Obsessive Compulsive Disorder (OCD)
Obsessive Compulsive Disorder (OCD) is a mental health condition characterized by recurrent obsessive thoughts or compulsive acts or, commonly, both (1,2). A compulsion can be repetitive behaviours, or a mental act completed to temporarily relieve the unpleasant feelings brought on by the obsessive thought (2). The repetitive thoughts and behaviours are thought to share similarities in aetiology and key diagnostic validators, with symptoms ranging from mild to severe (2). The ICD-11 groups OCD in a category called ‘Obsessive-compulsive or related conditions’ and is differentiated from other conditions in this category such as body-focused repetitive behaviour disorders (which are primarily characterised by recurrent and habitual actions directed at the integument e.g., hair-pulling, skin-picking and lack a prominent cognitive aspect) and hoarding disorder (as it is not associated with intrusive unwanted thoughts but rather is characterised by a compulsive need to accumulate possessions and distress related to discarding them) (1).
OCD can cause distress and significant impairment in personal, family, social, educational, occupational, or other important areas of functioning (1). OCD is ranked as one of the top ten most disabling illnesses, measured by lost income and decreased quality of life (3). In children and adolescents there is clear clinical evidence that OCD is often associated with significant disruption and impairment in family, social and academic life and can have adverse impacts on psychosocial development (4). More severe OCD is associated with increased risks of comorbid disorders including anxiety disorders, tic disorders, attention deficit/hyperactivity disorder (ADHD), and personality disorders (1). Common differential diagnoses and co-occurring conditions for OCD in children and adolescents include anxiety, depression, tic disorder, behaviours associated with developmental stage, ADHD and autism. All healthcare professionals offering psychological treatments to people with OCD should receive appropriate training (in the interventions they offer) and ongoing clinical supervision (2).
OCD affects children, adolescents, and adults. The prevalence rate of OCD is 1.0–3.0% in adults and around 0.25% -4% in children and adolescents aged 5 to 15 years (2,4,5). Onset of difficulties can develop at any age with peak onset in adolescence (6). The emergence of OCD was found to be before age 25 in 64% of people in a global meta-analysis of onset of mental health difficulties (6). Women are found to be 1.6 times more likely to experience OCD than men (7), and have a two-fold risk of experiencing OCD during pregnancy or after the birth of their baby within the 12-month postpartum period (8).
This information is for commissioners, managers, trainers, and health care practitioners to consider the evidence base for the delivery of psychological interventions for people with OCD. This information is also for people diagnosed with OCD, their families, and carers.
This topic introduction covers evidence-based psychological interventions used to manage OCD in children, young people, and adults, and the psychological practice/settings in which these interventions can be delivered. It does not cover pharmacological or other interventions. There are a wider range of non-psychological interventions and supports that are beyond the scope of this topic and full guidance on best practice can be found in NICE (2005) (2). It does not include body-focused repetitive behaviour disorders, body dysmorphic disorder or hoarding and separate topics will be developed for these areas in due course.
A comprehensive body of literature supports the effectiveness of psychological interventions for the treatment of OCD, with the quality of evidence ranging from low to high. To be consistent with our focus on interventions with the highest levels of efficacy and the strongest levels of evidence, where these exist, psychological interventions for treating OCD with no evidence and low levels of efficacy have not been included. The evidence tables below include interventions with high and moderate levels of evidence (A and B) and small to large levels of efficacy. The evidence is obtained from NICE guidance, systematic reviews/meta-analysis and RCTs of psychological interventions.
Overview of Evidence for Children and Young People
NICE guidance recommends guided self-help interventions, with support and information provided to their family or carers, for treating OCD in children and young people with mild functional impairment (2) If guided self-help is unavailable or ineffective, referral should be made to Child and Adolescent Mental Health Services (CAMHS). Strong evidence supports the delivery of CBT for the treatment of OCD for both children and young people (2,9-11). These include reports of large effect sizes for improvements in outcomes of OCD symptom severity, treatment response, and symptom/diagnostic remission (10). The available evidence also suggests that inclusion of parental involvement feature as part of cognitive behavioural therapies for CYP may be associated with larger effect sizes at post-treatment and follow-up (12). This suggests that parental involvement in delivering youth CBT, as opposed to no parental involvement feature, could possibly result in larger and longer-term effects. The importance of family involvement is also highlighted in other meta-analytic reviews that suggest including a range of family factors in CBT offered for OCD treatment in young people, and training parents to be involved in ERP (13,14). The level of parental involvement should be determined by developmental stage and informed by clinical assessment.
Evidence for other psychological interventions (including group CBT, ACT interventions within group format, and intensive interventions) is emerging (15-17), however these interventions are not yet as established as those mentioned above and therefore are not included in the table.
