This document provides guidelines for managing depression in individuals with obsessive-compulsive disorder (OCD) and body dysmorphic disorder (BDD). It begins by describing the prevalence of depression in OCD/BDD, with around 40% of people with OCD and 60% of people with BDD also experiencing depression. It then outlines treatment recommendations for mild, moderate, and severe depression based on UK National Institute for Health and Care Excellence guidelines. For mild depression, it recommends guided self-help, exercise, problem-solving, and computerized cognitive behavioral therapy initially before antidepressants. For moderate depression, it indicates cognitive behavioral therapy and behavioral activation are effective. The document provides detailed descriptions of behavioral activation techniques and cognitive strategies to manage

1. Manage Your Mood
in OCD & BDD
David Veale
www.veale.co.uk

2. Today’s objectives
•
•
•
Describe the NICE guidelines for
depression
Learn to recognize symptoms of
depression
How to use CBT (Behavioural
activation) & SSRI anti-depressants for
depression in OCD/ BDD

3. The size of the problem
OPCS 2000 England adults 16-64
10.8% community had mixed anxiety &
depression, 2.7% depression, 4.6%
GAD
More common in women (& men elderly)
Unemployment, live city, homeless
Separated or widowed men > separated
or divorced women > married
Link to alcohol & substance use

4. Depression in OCD/ BDD
About 40% people with OCD & 60% BDD have
depression
Which comes first? In large majority OCD/ BDD come
first
Magic Wand? Depression not a problem
In general, treat OCD/BDD and depression improves
However, depression usually interferes in treatment of
OCD/BDD

5. Recognize depression
At high risk if significant physical illness
or stress (or OCD/ BDD)
“During the past month….
Have you often had low energy?
Have you often felt down?
Have you often had little interest or
pleasure in doing things?
Have you often felt hopeless?”
•
If yes, to any question, ask...

6. Screening for depression
• Have you had difficulty concentrating?
• Have you lost weight or had a poor
appetite? (or comfort eating?)
• Have you been waking early or sleeping
long hours?
• Have you felt slowed up?
• Have you tended to feel worse in the
mornings?
Yes to 3 or more, high likelihood of depression
OCD/BDD often more frustration, low self-esteem &
hopelessness

7. Diagnosis depression
Adolescent – especially withdrawn and
irritability
Elderly and some some cultures – more
somatic symptoms
Often part of alcohol & substance abuse

8. Themes in depression
Loss
Inter-personal conflict spouse/boss
Change of role in life
Deficits in life
Failure to achieve an ideal or
perfectionism and highly self-critical

9. Suicide
Doctors & therapists will ask about suicidal plans:
Do you sometimes feel as if you’d like to end it all?
How long have you had these feelings? Do you have a
specific plan for your method?
Have you told anyone?
What’s stopped you so far?
Have you left you affairs in order?
Have you prepared a note?

10. Suicide
Risk factors:
• Significant depression or delusions; alcohol or
substance abuse;
• Hopelessness and sense that family would be
better off ;
• an organized plan or easily available method
• absence of protective factors (religion, loved
ones)
• regret at survival from a recent attempt
• attempt to avoid discovery from recent
attempt

11. Suicide risk
Higher risk (but often cannot change) if:
• history of deliberate self-harm, suicide
attempts or violence
• male (adolescent or elderly)
• living alone or socially isolated
• Have physical illness
• Socio-economic problems

12. Generalised Anxiety
Disorder
Mental anxiety - “Do you worry a lot?” (in
different areas)
Apprehension (“Do you feel “on edge”, have
difficulty concentrating, irritable?”)
Tension (“Do you feel restless? Fidgety? Do
you get frequent headaches? Are you unable
to relax?”)
Over-reactive (“Do you startle easily? Do you
have difficulty getting off to sleep”)
(GAD often confused with depression or is
comorbid. It is different from panic attacks)

13. Background to NICE
guidelines
There are many different types of
depression
Very few trials of treating depression in
people with OCD/ BDD

