Advances in psychiatric treatment (2009), vol. 15, 332–343 doi: 10.1192/apt.bp.107.004705

ARTICLE Risk assessment and management in obsessive–compulsive disorder David Veale, Mark Freeston, Georgina Krebs, Isobel Heyman & Paul Salkovskis

David Veale is an honorary harm to children may be tempted to play for safety SUMMARY senior lecturer and a consultant when conducting a risk assessment. However, a psychiatrist in cognitive behaviour Some people with obsessive–compulsive disorder person with OCD can be harmed by an incorrect or therapy at the NIHR Biomedical (OCD) experience recurrent intrusive sexual, Research Centre for Mental Health, unduly lengthy risk assessment, responding with aggressive or death-related thoughts and as a The South London and Maudsley increased doubts and fears about the implications result may be subjected to lengthy or inappropriate NHS Foundation Trust, King’s of their intrusive thoughts. At best this will lead College London, and The Priory risk assessments. These apparent ‘primary’ risks Hospital North London. Mark can be dealt with relatively easily through a careful to greater distress, avoidance and compulsive Freeston is Professor of Clinical understanding of the disorder’s phenomenology. behaviours, and mistrust of health professionals; Psychology at Newcastle University, However, there are other, less obvious ‘secondary’ at worst, to complete decompensation of the patient Newcastle upon Tyne. Georgina risks, which require more careful consideration. or break-up of the family. In reality, there is no need Krebs is a clinical psychologist working in the service for young This article discusses the differentiation of intrusive for overcautious reactions. Provided the clinician people with obsessive–compulsive thoughts and urges in people with OCD from has appropriate expertise in OCD, there are very disorder at the Maudsley Hospital, those experienced by sexual or violent offenders; rarely any serious doubts about the diagnosis. London. Isobel Heyman is an assessing the risk of self-harm and suicide; dis- Another recommendation of the NICE guidelines honorary senior lecturer at the cussing the nature of repugnant obsessions with a (National Collaborating Centre for Mental Health Institute of Psychiatry, King’s patient; assessing risk of harm and violence to the College London, and a consultant 2005: pp. 14–15) is: child and adolescent psychiatrist dependents and family living with someone with the working in the service for young disorder; and assessing the lack of insight and the In people who have been diagnosed with OCD, people with obsessive–compulsive use of the Mental Health Act. Issues specifically healthcare professionals should assess the risk disorder at the Maudsley Hospital, related to children and young people with OCD are of self-harm and suicide, especially if they have also been diagnosed with depression. Part of the London. Paul Salkovskis is also highlighted. Professor of Clinical Psychology risk assessment should include the impact of their and Applied Science at the Institute DECLARATION OF INTEREST compulsive behaviours on themselves or others. of Psychiatry and Clinical Director None. This article therefore discusses assessing the of the Maudsley Hospital Centre for Anxiety Disorders and Trauma. risk of harm to self and others from compulsions Correspondence Dr David Veale, and comorbidity, risk in therapy, poor insight and Centre for Anxiety Disorders and One of the recommendations of the National use of the Mental Health Act. Trauma, Maudsley Hospital, 99 Institute for Health and Clinical Excellence (NICE) Denmark Hill, London SE5 8AF, UK. (National Collaborating Centre for Mental Health Email: [email protected] Phenomenology of obsessions and 2005: p. 15) guidelines on obsessive–compulsive compulsions disorder (OCD) is: Risk assessment in OCD requires that the clinician If healthcare professionals are uncertain about the has a good working knowledge of the phenomenol- risks associated with intrusive sexual, aggressive or ogy of the disorder. Obsessions are unwanted death-related thoughts reported by people with OCD, they should consult mental health professionals with intrusive thoughts, doubts, images or impulses specific expertise in the assessment and management that repeatedly enter the mind (‘intrusions’). They of OCD. These themes are common in people with are distressing and ego-dystonic, but are acknowl- OCD at any age, and are often misinterpreted as edged by the patient as unreasonable or excessive. indicating risk. A minority have overvalued ideas, which can Our article discusses issues to be considered lead to confusion with psychosis (Veale 2002). when conducting a risk assessment in a person Compulsions are repetitive behaviours or mental with intrusive sexual, aggressive or death-related acts that the person feels driven to perform. They thoughts and contrasts the phenomenology of such can either be overt and observed by others (e.g. thoughts in OCD with that of similar thoughts in checking that a door is locked) or covert mental acts people who are at risk of sexual or violent offending that cannot be observed (e.g. mentally repeating a or self-harm. It discusses the initial management of certain phrase). repugnant obsessions and pitfalls that may occur. Intrusive thoughts, doubts or images are almost Professionals presented with an individual universal in the general population and their con- describing thoughts of violence, suicide or causing tent is indistinguishable from clinical obsessions

