Questions.
①Is the treatment effective?
②Is the treatment time long?
③What treatments are available?
④Where do I receive treatment?
Is the treatment effective?
Previous opinion: OCD is considered one of the two most difficult psychiatric disorders to treat.
Current opinion: The vast majority of patients with OCD can have their symptoms relieved with systematic treatment, and a significant number of patients can be “clinically cured”. The effectiveness of medication: 40-60%.
How long does treatment last? What is the duration of maintenance treatment?
Onset of action: The literature suggests that the onset of action is slower in OCD (8-12 weeks) than in depression (4-6 weeks), but with this onset of action, patients usually do not have the patience to wait and have to change doctors after 4 weeks of ineffectiveness. Therefore, we believe that 8 – 12 weeks is the full onset of action, while at 2 weeks, there is already a partial effect. For example, if the duration of compulsions is not reduced, but the level of pain is reduced, or if one still keeps compelling, but no longer compels family members to do the compulsive actions, this is a partial effect. If there is a 15% improvement in 2 weeks of treatment, continue to increase the dosage, and by 8-12 weeks of treatment, there may be an improvement of 35 (an effective definition of OCD is an improvement of 25-35 or more). If there is no improvement at all in 2 weeks of treatment, it is unlikely that the medication will suddenly be effective by 8-12 weeks, and it is advisable to change the medication at this time.
Maintenance: After complete remission, the radicals believe that the treatment amount should be continued for 3–6 months, and the conservatives believe that the treatment amount should be continued for 1–2 years before gradually reducing the medication, we believe that if the treatment amount is high, it is difficult to convince the patient to maintain it for a long time. We are afraid that if a high therapeutic dose is used, it will be difficult to convince patients to maintain it for a long time, and we are afraid that if a medium dose is used, it will be easier to convince patients to maintain it for 1 – 2 years before tapering, and in the process of tapering, tapering will be done every month by 1/4 – 1/ lO, with reductions toward 1/4 for paroxetine and 1/lO for chlorpromazine. During the reduction, the OCD recurs, and then the medication is returned to the previous dose. 50% of patients with OCD can sustain obsessive-compulsive symptoms for more than 30 years [1], so 50% of patients are maintained on medication for more than 3O years.
How long should I consider changing my medication for OCD?
A medication is treated for 12 weeks in full doses before considering a change of medication, with a personal recommendation of six months.
After an OCD treatment is effective, how long should the maximum dose last at least? Radical experts recommend 3-6 months; conservative experts (including most recent guidance) recommend 1-2 years. Many patients require long-term treatment.
What treatments are available?
1. Medication
Anti-compulsive treatment mechanism.
The main drugs that increase 5-HT energy are serotonin reuptake inhibitors (SRIs), which are classified as selective serotonin reuptake inhibitors (SRIs). Reuptake Inhibitors (SSRIs) and non-SSRIs, SSRIs include paroxetine, escitalopram, sertraline, fluoxetine, citalopram and fluvoxamine, and non-SRIs include chlorpromazine, venlafaxine and duloxetine.
② agonist sigma receptor, anti-forcible: fluvoxamine
③Norepinephrine (NE) recycling inhibitor, while NE agonizes a1 receptors on 5-HT neuronal cell bodies → 5-HT release ↑ → 5-HT conduction ↑ → forcing ↓: the active metabolite of chlorpromazine, norethindrone, is a norepinephrine (NE) recycling inhibitor.
The strength of 5-HT recycling inhibition reflects the strength of increased 5-HT conduction, ranked from strong to weak: paroxetine > escitalopram > sertraline > fluoxetine > citalopram > fluvoxamine.
Anti-forcing strength, in order from strong to weak: paroxetine > fluvoxamine > escitalopram > sertraline > fluoxetine > citalopram. The strong ones are paroxetine, fluvoxamine and escitalopram; the moderately potent ones are sertraline and fluoxetine; and the weak ones are citalopram.
Although there are strong and weak SSRIs, for a given individual, a strong SSRI (e.g., paroxetine) that is ineffective may be replaced by an intermediate-acting drug (e.g., sertraline), and an intermediate-acting drug (e.g., fluoxetine) that is ineffective may be replaced by citalopram. Therefore, when antiobsessive-compulsive drugs are not effective, other SSRIs should be tried in turn, without the limitation of “antiobsessive-compulsive strength”.
Principles of antiobsessive-compulsive drug therapy: long-term principle; adequate dosage principle
First-line pharmacotherapy: fluvoxamine, escitalopram, sertraline, paroxetine, and fluoxetine
Second-line drug therapy: chlorpromazine, venlafaxine, mirtazapine, cetiracetam, duloxetine
Third-line drug therapy: aliprazole, olanzapine and quetiapine
2.Psychotherapy
Cognitive behavioral therapy (especially exposure and ritual behavior blocking method)
①Ritual behavior blocking method: the method is coercive and requires a strong performer; the alternative is to encourage and advise the patient to stop the ritual behavior themselves.
②Exposure therapy: imaginary exposure and live exposure; step-by-step exposure and full-blown therapy; length of exposure: sustained prolonged exposure is more effective than short exposure (studies have found that sustained 90-minute exposure is the time required for anxiety reduction and for the desire to perform ritual behaviors to decrease); frequency of exposure therapy: once a day or twice a week can be used.
③ Intensive treatment procedures: information gathering and treatment planning phase; intensive EX/RP phase; home visits; maintenance phase.
3.Psychosurgery treatment
Deep brain electrical stimulation (DBS) and stereotactic surgery (cingulotomy, internal capsule forelimb dissection, subcaudate nucleus neurotomy, and limbic system cerebral white matter resection).
Indications: refractory OCD (history of more than 5 years, medication refractory and failed cognitive behavioral therapy).