神经外科学
神经外科消融术（晶状体前囊切开术、边缘叶脑白质切开术、扣带回切开术、伽玛刀放射外科）并未得到 FDA 许可，但对重度难治性强迫性障碍患者而言，如果一线、二线和强化治疗策略均无效，可以考虑此类方法。[55]American Psychiatric Association. Practice guideline for the treatment of patients with obsessive-compulsive disorder. Am J Psychiatry. 2007;164:1-56.[57]American Psychiatric Association. Guideline watch (March 2013): Practice guideline for the treatment of patients with obsessive-compulsive disorder. March 2013 [internet publication].http://psychiatryonline.org/pb/assets/raw/sitewide/practice_guidelines/guidelines/ocd-watch.pdf 这些年最常用的神经外科干预方法是扣带回切开术，该手术涉及到将双侧扣带回损毁。在一篇关于立体定向扣带回切开术的综述中，扣带回切开术被推荐为一项安全、副作用有限的手术，但综述作者提醒，它只能用于最难治的病例。[116]Cosgrove GR, Rauch SL. Stereotactic cingulotomy. Neurosurg Clin N Am. 2003 Apr;14(2):225-35.http://www.ncbi.nlm.nih.gov/pubmed/12856490?tool=bestpractice.com
经颅磁刺激治疗法 (TMS)
关于经颅磁刺激的研究结果不尽相同。 在 1997 年，一项研究发现，一次性刺激右侧前额皮质，能明显降低强迫性障碍患者的强迫冲动，持续效应超过 8 小时。[117]Greenberg BD, George MS, Martin JD, et al. Effect of prefrontal repetitive transcranial magnetic stimulation in obsessive-compulsive disorder: a preliminary study. Am J Psychiatry. 1997 Jun;154(6):867-9.http://www.ncbi.nlm.nih.gov/pubmed/9167520?tool=bestpractice.com 有一项试验报告，经颅磁刺激 (TMS) 没有效果。[118]Kang JI, Kim CH, Namkoong K, et al. A randomized controlled study of sequentially applied repetitive transcranial magnetic stimulation in obsessive-compulsive disorder. J Clin Psychiatry. 2009 Dec;70(12):1645-51.http://www.ncbi.nlm.nih.gov/pubmed/19709504?tool=bestpractice.com 另一项试验在抵抗治疗的强迫性障碍患者中开展，结果表明反复性前额皮质 TMS 并不优于假治疗，有证据表明存在安慰剂效应。[119]Mansur CG, Myczkowki ML, de Barros Cabral S, et al. Placebo effect after prefrontal magnetic stimulation in the treatment of resistant obsessive-compulsive disorder: a randomized controlled trial. Int J Neuropsychopharmacol. 2011 Nov;14(10):1389-97.http://www.ncbi.nlm.nih.gov/pubmed/21557884?tool=bestpractice.com 一项系统评价发现，运动辅助区和眶额皮质是重复经颅磁刺激 (rTMS) 的两个潜在靶区；与假性 rTMS 相比，使用 rTMS 刺激背外侧前额叶皮质没有产生有益作用。[120]Jaafari N, Rachid F, Rotge JY, et al. Safety and efficacy of repetitive transcranial magnetic stimulation in the treatment of obsessive-compulsive disorder: a review. World J Biol Psychiatry. 2012 Mar;13(3):164-77.http://www.ncbi.nlm.nih.gov/pubmed/21623668?tool=bestpractice.com 在得出rTMS有效的结论之前，需要进一步进行OCD治疗的对照研究。
脑深部电刺激 (DBS)
DBS与传统有创的治疗方法相比有几个重要的优势。 它的影响是可逆的，为微创操作。[121]Nuttin B, Cosyns P, Demeulemeester H, et al. Electrical stimulation in anterior limbs of internal capsules in patients with obsessive-compulsive disorder. Lancet. 1999 Oct 30;354(9189):1526.http://www.ncbi.nlm.nih.gov/pubmed/10551504?tool=bestpractice.com 各项研究中的靶区包括双侧内囊前肢、右侧伏隔核壳区、下丘脑核、尾状核腹侧。[121]Nuttin B, Cosyns P, Demeulemeester H, et al. Electrical stimulation in anterior limbs of internal capsules in patients with obsessive-compulsive disorder. Lancet. 