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National Collaborating Centre for Mental Health (UK). Obsessive-Compulsive Disorder: Core Interventions in the Treatment of Obsessive-Compulsive Disorder and Body Dysmorphic Disorder. Leicester (UK): British Psychological Society; 2006. (NICE Clinical Guidelines, No. 31.)

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Obsessive-Compulsive Disorder: Core Interventions in the Treatment of Obsessive-Compulsive Disorder and Body Dysmorphic Disorder.

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5PSYCHOLOGICAL INTERVENTIONS

5.1. INTRODUCTION

Psychological interventions have been described for obsessive-compulsive disorder since the time of Freud. However, despite extensive writing about the disorder, OCD was generally considered to be virtually untreatable for over 50 years. In 1966 Victor Meyer described the successful treatment of two people with OCD by what would now be considered as the forerunner of modern day CBT treatments by changing cognitions and blocking compulsive rituals (Meyer, 1966). Following on from this, staff at the Maudsley Hospital developed behaviour therapy (BT) techniques in the early 1970s that offered hope for the first time and demonstrated efficacy in a series of small quasi-experimental studies (Marks et al., 1975; Rachman et al., 1971; Rachman et al., 1973). Other researchers in the UK, Europe and North America rapidly experimented with a range of behavioural techniques (Emmelkamp & Kraanen, 1977; Foa & Goldstein, 1978; Rabavilas et al., 1979).

By the early 1980s the common elements of several procedures that had been developed at different centres evolved into what is now known as exposure and response prevention (ERP) (see Steketee, 1994 for a review). Given the absence of effective treatments until the seventies, the early studies were so convincing that most researchers explored different ways of delivering the treatment components in trials looking at the differential efficacy of treatment formats rather than conducting randomised controlled trials to establish efficacy against non-treatment or attention controls. In fact, with one or two exceptions, most of the controlled trials date from after 1990.

With the rise of cognitive therapy in the eighties (Salkovskis, 1985), a variety of cognitive approaches have also been developed, mostly in combination with behavioural techniques (Freeston et al., 1996; Salkovskis, 1999; Salkovskis & Warwick, 1986; van Oppen & Arntz, 1994). While many therapists have continued to offer a variety of psychological approaches, there has been relatively little written about other approaches and even less research.

5.2. BEHAVIOUR AND COGNITIVE THERAPIES

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:

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)

5.2.5.1. Behaviour therapy versus control (systematic relaxation, anxiety management or waitlist)

Clinical evidence statements4
Efficacy5Included studies
There is evidence suggesting a difference favouring ERP over anxiety management control on reducing obsessive-compulsive symptoms as measured by the clinician-rated Y-BOCS (K = 1; N = 18; SMD = −2.89; 95% CI, −4.30 to −1.48). ILINDSAY1997
There is evidence suggesting a difference favouring clinician-guided ERP over systematic relaxation control on reducing obsessive-compulsive symptoms as measured by the self-reported Y-BOCS (K = 1; N = 121; SMD = −1.10; 95% CI, −1.49 to −0.72). IGREIST2002
There is limited evidence suggesting a difference favouring computer-guided behaviour therapy over systematic relaxation control on reducing obsessive-compulsive symptoms as measured by the self-reported Y-BOCS (K = 1; N = 121; SMD = −0.68; 95% CI, −1.05 to −0.31). IGREIST2002
There is limited evidence suggesting a difference favouring ERP over controls on reducing obsessive-compulsive symptoms as measured by the Padua Inventory (K = 1; N = 18; SMD = −1.28; 95% CI, −2.32 to −0.24). ILINDSAY1997
There is limited evidence suggesting a difference favouring ERP over anxiety management control on reducing the impact of OCD on life and activities as measured on an interference rating scale (K = 1; N = 18; SMD = −3.16; 95% CI, −4.64 to −1.67). ILINDSAY1997
There is limited evidence suggesting a difference favouring clinician-guided ERP over systematic relaxation control on improving functioning as measured by the patient-rated Work and Social Adjustment Scale (K = 1; N = 121; SMD = −0.60; 95% CI, −0.96 to −0.23). IGREIST2002
There is limited evidence suggesting a difference favouring computer-guided ERP over systematic relaxation control on improving functioning as measured by the patient-rated Work and Social Adjustment Scale (K = 1; N = 121; SMD = −0.40; 95% CI, −0.76 to −0.04). IGREIST2002
There is evidence suggesting a difference favouring clinician-guided ERP over systematic relaxation control on the likelihood of treatment response, defined as ‘much improved’ or ‘very much improved’ on the Clinical Global Impressions (CGI) scale (K = 1; N = 125; RR = 0.51; 95% CI, 0.38 to 0.69). IGREIST2002
There is limited evidence suggesting a difference favouring computer-guided ERP over systematic relaxation control on the likelihood of treatment response, defined as CGI ‘much improved’ or ‘very much improved’ (K = 1; N = 123; RR = 0.73; 95% CI, 0.59 to 0.91). IGREIST2002
Tolerability
The evidence is inconclusive and so it is not possible to determine if there is a clinically important difference between behaviour therapy and controls on leaving the study early (K = 2; N = 125; RR = 4.47; 95% CI, 0.51 to 38.92). IGREIST2002
LINDSAY1997

5.2.5.2. CBT versus waitlist control

Clinical evidence statements
EfficacyIncluded studies
There is limited evidence suggesting a difference favouring group CBT over waitlist control on the likelihood of treatment response, defined as a 35% or greater reduction on the clinician-rated Y-BOCS (K = 1; N = 47; RR = 0.32; 95% CI, 0.17 to 0.59). ICORDIOLI2003
There is limited evidence suggesting a difference favouring CBT over waitlist on reducing obsessive-compulsive symptoms as measured on the clinician-rated Y-BOCS in patients with obsessive symptoms only (K = 1; N = 29; SMD = −1.18; 95% CI, −1.98 to −0.38). IFREESTON1997
There is evidence suggesting a difference favouring group CBT over waitlist on reducing obsessive-compulsive symptoms as measured on the clinician-rated Y-BOCS (K = 1; N = 47; SMD = −1.18; 95% CI, −1.81 to −0.56). ICORDIOLI2003
There is limited evidence suggesting a difference favouring CBT over waitlist control on reducing obsessive-compulsive symptoms as measured by the Padua Inventory (K = 1; N = 29; SMD = −0.83; 95% CI, −1.59 to −0.07). IFREESTON1997
There is limited evidence suggesting a difference favouring group CBT over waitlist control on improving psychological quality of life as measured by the WHOQOL-BREF psychological subscale (K = 1; N = 47; SMD = −0.59; 95% CI, −1.18 to −0.01). ICORDIOLI2003
There is limited evidence suggesting a difference favouring group CBT over waitlist control on improving environmental quality of life as measured by the WHOQOL-BREF environmental subscale (K = 1; N = 47; SMD = −1.05; 95% CI, −1.66 to −0.44). ICORDIOLI2003
There is limited evidence suggesting a difference favouring CBT over waitlist control on reducing anxiety symptoms as measured by the Beck Anxiety Inventory in patients with obsessive symptoms only (K = 1; N = 29; SMD = −0.87; 95% CI, −1.64 to −0.10). IFREESTON1997
Tolerability
The evidence is inconclusive and so it is not possible to determine if there is a clinically important difference between CBT and waitlist on the likelihood of leaving the study early (K = 2; N = 76; RR = 0.77; 95% CI, 0.24 to 2.49). IFREESTON1997
CORDIOLI2003

