Obsessive Compulsive Disorder: A Critical Analysis - Case Study Example

Obsessive Compulsive Disorder: A Critical Analysis Two-years ago, ago a case study by Wagner presented the following disturbing details of a child afflicted by OCD: Maria was 9 years old when she heard a TV news item about an outbreak of hepatitis that originated at a local bakery. Long after the alarm had subsided, she couldnt stop worrying about it. At first, she feared that she might have contracted hepatitis and began washing her hands with increasing frequency. Then she began to worry that she herself could spread hepatitis and be responsible for the deaths of others. (Wagner, 2008.p.5) The excerpt above shows how OCD can affect lives of even children. What is OCD, to be exact? The National Institute of Mental Health (NIMH) defined Obsessive Compulsive Disorder as “an anxiety disorder characterized by recurrent, unwanted thoughts (obsessions) and/or repetitive behaviors (compulsions)”. Individuals afflicted with this disorder resort to “rituals” such as repetitive cleaning, hand-washing or checking to relieve the anxiety being felt. People with OCD repeatedly wash their hands in the hope that such practice would prevent them from getting contaminated with germs. Ironically, when the aforementioned behavior is not performed, anxiety increases instead of being relieved. A person with the obsessive-compulsive personality disorder is preoccupied with rules, orderliness, and control. It is diagnosed to people whose high expectations are rigorously followed to the point where the behavior becomes persistent and disabling. The people infected with the obsessive compulsive personality disorder tend to annoy the people around them. Ill persons normally find themselves alone later on in life for that reason. For clarification purposes, OCD is a mental disorder which is not similar with having an Obsessive Compulsive Personality Disorder. On the contrary, OCPD is a rare disorder in which only 7.9% of the general population in the United States is sickened with (Internet Mental Health) and the obsessive compulsive personality disorder, according to Phillip W. Long, MD, “is seen in 3% - 10% of psychiatric outpatients.” OCD is characterized by intrusive thoughts such as believing that a devil or another being could possibly harm them or their loved ones. Such thoughts results into behavior that seems paranoid such as being overly protective of people close to them. On the other hand, OCD personality disorder is more concerned with rules, standards, guidelines which make a person a “perfectionist”. OCD is a mental disorder with two different but related components. These are intrusive thoughts, the “obsessive” part of the disorder, and repetitive behaviors, the “compulsive” part of the disorder (Rachman,2003, p.21). Aardema ( 2007) characterized OCD as ego-dystonic which meant that the individual’s elf-concept is not compatible with the disorder ( p.187). On the contrary, OCD personality disorder is ego-syntonic which is defined by Dorland’s Medical dictionary as “ aspects of a persons thoughts, impulses, attitudes, and behavior that are felt to be acceptable and consistent with the self-conception.” The obsessive compulsive personality disorder and obsessive compulsive disorders should not be confused with one another. The two show similar symptoms but OCD is more severe than OCPD. People with OCPD believe that their actions are completely normal while those with OCD know that they are sick but are compelled to act upon their sickness anyway. OCD sufferers have troublesome work experiences while those suffering from OCPD generally suffer from damaging social-relationships Later in this paper, a case about Maria would be presented to show the serious effects of OCD on a young girl’s life. Prevalence of OCD According to medicine.net , disease epidemiology defines “ incidence is the number of newly diagnosed cases during a specific time period”. Prevalence on the other hand meant the number of cases in a specific time period. IN DSM-IV, the prevalence of OCD is illustrated as follows: Community studies have estimated a lifetime prevalence of 2.5% and a one-year prevalence of 0.5%-2.1% in adults….Community studies of children and adolescents have estimated lifetime prevalence of 1%-2.3% and a 1-year prevalence of 0.7%.(DSM-IV,2000,p.460). Moreover, in a 2008 report by NIMH in its website, it cited that no less than “2.2 million Americans age 18 and older have OCD” and early symptoms can be apparent during childhood; however, the onset usually happens at age 19 ( qtd. from nimh.gov,2009). All mental disorders can lead to serious consequences for the individuals who are affected by it. Perhaps among the mental illness known to man, OCD subjects the patients to casual and daily ridicule. People make continual references to being obsessive or compulsive about one thing or another all the time in a way that to someone who actually struggles with OCD can feel slighting and incredibly dismissive. Those who have this condition, far from finding it a joke, can in fact find it crippling and are often deeply ashamed of their thoughts and behaviors. As aforementioned, the disease have both compulsive and obsessive symptoms. Both of these symptoms cause anxiety, and the anxiety increases dramatically if the individual tries to resist either compulsions or obsessions (Rachman, 2003, p. 21). Generally, the obsessions and compulsions are related to each other. For example, if a person has obsessions about cleanliness (a common obsession), then that person is likely to have compulsions around the issue of cleanliness as well – for example he or she might continually clean the kitchen, bleaching the cabinets over and over and scrubbing the floor with a toothbrush. If this individual tries to stop cleaning all the time (or even to stop thinking about cleaning all the time), the persons anxiety level is likely to rise. This results to most cases wherein when individuals have not received treatment, they are very anxious and allow the obsessions and compulsions unfettered access. In short, their daily lives are consumed by OCD. While cleanliness is certainly a common obsession for people with OCD, there are other common obsessions and associated compulsions, including hoarding and focus on religious and sexual issues. Most people with OCD feel ashamed of their feelings and recognize that their actions are irrational. Most people with OCD would like to stop their behaviors and their thoughts. They simply do not know how to do so, and this fact can lead to secondary mental disorders such as depression (Wilson & Veale, 2005, p. 61). Therefore, people with OCD must immediately seek treatment so that intervention can be timely and effective. OCD: Cognitive –Behavioral Theory Cognitive Behavioral Theory is an approach to OCD which views the disease as not clinical but rather behavioral. The main focus of early behavioral theories on OCD were more concerned on “overt compulsive “ behaviors such as hand-washing and flicking of switches (Clark, 2003 ). The first OCD theory can be possibly linked to early theories about anxiety . Nevertheless, the earliest behavioral theory about OCD was b” based on O.H. Mower’s two-stage theory of fear and avoidance “ ( Clark, 2003 ,p.51 ). Later, Rachmann focused his studies on obsessions and compulsions. According to the book Cognitive Behavioral Therapy for OCD “the behavioral model predicts that obsession-prone individuals will be more responsive or sensitive to certain unwanted intrusive thoughts or obsessions” ( p.54). Likewise, the book Obsessive-Compulsive Behavior: Disorder, Theory and Treatment illustrated the difference between normal and intrusive thoughts by stating that: The crucial difference between normal intrusive thoughts and obsessions thus lies in the meaning attached by obsessional patients to their intrusions, as an indication (a) that harm to themselves or to others is a particularly serious risk, and (b) that they may be responsible for such harm (or its prevention).