What Can I Do About My Treatment-Resistant OCD?

Obsessive-compulsive disorder (OCD) is a common anxiety condition characterized by repetitive thoughts, urges, beliefs, and images (obsessions) and/or ritualistic behaviors or mental acts (compulsions). These compulsions are performed to ease stress and anxiety. Between 1% and 3% of the population struggles with OCD, which is universally considered a “disability.” OCD can occur alone or in addition to other mental health conditions or addictions.

OCD treatments may include therapy and/or medication(s). However, first-line OCD treatments typically involve selective-serotonin reuptake inhibitors (SSRIs), cognitive-behavioral therapy (CBT), and exposure-response (ERP) therapy, because these treatment approaches appear the most effective in treating OCD symptoms. Still, these therapies may not be effective for some people with the condition (with “effectiveness” being defined as at least a 35% reduction on the Yale-Brown Obsessive-Compulsive Scale (Y-BOCS)).

Before selecting treatment options, it is important to consider certain factors – i.e., experience, motto, accessibility, approach, methods, aim, goal(s), purpose, benefits, timeline, suitability, etc. For some with mild or moderate OCD, CBT and ERP therapy are the keys to success. While for others with more severe OCD symptoms, SSRIs (i.e., Prozac, Paxil, or Zoloft), may be the path to being “OCD-free,” especially when OCD is combined with depression.

But what happens when conventional OCD treatments fail?

What is Treatment-Resistant OCD?

Treatment-resistant OCD occurs when conventional OCD treatments (medication(s), self-help tools, lifestyle changes, and/or therapies) fail to yield positive results. In other words, when various OCD treatments do not ease or eliminate your OCD symptoms, it is referred to as “treatment-resistant OCD.”

How Common is Treatment-Resistant OCD?

Approximately one in 40 (1.2%) adults struggle with OCD. The percentage of people with treatment-resistant OCD is unknown, however, it is presumed that approximately 30% of people with OCD struggle with a form of OCD that does not respond or does not respond well to conventional OCD treatments.

These individuals need additional OCD treatments to address stubborn obsessions and compulsions. If the conventional OCD treatments do not work, it is important to research your options, consult your doctor, and/or try different options to find the one that works best for your specific form of OCD.

Note: While living with treatment-resistant OCD can be challenging, it is important to remember that you still have options. It may take time to find the right treatment, but all hope is not gone. You can still get your OCD symptoms under control – you just have to be patient.

Why is OCD So Hard to Treat?

The truth is there is no universal reason why it is sometimes hard to treat OCD. OCD, in general, can be complex, which can make it feel hard to treat.

However, certain factors can make treating this condition a little more challenging for some people:

• A faulty belief system or illogical beliefs when it comes to your thoughts and behaviors
• An inability to accurately process information
• Being unaware or clueless of your surroundings
• Having a family history of OCD and/or other mental health conditions
• Being reluctant to seek help for fear of the unknown
• Being embarrassed by or ashamed of your OCD symptoms
• Being afraid to share your OCD-related fears and concerns with others
• Feeling guilty or responsible for your thoughts and behaviors
• Not wanting to take medication because of a lack of faith in pharmaceuticals or fear of side effects

Note: OCD is a complicated disorder, and there is no one answer to why it is so hard to treat. However, the reasons listed above may contribute to this. If you are struggling with treatment-resistant OCD, please don’t hesitate to reach out for help.

What Does Treatment-Resistant OCD Look Like in Real-Time?

Living with treatment-resistant OCD can be challenging to say the least. And, while CBT, ERP, and even ACT are common OCD treatments, they may not work for everyone. What does that mean? It means that it may take time to find the right OCD treatment for you.

Sharing your experiences with others, who are going through the same thing or something similar, can provide you with some much-needed support while you search for an OCD treatment that will yield the desired results (i.e., reduced OCD symptoms).

An OCD support group can also help you feel less alone and more optimistic about your future. It can reassure you that you will find the right OCD treatment – even if it takes a little longer than you anticipated. For people with treatment-resistant OCD, patience, creativity, and good communication are crucial for success.

It also helps to have a supportive group of friends and loved ones to help you cope with treatment-resistant OCD. A strong support group can encourage you to keep going even when you want to give up. They can also smother you with love, compassion, understanding, positive vibes, and good old-fashioned advice.