5.2.6. Psychological interventions versus other psychological interventions

5.2.6.1. Behaviour therapy versus cognitive therapy

Clinical evidence statements
EfficacyIncluded studies
There is limited evidence suggesting a difference favouring group behaviour therapy over group cognitive therapy on the likelihood of recovering at 12 months' follow-up, defined as a reliable change on the clinician-rated Y-BOCS and a clinician-rated Y-BOCS score less than 13 (K = 1; N = 93; RR = 0.74; 95% CI, 0.6 to 0.92). IMCLEAN2001
Tolerability
The evidence is inconclusive and so it is not possible to determine if there is a clinically important difference between behaviour therapy and cognitive therapy on the likelihood of leaving the study early (K = 4; N = 305; RR = 0.97; 95% CI, 0.63 to 1.47). ICOTTRAUX2001
VANOPPEN1995
MCLEAN2001
WHITTAL2005

5.2.6.2. Behaviour therapy versus CBT

Clinical evidence statements
EfficacyIncluded studies
There is limited evidence suggesting a difference favouring CBT over behaviour therapy on reducing obsessive-compulsive symptoms at 6 months' follow-up as measured on the clinician-rated Y-BOCS (K = 1; N = 35; SMD = 0.86; 95% CI, 0.16 to 1.56). IVOGEL2004
Tolerability
The evidence is inconclusive and so it is not possible to determine if there is a clinically important difference between behaviour therapy and CBT on the likelihood of leaving the study early (K = 1; N = 35; RR = 6.74; 95% CI, 0.94 to 48.29). IVOGEL2004

5.2.6.3. Behaviour therapy versus rational-emotive therapy

Clinical evidence statements
EfficacyIncluded studies
The evidence is inconclusive and so it is not possible to determine if there is a clinically important difference between behaviour therapy and rational-emotive therapy on the efficacy of treatment. IEMMELKAMP1988
EMMELKAMP1991

5.2.6.4. Self-exposure versus partner-assisted exposure therapy

Clinical evidence statements
EfficacyIncluded studies
The evidence is inconclusive and so it is not possible to determine if there is a clinically important difference between self-exposure and partner-assisted exposure on the efficacy of treatment. IEMMELKAMP1983

5.2.6.5. Imaginal plus live ERP versus live ERP

Clinical evidence statements
EfficacyIncluded studies
The evidence is inconclusive and so it is not possible to determine if there is a clinically important difference between imaginal plus live ERP and live ERP on the efficacy of treatment. IDEARAUJO1995

5.2.6.6. Exposure plus relapse prevention versus exposure plus associative therapy

Clinical evidence statements
EfficacyIncluded studies
The evidence is inconclusive and so it is not possible to determine if there is a clinically important difference between exposure plus relapse prevention and exposure plus associative therapy on the efficacy of treatment. IHISS1994

5.2.6.7. Audiotaped exposure to anxiogenic thoughts versus audiotaped exposure to neutral thoughts

Clinical evidence statements
EfficacyIncluded studies
The evidence is inconclusive and so it is not possible to determine if there is a clinically important difference between audiotaped exposure to anxiogenic thoughts and audiotaped exposure to neutral thoughts on the efficacy of treatment. ILOVELL1994

5.2.6.8. Computerised ERP (BTSTEPS) plus scheduled support versus computerised ERP (BTSTEPS) plus requested support

Clinical evidence statements
EfficacyIncluded studies
The evidence is inconclusive and so it is not possible to determine if there is a clinically important difference between BTSTEPS plus scheduled support and BTSTEPS plus requested support on reducing obsessive-compulsive symptoms as measured by the Y-BOCS (K = 1; N = 36; SMD = −0.55; 95% CI, −1.22 to 0.12). IKENWRIGHT2005
Tolerability
There is evidence suggesting a clinically significant effect of fewer patients being likely to leave the study early in BTSTEPS plus scheduled support when compared with BTSTEPS plus requested support (K = 1; N = 44; RR = 0.23; 95% CI, 0.08 to 0.70). IKENWRIGHT2005

5.2.6.9. Family-based behaviour therapy versus patient-based behaviour therapy

Clinical evidence statements
EfficacyIncluded studies
There is limited evidence suggesting a difference favouring family-based behaviour management over patient-based behaviour management on reducing obsessive-compulsive symptoms as measured by the Maudsley Obsessive-Compulsive Inventory (K = 1; N = 30; SMD = −0.89; 95% CI, −1.65 to −0.14). IMEHTA1990
There is evidence suggesting a difference favouring family-based behaviour management over patient-based behaviour management on reducing obsessive-compulsive symptoms at 6 months' follow-up as measured by the Maudsley Obsessive-Compulsive Inventory (K = 1; N = 30; SMD = −1.44; 95% CI, −2.25 to −0.62). IMEHTA1990
There is evidence suggesting a difference favouring family-based behaviour management over patient-based behaviour management on reducing depression as measured by the Zung Self-rating Depression scale (K = 1; N = 30; SMD = −1.38; 95% CI, −2.19 to −0.58). IMEHTA1990
There is evidence suggesting a difference favouring family-based behaviour management over patient-based behaviour management on reducing depression at 6 months' follow-up as measured by the Zung Self-rating Depression scale (K = 1; N = 30; SMD = −1.81; 95% CI, −2.67 to −0.94). IMEHTA1990
There is limited evidence suggesting a difference favouring family-based behaviour management over patient-based behaviour management on improving social adjustment at work as measured by the Global Assessment of Severity (K = 1; N = 30; SMD = −0.91; 95% CI, −1.67 to −0.16). IMEHTA1990
There is evidence suggesting a difference favouring family-based behaviour management over patient-based behaviour management on improving social adjustment at work at 6 months' follow-up as measured by the Global Assessment of Severity (K = 1; N = 30; SMD = −1.34; 95% CI, −2.15 to −0.54). IMEHTA1990
There is limited evidence suggesting a difference favouring family-based behaviour management over patient-based behaviour management on improving family adjustment as measured by the Global Assessment of Severity (K = 1; N = 30; SMD = −0.78; 95% CI, −1.52 to −0.03). IMEHTA1990