1999 Oct 30;354(9189):1526.http://www.ncbi.nlm.nih.gov/pubmed/10551504?tool=bestpractice.com[122]Aouizerate B, Cuny E, Martin-Guehl C, et al. Deep brain stimulation of the ventral caudate nucleus in the treatment of obsessive-compulsive disorder and major depression. Case report. J Neurosurg. 2004 Oct;101(4):682-6.http://www.ncbi.nlm.nih.gov/pubmed/15481726?tool=bestpractice.com[123]Sturm V, Lenartz D, Koulousakis A, et al. The nucleus accumbens: a target for deep brain stimulation in obsessive-compulsive- and anxiety-disorders. J Chem Neuroanat. 2003 Dec;26(4):293-9.http://www.ncbi.nlm.nih.gov/pubmed/14729131?tool=bestpractice.com[124]Mallet L, Mesnage V, Houeto JL, et al. Compulsions, Parkinson's disease, and stimulation. Lancet. 2002 Oct 26;360(9342):1302-4.http://www.ncbi.nlm.nih.gov/pubmed/12414208?tool=bestpractice.com[125]Goodman WK, Foote KD, Greenberg BD, et al. Deep brain stimulation for intractable obsessive compulsive disorder: pilot study using a blinded, staggered-onset design. Biol Psychiatry. 2010 Mar 15;67(6):535-42.http://www.ncbi.nlm.nih.gov/pubmed/20116047?tool=bestpractice.com[126]Huff W, Lenartz D, Schormann M, et al. Unilateral deep brain stimulation of the nucleus accumbens in patients with treatment-resistant obsessive-compulsive disorder: outcomes after one year. Clin Neurol Neurosurg. 2010 Feb;112(2):137-43.http://www.ncbi.nlm.nih.gov/pubmed/20006424?tool=bestpractice.com[127]Denys D, Mantione M, Figee M, et al. Deep brain stimulation of the nucleus accumbens for treatment-refractory obsessive-compulsive disorder. Arch Gen Psychiatry. 2010 Oct;67(10):1061-8.http://archpsyc.jamanetwork.com/article.aspx?articleid=210896http://www.ncbi.nlm.nih.gov/pubmed/20921122?tool=bestpractice.com 最近的一项评价指出，存在最有力的证据支持使用双侧丘脑底核作为目标，但证据不足，无法建议对药物治疗无效的强迫症患者使用单侧深部脑刺激 (DBS) 。[128]Hamani C, Pilitsis J, Rughani AI, et al. Deep brain stimulation for obsessive-compulsive disorder: systematic review and evidence-based guideline sponsored by the American Society for Stereotactic and Functional Neurosurgery and the Congress of Neurological Surgeons (CNS) and endorsed by the CNS and American Association of Neurological Surgeons. Neurosurgery. 2014 Oct;75(4):327-33.http://journals.lww.com/neurosurgery/Fulltext/2014/10000/Deep_Brain_Stimulation_for_Obsessive_Compulsive.11.aspxhttp://www.ncbi.nlm.nih.gov/pubmed/25050579?tool=bestpractice.com
文拉法辛