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(Rachman 1978). By definition, such intrusions oc- and in children growth retardation and arrested cur outside the volition of the person experiencing pubertal development. Another example may be them, and tend to interrupt other mental activity harm from overexposure to disinfectant following because they are inconsistent with the person’s from a compulsion to clean. By analogy, this is like usual value system. Examples of normal intrusive someone with a phobia of wasps who drives off the thoughts include the image of touching the geni- road when they realise that there is a wasp in the talia of a child, worry (in the absence of any evi- car. Secondary risks also occur from compulsive dence) as to whether one had caused an accident on hoarding,† when a house may become unsanitary, †See Lopez Gaston et al: Hoarding the way home, urges or impulses to attack a loved damp or a fire risk as a result of the behaviour. behaviour: building up the ‘R factor’. pp. 344–53, this issue. Ed. one with a kitchen knife, or thoughts and images More commonly, irreversible harm may occur in of jumping onto a railway track in front of an on- young people whose OCD is severe during critical coming train. Because these types of intrusion can phases of development. For example, withdrawal and do feature in OCD, the difference between nor- from school and social interactions because of mal intrusive thoughts and obsessional thoughts severe OCD can lead to significant deficits in lies not in the content itself but in the appraisals cognitive and social development. Individuals that individuals with the disorder attach to the oc- may fail to develop autonomy in key areas owing currence or content of the intrusions (Salkovskis to their inability to carry out normal routines and 1985, 2008; Rachman 1997). These appraisals and their dependence on others. All people with the the compulsions that they motivate are thought to disorder find that symptoms frequently interfere determine why intrusions are more frequent and significantly with life opportunities, with some distressing in OCD. chances lost irretrievably. Where compulsions are concerned, urges that Risks in OCD are themselves obsessions need to be distinguished The phenomenology of OCD should lead us to con- from urges arising as responses to obsessions. sider two types of risk (Key points 1). The first – Once this is done, the risks are relatively obvious. primary risk – is only apparent and arises directly Thus, if someone has an obsessional fear of cutting from an obsession. The risk is that the patient will themselves, you can be very certain that they will not act on an obsession (e.g. suicide or sexual acts with harm themselves. However, if the idea of harming a child) or impulsively act out an obsessional fear. others is the obsession, they might respond by At its simplest, this need never be a concern: there cutting themselves rather than harming someone are no recorded cases of a person with OCD carry- they love. Secondary risks are often subtle. For ing out their obsession. By definition, such intru- example, a parent who is constantly preoccupied sions are unacceptable and ego-dystonic, and the with their obsessions may become less responsive person is no more likely to act on their intrusions and emotionally available to their children. than a person with height phobia is to jump off We will now apply these general principles to the a tall building. The obsession represents a type assessment of specific concerns, first where there of fear or worry that the patient does not want to are intrusive sexual thoughts and then in the case happen; like all fears or worries, it concerns ideas of violent thoughts. that the patient wishes to avert at all costs. Of much greater concern is secondary risk – the Assessing intrusive sexual thoughts unintended consequence of acting on compulsions An assessment in OCD primarily involves clearly and urges to avoid anxiety-provoking situations. formulating the problems the patient is experiencing There can be significant secondary risk associated rather than seeking to ‘rule out’ forensic and sex- with OCD. For example, a person with contamination offending factors. Gordon & Grubin (2004) have fears in relation to eating and drinking may described how to assess risk in sexual offenders severely restrict food and fluid intake, leading and Marshall & Langton (2005) discuss the in some cases to dehydration, malnourishment, nature of sexual thoughts in sexual offenders. Box 1 outlines factors that might distinguish between sexual thoughts in OCD and in potential sexual KEY POINTS 1 Risk in OCD offending. These are discussed in more detail

K Primary risk Risk arising directly from an below. obsession People who have OCD might worry about their intrusive sexual thoughts, images or impulsive
K Secondary risk Unintended consequences of acting on compulsions and urges to avoid urges, which are experienced as ego-dystonic anxiety-provoking situations and repugnant to the individual. They may be experiencing:

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Is the intrusive thought or image ego-dystonic? BOX 1 OCD or potential sexual offender? In adults with OCD, intrusive sexual thoughts are Various factors differentiate the intrusive sexual thoughts ego-dystonic, i.e. they are entirely repugnant. They of people with OCD from those of sexual offenders are totally at odds with the values of the individual
K Ego-dystonicity of the thoughts and there is no aspect of them that is attractive or

K Failure to act on or masturbate to the thoughts sexually stimulating (but see the section on sexual arousal below). Thus, someone with OCD with
K Avoidance of trigger situations intrusive thoughts about having sex with children
K Efforts to suppress the thoughts is likely to be extremely caring towards children.
K Very frequent or constant occurrence of the thoughts They are likely to: (a) already be a parent and/or
K Dominant anxiety, distress and guilt about the thoughts working with children (or would very much like
K Overdisclosure of irrelevant past sexual history to be so involved in the future); and (b) evaluate

K Wanting help and seeking referral to mental health themselves as ‘bad’ for having such thoughts. services Ego-dystonicity in young people, however, can be especially difficult to assess, as they are
K Presence of additional obsessive–compulsive symptoms often still in the process of sexual development and maturation. They may therefore feel very confused as to whether a sexual thought is
K a doubt that they might have acted upon such wanted or unwanted, permitted or deviant. It is urges in the past (usually leading to a compulsion not uncommon for young people to have sexual of mental reviewing of past actions); obsessions involving children, parents, siblings,
K a worry that they may act upon such urges animals or objects, which may be very confusing in the future (usually leading to avoidance of and distressing. In children with OCD, especially situations that are regarded as risky, together the younger ones, there may be more difficulty in with repeated reassurance seeking); in a young eliciting ego-dystonicity (Geller 2006). The young person with little or no sexual experience, such child may lack the cognitive maturity to identify worries may be especially intense in relation to thoughts as unwanted, may think it is ‘weird’ to sexual orientation; say so, or may feel that if they admit to wishing
K a worry that they may be wrongly accused of they did not have symptoms, they may be asked to acting on such urges (usually associated with stop ritualising, which they fear would be difficult not disclosing details or repeated seeking of and anxiety-provoking. So it is important to note reassurance); that the absence of ego-dystonicity or insight does
K an evaluation that they are a bad person for not exclude the diagnosis of OCD, especially in a having such thoughts and images (usually child or adolescent. By contrast, a paedophile is leading to attempts to control, remove, or atone likely to regard sexual thoughts as ego-syntonic: for the thought). to be more ambivalent about having such thoughts The difficulties in identifying intrusive thoughts and to find them attractive at least some of the as being related to OCD usually occur when the time or to be cautious about revealing their true assessor lacks experience with the disorder. feelings. This is especially the case when people report thoughts and worries about acting on sexual or Is the current behaviour consistent with the intrusive violent urges. Problems may arise for occupational thoughts and images? health staff when assessing people with OCD who People with OCD neither act on their intrusive work with children and report intrusive sexual sexual thoughts nor fantasise or masturbate about thoughts. Problems can also arise because either them. They may, however, experience the unwanted the patient or assessor seeks reassurance in ways intrusions when they masturbate to an adult that increase doubt or anxiety in both parties (e.g. fantasy or have sex, and become confused as to ‘Are you 100% confident that these are obsessional whether the thoughts are ego-dystonic or whether thoughts rather than something else?’). This they wanted to have them. Very rarely, people with represents a transmission of obsessional worries OCD might appear to act once on their obsessional from the patient to the clinician. urge but in a way that is not significantly harmful. We highlight below the most common issues Thus, a man with OCD said he once accessed child in assessing intrusive sexual thoughts about pornography to check whether he was aroused by children. It is to be noted that no single difference it but typically reacted with repugnance. A woman is sufficient to make a differential judgement; the with OCD described how she once touched her overall pattern of differences is what counts. baby daughter’s genitalia to check whether she

