16 July 2020

“Mental health staff may have limited exposure to emergencies associated with obsessive–compulsive disorder (OCD) during postgraduate training.

“The first time they encounter a person in the midst of severe obsessions, or one who has compulsively self-harmed in response to such obsessions, might be when working on call covering the emergency department.”

These are the opening lines of an educational article co-written by CNWL’s Dr Alex Thomson, Consultant Liaison Psychiatrist at the Department of Psychological Medicine, Northwick Park Hospital; Dr Erika Palombini, core psychiatry specialty registrar, and second author; Dr Joel Richardson, foundation doctor in psychiatry, for BJPsych Bulletin.

The article presents the lived experience of one of the authors as a clinical scenario to illustrate the severity of disability and the rates of self-harm and suicide-related mortality caused by OCD.

The recognition and assessment of OCD is described, along with what helps in emergency situations.

The scenario describes how the emergency department registrar has referred to the doctor on call for psychiatry a 37-year-old professional who is in resus with police in a state of extreme distress, with self-inflicted chemical burns from corrosive alkali on her arms and torso, and haemoptysis caused by the associated fumes. This is her 133rd attendance in four years.

The article, which also hears the patient perspective, asks what the correct response to the scenario is and goes on to describe the ongoing scenario through the perspective of both the doctor and the patient.

It also goes on to look at the severity of OCD, the link between OCD and self-harm, the risks of suicide of people with OCD, assessment and practical management of OCD.

Reflecting on the article, the authors say: “We have used the lived experience of OCD, self-harm and mental health services to illustrate a scenario which may be encountered by mental health staff working on call in emergency departments. This highlights several learning points about OCD, self-harm and on-call working.

“When on call, working collaboratively alongside other medical specialties is of benefit to patients. When seeing people who have self-harmed, retaining compassion, curiosity and hope for change, and ensuring a skilled assessment every time, can improve both patient experience and clinical outcomes.

“The recognition and diagnosis of OCD are essential elements of mental health staff's clinical skills; identifying and treating OCD can alleviate significant suffering and disability, and can save lives.”

The patient’s reflections are illuminating: “What matters to me in the emergency department isn't just about ‘assessment’ but is about providing help.

“There is a longer-term element in considering my ability to recover and to continue working: ensuring that I receive effective long-term treatment for OCD. Being correctly diagnosed with OCD has been life-saving for me. Until that point I was caught in a cycle of obsessions and compulsions which were causing me so much harm as to become life-threatening. I couldn't see a way out other than taking my own life to prevent me hurting or killing other people, but the correct diagnosis has improved things in ways I wouldn't have believed were possible.”

The article is available here: https://cambridge.org/core/journals/bjpsych-bulletin/article/when-selfharm-is-about-preventing-harm-emergency-management-of-obsessivecompulsive-disorder-and-associated-selfharm/AB29394E48CDCB659B642D71B5D69462/core-reader