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.     

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.     

A Comparison of Obsessive–Compulsive Personality Disorder Scales

In this study, we utilized a large undergraduate sample (N = 536), oversampled for the Diagnostic and Statistical Manual of Mental Disorders (4th ed., text revision [DSM–IV–TR]; American Psychiatric Association, 2000) obsessive–compulsive personality disorder (OCPD) pathology, to compare 8 self-report measures of OCPD. No prior study has compared more than 3 measures, and the results indicate that the scales had only moderate convergent validity. We also went beyond the existing literature to compare these scales to 2 external reference points: their relationships with a well-established measure of the five-factor model of personality (FFM) and clinicians' ratings of their coverage of the DSM–IV–TR criterion set. When the FFM was used as a point of comparison, the results suggest important differences among the measures with respect to their divergent representation of conscientiousness, neuroticism, and agreeableness. Additionally, an analysis of the construct coverage indicated that the measures also varied in terms of their representation of particular diagnostic criteria. For example, whereas some scales contained items distributed across the diagnostic criteria, others were concentrated more heavily on particular features of the DSM–IV–TR disorder.     

Risking Everything in Obsessive–Compulsive Disorder: An Analogue Decision-Making Study

An experiment examined decision-making processes among nonclinical participants with low or high levels of OCD symptomatology (N?=?303). To better simulate the decision environments that are most likely to be problematic for clients with OCD, we employed decision tasks that incorporated “black swan” options that have a very low probability but involve substantial loss. When faced with a choice between a safer option that involved no risk of loss or a riskier alternative with a very low probability of substantial loss, most participants chose the safer option regardless of OCD symptom level. However, when faced with choices between options that had similar expected values to the previous choices, but where each option had some low risk of a substantial loss, there was a significant shift towards riskier decisions. These effects were stronger when the task involved a contamination based, health-relevant decision task as compared to one with financial outcomes. The results suggest that both low and high symptom OC participants approach decisions involving risk-free options and decisions involving risky alternatives in qualitatively different ways. There was some evidence that measures of impulsivity were better predictors of the shift to risky decision making than OCD symptomatology.

     

Flexible Manualized Treatment for Pediatric Obsessive–Compulsive Disorder: A Case Study

The following case study describes the treatment of an 8 year-old girl with early-onset obsessive compulsive disorder using a manualized cognitive-behavioral therapy with exposure and response prevention (CBT/EPR) protocol, implemented using a “flexibility within fidelity” approach. The case study focuses on how the treatment manual was successfully implemented in a flexible manner to address unique aspects of the case. These unique factors included the child’s extreme shyness at the beginning of treatment (with implications for rapport building), the primarily obsessional presentation of this child’s symptoms, the child’s avoidance of discussing the content of her obsessive thoughts, and secondary depressive symptoms (excessive guilt, frequent crying, and sadness) that contributed to the child’s impairment and distress. Assessment of progress indicated improvement in symptoms after four sessions of cognitive skill building and again in the last five sessions after implementing increased exposure to obsessive thoughts using narrative techniques. The implications for clinicians and student therapists, including the importance of rapport building, developmentally tailoring treatment, and flexibly implementing treatment to address the unique characteristics of the individual patient are discussed.     

Comorbidity of Pediatric Obsessive–Compulsive Disorder and Anxiety Disorders: Impact on Symptom Severity and Impairment

This study explored the impact of comorbidity on symptom severity and treatment outcome in a sample of 75 pediatric Obsessive–Compulsive Disorder (OCD) patients. Forty received cognitive–behavioral therapy (CBT). Overall, 56% had a comorbid disorder. Results revealed that youth with comorbid disorders (anxiety or otherwise) endorsed significantly more anxiety symptoms than youth with OCD only. Youth with comorbidities instead of or in addition to anxiety exhibited more severe OCD symptoms than youth with OCD alone or an anxiety-only comorbidity. Youth in the comorbidities instead of or in addition to anxiety group had the poorest CBT response relative to the other groups. These results suggest that relative to those with OCD alone or with an anxiety disorder comorbidity, youth with comorbidities instead of or in addition to anxiety have a differing clinical presentation (e.g., more severe symptoms) and worse psychotherapy outcome.

