How fast does SSRI/addition of anti-psychotic adjuvant work in OCD?

[caxoo]

How fast in your clinical experience does it take for SSRI to kick into effect (let's say ~50% response) in OCD?

When pt is already on SSRI, how fast does it take for anti-psychotic adjuvant to kick into effect?

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[romanticscience]

I'm not an OCD expert but I quickly pubmed'd a clinical trial using risperidone augmentation.

Risperidone augmentation of SRI treatment for refractory obsessive-compulsive disorder - PubMed

These results suggest that risperidone augmentation is effective and well tolerated in patients with SRI-refractory obsessive-compulsive disorder. Response to risperidone augmentation appears to be influenced by symptom subtypes and comorbid conditions. Controlled trials are required to confirm...

pubmed.ncbi.nlm.nih.gov

From results: "Of the 16 patients who tolerated combined treatment, 14 (87%) had substantial reductions in obsessive-compulsive symptoms within 3 weeks."

I often find the method sections of the clinical trials helpful for these types of questions, especially dosing details.

 

[caxoo]

I'm not an OCD expert but I quickly pubmed'd a clinical trial using risperidone augmentation.

Risperidone augmentation of SRI treatment for refractory obsessive-compulsive disorder - PubMed

These results suggest that risperidone augmentation is effective and well tolerated in patients with SRI-refractory obsessive-compulsive disorder. Response to risperidone augmentation appears to be influenced by symptom subtypes and comorbid conditions. Controlled trials are required to confirm...

pubmed.ncbi.nlm.nih.gov

From results: "Of the 16 patients who tolerated combined treatment, 14 (87%) had substantial reductions in obsessive-compulsive symptoms within 3 weeks."

I often find the method sections of the clinical trials helpful for these types of questions, especially dosing details.

Excellent exactly what I was looking for ty, I also pubmeded before asking the Q but my search skills seem to be weaker than yours

 

[MacDonaldTriad]

Be careful, there is a large literature of SGAs causing a worsening of OCD. They block post synaptic 5HT-2 receptors and can cause OCD symptoms in people who have never had OCD symptoms. SGAs are listed as an augmentation strategy for OCD and they can be useful, but it can go both ways so pay attention.

 

[clausewitz2]

Be careful, there is a large literature of SGAs causing a worsening of OCD. They block post synaptic 5HT-2 receptors and can cause OCD symptoms in people who have never had OCD symptoms. SGAs are listed as an augmentation strategy for OCD and they can be useful, but it can go both ways so pay attention.

This is fairly well established for clozapine as a well-documented phenomenon and I am reasonably convinced by the literature that it might happen with olanzapine as well, but the evidence beyond those two is very sparse. I am just not impressed by the available data for risperidone, for instance. I suspect that even when risperidone appears to be causing OCS (generally we are talking about new OCD sx, rather than suddenly meeting criteria for the disorder per se), probably what is happening is other concerns have been addressed sufficiently for less pressing or less distressing things to come to the fore and become the focus of attention.

In general with SSRIs in OCD expert opinion is going to tell you 6-8 weeks for assessing clinical response, with a fair amount of evidence that for assessing the full magnitude of response requiring you waiting out till 12 weeks. There's been less done that clearly separates the response curves for what might be called "conventional" SSRI dosing (e.g. sertraline up to 200 mg) and "OCD" dosing (e.g. sertraline up to 400 mg). I treat a lot of OCD and tend to be more aggressive about getting to OCD dosing, but it still takes a few weeks and I have at times stopped titrations primarily because things improved so much after 4ish weeks that there didn't seem to be a point to increasing it.

Bear in mind thought that some people with OCD experience tremendous improvement very rapidly early in treatment with appropriate psychoeducation and basic EX/RP principles. turns out knowing there's a name for having thoughts you don't want about murdering your whole family every day and an explanation possible beyond "you're a psychopath" can make a big difference for some people.

 

[romanticscience]

I just had an ocd patient who felt very lonely about not being invited to homecoming stating he wanted to shoot up his school. I had to tell the school.

