TORONTO – Childhood obsessive-compulsive disorder often responds very well to an intense course of cognitive-behavioral therapy with an emphasis on exposure and response prevention.
Unfortunately, up to 5 million patients in the United States and Canada are not receiving complete treatment for their OCD, because few clinicians are trained in this kind of therapeutic approach, Eric A. Storch, Ph.D., said at the joint annual meeting of the American Academy of Child and Adolescent Psychiatry and the Canadian Academy of Child and Adolescent Psychiatry.
“There's definitely a lack of training in this area,” said Dr. Storch of the University of Florida, Gainesville. “Some therapists are also reluctant to even try it. But to the question, 'Does CBT work for OCD?' the answer is a resounding yes.”
Three randomized controlled trials have shown the effectiveness of exposure and response prevention (ERP) techniques, he said. A 1998 trial included 22 children aged 8–18 years who were randomly assigned to ERP or clomipramine for 12 weeks. Those on ERP showed an average improvement of almost 60%, compared with a 33% improvement for those in the medication arm (J. Am. Acad. Child Adolesc. Psychiatry 1998;37:1022–9).
One of the 2004 studies randomized 77 children aged 7–17 years to individual or group cognitive-behavioral family-based therapy or a 4–6 week wait list. The children in both therapy groups improved similarly, with symptom reductions of more than 60%, while symptoms increased slightly in the wait-list group (J. Am. Acad. Child Adolesc. Psychiatry 2004;43:46–62). A study of 48 patients aged 8–19 years old by several of the same researchers also found that treatment gains were maintained; 70% of subjects in individual therapy and 84% in group therapy were diagnosis free at a follow-up of 12–18 months (J. Am. Acad. Child Adolesc. Psychiatry 2005;44:1005–14).
The Pediatric OCD Treatment Study, also published in 2004, randomized 112 children aged 7–17 years to CBT alone, sertraline alone, combined CBT and sertraline, or placebo for 12 weeks. Rates of remission were 54% in the combination group, 39% in the CBT group, and 21% in the sertraline only group (JAMA 2004;292:1969–76).
Dr. Storch is now conducting his own trial. It includes 31 children aged 7–17 years, who were randomized to intensive CBT (14 sessions in 3 weeks) or 14 weekly CBT sessions. Preliminary findings indicate a greater improvement in the intensive CBT group (94%) than inthe weekly group (67%).
Up to 80% of OCD has a childhood onset, Dr. Storch said. Without treatment, these children face a life of disruptive thoughts and behaviors. “It doesn't remit,” he said. “There is tremendous impairment: Grades drop, kids get picked on, and the family is affected.”
In OCD, a neutral object becomes associated with increasing anxiety, he said. The patient develops rituals to decrease his anxiety level. “The rituals start small, but they grow exponentially because the patient becomes tolerant to them. In order to maintain the same reduction in stress, the rituals have to become more complex.”
Exposure and response prevention therapy aims to decrease the anxiety associated with the thought by exposing patients to whatever provokes the associated ritual, while asking them to refrain from engaging in the ritual. “Not doing so causes the anxiety to gradually and naturally decrease,” Dr. Storch said.
Each ritual must be extinguished completely before moving on to the next. It's best to start out with the smallest one and then tackle the more difficult ones, he said. “We'll say, for example, 'Don't check the faucet when you go out, but you can still do all your other things.' The key, however, is you can't progress until this one thing is mastered.”
Although actually refraining from the ritual is most effective, patients can also practice refraining in their imaginations. “Duration and frequency are important. If you can expose them for long periods frequently, you will have better results.”
Cognitive restructuring is another component of the treatment, Dr. Storch said.
“OCD arises from inaccurate beliefs about stimuli. The aim is to teach the patient to identify and correct anxiety-provoking thoughts that motivate compulsive behaviors–to help them identify the thought and then appraise it accurately,” he explained. Common cognitive errors are doubt (“I can't remember if I locked my door”); fusion of thought and action (“If I think about something, it must mean I want to do it”); catastrophic thinking (“I'll get sick and die if I go near sick people without washing up”); and responsibility (“If my mom gets cancer, it will be my fault”).
Dr. Storch addresses these cognitive errors by asking patients to keep a thought record. The document consists of recording the action, the thought that came with it, the accompanying anxiety or fear level, and the resulting ritual.