Obsessive Compulsive Disorder at Johns Hopkins

Hopkins OCD Clinic

Drs Nestadt and Bienvenu co-direct the Hopkins OCD Clinic. Both psychiatrists are experienced in the clinical management of OCD and are actively involved in research pertaining to OCD. The clinic provides comprehensive assessments for individuals suffering from OCD or related disorders. Patients, or their clinicians, can seek a consultation or ‘second opinion’ or can receive treatment in the clinic. The clinic works with several behavioral psychologists in the area who provide the behavioral therapy component.

For appointments, contact Marvin Pittman at (410) 955-4838 or mail: Meyer 4-181 Johns Hopkins Hospital, 600 N Wolfe St., Baltimore MD 21205; or email gnestadt@jhmi.edu

General OCD Treatment Information

Effective treatments for each person with OCD varies just as the symptoms of OCD vary from person to person. The individual affected by OCD and their family members and friends can benefit from learning all they can about the disorder. Treatments can include one or more of the following:

Medications

Finding the most effective medication is important and useful. A series of trials on different medications is not uncommon. Psychiatrists can prescribe medications for OCD. It is important to discuss your symptoms honestly and openly and report any side effects you experience when taking medications. Although medications may have side effects, they can be very effective in reducing the symptoms of OCD with minimal adverse side effects. It is important to learn as much about the medication as possible, given that some medications do adversely interact with alcohol, other medications, sunlight, certain foods, etc. Medications commonly prescribed for OCD include Anafranil, Luvox, Paxil, Prozac, Zoloft, and Effexor.

Cognitive-Behavioral Therapy

Behavior therapy is currently the non-pharmacological treatment of choice in the treatment of OCD. A clinical psychologist trained in behavioral therapy techniques can work with you to effectively reduce symptoms of OCD. Behavior therapy (specifically, exposure with response prevention) is often as effective than medication alone, but the most successful treatment often is a combination of medication and behavioral therapy.

The behavioral model of states that obsessions give rise to anxiety, and this anxiety is then reduced by compulsive behaviors. That is, compulsive rituals are strengthened and maintained because they decrease the anxiety by terminating the event that gives rise to it. For example, some event, such as touching a doorknob, activates an obsessive thought, such as that of contamination. The obsessive thought next generates feelings of anxiety and discomfort, which are relieved by performance of a compulsive ritual, such as hand washing. Successful behavior therapy first breaks the connection between the obsessive thought and the anxiety it produces and then breaks the connection between the performance of a ritual and the reduction in anxiety that follows. The former is accomplished by exposure and the latter by response prevention. Thus, the behavioral treatment of OCD based on this model is called exposure and response prevention. In exposure, patients confront (expose themselves to) the object, thought, or situation that frightens them. Exposure can consist of real contact with the feared object (in vivo exposure) or only in the patient’s imagination (imaginary exposure). In response prevention, compulsive rituals that function to decrease the distress brought on by obsessive thoughts are delayed or prevented entirely. Habituation is the process by which exposure therapy is thought to work. Obsessive thoughts or images produce feelings of anxiety or distress that continue to increase to very uncomfortable levels. In the absence of a neutralizing ritual, this distress will eventually decrease to levels that are tolerable or vanish almost entirely. At this point the rituals will disappear because there is nothing left to escape from and they are no longer reinforced by reductions in anxiety.

Hospitalization

As with any psychiatric disorder, OCD can cause a range of impairment. In rare cases, psychiatric inpatient hospitalization is necessary for individuals with severe OCD symptoms. OCD can become debilitating at times and significantly affect one’s functioning.

