Obsessive—Compulsive Disorder
Jamie Snyder MD
Introduction and Background
Symptoms of obsessive—compulsive disorder (OCD) were described as far back as 1467, though in the frame of reference of that time, these symptoms were considered evidence of possession by the devil. Religious texts in the 1600s described “scrupulosity,” excessive devotion, and extremes of religious doubting. Pioneers in psychiatry began studying the phenomenon as early as 1838. Sigmund Freud noted obsessions and compulsions early in his professional career, and Anna Freud proposed that ego deficits and conflicting drives led to obsessional neuroses. For many years it was thought that environmental factors, and especially family problems, played a major role in the development of OCD, leading to blaming and guilt during psychoanalytic treatment, which was the predominant treatment for many years. However, the ineffectiveness of psychoanalytic treatment for OCD has led to newer conceptualizations and treatments for this serious and tenacious disorder that frequently has its onset during childhood.
Since the 1980s there has been an explosion of research in OCD related to the discovery that the serotonin-specific reuptake inhibitors (SSRIs) can help many patients with OCD. The development of techniques like the magnetic resonance imaging (MRI) to better examine brain structure, as well as positron emission tomography (PET) and single photon emission computed tomography (SPECT) scanning to study brain metabolism and function, has played important roles as well. Studies regarding the prevalence of OCD have found that it is neither as rare as was once thought nor as prevalent as initially reported. Recent research has found evidence of genetic transmission of OCD, and possibly an infective etiology. Thus, work over the past two decades has increased the understanding and treatment of children and adolescents with OCD.
Clinical Features
Definition
In the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV), OCD is defined as one of the anxiety disorders. Individuals with OCD experience certain states of mind as anxiety provoking and distressing in ways that are similar to the other anxiety disorders, but with obsessions and attempts to alleviate the obsessional anxiety with compulsive behaviors. Obsessions are defined as recurrent and persistent ideas, thoughts, impulses, or images that are experienced as intrusive and inappropriate and cause marked anxiety or distress. They are more than simply excessive worries about real-life problems as the individual recognizes that they are the product of his or her own mind, and tries to ignore or suppress them. Compulsions are defined as repetitive behaviors or mental acts that the individual feels driven to perform and are aimed at preventing distress or some dreaded event. They are not realistically connected with what they are designed to prevent or are clearly excessive. Compulsions differ from stereotypies
often observed in youth with mental retardation or pervasive developmental disorders (PDDs) in that they are complex, are aimed at neutralizing an obsession, and usually serve a clear purpose unlike nonfunctional stereotypic behaviors (e.g., rocking or head-banging).
often observed in youth with mental retardation or pervasive developmental disorders (PDDs) in that they are complex, are aimed at neutralizing an obsession, and usually serve a clear purpose unlike nonfunctional stereotypic behaviors (e.g., rocking or head-banging).
OCD requires either obsessions or compulsions accompanied by marked distress, consuming more than 1 hour per day, or interfering with functioning. At some point the individual recognizes that his or her symptoms are excessive or unreasonable, though DSM-TVnotes that this criterion does not apply to children. Symptoms should not be due to a substance or a general medical condition. If another diagnosis is present, the content of the obsessions should be different from the symptoms typical of the comorbid disorder, for example, more than food and eating obsessions in an eating disorder and more than hair-pulling in trichotillomania.
OCD Symptoms
The presentation of OCD can vary widely. For those children that are secretive about their difficulties, the presenting parental concerns may be temper tantrums, decreased school performance, food restrictions, or dermatitis rather than OCD. Temper tantrums in children with OCD tend to occur when their compulsions are prevented or interrupted. Decreased school performance occurs for a variety of reasons, for example, due to redoing work until some impossible level of perfection is reached, or the child will often refuse to turn in his or her work if it is not perfect, or classes may be missed while performing bathroom rituals at school or other rituals like repeatedly going in- and outdoors or up- and downstairs even to the point of missing classes altogether. Food refusals or restrictions may be based on obsessive fears about contamination, about becoming fat, ordering rituals about food placement on the plate, or intolerance of foods touching one another. Dermatitis can result from washing compulsions. Sometimes cleaning compulsions can present as a toilet stopped up from repeated wiping after defecation, or with high-volume use of soap, water, towels, or excessive clothing changes.
