Step 1: Awareness and recognition

• collaborate with local and national voluntary organisations to increase awareness and understanding of the disorders and improve access to high-quality information about them (make this available to primary and secondary healthcare professionals and other public services who may come into contact with people of any age with OCD or BDD)
• collaborate with people with the disorders and their family/carers to provide training for all mental health professionals, cosmetic surgeons and dermatology professionals.

Step 6: Intensive treatment and inpatient services for people with obsessive-compulsive disorder or body dysmorphic disorder

• continuing access to specialist treatment services staffed by multidisciplinary teams of healthcare professionals with expertise in the management of the disorders should be available.

• there is risk to life
• there is severe self-neglect
• there is extreme distress or functional impairment
• adequate trials of psychological, pharmacological and combined treatment over long periods of time have not been successful in other settings
• there are additional diagnoses making outpatient treatment more complex, such as severe depression, anorexia nervosa or schizophrenia
• the person has reversal of normal night/day patterns, making attendance for daytime therapy impossible
• compulsions and avoidance behaviour are so severe or habitual, normal activities of daily living cannot be undertaken.

• have severe OCD or BDD with a high level of distress and/or functional impairment and where there has been no response to outpatient treatment
• show significant self-neglect or risk of suicide.

• Existing published criteria (such as Matthews and Eljamel, 2003)Matthews K, Eljamel MS (2003) Status of neurosurgery for mental disorder in Scotland. Selective literature review and overview of current clinical activity. British Journal of Psychiatry 182: 404–11. should be used to guide decisions about suitability.
• Multidisciplinary teams with a high degree of expertise in the pharmacological and psychological treatment of OCD should have been recently involved in the patient's care. All pharmacological options should have been considered and every attempt should have been made to engage the individual in CBT (including ERP) and cognitive therapy, including very intensive and/or inpatient treatments.
• Standardised assessment protocols should be used pre- and post-operation and at medium- and long-term follow-ups in order to audit the interventions. These assessment protocols should include standardised measures of symptoms, quality of life, social and personality function, as well as comprehensive neuropsychological tests.
• Services offering assessment for neurosurgical treatments should have access to independent advice on issues such as adequacy of previous treatment and consent and should be subject to appropriate oversight.
• Post-operative care should be carefully considered, including pharmacological and psychological therapies.
• Services offering assessment for neurosurgical treatments should be committed to sharing and publishing audit information.

Discharge after recovery

• Review for 12 months.
• Agree frequency of contact with the patient and/or family/carers and record in the notes.
• Patients can be discharged to primary care after 12 months if recovery is maintained.

• For patients in whom there has been no response to treatment, use care coordination (or other suitable processes) at the end of any specific treatment programme to identify any need for continuing support and the appropriate services to address it.