22nd February 2024

Management

Treatment, as with other anxiety disorders, consists of a stepped approach. 

Mild functional impairment

• Education and self-help
• Low intensive CBT remains the first-line therapy. In OCD, the CBT intervention used is called exposure and response prevention (ERP). When a patient gets an obsessional thought, they are encouraged to sit with the feeling of anxiety and distress this causes instead of carrying out a compulsion. They are encouraged to discuss the feelings the obsession causes with the therapist. Similar exposure therapy is used in PTSD. This form of CBT is believed to be extremely effective. 

If a patient is unable to undertake low intensity CBT, or is not responsive to it, they should be treated for moderate functional impairment. 

Moderate functional impairment

• A choice of intensive CBT with ERP or drug therapy can be offered. 
• SSRI is the first line for drug therapy. Escitalopram, fluoxetine, sertraline, and paroxetine are all licensed for OCD. Citalopram can also be used as a first line; however, it is currently unlicensed for OCD.
• Clomipramine (TCA) can be given if SSRIs are contraindicated, if the patient prefers the TCA or if they’ve had a better response with it previously. 

Patients who do not receive enough benefit from these treatments should be treated for severe functional impairment. 

Severe functional impairment

• Dual therapy: intensive CBT combined with drug treatment
• Referral to specialist psychiatric services- consider if the OCD is chronic, debilitating and restricting daily life. Also, consider referral in patients who are not improving despite having >2 courses of CBT, including ERP in combination with antidepressants.