Basics
- Obsessive-compulsive disorder (OCD) is a psychiatric illness manifested by recurrent and persistent obsessions and compulsions.
- Obsessions are defined as intrusive, unwanted thoughts, images, or impulses that cause the patient distress, and attempts are made to ignore or suppress these thoughts.
- Compulsions are repetitive actions that patient feels driven to perform in response to an obsession. The behaviors are aimed at preventing or reducing anxiety or distress or preventing some dreaded event or situation.
- It is not necessary that children recognize these thoughts or behaviors to be excessive or unreasonable.
- The obsessions or compulsions cause marked distress, are time consuming (>1 hour daily), and cause impairment in daily functioning.
- Not attributed to physiologic effects of a substance nor are explained by another mental disorder
- Specified as "with good or fair insight, " "with poor insight, " "with absent insight/delusional beliefs, " or tic-related
Epidemiology
- There are at least 1 in 200 " or 500,000 " children and adolescents that have OCD. This figure is similar to the number of children who have diabetes.
- OCD can start at any time from preschool to adulthood.
- Although OCD does occur at earlier ages, there are generally two age ranges when OCD first appears. The first range is between ages 10 and 12 years and the second between the late teens and early adulthood.
Risk Factors
- Familial heritability pattern
- Moderate genetic component based on twin studies
- Acute streptococcal infection (PANDAS)
Commonly Associated Conditions
- Depression
- Anxiety disorders
- Tourette syndrome
- Trichotillomania
Diagnosis
History
- The diagnostic evaluation should entail gathering data through separate interviews with the child/adolescent and the parents.
- Current symptoms should be elicited within attention to severity, duration, and level of functional impairment.
- Core symptoms should be elicited concerning the content of obsessions and the nature of compulsions. These are most frequently checking behaviors, repetition rituals, or a focus on symmetry and organization.
- Sensitivity in assessing violent or sexually intrusive thoughts is necessary, as children may be uncomfortable disclosing these.
- Compulsions may manifest in physical action or in mental repetition.
- Assess the amount of functional impairment by estimating the time spent occupied by obsession and compulsions and how it interferes with their daily lives.
- Explore their level of insight into the irrationality of the symptoms. Diagnostically, children do not have to recognize the symptoms to be excessive. Assess any parental accommodation of the ritualized behaviors, such as excessive cleaning.
- Determine if the onset was acute, severe, and temporally associated with symptoms of a streptococcal infection.
Physical Exam
No pertinent findings
Diagnostic Tests & Interpretation
Lab
- No pathognomonic laboratory findings
- If onset is acute, severe, and associated with symptoms of a streptococcal infection, consider obtaining an ASO titer.
Diagnostic Procedures/Other
Diagnostic scales: Children 's Yale-Brown Obsessive Compulsive Scale (CY-BOCS)
Differential Diagnosis
- Pervasive developmental disorders
- Delusional disorder
- Obsessive-compulsive personality disorder
- Body dysmorphic disorder
- Anorexia nervosa
- Trichotillomania
- Tourette syndrome
- Schizophrenia
- Sydenham chorea
- Pediatric autoimmune neuropsychiatric disorders associated with strep infections (PANDAS)
Treatment
General Measures
There are 2 types of treatment for OCD, psychosocial treatment and pharmacotherapy.
- Cognitive behavioral therapy (CBT) is most effective and well-studied psychosocial treatment:
- Selective serotonin reuptake inhibitors (SSRIs) are the 1st-line agents for medication management.
- Start intervention with CBT alone and add medication if treatment response is limited.
- Emphasis is placed on graduated exposure with response prevention.
- Parental education is an important aspect of treatment adherence.
- Pitfalls
- Failing to use appropriate psychosocial treatments especially school-based modifications
- Not identifying the extent of the functional impairment
- It is important to recognize
- The child 's fear of the internal thoughts he or she is having
- The parents ' desire to have a "normal " child and thus their tendency to minimize/reassure the child who has concerns
Medication
- SSRIs (1st-line) once-daily oral dosing; initiate 1/2 the starting dose for children with anxiety disorders:
- Fluoxetine (Prozac) (10 " 60 mg)
- Sertraline (Zoloft) (25 " 200 mg)
- Fluvoxamine (Luvox) (25 " 200 mg)
- Side effects include GI upset, headaches, dizziness, and agitation.
- Close monitoring is recommended (see next section).
- Tricyclic antidepressants (TCAs) are 2nd-line agents:
- Clomipramine (Anafranil) (25 " 250 mg PO once daily)
- Side effects include dizziness, xerostomia, blurred vision, postural hypotension, tachycardia, sedation, and constipation.
Alert
A black box warning by the FDA indicates that all antidepressants may increase suicidal thinking and behavior in children and adolescents.
Ongoing Care
Follow-up Recommendations
Patient Monitoring
- Monitoring of response to psychosocial treatment should be performed routinely every 2 " 3 months.
- If medication is initiated, close monitoring on a weekly basis is recommended for the 1st 4 weeks, followed by monthly monitoring.
- CBT is performed on a weekly or twice weekly regimen.
- Monitoring of any emerging comorbidities is suggested.
Prognosis
- OCD is a chronic condition. Treatments have been demonstrated to show significant response, but remission of symptoms is rare.
- Childhood onset is a poor prognostic indicator.
Additional Reading
- Coskun M, Zoroglu S, Ozturk M. Phenomenology, psychiatric cormorbidity and family history in referred preschool children with obsessive compulsive disorder. Child Adolesc Psychiatry Ment Health. 2012;6(1):36. [View Abstract]
- March JS, Pediatric OTC Treatment Study Team. Cognitive-behavior therapy, sertraline, and their combination for children and adolescents with obsessive-compulsive disorder: the Pediatric OCD Treatment Study (POTS) randomized-controlled trial. JAMA. 2004;292(16):1969 " 1976. [View Abstract]
- O 'Neill J, Gorbis E, Feusner JD, et al. Effects of intensive cognitive-behavioral therapy on cingulate neurochemistry in obsessive-compulsive disorder. J Psychiatr Res. 2013;47(4):494 " 504. [View Abstract]
- Robinson S, Turner C, Heyman I, et al. The feasibility and acceptability of a cognitive-behavioural self-help intervention for adolescents with obsessive-compulsive disorder. Behav Cogn Psychother. 2013;41(1):117 " 122. [View Abstract]
Codes
ICD09
- 300.3 Obsessive-compulsive disorders
- 312.39 Other disorders of impulse control
- 301.4 Obsessive-compulsive personality disorder
ICD10
- F42 Obsessive-compulsive disorder
- F63.3 Trichotillomania
- R46.81 Obsessive-compulsive behavior
- F60.5 Obsessive-compulsive personality disorder
SNOMED
- 191736004 Obsessive-compulsive disorder (disorder)
- 17155009 trichotillomania (disorder)
- 247963001 compulsive checking (finding)
- 67431008 Compulsion expressed as ritual (finding)
- 247964007 Compulsive repeating (finding)
- 247971002 Compulsive arrangement of objects (finding)
FAQ
- Q: Is OCD inherited?
- A: Although no specific genes for OCD have been identified, there appears to be familial relationship to its inheritance.
- Q: What causes OCD?
- A: There is no proven cause of OCD. Research suggests that OCD involves problems in communication between the front part of the brain (the orbital cortex) and deeper structures (the basal ganglia).
- Q: Is there a cure?
- A: OCD is a chronic condition, but effective treatments are available.