Neurosurgery
Ablative neurosurgery (anterior capsulotomy, limbic leucotomy, cingulotomy, and gamma knife radiosurgery) are procedures that are not US Food and Drug Administration (FDA)-approved and are reserved for patients with severe, treatment-refractory OCD who have been unresponsive to first- and second-line treatments, including augmentation strategies.[61]American Psychiatric Association. Practice guideline for the treatment of patients with obsessive-compulsive disorder. Jul 2007 [internet publication].
https://psychiatryonline.org/pb/assets/raw/sitewide/practice_guidelines/guidelines/ocd.pdf
[63]American Psychiatric Association. Guideline watch (March 2013): practice guideline for the treatment of patients with obsessive-compulsive disorder. Mar 2013 [internet publication].
http://psychiatryonline.org/pb/assets/raw/sitewide/practice_guidelines/guidelines/ocd-watch.pdf
The most commonly used neurosurgical intervention in recent times has been cingulotomy, a procedure that involves bilateral lesioning of the cingulate gyrus. In a review of stereotactic cingulotomy, cingulotomy was recommended as a safe procedure with limited adverse effects, although the review authors caution that it be reserved for only the most treatment-refractory cases.[128]Cosgrove GR, Rauch SL. Stereotactic cingulotomy. Neurosurg Clin N Am. 2003 Apr;14(2):225-35.
http://www.ncbi.nlm.nih.gov/pubmed/12856490?tool=bestpractice.com
Deep brain stimulation (DBS)
DBS offers several important advantages over traditional lesioning procedures. Its effects are reversible and it is minimally invasive.[129]Nuttin B, Cosyns P, Demeulemeester H, et al. Electrical stimulation in anterior limbs of internal capsules in patients with obsessive-compulsive disorder. Lancet. 1999 Oct 30;354(9189):1526.
http://www.ncbi.nlm.nih.gov/pubmed/10551504?tool=bestpractice.com
It has also been shown to be effective and tolerable in the long-term (mean follow-up, 6.8 years).[130]Graat I, Mocking R, Figee M, et al. Long-term outcome of deep brain stimulation of the ventral part of the anterior limb of the internal capsule in a cohort of 50 patients with treatment-refractory obsessive-compulsive disorder. Biol Psychiatry. 2020 Aug 28;S0006-3223(20)31877-1.
https://www.doi.org/10.1016/j.biopsych.2020.08.018
http://www.ncbi.nlm.nih.gov/pubmed/33131717?tool=bestpractice.com
Sites targeted in studies have included the anterior limbs of the internal capsule bilaterally, the shell region of the right nucleus accumbens, the subthalamic nucleus, and the ventral caudate nucleus.[129]Nuttin B, Cosyns P, Demeulemeester H, et al. Electrical stimulation in anterior limbs of internal capsules in patients with obsessive-compulsive disorder. Lancet. 1999 Oct 30;354(9189):1526.
http://www.ncbi.nlm.nih.gov/pubmed/10551504?tool=bestpractice.com
[131]Aouizerate B, Cuny E, Martin-Guehl C, et al. Deep brain stimulation of the ventral caudate nucleus in the treatment of obsessive-compulsive disorder and major depression. Case report. J Neurosurg. 2004 Oct;101(4):682-6.
http://www.ncbi.nlm.nih.gov/pubmed/15481726?tool=bestpractice.com
[132]Sturm V, Lenartz D, Koulousakis A, et al. The nucleus accumbens: a target for deep brain stimulation in obsessive-compulsive- and anxiety-disorders. J Chem Neuroanat. 2003 Dec;26(4):293-9.
http://www.ncbi.nlm.nih.gov/pubmed/14729131?tool=bestpractice.com
[133]Mallet L, Mesnage V, Houeto JL, et al. Compulsions, Parkinson's disease, and stimulation. Lancet. 2002 Oct 26;360(9342):1302-4.
http://www.ncbi.nlm.nih.gov/pubmed/12414208?tool=bestpractice.com
[134]Goodman WK, Foote KD, Greenberg BD, et al. Deep brain stimulation for intractable obsessive compulsive disorder: pilot study using a blinded, staggered-onset design. Biol Psychiatry. 2010 Mar 15;67(6):535-42.
