Reduction of subjective distress in CBT for childhood OCD: Nature of change,predictors, and relation to treatment outcome

Little research has investigated changes in subjective distress during cognitive-behavioral therapy (CBT) for anxiety disorders in youth. In the current study, 40 youth diagnosed with primary obsessive-compulsive disorder (OCD; M age = 11.9 years, 60% male, 80% Caucasian) and 36 parent informants completed separate weekly ratings of child distress for each OC symptom during a 12-session course of CBT. Between-session changes in distress were calculated at the start of, on average throughout, and at the end of treatment. On average throughout treatment, child- and parent-reported decreases in child distress were significant. Baseline OCD severity, functional impairment, and internalizing symptoms predicted degree of change in child distress. Additionally, greater decreases in child distress were predictive of more improved clinical outcomes. Findings advance our understanding of the strengths and limitations of this clinical tool. Future studies should examine youth distress change between and within CBT sessions across both subjective and psychophysiological levels of analysis.     

Longitudinal trajectory and predictors of change in family accommodation during exposure therapy for pediatric OCD

Family accommodation (FA) is key in the maintenance of OCD. However, most studies are cross-sectional, and have not identified long-term trajectories and correlates of FA changes over treatment. This study investigated changes in clinician-rated FA over 10 sessions of cognitive behavioral therapy (CBT) for 142 children with OCD, as well as several key predictors/correlates: (a) clinician-rated OCD symptom severity, (b) child- and parent-rated functional impairment, (c) parent-rated treatment expectancies, and (d) child- and parent-rated therapeutic alliance. Multi-level models indicated that FA changed significantly during treatment, with gains maintained over 6-months. Baseline clinician-rated OCD severity did not predict changes in FA. Significant interactions indicated that children with higher child- and parent-rated impairment exhibited greater FA improvements over treatment (versus children with lower impairment). Child- and parent-rated therapeutic alliance and parent-rated expectancies did not predict FA changes. Finally, FA mediated the relationship between OCD severity and parent- (but not child-) rated impairment. Reverse mediation models were also significant. Findings indicate that CBT can successfully reduce FA (a) even if children experience high OCD severity and interference in school, relationships, and family life, and (b) regardless of non-specific factors like treatment expectancies and alliance. FA reductions are an important mechanism mediating treatment response.     

Outcomes of Cognitive Behaviour Therapy for Obsessive Compulsive Disorder in a Clinical Setting: A 10-Year Experience from a Specialist OCD Service for Children and Adolescents

Controlled studies show that cognitive behavior therapy (CBT) is an efficacious treatment for young people with obsessive compulsive disorder (OCD). More evidence is needed for effectiveness in clinical settings. We conducted a case note review of 318 patients attending an OCD clinic. Outcomes for 75 patients who received treatment in the clinic were analysed. Following acute treatment, total CYBOCS (Children Yale-Brown Obsessive Compulsive Scale) score was significantly reduced (22.6 to 10.9, p  = .0001). Gains were maintained at long-term follow-up. Our results suggest that CBT is an effective treatment for child and adolescent OCD delivered in a clinical setting.     

Evidence for successful implementation of exposure and response prevention in a naturalistic group format for pediatric OCD

Background: Although exposure and response prevention (ERP) is an effective treatment for youth with obsessive–compulsive disorder (OCD), the majority of studies, randomized clinical trials of individual therapy, find variability in treatment response. We evaluated the potential role of individual differences in OCD presentation, comorbid disorders, age, and gender on treatment effects. Moreover, we examined these potential effects in a group format in a naturalistic, clinic‐based sample of patients. Methods: Pediatric patients with a DSM‐IV diagnosis of OCD ( n =41) were treated with ERP in an intensive outpatient community‐based program. OCD, mood, and anxiety symptom severity was measured at baseline, during treatment, and at discharge. Trajectories and predictors of treatment outcome were measured using linear growth models. Results: We found that group‐based ERP was effective in reducing pediatric OCD symptom severity in a naturalistic treatment setting irrespective of age or gender. Furthermore, ERP was found to be effective at reducing depressive symptoms but not other anxiety symptoms. We also found inter‐individual variability in the discharge levels of contamination, symmetry, and intrusive sexual thoughts and in the rate of severity reduction of intrusive sexual thoughts. Conclusion: Group‐based ERP is an effective treatment for children and adolescents with OCD. Several factors, including symptom dimensions and comorbid psychopathology, are associated with treatment response and outcome in this pediatric population. Depression and Anxiety, 2011. © 2011 Wiley‐Liss, Inc.     