5.2.7. Therapist time in psychological interventions

5.2.7.1. Introduction

Although the efficacy of CBT (including ERP) is generally widely accepted, there is great variability in exactly how treatment is delivered. Group and individual treatments for OCD usually show a high degree of overlap in that planning for and carrying out ERP exercises between sessions is believed to be one of the most important components. Likewise, ERP may be delivered through guided self-help using books or computer-based packages with minimal support from therapists. Indeed, guided self-help may be conceptualised as an alternative delivery format of ERP rather than a distinct form of intervention. Finally, in individual formats, therapist input can vary from extremely brief (for example, 15 minutes per week) to highly intensive (e.g. 2 hours per day, 5 days per week, for 3 weeks). Consequently, it is difficult to determine what an adequate ‘dose’ of CBT may be. The aim of this review is thus to examine treatment intensity. Although intensity can be defined in a number of ways such as frequency and duration of sessions, from a resource viewpoint, the therapist time per patient may be considered a proxy. As a result, a course of group CBT, over and beyond any advantages that may arise from the interaction of group members, may be considered a lower intensity treatment if the number of therapist hours per patient is below that of an equivalent course of individual CBT.

5.2.7.2. Current practice

ERP for OCD was developed in the 1970s in specialist units in the UK, often in an inpatient setting (see Marks, 1997), as well as elsewhere in Europe and the US. Since that time psychological treatment for OCD has been delivered mainly in secondary and tertiary care. But because there remain difficulties in accessing trained behavioural and cognitive therapists in a timely manner and because provision varies from one region to another (Shapiro et al., 2003), there may be a role for forms of CBT requiring relatively little therapist input that can be delivered by a broader range of healthcare professionals. These professionals may not have been trained extensively in CBT, but if they have been trained to deliver the key components of the therapy in an effective way, access and availability could improve (Lovell & Richards, 2000). Brief CBT-based therapies have become increasingly available in primary care settings over the last 5 years for a variety of disorders and there is evidence of expansion. However, although the essential features of ERP are easy to grasp, its application in OCD can be complicated. Thus, even though low intensity treatments may be effective for some people, there is likely to be a role for traditional individual CBT for those who have not adequately responded to treatment with lower intensity treatment. Furthermore, given the heterogeneity of clinical presentation found in OCD, there may be a proportion of people with OCD for whom low intensity treatments may not be suitable due to the need to substantially adapt approaches.

5.2.7.3. Method

The aim of this review was to determine whether the number of hours spent by a therapist per client in session predicted the efficacy of psychological interventions in patients with OCD. Due to time constraints, the review considered only studies on adult patients with OCD. For inclusion, studies had to report pre- and post-treatment scores of an outcome measure, such as the Y-BOCS, and the number of therapist hours per client. The latter was calculated as [the number of hours per session X total number of sessions] multiplied by the number of therapists per session. If the mode of treatment delivery was group therapy, then the number of therapist hours was divided by the number of patients per group.

Based on the distribution of the number of therapist hours per client across the studies, the studies were categorised into high, medium and low intensity groups. Interventions in which the number of therapist hours per client was less than 10 were classified as low treatment intensity interventions. Interventions in which the number of therapist hours per client was 10 or more and less than 30 were classified as medium intensity interventions. Interventions with more than 30 therapist hours per client were classified as high intensity interventions.

5.2.7.4. Studies considered

A new systematic search for studies of psychological interventions in adults with OCD was conducted. The review considered studies that included exposure and/or response prevention and/or cognitive therapy as part of the intervention. The search identified 1,107 studies of which 1,037 were excluded as being irrelevant. Of the 69 studies that could potentially be included, 19 studies were excluded because the patients were children with OCD (K = 14) or had BDD (K = 5). Other reasons for exclusion were that the data was not extractable (K = 10), the number of therapist-hours per client could not be extracted (K = 5), the study had less than 5 participants in the treatment group (K = 1), the report was a case study (K = 2), the report was a review of the literature (K = 1), the study tested a pharmacological intervention (K = 1), the study was in German (K = 1).

The number of studies included in the review was 29 (BOUVARD2002; CHAMBLESS1999; CORDIOLI2003; DEARAUJO1995; EMMELKAMP1983; EMMELKAMP1988; EMMELKAMP1991; ENRIGHT1991; FOA1984; FOA1985; FOA2004; FREESTON1997; FRITZLER1997; GREIST2002; HISS1994; HUGHES2004; LINDSAY1997; MCKAY1996; MCLEAN2001; WHITTAL2005; NEZIROGLU2001; OCONNOR1999; ROSQVIST2001; ROTHBAUM2000; TAYLOR2003; VANOPPEN1995; VANNOPPEN1997; VANNOPPEN1998; VOGEL2004).

5.2.7.5. Sub-group analysis

Based on the 10 and 30 cut-off scores of the number of therapist hours per client, 11 interventions from 8 studies were classified as low intensity (CORDIOLI2003; EMMELKAMP1983_COUPLES; EMMELKAMP1983_PATIENT; ENRIGHT1991; FRITZLER1997; HUGHES2004; MCLEAN2001_BT; MCLEAN2001_CT; TAYLOR2003_DELAYED; TAYLOR2003_IMMEDIATE; VANNOPPEN1998), 22 interventions from 14 studies were classified as medium intensity (BOUVARD2002; CHAMBLESS1999; DEARAUJO1995_EXV; DEARAUJO1995_EXI; EMMELKAMP1988_BT; EMMELKAMP1988_CT; EMMELKAMP1991_BT; EMMELKAMP1991_CT; HISS1994_AT; HISS1994_RP; GREIST2002_CLINICIAN BT; LINDSAY1997; OCONNOR1999; ROTHBAUM2000; VANNOPPEN1997_GROUP BT; VANNOPPEN1997_MFBT; VANOPPEN1995_BT; VANOPPEN1995_CT; VOGEL2004_BT; VOGEL2004_CBT; WHITTAL2005_BT; WHITTAL2005_CT) and 10 interventions from 7 studies were classified as high intensity (FOA1984_ERP; FOA1984_EX; FOA1984_RP; FOA1985_EXI; FOA1985_EXV; FOA2004; FREESTON1997; MCKAY1996; NEZIROGLU2001; ROSQVIST2001). The pre- and post-treatment scores on the study's key measure of efficacy were entered into the Review Manager software, which was used to estimate heterogeneity across all studies and to produce an effect size for each sub-group calculated as the SMD between the pre- and post-treatment scores.