http://www.ncbi.nlm.nih.gov/pubmed/20116047?tool=bestpractice.com
[135]Huff W, Lenartz D, Schormann M, et al. Unilateral deep brain stimulation of the nucleus accumbens in patients with treatment-resistant obsessive-compulsive disorder: outcomes after one year. Clin Neurol Neurosurg. 2010 Feb;112(2):137-43.
http://www.ncbi.nlm.nih.gov/pubmed/20006424?tool=bestpractice.com
[136]Denys D, Mantione M, Figee M, et al. Deep brain stimulation of the nucleus accumbens for treatment-refractory obsessive-compulsive disorder. Arch Gen Psychiatry. 2010 Oct;67(10):1061-8.
http://archpsyc.jamanetwork.com/article.aspx?articleid=210896
http://www.ncbi.nlm.nih.gov/pubmed/20921122?tool=bestpractice.com
A systematic review has suggested that the strongest evidence exists for the use of bilateral subthalamic nuclei as a target, and that there is insufficient evidence to recommend the use of unilateral DBS in medically refractory patients with OCD.[137]Staudt MD, Pouratian N, Miller JP, et al. Congress of Neurological Surgeons systematic review and evidence-based guidelines for deep brain stimulations for obsessive-compulsive disorder: update of the 2014 guidelines. Neurosurgery. 2021 Mar 15;88(4):710-2.
https://www.doi.org/10.1093/neuros/nyaa596
http://www.ncbi.nlm.nih.gov/pubmed/33559678?tool=bestpractice.com
The UK National Institute of Health and Care Excellence (NICE) recommends that DBS for chronic, severe treatment-resistant OCD in adults should only be used in a research context because of inadequate evidence for both efficacy and safety.[138]National Institute for Health and Care Excellence. Deep brain stimulation for chronic, severe, treatment-resistant obsessive-compulsive disorder in adults. Apr 2021 [internet publication].
https://www.nice.org.uk/guidance/ipg693
Venlafaxine
Active comparator trials and open-label studies support the efficacy of venlafaxine, a serotonin-noradrenaline reuptake inhibitor (SNRI), in OCD.[139]Denys D, van Megen HJ, van der Wee N, et al. A double-blind switch study of paroxetine and venlafaxine in obsessive-compulsive disorder. J Clin Psychiatry. 2004 Jan;65(1):37-43.
http://www.ncbi.nlm.nih.gov/pubmed/14744166?tool=bestpractice.com
[140]Denys D, van der Wee N, van Megen HJ, et al. A double blind comparison of venlafaxine and paroxetine in obsessive-compulsive disorder. J Clin Psychopharmacol. 2003 Dec;23(6):568-75.
http://www.ncbi.nlm.nih.gov/pubmed/14624187?tool=bestpractice.com
[141]Albert U, Aguglia E, Maina G, et al. Venlafaxine versus clomipramine in the treatment of obsessive-compulsive disorder: a preliminary single-blind, 12-week, controlled study. J Clin Psychiatry. 2002 Nov;63(11):1004-9.
http://www.ncbi.nlm.nih.gov/pubmed/12444814?tool=bestpractice.com
Non-responders could be switched to venlafaxine, but there is conflicting evidence for this strategy and at least one study reported that venlafaxine was less effective than paroxetine if previous treatment with other selective serotonin-reuptake inhibitors (SSRIs) had failed.[61]American Psychiatric Association. Practice guideline for the treatment of patients with obsessive-compulsive disorder. Jul 2007 [internet publication].
https://psychiatryonline.org/pb/assets/raw/sitewide/practice_guidelines/guidelines/ocd.pdf
[63]American Psychiatric Association. Guideline watch (March 2013): practice guideline for the treatment of patients with obsessive-compulsive disorder. Mar 2013 [internet publication].
http://psychiatryonline.org/pb/assets/raw/sitewide/practice_guidelines/guidelines/ocd-watch.pdf
[139]Denys D, van Megen HJ, van der Wee N, et al. A double-blind switch study of paroxetine and venlafaxine in obsessive-compulsive disorder. J Clin Psychiatry. 2004 Jan;65(1):37-43.