A pilot study of intensive 7-day internet-based cognitive behavioral therapy for social anxiety disorder

Accessible, affordable cognitive behavioral therapy (CBT) options for Social Anxiety Disorder (SAD) that allow for rapid symptom improvement are needed. The present study investigated the first intensive, 7-day internet-based CBT for SAD. An open pilot trial was conducted to test the acceptability, feasibility and preliminary outcomes of the program in a sample of 16 participants (9 females, M age = 40.34, SD = 10.55) with a DSM-5 diagnosis of SAD. Participants were enrolled into the 6-lesson online program, and completed the Social Phobia Scale [SPS], Social Interaction Anxiety Scale [SIAS], Patient Health Questionnaire-9 (PHQ-9), and Work and Social Adjustment Scale (WSAS) at baseline, post and one month follow-up. We found support for the feasibility and acceptability of the program; 15 participants (93.8%) completed the program, and all participants reported the program was satisfactory. Large, significant reductions in social anxiety severity on both the SPS and SIAS (Hedges’ g_s = 1.26–1.9) and functional impairment (WSAS; g_s = 0.88–0.98) were found at post-treatment and follow-up. Medium, significant reductions in depressive symptom severity were also found (g_s = 0.88–0.98 at post and follow-up, respectively). A third of participants scored below the clinical cut-off on both the SPS and SIAS at post-treatment and follow-up. A randomized controlled trial with longer follow-up is needed to evaluate the efficacy of this intensive internet-based treatment for SAD. Implications and future research directions are discussed.     

Evidence Based Research in CBT with Adolescent Eating Disorders

Cognitive behaviour therapy (CBT) is increasingly becoming the treatment of choice for a number of adolescent mental health problems, including depression ( Harrington et al., 1998 ) and obsessive compulsive disorder (OCD), ( March, 1995 ). In considering the role of CBT in the treatment of adolescent eating disorders, it is helpful to review the phenomenology of anorexia and bulimia nervosa in this age group and to assess the theoretical relevance of a cognitive behavioural approach to their management. The evidence base has been reviewed in the recently published National Institute of Clinical Excellence (NICE) Guidelines on the treatment of eating disorders ( NICE, 2004 ). To date, CBT approaches have not been widely tested in controlled trials in this age group. However, a randomised controlled treatment trial is under way in the North West of England (The TOuCAN Trial), in which CBT is an important component of one of the interventions being studied and this will be described.     

The therapeutic alliance in the cognitive behavioral treatment of pediatric obsessive-compulsive disorder

Although cognitive-behavioral therapy (CBT) for pediatric obsessive–compulsive disorder (OCD) is considered a first-line treatment, not all youth have a positive treatment response, suggesting need for investigating factors that may enhance or reduce treatment effects. Few studies have investigated predictors of treatment response in pediatric OCD, and there is an absence of studies examining the influence of treatment process variables (e.g., therapeutic alliance [TA]) on treatment outcome. Using a multiple-informant and multiple-time point design, the current study examined the role of the TA in family-based CBT for pediatric OCD. Analyses examined (1) the predictive value of the TA on OCD symptom reduction and (2) whether changes in the TA over time predict treatment response. Findings indicated that (1) stronger child-rated, parent-rated, and therapist-rated TAs were predictive of better treatment outcome and (2) larger and more positive early alliance shifts (as rated by changes in child-rated TA between sessions 1 and 5) were predictive of better treatment outcome. Implications for the treatment of youth with OCD within family-based CBT are discussed.     

Evaluation of exposure with response-prevention for obsessive compulsive disorder in childhood and adolescence

The present study was undertaken to estimate the effect of exposure plus response-prevention (E/RP), delivered alone intensively over 5-weeks and without concomitant pharmacotherapy, for children and adolescents with OCD. Twenty children and adolescents with OCD, not receiving medication for this condition, were randomized to E/RP or a wait-list condition. Statistically and clinically significant symptomatic improvement was found in the E/RP group compared with controls, with improvement maintained at follow-up an average of 14 weeks later. Effect size in the main intention-to-treat analysis was 1.23 and in the secondary per protocol analysis was 1.64. This study lends further support to the view that E/RP is an effective treatment for childhood OCD.     

