وسواس دگرگونی در اختلال وسواس در کودکان: خصوصیات بالینی و پاسخ درمانی برای رفتاردرمانی شناختی

Abstract Background and objectives Transformation obsessions denote an under-reported symptom of Obsessive Compulsive Disorder (OCD), characterised by an excessive fear of turning into another person/object or acquiring unwanted characteristics. Relative to other OCD symptoms, little is known about the clinical presentation of transformation obsessions. The study aims to examine the clinical correlates and treatment prognosis of transformation obsessions in a paediatric OCD sample. Methods The sample consisted of 346 youths with a primary diagnosis of OCD. Patients with and without transformation obsessions were compared in terms of demographic and clinical characteristics, and CBT outcomes.

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 and 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. Table 1. Brief description of an assessment of a case with transformation obsessions. Case 1 Lauren was a 16 year old girl with a 4-year history of anxiety and distressing worries about war and world dictators. Lauren described what health professionals labelled ‘pseudo auditory, visual, and tactile hallucinations’ of Hitler screaming and standing close to her, performing sexual acts on both her and members of her family. An antipsychotic medication was added to her pharmacological treatment due to references of Lauren's symptoms being ‘unusual and quasi-psychotic’ in nature, albeit not meeting criteria for full-blown psychosis. Lauren was referred to a specialist OCD Clinic for consultation and opinion on whether her presentation could be OCD. From the assessment it was noted that Lauren's ultimate fear was that of metamorphosis; specifically, her worries revolved around turning into Hitler and developing a Hitler moustache and male genitalia. Whilst she described occasions of Hitler speaking to her or images of Hitler, these sensations appeared to be originating in her own mind, and not in the external space, and tended to occur only in the context of high arousal and anxiety provoked by these thoughts. At assessment, Lauren reported extensive ritualistic behaviours (e.g. checking, repeating actions, mental rituals) to prevent the metamorphosis. The description of transformation obsessions and related compulsions, in the absence of psychotic symptoms (e.g. delusions), was consistent with an OCD diagnosis. Specifically, the differential diagnoses was guided by the following factors: 1) Lauren recognized that thoughts/worries/images about Hitler were the product of her mind and unreasonable, though still unwanted and highly distressing for her; 2) there was a clear link between compulsions and obsessions; Lauren described performing compulsions to reduce her distress and to prevent the feared event from occurring; and 3) Lauren's experiences of intrusive images differed qualitatively from typical visual hallucinations in the sense that they were described as faint images and a fear of having seen something, they were not recurrent, and occurred only in the context of heightened levels of anxiety and fear. Lauren scored 30 on the CY-BOCS, placing her in the severe range for OCD. Screening and detailed assessment allowed an accurate formulation of her fears as part of OCD, which in turn led to evidence-based treatment for OCD. Abbreviations: CY-BOCS, Children Yale-Brown Obsessive Compulsive Scale; CBT, Cognitive Behaviour Therapy; E/RP, Exposure and Response Prevention. Table options 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 and 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 and 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 and Geller and March, 2012, National Institute for Clinical Excellence NICE, 2005 and 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.

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 transformation obsessions. Given the occurrence of these symptoms in paediatric OCD and their potential functional impairment, clinicians should routinely screen for transformation obsessions. Improved screening may encourage early detection and appropriate treatment, potentially helping minimize the long-term risk associated with any OCD symptomatology. Overall, it is hoped the study highlights the necessity for further investigation into transformation obsessions to raise awareness and our understanding of OCD in all its manifestations.