Obsessive Compulsive Dis.Obsessive Compulsive Dis.in Children & Adolescentsin Children & Adolescents

Elham Shirazi MDElham Shirazi MD

Child & Adolescents PsychiatristChild & Adolescents Psychiatrist

ObsessionsObsessions

Thoughts , Images , ImpulsesThoughts , Images , Impulses Egodystonic , Intrusive , senseless , Egodystonic , Intrusive , senseless ,

InappropriateInappropriate Anxiety , Dysphoric AffectsAnxiety , Dysphoric Affects

(fear,disgust,doubt,incompleteness)(fear,disgust,doubt,incompleteness) Not Worries about Real Life Problems Not Worries about Real Life Problems Attempts to Ignore , Suppress , Attempts to Ignore , Suppress ,

Neutralize ThemNeutralize Them Recognized as Products of Own MindRecognized as Products of Own Mind

CompulsionsCompulsions

Repetitive Behavior , Mental ActsRepetitive Behavior , Mental Acts Response to Obsessions , Rigid Response to Obsessions , Rigid

RulesRules Prevent /Reduce : Distress , Prevent /Reduce : Distress ,

Dreaded Event , SituationDreaded Event , Situation No Realistic Connection with what No Realistic Connection with what

designed to Neutralized , Prevented designed to Neutralized , Prevented or Excessive or Excessive

CriteriaCriteria

Recurrent Persistent Obsessions & Recurrent Persistent Obsessions & CompulsionsCompulsions

At Some Point Recognized as At Some Point Recognized as Excessive , UnreasonableExcessive , Unreasonable

Distress , Time Consuming (1h/d) , Distress , Time Consuming (1h/d) , Interfere Routine ActivitiesInterfere Routine Activities

Not due to Substance / GMCNot due to Substance / GMC

With Poor Insight With Poor Insight !!

History History

1616Th centuryTh century : Description of one OCD variant : Description of one OCD variant (scrupulosity)(scrupulosity)

19031903 : First description of OCD in childhood (in a 5y : First description of OCD in childhood (in a 5y

old boy by old boy by Pierre JanetPierre Janet )) 19271927 : First survey of OCD in childhood (by catholic : First survey of OCD in childhood (by catholic

church that found 4% scrupulosity in female catholic church that found 4% scrupulosity in female catholic highschool students) highschool students)

19351935 : : Leo KannerLeo Kanner described the social isolation of OCD described the social isolation of OCD youngsters & family overinvolvement in child`s ritualsyoungsters & family overinvolvement in child`s rituals

19421942 : : BermanBerman described the similarities of childhood described the similarities of childhood

OCD & adult OCDOCD & adult OCD

History History

19551955 : : Louise DespertLouise Despert noticed the tendency of noticed the tendency of children to hide OCD symptoms & that children to hide OCD symptoms & that childhood OCD is more prevalent in boyschildhood OCD is more prevalent in boys

1980s1980s: Epidemiology Catchment Area (ECA) : Epidemiology Catchment Area (ECA) study finds that most adults with OCD report study finds that most adults with OCD report onset by adolescenceonset by adolescence

NIMHNIMH : The first systematic studies of : The first systematic studies of epidemiology , phenomenology & epidemiology , phenomenology & psychopharmacology of OCD in children & psychopharmacology of OCD in children & adolescentsadolescents

Epidemiology Epidemiology

Difficult to Study Prevalence & Epidemiology Difficult to Study Prevalence & Epidemiology Where should the line demarcating Where should the line demarcating Subclinical OCSubclinical OC

Features/Clinical OCDFeatures/Clinical OCD be drawn ? be drawn ? Parents with Subclinical OC can`t recognize Parents with Subclinical OC can`t recognize

Symptoms in their Child !Symptoms in their Child ! Secretiveness & No Insight in PatientsSecretiveness & No Insight in Patients Unfamiliarity with Diagnosis & Treatment among Unfamiliarity with Diagnosis & Treatment among

PhysiciansPhysicians Underdiagnosed & UndertreatedUnderdiagnosed & Undertreated Hidden EpidemicHidden Epidemic Prevalence Prevalence 0.8 - 3.6 %0.8 - 3.6 % Lifetime Prevalence Lifetime Prevalence 2.0 - 4.0 %2.0 - 4.0 % Subclinical OC up to Subclinical OC up to 20.0 %20.0 %

