Clinical and research developments in the treatment of paediatric obsessive-compulsive disorder

It is of crucial importance to identify and disseminate effective treatments for paediatric obsessive-compulsive disorder (OCD). OCD is time-consuming and distressing, and can substantially disable functioning at school, at home, and with peers (Piacentini, 2003). Children who do not receive treatment are at risk of psychological difficulties in adulthood, including continued OCD, clinical anxiety and depression, personality disorders, and social maladjustment (Wewetzer et al., 2001). Two-thirds of adult cases of OCD develop in childhood, and adults with OCD have lower employment, poorer academic achievement, and lower marital rates compared to non-OCD adults (Hollander et al., 1996; Koran, 2000; Lensi et al., 1996; Steketee, 1993). The distressing nature of OCD in childhood, accompanying psychosocial impairment and risk of future psychopathology, underscore the need to identify effective treatments. The primary aim of this thesis was to expand knowledge of evidence-based treatments for paediatric OCD. A mixed-methodology approach was employed to examine key issues in this area. The first study used meta-analytic methodology to determine the evidence supporting available treatments for paediatric OCD. An extensive literature search revealed over 100 published reports of treatments, encompassing a broad array of theoretical approaches and treatment strategies. Examples of treatments used for paediatric OCD included psychodynamic therapy, pharmacotherapy, cognitive-behavioural therapy (CBT), hypnosis, family therapy, immunotherapy, and homeopathy.Study 1 comprised the first known meta-analysis of randomised, controlled treatment trials (RCTs) for paediatric OCD. Included studies were limited to RCTs as they are the most scientifically valid means for determining treatment efficacy and provide a more accurate estimate of treatment effect by removing error variance associated with confounding variables. The literature search identified 13 RCTs containing 10 pharmacotherapy to control comparisons (N = 1016) and 5 CBT to control comparisons (N = 161). Random effects modelling yielded statistically significant pooled effect size (ES) estimates for pharmacotherapy (ES = 0.48, 95% CI = 0.36 to 0.61, p < .00001) and CBT (ES = 1.45, 95% CI = 0.68 to 2.22, p =.002). The results support the efficacy of CBT and pharmacotherapy, and confirm these approaches as the only two evidence-based treatments for paediatric OCD. Implications and suggestions for future research are discussed. The effectiveness of CBT provided impetus to further examine this treatment. Group CBT is an understudied treatment modality among children with OCD. It was hypothesised that group CBT would possess efficacy because of the effectiveness of individual CBT for children with OCD, the demonstrated effectiveness of group CBT among adults with OCD, the practical and therapeutic advantages afforded by a group treatment approach, and the embeddedness of the approach in robust psychological theory. The aim of the second study was to evaluate the efficacy of group CBT. The study comprised the largest known conducted randomised, placebo-controlled trial of group CBT for paediatric OCD.Twenty-two children and adolescents with a primary diagnosis of OCD were randomly assigned to a 12-week program of group CBT or a credible psychological placebo. Children were assessed at baseline, end of treatment, and at 1 month follow-up. Outcome measures included the Children’s Yale-Brown Obsessive-Compulsive Scale, global measures of OCD severity, Children’s Depression Inventory, and parent- and child-rated measures of psychosocial functioning. An intention-to-treat analysis revealed that children in the group CBT condition had statistically significantly lower levels of symptomatology at posttreatment and follow-up compared to children in the placebo condition. Analysis of clinical significance showed that 91% of children that received CBT were ‘recovered’ or ‘improved’ at follow-up, whereas 73% of children in the placebo condition were ‘unchanged’. Effect size analysis using Cohen’s d derived an effect of 1.14 and 1.20 at posttreatment and follow-up, respectively. These effects are comparable to results from studies of individual CBT. This study supported group CBT as an effective treatment modality for paediatric OCD and demonstrated that the effect extends beyond placebo and nonspecific treatment factors. In addition to treatment efficacy, the inherent worth of a treatment lies in its adoption by the relevant clinical population. Children with OCD are known to be secretive and embarrassed about symptoms, and there is often a long delay between onset of symptoms and treatment-seeking (Simonds & Elliot, 2001). An important observation during the course of conducting the RCT was that a high rate (39%) of eligible families declined participation.This led to the question, "What barriers prevent participation in group CBT for paediatric OCD?" Qualitative methodology was employed to address this research question. Eligible families that had declined participation in the RCT were contacted and invited to participate in semi-structured interviews that explored reasons for non-participation and positive and negative perceptions of group CBT. The average time between non-participation and interview was 1.33 years (SD = 3 months). Data were collected from nine families and thematic analysis methodology was utilised to identify emergent themes. Failure to participate was predicted by practical and attitudinal barriers. Practical barriers included a lack of time, distance, severity of OCD symptoms, financial, and child physical health. Attitudinal barriers included child embarrassment about OCD symptoms, child belief that therapy would be ineffective, fear of the social aspect of the group, lack of previous success with psychology, lack of trust in strangers, parental concern about the structure of the group, denial of a problem, and ‘not being ready for it’. Attitudinal barriers more frequently predicted treatment non-participation. Positive and negative perceptions of this treatment modality were informative. Parents showed no differences in preference for individual or group CBT. An important finding was that 56% of the children had not received treatment since parental expression of interest in the group CBT program. Application of the findings to methods that promote service utilisation is discussed

