Treatment-resistant obsessive-compulsive disorders

Abstract

Obsessive-compulsive disorders (OCD) are mainly treated with disorder-specific cognitive behavioral therapy using exposure and response management and/or selective serotonin reuptake inhibitors; however, asignificant subgroup of patients does not sufficiently benefit from this approach. This article provides an overview of treatment-resistant OCD. In this narrative review the definition, causes, diagnostic and therapeutic approaches to treatment-resistant OCD are addressed. Treatment resistance can be assumed in the absence of clinically relevant improvement under therapy, in the sense of areduction of < 25% on the Yale-Brown obsessive-compulsive scale and ascore of 4(no change) on the clinical global impression-improvement scale. The number of unsuccessful treatment attempts required to establish treatment resistance is defined differently. Causative factors include misdiagnosis, a high severity, comorbid disorders, substance use, specific symptom constellations, organic causes, environmental factors, and aggravating factors in psychotherapy and pharmacotherapy. Suggestions for diagnostic and therapeutic approaches based on the GermanS3 guideline on OCD are presented. For patients with treatment resistance to first-line therapy, useful diagnostic and therapeutic recommendations are available (psychotherapeutic, psychopharmacological and neurostimulation procedures).