Treatment algorithm

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer

ACUTE

mild to moderate symptoms: without comorbid personality disorders or dissociative symptoms

1st line – cognitive behavioral therapy

Back
ACUTE
|
mild to moderate symptoms: without comorbid personality disorders or dissociative symptoms
1st line – 

cognitive behavioral therapy

Patients with mild to moderate symptoms include those with Yale-Brown Obsessive-Compulsive Scale scores of 8 to 23.

For these patients, cognitive behavioral therapy is a first-line treatment option and involves exposure and response prevention.[56][63][64][120]

A graded hierarchy of symptom triggers is created with each patient. The therapist encourages the patient to expose him- or herself to the trigger (e.g., dirt). The patient is then encouraged to refrain from engaging in compulsive rituals (e.g., hand washing).

As symptoms begin to improve, more intense triggers are targeted. In addition, homework assignments focus on exposure to stimuli in naturalistic settings such as the home.

Consider – pharmacotherapy

Back
ACUTE
|
mild to moderate symptoms: without comorbid personality disorders or dissociative symptoms
Consider – 

pharmacotherapy

Treatment recommended for SOME patients in selected patient group

Combined treatment with pharmacotherapy and cognitive behavioral therapy (CBT) may be considered in people who do not have a satisfactory response to monotherapy.

Pharmacotherapy with either a selective serotonin-reuptake inhibitor (SSRI) or a tricyclic antidepressant (e.g., clomipramine) may be combined with CBT. Numerous studies have assessed the efficacy of SSRIs for this indication.[70][71][72][73] SSRIs have also been studied for anxiety disorders in children and adolescents.[76]

Clomipramine, the tricyclic antidepressant that most specifically inhibits the reuptake of serotonin, has been shown to be effective in the treatment of obsessive-compulsive disorder (OCD) in uncontrolled trials since the 1960s.[121]

Because of their more limited adverse-effect profile, SSRIs are considered the first-line pharmacologic treatment for OCD, although clomipramine is also widely used as a first-line treatment.[56][63][79]

Higher SSRI doses are often required to achieve symptom reduction in OCD than are used in depression, and improvement is usually slower and requires more time than is typically required in depressive conditions (10 to 12 weeks).[26][81]

Doses higher than the licensed maximum doses for OCD (presented here) may be used cautiously in some patients under specialist guidance with careful monitoring for adverse effects.

Primary options

fluoxetine: children ≥7 years of age: 10 mg orally once daily initially, increase gradually according to response, maximum 60 mg/day; adults: 20 mg orally once daily initially, increase gradually according to response, maximum 80 mg/day

More

OR

fluvoxamine: children ≥8 years of age: 25 mg orally (immediate-release) once daily initially, increase gradually according to response, maximum 200 mg/day (children ≤11 years of age) or 300 mg/day (children >11 years of age) given in 1-2 divided doses; adults: 50 mg orally (immediate-release) once daily initially, increase gradually according to response, maximum 300 mg/day given in 2 divided doses

More

OR

paroxetine: children ≥7 years of age: 10 mg orally (immediate-release) once daily initially, increase gradually according to response, maximum 60 mg/day; adults: 20 mg orally (immediate-release) once daily initially, increase gradually according to response, maximum 60 mg/day

More

OR

sertraline: children ≥6 years of age: 25 mg orally once daily initially, increase gradually according to response, maximum 200 mg/day; children ≥13 years of age and adults: 50 mg orally once daily initially, increase gradually according to response, maximum 200 mg/day

More

OR

clomipramine: children ≥10 years of age: 25 mg orally once daily initially, increase gradually according to response, maximum 200 mg/day; adults: 25 mg orally once daily initially, increase gradually according to response, maximum 250 mg/day

1st line – pharmacotherapy

Back
ACUTE
|
mild to moderate symptoms: without comorbid personality disorders or dissociative symptoms
1st line – 

pharmacotherapy

Patients with mild to moderate symptoms include those with Yale-Brown Obsessive-Compulsive Scale scores of 8 to 23. Pharmacotherapy alone is recommended if cognitive behavioral therapy (CBT) is unavailable, the patient prefers drug treatment alone, or the patient has a history of responding well to a particular agent.[56][63]

