Surgery in which parts of the brain are disconnected from one another.

The behaviour of taking medicine according to treatment dosage and schedule as intended by the prescriber. In this guideline, the term ‘adherence’ is used in preference to ‘compliance’, but is not synonymous with ‘concordance’, which has a number of meanings.

Any untoward medical occurrence in a patient who was given a pharmaceutical product, and which does not necessarily have a causal relationship with this treatment.

A psychological approach aimed at teaching people a set of skills to help them manage their own anxiety and stress. These include:

• Relaxation training: teaching techniques for relaxing major muscle groups in a way that decreases anxiety.
• Breathing retraining: teaching techniques of slow, abdominal breathing to avoid hyperventilation and the unpleasant physical sensations that accompany it.
• Positive thinking and self-talk: positive statements (for example, ‘I did it before and I can do it again’) are written on cards and rehearsed so that they can be used to replace the negative thoughts that often occur during stressful experiences.
• Assertiveness training: teaching the person how to express wishes, opinions, and emotions appropriately and without alienating others.

Drugs used to alleviate anxiety states.

This group of medicines all act on a brain chemical, dopamine. Their main use is in psychotic illness, but their dopamine blocking properties can help, when used together with other medicines, in some people with OCD, especially those who do not respond to standard treatments.

The addition of more than one potentially effective treatment together with the aim of enhancing the benefits.

People with OCD and BDD may be unable to engage in particular behaviours, go to specific places or interact with certain people related to their main fears and preoccupations. Even if they wished to do these things, they may find this impossible to do so because of the distress that would arise or through fear of unacceptably dangerous consequences. In OCD, people tend to avoid situations and objects as they can potentially trigger obsessional thoughts and compulsions. The individual sees such situations as risky and knows that they lead to a high level of anxiety and tension. For example, people with obsessions about germs and cleaning compulsions usually strive to avoid objects and situations that they believe to be contaminating. Therapeutic approaches such as BT and CBT seek to help people to overcome avoidance.

A psychological therapy and an umbrella term for a range of interventions including exposure and response prevention and behavioural activation (see below). Behaviour therapy, also called behaviour modification or behavioural psychotherapy refers to the use of learning theory in the treatment of psychological disorders. It is based on the belief that psychological problems are caused by faulty learning rather than a medical disease. BT aims primarily to help people to manage/change unhelpful behaviours. For example, in OCD, behaviour therapy often involves confronting feared situations (exposure) and refraining from performing rituals (response prevention). For OCD and BDD, BT is often synonymous with exposure and response prevention (see below).

A preoccupation with an ‘imagined’ defect in one's appearance or where there is a slight physical anomaly, the person's concern is markedly excessive. To fulfil diagnostic criteria in DSM-IV, the person must be either significantly distressed or impaired in their occupational or social functioning. The older term, ‘dysmorphophobia’ was first introduced by an Italian psychiatrist Morselli in 1886 although it is now falling into disuse probably because ICD-10 has discarded it and subsumed it under that of hypochondriacal disorder.

A study of the treatment of a number of people that is normally evaluated with standardised instruments at different times such as before treatment, after treatment and at follow-up some time after treatment. Unlike controlled trials or cohort studies, there is usually no control or comparison group. Although useful in early studies of new treatments, they are not considered to be a rigorous test of a treatment,

A detailed description of the treatment of a single individual. Such studies may have an important role in the development of new treatments, but do not generally allow strong conclusions to be made about effectiveness.

A person younger than 12 years of age.

A form of psychotherapy that is based on a combination of ideas from psychodynamic theory, with techniques from cognitive therapy. It involves looking at the individual's patterns of relating to others, as well as their behaviours and problems, which is based on a model called the Procedural Sequence Model.

In the treatment of OCD and BDD, CBT generally combines elements of BT such as ERP and elements of CT such as techniques to change beliefs about the things that they find distressing. For people with OCD this often involves reducing catastrophic thinking and the exaggerated sense of responsibility often seen in people with OCD. All CBT programs for OCD include an element of psychoeducation about obsessions and compulsions and a rationale for the interventions.

