Obsessive compulsive disorder

350 Pages·2006·1.2 MB·English

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

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

Contents

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

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

Guideline development group members

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

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.
Although the evidence base is rapidly expanding, there are a number of major gaps
and future revisions of this guideline will incorporate new scientific evidence as it
develops. The guideline makes a number of research recommendations specifically to
address these gaps in the evidence base. In the meantime, we hope that the guideline
will assist clinicians, people with these disorders and their carers by identifying the
merits of particular treatment approaches where the evidence from research and
clinical experience exists.

1.1
NATIONAL GUIDELINES

1.1.1
What are clinical practice guidelines?

Clinical practice guidelines are ‘systematically developed statements that assist
clinicians and patients in making decisions about appropriate treatment for specific
conditions’ (Mann, 1996). They are derived from the best available research evidence,
using predetermined and systematic methods to identify and evaluate the evidence
relating to the specific condition in question. Where evidence is lacking, the guide-
lines incorporate statements and recommendations based upon the consensus
statements developed by the Guideline Development Group (GDG).
Clinical guidelines are intended to improve the process and outcomes of
healthcare in a number of different ways. Clinical guidelines can:
G Provide up-to-date evidence-based recommendations for the management of
conditions and disorders by healthcare professionals
G Be used as the basis to set standards to assess the practice of healthcare professionals
G Form the basis for education and training of healthcare professionals

Introduction

9

G Assist patients and carers in making informed decisions about their treatment
and care
G Improve communication between healthcare professionals, patients and carers
G Help identify priority areas for further research.

1.1.2
Uses and limitations of clinical guidelines

Guidelines are not a substitute for professional knowledge and clinical judgement.
They can be limited in their usefulness and applicability by a number of different
factors: the availability of high quality research evidence, the quality of the method-
ology used in the development of the guideline, the generalisability of research
findings and the uniqueness of individuals with OCD.
Although the quality of research in OCD and BDD is variable, the methodology
used here reflects current international understanding on the appropriate practice for
guideline development (AGREE: Appraisal of Guidelines for Research and
Evaluation Instrument; www.agreecollaboration.org), ensuring the collection and
selection of the best research evidence available, and the systematic generation of
treatment recommendations applicable to the majority of people with these disorders
and situations. However, there will always be some people and situations for which
clinical guideline recommendations are not readily applicable. This guideline does
not, therefore, override the individual responsibility of healthcare professionals to
make appropriate decisions in the circumstances of the individual, in consultation
with the person with OCD and/or carer.
In addition to the clinical evidence, cost-effectiveness information, where
available, is taken into account in the generation of statements and recommendations
of the clinical guidelines. While national guidelines are concerned with clinical and
cost effectiveness, issues of affordability and implementation costs are to be
determined by the NHS.
In using guidelines, it is important to remember that the absence of empirical
evidence for the effectiveness of a particular intervention is not the same as evidence for
ineffectiveness. In addition, of particular relevance in mental health, evidence-based
treatments are often delivered within the context of an overall treatment programme
including a range of activities, the purpose of which may be to help engage the person
with OCD, and to provide an appropriate context for the delivery of specific interven-
tions. It is important to maintain and enhance the service context in which these inter-
ventions are delivered; otherwise the specific benefits of effective interventions will be
lost. Indeed, the importance of organising care in order to support and encourage a good
therapeutic relationship is at times as important as the specific treatments offered.

1.1.3
Why develop national guidelines?

The National Institute for Health and Clinical Excellence (NICE) was established as a
Special Health Authority for England and Wales in 1999, with a remit to provide a single

Introduction

10

source of authoritative and reliable guidance for patients, professionals and the public.
NICE guidance aims to improve standards of care, to diminish unacceptable variations
in the provision and quality of care across the NHS and to ensure that the health service
is patient-centred. All guidance is developed in a transparent and collaborative manner
using the best available evidence and involving all relevant stakeholders.
NICE generates guidance in a number of different ways, two of which are relevant
here. First, national guidance is produced by the Technology Appraisal Committee to
give robust advice about a particular treatment, intervention, procedure or other
health technology. Second, NICE commissions the production of national clinical
practice guidelines focused upon the overall treatment and management of a specific
condition. To enable this latter development, NICE has established seven National
Collaborating Centres in conjunction with a range of professional organisations
involved in healthcare.

