john ocd case study

Obsessive Compulsive Disorder Treated without Medication – John

Severe OCD since 4th Grade

John was a very bright young fellow who was heading off to an Ivy League university in the fall. He was suffering from very severe OCD since 4th grade. He had tried Cognitive Behavioral Therapy, however it didn’t help. He refused exposure and response prevention therapy. Eventually, his OCD became so severe that he refused to extend his elbow because of his belief that such an action would cause harm to someone he loved. He also refused medication.

Headaches, GI Problems, and Weight Problems

His Yale-Brown Obsessive Compulsive scores was= 29 (obsessive=12, compulsive=17). He complained of headache, many gastrointestinal problems (nausea, diarrhea, constipation, stomach pains, flatulence, reflux, and perhaps related, and inability to gain weight, despite a well balanced and healthy diet).

Family History of OCD

John’s family history revealed OCD in his grandmother, a suicide by that grandmother’s sister, using a gun. His father was anxious, depressed and impulsive, but high functioning and successful. His father’s sister was described as very intense, persistent, and obsessive. His other grandmother was depressed and his grandfather’s father was alcoholic.

ORIGINAL RESEARCH article

Imagery rescripting on guilt-inducing memories in ocd: a single case series study.

1 Associazione Scuola di Psicoterapia Cognitiva (APC-SPC), Rome, Italy
2 Department of Social and Developmental Psychology Sapienza, University of Rome, Rome, Italy
3 Department of Human Sciences, Marconi University, Rome, Italy

Background and objectives: Criticism is thought to play an important role in obsessive-compulsive disorder (OCD), and obsessive behaviors have been considered as childhood strategies to avoid criticism. Often, patients with OCD report memories characterized by guilt-inducing reproaches. Starting from these assumptions, the aim of this study is to test whether intervening in memories of guilt-inducing reproaches can reduce current OCD symptoms. The emotional valence of painful memories may be modified through imagery rescripting (ImRs), an experiential technique that has shown promising results.

Methods: After monitoring a baseline of symptoms, 18 OCD patients underwent three sessions of ImRs, followed by monitoring for up to 3 months. Indexes of OCD, depression, anxiety, disgust, and fear of guilt were collected.

Results: Patients reported a significant decrease in OCD symptoms. The mean value on the Yale−Brown Obsessive Compulsive Scale (Y-BOCS) changed from 25.94 to 14.11. At the 3-month follow-up, 14 of the 18 participants (77.7%) achieved an improvement of ≥35% on the Y-BOCS. Thirteen patients reported a reliable improvement, with ten reporting a clinically significant change (reliable change index = 9.94). Four reached the asymptomatic criterion. Clinically significant changes were not detected for depression and anxiety.

Conclusions: Our findings suggest that after ImRs intervention focusing on patients’ early experiences of guilt-inducing reproaches there were clinically significant changes in OCD symptomatology. The data support the role of ImRs in reducing OCD symptoms and the previous cognitive models of OCD, highlighting the role of guilt-related early life experiences in vulnerability to OCD.

Introduction

Obsessive-compulsive disorder (OCD) is a common clinical condition experienced by about 1.2% of the population and with an estimated lifetime prevalence of 2.3% ( 1 , 2 ). OCD produces suffering and seriously compromises patients’ overall quality of life, weighing heavily also on the quality of life of the co-habiting family ( 3 – 6 ).

OCD is characterized by obsessions and compulsions. Obsessions are “ recurrent and persistent thoughts, urges, or impulses that are experienced at some time during the disturbance, as intrusive and unwanted, and that in most individuals causes marked anxiety or distress” . Compulsions are “repetitive behaviors … or mental acts … that the individual feels driven to perform in response to an obsession or according to rules that must be applied rigidly. The behaviors or mental acts are aimed at preventing or reducing anxiety or distress, or preventing some dreaded event or situation” ( 7 ).

A crucial role in OCD onset and maintenance has been attributed to responsibility and guilt by Rachman ( 8 – 10 ) and by Salkovskis ( 11 ). Results from different studies have corroborated this thesis. OCD patients experience more intense guilt and higher responsibility when compared to other people ( 12 – 17 ). OCD patients are characterized by high levels of fear of guilt ( 18 – 20 ). Takahashi et al. ( 21 ) found similar brain activity between OCD patients when exposed to stimuli eliciting OCD symptoms, and nonclinical subjects when exposed to stimuli eliciting guilt. Moreover, studies have corroborated the hypothesis that compulsions are aimed at reducing or preventing responsibility and guilt. Lopatcka and Rachman ( 22 ) and Shafran ( 23 ) have shown that OCD symptoms diminish when the level of responsibility is lowered, by asking to put an agreement in writing, so the responsibility for any consequence for not carrying out the compulsions was of the experimenter or by varying the presence or absence of the experimenter during the behavioral task. Cognitive Therapy Interventions (e.g., Socratic dialogue, pie-technique, double-standard technique, and the court technique) aimed at reducing the responsibility and consequentially the risk of being guilty ( 24 – 26 ) lead to a significant reduction of OCD symptoms. Additionally, when responsibility and fear of guilt are induced experimentally, especially when associated with the fear of making mistakes, nonclinical participants begin to behave in an obsessive-compulsive–like way and those with OCD show an increase in obsessive-compulsive behaviors ( 16 , 18 , 27 – 29 ). Arntz and colleagues ( 30 ) experimentally induced the sense of responsibility and the fear of guilt in OCD patients, in other-clinical and nonclinical groups. Checking behaviors were higher in OCD patients than in the other two groups. This result suggest that OCD patients, regardless the subtype, are particularly sensitive to responsibility and fear of guilt. One might ask if checking behaviors are aimed at reducing or preventing responsibility and guilt, while washing behaviors are only aimed at reducing or preventing disgust and not responsibility and guilt. According to Bhikram et al. [( 31 ), 300] “ exaggerated and inappropriate disgust reactions may drive some of the symptoms of OCD, and in some cases, may even eclipse feelings of anxiety .” Two questions arise: What is the relationship between guilt and disgust? Is it possible that guilt implies the activation of disgust resulting in washing behavior? Some studies ( 32 , 33 ) found the so-called Macbeth effect “ that is, a threat to one’s moral purity induces the need to cleanse oneself … physical cleansing alleviates the upsetting consequences of unethical behavior and reduces threats to one’s moral self-image .” [( 32 ), 1451]. This effect has not been detected in some studies ( 34 ), but Reuven et al. ( 35 ) found it particularly prominent in OCD. Ottaviani et al. ( 36 ) found that in nonclinical participants, the induction of a specific sense of guilt, the deontological guilt, which is related to having transgressed moral norms, regardless of whether someone has been harmed ( 37 , 38 ) elicits obsessive-like washing behaviors, which reduce guilt and increase positive emotions ( 39 ).

It is plausible, therefore, that all obsessive symptomatology, not only checking compulsions, are the expression of an intense concern for one’s own morality, in particular for the deontological morality ( 37 , 38 , 40 ).

Such moral concern is found in Ehntholt’s and colleagues work ( 41 , 779):

“OCD patients reported more fear that others would see them in a completely negative manner, e.g., others would “loathe” or “despise” them if it was possible that they would cause others harm or problems, suggesting a sensitivity to blame and criticism. Our findings that those in the OCD group are more sensitive to the criticism of others is also consistent with Turner, Steketee & Foa ( 1979 )” .

In line with these results are those from a small pilot study from Mancini and colleagues ( 42 ), where OCD participants, compared to non-OCD, showed higher distress when exposed to Ekman’s Pictures of Facial Affect of contempt, anger, disgust, if requested to imagine that such expressions were addressed to them and, above all, that they deserved them. Moreover, OCD participants declared, more than other participants, that they reminded them the faces of the parents, or one of the two, and their parents’ facial expressions at a time when they were being reproached and experiencing intense distress. In fact, families of obsessive patients are described as demanding and critical [see ( 43 – 45 )]. In a recent study, Basile et al. ( 46 ) found that OCD patients reported significantly more painful memories of guilt-inducing blame/reproach compared to a non-OCD group.

An interesting observation of the type of discipline used by parents of future OCD patients is the threat to the continuity of the relationship itself ( 47 ). Clinical observations show that in cases of reproach, parents of future OCD patients withdraw love, ignore the child and are not prone to forgive ( 45 ). It is plausible that these experiences have taught the patient that a small mistake is enough to receive serious, aggressive, contemptuous, demeaning reproaches by significant figures such as parents, without having the possibility to justify oneself or be forgiven, and that his/her behavior can determine the end of such significant relationships ( 45 ). Briefly, the expectation that guilt has catastrophic consequences may derive from these kinds of experiences. Along the same lines, according to Pace et al. ( 43 ), obsessive behaviors may be considered as strategies used by the child to avoid criticism and obtain approval. According to Cameron ( 48 ), obsessive behaviors may be created as methods to obtain the parents’ satisfaction and avoid being criticized. Some studies suggest that obsessions could also be intrusive mental images that evoke adverse early experiences ( 49 ), and that obsessive thoughts have implications for a person’s sense of self ( 50 ) as well as such guilt-inducing experiences.

It is possible to modify the meaning attached to past adverse or traumatic events, especially childhood or adolescence events, intervening in those events’ memories through imagery rescripting (ImRs). ImRs is an experiential technique that has shown promising results in different clinical disorders ( 51 , 52 ). It has been theorized that the way ImRs works is by changing the meaning attached to memories ( 53 ).

ImRs has been employed in OCD by Veale et al. [( 54 ), 230] who stated that:

“Cognitive Behavioral Therapy (CBT), including exposure and response prevention, remains the psychological treatment of choice for Obsessive-Compulsive Disorder … However, a significant proportion of cases still fail to respond to CBT … This has prompted the search for new target areas for intervention, in the hope that outcomes can be improved.”

Veale et al. ( 54 ) examined the efficacy of one single ImRs session, as a standalone intervention, where intrusive images linked to aversive memories were present. The presence of intrusions linked to aversive past events has been detected in many studies ( 49 , 55 , 56 ). In the study of Veale et al. ( 54 ) after ImRs, nine patients showed a reliable change and seven a clinically significant change at the 3-month follow-up session. A major change was detected three months after the end of treatment. More recently, Maloney et al. ( 57 ) investigated the efficacy of ImRs as a treatment for OCD cases that were not responsive to standard exposure and response prevention. In the study, the authors investigated the efficacy of 1–6 ImRs sessions in 13 OCD patients who experienced intrusive distressing images associated with OCD. Of those 13 patients, 12 reached an improvement of at least 35% in OCD symptoms. Six patients reached the improvement after only a single ImRs session, whereas the rest required 2–5 ImRs sessions. The results of both studies were very promising, suggesting the opportunity to carry out other studies on ImRs’ efficacy on OCD.

Starting from the work of Veale et al. ( 54 ) and considering the role of guilt-inducing reproaches in the development of the fear of guilt, we hypothesize that an intervention of ImRs on childhood memories of guilt-inducing reproach in OCD people could reduce current obsessive symptoms.

The main hypothesis that we wanted to test is that after an intervention of ImRs, OCD symptoms—regardless the subtype—would decrease and that change would be maintained.

We also hypothesize a reduction in both the fear of guilt and in the propensity to disgust.

In addition we measured the effect of ImRs on anxiety and depression, to control the effect of ImRs on these two emotions. We expected that the effect of ImRs would be less than the one on specific obsessive symptoms, due to the specific nature of ImRs intervention on memories for OCD.

The study is centered on a single-case series experimental design. According to Lobo et al. ( 58 ), in single-case studies, indexes are assessed repeatedly for each participant across time. The different interventions are defined as “phases,” and one phase is considered as a baseline for comparison. In single case studies, a control group is not required because each participant represents a proper control.

Participants

A sample of 18 participants seeking treatment for OCD at “Studio di Psicoterapia Cognitiva” in Rome was enrolled for the study. At an early stage, recruitment was attempted through the Internet and flyers’ announcements, but these modalities were ineffective.

Twenty-four people, seeking treatment voluntarily, were asked to enroll in the study and two refused to take part. Of the 22 participants who accepted, 18 completed the procedure, two dropped out and two were excluded due to a change of psychopharmacological drugs during the procedure.

Approximately two thirds had received prior treatment and were not awaiting other treatments, but a few started a treatment after the last follow-up. Nobody was in treatment during the 9 months of the experimental trial.

The participants were not preselected for showing a relevant memory, but all showed at least one memory, Table 1 reports gender, age, disorder duration in years, and OCD subtypes for each subject. Mental contamination refers to that form of contamination arising from “ experiencing psychological or physical violation. The source of the contaminations is a person, not contact with an inert inanimate substance ” ( 4 , 59 ).

Table 1 Clinical summary of participants.

Inclusion Criteria

Participants were included if they were aged 18–65 years with an OCD diagnosis according to DSM-5 ( 7 ) and a score on the Yale–Brown Obsessive Compulsive Scale (Y-BOCS) higher than 18.

Exclusion Criteria

Patients were excluded if they were having ongoing psychotherapy, if psychotherapy had ended less than three months prior to the beginning of the procedure or if psychopharmacological drugs had been changed in the last three months or during the procedure.

To monitor for possible changes in drug therapy, at each assessment meeting the participants were asked whether the therapy had remained constant. The participants received the same procedure but if there was a change in drugs their data were not considered in the analysis because we could not be sure whether the effect on symptoms was attributable to the intervention or to the change in drugs.

A further exclusion criterion was a comorbid diagnosis of psychosis, schizotypy, mania, borderline personality disorder, alcoholism, impaired cognitive function (assessed on the basis of the educational level and with a clinical interview) or dissociation symptoms [a score higher than 30 on the Dissociative Experiences Scale: ( 60 )].

1. The Structured Clinical Interview for DSM-5 [SCID-5; ( 61 )] is a clinician-administered semi-structured interview, aimed at assessing diagnoses according to the fifth edition of the DSM [DSM-5; ( 7 )].

2. The Dissociative Experiences Scale [DES; ( 60 )].

The DES is a 28-item self-report questionnaire that assesses forms of dissociation. The scores range from 0 (never) to 100 (always). The DES has proven to have adequate test–retest reliability as well as a good internal consistency, and good clinical validity ( 62 , 63 ). A cutoff score of 30 to detect dissociative psychopathology in clinical sample is recommended ( 64 , 65 ).

3. The Yale–Brown Obsessive-Compulsive Scale [Y-BOCS; ( 66 )].

4. The Y-BOCS is a 10-item clinician-rated scale that assesses the severity of obsessive-compulsive symptoms and the effectiveness of treatment. The clinician attributes a score from 0 (absence of symptoms) to 4 (very severe symptoms). The total score is in a range from 0 to 40. Higher scores indicate more severe OCD symptomatology. The scale has proven to have high internal consistency [alpha = 0.82; ( 67 )].

5. The Obsessive-Compulsive Inventory [OCI-r; ( 68 )].

The OCI-r is an 18-item self-report questionnaire, which assesses the severity of OC symptoms on the 5-point Likert scale. There are six subscales (washing, checking, ordering, obsessing, hoarding, and mental neutralizing). The total score ranges from 0 to 72. The OCI-r Italian version ( 67 ) showed good internal consistency as well as a convergent and divergent, and criterion validity [alpha = 0.85; ( 67 )].

6. The Beck Depression Inventory-Second Edition [BDI-II; ( 69 )]. The BDI-II is a 21-item self-report, measuring the severity of several components of depression. The Italian version of the BDI-II has proven to have good internal consistency [alpha = 0.80; ( 70 )] as well as good convergent and divergent and criterion validity ( 70 , 71 ).

7. The Beck Anxiety Inventory [BAI; ( 72 )]. The BAI is a 21-item self-report, that measures the severity of anxiety. The BAI Italian version shows good internal consistency [alpha = 0.89; ( 70 )] as well as good convergent and divergent, and criterion validity ( 70 , 73 ).

