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Obsessive Compulsive Disorder (OCD) in Children/Youth: Information for Primary Care

Summary: Obsessive compulsive disorder (OCD) is marked by obsessions and compulsions that cause distress. Obsessions are persistent thoughts, images, or impulses that are intrusive and pointless. Compulsions are repetitive behaviors that the patient feels driven to perform in response to the obsessions. Fortunately, various strategies including counseling/therapy (e.g. cognitive behaviour therapy), as well as medications exist to help with OCD.
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Case

  • Teenager who washes his hands numerous times a day, to the point that his hands are raw and sore from all the washing
  • Will get extremely upset if others touch him because he thinks he will be contaminated with disease causing germs
  • Stressors include parental separation and being bullied at school

Epidemiology

  • Point prevalence 0.2% (Waddell et al, 2002),
  • Lifetime prevalence of 1.9% to 3.0% and is significantly associated with both tics and ADHD.

Symptoms

  • Excessive cleaning (eg: handwashing, toothbrushing, showering)
  • Repeating rituals (eg: going in and out of doors, restarting phrases, rereading)
  • Checking rituals (checking the doors are locked, the appliances are tuned off, that the homework is perfect).

Hx/Interviewing Questions

For the patient:

  • Obsessions: “Do you have any disturbing thoughts, images or urges that keep coming back to you, and that are hard to get out of your head? E.g. feeling contaminated or that terrible things are going to happen?”
  • Compulsions: “Do you have any habits or rituals that absolutely have to do, other wise you feel upset? E.g. washing or cleaning over and over again, or counting things over and over again…

For caregivers, parents, family members:

  • Obsessions: “Any thoughts that s/he gets over and over again?”
  • Compulsions: “Any habits or rituals that s/he absolutely has to do, over and over again?”

Screening / Diagnostic Tools

Physical Exam (Px)

  • Behaviour
    • Fear of contamination may lead to avoidance of shaking hands with the health care professional; avoidance of touching things such as doorknobs in the office; keeping on jackets and coats
    • Need for symmetry may manifest in touching or doing things in a symmetrical fashion
  • Appearance
    • Hands may appear red and chapped chapping from repetitive washing

DSM Criteria

DSM-5, compared to DSM-IV

  • Obsessive-compulsive and related disorders include:
    • ​OCD
    • Body dysmorphic disorder
    • Trichotillomania (hair pulling disorder)
    • Hoarding disorder
    • Excoriation (skin-picking)

DSM-IV Diagnosis

A.  Either obsessions or compulsions with obsessions as defined by (1), (2), (3) and (4)

  1. Recurrent and persistent thoughts, impulses or images that are experienced at some time during the disturbance, as intrusive an inappropriate and that cause marked anxiety or distress.
  2. The thoughts, impulses or images are not simply excessive worries about real life problems.
  3. The person attempts to ignore or suppress such thoughts, impulses or images or to neutralize them with some other thought or action.
  4. The person recognizes that the obsessional thoughts, impulses or images are a product of his/her own mind (not imposed from without as in thought insertion).

Compulsions as defined by (1) and (2)

  1. Repetitive behaviors (e.g. hand washing, ordering, checking) or mental acts (e.g. praying, counting, repeating words silently) that the person feels driven to perform in response to an obsession, or according to rules that must be applied rigidity.
  2. The behaviors or mental acts are aimed at preventing or reducing distress or preventing some dreaded event or situation, however, these behaviors or mental acts either are not connected in a realistic way with what they are designed to neutralize or prevent or are clearly excessive.

Differential Diagnosis

  • Medical conditions that can cause or contribute to anxiety symptoms in general include:
    • Gastric ulcer
    • Asthma
    • Thyroid problems
    • Overuse of stimulant medications (e.g. ADHD medications, caffeine, diet pills, decongestants)
  • Medications that can mimic OCD include:
    • Paediatric Autoimmune and Neurologic Diseases Associated with Streptococcal Infection (PANDAS)

Investigations

  • There are no unique laboratory measures for diagnosing OCD
  • However, if the onset of obsessions or compulsions is believed to be associated with a PANDA or a recent infection, it is possible to test for
    • Streptococal infection, e.g. throat swab
    • Antistreptolysin O Titre (ASOT)

