Annals of Psychotherapy & Integrative Health - Fall and Winter 2011 (Sample)

Grand Master

YanGTeaches Us the Art of Tai Chi

How Far we Have CoMe: UnderstandinG obsessive-CoMpUlsive disorder in CHildren and adolesCents

natUral reMedYMilk Thistle

tHe brain’s drUGstore:

tHe relationsHip between pills and non-drUG

alternatives

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Fall / winter 2011Volume 14 , number 3

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Departments08 mind news 34 new members

51 short story By James mcadams

70 book reviews

76 Ce test pages

Features18 how Far have we Come in unDerstanDing obsessiVe-CompulsiVe DisorDer in ChilDren anD aDolesCents?By Karin TochKov, Phd

52 the brain’s drugstore By sara rendell and michael anch, Phd

78 internet deFamation: DeFenDing Your name By Josh roBerTs

36

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on the CoverhoW far havE WE comE 18confErEncE Wrap up 30grand mastEr yang 36thE brain’s drugstorE 52milk thistlE 46guidEd mEditation 56


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fall/winter 2011 • Volume 14 , number 3

4 Fall / Winter 2011 Annals of Psychotherapy & Integrative Health www.americanpsychotherapy.com

08

36 the art oF tai ChiBy TrysTa herzog

46 natural remediesmilk thistlenccam clearinghouse

48 guided meditation For First thing in the morning and Coming homeBy eve elioT

Columns12 Chair’s Corner: walkin’ anD talkin’By daniel J. reidenBerg, Psyd, FaPa, BcPc, mTaPa

16 Culture notes: pills, pills, & more pillsBy irene rosenBerg Javors, lmhc, med, daPa

52 Chaplain’s Column: the purpose oF ritualBy chaPlain david J. Fair, Phd, chs-v, cmc

68 praCtiCe management: in the health Care reForm moVement, what is moVing us?By ronald hixson, Phd, lPc, lmFT, BcPc

78 Chaplain’s brieF: workplaCe praYer rooms By Kim nimon, Phd

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Annals of Psychotherapy & Integrative Health (ISSN 1535-4075) is published quarterly by the American Psychotherapy Association. Annual membership for a year in the American Psychotherapy Association is $165. The views expressed in Annals of Psychotherapy & Integrative Health are those of the authors and may not reflect the official policies of the American Psychotherapy Association. Abstracts of articles published in Annals of Psychotherapy & Integrative Health appear in e-psyche, Cambridge Scientific Database, PsycINFO, InfoTrac, Primary Source Microfilm, Gale Group Publish-ing’s InfoTrac Database, Galenet, and other research products published by the Gale Group.

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if You don’t snooze, do YoU lose?

mind news

Wake-Sleep Patterns Affect Brain Synapses During Adolescencean ongoing lack of sleep during adolescence could lead to more than

dragging, foggy teens, a university of wisconsin-madison study suggests.

researchers have found that short-term sleep restriction in adolescent

mice prevented the balanced growth and depletion of brain synapses,

connections between nerve cells where communication occurs.

“adolescence is a sensitive period of development during which the

brain changes dramatically,” Cirelli says. “there is a massive remodeling

of nerve circuits, with many new synapses formed and then eliminated.”

Cirelli and colleagues wanted to see how alterations to the sleep-wake

cycle affected the anatomy of the developing adolescent brain.

using a two-photon microscope, researchers indirectly followed the

growth and retraction of synapses by counting dendritic spines, the elon-

gated structures that contain synapses and thus allow brain cells to re-

ceive impulses from other brain cells. they compared adolescent mice

that for eight to 10 hours were spontaneously awake, allowed to sleep or

forced to stay awake. the live images showed that being asleep or awake

made a difference in the dynamic adolescent mouse brain: the overall

density of dendritic spines fell during sleep and rose during spontaneous

or forced wakefulness.

the experiments are under way, but Cirelli can’t predict the outcome.

“it could be that the changes are benign, temporary, and reversible,” she

says, “or there could be lasting consequences for brain maturation and

functioning.”University of Wisconsin-Madison (2011, Oct 10). If you don’t snooze do you lose? Wake-sleep patterns affect brain synapses during adolescence. ScienceDaily. Retrieved from http://www.sciencedaily.com/releases/2011/10/111009140219.htm


SPiriTUAl reTreAT Can lower Depression, raise Hope in Heart PatientsAttending a non-denominational spiritual retreat can help patients with severe heart trouble feel less depressed and more hopeful about the future, a University of Michigan Health System study has found.

Heart patients who participated in a four-day retreat that included techniques such as meditation, guided imagery, drumming, journal writing, and outdoor activities saw immediate improvement in tests measuring depression and hopefulness. Those improve-ments persisted at three-and six-month fol-low-up measurements.

The study was the first randomized clini-cal trial to demonstrate an intervention that raises hope in patients with acute coronary syndrome, a condition that includes chest pain and heart attack. Previous research has shown that hope and its opposite, hopeless-ness, have an impact on how patients face uncertain futures.

“The study shows that a spiritual retreat like the Medicine for the Earth program can jumpstart and help to maintain a return to psycho-spiritual well-being,” says study lead author Sara Warber, M.D., associate profes-sor of family medicine at the U-M Medical School and director of U-M’s Integrative Medicine program. “These types of inter-ventions may be of particu-lar interest to patients who do not want to take antidepres-sants for the de-pression symp-toms that often accompany cor-onary heart dis-ease and heart attack.”

The findings were published in the July issue of Explore: the Journal of Science and Healing.

PAreNTAl WeigHT Strongly influences Thinness in ChildrenChildren with thinner parents are three times more likely to be thin than children whose parents are overweight, according to a new study by UCL researchers.

The study, published October 3 in the Archives of Pediatrics & Adolescent Medicine, shows strong familial influence on pediatric thinness. It was based on results from the Health Survey for England, in which data are collected annually from multiple households. From 2001 to 2006, trained interviewers recorded the heights and weights of parents and up to two children in 7,000 families, and used this information to calculate their BMI.

The results showed a strong association between children’s and parents’ body size. When both par-ents were in the thinner half of the healthy-weight range, the chance of the child being thin was 16.2%, compared with 7.8% when both parents were in the upper half of the healthy weight range, 5.3% with two overweight parents, and only 2.5% for children with two obese parents.

Professor Jane Wardle, UCL Epidemiology & Public Health, added: “Parents are often con-cerned if their child is thin, but it may just be their ‘skinny genes’. All genes have two versions, called alleles. We might think of weight-related genes as having a ‘skinny’ and ‘curvy’ allele. Thinner parents are likely to have more of the skinny alleles, increasing the chance of passing them on to their children. A child who inherits more of the skinny alleles from their par-ents will be naturally thinner.”

Cancer Research UK (2011, Oct 4). Parental weight strongly influences thinness in children. ScienceDaily. Retrieved from http://www.sciencedaily.com/releas-es/2011/10/111003161933.htm

Media Habits of Young People

May Make Them Drink More;

WHAT SHoulD BE DonE?

Media companies are increasingly targeting adolescents with TV shows that

feature violence, alcohol and drugs. An interdisciplinary research project

with researchers from the University of Gothenburg, Sweden, and colleagues

from the UK is looking closer at how society and others should react to the link

between young people’s media habits and their alcohol consumption.

The project, called Alcopop TV Culture, is funded by the European Com-

mission’s Daphne III program. It sets out to study the relationship between

adolescent (age 10-25) media habits and alcohol consumption. A central

issue is how the responsibility for increased adolescent drinking should be

shared among different parties, such as state authorities, the alcohol in-

dustry, families and the adolescents themselves.

The goal of the project is to develop a draft policy on how to allocate

shared responsibility for use across Europe. This is not an easy task. The explo-

sive growth of the global media landscape (internet, social media, etc.)

implies that potential tools such as age limits and airtime regulations are

becoming increasingly difficult to implement.

‘It is pretty clear that adolescents often feel belittled, for example, by

societal campaigns and organizations that come to talk to them about

alcohol. This is one reason why we have a Facebook and a Twitter page

full of new research reports, news and debates. We hope that the ado-

lescents will use the page to gain information and to share their opinions,’

says Munthe.

University of Gothenburg (2011, Oct 10). Media habits of young people may make them drink more; what should be done? ScienceDaily. Retrieved from http://www.sciencedaily.com/releas-es/2011/10/111010075458.htm


a compound found in green tea shows

great promise for the development of

drugs to treat two types of tumors and

a deadly congenital disease. the dis-

covery is the result of research led by

principal investigator, Dr. thomas smith

at the Donald Danforth plant science

Center and his colleagues at the Chil-

dren’s hospital of philadelphia.

using atomic structures to un-

derstand the differences between

animals and plants, Dr. smith and his

colleagues discovered that two com-

pounds found naturally in green tea

are able to compensate for this genet-

ic disorder by turning off gDh in isola-

tion and when the green tea com-

pounds were administered orally.

the smith lab also used X-ray

crystallography to deter-

mine the atomic struc-

ture of these green tea

compounds bound

to the enzyme. with

this atomic informa-

tion, they hope to be

able to modify these

natural compounds

to design and de-

velop better drugs. their

findings were recently pub-

lished in the Journal of bio-

logical Chemistry.

