The treatment of OCD and BDD in the NHS

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. 

Resources

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)

 

Therapy in the NHS

I have been continuing with my placement in an NHS Mental Health Trust and it seems that with every visit I learn something new.  I had been familiar with Cognitive Behavioural Therapy (CBT) before the start of my placement through my lectures and my own prior knowledge. However, this week I attended a team meeting in a sexual behaviour unit in a forensics unit and learned about the Dialectical behaviour therapy treatment programme.

Dialectical behaviour therapy (DBT), a cognitive behavioural therapy, was developed by Marsha Linehan, PhD, at the University of Washington, and is a type of psychotherapy (sometimes called “talking therapy”) for borderline personality disorder (BPD). Of course I get reminded that in psychiatry one is often dealing with the treatment of sometimes severe mental illnesses.  In psychotherapy, especially private practice, one is less likely to encounter clients with the onset of such illnesses. Mentalization-based treatment (MBT) is a type of psychotherapy created to treat people with borderline personality disorder. Reflecting back group psychotherapy is also a new concept to me. However, it is apt that I am about to start group process work on my course when compulsory attendance is required for the  duration of the work.

I am often asked why I don’t offer a critique of these models in my blog posts.  However, whilst I might have some preliminary thoughts and views, I need to gain exposure of how these models work in practice before I can comment on the effectiveness of these models. One thing for sure is that awareness of more treatment models is helpful for devising short term treatment models for my new placement in a counselling centre in West London which offers clients 6 sessions, in the first instance.  This will be a great  opportunity to blend theory with practical application.

My NHS placement also offers invaluable insight into how treatments such as ECT and pharmacological treatment work for depressed patients.    More about this in future posts …..

Resources:
Psychotherapy in the NHS
OCD
Borderline Personality Disorder (BPD)
Eating Disorders

It is intriguing how some patients can invoke certain feelings and not others.

It was good to get back to my psychiatric placement at an NHS Mental Health Trust today and to a ward review meeting.  I have been sitting in on clinic sessions at a university hospital with consultant psychiatrists covering new assessments, outpatient follow up appointments as well as team meetings discussing the management of care. It was two weeks since I was last at this ward review and it was heartening to notice the visible improvement in some patients in the intervening period.

There were a couple of patients who had regressed and this was producing some feelings in me (what is called counter transference). One patient, a middle aged man suffering with severe depression, was continuing to present with anxiety and helplessness.   I felt like wanting to hug him.  However, his depression is so severe that he has been prescribed a course of ECT. It is intriguing how some patients can invoke certain feelings and not others. Perhaps counter transference is when our own stuff and issues have been triggered and when we identify with the personal circumstances. I was particularly taken by the love and support of his partner (who was present in the session) and who appeared to be a rock of support in spite of very challenging circumstances.  The experience made me aware of the vital role that carer groups undertake in the management of support networks for families and friends of those suffering from mental illness.

Related posts. 
The 1-1 relationship between psychiatrist and patient
The importance of challenge in the therapeutic relationship 
Transference and counter transference
Resistance in therapy
Dr Marie Keenan interview

Paranoid schizophrenia – not that dissimilar in some ways to high blood pressure or diabetes

I have been enjoying my psychiatric observational placement and have had a rich environment in which to observe an NHS mental health care setting. I have been shadowing the consultant psychiatrist in outpatient clinics and in (locked) ward rounds as well as attending team meetings of a community mental health team (CMHT). I have also attended a Mental Health Act Tribunal meeting as an observer and that was an added bonus to my training. The whole experience has given me great insight into the care plans of patients suffering with various mental illnesses as well as to the current legislative and legal environment surrounding hospital care. 

It was baffling at times when I started as all I was hearing was abbreviated terms that I did not understand.  For instance, terms such as CPA (Care Programme Approach),  CTO (Community Treatment Order), IAPT (the Improving Access to Psychological Therapies), DNA (did not attend), AMHP (Approved Mental Health Professional) were banded around at will and often I felt like asking people to slow down. However, finding out how the NHS practices work has been an interesting learning curve as well as understanding the role of patient care co-ordinators. 

.As I said in a previous post the 1-1 session between psychiatrist and patient is essentially a business like arrangement where discussion centres on how to agree a treatment plan.   

Spotting the symptoms of these illnesses will be a critical part of the placement for me and will be an on-going process.  I am also intrigued about the formulation of care treatment plans. In depressed patients medication is prescribed but often with CBT sessions.  With “paranoid schizophrenia” CBT sessions can be a part of treatment but there is more evident symptoms of psychosis. It seems that the  more patients understand about their condition the more they will realise and appreciate the need to take long term medication. Consultant psychiatrists describe their illness as not being that dissimilar in some ways to high blood pressure or diabetes in that it needs regular and long term medication to remain healthy and help keep the symptoms away. The care plan will outline the relapse symptoms so that the wider healthcare team can be enpowered to spot signs of relapse.

I have wondered what it would have been like for people suffering from mental illness in times past when anti psychosis medicine was not around and when there was a very different societal attitude to mental illness. Some hospitals indeed would have had up to 4 times the number of in patients as recently as 50 years ago. My own intrigue about nature vs. nurture and the cause of mental illness diagnosis – whether it is due to genetic issues, personality disorder or psychosis –  will continue.

More soon.

 Related post
The 1-1 session between patient and psychiatrist