Obsessive Compulsive Dis. in Children

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Obsessive Compulsive Dis.in Children
Adolescents

• Elham Shirazi MD
• Child Adolescents Psychiatrist

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Obsessions

• Thoughts , Images , Impulses
• Egodystonic , Intrusive , senseless ,
  Inappropriate
• Anxiety , Dysphoric Affects (fear,disgust,doubt,
  incompleteness)
• Not Worries about Real Life Problems
• Attempts to Ignore , Suppress , Neutralize Them
• Recognized as Products of Own Mind

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Compulsions

• Repetitive Behavior , Mental Acts
• Response to Obsessions , Rigid Rules
• Prevent /Reduce Distress , Dreaded Event ,
  Situation
• No Realistic Connection with what designed to
  Neutralized , Prevented or Excessive

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Criteria

• Recurrent Persistent Obsessions Compulsions
• At Some Point Recognized as Excessive ,
  Unreasonable
• Distress , Time Consuming (1h/d) , Interfere
  Routine Activities
• Not due to Substance / GMC
• With Poor Insight !

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History g

• 16Th century Description of one OCD variant
  (scrupulosity)
• 1903 First description of OCD in childhood (in
  a 5y
• old boy by Pierre Janet )
• 1927 First survey of OCD in childhood (by
  catholic church that found 4 scrupulosity in
  female catholic highschool students)
  
• 1935 Leo Kanner described the social isolation
  of OCD youngsters family overinvolvement in
  childs rituals
• 1942 Berman described the similarities of
  childhood
• OCD adult OCD

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History g g

• 1955 Louise Despert noticed the tendency of
  children to hide OCD symptoms that childhood
  OCD is more prevalent in boys
• 1980s Epidemiology Catchment Area (ECA) study
  finds that most adults with OCD report onset by
  adolescence
• NIMH The first systematic studies of
  epidemiology , phenomenology
  psychopharmacology of OCD in children
  adolescents

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Epidemiology g

• Difficult to Study Prevalence Epidemiology
• Where should the line demarcating Subclinical OC
  Features/Clinical OCD be drawn ?
• Parents with Subclinical OC cant recognize
  Symptoms in their Child !
• Secretiveness No Insight in Patients
• Unfamiliarity with Diagnosis Treatment among
  Physicians
• Underdiagnosed Undertreated
• Hidden Epidemic
• Prevalence 0.8 - 3.6
• Lifetime Prevalence 2.0 - 4.0
• Subclinical OC up to 20.0

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Epidemiology g g

• 1/4 of Subclinical OC / OCPD full OCD Criteria
  at follow up
• Bimodal Age of Onset
• Child mean onset 10 y (40 lt15 y)
• Adult mean onset 21 y
• Onset
• Boys Prepubertal ( girlslt boys )
• Girls Pubertal ( girls boys )
• Early Onset OCD more likely
• Boy , Genetic , Positive Family History for
  OCD Tic Disorder

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Etiology

• Neuropsychiatric Dis., Unknown Heterogeneous
  Et.
• Abnormal Corticostriatal-Thalamocortical Pathway
• Frontal Lobe ,Limbic System ,Basal Ganglia
  Dysfunction
• Abnormal Circuit linking Basal Ganglia to Cortex
• Basal Ganglia Damage ( injury, tumor , CO
  poisoning , Encephalitis , )
• Serotonin Hypothesis Serotonin - Dopamine
  Dysregulation
• Genetic (more concordance in MZ ,20 OCD in
  first relatives - with different symptoms no
  modeling )
• Abnormal CNS Oxytocin Metabolism
• Environmental Triggers

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Clinical Presentation g

• Similar to Adults ( no relationship between age
  symptoms )
• Most endorsed all common symptoms at some point
• Most experience wide variety of OC sympt. over
  time
• Symptoms wax wane over time
• Most Obsession Compulsion ( only obsessions or
  only compulsions are rare )
• Stress exacerbate OC symptoms
• Generally reach clinical attention 7 - 8 y after
  onset
• Most not neat , compliant or attentive outside
  sympt. ( Disorganization Perfectionism )
• Children want parents to collaborate ( patient
  parent entwined in rituals )