8. The Fear of Guilt Sclale [FOGS; ( 19 , 20 )]. FOGS is a 17-item self-report scale, ranging from 0 to 7, assessing the extent to which a person values and fears guilt and how she/he behaves in relation to guilt. The FOGS consists of two factors: Punishment (drive to punish oneself for feelings of guilt) and Harm Prevention (drive to proactively prevent guilt). The FOGS demonstrated strong internal consistency as well as convergent and divergent validity [alpha = 0.92; ( 20 )]. It also significantly predicted OCD symptom severity over measures of neuroticism, depression, trait guilt, and inflated responsibility beliefs ( 19 ).

9. The Disgust Propensity Questionnaire [DPQ; ( 74 )]. DPQ is a 33-item scale aimed at assessing the individual’s propensity for disgust. The participant expresses the agreement on a 5-point Likert scale from 0 (“not at all”) to 4 (“very much”). The total score range is from 0 to 132. The questionnaire has been proven to have a one-factor structure, as well as good internal consistency [alpha in the range 0.85–0.91; ( 74 )] as well good test–retest reliability (ICC = 0.85) and also construct validity ( 74 ).

Participants who accepted to be enrolled in the study signed an informed consent form. In an initial clinical interview, we checked for inclusion and exclusion criteria. The inclusion criteria were assessed through clinical interview and the Structured Clinical Interview for DSM-5 (SCID-5: 61). Diagnostic interviews were conducted by experts who had a master’s degree in psychodiagnosis, were trained to administer the SCID and conducted the interview according to the reference manuals; they were also blind to the study’s hypothesis. In the second session we measured the obsessive symptoms’ subtype and severity; and in the third meeting we ran an ad hoc interview on memories (see Appendix) in order to detect guilt-inducing reproaches memory that could be examined in the three following ImRs sessions. The selection of the memories was driven by the aim of intervening on generic memories of guilt-inducing reproaches not necessarily related to the current symptomatology. We selected memories in a different way from Veale et al. ( 54 ), where the authors selected participants who experienced intrusive imagery as part of their OCD, which was considered by the participant and assessor to be emotionally linked to memories of past aversive events, and from Maloney et al. ( 57 ), where intrusive imagery was selected because it was associated with OCD and considered by the patient to be linked to memories of aversive events.

We asked participants to recall reproaches similar to those which had been found by Basile et al. ( 46 ).

As already stated, we found, for each participant, generic memories of guilt-inducing reproaches, and so no one was excluded for this reason.

In particular, we focused on generic reproach experiences not necessarily related to the symptom domain. For example, a childhood memory selected by an OCD patient with washing symptoms was not directly related to being reproached for being dirty, but rather was independent of the symptom domain. The first criterion used for the memory’s selection was the earliest childhood memories reported by the participants, the second was the most intense memory from an emotional point of view.

Participants received a symptoms’ assessment and then as Veale and colleagues ( 54 ) did were randomized to 4, 8, 12, or 16 days of symptom monitoring before receiving ImRs (4 participants in the condition of 4 days monitoring, 5 in the condition of 8 days monitoring; 4 in the condition of 12 days monitoring; 5 in the condition of 16 days monitoring). Within the three 45-min ImRs treatment sessions, the previously selected memory was addressed and rescripted. For each participant, we selected one memory that was rescripted during the three sessions. The clinicians who ran the ImRs sessions were all experts in cognitive-behavioral therapy (CBT) for OCD (with an average of 10 years of experience) and in imagery techniques and the adherence to the protocol was supervised by three trainers and supervisors in ImRs. Based on the work of Veale et al. ( 54 ), we carried out each ImRs session according to Arntz’s three-stage technique ( 75 ), adapting it to the Schema Therapy suggestions ( 76 ) for patients with difficulty meeting their needs autonomously. The technique consisted of a first phase in which the patient was invited to relive the memory with his/her eyes closed, from the standpoint of their childhood self. In the second phase, the patient looked at the same event as an adult, tried to detect the unmet need of his/her childhood self and proposed an imaginative change (the rescripting) aimed at satisfying the unmet emotional needs. In the third phase, the patient as a child looked at the event with the changes proposed by the adult. In line with the procedure, if the patient could not find a solution to the unmet need in the second phase, the therapist then suggested some interventions or asked the patient to include the therapist into the image of their childhood, in order to meet the patient’s needs. The traditional protocol was employed as proposed by Arntz—“ part of rescripting involves a secure adult that meets the child’s needs to be reassured and comforted ” [( 53 ), 467]. By unmet need we mean the core emotional need, whose unfulfillment is the cause of the emotional sufferance. The intervention of the adult in the second phase, and the rescripting, are stimulated by the clinician’s questions: “Is there anything you would like to do?” “Is there anything that should be done?”

After each session, as per the traditional protocol ( 53 , 77 ), the patient listened to a recording of the session between one session and the next. Data were not collected between sessions. After clinical intervention, four follow-up assessment sessions (at 7, 30, 60, and 90-day intervals, respectively) were held, as in Veale et al. ( 54 ).

An outline of the procedure is shown in Figure 1 and the procedure has been approved by the ethical committee of Guglielmo Marconi University.

Figure 1 Procedural timeline.

Appendix Table 1 shows a summary of the contents of the rescripted memories. It reports the event and the emotion experienced, the participant’s age in the memory and meaning attached to the memory, verbally expressed by the participant. The “Emotion and meaning of memory” refers to the answers that participants gave when, in the first phase of rescripting, the patient was invited to relive the memory with his/her eyes closed, from the standpoint of their childhood self. In that phase of the technique they were asked: “What is happening?” “What do you feel?” “What do you think about the situation?” and the therapist just wrote down the participant’s verbal expression. “New meaning” after the ImRs refers to the event’s appraisals after the third intervention and the answers to the question the therapist asks “What do you think about the situation?,” which is asked in the third phase of rescripting, when the patient as a child looked at the event with the changes proposed by the adult in the second phase of the technique.

Statistical Analysis

Data were analyzed using the Statistical Package for Social Science (SPSS 25, Inc., Chicago, IL) for parametric and nonparametric analyses, while the Leeds Reliable Change Indicator was used to calculate change indexes ( 78 , 79 ).

Beyond initial descriptive analyses, we calculated reliable and clinically significant change indexes for all clinical measures (Y-BOCS, OCI-r, BAI, and BDI-II). Like Veale and colleagues ( 54 ), we considered the over-time change of the Y-BOCS total score. In particular, we considered indexes related to (a) reliable change and (b) clinically significant change ( 80 ). We evaluated the change in scores from screening to 90-day follow-up of at least 2 standard deviations (SDs) from the original mean. A reliable change was identified by the Leeds Reliable Change Indicator as a 10-point reduction on the Y-BOCS. A clinically significant change is the condition where criterion a was satisfied and the participant’s scores were under the clinical cutoff (for the Y-BOCS, score less than 17). As proposed by Veale and colleagues ( 54 ), we considered Pallanti’s asymptomatic criterion ( 81 ), which refers to an approximate total absence of OCD symptoms. The asymptomatic criterion for OCD has been defined as a recovery on the Y-BOCS (score 7 or less). The same analysis was performed for the OCI-r total score.

Paired samples t-tests and Wilcoxon signed-rank tests on the different measures (e.g., Y-BOCS, OCI-r, BAI, and BDI-II) were also performed between screening and 90-day follow-up, as well as, between pre-ImRs baseline and 90-day follow-up.

Afterward, two distinct linear mixed regression models were performed in order to test the fixed effect of the ImRs treatment on the OCD-related measures (i.e., Y-BOCS and OCI-r) and its random variations across patients. The strength of these kinds of models’ lies in the fact that the random variability of the parameters is also taken into account. Thus, the analysis allowed us to estimate whether the OCD-related symptoms decreased after the ImRs intervention and across the different measurement times, simultaneously considering the random variability of such hypothesized reduction for each of the 18 patients. Before running the analyses, it was necessary to carry out a restructuring of the data. Thus, we changed the data matrix from a wide format to a long format. Afterward, we stacked the scores of the Y-BOCS and OCI-r, obtained at each measurement time, into two distinct variables. These variables were in turn associated with an indicator of the measurement times (i.e., pre-ImRs baseline, 7-, 30-, 60-, and 90-day follow-up). Since we were interested in testing the effectiveness of the ImRs intervention, we focused our attention on the observed changes starting from the pre-ImRs baseline. Thus, the indicator variable was centered on the pre-ImRs assessment by coding such time point as 0. In this way, we were able to test the fixed effect of the time and the related random variability of intercept and slope. Moreover, we also estimated the quadratic effect of the time to test whether the differences that had emerged were in the extremes of the experimental region or inside it. These analyses were performed with the lme4 package ( 82 ) using RStudio ( 83 ), a graphical interface for R software. Both models were tested using a restricted maximum likelihood method (REML).

Then, a mixed ANOVA was conducted to determine the extent to which levels of change on fear of guilt (low vs. high) affected ImRS intervention on obsessive symptoms.

Finally, we computed intercorrelations among all the variables investigated at the 90-day follow-up in order to explore the relationships among them after the ImRs intervention.

First, we explored the structure of our data by means of some descriptive statistics (see Table 2 ). Thus, we computed the mean and the related standard deviations of each measure at the different detection times. Moreover, because of the reduced size of the sample under examination, we also computed the median and considered the interquartile range as a measure of the data dispersion from their central value.

Table 2 Descriptive statistics: Means, Standard Deviations, Median and Inter-Quartile Range (IQR) of the Yale–Brown Obsessive–Compulsive Scale (Y-BOCS), Obsessive–Compulsive Inventory revised (OCI-r), Beck Depression Inventory - Second Edition (BDI-II), Beck Anxiety Inventory (BAI), Fear of Guilt Scale (FOGS), Disgust Propensity Questionnaire (DPQ), Dissociative Experience Scale (DES).

Clinical Response to Imagery Rescripting

At the 3-month follow-up, 14 of the 18 participants (77.7%) achieved an improvement of ≥35% on the Y-BOCS, defined by Farris ( 84 ) and Mataix-Cols et al. ( 85 ) as corresponding to the most predictive of treatment response. Based on the results of the retrospective investigation of Tolin et al. ( 86 ), that is, the reduction criterion of at least 30% on the Y-BOCS as optimal for determining clinical improvement, it is possible to say that 15 participants (83%) reported a significant improvement.

Eleven of the 18 participants (61%) reached an absolute raw score of 12 or less on the Y-BOCS measure, which is identified by Lewin et al. ( 87 ) as optimal for predicting remission in a clinical setting. Based on Pallanti’s asymptomatic criterion ( 81 ), four participants reached the asymptomatic criterion (7 or less on Y-BOCS) at 90-day follow-up.

Reliable and Clinically Significant Change on the Y-BOCS

Of the whole sample, 13 patients reported a reliable change, with 10 of them revealing a clinically significant change on the OCD clinical measure (RCI = 9.94) using criterion A. The average scores from pretreatment and post-treatment met the criteria for reliable and clinically significant change.

Figure 2A reports single participants’ pretreatment Y-BOCS scores on the x-axis and post-treatment scores on the y-axis. Participants, who were in the lower-right quadrant and under the parallel lines achieved a reliable and clinically significant change.

Figure 2 Reliable and clinically significant change for (A) Y-BOCS (Yale–Brown Obsessive Compulsive Scale) and (B) for OCI-r (Obsessive-Compulsive Inventory revised) at 90-day follow-up.

Reliable and Clinically Significant Change on the OCI-r

At the 90-day follow-up, considering the OCI-r, 12 patients showed no significant improvement, 1 deteriorated (reached 17 points on the scale), while five participants reliably improved, with four of them showing a clinically significant change (RCI = 13.49), using criterion C. According to Jacobson and Truax ( 80 ), if you do not have an externally determined cut score you can use one based on statistical criteria. Criterion C is the one suggested, when clinical and comparison groups’ norms overlap. The average scores from pretreatment and post-treatment did not meet the criteria for reliable and clinically significant change.

Figure 2B reports single participants’ pretreatment OCI-r scores on the x-axis and post-treatment scores on the y-axis. Participants, who were in the lower-right quadrant and under the parallel lines achieved a reliable and clinically significant change.

Reliable and Clinically Significant Change on the BDI-II and BAI

Of the total sample, nine patients did not show any improvement in depressive symptoms as assessed with the BDI-II (RCI = 11.36). One deteriorated, eight reliably improved, and six showed clinically significant change. When assessing for any clinically significant change on the BAI, 12 showed no improvement, and 6 improved (RCI = 11.69). The average scores from pretreatment and post-treatment did not meet the criteria for reliable and clinically significant change.

Parametric and Nonparametric Comparisons

In order to obtain an estimate of the reduction of the scores on the examined measures after the ImRs treatment, we implemented both parametric and nonparametric tests. As parametric test, we conducted several paired samples t-tests. The comparisons concerned the scores obtained by the patients at the screening phase and at the 90-day follow-up on all the measures used in the study, except for the Dissociative Experiences Scale ( 60 ). Table 3 clearly shows that at the 90-day follow-up (vs. Screening) there are significant reductions in all the measures considered, and that these significant decreases are accompanied by remarkable effect sizes. A unique exception was represented by the comparison concerning the DPQ, which turned out to be only marginally significant.

Table 3 Paired samples t-test for the scores at the Screening detection time compared to 90-day follow-up and for the scores at pre-ImRs baseline compared to 90-day follow-up.

Furthermore, we also tested further comparisons between the scores obtained on the clinical measures of Y-BOCS, OCI-r, BDI-II, and BAI at the pre-ImRs baseline and at the 90-day follow-up. This analysis was therefore more focused on the effectiveness of the ImRs treatment. As expected, our hypotheses were corroborated: The paired samples t-tests revealed a significant decrease in scores on the four clinical measures. Also, in this case the reductions were associated with an effect of noticeable magnitude. The effect size of each paired samples t-test was computed by dividing the emerged differences by the standard deviation of the interested baseline. As highlighted by Morris ( 88 ), this procedure provides more reliable effect size estimates compared to using post-test or pooled standard deviation as denominator.

The results that emerged from the t-tests therefore seemed to provide empirical evidence about the effectiveness of the ImRs treatment. Given the relatively small number of participants, in order to provide some evidence to the robustness of the findings, we ran a post-hoc power analysis on the t-test conducted in the study, by using GPower. Specifically, we implemented a post-hoc power analysis for testing difference between two dependent means (matched pairs). By setting a medium effect size (Cohen’s d) of 0.7, error probability of 0.05, and two tailed distribution, the analysis revealed a statistical power of 0.80 associated to the sample size of 18 participants.

Moreover, we tried to provide further support and robustness to our results through a nonparametric test. Thus, we implemented a Wilcoxon signed-rank test for the nonparametric comparison of the Y-BOCS, OCI-r, BDI-II, and BAI scores between the pre-ImRs baseline and at the 90-day follow-up. As can be seen in Table 4 , results were consistent with those of paired samples t-tests. Specifically, the Wilcoxon tests showed a decrease of both scores of Y-BOCS and BAI for 16 participants, as well as, a reduction in the scores of BDI-II and OCI-r for 12 and 11 patients, respectively. Moreover, all test statistics were associated with an effect size (r) between medium and high values. These effect sizes were computed by dividing the z test statistic by the square root of the total number of observations ( 89 ).

Table 4 Wilcoxon signed-rank test (nonparametric).