Systematic studies have shown heterogeneity in the onset and course of children’s illness, as well as age at onset, comorbid diagnoses, and accompanying neurologic symptoms, such as tics, or choreiform movements. The typical presentation includes obsessions and compulsions, often multiple; however, having only obsessions may be more common. This presentation can include all the symptoms of obsessions but without the compulsions, so that these children present with the internal distress and anxiety characteristics of obsessions but without the repetitive habits characteristic of compulsions. If children have insight, that is, they have an understanding that their thoughts are unusual or irrational and/or that there is something wrong with them and they can report their distress, this diagnosis is not difficult to make. However, if children lack insight, that is, they do not feel there is anything wrong with them, or perhaps feel that others are unreasonable, or they are unable to describe their inner distress, the diagnosis can be difficult. Over time, the objects and content of obsessions and compulsions may change. Most patients in one long-term study endorsed all of the common symptoms at some point during the course of their illness.
In an adolescent study, the most common categories of obsessions were contamination fears, fears regarding safety of themselves or loved ones, exactness or symmetry, and religious scrupulousness. Less common were concerns regarding bodily functions, lucky numbers, and sexual or aggressive preoccupations. In adults, aggressive and sexual preoccupations are more common. Obsessional slowness is a potentially disabling presentation in which a child moves dramatically slowly. Careful assessment may reveal preoccupation with multiple mental rituals that interfere with normal activities.
The most common compulsions in an adolescent study, in descending order of frequency, were cleaning rituals, repeating actions (doing and undoing), and checking rituals. Less common were rituals to protect themselves/others from illness or injury (e.g., avoiding “contaminated” objects), ordering maneuvers, and counting behaviors. Although some compulsions are tied to a
specific worry/obsession, many consist of repeating an action until it “feels right.” For example, these youth may go in and out through a door, or up- and downstairs, until they “get it right.” The sense of closure or completion that the child seeks may require symmetry, such as repeating an action with both left and right hands or repeating actions an odd or even number of times. Compulsive rereading or rewriting can interfere with school performance. Mental rituals may consist of silent praying, repetition, counting, or having to think about or look at something in a particular way until it feels “right.” Children with OCD are less able than adults to specify what their rituals are intended to avert, beyond a vague idea of something bad happening.
specific worry/obsession, many consist of repeating an action until it “feels right.” For example, these youth may go in and out through a door, or up- and downstairs, until they “get it right.” The sense of closure or completion that the child seeks may require symmetry, such as repeating an action with both left and right hands or repeating actions an odd or even number of times. Compulsive rereading or rewriting can interfere with school performance. Mental rituals may consist of silent praying, repetition, counting, or having to think about or look at something in a particular way until it feels “right.” Children with OCD are less able than adults to specify what their rituals are intended to avert, beyond a vague idea of something bad happening.
Compared to the general clinical population, children with OCD may be more selectively impaired. On the surface, they may appear to function well. School and social performance may be preserved until the symptoms become quite severe. This is partly due to awareness that their thoughts/symptoms are odd or unusual, so they can be quite embarrassed and secretive about the severity of their impairment. They often engage their families in assisting them in their rituals such as cleaning or checking for them, or “covering” for them, such as making excuses if they miss school. Some patients can accept that something is done “right” if the parent does it for them. The child may become angry with the parents for trying to seek assistance for the problems. The parents want to believe that the symptoms are “just a phase.” Often by the time they come to clinical attention, the whole family revolves around the child and his or her symptoms, often not realizing how much time or money they spend supporting the child’s symptoms, for example, by doing many loads of laundry, using numerous bars of soap, and paying increased water bills for a child with contamination fears. Frequently, the initial manifesting symptoms can be perceived as adaptive, such as thinking that cleanliness is good, perfect homework is a good thing, and organizing is a positive behavior. The child does not always share the disturbing thoughts with parents, so well-meaning clinicians sometimes reassure parents that all is well/“normal” without asking all the right questions. Parents often prefer to accept reassurances rather than accept that there is something wrong with their child.
