Variability in emotion regulation in paediatric obsessive-compulsive disorder: Associations with symptom presentation and response to treatment

Highlights

• There are variations in the ability of children with OCD to modulate emotions.

• Children higher and lower on emotional control (EC) differ on clinical correlates.

• Children with greater EC were more likely to have favourable treatment response.

Abstract

This study explored whether variability in emotion regulation was associated with several clinical correlates of OCD and an attenuated response to treatment. Participants in this study were 137 youth (and their parents) aged 7–17 years with a primary diagnosis of OCD. Parents completed study questionnaires and children received intensive CBT with exposure and response prevention treatment. A median split of responses to the baseline Emotional Control (EC) index of the BRIEF, resulted in two groups of children – those with relatively greater and poorer EC. The results indicated that children in the relatively poorer EC group had significantly greater OCD severity, more family accommodation, internalising and externalising symptoms. They were also more likely to have a comorbid diagnosis of oppositional defiant disorder or social phobia. Additionally, children with relatively greater EC were more likely to have attained response or remission of their symptoms immediately following treatment. Similarly, at three months following treatment there were fewer responders to treatment among the lower EC group relative to the higher EC group; however, there was no significant difference for treatment remission between groups. Therefore, EC may be an indicator for a more severe presentation of OCD and a poorer response to treatment.

Introduction

Cognitive-behavioural theories of obsessive-compulsive disorder (OCD) emphasise the central role of obsessional beliefs in the development and maintenance of symptoms. Indeed, the role of obsessional thinking and belief biases in the clinical expression of OCD is well established (Farrell, Waters, & Zimmer-Gembeck, 2012; Myers, Fisher, & Wells, 2009; Rachman, 1993; Salkovskis, 1998). Cognitive models propose that inflated responsibility beliefs (Salkovskis, Forrester, & Richards, 1998), thought-action-fusion beliefs (Rachman, 1993) and meta-cognitive beliefs (Myers et al., 2009) maintain maladaptive thought appraisals which perpetuate an individual's experience of distress. This subjective experience of emotional distress in patients with OCD drives pathological, time consuming neutralising behaviours, in the form of excessive rituals (overt and/or covert), as well as extreme avoidance behaviours, often resulting in debilitating impairment. Whilst decades of research have closely examined the role of cognition and belief biases in OCD, by contrast very limited research has examined the role of emotions, and in particular emotion regulation (ER), in the maintenance of OCD. Given that compulsions represent a maladaptive strategy of regulating one's subjective and intolerable distress, the degree to which individuals with OCD may experience difficulties in emotional control (EC), an index of ER, warrants further attention.

In children with OCD, heightened emotional distress is part and parcel of the disorder (Barrett, Healy-Farrell, Piacentini, & March 2004). Children with OCD often experience extreme emotional distress in response to intrusions, contact with feared stimuli, the process of engaging in excessive rituals, or being interrupted from completing rituals. This distress may take the form of anxiety, disgust, dread, fear, anger and irritability. In severe cases, emotional distress presents as rage and explosive behaviour. There is a small but growing body of literature examining this extreme expression of emotion, whereby explosive emotional outbursts in children with OCD (Krebs et al., 2013; Storch et al., 2012; Storch, Jones, Lewin, Mutch, & Murphy, 2011) may suggest underlying ER deficits that characterise at least a proportion of these youth. For instance, Storch et al. (2011) conducted a preliminary study examining parents' qualitative accounts of rage experiences in 80 children with OCD. They found that rage was present in 27.5% of the sample and was associated with greater OCD severity and increased frequency of obsessions and compulsions. Interestingly, they found no significant differences in co-morbidities (particularly anxiety, mood, and attention-deficit symptoms) among those who exhibited signs of rage versus those who did not (Storch et al., 2011). In a subsequent study, Storch et al. (2012) explored children's rage attacks, which were conceptualised as recurrent explosive behaviour, among a different sample of youth (n = 86), aged 6–16 years with a primary diagnosis of OCD. The findings indicated more than half the sample experienced clinically significant levels of rage, which was associated with greater OCD severity, as well as greater parent-rated functional impairment. Furthermore, they found that rage was a significant and unique predictor of functional impairment beyond OCD severity. Storch et al. (2012) suggested that these episodes of rage were likely to represent the child's inability to regulate their internal distress, and moreover, that the feeling of calmness which were self-reported to follow these episodes provided negative reinforcement for the explosive behaviour.

