Transcript Obsessive Compulsive Dis. in Children & Adolescents

Obsessive Compulsive Dis.
in Children & Adolescents
Elham Shirazi MD
Child & Adolescents Psychiatrist
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
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

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
!
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 child`s
rituals
1942 : Berman described the similarities of childhood
OCD & adult OCD
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
Epidemiology g










Difficult to Study Prevalence & Epidemiology
Where should the line demarcating Subclinical OC
Features/Clinical OCD be drawn ?
Parents with Subclinical OC can`t 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 %
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% <15 y)
Adult mean onset 21 y
Onset :
Boys : Prepubertal ( girls< boys )
Girls : Pubertal ( girls= boys )
Early Onset OCD more likely :
Boy , Genetic , Positive Family History for OCD & Tic
Disorder
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







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 )
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 can`t
relate them to specific Obsessions
Some Anxious & Perfectionist
May become Defiant , Demanding & Assaultive to
perform Compulsions
Timing , Severity & Content are important for
Diagnosis
Clinical Presentation g g g

Most Common :
Cleaning
Repeating
Counting
Arranging
Hoarding
85 % ( experienced at some point )
51 %
Checking
46 %
18 %
Ordering
17 %
17 %
Scrupulosity 13 %
11 %
Fear of Harm 4 %
Just so - Just right
Clinical Presentation g g g g
decreased school
function
unable completing
assignments (redoing
first questions many
times)
food restriction
going in & out doors
repeatedly
getting up & down
from chairs
making sure that doors
& windows are locked
compulsive
reassurance seeking
irritability
,impulsivity ,temper
tantrum
Clinical Presentation g g g g g
fear of harm coming to
self or others
hoarding of useless
objects
wearing cloths or using
towels only once
spending long hours
doing homework
long rigid bedtime
rituals
focus on germs or
contamination
internal sense
that it doesn't
feel right
Clinical Presentation g g g g g g
excessive moralization
erasing papers
excessively
rereading paragraphs
fear of having an
illness
touching ,counting
ordering ,arranging
excessive cleaning
& washing
symmetry
dermatitis
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 , visualmemory & executive functions
Up to 80 % Comorbidity
Those psychiatric disorders are high even in their first
relatives !
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 < 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 ,...
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
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 )
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
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 (8y<)
Sertraline …….... 25-300 mg (6y<)
Paroxetine ……... 20-80 mg
Citalopram …….. 10-40 mg
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 )
Treatment
g g g
Clomipramine :




second line
response rate 75 %
up to 5 mg/kg or 250 mg (10y<)
adverse effect in children < adults
toxicity,seizure,EKG changes,dry
mouth,constipation,stomach
discomfort,somnolence,headache,
dizziness,tremor,sweating,insomnia
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
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
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
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
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
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
Obsessive Compulsive Dis.
in Children & Adolescents
Elham Shirazi MD
Child & Adolescents Psychiatrist