Epidemiology
As with any disorder presenting in childhood, the context of what is “normal for age” must be understood. Mild or transient obsessions and compulsions are common in the general population. A survey mailed to parents of children less than 6 years old found that urges to make things “just right” and preoccupations with symmetry and rules are very common in this group. A recent study of nonclinical samples found that 60% of fourth graders reported preoccupations with guilt about lying, as well as engaging in checking behaviors, while 50% reported contamination and germ fears.
The difficulty in assessing the prevalence of OCD comes in distinguishing the disorder from symptoms that occur as common experiences and as developmental phenomena. Screening tools used in various population studies throughout the years have varying levels of sensitivity and appear to differ greatly from clinical assessment tools, making it difficult to compare prevalence rates across studies.
The first prevalence reports for childhood OCD ranged from 0.2% to 1.2%. A rigorous study of a general adolescent population in 1988 reported a weighted point prevalence of 1% with lifetime prevalence of 1.9%. Many investigators have used the term subclinical OCD to describe subjects reporting substantial symptoms without the severity needed to meet the full OCD criteria. Depending on the definition used, prevalence estimates of subclinical OCD in adolescence range from 4% to 19%.
Males and females appear to be equally affected though male patients may have an earlier age of onset. In a 1991 study, 35% of adult males reported that they had onset of their symptoms between the ages of 5 and 15 years, compared with 20% of females. In another study, boys were more likely to have early onset and a family member with OCD or Tourette syndrome,
while girls were more likely to have adolescent onset. There do not appear to be any differences in prevalence based on race/ethnicity or geography.
while girls were more likely to have adolescent onset. There do not appear to be any differences in prevalence based on race/ethnicity or geography.
Etiology and Pathogenesis
Genetic studies show evidence for a genetic component in OCD. Concordance rates are elevated in monozygotic twins compared to dizygotic ones, and higher rates for OCD are seen among first-degree relatives of clinical patients with OCD. An additional finding was that earlier age of onset was associated with greater “familiality,” that is, a greater likelihood of OCD among relatives.
Elevated rates of OCD among patients with Tourette syndrome, and elevated occurrence of tics and a family history of tics among OCD patients, suggest that the two disorders may have a similar genetic origin.
A number of structural and functional neuroimaging studies have examined patients with OCD compared to never-ill controls, both adults and adolescents. While studies are not conclusive yet, several computerized tomography (CT) studies in the 1980s and structural MRI studies of the 1990s suggested abnormalities in the frontal cortex and the caudate nuclei of patients with OCD. Functional studies using PET reported increased activity in the orbital gyri and the caudate nuclei, which reversed with medication treatment. A functional MRI study in 1996 pointed to elevated activity in the frontal cortex, the caudate and lenticular nuclei, and the amygdala. Finally, functional magnetic resonance spectroscopy studies in 2000 found elevated glutamate levels in the caudate nuclei of 11 treatment-naïve pediatric subjects. After treatment with paroxetine, levels were equivalent to those in normal controls.
Pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections (PANDAS) may be an important mechanism in the development of OCD in 10% to 20% of OCD patients. Typically, symptoms arise, or exacerbate, acutely after a streptococcal infection, often accompanied by the development of tics. This phenomenon may be related to obsessive—compulsive symptoms seen in Sydenham’s chorea. Similar to rheumatic carditis, there is some evidence that antineuronal antibodies formed against group A beta-hemolytic streptococcal cell wall antigens cross-react with caudate neural tissue. Reviewing numerous studies that have been done in the last decade looking at PANDAS, the findings are equivocal. Therefore, it appears that treatment geared toward curbing immunologic responses, such as plasmapheresis or immunoglobulin therapy, is worth considering only for acute infection-related onset or severe exacerbation of symptoms.
Differential Diagnosis and Comorbidity
There are many disorders that either coexist with OCD or have obsessions or compulsions as part of their manifestation. Some authors argue that to organize a whole group of heterogeneous disorders and comorbid features under the term OCD based on the presence of a single symptom seems arbitrary. There is also some evidence for various “types” of OCD, such as tic related versus non—tic related.
Care must be taken not to equate subclinical obsessions and compulsions with OCD, especially in adolescents who may be demonstrating signs and symptoms of obsessive-compulsive personality disorder (OCPD) (Table 9-1).
