See discussions, stats, and author profiles for this publication at: https://www.researchgate.

net/publication/285131639

Obsessive Compulsive Disorder

Chapter · January 2016

CITATIONS READS

0 2,844

2 authors:

Rachana Pole Dr.G.K. Vankar

6 PUBLICATIONS   3 CITATIONS   
Parul Universiy
128 PUBLICATIONS   1,190 CITATIONS   
SEE PROFILE
SEE PROFILE

Some of the authors of this publication are also working on these related projects:

Traditional Healing View project

Attitude View project

All content following this page was uploaded by Dr.G.K. Vankar on 30 November 2015.

The user has requested enhancement of the downloaded file.

 PART
8
Child Psychiatry,
Developmental
and Behavioral
Pediatrics

Ch-17.indd 361 24-04-2015 16:02:42

Ch-17.indd 362 24-04-2015 16:02:42
 Recent Advances in Pediatrics—23: Hot Topics

17 Obsessive Compulsive
Disorder
Rachana Pole, GK Vankar

INTRODUCTION
Obsessions are defined as persistent thoughts, images, or impulses that are
ego-dystonic, intrusive, and, for the most part, senseless. ‘‘Compulsions
are repetitive, purposeful, and intentional behaviors that are performed
in response to an obsession, according to certain rules, or in a stereotyped
fashion.’’
Obsessions generate intense fear whereas compulsions are the mental or
physical acts performed in order to relieve the distress caused by obsessions.
Whilst adolescents and adults often realize irrationality of their thoughts,
children often fail to do that and thus differ from adult obsessive-compulsive
disorder (OCD).

Ch-17.indd 363 24-04-2015 16:02:44

 364 RAP—23: Hot Topics

EPIDEMIOLOGY
Childhood OCD tends to be more common in females than in males.
However by adolescence the ratio equalizes. in adults the disorder is slightly
more common in females than males.1 The Isle of Wight study,2 reported
‘‘mixed obsessional/anxiety disorders’’ in 7 of 2199 (0.3%) in a survey of 10-
and 11-year-old children. In a whole-population adolescent epidemiologic
study of OCD, Flament and colleagues in1988 reported a prevalence rate of
0.8% and a lifetime prevalence of 1.9%.3 These figures suggest that OCD is a
relatively common psychiatric disorder in adolescents.

ETIOLOGY

Biological Factors
Serotonin-dysregulation of serotonin has been hypothesized to have a role
in etiopathogenesis of OCD. The positive therapeutic response to SSRI is a
evidence in favor of this hypothesis. Researchers have measured the levels
of 5HIAA in CSF and have found variable levels of the same in CSF in OCD
patients.
Norepinephrine-dysregulation of norepinephrine has been proposed to
play a role in etiological role.
The response to pharmacotherapeutic agent clonidine is in favor of this
hypothesis.

Neuroimmunological Theory
Poststreptococcal autoimmunity is hypothesized to be an additional etiologic
pathway in a subset of children with OCD and tic disorders.4 This subset of
children experiences a sudden onset of OCD and/or motor tics in association
with group A streptococcal (GAS) infections (e.g. ‘‘strep throat’’), a disorder
classified as pediatric autoimmune neuropsychiatric disorders associated
with streptococcal infections (PANDAS). Box 17.1 presents its characteristic
features.
Positive streptococcal titers and cultures are very frequent in children
during regional streptococcal outbreaks, triggering the requirement for two
infection-associated exacerbations.
The cause of OCD and tics in the PANDAS subgroup is unknown but
is theorized to occur as a result of post-streptococcal autoimmunity in a
manner similar to that of Sydenham’s chorea. The working hypothesis for the

Box 17.1: Characteristics of pediatric autoimmune neuropsychiatric disorders associated

with streptococcal infections (PANDAS)
• Abrupt prepubertal onset of OCD and/or tics
• Significant impairment within 48 hours of symptom onset
• Associated chorea or hyperactivity
• Temporal association of exacerbations with at least two streptococcal infections.

