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Clinical Case Studies
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Relapse Following Successful Intensive Treatment of Pediatric

Obsessive-Compulsive Disorder: A Case Study
Stephen P. Whiteside and Jonathan S. Abramowitz
Clinical Case Studies 2006; 5; 522
DOI: 10.1177/1534650105278456
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CLINICALAbramowitz
10.1177/1534650105278456
Whiteside,
CASE STUDIES
/ INTENSIVE
/ December
PEDIATRIC
2006
OCD
Relapse Following Successful

Intensive Treatment of Pediatric
Obsessive-Compulsive Disorder
A Case Study
STEPHEN P. WHITESIDE
JONATHAN S. ABRAMOWITZ
Mayo Clinic
Abstract: This case study describes the use of intensive exposure and response prevention
(ERP) for the treatment of pediatric obsessive-compulsive disorder (OCD). The adolescent
described in this report lives a long distance from treatment providers with expertise in
managing severe OCD symptoms. Thus, he has to travel out of town for effective therapy.
The treatment program results in substantial immediate benefits. However, gradual relapse
is noted once treatment is over and the patient returns to his home environment. Obstacles
to the accessibility of ERP for pediatric OCD, conducting successful treatment, and generalizing and maintaining gains are discussed with the aim of drawing attention to, and facilitating the prevention of, these difficulties. Suggestions for addressing the shortcomings
highlighted by this case are presented.
Keywords: obsessive-compulsive disorder; adolescents; intensive treatment; exposure and
response prevention; treatment failure
1.
THEORETICAL AND RESEARCH BASIS
For a number of reasons, the reporting of successful case studies (i.e., cases in
which the desired outcome is achieved) is the norm. Examination of successful cases
(a) demonstrates the capabilities of a particular treatment approach for a particular problem (although the outcome attained for any specific case might not be typical), (b) can
highlight a particular style of treatment delivery or technique for overcoming a common
obstacle, and (c) probably has self-serving effects in one way or another. However, as
some authors have pointed out, we also have much to learn from our failures, even if it
AUTHORS NOTE: The authors would like to thank Sarah Kalsy for her contribution to this article. Stephen P.
Whiteside, Mayo Clinic Department of Psychiatry and Psychology, 200 First St. SW, Rochester, MN 55905. E-mail:
whiteside.stephen@mayo.edu.
CLINICAL CASE STUDIES, Vol. 5 No. 6, December 2006 522-540
DOI: 10.1177/1534650105278456
2006 Sage Publications
522

Whiteside, Abramowitz / INTENSIVE PEDIATRIC OCD
523
involves owning up to defeat (Foa & Emmelkamp, 1983). The widespread reporting and
open discussion of clinical failures can reduce personal feelings of failure, provide alternate explanations to blaming the patients lack of motivation, and improve existing
treatments (Emmelkamp & Foa, 1983). In this spirit, the current report presents the case
of an adolescent for whom intensive treatment for obsessive-compulsive disorder
(OCD) did not achieve its long-term expectations. Although parts of the treatment program were initially successful, they clearly failed to generalize to other important areas.
Through examination of the successes and perils of this case, we discuss some of the current challenges in the treatment of child anxiety disorders, such as access to treatment,
timing of sessions, and use of follow-up care.
OCD is an anxiety disorder that involves (a) intrusive unwanted thoughts, ideas, or
images that evoke anxiety (obsessions) and (b) deliberate behavioral or mental rituals to
neutralize this distress (compulsions). The lifetime prevalence of the illness has been
estimated to be between 2% and 3% (Antony, Downie, & Swinson, 1998). Untreated
symptoms typically persist and as many as 80% of adult OCD cases develop during childhood (Pauls, Alsobrook, Goodman, Rasmussen, & Leckman, 1995). Moreover, sufferers
usually experience impairment in social, academic, or family functioning. Considering
its prevalence and associated personal costs, OCD is clearly a significant public health
concern. Given the fact that childhood onset may predict adult morbidity (March,
1995), it is imperative to identify and disseminate effective interventions for this disorder
in pediatric populations.
Cognitive-behavioral therapy (CBT) involving the procedures of exposure and
response prevention (ERP) is the most well-researched psychological treatment for
OCD (e.g., March & Leonard, 1996) and is considered the treatment of choice for children and adolescents (Expert Consensus Guidelines; Frances, Docherty, & Kahn,
1997). A multisite randomized controlled comparison of Sertraline, CBT, and their
combination for pediatric OCD indicated that combined treatment was more effective
than either monotherapy, which did not differ in efficacy from each other (Pediatric
OCD Treatment Study Team, 2004). Importantly, these results were complicated by differing success rates at different sites and are inconsistent with results from the adult literature that suggests combined treatment is not more effective than CBT alone (Foa et al.,
in press). Moreover, a meta-analytic study indicated that pharmacotherapy and CBT are
each effective in reducing pediatric OCD symptoms, with CBT producing larger effect
sizes and greater rates of clinically significant improvement compared to medication
(Abramowitz, Whiteside, & Deacon, 2005).
CBT is based on an empirically demonstrated conceptualization of the phenomenology of OCD. In this model, unwanted, intrusive obsessional thoughts lead to an
increase in distress, whereas ritualistic behaviors (including mental rituals) provide an
escape from, or reduction in, obsessional distress. However, performance of rituals also
interferes with the extinction of obsessional fears because by escaping, the individual
fails to learn that his or her fears are unrealistic. Moreover, rituals are negatively rein-

