BJPsych Advances (2015), vol. 21, 196–205  doi: 10.1192/apt.bp.113.

011759

ARTICLE Obsessive–compulsive disorder

in young people
Tim I. Williams & Roz Shafran

Tim Williams is an Associate OCD in DSM-5

Professor in the Institute of Obsessive–compulsive disorder (OCD) is one of the
Education at the University of most debilitating psychiatric conditions in young DSM-5 no longer subsumes OCD under the anxiety
Reading and an educational and people. In DSM-5 it is no longer characterised as disorders category, but groups it with body
clinical psychologist with Berkshire an anxiety disorder, but instead is part of a group of dysmorphic disorder, trichotillomania, hoarding
Healthcare NHS Foundation Trust.
‘obsessive–compulsive and related disorders’. In disorder, excoriation (skin-picking) disorder
Roz Shafran is Professor of
Translational Psychology in the the past 10 years, cognitive–behavioural therapy and other disorders (American Psychiatric
Department of Neurosciences (CBT) has become well established as the first- Association 2013). This change was based on
and Mental Health at University choice treatment. This article explains some of the
evidence that these disorders share some aspects
College London’s Institute of Child elements of CBT and describes new directions in
Health. Correspondence  Dr Tim of phenomenology, such as being motivated by
research which might improve interventions.
I. Williams, Institute of Education, escape from unpleasant feelings through repetitive
University of Reading, London Road LEARNING OBJECTIVES behaviour. The category now requires a judgement
Campus, 4 Redlands Road, Reading • Become aware of the evidence supporting psy­ about the degree of insight that the person shows:
RG1 5EX, UK. Email: timothy.
[email protected] cho­logical treatments for OCD in young people good/fair, poor or delusional/absent. Children
• Learn the recommendations for first-line treat­ and young people are not required to show ego-
ment of OCD in young people dystonicity, which is a difficult construct to
• Gain an understanding of the CBT methods used convey to this age group. It is also important to
for OCD in young people note that it is possible to have either obsessions
DECLARATION OF INTEREST
alone or compulsions alone, although in children
pure obsessions are rare (Swedo 1989). Clinicians
None
should be aware that patients presenting with
no overt compulsions may be using mental
Obse ssive – compu lsive d isorder (OCD) is rituals to control their distressing feelings. Pure
characterised by the presence of unwanted, compulsions appear more common, perhaps
intrusive obsessions (unpleasant thoughts, images because many children find it hard to identify the
or urges) and compulsions (repetitive behaviours obsessions clearly.
which may be covert, e.g. mental counting). OCD In clinical practice it can be particularly hard to
in childhood and adolescence has benefitted from distinguish OCD from generalised anxiety disorder
an explosion in research since the 1980s. Studies in (GAD) (Comer 2004). Examining the young
the USA and the UK have demonstrated that OCD person’s beliefs about the personal significance
in young people can be managed with medication or meaning of their intrusive thoughts has been
and, more recently, that cognitive–behavioural suggested as a useful strategy to help distinguish
therapy (CBT) should be the first-choice treatment. between these two diagnoses. In young people with
autism spectrum disorder, it can also sometimes be
Epidemiology challenging to differentiate the compulsions that
characterise OCD from the repetitive behaviours of
Flament et al (1988) showed that about 1% of
autism, which may be motivated by pleasure. Only
teen­agers could be diagnosed as having OCD and
careful enquiry and observation will show whether
that many young people were not being diagnosed
the repetitive behaviours are driven primarily by
because they did not seek help. Subsequent
anxiety/distress or by enjoyment/pleasure.
estimates found that OCD affects between 0.3 and
5.6% of 5- to 18-year-olds. The highest estimate
was found in Israel among young armed forces Interventions and guidelines
recruits (Zohar 1992) and the lowest estimate The National Institute for Health and Care Excel­
in a representative sample of the UK population lence (NICE) guidance on the treat­ment of OCD
(Heyman 2001). Heyman et al (2001) also found explicitly includes young people (NICE 2005). It
that the prevalence varied with age (Fig. 1), recommends a stepped-care approach, starting
increasing exponentially to the teenage years. with self-help materials and guidance provided by

196
 OCD in young people

primary care pro­fessionals, progressing if neces­ 0.7

sary to CBT and then to medication. If a young
person does not benefit from a single course of 0.6
CBT, a selective serotonin reuptake inhibitor
(SSRI), alternative SRRI or clomipramine can 0.5