Obsessive-Compulsive Personality Disorder
OCPD is, as the name suggests, a personality disorder that is coded on Axis II of the DSM-IV nomenclature. Because OCPD is a personality disorder, its symptoms represent a stable characteristic pattern of daily functioning, as opposed to the waxing and waning symptoms of OCD, which appear to represent an illness superimposed on an individual’s personality. These
two disorders do not appear to represent a simple continuum of obsessive—compulsive symptomatology, and some investigators have bemoaned the similar terminology. Patients with OCPD do not usually experience their obsessional and compulsive behaviors as egodystonic; that is, the symptoms do not provoke anxiety in them, and ordinarily the symptoms do not result in significant functional impairment, except perhaps in social or intimate relationships. OCPD does tend to exacerbate with an individual’s level of stress, but persists at some level all the time. Most patients with OCD do not exhibit OCPD, but it does appear to be more common among patients with OCD and their relatives than in the general population, especially among those with hoarding symptoms. This may reflect a spectrum of conditions with vertical transmission.
two disorders do not appear to represent a simple continuum of obsessive—compulsive symptomatology, and some investigators have bemoaned the similar terminology. Patients with OCPD do not usually experience their obsessional and compulsive behaviors as egodystonic; that is, the symptoms do not provoke anxiety in them, and ordinarily the symptoms do not result in significant functional impairment, except perhaps in social or intimate relationships. OCPD does tend to exacerbate with an individual’s level of stress, but persists at some level all the time. Most patients with OCD do not exhibit OCPD, but it does appear to be more common among patients with OCD and their relatives than in the general population, especially among those with hoarding symptoms. This may reflect a spectrum of conditions with vertical transmission.
TABLE 9-1 DSM-IV-TRDiagnostic Criteria, Comparison of OCD with OCPD | ||||||||||||||||||
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Tic Disorders
At least 50% of children and adolescents with Tourette syndrome develop obsessive-compulsive symptoms or disorder by adulthood. Conversely, a personal or family history of tics is found in nearly 60% of children and adolescents seeking treatment for OCD, ranging from simple, mild, and transient tics up through Tourette syndrome. Recent studies suggest a difference in clinical presentation, neurobiology, and responsiveness to pharmacologic interventions between tic-related and non-tic-related OCD. Though there is significant overlap, these two possible subtypes appear to differ in gender ratio, age at onset, and the number and nature, but not severity, of symptoms. Some investigators have described these subtypes as early onset versus pubertal onset. Tic-related OCD appears to have earlier onset and to occur more frequently in boys than in girls, as well as a generally less satisfactory response to treatment with an SSRI. While it is clearly important to assess for tics in a patient with OCD due to a high rate of comorbidity, the importance of such assessment will likely increase even further as more is learned about potential subtypes of OCD and differential treatment protocols.
Anxiety and Mood Disorders
One third to one half of children with OCD have a current or past history of another anxiety disorder, commonly generalized anxiety disorder (GAD) or separation anxiety disorder (SAD). Children with GAD worry about many issues that are generally realistic but excessive. They do not demonstrate odd irrational thoughts, nor do they demonstrate compulsive behaviors intended to manage their intrusive irrational thoughts. GAD may coexist with OCD. Such children show baseline worry and hyperarousal in addition to their specific obsessive—compulsive symptoms. Anxiety associated with SAD is specific to separation from the attachment figure, generally the mother, and is relieved by being in that person’s presence. Such youth may have major tantrums upon separation, and these tantrums may be difficult to differentiate from the tantrums associated with OCD.
Depressive disorders are also commonly comorbid with rates reported from 20% to 73%. Many depressed children demonstrate irritability as their core mood symptom, rather than a depressed mood or anhedonia. As irritability is also a common symptom of OCD, other symptoms of depression should be examined to either confirm or eliminate depressive disorders in the differential.
Pervasive Developmental Disorders
Children with PDDs, like autism or Asperger disorder, often have repetitive behaviors and routines, as well as unusual preoccupations with inanimate items such as fans, maps, or numbers, which caregivers may describe as obsessive—compulsive. Though these characteristics can cause functional impairment or be disturbing to others, the cognitive and language delays typical of these disorders make it difficult to assess whether the child finds these symptoms distressing, that is, whether they are anxiety provoking for the child. Typically, their rigid insistence on routines is part of a larger difficulty making transitions, as well as a need for sameness and structure, or more simply perseveration. While the diagnosis of OCD may not be completely applicable to these children, the obsessive—compulsive symptoms appear to share common features with uncomplicated OCD, such as high rates of OCD in first-degree relatives and potential responsiveness to SSRIs. Finally, PDD and OCD can co-occur. In this case, children must demonstrate the core PDD symptoms of deficits in interpersonal relatedness in addition to criterion symptoms of OCD.
