Obsessive Compulsive Disorder Ocd 1

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Obsessive compulsive disorder (OCD)
Background information
Information resources for patients and carers
Updates to this pathway
Obsessive compulsive disorder (OCD) clinical presentation
History and examination
Consider differential diagnoses
Diagnosis of obsessive compulsive disorder (OCD)
Severe functional impairment
Moderate functional impairment
Mild functional impairment
Consider urgent referral to Mental Health Team
Intensive CBT or drug therapy
Cognitive behavioural therapy (CBT) and self management
Refer to Mental Health Team
Ineffective - consider referral to Mental Health Team
Effective - continue CBT and follow-up
Ineffective - more intensive CBT or drug therapy
Effective - continue CBT and follow-up
Refer to Mental Health Team
Refer to Mental Health Team Refer to Mental Health Team Effective - continue and follow-up
First-line therapies
Intensive CBT including exposure and response prevention (ERP)
Drug therapy
Consider self help group for additional support
Review first-line therapy
Poor response - trial alternative therapies
Good response maintain treatment
Review
Consider inpatient treatment
Good response discontinue treatment
Consider referral to specialist treatment service
Refer to specialist treatment service
Published: 29-Jul-2010
Valid until: 29-Feb-2012 Map of Medicine Ltd All rights reserved
This care map was published by International. A printed version of this document is not controlled so may not be up-to-date with the latest clinical information.
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http://eng.mapofmedicine.com/evidence/map/obsessive_compulsive_disorder_ocd_1.html

1 Background information
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Scope: assessment and management of obsessive compulsive disorder (OCD), in primary and secondary care pharmacological and non-pharmacological treatments treatments in adults with special considerations in children and adolescents, the elderly, and in pregnant and breastfeeding women Out of scope: body dysmorphmic disorder (BDD) related pathways include: depression anxiety self harm adverse effects of antipsychotic treatments Definition: OCD is defined as the presence of obsessional thoughts or compulsive acts, or most commonly, both. obsessions are recurring thoughts, images or impulses that leads to marked anxiety. compulsions are repetitive behaviours or mental acts guided by obsessions or following certain rules, to try and reduce distress or prevent imagined negative events Prevalence: estimates vary between 0.8-3% in adults, and 0.25-2% in children and adolescents [1] Prognosis: untreated OCD can often persist; approximately 48% of people continue to have OCD 30 years after diagnosis [1] Complications: OCD can have severe effects on the quality of life and the ability for sufferers to study or work References: [1] Clinical Knowledge Summaries (CKS). Obsessive-compulsive disorder. Version 1.0. Newcastle upon Tyne: CKS; 2008. [2] Koran LM, Hanna GL, Hollander E. Practice guideline for the treatment of patients with obsessive-compulsive disorder. Washington DC: American Psychiatric Association (APA); 2007. [3] National Collaborating Centre for Mental Health (NCCMH), National Institute for Health and Clinical Excellence (NICE). Obsessive Compulsive Disorder: Core interventions in the treatment of obsessive-compulsive disorder and body dysmorphic disorder. Clinical guideline 31. London: The British Psychological Society (BPS) and The Royal College of Psychiatrists (RCPSYCH); 2005.
2 Information resources for patients and carers

Quick info:
Patients and carers in England and Wales can access this pathway through NHS Choices at http:// healthguides.mapofmedicine.com/choices/map/obsessive_compulsive_disorder1.html The following resources have been produced by organisations certified by The Information Standard: 'Obsessive compulsive disorder' (URL) from Bupa at http://www.bupa.co.uk 'Obsessional states' (URL) from Datapharm at http://www.medicines.org.uk/guides 'Treating obsessive compulsive disorder (OCD) and body dysmorphic disorder (BDD) in adults, children and young people' (PDF) from National Institute for Health and Clinical Excellence (NICE) at http://www.nice.org.uk 'Obsessive compulsive disorder' (PDF) from Patient UK at http://www.patient.co.uk Rethink at http://www.rethink.org 'Obsessive compulsive disorder' (URL) from Royal College of Psychiatrists at http://www.rcpsych.ac.uk Information for carers and people with disabilities is available at: 'Caring for someone' (URL) from Directgov at http://www.direct.gov.uk 'Disabled people' (URL) from Directgov at http://www.direct.gov.uk Explanations of clinical laboratory tests used in diagnosis and treatment are available at Understanding Your Tests (URL) from Lab Tests Online-UK at http://www.labtestsonline.org.uk. The Map of Medicine is committed to providing high quality health and social care information for patients and carers. For details on how these resources are identified, please see Map of Medicine Patient and Carer Information. NB: This information appears on each page of this pathway.
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3 Updates to this pathway
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Date of publication: 30-Jul-2010 Three nodes now appear at the top of each pathway page. These provide: easy access to scope and background information on each page of the pathway whilst reducing repetition between nodes easy access to patient resources/leaflets information on pathway updates This pathway has been updated in line with the following guidelines: [1] Clinical Knowledge Summaries (CKS). Obsessive-compulsive disorder. Version 1.0. Newcastle upon Tyne: CKS; 2008. [2] Koran LM, Hanna GL, Hollander E. Practice guideline for the treatment of patients with obsessive-compulsive disorder. Washington DC: American Psychiatric Association (APA); 2007. [3] National Collaborating Centre for Mental Health (NCCMH), National Institute for Health and Clinical Excellence (NICE). Obsessive Compulsive Disorder: Core interventions in the treatment of obsessive-compulsive disorder and body dysmorphic disorder. Clinical guideline 31. London: The British Psychological Society (BPS) and The Royal College of Psychiatrists (RCPSYCH); 2005. [5] Baldwin DS, Anderson IM, Nutt DJ. Evidence-based guidelines for the pharmacological treatment of anxiety disorders: recommendations from the British Association for Psychopharmacology. J Psychopharmacol 2005; 19: 567-96. Further information was provided by the following references: [4,6-10]. For more information, please see the pathway's Provenance certificate. Practice-based knowledge has been contributed to this pathway by: Selected members of Map of Medicine (MoM) Clinical Editorial team, and independent reviewers invited by Map of Medicine The pathway has been completely restructured and redrafted in line with the Map of Medicine's editorial methodology and to bring it in line with current clinical practice. NB: This information appears on each page of this pathway.
4 Obsessive compulsive disorder (OCD) - clinical presentation

