Transcription
Hello everyone. I think people are filtering through. I am Professor Subav. I am the dean of the Royal College of Psychiatrist and uh very warm welcome to all of you. Um it's uh it's a really um special session for me. I think in many ways this is my last session uh as dean to uh introduce the deans grand rounds. Uh I think we've had 19 deans grand rounds so far. Thousands of you have attended from all over the world and the feedback has been absolutely amazing. So I really wanted to thank Rian and the team for organizing this and for Deepa um to Deepipa Krishna for leading the deans grand round. so so very effectively. Uh it's also a pleasure to really have this session today. I think uh the session is entitled OCD a silent global epidemic. Um I think I was um I'm a laz psychiatrist so I don't probably see as many cases of OCD as as one might have done um you know in my previous role as a community psychiatrist but um every now and then I do come across it and it's just a reminder of how very disabling um OCD can be how very traumatic OCD can be not just for the patients but uh for the carers who are managing and supporting uh you know the OCD uh presentation they are seeing in their loved ones life every day. So I'm really looking forward to this session today. Um and um yes I'm also this is my first deans grand rounds as the president-elect. So I will hopefully continue to stay involved in this um in in this endeavor um over the next three years of my term.
Um I'll just um mention a few house rules. I think some of you who are regulars are familiar with these rules. Uh so um do feel free to use the chat say hello um where have you logged in from today it's always nice and sociable to do that but please be courteous and civil. I think our team will be monitoring the chat and if there are any inappropriate comments I think we will take action. Um u we uh will be using the Q&A function to monitor the questions to the panel. So please use the Q&A box. Uh I think it's a very interesting um and amazing panel today. Uh Himmanu I've worked with for such a long time. An international expert in OCD. Chrissy uh you're so multi-talented. I I you know I think from OCD to perinatal to knitting. I mean you do everything. So I don't know how you manage all of that. Uh it's incredible. And Margaret I don't know you very well but uh your CV looks amazing. I mean you're doing fundraising and then you're also doing research. So that's amazing. Uh and then you're representing Orchard OCD, which I think is a is a leading charity in leading research and uh in kind of really addressing uh providing solutions to our patients OCD. So I think we really look forward to hearing from all of you today.
Um so the final um pieces of housekeeping from me are that if you have any technical issues, please try leaving the webinar and rejoining via your link. um uh or you can use the chat functions where a team member will assist you. Um the webinar webinar will be recorded. We've had a record number of attendance uh delegate sign up to over a thousand and I can see that nearly half of those thousand are attending live. So uh which is which is quite quite remarkable. Um and your certificate of attendance will be sent out next week. you will be eligible to claim 1.5 CPD points and uh you'll be sent an email once the recording and the slides are available next week. So, and please complete the feedback form. I think um the Deepa is is trying to colleate all the data to see how you all are responding to to the deans grand rounds. The whole purpose of Dean's grand round is to bridge that gap between evidence and practice. So clinicians like you can start making a difference to our patients lives tomorrow uh today even you know so I think I think I hope that uh you all will will will engage with the feedback and let us know what you're doing very well. So over to you Deepa thank you again and uh well this might be the last time I'll see you as dean but uh looks like it's a successful program that you're organizing so good luck and congratulations.
Thank you so much Sub and thank you for joining. Indeed, it's a special session today. Uh and I'm so pleased to have such record numbers and you know such continued engagement from all our members. Um so without any further delay, we have a fantastic lineup of speakers as subod mentioned. Uh today we'll be looking at how we bridge the evidence uh practice gap uh around obsessive compulsive disorder um using an evidence-based data informed and u we've got lived experience uh uh story to share as well here. So using all these three lenses uh we look at how we can bridge this gap. Um so essentially in today's session we'll look at what's the global burden of OCD the challenges around diagnosis and classification and uh what's the latest neurobiological insights shaping our understanding of this condition and uh we'll also examine some current uh treatment uh limitations and what are the emerging approaches uh while bringing together clinical expertise um new research insights and lived experience to reframe OCD uh as a major global health priority.
Um, and we have, as I said, we have three fantastic speakers. So, I'm going to introduce Dr. Himman Shutiagi first. Um, um, and uh, we we'll then have Margarita and Chrissy joining us later in the sessions. So, we have uh, full bios for all the speakers on our web page. So, please do have a look. Um, so Dr. Dr. Hman Shitiagi is a clinical uh academic neurosychiatrist at UCL Queen Square Institute of Neurology and he's also a medical psychotherapist specializing in CBT. Um and he runs a specialist national clinic for OCD uh comorbid with Tourett syndrome at the National Hospital for Neurology and Neuros Surgery uh London. Uh I think there's uh there's plenty of things that you've achieved uh Himmanu and this uh uh you're quite uh uh active as a clinical academic in in this area. Um so you've also coordinated a first UK trial investigating uh deep brain stimulation for severe and treatment refractory OCD. Um so um again this um plenty of achievements and it's re it's a real pleasure to have you uh sharing your expertise uh uh to this uh uh audience today. So over to you Hibanchu.
>> Thank thank you for inviting and uh uh again congratulations to Dr. Dwe, Professor Dwe uh for uh uh winning this election. I always say that uh the title of our talk is silent epidemic which also is and I always say that silent epidemics need powerful voices and what better uh could be to have the president share this symposium on the silent epidemic. So thank you for having me here and uh thank you for the kind introduction and glad to see the over 500 people uh logged in. So we hope we can make some uh uh create more awareness about OCD. Just to move to the next slide please. Thank you. Uh so I work at Queen Square. uh I've been working there for last uh 14 years and only recently realized uh that uh the central middle sex hospital where one of the most effective treatment for OCD exposure treatment was first trial is was part of the campus. So I just put in that picture uh there uh as a homage uh to Victor who did the first clinical trial of exposure treatment in 1960s and established uh most effective form of psychotherapy for OCD. uh it sadly the hospital does not exist but uh uh hopefully we carry on the legacy of Victor at this site. Can we move on to the next slide please?
So this is uh because we are focusing mostly on silent OCD being a silent epidemic. This is what I thought I'll talk about rather than uh the latest uh uh research data which I usually do and uh the reasons why OCD is uh not spoken that much or not uh seen that much in clinical practice. And there are a number of factors regarding that. Some are systemic factors, some are related to the illness, some are related uh to uh cultural uh differences. But the most uh prominent factor uh most uh I think striking factor here is the prevalence gap. If you move to the next slide, we can see that uh if we count the number of OCD patients, we see one out of every 50 individual might have a lifetime uh risk of developing OCD. But if you look at the patients who are eventually diagnosed with OCD, that number is much smaller. So that is next please. that is one in 135. So we miss a lot of patients who have OCD and this is uh never diagnosed. So around uh two out of three patients with diagnosible OCD are never diagnosed in their lifetime. This is what this statistics mean and that is the prevalence paradox or the prevalence gap in OCD. And next please.
