An Inhibitory Learning Approach to Cognitive-Behavioral Therapy for Children and Adolescents

Although exposure-based cognitive-behavioral therapy (CBT) is efficacious for childhood anxiety and obsessive–compulsive disorder (OCD), many youth do not adequately respond to treatment. Extinction learning is an important process in exposure-based CBT. However, youth with anxiety disorders and OCD exhibit impairments in extinction processes that are best characterized by deficits in inhibitory learning. Therefore, the utilization of strategies to optimize inhibitory learning during exposures may compensate for these deficits, thereby maximizing extinction processes and producing more robust treatment outcomes for exposure-based CBT. This paper reviews several strategies to optimize inhibitory learning in youth with anxiety disorders and OCD, and presents practical examples for each strategy. This paper also highlights the difference between inhibitory learning-based exposures and prior conceptual approaches to exposure therapy in clinical practice. It concludes with a discussion of future directions for clinical research on inhibitory learning and exposure-based CBT in youth.     

First-Line Treatment for Pediatric Obsessive–Compulsive Disorder

Pediatric obsessive–compulsive disorder (OCD) is a common psychiatric disorder that impairs children’s functioning in home, school, and community settings. Once thought to be an untreatable or treatment refractory disorder, evidence-based treatments now exist for pediatric OCD. Various psychological treatment approaches for pediatric OCD have been investigated and research supports the use of cognitive-behavioral therapy (CBT) with exposure and response prevention (E/RP) and combined CBT/E/RP with serotonin reuptake inhibitor pharmacotherapy. This paper reviews these approaches and highlights the prominent role of CBT/E/RP as a first-line treatment for pediatric OCD.     

The role of treatment expectancy in youth receiving exposure-based CBT for obsessive compulsive disorder

The purpose of this investigation was to examine correlates of parent, child, and therapist treatment expectations and their role in the exposure-based treatment of childhood obsessive compulsive disorder (OCD). Treatment expectations were assessed among 49 youth with primary OCD, their parents, and therapists as part of the baseline evaluation and post-treatment clinical outcomes were determined by blind evaluators. Baseline depressive symptoms, child/parent-rated functional impairment, externalizing behavior problems, number of comorbid psychiatric disorders, and a lower perception of control were associated with lower pre-treatment expectations. Parent expectation was associated with parental OCD symptoms, child depressive symptoms and child-reported impairment. Therapist expectations inversely correlated with child depressive symptoms, externalizing problems, and child-rated impairment. Pre-treatment OCD severity and prior treatment history were not linked to expectancy. Finally, higher treatment expectations were linked to better treatment response, lower attrition, better homework compliance, and reduced impairment.     

Cognitive Behavior Therapy for Obsessions and Compulsions: New Applications and Emerging Trends

This paper describes recent developments in the cognitive behavioral treatment (CBT) of obsessive compulsive disorder (OCD). Although behavioral treatment of OCD consisting of exposure and response prevention (ERP) has been shown to be clinically effective, certain limitations with ERP have led clinical researchers to propose that treatment should be augmented with direct cognitive interventions. Modification of dysfunctional beliefs and faulty appraisals or interpretations of the obsession are now considered a crucial component of CBT for obsessions and compulsions. This paper discusses the conceptual basis of the new CBT for OCD and reviews its limited empirical status. A case example is provided in which CBT is used to treat obsessional ruminations of becoming sick. The article concludes with a discussion of the challenges and pitfalls involved in offering CBT for obsessions and compulsions.     

Obsessive beliefs predict cognitive behavior therapy outcome for obsessive compulsive disorder

Cognitive accounts of obsessive compulsive disorder (OCD) assert that core beliefs are crucial to the development, maintenance, and treatment of the disorder. There are a number of obsessive beliefs that are considered fundamental to OCD, including personal responsibility, threat estimation, perfectionism, need for certainty, importance of thoughts, and thought control. The present study investigated if pretreatment severity of obsessive beliefs, as well as the change in obsessive beliefs following treatment, predicted intensive, residential cognitive behavioral therapy (CBT) treatment outcome. A series of hierarchical regression analyses were carried out to investigate the relations between obsessive beliefs and treatment outcome. Results indicated that inflated pretreatment responsibility/threat estimation beliefs were significantly related to less overall obsessive compulsive (OC) symptom reduction at discharge, explaining 2% of the overall variance. Changes in obsessive beliefs broadly, and importance/control of thoughts specifically, were positively related to overall OC symptom reduction at discharge, respectively explaining 18% and 3.6% variance. Results are modestly consistent with a number of theoretical models, which argue that inflated responsibility, threat estimation, and thought control are important to the maintenance and treatment of OCD.     