Donald Danforth Plant Science Center (2011, Aug 15). Green tea is ef-fective in treating genetic disorder and types of tumors, study suggests. Science-Daily. Retrieved from http://www.science-daily.com/releases/2011/08/110815113607.htm

mind news

increased use of bikes for commuting offers Economic, health benefits

grEEn tEa is Effective in treating genetic disorder and types of tumors, study suggests


Cutting out short auto trips and replacing them with mass transit and active transport would yield major health benefits, according to a study just pub-lished in the scientific journal Environmental Health Perspectives.

The biggest health benefit was due to replacing half of the short trips with bicycle trips during the warmest six months of the year, saving about $3.8 billion per year from avoided mortality and reduced health care costs for conditions like obesity and heart disease.

The report calculated that these measures would save an estimated $7 billion, including 1,100 lives each year from improved air quality and increased physical fitness.

“Moving five-mile round trips from cars to bikes is a win-win situa-tion that is often ignored in discussions of transportation alternatives,”

says Jonathan Patz, director of the Global Health Institute at the Univer-sity of Wisconsin-Madison. “We talk about the cost of changing energy systems, the cost of alternative fuels, but we seldom talk about this kind of benefit,” he says.

By lessening the use of fossil fuels, a reduction in auto usage also benefits the climate, Patz adds. “Transportation accounts for one-third of greenhouse gas emissions, so if we can swap bikes for cars, we gain in fitness, local air quality, a reduction in greenhouse gases, and the

personal economic benefits of biking rather than driving. It’s a four-way win,” he adds.

University of Wisconsin-Madison (2011, Nov 2). Increased use of bikes for commuting offers economic, health ben-efits. ScienceDaily. Retrieved from http://www.sciencedaily.

com/releases/2011/11/111102082804.htm

social rejection can cause stress in preschoolers, adolescents, and adults. a new study has

found that friendships serve as a buffer against the negative effects of classmates’ rejection.

the study, conducted by researchers at radboud university nijmegen in the netherlands,

appears in the journal Child Development. it looked at almost 100 fourth graders to deter-

mine whether victimization and exclusion by peers were related to increases in cortisol, and

whether friendships moderated this association. Children who were excluded by their class-

mates had elevated levels of cortisol at school, the study found. they also had a smaller

decline in cortisol over the course of the day. both of these findings may indicate that exclu-

sion is stressful. this was even more pronounced for excluded kids who had few friends or

had friendships that were characterized as low in quality.

Society for Research in Child Development (2011, Oct 26). Friendship makes a difference in stress regulation. Science-Daily. Retrieved from http://www.sciencedaily.com/releases/2011/10/111026091229.htm

friEndshipmakes a difference in stress regulation

After men become fathers for the first time, they show significant decreases in crime, tobacco, and alcohol use, according to a new, 19-year study.

“These decreases were in addition to the general tendency of boys to engage less in these types of behaviors as they approach and enter adulthood,” said David Kerr, assistant professor of psy-chology at Oregon State University and lead author of the study. “Controlling for the aging process, fatherhood was an independent factor in predicting decreases in crime, alcohol and tobacco use.”

“This research suggests that fatherhood can be a transfor-mative experience, even for men engaging in high risk

behavior,” he said. “This presents a unique window of opportunity for intervention, because new

fathers might be especially willing and ready to hear a more positive message and make behavioral changes.” The study was pub-lished in the current issue of the Journal of Marriage and Family. Collaborators in-cluded the Oregon Social Learning Cen-ter in Eugene, Ore., and the University

of Houston.

Oregon State University (2011, Nov 8). Fatherhood can help change a man’s

bad habits. ScienceDaily. Retrieved from http://www.sciencedaily.com/releas-

es/2011/11/111107161800.htm

Parents who joke and pretend with their toddlers are giving their children a head start in terms of life skills. Most parents are naturals at playing the fool with their kids, says a new research project funded by the Eco-nomic and Social Research Council (ESRC). However parents who feel they may need a little help in doing this can learn to develop these life skills with their tots.

The study examined whether parents offer different cues such as tone or pitch of voice in order to help their toddlers understand and differentiate between joking and pretending. Findings reveal that parents rely on a range of language styles, sound and non-verbal cues. For example, when pretending, parents often talk slowly and loudly and repeat their actions. Conversely, parents tend to cue their children to jokes by showing their disbelief through lan-guage, and using a more excited tone of voice.

“We found that most parents employ these different cues quite naturally to help their toddlers understand and differentiate these concepts,” researcher Dr. Elena Hoicka points out. “While not all parents feel confident in their natural abilities, the research does show that making the effort to interact in this way with toddlers is important. Knowing how to joke is great for making friends, dealing with stress, thinking creatively and learning to ‘think out-side the box’. Pretending helps children learn about the world, interact with others, be creative and solve problems.”

Economic and Social Research Council (2011, Oct 27). Joking, pretending with toddlers gives them head start in life skills. ScienceDaily. Retrieved from http://www.sciencedaily.com/releases/2011/10/111027112508.htm

Joking, pretending with toddlers gives them head start in life skills

fathErhood can help change a man’s bad habits



think back to high school and try to remember your prin-cipal. What was his/her name? What do you remember

most about him/her? Did you ever have the chance to talk with this person (not about something that you were in trouble

for)? I’m guessing most of us don’t even recall our high school principal, let alone anything significant about them and what they

did for us. For the fewer of us that do remember, I’d suspect it was for something we might want to forget. I want to introduce you to the principal you wish you would have had. More than that, this principal is one you wish your children had. He has a lot to teach therapists everywhere about caring, one person at a time.

Mike Farley, or Mr. Farley as most of his students know him, is the principal of a very large suburban high school. One of the largest districts in the Minnesota with over 28,000 students, Anoka High School sees 2,400 students pass through its doors each year, is diverse, leads in academics and sports, and is filled with pride. The school’s mascot, ironically, is a tornado and for the last two years Anoka High School has been through the storm of its life that has been weathered with the leadership of Mr. Farley. Mr. Farley is not the principal you remember and probably isn’t the typical principal buried in administrative paperwork, emails and meetings. Instead, he is out with his students. Present. Available. Interested in them, the good, the bad, and everything in between.

When you run any business that has dozens of direct reports and employees you are bound for challenges. Rarely does everyone agree with your decisions. Less frequently are you seen as popular.

Nonetheless you still lead and you still have followers. Your time is spent meeting competing demands of (in this case) union rules and regulations, your desires for results, meeting outcome measures, and making people happy. Imagine trying to do this every year and you now have a small sense of what Mr. Farley has to face each year as the student body changes. While you can plan for problems and challenges, you can never plan for everything, and two years ago Anoka High School and other schools in the district were in the direct path of a storm not of natural forces, but of multiple suicides.

I was called in as a consultant by the district office after two stu-dents had taken their lives. My job was to help the district assess what might be happening, reduce the risk of contagion (a particu-larly significant problem for youth and in school settings), and get a message out to the faculty and students in the district that sui-

CHAIR’S CORNER

Walkin’ and Talkin’: Caring one person at a timeBy: Daniel J. Reidenberg, PsyD,Fellow, American Psychotherapy Association, Board Certified Professional Counselor, Master Therapist


cide can be prevented. As planning and funding was sought to get everything ready to be implemented, additional suicides tragically occurred in the district. In the age of new technology, youth spread many messages about their friends who had died, some accurate, many not. By the time we were able to get things underway, 5 or 6 students had taken their life in a few months and contagion was apparent in this community. Suicide attempts and ideation were a regular occurrence for youth and hospital beds were filling with youth from this community who were deemed at risk of suicide. Local, regional and national media picked up on “the story” and to this date hasn’t let it go.

I went to the schools and held debriefings for the faculty of each school. I arranged for speakers to talk to the youth and we conduct-ed an in-service training for faculty, counselors, administration, etc. Feelings were intense in every school. Teachers were on edge, wait-ing for the next suicide to occur. People were “afraid to answer the phone” and hear “who died now.” Youth that I spoke with told me they felt that “school was becoming a place where people just killed themselves whenever they had a problem.” But one man, Mr. Farley, stood up and out and said no more: “I am not having this happen in my school again.” He felt that the school was like a fam-ily and, as a member of the family in the community, something needed to be done.