Krebs et al. (2013) also examined explosive behaviour in children with OCD (n = 387) using both parent and child report. They found that more than a third of children in their sample exhibited explosive behaviours, and furthermore, these behaviours were two to three times more likely to occur in children with OCD relative to healthy controls. Interestingly, they found that OCD severity was not a unique predictor of explosive behaviour; whereas higher levels of comorbid depressive symptoms were. These extreme displays of emotion dysregulation in children with OCD are not only crippling for the child, but they also significantly and negatively impact on the entire family unit. Indeed, family members often begin to engage in pathological reassurance giving, assisting with rituals and modifying normal family routines in an attempt to prevent these OCD-fuelled, explosive emotional outbursts from occurring, or to calm the child down when they do occur. This process, referred to as family accommodation, has been associated with substantial impairments for the entire family and increased symptom severity for the child in the long-term (Peris et al., 2008; Stewart et al., 2008; Storch et al., 2007). Given the high frequency with which family accommodation occurs (e.g., 70–75% of families, Storch et al., 2007) and its negative impact on child outcomes, greater understanding of the mechanisms that drive accommodation behaviours is needed.

Among the most widely supported theoretical models of ER is Gross' (1998) process model of ER. This model of ER describes an information-processing framework in which five strategies (situation selection, situation modification, attentional deployment, cognitive change and response modulation) are distinguished by the point at which they are likely to be enacted in the process of generating emotions (Gross, 1998; Gross & Thompson, 2007). Interestingly, the process model of ER provides a theoretical explanation for the process of family accommodation in paediatric OCD. Gross and Thompson (2007) describe one aspect of ER through the process of situation modification, whereby changes are made to aspects of an individual's external environment or situation, in order to change the emotional impact that it could potentially have. Thus, situation modification may explain family accommodation in paediatric OCD, highlighting that emotion dysregulation and parental attempts to regulate their child's distress may be at the core of family accommodation.

Emotion regulation is a broad psychological process whereby an individual uses specific strategies to modify the magnitude and/or duration of an emotional response in order to cope (Gross, 1998; 2013). Given that this regulatory process is interactive, occurring between the individual and their environment, the way in which individuals regulate their emotions is highly context dependent and different methods of regulation may have different consequences (Gross, 2013). While there are various definitions in the literature describing emotion dysregulation, there is a general consensus that dysregulation refers to a failure in the ER process that inadvertently leads to problematic emotional states and behavioural responses (Gross, 2013). Dysregulation of emotion is associated with a poor understanding of one's emotions, which then may lead to more negative and more intense emotional and behavioural responses (McGuire et al., 2013; Mennin, Heimberg, Turk, & Fresco, 2005).

Children with OCD who are more emotionally dysregulated may represent the previously described subset of youth who exhibit co-occurring explosive behaviours and may be more resistant to treatment. Unfortunately, while ER has been widely studied in relation to anxiety disorders in children (Penza-Clyve & Zeman, 2002; Suveg & Zeman, 2004; Zeman, Shipman, & Suveg, 2002), there has been limited empirical focus examining ER in paediatric OCD (Bender, Pons, Harris, Esbjorn, & Reinholdt-Dunne, 2015; Berman, Shaw, Curley, & Wilhelm, 2018). Bender, Pons, Harris, Esbjørn, and Reinholdt-Dunne (2015) found that among a sample of clinically anxious children (n = 16, aged 8–12 years), those with OCD had greater difficulty understanding emotions and experienced more emotion dysregulation than children with other presentations of anxiety. More recently, Berman et al. (2018) examined the role of emotional suppression (attempts to ignore the emotion one is experiencing and avoid its expression) in a sample of 27 youth aged 8–18 years, most of whom met diagnostic criteria for OCD. These authors found that children's use of emotional suppression mediated the relationship between obsessive beliefs and OC symptom severity, after controlling for child age and anxiety/depression severity. While these studies have highlighted important associations between OCD and ER in general, neither study explored the potential implications of ER deficits for treatment response.

