Although selective serotonin reuptake inhibitors
(SSRIs) have revealed new avenues for OCD treatment,
about 40% of patients do not respond, or respond only
partially to this approach. In those resistant patients, the
possibility of adding on antipsychotic, and especially the
new atypical antipsychotic is often raised.
Data in regard to augmentation of OCD patients who
did not respond to treatment with SSRI suggest that
risperidone might have a specific therapeutic potential in
this subset of patients. The role of antipsychotics with
5HT1D properties like ziprasidone need to be studied.
The data supporting the role of antipsychotic
medication in obsessive compulsive disorder with poor
insight are not convincing. However, at times the
treatment dilemma (antipsychotic or antiobsessive)
actually derives from diagnostic ambiguity; many of the
very severe ego-syntonic obsessive compulsive patients
may be erroneously diagnosed as schizophrenic, while
they are actually severe OCD, and as such should be
treated initially with antiobsessive medication and not
antipsychotic. In fact, there is data to suggest that poor
insight is not related to treatment outcome with SSRI in
OCD, so there is no reason to suggest that an
antipsychotic is always of extra benefit in these cases.
The prevalence of OCD amongst schizophrenic
patients ranges from 10-25% and has a negative effect on
the prognosis for that substantial proportion of
schizophrenic patients. In the past, a diagnosis of
comorbid schizophrenia and OCD was not possible, but
the DSM IV introduced it as a viable comorbidity. It is
specified, however, that the obsessions must not be
restricted to the delusional content of the schizophrenia
presentation. Preliminary data implies that for this subset
of patients (the schizo-obsessive patients) a combination
of antipsychotic and antiobsessive medication might be
useful.
In OCD with tic disorder, combination treatment using
highly potent dopamine blockers and selective serotonin
inhibitors is effective. However, the use of dopamine
blockers in OCD is not limited to this subset of patients;
dopamine blockers such as risperidone and quetiapine are
effective augmentation therapy in treatment-resistant
patients. Some of the most severe cases are those in which
the family is involved in "helping" the patient. Unless
patients undergo detailed and well-planned cognitivebehavioral
therapy, along with careful evaluation and
assessment of the family environment, they cannot be
considered "resistant." For those patients who are actually
resistant, neurosurgery, gamma knife treatment and, more
recently, deep brain stimulation have been proposed, but these should be reserved as last-resort options.
With advances in our understanding of the complexity
of OCD and OCRDs, it may be possible to tailor treatment
to the specific needs of individual patients. Sophisticated
pharmacologic interventions and treatment that takes
environmental factors into account, along with
improvements in diagnostic skills, all provide new hope
for this intriguing group of patients with OCD.
There is also some data about use of antipsychotics in
PTSD, in generalized anxiety disorder, social phobia and
other anxiety disorders. However, there is still much
research to be done about the benefits of different
antipsychotic medications, either as augmentation to
current medication or as monotherapy, in anxiety disorders.