(Menzies & de Silva, 2003, p. 60) Thereby, the most common and non-intrusive treatment used in behavioral therapy for OCD is ERP ( Exposure and response prevention). Although this treatment cannot be the “end all” for certain OCD cases that can be considered resistant, it is an applicable intervention especially for young people with OCD. The following case study presents a young boy with OCD who was treated using Cognitive Behavioral Therapy. OCD : A CASE STUDY The following case was taken from “Covert Symptoms of Obsessive-compulsive Disorder in Children: a Case Study “ by Michael F. Detweiler and Anne Marie Albano. The case was published the Journal of Cognitive Psychotherapy in 2001. The main subject was a 10-year old child who was referred to as Peter. Peter’s symptoms were typical of compulsions such as habitually repeating things until everything felt right. These behavior included flicking light switches, constantly arranging his clothes as well as furniture around the house, hand-waving, and complex bathroom rituals that must be meticulously done before leaving his home. His actions were not limited to the aforementioned behavior , in fact, Peter also resorted to mentally repeating words as well as steps to check himself. Assessment Peter was initially assessed using the “Anxiety Disorders Interview Schedule for DSM-IV (ADIS)” ( Detweiler and Albano, 2001). The result of the ADIS was surprising as it reported that “Peter (and/or his parents) endorsed symptoms consistent with additional diagnoses as well (i.e., generalized anxiety disorder, social phobia, and agoraphobia without a history of panic) ( Ibid) . What is more provoking is the fact that Peter’s self-report assessment revealed that he never experienced anxiety or other depressive symptoms correlated with OCD. The case thoroughly discuss the reasons for the discrepancy but this paper is not exploring such topic. The important point is that accurate assessment can lead to proper diagnosis and treatment. Treatment Peter’s therapists focused mainly on Peter’s OCD which was reportedly severe according to the assessment. Also, the subject and his parents are aware of the inconvenience caused by Peter’s OCD which results to interference in his daily activities. The treatment was characterized by: Treatment for Peters OCD proceeded in accordance with the protocol outlined by Knox and colleagues (1996). This 12- to 16-week protocol is based upon a behavioral formulation of OCD, and actively incorporates a parent training portion. As part of this training, both of Peters parents were educated in the three component model of anxiety and taught to conceptualize anxiety in terms of cognitive, behavioral, and physiological responding.( Detweiler and Albano,2001) Treating Peter was a challenge for the therapists since his parents had tight schedules and could hardly participate in the sessions. This was further complicated by the fact that Peter himself was uncooperative at times. There was much pressure as the parents insisted that they should see significant results in a short span of time ( as early as three months) since school year would resume by then. Nevertheless, the treatment went along albeit irregular schedules. The result: Peter’s OCD lessened as well as his mother’s symptoms. Of course, not all patients recover fully and there is a possibility of relapse. It must also be emphasized that Peter’s case was rather rare since OCD manifests by age 19 according to NIMH ( as mentioned in the beginning of this paper). The important thing however is the fact that people with OCD can be helped by medical professionals but cooperation is needed especially on the part of the patient so treatment would be effective. The Y-BOCS: Effective Assessment Tool for OCD The Yale-Brown Obsessive Compulsive Scale (Y-BOCS) is an instrument to determine the severity of obsessive-compulsive disorder (OCD) symptoms. Wayne Goodman and his colleagues in 1989 presented the Yale-Brown Obsessive Compulsive Scale.  It is used widely in research and clinical practice to rate the severity of OCD and to examine progress during treatment. This scale, which measures obsessions separately from compulsions, particularly measures the level of symptoms of obsessive-compulsive disorder without being influenced towards the nature of obsessions or compulsions present. The scales have 10-items each and all the items are rated from 0 to 4 with 0 indicating no symptoms and 4 indicating extreme symptoms (Goodman, Price, Rasmussen, Mazure, Fleischmann, Heninger & Charney, 1989).  Stengler-Wenzke, K. et al (2004) conducted a study using the Yale-Brown Obsessive Compulsive Scale to determine the severity of obsessive-compulsive disorder symptoms in patients. The Y-BOCS was administered by the nurses on the patients to explore the level of severity of the obsessive-compulsive symptoms. The findings from the study highlights the importance of Y-BOCS as a useful tool for nurses as it facilitates the diagnosis by identifying the thought processes and behavior patterns common to OCD. Nurses can diagnose the OCD symptoms and can take appropriate measures in the treatment plan. A component of the Y-BOCS is the Obsession Rating Scale which is shown below: Yale-Brown Obsessive Compulsive Scale (Y-BOCS): OCD Severity Rating Test Obsession Rating Scale ITEM RANGE OF SEVERITY 1. Time Spent on Obsessions 0 hrs/day 0-1 hrs/day 1-3 hrs/day 3-8 hrs/day 8+ hrs/day   Avg Occurrence 0  1  2  3  4  2. Interference from Obsessions None Mild Definite but Manageable Substantial Impairment Incapacitating   Avg Occurrence 0  1  2  3  4  3. Distress from Obsessions None Little Moderate but Manageable Severe Near Constant, Disabling   Avg Occurrence 0  1  2  3  4  4. Resistance to Obsessions Always Resists Much Resistance Some Resistance Often Yields Completely Yields   Avg Occurrence 0  1  2  3  4  5. Control Over Obsessions Complete Control Much Control Some Control Little Control No Control   Avg Occurrence 0  1  2  3  4  Compulsion Rating Scale ITEM RANGE OF SEVERITY 1. Time Spent on Compulsions 0 hrs/day 0-1 hrs/day 1-3 hrs/day 3-8 hrs/day 8+ hrs/day   Avg Occurrence 0  1  2  3  4  2. Interference from Compulsions None Mild Definite but Manageable Substantial Impairment Incapacitating   Avg Occurrence 0  1  2  3  4  3. Distress when Resisting Compulsions None Little Moderate but Manageable Severe Near Constant, Disabling   Avg Occurrence 0  1  2  3  4  4. Resistance to Compulsions Always Resists Much Resistance Some Resistance Often Yields Completely Yields   Avg Occurrence 0  1  2  3  4  5. Control Over Compulsions Complete Control Much Control Some Control Little Control No Control   Avg Occurrence 0  1  2  3  4  (Goodman, Price, Rasmussen, Mazure, Fleischmann, Heninger & Charney, 1989). Total Yale-Brown Obsessive-Compulsive Scale score: range of severity for patients who have both obsessions and compulsions. 0-7 Subclinical 8-15 Mild 16-23 Moderate 24-31 Severe 32-40 Extreme Goodman, W. K. et al (1989) conducted a study which involved four scales and 40 obsessive-compulsive disorder patients at different phases of treatment. The Cronbachs alpha coefficient indicated that the interrater reliability for the total Yale-Brown Scale score and each of the 10 individual items was excellent, with a high degree of internal consistency among all item scores. These results indicate that the Yale-Brown Scale is a reliable tool for determining the severity obsessive-compulsive disorder symptoms. A similar study conducted by Goodman, W. K. et al (1989) investigated the validity of the Yale-Brown Scale and its sensitivity to change. Three patients of obsessive-compul sive disorder (N= 81) were studied to determine the convergent as well as the discriminant validity in baseline ratings. The total Yale-Brown Scale scores highly correlated with two of three independent determinants of depression and of anxiety in patients with obsessive-compulsive disorder with negligible secondary symptoms. Thus, the study indicated that Yale-Brown Scale was a valid tool for determining the severity of obsessive-compulsive disorder symptoms. Conclusion OCD affects the lives of no less than 2 million Americans beginning at age 19. However, some people with OCD manifest its full-blown symptoms even at an early age as presented in the case of Peter. Because of this, mental health professionals like doctors, psychiatrists, and even nurses must pursue more research that would help them treat people with OCD. Treatment is not costly but time-consuming as well. Although there are many intervention programs for OCD that can be suited to the severity of the disease, the key to recovery is cooperation from the patients as well as his/her loved ones. References Aardema, F. & OConnor. (2007). The menace within: obsessions and the self. International Journal of Cognitive Therapy, 21, 182-197. Clark, D.