Information on OCD, research and treatment

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Complementary and alternative therapies

Background

Reaching a satisfactory treatment outcome in moderate to severe OCD can be difficult to achieve. It is universally acknowledged that current OCD drug and cognitive-behavioural therapies are suboptimal and many have troublesome side effects. As such, patients often consider less traditional treatment options including complementary and alternative medicine (CAM) therapies. Over the past few decades, CAM treatments have been evaluated using more familiar Western research standards in order to better assess comparative effectiveness. Interventions that have been proposed as possible OCD treatment options, almost exclusively in conjunction with usual therapy, include naturally occurring nutrient supplements, plant-based substances, and acupuncture and related treatments.

Understanding that the majority of CAM treatments for OCD still have insufficient proof of effectiveness by Western standards, their generally high safety profiles and lower costs generate continued interest. Below, we will review CAM therapies that are more likely to be encountered in real world OCD management.

Nutrient supplements

Some neutraceuticals have undergone evaluation for OCD, although the side effect and outcomes data in most cases is rather thin. Insights can also be based on studies that have investigated nutrient supplements for anxiety and depressive disorders. Despite the limited proof of direct benefit in OCD management, some supplements may have additional value in selected patients with anxiety and/or depression as co-existent disorders or as part of the OCD per se.

Inositol

Inositol is a naturally occurring, vitamin-like compound that is sometimes incorrectly referred to as vitamin B8. Normal diets account for some of our inositol stores and the remainder is synthesized in the body (which, by the way, is why it is technically not a vitamin). Inositol participates in essential cellular, hormonal and regulatory processes that include nerve signal transmission in the brain. It appears to have some effectiveness in the treatment of diabetic nerve pain, panic disorder, anxiety, and depression (85, 86). Although its exact mechanism of action in the brain needs further study, large supplemental inositol doses appear to increase serotonin levels (87).

Studies done over the last two decades have shown mixed results for inositol as add-on treatment for OCD. Notably, controlled studies by the same group initially reported a favourable OCD response to inositol that was not shown in a subsequent trial (88, 89). The absence of significant improvements of OCD symptoms from add-on inositol is also supported by results of another investigation (90).

In summary:

Ÿ   Neither controlled studies nor a recent meta-analysis have provided consistent scientific proof of inositol effectiveness in OCD.

Ÿ   For patients who remain interested in inositol, there does not appear to be any contraindication to taking it with an SSRI, both of which increase serotonin through different pathways.

Ÿ   In previous studies, high doses were usually prescribed. Serious side effects are not reported, and those that do occur are usually mild and self-limited.

n-Acetylcysteine (n-AC)

Interest in n-AC as a possible treatment for OCD is based on actions that result in reduced glutamate activity (91). Indirect support for the use of n-AC for OCD comes from evidence of effectiveness for patients with repetitive hair pulling (trichotillomania), which is an OCD-like condition. A recent review of n-AC in controlled OCD clinical studies found encouraging but insufficient evidence of effectiveness (92). In one of these studies, the initial improvement of OCD symptoms after 12 weeks of treatment was no longer seen after 16 weeks (91). Another 12-week placebo controlled study of add-on n-AC treatment for severe, SSRI-resistant OCD patients found promising results. At the end of the study, the average Y-BOCS score for those taking n-AC decreased nearly 40% compared to a 21% improvement in the placebo group. The investigators note that the improvements in the n-AC group did not appear until 12 weeks of treatment (93). No serious side effects are reported and the N-AC was generally well tolerated. The total doses used in these studies were in the 2,400 to 3,000 mg per day range. At this point, n-AC appears to be a promising add-on treatment for SSRI-resistant patients although more data, including patient selection and long term follow up, is needed to confirm these initial impressions. This data may soon be available from several clinical trials currently underway.

Glycine

Glycine functions as a neurotransmitter in the spinal cord and brain. In the brain it appears to function at a specific glutamate receptor that, like GABA, inhibits glutamate-mediated nerve excitability. In a case report, high dose glycine was used to treat a multi-drug resistant adolescent with severe and complex OCD (94). Following treatment there was a very substantial reduction of symptoms such that the patient became quite functional over the ensuing five years with only occasional and relatively mild symptom relapses. However, in a placebo-controlled study, those patients who received oral glycine showed a marginally better result compared to placebo (95). Glycine is notorious for being particularly unpalatable, which is the reason that nearly 50% of those treated with glycine dropped out of the study, despite premixing it with orange juice and other attempts to partly reduce the revulsive taste.

