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The Family & OCD


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The Family & OCD

  2. 2. Outline <ul><li>Development of OCD – genetic predisposition? modeling? </li></ul><ul><li>Maintenance of OCD – embeddedness within the family </li></ul><ul><ul><li>Characteristics of family members and the family environment </li></ul></ul><ul><ul><li>Family-based (FB) predictors of natural treatment response </li></ul></ul><ul><li>Treatment of OCD – role in behavioral interventions, efficacy of family-based Cognitive-Behavioral Therapy </li></ul><ul><ul><li>Primary components of FB CBT for pediatric OCD </li></ul></ul>II. Explore the Role of the Family in the : I. Brief Introduction to OCD III. Summary & Clinical Recommendations IV. Future Directions
  3. 3. OCD Defined <ul><li>A neurological disorder defined by recurrent, unwelcome thoughts (obsessions) and repetitive behaviors or mental acts (compulsions) </li></ul><ul><li>Up to half of all OCD cases have their onset in childhood </li></ul><ul><ul><li>Child prevalence: 1-4% (Zohar, 1999) </li></ul></ul><ul><li>OCD (esp. early on) can be chronic & debilitating (Rufer et al., 2005) </li></ul>
  4. 4. “ Counting really bogged me down. I would wash my hair three times as opposed to once because three was a good luck number and one wasn’t. When I set my alarm at night, I had to set it to a number that wouldn’t add up to a ’bad’ number. ” “ Getting dressed in the morning was tough, because if I didn’t follow my routine, I’d get anxious and would have to get dressed again. I always worried that if I didn’t do something, my parents were going to die. I’d have these terrible thoughts of harming them. It was completely irrational, but the thoughts triggered more anxiety and more senseless behavior. B/c of the time I spent on rituals, I was unable to do a lot of things.”
  5. 5. II (A). Role of Family in the Development of OCD <ul><li>The Familial Nature of OCD: Strong genetic component (especially in early onset cases) </li></ul><ul><ul><li>Concordance rates of approx. 67% and 31% for MZ and DZ twins, respectively (Billett, Richter, & Kennedy, 1998) </li></ul></ul><ul><ul><li>Higher OCD prevalence rates in the first degree relatives of OCD probands than the general population (Pauls et al, 1995) </li></ul></ul><ul><ul><li>Higher rates of anxiety disorders & depression in relatives (Black et al., 1992) </li></ul></ul><ul><li>Empirical investigation of the possible effects of the family’s social role in the development of childhood OCD is limited. </li></ul><ul><ul><li>Parental modeling? </li></ul></ul>
  6. 6. II (B). Role of Family in the Maintenance of OCD <ul><li>Interactive cycle between child and family functioning </li></ul><ul><li>Reciprocal relationship </li></ul>Member w/OCD Family
  7. 7. II (B). Role of Family in the Maintenance of OCD (cont). <ul><li>Family Accommodation (FA): the degree to which family members change their lives and routines in response to the child’s OCD (EOI*) </li></ul><ul><ul><li>Direct involvement in the child’s symptoms </li></ul></ul><ul><ul><li>Indirect involvement in the OCD – e.g., family members modify their routines to prevent sx escalation or reduce the child’s distress </li></ul></ul><ul><li>Family Interaction Style </li></ul><ul><ul><li>Criticism , hostility , emotional over-involvement , and the patient’s perceptions of criticism </li></ul></ul><ul><ul><li>High Expressed Emotion (EE): a family environment characterized by hostility, criticism, or emotional over-involvement (also referred to as “antagonistic”) </li></ul></ul>Alternative hypothesis: OCD is exaggerated +/or maintained through parental/sibling involvement and accommodation, and/or overly negative family interactions. *Emotional over- involvement Accommodation Sp lit Antagonism Note : Accommodation is analogous to emotional over-involvement. Note : Antagonism is analogous to high EE in family interactions.