Across all studies, there was statistically significant heterogeneity2 = 174.46; df = 44; p < 0.00001; I2 = 74.8%).

The effect size for each sub-group was:

  • Low intensity group: N = 261; SMD = −0.93; 95% CI, −1.11 to −0.75
  • Medium intensity group: N = 461; SMD = −1.44; 95% CI, −1.59 to −1.29
  • High intensity group: N = 157; SMD = −1.65; 95% CI, −1.91 to −1.38.

There was significant heterogeneity within the medium intensity sub-group (χ2 = 38.3; df = 19; p = 0.005). Therefore, sensitivity analysis was used to examine the effect of removing outliers. By excluding Lindsay, 1997, heterogeneity was reduced (χ2 = 29.9; df = 18; p = 0.04), while the effect size remained similar (N = 452; SMD = −1.42; 95% CI, −1.57 to −1.27).

To examine whether number of therapist hours predicted treatment efficacy, a meta-regression analysis was performed controlling for the year of publication, study design (RCT or non-RCT), and treatment modality (individual or group). The number of therapist hours per client significantly predicted change in efficacy scores following treatment, z = −2.09; p = 0.04, after controlling for publication date, zdate = 0.29, p = 0.77, study design, zstudy design = −1.30, p = 0.19, and treatment modality, ztreatment modality = 0.93, p = 0.35. When a sensitivity analysis was conducted by removing outliers (Lindsay, 1997), therapist hours still significantly predicted change in efficacy scores, z = −2.24, p = 0.03, after controlling for publication date, zdate = 0.24, p = 0.81, study design, zstudy design = −1.17, p = 0.24, and treatment modality, ztreatment modality = 0.82, p = 0.41.

5.2.7.6. Limitations

There are important limitations to this review as (1) therapist time is only a proxy for treatment intensity, (2) therapist time is confounded with treatment format (group versus individual), (3) these studies were not designed to address this particular question, (4) although all studies included some degree of ERP, the exact content was unknown, and (5) while mean symptom severity in these studies is typically in the moderate range, it is not possible to link response to initial severity. Furthermore, as in almost all studies of CBT, there is generally insufficient control over the degree of patient adherence and particularly of the quantity of work conducted between sessions. Likewise therapist training, competence and adherence for each of the interventions are not adequately controlled. Little is known, as yet, about the effects of sequential CBT treatments that would arise in the proposed stepped care model. Properly designed prospective studies that examine all these factors are needed; in particular, the severity and complexity of OCD needs to be taken into account.

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. PSYCHOANALYSIS

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. OTHER PSYCHOLOGICAL INTERVENTIONS

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):

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

5.4.6.1. Hypnosis

There were eight published articles on hypnosis; all were case studies reporting on one or more adults (Churchill, 1986; Dormaar, 1987; Erickson, 1973; Harvey & Green, 1990; Johnson & Hallenbeck, 1985; Moore & Burrows, 1991; Scrignar, 1981; Walker, 1981). Three of these case reports were not reviewed further because in two (Erickson, 1973; Walker, 1981) the diagnosis was obsessional personality and the third (Dormaar, 1987) did not include a DSM/ICD diagnosis or equivalent detailed clinical description of OCD. Three of the remaining case reports reported using a multifaceted approach combining hypnosis with one or more other treatment modalities, namely: conjoint family therapy (Churchill, 1986); the behavioural technique of flooding (Scrignar, 1981); relaxation, cognitive and behavioural strategies and pharmacotherapy (Moore & Burrows, 1991). Five of the clinical case reports involved only one client (Churchill, 1986; Harvey & Green, 1990; Johnson & Hallenbeck, 1985; Moore & Burrows, 1991; Walker, 1981), one of which involved the family in treatment (Churchill, 1986). Another article (Scrignar, 1981) reported on the treatment of two people.

Although these case reports generally reported improvement, their validity is severely restricted by the fact that they are uncontrolled case reports and have numerous methodological deficiencies such as a lack of standardised diagnoses, combined treatment modalities, and lack of recognised outcome measures.

5.4.6.2. Homeopathy

Five published articles on homeopathy were identified; three were clinical case reports of one adult (Norland, 1988; Reichenberg & Ullman, 1999; Reichenberg & Ullman, 1998b) and two were clinical case reports of one or more young persons (Reichenberg & Ullman, 1998a; Reichenberg & Ullman, 2000). One of the articles (Reichenberg & Ullman, 1999) also reported on the cases of three young persons. All of the adult case reports reported improvement in symptoms. However, it is difficult to draw meaningful conclusions as the numbers were small and the use of standardised diagnostic or outcome measures was not reported.

5.4.6.3. Marital/couple therapy

Two articles were identified on marital therapy (Hafner, 1982; Stern, 1973) and one on couple therapy (Keiley, 2002). All were clinical case reports of one or more adults. Hafner (1982) reported on the treatment of five inpatients using a multi-modal treatment programme: behaviour therapy, individual and group psychotherapy, conjoint marital and family therapy, social skills training and pharmacotherapy. Improvement in symptoms was reported during inpatient stay, however all clients relapsed on returning home. Stern and Marks (1973) reported on the treatment of a single case of obsessive compulsive neurosis with marital discord using contract therapy and Keiley (2002) described the use of affect regulation and attachment focused treatment with one OCD client and their partner. Again a variety of factors such as small numbers, other interventions, and lack of specified outcome measures of OCD symptoms hamper interpretation of these reports.

5.4.6.4. Transactional analysis

Two articles on transactional analysis were identified (Gomez de Setien, 1982; Pelton, 1987); both were primarily a description of the treatment technique. There was insufficient information on diagnosis, assessment and outcome of treatment to allow any conclusions about treatment effects.

5.4.6.5. Other therapies

Other case reports have appeared in the literature for psychological and alternative/complimentary therapeutic strategies, but no single technique has more than one case report. Those identified were systemic therapy (Sheinberg, 1988), an integrated psychological approach (Fields, 1998), paradoxical intention (Yoder, 1994), gestalt therapy (Morphy, 1980), counselling (Pollard, 2001), morita therapy (Gomibuchi et al., 2000) and group cognitive analytic therapy (Mitzman & Duigan, 1993). Many of the difficulties encountered in the above reviews were found in these case reports thereby limiting any conclusions that could be drawn.

5.4.6.6. Virtual reality therapy

Becker and North (1998) described the development of the virtual reality therapy system (VRT-2002) for the treatment of various psychological disorders including OCD through exposure methods. Virtual reality therapy consists of using computer technology to support ERP by exposing the patient to a virtual representation of the environment that contains the feared situation rather than taking the patient into the actual environment or having the patient imagine the stimulus.

