Katharine Phillips, MD: Various Treatments for Obsessive-Compulsive Disorders

Shame surrounds many people with obsessive-compulsive disorders, leading to conditions like OCD, body dysmorphic disorder, and trichotillomania being underrecognized in clinical settings. Katharine Phillips, professor of psychiatry at Weill Cornell Medical College, presented this topic, as well as obsessive-compulsive treatment options, at the annual American Psychiatric Association (APA) conference in New York.^1,2

Patients with OCD often can be embarrassed by their intrusive thoughts, whether that be sexual thoughts or thoughts of harming others.

“Those thoughts are sometimes hard for patients to spontaneously mention to clinicians,” Katharine Phillips, professor of psychiatry at Weill Cornell Medical College, told HCPLive.

People with body dysmorphic disorder often do not mention their symptoms to clinicians because of embarrassment and worry they will be judged or viewed as vain.

“Because they're so worried about how they look, and [body dysmorphic disorder] is not about that,” she said. “It's about it's about having intrusive thoughts and not seeing yourself correctly.”

Trichillomania and the skin picking disorder are associated with a lot of shame. Since people feel ashamed to bring up their symptoms, Phillips said it is crucial to screen patients for these disorders and to ask questions to see if they have recurrent or intrusive, unwanted thoughts.

She said to screen for body dysmorphic disorder, a clinician can ask a simple question: “Are you worried about how you look?” They can even normalize the question by phrasing it as “Many people worry about how they look. Is that a problem for you?”

For both OCD and body dysmorphic disorder, she uses a cut point of about an hour or more a day for having these thoughts. People need at least an hour of clinically significant distress due to the thoughts of body dysmorphic disorder and an hour of significant impairment in functioning for OCD.

She said it can be straightforward to diagnose these disorders. People with body dysmorphic disorder may think their lips are asymmetrical or their head is not exactly even. People with trichotillomania may have noticeable lesions on their skin or patches of hair; clinicians should ask these patients if they are pulling out their hair and if it is hard to control or repetitive.

“It's important to make sure that the hair pulling, and the skin picking are not triggered by thoughts at the skin or the hair look bad because that is body dysmorphic disorder,” she said.

The first-line treatment for OCD and body dysmorphic disorder is serotonin reuptake inhibitors (SSRIs) and these patients tend to need higher doses than patients with other disorders, such as fluoxetine Prozac at 120 mg a day and sertraline 400 mg a day.

“Not everyone needs these high doses, but on average, the necessary doses of SSRIs are pretty high,” she explained.

For glutamate modulators, she prescribes n-acetyl cysteine as high as 18000 mg twice a day, starting with a lower dose, and memantine as high as 20 mg twice a day.

Hoarding disorder is more difficult to treat with medication, so cognitive behavioral therapy is often used. Cognitive behavioral therapy also can be used for body dysmorphic disorders and Phillip advises patients to look in the mirror and improve their ability to look at the bigger picture in their appearance.

“It's a quick mirror exercise about 5 minutes a day where they learn to describe themselves from head to toe, not zero in on the things they don't like, and using neutral non-judgmental language,” Phillips said.

References

1. ^{Derman, C. Katharine Phillips, MD: Differences Between OCD, Body Dysmorphic Disorder. HCPLive. May 10, 2024. https://www.hcplive.com/view/katharine-phillips-md-differences-between-ocd-body-dysmorphic-disorder. Accessed May 10, 2024.}
2. ^{Phillips, K. Obsessive-Compulsive Spectrum Disorders: Clinical Presentations and Treatments. Session presented at: American Psychiatric Association (APA) 2024 Annual Meeting. New York, NY. May 4, 2024.}