The essential features of OCD identified in DSM-IV-TR are "recurrent obsessions or compulsions (Criterion A) that are severe enough to be time consuming (i.e., they take more than 1 hour a day) or cause marked distress or significant impairment (Criterion C)" (1, pp. 456–457). Obsessions are intrusive, persistent, unwanted thoughts, impulses, or images that give rise to marked anxiety or distress. Compulsions are physical or mental acts that the patient feels driven to perform in order to magically prevent some feared event, to undo some thought, or to reduce anxiety or distress.

Compulsive acts—also known as rituals—are carried out repetitively, excessively, and usually according to rules or in a rigid manner. Obsessions may occur spontaneously or be evoked by a feared environmental stimulus or event. Mental compulsions such as counting, praying, or reviewing actions, conversations, or lists are initiated by the patient willfully, with the aim of feeling safer or reducing anxiety or distress.

The most common obsessional themes are fears of being contaminated or spreading contamination, accidentally or purposely harming others, making a significant mistake, committing a religious offense or moral infraction, contracting a disease, and being considered homosexual or committing homosexual or pedophilic acts.

Hoarding, when a symptom of OCD, is not usually feared, though it may be regretted. Individuals with OCD may also obsess about orderliness or symmetry, lucky or unlucky numbers or colors, needing to know or remember, heterosexual acts, or bodily health. Obsessions are often accompanied by a feeling of doubt, uncertainty, or incompleteness that drives repetitive thought or action and are often colored by an inflated estimate of danger, an increased sense of responsibility, or a need for certainty or perfection.

Psychiatric management of OCD is indicated when symptoms interfere with functioning or cause significant distress. Although transient OCD is found in community surveys, OCD seen in clinical practice is usually a chronic illness with a waxing and waning course. With appropriate treatment, OCD symptoms usually improve over weeks or months and may become mild or even subside into remission over months or years. Thus, treatment planning and psychiatric management will be iterative processes adapted to the patient's current status and response to previous interventions.

Psychiatric management encompasses a broad collection of professional actions and interventions designed to benefit the patient. These actions and interventions include providing the following:

• Pharmacotherapy and psychotherapy in the appropriate setting, as indicated by patient preference and clinical judgment;
• Guidance to the patient and involved family members about educational materials that are available in published form and on the Web (see Appendix); and
• Information about local support groups (see Appendix).

Psychiatric management should be offered throughout the course of illness at an intensity consistent with the patient's needs, capacities, and desires. The components of psychiatric management across the stages of illness are described in more detail below.

As in all of medicine, the physician first attempts to establish and then to maintain a therapeutic alliance so that the patient's care is a joint endeavor. The therapeutic alliance allows the psychiatrist to obtain the information needed to plan effective treatment. The alliance allows the patient to trust the physician and helps motivate adherence to collaboratively planned treatments. It is important to tailor one's communication style to the patient's needs and capacities, along continua from detailed to general, from biologically to psychosocially framed, and from warm to neutral. Explaining symptoms in understandable terms is both encouraging and comforting to patients. The excessive doubting that is characteristic of OCD may require special approaches to building the alliance. For example, the clinician may need to allow the patient more time to consider treatment decisions and may need to repeat explanations (a limited number of times) and at several visits. Increased attention to excessive worry about medication side effects, perfectionism, or checking behaviors may be needed. Treatment of patients with OCD has a potential for transference and/or countertransference issues that may disrupt adherence and the therapeutic alliance. In building the alliance, the psychiatrist should also consider the patient's feelings and actions toward him or her, as well as why the patient has come to him or her specifically, and why at this point in time. What does the patient want and expect? How are these desires and expectations affected by the patient's cultural background, religious background, beliefs about the illness (its cause, effects, and mechanisms), and experience with past treatments?

The psychiatrist should assess the patient for symptoms of OCD, guided by the diagnostic criteria of DSM-IV-TR (Table 1).

OCD is likely to be underdiagnosed unless specific screening occurs (2). Screening questions might include some of the following: Do you have unpleasant thoughts you can't get rid of? Do you worry that you might impulsively harm someone? Do you have to count things, or wash your hands, or check things over and over? Do you worry a lot about whether you performed religious rituals correctly or have been immoral? Do you have troubling thoughts about sexual matters? Do you need things arranged symmetrically or in a very exact order? Do you have trouble discarding things, so that your house is quite cluttered? Do these worries and behaviors interfere with your functioning at work, with your family, or in social activities?

As part of the assessment, the psychiatrist must differentiate obsessions, compulsions, and rituals from similar symptoms found in other disorders. Unlike obsessions, depressive ruminations are experienced as consistent with one's self-image or values. They often focus on past events but, like obsessions, may concern possible current or future negative events or anticipated failures. The subject matter of depressive ruminations usually concerns self-criticism, failures, guilt, regret, or pessimism regarding the future. Depressive ruminations do not elicit compulsive rituals. The worries of generalized anxiety disorder focus on real life problems and usually do not lead to compulsive rituals, although, as in OCD, the sufferer may try to convince himself or herself that the fear is groundless or may check on the safety of loved ones. Generalized anxiety disorder may also present as a vague but troubling feeling of foreboding, whereas the obsessions of OCD always have clear content. The intrusive thoughts and images of posttraumatic stress disorder are replays of actual events, not anticipations of future events. Obsessions held with delusional conviction can be distinguished from schizophrenic and manic delusions by the absence of other signs and symptoms of these disorders. Moreover, delusional obsessions will have typical OCD content rather than content related to persecution, grandiosity, passivity experiences, or ideas of reference.

OCD can be differentiated from hypochondriasis by noting that the hypochondriacal fear or belief regarding serious disease arises from misinterpretation of ordinary bodily signs and symptoms. In OCD such fears arise from external stimuli—for example, a patient fearing he has contracted AIDS because he was served by a waiter wearing a bandage, possibly exposing him to blood. In addition, an individual with hypochondriasis does not have insight into the irrationality of his or her fears and behaviors, whereas some insight is usually present in OCD. In body dysmorphic disorder, the recurrent and intrusive preoccupations are limited to the fear or belief that one has a disturbing physical defect, when in reality the defect is nonexistent or slight. In anorexia nervosa and bulimia nervosa, the intrusive thoughts and irrational behaviors center on weight and its effects on self-evaluation. In contrast to the thoughts and urges of paraphilias, OCD-related sexual obsessions or images (e.g., fears of homosexuality, images of having sex with a child) lead to avoidance behaviors, are morally abhorrent, and are resisted. Similarly, in OCD, obsessions regarding a sexual partner are experienced as alien to the self and are not accompanied by stalking behavior.

Differentiating urges to harm an infant that occur as postpartum symptoms of OCD from superficially similar symptoms of postpartum depression is critical. The OCD urges are not accompanied by depressed mood and are experienced as inconsistent with one's self, are resisted, or induce efforts to neutralize the urges through other behaviors. Although OCD rituals aimed at avoiding harming the infant may interfere with attachment or normal maternal behaviors and may require treatment, there is little risk of direct harm to the infant. In contrast, the impulses or ideas that arise in postpartum depression may be experienced as justified, may not be strongly resisted, and emerge from depressed mood and other signs and symptoms of major depression. In postpartum depression, taking steps to protect the infant may be necessary (3).

