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Treatment-resistant obsessive-compulsive disorder (OCD) refers to OCD that persists after trials of at least twoevidence-based treatments, typically cognitive behavioral therapy (CBT) incorporatingexposure and response preventionand an adequate trial of a selective serotonin reuptake inhibitor (SSRI).
Despite following treatment guidelines, symptoms remain at a clinically significant level, causing distress and impairment in functioning. More intensive or alternative interventions may be required for these refractory cases.
Woman with ocd syndrome clutches head for fear of contracting infection, stands near icons with faucet and door handle and a checklist in circle around her head.
Krebs, G., & Heyman, I. (2010). Treatment-resistant obsessive-compulsive disorder in young people: Assessment and treatment strategies.Child and Adolescent Mental Health, 15(1), 2–11.https://doi.org/10.1111/j.1475-3588.2009.00548.x
Key Points
Rationale
Cognitive behavioral therapy (CBT) with exposure and response prevention (ERP) techniques and pharmacotherapy with selective serotonin reuptake inhibitors (SSRIs) are considered first-line treatments for OCD.
Multiplerandomized controlled trialshave demonstrated the efficacy of these interventions, with 40-88% of pediatric OCD patients achieving remission with CBT and 25-44% showing symptom improvement with SSRIs (Barrett et al., 2004; POTS, 2004). Consequently, practice guidelines universally recommend CBT/ERP and SSRIs as the initial treatments for OCD (APA, 2007; NICE, 2005).
However, a subset of OCD patients fail to respond adequately to these first-line treatments even when properly administered at therapeutic doses and duration.
By definition, treatment response refers to at least a 35-40% decrease in Yale-Brown Obsessive Compulsive Scale (YBOCS/CYBOCS) scores, while remission signifies a score below 12-14 (Farris et al., 2013).
Individuals who remain symptomatic after evidence-based care delivered according to guidelines can be categorized as having treatment-resistant OCD.
Given the distress and functional impairment resulting from residual OCD symptoms, alternate interventions with higher efficacy are needed for these refractory patients. The pathophysiology underlying lack of response needs to be elucidated.
Treatment resistance likely involves complex interactions between biological vulnerabilities, genetic factors, and psychosocial variables. Elucidating these mechanisms can pave the way for novel personalized therapies.
It is unclear whether these patients have “technical” treatment failures, where treatment delivery was inadequate, or “serious” failures where patients are truly treatment refractory (Rachman, 1983)
Method
Naturalistic pre-post study design
Sample
Participants were youth with severe, treatment-refractory OCD who were referred to a national specialist clinic. All had inadequate response to both previous CBT and SSRI trials meeting referral criteria.
N= 43 consecutive referrals who completed outpatient CBT
Measures
Procedure
Analysis
Results
Overall, specialist CBT was associated with a 43% decrease in OCD severity, with 58% meeting criteria for treatment response. Secondary outcomes also improved.
Primary Outcome (CY-BOCS scores)
Secondary Outcomes
Clinical Response
Insight
Strengths
Limitations
Clinical Implications
References
Primary reference
Other references
Ginsburg, G. S., Kingery, J. N., Drake, K. L., & Grados, M. A. (2008). Predictors of treatment response in pediatric obsessive-compulsive disorder.Journal of the American Academy of Child and Adolescent Psychiatry, 48(9), 868-878.https://doi.org/10.1097/CHI.0b013e3181799ebd
Pediatric OCD Treatment Study (POTS) Team (2004). Cognitive-behavior therapy, sertraline, and their combination for children and adolescents with obsessive-compulsive disorder.JAMA, 292(16), 1969-1976.https://doi.org/10.1001/jama.292.16.1969
Rachman, S. (1983). Obstacles to the successful treatment of obsessions. In E. B. Foa & P. M. G. Emmelkamp (Eds.),Failures in behavior therapy(pp. 35–57). New York: Wiley and Sons.
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Olivia Guy-Evans, MSc
BSc (Hons) Psychology, MSc Psychology of Education
Olivia Guy-Evans is a writer and associate editor for Simply Psychology. She has previously worked in healthcare and educational sectors.
Saul McLeod, PhD
BSc (Hons) Psychology, MRes, PhD, University of Manchester
Saul McLeod, PhD., is a qualified psychology teacher with over 18 years of experience in further and higher education. He has been published in peer-reviewed journals, including the Journal of Clinical Psychology.