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Clinical Presentation g g

• Often Secretive Embarrassed about Symptoms
• Attempt to Deny , Minimize Disguise Rituals
• ( I can stop any time I want ! )
• Some Deny any Anxiety or Distress
• Some recognize Compulsions Rituals but cant
  relate them to specific Obsessions
• Some Anxious Perfectionist
• May become Defiant , Demanding Assaultive to
  perform Compulsions
• Timing , Severity Content are important for
  Diagnosis

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Clinical Presentation g g g

• Most Common
• Cleaning 85 ( experienced at some
  point )
• Repeating 51 Checking 46
  
• Counting 18 Ordering 17
  
• Arranging 17 Scrupulosity 13
  
• Hoarding 11 Fear of Harm 4
• Just so - Just right

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Clinical Presentation g g g g
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
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Clinical Presentation g g g g g
fear of harm coming to self or others
focus on germs or contamination
hoarding of useless objects
wearing cloths or using towels only once
spending long hours doing homework long rigid
bedtime rituals
internal sense that it doesn't feel right
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Clinical Presentation g g g g g g
excessive moralization
touching ,counting
fear of having an illness
erasing papers excessively rereading paragraphs
ordering ,arranging symmetry
excessive cleaning washing dermatitis
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Comorbidity

• Up to 75 Anxiety Dis.
• Up to 70 Mood Dis. (often follows OCD -
  commonly Depression )
• Up to 50 ODD or ADHD (often precedes OCD )
• Up to 50 Tic Dis. (by adulthood OC sympt.
  accompany Tic Dis. in 50 )
• Up to 15 OCPD ( some develop OCPD as coping )
• Some have impairments in visual-motor ,
  visual-memory executive functions
• Up to 80 Comorbidity
• Those psychiatric disorders are high even in
  their first relatives !

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Tic -Related Early Onset OCD

• Tic /OCD may be different manifestations of same
  gene !
• Tic /OCD high rate of TIC /OCD in first
  relatives
• Girls lt Boys
• Earlier Onset
• touching ,rubbing ,blinking ,staring ,symmetry,
• exactness ,incompleteness ,intrusive
  aggressive thoughts ,hoarding ,ordering
  ,repeating ,counting ,
• just so ...
• less satisfaction with SSRI alone !
• Non-Tic Related OCD cleaning,checking ,...

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PANDAS

• Pediatric Autoimmune Neuropsychiatric Disorder
  associated
• with Streptococcal Infection
• Autoimmune Subgroup of OCD
• Ab against GABHS cross-reacts with Caudate Tissue
• Can cause OCD , Tic , Sydenham Chorea
• Abrupt early-onset/exacerbation of OCD/Tic
  symptoms after Respiratory Tract Infection
  (GABHS)
• Acute worsening of symptoms remission periods
• May cause dramatic deterioration
• Often have neurological signs
• Throat Culture , ASOT , Anti DNA GABHS , ANA
• Treatment is still under investigation !
• Plasmapheresis , IV Immunoglubuline , Penicillin
  Prophylaxis

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Differential Diagnosis

• OC symptoms may be seen in
• .
• Mood Dis.(mostly
• Depression)
• Anxiety Dis.
• Mental Retardation
• PDD
• Tic Disorder
• Brain Damage
• CNS Tumors
• CNS Injuries
• TLE
• CO Poisoning

• Allergic Reaction to Wasp Sting
• Post Viral Encephalitis
• Sydenham Chorea
• Prader-Willi Syndrome
• High dose Stimulants
• Dopamine Agonists
• Benign Habits
• Developmentally Normal OC like Symptoms ( 2/3 of
  2-4y Preschool Children )

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Prognosis

• early onset OCD is a chronic disorder
• up to 70 still symptomatic after 15 years
• up to 50 subclinical OC symptoms
• 50 symptomatic as adults
• 10 true remission
• small number have debilitating course
• .
• Poor Prognosis
• parental psychopathology
• history of Tic or ODD
• high EE in family
• poor response to treatment