Quick info:
People with obsessive compulsive disorder (OCD) may not want to disclose their symptoms. However, it is important to distinguish whether the patient displays any obsessive or compulsive behaviour such as: contamination from dirt fear of harm excessive concern with order repeated checking eg locking doors, turning taps off A series of direct questions can be asked when performing an examination, to assist the diagnosis and assessment of severity of functional impairment. This information was drawn from the following references: [1] Clinical Knowledge Summaries (CKS). Obsessive-compulsive disorder. Version 1.0. Newcastle upon Tyne: CKS; 2008. [2] Koran LM, Hanna GL, Hollander E. Practice guideline for the treatment of patients with obsessive-compulsive disorder. Washington DC: American Psychiatric Association (APA); 2007. [3] National Collaborating Centre for Mental Health (NCCMH), National Institute for Health and Clinical Excellence (NICE). Obsessive Compulsive Disorder: Core interventions in the treatment of obsessive-compulsive disorder and body dysmorphic disorder. Clinical guideline 31. London: The British Psychological Society (BPS) and The Royal College of Psychiatrists (RCPSYCH); 2005.
5 History and examination

Quick info:
When taking the patient's history, assess: family history for history of alcohol or drug abuse thought patterns in obsessive compulsive disorder (OCD), the person recognises the unwanted thoughts as generated from their own mind, in contrast to 'thought insertion' ideas, eg in schizophrenia
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the associated behaviours checking and cleaning rituals are the most common; others include order, hoarding, superstitious behaviours and counting effects on patient's psychosocial functioning: effect on their daily life and employment or schooling hazards to physical health (due to hoarding objects or repetitive washing) for co-morbid conditions such as depression, drug abuse, risk of self harm and suicide effects on the family including carer and/or dependent children Obsessions may include (most to least common): contamination from dirt, germs, viruses, bodily fluids, chemicals, sticky or dangerous substances fear of causing harm to self or others by acts of omission, eg door locks are not secure perfectionism excessive attention to order or symmetry obsession with body or physical symptoms religious, sacrilegious or blasphemous thoughts sexual thoughts, eg paedophilia desire to hoard worn out or useless possessions violent or aggressive thoughts magical or superstitious thoughts (in children) Compulsions may include (most to least common): checking, eg gas, taps, locks decontamination, cleaning, and washing repetition of acts mental compulsions eg repetition of special words or prayers ordering, symmetry, exactness hoarding or collecting counting limitation of function (eg prevents social contact) and may cause anxiety and distress insight at some point during course of disorder, the person recognises and tries to resist obsessions and compulsions Asking the following questions may aid diagnosis: do you check things a lot? do you wash a lot? do your daily activities take a long time to complete? do you always need to put things in a special order? It may also be helpful to get the patient to document an estimate of how long they spend obsessing or performing compulsive acts. This information was drawn from the following references: [1] Clinical Knowledge Summaries (CKS). Obsessive-compulsive disorder. Version 1.0. Newcastle upon Tyne: CKS; 2008. [2] Koran LM, Hanna GL, Hollander E. Practice guideline for the treatment of patients with obsessive-compulsive disorder. Washington DC: American Psychiatric Association (APA); 2007. [3] National Collaborating Centre for Mental Health (NCCMH), National Institute for Health and Clinical Excellence (NICE). Obsessive Compulsive Disorder: Core interventions in the treatment of obsessive-compulsive disorder and body dysmorphic disorder. Clinical guideline 31. London: The British Psychological Society (BPS) and The Royal College of Psychiatrists (RCPSYCH); 2005.
6 Consider differential diagnoses

Quick info:
Other conditions may sometimes be misdiagnosed as obsessive compulsive disorder (OCD) eg: arrhythmias causing palpitations Tourette's syndrome tic disorders obsessive compulsive disorder (OCD) is often co-morbid with Tourette's syndrome or tic disorders Asperger's syndrome autism trichotillomania health anxiety phobic disorders (particularly vomit phobia) schizophrenia, which is characterised by delusional beliefs, and may manifest as obsessive thoughts body dysmorphic disorder, characterised by pre-occupation with imagined defects or minor physical anomalies generalised anxiety disorder characterised by ruminations (may be confused with obsessions)
Published: 29-Jul-2010 Valid until: 29-Feb-2012 Map of Medicine Ltd All rights reserved
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anxiety caused by drugs (eg cannabis) or drug (including alcohol) withdrawal depression (can be associated with obsessive thoughts) This information was drawn from the following references: [1] Clinical Knowledge Summaries (CKS). Obsessive-compulsive disorder. Version 1.0. Newcastle upon Tyne: CKS; 2008. [2] Koran LM, Hanna GL, Hollander E. Practice guideline for the treatment of patients with obsessive-compulsive disorder. Washington DC: American Psychiatric Association (APA); 2007.
7 Diagnosis of obsessive compulsive disorder (OCD)

Quick info:
Diagnosis can be confirmed using the ICD-10 and DSM-IV classification systems. See the WHO's ICD-10 classification of mental and behavioural disorders. Both systems must include the presence of either obsessions or compulsions which the patient must acknowledge are excessive and a product of their mind [3]. It is important to assess whether the patient's functional impairment is severe, moderate, or mild to be able to guide management. It is also important to assess the risk of self harm or suicide, as well as the impact of their behaviour on others [1]. If you are uncertain of the diagnosis, or level of severity of functional impairment, refer to Mental Health Team [1]. NB: According to DSM-IV, insight is not a criteria for childhood obsessive compulsive disorder (OCD), as they may not realise that their obsessive thoughts are unreasonable [2]. References: [1] Clinical Knowledge Summaries (CKS). Obsessive-compulsive disorder. Version 1.0. Newcastle upon Tyne: CKS; 2008. [2] Koran LM, Hanna GL, Hollander E. Practice guideline for the treatment of patients with obsessive-compulsive disorder. Washington DC: American Psychiatric Association (APA); 2007. [3] National Collaborating Centre for Mental Health (NCCMH), National Institute for Health and Clinical Excellence (NICE). Obsessive Compulsive Disorder: Core interventions in the treatment of obsessive-compulsive disorder and body dysmorphic disorder. Clinical guideline 31. London: The British Psychological Society (BPS) and The Royal College of Psychiatrists (RCPSYCH); 2005.
8 Severe functional impairment