(2003) Cognitive Behavioral Therapy for OCD. Retrieved from http://books. google.com. ph/books?id=RxjkCMmlCTMC&printsec= frontcover&dq= OCD+ Cognitive+BehavioralTheory&source=bl&ots=nn04Yp23W1&sig=OHW45JpGK7TyeLhzR1_G7qMohPA&hl=tl&ei=kn-oS4nXOsyOkQWp9LWoAw&sa=X&oi =book_ result&ct=result&resnum=10&ved=0CDsQ6AEwCQ#v=onepage&q=OCD%20Cognitive%20Behavioral%20Theory&f=fals.on 15 March 2010. Detweiler, M. F., & Albano, A. M. (2001). Covert Symptoms of Obsessive-compulsive Disorder in Children: a Case Study. Journal of Cognitive Psychotherapy, 15(2), 75+. Retrieved March 22, 2010, from Questia database: http://www.questia.com/ PM.qst? a=o&d=5035300837 Goodman, W. K., Price, L. H., Rasmussen, S. A, Mazure C., Fleischmann, R. L. Heninger, G. R. and Charney, D. S. (1989). The Yale-Brown Obsessive-Compulsive Scale: Development, use and reliability. Retrieved March 6, 2010, from http://www.brainphysics.com/research /ybocs_goodman89a.pdf Menzies, R. G. & de Silva, P. (Eds.). (2003). Obsessive Compulsive Disorder: Theory, Research, and Treatment. Chichester, England: Wiley. Retrieved March 22, 2010, from Questia database: http://www.questia.com/PM.qst?a=o&d=111608294 Mayerovitch, J., Galbaud du Fort, G., Kakuma, R., Bland,R., Stephen R., Pinard, G. Treatment seeking for obsessive-compulsive disorder: Role of obsessive-compulsive disorder symptoms and comorbid psychiatric diagnoses .Comprehensive Psychiatry - March 2003 (Vol. 44, Issue 2, Pages 162-168, DOI: 10.1053/comp.2003.50005) NIMH . Obsessive-Compulsive Disorder, OCD. (2010, February 18). NIMH · Home. Retrieved February 21, 2010, from http://www.nimh.nih.gov/ health/ topics/ obsessive-compulsive-disorder-ocd/index.shtml. NIMH. The Numbers Count: Mental Disorders in America. (2009, September 9). NIMH · Home. Retrieved March 23, 2010, from http://www.nimh.nih.gov/health/publications/the-numbers-count-mental-disorders-in-america/index.shtml#OCD. "Obsessive-Compulsive Personality Disorder." Internet Mental Health. N.p., n.d. Web. 22 Mar. 2010. . Rachman, S. (2003). The treatment of obsessions. Oxford: Oxford University Press. Wagner, A. P. (2008, May/June). Case Studies, the Worry Hill. Psychotherapy Networker, 32,. Retrieved March 22, 2010, from Questia database: http://www.questia.com/PM. qst?a =o&d=5035235236 Wilson, R. & Veale, D. (2005). Overcoming Obsessive-Compulsive Disorder. London: Constable & Robinson Ltd. Covert Symptoms of Obsessive-compulsive Disorder in Children: a Case Study by Michael F. Detweiler , Anne Marie Albano One characteristic of obsessive-compulsive disorder (OCD) that has served to impede the treatment outcome of exposure therapy has been the presence of cognitive symptoms (Rachman & Hodgson, 1980; Salkovskis & Westbrook, 1989). Although this phenomenon is rarely seen in younger children (Sweedo, Rapoport, Leonard, Lenane, & Cheslo w, 1989), the resulting obstruction to treatment efficacy is often greatly compounded in these cases. The privacy of these covert symptoms means that the therapist is restricted to the childs verbal descriptions of them. Low motivation and weak insight into the degree of interference of the disorder could create difficulty for the child in describing the nature of any cognitive symptoms present. Additionally, low insight in children increases the likelihood that children can persist in their cognitive rituals while overt behavioral compulsions are targeted in therapy. Further, it has been proposed that these cognitive rituals may interfere with the course of "information processing" required to interrupt the persistence of anxiety (Foa & Kozak, 1986). For reasons such as these, parents have been invited to take an active part in the treatment of their child (see Dalton, 1983; Knox, Albano, & Barlow, 1996; Piacentini, Gitow, Jaffer, Graae, & Whitaker, 1994). Parental involvement in therapy may be particularly useful when children are affected with OCD, as parents often find themselves unintentional agents in their childrens ritualistic behaviors (Knox et al., 1996). The need to systematically investigate the potential benefit of parental involvement in OCD treatment still exists (Knox et al., 1996). METHODS Subject Peter was a 10-year-old, Caucasian male, with symptoms consisting primarily of just right compulsions (compulsions employed and repeated until things "feel just right"). Peters overt behavioral compulsions included acts of handwaving, light switch flicking, clothes arranging, furniture arranging, and a complex ritual performed each morning before leaving the house. His cognitive rituals included acts of mentally repeating words, mental counting, and mentally repeating steps as a performance check. Assessment Diagnostic status was assessed using the Anxiety Disorders Interview Schedule for DSM-IV (ADIS), Child and Parent versions (Silverman & Albano, 1996a; 1996b). In addition, Peter and/or his parents completed the Childrens Depression Inventory (GDI; Kovacs, 1982), the Revised Childrens Manifest Anxiety Scale (RCMAS; Reynolds & Richmond, 1978), and the Child Behavior Checklist (CBCL; Achenbach, 1991). Table 1 provides a summary of assessment information. Weekly monitoring forms were administered to track the levels of distress and interference caused by individual symptoms. These forms consisted of Fear and Avoidance Hierarchies (FAH) composed of items reflecting Peters OCD symptomatology. The FAH was constructed with the aid of the Ley ton Obsessional Inventory-Child Version (LOI; Berg, Rapoport, & Flament, 1986). Severity ratings for the FAH were provided along a 0-8 scale, so as to be in keeping with severity ratings obtained from the ADIS interview. Results of the initial ADIS indicated that in addition to a principal diagnosis of OCD, Peter (and/or his parents) endorsed symptoms consistent with additional diagnoses as well (i.e., generalized anxiety disorder, social phobia, and agoraphobia without a history of panic). Surprisingly, however, Peters responding on self-report assessment measures suggested that he did not appear to be experiencing any significant anxiety or depressive symptoms. There are several explanations for this discrepancy. First, it is possible that Peter was down-playing his symptoms in an attempt to present himself in a more positive light. Although this explanation seems plausible given Peters comorbid diagnosis of social phobia, we do not necessarily believe this to be the case. Peter did not obtain an elevated score on the lie scale of the RCMAS, a direct measure of the childs tendency to respond in a socially desirable manner. Further, given his high degree of disclosure during the ADIS interview, we find it hard to believe that Peter would suddenly begin to respond in a more guarded fashion on self-report measures. Second, it is possible that Peters parents simply may have responded to the ADIS interview with a proclivity for yea-saying. Given that the ADIS provides a composite diagnosis based upon an integration of both parent and child reports, heavy parental endorsement of symptoms that were only mildly endorsed by the child may yield a composite diagnosis rated high in severity. A quick glance at Figures 1 and 2 reveals that Peters parents also routinely provided higher ratings on weekly monitoring forms. Unfortunately, however, none of the questionnaires