Dysregulation in pediatric obsessive compulsive disorder

Although obsessive compulsive disorder (OCD) and common co-occurring conditions share deficits in self-regulatory abilities, there has been minimal examination of impaired self-regulation (dysregulation) in youth with OCD. This study examined the association of dysregulation with symptom severity, impairment, and treatment outcome in pediatric OCD. Clinicians assessed obsessive-compulsive severity, family accommodation and global severity in 144 youth with OCD. Youth completed self-report severity ratings of anxiety and depressive symptoms. Parents completed the Child Behavior Checklist (CBCL), and both children and parents completed parallel ratings of obsessive-compulsive impairment. Ninety-seven youth received cognitive behavioral therapy (CBT) and were re-assessed after treatment. Dysregulation was assessed using the CBCL-Dysregulation Profile. Before treatment, dysregulated youth exhibited greater obsessive-compulsive symptom severity, depressive mood, family accommodation, and impairment than non-dysregulated youth. The magnitude of dysregulation directly predicted child-rated impairment, parent-rated impairment, and family accommodation, beyond obsessive-compulsive severity. The magnitude of pretreatment dysregulation predicted treatment discontinuation but not treatment response. Obsessive-compulsive symptom severity and dysregulation level significantly decreased after CBT. Dysregulated youth with OCD presented as more clinically severe than their non-dysregulated counterparts, and may require more individualized interventions to reduce dysregulated behavior to prevent CBT attrition. For treatment completers, CBT was associated with a decrease in dysregulation level.     

Cognitive-behavioral therapy for obsessive-compulsive disorder in children and adolescents

Obsessive-compulsive disorder (OCD) is a common, chronic, and impairing condition in youth. Cognitive-behavioral therapy (CBT), now widely recognized as the gold standard intervention for childhood OCD, relies on exposure and response prevention, and also includes psychoeducation, creation of a symptom hierarchy, imaginal exposures, cognitive interventions, and a contingency management system. This article reviews the theoretical underpinnings of current CBT approaches, key components of treatment, developmental considerations specific to childhood OCD, and evidence supporting the use of this psychosocial intervention. The current state of knowledge will be aided by further study of predictors and mechanisms of CBT treatment response.     

Cognitive behavioral therapy of obsessive-compulsive disorder

Until the mid-1960s, obsessive-compulsive disorder (OCD) was considered to be treatment-resistant, as both psychodynamic psychotherapy and medication had been unsuccessful in significantly reducing OCD symptoms. The first real breakthrough came in 1966 with the introduction of exposure and ritual prevention. This paper will discuss the cognitive behavioral conceptualizations that influenced the development of cognitive behavioral treatments for OCD. There will be a brief discussion of the use of psychodynamic psychotherapy and early behavioral therapy, neither of which produced successful outcomes with OCD. The main part of the paper will be devoted to current cognitive behavioral therapy (CBT) with an emphasis on variants of exposure and ritual or response prevention (EX/RP) treatments, the therapy that has shown the most empirical evidence of its efficacy.     

Sequential cognitive-behavioral therapy for children with obsessive-compulsive disorder with an inadequate medication response: a case series of five patients

Few data have been reported on the efficacy of cognitive-behavioral therapy (CBT) for youth with obsessive-compulsive disorder (OCD) who have not responded to prior treatment with medication. Given this, we report an open trial of CBT for children who have remained symptomatic following medication trials. Five children with OCD who had an inadequate response to psychotropic medications (e.g., limited response and/or unable to be titrated to a complete dose due to side effects) received treatment in a 3-week intensive CBT program. Assessments were conducted at baseline and after treatment. All participants were classified as treatment responders (much improved or very much improved) and the severity of clinician-rated OCD symptoms and impairment significantly decreased after the intervention. Although a number of limitations of this preliminary report exist, this study provides preliminary support for the utility of an intensive intervention for youth with OCD who have had an inadequate response and/or adverse side effects.     