For these patients, pharmacotherapy with either a selective serotonin-reuptake inhibitor (SSRI) or a tricyclic antidepressant (e.g., clomipramine) is a first-line treatment option. Numerous studies have assessed the efficacy of SSRIs for this indication.[70][71][72][73] SSRIs have also been studied for anxiety disorders in children and adolescents.[76]

Clomipramine, the tricyclic antidepressant that most specifically inhibits the reuptake of serotonin, has been shown to be effective in the treatment of obsessive-compulsive disorder (OCD) in uncontrolled trials since the 1960s.[121]

Because of their more limited adverse-effect profile, SSRIs are considered the first-line pharmacologic treatment for OCD with or without concurrent CBT,​​​ although clomipramine is also widely used as a first-line treatment.[56][63][79]​​

Higher SSRI doses are often required to achieve symptom reduction in OCD than are used in depression, and improvement is usually slower and requires more time than is typically required in depressive conditions (10 to 12 weeks).[26][81]

Doses higher than the licensed maximum doses for OCD (presented here) may be used cautiously in some patients under specialist guidance with careful monitoring for adverse effects.

Primary options

fluoxetine: children ≥7 years of age: 10 mg orally once daily initially, increase gradually according to response, maximum 60 mg/day; adults: 20 mg orally once daily initially, increase gradually according to response, maximum 80 mg/day

More

OR

fluvoxamine: children ≥8 years of age: 25 mg orally (immediate-release) once daily initially, increase gradually according to response, maximum 200 mg/day (children ≤11 years of age) or 300 mg/day (children >11 years of age) given in 1-2 divided doses; adults: 50 mg orally (immediate-release) once daily initially, increase gradually according to response, maximum 300 mg/day given in 2 divided doses

More

OR

paroxetine: children ≥7 years of age: 10 mg orally (immediate-release) once daily initially, increase gradually according to response, maximum 60 mg/day; adults: 20 mg orally (immediate-release) once daily initially, increase gradually according to response, maximum 60 mg/day

More

OR

sertraline: children ≥6 years of age: 25 mg orally once daily initially, increase gradually according to response, maximum 200 mg/day; children ≥13 years of age and adults: 50 mg orally once daily initially, increase gradually according to response, maximum 200 mg/day

More

OR

clomipramine: children ≥10 years of age: 25 mg orally once daily initially, increase gradually according to response, maximum 200 mg/day; adults: 25 mg orally once daily initially, increase gradually according to response, maximum 250 mg/day

Consider – cognitive behavioral therapy

Back
ACUTE
|
mild to moderate symptoms: without comorbid personality disorders or dissociative symptoms
Consider – 

cognitive behavioral therapy

Treatment recommended for SOME patients in selected patient group

Cognitive behavioral therapy (CBT) involves exposure and response prevention.[56][63][64][120]​ Combined treatment with CBT and pharmacotherapy may be considered in people who do not have a satisfactory response to monotherapy.

A graded hierarchy of symptom triggers is created with each patient. The therapist encourages the patient to expose him- or herself to the trigger (e.g., dirt). The patient is then encouraged to refrain from engaging in compulsive rituals (e.g., hand washing).

As symptoms begin to improve, more intense triggers are targeted. In addition, homework assignments focus on exposure to stimuli in naturalistic settings such as the home.

2nd line – increase in dose of current drug or consideration of combination drug therapy

Back
ACUTE
|
mild to moderate symptoms: without comorbid personality disorders or dissociative symptoms
2nd line – 

increase in dose of current drug or consideration of combination drug therapy

The first step in the case of a partial responder (25% to 35% reduction in Yale-Brown Obsessive-Compulsive Scale [Y-BOCS] score) at the sixth to eighth week of treatment should be to increase the dose of the current drug.

