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At the heart of general practice since 1960

November 2007:Helping patients to overcome obsessive compulsive disorder

How can OCD be diagnosed?

Are children and adults managed differently?

What is the role of SSRIs?

How can OCD be diagnosed?

Are children and adults managed differently?

What is the role of SSRIs?

Obsessive-compulsive disorder (OCD) is common, chronic and debilitating. the World Health Organization ranks OCD in the top 20 most disabling conditions, and the estimated worldwide prevalence is 1-2%.1 In the UK alone there are estimated to be more than a million people with OCD, many of whom are unaware that it is a treatable condition.

OCD is characterised by intrusive unwanted thoughts (obsessions) and ritualistic behaviours (compulsions).

It can occur in children as young as six (see case study 1, below), and most patients who develop OCD will have symptoms in childhood or adolescence. Some develop OCD in adult life, and there is a subgroup of patients who develop it for the first time in old age. There is an equal incidence in both sexes.

Sufferers of OCD recognise that their obsessions originate from their own mind, but experience them as out of character, unwanted and distressing (ego-dystonic). Common obsessions include fears and concerns about germs or contamination, symmetry and order, safety, worries about hurting others or themselves and unwanted sexual thoughts.

Compulsions are repetitive stereotyped behaviours, typically for the purpose of ‘neutralising' the fear or anxiety provoked by the obsession. Patients realise that the action is purposeless but cannot resist performing it and often fear that ‘something bad' might happen if they do not do it. Common compulsions include checking, touching, lining up items, handwashing, cleaning and counting. As the severity of symptoms increases, OCD can consume the patient's daily life. Peer and family relationships often suffer and individuals may even become housebound or stop attending school.

Recognition of OCD by health professionals and public awareness of the condition have significantly improved in recent years. Nevertheless, feelings of shame and guilt cause some sufferers to delay seeking help for years. Several studies2,3 have reported a delay of more than 10 years from onset of symptoms to first treatment.

What causes OCD?

The aetiology of OCD is unknown but includes environmental and genetic factors. Epidemiological studies, including twin and family studies, strongly support a genetic component for OCD.4

Brain areas implicated in OCD include the basal ganglia and orbitofrontal cortex. Brain diseases affecting these areas, such as Tourette syndrome, Huntington's chorea and Sydenham's chorea, are associated with high rates of obsessive-compulsive symptoms.

A fluctuating form of OCD and tics that is seen following some streptococcal infections is termed PANDAS (paediatric autoimmune neuropsychiatric disorders associated with streptococcal infection); it is thought to be mediated by antibodies binding to basal ganglia (see case study 2, below).5 These are current areas of ongoing research.

Some disorders that seem to be related to OCD are termed obsessive-compulsive spectrum disorders. They include body dysmorphic disorder, trichotillomania, and Tourette syndrome. Whether these are causally related to OCD remains unclear.

Cognitive models for OCD have proposed various mechanisms underlying the development of most obsessions, including excessive doubt, the need for completeness, shame and abnormal assessment of risk.

Diagnosing OCD

The diagnostic criteria for OCD, as set out in the International Classification of Diseases, 10th revision (ICD-10), are as follows:

• Obsessions or compulsions (or both) must have been present on most days for a period of at least two weeks

• Obsessions and compulsions originate from the mind of the patient, are repetitive and unpleasant (at least one recognised as excessive and unreasonable)

• At least one must be unsuccessfully resisted (although resistance may be minimal in some cases)

• Carrying out the obsessive thought or compulsive act is not intrinsically pleasurable

• Obsessive-compulsive symptoms must be a source of distress and interfere with function.

The National Institute for Health and Clinical Excellence (NICE) recommended six screening questions in their recent guideline (see box 1, below).1

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If a patient answers yes to more than one of the above questions, it may be that he/she has OCD. It is often useful to get patients to describe their average day as this can reveal the true functional impact of their symptoms.

It is important to assess risk and ask about self-harm or any suicidal ideation.

OCD is often comorbid with other common psychiatric conditions, such as depression, anxiety, specific phobias, social phobias, eating disorders, alcohol dependence, panic disorder and Tourette syndrome; patients should therefore be screened for these conditions. Many patients with an autism spectrum disorder can present with features of OCD, and the correct identification and treatment of these symptoms can be helpful. OCD can also occur in schizophrenia and, although amenable to treatment, is associated with a worse prognosis.6

Treatment guidelines

Effective treatment exists for OCD in the form of cognitive behaviour therapy (CBT) and medication. NICE recommends a ‘stepped care' model with increasing intensity of treatment according to clinical severity and complexity.1 OCD is classified into three categories – mild, moderate or severe – depending on the level of distress and functional impairment.

