Chapter 11: Obsessive-Compulsive and Related Disorders

Obsessive-Compulsive Disorder (OCD)

• may exhibit obsessions, compulsions, or both.

• Obsessions are unwanted recurrent and persistent thoughts, urges, or images that continually intrude into consciousness, causing anxiety and stress

• Compulsions are behaviors or mental acts the child is compelled to perform repeatedly, in a stereotypical fashion, although he or she may have no desire to do so.

Body Dysmorphic Disorder

• associated with an intrusive, unwanted, and time-consuming preoccupation of a perceived defect or flaw in physical appearance that others do not perceive

• may result in excessive mental acts or repetitive behaviors that are difficult to resist or control

Hoarding Disorder

excessive acquisition of and persistent difficulty discarding or parting (including throwing away, selling, giving away, or recycling) with possessions (including animals), congested and cluttered active living areas in which their intended use becomes substantially compromised, and marked functional impairment in familial, social, or occupational areas

Trichotillomania (Hair-pulling disorder)

characterized by the recurrent pulling out of one’s own hair, repeated attempts to reduce or stop hair pulling, and significant impairment and distress due to the hair pulling behavior

Excoriation (Skin-Picking Disorder)

is characterized by recurrent skin picking resulting in skin lesions, repeated attempts to reduce or stop skin picking, and experiencing significant impairment and distress due to the skin picking behavior

Four Criteria of OCD

• Criteria 1: Presence of Preoccupation, Urge, or Both Exhibited by the Individual

• Criteria 2: Functional Impact of Obsessions and Compulsions

• Criteria 3: Nonphysiological Cause

• Criteria 4: Best Explained by OCD Diagnosis

Criteria 4: Best Explained by OCD Diagnosis

The child’s or adolescent’s thoughts, urges, or images are not better suited for a different mental disorder

Criteria 3: Nonphysiological Cause

Obsessive thoughts, urges, or images are not a result of substance use or exhibited as a side effect of a medication that the child or adolescent is currently taking.

Criteria 2: Functional Impact of Obsessions and Compulsions

These mental preoccupations and compulsive urges take significant time during the day (more than one hour) and cause the child or adolescent significant discomfort or anxiety to the point of impairment within daily functioning.

Criteria 1: Presence of Preoccupation, Urge, or Both Exhibited by the Individual

• Preoccupation is defined as regular thoughts or images that are intrusive and unwanted and cause the child or adolescent to experience marked distress or anxiety.

• A compulsive urge is defined as repetitious behavior (mental or physical) children or adolescents think they must do to reduce anxiety or distress, or prevent some dreaded event or situatio

Assessment Strategies

• Previsit Screening

• Diagnostic Interviews

• Behavioral Observations

• Evidence-Based Assessments

Evidence-Based Assessments

• 11 common assessment instruments that counselors utilize

  • Children’s Yale-Brown Obsessive-Compulsive Scale (CY-BOCS)

  • Children’s Florida Obsessive-Compulsive Inventory (C-FOCI)

  • Children’s Obsessional Compulsive Inventory

  • Child OCD Impact Scale Revised-Child/Adolescent Report and Parent Report (COIS-R)

  • Clinical Global Impression Scale—Severity (CGI-S)

  • Family Accommodation Scale (FAS)

  • Family Environmental Scale (FES)

  • Leyton Obsessional Inventory-Child Version (LOI-CV)

  • National Institute of Mental Health Global Obsessive-Compulsive Scale (NIMH-GOCS)

  • Obsessive Compulsive Inventory—Child Version (OCI-CV)

Obsessive Compulsive Inventory—Child Version (OCI-CV)

• The OCI-CV has 21 items, completed by the child or adolescent, concerning his or her symptoms across the past month

• provide a measure of symptom presence and dimensionality for youth.

• It comprises six subscales, namely doubting/checking, obsessions, hoarding, washing, ordering, and neutralizing, that have been verified through a confirmatory factor analysis

National Institute of Mental Health Global Obsessive-Compulsive Scale (NIMH-GOCS)

To complete the NIMH GOCS, clinicians complete a single item that assesses global diagnostic severity. The scale for the single item ranges from 1 (“minimal symptoms, within normal range”) to 15 (“very severe”).

