Obsessive-Compulsive Disorder and Body Dysmorphic Disorder

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1 South West London and St George s Mental Health NHS Trust Trustwide Service for Obsessive-Compulsive Disorder and Body Dysmorphic Disorder Springfield University Hospital A Referrer s Guide

2 1 Who we are We are a comprehensive service for Obsessive Compulsive Disorder (OCD)/ Body Dysmorphic Disorder (BDD) and other severe neurotic disorders modelled on NICE Guidance and the stepped-care approach. While we offer outpatient and intensive home-based service for patients with OCD or BDD who have failed all previous treatments (*at Levels 4 or 5), we also offer a stepped approach for people with less severe conditions. We operate on a Hub and Spoke design with therapists based in and accepting referrals from the London boroughs of: Kingston Merton Richmond Sutton Wandsworth The team comprises psychiatrists from training grades to consultant and all of whom have a special interest and training in CBT as well as specialist CBT therapists.

3 2 3 6 Involvement of inpatient care or intensive treatment programme Who the service is for Involvement of MDT with specific expertise Involvement of multidisciplinary care (CMHT) in primary and secondary care Management and initial treatment in general practice We offer graded intervention for patients with OCD/BDD and other severe neurotic disorders. In general we will accept for treatment patients with severe, complex, resistant disorders providing community and home-based interventions. We offer advice of medication and psychopharmacology in addition to Cognitive Behavioural Therapy (CBT). 1 2 Recognition and assessment in primary care and hospital settings Awareness and recognition by individuals and the NHS Stepped care model for OCD/BDD As well as OCD and BDD, we also can provide expert CBT and advice for patients with other neurotic conditions who have not improved on treatment within Community Mental Health Teams. Examples are: severe panic disorders, post-traumatic stress disorder as well as some types of chronic fatigue or certain anxiety disorders. To be considered for treatment in the Trustwide service, patients must be over 18 years and be at Level 5 severity according to NICE guidelines. In general, patients should have had a previous trial of CBT and a trial of medication. We are unable to accept people with: The service for patients of Level 6 severity is funded centrally by the Department of Health and is a separate standalone provision. acute psychosis overwhelming depression anti-social behaviour drug or alcohol dependency current self harming or violent behaviour

4 4 5 In addition, we offer joint assessment and therapy with the local secondary care providers with patients who are proving resistant to treatment and are at Level 4 severity. For example, we will offer joint assessment and advice for mental health care workers in Community Mental Health Teams who have resistant patients who are not responding to usual treatments. We also offer graded input for patients with OCD/BDD at Level 1 through to 4. With limited resource and with 1-3% of the adult population suffering from OCD/BDD, it clearly is unrealistic for us to treat all OCD/BDD patients. However, we are keen to ensure all patients receive optimal treatment for recovery and thus are happy to be involved in a range of different ways. Examples of interventions we have provided and can provide include: Provision of information leaflets for patients and carers about OCD and it s treatment The dedicated web-based learning about OCD which is designed to provide relevant information to GPs and other health care workers dealing with OCD patients Setting up of OCD treatment groups in collaboration with Primary Care Increasing Access to Psychological Therapies (IAPT) services Providing advice on therapy and medication to any health care worker working with OCD patients Providing Clinical Supervision and academic talks to primary and secondary care workers. Our service has been used as an exemplar by NICE, and we featured on the NICE shared-learning websites from

5 6 7 What we offer The service operates a Hub and Spoke model of care with one therapist in each borough: Richmond Kingston Wandsworth OCD/ BCPU BDD Sutton Merton Our standard treatment model involves CBT on a 1:1 basis using graded exposure and self-imposed ritual prevention, alongside minimal medication compatible with health. When indicated, other approaches include cognitive reattribution and psycho-education. The service also endeavours to educate and raise public awareness, working in conjunction with colleagues in Primary Care and Community Mental Health Teams to deliver evidence-based best practice treatment for OCD and BDD. Out-patient or home-based assessment is offered using the bio-social-psychological model. All patients are treated in the community. This may involve out-patient visits to one of the borough-based clinics across the Trust, and possibly home-based treatment if determined by the severity of the symptoms. This can extend to advising members of the patient s family. Generally starting with five sessions, the frequency and duration of therapy are dependent upon the patient s progress. Treatment is tailored to a patient s individual needs, ranging from a 30-minute review to a six-hour exposure session.

6 8 9 Clinical outcomes 30 Clinical outcome with 92 OCD patients of Level 5 severity Sample 41 men (45%) and 51 women (55%) 74% unmarried 43% unemployed Average age 38 years (range years, SD = 13) Average duration of OCD (19 years, SD = 9) Measure Before Mid After Statistical Treatment Treatment Treatment Significance (12 weeks) 0 Before treatment After 12 weeks treatment After 24 weeks treatment YBOCS < BDI < YBOCS Yale Brown Obsessive Compulsive Scale which measures severity of OCD, with 0 being a normal score and a maximum of 40 (therapist rated) BDI Beck Depression Inventory which measures severity of depressive symptoms with under 10 being normal and a maximum of 63 (patient rated) Overall this represents: a 44% reduction in OCD symptomatology at 24 weeks measured by YBOCS (n = 92) a 41% reduction in Depressive symptomatology at 24 weeks measured by BDI (n = 92)

7 10 11 Case Vignette Referrals Miss Z was a 57 year old health care worker with a 43 year history of OCD. She had managed to work for much of her life but had been subject to multiple grievance procedures by employers and was currently registered disabled. Over the previous five years she had not worked but stayed at home alone. Before treatment getting up and dressed took her five to six hours and showering could take up to three hours. For these reasons she restricted her trips outside to once a week to do her shopping and would shower weekly. Following 24 hours of specialised therapy she now goes out daily after having a shower. She has started in a new voluntary job and has managed to travel abroad for a holiday, which she had been unable to do for the last ten years. Referrals are welcomed from primary care and from secondary mental health services across the five boroughs. Having completed the unit s referral form, which can be supplied on request, the referral should be directed to the Borough Therapist in person. Referrers are expected to identify clearly a patient s current problems and relevant history, with copies of recent CPA and risk assessment documentation. The CPA process is normally managed by the referring Mental Health team. The patient s care co-ordinator should be named, together with details of any ongoing involvement. Mental Health teams may also seek telephone consultation.

8 12 Contact details Trustwide Service for OCD and BDD Building 15 (Teak Tower) Springfield University Hospital 61 Glenburnie Road London SW17 7DJ Tel: Fax: Switchboard tel: Specialist Services Directorate tel: How to find us The nearest tube station to Springfield Hospital is Tooting Bec (Northern Line), a minute walk. Bus G1 serves Springfield Hospital itself. On nearby Trinity Road there are buses 219 and 319. On Upper Tooting Road there are buses 57, 155, 219 and 355. On Tooting Bec Road there are buses 249 and 319. Design from The Drawing Room Photography by Paul Lapsley Revise Feb 2012