Intensive Exposure and Response Prevention (ERP) for OCD - Criteria for referral to the AIS
The following criteria are intended to act as a guide to referral, rather than an absolute determination of who will be accepted for assessment. All referrals are accepted on a case-by-case basis and clinicians are advised to contact the service if there are any uncertainties regarding suitability.
Comments on criteria compared to other specialist services
Our criteria are broadly consistent with other specialist services in the UK with some differences; the main one being the burden of symptoms measured on the Y-BOCS. As there may be a range of factors that affect someone’s functioning and need for treatment (for example, comorbid conditions) the following should be seen as indicative rather than absolute.
- Diagnosis of Obsessive-Compulsive Disorder made according to ICD-10 (World Health Organisation, 1992), DSM-IV (American Psychiatric Association, 1994), or DSM-5 (American Psychiatric Association, 2013);
a. Comorbid diagnoses of Obsessive-Compulsive Personality Disorder (OCPD) or Asperger’s Syndrome are not absolute contraindications, but they should not be the primary diagnosis and full criteria for OCD should be met. The severity of symptoms should be significant enough to indicate that personality disorder is insufficient to account for the impairments in functioning.
b. Similarly, comorbid anxiety disorders (e.g. Generalized Anxiety Disorder, Agoraphobia) and depression are common in OCD. These are not a contraindication to referral, but it is expected that efforts have been made to determine that OCD is the primary source of the anxiety symptoms. Such efforts are likely to involve targeted treatment of the other conditions.
2. Symptoms of OCD have persisted for ≥ 2 years without improvement and despite treatment;
3. Severity of OCD, measured using the clinician-rated Y-BOCS, should be ≥ 24 (severe), although in most cases it is likely to be higher;
4. Global Assessment of Functioning (GAF) should be ≤ 50. This means that symptoms are severe and result in “serious impairmentin social, occupational or school functioning”;
5. The patient has had ≥ 2 trials of serotonin re-uptake inhibitors at maximum (or maximum-tolerated) dose – one of which should ideally be Clomipramine. Each trial should have been for ≥ 12 weeks;
6. The patient has had at least one trial of antipsychotic augmentation with one of the following: Risperidone, Aripiprazole, or Quetiapine. The augmentation trial should be ≥ 6 weeks in duration, and ideally 8-12 weeks;
7. The patient has had ≥ 20 hours of Exposure and Response Prevention, delivered by a therapist with experience in the treatment of OCD. Therapy should have been home-based where symptoms relate to the home environment. Documentation of treatment should be sufficient to appraise the content, delivery, and outcome of such treatment.
- The service is unable to provide extensive support and/or supervision to patients that do not meet the above inclusion criteria. There is a clear understanding in commissioning arrangements that treatment at steps 1 to 4 in the NICE guidelines will be provided by NHS Boards.
- In addition, the provision of 20 hours of exposure and response prevention, delivered in the patient’s home, should be available within secondary care MH services as stipulated by the Psychological Therapies Matrix (NHS Scotland, 2008).
- Where additional treatment steps are indicated, the service may be able to advise on further management, but it cannot supervise or deliver behavioural treatments for patients that are unable to access such treatment in their local area. In some cases, it may be able to advise referrers and/or patients and carers on accessing such treatment.
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