Quick info:
Patients have obsessive thinking and compulsive behaviour for three or more hours a day [1]. Patient's behaviour has a severe impact on daily activities such as work/schooling and family life [3]. NB: Children who are diagnosed with moderate to severe functional impairment will need to be referred to the Child and Adolescent Mental Health Services (CAMHS) [1]. References: [1] Clinical Knowledge Summaries (CKS). Obsessive-compulsive disorder. Version 1.0. Newcastle upon Tyne: CKS; 2008. [3] National Collaborating Centre for Mental Health (NCCMH), National Institute for Health and Clinical Excellence (NICE). Obsessive Compulsive Disorder: Core interventions in the treatment of obsessive-compulsive disorder and body dysmorphic disorder. Clinical guideline 31. London: The British Psychological Society (BPS) and The Royal College of Psychiatrists (RCPSYCH); 2005.
9 Moderate functional impairment

Quick info:
Patients have obsessive thinking and compulsive behaviour for about two hours a day [1]. Patient's behaviour has a moderate impact on daily activities such as work/schooling and family life [3]. It can be difficult to diagnose moderate functional impairment, therefore, if there is any doubt, patient should be referred straight to the Mental Health Team [1]. NB: Children who are diagnosed with moderate to severe functional impairment will need to be referred to the Child and Adolescent Mental Health Services (CAMHS) [1]. References: [1] Clinical Knowledge Summaries (CKS). Obsessive-compulsive disorder. Version 1.0. Newcastle upon Tyne: CKS; 2008.
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[3] National Collaborating Centre for Mental Health (NCCMH), National Institute for Health and Clinical Excellence (NICE). Obsessive Compulsive Disorder: Core interventions in the treatment of obsessive-compulsive disorder and body dysmorphic disorder. Clinical guideline 31. London: The British Psychological Society (BPS) and The Royal College of Psychiatrists (RCPSYCH); 2005.
10 Mild functional impairment

Quick info:
Patients have obsessive thinking and compulsive behaviour for about one hour a day [1]. Patient's behaviour has limited impact on daily activities such as work/schooling and family life [3]. References: [1] Clinical Knowledge Summaries (CKS). Obsessive-compulsive disorder. Version 1.0. Newcastle upon Tyne: CKS; 2008. [3] National Collaborating Centre for Mental Health (NCCMH), National Institute for Health and Clinical Excellence (NICE). Obsessive Compulsive Disorder: Core interventions in the treatment of obsessive-compulsive disorder and body dysmorphic disorder. Clinical guideline 31. London: The British Psychological Society (BPS) and The Royal College of Psychiatrists (RCPSYCH); 2005.
11 Consider urgent referral to Mental Health Team

Quick info:
Urgent referral for a psychiatric assessment should be considered for any patients with a suspected high risk of self harm or suicide, or who pose a risk to others [1]. Reference: [1] Clinical Knowledge Summaries (CKS). Obsessive-compulsive disorder. Version 1.0. Newcastle upon Tyne: CKS; 2008.
12 Intensive CBT or drug therapy

Quick info:
There are several factors to consider at each stage of treatment, including [2]: patient's motivation severity of symptoms suicide risk other co-existing psychiatric or medical disorders drug side effects past treatment history whether women are of childbearing age elderly patients Treatment for moderate functional impairment includes intensive cognitive behavioural therapy (CBT) including exposure and response prevention (ERP), or drug therapy (if necessary) [1]. Intensive CBT involves more than 10 therapist hours per patient [1]. For children, CBT should always take place in the context of the child's cognitive development, which may not always correlate with age [4]. Drug therapy may involve prescribing a selective serotonin re-uptake inhibitor (SSRI), eg fluoxetine, as these have been shown to alleviate symptoms and improve quality of life. Consider [3,5]: a trial for 12 weeks, as drugs may not show a response before this (if patient responds, continue drugs after 12 week trial) trials should be up to the maximum tolerated dose there is often a dose response relationship in obsessive compulsive disorder (OCD) when starting the drug or changing the dose: monitor the patient for agitation, self-harm or suicidal thoughts, especially in young adults (under age 30 years); or if the patient is also depressed, or if they are at risk of suicide checking for other medication interactions Consider prescribing clomipramine as an alternative to an SSRI if preferred by the patient, or if they have previously had a good response to it [1]. Some studies have shown clomipramine to have a lower adherence rate due to its increased side effects [6]. Special considerations for prescribing drug therapy include [5]: children: SSRI's should only be prescribed by a child and adolescent psychiatrist [1]
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reserve pharmacological treatment only for those children where psychological treatment has been unsuccessful consider dosages carefully in relation to age and size carefully monitor for adverse side effects SSRI's have been shown to be effective in reducing overall symptom severity [7] elderly: check for drug interactions lower dosage due to reduced metabolism pregnancy and breastfeeding: avoid drugs if possible consider potential risks and benefits of any pharmacological treatment fluoxetine should be used as first-line drug in pregnancy, but should not be used in breastfeeding References: [1] Clinical Knowledge Summaries (CKS). Obsessive-compulsive disorder. Version 1.0. Newcastle upon Tyne: CKS; 2008. [2] Koran LM, Hanna GL, Hollander E. Practice guideline for the treatment of patients with obsessive-compulsive disorder. Washington DC: American Psychiatric Association (APA); 2007. [3] National Collaborating Centre for Mental Health (NCCMH), National Institute for Health and Clinical Excellence (NICE). Obsessive Compulsive Disorder: Core interventions in the treatment of obsessive-compulsive disorder and body dysmorphic disorder. Clinical guideline 31. London: The British Psychological Society (BPS) and The Royal College of Psychiatrists (RCPSYCH); 2005. [4] Munoz-Solomando A, Kendall T, Whittington CJ. Cognitive behavioural therapy for children and adolescents. Curr Opin Psychiatry 2008; 21(4):332-337. [5] Baldwin DS, Anderson IM, Nutt DJ. Evidence-based guidelines for the pharmacological treatment of anxiety disorders: recommendations from the British Association for Psychopharmacology. J Psychopharmacol 2005; 19: 567-96. [6] Choi YJ. Efficacy of treatments for patients with obsessive-compulsive disorder: a systematic review. J Am Acad Nurse Pract 2009; 21: 207-13. [7] Ipser JC, Stein DJ, Hawkridge S et al. Pharmacotherapy for anxiety disorders in children and adolescents. Cochrane Database Syst Rev 2009; CD005170.
13 Cognitive behavioural therapy (CBT) and self management

