Transformation obsessions in paediatric obsessive-compulsive disorder: Clinical characteristics and treatment response to cognitive behaviour therapy
Introduction
Obsessive Compulsive Disorder (OCD) is a significant mental health problem, affecting 1%–3% of young people under 18 years old (Heyman et al., 2001). OCD encompasses a range of symptom dimensions (Mataix-Cols et al., 2008, Mataix-Cols et al., 2005), including bizarre and magical obsessions. Volz and Heyman (2007) coined the term ‘transformation obsessions’ to refer to a subgroup of young people presenting to a specialist OCD clinic with a ‘fear of turning into someone else or another object or acquiring unwanted characteristics’. Young people with transformation obsessions may, for example, have obsessional worries about becoming unpopular or losing their athletic skills or intelligence. Transformation obsessions can also manifest as a fear of turning into a specific person (e.g. Hitler – see Table 1) or even an animal (e.g. a rat; see Volz & Heyman, 2007). This type of obsessional fear has also been recognised in the adult literature and referred to as ‘fear of morphing’ (Rachman, 2006). Despite recognition of transformation or fear of morphing as a symptom of OCD across the lifespan, relatively little is known about the clinical significance or correlates of this symptom.
In their original description of transformation obsessions, Volz and Heyman (2007) described 9 young people aged 11–17 years presenting with this symptom. Transformation obsessions were noted to be relatively rare, affecting only 9 out of 259 young people with OCD who were referred to a specialist clinic over a 4-year period. Importantly, the case series highlighted the common difficulty that clinicians experience in correctly diagnosing transformation obsessions due to their bizarre and unusual nature. In particular, misdiagnosis of transformation obsessions as being part of a psychotic disorder is a concern among this group (see Table 1). Better understanding the broader phenotype of transformation obsessions may aid accurate diagnosis. To date, no study has empirically examined and compared the clinical correlates of youths with transformation obsessions relative to young people with other forms of OCD.
In the adult OCD literature, transformation obsessions have been conceptualised as a form of ‘mental’ contamination, that is, a form of contamination fears involving feelings of dirtiness or pollution evoked in the absence of direct contact with a contaminant (Rachman, 2006, Warnock-Parkes et al., 2012). Whilst important differences have been observed between mental and contact contamination (e.g. mean of contagion, associated rituals, etc) (Rachman, 2006, Warnock-Parkes et al., 2012), both trigger a sense of dirtiness and have been associated with washing/cleaning compulsions which the patient engages in an attempt to remove/reduce feelings of dirtiness (Coughtrey, Shafran, Knibbs, & Rachman, 2012; Rachman, 2006). Currently, there is no empirical evidence to-date to support the notion that transformation obsessions, as a form of mental contamination, fall within the contamination dimension of OCD. Indeed, the association between transformation obsessions and contamination remains to be confirmed. Interestingly, in their case series, Volz and Heyman (2007) reported that only two out of the nine young people with transformation obsessions presented with washing or cleaning compulsions, suggesting that these obsessions may not necessarily be linked to contamination. On the contrary, anecdotal evidence suggests that patients with transformation obsessions typically describe their symptoms as a fear of harm coming to them, in a way that is akin to aggressive obsessions. To clarify the conceptualization and nature of transformation obsessions, their relation to OCD dimensions symptoms requires further investigation.