This can be done by the use of a validated questionnaire such as the Yale Brown obsessive-compulsive scale (Y-BOCS)7-9, which assesses symptoms and their impact, aids diagnosis and provides a useful baseline measure for monitoring response to treatment. This self-complete questionnaire can help patients identify the range of obsessions and compulsions they are experiencing, and the impact of these symptoms.

Completing a questionnaire such as this should not take the place of a clinical assessment, and the results are not diagnostic in themselves.

In its treatment guideline, NICE emphasises the need for increased public recognition of OCD along with the importance of education and information for sufferers and their families (see figure 1,and figure 2, attached). Guided self-help can be effective in mild OCD and this can be offered by GPs (see box 2, below, for suggested literature and websites). If this is ineffective or unsuitable, then CBT should be offered. CBT with exposure and response prevention (ERP) is the evidence-based psychological treatment for OCD.

Children, adolescents and adults with significant obsessive-compulsive symptoms should usually be referred to a mental health professional for further assessment, confirmation of diagnosis and detection of comorbidities. Ideally, all individuals with OCD should be offered CBT. In children and adolescents CBT is the recommended first-line treatment, whereas adults may be offered either SSRIs or CBT (see figures 1 and 2,attached). However there is emerging clinical evidence that CBT, or CBT combined with medication, may offer a more prolonged remission, prevent relapse, and allow discontinuation of SSRIs in some individuals.

For children and adolescents SSRIs should be offered only if CBT has been declined or is unsuccessful. SSRIs should be initiated by a child and adolescent psychiatrist, and continuing treatment may take the form of shared care with the GP or other health professional. There is no systematic evidence that any one SSRI is more effective. Some individuals may respond better to one SSRI, or have unacceptable side-effects, so failure of one SSRI should be followed by trials of alternative SSRIs. It is important to ensure that drugs are trialled at an adequate dose and for an appropriate period. Following this a trial of clomipramine is indicated, if there is no or limited response to SSRIs.

In cases of treatment refractory OCD and severe OCD, augmenting strategies may be used, and these should be initiated by psychiatric services. For example a trial of low-dose dopamine antagonist such as risperidone, in combination with an SSRI.

It is recommended in the NICE guideline that treatment is continued for 6-12 months once remission is obtained. If individuals relapse on discontinuation of medication, longer-term treatment should be considered. The dose needed to obtain recovery is the dose needed to maintain remission, not a lower dose.

Cognitive behaviour therapy

CBT is effective in treating the symptoms of OCD. The technique most strongly associated with remission is ERP. It can achieve response rates of up to 85% and is effective for both children and adults.10

ERP involves a graded exposure programme, designed with individual patients, to help them address their fears gradually. They are urged to resist carrying out a ritual, and to manage the anxiety associated with this. By doing this, they are able to see that their anxiety lessens without the ritual being performed. This is a collaborative piece of work (often with the family as well as the patient) that involves psychoeducation around OCD and discussion about the nature and function of anxiety itself. It begins with easy challenges, progressing to the more difficult, and requires patients to practise tolerating anxiety while monitoring their physical and emotional responses. Persistence is needed, as the link between obsessions and rituals is ingrained and difficult to break.

At the core of ERP is the understanding that compulsions only relieve anxiety temporarily and actually lead to increased anxiety in the long term. The cognitive model of OCD suggests that distorted reasoning is at the heart of the disorder and this is often used in combination with ERP. Patients are encouraged to rethink overvalued beliefs, for example about risk or personal responsibility, and to carry out ‘behavioural experiments' to test the validity of their beliefs.

Medication

Large-scale clinical trials11,12 have proved that SSRIs are effective in treating OCD in children and adults. Higher doses and a longer course than used for depression may be required to treat OCD. The therapeutic response has been shown to increase gradually over weeks and months and benefits continue to accrue for up to six months.14

A therapeutic trial of 12 weeks at the maximum tolerated dose is recommended. Several studies have shown that people with OCD continue to benefit from long-term drug treatment, and relapse if the drug is discontinued or switched to placebo under trial conditions.13

It is important to warn patients that SSRIs may have side-effects, such as nausea and agitation, and to emphasise that they emerge early but abate later. Clomipramine is reserved for patients in whom SSRIs have been ineffective.

