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Anxiety Disorder, Obsessive-Compulsive Disorder
Updated: May 15, 2006
Introduction
Obsessive-compulsive disorder (OCD) is a significant neurobiological disorder that severely can disrupt academic, social, and vocational functioning. The major feature of this disorder is recurring obsessions and compulsions that interfere with a person's life. Once believed to be relatively rare in children and adolescents, OCD now is believed to affect as many as 2% of children. Among adolescents with OCD, the literature indicates that very few receive an appropriate and correct diagnosis, and even fewer receive proper treatment. This finding is unfortunate because effective cognitive, behavioral, and pharmacologic treatments are now available.
Pathophysiology
Diagnosis of obsessive-compulsive disorder (OCD) is not exclusionary. Other anxiety disorders, tic disorders, and disruptive behavior disorders, as well as learning disabilities, are common comorbidities with OCD. Other obsessive-compulsive type disorders, such as body dysmorphic disorder, trichotillomania, and habit problems (eg, nail biting) are less common, but certainly not rare.
OCD is considered a neuropsychiatric disorder. In the history of treatment, insight-oriented psychotherapy did not appear to improve OCD, and psychodynamic understanding was not helpful. OCD symptoms do not appear to represent intrapsychic conflicts within individuals. Indeed, relatively few OCD behaviors exist, and they are experienced in much the same manner by patients, regardless of their interpersonal histories.
Frequency
In the United States, obsessive-compulsive disorder (OCD) is substantially more common in children and adolescents than once believed and has a 6-month prevalence of approximately 1 in 200 children and adolescents, while the prevalence of OCD occurring at any time during childhood is assumed to be 2-3 per 100 children. Among adults with OCD, interview data indicate that one third to one half developed the disorder during childhood. Unfortunately, this disorder often goes unrecognized in children and adolescents.
In one epidemiologic survey, 18 children were found to have OCD, and only 4 were receiving any professional mental health care. Not one of these 4 was diagnosed properly. Reasons advanced for the underdiagnosis and lack of treatment include some factors specific to OCD, including the secretiveness of the disorder and lack of insight by the patients. Also, many of the symptoms of OCD are found in other disorders, leading to misdiagnosis.
OCD has been studied most comprehensively at the National Institute of Mental Health with referred patients, who likely represent more severe cases. In those studies, the modal age of onset was 7 years; the mean age was 10.2 years. These figures imply the possible existence of an early-onset group and a second group with onset in adolescence. Boys are more likely to have a prepubertal onset and a family member with OCD or Tourette syndrome. Girls are more likely to have onset of OCD during adolescence. OCD is more common in whites than African American children in clinical samples. However, epidemiologic data suggest no differences in prevalence as a function of ethnic group or geographic region.
Clinical Course
Recurring obsessions and/or compulsions causing distress or interfering with a person's life characterize obsessive-compulsive disorder (OCD). Obsessions are defined as recurrent and persistent thoughts, images, or impulses that are egodystonic, intrusive, and, for the most part, acknowledged as senseless. Obsessions usually are accompanied by dysphoric affect, such as fear, doubts, and disgust. Children and adolescents with OCD typically first try to ignore, suppress, or deny obsessive thoughts and may not report the symptoms as egodystonic or senseless. However, by trying to neutralize excessive thoughts, individuals with OCD very quickly change their behaviors by performing some type of compulsive actions, which are repetitive purposeful behaviors performed in response to the obsession. Usually, these repetitive actions follow certain rules or are quite stereotyped.
Some compulsions observed include behaviors such as washing, counting, or lining up of objects. Other compulsions are covert mental acts such as counting or reading a passage again and again. These compulsions also serve to reduce the anxiety produced by the obsessive thoughts. If something interferes with or blocks the compulsive behavior, the child feels heightened anxiety or fear and can become quite upset and oppositional.
