'Excessive and Unreasonable': The Relation Between Clinical Insight and Clinical Correlates and Treatment Outcomes in Obsessive-Compulsive Disorder Across the Life Course

Individuals with mental disorders possess varying levels of clinical insight-the degree to which one understands that they are afflicted with a mental disorder and that their symptoms are manifestations of this psychopathology. Although clinical insight in OCD is thought to play an especially important role in determining various clinical characteristics and treatment outcomes, insight has not been sufficiently addressed developmentally, the importance of which this review will elucidate. Findings from this review suggest that clinical insight is typically associated with more complex cases and worse treatment outcomes across the life course, and also reveal nuances between pediatric and adult OCD cases with low insight. Implications of these findings, future research directions, and recommendations for the field are discussed.

Parent Management Training Augmentation to Address Coercive and Disruptive Behavior in Cognitive-Behavioral Therapy for Pediatric Obsessive-Compulsive Disorder

Coercive and disruptive behaviors commonly interfere with cognitive-behavioral therapy (CBT) trials among youths with obsessive-compulsive disorder (OCD). Although evidence supports parent management training (PMT) for reducing disruptive behavior, no group-based PMT interventions exist for OCD-related disruptive behaviors. We studied feasibility and effectiveness of group-based adjunctive PMT among non-randomized, OCD-affected families receiving family-based group CBT. Linear mixed models estimated treatment effects across OCD-related and parenting outcomes at post-treatment and 1-month follow-up. Treatment response for 37 families receiving CBT + PMT (M_age = 13.90) was compared to 80 families receiving only CBT (M_age = 13.93). CBT + PMT was highly accepted by families. Families who received CBT + PMT had improved disruptive behaviors, parental distress tolerance, and other OCD-related outcomes. OCD-related outcomes did not significantly differ between groups. Results support CBT + PMT as effective treatment for pediatric OCD that may not provide incremental benefits beyond CBT alone. Future research should determine feasible and effective ways to incorporate key PMT components into CBT-based interventions.

Economic Analyses of Obsessive-Compulsive Disorder Interventions: A Systematic Review

BACKGROUND

Obsessive-compulsive disorder (OCD) is a neuropsychiatric condition featuring patterns of obsessions, compulsions, and avoidant behaviors that are often time consuming and distressing to affected individuals. Cognitive-behavioral therapy (CBT) with exposure and response prevention and/or serotonin reuptake inhibitors are first-line treatments for OCD, though other therapeutic interventions may serve as economically practical modalities under various circumstances. Exploring and understanding the cost effectiveness of all indicated OCD interventions are important to inform therapeutic decisions and provide quality patient-centered care at a cost that is not burdensome to the patient and/or healthcare system.

METHODS

A systematic literature review was performed and studies were extracted from PubMed, Embase, Ovid MEDLINE, and Cochrane. All cost-effectiveness studies that included economic analyses with respect to OCD treatment modalities and were written in English and published between January 2010 and July 2022 were eligible for inclusion in the present study. We report a narrative synthesis of the findings and quality appraisal of the selected references.

RESULTS

Of the 707 references returned in the literature search, a total of 18 cost-effectiveness studies were included for review. Compared with treatment as usual, several studies reported clinical superiority and cost effectiveness of Internet-based CBT programs for adults and children with OCD at various willingness-to-pay thresholds and economic reference indicators, though cost effectiveness relative to in-person CBT with exposure and response prevention is unclear and estimates of efficacy are likely lower for Internet-based CBT. One study favored the cost utility of serotonin reuptake inhibitor monotherapy over CBT with exposure and response prevention although efficacy estimates of the former tend to be lower, and relative cost differences were low. Five studies evaluated the cost effectiveness of high-intensity neuroaugmentation, including deep brain stimulation and stereotactic radiosurgical capsulotomy, in the context of treatment-refractory OCD.

CONCLUSIONS

Despite the relatively high prevalence of OCD worldwide, cost-effectiveness data for therapeutic modalities remain sparse. Because of the chronic nature of OCD, the cost of treatment accumulates and may lead to a significant financial burden over time, particularly when non-evidence-based interventions are used. However, several alternative therapeutic modalities hold promise for economic practicality without significant sacrifice in clinical efficacy. Future studies are necessary to directly compare the cost effectiveness of such therapeutic alternatives with the current standard of care, CBT with exposure and response prevention.

Understanding why people with OCD do what they do, and why other people get involved: supporting people with OCD and loved ones to move from safety-seeking behaviours to approach-supporting behaviours

The distress inherent in obsessive compulsive disorder (OCD) can often lead to partners, family members and friends becoming entangled with the OCD in terms of being drawn into performing certain behaviours to try and reduce the distress of their loved one. In the past this has often been referred to somewhat pejoratively as collusion, or more neutrally as accommodation. In this paper we emphasise that this is usually a natural human response to seeing a loved one in distress and wanting to help. This paper provides detailed clinical guidance on how to understand this involvement and how to include others in the treatment of OCD along with practical tips and hints around potential blocks that may require troubleshooting. It also details the relatively recently introduced concept of approach-supporting behaviours, and provides guidance on how to distinguish these from safety-seeking behaviours. The ‘special case’ of reassurance seeking is also discussed.

Key learning aims

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Obsessive-Compulsive Symptoms in an Adolescent with Intellectual Disability

Individuals with intellectual disability (ID) experience various psychiatric comorbidities including anxiety, depression, and obsessive-compulsive disorder (OCD) in a rate that is equivalent or higher than individuals without ID. Unfortunately, these cooccurring conditions are often missed during the evaluations due to various reasons, including their atypical presentation. In this case report, we present the clinical symptoms of an adolescent with mild ID who presented with irritability and was diagnosed with OCD following a comprehensive assessment. The treatment course is also summarized as well as the positive outcome to selective serotonin reuptake inhibitor (SSRI) medication. In this report, we discuss potential factors that increase the rate of psychiatric comorbidities including OCD in individuals with ID. Furthermore, in the context of limited research in this area, we recommend additional studies in order to build a detailed understanding of the clinical presentation of psychiatric cooccurring disorders in individuals with ID with the goal of enhancing assessment tools in the future.

Examining the Psychometric Properties and Clinical Correlates of the Korean Version of the Family Accommodation Scale-Self-Rated Version for Obsessive-Compulsive Disorder

OBJECTIVE

We aimed to develop a Korean version of the Family Accommodation Scale-Self-Rated (FAS-SR), to investigate its reliability and validity and to study the clinical correlates of family accommodation in families with obsessive compulsive disorder (OCD) patient.

METHODS

The FAS-SR was translated into Korean under the original author's supervision. Forty-two patients with OCD and their closest relatives participated. The internal consistency was estimated using Cronbach's alpha and the split half method. Convergent and divergent validity were identified by measuring with other clinical variables. Test-retest reliability was also calculated.

RESULTS

The reliability analyses showed that Korean version of the FAS-SR demonstrated excellent internal consistency (Cronbach's alpha=0.91) and test-retest reliability (Intraclass correlation coefficient=0.93). It showed good convergent validity when simultaneously assessed OCD symptom severity, global functioning and relative's psychological distress.

