Given the prevalence of anxiety disorders, and obsessive-compulsive disorder (OCD) in particular, the authors want to present a 10-part “OCD Treatment Planning Worksheet” for patients, families, therapists, and referring/collaborating prescribers.
Once OCD is suspected via clinical interview, collateral interview (with spouse, parent, etc.), and the Yale-Brown Obsessive Compulsive Scale (Y-BOCS) or for children, the CY-BOCS, is administered, this worksheet will hopefully enable practitioners to get a “satellite view” of the patient’s past and current treatment (pharmacologic and/or psychotherapeutic) history so as to begin to strategize an effective treatment plan. Scoring cutoffs for the Y-BOCS can be seen at the bottom of the worksheet. The Y-BOCS is a simple 10-question self-rating scale that has five questions having to do with obsessions and 5 questions having to do with rituals or compulsions.
In general, most OCD patients have not had adequate trials of either pharmacotherapy or psychotherapy (for OCD, the gold standard being BT [IVE+RP=in-vivo exposure+ritual prevention]). Often, patients have tried anti-obsessional agents but have rarely had adequate trials of these agents if adequate trial is defined as adequate dose for adequate duration of dose. For most patients with mild-to-moderate OCD, behavior therapy or CBT is typically the treatment of choice, whereas for moderate-to-severe OCD behavior therapy/CBT along with pharmacotherapy is the typical treatment of choice. At this point, the approved anti-obsessionals include:
Although not formally approved for OCD, Paxil CR®, citalopram (Celexa®), and escitalopram (Lexapro®) are frequently used off-label. Luvox® is currently not available in the US as a branded agent. Although clomipramine (Anafranil®) was the 1st agent to be formally FDA approved for OCD in the US, due to it’s being a tricyclic agent with all the attendant side-effects (sedation, cardiotoxicity, lethality in overdose, and anticholinergic effects), it is rarely, if ever, currently used as a 1st -line agent. Prozac® and Paxil® are frequently used off-label in pediatric and adolescent populations.
The authors utilize this worksheet with the patient, their family, and send copies to the referring or collaborating physician. The ten (10) components of the worksheet are:
(1) Co-Morbidity:
As is true for most of the Axis I Anxiety Disorders, often OCD is co-occurring with other Axis I and/or Axis II disorders. Common co-morbid/co-morbid diagnoses include MDE (major depressive episode), panic disorder, and substance use (drug & alcohol) disorders.
(2) Axis III: Medical:
This block simply allows the clinician to note any current organic/medical conditions of the patient. Before treating OCD as OCD, it is important to be in the process of ruling out other medical conditions that might have obsessive-compulsive qualities such as pica (appetite for non-nutritive substances often seen in the developmentally disabled) or PANDAS (pediatric autoimmune neuropsychiatric disorder associated with streptococcal infections).
(3) CY-BOCS/Y-BOCS:
This block allows the clinician to give the raw score and severity rating (sub-clinical, mild, moderate, severe, or extreme) for the results of the Yale-Brown Obsessive Compulsive Scale (Goodman, et. al., 1989). Five questions on obsessions (time spent, interference from, distress from, resistance to, and control over) and five questions on compulsions (time spent, interference from, distress from, resistance to, and control over) are scored on a 5-point (0-4) Likert-type scale to arrive at the raw score. A copy of the Y-BOCS can be found at: http://brainphysics.com/ybocs.php
(4) Estimated Age of Onset:
Epidemiologic studies suggest a bi-modal age of onset with many OCD patients having their 1st OCD “break” at age range 10-15 and another peak of 1st onset between ages 25-30. More and more clinicians, however are reporting seeing children presenting with severe OCD at younger and younger ages.
(5) Current Medications:
In this box, the clinical can simply note what psychotropic and/or non-psychotropic agents the patient may be taking. We are not aware of any particular medication or group of medications that would be the cause of an iatrogenic OCD, i.e. medications that cause symptoms of OCD as a result of their use.
