong self-doubts, or they serve to regulate relationships with close caregivers. It is recommended that relatives be included in the therapy, especially if they are involved in the rituals.

The combination of cognitive behavioral therapy and drug therapy is not generally superior to cognitive behavioral therapy alone. Additional drug treatment is advantageous if there is also severe (comorbid) depression and / or obsessive-compulsive thoughts determine the clinical picture.

Medication

So-called selective serotonin reuptake inhibitors (SSRI) (citalopram, escitalopram, fluoxetine, fluvoxamine, paroxetine or sertraline) are particularly recommended for drug therapy. These drugs are also used for depression, but also work independently for obsessive-compulsive disorders. An alternative to the SSRIs is the non-selective serotonin reuptake inhibitor clomipramine, which on average leads to more side effects than the SSRI, so that it is viewed more as a second choice.
If the response to SSRIs is inadequate, despite a sufficiently long and high dose, augmentation with a low-dose atypical antipsychotic is recommended. Augmentation is understood to mean the addition of substances to an antidepressant which, on their own, show no or hardly any antidepressant or, in this case, “anti-obsessive” effects. In combination with an antidepressant, however, these substances lead to an increase in the effectiveness of the antidepressant against the obsessive-compulsive symptoms and thus to an improved overall effect. This augmentation is successful in about 1/3 of the patients who have not previously responded to SSRI monotherapy; patients with additional tic disorders benefit in particular.

Basically, the dosage of the SSRI in obsessive-compulsive disorder should be in the upper dose range, but the dosage must always be discussed with the treating doctor. A relatively long period of at least 4 weeks for the onset of action and 8-12 weeks for the maximum effect must be expected. The withdrawal should always be done gradually; the right time for this depends in particular on the course of the additional cognitive behavioral therapy.

In particular, taking long-term effects into account, drug treatment should always be combined with cognitive-behavioral therapy measures.