活性药物对照试验和开放性研究支持其对强迫性障碍治疗的有效性。[36]Steketee G, Frost R, Bogart K. The Yale-Brown Obsessive Compulsive Scale: interview versus self-report. Behav Res Ther. 1996 Aug;34(8):675-84.http://www.ncbi.nlm.nih.gov/pubmed/8870295?tool=bestpractice.com[41]Heyman I, Mataix-Cols D, Fineberg NA. Obsessive-compulsive disorder. BMJ. 2006;333:424-429.http://www.ncbi.nlm.nih.gov/pubmed/16931840?tool=bestpractice.com[129]Di Nardo P, Moras K, Barlow DH, et al. Reliability of DSM-III-R anxiety disorder categories. Using the Anxiety Disorders Interview Schedule-Revised (ADIS-R). Arch Gen Psychiatry. 1993 Apr;50(4):251-6.http://www.ncbi.nlm.nih.gov/pubmed/8466385?tool=bestpractice.com 当治疗无效时可考虑换用文拉法辛，但应该注意的是，关于这种治疗方案的证据是冲突的，至少有一项研究报道过，当既往用其他选择性 5-羟色胺再摄取抑制剂 (SSRI) 药物治疗无效时，文拉法辛的疗效低于帕罗西汀。[55]American Psychiatric Association. Practice guideline for the treatment of patients with obsessive-compulsive disorder. Am J Psychiatry. 2007;164:1-56.[57]American Psychiatric Association. Guideline watch (March 2013): Practice guideline for the treatment of patients with obsessive-compulsive disorder. March 2013 [internet publication].http://psychiatryonline.org/pb/assets/raw/sitewide/practice_guidelines/guidelines/ocd-watch.pdf[130]Denys D, van Megen HJ, van der Wee N, et al. A double-blind switch study of paroxetine and venlafaxine in obsessive-compulsive disorder. J Clin Psychiatry. 2004 Jan;65(1):37-43.http://www.ncbi.nlm.nih.gov/pubmed/14744166?tool=bestpractice.com[131]Denys D, van der Wee N, van Megen HJ, et al. A double blind comparison of venlafaxine and paroxetine in obsessive-compulsive disorder. J Clin Psychopharmacol. 2003 Dec;23(6):568-75.http://www.ncbi.nlm.nih.gov/pubmed/14624187?tool=bestpractice.com[132]Albert U, Aguglia E, Maina G, et al. Venlafaxine versus clomipramine in the treatment of obsessive-compulsive disorder: a preliminary single-blind, 12-week, controlled study. J Clin Psychiatry. 2002 Nov;63(11):1004-9.http://www.ncbi.nlm.nih.gov/pubmed/12444814?tool=bestpractice.com
加用5-HT3拮抗剂昂丹司琼
这个药抗强迫的机制可能是通过阻断5-羟色胺3受体来抑制多巴胺功能。 一项单盲和一项双盲安慰剂对照试验证明了昂丹司琼作为 5-羟色胺再摄取抑制剂的增强剂在有治疗抵抗患者中的有效性。[133]Soltani FS, Sayyah M, Feizy F, et al. A double-blind, placebo-controlled pilot study of ondansetron for patients with obsessive-compulsive disorder. Hum Psychopharmacol. 2010 Aug;25(6):509-13.http://www.ncbi.nlm.nih.gov/pubmed/20737524?tool=bestpractice.com[134]Pallanti S, Bernardi S, Antonini S, et al. Ondansetron augmentation in treatment-resistant obsessive-compulsive disorder: a preliminary, single-blind, prospective study. CNS Drugs. 2009 Dec;23(12):1047-55.http://www.ncbi.nlm.nih.gov/pubmed/19958042?tool=bestpractice.com
右旋安非他命和咖啡因
这个作用机制的可能的解释是，这两种药物通过增加多巴胺的释放，来增强前额叶皮层D1受体的刺激进而增加将注意力从强迫观念上移开的能力，从而减少强迫行为的冲动。 在一项双盲、安慰剂对照试验中，咖啡因和右旋苯丙胺对治疗抵抗的患者是有效的。[135]Koran LM, Aboujaoude E, Gamel NN. Double-blind study of dextroamphetamine versus caffeine augmentation for treatment-resistant obsessive-compulsive disorder. J Clin Psychiatry. 2009 Nov;70(11):1530-5.http://www.ncbi.nlm.nih.gov/pubmed/19573497?tool=bestpractice.com
阿片类物质