At 12 weeks, if a patient has exhibited a partial response to an agent, augmentation strategies might be preferred to switching to a different drug. Augmentation strategies include: increasing the dose of the current drug to the highest tolerable dose (doses higher than the licensed maximum doses for obsessive-compulsive disorder [OCD] may be used cautiously in some patients under specialist guidance with careful monitoring for adverse effects); using intravenous citalopram or clomipramine (however, these formulations are not available in general clinical settings in the US); or combining regimens (e.g., selective serotonin-reuptake inhibitor [SSRI] plus clomipramine, or SSRI plus an antipsychotic).[91]

Caution is advised if using citalopram, because of its association with QT interval prolongation. Special caution is advised in those over 60 years of age or who have pre-existing potential for QTc prolongation/arrhythmias either due to inherent disease or due to other concomitant drugs.[63][78][89]

If the patient does not respond to the highest tolerated dose of SSRI for 12 weeks, augmentation with an antipsychotic may be considered. It should also be noted that some antidepressants may inhibit antipsychotic metabolism; cytochrome P450 2D6 inhibition by fluoxetine and paroxetine may be particularly important. Several studies have suggested that risperidone is effective as an augmentation agent in OCD.[92][93][94][95][97]​​ Evidence also exists for haloperidol, quetiapine, and olanzapine.[96][97][100][122][123][124][125][126]​​ Due to an association with metabolic syndrome, use should be accompanied by screening of lipids, fasting glucose, and other metabolic syndrome indicators.

Prior to starting combination therapy with an SSRI plus clomipramine, a screening EKG should be performed, heart rate and BP should be monitored as the dose is titrated, and plasma levels of clomipramine and desmethylclomipramine should be assayed 2 to 3 weeks after reaching a dose of 50 mg/day.[56] The total plasma level of clomipramine and desmethylclomipramine should be kept below 500 nanograms/mL, to avoid CNS and/or cardiac toxicity.[56][127]

Consider – cognitive behavioral therapy

Back
ACUTE
|
mild to moderate symptoms: without comorbid personality disorders or dissociative symptoms
Consider – 

cognitive behavioral therapy

Treatment recommended for SOME patients in selected patient group

If the patient has not had an adequate trial of cognitive behavioral therapy (CBT), in the form of exposure and response prevention, it should be added to the treatment regimen.

A graded hierarchy of symptom triggers is created with each patient. The therapist encourages the patient to expose him- or herself to the trigger (e.g., dirt). The patient is then encouraged to refrain from engaging in compulsive rituals (e.g., hand washing).

As symptoms begin to improve, more intense triggers are targeted. In addition, homework assignments focus on exposure to stimuli in naturalistic settings such as the home.

2nd line – transcranial magnetic stimulation

Back
ACUTE
|
mild to moderate symptoms: without comorbid personality disorders or dissociative symptoms
2nd line – 

transcranial magnetic stimulation

Transcranial magnetic stimulation (TMS), a form of noninvasive brain stimulation (NIBS), uses magnetic fields to stimulate neurons in the brain, and enhance neuroplasticity, mostly targeting the presupplementary motor area, the dorsolateral prefrontal cortex, and the anterior cingulate.[31][32][33][34]​ Because TMS is an intervention that includes different patterns and locations of stimulation, treatment can be tailored to each individual’s underlying pathophysiology.

Treatment with TMS is safe and effective in improving obsessive-compulsive disorder (OCD) symptoms in patients unsuccessfully treated with cognitive behavioral therapy (CBT) or selective serotonin-reuptake inhibitors (SSRIs) and should be considered after the first treatment failure (whether CBT or pharmacotherapy) in mild to moderate cases.[107]

TMS can be used as monotherapy or other treatments (e.g., CBT) can be added to augment the TMS effects.

Consider – pharmacotherapy

Back
ACUTE
|
mild to moderate symptoms: without comorbid personality disorders or dissociative symptoms
Consider – 

pharmacotherapy

Treatment recommended for SOME patients in selected patient group

In clinical practice, transcranial magnetic stimulation (TMS) may be most beneficial in resistant forms of obsessive-compulsive disorder (OCD), especially if used in combination with pharmacologic therapy.[108][109]​​ Options for pharmacotherapy depend on the treatments used in the first-line setting and the treatments the patient is currently receiving.

