5.2.1. Introduction

More than 30 years of published research and a large number of authoritative accounts have led to a widely held consensus that behaviour therapy is an effective treatment for OCD. Indeed, the successful treatment of OCD was one of the early success stories for behaviour therapy. The early experimentation with a diverse range of behaviourally based procedures has evolved into a therapy with a central technique, ERP, that can be used in a variety of formats, including book and computer-based self-help, group therapy, and individual therapy that ranges from minimal therapist contact or telephone contact through to intensive outpatient and inpatient regimes (Foa & Franklin, 2000; Himle et al., 2003; Lovell et al., 2000; Marks, 1997). Cognitive therapies have emerged more recently with the hope that they would improve the efficacy of behaviour therapy and provide an alternative to those who have difficulty in engaging in ERP (Salkovskis & Warwick, 1986; Wilhelm, 2000). Many contemporary treatment approaches combine behavioural and cognitive approaches, but there are proponents of purer forms of both. It is important to note that in general, published treatment studies almost certainly do not cover all symptom presentations equally. Washing/cleaning and checking are probably well represented, but obsessions without overt compulsions and hoarding are most likely to be underrepresented except in studies that specifically target these forms. It is difficult to know the extent to which other less frequent forms are included in treatment studies, or their response to treatment (see also Mataix-Cols et al., 2002a).

5.2.2. Current practice

During the rapid development of behaviour therapy in seventies, Professor Isaac Marks established a training programme at the Maudsley Hospital in 1972 to develop behaviour therapy skills among psychiatric nurses. This programme, and others that followed, established a strong core of skilled behaviour nurse therapists working in the NHS (Gournay et al., 2000). The work at the Maudsley and other centres also influenced professional training for psychologists and psychiatrists, among others, and so emerged a strong multidisciplinary tradition for behaviour therapy in centres throughout the UK. Multidisciplinary training in cognitive therapy developed in the early nineties and in 2004 there were over twenty post-qualification courses across the UK offering training in cognitive and behavioural therapies (www.babcp.org). There are, however still gaps in the provision of training and although most are accredited with universities, accreditation by the British Association of Cognitive and Behavioural Therapies is not yet widespread. Almost all basic professional training in psychiatry, psychology and nursing includes some training in these therapies. Thus, there is a large body of clinicians with knowledge of these approaches, although there are relatively few with specific expertise and experience in the application of cognitive and behavioural therapies to the treatment of OCD.

Therapists with the necessary expertise have traditionally been found in secondary and tertiary care settings. There is an unequal distribution of accredited therapists across the UK (Shapiro et al., 2003) and the picture is likely to be similar with trained but non-accredited therapists. However, there are increasing numbers of clinicians with CBT training in primary care and there are a number of recent training programmes to enable professionals in primary care with little CBT experience to provide assisted self-help to people with anxiety disorders (for example, Lovell et al., 2003), including OCD.

A recent report from the Department of Health (2004), addresses issues related to current provision of psychological therapies, training, supervision, and competence. While not limited to CBT, the report makes a number of recommendations on these issues and provides guidance on the organisation and provision of training, continuing professional development, and clinical supervision.

5.2.3. Interventions included in the review

The following interventions were included:

• Behaviour therapy
• Cognitive therapy
• Cognitive behavioural therapy
• Rational-emotive therapy.

5.2.4. Studies considered for review³

The review team conducted a new systematic search for RCTs that assessed the efficacy and tolerability of behavioural and cognitive therapies among adults with OCD. Thirty-seven studies were identified, of which 20 did not meet the inclusion criteria of the GDG. The 17 included studies provided efficacy data from 820 participants and tolerability data from 734 participants.

Of the included studies, two compared ERP with systematic relaxation or anxiety management (GREIST2002; LINDSAY1997), and two compared CBT with waitlist controls (CORDIOLI2003; FREESTON1997) Four studies compared ERP with cognitive therapy (COTTRAUX2001; MCLEAN2001; VANOPPEN1995; WHITTAL2005), one study with CBT (VOGEL2004), two with rational-emotive therapy (EMMELKAMP1988; EMMELKAMP1991), and seven with other variants of behaviour therapy (DEARAUJO1995; EMMELKAMP1983; GREIST2002; HISS1994; KENWRIGHT2005; LOVELL1994; MEHTA1990).