completed by the parents contained a scale by which to interpret their response style. A third explanation (and the one we tend to weigh the most heavily) concerns the functional impairment of Peters OCD. It is possible that his condition produced a greater disruption in the lives of his parents than for Peter himself, and this difference in conceptualization of functional impairment is reflected in the differences in severity ratings between Peter and his parents. Though Peters symptoms were distressing to him, his parents were frequent participants in his rituals and often found themselves having to rearrange a great portion of their everyday lives to accommodate him. The ADIS interview does screen for the degree of functional impairment. Although Peter was readily able to report how having OCD "messes things up in his life," he generally did so in vague terms (e.g., "makes me feel bad, tires me out, makes me look weird," etc.). Peters parents, however, were better able to describe the degree of impairment in concrete functional terms (e.g., length of time spent engaging in rituals, frequency of arriving somewhere late because of adherence to rituals, frequency of family arguments resulting from disruption of rituals, etc.). Thus, the tendency for Peters parents to typically provide higher severity ratings on assessment measures and monitoring forms may simply reflect greater insight into the degree of impairment rather than a tendency to overendorse items. Parental responding on the CBCL helped to provide additional qualitative assessment. Responding on this measure revealed that Peters mother conceptualized his difficulties as complications of anxiety and depression. She also noted the significant thought problems that she felt resulted from both his lengthy engagement in cognitive compulsions and his obsessive preoccupation with always having to be right, even in the light of blatantly conflicting evidence. Treatment Despite multiple diagnoses at pre-treatment, the therapists began by targeting Peters OCD symptoms for a number of reasons. Assessment results yielded severity ratings that suggested that the primary target for Peters intervention was his OCD. Further, both Peter and his parents identified his OCD as being their primary concern. Finally, it was hypothesized that treatment targeting OCD exclusively would generalize to behavior related to his other diagnoses. Treatment for Peters OCD proceeded in accordance with the protocol outlined by Knox and colleagues (1996). This 12- to 16-week protocol is based upon a behavioral formulation of OCD, and actively incorporates a parent training portion. As part of this training, both of Peters parents were educated in the threecomponent model of anxiety and taught to conceptualize anxiety in terms of cognitive, behavioral, and physiological responding. Peters parents observed initial imaginal and initial in-vivo exposures to help them acclimate to the process of exposure and response prevention. This proved useful for several reasons. During the exposures, the therapist was able to alert Peters parents to his subtle escape/avoidance attempts and prompt them to limit similar such behaviors during between-session practice exposures they conducted at home. Additionally, Peters mother admitted that she was initially hesitant to ask her son to enter and remain in uncomfortable situations before first observing the modeling of technique by the therapist. Peters parents were also trained in the detailed monitoring of Peters symptoms and were primarily responsible for completing that task. This parental involvement in the monitoring process allowed them to view first hand the reduction of discomfort following exposure and response prevention. As treatment progressed, Peters parents often responded to his hesitation by reminding him of the success that they themselves had observed during earlier exposures. Both parents maintained this degree of parental monitoring and involvement in "homework" exposures over the entire course of treatment. Peters completed FAH served to dictate the course of intervention as less distressful items (those low on the FAH) were targeted first. Hierarchy items were first approached through imaginal exposures, and then through in-vivo exposures. Weekly rating of the FAH provides the therapist with an update as to the distress and interference of each of the items and thus offers a continuous measure of treatment effectiveness. In addition, parentally monitored homework assignments of daily imaginal and in-vivo exposures aid in maintaining gains between sessions. As was the case for Peter, FAHs may sometimes be modified over the course of treatment to include novel symptoms as they present themselves or to refine the operational definitions of vague symptoms in light of ongoing assessment (e.g., "/ dont like to handle money " becomes "/ dont like to handle dirty, old, wrinkled paper money"). Peters initial FAH contained 11 items of various cognitive and behavioral symptoms. Treatment initially targeted the overt behavioral items with considerable success (see Table 2). However, following eight sessions, it became clear that the initial hierarchy was not specific enough to discriminate between a number of Peters remaining cognitive compulsions. At this point in treatment, Peter had received a considerable degree of psychoeducation and was much better able to conceptualize and describe his cognitive compulsions than he was able to do at his initial assessment. So, Peter was asked to reassess the three remaining items on his FAH, and to create new, more specific hierarchy items. Peters new hierarchy consisted of eight more specific items (see Table 3). At this point, in-vivo exposures were attempted for these cognitive rituals. However, these exposures proved logistically difficult to conduct, and it became increasingly difficult to induce therapeutic levels of anxiety during the exposures. Peter continued to maintain that his cognitive rituals produced only minimal distress. However, his parents disagreed, noting that his attention and concentration seemed limited and that he began to appear noticeably "spacey" to others during periods of covert ritualizing. Therapeutic attention at this point in treatment focused upon reinforcing the rationale for the inclusion of cognitive symptoms in an exposure and response-prevention paradigm, and upon increasing Peters motivation to adhere to treatment where cognitive symptoms were concerned. As part of a reification exercise, Peter was asked to imagine what his OCD would look like and then name it and draw a picture of it. Rather than view OCD as a constellation of symptoms, from that point forward we conceptualized OCD as an "enemy" that was trying to wreak havoc in Peters life, anyway it could. We explained to Peter that OCD had three main weapons, corresponding to the three components of anxiety. OCD could either: 1. Trick you into doing things that you dont want to do [behavioral], 2. Make you feel bad inside [physiological], and/or 3. Make you think uncomfortable things or repeat things in your head over and over [cognitive]. We also explained that OCD was very sneaky and enjoyed trying to trick people into doing these things without them even realizing it. The best way to overcome OCD, it was explained, is to beat it at its own game [exposure + response prevention]. We explained to Peter that OCD tried to get him to make everything just right. So, in order to beat OCD, he should try to purposefully mess things up and resist fixing it until his OCD "surrendered." Peter enjoyed this new conceptualization and his motivation to participate in exposure and response prevention increased. His parents further enticed him by promising the reward of a video game system at the end of treatment for "working hard to beat OCD." This approach presented Peter with a new rationale for targeting cognitive rituals whether or not he himself considered them to be impairing. His "plan of attack" involved challenging all rituals. Otherwise, he stood the risk of allowing tricky