Isabella

Isabella is a 35-year-old female with a history of treatment-resistant OCD. She is currently in an outpatient mental health clinic. When Isabella first came to the clinic, she was prescribed Zoloft for her OCD symptoms, which was ineffective. She was then switched to Luvox, which was gradually increased until she hit the maximum dosage of 300mg, per day.

Isabella experienced a slight improvement in her symptoms once she hit the maximum dosage (300mg) of Luvox. During this time, she also began CBT and ERP therapy and to date, she consistently attends the therapy sessions.

Isabella is still experiencing severe OCD symptoms, such as repeatedly checking the locks on windows and doors at the clinic and making sure the water faucets are turned off in the bathrooms. Her “danger” obsession and the need to “feel safe” by performing these actions often causes her to be late for work and important appointments (i.e., doctor’s appointments).

She was unable to tolerate clomipramine (a tricyclic antidepressant), risperidone (an antipsychotic), or aripiprazole (an atypical antipsychotic). As a result, Isabella is now hesitant about trying new medications. The thought of having a “surgical procedure” to ease her OCD symptoms also scares her.

The next step? Possibly, transcranial magnetic stimulation (TMS). The FDA recently approved TMS as a viable OCD treatment, which may help reduce or alleviate Isabella’s treatment-resistant OCD symptoms.

When OCD Symptoms Are Resistant to Conventional Interventions How Are They Treated?

An inadequate treatment response with SSRIs (antidepressants) or CBT may warrant combining the two treatments, if possible. Studies also indicate that in severe cases of OCD, SSRIs may need to be utilized longer than the average 4-6 weeks.

Researchers have found that prolonging the use (6-8 weeks) of SSRIs may be beneficial for some cases of treatment-resistant OCD. A meta-analysis also suggests that higher doses are linked to greater effectiveness, as compared to low or moderate doses. Keep in mind, however, that higher doses can lead to more pronounced side effects and complications.

And, according to a 2015 study, it may be worthwhile to consider going beyond the FDA-approved maximum dosage of SSRIs and other anti-anxiety medications, but this should only be attempted in severe cases of treatment-resistant OCD. Conversely, research suggests that lower doses of clomipramine combined with an enzyme inhibitor may effectively treat stubborn OCD symptoms, especially if clomipramine alone fails to yield the desired results (fewer obsessions and compulsions).

When there is only a slight or partial improvement in OCD symptoms, adding an antipsychotic may up the chances of achieving “OCD remission.” Still, only about one-third of people with treatment-resistant OCD will respond to antipsychotics.

Overall, risperidone and aripiprazole (atypical antipsychotics) have shown the greatest effectiveness when treating stubborn OCD symptoms. Low doses of risperidone and aripiprazole tend to be the most effective – up to 3mg, per day, for risperidone and up to 15mg, per day, for aripiprazole.

Other atypical antipsychotics (i.e., olanzapine and quetiapine) have also been used “off-label” to treat stubborn OCD symptoms, although evidence is limited and inconclusive. There is also little evidence that haloperidol is effective for treatment-resistant OCD with some researchers citing “poor tolerability” for its ineffectiveness.

Researchers are just now beginning to understand the genetic/biological undercurrents of OCD, such as glutamatergic molecular signaling changes, immunological factors, and cortico-striato-thalamic-cortical (CSTC) tracts dysfunctions. As a result, a variety of novel (new) options are arising for treatment-resistant OCD.

Other possible treatments for resistant OCD symptoms include:

Glutamate

Some studies suggest that OCD may stem from glutamatergic dysfunction (too much glutamate). Glutamate is a non-essential amino acid that does not cross the blood/brain barrier. Glutamate is a precursor to GABA, a neurotransmitter (chemical messenger in the brain). GABA is found in a variety of foods – plant-based and animal products, such as mushrooms, eggs, bone broth, nuts, seafood, lean meats, etc.

N-acetylcysteine (NAC), an amino acid, is an agent that regulates glutamatergic signaling, an intricate two-way communication system, located between your brain and your gastrointestinal tract. Low levels of NAC may trigger or worsen OCD symptoms and/or make them more resistant to conventional OCD treatments.

A 2020 systematic review/meta-analysis found that administering 600mg-to-3000mg of NAC, a once-a-day, is not only tolerable but also “safe.” However, the jury is still out when it comes to its true effectiveness.

Riluzole, a benzothiazole, changes how certain “natural substances” behave and impact nerves and muscles. Riluzole prevents glutamate from being released in the body and supports the astrocyte (star-shaped cells in your brain and spinal cord) absorption of glutamate. Studies, however, have yielded mixed results, when comes to the effectiveness of Riluzole in the treatment of resistant OCD symptoms.