All included studies were between 3 and 44 weeks long (mean length = 12 weeks). Patients were treated in an outpatient setting in eight studies; the setting was unclear in the remaining nine studies. In one study (FREESTON1997), the patients had obsessive symptoms only. Another study (LOVELL1994) was concerned with patients with rituals only. Four studies were conducted in the US, four in the Netherlands, three in the UK, and one each in Australia, Brazil, Canada, France, India and Norway. The average age of the participants was 35 years and the average duration of illness was 12.26 years.

Full details of the studies included in the guideline and the reasons for excluding are given in Appendix 16.

5.2.5. Psychological interventions versus control (systematic relaxation, anxiety management or wait list)

5.2.6. Psychological interventions versus other psychological interventions

5.2.7. Therapist time in psychological interventions

5.2.8. Clinical summary

As noted in the introduction, despite 35 years of research into the cognitive behavioural treatment of OCD, there are a limited number of RCTs that compare active treatments with controls. Those that exist indicate that clinician-guided ERP is an effective treatment for OCD. One study found that family-based behaviour therapy including ERP was superior to individual therapy. This study was conducted in India and these findings may not necessarily apply widely in the UK, although experts would certainly consider involving the family in many cases.

There is also some evidence for computerised ERP some indication that there should be scheduled support as fewer people left the study early when it was delivered with scheduled brief support sessions rather than support on request.

There is as yet little evidence for either cognitive therapy or CBT from RCTs against control conditions although the effects observed from head to head trials suggest that effects post-treatment are of a similar order to ERP. There is support for CBT (including ERP) for obsessive thoughts. Likewise, group CBT has been shown to be effective compared with waitlist control.

Currently there is no evidence showing that cognitive therapy is more or less effective than ERP alone. One study did find that adding cognitive therapy to ERP midway through treatment resulted in a better outcome at 6 months' follow-up. However, a second study found that group ERP was superior to group cognitive therapy at 12 months' follow-up. This question may never be answered in a convincing way as it is difficult to deliver two distinct, non overlapping-treatments. Many modern exposure-based treatments do include a high informational content and the strategies used to engage people in ERP can resemble cognitive therapy. Likewise, most current cognitive therapy explicitly seeks behaviour change but is not operating within a habituation paradigm. Although there is as yet no research on those who refuse, fail to engage with, or do not respond to ERP, cognitive therapy may yet have a role to play for these individuals, either as a new modality, or as a means of ultimately engaging them in ERP.

The review of therapist hours as an indicator of intensity revealed that the effect sizes (between pre- and post-treatment) for all three treatment intensity bands were large or greater (>0.8 SMD) although these are not controlled comparisons. Despite such effects, a proportion of patients in all three bands will not have benefited from treatment, and others will have shown a limited response and have residual symptoms that require further treatment, perhaps more likely in the low intensity band because of the smaller treatment effect. However, patients receiving more therapist hours of cognitive and behavioural intervention per patient were more likely to improve on OCD symptom severity compared with patients receiving fewer therapist hours. This effect was strongest when comparing patients receiving fewer than 10 therapist hours per patient with patients receiving more than 10 therapist hours per patient of psychological intervention. These findings together suggest that there may be benefit in more intensive forms of therapy over less intensive forms of therapy when calculated in terms of therapist hours per client.

Despite the preliminary nature of these findings and the limitations noted above, there are important implications for stepped care as less intensive therapies have a role to play, particularly in primary care and there may be benefits for some people receiving care in this setting rather than in secondary care or specialist services. There is also clearly a role for more intensive treatment, usually individual therapy, which may be found in increasingly specialist settings, especially for those for whom initial lower intensity interventions have proved inadequate.

5.3.1. Introduction

Until the 1960s psychoanalysis was widely viewed as the treatment of choice for neurosis and so for all of the anxiety disorders including OCD. Psychoanalysis for OCD was heavily influenced by the work of Freud's 14 papers on the subject, including his classic case history of the ‘Rat Man’ (Freud, 1909). Freud's conceptualisation of obsessional phenomena focuses on anxiety derived from unresolved Oedipal conflicts resulting in anal-sadistic regression, which the ego fends off through defence mechanisms such as reaction formation, intellectualisation, undoing and isolation (Barth, 1990; Freud, 1909). Although some authors have expanded on, or offered other psychoanalytic formulations of OCD (Esman, 2001; Wells, 1990), the Freudian conceptualisation remains powerful today. As late as 2001 Burgy wrote: ‘Attention is focused on the intrapsychological structure and conflicts, so that Freud's theory of an internal dependence on the superego instead of the external dependence on people around continues to prevail in obsessive compulsive neurosis’ (Burgy, 2001).