A brief description of one scene for OCD was provided and a second was said to be under development. Evaluation of the effectiveness and efficiency of VRT-2002 in the treatment of OCD has yet to be reported. Further, given the often idiosyncratic nature of concerns in OCD, it may be difficult to develop the required stimuli for more than a few subgroups of patients who have common concerns.

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. PSYCHOLOGICAL INTERVENTIONS FOR CHILDREN AND YOUNG PEOPLE WITH OCD

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:

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.

5.5.4.1. Individual CBFT versus waitlist control

Clinical evidence statements
EfficacyIncluded studies
There is limited evidence suggesting a difference favouring individual CBFT over waitlist on reducing obsessive-compulsive symptoms as measured on the clinician-rated CY-BOCS (K = 1; N = 46; SMD = −2.73; 95% CI, −3.55 to −1.91). IBARRETT2004
There is limited evidence suggesting a difference favouring individual CBFT over waitlist on improving family functioning as measured on the FAD mother's rating scale (K = 1; N = 32; SMD = −0.93; 95% CI, −1.67 to −0.19). IBARRETT2004

5.5.4.2. Group cognitive behavioural family therapy versus waitlist control

Clinical evidence statements
EfficacyIncluded studies
There is limited evidence suggesting a difference favouring group CBFT over waitlist on reducing obsessive-compulsive symptoms as measured on the CY-BOCS (K = 1; N = 53; SMD = −2.54; 95% CI, −3.28 to −1.81). IBARRETT2004
There is limited evidence suggesting a difference favouring group CBFT over waitlist on reducing depressive symptoms as measured on the Childrens Depression Inventory (K = 1; N = 38; SMD = −0.78; 95% CI, −1.46 to −0.11). IBARRETT2004
There is limited evidence suggesting a difference favouring group CBFT over waitlist on improving family functioning as measured on the FAD mother's rating scale (K = 1; N = 40; SMD = −0.78; 95% CI, −1.45 to −0.11). IBARRETT2004

5.5.4.3. Individual CBFT versus group CBFT

Clinical evidence statements
EfficacyIncluded studies
There is limited evidence suggesting a difference favouring group CBFT over individual CBFT on reducing anxiety as measured by the Multidimensional Anxiety Scale in Children (MASC) (K = 1; N = 42; SMD = 0.66; 95% CI, 0.03 to 1.28). IBARRETT2004

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).

5.5.6.1. Evidence for psychological interventions

What interventions have the best outcome as measured by reduction of symptoms?
Behaviour therapy

Almost all studies have used behavioural therapy interventions, even if they are combined with other psychological therapies. The most commonly used is graded ERP. Studies have also investigated flooding, extinction, operant techniques, modelling, shaping and pacing.

ERP

ERP is the most researched therapeutic intervention in child and adolescent OCD studies and appears to be the most promising. Out of the 53 studies analysed, more than 30 reported using either exposure or response prevention, or both, indicating that ERP appears to be the treatment of choice. All of the open trials, two of the consecutive case series (Waters et al., 2001; Williams & Allsopp, 1999), and all but two of the single case design studies (Francis, 1988; Franklin et al., 2001) used ERP as part of their intervention packages. The CBT studies that have incorporated ERP have shown a range of outcomes from 87% of children rated as improved post-therapy (Bolton et al., 1983) to more modest results of 25% mean reduction in symptoms on the CY-BOCS (Thienemann et al., 2001). Two open clinical trials concentrated upon more of a behavioural invention, focusing on ERP with parental involvement. Franklin and colleagues (1998) reported a mean reduction on the CY-BOCS score of 67% at post-treatment and 62% at follow-up (Franklin et al., 2003). Scahill and colleagues (1996) reported a mean post-treatment reduction of 61% on the CY-BOCS in a pilot study of behavioural therapy, ERP, and pharmacology, with a reduction of 51% at 3 months' follow-up. There has been one open clinical trial of group behaviour therapy, consisting of therapist assisted ERP and behavioural homework, which reported clinically significant improvement post-treatment and at 6 months' follow-up (Fischer et al., 1998). There have been no open trials that have only used individual ERP. Taken together, the data from these studies is encouraging and points to the efficacy of ERP.

Extinction

Extinction is used to describe the techniques involved when the child or young person's OCD behaviours are being maintained by the verbal responses of others in the environment. There are seven case studies that have included extinction in their intervention. It has been mostly used in cases of compulsive questioning and reassurance seeking, where parents have been instructed not to provide reassurance. There has been one single case ABAB design study that used an extinction procedure to treat reassurance seeking behaviour. The study indicated that during the extinction phase reassurance-seeking behaviour remitted, and returned on the non-extinction phase. The results indicated that the child had completely stopped asking for reassurance at one month's follow-up, once extinction was re-employed (Francis, 1988). Similar positive results have been reported in a case report of extinction for reassurance seeking in a 5 year-old child (Tolin, 2001). Other case reports have used extinction together with other therapeutic interventions, making it difficult to assess the effectiveness of the extinction component. It has been used as part of family therapy interventions (Dalton, 1983; Fine, 1973; Morelli, 1983), with insight-orientated psychotherapy (Willmuth, 1988), and social skills approaches (Hallam, 1974). The studies have all reported positive treatment gains, but due to the lack of controlled studies and methodological weaknesses the use of extinction in child and adolescent OCD still remains unsubstantiated.

Other behavioural interventions

There are several case reports that have reported positive effects with other behavioural strategies. Three case reports have reported positive effects with modelling, shaping and pacing (Clark et al., 1982; March & Mulle, 1998; Ong & Leng, 1979; Warneke, 1985), mostly in the treatment of obsessional slowness in eating, grooming and washing. Only one case report used flooding, and this was in conjunction with graded ERP (Harris & Wiebe, 1992). A larger number of studies have acknowledged that operant techniques and behavioural rewards may play a positive role indirectly in creating change by helping the child attempt exposure, but again this is always used in combination with other treatment strategies and so is an adjunct to enhance other strategies rather than a strategy in its own right (Bolton et al., 1983; Bolton & Turner, 1984; Dalton, 1983; Fine, 1973; Green, 1980; Ong & Leng, 1979; Owens & Piacentini, 1998; Piacentini et al., 1994; Piacentini et al., 2002; Querioz et al., 1981; Warneke, 1985; Yamagami, 1978).