引起皮质纹状体通路谷氨酸水平的改变。 一项双盲、交叉研究证明，添加吗啡，联合或不联合其他强化药物，都优于安慰剂。[136]Koran LM, Aboujaoude E, Bullock KD, et al. Double-blind treatment with oral morphine in treatment-resistant obsessive-compulsive disorder. J Clin Psychiatry. 2005 Mar;66(3):353-9.http://www.ncbi.nlm.nih.gov/pubmed/15766302?tool=bestpractice.com
托吡酯
引起皮质纹状体通路谷氨酸水平的改变。 一份病例报告提示，托吡酯强化治疗是有效的。[137]Hollander E, Dell'Osso B. Topiramate plus paroxetine in treatment-resistant obsessive-compulsive disorder. Int Clin Psychopharmacol. 2006 May;21(3):189-91.http://www.ncbi.nlm.nih.gov/pubmed/16528143?tool=bestpractice.com 但是，一项关于托吡酯强化治疗用于难治性强迫性障碍患者的双盲、安慰剂对照试验显示，托吡酯只对强迫行为有效，对强迫思维无效。[138]Berlin HA, Koran LM, Jenike MA, et al. Double-blind, placebo-controlled trial of topiramate augmentation in treatment-resistant obsessive-compulsive disorder. J Clin Psychiatry. 2011 May;72(5):716-21.http://www.ncbi.nlm.nih.gov/pubmed/20816027?tool=bestpractice.com
利鲁唑
引起皮质纹状体通路谷氨酸水平的改变。 一项开放试验证明了利鲁唑强化治疗的有效性。[139]Coric V, Taskiran S, Pittenger C, et al. Riluzole augmentation in treatment-resistant obsessive-compulsive disorder: an open-label trial. Biol Psychiatry. 2005 Sep 1;58(5):424-8.http://www.ncbi.nlm.nih.gov/pubmed/15993857?tool=bestpractice.com
米氮平
还应该注意的是，使用米氮平进行强化已经被证明可以加速选择性 5-羟色胺再摄取抑制剂 (SSRI) 的反应，是一种有效的强迫症治疗方法。[140]Pallanti S, Quercioli L, Bruscoli M. Response acceleration with mirtazapine augmentation of citalopram in obsessive-compulsive disorder patients without comorbid depression: a pilot study. J Clin Psychiatry. 2004 Oct;65(10):1394-9.http://www.ncbi.nlm.nih.gov/pubmed/15491244?tool=bestpractice.com[141]Koran LM, Gamel NN, Choung HW, et al. Mirtazapine for obsessive-compulsive disorder: an open trial followed by double-blind discontinuation. J Clin Psychiatry. 2005 Apr;66(4):515-20.http://www.ncbi.nlm.nih.gov/pubmed/15816795?tool=bestpractice.com 米氮平能够增强 5-羟色胺能功能，其机制与再摄取抑制不同。
苯二氮卓类、加巴喷丁或丁螺环酮
当残留症状与重度焦虑有关时，这些药物可能有用。[142]Pato MT, Pigott TA, Hill JL, et al. Controlled comparison of buspirone and clomipramine in obsessive-compulsive disorder. Am J Psychiatry. 1991 Jan;148(1):127-9.http://www.ncbi.nlm.nih.gov/pubmed/1984696?tool=bestpractice.com[143]Menkes DB. Buspirone augmentation of sertraline. Br J Psychiatry. 1995 Jun;166(6):823-4.http://www.ncbi.nlm.nih.gov/pubmed/7663840?tool=bestpractice.com
纳曲酮
对严重的梳理行为有效
D-环丝氨酸增强暴露疗法
可能导致对暴露疗法更快地应答，[144]Kushner MG, Kim SW, Donahue C, et al. D-cycloserine augmented exposure therapy for obsessive-compulsive disorder. Biol Psychiatry. 2007 Oct 15;62(8):835-8.http://www.ncbi.nlm.nih.gov/pubmed/17588545?tool=bestpractice.com 但是有些研究表明，加用 D-环丝氨酸治疗并未使成人或儿童的治疗结局得以改善。[145]Storch EA, Merlo LJ, Bengtson M, et al. D-cycloserine does not enhance exposure-response prevention therapy in obsessive-compulsive disorder. Int Clin Psychopharmacol. 