Consider – cognitive behavioral therapy

Back
ACUTE
|
mild to moderate symptoms: without comorbid personality disorders or dissociative symptoms
Consider – 

cognitive behavioral therapy

Treatment recommended for SOME patients in selected patient group

Cognitive behavioral therapy (CBT) involves exposure and response prevention.[56][63][64][120]​​ Combined treatment with transcranial magnetic stimulation (TMS) and CBT may be considered in people who do not have a satisfactory response to monotherapy with either treatment or who do not respond adequately to pharmacotherapy. Concurrent CBT targets the same dysfunctional neural circuitry as TMS, enhancing neuroplasticity in the targeted neural circuit to improve outcomes.[110]

A graded hierarchy of symptom triggers is created with each patient. The therapist then encourages the patient to expose him- or herself to the trigger (e.g., dirt). The patient is then encouraged to refrain from engaging in compulsive rituals (e.g., hand washing).

As symptoms begin to improve, more intense triggers are targeted. In addition, homework assignments focus on exposure to stimuli in naturalistic settings such as the home.

3rd line – consideration of switching to a different antidepressant

Back
ACUTE
|
mild to moderate symptoms: without comorbid personality disorders or dissociative symptoms
3rd line – 

consideration of switching to a different antidepressant

If patients have not achieved at least a 25% reduction in Y-BOCS score or a 4 on the clinical global impression (CGI) scale after 12 weeks at full dose of a single drug, switching to a different drug is recommended, because patients may respond to one drug better than another.[56][63]​ However, there is also evidence suggesting that patients who failed to respond to the initial drug may be less likely than treatment-naive patients to respond to further trials of other drugs.[119]

The label "treatment-resistant" is generally used to describe patients who have failed to respond to at least two adequate trials of clomipramine or selective serotonin-reuptake inhibitors (SSRIs) for at least 12 weeks.

Primary options

fluoxetine: children ≥7 years of age: 10 mg orally once daily initially, increase gradually according to response, maximum 60 mg/day; adults: 20 mg orally once daily initially, increase gradually according to response, maximum 80 mg/day

More

OR

fluvoxamine: children ≥8 years of age: 25 mg orally (immediate-release) once daily initially, increase gradually according to response, maximum 200 mg/day (children ≤11 years of age) or 300 mg/day (children >11 years of age) given in 1-2 divided doses; adults: 50 mg orally (immediate-release) once daily initially, increase gradually according to response, maximum 300 mg/day given in 2 divided doses

More

OR

paroxetine: children ≥7 years of age: 10 mg orally (immediate-release) once daily initially, increase gradually according to response, maximum 60 mg/day; adults: 20 mg orally (immediate-release) once daily initially, increase gradually according to response, maximum 60 mg/day

More

OR

sertraline: children ≥6 years of age: 25 mg orally once daily initially, increase gradually according to response, maximum 200 mg/day; children ≥13 years of age and adults: 50 mg orally once daily initially, increase gradually according to response, maximum 200 mg/day

More

OR

clomipramine: children ≥10 years of age: 25 mg orally once daily initially, increase gradually according to response, maximum 200 mg/day; adults: 25 mg orally once daily initially, increase gradually according to response, maximum 250 mg/day

Consider – cognitive behavioral therapy

Back
ACUTE
|
mild to moderate symptoms: without comorbid personality disorders or dissociative symptoms
Consider – 

cognitive behavioral therapy

Treatment recommended for SOME patients in selected patient group

If the patient has not had an adequate trial of cognitive behavioral therapy (CBT), in the form of exposure and response prevention, it should be added to the treatment regimen.

A graded hierarchy of symptom triggers is created with each patient. The therapist encourages the patient to expose him- or herself to the trigger (e.g., dirt). The patient is then encouraged to refrain from engaging in compulsive rituals (e.g., hand washing).

As symptoms begin to improve, more intense triggers are targeted. In addition, homework assignments focus on exposure to stimuli in naturalistic settings such as the home.

4th line – further specialist evaluation

Back
ACUTE
|
mild to moderate symptoms: without comorbid personality disorders or dissociative symptoms
4th line – 

further specialist evaluation

After trials with clomipramine and at least two selective serotonin-reuptake inhibitors (SSRIs), with augmentation using cognitive behavioral therapy, a patient may be classified as a nonresponder.

