1. Obsessive-compulsive disorder
Clinical Guideline
Published: November 2005
NOTES FOR PRESENTERS
You can add your own organisation’s logo alongside the NICE logo
DISCLAIMER
This slide set is an implementation tool and should be used alongside the published guidance. This information does not supersede or replace the guidance itself.
Although the guideline covers the core interventions in the treatment of obsessive compulsive disorder and body dysmorphic disorder, the slide set focuses on obsessive compulsive disorder.

2. NICE clinical guidelines
Recommendations for good practice based on best available evidence of clinical and cost effectiveness
DH document ‘Standards for better health’ expects organisations will work towards implementing clinical guidelines
Healthcare Commission will monitor compliance with NICE guidance
NOTES FOR PRESENTERS 2

3. Rationale for the guideline
OCD is a potentially life-long disabling disorder and is poorly recognised and under-treated
Individuals in some studies report waiting an average of 17 years before the correct management is initiated
Treatment occurs in a wide range of NHS settings – provision and uptake is varied
NOTES FOR PRESENTERS
Refer to Scope section 3.0 3

4. What does this guideline cover?
Children, young people and adults with OCD/BDD – mild, moderate and severe functional impairment
A stepped-care approach to recognition, assessment, treatment interventions, intensive treatment and inpatient services, discharge and re-referral
Who is it aimed at?
Healthcare professionals who share in the treatment and care of people with OCD/BDD
Commissioners of services
Service users, families/carers
NOTES FOR PRESENTERS
THE SLIDE SET IS FOCUSED ON OBSESSIVE COMPULSIVE DISORDER – PLEASE REFER TO FULL GUIDELINE, NICE GUIDELINE AND NICE QRG FOR MORE INFORMATION RELATING TO BODY DYSMORPHIC DISORDER
Target audience: psychiatrists, clinical psychologists, mental health nurses, community psychiatric nurses, social workers, practice nurses, secondary care medical staff, paramedical staff, occupational therapists, pharmacists, paediatricians, other physicians, GPs, family/other therapists. For commissioners and service planners.
The guideline covers:
Children = age 8 – 11 years
Young people = 12 – 18 years
Adults 4

5. What is OCD?
Obsessive-compulsive disorder (OCD): characterised by the presence of either obsessions (repetitive, distressing, unwanted thoughts) or compulsions (repetitive, distressing, unproductive behaviours) – commonly both. Symptoms cause significant functional impairment/distress
Diagnostic criteria:
ICD-10/DSM-IV – must include the presence of either compulsions or obsessions
NOTES FOR PRESENTERS
Refer to full guideline –
section and Appendix 15 gives a comparison of diagnostic criteria from ICD-10 and DSM-IV)
The diagnostic criteria ICD-10 (included within the broad category of Neurotic, Stress-related and Somatoform disorders) and DSM-IV (classified as an anxiety disorder) are virtually identical and must include the presence of either obsessions or compulsions. The obsessions must cause marked distress or significantly interfere with the patient’s occupational and / or social functioning, usually by wasting time.
Section 2.1.5
It may take individuals between years or longer to seek professional help.
Recurrent compulsions and obsessions interfere with work/educational, home, family and social functioning.
OCD is often complicated by depression. 5

6. How common is OCD?
Estimated UK prevalence 1-2% of adult population - fourth most common mental disorder after depression, alcohol and substance abuse, and social phobia
1% of young people – adults often report experiencing first symptoms in childhood
Onset can be at any age. Mean age is late adolescence for men, early twenties for women
NOTES FOR PRESENTERS 6

7. Recommendations identified as key priorities
All people with OCD should have access to evidence-based treatments: CBT including exposure and response prevention (ERP) and/or pharmacology
CBT (including ERP) should be offered in a variety of formats
NOTES FOR PRESENTERS
CBT and ERP can be delivered in a variety of formats:
Low intensity
Less than 10 therapist hours
brief individual CBT (including ERP) using structured self-help materials
Brief individual CBT (including ERP) by telephone
Group CBT (including ERP) (more than 10 hours of therapy)
More intensive
More than 10 hours of therapy 7

