The Expert Consensus Guideline Series:
Treatment of Obsessive-Compulsive Disorder Editors: John S. March, MD, MPH; Allen Frances, MD; Daniel Carpenter, PhD; David A. Kahn, MD

CONTENTS:

GUIDELINES

SURVEY RESULTS

PATIENT-FAMILY HANDOUT

 


The Expert Consensus Panel for Obsessive-Compulsive Disorder

The following participants in the Expert Consensus Survey were identified from several sources: participants in a recent NIMH consensus conference on OCD; participants in the International Obsessive Compulsive Disorders Conference (IOCDC); members of the Obsessive-Compulsive Foundation Scientific Advisory Board; and other published clinical researchers. Of the 79 experts to whom we sent the obsessive-compulsive disorder survey, 69 (87%) replied. The recommendations in the guidelines reflect the aggregate opinions of the experts and do not necessarily reflect the opinion of each individual on each question.

Margaret Altemus, M.D.
NIMH

Jambur V. Ananth, M.D.
Harbor-UCLA Medical Center

Lee Baer, Ph.D.
Massachusetts General Hospital

David H. Barlow, Ph.D.
Boston University

Donald W. Black, M.D.
University of Iowa

Pierre Blier, M.D.
McGill University

Maria Lynn Buttolph, M.D.
Massachusetts General Hospital

Alexander Bystritsky, M.D.
UCLA School of Medicine

Cheryl Carmin, Ph.D.
University of Illinois, Chicago

Diane Chambless, Ph.D.
University of North Carolina-Chapel Hill

David Clark, Ph.D.
University of New Brunswick

Edwin H. Cook, M.D.
University of Chicago

Jean Cottraux, M.D.
Université Lyon, France

Jonathan R. T. Davidson, M.D.
Duke University Medical Center

Pedro Delgado, M.D.
University of Arizona, Tucson

Paul M. G. Emmelkamp, M.D.
University of Groningen

Brian A. Fallon, M.D.
Columbia University

Martine Flament, M.D.
La Salpetriere, Pavillon Clerambault

Martin Franklin, Ph.D.
Allegheny University

Mark Freeston, Ph.D.
Université Laval

Randy Frost, Ph.D.
Smith College

Daniel Geller, M.D.
McLean Hospital

Wayne K. Goodman, M.D.
University of Florida College of Medicine

Tana A. Grady, M.D.
Duke University Medical Center

Benjamin Greenberg, M.D.
NIMH

Daniel Greenberg, M.D.
Jerusalem Mental Health Center, Herzog Hospital

John H. Greist, M.D.
Dean Foundation for Health Research

Gregory Hanna, M.D.
University of Michigan Medical Center, Child & Adolescent Psychiatric Hospital

William A. Hewlett, M.D.
Vanderbilt Medical School

Eric Hollander, M.D.
Mt. Sinai School of Medicine

Bruce Hyman, Ph.D.
Hollywood, Florida

James W. Jefferson, M.D.
Dean Foundation for Health Research

Michael A. Jenike, M.D.
Harvard Medical School

David J. Katzelnick, M.D.
Dean Foundation for Health Research

Suck Won Kim, M.D.
University of Minnesota Health Center

Lorrin M. Koran, M.D.
Stanford Medical Center

Michael Kozak, Ph.D.
Medical College of Pennsylvania/EPPI

James F. Leckman, M.D.
Yale University

Henrietta L. Leonard, M.D.
Brown University

Charles Mansueto, Ph.D.
Silver Spring, Maryland

Isaac Marks, M.D.
Institute of Psychiatry, London

Arturo Marrero, M.D.
Newark Beth Israel Hospital

Christopher McDougle, M.D.
Yale University School of Medicine

Richard McNally, Ph.D.
Harvard University

Fugen Neziroglu, Ph.D.
Institute for Bio-Behavioral Therapy & Research, Great Neck, New York

