OCD and Body Dysmorphic Disorder: A NICE CG31 Staff Guide

Obsessive-compulsive disorder (OCD) and body dysmorphic disorder (BDD) are often misunderstood. OCD is far more than a liking for tidiness, and BDD is far more than vanity. Both can take over a person's day, damage relationships and work, and bring a real risk of depression and suicidal thoughts. NICE guideline CG31 covers recognising, assessing, diagnosing and treating both conditions in adults, young people and children aged 8 and over. This guide sets out what care and health staff need to know. It is general information, not clinical advice, and staff should always check the current version of the guideline.

What OCD and BDD involve

OCD has two linked parts. Obsessions are unwanted, distressing thoughts, images or urges that keep coming back. Compulsions are repeated behaviours or mental acts, such as checking, washing, counting or repeating phrases, that the person feels driven to do to reduce distress or to stop a feared outcome. BDD involves a preoccupation with perceived flaws in appearance, which others often cannot see, and repetitive behaviours such as mirror checking, camouflaging or seeking reassurance. In both conditions the person usually knows the behaviours are excessive, which adds to their shame and the tendency to hide them.

Signs staff may notice

• Very long routines for washing, dressing, checking doors or medicines, or repeated requests for reassurance.
• Avoiding places, people or objects linked to a fear, such as contamination or harm.
• Spending excessive time looking in mirrors, or avoiding mirrors, photographs and social situations.
• Skin damage from washing, or repeated requests for cosmetic procedures.
• Distress, low mood or comments suggesting hopelessness.

The stepped care model in NICE CG31

NICE CG31 uses a stepped care model across six levels. Steps one and two cover awareness, recognition and assessment in primary care. Step three is initial management by GPs and primary care teams. Step four involves multidisciplinary care where there is other illness or a poor response, and step five specialist multidisciplinary teams for significant comorbidity or treatment-resistant illness. Step six covers inpatient or intensive services for severe, treatment-refractory cases. The guideline also says that services should have access to a specialist OCD and BDD multidisciplinary team and that professionals delivering treatment should have appropriate training.

What treatment looks like

The main psychological treatment is cognitive behavioural therapy (CBT) including exposure and response prevention, often shortened to ERP. In ERP the person gradually faces the situations that trigger obsessions while resisting the urge to carry out compulsions. NICE's quick reference guide describes up to 10 therapist hours of low-intensity CBT with ERP for adults with mild impairment, and more than 10 therapist hours of more intensive CBT for those with greater impairment. SSRI medicines are recommended as an option for adults, and the quick reference says treatment should continue for at least 12 months to reduce the chance of relapse in adults, with a shorter minimum of 6 months after remission for children. Always check current NICE guidance before quoting these numbers, because the guideline is under review: NICE records it as last reviewed in July 2024 with an update in progress.

How staff can help without feeding compulsions

Well-meant help can unintentionally strengthen OCD. Giving repeated reassurance, doing rituals for the person or allowing routines to dominate the day can keep the cycle going. A better approach is to agree with the person and the clinical team how staff should respond. This might mean a calm, consistent statement that you understand it is difficult, followed by encouragement to use the strategies from therapy. Do not force the person to stop a compulsion, and do not make jokes or comparisons with ordinary tidiness.

Practical steps include:

• Record how much time routines take and how they change, which helps clinicians judge progress.
• Make sure the person can attend therapy sessions and complete any between-session tasks.
• Support medicines routines and report side effects promptly.
• Be alert to a rise in distress as exposure work starts, because this is expected but needs support.

Risk and co-occurring conditions

NICE says that assessment should include risk, including suicide and self-harm. People with OCD or BDD often have depression, anxiety, or other conditions such as tic disorders or eating disorders, and some also use alcohol or drugs to cope. If you are concerned about a person's safety, follow your employer's procedures; see our guide to suicide and self-harm awareness training. A trauma-informed, non-judgemental approach also matters, as set out in trauma-informed care in practice.

Frequently asked questions

Is OCD the same as being a perfectionist?

No. OCD involves distressing unwanted thoughts and compulsions that consume time and cause impairment, not just high standards.

Can people recover?

Many people improve substantially with the right therapy and, for some, medicine. Staff should avoid promising any specific outcome and should support continued treatment.

What training helps?

Mental health awareness and recognising risk are good places to begin. Our mental health first aid training guide and the Learnsignal CPD hub list options.

Source: NICE guideline CG31, Obsessive-compulsive disorder and body dysmorphic disorder: treatment, and its quick reference guide. This article is general information, not clinical advice.