What is the recommended treatment for a patient presenting with obsessive-compulsive disorder (OCD) checking behaviors?

Managing OCD Checking Behaviors

Cognitive-behavioral therapy with exposure and response prevention (ERP) is the treatment of choice for OCD checking behaviors, with a number needed to treat of 3 compared to 5 for SSRIs, and should consist of 10-20 sessions where patients practice abstaining from checking compulsions while being exposed to uncertainty-provoking situations. 1

First-Line Treatment Approach

CBT with ERP as Primary Treatment

• Start with CBT-ERP as monotherapy for most patients, delivering 10-20 individual or group sessions either in-person or via internet-based protocols 1
• The core intervention involves gradual exposure to situations that trigger checking urges (e.g., leaving the house, turning off appliances) while specifically instructing patients to abstain from performing checking behaviors 1
• Integrate cognitive reappraisal techniques to address dysfunctional beliefs about uncertainty and feared catastrophic outcomes that drive the checking compulsions 1
• Between-session homework is the strongest predictor of treatment success—patients must practice ERP exercises at home without performing checking behaviors 1

When to Use Medication

Initiate an SSRI at higher-than-depression doses if any of the following apply: 1

• CBT expertise is unavailable in your area
• Patient explicitly prefers medication over psychotherapy
• Severe comorbid depression is present that requires immediate pharmacological intervention
• OCD severity is so extreme that the patient cannot actively participate in psychotherapy sessions

SSRI Dosing Specifics

• For fluoxetine: Start adults at 20 mg/day in the morning; may increase after several weeks if insufficient improvement, with a dose range of 20-60 mg/day recommended (maximum 80 mg/day) 2
• For adolescents and higher-weight children: Start at 10 mg/day, increase to 20 mg/day after 2 weeks, with a range of 20-60 mg/day 2
• For lower-weight children: Start at 10 mg/day with a target range of 20-30 mg/day 2
• All SSRIs show similar efficacy; select based on adverse effect profiles, drug interactions, and comorbid conditions 1
• Allow 8-12 weeks at maximum tolerated dose before declaring treatment failure, as the full therapeutic effect may be delayed until 5 weeks or longer 1, 2

Combination Therapy

Begin with combined CBT plus SSRI for moderate-to-severe OCD, including severe checking behaviors that significantly impair daily functioning 1

• Recent meta-analyses suggest combination treatment is more effective than CBT alone, particularly in severe OCD 3
• While SSRI monotherapy may be most cost-effective, combined treatment appears most clinically effective especially compared to CBT monotherapy 3

Critical Pitfalls: Family Accommodation

The major pitfall in treating checking OCD is family accommodation, where family members enable the checking behavior by providing reassurance or participating in checking rituals 1

• Provide psychoeducation to family members about how their well-intentioned responses (e.g., confirming the door is locked, checking appliances together) maintain the OCD cycle and undermine treatment 1
• Instruct family members to compassionately decline providing reassurance while supporting the patient's ERP work 1
• Family involvement is crucial for treatment success and should be incorporated whenever possible 1

Treatment-Resistant Cases

If inadequate response after adequate trials of first-line treatments: 1

• Switch to a different SSRI or try higher doses within the therapeutic range
• Add antipsychotic augmentation: Aripiprazole or risperidone have the strongest evidence for OCD augmentation 1, 4
• Consider clomipramine, which is more efficacious than SSRIs in meta-analyses but has lower tolerability 1
• Intensive CBT protocols with multiple sessions over days, sometimes inpatient settings 1
• Deep repetitive transcranial magnetic stimulation (rTMS), which is FDA-approved for OCD 1

Long-Term Management

• Continue treatment for a minimum of 12-24 months after achieving remission due to high relapse risk 1, 5
• OCD is a chronic condition and long-term continuation is reasonable for responding patients 5
• Maintain patients on the lowest effective dosage with periodic reassessment 2
• Monitor adherence to between-session homework as this is the strongest predictor of both short-term and long-term outcomes 1