The Dental Cognitions Questionnaire in CBT for dental phobia in an adolescent with multiple phobias

A case of an adolescent boy with multiple phobias who was treated successfully for his dental phobia is described to illustrate the clinical utility of the Dental Cognitions Questionnaire (DCQ) in aiding effective cognitive-behavior therapy. The client showed drops in dental anxiety that coincided with the use of the DCQ in cognitive restructuring, and there was a close correlation between dental cognitions and degree of dental anxiety over the time-course of therapy and follow up.     

Quality of life with OCD. A self-reported survey among members of the Danish OCD association

Obsessive–compulsive disorder (OCD) is today the fourth most frequent diagnosis issued within psychiatry. OCD can be quite incapacitating for the affected person and often becomes chronic. The purpose of the present study has been to help illuminate the character of the quality of life among the members of the Danish OCD Association. The data was compiled from 406 questionnaires sent out to all those members of the Danish OCD Association who had reported to suffer from OCD. The level of response was 54.4%. Persons with OCD signalled striking influences on their academic, occupational and social functions and thereby a corresponding influence on their quality of life in general. Emerging were significant levels of comorbidity and suicidal tendency. The time interval between symptom onset and the establishment of a correct diagnosis was found to be 13?years in average in this study. There appeared to be a marked tardiness in treatment as a consequence of the latency period between onset of symptoms and the establishment of a diagnosis. This has proven to be of importance in relation to the provision of proper treatment, the developmental course of the OCD condition, and not least in the quality of life for the person with OCD as well as his/her family members.     

Exposure plus response prevention versus exposure plus safety behaviours in reducing feelings of contamination, fear, danger and disgust. An extended replication of Rachman, Shafran, Radomsky & Zysk (2011)

Background and objectives

Safety behaviours are widely held to impede the beneficial effects of exposure, certainly in OCD. Recently, Rachman, Radomsky, Shafran, and Zysk (2011) challenged this view. Healthy volunteers repeatedly touched a contaminant in two sessions. Half of the participants did not engage in safety behaviours after touching (exposure + response prevention), while the other half did (exposure + safety behaviours, i.e., cleaning hands with a hygienic wipe). Scores of contamination, fear, danger, and disgust decreased in both sessions and the effects were not impeded by safety behaviours. Three potential artefacts were identified in the Rachman et al. study: a no-treatment control group was lacking, the stop rules for ending exposure differed between conditions, and positive expectations may have been induced in the safety behaviours group. We tried to critically replicate the main findings.

Method

The Rachman et al. (2011) study was replicated, with 44 volunteers but stop rules and expectations were similar between treatments, and effects were also assessed in a no-intervention control group.

Results

Relative to the control condition, both exposure interventions induced reliable decreases in feelings of contamination, fear, danger, and disgust. The decline followed an exponential curve with the largest gains at the first trials of each session.

Limitations

Findings were obtained from a non-clinical sample.

Conclusion

The findings attest to the robustness of the Rachman et al. findings, and challenge the notion that safety behaviours should be dismissed categorically in exposure treatments.     

Developmental and clinical predictors of comorbidity for youth with obsessive compulsive disorder

ObjectiveTo date, few studies of childhood obsessive compulsive disorder (OCD) have been adequately powered to examine patterns and predictors of comorbidity, despite the frequency with which it occurs. We address this gap, drawing on a large sample of youth with OCD who were systematically assessed through research and clinical programs in a university-based specialty program for children and adolescents with OCD. We examine patterns of comorbidity across different epochs of development and predict specific classes of OCD (comorbidity internalizing/externalizing/both) from key demographic and clinical variables that may be useful in guiding individualized treatment.MethodA total of 322 youths (mean age = 12.28, 53% male) were assessed using the Anxiety Disorders Interview Schedule (ADIS; Silverman and Albano, 1996), the Children's Yale Brown Obsessive Compulsive Scale (CYBOCS; Scahill et al., 1997) and other standardized measures.ResultsConsistent with prior research, 50% of youth met criteria for a co-occurring anxiety or depressive disorder. Rates of externalizing disorders were lower (16%). Developmental differences emerged such that older youth met criteria for a higher number of co-occurring disorders. As expected, adolescents in particular were more likely to have a co-occurring internalizing disorder compared to early or pre-adolescent peers. Surprisingly, they were also more likely to have a comorbid externalizing disorder. Developmental trends were particularly striking with respect to depression, with adolescents with OCD demonstrating a six-fold greater likelihood of co-occurring depressive disorder compared to younger counterparts.DiscussionClinical implications are discussed with eye toward tailoring interventions, particularly during the transition to adolescence when youth are at heightened risk for depression.     