The diagnostic criteria for OCD specify that a child or adolescent may have either obsessions or compulsions, although nearly all children with this disorder have both. The symptoms must cause some distress, consume more than 1 hour per day, or must significantly interfere with school, social activities, or important relationships. The Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) is quite clear that at some point, patients affected with OCD need to recognize that their obsessions come from within their own minds and are not worries about genuine problems. In a similar way, compulsions must be observed as excessive or unreasonable. Thus, the clinician does not include nightly bedtime rituals or other typical normative daily patterns as suggestive of this disorder.
Although most adolescents and some children with OCD recognize the senselessness of the disorder, the requirement of insight into the disorder is not required for the diagnosis of OCD in children. As with many neuropsychiatric disorders, a chronic waxing and waning of symptoms occurs in the chronic disorder of OCD. Thus, many families choose not to seek treatment because the symptoms have decreased independent of treatment in the past.
Another requirement to make the diagnosis is that specific content of obsessions cannot be related to another psychiatric diagnosis (eg, obsessive thoughts about food may be the result of an eating disorder, paranoid thoughts may be related to a psychotic thought disorder). Not confusing OCD with normal ritualistic behavior of childhood is important. Most children exhibit typical, age-dependent, compulsive behaviors. Frequently, young children prefer that events occur in a particular way, they insist on specific bedtime or mealtime rituals, and they become distressed if these rituals are disrupted.
Cross-sectional research of ritualistic behavior in children demonstrates that these behaviors appear when the individual is aged approximately 18 months, peak when the individual is aged approximately 2-3 years, and decline afterward. Presence of these behaviors appears to be related to mental age; thus, children who are mentally retarded and have cognitive levels at a developmental age of 2-3 years may have higher rates of compulsive behaviors, which are appropriate to their cognitive levels of development. These behaviors are best understood by acknowledging that they involve mastery and control of their environment, and, usually, they decrease to low levels by middle childhood. As a child ages, compulsive behaviors are replaced by hobbies or focused interests. Normative compulsive behaviors can be discriminated from OCD on the basis of content, timing, and severity. Normative compulsive behaviors do not interfere with daily functioning.
One of the leading causes of death of patients with OCD is suicide. Estimates reflect as many as 10% of patients with OCD make suicide attempts in adolescent and adult years.
Usual Behavioral Features
Sets of common obsessions and compulsions are observed in pediatric individuals with obsessive-compulsive disorder (OCD). Typically, these sets are described best as "just so" behaviors, in which certain things have to be arranged or performed in a particular way to relieve the anxiety. The most clinically useful and detailed symptoms checklist is included in the Yale-Brown Obsessive-Compulsive Scale. The most common theme of obsessions are contamination themes, and the related compulsive behavior is washing, usually compulsive handwashing. Along with contamination themes, problems with aggressive obsessions, sexual obsessions, the need for symmetry and order, obsessions about harm to oneself or others, and the need to confess exist. These excessive thoughts result in the common compulsive behaviors of washing, repeating, checking, touching, counting, arranging, hoarding, or praying.
When overt, observable compulsive behaviors are relatively easy to observe to make the diagnosis (eg, washing, repeating, checking, touching); covert behaviors (eg, counting, praying, reading something again and again) are harder to assess and evaluate. If OCD is suspected and if a child is taking an extremely long time to complete some tasks, a high likelihood exists that the child may be engaged in one of these covert rituals.
Evaluation
Differentials
Childhood Habits and Stereotypic Movement Disorder
Anxiety Disorder: Trichotillomania
Attention Deficit Hyperactivity Disorder
Pervasive Developmental Disorder: Asperger Syndrome
Child Abuse and Neglect: Posttraumatic Stress Disorder
Other Problems to be Considered
Major depressive disorder
Diagnostic tests
If obsessive-compulsive disorder (OCD) is suspected, referral to a mental health professional is indicated. A complete family history is essential, especially any history of relatives who may have OCD or Tourette syndrome, as is a history of any infection that may have preceded the onset of symptoms. Accurate assessment is essential. Of structured interviews and psychological tests used, the Yale-Brown Obsessive-Compulsive Scale is considered the instrument of choice in making the definitive diagnosis.