Michele Pato, M.D.
SUNY Buffalo, Buffalo General Hospital

Frederick Penzel, Ph.D.
Huntington. New York

Katharine A. Phillips, M.D.
Butler Hospital

Teresa A. Pigott, M.D.
University of Texas Medical Branch-Galveston

C. Alec Pollard, Ph.D.
St. Louis University

Lawrence Price, M.D.
Brown University

S. Rachman, Ph.D.
University of British Columbia

Judith L. Rapoport, M.D.
NIMH

Steven A. Rasmussen, M.D.
Butler Hospital

Scott Rauch, M.D.
Massachusetts General Hospital

Mark A. Riddle, M.D.
Johns Hopkins

Jerilyn Ross, LICSW
The Ross Center for Anxiety & Related Disorders

Barbara Rothbaum, Ph.D.
Emory University

Paul Salkovskis, Ph.D.
Warneford Hospital, Oxford University

Jeffrey M. Schwartz, M.D.
UCLA Neuropsychiatric Institute

David Spiegel, M.D.
Boston University

Dan Stein, M.D.
University of Stellenbosch, South Africa

Gail Steketee, Ph.D.
Boston University

Susan Swedo, M.D.
NIMH

Richard Swinson, M.D.
Clarke Institute of Psychiatry

Barbara Van-Noppen, ACSW
Brown University

Patricia Van Oppen, Ph.D.
Free University of Amsterdam

Lorne Warneke, M.D.
University of Alberta, Edmonton

Jose Yaryura-Tobias, M.D.
Institute for Bio-Behavioral Therapy & Research, Great Neck, New York

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Guideline 1: Selecting the Initial Treatment Strategy
1A. Treatment Choice by Severity of Illness and By Age
Summary: The experts usually prefer to begin the treatment of OCD patients with either CBT alone or with a combination of CBT and medication (CBT+SRI). The likelihood that medication will be included in the recommendation varies with the severity of the OCD and the age of the patient. In milder OCD, CBT alone is the initial choice. As severity increases, the experts are more likely to add medications to CBT as the initial treatment or to use medication alone. In younger patients, the experts are more likely to use CBT alone.
 

Adult OCD

Adolescent OCD

Prepubertal OCD

 

Milder*

More Severe*

Milder

More Severe

Milder

More Severe

First Line

CBT** first

CBT+SRI***

SRI first

CBT first

CBT + SRI

CBT first

CBT first

Second line

CBT+SRI

SRI first

CBT first

CBT + SRI

SRI first

CBT first

SRI first

CBT+SRI

SRI first

CBT+SRI

SRI first

*Mild OCD (Yale-Brown Obsessive-Compulsive Scale 10-18) causes distress but not necessarily dysfunction; help from others is usually not required to get through the day. Moderate OCD (YBOCS 18 -29) causes both distress and functional impairment. Severe OCD (YBOCS = 30 or above) causes serious functional impairment requiring significant help from others.

**CBT: cognitive-behavioral therapy

***SRI (serotonin reuptake inhibitor) refers to the five compounds clomipramine, fluoxetine, fluvoxamine, paroxetine, and sertraline; SSRI (selective SRI) refers to all but clomipramine.

 

1B. Other Factors That Affect the Choice of Treatment
Summary: We also asked the experts a series of questions concerning the relative efficacy, durability, speed, tolerability and acceptability of CBT alone, medication alone, and combined treatment (CBT + SRI). Table 1B examines to what extent each treatment is rated as first, second, or third line across these dimensions for patients with either mild or severe OCD. Combined treatment is the experts' favorite in most comparisons suggesting that overall it may be the most acceptable and successful treatment approach for the majority of adult patients.
 

Efficacy

Speed

Durability

Tolerability

Acceptability

  Milder Severe Milder Severe Milder Severe Milder Severe Milder Severe
CBT + SRI First First First First First Second First First First First
CBT First Second First Second First Second First Second First Second
Medication Second Second Second Second Second Third Second First Second First
Efficacy represents the likelihood of meaningful symptom remission.