The Role of the Family in Childhood Obsessive–Compulsive Disorder

While obsessive–compulsive disorder is widely recognized to have a strong genetic component, psychosocial factors are also acknowledged to be important. The primary focus of this paper is on familial factors associated with OCD in children and adolescents. It explores the family context as a possible risk factor in the development and maintenance of the disorder, including parental modeling, expressed emotion, parenting style, and family accommodation of the child's symptoms. The involvement of the family in the treatment of the disorder is also reviewed. Finally, future directions for research investigating familial factors in childhood OCD are presented.     

Evidence-Based Assessment in Children and Adolescents with Obsessive–Compulsive Disorder

The assessment of varied psychiatric disorders, including obsessive–compulsive disorder (OCD), is shifting towards the use of evidence-based assessments (EBAs). This shift has fostered the development, validation and adaptation of several measures to rate obsessive–compulsive symptoms and other related problematic areas such as functional impairment or family attitudes among others. The aim of this paper is to present a systematic review of psychometric studies on pediatric OCD-specific measures to classify these according to assessment evidence-based criteria. Selection criteria that determined which studies were included in the review were: (1) analyzing an OCD measure and (2) including participants’ age being 18 years or younger. The literature search procedure was conducted in Medline, PsycINFO, PsycARTICLES, ERIC, Cochrane Library, and Scholar Google databases and enabled us to locate 42 studies which analyzed psychometric properties of 14 OCD measures studied in children and adolescents. Instruments were grouped into the following assessment areas: symptom presence and severity, functional impairment, family functioning and cognitive dimensions of OCD. Psychometric data regarding internal structure, internal consistency, reliability, validity and diagnostic precision were also reported. Further, measures were classified as well-established, approaching well-established and promising assessments in terms of reliability and validity. We concluded that the assessment of OCD in pediatric populations is a growing field that in a short-medium term could provide a wide variety of EBAs for the evaluation obsessive–compulsive symptoms and other OCD-related dimensions. The paper concludes by highlighting directions for future research.     

Pragmatic Competency and Obsessive–Compulsive Disorder: A Comparative Assessment with Normal Controls

Unlike such cognitive impairments as autism and schizophrenia, the speech pattern in obsessive–compulsive disorder (OCD) has largely remained underrepresented. We examined the pragmatic competence of OCD-affected individuals under two variant modes: pragmatic recognition and pragmatic production. In the recognition phase, the informants completed a discourse completion test around two speech acts of request and apology (20 high power distance situations). The production phase was carried out through an interview during which the informants’ communication behaviors were rated on the basis of the Orion’s pragmatic language skills checklist (OPLS) subscales. No significant difference was observed between the normal and OCD groups in terms of pragmatic recognition. Moreover, considering the OPLS subscales, although the normal controls significantly outperformed in non-verbal communication and expressive skills, the overall pragmatic production ability of the two groups was statistically alike. The results are discussed in relation to the two competing disorders of autism and social anxiety.     

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.     

Predicting Treatment Outcomes From Internet-Based Cognitive Behavior Therapy for Obsessive–Compulsive Disorder

Internet-based cognitive-behavioral therapy (ICBT) with therapist support shows promise as a treatment for obsessive-compulsive disorder (OCD). Yet, not all patients respond to ICBT. It is therefore important to identify predictors of ICBT outcomes to determine who is likely to benefit. Relative to the large literature on predictors of outcomes for in-person CBT for OCD, very few studies have investigated ICBT predictors. Therefore, we analyzed predictors of outcome in an open trial (n = 30) of ICBT for OCD using the OCD-NET platform, which consists of 10 online modules delivered with therapist support. The Yale-Brown Obsessive-Compulsive Scale (YBOCS) was administered by independent raters as the primary outcome measure at baseline and posttreatment. In this sample, greater baseline OCD severity and OCD-related avoidance behaviors were associated with higher end-state OCD symptoms (i.e., poorer outcome). Patients with a past history of face-to-face CBT for OCD also had worse outcomes. Although these results require replication, these factors may identify individuals at risk for poor ICBT outcomes.     