  8. 8. Family Distress, Accommodation, & Participation Renshaw et al., 2005
  9. 9. Family Accommodation (FA) <ul><li>Calvocoressi et al. (1999) </li></ul><ul><ul><li>FA correlated significantly w/patient symptom severity, family dysfunction, and relatives’ stress </li></ul></ul><ul><li>Amir, Freshman, & Foa (2000) </li></ul><ul><ul><li>Greater FA (especially modifying one’s routine) correlated with more severe OCD symptoms after tx </li></ul></ul><ul><li>Ferrao et al. (2006) </li></ul><ul><ul><li>Higher scores on the FA Questionnaire independently predicted tx refractoriness </li></ul></ul><ul><li>Storch et al. (2007) </li></ul><ul><ul><li>FA significantly related to (in fact, a mediator) between OCD symptom severity and child functional impairment </li></ul></ul><ul><li>Summary: </li></ul><ul><li>Most families report accommodation by both parents AND sibs. </li></ul><ul><li>FA  significant disruption in family life, personal distress </li></ul>
  10. 10. Family Interaction Style <ul><li>Allsopp & Verduyn (1990) </li></ul><ul><ul><li>70% of parents - accommodation; 20% -“open anger” </li></ul></ul><ul><li>Hibbs et al. (1991) </li></ul><ul><ul><li>73% of OCD mothers & 46% of OCD fathers classified as high EE, compared to 31% and 22% of nonclinical mothers & fathers (no diff. between OCD & DBD groups) </li></ul></ul><ul><li>Barrett, Shortt, & Healy (2002) </li></ul><ul><ul><li>Parents & children in the OCD group could be differentiated from families in the other groups based on both less positive parent and child behavior </li></ul></ul><ul><li>Farrell et al. (2007) </li></ul><ul><ul><li>Significant differences in family interactions from pre-to post-CBT tx:  in neg behaviors,  in positive behaviors </li></ul></ul><ul><li>Summary: </li></ul><ul><li>The family environment and interaction patterns within OCD families </li></ul><ul><li>are generally less positive, less warm, & higher in EE. </li></ul><ul><li>The negative interactive behaviors in families are reciprocal . </li></ul>
  11. 11. <ul><li>Family environment & interaction style may predict tx relapse: </li></ul><ul><ul><li>Chambless & Steketee (1999) </li></ul></ul><ul><ul><ul><li>OCD patients’ perceptions of family members as more critical, the presence of hostility, & higher overinvolvement predicted worse tx outcomes </li></ul></ul></ul><ul><ul><li>Van Noppen et al. (2005) </li></ul></ul><ul><ul><ul><li>Relatives’ attributions of control and responsibility were related to higher rates of criticism, hostility, overinvolvement, and accommodation in relatives, as well as more severe symptoms in patients </li></ul></ul></ul>II (C). Role of Family in the Treatment of OCD
  12. 12. <ul><li>Family-based intervention & tx appears essential </li></ul><ul><ul><li>Expert guidelines & AACAP parameters advocate for the involvement of family members </li></ul></ul><ul><li>Family members are likely to be directly and/or indirectly impacted (distressed) by the OCD. </li></ul><ul><li>2) Family members are likely to be involved in maintaining OCD via family responses that are accommodating and/or antagonistic. </li></ul><ul><ul><li>It may be especially important to challenge attributions of control. </li></ul></ul><ul><li>Some family members may also suffer from OCD or obsessional symptoms and may directly benefit from involvement in tx. </li></ul><ul><li>4) To help the individual with OCD maintain tx gains. </li></ul>Summary: Reasons for a Family-Based Tx Approach Summary Slide
  13. 13. <ul><li>Cognitive Behavioral Therapy (CBT) is the treatment of choice for OCD in both adults and children  Thus, a family-based CBT tx model has been advocated, especially for children. </li></ul><ul><li>CBT aims to change negative thinking and maladaptive behaviors </li></ul><ul><ul><li>Exposure & Response (Ritual) Prevention (E/RP) w/Cognitive Processing – “gold standard” for OCD </li></ul></ul><ul><ul><ul><li>Patient is systematically exposed to symptom triggers of gradually increasing intensity while working to suppress his or her usual ritualized responses </li></ul></ul></ul>A Primer for the Treatment of OCD
  14. 14. <ul><li>* Forming a team approach to support the fight against OCD </li></ul><ul><li>Typical Primary Components: </li></ul><ul><li>Psychoeducation </li></ul><ul><ul><li>Educate parents about the bio basis of OCD, correct misattributions, & differentiate OCD & non-OCD behaviors </li></ul></ul><ul><li>Parent Training </li></ul><ul><ul><li>Teach parents behavior management techniques, teach to manage own anxiety, & develop a behavior modification plan </li></ul></ul><ul><li>Family Treatment </li></ul><ul><ul><li>Teach strategies to  FA,  neg &  pos family interactions, &  pos family problem-solving skills </li></ul></ul><ul><li>Cognitive-Behavioral Strategies </li></ul><ul><ul><li>Teach family to externalize OCD (“boss back”), build a fear hierarchy, and implement E/RP </li></ul></ul>Family-Based CBT for Children
  15. 15. <ul><li>Mehta (1990) </li></ul><ul><ul><li>OCD patients who were aided in exposure therapy by a family member benefited significantly more than patients who received no family participation & were more likely to maintain tx gains over the long-term </li></ul></ul><ul><li>Knox, Albano, & Barlow (1996) </li></ul><ul><ul><li>E/RP alone resulted in little to no change in the freq. of OCD compulsions in young children while E/RP applied by parents saw improvements in all of the children </li></ul></ul><ul><li>Grunes, Neziroglu, & McKay (2001) </li></ul><ul><ul><li>Individuals whose family members received psychoeducation & individually tailored interventions aimed at  neg. communication showed significantly greater reductions in OCD symptoms at post-tx & 1-mos. follow-up </li></ul></ul>Preliminary Evidence of Effectiveness of FB-CBT
