Treating OCD

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Looking for answers to the debilitating problems of obsessive compulsive disorder

More than a million people in the United Kingdom are estimated to have obsessive compulsive disorder (OCD) and many are unaware that it is a treatable condition. It can occur in children as young as six, and most patients who develop OCD will have symptoms in childhood or adolescence.

OCD is common, chronic and debilitating. The World Health Organisation ranks OCD in the top 20 most disabling conditions, affecting around one to two per cent of the population worldwide. It affects males and females equally.

OCD is characterised by intrusive unwanted thoughts (obsessions) and ritualistic behaviours (compulsions). Sufferers of OCD recognise that their obsessions originate from their own mind, but experience them as out of character, unwanted and distressing. Common obsessions include fears and concerns about germs or contamination, symmetry and order, safety, worries about hurting others or themselves and unwanted sexual thoughts.

Compulsions are repetitive stereotyped behaviours, typically for the purpose of neutralising the fear or anxiety provoked by the obsession. Patients realise that the action is purposeless but cannot resist performing it and often fear that something bad might happen if they do not do it. Common compulsions include checking, touching, lining up items, hand washing, cleaning and counting.{pullquote}Patients realise that the action is purposeless but cannot resist performing it{/pullquote}

As the severity of symptoms increase, OCD can consume the patients’ daily life. Peer and family relationships often suffer and individuals may even become housebound or stop attending school.

At the South London and Maudsley (SLaM) NHS Foundation Trust, our unit is home to the only specialist service for children and adolescents with OCD in the UK. We also assess and treat OCD related anxiety disorders in young people with a developmental disorder, for example, high functioning autistic spectrum disorders or neurological conditions.

OCD occurs in about one per cent of under 18-year-olds. While rates do not appear to be increasing, there is greater recognition of OCD and better treatments are now available. When effectively treated, most people with OCD can get better and resume normal functioning. When untreated, it can lead to severe and life-long disability.

Cognitive behavioural therapy (CBT) is the first choice treatment for children and adolescents with OCD. However, studies in adults have shown that people with OCD can benefit from appropriate medication, in conjunction with therapy.

NICE recommends a “stepped care” model with increasing intensity of treatment according to severity. OCD is classified into three categories – mild, moderate or severe – depending on the level of distress and functional impairment.

We are currently running two trials to help improve the treatment of young people with OCD – one looking at CBT over the telephone, and the other exploring the benefits of the drug D-Cycloserine. The telephone CBT trial compares CBT carried out over the telephone with standard face-to-face CBT. Treatment involves 14 weekly CBT sessions with a specialist therapist, either at the clinic or over the telephone (random allocation). Evidence has shown that CBT for OCD in children and adolescents works as well over the phone as face-to-face.

We expect that the two formats of CBT will work equally well, and by demonstrating this we will be able to offer telephone CBT to more families in the future. This will be especially important for young people and families who live at a distance from the nearest expert treatment centre.

The second trial taking place is investigating whether the efficiency of CBT for OCD can be enhanced when combined with a drug called D-Cycloserine. This drug has been shown to enhance CBT outcomes in adults by speeding up the process in which people become less afraid of their feared stimulus.

Treatment involves 14 weekly CBT sessions with a specialist therapist at our clinic. In addition to CBT, half the participants will receive D-Cycloserine after their therapy sessions, and half will receive a placebo sugar pill (random allocation).

Randomised controlled trials are the gold-standard for trying to see if one treatment is better, worse, or the same as the current best treatment. In the case of the D-Cycloserine trial, there is some evidence that taking this medicine in combination with cognitive behaviour therapy for OCD, makes the treatment quicker and easier.

The child learns with less effort that they can cope with the anxiety associated with resisting carrying out a ritual, and that this fear goes away on its own. The trial is “double-blind”, which means that until we analyse the result neither the therapist nor the child knows if they are taking active medication or placebo. We hope the trial will show that D-Cycloserine can be used to improve effectiveness of CBT for children with OCD.  {pullquote}When untreated, OCD can lead to severe and life-long disability{/pullquote}

Preliminary results for both trials are expected towards the end of 2011, although full analysis will not be possible until a twelve month follow-up after the trials are “un-blinded”.

For young people with OCD in school, life can be miserable and beset with challenges that are hard to imagine. However, by working with young people, parents and teachers, lives can be turned around and young people with OCD can become part of a nurturing school environment and have a greater chance of succeeding in life.

Recognition of OCD by health professionals and public awareness of the condition have significantly improved in recent years. Nevertheless, feelings of shame and guilt cause some sufferers to delay seeking help for years. Research has shown that it is often more than 10 years from onset of symptoms to first treatment.

OCD is a devastating illness, both for the young people suffering from obsessions and compulsions, but also for their family. However, by working together we can help young people and their families to gain control of their lives, and help them towards an anxiety-free future. Educating health professionals in recognising the symptoms of OCD is an important step towards better understanding and treatment of OCD in both children and adults.

Case study: Michaela’s story

Michaela, a seven-year-old girl, is brought to the GP by her parents. They report that over the past year she has become withdrawn and has started to worry excessively. She is washing her hands repeatedly (so much so that they are chapped and raw) and is worried about catching diseases, particularly bird flu and HIV. Nothing can reassure her and she is now avoiding watching TV, as the news has recently featured bird flu. This is preventing her watching cartoons, which used to be one of her favourite activities. She has also started checking things repeatedly. She is having trouble sleeping and concentrating at school.  There is no family history of OCD.

This is a fairly classic presentation of OCD, with fears of contamination associated with compulsive hand washing and increasing anxiety. It is of moderate severity and should respond well to treatment.

Further information

Dr Isobel Heyman is a consultant child and adolescent psychiatrist and is head of the OCD Service for children and adolescents at the South London and Maudsley NHS Foundation Trust (SLaM):
www.national.slam.nhs.uk/camhs-ocd

Dr Heyman’s team is keen to receive telephone or referrals enquiries in relation to the two treatment trials discussed above.

For more information on OCD, visit:
www.ocdaction.org.uk

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