Cognitive behavioral therapy (CBT) and psychotropic medications are the first-line treatments for OCD. Other forms of psychotherapy, such as psychodynamics and psychoanalysis, may help in managing some aspects of the disorder, but in 2007 the American Psychiatric Association (APA) noted a lack of controlled studies showing their efficacy "in dealing with the core symptoms of OCD." Therapy One exposure and ritual prevention activity would be to check the lock only once and then leave. The specific technique used in CBT is called exposure and response prevention (ERP), which involves teaching the person to deliberately come into contact with situations that trigger obsessive thoughts and fears (exposure) without carrying out the usual compulsive acts associated with the obsession (response prevention). This technique causes patients to gradually learn to tolerate the discomfort and anxiety associated with not performing their compulsions. For many patients, ERP is the add-on treatment of choice when selective serotonin reuptake inhibitors (SRIs) or serotonin-norepinephrine reuptake inhibitors (SSRIs) medication does not effectively treat OCD symptoms or vice versa for individuals who begin treatment with psychotherapy. For example, a patient might be asked to touch something very mildly contaminated (exposure) and wash their hands only once afterward (response prevention). Another example might entail asking the patient to leave the house and check the lock only once (exposure) without going back to check again (response prevention). After succeeding at one stage of treatment, the patient's level of discomfort in the exposure phase can be increased. When this therapy is successful, the patient will quickly habituate to an anxiety-producing situation, discovering a considerable drop in anxiety level. ERP has a strong evidence base and is considered the most effective treatment for OCD. However, this claim was doubted by some researchers in 2000, who criticized the quality of many studies. A 2007 Cochrane review also found that psychological interventions derived from CBT models were more effective than treatment as usual consisting of no treatment, waiting list, or non-CBT interventions. For body-focused repetitive behaviors (BFRB), behavioral interventions such as habit-reversal training and decoupling are recommended. Psychotherapy in combination with psychiatric medication may be more effective than either option alone for individuals with severe OCD. Medication A blister pack of clomipramine under the brand name Anafranil The medications most frequently used to treat OCD are antidepressants including selective serotonin reuptake inhibitors (SSRIs) and serotonin-norepinephrine reuptake inhibitors (SNRIs). Clomipramine, a medication belonging to the class of tricyclic antidepressants, appears to work as well as SSRIs but has a higher rate of side effects. SSRIs help people with OCD by inhibiting the reabsorption of serotonin by the nerve cells after carry message from neuron to synapse, thus more serotonin is available to pass further messages between nearby nerve cells. SSRIs are a second-line treatment of adult OCD with mild functional impairment and as first-line treatment for those with moderate or severe impairment. In children, SSRIs can be considered as a second-line therapy in those with moderate to severe impairment, with close monitoring for psychiatric adverse effects. Patients treated with SSRIs are about twice as likely to respond to treatment as are those treated with placebo, so this treatment is qualified as efficacious. Efficacy has been demonstrated both in short-term (6–24 weeks) treatment trials and in discontinuation trials with durations of 28–52 weeks. In 2006, the National Institute of Clinical and Health Excellence (NICE) guidelines recommended augmentative second-generation (atypical) antipsychotics for treatment-resistant OCD. Atypical antipsychotics are not useful when used alone, and no evidence supports the use of first-generation antipsychotics. For OCD, there is tentative evidence for risperidone and insufficient evidence for olanzapine. Quetiapine is no better than placebo with regard to primary outcomes, but small effects were found in terms of YBOCS score. The efficacy of quetiapine and olanzapine are limited by an insufficient number of studies. A 2014 review article found two studies that indicated that aripiprazole was "effective in the short-term" and found that "there was a small effect-size for risperidone or anti-psychotics in general in the short-term"; however, the study authors found "no evidence for the effectiveness of quetiapine or olanzapine in comparison to placebo." While quetiapine may be useful when used in addition to an SSRI/SNRI in treatment-resistant OCD, these drugs are often poorly tolerated, and have metabolic side effects that limit their use. A guideline by the APA suggested that dextroamphetamine may be considered by itself after more well-supported treatments have been tried. Procedures Electroconvulsive therapy (ECT) has been found to have effectiveness in some severe and refractory cases. Surgery may be used as a last resort in people who do not improve with other treatments. In this procedure, a surgical lesion is made in an area of the brain (the cingulate cortex). In one study, 30% of participants benefitted significantly from this procedure. Deep brain stimulation and vagus nerve stimulation are possible surgical options that do not require destruction of brain tissue. In the United States, the Food and Drug Administration approved deep-brain stimulation for the treatment of OCD under a humanitarian device exemption requiring that the procedure be performed only in a hospital with special qualifications to do so. In the United States, psychosurgery for OCD is a treatment of last resort and will not be performed until the person has failed several attempts at medication (at the full dosage) with augmentation, and many months of intensive cognitive–behavioral therapy with exposure and ritual/response prevention. Likewise, in the United Kingdom, psychosurgery cannot be performed unless a course of treatment from a suitably qualified cognitive–behavioral therapist has been carried out. Children Therapeutic treatment may be effective in reducing ritual behaviors of OCD for children and adolescents. Similar to the treatment of adults with OCD, CBT stands as an effective and validated first line of treatment of OCD in children. Family involvement, in the form of behavioral observations and reports, is a key component to the success of such treatments. Parental interventions also provide positive reinforcement for a child who exhibits appropriate behaviors as alternatives to compulsive responses. In a recent meta-analysis of evidenced-based treatment of OCD in children, family-focused individual CBT was labeled as "probably efficacious," establishing it as one of the leading psychosocial treatments for youth with OCD. After one or two years of therapy, in which a child learns the nature of their obsession and acquires strategies for coping, they may acquire a larger circle of friends, exhibit less shyness, and become less self-critical. Although the known causes of OCD in younger age groups range from brain abnormalities to psychological preoccupations, life stress such as bullying and traumatic familial deaths may also contribute to childhood cases of OCD, and acknowledging these stressors can play a role in treating the disorder.
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