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Treatment g

• Choice SRI CBT
• SSRI
• First Line
• effectiveness in children adults
• response rate 50-60
• 20-50 typical symptom reduction
• Fluoxetine . 5-80 mg
• Fluvoxamine ... 25-300 mg (8ylt)
• Sertraline .... 25-300 mg (6ylt)
• Paroxetine ... 20-80 mg
• Citalopram .. 10-40 mg

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Treatment g g

• Most Common Adverse Effects of SSRIs
• .
• GI complications
• nausea
• insomnia
• decreased sleep
• efficiency
• drowsiness
• daytime sedation
• decreased cognitive
• performance
• hyperstimulation

• headache
• agitation
• tremor
• akathisia
• increased tic
• disinhibition
• hypomania
• frontal lobe syndrome (apathy /or disinhibition )

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Treatment g g g

• Clomipramine
• second line
• response rate 75
• up to 5 mg/kg or 250 mg (10ylt)
• adverse effect in children lt adults
• toxicity,seizure,EKG changes,dry
  mouth,constipation,stomach discomfort,somnolence,h
  eadache,
• dizziness,tremor,sweating,insomnia

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Treatment g g g g

• In Many Cases No symptom relief until 6-10
  weeks
• ( positive response only after 2-3 months)
• evaluating treatment response to SRI Can be
  done after 12 weeks
• no increase in dosage,augmentation or drug change
  is recommended before 12 weeks
• Preferable starting with low dose increasing
  slowly
• Duration is as critical as Dosage !
• If no response after 10-12 weeks Switch to
  another SRI !
• Up to 1/3 Don't respond to monotherapy

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Treatment g g g g g

• Augmentation
• only after failing of 2 SSRIs trial 1 CBT
  course
• If Anxious augment with
• Buspirone 5-30 mg Clonazepam 0.25-3 mg
  Risperidone 1-6 mg
• If Affective Symptoms augment with
• Lithium 0.8-1.2 meq/lit Risperidone 1-6 mg
• If Tic , schizo-obsessive symptoms Schizotypal
  Personality augment with
• Haloperidol 1-15 mg Risperidone 1-6 mg
  Clonazepam 0.25-3 mg

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Treatment g g g g g g

• If 12-18 months symptom-free
• Decrease Dose 25 Q 2 months
• Continue CBT booster sessions
• Many require long-term maintenance !
• OCD Tic or Schizotypal Personality or soft
  neurological signs No well response to SRI

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Treatment g g g g g g g

• CBT
• response rate 75-80
• typical symptom reduction 45-60
• 12-20 sessions
• (booster sessions needed time to time !)
• 1) Information gathering
• 2) Rank ordered list Least difficult ones
  first !
• 3) Therapist assisted systematically
• Exposure/Response Prevention
• 4) Homework assignment

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Treatment g g g g g g g g

• Factors Increasing the Effect of CBT
• Psychoeducation
• Using Anxiety Reducing Strategies (relaxation
  training ,...)
• Overt Behavioral Rewards
• Graphic Feedback of Progress
• Family Involvement Support (family therapy)
• Motivated Patient
• Cooperation with Treatment
• Overt Rituals
• Ability to Monitor Report Symptoms
• Low Comorbidity
• Well Trained Psychotherapist

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Treatment g g g g g g g g g

• Poor Response to CBT
• Very Young Age
• MR,PDD,DBD,MDD
• High Comorbidity
• Family Conflict
• Obsession without Compulsion (better response to
  modeling,shaping,thought stopping)
• Obsessional Slowness (the same as above )
• Mental Compulsions (the same as above )
• Just-So Compulsion (better response to habit
  reversal competing motoric response)
• Internalizing Symptoms,Low Social
  Function,Anhedonia

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Obsessive Compulsive Dis.in Children
Adolescents

• Elham Shirazi MD
• Child Adolescents Psychiatrist