Download Child and Adolescent Psychopathology

Chapter 23:
Obsessive-Compulsive Disorder
and Trichotillomania
Jennifer Cowie
Michelle Clementi
Deborah C. Beidel
Candice A. Alfano
Overview
 DSM-5 changes
 Obsessive-Compulsive and Related Disorders category
 Includes OCD and Trichotillomania (TTM)
 OCD and TTM may be related due to:
 1) Presence of repetitive behavior
 2) Similar response to pharmacological treatments
 3) Higher than expected rates of TTM among relatives of OCD
patients and vice versa
 Relationship between the two disorders is not clear
OCD
 Prevalence: 2–3% by late adolescence (Zohar, 1999)
 Average age onset: 10 years old
 Range 5–18 years
 Core features: obsessions and compulsions
 Obsessions: intrusive, unwanted thoughts or feelings that create
significant distress
 Compulsions: ritualistic behaviors performed in an effort to relieve
distress
 When only one component is present, children (relative to
adolescents) are more likely to present with compulsions
rather than obsessions
Trichotillomania
 Defined: recurrent pulling out of one’s hair
 Lifetime prevalence rate: 0.6% in adults
 Hair pulling often occurs in conjunction with:
 Negative emotions (e.g., stress, irritation, doubt)
 When the individual is sitting alone (e.g., doing homework)
 After significant life events (e.g., starting school)
 Two subtypes of hair pulling:
 “Focused”: Hair pulling occurs under conscious awareness
 “Autonomic”: Hair pulling occurs outside of awareness (e.g.,
during sedentary or mindless activities, such as watching TV)
TTM
 Survey of 133 youths with TTM aged 10 to 17 found
that most common sites of hair pulling are:
 Scalp (86%), eyelashes (52%), eyebrows (38%), pubic region
(27%), legs (18%), arms (9%)
 Some children eat the hair
 In certain instances, hair pulling co-occurs with thumb
sucking
 Mean age onset: early to midadolescence (Duke et al.,
2009)
Psychosocial Treatment for OCD
 CBT consisting of exposure and response prevention
(ERP) is the treatment of choice for children and
adolescents with OCD
 Goal of ERP is to weaken associations between
obsession and anxiety, and between compulsions and
experiencing anxiety relief
 Exposure hierarchy developed: begins with easier
tasks and works up to more challenging tasks
 Exposures should not be discontinued until the child’s SUDS
ratings have decreased by at least 50% from the peak anxiety
rating
Exposures
 In vivo exposures: Child confronts the feared stimulus
 For example by touching an item believed to be contaminated
 To promote generalization, exposures can be conducted outside of
sessions in other anxiety-provoking settings (e.g., school, home)
 Imaginal exposures: may be necessary when obsessions
include inappropriate content or are not easily reproduced in the
treatment setting
 Exposures that are more vivid and realistic are more effective
(Piacentini et al., 1994)
 Research examining efficacy of ERP indicates that exposure is
the most critical component in the treatment of pediatric OCD
Cognitive Restructuring
 Consists of identifying and relabeling obsessive
thoughts in order to achieve some “distancing” from
OCD symptoms
 E.g., “I’m not really going to make my mom die if I don’t say
good-bye to her. It’s just my OCD talking.”
