Treatment

Assessment first; then three modalities, chosen and combined to suit you

Every effective treatment for OCD works on the same thing. Decades of imaging and neurosurgical research have traced obsessions and compulsions to over-activity in a loop connecting the frontal cortex, the striatum and the thalamus. Serotonergic medication dampens it; exposure-based therapy re-trains it; deep brain stimulation and other neuromodulation reset it directly. Understanding this is what lets me use the three modalities together rather than in sequence, and what allows me to say, when one has failed, what should reasonably come next.

Assessment: Every course of treatment I offer begins with a full assessment, usually over one extended consultation: the history of your illness and of every treatment tried (how long, at what dose or intensity, and with what result); screening for the conditions that commonly accompany OCD and change how it should be treated; your physical and neurological health, with investigations where indicated; and standardised severity measures so that progress can be tracked objectively. You receive a written opinion, which with your consent I share with your GP and anyone already treating you.
I. Medication: I manage medication for OCD, tics and complex comorbidities, including augmentation strategies for treatment-resistant illness, drawing on more than twenty-five years of clinical practice in tertiary settings.
II. Exposure-based cognitive behavioural therapy: I deliver specialist CBT as a medical psychotherapist with a CCT in the modality: exposure and response prevention (ERP) for OCD and related disorders, and habit reversal training for tics, Tourette syndrome and body-focused repetitive behaviours.
III. Neuroscience-based treatments: I assess and advise on neuromodulation for severe, treatment-refractory OCD, including deep brain stimulation, drawing on my leadership of the UK's first DBS-for-OCD trial and my ongoing research into the brain circuits of OCD.
Intensity and pathways: Complex OCD often needs more than weekly outpatient sessions. Depending on severity, I may intensify treatment (more frequent or home-based exposure work, or therapy that I direct and a therapist experienced in the particular comorbidity delivers), and where an outpatient practice is not enough, I help you reach the services that are: the nationally commissioned intensive and inpatient OCD services, my NHS Tourette syndrome and OCD clinic at Queen Square, and the multidisciplinary neuromodulation pathway at the National Hospital. I provide second opinions to GPs, psychiatrists and therapists already involved in a patient's care.

A first course of treatment

For most people the first course runs to a four-month plan, with medication and exposure-based therapy started together and a clear decision point at the end.

Month 1Diagnosis and preparation. We start medication, and exposure-based CBT begins with psychoeducation and planning: agreeing what will be faced, and in what order.

Month 2Medication is maintained and side-effects managed. Therapy targets avoidance and safety behaviours, the habits that keep the illness going.

Month 3I monitor your response with standardised measures, looking for evidence of habituation: the feared situations provoke less, and for a shorter time.

Month 4We establish whether you have responded and work on generalising the gains. Then a decision: consolidate and plan for relapse prevention, or step up in dose, intensity or augmentation, or refer onward.

Serotonergic medication for OCD is used at higher doses than for depression and needs ten to twelve weeks at a therapeutic dose before it can be judged; exposure-based CBT typically takes twelve to twenty sessions, and the combination is more effective than either alone. Around half of people respond well to a first course; those who do not are exactly the people my practice exists for.

I will discuss any treatment I recommend with you in full, including its expected benefits, risks and alternatives, so that you can make an informed decision. Treatment is tailored to each patient; no single approach suits everyone.