Prospective relationship between obsessive-compulsive and depressive symptoms during multimodal treatment in pediatric obsessive-compulsive disorder

Implementation and Preliminary Outcomes of an Exposure-Based Summer Camp for Pediatric OCD and Anxiety

Despite the high prevalence of anxiety disorders in children and adolescents and the existence of effective evidence-based treatments for them, access to psychological care remains a major public health concern. Summer camps may provide an effective treatment avenue for youth who might not otherwise have access to care. This study describes the design and implementation of Fear Facers, a semistructured, 5-day, daytime exposure-therapy-based summer camp designed for youth with a primary diagnosis of obsessive-compulsive disorder (OCD), social anxiety, separation anxiety, or a specific phobia. Preliminary data regarding feasibility and patient outcomes is also reported. Among 52 children and adolescents aged 7 to 16 who attended one of six camp sessions between 2018 and 2021, significant reductions in anxiety (d = 0.54) and OCD symptoms (d = 0.57) were observed from pre-camp to immediately post-camp. A subset of campers who were followed for an additional 3 months post-camp (n = 22) showed maintenance of treatment gains. Retention rates for the intervention were high. Our investigation provides further support for the use of a camp-based design for cognitive-behavioral approaches, and may provide a unique setting to maximize elements of inhibitory learning in exposures. We also discuss a number of elements regarding feasibility that need consideration for those hoping to develop similar interventions.

Obsessive-compulsive disorder in youth and young adults with depression: Clinical characteristics of comorbid presentations

Obsessive-compulsive disorder (OCD), anxiety disorders, and depressive disorders are highly comorbid, and each contribute to significant functional impairment for affected youth. Comorbid anxiety disorders in depressed youth have been associated with greater depressive symptom severity and impairment, but the impact of comorbid OCD in this population remains unclear. Accordingly, the present study examined the differential clinical characteristics of youth with depression and comorbid OCD relative to age/gender matched depressed youth with no such comorbidity and to those with depression and a comorbid (non-OCD) anxiety disorder. A sample of 797 youth and young adults ages 8-20 years who met diagnostic criteria for depression alone, depression with co-occurring OCD or any anxiety disorder were included in the present study. Rates of comorbid anxiety and OCD were very high (60.5% and 15.5%, respectively). Relative to youth with only depression, depressed youth with comorbid OCD or anxiety had greater severity of depression, suicidality, and overall impairment in social, physical, and emotional functioning. These results highlight the contribution of OCD or anxiety comorbidity in more complex clinical presentations for depressed youth.

Examining depression symptoms within OCD: the role of experiential avoidance

BACKGROUND

Obsessive compulsive disorder (OCD) and depression commonly co-occur. Past research has evaluated underlying mechanisms of depression in the context of other diagnoses, but few to no studies have done this within OCD.

AIMS

This study examines the relationships between distress tolerance (DT), experiential avoidance (EA), depression, and OCD symptom severity across intensive/residential treatment (IRT) for OCD. It was hypothesized that all variables would be significantly moderately related and EA would emerge as a potential contributing factor to change in depression and OCD symptoms across IRT for OCD.

METHOD

The sample included 311 participants with a primary diagnosis of OCD seeking IRT. Correlations were performed between all variables at both admission and discharge. A two-step hierarchical regression with change in OCD symptoms and change in DT in the first block and change in EA in the second block examined if change in EA explained change in depression above and beyond change in OCD and DT ability.

RESULTS

At both admission and discharge, higher EA, lower DT, and higher OCD symptom severity were significantly associated with more depressive symptoms. Change in EA explained a significant amount of variance in change in depression above and beyond change in OCD symptom severity and change in DT.

CONCLUSIONS

This study expands past results within an OCD sample, emphasizing EA as an important treatment target in OCD. Future studies could utilize samples from other treatment contexts, use a measure of EA specific to OCD, and utilize a longitudinal model that takes temporal precedence into account.

Predictors of Parental Accommodation and Response Treatment in Young Children With Obsessive-Compulsive Disorder

