1. Chapter 23: Obsessive-Compulsive Disorder and Trichotillomania Jennifer Cowie Michelle Clementi Deborah C. Beidel Candice A. Alfano

2. 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 behavior 2) Similar response to pharmacological treatments 3) Higher than expected rates of TTM among relatives of OCD patients and vice versa Relationship between the two disorders is not clear

3. OCD Prevalence: 2–3% by late adolescence (Zohar, 1999) Average age onset: 10 years old Range 5–18 years Core features: obsessions and compulsions Obsessions: intrusive, unwanted thoughts or feelings that create significant distress Compulsions: 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

4. 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)

5. 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)

6. 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 tasks Exposures should not be discontinued until the child’s SUDS ratings have decreased by at least 50% from the peak anxiety rating

7. Exposures In vivo exposures: Child confronts the feared stimulus For example by touching an item believed to be contaminated To 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

8. Cognitive Restructuring Consists of identifying and relabeling obsessive thoughts in order to achieve some “distancing” from OCD symptoms E.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

9. 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)

10. 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)

11. Treatment for Trichotillomania Behavioral therapy (BT) with habit reversal training (HRT) for treating adults with TTM is well established Studies 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 hair Annoyance 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

12. Parent Involvement: OCD Parents and siblings often accommodate a child’s ritualistic behavior Reinforce 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

13. 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 items Important to assist parent in utilizing consistent reinforcement Family conflict and parental frustration can confound treatment outcome

14. Adaptations and Modifications: OCD Psychosocial interventions can be modified for younger children with OCD Children as young as 5 can be treated with evidence-based approaches (March et al., 2004) Make developmentally driven modifications E.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

15. 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 OCD Treatment: 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

16. Adaptation and Modification: TTM Selection of specific intervention components dependent on the child’s age E.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

17. 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

18. Assessment: TTM No “gold standard” for assessing TTM Most tools designs for adult populations E.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

19. 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

20. 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