CONCLUSION

The findings suggest that Korean version of the FAS-SR is a reliable and valid tool for assessing family accommodation in Korean patients with OCD in both research and clinical settings.

The Chinese version of the family accommodation scale for obsessive-compulsive disorder self-rated: reliability, validity, factor structure, and mediating effect

BACKGROUND

Family accommodation (FA) in obsessive compulsive disorder (OCD) is a common phenomenon. Based on the cost of training interviewers and the time required to administer the scale, the Family Accommodation Scale for Obsessive-Compulsive Disorder Interviewer-Rated (FAS-IR) has been restricted to specific settings. A self-rated version of the family accommodation scale may solve these problems. The aim of this study was to examine the reliability, validity and factor structure of the Family Accommodation Scale Self-rated version (FAS-SR), and the relationship among FA, symptom severity and functional impairment.

METHODS

In total, 171 patients with OCD and 145 paired relatives participated in this study. The Sheehan Disability Scale (SDS), Obsessive-Compulsive Inventory Revised (OCI-R), Zung Self-Rating Depression Scale (Zung-SDS), 12-item Family Assessment Devices (FAD-12), Clinical Global Impression of Severity Scale (CGI-S), Global Assessment of Functioning (GAF), and Yale-Brown Obsessive-Compulsive Scale (Y-BOCS) were used as tools for patients. The FAS-SR, FAS-IR, FAD-12, and the patients' symptom severity of Y-BOCS compulsion were used as tools for relatives. The psychometric properties of the FAS-SR were evaluated using Cronbach's alpha coefficient, test-retest reliability and validity. Mediation analysis was used to determine the relationship among FA, symptom severity and functional impairment.

RESULTS

A total of 97.9% of relatives of OCD patients reported at least one kind of FA behavior, and 56.6% of participants engaged in FA every day in the past week. The FAS-SR includes a three-factor structure: (1) providing reassurance and participation; (2) facilitation; and (3) modification. The scale's Cronbach's alpha and test-retest coefficients were 0.875 and 0.970, respectively. The total FAS-SR score was significantly positively associated with the Y-BOCS, FAD-12, CGI-S, FAS-IR, and SDS scores, and negatively associated with the total GAF score. FA partially mediated the relationship between symptom severity and functional impairment.

CONCLUSION

The FAS-SR was proven to have satisfactory psychometric properties, and can play an important role in the evaluation and early intervention of OCD. This result indicates the importance of assessing symptom severity in conjunction with FA when evaluating OCD patients' functional impairment.

Psychoeducation focused on family accommodation: a practical intervention for parents of children and adolescents with obsessive-compulsive disorder

Obsessive-compulsive disorder (OCD) is a neuropsychiatric disorder that is frequently diagnosed in children and adolescents. In pediatric OCD, family plays an important role in the development and maintenance of the disease. In this relationship, both genetic and behavioral factors, such as parental modeling and family accommodation, are significant. Parental modeling concerns the daily enactment of dysfunctional behavioral patterns by a parent with OCD, which may influence children. Family accommodation, in contrast, describes the direct participation of parents in their child's compulsive rituals, by modifying daily routines or by facilitating avoidance of OCD triggers, to decrease the child's distress and time spent executing compulsions. Approximately 80-90% of the relatives of OCD patients actively participate in patients' rituals. The literature demonstrates that a high level of family accommodation is associated with OCD symptom severity, reduced response to cognitive-behavioral treatment (CBT), and a higher risk of therapy dropout.Despite this, no studies have aimed at delineating practical guidance for psychotherapists to support parents in reducing family accommodation.The main aim of this paper is to propose a psychoeducation intervention focused on cognitive-behavioral strategies to help families to manage their child's OCD behaviors without enacting dysfunctional family accommodation behaviors in order to support their child's successful therapy.

Knowledge and competency standards for specialized cognitive behavior therapy for pediatric obsessive-compulsive disorder

Although exposure-based cognitive behavior therapy (CBT) and pharmacotherapy have demonstrated efficacy for obsessive-compulsive disorder (OCD), the lack of clinicians effectively trained in these treatments significantly limit effective intervention options for affected youth. This is very unfortunate since child onset is reported by 50% of adults with OCD. To ameliorate this serious global issue the 14 nation International Obsessive-Compulsive Disorders Accreditation Task Force (ATF) of The Canadian Institute for Obsessive Compulsive Disorders (CIOCD) has developed knowledge and competency standards recommended for specialized treatments for OCD through the lifespan. Currently available guidelines are considered by experts to be essential but insufficient because there are not enough clinicians with requisite knowledge and competencies to effectively treat OCD. This manuscript presents knowledge and competency standards recommended for specialized cognitive behavior therapy (CBT) for pediatric OCD, derived from comprehensive literature review and expert synthesis. In addition to standards covering the elements of individual CBT-based assessment and treatment, family and school interventions are addressed given the critical role these domains play in the psychosocial development of youths. The ATF standards presented in these phase two papers will be foundational to the upcoming development of certification (individuals) and accreditation (sites) for specialized treatments in OCD through the lifespan.

Specialty knowledge and competency standards for pharmacotherapy for pediatric obsessive-compulsive disorder

Evidence based treatments for pediatric Obsessive-Compulsive Disorder (OCD) are delivered with varying levels of expertise. This paper is part of the phase two series by the International OCD Accreditation Task Force (ATF) to advance a standardized high level of care globally. This paper presents specific knowledge and competencies recommended for specialized practice for pediatric psychopharmacologists working with OCD, developed by an international group of clinicians with extensive expertise in assessment and treatment of OCD. Tabulated knowledge and competency standards are operationalized as clinician abilities with specification of evidence for each standard. The distinction between current practice guidelines and ATF standards is discussed. Drug treatment has a solid evidence base. However, it should not be applied isolated, but informed by broad competence in general child and adolescent psychiatry and pediatrics. Other treatment relevant areas such as specialty CBT, family functioning, developmental issues, and neurobiology require consideration. Drug treatment includes several phases with varying degrees of evidence: Starting up medication, titration to maximum tolerated dose, maintenance, termination, and relapse prevention. In complex cases, pharmacotherapy with weak evidence may be needed to target symptoms and/or co-morbidity. The ATF knowledge and competency standards presented will be reviewed and updated commensurate with research.

Translation and Cross-Cultural Adaptation of the Family Accommodation Scale for Obsessive-Compulsive Disorder Into Chinese

Family accommodation is a phenomenon that has been associated with worse treatment outcome of patients with obsessive-compulsive disorder (OCD) and greater severity of symptoms and levels of functional impairment. Yet, there are no Chinese scales to assess family accommodation in OCD among family members. The present study aimed to illustrate the steps of translation and cross-cultural adaptation of the Chinese versions of the Family Accommodation Scale (FAS). After obtaining authorization of the developers, the Chinese versions of the FAS were translated and adapted from the English versions based on a standard protocol, following six steps: forward translation, pilot administration, language adjustment and cultural adaptation, back-translation, review and minor edit, and final approval of the developer. Thirty-five pairs of patients and corresponding relatives with different education levels were administered the FAS in the pretest stage. This study found that the semantic, idiomatic, and conceptual equivalence were obtained between the Chinese versions and original English scales, and the Chinese versions of FAS were well translated and culturally adapted. We also found that the Chinese versions of the FAS can be easily understood by people of different socioeconomic statuses.