Speed refers to how quickly symptom remission begins.

Durability refers to the probability of symptom recurrence when treatment is withdrawn.

Tolerability is the degree to which patients find the treatment to be free of major or prohibitive side effects.

Acceptability refers to positive patient expectations that influence choice of treatment.

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Guideline 2: Selecting Specific Cognitive-Behavioral (CBT) Techniques
Editors note: Table 2A describes the specific CBT treatment strategies that were endorsed by the experts and table 2B describes the level of care and intensity of services for CBT. Cognitive-behavioral therapy involves the combination of behavior therapy (E/RP) and Cognitive Therapy (CT). Behavior therapy for OCD (BT in CBT) most specifically involves Exposure (E) and Response or Ritual Prevention (RP). Exposure (E) capitalizes on the fact that anxiety usually attenuates after sufficient duration of contact with a feared stimulus. Thus, patients with obsessions related to germs must remain in contact with "germy" objects until their anxiety is extinguished. Repeated exposure is associated with decreased anxiety until, after multiple trials, the patient no longer fears contact with the specifically targeted stimulus. In order to achieve adequate exposure, it is usually necessary to help the patient block the rituals or avoidance behaviors, a process termed response or ritual prevention (RP). For example, patients with germ worries must not only touch "germy things," but must also refrain from ritualized washing until their anxiety diminishes, a process termed exposure and response prevention (E/RP). Cognitive therapy (CT), which may be added to E/RP, addresses such things as faulty estimation of danger or the exaggerated sense of personal responsibility often seen in OCD patients. Other techniques such as thought stopping and distraction (which involve suppressing or "switching off" OCD symptoms) and contingency management (which emphasizes rewards and costs as incentives for ritual prevention) are generally thought to be less effective than standard CBT.
2A. Selecting a CBT Strategy

(bold italics = treatment of choice)

Summary: The experts consider the combination of exposure and response prevention as the optimal behavioral psychotherapy for OCD, while cognitive therapy may provide additional benefit by directly targeting distorted "OCD beliefs" and/or by improving compliance with E/RP.
  Obsessions Compulsions
First line Exposure plus response prevention (E/RP)

E/RP + Cognitive Therapy (CT)

E/RP

E/RP + CT

Second line CT

Exposure

Response Prevention

CT

Exposure

Further recommendations:

Cognitive therapy may be more useful for pathological doubt, aggressive obsessions, and scrupulosity or other "OCD beliefs" as contrasted to "urge" like symptoms such as arranging or touching rituals. Habit reversal, which depends primarily on establishing a set of competing responses, may be especially useful for tic-like compulsions.

Patients with little insight do not do as well with any of the specified treatment interventions. CT may help sharpen insight, however.

 

2B. Level of Care for CBT

(bold italics = treatment of choice)

Summary: The experts’ recommend beginning treatment with weekly, individual CBT sessions and may also use between session homework assignments or therapist assisted out-of -office (in vivo) exposure and response prevention. Group CBT or behavioral family therapy are second line alternatives. The experts recommend 13-20 sessions as the appropriate number of CBT treatments for the typical patient. When speed is of the essence or OCD is particularly severe in adults, intensive CBT (daily CBT for 3 weeks) may be preferable.
  First line Second line
Intensity and setting Weekly office + E/RP homework

Weekly office + out-of-office therapist assisted E/RP

Intensive CBT (50 hours of daily CBT over 3 weeks)

