OCD Alongside a Neurological Condition
The brain does not respect the boundary between neurology and psychiatry. Nor do I
Obsessions and compulsions can appear for the first time after a stroke, a head injury or an encephalitis; they occur in Parkinson's disease, in Huntington's disease, in epilepsy and in the movement disorders; and long-standing OCD can be transformed by a neurological illness arriving on top of it. These patients fall between two specialties. Neurologists see the lesion and not the ritual; psychiatrists see the ritual and not the lesion. I have spent my career at the National Hospital for Neurology and Neurosurgery, the oldest neurological hospital in the world, working across that line, for seven years as consultant psychiatrist to its neurorehabilitation unit, and now within its unit of functional neurosurgery.
- Why it matters
- OCD is a circuit disorder: over-activity in a loop connecting the frontal cortex, the striatum and the thalamus. A neurological illness that damages or disturbs that loop, in the basal ganglia particularly, can produce OCD, worsen it, or change how it responds to treatment. Medication that suits one condition may worsen the other; exposure therapy may need to be adapted to cognitive impairment, fatigue or physical limitation. Getting the neurology right is the first step in getting the psychiatry right.
- What I assess
- The timeline: which came first, and what changed when. The neurology: imaging, investigations and the opinions of the neurological team, which I read and, where needed, add to. The phenomenology: whether the repetitive behaviour is a compulsion, a tic, a stereotypy, a perseveration or a habit, each has a different cause and a different treatment. And the whole person: mood, cognition, sleep, pain and the effects of existing medication.
- How I work
- Closely with neurologists, neurosurgeons and neuropsychologists, in the setting where those colleagues are down the corridor. Treatment draws on the same three modalities as for any OCD, medication, exposure-based therapy and neuromodulation, chosen with the neurological condition in view. I also provide neuropsychiatric opinions for neurological and rehabilitation teams elsewhere who suspect OCD in their patients.
- Referral
- GPs, neurologists and rehabilitation services can refer to my NHS clinic at Queen Square; private assessment is available at Queen Square Private Consulting Rooms, in person or by video.
To arrange an assessment
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