Younhg people with OCD, %

be considered in conjunction with CBT. A final
stage involves various options for in-patient 0.4
care, specialised living arrange­ments or adding
clomipramine or an alternative SSRI to CBT. 0.3
In their guideline watch, an update on the 2007
American Psychiatric Association guidelines, 0.2
Koran & Blair Simpson (2013) recommend that
treatment should take place in the least restric­ 0.1
tive setting for providing either CBT or medica­t ion
(SSRIs). Combined treatment should be offered 0
5–7 8–10 11–12 13–15
only when either treatment alone has proven Age, years
ineffective. However, the guideline watch has no
FIG 1 Estimated prevalence of obsessive–compulsive disorder (OCD) in young people at varying
specific section on the treatment of children. The
ages, together with best-fit exponential curve (after Heyman 2001, with permission).
American Academy of Child and Adolescent Psy­
chiatry (AACAP) does not make such clear recom­ of depression and panic disorder were identified
mendations in its Facts for Families series, stating by Beck (1979) and Clark (1988) respectively.
only that: ‘Most children with OCD can be treated Emotions came to be seen as a consequence not of
effectively with a combination of psychotherapy the event but of the interpretation of the event and
(especially cognitive and behavioral techniques) its personal meaning. In panic attacks, normal
and certain medications for example, serotonin physical symptoms that accompany anxiety
reuptake inhibitors (SSRI’s)’ (AACAP 2013). were interpreted catastrophically, for example as
indicating that a heart attack was imminent. For
Psychological therapies OCD, it had been demonstrated that unwanted
The most effective psychological therapies for OCD intrusive thoughts were experienced widely
are based on learning theory. The idea behind (Rachman 1978) and cognitive theorists sugges­
their first use was straightforward: the rituals ted that the interpretation of normal unwanted
were being driven and reinforced by a reduction intrusive thoughts transformed them into
in discomfort caused by the obsession. Often, the obsessions (Salkovskis 1985). In particular, it was
obsession is expressed in the form of some type proposed that the interpretation of such thoughts
of physical harm coming to a person close to the as indicating personal responsibility for harm was
patient, but it can be more nebulous, and some pivotal in causing and maintaining OCD. Personal
children are unable to articulate the discomfiting responsibility is defined as ‘the belief that one has
idea clearly. The behavioural treatment therefore power which is pivotal to bring about or prevent
consisted of trying to break the link between the subjectively crucial negative outcomes’ (Salkovskis
reduction of discomfort and the compulsion by
allowing the self to experience the anxiety and not
Intrusive thought
perform the compulsion (Fig. 2). The procedure
(obsession)
was therefore described as exposure and response
prevention (ERP). Abramovitz (1997) concluded
that ERP was an effective intervention for adults, Anxiety or distress
but until recently (Skarphedinsson 2015) there
Response
was less evidence for its use in children. prevention
Repetitive behaviour
Cognitive–behavioural therapies (compulsion)
In the early 1980s, it became clear that many
people with OCD were unable to use the tech­
niques of ERP because they found them too Feel better
unpleasant. In retrospect, this is unsurprising
since a strict implementation of ERP requires the FIG 2 Behavioural treatment of obsessive–compulsive
patient to put themselves in situations that they disorder: response prevention aims to break the link
find aversive. At the same time, the cognitive bases between the emotional changes and the compulsions.