Quick info:
Initial treatment for mild functional impairment should involve low intensity cognitive behavioural therapy (CBT), including exposure and response prevention (ERP). This should involve less than 10 therapist hours per patient, and may include one of the following [1,3]: brief individual CBT with ERP with self help materials brief individual CBT with ERP by phone group CBT with ERP which may be for more than 10 hours The CBT should involve a primary care mental health worker, or other primary healthcare professional with appropriate expertise. If this is not available then referral to the Mental Health Team is required [1]. For children, CBT should always take place in the context of the child's cognitive development, which may not always correlate with age [4]. References: [1] Clinical Knowledge Summaries (CKS). Obsessive-compulsive disorder. Version 1.0. Newcastle upon Tyne: CKS; 2008. [3] National Collaborating Centre for Mental Health (NCCMH), National Institute for Health and Clinical Excellence (NICE). Obsessive Compulsive Disorder: Core interventions in the treatment of obsessive-compulsive disorder and body dysmorphic disorder. Clinical guideline 31. London: The British Psychological Society (BPS) and The Royal College of Psychiatrists (RCPSYCH); 2005. [4] Munoz-Solomando A, Kendall T, Whittington CJ. Cognitive behavioural therapy for children and adolescents. Curr Opin Psychiatry 2008; 21: 332-7.
15 Ineffective - consider referral to Mental Health Team

Quick info:
If there is an inadequate response to initial treatment, refer to Mental Health Team [1]. Reference: [1] Clinical Knowledge Summaries (CKS). Obsessive-compulsive disorder. Version 1.0. Newcastle upon Tyne: CKS; 2008.
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16 Effective - continue CBT and follow-up
Quick info:
Cognitive behavioural therapy (CBT) should be followed up every month [2]. Response to drug therapy should be reviewed after 12 weeks [5]. If initial 12 week response to drug therapy has been successful, continuing therapy for 12 months is recommended to reduce the risk of relapse [1]. If a patient has taken maintenance medication for 1 year without relapse, and has been fully functioning for 12 weeks, consider discontinuing medication [3]. Patients, family and carers should be advised that [1]: there is a risk of relapse even after successful treatment and recovery they should seek help as soon as possible if symptoms recur References: [1] Clinical Knowledge Summaries (CKS). Obsessive-compulsive disorder. Version 1.0. Newcastle upon Tyne: CKS; 2008. [2] Koran LM, Hanna GL, Hollander E. Practice guideline for the treatment of patients with obsessive-compulsive disorder. Washington DC: American Psychiatric Association (APA); 2007. [3] National Collaborating Centre for Mental Health (NCCMH), National Institute for Health and Clinical Excellence (NICE). Obsessive Compulsive Disorder: Core interventions in the treatment of obsessive-compulsive disorder and body dysmorphic disorder. Clinical guideline 31. London: The British Psychological Society (BPS) and The Royal College of Psychiatrists (RCPSYCH); 2005. [5] Baldwin DS, Anderson IM, Nutt DJ. Evidence-based guidelines for the pharmacological treatment of anxiety disorders: recommendations from the British Association for Psychopharmacology. J Psychopharmacol 2005; 19: 567-96.
17 Ineffective - more intensive CBT or drug therapy