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would insert her finger. Men with OCD may very being caught. They are more likely to experience rarely masturbate to an adult fantasy before going pleasure from the thoughts, although some may into situations where they may be in contact with also feel guilty or remorseful early in their ‘career’ a child with the goal of reducing the likelihood of if they have acted on the thoughts in any way. sexual arousal while there. Sexual offenders are more likely to use sadomasochistic or paedophilic Does the person experience sexual arousal with pornography regularly for pleasure. intrusive thoughts? Self-reported sexual arousal is an unreliable Does the person try to avoid situations or activities indicator of sexual interest. Someone with OCD that trigger the intrusive sexual thoughts and images? may be especially sensitive and may consequently People with sexual obsessions that involve children overreport arousal (Warwick 1990). They may typically avoid being alone or near young people. monitor and check the state of arousal in their Avoidance behaviour may be quite subtle, particu- genitalia. However, selective attention and larly in children and adolescents, where parents feedback on the degree of arousal may increase or other authority figures may prevent gross both blood flow and level of arousal. In addition, avoidance. For example, the teenager with a sexual the experience of anxiety may be confused with obsession about younger children may attend sexual arousal. As far we are aware, phallometric school, but avoid looking at younger children and evidence of response to sexual stimuli has not been wait to catch a later bus after the younger children conducted in OCD, nor should it. However, it has have gone home. A paedophile is more likely to been shown that anxiety increases phallometric consciously seek out places where children play or indices in normal men. Many clinicians believe find opportunities to be alone with them. the opposite to be true, leading them to doubt whether or not a patient with an obsession has an Does the person attempt to suppress, neutralise or anxiety disorder when they report physical signs distract themselves from intrusive sexual thoughts? of arousal; some male patients show clear signs of Individuals with OCD are more likely to try to physical arousal in obsessional situations – this is avoid, neutralise or suppress repugnant thoughts. not an indication of sexual interest, but of anxiety They may sometimes examine them in detail to (Warwick 1990). check whether they truly find them repulsive. A potential paedophile may sometimes try to Is there comorbidity? suppress or avoid intrusive thoughts but is more Comorbidity with Axis I or II disorders may be likely to engage with them. present in both OCD and sexual offenders. However, the issue becomes complex when a person with How frequent are the intrusive thoughts and images? OCD (in one domain such as contamination) is, People with OCD are likely to experience frequent for example, sexually immature and might have intrusive thoughts that may dominate their mental paedophilic sexual fantasies (a different domain). life as they constantly monitor their thoughts for Thus, an understanding of the psychopathology is signs of danger and then try to suppress them. crucial as in such an individual the sexual thoughts A person at risk of paedophilia is likely to have are not ego-dystonic. intrusive thoughts that are less frequent and which are more likely to be cued by specific triggers such Does the person easily disclose material? as childcare activities. Some sexual offenders People with OCD are usually extremely ashamed experience intrusive thoughts only when they are of their intrusive thoughts and often do not reveal intoxicated. When the thoughts are frequent then the details (equally, a paedophile may not reveal a paedophile is more likely to be elaborating them the details of their thoughts because of their fear in detailed fantasies. of being caught). An interview with someone with OCD therefore needs to be sensitively handled. What is the dominant emotion? If an individual is unable to disclose the details People with OCD seek help because they are of their intrusions, then the interviewer might extremely anxious and distressed by thoughts, offer a multiple choice answer (e.g. ‘I myself have images or urges. They will feel guilty simply had and talked to a lot of patients with intrusive because they have the thoughts even though thoughts or images that concern, for example, they do not experience any pleasure from them. rape, homosexuality, sex with children, sex with a A potential paedophile or violent offender is less parent or an animal, or some thought or image that likely to be distressed by such thoughts or the I find personally unacceptable. Do you experience distress is understood by the motivation to avoid any intrusive thoughts like these?’).

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Another problem in OCD is the overdisclosure Is there a history of sexual abuse, or of accidental or of an irrelevant past sexual history and a search deliberate exposure to sexually explicit material? for past peccadilloes (e.g. reporting that as an There are obvious risks to missing a history of adolescent they once looked through a window sexual abuse in a distressed child, but equally there with a pair of binoculars to view a woman are risks to incorrectly assuming that a child or undress ing) in an effort to find evidence that adolescent with intrusive sexual thoughts has been they may be a sexual offender. Individuals may abused, when in fact they have OCD alone. Thus, also be excessively concerned about their own some children with OCD have compulsions that exploratory sexual behaviour with peers during involve their genitals, such as excessive washing, childhood or adolescence. They may report events repeated touching or checking behaviours. In most where they think they may have become aroused cases, however, these thoughts and behaviours are inappropriately. Overreporting may be a way of part of the disorder, not signs of sexual abuse, and reassurance-seeking or neutralising anxiety. excessive questioning or investigations for child Occasionally, children and adolescents with sexual abuse can do significant harm. comorbid behavioural disorders disclose their Although sexual abuse must always be consid- obsessions in quite an aggressive and intrusive way ered in a child with sexual preoccupations and/or to provoke distress in others. behaviours, the authors of one case series they felt A paedophile is less likely to reveal information confident in excluding sexual abuse (Healy 1991). but more likely to have a history of exploitation or None of the children had disclosed abuse, nor abuse of others, or of sexual offences. did they show affective change when discussing this possibility or seem burdened by a ‘secret’. In What is the motivation to seek help? addition, family relationships were good, unlike People with OCD are motivated to seek help those commonly seen with intrafamilial abuse, because they regard their intrusive thoughts or and symptoms improved quickly when the children images as repugnant and they are fearful of acting received appropriate treatment for obsessions. on them. They are extremely worried about the In another case series, however, the authors report implications of their urges towards children and onset of OCD in two young children after sexual about acting in such a way. abuse or sex-play, and suggest that these experiences A paedophile is more likely to be worried by the had become incorporated into obsessional content consequences of being caught. However, sometimes (Freeman 2000). Both children rapidly disclosed people with OCD are concerned that they may be these events, so appropriate interventions were incorrectly accused (e.g. because they left DNA in incorporated into the management plan. the vicinity of a crime, and that others will think Thus, it is appropriate that a clinician assessing they are a bad person and the complete opposite a child with sexual obsessions considers the issue of what they are). of child sexual abuse while remaining aware that excessive questioning may be harmful. What is the nature of the referral? Assessing intrusive thoughts of violence People with OCD are likely to have sought referral Intrusive thoughts and images of violence or because they are very worried about their thoughts. aggression can be assessed in exactly the same way Occasionally they will be referred for specialist as the primary risks of intrusive sexual thoughts, evaluation because they have revealed the content and similar issues arise (Box 2). to others who have also interpreted the thoughts as a sign of risk. A person at risk of paedophilia is less likely to seek help voluntarily and is more likely to BOX 2 Factors suggesting OCD in thoughts of be referred by an external agency. violence