Psychoanalysis focuses on the identification, clarification and alteration of the defence mechanisms that maintain the anxiety (Salzman, 1997). Treatment emphasises the relationship between therapist and patient and involves transference, counter-transference and interpretation (Salzman, 1983). Traditional psychoanalysis involves a highly trained practitioner who provides up to four sessions a week over a period of up to several years although less frequent sessions and shorter courses of treatment may be offered.

Psychoanalysis for OCD remains a treatment option in parts of England and Wales where such services are available. However, over the last 3 decades psychoanalytic therapy has become less frequent as a treatment for OCD. This may be because the emergence and widespread acceptance of treatments such as specific pharmacological therapies and CBT for OCD have provided a range of treatment options for which there is an evidence base.

5.3.2. Studies considered for review

No systematic reviews or meta-analyses of the effectiveness of psychoanalysis for OCD were found therefore a narrative review was undertaken. Only papers written in English were considered and a total of 64 papers were reviewed (dating from 1912 to 2002). None of the papers considered for review was an RCT or cohort study and so the evidence reviewed consists of single case reports, a few case series, and theoretical reviews.

5.3.3. Descriptive review

Many of the articles describe single case reports detailing the nature of the analysis in both adults (Boehm, 2002; Cela, 1995; Finell & McDougall, 1985) and children (Fingert Chused, 1999; Karush, 1998). A few articles were found citing case series, though the maximum number of patients in these studies was three (Fingert Chused, 1999; Lang, 1997). Moreover, Lang (1997) used these cases to illustrate unconscious determinants rather than to report outcome. Some authors described group analytic treatment (Schwartz, 1972; Wells, 1990), but these case reports do not report outcome in any systematic way. A number of the single cases provided a description of ongoing analysis with a patient (Boehm, 2002; Deri, 1990; Willick, 1995), but did not provide any measure of outcome.

The single case reports that reported successful outcome (Chatterji, 1963; Parfitt, 1999) did not report clinical process or any measure of outcome. More importantly, the individualised nature of psychoanalytic interventions makes it almost impossible to replicate. Several of the articles and case reports acknowledge the limitations of psychoanalysis for OCD in terms of its ineffectiveness, and argue against its utility in integrating it with other interventions (Fingert Chused, 1999; Gabbard, 2001; Kay, 1996). For example, psychoanalysis has been used to help engage people with OCD to undertake other forms of treatment such as CBT (McCarter, 1997), and in conjunction with pharmacotherapy and behavioural treatments in both adults (Leib, 2001) and children (Gold-Steinberg & Logan, 1999). However, such combination treatments tell us little about the effect of each individual intervention, and the absence of outcome measures precludes any conclusions regarding treatment efficacy.

Despite generally poor outcomes many of the case reports reported intense analytic therapy ranging from one to four sessions per week over periods extending from 6 months to 19 years (Boehm, 2002; Cela, 1995; Juni, 1987). Esman (2001) sums up the evidence base: ‘In our series of 21 patients who were collectively the recipients of more than one century of psychodynamic treatments, we had no reason to be ... optimistic’.

5.3.4. Clinical summary

There is no evidence of efficacy or effectiveness for psychoanalysis in the treatment of OCD. Given the lack of evidence and the resources required for such intensive treatment, there is doubt as to whether it has a place in mental health services for OCD.

5.4.1. Introduction

Although the efficacy and effectiveness of CBT has been demonstrated, there are limits to its utility. Emmelkamp and Foa (1983) cited that 30% of OCD sufferers declined behaviour therapy while Kozak and colleagues (2000) reported during the course of their study that 40% of those who commenced behaviour therapy did not complete treatment. ERP can be unpleasant and distressing to clients and may lead to discontinuation of therapy. When taking into account those who refuse or drop out of treatment and those who do not benefit immediately or relapse, researchers have estimated that those treated successfully with behaviour therapy is around 55% (Stanley & Turner, 1995).

Although there is a strong evidence base for cognitive and behavioural therapies, people with OCD who are seeking help frequently indicate that they would like to be informed about a range of other treatments, their efficacy and availability. If first-line treatments are unavailable, have been unsuccessful, or discontinued due to distress or intolerable side effects, it may be useful for clinicians and people with OCD to know about other psychological interventions that could be beneficial.

5.4.2. Current practice

Current practice in the treatment of OCD using other psychological interventions and alternative/complimentary therapies is difficult to determine, as there is a paucity of literature. To date there has been one published RCT on an alternative therapy (yogic meditation) in the treatment of OCD in adults. No RCTs have been published on any of the other psychological interventions that have been used with OCD. Furthermore, no well-designed single case studies have been published on either other psychological interventions or alternative/complementary therapies. The literature is limited and restricted to clinical case reports of one or more adults with OCD. Subsequently, the number of OCD clients treated using other psychological or alternative/complementary therapies is small, with minimal replication for any given approach.

