Overview of Obsessive-compulsive Disorder: An Expert Interview With Steven J. Brodsky, PsyD

Laurie Barclay, MD

Disclosures

February 16, 2009

Editor's Note

Media attention on obsessive-compulsive disorder (OCD) has caused better recognition by the lay public as well as by clinicians, leading to an apparent increase in prevalence of this disorder. Recently recognized subtypes of OCD include scrupulosity, or OCD focused on religious practices or beliefs. Exposure-response prevention (ERP) is currently the most widely accepted treatment, and it is usually effective in compliant patients.

To learn more about the clinical presentation and management of OCD, Medscape interviewed Steven J. Brodsky, PsyD, a licensed clinical psychologist who specializes in cognitive behavioral therapy for OCD, phobias, and panic disorder. He is in solo practice in New York, NY.

Medscape: Is OCD on the rise, and/or are lay persons as well as clinicians now more aware of it?

Dr. Brodsky: People are definitely more aware of OCD; there's been much more media coverage in recent years. In light of that, it's difficult to determine if there's been an increase in prevalence of the condition. Just 15 years ago, OCD was not well understood -- now it has risen from relative obscurity to front-page news.

The statistics suggest that 2% of the population, which translates into 6 million people in the United States, have OCD.

Medscape: Please define and describe scrupulosity, or OCD as it manifests regarding religious practices and beliefs in persons of faith.

Dr. Brodsky: Each individual case varies, but generally speaking, scrupulosity can take a couple of different forms. Some specifically religious cases involve the person having negative thoughts or obsessions that they may have committed a sin within their faith. It could, for example, involve more ritualistic aspects, such as whether they prayed correctly, or an ethical code of conduct, for instance, honesty.

When a person thinks they might have sinned, they engage in a compulsion, or some kind of self-reassuring behavior. Either the individual will try to correct the situation they believe they committed by doing it over, for example, repeating their prayers, or by approaching the person they think they've mistreated. They may also try self-reassurance by trying to talk themselves out of the belief that they've sinned.

Other forms of scrupulosity may involve a feeling of being overly responsible for others, such as worrying about public safety issues. If they see something that they think could cause harm, they feel responsible to remove it from public exposure to safeguard other individuals.

Medscape: What are the consequences of OCD in terms of complications, comorbid conditions, and lost productivity?

Dr. Brodsky: OCD causes tremendous delay in activities and functions, which slows down productivity. The stress of OCD itself is exhausting and depletes people of their energy. Like all anxiety disorders, attention and memory are compromised. OCD accounts for a great deal of lost productivity and even absence from the work force entirely. There are people whose work is compromised or who are even disabled by OCD.

It is not uncommon for people with OCD to have comorbid attention-deficit disorder or tic disorders. Virtually everybody with OCD is depressed, at least secondarily to the OCD, which is a very frustrating condition.

Medscape: What treatment regimens or combinations of therapies do you think are most effective in OCD?

Dr. Brodsky: Research studies have shown that exposure response prevention (ERP) -- a form of psychotherapy -- is more effective than medication alone. In many cases, ERP may be even more effective than combined medication and ERP in terms of overall efficacy and relapse rates.

However, psychopharmacology may be helpful in more severe cases where people are overwhelmed because they are in a crisis or because they are unable to engage in ERP, which involves a certain amount of motivation and hard work. People who receive ERP are usually able to reduce or eliminate medication by the end of therapy.

Medscape: What is the status of currently available pharmacotherapy and drugs in development for OCD?

Dr. Brodsky: There are at least a dozen drugs that are used for OCD. The first strategy that is tried is use of selective serotonin reuptake inhibitors. Prozac®, Zoloft®, and Celexa® have been around longer; the more recent ones are Paxil®, Luvox®, and Lexapro®. An older drug is Anafranil®, a tricyclic antidepressant that may be associated with more side effects. When these fail, Effexor® is sometimes used.

Recently, in more complicated or severe cases, low-dose neuroleptics or supplements, such as inositol, a B vitamin, have enhanced the effectiveness of these medications.

Medscape: What is the prognosis for individuals with OCD, both untreated and with best available treatment?

Dr. Brodsky: With the best available treatment, I think the prognosis is quite good. Obviously, everything depends on the patient's compliance. The therapy itself is very collaborative -- it involves a lot of homework assignments on the part of the patient, several exposure exercises throughout the day. Usually these can be rather brief, but it does require a certain amount of discipline and motivation. If the client follows through, the prognosis is very good.

This assumes that the patient has received the right type of treatment. Unfortunately, the vast majority of people get no help at all. To be sure they're getting the right type of treatment, prospective patients can ask 2 test questions of their therapist. The first is: "Is ERP the therapist's main method of treating OCD?" Other treatments such as hypnosis or biofeedback are not even close in effectiveness.

The second question is, "How many patients with OCD have you successfully treated?" By successful, I mean that treatment pretty much got rid of most symptoms and that they were able to eliminate medication by the end of treatment.

Medscape: What additional research do you think needs to be done in OCD?

Dr. Brodsky: Certainly research to find medications for more severe cases and new approaches to work with more resistant patients who have certain comorbid conditions, such as an Axis II personality disorder, which can create resistance to therapy.

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