Rarely, cases may be related to an organic cause (e.g., neurodegenerative processes, poststroke obsessive-compulsive disorder [OCD] phenomena, hypothyroidism, or other so-called "acquired" forms of OCD that can occur as a result of Huntington disease, Sydenham chorea, rheumatic fever, bacterial or viral infection, or encephalitis). The characteristics of the residual clinical features should guide the choice of further treatment.

At this point, further specialist evaluation is suggested, as other augmentation regimens may be warranted, depending on comorbidities or prevalent features in the individual patient's OCD symptomatology.

severe symptoms or with comorbid personality disorders or dissociative symptoms

1st line – cognitive behavioral therapy plus pharmacotherapy

Back
ACUTE
|
severe symptoms or with comorbid personality disorders or dissociative symptoms
1st line – 

cognitive behavioral therapy plus pharmacotherapy

Patients with severe symptoms include those with Yale-Brown Obsessive-Compulsive Scale scores of 24 to 40.

Drug therapy may alleviate severe symptoms enough to allow participation in cognitive behavioral therapy (CBT).[56][63]

Those who do not respond to monotherapy with either CBT or pharmacotherapy, especially those who have comorbid personality disorders or dissociative symptoms, may benefit from combined therapy.[85][86][87]

Combining CBT with pharmacotherapy is indicated as first-line treatment for comorbid obsessive-compulsive disorder (OCD) with depression.

Primary options

fluoxetine: children ≥7 years of age: 10 mg orally once daily initially, increase gradually according to response, maximum 60 mg/day; adults: 20 mg orally once daily initially, increase gradually according to response, maximum 80 mg/day

More

OR

fluvoxamine: children ≥8 years of age: 25 mg orally (immediate-release) once daily initially, increase gradually according to response, maximum 200 mg/day (children ≤11 years of age) or 300 mg/day (children >11 years of age) given in 1-2 divided doses; adults: 50 mg orally (immediate-release) once daily initially, increase gradually according to response, maximum 300 mg/day given in 2 divided doses

More

OR

paroxetine: children ≥7 years of age: 10 mg orally (immediate-release) once daily initially, increase gradually according to response, maximum 60 mg/day; adults: 20 mg orally (immediate-release) once daily initially, increase gradually according to response, maximum 60 mg/day

More

OR

sertraline: children ≥6 years of age: 25 mg orally once daily initially, increase gradually according to response, maximum 200 mg/day; children ≥13 years of age and adults: 50 mg orally once daily initially, increase gradually according to response, maximum 200 mg/day

More

OR

clomipramine: children ≥10 years of age: 25 mg orally once daily initially, increase gradually according to response, maximum 200 mg/day; adults: 25 mg orally once daily initially, increase gradually according to response, maximum 250 mg/day

2nd line – increase in dose of current drug or consideration of combination drug therapy

Back
ACUTE
|
severe symptoms or with comorbid personality disorders or dissociative symptoms
2nd line – 

increase in dose of current drug or consideration of combination drug therapy

The first step in the case of a partial responder at the sixth to eighth week of treatment should be to increase the dose of the current drug.

At 12 weeks, if a patient has exhibited a partial response to an agent, augmentation strategies might be preferred to switching to a different drug. Augmentation strategies include: increasing the dose of the current drug to the highest tolerable dose (doses higher than the licensed maximum doses for obsessive-compulsive disorder [OCD] may be used cautiously in some patients under specialist guidance with careful monitoring for adverse effects); using intravenous citalopram or clomipramine (however, these formulations are not available in general clinical settings in the US); or combining regimens (e.g., selective serotonin-reuptake inhibitor (SSRI) plus clomipramine, or SSRI plus an antipsychotic).[91]

Caution is advised if using citalopram, because of its association with QT interval prolongation. Special caution is advised in those over 60 years of age or who have pre-existing potential for QTc prolongation/arrhythmias either due to inherent disease or due to other concomitant drugs.[63][78][89]

If the patient does not respond to the highest tolerated dose of SSRI for 12 weeks, augmentation with an antipsychotic may be considered. It should also be noted that some antidepressants may inhibit antipsychotic metabolism; cytochrome P450 2D6 inhibition by fluoxetine and paroxetine may be particularly important. Several studies have suggested that risperidone is effective as an augmentation agent in OCD.[92][93][94][95][97]​​ Evidence also exists for haloperidol, quetiapine, and olanzapine.[96][97][100][122][123][124][125][126]​​ Due to an association with metabolic syndrome, use should be accompanied by screening of lipids, fasting glucose, and other metabolic syndrome indicators.

