Behavior therapy in children and adolescents with obsessive-compulsive behavior: Connecting development, behavior, neurobiology and therapy

Beginning with a brief report on the 'state of the art', the authors present a new concept connecting development, behavior, neurobiology and therapy of obsessive-compulsive disorder. Besides neurobiological factors, failures in coping with anxiety during developmental, learning, and adaptation processes may contribute to the appearance of obsessive-compulsive behavior. The repetition of 'problem solving strategies' which seem to be, initially, successful in reducing anxiety may lead to increasing facilitation of those neuronal networks that underlie the obsessive thoughts and compulsive acts. In order to eliminate compulsive behavior these stabilized neuronal connections must be 'destabilized' in a first step. This can be done by means of 'stimulus exposure with response prevention'. On the basis of subjectively experienced uncontrollability during the exposure situations, stress-responsive neuronal networks are activated and comprehensive neuroendocrine stress reactions are triggered that may result (by long-term repetition) in the destabilization of the facilitated connections, sometimes even their elimination. On the other hand, new 'non-compulsatory' neuronal connections must be formed to provide a basis for alternative behavioral and coping patterns, in particular in response to demands and situations that cause anxiety. This can be achieved by steadily practicing adequate behavioral responses. Thus, demands which were previously felt to be uncontrollable are increasingly experienced as controllable and can be coped with by cognitive reflection and/or by behaving in a suitable manner. During such a cognitive-behavioral 'structuring' neuronal process, medication with selective serotonin re-uptake inhibitors and behavior therapy can be usefully combined. To stabilize these newly formed neuronal patterns, situations that still cause anxiety, worrying, tension or restlessness must be successfully self-managed over an extended period. During these challenges, now experienced as controllable, activation of stress-responsive systems is only brief and newly established neuronal connections are therefore facilitated and consolidated. Thus, it is possible to achieve increasing reduction of obsessive-compulsive behavior while improvement is observed concerning coping with demands and situations that previously caused anxiety.