Biweekly E/RP

Partial hospital

Inpatient hospital

Format Individual Group

Individual + family therapy

Behavioral family therapy

Number of Sessions 13–20 sessions

7–12 sessions

20–50 sessions

3–6 sessions

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Guideline 3: Selecting A Specific Medication Strategy
Summary: Among the classes of medications, the serotonin reuptake inhibitors (SRIs) are by far the most effective for OCD and the experts recommend all five SRIs as first line treatments for OCD. If the patient does not respond to the average dose of an SRI, the experts recommend gradually increasing the dose to its maximum within 4–8 weeks from the start of treatment. When a patient is having a partial response to an average dose of an SRI, the experts suggest gradually increasing the dose to its maximum within 5–9 weeks from the start of treatment. They consider 8–13 weeks an adequate medication trial before changing medication or augmenting with another agent.
  Drugs*

Dosage Range (mg)

Average Daily Dose (mg)

No Response to
Average SRI dose
Partial Response to Average SRI dose
First Line Fluvoxamine

Fluoxetine

Clomipramine

Sertraline

Paroxetine

100–300

20–80

100–300

75–225

20–60

200

50

200

150

50

Push SRI to maximum dose in 4–8 weeks from the start of treatment Push SRI to maximum dose in 5–9 weeks from the start of treatment
* Dosage ranges are rounded off to the nearest "pill dose." Dosages for individual patients may be larger or smaller, depending on the individualized dose-response curve. Medications are listed in order of the experts’ mean scores.

Further recommendations:

The experts recommend switching to another SRI if there is no response after 4–6 weeks at a maximum dose.

Other treatments, including venlafaxine, MAOIs, and clonazepam, are considered third line and may be worth a try when the SRIs themselves have not proven helpful.

SRIs are more likely to be helpful for pathological doubt, aggressive obsessions and urges, and mental rituals than for slowness, hoarding, and tic-like symptoms.

Editorial Comment: When increasing the dose to the maximum, it is generally wise to wait 2–4 weeks between dose increases to allow sufficient time to establish a dose-response relationship. A few patients who show a partial response to medication and few side effects may benefit from doses substantially higher than those listed as the conventional maximum. The dose of medication for such patients should not be increased to high levels until at least 12 weeks of treatment have elapsed.

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Guideline 4: When There is Still Room for Improvement
Editors’ note: Unfortunately, some patients do not respond adequately or at all to the initial treatment plan. Guideline 4A provides the experts’ recommendations for what to do next when the initial treatment plan of CBT or SRI or a combination of the two has not produced satisfactory improvement. Guideline 4B provides recommendations concerning how long to wait before making changes in the treatment regimen. Strategies for patients who continue to have an inadequate response after several treatment trials are outlined in Guideline 5.
4A: Inadequate Response to First Line Treatment: What to Do Next
Summary: The experts recommend adding an SRI when patients have not responded well to CBT alone. When patients have not done well with medication management alone, the experts recommend either adding CBT or switching to another SRI. Thus, combined CBT and medication is the experts’ preference for most patients who have not responded to an initial trial of either CBT or medication alone. In patients who have shown no response to combined treatment, the experts recommend switching SRIs and continuing CBT. In patients with a partial response to combination therapy, they recommend switching SRIs, providing more CBT, and possibly augmenting with another medication.

(bold italics = treatment of choice)

 

Inadequate Response to
CBT only

Inadequate Response to
SRI alone

Inadequate Response to
Combined CBT/SRI

 

No response

Partial response

No response

Partial response

No response

Partial response

First line

Add SRI

Add SRI

New CBT technique or intensity

Add CBT

Switch SRIs

Add CBT

Switch SRIs

Switch SRIs

Switch SRIs

New CBT technique or intensity

Augment meds

Second line

New CBT technique* or intensity

New CBT setting or format§

New CBT setting or format

Augment meds§§

New CBT setting or format

Augment meds

New CBT setting or format

Augment meds

New CBT technique or intensity

New CBT setting or format

New CBT setting or format

*New CBT technique: e.g., satiation, thought stopping, habit reversal, relaxation

New CBT intensity: additional CBT sessions or intensive CBT

New CBT setting: e.g., using a partial hospital or inpatient behavioral unit to conduct therapist-assisted E/RP

§New CBT format: e.g., family or group therapy

§§For details on specific augmentation strategies, see Guideline 5.