14. Different types of depression Problem for controlled trials
Consider 2 young unmarried female
patients; both aged 18; both have same
depression score (e.g of 24 on standard
scale)

15. Patient 1: is a lone
mother
Parents divorced
Mother was depressed
Sexual abuse since age
11
Left home age 14
Casual sex since
Depressed for 2 years
Recently worse since
child taken into care

16. Patient 1: is a lone mother Patient 2: university
student
Parents divorced
Supportive parents
Mother was depressed
No FH of depression
Sexual abuse since age
Many friends
11
Left home age 14
Casual sex since
Depressed for 2 years
Recently worse since
child taken into care
Affair with boyfriend last
2 years
He recently left with
another girl
Depressed for 2 weeks
since he left

17. Who is responsible for
care?
What do they do?
Why do they
do it?
Acute Wards
CMHT, OPD, crisis
team, Day Hospital
PCMHW, GP, Counsellor,
social worker, psychologist
GP, Practice nurse,
Practice counsellor
Risk to Life
Treatment resistance
frequent recurrences
Moderate or Severe
Depression
Mild Depression
Recognition
Medication,ECT
nursing care
Medication, complex
Psychological i.v’s
Medication,Brief psych.
interventions, support groups
Active Review: Guided Self
Help or CBT, Exercise

18. Mild depression
Guided self-help CBT
[A]
Physical exercise
[B]
Problem solving
[B]
Computerised CBT
[B]
“watchful waiting”
[GPP]
St. John’s Wort (with reservations) [B]
AD’s not recommended for initial Rx of mild
depression
[C]

19. When “watchful wait” ?
• Less than 2 weeks
• Symptoms mild and intermittent
• Good social support
• No family history of depression
• No past history of depression
(In OCD, BDD - depression is secondary
and treatment is progressing to plan?)

20. Mild depression
Guided self-help with therapist
[A]
Physical exercise
[B]
Problem solving or counselling
[B]
Computerised CBT
[B]
“watchful waiting”
[GPP]
St. John’s Wort (with reservations) [B]
AD’s not recommended for initial Rx of mild
depression
[C]

21. Guided self-help based on CBT – David
Burns- Feeling Good http://www.feelinggood
.com/

22. Overcoming depression
Chris Williams
Guided self help CBT
Published in UK
Also CD ROM
http://http://www.fiveareas.com/

23. Focus on Behavioural Activation
• Psychological understanding of
depression
• Effective treatments for depression
• Sleep management
• Eating healthily
• Problem Solving
• Exercise
• Alcohol, substances
• St John’s Wort
• Medication

24. Mild depression
Guided self-help
[A]
Computerised CBT
[B]
Physical exercise
[B]
Problem solving or counselling
[B]
“watchful waiting”
[GPP]
St. John’s Wort (with reservations) [B]
AD’s not recommended for initial Rx of mild
depression
[C]

25. Computerised CBT
NICE Technology appraisal, 2002
Calipso (www.fiveareas.com )
Beating the Blues (Ultrasys)
Restoring the Balance (Mental Health
Foundation)
Mood Gym http://moodgym.anu.edu.au/

26. Mild depression
Guided self-help
[A]
Physical exercise
[B]
Problem solving or counselling
[B]
Computerised CBT
[B]
“watchful waiting”
[GPP]
St. John’s Wort (with reservations) [B]
AD’s not recommended for initial Rx of mild
depression
[C]

27. Physical exercise
Dose 45-60 minutes, 3 times a week for
12 weeks
Adherence – just telling someone to
exercise not effective (difficult enough
when not depressed)
Trials are different (bias in who is
recruited, enthusiastic trainer, often
group)

28. Mild depression
Guided self-help
[A]
Physical exercise
[B]
Problem solving or counselling
[B]
Computerised CBT
[B]
“watchful waiting”
[GPP]
St. John’s Wort (with reservations) [B]
AD’s not recommended for initial Rx of mild
depression
[C]