8. Recommendations identified as key priorities
PCTs, mental healthcare trusts and children’s trusts that provide mental health services should have access to a specialised OCD multidisciplinary healthcare team
Anyone who has relapsed and has been re-referred should be seen as soon as possible
NOTES FOR PRESENTERS
Refer to QRG and NICE guideline –
- Section key priorities
Access to specialised team –
help to increase the skills of mental health practitioners in the assessment and evidence-based treatment of children and adults with OCD
Provide high quality advice
Understand family and developmental needs
Conduct expert assessment and specialist cognitive-behavioural and pharmacological treatment when appropriate.
Children, young people and adults who have been successfully treated, discharged but re-referred after a first episode of OCD should be seen as soon as possible rather than placed on a routine waiting list 8

9. Stepped-care model
The model provides a framework in which to organise the provision of services in order to identify and access the most effective interventions
Stepped care attempts to provide the most effective but least intrusive treatments appropriate to a person’s needs
The recommendations in the NICE guidance are structured around the stepped-care model
NOTES FOR PRESENTERS
Refer to NICE guideline and full guideline –
Section 2.5
The guideline suggests that a stepped care model could prove useful if applied to UK settings to encourage access to intensive treatment when severity or risk indicate less intensive treatment would be inappropriate.
Each step introduces additional interventions: the higher steps normally assume interventions in the previous step have been offered/attempted but there are situations when an individual may be referred to any appropriate level.
The guidance follows the steps in the figure on slide 10 9

10. STEP 6 Inpatient care or intensive treatment
STEPPED CARE MODEL
Who is responsible for care?
STEP 6 Inpatient care or intensive treatment
programmes. CAMHS Tier 4
STEP 5 Multidisciplinary teams with specific expertise in
management of OCD. CAMHS Tiers 3 and 4
STEP 4 Multidisciplinary care in primary or secondary care.
CAMHS Tiers 2 and 3
STEP 3 GPs and primary care team, primary care mental health
worker, family support team. CAMHS Tiers 1 and 2
STEP 2 GPs, practice nurses, school health advisors, general health
settings. CAMHS Tier 1
NOTES FOR PRESENTERS
Refer to QRG (page 7) NICE guideline –
Section 1.2
Each step introduces additional interventions: the higher steps normally assume interventions in the previous step have been offered and/or attempted but there are situations where an individual may be referred to any appropriate level.
The guidance follows the steps in the figure
STEP 1 Individuals, public organisations, NHS 10

11. STEP 1 Awareness and recognition
PCTs, mental healthcare trusts and children’s trusts that provide
mental health services should:
have access to a specialist OCD multidisciplinary team offering age-
appropriate care
Specialist mental healthcare professionals/teams in OCD should:
collaborate with local and national voluntary organisations to increase
awareness and understanding of the disorders and improve access to
high quality information about them
collaborate with people with the disorders and their family/carers to
provide training for all mental health professionals
NOTES FOR PRESENTER
Step 1 applies to any age group 11

12. Step 2 Recognition and assessment
Routinely consider and explore the possibility of comorbid OCD
for people:
at higher risk of OCD, such as those with symptoms of:
- depression
- anxiety
- alcohol or substance abuse
- BDD
- an eating disorder
attending dermatology clinics
NOTES FOR PRESENTER
Step 2 applies to any age group
Refer to QRG (page 9)and NICE guideline –
Sections to
People at higher risk of OCD – ask direct questions about possible symptoms, such as:
Do you wash or clean a lot?
Do you check things a lot?
Is there any thought that keeps bothering you that you’d like to get rid of but can’t?
Do your daily activities take a long time to finish?
Are you concerned about putting things in a special order or are you very upset by mess?
Do these problems trouble you?
Ask direct questions about possible symptoms 12

13. Step 2 Recognition and assessment
For any person diagnosed with OCD:
assess risk of self-harm and suicide (particularly if depression already
diagnosed)
include impact of compulsive behaviours on patient and others in risk
assessment
consider other comorbid conditions or psychosocial factors that may
contribute to risk
consult mental health professional with specific expertise in OCD if
uncertain about risks associated with intrusive sexual, aggressive or death-
related thoughts. (These themes are common in OCD and are often
misinterpreted as indicating risk.)
NOTES FOR PRESENTER
Refer to QRG (page 9)
Step 2 is applicable to any age group 13