http://www.ncbi.nlm.nih.gov/pubmed/14744166?tool=bestpractice.com
[140]Denys D, van der Wee N, van Megen HJ, et al. A double blind comparison of venlafaxine and paroxetine in obsessive-compulsive disorder. J Clin Psychopharmacol. 2003 Dec;23(6):568-75.
http://www.ncbi.nlm.nih.gov/pubmed/14624187?tool=bestpractice.com
[141]Albert U, Aguglia E, Maina G, et al. Venlafaxine versus clomipramine in the treatment of obsessive-compulsive disorder: a preliminary single-blind, 12-week, controlled study. J Clin Psychiatry. 2002 Nov;63(11):1004-9.
http://www.ncbi.nlm.nih.gov/pubmed/12444814?tool=bestpractice.com
Augmentation with ondansetron
A possible mechanism of this agent’s anti-obsessional efficacy involves dopaminergic inhibition by 5-HT3 receptor blockade. One single-blind and one double-blind placebo-controlled trial showed the efficacy of ondansetron in combination with SSRIs in treatment-resistant patients.[142]Soltani FS, Sayyah M, Feizy F, et al. A double-blind, placebo-controlled pilot study of ondansetron for patients with obsessive-compulsive disorder. Hum Psychopharmacol. 2010 Aug;25(6):509-13.
http://www.ncbi.nlm.nih.gov/pubmed/20737524?tool=bestpractice.com
[143]Pallanti S, Bernardi S, Antonini S, et al. Ondansetron augmentation in treatment-resistant obsessive-compulsive disorder: a preliminary, single-blind, prospective study. CNS Drugs. 2009 Dec;23(12):1047-55.
http://www.ncbi.nlm.nih.gov/pubmed/19958042?tool=bestpractice.com
Augmentation with dexamfetamine and caffeine
The increased release of dopamine induced by both dexamfetamine and caffeine might increase D1 receptor stimulation in the pre-frontal cortex, increasing the ability to shift attention away from obsessions, and thus decreasing urges to perform compulsions. Both caffeine and dexamfetamine added after an adequate SSRI or SNRI trial were effective in treatment-resistant patients in a double-blind, placebo-controlled trial.[144]Koran LM, Aboujaoude E, Gamel NN. Double-blind study of dextroamphetamine versus caffeine augmentation for treatment-resistant obsessive-compulsive disorder. J Clin Psychiatry. 2009 Nov;70(11):1530-5.
http://www.ncbi.nlm.nih.gov/pubmed/19573497?tool=bestpractice.com
Augmentation with opioids
Opioids alter the glutamatergic tone of the corticostriatal pathway. One double-blind crossover study demonstrated that adding morphine, with or without other augmenting agents, to treatment with SSRIs was superior to placebo in reducing symptoms in some treatment-resistant patients with OCD.[145]Koran LM, Aboujaoude E, Bullock KD, et al. Double-blind treatment with oral morphine in treatment-resistant obsessive-compulsive disorder. J Clin Psychiatry. 2005 Mar;66(3):353-9.
http://www.ncbi.nlm.nih.gov/pubmed/15766302?tool=bestpractice.com
Augmentation with topiramate
Topiramate alters the glutamatergic tone of the corticostriatal pathway. One case report suggested that augmentation of SSRI treatment with topiramate might be effective in improving OCD symptom severity in patients with treatment-resistant OCD.[146]Hollander E, Dell'Osso B. Topiramate plus paroxetine in treatment-resistant obsessive-compulsive disorder. Int Clin Psychopharmacol. 2006 May;21(3):189-91.
http://www.ncbi.nlm.nih.gov/pubmed/16528143?tool=bestpractice.com
However, a more recent double-blind, placebo-controlled trial of topiramate augmentation in treatment-resistant patients with OCD suggested that topiramate may be beneficial only for treatment of compulsions and not for treatment of obsessions.[147]Berlin HA, Koran LM, Jenike MA, et al. Double-blind, placebo-controlled trial of topiramate augmentation in treatment-resistant obsessive-compulsive disorder. J Clin Psychiatry. 2011 May;72(5):716-21.