Incompleteness and Disgust Predict Treatment Outcome in Pediatric Obsessive-Compulsive Disorder

Increasing evidence suggests that pediatric obsessive-compulsive disorder (OCD) is motivated not only by fear but also by feelings of incompleteness and disgust. However, it is currently unclear whether emotion involvement in OCD symptoms is associated with treatment response in youth with OCD. The present study examined whether treatment outcome for youth with OCD was predicted by the degree to which fear, disgust, and incompleteness were involved in baseline OCD symptoms. Children and adolescents with OCD entering treatment for this condition (N = 111) were administered standardized OCD symptom measures and an interview designed to assess the degree of fear, incompleteness, and disgust experienced during current OCD symptoms. Follow-up assessments occurred on average 13 months after baseline with each participant coded for outcome according to internationally acknowledged change criteria for pediatric OCD. Higher levels of incompleteness and disgust as part of baseline OCD symptoms predicted poorer outcome. The degree of fear during baseline OCD symptoms did not predict outcome. If replicated under controlled conditions, these results suggest that incompleteness and disgust may act as barriers to improvement in pediatric OCD and that treatment modifications that target these emotion-related motivators may improve outcome for a subset of youth.

Clinical significance of family accommodation and parental psychological distress in a sample of children and adolescents with obsessive-compulsive disorder aged 8-17 years old

BACKGROUND

Family Accommodation (FA) refers to the involvement of family members (especially parents) in the compulsive behaviors of children and adolescents with Obsessive-Compulsive Disorder (e.g. modifying family routines or facilitating avoidance of obsessive-compulsive triggers). Many studies have examined the high prevalence of FA in this clinical population; however, less is known about its clinical significance and relationship to the individual psychological distress of parents. In our study, we investigated the clinical significance of FA examining its relationship with obsessive-compulsive symptomatology, functioning, anxiety and depressive symptoms in a clinical sample (n = 51) of children and adolescents with Obsessive-Compulsive Disorder (OCD) aged 8-17 years old and their parents, included to examine their individual psychological distress.

METHODS

The sample was divided into two groups: the High Accommodation group (n = 36) and the Low Accommodation group (n = 15).

RESULTS

Results demonstrated that children and adolescents in the OCD High Accommodation group reported major functional impairment in global (p = .001313), social (p = .000334) and role (p = .000334) domains, and higher depressive symptoms than the Low Accommodation group. Both fathers and mothers from the High Accommodation group reported a higher level of individual psychological distress compared to mothers and fathers from the Low Accommodation group (p = .040365).

CONCLUSIONS

The findings of this study show that FA is common in children and adolescents with OCD and it could cause not only an impairment of the patient's global, social and role functioning but also a high level of individual psychological distress in the single parent. The presence of FA should therefore be carefully investigated and considered in planning assessment and treatment of OCD in children and adolescents.

A prospective study of intensive in-patient treatment for obsessive-compulsive disorder

Multimodal in-patient treatment incorporating intensive cognitive-behaviour therapy (CBT) and medication management is a promising alternative for obsessive-compulsive disorder (OCD) patients who do not respond to standard out-patient treatment. We prospectively examined the short-term outcome and predictors of outcome of intensive in-patient treatment in a largely pharmacotherapy-resistant OCD sample. Fifty eight consecutive patients, admitted for treatment of OCD were evaluated at admission, at discharge and 2 months post-discharge for psychiatric diagnosis, personality disorders, obsessive beliefs, insight into obsessions and severity of obsessive-compulsive, depressive and anxiety symptoms. All patients received comprehensive treatment consisting of a combination of pharmacotherapy and intensive CBT. The mean Y-BOCS score was 29.38(±5.72) at admission, which reduced to 16.62(±7.91) at discharge and 16.75(±8.85) at follow-up. Thirty five participants (60.3%) met the prespecified criteria for response and 19 (32.8%) for remission. There was a significant reduction in Y-BOCS scores at discharge [43.67 (23.81)%] and post-discharge follow-up [2.18 (29.32)%] as compared to baseline (p<0.01). Baseline Browns Assessment of Beleifs Scale score (insight) was the only variable that statistically differentiated responders and non-responders. In-patient treatment is an effective treatment for medication resistant, severe and chronic OCD. Poor insight is a potential predictor of non-response to in-patient treatment.

Family functioning in pediatric trichotillomania, obsessive compulsive disorder, and healthy comparison youth

Pediatric trichotillomania (TTM) is an understudied condition that can be highly impairing; little is known about family environmental features that shape its development and course. We examined family functioning among age and gender-matched groups of youth with primary TTM (n = 30; mean age = 12.87), obsessive compulsive disorder (OCD; n = 30; mean age = 12.70), and no psychiatric history (healthy controls; HC; n = 30; mean age = 12.46). An additional group of n = 25 TTM cases was employed to examine relationships between TTM severity and family functioning. All youth completed standardized diagnostic assessment, including the Family Environment Scale (FES) and Children's Report of Parenting Behavior Inventory (CRPBI). Family functioning was more impaired among both TTM and OCD cases relative to controls, as evidenced by higher levels of child-reported FES conflict and lower cohesion, expressiveness, and organization. Less consistent findings emerged on parent report, with cohesion, but not conflict, distinguishing the HC and clinical groups. In keeping with prior research, parents of TTM-affected youth also reported lower expressiveness and cohesion than parents in the OCD group. There was limited evidence for links between hair-pulling severity and family impairment and no links to parenting behavior. Findings are discussed in terms of implications for family focused treatment.

Comorbid Psychopathology and the Clinical Profile of Family Accommodation in Pediatric OCD

Family accommodation (FA) has been linked with myriad negative outcomes in pediatric obsessive-compulsive disorder (OCD), but extant literature has yielded differential relationships between FA and clinical variables of interest. Consequently, this study examined the phenomenology, clinical profile, and effects of comorbid psychopathology on FA to better understand these behaviors. A total of 150 youths and their caregivers completed clinician- and self-reported measures at a baseline visit for a larger randomized controlled trial. Sociodemographic variables were not associated with FA, but specific types of OCD symptom clusters were. Higher OC-symptom severity and functional impairment were associated with increased FA. Comorbid anxiety disorders moderated the relationship between OC-symptom severity and FA, but comorbid attention deficit hyperactivity, oppositional defiant, and mood disorders did not. Internalizing and externalizing problems both mediated the relationship between FA and functional impairment. These findings provide clinical implications for important treatment targets and factors that may impact FA.

The SPACE program, a parent-based treatment for childhood and adolescent OCD: The case of Jasmine

Current evidence-based treatments for obsessive-compulsive disorder in children and adolescents include cognitive-behavioral therapy, specifically exposure and response prevention, and psychopharmacological treatments. Despite the established efficacy of these treatments, many youth do not benefit from them, and barriers, including lack of motivation and resistance to treatment, prevent many youth from even attempting them. Parent-based treatments offer an alternative approach to child-based therapy. SPACE (Supportive Parenting for Anxious Childhood Emotions) is a parent-based treatment that focuses on systematically reducing family accommodation, or the changes that parents make to their own behavior to help a child avoid or alleviate distress related to the disorder, while increasing supportive responses to the child's symptoms. This article presents the theoretical background for SPACE and illustrates its implementation through a case description. Conclusions and knowledge to be gained from the case are discussed.