14. Patient cannot engage in/CBT (+ERP) is inadequate
Steps 3~5 Treatment options for adults
with OCD
Mild functional Moderate functional Severe functional
impairment impairment impairment
Brief CBT (+ERP)
< 10 therapist hours
(individual
or group
formats)
Offer choice of:
more intensive CBT
(+ERP)
>10 therapist hours or
course of an SSRI
Inadequate response at 12 weeks
Multidisciplinary review
Offer combined
treatment of
CBT (+ERP)
and an SSRI
NOTES FOR PRESENTER
Please refer to the NICE guideline and QRG (pages 10 and 11) for the full overview of treatment pathway
Mild functional impairment: if the patient cannot engage in CBT (with ERP) or CBT (with ERP) is inadequate, consider:
Moderate functional impairment: if inadequate response at 12 weeks, multidisciplinary review and consider:
Severe functional impairment: if inadequate response at 12 weeks, or no response to SSRI or patient has not engaged in CBT, consider: (refer to next slide 15)
Refer to QRG (page 10) and NICE guideline –
Section to
The intensity of psychological treatment has been defined as the hours of therapist input per patient. By this definition, most group treatments are defined as low intensity treatment (less than 10 hours of therapist input per patient), although each patient may receive a much greater number of hours of therapy.
CBT and ERP can be delivered in a variety of ways e.g. individual / group therapy, telephone, books and self-help.
Patient cannot engage in/CBT (+ERP) is inadequate
Please refer to QRG for full overview of treatment pathway 14

15. Steps 3~5 Treatment options for adults
Severe functional impairment:
offer combined treatment with CBT (including ERP) and an SSRI *
Offer either: a different SSRI or clomipramine *
Refer to multidisciplinary team with expertise in OCD *
Consider:
additional CBT (including ERP), or cognitive therapy
adding an antipsychotic to an SSRI or clomipramine
combining clomipramine and citalopram
NOTES FOR PRESENTER
This slide continues from the previous slide (slide 14)
* If there has been inadequate response or the patient cannot engage – move to the next step
Do not routinely initiate treatments such as combined antidepressant and
antipsychotic augmentation in primary care 15

16. Steps 3~5 Treatment options for children and young people with OCD
Mild functional Moderate to severe
impairment functional impairment
Consider guided
self-help
support and
information for
family/carers
Offer CBT (+ERP)
involve family/
carers
(individual or
group formats)
Consider an
SSRI
(with careful
monitoring)
Ineffective or refused
Ineffective
or refused
NOTES FOR PRESENTERS
Please refer to NICE guideline and QRG (page 12) for full overview of treatment pathway for children and young people
OCD – use licensed medication, either:
Sertraline
Fluvoxamine *
* At the date of publication (November 2005) the following do not have a UK Marketing Authorisation: fluvoxamine for use in OCD in children younger than aged 8 years, fluoxetine for OCD in children and young people.
Please refer to QRG for full overview of treatment pathway 16

17. Steps 3~5 Treatment options for children and young people
Consider an SSRI (e.g. use licensed medication) and carefully monitor for
adverse events *
Multidisciplinary review *
SSRI + ongoing CBT (including CBT)
Consider use in 8-11 year age group
Offer to year age group
Carefully monitor for adverse events, especially at start of treatment
NOTES FOR PRESENTER
This slide continues from the previous slide (16)
Refer to QRG (page 12)
Mild functional impairment: If guided self-help ineffective or refused, consider:
Moderate to severe functional impairment: If patient cannot engage with or declines CBT (with ERP), consider:
Consider an SSRI and carefully monitor for adverse events.
If SSRI prescribed, use in combination with concurrent CBT (with CBT)
SSRIs should only be used after assessment and diagnosis by a child/adolescent psychiatrist who should be involved in decisions about dose changes and discontinuation.
Use low starting dose, especially for young children
OCD – use licensed medication, either:
Sertraline
Fluvoxamine *
* At the date of publication (November 2005) the following do not have a UK Marketing Authorisation: fluvoxamine for use in OCD in children younger than aged 8 years, fluoxetine for OCD in children and young people. *
Consider either (especially if previous good response to):
a different SSRI
clomipramine 17