 Behavioral experiments can be useful to test the
veracity of thoughts directly (i.e., testing the power of a
thought to make something happen)
 Cognitive restructuring can help some children cope
with extreme anxiety during difficult exposures
Other Components
of CBT for OCD
 Psychoeducation: OCD described as a neurobiological disorder
using a medical model; symptoms viewed as external from the
child
 Anxiety management techniques: includes diaphragmatic
breathing, progressive muscle relaxation, constructive self-talk,
humorous visualizations (e.g., picturing OCD as a funny cartoon
character)
 Contingency management: rewarding a child for attempting or
completing in-session exposures or homework
 Relapse prevention: any unrealistic expectations are addressed
(e.g., belief that symptoms will completely disappear)
Psychosocial and Pharmacological
Treatments for OCD
 SSRIs (e.g., fluoxetine, fluvoxamine) commonly used to treat pediatric
OCD (Geller et al., 2003)
 Children treated with SSRIs report reduced symptoms, but often
symptoms still remain severe enough to meet most clinical trials’
entrance criteria (March et al., 2004)
 33% fail to benefit from pharmacotherapy alone
 Children who receive combined CBT and pharmacotherapy (i.e.,
sertraline) showed significant greater reduction in symptoms than those
treated with CBT or medication alone
 Psychosocial interventions are first line of treatment for pediatric OCD
 Pharmacological interventions recommended in combination with CBT for more
severe cases of the illness (Geller & March, 2012)
Treatment for Trichotillomania
 Behavioral therapy (BT) with habit reversal training
(HRT) for treating adults with TTM is well established
 Studies for BT in children with TTM are limited
 Some success in children with a range of
traditional BT:
 Overcorrection: engage in positive practice of having children
comb or brush their hair
 Annoyance review: having children acknowledge the
problematic nature of hair pulling and their reasons for wanting
to stop
 Differential reinforcement of other behavior: giving the child
attention only when pulling behavior is absent
Parent Involvement: OCD
 Parents and siblings often accommodate a child’s
ritualistic behavior
 Reinforce a child’s irrational belief and may undermine
therapy
 Parental involvement in symptoms has been found
to be related to greater symptom severity (Bipeta
et al., 2013)
 Parent components have been added to CBT
trials; however, no clear findings determined
Parent Involvement: TTM
 Parents critical to success
 During awareness training of HRT, parents play
essential role in assisting with identification of pulling
behavior
 Parents may unintentionally reinforce pulling behavior
by providing negative attention or access to tangible
items
 Important to assist parent in utilizing consistent reinforcement
 Family conflict and parental frustration can confound
treatment outcome
Adaptations and Modifications:
OCD
 Psychosocial interventions can be modified for younger
children with OCD
 Children as young as 5 can be treated with evidence-based
approaches (March et al., 2004)
 Make developmentally driven modifications
 E.g., many young children have difficulty fully understanding the
rationale of exposure tasks, so psychoeducation can be conducted
separately with the parent to ensure parental understanding of
treatment
 Comorbid diagnoses: may attenuate treatment response
 Group-based or technology-based treatments
Intensive Treatments OCD
 Youth with treatment-resistant OCD may benefit
from more intensive treatments
 Example: Bjorgvinsson and colleagues (2008)
studied 23 adolescents with treatment-resistant
OCD
 Treatment: medication management and 90-minute ERP
sessions followed by 60 minutes of self-directed
exposures; at three evenings per week
 Results: significant reductions in obsessions,
compulsions, state and trait anxiety
Adaptation and Modification:
TTM
 Selection of specific intervention components
dependent on the child’s age
 E.g., cognitive strategies may be more appropriate for
older children and adolescents whereas younger children
may be more motivated by rewards
 To increase likelihood of compliance:
 1) Keep the self-monitoring as simple as possible (no
more than one page per day)
 2) Small rewards for completion of self-monitoring and/or
behavioral assignments
Assessment: OCD
 Diagnostic interviews, clinician ratings, child and parent report, self-
monitoring, behavioral assessment
 Depending on the child’s age, diagnostic and clinical interviews might be
conducted privately with adolescents but in the presence of parents for younger
children
 Treatment effects often measured with semistructured interviews and clinician
ratings scales (e.g., ADIS, CY-BOCS)
 Self-report: LOI-CV, COIS-R
 Parent-report: COIS-R
 Behavioral avoidance tests (BATs): used to provide objective
assessment of OCD symptoms
 Self-monitoring
Assessment: TTM
 No “gold standard” for assessing TTM
 Most tools designs for adult populations
 E.g., NIMH Trichotillomania Impairment Scale
 Diagnostic interviews: NIMH Diagnostic Interview
Schedule for Children specifically assesses for TTM in
pediatric populations
 Self-monitoring procedures can be implemented to
gauge treatment success related to changes in hair
pulling urges and frequency
Clinical Case: OCD
 Mark: 12-year-old boy
 Referred for evaluation of compulsive behaviors:
excessive hand washing, needing to touch objects,
complete rituals in symmetry
 Treatment plan: imaginal and in vivo exposure with
response prevention
 Outcome: 14 clinic sessions and homework
assignments; rituals decreased to less than 5 minutes
per day and obsessions less then 10 minutes per day
Clinical Case: Melanie
 6-year-old girl
 Presenting issues: chronic hair pulling, tends to suck
thumb at night while pulling her hair
 Treatment plan: psychoeducation about TTM,
eliminating attention for hair pulling, hourly sticker plan
 Outcome: Measured by counting the number of hairs
pulled daily, self-monitoring data useful in determining
the efficacy of the program and when to make
alterations