Guided self help for Guided self help for Obsessive Compulsive Obsessive Compulsive

DisorderDisorderProfessor Karina LovellProfessor Karina Lovell

Aims of the workshopAims of the workshop What is guided self help?What is guided self help? Does guided self help work in OCD?Does guided self help work in OCD? How is guided self help applied with How is guided self help applied with

someone with OCDsomeone with OCD

Obsessive compulsive disorderObsessive compulsive disorder OCD is a major disorder and under recognized OCD is a major disorder and under recognized

public health problem. public health problem. Obsessive-compulsive disorder can occur at any Obsessive-compulsive disorder can occur at any

age but most often presents for the first time in age but most often presents for the first time in adolescence adolescence

Lifetime prevalence (1.9-3.0%)Lifetime prevalence (1.9-3.0%) There is evidence that without adequate There is evidence that without adequate

treatment the disorder tends to have a chronic treatment the disorder tends to have a chronic fluctuating coursefluctuating course

ObsessionsObsessionsObsessionsObsessions are repetitive, recurring thoughts, are repetitive, recurring thoughts,

ideas, images or impulses that are ideas, images or impulses that are experienced as intrusive and are usually experienced as intrusive and are usually distressing or anxiety provoking. Such distressing or anxiety provoking. Such thoughts are often centered on dirt and thoughts are often centered on dirt and contamination, accidental harm, illness, contamination, accidental harm, illness, aggression, sex, orderliness and perfection.aggression, sex, orderliness and perfection.

CompulsionsCompulsionsCompulsions: Compulsions: (rituals) are repetitive and (rituals) are repetitive and

intentional acts and serve to reduce anxiety intentional acts and serve to reduce anxiety the thoughts provoke. The person the thoughts provoke. The person recognizes that their behavior is excessive or recognizes that their behavior is excessive or unreasonable.unreasonable.

Obsessions and compulsionsObsessions and compulsions

ObsessionsObsessions Bodily fluidsBodily fluids AsbestosAsbestos Unspecified germsUnspecified germs Disease specificDisease specific Radiation Radiation Animal specificAnimal specific

CompulsionsCompulsions Washing excessivelyWashing excessively AvoidanceAvoidance ReassuranceReassurance Magical numbersMagical numbers

What is guided self helpWhat is guided self help A self-administered interventionA self-administered intervention Involves a health technology (book, Involves a health technology (book,

computer, audio tape)computer, audio tape) Facilitated by a health professionalFacilitated by a health professional Role of facilitator is to guide, support, Role of facilitator is to guide, support,

review and monitorreview and monitor

What is guided self helpWhat is guided self help GSH is one of many interventions deemed GSH is one of many interventions deemed

a low intensity interventiona low intensity intervention Others include, telephone, computer Others include, telephone, computer

delivered, groups and internet delivery.delivered, groups and internet delivery.

Rationale for alternative Rationale for alternative delivery systemsdelivery systems

Does not meet policy recommendationsDoes not meet policy recommendations Lack of therapist’sLack of therapist’s Traditional service deliveryTraditional service delivery Poor accessPoor access High waiting listsHigh waiting lists

Stepped-care modelStepped-care model The model provides a framework in which to organise the The model provides a framework in which to organise the

provision of services in order to identify and access the provision of services in order to identify and access the most effective interventionsmost effective interventions

Stepped care attempts to provide the most effective but Stepped care attempts to provide the most effective but least intrusive treatments appropriate to a person’s needsleast intrusive treatments appropriate to a person’s needs

The recommendations in the NICE guidance are The recommendations in the NICE guidance are structured around thestructured around the stepped-care modelstepped-care model

STEP 6 Inpatient care or intensive treatment programmes. CAMHS Tier 4

STEP 5 Multidisciplinary teams with specific expertise in management of OCD. CAMHS Tiers 3 and 4

STEP 4 Multidisciplinary care in primary or secondary care.CAMHS Tiers 2 and 3

STEP 3 GPs and primary care team, primary care mental health worker, family support team. CAMHS Tiers 1 and 2

STEP 2 GPs, practice nurses, school health advisors, general health settings. CAMHS Tier 1

STEP 1 Individuals, public organisations, NHS

STEPPED CARE MODEL

Treatment options for adults with OCD

Mild functional Moderate functional Severe functional impairment impairment impairment

Brief CBT (+ERP)< 10 therapist hours

(individual or groupformats)

Offer choice of:more intensive CBT

(+ERP)>10 therapist hours

orcourse of an SSRI

Patient cannot engage in/CBT (+ERP) is inadequate

Offer combinedtreatment ofCBT (+ERP)and an SSRI

Inadequate response at 12 weeks

Multidisciplinary review

Low intensity interventions - Low intensity interventions - definitiondefinition

Less than 10 hours of therapist time Less than 10 hours of therapist time per patientper patient

CBT includes exposure and response CBT includes exposure and response prevention (ERP)prevention (ERP)

The intensity of the intervention is The intensity of the intervention is dependent upon the degree of dependent upon the degree of functional impairment and patient functional impairment and patient preferencepreference

Low intensity interventionsLow intensity interventions

Brief individual CBT (including ERP) using Brief individual CBT (including ERP) using structured self help structured self help

Brief individual CBT (including ERP) by Brief individual CBT (including ERP) by telephonetelephone

Group CBT (including ERP)Group CBT (including ERP)

Recommendations identified Recommendations identified as key prioritiesas key priorities

All people with OCD should have All people with OCD should have access to evidence-based treatments: access to evidence-based treatments: CBT including exposure and response CBT including exposure and response prevention (ERP) and/or pharmacologyprevention (ERP) and/or pharmacology

But, limited availability of CBTBut, limited availability of CBT TherapistsTherapists Waiting timesWaiting times AccessAccess

Recommendations identified Recommendations identified as key prioritiesas key priorities

CBT (including ERP) should be CBT (including ERP) should be offered in a variety of formatsoffered in a variety of formats

Treatment programmes for formats Treatment programmes for formats other than standard individual CBT other than standard individual CBT exist but have not been widely exist but have not been widely disseminated (including guided self disseminated (including guided self help, telephone and groups)help, telephone and groups)

Small group workSmall group work In small groups discuss your views on the In small groups discuss your views on the

stepped care model recommended by the stepped care model recommended by the NICE guidelines and the advantages and NICE guidelines and the advantages and disadvantages of guided self help.disadvantages of guided self help.