18. Step 6 - Intensive treatment and inpatient services
People with severe/chronic problems should have continuing access to multidisciplinary teams with specialist expertise in OCD
Inpatient services are appropriate for a small proportion of people with OCD
A small minority of adults will need suitable accommodation in a supportive environment in addition to treatment
NOTES FOR PRESENTERS
Refer to QRG (page 21) and NICE guideline –
Section , and
OCD can usually be managed in the community and in primary care. However, inpatient services, with specific expertise in OCD, may be appropriate for a small proportion of people with OCD when:
There is risk to life
There is severe self-neglect
There is extreme distress or impairment
A person has not responded to adequate trials of pharmacological/psychological/combined treatments over long periods of time in other settings
A person has additional diagnoses, such as severe depression, anorexia nervosa or schizophrenia, that make outpatient treatment more complex
A person has a reversal or normal night/day patterns that make attendance at any day-time therapy impossible
The compulsions and avoidance behaviour are so severe or habitual, normal activities of daily living cannot be undertaken
In addition to treatment, suitable accommodation in a supportive environment may be necessary for some adults with long-standing and disabling obsessive compulsive symptoms that interfere with daily living, in order to enable them to develop life skills for independent living.
Children and young people with severe OCD / BDD with high levels of distress and/or impaired functioning and who have not responded to adequate treatment in outpatient settings or those with significant self-neglect or risk of suicide should be offered assessment for intensive inpatient treatment.
People re-referred should not be placed on a routine waiting list. 18

19. Discharge after recovery
When in remission, review regularly for 12 months by a mental health professional – frequency to be agreed between the healthcare professional and person with OCD
At the end of the 12-month period if recovery is maintained the person can be discharged to primary care
If relapse – see as soon as possible
NOTES FOR PRESENTERS
Refer to QRG page 22 19

20. Psychological interventions - adults
CBT (including ERP) is the mainstay of psychological treatment
Consider CBT (including ERP) for patients with obsessive thoughts without overt compulsions
Consider cognitive therapy adapted for OCD:
- as an addition to ERP to enhance long-term symptom reduction
- for people who refuse or cannot engage with treatments that include ERP
NOTES FOR PRESENTERS
Refer to QRG (page 14) and NICE guideline –
Section
ERP = exposure to obsessive thoughts and response prevention of mental rituals and neutralising strategies
Psychological treatment is aimed at improving coping skills and reducing symptoms.
All healthcare professionals offering treatments for OCD to people of any age should:
receive appropriate training in these interventions and there should be on-going clinical supervision in line with recommendations in Organising and Delivery Psychological Therapies (Department of Health 2004). Available from
Refer to NICE guideline –
Sections , and
CBT and ERP can be delivered in a variety of ways: individual / group, telephone, books and self-help.
Consider involving a family member or carer as co-therapist in ERP.
The intensity is dependent upon the degree of functional impairment and patient preference. For people with significant functional impairment, access to appropriate support for travel and transport may be necessary to allow them to attend for treatment. 20

21. Psychological interventions - adults
If a family member/carer is involved in compulsive behaviours, avoidance or reassurance seeking, treatment plans should help them to reduce their involvement in a supportive way
The intensity of intervention is dependent upon the degree of functional impairment and patient preference
NOTES FOR PRESENTERS 21

22. Psychological interventions – children and young people
Guided self-help, CBT (including ERP) recommended
Work collaboratively and engage the family or carers
Identify initial and subsequent treatment targets collaboratively with the patient
Consider the wider context including other professionals involved with the child
Maintain optimism in child and family or carers
Consider including rewards to enhance motivation
NOTES FOR PRESENTERS
Refer to QRG (page 15) – Consider offering one or more additional sessions after completion of CBT, if needed, at review appointments.
Refer to NICE guideline –
Section
All healthcare professionals offering treatments for OCD to people of any age should:
Receive appropriate training in these interventions and there should be on-going clinical supervision in line with recommendations in Organising and Delivery Psychological Therapies (Department of Health 2004). Available from
Sections , and
Things to consider in the cognitive-behavioural treatment of children and young people with OCD or BDD -
Section 22