K Ego-dystonicity Are other symptoms of OCD present?
K Absence of past behaviour consistent with the thought Many people with OCD who experience intrusive
K Presence of avoidance behaviour (e.g. avoidance of thoughts and images of a personally repugnant knives or sharp implements) sexual content will also have obsessions and
K Frequent thoughts compulsive behaviours in other domains (e.g. washing, checking, order). Other obsessive–
K High degree of distress compulsive symptoms are probably less likely to
K Strong motivation to seek help occur in sexual offenders.

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Postnatal OCD acting on their compulsion or avoidance in their Images of stabbing are common; intrusive thoughts usual way. Substance misuse can increase this such as putting the baby in a saucepan or micro- impulsivity. wave can also occur. Mothers often experience intrusions about acting on urges to suffocate or Case study: When seeking help makes things worse stab their baby. Such thoughts are quite prevalent A patient with OCD was worried that he might be a paedophile. When his niece sat on his knee, he in mothers and there are several well-described started to panic because he was worried that he was case studies (e.g. Sichel 1993; Maina 1999). The becoming aroused. He went to the toilet to check differential diagnosis is with puerperal psychosis† whether his penis was ‘getting any bigger’. †Identifying and caring for women at (especially in the absence of a history of OCD). He sought help and saw a psychiatrist. Concerned risk of puerperal psychosis will be by the patient’s doubts about whether he was discussed by Ian Jones & Sue Smith However, OCD is extremely unlikely to first occur aroused, she arranged a full risk assessment and in the next issue of Advances. in the context of a depressive psychosis. Conducting informed Social Services, who met with the patient an incorrect or lengthy risk assessment or placing and his family. As a consequence, his OCD became an adult with the mother at all times can be harmful worse because his fears that he might be a danger to as it can have the unwanted effect of increasing the child were now apparently confirmed. His doubts increased and he felt unable to seek further help as her doubts, reducing her confidence and leading he believed that treating the thoughts as symptoms to greater distress, avoidance and compulsive of OCD might cause him to let down his guard and behaviours. In the absence of other psychotic to act on them. features, such thoughts can be understood as an Individuals with OCD may undergo unnecessary, escalation of less unusual thoughts about causing lengthy and damaging risk assessments, which harm. In such cases, reports of thoughts or images make their disorder worse. The case study is an of violent content can cause well-meaning mental illustrative case history. A person with OCD hates health professionals inappropriately to anticipate uncertainty and the initial assessment is not an a risk of infanticide or harm to a child. appropriate time to introduce patients to tolerating doubt (although it may be important to do so Secondary-risk violence later in therapy when there is a good therapeutic People with OCD are occasionally violent alliance). Box 3 shows how patients have described not because of obsessions about violence but assessments by health professionals. because of extreme distress when someone either inadvertently or deliberately tries to prevent or Management of repugnant obsessions terminate the compulsion or ‘breaks the rules’. There are only two evidence-based treatments The secondary risk is that individuals can become for OCD: cognitive–behavioural therapy (CBT) violent or intimidating towards family members or (Veale 2007) and selective serotonin reuptake health professionals (e.g. if someone ‘contaminates’ inhibitors (SSRIs) (National Collaborating Centre a clean object or says a word that is avoided, a for Mental Health 2005). There may be a lengthy person with OCD can feel extremely threatened). waiting list for CBT and if an SSRI has been This is particularly likely to occur in children or prescribed then there is usually a delay before any adolescents because there is commonly a very high potential benefit is gained from the medication. It level of family involvement in rituals, which can lead to a great deal of frustration and anger in the home (Storch 2007). BOX 3 Examples of patients’ comments regarding their assessments Another group vulnerable to angry or violent outbursts are people with OCD in the context of ‘He gave me a differential diagnosis which ‘He implied I might have an unconscious an autism-spectrum disorder, especially when made me panic as it increased my doubts wish to stab my baby.’ there are very rigid routines. Such individuals about whether I did have OCD.’ ‘He said it was extremely rare for such commonly have a poor understanding of their own ‘She said that, to be on the safe side, it thoughts to mean that someone was and others’ mental states (Baron-Cohen 2001); would be better if I avoided working with dangerous, but if I was still worried, I could they may therefore have difficulty in empathising children until I had received treatment.’ go for a specialist assessment at the sexual with the effect of their compulsions on others, may ‘He said SSRIs might reduce my sexual offenders unit.’ be unable to explain what they are experiencing, urges so I assumed he must think there was ‘She said it was very rare for this type of or may be unable to deal with the situation by a problem.’ violent thought to lead people to act on expressing affect appropriately. In such cases, ‘She said I was unlikely to act out any urges it, but “as you obviously have a problem the individual is not acting on their obsession; but she was still obliged to notify Social dealing with anger, then therapy would be a good idea”.’ rather they are acting in response to the distress, Services.’ frustration and anger when they are thwarted in