Does d-Cycloserine Augmentation of CBT Improve Therapeutic Homework Compliance for Pediatric Obsessive–Compulsive Disorder?

Clinical studies in adults and children with obsessive–compulsive disorder (OCD) have shown that d-cycloserine (DCS) can improve treatment response by enhancing fear extinction learning during exposure-based psychotherapy. Some have hypothesized that improved treatment response is a function of increased compliance and engagement in therapeutic homework tasks, a core component of behavioral treatment. The present study examined the relationship between DCS augmented cognitive-behavioral therapy (CBT) and homework compliance in a double-blind, placebo controlled trial with 30 youth with OCD. All children received 10 CBT sessions, the last seven of which included exposure and response prevention paired with DCS or placebo dosed 1 h before the session started. Results suggested that DCS augmented CBT did not predict improved homework compliance over the course of treatment, relative to the placebo augmented CBT group. However, when groups were collapsed, homework compliance was directly associated with treatment outcome. These findings suggest that while DCS may not increase homework compliance over time, more generally, homework compliance is an integral part of pediatric OCD treatment outcome.     

Recollections of parent–child relationships,attachment insecurity,and obsessive–compulsive beliefs

To adequately understand Obsessive Compulsive Disorder (OCD), it is important to understand the developmental origins of obsessive beliefs and corresponding compulsive acts. Prior work has shown that having cold, neglectful parents in childhood and/or insecure attachment styles are both linked to emotional disturbances. In this study, we explored the potential contributions of early parent–child relationships to attachment styles and the severity of obsessive–compulsive beliefs in adulthood. A sample of 397 college students completed online, self-report measures of retrospective parent–child relationships, adult attachment styles, and ongoing obsessive–compulsive symptoms. Analyses revealed that attachment anxiety partially mediated the association between parent–child relationships and obsessive beliefs; attachment avoidance failed to operate as a mediating mechanism. Our findings provide support for interpersonal approaches to obsessive–compulsive symptoms and disorder, with implications for the continuity of relationship dysfunction from childhood into adulthood.     

Combining Pharmacotherapy with cognitive-behavioral interventions for obsessive-compulsive disorder

This paper reviews the evidence-based literature concerning the efficacy and effectiveness of cognitive behavior therapy (CBT), drug treatment and their combination for obsessive compulsive disorder (OCD). After a brief outline of the seminal studies, the state of the art is presented with reference to the consensual recommendations proposed in the last 10 years. Management of OCD rests on potent selective serotonin reuptake inhibitors and CBT, used separately, sequentially, or concurrently. A hierarchical model for clinical decision-making is reported. With greater severity of OCD, it is recommended to add medications. However, the response rate is still too low in many patients, and some patients remain refractory to any kind of treatment. This stresses the importance of joint efforts of psychological and biological teams to develop new treatments.     

Irritability in Children and Adolescents With OCD

Irritability is a common, impairing transdiagnostic symptom in childhood psychopathology, though it has not been comprehensively studied in pediatric obsessive-compulsive disorder (OCD). Further, the central cognitive behavioral treatment component for OCD, exposure and response prevention therapy (ERP), has been recently proposed as a treatment for irritability. This study aimed to evaluate whether certain clinical characteristics are associated with irritability in pediatric OCD and whether irritability reduces following ERP. Participants were 161 youth (ages 7–17) with OCD and a caregiver participating in a randomized controlled trial of D-cycloserine or pill placebo augmented ERP. Participants completed validated assessments during treatment. Irritability was significantly and positively associated with depressive symptoms, defiance, functional impairment, and family accommodation, but was not associated with pretreatment OCD severity, symptom dimensions, obsessive beliefs. Irritability significantly declined following treatment, with over half of youth with any pretreatment irritability experiencing clinically significant change, though this change was not related to OCD improvement. Results suggest that irritability may be a marker of psychiatric comorbidity, parental accommodation, and impairment in youth with OCD. Implications for the exposure-based treatment of irritability are discussed.     