Are SSRIs safe to use in children?

The possible link between SSRIs and suicidal behaviour in children remains controversial. Large meta-analyses suggest that although there may be a link between SSRIs and suicidal ideation in children, there is no proven association between SSRIs and completed suicide. The results of these trials have been consistently difficult to interpret because of confounding factors. For example, studies were done on an unrepresentative selective population who were more unwell and already at increased risk of suicide.15,16 Several trials conclude that the use of sertraline in children and adolescents with OCD is both safe and effective.17

Available evidence suggests that treatment with an SSRI carries little risk. However, it is advisable to exercise caution when there is comorbid depression or suicidal ideation. SSRIs are currently not a first-line treatment in children with OCD, but remain an effective and relatively safe therapeutic option.

SSRIs should be initiated by a child and adolescent psychiatrist, and long-term prescribing and monitoring may be undertaken jointly with the GP.

Is psychological treatment better than medication?

The available evidence suggests that drugs and psychological treatment (CBT) are equally effective.13 There are no conclusive data currently available on whether CBT plus medication is more effective than either treatment alone. Although CBT is the recommended first-line therapy, many local services have limited access to psychological therapies or long waiting lists, and in these areas SSRI therapy is a first-line and useful therapy. There is evidence that the majority of patients who have been treated with medication alone (that is, have not learnt CBT strategies) will relapse on discontinuation of medication.18 Clinical experience suggests that CBT, either instead of or in combination with medication, will prolong remission and prevent relapse, but this needs confirmation in long-term follow-up trials.

Does treatment work?

If untreated, OCD generally persists,19 but effective treatment is available. Many of these patients will remain well, while others may relapse at times during their life. On relapsing, many patients respond promptly to ‘top-up' CBT or restarting medication and it is important that they have prompt access to services and treatment (see case study 3, below).

What if treatment doesn't work?

If patients fail to respond to CBT, drugs or a combination of the two, a referral to specialist OCD services is indicated. This will involve: further assessment looking specifically for comorbid conditions such an autism spectrum disorder; reappraisal of CBT therapies already undertaken; and optimising medication. Switching between classes of SSRI can be effective, as can augmenting SSRI therapy with a low dose antipsychotic, for example risperidone. This needs careful monitoring and is only done in a specialist setting.

The 2005 NICE guideline on assessment and treatment of OCD acknowledged that there is a small group of individuals with extremely severe OCD that has been resistant to the evidence-based treatments delivered by local specialist services. In April 2007, a national service for the most severe cases in children, teenagers and adults was commissioned by the Department of Health National Commissioning Group, and patients throughout England and Scotland who meet these criteria may be considered for treatment in one of the four specialist OCD treatment centres.20

Conclusion

OCD is a significantly impairing mental illness that affects 1–2% of the population throughout their lifespan. It is currently underdetected and undertreated, but increased public awareness, effective voluntary sector representation as well as the NICE guideline should lead to earlier recognition and treatment. Brief screening by GPs, as well as GP participation in the stepped-care management of OCD and delivery of the evidence-based treatments, will assist in this process.

Key points Figure 1: Flow chart for the treatment of obsessive-compulsive disorder (OCD) in children and young people Figure 2: Flow chart for the treatment of obsessive-compulsive disorder (OCD) in adults Case study 1

Michaela, a seven-year-old girl, is brought to the GP by her parents. They report that over the past year she has become withdrawn and has started to worry excessively. She is washing her hands repeatedly (so much so that they are chapped and raw) and is worried about catching diseases, particularly bird flu and HIV. Nothing can reassure her and she now avoids watching TV, as the news has recently featured bird flu. This is preventing her watching cartoons, which used to be one of her favourite activities. She has also started checking things repeatedly. She is having trouble sleeping and concentrating at school. There is no family history of OCD.

Comment
This is a fairly classic presentation of OCD, with fears of contamination associated with compulsive handwashing and increasing anxiety. It is of moderate severity and should respond well to treatment.