Epidemiology Epidemiology

1/41/4 of Subclinical OC / OCPD : full OCD Criteria of Subclinical OC / OCPD : full OCD Criteria at follow upat follow up

Bimodal Age of Onset :Bimodal Age of Onset :

Child mean onset Child mean onset 10 y 10 y (40% <15 y)(40% <15 y)

Adult mean onset Adult mean onset 21 y21 y Onset :Onset :

BoysBoys : Prepubertal ( girls< boys ) : Prepubertal ( girls< boys )

GirlsGirls : Pubertal ( girls= boys ) : Pubertal ( girls= boys ) Early Onset OCD more likely :Early Onset OCD more likely :

Boy , Genetic , Positive Family History for OCD & Boy , Genetic , Positive Family History for OCD & Tic DisorderTic Disorder

EtiologyEtiology Neuropsychiatric Dis.Neuropsychiatric Dis., Unknown & Heterogeneous , Unknown & Heterogeneous

Et.Et. Abnormal Abnormal Corticostriatal-Thalamocortical PathwayCorticostriatal-Thalamocortical Pathway Frontal Lobe ,Limbic System ,Basal GangliaFrontal Lobe ,Limbic System ,Basal Ganglia

DysfunctionDysfunction Abnormal Circuit linking Abnormal Circuit linking Basal GangliaBasal Ganglia to to Cortex Cortex Basal GangliaBasal Ganglia Damage ( Damage ( injury, tumor , CO poisoninginjury, tumor , CO poisoning , ,

Encephalitis ,…Encephalitis ,… ) ) SerotoninSerotonin Hypothesis : Hypothesis :Serotonin - DopamineSerotonin - Dopamine

DysregulationDysregulation GeneticGenetic (more concordance in (more concordance in MZMZ , ,20 %20 % OCD in first OCD in first

relatives - with different symptoms & no modeling ) relatives - with different symptoms & no modeling ) Abnormal CNS Abnormal CNS OxytocinOxytocin Metabolism Metabolism

EnvironmentalEnvironmental Triggers Triggers

Clinical Presentation Clinical Presentation

Similar to Adults ( no relationship between age & Similar to Adults ( no relationship between age & symptoms )symptoms )

Most endorsed Most endorsed all common symptomsall common symptoms at at some pointsome point Most experience wide variety of OC sympt. over Most experience wide variety of OC sympt. over

timetime Symptoms Symptoms wax & wane over timewax & wane over time Most Obsession + CompulsionMost Obsession + Compulsion ( ( only obsessions oronly obsessions or

only compulsions are rareonly compulsions are rare ) ) Stress exacerbate OC symptomsStress exacerbate OC symptoms Generally Generally reach clinical attention 7 - 8 y after onsetreach clinical attention 7 - 8 y after onset Most not neat , compliant or attentive outside Most not neat , compliant or attentive outside

sympt. ( sympt. ( Disorganization + PerfectionismDisorganization + Perfectionism ) ) Children want parents to collaborateChildren want parents to collaborate ( ( patient &patient &

parent entwined in ritualsparent entwined in rituals ) )

Clinical Presentation Clinical Presentation

Often Often Secretive & EmbarrassedSecretive & Embarrassed about about SymptomsSymptoms

Attempt to Attempt to Deny , Minimize & Disguise RitualsDeny , Minimize & Disguise Rituals

( ( I canI can stop any time I want !stop any time I want ! ) ) Some Some Deny any Anxiety or DistressDeny any Anxiety or Distress Some recognize Compulsions & Rituals but Some recognize Compulsions & Rituals but

can`tcan`t relate them to specific Obsessionsrelate them to specific Obsessions Some Some Anxious & PerfectionistAnxious & Perfectionist May become May become Defiant , Demanding & Assaultive Defiant , Demanding & Assaultive

toto perform Compulsionsperform Compulsions Timing , Severity & Content are important for Timing , Severity & Content are important for

Diagnosis Diagnosis

Clinical Presentation Clinical Presentation

Most Common :Most Common :

Cleaning Cleaning 85 %85 % ( experienced at some point ( experienced at some point ))