Mood, personality disorder symptoms and disability in obsessive compulsive hoarders: a comparison with clinical and nonclinical controls

Hoarding is a symptom of obsessive compulsive disorder (OCD), as well as a diagnostic criterion for obsessive compulsive personality disorder (OCPD). One recent study suggests that people who suffer from compulsive hoarding report more general psychopathology than people who do not [Frost, R.O., Krause, M.S., & Steketee, G. (1996). Hoarding and obsessive compulsive symptoms. Behavior Modification, 20, 116-132]. The present study addressed whether persons with OCD hoarding exhibit more depression, anxiety, OCD and personality disorders symptoms than community controls, OCD nonhoarders, or other anxiety disorder patients. Disability was also examined. Hoarding subjects were older than the other three groups, but age did not account for any of the differences observed among the groups. Compared to controls, OCD hoarding, nonhoarding OCD and anxiety disorder patients showed elevated YBOCS scores, as well as higher scores on depression, anxiety, family and social disability. Compared to nonhoarding OCD and anxiety disorder patients, OCD hoarding patients scored higher on anxiety, depression, family and social disability. Hoarding subjects had greater personality disorder symptoms than controls. However, OCD hoarding subjects differed from OCD nonhoarding and anxiety disorder subjects only on dependent and schizotypal personality disorder symptoms. The findings suggest that hoarding is associated with significant comorbidity and impairment compared to nonhoarding OCD and other anxiety disorders.     

Phenomenology of Early Childhood Onset Obsessive Compulsive Disorder

This paper describes the phenomenological features of early childhood onset obsessive compulsive disorder (OCD; defined as children meeting DSM-IV criteria for OCD with age of onset <8 years). Fifty-eight children (ages 4–8) were included in the sample. OCD and comorbid diagnoses were determined by structured interview, and OCD severity was measured using the Children’s Yale-Brown Obsessive Compulsive Scale (CY-BOCS). Mean age of OCD onset was almost five, and mean age of presentation was between 6 and 7. Mean symptom severity was in the moderately severe range. Comorbidity and family history of OCD were common. Contamination and aggressive/catastrophic obsessions and washing and checking compulsions were endorsed most frequently. Results indicate that early childhood onset OCD may have a lower boy to girl ratio and lower rates of depressive disorders, but may be similar to later childhood onset OCD in terms of OCD symptom presentation and severity.     

Worry and Rumination in Generalized Anxiety Disorder and Obsessive Compulsive Disorder

Ample work has already been conducted on worry and rumination as negative thought processes involved in the etiology of most of the anxiety and mood related disorders. However, minimal effort has been exerted to investigate whether one type of negative thought process can make way for another type of negative thought process, and if so, how it subsequently results in experiencing a host of symptoms reflective of one or the other type of psychological distress. Therefore, the present study was taken up to investigate whether rumination mediates the relationship between worry and generalized anxiety disorder (GAD), and between worry and obsessive compulsive disorder (OCD) in two clinical groups. Self-report questionnaires tapping worry, rumination, generalized anxiety disorder (GAD), and obsessive compulsive disorder (OCD) were administered to a clinical sample of 60 patients aged 30–40. Worry, rumination, generalized anxiety disorder (GAD), and obsessive compulsive disorder (OCD) correlated substantially with each other, however, rumination did not mediate the relationship between worry and generalized anxiety disorder (GAD) and between worry and obsessive compulsive disorder (OCD). We also analyzed differences of outcome variables within two clinical groups. These results showed that worry and rumination were significantly different between GAD and OCD groups.     

Combining Pharmacotherapy with Cognitive‐Behavioral Interventions for Obsessive‐Compulsive Disorder

This paper reviews the evidence‐based literature concerning the efficacy and effectiveness of cognitive behavior therapy (CBT), drug treatment and their combination for obsessive‐compulsive disorder (OCD). After a brief outline of the seminal studies, the state of the art is presented with reference to the consensual recommendations proposed in the last 10 years. Management of OCD rests on potent selective serotonin re‐uptake inhibitors and CBT, used separately, sequentially, or concurrently. A hierarchical model for clinical decision‐making is reported. With greater severity of OCD, it is recommended to add medications. However, the response rate is still too low in many patients, and some patients remain refractory to any kind of treatment. This stresses the importance of joint efforts of psychological and biological teams to develop new treatments.     