Although CBT is available in many places in the NHS in England and Wales, people with OCD continue to be offered a range of other psychological treatments. There are a number of factors why this is likely to be the case. First, many psychological therapists are trained in modalities other than CBT and so would tend to offer the therapy in which they are trained. Second, some psychological therapists have a level of knowledge of a range of therapeutic modalities and choose an eclectic position. They would use elements of different therapies based on the way that they understand the person's particular problems and their view of what may be effective elements. Third, referrers to psychological services may choose to refer to particular therapeutic modalities based on their own training and understanding of the person with OCD. Finally, if choice is available, people with OCD may choose particular therapeutic modalities that either conform to their own understanding of their difficulties or because other options may appear too daunting or anxiety provoking.

5.4.3. Interventions included in the review

A number of commonly used treatments were considered for review (although the list is not exhaustive):

• Yogic meditation
• Hypnosis
• Homeopathy
• Marital therapy
• Transactional analysis
• Systemic therapy
• Integrated psychological approach
• Paradoxical intention
• Gestalt therapy
• Counselling
• Morita therapy
• Group cognitive analytic therapy
• Virtual reality therapy.

5.4.4. Studies considered for review

A systematic review of all relevant literature identified one RCT on yogic meditation (Shannahoff-Khalsa et al., 1999) and 26 articles of clinical case reports without comparative treatments that described other psychological and alternative/ complementary therapies in the treatment of OCD in adults (Becker & North, 1998; Churchill, 1986; Dormaar, 1987; Erickson, 1973; Fields, 1998; Gomez de Setien, 1982; Gomibuchi et al., 2000; Hafner, 1982; Harvey & Green, 1990; Johnson & Hallenbeck, 1985; Keiley, 2002; Mitzman & Duigan, 1993; Moore & Burrows, 1991; Morphy, 1980; Norland, 1988; Pelton, 1987; Pollard, 2001; Reichenberg & Ullman, 1998a; Reichenberg & Ullman, 1998b; Reichenberg & Ullman, 1999; Reichenberg & Ullman, 2000; Scrignar, 1981; Sheinberg, 1988; Stern, 1973; Walker, 1981; Yoder, 1994). The systematic review did not identify any literature for acupuncture, neuro-linguistic processing, reflexology or aromatherapy in the treatment of OCD in adults.

5.4.5. RCT of yogic meditation

Shannahoff-Khalsa and colleagues (1999) compared the efficacy of two yogic meditation protocols in the treatment of OCD: kundalini yoga meditation and relaxation response plus mindfulness meditation. The study was in two phases; the first a 3-month RCT, the second involving the groups merging and the efficacious protocol being employed for a further 12 months. Inclusion and exclusion criteria were determined prior to enrolment and a DSM-III-R diagnosis of OCD was established. The primary outcome measure used was the Y-BOCS. Groups were matched for age, sex and medication status before randomisation of group to therapy. Fourteen adults completed phase one, seven in each group. The authors reported that kundalini yoga meditation was an effective treatment for OCD when compared with baseline measures and also when compared with the alternative protocol. However, these published results should be viewed with caution as subsequent reanalysis with Review Manager (Cochrane Collaboration, 2004) failed to support these assertions apart from a scale measuring a construct labelled Purpose in Life.

5.4.6. Clinical case reports

5.4.7. Clinical summary

The literature revealed very few clinical case reports of other psychological therapies in the treatment of OCD in adults. Those that were identified were primarily small in sample size, often including only one client. No clinical case reports used standardised outcome measures, although one report, (Fields, 1998), used a recognised validated measure at baseline. The largest number of clinical case reports identified for any one intervention was hypnosis: eight articles were identified and five reviewed. Although improvement was reported in these cases, in three cases other concurrent treatment was provided, leading to difficulty attributing causality. No comparative clinical case reports were identified.

There is insufficient evidence to support the use of other psychological therapies, hypnosis, or homeopathy therapies as routine treatments for the core features of OCD. This lack of evidence is in contrast with a much larger evidence base for cognitive and/or behavioural therapies although there are important limitations to the latter. Based on current evidence, ensuring access to adequate cognitive and/or behavioural therapies would currently appear to provide people with OCD with the best chance of improvement through psychological therapies.