Sleep-Related Problems in Pediatric Obsessive-Compulsive Disorder and Intensive Exposure Therapy

Limited research has examined sleep-related problems (SRPs) among children and adolescents with obsessive-compulsive disorder (OCD). The present study addresses this gap by investigating preliminary associations between SRPs, demographic factors (gender and age), family variables (family accommodation and parental stress), and clinical factors (medication status, internalizing and externalizing symptoms, OCD severity, OCD-related impairment), and treatment outcomes in a sample of 103 youth (aged 7 to 17 years; 53% female) with a primary diagnosis of OCD. Clinician, parent, and child measures were used to assess demographic, family, and clinical predictors. SRPs were assessed using an 8-item measure comprising items of the Child Behaviour Checklist, Child Depression Inventory, and Multidimensional Anxiety Scale for Children as used in previous studies. Results showed that SRPs were highly prevalent among this sample and that more SRPs were associated with younger age, internalizing problems, and functional impairment. However, SRPs were not an independent predictor of OCD severity, impairment, or treatment response. Preliminary findings suggest that SRPs among youth with OCD may be more strongly associated with broader internalizing symptoms than with OCD itself. Future longitudinal research is warranted to further explore the complexity of SRPs when co-occurring with pediatric OCD.

Coercive and disruptive behaviors mediate group cognitive-behavioral therapy response in pediatric obsessive-compulsive disorder

PURPOSE

Coercive and disruptive behaviors (CDBs) are commonplace in pediatric obsessive-compulsive disorder (OCD) and are associated with increased disorder impact and reduced treatment response. Prior research suggests that CDBs mediate the cross-sectional relationship between family accommodation and OCD symptom severity; however, the impact of reducing CDBs on other treatment outcomes has yet to be studied.

METHODS

Participants comprised 49 OCD-affected youth (42.9% male, M_age at baseline = 13.7) and their parent(s) who completed a 12-week, group family-based cognitive-behavioral treatment at an OCD specialty clinic. Outcomes included parent-report measures of CDBs, family accommodation, symptom severity, and both child- and family-level impairment. Descriptive, correlation, and regression analyses were followed by tests of indirect effects (mediation).

RESULTS

Changes in all outcome variables had moderate to strong correlations with each other. As hypothesized, CDB decreases predicted positive changes in OCD severity as well as in child and family impairment. Further, whereas improvement in OCD severity predicted changes in child and family impairment, improvements in family accommodation were not directly predictive of any outcomes. Consistent with hypotheses, changes in CDBs mediated relationships between changes in accommodation and child- and family-level impairment, as well as relationships between changes in OCD severity and both levels of impairment. Additional exploratory analyses found that changes in symptom severity significantly mediated relationships between changes in CDBs and both levels of impairments.

CONCLUSIONS

Findings suggest that attention to reducing CDBs is warranted in the treatment of pediatric OCD, and that accommodation reductions lead to meaningful improvements in child and family functioning only when CDBs and/or symptoms are also reduced. Future family-based treatments may benefit from inclusion of components specifically targeting CDBs that occur within the context of accommodating OCD symptoms.

Comparing OCD-affected youth with and without religious symptoms: Clinical profiles and treatment response

BACKGROUND

Childhood obsessive-compulsive disorder (OCD) is a heterogeneous psychiatric condition, with varied symptom presentations that have been differentially associated with clinical characteristics and treatment response. One OCD symptom cluster of particular interest is religious symptoms, including fears of offending religious figures/objects; patients affected by these symptoms have been characterized as having greater overall OCD severity and poorer treatment response. However, the extant literature primarily examines this symptom subtype within adults, leaving a gap in our understanding of this subtype in youth.

METHOD

Consequently, this study examined whether presence of religious symptoms in OCD-affected children and adolescents (N = 215) was associated with greater clinical impairments across OCD symptoms and severity, insight, other psychiatric comorbidity, family variables, or worse treatment response.

RESULTS

Results found that youth with religious OCD symptoms presented with higher OCD symptom severity and exhibited more symptoms in the aggressive, sexual, somatic, and checking symptom cluster, as well as the symmetry, ordering, counting, and repeating cluster. Religious OCD symptoms were also significantly associated with poorer insight and higher family expressiveness. No differences in treatment response were observed in youths with versus without religious OCD symptoms.

CONCLUSION

Ultimately, youths with religious OCD symptoms only differed from their OCD-affected counterparts without religious symptoms on a minority of clinical variables; this suggests they may be more comparable to youths without religious OCD symptoms than would be expected based on the adult OCD literature and highlights the importance of examining these symptoms within a pediatric OCD sample.

An Initial Case Series of Intensive Cognitive-Behavioral Therapy for Obsessive-Compulsive Disorder in Adolescents with Autism Spectrum Disorder

Obsessive-compulsive disorder (OCD) is prevalent among youth with autism spectrum disorder (ASD). Cognitive-behavioral therapy (CBT) with ASD-specific modifications has support for treating OCD in this population; however, use of intensive CBT in youth with ASD and severe OCD has not been tested. The current study examined the preliminary effectiveness of an individualized intensive CBT protocol for OCD in adolescents with ASD. Nine adolescents (aged 11-17 years) completed a regimen of intensive CBT (range 24-80 daily sessions) incorporating exposure with response prevention (ERP). Treatment materials, language and techniques were modified in accordance with evidence-based findings for this population. Seven of nine participants (78%) were treatment responders, and large treatment effects (d = 1.35-2.58) were obtained on primary outcomes (e.g., obsessive-compulsive symptom severity). Preliminary findings suggest that an intensive CBT approach for OCD is effective among adolescents with ASD.

White Matter Features Associated With Autistic Traits in Obsessive-Compulsive Disorder

Obsessive-compulsive disorder (OCD) is among the most debilitating psychiatric disorders. Comorbid autism spectrum disorder (ASD) or autistic traits may impair treatment response in OCD. To identify possible neurostructural deficits underlying autistic traits, we performed white matter tractography on diffusion tensor images (DTI) and assessed autistic trait severity using the Autism-Spectrum Quotient (AQ) in 33 OCD patients. Correlations between AQ and the DTI parameters, fractional anisotropy (FA), mean diffusivity (MD), axial diffusivity (AD), and radial diffusivity (RD) were examined in major white matter tracts that were suggested to be altered in previous OCD studies. We found a negative correlation between AQ and FA and positive correlations between AQ and MD, AD and RD in the left uncinate fasciculus using age, Beck Depression Inventory, Yale-Brown Obsessive-Compulsive Scale, intelligence quotient and medication as covariates. However, we could not detect the significant results between AQ and all DTI parameters when adding gender as a covariate. In addition, in the ASD comorbid group, FA in the left uncinate fasciculus was significantly lower than in the non-ASD comorbid group and MD and RD were significantly higher than in the non-ASD group. These results did not survive correction for multiple comparisons. In ASD, the socio-emotional dysfunction is suggested to be related to the alteration of white matter microstructure in uncinate fasciculus. Our results suggest that variations in white matter features of the left uncinate fasciculus might be partly explained by autistic traits encountered in OCD patients.