Often the nature of the excessive thoughts leads to misdiagnosis. Common misdiagnoses for OCD include posttraumatic stress disorder (PTSD) and attention deficit/hyperactivity disorder (ADHD). For example, if a child has obsessive sexual thoughts, clinicians commonly assume that some type of sexual abuse is underlying these thoughts, leading to a diagnosis of PTSD. Unfortunately, treatment then takes the form of further exploration and discussion of these thoughts, which may make them more frequent and prominent. In general, a psychodynamic approach (ie, discussing these problems at length to get at underlying causes) may reinforce and worsen the symptoms. Thus, for a child presenting with anxiety symptoms and compulsive behaviors that are worsening or not responding to talk therapy, the clinician should consider the possibility of OCD.
OCD also can be confused with ADHD. At first, seeing how these 2 disorders overlap may be difficult; however, in the classroom situation, these disorders may present in a similar fashion. When children with OCD are preoccupied with their obsessive thoughts and covert counting or rereading rituals in school, the teacher perceives the children as being inattentive. Children engaged in the compulsively driven behaviors often have a very high level of energy and activity. According to the DSM-IV criteria for ADHD, most children with OCD are inattentive and often hyperactive and/or impulsive. Also, in an attempt to maintain focus and control, children with ADHD can become compulsively rigid and perseverative.
Because the behaviors observed in persons with OCD often are stereotypical and repetitive, 2 other disorders, both in the developmental disability spectrum, commonly are confused with OCD. First, children with mild autism or Asperger disorder also may have repetitive thoughts and specific stereotypic compulsive behaviors. While disorders in the autistic spectrum are considered to be pervasive developmental disorders (PDD) and quite different than OCD, at times the differential diagnosis between the 2 sets of disorders is somewhat difficult to make.
In individuals with OCD, the behaviors are usually included in those described in Usual Behavioral Features; however, they may change form. Thus, a child with OCD may have a handwashing compulsive behavior, which may change later to a need for order. However, a child with OCD, when not preoccupied with obsessive thoughts, does not have social difficulties of relatedness or communication problems. In persons with autism or Asperger disorder, the compulsive behaviors do not tend to change over time. Often, a child with autism may have the same preoccupation for years. In addition, autistic stereotypic behaviors tend to be unique to the child; in persons with OCD, stereotypic behaviors are almost always those discussed in Usual Behavioral Features. Social difficulties and communication problems are key intrinsic features of Asperger disorder on the PDD spectrum.
Causes
Obsessive-compulsive disorder (OCD) is considered a neuropsychiatric disorder. OCD symptoms do not appear to represent intrapsychic conflicts within individuals. Indeed, relatively few OCD behaviors exist, and they are experienced in much the same manner by patients, regardless of their interpersonal histories.
Initial successes in treatment of OCD with selective serotonin reuptake inhibitors (SSRIs) have led to a neuropsychiatric explanation of a serotonin-mediated "grooming behavior" that has been disrupted. In addition, clear family genetic studies demonstrate that, in some cases, both OCD and Tourette syndrome may represent expressions of the same gene. Tic disorders occur more frequently in individuals who have OCD, and first-degree relatives of patients with OCD have higher rates of tic disorders, a full Tourette syndrome, and OCD.
Neuroimaging studies suggest abnormalities in neurologic circuits that link cortical areas to the basal ganglia. These circuits appear to change in response to successful treatment with either SSRI medication or cognitive behavior therapies (CBTs). Also, neurotransmitter and neuroendocrine abnormalities have been documented in childhood-onset OCD. Thus, as increasing genetic, neural imagery, and neurotransmitter data are accumulating, the data strongly suggest a neuropsychiatric origin for this disorder.