OCD to sneak in under the radar, so to speak. Peters rituals were presented as individual battles fought between him and OCD. Once all of the battles had been fought, we could be sure that his war against OCD was won. As part of his "training" for this war, Peter was taught how to act as his own therapist. He was instructed to practice response prevention whenever the urge to engage in these cognitive rituals presented itself. Fortunately for us, these cognitive rituals were normally occurring at a high enough frequency that the issue of how to elicit them for the purposes of practicing exposure and response prevention never arose. Because of the privacy of covert rituals, Peter was further told that he would have to "fight those battles" on his own. His parents role was simply to remind him of the importance of recognizing OCDs attempts to trick him and to remind Peter to practice exposure and response prevention regularly. Peter agreed to this approach and his treatment continued for four additional sessions until the severity of his symptoms were considered subclinical (see Figures 2 and 3). DISCUSSION Peters initial prognosis at the time of intake looked less than promising. His parents each had highly active schedules. He had experienced treatment failure in the past. He was currently presenting with a complex diagnostic profile. Peter had difficulty describing his OCD symptoms and found it difficult to simply acknowledge, let alone conceptualize, his cognitive compulsions. This obstacle hindered intervention via exposures and practically guaranteed the total absence of response prevention. To make matters worse, Peters parents frequently indicated that they hoped to see significant treatment gains by the beginning of the new school year, mere months away. Peters initial positive response, however, seemed to bolster his motivation to participate in treatment. The cognitive-behavioral foundation of the protocol provided both Peter and his parents with a conceptualization of OCD and an insight into his distress that was not provided in earlier interventions. Despite their work schedules, both of Peters parents took active roles in his treatment program and expressed satisfaction for being able to engage in encouraging interactions with their son. With a strong emphasis on psychoeducation and the repeated successes in treating his overt, behavioral compulsions, results gradually generalized to the symptoms of Peters related comorbid disorders. The cognitive-behavioral treatment for OCD incorporating parental involvement in this case study can be considered successful for several reasons. Observed treatment effectiveness was both exceptional and well maintained. At 3-month follow-up, not only did Peter fail to meet clinical severity for OCD, but the vast majority of his ritualistic OCD behaviors were still absent, despite increases in subjective levels of anxiety (as indicated by Peters RCMAS) compared to pretreatment levels. Although further assessments are warranted to determine the longterm efficacy of the program, it is hypothesized that the increase in Peters reported levels of anxiety can be attributed to the start of his new school year rather than to a weakness in the protocols degree of relapse prevention. What is notable, however, is that academic difficulties reported at pre-treatment did not accompany Peter his following school year. In addition, benefits gained from the OCD protocol generalized to Peters comorbid disorders without directly targeting them in therapy. Peter was free of any mental disorders at post-treatment and 3-month follow-up assessment points. Although not of clinical significance at the time of pre-treatment assessment, Peter still exhibited a noticeable decline in depressive symptomatology. Another noticeable advantage observed in the results of this case study concerns the secondary gains obtained by Peters parents. Qualitative assessment reveals that Peters parents acknowledged a considerable decline in parental stress following treatment. In addition, Peters mother also experienced a substantial drop in her own depressive symptomatology after taking an active part in Peters treatment process. Her total BDI score dropped from a score of 8 at pre-treatment to a score of 0 by 3-month follow-up. Judging from the literature, Peters case is not atypical from other clinical cases of OCD observed in children. Large numbers of individuals with OCD report an onset before the age of 18 (Riddle, 1998) and comorbid diagnoses are not uncommon (March & Leonard, 1996). Low levels of motivation and reluctance to report symptoms have been noted in child patients (Grades & Riddle, 1999). More recent clinical emphasis has been placed upon utilizing parental training components as useful adjuncts to cognitive-behavioral treatment for OCD with children (March, 1995; March & Mulle, 1998; Riddle, 1998). However, we believe the current case study extends this trend by illustrating the resulting benefit of going beyond the customary training and including parents in the treatment process as well. Including Peters parents in the treatment process served to extend the scope of the intervention between sessions. This parental inclusion likely improved the consistency between parents and therapists and may have served to increase Peters generalization of treatment gains from the clinic environment to the home environment. Additionally, inclusion probably served to improve monitoring and the ongoing assessment of Peters symptom patterns and severity. Subtle escape/ avoidance behaviors that might otherwise have been missed were more likely to be identified and reduced by treatment-savvy parents. Monitoring that might not have taken place otherwise was completed as part of the task demands inherent to this parental inclusion component. Symptoms that Peter would not or could not adequately report were made available to the therapist, thanks to parental report. Parental participation modeled treatment adherence and likely improved Peters motivation to participate. Finally, if nothing else, this inclusion likely helped to return a sense of control to the distressed parents of a child whose clinical presentation was hallmarked by an overwhelming lack of control. -1- Questia Media America, Inc. www.questia.com Publication Information: Article Title: Covert Symptoms of Obsessive-compulsive Disorder in Children: a Case Study. Contributors: Michael F. Detweiler - author, Anne Marie Albano - author. Journal Title: Journal of Cognitive Psychotherapy. Volume: 15. Issue: 2. Publication Year: 2001. Page Number: 75+. © 2001 Springer Publishing Company. Provided by ProQuest LLC. All Rights Reserved. Case Studies,the Worry Hill by Aureen Pinto Wagner Case Studies By Aureen Pinto Wagner The Worry Hill A child-friendly approach to OCD Maria was 9 years old when she heard a TV news item about an outbreak of hepatitis that originated at a local bakery. Long after the alarm had subsided, she couldnt stop worrying about it. At first, she feared that she might have contracted hepatitis and began washing her hands with increasing frequency. Then she began to worry that she herself could spread hepatitis and be responsible for the deaths of others. She refused to touch or hug anyone, including her parents. This was followed by a constant fear that shed contaminate the seats on which she sat at home, at school, and on the bus. Maria began wiping herself clean to the point that she was chafed and bleeding. By the time she came in for treatment a year later, she was spending 45 minutes in the shower, 30 minutes at the sink each time she washed her hands, and 45 minutes cleaning up after each time she used the toilet. She barely made it to school most days. Marias mother felt compelled to assist her daughter with her cleansing rituals and to provide endless reassurance that she wouldnt get hepatitis. If she didnt do so, Maria could be in the bathroom for four to six hours, and definitely wouldnt make it to school that day. Maria has obsessive-compulsive disorder (OCD), an often debilitating