So uh the estimate is that uh because of this we are missing millions of patients. Now this is not a u static statistic. Uh this number has been much worse in the past and we don't have to look much further back. If you look at any of the textbook from 1970s. Next please. We'll see this number to be one in one 20,000. So we missed many more patients uh than than we do now. So we are definitely improving. The prevalence has increased by 3900% over last 50 years. It is not because the illness is becoming more prevalent but because we are becoming more we are becoming better at identifying it and more people are able to conceptualize it as an illness rather than just a quirk. Things changed when we started uh clarifying what OCD is. We started defining it with DSM3 ICD uh and we had standardized diagnostic criterias. Things changed massively over the 1980s 1990s. we became much better uh at identifying OCD and also with the emergence of effective treatment like exposure treatment and pharmacological treatment we also became more confident in identifying and treating uh uh the illness. So today the prevalence of OCD is considered to be somewhere between 1.5 to 3% depending on which uh large uh population study we are looking at yet clinical detection rates are still less than 1%. So this is something we uh speak a lot about in uh at various forums and this is where as clinicians we can make a lot of difference by thinking about OCD when we are seeing anyone. Next please. Next please.
So why OCD uh is so hard to diagnose? There are lot lot of uh barriers in the diagnosis of OCD. one uh as I was saying that uh some of these barriers are related to the way the illness presents. Uh it also presents with uh some of the most difficult thoughts any person can have. Uh egotistonic taboo thoughts uh thoughts about harming someone, thoughts about killing an thoughts about physically or sexually abusing someone. We know these are not easy thoughts to talk about and uh in fact even the existence of these thoughts in someone mind can be extremely distressing for the person and they are not able to speak to anyone including the closest relationship or even a professional about it. So that is uh one of the first factor that there is a big egoistonic barrier. OCD latches onto the things which are most valuable to a person and uh if something is confronting uh uh the um your values your morality it is extremely difficult to speak about and uh so this egoistonic barrier is there by uh how the illness presents. Next please.
In addition, there is uh uh trivial trivialization of uh uh the illness in the popular media in television, in newspapers, even in common culture, in dialogues, we would hear uh in movies or the banter we will hear uh people would uh casually refer to OCD that I'm so OCD about keeping my desk tidy, I'm so organized, I'm so OCD. It is heard most of us have heard that in everyday conversation every single day and this trivializes the illness. It's not something people can uh consider uh as a quirk. It is an illness which causes real distress and drives uh lot of people to uh extreme amount of physical and mental suffering. It is also one of the illnesses which has uh one of the highest uh uh rates of attempted suicide. But because of this uh casual trivialization uh it is underestimated both by patients who are suffering from the uh uh OCD clinicians carers people who are talking to these patients policy makers etc. Means uh if we think this is does not make a lot of difference we just need to look at the research funding for OCD which is uh the lowest in any major mental illness. In fact, uh it is uh the second lowest in all the research funding allocated to all named illnesses. If we look at uh what the NHS allocated in 2024 or 20 2014, there's a study done by Richard OCD. Next please.
Now there is another reason why OCD is uh not diagnosed quickly or misdiagnosed or late diagnosed. uh it uh there is a clinical camouflage. We have to ask the right questions to get to the uh right diagnosis at a very early stage when symptoms might not be very well defined otherwise we risk delaying the diagnosis. It uh starts in uh uh most of the OCD patients would have OCD onset in late childhood early adolescence. At that time uh uh it is difficult uh to differentiate between the symptoms as they can mix with the anxiety disorders. They can present with mood disorders if there is a secondary uh mood impact of having OCD which people are not able to uh speak about. It can sometimes uh look like uh uh other major mental illnesses or present with the similar symptoms seen in other major mental illnesses or neurodedevelopmental disorders like ADD, ASD. Now the impact of having all these complicating factors means one estimate is what one in five OCD patient when they present to primary care to GP they get misdiagnosed and uh that is what I see uh uh from uh my I worked as a level six uh consultant in OCD that is the highest uh treatment level in uh in uh UK. uh I worked as a consultant there for a few years and uh that gave me the advantage of having a bird's eye view of the whole treatment pathway of OCD starting from the initial presentation till uh CHD and specialist unit and then coming to the national inpatient unit and that is what we see in most of the cases who reach the national uh treatment uh centers that uh OCD either has been misdiagnosed earlier on or has been uh diagnosed uh uh there was delay in diagnosis or they were mistreated Uh next please.
So who is affected by this gap in uh the prevalence uh that we are not diagnosing two out of three patients with OCD? There are around 280 million people worldwide. That's the uh probably the population of uh uh top uh five country one of the top five countries. There is a two to 3% lifetime prevalence. We are not diagnosing most of them and this illness is not a trivial illness although uh we do uh see a lot of trivialization. It is the 10th leading cause of disability according to who as they estimated in uh 2000 and this includes all causes of morbidity not only the mental illnesses. So we are talking about physical health conditions and OCD still features in the top uh 10 as uh uh calculated by who around 20 years ago. There could be up to 17 years uh delay in getting to the right treatment. Uh that is what uh it's not average. Sorry that's a mistake on the slide. Up to 17 years uh delay in getting to the right treatment. The onset is in childhood adulthood the formative years when people are doing uh uh uh education or uh they are trying to establish themselves in life. So it affects really formative years of someone. it can have lifelong impact even if it's successfully treated. Uh any delay uh at that time in getting to the right treatment would show up later in the trajectory of that person in terms of education, in terms of relationship, in terms of career development. My colleague uh Dr. Jaraja is going to talk about the perinatal OCD but uh just to put one statistic out there that uh only less than 5% of patients with perinatal OCD get diagnosed. So the situation is even more uh dire there. Next please.
There is also uh a increased risk to the patient. One in seven OCD patients attempt suicide. Now this figure has changed uh over uh the uh around 15 years I've been doing uh OCD work. Uh when I started this uh uh this figure was much lower. uh we were told that OCD patients the prevalence of suicide attempts in OCD or completed suicide is quite uh low maybe comparable to general population which is not true and this is what we see in clinical population now the big uh epidemological studies have put this question to rest there's a very high risk of attempted suicide and completed suicide in OCD one in seven patients will attempt uh suicide there is 10 times higher uh mortality rate than general population and this is we But we are talking about patients who have been diagnosed with OCD and we have to remember that two out of three patients are not diagnosed with OCD. In order to understand that further we I had a student who uh few years ago looked into coroner's reports of patients who have not been diagnosed with OCD but the reports will indicate they might have uh OCD uh to look at the uh possibility of OCD in uh patients uh suicides which have been investigated by coroner. We looked at around uh uh 2 to 3,000 reports from five English speaking countries and we found a high uh rate of uh uh suicide in potential OCD patients even in those. So this number probably must would be much higher than what it looks and this is often missed as well. Next please.
Now there is uh another uh presentation of OCD which I have over the years uh started to call dangerous OCD physically dangerous OCD. OCD is not only a mental health problem it causes real physical risk uh to patients. Um there could be uh risk of uh uh skin uh problems, skin infection uh in fact severe skin infection because of neglect or decontamination rituals. There could be injury by ingesting chemicals. There could be uh I had a patient recently who almost lost one of the legs because of uh untreated diabetic neuropathy. And there could be uh risk to nutritional status. Patients with OCD can uh lose uh weight to uh put them at risk of uh severe complication, medical complications. In fact uh do uh Dr. German uh uh the consultant uh under whom I trained 20 years ago uh 15 years ago uh did a study looking at the number amount of renal failure in the inatient unit and one in five patient had some sort of renal uh uh problems uh uh in that study there could be uh other uh risks which patients can expose themselves to depending on the subtypes because of overing because of body dysmorphic disorder where self direct which is a related disorder where self uh directed uh body modifications or uh self cosmetic surgery are quite common. There are also social risks uh in terms of extreme withdrawal from the family, friends, extreme withdrawal from relationships uh and then uh leading to self- neglect. Next, please.