Differentiating compulsions from the complex vocal or motor tics sometimes seen in Tourette's disorder can be difficult. Tics, unlike compulsions, are neither preceded by thoughts nor aimed at relieving anxiety or preventing or undoing an external, undesired event (4). DSM-IV-TR (1, p. 108) defines a tic as "a sudden, rapid, recurrent, nonrhythmic, [and] stereotyped motor movement or vocalization." Tics are often preceded by premonitory sensations such as muscular tension and may involve repeating an action until an unpleasant, localized, physical tension or a sense of incompleteness is relieved (5, 6). Complex motor tics can take the form of arranging, ordering, touching, or making objects symmetrical (5). Repeating an action until "it feels right" (e.g., repeatedly closing a door until the right sound or sensation of closure is achieved) may be a complex tic or a compulsion, or reflect elements of both. Complex tics may be more likely in individuals with a personal or family history of motor or phonic tics; individuals with a history of hypersensitivity to sensations associated with scratchy fabrics, the touch of clothing labels, or to uneven shoelaces or socks; and individuals with co-occurring diagnoses of attention-deficit disorder or learning disorder (5).

Differentiating OCD from obsessive-compulsive personality disorder (OCPD) may also be difficult. In addition, OCD and OCPD may co-occur (7, 8). In fact, the greater prevalence of OCPD in first-degree relatives of OCD patients than of control subjects suggests the possibility of a genetic relationship between the two disorders (9). Although hoarding, scrupulosity, perfectionism, and preoccupation with rules, order, and lists may occur in both disorders, a number of factors may help distinguish OCD and OCPD. For example, in OCD, anxiety about feared consequences of forgoing compulsive behaviors is prominent, whereas in OCPD, the focus is on "doing things my way, the right way" (i.e., on the need for control). In OCD, perfectionism and preoccupation with rules is usually focal and limited to feared events; in OCPD these traits globally color the individual's attitudes and behavior. Fundamentally, the person with OCPD experiences the concerns and behaviors as part of the normal self and does not resist them but, to the contrary, considers them valued attributes. Despite the fact that OCPD traits often irritate companions or associates, the individual with OCPD has no desire to change these traits.

Use of the Y-BOCS Symptom Checklist (10), which allows the recording of current and past symptoms, or the 18-item Obsessive-Compulsive Inventory (11) may be helpful. These scales may help document both the variety and the clustering of the patient's symptoms. The Y-BOCS Symptom Checklist lists 40 obsessions, 15 behavioral compulsions, 5 mental compulsions, and 9 miscellaneous compulsions.

The psychiatrist should consider using a rating scale such as the 10-item Y-BOCS scale (10, 12) to record baseline severity since this provides a way to measure response to treatment. The Y-BOCS rating can also be compared with the patient's and the family's impressions of severity. The Y-BOCS scale evaluates obsessions and compulsions separately and, for each of these two symptom dimensions, measures the time spent and the degrees of distress, interference with functioning, resistance to the symptoms, and success in resisting. The Y-BOCS may be found at the following Web sites: http://healthnet.umassmed.edu/mhealth/YBOCRatingScale.pdf or www.peaceofmind.com/YBOCS.pdf. The Obsessive-Compulsive Inventory 11, a self-rated scale, may also be considered. A simpler measure is a visual analog scale in the form of a thermometer with the bottom labeled "no OCD symptoms" and the top labeled "incapacitating OCD symptoms." Encouraging the patient to use a self-rated scale will help him or her become a better self-observer and may aid in identifying factors that aggravate or ameliorate symptoms. If a rating scale is not used, the psychiatrist should document the patient's estimate of the number of hours per day spent in obsessing and in performing compulsive behaviors, and the degree of effort applied to trying to escape the obsessions (by distraction or accepting passive awareness, not by counter-argument) and to resisting the behaviors. Recording items or situations that the patient actively avoids because of OCD also provides a useful baseline against which change can be measured.

The psychiatrist should consider recording co-occurring conditions and their effects on the patient's functioning. For monitoring depression, which is commonly present and may aggravate OCD symptoms, the clinician might also consider self-rated scales. These can be as simple as visual analog scales or scales measuring symptoms of interest using a "0 to 10" severity rating. Formal self-rated scales that may be useful include the Patient Health Questionnaire (PHQ-9) (13, 14), Beck Depression Inventory–II (BDI-II) (15), Zung Depression Scale (16), and the patient versions of the Inventory of Depressive Symptomatology (IDS) or the shorter 16-item Quick-IDS (QIDS) (17).

OCD symptoms may seriously impair self-care, interpersonal relationships, vocational ability, marital and family relationships, child-rearing capacities, and use of leisure time. Thus, it may be useful to include a rating of disability—for example, the self-rated, three-item Sheehan Disability Scale (SDS) (18, 19), which records disability in the domains of work, family, and social relationships. Some patients, however, may not accurately recognize the degree of their disability until after successful treatment. For most patients, OCD seriously impairs quality of life (20). A rating of the patient's quality of life, using a scale such as the Quality of Life Enjoyment and Satisfaction Questionnaire (Q-LES-Q) (21) or the more detailed World Health Organization Quality of Life Survey (WHOQOL-100) (22), can provide a broader measure of disease impact and of the results of treatment.

In individuals with OCD, as with all psychiatric patients, assessing the risk for suicide and self-injurious behavior, as well as the risk for harm to others, is crucial. Collateral information from family members or others can be helpful in assessing such risks. When these risks are present, it is important to arrange treatments that will enhance the safety of the patient and others. Although accurate prediction of dangerousness to self or others is not possible in a given individual at a given point in time, many factors have been associated with increased risk in groups of individuals and are, therefore, important to determine.

In assessing and estimating the patient's potential for self-injury or suicide, a number of factors should be taken into consideration. Individuals with OCD alone or with a lifetime history of any co-occurring disorder have a higher suicide attempt rate than do individuals in the general population (23, 24). In rare instances, self-injury can also be directly or indirectly associated with compulsive behaviors. Because increased risk of suicide attempts and suicide has been associated with specific psychiatric symptoms and disorders, the psychiatrist will also want to assess for hopelessness, agitation, psychosis, anxiety, or panic attacks, as well as the presence of mood or substance use disorders, schizophrenia, borderline personality disorder, or other disorders associated with heightened risk. Risk for suicide and for suicide attempts is also increased by a history of previous suicide attempts, including aborted attempts. Thus, if a patient has this history, the nature of those attempts and their potential lethality should be determined. It is also essential to determine whether the patient has had thoughts of death, self-harm, or suicide and the degree to which the patient intends to act on any such thoughts. If a patient has considered suicide, the extent of planning or preparation and the relative lethality of any planned suicide methods should be considered. The availability of the means for suicide, including firearms, should also be explored. Also relevant is any family history of suicide, recent exposure to suicide or suicide attempts by others, real or perceived lack of social supports, and recent losses, including impairments resulting from medical conditions. Cultural, religious, and ethnic factors can also modify suicide risk. Further information is available in APA's Practice Guideline for the Assessment and Treatment of Patients With Suicidal Behaviors (25).

The psychiatrist should also evaluate the patient's potential for harming others. This evaluation will include inquiring about whether the patient has had thoughts or urges to harm others and when these thoughts and urges have led to aggression toward others in the past. Such questioning should be sensitive to the fact that patients may fear thoughts, impulses, urges, or images related to harming others or to sexually abusing a child, even though these are experienced as alien to the self and true desires. Although acting on such impulses or thoughts has not been reported in OCD, the patient may fear loss of control and engage in extensive avoidance rituals. OCD symptoms can occasionally be associated with direct or indirect potential for harm to others. For example, OCD symptoms can interfere with parenting, leading the patient, for example, to avoid or neglect his or her children, to "clean" them inappropriately with bleach or other harmful substances, or to insist on inappropriate neatness. In such cases, the psychiatrist may have to work with the unaffected parent or social agencies to mitigate the effects of OCD symptoms on the patient's children. On rare occasions, individuals with OCD have become distressed and aggressive when others interfered with the performance of compulsive rituals. Finally, in assessing the potential for harm to others, the psychiatrist should consider the possibility that aggressive behavior can be associated with co-occurring disorders such as substance use, impulse control, and personality disorders.