OCD Scores in the Different Protocol Phases

In order to detect OCD symptom severity across time, we performed two distinct linear mixed regression models for the Y-BOCS and OCI-r, respectively. The first linear mixed regression pertained to the changes of OCD-related symptoms detected by the Y-BOCS. We expected to find a significant reduction in the Y-BOCS score across the measurement times. In particular, we expected to find a remarkable difference between the pre-ImRs baseline and the 7-day follow-up. For this reason, in addition to the linear fixed effect of the time, we also estimated its quadratic effect. This allowed us to test whether the differences that had emerged were in the extremes of the experimental region or inside it. Moreover, we expected to find such significant relationships regardless of the randomized duration (i.e., 4, 8, 12, or 16 days) of symptoms monitoring before receiving ImRs. Thus, we estimated the fixed effect considering the time indicator variable as a predictor and the scores obtained on the Y-BOCS at the different detection time, stacked into a single variable, as the criterion. The duration of symptoms monitoring at the pre-ImRs baseline represented the covariate in the model.

Analysis revealed a negative and significant main effect of the time on the Y-BOCS ( B = −.18; SE = .04; t = −3.82; p <.001; 95%CI = −.2684, −.0836), which indicated a reduction of the OCD symptoms severity across the different detections (see Figure 3A ). Moreover, analysis also highlighted a significant quadratic effect of the time ( B = .001; SE = .0004; t = 2.11; p = .041; 95%CI = .0004, .0020), suggesting that the stronger differences were to be found in the protocol phases. The more pronounced difference was indeed between the pre-ImRs baseline and the 7-day follow-up. This result was also corroborated by the pairwise comparisons conducted on the estimated marginal means scores of each detection time (see Table 5A ). The randomized duration of symptom monitoring did not exert any effect ( B = .01; SE =.28; t = 0.04; p = .97; 95%CI = −.5893, .6099).

Figure 3 Quadratic fixed effect of time (A) on Y-BOCS and (B) on OCI-r scores.

Table 5A Pairwise comparisons based on Y-BOCS estimated marginal means at the different protocol phases.

Regarding the random variability of intercept and slope, we found further support for our hypothesis. Analysis yielded a significant random variation of the intercept ( B = 39.1; SE = 15.9; Z = 2.45; p = .014; 95%CI = 17.60, 86.98), which simply indicated that patients reported different degrees of OCD symptom severity at the pre-ImRs assessment. More importantly, we also found a nonsignificant random effect for the time slope ( B = .001; SE = .013; Z = 0.80; p = .423; 95%CI = −.0001,.0117). Such a result strengthens our result, highlighting how the ImRs intervention produced similar effect across the 18 patients (see Figure 4A ).

Figure 4 Intercept and slope random variability of time (A) on Y-BOCS and (B) on OCI-r scores across the 18 patients.

The second linear mixed regression model followed the same procedure as the first, but considering the scores on the OCI-r as dependent variable. Also, in this case, we found results consistent with our expectations. Specifically, analysis showed a negative main effect of the time on the decreases of the OCI-r across the protocol phases ( B = −.23; SE =.08; t = −3.15; p = .003; 9 5%CI = −.3910, −.0875), as well as a significant time quadratic effect ( B = .002; SE =.0008; t = 2.49; p = .016; 95%CI = .0003,.0037). Graphical representation of the quadratic effect is shown in Figure 3B . Note that these coefficients represent unique associations, once the duration of symptom monitoring was checked ( B = .17; SE =.48; t = 0.34; p = .735; 95%CI = −.8614, 1.193). The more remarkable reduction of the OCD symptom severity emerged between the pre-ImRs baseline and the 7-day follow-up. Furthermore, in this case the pairwise comparisons supported such result (see Table 5B ). Moreover, random effects estimates revealed a nonsignificant random variation in the slope ( B = .002; SE = .003; Z = 0.69; p = .492; 95%CI = −.0001,.0363), as well as an expected significant variation in the pre-ImRs baseline scores ( B = 117.18; SE = 46.65; Z = 2.51; p = .012; 95%CI = 53.70, 255.68) of the OCI-r across patients (see Figure 4B ).

Table 5B Pairwise comparisons based on Oci-r estimated marginal means at the different protocol phases.

Differences Between High and Low Change at FOGS

In order to clarify the role played by guilt in the change of OCD symptom severity, we implemented two distinct mixed ANOVA on the OCI-r and Y-BOCS. In both analyses, the within factor was thus represented by the scores on these measures at the pretreatment and at the 90-day follow-up measurement times. With regard to the between factor, we split the sample into two subgroups based on the FOGS change score from the prescreening to the 90-day follow-up. Specifically, we computed the differences between the FOGS scores at such phases and then we divided participants based on the sample median value of 5.5. In this way, we obtained low and high FOGS change groups, respectively composed by 8 and 9 participants.

The mixed ANOVA on the OCI-r showed a significant effect of the treatment ( F[1, 15] = 8.29, p = .01), as well as a significant interactive effect among the within factor and the FOGS change groups ( F[1, 15] = 7.99, p = .01). As can be observed in Figure 5 , we found a significant decrease in the OCD symptom severity for participants who reported a high FOGS change score ( Mean Diff = 14.22, se = 3.42, p = .001, 95%CI = 6.93, 21.51), whereas nonsignificant differences emerged in the group of low FOGS change score ( Mean Diff = .125, se = 3.63, p = .97, 95%CI = −7.61, 7.86). Pairwise comparisons also revealed a marginally significant difference between the average score of the two groups at the 90-day follow-up ( Mean Diff = 15.22, se = 7.89, p = .07, 95%CI = −1.74, 31.91) and no difference at the pretreatment. These differences were respectively accompanied by standardized effect size (i.e., Cohen’s d ) equal to 1.7, 0.01, 0.93, 0.07. Consistently, between-subject analyses highlighted a nonsignificant main effect of the FOGS change score factor ( F[1, 15] = 1.28, p = .27).

Figure 5 Differences between high and low change at FOGS on the OCI-r.

In contrast, the mixed ANOVA on the Y-BOCS revealed that the decrease on such measure was not moderated by the FOGS change score ( F[1, 15] = 1.34, p = .26), and also that the between-subject effect of this factor was not significant ( F[1, 15] = 0.77, p = .40). In this case, we only found a significant within-subjects main effect of the treatment, which showed that the Y-BOCS scores decreased similarly for participants with both high and low change on the FOGS ( F[1, 15] = 37.99, p <.001).

Intercorrelations Among Measures at the 90-Day Follow-Up

Finally, in order to observe the correlations among the measures involved in the study, we computed correlations between all the outcome variables at 90-day follow-up. As can be seen in Table 6 , we found significant correlation among most of the interested variables. Specifically, we observed a positive association between OCD symptomatology (both assessed with Y-BOCS and OCI-r), BDI, BAI and DPQ, whereas we witnessed that the FOGS was only positively related with the OCD symptomatology assessed by OCI-r.

Table 6 Intercorrelations among the measures assessed at the 90-day follow-up.

The main result of our study is that after three ImRs sessions on guilt-inducing memories, OCD participants experienced a significant clinical reduction of symptoms.

Comparison between OCD measures at screening and at the 90-day follow-up indicates a significant clinical improvement in symptomatology, in terms of greater management of thoughts and obsessions, less time occupied and less interference in general, greater control over compulsions and an increased awareness of discomfort and exaggerated thoughts, as assessed by Y-BOCS. At the 90-day follow-up, the total OCI-R scores significantly diminish, the average scores from pretreatment and post-treatment did not meet the clinically reliable change criteria.

The difference between Y-BOCS and OCI-R is not surprising, in fact it is in line with the work of Abramowitz and Deacon ( 6 ), which found a low correlation between the OCI-r and Y-BOCS severity scores in a group of OCD patients. Sulkowski et al. ( 90 ) suggested that this might be because of the differences in symptom “coverage” by the OCI-r and Y-BOCS as stated by Maloney and colleagues who concluded that “ the clinician-administered Y-BOCS and the self-report OCI capture different aspects of symptomatology or of its improvement ” [( 57 ), p. 6].

Our results are in line with the study by Veale et al. ( 54 ) and Maloney et al. ( 57 ). ImRs confirms its promising application in treating OCD, underlining the importance of working on memory of past events. Veale et al. ( 54 ) and Maloney et al. ( 57 ), who focused on past aversive memories emotionally linked to present recurrent, intrusive and distressing images, detected through Speckens’s interview ( 49 ). We, instead, chose to focus on childhood memories of guilt-inducing reproaches, detected while asking the participants to remember events characterized by features found by Basile et al. ( 46 ). What is interesting is the meaning attached to the memories selected by Veale et al. ( 54 ), which, in many cases, related to a negative moral judgement about the self. The beliefs reported by participants in the work of Veale et al. ( 54 ), are similar to those reported by the participants of this study, even though the memories are somewhat different. This may suggest that the interpretation of guilt-inducing reproaches may be similar to how future OCD patients interpret even other experiences. Although the memories selected in this study were not necessarily related to current symptoms, they may have been related if they were associated with intrusive images.

It is interesting to observe that all the participants found events characterized by the features found by Basile et al. ( 46 ). All the participants remembered having felt, during the episodes, an intense sense of guilt and having thought themselves to be a “bad person.” Looking at Appendix Table 1 , subjects reattribute the causes of what happened to something external and not to their own wickedness, worthlessness, lack of ability, or defect. In particular, for the case of the reattribution of culpability, the new meaning after intervention is more flexible and participants recognize that the fault committed was not so serious or that they too have the right to make mistakes. As proposed by Arntz ( 53 ) ImRs confirms its efficacy in changing the meanings attached to past adverse events in childhood or adolescence.

ImRs, as hypothesized, showed a significant reduction of the fear of guilt. Interestingly, participants who showed a higher reduction in fear of guilt displayed a higher reduction in obsessive symptoms, when assessed by OCI-R. This result suggests that fear of guilt moderates the ImRs effect on obsessive symptoms and this effect is consistent with the hypothesis that fear of guilt plays a central role in the onset and maintenance of OCD symptoms ( 18 , 91 ).

ImRs reduced the disgust propensity, but in a marginal way, less intense than what was hypothesized, as ImRs doesn’t directly targeted disgust.

The intervention on the memories of guilt-induced reproaches reduced depression and anxiety in a statistically significant way. A similar result was observed in the work of Maloney et al. ( 57 ). However, the improvement did not meet the criteria for reliable and clinically significant change. At the last follow-up a correlation was observed between anxiety and depression and OCD symptoms when assessed by Y-BOCS. The reduction in anxiety is easily understandable, since very often this emotion accompanies obsessive symptoms. Zandberg et al. ( 92 ) found a reduction in depression following the improvement in obsessive symptoms. This is understandable considering that, in many cases, depression is related to the frustration and distress of having obsessive symptoms. For example, obsessive symptoms may involve a reduction in interpersonal relationships and may also produce a reduction in self-esteem and self-effectiveness.

The present work sheds light on the role that repeated experiences of criticism, and consequent guilt induction, might play in the genesis of dysfunctional beliefs about the self that are related to OCD development. This evidence should encourage clinicians to consider the role of sensitizing experiences in OCD treatment, addressing guilt-specific intervention.

Limitations

The findings of this study must be viewed in light of some limitations.

The main limitation of this study is the small sample size. A larger sample would allow an evaluation specifically separated by subtypes, to test whether ImRs on guilt-inducing memories of reproaches shows the same result in all OCD subtypes. Certainly, considering that our study, together with the study by Veale et al. ( 54 ) and the study by Maloney et al. ( 57 ) that assess the efficacy of ImRs in OCD, it may be worth investing more resources to conduct a randomized controlled trial study. Another limit of this study is related to the absence of a control group, in fact, without it, we cannot exclude that ImRs on guilt-inducing reproaches is not effective in other disorders, for example in social phobia, and therefore its effect in OCD is nonspecific. In addition, we are unable to say whether ImRs on memories noncharacterized by guilt-inducing reproaches, such as abandonment, can be equally effective in treating obsessive symptoms.

Moreover, the study is missing multiple assessments carried out in different phases and between sessions. The intensity of beliefs and emotions that were connected to the episode targeted in ImRs were not measured.

Future Directions

Assessing the effectiveness of ImRs on memories of guilt-inducing reproaches for participants with different disorders may be carried out, with the aim of understanding the similarities and differences between the effect of sensitizing experiences with OCD participants. When considering OCD, future research could consider randomized controlled trials, comparing the effect on OCD symptoms of ImRs on guilt-inducing memories, of other techniques aimed at changing the emotional valence of memories and comparing the effect by selecting memories with other emotional valences.

This research supports the importance of taking into account work on the historical vulnerability of OCD in CBT. In line with this proposal, recent work ( 93 ) has offered the first suggestion of an integration between CBT and Schema Therapy, aimed at reducing OCD’s historical vulnerability. However, further studies on techniques aimed at changing this vulnerability are necessary.

Data Availability Statement

The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.

Ethics Statement

The studies involving human participants were reviewed and approved by Ethical committee of Guglielmo Marconi University. The patients/participants provided their written informed consent to participate in this study. Written informed consent was obtained from the individual(s) for the publication of any potentially identifiable images or data included in this article.

Author Contributions

KT, BB, TC, BS, SF, AG, OIL, CP, GR, and AMS carried out the interventions. KT wrote the manuscript with support from BB and VP, who analyzed the data. GF contributed to sample preparation and FM conceived the original idea and supervised the project. All authors contributed to the article and approved the submitted version.

Conflict of Interest

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Acknowledgments

We thank Flavia Sorbara and Federica Visco Comandini for their assistance with assessment and organization of the data. This research did not receive any specific grant from funding agencies in the public, commercial or not-for-profit sectors.

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Table A1 Summary of the contents of the rescripted memories.

Procedure to Detect Guilt-Inducing Reproach Memories

The target of the intervention is memory of:

● Guilt

● Hypo-/Hyper-responsibility

● Observation of the guilt-inducing experiences on someone else

● Have caused real harm

● Responsibility for choosing the right partner

Interview on Guilt-Inducing Memories

PLAN A (Direct questions to the patient, examples are requested):

● Did you often feel guilty as a child?

● As a child, were you afraid you might be guilty of something?

● Have you ever caused anyone real harm?

● As a child, did you feel responsible for the well-being of someone close to you?

● Were there times when you felt you were not up to your responsibilities?

Questions about the family of origin:

How old is your father? What is/was your father like? Give me three adjectives to describe him.

When you were a child, did your father make you feel guilty? (ask for examples)

Were you afraid of being scolded by your father? (ask for examples)

When you were a child, did your father often scold you or someone close to you? (ask for examples)

The same procedure with mother or other significant figures (e.g., grandparents)

NOTE: WHEN THE PATIENT PROVIDES MORE THAN A MEMORY OF EQUAL RELEVANCE, CHOOSE THE OLDEST, THAN THE MOST PAINFUL.

PLAN B (Imagery assessment):

We ask the patient, using his/her imagination, to describe the last time she/he felt guilty.

Through the floating back, using emotion and mental status as a bridge, we ask her/him when she/he felt this way as a child.

NOTE: TO AVOID PROLONGED EXPOSURE OF THE PATIENT TO THE MEMORY, ONCE THE MEMORY HAS BEEN RECALLED, ASK THE PATIENT TO DESCRIBE THE MEMORY FACE TO FACE.

PLAN C (Scripts of memories):

We ask the patient to read some prototype memories and ask whether she/he has similar memories:

Guilt-inducing

When Peter was in elementary school, his father usually accompanied him to school. Despite his efforts, Peter had some difficulty getting out of the house on time and his father often became furious. Peter remembers the time when his father went on a rant in a loud and angry voice, with an outraged expression on his face and without looking him in the eye, while tinkering with the car keys to start the car: “The daily drop of poison!” and, “Life is good, huh. Who cares if your dad wakes up at 6:00 every morning to drive you to school on time then runs to work to support the family and allows you and your sister to study! This is the thanks I get!” After that the father did not speak for the rest of the day. At that moment, Peter was stunned, intimidated and mortified. What most distressed him was that he faced at least five hours of school, knowing he would feel a kind of boulder in his stomach and could not do anything to remedy it.