Trichotillomania
This disorder is defined as persistent hair-pulling to the point of alopecia, and is classified in DSM-IV as an impulse-control disorder, not an anxiety disorder. However, many investigators
now think of trichotillomania as part of an “obsessive—compulsive spectrum disorder” as it shares similarities with OCD in being a repetitive behavior associated with specific “urges” or “need” to perform the behavior. Many children and adolescents with trichotillomania do not manifest any other OCD symptoms, but the rate of OCD is elevated in this population and their first-degree relatives.
now think of trichotillomania as part of an “obsessive—compulsive spectrum disorder” as it shares similarities with OCD in being a repetitive behavior associated with specific “urges” or “need” to perform the behavior. Many children and adolescents with trichotillomania do not manifest any other OCD symptoms, but the rate of OCD is elevated in this population and their first-degree relatives.
Disruptive Behavior Disorders
Most children with OCD are neat, overly compliant, or attentive to detail only within the context of their symptoms. For example, children that are perfectionistic about their schoolwork may have an extremely messy bedroom. Indeed, they may be irritable or impulsive, and as many as half of the children with OCD may meet criteria for a disruptive behavior disorder like attention-deficit hyperactivity disorder (ADHD) or oppositional defiant disorder. This particular comorbidity makes it difficult to determine the relative mix of compulsiveness versus being oppositional or inattentive in any particular behavioral incident. Previously well-behaved children may become defiant, demanding, and even assaultive in the desperate drive to perform their compulsion. On the other hand, children with oppositional tendencies frequently learn to claim their OCD as the basis for all their misbehavior.
Other Disorders
Obsessive—compulsive symptoms and disorder are common in patients with anorexia or bulimia nervosa. While obsessions related to food, exercise, or body image would be subsumed within the eating disorder diagnosis, symptoms can extend to the full range of obsessions and compulsions including symmetry, doubting, contamination, checking, counting, and ordering. In the latter case it would then be appropriate to make a separate diagnosis of OCD.
Body dysmorphic disorder is characterized by an obsessional preoccupation with an imagined or slight defect in appearance. This is frequently accompanied by obsessive grooming or mirror-checking rituals. It is not yet clear what relationship this disorder has to OCD.
Because of the bizarre nature of their behavior and their thought processes, childhood OCD can be mistaken for a psychotic disorder. If the child is unable to consider the possibility that his or her symptoms originate in the mind, that is, the child lacks insight, or if there is a dramatic deterioration in functioning, psychosis should be considered. In most cases of OCD, thinking remains reality based except for the area of obsessional concern, and the content of the “bizarre” thoughts is related to the obsessional theme and is not generalized; unless there are hallucinations, psychosis would not be an appropriate diagnosis. However, schizophrenia can also co-occur with OCD or present with OCD symptoms and should be considered in older children and adolescents with psychotic features.
In 2008, a study by Storch and colleagues found that sleep-related problems were quite common in children with OCD and correlate with OCD symptom severity. Since sleep problems may contribute to morbidity of many types, treatment of the sleep problem may be important.
As noted in Table 9-2, several medical conditions or medication side effects can induce OCD symptoms, but this would preclude the diagnosis of OCD.
There are a large number of children with poor social skills, low frustration tolerance, cognitive unevenness, and problems with mood, anxiety, and/or attention that do not fit easily into any single diagnostic category. They are often irritable, perseverative, overfocused on specific topics, unable to shift tasks easily, and insistent that things be done “just right,” with intense outbursts resulting if they are denied. Authors have used various descriptors for this group of children, depending on their theoretical or professional background. More research is needed with this group of children to delineate their relationship to OCD.
TABLE 9-2 Differential Diagnosis for Obsessive-Compulsive Disorder | ||||||||||||||||||||||||||||||||||||
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