Investigating the role of Emotion Regulation in paediatric Obsessive-Compulsive Disorder (OCD): associations with symptoms and treatment response

Abstract

Cognitive-behavioural (CB) theories that explain Obsessive-Compulsive Disorder (OCD) have largely focused on the role of maladaptive belief biases as drivers of the individual’s experience of anxiety or distress, pathological avoidance behaviours and compulsions. One potential limitation of current CB models is the limited focus on the extent to which deficits in emotion regulation (ER) may account for a reliance on maladaptive regulatory processes (avoidance and neutralising compulsions), which also serve to maintain OCD symptomatology. Recently, researchers have begun to examine the potential role of ER in adult and paediatric OCD. However, of the limited number of studies completed to date most have utilised community rather than clinical samples and there are even fewer studies involving youth with OCD. Moreover, there are no studies to date examining the role of ER strategies in cognitive-behavioural treatment of paediatric OCD. Accordingly, this thesis aimed to elucidate the role of ER in OCD symptom expression and treatment by using a combination of self- and parent-report measures of ER to examine the relationship between ER, symptoms and associations with treatment response in relatively large, well-defined clinical samples of children and youth with a primary diagnosis of OCD. These studies represent the most comprehensive examination of the role of ER in paediatric OCD to date, and aim to inform current theoretical models of OCD, as well as inform treatment advances. The first study of this PhD explored whether youth with OCD who experience deficits in emotional control (as indexed by parental report on the Behaviour Rating Inventory of Executive Function, n = 137) differed in their OCD symptom expression, comorbidity and response to evidence-based treatment, relative to youth with OCD who had greater emotional control (n = 68). The findings indicated that those lower on emotional control (n = 69) had significantly greater OCD severity, famil y accommodation, internalising and externalising symptoms, an d were less likely to respond favourably to treatment. The second study involved a clinical sample of 72 youth (aged 7 to 17 years) with a primary diagnosis of OCD and examined self-reported parent perceptions of child ER and associations with family accommodation (FA), as well as explored potential child and parent variables that predicted negative parental perception of child ER ability. The findings of this study revealed that child externalising symptoms and parental depression uniquely predicted negative parental perception of their child’s ER ability. Furthermore, while negative parental perception of child ER was moderately and positively correlated with FA, it was not found to be a unique predictor of FA after controlling for previously established predictors. The third and final study built on the findings of the first study by examining a wide range of specific adaptive and maladaptive ER strategies among youth with a primary diagnosis of OCD (n = 65, aged 7 to 17 years), both before and after treatment, and the degree to which changes in ER strategies following intensive cognitive-behavioural treatment predicted a treatment response at post-treatment and three months following treatment. The findings of this final study indicated significant improvements in four adaptive and five maladaptive ER strategies. Additionally, pre- to post-treatment increases in Acceptance and decreases in Suppression were significant unique predictors of OCD severity at post-treatment, and increases in Acceptance and decreases in Self-Blame were significant unique predictors of OCD severity 3 months following treatment. Taken together, the findings from the three empirical studies reported herein indicate that deficits in ER form a part of the clinical picture of OCD in youth and may be associated with several clinical correlates known to be associated with a poorer treatment response. For instance, deficits in ER are associated with greater externalising symptoms in youth with OCD, and together with parental self-reported depression may be associated with parents having more negative perceptions of their child’s ability to regulate their emotions. Furthermore, given that Acceptance was found to be a particularly strong predictor of favourable treatment response over time, emphasising Acceptance in evidence-based cognitive-behavioural treatment for OCD or augmenting such treatments with an ER training component may potentially enhance the efficacy of evidence-based treatments and ultimately improve treatment response.