McGuire et al. (2013) examined impaired self-regulation among a sample of youth (n = 144) with OCD using the child behaviour checklist as a measure of dysregulation, and a proportion of this sample (n = 97) received CBT treatment. At baseline, they found that youth higher on dysregulation had greater OCD severity and impairment, greater family accommodation and more severe depression than those who were less dysregulated. Furthermore, baseline dysregulation predicted OCD severity, impairment, family accommodation, and premature treatment discontinuation, but was not found to predict treatment response (McGuire et al., 2013). A study by McNamara et al. (2014) is the only one to date that has specifically examined ER as a predictor of treatment response among children with OCD. McNamara et al. (2014) examined emotional control (EC), other executive functioning domains, OCD symptom severity and response to treatment among 56 children (aged 7–17 years) with a diagnosis of OCD. Their findings indicated that EC moderated treatment outcome (McNamara et al., 2014) such that children who had poorer EC at baseline experienced less of a reduction in OCD symptom severity following intervention, compared to those with greater EC. Therefore, identifying whether differences in baseline EC characterise children with OCD, and whether these differences have associations with important clinical correlates and varying degrees of treatment response over time, may provide a rationale for augmenting treatment by addressing deficits in ER more specifically to improve treatment outcome.

The current study aimed to examine the role of ER in OCD, specifically examining clinical correlates associated with variability in ER, and the degree to which this might be associated with an attenuated response to treatment. The study examined parent-reported EC, an index of ER, in a paediatric OCD sample (n = 137) using a reliable and well-validated parent-report scale (sub-scale from the Behaviour Rating Inventory of Executive Function, BRIEF; Gioia, Isquith, Guy, & Kenworthy, 2000). The study classified youth in the sample as having relatively poorer EC compared to those with greater EC. EC assessed the child's ability to modulate emotional responses e.g., the child's tendency to react with more emotional intensity to situations than other children. In order to examine differences in the clinical expression of youth with relatively poorer EC, a median split on the EC subscale resulted in two groups of children – those higher in EC (mean t-score = 53.21, SD = 5.59) and those lower on EC (mean t-score = 73.57, SD = 7.02). Therefore, youth classified as having relatively poorer EC did not necessarily obtain an EC score that indicated a clinically significant deficit in EC (clinically significant deficit t-score = 65). The study investigated associations between EC and a range of clinical constructs including OCD severity, family accommodation, internalising and externalising symptoms, comorbidity, and immediate, as well as longer-term treatment response.

Specifically, this study aimed to: (a) examine whether children with relatively poorer EC had significantly more severe OCD, family accommodation, internalising symptoms, and externalising symptoms, relative to children with greater EC; (b) examine whether children with relatively poorer EC were characterised by specific comorbid diagnoses relative to those with greater EC, and finally (c) to examine whether children with relatively poorer EC had a poorer response to treatment, immediately following brief, intensive cognitive-behavioural therapy with exposure and response prevention (CBT-ERP), and at 3-month follow up. In line with these aims, it was hypothesised that:

H1

children with relatively poorer EC would have significantly more severe OCD, significantly more family accommodation and significantly higher internalising and externalising symptoms, relative to children with higher EC.

H2

children with relatively poorer EC were more likely to have comorbid diagnoses of Oppositional Defiant Disorder (ODD) and Depression/Dysthymia, than other commonly occurring comorbid diagnoses (specifically, Attention Deficit/Hyperactivity Disorder, Autism Spectrum Disorder, Generalised Anxiety Disorder, Separation Anxiety Disorder, Social Phobia, Panic Disorder, Agoraphobia and Specific Phobia) relative to those with greater EC.

H3

children with relatively poorer EC would have a poorer response to treatment, immediately following intervention and at 3-month follow up, compared to children with higher EC.