Ch-17.indd 364 24-04-2015 16:02:44

 Obsessive Compulsive Disorder 365
pathophysiology begins with a group A beta-hemolytic streptococcal (GAS)
infection in a susceptible host that results in the production of antibodies (to
GAS), which cross-react with the cellular components of the basal ganglia.
The neuropsychiatric symptoms are hypothesized to arise from an interaction
of these antibodies with neurons of the basal ganglia.

Neuroimaging
Neuroimaging in patients with OCD has indicated altered function in
the neurocircuitry between orbitofrontal cortex, caudate, and thalamus.
Positron emission tomography (PET) studies have shown increased activity
in the frontal lobes, the basal ganglia and the cingulum of patients with
OCD. Pharmacological and behavioral treatments reportedly reverse these
abnormalities. Computed tomographic (CT) and magnetic resonance imaging
(MRI) studies have found bilaterally smaller caudates in patients with OCD.5

Genetics
First-degree relatives of individuals with OCD were approximately four-fold
risk to develop OCD than relatives of unaffected controls. Family studies
suggest that early-onset OCD may be particularly heritable form of the
disorder, with relatives of early-onset OCD cases being ten-fold more likely
than control relatives to develop the disorder. Similarly, within adulthood
OCD cohorts, earlier age of onset has been associated with increased
heritability of symptoms.
First-degree relatives of OCD patients also appear to be at higher risk of
developing tic symptoms.6
Pauls and colleagues7 to hypothesized initially that some forms of OCD
may represent alternative expressions of the genes responsible for TS. Despite
large ongoing genetic studies, the gene for OCD or TS has not been identified.

Other Biological Factors

A higher than usual incidence of nonspecific EEG abnormalities occurs in
patients with OCD. Sleep EEG studies have found abnormalities similar to
those in depressive disorders, such as decreased rapid eye movement latency.
Neuroendocrine studies have shown nonsuppression on the
dexamethasone-suppression test in about one-third of patients and
decreased growth hormone secretion with clonidine infusions.

Behavioral Factors5
According to learning theorists, obsessions are conditioned stimuli. A
relatively neutral stimulus becomes associated with fear or anxiety through
a process of respondent conditioning by being paired with events that are
noxious or anxiety-producing. Thus, previously neutral objects and thoughts
become conditioned stimuli capable of provoking anxiety or discomfort.

Ch-17.indd 365 24-04-2015 16:02:44

 366 RAP—23: Hot Topics

Compulsions are established in a different way. When a person discovers

that a certain action reduces anxiety attached to an obsessional thought, he
or she develops active avoidance strategies in the form of compulsions or
ritualistic behaviors to control the anxiety. Gradually, because of their efficacy
in reducing a painful secondary drive (anxiety), the avoidance strategies
become fixed as learned patterns of compulsive behaviors.

Psychosocial Factors

Personality Disorder
Obsessive-compulsive personality disorder is characterized by an obsessive
concern for details, perfectionism, and other similar personality traits. Only
about 15–35% of patients with OCD have had premorbid obsessional traits
(Box 17.2).

Psychodynamic Factors8
In classic psychoanalytic theory, OCD was termed obsessive-compulsive
neurosis and was considered a regression from the oedipal phase to the anal
psychosexual phase of development. When patients with OCD feel threatened
by anxiety about retaliation for unconscious impulses or by the loss of a
significant object’s love, they retreat from the oedipal position and regress to
an intensely ambivalent emotional stage associated with the anal phase.
Psychodynamic theory also provides explanations about maintenance
of OCD symptoms through secondary gain, family attitudes and avoidance
from personal stressors as well.

