Obsessive Compulsive Disorder (25 page)

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Salkovskis, Waite and Williams

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OCD can provoke negative reactions in the sufferer and those around them when recognised.

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OCD is too often seen as untreatable.

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Treatment is scarce and difficult to access, usually with very long delays.

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The quality of CBT offered is often extremely poor.

Developmental issues

Not surprisingly, treatments for OCD in young people are a spin-off from work with adults and inevitably modifications are required, with the risk that some elements of treatment become ‘lost in translation’. By the same token, it seems likely that some entirely new elements may be required for young people in order to achieve the same goals as in adults. It almost goes without saying that development and adaptation of treatment depends on an understanding of the cognitive abilities and capacities of young people. This is not only a problem to be solved, but also an advantage to be exploited. The fact that young people are in a state of flux in terms of their beliefs and particularly open to new learning (relative to the more rigid cognitive structures of adults) is a positive factor which could be better utilised.

In terms of assessment, one of the main challenges is to determine whether obsessional thinking and compulsive behaviours reflect a variant of normal development, OCD or some other clinical problem. A thorough detailed assessment with high levels of validity is key in determining this.

Children as young as three years may be referred with repetitive behaviours and while some of these, such as head-banging or rocking themselves to sleep at night have little to do with OCD, others such as touching objects or rituals may be intended to prevent harm occurring and reflect OCD. It is all the more difficult when young people may struggle to articulate their beliefs or explain why they are carrying out certain behaviours. Clinicians need to develop ways of gathering information (including, but not confined to, asking understandable questions) in order to understand what the young person is experiencing and what treatment strategies may be most appropriate. It seems clear that the kind of beliefs which appear to motivate obsessional behaviour in adults are present in children, but that younger children find it harder to articulate them.

In general, the literature on OCD in young people does not systematic-ally distinguish between early, prepubertal onset and adolescent onset and so it still remains unclear as to whether the course and outcome of OCD in these two groups is the same. Studies on early onset OCD in people assessed in adulthood suggest that early onset is more likely to be comorbid with tic disorders (e.g. Geller
et al.
, 1998) and it may be that this is quite different to the OCD developed later on. However, most studies in this field are difficult to interpret because of sampling problems. In our clinical experience, the compulsions seen in some of our younger people may be carried out for reasons rather less obviously focused on reducing objectively serious harm (e.g. death of self or a parent), and more focused on gaining control over their environment. In the latter instance, the course of treatment has been
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rather different to other young people with OCD and some of these youngsters have gone on to develop externalising disorders, such as oppositional defiant disorder. If there are different subtypes of OCD, it is crucial that we understand them better, which in turn should have important implications for treatment. As with other types of anxiety-related avoidance, ritualising and compulsive behaviours can represent a ‘final common pathway’. For example, panic patients and patients with severe osteoporosis both tend to show agoraphobic avoidance as a result of their fear of the consequences of being out of the house; the basis of the feared catastrophe motivating avoidance is however quite different.

• We have only an incomplete understanding of how developmental issues link to the development and treatment of OCD

in young people.

• Treatments are a ‘spin-off’ from work with adults and inevitably modifications are required.

• It is likely that some entirely new elements will be needed with younger people to achieve the same goals as in adults.

Understanding thinking patterns across age ranges

We have some understanding of maintenance but little information about
the origins of OCD

A number of studies (e.g. Barrett and Healy, 2003; Libby
et al.
, 2004) suggest that the beliefs which characterise OCD in adults, such as inflated responsibility and the closely linked concept of overimportance of thoughts, are also present in young people. However, reliance on studies that pool data from young people across broad age ranges means that we are unclear as to how beliefs manifest at particular ages and how they evolve. We have much to learn about how both intrusive thoughts and their appraisals develop and everything to learn about how they begin.

It is widely recognised that most people (including young children) experience personally unacceptable intrusive thoughts, images, impulses and doubts, and it is self-evidently true that OCD develops when the young person fails to learn to disregard such intrusions. However, what is less clear is why some young people are able to disregard them and others are not. A leading view is that it relates to the young person becoming aware of their own ‘agency’; that is, once they become aware they can cause bad things to happen, it is a corollary that they have the ability to make bad things not happen by what they do. However, it is also clear that superstitious ideas (such as bad things happening if cracks in the pavement are stepped on) are common enough to be regarded as part of normal development. It may be that more fundamental beliefs and values are involved in the appraisals 140

Salkovskis, Waite and Williams

linked to the development of OCD. Identifying these is difficult in adults and likely to be more difficult still in younger age groups. Such issues are likely to be important if early intervention and prevention are to be considered.

It has been suggested that cognitive factors may be less important in younger children and that compulsions may be more habitual and driven by a physical urge. In such instances, it is suggested that a cognitive explanation may develop in an attempt to give meaning to the behaviour rather than as a motivator. We believe this conclusion is based on inappropriate assessment of cognition in young children. There is a clear need to develop more sophisticated assessment strategies appropriate to such children’s abilities to communicate the beliefs they have.

Vulnerability and aetiological factors in obsessional problems

As with other psychiatric problems, we have a great deal of data concerning factors associated with OCD, with these probably being involved in the maintenance of the problem. In some instances (such as responsibility appraisals) it can also reasonably be hypothesised that these factors may be part of the origins of OCD, but it is much harder to establish causal links as opposed to associations. There is little in the way of purely empirical or descriptive data on the aetiology of OCD, so much of our limited theoretical understanding has to come from generalisations of the theory.