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Williams & Shafran

1996: p. 111). Experimental data support the used by mental health professionals and instead of
link with OCD. Shafran (1997) showed that the talking about anxiety or fear will describe horrible
presence of an experimenter could decrease the feelings, distress or discomfort. They may also be
feeling of responsibility and hence the urges to unable to access clear cognitions that drive the
neutralise it in adults with OCD. In a younger OCD, but accept the terminology ‘urge’ or ‘nasty
population, Reeves et al (2010) demonstrated that feeling’. It is important that the therapist accepts
increasing responsibility led children without OCD the young person’s own words and uses them in
to check their actions more, in a way that appeared subsequent sessions.
similar to checking in OCD. Over time, cognitive The term CBT has been used to describe a
theories have suggested that intrusive thoughts number of different protocols in OCD. They all
are transformed into obsessions when they are seek to address the cognitive biases of the disorder,
interpreted as having personal significance, but they differ in the emphasis placed on cognitive
particularly in terms of the person thinking that techniques as compared with behavioural ones
they are ‘mad, bad or dangerous’ (Rachman 1997). (primarily ERP). Table 1 outlines the differences
The cognitive model of OCD led to cognitive– between behavioural experiments as used in CBT
behavioural interventions based on the premise and ERP. Guidelines often obscure the issue by
that it is important to change both the patient’s describing a recommended treatment as cognitive
misinterpretation of the meaning of their intrusive therapy with exposure and response prevention,
thoughts and the behavioural cycle in which for example ‘CBT (including ERP)’ (NICE 2005:
compulsions and avoidance maintained anxiety p. 42). Most published treatment protocols also
and beliefs about danger (Fig. 3). The precise fail to distinguish between cognitive methods and
manner in which this is done varies. In the USA, ERP. Since there are no published trials involving
a treatment manual for children described a CBT young people that directly compare CBT with ERP,
that used a narrative, externalising context and it is not possible to make clear recommendations,
concentrated on behaviour change (March 1998), although a recent review on the efficacy of
whereas in the UK, CBT has tended to concentrate psychological treatments in adults addresses this
on changing the appraisals of cognitions through issue (Ponniah 2013). Most published trials have
behavioural experiments to test out beliefs (Bolton adopted cognitive techniques often in conjunction
2011; Reynolds 2013). Here we will focus on a with ERP, and we therefore focus on those here.
cognitive approach to OCD, as this is an exciting
area of development. The elements of CBT
The foundation for CBT is collaboration between
A cognitive approach the therapist as an expert in OCD and the patient
CBT depends on a thorough understanding of the as the expert in their own thinking and behaviour
patient’s experiences and thinking which may (Box 1). The therapist and patient may bring in other
require the adoption of patients’ own vocabulary family members as and when their involvement in
to describe the difficulties that they face. Young the maintenance cycles becomes apparent.
people with OCD will often not recognise the terms First, the therapist and the patient develop an
initial formulation which evolves and forms the
basis for the activities of treatment.
Intrusive thought, urge or image

BOX 1 Key components of CBT

Cognitive–behavioural
Interpretation, appraisal, beliefs
therapy • Initial formulation
• Psychoeducation
• Experiments to:
• test beliefs
Compulsions,
• test emotional reactions
Avoidance Hypervigilance Emotion
rituals • identify obstacles to change
• Behavioural change
• Generalisation
• Relapse prevention – including stress inoculation and
FIG 3 How cognitive–behavioural therapy affects obsessive–compulsive disorder. Note that,
problem-solving
unlike exposure and response prevention, the treatment affects the cognitive aspects as
well as the behaviour.

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 OCD in young people

The next element is often educational, including TABLE 1 Differences between behavioural experiments and exposure and response
informing patients about the prevalence of OCD in prevention
their age group and helping them to understand
Exposure and response
that OCD is not a form of psychosis (patients often Behavioural experiments prevention
say that they are afraid that they are ‘going mad’),
Primary purpose To test the validity of a specific To facilitate habituation – becoming
explaining the nature of human thinking and that belief/s accustomed to the fear stimuli
unwanted intrusive thoughts are almost universal.
Frequency Usually once is sufficient Exposures repeated multiple times
Each session is followed by between-session work
(the term ‘homework’ can be used, but some Systematically No Yes, generally from least frightening
graded to most frightening; a fear hierarchy
young people find it unhelpful). Such work may
include conducting surveys to find out the types of Fear hierarchy Not necessary to construct a fear Fear hierarchy is constructed
hierarchy
thinking experienced by siblings or peers who do
Duration Brief Prolonged exposures, often for an
not have OCD to establish the universal nature of
hour or more
unwanted intrusive thoughts.
Evokes anxiety Not necessary Essential
The next stage is the use of behavioural
experiments that examine the validity of the Response Irrelevant Essential
prevention
young person’s beliefs in such a way that they are
able to realise that their feared event is unlikely Aim Change cognitions Change anxiety response – strictly
speaking to decouple emotional and
to happen. Such a realisation enables them to behavioural response from stimulus
let go of their compulsions and changes the
interpretation of their obsessions. This contrasts
with ERP, where the same ends are served by catchy tunes that we cannot forget. Earworms are
systematic graded exposure of the young person interesting intrusive thoughts since they are rarely
to a frightening event and not letting them carry troublesome (Beaman 2010). As a result, nearly
out any compulsive activities. every patient can tell the therapist what they do
about earworms and how successful they are. It
The formulation  is also helpful to demonstrate failures of thought
The formulation incorporates both historical control. Understandably, people try to suppress
information about the development of OCD and
where it may have come from and the maintenance
My upsetting thoughts,
cycles. In our work we have used a diagram called pictures, feelings or doubts
the ‘vicious flower’ to illustrate maintenance
cycles (Fig. 4).
In general, we identify four maintenance cycles:
•• hypervigilance for threatening information This belief
•• counterproductive repetitive behaviours that made me
manage anxiety/distress but maintain pre­ feel …