1.1.4
The National Collaborating Centre for Mental Health

This guideline has been commissioned by NICE and developed within the National
Collaborating Centre for Mental Health (NCCMH). The NCCMH is a collaboration
of the professional organisations involved in the field of mental health, national
patient and carer organisations, a number of academic institutions and NICE. The
NCCMH is funded by NICE and is led by a partnership between the Royal College
of Psychiatrists’ research unit (College Research and Training Unit – CRTU) and the
British Psychological Society’s equivalent unit (Centre for Outcomes Research and
Effectiveness – CORE).

1.1.5
From national guidelines to local protocols

Once a national guideline has been published and disseminated, local healthcare
groups will be expected to produce a plan and identify resources for implementation,
along with appropriate timetables. Subsequently, a multidisciplinary group involving
commissioners of healthcare, primary care and specialist mental health professionals,
patients and carers should undertake the translation of the implementation plan into
local protocols taking into account both the recommendations set out in this guideline
and the priorities set in the National Service Framework for Mental Health and related
documentation. The nature and pace of the local plan will reflect local healthcare
needs and the nature of existing services; full implementation may take a considerable
time, especially where substantial training needs are identified.

1.1.6
Auditing the implementation of guidelines

This guideline identifies key areas of clinical practice and service delivery for local
and national audit. Although the generation of audit standards is an important and

Introduction

11

necessary step in the implementation of this guidance, a more broadly based
implementation strategy will be developed. Nevertheless, it should be noted that the
Healthcare Commission will monitor the extent to which Primary Care Trusts (PCTs),
trusts responsible for mental health and social care and Health Authorities have
implemented these guidelines.

1.2
THE NATIONAL OBSESSIVE-COMPULSIVE DISORDER
GUIDELINE

1.2.1
Who has developed this guideline?

The Guideline Development Group was convened by the NCCMH and supported by
funding from NICE. The GDG included people with OCD and a carer, and profes-
sionals from psychiatry, clinical psychology, child psychology, nursing, and general
practice.
Staff from the NCCMH provided leadership and support throughout the process
of guideline development, undertaking systematic searches, information retrieval,
appraisal and systematic review of the evidence. Members of the GDG received
training in the process of guideline development from NCCMH staff and people with
OCD received training and support from the NICE Patient and Public Involvement
Programme. The NICE Guidelines Technical Adviser provided advice and assistance
regarding aspects of the guideline development process.
All GDG members made formal declarations of interest at the outset, which
were updated at every GDG meeting. The GDG met a total of 21 times throughout
the process of guideline development. The GDG met as a whole, but key topics
were led by a national expert in the relevant topic. The GDG was supported by the
NCCMH technical team, with additional expert advice from special advisers
where needed. The group oversaw the production and synthesis of research evidence
before presentation. All statements and recommendations in this guideline have been
generated and agreed by the whole GDG.

1.2.2
For whom is this guideline intended?

This guideline will be relevant for people with a diagnosis of obsessive-compulsive
disorder (OCD) or body dysmorphic disorder (BDD) aged 8 years and over.
The guideline covers the care provided by primary, community, secondary, terti-
ary, and other healthcare professionals who have direct contact with, and make deci-
sions concerning the care of adults, children and young people with OCD and BDD.
The guideline will also be relevant to the work, but will not cover the practice, of
those in:
G occupational health services
G social services
G the independent sector.

Introduction

12

The experience of OCD or BDD can affect the whole family and often the community.
The guideline recognises the role of both in the treatment and support of people with
these conditions.

1.2.3
Specific aims of this guideline

The guideline makes recommendations for the identification, treatment and
management of OCD and BDD. Specifically, it aims to:
G Evaluate the role of specific psychological interventions in the treatment and
management of OCD and BDD.
G Evaluate the physical management and role of specific pharmacological agents in
the treatment of OCD and BDD.
G Evaluate the role of other biological interventions in the management of OCD and
BDD.
G Integrate the above to provide best practice advice on the care of individuals with
a diagnosis of OCD or BDD throughout the course of the disorder.
G Promote the implementation of best clinical practice through the development
of recommendations tailored to the requirements of the NHS in England and
Wales.