5.5.1. Introduction

Several interventions have been used in the treatment of children and young people with OCD. These include behavioural interventions such as exposure, response prevention, flooding, extinction, shaping and operant techniques. Cognitive behavioural protocols have been developed that include behavioural techniques, as well as incorporating anxiety management, cognitive restructuring and parental involvement (March et al., 1994). Finally, there have been several uncontrolled studies that have used other therapeutic approaches, almost always in conjunction with behavioural techniques, that include systemic and psychodynamic approaches (Crago, 1995; O'Connor, 1983), individual psychotherapy (Warneke, 1985), insight-orientated therapy (Friedmann & Silvers, 1977; Willmuth, 1988), family therapy (Dalton, 1983; Goodman, 1988), hypnotic induction (Kellerman, 1981), social skills training (Hallam, 1974), and unspecified milieu therapy (Apter et al., 1984).

Management and treatment is often complicated in children and young people with OCD as they frequently have other comorbid problems (Last & Strauss, 1989). For instance, in a survey of 70 children and young people with OCD, only 26% had OCD as their sole disorder (Swedo et al., 1989). Frequently children and young people also present with secondary anxiety disorders, including generalised anxiety disorder, separation anxiety in younger children, and social anxiety in young people. Furthermore, a major complication of OCD in young people is the development of social avoidance and withdrawal from family and friends. Aggressive behaviour and temper tantrums can also be a management problem, and frequently occur when rituals are interrupted. Therefore the careful assessment and consideration of treating comorbid problems is necessary in clinical practice.

Although OCD in young people is similar to that found in adults, there are various developmental differences that are important to consider in the management and treatment of the young. Young children's obsessional thoughts are more likely to be characterised by ‘magical’ or superstitious thinking (e.g. ‘If I don't count up to 20 my parents will die’). Treatment needs to take account of the child's developmental stage in order to engage them in a collaborative working relationship. Age-appropriate delivery may also include the use of metaphors in order to explain difficult psychological processes, for example the use of the ‘white bear’ experiment to explain the persistence of intrusive thoughts (Shafran, 1997). Researchers have also utilised game formats of ERP interventions in order to appeal to younger children (Moritz, 1998). Young children are also more orientated in the present than adults and may be less motivated to engage in difficult activities in order to achieve future positive changes.

Furthermore, the child's age-appropriate dependence on his or her family is a key difference between the presentation of children/young people and adults. As outlined in a study by Bolton and colleagues (1983), members of the family are almost always involved in the young person's rituals, although the nature and extent of involvement often varies. Involvement can range from the relatively mild, such as occasionally providing the child with reassurance, to the extreme where the parent is highly immersed in all of the child's rituals. The degree to which families can become involved with the child or young person's OCD can lead to difficulties in management and can affect treatment compliance. Frequently, one parent is more involved than the other and the parents may not work together as a team (Bolton et al., 1983; Dalton, 1983). Some families react to their child's presentation of OCD by becoming critical and rejecting, alienating the child and adding to management difficulties. Parental behaviours may inadvertently reinforce and maintain the child's difficulties with OCD, and are often a source of family upset and discomfort. These factors have led to the frequent inclusion of family members in most of the CBT treatment protocols. Family members are often provided with psychoeducation and may be encouraged to participate in some processes of therapy, such as ERP

5.5.2. Current practice

Current practice for the treatment of young people with OCD varies widely according to professional orientation, training, and availability of resources. Multidisciplinary teams may offer a range of therapeutic interventions, often combining psychological and pharmacological treatments. CBT protocols for children and young people have been developed that can guide practitioners on the practice of cognitive and behavioural strategies with young people (March & Mulle, 1998). Most young people are treated on an outpatient basis unless the extent of their symptoms, distress and interference in their daily levels of functioning warrants an inpatient admission.

The aim of psychological treatment for children and young people with OCD is to reduce symptoms, distress and interference in daily functioning. A positive outcome would also include improved social, educational and family functioning. Treatment is further aimed at improving the young person's coping skills and teaching strategies to prevent future relapse.

OCD in children and young people has received relatively little empirical study compared with adult OCD, and many questions currently remain unanswered by the literature. To date there have been only two published randomised controlled trials of the psychological treatment of children and young people with OCD, and no systematic replication studies. Caution is needed when interpreting the results of the published studies as many have significant limitations that reduce the confidence that can be placed in their results. Although most studies report a large percentage of responders to treatment, this is often measured by different criteria across studies, and may not always represent clinically meaningful change. The participants often have a range of comorbid difficulties, may be receiving concurrent pharmacological treatment, or are receiving components of two or more treatment approaches. Furthermore, most studies are of adolescents, thus making it difficult to generalise to younger children. The methodological weaknesses found in most studies of childhood OCD indicate caution must be exercised in making statements about treatment efficacy.