In completing the psychiatric assessment, the psychiatrist will usually include the elements of the adult general psychiatric evaluation as described in APA's Practice Guideline for the Psychiatric Evaluation of Adults, 2nd edition (26). Facets of the assessment that are of particular relevance to individuals with OCD are highlighted in Table 2.

At all phases of subsequent assessment, the psychiatrist should be alert for signs, symptoms, and history suggesting the possibility of co-occurring conditions. Particular attention should be given to mood disorders, since depressive disorders (27, 28) and bipolar disorder (29, 30) are more common in patients with OCD than in the general population. Careful exploration for family history for bipolar disorder is also important in view of the risk of precipitating hypomania or mania with anti-OCD medications.

Other anxiety disorders (panic disorder, generalized anxiety disorder, social phobia) are common in OCD patients (24, 31, 32) and may complicate treatment planning as described later in this guideline (Sections III.A.5 and III.A.6).

Tics are common in individuals with OCD. Conversely, OCD has been diagnosed in 28%–62% of individuals with Tourette's disorder (33). In patients with co-occurring OCD and Tourette's disorder, use of a rating scale such as the Yale Global Tic Severity Scale (YGTSS) (34) may be helpful. This scale provides anchor points for rating the number, frequency, intensity, complexity, interference, and impairment associated with motor and phonic tics.

Anorexia nervosa and bulimia nervosa may be more common in men and women with OCD than in the general population (24, 35). The prevalence of OCD appears to be elevated in patients with either anorexia nervosa or bulimia nervosa (36–38).

Evaluation should also include screening for alcohol or substance abuse or dependence. In some (31, 39) but not all studies (24), an increased risk of alcohol abuse and dependence has been noted. In addition, the presence of a substance use disorder will influence treatment planning (Section III.A.8).

Other disorders with elevated prevalence in OCD include certain impulse-control disorders, such as skin picking and trichotillomania. In children and adolescents with OCD, the prevalence of attention-deficit/hyperactivity disorder (ADHD) and of oppositional defiant disorder (ODD) is elevated (40). Since structured interview instruments lack modules for developmental disorders, the absence of prevalence data regarding ADHD in adult OCD patients may represent an error of omission. Given that about half of early-onset OCD patients with co-occurring ADHD will continue to have clinically significant ADHD symptoms in adulthood, assessing adult OCD patients for ADHD may be helpful. Assessment instruments include the Conners Adult ADHD Rating Scales (CAARS) (41) and the Wender Utah Rating Scale (WURS) (42), among others (e.g., see reference 43).

In assessing the past psychiatric history, a chronological history should be obtained of past psychiatric illnesses, including substance use disorders and treatment, and of hospitalizations. More specifically, the psychiatrist should attempt to document the longitudinal course of the patient's symptoms and their relationship to aggravating or ameliorating factors, including treatment. Details of the patient's past medication trials should be obtained to ensure that drug doses and trial durations have been adequate, to understand side effects and other factors influencing adherence, and to evaluate the degree of response. The nature, extent, and response to all trials of psychotherapy, including cognitive-behavioral therapy, should also be documented. When past medical records are accessible, these can be helpful in augmenting the treatment history provided by the patient. Past histories of psychiatric symptoms or co-occurring disorders will influence treatment planning and should also be elicited, such as alcohol or substance abuse or dependence (Section III.A.8), prominent fluctuations in mood (Section III.A.4), or panic attacks (Section III.A.5).

The general medical history should document any current general medical conditions, recent or relevant hospitalizations, and any history of head trauma, loss of consciousness, or seizures. The psychiatrist should also consider whether the OCD is a rare manifestation of a general medical condition (e.g., brain trauma, stimulant abuse, carbon monoxide poisoning, parkinsonism). Evaluation of such potential etiologies does not require screening with imaging studies (44), as these disorders are usually obvious from history and examination (33). Current medications and doses should be reviewed to determine potential pharmacokinetic and pharmacodynamic interactions with psychotropic drugs. Herbal or "natural" remedies must also be inquired about, along with hormonal therapies, vitamins, other over-the-counter medications, and other alternative or complementary treatments. Allergies and sensitivities to medications, including the nature of the patient's reaction, should be recorded. On careful exploration, reactions the patient describes as "allergies" will sometimes turn out to be unpleasant but manageable side effects. In performing the review of systems, the psychiatrist should record the presence and severity of somatic or psychological symptoms that could be confused with medication side effects.

In assessing the patient's developmental, psychosocial, and sociocultural history, the psychiatrist should review the stages of the patient's life, with attention to developmental transitions in childhood and adulthood and the patient's capacity to achieve stable and gratifying familial and social relationships. A sexual history will identify the nature of the patient's sexual relationships, including impulsive or high-risk sexual behaviors. It will also provide baseline information on patient concerns or sexual dysfunctions from which to judge potential side effects of psychotropic medications. An educational and occupational history (including military history) will help in evaluating the extent to which OCD symptoms have interfered with academic or vocational achievement. The psychiatrist should also assess the patient's primary support group and sociocultural supports (e.g., spouse/partner, children, other family or friends, community or faith-based organizations), as well as their possible role in facilitating treatment and in maintaining or exacerbating symptoms. Assessing the family's understanding of the patient's illness and of potential treatments is similarly important for treatment planning. Other specific information that may be relevant to the assessment of psychosocial stressors includes living arrangements; sources of income, insurance, or prescription coverage; access to transportation and health care; and past or current involvement with social agencies or the justice system.

In assessing the family history, the presence of OCD among family members is of interest for how it may affect the patient's expectations about the illness and its treatment. Although OCD is associated with genetic risk, the clinician should not expect concordance of specific OCD symptoms among siblings or across generations, with the possible exception of hoarding and ordering symptoms (45). A family history of other psychiatric disorders (e.g., major depression, bipolar disorder, panic disorder, generalized anxiety disorder, social phobia, substance use disorders) is also relevant, since it contributes to an increased risk of co-occurring disorders that may influence treatment choice. A family history of tics or Tourette's disorder suggests a need for careful exploration of these disorders in the patient, as their presence could influence treatment response.

The mental status examination involves the systematic collection and recording of data related to the patient's signs and symptoms of illness during the interview. The examination includes consideration of the patient's appearance and general behavior, including the patient's degree of cooperativeness. Psychomotor abnormalities (e.g., tics, mannerisms, rituals, abnormal involuntary movements) are also noted. The patient's mood should be assessed, since the presence of mood symptoms may alter cooperation with treatment or suggest a co-occurring mood disorder. In addition to specific obsessions and compulsions, other abnormalities in thought content (e.g., phobias, overvalued ideas, ideas of reference, delusions, suicidal or homicidal ideas) or thought process (e.g., circumstantiality) may be present. Perceptual disturbances (e.g., illusions, hallucinations) or disturbances in sensorium or cognition are less commonly observed and suggest the presence of a co-occurring disorder. Assessing the patient's degree of insight into the irrationality of the OCD symptoms and motivation and expectations of treatment is essential to treatment planning. Also crucial is the degree to which OCD is affecting judgment, as measured by OCD's effects on the patient's management of the ordinary decisions of daily life.

