Obsessive- compulsive disorder: Core interventions in the treatment of obsessive- compulsive disorder and body dysmorphic disorder National Clinical Practice Guideline Number 31 developed by National Collaborating Centre for Mental Health commissioned by the National Institute for Health and Clinical Excellence published by The British Psychological Society and The Royal College of Psychiatrists © The British Psychological Society & The Royal College of Psychiatrists, 2006 The views presented in this book do not necessarily reflect those of the British Psychological Society, and the publishers are not responsible for any error of omission or fact. The British Psychological Society is a registered charity (no. 229642). All rights reserved. No part of this book may be reprinted or reproduced or utilised in any form or by any electronic, mechanical, or other means, now known or hereafter invented, including photocopying and recording, or in any information storage or retrieval system, without permission in writing from the publishers. Enquiries in this regard should be directed to the British Psychological Society. British Library Cataloguing-in-Publication Data A catalogue record for this book is available from the British Library. ISBN 1 85433 430 1 Distributed in North America by Balogh International Inc. Printed in Great Britain by Stanley L. Hunt (Printers) Ltd, Rushden, Northamptonshire. developed by National Collaborating Centre for Mental Health Royal College of Psychiatrists’ Research and Training Unit Standon House, 4th Floor 21 Mansell Street London E1 8AA commissioned by National Insitute for Health and Clinical Excellence Midcity Place London WC1V 6NA www.nice.org.uk published by The British Psychological Society St Andrews House 48 Princess Road East Leicester LE1 7DR www.bps.org.uk and The Royal College of Psychiatrists 17 Belgrave Square London SW1X 8PG www.rcpych.ac.uk CONTENTS GUIDELINE DEVELOPMENT GROUP MEMBERS 6 1. INTRODUCTION 9 1.1 National guidelines 9 1.2 The national obsessive-compulsive disorder guideline 12 2. OBSESSIVE-COMPULSIVE DISORDER AND BODY DYSMORPHIC DISORDER 15 2.1 OCD 15 2.2 BDD 24 2.3 Treatment and management in the NHS 27 2.4 Detection, assessment and diagnosis 31 2.5 Stepped care 41 2.6 Clinical practice recommendations 41 3. THE EXPERIENCE OF PEOPLE WITH OCD AND BDD AND THEIR FAMILIES AND CARERS 47 3.1 Personal testimonies from people with OCD and BDD 47 3.2 The perspective of people with OCD and BDD 56 3.3 Summary of the needs of people with OCD and BDD 59 3.4 Personal testimonies from family members/carers 59 of people with OCD 3.5 Understanding the impact of OCD on family members 71 and carers 3.6 Specific issues for children and families 73 3.7 Sources of user and carer advice 74 3.8 Clinical practice recommendations 74 4. METHODS USED TO DEVELOP THIS GUIDELINE 76 4.1 Overview 76 4.2 The Guideline Development Group 76 4.3 Clinical questions 78 4.4 Systematic clinical literature review 78 4.5 Health economics review strategies 87 4.6 Stakeholder contributions 87 4.7 Validation of this guideline 88 5. PSYCHOLOGICAL INTERVENTIONS 89 5.1 Introduction 89 5.2 Behaviour and cognitive therapies 89 5.3 Psychoanalysis 102 5.4 Other psychological interventions 104 Contents 5.5 Psychological interventions for children and young people 108 with OCD 5.6 Psychological interventions for people with BDD 120 5.7 Clinical practice recommendations 122 6. PHARMACOLOGICAL INTERVENTIONS 127 6.1 Introduction 127 6.2 Current practice 127 6.3 SSRIs 128 6.4 Clomipramine 140 6.5 Other tricyclic antidepressants 145 6.6 Tricyclic related antidepressants 147 6.7 Serotonin and noradrenaline reuptake inhibitors (SNRIs) 148 6.8 Monoamine-oxidase inhibitors (MAOIs) 149 6.9 Anxiolytics 151 6.10 SSRIs/clomipramine versus non-SRIs 153 6.11 Other pharmacological interventions 154 6.12 Treatment strategies for patients showing an incomplete 157 response to SRIs 6.13 Pharmacological interventions for children and young people 164 with OCD 6.14 Pharmacological interventions for people with BDD 169 6.15 Clinical practice recommendations 173 7. COMBINED INTERVENTIONS AND INTENSIVE 180 INTERVENTIONS 7.1 Introduction 180 7.2 Psychological versus pharmacological interventions 180 7.3 Combination interventions 183 7.4 Clinical practice recommendations 189 8. OTHER MEDICAL INTERVENTIONS 194 8.1 Introduction 194 8.2 Electroconvulsive therapy 194 8.3 Transcranial magnetic stimulation 196 8.4 Neurosurgery 197 8.5 Medical interventions in children with OCD due to PANDAS 207 8.6 Clinical practice recommendations 210 9. USE OF HEALTH SERVICE RESOURCES 211 9.1 Methods of economic evaluation 211 9.2 Use of health service resources 211 9.3 Primary care drug therapy versus secondary care CBT versus 212 combined CBT plus SSRI