occupation
•• emotional changes
•• avoidance. I tried to avoid
upsetting thoughts
The problem was
CBT aims to identify all four and enable the I believed
or urges by …
Because of this belief
patient to break the cycles by learning in a safe I carried out rituals to stop that these thoughts
way that they are not needed. For this reason, the the danger and to make me meant …
cognitive distortions seen in the formulation need feel better

to be altered so that the patient can change what

they do and think. This belief
made me
‘look out’
Psychoeducation  for danger
by …
Education about thinking is important because
patients often do not understand that the brain
is always producing thoughts, even those that
are uncalled for (‘intrusive thoughts’), and that
struggling against those thoughts is unhelpful. FIG 4 Vicious flower to help in building a formulation. Each petal represents a cycle that
Nearly everyone has intrusive thoughts, which maintains the problem. The arrow shows the connection between the intrusive thought
can be illustrated by the case of ‘earworms’ or and its interpretation or appraisal.

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Williams & Shafran

intrusive thoughts, but these efforts are rarely met person is concerned with contamination and the
with success. This can be demonstrated in the experiment is to eat a biscuit without washing
therapy session by trying to suppress an image, their hands, the OCD hypothesis would be that
for example a pink giraffe. The therapist may then they will become ill after eating the biscuit. The
explore with the patient the frequency of occurrence non-OCD hypothesis would be that they will
of obsessions through the day, thus demonstrating initially be worried about becoming ill, but that
that the individual experiences fewer obsessions the worry would decline.
when they are busy, because their mind is occupied
with other things. Conversely, when they are less Behavioural experiments in practice:
occupied, for instance at bedtime, the OCD recurs cognitive error remediation
more often. In this section we describe a few experiments that
The next phase is to help the patient understand challenge thinking patterns that are common
anxiety and how it works. This involves under­ in OCD. For more experiments see, for example,
standing the short-lived nature of the surge in fear Waite & Williams (2009) and Derisley et al (2008).
that results from a single frightening event (e.g. a
balloon bursting unexpectedly). The rapid decline Thought–action fusion
in anxiety following a single event is common to
One thinking error that occurs commonly is
most people, so they are aware that they do not
thought–action fusion. This has two components,
remain anxious indefinitely. Psychoeducation
one of which is the belief that thinking about a
includes describing and drawing an anxiety curve,
bad event happening to another person makes it
demonstrating that anxiety peaks after provoca­
more likely to happen. This is a particular form of
tion, but has a natural course of decline consistent
magical thinking that is common in young people
with adrenaline surges following a fear-inducing
with OCD. It is often amenable to testing. For
event. This is contrasted with the compulsions,
example, the young person can be asked to perform
which reduce the anxiety rapidly, thus reinforcing
an experiment: to think about their mother having
their use. At the same time it is helpful to get the
a minor accident (e.g. twisting her ankle) within
patient to understand that they might interpret
a particular time period (e.g. before the next
events differently depending on where they
session) and seeing whether or not it happens. The
are. So, a bang in the night at home could be a
subsequent experiment would build on this, with
burglar breaking in or it could be the cat knocking
the young person thinking about a slightly more
something over in the kitchen again. The matter
serious mishap occurring to their loved one and
of interpretation is important, because the theory
again seeing whether it happens. Ultimately, the
makes clear that a major part of the problem in
experiments provide personally relevant informa­
OCD is how the obsessive thoughts are interpreted.
tion that the young person cannot cause harm to a
Behavioural experiments loved one simply by thinking about it.