A psychological therapy and an umbrella term that covers a range of interventions that focus on altering/modifying unhelpful thoughts and behaviour. Typically it helps people to modify unhelpful negative cognitions (that is, interpretations, thoughts and beliefs) that lead to disturbing emotions, unhelpful behaviours and impaired functioning. For OCD, this may be about taking excessive responsibility or giving too much importance to obsessive thoughts. For BDD, this may be about altering extreme self-focused attention on a distorted body image and the meaning that is attached to the body image. People may be encouraged to test out the new ways of thinking through behavioural experiments, but CT does not usually rely on repeated exposure as in ERP.

(also known as follow-up, incidence, longitudinal, or prospective study)

An observational study in which a defined group of people (the cohort) is followed over time and outcomes are compared in subsets of the cohort who were exposed or not exposed, or exposed at different levels, to an intervention, or other factor of interest. Cohorts can be assembled in the present and followed into the future (a ‘concurrent cohort study’), or identified from past records and followed forward from that time up to the present (a ‘historical cohort study’). Because random allocation is not used, matching or statistical adjustment must be used to ensure that the comparison groups are as similar as possible.

More than one diagnosis/disorder occurring in the same person.

Compulsions, sometimes known as rituals, are behaviours that people feel pressured to do to reduce anxiety, guilt and distress, or to prevent harm from occurring. Compulsions are often repeated, conducted according to strict rules, and time consuming. Although the goal may be to reduce anxiety, performing them can also lead to distress and frustration. The pressure to engage in these behaviours can prevent people from doing other things that they wish to do and cause significant impact on their lives and the lives of those around them. Compulsions can take almost any form but common forms include washing and cleaning, checking, hoarding, ordering and arranging, and repeated questions. Many compulsions are overt, that is, they could be observed by others, for example, hand washing rituals. However, other compulsions are covert, that is, they could not be seen by others because they are of a mental nature, for example, mentally repeating sentences. Although many people may try to resist these behaviours, they may find themselves unable to do so either because of the distress caused by resisting them or because they believe that the consequences of not performing the compulsion are unacceptably dangerous.

The range within which the ‘true’ values (for example, size of effect of an intervention) are expected to lie with a given degree of certainty (for example, 95% or 99%). Confidence intervals represent the probability of random errors, but not systematic errors or bias.

An experiment in which investigators allocate eligible people into groups to receive or not to receive one or more interventions that are being compared.

A type of full economic evaluation that compares competing alternatives of which the costs and consequences vary. The outcomes are measured in the same non-monetary (natural) unit. It expresses the result in the form of an incremental (or average or marginal) cost-effectiveness ratio.

The costs of all the goods, services and other resources that are consumed in the provision of a health intervention. They can be medical or non-medical.

The lost productivity suffered by the national economy as a result of an employee's absence from the workplace through illness, decreased efficiency or premature death.

A range of counselling methods are used in practice, including supportive, psychodynamic, and cognitive behavioural counselling. The most widely practiced form of counselling is supportive counselling/psychotherapy. This is defined as a way of relating and responding to another person, so that the person is helped to explore their thoughts, feelings and behaviour; to reach clearer self-understanding; and then is helped to find and use their strengths so that they cope more effectively with their lives by making appropriate decisions, or by taking relevant action. Counselling is essentially a purposeful relationship in which one person helps another to help him- or herself. In most cases it does not attempt to directly change the key features of OCD or BDD but can address a range of issues that may affect the individual.

The administration of two or more experimental therapies one after the other in a specified or random order to the same group of patients.

A trial in which neither the participants nor the investigators (outcomes assessors) are aware of which intervention the participants are given. The purpose of blinding the participants (recipients and providers of care) is to prevent performance bias. The purpose of blinding the investigators (outcome assessors) is to protect against detection bias.

A term no longer used to indicate leaving a study before its completion (the term ‘leaving the study early’ is now preferred).

Technique developed to assess both costs and consequences of alternative health strategies and to provide a decision-making framework.

The extent to which a specific intervention, when used under ordinary circumstances, does what it is intended to do. Clinical trials that assess effectiveness are sometimes called management trials.

The extent to which an intervention produces a beneficial result under ideal conditions. Clinical trials that assess efficacy are sometimes called explanatory trials and are restricted to participants who fully co-operate. The randomised controlled trial is the accepted ‘gold standard’ for evaluating the efficacy of an intervention.