29. St John’s Wort
Hypericum perforatum
300-600mg recommended daily dose
Bought over the counter but tell GP if other drugs
Improvement should occur within 3-5 weeks
Continue for at least 6 months
BUT interacts with some drugs (warfarin, coumadin,
theophylline, digoxin, contraceptive pill)
Do not combine with standard ant-dperessants
No evidence for benefit in OCD/ BDD
St John’s Wort Helpline 01803 528 668

30. Mild depression
Guided self-help
[A]
Physical exercise
[B]
Problem solving or counselling
[B]
Computerised CBT
[B]
“watchful waiting”
[GPP]
St. John’s Wort (with reservations) [B]
AD’s not recommended for initial Rx of mild
depression
[C]

31. Severity of depression and
placebo response in adults
Per cent response
70
60
50
40
30
20
10
15
21
27
Baseline HAM-D
Angst (1993)
33
0
Placebo
Antidepress

32. Anti-depressants
SSRIs for OCD/ BDD (fluoxetine,
citalopram, sertraline, paroxetine,
fluvoxamine)
• Also recommended for depression in
OCD/BDD
• Highest tolerated dose, daily
• Side effects can usually be managed
• Withdraw gradually
• Duration?
•

33. Seasonal Affective
Disorder
Recurrent seasonal depression onset winter
Atypical symptoms
• Increased sleep
• Increased appetite/ weight gain
• Lethargy
Mild version very common
Phototherapy

35. Phototherapy for SAD
Phototherapy daily in Winter - starting in
autumn
Sit 2-3 feet away from light box whilst doing
other activities
Response often within four days
10,000 lux for half an hour morning (or if poor
response morning and afternoon)
Not available on the NHS but can trial
Seasonal Affective Disorder Association www.
sada.org.uk
Outside In www.outsidein.co.uk

36. Mild depression
Guided self-help
[A]
Physical exercise
[B]
Problem solving or counselling
[B]
Computerised CBT
[B]
“watchful waiting”
[GPP]
St. John’s Wort (with reservations!) [B]
AD’s not recommended for initial Rx of mild
or sub-threshold depression
[C]

37. Counselling
For mild to moderate depression, recent
onset (not chronic depression)
Insufficient evidence for benefit at 6
months
6-8 sessions over 10 weeks
Counselling is a generic term and covers
many different types from “support”,
psychodynamic to problem solving
No evidence in OCD/ BDD

38. Psychological treatments for
moderate depression
If psychological treatment for depression, CBT
and BA

39. Behavioural Activation
•
•
•
•
•
BA as effective as CBT, and probably easier
to apply in OCD/ BDD
Therapists not always enthusiastic as it lacks
complexity and no focus on reasons
BA is available in NHS IAPT (Increasing
Access to Psychological Therapies)
www.iapt.nhs.uk
Ask if therapist accredited by BABCP or
receives supervision from senior therapist
Ask if training in Behavioral Activation for
depression

40. Behavioural Activation
Depression occurs when a person tries to avoid or control
unpleasant feelings and copes by becoming withdrawn and
inactive and brooding about the past. Trying to escape or
control the way you feel works in the short term (and therefore
more likely to do it again)
It is normal to want to avoid unpleasant feelings but there are
number of unintended consequences
• You miss out on pleasurable/satisfying events and opportunities
• They make you brood and worry more (get depressed about
being depressed)
• They stop you doing what is important in your life
• They have effect on others (e.g. people get annoyed or
sarcastic or take away responsibility from you)
• They prevent you from testing out some of your beliefs
i.e they make you more depressed in the long term

41. Consequences
•
•
•
•
•
Withdraw and become inactive
Lose out on events that normally bring satisfaction or
pleasure
Ruminate more and becoming more depressed
Actions have an effect on others
Goal is willingness to experience unpleasant
thoughts and feelings – not to avoid, control or
manage feelings but acknowledge them and to act in
by still doing what is important in your life (despite
how you feel)

42. Behavioural Activation
Good relationship with therapist
Therapist is a coach
Good psychological understanding of what
maintains depression
If OCD/ BDD and more sever symptoms, done
in parallel with treatment for OCD/ BDD

43. Behavioural Activation
•
•
•
•
Define what you are avoiding
Identify what is important to you (your
valued directions in life)
Gradually structure day/ timetable
activities and act according to a plan of the
acts avoided and valued directions rather
than how you feel
No search for internal causes or reasons
from the past. No focus on content of
thoughts.