CBT

Out of the 53 intervention studies, 19 reported using a CBT intervention (Benazon et al., 2002; Bolton & Turner, 1984; Detweiler & Albano, 2001; Franklin et al., 2001; Freeston, 2001; Kearney & Silverman, 1990; Kellerman, 1981; March et al., 1994; March & Mulle, 1995; Ownby, 1983; Piacentini et al., 1994; Piacentini et al., 2002; Scahill et al., 1996; Thienemann et al., 2001; Tolin, 2001; Waters et al., 2001; Weiner, 1967; Wever & Rey, 1997; Williams & Allsopp, 1999). The open clinical trials that have used CBT protocols have incorporated sessions that include psychoeducation, anxiety management, cognitive training, behavioural rewards, ERP, as well as parental involvement. The cognitive element frequently included training in consecutive self-talk and positive coping strategies (March et al., 1994). The CBT open clinical trials and case series studies have shown a range of outcomes with mean symptom reduction rates ranging from 25% (Thienemann et al., 2001) to 79% (Piacentini et al., 2002). The majority of studies have reported a mean symptom reduction on the CY-BOCS between 45 to 70% at post-treatment and at follow-up (Benazon et al., 2002; Franklin et al., 1998; March et al., 1994; Scahill et al., 1996; Waters et al., 2001; Wever & Rey, 1997). Furthermore results from a small number of single case design studies have also yielded positive results for CBT (Detweiler & Albano, 2001; Freeston, 2001; Kearney & Silverman, 1990; March & Mulle, 1995).

The CBT protocols frequently incorporate anxiety management training (AMT), which often includes progressive muscle relaxation, diaphragmatic breathing and coping imagery. As this is often presented together with other behavioural strategies including ERP, it is difficult to judge whether AMT is effective or necessary in the treatment of child and adolescent OCD. There have been no studies that have just used AMT to treat OCD. One open trial has examined whether a simplified manualised CBT approach to ERP without AMT is effective (Franklin et al., 1998). The results showed a mean CY-BOCS reduction of 67% at post-treatment and 62% at follow-up. From these results the authors argue that AMT is not a necessary component of CBT and may only serve to make ERP more accessible to younger people (the main active ingredient in treatment being ERP). Some clinicians have gone as far as arguing against the use of AMT as part of a first-line intervention for OCD (Tolin & Franklin, 2002), because intentionally eliciting anxiety through exposure work, whilst also learning strategies to minimise anxiety (through anxiety management), is likely to confuse the young person, and at a theoretical level, may interfere with habituation to anxiety, the putative mechanism for therapeutic change in ERP They acknowledge that AMT may be a useful adjunct to ERP if children are so anxious at baseline that they are unable to tolerate ERP (Tolin & Franklin, 2002). There is no evidence that AMT alone is effective in the treatment of children and young people with OCD.

Cognitive therapy

There has been little research that has specifically investigated cognitive therapy in children and young people with OCD. As cognitive therapy strategies are often combined with other treatment approaches in CBT protocols, it is difficult to judge how effective the cognitive components are, compared with ERP, in effecting change. Cognitive restructuring is aimed at challenging the child's thought processes by questioning the reality of his or her obsessions and the necessity of the compulsive behaviours, and it has been used in two studies that reported positive results (Kearney & Silverman, 1990; March & Mulle, 1995). Finally, several uncontrolled case studies specify teaching children positive self-statements (for example, ‘I'm not afraid of germs, I can do this’) to repeat during exposure (Willmuth, 1988; Zikis, 1983). Only one study has focused on utilising a more cognitive approach to treat a consecutive case series of six young people with OCD. The treatment protocol focused upon normalising intrusive thoughts, reappraising notions of responsibility, helping the young person re-evaluate the basis of their fears, and conducting behavioural experiments (Williams et al., 2002). The results showed good clinical outcomes for the cases, with cognitive changes in responsibility appraisals being associated with clinical improvement. One single case study has used an alternating design of response prevention and cognitive therapy, with the cognitive element including identifying obsessional thinking, examining more realistic probabilities, and conducting behavioural experiments (Kearney & Silverman, 1990). The results indicated that the total average improvement in symptoms for both procedures was similar, and that the combination of the two treatments was found to be effective in eliminating OCD. Research into cognitive therapy with children and young people is still in its infancy, therefore the specific efficacy of cognitive therapy for the treatment of OCD in children and young people has yet to be proven.

Strategies for obsessive thoughts

In some of the open clinical trials, treatment protocols include other thought stopping and satiation. These interventions have also been used in various case reports. Thought stopping is intended to interrupt the occurrence of obsessive thoughts, and positive treatment effects have been reported by the few studies that have specifically implemented thought stopping in the treatment of OCD (Frare & Lebel, 1996; Friedmann & Silvers, 1977; Kellerman, 1981; Ownby, 1983), although three of these studies are more than 20 years old. Finally, satiation is produced by repeating obsessional thoughts, or replaying an audiotape of obsessions. Five investigations of OCD have reported positive effects when satiation techniques have been incorporated (Friedmann & Silvers, 1977; Green, 1980; Kellerman, 1981; O'Connor, 1983; Taylor, 1985). These approaches would now be considered a variant of exposure that may or may not have been accompanied with response prevention.

Therapies that target family function

There have been nine case reports that have incorporated family therapy into their treatment protocols with one or more children and young people. These have mostly described strategies aimed at altering the family system, and increasing communication and emotional expression within the young person's family. There have been two reports that have included procedures designed to alter family dynamics directly (Bolton et al., 1983; Dalton, 1983). However most of the family therapy studies also include either acknowledged or unacknowledged behavioural components, including exposure, extinction and operant reinforcement (Dalton, 1983; Fine, 1973; Hafner et al., 1981; Harbin, 1979; O'Connor, 1983). Two studies adopted systemic family therapy approaches where OCD was represented as a metaphor for family dysfunction (Dalton, 1983; O'Connor, 1983). These investigations encouraged ERP as a ‘paradoxical intervention’, making it impossible to determine how or whether the family intervention added to conventional, if implicit, cognitive behavioural approaches. Only two case reports focused more specifically on strategic therapy (Goodman, 1988) and marital and family therapy (Hand, 1988) specifically. One other case report described positive gains for a child with OCD by using a cognitive intervention aimed at decreasing angry cognitions in the mother (Morelli, 1983). Although the results of these reports all outline improvements in symptoms, they have methodological flaws; either in the specification of the treatment or in the measurement of OCD symptoms and/or family function. Consequently, the specific efficacy of these approaches has yet to be proven.