Obsessional Beliefs and Symptoms of Obsessive–Compulsive Disorder in a Clinical Sample

The aim of the present study was to investigate the relationships among a broad range of obsessive–compulsive disorder (OCD) symptoms and obsessional beliefs in a clinical sample of OCD patients. Ninety-nine treatment-seeking adult OCD patients completed the Obsessive Beliefs Questionnaire and the Obsessive–Compulsive Inventory-Revised. Hierarchical regression analyses, controlling for comorbid symptoms, suggested that washing was predicted by responsibility/threat estimation beliefs. Checking/doubting was not predicted by any obsessional beliefs. Hoarding was predicted by perfectionism/certainty beliefs. Neutralizing was predicted by responsibility/threat estimation beliefs. Obsessing was predicted by importance/control of thoughts and perfectionism/certainty beliefs. Ordering was predicted by perfectionism/certainty beliefs. A principal components analysis of OCD symptom dimensions and accompanying beliefs yielded two components, accounting for 53% of the variance: one, which was labeled “Fear/Threat,” consisted of importance/control of thoughts, obsessing, responsibility/threat estimation, and washing. The second, which was labeled “Incompleteness/Not Just Right,” consisted of neutralizing, perfectionism/certainty, checking/doubting, and hoarding.     

Hierarchical Structure of Dysfunctional Beliefs in Obsessive‐Compulsive Disorder

The Obsessive Beliefs Questionnaire was developed as a comprehensive measure of dysfunctional beliefs, which cognitive models consider to be etiologically related to obsessive‐compulsive disorder. Obsessive Beliefs Questionnaire subscales tend to be highly correlated, which raises the question of whether obsessive‐compulsive‐related beliefs are hierarchically structured, consisting of lower‐order factors loading on 1 or more higher‐order factors. To investigate the nature and relative importance of these factors, a hierarchical factor analysis was conducted (n = 202 obsessive‐compulsive disorder patients), using a Schmid‐Leiman transformation. Results indicated a higher‐order (general factor) and 3 lower‐order factors: (i) responsibility and overestimation of threat, (ii) perfectionism and intolerance of uncertainty and (iii) importance and control of thoughts. The high‐order factor accounted for more variance in Obsessive Beliefs Questionnaire scores (22%) than did the lower‐order factors (6–7%), thereby underscoring the importance of the higher‐order factor. Despite the importance of the higher‐order factor, the lower‐order factors significantly predicted unique variance in measures of obsessive‐compulsive symptoms, including severity ratings of compulsions. These finding suggest that cognitive models of obsessive‐compulsive disorder should take into consideration the hierarchic structure of obsessive‐compulsive‐related beliefs.     

Potentials and Limitations of Cognitive Treatments for Obsessive‐Compulsive Disorder

Exposure and response prevention (ERP) is a well‐established treatment for obsessive‐compulsive disorder (OCD). However, it is not completely effective for many patients, and some do not benefit from or tolerate this treatment. Over the past 3 decades there has been growing interest in using cognitive interventions, either as adjuncts or alternatives to exposure‐based treatments such as ERP, to address these shortcomings. Cognitive therapy and cognitive behavior therapy for OCD have both demonstrated greater efficacy than no treatment at all, and appear to have a lower incidence of dropout than ERP. Unfortunately, however, for the average OCD patient, cognitive interventions have not improved treatment efficacy; that is, cognitive interventions, either alone or combined with ERP, are no more effective than ERP alone. Reasons for this disappointing result are considered, and indications for the use of cognitive interventions are discussed. Future research directions are suggested in order to evaluate more fully the merits of, and indications for, cognitive methods for treating OCD.     