Each behav ioura l exper iment should be Responsibility 

accompanied by hypotheses or predictions about
Another thinking error common in people with
what might happen and why. In general we
OCD is the belief that they alone are responsible
contrast two hypotheses: the OCD hypothesis and
for the prevention of harm. The method generally
a non-OCD hypothesis. For instance, if the young
used to challenge this belief is the responsibility
pie chart. The therapist uses a recent occasion
Other people sneezing when some type of harm has occurred, e.g.
10 5 Other people coughing catching a cold. A person with OCD may believe
Other people breathing on the person in a queue that they failed to prevent someone they know
10 from catching a cold. The therapist runs through
The other person walking around with wet hair
30
The other person getting chilled
the most likely ways the person caught their cold,
starting with the most probable, such as exposure
The patient not washing their hands enough
to the sneezes and coughs of others with colds,
20
and estimates the likelihood of each cause being
responsible (Fig. 5).

25
Black and white thinking
Sometimes people with OCD have particularly
FIG 5 Responsibility pie chart showing that the patient’s hand-washing compulsion has a minor ‘black and white’ or ‘all-or-nothing’ thinking. For
effect on the chances of another person catching a cold. example, a young man might believe that he is a

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 OCD in young people

good person only if he has completely pure thoughts Worst Best

person person
all the time. Any bad thoughts would mean that he
was a bad person. So if he had unwanted sexual
thoughts, he interpreted it to mean that he was a Adolf School Me Big Dad Mum Mother
Hitler bully sister Teresa
bad person. The therapist might explore this belief
using a continuum diagram (Fig. 6), examining the
FIG 6 Continuum diagram illustrating how reference to end points can make self-evaluation
types of thoughts that someone like Mother Teresa
more realistic.
(an extremely good person) would have at one
end, and the thoughts that characterised Hitler that behavioural experiments are carried out. In
(an extremely bad person). Other people, such as one trial, there were explicit instructions for the
the young man’s parents, sister and the school therapist to ensure that the young person took
bully, can also be placed along the continuum ownership of their own treatment by working
and the sorts of thoughts they might have can be through stages: therapist-generated experiments
discussed. This can shift the young man’s belief on which the child reported; child-generated
that occasional sexual thoughts make him as bad experiments on which the child reported; child-
a person as Hitler. generated experiments with no reporting (Bolton
2011). At the end, if the child is successfully
Perfectionism and uncertainty  engaged in treatment, they will have learned
Often young people with OCD believe that they enough techniques to manage their own OCD
must do things perfectly to avoid disasters. A without recourse to the therapist’s advice.
typical example would be the need for homework A number of techniques can be used for relapse
to have no crossings out in it. The obvious prevention. For example, reminders to use the
experiment is to submit to the teacher a piece of hand-outs and diaries from the active phase of
homework with a deliberate crossing out in it. It therapy can be written on sticky notes that the
is important to consider predictions from both an young person keeps in their bedroom or can be
OCD view and non-OCD view. For this example, stored electronically somewhere secure (e.g. using
the OCD prediction might be that the homework cloud computing). The choice of techniques will
will be returned to the young person for her be driven by the young person and their parents.
to do it again and again until it is perfect. The
alternative (non-OCD) prediction would be that Evidence for cognitive and behavioural
the teacher is unlikely to notice anything, but therapies
that the young person would be very anxious for a
The first randomised controlled trial of behav­
while after handing the work in and anxious again
ioural therapy for OCD in young people was that
on its return. A cooperative youngster might even
of de Haan et al (1998), who compared it with drug
complete a record of her feelings every 10 minutes
treatment (clomipramine). They concluded that the
following the handing in.
approach ‘produced stronger therapeutic changes
than clomipramine’. Subsequently, evidence has
Encouraging the patient’s participation
accumulated that CBT or behavioural therapy
Part of the art of the expert CBT therapist is to reduces symptom severity in OCD more than
enable the young person to see that change is being on a treatment waiting list (Manassis 2010),
possible by helping them do the experiments. One although comparisons with pharmacological
way of making this easier is for the therapist to treatments have proved less easy to interpret. The
demonstrate the experiment themselves before difficulties may result from site effects such as
asking the patient to do it too. This might be eating the site-specific variations in treatment outcome
a biscuit without first washing your hands. It is reported by March et al (2004) in the Pediatric
important that the difficulty of the experiment is Obsessive–Compulsive Disorder Treatment Study
agreed together with the patient, so that it can be (POTS), further confounded by different nation-
achieved and also provide meaningful information specific referral patterns. The limited long-term
about the validity of the patient’s fears. evidence suggests that patients successfully treated
with CBT remain diagnosis free for at least 7 years
Generalisation and relapse prevention  (O’Leary 2009).
CBT will always include homework to be done In the UK, two pilot trials established the
between sessions. It is conventional for parents efficacy of CBT for young people in out-patient
to be asked to ensure that this is completed. settings (Bolton 2008; Williams 2010). More
Certainly, if the parents have knowledge of the recently, a study compared a short form of CBT (an
techniques of CBT they are better placed to ensure average of 5 sessions) with the standard 12-session