Omega-3 fatty acids (O-3FA)

Omega-3 fatty acids are polyunsaturated fatty acids,[1] more commonly referred to as fish oil, that play critical roles in cellular structure, metabolic processes, and signal transmission. The latter includes neurotransmitters. From the neuropsychiatric standpoint, there is evidence of a role for O-3FA, in the form of fish oil supplementation, in several psychiatric illnesses, particularly major depression (96-98). In real world management of depressive disorders, fish oil is frequently recommended as possibly helpful and quite safe.

In a controlled trial of O-3FA as add-on therapy for OCD, no beneficial effect was found (99). However, the study was uncommonly short (six weeks). Another placebo-controlled trial investigated the effects of EPA/DHA[2] for children and adolescents with Tourette Syndrome[3] (100) over 20 weeks. The outcomes analyses also showed no significant improvement of either obsessive-compulsive or depressive symptoms as well. Despite the lack of support for using O-3FA for OCD, it may offer some benefit if there is co-existing depression.

A number of foods are relatively rich in O-3FA, especially flax seed oil and fish. There are other natural sources rich in O-3FA, as well. It is important to be aware that the amount of O-3FA can vary considerably in similar foods, in large part the result of how foods are prepared. For example, fresh salmon contains an amount of fish oil that is about 13 fold that of smoked salmon, and nearly 30 times that from canned salmon.

At this time, the available data supporting O-3FA effectiveness in OCD is extremely scant, and what little exists shows no benefit for its use although serious side effects are extremely rare.

Plant and herbal preparations in OCD

Plant-based medicines have been tested in anxiety disorders (101), but only a few have undergone a clinical trial for OCD. These are St. John’s wort, milk thistle, borage, and valerian root. While there are several other plant-derived treatments used for OCD, information is far too scant to judge any effectiveness. These include Kava and Wisthania somnifera root extract.  However, a number of plant-based remedies have been convincingly found to have a degree of effectiveness in primary depressive and anxiety disorders. These will not be discussed in this report except to emphasize that the mood disturbances often occurring in OCD patients may also merit additional therapy.

From a general safety standpoint, the majority of herbal remedies are exempt from regulatory oversight, and therefore at risk for poor manufacturing processes, including the presence of potentially harmful contaminants.

St. Johns Wort (Hypericum perforatum)

St. John’s wort (SJW) appears to be useful for mild to moderate depression; in some studies the effect was similar to an SSRI. Several case reports and uncontrolled trials also suggest some efficacy in anxiety disorders, but this is not a firm finding. While its actions on NT in the brain are incompletely understood, they include increased serotonin levels.

Although a small trial of SJW for OCD in 2000 was encouraging (102), this same group conducted a more recent 12-week controlled, double blind clinical study of SJW and placebo in 60 individuals with moderate to severe OCD.(103) At the end of treatment, the SJW group had Y-BOCS and anxiety rating scores that were virtually the same as the placebo group and only minimally different from their baseline values. Side effects from SJW include anxiety, panic attacks, headaches, nausea, abrupt increases of blood pressure, dry mouth, and skin irritation associated with sun exposure. It is important to recognise two additional potentially harmful effects. SJW can interfere with the effectiveness of a number of critical drugs by lowering their concentrations. Among these are birth control pills, blood thinners, heart disease drugs, and several drugs used to treat human immunodeficiency virus (HIV), cancer, and anti-rejection medications used in organ transplantation. There also is the risk of excessive and potentially dangerous levels of brain serotonin when SJW is combined with an SSRI or similarly acting drug.(104)

Thus, there is little current evidence of a beneficial role for SJW in OCD. This observation, as well as its side effects and potentially harmful interactions with other drugs, should dissuade its use.

Milk thistle (Silybum marianum)

This plant, a member of the same family as sunflowers and daisies, has been used over several millennia for a wide range of medicinal applications (105). Records from the 1st century AD attribute “healing properties” to milk thistle, and more than four centuries ago it was purported to be an effective treatment for melancholia and as a liver remedy. Its contemporary uses range from heartburn and hangovers to a protectant for liver cell injuries and as a potentially life-saving measure for poisonous mushroom ingestion. The authors of a recent study remarked that folklore in their particular region (Iran) has long considered milk thistle to be a remedy for obsessions and compulsions (105, 106).

