Treatment

The National Institute for Clinical Excellence (NICE) recommends a “stepped care” approach, with increasing intensity of treatment according to clinical severity and complexity.

Standardised instruments may be used to assess the severity of the condition and monitor response to treatment. These include the obsessive compulsive inventory (short self completed questionnaire) or the Yale Brown obsessive compulsive scale (Y BOCS) which is the best validated instrument.

Cognitive behavioural therapy (CBT) focuses on remedying the faulty reasoning associated with OCD. During CBT, the therapist encourages the person to re-evaluate overvalued beliefs about risk or personal responsibility, and to carry out behavioural experiments to test the validity of their beliefs.

Exposure and response prevention (ERP) is the most effective psychological technique in the treatment of OCD. It is usually combined with CBT but it is not clear whether the addition of CBT improves outcome. In ERP the person generates a hierarchy of feared situations and then practices facing the fear (exposure) while monitoring the anxiety and experiencing that it lessens without the need to carry out a ritual (response prevention). The therapist helps the person design a graded programme of exposure and response prevention and encourages the person to work on the easiest challenges first. The person requires education about the mechanisms of anxiety in order to understand that repeated exposure leads to reduced anxiety as well as reduction in obsessions. Practice is required as it is likely that people with OCD will have been reinforcing their behaviours by avoiding feared situations or carrying out rituals to deal with their fears for a considerable time.

The NICE “stepped care” approach is summarised below, but it should be noted that treatment provision and expertise vary across the country. The stepped care approach is also shown in diagram form – click here for diagram

• Treatment - Mild functional impairment
• Treatment - Moderate functional impairment
• Treatment - Severe functional impairment

Treatment - Mild functional impairment

People with a mild functional impairment should be offered low intensity treatments (less than 10 hours of therapist input per person).

These include:-

• Brief individual CBT (including ERP) using structured self help materials
• Brief individual CBT (including ERP) by telephone
• Group CBT (including ERP)

People who are unable to engage in low intensity CBT (including ERP) or for whom low intensity treatment has proved to be inadequate, should be offered the choice of either a course of an SSRI or more intensive CBT (including ERP) (more than 10 therapist hours per person).

The initial drug treatment should be one of the following Selective Serotonin Reuptake Inhibitors (SSRIs):- fluoxetine, paroxetine, sertraline or citalopram.

Treatment - Moderate functional impairment

People with moderate functional impairment should be offered the choice of either a course of an SSRI or more intensive CBT (including ERP).

If there has not been an adequate response to treatment with SSRI alone or intensive CBT (including ERP) alone, a multidisciplinary review within either primary or secondary care should be carried out, and combined treatment with CBT (including ERP) and an SSRI should be offered.

Treatment - Severe functional impairment

• People with severe functional impairment should be offered combined treatment with an SSRI and CBT (including ERP).
• If there has not been an adequate response to combined treatment with CBT and an SSRI, a different SSRI or clomipramine should be offered.
• If there has been no response to a full trial of at least one SSRI alone, a full trial of CBT and an SSRI and a full trial of clomipramine alone, the person should be referred to a multidisciplinary team with specific expertise in the treatment of OCD for assessment and further treatment planning.
• Following multidisciplinary review, the following treatment options should be considered:-
• Additional CBT (including ERP) or cognitive therapy
• Adding an antipsychotic to an SSRI or clomipramine
• Combining clomipramine and citalopram
• People with severe chronic treatment resistant OCD should be under the care of specialist treatment services (local, regional or national).
• At this stage, inpatient care or other intensive (home based treatments) programmes may be offered.

A small minority of people with longstanding and disabling OCD, which interferes with daily living and has prevented them from developing a normal level of autonomy, may, in addition to treatment, need accommodation in a supported environment.

Neurosurgery is extremely rarely offered and only for the most severely affected people with OCD who have failed to respond to other treatments.

Deep brain stimulation is relatively new technique but clinical studies so far are too small to reach any conclusion about efficacy, and it is suggested that further clinical studies are required.

There is no evidence to support the use of psychodynamic psychotherapy in OCD.

If treatment with an SSRI is effective, it should be continued for at least 12 months to prevent relapse. If continued for more than 12 months then regular review of the need to continue should be carried out.

Amended June 2008