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Williams & Shafran

form and found them to be equally effective found in relation to family interactions to OCD
(Bolton 2011). Two further trials have established symptoms. Similarly, Flessner et al (2011) showed
that the benefits of CBT do not depend on delivery that parental anxiety is associated with more
method (telephone v. face to face) (Turner 2014) accommodation to rituals and more reassurance-
or presence/absence of parent during treatment seeking. Second is further understanding of how
(Reynolds 2013). The latter finding is somewhat families manage or accommodate the symptoms
surprising considering the role that parents are of OCD. Lebowitz et al (2014) identified two
considered to play in childhood anxiety disorders. types of family accommodation to OCD in young
Finally, the utility of CBT has recently been shown people: direct and indirect. Direct accommodation
with children as young as 4 years of age (Freeman is when family members complete aspects of the
2014), thus extending the age range. child’s rituals. Indirect accommodation is when
they try to avoid provoking compulsions or
Pharmacological therapies obsessions. Family accommodation may reduce
Fineberg & Brown (2011) reviewed the literature the effectiveness of CBT by preventing the child
on pharmacotherapies for young people with OCD. from engaging in experiments at home to test
In brief, treatment with clomipramine seems to be beliefs (Storch 2007).
an effective option, but its side-effects mean that
it is poorly tolerated (Leonard 1989). SSRIs such
Family-based CBT
as fluvoxamine (Riddle 2001), fluoxetine (Riddle The evidence for the benefits of family involvement
1992) and sertraline (March 2004) have all shown in CBT itself are equivocal. Barrett et al (2004)
promise in randomised controlled trials. March et found that treating OCD with family-based CBT
al (2006) suggested that sertraline showed the best was effective, possibly more than individual
profile. However, as mentioned earlier, the results CBT, but Reynolds et al (2013) found that the
showed a remarkable variability in effect sizes presence of a parent in sessions had no effect.
between sites, which suggests that the utility of Although surprising, it is the Barrett trial that is
sertraline may be overstated. The British National the outlier in terms of effect size in both OCD and
Formulary for Children (Paediatric Formulary in other anxiety disorder trials for young people
Committee 2014)) recommends only two SSRIs for (Reynolds 2012).
OCD, fluvoxamine and sertraline. In the UK, the
Medicines and Healthcare Products Regulatory Bias-specific CBT
Agency (2014) has advised that ‘Information Contamination obsessions
from clinical trials has shown an increased risk Improving CBT requires better understanding of
of suicidal behaviour in adults aged less than 25 the cognitive biases in OCD, particularly those
years with psychiatric conditions who were treated associated with different types of OCD. Rachman
with an antidepressant’. (2004) has suggested that contamination fears
Other drugs, such as atypical antipsychotics, may require a specific approach. Contamination
have been proposed as useful adjuncts to SSRIs itself may also be subdivided by phenomenology
(Fitzgerald 1999). In addition, D-cycloserine has into mental and physical. Physical or ‘contact’
been trialled, with promising preliminary results contamination can be driven by fear of disease,
(Storch 2010). harmful substances or dirt. ‘Mental contamination’
occurs in the absence of physical contact, but
Future prospects leaves the person feeling dirty and polluted.
Although CBT often substantially reduces the Often the source of the contamination in mental
level of symptoms in OCD, a significant proportion contamination is human (e.g. the person’s own
of patients – as many as one-third (Bolton 2011) thoughts) and, unlike contact contamination, the
– do not show return of OCD symptoms to a non- person is uniquely vulnerable to the contaminant.
clinical level. The benefits of medication are often This form of contamination includes ‘morphing’
lost when it is discontinued. This suggests that or ‘transformation obsessions’, in which the young
the understanding of how best to treat OCD is person fears that they may assume the undesirable
still limited. In the past few years, a number of characteristics of another person (Volz 2007).
promising lines of research have developed that Recent research (e.g. Coughtrey 2014) has shown
give hope that outcomes will improve. that people who are fearful of contami­nation are
Research findings in two key areas are driving much more likely to report contamination by
change in treatment methods. First, there is remote connections (distant contact). For example,
evidence that parental anxiety may adversely one young person was afraid that they might lose
affect treatment response, as Keeley et al (2008) their intelligence if they walked past a homeless

