Marija has had OCD for 30 years since adolescence, her treatment included exposure and response prevention at the Institute of Psychiatry, many years ago. Her most recent therapist has suggested she try this again. But closer examination of her notes reveal that she simply felt better for some months after exposure and response prevention. When I asked her did she return to her usual self after exposure and response prevention she said ‘no’, but was 80% better for a while. Whilst exposure and response prevention is a NICE recommended treatment, at most only 50% recover. The NICE guidance can as applied to routine practice create a tunnel vision. She is a classic example of how clinicians stop at the first identified disorder. Whilst she clearly has severe OCD, there is no mention at all in the voluminous records that she has also been suffering from panic disorder, depression and illness anxiety disorder, all of which have gone untreated. Her son commented ‘I always knew there was more than just OCD’.
Marija was relieved that there was some new potentially beneficial therapeutic targets and that a ‘light touch’ with her OCD rather than ‘battling with my thoughts’ might be useful. She entered a different mode when I suggested a) that she had performed an experiment by not completing her rituals when she was asleep and found she came to no more harm than when awake and b) would not ring the local radio station to tell them that everybody must perform her rituals to stop harm coming to their loved ones c) she had performed rituals for a year as a 8 year old but when she gave them up nothing happened.
Marija has gone through a revolving door of mental health clinicians, which could have been stopped by a careful reassessment and history taking using a standardised diagnostic interview.
Dr Mike Scott