http://www.ncbi.nlm.nih.gov/pubmed/20816027?tool=bestpractice.com
Augmentation with riluzole
Riluzole alters the glutamatergic tone of the corticostriatal pathway. An open-label trial showed significant efficacy of augmentation of existing pharmacotherapy with riluzole in treatment-resistant OCD.[148]Coric V, Taskiran S, Pittenger C, et al. Riluzole augmentation in treatment-resistant obsessive-compulsive disorder: an open-label trial. Biol Psychiatry. 2005 Sep 1;58(5):424-8.
http://www.ncbi.nlm.nih.gov/pubmed/15993857?tool=bestpractice.com
Augmentation with mirtazapine
Mirtazapine augmentation of SSRI treatment has been shown not only to be an effective pharmacotherapy for OCD, but also to accelerate the treatment response.[149]Pallanti S, Quercioli L, Bruscoli M. Response acceleration with mirtazapine augmentation of citalopram in obsessive-compulsive disorder patients without comorbid depression: a pilot study. J Clin Psychiatry. 2004 Oct;65(10):1394-9.
http://www.ncbi.nlm.nih.gov/pubmed/15491244?tool=bestpractice.com
[150]Koran LM, Gamel NN, Choung HW, et al. Mirtazapine for obsessive-compulsive disorder: an open trial followed by double-blind discontinuation. J Clin Psychiatry. 2005 Apr;66(4):515-20.
http://www.ncbi.nlm.nih.gov/pubmed/15816795?tool=bestpractice.com
Mirtazapine enhances serotonergic function by a mechanism distinct from reuptake inhibition.
Augmentation with buspirone
Augmentation with buspirone may be useful if residual symptoms are related to severe anxiety.[151]Pato MT, Pigott TA, Hill JL, et al. Controlled comparison of buspirone and clomipramine in obsessive-compulsive disorder. Am J Psychiatry. 1991 Jan;148(1):127-9.
http://www.ncbi.nlm.nih.gov/pubmed/1984696?tool=bestpractice.com
[152]Menkes DB. Buspirone augmentation of sertraline. Br J Psychiatry. 1995 Jun;166(6):823-4.
http://www.ncbi.nlm.nih.gov/pubmed/7663840?tool=bestpractice.com
Augmentation with naltrexone
Augmentation with naltrexone may be helpful if intensive grooming behaviours are present.
Cycloserine augmented exposure therapy
Augmentation of exposure and response prevention (ERP) with cycloserine may lead to a more rapid response to exposure treatment, although studies have found no difference in treatment outcome with cycloserine augmentation in either adult or paediatric patients.[153]Kushner MG, Kim SW, Donahue C, et al. D-cycloserine augmented exposure therapy for obsessive-compulsive disorder. Biol Psychiatry. 2007 Oct 15;62(8):835-8.
http://www.ncbi.nlm.nih.gov/pubmed/17588545?tool=bestpractice.com
[154]Storch EA, Merlo LJ, Bengtson M, et al. D-cycloserine does not enhance exposure-response prevention therapy in obsessive-compulsive disorder. Int Clin Psychopharmacol. 2007 Jul;22(4):230-7.
http://www.ncbi.nlm.nih.gov/pubmed/17519647?tool=bestpractice.com
[155]Storch EA, Wilhelm S, Sprich S, et al. Efficacy of augmentation of cognitive behavior therapy with weight-adjusted d-cycloserine vs placebo in pediatric obsessive-compulsive disorder: a randomized clinical trial. JAMA Psychiatry. 2016 Aug 1;73(8):779-88.
http://jamanetwork.com/journals/jamapsychiatry/fullarticle/2529151
http://www.ncbi.nlm.nih.gov/pubmed/27367832?tool=bestpractice.com
[156]Farrell LJ, Waters AM, Tiralongo E, et al. Efficacy of D-cycloserine augmented brief intensive cognitive-behavioural therapy for paediatric obsessive-compulsive disorder: a randomised clinical trial. Depress Anxiety. 2022 Jun;39(6):461-73.
https://pmc.ncbi.nlm.nih.gov/articles/PMC9303435
http://www.ncbi.nlm.nih.gov/pubmed/35084071?tool=bestpractice.com
[157]Kvale G, Hansen B, Hagen K, et al. Effect of D-cycloserine on the effect of concentrated exposure and response prevention in difficult-to-treat obsessive-compulsive disorder: a randomized clinical trial. JAMA Netw Open. 2020 Aug 3;3(8):e2013249.