524
CLINICAL CASE STUDIES / December 2006
forced by the immediate sense of relief (anxiety reduction) that results in their wake.
This pattern of persistent anxiety, ritualizing, and negative reinforcement becomes a
self-perpetuating cycle that CBT aims to weaken. In particular, exposure, which
involves prolonged and repeated confrontation with obsessional stimuli, weakens connections between obsessional thoughts and anxiety. Response prevention, which entails
refraining from ritualistic behavior, is aimed at weakening the pattern of relying on rituals to reduce obsessional anxiety. In this process, as obsessional fear naturally dissipates
with time without rituals (a process known as habituation), the patient learns that
compulsive rituals are not necessary to prevent disaster or reduce anxiety.
Although ERP is effective for pediatric OCD, there are at least three obstacles to its
widespread use. First, the number of professionals with adequate training to administer
ERP is limited. Second, many practitioners are resistant to using ERP because of their
reluctance to purposely evoke anxiety in children, even if this anxiety is temporary and a
necessary part of this empirically supported treatment. Third, successful ERP requires a
thorough understanding of the patients symptoms on a functional level (as opposed to a
descriptive level), which may be challenging, especially with mental rituals. Whereas
the functional analysis of obsessive-compulsive symptoms is straightforward for patients
with overt compulsive rituals (e.g., washing, checking), the presence of mental rituals
for many patients complicates the clinical presentation (i.e., both the obsessions and the
compulsions are thoughts). For example, a patient who complains of frequent religious
obsessions that include prayers and unacceptable blasphemous ideas may actually be
responding to the latter (unwanted ideas) with the former (ritualistic prayer). Correctly
identifying the function of these distinct mental phenomena is critical to developing an
effective treatment plan, yet some presentations of OCD can bewilder even the most
experienced of clinicians.
For psychological treatments with demonstrated efficacy, such as ERP, the careful
examination of treatment failures can be used to better understand the therapeutic process. It also affords speculation as to the causes of failure and possible methods to prevent
future defeat. The present case report illustrates some of the challenges to successful
treatment of pediatric OCD, including the perils and potentials of intensive therapy for
patients who must travel a long distance for treatment. Although such a treatment program addresses access problems on one hand, it can raise problems with the need for
generalization back to the home environment on the other. This case also exemplifies
how exposure to the most feared obsessional stimuli is a critical part of ERP despite the
fact that it produces a temporarily high degree of distress. Finally, this case illustrates the
application of functional analysis to treatment planning for an atypical OCD symptom
presentation.

2.
525
CASE STUDY
PRESENTING COMPLAINTS
C. A. (not his actual initials), a 14-year-old Caucasian American male in the eighth
grade, was referred to our unit from a resource list provided by the ObsessiveCompulsive Foundation. At his initial evaluation, C. A. stated that he was constantly
bothered by thoughts of suffering brain damage and participating in immoral acts. In
addition, he was spending a great deal of time trying to avoid activities that might suggest
that he had brain damage and to minimize the chances that he would get brain damage.
Although C. A. had been a good student who enjoyed learning, he was currently having
difficulty in school because of his OCD symptoms. He also reported no longer reading
for enjoyment, which was one of his favorite activities. C. A.s treatment history included
both medication and psychotherapy.
A semistructured interview using the Childrens Yale-Brown ObsessiveCompulsive Scale (CY-BOCS; Goodman, Price, Rasmussen, Mazure, Delgado, et al.,
1989; Goodman, Price, Rasmussen, Mazure, Fleishmann, et al., 1989; Scahill et al.,
1997) and symptom checklist confirmed a diagnosis of OCD (Diagnostic and Statistical
Manual of Mental Disorders, 4th ed.; American Psychiatric Association, 1994). C. A.
also met the diagnostic criteria for Depressive Disorder Not Otherwise Specified, but
these complaints were clearly secondary to his OCD. C. A. had good insight into the
senselessness of his OCD symptoms.
HISTORY
C. A. was born and raised in an upper-middle-class community in a small town in

the midwestern United States. He lived with both of his biological parents and his older
brother. C. A. considered himself a religious Christian with strong moral values. He had
typically been able to achieve at a high level in school without putting forth his best
effort. His interests included reading, especially historical and scientific literature. C. A.s
mother described him as somewhat shy and introverted. However, at the time of assessment, C. A. reported feeling satisfied with his group of friends. He appeared to have a
supportive family and denied any history of abuse or trauma. There was no evidence that
C. A. was using alcohol or illegal drugs.
C. A. recalled that his OCD symptoms began in the first grade, when he experienced persistent concerns about germs that led to frequent hand washing. At that point,
he began treatment with Sertraline, which was maintained with good results until after
seventh grade, when it was discontinued because of intolerable side effects. On discontinuation of the medicine, C. A.s symptoms worsened. Treatment with Escitalopram
was initiated but without significant benefit. C. A. also worked with a psychotherapist but
did not receive CBT.