Economically, it's a similar uh uh situation. OCD is a chronic illness. It's not an episodic illness. It can wax in vain but it would not disappear if we leave it untreated. It cost a lot to the economy. In fact, one of the estimate in 2014 estimate uh suggested that it will cost uh around 1 million plus indirect uh and indirect cost which is NHS direct treatment benefits welfare loss tax revenue and social care prices. We did another uh uh cost effectiveness study only from the point of view of uh uh neurom modulation uh ablative neurom modulation treatment last year which is in press which already published which shows us a similar uh data as well in terms of economic impact of having untreated OCD. Next please.
Now there are a lot of myths about OCD that it is being about being uh neat and organized. As clinicians, we all are very aware of these myths. OCD uh uh being an anxiety disorder or patients can just stop rituals etc. All these are untrue and we have good evidence to uh uh dispel all these myths. I will not go into details because the clinical audience I would expect uh people to know uh most of this but if you need any references you can uh send me a message later on. Please next.
>> You have four minutes please.
>> Four minutes. Okay, thank you. Uh I will probably need uh five more minutes to wrap a few things up.
>> That's fine. Thank you.
>> Now, um one thing uh I would like to highlight to uh the clinical audience is uh OCD and the relationship between OCD and psychiatry and OCD has uh long been a prototypical disorder in psychiatry. Means if you look at the history of psychiatry if you look at the classification debates from 1970s if you look at whether it's a neurosis psychosis or uh what should be the prototypical candidate for uh Freud uh for example psychoalysis or what should be a prototypical candidate for clomine one of the first medication we uh figured out or for psychoso surgery from 1940 OCD has always been there as a prototypical illness and that is the case still OCD is currently a prototypical neuroscychiatric disorder And I would say that we should uh probably call it a flagship prototype for psychiatry. And uh next please. Next please.
In terms of neuroscychiatry, neurobiology of OCD what we know that cortical stratothalamocortical uh loop is at the root of uh this disorder and uh for the last 24 5 years we have uh indisputable evidence to suggest that this is uh uh overactivity in parts of CSTC circuit is causing OCD. It's not just a correlation. And it has been proven beyond uh uh doubt that it is a cause c positive uh uh reason for OCD. There could be different uh uh pathologies in the CSTC circuit uh and which might manifest in different ways. There are different loops which get affected in different presentation of but the mechanism remains the same. Next please.
So uh next please. The point I would like to uh make here is uh although there are different treatments for OCD uh there are effective pharmacological treatment in terms of anti-obsessional medication most of them are SSRI except chromocroine there is also very effective exposure based cognitive behavioral uh treatment for OCD and there if that does not work we can look into emerging treatments neuromodary treatments like TMS uh deep brain stimulation or ablative neurom modulation which is single and capsule which are still being offered uh for obsessive compulsive disorder. But the point I would like to make here is regardless of the nature of treatment all treatments converge on the same uh problem in the brain that is this overactivation uh in the CS part of the CSTC circuit and what we see in successfully treated patient regardless of the treatment we have used is there's reduction in uh the parts of the CSTC circuit because of that. So regardless of whatever modality we are using whether we are treating in a therapy unit with the exposure or treating in uh psychiatric uh CHT as with the anti-obsessional medication we are looking at the same uh changes in the brain. Next please.
Now this is the step care model for NICE. I've referred to this was uh made in 2005. NICE guidelines as many of us would know is current for OCD is currently undergoing revision and uh the new guidelines would be uh prepared and published uh hopefully this by the end of this year. But uh the previous nice guidelines introduced something called a stepped care pathway which is uh being adopted and most of the OCD services are designed around this pathway. Uh just to summarize it very quickly uh level three is where the patient will see the GP for the first time. Uh level four would be where patient will see a CHD clinician or psychiatrist uh for the first time. Level five and level six would be the specialist OCD team whose main fun uh job function is to treat uh OCD and support CHDs. The inpatient treatment uh units uh there are two inpatient treatment units in the country would uh belong to level six. Sometimes it could be level five as well. Now over the last 20 years there has been a lot of development in terms of new uh emerging treatments uh for OCD. we have uh TMS deep brain stimulation uh neur uh ablative neuromodulation has always been around. So all these can be clustered together to see a level higher than six a virtual level seven which is not present in uh uh stepped care pathway formally but uh most of the referrals to this level come after failing the level six treatment. Next please.
So in terms of evidence-based treatment, I'll stop at this slide as well. In terms of evidence based treatment for OCD, uh we have uh antioxidial medication. There is a very effective firstline phicotherapy which is six SSRIs which is focitin, certain, fluoxin, acetylopram, peroxitine and one uh TCA chloroproine. uh the six SSRIs are used as the first line. uh chromium bromine can be used uh after any of these trials fail or two trials of SSRI can be done if the first SSRI fails that is also recommended by SSRI uh by NICE. uh we can also use a supernormal dose of anti-opsessionals that means foxitine uh can be used beyond 60 migrine can be used beyond 200 mgs to treat uh OCD when it is not responding to first and second line treatment u however that can only be delivered by a specialist uh specialist being the psychiatrist in the situation with the adequate monitoring uh the trial the most of the evidence support that on anti-obsessional you have to stay on it for a longer period of time before giving up on it. uh uh it could be up to 16 weeks. So uh longer trials are more uh effective trials here. 40 to 60% will respond to these trials of medication which is quite a good number uh considering uh if we compare with other uh mental illnesses. uh augmentation there are number of augmentation strategies some are mentioned in the nice guidelines for 2025 or 2005 but most of them are covered in recent uh guidelines from other sources like BAP uh similarly exposure treatment which is the gold standard psychological treatment for OCD uh it uh includes 12 to 20 sessions and uh nice would suggest that if one single trial fails we can do another trial for the patient uh or we can combine in medication with exposure to improve the response rate. The response rates are similar to that of medication. So it's an illness where we have two different treatment pathways. Both are highly effective to the extent that we can arguably say that OCD is one of the most treatable mental illness. And when we treat it successfully, we do we are not looking at residual cognitive deficits. people can go about uh their education, their career, their relationship as close to normal as possible. In fact, the aim for most of the treatment is to get a recovery to the primobid function. So I'll stop at this slide to let other speakers. Thank you very much.
>> Thank you Himmania that was indeed a very interesting session. and you very well summarized the diagnostic complexity, the societal burden and you know the current evidence-based treatment. So thank you for that. Um so I think there there there was a slight uh technical glitch with the Q&A box that should be resolved now. So please post your questions in the Q&A box. Um and we'll try to take all the questions towards the end of the session. Uh so without any further delay I would like to invite uh Margarita Zenoni. Uh um so Margarita thank you for joining us. Um Margarita is an OCD researcher and she brings a uniquely powerful perspective through her lived experience of the condition. So alongside her academic work she leads fundraising at Orchard OCD which is a charity supporting people affected by OCD. And uh this chat has played a key role in delivering uh major patient focused and international scientific conferences uh public lectures and uh funded research initiatives and I think Margarita is going to share uh a very interesting uh conference that's upcoming conference uh details later. So I also want to share that Margarita was awarded 2025 uh rising star of the year award by uh women in neuroscience UK um which is a national honor recognizing brilliant minds shaping the future of neuroscience through their research. Um so um in this session Margarita will be sharing her lived experience and the impactful work through the orchard OCD. So over to you Margarita.