Prior to starting combination therapy with an SSRI plus clomipramine, a screening EKG should be performed, heart rate and BP should be monitored as the dose is titrated, and plasma levels of clomipramine and desmethylclomipramine should be assayed 2 to 3 weeks after reaching a dose of 50 mg/day.[56] The total plasma level of clomipramine and desmethylclomipramine should be kept below 500 nanograms/mL, to avoid CNS and/or cardiac toxicity.[56][127]

Consider – cognitive behavioral therapy

Back
ACUTE
|
severe symptoms or with comorbid personality disorders or dissociative symptoms
Consider – 

cognitive behavioral therapy

Treatment recommended for SOME patients in selected patient group

If the patient has not had an adequate trial of cognitive behavioral therapy (CBT), in the form of exposure and response prevention, it should be added to the treatment regimen.

A graded hierarchy of symptom triggers is created with each patient. The therapist encourages the patient to expose him- or herself to the trigger (e.g., dirt). The patient is then encouraged to refrain from engaging in compulsive rituals (e.g., hand washing).

As symptoms begin to improve, more intense triggers are targeted. In addition, homework assignments focus on exposure to stimuli in naturalistic settings such as the home.

2nd line – transcranial magnetic stimulation

Back
ACUTE
|
severe symptoms or with comorbid personality disorders or dissociative symptoms
2nd line – 

transcranial magnetic stimulation

​Transcranial magnetic stimulation (TMS), a form of noninvasive brain stimulation (NIBS), uses magnetic fields to stimulate neurons in the brain, and enhance neuroplasticity, mostly targeting the presupplementary motor area, the dorsolateral prefrontal cortex, and the anterior cingulate.[31][32][33][34]​ Because TMS is an intervention that includes different patterns and locations of stimulation, treatment can be tailored to each individual’s underlying pathophysiology.

Treatment with TMS is safe and effective in improving obsessive-compulsive disorder (OCD) symptoms in patients unsuccessfully treated with cognitive behavioral therapy (CBT) or selective serotonin-reuptake inhibitors (SSRIs) and should be considered after the first treatment failure (whether CBT or pharmacotherapy) in severe cases.[107]

TMS can be used as monotherapy or other treatments (e.g., CBT) can be added to augment the TMS effects.

Consider – pharmacotherapy

Back
ACUTE
|
severe symptoms or with comorbid personality disorders or dissociative symptoms
Consider – 

pharmacotherapy

Treatment recommended for SOME patients in selected patient group

In clinical practice, transcranial magnetic stimulation (TMS) may be most beneficial in resistant forms of obsessive-compulsive disorder (OCD), especially if used in combination with pharmacologic therapy.[108][109]​​ Options for pharmacotherapy depend on the treatments used in the first-line setting and the treatments the patient is currently receiving.

Consider – cognitive behavioral therapy

Back
ACUTE
|
severe symptoms or with comorbid personality disorders or dissociative symptoms
Consider – 

cognitive behavioral therapy

Treatment recommended for SOME patients in selected patient group

Cognitive behavioral therapy (CBT) involves exposure and response prevention.[56][63][64][120]​​ Combined treatment with transcranial magnetic stimulation (TMS) and CBT may be considered in people who do not have a satisfactory response to monotherapy with either treatment or who do not respond adequately to pharmacotherapy. Concurrent CBT targets the same dysfunctional neural circuitry as TMS, enhancing neuroplasticity in the targeted neural circuit to improve outcomes.[110]

A graded hierarchy of symptom triggers is created with each patient. The therapist then encourages the patient to expose him- or herself to the trigger (e.g., dirt). The patient is then encouraged to refrain from engaging in compulsive rituals (e.g., hand washing).