526
ASSESSMENT
Thorough assessment is critical for case formulation and development of a successful cognitive-behavioral treatment plan. Therefore, we discuss the therapists functional
assessment of C. A.s anxiety-related thoughts and behaviors in detail. Following this, we
describe how the case was conceptualized and a treatment plan formulated on that
understanding. Because OCD is characterized by anxiety-evoking thoughts as well as
purposeful efforts to reduce this anxiety, assessment focused on identifying these specific
phenomena. It is also important to evaluate the patients fear-based avoidance and
appraisal of his or her intrusive thoughts when developing a case formulation.
First, the therapist inquired about external cues that triggered C. A.s intrusive
thoughts. C. A. reported that cleaning solutions, lead paint, insect repellant, and other
household solvents and objects provoked obsessional thoughts about brain damage.
Fear was also triggered by situations in which there were expectations to learn or remember information, particularly school and reading. Stimuli that triggered fears of contamination included saliva, bathrooms, and glue. In addition, C. A. reported that when in the
company of his family, he had unwanted thoughts of engaging in sexual intercourse.
Finally, information about drugs evoked unwanted doubts that perhaps he had used
street drugs in the past or would do so in the future, which he felt was immoral and might
lead to brain damage.
Next, the therapist assessed C. A.s appraisals of his unwanted intrusive thoughts
and efforts to manage resultant distress. C. A. found his obsessional thoughts and doubts
highly distressing and believed that there was a good chance that his feared consequences could occur. Moreover, he believed that the more he thought about these
thoughts, the more likely they were to come true. He felt it was immoral to have sexual
thoughts and believed that he should be able to exert complete control over them. The
therapist then asked C. A. how he had responded to these upsetting thoughts. C. A.
stated that he tried to minimize contact with substances that he thought would give him
brain damage. For example, he would avoid individuals using bug spray or thoroughly
wash himself if he came in contact with chemicals. Moreover, he believed that if he
breathed through his mouth (as opposed to his nose), this would reduce his risk of brain
damage or at least reduce his worries by reducing his awareness of the feared chemicals.
The therapist also asked about neutralizing, mental rituals, and other strategies that
C. A. used to control his unwanted thoughts. The patient stated that intrusive thoughts
of drug use and sexual acts led him to repeatedly reassure himself that he would not, or
had not, engaged in these activities. He also used prayer rituals to ask for assistance in
preventing these feared outcomes.
Assessment also included administration of the following interview and self-report
measures of OCD, depression, and anxiety, both before and after treatment:
CY-BOCS. Used to measure OCD symptoms, the CY-BOCS is a semistructured
clinical interview that also includes a 10-item severity scale (Goodman, Price, Rasmus-

527
sen, Mazure, Delgado, et al., 1989; Goodman, Price, Rasmussen, Mazure, Fleishmann
et al., 1989; Scahill et al., 1997). Obsessions and compulsions are rated separately, yielding two subscores (ranging from 0 to 20) that are added to produce a total score (range 0
to 40). Symptoms are rated on a 5-point Likert-type scale from 0 = no symptoms to 4 =
severe symptoms. Items include (a) time spent on symptoms, (b) interference, (c) distress,
(d) resistance, and (e) control over symptoms. Efforts to neutralize or reduce obsessional
anxiety (e.g., mental rituals) were rated on the Compulsions subscale. The CY-BOCS
has satisfactory psychometric properties and has been found to be sensitive to treatment
effects (e.g., Goodman, Price, Rasmussen, Mazure, Delgado, et al., 1989; Goodman,
Price, Rasmussen, Mazure, Fleishmann, et al., 1989; Scahill et al., 1997).
Kovacs Childrens Depression Inventory (CDI). This inventory consists of 27 items
that assess depressive symptoms in five areas (negative mood, interpersonal problems,
ineffectiveness, anhedonia, and negative self-esteem; Kovacs, 1992). Each item is composed of three statements that reflect symptom severity. The statements are scaled from
0 = no disturbance to 2 = maximal disturbance. The total score can range from 0 to 54.
The CDI has internal consistency coefficients that range from .71 to .89 and correlates
strongly with other measures of depression.
The Spence Childrens Anxiety Scale (SCAS). The SCAS (Spence, 1998) is a 45item Likert-type self-report questionnaire designed to measure anxiety in children and
adolescents. The SCAS yields six basic scales: Panic Attacks and Agoraphobia, Separation Anxiety, Physical Injury Fears, Social Phobia, Obsessive-Compulsive, and Generalized Anxiety. Internal reliability coefficients for the total scale, .92, and the subscales
(ranging from .60 to .82) are acceptable. Six-month test-retest reliability ranges from .45
to .57 for the subscales and is .60 for the total scale. Spence and others present validity
data supporting the SCAS (Muris, Merckelbach, Ollendick, King, & Bogie, 2002;
Muris, Schmidt, & Merckelbach, 2000; Spence, 1998). C. A.s mother completed a parent report scale that also has acceptable psychometric properties (Nauta et al., 2004).
Sheehan Disability Scale (SDS). The SDS is a commonly used three-item measure of the degree to which clinical symptoms interfere with work, social and leisure
activities, and family and home responsibilities (Sheehan, 1986). This scale was adapted
to be completed by the patients parent. The parent provided two ratings for each area
(work, social, and home). First, the parent rated the degree to which the childs symptoms interfered with the patients life and, second, the degree to which the childs symptoms interfered with the parents life.
Assessment at the initial evaluation indicated that C. A. had severe OCD symptoms (Figure 1), mild depressive symptoms (CDI t score of 63), and significant anxiety
(SCAS total scores of 28 and 23 on child and parent report, respectively). His anxiety was
primarily in the areas of OCD, social and general anxiety, and specific fears (Figure 2).