Interpersonal Functioning in Obsessive–Compulsive Personality Disorder

The core symptoms of obsessive–compulsive personality disorder (OCPD) often lead to interpersonal difficulties. However, little research has explored interpersonal functioning in OCPD. This study examined interpersonal problems, interpersonal sensitivities, empathy, and systemizing, the drive to analyze and derive underlying rules for systems, in a sample of 25 OCPD individuals, 25 individuals with comorbid OCPD and obsessive–compulsive disorder (OCD), and 25 healthy controls. We found that OCPD individuals reported hostile-dominant interpersonal problems and sensitivities with warm-dominant behavior by others, whereas OCPD+OCD individuals reported submissive interpersonal problems and sensitivities with warm-submissive behavior by others. Individuals with OCPD, with and without OCD, reported less empathic perspective taking relative to healthy controls. Finally, we found that OCPD males reported a higher drive to analyze and derive rules for systems than OCPD females. Overall, results suggest that there are interpersonal deficits associated with OCPD and the clinical implications of these deficits are discussed.     

An open clinical trial of cognitive-behaviour therapy in children and adolescents with obsessive-compulsive disorder administered in regular outpatient clinics

The aim of the present study was to examine the effectiveness of manual-guided cognitive-behaviour therapy (CBT) for childhood obsessive-compulsive disorder (OCD) administered within three regular, i.e., non-academic, Norwegian outpatient child psychiatric clinics. METHODS: A total of 28 youngsters, aged 8-17 with primary OCD entered the study. Assessment at intake included Norwegian versions of the K-SADS-PL, Children's Yale-Brown Obsessive Compulsive Scale (CY-BOCS), and a measure of OCD-specific functional impairment (Child OCD Impact Scale (COIS)). Therapy consisted of 12 manual-guided sessions with combined individual and family CBT-based interventions and was conducted by psychologists and physicians under training and supervision. Outcome was assessed after treatment and at 3- and 6-month follow-ups by means of the CY-BOCS, the Clinical Global Impression (CGI) and the CGI-Improvement scales, and the COIS. RESULTS: Twenty-four youngsters (86%) completed treatment and were available for the follow-up assessments. Significant improvements were found on all outcome measures after treatment, including a mean symptom reduction on the CY-BOCS of 60.6%, increasing to 68.8% at the 6-month follow-up. Estimates of within-group effect sizes showed strong effects of treatment. CONCLUSION: The results of the present study suggest that manual-guided CBT for childhood OCD can be successfully implemented in non-academic community child psychiatric settings with outcomes in accordance with previous findings from highly specialised university clinics.     

Summer Camp Program for Children With Obsessive–Compulsive Disorder: Description and Preliminary Observations

Summer camp programming has a rich history of promoting childhood development. In the care of children with specific childhood psychiatric disorders, the incorporation of targeted cognitive-behavioral principles provides an opportunity to marry targeted evidence-based practices with broader development, in particular social, emotional, and fine- and gross-motor development. This union is synergistic, providing the practitioner with an opportunity to employ cognitive-behavioral practices in an environment that may overcome common barriers to effective interventions outside the scope of the targeted illness. In this paper, the authors describe the preliminary findings concerning a weeklong, 25-hour summer camp program targeting childhood obsessive–compulsive disorder (OCD). Nine children ages 9–12 years participated in this pilot program. Child and parent feedback alike suggested strong treatment acceptability and efficacy in targeting both core symptoms of OCD as well as associated developmental deficits. The camp’s implementation of exposure and response prevention enables an opportunity to report on the capability of employing these strategies in a summer camp setting. In conjunction with an evidence-based treatment program for childhood OCD, a summer camp program specifically targeted for children with OCD presents a valuable tool for improving child welfare and reducing functional impairments.     