5.5.3. Interventions included in the review

The contemporary psychological treatment approaches identified by the GDG and included in the review are:

• Behaviour therapy
• CBT
• Cognitive therapy
• Family therapies
• Psychoanalysis, psychoanalytic/psychodynamic/supportive/insight-orientated psychotherapy.

5.5.4. Studies considered for review

The review team conducted a new systematic search for RCTs that assessed the efficacy and tolerability of behavioural and cognitive therapies among children with OCD. The search identified one study (BARRETT2004).

The study compared individual cognitive behavioural family therapy (CBFT) with group CBFT and waitlist control. The duration of treatment was 14 weeks long, with 3 and 6 months' follow-up. The mean age of the participants was 12 years.

5.5.5. Clinical summary

The only study to date suggests that CBT (including ERP) involving the family is effective in reducing OCD symptoms in both individual and group formats. There is some evidence to suggest that these treatments also improve family function. There is also evidence to suggest that group therapy is somewhat more effective than individual therapy in reducing the young person's anxiety.

5.5.6. Descriptive review

Sixty-nine articles were identified that described or investigated the psychological treatment of OCD in one or more children or young people. Of the 69 articles, 53 were direct clinical investigations.

Fifteen papers were clinical review articles or chapters of the general psychological treatment of OCD in children and young people (AACP, 1998; Albano & DiBartolo, 1997; Franklin et al., 2003; Geffken et al., 1999; King & Scahill, 1999; King et al., 1998; March, 1995; March & Mulle, 1996; March & Mulle, 1998; March et al., 2001; Piacentini, 1999; Rapoport et al., 1993; Tolin & Franklin, 2002; Wolff & Wolff, 1991; Wolff & Rapoport, 1998).

Ten were open clinical trials involving 10 to 42 children. A protocol driven CBT manual based on the work of March and Mulle (1998) was used for several of the open clinical trials (Barrett et al., 2003; March et al., 1994), with one using a group format (Thienemann et al., 2001). The protocol incorporated psychoeducation, anxiety management training (AMT), stimulus hierarchies, graded ERP, family participation and cognitive training such as thought stopping, constructive self-talk and cognitive restructuring. One study used a protocol developed by Piacentini and colleagues (2002), which involved ERP, behavioural rewards, cognitive restructuring and parental involvement. Two other studies have concentrated upon graded ERP parent sessions (Franklin et al., 1998; Scahill et al., 1996). One open clinical trial used an adolescent group format (Fischer et al., 1998) based on a behavioural protocol developed by Krone and colleagues (1991). One used treatment-naive children and adolescents (Benazon et al., 2002). Finally, one open clinical trial compared CBT with medication (Wever & Rey, 1997). Methodologically, it is difficult to draw conclusions from these studies as to which components of the treatment package were the most effective ingredients of change. The results of the open trial studies could also be affected by bias as none used assessors that were blind to the treatment conditions.

Three studies were case series of consecutively referred young people, involving six to ten cases, and standardised protocols. The first study (N = 10) investigated pharmacological and psychological treatment that included ERP and cognitive methods for coping with anxiety and challenging appraisals (Williams & Allsopp, 1999). The second (N = 7) investigated individual CBT based on the protocol developed by March and Mulle (1998) and a parallel parent skills training module (Waters et al., 2001). The third (N = 6) investigated cognitive treatment, which included reappraising notions of responsibility (Williams et al., 2002).

Nine were experimental single case designs involving one or more individuals, defined as any report that provides a quantitative baseline assessment plus either assessment across multiple symptom domains (multiple baseline design) or treatments (such as ABAB design) (Detweiler & Albano, 2001; Francis, 1988; Freeston, 2001; Green, 1980; Harris & Wiebe, 1992; Kearney & Silverman, 1990; Knox et al., 1996; March & Mulle, 1995; Moritz, 1998).

