1. OCD is characterised by both obsessions and compulsions
Obsessions are recurrent, unwanted intrusive thoughts, doubts, images or urges. These are experienced as distressing, unreasonable or excessive. People with OCD believe that these thoughts are significant, dangerous or immoral in some way. Typical obsessions are based on fears of contamination, causing harm to one self or others, intrusive sexual or violent thoughts, need for order or hoarding. This leads to compulsions – the urge to perform repetitive behaviours or mental acts with the aim of preventing the feared outcome and to alleviate the associated anxiety. These typically include compulsive washing or checking, seeking reassurance, ordering and hoarding. People with OCD frequently avoid triggers for their obsessions e.g. touching a toilet seat.
2. Compulsions can be both overt and covert
Many compulsions in OCD are obvious and observable such as excessive handwashing or repeated checks of doors, appliances etc. Covert compulsions are the mental equivalent, including ‘cancelling out’ intrusive thoughts with other thoughts, counting, praying or trying to remember. Mental compulsions can be quite complex.
3. Consider the diagnosis when patients describe avoidance behaviour
A diagnosis is usually relatively easy to make when a person expresses either obsessions or compulsion (but typically both) in the context of avoidance behaviour and fears of causing harm to themselves or others. Harm is used here in the broadest sense – for example feeling dirty when contaminated and becoming more anxious leading to a fear of losing control or the anxiety going on forever.
4. Reassure patients that the condition is treatable
OCD is treatable. It is possible to significantly improve the quality of a person’s life. Therapy is usually done one-to-one, and home visits may sometimes be needed. Occasionally family members or a carer may need to be involved in the treatment because they are over-involved in the compulsions or avoidance behaviour. A small number of patients need a more intensive programme in a residential unit or as an inpatient for several months.
5. Familiarise yourself with the NICE guidelines on OCD
Refer to NICE 2006 guidelines regarding psychological and pharmacological interventions for OCD and body dysmorphic disorder (BDD). The first-line treatment for mild OCD is CBT, which is specific for OCD. For moderate OCD, patients should be offered a choice of either CBT or a SSRI. For severe OCD, then a combination of CBT and a SSRI should be offered.
6. Make a referral to an IAPT service for CBT
Increasing Access to Psychological Therapies (IAPT) services in England provide easier access to CBT for OCD. More severe or complex cases are likely to be seen in secondary care. Treatment can be very effective and referral options to specialist services are available for people if local provision is unavailable or has not been successful. A national specialist commissioning service funded by the Department of Health takes referrals from secondary care for ‘severe and treatment refractory’ patients.
7. Increase to the maximum tolerated dose of SSRI
SSRIs can be helpful in moderate to severe OCD. There is a dose-response ratio so increasing to the maximum tolerated dose is usually the best strategy. It is best not to refer to SSRIs as anti-depressants as they reduce symptoms of OCD in the absence of depression. The main problem with SSRIs or clomipramine (a potent serotonin reuptake inhibitor) is that there is a high rate of relapse in the months after the medication is discontinued.
8. Provide information about self-help and support
Having good information on the disorder can help people make sense of their symptoms and begin to recover. A number of books such as Overcoming OCD by David Veale and Rob Willson are available on the Books Prescription Scheme or to purchase to assist people to help themselves. Charities and support groups such as OCD Action provide information and support for sufferers and their families.
9. Normalise the experience of intrusive thoughts
Everyone experiences some version of an intrusive thought or image. It might be an image of jumping in front of the train whilst standing on the platform or a sudden doubt about whether you locked your front door as you leave your home. Most people, most of the time, are able to dismiss these thoughts. In OCD, there are strong beliefs that thinking such thoughts is the same as acting on them or that it is immoral to have certain thoughts. Consequently people with OCD feel compelled to respond to the thoughts, taking action such as avoiding train platforms or driving back to check the door. Intrusive sexual and violent thoughts or images are entirely normal and do not require special risk assessments.
10. Commend your patient for raising OCD with you
OCD is often associated with embarrassment, guilt and shame. People are unwilling to discuss the nature of their problem as they may believe that their concerns will be dismissed as trivial, or believe that they will not be understood. It is not their fault they have OCD. Making the step to discuss their problems with you will have taken courage and resolve. Note that the average time it takes to seek help from onset is about 10 years.
Dr David Veale is a consultant psychiatrist in CBT at the South London and Maudsley Trust and is chair of the NICE Evidence Update on OCD and BDD