528
Figure 1. Scores on the Measure of the Severity of Obsessive-Compulsive Symptoms at Each Assessment
NOTE: CY-BOCS = Childrens Yale-Brown obsessive compulsive scale; tx = treatment; F/U = telephone follow-up.
Figure 2. Scores on Child and Parent Ratings of Specific Anxiety Disorder Symptoms at the Initial
Evaluation and Posttreatment Compared to Normative Data
NOTE: Evaluation = scores based on child and parent responses at the initial evaluation. Posttreatment = scores based on
child and parent responses at the final treatment session. Average = average scores for nonclinical populations: SCASc
(Muris et al., 2000); SCASp (Nauta et al., 2004). SCAS = Spence childrens anxiety scale, C = child report; P = parent
report. Scales: panic = panic attack and agoraphobia, sep = separation anxiety, phys = physical injury fears, social = Social
phobia, ocd = obsessive-compulsive, and gen = generalized anxiety disorder/overanxious disorder.
C. A.s symptoms were affecting his functioning to a moderate to severe degree and
affecting his mothers functioning to a mild to moderate degree (Figure 3).

Figure 3
529
Scores on a Measure of Disability Resulting From OCD Symptoms at Evaluation,

Posttreatment, and Follow-Up
NOTE: Modified SDS = Sheehan Disability Scale, modified to measure dysfunction in patient and parents work, social
and family life resulting form childs OCD symptoms; F/U = telephone follow-up.
CASE CONCEPTUALIZATION
C. A.s complaints were conceptualized based on the aforementioned cognitivebehavioral model of OCD. His intrusive thoughts were considered normal stimuli that
occur in 90% of the population at large (Rachman & de Silva, 1978). Consistent with
the cognitive theory of emotional disorders (e.g., Beck, 1976), the excessive fear and anxiety associated with such thoughts was viewed as resulting from catastrophic misinterpretations of the thoughts presence and significance (e.g., Thinking about using drugs
makes it more likely that I will use them even if I dont want to).
C. A.s avoidance of external fear triggers was seen as a method for preventing
unwanted intrusive thoughts and related distress. Similarly, compulsive rituals, such as
washing and praying, were seen as methods of decreasing anxiety from situations and
intrusive thoughts that he could not avoid. Because avoidance and ritualizing reduced
distress in the short term, C. A. resorted to them whenever he had obsessive thoughts.
However, in the long term, these coping strategies prevented C. A. from learning to manage uncertainty and from discovering that his fears of brain damage and committing
inappropriate actions, although unpleasant, were most likely harmless and unfounded.
Thus, passive avoidance and ritualizing served to maintain C. A.s pathological fears
associated with objectively harmless thoughts and situations. Moreover, C. A.s fear of
these thoughts was increasing his attention to, and preoccupation with, them.
Foa and Kozak (1986) have suggested that the reduction of pathological fear
requires confrontation with the feared stimulus along with presentation of corrective
information (i.e., that disastrous consequences do not occur). Therefore, the conceptualization described above leads to exposure as a primary treatment procedure. Repeated

530
and prolonged exposure to situations that evoke intrusive thoughts, as well as exposure to
the thoughts themselves, would help C. A. discover that these stimuli are not threatening. However, C. A. must also curtail behavioral and mental rituals because these escape
and avoidance strategies prevent prolonged exposure and maintain beliefs that intrusive
thoughts are dangerous. Thus, response prevention is instituted to help weaken the
associations between rituals and anxiety reduction.
COURSE OF TREATMENT AND ASSESSMENT OF PROGRESS
A time-series design was used to examine the effects of treatment. Treatment was
initiated 10 weeks after the initial evaluation. This delay provided an opportunity to
assess the severity and stability of C. A.s symptoms and to determine to what extent they
might spontaneously remit. This period was followed by 14 daily therapy sessions, 4 or 5
days per week, during 3 weeks. This intensive treatment schedule was chosen because it
was not feasible for C. A. and his mother to travel back and forth between home and the
clinic for appointments (sessions were held on a daily basis to minimize the length of
time that C. A. and his mother were away from home). During the 3 weeks of treatment,
the patient and his mother resided in a local extended-stay motel. Comprehensive
assessments of overall symptom severity were conducted at the initial evaluation before
the beginning of treatment (pretreatment) and following treatment (posttreatment).
C. A. was contacted by phone to assess his symptoms and to have brief follow-up sessions
with the therapist at 6 and 12 weeks after the termination of treatment (follow-up). At the
initial evaluation, C. A.s score on the CY-BOCS of 23 fell in the moderate range of severity (Figure 1). However, during the 10-week no-treatment phase, his OCD symptoms
worsened to the severe range, perhaps because of a change in his medication: Escitalopram
was discontinued and fluvoxamine initiated. Before beginning treatment, C. A. had a
score of 27 on the CY-BOCS: 13 on the Obsessions scale and 14 on the Compulsions
scale.
During the first two treatment sessions, the therapist collected detailed information about C. A.s OCD symptoms and consolidated this information into a conceptualization of OCD that was discussed with C. A. This conceptualization (discussed above)
helped C. A. understand how avoidance and rituals maintained his OCD symptoms and
how these symptoms could be improved with ERP. C. A. practiced gradual, hierarchydriven in vivo and imaginal exposure to fear-evoking stimuli during Sessions 3 through
13. Homework exposure practice was assigned for completion between sessions. Instructions to refrain from ritualistic or neutralizing behaviors (response prevention) were also
given. The final sessions also included a thorough assessment and discussion of methods
C. A. could use to maintain his treatment gains. C. A.s mother attended at least part of
each session to learn about the cognitive-behavioral conceptualization of OCD and how
she could help C. A. conduct exposure practice outside the therapists office. During