  16. 16. Summary & Clinical Recommendations <ul><li>Preliminary evidence suggests that the family’s accommodation of obsessional symptoms or their overly antagonistic response to such symptoms play a powerful maintaining role in OCD, albeit in different ways. </li></ul><ul><ul><li>Thus, it would seem to be especially important to involve family members in treatment to correct these interactional patterns, although, larger studies are still needed. </li></ul></ul><ul><li>At present, most authors advocate family intervention as an adjunct to, not a replacement of , E/RP or pharmacotherapy (e.g., March & Mulle,1994; Steketee & Van Noppen, 2003). </li></ul>
  17. 17. <ul><li>Family participation in medication-based interventions </li></ul><ul><li>Family influence in therapy with treatment-refractory patients who have not benefited readily from standard interventions </li></ul><ul><li>Preventative family-based cognitive-behavioral therapy for at-risk children whose parents have OCD or some other anxiety disorder </li></ul><ul><ul><ul><li>Effectiveness trial currently underway @ JHU </li></ul></ul></ul>Some Future Directions
  18. 18. references Allsopp, M., & Verduyn, C. (1990). Adolescents with obsessive compulsive disorder: A case note review of consecutive patients referred to a provincial regional adolescent psychiatry unit. Journal of Adolescence, 13 , 157-169. Amir, N., Freshman, M., & Foa, E. B. (2000). Family distress and involvement in relatives of obsessive-compulsive disorder patients. Journal of Anxiety Disorders, 14(3), 209-217. Barrett, P. M., Shortt, A., & Healy, L. (2002). Do parent and child behaviours differentiate families whose children have obsessive-compulsive disorder from other clinic and non-clinic families? Journal of Child Psychology and Psychiatry, 43 , 597–607. Black, D. W., Gaffney, G., Schlosser, S., & Gabel, J. (1998). The impact of obsessive-compulsive disorder on the family: Preliminary findings. Journal of Nervous and Mental Disease, 186, 440-442. Calvocoressi, L., Mazure, C., Kasl, S. V., Skolnick, J., Fisk, D., Vegso, S. J., et al. (1999). Family accommodation of obsessive-compulsive symptoms: Instrument development and assessment of family behavior. Journal of Nervous and Mental Disease, 187 , 636-642. Chambless, D. L., & Steketee, G. (1999). Expressed emotion and behavior therapy outcome: A prospective study with obsessive-compulsive and agoraphobic outpatients. Journal of Consulting and Clinical Psychology, 67 (5), 658-665. Farrell, L. J., & Barrett, P. M. (2007). The function of the family in childhood obsessive-compulsive disorder: Family interactions and accommodation. Mahwah, NJ: Lawrence Erlbaum Associates. Ferrão, Y. A., Shavitt, R. G., Bedin, N. R., de Mathis, M. E., Carlos, L. A., Fontenelle, L. F., et al. (2006). Clinical features associated to refractory obsessive-compulsive disorder. Journal of Affective Disorders, 94 (1-3), 199-209. Grunes, M. S., Neziroglu, F., & McKay, D. (2001). Family involvement in the behavioral treatment of obsessive-compulsive disorder: A preliminary investigation. Behavior Therapy, 32 , 803-820. Hibbs, E. D., Hamburger, S. D., Lenane, M., Rapoport, J. L., Kruesi, M. J. P., Keysor, C. S., et al. (1991). Determinants of expressed emotion in families of disturbed and normal children. Journal of Child Psychology and Psychiatry, 32 (5), 757-770. Knox, L. S., Albano, A. M., & Barlow, D. H. (1996). Parental involvement in the treatment of childhood compulsive disorder: A multiple baseline examination incorporating parents. Behavior Therapy, 27 (1), 93-114. Renshaw, K. D., Steketee, G., & Chambless, D. L. (2005). Involving family members in the treatment of OCD. Cognitive Behaviour Therapy, 34 (3), 164-175. Rufer, M., Grothusen, A., Mass, R., Peter, H., & Hand, I. (2005). Temporal stability of symptom dimensions in adult patients with obsessive-compulsive disorder. Journal of Affective Disorders, 88 , 99-102. Storch, E. A., Geffken, G. R., Merlo, L. J., Jacob, M. L., Murphy, T. K., Goodman, W. K., et al. (2007). Family accommodation in pediatric obsessive-compulsive disorder. Journal of Clinical Child and Adolescent Psychology, 36 (2), 207-216. Storch, E. A., Merlo, L. J., Lehmkuhl, H., Geffken, G. R., Jacob, M., Ricketts, E., et al. (2008). Cognitive-behavioral therapy for obsessive--compulsive disorder: A non-randomized comparison of intensive and weekly approaches. Journal of Anxiety Disorders, 22 (7), 1146-1158. Van Noppen, B., & Steketee, G. (2003). Family approaches to treatment for obsessive compulsive disorder. Revista brasileira de psiquiatria, 25 (1), 43-50. Waters, T. L., & Barrett, P. M. (2000). The role of the family in childhood obsessive-compulsive disorder. Clinical Child and Family Psychology Review, 3 (3), 173-184. Zohar, A. H. The epidemiology of obsessive-compulsive disorder in children and adolescents. Child and Adolescent Psychiatric Clinics of North America, 8 , 445-460.