Management / Treatment

  • If OCD due to PANDAS is suspected
    • Treat any active streptococcal infection
    • Consider referral to Neurology and Psychiatry
       
  • Psychological Treatment
    • Mild to moderate OCD
      • Cognitive behavioural therapy (CBT) with Cognitive restructuring and Exposure with response prevention (E/RP)

Medication Treatment

  • Medications may be indicated if OCD symptoms have not responded to non-medication treatment (such as CBT), or for moderate to severe OCD, or if CBT not available
     
  • First-line:
    • SSRIs as they are reasonably well tolerated
    • Serotonin medication
      • If using SSRIs, look out for typical side effects which include insomnia, nausea, agitation, tremor and fatigue.
      • Fluvoxamine, fluoxetine, paroxetine, sertraline
         
  • Second-line:
    • Clomipramine is felt to be effective, but is not started first line due to increased side effects compared to SSRI
    • Venlafaxine XR
    • Citalopram
    • Mirtazapine,
    • Adjunctive risperidone
       
  • Third-line:
    • Augmentation strategies with atypical antipsychotics, e.g. adding Risperidone to SRI
    • Adjunctive: mirtazapine, olanzapine, quetiapine, haloperidol, gabapentin, topiramate, tramadol, riluzole, St John’s wort, pindolol
    • IV clomipramine, escitalopram, phenelzine, tranylcypromine

Patient Handout

More...

 

 

Clinical Practice Guidelines

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    Obsessive compulsive disorder (OCD) and body dysmorphic disorder (BDD)
    Published 2005
    Produced By National Institute for Health and Clinical Excellence (NICE)
    Ages Served All ages
    Website guidance.nice.org.uk/cg31
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    Practice Parameter for the Assessment and Treatment of Children and Adolescents With Obsessive-Compulsive Disorder (OCD)
    Published 2012
    Produced By American Academy of Child and Adolescent Psychiatry (AACAP)
    Ages Served Up to 18 years
    Website www.aacap.org/cs/root/member_information...

Self-Help Books

  • Foa EB, Wilson R. Stop obsessing: how to overcome your obsessions and compulsions. Revised. New York (NY): Bantam Books; 2001.
  • Grayson J. Freedom from obsessive-compulsive disorder: a personalized recovery program for living with uncertainty. New York (NY): Berkeley Publishing Group; 2004.
  • Hyman BM, Pedrick C. The OCD workbook: your guide to breaking free from obsessive-compulsive disorder. 2nd ed. Oakland (CA): New Harbinger Publications; 2005.
  • Purdon C, Clark DA. Overcoming obsessive thoughts: how to gain control of your OCD. Oakland (CA): New Harbinger Publications; 2005.

Reference

  • Clinical Practice Guideline, Management of Anxiety Disorders, Chtp 6, Obsessive Compulsive Disorder, Canadian Psychiatric Association
  • Geller et al.: Which SSRI? A Meta-Analysis of Pharmacotherapy Trials in Pediatric Obsessive-Compulsive Disorder, Am J Psychiatry 160:1919-1928, November 2003
  • Alario, A & Birnkrant, J (2008), Practical Guide to the Care of the Pediatric Patient, 2nd edition. Elsevier.
  • Kaplan & Sadock's synopsis of psychiatry : behavioral sciences/clinical psychiatry / Benjamin J. Sadock; 10th ed., Wolter Kluwer/Lippincott Williams & Wilkins, 2007.
  • Waddell, C; Offord, D; Shepherd, C; Hua, J; McEwan, K (2002), Child Psychiatric Epidemiology and Canadian Public Policy-Making: The State of the Science and the Art of the Possible, Can J Psychiatry, 47:825-832.

About this Document

Written by members of the eMentalHealth.ca/PrimaryCare team which includes members of the Department of Psychiatry and Family Medicine at the University of Ottawa. Reviewed by members of the Family Medicine Program at the University of Ottawa, including Dr's Farad Motamedi; Mireille St-Jean; Eric Wooltorton.

Disclaimer

Information in this pamphlet is offered ‘as is' and is meant only to provide general information that supplements, but does not replace the information from a health professional. Always contact a qualified health professional for further information in your specific situation or circumstance.

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Date Posted: Sep 11, 2012
Date of Last Revision: Jul 21, 2017

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