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is therefore helpful for the clinician to be confident Secondary risk about the diagnosis and provide good rationale for The assessment of the secondary suicide risk of the patient’s experience of repugnant obsessions. self-harm becomes more complicated if, over When working with children or teenagers and their time, the individual becomes more depressed and parents, it is important to ensure that parents are hopeless or has a comorbid personality disorder educated alongside the young person, as parents that is associated with impulsive behaviour. People may fear, for example, that their child is growing with OCD are at greater risk of suicide than the up to become a paedophile or sexual offender. general population. In the survey by Torres et al This only contributes to the child’s anxiety and (2006), at least a quarter of people with OCD had avoidance as, for example, they may be made to attempted suicide at some time in their life. In such stop doing their previous baby-sitting job. It is situations, it is usually helpful to establish the important for people with OCD and their families main problem as well as the motivation for ending to understand the nature of intrusive thoughts life. Motivation arises from increased feelings of and professionals need to be very confident in hopelessness about progress in overcoming the informing them (Box 4). disorder or accessing therapy, or the individual’s belief that they pose a real danger to others. They Assessing risk of thoughts of self-harm may then desire to escape from their intrusive and suicide thoughts and make plans to end their life. In a small number of instances, patients may Primary risk take their own life as a compulsive act. For The obsessional thoughts of someone with OCD example, a person who is terrified that they will may concern self-harm or suicide. In this respect harm their loved ones may take their own life in they are no different from intrusive thoughts of order to protect them; we are aware of several violence to others and similarly present an apparent sad cases of this happening. Others may have primary risk. For example, a person fears that they comorbid borderline personality disorder and be may put their fingers in an electric socket or jump self-harming as a way of regulating their mood and from a great height or take their own life (when reducing their level of anxiety (e.g. a person with they do not want to). In fact, most people with borderline personality disorder may self-harm as a OCD would not want to die by suicide because of way of reducing feelings of contamination). the harm that they would cause to others through doing so. In cases where OCD has been clearly Compulsive self-harm established, and the thoughts about the fear of Occasionally, self-harming may become part of a self-harm or suicide (e.g. acting impulsively) are compulsion; for example, cutting, burning or hitting ego-dystonic, then the case should be managed as oneself as a form of neutralising an unacceptable for any other intrusion about violence. thought or image. We have seen cases in which

BOX 4 Reassuring patients and families about intrusive thoughts

K Intrusive sexual and violent thoughts are
K A person with OCD is at no greater risk of Thus, a young mother with OCD can and should normal and very common in the general causing harm than is any other member of be left alone with her baby when using kitchen population the public (they may even be at a lower risk) knives or other items that have been avoided due Clinicians should explain that a person would be A search on the database of the special to her fear of causing harm. The man worried abnormal and lack any morals if he or she did (high-security) hospitals in England revealed no about stabbing his partner might be encouraged not have such thoughts and might disclose their patients with sexual offences admitted with a to sleep with a knife by his bedside; the woman own. The reason why individuals with OCD have diagnosis of OCD since records have begun. The worried about intrusive sexual thoughts should such thoughts more frequently is because they collective experience of OCD specialists from be playing with children in the way they normally worry a great deal about harming others and try around the world shows that obsessions about do – the clinician should tell her that if they had not to have such thoughts. Intrusive thoughts are causing harm do not lead people to harm others. children they would be happy to hire her as a part of being human and if they are upsetting, baby-sitter. this indicates a person’s values. Thus, religious
K People with OCD should not avoid cues that people are upset by blasphemous thoughts, may trigger their obsession or make them
K Showing physical signs of sexual arousal is moral people are upset by thoughts of acting worse and they should try to resist the urge not a sign of being a paedophile – anxiety, immorally, and so peace-loving, gentle people to rationalise their experience or repeatedly selective attention and monitoring arousal in with high standards of behaviour and a strong reassure themselves one’s genitalia can increase these signs sense of what is right and wrong are upset by Rationalising and reassuring are covert Patients may benefit from self-help books that sexual or violent thoughts. compulsions which maintain their obsessions. discuss these issues in more detail (Veale 2005).