Repeating Repeating 51 %51 % Checking Checking 46 %46 %

Counting Counting 18 %18 % Ordering Ordering 17 %17 %

Arranging Arranging 17 %17 % Scrupulosity Scrupulosity 13 %13 %

Hoarding Hoarding 11 %11 % Fear of Harm Fear of Harm 4 %4 %

Just so - Just rightJust so - Just right

Clinical Presentation Clinical Presentation

going in & out doors repeatedly

getting up & down from chairs

decreased school function

unable completing assignments (redoing first

questions many times)

compulsive reassurance

seeking

making sure that doors & windows

are locked

irritability ,impulsivity ,temper

tantrum food restriction

Clinical Presentation Clinical Presentation

fear of harm coming to self or others

focus on germs or contamination

wearing cloths or using towels only once

spending long hours

doing homework

long rigid bedtime rituals

hoarding of useless objects

internal sense that it doesn't

feel right

Clinical Presentation Clinical Presentation

excessive moralization

touching ,counting

erasing papers excessively

rereading paragraphs

ordering ,arranging

symmetry

fear of having an illness

excessive cleaning & washing

dermatitis

ComorbidityComorbidity

Up to Up to 75 %75 % Anxiety Dis.Anxiety Dis. Up to Up to 70 %70 % Mood Dis.Mood Dis. (often follows OCD - (often follows OCD -

commonly commonly DepressionDepression ) ) Up to Up to 50 % ODD or ADHD50 % ODD or ADHD (often precedes OCD ) (often precedes OCD ) Up to Up to 50 % Tic Dis.50 % Tic Dis. (by adulthood OC sympt. (by adulthood OC sympt.

accompany Tic Dis. in 50 % )accompany Tic Dis. in 50 % ) Up to Up to 15 % OCPD15 % OCPD ( some develop OCPD as ( some develop OCPD as

coping )coping ) Some have impairments in visual-motor , visual-Some have impairments in visual-motor , visual-

memory & executive functionsmemory & executive functions Up to Up to 80 % Comorbidity80 % Comorbidity Those psychiatric disorders are high even in their Those psychiatric disorders are high even in their

first relativesfirst relatives !!

Tic -Related Early Onset OCDTic -Related Early Onset OCD

Tic /OCDTic /OCD may be different manifestations of may be different manifestations of samesame gene !gene !

Tic /OCDTic /OCD : high rate of TIC /OCD in first relatives : high rate of TIC /OCD in first relatives Girls < Girls < BoysBoys Earlier OnsetEarlier Onset touching ,rubbing ,blinking ,staring ,symmetry,touching ,rubbing ,blinking ,staring ,symmetry,

exactness ,incompleteness ,intrusive aggressive exactness ,incompleteness ,intrusive aggressive thoughts ,hoarding ,ordering ,repeating ,counting thoughts ,hoarding ,ordering ,repeating ,counting ,,

just so ...just so ... less satisfaction with SSRI alone !less satisfaction with SSRI alone ! Non-Tic Related OCD : Non-Tic Related OCD : cleaning,checking ,...cleaning,checking ,...

PANDASPANDASPediatric Autoimmune Neuropsychiatric Disorder associated Pediatric Autoimmune Neuropsychiatric Disorder associated

with Streptococcal Infectionwith Streptococcal Infection

AutoimmuneAutoimmune Subgroup of OCD Subgroup of OCD AbAb against against GABHSGABHS cross-reacts with cross-reacts with Caudate TissueCaudate Tissue Can causeCan cause OCD OCD , , TicTic , , Sydenham ChoreaSydenham Chorea Abrupt early-onset/exacerbation of OCD/Tic Abrupt early-onset/exacerbation of OCD/Tic

symptoms after symptoms after Respiratory Tract InfectionRespiratory Tract Infection ( (GABHSGABHS)) Acute worsening of symptoms + remission periodsAcute worsening of symptoms + remission periods May cause dramatic deteriorationMay cause dramatic deterioration Often have Often have neurological signsneurological signs Throat Culture , ASOT , Anti DNA GABHS , ANAThroat Culture , ASOT , Anti DNA GABHS , ANA Treatment is still under investigation !Treatment is still under investigation ! Plasmapheresis , IV Immunoglubuline , Penicillin Plasmapheresis , IV Immunoglubuline , Penicillin