An Internet administered treatment program for obsessive-compulsive disorder: a feasibility study

The present study evaluates efficacy of a new Internet-administered cognitive behavioral therapy (CBT) protocol, The OCD Program, designed to treat obsessive-compulsive disorder (OCD) remotely. This protocol comprises 8 online lessons delivered over 8 weeks and incorporates cognitive and behavioral techniques. Twenty-two individuals with a principal diagnosis of OCD received CBT-based online lessons, homework assignments, twice weekly contact from a clinical psychologist, and automated emails. Eighty-one percent of participants completed the lessons within the 8-week program. Post-treatment and 3-month follow-up data were collected from 21/21 (100%) and 19/21 (91%) participants, respectively. Participants improved significantly on the primary outcome measures, the Yale-Brown Obsessive Compulsive Scale and Obsessive Compulsive Inventory-Revised, with within-groups effect sizes (Cohen's d) at follow-up of 1.28 and 0.60, respectively. Participants rated the procedure as highly acceptable despite receiving an average of only 86min (SD=54.4min) telephone contact with the therapist over the 8 weeks. These results provide preliminary support for efficacy of Internet-administered treatment for obsessive-compulsive disorder.     

Family-based treatment of early-onset obsessive-compulsive disorder

Despite a meaningful common core of symptoms observed across the life span, there are particularly unique features of early-onset (prepubertal) obsessive-compulsive disorder (OCD) that make consideration of early presentation different from adolescent or adult onset and that may have important implications for treatment. This article will first review the unique features of early-onset OCD, focusing particular attention to the developmental and familial context of these children's symptoms. The literature on behavioral family interventions for other childhood disorders, specifically anxiety, as well as that on family processes (e.g., parent-child interactions) in families of children with OCD will be reviewed. The pediatric OCD cognitive-behavioral therapy (CBT) literature (CBT alone and CBT plus medication) will also be reviewed, focusing on current evidence-based treatment guidelines. Finally, a model of family-based treatment for young children with OCD and some preliminary pilot data will be presented.     

Aripiprazole augmentation of incomplete treatment response in an adolescent male with obsessive-compulsive disorder

We report the case of adolescent male with obsessive-compulsive disorder (OCD) who had an incomplete response to combined cognitive-behavioral therapy (CBT) and sertraline before successful augmentation of CBT with aripiprazole. Standardized assessments indicated significant reductions in OCD symptomatology associated with both initial treatment and aripiprazole augmentation. This case suggests that aripiprazole may have utility as an augmenting agent of CBT in adolescents with OCD and underscores the need for conducting controlled studies to test this hypothesis.     

A neuropsychiatric review of pediatric obsessive-compulsive disorder: etiology and efficacious treatments

Pediatric obsessive-compulsive disorder (OCD) is a chronic neuropsychiatric condition associated with broad impairments in functioning. This paper outlines current etiological theories of OCD, providing a review of neuroanatomical, neurochemical, neuroimmunological, and cognitive–behavioral explanations. Subsequently, first-line treatment modalities are discussed (serotonin reuptake inhibitors [SRIs] and cognitive–behavioral therapy [CBT] with exposure and response prevention [E/RP]) in the context of recent pharmacological, CBT, and combined trials.     

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.     

药物治疗与合并认知行为治疗对强迫症疗效的比较

目的探讨认知行为心理治疗(CBT)在强迫症(OCD)患者各亚型治疗中的有效性和规律性。方法本研究为临床对照研究。符合入组标准的强迫症患者按患者自愿原则分为两组,治疗观察3、6、12个月。疗效评定分别运用Yale-Brown强迫量表,自拟的自评好转程度量表和临床疗效评定。结果认知行为心理治疗合并药物治疗组31例,临床有效率70.9%,其中治愈率1.8%。单纯药物治疗组24例,临床有效率33.3%。Yale-Brown强迫量表和自评量表得分在6个月和12个月两组有显著差异(P<0.05)。其中强迫症亚型(怕脏型、反复检查型和反复担心型)的疗效比较,怕脏型在治疗3个月末两组间自评量表评分有显著性差异(P<0.05);反复担心型在治疗6个月末两组间Yale-Brown强迫量表总分有显著性差异(P<0.05);反复检查型两组间无统计学差异。结论认知行为心理治疗合并药物治疗强迫症的疗效明显优于单纯药物治疗。强迫症的亚型在治疗中的有效性次序为:反复担心型>怕脏型>反复检查型。     

Group behavioral therapy for adolescents with tic-related and non-tic-related obsessive-compulsive disorder