23. How to use pharmacological treatments - adults
Starting treatment
address common concerns about taking medication with the patient e.g. potential side effects including worsening anxiety
explain that OCD responds to drug treatment in a slow and gradual way and that improvements may take weeks or months
Choice of drug
initial pharmacological treatment should be an SSRI
if drug treatment effective, consider continuing for 12 months to prevent relapse and then review with the patient
consider prescribing a different SSRI if prolonged side effects
NOTES FOR PRESENTERS
Starting the treatment – refer to NICE guideline section
Choice of drug treatment – refer to NICE guideline section to
Initial SSRI should be one of the following: Fluoxetine, fluvoxamine, paroxetine, sertraline or citalopram.
Apart from SSRIs and clomipramine, other anti-depressants are generally not helpful.
Drugs not recommended for OCD:
The following should not normally be used without comorbidity –
Tricyclic antidepressants (except clomipramine)
Tricyclic-related antidepressants
SNRIs (including venlafaxine)
MAOIs
Anxiolytics (except cautiously for short periods to counter early activation of SSRIs)
Antipsychotics as monotherapy should not normally be used for OCD 23

24. How to use pharmacological treatments - adults
Monitoring risk
Monitor closely on a regular basis particularly:
- during the early stages and during dose changes of SSRI treatment
- adults younger than 30
- people who are depressed or considered to present an increased suicide risk
Consider prescribing limited quantities of medication and enlisting others e.g. other carers may contribute to the monitoring until the risk is no longer significant
NOTES FOR PRESENTERS
Refer to NICE guideline –
Sections 1.5.3
Current published evidence suggests that SSRIs are effective in treating adults with OCD. However, SSRIs may increase the risk of suicidal thoughts and self-harm in people with depression and in younger people. It is currently unclear whether there is an increased risk for people with OCD. Regulatory authorities recommend caution in the use of SSRIs until evidence for differential safety has been demonstrated.
Monitoring risk – refer to NICE guideline section 24

25. How to use pharmacological treatments - adults
Poor response to initial treatment
if symptoms not responded adequately within 12 weeks to treatment with an SSRI or CBT (including ERP) - conduct multidisciplinary review
consider offering combined treatment of CBT (including ERP) and an SSRI
consider offering a different SSRI or clomipramine if symptoms not responded to combined treatment
then if not responded, consider referral to multidisciplinary team with specific expertise in OCD for comprehensive assessment and further treatment planning
NOTES FOR PRESENTERS
Poor response to initial treatment for adults
Refer to NICE guideline –
Section 1.5.4
How to use clomipramine for adults
Section 25

26. How to use pharmacological treatment - adults
Discontinuing treatment
taper the dose gradually when stopping treatment in order to minimise potential discontinuation/withdrawal symptoms
encourage people to seek advice if they experience significant discontinuation/withdrawal symptoms
NOTES FOR PRESENTERS
Poor response to initial treatment for adults
Refer to NICE guideline –
Section 1.5.4 26

27. When to use pharmacological treatments – children and young people
If CBT ineffective or refused - carry out a multidisciplinary review and consider adding an SSRI
Sertraline and fluvoxamine are the only SSRIs licensed for use in children and young people with OCD*
Monitor carefully and frequently
If successful, continue for 6 months post remission
Withdraw slowly with monitoring
NOTES FOR PRESENTERS
Refer to QRG (page 13) –
If SSRI prescribed, use in combination with concurrent CBT (with CBT)
SSRIs should only be used after assessment and diagnosis by a child/adolescent psychiatrist who should be involved in decisions about dose changes and discontinuation.
Use low starting dose, especially for young children
OCD – use licensed medication, either:
Sertraline
Fluvoxamine *
* At the date of publication (November 2005) the following do not have a UK Marketing Authorisation: fluvoxamine for use in OCD in children younger than aged 8 years, fluoxetine for OCD in children and young people.
Refer to NICE guideline –
Section 1.5.5
Current published evidence suggests that SSRIs are effective in treating children and young people with OCD.
The only SSRI licensed for use in children and young people with OCD is sertraline.
When used as a treatment for depression, SSRIs can cause significant adverse reactions including increased suicidal thoughts and risk of self-harm but it is not know whether this same risk occurs with their use in OCD. SSRIs may be safer in depression when combined with psychological treatments (see the NICE guide Depression in children and young people – 028). Given that the UK regulatory authority has advised that similar adverse reactions cannot be ruled out in OCD, appropriate caution should be observed, especially in the presence of comorbid depression.
Section
If an SSRI is to be prescribed to children and young people with OCD, it should only be following assessment and diagnosis by a child and adolescent psychiatrist who should also be involved in decisions about dose changes and discontinuation.
Section
Children and young people with OCD started on SSRIs should be carefully and frequently monitored and seen at an appropriate and regular basis agreed by the patient, his or her family or carers an the healthcare professional and this should be recorded in the notes.
Section
The starting dose of medication for children and young people with OCD should be low, especially in younger children. A half or quarter of the normal starting dose may be considered for the first week.
For recommendations on how to use clomipramine in children and young people and how to stop or reduce SSRIs and clomipramine – refer to NICE guideline – sections to 27

