Obsessive Compulsive Disorder (4 page)

• being given too much responsibility

• being given too little responsibility

• exposure to rigid or extreme codes of conduct

• incidents where that person’s action or inaction contributed to serious misfortune

• incidents where the person erroneously assumed that their thoughts, actions or inactions contributed to a serious misfortune.

As Salkovskis
et al.
(1999) point out, these factors are unlikely to be the sole causes of developing OCD. Personal vulnerabilities such as sensitivity to criticism or negative events are also likely to play a part. As yet there have been no studies exploring these mechanisms in young people with OCD.

Family functioning

For many families coping with their child’s OCD is a strain. The symptoms of OCD may affect the living arrangements at home or the capacity of the family to go out together. For instance, if the young person is unable to leave the house without spending half an hour in the bathroom, then the morning routine of getting ready to go to work or school may be disrupted. It may be that the young person is unable to complete tasks without asking the parents for reassurance that the tasks have indeed been completed correctly or they may get parents to carry out compulsions for them, such as turning out the bedroom light before going to sleep. Recent studies have suggested that there are particular issues which differentiate families of children with OCD from those that have children with other types of problem. Barrett
et al.
(2002) found that parents of children with OCD were less confident in their children’s abilities and independence skills than parents of children with other anxiety disorders and were less likely to use positive problem-solving techniques. Derisley
et al.
(2005) found that parents of children with OCD

tended to cope with problems by avoiding them.

However, research on the best way of helping families overcome these difficulties is still at an early stage. There are not yet any studies comparing individual CBT with CBT involving families in young people with OCD.

However, Barrett
et al.
(2004) obtained greater effect sizes using family CBT

than the effect sizes in the paediatric OCD treatment study (POTS) trial (March
et al.
, 2004). Where comparative studies have been carried out in anxiety disorders more generally, the picture is unclear; for example,
Introduction to obsessive compulsive disorder
13

Cobham
et al.
(1998) only found limited benefits in involving parents in the intervention.

Research on family involvement is still at an early stage and so far studies on anxiety disorders more generally have found limited benefits in involving parents in therapy.

Behavioural models of OCD

Behavioural theories of OCD stem from Mowrer’s (1960) two-factor theory of the development of anxiety, which involves both classical and operant conditioning. Obsessions are previously neutral stimuli which have become associated with anxiety. The individual then develops avoidance and escape responses, such as washing or checking, that terminate exposure to the feared stimulus. The behaviours are negatively reinforced, which makes them more likely to occur and termination of exposure prevents the anxiety from extinguishing (Rachman, 1971).

Behavioural treatments of OCD

Behavioural accounts led to the development of exposure and response prevention (ERP) as a psychological treatment for OCD (Meyer, 1966; Rachman
et al.
, 1971). This involves encouraging the individual to expose themselves to the thoughts, situations or activities that induce anxiety for a prolonged period of time, without carrying out the compulsion or other responses that normally terminate the exposure. As a result, they learn to tolerate the anxiety or discomfort, over time the anxiety decreases and through repetition it eventually habituates. In addition, they may discover that the feared consequence does not occur.

Early studies in adults demonstrated that ERP was a successful treatment (Meyer
et al.
, 1974; Rachman and Hodgson, 1980); around 60 to 70 per cent of individuals with compulsions who completed treatment made significant improvements (Abramowitz, 1996). However, behavioural treatments have been difficult to apply to young people who ruminate or do not have compulsions and treatment refusal and drop-outs have been common.

There has been one randomised controlled trial of ERP in young people (Bolton and Perrin, 2008), which found that ERP reduced OCD symptoms substantially as compared with a waiting list condition.

Psychological interventions for OCD began in the 1960s with the development of ERP and this led to reasonable success with adults and later with young people.

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Williams and Waite

Cognitive theories of OCD

Most cognitive accounts of OCD have developed from Rachman and de Silva’s (1978) finding that almost 90 per cent of a non-clinical sample reported intrusive thoughts that were no different to the obsessional thoughts experienced in OCD. This finding has been subsequently replicated and more recently there is evidence to suggest that compulsions do not differ in content to normal ritualistic behaviour (Fiske and Haslam, 1997; Muris
et al.
, 1997). These findings suggest that the basic phenomenon involved in OCD is extremely common.

Salkovskis (1985) hypothesised that the key difference between people with and without OCD is the way in which the intrusive thoughts are interpreted, both in terms of their occurrence and content. In individuals without OCD, intrusive thoughts are generally not interpreted as being meaningful and as a result they are able to dismiss them. However, in individuals with OCD the thoughts are seen as an indication that they might be responsible for harm to themselves or others unless they take action to prevent it.

Responsibility appraisals are defined as ‘the belief that one has power which is pivotal to bring about or prevent subjectively crucial negative outcomes’.

Consequently, the individual attempts to suppress and neutralise the thought through compulsions, avoidance of situations related to the thought, seeking reassurance or by attempting to get rid of the thought.

The aim of these neutralising behaviours is to reduce the perceived responsibility. However, they actually make further intrusive thoughts more meaningful and more likely to occur, evoke more discomfort and lead to further neutralising.

Rachman (1997, 1998, 2003) extends the cognitive theory to suggest that in OCD, individuals catastrophically misinterpret the significance of their normal intrusive thoughts and this causes obsessions. For an intrusive thought to become an obsession, it must be misinterpreted as important, personally significant, contrary to the individual’s value system and having potential and serious consequences (even if it is perceived to be unlikely).