Marked clinical improvement, recovery, and full remission, if they occur, do not occur rapidly (46). Thus, persistent goals of treatment include decreasing symptom frequency and severity, improving the patient's functioning, and helping the patient to improve his or her quality of life (in family, social, work/school, home, parental, and leisure domains). Treatment goals also include enhancing the patient's ability to cooperate with care despite the frightening cognitions that are typical of OCD; anticipating stressors likely to exacerbate the condition and helping the patient develop coping strategies; providing assistance and support in dealing with stresses; monitoring the patient's psychiatric status and intervening as indicated; minimizing any adverse effects of treatment (e.g., medication side effects); and educating the patient and family regarding the disorder and its treatment. Reasonable treatment outcome targets include less than 1 hour per day spent obsessing and performing compulsive behaviors; no more than mild OCD-related anxiety; an ability to live with uncertainty; and little or no interference of OCD with the tasks of ordinary living. However, some patients will be unable to reach these targets, despite the psychiatrist's and the patient's best efforts.

In general, patients should be cared for in the least restrictive setting that is likely to be safe and to allow for effective treatment. Consequently, the appropriate treatment setting will depend on a number of factors:

1. Hospital treatment (47) may be indicated by suicide risk, an inability to provide adequate self-care, danger to others, need for constant supervision or support, an inability to tolerate outpatient medication trials because of side effects, need for intensive CBT, the presence of medical conditions that necessitate hospital observation while medications are initiated, or by co-occurring conditions that themselves require hospital treatment, such as severe or suicidal depression, schizophrenia, or mania.
2. Residential treatment (48) may be indicated in individuals with severe treatment-resistant OCD, who require multidisciplinary treatment in a highly structured setting that permits intensive individual and group CBT as well as psychopharmacologic management with close monitoring of treatment adherence over a period of several months.
3. Partial hospitalization (49) may be indicated by a need for daily CBT and monitoring of behavior or medications or a supportive milieu with other adjunctive psychosocial interventions, or to stabilize and increase the gains made during a period of full hospitalization. Goals of treatment include restoring the patient's ability to function in daily life without intensive monitoring; reduction of symptoms to a level consistent with outpatient treatment; prevention of relapse; and maintenance and improvement of social functioning.
4. Home-based treatment may be necessary for patients with hoarding or, initially, for those with contamination fears or other symptoms so impairing that they cannot come to the office or clinic. Home-based treatment may also be indicated for individuals who experience symptoms primarily or exclusively at home.
5. Outpatient treatment is usually sufficient for the treatment of OCD, but the intensity may vary from daily psychotherapy, such as intensive CBT, to treatment less than once a week (after achieving substantial symptom reduction and stabilization).

Factors influencing adherence can be thought of as related to the illness, the patient, the physician, the patient-physician relationship, the treatment, and the social or environmental milieu (50). The fears, doubting, and need for certainty that are characteristic of OCD can influence the patient's willingness and ability to cooperate and can challenge the physician's patience. Patients may, for example, obsess about possible medication side effects and, as a result, refuse pharmacotherapy. Cognitive and motivational effects of co-occurring conditions such as major depression must also be taken into account. Thus, it is useful to determine what the treatment will require of the patient and the way in which these requirements match his or her skills, resources, coping methods, priorities, and goals. Providing the patient and family with education (see Appendix) can be beneficial, because the patient's beliefs about the nature of the illness and its treatments will influence adherence. For example, it is important to inform patients about the delay between starting medication and experiencing substantial symptom relief, and the need for extended periods of medication taking (51).

Medication side effects can influence adherence. The patient's culture, however, may limit his or her willingness to report them (e.g., sexual side effects) or how discomfiting they are. Since effective medications differ both in side-effect profiles and in their adverse effects on a given patient, the psychiatrist has many options for responding to the patient's concerns and preferences. Informing the patient about any likely side effects, responding quickly to side effect concerns, and scheduling follow-up appointments soon after starting or changing medications will enhance adherence.

In describing CBT, the clinician should note that it involves confronting feared thoughts and situations, but at a tolerable rate. The therapist is a supportive coach, not a disciplinarian, and encourages behavior change and praises successes while validating the difficulty of confronting the OCD symptoms.

As with all psychotherapies, how the patient thinks, feels, and acts toward the clinician can decrease cooperation with CBT, the only psychotherapy with documented efficacy for OCD. For example, patients may seek excessive reassurance or have difficulty committing to treatment options. These reactions can often be dealt with in the course of CBT. At other times, improving the patient's degree of cooperation may be best accomplished with another form of psychotherapy. Motivational interviewing (52) and other psychosocial interventions designed to enhance readiness for change may help to improve a patient's motivation for treatment. Clinician-related issues in the therapeutic alliance may also interfere with adherence and therapeutic success. Use of consultation can sometimes be helpful in resolving such impediments.

The psychiatrist should also consider the role of the patient's family and social support system in treatment adherence. Family members may be important allies in the treatment efforts (53). By contrast, family members may provide repeated inappropriate reassurance in efforts to reduce the patient's anxiety or inappropriately offer to do the patient's checking rituals so the patient can get more rest. The family or significant others may not understand that OCD is an illness that gives rise to the patient's compulsive behaviors. They may accuse the patient of being weak or "crazy" or may react to symptomatic behavior with inappropriate anger. They may also be adversely affected by rituals, such as excessive cleaning, or by the patient's insistence on avoiding "contaminated" places. Family therapy may be indicated to deal with hostility, dependency, or other family system issues. When a patient with OCD refuses or prematurely discontinues treatment, family members and others negatively affected by the OCD may benefit from therapy. Under these conditions, the goals of therapy may be to reduce the OCD's impact on the rest of the family and to teach family members how to support recovery from OCD.

Finally, practical issues such as treatment cost, insurance coverage, and transportation may need to be addressed. Pharmaceutical companies may provide free medications for patients with severe financial limitations, with the exact criteria differing from company to company. Information on patient assistance programs is available from the pharmaceutical company Web sites, from the Web site of the Partnership for Prescription Assistance (www.helpingpatients.org), and from Rx Assist (www.rxassist.org).

Patients often have little knowledge of the nature, biology, course, and treatment of their disorders. Those with childhood onset of OCD may confuse symptoms with aspects of their innate selves. All patients with OCD should be provided with information and access to educational materials explaining the nature of the disorder and the range of available treatments. Education will help destigmatize the illness and allow the patient to make more fully informed decisions about treatments. Education may also increase the patient's motivation and ability to cooperate in care. When appropriate, education should also be offered to involved family members. The appendix to this guideline contains lists of self-help books for patients with OCD and co-occurring OCD spectrum disorders (see also references 33, 54, 55), patient advocacy group Web sites that provide scientifically reliable information, Web sites that provide information on the use of medications in pregnancy and during breastfeeding, and scientifically reliable, broader mental health Web sites. All OCD patients should be made aware of the Obsessive Compulsive Foundation (www.ocfoundation.org), which provides both educational materials and access to support groups.

The psychiatrist should coordinate the patient's care with physicians treating co-occurring medical conditions, with other clinicians, and with social agencies such as schools and vocational rehabilitation programs. For patients whose OCD symptoms or medications impair dental health, coordination with the patient's dentist will also be useful.

OCD-related functional impairments may involve family, social, academic, or occupational roles or financial problems. Consequently, under some circumstances, the psychiatrist may need to provide government agencies, schools, employers, and others with written documentation on the patient's behalf. For example, the psychiatrist may have to write to the federal Internal Revenue Service and state tax authorities to explain that a patient's hoarding or procrastination has prevented timely filing of income tax returns. A letter regarding special provisions for participation in or excuse from jury duty may also be appropriate. Students may need letters explaining the need for special dormitory living situations or academic accommodations. Employers may need help in understanding what accommodations are appropriate in light of the Americans With Disabilities Act (56), and referral to a state vocational rehabilitation agency or an occupational therapist may be indicated. For OCD of disabling severity, the psychiatrist must be willing to write to government agencies that control access to disability income, publicly financed health care, or government-supported housing.

