Intensive treatment for OCD

The following is a brief description of intensive exposure and response prevention (ERP) treatment for OCD. It covers descriptions of the model and also inclusion/ exclusion criteria.

Introduction

Intensive OCD treatment in the AIS

Prior to 2013, a small number of Scottish patients with difficult-to-treat OCD had to travel to specialist inpatient treatment centres in England because inpatient ERP was not available in Scotland. This separated them from their families, their support system(s), and their local services.

From 1 April 2013, the Advanced Interventions Service has been able to offer intensive/ inpatient treatment programmes for Scottish patients with OCD. This is funded by NHS Scotland and is free to NHS Boards in Scotland.

Delivering intensive ERP in Scotland

We believe that any gains from intensive ERP will only be maintained with a clear treatment plan that can continue after discharge, and we aim to be working with referring NHS Boards before, during, and after any inpatient programme to ensure maximum benefit. In some cases, we may recommend additional treatment prior to admission and we will work with members of the referring team to help support this.

We would expect that referrals would come from consultant psychiatrists who continue to be involved in the ongoing care of the patient. Please read more about making a referral below.

Psychological treatment of Obsessive-Compulsive Disorder

Individuals with OCD who are referred to the Advanced Interventions Service initially participate in a detailed review of their current and past experience of the condition and their previous treatment history. Assessment involves: face-to-face interviews with staff from the service; measures of how severe the symptoms are made using rating scales; and a detailed examination of their case notes. Particular attention is paid to the type of psychological therapy they have received and their response to it.

Normally, to meet the criteria for treatment resistance, the person should have had two attempts at psychological therapy from a suitably experienced (and, ideally, accredited) Cognitive Behavioural Therapist. Each of the attempts should have included at least twenty hours of Exposure and Response Prevention. If, at the end of this treatment, the person continues to have significant symptoms which are impairing their ability to function then they may be considered to be resistant to standard psychological treatment.

The results of this initial review are discussed with the individual and treatment recommendations, which may include drug and psychological interventions, are explored. In certain circumstances the individual may be offered further treatment in Dundee. This treatment may be offered on an out-patient basis or involve treatment while an inpatient.

The key ingredients for successful Exposure and Response Prevention (ERP)

About ERP

Exposure and Response Prevention, sometimes known as Exposure and Ritual Prevention has been described as one of the most successful psychological treatments currently available. This type of treatment is based on experimental research of human and animal models of OCD. The results of this research enables clinicians and people suffering from OCD to understand the underlying mechanisms that produce such distressing, time consuming and often prolonged suffering. In addition the rationale for the treatment is made explicit, i.e. people understand an explanation how their OCD "works" and the steps needed to overcome it. Contemporary ERP for treatment resistant OCD, delivered on an outpatient or inpatient basis, involves systematic, therapist assisted (or guided) prolonged exposure to situations or stimuli that provoke obsessional fear accompanied by abstaining from compulsive behaviour.

Formulation and delivery of ERP

For example, a person who has contamination obsessions and who is driven to hand wash excessively (the compulsive behaviour) would experience treatment in the following way:

The therapist and the patient would agree a plan of specific exposure exercises that target important areas of the OCD that interfere with the patients day-to-day functioning. There are several important rules which ensure the success of this type of therapy; not least that person knows in advance what is required of them. Typically the exercises start with less difficult or distressing situations, e.g. touching a clean sink or tap, and then progress to more difficult tasks such as touching unwashed basins or taps. Eventually therapy is delivered in the persons own home where often the most troubling symptoms occur. Planning with the person, delivering the exposure in certain ways, dealing with easier targets early and graduating to more difficult tasks later on, and treating people in their own homes are the systematic part of therapy.
Touching the feared object is the exposure part of therapy. As previously stated, successful treatment involves making sure that certain carefully thought-out rules, derived from the model of OCD, are adhered to.
In the case of someone with contamination obsessions and hand washing compulsions, when the patient abstains from hand washing this is called 'response prevention'. Response prevention does not simply involve the therapist stopping the person carrying out hand washing, but depends on the patient being convinced that by resisting the urge to hand wash during the exercise they can reduce the levels of discomfort that they feel in the long run.