Thirty-two papers were clinical case reports of one or more children. These are defined as having insubstantial descriptions of assessment, treatment, and/or outcome with little or no accompanying quantitative data. None of the studies measured multiple symptom domains (multiple baseline design) or treatments (such as ABAB design). Many of these studies combine two or more treatments, making it difficult to assess which approach was more effective. Two papers described consecutive cases of young people (eight and fifteen cases respectively) referred for treatment (Apter et al., 1984; Bolton et al., 1983), with one including a long-term follow-up (Bolton et al., 1996). The following described one or more cases: (Bolton & Turner, 1984; Clark et al., 1982; Crago, 1995; Dalton, 1983; Desmarais & Lavallee, 1988; Fine, 1973; Franklin et al., 2001; Frare & Lebel, 1996; Friedmann & Silvers, 1977; Goodman, 1988; Hafner et al., 1981; Hallam, 1974; Hand, 1988; Harbin, 1979; Kellerman, 1981; Morelli, 1983; O'Connor, 1983; Ong & Leng, 1979; Owens & Piacentini, 1998; Ownby, 1983; Piacentini et al., 1994; Querioz et al., 1981; Stanley, 1980; Tolin, 2001; Warneke, 1985; Weiner, 1967; Willmuth, 1988; Yamagami, 1978; Zikis, 1983).

5.5.7. Clinical summary

• Research evidence from one RCT, open clinical trials, case series, single case studies and case reports all point to the efficacy of CBT, which incorporates ERP, in the treatment of OCD in children and young people.
• In terms of format of treatment, there is evidence to suggest that involving parents in the treatment of their children, especially in CBT protocols incorporating ERP, is linked to good outcome.
• Limited research indicates that there is no difference between intensive and weekly sessions, but further research is needed to substantiate these findings.
• Although cognitive therapy may have some utility, to date the lack of outcome studies makes it difficult to draw definite conclusions about its effectiveness.
• Anxiety management training is often included in CBT protocols, but there is little evidence to point to its direct treatment effect for OCD for young people.
• For compulsive questioning and reassurance seeking, some studies suggest that extinction may be beneficial, but its use for other forms of OCD remains unsubstantiated.
• There is no evidence for the use of modelling, shaping and pacing in the treatment of OCD.
• Many studies include the use of operant rewards as an adjunct to therapy, alongside ERP interventions, to increase the child's motivation in therapy.
• There is currently no evidence that treatments aimed at changing family functioning can in themselves bring about an improvement in OCD symptoms among children with OCD.
• There is no evidence to suggest that psychotherapy approaches (psychodynamic, insight-oriented) are effective in the treatment of OCD.
• In terms of developmental factors, lack of research makes it difficult to ascertain whether there are differences in treatment outcomes for children under the age of 11 years, compared with young people aged over 11 years of age. However, the incorporation of younger children in several open clinical trials indicates that CBT protocols appear to be equally accessible when adapted to younger children.

5.6.1. Introduction

The cognitive and behavioural manifestations of BDD resemble, at least superficially, those found in other disorders as do the social anxiety and avoidance that are commonly associated with BDD. Consequently, as for other disorders with these types of features, a variety of psychological approaches have been attempted or developed.

5.6.2. Current practice

There are no surveys on what psychological interventions are used for BDD in the UK or what proportion of patients with BDD receives a psychological treatment. Many individuals with BDD have difficulty accepting a psychological or pharmacological intervention and prefer to either avoid or camouflage their appearance, alternatively they seek a cosmetic or dermatological procedure. Few mental health professionals have clinical experience in treating many patients with BDD.

Current practice is not underpinned by a strong evidence base. There are few studies upon which to base clinical decisions and doubts about the generalisability of research findings to people encountered in practice who may refuse to participate in therapy.

5.6.3. Interventions included in the review

The following interventions were included:

• CBT
• Behaviour therapy
• Cognitive therapy.

5.6.4. Studies considered for the review

The review team conducted a new systematic search for studies that examined psychological interventions in BDD. Two RCTs were identified.

Rosen and colleagues (1995) conducted an RCT of group CBT in 54 participants with BDD. Results indicated that 81.5% of the 27 patients were clinically improved after treatment. Treatment involved a small group format for an 8-week period. Therapy sessions consisted of education about causation and treatment of BDD, constructing a hierarchy of distressing aspects of their appearance, homework assignments involving exposure to anxiety provoking situations and preventing body checking behaviours, as well as keeping a body image diary. The participants in this study were different from those described in other centres, as they were less severely impaired by BDD, they were all female and the most common preoccupation was their weight and shape. However they did not have a diagnosable eating disorder.

Veale and colleagues (1996b) conducted an RCT of CBT in 19 participants who were predominantly female but more severely impaired than those in the Rosen and colleagues study. There was a 50% reduction in symptoms on the main outcome measure (Y-BOCS, modified for BDD). The emphasis in the therapy was helping the individual to have a good psychological understanding of the factors that maintained the symptoms, behavioural experiments to test out an alternative theory, exposure to situations avoided and dropping of excessive safety behaviours and rituals.