Mr. Farley was clearly frustrated by what was happening. More than being frustrated, he was sad and concerned and he wanted this to stop. He also wanted his students to know that not only was school a safe place to be, but that people there cared about them. Yes, Mr. Farley set out to create an environment that was going to be a safety net for his students. Despite all that had happened

already to them, he was insistent on learning ev-erything he could about suicide, mental health, resiliency, self-esteem and positive behavior change. After consulting with experts, reading and researching best practices, and relying on his own experiences as a coach and parent, he set out to make a difference.

He started by taking a simple “thumbs ap-proach” to finding out where the students were. What did he mean by this? At any moment, in any location, he would ask his students for a thumbs assessment. Thumbs up meant they were ok or better. A thumb in the middle or pointing down meant there was cause for con-cern. Most often the kids would give him a thumbs-up, but occasionally it would be in the middle or down. If it was not up, Mr. Farley’s

next intervention was what I believe has made the difference for the students as they lived through the storm.

When Mr. Farley didn’t get a thumbs-up, he would walk right over to that student or call them over and ask them “What’s up? How are you doing?” It was really simple and clear, but what struck me most about this approach was what happened next. If the stu-dent was hesitant or reluctant in answering him, or they admit-ted things weren’t so great, at that moment he would say to them “C’mon, we’re walkin’ and we’re talkin.” And that was it. He didn’t just send them to someone else. He didn’t say to the student come see me after your next class. He didn’t tell them he had a meeting to go to and to stop by his office later. Instead what he did was say to them right here, right now, you are my priority and I’m listening to you. We’re spending time together and working on this problem, whatever it is, until you can give me a thumbs-up.

If you ask Mr. Farley about this, he will tell you he was just do-ing what anyone else would do. He would tell you that this ap-proach might not work for someone else, but for him it was all that he could do and he wasn’t going to give up on it. He would tell you that some of the students just didn’t have anyone at home that would do this and while he wasn’t their parent, he did care and he wanted them to know that someone in their life did. For real. For now. For whatever reason they needed them to. And Mr. Far-ley’s approach spread among the people who worked for him and throughout his building a sense of community grew. A pseudo, but real family who cared about everyone developed and going beyond what he ever envisioned, and it even spread to some of the students who started helping other students. His plan was working and the beauty of this was that he never really planned on it to turn out as it

CHAIR’S CORNER

What did he mean by this? at any moment, in any location, he would ask his students for a thumbs assessment.


did. Rather, he did what he thought was right and made a difference. A lifesaving difference to many, all at the same time as maintaining a clear expectation that when they were in school they were there to learn. In the time since Mr. Farley began this approach there have not been any suicides in his school and after the storm that hit his com-munity, this is something he can be proud of even though he never thought he was going into the business of saving lives.

1. Anyone can make a difference in someone’s life. In a therapeutic relationship that might be you, but it also might not be you and that is ok too. What is important is that you help your client’s figure out who that person is and how they can be helpful to them. If it is you, realize how important you are to them. Re-member that your act of caring, being sensitive, open and real with them might be what they need to get by and get better in a difficult time in their life. Maybe it is more than one person, and I would suggest that it should be. Help them build a support network of people who can be there for them for all kinds of things that hap-pen in their life. It is also important to help them understand that X or Y person can in fact make a difference for them. Some clients discount certain people in their lives (parents, siblings, neighbors, etc.) and we can help them see the benefits that anyone can bring to their lives. (Of course we want to be mindful that in most cases we don’t know these other people and we are relying on their report(s) of them to help us determine the good/bad they might bring to our client’s life.) The most important thing is that they learn to be open to anyone being someone who can make a difference. In Mr. Farley’s case, the students never thought the principal would care or spend the time with them. They thought that would be saved for their counselor. Mr. Farley showed them that anyone can and will be there for you if they commit to doing so.

2. Sometimes it’s the simple things that make a big differ-ence. Often I hear therapists analyzing and over-analyzing a ses-sion or statement a client made. Sometimes therapists look deeper into things that happen in their clients’ lives and while at times that might be important, other times we just need to see and hear things for what they are. At those times we can be very helpful to our clients by letting them know that ‘it is what it is’ and it might just not be any more than that. This is a double-bind therapists get into when they look too deep and/or the clients do. So be ok seeing that the problem or the solution might be much simpler, and help your clients see this as well.

3. Give every client your full attention. I’ve written about this before and will say it again…if you can’t fully attend to your client, you should not see them. You will do them the responsible and ethical thing by referring them to someone who can. If it is just

that day and for whatever reason(s), cancel and reschedule. Again, this will be better for your client in the long run than trying to fake being attentive or being caught by your client in your distraction. Therefore, just as Mr. Farley put everything aside when he came across a student who wasn’t able to give him a thumbs-up, recognize that you must give your clients everything that you have focused on them when they are in your office.

4. Develop a way to monitor your clients on how they are doing. From the beginning of your work with them, talk with them about what their baseline is and how they can share where they are at relative to that baseline so you have a sense of this easily and over time. You don’t need to use a thumbs-up or down approach, but you can, especially with children. Another simple way to do this are the old fashioned “where are you today on a 1-10 scale” approach. There is nothing wrong with this and there are many new technological approaches to getting clients to assess themselves just like this on a daily basis through text messages so they can chart their progress on a daily/weekly/monthly basis. I recommend you have a similar way of communicating this between you and your clients to chart their progress in therapy. For some it offers a non-threatening way of shar-ing where they are at any one particular time.

5. Remember that progress in therapy can be redirected at any moment in the process, and this too can be ok. Mr. Farley’s day never started thinking he would come across a student who needed him. Rather, he thought each day would be something different and he was prepared for that. I have talked with a number of therapists that seem to think/want their clients to come in and keep moving forward with their treatment plan and that is good, as we would like it to be. However, when something in their client’s life has derailed that progress they try and keep bringing them back “on track.” Therapists have a funny way of seeing distractions in client’s lives as a defense mechanism. Sometimes that is true, other times it is not and we must be ready every day for the reality of what is happening in our client’s lives outside of their treatment plan.

Finally, always be conscious of the fact that what your client sees as being significant, regardless of what it is, is incredibly impor-tant to them. We should be aware that if a client is struggling with someone, something or anything and it is a “10” for them, our job is to help them get it to be more manageable whether that is a relationship, an insecurity or any one of hundred problems clients bring to us. Regardless of what it is, remember that you too are (always) “walkin’ and talkin” with your patients helping them to better navigate their life.

ABouT THE AuTHoRDANIEL J. REIDENBERG, PsyD, FAPA, DAPA, MTAPA, is the chair of the American Psychotherapy Asso-ciation’s Executive Advisory Board and has been a member since 1997. He is a Fellow and Master Therapist of the American Psychotherapy Asso-ciation and executive director of Suicide Aware-ness Voices of Education (SAVE) in Minneapolis, Minnesota. Contact him with your thoughts at [email protected].

CHAIR’S CORNER

So what are the lessons that we as therapists can

learn from Mr. Farley?

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Culture Notes: Essays on Sane LivingBy Irene Rosenberg JavorsHave we all lost our minds? It’s a question we have all asked ourselves as we ponder such modern occurrences as “reality” TV, road rage, and terrorism. Javors’ collec-tion of her columns from the Annals of the American Psychotherapy Association offers prescriptions for “sane living” in the face of life’s challenges. Paperback.

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n the article “So Young and So Many Pills (Wall Street Jour-nal, December 28, 2010, sec.D, p.1), Anna Wilde Mathews

reports that “more than 25% of kids and teens in the U.S. take prescriptions on a regular basis.” She goes on to inform us that

“children and teens (are taking a wide variety of ) medications once considered only to be for adults, from statins to diabetes pills and sleep drugs.” She also states that “prescriptions for antihyperten-sives in people aged 19 and younger could hit 5.5 million this year.”

Mathews further informs us that anti-psychotic medications have been prescribed to 6,546,000 young people, with the follow-ing breakdown: 1,396,000 to children 0–9 years and 5,150,000 to those 10–19 years; antidepressants to 9,614,000: 1,026,000 to children 0-9 years and 8,588,000, 10–19 years; and medications for ADHD (attention deficit hyperactivity disorder) to 24,357,00: 7,018,000 to ages 0–9 years and 17,339,000 to ages 10–19 years.

My first response to reading these statistics: “Wow!” My next: What is going on here? And why are so many of our children and teens suffering from such chronic conditions? Mathews suggests that early detection may account for some of these numbers. She also points out that researchers attribute some of what’s going on to “unhealthy diets and lack of exercise among children, which lead to

too much weight gain and obesity,” and that this “also fuels the use of some treatments, such as those for hypertension.”

For the most part, children are given medications that have been tested in adults and not young people. We have no idea what these drugs are doing to children. Mathews quotes Dr. Danny Benjamin, who is “leading a new National Institutes of Health initiative to study drugs in children,” as saying, “we know we’re making errors in dosing and safety.” He suggests that “parents do as much research as they can to understand the evidence for the medicine.”