Troriluzole, a precursor of Riluzole and a potential antidepressant, may also be a suitable option for treatment-resistant OCD. Researchers have found that combining Troriluzole with memantine (an N-methyl-D-aspartate receptor (NMDA-R) antagonist) may be an effective treatment option for people, who are struggling with impenetrable OCD symptoms.

Another NMDA-R antagonist, ketamine, a dissociative anesthetic with hallucinogen effects, has shown promise in the treatment of resistant OCD, however, studies have produced mixed results. Another medication that may help ease treatment-resistant OCD is intranasal esketamine, a dissociative hallucinogen medication that is used as an antidepressant. However, study results have been mixed in this case, as well.

Surprisingly, some researchers suggest that CBT may strengthen the effects of IV ketamine/intranasal esketamine. Lamotrigine and topiramate, anticonvulsants, responsible for regulating glutamatergic signaling, may be beneficial for treatment-resistant OCD, although study results have also been mixed.

Noninvasive Neurostimulation

In the past few years, researchers have focused on circuit-level brain changes linked to mental health conditions, like OCD, and the regulation of these brain circuits. OCD has been linked to cortico-striatal-thalamic-cortical (CSTC) loop dysregulation (hyperactivity). And, as such, studies suggest that noninvasive brain-altering stimulation methods (transcranial magnetic stimulation (TMS) and transcranial direct current stimulation (tDCS) may be effective for treating stubborn OCD symptoms.

Repetitive transcranial magnetic stimulation (TMS), which relies on magnetic pulses to regulate neurocircuitry (brain circuits or regions), may be a viable option for people suffering from treatment-resistant OCD. A recent meta-analysis reported that active TMS in the dorsolateral prefrontal cortex and the supplementary motor area (SMA) may alleviate obstinate OCD symptoms.

Deep TMS which uses an H-shaped coil to trigger deep brain regions and target the anterior cingulate cortex and medial prefrontal cortex (brain regions), may provide relief for resistant OCD symptoms. Deep TMS was the first FDA-approved method for treatment-resistant OCD and appears to be both safe and effective, especially when the bilateral dorsomedial prefrontal cortex is the main target.

New TMS developments, like theta-burst stimulation (TBS), may improve OCD and shorten the treatment time, although study results, to date, have failed to yield a significant improvement in treatment-resistant OCD symptoms.

Transcranial direct current stimulation (tDCS) is another noninvasive neurostimulation method that may provide relief to some people, who are struggling with stubborn OCD symptoms. tDCS involves placing two electrodes on the scalp and administering a mild electric current to the brain. This method targets the supplementary motor area (SMA) and orbitofrontal cortex, areas of the brain linked to OCD symptoms, however, the study results have been mixed.

Electroconvulsive therapy (ECT) may also be used to wrangle stubborn OCD symptoms back under control. ECT triggers non-specific seizures, which can help ease depression and anxiety. In some cases, ECT has also helped some people, who are struggling with OCD symptoms that have been resistant to conventional OCD treatments. Although, study results are inconclusive.

Lastly, magnetic seizure therapy, which relies on magnetic pulses to trigger non-specific seizures, has been used in the past to address treatment-resistant OCD. However, study results suggest that this noninvasive neurostimulation method is ineffective for this purpose.

Inflammation

Abnormal immune system functioning is believed to play a role in OCD. More specifically, autoimmune conditions are linked to OCD in children and adults, who have elevated inflammatory markers in their brains – as compared to people, who do not have OCD. As a result, anti-inflammatory/immune regulating treatments may help treat resistant OCD symptoms.

Researchers also suggest that celecoxib, a nonsteroidal anti-inflammatory drug, with cyclooxygenase-2 enzyme inhibition, may be effective for treating stubborn OCD symptoms – when combined with SSRIs.

Moreover, studies suggest that minocycline, an antibiotic with anti-inflammatory and anti-glutamatergic properties, has shown promise in the treatment of resistant OCD symptoms, especially when it is combined with fluvoxamine (Luvox). Currently, rituximab, an intravenous monoclonal antibody, is also being considered for treatment-resistant OCD.

Lastly, gut microbiota, gastrointestinal microorganisms, are responsible for maintaining a homeostatic immune system response, which appears to be irregular in adults with OCD. As a result, researchers are beginning to consider probiotics as a possible treatment for persistent OCD symptoms. Although animal studies have shown that probiotics may benefit OCD, human clinical trials are still in process.