For those OCD experts, any advice on how to handle related situations (i.e., intrusive violent thought)? The medico-legal risk seems to, unfortunately, hinge too much on phenomenology. Which, sadly, very few appreciate. Another example would be a pedophilic obsession and child-lining responsibility.

I've heard the lore that those with violent obsessions are at lower risk of violence. Is there evidence for that?

Lastly, any help with differentiating obsessions in those with identity disturbance (BPD or dissociative d/o), where they have difficulty with the "intrusion" part ("Intrusive to what, I don't know who I am").

The below article has been helpful for me:

Obsession in the strict sense: A helpful psychopathological phenomenon in the differential diagnosis between obsessive-compulsive disorder and schizophrenia - PubMed

The paper presented follows the hypothesis that differentiation between obsessive-compulsive disorder and schizophrenia is possible only by focusing on the single phenomenon of obsession. The statement of a nosological specificity of obsession, called obsession in the strict sense, is set...

pubmed.ncbi.nlm.nih.gov

 

[romanticscience]

Excellent exactly what I was looking for ty, I also pubmeded before asking the Q but my search skills seem to be weaker than yours

No worries, it took me some time too. Limiting the search to "clinical trials" does the trick.

 

[clausewitz2]

I just had an ocd patient who felt very lonely about not being invited to homecoming stating he wanted to shoot up his school. I had to tell the school.

So did he actually want to shoot up his school, or did he just have repetitive unwanted thoughts or imaged pop into his head about him shooting up his school?

If it was actually the later I think that may not have been the right call.

 

[clausewitz2]

For those OCD experts, any advice on how to handle related situations (i.e., intrusive violent thought)? The medico-legal risk seems to, unfortunately, hinge too much on phenomenology. Which, sadly, very few appreciate. Another example would be a pedophilic obsession and child-lining responsibility.

I've heard the lore that those with violent obsessions are at lower risk of violence. Is there evidence for that?

Lastly, any help with differentiating obsessions in those with identity disturbance (BPD or dissociative d/o), where they have difficulty with the "intrusion" part ("Intrusive to what, I don't know who I am").

The below article has been helpful for me:

Obsession in the strict sense: A helpful psychopathological phenomenon in the differential diagnosis between obsessive-compulsive disorder and schizophrenia - PubMed

The paper presented follows the hypothesis that differentiation between obsessive-compulsive disorder and schizophrenia is possible only by focusing on the single phenomenon of obsession. The statement of a nosological specificity of obsession, called obsession in the strict sense, is set...

pubmed.ncbi.nlm.nih.gov

One useful way is also to assess for associated compulsions. If there do not appear to be any that are identifiable, it is unlikely to be OCD and the literature and OCD experts are fairly unified in saying this. Genuine 'Pure O' isn't really a thing. Having said that, the compulsions can be 100% mental and sometimes hard to identify. Still, if the only reaction to the distress of the thoughts is attempts at distraction (e.g. smoking weed), probably not OCD.

 

[birchswing]

I just had an ocd patient who felt very lonely about not being invited to homecoming stating he wanted to shoot up his school. I had to tell the school.

What is the connection to OCD in this case?

If it was OCD intrusive thoughts, they are fairly distinguishable. Causing distress, perseverating, "what if this then this, then that means that. . . " etc.

For those OCD experts, any advice on how to handle related situations (i.e., intrusive violent thought)? The medico-legal risk seems to, unfortunately, hinge too much on phenomenology. Which, sadly, very few appreciate. Another example would be a pedophilic obsession and child-lining responsibility.

I've heard the lore that those with violent obsessions are at lower risk of violence. Is there evidence for that?

Lastly, any help with differentiating obsessions in those with identity disturbance (BPD or dissociative d/o), where they have difficulty with the "intrusion" part ("Intrusive to what, I don't know who I am").