Most recently, investigators have found OCD symptoms that arise from, or are strongly exacerbated in, the context of group A beta hemolytic streptococcal (GABHS) infection, which has been given the eponym pediatric autoimmune neuropsychiatric disorders associated with streptococcal infection (PANDAs). Sudden exacerbation of OCD symptoms in the presence of upper respiratory tract illness marks these cases. The mechanism is believed to be caused by antineuronal antibodies formed against group beta-hemolytic streptococcal cell wall antigens, which cross-react with caudate neural tissue and initiate OCD symptoms. Reactions against other infections, including viral agents, are also being considered. Current research is evaluating this particular factor in the development of OCD. These cases are believed to comprise a fairly small percentage (ie, <5%) of all persons with OCD, but this may be an important mechanism in children who may have had some tendencies or subclinical OCD symptoms prior toinfection.
Treatment
Medical care
Successful treatment of this chronic disorder involves both the judicious use of SSRIs and structured psychotherapy designed to provide the patient with the skills to master the obsessive thoughts and accompanying compulsive behaviors. Management of infectious etiologies remains uncertain and may include strategies similar to those for Sydenham chorea.
SSRIs are greatly preferred over the other classes of antidepressants. Because the adverse effect profile of SSRIs is less prominent, improved compliance is promoted. SSRIs do not have the cardiac arrhythmia risk associated with tricyclic antidepressants. Arrhythmia risk is especially pertinent in overdose, and suicide risk must always be considered when treating a child or adolescent with mood disorder.
Physicians are advised to be aware of the following information and use appropriate caution when considering treatment with SSRIs in the pediatric population.
In December 2003, the UK Medicines and Healthcare Products Regulatory Agency (MHRA) issued an advisory that most SSRIs are not suitable for use by persons younger than 18 years for treatment of "depressive illness." After review, this agency decided that the risks to pediatric patients outweigh the benefits of treatment with SSRIs, except fluoxetine (Prozac), which appears to have a positive risk-benefit ratio in the treatment of depressive illness in patients younger than 18 years.
In October 2003, the US Food and Drug Administration (FDA) issued a public health advisory regarding reports of suicidality in pediatric patients being treated with antidepressant medications for major depressive disorder. This advisory reported suicidality (both ideation and attempts) in clinical trials of various antidepressant drugs in pediatric patients. The FDA has asked that additional studies be performed because suicidality occurred in both treated and untreated patients with major depression and thus could not be definitively linked to drug treatment.
However, a recent study of more than 65,000 children and adults treated for depression between 1992 and 2002 by the Group Health Cooperative in Seattle found that suicide risk declines, not rises, with the use of antidepressants. This is the largest study to date to address this issue.
Currently, evidence does not support an increased risk of suicide in obsessive-compulsive disorder (OCD) or other anxiety disorders treated with SSRIs.
Psychotherapy
CBT routinely is described as the psychotherapeutic treatment of choice for adults, children, and adolescents who have been diagnosed with OCD. Unlike psychodynamic or insight-oriented psychotherapy, CBT helps the child understand the disorder and develop strategies to identify problem situations and resist giving in to the obsessive thoughts and compulsive behaviors. Treatment relies heavily on exposing the individual to the problem situations and then preventing the compulsive response. The resulting anxiety then is managed by training children to use strategies that help them work with their anxiety in a more effective and less disruptive way.
However, exposure to the anxiety-producing object is the key to success in treatment. Thus, for children who compulsively wash their hands because they feel that the hands are dirty or contaminated, the therapist may have them intentionally touch things that are dirty and then have patients wait several hours before washing their hands. This results in very high anxiety after the initial contamination, followed by a gradual reduction in anxiety over time, until hand washing is allowed some hours later. In pediatric patients, this exposure is presented gradually, under the patients' control, after patients have been taught other ways of managing their anxiety and fear.