therapy 9.4 Interpretation 213 9.5 Non-healthcare burden 220 9.6 Conclusions and future recommendations 222 Contents 10. SUMMARY OF RECOMMENDATIONS 223 10.1 Good practice points relevant to the care of all people with 224 OCD or BDD and their families or carers 10.2 Stepped care for adults, young people and children with 227 OCD or BDD 10.3 Step 1: awareness and recognition 227 10.4 Step 2: recognition and assessment 229 10.5 Steps 3–5: treatment options for people with OCD or BDD 230 10.6 Step 6: intensive treatment and inpatient services for people 243 with OCD or BDD 10.7 Discharge after recovery 244 10.8 Research recommendations 245 10.9 Audit table 246 11. APPENDICES 252 12. REFERENCES 291 13. ABBREVIATIONS 337 14. GLOSSARY 340 GUIDELINE DEVELOPMENT GROUP MEMBERS Professor Mark Freeston (Chair Guideline Development Group) Professor of Clinical Psychology, University of Newcastle upon Tyne Newcastle, North Tyneside and Northumberland Mental Health NHS Trust Dr Tim Kendall (Facilitator, Guideline Development Group) Co-Director, The National Collaborating Centre for Mental Health Deputy Director, Royal College of Psychiatrists’ Research Unit Consultant Psychiatrist and Medical Director, Community Health Sheffield NHS Trust Dr Jo Derisley Chartered Clinical Psychologist, Norfolk & Waveney Mental Health Partnership NHS Trust, Honorary Lecturer, University of East Anglia Dr Naomi Fineberg Consultant Psychiatrist, Queen Elizabeth II Hospital, Welwyn Garden City Ms Tracey Flannaghan Nurse in Practice, CBT Department, Glenfield Hospital, Leicester Dr Isobel Heyman Consultant Child Psychiatrist, Maudsley and Great Ormond Street Hospitals, Children’s Department, Maudsley Hospital, London Mr Richard Jenkins Systematic Reviewer (2003–2004), The National Collaborating Centre for Mental Health Mr Christopher Jones Health Economist, The National Collaborating Centre for Mental Health Ms Gillian Knight Representative for People with OCD, London Dr Karina Lovell Senior Lecturer, School of Nursing, Midwifery and Social Work, University of Manchester, Manchester Dr Catherine Pettinari Senior Centre Project Manager, The National Collaborating Centre for Mental Health 6 Guideline development group members Ms Preethi Premkumar Research Assistant, The National Collaborating Centre for Mental Health Mr Cliff Snelling Representative for Carers of People with OCD, Northampton Dr Clare Taylor Editor, The National Collaborating Centre for Mental Health Mr Rowland Urey Representative for People with OCD, Oldham Open User Forum, Oldham Dr David Veale Consultant Psychiatrist in Cognitive Behaviour Therapy, The Priory Hospital North London and the South London and Maudsley Trust Honorary Senior Lecturer, Institute of Psychiatry, King’s College, London Ms Heather Wilder Information Scientist, The National Collaborating Centre for Mental Health Dr Craig Whittington Senior Systematic Reviewer (2004–2005), The National Collaborating Centre for Mental Health Dr Steven Williams General Practitioner, The Garth Surgery, Guisborough 7 ACKNOWLEDGEMENTS The OCD Guideline Development Group and the National Collaborating Centre for Mental Health (NCCMH) review team would like to thank the following people: Those who acted as advisers on specialist topics or have contributed to the process by meeting with the Guideline Development Group: Ms Elizabeth Borastero, Patient/carer issues Professor Isaac Marks, Institute of Psychiatry, King’s College London, Computerised cognitive behavioural therapy Professor Keith Matthews, Division of Pathology and Neuroscience, University of Dundee, Neurosurgical treatments The people with obsessive-compulsive disorder (OCD), body dysmorphic disorder (BDD) and carers who contributed testimonies to the chapter on the experience of OCD and BDD. 8 Introduction 1. INTRODUCTION This guideline has been developed to advise on the identification, treatment and management of obsessive-compulsive disorder (OCD) and body dysmorphic disorder (BDD). Although distinct disorders, OCD and BDD share a number of common features and there is a high degree of similarity between the treatments for the two conditions. The guideline recommendations have been developed by a multidiscipli- nary team of healthcare professionals, people with OCD, a carer and guideline methodologists after careful consideration of the best available evidence. It is intended that the guideline will be useful to clinicians and service commissioners in providing and planning high quality care for those with OCD and BDD while also emphasising the importance of the experience of care for people with OCD, BDD, and carers. This guideline addresses aspects of service provision, psychological and pharma- cological approaches for those with OCD and BDD from the age of 8 upwards.