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COGNITIVE BEHAVIORAL THERAPY FOR CHILDREN WITH PANDAS/PANS. Brad Riemann, Ph.D. Clinical Director, OCD Center and CBT Services Rogers Memorial Hospital. BRAD RIEMANN. Clinical psychologists. Clinical Director, OCD Center at Rogers Memorial Hospital.

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Cognitive behavioral therapy for children with pandas pans

COGNITIVE BEHAVIORAL THERAPY FOR CHILDREN WITH PANDAS/PANS

Brad Riemann, Ph.D.

Clinical Director, OCD Center and CBT Services

Rogers Memorial Hospital


Brad riemann
BRAD RIEMANN

  • Clinical psychologists.

  • Clinical Director, OCD Center at Rogers Memorial Hospital.

  • Chair, Clinical Advisory Committee of IOCDF.

  • Member of Scientific Advisory Board of IOCDF.

  • Member of Clinical Advisory Board of ADAA.


Introduction
INTRODUCTION

  • Overview of cognitive behavioral therapy (CBT) for obsessive compulsive disorder (OCD).

    • Components of CBT.

    • Keys to making exposure successful.

    • Thought challenging.

    • Assessment.

    • General outcomes.

  • Role of CBT for PANDAS/PANS.

    • Role of family in treatment.

    • Storch et al., 2006.


Rogers memorial hospital ocd center
Rogers Memorial Hospital OCD Center

  • Private, free standing nonprofit psychiatric facility.

  • 7th largest behavioral health care system in U.S.

  • Levels of care for child and adults.

    • Intensive outpatient (12 hours per week).

    • Day treatment (20 hours per week).

    • Residential (30 hours per week).


Cbt for ocd
CBT FOR OCD

  • CBT, alone or in combination with sertraline, is first line treatment for pediatric OCD (POTS Team, 2004).


Cbt components
CBT COMPONENTS

  • Behavior Therapy (Exposure and Ritual Prevention; ERP).

    • Key element to effective treatment for OCD.

    • Meyer (1966).

    • Based on the principle of habituation.

    • Habituation is the decrease in anxiety experienced with nothing but the passage of time.

  • Cognitive restructuring (Thought Challenging).

    • Targets errors in thinking.

    • Use as an addition to ERP (85% - 15% split).


Exposures and keys to success
EXPOSURES AND KEYS TO SUCCESS

  • Exposure is placing an individual in feared situations (targets the obsessions).

  • Needs to be prolonged enough to lead to within trial habituation (at least 50% reduction in anxiety).

  • Needs to be repetitive enough to lead to between trial habituation (until causes minimal to no anxiety).

  • Needs to be graduated (increases compliance).

    • We start people off in their 3’s (just below midpoint of 0-7 scale).


Ritual prevention
RITUAL PREVENTION

  • Blocking the typical response or ritual before, during, and after exposure so habituation can take place (targets compulsions).


Thought challenging
THOUGHT CHALLENGING

  • Global targets.

    • Increasing tolerance of uncertainty.

    • Decreasing perceived need to control thoughts (e.g., suppression of unwanted thoughts).

    • Decreasing the perceived importance of thoughts.

  • Specific targets.

    • Probability overestimation errors (e.g., getting HIV from touching a door handle).

    • Catastrophizing errors (e.g., someone in men’s room didn’t wash their hands after using toilet).


Assessment
ASSESSMENT

  • Yale-Brown Obsessive-Compulsive Scale (Y-BOCS; Goodman et al., 1989).

    • 60 symptom checklist.

      • Self-report version.

      • Childhood version (CY-BOCS).

    • 10 item severity rating scale (0-4).

      • 5 questions regarding obsessions.

      • 5 questions regarding compulsions.

      • Mean score for OCD = 24.


Ybocs
YBOCS

  • 0- 7 = subclinical.

  • 8-15 = mild.

  • 16-23 = moderate (16 trial cut-off).

  • 24-31 = severe.

  • 32-40 = extreme.


Treatment steps for erp
TREATMENT STEPS FOR ERP

  • CYBOCS symptom checklist.

    • Yes or no.

  • Detailed information gathering.

    • Generate lists of things can not do as a result.

  • Create specific, individualized exposure exercises for each area.

  • Rate each specific exercise on a “subjective units of distress scale” (SUDS; Rogers uses 0-7 scale).

  • Create exposure hierarchy.

  • Assign ERP assignments.


Outcomes in general
OUTCOMES IN GENERAL

  • Effective (80-85% improvement rates; Foa et al., 1996a) and robust (low relapse rates, Foa et al., 1996b).

