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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.)

Cover of Obsessive-Compulsive Disorder

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

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This guideline has been developed to advise on the identification, treatment and management of obsessive-compulsive disorder (OCD) and body dysmorphic disorder (BDD). Although distinct disorders, OCD and BDD share a number of common features and there is a high degree of similarity between the treatments for the two conditions. The guideline recommendations have been developed by a multidisciplinary team of healthcare professionals, people with OCD, a carer and guideline methodologists after careful consideration of the best available evidence. It is intended that the guideline will be useful to clinicians and service commissioners in providing and planning high quality care for those with OCD and BDD while also emphasising the importance of the experience of care for people with OCD, BDD, and carers.

This guideline addresses aspects of service provision, psychological and pharmacological approaches for those with OCD and BDD from the age of 8 upwards. Although the evidence base is rapidly expanding, there are a number of major gaps and future revisions of this guideline will incorporate new scientific evidence as it develops. The guideline makes a number of research recommendations specifically to address these gaps in the evidence base. In the meantime, we hope that the guideline will assist clinicians, people with these disorders and their carers by identifying the merits of particular treatment approaches where the evidence from research and clinical experience exists.


1.1.1. What are clinical practice guidelines?

Clinical practice guidelines are ‘systematically developed statements that assist clinicians and patients in making decisions about appropriate treatment for specific conditions’ (Mann, 1996). They are derived from the best available research evidence, using predetermined and systematic methods to identify and evaluate the evidence relating to the specific condition in question. Where evidence is lacking, the guidelines incorporate statements and recommendations based upon the consensus statements developed by the Guideline Development Group (GDG).

Clinical guidelines are intended to improve the process and outcomes of healthcare in a number of different ways. Clinical guidelines can:

  • Provide up-to-date evidence-based recommendations for the management of conditions and disorders by healthcare professionals
  • Be used as the basis to set standards to assess the practice of healthcare professionals
  • Form the basis for education and training of healthcare professionals
  • Assist patients and carers in making informed decisions about their treatment and care
  • Improve communication between healthcare professionals, patients and carers
  • Help identify priority areas for further research.

1.1.2. Uses and limitations of clinical guidelines

Guidelines are not a substitute for professional knowledge and clinical judgement. They can be limited in their usefulness and applicability by a number of different factors: the availability of high quality research evidence, the quality of the methodology used in the development of the guideline, the generalisability of research findings and the uniqueness of individuals with OCD.

Although the quality of research in OCD and BDD is variable, the methodology used here reflects current international understanding on the appropriate practice for guideline development (AGREE: Appraisal of Guidelines for Research and Evaluation Instrument;, ensuring the collection and selection of the best research evidence available, and the systematic generation of treatment recommendations applicable to the majority of people with these disorders and situations. However, there will always be some people and situations for which clinical guideline recommendations are not readily applicable. This guideline does not, therefore, override the individual responsibility of healthcare professionals to make appropriate decisions in the circumstances of the individual, in consultation with the person with OCD and/or carer.

In addition to the clinical evidence, cost-effectiveness information, where available, is taken into account in the generation of statements and recommendations of the clinical guidelines. While national guidelines are concerned with clinical and cost effectiveness, issues of affordability and implementation costs are to be determined by the NHS.

In using guidelines, it is important to remember that the absence of empirical evidence for the effectiveness of a particular intervention is not the same as evidence for ineffectiveness. In addition, of particular relevance in mental health, evidence-based treatments are often delivered within the context of an overall treatment programme including a range of activities, the purpose of which may be to help engage the person with OCD, and to provide an appropriate context for the delivery of specific interventions. It is important to maintain and enhance the service context in which these interventions are delivered; otherwise the specific benefits of effective interventions will be lost. Indeed, the importance of organising care in order to support and encourage a good therapeutic relationship is at times as important as the specific treatments offered.

1.1.3. Why develop national guidelines?

The National Institute for Health and Clinical Excellence (NICE) was established as a Special Health Authority for England and Wales in 1999, with a remit to provide a single source of authoritative and reliable guidance for patients, professionals and the public. NICE guidance aims to improve standards of care, to diminish unacceptable variations in the provision and quality of care across the NHS and to ensure that the health service is patient-centred. All guidance is developed in a transparent and collaborative manner using the best available evidence and involving all relevant stakeholders.