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severe harm, including self-blinding, occurred Schizophrenia and psychosis as a direct result of a compulsion. Merely telling Obsessive–compulsive disorder can also be the person that they are at risk because of their comorbid with schizophrenia. Some clinicians potentially or actually self-injurious compulsion is subsume a diagnosis of OCD within a hierarchical very unlikely to help on its own. Such individuals model. It is then assumed that if the psychosis is are usually carrying out compulsions to prevent treated then the obsessive–compulsive symptoms themselves from being responsible for harm will also improve. However, when psychotic to others, so appealing to their sense of self- symptoms are controlled then the symptoms of preservation is ineffective. OCD often become more prominent and should be treated in their own right. Comorbidity In young people, there may be a greater risk that Comorbidity can complicate the assessment of OCD is wrongly diagnosed as a psychotic illness, risk in OCD and there may be risks related to the especially if they present with unusual obsessions, comorbid disorder. However, a good understanding which are mistaken for delusions. Sometimes of the phenomenology in the particular patient will the distress caused by bizarre and frightening resolve such issues. obsessions leads to fear-driven behaviours, which are interpreted as behavioural manifestations of Depression psychosis, such as shouting out loud in an attempt Depression is the most common comorbid condition. to cancel out thoughts. In one series of young It is often secondary to OCD, in which case: people presenting with unusual obsessions about magically acquiring unwanted characteristics
K the patient describes their OCD as their biggest from others (termed ‘transformation obsessions’), problem; the majority had previously received an incorrect
K the symptoms of depression developed after the diagnosis of psychosis and had often been prescribed onset of the OCD; unnecessary antipsychotic medication (Volz 2007).
K the person predicts that the symptoms of Sometimes severe avoidance behaviour and self- depression would improve if the OCD were neglect in a person with OCD appears similar effectively treated. to negative symptoms of schizophrenia and the Very occasionally patients have a comorbid diagnosis of OCD is overlooked. bipolar disorder or recurrent depression in which There are extremely rare cases of comorbid obsessions and compulsions are symptoms of command hallucination in OCD (usually in the depression. Here the onset of depression and context of trauma and an emotionally unstable symptoms of OCD are simultaneous, and if the personality disorder), which can potentially lead depression is effectively treated then the OCD to violence. Such hallucinations (which are usually improves. ego-syntonic) can be confused as being related to The most important message to give to people the obsession but are in fact distinct processes. The with OCD who are suicidal is that the disorder assessment should focus on the emotional stability is treatable. Behavioural activation is probably and propensity to shift into a psychotic state and the most helpful psychological approach in OCD the contexts in which it occurs. with comorbid depression. This is because if the Antisocial personality disorder depression is severe, it may be more effective than standard cognitive therapy (Dimidjan 2006; Veale In extremely rare cases, OCD exists with comorbid 2008). It also targets cognitive processes such antisocial personality disorder and a history of as depressive rumination and avoids the risk of crime and violence, in which some of the intrusive patients trying to challenge the content of their urges are ego-dystonic in some domains (e.g. obsessions, which is unhelpful. Sometimes it contamination) but not in others (e.g. violent may take time to access a specialist service in impulses). Alternatively, some of the intrusions CBT for OCD or to find the right approach. For may be ego-syntonic (e.g. people who the person pharmacotherapy of depression comorbid with believes ‘deserve’ to be harmed) and ego-dystonic OCD, potent or selective serotonin reuptake at other times (e.g. causing harm to loved ones by inhibitors are more effective than noradrenergic not being careful enough). reuptake inhibitors (Hoehn-Saric 2000). If two or more selective serotonin reuptake inhibitors Assessing secondary risk of harm to family (SSRIs) are ineffective, then augmenting the SSRI members with a noradrenergic reuptake inhibitor may be Family members respond to OCD in many different helpful (Mancini 2002). ways. They may accommodate an individual’s

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avoidance and compulsions, either allowing accommodation. The ideal goal is to help family them to engage in them or becoming involved in members to be emotionally supportive without them and so reinforcing them. In this regard, the accommodating or excessively controlling the person with OCD may be bullying some members person with OCD. At times families may decide of the family to comply with their compulsions. to compromise as they reduce their involvement. Alternatively, the family may be overprotective and Changes may take time to implement if members of seek to minimise distress by allowing the person the family have been enmeshed in the rituals for a with OCD to reduce their sphere of activities. long time. Equally, the person with OCD will need They can also become aggressive or sarcastic to accept that they cannot expect others to comply and this interpersonal conflict can exacerbate with their demands or to live with such behaviour. the problem. Others may deny or minimise the If they feel threatened, family members should problem or avoid the person with OCD as much be asked to call the police or to seek protection as possible. Sometimes the behaviours associated through the courts. Ideally, family members work with the disorder may cause family members to with sufferers to support them in the process become restricted in their activities (e.g. using the of change, rather than supporting continued bathroom) or their freedom to use certain rooms in obsessions and compulsions. the home (e.g. because of hoarding) and they may become reluctant to invite visitors. Assessing secondary risk of harm to young When a carer or family member becomes children completely involved in the management of a A bigger problem may exist when an adult with person’s OCD, the risks of exhaustion, distress OCD has charge of young children who are forced and depression associated with the burden of care to accommodate the disorder. Sometimes the risk may also need to be assessed. This is a particular of physical harm is minimal, for example over- problem in the older parents of adults with chronic zealousness about hand-cleaning, insistence that OCD. The individual is able to function only as a child is bathed when they come into the home a result of complete devotion on the part of their or refusal to allow outside play. However, in some parents, whose ‘retirement’ gradually slips away. situations, the behaviour of a person with OCD The parents, apart from their own self-sacrifice, may become emotionally or physically abusive fear (accurately) that on their death their son or (e.g. using disinfectants such as bleach to clean daughter will be unable to cope. However, the son the child; never allowing the child to play with or daughter is so focused on day-to-day obsessions other children) even though their desire is to be that they neither see their parents’ distress nor a good parent. In such cases, the individual is the likely consequences of continued dependence usually extremely caring towards their children or failure to seek treatment. and strongly values being a good parent. Probably Frequently, family members’ coping mechanisms the greatest risk to children is emotional neglect differ, leading to further discord when they disagree arising from the parent’s preoccupation. An adult over the best way of dealing with the situation. in the grip of OCD can be insensitive to the needs As noted above, when someone in the family who of a child for stimulation and emotional warmth. usually accommodates a ritual or avoidance refuses In hoarding, the obsessional problem takes over to do so or accidentally interferes in a compulsion, the child’s environment; in extreme cases, the an individual with OCD may become severely child may have to sleep in a small space cleared in anxious and aggressive. The problem more often the hoarder’s possessions, or the house may have occurs in adolescents or individuals with Asperger become a hazard as a result of the behaviour. At syndrome, who may react impulsively or lack the other extreme, normal amenities, including empathy. Such incidents are uncommon, but if the heating and lighting, might be denied to the child behaviour were to occur repeatedly and there is a because of the adult’s preoccupations. A collateral risk of significant harm, then it would become of history is an important basis on which to discuss greater concern and may prompt the individual or with the parent or carers who do not have OCD the family to seek help. A collateral history, sometimes possible risks to the child. without the person with OCD being present, may therefore be important. Involving child protection services A key issue in assessment is the discrepancy Action if risk is identified between the degree of harm that the person with If family members are at risk, then a decision will OCD believes they are causing to their child and need to be made about admitting the individual that which the child, another family member or the with OCD to hospital or finding alternative professional believes is being caused. Ultimately