The below article has been helpful for me:

Obsession in the strict sense: A helpful psychopathological phenomenon in the differential diagnosis between obsessive-compulsive disorder and schizophrenia - PubMed

The paper presented follows the hypothesis that differentiation between obsessive-compulsive disorder and schizophrenia is possible only by focusing on the single phenomenon of obsession. The statement of a nosological specificity of obsession, called obsession in the strict sense, is set...

pubmed.ncbi.nlm.nih.gov

This is why Germany does not allow any medical provider to report anything.

You can't have two competing patients: the patient and the public interest.

Psychiatrists and therapists in Germany are like priests. Actually all doctors are. There is no mandatory reporting, let alone optional reporting.

The patient interest is the only interest. Not even a terrorist attack threat could be reported.

There have been studies of mandatory reporting laws and found that most in the US involving children were unfounded. You could make an argument that helping people with unhealthy predilections and forsaking mandatory reporting could improve things for both the patient and the public interest.

Edit: I was just re-reading the Germanwings case (the pilot committed suicide and took a commercial plane down and had been seeing psychiatrists for psychosis and depression), and I'm unclear now if the reporting is allowable. It looks like it's frowned upon, but maybe is possible. But definitely not mandatory.

 

[PikminOC]

What is the connection to OCD in this case?

If it was OCD intrusive thoughts, they are fairly distinguishable. Causing distress, perseverating, "what if this then this, then that means that. . . " etc.

This is why Germany does not allow any medical provider to report anything.

You can't have two competing patients: the patient and the public interest.

Psychiatrists and therapists in Germany are like priests. Actually all doctors are. There is no mandatory reporting, let alone optional reporting.

The patient interest is the only interest. Not even a terrorist attack threat could be reported.

There have been studies of mandatory reporting laws and found that most in the US involving children were unfounded. You could make an argument that helping people with unhealthy predilections and forsaking mandatory reporting could improve things for both the patient and the public interest.

Edit: I was just re-reading the Germanwings case (the pilot committed suicide and took a commercial plane down and had been seeing psychiatrists for psychosis and depression), and I'm unclear now if the reporting is allowable. It looks like it's frowned upon, but maybe is possible. But definitely not mandatory.

This is America

 

[Mad Jack]

What is the connection to OCD in this case?

If it was OCD intrusive thoughts, they are fairly distinguishable. Causing distress, perseverating, "what if this then this, then that means that. . . " etc.

This is why Germany does not allow any medical provider to report anything.

You can't have two competing patients: the patient and the public interest.

Psychiatrists and therapists in Germany are like priests. Actually all doctors are. There is no mandatory reporting, let alone optional reporting.

The patient interest is the only interest. Not even a terrorist attack threat could be reported.

There have been studies of mandatory reporting laws and found that most in the US involving children were unfounded. You could make an argument that helping people with unhealthy predilections and forsaking mandatory reporting could improve things for both the patient and the public interest.

Edit: I was just re-reading the Germanwings case (the pilot committed suicide and took a commercial plane down and had been seeing psychiatrists for psychosis and depression), and I'm unclear now if the reporting is allowable. It looks like it's frowned upon, but maybe is possible. But definitely not mandatory.

I've seen more than one life likely saved by our ability to report. One of which was a prevented mass shooting incident, with clear intent and plan to act within days of the report

 

[Mad Jack]

Be careful, there is a large literature of SGAs causing a worsening of OCD. They block post synaptic 5HT-2 receptors and can cause OCD symptoms in people who have never had OCD symptoms. SGAs are listed as an augmentation strategy for OCD and they can be useful, but it can go both ways so pay attention.

Do you know of any decent data on aripiprazole or brexpiprazole? I would imagine they would stand out with regard to OCD from other atypicals, but as we all know receptor profiles and theories do not always equate to data and clinical results

 

[clausewitz2]

What is the connection to OCD in this case?

If it was OCD intrusive thoughts, they are fairly distinguishable. Causing distress, perseverating, "what if this then this, then that means that. . . " etc.

This is why Germany does not allow any medical provider to report anything.

You can't have two competing patients: the patient and the public interest.