Editorial Comment: While the experts find the average efficacy of the five SRIs to be equal, individual patients may respond better to one SRI than another, so that sequential trials are necessary in patients who have not responded to any single SRI.

4B. When to Rethink Your Strategy If the Patient Is Having an Inadequate Response
Summary: The following table provides suggestions about how to time changes in treatment for patients who are having an inadequate response to the previous intervention.
Current Treatment Status No Response Partial Response
When to add medication for a patient who has started with CBT alone For more severe OCD, give weekly CBT for 2 weeks before adding medication

For milder OCD, give weekly CBT for 4 weeks before adding medication

For more severe OCD, give weekly CBT for 4 weeks before adding medication

For milder OCD, give weekly CBT for 7 weeks before adding medication

When to add CBT for a patient who has started with medication alone* Try medication alone for 4–8 weeks before adding CBT Try medication alone for 4–8 weeks before adding CBT
If the patient prefers to stay on CBT alone but has inadequate response after 6 sessions Try 3–6 additional sessions Try 4–10 additional sessions
If the patient has failed trials of 2–3 SSRIs Consider a trial of clomipramine Consider a trial of clomipramine

* Editors’ recommendation.

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Guideline 5: Strategies for the Treatment-Refractory Patient
Summary: The experts have somewhat less agreement about what to do next in managing treatment-refractory patients (those who fail to respond to well-delivered sequential SRI trials combined with expert CBT). They recommend adding an augmenting medication, especially if the patient exhibits associated features (e.g., tics or a comorbid anxiety disorder) that might predict a positive response to augmentation. Second line recommendations are to try a new CBT setting, technique, or intensity, or to switch to another SRI or an MAOI. Finally, in patients with extremely severe and nonremitting OCD, IV clomipramine, neurosurgery,(internal capsulotomy) or ECT (if the patient is also depressed) may sometimes be considered.
  No response to CBT
plus 3 SRIs trials ,*
Partial response to CBT
plus 3 SRI trials,*
First line Augment with another
medication
Augment with another
medication
Second line New CBT setting or format

New CBT technique or intensity

Switch to another SRI

Switch to MAOI

New CBT setting or format

New CBT technique or intensity

Switch to another SRI

Switch to MAOI

Infrequently needed, but sometimes life saving interventions Try IV clomipramine

ECT if also depressed

Neurosurgery

Try IV clomipramine
* Assumes one of the trials was clomipramine

Further recommendations:

There are a variety of augmentation strategies that can be tried in OCD, including clomipramine, clonazepam, conventional neuroleptics, buspirone, risperidone, and a second SSRI added to the first one. The editors suggest tailoring the choice of augmentation medications to the individual clinical presentation. Clomipramine may be useful in boosting the response of a patient treated with an SSRI who is not having an adequate response. Neuroleptics may be helpful for patients who are not having an adequate response to an SRI and who have a comorbid tic disorder; OCD symptoms such as compulsive touching that resemble tics; or comorbid schizotypy. Clonazepam may be a helpful augmentation agent for patients with a comorbid anxiety disorder.

While little empirical documentation exists, case studies and open trials support the same augmentation strategies for pediatric as for adult patients.

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Guideline 6: Treatment Strategies for the Maintenance Phase
Summary: Once patients have responded to the acute phase of treatment for OCD, it is important to consolidate treatment gains during the maintenance phase. The experts recommend monthly follow-up visits for at least 3–6 months and consider rapid discontinuation of medications unacceptable. Booster CBT sessions may help reduce the risk of relapse when medication is withdrawn. The experts recommend considering long-term or lifelong prophylactic maintenance medication after two to four severe relapses or three to four mild to moderate relapses.

