CBT with young people and families

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

Cognitive behaviour therapy for OCD

Cognitive behaviour therapy (CBT) for OCD developed as an attempt to increase adherence to ERP, by helping the individual to modify dysfunctional thoughts and beliefs (Salkovskis and Warwick, 1985). However, as theoretical and empirical studies on cognitions in OCD developed, CBT has evolved as a treatment in its own right. It is based on modifying key beliefs and appraisals so that the individual learns that intrusive thoughts are not of special significance and do not indicate increased responsibility or probability of harm. CBT aims to help the individual to construct and test a new and less threatening model of their experience through developing an understanding of how the problem may be working and then testing this out through behavioural experiments to learn that the problem is about thinking and worry, rather than actual danger or harm. Whereas in ERP the individual is encouraged to stop carrying out compulsions, in CBT the individual is encouraged to carry out experiments to identify and challenge their misinterpretations. As a result, they learn that they no longer need to carry out compulsions.

It is clear that CBT is effective in significantly reducing symptoms of OCD and that these gains are maintained post-treatment (Clark, 2004). There is evidence that it is effective with symptoms that have been more difficult to treat with ERP, such as obsessional ruminations and hoarding (Freeston et al., 1997; Hartl and Frost, 1999). More recently, controlled trials with adults have compared CBT to ERP and found CBT to be superior to ERP in reducing symptom severity and shifting obsessional beliefs (Rector et al., 2006; Salkovskis et al., in press).

Cognitions in young people with OCD

There is evidence to suggest that young people in general also experience intrusive thoughts that are no different to those experienced in OCD and that if the thoughts cause distress and/or are more actively managed, they tend to persist for longer (Allsopp and Williams, 1996). Studies comparing young people with OCD to non-anxious controls or young people with other anxiety disorders have sought to investigate whether the same belief domains shown in adults with OCD are present in younger populations. Libby et al. (2004) found that young people with OCD had significantly more responsibility appraisals and beliefs around thought–action fusion than anxious controls. Barrett and Healy (2003) also found inflated responsibility and increased thought–action fusion and higher ratings of harm severity in young people with OCD but that the differences were not significant. This may reflect differences in measures used, or it may be that as this was with a younger sample cognitions may not be fully developed. Nevertheless, they did find the group of young people with OCD were significantly different when it came to cognitive control. This provides some preliminary evidence that young people with OCD demonstrate similar cognitions identified in adults with OCD.

Behavioural treatments of OCD

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

Early studies in adults demonstrated that ERP was a successful treatment (Meyer et al., 1974; Rachman and Hodgson, 1980); around 60 to 70 per cent of individuals with compulsions who completed treatment made significant improvements (Abramowitz, 1996). However, behavioural treatments have been difficult to apply to young people who ruminate or do not have compulsions and treatment refusal and drop-outs have been common. There has been one randomised controlled trial of ERP in young people (Bolton and Perrin, 2008), which found that ERP reduced OCD symptoms substantially as compared with a waiting list condition.

Behavioural models of OCD

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

OCD Brain structure and chemistry

Biological accounts of OCD have sought to explain OCD in terms of general deficits in specific areas of the brain or in differences in neurotransmitters. Studies have focused particularly on serotonin, the neurotransmitter that is known to modulate mood, emotion, sleep and appetite and is implicated in the control of numerous behavioural and physiological functions. The finding that particular medications which act as serotonin reuptake inhibitors (SSRIs) can be effective in reducing OCD symptoms led to the initial hypothesis that there may be an abnormality in serotonin and studies have reported different levels of serotonin in OCD (e.g. Insel et al., 1985; Zohar et al., 1988). In addition, brain scanning studies have been used to suggest that there are biological differences in OCD, such as differing metabolic rates in the part of the brain known as the fronto-striatal system (e.g. Baxter et al., 1988). However, just because differences are found does not necessarily mean that there is a deficit or abnormality. Baxter et al. (1992) demonstrated that the anomalies detected through brain scanning can resolve through medication or behaviour therapy, suggesting that any neurological changes are reversible.

If OCD is caused by biological factors, theories need to be able to account for the effectiveness of treatment and to explain how psychological therapy may work. Theories must also be able to account for the phenomenology of OCD more broadly, such as why memory and decision-making problems only occur in situations linked to the obsessional problem. To progress our understanding, biological accounts of OCD need to be able to generate specific predictions based on the phenomenology of OCD and must be able to provide evidence to evaluate them.