  • “Only” side effect is increased anxiety during treatment (can manage by conducting graduated exposure).

  • Quick improvements (many after first week of treatment).


The role of cbt in pandas pans
THE ROLE OF CBT IN PANDAS/PANS?

  • Reduce acute impairment and symptomology.

  • Prepare and empower parents and child for potential future symptom exacerbations.

  • Not a lot of data as of yet (larger samples being collected).


How cbt differs in pandas pans
HOW CBT DIFFERS IN PANDAS/PANS

  • It generally does not…

  • However, you have to consider potential factors:

    • Symptom severity.

    • Family factors.

    • Potential for future symptom exacerbations.


Symptom severity
SYMPTOM SEVERITY

  • Symptoms may be extremely severe shortly after an exacerbation/onset of PANDAS/PANS.

    • Determine realistic timing of intervention.

    • May have to move more slowly through hierarchy.

    • May have to start lower than 3’s.


Family factors and accommodation
FAMILY FACTORS AND ACCOMMODATION

  • Dramatic onset of symptoms changes family functioning considerably.

    • How are the parent/family doing?

  • As a result “ family accommodations” may be made in an attempt to cope with and reduce symptoms.

    • Unfortunately has opposite effect (makes things worse).

  • Treatment model is to train “parents as therapists”.

    • Address family accommodation in the course of treatment.

    • Always include parents in session.


Potential for future exacerbations
POTENTIAL FOR FUTURE EXACERBATIONS

  • Although good probability for response, symptoms may return.

  • CBT provides family with a tool set for addressing such occurrences.

    • Empowering families.

    • Able to sort out what to do next should symptoms return.

  • May reduce severity of future episodes.


Outcome data
OUTCOME DATA

  • Case report of CBT for rapid onset pediatric OCD of the PANDAS phenotype in a six-year-old boy. (Storch et al., 2004).

    • Over a one-week intensive CBT protocol, marked symptom reductions measured by the CY-BOCS were found (pre-treatment of 34 (extreme), post-treatment of 8 (low mild); treatment gains were maintained for one-year.

  • Considerable clinical experience from several centers around country (Rogers, USF).


Storch et al 2006
STORCH ET AL. (2006)

  • PARTICIPANTS.

    • Seven children with PANDAS related OCD.

    • Aged 9-13 years.

    • 4 males, 3 females.

    • CY-BOCS total score ≥ 16.

    • Stable on all medication at least 8 weeks prior to study.


Cognitive behavioral therapy for children with pandas pans

Subject

Age/Gender

Primary Obsessions

Primary Compulsions

1.

10-year-old female

Contamination fears

Aggressive thoughts

Somatic

Washing/Cleaning

Checking

Ordering/arranging

Reassurance seeking

2.

10-year-old male

Contamination fears

Aggressive thoughts

Sexual thoughts

Washing/Cleaning

Repeating

Counting

Reassurance seeking

3.

12-year-old male

Contamination fears

Washing/Cleaning

4.

11-year-old female

Contamination fears

Aggressive thoughts

Magical thoughts

Washing/Cleaning

Checking

Ordering/Arranging

Reassurance seeking

5.

13-year-old male

Contamination fears

Aggressive thoughts

Washing/Cleaning

Checking

Ordering/ Arranging

6.

9-year-old male

Contamination fears

Somatic fears

Washing/ Cleaning

Checking

Ordering/Arranging

Reassurance seeking

7.

11-year-old female

Contamination fears

Washing/Cleaning

Checking

Ordering/arranging

Reassurance seeking

Clinical Presentation


Procedure
PROCEDURE

  • Assessments were conducted at three time points:

    • Pre-treatment.

    • Post-treatment.

    • 3-month follow-up.

  • All patients received 14 90-minute CBT sessions over 3 weeks (abbreviated intensive outpatient).




Results continued
RESULTS (continued)

  • Using very strict criteria, 86% (6/7) were significantly improved at post-treatment assessment and 50% (3/6) at follow-up.

  • 71% (5/7) no longer met criteria for OCD at post-treatment and 50% (3/6) at follow-up.


Take home points
TAKE HOME POINTS

  • CBT should be part of the treatment of PANDAS/PANS.

    • Despite etiological factors, rituals still reduce anxiety which reinforce further symptoms.

    • Very few doubt that OCD is caused by a neurobiological abnormality yet CBT works very well for it.

  • Family involvement is huge – parents as therapist model.

    • Empowers families.

    • May reduce impact of future bouts.

  • Can use other CBT interventions to treat other symptoms (e.g., habit reversal training for tics).