As symptoms begin to improve, more intense triggers are targeted. In addition, homework assignments focus on exposure to stimuli in naturalistic settings such as the home.

3rd line – consideration of switching to a different antidepressant

Back
ACUTE
|
severe symptoms or with comorbid personality disorders or dissociative symptoms
3rd line – 

consideration of switching to a different antidepressant

If patients have not achieved at least a 25% reduction in Y-BOCS score or a 4 on the clinical global impression (CGI) scale after 12 weeks at full dose of a single drug, switching to a different drug is recommended, because patients may respond to one drug better than another.[56][63]​ However, there is also evidence suggesting that patients who failed to respond to the initial drug may be less likely than treatment-naive patients to respond to further trials of other drugs.[119]

The label "treatment-resistant" is generally used to describe patients who have failed to respond to at least two adequate trials of clomipramine or selective serotonin-reuptake inhibitors (SSRIs) for at least 12 weeks.

Primary options

fluoxetine: children ≥7 years of age: 10 mg orally once daily initially, increase gradually according to response, maximum 60 mg/day; adults: 20 mg orally once daily initially, increase gradually according to response, maximum 80 mg/day

More

OR

fluvoxamine: children ≥8 years of age: 25 mg orally (immediate-release) once daily initially, increase gradually according to response, maximum 200 mg/day (children ≤11 years of age) or 300 mg/day (children >11 years of age) given in 1-2 divided doses; adults: 50 mg orally (immediate-release) once daily initially, increase gradually according to response, maximum 300 mg/day given in 2 divided doses

More

OR

paroxetine: children ≥7 years of age: 10 mg orally (immediate-release) once daily initially, increase gradually according to response, maximum 60 mg/day; adults: 20 mg orally (immediate-release) once daily initially, increase gradually according to response, maximum 60 mg/day

More

OR

sertraline: children ≥6 years of age: 25 mg orally once daily initially, increase gradually according to response, maximum 200 mg/day; children ≥13 years of age and adults: 50 mg orally once daily initially, increase gradually according to response, maximum 200 mg/day

More

OR

clomipramine: children ≥10 years of age: 25 mg orally once daily initially, increase gradually according to response, maximum 200 mg/day; adults: 25 mg orally once daily initially, increase gradually according to response, maximum 250 mg/day

Consider – cognitive behavioral therapy

Back
ACUTE
|
severe symptoms or with comorbid personality disorders or dissociative symptoms
Consider – 

cognitive behavioral therapy

Treatment recommended for SOME patients in selected patient group

If the patient has not had an adequate trial of cognitive behavioral therapy (CBT), in the form of exposure and response prevention, it should be added to the treatment regimen.

A graded hierarchy of symptom triggers is created with each patient. The therapist encourages the patient to expose him- or herself to the trigger (e.g., dirt). The patient is then encouraged to refrain from engaging in compulsive rituals (e.g., hand washing).

As symptoms begin to improve, more intense triggers are targeted. In addition, homework assignments focus on exposure to stimuli in naturalistic settings such as the home.

4th line – further specialist evaluation

Back
ACUTE
|
severe symptoms or with comorbid personality disorders or dissociative symptoms
4th line – 

further specialist evaluation

After trials with clomipramine and at least two selective serotonin-reuptake inhibitors (SSRIs), with augmentation using cognitive behavioral therapy, a patient may be classified as a nonresponder.

Rarely, cases may be related to an organic cause (e.g., neurodegenerative processes, poststroke obsessive-compulsive disorder [OCD] phenomena, hypothyroidism, or other so-called "acquired" forms of OCD that can occur as a result of Huntington disease, Sydenham chorea, rheumatic fever, bacterial or viral infection, or encephalitis). The characteristics of the residual clinical features should guide the choice of further treatment.

At this point, further specialist evaluation is suggested as other augmentation regimens may be warranted depending on comorbidities or prevalent features in the individual patient's OCD symptomatology.

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Choose a patient group to see our recommendations

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups. See disclaimer

Use of this content is subject to our disclaimer