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it may be appropriate to notify Social Services, clinics and their physical health may have been especially when the person lacks insight into the compromised. Typically the parents are at the degree of harm being caused to the child and is end of their tether, having supported their child refusing to engage in treatment. Ensuring proper for many years and may appeal to their general care of the children can be a helpful motivator, practitioner and local mental health services for but not when couched in terms of a threat. The help. They might be told that because their child prospect of involving care agencies or the act itself is not suffering from a ‘severe mental illness’, or may inhibit the patient from engaging properly is not going to take their own life or harm anyone with treatment. If the treating clinician can see in the community and is not psychotic, an out- no hope of sufficiently speedy change (i.e. within patient appointment is sufficient: ‘If they don’t the timescale likely to avert serious harm to the want to come to such an appointment then that children), referral to social services needs to be is their choice’. Such patients may pose dilemmas discussed. If possible, referral should be made by for mental health professionals and be difficult someone not directly involved in the treatment to engage, but severe mental disorder should be in order to minimise negative effects on the characterised by the degree of handicap not the therapeutic alliance. It is to be hoped that treatment diagnosis. If a local service is unable to assist or will continue in parallel with proceedings related does not have the expertise then the person should to child protection. be referred to a specialist service for OCD.

Siblings Access to and engagement in treatment Finally, especially with children and adolescents Domiciliary visits may be needed for individuals with OCD, it is important to consider the risk to with poor insight or those who have become siblings. There are circumstances where siblings housebound. They might be encouraged to engage sharing a room with a child with OCD may with a cognitive–behavioural model of OCD, offered became very distressed, for example, by the child medication and helped to follow their important who is up all night ritualising, preventing them directions in life despite their disorder. The family sleeping, and so affecting school performance and may also need help in working as a team to set other aspects of functioning. Aggression can be progressive boundaries around their involvement. especially marked between a child suffering from People who cannot be treated as out-patients or OCD and their siblings. Sometimes a brother or on domiciliary visits may find admission to a sister becomes incorporated into obsessions, the specialist residential unit with frequent CBT more child with OCD believing they are ‘contaminated’ helpful. by them, and avoiding all contact with them or Involuntary admission on an acute ward should even with anything they have touched. Sometimes, be avoided if at all possible. Cognitive–behavioural siblings without OCD learn quickly to identify therapy without the patient’s active involvement is the triggers for their affected sibling’s fears and almost certain to fail, so involuntary admission is purposely taunt them by forcing exposure to a only used when any secondary risks reach serious feared stimulus such as an object believed to be proportions or there is a need to break a cycle of dirty. Although encouraging the whole family to involvement by a relative. The Mental Health Act help with exposure tasks as part of therapy can can theoretically be used for a trial of medication be helpful, this needs to be done with the patient’s because of a serious risk to the patient or a need explicit permission and built into a graded to remove the patient from their family or home exposure programme rather than being imposed. environment. When patients are admitted to an Purposeful or even unintentional teasing by a acute ward, little is usually gained by staff trying sibling can cause aggressive outbursts from the to control compulsions, although boundaries may child with OCD. be needed for the practical running of a ward (e.g. the number of paper rolls or plastic gloves used or Assessing secondary risk in people with poor length of time taken in a communal shower). insight Cognitive–behavioural therapy has to be done on Chronic, severe OCD may leave individuals a voluntary basis but if a patient with OCD has to housebound and severely disabled, but if they be detained under the Mental Health Act, then it lack insight into their condition they may not be would be good practice for an experienced therapist ready to change. Patients may have developed a to try to start the process of engagement and a reverse sleep pattern, a history of self-neglect and formulation of the factors that are maintaining the excessive dependence on their parents for several problem. If the process is successful then CBT can years. They may be unable to attend out-patient be continued on a voluntary or out-patient basis.

