The Pediatric Obsessive-Compulsive Disorder Treatment Study II: rationale, design and methods

This paper presents the rationale, design, and methods of the Pediatric Obsessive-Compulsive Disorder Treatment Study II (POTS II), which investigates two different cognitive-behavior therapy (CBT) augmentation approaches in children and adolescents who have experienced a partial response to pharmacotherapy with a serotonin reuptake inhibitor for OCD. The two CBT approaches test a "single doctor" versus "dual doctor" model of service delivery. A specific goal was to develop and test an easily disseminated protocol whereby child psychiatrists would provide instructions in core CBT procedures recommended for pediatric OCD (e.g., hierarchy development, in vivo exposure homework) during routine medical management of OCD (I-CBT). The conventional "dual doctor" CBT protocol consists of 14 visits over 12 weeks involving: (1) psychoeducation, (2), cognitive training, (3) mapping OCD, and (4) exposure with response prevention (EX/RP). I-CBT is a 7-session version of CBT that does not include imaginal exposure or therapist-assisted EX/RP. In this study, we compared 12 weeks of medication management (MM) provided by a study psychiatrist (MM only) with two types of CBT augmentation: (1) the dual doctor model (MM+CBT); and (2) the single doctor model (MM+I-CBT). The design balanced elements of an efficacy study (e.g., random assignment, independent ratings) with effectiveness research aims (e.g., differences in specific SRI medications, dosages, treatment providers). The study is wrapping up recruitment of 140 youth ages 7–17 with a primary diagnosis of OCD. Independent evaluators (IEs) rated participants at weeks 0,4,8, and 12 during acute treatment and at 3,6, and 12 month follow-up visits

Treatment of Symmetry-Obsessive-Compulsive Disorder

Symmetry and ordering obsessions and compulsions are among the most prevalent obsessive-compulsive disorder (OCD) symptom subtypes, often emerging in early childhood or adolescence. This chapter first discusses the phenomenology of this particular subtype, including distinct cognitive and emotional features that underlie symmetry-based concerns. Following is a case study describing Natalie X, a 27-year-old female patient with chronic symmetry-type OCD, the severity of which had fluctuated throughout her lifetime. She presented with persistent worries and rituals revolving around dividing objects and thoughts into gender categories of boy or girl, and she experienced considerable distress if items were not balanced across these boy/girl classes. Exposure response prevention (ERP) and cognitive therapy techniques were implemented in order to break the reinforcing cycle of Natalie’s compulsions and restructure her maladaptive automatic thoughts. Therapy occurred over 23 sessions and included psychoeducation about OCD and corresponding treatment tactics, a functional analysis of her specific triggers and behaviors, and exposures along a fear hierarchy. Motivational interviewing (MI) tactics were incorporated to enhance motivation and adherence to exposure exercises, while cognitive restructuring helped address her dysfunctional beliefs, such as overestimation of danger associated with asymmetry. Continual monitoring of symptoms and a collaborative working approach helped the therapist best tailor the cognitive and behavioral techniques towards Natalie’s needs throughout the treatment. Natalie’s symmetry symptoms and the level of impairment met criteria for remission at termination, illustrating the efficacy of ERP and cognitive therapy in treating this common subtype of OCD