La polifarmacia en los pacientes refractarios debe evaluarse desde el punto de vista terapéutico y desde los posibles efectos colaterales, incluyendo el síndrome serotoninérgico, el fenómeno de supresión, los efectos extrapiramidales y las interacciones fármaco-fármaco (218).

La terapia electroconvulsiva (TEC) se ha intentado con frecuencia en pacientes con trastorno obsesivo compulsivo (TOC) grave los beneficios logrados han sido ocasionales. Probablemente, los pacientes que respondieron a la TEC tenían depresión primaria con síntomas secundarios de trastorno obsesivo compulsivo (TOC), o exacerbación del trastorno obsesivo compulsivo (TOC) primario debido a la superposición de depresión secundaria. Hay pocas indicaciones y ninguna evidencia convincente de que el trastorno obsesivo compulsivo (TOC) primario responda a la terapia electroconvulsiva.

Un ensayo abierto sugirió que 20 minutos de estimulación magnética transcraneal (EMT) prefrontal lateral derecha administrada al 80% del umbral motor produjo una reducción de los síntomas obsesivo-compulsivos de ocho horas de duración. La estimulación magnética transcraneal prefrontal lateral izquierda no fue eficaz y la estimulación mediooccipital aumentó los síntomas obsesivo-compulsivos (219, 220, 221, 222, 223, 224, 225, 226, 227, 228, 229).

Conclusión:

Es posible señalar, por lo anteriormente expuesto, que la falta de respuesta en los pacientes refractarios a inhibidores selectivos de la recaptación de serotonina (ISRS) refleja una heterogeneidad neurobiológica subyacente donde las alteraciones en la neurotransmisión serotoninérgica de estos pacientes sea diferente a la de los pacientes respondedores, o que los síntomas del trastorno obsesivo compulsivo (TOC) resulten de anormalidades en otros sistemas de neurotransmisores, tales como el dopaminérgico y gabaérgico.

Existen numerosas estrategias para el manejo del trastorno obsesivo compulsivo (TOC) refractario y resistente, de acuerdo a los datos publicados; las estrategias que potencian el tratamiento son las indicadas en primer lugar especialmente en aquellos pacientes con una favorable respuesta inicial que no llega a transformarse en una completa luego de un período razonable de tiempo. El uso del agregado neuroléptico al inhibidor selectivo de la recaptación de serotonina (ISRS) inicial es el tratamiento de primer orden en esto paciente dejando el manejo psicoquirúrgico paro los trastorno obsesivo compulsivo (TOC) de graves a severos.