Quick info:
If initial treatment for mild functional impairment is unsuccessful, further treatment includes more intensive cognitive behavioural therapy (CBT) including exposure and response prevention (ERP), or drug therapy (if necessary) [1]. Intensive CBT involves more than 10 therapist hours per patient [1]. Drug therapy may involve prescribing a selective serotonin re-uptake inhibitor (SSRI), eg fluoxetine, as these have been shown to alleviate symptoms and improve quality of life. Consider [3,5]: a trial for 12 weeks, as drugs may not show a response before this (if patient responds, continue drugs after 12 week trial) trials should be up to the maximum tolerated dose there is often a dose response relationship in obsessive compulsive disorder (OCD) when starting the drug or changing the dose: monitor the patient for agitation, self-harm or suicidal thoughts, especially in young adults (under age 30 years); or if the patient is also depressed, or if they are at risk of suicide checking for other medication interactions Consider prescribing clomipramine as an alternative to an SSRI if preferred by the patient, or if they have previously had a good response to it [1]. Some studies have shown clomipramine to have a lower adherence rate due to its increased side effects [6]. Special considerations for prescribing drug therapy include [5]: children: SSRI's should only be prescribed by a child and adolescent psychiatrist [1] reserve pharmacological treatment only for those children where psychological treatment has been unsuccessful consider dosages carefully in relation to age and size carefully monitor for adverse side effects SSRI's have been shown to be effective in reducing overall symptom severity [7] elderly: check for drug interactions lower dosage due to reduced metabolism pregnancy and breastfeeding: avoid drugs if possible consider potential risks and benefits of any pharmacological treatment fluoxetine should be used as first-line drug in pregnancy, but should not be used in breastfeeding If there is an inadequate response to initial treatment, refer to Mental Health Team [1]. References: [1] Clinical Knowledge Summaries (CKS). Obsessive-compulsive disorder. Version 1.0. Newcastle upon Tyne: CKS; 2008.
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[2] Koran LM, Hanna GL, Hollander E. Practice guideline for the treatment of patients with obsessive-compulsive disorder. Washington DC: American Psychiatric Association (APA); 2007. [3] National Collaborating Centre for Mental Health (NCCMH), National Institute for Health and Clinical Excellence (NICE). Obsessive Compulsive Disorder: Core interventions in the treatment of obsessive-compulsive disorder and body dysmorphic disorder. Clinical guideline 31. London: The British Psychological Society (BPS) and The Royal College of Psychiatrists (RCPSYCH); 2005. [5] Baldwin DS, Anderson IM, Nutt DJ. Evidence-based guidelines for the pharmacological treatment of anxiety disorders: recommendations from the British Association for Psychopharmacology. J Psychopharmacol 2005; 19: 567-96. [6] Choi YJ. Efficacy of treatments for patients with obsessive-compulsive disorder: a systematic review. J Am Acad Nurse Pract 2009; 21: 207-13. [7] Ipser JC, Stein DJ, Hawkridge S et al. Pharmacotherapy for anxiety disorders in children and adolescents. Cochrane Database Syst Rev 2009; CD005170.
18 Effective - continue CBT and follow-up

Quick info:
Cognitive behavioural therapy (CBT) should be followed up every month [2]. If it is improving symptoms, it should be continued until the patient is fully functioning [3]. If patient has lasted the course, and has improved without a relapse, CBT does not need to be continued [3]. Patients, family and carers should be advised that [1]: there is a risk of relapse even after successful treatment and recovery they should seek help as soon as possible if symptoms recur References: [1] Clinical Knowledge Summaries (CKS). Obsessive-compulsive disorder. Version 1.0. Newcastle upon Tyne: CKS; 2008. [2] Koran LM, Hanna GL, Hollander E. Practice guideline for the treatment of patients with obsessive-compulsive disorder. Washington DC: American Psychiatric Association (APA); 2007. [3] National Collaborating Centre for Mental Health (NCCMH), National Institute for Health and Clinical Excellence (NICE). Obsessive Compulsive Disorder: Core interventions in the treatment of obsessive-compulsive disorder and body dysmorphic disorder. Clinical guideline 31. London: The British Psychological Society (BPS) and The Royal College of Psychiatrists (RCPSYCH); 2005.
22 Effective - continue and follow-up

Quick info:
Cognitive behavioural therapy (CBT) should be followed up every month [2]. Response to drug therapy should be reviewed after 12 weeks [5]. If initial 12 week response to drug therapy has been successful, continuing therapy for 12 months is recommended to reduce the risk of relapse [1]. If a patient has taken maintenance medication for 1 year without relapse, and has been fully functioning for 12 weeks, consider discontinuing medication [3]. Patients, family and carers should be advised that [1]: there is a risk of relapse even after successful treatment and recovery they should seek help as soon as possible if symptoms recur References: [1] Clinical Knowledge Summaries (CKS). Obsessive-compulsive disorder. Version 1.0. Newcastle upon Tyne: CKS; 2008. [2] Koran LM, Hanna GL, Hollander E. Practice guideline for the treatment of patients with obsessive-compulsive disorder. Washington DC: American Psychiatric Association (APA); 2007. [3] National Collaborating Centre for Mental Health (NCCMH), National Institute for Health and Clinical Excellence (NICE). Obsessive Compulsive Disorder: Core interventions in the treatment of obsessive-compulsive disorder and body dysmorphic disorder. Clinical guideline 31. London: The British Psychological Society (BPS) and The Royal College of Psychiatrists (RCPSYCH); 2005. [5] Baldwin DS, Anderson IM, Nutt DJ. Evidence-based guidelines for the pharmacological treatment of anxiety disorders: recommendations from the British Association for Psychopharmacology. Journal of Psychopharmacology 2005; 19(6):567-596
23 First-line therapies
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Quick info:
Severe obsessive compulsive disorder (OCD) is usually managed by a combination of cognitive behavioural therapy (CBT) and drug therapy [1,2,3]. There are several factors to consider at each stage of treatment, including [2]: patient's motivation severity of symptoms suicide risk other co-existing psychiatric or medical disorders drug side effects past treatment history whether women are at childbearing age elderly patients References: [1] Clinical Knowledge Summaries (CKS). Obsessive-compulsive disorder. Version 1.0. Newcastle upon Tyne: CKS; 2008. [2] Koran LM, Hanna GL, Hollander E. Practice guideline for the treatment of patients with obsessive-compulsive disorder. Washington DC: American Psychiatric Association (APA); 2007. [3] National Collaborating Centre for Mental Health (NCCMH), National Institute for Health and Clinical Excellence (NICE). Obsessive Compulsive Disorder: Core interventions in the treatment of obsessive-compulsive disorder and body dysmorphic disorder. Clinical guideline 31. London: The British Psychological Society (BPS) and The Royal College of Psychiatrists (RCPSYCH); 2005.
24 Intensive CBT including exposure and response prevention (ERP)