The person is encouraged to confront the feared object, situation, or thought that provokes anxiety (exposure) and resist engaging in the compulsive or other behaviour that would rapidly reduce anxiety (response prevention) until the anxiety gradually reduces of its own accord. For example, people with obsessions about contamination are encouraged to stay in contact with the ‘germy’ object (for example, handling money) until their anxiety decreases (habituates). Thus, through repeated exposure, the person is said to habituate so that the object, situation or thought no longer provokes anxiety and the urge to engage in the compulsive behaviour is no longer present. The ERP programme is usually conducted in a progressive way, starting with objects, situations, or thoughts that produce relatively low levels of distress. Exposure can be conducted in a variety of ways including in vivo (that is direct confrontation with the feared object or situation) and in imagination (where the person repeatedly imagines the feared object, thought, or situation). Taped scenarios can be used for exposure, especially when the cause of distress is particular obsessive thoughts. The technique can be used within structured therapy with the therapist present or with instructions from the therapist who is not present. It can also be used with support from a family member or other members of self-help groups, or alone as part of a pure self-help programme.

Originally developed for the treatment of trauma, patients are instructed to focus on a trauma-related image and its accompanying feelings, sensations and thoughts, while visually tracking the therapist's fingers as they move back and forth in front of the patient's eyes. After each set of approximately 20 eye movements, patients are instructed let go of the memory and to discuss their reactions. This process is repeated, and includes focusing on different memories that come up in connection with the trauma. Once distress is reduced, patients are instructed to focus on the target image while rehearsing a positive thought connected to the image.

A form of psychotherapy that is based on the idea that the behaviours of individuals and families is influenced and maintained by the way other individuals and systems interact with them both within and outside of the family. When a member of the family has a problem that is persistent it can often dominate family life and impact significant on family function, interaction and communication. The aim of family therapy is to help family members recognise and understand how they function as a family and in particular how their patterns of interaction may have become organised around the symptoms or problems of one of their members. Where these patterns of interaction have become unhelpful and perhaps contribute to the maintenances of the problem, the family is helped to develop more functional patterns of organising and interacting within the family. Families are generally seen together but may at times be seen by the family therapists individually or with only some members of the family. Family therapy draws on a number of theoretical principles/approaches that may be used singularly or together in therapy. In the treatment of OCD various forms of family therapy are used, these include systemic, strategic, cognitive behavioural, and narrative family therapy although in practice these approaches tend to overlap:

• Systemic family therapy tends to focus on the meaning of OCD symptoms within the family unit. The therapy tends to see OCD symptoms as a sign that the family unit is stressed, leading to difficult, unspoken emotions between family members. A systemic treatment might involve the therapists exploring ‘OCD stories’ within a family, thus changing the way that the family members have co-created the meaning of OCD. This is aimed at improving relationships within the family and in turn, changing the meaning of the individual's symptoms to allow for changes in their behaviour.
• Strategic family therapy tends to focus on power issues within the family, which in turn may well impact on both family members' understanding and response to OCD, and the OCD symptoms themselves. The rationale is that a more flexible, creative family structure may reduce stress, and challenge the ‘power’ of the OCD symptoms.
• Cognitive behavioural family therapy (CBFT) as a treatment for OCD is based on the recognition that families of people with OCD become involved in trying to help manage the distress and the interference caused by the compulsions. The OCD thus disrupts family relationships. The focus of the treatment is to help the family understand how their well-intentioned involvement can inadvertently maintain the disorder and then help them withdraw from the compulsions. In some cases, especially with children, family members may act as co-therapists to help with ERP. Although the aim is to improve family relationships, the focus is more on reducing a particular individual's obsessive-compulsive symptoms in which other family members have become involved.
• Narrative family therapy proposes that individuals and families acquire certain stories about themselves which have the effect of filtering their experiences and thereby selecting what information gets focused on how it is understood and how this determines how individual problems within the family are perceived and addressed. Narrative family therapy is concerned with finding ways for families to develop new stories or expressions through which to enable them to change their lives.

A graphical display of results from individual studies on a common scale, allowing visual comparison of trial results and examination of the degree of heterogeneity between studies.

Recommended good practice based on the clinical experience of the Guideline Development Group.