https://pmc.ncbi.nlm.nih.gov/articles/PMC7426745
http://www.ncbi.nlm.nih.gov/pubmed/32789516?tool=bestpractice.com
In a study that examined whether antidepressant status influenced the response to cycloserine-augmented ERP in the treatment of OCD, patients who were not on antidepressants were more likely to achieve remission than those who were.[158]Andersson E, Hedman E, Enander J, et al. D-cycloserine vs placebo as adjunct to cognitive behavioral therapy for obsessive-compulsive disorder and interaction with antidepressants: a randomized clinical trial. JAMA Psychiatry. 2015 Jul;72(7):659-67.
http://www.ncbi.nlm.nih.gov/pubmed/25970252?tool=bestpractice.com
Aqueous extract of Echium amoenum
An initial study indicates that Echium amoenum is efficacious in reducing obsessions and compulsions without adverse effects.[159]Sayyah M, Boostani H, Pakseresht S, et al. Efficacy of aqueous extract of Echium amoenum in treatment of obsessive-compulsive disorder. Prog Neuropsychopharmacol Biol Psychiatry. 2009 Nov 13;33(8):1513-6.
http://www.ncbi.nlm.nih.gov/pubmed/19737592?tool=bestpractice.com
Celecoxib
There is an increasing focus on the neuroinflammatory component of OCD as a means of therapeutic targeting.[35]Gerentes M, Pelissolo A, Rajagopal K, et al. Obsessive-compulsive disorder: autoimmunity and neuroinflammation. Curr Psychiatry Rep. 2019 Aug 1;21(8):78.
http://www.ncbi.nlm.nih.gov/pubmed/31367805?tool=bestpractice.com
[25]Attwells S, Setiawan E, Wilson AA, et al. Inflammation in the neurocircuitry of obsessive-compulsive disorder. JAMA Psychiatry. 2017 Aug 1;74(8):833-40.
https://pmc.ncbi.nlm.nih.gov/articles/PMC5710556
http://www.ncbi.nlm.nih.gov/pubmed/28636705?tool=bestpractice.com
Celecoxib is a selective cyclo-oxygenase (COX)-2 inhibitor that prevents COX enzymes from catalysing the formation of prostanoids. Preliminary evidence suggests that the anti-inflammatory effects of celecoxib may help modulate the behavioural symptoms of OCD if used alone in or in combination with SSRIs.[160]Shalbafan M, Mohammadinejad P, Shariat SV, et al. Celecoxib as an adjuvant to fluvoxamine in moderate to severe obsessive-compulsive disorder: a double-blind, placebo-controlled, randomized trial. Pharmacopsychiatry. 2015 Jul;48(4-5):136-40.
https://www.doi.org/10.1055/s-0035-1549929
http://www.ncbi.nlm.nih.gov/pubmed/25959196?tool=bestpractice.com
[161]Shahini N, Talaei A, Shalbafan M, et al. Effects of celecoxib adjunct to selective serotonin reuptake inhibitors on obsessive-compulsive disorder. Basic Clin Neurosci. 2021 Jul-Aug;12(4):489-98.
https://www.doi.org/10.32598/bcn.2021.1998.1
http://www.ncbi.nlm.nih.gov/pubmed/35154589?tool=bestpractice.com
Clinical trials in individuals with OCD are ongoing.[162]Westwell-Roper C, Best JR, Elbe D, et al. Celecoxib versus placebo as an adjunct to treatment-as-usual in children and youth with obsessive-compulsive disorder: protocol for a single-site randomised quadruple-blind phase II study. BMJ Open. 2022 Jan 31;12(1):e054296.
https://www.doi.org/10.1136/bmjopen-2021-054296
http://www.ncbi.nlm.nih.gov/pubmed/35105633?tool=bestpractice.com
Computer-aided psychotherapy
Computer-aided psychotherapy is a promising emerging area of research in the psychotherapeutic treatment of anxiety disorders.[163]Olthuis JV, Watt MC, Bailey K, et al. Therapist-supported internet cognitive behavioural therapy for anxiety disorders in adults. Cochrane Database Syst Rev. 2016;3:CD011565.
