Treatment for Severe Anxiety, OCD, and Impulsivity-Excessive Shopping
For severe anxiety, OCD, and impulsivity characterized by excessive shopping, the first-line treatments are cognitive behavioral therapy (CBT) with exposure and response prevention (ERP) and/or selective serotonin reuptake inhibitors (SSRIs) at higher doses than typically used for depression. 1
First-Line Pharmacotherapy
SSRIs for OCD and Anxiety
- Fluoxetine: Start at 20 mg/day and increase to 40-60 mg/day for OCD (higher than depression dosing) 1, 2
- Other SSRIs: Similar efficacy to fluoxetine but with different side effect profiles 1
- Higher SSRI doses are typically needed for OCD than for anxiety disorders or depression 1
- Allow 8-12 weeks at therapeutic dose to determine efficacy 1
Medication Selection Considerations
- Choose SSRI based on:
- Side effect profile
- Past treatment response
- Potential drug interactions
- Presence of comorbid conditions 1
- For impulsive shopping specifically, citalopram has shown efficacy in an open-label study 3
First-Line Psychotherapy
Cognitive Behavioral Therapy (CBT)
- ERP (Exposure and Response Prevention): Most effective psychological treatment for OCD 1
- 10-20 sessions
- Can be delivered individually or in group format
- In-person or via internet-based protocols 1
- For anxiety: CBT specifically developed for anxiety disorders is recommended 1
- Patient adherence to between-session homework is the strongest predictor of good outcomes 1
Treatment Algorithm
Step 1: Initial Treatment Selection
- If patient prefers psychotherapy or has contraindications to SSRIs: Start with CBT/ERP
- If patient has severe symptoms preventing engagement with CBT or prefers medication: Start with SSRI
- If both are available and acceptable: Consider combined approach
Step 2: SSRI Titration for OCD
- Start with fluoxetine 20 mg/day (adults) or 10 mg/day (lower weight individuals) 2
- After several weeks, if insufficient improvement, increase dose
- Target dose range: 40-60 mg/day for OCD 1, 2
- Maximum dose: 80 mg/day (though doses up to 650 mg/day equivalent have been studied for refractory OCD) 4
Step 3: Monitoring and Adjustment
- Evaluate response after 8-12 weeks at therapeutic dose 1
- Monitor for side effects: sexual dysfunction, weight gain, sedation, hyperhidrosis, tremor 4
- Higher doses of SSRIs may be needed but come with increased side effects 1
Step 4: For Inadequate Response
- If partial response to SSRI: Consider augmentation with CBT if available
- If no response to first SSRI: Switch to another SSRI
- If multiple SSRI failures: Consider clomipramine (though has more side effects than SSRIs) 1
- For treatment-resistant cases: Consider augmentation with antipsychotics or glutamate-modulating agents 1
Special Considerations for Impulsivity/Excessive Shopping
- Compulsive shopping responds to SSRI treatment, particularly citalopram 3
- Target the underlying anxiety and obsessive-compulsive features
- Higher doses may be required similar to OCD treatment 4
- Long-term maintenance therapy reduces relapse risk 3
Pitfalls and Caveats
Dosing errors: Using depression-level doses of SSRIs for OCD is ineffective; higher doses are typically required 1
Premature discontinuation: Full therapeutic effect may be delayed until 5+ weeks of treatment 2
Inadequate trial duration: Evaluate efficacy only after 8-12 weeks at therapeutic dose 1
Overlooking comorbidities: Presence of tics, schizotypic personality, or certain obsession types may predict poorer response 5
Side effect management: Higher SSRI doses increase adverse effects; monitor carefully but recognize that some early side effects (nervousness, insomnia) may actually predict good response 5
Discontinuation syndrome: Avoid abrupt discontinuation of SSRIs due to withdrawal symptoms
By following this treatment approach with appropriate medication dosing and evidence-based psychotherapy, most patients with severe anxiety, OCD, and impulsive shopping behaviors can achieve significant symptom reduction and improved quality of life.