Obsessions then persist as neutralisation and avoidance stop the individual finding out that the perceived consequence does not occur. Certain cognitive biases can then increase the significance of obsessional thinking, such as thought–action fusion or inflated responsibility. Thought–action fusion involves the individual regarding the obsessional thought as being morally equivalent to carrying out the action (e.g. having a thought of harming someone is as bad as actually doing it) and/or feeling that having the thought increases the likelihood of it coming true (Rachman and Shafran, 1998).

Responsibility beliefs may also contribute to catastrophically misinterpret-ing intrusive thoughts and may be a cause or effect of thought–action fusion.

In 1995, a group of international researchers agreed to collaborate to develop and evaluate measures of cognition in OCD. Known as the Obsessive Compulsive Cognitions Working Group (OCCWG), they reached a consensus about the key cognitions in OCD, identifying six major belief
Introduction to obsessive compulsive disorder
15

domains that they believed were significant in OCD (OCCWG, 1997).

These were:

•
inflated responsibility
– the belief that one has power which is pivotal to bring about or prevent subjectively crucial negative outcomes

•
overimportance of thought
– the belief that the presence of an intrusive thought indicates that it is important

•
overestimation of threat
– an exaggeration in the estimation of the probability or severity of harm

•
the controllability of thoughts
– the belief that it is possible, desirable and necessary to control thoughts

•
intolerance of uncertainty
– the belief that it is necessary to be certain and that it will be impossible to cope without complete certainty

•
perfectionism
– the belief that there is a perfect solution to every problem, that doing something perfectly is not only possible but also necessary, and that even minor mistakes will have serious consequences.

Some of these cognitions appear to be specific to OCD, such as inflated responsibility, while others such as perfectionism are relevant to OCD but also occur commonly in other disorders.

Cognitions in young people with OCD

There is evidence to suggest that young people in general also experience intrusive thoughts that are no different to those experienced in OCD and that if the thoughts cause distress and/or are more actively managed, they tend to persist for longer (Allsopp and Williams, 1996). Studies comparing young people with OCD to non-anxious controls or young people with other anxiety disorders have sought to investigate whether the same belief domains shown in adults with OCD are present in younger populations.

Libby
et al.
(2004) found that young people with OCD had significantly more responsibility appraisals and beliefs around thought–action fusion than anxious controls. Barrett and Healy (2003) also found inflated responsibility and increased thought–action fusion and higher ratings of harm severity in young people with OCD but that the differences were not significant. This may reflect differences in measures used, or it may be that as this was with a younger sample cognitions may not be fully developed.

Nevertheless, they did find the group of young people with OCD were significantly different when it came to cognitive control. This provides some preliminary evidence that young people with OCD demonstrate similar cognitions identified in adults with OCD.

Cognitive accounts of OCD suggest that intrusive thoughts are experienced by most of the population and that the key difference between people with and without OCD is the way in which the intrusive thoughts are interpreted in terms of their occurrence and content.

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Williams and Waite

Cognitive behaviour therapy for OCD

Cognitive behaviour therapy (CBT) for OCD developed as an attempt to increase adherence to ERP, by helping the individual to modify dysfunctional thoughts and beliefs (Salkovskis and Warwick, 1985). However, as theoretical and empirical studies on cognitions in OCD developed, CBT

has evolved as a treatment in its own right. It is based on modifying key beliefs and appraisals so that the individual learns that intrusive thoughts are not of special significance and do not indicate increased responsibility or probability of harm. CBT aims to help the individual to construct and test a new and less threatening model of their experience through developing an understanding of how the problem may be working and then testing this out through behavioural experiments to learn that the problem is about thinking and worry, rather than actual danger or harm. Whereas in ERP the individual is encouraged to stop carrying out compulsions, in CBT the individual is encouraged to carry out experiments to identify and challenge their misinterpretations. As a result, they learn that they no longer need to carry out compulsions.

It is clear that CBT is effective in significantly reducing symptoms of OCD and that these gains are maintained post-treatment (Clark, 2004).

There is evidence that it is effective with symptoms that have been more difficult to treat with ERP, such as obsessional ruminations and hoarding (Freeston
et al.
, 1997; Hartl and Frost, 1999). More recently, controlled trials with adults have compared CBT to ERP and found CBT to be superior to ERP in reducing symptom severity and shifting obsessional beliefs (Rector
et al.
, 2006; Salkovskis
et al.
, in press).

CBT with young people and families

A number of studies of CBT with young people have been carried out. One of the earliest controlled studies demonstrated that CBT was as effective as clomipramine for the control of the symptoms of OCD (de Haan
et al.
, 1998). Subsequent studies have compared CBT with waiting list controls (Bolton and Perrin, 2008), with sertraline (Asbahr
et al.
, 2005; March
et al.
, 2004) and have delivered CBT in family (Barrett
et al.
, 2004) or group formats (Asbahr
et al.
, 2005). All of the CBT programmes have produced similar improvements in measures of OCD. Nevertheless, there are differences between the approaches adopted. Most forms of CBT have focused on encouraging the young person to manage the anxiety or discomfort associated with ERP (e.g. see March and Mulle, 1998). In this book we describe a different approach which encourages the young person to find out for themselves how their thinking is the problem rather than their behaviour and draws on the developments made in the adult field. There are no direct comparisons of this approach with others.

CBT is based on modifying key beliefs and appraisals with the aim of helping the individual to construct and test a new and less threatening model of their experience.