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Sometimes transfer to a specialist unit in OCD and engage and treat patients with poor insight and MCQ answers finding alternative accommodation may assist in decide which patients should be referred onwards 1 2 3 4 5 breaking a cycle which became established in the to specialist centres for more intensive treatments a f a f a f a f a f b t b t b f b f b t family environment. or therapists more experienced in OCD. c f c f c f c f c f d f d f d f d t d f When living at home is no longer an option References e f e f e t e f e f If a young person is unlikely to be able to manage on Baron-Cohen S (2001) Theory of mind and autism: a review. In International their own and the parents can no longer cope, then Review of Research in Mental Retardation: Autism (ed LM Glidden): 169–84. Academic Press. they should be advised on how to request that their child be rehoused or otherwise accommodated. Dimidjian S, Hollon SD, Dobson KS, et al (2006) Randomized trial of behavioral activation, cognitive therapy, and antidepressant medication Seeking rehousing may motivate someone with in the acute treatment of adults with major depression. Journal of OCD to change if they feel unable to cope without Consulting and Clinical Psychology; 74: 658–70. family support. The NICE (2005) guidelines also Freeman JB, Leonard HL (2000) Sexual obsessions in obsessive– recognise that some people with chronic OCD and compulsive disorder. Journal of American Academic Child and Adolescent Psychiatry; 39: 141–2. who have never developed an adequate level of Geller DA (2006) Obsessive–compulsive and spectrum disorders in children functioning may need supportive accommodation and adolescents. Psychiatric Clinics of North America; 29: 353–70. in addition to therapy. Gordon H, Grubin D (2004) Psychiatric aspects of the assessment and treatment of sex offenders. Advances in Psychiatric Treatment; 10: Assessing risk in therapy 73–80. Successful CBT often involves exposure or Healy N, Fitzpatrick C, Fitzgerald E (1991) Clinical note: childhood neurotic behavioural experiments that might be regarded disorders with a sexual content need not imply child sexual abuse. Journal of Child Psychology and Psychiatry; 32: 857–63. by some health practitioners as having a health Hoehn-Saric R, Ninan P, Black DW, et al (2000) Multicenter double-blind risk or as morally unacceptable. Examples include comparison of sertraline and desipramine for concurrent obsessive– putting one’s hand down a toilet bowl; playing with compulsive and major depressive disorders. Archives of General a Ouija board or trying to wish death on a loved Psychiatry; 57: 76–82. one. These tasks need to be viewed in the context Maina G, Albert U, Bogetto F, et al (1999) Recent life events and obsessive–compulsive disorder (OCD): the role of pregnancy/delivery. of the patient’s obsessions. Furthermore, the tiny Psychiatry Research; 89: 49–58. risk from tasks such as exposure to contaminants Mancini C, Van Ameringen M, Farvolden P (2002) Does SSRI augmentation needs to be weighed against the much larger with antidepressants that influence noradrenergic function resolve mental health risks and handicap from not doing depression in obsessive–compulsive disorder? Journal of Affective such tasks. When patients leave specialist units it Disorders; 68: 59–65. is essential that professionals liaise so that patients Marshall WL, Langton CM (2005) Unwanted thoughts and fantasies experienced by sexual offenders. In Intrusive Thoughts in Clinical are supported in repeating such tasks and are not Disorders: Theory, Research, and Treatment (ed DA Clark): 199–225. undermined by well-meaning health professionals Guilford Press. less familiar with OCD and treatment with CBT. National Collaborating Centre for Mental Health (2005) Obsessive– Compulsive Disorder: Core Interventions in the Treatment of Obsessive– Compulsive Disorder and Body Dysmorphic Disorder. Clinical Guideline Services for people with OCD 31. NICE. The NICE guidelines (National Collaborating Rachman SJ, de Silva P (1978) Abnormal and normal obsessions. Centre for Mental Health 2005: p. 13) state that: Behaviour Research and Therapy; 16: 233–48. Each PCT [primary care trust], mental healthcare Rachman S (1997) A cognitive theory of obsessions. Behavior Research trust and children’s trust that provides mental health and Therapy; 35: 793–802. services should have access to a specialist OCD/BDD Salkovskis P (1985) Obsessional–compulsive problems: a cognitive– [body-dysmorphic disorder] multidisciplinary team behavioural analysis. Behaviour Research and Therapy; 23: 571–83. offering age-appropriate care. This team would Salkovskis P, Kirk J (2008) Obsessional disorders. In Cognitive Behaviour perform the following functions: increase the skills Therapy for Psychiatric Problems: A Practical Guide (eds K Hawton, PM of mental health professionals in the assessment and Salkovskis, J Kirk, et al): 129–68. Oxford University Press. evidence-based treatment of people with OCD or Sichel DA, Choen LS, Dimmock JA, et al (1993) Postpartum obsessive– BDD, provide high-quality advice, understand family compulsive disorder: a case series. Journal of Clinical Psychiatry; 54: and developmental needs, and, when appropriate, 156–9. conduct expert assessment and specialist cognitive- behavioural and pharmacological treatment. Storch EA, Geffken GR, Merlo LJ, et al (2007) Family accommodation in pediatric obsessive–compulsive disorder. 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Veale D (2007) Cognitive–behavioural therapy for obsessive–compulsive Volz C, Heyman I (2007) Transformation obsession in young people disorder. Advances in Psychiatric Treatment; 13: 438–46. with obsessive–compulsive disorder (OCD). Journal of the American Veale D (2008) Behavioural activation for depression. Advances in Academy of Child and Adolescent Psychiatry; 46: 766–72. Psychiatric Treatment; 14: 29–36. Warwick HM, Salkovskis PM (1990) Unwanted erections in Veale D, Willson R (2005) Overcoming Obsessive Compulsive Disorder. obsessive–compulsive disorder. British Journal of Psychiatry; 157: Robinson. 919–21.

MCQs 3 When depression occurs secondary to OCD: c the parents are the main problem since they 1 Intrusive sexual thoughts about a the patient usually describes their depression collude with the patient children: as their biggest problem d every effort should be made to engage the a are always a sign of a paedophilia b the symptoms of depression usually develop person in treatment on domiciliary visits b occur in the normal population before the onset of OCD e rehousing away from carers is unlikely to c should necessitate immediate reporting to c noradrenergic reuptake inhibitors should be motivate a person with OCD to change. social services used before serotonin reuptake inhibitors for d are a sign that a person is bad and disgusting treating depression in OCD 5 Children and adolescents with OCD: e can be suppressed if the person tries hard d the symptoms of depression can only be a should always be referred to social services if enough. treated with antidepressant medication they disclose sexual obsessions e the symptoms of depression are usually b should always be invited to have their parents 2 People with OCD: overcome when OCD is treated. involved in their treatment a are never violent or aggressive c are more likely to be developing a homosexual b may have intrusive violent thoughts which are 4 In people with OCD who are housebound orientation if they have sexual obsessions ego-dystonic and repugnant and have little insight: d will not behave aggressively unless they have a c never act on urges of self-harm a admission under Mental Health Act should comorbid diagnosis in addition to OCD d have a higher risk of acting on their intrusive always be used e may have more insight into the unnecessary violent thoughts b an out-patient appointment should be offered nature of obsessions and compulsions. e are at a lower risk of taking their own life. and it is up to them if they want to attend

’Amber innocent ‘ by Joan Adeney Easdale POEM Selected by Femi Oyebode

The sun was sinking. For so things happen when the tailor turns the key The life of Joan Adeney Easdale In an upstairs window And goes away, and no one’s there to see. (1913–1998) has recently been described in a biography Who A tailor’s dummy underwent transfiguration. None can witness when a change is wrought Was Sophie? The Lives of My A crimson tape-measure crossed the bust Till afterwards. Few have heard Grandmother, Poet and Stranger, As an order, such as queens wear, The last tick before the clock stops short written by her granddaughter Celia And her diamonds were scintillating dust. Or seen the crack appear upon the ceiling. Robertson. Joan Easdale was admitted to Holloway Sanatorium Paper-covered books curled, in October 1954 and remained A needle slid towards the scissors on the sill, there until September 1961, when Shadows unfurled she discharged herself. She lived Like rolls of dark crêpe across the counter. as a vagrant for a period and later settled in Nottingham. The poem is an extract from ‘Amber Innocent’, published by The Hogarth Press in 1939. Reproduced with permission. doi: 10.1192/apt.15.5.343

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