http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD011565.pub2/full
http://www.ncbi.nlm.nih.gov/pubmed/26968204?tool=bestpractice.com
It may prove to be particularly useful in rural areas, in which trained clinical psychologists are not available.[164]Cuijpers P, Marks IM, van Straten A, et al. Computer-aided psychotherapy for anxiety disorders: a meta-analytic review. Cogn Behav Ther. 2009;38(2):66-82.
http://www.ncbi.nlm.nih.gov/pubmed/20183688?tool=bestpractice.com
However, one randomised controlled trial that included adults with moderate to severe OCD, who were already on the waiting list to receive therapist-led cognitive behavioural therapy (CBT), found that offering people book-based or computer-based CBT, together with phone support from a ‘psychological wellbeing practitioner’, did not improve their obsessive compulsive symptoms after 3 or 12 months. This suggests that book-based and computer-based CBT is unlikely to be an effective strategy in patients with moderate to severe OCD symptoms, although further research is needed to determine its efficacy for patients with milder OCD symptoms.[165]Lovell K, Bower P, Gellatly J, et al. Clinical effectiveness, cost-effectiveness and acceptability of low-intensity interventions in the management of obsessive-compulsive disorder: the Obsessive-Compulsive Treatment Efficacy randomised controlled Trial (OCTET). Health Technol Assess. 2017 Jun;21(37):1-132.
https://www.journalslibrary.nihr.ac.uk/hta/hta21370#/full-report
http://www.ncbi.nlm.nih.gov/pubmed/28681717?tool=bestpractice.com
[166]Salazar de Pablo G, Pascual-Sánchez A, Panchal U, et al. Efficacy of remotely-delivered cognitive behavioural therapy for obsessive-compulsive disorder: an updated meta-analysis of randomised controlled trials. J Affect Disord. 2023 Feb 1;322:289-99.
https://www.sciencedirect.com/science/article/pii/S016503272201254X
http://www.ncbi.nlm.nih.gov/pubmed/36395988?tool=bestpractice.com
CBT plus motivational interviewing
Motivational interviewing is a widely used psychotherapeutic technique to increase motivation for behaviour change. If used in conjunction with CBT for OCD, children between the ages of 6 and 17 years in a family-based OCD treatment required an average of three fewer therapy sessions to achieve the same outcomes as those receiving CBT alone.[167]Merlo LJ, Storch EA, Lehmkuhl HD, et al. Cognitive behavioral therapy plus motivational interviewing improves outcome for pediatric obsessive-compulsive disorder: a preliminary study. Cogn Behav Ther. 2010;39(1):24-7.
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2861340
http://www.ncbi.nlm.nih.gov/pubmed/19675960?tool=bestpractice.com
Two sessions of motivational interviewing (with an additional thought-mapping technique) have also been a useful adjunct to standard CBT in adults with OCD.[168]Meyer E, Souza F, Heldt E, et al. A randomized clinical trial to examine enhancing cognitive-behavioral group therapy for obsessive-compulsive disorder with motivational interviewing and thought mapping. Behav Cogn Psychother. 2010 May;38(3):319-36.
http://www.ncbi.nlm.nih.gov/pubmed/20353621?tool=bestpractice.com
[169]Meyer E, Shavitt RG, Leukefeld C, et al. Adding motivational interviewing and thought mapping to cognitive-behavioral group therapy: results from a randomized clinical trial. Rev Bras Psiquiatr. 2010 Mar;32(1):20-9.
http://www.scielo.br/scielo.php?script=sci_arttext&pid=S1516-44462010000100006&lng=en&nrm=iso&tlng=en
http://www.ncbi.nlm.nih.gov/pubmed/20339731?tool=bestpractice.com
Although there have been some promising results, at least one study did not find that an additional motivational interviewing component improved adherence or treatment outcome.[170]Simpson HB, Zuckoff AM, Maher MJ, et al. Challenges using motivational interviewing as an adjunct to exposure therapy for obsessive-compulsive disorder. Behav Res Ther. 2010 Oct;48(10):941-8.