Psychoanalysis, psychoanalytic/psychodynamic/supportive/individual psychotherapy

There are seven reports of different forms of individual psychotherapy for children and young people with OCD that appear in the recent literature (Apter et al., 1984; Bolton et al., 1983; Crago, 1995; Friedmann & Silvers, 1977; O'Connor, 1983; Warneke, 1985; Willmuth, 1988). All of the studies used a theoretically eclectic combination of treatment approaches. Three of these reported unspecified ‘milieu therapy’ as an additional feature (Apter et al., 1984; Bolton et al., 1983; Friedmann & Silvers, 1977). Several included individual work, parent work, and group activities, frequently with behavioural interventions or narrative approaches (Crago, 1995). The studies all reported symptom reduction, but this is unsubstantiated as none uses standardised measures of outcome. To date the specific efficacy of these approaches for the treatment of OCD in children and young people has yet to be proven.

Are there developmental differences in the treatments most likely to achieve improvements in the identified outcomes for children (aged 8 –11 years) and young people (12–18 years)?

Most of the intervention studies have concentrated upon the adolescent age group (12–18 years). There have only been 13 studies describing children with one or more children aged 11 years and under (Desmarais & Lavallee, 1988; Fine, 1973; Francis, 1988; Frare & Lebel, 1996; Goodman, 1988; Knox et al., 1996; March, 1995; Moritz, 1998; O'Connor, 1983; Querioz et al., 1981; Stanley, 1980; Tolin, 2001; Waters et al., 2001). These have highlighted the usefulness of CBT protocols, ERP and extinction with younger children. Several open clinical trials have used a range of ages, from 7–17 years, but analyses have not been conducted to ascertain whether there is a difference in treatment outcome dependent upon age. One study involved five children under the age of 11 years, and seven young people over the age of 11 years, and reported that 11 out of 12 did not meet criteria for OCD post-therapy (Barrett et al., 2003), indicating that age did not appear to affect outcome. One study used a single subject cross-over design with four children aged 6–11 years. The researcher used a manualised game program to developmentally present psychoeducation and behavioural interventions. The results showed that OCD symptom severity decreased during treatment (Moritz, 1998). Preliminary evidence therefore suggests that CBT protocols may be equally accessible to younger children, but further research is needed.

What should the duration and intensity of the specified treatment be?

Most of the treatment trials have used weekly sessions, with CBT treatment protocols ranging from 12 to 22 sessions. There has been only one study that has compared intensive CBT sessions (18 sessions over 1 month) with weekly CBT sessions (16 sessions over 4 months). Children with daily sessions did not show superior outcomes to those with weekly sessions (Franklin et al., 1998). However, methodological limitations, including lack of random assignment, restrict the confidence that can be placed in this finding. It is likely that the more severely affected children received daily ERP, whereas less severely ill children were given weekly treatment. One participant was written up as a case report, and the authors reported markedly reduced OCD symptoms after two evaluation sessions and 11 daily sessions (Franklin et al., 2001), with the child falling in the sub-clinical range at post-therapy. A further study investigating a combined behavioural and pharmacological protocol offered on an intensive basis (10 daily sessions of CBT) showed a 68% remission rate and a 60% decrease in symptoms at 4 weeks (Wever & Rey, 1997). There are currently insufficient comparative studies to draw conclusions about the effectiveness of more intensive treatment approaches.

What is the most effective format for treating children and young people with OCD?

Very few studies in the literature have taken a purely individual format of treatment. The large majority of studies combine individual therapy with some family sessions aimed at parent skills training. All of the open case trials and CBT protocols include parent sessions in order to provide psychoeducation, build problem-solving skills, teach strategies to reduce family involvement in the OCD, and encourage family support. All reported positive effects by involving parents in therapy. Parents are often involved by assisting in the between-session exposure sessions and with ensuring treatment adherence. Only one study to date has attempted to empirically investigate the role of involving parents in CBT protocols. Knox and colleagues (1996) used a staggered baseline design to assess whether the addition of active parental participation to ERP would improve the effectiveness of the treatment. The results indicate that children reported less distress associated with their rituals (decreased SUDS ratings) when their parents were involved in therapy and were taught to ignore their compulsions (Knox et al., 1996). One single case design study (Francis, 1988), and one case report (Tolin, 2001), found that extinction, practiced by the parents, was effective in decreasing compulsive reassurance seeking.

One RCT investigated group formats of CBT and showed no difference between individual and group formats (Barrett et al., 2003). Two open clinical trials investigated group formats of CBT treatment with young people (Fischer et al., 1998; Thienemann et al., 2001). The first study was an open trial of behavioural group therapy with 15 young people, concentrating on ERP. Fischer and colleagues reported that all participants showed significant improvements on the CY-BOCS at post-treatment and at 6 months' follow-up. The second study investigated a CBT group that incorporated ERP with cognitive therapy with 18 children. Thienemann and colleagues reported a mean CY-BOCS reduction of 25%.

Preliminary results indicate that group formats of treatment may be an effective format of treatment, but both studies also incorporated parent sessions. From the other studies it is difficult to judge the treatment effects of group format of treatment, compared with the content of treatment, but involving parents in the child's therapy seems to be the treatment of choice.

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. PSYCHOLOGICAL INTERVENTIONS FOR PEOPLE WITH BDD

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:

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).

Children and young people with BDD

There are no RCTs of any psychological interventions in children and young people with BDD. There is one successful case report of behaviour therapy (Braddock, 1982); one successful case report of behaviour therapy combined with doxepine (Sobanski & Schmidt, 2000); one of multiple treatment modalities (psychodynamic therapy, CBT, family therapy and medication) (Horowitz et al., 2002) and one of psychodynamic therapy (Philippopulis, 1979).

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. CLINICAL PRACTICE RECOMMENDATIONS

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]

Initial treatment options

Effective treatments for OCD and BDD 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.

Irrespective of the level of care, the following recommendations should be taken into account when selecting initial treatments for people with OCD or BDD. The specific recommendations as to how to provide these treatments follow in the subsequent sections.

Regulatory authorities (including the Medicines and Healthcare products Regulatory Agency6) have identified that the use of SSRIs to treat depression in children and young people may be associated with the appearance of suicidal behaviour, self-harm or hostility, particularly at the beginning of treatment. There is no clear evidence of an increased risk of self-harm and suicidal thoughts in young adults aged 18 years or older. But individuals mature at different rates and young adults are at a higher background risk of suicidal behaviour than older adults. Hence, young adults treated with SSRIs should be closely monitored as a precautionary measure. The Committee on Safety of Medicine's Expert Working Group on SSRIs, at a meeting in February 2005, advised that it could not be ruled out that the risk of suicidal behaviour, hostility and other adverse reactions seen in the paediatric depression trials applies to use in children or young people in all indications. Consequently, the recommendations about the use of SSRIs for people with OCD or BDD have taken account of the position of regulatory authorities.

