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Obsessive Compulsive Dis. in Children & Adolescents Elham Shirazi MD Child & Adolescents Psychiatrist.

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Presentation on theme: "Obsessive Compulsive Dis. in Children & Adolescents Elham Shirazi MD Child & Adolescents Psychiatrist."— Presentation transcript:


2 Obsessive Compulsive Dis. in Children & Adolescents Elham Shirazi MD Child & Adolescents Psychiatrist

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

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

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

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

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

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

9 Epidemiology  n 1/4 of Subclinical OC / OCPD : full OCD Criteria at follow up n Bimodal Age of Onset : Child mean onset 10 y (40% <15 y) Child mean onset 10 y (40% <15 y) Adult mean onset 21 y Adult mean onset 21 y n Onset : Boys : Prepubertal ( girls< boys ) Boys : Prepubertal ( girls< boys ) Girls : Pubertal ( girls= boys ) Girls : Pubertal ( girls= boys ) n Early Onset OCD more likely : Boy, Genetic, Positive Family History for OCD & Tic Disorder Boy, Genetic, Positive Family History for OCD & Tic Disorder

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

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

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

13 Clinical Presentation  n Most Common : Cleaning 85 % ( experienced at some point ) Cleaning 85 % ( experienced at some point ) Repeating 51 % Checking 46 % Repeating 51 % Checking 46 % Counting 18 % Ordering 17 % Counting 18 % Ordering 17 % Arranging 17 % Scrupulosity 13 % Arranging 17 % Scrupulosity 13 % Hoarding 11 % Fear of Harm 4 % Hoarding 11 % Fear of Harm 4 % Just so - Just right Just so - Just right

14 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

15 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

16 Clinical Presentation  excessive moralizationtouching,counting erasing papers excessively rereading paragraphs ordering,arranging symmetry fear of having an illness excessive cleaning & washing dermatitis

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

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

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

20 Differential Diagnosis n Allergic Reaction to Wasp Sting n Post Viral Encephalitis n Sydenham Chorea n Prader-Willi Syndrome n High dose Stimulants n Dopamine Agonists n Benign Habits n Developmentally Normal OC like Symptoms ( 2/3 of 2-4y Preschool Children ) OC symptoms may be seen in :. n Mood Dis.(mostly Depression) Depression) n Anxiety Dis. n Mental Retardation n PDD n Tic Disorder n Brain Damage n CNS Tumors n CNS Injuries n TLE n CO Poisoning

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

22 Treatment  n Choice : SRI + CBT SSRI : SSRI : n First Line n effectiveness in children = adults n response rate 50-60 % n 20-50 % typical symptom reduction n Fluoxetine ………. 5-80 mg n Fluvoxamine …... 25-300 mg (8y<) n Sertraline …….... 25-300 mg (6y<) n Paroxetine ……... 20-80 mg n Citalopram …….. 10-40 mg

23 Treatment  n headache n agitation n tremor n akathisia n increased tic n disinhibition n hypomania n frontal lobe syndrome (apathy &/or disinhibition ) Most Common Adverse Effects of SSRIs:. n GI complications n nausea n insomnia n decreased sleep efficiency efficiency n drowsiness n daytime sedation n decreased cognitive performance performance n hyperstimulation

24 Treatment  Clomipramine : n second line n response rate 75 % n up to 5 mg/kg or 250 mg (10y<) n adverse effect in children < adults toxicity,seizure,EKG changes,dry mouth,constipation,stomach discomfort,somnolence,headache, toxicity,seizure,EKG changes,dry mouth,constipation,stomach discomfort,somnolence,headache, dizziness,tremor,sweating,insomnia dizziness,tremor,sweating,insomnia

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

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

27 Treatment  n If 12-18 months symptom-free : Decrease Dose 25 % Q 2 months Decrease Dose 25 % Q 2 months n Continue CBT booster sessions n Many require long-term maintenance ! n OCD + Tic or Schizotypal Personality or soft neurological signs : No well response to SRI

28 Treatment  CBT : n response rate 75-80 % n typical symptom reduction 45-60 % n 12-20 sessions (booster sessions needed time to time !) (booster sessions needed time to time !) 1) Information gathering 1) 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 assignment 4) Homework assignment

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

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

31 Obsessive Compulsive Dis. in Children & Adolescents Elham Shirazi MD Child & Adolescents Psychiatrist

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