Bibliografía

1. Kessler RC, Berglund P, Demler O, Jin R, Merikangas KR, Walters EE: Lifetime prevalence and age-of-onset distributions of DSM-IV disorders in the National Comorbidity Survey Replication. Arch Gen Psychiatry 2005; 62: 593-602.
2. Tukel R, Ertekin E, Batmaz S, Alyanak F, Sozen, A, Aslantas B, Atli H, Ozyildirim I: Influence of age of onset on clinical features in obsessive-compulsive disorder. Depress Anxiety 2005; 21: 112-117.
3. Nestadt G, Bienvenu OJ, Cai G, Samuels J, Eaton WW: Incidence of obsessivecompulsive disorder in adults. J Nerv Ment Dis 1998; 186: 401-406..
4. Skoog G, Skoog I: A 40-year follow-up of patients with obsessive-compulsive disorder. Arch Gen Psychiatry 1999; 56: 121-127.
5. Rasmussen SA, Eisen JL: Clinical and epidemiologic findings of significance to neuropharmacologic trials in OCD. Psychopharmacol Bull 1988; 24: 466-470.
6. Perugi G, Akiskal HS, Gemignani A, Pfanner C, Presta S, Milanfranchi A, Lensi P, Ravagli S, Maremmani I, Cassano GB: Episodic course in obsessive-compulsive disorder. Eur Arch Psychiatry Clin Neurosci 1998; 248: 240-244.
7. Fireman B, Koran LM, Leventhal JL, Jacobson A: The prevalence of clinically recognized obsessive-compulsive disorder in a large health maintenance organization. Am J Psychiatry 2001; 158: 1904-1910.
8. Foa EB, Huppert JD, Leiberg S, Langner R, Kichic R, Hajcak G, Salkoviskis PM: The Obsessive-Compulsive Inventory: development and validation of a short version. Psychol Assess 2002; 14: 485-496.
9. Goodman WK, Price LH, Rasmussen SA, Mazure C, Fleischmann, RL Hill CL, Henninger GR, Charney DS: The Yale-Brown Obsessive Compulsive Scale: part I. Development, use, and reliability. Arch Gen Psychiatry 1989; 46: 1.006-1.012.
10. American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, 4th ed, Text Revision. Washington, D.C., American Psychiatric Association, 2000.
11. Atmaea M, Kuloglu M, Tezcan E, Gecici O. (2002) Quetiapine augmentation in patients with treatment resistant obsessive-compulsive disorder: a singleblind, placebo-controlled study. Int Clin Psychopharmacol1May; 17 (3): 11 5 - 11 9
12. Barr LC, Goodman WC, Price LH et al. (1992) The serotonin hypothesis of obsessive compulsive disorder: Implications of Pharmacologic challenge studies. J Clin Psychiatry 53 S: 17-28
13. Baxter SL J r, Schwartz JM, Berman KS, et al. (1992) Caudate glucose metabolic rate changes with both drug and behaviour therapy for OCD. A r c i v e s of General Psychiatry. 49, 681-9
14. Berman L, Sapers B L, Chang H H J, Losonczy M E, et al. (1995)Treatment of obsessive-compulsive symptoms in schizophrenic patients with clomipramine. Journal of Clinical Psychopharmacology, 15, 2 0 6 - 1 0
15. Anath J, Pecknold J, Van der Steen N, Engelsmann F.: Double-blind comparative study of chlorimipramine in obsessive neurosis. Cur Ther Res 1979; 25(6): 703-709.
16. Rapoport J, Elkins R, Mikkelsen E. Clinical controlled trial of chlorimipramine in adolescent with obsessive-compulsive disorder. Psychopharmacol Bull 1980; 16: 61-63.
17. Insel T, Murphy D, Cohen R y cols. Obsessive-compulsive disorder. A double-blind trial of clomipramine and clorgiline. Arch Gen Psychiatry 1983; 40: 605-612.
18. Thoren P, Asberg M, Cronholm B y cols. Clomipramine treatment of obsessive-compulsive disorder. Acontrolled clinical trial. Arch Gen Psychiatry 1980; 37: 1281-1285.
19. DeVeaugh-Geiss J, Katz RJ, Landau P y cols. Clomipramine in the treatment of patients with obsessive-compulsive disorder: Clomipramine Collaborative Study Group. Arch Gen Psychiatry 1991; 48: 730-731.
20. Vallejo J, Olivares J, Marcos T, Bulbena A, Menchón J. Clomipramine versus phenelzine in obsessive-compulsive disorder. A controlled clinical trial. Br J Psychiatry 1992; 161: 665-670.
21. Hollander E, Pallanti S. Current and experimental therapeutics of OCD. En Neuropsychopharmacology, The Fifth Generation of Progress. Davis KL, Charney D, Coyle JT, Nemeroff Ch editors. 5º ed. Lipincott Williams & Wilkins: Philadelphia;2002. p. 1647-64.
22. Pallanti S, Hollander E, Goodman WK. A Qualitative analysis of nonresponse: management of treatment-refractory obsessive-compulsive disorder. J Clin Psychiatry 2004;65(suppl 14):6-10.
23. Mataix-Cols D, do Rosario-Campos MC, Leckman JF. A Multidimensional Model of Obsessive-Compulsive Disorder. Am J Psychiatry 2005;162(2):228-38.
24. Janardhan Reddy YC; D'Souza MS; Shetti CP. An 11-to 13-year follow-up study with obsessive-compulsive disorder. J Clin Psychiatry 2005;66(6):744-9.