Quick info:
Cognitive and behavioural component psychotherapies including exposure and response prevention (ERP) may improve quality of life for many patients [1,3]. The National Institute for Health and Clinical Excellence (NICE) recommends individual or group cognitive behavioural therapy (CBT) including ERP [3], which: should be intensive, involving more than 10 therapist hours per patient [1]. requires exposure to anxiety provoking stimuli in an attempt to reduce the learned behaviours associated with them [2] this may cause intolerable anxiety to some patients [2] may be best reserved for mild to moderate obsessive compulsive disorder (OCD) [3], but has been shown to be very effective (particularly group therapy) [8] For children, CBT should always take place in the context of the child's cognitive development, which may not always correlate with age [4]. References: [1] Clinical Knowledge Summaries (CKS). Obsessive-compulsive disorder. Version 1.0. Newcastle upon Tyne: CKS; 2008. [2] Koran LM, Hanna GL, Hollander E. Practice guideline for the treatment of patients with obsessive-compulsive disorder. Washington DC: American Psychiatric Association (APA); 2007. [3] National Collaborating Centre for Mental Health (NCCMH), National Institute for Health and Clinical Excellence (NICE). Obsessive Compulsive Disorder: Core interventions in the treatment of obsessive-compulsive disorder and body dysmorphic disorder. Clinical guideline 31. London: The British Psychological Society (BPS) and The Royal College of Psychiatrists (RCPSYCH); 2005. [4] Munoz-Solomando A, Kendall T, Whittington CJ. Cognitive behavioural therapy for children and adolescents. Curr Opin Psychiatry 2008; 21: 332-7. [8] Jonsson H, Hougaard E. Group cognitive behavioural therapy for obsessive-compulsive disorder: a systematic review and metaanalysis. Acta Psychiatr Scand 2009; 119: 98-106.
25 Drug therapy
Quick info:
First-line drug treatment should involve selective serotonin re-uptake inhibitors (SSRI), eg fluoxetine, as these can alleviate symptoms and improve quality of life. Consider [3,5]: a trial for 12 weeks, as drugs may not show a response before this (if patient responds, continue drugs after 12 week trial) trials should be up to the maximum tolerated dose there is often a dose response relationship in obsessive compulsive disorder (OCD)
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when starting the drug or changing the dose: monitor the patient for agitation, self-harm or suicidal thoughts, especially in young adults (under age 30 years); or if the patient is also depressed or if they are at risk of suicide checking for other medication interactions Consider prescribing clomipramine as an alternative to an SSRI if preferred by the patient, or if they have previously had a good response to it [1]. Some studies have shown clomipramine to have a lower adherence rate due to its increased side effects [6]. Special considerations for prescribing drug therapy include [5]: children: reserve pharmacological treatment only for those children where psychological treatment has been unsuccessful consider dosages carefully in relation to age and size carefully monitor for adverse side effects SSRI's have been shown to be effective in reducing overall symptom severity [7] elderly: check for drug interactions lower dosage due to reduced metabolism pregnancy and breastfeeding: avoid drugs if possible consider potential risks and benefits of any pharmacological treatment fluoxetine should be used as first-line drug in pregnancy, but should not be used in breastfeeding References: [1] Clinical Knowledge Summaries (CKS). Obsessive-compulsive disorder. Version 1.0. Newcastle upon Tyne: CKS; 2008. [3] National Collaborating Centre for Mental Health (NCCMH), National Institute for Health and Clinical Excellence (NICE). Obsessive Compulsive Disorder: Core interventions in the treatment of obsessive-compulsive disorder and body dysmorphic disorder. Clinical guideline 31. London: The British Psychological Society (BPS) and The Royal College of Psychiatrists (RCPSYCH); 2005. [5] Baldwin DS, Anderson IM, Nutt DJ. Evidence-based guidelines for the pharmacological treatment of anxiety disorders: recommendations from the British Association for Psychopharmacology. J Psychopharmacol 2005; 19: 567-96. [6] Choi YJ. Efficacy of treatments for patients with obsessive-compulsive disorder: a systematic review. J Am Acad Nurse Pract 2009; 21: 207-13. [7] Ipser JC, Stein DJ, Hawkridge S et al. Pharmacotherapy for anxiety disorders in children and adolescents. Cochrane Database Syst Rev 2009; CD005170.
26 Consider self help group for additional support

Quick info:
Patients and families may benefit from joining a self help group please see OCD action [1,3]. Patients may also get significant benefit from psycho-educational material such as specific self help books based upon cognitive behavioural therapy (CBT) [3]. References: [1] Clinical Knowledge Summaries (CKS). Obsessive-compulsive disorder. Version 1.0. Newcastle upon Tyne: CKS; 2008. [3] National Collaborating Centre for Mental Health (NCCMH), National Institute for Health and Clinical Excellence (NICE). Obsessive Compulsive Disorder: Core interventions in the treatment of obsessive-compulsive disorder and body dysmorphic disorder. Clinical guideline 31. London: The British Psychological Society (BPS) and The Royal College of Psychiatrists (RCPSYCH); 2005.
27 Review first-line therapy

Quick info:
Cognitive behavioural therapy (CBT) should be followed up every month [2]. Response to drug therapy should be reviewed after 12 weeks [5]. References: [2] Koran LM, Hanna GL, Hollander E. Practice guideline for the treatment of patients with obsessive-compulsive disorder. Washington DC: American Psychiatric Association (APA); 2007. [5] Baldwin DS, Anderson IM, Nutt DJ. Evidence-based guidelines for the pharmacological treatment of anxiety disorders: recommendations from the British Association for Psychopharmacology. J Psychopharmacol 2005; 19: 567-96.
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28 Poor response - trial alternative therapies
Quick info:
For patient's who have a poor response to cognitive behavioural therapy (CBT) and drug therapy, consider: increasing dose of selective serotonin re-uptake inhibitor (SSRI) or clomipramine [5]: higher doses of SSRI have been associated with greater efficacy, and also a higher side effect burden [9] consider a different SSRI [5] adding an antipsychotic to the SSRI [3] combining clomipramine and citalopram [3] more intensive CBT or other cognitive therapy [3] Alternative SSRI's and/or antipsychotics may need to be trialled until an appropriate one is found which relieves symptoms [3,5]. References: [3] National Collaborating Centre for Mental Health (NCCMH), National Institute for Health and Clinical Excellence (NICE). Obsessive Compulsive Disorder: Core interventions in the treatment of obsessive-compulsive disorder and body dysmorphic disorder. Clinical guideline 31. London: The British Psychological Society (BPS) and The Royal College of Psychiatrists (RCPSYCH); 2005. [5] Baldwin DS, Anderson IM, Nutt DJ. Evidence-based guidelines for the pharmacological treatment of anxiety disorders: recommendations from the British Association for Psychopharmacology. J Psychopharmacol 2005; 19: 567-96. [9] Bloch MH, McGuire J, Landeros-Weisenberger A et al. Meta-analysis of the dose-response relationship of SSRI in obsessivecompulsive disorder. Mol Psychiatry 2009; [Epub ahead of print].
29 Good response - maintain treatment