Leyton Obsessional Inventory-Child Version (LOI-CV)

• The LOI-CV was created for children as an adaption from the Leyton Obsessive Inventory for adults

• is a 20-item self-report questionnaire for children and adolescents that explores three factors, namely obsessions/incompleteness, compulsions, and a concern with cleanliness

Family Environmental Scale (FES)

• is administered to the individual’s primary caregivers and the individual herself or himself

• explores the overall functioning of the family’s social environment and the interpersonal relationships

• self-report measurement assesses three dimensions of the family environment: directions of personal growth, basic organization and structure, and interpersonal relationships

Family Accommodation Scale (FAS)

measures the extent to which family members have accommodated compulsions across the most recent month

Clinical Global Impression Scale—Severity (CGI-S)

• CGI-S is a single-item rating of global OCD severity based on a rating scale ranging from 0, “no illness,” to 6, “serious illness”

• requires counselors to consider functioning and severity beyond specific symptoms.

Child OCD Impact Scale Revised-Child/Adolescent Report and Parent Report (COIS-R)

• assesses the level of functional impairment across three contexts, namely family/home, school, and social.

• The COIS-R includes 33 items, which are rated on three-point Likert-type measures.

Children’s Obsessional Compulsive Inventory

• was a self-report instrument for measuring observable obsessive compulsive symptoms. The initial version was updated to include an assessment of compulsions, avoidance behaviors, range of obsessions, and personality characteristics observed in OCD

• The VOCI rates the 55-items on a five-point Likert-type scale to attend to therapeutic change by exploring the following subscales: hoarding, obsessions, contamination, and checking

Children’s Florida Obsessive-Compulsive Inventory (C-FOCI)

• is a self-report instrument that consists of 17 symptoms on a yes/no checklist and five items that measure symptom severity and impact on functioning

• The five items assess the level of control, amount of time, degree of interference, level of distress, and extent of control of the symptoms in the past month.

Children’s Yale-Brown Obsessive-Compulsive Scale (CY-BOCS)

• is the most well established and most frequently used instrument to assess the level of severity of OCD symptomology

• provides severity data across five subscales: (1) time occupied with symptoms, (2) level of interference, (3) distress, (4) resistance, and (5) level of symptom control. It is a semistructured interview clinicians complete.

Behavioral Observations

counselors can request that parents and teachers conduct behavioral observations. Because others frequently observe the child’s or adolescent’s compulsions, this assessment strategy can yield important diagnostic data

Diagnostic Interviews

A structured clinical interview (SCI) for DSM-5 disorders helps mental health professionals determine an accurate diagnosis for OC and related disorders. A SCI uses standardized questions to ensure that each person is offered the same experience to explore OC and related symptoms.

Previsit Screening

may ease parents and children into the counseling experience and is an opportunity for parents to receive the necessary informed consent related to assessments, diagnostic testing, interviews, observations, and parent/child checklist

Therapies

• Behavioral Therapy

• Cognitive Therapy

• Cognitive Behavioral Therapy

• Family-Focused Therapy

• Psychopharmacology

Psychopharmacology

consistently supports the positive impact of pharmacotherapy with SSRIs, either independently or coupled with CBT with exposure/response prevention, on reducing OCD symptomatology and increasing client functioning at home and school

Family-Focused Therapy

For many families in which there is a child or adolescent diagnosed with OCD, parents/caregivers can feel overwhelmed, engage in accommodation behaviors that can exacerbate OCD symptomatology, be asked to serve as therapeutic coaches, and manifest anxiety that can increase OCD symptomatology

Cognitive Behavioral Therapy

• CBT, exposure and response prevention (ERP) is a technique that is commonly found. ERP consists of confronting the anxiety provoking triggers, either by in vivo exposure or mental imagery, while consciously not engaging in compulsions that would reduce the client’s anxiety or distress

Cognitive Therapy

• is efficacious alone but is more effective when paired with another technique

Behavioral Therapy

• involves first identifying the maladaptive behaviors the client desires to be addressed

• the counselor may choose to have the client and his and her parents rank the compulsive behaviors, with the least distressing or debilitating behavior being the focus of counseling first and then focusing on the other behaviors as they are ordered in terms of distress.

• ERP consists of daily exposure to stimuli typically avoided by the child or adolescent.