Hyper-responsibility

When Albert was nine years old, his mother had a health problem and his father was often out of the house because of work. He was considered by all to be a very responsible child for his age.

He was very diligent, taking his two younger sisters to school when their mother couldn’t get out of bed. He also prepared lunch for his sisters and reminded his mother to take the medication the doctor prescribed. Albert put others’ need ahead of his own. For example, he once gave up going to his best friend’s birthday party, which he had been looking forward to for a long time, because his mother was in bed with a headache and he wouldn’t leave her alone.

Observation of someone else’s guilt-inducing experiences

Anna has a sister named Silvia, who is seven years old and attends elementary school.

Once, Silvia got a teacher’s note saying her behavior was too lively in class. When she came home, Silvia didn’t tell her parents, and wanted to keep the note hidden from her father.

At some point, she confessed it to her mom, who told her dad. Anna saw the father who, having “discovered the lie,” got very angry and screamed at Silvia in an aggressive and contemptuous tone: “You have a guilty conscience, like a panty dirty with poo. You are not sincere, you are not truthful.” Anna saw Silvia burst into tears and felt a strong sense of guilt, for both the note and the lie, and for not knowing how to remedy the situation.

Having caused real harm

Maria is eight years old and has a younger sister and often plays catch in her arms, pretending to be her mother. Maria loves her sister very much and her mother is very happy with the relationship that is being established between the two sisters. One day, while she is in the kitchen with her mother, Maria takes her little sister in her arms and tenderly begins to play with her. The little one, unpredictably, waddles, falls to the ground and starts to bleed from the lip. The mother rushes to rescue the little one and says nothing to Maria, who is frightened by the blood that she sees dripping from the baby’s lip and feels deeply guilty for harming her sister.

Relationship OCD

Mario remembers how worried he was when his parents got divorced. Every night, for example, and during the night, he would go to the bedroom to check that his parents were sleeping together. They argued daily, and the arguments were often very heated and ended most often with the mother crying and the father slamming the door. In these discussions Mario took sides with his mother, was angry with his father, and thought that he had married her only for economic convenience, not because he loved her, since he humiliated her constantly. The mother suffered greatly from the father’s attitude toward other women and toward the family; attentive and seductive toward the former, cold and detached at home. Mario recounts this episode: the whole family was at the table with his mother’s cousin, her husband and their two children. He remembers how his father was full of attention toward his mother’s cousin: “He changed physically, almost became taller, the tone of voice, his eyes, his face, his smile, all bent to seduce, not caring that my mother and all of us were there.

It was really humiliating for her and I felt anger and disgust growing inside me.”

Hypo-responsibility

Antony is 18 years old and has recently left his small village of origin to move to a large city to attend university. It was a big change: Now Antony has to take care of the house, do the shopping, and also devote himself to his studies. One day, when there are only a few days left before the first exam, Antony realizes that he has completed only half of the planned program. At that moment Antony feels unable to face his responsibilities and remembers how his mother protected him all the time and how, when he was at home with her, he was relieved not to have any responsibilities.

Keywords: obsessive-compulsive disorder, imagery rescripting, memories, criticism, guilt

Citation: Tenore K, Basile B, Cosentino T, De Sanctis B, Fadda S, Femia G, Gragnani A, Luppino OI, Pellegrini V, Perdighe C, Romano G, Saliani AM and Mancini F (2020) Imagery Rescripting on Guilt-Inducing Memories in OCD: A Single Case Series Study. Front. Psychiatry 11:543806. doi: 10.3389/fpsyt.2020.543806

Received: 07 May 2020; Accepted: 03 September 2020; Published: 30 September 2020.

Reviewed by:

Copyright © 2020 Tenore, Basile, Cosentino, De Sanctis, Fadda, Femia, Gragnani, Luppino, Pellegrini, Perdighe, Romano, Saliani and Mancini. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY) . The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.

*Correspondence: Katia Tenore, [email protected]

Disclaimer: All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher.

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Published: 11 July 2020

Obsessive compulsive disorder in very young children – a case series from a specialized outpatient clinic

Veronika Brezinka ORCID: orcid.org/0000-0003-2192-3093 1 ,
Veronika Mailänder 1 &
Susanne Walitza 1

BMC Psychiatry volume 20 , Article number: 366 ( 2020 ) Cite this article

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Paediatric obsessive-compulsive disorder (OCD) is a chronic condition often associated with severe disruptions of family functioning, impairment of peer relationships and academic performance. Mean age of onset of juvenile OCD is 10.3 years; however, reports on young children with OCD show that the disorder can manifest itself at an earlier age. Both an earlier age of onset and a longer duration of illness have been associated with increased persistence of OCD. There seems to be difficulty for health professionals to recognize and diagnose OCD in young children appropriately, which in turn may prolong the interval between help seeking and receiving an adequate diagnosis and treatment. The objective of this study is to enhance knowledge about the clinical presentation, diagnosis and possible treatment of OCD in very young children.

Case presentation

We describe a prospective 6 month follow-up of five cases of OCD in very young children (between 4 and 5 years old). At the moment of first presentation, all children were so severely impaired that attendance of compulsory Kindergarten was uncertain. Parents were deeply involved in accommodating their child’s rituals. Because of the children’s young age, medication was not indicated. Therefore, a minimal CBT intervention for parents was offered, mainly focusing on reducing family accommodation. Parents were asked to bring video tapes of critical situations that were watched together. They were coached to reduce family accommodation for OCD, while enhancing praise and reward for adequate behaviors of the child. CY-BOCS scores at the beginning and after 3 months show an impressive decline in OCD severity that remained stable after 6 months. At 3 months follow-up, all children were able to attend Kindergarten daily, and at 6 months follow-up, every child was admitted to the next level / class.

Conclusions

Disseminating knowledge about the clinical presentation, diagnosis and treatment of early OCD may shorten the long delay between first OCD symptoms and disease-specific treatment that is reported as main predictor for persistent OCD.

Peer Review reports

Paediatric obsessive compulsive disorder [ 1 ] is a chronic condition with lifetime prevalence estimates ranging from 0.25 [ 2 ] to 2–3% [ 3 ]. OCD is often associated with severe disruptions of family functioning [ 4 ] and impairment of peer relationships as well as academic performance [ 5 ]. Mean age of onset of early onset OCD is 10.3 years, with a range from 7.5 to 12.5 years [ 6 ] or at an average of 11 years [ 7 ]. However, OCD can manifest itself also at a very early age - in a sample of 58 children, mean age of onset was 4.95 years [ 8 ], and in a study from Turkey, OCD is described in children as young as two and a half years [ 9 ]. According to different epidemiological surveys the prevalence of subclinical OC syndromes was estimated between 7 and 25%, and already very common at the age of 11 years [ 10 ].

Understanding the phenomenology of OCD in young children is important because both an earlier age of onset and a longer duration of illness have been associated with increased persistence of OCD [ 11 , 12 , 13 ]. One of the main predictors for persistent OCD is duration of illness at assessment, which underlines that early recognition and treatment of the disorder are crucial to prevent chronicity [ 10 , 14 , 15 ]. OCD in very young children can be so severe that it has to be treated in an inpatient-clinic [ 16 ]. This might be prevented if the disorder were diagnosed and treated earlier.

In order to disseminate knowledge about early childhood OCD, detailed descriptions of its phenomenology are necessary to enable clinicians to recognize and assess the disorder in time. Yet, studies on this young population are scarce and differ in the definition of what is described as ‘very young’. For example, 292 treatment seeking youth with OCD were divided into a younger group (3–9 years old) and an older group (10–18 years old) [ 17 ]. While overall OCD severity did not differ between groups, younger children exhibited poorer insight, increased incidence of hoarding compulsions, and higher rates of separation anxiety and social fears than older youth. It is not clear how many very young children (between 3 and 5 years old) were included in this study. Skriner et al. [ 18 ] investigated characteristics of 127 young children (from 5 to 8) enrolled in a pilot sample of the POTS Jr. Study. These young children revealed moderate to severe OCD symptoms, high levels of impairment and significant comorbidity, providing further evidence that symptom severity in young children with OCD is similar to that observed in older samples. To our knowledge, the only European studies describing OCD in very young children on a detailed, phenotypic level are a single-case study of a 4 year old girl [ 16 ] and a report from Turkey on 25 children under 6 years with OCD [ 9 ]. Subjects were fifteen boys and ten girls between 2 and 5 years old. Mean age of onset of OCD symptoms was 3 years, with some OCD symptoms appearing as early as 18 months of age. All subjects had at least one comorbid disorder; the most frequent comorbidity was an anxiety disorder, and boys exhibited more comorbid diagnoses than girls. In 68% of the subjects, at least one parent received a lifetime OCD diagnosis. The study reports no further information on follow-up or treatment of these young patients.

In comparison to other mental disorders, duration of untreated illness in obsessive compulsive disorder is one of the longest [ 19 ]. One reason may be that obsessive-compulsive symptoms in young children are mistaken as a normal developmental phase [ 20 ]. Parents as well as professionals not experienced with OCD may tend to ‘watch and wait’ instead of asking for referral to a specialist, thus contributing to the long delay between symptom onset and assessment / treatment [ 10 ]. This might ameliorate if health professionals become more familiar with the clinical presentation, diagnosis and treatment of the disorder in the very young. The purpose of this study is to provide a detailed description of the clinical presentation, diagnosis and treatment of OCD in five very young children.

We describe a prospective 6 month follow-up of five cases of OCD in very young children (between 4 and 5 years old) who were referred to the OCD Outpatient Treatment Unit of a Psychiatric University Hospital. Three patients were directly referred by their parents, one by the paediatrician and one by another specialist. Parents and child were offered a first session within 1 week of referral. An experienced clinician (V.B.) globally assessed comorbidity, intelligence and functioning, and a CY-BOCS was administered with the parents.

Instruments

To assess OCD severity in youth, the Children Yale-Brown Obsessive Compulsive Scale CY-BOCS [ 21 ] is regarded as the gold standard, with excellent inter-rater and test-retest reliability as well as construct validity [ 21 , 22 ]. The CY-BOCS has been validated in very young children by obtaining information from the parent. As in the clinical interview Y-BOCS for adults, severity of obsessions and compulsions are assessed separately. If both obsessions and compulsions are reported, a score of 16 is regarded as the cut-off for clinically meaningful OCD. If only compulsions are reported, Lewin et al. [ 23 ] suggest a cut-off score of 8. In their CY-BOCS classification, a score between 5 and 13 corresponds to mild symptoms / little functional impairment or a Clinical Global Impression Severity (CGI-S) of 2. A score between 14 and 24 corresponds to moderate symptoms / functioning with effort or a CGI-S of 3. Generally, it is recommended to obtain information from both child and parents. However, in case of the very young patients presented here, CY-BOCS scores were exclusively obtained from the parents. The parents of all five children reported not being familiar with any obsessions their child might have. In accordance with previous recommendations [ 23 ], a cut-off point of 8 for clinically meaningful OCD was used.

Patient vignettes

Patient 1 is a 4 year old girl, a single child living with both parents. She had never been separated an entire day from her mother. At the nursery, she suffered from separation anxiety for months. Parents reported that the girl had insisted on rituals already at the age of two. In the evening, she ‚had‘ to take her toys into bed and had got up several times crying because she ‚had to‘ pick up more toys. In the morning, only she ‚had the right‘ to open the apartment door. When dressing in the morning, she ‚had‘ to be ready before the parents. Only she was allowed to flush the toilet, even if it concerned toilet use of the parents. Moreover, only she ‘had the right’ to switch on the light, and this had to be with ten fingers at the same time. If she did not succeed, she got extremely upset and pressed the light button again and again until she was satisfied. The girl was not able to throw away garbage and kept packaging waste in a separate box. In the evening, she had to tidy her room for a long time until everything was ‚right‘. Whenever her routine was changed, she protested by crying, shouting and yelling at her parents. Moreover, she insisted on repeating routines if there had been a ‚mistake‘. In order to avoid conflict, both parents adapted their behavior to their daughter’s desires. In the first assessment with the parents, her score on the CY-BOCS was 15, implying clinically meaningful OCD. Psychiatric family history revealed that the mother had suffered from severe separation anxiety as a child and the father from severe night mares. Both parents described themselves as healthy adults.

Patient 2 is a four and a half year old boy, the younger of two brothers. He was reported to have been very oppositional since the age of two. Since the age of three, he insisted on a specific ritual when flushing the toilet – he had to pronounce several distinct sentences and then to run away quickly. Some months later he developed a complicated fare-well ritual and insisted on every family member using exactly the sentences he wanted to hear. If one of these words changed, he started to shout and threw himself on the floor. After a short time, he insisted on unknown people like the cashier at the supermarket to use the same words when saying good-bye.Moreover, he insisted that objects and meals had to be put back to the same place as before in case they had been moved. When walking outside, he had to count his steps and had to start this over and over again. In the morning, he determined where his mother had to stand and how her face had to look when saying good-bye. In order to avoid conflict, parents and brother had deeply accommodated their behavior to his whims. On the CY-BOCS, patient 2 reached a score of 15, which is equivalent to clinically meaningful OCD. Neither his father nor his mother reported any psychiatric disorder in past or present.

Patient 3 is a 4 year old boy referred because of possible OCD. Since the age of three, he had insisted on things going his way. When this was not the case, he threw a temper tantrum and demanded that time should be turned back. If, for example, he had cut a piece of bread from the loaf and was not satisfied with its form, he insisted that the piece should be ‘glued’ to the loaf again. Since he entered Kindergarten at the age of four, his behavior became more severe. If he was not satisfied with a certain routine like, for example, dressing in the morning, he demanded that the entire family had to undress and go to bed again, that objects had to lie at the same place as before or that the clock had to be turned back. In order to avoid conflict, the parents had repeatedly consented to his wishes. His behavior was judged as problematic at Kindergarten, because he demanded certain situations to be repeated or ‚played back‘. When the teacher refused to do that, the boy once run away furiously. On the CY-BOCS, patient 3 reached a score of 15. The mother described herself as being rather anxious (but not in treatment), the father himself as not suffering from any psychiatric symptoms. However, his mother had suffered from such severe OCD when he was a child that she had undergone inpatient treatment several times. This was also the reason why the parents had asked for referral to a specialist for the symptoms of their son.

Patient 4 is a 5 year old girl, the eldest of three siblings. Since the age of two, she was only able to wear certain clothes. For months, she refused to wear any shoes besides Espadrilles; she was unable to wear jeans and could only wear one certain pair of leggings. Wearing warm or thicker garments was extremely difficult, leading to numerous conflicts with her mother in winter. Socks had to have the same height, stockings had to be thin, and slips slack. When dressing in the morning, she regularly got angry and despaired and engaged in severe conflicts with her mother; dressing took a long time, whereas she had to be in Kindergarten on time. Her compulsions with clothes seemed to influence her social behavior as well; she had been watching other children at the playground for 40 min and did not participate because her winter coat did not ‚feel right‘. She started to join peers only when she was allowed to pull the coat off. She also had to dry herself excessively after peeing and was reported to be perfectionist in drawing, cleaning or tidying. Her CY-BOCS score was 15, equivalent to clinically meaningful OCD. Both parents described themselves as not suffering from any psychiatric problem in past or present. However, the grandmother on the mother’s side was reported to have had similar compulsions when she was a child.