>> Thank you very much Deepa. Can you hear me? Yes, we can. Thank you. So, good afternoon everyone. My name's Margarita Zenoni. As Deepa said, I'm a PhD candidate at the University of Cambridge where I studied the relationship between trauma and obsessivempulsive disorder. I'm also head of research, fundraising, and communication at Orchard OCD. And especially importantly for today, I'm someone with lived experience of OCD. Next slide, please.
All right. So, Dr. Thiagi already mentioned uh OCD is an incredibly stigmatized and trivialized condition which for decades has been misrepresented by the media as a quirk personality trait. It's been turned into an adjective to use for people who are particularly organized or love clean spaces. And it's been talked about even as something to aspire to sometimes. Like look at this. Look at these images on the slide. Aren't they great? Don't they look fantastic? But in case you aren't completely convinced yet, I feel the need to tell you something. OCD is really nothing like the social media or Google representation of it. It has nothing to do with being excessively organized, germaphobic, or cleanliness as freaks. Next slide, please.
Okay, this is very much what what OCD feels like to me and I dare to say to most people, if not all of all of them suffering from OCD, a cage. People with OCD live in a cage and are desperate for help, but they often feel too ashamed to ask for it because of the huge stigma attached to this condition and the egoistonic nature of the condition that Dr. Thiagi mentioned before. So honestly from a lived experience perspective, it doesn't surprise me that the World Health Organization classifies OCD as one of the 10 most disabling illnesses globally, including all mental and organic diseases. Next slide, please.
Now, imagine if you weren't closing your eyes. If you're particularly sensitive, don't close your eyes. Um, but imagine if your brain was possessed by the cruellest dictator history has ever seen. They have total control on your brain. They've taken it all from you. And now imagine if they made you think over and over and over again about the most distressing and shameful thoughts and images often accompanied by bodily intrusive sensations making you feel guilty and miserable. And what if they then told you the only way out of the agony, the only way to find some sort of relief from those arthic thoughts is to carry out repeated physical or mental behaviors for five, 6, 12 hours a day nonstop. You would do it. I can guarantee you. The problem is the fleeting sense of relief that these behaviors offers offer. So the compulsions of the of the sea of the OCD offer only serves to reinforce the obsessions and what they do is they further and snare the person affected. Living with OCD and struggling with it feels very much like being co cked in in quicksin. The more you struggle, the deeper you sink. Like you're trapped by your own frantic attempts to escape. But at the same time, that's the only way you know to free yourself. But it doesn't work. It makes exactly the opposite. It makes you sink deeper and deeper and deeper every time. You then go to bed, fall asleep, often exhausted by your own mind. That's the main reason usually when why people with OCD fall asleep in the evening. You might even dream your obsessions and wake up in the group of anguish during the night. And then when the sun rises and you wake up, the cycle starts again and again and again. And it's endless. It feels endless. And it is. It's it really feels like a constant nightmare. You leave in a real cage you can't escape from. This is the reality of people living with OCD. Now, I know you can't reply to me, but I'm asking you, does it sound even vaguely similar to the media representation of it we're used to? One of the main problems of OCD, unfortunately, is that despite being such a devastating illness, it can be completely hidden, as I mention mentioned earlier, silent, invisible from the outside. Next slide please.
Here I want to share with you something uh that it's quite personal but I think I or I hope it conveys it can convey the anguish that living with OCD um provokes and how difficult it is to then speak about it. So I still very clearly remember the day when I stepped on the bus to go to school. It was September 2013. I was 17. And my brain convinced me but deeply convinced me that if I had even only accidentally touched someone on the bus with my shoes, backpack, jacket, that person would be severely injured or something terrible would happen to them later on in the day. So, I stepped on the bus organizing. It was 7:30 a.m. I was in Milan in Italy, the city where I come from. And the bus you see on the slide, the 54 is exactly the bus I took every morning. And my one of the first full-blown episodes on my of my OCD happened just there. So, it was super packed um because it was full of people heading to work and school. And to prevent my backpack or jacket or shoes from touching anyone else was simply impossible. And my brain knew it. I knew that was an absolutely irrational thought. But I deeply deeply believe that I could not touch them. It was at that moment and obviously I did I did touch them. I graced them. It was impossible not to. And it was at that moment that my hand began to fill with terrible thoughts about what would happen to those people because of me because I had accidentally inevitably graded them. They would be dead. They would be hit by a car getting off the bus or even worse my mind starting bombarding me with images of of of women being raped because of me. When I got to the stop I had to get off at about 200 m from the school and that the door you see here on the slide at the entrance of my high school, I felt my brain on fire. I was completely unable to understand what was happening to me. Nothing similar had ever gone through my mind before. And when I entered the classroom, despite all my best efforts and intentions to concentrate on the lesson, and I loved studying, I remember when there was something inside my head, a compelling force of really devastating power opposing my every attempt to decide where to direct my attention. And it was there, in that moment, I realized that I was no longer a master of my mind, nor even of my best intentions. And I started to feel like a prisoner. And I really was a prisoner. I I really feel like my brain had line up against me and taken me hostage. And from that day on, for the next 3 years, it was shouting my head every day, every minute, every second of my days, the obscinest things you can think of, making my life obviously a living hell. It was incredibly hard to concentrate in school because to take to read even one page of a book, it could take me up to two three hours because of all the intrusive thoughts and images bombarding my mind. So I could not concentrate. My grades um dropped immediately. My body started to be in a constant state of hypertension which then I understood was an involuntary reaction to all the intrusive violent images bombarding my mind. And over time this also led led my body to the development of other physical issues that I had to take care to to take care of later on in my life. But now I would like to look to you to look at the the picture the the picture in the in the bottom right um angle of the slide. Did I look like someone living with a severely debilitating mental illness? No, I think I didn't. And this is exactly what I mean when I say OCD can be completely invisible. I can guarantee you that was one what was one of those nights at the club with my classmates where I tried to fit in because I always say no. I didn't want to go. I didn't want to go because the O I was devastated by the OCD. But every now and then I tried because I was becoming an outsider. I was considered weird anyway cuz I did had weird behaviors to the OCD. Uh I asked a lot of assurance questions and they were weird questions to other teenagers. So I did try to fit in. I did try to to to smile in pictures. But it in I still remember that moment at the club that night was one of my classmates was was turning 18 and she had invited me and what was happening that precise moment is that I was bombarded bombarded by intrusive thoughts and images and there was deafany music which was making things worse. that I wanted to feed in at all costs because I had tried to tell one of them what was going through my mind. But what I received back was a very weird look as if I have no idea what you're talking about. This is really weird. Let's just, you know, let's change topic. Um, so yeah, what you do is trying to feed in. But my quality of life back then, I can guarantee you, was way, way below zero. Next slide please.
When I finished my bachelor uh well first of all compared to my high school years my bachelor years were much much better for different reason. I have gone through a cycle of um CBT therapy that had helped at least partially. I would be very angry later on in life with my psychologist because she she never sent me to a psychiatrist and she never put me on any SSI which I would only discover during my first relapse that would help me a lot. So anyway, those three years were better than the three year in high school. But especially the three here in high school, I mean, I could have lived them much better if only I was 3 ft um in a in a better way, in a in a more adequate way as you would treat someone with uh moderate to severe OCD, not just through CBT, but considering medications. Anyway, when I finished my bachelor and I was prep and was preparing to move from Milan to London for my masters at uh at UCL, I felt as though life was finally opening up in front of me. Really, I was about to realize a dream I had carried since adolescence, living in London, a city I had loved for years and studying at one of the best universities in the world. And for the first time in years, my OCD symptoms are completely disappeared. They were gone. I felt freer that freer than I had in a very very long time and happier than I had ever been in years. And somehow, perhaps naively, I thought my story with OCD was over. I didn't think about relapses back then. I thought I was finally free. I thought I would never again be as unwell as I had been in high school. And after all, to be honest, it was hard to imagine anything darker than the last three years of high school. But clearly, um things were not meant to go as I as I thought. Next slide, please.
