Treatment Guidelines for Obsessive-Compulsive Disorder (OCD)

Table of contents

1.    Introduction

1.1    Foreword
1.2    Who are these guidelines intended for?
1.3    Structure of these guidelines
1.4    Further reading

2.    General Principles of Management

2.1    Rating scales are your friend
2.2    Don’t overlook comorbidity
2.3    Be in it for the long game
2.4    It’s not drugs *or* ERP – it’s both
2.5    Severity of OCD is likely to affect treatment choice
2.6    Therapists need to be trained in the treatments they are providing
2.7    Is CBT as good as ERP? Aren’t they the same thing?
2.8    Target doses for drug treatment
2.9    Choosing drugs

3.    Treatment Steps

3.1    Step 1: SSRIs

3.1.1    Evidence base to support Step 1
3.1.2    Are all SSRIs equal?
3.1.3    When should you increase the dose?
3.1.4    Are high doses necessary?
3.1.5    Is it worth switching to a different SSRI?

3.2    Step 2: Clomipramine

3.2.1    Is Clomipramine more effective than other SRIs?
3.2.2    Many patients don’t seem to tolerate it. What can I do to increase tolerability?

3.3    Step 3a: Augmentation with antipsychotics

3.3.1    Which is the best antipsychotic to augment with?
3.3.2    What sorts of doses are appropriate?
3.3.3    Are all antipsychotics worth trying?
3.3.4    Can I augment any SRI with antipsychotics?
3.3.5    Should I stop the antipsychotic before changing the SRI?

3.4    Step 3b: Augmentation with other drugs

3.4.1    Introduction
3.4.2    Lamotrigine
3.4.3    Topiramate
3.4.4    D-Cycloserine

3.5    Steps 4-6: Systematic trials of SRI ± augmentation

3.5.1    Introduction
3.5.2    Clomipramine + SSRI
3.5.3    Venlafaxine

3.6    Novel treatments

3.6.1    Introduction
3.6.2    Memantine
3.6.3    Riluzole
3.6.4    Ondansetron
3.6.5    Nicotine
3.6.6    N-Acetylcysteine
3.6.7    Minocycline

3.7    Summary of novel treatments

4.    Specific types of OCD

4.1    Drug treatment of hoarding
4.2    Body-Dysmorphic Disorder (BDD)

4.2.1    Psychological therapy
4.2.2    Drug treatment

4.3    Psychotic symptoms in OCD (‘Schizo-OCD’)
4.4    Pure obsessions (‘Pure-O’)

5.    Troubleshooting

5.1    My patient can only tolerate high doses for short periods of time
5.2    My patient can’t tolerate anything
5.3    Symptoms get so bad when switching that it’s impossible to switch

6.    Appendices

6.1    Appendix 1: General inclusion criteria for referral to the AIS
6.2    Appendix 2: General exclusion criteria
6.3    Appendix 3: General treatment criteria
6.4    Appendix 4: Detailed treatment criteria for referral
6.5    Appendix 5: Detailed treatment criteria for entry onto OCD pathway
6.6    Appendix 5: Detailed treatment criteria for intensive/inpatient treatment
6.8    Appendix 5: Detailed treatment criteria for neurosurgical treatment

7.    References

 

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