Chapter 23: Obsessive-Compulsive Disorder

and Trichotillomania

Jennifer CowieMichelle ClementiDeborah C. BeidelCandice A. Alfano

Overview

DSM-5 changes

Obsessive-Compulsive and Related Disorders category

Includes OCD and Trichotillomania (TTM)

OCD and TTM may be related due to: 1) Presence of repetitive behavior2) Similar response to pharmacological treatments3) Higher than expected rates of TTM among relatives of OCD

patients and vice versa

Relationship between the two disorders is not clear

OCD

Prevalence: 2–3% by late adolescence (Zohar, 1999)

Average age onset: 10 years oldRange 5–18 years

Core features: obsessions and compulsionsObsessions: intrusive, unwanted thoughts or feelings that create

significant distressCompulsions: ritualistic behaviors performed in an effort to relieve

distress

When only one component is present, children (relative to adolescents) are more likely to present with compulsions rather than obsessions

Trichotillomania

Defined: recurrent pulling out of one’s hair

Lifetime prevalence rate: 0.6% in adults

Hair pulling often occurs in conjunction with: Negative emotions (e.g., stress, irritation, doubt)When the individual is sitting alone (e.g., doing homework)After significant life events (e.g., starting school)

Two subtypes of hair pulling: “Focused”: Hair pulling occurs under conscious awareness“Autonomic”: Hair pulling occurs outside of awareness (e.g.,

during sedentary or mindless activities, such as watching TV)

TTM

Survey of 133 youths with TTM aged 10 to 17 found that most common sites of hair pulling are: Scalp (86%), eyelashes (52%), eyebrows (38%), pubic region

(27%), legs (18%), arms (9%)

Some children eat the hair

In certain instances, hair pulling co-occurs with thumb sucking

Mean age onset: early to midadolescence (Duke et al., 2009)

Psychosocial Treatment for OCD

CBT consisting of exposure and response prevention (ERP) is the treatment of choice for children and adolescents with OCD

Goal of ERP is to weaken associations between obsession and anxiety, and between compulsions and experiencing anxiety relief

Exposure hierarchy developed: begins with easier tasks and works up to more challenging tasksExposures should not be discontinued until the child’s SUDS

ratings have decreased by at least 50% from the peak anxiety rating

Exposures

In vivo exposures: Child confronts the feared stimulusFor example by touching an item believed to be contaminatedTo promote generalization, exposures can be conducted outside of

sessions in other anxiety-provoking settings (e.g., school, home)

Imaginal exposures: may be necessary when obsessions include inappropriate content or are not easily reproduced in the treatment setting

Exposures that are more vivid and realistic are more effective (Piacentini et al., 1994)

Research examining efficacy of ERP indicates that exposure is the most critical component in the treatment of pediatric OCD

Cognitive Restructuring

Consists of identifying and relabeling obsessive thoughts in order to achieve some “distancing” from OCD symptomsE.g., “I’m not really going to make my mom die if I don’t say

good-bye to her. It’s just my OCD talking.”

Behavioral experiments can be useful to test the veracity of thoughts directly (i.e., testing the power of a thought to make something happen)

Cognitive restructuring can help some children cope with extreme anxiety during difficult exposures

Other Components of CBT for OCD

Psychoeducation: OCD described as a neurobiological disorder using a medical model; symptoms viewed as external from the child

Anxiety management techniques: includes diaphragmatic breathing, progressive muscle relaxation, constructive self-talk, humorous visualizations (e.g., picturing OCD as a funny cartoon character)

Contingency management: rewarding a child for attempting or completing in-session exposures or homework

Relapse prevention: any unrealistic expectations are addressed (e.g., belief that symptoms will completely disappear)

Psychosocial and Pharmacological Treatments for OCD

SSRIs (e.g., fluoxetine, fluvoxamine) commonly used to treat pediatric OCD (Geller et al., 2003)

Children treated with SSRIs report reduced symptoms, but often symptoms still remain severe enough to meet most clinical trials’ entrance criteria (March et al., 2004)

33% fail to benefit from pharmacotherapy alone

Children who receive combined CBT and pharmacotherapy (i.e., sertraline) showed significant greater reduction in symptoms than those treated with CBT or medication alone