As mental health professionals working with children, teens, parents, and other health care providers, we need to become very well-informed about all the medications that are prescribed for our clients. We need to be cautious in making a diagnosis as well as

making sure to watch out for and identify side effects from the prescribed medication(s). We need to support parents’ efforts to find out as much as possible about the medications that are given to their children.

Mathews reports that “parents and doctors also say nondrug alter-natives should be explored where possible.” She quotes Tom Wells, professor of pediatrics at the University of Arkansas for Medical Sciences, as saying, “obesity is really the biggest cause I see for high blood pressure in adolescents...but only 10% of families adhere to (his) diet and exercise recommendations.”

As counselors, we need to re-evaluate our relationship to medica-tion. Do we suggest medication too quickly? Are there other ways of dealing with the problem? Are we still searching for the “magic bullet,” the quick fix to cure what ails us? How do we find a balance between over-reliance on drugs for symptom relief and finding a drug-free path to cope with and/or overcome pain and ill health? Are these chronically sick children who are suffering from asthma, high blood pressure and cholesterol, depression, bipolar disorder, ADHD, insomnia, and diabetes the proverbial “canaries in the mine,” sending us a loud message that the way we live, now, is mak-ing us very sick, if not killing us?

I hope that we are listening!

ABouT THE AuTHoRIRENE ROSENBERG JAVORS is a Diplomate of the American PsychotherapyAssociation, a li-censed mental health counselor, and a psycho-therapist in New York City. She is also an adjunct associate professor of mental health counseling in the Mental Health Counseling Program of the Ferkauf Graduate School of Psychology at Yeshi-va University. She is the author of Culture Notes: Essays on Sane Living (ACFEI Media, 2010).

Pills, Pills, & More PillsMedicating Children and Adolescents

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CE ARTICLE: 1 CE Credit


How far have we come

in understanding obsessive-compulsive disorder in children and adolescents?

By Karin Tochkov, Ph.D.

Suffering from OCD often means

feeling like a prisoner in your own mind and body, nOt being able to enjoy life to the full-est and having to live a life

that is all consumed by

anxiety & fear.



AbstractThe purpose of this paper is to review the current empirical

literature on obsessive-compulsive disorder in children and

adolescents. The results are discussed from a developmental

perspective, thus emphasizing different factors responsible for

the development and maintenance of OCD in children and

adolescents. The main contributing factors include genetic

transmission in families as well as the effect of the environ-

ment (family, society, culture). The study concludes that

a comprehensive theoretical model is needed to take all

empirical results into consideration in order to pres-

ent a developmental explanation of the predispo-

sition, onset, development, and maintenance

of OCD in children and adolescents.

This article is approved by the following for 1 continuing education credit:The American College of Forensic Examiners International is ap-proved by the American Psychological Association to sponsor continuing education for psychologists. The American College of Forensic Examiners International maintains responsibility for this program and its content.

The American Psychotherapy Association® provides this continuing education credit(s) for Diplomates and certified members, who we recommend obtain 15 credits per year to maintain their status.

Measurable and observable learning objectives:Explain the main differences of OCD in children and adolescents versus adults.

Discuss epidemiology and clinical features of OCD in children and adolescents.

Identify causes and contributing factors of OCD in children and adolescents.

KEYWORDS: obsessive-compulsive disorder; childhood psychopa-thology; epidemiology

TARGET AUDIENCE: Psychotherapy researchers, psychologists, psychotherapists

PROGRAM LEvEL: Intermediate

DISCLOSURES: The author has nothing to disclose.

PREREqUISITES: none


IntroductionObsessive-compulsive disorder (OCD) is an anxiety disorder, characterized by obsessive

thoughts which cause anxiety and distress and compulsions which aim at neutralizing this anxi-

ety. OCD can take different forms and can cause a high degree of impairment in everyday life. In

particular, rituals and other compulsive behavior can be extremely time-consuming. Suffering

from OCD often means feeling like a prisoner in your own mind and body, not being able to

enjoy life to the fullest and having to live a life that is all consumed be anxiety and fear. Every day

life can become unbearable, and even minor tasks might take an eternity to be completed until

the never-ending compulsions and rituals are obediently carried out. The more habits to avoid

the anxieties that are developed, the harder it will become to face the fear.

In the following section, different clinical aspects of OCD in children and adolescents are pre-

sented and contrasted with OCD in adults. The different causes of OCD are then briefly summa-

rized. The main body of the paper reviews empirical results of genetic influences and environ-

mental effects on OCD in children and adolescents.

1-3%; however, there are no estimates of prevalence of OCD in children (Riddle, 1998). Estimates of the mean age at onset for children and adolescents range between 10 and 11.44 for boys and between 10.2 and 13.5 for girls (Hanna, 1995; Toro et al., 1992). Geller et al. (2001) find in their sample of 101 subjects that mean age of onset is 6 in children, 10 in adolescents and 21 in adults, where all these numbers refer to males.

In adults, OCD is equally common in males and females. In con-trast, it has been observed that boys have a higher rate of OCD than girls during childhood and adolescence. Hanna (1995) estimates the male-female ratio to be 3:2, Geller et al. (2001) estimates it at 2:1 and observe that boys have both an earlier age of onset and more severe symptoms than girls.

A legitimate question stemming from all these differences between children and adults regarding the epidemiology of OCD is how simi-lar juvenile and adult forms of OCD are. Geller et al. (2001) demon-strates that there is a clear discontinuity between the OCD in adults and the OCD in children and adolescents. This result suggests that juvenile OCD is a unique developmental subtype of adult OCD.

The preceding discussion of clinical features makes clear that OCD in children and adolescents has many different aspects which demon-strate the importance of a developmental perspective on OCD.

Causes and contributing factors for OCD in childhood and adolescenceSeveral theories have been proposed to explain the development and maintenance of OCD, and the fact that the overwhelming ma-jority of OCD patients have an onset of the disorder in childhood

U N D E R S TA N D I N G O C D I N C H I L D R E N A N D A D O L E S C E N T S

OCD in children and adolescents: Epidemiology and clinical featuresThe essential features of OCD are recurrent obsessions and compul-sions that are extremely time-consuming and cause a severe distress and impairment. Obsessions are defined as recurrent thoughts and images, compulsions are defined as recurrent behaviors (American Psychiatric Association, 2000). Obsessions can be about contami-nation, religion, superstitions and perfectionism. Compulsions can take many different forms, such as decontamination, hoarding, checking, counting, touching, etc. The most important aspect from the developmental perspective is whether OCD in children and ado-lescents is different from OCD in adults. The classification of OCD in children and adolescents according to the latest edition of DSM-IV-TR is similar to that in adults. The exception is that children are not expected to recognize that their obsessions or compulsions are excessive or unreasonable (American Psychiatric Association, 2000).

Although the symptoms are distressing somehow to these chil-dren, they cannot recognize or express a direct relation between their obsessive symptoms and compromised daily life activities. Moreover, the cognitive development of children may not fa-cilitate the observation and description of his/her own thoughts. Often children may be frightened or confused by their thoughts, making them more likely to hide their symptoms from parents and clinicians. Consequently, children are less likely to report their obsessions and can be underdiagnosed and undertreated.

OCD usually emerges during childhood or adolescence. It has been estimated that around 80% of adults with OCD iden-tify their onset of symptoms before age 18 (Pauls et al., 1995). Lifetime prevalence of OCD in adults and adolescents is between


or adolescence. Generally, these theories can be divided into bio-logical and genetic models emphasizing the role of genetic factors, neurological processes and brain malfunctions, and psychological models focusing on the influences of cognitive processes, learning of behavior, and environmental factors (family, culture, and reli-gion). The review of the literature in the following sections will fo-cus exclusively on the genetic and the environmental factors which contribute to the pathogenesis of OCD in children and adolescents.

Genetic factorsOver the years, many studies have indicated that OCD is likely to have genetic origins. Therefore, there may be an underlying pre-disposition for OCD to occur in certain children and adolescents stemming from heritable factors. Evidence for genetic influences in the onset of OCD during childhood has come primarily from family and twin studies.

Family studies provide one of the common means of analysis of genetic factors since all family members share common genes. There are two techniques used to determine prevalence of OCD in relatives: the family-history method and the family-study method. Early studies applying the family-history method assessed relatives and determined diagnoses based solely on the information provid-ed by the proband. In contrast, more recent studies have used the family-study method, in which all available first-degree relatives are interviewed directly (Billett et al., 1998; Alsobrook et al., 1998).

Especially in the case of children and adolescents, the family-study method appears to be the more suitable alternative since children have more difficulties explaining in detail the obsessive-compulsive behavior of their relatives than adults. Although not as many family studies with children were conducted as with adults, there is nevertheless enough evidence that early onset of OCD in childhood is affected by heritable factors. Riddle et al. (1990) inter-viewed the parents of 21 children and adolescents between the ages of 7-17 with OCD. Fifteen of them (71%) had a parent with either OCD or obsessive-compulsive symptoms. In other words, 15 of the 42 parents (35.7%) were diagnosed with clinical or subclinical OCD. Unfortunately, this study gives no information concerning siblings or rates of diagnosis in siblings. Moreover, no control group was included which makes conclusions more difficult to make.