Silimarin has been identified as a principal active compound in milk thistle. Among its several actions, silimarin acts on several brain neurotransmitters, including enhancement of serotonin activity (106).   In what currently appears to be the only controlled study of a possible role for OCD, milk thistle was compared to the SSRI fluvoxamine in an eight-week trial. All study subjects had baseline Y-BOCS scores of ≥21 points and were off all psychopharmacological drugs for a minimum of six weeks. While the average Y-BOCS scores progressively decreased for both the SSRI and mild thistle groups, the fluvoxamine and milk thistle groups decreased by about 11 and 12.5 points respectively, with average outcome scores of 17 and 20 for fluvoxamine and milk thistle, respectively. Although these are highly significant improvements, the comparative outcomes of the two groups were essentially the same.

Several aspects of this study, however, raise some questions. First is that authors do not make clear whether the baseline Y-BOCS scores were comparable to those obtained before drug therapy was stopped, particularly since the actual average score for the entire group was about 41.

Also, this study was conducted over eight weeks, and given the longer period of time before SSRI effects are maximized it is not known whether a longer study period would have shown different outcomes.

The types and frequency of side effects for both groups were essentially the same, and typical for those that occur with SSRIs. Milk thistle can also affect the metabolism of other drugs and thus should not be taken without professional guidance.

Borage (Echium amoenum)

Borage is another herbal preparation that has been used as a remedy for numerous conditions over a period of time that extends, at least, back to its use by Romans several hundred years BC. Among its many cited properties are benefits for anxiety and mood disorders. Its anxiolytic and sedative properties have been demonstrated in humans (107) with claims of comparability to diazepam (Valium).

Its mechanisms of action are, as yet, unclear, and only one direct study of its use in OCD could be identified. A preparation from dried borage flowers was tested in a controlled, six week study (108). Both Y-BOCS scores, and Hamilton Anxiety Rating Scales (HAM-A)[4], were tested repeatedly during the treatment period.

At the conclusion of the trial, significantly lower Y-BOCS scores were observed in the treatment group compared to those given placebo. Overall, however, the amounts that the scores decreased were considered to convey little overall improvement of OCD symptoms. Consistent with previous observations, however, the HAM-A scores improved significantly for those receiving borage. The authors concluded that, although the OCD findings were disappointing, the effects on anxiety were of merit since generalised anxiety is common in patients with OCD.

The uses of borage for OCD and in studies of other psychiatric disorders have reported little to no common side effects. However, borage may contain chemicals known as pyrrolizidine alkaloids that may cause liver injury or cancer if used in high doses over long time periods. For those taking borage, caution is advised to only use borage preparations that have been tested and deemed free of these potentially harmful compounds.

Valerian root (Valeriana officinalis L)

Valerian is a sweetly scented flowering plant, the root of which is dried and available as a herbal remedy. It has long been used as a treatment for insomnia, particularly in the Middle East. Additional claims of effectiveness for other conditions such as anxiety, pain, and migraine headache have little scientific support (109). Compounds in Valerian root are believed to bind to the same GABA NT receptors as benzodiazepams.[5] However, based on a single, small, controlled study of anxiety treatment, valerian was no better than placebo and inferior to diazepam (110).

Given its effects on GABA, one small, but randomised and controlled eight week investigation of valerian root was carried out with OCD patients whose baseline Y-BOCS scores were at least 21 (111). The patients were taking no other medications for at least two weeks before the study began and were not receiving CBT. The principal finding was that treatment with valerian root resulted in significantly superior reductions of Y-BOCS scores compared to controls. These differences first appeared after four weeks of treatment. Like the anxiety study, however, only this one small OCD investigation of OCD is reported, and there is insufficient evidence to draw any conclusions about the efficacy of valerian for OCD.

Treatment with valerian root appears to be well tolerated, and side effects are minor, although it is not surprising that more than half of those treated with valerian experienced somnolence. The investigators also made the point that there is no reported sexual dysfunction that has been attributed

Non-conventional and alternative treatments

Acupuncture and related treatments

Several controlled clinical trials have studied the effectiveness of various acupuncture-based techniques for obsessive-compulsive and anxiety disorders. These include investigations in which the effectiveness of acupuncture as sole therapy as well as adjuncts to traditional drug therapy and a variety of wellness-based interventions. In general, the results of these studies support a role for acupuncture in OCD. Most recent studies of therapeutic acupuncture for OCD and related disorders have used electro-acupuncture (EA)[6], which purportedly enhances the acupuncture effect although treatment equivalency has also been reported. In one such study, patients refractory to conventional drug and cognitive-behavioural therapies were randomly assigned to two groups: one group received EA as add-on treatment while the other served as a control (112). Outcome Y-BOCS and Clinical Global Impression[7] severity scores at the end of treatment were significantly improved in the EA treated group. The results also were superior to the control group.