Low intensity treatments – self-Low intensity treatments – self-help materials with minimal help materials with minimal

therapist contact - The Evidencetherapist contact - The Evidence Fritzler et al (1997) found that a third of Fritzler et al (1997) found that a third of

people with OCD made clinically significant people with OCD made clinically significant improvement with a CBT based self-help improvement with a CBT based self-help manual and minimal therapist contactmanual and minimal therapist contact

Lovell (2005) uncontrolled study found self Lovell (2005) uncontrolled study found self help manuals and minimal therapist contact help manuals and minimal therapist contact with people with OCD promisingwith people with OCD promising

Low intensity treatments: Low intensity treatments: The EvidenceThe Evidence

Lovell (2000) pilot study (CBT)Lovell (2000) pilot study (CBT) Taylor (2003) open study ( CBT with self help Taylor (2003) open study ( CBT with self help

book)book) Griest (2002) RCT ( CBT- computer Griest (2002) RCT ( CBT- computer

accessed by telephone and work book)accessed by telephone and work book) Lovell (2005) RCT compared CBT by Lovell (2005) RCT compared CBT by

telephone or face to face with adults with telephone or face to face with adults with OCDOCD

Meta-analysis of treatment intensity for Meta-analysis of treatment intensity for CBTCBT

Grouping Therapist hours/patient into bands

Treatment intensityTreatment intensity Study Study armsarms

NN SMDSMD CICI

Low (<10 hrs)Low (<10 hrs) 1111 261261 .93.93 0.75 - 1.110.75 - 1.11

Medium (10-30)Medium (10-30) 2222 461461 1.441.44 1.29 - 1.591.29 - 1.59

High (> 30)High (> 30) 1010 157157 1.651.65 1.38 - 1.911.38 - 1.91

Medium, High > Low Low works, medium and high work better

Self help materialsSelf help materials Wagner A. Wagner A. Up and down the worry hill: a children's book about obsessive Up and down the worry hill: a children's book about obsessive

compulsive disorder and its treatmentcompulsive disorder and its treatment. New York: Lighthouse Press, 2002—An . New York: Lighthouse Press, 2002—An illustrated book designed to help parents and professionals to explain obsessive-illustrated book designed to help parents and professionals to explain obsessive-compulsive disorder to younger children through the story of "Casey," a young compulsive disorder to younger children through the story of "Casey," a young boy with the disorder boy with the disorder

Wever C, Phillips N. Wever C, Phillips N. The secret problemThe secret problem. Sydney: Shrink-Rap Press, 1996—A . Sydney: Shrink-Rap Press, 1996—A cartoon book that describes obsessive-compulsive disorder in clear and simple cartoon book that describes obsessive-compulsive disorder in clear and simple language to help children, teenagers, and parents to understand it and its language to help children, teenagers, and parents to understand it and its treatment treatment

Hyman B, Pedrick C. Hyman B, Pedrick C. The OCD workbook: your guide to breaking free from The OCD workbook: your guide to breaking free from obsessive-compulsive disorderobsessive-compulsive disorder. Oakland, CA: New Harbinger Publications, 2005. Oakland, CA: New Harbinger Publications, 2005—A self help manual for adults and older adolescents, which guides the patient —A self help manual for adults and older adolescents, which guides the patient through exposure with response prevention; includes advice for family members through exposure with response prevention; includes advice for family members

Veale D, Willson R. Veale D, Willson R. Overcoming obsessive compulsive disorderOvercoming obsessive compulsive disorder. London: . London: Constable & Robinson, 2005—A self help book suitable for adults and older Constable & Robinson, 2005—A self help book suitable for adults and older teenagers teenagers

Lovell, KOCD self help manual (available on request)Lovell, KOCD self help manual (available on request) Schwartz JM. Schwartz JM. Brain lock: free yourself from obsessive compulsive behaviourBrain lock: free yourself from obsessive compulsive behaviour. .

New York: Harper Collins, 1997—A self treatment manual suitable for adults and New York: Harper Collins, 1997—A self treatment manual suitable for adults and older adolescentsolder adolescents

Application: self-help with Application: self-help with minimal therapist contactminimal therapist contact

Patient centred assessmentPatient centred assessment Involvement of families Involvement of families Self help materials (which ones?)Self help materials (which ones?) Ongoing monitoring (process and outcome Ongoing monitoring (process and outcome

measures)measures) Collaborative workingCollaborative working Includes exposure and response Includes exposure and response

preventionprevention 20-40 minute sessions20-40 minute sessions

Small group workSmall group work Discuss the self help resources that you Discuss the self help resources that you

have used and would recommend?have used and would recommend? Identify a spokesperson to feed back to Identify a spokesperson to feed back to

the larger groupthe larger group

QuestionsQuestions

Thank you for listeningThank you for listening

Karina.Lovell@manchester.ac.ukKarina.Lovell@manchester.ac.uk