2007 Jul;22(4):230-7.http://www.ncbi.nlm.nih.gov/pubmed/17519647?tool=bestpractice.com[146]Storch EA, Wilhelm S, Sprich S, et al. Efficacy of augmentation of cognitive behavior therapy with weight-adjusted d-cycloserine vs placebo in pediatric obsessive-compulsive disorder: a randomized clinical trial. JAMA Psychiatry. 2016 Aug 1;73(8):779-88.http://jamanetwork.com/journals/jamapsychiatry/fullarticle/2529151http://www.ncbi.nlm.nih.gov/pubmed/27367832?tool=bestpractice.com 在一项研究中，研究人员检查了抗抑郁状态是否会影响强迫症治疗中 D-环丝氨酸增强暴露疗法的效果，他们发现，未服用抗抑郁药物的患者比服用抗抑郁药物的患者更有可能获得缓解。[147]Andersson E, Hedman E, Enander J, et al. D-cycloserine vs placebo as adjunct to cognitive behavioral therapy for obsessive-compulsive disorder and interaction with antidepressants: a randomized clinical trial. JAMA Psychiatry. 2015 Jul;72(7):659-67.http://www.ncbi.nlm.nih.gov/pubmed/25970252?tool=bestpractice.com
琉璃苣 (Echium amoenum) 的水提取物
一项初步研究表明，该物质能有效减轻强迫思维和强迫行为，并且没有副作用。[148]Sayyah M, Boostani H, Pakseresht S, et al. Efficacy of aqueous extract of Echium amoenum in treatment of obsessive-compulsive disorder. Prog Neuropsychopharmacol Biol Psychiatry. 2009 Nov 13;33(8):1513-6.http://www.ncbi.nlm.nih.gov/pubmed/19737592?tool=bestpractice.com
计算机辅助心理治疗
在焦虑障碍心理治疗方面，计算机辅助心理治疗是一种很有前途的新兴研究领域。[149]Olthuis JV, Watt MC, Bailey K, et al. Therapist-supported internet cognitive behavioural therapy for anxiety disorders in adults. Cochrane Database Syst Rev. 2016;3:CD011565.http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD011565.pub2/fullhttp://www.ncbi.nlm.nih.gov/pubmed/26968204?tool=bestpractice.com 在缺乏经过培训的临床心理学专科医生的农村地区，此方法可能特别有用。[150]Cuijpers P, Marks IM, van Straten A, et al. Computer-aided psychotherapy for anxiety disorders: a meta-analytic review. Cogn Behav Ther. 2009;38(2):66-82.http://www.ncbi.nlm.nih.gov/pubmed/20183688?tool=bestpractice.com 然而，一项针对中度至重度强迫症成人患者的随机对照试验（这些患者已经在等待接受治疗师主导的认知行为疗法 [CBT]）发现，为患者提供基于书籍或基于计算机的 CBT 以及来自“心理健康执业医师”的电话支持并未在 3 或 12 个月后改善其强迫症状。这表明，基于书籍和基于计算机的 CBT 不太可能成为有中度到重度症状患者的有效策略，但还需要进一步研究来确定其对轻度症状患者的疗效。[151]Lovell K, Bower P, Gellatly J, et al. Clinical effectiveness, cost-effectiveness and acceptability of low-intensity interventions in the management of obsessive-compulsive disorder: the Obsessive-Compulsive Treatment Efficacy randomised controlled Trial (OCTET). Health Technol Assess. 2017 Jun;21(37):1-132.https://www.journalslibrary.nihr.ac.uk/hta/hta21370#/full-reporthttp://www.ncbi.nlm.nih.gov/pubmed/28681717?tool=bestpractice.com
认知行为疗法 (CBT) 结合动机性访谈