Clinical Feedback About Empirically Supported Treatments for Obsessive‐Compulsive Disorder

Previous evidence for the treatment of obsessive‐compulsive disorder (OCD) has been derived principally from randomized controlled trials. As such, evidence about the treatment of OCD has unilaterally flowed from researchers to clinicians. Despite often having decades of experience treating OCD, clinicians’ feedback on their clinical observations in using these treatments has not been solicited. The current study contacted clinicians for their clinical observations on empirically supported treatments for OCD to identify commonly used cognitive-behavioral techniques and their limitations in their practices. One hundred eighty-one psychotherapists completed an online survey. The average participant practiced psychotherapy for 15 years, worked in private practice, held a doctorate, and treated an average of 25 clients with OCD in their lifetime. In regard to the most common techniques, behavioral strategies involving exposure to a feared outcome and prevention of a compulsive ritual were the most frequent group of interventions, followed by techniques that attempted to identify and challenge irrational thoughts. However, the majority of participants also reported incorporating mindfulness or acceptance-based methods. Based on therapists’ reports, the most common barriers to the efficacy of cognitive-behavioral interventions included limited premorbid functioning, chaotic lifestyles, controlling and critical families, OCD symptom severity, OCD symptom chronicity, and comorbidities. This study provides insight into common practices and limitations in clinical practice to inform future clinically relevant treatment research.     

The Impact of Modifying Interpretive Bias on Contamination-Related Obsessive–Compulsive Symptoms

Cognitive-behavioural models of obsessive–compulsive disorder (OCD) propose that a tendency to negatively interpret ambiguous thoughts and situations plays a key role in maintaining the disorder. Moreover, some researchers have proposed that negative interpretive biases may share a common processing mechanism with attentional biases, with changes in one predicted to lead to changes in the other. The current study examined whether training positive (i.e., adaptive) interpretive bias of contamination-related OCD concerns using a cognitive bias modification paradigm (CBM-I) would lead to reductions in contamination concerns, as well as changes in contamination-related attentional bias. Undergraduate students with high levels of contamination-related OCD symptoms were randomly assigned to receive either positive (n?=?31) or neutral (n?=?33) CBM-I training. Participants in the positive training condition, relative to the neutral training condition, showed a significantly greater increase in positive interpretive bias, significantly less within-session behavioural avoidance of contaminants, and significantly reduced contamination-related cognitions (at one-week follow-up). Contrary to expectations, CBM-I training did not differentially impact attentional bias nor self-reported contamination-related OCD symptoms. We discuss future directions in applying CBM-I to contamination-related OCD.

     

A General and Maladaptive Personality Perspective on Youth Obsessive–Compulsive Symptoms

Based on Krueger's (2005) conceptual model of the personality-psychopathology relationship, this study examines how personality predicts different youth obsessive–compulsive symptoms, comparing the relative contribution of general and maladaptive personality traits. Three-hundred forty-four adolescents provided self-reports on an obsessive–compulsive scale, and their mothers rated their child's general and maladaptive personality. Hierarchical regression analyses revealed that personality differentially predicts obsessive–compulsive symptomatology, and that the relative significance of general versus maladaptive personality predictors differs across various forms of obsessive–compulsive pathology. The results are discussed in terms of the value of including both general and maladaptive personality measures in the assessment of early obsessive–compulsive difficulties.     

Parental Accommodation Predicts Symptom Severity at Long-Term Follow-Up in Children with Obsessive–Compulsive Disorder: A Preliminary Investigation

Pediatric obsessive–compulsive disorder (OCD) is a chronic condition affecting millions of children. Though well intentioned, accommodation (i.e., a parent’s attempt to assuage their child’s distress and anxiety) is thought to increase OCD symptom severity and may cause greater OCD-related impairment. The present study sought to examine the relative contribution of parental accommodation in predicting OCD symptom severity. Children between the ages of 6 and 18 (and their parents) participated in a prospective, longitudinal study investigating the course of pediatric OCD utilizing a longitudinal design. Data was collected at intake (n = 30) and two-years (n = 22) post-intake controlling for age, anxiety and depression. Parental accommodation (measured at intake) significantly predicted OCD symptom severity and was the strongest predictor at both intake and two-year follow-up. These preliminary findings highlight the importance of further research seeking to delineate factors relevant to the development and maintenance of accommodation as well as parent-level variables that might mediate the relationship between accommodation and OCD symptom severity.