The relationship between worry, rumination, and comorbidity: Evidence for repetitive negative thinking as a transdiagnostic construct

Background: Repetitive negative thinking (RNT) increases vulnerability to multiple anxiety and depressive disorders and, as a common risk factor, elevated RNT may account for the high levels of comorbidity observed between emotional disorders. The aims of this study were to (a) compare two common forms of RNT (worry and rumination) across individuals with non-comorbid anxiety or depressive disorders, and (b) to examine the relationship between RNT and comorbidity.Methods: A structured diagnostic interview and measures of rumination, worry, anxiety, and depression were completed by a large clinical sample with an anxiety disorder or depression (N=513) presenting at a community mental health clinic.Results: Patients without (n=212) and with (n=301) comorbid diagnoses did not generally differ across the principal diagnosis groups (depression, generalised anxiety disorder, social anxiety disorder, panic disorder) on worry or rumination. As predicted, comorbidity was associated with a higher level of RNT.Limitations: Cross-sectional design precluded causal conclusions and findings may not generalize to excluded anxiety disorders.Conclusions: Consistent with the transdiagnostic hypothesis, RNT was associated with a range of anxiety disorders and depression and with comorbidity for those with a principal depressive disorder, supporting recent evidence that RNT is a transdiagnostic process. The presence of RNT, specifically worry and rumination, should be assessed and treated regardless of diagnostic profile. Future research may show that both pure and comorbid depressed or anxious patients receive incremental benefit from transdiagnostic protocols developed to treat core pathological processes of RNT traditionally associated with separate disorders

Prevalence and contributing factors to recurrent binge eating and obesity among black adults with food insufficiency: findings from a cross-sectional study from a nationally-representative sample

Background: Living in a food-insecure or food insufficient household may increase risk for binge eating and obesity. Because racial disparities in food access, obesity, and access to treatment for disordered eating exist, it is important to examine these relationships in Black populations. Methods: We conducted a secondary analysis of data from the National Survey of American Life (N = 4553), a nationally- representative sample of Black Americans, including African Americans and Afro-Caribbeans. Logistic regression was used to explore the association of food insufficiency with obesity and binge eating. Results: In the total sample of Black Americans, the prevalence of food insufficiency was 10.9% (95% CI 10.0–11.8%). Food insufficiency was not significantly associated with obesity in Black Americans, but when associations were explored in analyses stratified by ethnicity and sex, food insufficiency significantly predicted an increased odds of obesity in Afro-Caribbeans (odds ratio [OR] = 1.47, 95% CI 1.01, 2.13). Individuals experiencing food insufficiency were more likely to report recurrent binge eating in the last 12 months (3% v 2%, P = 0.02) and a lifetime history of binge eating (6% v 3%, P = 0.004) compared to those who were food sufficient. After adjusting for socio-demographic factors, food insufficiency was not significantly associated with recurrent binge eating in Black Americans or in sex- and ethnicity-stratified analyses. Conclusion: The present study reveals a more complex relation between food insufficiency and binge eating than previously thought—although an association existed, it was attenuated by an array of sociodemographic factors. Our results also underscore the importance of considering ethnicity as different patterns emerged between African American and Afro-Caribbean participant

Childhood anxiety trajectories and adolescent disordered eating: Findings from the NICHD study of early child care and youth development: Childhood Anxiety Trajectories

The goal of the present paper was to examine whether childhood anxiety trajectories predict eating psychopathology. We predicted that girls with trajectories of increasing anxiety across childhood would have significantly greater risk of disordered eating in adolescence in comparison to girls with stable or decreasing trajectories of anxiety over childhood

Psychometric properties of the Compulsive Exercise Test in an adolescent eating disorder population

The objective of this study was to evaluate the factor structure, validity, and reliability of the Compulsive Exercise Test (CET) in an adolescent clinical eating disorder population. The data source was the Helping to Outline Paediatric Eating Disorders (HOPE) Project, a prospective ongoing registry study comprising consecutive paediatric tertiary eating disorder referrals. Adolescents (N = 104; 12-17 years) with eating disorders completed the CET and other measures. Factor structure, convergent validity, and internal consistency were evaluated. Despite failing to identify a factor structure, the study provided clear evidence of the multidimensionality of the measure. The total score correlated significantly with measures of eating pathology, perfectionism, and frequency of exercise for shape and weight control (r = 0.32-0.70, ps \u3c 0.05). More research into the multidimensional nature of compulsive exercise in clinical populations is needed, Further, research into compulsive exercise offers promise as an addition to existing cognitive behavioral models and treatments for eating disorders