OCD patients who are parents of young children may want advice regarding the genetic risk of OCD. The clinician may wish to refer these parents to a genetic counselor, but should be aware of the available data (Section IV.D). The psychiatrist should help patients concerned about the possibility of OCD in their children find clinicians who can conduct an appropriate evaluation. (Educational materials for parents of children with OCD are included in the Appendix.)

CBT and SRIs are recommended on the basis of clinical trial results as safe and effective first-line treatments for OCD. SRIs include clomipramine and all of the SSRIs. Whether to recommend a form of CBT, an SRI, or combined treatment will depend on a number of factors. These include the nature and severity of the patient's symptoms, the nature of any co-occurring psychiatric and medical conditions and their treatments, the availability of CBT, and the patient's past treatment history, current medications, and preferences. Because most treatment studies have been of 3–4 months' duration, only limited data are available to guide long-term treatment decisions (Section II.C).

The evidence base for the form of CBT that relies primarily on behavioral techniques, such as ERP (57), is the strongest (58–60). Data also support the use of CBT that focuses on cognitive techniques aimed at identifying, challenging, and modifying dysfunctional beliefs (61–64) if these techniques are combined with behavioral experiments. However, some data suggest, and many clinical experts believe, that the most effective form of CBT for OCD integrates exposure, response prevention (behavior that results in not performing rituals), discussion of feared consequences and dysfunctional beliefs, and relapse prevention. There are few data from controlled trials to support cognitive therapy without ERP or behavioral experiments.

CBT alone, consisting of ERP, is recommended as initial treatment for a patient who is not too depressed, anxious, or severely ill to cooperate with this treatment modality, or who prefers not to take medications. The patient must be willing to do the work that CBT requires (e.g., regular behavioral homework).

An SRI alone is recommended for a patient who has previously responded well to a given drug or prefers treatment with an SRI alone. Starting with an SRI alone may enhance cooperation with treatment by diminishing symptom severity. Thus, an SRI alone may also be considered in patients who have severe OCD or are not otherwise able to cooperate with the demands of CBT. An SRI alone may also be necessary if CBT is not accessible or available.

The available data suggest that combining an SRI and CBT consisting of ERP is more effective than monotherapy in some patients but is not necessary for all (65). Combined treatment should be considered for patients with an unsatisfactory response to monotherapy, for those with co-occurring psychiatric conditions for which SRIs are effective, and for those who wish to limit the duration of treatment with medication. In the latter instance, uncontrolled follow-up studies suggest that CBT consisting of ERP may delay or mitigate relapse when SRI treatment is discontinued (66–68). Combined treatment may also be considered in patients with severe OCD, since the medication may diminish symptom severity sufficiently to allow the patient to engage in CBT.

Clomipramine, fluoxetine, fluvoxamine, paroxetine, and sertraline, which are approved by the FDA for treatment of OCD, are recommended pharmacological agents. Although meta-analyses (59, 69, 70) of placebo-controlled trials suggest greater efficacy for clomipramine than for fluoxetine, fluvoxamine, and sertraline, the results of head-to-head trials comparing clomipramine and SSRIs directly do not support this impression (Section V.A.1). Because the SSRIs have a less troublesome side-effect profile than clomipramine (see Section II.B.2.b), an SSRI is preferred for a first medication trial. Although all SSRIs (including citalopram and escitalopram) appear to be equally effective, individual patients may respond well to one and not to another. The reasons for this patient-specific response are unknown, and no demographic or clinical variables are sufficiently accurate predictors of treatment outcome to permit their use in selecting medications (71).

In choosing among the SSRIs, the psychiatrist should consider the safety and acceptability of particular side effects for the patient, including any applicable FDA warnings, potential drug interactions, past treatment response, and the presence of co-occurring general medical conditions. For example, paroxetine, the SSRI most associated with weight gain (72) and the most anticholinergic SSRI, would not be the first choice for patients with obesity, diabetes mellitus, constipation, or urinary hesitancy.

Another factor in choosing among medications is the degree to which they alter metabolism through the hepatic cytochrome P450 enzyme system or uridine 5'-diphosphate glucuronosyltransferases (UGTs), act at the P-glycoprotein transporter, or displace drugs tightly bound to plasma proteins (e.g., see references 73–76). Many interactions, however, reflect only in vitro data, and their clinical importance is not established. Citalopram, escitalopram, and sertraline (along with venlafaxine and mirtazapine) have few or no important known drug interactions. Web sites providing data on potential drug interactions include http://medicine.iupui.edu/flockhart and http://mhc.com/Cytochromes. For up-to-date clinical reports of interactions between specific SRIs and other medications, psychiatrists can consult the federal National Library of Medicine database at http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?DB=pubmed, which is also accessible by entering the term "pubmed" in a search engine. Since there are very few serious risks associated with treatment with SSRIs (e.g., the risk of serotonin syndrome from adding an SSRI to an MAOI, tramadol, meperidine, or dextromethorphan [77, 78]), the psychiatrist will much more often have to consider the relative potential for specific SSRIs to interact with the patient's other medications, particularly given the higher doses of SSRIs that are often used in treating OCD.

Although no definitive data are available, the response of first-degree relatives to particular medications may be predictive of the patient's response because of genetic similarity. This is a subject, however, for future research.

The need to educate the patient about any medication recommended has been emphasized earlier. Table 3 displays suggested starting doses, known effective doses, maximum recommended doses, and maximum doses occasionally prescribed for each SRI. For most patients, the starting dose is that recommended by the manufacturer.

For patients who are worried about side effects, the medication can be started at half the listed dose or less, since many SSRIs (e.g., citalopram, escitalopram, fluoxetine, paroxetine, and sertraline) are available in liquid form or in pills that can be split. Lower initial medication starting doses and more gradual dose titration may also be needed in patients with co-occurring anxiety disorders, who may experience a transient worsening of anxiety symptoms. Experience with pharmacotherapy in the elderly indicates that lower starting doses of medication and a more gradual approach to dose increase are often advisable. Most patients will not experience substantial improvement until 4–6 weeks after starting medication, and some who will ultimately respond will experience little improvement for as many as 10–12 weeks. Available trial data suggest that higher SSRI doses produce a somewhat higher response rate and somewhat greater magnitude of symptom relief (79–82). Some patients, such as those who have had little response to previous treatments and are tolerating the medication well, may benefit from even higher doses than those shown in the last column of Table 3. In these instances, the patient should be closely monitored for side effects, including the serotonin syndrome. Moreover, patients who have not responded to a known effective dose after 10–12 weeks may respond at higher doses (83, 84). For this reason, some clinicians prefer to titrate doses more rapidly (in weekly increments to the maximum recommended dose if this is comfortably tolerated), rather than waiting for 1–2 months before each dose increment to evaluate results.

No evidence suggests that OCD treatment outcome is related to plasma levels of clomipramine (85), fluoxetine (86), fluvoxamine (87), or sertraline (82). However, these studies were not designed to identify whether rapid or ultra-rapid metabolizers of these medications were more likely to be nonresponders.

Unlike the SSRIs, clomipramine also blocks norepinephrine reuptake, muscarinic cholinergic receptors, H₁ histamine receptors, and ₁-adrenergic receptors, as well as sodium channels in the heart and brain. Thus, clomipramine is more likely to induce anticholinergic effects such as tachycardia, dry mouth, constipation, and blurred vision, although these typically diminish over time. Clomipramine is also more likely to induce delayed urination or, uncommonly, urinary retention. Histaminic blockade is associated with weight gain and sedation. Adrenergic blockade may lead to orthostatic hypotension and postural dizziness. Sodium channel blockade can induce cardiac arrhythmias or seizures (estimated to occur in 0.7% of patients treated with clomipramine at a dose of up to 300 mg/day for as many as 6 years [88]). In view of clomipramine's less favorable side-effect profile, expert opinion favors one or more SSRI trials before trying clomipramine (89). Starting clomipramine at a dose of 25 mg/day or less will increase its early tolerability (90).