Recent Developments in Drug Treatments for OCD

• In a small study involving 21 people with treatment-resistant OCD, researchers added Seroquel (or generic name quetiapine) to a serotonin reuptake inhibitor (SRI). For 16-weeks patients received either Seroquel and a SRI, or a SRI and a placebo. Seroquel reportedly was well tolerated. Primary analysis on a self-reporting questionnaire of OCD severity (Y-BOCS) demonstrated a 14% improvement as compared to a 6% for those who received the SRI and a placebo. This is promising information, but larger studies are needed to explore the efficacy of Seroquel and other antipsychotic medications when used as an adjunct treatment in resistant OCD. (Int. Clinical Psychopharmacology, July 2005).
• A study compared two different types of therapy for the treatment of OCD. Researchers from the University of British Columbia evaluated exposure and response prevention (ERP) and cognitive behavior therapy (CBT) which was provided to participants for 12-weeks in individual treatment. ERP is based on the theory of prolonged exposure, whereas CBT is an approach of cognitively challenging intrusive thoughts. Both ERP and CBT were found to be effective treatments. Over 50% symptom reduction was reported after 10-12 hours of individual therapy, and maintained for 3 months after the end of treatment. Other research has suggested that ERP may be effective also in a group therapy setting because of the added positive reinforcement of the group members. (Behaviour Research and Therapy, article in press).
• Several research studies have recently been conducted involving medications for OCD. In a rigorous study involving over 250 individuals with OCD, researchers found that Luvox CR (controlled release; generic name fluvoxamine) was associated with a significant decrease in the severity of OCD. The researchers were particularly interested in the finding that participants' symptoms began decreasing as early as the second week of treatment (Journal of Clinical Psychiatry, June 2003).
• A preliminary study was conducted with individuals whose OCD symptoms did not respond to typically prescribed medication such as Prozac, Paxil, and Zoloft. These drugs are known as SSRIs (selective serotonine reuptake inhibitors). The researchers explored whether prescribing the drug Zyprexa (olanzapine) along with SSRI medication would help. They found that 46% of the participants with Zyprexa added to their treatment showed improvement in their OCD symptoms (Journal of Clinical Psychiatry, April 2004).
• Another preliminary study was conducted using the drug Zofran (ondansetron). This drug has traditionally been used to prevent nausea caused by cancer treatment, anesthesia, and surgery. Also, some studies suggested that Zofran decreases anxiety. Although the number of participants in this study was small, 37% achieved a significant reduction in OCD symptoms. The researchers suggest that Zofran may have promise as a treatment for some individuals suffering from OCD. (Journal of Clinical Psychiatry, Sept. 2003).
• Another study showed that Effexor (venlafaxine) appears to be beneficial for treating people with OCD, including those who have failed to respond to typically prescribed medications such as Prozac, Paxil, and Zoloft, which are known as SSRIs (selective serotonine reuptake inhibitors). Researchers have also found Effexor to be as effective in treating OCD as Anafranil (clomipramine), but with fewer side effects. In one study, 38% of patients taking Effexor experienced no side effects whatsoever, compared to 8% of those taking Anafranil. (Journal of Clinical Psychiatry, 2002, 63; and 2003, 64.)
• Several research studies have been conducted recently involving medications for OCD. Results have shown that Luvox is effective for treating OCD in children. Zoloft has been found to be effective in long-term maintenance therapy for OCD. Also, Prozac may be helpful to some individuals with Body Dysmorphic Disorder, which involves excessive preoccupation with an aspect of one's appearance. (Journal of American Academy of child & Adolescent Psychiatry, 2001, 40; American Journal of Psychiatry, 2002, 159; Archives of General Psychiatry, 2002, 59.)

Promising New Treatments for Severe OCD

One of the collaborating institutions of our project, Brown University, has been researching new treatments for those with severe OCD. These surgical procedures are for individuals who have been unsuccessful in their previous treatment with medication and behavioral therapy. About 20% of people have OCD symptoms that are resistant to the usual treatments. These relatively new procedures may provide beneficial relief.

Deep Brain Stimulation

This procedure involves surgically implanting 2 electrical stimulators, one on each side of the brain, in areas that are involved in OCD symptoms. These 2 stimulators are then connected to pacemaker-like devices. The devices can be adjusted to deliver the amount of electrical stimulation necessary to help control an individual's symptoms. So far, patients in the Brown study have improved 25-50%. All participants had previously been unable to work -- all are now either working part-time or have returned to school. Use of this treatment began in Europe approximately 4 years ago. Researchers at Brown University's Butler Hospital have been testing the procedure since February 2001. A total of 16 participants worldwide have undergone this procedure for OCD. It is routinely used for movement disorders such as Parkinson's disease, and thousands of individuals not responding to regular treatment use the implanted electrical devices. One advantage of deep brain stimulation is that it is reversible and adjustable. The devices can be completely removed if the stimulation does not work for a patient. Overall, patients with OCD have reported an improved quality of life following the treatment. Noting that more research needs to be done, the researchers are cautiously optimistic about the benefits of this treatment for those with previously untreatable OCD. For more inforamtion, please contact Dr. Benjamin Greenberg at Brown Univeristy (Benjamin_Greenberg@Brown.EDU).