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OBSESSIVE COMPULSIVE DISORDERTREATMENT OF OCDToday, pharmacotherapy or cognitive behavioural therapy (CBT), used alone or simultaneously, have been shown to be efficacious in the treatment of OCD. Where symptomatology is limited and co - occurring illnesses absent, CBT is the first choice. When OCD is treatment resistant, psychosurgery although rarely undertaken, shows a marked improvement in up to 50% of patients. COGNITIVE BEHAVIOURAL THERAPY (CBT) Cognitive therapyCognitive therapy in the treatment of OCD is in its experimental stages. The aim of such therapy is to correct the thoughts and feelings that underlie the obsessions. Behavioural TherapyNumerous studies now show that exposure and response prevention therapy is effective in the treatment of OCD. This therapy involves exposure to the feared situation and inhibiting the performance of a compulsion. Using this therapy, between 50 - 70% of patients improve for up to six years, however, it has several limitations. It is essentially without effect where there are covert rituals and up to 25% will not commence or continue with this therapy. Where there is comorbidity, it is even less efficacious. Patient education is vital prior to using behavioural therapy emphasising that initial discomfort is likely but that over time, with repeated exposure, less distress occurs, a phenomenon known as habituation. Exposure commences with items that provoke only moderate levels of discomfort and each treatment session should continue until habituation occurs. DRUG ASSISTED TREATMENTTreatment studies show that medications with effects on the serotonergic system are the most efficacious in OCD and all have indications as antidepressants. The only tricyclic anti - depressant effective in OCD is clomipramine (Anafranil). All the specific serotonin reuptake inhibitors (SSRIs) are effective in the treatment of OCD with symptom reduction occurring after several weeks. (See Table 4) Pharmacotherapy rarely results in a total reduction of symptoms; a partial response is the norm. On discontinuation of medication, relapse is high, 80% report some return of symptoms. When one anti - obsessional drug is without effect or has only partial effect, another should be tried. Augmentation therapy occurs if following an adequate trial and dose of an anti - obsessional drug there occurs no sustained reduction of symptoms. An adequate trial is defined as a period greater than ten weeks. Only limited studies, however, have investigated pharmacological augmentation. Agents found to be effective include Clonazepam, Buspirone, Lithium and Clonidine. The conventional anti-psychotics Pimozide and Haloperidol, and the newer atypical anti-psychotics Risperidone, Seroquel and Zyprexa have also been shown, in limited studies, to be efficacious augmenting agents. Combined Drug Assisted Treatment and Behavioural TherapyStudies suggest that the effectiveness of medication is enhanced when combined with behavioural therapy. Moreover, if drug discontinuation occurs, the improvement is more likely to be sustained if behavioural therapy has been used. The rule is that pharmacotherapy should be used simultaneously with behavioural therapy. Table 4 Common drugs used in treating OCD
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