In a comparison of outcomes for patients who received EA with clomipramine, and those treated with clomipramine alone, both patient groups had starting Y-BOCS scores in the moderate to severe range (113). Although improved outcomes were noted for both groups, those receiving EA and clomipramine had significantly superior results to clomipramine alone, and a greater proportion of the EA group had 75% or greater improvement of their Y-BOCS scores. Similar beneficial effects of EA were found in an uncontrolled study of a group of patients with at least two years of drug resistance (114). Y-BOCS scores improved from an initial average score of 23 to 16 following treatment. Also notable is the fact that, following treatment, nearly 25% of the group were essentially symptom-free, and an additional 29% experienced marked improvement such that symptoms diminished sufficiently to allow less disruption of the patient’s daily activities.

Also relevant to some patients with OCD, acupuncture has shown effectiveness for anxiety and depressive disorders in several controlled clinical trials. In one recent study, acupuncture alone and in combination with integrative therapy[8] was compared to conventional treatment provided at the patient’s primary care centre (115). Following eight weeks of treatment, acupuncture alone, and in combination with integrative therapy, had similar degrees of improvement for both anxiety and depression, and both were significantly superior to conventional treatment. In a six month follow up of the study, the investigators found that the eight week improvements were sustained in both the acupuncture and acupuncture + integrated therapy groups, whereas little changed for those receiving conventional intervention. Other studies have shown similar benefits from acupuncture, in particular for anxiety.

In summary, in addition to Chinese medical data, studies are accumulating in Western medical journals that provide support for using acupuncture as solitary or add-on treatment of OCD. Moreover, a secondary effect on the anxiety that usually accompanies obsessions may be of benefit.

Psychosocial techniques

There are many claims of OCD treatment effectiveness with the use of various meditation, mindfulness, and cognitive behaviour-type techniques. The purported effectiveness of many is largely based on anecdotal or observational impressions. Nonetheless, a healthy mind-body state can be a boon to those who seek to reduce stress and strengthen coping skills, and OCD patients are no exception. Because of the similarities between many of these psychosocial activities and cognitive therapy, a discussion about the compatibility of the techniques with a cognitive or behavioural therapist is advised.

Several studies of self-help techniques have been evaluated for OCD or obsessive and compulsive-like behaviors. These include Acceptance and Commitment Therapy (ACT),[9] Movement Decoupling,[10] Progressive Relaxation Training (PRT) (116),[11] and Kundalini yoga (KY).[12]

Acceptance and Commitment Therapy has been used in conjunction with OCD treatment. ACT purportedly reduces or eliminates the need for direct exposure to obsession triggers as is necessary in ERP. Proponents of ACT cite patient refusal, poor compliance and high dropout rates in ERP therapy as particular reasons to consider alternative therapies. A recent randomized study compared ACT to Progressive Relaxation Training (PRT) (116). Scores improved for both groups after eight weeks and three months, although ACT showed significantly greater improvement compared to PRT.

Y-BOCS scores (% reduction)* ACT PRT
End of 8 week study 46% 24%
Three months after study 54% 36%

 

The study results also demonstrated improved levels of depression for those with depression at study onset.

Movement Decoupling has shown some effectiveness for the treatment of patients with trichotillomania[13] (117). People with trichotillomania suffer from compulsive hair pulling with hair loss. It is considered to be a disorder in the OCD spectrum of mental illnesses. However, there is no current evidence of its effectiveness in OCD.

Another technique that has gained some attention is Kundalini yoga (KY). Using a KY program that accommodated OCD symptoms, an early study showed encouraging results (118). This same group of investigators subsequently performed a randomized and controlled study of patients with moderate to severe OCD (119). Study groups received either Kundalini yoga (KY) or a program the combined Relaxation Response and Mindfulness Meditation[14] therapies. The latter two treatments have previously demonstrated general benefit in anxiety reduction and emotional distress. At three months the KY group showed significant improvement as reflected by a 38% average reduction of Y-BOCS scores compared to a non-significant trend of 14% for the control group. After 15 months of therapy, the average improvement was 70% for those treated with KY, and all of the patients taking medication at study entry were able to have their medication doses reduced or discontinued.

