Obsessive-Compulsive Disorder (OCD)
Treatment of OCD
Because OCD is one of several anxiety disorders believed to be mediated by serotonin transmission, treatment often focuses on boosting levels of serotonin. A high density of serotonin receptors is located in areas of the brain involved in the mediation of fear and anxiety (eg, the hippocampus and amygdala), and stimulation of these receptors is believed to reduce activity in these neurons, thus reducing the fear response. Therefore, OCD treatment typically involves substances that support availability of serotonin, including pharmaceuticals and nutritional supplements.
Drugs currently used to treat OCD and other anxiety disorders usually fall into one of three categories: selective serotonin reuptake inhibitors (SSRIs), tricyclic antidepressants, and benzodiazepines. The Food and Drug Administration (FDA) has ordered that a black box warning appear on the label of all antidepressants, advising consumers that use of these drugs carries an increased risk of suicidal thoughts and behaviors in children and adolescents.
SSRIs. SSRIs inhibit the reuptake of serotonin (5-hydroxytryptamine, or 5-HT) into nerve terminals, which allows serotonin to remain available to stimulate a large number of 5-HT receptors. This results in an elevation in mood and a reduction in anxiety symptoms. Clomipramine was the first FDA approved SSRI for OCD. Other SSRIs, including fluoxetine, fluvoxamine, paroxetine, and sertraline, have shown similar efficacy.
Although SSRIs tend to cause fewer side effects than older antidepressants (tricyclics, for example), they are not without side effects. Some people experience nausea, diarrhea, agitation, or stomach upset when they begin taking SSRIs, but these symptoms usually disappear after a few weeks. Approximately 15 to 20% of patients who take SSRIs have significant insomnia, and sexual dysfunction (decreased libido, delayed or absent orgasm) is a problem for many individuals as well. Weight gain may occur in some patients.
Tricyclic antidepressants. Tricyclic antidepressants work by inhibiting the reuptake of norepinephrine (a neurotransmitter in the brain) and inhibiting some serotonin reuptake. Tricyclics used in the treatment of OCD include amitriptyline and clomipramine. Milder side effects may include dizziness, drowsiness, dry mouth, and weight gain, while dangerous adverse effects include cardiac arrhythmias and seizures. Tricyclic use is associated with weight gain to a much greater degree than SSRIs.
Benzodiazepines. Benzodiazepines are used to induce sedative, muscle-relaxant, anticonvulsant, and antianxiety effects. Benzodiazepines have largely been replaced by SSRIs in the treatment of OCD and other anxiety disorders, although are still used in some cases.
Hormones and OCD
A number of studies have shown that people with OCD are likely to have abnormal hormone levels and that hormones may play a role in triggering or worsening OCD (Altemus 1999). For instance, several research groups have noticed that women with OCD tend to experience worse symptoms during premenstrual periods, when estrogen levels are highest (Rapkin 2002). Estrogen is known to promote anxiety and other feelings that may exacerbate OCD. Among men, at least one case report exists of successful treatment with antiandrogenic therapy that greatly reduced the levels of sex hormones (Eriksson 2000).
Based on these studies, comprehensive hormone testing and correction may be warranted on an individual basis. Women who are estrogenic, or have elevated levels of estrogen, may consider progesterone therapy to balance high estrogen levels. Progesterone is known to inhibit anxiety and seizure activities in other diseases and, although it has not been tested specifically in OCD, may help reduce symptoms (Herzog 1999).
Additionally, the pineal hormone melatonin is well known to induce sleep in humans. At least one study has shown that people with OCD tend to have depressed melatonin levels, along with elevated levels of the stress hormone cortisol (Monteleone 1995).
Other treatment approaches, including psychotherapy, exercise, and relaxation methods, can be used in addition to pharmaceutical and nutritional therapies or as treatment options if conventional medications have failed.
Psychotherapy. Some people with OCD have had success with specific types of behavioral therapy. One approach, called exposure and response prevention (ERP), appears to have long-lasting effects and work best in patients who are highly motivated and have a positive attitude about treatment. ERP involves having patients deliberately confront their feared object or idea, then refrain from either acting out or ritualizing to obtain relief. Compulsive hand washers, for example, may be asked to touch an object they believe is contaminated and then may be urged to avoid washing for several hours until the anxiety has decreased.
In a study, 113 patients with OCD took part in group exposure and response prevention therapy for either 7 or 12 weeks. The investigators found that improvements in obsessions, compulsions, and depression were evident in both treatment groups at the end of treatment and long-term follow-up; also, that the outcomes did not differ significantly between the two groups (Himle 2001).
To see how ERP compares to medication (clomipramine) or placebo or when combined with clomipramine, a multisite, randomized, controlled trial was conducted for 12 weeks in 122 adults with OCD. The investigators were interested in response (defined as a decrease in symptoms) or remission (minimal symptoms after treatment). At the end of treatment, there were significantly more responders and remitters in both ERP groups than in the clomipramine-alone or placebo groups. In terms of remission alone, 58% achieved it in the ERP-plus-clomipramine group, 52% in the ERP-alone group, 25% in the clomipramine-only group, and none achieved remission in the placebo group (Simpson 2006).
Not all patients with OCD benefit from or tolerate the ERP approach. For them, cognitive interventions may be an option. Cognitive-behavioral therapy for OCD, in which patients attempt to change their beliefs and thinking patterns, has only recently been investigated. A study compared the efficacy of ERP therapy and cognitive-behavioral therapy in 59 patients with OCD. The patients were randomly assigned to receive ERP therapy or cognitive-behavioral therapy for 12 weeks. At post-treatment and three-month follow-up, recovery status in both groups ranged from 58 to 76%, but there was no significant difference between the two groups (Whittal 2005).
Exercise. The healing power of exercise is often touted by health care professionals, and various studies support this recommendation. In a review of three separate meta-analyses, investigators found that patients who participated in at least 21 minutes of daily aerobic exercise experienced a reduction in anxiety (Petruzzello 1991). A second study noted that regular exercise may help people who suffer from OCD, phobias, and other psychiatric disorders. When the investigators examined studies of anxiety disorder and exercise dating back to 1981, they found that strength training, running, walking, and other forms of aerobic exercise help relieve mild to moderate depression and may also help treat anxiety and substance abuse (Tkachuk 1999).
Relaxation techniques. Beginning in the 1970s, evidence has accumulated that relaxation techniques (eg, meditation and self-hypnosis) can reduce stress and anxiety (Benson 1978). One problem with relaxation studies is compliance and the accompanying high drop-out rates. This problem, however, does not negate the fact that meditation and other relaxation techniques, when practiced regularly, can be effective in relieving stress and producing feelings of calm.
Clinical studies and observations of experts show that yogic breathing, meditation, and good posture enhances mood, stress tolerance, well-being, and mental focus (Brown 2005). A study found a specific Kundalini yoga protocol to be effective in treating OCD as well as a broad range of anxiety disorders (Shannahoff-Khalsa 2004).
Hormones. Both men and women may consider comprehensive hormone testing to see whether they are suffering from abnormal hormone levels. If so, bioidentical hormone therapy may be recommended. For more information on bioidentical hormone testing, please see the Female Hormone Restoration or Male Hormone Restoration protocols.