Cognitive-behavioral treatment of childhood obsessive-compulsive disorder in community-based clinical practice: clinical significance and benchmarking against efficacy

Objective

To evaluate the feasibility and outcomes of evidence-based (EB) manualized, cognitive-behavioral treatment (CBT) for childhood obsessive-compulsive disorder (OCD), when delivered in an outpatient community-based specialist clinic.

Method

This study, conducted in an outpatient private clinic in South-East Queensland Australia, involved thirty-three children and adolescents with OCD. Children were assessed at pre- and post-treatment, by means of diagnostic interviews, symptom severity interviews, and self-report. Treatment involved 12 sessions CBT delivered either individually or in small groups and included parental involvement.

Results

Manualized CBT could be transported to the community setting effectively, with 63% of the current sample responding positively, based on post-treatment diagnosis. Significant change was evident across a wide-range of outcomes; including, diagnostic severity, symptom severity, child reported depression and anxiety, and both child and parent reported OCD functional impairment.

Conclusions

This study provides evidence for the transportability of manualized CBT in clinical community practice for pediatric OCD. The next important step is larger community based dissemination and effectiveness studies to advance both research and clinical practice outcomes.     

Changes in quality of life following cognitive-behavioral therapy for obsessive-compulsive disorder

Cognitive-behavioral therapy (CBT) incorporating exposure and response prevention is a first line treatment for obsessive-compulsive disorder (OCD). Although, the efficacy of CBT in reducing OCD symptoms is well documented, less is known about its effects on quality of life (QOL). In the current study, functional impairment aspects of QOL (as measured by the Sheehan Disability Scale) were assessed among 70 adult outpatients with OCD before and after CBT. Statistically significant improvements in QOL and large pre- to post-treatment effect sizes were observed for work, social, and family functioning. Improvements in social and family functioning were predicted by improvements in OCD symptom severity even after controlling for improvements in depressive symptoms. In addition, clinically significant change in OCD symptoms and QOL were highly related, although there was a subset of participants whose symptoms improved without corresponding improvements in QOL. These results suggest that the effects of CBT may extend beyond OCD symptom reduction to QOL.     

Intensive Family-Based Cognitive-Behavioral Therapy for Pediatric Obsessive-Compulsive Disorder: Applications for Treatment of Medication Partial- or Nonresponders

Serotonin reuptake inhibitor medications and cognitive-behavioral therapy (CBT) are both effective treatments for pediatric obsessive-compulsive disorder (OCD). Despite recommendations that youth with OCD be treated with CBT alone or together with serotonin reuptake inhibitor medication, many youth are treated with medication alone or with non-CBT psychotherapy initially. Although effective, symptom remission with medication alone is rare (e.g., only 21.4% of youth achieved remission with sertraline in the Pediatric OCD Treatment Study, 2004) and residual symptoms often remain (e.g., 58% of subjects in the March et al. [1998] sertraline trial were not considered treatment responders). This paper reviews the literature on the efficacy of CBT for pediatric OCD, particularly as it relates to the treatment of youth with prior inadequate response to medication. It also describes an intensive, family-based CBT program for children and adolescents with OCD and support for its efficacy among those with prior partial- or nonresponse to medication. Finally, we present a case study of an adolescent girl with OCD who participated in the intensive treatment program after having limited benefit from medication and non-CBT psychotherapy and experienced a favorable response.     

Obsessive-Compulsive Disorder in Late Life

Although obsessive-compulsive disorder (OCD) has received increasing attention, the study and treatment of OCD in late life has been neglected. The obsessions and compulsions seen with older adults do not appear to differ from the symptoms experienced by other age groups, although developmental issues might influence symptom focus (e.g., memory functioning-related obsessions). Hoarding difficulties might be prevalent in late life, although additional studies are needed. Seniors with OCD can present with comorbid psychiatric disorders, multiple general medical problems, and impaired cognitive functioning, complicating evaluation. There have not been controlled clinical trials of cognitive-behavioral therapy (CBT) for late-life OCD, although initial reports suggest older adults respond to CBT that includes age-related treatment modifications. We illustrate the challenges to assessing and treating older adults with OCD with case examples involving memory-related obsessions and clinical hoarding. The successful strategies used for adapting CBT for the treatment of late-life generalized anxiety disorder might serve as a model for advancing the study and treatment of late-life OCD.