Overview of Evidence for Adults
Psychological interventions for adults with OCD can be delivered in a variety of formats. In adults with mild functional impairment, NICE recommends brief (low intensity) cognitive-behavioural therapy (CBT) that includes exposure and response prevention (ERP) (2). The delivery format for low-intensity CBT can include brief individual CBT+ ERP with structured self-help materials, brief individual CBT+ERP by phone, or group CBT+ERP (2). For adults with moderate functional impairment, intensive CBT+ ERP is recommended (2). For adults with severe functional impairment, NICE suggests the consideration of combined selective serotonin reuptake inhibitor (SSRI) and CBT+ ERP treatment (2).
The recommendations are supported by strong evidence of medium to large efficacy when these interventions are compared to treatment as usual or placebo control groups (11,18-20) and when compared to other forms of pharmacological treatment (2,21,22). The evidence also suggests the effectiveness of CBT when it is delivered in different formats, including in individual and group format (23,24), as technology-delivered CBT with minimal therapist support (25,26) or intensity of delivery (27). There is also evidence that CBT is as effective in routine clinical settings as it has been found to be in efficacy trials (23). Available evidence also demonstrates the effectiveness of ERP in the treatment of OCD in adults (21,24,27).
Evidence indicates that inference-based CBT has been successful in treating OCD amongst adult populations (28-30). Evidence from randomised control trials and lower quality trials indicate that inference-based CBT is efficacious in reducing the severity of OCD symptoms, unhelpful beliefs, and inferential confusion with large effect from pre-treatment to posttreatment maintained at three or six months follow up (28,30). Inference-based CBT has been applied to specific subtypes of OCD where it has changed inferential confusion and perception of threat (30). It has also been applied with people with OCD and poor insight, resulting in significant improvement after treatment, with results indicating that both CBT and IBA are effective treatments for OCD with poor insight (29).
In people with severe, chronic, treatment refractory OCD, there should be continuing access to specialist treatment services with expertise in the management of the disorders along with medication and consideration of inpatient services (2).
Evidence for other psychological interventions including ACT and mindfulness-based interventions is emerging but are not yet as established as the interventions mentioned above and therefore not included in the table (31). There is emerging evidence to suggest that including family in treatments to treat adults with OCD can improve efficacy, but it is not included at present due to the quality of the evidence (32).
Overview of learning for Older People
There is a lack of controlled clinical trials of cognitive-behavioral therapy (CBT) for late-life OCD, although initial reports suggest older people respond to CBT that includes age-related treatment modifications (33). Clinicians are advised that there are differences in presentation of psychological problems in later life and to consult Delivering Effective Psychological Therapies and Interventions to Older People for further information on factors relevant to practice.
Overview of Evidence for Harms and Adverse Effects
Psychological therapies have the potential to have adverse effects. Until recently, information on potential harms and rates of adverse effects have not been gathered systematically. Although reports of adverse effects are increasingly included in research trials and gathered as part of service provision we do not know if psychological interventions cause more, fewer or similar numbers of adverse effects than no treatment or another treatment, because the evidence in this area is of very low quality at present.
| Recommendations | Who for? | List of Interventions | Type of psychological practice | Evidence | Efficacy |
| First line intervention |
CYP with mild functional impairment | Guided self-help interventions with family support and information (2) | Specialist | B | N/A |
| First line intervention |
CYP presenting with OCD severity |
CBT with exposure and response prevention and family involvement (2,11,13,14) | Specialist | A | Large |
| Alternative (if family unable to be involved) | CYP presenting with OCD | CBT with exposure and response prevention without family involvement (2,11) | Specialist | A | Moderate-Large |
| Alternative | CYP presenting with OCD | CBT without ERP (11,12) | Specialist | Large |
| Recommendation | Who for? | Intervention | Type of Psychological practice | Level of evidence | Efficacy |
| First line intervention | Adults with mild OCD | Brief CBT including Exposure and Response Prevention (ERP) which should consist of: Self-help materials supported by practitioner contact (online, telephone or in-person) (2,25,26) | Skilled/enhanced | A | Medium |
| First line intervention |
Adults with OCD | Cognitive behavioural therapy with or without ERP which can be delivered individually or in a group (2,11,18-20,23,34) | Specialist | A | Medium-Large |
| Alternative (evidence less established) | Adults with OCD (including those who may not have responded to initial CBT treatment) | Inference-Based CBT (28-30) | Specialist | B | Large |
| Intensive and/or combine interventions including any of the above interventions, medication and adjunctive care (2,35) | Skilled/Specialist | N/A |
With thanks to James Gregory from NHS Wales who participated in the advisory and technical groups and to OCD-UK for their feedback.
Technical group: Rhiannon Buick, Cara Cockburn, James Gregory, Naomi Harding, Leeanne Nicklas, Stephanie Pratt.
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