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OCD

OCD

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PRACTICE GUIDELINE FOR THE
 Treatment of Patients WithObsessive-Compulsive Disorder
WORK GROUP ON OBSESSIVE-COMPULSIVE DISORDER
Lorrin M. Koran, M.D., Chair 
Gregory L. Hanna, M.D.Eric Hollander, M.D.Gerald Nestadt, M.D.Helen Blair Simpson, M.D., Ph.D.
 This practice guideline was approved in October 2006 and published in Ju
ly 
2007. A guideline watch, summarizing significant developments in the scientific literature since publication of this guide-line, may be available in the Psychiatric Practice section of the American Psychiatric Association (APA) Web site at www.psych.org.Dr. Koran has received research grants from Forest Pharmaceuticals, Pfizer, Eli Lilly, Ortho-McNeil, Somaxon, and Jazz Pharmaceuticals. He has received honoraria from the Forest Pharmaceuticals Speakers Bureau and the PfizerSpeakers Bureau. He has received consultant fees from Cypress Bioscience. Dr. Hanna reports no competing interests.Dr. Hollander has received research grants from the National Institute of Mental Health, the National Institute of Neurological Disorders and Stroke, the National Institute on Drug Abuse, the Office of Orphan Products Developmentof the U.S. Food and Drug Administration, Pfizer, GlaxoSmithKline, Wyeth, Eli Lilly, Janssen, and Abbott. He hasserved on advisory boards for Forest Pharmaceuticals, Abbott, and Somaxon. Dr. Nestadt reports no competing inter-ests. Dr. Simpson reports no competing interests. The Executive Committee on Practice Guidelines has reviewed thisguideline and found no evidence of influence from these relationships.
Suggested citation:
American Psychiatric Association. Practice guideline for the treatment of patients with obsessive-compulsivedisorder. Arlington, VA: American Psychiatric Association, 2007. Available online at http//www.psych.org/psych_pract/treatg/pg/prac_ guide.cfm.
 
AMERICAN PSYCHIATRIC ASSOCIATIONSTEERING COMMITTEE ON PRACTICE GUIDELINES
 John S. McIntyre, M.D., Chair Sara C. Charles, M.D., Vice-Chair 
Daniel J. Anzia, M.D.Ian A. Cook, M.D. Molly T. Finnerty, M.D.Bradley R. Johnson, M.D. James E. Nininger, M.D.Paul Summergrad, M.D.Sherwyn M. Woods, M.D., Ph.D. Joel Yager, M.D.
AREA AND COMPONENT LIAISONS
 Joseph Berger, M.D. (Area I)C. Deborah Cross, M.D. (Area II)Harry A. Brandt, M.D. (Area III)Philip M. Margolis, M.D. (Area IV) John P.D. Shemo, M.D. (Area V)Barton J. Blinder, M.D. (Area VI)David L. Duncan, M.D. (Area VII) Mary Ann Barnovitz, M.D.Sheila Hafter Gray, M.D.Sunil Saxena, M.D. Tina Tonnu, M.D.
STAFF
Robert Kunkle, M.A., Senior Program Manager Amy B. Albert, B.A., Project Manager Thomas J. Craig, M.D., M.P.H., Director, Department of Quality Improvement and PsychiatricServicesDarrel A. Regier, M.D., M.P.H., Director, Division of Research
MEDICAL EDITOR
Laura J. Fochtmann, M.D.
 
CONTENTS
STATEMENT OF INTENT. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .7GUIDE TO USING THIS PRACTICE GUIDELINE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .7DEVELOPMENT PROCESS. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .8
PART A: TREATMENT RECOMMENDATIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .9
I.EXECUTIVE SUMMARY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .9A.Coding System. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .9B.Executive Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .91.Psychiatric Management. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9a.Establishing a Therapeutic Alliance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9b.Assessing the Patient’s Symptoms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9c.Using Rating Scales . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9d.Enhancing the Safety of the Patient and Others . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10e.Completing the Psychiatric Assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10f.Establishing Goals for Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10g.Establishing the Appropriate Setting for Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10h.Enhancing Treatment Adherence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 112.Choosing an Initial Treatment Modality . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 113.Choosing a Specific Pharmacological Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 114.Choosing a Specific Form of Psychotherapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 115.Implementing a Treatment Plan. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12a.Implementing Pharmacotherapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12b.Implementing Cognitive-Behavioral Therapies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12c.Changing Treatments and Pursuing Sequential Treatment Trials . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 126.Discontinuing Active Treatment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13II.FORMULATION AND IMPLEMENTATION OF A TREATMENT PLAN . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .13A.Psychiatric Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .141.Establish a Therapeutic Alliance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 142.Assess the Patient’s Symptoms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 143.Consider Rating the Severity of OCD and Co-occurring Symptoms and Their Effects on the Patient’s Functioning. . 164.Evaluate the Safety of the Patient and Others. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 175.Complete the Psychiatric Assessment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 186.Establish Goals for Treatment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 217.Establish the Appropriate Setting for Treatment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 218.Enhance Treatment Adherence. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 219.Provide Education to the Patient and, When Appropriate, to the Family . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2210.Coordinate the Patient’s Care With Other Providers of Care and Social Agencies. . . . . . . . . . . . . . . . . . . . . . . . 22

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