Patient 5 was a four and a half year old girl referred because of early OCD. She had one elder brother and lived with both parents. At the age of 1 year, patient 5 was diagnosed with a benign brain tumor (astrocytoma). The tumor had been removed for 90% by surgery; the remaining tumor was treated with chemotherapy. The first chemotherapy at the age of 3 years was reasonably well tolerated. Shortly thereafter, the girl developed just-right-compulsions concerning her shoes. When the second chemotherapy (with a different drug) was started at the age of four, compulsions increased so dramatically that she was referred to our outpatient clinic by the treating oncologist. She insisted on her shoes being closed very tightly, her socks and underwear being put on according to a certain ritual, and her belt being closed so tightly that her father had to punch an additional hole. She refused to wear slack or new clothes and was not able to leave the toilet after peeing because ‘something might still come’; she used large amounts of toilet paper and complained that she wasn’t dry yet. She also insisted on straightening the blanket of her bed many times. She was described by her mother as extremely stressed, impatient and irritable; she woke up every night and insisted to go to the toilet, from where she would come back only after intense cleaning rituals. In the morning, she frequently threw a severe temper tantrum, including hitting and scratching the mother, staying naked in the bathroom and refusing to get dressed because clothes were not fitting ‚just right‘or were not tight enough. Shortly after the start of the second chemotherapy, the girl had entered Kindergarten which was in a different language than the family language. Moreover, her mother had just taken up a new job and had to make a trip of several days during the first month. Although the mother gave up her job after the dramatic increase in OCD severity, the girl’s symptoms did not change. As an association between chemotherapy and the increase in OCD symptoms could not be excluded, the treating oncologist decided to stop chemotherapy 2 weeks after patient 5 was presented with OCD at our department. At the moment of presentation, she arrived at Kindergarten too late daily, after long scenes of crying and shouting, or refused to go altogether. She reached a score of 20 on the CY-BOCS, the highest score of the five children presented here. Her father described himself as free of any psychiatric symptoms in past or present. Her mother had been extremely socially anxious as a child.

None of the siblings of the children described above was reported to show any psychiatric symptoms in past or present (Table 1 ).

The five cases described above show a broad range of OCD symptomatology in young children. Besides Just-Right compulsions concerning clothes, compulsive behavior on the toilet was reported such as having to pee frequently, having to dry oneself over and over again as well as rituals concerning flushing. Other symptoms were pronouncing certain words or phrases compulsively, insisting on a ‘perfect’ action and claiming that time or situations must be played back like a video or DVD if the action or situation were not ‘perfect enough’. The patients described here have in common that parents were already much involved in the process of family accommodation. For example, the parents of patient 3 had consented several times to undress and go to bed again in order to ‘play back’ certain situations; they had also consented turning back the clock in the house. The parents of patient 2 had accommodated his complicated fare-well ritual, thus having to rush to work in the morning themselves. However, all parents were smart enough not just to indulge their child’s behavior, but to seek professional advice.

Treatment recommendations

Practice Parameters and guidelines for the assessment and treatment of OCD in older children and adolescents recommend cognitive behavior therapy (CBT) as first line treatment for mild to moderate cases, and medication in addition to CBT for moderate to severe OCD [ 24 , 25 ]. However, there is a lack of treatment studies including young children with OCD [ 26 ]. A case series with seven children between the age of 3 and 8 years diagnosed with OCD describes an intervention adapted to this young age group. Treatment emphasized reducing family accommodation and anxiety-enhancing parenting behaviors while enhancing problem solving skills of the parents [ 27 ]. A much larger randomized clinical trial for 127 young children (5 to 8 years of age) with OCD showed family-based CBT superior to a relaxation protocol for this age group [ 14 ]. Despite these advances in treatment for early childhood OCD, availability of CBT for paediatric OCD in the community is scarce due to workforce limitations and regional limitations in paediatric OCD expertise [ 28 ]. This is certainly not only true for the US, but for most European countries as well.

When discussing treatment of OCD in young children, the topic of family accommodation is of utmost importance. Family accommodation, also referred to as a ‘hallmark of early childhood OCD’ [ 15 ] means that parents of children with OCD tend to accommodate and even participate in rituals of the affected child. In order to avoid temper tantrums and aggressive behavior of the child, parents often adapt daily routines by engaging in child rituals or facilitating OCD by allowing extra time, purchasing special products or adapting family rules and organisation to OCD [ 29 , 30 , 31 ]. Although driven by empathy for and compassion with the child, family accommodation is reported to be detrimental because it further reinforces OCD symptoms and avoidance behavior, thus enhancing stress and anxiety [ 4 , 32 ].

Parent-oriented CBT intervention

At the moment of first presentation, the five children were so severely impaired by their OCD that attendance of (compulsory) Kindergarten was uncertain. All parents reported being utterly worried and stressed by their child’s symptoms and the associated conflicts in the family. However, no single family wanted an in-patient treatment of their child, and because of the children’s young age, medication was not indicated. Some families lived far away from our clinic and / or had to take care of young siblings.

Therefore, a CBT-intervention was offered to the parents, mainly focusing on reducing family accommodation. This approach is in line with current treatment recommendations to aggressively target family accommodation in children with OCD [ 15 ]. Parents and child were seen together in a first session. The following sessions were done with the parents only, who were encouraged to bring video tapes of critical situations. The scenes were watched together and parents were coached to reduce family accommodation for OCD, while enhancing praise and reward for adequate behaviors of the child. Parents were also encouraged to use ignoring and time-out for problematic behaviors. As some families lived far away and had to take care of young siblings as well, telephone sessions were offered as an alternative whenever parents felt the need for it. Moreover, parents were prompted to facilitate developmental tasks of their child such as attending Kindergarten regularly, or building friendships with peers. The minimal number of treatment sessions was four and the maximal number ten, with a median of six sessions.

Three of the five children (patients 3, 4 and 5) were raised in a different language at home than the one spoken at Kindergarten. This can be interpreted as an additional stressor for the child, possibly enhancing OCD symptoms. Instead of expecting their child to learn the foreign language mainly by ‚trial and error‘, parents were encouraged to speak this language at home themselves, to praise their child for progress in language skills and to facilitate playdates with children native in the foreign language.

Three and six months after intake, assessment of OCD-severity by means of the CY-BOCS was repeated. Table 2 shows an impressive decline in OCD-severity after 3 months that remained stable after 6 months. At 3 months follow-up, all children were able to attend Kindergarten daily, and at 6 months follow-up, every child was admitted to the next level of Kindergarten or, in the case of patient 4, to school.

We report on five children of 4 and 5 years with very early onset OCD who were presented at a University Department of Child and Adolescent Psychiatry. These children are ‚early starters‘with regard to OCD. As underlined in a recent consensus statement [ 10 ], delayed initiation of treatment is seen as an important aspect of the overall burden of OCD (see also [ 19 ]). In our small sample, a CBT-based parent-oriented intervention targeting mainly family accommodation led to a significant decline in CY-BOCS scores after 3 months that was maintained at 6 months. At 3 months, all children were able to attend Kindergarten daily, and at 6 months, every child was admitted to the next grade. This can be seen as an encouraging result, as it allowed the children to continue their developmental milestones without disruptions, like staying at home for a long period or following an inpatient treatment that would have demanded high expenses and probably led to separation problems at this young age. Moreover, the reduction on CY-BOCS scores was reached without medication. The number of sessions of the CBT-based intervention with the parents varied between four and ten sessions, depending on the need of the family. Families stayed in touch with the therapist during the 6 month period and knew they could get an appointment quickly when needed.

A possible objection to these results might be the question of differential diagnosis. Couldn’t the problematic behaviors described merely be classified as benign childhood rituals that would change automatically with time? As described in the patient vignettes, the five children were so severely impaired by their OCD that attendance of Kindergarten – a developmental milestone – was uncertain. Moreover, parents were extremely worried and stressed by their child’s symptoms and associated family conflicts. In our view, it would have been a professional mistake to judge these symptoms as benign rituals not worthy of diagnosis or disorder-specific treatment. One possible, but rare and debated cause of OCD are streptococcal infections, often referred to as PANS [ 33 ]. However, in none of the cases parents reported an abrupt and sudden onset of OCD symptoms after an infection. Instead, symptoms seem to have developed gradually over a period of several months or even years. In the case of patient 5 with the astrocytoma, first just-right compulsions appeared at the age of three (after the first chemotherapy), and were followed by more severe compulsions at the age of four, when – within a period of 6 weeks – a new chemotherapy was started, the mother took up a new job and the patient entered Kindergarten. Diagnosing the severe compulsions of patient 5 as, for example, adjustment disorder due to her medical condition would not have delivered a disorder-specific treatment encouraging parents to reduce their accommodation. This might have led to even more family accommodation and to more severe OCD symptoms in the young girl. Last but not least, a possible objection might be that the behaviors described were stereotypies. However, stereotypies are defined as repetitive or ritualistic movements, postures or utterances and are often associated with an autism spectrum disorder or intellectual disability. The careful intake with the children revealed no indication for any of these disorders.

Data reported here have several limitations. The children did not undergo intelligence testing; their reactions and behavior during the first session, as well as their acceptance and graduation at Kindergarten were assumed as sufficient to judge them as average intelligent. Comorbidities were assessed according to clinical impression and parents’ reports. The CBT treatment was based on our clinical expertise as a specialized OCD outpatient clinic. It included parent-oriented CBT elements, but did not have a fixed protocol and was adjusted individually to the needs of every family. Last but not least, no control group of young patients without an intervention was included.

Conclusions and clinical implications

We described a prospective 6 month follow-up of five cases of OCD in very young children. At the moment of first presentation, all children were so severely impaired that attendance of Kindergarten was uncertain. Parents were deeply involved in accommodating their child’s rituals. Because of the children’s young age, medication was not indicated. Therefore, a minimal CBT intervention for parents was offered, mainly focusing on reducing family accommodation. CY-BOCS scores at the beginning and after 3 months show an impressive decline in OCD severity that remained stable after 6 months. At 3 months follow-up, all children were able to attend Kindergarten daily, and at 6 months follow-up, every child had been admitted to the next grade. OCD is known to be a chronic condition. Therefore, in spite of treatment success, relapse might occur. However, as our treatment approach mainly targeted family accommodation, parents will hopefully react with less accommodation, should a new episode of OCD occur. Moreover, parents stay in touch with the outpatient clinic and can call when needed.

The clinical implications of our findings are that clinicians should not hesitate to think of OCD in a young child when obsessive-compulsive symptoms are reported. The assessment of the disorder should include the CY-BOCS, which has been validated in very young children by obtaining information from the parent. If CY-BOCS scores are clinically meaningful (for young children, a score above 8), a parent-based treatment targeting family accommodation should be offered.

By disseminating knowledge about the clinical presentation, assessment and treatment of early childhood OCD, it should be possible to shorten the long delay between first symptoms of OCD and disease-specific treatment that is reported as main predictor for persistent OCD. Early recognition and treatment of OCD are crucial to prevent chronicity [ 14 , 15 ]. As children and adolescents with OCD have a heightened risk for clinically significant psychiatric and psychosocial problems as adults, intervening early offers an important opportunity to prevent the development of long-standing problem behaviors [ 10 , 19 ].

Availability of data and materials

All data generated or analyzed during this study are included in this published article [and its supplementary information files].

Abbreviations

Obsessive compulsive behavior

Child Yale-Brown Obsessive Compulsive Scale

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V.B. conducted the diagnostic and therapeutic sessions and wrote the manuscript. V.M. was responsible for medical supervision and revised the manuscript. S.W. supervised the OCD treatment and research overall, applied for ethics approval and revised the manuscript. All authors have read and approved the manuscript.

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V.B. and V.M. declare that they have no competing interests. S.W. has received royalties from Thieme, Hogrefe, Kohlhammer, Springer, Beltz in the last 5 years. Her work was supported in the last 5 years by the Swiss National Science Foundation (SNF), diff. EU FP7s, HSM Hochspezialisierte Medizin of the Kanton Zurich, Switzerland, Bfarm Germany, ZInEP, Hartmann Müller Stiftung, Olga Mayenfisch, Gertrud Thalmann, Vontobel-, Unisciencia and Erika Schwarz Fonds. Outside professional activities and interests are declared under the link of the University of Zurich www.uzh.ch/prof/ssl-dir/interessenbindungen/client/web/

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Brezinka, V., Mailänder, V. & Walitza, S. Obsessive compulsive disorder in very young children – a case series from a specialized outpatient clinic. BMC Psychiatry 20 , 366 (2020). https://doi.org/10.1186/s12888-020-02780-0

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Case Report: Obsessive compulsive disorder in posterior cerebellar infarction - illustrating clinical and functional connectivity modulation using MRI-informed transcranial magnetic stimulation

Urvakhsh Meherwan Mehta Roles: Conceptualization, Data Curation, Formal Analysis, Funding Acquisition, Investigation, Methodology, Writing – Original Draft Preparation, Writing – Review & Editing Darshan Shadakshari Roles: Data Curation, Investigation, Resources, Writing – Review & Editing Pulaparambil Vani Roles: Data Curation, Investigation, Methodology, Supervision, Writing – Review & Editing Shalini S Naik Roles: Methodology, Project Administration, Writing – Review & Editing V Kiran Raj Roles: Data Curation, Formal Analysis, Visualization, Writing – Review & Editing Reddy Rani Vangimalla Roles: Data Curation, Formal Analysis, Visualization, Writing – Review & Editing YC Janardhan Reddy Roles: Supervision, Writing – Review & Editing Jaya Sreevalsan-Nair Roles: Formal Analysis, Investigation, Visualization, Writing – Review & Editing Rose Dawn Bharath Roles: Conceptualization, Formal Analysis, Investigation, Methodology, Supervision, Visualization, Writing – Review & Editing

This article is included in the Wellcome Trust/DBT India Alliance gateway.

Obsessive Compulsive Disorder, Cerebellar cognitive affective syndrome, Neuromodulation, Functional brain connectivity, Cerebellar infarct, Theta burst stimulation

Revised Amendments from Version 1

The new version provides more clinical details about the patient, in response to the review comments raised. These include details and justifications for past treatment, iTBS treatment details, rationale for performing an MRI scan and follow-up information beyond the earlier reported period of three months.

See the authors' detailed response to the review by Shubhmohan Singh See the authors' detailed response to the review by Peter Enticott

Introduction

Cortico-striato-thalamocortical circuitry dysfunction is central to an integrated neuroscience formulation of obsessive-compulsive disorder (OCD) 1 , 2 . However, more recent large-scale brain connectivity analyses implicate the role of the cerebello-thalamocortical networks also 3 . Here, we report a case of OCD secondary to a cerebellar lesion. We test the mediating role of the cerebellum in the manifestation of OCD by manipulating the frontal-cerebellar network using MRI-informed transcranial magnetic stimulation (TMS).

Case report

A 21-year-old male, an undergraduate student from rural south India, presented to our emergency with suicidal thoughts. History revealed three years of academic decline, pathological slowness in routine activities (e.g., bathing, eating, dressing up, and using the toilet), repetitive ‘just-right’ behaviors (e.g., wiping his mouth after eating, clearing his throat, pulling down his shirt, mixing his food in the plate and walking back and forth until ‘feeling satisfied’). As a result, he spent up to three hours completing a meal or his toilet routines. Before presentation to us, he had received trials with two separate courses of electroconvulsive therapy (ECT) – six bitemporal ECTs at first, followed by nine bifrontal) spaced about two months apart. ECT was prescribed because of a further deterioration in his condition over the prior 18-months, with reduced oral intake, weight loss, grossly diminished speech output, and passing urine in bed (as he would remain in bed secondary to his obsessive ambitendency, as disclosed later). His oral intake and speech output improved with both ECT treatments, only to gradually worsen over the next few weeks. Given the potential catatonic phenomena (withdrawn behaviour and mutism) in the background of ongoing academic decline, slowness and stereotypies, he was also treated with oral olanzapine 20mg for eight weeks and risperidone 6mg for six weeks with minimal change in his slowness and repetitive behaviors. He did not receive any antidepressant medications. Psychotherapy was also not considered given the limited feasibility due to the severe withdrawal and near mutism. We could not elicit any contributory clinical history of prodromal or mood symptoms from adolescence when we evaluated his past psychiatric and medical history. Two months after the last ECT treatment, he presented to our emergency services with suicidal thoughts. He was admitted, and mental status examination revealed aggressive (urges to harm himself by jumping in front of a moving vehicle or touching electric outlets) and sexual obsessions with mental compulsions and passing urine in bed (as he could not go to the toilet in time due to obsessive ambitendency). The Yale-Brown Obsessive-Compulsive Scale (YBOCS) severity score was 29 4 . He had good insight into obsessions, but not the ‘just right’ repetitive behaviors; it was, therefore, challenging to engage him in psychotherapy. We treated him with escitalopram 40mg and brief psychoeducation before being discharged. After three months, his obsessions had resolved, but pathological slowness, ‘just right’ phenomena, and passing urine in bed had worsened (YBOCS score 31).