condition that affects from one to three percent of children in the U.S. A growing body of evidence suggests that neuropsychiatric, genetic, immunologic, behavioral and cognitive factors may all play a role in the development and maintenance of OCD. Over the past 15 years, the literature has repeatedly shown that OCD in children can be successfully treated with cognitive-behavioral therapy (CBT)--specifically, exposure and ritual prevention (ERP). CBT has a 65- to 80-percent success rate with youngsters, similar to the success rate with adults. ERP involves gradually facing ones fears to test their reality while refraining from rituals. It helps people with OCD realize that their obsessive fears dont come true and that the anxiety they experience subsides as a result of autonomic habituation. But while CBT is widely considered the treatment of choice for children with OCD, effectiveness is contingent on overcoming a formidable obstacle: childrens reluctance to engage in ERP because they think that facing their fears without performing rituals will be too scary and impossible. The therapist and the childrens families must find a way to help the children get past the discomfort of giving up rituals that seem to protect them against overwhelming fears. To do that, Ive devised a CBT treatment approach tailored to the special needs and cognitive capabilities of children. Its aimed at thoughtfully cultivating treatment readiness before embarking on ERP. Building Treatment Readiness Children who arent properly prepared for how ERP works and what it entails are more likely to become ambivalent or afraid, withdraw from exposures, and refuse to do practice exercises. When they understand how exposure and habituation work, theyre more willing to tolerate the initial anxiety experienced during ERP, because they know itll increase and then subside. The four steps in building readiness to undergo the added anxiety engendered by CBT--Stabilization, Communication, Persuasion, and Collaboration--are illustrated in Marias journey to recovery. Stabilization comes first. When I met Maria, she was shy and embarrassed as her parents described her symptoms and their futile struggle to get her to see reason. "I know Im washing too much," she said quietly, "but I just cant stop." Her parents, like most parents seeking help for their childs OCD, expressed a sense of urgency. They asked if they should be actively fighting the OCD by "getting tough" with their daughter and refusing to give in to her rituals. I said that our first focus was on stabilization and that it wasnt the right time to withdraw support for Maria, who was already overwhelmed and struggling to function each day. Instead, I encouraged them to function in "survival mode"--to be flexible in their expectations, accommodate their daughter temporarily at home and school, and cut back on discretionary commitments to reduce her stress and conserve time and energy for future treatment. In this first session, I focused on setting the foundation for treatment and getting everyone on the same page. I began with a clear description of OCD. "Everyone has worries, Maria. But when you have OCD, your brain sends you a lot of worry messages that get stuck in your mind, even when theres no reason to be worried. Its like it would be if you rang the doorbell and the button got stuck: the doorbell would keep ringing. OCD is like a Ôworry bell in your brain that gets stuck. The worry thoughts that OCD puts in your brain are called Ôobsessions. The things you do over and over again to make the obsessions go away are called Ôcompulsions or Ôrituals." I let Maria and her parents know that there are about one million children in America who have OCD. Maria was surprised and pleased to hear that she wasnt the only one with OCD. She was curious to hear about other children like her. "Everyones OCD can be a little different--people can have obsessions about getting hurt or having bad luck," I explained. "Sometimes, they may even have thoughts that theyve said or done something really bad when they actually havent. Rituals can also be of many types, like checking things, counting, cleaning, or saying ÔIm sorry all the time." To alleviate blame and shame and build an alliance with the family, I then discussed the current understanding of OCD as a neurobehavioral disorder. "Having OCD isnt your fault. Its not your parents fault either. Its like having allergies or asthma--it happens to you because youre more sensitive to it. Sometimes there are other people in your family who are also sensitive and have OCD. OCD isnt something you do on purpose to get attention or because youre lazy. Sometimes your parents or your teachers or friends may think that youre just being stubborn or annoying. Its hard for them to understand that you dont want to do it, but you dont know how to stop." Maria glanced at her parents with a "See, I told you!" look, as her mother tearfully acknowledged having had such reactions. Communication is key. Most children and families arent aware that the body is designed to habituate naturally to anxiety. I developed the Worry Hill metaphor to make CBT more child-friendly and prepare children for treatment, by helping them understand how exposure leads to habituation. Its a drawing of a bell-shaped curve that graphically illustrates how anxiety rises with exposure until it reaches a peak, and then, if the child persists in resisting the urge to employ the usual anxiety-avoidance tactics, automatically begins to decline. In our second session the next week, I explained to Maria and her parents, "Learning how to stop OCD is like riding your bicycle up and down a hill. At first, facing your fears and not doing your rituals feels like riding up a big Worry Hill, because its tough. You have to work hard to huff and puff up a hill, but if you keep going, you can get to the top. Once you get to the top, its easy and fun to coast down the hill. "Of course, you can only coast down the hill if you first get to the top. Likewise, you can only get past your fears if you face them. You have to stick it out without doing your rituals until the bad feeling goes away. Then youll see that your fears dont come true. But if you give in to the rituals, its like rolling backwards down the hill. You dont give yourself a chance to find out that your fears wont come true, even when you dont do rituals." Maria listened and nodded. She liked riding her bicycle, she said, and it made sense to her. The key to CBT for contamination fears is learning to accept the difference between unpleasant and dangerous. Maria needed to learn that although she didnt like the "dirty" feeling involved, not washing her hands wasnt calamitous or life-threatening. In any case, shed never be able to completely avoid the possibility of contamination--germs are everywhere. In short, she needed to learn to live with the discomfort of possible contamination. "Maria, you may not like the dirty feeling," I explained, "but by touching things and not washing your hands, youll get used to the feeling. Its just like the cold water in a swimming pool--you dont like it at first, but you get used to it when you stay in it for a while. Youll also learn that your fear of getting hepatitis wont come true." Maria listened thoughtfully, cringing at the mention of not washing her hands, but then nodded to indicate she understood. Persuasion involves helping children see the necessity for change, the possibility for change, and their innate power to change. Understanding both the costs of OCD to themselves and the benefits of overcoming it convinces children that change is necessary. When I tell stories of other youngsters whove ridden up the Worry Hill, successfully overcoming OCD, children begin to believe that they have the power to do the same thing. Children love these stories, but they also need to understand how difficult ERP may be. To help persuade Maria to try this approach, I explained, "Exposure may be hard, though probably not any harder than your life with OCD is right now. In fact, its often