Summary

Alternative medicine is developing a firm foothold in several niches of Western medicine, although skeptics are leery of these treatments and await the results of more conventional study methods in sufficient numbers of patients. As is also true for many of the nutrition and herbal remedies discussed previously, the assessments of acupuncture and psychosocial therapies for OCD are hampered because most of the data are based on case reports and/or studies of generally poor quality. Nonetheless, appropriately designed research studies are appearing. Furthermore, most clinicians would agree that statistical proof of benefit is only a part of an assessment of effectiveness for a particular clinical intervention, and experience does matter a great deal. Also, even if not OCD specific, many acupuncture and psychosocial methods show promise for management of anxiety and depression, and are likely to be of interest to many OCD patients. Nonetheless, it is strongly recommended that patients considering alternative or complementary treatments should first have an open discussion with their principal therapists. They often will offer opinions about which forms of these alternative therapies would be most complementary to the person’s treatment goals.

[1]   Fats may be classified as saturated (including trans fats), or unsaturated, based on certain molecular structure characteristics. Both mono- and polyunsaturated fats can help to lower unhealthy cholesterol balance, and appear to diminish risks of heart disease and several other conditions. Excess saturated fats, particularly trans fats, increase levels of bad (LDL) cholesterol and create inflammation, both of which have been associated with heart disease, stroke, and other chronic medical illnesses.

[2]   Eicosapentanoic acid (EPA) and docosapentanoic acid (DHA) are two types of 0-3FA that show particular effectiveness in several settings. These are mentioned here because products containing O-3FAs often state their EPA and DPA contents. Of interest, recent studies have resulted in findings that EPA and DHA affect neurotransmitter signaling by increasing serotonin activity and interfering with dopamine function.

[3]   Tourette syndrome (TS) is a neuropsychiatric disorder beginning in childhood characterized by uncontrollable, repetitive tics and, often, involuntary vocalisations. There is genetic and clinical evidence suggesting that this disorder and OCD may have overlapping symptoms; up to 50% to 60% of TS patients have OCD symptoms and a similar proportion of OCD patients have tics and 15% will have TS.

[4]  The Hamilton Anxiety Rating scale is a frequently used, clinician-administered questionnaire that results in a quantitative anxiety score. There are 14 items, each assigned 0 to 4 points, and therefore a possible maximum score of 56. A total score of <17 indicates a trivial to mild condition, 18-24 is mild to moderate, and 25-30 severe.

[5]   Benzodiazepam is a class of drugs used primarily to treat anxiety. There are numerous members of this class among which are diazepam (Valium), lorazepam (Ativan), alprazolam (Xanax), and clonazepam (Klonopin).

[6]     Electro-acupuncture is a technique whereby electrical micro currents applied to the needles at traditional acupuncture sites purportedly enhance the traditional acupuncture results.

[7]   The Clinical Global Impression – Severity scale (CGI-S) is a seven point clinician rating of the severity of a patient’s mental illness relative to their previous experiences with other patients who have the same diagnosis. Scores range from 1 (normal) to 7 (extremely severe) and, as such, lower is better.

[8]   The basis for integrative therapy is to strengthen a patient’s ability to identify and cope with factors that promote health and well being, rather than on those that are disease focused.

[9]   As described by one investigator, ACT teaches patients to be willing to view and accept inner experiences without seeking to change, judge them, or let them become part of your self-image. Patients are encouraged to choose to direct his or her behaviour towards valued goals.

[10]   In movement decoupling, patients learn how to redirect compulsive movements. Its relevance to OCD is based on its effectiveness for trichotillomania which is the urge to pull out one’s hair (see text).

[11]   PRT is a progressive relaxation technique that uses muscle group tension and relaxation, particularly for the relief of anxiety.

[12]   Kundalini yoga is comprised of physical workouts, meditation, and complex breathing techniques, some of which have individual similarities to other yoga forms.   There is a particular emphasis on consciousness embedded in the yoga sessions.

[13] A disorder in the OCD spectrum of mental illnesses, trichotillomania has been found to respond to movement decoupling therapy. For example, this technique can be used to condition a patient such that the compulsive hand movement to the head is retrained so that the initial action does not end in the hair, but instead continues to become another activity such as lifting the arm into a stretch.

[14]  The combination of RR and MM provide a mix of techniques to achieve a state of peacefulness and physical relaxation. Through this state, patients can be taught to identify the nature of disturbing cognitions or mental thoughts and, importantly, rather than reacting to them, learning to disconnect and observe them non-judgmentally.

 

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