Background: Cognitive-behavioral family-based treatment (CBFT) is the treatment standard in very young children with obsessive-compulsive disorder (OCD), which includes the same core components of cognitive-behavioral therapy (CBT) with significant family involvement. Although the latter reports high rates of remission, some children do not improve with treatments. Therefore, it is necessary to identify possible moderating variables such as comorbidity, severity of disorder, years of onset, parental anxiety, and parental accommodation. This study has two main aims: (1) to propose a predictive model on family accommodation (father and mother), taking into account variables related to the children (severity of obsessive-compulsive responses, internalizing and externalizing symptoms, and comorbidity) and with the parents before intervention (worry, accommodation of one parental member over the other) and (2) to examine the mediating role of externalizing symptoms and mother's accommodation in the relation between initial severity and improvement of severity of obsessive-compulsive responses in children aged 5-8 years. Methods: Participants comprised 56 children with OCD [mean = 6.61 (SD = 0.76)] and their parents; 79% of the sample was men. Treatment was implemented by two clinicians specialized in OCD (>15 years of experience). Clinicians were trained to administer CBT protocol in the same way. They were doctors of clinical psychology and researchers at the OCD. Results: Mother's accommodation was associated with child variables (Child Behavior Checklist-Externalizing and Initial Severity, Children's Yale-Brown Obsessive-Compulsive Scale). Father's accommodation could be explained by parent variables (mother's accommodation and worry). Simple mediation model tested using the SPSS macro PROCESS supported the relation of the initial severity of symptoms with that following intervention, through the simple indirect effect of externalizing symptoms of the child. Conclusions: Comorbidities with externalizing symptoms, father's worry, and mother's accommodation were variables that should be controlled in treatment of pediatric OCD.

The long-term association of OCD and depression and its moderators: A four-year follow up study in a large clinical sample

Background:

Depression is the most common comorbidity in obsessive-compulsive disorder (OCD). However, the mechanisms of depressive comorbidity in OCD are poorly understood. We assessed the directionality and moderators of the OCD-depression association over time in a large, prospective clinical sample of OCD patients.

Methods:

Data were drawn from 382 OCD patients participating at the Netherlands Obsessive-Compulsive Disorder Association (NOCDA) study. Cross-lagged, structural equation modeling analyses were used to assess the temporal association between OCD and depressive symptoms. Assessments were conducted at baseline, two-year and four-year follow up. Cognitive and interpersonal moderators of the prospective association between OCD and depressive symptoms were tested.

Results:

Cross-lagged analyses demonstrated that OCD predicts depressive symptoms at two-year follow up and not vice a versa. This relationship disappeared at four-year follow up. Secure attachment style moderated the prospective association between OCD and depression.

Conclusions:

Depressive comorbidity in OCD might constitute a functional consequence of the incapacitating OCD symptoms. Both OCD and depression symptoms demonstrated strong stability effects between two-year and four-year follow up, which may explain the lack of association between them in that period. Among OCD patients, secure attachment represents a buffer against future depressive symptoms.

Cognitive and behavioral correlates of depressive symptoms in a community sample of adolescents

Research in adults demonstrates a positive association among obsessive-compulsive symptoms, eating pathology, cognitive distortions, and comorbid depressive symptoms. Given that adolescence is characterized by unique and rapid changes in biopsychosocial processes, it is imperative to elucidate the relationship between these variables in youth. In this cross-sectional study, we explored whether obsessive-compulsive symptoms, thought-action fusion, thought-shape fusion, and eating pathology would be positively associated with and predict depressive symptoms in a school-based community sample of adolescents (n = 86; M_age = 15.60). All study variables were positively correlated with depressive symptoms. Results indicated that obsessive-compulsive symptoms, thought-shape fusion, and eating pathology explained a significant proportion of variance in depressive symptoms, whereas thought-action fusion did not. In accordance with the cognitive behavioral model of psychopathology, these findings highlight the relationships between key interrelated correlates of depressive symptoms that may be pertinent targets for prevention and treatment efforts in adolescents.

Improvement in anxiety and depression symptoms following cognitive behavior therapy for pediatric obsessive compulsive disorder

Pediatric obsessive-compulsive disorder (OCD) co-occurs frequently with other mental health conditions, adding to the burden of disease and complexity of treatment. Cognitive behavioral therapy (CBT) is efficacious for both OCD and two of its most common comorbid conditions, anxiety and depression. Therefore, treating OCD may yield secondary benefits for anxiety and depressive symptomatology. This study examined whether anxiety and/or depression symptoms declined over the course of OCD treatment and, if so, whether improvements were secondary to reductions in OCD severity, impairment, and/or global treatment response. The sample consisted of 137 youths who received 12 sessions of manualized CBT and were assessed by independent evaluators. Mixed models analysis indicated that youth-reported anxiety and depression symptoms decreased in a linear fashion over the course of CBT, however these changes were not linked to specific improvements in OCD severity or impairment but to global ratings of treatment response. Results indicate that for youth with OCD, CBT may offer benefit for secondary anxiety and depression symptoms distinct from changes in primary symptoms. Understanding the mechanisms underlying carryover in CBT techniques is important for furthering transdiagnostic and/or treatment-sequencing strategies to address co-occurring anxiety and depression symptoms in pediatric OCD.

Relationships between obsessive-compulsive disorder, depression and functioning before and after exposure and response prevention therapy

OBJECTIVE

Obsessive-compulsive disorder (OCD) is associated with impaired functioning and depression. Our aim was to examine relationships between OCD symptoms, depression and functioning before and after exposure and response prevention (ERP), a type of cognitive-behavioural therapy for OCD, specifically examining whether functioning, depression and other cognitive factors like rumination and worry acted as mediators.

