Obsessive-Compulsive Disorder (OCD)
Novel and Emerging Therapies
Amisulpride is a second-generation antipsychotic drug that is widely available outside the United States (Svestka 2007; Szarfman 2006). It blocks the action of dopamine in the brain (Komossa 2010; Schoemaker 1997). In an open-label trial, 10 patients received 200 mg amisulpride as augmentation therapy for six weeks. Average Y-BOCS scores decreased from 25.3 at study entry to 12.2 by the end of the study (Miodownik 2015). An earlier, similarly designed trial in 20 patients used 200‒600 mg per day of amisulpride, in addition to an SSRI, for 12 weeks. Y-BOCS scores decreased from 26.7 at baseline to 12.5 at the end of the study (Metin 2003).
Repetitive Transcranial Magnetic Stimulation
Repetitive transcranial magnetic stimulation (rTMS) is a method of stimulating specific brain regions through the use of magnetic current similar to that used in magnetic resonance imaging (MRI). It is an FDA-approved treatment for major depression in patients who have not responded to at least one antidepressant drug. This procedure does not require anesthesia, and the magnetic pulse penetrates no more than two inches into the brain from a magnetic coil placed over the forehead on the scalp. The mechanism of action of rTMS is not completely understood, but it is thought that because OCD has been associated with increased neural activity in the prefrontal cortex of the brain, the inhibitory effects of magnetic therapy may be beneficial (Blom 2011; NIH 2015; Mayo Clinic 2015).
rTMS is a lower-risk procedure than deep brain stimulation; seizures and hearing damage are the most serious side effects. Selection of the best brain regions for rTMS treatment is an evolving area of investigation, with newer studies finding more effective treatment regimens (Saba 2015; Jaafari 2012; Lapidus 2014). A rigorous analysis of published studies concluded that rTMS is an effective augmentation to SSRI medication, though many authors call for large, randomized trials to fully clarify the value of rTMS in treating OCD (Ma 2014; Jaafari 2012).
Surgical treatments may be considered in extreme, debilitating OCD cases that do not respond to exposure therapy and medication (Yip 2014; Grant 2014).
Ablative neurosurgery. Ablative neurosurgery techniques destroy or “ablate” specific regions or connections in the brain using precisely placed radiofrequency probes (Hariz 2013). Some studies have found ablative neurosurgery an effective treatment for severe, treatment-resistant OCD (Pepper 2015).
Ablative neurosurgery is available only at specialty centers, is not FDA-approved for treatment of OCD, and carries a substantial risk of adverse effects, including postoperative seizures and memory problems (BPS 2006c; Grant 2014; Soomro 2012; Sudak 2012; Rück 2008).
Non-invasive ablative neurosurgery . A newer, non-invasive ablative neurosurgery technique uses an MRI-guided, focused ultrasound device called ExAblate 4000. In one study of four patients, ultrasound ablation resulted in a gradual, 33% average reduction in Y-BOCS scores over the six months following the procedure, along with rapid and substantial improvements in depression and anxiety (61.1% and 69.4% average reductions, respectively) (Jung 2014).
The term “chronotherapy” refers to treatment that interacts with or modulates the body’s sleep-wake cycles (ie, the circadian rhythm). Chronotherapy has been applied to a range of conditions including major depression, high blood pressure, and even cancer (Martiny 2012; Eriguchi 2003; Watanabe 2013). Hormone dysregulation and disordered sleep patterns have been observed in people with OCD symptoms. Also, some evidence suggests OCD may respond to the drug agomelatine, which is chemically related to melatonin, and is considered a melatonergic antidepressant (Dubovsky 2009; Tzavellas 2014; Coles 2011; Lange 2012). In a rigorous review of 12 studies, patients with OCD were found to have shorter duration of sleep and more disordered sleep than healthy controls (Nota 2015). The hormone melatonin and bright light are powerful chronotherapeutic agents (Dodson 2010; Martiny 2015; Portaluppi 2010; Innominato 2010).
A case report of a 54-year old woman who had severe OCD and was treated with chronotherapy shows the promise of this modality. This patient had not responded to medication and psychotherapy. After adjusting her sleep schedule from 6 AM to 1 PM, to 12 AM to 10 AM, she experienced a 43% (15-point) reduction in her Y-BOCS (Coles 2011). Controlled studies on chronotherapy for OCD are still needed.
Remote Cognitive-Behavioral Therapy
Cognitive-behavioral therapy (CBT) is typically delivered face-to-face by a trained psychotherapist. However, technology-based delivery (through the internet, remote communication technologies, or deliverables like DVDs) may improve access to the treatment and may benefit patients reluctant to engage in face-to-face therapy, or unable to conveniently meet with a trained therapist. In a rigorous review of 8 randomized controlled trials, remote technology-based CBT was superior to controls for OCD, with a non-significant difference between therapist- and technology-administered CBT (Dèttore 2015).
Neurofeedback is a form of biofeedback that allows a patient to influence their own brain activity through interaction with an electroencephalogram (EEG) display. This is a non-invasive technique in which, through concentration, a patient can learn to modify dysfunctional brain activity associated with neuropsychological disorders such as OCD (Deng 2014). Three case reports of individuals with moderate-to-severe OCD (Y-BOCS scores 16–26) demonstrated a marked reduction in Y-BOCS scores (Hammond 2005). In a separate review of clinical reports on 36 individuals whose OCD did not respond to pharmacotherapy, neurofeedback treatment (from 9 to 84 sessions, each lasting 60 minutes per day) resulted in clinical improvements in 33 of 36 patients. Nineteen of these patients maintained their improvements for two years after cessation of neurofeedback treatment (Sürmeli 2011).
Mindfulness-Based Cognitive Therapy
Mindfulness is attention to moment-by-moment experience in a non-judgmental way (Chiesa 2011). Mindfulness-based interventions use mindfulness meditation to teach OCD patients to recognize and refocus or “let go” of obsessive intrusions into their thoughts and feelings (Hanstede 2008). Mindfulness exercises can also incorporate yoga, breathing exercises, as well as body-scanning, a technique in which each external body part is mentally “scanned” for sensations like pain or warmth. Mindfulness-based cognitive therapies have been successful in reducing OCD symptoms (as measured by Y-BOCS scores) in multiple case reports and one small study (Hale 2012). In the study, OCD patients were trained to refocus obsessive attention through the use of mindfulness exercises. They were also trained to identify individual OCD triggers and perform mindfulness and attention exercises whenever they noticed obsessive thoughts; two-thirds of patients in the study reported reductions in OCD symptoms (Hertenstein 2012).