A way of providing psychotherapy that usually involves one or more healthcare professionals and a group of patients. The patients are encouraged to understand their own and one another's difficulties with the goal of making changes. Most individual psychological therapies have also been provided in group format; for example, group cognitive behavioural therapy or group behaviour therapy

A self-help programme for OCD in which a healthcare professional provides support, guidance and encouragement but does not take on the role of a formal therapist. Such programmes may use a self-help manual and the healthcare professional may work face-to-face, by telephone or by computer.

This occurs when there is more variation between the study results (in a systematic review) than would be expected to occur by chance alone.

This involves giving the patient instructions (for example, ‘focus on your right arm and on the sensation that it is getting lighter and lighter’) to induce a state of highly focused attention, a reduced awareness of peripheral stimuli and a heightened responsiveness to social cues (suggestibility).

A process in which the doses, indications, cautions, contraindications, and side effects of a drug are authorised for use by regulatory authorities. The decision to apply for a license for a patient condition depends on many factors. Drugs may be used outside their licensed indications.

The use of statistical techniques in a systematic review to integrate the results of the included studies. Also used to refer to systematic reviews that use meta-analysis.

A meditation based approach to treatment that has been developed in particular for relapse prevention. Mindfulness has been defined as ‘paying attention in a particular way: on purpose, in the present moment and non-judgmentally’. Mindfulness-based cognitive therapy aims to help patients make a shift in their relationship to thoughts, feelings and sensations, learning to perceive them as ‘events in the mind’ rather than as ‘self or necessarily true.

A group of drugs that act by inhibiting the enzyme monoamine-oxidase.

A measure of the relative benefit of the experimental treatment that can be obtained by dividing the experimental odds by the control odds.

Sometimes known as obsessive thoughts or ruminations, obsessions are unwanted and recurrent thoughts, doubts, or images that intrude into one's mind despite attempts to resist or control them. They may be fleeting thoughts, or they may stick in one's mind for long periods of time despite attempts to dislodge them. They are upsetting and may cause anxiety, guilt and shame. They usually lead to compulsions and/or avoidance (see above) as people try to remove or control the thoughts, deal with the situations that the thoughts refer to, or reduce the distress. The thoughts may be about almost any content, but common themes include dirt and contamination and their effects on self or others, harm that one may cause to others or failure to prevent harm from occurring, personally unacceptable blasphemous, immoral, or sexual thoughts, or excessive preoccupation with moral, religious or existential questions.

Refers to research studies which show that in some individuals OCD appears to be triggered by streptococcal infection.

The terms ‘patient’ or ‘person with OCD/BDD’ are used in this guideline to identify the person presently or formerly with the condition and/or receiving services in the present or past. The term ‘sufferer’ is sometimes used by self-help groups.

A school of psychology and a method of treating mental health problems that is based upon the teachings of Sigmund Freud (1856–1939). There are many different psychoanalytic theories of OCD. Obsessions and compulsions are seen as symptoms of some deeper problem in the person's unconscious mind. The compulsive acts and obsessional thoughts are seen as defensive reactions that suppress the real hidden anxieties.

Focuses on understanding the meaning of the target symptoms such as obsessions in the context of the individual's personality, attitudes and early experiences. The emphasis lies on resolving the unconscious conflicts that are thought to underlie the symptoms. Treatment strategies include exploratory insight-oriented, supportive or directive activity, working with transference, but with the therapist using a less strict technique than that used in psychoanalysis.

Educating people with OCD/BDD and their families about the symptoms of the condition, possible origins of the condition, its evolution over time, and the various treatments available. It also includes education about the symptoms and treatment of any comorbid disorders such as depression.

Used in some treatment studies to show improvement in a person's condition beyond reduction in symptoms, measures of QOL can be defined broadly and include satisfaction, especially within important areas of one's life, the level of functioning in different areas, and the objective circumstances in which one lives. In many studies, however, QOL is defined narrowly as the level of functioning or degree of handicap which is one important aspect but limited as a marker of quality.

Method used to generate a random allocation sequence, such as using tables of random numbers or computer-generated random sequences. The method of randomisation should be distinguished from concealment of allocation, because if the latter is inadequate selection bias may occur despite the use of randomisation. For instance, a list of random numbers may be used to randomise participants, but if the list were open to the individuals responsible for recruiting and allocating participants, those individuals could influence the allocation process, either knowingly or unknowingly.