The cognitive theory of the development of obsessional disorder suggests that, as a result of prior experience, the individual develops particular assumptions (particularly about their own thinking and what this means, but also about issues surrounding prevention of harm and responsibility for it).

These assumptions may be self-evidently problematic (sometimes) or may initially appear to be innocuous (more commonly). At some later time, the occurrence of a particular critical incident or series of such incidents has the effect of activating the assumptions, leading to appraisals linked to responsibility for harm by what is done or not done. Such critical incidents are defined as events or situations which activate the previously ‘silent’

assumptions. Usually this means that critical incidents ‘mesh’ with beliefs;
e.g.
the incident or situation fulfils the conditions inherent in the assumption. The development of attempts to resist, to avoid and to neutralise (also regarded as linked to such assumptions) triggers maintenance cycles as defined in the theory.

Salkovskis
et al.
(1999) have proposed that several patterns of belief and experience may be involved in the origins of OCD (or vulnerability to its development), but highlighted the problems in researching such issues in the clinic, where people typically present between 7 and 12 years after the onset of their problems, rendering attempts to identify the origins particularly problematic. However, working with a younger age group may offer new opportunities for investigation of the origins of OCD. By definition, young people living under the care of their parents are likely to come to professional attention much earlier than independent adults, as parents spot
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changes in their behaviour, mood or attitudes and seek help on the young person’s behalf.

In most instances, the evolution of obsessional symptoms and linked beliefs is likely to be a subtle and interactive process taking place over many years in ways which are hard to detect even for the young person themselves.

We have previously identified a set of more obvious patterns that are likely to be relatively easy to detect on the basis of retrospective or concurrent self-report. Five patterns are suggested: note that some, but not all, are mutually exclusive: 1

An early developed and broad sense of perceived responsibility for avoiding threat which has been deliberately or implicitly encouraged and promoted during childhood by parental significant figures and circumstances, leading to enduring and ‘justified’ beliefs about the importance of a sense of responsibility.

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Rigid and extreme codes of conduct and duty, including religious and moral principles.

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Childhood experience in which sensitivity to ideas of responsibility develops as a result of being shielded from it. This may include over-indulgence (being spoiled) and/or may be the consequence of the implication or by the communication by those around them that the child is in some sense incompetent.

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A specific incident or series of incidents in which actions or inaction actually contributed in a significant way to a serious misfortune that affects oneself or, often more importantly, others (e.g. being involved in a causal chain resulting in injury or death, such as distracting someone who then has an accident or placing an object somewhere that later harms someone).

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An incident in which it wrongly appeared that one’s thoughts and/or actions or inaction contributed to a serious misfortune (e.g. wishing that someone comes to harm, then this ‘coming true’).

Other factors may also contribute, including actual or perceived criticism, acute or sudden increases in levels of personal responsibility and additional experiences of the type described in points (3) and (4) above: 1

Criticism and blame
. An experience of systematic criticism and/or scape-goating may contribute to the development of an inflated sense of responsibility. The criticism may be parental in origin, or may occur at school. We suggest that criticism will increase the subjective cost of being responsible, for example, ‘If I make a mistake, people will blame me.’ That is, there is an additional consequence to not acting in a responsible manner. Note that this does not imply that criticism alone is sufficient to create an inflated sense of responsibility.

2

Increased levels of responsibility
. In people who are already predisposed to such beliefs, a situational increase in responsibility may lead to an inflated sense of responsibility. There are at least two patterns. In the 142

Salkovskis, Waite and Williams

first, the number of responsible roles gradually creeps up incrementally where the person acquires additional obligations or duties. These obligations or duties may be imposed, but among those who already have a strongly developed sense of responsibility, they may be willingly accepted or actively sought out. In the second, the level of responsibility may jump rapidly with a change in circumstances such as the transition from a two parent to single parent family, moving from primary to secondary school, and so on.

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Activating or coincidental events
. Incidents involving real or perceived responsibility or blame for events causing harm, perceived ‘near misses’, or coincidental events that are interpreted as the person having caused harm can all create an inflated sense of personal responsibility by themselves. However, in combination with the patterns of development discussed above, such events or additional events of these types may further inflate responsibility. Such events have previously been characterised as ‘critical incidents’. Such incidents would not in themselves necessarily trigger obsessional problems. However, these events (they are often, but not only, adverse life events) can combine and ‘mesh’ with pre-existing attitudes and assumptions to trigger responsibility appraisals and the factors which may serve to maintain such appraisals.

Clearly, understanding causal factors better is likely to facilitate both primary and secondary prevention. However, before such ambitious undertakings are implemented, the empirical basis of causal factors needs to be established. Data on parenting styles in OCD has produced little evidence of a particular pattern of parental behaviour or interaction. However, based on the current analysis, more than one parenting style could contribute to an inflated sense of responsibility. An implication of the present analysis is that, if both being given too much responsibility and too little responsibility can contribute, then measures taken from these hypothesised subgroups could well cancel each other out in an overall analysis. It may be more useful to use cluster analysis or other such as semi-ideographic strategies to establish meaningful profiles leading to OCD as a ‘final common pathway’. Development of an inflated sense of responsibility may for some people be best modelled as accumulating experiences that individually may have relatively little effect.