NICE generates guidance in a number of different ways, two of which are relevant here. First, national guidance is produced by the Technology Appraisal Committee to give robust advice about a particular treatment, intervention, procedure or other health technology. Second, NICE commissions the production of national clinical practice guidelines focused upon the overall treatment and management of a specific condition. To enable this latter development, NICE has established seven National Collaborating Centres in conjunction with a range of professional organisations involved in healthcare.

1.1.4. The National Collaborating Centre for Mental Health

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

1.1.5. From national guidelines to local protocols

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

1.1.6. Auditing the implementation of guidelines

This guideline identifies key areas of clinical practice and service delivery for local and national audit. Although the generation of audit standards is an important and necessary step in the implementation of this guidance, a more broadly based implementation strategy will be developed. Nevertheless, it should be noted that the Healthcare Commission will monitor the extent to which Primary Care Trusts (PCTs), trusts responsible for mental health and social care and Health Authorities have implemented these guidelines.


1.2.1. Who has developed this guideline?

The Guideline Development Group was convened by the NCCMH and supported by funding from NICE. The GDG included people with OCD and a carer, and professionals from psychiatry, clinical psychology, child psychology, nursing, and general practice.

Staff from the NCCMH provided leadership and support throughout the process of guideline development, undertaking systematic searches, information retrieval, appraisal and systematic review of the evidence. Members of the GDG received training in the process of guideline development from NCCMH staff and people with OCD received training and support from the NICE Patient and Public Involvement Programme. The NICE Guidelines Technical Adviser provided advice and assistance regarding aspects of the guideline development process.

All GDG members made formal declarations of interest at the outset, which were updated at every GDG meeting. The GDG met a total of 21 times throughout the process of guideline development. The GDG met as a whole, but key topics were led by a national expert in the relevant topic. The GDG was supported by the NCCMH technical team, with additional expert advice from special advisers where needed. The group oversaw the production and synthesis of research evidence before presentation. All statements and recommendations in this guideline have been generated and agreed by the whole GDG.

1.2.2. For whom is this guideline intended?

This guideline will be relevant for people with a diagnosis of obsessive-compulsive disorder (OCD) or body dysmorphic disorder (BDD) aged 8 years and over.

The guideline covers the care provided by primary, community, secondary, tertiary, and other healthcare professionals who have direct contact with, and make decisions concerning the care of adults, children and young people with OCD and BDD.

The guideline will also be relevant to the work, but will not cover the practice, of those in:

  • occupational health services
  • social services
  • the independent sector.

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

1.2.3. Specific aims of this guideline

The guideline makes recommendations for the identification, treatment and management of OCD and BDD. Specifically, it aims to:

  • Evaluate the role of specific psychological interventions in the treatment and management of OCD and BDD.
  • Evaluate the physical management and role of specific pharmacological agents in the treatment of OCD and BDD.
  • Evaluate the role of other biological interventions in the management of OCD and BDD.
  • Integrate the above to provide best practice advice on the care of individuals with a diagnosis of OCD or BDD throughout the course of the disorder.
  • Promote the implementation of best clinical practice through the development of recommendations tailored to the requirements of the NHS in England and Wales.

1.2.4. The structure of this guideline

The guideline is divided into chapters, each covering a set of related topics. The first two chapters provide a general introduction to guidelines and to OCD/BDD. The third chapter provides testimonies regarding the experience of people with OCD and BDD and their families and carers. The fourth chapter details the methods used to develop the guideline. Chapters 5 to 8 provide the evidence that underpins the recommendations and Chapter 9 covers the use of health service resources. The final chapter provides a summary of the recommendations.

Each evidence chapter begins with a general introduction to the topic that sets the recommendations in context. Depending on the nature of the evidence, narrative reviews or meta-analyses were conducted. Therefore, the structure of the chapters varies. Where appropriate, details about current practice, the evidence base and any research limitations are provided. Where meta-analyses were conducted, information is given about both the interventions included and the studies considered for review. This is followed by selected clinical evidence statements (a complete list of evidence statements can be found in Appendix 18). Clinical summaries are then used to summarise the evidence presented. Finally, recommendations related to each topic are presented at the end of each chapter. On the CD-ROM, full details about the included studies can be found in Appendix 16. Where meta-analyses were conducted, the data are presented using forest plots in Appendix 17 (see Text Box 1 for details).

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Text Box 1

Appendices on CD-ROM.

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.

Bookshelf ID: NBK56482


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