531
later sessions, she merely checked in with the therapist at the end of each session to help
review and plan practice assignments.
Psychoeducation is viewed as an important component of CBT for OCD because
it helps the patient benefit from ERP techniques (Abramowitz, Franklin, & Cahill,
2003). To normalize the presence of intrusive thoughts, the therapist discussed how the
content of these thoughts in OCD does not differ from intrusive thoughts experienced
by individuals without. Several types of misinterpretations of thoughts common in OCD
were discussed: for example, thought-action fusion (Shafran, Thordarson, & Rachman,
1996), inflated responsibility (Salkovskis, 1999), intolerance of uncertainty (Tolin,
Abramowitz, Brigidi, & Foa, 2003), and examples relevant to C. A.s symptoms. To
ensure thorough comprehension, C. A. actively participated in learning the CBT model
of OCD and its treatment by describing how his symptoms fit the model, explaining the
model in his own words, and teaching the information to his mother.
Next, the therapist used the CBT model discussed above to describe how rituals
and avoidance maintain erroneous interpretations of unwanted thoughts. In addition,
the discussion included research demonstrating that attempts to suppress a thought paradoxically lead to an increase in the frequency of that thought (e.g., Wegner, Schneider,
Carter, & White, 1987). Once C. A. understood this conceptualization, the therapist
introduced the concepts of ERP as procedures to reduce obsessional thoughts and urges
to perform rituals. It was highlighted that ERP was not intended to curtail unpleasant
thoughts per se (indeed, everyone has such thoughts) but rather to correct C. A.s interpretation of these thoughts. C. A. appeared to understand this material.
C. A. and the therapist developed a hierarchy of situations and thoughts to be confronted both in real life (in vivo) and in imagination. Items to be confronted first were
those that evoked moderate levels of distress. Increasingly difficult stimuli were confronted at each successive session. The level of distress evoked by a given situation was
assessed by C. A. using the Subjective Units of Distress Scale (SUDS); a rating from 0 (no
anxiety) to 100 (intense anxiety). C. A. agreed to confront these situations and remain
exposed until the obsessional distress had decreased significantly (a substantial decrease
in SUDS) despite not ritualizing or performing any neutralizing behaviors. Table 1 presents the initial exposure hierarchy and corresponding SUDS ratings.
Early hierarchy items involved intrusive thoughts of committing inappropriate
acts or of having brain damage. These intrusions included thinking that past or future
drug use will cause him brain damage. C. A. had never used drugs in the past, nor did he
report any desire to do so in the future. To reduce the anxiety caused by these thoughts,
he confronted them by writing out and repeating a list of his most feared thoughts, such
as
When I go home, I will buy and smoke marijuana and then spray paint in a bag and inhale
it. This will make me feel so good that I will do it all the time and not care that I get so much
brain damage that I cannot finish school or get a job.

532
TABLE 1
C. A.s Planned Exposure Treatment Hierarchy

Situation or Thought
1
2
3
4
5
6
7
8
9
10
SUDS
Think I have or will do drugs

Think about hurting family members
Touch recently cleaned surface
Think I have brain damage and cannot learn
Think I do not understand while reading nonfiction
Be near someone else using household spray chemicals
Think I do not understand while reading science
Think of having sex before marriage and with mother
Personally use household spray chemicals
Touch or breathe in household spray chemicals
15
25
30
35
35
40
45
50
80
95
NOTE: SUDS = Subjective Units of Distress Scale.
The therapist recorded C. A.s SUDS level at the beginning of the exercise and at 2-min
intervals throughout the exposure. C. A. was also instructed not to neutralize his distress
by telling himself that the statements are not true or by trying to distract himself. As
expected, C. A.s anxiety ratings initially increased as he generated his unwanted
thoughts but decreased to baseline within 40 min. During the exposure, the therapist
encouraged cognitive restructuring through Socratic questioning as follows:
S. W. (author): What about these thoughts makes you nervous?
C. A.: It would be bad to do drugs or have brain damage.
S. W.: Yes, it would, but is talking about it or thinking about it the same as doing
drugs or having brain damage?
C. A.: No, I guess not.
S. W.: So, why do you think these thoughts are making you so nervous? Think back
to our discussion of how you tend to interpret your thoughts.
C. A.: Hmmm. I guess Im doing a thought-action fusion.
S. W.: OK. Explain what you mean.
C. A.: I guess I worry that if I think about doing drugs, it will make me actually do it.
S. W.: Is that true?
C. A.: Well, couldnt that happen?
S. W.: What happened when you thought about throwing the pen at me.
C. A.: I didnt do it.
S. W.: Why not?
C. A.: Because I didnt want to . . . I see what you mean. If I dont want to do something, just thinking about it wont make me go through with it.
It is important to point out that the therapist should not challenge the patients
intrusive thought per se. In other words, the aim of therapy is not to convince C. A. that
he will never do drugs or get brain damage. Such an approach would be equivalent to