We then obtained a plain and contrast brain MRI, to rule out an organic aetiology given the atypical nature of symptoms (apparent urinary incontinence) and the poor treatment response. The MRI revealed a wedge-shaped lesion in the right posterior cerebellum, suggestive of a chronic infarct in the posterior inferior cerebellar artery territory ( Figure-1A ). MR-angiogram revealed no focal narrowing of intracranial and extracranial vessels. Electroencephalography, cerebrospinal fluid analysis, autoimmune and vasculitis investigations were unremarkable. Echocardiogram was normal and the sickling test for sickle cell anemia was also negative. We specifically inquired about history of loss of consciousness, seizures or motor incoordination, but these were absent. His neurological examination with a detailed focus on cerebellar signs was unremarkable. The International Cooperative Ataxia Rating Scale (ICARS) score was zero. The Cerebellar Cognitive Affective Syndrome (CCAS) scale revealed >3 failed tests – in domains of attention, category switching, response inhibition, verbal fluency, and visuospatial drawing, suggestive of definite CCAS 5 .

Cerebellar lesion detection ( A & B ), its functional connectivity map ( C ) and MRI-guided transcranial magnetic stimulation delivery ( D ). Average blood oxygen level-dependent (BOLD) signal time-series were extracted from voxels within a binarized lesion-mask that overlapped with the right crus II ( 1A & 1B ). This was used as the model predictor in a general linear model to determine the brain regions that temporally correlated with the lesion-mask using FSL-FEAT 11 . The resultant seed-to-voxel connectivity map (z-thresholded at 4) was used to identify the best connectivity of the seed with voxels in the pre-supplementary motor area (pre-SMA; MNI x=3; y=13; z=58; 1C ). Six-hundred pulses were delivered as triplet bursts at theta frequency and 90% of the resting motor threshold (50 Hz; 2s on; 8s off) using a MagPro X100 (MagVenture, Denmark) device under MR-guided neuronavigation using the Brainsight stereotaxic system (Rogue Research, Montreal, Canada) with a figure-of-eight coil held with the handle in line with the sagittal plane, pointing toward the occiput to stimulate the pre-SMA site ( 1D ).

MRI-informed neuromodulation

Owing to inadequate treatment response and the possibility of OCD secondary to the cerebellar lesion, we discussed with the patient about MRI-informed repetitive transcranial magnetic stimulation (rTMS) and obtained his consent. The presence of a lesion involving a node (cerebellum) within the cerebello-thalamo-cortical circuit – a key pathway for error monitoring 6 and inhibitory control 7 – cognitive processes typically impacted in OCD prompted us to utilize a personalized-medicine approach to treatment. We acquired a resting-state functional-MRI echoplanar sequence (8m 20s; 250-volumes) in duplicate – before, and one-month after rTMS treatment on a 3-Tesla scanner (Skyra, Siemens), using a 20-channel coil with the following parameters: TR/TE/FA= 2000ms/30ms/78; voxel=3mm isotropic; FOV=192*192.

Image processing was performed using the FMRIB Software Library (FSL version-5.0.10) 8 . Figure 1 describes how we obtained a seed-to-voxel connectivity map to identify the best connectivity of the cerebellar lesion-seed with voxels in the pre-supplementary motor area (pre-SMA; MNI x=3; y=13; z=58) – a commonly used site for neuromodulation in OCD 9 . This area demonstrates connections with the non-motor (ventral dentate nucleus) parts of the posterolateral cerebellum 10 and contributes to error processing and inhibitory control along with the cerebellum 7 .

We augmented escitalopram with rTMS, administered as intermittent theta-burst stimulation (iTBS) to the pre-SMA coordinates ( Figure-1D ). Six-hundred pulses were delivered as triplet bursts at theta frequency and 90% of the resting motor threshold (50 Hz; 2s on; 8s off) using a MagPro X100 (MagVenture, Farum, Denmark) device under MR-guided neuronavigation using the BrainSight stereotaxic system (Rogue Research, Montreal, Canada) with a figure-of-eight (MagVenture MCF-B-70) coil held with the handle in line with the sagittal plane, pointing toward the occiput to stimulate the pre-SMA site. We hypothesized that iTBS 12 to the pre-SMA could adaptively engage the cerebellum lesion, with which it shares neuronal oscillation frequencies, and hence improve the disabling symptoms. He received 27 iTBS sessions, once daily over the next month. Following ten sessions, he began to show a reduction in his repetitive behaviors, and by the 15 th session, he acknowledged that his behaviors were irrational. The YBOCS severity score had reduced to 24 (~22.5% improvement), which remained the same, even at the end of 27 sessions of iTBS treatment. There was no change in the CCAS and ICARS scores. The clinical benefits remained unchanged until three months of follow-up. Subsequently, we observed a gradual reversal to pre-TMS symptom severity. Maintenance TMS was suggested but was not feasible due to logistic reasons and therefore he was initiated on oral fluoxetine that was gradually increased to 80mg/day, with which we observed minimal change in symptoms over the next four months.

Post-neuromodulation functional connectivity visualization

The pre- and post-rTMS scans 13 were parcellated into 48-cortical, 15-subcortical, and 28-cerebellar regions as per the Harvard-Oxford 14 and the Cerebellum MNI-FLIRT atlases 15 . Average BOLD-signal time-series from each of these nodes, obtained after processing within FSL version-5.0.10, were then concatenated to obtain a Pearson’s correlation matrix between 91 nodes, separately for the pre- and post-TMS studies.

We analyzed the two 91 × 91 matrices using the Rank-two ellipse (R2E) seriation technique for node clustering 16 ( Figure 2 ). This technique reorders the nodes by moving the ones with a higher correlation closer to the diagonal. Thus, blocks along the diagonal of the matrix visualization show possible functional coactivating clusters.

Rank-two ellipse seriation-based visualization of correlation matrix before ( A ) and after ( B ) rTMS treatment. The dotted-black boxes denote the cerebellar network and other connected networks, where the green boxes show the inter-network overlap. Thus, we see that the overlapped region in ( 2A ) has now transitioned to three different overlapped areas in ( 2B ), which shows the increase in the overlap between modular networks after treatment. Cerebellar nodes are denoted in black, cortical nodes in blue and subcortical nodes in green. The lesion node (right crus II) and the region of neuro-stimulation are given in red; R2E= Rank-two ellipse.

We observed (a) extended connectivity of the cerebellar network after iTBS treatment as evidenced through its diminished modularity – the larger cerebellar cluster/block had an increased overlap with both anterior and posterior brain networks as observed along the diagonal in ( Figure 2B ), and (b) formation of better-defined sub-clusters within the larger cerebellar cluster indicating improved within-network modularity of distinct functional cerebellar networks [e.g., vestibular (lobules IX and X) and cognitive-limbic (crus I/II and vermis)].

Conclusions

We illustrate a case of OCD possibly secondary to a posterior cerebellar infarct, supporting the role of the cerebellum in the pathophysiology of OCD 3 . That OCD was perhaps secondary to the posterior cerebellar lesion is supported by several lines of evidence. Firstly, there seemed to be a possible temporal correlation between the duration of OCD and the chronic nature of the cerebellar lesion. Despite the challenges in inferring a precise temporal relationship based on clinical history, the signal changes with free diffusion and atrophy indicated that the infarct was indeed chronic, supporting the symptom onset at about three years before presentation. Previous studies have indeed reported OCD in posterior cerebellar lesions 17 – 19 . Secondly, the clinical phenotype was somewhat atypical, characterized by severe ambitendency, precipitating urinary incontinence, and poor insight into compulsions along with comorbid CCAS. Thirdly, our patient was resistant to an anti-obsessional medication but improved partially with neuromodulation of the related circuit. The MRI-informed iTBS engaged the lesion-area by targeting its more superficial connections in the frontal lobe. The changes in clinical observations paralleled the changes in cerebellar functional connectivity – enhanced within-cerebellum modularity and expanded cerebellum to whole-brain connectivity.

This report adds to the growing evidence-base for the involvement of the posterior cerebellum in the pathogenesis of OCD. Drawing conclusions from a single case study and the absence of a placebo treatment will prevent any confirmatory causal inferences from being made. The opportunity to examine network-changes that parallel therapeutic response in an individual with lesion-triggered psychiatric manifestations not only helps mapping symptoms to brain networks at an individual level 13 but also takes us a step further to refine methods to deliver more effective personalized-medicine in the years to come.

Data availability

Underlying data.

Harvard Dataverse: PICA OCD Raw fMRI files NII format. https://doi.org/10.7910/DVN/X12BZD 20 .

This project contains the following underlying data:

- postTMS_fmri.nii (raw post TMS fMRI file)

- preTMS_fmri.nii (Raw pre TMS fMRI file)

Reporting guidelines

Harvard Dataverse: PICA OCD case report CARE guidelines for case reports: 13-item checklist. https://doi.org/10.7910/DVN/2XKSXL 21 .

Data are available under the terms of the Creative Commons Zero "No rights reserved" data waiver (CC0 1.0 Public domain dedication).

Written informed consent for publication of their clinical details and clinical images was obtained from the patient.

Acknowledgments

We thank our patient and his parents for permitting us to collate this data for publication.

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Comments on this article Comments (0)

Open peer review.

Competing Interests: No competing interests were disclosed.

Reviewer Expertise: Cognitive neuroscience

Respond or Comment
COMMENT ON THIS REPORT

Is the background of the case’s history and progression described in sufficient detail?

Are enough details provided of any physical examination and diagnostic tests, treatment given and outcomes?

Is sufficient discussion included of the importance of the findings and their relevance to future understanding of disease processes, diagnosis or treatment?

Is the case presented with sufficient detail to be useful for other practitioners?

This is a very interesting case report, even without the intervention component (which itself is a fascinating approach to neuromodulation). I particularly appreciated the approach to regional (SMA)
This is a very interesting case report, even without the intervention component (which itself is a fascinating approach to neuromodulation). I particularly appreciated the approach to regional (SMA) targeting, which involved resting state fMRI to detect functional connectivity with the affected cerebellar region. The report itself is very clear and well-written.
ECT appears to have been provided in the context of a depressive episode, but were other (e.g., psychotherapy, pharmacotherapy) treatments initially trialled? It would be useful to present any clinical history from adolescence, although this may not be feasible.
Please describe the reason for conducting MRI; why was this not undertaken earlier?
Was iTBS the “standard” course (i.e., 600 pulses, trains comprising 3 pulses at 50 Hz, repeated for 2 seconds at 5 Hz, followed by an 8-second ITI)? How was intensity determined (e.g., 70%RMT, 80%AMT)? Specify the stimulator, coil type, and neuronavigation method.
Given that the duration of both the cerebellar lesion and OCD symptoms seems quite unclear, it is somewhat difficult to suggest a temporal relationship (as stated in the Conclusion).
Was the patient followed-up over a longer-term period? I would be interested to know if these improvements are lasting (i.e., longer than 3 months), although again this might not be possible.

Reviewer Expertise: Neuromodulation, psychiatry

Author Response 11 Sep 2020 Urvakhsh Mehta , Department of Psychiatry, National Institute of Mental Health and Neurosciences, India, Bangalore, 560029, India 11 Sep 2020 Author Response We thank this reviewer for the time taken to provide constructive feedback and the encouraging comments on this report. Competing Interests: None We thank this reviewer for the time taken to provide constructive feedback and the encouraging comments on this report. We thank this reviewer for the time taken to provide constructive feedback and the encouraging comments on this report. Competing Interests: None Close Report a concern Reply -->

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Shubhmohan Singh , Postgraduate Institute of Medical Education and Research, Chandigarh, India
Peter Enticott , Deakin University, Geelong, Australia

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Case Study of a Middle-Aged Woman’s OCD Treatment Using CBT and ERP Technique

Clinical Medical Reviews and Reports

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Case report, case formulation, intervention, preparation phase of erp, middle phase of erp, steps of hierarchy, booster sessions, quick links.

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Research Article | DOI: https://doi.org/10.31579/2690-8794/102

Deepshikha Paliwal 1*
Anamika Rawlani 2

1 M.Sc. Clinical Psychology, Dev Sanskriti University, Ranchi, India. 2 M.Phil Clinical Psychology, RINPAS Ranchi, India.

*Corresponding Author: Deepshikha Paliwal, M.Sc. Clinical Psychology, Dev Sanskriti University, Ranchi, India.

Citation: Deepshikha Paliwal and Anamika Rawlani (2022) Case Study of a Middle-Aged Woman’s OCD Treatment Using CBT and ERP Technique. Clinical Medical Reviews and Reports 4(3): DOI: 10.31579/2690-8794/102

Copyright: © 2022, Deepshikha Paliwal, This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Received: 01 September 2021 | Accepted: 04 December 2021 | Published: 10 January 2022

Keywords: OCD; CBT; ERP; salkovskis’s model

Introduction : This is a case report of a middle-aged woman, who was experiencing “obsessive” thoughts related to the “Bindi” (decorative piece wear by women on the forehead) and cleaning “compulsions”. Present case report discusses the patient’s assessment, case formulation, treatment plan and the effectiveness of the CBT and ERP sessions in reducing OCD symptoms.

Methodology: The patient was treated with Cognitive Behavior Therapy (CBT) along with Exposure Response Prevention (ERP) technique. The assessment of the case was done with the Y-BOCS rating scale, Beck’s Depression Inventory, Obsessive Beliefs Questionnaire, and Behavior Analysis Performa which suggested the higher severity level of the patient’s symptoms. Parallel to the assessment sessions, detailed case history related to the onset of the problem, difficulties faced because of the disorder, childhood incidences, family chart, marital issues, and medical history were discussed with the patient. Based on the reported details, the case was formulated according to the Salkovoskis inflated sense of responsibility model. After the case formulation, the treatment plan was designed which involved ERP sessions and restructuring of the cognitive distortions (beliefs, thoughts, and attitude).

Results: After the completion of the twenty-five therapy sessions, the patient reported improvement in the coping of anxiety-provoking thoughts and reduced level of the washing compulsions. The effects of the therapy were checked and found maintained up to two months follow up.

Conclusion: CBT and ERP technique is an effective treatment in reducing obsessive and compulsive symptoms of the patient.

