Intensive Exposure and Response Prevention (ERP) for OCD - Criteria for intensive/inpatient treatment service

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Criteria for intensive/ inpatient treatment service

The following criteria will be used for assessing suitability to entry into the intensive/inpatient service. The criteria are not absolute, and will be used as a guide when considering individuals for intensive treatment.

Inclusion Criteria

1.    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 intensive treatment, 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. In the majority of cases, total duration of illness is expected to be in excess of 5 years;

3.    Severity of OCD, measured using the clinician-rated Y-BOCS, is likely to be ≥ 28 (severe). In most cases, it is expected that symptoms will be in the ‘extreme’ range (≥ 32);

4.    Global Assessment of Functioning (GAF) should typically be ≤ 40. This means that symptoms are severe and result in “…major impairment in several areas, such as work or school, family relations, judgment, thinking, or mood”. It is unlikely, for example, that patients are able to work or function adequately in any major area and they will be dependent on family, carers, or services.

5.    The patient has had ≥ 3 trials of serotonin re-uptake inhibitors at maximum (or maximum-tolerated) dose – one of which should be Clomipramine (unless it was not tolerated). Each trial should have been for ≥ 12 weeks;

6.    The patient has had at least two trials of antipsychotic augmentation with either Risperidone or Aripiprazole. If one of the trials was Quetiapine, we would consider this on a case-by-case basis.[1] The augmentation trial should be ≥ 6 weeks in duration, and ideally 8-12 weeks. Augmentation of Clomipramine with an antipsychotic drug (wherever tolerated) should have been completed.

7.    The patient has had at least one unsuccessful trial of Exposure and Response Prevention, being ≥ 20 hours in duration. This should have been 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.

Exclusion Criteria

1.    Demonstrated lack of willingness to engage in behavioural therapy, or evidence of intolerability to levels of anxiety associated with ERP.

2.    Insufficient insight to understand the model and rationale for treatment.

3.    Concurrent substance misuse disorder which requires any intervention other than continuation of maintenance treatment.

4.    Concurrent major depressive illness that is severe enough to impair ability to engage in ERP or carries a significant risk of self-harm and/or suicide.

5.    Concurrent personality disorder (e.g. borderline personality disorder) which is severe enough to affect treatment.

6.    Body Dysmorphic Disorder (BDD) where BDD is the primary symptom domain and which is not associated with significant OCD. See section B4.b)   below for more details.

7.    Autism Spectrum Disorder (e.g. Asperger’s syndrome) where symptoms are considered to be more appropriately attributable to the ASD, rather than OCD. See section B4.c)   below for more details.


[1] Augmentation trials should be sequential. There is no evidence that combined use of antipsychotics is beneficial.

References

AMERICAN PSYCHIATRIC ASSOCIATION. Diagnostic and Statistical Manual of Mental Disorders (Fourth Edition). Washington, DC: American Psychiatric Press; 1994.

AMERICAN PSYCHIATRIC ASSOCIATION. Diagnostic and Statistical Manual of Mental Disorders (Fifth Edition). Washington, DC: American Psychiatric Press; 2013. http://dx.doi.org/10.1176/appi.books.9780890423349

NATIONAL INSTITUTE FOR HEALTH AND CARE EXCELLENCE. Obsessive-compulsive disorder: Evidence Update September 2013. London: National Collaborating Centre for Mental Health. http://www.evidence.nhs.uk/evidence-update-47

NATIONAL INSTITUTE FOR HEALTH AND CLINICAL EXCELLENCE. CG31. Obsessive-compulsive disorder: core interventions in the treatment of obsessive-compulsive disorder and body dysmorphic disorder. London: National Collaborating Centre for Mental Health. http://www.nice.org.uk/CG031

WORLD HEALTH ORGANISATION. International Statistical Classification of Diseases and Related Health Problems, 10th Revision. Geneva: World Health Organisation; 1992. http://www.who.int/classifications/icd/en/GRNBOOK.pdf