METHODS

Forty-four individuals with OCD were randomised to 4 weeks of intensive ERP treatment first (n = 23) or waitlist then treatment (n = 21). We used a bootstrapping method to examine mediation models.

RESULTS

OCD symptoms, depression and functioning significantly improved from pre- to post-intervention. Functioning mediated the relationship between OCD symptoms and depression and the relationship between functioning and depression was stronger at post-treatment. Depression mediated the relationship between OCD symptoms and functioning, but only at post-intervention. Similarly, rumination mediated the relationship between OCD symptoms and depression at post-intervention.

CONCLUSIONS

Our findings suggest that after ERP, relationships between depression and functioning become stronger. Following ERP, treatment that focuses on depression and functioning, including medication management for depression, cognitive approaches targeting rumination, and behavioural activation to boost functionality may be important clinical interventions for OCD patients.

Quality of Life in Children and Youth with Obsessive-Compulsive Disorder

OBJECTIVE

The study examined clinical correlates of quality of life (QoL), impact of treatment on QoL, and predictors of QoL change among children with obsessive-compulsive disorder (OCD).

METHODS

One hundred forty-two children with primary OCD who were enrolled as part of a larger clinical trial participated. Children were administered a structured diagnostic interview, as well as clinician-administered measures of OCD and depression symptom severity. Children and parents completed reports of QoL, as well as measures of impairment and internalizing and externalizing symptoms. Youth received 10 sessions of family-based cognitive-behavioral therapy (CBT).

RESULTS

At baseline, QoL was inversely related to obsessive-compulsive symptom severity, impairment, externalizing and internalizing symptoms, and severity of depression symptoms according to children and parents. After CBT, QoL improved according to parent ratings, but not child ratings. None of the predictors examined were associated with changes in QoL scores over time. Impairment, and externalizing and internalizing symptoms predicted QoL after accounting for OCD symptom severity. After accounting for OCD symptoms, externalizing symptoms inversely predicted changes in QoL.

CONCLUSION

These data suggest that QoL is related to more severe clinical presentation and improves with evidence-based treatment, but QoL improvements may be inversely related to externalizing symptomology.

A network perspective on comorbid depression in adolescents with obsessive-compulsive disorder

People with obsessive-compulsive disorder [OCD] frequently suffer from depression, a comorbidity associated with greater symptom severity and suicide risk. We examined the associations between OCD and depression symptoms in 87 adolescents with primary OCD. We computed an association network, a graphical LASSO, and a directed acyclic graph (DAG) to model symptom interactions. Models showed OCD and depression as separate syndromes linked by bridge symptoms. Bridges between the two disorders emerged between obsessional problems in the OCD syndrome, and guilt, concentration problems, and sadness in the depression syndrome. A directed network indicated that OCD symptoms directionally precede depression symptoms. Concentration impairment emerged as a highly central node that may be distinctive to adolescents. We conclude that the network approach to mental disorders provides a new way to understand the etiology and maintenance of comorbid OCD-depression. Network analysis can improve research and treatment of mental disorder comorbidities by generating hypotheses concerning potential causal symptom structures and by identifying symptoms that may bridge disorders.

Neural dysfunction during temporal discounting in paediatric Attention-Deficit/Hyperactivity Disorder and Obsessive-Compulsive Disorder

Both Attention-Deficit/Hyperactivity Disorder (ADHD) and Obsessive-Compulsive Disorder (OCD) are associated with choice impulsivity, i.e. the tendency to prefer smaller immediate rewards over larger delayed rewards. However, the extent to which this impulsivity is mediated by shared or distinct underlying neural mechanisms is unclear. Twenty-six boys with ADHD, 20 boys with OCD and 20 matched controls (aged 12-18) completed an fMRI version of an individually adjusted temporal discounting (TD) task which requires choosing between a variable amount of money now or £100 in one week, one month or one year. Activations to immediate and delayed reward choices were compared between groups using a three-way ANCOVA. ADHD patients had steeper discounting rates on the task relative to controls. OCD patients did not differ from controls or patients with ADHD. Patients with ADHD and OCD showed predominantly shared activation deficits during TD in fronto-striato-insular-cerebellar regions responsible for self-control and temporal foresight, suggesting that choice impulsivity is mediated by overlapping neural dysfunctions in both disorders. OCD patients alone showed dysfunction relative to controls in right orbitofrontal and rostrolateral prefrontal cortex, extending previous findings of abnormalities in these regions in OCD to the domain of choice impulsiveness.

Repetitive Behaviours and Restricted Interests in Individuals with Down Syndrome-One Way of Managing Their World?