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 OCD in young people

person begging in the street, so she would cross the 3

road and want to wash her hands to prevent this
happening. Coughtrey et al (2013) have suggested 2.5
that CBT for mental contamination should
2
include gathering information about perceived

Effect size
sources of contamination, obtaining a detailed 1.5
history of events leading to the development of
1
contamination obsession, considering physical
and psychological betrayals, identifying beliefs 0.5
about mental contamination and its spread, and
detailing any mental imagery that might cause 0
Cognitive–behavioural Medication Combined
the patient to feel contaminated. This enables therapy treatments
therapist and patient to build up a personalised
formulation of the problems before embarking on FIG 7 Effect sizes of different treatment options for obsessive–compulsive disorder in children
a treatment protocol that varies from the standard (data from Sànchez-Meca 2014).
CBT by including an emphasis on psychoeducation
about the mental contamination and correctly Experimenting with different ways of reacting to
labelling mood states. the obsessions enables patients to find alternative
ways of managing distressing ideas. Young people
Obsessive checking taking part in cognitive–behavioural interventions
find that this knowledge enables them to overcome
If contamination fears require specific tailoring
their OCD to a large extent.
of CBT protocols, then it may be that other types
Developments in psychological treatment are
of OCD, such as checking, also require a tailored
likely to come from greater understanding of the
approach. For instance, it is possible that checking
particular aspects of cognition that are involved in
is driven by an inappropriate over-monitoring of
different types of compulsive behaviour. There are
memory, resulting in memory distrust (Radomsky
already indications that washing and its associated
2010). The finding that repeated checking causes
contamination fears are linked to unusual
memory distrust is robust in adults, but has not
understanding of how contamination spreads.
been studied in young people. Nevertheless, it may
Similarly, checking may be linked to problems
be useful to bear in mind the recommendation by
satisfactorily monitoring one’s own behaviour,
Radomsky and colleagues that therapy should
and religion-focused OCD (scrupulosity) may be
include a behavioural experiment in which patients
motivated by an intolerance of uncertainty. In its
receive personalised information about the impact
turn, greater understanding of particular cognitive
of repeated checking on memory confidence.
errors leads to improved psychological treatment.
Scrupulosity Developments in drug treatment should similarly
arise from greater understanding of brain
Abramovitz & Jacoby (2014) have described a for­
pathways that are changed by OCD. However,
mulation for scrupulosity (religious obsessions and
the greater challenge is to find a pharmacological
ritual-focused OCD) that suggests that intolerance
intervention that has an enduring effect instead of
of uncertainty plays a central role. They propose
requiring ongoing medication.
that treatment should include experiments to dem­
onstrate that it is possible to tolerate uncertainty
rather than expending significant amounts of
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MCQs 3 In CBT for OCD: c does experiments to discover how their OCD
Select the single best option for each question stem a the therapist listens to what the young person works
says and interprets it in terms of relationships d discusses the reasons why they have
1 DSM-5 classifies OCD as a type of: b the therapist instructs the young person on developed OCD
a anxiety disorder how to overcome their OCD e expresses their feelings repeatedly.
b psychotic disorder c the therapist and the young person discuss
c emotional disorder strategies for living with OCD 5 Experiments are used in CBT to:
d repetitive behaviour disorder d the young person and the therapist work a change behaviour
e impulse control disorder. together to discover how the OCD works b change thinking patterns
e none of the above. c find out how the world works, so as to change
2 The initial treatment for OCD in young thinking patterns and behaviour
people recommended by NICE: 4 During the course of CBT, the young d test scientific hypotheses
a relaxation person: e achieve all of the above.
b psychodynamic psychotherapy a is encouraged to face up to their fears and not
c self-help back down, no matter how difficult it is
d medication b learns that their intrusive thoughts do not
e cognitive–behavioural therapy. reflect reality (predict the future)

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