Authors: Ulrich Voderholzer · Research

What Are the Latest Developments in Understanding and Treating Obsessive-Compulsive Disorder?

Recent advances in classifying, diagnosing and treating OCD and related disorders offer hope for improved care.

Source: Voderholzer, U. (2022). Obsessive-Compulsive Disorder and Obsessive-Compulsive Spectrum Disorders. Der Nervenarzt, 93, 659-660. https://doi.org/10.1007/s00115-022-01335-w

What you need to know

  • Obsessive-compulsive disorder (OCD) is more common than many realize, but often goes undiagnosed due to patients hiding symptoms.
  • New classification systems better capture OCD and related disorders, which may improve diagnosis and treatment.
  • Cognitive behavioral therapy with exposure and response prevention remains the most effective treatment for OCD.
  • Researchers are learning more about the unique brain patterns associated with OCD.
  • New clinical guidelines provide updated recommendations for diagnosing and treating OCD across age groups.

Obsessive-compulsive disorder (OCD) is a mental health condition characterized by unwanted, intrusive thoughts (obsessions) and repetitive behaviors or mental acts (compulsions) that a person feels driven to perform. While many people experience occasional obsessive thoughts or compulsive behaviors, those with OCD find that these symptoms significantly interfere with their daily lives.

OCD is more common than many people realize. A recent epidemiological study in Germany found that OCD was the fourth most common mental health disorder. However, due to feelings of shame and attempts to hide symptoms, OCD often goes undiagnosed even when people are receiving mental health treatment for other issues. This highlights the importance of healthcare providers specifically asking about OCD symptoms during initial evaluations.

For many people with OCD, symptoms first appear in childhood or adolescence. The most common age of onset is between 18-25 years old. Like anxiety disorders, OCD often follows a chronic course and can have major impacts on a person’s education, career, relationships, and quality of life if left untreated. The stress of living with OCD can also lead to other mental health issues like depression or substance use disorders.

In recent years, there have been some important changes in how OCD and related disorders are classified in diagnostic manuals. The latest version of the International Classification of Diseases (ICD-11) now has a separate chapter for “Obsessive-Compulsive or Related Disorders.” This better reflects current research and clinical understanding of these conditions.

Some key disorders now grouped with OCD include:

  • Body dysmorphic disorder (excessive concern about perceived flaws in physical appearance)
  • Hoarding disorder (difficulty discarding possessions and excessive acquiring of items)
  • Hair-pulling disorder (trichotillomania)
  • Skin-picking disorder (excoriation disorder)
  • Hypochondriasis (illness anxiety disorder)
  • Olfactory reference disorder (preoccupation with the belief that one emits a foul or offensive body odor)

This new classification system has some similarities to the DSM-5 (the diagnostic manual used in the United States), but also some key differences. For example, the ICD-11 includes hypochondriasis and tic disorders in the OCD chapter, while the DSM-5 does not.

Having a more accurate classification system that aligns with current scientific understanding may help improve diagnosis and treatment of these disorders. It may also encourage more research into these conditions.

Brain Patterns in OCD

Researchers have made progress in understanding the neurobiology of OCD - in other words, how the brains of people with OCD may function differently. Studies have found that people with OCD show some characteristic patterns of brain activity and connectivity that differ from those seen in other anxiety disorders.

Some key findings about the neurobiology of OCD include:

  • Overactivity in certain brain circuits, particularly those involving the orbitofrontal cortex, anterior cingulate cortex, and striatum
  • Differences in how certain neurotransmitters (chemical messengers in the brain) function, especially serotonin and glutamate
  • Potential involvement of the immune system in some cases of OCD

These neurobiological differences help explain why OCD is now classified separately from anxiety disorders in diagnostic manuals. They also provide potential targets for new treatments.

Researchers are also investigating the potential role of autoimmune processes in some cases of OCD. This refers to situations where the body’s immune system may mistakenly attack healthy brain cells, potentially contributing to OCD symptoms. While this area of research is still developing, it opens up possibilities for new treatment approaches in the future.

Evidence-Based Treatments for OCD

The treatment with the strongest evidence of effectiveness for OCD remains cognitive behavioral therapy (CBT) with exposure and response prevention (ERP). In this type of therapy, patients gradually confront situations that trigger their obsessions while refraining from performing compulsions. Over time, this helps reduce anxiety and break the cycle of obsessions and compulsions.

Despite its proven effectiveness, many people with OCD do not receive CBT with ERP, or do not receive it at an adequate intensity. Increasing access to this treatment remains an important goal.

For medication treatment, selective serotonin reuptake inhibitors (SSRIs) are the first-line option. These medications can help reduce OCD symptoms in many patients, though they are generally not as effective as CBT with ERP.

For patients who do not respond to initial treatments, options may include:

  • More intensive CBT
  • Trying a different SSRI or increasing the dose
  • Augmenting SSRI treatment with antipsychotic medications
  • Deep brain stimulation (in very severe, treatment-resistant cases)

Unfortunately, no major breakthroughs in OCD treatment have emerged in recent years. New medications or alternative psychotherapy approaches that are more effective than current options are not expected in the near future. Therefore, a key priority is ensuring that existing evidence-based treatments are more widely and consistently implemented in clinical practice.

New Clinical Guidelines

New clinical practice guidelines for OCD have recently been published or are soon to be released:

  • In 2021, the first evidence-based guideline for diagnosis and treatment of OCD in children and adolescents was published for German-speaking countries.
  • An updated version of the adult OCD treatment guideline is expected to be published soon.

These guidelines synthesize the latest research evidence and expert consensus to provide recommendations for clinicians. While the core treatment recommendations (CBT with ERP as first-line treatment, SSRIs as first-line medication) have not changed dramatically, the guidelines do include some new, practically relevant recommendations on topics like:

  • Appropriate intensity and delivery of psychotherapy
  • Use of internet-based and computerized treatments (e-mental health)
  • Addressing OCD symptoms that occur alongside other mental health conditions

Implementation of these evidence-based guidelines in routine clinical practice is an important goal to improve the quality of care for people with OCD.

OCD and Psychosis

Some people experience symptoms of both OCD and psychotic disorders like schizophrenia. This combination of symptoms can be particularly challenging to treat effectively.

Research in the past decade has provided some helpful insights for clinicians treating patients with both OCD and psychosis:

  • OCD symptoms are common in people with schizophrenia and other psychotic disorders, occurring in an estimated 12-30% of patients.
  • These OCD symptoms often cause significant distress and functional impairment beyond the effects of psychosis alone.
  • Standard OCD treatments like CBT with ERP can be effective for many patients with psychosis, though they may need to be adapted.
  • Certain antipsychotic medications may actually induce or worsen OCD symptoms in some patients.

Clinicians should be aware of the possibility of OCD symptoms in patients with psychotic disorders, as they may otherwise go unrecognized and untreated. Careful medication management and adapted psychotherapy approaches can help address both the psychotic and obsessive-compulsive symptoms.

Conclusions

  • OCD is more common than many people realize and new classification systems may help improve diagnosis and treatment.
  • Cognitive behavioral therapy with exposure and response prevention remains the gold-standard treatment, but is underutilized.
  • Neurobiological research is shedding light on brain differences in OCD, which may lead to new treatments in the future.
  • New clinical guidelines provide updated, evidence-based recommendations to help clinicians provide the best care for people with OCD.
  • Improving implementation of existing effective treatments in routine clinical practice is a key priority for enhancing OCD care.
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