Family accommodation of anxiety symptoms in youth undergoing intensive multimodal treatment for anxiety disorders and obsessive-compulsive disorder: Nature, clinical correlates, and treatment response

BACKGROUND

Family accommodation is associated with a range of clinical features including symptom severity, functional impairment, and treatment response. However, most previous studies in children and adolescents investigated family accommodation in samples of youth with obsessive-compulsive disorder (OCD) or anxiety disorders receiving non-intensive outpatient services.

AIMS

In this study, we aimed to investigate family accommodation of anxiety symptoms in a sample of youth with clinical anxiety levels undergoing an intensive multimodal intervention for anxiety disorders or OCD.

PROCEDURES

We first assessed the internal consistency of the Family Accommodation Scale - Anxiety (FASA). We next examined family accommodation presentation and correlates.

RESULTS

The FASA showed high internal consistency for all subscales and total score, and good item and subscale correlations with the total score. All parents reported at least mild accommodation, and the mean levels of family accommodation were particularly high. Child age, anxiety severity, and comorbid depressive symptoms predicted baseline accommodation. However, the association between anxiety severity and family accommodation no longer remained significant after adding the other factors to the model. In addition, family accommodation partially mediated the relationship between anxiety severity and functional impairment. Finally, post-treatment changes in family accommodation predicted changes in symptom severity and functional impairment.

CONCLUSIONS

These findings suggest the FASA is an appropriate tool to assess family accommodation in intensive treatment samples. Further, they underline the importance of addressing family accommodation in this population given the particularly high levels of accommodating behaviors and the evidence for adverse outcomes associated with this feature.

Obsessive-Compulsive Disorder in Paediatric and Adult Samples: Nature, Treatment and Cognitive Processes. A Review of the Theoretical and Empirical Literature

The appraisal model of obsessive-compulsive disorder (OCD) suggests that six key appraisal domains contribute to the aetiology and maintenance of OCD symptoms. An accumulating body of evidence supports this notion and suggests that modifying cognitive appraisals may be beneficial in reducing obsessive-compulsive symptomatology. This literature review first summarises the nature of OCD and its treatment, followed by a summary of the existing correlational and experimental research on the role of cognitive appraisal processes in OCD across both adult and paediatric samples. While correlational data provide some support for the relationship between cognitive appraisal domains and OCD symptoms, results are inconclusive, and experimental methods are warranted to determine the precise causal relationship between specific cognitive appraisal domains and OCD symptoms.

The Treatment Worries Questionnaire: Conjoined measures for evaluating worries about psychosocial treatment in youth and their parents

Treatment worries, which surround requirements and results of obtaining treatment, may represent an important construct; however, previous measures were limited by their specificity, format, and lack of parent report. Therefore the present study examined the initial outcomes and psychometrics of corresponding measures of treatment worries in youth (Treatment Worries Questionnaire - Child; TWQ-C) and their parents (Treatment Worries Questionnaire - Parent; TWQ-P). Participants were 94 youth (7-17-years old) and parent dyads presenting for treatment of an anxiety disorder. Dyads completed the TWQ-C and TWQ-P along with additional measures prior to initiating treatment. Treatment worries were endorsed in the mild-moderate range by youth and the TWQ-C demonstrated good-excellent internal consistency, a three-factor structure, and consistent convergent and divergent relationships. Treatment worries were endorsed in the low-mild range by parents and the TWQ-P demonstrated fair-good internal consistency, a four-factor structure, and consistent divergent relationships, but variable (by factor) convergent relationships. The results provide information on treatment worries and support the use of the TWQ-C and TWQ-P as broad assessments of the concept. Low endorsement of worries among parents likely relates to the treatment-seeking nature of the sample. Future investigations using the TWQ-C and TWQ-P in a variety of samples is warranted.

A preliminary study of cognitive-behavioral family-based treatment versus parent training for young children with obsessive-compulsive disorder

BACKGROUND

Cognitive-Behavioral Family-Based Treatment (CBFT) is the standard of care in young children with OCD. Developmental considerations, parent desires, and cost-effective advantages motivate research to explore the relative efficacy of parent-only interventions. The main goal in this study was to test the effectiveness and feasibility of a parent only intervention for OCD in young children, comparing, in a preliminary fashion the relative efficacy of reducing obsessive-compulsive symptoms through two treatment conditions: 1) an individual CBFT for early OCD involving both parents and children, and 2) the family component of the intervention involving only individual Parent Training (PT).

METHODS

Twenty treatment-seeking families from two private outpatient clinics in Spain were alternately assigned to one of the two treatment conditions. Participants had a primary diagnosis of OCD and a mean age of 6.62 years (65% males). Interventions were conducted by the same therapist and the assessments were administered by independent clinicians who were blind to the experimental conditions of the participants. Assessment time-points were pretreatment, posttreatment, and 3-month follow-up (including diagnosis, symptom severity, global functioning, family accommodation, externalizing and internalizing symptoms, and satisfaction measures).

RESULTS

The two ways of implementation, involving child and parents (CBFT) or involving only parents (PT), produced clinical improvements and were well-accepted by parents and children. The CBFT condition was superior to the PT condition in reducing externalizing problems.

LIMITATIONS

reduced sample size and absence of randomization were the main limitations of this study.

CONCLUSIONS

these results suggest, in a preliminary manner, that the need to have the child present at session with the clinician could be decreased for some children, as well as the overall feasibility of working only with parents for the implementation of CBT for OCD in very young children.

Anxiety sensitivity and family accommodation in obsessive-compulsive disorder

BACKGROUND

Although anxiety sensitivity (AS) presents in adults with obsessive-compulsive disorder (OCD), it has received minimal empirical attention. There are postulated connections between AS and family accommodation, but this relationship has yet to be formally examined.

METHODS

The present study included 58 adults with OCD who completed a clinician-rated measure of OCD symptom severity, as well as self-report measures assessing AS, family variables, impairment, and co-occurring psychopathology.

RESULTS

Participants' AS moderately correlated with family accommodation, family functioning, and depression, while strongly correlating with anxiety symptoms. The Fear of Cognitive Dyscontrol AS subscale moderately correlated with multiple domains of functional impairment, and predicted family accommodation beyond the effects of OCD symptom severity. Family accommodation mediated the relationship between the Fear of Cognitive Dyscontrol AS subscale and functional impairment.

LIMITATIONS

The study was cross-sectional in nature, limiting the ability to establish directionality and causation. The sample was also limited to adults with OCD and their own symptomology, necessitating further investigations of these constructs in pediatric samples and psychopathology in the caregivers/relatives.

CONCLUSIONS

These findings highlight the importance of considering fears regarding the loss of mental control within the context of family accommodation in OCD when evaluating functional impairment.

