What is the recommended treatment for a patient with severe OCD and trichotillomania, considering safety for potential pregnancy?

Treatment of Severe OCD with Trichotillomania in a Woman Planning Pregnancy

For this 37-year-old woman with severe OCD (Y-BOCS 32) and trichotillomania planning pregnancy within a year, the optimal treatment is cognitive-behavioral therapy with exposure and response prevention (ERP) as first-line therapy, combined with an SSRI—specifically sertraline or fluoxetine rather than citalopram—given their superior evidence base and FDA approval for OCD. 1, 2, 3

Why CBT with ERP Should Be Primary Treatment

Cognitive-behavioral therapy with ERP is the psychological treatment of choice for OCD and demonstrates superior efficacy compared to pharmacotherapy alone, with a number needed to treat of 3 for CBT versus 5 for SSRIs. 1, 2, 4 This is particularly important for this patient given:

• Her severe symptoms (Y-BOCS 32) require the most effective intervention 1
• Pregnancy planning within one year makes minimizing medication exposure desirable 4
• Patient adherence to between-session homework (ERP exercises) is the strongest predictor of treatment success 1, 4

For her specific presentations, ERP should target:

• Gradual exposure to uncertainty about car/belongings without taking photos or checking 1, 4
• Exposure to hair-pulling urges while preventing the pulling behavior 1
• Abstaining from compulsive checking of notes and photos 1

Pharmacotherapy Selection: Critical Error in Current Plan

The choice of citalopram in this case is suboptimal. While citalopram has evidence for OCD treatment 5, sertraline and fluoxetine have FDA approval specifically for OCD and should be considered first-line SSRIs. 3, 6 The FDA label for fluoxetine explicitly supports its use in OCD at doses of 20-80 mg/day 3, and sertraline has demonstrated efficacy in multiple double-blind, placebo-controlled studies specifically for OCD 6.

Key pharmacotherapy considerations for this patient:

• Higher SSRI doses are required for OCD than depression—typically 40-80 mg fluoxetine or 150-200 mg sertraline 1, 4, 3
• The starting dose of citalopram 10 mg is far below therapeutic range for severe OCD 1
• Treatment duration of 8-12 weeks at maximum tolerated dose is necessary before determining efficacy 1, 4, 7
• Her previous sertraline trial was only 2 months (8 weeks), which may have been adequate duration but the cognitive side effects she experienced are important to consider 1

Pregnancy Planning Considerations

For women of childbearing age planning pregnancy, treatment decisions must balance OCD severity against fetal risk:

• Untreated severe OCD (Y-BOCS 32) significantly impairs functioning and quality of life, which itself poses risks during pregnancy 1
• SSRIs as a class have the most safety data in pregnancy, though no medication is without risk 1, 4
• CBT with ERP has no fetal risk and should be maximized before and during pregnancy 1, 2, 4
• If medication is necessary, sertraline and fluoxetine have more extensive pregnancy safety data than citalopram 3, 6

Trichotillomania-Specific Treatment

Trichotillomania is classified as an obsessive-compulsive related disorder but responds differently to treatment than OCD. 1 The evidence shows:

• Behavioral therapy (habit reversal training and ERP) is the most effective treatment for trichotillomania 8
• SSRIs have mixed evidence for trichotillomania—fluoxetine showed 34% improvement in severity scores in open trials, with 60% improvement among responders 9
• N-acetylcysteine (1200-2400 mg/day) has evidence for trichotillomania and may be considered as augmentation 8
• Olanzapine showed 85% response rates in a randomized controlled trial for trichotillomania, though weight gain and metabolic effects limit its use, especially in pregnancy planning 10

Recommended Treatment Algorithm

Step 1: Immediate initiation (current)

• Intensive CBT with ERP should be prioritized—consider referral for intensive protocols with multiple sessions weekly given severity 1, 2
• Psychiatry referral is appropriate for medication management and treatment-resistant planning 1, 2
• If continuing pharmacotherapy, switch from citalopram to sertraline 50 mg daily or fluoxetine 20 mg daily 3, 6

Step 2: Dose optimization (weeks 2-8)

• Increase SSRI to therapeutic doses for OCD: sertraline 150-200 mg/day or fluoxetine 60-80 mg/day 1, 3
• Continue intensive ERP with homework compliance monitoring 1, 4
• Monitor for adverse effects, particularly sexual dysfunction and GI symptoms 1

Step 3: Reassessment at 8-12 weeks

• If Y-BOCS reduction <25%, consider treatment-resistant strategies 1, 2
• For treatment-resistant OCD: add CBT if not already optimized, consider clomipramine (though less ideal for pregnancy planning), or antipsychotic augmentation 1, 2, 7
• For persistent trichotillomania: add N-acetylcysteine 1200-2400 mg/day 8

Step 4: Pre-pregnancy planning (6-12 months before conception)

• Reassess need for medication if CBT has achieved substantial improvement 1, 4
• If medication necessary, continue lowest effective dose 4
• Maintain CBT with monthly booster sessions to prevent relapse 4

Critical Pitfalls to Avoid

Common errors that compromise outcomes:

• Using inadequate SSRI doses or insufficient trial duration (<8-12 weeks) is the most common cause of apparent treatment resistance 1, 4
• Starting citalopram at 10 mg for severe OCD (Y-BOCS 32) is therapeutically insufficient 1
• Failing to provide or refer for evidence-based CBT with ERP, which has superior efficacy to medication alone 1, 2
• Premature medication discontinuation before 12-24 months of remission increases relapse risk substantially 1, 4
• Not addressing family accommodation behaviors (partner participating in checking rituals or providing reassurance) 4
• Neglecting the distinct treatment needs of comorbid trichotillomania versus OCD 1, 8

Monitoring Requirements

Essential monitoring for this patient:

• Y-BOCS scores at baseline, 4 weeks, 8 weeks, and 12 weeks to objectively track response 4, 7
• Weekly monitoring for mood changes and suicidality during first month of SSRI treatment 1, 4
• ECG monitoring is appropriate given QTc baseline of 407ms, though citalopram has more QT concerns than sertraline/fluoxetine 1
• Serum sodium at 4 weeks is reasonable given SSRI-associated hyponatremia risk 1
• Assessment of CBT homework adherence at each session, as this predicts outcome 1, 4

The current plan requires modification: prioritize intensive CBT with ERP, consider switching to sertraline or fluoxetine at therapeutic OCD doses, and integrate trichotillomania-specific interventions including potential N-acetylcysteine augmentation. 1, 2, 3, 8, 6