Obsessive Compulsive Disorder

Obsessive-compulsive disorder (OCD) may be characterised by the presence of obsessions or compulsions, but commonly both.

• Obsessions are unwanted intrusive thoughts, images or urges that repeatedly enters the person's mind.
• Compulsions are repetitive behaviours or mental acts that the person feels driven to perform. They can be overt (observable by others), e.g.checking a door is locked, or covert - e.g. a mental act that cannot be observed, such as repeating a certain phrase in one's mind.
• Body Dysmorphic Disorder (BDD) is a preoccupation with an imagined defect in appearance, or excessive concern over a slight physical anomaly. It is characterised by time-consuming behaviours such as mirror gazing, comparing one's appearance with others, excessive camouflaging to hide the defect, skin picking and seeking reassurance.

• OCD - studies vary, but the figure for prevalence ranges from 1-3%. Population surveys produce different results from audits of clinical samples and seem to suggest a predominance of females.
• BDD - a similar phenomenon is seen. 0.5-0.7% is reported in audits of of clinical samples, but population surveys suggest a higher figure of 1-2%.

The GP's Role

NICE recommend referral to a specialist multi-discipline team offering age-appropriate care. This is unlikely to be available in many areas due to lack of resources, but it is worth getting in touch with local mental health trusts to see what is currently available. The GP's role depends on expertise but it should be remembered that drug management should be part of a package which includes psychological care.
In all patients, however the GP will need to:

• Identify cases
  • For patients at risk of OCD (depression, anxiety, BDD, substance misuse, or eating disorder), ask the following questions:
    • Do you wash or clean a lot?
    • Do you check things a lot?
    • Is there any thought that keeps bothering you that you would like to get rid of but can not?
    • Do your daily activities take a long time to finish?
    • Are you concerned about putting things in a special order or are you very upset by mess?
    • Do these problems trouble you?
  • For patients at risk of BDD (depression, social phobia, substance misuse, OCD, eating disorder, mild disfigurement or blemish seeking dermatology or cosmetic surgery referral), ask the following questions:
    • Do you worry a lot about the way you look and wish you could think about it less?
    • What specific concerns do you have about your appearance?
    • On a typical day, how many hours a day is your appearance on your mind? (More than 1 hour a day is considered excessive).
    • What effect does it have on your life?
    • Does it make it hard to do your work or be with friends?
• Assess severity - i.e. how much it is affecting the patient's ability to function in everyday life
• Assess risk of self-harm or suicide, and presence of co-morbidity such as depression
• Arrange referral to appropriate secondary care provision
• Ensure continuity of care to avoid multiple assessments, gaps in service, and a smooth transition from child to adult services (many patients have lifelong symptoms)
• Promote understanding - make patients/families aware of involuntary nature of symptoms. Consider patient information leaflets, contact numbers of self-help groups, etc.
• Consider the bigger picture - cultural, social, emotional and mental health needs
• If patient is a parent, consider child protection issues

(OCD and BDD) Patients with mild functional impairment - can be managed with low intensity psychological treatment. This may involve:

• Individual Cognitive Behaviour Therapy (CBT) plus Exposure and Response Prevention (ERP)*
• Individual CBT and ERP by telephone
• Group CBT

*ERP is a technique in which patients are repeatedly exposed to the situation causing them anxiety (e.g. exposure to dirt) and are prevented from performing repetitive actions which lessens that anxiety (e.g. washing their hands). This method is only used after extensive counselling and discussion with the patient who knows fully what to expect. After an initial increase in anxiety, the level gradually decreases. This is extremely therapeutic, as the patient feels that they have confronted their worse fears without anything terrible happening.

• Adults with mild symptoms should be offered an selective serotonin reuptake inhibitor (SSRI) if they cannot engage in low-intensity psychological treatment, if such treatment has failed, or if they opt not to have more intensive psychological treatment.
• Adults with moderate symptoms or where low-intensity psychological treatment has failed should be offered high-intensity CBT and ERP (more than 10 hours per patient) or an SSRI.
• Adults with severe symptoms - offer high-intensity psychological therapy plus an SSRI.

(OCD and BDD)

• Mild dysfunction - offer guided self help. As for moderate to severe if this fails.
• Moderate to severe - offer CBT ERP as for adults but involve family/carers: individual or group depending on the preference of the patient.
• If psychological treatment fails, factors which might require other interventions may be involved, e.g.co-existence of comorbid conditions, learning disorders,persisting psychosocial risk factors such as family discord, presence of parental mental health problems. In children over the age of 8, adding SSRI might be appropriate,following multidisciplinary review (but see below concerning safety issues.)

Using SSRIs^1,5-6

see Selective serotonin re-uptake inhibitors and below:

• SSRI's in Adults Evidence for use of SSRIs in OCD is stronger than for BDD. Caution is advised in view of increased risk of suicidal thoughts and self-harm in people with depression. It is unclear whether this applies to people with OCD or BDD in absences of other co-morbidity; further guidance is awaited.
  When prescribing, discuss the following and provide written supporting material:
  • Craving and tolerance do not occur.
  • There is a risk of discontinuation/withdrawal symptoms on stopping the drug, missing doses, or reducing the dose.
  • There is a range of potential side effects, (see individual drugs) including worsening anxiety, suicidal thoughts and self-harm, which need to be carefully monitored, especially in the first few weeks of treatment.
  • There is commonly a delay in onset up to 12 weeks, although depressive symptoms improve more quickly.
  • In high risk patients, prescribe limited quantities, keep in contact especially during first few weeks, and actively monitor for akathesia (restlessness and the urge to move), suicidal ideation, increased anxiety, agitation
  • Monitor all patients around time of dosage changes.
  • For OCD NICE recommends fluoxetine, fluvoxamine, paroxetine, sertraline or citalopram. There are no significant differences in efficacy.
  • For BDD NICE recommends fluoxetine as there is more supporting evidence than for other SSRIs.
  • If there is no response to a standard dose, check compliance, check interaction with drugs and alcohol, then consider titrating to maximum dose according to the Product Characteristics.
  • Continue for at least twelve months, withdraw gradually.
• SSRI's in Children and young people (8-18 years)
  • Caution is advised as there is a risk of self-harm or suicide in patients with depression. Only prescribed by specialists, in conjunction with psychological therapy following assessment by child and adolescent psychiatrist who should also be involved in dosage changes and discontinuation.
  • Sertraline and fluoxetine are the only SSRIs licensed for this use, unless significant co-existing depression is evident, in which case fluoxetine should be used.
  • For BDD, use fluoxetine. In the presence of depression, follow NICE guidance for treatment of childhood depression.
  • Discuss adverse effects, dosage, monitoring etc with patient/family/carers as per adults (see above).

Treatment Failures (applicable to adults, children and young people)^1,4,7-8

The following in conjunction with specialist assessment and multi-disciplinary review:

• Try another SSRI
• Change to clonidine - but greater tendency to produce adverse effects. Do baseline ECG and check BP, start with small dose, titrate according to response, monitor regularly.
• Antipsychotics - sometimes used to augment effect of SSRI
• In-patient treatment - for 'last resort' treatment failures
• Residential/supportive care - for patients with chronic severe dysfunction
• Neurosurgery - not usually recommended, but has been tried with limited success