Is this Cognitive Behavioural Therapy (CBT)?

The answer to this question is complicated because the Cognitive Behavioural Therapy (CBT) approach to OCD often includes some aspects of treatment that are very similar to ERP. In addition much of the literature about the nature and treatment of OCD uses "CBT" as an umbrella term that includes ERP.

Our current understanding of OCD acknowledges that cognitive factors do contribute to the severity and prolonged course of the condition. Such factors may include: unhelpful beliefs about responsibility; the importance of certain thoughts to the individual; and perfectionism. Typically, we focus on Exposure and Response Prevention but also explore the contribution of the person’s thoughts and beliefs about themselves and the issues they are concerned about. Some, but not all people, find this aspect of treatment helpful.

Inpatient ERP in Dundee

Some individuals, following detailed assessment, are recommended to have treatment while staying in our local inpatient unit (Carseview Centre). The length of the stay is typically around 3-4 weeks. People are encouraged to use their new skills in managing their OCD in increasingly normal situations and latterly in their own homes. Currently the therapy is delivered on an individual basis.

The first week of the stay involves understanding how their OCD 'works' for them, and developing with the therapist an outline programme for the next week. This means that the therapist and person agree what will happen in their treatment programme in terms of exposure and response prevention. These plans are reviewed weekly. The agreed plan can be adapted or changed to suit the individual and their pace of progress. The aim of treatment is to deliver around 15 hours of therapist-guided ERP each week, supported by self-directed 'homework'. The overall goal of a treatment programme is to deliver 40-60 hours of treatment.

Home treatment

At the end of inpatient treatment, the AIS therapists will deliver around one week of treatment at home, helping the family to support the changes and to change the 'rules' that sustained previous behaviours.

In addition we believe it is an advantage for the services that originally referred the person to be involved in the later stages of the treatment. This enables them to understand not only the patient and their difficulties, but also the nature of their treatment and how to ensure progress continues when the person returns home.

Making a referral

We invite referrals from senior clinicians who have been involved in the previous management of the patient. Whilst we would consider referrals on a case-by-case basis, it is generally expected that patients will have failed to respond to a range of pharmacological and psychological treatments. This would typically include at least two trials of a Serotonin Reuptake Inhibitor (one of which should ideally be Clomipramine), and a trial of an antipsychotic drug (ideally Risperidone) as an augmentation agent.

In addition, patients should have had a robust trial of Exposure and Response Prevention (ERP) delivered by a therapist with expertise in OCD.

Where there have been difficulties in accessing or delivering ERP, we would suggest that clinicians discuss such referrals with us. We recognise that access to skilled ERP is sometimes difficult and we may be able to help with delivering local workshops and training.

Please note that the thresholds for referral to the AIS for specialist assessment and the thresholds for admission to the intensive treatment programme are different. Not all patients assessed will be considered suitable for intensive treatment - most people will receive further recommendations for treatment.

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.

Inclusion criteria

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);
- 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.
- 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.
Symptoms of OCD have persisted for ≥ 2 years without improvement and despite treatment;
Severity of OCD, measured using the clinician-rated Y-BOCS, should be ≥ 24 (severe), although in most cases it is likely to be higher;
Global Assessment of Functioning (GAF) should be ≤ 50. This means that symptoms are severe and result in “serious impairmentin social, occupational or school functioning”;
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;
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;
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.

Exclusion criteria

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.

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

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);
- 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.
- 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.
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;
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);
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.
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;
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.
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

Demonstrated lack of willingness to engage in behavioural therapy, or evidence of intolerability to levels of anxiety associated with ERP.
Insufficient insight to understand the model and rationale for treatment.
Concurrent substance misuse disorder which requires any intervention other than continuation of maintenance treatment.
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.
Concurrent personality disorder (e.g. borderline personality disorder) which is severe enough to affect treatment.
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.
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