Lenane et al. (1990) interviewed not only parents but also siblings of 45 children and adolescents with severe OCD. A total of 145 first-degree relatives were interviewed. Twenty-five percent of fathers and 9% of mothers had OCD. When obsessive-compulsive behavior is included, the risk for all first-degree relatives was 35%. As in the pre-vious study, there was again no control group. Lenane et al. (1990) also looked for any relationship between the children’s primary OCD symptoms and those of their respective relatives. They found no con-sistent pattern between parents and children, or between older and younger siblings. Hence, it cannot be simply stated that obsessive-compulsive symptoms are observed and learned by younger relatives.

Furthermore, in another family study Last et al. (1991) interviewed first and second-degree relatives of 152 children with different anxi-ety disorders. In contrast to previous studies, a control group of 87 children was also included. The results indicate that a trend for OCD is more prevalent among relatives of children with OCD than among

relatives of children with other anxiety disorders. This in turn suggests that the risk was specific for OCD, and further supports the genetic model of early onset of OCD.

Toro et al. (1992) explored par-ents and siblings of 72 children and adolescents aged 5-18 with a diagnosis of OCD. The major-ity of the probands (57%) had some first-degree relative with a psychiatric diagnosis, however only 11 probands (15.3%) had a first-degree relative diagnosed with OCD. This result is much lower than the previous studies, but it is mainly due to the procedure used for diagnosing the relatives. No interviews were conducted, only the diagnoses stated in the clinical records of the children were used.

Not all studies report such high rates of OCD in families. In particular, phenotype definition and age at onset appear to influence the family aggregation of OCD. For instance, Black et al. (1992) interviewed 120 first-degree relatives of 32 pro-bands with OCD and 33 psychiatrically normal controls. The OCD probands had a mean onset age of 11.04 years. The first-degree relatives of probands with OCD were significantly more likely to experience anxiety disorders than were relatives of controls. However, the prevalence of OCD itself was very low among both groups’ rela-tives. Only 3% of the relatives of OCD patients were di-agnosed with OCD. When obsessive-compulsive behavior was included, this number climbed to 21%. These results indicate that an anxiety disorder may be transmitted in families in which a mem-ber has OCD, but its expression within these families is variable.

Similarly, Pauls et al. (1995) gathered interview data from 466 first-degree relatives of 100 probands with OCD. The mean onset age here was 10.2 years. In addition, 113 first-degree relatives of 33 psychiatrically unaffected probands were studied with the same interviews. The results show that 10.3% of the relatives were diag-nosed with OCD as compared to only 1.9% in the control group. Eight percent of relatives were diagnosed with obsessive-compulsive behavior. These results, paired with those from the study by Black et al. (1992) indicate that OCD is a heterogeneous condition. Some cases were familial, but in other cases there appeared to be no family history of OCD. However, there was a two-fold increased risk for OCD and a four-fold increased risfor obsessive-compulsive behavior in relatives of probands with childhood-onset OCD as compared to a later onset (after the age of 18). This is a sign that an early onset of OCD can be interpreted as a more severe form of the disorder with a greater genetic loading. This certainly distinguishes OCD in children and adolescents from OCD in adults.

In a more recent family study, similar results were achieved. Nestadt et al. (2000) interviewed 80 probands with OCD and 343


in relatives of probands with later onset was 0 (0%) of 49. Thus, no cases of OCD were found in the case of relatives of probands with late onset of OCD. In other words, the younger the age at onset, the higher the famili-ality of OCD. This suggests that cases of OCD with early age at onset are more likely to yield information about the genetic origins of this disorder – a further sign that developmental aspects and genetics are intertwined in the case of OCD.

Black et al. (1992) and Pauls et al. (1995) have observed that OCD in children and adolescents can be a heterogeneous condition, with some cases

being familial and others not. Albert et al. (2002) conducts the most recent family study with 74 probands with OCD onset in childhood and adoles-

cence (mean onset age is 12.1 years). First-degree relatives were diagnosed either using the family-history or the family-study method. Eleven percent of

the probands had at least one family member with OCD, which is again in the range of previous estimates. The interesting result of this study however is the finding that there is no significant difference between the phenomenological characteristics of OCD probands with OCD family

members and OCD probands with normal family members.In summary, family studies suggest that genetic factors lead to a certain

vulnerability of children and adolescents to develop OCD. The estimates of the rate of OCD in first-degree relatives from the studies discussed

above range from 3% to 15%. However, if the obsessive-compulsive behavior of first-degree relatives is included, then the range in-

creases to 17-35%, which is overwhelmingly higher than the normal prevalence rate of 1-2%. The big differences in the

estimates appear to be mainly due to different methodolo-gies used. As already mentioned, some include control groups, other did not. Some base their diagnoses of the relatives from direct structured interviews, other used data from existing data on relatives in the folders of child probands. Despite all those differences, the re-sults of the family studies are in favor of a heritable factor in OCD. Moreover, symptom patterns have generally been observed to differ between probands and relatives, making an environmental explanation

less likely.Besides the traditional family studies on OCD, more

recent studies on family transmission have focused on comorbidity between OCD and other disorders. Bellodi

et al. (2001) proposed for instance that eating disorders should be considered a specific type of OCD. They found

that the morbidity risk for obsessive-compulsive spectrum dis-orders was significantly higher among the first-degree relatives of

the eating disorder probands (adolescent females) than among the relatives of the controls. Grados (2001) examined whether tic disorders

are part of the familial phenotype of OCD. Their results show that OCD probands and their first-degree relatives had a greater lifetime prevalence of tic disorders compared to controls. Younger age-at-onset of OCD symptoms and male gender in the OCD probands were associated with increased tic disorders in relatives. Such studies are limited by being unable to neutralize the environ-mental effect contrary to adoption studies and particularly the subtype of cross fostering design to exclude environmental effects, although no research articles are available with this methodology as the case for adults.

Twin studies have provided some additional evidence for the heritability of OCD. These studies provide some indication of the relative rates for concordant and discordant Monozygotic and Dizygotic twin pairs. The method used consists


the interesting result of this study however is the finding that there is no significant difference between the phenomenological characteristics of oCd probands with OCD family members and OCD probands with normal family members.

of their first-grade relatives. A control group of similar dimensions was included. The first-degree relatives of probands diagnosed with OCD had a nearly 5-fold higher lifetime prevalence of OCD when compared to the controls. The median age at onset of symptoms was about 11 years; more than 75% of the probands had onset by age 14 years, and 90% by age 17 years. The prevalence of OCD in the relatives of probands with an onset age below 17 was 38 (13.8%) of 276, whereas the prevalence



Authors Sample size / Mean Age Methodology Results

Bellodi et al.(2001)

Probandsn = 136 (M = 22.12; SD = 4.93)Controlsn = 72 (M = 39; SD = 12.84)Case Relatives n = 436Father: M = 53.54; SD = 7.60Mother: M = 49.80; SD = 8.90Brothers: M = 23.30; SD = 9.21Sisters: M = 22.97; SD = 8.71Control Relativesn = 358Father: M = 64.63; SD = 12.22 Mother: M = 61.87; SD = 11.73Brothers: M = 36.97; SD = 14.97Sisters: M = 43.20; SD = 14.57

Utilized family study and family history methods.

Studied the prevalence of obsessive-compulsive spectrum disorders in first-degree relatives of probands with eating disorders.

Proband inclusion was determined by clinical diagnosis

First-degree relatives of probands were interviewed directly or were evaluated by family history methods to determine symptoms.

The morbidity risk for obsessive compulsive spectrum disorders was found to be higher among relatives of eating disorder probands in comparison to the control group. These findings were independent of a comorbid obsessive compulsive spectrum disorders in the eating disorder probands.

Black et al.(1992)

Probands n = 32 (M = 38.3; SD = 10.9)Controlsn = 33 (M = 38.1; SD = 10.0)Case Relativesn = 120 (Interviewed)M = 41.8; SD = 15.7Control Relatives n = 129 (Interviewed)M = 41.1; SD = 15.7


Included OCD and subsyndromal OCD symptoms

Probands met DSM-III criteria for OCD.

Relatives were evaluated with structured and unstructured interview methods as well as several scales and inventories

The morbidity risk for anxiety disorders was increased among the relatives of OCD participants, but the risk of OCD was not.

First-degree relatives of probands with OCD are significantly more likely to experience anxiety disorders than relatives of psychiatrically normal controls.