Quick info:
If initial 12 week response to therapy has been successful, continuing drug therapy for 12 months is recommended to reduce the risk of relapse [1]. Reference: [1] Clinical Knowledge Summaries (CKS). Obsessive-compulsive disorder. Version 1.0. Newcastle upon Tyne: CKS; 2008.
30 Review
Quick info:
If a patient has taken maintenance medication for 1 year without relapse, and has been fully functioning for 12 weeks, consider need for continued treatment. Factors favouring more prolonged treatment include [3]: longer and more severe illness continuing symptoms greater number of previous relapses co-morbidities poor social support ongoing psychosocial problems Do not stop medications abruptly in order to minimise discontinuation or withdrawal symptoms; taper medications over a few weeks and monitor for relapse [3,5]. Patients, family and carers should be advised that [1]: there is a risk of relapse even after successful treatment and recovery they should seek help as soon as possible if symptoms recur If a patient fails to respond to appropriate interventions, consider [10]: intensive cognitive behavioural therapy (CBT); or cognitive therapy References: [1] Clinical Knowledge Summaries (CKS). Obsessive-compulsive disorder. Version 1.0. Newcastle upon Tyne: CKS; 2008. [3] National Collaborating Centre for Mental Health (NCCMH), National Institute for Health and Clinical Excellence (NICE). Obsessive Compulsive Disorder: Core interventions in the treatment of obsessive-compulsive disorder and body dysmorphic disorder. Clinical guideline 31. London: The British Psychological Society (BPS) and The Royal College of Psychiatrists (RCPSYCH); 2005. [5] Baldwin DS, Anderson IM, Nutt DJ. Evidence-based guidelines for the pharmacological treatment of anxiety disorders: recommendations from the British Association for Psychopharmacology. J Psychopharmacol 2005; 19: 567-96.
Page 12 of 16

[10] Map of Medicine (MoM) Clinical Editorial team, and independent reviewers invited by Map of Medicine. London: MoM; 2010.
31 Consider inpatient treatment

Quick info:
Non-responsive obsessive compulsive disorder (OCD) is defined as a [10]: poor response; or failure to respond to: two or more sets of adequate cognitive behavioural therapy (CBT) two or more trials of selective serotonin reuptake inhibitor (SSRI) medication (at least one should have been augmented with appropriate trials of clomipramine or atypical antipsychotic medication) Consider inpatient services when [3]: there is: risk to life severe self-neglect extreme distress or functional impairment there has been no response to adequate trials of treatment over long periods of time in another setting the patient has additional diagnoses, eg: severe depression anorexia nervosa schizophrenia the patient has a reversal of normal night/day patterns the compulsions and avoidance behaviours are so severe or habitual that they cannot undertake normal activities Reference: [3] National Collaborating Centre for Mental Health (NCCMH), National Institute for Health and Clinical Excellence (NICE). Obsessive Compulsive Disorder: Core interventions in the treatment of obsessive-compulsive disorder and body dysmorphic disorder. Clinical guideline 31. London: The British Psychological Society (BPS) and The Royal College of Psychiatrists (RCPSYCH); 2005. [10] Map of Medicine (MoM) Clinical Editorial team, and independent reviewers invited by Map of Medicine. London: MoM; 2010.
32 Good response - discontinue treatment

Quick info:
If patient has been fully functioning for 12 weeks and is in remission with no clinically significant symptoms, medication may be discontinued [1]. Withdraw the drug gradually over several weeks, monitoring for withdrawal symptoms or relapse [3]. Continue non-drug treatments during drug withdrawal to reduce the risk of relapse [3]. References: [1] Clinical Knowledge Summaries (CKS). Obsessive-compulsive disorder. Version 1.0. Newcastle upon Tyne: CKS; 2008. [3] National Collaborating Centre for Mental Health (NCCMH), National Institute for Health and Clinical Excellence (NICE). Obsessive Compulsive Disorder: Core interventions in the treatment of obsessive-compulsive disorder and body dysmorphic disorder. Clinical guideline 31. London: The British Psychological Society (BPS) and The Royal College of Psychiatrists (RCPSYCH); 2005.
33 Consider referral to specialist treatment service

Quick info:
People with severe, chronic, treatment refractory obsessive compulsive disorder (OCD) should have continuing access to specialist treatment services [3] consider referral to National Commissioning Group Service for treatment resistant OCD [10]. References: [3] National Collaborating Centre for Mental Health (NCCMH), National Institute for Health and Clinical Excellence (NICE). Obsessive Compulsive Disorder: Core interventions in the treatment of obsessive-compulsive disorder and body dysmorphic disorder. Clinical guideline 31. London: The British Psychological Society (BPS) and The Royal College of Psychiatrists (RCPSYCH); 2005. [10] Map of Medicine (MoM) Clinical Editorial team, and independent reviewers invited by Map of Medicine. London: MoM; 2010.
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Page 14 of 16

Key Dates
Published: 29-Jul-2010, by International Valid until: 29-Feb-2012
Accreditations
The care map is accredited by: The Chief Knowledge Officer of the NHS: Disclaimer
Evidence summary for Obsessive compulsive disorder (OCD)