About a month before moving to London, something began to shift in my mind again. And just as suddenly as it had disappeared, the OCD returned. At first, it returned with a bit more mercy than I remembered it. But within weeks, it had violently thrown me back into the nightmare, into the cage. I had lived a few years earlier. So there I was. I was back in the cage. I was in London studying what I loved most in the world. I studied I did my masters in clinical mental health sciences uh at UCL. I was in a fantastic university but at the same time I was in that cage again trapped in in exactly the same prison I had known before and I started to be terribly scared because I I knew what was coming. So during lectures at UCL my frustration and pain became simply unbearable. My mind was completely absent from the room and as a result so was I. The intrusive thoughts and images consumed everything. OCD swallowed every opportunity for joy, growth, and connection around me. And once again, that torment was completely invisible from the outside. Look at the pictures here, please. Like the pictures where where there's my face. That's exactly how I looked o over the entirety of that period. What was going on through my mind was much more similar symbolically to what you see in the bottom right of the slide. Next slide please.
Now very briefly on recovery I was treated with certuline and 12 sessions of ERP. um offered by UCL and thanks God for me that combination worked to be honest I also read a lot about the condition self-help books studying in the division of psychiatry of UCL certainly did help because I was surrounded by people that were understanding I needed to do my masters over two years instead of one because I was just too ill to keep studying and forcing myself to because anyway I could not study because it was was it was impossible. I tried but everything I ended up with was huge headaches and just falling asleep on the books because of the of the tiredness that the OCD provoked. But this combination for me worked. So I'm among those 50 60% of people with OCD that do respond to firstline treatments and I consider myself lucky for this. Next slide please.
So I was able to gain my life back from OCD once again then therefore feeling much much better focus on my studies again during the second year of the masters and graduating from UCL. It was at that time after recovering from OCD for the second time which which for me was like coming back from hell. I think for anybody with OCD that heals from OCD, it's like coming back from hell that I felt I felt very deeply within myself that I wanted and I needed somehow to find meaning in all that suffering, making something out of that that was bigger than the illness. So I decided that I would turn my mental pain into an opportunity not only for myself but hopefully for many other individuals with OCD, too. And I realized that for me the best way to do that was to dedicate my career to understanding this this condition better to understand how the brain can produce something so detrimental and devastating to the to to the human brain and to the human being as a whole and to contribute through scientific research to the development of better treatments for OCD. So after my masters, I worked for a year and a half as a research assistant and then I applied to Cambridge for a PhD position. Next slide please.
So I've started my PhD at Cambridge University funded by Orchard OCD. And here I I'm summarizing because I'm I'm I'm aware of time. Um, now I'm working for Archer OCD, which I'm going to uh spend a few words about uh in the next uh 3 minutes. I'm working for Orchard OCD and I'm doing my PhD alongside it. I It's great. I mean, I love the life I'm leading now and I could have never imagined this uh 8 n years ago. And to like honestly, not every day is easy. I'm on flock sitting at the moment. I still, you know, OCD still sometimes makes me hear its voice. But I can finally say that 10 years after that bus journey to school, I have found a way to turn pain into purpose. That's for sure. Next slide, please.
Now, briefly on Orchard OCD. What is Orchard OCD? is the UK's only non-for-profit organization dedicated exclusively to advancing scientific research into obsessive compulsive and related disorders since 2017. Um, Orcher has been guided by people with lived experience alongside worldleading scientists and clinicians. And I think it's fair to say that Orchard's become a pioneering force in the field. I've joined Orchard a few months earlier starting my PhD in in May 2023. So it's its birth precedes me. Uh our work is driven by a commitment to accelerating progress towards a deeper understanding of of of OCD and related conditions, the development of more effective treatments for these conditions and better outcomes for everyone affected by them. And how do we do it? We mainly do it um in three in three key ways. By funding innovative research on
important scientific questions and novel interventions, often difficult to fund research through other sources by tackling major barriers that slow the pace of progress. For instance, through our orchard ICD registry. Um I'll let you know more about it uh later on if you if you wish. And by creating opportunities for meaningful collaboration and exchange between researchers, clinicians, and people with lived experience.
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Okay, very quickly here, these are our trustees whose expert subs commitment especially helps shape the direction of our work every day.
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And these are our scientific advisors who provide a depth of clinical and research expertise that underpins really everything we do. To be honest, there are others too that are not officially among our scientific advisors. But um, to whom we often go to for scientific advice and to whom I personally go to us for scientific advice for my PhD.
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Now, um, these are uh the four studies Orchard OCD fully funded so far. These are just four of the projects we've funded at organi and organized so far. Um, they are the the research studies say for which we fundraised and and uh and fully funded. The first is the silo CD study, a feasibility study exploring the effects of psilocybin on compulsivity and its neurocognitive and clinical correlates. The manuscript was published in comprehensive psychiatry just last year. The second is the fits sock study which explored transcranial direct calin stimulation TDCS as a potential treatment for OCD, including stimulation of two brain regions, the left orbital frontal cortex and the supplementary motor area. The results were published, the results of the pilot study were published in 2023, very positive. Now we're looking for funding to fund um a larger um clinical trial. The third study is the toll study, a double-blind randomized placebo-controlled trial testing tolcapon. Um, tolcapon is a drug more commonly associated with Parkinson's disease. But uh, we're test they are testing the toolkin as a potential treatment for OCD following promising earlier pilot findings from the same team at the University of Chicago. This is our international study because they are outside the UK. They are in Chicago indeed. And this stud is expected to conclude by the end of this summer. And the fourth study is the trauma OCD study which is also the core of my PhD. Uh, and we are aiming to understand the role of aarent memory processing in the relationship between trauma/fulblown PTSD and OCD with a particular focus on mental imagery.
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Okay, this is the last slide, but at the moment probably the most important to me. Um, we were recently awarded as OrCD, we were recently awarded a welcome trust award to organize what will be Europe's largest in-person conference dedicated entirely to the most cutting-edge science in obsessive-compulsive and related conditions. It will take place in London at 30 Houston Square. So basically King's Cross on the 4th and 5th of June this year. So in about seven, eight weeks' time. The program will cover topics, the program which is publicly available. We cover topics including predictive biomarkers, precision medicine, new drug targets, neuromodulation, advances in psychotherapy, the role of LLM in future psychiatry research, and other topics as well. It's it's a vast program. There are now fewer than 40 tickets left uh out of 300. So, if you're interested, I warmly encourage you to book soon to scan the QR code. We're also offering a 50% discount uh on request. Uh, and the conference carries 14 CPD points. So, I thought it might be a great opportunity for this audience.
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Well, thank you very much for the opportunity to share my to share my story with you.