Traumatic and Adverse Attachment Childhood Experiences are not Characteristic of OCD but of Depression in Adolescents

We investigated whether adverse attachment experience might contribute to the development of obsessive-compulsive disorder (OCD). We interviewed 100 adolescents, 25 each with primary OCD, depressive disorder (DD), OCD plus DD and general population controls (CTRs) using the adult attachment interview to assess attachment experiences (AEs), including traumatic and adverse AE (TAE). Adolescents with OCD, OCD+DD and DD had little evidence of secure base/safe haven parental behaviour and their childhood attachment needs judged to be rejected as compared to the controls. Overprotection was not characteristic of OCD, and parents using the child for their own needs (elevated levels of involving/role reversal) occurred only in DD, with low levels in OCD, OCD+DD and CTR. Traumatic experiences, often multiple, and/or attachment related were reported significantly more often in the DD group, and was less common in OCD+DD, CTR and particularly in the OCD group. In OCD, little TAE was reported and adverse AE were less serious and seem unlikely to contribute directly to OCD aetiology. In DD and to some degree in OCD+DD serious AE/TAE may have some etiological significance for the depressive states.

Brief strategic therapy for obsessive-compulsive disorder: a clinical and research protocol of a one-group observational study

INTRODUCTION

Obsessive-compulsive disorder (OCD) is a disabling psychopathology. The mainstay of treatment includes cognitive-behavioural therapy (CBT) and medication management. However, individual suffering, functional impairments as well as the direct and indirect costs associated with the disease remain substantial. New treatment programmes are necessary and the brief strategic therapy (BST) has recently shown encouraging results in clinical practice but no quantitative study has as yet been conducted.

METHODS AND ANALYSIS

The clinical effectiveness of the OCD-specific BST protocol will be evaluated in a one-group observational study. Participants will be sequentially recruited from a state community psychotherapy clinic in Dublin, Ireland. Outcome measures will be the Yale-Brown Obsessive Compulsive Scale (Y-BOCS) and the Beck Depression Inventory-II (BDI-II). Data will be collected at baseline, at treatment termination and at 3 month follow-up. The statistical significance of the post-treatment effect will be assessed by the paired-sample Student t test, while clinical significance will be evaluated by means of the equivalence testing method, which will be also used to assess the maintenance of effect at follow-up.

ETHICS/DISSEMINATION

The present study is approved by the Hesed House Ethics Board in Dublin. Findings will enhance the evidence-based knowledge about the clinical effectiveness of BST in treating OCD symptoms, prior to assessing its efficacy in a randomised and controlled clinical trial, and will be disseminated through publication in peer-reviewed journals and conference presentations.

Cognitive-Behavioral Therapy for Adolescent Body Dysmorphic Disorder: A Pilot Study

Body dysmorphic disorder (BDD) is a relatively common and severe disorder that typically onsets in adolescence, but often goes unrecognized. Despite BDD's severity and early onset, treatment outcome research on adolescent BDD is scarce. Cognitive-behavioral therapy is the gold-standard psychosocial treatment for BDD in adults and has shown promise in adolescents. The current study examined the development and testing of a new CBT for adolescents with BDD. We tested feasibility, acceptability, and treatment outcome in a sample of 13 adolescents (mean age 15.23years, range: 13-17) with primary BDD. Treatment was delivered in 12-22 weekly individual sessions. Standardized clinician ratings and self-report measures were used to assess BDD and related symptoms pre- and posttreatment and at 3- and 6-months follow-up. At posttreatment, BDD and related symptoms (e.g., insight, mood) were significantly improved. Scores on the Yale-Brown Obsessive Compulsive Scale for BDD indicated a 50% (intent-to-treat) and 68% (completer) improvement in BDD symptoms. Seventy-five percent of adolescents who started treatment and 100% of completers were considered treatment responders. Treatment gains were maintained at follow-up. High patient satisfaction ratings and patient feedback indicated that treatment was acceptable. This represents the largest study of a psychosocial treatment for adolescent BDD.

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.

Child-focused treatment of pediatric OCD affects parental behavior and family environment

This study aimed to investigate the impact of child-focused pediatric OCD treatment on parental anxiety, family accommodation and family environment. Forty-three parents (72.1% female, mean age±SD=43.1±5.6 years) were evaluated at baseline and after their children's (n=33, 54.5% female, mean age±SD=12.9±2.7 years) randomized treatment with Group Cognitive-Behavioral Therapy or fluoxetine for 14 weeks. Validated instruments were administered by trained clinicians. Parents were assessed with the State-Trait Anxiety Inventory (STAI), the Family Accommodation Scale (FAS) and the Family Environment Scale (FES). The Yale-Brown Obsessive-Compulsive Scale was administered to children. Significant findings after the children's treatment include decreased family accommodation levels (participation, modification and distress/consequences domains); increased cohesion and active-recreational components of the family environment. In addition, changes in the FAS distress/consequences and the FES cohesion subscores were correlated with the children's clinical improvement. These results suggest that child-focused OCD treatment may have a positive impact on family accommodation and family environment. Future studies should further clarify the reciprocal influences of pediatric OCD treatment and family factors.

A Promising Preliminary Study of Aripiprazole for Treatment-Resistant Childhood Obsessive-Compulsive Disorder

BACKGROUND

Obsessive-compulsive disorder (OCD) is a relatively frequent disease in childhood, which is generally treated with selective serotonin reuptake inhibitors (SSRIs) and/or clomipramine and cognitive behavioral therapy (CBT). However, nearly half of the cases are treatment resistant. Aripiprazole was shown to be beneficial in augmentation therapy in treatment-refractory OCD. This study evaluated its effectiveness as a single agent in these cases.

METHODS

Sixteen children (nine girls, seven boys), who were nonresponders to treatment with at least two types of SSRIs and CBT, were administered 12 weeks of aripiprazole treatment with a mean dose of 4.75 mg/day (range: 2-7.5 mg/day). Treatment outcomes were evaluated by the Childhood Yale-Brown Obsessive Compulsive Scale (CY-BOCS), and the Clinical Global Impressions-Severity and Improvement (CGI-S and CGI-I) scales.

RESULTS

Children with a mean age of 10.9±2.9 years had severe obsessive compulsive symptoms at baseline, and >80% of them had another comorbid psychiatric disease. Significant improvements in symptoms were achieved after 12 weeks of aripiprazole treatment, which were evaluated by significant decreases in symptom scores in the CY-BOCS, and improvements in CGI-I scores.

CONCLUSIONS

This very small study of aripiprazole, given to children with OCD resistant to at least 12 weeks treatment with at least two SSRIs and CBT, demonstrated striking improvement in CGI scores (all subsets, p≤0.002) for 13 of 16 children, and halved all CY-BOCS subscores after ∼12 weeks of treatment.

Family functioning in paediatric obsessive compulsive and related disorders

OBJECTIVE

Research among youths with obsessive compulsive disorder (OCD) has shown a significant relationship between illness severity, treatment outcome, and the family environment yet little work has been undertaken among the broader class of obsessive compulsive and related disorders (OCRDs) - Trichotillomania, body dysmorphic disorder (BDD), skin picking disorder (SPD), and hoarding. The aim of this study was to (1) review the family functioning literature among paediatric OCRDs, (2) address limitations to previous studies, and (3) highlight areas in need of further research.

METHODS

A review of the literature was conducted using several databases (i.e., Google Scholar, PubMed, ScienceDirect) and employing key search terms (e.g., 'family functioning', 'paediatric OCD'). The resultant articles examined several domains subsumed under the broader heading of family environment including parental mental health, parenting practices, family dynamics, family involvement with symptoms, and family emotional climate.