http://www.ncbi.nlm.nih.gov/pubmed/20609435?tool=bestpractice.com
Family-based CBT
Family-based CBT has also been examined for the treatment of OCD and was found to be superior to relaxation for the reduction of OCD symptoms and functional impairment in children aged 5 to 8 years.[171]Freeman J, Sapyta J, Garcia A, et al. Family-based treatment of early childhood obsessive-compulsive disorder: the Pediatric Obsessive-Compulsive Disorder Treatment Study for Young Children (POTS Jr) - a randomized clinical trial. JAMA Psychiatry. 2014 Jun;71(6):689-98.
http://archpsyc.jamanetwork.com/article.aspx?articleid=1861509
http://www.ncbi.nlm.nih.gov/pubmed/24759852?tool=bestpractice.com
Inference-based CBT
In contrast to ERP, inference-based CBT focuses on adjusting cognitions upstream and, if successful, may eliminate the need for exposure work. Early evidence suggests inference-based CBT is effective and may be an alternative treatment option for those with OCD.[172]Aardema F, Bouchard S, Koszycki D, et al. Evaluation of inference-based cognitive-behavioral therapy for obsessive-compulsive disorder: a multicenter randomized controlled trial with three treatment modalities. Psychother Psychosom. 2022;91(5):348-59.
https://karger.com/pps/article/91/5/348/826583/Evaluation-of-Inference-Based-Cognitive-Behavioral
http://www.ncbi.nlm.nih.gov/pubmed/35584639?tool=bestpractice.com
Satiation therapy
In satiation therapy, individuals are instructed to increase their engagement with obsessions and compulsions, effectively doubling or tripling the amount that they think about their obsession and engage in their rituals. The goal is to reduce the pleasure in engaging in OCD symptoms, leading to their reduction. In one study in Iranian males, satiation therapy was found to be as effective as ERP in reducing Yale-Brown Obsessive-Compulsive Scale (Y-BOCS) scores.[173]Khodarahimi S. Satiation therapy and exposure response prevention in the treatment of obsessive compulsive disorder. J Contemp Psychotherapy. 2009;39:203-7.
https://www.researchgate.net/publication/226561979_Satiation_Therapy_and_Exposure_Response_Prevention_in_the_Treatment_of_Obsessive_Compulsive_Disorder
Quality of life therapy (parenting intervention for mothers of children with OCD)
This is an intervention for mothers of children with OCD. It was found to be helpful in decreasing OCD symptoms in children and increasing quality of life for both mother and child.[174]Abedi MR, Vostanis P. Evaluation of quality of life therapy for parents of children with obsessive-compulsive disorders in Iran. Eur Child Adolesc Psychiatry. 2010 Jul;19(7):605-13.
http://www.ncbi.nlm.nih.gov/pubmed/20157835?tool=bestpractice.com
Third wave therapies
Third wave therapies include mindfulness and acceptance and commitment therapy (ACT). Studies evaluating the efficacy of third wave therapies in people with OCD have been small, with methodological limitations; further research is required.[175]Külz A, Barton B, Voderholzer U, et al. Third wave therapies of cognitive behavioral therapy for obsessive compulsive disorder: a reasonable add-on therapy for CBT? State of the art [Article in German]. Psychother Psychosom Med Psychol. 2016 Mar;66(3-4):106-11.
http://www.ncbi.nlm.nih.gov/pubmed/27035439?tool=bestpractice.com
[176]Claus N, Miegel F, Jelinek L, et al. Perfectionism as possible predictor for treatment success in mindfulness-based cognitive therapy and metacognitive training as third-wave treatments for obsessive-compulsive disorder. Cogn Ther Res. 2023 Jun;47(3):439-53.
https://link.springer.com/article/10.1007/s10608-023-10361-0
[177]Philip J, Cherian V. Acceptance and commitment therapy in the treatment of obsessive-compulsive disorder: a systematic review. J Obsessive Compuls Relat Disord. 2021 Jan 1;28:100603.
Augmentation with memantine
Memantine augmentation of first-line pharmacotherapy for moderate to severe OCD is effective after 8 weeks, while being well tolerated and with only mild and transient adverse effects.[178]Modarresi A, Chaibakhsh S, Koulaeinejad N, et al. A systematic review and meta-analysis: memantine augmentation in moderate to severe obsessive-compulsive disorder. Psychiatry Res. 2019 Dec;282:112602.
http://www.ncbi.nlm.nih.gov/pubmed/31630042?tool=bestpractice.com