(6) Family History of Mood/Anxiety Disorder:
Given that OCD probably has biologic/familial predisposition, it is important to ask about the existence of mood and/or anxiety disorders in the patient’s family tree. The existence of such, not just OCD, statistically increases the likelihood of an endogenous component to their own OCD symptoms.
(7) Behavior Therapy (Exposure + Response/Ritual Prevention):
This box simply allows the clinician to determine if there has been any previous behavior therapy (which is rare), and current behavior therapy (also rare), what the family support is like, if any, their intrinsic motivation, and any OCD support group. The intrinsic motivation is important to assess given the nature of the treatment being an anxiety-provoking (not anxiety-reducing) model. If patients don’t have higher levels of intrinsic motivation, they are less likely to do the work required both in and in-between sessions. The third author has run OCD support groups that sometimes involve just OCD patients and other groups that include non-OCD family members. These groups involve leaving the office setting and doing in-community exposure for 2 hours at a time. Even those who say they’ve had BT, once questioned closely have usually NOT had an adequate trial of BT. In addition, the most important factor in mitigating against relapse once anti-obsessional medication is discontinued, is an adequate trial of BT.
(8) Axis II (Personality Disorders):
This box allows the clinician to note any co-morbid Axis II (personality disorder) condition. Those include:
Some have referred to the above 3 Axis II clusters as “the Wierds, the Wilds, and the Worrieds.”
The most likely cluster pre-disposing and/or co-morbid with OCD is Cluster C. Of the cluster C disorders, however, OCP is not the most common precursor to OCD, albeit frequent.
(9) Obsessive-Compulsive Spectrum:
This box allows the clinician to note any co-occurring OC spectrum disorders such as trichotillomania (hair pulling), BDD (body dysmorphic disorder), etc. If present and severe, the pharmacologic drug class of choice is the same as for OCD, that is the SSRIs.
(10) Previous Anti-Obsessional Trial:
This box allows the clinician to note any previous trials (adequate or not) of anti-obsessional agents. The name of the drug, it’s maximum dose, and length of time on that dose can be noted. Rarely do we find patient’s who’ve actually had adequate trials of anti-obsessionals even if they have not had dose-limiting side-effects. The pharmacologic rule “start low, go slow, and work high” is often necessary with anti-obsessionals. The latency of onset of action of the SSRIs when used to treat OCD is approximately twice as long as using these same agents in major depression (e.g. 2 months instead of 1 month). In addition, the doses needed for efficacy using the SSRIs in OCD is often higher than when using these same agents for major depression.
The ladder and steps on the worksheet represent some of the metaphors used in BT. Patients need to go UP the ladder or steps of anxiety to ultimately reduce the fear/anxiety. OCD obsessions/fears/worries need to be faced systematically in graded, hierarchical ways. People have to give up control to get control. To the degree that people have to have control (i.e. continue ritualizing) they will continue to lose control (i.e. the OCD will typically get worse even though the rituals/compulsions give brief, immediate relief).
A common saying we use is:
E2E/A2A: Exposure leads to Extinction/Avoidance leads to Anxiety
We trust clinicians will find this worksheet useful in their work with OCD patients. In the next issue of The IP we will be presenting an integrated “Treatment of Obsessive-Compulsive Disorder” algorithm. For many patients, especially those with moderate-to-severe OCD the combination of psychotherapy and pharmacotherapy has a synergistic effect such that 1+1=3!
An important organization for information about OCD (diagnosis, treatment, clinical trials, in-the-pipeline studies/medications, support groups, literature) is: the Obsessive Compulsive Foundation (OCF) which can be found at: www.ocfoundation.org
Trevor Egli is a Senior Psychology Major at Franklin & Marshall College, Lancaster, PA. Jenna Johnston, M.S. is a Marriage & Family Therapy Intern at Fuller Psychological & Family Services, Pasadena, CA. Dan Egli, Ph.D., is in Solo Practice, Williamsport, PA.