Case study 2

Andy is 10 years old. His parents report a change in behaviour which started six months ago. He started to ‘hear voices' inside his head which told him not to eat, to hold his breath and to keep his eyes closed. He has a name for this voice and calls it ‘Eddie'. He has begun checking things and if he touches something with one hand, he will then have to touch it with the other. He has extensive rituals around getting up and going to sleep and these are making him late for school (sometimes this can make his Dad very late for work, as Andy has to go back and start his rituals all over again if he does one thing wrong). Andy is very distressed and is unable to concentrate at school. Six months ago he had an episode of tonsillitis, which was treated with antibiotics and confirmed as a group A streptococcal infection. He has never had any psychiatric or OCD symptoms before this episode, but has an aunt with a history of OCD.

Comment
Children with OCD who report hearing voices can be wrongly diagnosed as psychotic. The key features in this case are that the voices are inside his head (and further questioning will usually reveal that the child believes them to be the product of his/her own mind, although unwanted). He is experiencing anxiety and distress and is carrying out ritualistic checking compulsions which have the function of reducing anxiety. It is important to note the family history and also the previous history of group A streptococcal infection. This has been linked to PANDAS where OCD symptoms appear following a group A streptococcal infection. It is thought to be an autoimmune condition that results from antibodies binding to the basal ganglia. It responds well to regular treatments for OCD, but there may be a role for antibiotics and aggressive management of further streptococcal infections.

Case study 3

Andy is 10 years old. His parents report a change in behaviour which started six months ago. He started to ‘hear voices' inside his head which told him not to eat, to hold his breath and to keep his eyes closed. He has a name for this voice and calls it ‘Eddie'. He has begun checking things and if he touches something with one hand, he will then have to touch it with the other. He has extensive rituals around getting up and going to sleep and these are making him late for school (sometimes this can make his Dad very late for work, as Andy has to go back and start his rituals all over again if he does one thing wrong). Andy is very distressed and is unable to concentrate at school. Six months ago he had an episode of tonsillitis, which was treated with antibiotics and confirmed as a group A streptococcal infection. He has never had any psychiatric or OCD symptoms before this episode, but has an aunt with a history of OCD.

Comment
Children with OCD who report hearing voices can be wrongly diagnosed as psychotic. The key features in this case are that the voices are inside his head (and further questioning will usually reveal that the child believes them to be the product of his/her own mind, although unwanted). He is experiencing anxiety and distress and is carrying out ritualistic checking compulsions which have the function of reducing anxiety. It is important to note the family history and also the previous history of group A streptococcal infection. This has been linked to PANDAS where OCD symptoms appear following a group A streptococcal infection. It is thought to be an autoimmune condition that results from antibodies binding to the basal ganglia. It responds well to regular treatments for OCD, but there may be a role for antibiotics and aggressive management of further streptococcal infections.

Box 2: Additional educational resources

For children
• Wagner AP. Up and Down the Worry Hill: A children's book about obsessive-compulsive disorder and its treatment. 2nd edn. New York: Lighthouse Press, 2002. An illustrated book designed to help parents and professionals explain the disorder through the story of ‘Casey', a young boy with OCD

For adolescents
• March JS, Benton CM. Talking Back to OCD: The program that helps kids and teens say ‘no way' – and parents say ‘way to go.' New York, The Guilford Press, 2007
• Wells J. Touch and Go Joe: An adolescent's experience of OCD. London: Jessica Kingsley Publishers, 2006

For adults
• Hyman BM, Pedrick C. The OCD Workbook: Your guide to breaking free from obsessive-compulsive disorder. Oakland, CA: New Harbinger Publications, 2005. A self-help manual for adults and older adolescents that takes the patient through exposure with response prevention and includes advice for family members
• Veale D, Wilson R. Overcoming Obsessive-Compulsive Disorder. London: Constable and Robinson, 2005. A self-help book for adults and adolescents

Useful websites
• The Maudsley Hospital Clinic for Young People with OCD provides information for young people and their carers on OCD and how to recover
www.ocdyouth.info
• OCD Action is a national OCD charity that provides information and support www.ocdaction.org.uk

OCDBox1 Authors

Dr Lisa Conlan
BSc MB BS
senior house officer in psychiatry, National and Specialist OCD Service for Young People, The Maudsley Hospital, London

Dr Isobel Heyman
MB BS PhD MRCPsych
consultant child and adolescent psychiatrist, National and Specialist OCD Service for Young People, The Maudsley Hospital, London and honorary senior lecturer, Institute of Psychiatry, London

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