Cognitive Behaviour Therapy (CBT) is an effective and recommended psychological treatment for OCD in adults and children (Barrett et al., 2004, Geller and March, 2012, National Institute for Clinical Excellence NICE, 2005, POTS, 2004). CBT incorporating exposure with response prevention (E/RP) is effective for approximately 70% of young people with OCD, and is associated with a 40–64% reduction in symptoms (Watson & Rees, 2008). To date, only one small case series illustrated the benefits of treating transformation obsessions with CBT (Volz & Heyman, 2007); in this study, the authors described cases where full recovery was obtained by tackling transformation obsessions using ERP-based CBT. More research is available on treatment outcomes for mental contamination which, as reported above, is a term used to encapsulate transformation obsessions. Rachman (2006) proposes that with mental contamination, standard CBT needs to be modified and focus more on cognitive techniques and less on E/RP. For example, Warnock-Parkes et al. (2012) describe a case of a man with a 20 year history of mental contamination associated with traumatic memories who had not responded to E/RP-based CBT delivered through a specialist OCD service. He received modified cognitive therapy incorporating imagery work to address his appraisals of key events that had given rise to his feelings of contamination. Following the course of cognitive therapy, his symptoms decreased from the severe to sub-clinical range. This case report highlights the need for further research to test the extent to which cognitive therapy is superior to E/RP-based CBT in the treatment of mental contamination. Of note, the above case study as well as the majority of existing research do not address fears of morphing specifically; indeed, it remains to be empirically confirmed whether CBT requires modification to successfully address transformation obsessions. The lack of research addressing how to best treat transformation obsessions and suggestions that mental contamination (and by default, transformation obsessions based on the current conceptualisation) is less responsive to ERP-based CBT, highlights the needs to empirically explore whether transformation obsessions respond to CBT to the same extent as other OCD symptoms in young people.
The aims of the present study were threefold. First, we aimed to explore transformation obsessions in a large paediatric OCD sample by comparing patients with and without transformation obsessions on demographic and clinical characteristics. Second, the study sought to determine the OCD symptom dimension most closely associated with transformation obsessions. We tested two competing hypotheses: that transformation obsessions are a form of mental contamination (Rachman, 2006) and will therefore load on the previously established “contamination” dimension (e.g. Mataix-Cols et al., 2005); or alternatively, that transformation obsessions are most closely related to aggressive obsessions and will therefore fall under the “forbidden thoughts” OCD dimension. The third and final aim was to examine the effect of transformation obsessions on CBT response.
Section snippets
Participants
A total of 346 young people who were referred to the National and Specialist Paediatric OCD & Related Disorders Clinic at the Maudsley Hospital (London) between 2004 and 2011 and who met ICD-10 diagnostic criteria for OCD were included in the study. The diagnosis was confirmed by a specialist multidisciplinary team during a comprehensive assessment, as described in detail elsewhere (Nakatani et al., 2011). Two hundred and seventeen participants (56.7%) received CBT at the clinic and had
Results
The sample consisted of 189 (54.6%) boys and 157 (45.5%) girls, with a mean age of 14.4 years (SD 2.2; range 7–18); age at onset of OCD was 10.7 years (SD 3.1). The mean total CY-BOCS score at assessment was 26.4 (SD 5.6), indicative of moderate OCD severity.
A total of 35 (10.1%) OCD patients endorsed transformation obsessions. Demographic and clinical characteristics of OCD patients with and without transformation obsessions are presented in Table 2. Individuals with transformation obsessions
Discussion
To our knowledge, this is the first study to systematically examine clinical correlates of paediatric OCD patients presenting with transformation obsessions. The study sheds light on the phenomenological similarities that these obsessions share with other OCD symptoms, in terms of clinical correlates and treatment prognosis.
Results indicate that transformation obsessions were relatively common in our clinical sample, with approximately 10% of youth with a primary diagnosis of OCD endorsing
Conclusions
With these caveats in mind, and to conclude, whilst associated with certain clinical features (in terms of gender, medication, and severity of obsessions), overall transformation obsessions do not differ significantly on demographic features and prognosis, compared with other forms of obsessional thoughts. The study cautiously validates the effectiveness of using conventional E/RP-based CBT interventions that are developmentally tailored to successfully address the core fear underlying
Acknowledgements
Georgina Krebs receives salary support from the National Institute for Health Research (NIHR) Mental Health Biomedical Research Centre at South London and Maudsley NHS Foundation Trust and King's College London. The views expressed are those of the author(s) and not necessarily those of the NHS, the NIHR or the Department of Health.
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