Efficacy of a prevention program for postpartum obsessive-compulsive symptoms

Obsessive-Compulsive Disorder (OCD) has emerged as a common and impairing postpartum condition. Prospective studies have identified psychological vulnerabilities for the emergence of postpartum obsessive-compulsive symptoms (OCS), including general anxiety symptoms, pre-existing OCS, and specific cognitive distortions. The identification of these factors makes feasible the development of prevention programs that could reduce the impact of postpartum OCS. The present investigation examined a cognitive-behavioral prevention program using a randomized, double blind, controlled trial. Expecting mothers in their 2nd or 3rd trimester with an empirically established, malleable risk factor for postpartum OCS received either the prevention program (N = 38) or a credible control program (N = 33), both of which were incorporated into traditional childbirth education classes. Results revealed that at 1 month, 3 months, and 6 months postpartum, the prevention program was associated with significantly lower levels of obsessions and compulsions than was the control condition (all p’s < 0.05). Group differences remained significant even after controlling for baseline OCS and depression symptoms. Those in the prevention condition also reported decreasing levels of cognitive distortions, in contrast to the control condition (p’s < 0.05). Results support the potential utility of incorporating a CBT-based OCS prevention program into childbirth education classes.     

COVID-19 and OCD: Potential impact of exposure and response prevention therapy

This brief clinical review critically assesses the use of exposure and response prevention therapy (ERP) for patients with obsessive-compulsive disorder (OCD) in light of the COVID-19 pandemic. We discuss the ethical and practical considerations that clinicians employed in past infectious disease outbreaks, as well as general safety measures routinely practiced in the conduct of exposure therapy. During this time, concerns regarding the feasibility of ERP have emerged, especially with strict guidelines on social distancing and on following other preventative behaviors. While ERP may have to be modified to follow public health guidelines, this review outlines a) how ERP has been adapted in the context of other infectious triggers; b) the potential impacts on OCD patients of attenuated ERP, and c) minimizing concerns related to litigation. A case report is provided detailing ERP personalized given COVID-19 related considerations. In all, we advise against modifying therapies in ways that may jeopardize the efficacy of patient care or progress.     

Internet-delivered exposure therapy versus internet-delivered cognitive behavioral therapy for panic disorder: A pilot randomized controlled trial

AimTo compare the efficacy and acceptability of internet-delivered exposure therapy for panic disorder, to multi-component internet-delivered cognitive behavioral therapy (iCBT) that included controlled breathing, cognitive restructuring and exposure.MethodsParticipants with panic disorder, with or without agoraphobia, were randomized to internet-delivered exposure therapy (n = 35) or iCBT (n = 34). Both programs were clinician guided, with six lessons delivered over eight weeks. Outcomes included panic disorder and agoraphobia symptom severity, as well as depression symptom severity, functional impairment and days out of role.ResultsParticipants in both conditions displayed a large reduction in panic disorder symptom severity (ds >1.30) from pre- to post-treatment. Participants in both conditions displayed medium to large reduction in agoraphobia and depression symptom severity, functional impairment and days out of role. Effects were maintained at three- and six-month follow-up. There was no significant difference between the interventions in clinical outcomes, adherence or treatment satisfaction.ConclusionsInternet-delivered exposure therapy appeared to be as acceptable and efficacious as more established iCBT, despite including less strategies. However, a fully powered replication is now needed to compare the two approaches.     

How to treat OCD in patients with Tourette syndrome

Obsessive-compulsive disorder (OCD) constitutes an etiologically heterogeneous set of conditions, including a subtype that seems etiologically related to Tourette syndrome (TS). In order to treat OCD patients optimally, the clinician needs to integrate educational, psychological and pharmacological approaches. The most effective psychological intervention is cognitive-behavior therapy (CBT). Drug treatment includes clomipramine and all selective serotonin reuptake inhibitors (SSRIs). A subgroup of OCD patients, however, shows no significant improvement. Few studies suggest that the presence of tics is associated to a worse treatment response to SSRIs and that such patients benefit from combined therapy of serotonin-reuptake inhibitors plus neuroleptics. Independently of the presence of tics, there are several different augmentation strategies for resistant cases with drugs that interfere in the dopamine, serotonin, opioid and gonadal hormone systems. In addition, new therapies are now being tested against presumed postinfectious autoimmune processes. Finally, new developments are promising in neural circuit-based therapies, including neurosurgery for refractory patients.