In this section, we are going to discuss presentations and treatment plans for OCD and PTSD.
OCD and PTSD are part of a larger group of anxiety disorders.
It is important to know that medications can induce anxiety. Below are some that can do that:
- Antidepressants
- Stimulants
- Anticholinergics
- Albuterol
- Pseudoephedrine
- Alcohol/sedative
- Levodopa
- Levothyroxine
- Prednisone
Rapid titration of any of these can cause anxiety.
OCD Overview
“Thoughts that are unwanted, recurrent, and intrusive.”
OCD is more common in females than males and more in teens than adults. It is unlikely for someone in their 40s to present with new onset of OCD. It is also unlikely that OCD is the only mental disorder that the patient has. 75% of OCD have comorbid with GAD.
OCD is a cycle of obsession, anxiety, compulsions, and relief.
OCD: Goal of Treatment
- Decrease in symptoms
- Improve functioning
- Improve the quality of life
- Ultimately we work toward remission, but here remission is a clinical rarity.
OCD Treatment Consideration
- First: establish rapport and consider the patient’s preference into the treatment plan
- Second: Can have a monotherapy or pharmacologic, non-pharmacologic, or both.
- Pharmacologic would look into SSRIs or clomipramine
- SSRIs and clomipramine have similar efficacy, but SSRIs are preferred as first trial due to more favorable side effect proviles
- The preferred SSRI is fluvoxamine (Luvox).
- The dose must be titrated very slowly (10-12 weeks), and the effective maintenance dose can be much higher than the maximum dose listed on the package insert.
- “Slower titration, longer time, higher dose than MDD.”
- Pharmacologic is a good option for those that are not interested in CBT, or prefer medication over CBT, we had success on SSRI or clomipramine before.
- Adequate duration of at least 1-2 years.
- Psychologic would be cognitive behavioral therapy.
- CBT is unique because it incorporates exposure and response, which helps desensitize patients. This is the only true cure for anxiety (exposure), but this must be done carefully.
- This is a first-line treatment for mild to moderate OCD.
- It is important to note that CBT has side effects as well, and patients should have emotions under control before attempting this. This is why sometimes it’s easier to start with pharmacologic therapy.
- CBT is unique because it incorporates exposure and response, which helps desensitize patients. This is the only true cure for anxiety (exposure), but this must be done carefully.
- Pharmacologic would look into SSRIs or clomipramine
- **BZDs are generally not in the treatment plan**
- For severe OCD: Consider a combination of pharmacologic and psychotherapy.
PTSD Overview
Females are twice as likely to get PTSD. All of the people experience traumatic events, and only about 10% will go on to develop PTSD. There are multiple reasons for this. It is pretty complex.
Remember that patients with PTSD rarely only have PTSD. Usually, they have other comorbidities as well. Substance abuse is a common theme. Traumatic brain injury (TBI) is a risk factor as well. When people have TBI, it negatively impacts their ability to respond to psychotropic drugs.
PTSD Treatment
SSRI SSRI SSRI!
SSRIs are our main go-to. They help with intrusive thoughts and nightmares. They do not help with avoidance symptoms. Titration is very important! Start low and go slow. They patients, as mentioned before, usually end up with higher dose than MDD and longer duration.
Patients should try the medications for 6-8 weeks before test failure.
Prazosin may be considered as an adjunct. It probably helps but meh. The data is mixed. It’s typically used for blunting adrenaline hyperactivity, especially in those with sleep disturbance. Consider this medication when the patient is hypervigilance during the day.
- The starting dose is 1mg at bedtime
- Titrate by 1mg every 2-3 days, then 2-5mg per week based on ADRs and patient response. Max of 16mg per bedtime.
- This medication is indicated for hypertension as well, but because it is lipid soluble, it can get through the BBB to blunt the effect of NE.
- Side effects include dizziness, drowsiness, HA, and orthostatic hypotension.
Another note on TBI. It is complicated because of negative responses to medication, and sometimes the patients don’t know they have TBI. We should aggressively treat comorbidities when patients have TBI. Usually, patients are treated with second-generation antipsychotics, TMS, and psychotherapies.
BZDs should be avoided because they are less effective. BZDs can make PTSD patients more impulsive, leading to more drug abuse and more suicide. Sometimes, in an unavoidable situation, they are used for comorbidities.
TCAs are another one that should be avoided because of their narrow therapeutic index. It is very easy to overdose. Combined with the increased risk of suicide, this class should be avoided altogether.