>> Thank you, Margarita. That was indeed a very powerful session uh sharing your experience and the expertise in the work so far through the orchard OCDs. Thank you. Um, so without any further delay, over to uh Dr. Chrissy Jaja. So, um, uh Chrissy is a consultant perinatal psychiatrist. Uh, she's a writer and research lead for perinatal services at Central and Northwest uh London NHS Foundation Trust. Uh, which is based at Chelsea and Westminster Hospital. Uh, you can see the full bio for Chrissy in uh uh the chat as well as on our web page. Um, um Chrissy is a scientific advisor for the maternal OCD charity and she has extensive clinical and academic uh expertise in assessment and treatment of perinatal OCD. Again, something quite close to my heart as a perinatal psychiatrist myself. So really good to have you, Chrissy, and thank you for joining. Over to you.
Thank you so much and and thank you Margarita for that very powerful uh talk and also to Habachu. I'm going to come at OCD from a slightly different angle, thinking about women's health, life course, and how OCD can present from puberty up into um menopause.
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So, some of you might know that the term hysteria actually has Greek and Latin origins. Hysteria meaning of the womb. And it was traditionally classified as a women's only disease. So to be hysterical, even till this day and age, if you describe someone as hysterical, you're almost always referring to a woman. Now, I could talk about this topic all day long, but I've just put a few very excellent books um that are available um, some older, some brand new, some from members of the Royal College of Psychiatry here. If you're interested in this topic about how women's health and particularly mental health has been treated um, or should I say not treated over centuries. Um, as part of my work as an honorary fellow for uh the George Institute for Global Health at Imperial um, I'm part of the women's group there and some of the research is just shocking, really. Uh, I'm not sure if you know, but 50% uh of women are greater likelihood of being misdiagnosed after a heart attack. Uh, 80% uh more women are affected by neurological disorders than men. And when it comes to OCD, women are 1.6 times more likely to experience OCD than men in their lifetime. And this risk dramatically increases during the perinatal period, which I'll be talking about later.
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So, as I said, we'll be talking about women's health across the life course. Um, obviously, we could talk about this all day long, but I'm aware of the time, so I'll just be glossing over this. Um, but do feel free to contact me afterwards if you'd like more information, of course.
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So, the big question I suppose to ask, and I get asked, I think, every week, is there a link between OCD and hormones, particularly female hormones, uh, in the perinatal period? Um, when we think about OCD in childhood, we know that it's a common condition in childhood and it affects boys and girls pretty much equally. Um, however, there's lots of interest uh recently into the impact of hormones on mental health and particularly with this in mind, whether hormone replacement therapy could be a promising uh alternative treatment to not only mental health disorders um in women but also for OCD. Uh, a couple of good examples just um to illustrate this point is premenstrual syndrome and premenstrual dysphoric disorder, which is at its very most extreme and can cause suicidal ideation as well. The sad thing about these conditions is that they often fall between the gaps of care. So, um, people suffering with these conditions don't know who to turn to. Is it their GP? Is it the endocrinologist? Is it a gynecologist? Or is it a psychiatrist? Sadly, we're not serving uh these women correctly. Coming back to OCD, uh, the latest research shows that there is an increase in OCD symptoms around the age of starting your period. And we know that there are monthly variations. So, in the lead-up to getting your period, um, OCD symptoms can worsen. We know that there's an increase of relapse in pregnancy and after having a baby, but interestingly, not so much in menopause. So, um, I'll come on to menopause at the end of the slides. Um, but all of this in turn, I guess, is we're possibly thinking that there might be a link between the sex hormones estrogen and progesterone. Um, but unfortunately, we need more research in this area. Absolutely.
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Thinking more about women as they go through the life course, they're studying, they're working. Margarita talked about this in her very powerful personal uh story. It can really affect your quality of life. And as Manu mentioned, this is not a trivial condition. It's not just about being tidy or organized. This is often a hidden condition, a silent condition that carries a lot of shame and stigma. As you can imagine, if you're having repetitive, intrusive thoughts all day long, you could have reduced productivity at school or at work. Um, you may have compulsive behaviors, meaning that you have to repeat certain tasks or do things again and again to get it just right. Or if you get disrupted in your flow, if someone interrupts you, you have to start all over again. So, if you're working to a deadline, this can be really difficult. If you have issues around contamination or even getting out of your home due to fears of the outside world, you might prefer or need to work remotely. But this can obviously affect your work um and socializing in the workplace. Interestingly, there were some studies that came out in COVID that people's OCD improved slightly during lockdown because you were in a controlled environment in the bubble, literally and figuratively, but actually, there was a sharp increase in symptoms on the end of lockdown. So, when we had to re-enter the real world, of course, when we're thinking about jobs and occupations, it might actually have an impact on your career of what you decide to work in or not work in. Um, I once had a patient who had very severe contamination fears and was constantly washing her hands, and then she went on to develop a a career in infection control, and essentially his OCD was hidden in plain sight. Everyone thought he was an absolute brilliant example in the workplace because he was constantly washing his hands. If you're having taboo thoughts about harm, uh, such as people thinking you might be a pedophile, for example, you may avoid going into a career in education or working with children. There's a really great document from OCD Action charity on employment rights for people with OCD. So, if you are a clinic clinician or know somebody who's having uh OCD and difficulties in the workplace, I highly recommend looking at that as it it as it summarizes the new Equality Act or newish Equality Act um and how we can ensure people with OCD have dignity in the workplace and don't face mental health discrimination.
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Now, coming on to relationships. We've talked a little bit about this, but yes, it really can affect your relationships with your family, with your friends, and obviously in an intimate relationship setting as well. Um, you may not want to tell the people around you that you're suffering with OCD or having difficulties with it. It might be embarrassing to talk about. Um, you may not want to share your personal space or may avoid living together with people because you don't want people to see your routines and rituals at home. You might avoid socializing um because it's out of your usual routines or you know the environment is an uncontrolled environment. When it comes to physical intimacy, there's a whole myriad of issues that can occur from fear of infection such as sexually transmitted diseases or contamination fears from bodily fluids. Um, there might be compulsive rituals around sex and intimacy um that can be quite off-putting or or you the person might just avoid the whole topic altogether and not engage in any intimate activity at all. In terms of the dynamics of relationships, we see a lot of reassurance seeking. Um, and this can put relationships at a huge strain. Um, we know from clinically working that people will um in families and in partnerships um they will seek a lot of reassurance from their partner and even family members and partners might um take part in the rituals themselves, go along with the routines and rituals just to keep the family peace um because that is easier than confronting or challenging the person's um OCD obsessions and compulsions. And the last sub-theme I just wanted to draw attention to was relationship OCD, which is where there are significant doubts creeping in about the partner. It could be about the fidelity of the partner or fidelity of themselves or and um how this can impact on the relationship even when there is no reason to suspect that there has been any infidelity.