Have you ever felt like a sudden urge to hurt somebody? What if such urges continuously appear in your head? What would you do to stop these urges? Would you be able to continue your day to day life normally with such urges? Clinical Psychologists studied the repetitive occurrence of unwelcoming thoughts, urges, doubts, and images which create anxiety. They gave it the term “Obsessions”. These obsessions are dreadful, frightening, and intolerable to the extent that they might hinder the natural flow of one’s personal, professional, and social life. The person who suffers from such anxiety-provoking thoughts tries to deal with the distress caused by such ‘obsessions’ by adopting some behavior or activity which temporarily relieve them from the anxiety and the feared consequences. This behavior could be anything like washing hands, cleaning, repeatedly checking the door, or repeating some phrases in the head. Psychologists called such repetitive behaviors or activities as “Compulsions”. According to APA (1994), if the presence of obsessions and/or compulsions is time-consuming (more than an hour a day), cause major distress, and impair work, social, or other important functions then the person will be diagnosed with Obsessive-Compulsive Disorder (OCD). Recent epidemiological studies suggest that OCD affects between 1.9 to 2.5% of the world population at some point in their lives, creating great difficulties on a professional, academic and social level (DSM-IV-TR, 2001). OCD affects all cultural and ethnic groups and, unlike many related disorders, males and females are equally affected by this disorder (Rasmussen & Eisen, 1992). OCD is one of the most incapacitating of anxiety disorders having been rated as a leading cause of disability by the World Health Organization (1996). The major cause of OCD is still unknown; there could be some genetic components responsible for it (DSM-5). Child abuse or any stress-inducing event could be the risk factor involved in the history of OCD patients. The severity of the symptoms related to obsessions and compulsions provides the basis of the diagnosis in OCD which rules out any other drug-related or medical causes. Clinical Psychologists use rating scales like Y-BOCS (Fenske & Schwenk, 2009), self-reports, and Behavior Analysis Performa to assess the severity level of the symptoms. Based on the severity, the treatment plan is designed. Treatment of OCD involves psychotherapy and antidepressants. Psychotherapy such as Cognitive Behavior Therapy (CBT) is an effective psycho-social treatment of OCD (Beck, 2011). In CBT, a “problem-focused” approach is used to treat the diagnosed psychological disorder by challenging and changing core beliefs, negative automatic thoughts, and cognitive distortions of the patient. CBT involves Exposure Response Prevention (ERP) as a technique to treat OCD in which the patient is exposed to the cause of the problem and not allowed to repeat the ritual behavior (Grant, 2014). ERP has promising results with 63% of OCD patients showing favorable responses after following the therapy sessions (Stanley & Turner, 1995).

This is a case of a 31 years old woman, who belongs to a middle socio-economic background, currently living with her in-laws, husband, and daughter. The patient was experiencing obsessive thoughts related to the contamination spread by ‘bindi’ along with the compulsive behavior of washing and cleaning from the last five years. The patient reported that she always tried to check the contact of ‘Bindi’ with anything because that contact makes her incapacitate to control the situation. She took two and three hours (on daily basis) in washing and cleaning her home, scrubbing her daughter, cleaning the daughter’s school bag after returning from school, husband’s bag, and other usable items, so that she can stop the contamination from spreading everywhere. The patient has a history of facing interpersonal issues with family members since her childhood. Her father was alcohol dependent and the mother was the patient of depression. The financial condition of the family was not good. When the patient was 17 years old, her father died due to kidney failure, and her mother got hospitalized because of depression. From a very young age, the patient had to bear the responsibility of the family by taking tuitions. At first, she developed the fear of contamination at the age of 19, when she was in her graduation’s first year, for that she was taken to the Psychiatrist. She responded well to the medicines and stopped showing all the symptoms. At the age of 25, when the patient got pregnant she again developed the fear of contamination, which made her husband and in-laws uncomfortable and family disputes began. Her husband took her to the psychiatrist who referred her for the psychotherapy but she didn’t attend the psychotherapy sessions properly and continuously lived with the obsessions and compulsions up to the present referral where the patient was assessed with Y-BOCS rating scale, BDI, EBQ, and Behavioral Analysis Performa. Based on the assessment, she was diagnosed with OCD having symptoms of obsessions related to the contamination by ‘Bindi’ and washing compulsions. Detailed case history related to the onset of the problem, childhood incidences, family history, marital history, medical history, and other relevant information were also collected. The case was formulated according to Salkovoskis’s inflated sense of responsibility model as the patient’s reported details were signifying the negative interpretations of her responsibility for self and others. After the case formulation, the treatment plan was designed which involved sessions of ERP technique along with the alteration of cognitive distortions (ideas, beliefs, and attitudes) through the cognitive restructuring method of CBT.

1. Yale-Brown Obsessive-Compulsive Scale (YBOCS):

In cognitive-behavioral studies, Y-BOCS is used to rate the symptoms of OCD. This scale was designed by Goodman et al. (1989) to know the baseline and the recovery rate of the ‘severity of obsessions’, ‘severity of compulsions’ and ‘resistance to symptoms’. This is a five-point Likert scale that clinicians administer through a semi-structured interview in which a higher score indicates higher disturbances. The excellent psychometric properties of this scale quantify the severity of the obsessions and compulsions as well as provide valuable qualitative information which makes it very useful for both diagnosis of the OCD and the designing of its treatment plan.

2. Beck Anxiety Inventory (BAI):

Aaron T. Beck (1988) developed BAI as a four-point Likert scale which consists of 21 items of ‘0 to 3’ scores on each item (Higher score means higher anxiety). If the Patient’s scores are from 0 to 7 then interpret as ‘minimal anxiety’, 8 to 15 as ‘mild anxiety’, 16 to 25 as ‘moderate anxiety’, and 30 to 63 as ‘severe anxiety’. BAI assesses common cognitive and somatic symptoms of anxiety disorder and is considered effective in discriminating between the person with or without an anxiety disorder. This scale provides valuable clinical information but is not used by clinicians for diagnostic purposes.

3. Obsessive Belief Questionnaire (OBQ):

OBQ is used to assess the beliefs and appraisals of OCD patients which are critical to their pathogenesis of obsessions (OCCWG, 1997, 2001). This scale consists of 87 belief statements within six subscales which represent key belief domains of OCD. The first subscale is ‘Control of thoughts’ (14 items), the second is ‘importance of thoughts’ (14 items), third is, responsibility (16 items), fourth is ‘intolerance of uncertainty’ (13 items), the fifth is an overestimation of threat (14 items), and sixth is ‘perfectionism’ (16 items). Response on this measure is the general level of agreement of the respondents with the items on a 7 point rating scale that ranges from (-3) “disagree very much” to (+3) “agree very much”. On the respective items summing of the scores is done to calculate the subscale scores.

4. Behavior Analysis Performa

This study used ‘Behavior Analysis Performa’ to do the functional analysis of the patient’s behavior. This Performa collects the details of the patient’s behavioral excess, deficits, and assets, his or her motivational factors behind maintaining and reinforcing ill behaviors, as well as, the medical, cultural, and social factors which contributed to the development of the illness.

Based on the reported details and the assessment, the case was formulated according to the Salkovoskis model (1985). This model suggests that the patient’s main negative interpretation revolves around the idea that his or her actions might have harmful outcomes for self or others. This interpretation of responsibility increases selective attention and maintains negative beliefs (Salkovskis, 1987). Here, in this case, the patient had to face the disturbing family environment which significantly has a role in the formation of maladaptive schemas related to her negative view of self, the world, and the future. The patient’s beliefs assessment reports signified that her major dysfunctional assumptions were ‘if harm is very unlikely, I should try to prevent it at any cost’ and ‘if I don’t act when I foresee danger then I am to blame for any consequences’. Intrusive thought for her was that ‘bindi contaminates dirt’ and neutralizing action for this intrusive thought was ‘washing and cleaning things’. She paid her keen attention to the thought that ‘I should not be get touched with bindi’ and misinterpreted and over signified it by avoiding bindi and preventing the contamination. Her safety behavior included avoiding going out, (especially beauty parlors and cosmetic shops), and getting touched with anyone on roads and market places. The result of such avoidance was tiredness, anxiousness, aggressiveness, and distressed mood state. The graphical representation of the case formulation is shown in Appendix 1 at the end of this paper.

After the case formulation, the treatment plan was designed. The patient had dysfunctional assumptions related to her responsibility for self and others. She had obsessions related to the contamination spread by ‘Bindi’ associated with washing and cleaning compulsions. As she was taken by her husband for the therapy, so it was important to socialize her and her family with the OCD to develop insight for the disorder. After socializing them with OCD, they were taught the basic structure of the cognitive behavior model that how patient’s thoughts, emotions, physical sensations, and behavior all are interrelated and affect each other in a vicious circle.

In the preparatory phase, the patient was introduced with the ERP technique, how does it work and how much her cooperation and will power are required for the success of this technique. After introducing the ERP technique to her, behavioral analysis was done with the patient by using a down-arrow method to make the list of the situations she uses as safety strategies and maintains her negative beliefs.

In the next session, the patient was told to imagine her exposure with different situations which she avoids and asked her to rate the level of anxiety in all the situations on a scale of 1 to 10. After this imaginary exposure, a hierarchy was made from the least anxiety-provoking event to the high anxiety-provoking event. Here is the list of different situations which the patient rated based on the level of anxiety:

In this phase, the patient was gradually exposed with the least anxiety-provoking situation to the highest-anxiety provoking situation. The patient’s husband worked as a co-therapist and accompanied her in all the situations and observed her anxiety levels and other behaviors. The patient was asked to rate her anxiety level on a scale of 1 to 10 after every exposure.

In the first step of exposure, patient was instructed to go out with the husband in the market area where ‘Bindi’ was hanging on the walls , she was instructed to watch them from some distance and observe her level of anxiety varying with time . She was strictly instructed not to avoid the situation and to face the anxiety levels without skipping. In the next session, she was asked what she exactly felt when she was watching the bindi packets, she replied that at first sight of bindi she felt disgusted and wanted to go away but she gave self instructions to her that these are very far and cannot contaminate her so she kept sitting there and with time her anxiety level also came down.
In the second step of the hierarchy she was instructed for sitting at a distance from the cosmetics shop and observe the ladies entering and purchasing bindi there , her husband was told to work as a co-therapist and checks the anxiety levels and reactions of his wife during the exposure. In the next session, she was again asked for the thoughts and levels of anxiety during the observation, husband reported that at first she showed some anger and was looking very anxious while observing the ladies with bindi but when he reminded her about the nature of therapy, she managed to sit there and sometime later became relaxed.
In the third step of the hierarchy patient was instructed to enter into the cosmetic shop and remain stand there for a short while without purchasing anything and to face the levels of anxiety varying with time. In the session, she was asked to report the anxiety level. She reported that just when she entered the shop she was trying to not get touched with anything and felt like she would lose her control and became very anxious but with self instructions she managed herself to stand there after sometime anxiety level came down and she felt little relaxed.
In the fourth step, the patient was instructed to enter into the cosmetic shop and to purchase some common items other than ‘Bindi’ . In the next session, husband reported that she was attentively noticing the shopkeeper’s movements. Though, she purchased some ribbons but denied to touch them and asked him to put them in his bag and told him to give only the fixed amount of ribbon’s cost to the shopkeeper so that exchange could not be needed from shopkeeper’s contaminated hands. The husband also observed that during the whole exposure, the patient was looking very distressed and anxious and was involved in safety strategies and managed to calm down only when he reminded her about the process of therapy. The patient was then asked to report her anxiety level in this step of exposure.
In the fifth step, patient was instructed to go into the market and purchase a packet of small colorful bindi and face the anxiety levels . In the next session, she was asked to express the anxiety and rate it on a scale of 1 to 10. The patient reported that when she was purchasing the bindi, she felt dreadful and thought that she would take bath after returning home. Somehow, she purchased the packet and gave it to the husband to put it in his bag. After returning home, she got involved in her daughter’s work but thoughts of washing and bathing were going on in her mind. Later on, she could not get the time for bathing and she instructed herself to bath in the morning, after this thought she felt very relaxed and had this feeling of winning over her obsessions.
In the sixth step, patient was instructed to purchase some colorful bindi packets and try to keep them with herself and strictly prevent herself from hand-washing for one hour. In the next session, she reported that this time she was not that anxious while purchasing bindi packets but after putting them in her bags she was trying to avoid getting touched with her daughter and mother in law because her mother in law would enter into the kitchen and contaminate everything. Meanwhile, her daughter ran towards her and hugged her. Immediately, she became very restless and angry with the daughter and thought about to wash her. However, she felt incapacitated as her daughter ran everywhere in the house and touched everything. She got anxious but managed this thought of contamination and decided to not wash anything. After this, she felt relaxed.
In the seventh step of the hierarchy, the patient was instructed to apply a small bindi on her forehead and restricted to not wash her hands for at least four hours . In the next session, she reported that she applied the bindi and her husband and her mother-in-law were feeling very happy but she felt anxious and closed her fist for not touching anything till hand-washing. After some time, in other household works, she forgot about it but suddenly when she realized that she had applied bindi, she immediately washed her hands but even then kept wearing it for the whole day.
In the eighth step, the patient was instructed to apply red color velvet medium size Bindi and prevent hand washing for minimum of two hours . In the next session, she reported that now her level of anxiety has fallen down and now she feels less anxious after applying bindi and managed to not wash her hands for two hours without any much restlessness.
In the ninth step of the hierarchy, the patient was instructed to apply red color velvet medium size Bindi and prevent hand washing for minimum of four hours and try to make herself normal and gradually start touching things in these hours. In the next session, she reported that now she feels capable to face her feelings of disgust with bindi and manages to make her mind for not washing things after getting touched with the bindi. Though some thoughts of contamination keep coming in between but she immediately reminds herself that ‘Bindi’ can’t contaminate anything.
In the tenth step of hierarchy, the patient was instructed to apply bindi on her forehead and keep some of them in her bag preventing washing her hands for maximum hours possible. In the next session, she reported that now she feels more capable to conquer over her thoughts of contamination and more determined to not washing and cleaning after such obsessions.

With each ERP session, the patient came to realize that the nature of anxiety is that it goes up with the triggering event but with the passage of time, automatically comes down. She also developed the insight that she had fear from the thoughts of contamination and with its associated anxiety more than ‘Bindi’ itself.

After the ERP sessions, the patient was given two booster sessions in which she was taught the ways to deal with the anxiety after the termination of therapy in her day to day life situations. In those sessions, she was asked to imagine her home, her room, and herself with Bindi on her forehead and doing household chores like cooking, cleaning the things, etc. When the patient was asked to express herself during the imagination, she reported that she is feeling more confident now to stick on her thought that bindi can’t contaminate, it’s her idea and there is no use of washing hands and other things because of the fear of contamination. Her husband and mother-in-law were also instructed to remind her again and again about the things she learned during the therapy sessions. After the declaration of the patient that she is feeling better now and ready to face the anxiety on her own, therapy sessions were terminated.

One month later, the patient was contacted for the follow-up and asked about her coping with the anxiety through telephonic conversation. She reported that thoughts of contamination came in her mind but she is in better condition than previous after taking the ERP sessions.

After two months, the patient came for the session again with the complaints that sometimes she became weak and washed her hands with the thought of contamination. After washing, she repented on her behavior which lowers down her confidence in conquering over the illness. Then she was instructed that washing hands strengthens the thought of contamination so she should avoid it as much as possible but this doesn’t mean that she has not gained anything with the therapy, she was reminded about her previous condition that how much it was unbearable for her to even think about the bindi but now she is applying it on her forehead which shows that only the traces of the illness left, most of it is already recovered. In this way, the patient became relaxed and felt more determined to continue with the learnings during the sessions.

After the termination of the therapy sessions, the patient’s obsessive and compulsive symptoms were found reduced on the Y-BOCS symptom checklist:

With the graded exposure sessions, her anxiety level also came down from the rating of 10 in the beginning sessions to the rating of 4 in the endings sessions on a scale of 1 to 10.

The patient’s BAI score was also fallen down from pre-intervention- 36 (Extreme level of anxiety) to post intervention- 13 (mild level of anxiety) which suggests 36% reduction in the anxiety level of the patient.

