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Aims and MethodNational guidelines for the assessment and treatment of obsessive–compulsive disorder (OCD) and body dysmorphic disorder were published in 2005 by the National Institute for Health and Clinical Excellence (NICE). Local services are unable to treat a small but significant number of the most severely ill patients successfully, and the guidelines recommend that such patients should have access to highly specialised care. From 1 April 2007, the Department of Health decided to centrally fund treatment services for severe, chronic, refractory OCD and BDD. We describe a new National Service for Refractory OCD; its rationale, treatments offered, referral criteria and expected clinical outcomes.ResultsInitial results from one centre show an average 42% reduction in OCD symptoms at the end of treatment.Clinical ImplicationsThe operational challenges and potential generalisability of this model of healthcare delivery are discussed. We present a summary of the progress made so far in establishing a new, coherent National Service for Refractory OCD, 18 months after the NICE guideline was published. the aim of the paper is to educate clinicians about the service and describe its rationale, treatments offered, referral criteria and expected clinical outcomes.

The case history of a woman with severe and enduring anorexia nervosa and obsessive–compulsive disorder (OCD) with contamination fears is presented. These contamination fears centred on her fear of contamination by fat and fatty substances as she worried about gaining weight. Previous treatment with graded exposure had shown no clinically significant benefits. She was admitted to a specialist unit for the treatment of OCD as an inpatient. Due to the previous failure of the recognised psychological treatments for OCD it was decided to use the new psychoeducational approach of danger ideation reduction therapy (DIRT). This treatment resulted in an improvement in her OCD symptoms despite the fact that the emphasis of the treatment was on the risk of bacteria and dirt. It is believed that this is the first documented case of DIRT being used for a patient with anorexia nervosa and OCD.

Aims and MethodIn November 2005, the National Institute for Health and Clinical Excellence published guidelines for the treatment of obsessive–compulsive disorder (OCD) and body dysmorphic disorder. These guidelines incorporated a stepped care approach with different interventions advised throughout the patient pathway. South West London and St George's Mental Health NHS Trust devised a system of expert clinicians with special expertise in OCD/body dysmorphic disorder to help deliver this model of care. To aid the delivery of service it was decided to operationalise the definitions of severity of OCD/body dysmorphic disorder at each of the stepped-care levels. Examples are given as to how this has been applied in practice. Outcome is presented in terms of clinical hours in the first year of operation.ResultsIn total, 108 patients were referred to the service in the first year. Many of these patients were treated by offering advice and support and joint working with the community mental health team and psychotherapy in primary care teams who had referred. Sixty-eight patients were treated by a member of the specialist service alone and 57 of these suffered from severe OCD. Outcome data from these 57 patients is presented using an intention-to-treat paradigm. They showed a clinically and statistically significant reduction in OCD symptoms after 24 weeks of cognitive–behavioural therapy comprising graded exposure and self-imposed response prevention. the mean Yale–Brown Obsessive Compulsive Scale score dropped from 28 (severe OCD) to 19 (considerable OCD). Depressive symptoms on the Beck Depression Inventory also decreased by an average 24% over the same period.Clinical ImplicationsThe feasibility of extending this model of service organisation to other areas and other diagnoses is discussed.

Aims and MethodA naturalistic study was conducted to examine the outcome on self-report and observer-rated measures in patients with severe, chronic, resistant obsessive–compulsive disorder (OCD) admitted to a specialised in-patient unit.ResultsTwenty-six patients were admitted over the study period. The mean age of all patients was 37 years (s.d.=13.8, range 18–61 years) and they had a mean duration of OCD of 18.4 years (s.d.=10.9, range 4–40 years). Instruments measuring severity demonstrated a 37–67% reduction in obsessive–compulsive symptoms and a 64% reduction in depressive symptoms after an average of almost 15 weeks in hospital.Clinical ImplicationsThis study demonstrates that specialised in-patient care can benefit a small group of severely ill patients with OCD who fail to respond to treatment in primary and secondary care.