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Coming on to perinatal OCD. So, I'm a perinatal psychiatrist and um it's my area of interest. You there are two types of OCD that we see. It could be someone who has a diagnosis of OCD and then decides to have children, or it could be a new onset condition. But as her said earlier, we know that this condition is very misunderstood, both OCD and perinatal OCD. It's often misdiagnosed, usually for postnatal depression and anxiety, as if everyone has got postnatal depression after having a baby. But often, more often than not, it's missed. In terms of clinical signs and symptoms to look out for, I think if you're in that spectrum of you're not sure whether it's a depression or an anxiety, some of the key hallmark features we see is that the themes of the OCD may shift and it might start to become focused on the child or the baby or in utero. So, worrying about the safety or harm coming to that baby. Um, I have had patients who have had antenatal OCD where they start to worry about paternity. So, they might be having multiple paternity tests to check if the father is the father of the baby. Um, in in a relationship type of OCD, feeding as well is a very difficult situation. Um, women might feel that their breast milk could be contaminated with infectious diseases like HIV. So, they may be reluctant to breastfeed or feeling very anxious about feeding. Um, they may have intrusive sexual thoughts while breastfeeding, worrying that people are thinking that they're a pedophile. Interestingly, the hormone oxytocin is released both um in um in sex but also in lactation at orgasm and lactation. So, from a biochemical perspective, there is an element of oxytocin which is a change in hormonal a hormonal shift in both scenarios and of course contamination fears. And we've got a new thing that's introduced which is bottles, and I've had women who have sterilized their bottles 10, 20 times a day, and the key thing in OCD in reference to anxiety is that it doesn't matter if you do it nine times, it's never enough. You just need to go back and do it for the 10th time. You do not feel settled. You do not feel relaxed or complete that it's done properly. So, it's very fleeting. The the reassurance that it provides is very fleeting. And then the last symptom that I would say if you see this, I would say it's more of an OCD rather than anything else is what I describe as a flash forward. So, we will know in post in post-traumatic stress disorder, we often talk about flashbacks. So, a visual image is a distressing visual image of something that's happened in the past, a memory. In perinatal OCD, we see the and OCD, we see these flash forwards of something horrific happening in the future. So, it's not happened yet, but you would have this visual image of maybe your baby at the bottom of the stairs, for example, or your child covered in blood, or a road traffic accident ahead of you. And these images are very distressing and can pop up multiple times a day. And when I see that, in my mind, it's almost always perinatal. It's almost always OCD. It doesn't occur that often with just a pure anxiety disorder.
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When thinking about trying for a family, um, we I see two types, really. I see people who may be avoiding starting a family in the first place, uh, for lots of different reasons. Uh, they're worrying about their OCD and their mental health, the idea of stopping medication to try for a baby. They're worried about the impact of OCD on future children, um, and avoidance of children, as I talked about before, if they're having taboo thoughts. The other end of the spectrum is when trying to conceive, um, they might become very obsessional about planning for a baby. So, buying hundreds of ovulation sticks, for example, or symptom spotting every minute of every day. Um, and this can lead to intimacy difficulties as well.
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In terms of the pregnancy and labor, we see a lot of reassurance seeking continuing, but this now with health professionals. Um, me and an obstetrician friend were talking about this, that we're seeing an increased rise in women requesting additional ultrasound scans, often privately. In the in the NHS, you're lucky if you get four antenatal scans in your nine months. I've had women who have booked four antenatal scans before the first scan has been offered at 12 weeks in the NHS, all because they're reassurance seeking to make sure the baby's okay. Now, this could be for other reasons as well, particularly that they've had traumatic experiences in the past, like miscarriage. Um, so they may be naturally anxious about miscarrying again. Um, there is the difficulty around medication, and we're in a double bind because women who may need or would benefit from medication may be reluctant to take it because they're fearful that it might impact the baby, but the whole point you you're advising on the medication is for the fear of um or for the OCD fears about um worrying about the baby. So, the treatment in itself becomes a symptom. Women may become uh fearful of intimate examinations um and contamination in hospital. I had a patient who brought a mop, her own mop and cleaning supplies to uh Chelsea and Westminster Hospital because she just didn't trust that things were sterilized properly. It coincides with other conditions like fear of childbirth, tocophobia, and an increased um request for cesarean section out of choice rather than for an actual medical reason. I think in these kind of scenarios, it's really important to work collaboratively with your midwives and with your uh obstetricians about um an adequate care plan for these women because they actually, it's as we've talked about before, it's a very disabling condition. It is not a trivial condition, and the unknowns of pregnancy and labor can exacerbate symptoms significantly.
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Coming on to parenting. OCD, both in mothers and fathers, can get worse after a baby is born. Now, I want to stress that becoming a parent, particularly a parent for the first time, it's a natural, it is natural to be concerned, caring, and worrying about your baby and your child. If, in fact, if I had a patient in my clinic who wasn't caring or worried about their child whatsoever, that would be a huge red flag to me. So, yes, of course, we it's important to be hypervigilant and cautious about caring for your baby. The problem in OCD is when this goes too far, when it's starting to interfere um in child-rearing behaviors, when it's starting to be restrictive to the child, um um reducing in social activities, not allowing family to even hold the baby, for example, avoidance of mother-baby groups, avoidance of appointments, vaccinations, etc., or because of OCD fears. Um, it's also really important to understand that again, if we already knew um that it's it's a stigmatized condition that people don't ask for help in OCD. People don't ask for help for maternal mental health issues either. The main fear being a reluctance to seek help because there's a fear that they will be reported to social services or their baby could be taken away. So, you can imagine all of this is suffering in silence.
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Why is this important? Why is perinatal OCD? Why am I talking about perinatal OCD? It carries a huge mortality of any time in a woman's life. The perinatal period is the most dangerous time. Sadly, mental health reasons still are the number one reason why women die after giving birth in the year after giving birth. And one in seven of these women died by suicide. This is more than any physical health issue related to childbirth. So, it's very, very important that it's detected.
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And I like this slide because this is a beautiful picture that describes um the thousand and one critical days from the moment of conception up until a child's first birthday. We call this the thousand and one critical days. A woman will see a health professional during this time, in these thousand and one critical days, more than she will any other time in her life. So, this is a golden opportunity for all of us health professionals to um assess, look out for signs and symptoms, diagnose, and offer treatment. And as as we've already said before, OCD is a treatable condition.
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Finally, just thinking about the menopause. We used to think that it didn't have much of an impact compared to other times in the life cycle of a woman, but I'm just sharing a meta-analysis that was published a month ago, which shows that it does make a difference. Um, 5% of women noted new onset symptoms at the time of menopause for OCD. Nearly a quarter of those surveyed had an exacerbation in OCD symptoms, and but 11% noticed an improvement. So, it's still a bit mixed. Of course, it is a transitional time in a woman's life with more maybe more likely stressful events, additional caring responsibilities, all of which are the perfect storm for worsening of OCD symptoms. And I'm just uh I've also put the new position statement from the college on menopause and mental health, which is definitely worth a read. And for those of you who are interested in this ovarian uh roller coaster that we we find ourselves on, we've actually made some changes in the MRC psych syllabus, both the syllabus and the curriculum to make sure that all psychiatry trainees have adequate understanding and knowledge of the biological, psychological, and social aspects of um mental health and um ovarian hormones as well.
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So, to summarize, it's we know that women are at a disadvantage in terms of their physical and mental health all over the world, but OCD can present in women more and also with unique symptoms across the life course, and it can affect all aspects of their life, and yes, it is a silent struggle for both OCD and women's mental health.
Final slide, please.
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So, that was me. I wrapped it up as quick as I could. Thank you so much. If you're interested more about these topics, we have an arty psych podcast called Beyond Baby Blues where we talk about these things. And also, just to say, I'm supposed to say this out loud, I've written a book called Understanding Perinatal OCD, a Guide for Professionals. It's out in a couple of months, but you can order it, pre-order now. Um, I go into all of these topics in a lot more detail. Thank you very much.