(bold italics = treatment of choice)

  Visit schedule for first 3–6 months after acute treatment When to consider medication taper How to discontinue medications Long-term prophylactic maintenance medication
Recommendations Monthly visits Not before 1–2 years Gradual* with monthly follow up After 2–4 severe relapses

After 3–4 mild
to moderate relapses

Also consider Weekly visits

Quarterly visits

  Gradual* with monthly CBT booster sessions

Medication visit only

 
*We defined gradual discontinuation as decreasing the medication by 25% and waiting 2 months before again decreasing the medication, depending on patient response.

Further recommendation: The experts’ replies reflect a tendency to recommend continuing medication for longer periods in patients who are not receiving CBT, probably reflecting the higher probability of relapse in patients withdrawn from medication who have not also received CBT.

Editorial Comments:

When patients are stable but still clinically symptomatic, they may be seen for medication maintenance or CBT booster sessions every 3 months, while patients in remission are seen yearly. Because, OCD is a lifetime waxing and waning condition, most OCD experts never end treatment, but leave the option open to return if OCD recurs.

Relapse prevention, including generalization training and booster sessions, especially when withdrawing medication, may increase the durability of CBT.

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Guideline 7: Minimizing Medication Side Effects
Summary: Since the overall efficacy of the different SRIs* is on average equal, tailoring the side effect profile to the patient’s needs and preferences is an important way of selecting among them. The experts’ ratings indicate that they believe that side effects differ most dramatically between the four SSRIs as a group and the tricyclic antidepressant, clomipramine (CMI), and that the SSRIs are generally better tolerated than CMI. Within the group of SSRIs, some side effects are more or less prominent with specific drugs (See Survey Question 18, p. XX).
Problematic Side Effect Drug(s) Less Likely to Cause Drug(s) More Likely to Cause

Cardiovascular

SSRIs

Clomipramine

Sedation

SSRIs

Clomipramine

Insomnia

Clomipramine

SSRIs

Anticholinergic

SSRIs

Clomipramine

Weight gain

SSRIs

Clomipramine

Sexual

SSRIs (but still common)

Clomipramine

Akathisia

Clomipramine

SSRIs

Nausea/Diarrhea

Clomipramine

SSRIs

*SRI (serotonin reuptake inhibitor) refers to the five compounds clomipramine, fluoxetine, fluvoxamine, paroxetine, and sertraline; SSRI (selective SRI) refers to all but clomipramine.

Fluoxetine, which has a much longer half-life than the other SSRIs, may cause fewer withdrawal symptoms when the medication is stopped, but side effects and the risk of drug interactions may persist for a somewhat longer period of time.

Editors’ comment: Side effects are usually dose and time dependent. More severe side effects are associated with larger doses and faster dosage increases involving a shorter time to maximum dose. Tolerance often develops over 6–8 weeks. Tolerance may be more likely to occur with some side effects (e.g., nausea) but not with other side effects (e.g., akathisia) of the SSRIs. Tolerance is less likely to occur with tricyclic side effects (e.g., postural hypotension; anticholinergic side effects).

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Guideline 8: Treatment of OCD Complicated by Comorbid Psychiatric Illness
Summary: Treatment of OCD is often complicated by the presence of other psychiatric disorders. Some comorbid disorders (e.g., tic or schizophreniform disorder) indicate the need for an additional treatment (e.g., a neuroleptic) that is augmentative for the OCD in addition to being a primary therapy for the comorbid disorder. In other cases, the treatments (e.g., stimulants for ADHD) target altogether different symptoms. The experts generally recommend parsimoniously combining treatments that are appropriate for the OCD and/or for the comorbid conditions. Therefore, in the table below, the term CBT includes cognitive-behavioral treatment for OCD as well as CBT elements appropriate for the comorbid conditions.
Comorbid disorder First line Second line
Panic disorder or social phobia CBT + SSRI

