What is obsessive-compulsive disorder (OCD)? - Chapter 18

What is this chapter about?

Obsessive compulsive disorder (OCD) is characterized by at least one irrational obsession (intrusive thoughts, images associated with a lot of stress) or compulsion (routine behaviours or mental acts that a person has to perform to feel good again), but often both are present. The first symptoms are often visible in childhood. Between 1% and 3% of children and adolescents suffer from OCD. Clinical interviews, questionnaires, mapping of the overall psychosocial functioning and functioning of the family are all part of the diagnostic process.

Both CBT and drug treatments based on SSRIs (selective serotine reuptake inhibitors) are effective in treating OCD in young people. CBT is the first choice of treatment. In children and adolescents, the obsessions are often aggressive, and obsessions are more likely to be sexual and religious in adults. Depending on the level of development, each child will experience and describe symptoms differently. Since children are more oriented in the present, they are often less motivated to perform difficult tasks that will be beneficial on the long term. The extent to which the family adapts to their child's disorder (participating in rituals, promoting or tolerating difficult situations) is associated with the severity of symptoms and the degree of clinical restrictions. Because often one parent is more involved in the disorder than the other and deals with it in a different way, this is often a source of a lot of relational stress.

How does OCD develop in young children?

There are several factors that contribute to the development of OCD in young people:

• Genetic vulnerability: In childhood OCD, the genetic factor (primary family) plays a greater role than in adulthood.
• Negative life events can trigger OCD.
• Parenting style: at least one parent of a child with OCD often has difficulty expressing warmth/affection, is overprotective, and/or demanding. Parents have less confidence in their child's skills, use less positive problem solving techniques and very little promote their child's independence. The stress experienced by the parents through the OCD is associated with the intensity of the symptoms and the degree of internalizing and externalizing problems.
• Psychopathology in the parents: it is difficult to determine whether this is the result of having a child with OCD, or whether this is partly a cause of the OCD in the child. In any case, this will maintain the OCD in the child and should be included in the formulation. These parents clearly use more cognitive and behavioural avoidance strategies than healthy parents, which automatically promotes such strategies in the child.
• The family often plays a major role in tolerating their child's OCD and excessive involvement in the expression of symptoms. It is therefore not uncommon for parents to have their own OCD symptoms which they can model to their child.

What is comorbidity?

As many as 80% of all children with OCD have a comorbid disorder, another disorder than the OCD. This often involves a comorbid anxiety disorder, usually a GAD, a social phobia or a SAD. When there is comorbidity, there are also conflicts within the family than if a child only suffers from OCD. In addition, depression is also a common comorbid disorder: up to 45% of children with OCD suffer from depression (leading to more severe OCD symptoms and more social problems). Thus, this means that these disorders do not exist in parallel, and that there is interaction between the disorders.

What is CBT with ERP?

CBT, which works with "exposure and response prevention" (ERP) has proven effective in children and adolescents. It is not only symptom reduction, but also about improving functioning in the social domain, at school and within the family.

ERP is based on the learning theory that states that OCD is maintained by: avoiding feared situations, or by "neutralizing" any perceived hazard. In other words, the child will try to avoid the situation, and if this fails or cannot be done, then the child will deal with the fear by exhibiting certain behaviors which reduces the chance of something terrible happening (such as repeatedly washing their hands) or neutralizing the fear (for example, by counting up to 100). These behaviors lead to a direct reduction of anxiety, which promotes repetition of these behaviors. However, such avoidant or neutralising behaviours do not teach the child that the fear is not so bad in reality. ERP guides the child in confronting the feared situation, without being allowed to neutralize the fear. This requires a lot of motivation/perseverance from the child. ERP is therefore associated with a high level of drop-out. Therefore, behavioural aspects of ERP are implemented in the CBT treatment, and ERP is not a treatment on its own.

What are models of OCD?

According to several CBT models, OCD is mainly triggered and maintained by the child's conviction about their obsession, and their consequent response.