533
providing reassurance. Instead, the therapist helped C. A. challenge his misinterpretation of the intrusive thoughts. At the end of the session, C. A. recounted the content of
the session to his mother so that the therapist could evaluate his comprehension and correct any misunderstandings. The therapist then instructed C. A. to repeat exposure to the
thoughts and to refrain from ritualizing before the next appointment.
At the fourth session, C. A. and his mother reported success with the homework
assignment. In fact, C. A. stated that the thoughts about drug use and brain damage no
longer bothered him. Sessions 4 through 6 focused on fears of household chemicals. To
address these fears, C. A.s exposures involved increasing contact with chemicals.
Response prevention included refraining from breathing through his mouth or washing
his hands. C. A.s most challenging exposure occurred during Session 4, when C. A.
decided to touch a bathroom floor that had a distinct odor of chemical cleaner. C. A. was
able to rub his hands on the floor and then contaminate himself by touching his head,
face, and mouth. The successful completion of such a challenging exposure was an
experience that C. A. could use later in treatment to bolster his confidence to tackle
other difficult exercises. By the end of Session 6, C. A. was rarely breathing through his
mouth ritualistically and was able to use household cleaners with little distress.
During the seventh session, treatment began to address C. A.s fears of learning.
C. A. worried that he had suffered brain damage as a result of his contact with airborne
chemicals throughout the years. He believed that if he tried to read and learn new material, he would not be able to understand this material, thus confirming that he was not
intelligent. A combination of cognitive restructuring and exposures were developed to
address this obsession. As an exposure task to address this particular fear, C. A. was asked
to quickly read two or three paragraphs from books of increasing difficulty and then write
a brief summary of what he had read. C. A. was asked to refrain from rereading any sentences during the exposures. Through these exercises, C. A. was able to decrease his anxiety during academic tasks.
Sessions 10 through 12 were spent addressing various remaining OCD symptoms
and continuing to work on C. A.s fears of household cleaners and learning. The most
distressing symptoms included intrusive thoughts of a sexual nature. C. A. would have
unacceptable intrusive thoughts about engaging in premarital sex or committing sex
acts with his own mother. He believed that he should be able to prevent himself from
having such thoughts and thus responded to them by trying to distract himself and reassure himself that he would not act on these thoughts. These neutralizing responses prevented C. A. from learning that his unwanted thoughts were harmless and that his anxiety would diminish, even if the thought remained. It was important to normalize this
experience by reiterating that the content of intrusive thoughts in OCD is indistinguishable from the thoughts of other people.
Imaginal exposures were similar to those for the drug use obsessions conducted
earlier. Working with the therapist, C. A. decided that the statement I will have sex
before marriage, including with my mother incorporated the entirety of his remaining

534
intrusive thoughts. During the session, C. A. repeated this statement out loud repeatedly. As expected, this was considerably difficult for him initially but with repetition
became mundane. At the end of the session, C. A. was able to articulate that the he felt
little, if any, anxiety because he realized that the exposure would not make him do something that he did not want to do.
At the end of the treatment, the majority of OCD patients who undergo ERP
report that their symptoms are reduced but that they continue to have some obsessional
thoughts (Abramowitz, 1998), and C. A. was no different. The final two sessions consisted of reviewing treatment and planning for maintenance of gains. This included a
discussion of the importance of continuing exposure to intrusive thoughts or situations
to prevent the return of symptoms. C. A. made a plan for continuing structured exposures at home and then beginning to fade them out with time. The importance of lifestyle exposures or on the fly exposures to anxiety-provoking thoughts as they arise in
everyday life was emphasized. In addition, the difference between lapse and relapse was
discussed, and C. A. and his mother were told to expect periodic lapses (particularly
when under more stress) during which he would have to use the skills learned in CBT to
maintain treatment gains. However, these lapses in improvement do not mean that he
will relapse or that his OCD will return to a clinical level.
C. A.s posttreatment total CY-BOCS score (Figure 1) indicated subclinical OCD
symptoms and his functioning had improved (Figure 3). C. A.s OCD symptoms were
also greatly reduced in comparison to the initial evaluation as indicated by self-report
questionnaires completed by himself and his mother (Figure 2). In addition, C. A.
reported a decrease in general worry and physical symptoms of anxiety. These scores
were consistent with the verbal reports of C. A. and his mother. At that time, C. A.s symptoms were judged to be disrupting his functioning at a mild to moderate level (11 out of
30) and that of his mother at a mild level (6 out of 30). These final results were discussed
with C. A. and his mother, and a phone follow-up was scheduled for 1 month later.
COMPLICATING FACTORS
Overall, C. A.s course of treatment proceeded favorably. He and his mother

grasped the cognitive-behavioral conceptualization of OCD and the rationale for using
ERP treatment procedures to weaken these symptoms. The most obvious complicating
factor to C. A.s receiving treatment was the distance he had to travel because of the lack
of access to skilled CBT providers in his home area. This obstacle was successfully
addressed initially with the intensive treatment package. Condensing the treatment into
3 weeks and conducting it during the summer months minimized the disruption to
C. A.s life. However, the lack of available treatment in C. A.s hometown prevented him
from receiving follow-up care. Booster sessions have been found to be helpful in managing symptoms and preventing relapse (Hiss, Foa, & Kozak, 1994). As will be discussed
below, this limitation adversely affected C. A.s long-term outcome.

