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Book Reviews |
Key Words: Books Reviewed
Once regarded as an untreatable condition, obsessive-compulsive disorder (OCD) is now known to be responsive to certain pharmacological and psychological interventions. Of the psychological therapies, those based on exposure and response prevention, and generally classified as cognitive-behavioral therapy (CBT), have demonstrated reliable and robust effects across several outcome studies (see review1). Most of these trials, however, have been conducted with adults, and existing treatment manuals reflect this. For those clinicians who work with children and adolescents, this manual by Marsh and Muelle has been long awaited and appears worth the wait.
Dr. Marsh and his colleagues at Duke have been distinguished contributors to our knowledge of OCD and its treatment and are pioneers in extending that knowledge to children and adolescents. In this book they share that expertise in what is likely to be regarded as the standard in treatment manuals for pediatric OCD. In addition to being well organized and written, this volume is clinically sensitive and practical. It accomplishes the elusive goal of communicating pertinent information in easily understood terms, which makes it useful to readers regardless of theoretical background or level of experience.
An introductory section very effectively surveys pediatric OCD, including its clinical presentation, epidemiology, comorbidity, and etiology. A sophisticated review of pharmacotherapeutic and psychological treatment guidelines follows, drawn from the Expert Consensus Treatment Guidelines for OCD.2 An overview of assessment strategies and the treatment model conclude Part 1 and are concise and clinically relevant.
Part 2, the bulk of the book, details the session-by-session treatment program developed by the authors. The general format addresses the treatment rationale, self-monitoring and coping skills, exposure and response prevention, and then longer-term recovery. Within this structure, the authors present the details of the approach (organized around each session's goals) in the setting of vignettes that follow the ongoing treatment of a child. Reading this section is like receiving specific, directive supervision from a seasoned specialist. Although the patient vignette format can seem rather idiomatic in its presentation of the intervention, its techniques, tips, and clinical pearls impressed me as well tested, and they give a feel for what these authors have found to be important therapeutic nuances. As a whole, the section offers the reader clear, specific, and clinically useful instruction in a proven approach.
Part 3 of the book, entitled "Troubleshooting," addresses some of those well known "other things" that enter therapy and render more standardized manuals less useful. One of the more sensitive topics discussed, for example, involves handling the discomfort an adolescent patient or a therapist may have regarding exposure to feared "homosexual themes." Others include recognizing and managing comorbid symptoms and other subtle features of OCD that can influence treatment outcome. To their credit, the authors also acknowledge the key role of the social system by addressing issues related to working with families and school systems.
This is an excellent volume that left this reviewer wanting only a few things, two of which I will note. One of CBT's unique contributions to the treatment of OCD has been its relative success in helping patients maintain their acute treatment gains while reducing their risk for relapse, and recent efforts to strengthen this benefit have been promising.3 I found myself wanting more emphasis on this aspect of treatment than was presented. Second, much of the section on etiology is a cogent presentation of advances supporting the neuropsychiatric model of OCD. This model also forms the basis of the authors' treatment rationale. Presentation of "emotional processing" models that drove the development of CBT for OCD,4 their evidence base, and rationales associated with them would have balanced this section, but perhaps would have taken it beyond the scope and purpose of the book. These two points, however, cannot be placed in context better than the authors did in their preface: "As in most areas of psychiatry and psychology, controversy abounds. This book, while rich in information, will not do justice to the edge of the field, and the reader may not agree with everything we say...the controversies will eventually yield to good science. Our goal...is to help children and adolescents with OCD lead more normal, happy, and productive lives."
To the clinician, Marsh and Muelle offer a clinically sensitive, highly applicable, evidence-based treatment approach to pediatric OCD. In doing so they generously extend the hope of recovery to the many children and their loved ones whose lives are so tragically altered by this debilitating disorder.
Footnotes
Dr. Bruce is Associate Professor and Codirector of the Anxiety and Mood Disorders Clinic, University of Illinois College of Medicine, Peoria, IL.
References
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