Anxiety management techniques may include relaxation training, distraction, or imagery. Often, the OCD is personified as something that makes the child perform an action. Thus, children learn to assess situations and ask themselves if they really want to do something, as opposed to the perception that the OCD is making them do something. For school-aged children, the development of mastery and control is a critical issue in their overall psychological growth; therefore, learning to overcome an irrational drive, such as one experienced with OCD, has a certain appeal to their own sense of mastery. With CBT, the initial goals are specific to 1 or 2 behaviors; however, as the patient becomes successful in coping with these situations, generalization usually occurs to other symptoms that have not been targeted. Usually, the patient reports an overall reduction in obsessive thoughts, general anxiety, and the need to perform certain actions.
Pharmacotherapy
Treatment of OCD in adults has demonstrated that medications are effective, and the existing studies of children with OCD using medications also tend to suggest some benefit. At this time, the SSRIs (ie, fluoxetine, fluvoxamine, paroxetine, sertraline) have been demonstrated to be effective treatments of OCD, and they have a lower rate of adverse effects compared to previously used medications. These SSRIs are considered to be the first-line medications for treatment of OCD. Fluoxetine and paroxetine have been demonstrated to be effective in controlled studies, while the others have demonstrated effectiveness in open trials.
A number of controlled studies are being conducted currently. Anecdotal reports suggest that the adverse effect profile for these medicines is similar for children as adults, except that children and adolescents appear to be more prone to agitation if started at usual adult doses. An expert consensus panel recommends trials with 2 or 3 of the SSRI medicines before switching to a different class of medication.
Clomipramine, the second-line medication, is the most extensively studied medication in the pediatric population. The FDA has approved clomipramine for the treatment of OCD in children aged 10 years and older. However, clomipramine results in a higher rate and severity of adverse effects in children. These are the same as those observed in adults (eg, anticholinergic, antihistaminic, alpha blocking). No unexpected long-term adverse reactions have been observed; however, tachycardia and slightly increased PR-, QRS-, and QT-corrected intervals on the ECG were noted. Given the potential for tricyclic antidepressant-related cardiotoxic effects, pretreatment and periodic ECG and therapeutic drug monitoring is warranted.
With all of these medicines, a large number of persons with OCD do not respond until 8-12 weeks of treatment (dissimilar to the shorter time noted in the treatment of depression); thus, waiting at least 8 (preferably 10) weeks before changing medicines or dramatically raising dosages is important. Approximately one third of patients do not respond to a particular SSRI, and the likelihood of responding drops significantly after 3 SSRI trials. Because properly executed CBT can be a very effective treatment on its own, complex medication strategies are not recommended until the patient has a trial of CBT, along with an SSRI.
Combination treatment
CBT and pharmacotherapy work well together clinically. Many clinicians believe that most children with OCD benefit from the combined treatment. Controlled studies are being conducted; at least 1 open trial demonstrated that CBT in combination with SSRI was far superior to either therapy alone. While CBT requires a skilled therapist and 10-20 sessions to complete, its advantage is that once the skills are learned, the patient can use them in the future. No specific predictors of treatment outcome have been identified for pediatric OCD. Children who can identify their obsessions as senseless and their rituals as useless and distressing are more motivated and better candidates for CBT. Comorbidity with other disorders, specifically oppositional disorders and/or ADHD, makes compliance with treatment more difficult. A calm supportive family environment in which parents and/or caregivers actively can support the child's coping strategies also should improve outcome.
Patient education
For excellent patient education resources, visit eMedicine's Anxiety Center. Also, see eMedicine's patient education articles, Anxiety, Panic Attacks, and Hyperventilation.
Keywords
obsessive-compulsive disorder, OCD, compulsive behavior, obsessive thinking, handwashing, repeating, checking, touching, counting, arranging, hoarding, praying, obsessive-compulsive neurosis, compulsive neurosis
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References
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Further Reading
Keywords
obsessive-compulsive disorder, OCD, compulsive behavior, obsessive thinking, handwashing, repeating, checking, touching, counting, arranging, hoarding, praying, obsessive-compulsive neurosis, compulsive neurosis
