Approaching obsessive compulsive disorder in primary care

This month we spoke to Consultant Psychiatrist Dr Andreas Schenk, on the subject of obsessive compulsive disorder (OCD).

Dr Schenk provides expert care and treatment for a variety of mental health conditions at Priory Hospital Southampton and The Manor Clinic, with a particular interest in OCD.

It is estimated that about 1 in every 50 people suffer with obsessive compulsive disorder (OCD) at some point in their lives and it affects men and women equally. This adds up to over one million people in the UK alone.

It is the fourth most common psychiatric illness and is associated with significant impairment in an individual’s functioning, their quality of life and their general health and wellbeing. If it is left untreated, OCD can become chronic and enduring illness, and can cause a variety of symptoms. 

Despite OCD being a common mental illness, most individuals seek treatment after several years of suffering with OCD, and many may not seek help at all due to fear of being labelled and judged. It is estimated that less than a third of OCD sufferers receive appropriate pharmacotherapy for their condition, and even less receive evidence-based psychotherapy. It is important to recognise that early OCD diagnosis and the correct treatment is imperative to a positive outcome.

Recognising when a patient has OCD

As a consultant psychiatrist, I have witnessed OCD being misdiagnosed by clinicians. Obsessions can be mistaken for psychosis, and mental compulsions can be difficult to recognise due to the lack of observable characteristic behaviour.

In our day-to-day conversations we often use words like ‘obsessive’ and ‘paranoid’ quite flippantly, in order to describe thoughts, feelings or behaviours. For example someone may say: “I’m paranoid about keeping my house clean” or “he’s a little obsessive about waxing his car”. Most of the time these words are used to describe harmless preferences or self-limiting quirks but for some people, the experience of having unwanted intrusive thoughts or repetitive behaviours can be debilitating.

OCD is an anxiety disorder in which people have unwanted and repeated thoughts, feelings or images (the ‘obsessions’) and engage in behaviours or mental acts in response to these (the ‘compulsions’). Usually the person carries out the compulsions in order to reduce the anxiety caused by obsessions, or to try and get rid of the obsessive thoughts, but this only brings temporary relief. Resisting the obsessive rituals can cause a distressing increase in tension and anxiety.

People often obsess about those things which they hold most dear. For example, a dedicated ambulance driver may obsess about knocking a pedestrian over, or a loving mother may obsess that she has accidentally poisoned her child. These obsessions are usually a profound source of distress for people, founded on an irrational fear that they might be capable of such acts.

Approaching OCD in primary care

A recommended approach to OCD management in primary care would include:

• An assessment of OCD symptoms and comorbid symptoms including suicidal thoughts
• Psychoeducation for the patient and family
• Other treatment options including durations
• Choice of treatment e.g. medication, cognitive behavioural therapy (CBT), or both
• Discussion on the side effects of drugs and the risk:benefit ratio
• Consideration of referral for specialist psychiatric evaluation
• Follow-up plan after initiating treatment

Assessment and evaluation for OCD in your GP surgery

A diagnosis of OCD is made if symptoms are:

• Time consuming e.g. more than an hour per day
• Distressing or cause significant interference in functioning

In routine general practice, using of structured / semi-structured interviews and rating scales is not usually essential. However, these tools may be useful in mapping out an individual’s specific obsessions and comparing severity scores over time.

I recommend the Yale-Brown Obsessive Compulsive Scale (YBOCS) – a symptom checklist and severity rating scale. It is the most widely used severity rating scale for OCD and is considered a gold standard instrument to measure severity.  

The YBOCS is a 10-item observer-rating scale, which is also available as a self-rated instrument.  A total score of ≥ 16 is considered to be indicative of clinically significant OCD. The YBOCS severity scale has an associated symptom check list of 15 categories of obsessions and compulsions.

Formulating a treatment plan

Once a diagnosis is established, a detailed assessment of symptom profile can be made and a treatment plan formulated. I find it useful to include family members in assessments and management as they will play a large part in the patient’s life.

Patients also benefit from being informed of the delay in experiencing the positive effects of medication and it is beneficial to inform them that improvement may occur over several months of continuous treatment. Psychotherapy options should also be discussed, given the often self-sustaining nature of OCD and modest response rates to medication.

Pharmacological treatment for OCD

Selective serotonin reuptake inhibitors (SSRIs) and clomipramine are currently recommended as first-line agents for drug treatment of OCD. According to current evidence, effective SSRIs include escitalopram, fluvoxamine, fluoxetine, paroxetine and sertraline. Compared with other anxiety disorders, OCD tends to have lower response rates to medication and somewhat higher doses of these drugs tend to be used. Higher doses are associated with greater efficacy in some, but not all, studies. 

It is generally recommended that an SSRI should be continued at maximum tolerated doses for at least 12 weeks before efficacy can be determined. It is also generally recommended that successful treatment with SSRIs should be maintained at the maximal effective dose for at least 12 months, however the majority of patients that I see, benefit from indefinite treatment to control symptoms and prevent relapse.

When should you refer to a specialist psychiatrist?

Despite the efficacy of SSRIs and clomipramine in many patients with OCD, approximately half of those treated show no or partial symptom improvement following treatment with a first-line drug. There is ongoing research into effective second-line strategies, and referral on to a specialist psychiatrist is recommended.

Second-line strategies, often employed in specialist practice, include high-dose treatment with serotonergic agents (sometimes above British National Formulary (BNF) recommendations), switching/combining antidepressants, and augmentation with antipsychotics. Other strategies such as glutamatergic agents, gabapentin, valproate, ondansetrone and cyproterone acetate require further evaluation and may have a role to play in future treatment.

Once a patient has had a formal psychiatric evaluation, the consultant psychiatrist could also advise on augmentation with psychotherapy. In order of strength of recommendation, the types of psychotherapy which would benefit someone with OCD are:

• CBT
• Behaviour therapy (including exposure and response prevention)
• Mindfulness
• Acceptance and commitment therapy (ACT)
• Stress management
• Relaxation training
• Thought stopping
• Dynamic therapy

Most of these therapies are available at Priory and your local consultant psychiatrist would be able to advise which would be most appropriate for an individual, taking into account their history, previous treatment response and comorbid conditions.