The most common side effects of the SSRIs include gastrointestinal distress (especially in the first weeks of treatment), agitation, insomnia or somnolence, increased tendency to sweat, and sexual side effects, including diminished libido and difficulty with erection and orgasm. A first step in managing any side effect is to consider whether lowering the drug dose may alleviate the side effect without loss of therapeutic effect. When this is not possible, specific interventions may be considered. Gastrointestinal distress can be minimized by starting with low doses; if mild queasiness or nausea occurs, it will usually disappear within 1–2 weeks at a constant dose. Insomnia may respond to the patient's taking the medication in the morning or to standard sleep hygiene measures, or may require addition of a sleep-promoting agent. Fatigue or sleepiness may respond to the addition of modest doses of modafinil (91). Cases of successful treatment of sweating have been reported with low doses of anticholinergic agents such as benztropine (92, 93), and with clonidine (94), cyproheptadine (95), and mirtazapine (96).

Few controlled trials have been published regarding the management of sexual side effects, which may affect one-third or more of patients (97). Management approaches include reducing the dose to the minimal effective dose; waiting for the symptom to remit (which clinical impression suggests may occur within 2 months in about 10% of patients); trying a once-weekly, one-day "drug holiday" before engaging in sexual activity; switching to another SSRI (which may relieve the sexual dysfunction but not control the patient's OCD); or adding a counteracting pharmacologic agent. The drug holiday approach may alleviate difficulties with erection or orgasm but not with libido. It is not effective for fluoxetine because of its long half-life (98) and may induce withdrawal symptoms if attempted with paroxetine or venlafaxine. Taking drug holidays more than once weekly risks a return of OCD symptoms. Case series and primarily uncontrolled studies report modest success in restoring libido, erection, and orgasm by addition of amantadine, bupropion, buspirone, yohimbine, Ginkgo biloba extract (99), ropinirole (100), or stimulants such as methylphenidate or dextroamphetamine. Adding bupropion has the best evidence base (101), but even this literature is mixed (102). Case series and uncontrolled studies report modest success in restoring erection or orgasm, but not libido, with cyproheptadine or mirtazapine (99). Controlled trials support the use of sildenafil, tadalafil, and vardenafil (103, 104) to restore erection and, in men (105) and women (106), to restore orgasmic ability.

Primarily on the basis of data in children and adolescents (Section III.B.4), concerns have been raised about the potential for increases in self-harming or suicidal behaviors in individuals treated with antidepressant medications, including SRIs. A meta-analysis in adults treated with SSRIs did not demonstrate increases in rates of suicide or suicidal thoughts, although there was weak evidence for an increase in self-harming behavior (107). A second meta-analysis noted an increase in the odds ratio for suicide attempts but did not report on the risk of other suicidal behaviors (108). However, interpretation of these results is difficult because of the confounds involved in calculating risks of suicide and other suicidal behaviors from meta-analyses (109). This is particularly true with regard to the use of antidepressants to treat OCD, because the majority of SSRI clinical trials involve depressed subjects, not subjects with OCD. In addition, studies using other methodologies, including a nested case–control study (110), a retrospective analysis of a large sample of computerized health plan records (111), and a large prospective effectiveness study in adult subjects with bipolar disorder (112), showed no increases in the likelihood of suicide or suicide attempts with antidepressant treatment. An additional nested case–control study also showed no increase in the risk of suicide but did note a small increase in the likelihood of self-harm (113). Although antidepressant treatment in adults does not appear to be associated with an increase in suicide, it is conceivable that side effects (e.g., anxiety, agitation, insomnia, irritability) may increase the chance of self-harming behaviors in some individuals (109). Thus, careful monitoring for such side effects, as well as for evidence of self-harming or suicidal thoughts or behaviors, is important, particularly in the early phases of treatment and after increases in antidepressant dose. Against these small risks, the benefits of antidepressant treatment must always be considered (114, 115).

SSRIs may be associated with increased intra-operative blood loss in patients also taking nonsteroidal anti-inflammatory drugs (116) and, along with clomipramine, may interact with anesthetics and opiate pain relievers. Patients should inform their surgeon and anesthesiologist if they are taking an SRI.

A drug discontinuation syndrome consisting most often of dizziness, nausea/vomiting, headache, and lethargy, but also including agitation, insomnia, myoclonic jerks, and paresthesias (117, 118), may occur if medication is suddenly stopped. The syndrome may occur after stopping any SRI but is most often seen after rapid discontinuation of paroxetine or the serotonin-norepinephrine reuptake inhibitor (SNRI) venlafaxine (117). Particularly for these latter medications, a slow taper over several weeks or more will minimize the likelihood of discontinuation symptoms. If symptoms do occur, raising the medication dose and slowing the taper may bring relief.

CBT is the only form of psychotherapy for OCD whose effectiveness is supported by controlled trials. There are no controlled studies that demonstrate effectiveness of dynamic psychotherapy or psychoanalysis in dealing with the core symptoms of OCD. Psychodynamic psychotherapy may still be useful in helping patients overcome their resistance to accepting a recommended treatment by illuminating their reasons for wanting to stay as they are (e.g., best adaptation, secondary gains). It may also be useful in addressing the interpersonal consequences of the OCD symptoms (119). Motivational interviewing may also help overcome resistance to treatment. As noted in Section II.B.1, the CBT variant that relies primarily on behavioral techniques such as ERP has the strongest evidence base (59, 60). Some data suggest that ERP is more effective if it integrates habituation with discussions of feared consequences and dysfunctional beliefs (120, 121) and with relapse prevention (122–125). For OCD patients without co-occurring depression, data from one large (N = 122) randomized controlled trial suggest that intensive CBT consisting of ERP may be superior to clomipramine monotherapy (123, 126).

Data also support CBT that primarily utilizes cognitive techniques such as identifying, challenging, and modifying dysfunctional beliefs when these techniques are combined with behavioral experiments (64, 121, 127–129), which can resemble ERP depending on how they are done. In direct comparisons, CBT utilizing cognitive techniques and behavioral experiments had efficacy similar to CBT consisting of ERP that focused only on habituation. Whether incorporating cognitive techniques with ERP is more effective than either treatment alone is under investigation (122). Only case reports support attempting to treat OCD with cognitive therapy alone, without exposure or behavioral experiments (129, 130). No controlled trials have evaluated other psychosocial methods for treating OCD that have been used in clinical practice (e.g., the "brain-lock technique" [131], other mindfulness approaches, acceptance and commitment therapy).

Cognitive-behavioral therapies have been delivered in individual, group (132–134), and family therapy sessions, with session length varying from less than 1 hour to 2 hours (135, 136) (for a summary of group and family therapy studies, see references 136, 137). One group has explored the delivery of behavior therapy by means of a self-instructional workbook that allows the patient to design and implement an individualized treatment plan. The patient couples the plan with a voice-activated telephone-response system accessible 24 hours a day to monitor and report progress (138, 139). The literature and expert opinion suggest that CBT sessions should be scheduled at least once weekly (63, 140). One study suggests that five sessions per week of CBT consisting of ERP may be more effective than once-weekly ERP sessions, but are not necessarily more effective than twice-weekly ERP sessions (141). The number of treatment sessions, their length, and the duration of an adequate trial have not been established, but expert consensus recommends 13–20 weekly sessions for most patients (140). More severely ill patients may require longer treatment and/or more frequent sessions. On the basis of clinical experience, clinicians should also consider booster sessions for more severely ill patients, patients who have relapsed in the past, and patients who show signs of early relapse. Finally, because the majority of treatment trials have been only 8–16 weeks long, the long-term persistence of treatment effects and the utility of periodic "booster sessions" require further study.