Previous research findings considered CBT as the most promising treatment of OCD (Stanley & Turner, 1995; Foa et al, 1999). CBT emphasizes the integration of cognitive-behavioral strategies like discussion techniques (Guided Discovery) and behavioral experiments (ERP) to formulate the problem and direct the treatment. Therapists try to identify the key distorted beliefs along with patients and allow them to test their beliefs which develop and maintain compulsive behaviors. This case identified the contamination with ‘Bindi’ as the pathological belief which was maintaining the compulsive behaviors of washing and cleaning. The cognitive hypothesis of Salkovoskis (1985) proposed that the origin of obsessional thinking lies in normal intrusive ideas, images, thoughts, and impulses which a person finds unacceptable, upsetting, or unpleasant. The occurrence and content of these intrusive cognitions are negatively interpreted as an indication that the person may be ‘responsible for harm’ or ‘prevent the harm’. Such an interpretation is likely followed by emotional reactions such as anxiety or depression. These emotional reactions lead to discomfort and neutralizing (Compulsive) behaviors like washing, cleaning, checking, avoidance of situations related to the obsessive thought, seeking reassurance, and attempts to exclude these thoughts from the mind. The present case supported this hypothesis of Salkovoskis’s model as intrusive thought of the patient was contamination spread by ‘Bindi’ which negatively interpreted as ‘I can avoid the likely harms by avoiding the contamination spread by Bindi’, such negative interpretation was raising her anxiety levels, making her attentive selective towards the ‘Bindi’, maintaining her compulsive acts and complying her to adopt the safety strategies.

Rachman (1983) predicted that behavioral experiments, in which the patient is exposed to the feared object, these intrusive thoughts are challenged by changing the pattern of thinking and behaving. Hodgson & Rachman (1972) initiated the series of clinical studies on patients with contamination and predicted that immediate washing reduces the anxiety. In one of their experimental study, they noted a similar degree of anxiety reduction when the patient was asked not to perform a compulsive act for one hour. They termed this phenomenon as ‘spontaneous decay’ which was established as the basis of ERP. Also, Foa & Kozak (1986) proposed that exposure techniques activate the network of cognitive fear and patients get new experience which is different from the existing pathological beliefs. This case confirmed this hypothesis as the patient initially thought that her exposure with ‘Bindi’ might cause some uncertain consequence with her but prolonged exposures provided her new experience that she could manage with her fear and anxiety which resulted in the improved coping with obsessional beliefs about contamination and urge to wash and clean. Her improved coping is evident in the statistically significant reduction of her scores on the standard measures like the Y-BOCS symptom checklist, BAI, and OBQ.

The results of this case study add on the value of CBT (that involves ERP technique) in the treatment of obsessive thinking related to the ‘fear of contamination’ and compulsive behavior of ‘washing and cleaning’. However, there is a need for more such case studies with more precision and effective treatment designs to provide valuable information related to the nature of OCD and its treatment.

In this case of OCD, patient’s symptoms were reduced to a manageable level and found maintained for two months which provides an evidence of the effectiveness of CBT and ERP technique in the treatment of OCD.

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Bibliotherapy and OCD: The Case of Turtles All The Way Down by John Green (2017)

2020, New Horizons in English Studies

This case study uses three different frameworks of inquiry to examine Turtles All the Way Down by John Green (2017) with a disability lens. The analysis extends beyond the traditional medical/ social dichotomy and considers how disability is tied to both agency and identity. Narratives and counter narratives of disability are also investigated, as well as disability markers used in previous scholarship. The discussion concludes with an argument to include the novel in secondary English classes to create mental health allies. A consideration for medical humanities scholars is also included to use Green's text with patients with OCD, as a way for readers to find an identifiable protagonist.

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This paper examines the very notion of Disability Authorship of the anomalous bodies through the Autosomatography, The Diving Bell and the Butterfly (1997) by the former editor-in-chief of French 'Elle' Jean-Dominique Bauby, which is a narrative that incorporates counter-narrative of empowerment, unlocks the credentials of the locked-in syndrome, employing the only three things that aren't paralyzed; his left eye, his imagination and his memory. The left eyelid is awakened to "superior seeing capacities" (Couser, 2007) in terms of his life before and after the catastrophic stroke, that is found, trapped within a Diving Bell. This inner life of Jean-Dominique, holds him captive, locking him in a territory where he discovers his imagination, as a free-flowing butterfly travelling to far off lands traversing time, and his desire "to transcend the limitations of the human".(Corne, 2010) This ability exceeds the physical norms and standard social model of a body that politicizes disability. The author's disappointed thoughts on the dependence nature of a "vegetable" lead to the recognition and acceptance of an independent thought process that makes him stand out as the abled-disabled, owning a body that matters. This autosomatographical piece of writing renders the author a function, not of advances in the medical treatment of locked-in syndrome, but his affirmation of control over his own body. Such control may not save him from the paralysis, yet his authorship of disability narrative helps him claim autonomy despite the disability. Apart from the implicit step-up in his own identity when the spatial capabilities and orientation are limited, this paper also scrutinizes the apprehension of such a condition by the others who can see him and interpret him as they like, that becomes an inherent element of his identity because he can "never actually occupy that point of view." (Schnabel, 2007)

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Joanna Rankin

Examining how readers of popular fiction respond to characters with disabilities and characters immersed in the lives of characters with disabilities, this paper serves to contribute to understandings of the meanings that readers ascribe to disability in popular culture using the public sphere of online discussion. Specifically, I study online reader discussion of three characters, namely: Trudi in Ursula Hegi’s (1996) Stones from the River, Icy in Gwyn Hyman Rubio’s (1998) Icy Sparks and Jewel in Brett Lott’s (1991) Jewel. I present findings from my analysis of reader discussion using readers’ descriptions of their identified connections with characters with disabilities. While these connections challenge the othering frequently cited in presentations of disability through readers’ recognition and appreciation of the well-rounded characters beyond traditional disability tropes, the unmet potential of reader discussion to challenge the status quo is also demonstrated through reade...

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Published in MUsings Spring 2018 The manner in which first-person narrators tell the reader their stories greatly impacts whether or not the reader views these narrators as trustworthy and reliable. In several cases, scholars and readers alike deem these narrators as “unreliable,” based on many different criteria within these stories that readers define as “true” or “factual.” Many scholars and readers take pleasure in scrutinizing the thoughts and actions of these narrators and evaluating what is in fact “true” within these sorts of narrations. Each of these “unreliable” narrators are categorized based on the underlying rationalization of their thoughts and actions; these are divided into four categories as defined by Riggan (1981). One of these classifications of the “unreliable” narrator is that of the “madman,” a narrator who suffers from a severe mental illness, and this impairment hinders the narrator’s ability to tell their story correctly (Riggan 133). However, a reading of these “madman” narrators through the lens of the social model of disability studies greatly impacts how the reader considers these narrators as “unreliable,” and ultimately questions how readers determine who is a “madman” and who is “sane.” As Michael Bérubé states, “disability demands a story” (43). I argue this perspective through an example of one of the narrators in Edgar Allan Poe’s short stories.

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Case Report

Juvenile obsessive compulsive disorder in a paediatric dentistry set-up, ruchi ahuja.

1 Department of Pedodontics and Preventive Dentistry, Peoples College of Dental Sciences and Research Centre, Bhopal, Madhya Pradesh, India

Anand L Shigli

2 Department of Pedodontics and Preventive Dentistry, Bharati Vidyapeeth Dental College, Sangli, Maharashtra, India

Gagan Thakur

3 Department of Oral and Maxillofacial Surgery, People's College of Dental Sciences and Research Centre, Bhopal, Madhya Pradesh, India

Upendra Jain

4 Department of Orthodontics, Peoples College of Dental Sceinces, Bhopal, Madhya Pradesh, India

Obsessive-compulsive disorder (OCD) is an anxiety disorder comprising uncontrollable thought processes and repetitive, ritualised behaviours that one feels compelled to perform. If an individual has OCD, he/she probably realises that his/her obsessive thoughts and compulsive behaviours are irrational but would still feel unable to resist them. It encompasses 1% to 4% of children in the USA and the manifestation of OCD in children is very different from that in adults. The older the child grows, so does the urge to hide their behaviours due to embarrassment from peers. It is necessary that dentists along with caretakers in schools or activity classes are familiar with this condition and its symptoms to be able to counsel or refer appropriately to help students with OCD cope effectively. 1 Substantial research has been carried out in juveniles with OCD. There is a supposition that juvenile OCD could be a developmental subtype of the disorder. Juvenile OCD seems to have a favourable prognosis. In all the studies of OCD in children and adolescents reported from India, male subjects have outnumbered female subjects. 2 3 Male prediliction in juvenile OCD is consistent with the previous clinical studies of juvenile OCD justifying the argument that gender distribution in OCD is developmentally sensitive. 4

Case presentation

An 10-year-old boy ( figure 1 ) reported to the paediatric dental office with chief symptoms of pain in tooth number 85 and the cariously decayed tooth number 75. Pulpectomy followed by a stainless steel crown was planned for 85 and glass ionomer restoration for 75. Dental treatment was planned in multiple visits as the patient had to be reassured time and again that the entire procedure would be carried out with the best of his consents ( figure 2 ). However, a strange behaviour pattern was always noticed as the treatment visits went by. He would feel uncomfortable and irritated if the dental assistant did not assure him that he had cleaned the instrument tray and the dental chair handles in front of him. Whenever the treatment ensued, he would fold his legs in a typical manner one over the other and make sure that his bare feet did not touch the chair, insisted on not straightening his legs because his feet might get contaminated. He would also appear to be humming something which could not be deciphered but seemed like a counting pattern. The patient's parents confirmed that nobody else in the family had the same behaviour pattern. The mother stated that her son was not performing well in school too as he would be busy repeating rituals like putting books in his bag again and again, following a specific pattern or otherwise setting up his geometry box in a specific manner. She added that some counselling sessions were also being carried out for him in school but that she was not aware of the details in this regard. He also insisted on following and stepping only on the line between two tiles while climbing the stairs to his classroom in school.

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Ten-year-old boy.

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Object name is bcr2015209864f02.jpg

Pulpectomy and stainless steel crown placement with 75 and glass ionomer restoration with 85.

Investigations

According to the clinical classification of OCD for a definite diagnosis, obsessional symptoms or compulsive acts or both, must be present on most days for at least two successive weeks and be a source of distress or interference with activities. The obsessional symptoms should have the following characteristics: (1) they must be recognised as the individual’s own thoughts or impulses: (2) there must be at least one thought or act that is still resisted unsuccessfully, even in the presence of others whom the sufferer no longer resists; (3) the thought of carrying out the act must not in itself be pleasurable (simple relief of tension or anxiety is not regarded as pleasure in this sense); (d) the thoughts, images or impulses must be unpleasantly repetitive. Though we could witness some of the aforementioned symptoms in the patient, a definite diagnosis for OCD could not be established in the dental office set-up. Therefore, we referred the patient to a paediatrician who with his team diagnosed his behaviour under the new upcoming fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), which includes a new chapter on Obsessive-Compulsive and Related Disorders to reflect the increasing evidence of these disorders’ relatedness to one another and distinction from other anxiety disorders, as well as to help clinicians better identify and treat individuals suffering from these disorders. The disorders included in this new chapter have enough similarities to group them together in the same diagnostic classification but enough important differences between them to exist as distinct disorders. There are certain specifiers for these disorders. The ‘with poor insight’ specifier for obsessive-compulsive disorder has been refined in DSM-5 to allow a distinction between individuals with good or fair insight, poor insight and ‘absent insight/delusional’ OCD beliefs (ie, complete conviction that OCD beliefs are true). Analogous ‘insight’ specifiers have been included for body dysmorphic disorder and hoarding disorder. These specifiers are intended to improve differential diagnosis by emphasising that individuals with these two disorders may present with a range of insights into their disorder-related beliefs, including absent insight/delusional symptoms. This change also emphasises that the presence of absent insight/delusional beliefs warrants a diagnosis of the relevant obsessive-compulsive or related disorder, rather than a schizophrenia spectrum and other psychotic disorder. The ‘tic-related’ specifier for OCD reflects a growing literature on the diagnostic validity and clinical utility of identifying individuals with a current or past comorbid tic disorder, because this comorbidity may have important clinical implications. 5

Differential diagnosis

Tic disorders, trichotillomania, generalised anxiety disorder (GAD), Schizophrenia, autism spectrum disorders, etc could be enlisted as the differential diagnosis for OCD. 6

Pulpectomy followed by a stainless steel crown for 85 and glass ionomer restoration for 75, as was planned, was carried out in multiple visits ( figure 2 ).

Outcome and follow-up

The patient was recalled for dental follow-up every 3 months and the integrity of the restorations was checked.

The thought processes and manner of behaving linked to OCD is often puzzling to parents. Deciphering signs and symptoms of OCD can be difficult as one may perceive the child's actions to be purposely disrespecting or reluctance to perform. The child may try to conceal their symptoms or may not be able to express their worries. The spectrum of symptoms may alter with time and their appearance may change too, which in turn makes it more difficult to establish the right diagnosis. If a dentist encounters such a case and appropriate referral is made in the proper frame of time, the child can benefit from prompt diagnosis and treatment. The symptoms may exaggerate in a stressful situation. If treatment is neglected, the condition may worsen and reflect in the form of limitations and withdrawal in other areas of the child’s life. Relationships with family, friends, at school and during evening sports may all be affected.

Chansky 7 reports that OCD affects at least 1 in 100 American children and that the average age of onset is 10.2. Children may be unaware, or unwilling to admit, that their behaviour may indicate the symptoms of a disorder. Families may need to be taught and trained about what they can reasonably expect from their child. Parents need to understand that therapy and medicines may reduce but not cure the symptoms.

The available literature indicates that OCD affecting children and adolescents is highly prevalent. Once believed to be relatively rare in children and adolescents, OCD is now thought to affect as many as 2–3% of children. Among adolescents with OCD, the literature indicates that very few receive an appropriate and correct diagnosis, and even fewer receive proper treatment. Paediatric-onset OCD or Juvenile OCD seems to share important similarities with the adult disorder but also shows important differences in the clinical expression of OCD, as these expressions may be actually driven by the age-dependent development of the patient. Children and adolescents with OCD typically first try to ignore, suppress or deny obsessive thoughts and may not report the symptoms as egodystonic or senseless. However, by trying to neutralise excessive thoughts, individuals with OCD very quickly change their behaviours by performing some type of compulsive actions, which are repetitive, purposeful behaviours carried out in response to the obsession. Usually, these repetitive actions follow certain rules or are quite stereotyped. Paediatric patients frequently demonstrate a poor understanding of their obsessions, and the added limited verbal expression usually makes diagnosis more difficult. Obsessions involving fear of harm and separation from the parent and caretaker, compulsions without obsessions and rituals involving family members are commonly seen.

There seems to be a bimodal distribution of age of onset of OCD, with one peak in preadolescent childhood and another in adulthood. Another distinction between child and adult OCD is gender representation. Whereas adult studies report either gender equality or a slight female predilection, paediatric clinical samples are clearly predominantly male. Family studies indicate that the disorder is highly familial and that a childhood onset of the disorder seems to be associated with a markedly increased risk for familial transmission of OCD, tic disorders and ADHD; however, in the present case, no such family history could be elicited.

The so-called ‘spectrum disorders’ related to OCD are less prominent in children and adolescents than in adults. Often, cognitive antecedents to these behaviours are less well developed than in more typical OCD, and behavioural interventions are the mainstay of treatment but with more variable success. 8

In a dental set-up, dealing with patients with OCD may frequently be cumbersome for the operator as he would have to succumb to the pattern in which such children demand that the treatment should be carried out. Treatment procedures and the entire chair side time may be unnecessarily prolonged due to the ritualistic repetitions of every act that these children usually indulge in.

Patient's perspective

The patient was happy to be relieved of dental pain and a positive dental attitude in the patient was successfully instilled, which was obvious as the visits went by.

Learning points

A pedodontist must gauge peculiar behavioural patterns in children so as to help diagnose obsessive-compulsive disorder at the earliest stage possible:

Child being very fussy and determined about outdoing things in a particular manner only.
Annoyance and reluctance to do things if activities around the child are not being performed in the manner the child wants them.
Patients may be too conscious about personal hygiene so very selective and protective about making bodily contact with others and accessories.

Competing interests: None declared.

Patient consent: Obtained.

Provenance and peer review: Not commissioned; externally peer reviewed.

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