Risk for obsessive compulsive symptoms (not meeting the full criteria for OCD) was increased among parents of OCD participants but not among the parents of controls

Nestadt et al(2000)

Probandsn = 80 (M = 36.6; SD = 11.6)Controlsn = 73 (M = 38.5; SD = 11.8)Case Relatives n = 343 (M = 48.1; SD = 18.9)Control Relatives n = 300 (M = 44.5; SD = 18.8)


Probands met DSM-IV criteria for OCD.

Collected data on OCD as well as obsessions and compulsions

Relatives were evaluated with direct interviews using structured and semi-structured instruments; family history information was collected through informant; various inventories were used

The lifetime prevalence of OCD was significantly higher in case relatives when compared with control relatives

The prevalence of definite and probable OCD was higher in case relatives

Case relatives had higher rates of both obsessions and compulsions – obsessions are more specific to familial aspect of OCD

Grados et al.(2001)

Probandsn = 77Controlsn = 66Case Relativesn = 323Control Relativesn = 289


Probands met DSM-IV criteria for OCD.

Probable and definite diagnoses of tic disorders and OCD were considered in the analysis.

The prevalence and severity of tic disorders and age-at-onset of OCD symptoms and were analyzed in relatives

Symptoms and severity were assessed by direct interviews, collateral informants, as well as several scales

Case probands and case relatives had a greater lifetime prevalence of tic disorders compared to control subjects.

First-degree relatives with OCD with tic disorders have an earlier age-at-onset of OCD symptoms compared to those that have OCD without tic disorder

Younger age-at-onset of OCD symptoms were associated with increased tic disorders in relatives.



Last et al.(1991)

Anxiety Probandsn = 94ADHD Probandsn = 58NPI Probandsn = 87Anxiety Case RelativesFirst Degree – n = 274Second Degree - n = 812ADHD Case RelativesFirst Degree – n = 152Second Degree – n = 484NPI Case RelativesFirst Degree – n = 240Second Degree – n = 718


First and second-degree relatives of children with anxiety disorders were compared with relatives of children with ADHD and children who have never had a psychiatric condition.

Probands met DSM-III-R criteria for their OCD or ADHD

Utilized direct structured interviews and diagnostic scales, as well as the family history method with first-degree relatives.

Second-degree relatives were assessed using the family history method.

Increased prevalence of anxiety disorders in the first-degree relatives of children with anxiety disorders compared with relatives of children with ADHD and normal controls

OCD and panic disorder were the only two anxiety disorders that showed a suggestion of a specific relationship in children and their relatives.

The specificity of the familial component involved in childhood anxiety disorders varies between disorders.

Lenane et al.(1990)

Probandsn = 46Case relatives n = 145


Structured interviews, family histories and several inventories were used to assess DSM-III OCD criteria, subclinical OCD and related symptoms, and other psychiatric disorders

30% of case probands had at least one first-degree relative with OCD - 45% of fathers and 65% of mothers received one or more other psychiatric diagnosis.

Results showed a larger familial rate of OCD over what is expected in the general population

The presenting obsessive-compulsive symptoms of case probands and their parents were usually dissimilar, which argues against simple social or cultural transmission.

Pauls et al.(1995)

Probands with OCDn = 100Probands without OCDn = 33OCD Case Relatives n = 466Non-OCD Case Relativesn = 113


Probands met criteria for DSM-III-R OCD.

Definite and probable (sub-threshold) diagnoses were used in analysis

Available first-degree relatives were interviewed directly with structured interviews, and family histories were taken from each informant using a semi-structured interview. Several scales were also used to assess symptoms.

The rates of OCD and sub-threshold OCD were significantly greater among the relatives of the case probands with OCD than among the comparison subjects.

The rates of tics were also significantly greater among the relatives of the case probands than among the comparison subjects.

The relatives of case probands with early onset were at a higher risk for both OCD and tics

Albert et al. (2002)

Probandsn = 74 (M = 34.3; SD = 11.8)Case Relatives n = 251 (Total)n = 231 (Directly interviewed; M = 42.5; SD = 21.3)


Probands met DSM-IV criteria for OCD

Utilized structured and semi-structured clinical interviews as well as rating scales with available relatives.

Information about unavailable relatives was collected through structured family history interviews with the proband and other family members as informants.

Data was collected on specific OCD symptoms and phenomenology

11% of the case probands had at least one family member with OCD.

There were no differences between the two types of OCD (familial versus non-familial) except for life events prior to the onset of OCD, which were more common and more severe.

There is a familial component in the expression of some forms of OCD.

Familial OCD patients are not characterized by peculiar clinical features, but appear to have a lower threshold for precipitating events. in non-familial OCD subtypes.

Riddle (1998) N/A

Provides and overview of pediatric OCD in terms of age of onset, classification, subtypes, prevalence, assessment, prognosis, and treatment.

Treatment components include long-term commitment, care management, and illness education—including CBT, behavior management, and medication.

The most effective treatments are SSRIs and exposure/response prevention.

Toro (1992)

Probandsn = 72 (M = 12.0; SD = 3.29)Controln = 72(Matched for age, sex, and date of consultation)

Clinical records of children with a DSM-III-R diagnosis of OCD were examined.

The presence of psychiatric history in first-degree relatives was examined. Only diagnoses formulated by specialists and stated in clinical records of obsessive children were considered.

57% of case probands had some first degree relative with a psychiatric diagnosis

15.3% of first-degree relatives were diagnosed with OCD.

Authors Sample size / Mean Age Methodology Results

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of comparing the number of MZ twins in which both members have OCD with the number of corresponding DZ twin pairs. If the concordance of MZ twins is higher than in DZ twins, genetic factors are certainly contributing to the development of OCD. Un-fortunately, no recent twin studies exist. But in general studies from 1980s and early 1990s find a concordant MZ:DZ ratio of 2:1 for OCD, which further supports the effect of genes on the onset of OCD in children and adolescents (Billett et al., 1998).

Family aggregation of OCD is necessary, but not sufficient, for the interference of genetic transmission, because parents and rela-tives transmit not only genes to their children, but also sociocul-tural factors that can lead to different phenotypes. In other words, common environmental factors can also contribute to the develop-ment of OCD in children with different genes. The best way to an-alyze environmental factors is to conduct adoption and separation studies. Unfortunately, such studies are nonexistent in the context of OCD due to the fact that extremely few children or twins with OCD are taken apart and adopted by different families. Studies on twins (concordance rate among monozygotic twins sharing 100% of the nuclear DNA versus dizygotic twins sharing only 50% of nuclear DNA) and adoption studies are lacking in the literature for this specific age group.

Once genetic factors were found to play a role in the early onset of OCD during childhood and adolescence, the main focus of research shifted away from family and twin studies, and concentrated on the application of DNA technology to the study of OCD. Therefore, most recent literature on the genetics of OCD is found in the area of molecular genetics where researchers try to isolate the specific genes (the common genes implicated in the etiology of OCD like those of MAO-B enzyme on the X chromosome, 5-HT reuptake proteins, 5-HT 2a and 2c receptors) which seem to be responsible for the early onset and development of OCD (Pato et al, 2002).

Psychological factorsWhile OCD is widely recognized to have a strong genetic compo-nent, psychosocial factors are also acknowledged to be important. The primary focus of this section is on familial and cultural/reli-gious context as possible risk factors in the development and main-tenance of the disorder in children and adolescents.

Freeman et al. (2000) presents the case of 10-year old boy and a 7-year-old girl diagnosed with OCD. The boy had been repeat-edly sexually abused by an older peer, and the obsession concern-ing contamination by germs and sexual images started immediately after the abuse stopped. No family history of OCD was found in the family, thus environmental factors (abuse by peers) seem to be the trigger of OCD. The case of the girl involves an incident of unwanted “sex play” with a peer. After this incident compulsive hand washing rituals developed. This shows the important role of guilt feelings of being the victim to sexual abuse provoked by the conscience in OCD psychopathology. When subjected to traumatic events children and adolescents often blame themselves. A common example of that is that many children see themselves as the reason their parents marriage ended in divorce and moreover interpret the events leading up to it as if they were among causes of such divorce. Children with their immature cognitive structures may have their own way of attributing cause-event relation, and are more liable for


self-blaming. The mother of the girl had OCD, which is a possible factor for the predisposition of her daughter, but the trigger was clearly an environmental factor (the “sex play”). These two cases suggest that OCD is a heterogeneous condition. Genetics can play a role, but environmental factors can be not only a trigger but the main reason for developing OCD in children.

A more recent study by Lochner et al. (2002) explores the link between a traumatic event in childhood and the development of OCD in children and adolescents. 74 female probands and 31 con-trols were included in the study. The age of the probands was as low as 12, but there were no exact numbers on the percentage of chil-dren or adolescents. The OCD probands exhibit much higher rates of severe childhood trauma (sexual and physical abuse as well as emotional neglect) than the controls, thus indicating that traumatic events in the childhood may be the reason for the early onset of OCD. This finding is further supported by Mangold et al. (2000) who found that boys with a family history of alcoholism reported more obsessive-compulsive behavior than females and controls.