Prior research supports the distinction between tic-related and non-tic-related obsessive-compulsive disorder (OCD) based on phenomenologic, etiologic, and neurobehavioral data. The present study examines whether response to psychosocial treatment differs in adolescents, depending on the presence of comorbid tics. Nineteen adolescents, 12-17 years of age, participated in 7-week, uncontrolled trial of group cognitive-behavioral treatment (CBT) for OCD. Eight of the patients had tic-related and eleven had non-tic-related OCD. The group CBT program included psycho-education, exposure and response prevention, cognitive strategies, and family involvement. Significant improvement was observed for all subjects on the Yale-Brown Obsessive Compulsive Scale ratings of obsessions, compulsions, and total OCD symptoms. Outcomes were similar for subjects with tic-related and non-tic-related OCD. These preliminary results suggest that the presence of comorbid tic disorders may not attenuate response to behavioral group treatment among adolescents.     

Cognitive behavioral therapy for obsessive-compulsive disorder: An update

Cognitive-behavioral therapy (CBT) for obsessivecompulsive disorder (OCD) has been shown to be a highly effective treatment for children and adults. In the current review, we briefly describe the historical developments of the treatment, and recent findings related to five areas of inquiry: 1) Does intensity of CBT impact outcome? 2) Does CBT work better on some subtypes of OCD than others? 3) How do cognitive and behavioral strategies relate to outcome? 4) How well does CBT work for children and adolescents with OCD? and 5) Does the combination of CBT and medication work better than CBT alone? After a discussion of these questions, we mention some areas currently being examined.     

The effect of a couple-based treatment for OCD on intimate partners

Background and objectivesThis study investigated the effect of a couple-based cognitive behavioral therapy (CBT) for the treatment of obsessive-compulsive disorder (OCD) on the intimate partners of patients. Previous research has shown this intervention to be efficacious in reducing OCD symptoms and comorbidities in patients.MethodIn an open-treatment trial, 16 couples completed the 16-session manualized treatment, and were followed up 6- and 12-months post-treatment.ResultsMultilevel modeling analyses were conducted to examine change over time, and results indicated that relative to baseline, partners showed improvements in relationship functioning, communication, and criticalness in the short-term, and maintained their gains in communication skills over the long-term.LimitationsThe non-controlled design and small sample size limit the certainty of the study's findings.ConclusionsOverall, this investigation offers preliminary evidence that including intimate partners in couple-based CBT for OCD has no negative effects on partners, and in fact, can provide them with residual positive effects.     

认知行为疗法治疗儿童青少年强迫症的脑影像学研究进展

50%的成人强迫症患者在童年或青少年期已出现强迫症的早期症状,及早干预可有效降低成人强迫症的患病率。认知行为疗法（cognitive behavioral therapy, CBT）是有效治疗儿童青少年强迫症的心理疗法之一,但目前其治疗机制尚未明确。近年来,脑影像学发展迅速,为探究CBT治疗的脑机制提供了重要的神经影像...     

Effects of behavioral therapy or pharmacotherapy on brain glucose metabolism in subjects with obsessive-compulsive disorder as assessed by brain FDG PET

This prospective study investigated the effect of pharmacotherapy (PT) and cognitive behavioral therapy (CBT) on cerebral glucose metabolism in adults with obsessive-compulsive disorder (OCD). Dynamic positron emission tomography (PET) of the brain with F-18-fluorodeoxyglucose (FDG) was performed before and after treatment in 16 subjects diagnosed for OCD for at least 2 years (PT: n=7). Pre-to-post-treatment change of scaled local metabolic rate of glucose (SLMRGlc) was assessed separately in therapy responders and non-responders. Correlation was tested between SLMRGlc change and change of OCD, depression, or anxiety symptoms. SLMRGlc increased in the right caudate after successful therapy. The increase tended to correlate with the improvement of OCD symptom severity. The finding of increased local caudate activity after successful therapy is in contrast to most previous studies. Possible explanations include effects of therapy on concomitant depression symptoms and/or the large proportion of early-onset OCD in the present sample.     

Treatment-resistant Obsessive-compulsive Disorder in Young People: Assessment and Treatment Strategies

Cognitive behaviour therapy (CBT) and selective serotonin reuptake inhibitors have both been established as effective interventions for paediatric obsessive-compulsive disorder (OCD), with CBT being the recommended first-line treatment in most cases. While the majority of young people respond well to these treatments, a significant proportion remain symptomatic. Although the research on treatment-resistant OCD remains limited, increasing empirical attention is being paid to predictors of treatment outcome in young people with OCD, and efforts are being made to identify the factors that hinder recovery. This article outlines potential barriers in treatment and highlights strategies for optimising outcome, with particular focus on cognitive behavioural techniques.     