The psychiatrist may elect to conduct CBT or to refer the patient for this or another adjunctive psychotherapy. Psychiatrists wishing to utilize various forms of CBT are encouraged to pursue training through workshops, conferences, and other training programs. In addition, they can consult a number of treatment manuals (128, 142–146) or other publications (33, 147–149) or obtain consultation from a clinician specializing in the use of CBT. The psychiatrist initiating CBT should explain to the patient the nature of the treatment, including its here-and-now focus, the rationale underlying treatment procedures, and what the patient will be required to do. When resources for CBT are not available, the psychiatrist can suggest and supervise the use of self-help treatment guides (Appendix) and recommend support groups such as those accessible through the Obsessive Compulsive Foundation (Appendix), although these interventions have not been subjected to controlled study.

At the start of therapy, the psychiatrist can use the Y-BOCS Symptom Checklist (10) to help the patient create a list of target symptoms, including obsessions, compulsions, and items or situations that are avoided because of OCD concerns. The patient ranks the listed items from least to most anxiety-provoking.

In CBT consisting of ERP, patients are taught to confront feared situations and objects (i.e., exposure) and to refrain from performing rituals (i.e., response prevention). Exposures may include in vivo confrontations (e.g., touching objects in public bathrooms) and imaginal confrontations of feared consequences (e.g., imagining becoming "dirty" from "contamination"). Exposures that provoke moderate anxiety are prescribed first, followed as quickly as tolerable by exposures of increasing difficulty. Moving at too slow a pace can diminish faith in the treatment and motivation to continue. Patients must face their fears for a prolonged period without ritualizing, allowing the anxiety or discomfort to dissipate on its own ("habituation"). The goal is to weaken the connections between feared stimuli and distress and between carrying out rituals and relief from distress.

As noted earlier, ERP can be combined with formal cognitive techniques aimed at dysfunctional beliefs (122). Dysfunctional beliefs in OCD include magical thinking (e.g., contamination by proximity), an inflated sense of responsibility for unwanted events, overestimations of the probability of feared events, the assumption that thoughts are morally equivalent to actions or inevitably lead to action ("thought-action fusion"), perfectionism, the belief that anxiety/ discomfort will persist forever, and the need for control. Whether ERP with cognitive therapy is superior to ERP alone is currently under investigation. However, many experts believe that integrating exposures (or behavioral experiments) with discussions of dysfunctional beliefs and feared consequences is likely to be the most effective treatment (120). Modifications of ERP that include formal cognitive techniques as well as other interventions have been suggested for OCD patients with certain symptoms (e.g., hoarding [150]) and those without overt rituals (e.g., see references 59, 149, 151).

The frequency of follow-up visits after a new pharmacotherapy is initiated may vary from a few days to 2 weeks. The indicated frequency of visits will depend on the severity of the patient's symptoms, the complexities introduced by co-occurring conditions, whether suicidal ideation is present, and the likelihood of troubling side effects. Patients should be seen as often as necessary for psychiatric management. They should be encouraged to telephone between visits if medication questions arise. If telephone calls become reassurance rituals, the physician should work with the patient and the patient's family to limit call frequency, using exposure (e.g., to the anxiety that prompts the urge to call) and response prevention (e.g., limiting calls), just as in treating any other ritual.

As noted earlier, symptom rating scales can sometimes be helpful for monitoring the response of OCD, co-occurring depression, or co-occurring anxiety disorders, or for keeping an objective record over time in those patients whose symptoms do not respond to initial treatments. Although use of scales is not expected in routine practice, keeping an objective record over time for patients who do not respond to initial treatments may be helpful.

The physician's goals are always to reduce suffering and disability while minimizing the adverse effects of treatment. First treatments rarely produce freedom from all OCD symptoms. In clinical trials, OCD "responders" are variously defined as those whose Y-BOCS scores decrease by at least 25%–35% from baseline or who are rated much improved or very much improved on the Clinical Global Impressions–Improvement scale (CGI-I) (152). But even these degrees of improvement leave much room for additional gains. Thus, the psychiatrist must decide with the patient when, whether, and how to alter the treatment approach.

Deciding whether to alter the treatment approach will depend on the degree of suffering and disability the patient wishes to accept. Because illness can bring secondary gains (familial attention and caring and freedom from responsibilities), and because depressed mood can diminish hopefulness, the psychiatrist may have to address these issues when the patient is not well motivated to pursue further treatments despite limited improvement in his or her OCD. In the opinion of CBT experts, 13–20 sessions of weekly outpatient CBT with daily homework or weekday daily CBT for 3 weeks (about 50 hours, half therapist-guided, half homework) is an adequate dose after which next steps can be considered (140). With regard to SRIs, expert opinion supports changing medication strategy (switching or augmenting) after a trial of 8–12 weeks, with at least 4–6 weeks at the highest comfortably tolerated dose (140). However, some patients may respond simply to a longer period of continued treatment with the same medication (84). There is no apparent relationship between OCD treatment outcome and plasma levels of SRIs (82, 85–87).

When the outcome of initial treatment has been unsatisfactory, the psychiatrist should first consider the possible contribution of several factors: problems in the therapeutic alliance; interference by co-occurring conditions such as panic disorder, major depression, alcohol or substance use disorders, or severe personality disorder; inadequate patient adherence to treatment; the presence of psychosocial stressors; the level of family members' accommodation to the obsessive-compulsive symptoms (153); and an inability to tolerate an adequate trial of psychotherapy or the maximum recommended drug doses. The psychiatrist should next consider extending or intensifying the psychotherapeutic or pharmacotherapeutic intervention. Figure 1 displays a treatment algorithm outlining potential next steps; Table 4 lists factors to be considered at each treatment step.

Figure 1 Algorithm for the Treatment of Obsessive-Compulsive Disorder (OCD) Note."Moderate response" means clinically significant but inadequate response. *Treatment with little supporting evidence (e.g., one or few small trials or case reports or uncontrolled case series). CBT = cognitive-behavioral therapy; ERP = exposure and response prevention; MAOI = monoamine oxidase inhibitor; SRI = serotonin reuptake inhibitor; SSRI = selective serotonin reuptake inhibitor.

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When the patient has an inadequate response to the initial treatment and no interfering factor can be identified, the psychiatrist and patient must decide on next treatment steps without the benefit of data from controlled trials comparing all the possibilities. The sequence of treatment trials shown in Figure 1 is based on expert opinion (e.g., reference 140 and contributors to this guideline).

Given the absence of definitive trial data, augmentation strategies might be preferred to switching strategies in patients who have had a partial response to the initial treatment. Modest evidence supports augmentation of SRIs with antipsychotic medications, including haloperidol (154), risperidone (155–157), quetiapine (158), or olanzapine (159). These trials report response rates in the range of 40% to 55%. Patients who do not respond to one antipsychotic augmenting agent may respond to another. A chart review study found that discontinuing successful augmentation after 1–12 months resulted in relapse for more than 80% (15/18) of patients, most within 2 months of discontinuation (160). Despite these promising data regarding antipsychotic augmentation in OCD, many questions about this treatment strategy remain unanswered, including the optimal dose for each drug, long-term tolerability, when and how to discontinue treatment, the drugs' relative augmentation efficacy, and the reasons that only some patients benefit. Further data are also needed on subsets of patients who may respond preferentially to specific augmentation strategies. For example, one study (154) suggests that augmentation with haloperidol helps only those patients with co-occurring tic disorders.

