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Mental Disorders

Medications for Obsessive-Compulsive and Related Disorders

Matthew D. Jacofsky, Psy.D., Melanie T. Santos, Psy.D., Sony Khemlani-Patel, Ph.D. & Fugen Neziroglu, Ph.D. of the Bio Behavioral Institute, edited by C. E. Zupanick, Psy.D.

Many psychiatric disorders benefit from the use of medication. However, the use of medication for some psychiatric disorders is somewhat controversial. This is certainly true for obsessive-compulsive and related disorders (OCRDs). Some clinicians would argue that medications do not treat the disorder itself, but instead only mask the symptoms. When medication is discontinued, the symptoms will generally return if psychotherapy has not been provided. However, other clinicians believe that symptoms originate from faulty brain chemistry. Thus, they conclude that medication does indeed treat the disorder. Further study is required before this debate is resolved. In the meanwhile, research specific to OCRDs supports the judicious use of medications; particularly when combined with cognitive behavioral psychotherapy.

medication bottlePsychiatric medications fall into six main categories: 1) antidepressants, 2) stimulants, 3) antipsychotics, 4) mood stabilizers, 5) anxiolytics, and 6) depressants. Obsessive compulsive and related disorders are most commonly treated with antidepressants and anxiolytics. Each category of medication affects different neurotransmitters. Neurotransmitters serve as chemical messengers in the brain. Scientists believe neurotransmitters play a key role in many psychiatric disorders.

The term "antidepressant" medication is misleading. So-called "antidepressant" drugs treat many conditions besides depression. These drugs affect two neurotransmitters, serotonin and norepinephrine. With respect to OCRDs, serotonin seems to be the primary neurotransmitter to target. Interestingly, both serotonin and norepinephrine are implicated in depressive disorders, anxiety disorders, and OCRDs. This makes a great deal of sense because these three groups of disorders commonly occur together. It is presumed these disorders share a similar etiology.

Two particular types of anti-depressant medications are used to treat OCRDs. The first group is called Selective Serotonin Reuptake Inhibitors (SSRIs). SSRIs are believed to relieve the obsessive thoughts and ritualistic behaviors by blocking (inhibiting) the re-absorption (re-uptake) of serotonin in the brain's receptor cells. This blocking action means there is more serotonin available. Therefore, SSRIs result in an increase of serotonin. The SSRIs include drugs such as: Luvox®, Zoloft®, Lexapro®, Celexa®, Prozac®, and Paxil®.

The second group of anti-depressant medications is called Serotonin Norepinephrine Reuptake Inhibitors (SNRIs). The SNRIs block the re-uptake of both serotonin and norepinephrine. This blocking action increases the levels of both serotonin and norepinephrine in the brain. These medications are considered more broad-spectrum medications. In some cases, the SNRIs are tried when the SSRIs are not effective. Some commonly prescribed SNRIs include: Effexor®, Pristiq®, and Cymbalta®.

Both SSRIs and SNRIs are not considered addicting, nor are they believed to create drug dependence. However, some people have reported difficulty when discontinuing these drugs. Anti-depressants drugs usually take about two weeks before they become effective.

There is another, older type of anti-depressant medication called tricyclics. One particular tricyclic, is called Clomipramine (Anafranil ®). Historically, Clomipramine was used to treat OCRDs with good results. Today, it is often prescribed when people do not respond to the SSRI or SNRIs. It is also a broad-spectrum medication that affects both serotonin and norepinephrine. Research shows that it can also be effective for trichotillomania (hair pulling).

Anxiolytic (or anti-anxiety) medication is another category of medication used to treat OCRDs. Benzodiazepines are a commonly prescribed type of anxiolytic. Benzodiazepines offer short-term, immediate relief of anxiety symptoms but can result in drug dependence. Therefore, these drugs are prescribed cautiously, and for a shorter duration of time. Because of their immediate effect, they are often used until the anti-depressants and/or psychotherapy become effective. Benzodiazepines increase the action of gamma aminobutyric acid (GABA) in the brain. GABA is a naturally occurring brain chemical. It slows down brain activity and results in a feeling of calm and relaxation. Commonly prescribed benzodiazepine drugs are: Xanax®, Librium®, Klonopin®, Valium®, and Ativan®. Another anxiolytic, Buspar®, is a non-addicting and non-sedating. It targets the same symptoms as benzodiazepines. Like the antidepressants drugs, Buspar® takes up to 2 weeks to take effect, whereas the benzodiazepines take effect immediately.

A third class of medications, called antipsychotics, can be used as an "augmentation" strategy. This means these medications are used in combination with other drugs to boost or enhance the treatment response. Clinicians consider this approach when someone experiences only a partial or inadequate response to their medications. Typical antipsychotics used for OCRDs include Risperdal®, Zyprexa®, and Seroquel®. When used to treat OCRDs, they are typically prescribed at lower doses than when used for psychotic disorders (e.g., schizophrenia).

There are advantages and disadvantages to psychiatric medications. Some people's symptoms make it difficult for them to attend and participate in therapy, or to practice therapy exercises. In these cases, medications can be very helpful by reducing symptoms that interfere with treatment. Medications are also beneficial when a person has a co-occurring disorder that interferes with treatment, such as depression. For example, a depressed person with obsessive-compulsive disorder may find it difficult to get out of bed in the morning. As such, they would have trouble attending therapy. In this case, medication can reduce the depressive symptoms so the person can benefit from therapy. Medications can also help people to better tolerate the more difficult and anxiety-provoking exposure and response prevention (ERP) exercises.

While medications have many advantages, there are also some disadvantages. Although newer medications have fewer side-effects than earlier drugs, some people still experience uncomfortable side-effects. Others do not respond as expected to medications, experiencing minimal benefit. The potential for drug dependence, and overuse with the benzodiazepines is also a concern.

Sometimes drugs can actually interfere with the therapeutic process. From a theoretical perspective, exposure and response prevention (ERP) works most effectively when people fully experience their anxiety so that habituation and extinction occur. The overuse of anti-anxiety medications interferes with that process. If overly sedated by anxiolytic drugs, a therapy participant may not experience anxiety during ERP sessions. Therefore, they will not receive the benefit of habituation and extinction.

Despite these disadvantages, many cognitive behavioral therapists recommend a conservative use of psychiatric medications. This is particularly true when cognitive-behavioral therapy is leading to less than desired improvement; or, when symptoms are severe enough to interfere with daily functioning.

People with OCRDs disorders are encouraged to discuss medications with their healthcare professionals. Psychiatrists, psychopharmacologists, neurologists, and psychiatric nurse practitioners are all good choices. These discussions enable people to make well-informed decisions about the pros and cons of medication. When a therapy participant is working with a non-prescribing practitioner, such as a psychologist or social worker, they should discuss their interest in medication with these providers as well. As mentioned, some therapies are less effective when medications are used. However, in general, the combination of medication and cognitive behavioral therapy complement each other quite well. Both have proven to be beneficial by improving people's symptoms and the quality of their lives.