Tics moderate treatment outcome with sertraline but not cognitive-behavior therapy in pediatric obsessive-compulsive disorder.

BACKGROUND: The presence of a comorbid tic disorder may predict a poorer outcome in the acute treatment of pediatric obsessive-compulsive disorder (OCD). METHODS: Using data from the National Institute of Mental Health (NIMH)-funded Pediatric OCD Treatment Study (POTS) that compared cognitive-behavior therapy (CBT), medical management with sertraline (SER), and the combination of CBT and SER (COMB), to pill placebo (PBO) in children and adolescents with OCD, we asked whether the presence of a comorbid tic disorder influenced symptom reduction on the Children's Yale-Brown Obsessive Compulsive Scale (CY-BOCS) after 12 weeks of treatment. RESULTS: Fifteen percent (17 of 112) of patients exhibited a comorbid tic disorder. In patients without tics, results replicated previously published intent-to-treat outcomes: COMB > CBT > SER > PBO. In patients with a comorbid tic disorder, SER did not differ from PBO, while COMB remained superior to CBT and CBT remained superior to PBO. CONCLUSIONS: In contrast to CBT outcomes, which are not differentially impacted, tic disorders appear to adversely impact the outcome of medication management of pediatric OCD. Children and adolescents with obsessive-compulsive disorder and a comorbid tic disorder should begin treatment with cognitive-behavior therapy alone or the combination of cognitive-behavior therapy plus a serotonin reuptake inhibitor.     

Nonpharmacological treatments for anxiety disorders

An evidence-based review of nonpharmacological treatments for anxiety disorders is presented. The vast majority of the controlled research is devoted to cognitive behavior therapy (CBT) and shows its efficiency and effectiveness in all the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) anxiety disorders in meta-analyses. Relaxation, psychoanalytic therapies, Rogerian nondirective therapy, hypnotherapy and supportive therapy were examined in a few controlled studies, which preclude any definite conclusion about their effectiveness in specific phobias, agoraphobia, panic disorder, obsessive-compulsive disorder (OCD), and posttraumatic stress disorder (PTSD), CBT was clearly better than psychoanalytic therapy in generalized anxiety disorder (GAD) and performance anxiety Psychological debriefing for PTSD appeared detrimental to the patients in one high-quality meta-analysis. Uncontrolled studies of psychosurgery techniques for intractable OCD demonstrated a limited success and detrimental side effects. The same was true for sympathectomy in ereutophobia. Transcranial neurostimulation for OCD is under preliminary study. The theoretical and practical problems of CBT dissemination are discussed.     

Cognitive-behavioral therapy for obsessive-compulsive disorder: a non-randomized comparison of intensive and weekly approaches

This study examined the relative efficacy of intensive versus weekly cognitive-behavioral therapy (CBT) for adults with obsessive-compulsive disorder (OCD). Sixty-two adults with OCD received either 14 sessions of weekly (n=30) or intensive CBT (n=32; daily psychotherapy sessions) in a non-randomized format. Assessments were conducted at Pre-treatment, Post-treatment, and 3-month Follow-up by raters who were blind to treatment group at the Pre-treatment assessment. Intensive and weekly CBT were similar in efficacy at Post-treatment and Follow-up and associated with large treatment effect sizes. Since many people with OCD do not have access to trained CBT providers, intensive treatment may be a viable option in such cases.     

Cognitive behavioral treatment for young children with obsessive-compulsive disorder.

Obsessive-compulsive disorder (OCD) is a distressing and functionally impairing disorder that can emerge as early as age 4. Cognitive behavior therapy (CBT) for OCD in youth shows great promise for amelioration of symptoms and associated functional impairment. However, the empirical evidence base for the efficacy of CBT in youth has some significant limitations, particularly as related to treating the very young child with OCD. This report includes a quantitative review of existing child CBT studies to evaluate evidence for the efficacy of CBT for OCD. It identifies gaps in the literature that, when addressed, would enhance the understanding of effective treatment in pediatric OCD. Finally, it presents a proposed research agenda for addressing the unique concerns of the young child with OCD.