The Reliability and Validity of the Clinical Perfectionism Questionnaire in Eating Disorder and Community Samples

Background: Clinical perfectionism is a risk and maintaining factor for anxiety disorders, depression and eating disorders. Aims: The aim was to examine the psychometric properties of the 12-item Clinical Perfectionism Questionnaire (CPQ). Method: The research involved two samples. Study 1 comprised a nonclinical sample (n = 206) recruited via the internet. Study 2 comprised individuals in treatment for an eating disorder (n = 129) and a community sample (n = 80). Results: Study 1 factor analysis results indicated a two-factor structure. The CPQ had strong correlations with measures of perfectionism and psychopathology, acceptable internal consistency, and discriminative and incremental validity. The results of Study 2 suggested the same two-factor structure, acceptable internal consistency, and construct validity, with the CPQ discriminating between the eating disorder and control groups. Readability was assessed as a US grade 4 reading level (student age range 9–10 years). Conclusions: The findings provide evidence for the reliability and validity of the CPQ in a clinical eating disorder and two separate community samples. Although further research is required the CPQ has promising evidence as a reliable and valid measure of clinical perfectionism

Clinical presentation of eating disorders in young males at a tertiary setting

Abstract Background Young males with eating disorders are a neglected study population in eating disorders. The aim of this study was to provide knowledge about the clinical presentation of eating disorders in young males. Methods The data source was the Helping to Outline Paediatric Eating Disorders (HOPE) Project (N ~ 1000), a prospective, ongoing registry comprising consecutive paediatric (<18 years) tertiary eating disorder referrals. Young males with DSM-5 eating disorders (n = 53) were compared with young females with eating disorders (n = 704). Results There was no significant difference in the prevalence of diagnosis of bulimia nervosa (2 % vs 11 %, p = 0.26) among sexes. Males had comparable duration of illness (9 months; p = 0.28) and a significantly earlier age of onset (M = 12 years; p <0.001). Shape concern (2.39 vs 3.57, p <0.001) and weight concern (1.97 vs 3.09, p <0.001) were lower in males, and body mass index z score (−1.61 vs −1.42, p = 0.29) and medical compromise (odds ratio [OR] = 0.64, 95 % CI: 0.36, 1.12) were comparable. Males had a two-folder higher odds of being diagnosed with unspecified feeding or eating disorders (40 % vs 22 % for females, p = 0.004). Driven exercise to control weight and shape was common and comparable in prevalence among males and females (51 % vs 47 %, p = 0.79) and males were less likely to present with self-induced vomiting (OR = 0.23, 95 % CI: 0.09, 0.59). Conclusion Boys with eating disorders are an understudied group with similarities and differences in clinical presentation from girls with eating disorders. Parents and physicians are encouraged to consider changes in weight, disturbed vital signs, and driven, frequent exercise for the purposes of controlling weight or shape, as possible signs of eating disorders among male children. Diagnostic classification, assessment instruments, conceptualisation, and treatment methods need to be refined to improve application to young males

The core symptoms of bulimia nervosa, anxiety, and depression: A network analysis.

Bulimia nervosa (BN) is characterized by symptoms of binge eating and compensatory behavior, and overevaluation of weight and shape, which often co-occur with symptoms of anxiety and depression. However, there is little research identifying which specific BN symptoms maintain BN psychopathology and how they are associated with symptoms of depression and anxiety. Network analyses represent an emerging method in psychopathology research to examine how symptoms interact and may become self-reinforcing. In the current study of adults with a Diagnostic and Statistical Manual for Mental Disorders-Fourth Edition (DSM-IV) diagnosis of BN (N = 196), we used network analysis to identify the central symptoms of BN, as well as symptoms that may bridge the association between BN symptoms and anxiety and depression symptoms. Results showed that fear of weight gain was central to BN psychopathology, whereas binge eating, purging, and restriction were less central in the symptom network. Symptoms related to sensitivity to physical sensations (e.g., changes in appetite, feeling dizzy, and wobbly) were identified as bridge symptoms between BN, and anxiety and depressive symptoms. We discuss our findings with respect to cognitive-behavioral treatment approaches for BN. These findings suggest that treatments for BN should focus on fear of weight gain, perhaps through exposure therapies. Further, interventions focusing on exposure to physical sensations may also address BN psychopathology, as well as co-occurring anxiety and depressive symptoms. (PsycINFO Database Recor

CBT4BN: A Randomized Controlled Trial of Online Chat and Face-to-Face Group Therapy for Bulimia Nervosa

Although cognitive-behavioral therapy (CBT) represents the first-line evidence-based psychotherapy for bulimia nervosa (BN), most individuals seeking treatment do not have access to this specialized intervention. We compared an Internet-based manualized version of CBT group therapy for BN conducted via a therapeutic chat group (CBT4BN) to the same treatment conducted via a traditional face-to-face group therapy (CBTF2F)