535
FOLLOW-UP
C. A. was contacted 6 weeks after completing the 3-week intensive ERP treatment.
At this time, C. A. had recently returned to school. Although he was functioning well, a
number of his OCD symptoms had returned (Figure 1). Unfortunately, C. A. reported
that he had not continued to conduct exposures and had relaxed his efforts at abstaining
from rituals. His obsessive fears now included worrying about chemical odors in the
bathroom at home and in his classrooms. In response to these fears, he had once again
returned to ritualistically breathing through his mouth and avoiding certain situations.
In addition, he continued to doubt whether he could learn as well as he could before.
Finally, C. A. had begun to experience intrusive blasphemous thoughts that he
responded to by praying for forgiveness. Despite these symptoms, he was attending
school and completing his homework. As it is common for some OCD symptoms to
return after treatment, C. A.s experience was normalized and described as a lapse rather
than a relapse. Finally, a detailed plan was generated with C. A. and his mother to
address the symptoms, including strategies to maintain motivation, such as the use of
goals and rewards.
The severity of C. A.s symptoms was again measured via telephone at 12 weeks following the completion of treatment. Although the severity of his OCD symptoms had
increased, he was able to maintain a high level of functioning (Figures 1 and 3).
Although C. A. and his mother had conducted a number of exposures to feared situations, C. A. continued to avoid certain anxiety-provoking stimuli. For instance, he had
resumed breathing through his mouth at school. Rather than completing exposures to
the air in his science classroom on his own, his mother had to plan an exposure under
her supervision after school. Although C. A. was not overtly resistant to ERP, he often did
not take the initiative on his own to complete these behaviors on a regular basis.
TREATMENT IMPLICATIONS OF THE CASE
The treatment of C. A. can be classified as only a partial success. On one hand,

C. A.s symptoms were effectively treated initially, and he was able to maintain improvement in his functioning at follow-up. This success illustrates a number of important
issues in the treatment of pediatric OCD. At the most basic level, this case provides a
clear demonstration that pediatric OCD can be effectively treated. Despite research
documenting effective interventions (e.g., Franklin et al., 1998; March & Leonard,
1996), some patients continue to receive the message that their symptoms are not amenable to treatment. More commonly, despite CBTs being the recommended first-line
treatment (Expert Consensus Guidelines: Frances et al., 1997), many children present
for their first course of therapy after multiple medications trials have failed to adequately
address their symptoms. The current case demonstrates that OCD can be effectively
addressed with CBT.

536
Furthermore, both C. A. and his mother expressed their satisfaction with the treatment. Although there were multiple occasions when C. A. expressed significant anxiety
and discomfort, he willingly participated throughout the sessions, including conducting
exposures to frightening and upsetting situations and thoughts. All the exposures were
completed successfully by C. A. and led to reductions in anxiety and intrusive thoughts.
Avoiding any challenging anxiety or distress-provoking items leaves the patient with lingering untreated symptoms and increases the chance for relapse.
This case has positive and negative implications for the accessibility of CBT. On
the positive side, this case demonstrates that pediatric OCD can be treated intensively
away from the childs home environment. This is important because it illustrates that the
treatment offered by the growing number of clinics that provide CBT for OCD can be
used by children and their families living great distances away. The negative implication
of this case is that the lack of mental health practitioners providing CBT necessitates
children traveling for effective treatment and not having access to local aftercare to prevent relapse. The experience of C. A. was not uncommon for our clinic, in which we
attempt to assist patients in finding treatment in their home area only to have them
return after they are unable to receive treatment locally.
It was disappointing that C. A.s initial reduction in OCD symptoms was not maintained once treatment ended. Although CBT teaches children strategies for managing
new symptoms, they often require continued assistance and support. Specifically, it is
often necessary to provide booster sessions to help children and their parents address the
first posttreatment symptom exacerbation. Other children may require a gradual tapering of treatment or regular booster sessions to maintain their gains.
The literature on massed versus spaced learning trials offers a possible (partial)
explanation for C. A.s relapse following successful treatment. In particular, Schmidt and
Bjork (1992) suggested that massed, as opposed to spaced, learning trials maximizes
immediate performance, yet results in deteriorating performance when such conditions
are removed. In contrast, longer (and varied) intervals between practice trials seemingly
impede learning during the acquisition phase but actually enhance long-term retention
because they provide increased opportunities to practice retrieval in varied contexts. Foa
and Kozak (1986) proposed that exposure therapy modifies fear structures (memories)
by providing opportunities for learning corrective information regarding the true dangerousness of feared stimuli. Thus, because C. A.s intensive treatment program constrained the time available for consolidation of corrective information and because the
contexts in which generalization could take place were limited (and did not include the
home environment), this particular treatment regimen may enhance the risk of a longterm return of fear (Rachman, 1979). Similar effects have been observed with massed
versus spaced exposure therapy for other anxiety problems (e.g., spider phobia; Rowe &
Craske, 1998).
Generalization of treatment gains to new objects and situations is an important
objective in the treatment of OCD. Frequently, not all feared stimuli can be brought