ProphylaxisProphylaxis

Differential DiagnosisDifferential Diagnosis

Allergic Reaction to Allergic Reaction to Wasp StingWasp Sting

Post Viral EncephalitisPost Viral Encephalitis Sydenham ChoreaSydenham Chorea Prader-Willi SyndromePrader-Willi Syndrome High dose StimulantsHigh dose Stimulants Dopamine AgonistsDopamine Agonists Benign HabitsBenign Habits Developmentally Normal Developmentally Normal

OC like Symptoms ( 2/3 OC like Symptoms ( 2/3 of 2-4y Preschool of 2-4y Preschool Children )Children )

OC symptoms may be seen OC symptoms may be seen in :in :

..

Mood Dis.(mostlyMood Dis.(mostly

Depression)Depression) Anxiety Dis.Anxiety Dis. Mental RetardationMental Retardation PDDPDD Tic DisorderTic Disorder Brain DamageBrain Damage CNS TumorsCNS Tumors CNS InjuriesCNS Injuries TLETLE CO PoisoningCO Poisoning

PrognosisPrognosis early onset OCD is a early onset OCD is a chronic disorderchronic disorder up to up to 70 %70 % still symptomatic after 15 years still symptomatic after 15 years up to up to 50 %50 % subclinical OC symptoms subclinical OC symptoms 50 %50 % symptomatic as adults symptomatic as adults 10 %10 % true remission true remission small number have debilitating coursesmall number have debilitating course..

Poor Prognosis :Poor Prognosis : parental psychopathologyparental psychopathology history of Tic or ODDhistory of Tic or ODD high EE in familyhigh EE in family poor response to treatmentpoor response to treatment

Treatment Treatment

Choice : SRI + CBTChoice : SRI + CBT

SSRI :SSRI : First Line First Line effectiveness in children = adultseffectiveness in children = adults response rate 50-60 %response rate 50-60 % 20-50 % typical symptom reduction20-50 % typical symptom reduction Fluoxetine ……….Fluoxetine ………. 5-80 mg 5-80 mg Fluvoxamine …...Fluvoxamine …... 25-300 mg (8y<) 25-300 mg (8y<) Sertraline ……....Sertraline …….... 25-300 mg (6y<) 25-300 mg (6y<) Paroxetine ……...Paroxetine ……... 20-80 mg 20-80 mg Citalopram ……..Citalopram …….. 10-40 mg 10-40 mg

Treatment Treatment

headacheheadache agitationagitation tremortremor akathisiaakathisia increased ticincreased tic disinhibitiondisinhibition hypomaniahypomania frontal lobe syndrome frontal lobe syndrome

(apathy &/or disinhibition (apathy &/or disinhibition ))

Most Common Adverse Effects of SSRIs:Most Common Adverse Effects of SSRIs:..

GI complicationsGI complications nauseanausea insomniainsomnia decreased sleepdecreased sleep

efficiencyefficiency drowsinessdrowsiness daytime sedationdaytime sedation decreaseddecreased cognitivecognitive

performanceperformance hyperstimulationhyperstimulation

Treatment Treatment

Clomipramine :Clomipramine : second linesecond line response rate 75 %response rate 75 % up to up to 5 mg/kg5 mg/kg or or 250 mg250 mg (10y<) (10y<) adverse effect in children < adultsadverse effect in children < adults

toxicity,seizure,EKG changes,dry toxicity,seizure,EKG changes,dry mouth,constipation,stomach mouth,constipation,stomach discomfort,somnolence,headache,discomfort,somnolence,headache,

dizziness,tremor,sweating,insomniadizziness,tremor,sweating,insomnia

Treatment Treatment

In Many Cases : No symptom relief until 6-10 weeksIn Many Cases : No symptom relief until 6-10 weeks

( positive response only after 2-3 months)( positive response only after 2-3 months) evaluating treatment response to SRI : Can be doneevaluating treatment response to SRI : Can be done

after 12 weeksafter 12 weeks no increase in dosage,augmentation or drug change is no increase in dosage,augmentation or drug change is

recommended before 12 weeksrecommended before 12 weeks Preferable : starting with low dose & increasingPreferable : starting with low dose & increasing slowlyslowly Duration is as critical as Dosage !Duration is as critical as Dosage ! If no response after 10-12 weeks : Switch to anotherIf no response after 10-12 weeks : Switch to another