Religion as a part of the cultural and familial environment can also play a key role in the genesis of OCD in children and adoles-cents. Although the epidemiology of OCD appears to be stable across cultures (Weissman et al., 1994), patients with religious ob-sessions may be over-represented in clinical populations of Muslim and Jewish cultures, as compared with clinical populations from the West and the Far East. The frequency of religious obsessions in clinical populations diagnosed with OCD is reported to be be-tween 5-10% in USA and Western Europe, as compared to 40-60% in Saudi Arabia, Israel and Egypt (Tek et al., 2001).

Tek et al. (2001) conducted a study with 45 patients diagnosed with OCD in Turkey. Religious obsessions were the main symp-tom of OCD in nineteen of the patients. Patients with religious obsessions, many of them adolescents, were significantly younger than patients without them. A family history of OCD character-ized 40% of the patients without religious obsessions and 45% of those with religious obsessions. Although the study does not men-tioned whether the OCD of the relatives was religious in nature, it can be concluded that such a high percentage of genetic loading is improbable when compared with the results of the family studies in the section on genetic factors above. It is more likely that religious obsessions and rituals performed by parents were observed by chil-dren and adolescents and contributed strongly to the development of OCD, without neglecting the fact that genetics play a role in the vulnerability and predisposition of such children.

Moreover, religious rituals often involve decontamination and pu-rification practices. In many religions the blasphemous thoughts are brushed off through repeated prayers or alleviating the guilt about committing a sin through confession in certain cultures. All these factors certainly increase the development of obsessive thoughts and compulsive behaviors based on religious teachings and practices. In some societies, religion plays a more dominant role than in others. Under pressure by society, family, and peers, or through education in religious schools, children and adolescents are more likely to develop OCD with religious obsessions.

Rituals are more common in Muslim and Jewish cultures, as both have many rituals as part of their religious practice represent-ing a medium to carry those obsessive symptoms. For example it is common in religions like Islam to pray several times a day at

specific scheduled times during the day and night. Washing rituals and other practices may be included in the daily activities of a person’s life. Blasphemous thoughts as a medium for obsessive thoughts are quite common in communi-ties where religious practices are widely present. The most recent study in the area takes religious education into account. Sica et al. (2002) examined 165 probands which were classified in three groups ac-cording to the degree of their religiosity. All probands were from Italy, a country where the Catholic religion plays a central role in the society. One central question in determining the religiosity was regarding attending a religious (Catholic) school. Individuals with a high or medium degree of re-ligiosity showed higher levels of OCD than individuals with a low degree of religiosity of the same age, educa-tion and gender. Furthermore, perfectionism was one of the dominant symptoms, which the authors link to the teaching of the Catholic religious thought at reli-gious schools.

Okasha et al. (2001) studied the prevalence of ob-sessive-compulsive symptoms (OCS) in a large sample of Egyptian adolescents. The risk and cultural factors associated with obsessive compulsive behavior include female gender, and first born, with aggressive, contami-nation, religious obsessions, and cleaning compulsions being most common.

In summary, recent evidence indicates that besides ge-netic factors, environmental factors can play an important role in explaining the early onset of OCD in children and adolescents. Traumatic events or familial relations can be the main trigger for OCD in children without any family history of OCD. At the same time, environmental factors can be the de-cisive event that unleashes an underlying genetic vulnerability to OCD in children with family history of OCD.

ConclusionsOne of the main features of OCD is its onset which begins for the overwhelm-ing majority of patients in childhood or adolescence. Many different develop-mental theories have been suggested in order to explain the early onset of OCD and its contributing factors. Genetic models emphasize the genetic transmis-sion of OCD from one generation to the next, neurological models suggest different malfunctions in the brain which in turn influence behavior, psy-chological studies have focused on cognitive distortions and psychosocial factors as the main contributors to the pathogenesis of OCD, and learning theories use conditioning to explain the onset of obsessions and compulsions. Although each of these theories has a certain degree of empirical support, there is no comprehensive model that can evaluate and order the different develop-mental pathways involved in the pathogenesis of OCD. Bolton (1996) proposes a neurodevelopmental pathway and a cognitive developmental pathway, but dis-regards genetics and environmental factors such as cultural and familial aspects.

Epidemiological and clinical data from a variety of cultural and geographic settings on obsessive-compulsive disorder, and many of the obsessive-compul-sive spectrum disorders, suggest that this is a group of disorders with a good degree of transcultural homogeneity (Matsunaga & Seedat, 2007). However, the content and themes that predominate in patients with these disorders and the course of the illness can be shaped by cultural, ethnic, and religious experi-ences. Across cultures, OCD is commonly comorbid with mood, anxiety and impulse-control disorders.


After this incident com-pulsive hand washing rituals developed. this shows the important role of guilt feelings of being the victim to sexual abuse provoked by the conscience in OCD psychopathology.



Future research in different areas such as molecular genetics, neurobiology, cognitive psychology, etc. should not emphasize so much the specific perspective, but should try to integrate different approaches and empirical finding in order to better explain the de-velopment and maintenance of OCD in children and adolescents.

References Albert, U., Maina, G., Ravizza, L., Bogetto, F. (2002). An exploratory study on obsessive-compulsive disorder with and without a familial component: Are there any phenomenological differences? Psychopathology, 35(1), 8-16.

Alsobrook, J., & Pauls, D. (1998). The genetics of obsessive-compulsive disor-der. In: Jenike, M., Baer, L. (eds.): Obsessive-compulsive disorders: Practical Man-agement, Toronto: Mosby.

American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders. (4th ed., Text revision). Washington, DC.

Bellodi, L., Cavallini, M., Bertelli, S., Chiapparino, D., Riboldi,, C., Smeraldi, E. (2001). Morbidity risk for obsessive-compulsive spectrum disorders in first-degree relatives of patients with eating disorders. American Journal of Psychiatry, 158(4), 563-569.

Billett, E., Richter, M., Kennedy, J. (1998). Genetics of obsessive-compulsive disorder. In: Swinson, R., Antony, M., Rachman, S., Richter, M. (eds.): Obses-sive-compulsive disorders: Theory, research, and treatment. New York: Guilford.

Black, D., Noyes, R., Rise, B., Goldstein, R., & Blum, N. (1992). A family study of obsessive-compulsive disorder. Archives of General Psychiatry, 49, 362-368

Bolton, D. (1996). Annotation: Developmental issues in obsessive compulsive disorder. Journal of Child Psychology and Psychiatry, 37, 131-137.

Evans, D., Leckman, J., Carter, A., Reznick, J., Henshaw, D., & Pauls, D. (1997). Ritual, habit and perfectionism: The prevalence and development of compulsive-like behavior in normal young children. Child Development, 68, 58-68.

Freeman, J., Leonard, H. (2000). Sexual obsessions in obsessive-compulsive disorder. Journal of the American Academy of Child and Adolescent Psychiatry, 39(2), 141-142.

Geller, D., Biederman, J., Faraone, S., Agranat, A. (2001). Developmental as-pects of obsessive-compulsive disorder: Findings in children, adolescents, and adults. The Journal of Nervous and Mental Disease, 189 (7), 471-477.

Grados, M. (2001). The familial phenotype of obsessive-compulsive disorder in relation to tic disorders: The Hopkins OCD Family Study. Biological Psychiatry, 50 (8), 559-565.

Hanna, G. (1995). Demographic and clinical features of obsessive-compulsive disorder in children and adolescents. Journal of the American Academy of Child and Adolescent Psychiatry, 34 (1), 19-27.

Last, C., Hersen, M., Kazdin, A., Orvaschel, H. (1991). Anxiety disorders in children and their families. Archives of General Psychiatry, 48(10), 928-934.

Lenane, M., Swedo, S., Leonard, H. (1990). Psychiatric disorders in first-degree relatives of children and adolescents with obsessive-compulsive disorder. Journal of the American Academy of Child and Adolescent Psychiatry, 29, 407-412.

Leonard, H., Goldberger, E., Rapoport, J., Cheslow, D., & Swedo, S. (1990). Childhood rituals: Normal development or obsessive-compulsive symptoms? Journal of the American Academy of Child and Adolescent Psychiatry, 29, 17-23.

Lochner, C., du Toit, P., Seedat, S., Niehaus, D., Stein, D. (2002). Childhood trauma in obsessive-compulsive disorder, trichotillomania, and controls. De-pression and Anxiety, 15(2), 66-68.

Mangold, D., Peyrot, M., Giggey, P., Wand, G. (2000). Endogenous opioid activity is associated with obsessive-compulsive symptomology in individuals with a family history of alcoholism. Neuropsychopharmacology, 22(6), 595-607.

March, J., & Leonard, H. (1996). Obsessive-compulsive disorder in children and adolescents: A review of past 10 years. Journal of the American Academy of Child and Adolescent Psychiatry, 35(10), 1265-1273.