537
into the office, and thus, homework assignments in the patients daily environment are
critical to transferring success in the office to everyday life. The spacing of treatment sessions on a weekly or twice-weekly basis for 8 to 16 weeks allows for the patient to conduct
exposures in places, such as home and school, where there are feared stimuli. This
important aspect of treatment is clearly not possible if the patient is a great distance from
home. These geographical barriers to generalization likely had a negative impact on
C. A.s long-term improvement. When C. A. returned home, he was immersed in a
home and school environment containing multiple objects that had been associated
with anxiety for a long time. Without regular sessions with a therapist, it is difficult to
conduct exposures to these stimuli. Moreover, learning is also dependent on internal
states, such as stress and depression (Eich, 1995). If C. A. experienced normal sources of
stress, such as returning to school, this change in mood might make it more difficult for
him to apply what he had learned about managing his OCD symptoms.
C. A.s case also demonstrates a failure in follow-up care. Perhaps a more concerted
effort could have been made to prepare him for his return home, where he would confront objects with long-standing associations to contamination as well as increased stress
and lack of therapeutic support. Possible interventions might include more sessions
spent on posttreatment planning, creation of a written home exposure plan, and more
frequent phone follow-ups. In addition, it may be necessary to have parents play an
increased role in treatment and follow-up, even with adolescents. Although C. A.s
mother was included in the treatment and was invaluable for completing the session
exposures, C. A.s treatment may have been improved by providing more specific training to her on how to function like an ERP therapist at home. For instance, treatment sessions could be led by the parent, with the therapist providing guidance as needed.
Within the session, the parent could help the patient determine the content of an exposure, lead the child through the exposure, monitor anxiety, and help the child through
cognitive exercises. This procedure would require substantial therapist input initially
with the goal of the therapist being primarily an observer toward the end of treatment.
Additionally, training parents in the use of positive reinforcement and designing a
specific plan may be useful for increasing the maintenance of gains. Examples of this
intervention might include planning with the parent and child that TV time will be contingent on completion of daily planned exposures or that completion of 10 exposures a
week will earn a desired prize. An increased emphasis on training parents to identify
obsessions, compulsions, and avoidance, as well as designing, implementing, and reinforcing exposures, may be necessary for intensive treatments when follow-up may not be
possible.
RECOMMENDATIONS TO CLINICIANS AND STUDENTS
For those interested in working with child anxiety disorders, it is recommended

that they receive training in CBT consisting of ERP for pediatric OCD. Training oppor-

538
tunities exist through the annual national meetings for organizations, such as the Association for Cognitive and Behavioral Therapy, Anxiety Disorders Association of America,
and the Obsessive-Compulsive Foundation. In addition, treatment manuals, such as
OCD in Children and Adolescents: A Cognitive-Behavioral Treatment Manual (March
& Mulle, 1998), are informative resources for those practitioners with a background in
cognitive-behavior therapy. For those who do not feel qualified to treat pediatric OCD, it
is important to realize that CBT is an effective treatment that can be provided to patients
even if they do not live close to a treatment facility. In these cases, appropriate referral is
vital and each of the above organizations has a Web site to assist with locating qualified
practitioners.
Practitioners skilled in ERP for pediatric OCD are encouraged to disseminate
their knowledge to colleagues who may not feel comfortable with the procedures. In
addition, it is recommended that these practitioners consider providing intensive interventions when they are planning treatment for children who are experiencing acute
symptoms and dysfunction or for whom weekly or biweekly sessions are not feasible.
However, when follow-up care will not be possible, it is suggested that more concerted
efforts with both patient and parent be made to plan for maintenance of gains. Training
parents to continue use of ERP procedures with their children at home through insession training may be an effective method for increasing generalization of treatment
gains. Finally, practitioners are encouraged to thoroughly address all of their patients
sources of OCD anxiety and not allow the patients, or the therapists, discomfort to interfere with optimal treatment.
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Stephen P. Whiteside is a pediatric psychologist and the director of the Child and Adolescent Anxiety Disorders Program at Mayo Clinic in Rochester, Minnesota. He received his PhD from the University of Kentucky in 2001 and completed an internship through Geisinger Medical Center. His research and clinical
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Jonathan S. Abramowitz, PhD, ABPP, is an associate professor of psychology and consultant at Mayo
Clinic in Rochester, Minnesota. He received his PhD in 1998 from the University of Memphis and completed his clinical internship at the Center of Treatment and Study of Anxiety within the Eastern Pennsylvania Psychiatric Institute. He has published numerous articles on the treatment and psychopathology of
obsessive-compulsive disorder.


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Clinical Case Studies

Relapse Following Successful Intensive Treatment of Pediatric

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Relapse Following Successful

THEORETICAL AND RESEARCH BASIS

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Whiteside, Abramowitz / INTENSIVE PEDIATRIC OCD

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Whiteside, Abramowitz / INTENSIVE PEDIATRIC OCD

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CLINICAL CASE STUDIES / December 2006

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CLINICAL CASE STUDIES / December 2006

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Scores on a Measure of Disability Resulting From OCD Symptoms at Evaluation,

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Whiteside, Abramowitz / INTENSIVE PEDIATRIC OCD

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C. A.s Planned Exposure Treatment Hierarchy

Think I have or will do drugs

NOTE: SUDS = Subjective Units of Distress Scale.

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Whiteside, Abramowitz / INTENSIVE PEDIATRIC OCD

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CLINICAL CASE STUDIES / December 2006

Overall, C. A.s course of treatment proceeded favorably. He and his mother

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Whiteside, Abramowitz / INTENSIVE PEDIATRIC OCD

The treatment of C. A. can be classified as only a partial success. On one hand,

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CLINICAL CASE STUDIES / December 2006

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Whiteside, Abramowitz / INTENSIVE PEDIATRIC OCD

For those interested in working with child anxiety disorders, it is recommended

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CLINICAL CASE STUDIES / December 2006

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Whiteside, Abramowitz / INTENSIVE PEDIATRIC OCD

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CLINICAL CASE STUDIES / December 2006

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