RESULTS

The literature reviewed demonstrated a strong relationship between paediatric OCD and adverse family functioning (e.g., parental symptoms of anxiety and depression, family accommodation, family strain and stress, parental guilt and fear) in all identified domains. While family functioning research in paediatric HPD was relatively scant, research suggested similar familial dysfunction (e.g., limited independence, low family cohesion, family violence). Collectively, only 1 article, examining BDD, assessed family functioning within other OCRDs.

CONCLUSIONS

This review supports the need for further research in the OCRDs. Limitations to the available literature and targeted suggestions for future research are discussed.

PRACTITIONER POINTS

The domains of family environment in this study indicate specific family functioning deficits that may serve as aetiological and/or maintenance factors in paediatric OCRDs, possibly contributing to the understanding of these complex disorders. The recognition of family deficits in paediatric OCRDs may prove beneficial in developing or bolstering preventative and/or therapeutic interventions. Insufficient number of articles pertaining to family functioning in some paediatric OCRDs (i.e., hoarding, skin picking) inhibits formal conclusions. Magnitudes of family functioning effects were not calculated; therefore, future research should consider meta-analytic analyses.

The Yin and Yang of support from significant others: Influence of general social support and partner support of avoidance in the context of treatment for social anxiety disorder

Support from social networks is generally considered to protect against mental disorder but in some circumstances support for negative behaviours (such as avoidance) may be counterproductive. Given the critical interplay between social anxiety disorder and social interactions, it is surprising that the relationship of support from significant others to this disorder has received so little attention. The current study evaluated the reciprocal relationships between perceived social support and perceived partner support for avoidance behaviours (avoidance support) among a sample of 131 participants with social anxiety disorder who were assessed three times within the context of a treatment outcome study. A new measure of partner support for avoidance behaviours was developed, called the Avoidance Support Measure, and showed adequate internal consistency and construct validity. Correlations at baseline showed significant negative relationships between perceived social support and social anxiety and significant positive relationships between avoidance support and social anxiety. Path analysis showed that perceived social support at Times 1 and 2 negatively predicted future social anxiety at Times 2 and 3. On the other hand, only a single predictive relationship involving avoidance support was significant and showed that social anxiety at Time 1 positively predicted avoidance support at Time 2. These early results point to the different ways that support from significant others might relate to social anxiety and suggest that further work in this area may be fruitful.

Symptom Accommodation Related to Social Anxiety Symptoms in Adults: Phenomenology, Correlates, and Impairment

BACKGROUND AND OBJECTIVES

Socially anxious individuals often engage in various safety and avoidant behaviors to temporarily decrease distress. Similarly, friends or family members may engage in accommodating behaviors, commonly manifesting through the facilitation of avoidance, completion of tasks, or schedule modifications. Studies examining symptom accommodation in adult social anxiety are lacking, so this study seeks to better understand symptom accommodation and its consequent impairment in socially anxious adults.

DESIGN AND METHODS

There were 380 undergraduate students who completed a battery of self-report questionnaires through an online system. Constructs assessed include social anxiety, symptom accommodation, and impairment as well as related variables such as general anxiety, fear of negative evaluation, alcohol use, and anxiety sensitivity.

RESULTS

Symptom accommodation was positively correlated with social anxiety symptoms, functional impairment, general anxiety, anxiety sensitivity, fear of negative evaluation, and alcohol use. Individuals with considerable social anxiety reported significantly higher levels of symptom accommodation than individuals who reported lower levels of social anxiety. Anxiety sensitivity predicted symptom accommodation beyond the contribution of social anxiety. Symptom accommodation mediated the relationship between social anxiety and impairment.

CONCLUSIONS

These data help elucidate the presentation and impact of symptom accommodation related to social anxiety. Implications for assessment, treatment, and future directions are presented.

Predictors of treatment response to intensive cognitive-behavioral therapy for pediatric obsessive-compulsive disorder

Intensive outpatient treatments for pediatric obsessive-compulsive disorder (OCD) have demonstrated efficacy for treating youth with OCD and may be especially useful for youth with severe symptomology and/or those who are partial- or non-responders to other forms of intervention. However, participation in these treatments can present challenges for youth and their families, and it is unclear if intensive treatments are more appropriate for certain individuals than others. Identification of potential predictors of treatment response and viability of intensive treatment at an individual level may aid families in their decision to participate in intensive cognitive-behavioral therapy (CBT). The present study aimed to examine the effects of three categories of predictors (demographics, OCD symptom characteristics, and comorbidity) on key target outcomes (post-treatment symptom severity, remission, and treatment response). Participants included 78 youth with a primary diagnosis of OCD who received 14 sessions of family based intensive CBT treatment over 3 weeks. Of the entire sample, 88.5% were classified as treatment responders, with 62.8% of the sample achieving clinical remission. Results identified three significant predictor variables (i.e., symptom severity, family accommodation, and gender) for post-treatment symptom severity and remission status within the context of the examined predictive models. No variables were identified as predictive of treatment response, and comorbidity was not identified as a predictor variable for any treatment outcome.

Pediatric acute-onset neuropsychiatric syndrome

Whether some instances of obsessive-compulsive disorder are secondary to infectious and/or autoimmune processes is still under scientific debate. The nosology has undergone an iterative process of criteria and acronyms from PITANDS to PANDAS to PANS (or CANS for neurology). This review focuses on the clinical presentation, assessment, proposed pathophysiology, and treatment of pediatric autoimmune neuropsychiatric disorders associated with streptococcus (PANDAS), and the newest iteration, pediatric acute-onset neuropsychiatric syndrome (PANS). Children who have these symptoms, which have become known as PANS, have been described by their parents as "changed children."

Cognitive behavior therapy for obsessive-compulsive and related disorders

Cognitive behavior therapy (CBT) is considered a first-line intervention for obsessive-compulsive disorder (OCD) across the lifespan. Efficacy studies of CBT with exposure and response prevention suggest robust symptom reduction, often with sustained remission. Acceptability of CBT is high, and the treatment is devoid of adverse side effects. The primary mechanism of CBT is based on operant principles, specifically extinction learning. The efficacy of extinction-based treatments such as CBT is being shown for other obsessive-compulsive spectrum disorders. This article reviews the theoretic basis, clinical application, and relevant treatment outcome research for CBT and related therapies for several obsessive-compulsive spectrum disorders.

How resistant is 'treatment-resistant' obsessive-compulsive disorder in youth?

OBJECTIVES

Obsessive-compulsive disorder (OCD) is often perceived as being difficult to treat. This study aimed to test the hypothesis that treatment non-response in routine clinical practice is often due to failures in the delivery of treatment, and that most patients who are apparently treatment-resistant will respond to treatment if adequately delivered.

DESIGN

Retrospective cohort data analysis.

METHODS

Forty-three young people with severe, treatment-resistant OCD (defined as Children's Yale-Brown Obsessive-Compulsive Scale [CY-BOCS] scores ≥ 30 and non-response to previous cognitive behaviour therapy [CBT] and selective serotonin reuptake inhibitors) were referred to a specialist clinic and completed a course of manualized CBT, with (N = 21) or without (N = 22) optimization of medication. A sub-sample (N = 15) completed a semi-structured interview to determine characteristics of their previous CBT; quality was assessed according to pre-determined criteria.