25. Cavedini P, Erzegovesi S, Ronchi P, et al. Predictive value of obsessive compulsive personality disorder in antiobsessional pharmacological treatment. Eur Neuropsychopharmacol 1997; 7: 45-49.
26. Denys D, Buger H, van Megen H, et al. A score for predicting response to pharmacotherapy in obsessive-compulsive disorder. Int Clin Psychopharmacol 2003; 18: 315-322
27. Dannon PN, Sasson Y, Hirschmann S, et al. Pindolol augmentation in treatment-resistant obsessive-compulsive disorder: a double-blind placebo controlled trial. Eur Neuropsychopharmacol 2000; 10: 165-169
28. Ackerman DL, Greenland S, Bystritsky, et al. Predictors of treatment response in obsessive-compulsive disorder: multivariate analyses from a multicenter trial of clomipramine. J Clin Psychopharmacol 1994; 14: 247-254
29. Okasha A. Chichester, West Sussex, UK, John Wiley & Sons, 2005, pp 457–459
30. Goodman WK, Price LH, Rasmussen SA, Mazure C3Fleischmann RL, Hill CL, Heninger GR, Charney DS:3The Yale-Brown Obsessive Compulsive Scale, I: development, 3use, and reliability. Arch Gen Psychiatry 1989;346:1006–1011
31. Foa EB, Huppert JD, Leiberg S, Langner R, Kichic R, 3Hajcak G, Salkovskis PM: The Obsessive-Compulsive3Inventory: development and validation of a short version.3Psychol Assess 2002; 14:485–496
32. Goodman WK, Price LH, Rasmussen SA, Mazure C, 3Delgado P, Heninger GR, Charney DS: The Yale-3Brown Obsessive Compulsive Scale, II: validity. Arch3Gen Psychiatry 1989; 46:1012–1016
33. LaSalle VH, Cromer KR, Nelson KN, Kazuba D, Justement3L, Murphy DL: Diagnostic interview assessed3neuropsychiatric disorder comorbidity in 334 individuals3with obsessive-compulsive disorder. Depress Anxiety32004; 19:163–173
33. Diniz JB, Rosario-Campos MC, Shavitt RG, Curi M, 3Hounie AG, Brotto SA, Miguel EC: Impact of age at onset and duration of illness on the expression of comorbidities3in obsessive-compulsive disorder. J Clin3Psychiatry 2004; 65:22–27
34. Koran LM: Obsessive-Compulsive and Related Disorders in Adults: A Comprehensive Clinical Guide. Cambridge, UK, Cambridge University Press, 1999
35. Daniel Navarro Bayón Psicothema 2004. Vol. 16, nº 2, pp. 241-247
36. Micallef J, Blin O. Neurobiology and Clinical Pharmacology of Obsessive- Compulsive Disorder. Clin Neuropharmacol 2001;24(4):1-28.
37. Nelson CJ. Tricyclics and Tetracyclics. En: Textbook of psychopharmacology, Third Edition. Schatzberg AF, Nemeroff ChB editors. 3º ed. American Psychiatric Press: Washington DC; 2004. p. 207-30
38. Mataix-Cols D, do Rosario-Campos MC, Leckman JF. A Multidimensional Model of Obsessive-Compulsive Disorder. Am J Psychiatry 2005;162(2):228-38.
39. American Psychiatric Association: Practice guideline for the psychiatric evaluation of adults, 2nd ed. Am J Psychiatry 2006; 163(suppl):3–36
40. Grabe HJ, Meyer C, Hapke U, Rumpf HJ, Freyberger HJ, Dilling H, John U: Lifetime-comorbidity of obsessive-compulsive disorder and subclinical obsessivecompulsive disorder in Northern Germany. Eur Arch Psychiatry Clin Neurosci 2001; 251:130–135
41. Overbeek T, Schruers K, Vermetten E, Griez E: Comorbidity of obsessive-compulsive disorder and depression: prevalence, symptom severity, and treatment effect. J Clin Psychiatry 2002; 63:1106–1112
42Winsberg ME, Cassic KS, Koran LM: Hoarding in obsessive-compulsive disorder: a report of 20 cases. J Clin Psychiatry 1999; 60:591-597
43. Skoog G, Skoog I: A 40-year follow-up of patients with obsessive-compulsive disorder. Arch Gen Psychiatry 1999; 56:121–127
44. Drummond LM: The treatment of severe, chronic, resistant obsessive-compulsive disorder. An evaluation of an in-patient programme using behavioural psychotherapy in combination with other treatments. Br J Psychiatry 1993; 163:223–229
45. Stewart SE, Stack DE, Farrell C, Pauls DL, Jenike MA: Effectiveness of intensive residential treatment (IRT) for severe, refractory obsessive-compulsive disorder. J Psychiatr Res 2005; 39:603–609
46. Bystritsky A, Munford PR, Rosen RM, Martin KM, 4Vapnik T, Gorbis EE, Wolson RC: A preliminary study4of partial hospital management of severe obsessivecompulsive disorder. Psychiatr Serv 1996; 47:170–1744
47. Leo RJ, Kuldip J, Bakhai YD: Nonadherence with psychopharmacologic treatment among psychiatric patients. Primary Psychiatry 2005; 12(June):33–39
48. Bourgeois JA: Compliance with psychiatric treatment in primary care: review and strategies. Primary Psychiatry 2005; 12(June):40–47
49. Miller WR, Rollnick S, Conforti K: Motivational Interviewing: Preparing People for Change, 2nd ed. New York, Guilford Press, 2002
50. Renshaw KD, Steketee G, Chambless DL: Involving family members in the treatment of OCD. Cogn Behav Ther 2005; 34:164–175