Matsunaga, H. & Seedat, S. (2007). Obsessive-compulsive spectrum disorders: Cross-national and ethnic issues. CNS Spectrums, 12(5), 392-400

Nestadt, G., Samuels, J., Riddle, M., Bienvenu, J. & Liang, K. (2000). A family study of obsessive-compulsive disorder. Archives of General Psychiatry, 57, 358-363.

Okasha, A., Ragheb, K., Attia, A. H., Seif El Dawla, A., Okasha, T. & Ismail, R. (2001). L’Encephale, 27(1), 8-14)

Pato, M., Pato, C., Pauls, D. (2002). Recent findings in the genetics of OCD. Journal of Clinical Psychiatry, 63 (Supp. 6), 30-33.

Pauls, D., Alsobrook, J. I., Goodman, W., Rasmussen, S., & Leckman, J. (1995). A family study of obsessive-compulsive disorder. American Journal of Psychiatry, 143, 76-84.

Riddle, M., Scahill, L., King, R., Hardin, M., Towbin, K. (1990). Obsessive-compulsive disorder in children and adolescents: Phenomenology and family history. Journal of the American Academy of Child and Adolescent Psychiatry, 19, 766-772.

Riddle, M. (1998). Obsessive-compulsive disorder in children and adolescents. British Journal of Psychiatry, 173 (Supp. 35), 91-96.

Sica, C., Novara, C., Sanavio, E. (2002). Religiousness and obsessive-compul-sive cognitions and symptoms in an Italian population. Behaviour Research and Therapy, 40(7), 813-823.

Tek, C., Ulug, B. (2001). Religiosity and religious obsessions in obsessive-com-pulsive disorder. Psychiatry Research, 104(2), 99-108.

Toro, J., Cervera, M., Osejo, E, Salamero, M. (1992). Obsessive-compulsive disorder in childhood and adolescence: A clinical study. Journal of Child Psy-chology and Psychiatry, 33, 1025-1037.

Valleni-Basile, L., Garrison, C., Jackson, K., Waller, J., McKewown, R., Addy, C., & Cuffe, S. (1994). Frequency of obsessive-compulsive disorder in a com-munity sample of young adolescents. Journal of the American Academy of Child and Adolescent Psychiatry, 33, 782-791.

Weissman, M. M., Bland, R. C., Canino, G. J., Greenwald, S., Hwu, H. G., Lee, C. K., Newman, S. C., Oakley-Browne, M. A., Rubio-Stipec, M., & Wickramaratne, P. J. (1994). The cross national epidemiology of obsessive compulsive disorder. Journal of Clinical Psychiatry, 55(Suppl), 5-10.

ABouT THE AuTHoRDR. KARIN TOCHKOV is an Assistant Profes-sor and Director of the Master’s Program in Clini-cal Psychology at Texas A&M University – Com-merce. A native of Germany, she completed her undergraduate work in Psychology at the Ru-precht Karls University in Heidelberg, Germany. She received her Ph.D. in Clinical Psychology from the State University of New York at Albany in 2007. As head of the Addictive Behaviors Re-

search Laboratory, Dr. Tochkov’s research focuses on the role of emo-tions and cognitive distortions in the development and maintenance of addictive behaviors. The results of her research have been present-ed at several national and international conferences, including the Annual Convention of the Association for the Advancement of Be-havior Therapy, the British Psychological Society Annual Meeting, and the World Congress of Psychology. Her publications have appeared, among others, in Judgment and Decision Making and International Gambling Studies. At Texas A&M University - Commerce, Dr. Tochkov regularly teaches graduate classes in Psychopatholgy, Assessment, and Group Psychotherapy. On the undergraduate level Dr. Tochkov teaches classes in Abnormal Psychology and Theories of Personality. She is also chairing the dissertation and thesis committees of students in the Educational Psychology Ph.D. program and the Master program in Clinical Psychology at Texas A&M University – Commerce. In 2010 Dr. Tochkov received the Provost Award for Research & Creative Activ-ity at Texas A&M University - Commerce and in Spring 2011 the Stu-dent Recognition Award for Teaching Excellence from the Texas A&M University System.


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2011ExEcutivE Summit

October 12–14BranSon, miSSouri

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Members enjoyed interacting with a

variety of exhibitors.

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annals oF psYChotherapY &

integratiVe health

35 the art oF tai Chi46 natural remeDies: milk thistle

56 guiDeD meDitation For waking up anD Coming home

Tai Chi was brought about for creating a balance

between mind, body, and nature, while encouraging

a heightened state of health and wellness.

Chuck Mercer / Tai Chi instructor at St. Johns Fitness Center, Springfield MO for 20 years.

By Trysta HerzogArt o

f

tai chiTa

i chi

is ab

out creating a foundation with the form, building on the

met

hod w

ith m

ovements, and creating a relationship be

twee

n mov

ements, all the while developing theJing, or

esse

nce; Chi (Qi), or vital energy;

and Shen, or spirit, within.

Tai chi opponents are not met w

ith

the sam

e rigidity of other Chinese marti

al ar

ts—

with force—but with def ection and using th

e

attacker’s own force against

him

Tai Chi History

By watching the slow, deliberate, and graceful steps of tai chi, the last use you might envision for the beautiful art form would be as a self-defense tool. However, out of the development of martial arts about eight centuries ago, tai chi was brought about for just that purpose: creating a balance between mind, body, and nature, while encouraging a height-ened state of health and wellness.

Tai chi opponents are not met with the same ri-gidity of other Chinese martial arts—force meeting with force—but with deflection and using the at-tacker’s own force against him.

The five leading tai chi styles—Chen, Yang, Wu/Hao, Wu, and Sun, respectively—are connected in their history as well as the energies they attempt to stimulate within their practitioners; they differ, however, in their interpretations of the original 13 movements and form.

Tai Chi Philosophy

For 20 years, Yang Jun said he’s taught many differ-ent types of students, but sees a commonality be-tween them.

“People come to try to understand life—try to find balance and understanding from tai chi,” he said. “You are following the philosophy of the kite in practice.

It is through constant practice, he said, that this inner peace can be reached, especially when you’re practicing with another person.

“Movements come from outside of things; it is the balance between you and another. Tai chi is very simple, but two things that keep changing—move-ments like left hand, right hand, left hand, right hand—it becomes very complicated.”

Tai chi is about creating a foundation with the form, building on the method with movements, and creating a relationship between movements, all the while developing the Jing, or essence; Chi (Qi), or vital energy; and Shen, or spirit, within.

“If you just know the movements, there’s no meaning behind it. First you have the philosophy to guide you, and then the steps will gradually show you how to do it. Nurture your energy, your skill, and your foundation.”

Master Yang Jun

Master Yang JunOriginating in the Hebei province of China during the early 1800s, the Yang style was first developed by Yang Lu Chan, who had been sent at a young age to train with the 14th generation Chen family. He later was hired to train the Chinese Imperial family. Now, six generations later, Master Yang Jun is keeping alive his family’s tradition of teaching others the martial art.

“At the beginning it was not my intention to start practicing tai chi,” he said. “I was actually just scared to be by myself.”

At five years old, Yang lived in China with his grandfather Master Yang Zhen Duo, who like many other Chinese residents practiced tai chi early each morning.

“My grandfather would lock me in the room and leave. I was scared, so the next day I ask, ‘Please take me with you.’ Sometimes after school, I wanted to play with the other kids, but my grandfather made me prac-tice. I didn’t know it then, but he wanted to have someone to continue the family art.”

Now proficient in tai chi chuan, sword, saber, push hands, and many other forms of tai chi, 43-year-old Yang Jun has operated a tai chi school in Seattle, Washington, since 1999 with his wife, Fang Hong—also a tai chi instructor—and their two children. The year before that, he began the International Yang Family Tai Chi Chuan Association.

He is also the first in the Yang family to live outside of China, taking with him the Yang style to teach across the United States and the world.

Chen: Fast and slow combined together with some jumping and stomping movements. Old form and cannon fist was created from the 17th generation.

yang: Started from the old form/frame from the Chen family. Yang movements are slow, even, gentle, big, and large.

wu/hao: First Wu style came from Yang and Chen styles and is slow, smooth, and small, and the posture is high with a smaller frame.

wu: Second Wu style comes from Quanyu who learned from Yang Ban Hou. They lean their body to the side, but when they lean they think about being straight.

sun: Movements combine three styles of tai chi together, Wu, Hsing-I, and Bagua.

Tai Chi Styles

www.yangfamilytaichi.com

38 Fall / Winter 2011 Annals of Psychotherapy & Integrative Health www.aaimedicine.com

5 Master Yang Jun

Mas

ter Y

ang

Jun

Annals of Psychotherapy & Integrative Health - Fall and Winter 2011 (Sample)

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Transcript of Annals of Psychotherapy & Integrative Health - Fall and Winter 2011 (Sample)