Psychiatrists and therapists in Germany are like priests. Actually all doctors are. There is no mandatory reporting, let alone optional reporting.

The patient interest is the only interest. Not even a terrorist attack threat could be reported.

There have been studies of mandatory reporting laws and found that most in the US involving children were unfounded. You could make an argument that helping people with unhealthy predilections and forsaking mandatory reporting could improve things for both the patient and the public interest.

Edit: I was just re-reading the Germanwings case (the pilot committed suicide and took a commercial plane down and had been seeing psychiatrists for psychosis and depression), and I'm unclear now if the reporting is allowable. It looks like it's frowned upon, but maybe is possible. But definitely not mandatory.

Germany is perhaps a unique case in the legal strength of individual privacy protections in general. Having had 50 years of the Gestapo+Stasi will tend to have that effect on a culture.

 

[clausewitz2]

Do you know of any decent data on aripiprazole or brexpiprazole? I would imagine they would stand out with regard to OCD from other atypicals, but as we all know receptor profiles and theories do not always equate to data and clinical results

Abilify does have the best evidence for use in augmenting SSRIs for OCD. I have not seen any studies looking at brexpiprazole for this indication.

 

[clausewitz2]

Not repetitive unwanted. Due to specific trigger of homecoming

Having a trigger is perfectly consistent with OCD. Was this person afraid they were going to shoot up the school, or actively planning out how to do it and wanted to?

 

[clausewitz2]

Above my pay grade. Let the police decide.

I'd suggest referring out people with OCD in the future.

 

[birchswing]

As someone with OCD, I have seen this fear in patient forums before regarding a need to confess (part of OCD) or discuss for clinical reasons intrusive thoughts and concern about mental health providers contacting the police. It's usually in the context of concern over the provider not understanding the nature of OCD. This seems like a step beyond that in which the nature is understood but there is either an indifference to it or a very broad sense of liability. This is the opposite of therapeutic. It's taking the message that these are just thoughts into "you really would do this," which is what the patient already fears. I've encountered much, much lower grade examples. For example, telling my PCP once I thought I had gotten a disease in the most implausible way. His response was, "We need to the test or you'll always worry." If he really understood OCD, he would know I was going to worry despite the test and that the test was reinforcing it. Not quite the same as calling the police.

Maybe there was something unique about this case in particular, but if so I didn't understand the reference to OCD in the context of it.

Given that this person does have OCD, it might be (probably will be) difficult for them to get help moving forward if their theme revolves around harm, and this was the outcome.

 

[birchswing]

I've seen more than one life likely saved by our ability to report. One of which was a prevented mass shooting incident, with clear intent and plan to act within days of the report

I was mistaken. It does seem like Germany has the ability to report with imminent harm. The articles I've looked up on it seem to be a bit all over the place. It seems like maybe it's a mix of the law being different and also a cultural difference. I am sure mandatory reporting has saved people, but I also wonder how many people could have been helped and prevented committing crimes by being able to discuss problems openly. Maybe unknowable.

 

[clausewitz2]

Will take that under advisement. Circular filed.

Mkay. Why would you want to treat something you don't know how or are inclined to assess?

 

[calvnandhobbs68]

Above my pay grade. Let the police decide.

I guess my next question would be how did you even know this was an OCD related obesession? All intrusive, violent, etc. thoughts are not OCD. Assessing whether this is ego dystonic or not is a pretty basic part of psychiatric assessment….I’d expect that kind of answer from a surgeon consulting me on one of their inpatients because some guy said he wanted to blow their brains out.

 

[splik]

For those OCD experts, any advice on how to handle related situations (i.e., intrusive violent thought)? The medico-legal risk seems to, unfortunately, hinge too much on phenomenology. Which, sadly, very few appreciate. Another example would be a pedophilic obsession and child-lining responsibility.

