Here at the Cincinnati Anxiety Center, we specialize in treating people with anxiety disorders and obsessive-compulsive disorders. Today I am going to discuss what it looks like from a medical point of view to help treat OCD. If you or anyone you know suffers with a form of OCD, you are aware of how debilitating the disorder can be and how resistant it can be to treatment.
Managing mental health disorders is best done with a multi-disciplinary approach - a team of people with varying educations and different experiences coming together to make a treatment plan to best help a person. As a nurse practitioner, I fit into this team as the “medical expert” and the “keeper of medication knowledge.” My part of the patient’s treatment plan is to provide more tools to help a person manage the symptoms of their disorder. Research shows we can change neurotransmitters in the brain with cognitive behavioral therapies (like exposure response prevention therapy), medications and alternative treatments such as TMS (Transcranial Magnetic Stimulation). Evidence suggests that combining some or all of these strategies will give us the greatest amount of success in treatment.
What is OCD?
OCD (Obsessive-Compulsive Disorder) can best be described by the DSM-V as presence of obsessions and/or compulsions that are time-consuming, cause significant distress, or interfere with a person’s daily life. Obsessions are recurrent and persistent thoughts, urges, or images that are intrusive or unwanted and cause marked anxiety or distress. A person will try to suppress these thoughts, urges, or images with some other thought or action. Compulsions are repetitive behaviors or mental acts that the person feels driven to perform in response to an obsession or rigid rule. The compulsion is aimed at reducing the anxiety or preventing a dreaded event. People with OCD will have some mixture of obsessions and compulsions. To decrease these symptoms, we aim treatment at enhancing neurotransmitters and creating neuroplasticity (the capacity for our brain cells to change in response to our behavior). Yes, you read that correctly, we can make changes to the way our brain works through strategies such as therapy, medication, and TMS!
How do we treat OCD with medication?
First-line medications for OCD are the Selective Serotonin Re-uptake Inhibitors (SSRI). Serotonin is a neurotransmitter that works in the brain to help regulate emotions that are involved in depression, anxiety, OCD, or panic (and more!). Signals in our brain create emotions by sending or stopping neuron signals with chemicals called neurotransmitters (serotonin, dopamine, norepinephrine, glutamate, GABA). SSRIs target serotonin by leaving more serotonin available to be used as signals between neurons. In some people this improves symptoms of anxiety, depression, and OCD and makes these emotions and thoughts more manageable. When using medications alone, most people can decrease their OCD symptoms by about 40-60%.
SSRIs have been well-researched and are proven safe and effective to treat OCD symptoms as a first-line treatment. Examples of SSRIs include: fluvoxamine, sertraline, fluoxetine, paroxetine, citalopram, and escitalopram. A medical professional will decide which medication to start based on a few key factors like additional mental health disorders, previous experiences with medication, family history of medication use, and the side effect profile.
What happens when you do not tolerate SSRIs? Our next step might be to try a SNRI (serotonin norepinephrine re-uptake inhibitor) like duloxetine, desvenlafaxine, and venlafaxine. These medications are similar to SSRIs except that they also try to enhance an additional neurotransmitter called norepinephrine. When SSRIs and SNRIs don’t work, clomipramine is a tricyclic antidepressant that has been well studied and is often very successful with OCD.
How can we treat OCD when medication and therapy aren’t enough?
Transcranial Magnetic Stimulation (TMS) can be used along with medication and/or therapy or used when these therapies are not successful. TMS is an FDA approved treatment for OCD. TMS works by using a large magnet that creates a small electrical field that directs energy into the mood center of your brain. For OCD this area of the brain is called the anterior cingulate cortex. To make TMS effective, we must first perform an exposure to activate the brain immediately prior to your treatment.
TMS can be an expensive and a time-consuming treatment, but the benefits can be life-changing. We are currently working hard as providers to encourage insurance companies to cover this FDA-approved treatment for OCD. A typical course of TMS is 36 sessions spread out over 8-9 weeks. Typically, a patient would come in for a TMS treatment 5 days a week for 6 weeks and then use the remaining sessions to wean off the treatment. Most patients will see improvement in symptoms around 2 weeks, but some will not see changes until the full 6 week treatment has been given.
Most patients will experience a 30% or greater reduction in symptoms with TMS treatment. This often doesn’t sound like much, but OCD is very resistant, and this is the goal with all treatments.
What other non-medication strategies are best for OCD?
Exercise regularly (get outside when you can!). Exercise can trigger the brain to make and use neurotransmitters more effectively. Eat a diet that is high in whole fruits and vegetables (we get most of our key nutrients here). To make chemicals like serotonin, we need vitamins and minerals that we can only get from the foods we eat.
There are very few supplements and herbal products that have been studied that can specifically target OCD. There are some products have been known to reduce anxiety by supporting stress responses and decreasing inflammation. Always talk to a healthcare professional before you take supplemental vitamins or herbal products to make sure they are right for you. These “natural” regimens can still create side effects, interact with each other medications, and can even make symptoms worse.
For more information visit the International Obsessive Compulsive Disorder Foundation.
You can see more about OCD and schedule a free consultation at the Cincinnati Anxiety Center by visiting https://www.theanxietycenter.com/ocd.