Modest evidence supports augmentation of SRIs with CBT (specifically, ERP) (161–163) and augmentation of CBT with SRIs (164, 165). Some studies have demonstrated no added benefit from combining SRIs and CBT (61, 123), but these findings are limited by high refusal and dropout rates and uncertainty about levels of treatment resistance (166, 167). Some evidence suggests that adding cognitive therapy to ERP may enhance the results, but this remains to be established. In the absence of definitive data, combination treatment is provided in clinical situations that include efforts to treat a co-occurring disorder that is SRI responsive, to augment a partial response to monotherapy (163), and to reduce the chance of relapse when medication is discontinued (67).

For patients who do not respond to their first SRI, expert opinion and clinical trial data support switching to a different SRI (85, 87, 168–171). However, the evidence does not allow one to predict the patient's chance of response to the new SRI. Clinical experience suggests that response rates to a second SRI trial are close to 50% but may diminish as the number of failed adequate trials increases. A switch to venlafaxine at doses ranging from 225 mg/day to 350 mg/day is supported by active comparator trials and open-label studies suggesting its effectiveness in treating OCD (171–173). A switch to mirtazapine is supported by one open pilot study and a double-blind discontinuation trial (174).

If the strategies described above are not effective, augmentation with other pharmacotherapies may also be considered. Expert opinion (140, 175) and three open-label studies (176–178) support clomipramine augmentation of SSRIs. If clomipramine is added, plasma levels of clomipramine and desmethylclomipramine should be assayed 2–3 weeks after reaching a dose of 50 mg/day, and the total plasma concentration should be kept below 500 ng/mL to avoid cardiac and central nervous system toxicity. Fluvoxamine most increases plasma clomipramine levels (178), but substantial increases may occur with fluoxetine and paroxetine. A screening electrocardiogram may be advisable in patients suspected of having heart disease or in patients over the age of 40. Pulse rate and blood pressure should be monitored as the dose of clomipramine is increased.

Positive case reports exist for lithium augmentation, and positive case series have been reported for buspirone augmentation. However, small controlled but methodologically limited trials of lithium and buspirone augmentation have been negative. Adding pindolol 2.5 mg three times daily was effective in one small, double-blind, placebo-controlled trial (179) but not in another (180). A small, 12-week, open-label study reported that augmentation of SRIs with riluzole 50 mg two times daily was often helpful, but methodological limitations prevent confidence that the benefit was due to riluzole itself (501). Small controlled augmentation trials with L-triiodothyronine and desipramine have produced generally negative results, and a double-blind, placebo-controlled trial found St. John's wort to be no better than placebo (181).

Adding once-weekly oral morphine sulfate 30–45 mg to various SSRIs with or without other augmenting agents was superior to placebo in a double-blind crossover study (182). However, morphine sulfate should be avoided in patients with contraindications to opiate administration, including a history of substance or prescription medication abuse, psychosis, mania, antisocial personality disorder, chronic obstructive pulmonary disease, or cardiovascular compromise. In addition, the psychiatrist should consider what precautions and documentation may be needed—for example, those described by the American Academy of Pain Medicine (www.painmed.org). In addition, positive case reports exist, along with a positive case series, for monotherapy with the weak narcotic agonist tramadol (183). And two small, double-blind, placebo-controlled, single-dose studies reported positive results for D-amphetamine 30 mg in unmedicated OCD subjects (184, 185). However, these drugs should be avoided in some patients (e.g., those with a history of alcohol or other substance abuse or dependence).

Other treatment strategies that are supported only by case series, case reports, or small open trials—literatures that are less likely to include negative experiences—include anticonvulsants, MAOIs, ondansetron, L-tryptophan, nicotine delivered via transdermal patch or chewing gum (186), and Kundalini yoga. For patients with severe treatment-resistant OCD, partial hospitalization (49, 187) and intensive residential treatment (48, 188,189) have been used.

Other somatic therapies should be considered only after first- and second-line treatments and well-supported augmentation strategies have been exhausted. With treatments such as these for which efficacy is uncertain, it is especially important to weigh the potential benefits against the side effects and other risks of therapy. For example, evidence for the use of electroconvulsive therapy (ECT) in OCD is limited to a single case series using a nonstandard form of ECT administration (190). In addition, ECT carries the risks of anesthesia and has side effects such as memory impairment. As a result, ECT cannot be recommended for the treatment of OCD but may be considered for treating co-occurring conditions for which it may be indicated (e.g., major depression, uncontrollable mania, and schizophrenia) (191–194). Transcranial magnetic stimulation (TMS) is associated with less potential for side effects, but evidence for its efficacy is limited. Deep brain stimulation (DBS), a reversible and adjustable neurosurgical intervention, has been reported to show efficacy in a few case series of individuals with severe, highly treatment-resistant OCD (195) but also has potential side effects.

The efficacy of ablative neurosurgery (anterior capsulotomy, limbic leucotomy, cingulotomy, and gamma-knife radiosurgery) in patients with severe, treatment-refractory, or intractable OCD has been evaluated in case reports and unblinded studies. Improvement rates have ranged from 35% to 50% (196–198). Although some studies report relatively high rates of improvement, the unblinded nature of these studies and the ongoing treatment of many patients limit interpretation of these results. In addition, potential adverse events range from personality changes, seizures, and hydrocephalus to transient mania and mild transient side effects such as urinary dysfunction. The recent development of less invasive (DBS) and non-invasive (TMS) procedures makes it harder to consider ablative neurosurgery as an alternative for highly treatment-resistant or intractable OCD. For the time being, DBS and ablative neurosurgical treatment for OCD should be performed only at sites with expertise in both OCD and these treatment approaches.

Successful medication treatment should be continued for 1–2 years before considering a gradual taper by decrements of 10%–25% every 1–2 months while observing for symptom return or exacerbation. Successful ERP should be followed by monthly booster sessions for 3–6 months, or more intensively if response has been only partial.

Four double-blind SRI discontinuation studies studied different SRIs, used different designs (e.g., length of observation and method of placebo substitution), and had different relapse definitions. These methodological differences have been associated with widely varying reported rates of relapse or discontinuation for insufficient clinical response after double-blind switch to placebo, ranging from 89% within 7 weeks to 24% within 28 weeks (80, 199–201). An open discontinuation study also reported significantly higher 6-month, 1-year, and 2-year relapse rates for the patients whose SRI treatment was discontinued (177). Thus, rates of relapse appear to be increased after discontinuation of SRI treatment but cannot be precisely specified. Given these observations, discontinuation of pharmacotherapy should be carefully considered, and for most patients, continued treatment of some form is recommended.

A review of CBT studies consisting of ERP (202) concluded that about three-quarters of patients receiving ERP (with and without concomitant medication) were doing well at a mean follow-up of a little more than 2 years after the index treatment course. The studies' methodological limitations make this finding inconclusive. In addition, the relapse definition utilized in this review differs from those used in the SRI studies, precluding comparison of relapse rates.

A multi-site study (123) found that responders to intensive ERP (with or without concomitant clomipramine) had a significantly lower relapse rate and longer time to relapse after treatment discontinuation than responders to clomipramine alone (67). Post hoc analyses generally supported these findings, albeit with substantial variability in observed relapse rates (203), depending on the specific definition of relapse.

Together, these data suggest that the response to CBT consisting of ERP may be more durable, at least in the short run, than response to some SRIs after these treatments are discontinued. However, the observed differences could be explained by other factors, including differences in the intensity of treatment before discontinuation, the rate of medication taper, the subjects studied, the length of follow-up, and the relapse criteria.