This pathway has been developed according to the Map of Medicine editorial methodology (http://mapofmedicine.com/ whatisthemap/editorialmethodology). The content of this pathway is based on high-quality guidelines [1-3,5,], critically appraised meta-analyses and systematic reviews [4,6-9]. Practice-based knowledge has been added by the Map of Medicines Clinical Editorial Team, and independent reviewers invited by Map of Medicine [10). Search date: Apr-2010
References
This is a list of all the references that have passed critical appraisal for use in the care map Obsessive compulsive disorder (OCD) ID Reference 1 Clinical Knowledge Summaries (CKS). Obsessive-compulsive disorder. Version 1.0. Newcastle upon Tyne: CKS; 2008. http://www.cks.nhs.uk/obsessive_compulsive_disorder#350948001 2 Koran LM, Hanna GL, Hollander E et al. Practice guideline for the treatment of patients with obsessivecompulsive disorder. Washington, DC: American Psychiatric Association (APA); 2007. http://www.psychiatryonline.com/pracGuide/loadGuidelinePdf.aspx?file=OCDPracticeGuidelineFinal0 5-04-07 3 National Collaborating Centre for Mental Health (NCCMH), National Institute for Health and Clinical Excellence (NICE). Core interventions in the treatment of obsessive-compulsive disorder and body dysmorphic disorder. Clinical guideline 31. London: The British Psychological Society (BPS) and The Royal College of Psychiatrists; 2005. http://www.nice.org.uk/nicemedia/pdf/cg031fullguideline.pdf 4 Munoz-Solomando A, Kendall T, Whittington CJ. Cognitive behavioural therapy for children and adolescents. Curr Opin Psychiatry 2008; 21: 332-7. http://www.ncbi.nlm.nih.gov/pubmed/18520736 5 Baldwin DS, Anderson IM, Nutt DJ. Evidence-based guidelines for the pharmacological treatment of anxiety disorders: recommendations from the British Association for Psychopharmacology. J Psychopharmacol 2005; 19: 567-96. http://www.bap.org.uk/pdfs/Anxiety_Disorder_Guidelines.pdf 6 Choi YJ. Efficacy of treatments for patients with obsessive-compulsive disorder: a systematic review. J Am Acad Nurse Pract 2009; 21: 207-13. http://www.ncbi.nlm.nih.gov/pubmed/19366379 7 Ipser JC, Stein DJ, Hawkridge S et al. Pharmacotherapy for anxiety disorders in children and adolescents. Cochrane Database Syst Rev 2009; http://www.ncbi.nlm.nih.gov/pubmed/19588367 8 Jonsson H, Hougaard E. Group cognitive behavioural therapy for obsessive-compulsive disorder: a systematic review and meta-analysis. Acta Psychiatr Scand 2009; 119: 98-106. http://www.ncbi.nlm.nih.gov/pubmed/18822090 9 Bloch MH, McGuire J, Landeros-Weisenberger A et al. Meta-analysis of the dose-response relationship of SSRI in obsessive-compulsive disorder. Mol Psychiatry 2009; [Epub ahead of print]: http://www.ncbi.nlm.nih.gov/pubmed/19468281 10 Map of Medicine (MoM) Clinical Editorial team,and independent reviewers invited by MoM. London: MoM; 2010.
Disclaimers
The Chief Knowledge Officer of the NHS
Page 15 of 16

It is not the function of the Chief Knowledge Officer of the NHS to substitute for the role of the clinician, but to support the clinician in enabling access to know-how and knowledge. Users of the Map of Medicine are therefore urged to use their own professional judgement to ensure that the patient receives the best possible care. Whilst reasonable efforts have been made to ensure the accuracy of the information on this online clinical knowledge resource, we cannot guarantee its correctness or completeness. The information on the Map of Medicine is subject to change and we cannot guarantee that it is up-to-date.
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Obsessive compulsive disorder (OCD)

Information resources for patients and carers

Updates to this pathway

Obsessive compulsive disorder (OCD) clinical presentation

History and examination

Consider differential diagnoses

Diagnosis of obsessive compulsive disorder (OCD)

Severe functional impairment

Moderate functional impairment

Mild functional impairment

Consider urgent referral to Mental Health Team

Intensive CBT or drug therapy

Cognitive behavioural therapy (CBT) and self management

Refer to Mental Health Team

Ineffective - consider referral to Mental Health Team

Effective - continue CBT and follow-up

Ineffective - more intensive CBT or drug therapy

Effective - continue CBT and follow-up

Refer to Mental Health Team

Intensive CBT including exposure and response prevention (ERP)

Consider self help group for additional support

Review first-line therapy

Poor response - trial alternative therapies

Good response maintain treatment

Consider inpatient treatment

Good response discontinue treatment

Consider referral to specialist treatment service

Refer to specialist treatment service

Valid until: 29-Feb-2012 Map of Medicine Ltd All rights reserved

Obsessive compulsive disorder (OCD)

2 Information resources for patients and carers

Valid until: 29-Feb-2012 Map of Medicine Ltd All rights reserved

Obsessive compulsive disorder (OCD)

4 Obsessive compulsive disorder (OCD) - clinical presentation

5 History and examination

Valid until: 29-Feb-2012 Map of Medicine Ltd All rights reserved

Obsessive compulsive disorder (OCD)

6 Consider differential diagnoses

Obsessive compulsive disorder (OCD)

7 Diagnosis of obsessive compulsive disorder (OCD)

8 Severe functional impairment

9 Moderate functional impairment

Valid until: 29-Feb-2012 Map of Medicine Ltd All rights reserved

Obsessive compulsive disorder (OCD)

10 Mild functional impairment

11 Consider urgent referral to Mental Health Team

12 Intensive CBT or drug therapy

Valid until: 29-Feb-2012 Map of Medicine Ltd All rights reserved

Obsessive compulsive disorder (OCD)

13 Cognitive behavioural therapy (CBT) and self management

15 Ineffective - consider referral to Mental Health Team

Valid until: 29-Feb-2012 Map of Medicine Ltd All rights reserved

Obsessive compulsive disorder (OCD)

17 Ineffective - more intensive CBT or drug therapy

Obsessive compulsive disorder (OCD)

18 Effective - continue CBT and follow-up

22 Effective - continue and follow-up