Management and treatment of obsessive-compulsive disorder

Introduction
The earliest reports of the potential efficacy in obsessive–compulsive disorder (OCD) of pharmacotherapy with the tricyclic drug clomipramine and of behavioural forms of psychotherapy, initiated in the 1960s and 1970s and subsequently validated in a series of seminal studies in the 1980s, produced a dramatic change in the psychiatric management of this serious and previously treatment-refractory disorder. Since that time, treatments for OCD have been subject to considerable scientific scrutiny and treatment ‘standards’ have been developed and refined in succeeding evidence-based treatment guidelines [1, 2].
The disorder usually arises in childhood or early adulthood, follows a chronic course (though episodic forms do occur), and is associated with substantial psychiatric comorbidity, frequently in the form of anxiety disorders, affective disorders, and other obsessive–compulsive and related disorders. Whereas substantial improvement can be achieved in many patients following standard treatment with serotonin reuptake inhibitors (SRIs) [selective serotonin reuptake inhibitors (SSRIs), clomipramine] and cognitive behavioural therapy (CBT), for approximately 50%, the response is incomplete and new treatment paradigms are sought. Several other conventional drug treatments for depression and anxiety have been investigated and found not to be effective in OCD, though evidence has accrued that dopamine receptor antagonists may be effective for individuals with SRI-resistant OCD when prescribed as an adjunct to the SRI. In this context, a developing role for somatic treatments has also emerged, with implications for clinical service development [2].
In this chapter, we review the management and treatment of OCD, including rational options for those failing to respond to standard treatments, based, as far as possible, on randomized controlled trial (RCT) data. Where relevant, we have cited review papers of good quality to maximize efficiency.