28. Special issues for children and families
Symptoms are similar in children, young people and adults and they respond to the same treatments
Stressful life events may worsen symptoms or relapse may occur:
- school transitions
- examination times
- relationship difficulties
- transition from adolescence to adult life
Parents may feel guilty and anxious
Increase in severity if left untreated
NOTES FOR PRESENTERS
Refer to full guideline 28

29. Needs of people with OCD
Early recognition, diagnosis and effective treatment
Information about the nature of OCD and treatment options
Respect and understanding
What to do in case of relapse
Information about support groups
Awareness of family/carer needs
NOTES FOR PRESENTERS
Refer to Full guideline 29

30. Implementation for clinicians
Diagnosis:
Increase your awareness and recognition of symptoms of OCD - be aware of those at higher risk and how difficult initial disclosure is for many people with OCD
Ask the ‘right’ questions – assessment
Treatment:
Involve patients and when appropriate, family/carers, fully in treatment options
Offer CBT (including ERP)
If pharmacological treatment is required, regularly monitor side effects of SSRIs (self-harm and suicide)
NOTES FOR PRESENTERS
Ensure continuity of care and minimise the need for multiple assessments by different health care professionals
Co-ordination of care across primary / secondary care interface
Initial disclosure difficult for many people with OCD
Recognition and assessment - co-morbidities – depression is common 30

31. Implementation for clinicians
Access to services:
Be aware of how to access specialist teams
Ensure you have access to local protocols
Training:
Identify your training needs in the use of CBT (including ERP) for OCD
Less therapist-intensive interventions have a role to play, particularly in primary care
NOTES FOR PRESENTERS 31

32. Implementation for managers
Actively disseminate the guidance
Carry out a baseline assessment
Develop and implement an action plan
Ensure CBT and specialist teams can be accessed appropriately
Identify professionals that require training or updating in CBT (including ERP) – less-therapist intensive interventions have a role to play, particularly in primary care
Include OCD within local education planning e.g. PTIs
Monitor and review
NOTES FOR PRESENTERS
This slide is intended as a discussion tool.
See NICE OCD implementation advice –
Multidisciplinary Protected Time Initiatives (PTIs) / Protected Leaning Time (PLTs) / GP lunchtime education sessions
Seamless transition between services – age related
Co-ordination of care – clear agreement who is responsible for patient and treatment
(possibly CPA) 32

33. Four implementation tools support this guidance
Costing tools
- a local costing template
- a national costing report
Implementation advice
Audit criteria
This slide set
The tools are available on our website: 33

34. Where is further information available?
Quick reference guide: summary of recommendations for health professionals -
NICE guideline -
Full guideline: all of the evidence and rationale behind the recommendations -
Information for the public: plain English version for people with OCD, carers and the public -
NOTES FOR PRESENTERS
The slides do not replace the full version of the guideline and should be used in conjunction with the Quick Reference Guide or Full guideline – links are displayed above.
What other NICE guidance should be considered?
Depression: management of depression in primary and secondary care -
Anxiety: management of anxiety in adults in primary, secondary and community care -
Depression in children: identification and management of depression in children and young people in primary care and specialist services -
Computerised cognitive behaviour therapy (CCBT) for the treatment of depression and anxiety – Publication expected September 2005) - 34

35. www.nice.org.uk NOTES FOR PRESENTERS
You can find more information on NICE and our work by visiting the website at 35