Psychosocial interventions are first line of treatment for pediatric OCD Pharmacological interventions recommended in combination with CBT for more

severe cases of the illness (Geller & March, 2012)

Treatment for Trichotillomania

Behavioral therapy (BT) with habit reversal training (HRT) for treating adults with TTM is well establishedStudies for BT in children with TTM are limited

Some success in children with a range of traditional BT: Overcorrection: engage in positive practice of having children

comb or brush their hairAnnoyance review: having children acknowledge the

problematic nature of hair pulling and their reasons for wanting to stop

Differential reinforcement of other behavior: giving the child attention only when pulling behavior is absent

Parent Involvement: OCD

Parents and siblings often accommodate a child’s ritualistic behaviorReinforce a child’s irrational belief and may undermine

therapy

Parental involvement in symptoms has been found to be related to greater symptom severity (Bipeta et al., 2013)

Parent components have been added to CBT trials; however, no clear findings determined

Parent Involvement: TTM

Parents critical to success

During awareness training of HRT, parents play essential role in assisting with identification of pulling behavior

Parents may unintentionally reinforce pulling behavior by providing negative attention or access to tangible itemsImportant to assist parent in utilizing consistent reinforcement

Family conflict and parental frustration can confound treatment outcome

Adaptations and Modifications: OCD

Psychosocial interventions can be modified for younger children with OCDChildren as young as 5 can be treated with evidence-based

approaches (March et al., 2004)

Make developmentally driven modificationsE.g., many young children have difficulty fully understanding the

rationale of exposure tasks, so psychoeducation can be conducted separately with the parent to ensure parental understanding of treatment

Comorbid diagnoses: may attenuate treatment response

Group-based or technology-based treatments

Intensive Treatments OCD

Youth with treatment-resistant OCD may benefit from more intensive treatments

Example: Bjorgvinsson and colleagues (2008) studied 23 adolescents with treatment-resistant OCDTreatment: medication management and 90-minute ERP

sessions followed by 60 minutes of self-directed exposures; at three evenings per week

Results: significant reductions in obsessions, compulsions, state and trait anxiety

Adaptation and Modification: TTM

Selection of specific intervention components dependent on the child’s ageE.g., cognitive strategies may be more appropriate for

older children and adolescents whereas younger children may be more motivated by rewards

To increase likelihood of compliance: 1) Keep the self-monitoring as simple as possible (no

more than one page per day)2) Small rewards for completion of self-monitoring and/or

behavioral assignments

Assessment: OCD

Diagnostic interviews, clinician ratings, child and parent report, self-monitoring, behavioral assessment Depending on the child’s age, diagnostic and clinical interviews might be

conducted privately with adolescents but in the presence of parents for younger children

Treatment effects often measured with semistructured interviews and clinician ratings scales (e.g., ADIS, CY-BOCS)

Self-report: LOI-CV, COIS-R

Parent-report: COIS-R

Behavioral avoidance tests (BATs): used to provide objective assessment of OCD symptoms

Self-monitoring

Assessment: TTM

No “gold standard” for assessing TTM

Most tools designs for adult populationsE.g., NIMH Trichotillomania Impairment Scale

Diagnostic interviews: NIMH Diagnostic Interview Schedule for Children specifically assesses for TTM in pediatric populations

Self-monitoring procedures can be implemented to gauge treatment success related to changes in hair pulling urges and frequency

Clinical Case: OCD

Mark: 12-year-old boy

Referred for evaluation of compulsive behaviors: excessive hand washing, needing to touch objects, complete rituals in symmetry

Treatment plan: imaginal and in vivo exposure with response prevention

Outcome: 14 clinic sessions and homework assignments; rituals decreased to less than 5 minutes per day and obsessions less then 10 minutes per day

Clinical Case: Melanie

6-year-old girl

Presenting issues: chronic hair pulling, tends to suck thumb at night while pulling her hair

Treatment plan: psychoeducation about TTM, eliminating attention for hair pulling, hourly sticker plan

Outcome: Measured by counting the number of hairs pulled daily, self-monitoring data useful in determining the efficacy of the program and when to make alterations