Thank you so much, Chris. Indeed, a very interesting session, especially around perinatal OCD and also association with menopause uh as well. So, yeah um, thank you for um for this presentation. So, I now would like to invite uh Himanshu, Margarita, alongside Chrissy. We have had plenty of questions. I have tried my best to um organize them into themes. So, I think we can take about three or four questions or themes rather, look at three or four themes, uh and and then wrap the session up. But um, first of all, thank you to the three of you, really amazing and fantastic presentations and uh the um discussions in the chat and the questions in itself uh uh, you know, sum up that it's a very well-received session. Um, so, just going to the first question then, which is an easy one perhaps, um, so I think there's a couple of people asking where can they uh u make referrals? Is there an NHS tertiary OCD treatment um center, and if if so, where can they make uh these uh where and how can they make these referrals?
>> Uh, yes, I'll uh take that question. As I uh was highlighting in my uh slides, that there is a step kit pathway in uh UK in NHS, which NHS have adopted, recommended by NICE, which divides OCD treatment into six levels. Usually, as a psychiatrist, when we are treating a patient with OCD, we are treating them at level four. Level four treatment would include first two trials of SSRI or a trial with clomipramine, and also exposure-based community uh mental health uh community therapy, which can include intensive therapy as well. If all of this fails, then there are grounds to make a referral for level five, tier five uh treatment. That means every trust, mental health trust in the country should have a specialist team whose job should be to treat these complex OCD patients, or tier six, which is a nationally commissioned uh consortium of services, mostly based around in and around London. And level five and level six, there are no specific guidance how the referrals should be made. It is up to the level four treating community mental health treatment clinician, usually a psychiatrist, to make that distinction. It uh can uh the referral criteria are usually published on the websites of these hospitals. The two inpatient units, one is based in Springfield Hospital, that is part of Southwest London St. George's, and then we have SLAM, which hosts both the outpatient and the residential treatment for uh OCD and related conditions. We also have a clinic for OCD in Hartfordshire, which is run by Professor Fineberg. If you look up these centers, you will find the referral criteria and the referral forms for them. There are no funding implications for that. The funding for the treatment at level six is directly through NHS England, provided they meet the clinical criteria for inclusion.
>> Thank you.
>> Happy to be approached if anyone needs any more clarification about any individual patients.
>> Brilliant. Thank you so much. Um, I think there's a cluster of questions around differential diagnosis. I've just clustered them all. I think there's been a couple of questions on differentiating rituals versus repetitive behaviors in OCD and autism or autistic spectrum condition. Um, and um, there's also questions around differentials um um differential diagnosis for around severe anxiety and psychosis. Um, there's um, so yeah, any any thoughts on that? Um, either Himanshu or Chrissy.
>> I think I tried to I noticed that there are a few questions about ASD and OCD overlap. I tried to answer a couple of them by giving some pointers about how we can make the distinction. However, I think most of the times we have to make these distinctions in the clinical encounters. So that means that it is not easy to generalize any ways to make this decision. But one of the key thing I use is looking at the drivers of these similar looking phenomena, whether it's obsessional intrusions or rituals. In they are mostly to provide self-regulation, and in OCD, they are causing distress. Sometimes both are present, in fact, most of the times both are present. So, if we go through the most distressing distressing symptoms and look at individual drivers, that usually leads to better diagnostic clarification and better treatment pathway for the patient as well. But I've explained that in more detail in the comments.
>> Thank you for that. I think there were some questions on novel and new treatment options like psilocybin and ketamine. I think Margarita, you shared a slide from Orchard OCD research. Perhaps we could share the links with them. Is there anything you wanted to add to that?
>> Yeah, I'm very happy to share the link. Very importantly, psilocybin is not considered a current option for OCD. Could be very unsafe, especially if taken out of clinical settings. Um, the results of the study were interesting, especially because they showed a significant effect on the compulsion scale of the Y-BOCS, which is the gold standard diagnostic scale for OCD. Um, but yeah, we are very far from using that in the clinic for OCD. Just wanted to underline this, but this study surely very interesting and the science behind it pretty strong. Yes, I will be happy to share the link to the publication.
>> Brilliant. Thank you, Margarita. I think the next big theme was around pharmacological treatment options. If um, um, I wonder Chrissy and Himanshu, if you can answer and clarify some of these things. So, I think there were questions around combining SSRIs with clomipramine and any SSRIs that are considered better than the others. Um, and how long should the treatment be continued after full remission of symptoms? Maybe Chrissy first and then Himanshu, you can add in.
>> Um, so from sort of the latest evidence and kind of clinical practice that we do, I mean, all of the SSRIs, most of the studies unfortunately group SSRIs as one, so it's very difficult to differentiate paroxetine versus citalopram, etc. Of some of some of the studies that I've read, sertraline is is the better option if possible. Whatever SSRI you choose, it's better to go for the highest dose you can. Clomipramine, there were some studies that compared clomipramine versus SSRIs total and found that clomipramine was better than all SSRIs total, but as you and I, deep as a perinatal psychiatrist, we have additional things to think about, which is harmful impacts on the baby. So, there are certain medicines we wouldn't choose because it's preferable in pregnancy or breastfeeding compared to maybe in Dr. Thiagi's clinic. Um, but yeah, I often use a combination of a of a sertraline at its highest dose plus a little bit of aripiprazole if if possible. We avoid risperidone for obvious reasons. I'll hand over to him.
>> Uh, no, yes, absolutely. Missed clomipramine and SSRI is a combination. We will avoid in most all cases. Uh, we have in the level six uh uh patient cohort over the years, we have had I think two or three instances where we use this, but it's a risky combination. It creates a very high risk for serotonin syndrome, and it is explicitly considered as a no-go area to combine SSRI and clomipramine. It's not I am aware that in some countries it is used as an option with intensive monitoring, but in UK, where patient safety is not that intensively monitored if you're treating them in primary care or in community, and we don't have provision to admit that many inpatients for OCD, it is not something that we will use. I'll strongly recommend against it. Another issue with clomipramine is there is uh in severe OCD, there is also up to 90% chance that the person would have secondary depression and with significant burden of suicidal ideation, and because of the repeated treatment failures, exposure treatment is not easy. If you fail exposure treatment after putting a lot of work, the depression and these feelings of helplessness can amplify, and to use clomipramine in those situations, a medication which has a very low threshold for being fatal in overdose, is another concern. So, that's why we keep it in reserve and we pro prescribe it within a specific patient group with careful monitoring and not combined with SSRI. So, I think the safer approach is to use a low-dose antipsychotic as an augmentation. That's much more doable, GP friendly, and more sustainable in the community.
>> That's um u thank you, that's really helpful, and Chrissy as well. Um, I guess we have come towards the end of the webinar. We've got such u um lots of interesting questions, and what we could do is perhaps collate some of the unanswered questions. I can see some new questions coming up in the chat as well, and maybe get back to those questions in our resource page when we share the recording and the slides. Um, so I want to draw this webinar to a close by thanking uh um Dr. Himanshu Shitiagi, Margarita Zenoni, and Dr. Chrissy Jay Raja for their fantastic presentations. Obviously, the topic in itself has drawn so much interest and engagement today. So, I'm really thankful to all the participants who are attending live today and for their active participation and engagement. Thank you to Georgie and Vian for all the hard work behind the scenes. Without them, I think this is not possible. It's it's been a smooth session. So, thank you for that. And obviously, a big thanks to Subodh, Professor Subodh Daw, who joined us earlier on. So, this was his last session as the Dean, but first session as President-Elect. So, really special one. Um, so, yeah, thank you everyone and have a good evening, and I hope to see many of you in our next session of Dean's Grand Rounds, which is in June. So, see you then. Thank you.
>> Thank you. Thank you.
>> Thank you very much.
>> Thank you everyone. Thank you so much.