Also termed ‘randomised clinical trial’, this is an experiment in which investigators randomly allocate eligible people into groups to receive or not to receive one or more interventions that are being compared. The results are assessed by comparing outcomes from the different groups. Through randomisation, the groups should be similar in all aspects apart from the treatment they receive during the study.

A systematically developed statement that is derived from the best available research evidence, using predetermined and systematic methods to identify and evaluate evidence relating to the specific condition in question.

Also known as risk ratio; the ratio of risk in the intervention group to the risk in the control group. The risk (proportion, probability or rate) is the ratio of people with an event in a group to the total in the group. A relative risk of 1 indicates no difference between comparison groups. For undesirable outcomes, an RR that is less than 1 indicates that the intervention was effective in reducing the risk of that outcome.

Relaxation therapy is aimed at teaching a patient to reduce the uncomfortable physical sensations that anxiety produces. Although there is a range of relaxation techniques, the most common one aims to help people relax by systematically tensing and relaxing various muscle groups. This can be used by itself to help people cope with stressful situations or as a part of desensitisation to specific fears. It is also a part of anxiety management training. In some trials of psychological treatments, relaxation has been used as a comparator condition.

See Compulsions

See Obsessions

Medicines that more selectively inhibit the reuptake of the neurotransmitter serotonin into the presynaptic neurone (see Serotonin reuptake inhibitors).

This involves following a self-help programme for OCD, either on one's own (pure self-help), with the support of a group (self-help groups), or with support, guidance and encouragement from a mental health professional (guided self-help). Self-help programmes can use books, computerised materials, audio and videotapes. Effective programmes aim to improve self-management skills in addition to providing knowledge and information.

Many people with health problems find it helpful to meet others with similar difficulties, for support, advice and social contact. These are usually run by people with the disorder, for people with the disorder (and sometimes their carers/families). Some groups also have professional support for some of their activities such as providing information.

Sensitivity analysis is a technique used in economic analysis or decision-making to allow for uncertainty by testing whether plausible changes in the values of the main variables affect the results of the analysis.

A group of drugs that act by inhibiting the neuronal reuptake of the neurotransmitter serotonin. These include SSRIs and other medicines such as clomipramine that act on other neurotransmitters as well as serotonin.

A sequence of treatment options aiming to provide the most appropriate and cost-effective interventions according to both patient need and locally available resources. When appropriate, simpler and less expensive interventions will be offered first, moving to more complex and intensive interventions if the patient has not benefited.

See patient

A tic is an involuntary, rapid, recurrent movement or sound. Examples of simple motor tics include eye-blinking and neck jerking. Simple vocal tics include throat clearing, barking noises, sniffing. Complex tics include jumping, or saying whole words. There is some suggestion that tics seem to be genetically related to OCD in that they can run in families; some people with OCD also have tics.

(or Gilles de la Tourette syndrome)

A chronic form of tic disorder where both vocal and motor tics have been present for a year or more. Some studies suggest that about half of people with Tourette's syndrome also have OCD although the opposite has not been shown.

An intervention involving the use of a pulsed magnetic field to induce changes in function in cortical structures. It was developed in 1985 (Barker et al., 1985) to investigate the cerebral cortical activity and more recently has been used therapeutically for some mental disorders, namely, depression and OCD. In OCD this treatment aims to modify prefrontal cortical activity in order to influence obsessive-compulsive symptoms.

A relative failure to respond adequately to a treatment.

A treatment trial where no attempt is made to compare the investigated treatment with a matched comparator, either active or neutral placebo.

An intervention developed for the control of epilepsy that cannot be managed by normal medical treatment. It involves the electrical stimulation of the vagus nerve within the neck by an electrode connected to a programmable stimulator.

An intervention consisting of the use of 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 method of meta-analysis used to combine measures on continuous scales (such as the Y-BOCS), where the mean, standard deviation and sample size in each group are known. The weight given to each study (for example, how much influence each study has on the overall results of the meta-analysis) is determined by the precision of its estimate of effect and, in the statistical software used by the NCCMH, is equal to the inverse of the variance. This method assumes that all of the trials have measured the outcome on the same scale.

A person between the ages of 12 and 18.