动机性访谈是一种通过增加动机来改变行为的心理治疗技术，目前应用广泛。对于接受以家庭为基础 OCD 治疗的 6-17 岁儿童，为了达到与单独使用 CBT 同样的结局，将动机性访谈与 CBT 联合应用可使治疗次数平均减少 3 次。[152]Merlo LJ, Storch EA, Lehmkuhl HD, et al. Cognitive behavioral therapy plus motivational interviewing improves outcome for pediatric obsessive-compulsive disorder: a preliminary study. Cogn Behav Ther. 2010;39(1):24-7.http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2861340/http://www.ncbi.nlm.nih.gov/pubmed/19675960?tool=bestpractice.com 两次动机性访谈治疗（附加思维映射技术）也成为成人强迫性障碍患者标准化 CBT 的有效辅助治疗。[153]Meyer E, Souza F, Heldt E, et al. A randomized clinical trial to examine enhancing cognitive-behavioral group therapy for obsessive-compulsive disorder with motivational interviewing and thought mapping. Behav Cogn Psychother. 2010 May;38(3):319-36.http://www.ncbi.nlm.nih.gov/pubmed/20353621?tool=bestpractice.com[154]Meyer E, Shavitt RG, Leukefeld C, et al. Adding motivational interviewing and thought mapping to cognitive-behavioral group therapy: results from a randomized clinical trial. Rev Bras Psiquiatr. 2010 Mar;32(1):20-9.http://www.scielo.br/scielo.php?script=sci_arttext&pid=S1516-44462010000100006&lng=en&nrm=iso&tlng=enhttp://www.ncbi.nlm.nih.gov/pubmed/20339731?tool=bestpractice.com 虽然有一些有前景的结果，但是至少有一个研究报道称并没有发现动机性访谈能增加依从性或者治疗效果。[155]Simpson HB, Zuckoff AM, Maher MJ, et al. Challenges using motivational interviewing as an adjunct to exposure therapy for obsessive-compulsive disorder. Behav Res Ther. 2010 Oct;48(10):941-8.http://www.ncbi.nlm.nih.gov/pubmed/20609435?tool=bestpractice.com
基于家庭的认知行为疗法 (CBT)
已经对以家庭为基础使用 CBT 治疗强迫性障碍做了调查，发现对于 5-8 岁的儿童，在减少强迫性障碍症状和功能损害方面，这种疗法优于放松疗法。[156]Freeman J, Sapyta J, Garcia A, et al. Family-based treatment of early childhood obsessive-compulsive disorder: the Pediatric Obsessive-Compulsive Disorder Treatment Study for Young Children (POTS Jr) - a randomized clinical trial. JAMA Psychiatry. 2014 Jun;71(6):689-98.http://archpsyc.jamanetwork.com/article.aspx?articleid=1861509http://www.ncbi.nlm.nih.gov/pubmed/24759852?tool=bestpractice.com
满灌疗法
在满灌疗法中，要求患者增加他们的强迫观念或强迫行为，让患者比平常增加2-3倍的强迫观念和仪式化行为。 目标是减少他们在OCD症状中获得的愉悦感，从而导致强迫症状的减少。 在伊朗男性中开展了一项研究，发现在降低耶鲁-布朗强迫量表 (Yale-Brown Obsessive-Compulsive Scale, Y-BOCS) 评分方面，餍足疗法与暴露和反应预防一样有效。[157]Khodarahimi S. Satiation therapy and exposure response prevention in the treatment of obsessive compulsive disorder. J Contemp Psychotherapy. 2009;39:203-7.
生活质量治疗（对OCD患儿的母亲进行养育方式的干预）
针对OCD患儿的母亲进行养育方式的干预， 研究表明，它对减少儿童OCD的症状和提高母子生活质量是有帮助的。[158]Abedi MR, Vostanis P. Evaluation of quality of life therapy for parents of children with obsessive-compulsive disorders in Iran. Eur Child Adolesc Psychiatry. 2010 Jul;19(7):605-13.http://www.ncbi.nlm.nih.gov/pubmed/20157835?tool=bestpractice.com
第三波疗法
第三波疗法包括正念 (mindfulness) 以及接纳和承诺疗法 (acceptance and commitment therapy, ACT)。 多项研究评估了第三波疗法用于强迫性障碍患者的有效性，但这些研究样本量小，有方法学限制；因此需要开展进一步研究。[159]Külz A, Barton B, Voderholzer U, et al. Third wave therapies of cognitive behavioral therapy for obsessive compulsive disorder: a reasonable add-on therapy for CBT? State of the art [Article in German]. Psychother Psychosom Med Psychol. 2016 Mar;66(3-4):106-11.http://www.ncbi.nlm.nih.gov/pubmed/27035439?tool=bestpractice.com