I've heard the lore that those with violent obsessions are at lower risk of violence. Is there evidence for that?
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Not an OCD expert but with my forensic hat on I would say it is very important to distinguish what is driving violent thoughts. If a patient has OCD without any other comorbidities that would elevate their risk of violence reports violent intrusive thoughts, then it would be harmful to report the patient to the police or report to reasonably identifiable "victims" because it would reinforce the patient's fears that they are dangerous, when in fact they are not. While in general, there is civil immunity for discharging duties to warn/protect, in this case, if the patient was harmed (for example attempts or dies by suicide as a result) then you could be liable because the reporting and management of the patient was negligent since the patient was never dangerous and this intervention harmful. Violent obsessions in OCD are associated with suicidality, not dangerousness to others.

In patients who have typical OCD it is really not difficult to distinguish violent obsessions from violent fantasies. The former are intrusive, the patient does not want to act on these thoughts, they are associated with significant anxiety and distress, often suicidal thoughts. There will typically be compulsions that go along with this (though these compulsions may not be obvious at first). Reassurance seeking (either that they haven't harmed anyone, or that they won't) is pretty common particularly in the context of the therapeutic relationship. Avoidant behaviors because of concerns of harming others are also common.

In terms of obsessions regarding molesting children, it is usually very easy to distinguish this from a pedophilic sexual orientation. Ask the patient whether the thoughts (whether distressing or not) are arousing. Do they get an erection when they have these thoughts? Are they primarily sexually attracted to children? Do they masturbate to these thoughts? Do they look at child pornography? The answer will be yes for those with pedophilic sexual orientation, whereas they will be no for patients with OCD. In addition, most pedophiles who don't have deviant attitudes towards sex with children (i.e. they believe children can't consent, that it is wrong) do not engage in sexual conduct with children (so called "virtuous pedophiles").

The exceptions to the above may be when there are comorbidities with OCD. Patients with ASD who have violent OCD obsessions may be at increased risk of violence (this is unclear but it may be that violence can become a compulsion in patients with deficits in emotion regulation, moral reasoning and ToM). Psychotic patients with OCD with violent obsessions may also have an elevated risk of violence. Patients with certain substance use disorders (alcohol, stimulants) who have violent or sexually violent obsessions may be at elevated risk of violence and sexual acting out in ways they would never do when not under the influence.

 

[clausewitz2]

While we are on the topic of OCD risk assessment as an aside, the one paper i have seen trying to break down suicide risk by OCD subtype found that hOCD/sexual orientation OCD was hands-down most predictive of attempted suicide.

 

[clausewitz2]

In terms of obsessions regarding molesting children, it is usually very easy to distinguish this from a pedophilic sexual orientation. Ask the patient whether the thoughts (whether distressing or not) are arousing. Do they get an erection when they have these thoughts? Are they primarily sexually attracted to children? Do they masturbate to these thoughts? Do they look at child pornography? The answer will be yes for those with pedophilic sexual orientation, whereas they will be no for patients with OCD. In addition, most pedophiles who don't have deviant attitudes towards sex with children (i.e. they believe children can't consent, that it is wrong) do not engage in sexual conduct with children (so called "virtuous pedophiles").

Nitpicky detail - some folks with pOCD will "test" themselves to try to "prove" they are not pedophiles, i.e., see if they get aroused in certain situations. Unfortunately, this tends to mean they hyperfocus on any unusual bodily sensation, especially anywhere near the groin, and seize on that as more reason to worry that they are experiencing arousal and thus really might be pedophiles. If you press people about whether the experience is the same as when they are aroused by more normative sexual situations/fantasies/experiences, they can usually articulate a difference, but obviously you are not going to succeed in arguing someone out of this theme. These folks are often incredibly resistant to the idea of EX/RP because the idea of being "okay" in any way with associations between sex and children is so repellent and monstrous-seeming to them.

 

[caxoo]

Anecdotally and n=1, pt improved rapidly with addition of antipsychotic, in both O and moreso in C

Now curious to see if there's exploration in the literature about immediate addition of antipsychotic to SSRI to achieve faster response in pts whose OCD is particularly distressing, instead of waiting a few months before declaring poor treatment response and then adding (with obvious monitoring of worsening OCD sx, as have been reported with neuroleps)