harder to think about exposure than it is to actually do it. Besides, the hard work of exposure at least gives you a chance to get rid of OCD; the work you put into OCD right now only makes it worse." In this way, I help the child understand that she has the power to take charge and take control of OCD--a liberating experience--instead of letting it control her. Collaboration makes the child a key partner in treatment. The child and family need to know that the therapist isnt the one wholl "fix" the childs OCD: only the child has the power to do that. "I wont force you to face your fears," I assured Maria. "You and I will discuss together what youll do when youre ready. But no one can ride a bicycle for you, so youll have to do it for yourself. Well take one step at a time, so that itll never be too scary." I told Marias parents, "For now, please keep helping Maria at home in the same way youve been doing. You, too, will have to learn how to let her face her fears without your help, but well do that after Maria feels more confident about handling the OCD on her own." Upon hearing that her parents would still be helping her and that shed be in charge of the degree of exposure shed try to handle, Maria sighed with relief and smiled. She seemed more relaxed and ready to participate. I deliberately dont begin ERP until the child voluntarily expresses readiness. I gave Maria my telephone number to call within the next week and let me know if shed like to go ahead. I received a call from her the next day. "Okay, Im going to try it. Im ready to beat my OCD! " I applauded her for her decision, and reiterated that wed work as a team to conquer her OCD, with no pressure from her parents or me. Had Maria not been ready to participate, I wouldnt have proceeded with ERP, but instead would have spent more sessions with her and her family to understand the source of her reluctance, and to address those issues in therapy first. Sometimes children just arent ready for ERP, and then this phase of treatment has to be deferred until they are. In some instances, medication may reduce the severity of anxiety symptoms, thereby making the possibility of ERP less daunting to the child. Rather than slow treatment and recovery down, building treatment readiness makes the entire process go faster. After a few sessions of readiness-building, children with moderate to severe symptoms can often begin to master OCD within 4 to 8 sessions of ERP--for a total treatment duration of 12 to 20 sessions. The RIDE Once the child has learned about ERP, its time for her to experience the relationship between gradual exposure and habituation. This shows her that if she can wait it out without doing her rituals, what she fears happening wont actually come to pass. Once she experiences this, her anxiety will dissipate naturally. The 4-step RIDE acronym (Rename the thought; Insist that you are in charge; Defy OCD by doing the opposite; Enjoy your victory) comprise the steps for successfully tackling the Worry Hill. The Defy step is the most critical, as this is the core exposure strategy. In essence, the RIDE teaches youngsters to stop, think, take control, and respond assertively to OCD, rather than default to an automatic compliance with it. The combination of the acronym, logical steps, and visual features of the Worry Hill make the ERP process easy to grasp, remember, and recall, even in the midst of anxiety. In our third session, Maria, her parents, and I sat down together and made a list of all the things Maria was afraid to do because of her fear of hepatitis, along with a list of all the rituals she employed to deal with her fears. Using a 10-point scale called a Fearmometer, she then rated how "scary" it would be to face each fear on the list. We then created an exposure hierarchy or "Fear Ladder," with the least scary items at the bottom of the ladder and scariest items at the top. Toward the bottom of Marias Fear Ladder were ERP tasks such as reading articles about hepatitis, describing the symptoms and causes of hepatitis to her parents, and repeating the word hepatitis several times in a conversation. In the middle of the ladder were items such as touching her parents on a clothed part of their body with unwashed hands, and touching herself on unclothed areas of her body with unwashed hands. At the top of the ladder were touching her parents with unwashed hands, using only 10 squares of toilet paper instead of an entire roll, sitting on chairs after using the toilet, and asking her parents to sit in the chairs that shed just "contaminated." It was time to begin the RIDE up and down the Worry Hill. Maria chose to start with an exposure exercise that shed rated a 2: reading an article describing hepatitis. She began the RIDE with tremendous courage, determination, and trust. "Its not me, its my OCD," she said, to prepare herself for this challenge. "Im in charge. Im going to do what I want to do, not what OCD wants me to do!" As she cautiously began reading, I used the Fearmometer to help her actively and tangibly experience the initial rise and peak in anxiety, followed by the onset of habituation. "Whats your feeling temperature now?" "Its a 5," she replied. Its making me sort of nervous." "Good, its going up!" I said. "That means youre riding up the Worry Hill, just as we expected." After she read a few more sentences, I asked, "How does it feel now? What can you say to yourself now?" Maria looked less apprehensive. "Im going to defy OCD. Im going to stick it out until the bad feeling goes away," she replied. A few sentences later, she exclaimed with surprise, "Oh, wow! My fear temperature went down. I went up to an 8 and now its a 2, and it only took a few minutes." We repeated this exercise three more times to promote practice and habituation. Afterward I asked Maria to compare her expectations with the real experience. She beamed with pride. Shed done it, and it was easier than shed expected. Maria agreed that shed practice this exercise three times daily at home with her parents until she no longer felt any anxiety from reading about hepatitis. Shed end the exercise when her feeling temperature was down to 2 or 3. I reminded Maria and her parents to stay with the assigned task, and not get ahead of themselves--all else should remain the same until wed collaboratively agreed to proceed. I then discussed with Marias parents how they could RALLY (Recognize OCD episodes; Ally with their child; Lead their child to the RIDE; Let go so their child could RIDE on her own; and reward and praise--say Yes, you did it!) for their child. I also set realistic expectations for recovery. Given the urgency for relief, theres often palpable disappointment when parents hear that it may take three to six weeks before their child is appreciably better. Once they understand how treatment works, however, most families realize that recovery is a journey, not a single event. Parents need to know that each child is unique and progress can occur in fits and starts, ups and downs. In the next session, Maria was ready for the next ERP exercise on the hierarchy. We reviewed her previous ERP experience to prime her for the upcoming one. She then went to the next item on her Fear Ladder: describing the symptoms and causes of hepatitis to her parents. They were surprised at how calmly she could talk about hepatitis, which previously had been a taboo word. During the next four sessions, Maria slowly but surely tackled each ERP step on her Fear Ladder. The tasks got harder. Using only a limited amount of toilet paper in the bathroom, sitting on the chairs in my office after using the toilet, and hugging her parents after that were the hardest. Although she struggled at times, she was determined and always made it to the top of the Worry Hill and down again. I helped Maria through the tougher exposures by reminding her of her previous successes, continually encouraging her efforts and urging her to "stick it out." Frequent Fearmometer ratings helped her acutely experience her anxiety escalate during exposure--cognitively, behaviorally, and