CBT alone

CBT + clomipramine

CBT + SRI + BZD*

CBT + MAOI +/- BZD

Depression CBT + SRI CBT alone

CBT + MAOI

CBT + SRI + BZD

Bipolar I or II (in remission on mood stabilizer alone) CBT + mood stabilizer

CBT + mood stabilizer + SRI

SRI + mood stabilizer
Schizophrenia SRI + neuroleptic CBT + SRI + neuroleptic
Tourette’s Syndrome CBT + SRI + conventional antipsychotic CBT + SRI + risperidone or a -2 agonist

CBT + SRI

CBT alone

Attention-Deficit/Hyperactivity Disorder CBT + SSRI + psychostimulant CBT + clomipramine + psychostimulant

CBT + SRI

CBT alone

Disruptive Behaviors SRI + CBT + family therapy

SSRI + CBT

CBT + family therapy

Clomipramine + CBT

SSRI

Clomipramine

CBT alone

*BZD = benzodiazepine

Further recommendations:

In milder depressions, the experts recommend beginning with CBT/MED or MED alone. In more severe depressions, the experts usually start with MED, although CBT/MED is also first line. In neither case do the experts recommend beginning with CBT alone.

When combining treatments, consider the impact of the comorbid condition. For example, the stage of illness (e.g., acute mania or schizophrenic psychosis) may make treatments for OCD unfeasible (CBT) or risky (an SRI).

Remember that combining medications may dramatically increase the risk for drug-drug interactions.

Editors’ recommendations

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Guideline 9: Treatment of OCD Complicated by Pregnancy or Comorbid Medical Illness
Summary: The experts recommend attempting to use CBT alone for patients with OCD who are pregnant or who also have medical complications, such as heart or renal disease, since the risk of drug therapy may outweigh the risk of the disorder in these cases. When the risk of OCD begins to rival the risk of the medical condition (e.g., a pregnant mother who will not eat because of contamination fears), then combined CBT and medication may become necessary.

(bold italics = treatment of choice)

  Pregnancy Heart Disease Renal Failure
First line CBT alone CBT alone

CBT + SSRI

CBT alone

CBT + SSRI

Second line CBT + SRI SSRI SSRI
Further recommendations:

It is important to consider the potential for drug-drug interactions when choosing an SRI.*

The increased risk of cardiovascular side effects with CMI as contrasted to the negligible risk with the SSRIs suggests that serial SSRI trials be conducted first in patients with heart disease.*

*Editors’ recommendation

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Guideline 10: Pharmacotherapy for OCD "Spectrum" Conditions
Summary: A variety of disorders share features with OCD and have been considered to be possible OCD spectrum disorders. There is, however, considerable disagreement regarding the extent to which patients with these disorders respond to treatments that are effective for OCD. Consistent with recent literature on this topic, the experts consider pharmacotherapy with an SRI to be a first line treatment only for body dysmorphic disorder and bulimia. The indications for most of these conditions must be considered highly preliminary since supporting data are limited.
  Responsiveness to SRI pharmacotherapy (listed in order of decreasing responsiveness)
First Line

Body Dysmorphic Disorder

Bulimia

Second Line

Trichotillomania

Hypochondriasis

Picking skin

Anorexia

Self-mutilation

Paraphilias

Other impulse control disorders

Gambling

Shoplifting

Editorial comments:

When the spectrum disorders listed above are comorbid with OCD, they should be treated with interventions that are appropriate for the specific disorder at the same time as treatment for OCD is also being implemented.

Disorders that are substantially aversive (e.g., tinged with negative affects) are more likely to respond to an SRI than disorders that involve substantial reward such as the paraphilias or gambling.

Just as disorders that more closely resemble OCD are more likely to respond to SRI medication, they are also more likely to respond to E/RP and CT. Disorders such as trichotillomania and skin picking usually do best with habit reversal. Impulse control disorders, such as pathological gambling, do best with support groups and contingency management.

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