5.6.5. Descriptive review

Older RCTs and case series on body image therapy were excluded from the metaanalysis or narrative review as these were for body dissatisfaction and not body dysmorphic disorder or dysmorphophobia (Butters & Cash, 1987; Rosen et al., 1989).

Neziroglu and Yaryura-Tobias (1993b) reported on the use of exposure and response prevention and cognitive therapy in five individuals with BDD and OCD. Participants were not on any medication and received either weekly or daily 90-minute sessions for 4 to 12 weeks. One individual dropped out and the other four showed significant improvement on observer rated measures. Results suggest that intensive sessions, more than once a week, seem to provide the greatest gains.

McKay and colleagues (1997) evaluated a maintenance follow-up programme for individuals with BDD after CBT. Individuals were contacted bi-weekly for assessment with all measures for a total of 6 months. All subjects were assessed at the follow-up and all had remained symptom free. Patients in the maintenance group, however, had continued to improve on measures of anxiety and depression and showed significantly lower levels of anxiety and depression at follow-up. McKay (1999) followed up these patients 2 years' later and noted treatment gains were maintained.

Wilhelm and colleagues (1999) evaluated group CBT in BDD. It led to significant improvement in both BDD and depressive symptoms. Participants received weekly 90-minute group CBT including psychoeducation, self-monitoring, cognitive restructuring, ERP, and scheduling of pleasant events and achievement oriented activities.

Geremia and Neziroglu (2001) investigated the role of cognitive restructuring. Four individuals with BDD were treated in a single-subject multiple baseline design in which each patient served as his/her own control. Treatment consisted of 7 weeks of 75-minute sessions twice a week for cognitive treatment followed by 3 weeks of follow-up data gathering. Results indicated that cognitive therapy resulted in statistically significant reductions in BDD symptoms, depression and anxiety in three out of the four patients. Minimal improvement was seen with overvalued ideation. In this study, no behavioural assignments were given but the authors suggest that this may enhance treatment efficacy.

There are also several older case reports or case series on the successful use of behaviour therapy by Munjack (1978), Solyom and colleagues (1985), Campisi (1995), Watts (1990), Marks and Mishan (1988) and Gomez-Perez and colleagues (1994). Some of the cases in the latter two were also being treated with medication. There also case reports of CBT by Schmidt and Harrington (1995) and Neziroglu and colleagues (1996) and descriptions of the addition of reverse role-play to behaviour therapy by Newell and Shrubb (1994) and Cromarty and Marks (1995). Vitiello and DeLeon (1990) reported one unsuccessful case after many years of psychoanalysis and then behaviour therapy with medication. Eye movement desensitisation and reprocessing (EMDR) resulted in improvement in six out of seven cases (Brown et al., 1997). There is one case report describing the use of psychodynamic psychotherapy (Bloch & Glue, 1988). A review and summary of the literature in cognitive behavioural treatments for BDD is provided by Neziroglu and Khemlani-Patel (2002).

5.6.6. Clinical summary

There is some evidence from two RCTs and several case series on the benefit of CBT in adults with BDD. Little is known about the optimum frequency, type or duration of the therapy or the rate of relapse in the long term. One case report and expert opinion suggest that optimal therapy may need more intensive sessions (e.g. more than once a week especially in the early stages). The average duration of outpatient therapy may need to be slightly longer than other disorders (e.g. 20 to 25 sessions). Some evidence exists on the benefit of group CBT but this has not been compared with individual CBT or a combination of the two. There is virtually no evidence on psychological interventions in young people with BDD.

5.7.1. Interventions for people with OCD or BDD

The treatments for OCD and BDD that are effective should be offered at all levels of the healthcare system. The difference in the treatments at the higher levels will reflect increasing experience and expertise in the implementation of a limited range of therapeutic options. For many people, initial treatment may be best provided in primary care settings. However, people with more impaired functioning, higher levels of comorbidity, or poor response to initial treatment will require care from teams with greater levels of expertise and experience in the management of OCD or BDD. Regardless of the level of care or the level of expertise, all professionals offering psychological treatments should have received appropriate training in the interventions they are offering. Furthermore, to ensure safe practice it is essential that they receive ongoing clinical supervision. The organisation and provision of training and clinical supervision should follow the recommendations found in Organising and Delivering Psychological Therapies (Doh, 2004).

5.7.1.1.

All healthcare professionals offering psychological treatments to people of all ages with OCD or BDD should receive appropriate training in the interventions they are offering and receive ongoing clinical supervision in line with the recommendations in Organising and Delivering Psychological Therapies (Doh, 2004). [GPP]