Invasive Procedures

Studies suggest people with extremely inflexible OCD symptoms may benefit from ablative neurosurgery and deep brain stimulation (DBS) – in addition to medications and CBT. Common OCD-related ablative procedures (the removal of tissue or a body part) include anterior capsulotomy (a brain surgery that involves removing lesions in the anterior limb of the internal capsule) and bilateral anterior cingulotomy (a last resort brain surgery for people with treatment-resistant OCD).

According to a 2016 study, people with resistant OCD experienced a 57% reduction in anterior capsulotomies and a 37% reduction in anterior cingulotomies (with 21% of people experiencing complications with capsulotomies, and 5% of people experiencing complications with cingulotomies).

Deep brain stimulation (DBS), on the other hand, is a reversible alternative to ablative surgery. DBS involves implanting electrodes in the brain to stimulate certain areas of it. This invasive procedure has been used for a variety of conditions, such as Parkinson’s disease, dystonia, and epilepsy, and in 2009, it received FDA approval for the use of refractory or treatment-resistant OCD.

According to a 2021 study, approximately 61% of people with treatment-resistant OCD experienced almost a 35% reduction on the Y-BOCS a year and a half after receiving DBS. Surprisingly, this percentage rose within 5 years (after receiving DBS for stubborn OCD symptoms) to about 71%.

Researchers concluded that people with refractory or treatment-resistant OCD, who undergo capsulotomies, typically experience a greater reduction on the Y-BOCS (51%) after receiving DBS, and are 9% more likely to enter remission, than people, who have not received DBS. However, there is still insufficient evidence, at this time, to accurately determine which procedure (DBS or ablative neurosurgery) is most effective for treatment-resistant OCD.

Novel Mechanisms

Novel or new OCD medications with unusual action mechanisms of action are currently being studied for treatment-resistant OCD. These novel medications include psilocybin, nabilone, nitrous oxide, tolcapone, ondansetron, and pregabalin.

Alternative treatments like mindfulness meditation, exercise, a healthy diet, yoga, online OCD treatment programs, hypnosis, and acupuncture are also being investigated. However, more research is needed to recommend “newer” medications and treatments for stubborn OCD symptoms.

Are There Other Ways Treatment-Resistant OCD Can Be Addressed?

Yes, there are other ways stubborn OCD symptoms can be treated, such as:

• Exploration

  It is extremely important to explore why your OCD medication is not working. A myriad of factors can contribute to a medication’s ineffectiveness, such as the dosage, your body chemistry, genetics, allergies or hypersensitivities, medical history, etc.

• Another medications

  If your OCD medication does not appear to be working, you may want to ask your doctor if he or she can switch you to another medication. There is an abundance of SSRIs that can be used to treat resistant OCD symptoms, such as Paxil, Luvox, Prozac, or Zoloft. Keep in mind, however, that changing to another medication may cause your OCD symptoms to temporarily worsen for about 4 weeks.

• Dosage Increase

  If your current OCD medication is not working, you may need a dosage increase to see results. However, it is important to consult with your doctor before increasing the dosage – as to avoid side effects and complications.

• Supplementation Therapy

  Supplementation therapy involves adding a second medication (usually an antipsychotic) with an antidepressant and/or CBT. This combination may be beneficial for those, who have not responded well to SSRIs alone.

• Clomipramine

  Clomipramine, a tricyclic antidepressant, is specifically used to treat pesky treatment-resistant OCD symptoms.

• Online OCD Treatment Program

  Online OCD treatment programs, like Impulse Therapy, can help you get a handle on your stubborn OCD symptoms. Impulse Therapy even offers an OCD assessment to help you determine if there is a possibility that you have OCD.

  This program can help you reduce or eliminate these symptoms, even if they are treatment-resistant. Most online programs can be used alone or with traditional OCD treatment techniques. With Impulse Therapy, you can shut down the obsessions and compulsions for good!

What is the Prognosis for Treatment-Resistant OCD?

The good news is there is hope for those suffering from treatment-resistant OCD.

Although stubborn OCD symptoms may be difficult to treat, with the right treatment, you can become “OCD-free.” The first step, however, is to tell someone what you are experiencing. OCD help is offered in a variety of forms, such as in-person and online OCD therapy sessions, support groups, books, apps, online OCD treatment programs, and self-help tools. These resources can offer you support, guidance, and hope, boosting the odds that you will succeed.