1.2.4
The structure of this guideline

The guideline is divided into chapters, each covering a set of related topics. The first
two chapters provide a general introduction to guidelines and to OCD/BDD. The third
chapter provides testimonies regarding the experience of people with OCD and BDD
and their families and carers. The fourth chapter details the methods used to develop
the guideline. Chapters 5 to 8 provide the evidence that underpins the recommenda-
tions and Chapter 9 covers the use of health service resources. The final chapter
provides a summary of the recommendations.
Each evidence chapter begins with a general introduction to the topic that sets the
recommendations in context. Depending on the nature of the evidence, narrative
reviews or meta-analyses were conducted. Therefore, the structure of the chapters
varies. Where appropriate, details about current practice, the evidence base and any
research limitations are provided. Where meta-analyses were conducted, informa-
tion is given about both the interventions included and the studies considered for
review. This is followed by selected clinical evidence statements (a complete list of
evidence statements can be found in Appendix 18). Clinical summaries are then used
to summarise the evidence presented. Finally, recommendations related to each topic
are presented at the end of each chapter. On the CD-ROM, full details about the
included studies can be found in Appendix 16. Where meta-analyses were
conducted, the data are presented using forest plots in Appendix 17 (see Text Box 1
for details).

Introduction

13

Introduction

14

Content
Appendix

Included/excluded studies
Appendix 16

Forest plots for psychological interventions
Appendix 17a

Forest plots for pharmacological interventions
Appendix 17b

Forest plots for psychological versus pharmacological
Appendix 17c
interventions, combination therapy, and other
medical interventions

Clinical evidence statements
Appendix 18

Text Box 1: Appendices on CD-ROM

2.
OBSESSIVE-COMPULSIVE DISORDER AND

BODY DYSMORPHIC DISORDER

This guideline is concerned with the identification, treatment and management of
obsessive-compulsive disorder (OCD) and body dysmorphic disorder (BDD) as
defined in the 10th edition of the International Classification of Diseases (ICD-10)
(World Health Organization, 1992). Reference is also made to criteria from the fourth
edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) for
OCD and BDD in this chapter.

2.1
OCD

2.1.1
Symptoms, presentation, and patterns of illness

Obsessive-compulsive disorder is characterised by the presence of either obsessions or
compulsions, but commonly both. An obsession is defined as an unwanted intrusive
thought, image or urge, which repeatedly enters the person’s mind. Obsessions are distress-
ing but are acknowledged as originating in the person’s mind, and not imposed by an
outside agency. They are usually regarded by the individual as unreasonable or excessive.
A minority are regarded as having overvalued ideas (Veale, 2002) and, rarely, delusions.
The person usually tries to resist an obsession, but in chronic cases this may be to a very
minor degree or not at all. The most common obsessions are listed in Table 1. The percent-
ages refer to the frequency in a survey of 431 individuals with OCD (Foa et al., 1995).
Unwanted intrusive thoughts, images or urges are almost universal in the general
population and their content is usually indistinguishable from clinical obsessions
(Rachman & de Silva, 1978). Examples include having the urge to push someone
under a train or a thought that the cooker has been left on. According to current
psychological models, the difference between a normal intrusive thought and an
obsessional thought is the meaning that OCD patients attach to the occurrence and/or
content of the intrusions. Individuals with OCD tend to believe that intrusive thoughts
and urges are dangerous or immoral and that they are able to prevent harm occurring
either to their self or a vulnerable person (Salkovskis et al., 1995).
Compulsions are repetitive behaviours or mental acts that the person feels driven
to perform. A compulsion can either be overt and observable by others, such as
checking that a door is locked, or a covert mental act that cannot be observed as in
repeating a certain phrase in the mind. Covert compulsions are generally more
difficult to resist or monitor than overt ones as they are can be performed anywhere
without others knowing and are easier to perform. A compulsion is not in itself
pleasurable which differentiates it from impulsive acts, such as shopping or gambling,
that are associated with immediate gratification. The term ‘ritual’ is synonymous with
compulsion but usually refers to behaviours that other people can see.

Obsessive-compulsive disorder and body dysmorphic disorder

15