Adults

In the current regulatory context, offer adults with OCD with milder impairments low intensity CBT first, reserving higher intensity CBT and specific drug treatments for those with greater impairment. The intensity of psychological treatment has been defined as the hours of therapist input per patient. By this definition most group treatments meet the definition of a low intensity treatment (<10 hours therapist input per patient), although each patient may be receiving a much greater number of hours of therapy.

5.7.1.2.

In the initial treatment of adults with OCD, low intensity psychological treatments (including ERP) (up to 10 therapist hours per patient) should be offered if the patient's degree of functional impairment is mild and/or the patient expresses a preference for a low intensity approach. Low intensity treatments include:

5.7.1.3.

Adults with BDD with mild functional impairment should be offered a course of CBT (including ERP) that addresses key features of BDD in individual or group formats. The most appropriate format should be jointly decided by the patient and the healthcare professional. [B]

Children and young people

In the current regulatory context regarding prescribing SSRIs (see above under ‘initial treatment options’), offer children and young people with OCD or BDD psychological treatments first. However, if a child/young person and/or their family are unable to engage in psychological treatment or it is declined, an SSRI may be cautiously considered with specific arrangements for careful monitoring of adverse events.

5.7.1.4.

For children and young people with OCD with mild functional impairment, guided self-help may be considered in conjunction with support and information for the family or carers. [C]

5.7.1.5.

Children and young people with OCD with moderate to severe functional impairment, and those with OCD with mild functional impairment for whom guided self-help has been ineffective or refused, should be offered CBT (including ERP) that involves the family or carers and is adapted to suit the developmental age of the child as the treatment of choice. Group or individual formats should be offered depending upon the preference of the child or young person and their family or carers. [B]

5.7.1.6.

All children and young people with BDD should be offered CBT (including ERP) that involves the family or carers and is adapted to suit the developmental age of the child or young person as first-line treatment. [C]

5.7.1.7.

The co-existence of comorbid conditions, learning disorders, persisting psychosocial risk factors such as family discord, or the presence of parental mental health problems, may be factors if the child or young person's OCD or BDD is not responding to any treatment. Additional or alternative interventions for these aspects should be considered. The child or young person will still require evidence-based treatments for his or her OCD or BDD. [C]

How to use psychological interventions for adults

Cognitive behavioural treatments involving ERP are effective treatments for OCD and BDD. The format and delivery of such therapy should take into account specific features of problems experienced by the person with OCD or BDD and the interventions should be adapted accordingly.

5.7.1.8.

For adults with obsessive thoughts who do not have overt compulsions, CBT (including exposure to obsessive thoughts and response prevention of mental rituals and neutralising strategies) should be considered. [B]

5.7.1.9.

For adults with OCD, cognitive therapy adapted for OCD may be considered as an addition to ERP to enhance long-term symptom reduction. [C]

5.7.1.10.

For adults with OCD living with their family or carers, involving a family member or carer as a co-therapist in ERP should be considered where this is appropriate and acceptable to those involved. [B]

5.7.1.11.

For adults with OCD with more severe functional impairment who are housebound, unable or reluctant to attend a clinic, or have significant problems with hoarding, a period of home based treatment may be considered. [C]

5.7.1.12.

For adults with OCD with more severe functional impairment who are housebound and unable to undertake home-based treatment because of the nature of their symptoms (such as contamination concerns or hoarding that prevents therapists' access to the patient's home), a period of CBT by telephone may be considered. [C]

5.7.1.13.

For adults with OCD who refuse or cannot engage with treatments that include ERP, individual cognitive therapy specifically adapted for OCD may be considered. [C]

5.7.1.14.

When family members or carers of people with OCD or BDD have become involved in compulsive behaviours, avoidance or reassurance seeking, treatment plans should help them reduce their involvement in these behaviours in a sensitive and supportive manner. [GPP]

5.7.1.15.

Adults with OCD or BDD with significant functional impairment may need access to appropriate support for travel and transport to allow them to attend for their treatment. [GPP]

5.7.1.16.

Towards the end of treatment, healthcare professionals should inform adults with OCD or BDD about how the principles learned can be applied to the same or other symptoms if they occur in the future. [GPP]

5.7.1.17.

When adults with OCD request forms of psychological therapy other than cognitive and/or behavioural therapies as a specific treatment for OCD (such as psychoanalysis, transactional analysis, hypnosis, marital/couple therapy) they should be informed that there is as yet no convincing evidence for a clinically important effect of these treatments. [C]

How to use psychological interventions for children and young people

Psychological treatments for children and young people should be collaborative and engage the family. Always consider the wider context and the other professionals involved with the child. Rewards to encourage the child can be helpful. When working with young people, the recommendations on the use of psychological interventions for adults may also be considered when appropriate.

5.7.1.18.

In the cognitive-behavioural treatment of children and young people with OCD or BDD, particular attention should be given to:

  • developing and maintaining a good therapeutic alliance with the child or young person as well as their family or carers
  • maintaining optimism in both the child or young person and their family or carers
  • collaboratively identifying initial and subsequent treatment targets with the child or young person
  • actively engaging the family or carers in planning treatment and in the treatment process, especially in ERP where, if appropriate and acceptable, they may be asked to assist the child or young person
  • encouraging the use of ERP if new or different symptoms emerge after successful treatment
  • liaising with other professionals involved in the child or young person's life, including teachers, social workers and other healthcare professionals, especially when compulsive activity interferes with the ordinary functioning of the child or young person
  • offering one or more additional sessions if needed at review appointments after completion of CBT. [GPP]
5.7.1.19.

In the psychological treatment of children and young people with OCD or BDD, healthcare professionals should consider including rewards in order to enhance their motivation and reinforce desired behaviour changes. [C]

Here and elsewhere in the guideline, each study considered for review is referred to by a study ID (primary author and date of study publication in capital letters, except where a study is in press or only submitted for publication, then a date is not used).

The full list of all evidence statements generated from meta-analyses (and the associated forest plots) are on the CD-ROM that accompanies the guideline (see Appendix 17 and Appendix 18).

In the case of SMD or WMD, negative effect sizes favour the treatment group.

Footnotes

3

Here and elsewhere in the guideline, each study considered for review is referred to by a study ID (primary author and date of study publication in capital letters, except where a study is in press or only submitted for publication, then a date is not used).

4

The full list of all evidence statements generated from meta-analyses (and the associated forest plots) are on the CD-ROM that accompanies the guideline (see Appendix 17 and Appendix 18).

5

In the case of SMD or WMD, negative effect sizes favour the treatment group.

6

www​.mhra.gov.uk/.

Copyright © 2006, The British Psychological Society & The Royal College of Psychiatrists.

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.

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