physiologically--and then dissipate during habituation, which gave her powerful, tangible feedback about how fears can be extinguished. With repeated practices, these difficult exposures became easier, until she was able to complete them successfully. She and her parents were overjoyed to be able to hug again! At home, Maria practiced the same exercises shed completed in session. These exercises were discussed with her parents, so that they could make the time and be encouraging as she tackled her daily practices. She wrote in her diary what she practiced each day and how it went. Within six sessions, Maria was able to ride the Worry Hill confidently and successfully. Now, it was time for her parents to stop enabling her. With Marias consent, a "weaning plan" was developed to gradually extricate her mother from her entwinement in her daughters rituals. In the next two sessions, I coached Marias parents about how to carry out this plan. They gradually decreased the number of reminders, the physical assistance, and the extra checking they provided for their daughter. When she sought reassurance, they redirected her rather than providing answers reflexively. "Is that you asking, or is it OCD? Do you want us to help you or help the OCD? What do you think you need to do with that OCD thought?" They helped her remember that the uncomfortable feeling would pass if she just waited it out. When she got distressed, they had to stick it out too, until their own anxiety passed. Marias parents had to climb their own Worry Hill. It was a good experience for them to be in her shoes briefly and see how hard it can be to withstand anxiety. Although challenging at the beginning, the weaning gradually became easier because it was planned and discussed ahead of time, and Maria had already experienced success with ERP. They celebrated their successes together. After eight weekly sessions of CBT, Maria and her parents reported an 80-percent improvement in her symptoms. OCD worries were now passing thoughts rather than paralyzing fears. After the RIDE Parents and children need to be prepared for the reality that OCD "slips" or relapses can happen, particularly at times of stress and transition. When prepared, theyre likely to have an organized and productive response, and less likely to become demoralized. Relapse-recovery training involves having realistic expectations about the future, recognizing the early signs of relapse, keeping things in perspective, and intervening immediately. I helped Maria and her parents think about relapse recovery in the context of the Worry Hill metaphor: "When you fall off your bicycle, you pick yourself up. If you made no attempt to get up, you wouldnt get anywhere. If you want to move on, you get up, dust yourself off, survey the damage, attend to it, and get right back on that bicycle." Therapy sessions were tapered off to once every other week and then to once a month for the next four months. These booster sessions were described as "tune-ups" for the bicycle ride, to make sure everything was still working well. We focused on nipping OCD symptoms in the bud. Maria and her parents discussed any symptoms that were present, and wed repeat the ERP process for each of them. Maria maintained treatment gains well for about a year before she experienced a "slip" at the beginning of the school year, when she began to have obsessive thoughts about getting AIDS. But she was back on track within two weeks, because both she and her parents were prepared for it, knew that times of transition or stress might trigger a relapse, and were prepared to ride up the Worry Hill again without getting unduly demoralized. Maria went through ERP exercises similar to those she undertook about hepatitis a year earlier. Her parents were careful not to enable her this time, and instead of giving her mindless reassurances, challenged her to face her fears and ride the Worry Hill, which she did successfully again. Its been four years, and Maria is now 15 years old. Shes successfully transitioned to high school. She reports occasional symptoms and "quirky" rituals, which shes been able to nip in the bud. Shes doing well and looking forward to becoming a journalist when she grows up. She says shed like to write some articles to tell others how she conquered OCD, to bring hope and optimism to the many children who are still struggling. Case Commentary By Martha Straus In this case study, Wagner describes a gold-standard treatment for a child with OCD, using a nuanced and comprehensive therapeutic approach. This exceptional protocol does much more than employ simple exposure techniques: it incorporates the best elements of family therapy, coaching, cognitive-behavioral strategies, and narrative work. Integrating research evidence, clinical expertise, and the specific needs of a young child and her parents, Wagner is able to effect enduring change. I suspect the clarity of explanation and speed of results will cause the uninitiated to believe this is a simple disorder to treat, but it isnt. This therapists dexterity only makes it look easy. I was particularly struck by the ways in which Wagner modified and infused cognitive-behavioral techniques with insights into child and family development. One of my frustrations with the application of CBT in child psychotherapy has been a tendency among practitioners to overrely on cognitive capacities that exceed a childs developmental ability, while diminishing the therapy relationship to little more than a first-session frill. In "real life" (as opposed to treatment manuals), kids often struggle with the expectations and assignments in CBT work, and have lots of other unaddressed problems. They squirm and moan, "Cant we play now?" Real-life therapists end up shooting hoops with a Nerf ball or cleverly shuffling a deck of cards to finagle five minutes of therapeutic conversation. And some kids dont do homework for school, so why should we expect that theyll do it for us? I appreciated the amount of time Wagner takes to build a treatment alliance with this fearful child and overwhelmed parents. She allows the child to control the pace of treatment (perhaps paradoxically galvanizing her into action by suggesting that its a hard assignment and require a long time before shes ready!). This respectful empowerment includes using child-sized imagery (e.g., riding a bike up and down a hill), careful psychoeducation, and reassurance for the parents. Once Maria is motivated to change, the treatment moves swiftly: she practices at home and in the office to conquer, in ascending order, all the fears shes acknowledged. Notably, her parents also learn the narrative technique of externalization: they find out how to respond to their daughter by distinguishing her voice from the needy and controlling agenda of OCD. Wagner rightfully notes that some kids take longer to begin exposure work. (In my experience, the actual treatment frequently uses up additional sessions, too.) She comments that more reluctant children may benefit from medication. Id suggest they might also be helped by other treatment approaches. For example, a straightforward (and more playful) narrative strategy with children--as well as their parents--can be effective in managing those OCD bullies. For OCD, exposure and ritual prevention strategies employed skillfully--as in this case--are clearly beneficial. Still, many problems of childhood are messy, poorly understood, and inadequately formulated. The DSM-IV is woefully inadequate in describing complex kids. Sometimes, though, a symptom constellation like OCD presents itself with diagnostic precision, and then we can turn with confidence to this strong, evidence-based practice model. For motivated children and families contending predominately with the incapacitation of OCD, the treatment plan described by Aureen Pinto Wagner is a clear guide to effective, sensitive intervention. Aureen Pinto Wagner, Ph.D., is clinical associate professor of neurology at the University of Rochester School of Medicine and Dentistry, and a member of Read More