This paper argues that the repetitive behaviour and restrictive interests (RBRI) displayed by individuals with Down syndrome have mostly positive functions. However, as research has developed from interests in Obsessional Compulsive Disorder or Autistic Spectrum Disorder, unfortunately a view has arisen that RBRI in individuals with Down syndrome are also likely to be pathological. This is particularly the case in adults. The paper reviews: (a) measures employed and the perspectives that have been used; (b) the development in typically developing individuals, those with Down syndrome, and those with other conditions associated with intellectual disability; (c) positive and possible negative effects of RBRI; and (d) the need for more research. The conclusion is that, for their level of development, RBRI are helpful for most individuals with Down syndrome.

The link between ADHD-like inattention and obsessions and compulsions during treatment of youth with OCD

Attention-deficit/hyperactivity disorder (ADHD) has been found to be highly comorbid in children and adolescents with obsessive-compulsive disorder (OCD). Some have proposed, however, that obsessive anxiety may cause inattention and executive dysfunction, leading to inappropriate ADHD diagnoses in those with OCD. If this were the case, these symptoms would be expected to decrease following successful OCD treatment. The present study tested this hypothesis and evaluated whether ADHD symptoms at baseline predicted OCD treatment response. Obsessive-compulsive and ADHD symptoms were assessed in 50 youth enrolled in a randomized controlled trial investigating selective serotonin reuptake inhibitor and cognitive behavioral treatment. Repeated-measures analysis of variance (RMANOVA) revealed that ADHD symptoms at baseline do not significantly predict treatment outcome. A multivariate RMANOVA found that OCD treatment response moderated change in inattention; participants who showed greater reduction in OCD severity experienced greater reduction in ADHD-inattentive symptoms, while those with less substantial reduction in obsessions and compulsions showed less change. These findings suggest that children and adolescents with OCD and inattention may experience meaningful improvements in attention problems following OCD treatment. Thus, in many youth with OCD, inattention may be inherently tied to obsessions and compulsions. Clinicians may consider addressing OCD in treatment before targeting inattentive-type ADHD.

Paediatric Obsessive-Compulsive Disorder and Depressive Symptoms: Clinical Correlates and CBT Treatment Outcomes

Depression frequently co-occurs with paediatric obsessive-compulsive disorder (OCD), yet the clinical correlates and impact of depression on CBT outcomes remain unclear. The prevalence and clinical correlates of depression were examined in a paediatric specialist OCD-clinic sample (N = 295; Mean = 15 [7 – 18] years, 42 % female), using both dimensional (Beck Depression Inventory-youth; n = 261) and diagnostic (Development and Wellbeing Assessment; n = 127) measures of depression. The impact of depressive symptoms and suspected disorders on post-treatment OCD severity was examined in a sub-sample who received CBT, with or without SSRI medication (N = 100). Fifty-one per-cent of patients reported moderately or extremely elevated depressive symptoms and 26 % (95 % CI: 18 – 34) met criteria for a suspected depressive disorder. Depressive symptoms and depressive disorders were associated with worse OCD symptom severity and global functioning prior to CBT. Individuals with depression were more likely to be female, have had a psychiatric inpatient admission and less likely to be attending school (ps < 0.01). OCD and depressive symptom severity significantly decreased after CBT. Depressive symptoms and depressive disorders predicted worse post-treatment OCD severity (βs = 0.19 and 0.26, ps < 0.05) but became non-significant when controlling for pre-treatment OCD severity (βs = 0.05 and 0.13, ns). Depression is common in paediatric OCD and is associated with more severe OCD and poorer functioning. However, depression severity decreases over the course of CBT for OCD and is not independently associated with worse outcomes, supporting the recommendation for treatment as usual in the presence of depressive symptoms.

Residential treatment outcomes for adolescents with obsessive-compulsive disorder

OBJECTIVE

We examined outcomes from a residential treatment program emphasizing exposure and response prevention (ERP) to determine if the typically robust response to this treatment in outpatient settings extends to patients treated in this unique context.

METHOD

One hundred and seventy-two adolescents with primary Obsessive-compulsive disorder (OCD) completed measures at admission and discharge. Almost all (92.4%) participants had at least two diagnoses and nearly half (44.2%) had three or more. Treatment consisted of intensive ERP (i.e., approximately 26.5 hr per week), additional cognitive behavioral therapy interventions, and medication management within a residential setting. In contrast to the samples reported on in the vast majority of other pediatric OCD trials, participants in the current study were living apart from their families and were immersed within the treatment setting, with staff members available at all times.

RESULTS

Paired sample t-tests revealed significant decreases in OCD and depression severity.

CONCLUSIONS

Results suggest that residential treatment for adolescents with OCD using a multimodal approach emphasizing ERP can be effective for complex cases with significant comorbidity. Results were comparable with several randomized controlled trials.