44. Functional Analysis
Learn ABC Model
A - Activating event/ trigger
B - Behaviour (what you do)
C - Consequences
- Immediate (reduction in negative
affect) which strengthens behaviour
- Unintended (long-term)

45. Behaviour in depression
Identify typical avoidance and escape
behaviours in a person with depression.
(Include behaviours that might function as
avoidance)

46. What do depressed people
avoid ?
Social
- withdrawn, not answer telephone,
- avoid thinking about problems in relationships &
family issues,
Non-social
- challenging tasks, rather than go out watch TV
- avoid thinking future, making decisions, taking
opportunities, not serious about work/education or
what to do in life, avoid problems of OCD/BDD
Some behaviours done in excess may function as
avoidance (sleep, exercise, gambling, alcohol)

47. Assess what used to
enjoy
Identify what one used to enjoy/ find
satisfying?
N.B May need a balance between
strengthen pleasant activities and
avoidance of thoughts and feelings (e.g.
watching video, using computer game)

48. Assess Valued Directions in
Life
Valued directions are not the same as goals
(e.g. get married and have children might be
a goal but to be a good partner and parent is
a valued direction all one’s life)
Aim is to identify valued directions in life to
incorporate in activity schedule (so not just
doing something for the sake of doing it)
Beware of values that are socially approved or
idealised values that identify the self

49. Activity Schedule
Baseline and to monitor subsequent
approach/avoidance activity,
One as planned timetable to guide activity and one
actual activity
Graded task assignments form what (a) avoid (b)
enjoyable and c) valued directions
Act according to plan not how one feels!
Support of family member/friend to keep to timetable
Imaginal and verbal rehearsal of tasks
Role play of tasks avoided

50. Rumination
Trying to find reasons for bad events in the past, reasons for
feeling bad (encouraged by some therapies)
(Why didn’t my mother love me? If only I’d done more work before
the exam. Why do I feel so awful? Why was I rejected?) Also
compare, self-attack
Solution:
1)
Identify when ruminate/ compare as automatic actvitiy
2)
Identify effect on mood, energy level, activity
3)
Turn “Why?”.. into action “How can I…?” do what is important
to me
4)
Identify motivation for ruminating
.

51. Worry (trying to solve all
potential problems)
Worry (e.g. What if my husband dies, what if I get
cancer, what if my boss doesn’t like the work, what
if…) (desire certainty and control) and trying to
prevent them from happening
Functional analysis (Trigger, Behaviour of worry,
Consequences ? Avoid)
Accept what is likely or severe and prepare for them
(e.g. Earthquake in LA – practise for it)
(e.g. death - make a will, guardian for children,
write obituary
(e.g. role play what explain to boss/interview)
Do not mentally prepare - only act/role play

52. Distancing self from
thoughts
Aim to reduce fusion with past memories
Thank one’s mind for it’s contribution to one’s mental
health
Label thinking styles (“Oh well done an excellent
example of catastrophising”)
Label thoughts e.g. “I’m having a thought….”
Metaphor of cars passing in road or leaves on stream
Self focussed attention - focus on external world

53. ACTION
Use whenever not sure about function of behaviour
A ssess how this behaviour serves you. What are my
goals in this situation (i.e. are you avoiding something
that is waiting that you do not want to do)
C hoose to avoid or activate (OK to avoid and feel
worse)
T ry out whatever behaviour has been chosen
I ntegrate any new behaviour repeatedly into a daily
routine
O bserver the outcome – write down what they did and
what happened (effect on mood
N ever give up