RESULTS

Specialist treatment was associated with significant reductions in OCD symptoms at post-treatment with gains maintained at 3-month follow-up. At the 3-month follow-up, 58% of patients showed a meaningful clinical response (≥ 35% drop on the CY-BOCS) and 22% were in remission (≤ 12 on the CY-BOCS). Patients whose medication was optimized tended (non-significantly) to have better responses. The quality of previous CBT was assessed in a sub-group of participants and rated as inadequate in 95.5% of cases. The most common inadequacy was insufficient focus on exposure techniques.

CONCLUSIONS

These findings provide support for the notion that treatment non-response in routine practice may be due to technical treatment failures and highlight the need to disseminate good quality evidence-based treatment among this population. Research is also needed to understand factors that impede outcome to further improve response and remission rates.

PRACTITIONER POINTS

Among young people with OCD, failure to respond to treatment in routine clinical practice may often reflect the nature of the treatment received. Exposure techniques may often be overlooked in CBT for OCD, potentially resulting in poor therapeutic response. Most young people with severe and apparent treatment-resistant OCD respond to outpatient CBT incorporating E/RP. Further research is needed to establish effective methods for disseminating good quality CBT for OCD.

Family-Based Cognitive-Behavioral Treatment for a Preschooler With Obsessive-Compulsive Disorder

Cognitive-behavioral therapy (CBT) with exposure and response prevention is known to be effective in the treatment of older youth (8-17) and adults with obsessive-compulsive disorder (OCD); however, very little is known about the effectiveness of these procedures during early childhood. As such, this case describes the application of a modularized family-based CBT approach focusing on exposure, differential reinforcement of other behaviors (DRO), and reductions in family accommodation with a preschool boy with a primary diagnosis of OCD. Following 12 consecutive family sessions over 6 weeks, “Charley,” a 4-year-old Caucasian male, showed substantial reductions in OCD symptomatology. Charley’s parents also reported improvements in oppositionality, peer functioning with siblings and at preschool, and in the parent–child relationship. All improvements were maintained at 3-month follow-up. These results provide preliminary support that CBT incorporating exposure, DRO, behavioral parent training, and reductions in family accommodation may be effective for preschoolers with OCD.

Evidence base update for psychosocial treatments for pediatric obsessive-compulsive disorder

Pediatric obsessive-compulsive disorder (OCD) is a chronic and impairing condition that often persists into adulthood. Barrett, Farrell, Pina, Peris, and Piacentini (2008), in this journal, provided a detailed review of evidence-based psychosocial treatments for youth with OCD. The current review provides an evidence base update of the pediatric OCD psychosocial treatment literature with particular attention to advances in the field as well as to the methodological challenges inherent in evaluating such findings. Psychosocial treatment studies conducted since the last review are described and evaluated according to methodological rigor and evidence-based classification using the JCCAP evidence-based treatment evaluation criteria (Southam-Gerow & Prinstein, this issue). Findings from this review clearly converge in support of cognitive-behavioral therapy as an effective and appropriate first line treatment for youth with OCD (either alone or in combination with medication). Although no treatment for pediatric OCD has yet to be designated as "well-established," both individual and individual family-based treatments have been shown to be "probably efficacious." Moderators and predictors of treatment outcome are discussed as are the areas where we have advanced the field and the areas where we have room to grow. The methodological and clinical challenges inherent in a review of the evidence base are reviewed. Finally, future research directions are outlined.

Optimizing treatment for complex cases of childhood obsessive compulsive disorder: a preliminary trial

Family factors such as conflict, blame, and poor cohesion have been found to attenuate response to cognitive behavior therapy (CBT) for pediatric obsessive compulsive disorder (OCD). This study examined the feasibility and acceptability of a brief, personalized intervention for cases of pediatric OCD complicated by these family features. Twenty youth with a primary Diagnostic and Statistical Manual of Mental Disorders (4th ed.) diagnosis of OCD (M age = 12.50 years; 55% male; 60% Caucasian) and their families participated. To be included in the study, families were required to evidence poor functioning on measures of blame, conflict, and/or cohesion. Eligible families were randomly assigned either to standard treatment (ST) with 12 weeks of individual child CBT that included weekly parent check-ins and psychoeducation or to Positive Family Interaction Therapy (PFIT), which consisted of 12 weeks of individual child CBT plus an additional 6 sessions of family treatment aimed at shifting family dynamics. Clinical outcomes were determined by blind independent evaluators using the Clinician's Global Impressions-Improvement (CGI-I) scale. All families completed the study. High levels of satisfaction were reported among participants in both arms of the study, despite the added burden of attending the PFIT sessions. Both mothers and fathers attended 95% of the PFIT family sessions. Families in the ST condition demonstrated a 40% response rate on the CGI-I; families in the PFIT condition demonstrated a 70% response rate. Treatment gains were maintained in both conditions at 3-month follow-up. Preliminary data suggest that PFIT is acceptable and feasible. Further testing and treatment development are needed to optimize outcomes for complicated cases of pediatric OCD.

Treatment of tics and tourette syndrome

OPINION STATEMENT

Tics come in a variety of types and frequencies; have a waxing and waning course; are exacerbated by stress, anxiety, and fatigue; and often resolve or improve in the teenage or early adult years. Tourette syndrome requires the presence of chronic, fluctuating motor and phonic tics. In addition to tics, individuals with Tourette syndrome often have a variety of comorbid conditions such as attention deficit hyperactivity disorder (ADHD), obsessive-compulsive disorder, depression and anxiety, episodic outbursts, and academic difficulties. These conditions often are a greater source of difficulty than the tics themselves. All patients with tics should be evaluated to assure proper diagnosis and to identify any associated psychopathology or academic difficulty. The treatment of tics begins with education of the patient and family, including discussions about the fundamentals of tics: their characteristics, etiology, outcomes, and available treatments. Therapy should be individualized based on the extent of impairment, available support, ability to cope, and the presence of other problems. Indications for the treatment of tics include psychosocial problems (loss of self-esteem, comments from peers, excessive worries about tics, diminished participation in activities), functional difficulties, classroom disruption, and physical discomfort. A variety of behavioral approaches can be used. Recent studies have emphasized the value of comprehensive behavioral intervention for tics (CBIT). Because habit reversal is the major component of CBIT, a cooperative patient, the presence of a premonitory urge, and a committed family are essential ingredients for success. If tic-suppressing medication is required, a two-tier approach and monotherapy are recommended. First-tier medications, notably the α-adrenergic agonists, are recommended for individuals with milder tics, especially persons with both tics and ADHD. Second-tier medications include various typical and atypical neuroleptics. Their sequence of prescription is often based on physician experience; I favor pimozide and fluphenazine. Atypical antipsychotics, such as risperidone and aripiprazole, have some advantages based on their side-effect profile and are particularly beneficial in individuals with significant co-existing behavioral issues. As will become readily apparent, however, few medications have been adequately assessed. Deep brain stimulation is an emerging therapy, but further data are required to optimize the location of electrode placement and stimulation and to determine precise indications for its implementation. Stimulant medication is effective in treating ADHD in children with tics; studies reducing concerns about its use are discussed.