I have always thought that we are all a little obsessive and compulsive to a greater or lesser extent whether it is the checking and rechecking we do in our every day lives or the occasional intrusive thought that cause us anxiety. However, for some people the incidence of obsessive-compulsive disorder (OCD) can destroy their lives and those of their families.
This week I had the pleasure of attending a ward round at the National OCD/BDD Service, which is affiliated with St Georges University of London. The service is a nationally and internationally renowned treatment centre dealing with severe, complex and resistant OCD and body dysmorphic disorder (BDD).
The National Commissioning Group for Highly Specialist Services (NCGHSS) of the Department of Health has commissioned a service for the treatment refractory Obsessive Compulsive Disorder (OCD) or Body Dysmorphic Disorder (BDD). The funding for such patients is by the Department of Health. Patients who do not meet such criteria can still be referred by the normal process and funded by their PCTs.
Patients will need to fulfil treatment refractory criteria: Have a Yale Brown Obsessive Compulsive Scale (YBOCS) score of 30 or more. Unsatisfactory response to previous therapy in primary and secondary care or a specialist regional service (where available). Recommended treatments are an offer of either pharmacotherapy and/or cognitive behaviour therapy according to patient choice. In-patients are required to fulfil the criteria for admission and in some cases may not fulfil all the treatment refractory criteria (e.g. if there is a risk to life or severe self-neglect but has had not yet had two courses of CBT as an out-patient). See the full criteria here.
The service combines behavioural and cognitive methods with state-of-the art psychopharmacological and other treatments where necessary. The service liaises closely with specialists who work in the neurobiology and psychopharmacology of these disorders as well as with psychotherapists of various schools.
Each patient is fully assessed and has an individualised treatment programme. Progress is constantly monitored using questionnaires of known reliability and validity. Thus, any treatment which is not effective is discovered early and the reasons why this is the case are examined and treatment changed or modified.
From what I understood the service does not use talking treatments much at all. CBT, so often the standard bearer talking therapy intervention in the NHS, is not considered effective with this group unless it is used in a very targeted way. The mainstay of treatment is Exposure and Response Prevention (ERP) repeated three times a day. ERP is a way to stop compulsive behaviours and anxieties from strengthening each other. Patients may have had a whole range of therapies before presenting at this specialist centre. For most ERP is what is needed in the form of the reliable regular three times a day course of treatment.
In ERP treatment, patients learn to resist the compulsion to perform rituals. The recovery targets are eventually to stop engaging in these behaviours. Before starting ERP treatment, patients make a list, or what is termed a “hierarchy” of situations that provoke obsessional fears. For example, a person with fears of contamination might create a list of obsessional cues that looks like this: touching garbage, using the toilet and shaking hands.
Are you affected by any of these issues? Please refer to the resource links below or speak to your GP.
The Centre for Anxiety Disorders and Trauma provides a national OCD/BDD service
Leaflets on OCD from the Royal College of Psychiatrists
OCD: A web guide for health professionals Contains useful links
Summary of NICE-recommended treatment approach for OCD Stepped care model for treatment of OCD
NICE Guideline: Obsessive compulsive disorder (OCD) and body dysmorphic disorder (BDD) (CG31)