SRI !SRI ! Up to Up to 1/31/3 : Don't respond to monotherapy : Don't respond to monotherapy

Treatment Treatment

Augmentation :Augmentation : only after failing of : 2 SSRIs trial + 1 CBT courseonly after failing of : 2 SSRIs trial + 1 CBT course

If If AnxiousAnxious : augment with : augment with

Buspirone 5-30 mg ; Clonazepam 0.25-3 mg ; Buspirone 5-30 mg ; Clonazepam 0.25-3 mg ; Risperidone 1-6 mgRisperidone 1-6 mg

If If Affective SymptomsAffective Symptoms : augment with : augment with

Lithium 0.8-1.2 meq/lit ; Risperidone 1-6 mgLithium 0.8-1.2 meq/lit ; Risperidone 1-6 mg If If Tic , schizo-obsessive symptoms ; SchizotypalTic , schizo-obsessive symptoms ; Schizotypal

Personality Personality : augment with: augment with

Haloperidol 1-15 mg ; Risperidone 1-6 mg ; Haloperidol 1-15 mg ; Risperidone 1-6 mg ; Clonazepam 0.25-3 mgClonazepam 0.25-3 mg

Treatment Treatment

If If 12-1812-18 months symptom-free : months symptom-free :

Decrease Dose Decrease Dose 25 % Q 225 % Q 2 months months Continue Continue CBT booster sessionsCBT booster sessions Many requireMany require long-term maintenance !long-term maintenance !

OCD + Tic or Schizotypal Personality or soft OCD + Tic or Schizotypal Personality or soft neurological signs : No well response to SRIneurological signs : No well response to SRI

Treatment Treatment

CBT :CBT : response rate response rate 75-80 %75-80 % typical symptom reduction typical symptom reduction 45-60 %45-60 % 12-20 sessions12-20 sessions

(booster sessions needed time to time !)(booster sessions needed time to time !)

1) Information gathering1) Information gathering

2) Rank ordered list : Least difficult ones first !2) Rank ordered list : Least difficult ones first !

3) Therapist assisted systematically 3) Therapist assisted systematically

Exposure/Response Prevention Exposure/Response Prevention

4) Homework assignment4) Homework assignment

Treatment Treatment

Factors Increasing the Effect of CBT :Factors Increasing the Effect of CBT : PsychoeducationPsychoeducation Using Anxiety Reducing Strategies (relaxation training ,...)Using Anxiety Reducing Strategies (relaxation training ,...) Overt Behavioral RewardsOvert Behavioral Rewards Graphic Feedback of ProgressGraphic Feedback of Progress Family Involvement & Support (family therapy)Family Involvement & Support (family therapy) Motivated Patient Motivated Patient Cooperation with TreatmentCooperation with Treatment Overt RitualsOvert Rituals Ability to Monitor & Report SymptomsAbility to Monitor & Report Symptoms Low ComorbidityLow Comorbidity Well Trained PsychotherapistWell Trained Psychotherapist

Treatment Treatment

Poor Response to CBT :Poor Response to CBT : Very Young AgeVery Young Age MR,PDD,DBD,MDDMR,PDD,DBD,MDD High ComorbidityHigh Comorbidity Family ConflictFamily Conflict Obsession without Compulsion (Obsession without Compulsion (better response tobetter response to

modeling,shaping,thought stoppingmodeling,shaping,thought stopping)) Obsessional Slowness (Obsessional Slowness (the same as abovethe same as above ) ) Mental Compulsions (Mental Compulsions (the same as abovethe same as above ) ) Just-So Compulsion (Just-So Compulsion (better response to habit reversal &better response to habit reversal &

competing motoric responsecompeting motoric response)) Internalizing Symptoms,Low Social Function,AnhedoniaInternalizing Symptoms,Low Social Function,Anhedonia

Obsessive Compulsive Dis.Obsessive Compulsive Dis.in Children & Adolescentsin Children & Adolescents

Elham Shirazi MDElham Shirazi MD

Child & Adolescents PsychiatristChild & Adolescents Psychiatrist