1. Inflated responsibility – Salkovski's model of OCD (1999). They state that the child feels overly responsible for preventing harm to himself and/or others.
2. Thought-Action-Fusion or TAF – Rachman's model of OCD (1993). Rachman argues that there are two types of TAFs underlying OCD: TAF Morality (having the intrusive thought about unacceptable behavior is morally equivalent to expressing that behavior), and TAF-Probability (thinking about a bad situation will increase the likelihood that it will happen).
3. Meta-cognitive beliefs – Well's and Papegeorgiou's model of OCD (1998). They say that obsessive thoughts are interpreted negatively because of the metacognitive beliefs about their meaning or its terrible consequences.

These models were initially developed to apply to adults with OCD, but are also all applicable to children with OCD. All models state that misinterpreting cognition is the most important perpetuating factor. In children, however, it is often the emotion and physical sensations that they misinterpret as being harmful or unacceptable.

Derisley and colleagues (2008) developed an OCD model called the "OCD staircase". This vicious circle shows how OCD is maintained and is very useful to use in practice, because it is easy to understand for children (and parents). The circle originally consists of four aspects: the obsession (and the meaning), the resulting fear, the successive compulsion and the resulting relieved feeling in the short term. For example: the door may not be locked so someone can enter (obsession) and I am responsible for their safety (meaning of the obsession). That this leads to fear, the coercive act and a feeling of relief speaks for itself. The relieved feeling reinforces the feeling that the child is responsible for safety. Derisley and colleagues assume that fear is the primary emotion, but children often indicate that it is an uncomfortable feeling, or some kind of irritation, frustration or anger, rather than fear. The vicious circle including the meaning of the emotion then consists of five aspects:

• The obsession (the chair is not straight).
• The emotion (an uncomfortable feeling, frustration).
• The meaning of the emotion (this feeling never goes away, I cannot sleep).
• Coercive act (straightening the chair).
• Feeling relieved in the short term.

This vicious circle can be extended with a semi-overlapping second vicious circle when there is a comorbid disorder (see page 283, Figure 18.4).

What are the challenges of working with young people with OCD?

According to Canavera and colleagues (2009), parents often report more severe OCD symptoms than their child (who sees the symptoms themselves as less severe). Therefore, it is often the parents who seek help for their child. If this decision is not made in accordance with the child, it will of course not benefit the involvement and motivation of the child in the treatment. Especially with the CBT for OCD symptoms it is important that the child is highly motivated, because he or she will have to do things that are very stressful and the thoughts discussed in sessions are often private and shameful for the child to discuss. To increase the child's involvement, the child may be asked to keep a diary so that he/she can see how much time the OCD is swallowing. Psycho-education can help to normalize the child's experience, so as to show that they are not unique or bad because they have annoying thoughts. This also teaches them that the intrusions are just thoughts, and so the therapist can create a healthy distance between the child and his/her thoughts. Furthermore, it teaches the parents that their behavior is likely to sustain the OCD. However, older adolescents who are more likely to experience sexual or shameful obsessions keep this as private as possible, leaving parents to not notice much of the OCD. In this case, the child and the therapist must carefully decide whether the CBT takes place on an individual basis or whether the parents are involved.

Parental involvement in the CBT has proven to be effective in adults with OCD, however, only a handful of studies have been conducted onto the effectiveness of this combination in children. The authors of the book argue that the formulation of the treatment should be drawn based on family factors.

Despite the obvious successes of CBT in the treatment of OCD, there remains a significant group of young people who do not respond to treatment. This subgroup probably developed OCD at a very young age, has a significantly deteriorated level of functioning, more severe symptoms and more comorbid problems. Their OCD is likely to become chronic. New theoretical models and associated treatments for this group should be at the top of the list for researchers in this area.

Obsessive compulsive disorder (OCD) is characterized by at least one irrational obsession (intrusive thoughts, images associated with a lot of stress) or compulsion (routine behaviours or mental acts that a person has to perform to feel good again), but often both are present. The first symptoms are often visible in childhood. Between 1% and 3% of children and adolescents suffer from OCD. Clinical interviews, questionnaires, mapping of the overall psychosocial functioning and functioning of the family are all part of the diagnostic process.