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Risk Assessment and Management in Obsessive–Compulsive Disorder David Veale, Mark Freeston, Georgina Krebs, Isobel Heyman & Paul Salkovskis

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Risk Assessment and Management in Obsessive–Compulsive Disorder David Veale, Mark Freeston, Georgina Krebs, Isobel Heyman & Paul Salkovskis 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 332 Advances in psychiatric treatment (2009), vol. 15, 332–343 doi: 10.1192/apt.bp.107.004705 Risk in obsessive–compulsive disorder (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.
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