Cognitive Factors8
According to cognitive view, OCD results from the interpretation of intrusive
thoughts rather than the frequency or content of these cognitions. Intrusive
thoughts lead to a perception that he or she is responsible for causing or
failing to prevent harm, hence obsessions result. In attempts to neutralize
intrusive thoughts (or obsessions) by motor or cognitive rituals, avoidance,
and reassurance-seeking behavior the patient’s tries to get rid of anxiety. The
most common cognitive error include thought-action fusion or the tendency
to equate thought with action (e.g. ‘I have thought something bad, that
means I have done it’), and exaggerated responsibility for potential untoward
consequences of inaction (e.g. “if I do not wash my hands and my children
will be sick, that would be my fault”).
Cognitive errors maintain and expand OCD symptoms in individuals
with biological vulnerability for OCD development.7 CTP).

Ch-17.indd 366 24-04-2015 16:02:44

 Obsessive Compulsive Disorder 367
Box 17.2:  Diagnostic criteria for obsessive compulsive disorder
•  Presence of obsessions, compulsions, or both:
  Obsessions are defined by 1 and 2:
  1. Recurrent and persistent thoughts, urges, or images that are experienced, at some time
during the disturbance, as intrusive and unwanted, and that in most individuals cause
marked anxiety or distress.
  2. The individual attempts to ignore or suppress such thoughts, urges, or images, or to
neutralize them with some other thought or action (i.e. by performing a compulsion).

  Compulsions are 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 individual feels driven to perform
in response to an obsession or according to rules that must be applied rigidly.
  2. The behaviors or mental acts are aimed at preventing or reducing anxiety or distress,
or preventing some dreaded event or situation; however, these behaviors or mental
acts are not connected in a realistic way with what they are designed to neutralize or
prevent, or are clearly excessive.
Note: Young children may not be able to articulate the aims of these behaviors or mental acts.
• The obsessions or compulsions are time-consuming (e.g. take more than 1 hour per day)
or cause clinically significant distress or impairment in social, occupational, or other
important areas of functioning.
• The obsessive-compulsive symptoms are not attributable to the physiological effects of a
substance (e.g. a drug of abuse, a medication) or another medical condition.
• The disturbance is not better explained by the symptoms of another mental disorder (e.g.
excessive worries, as in generalized anxiety disorder; preoccupation with appearance,
as in body dysmorphic disorder; difficulty discarding or parting with possessions, as in
hoarding disorder; hair pulling, as in trichotillomania hair-pulling disorder; skin picking,
as in excoriation skin-picking disorder; stereotypies, as in stereotypic movement disorder;
ritualized eating behavior, as in eating disorders; preoccupation with substances or
gambling, as in substance-related and addictive disorders; preoccupation with having an
illness, as in illness anxiety disorder; sexual urges or fantasies, as in paraphilic disorders;
impulses, as in disruptive, impulse-control, and conduct disorders; guilty ruminations,
as in major depressive disorder; thought insertion or delusional preoccupations, as in
schizophrenia spectrum and other psychotic disorders; or repetitive patterns of behavior,
as in autism spectrum disorder).
Specify if:
•  With good or fair insight: The individual recognizes that obsessive-compulsive disorder
beliefs are definitely or probably not true or that they may or may not be true. With poor
insight: The individual thinks obsessive-compulsive disorder beliefs are probably true.
•  With absent insight/delusional beliefs: The individual is completely convinced that
obsessive-compulsive disorder beliefs are true.
Specify if:
•  Tic-related: The individual has a current or past history of a tic disorder

Ch-17.indd 367 24-04-2015 16:02:44

 368 RAP—23: Hot Topics

CLINICAL FEATURES

Case Vignette
K is a 7-year-old girl whose mother has brought her to the psychiatrist for
she is concerned that her behavior has for last 3 months has become odd.
She washes her hands often and used soap whole day so much so that her
skin of palm peels off. K vehemently denies that there is anything wrong
with her. She does not touch door knob, handles, for fear of getting dirty. If
someone touches her pen she scrupulously washes the pen with detergent.
She worries that if she does not wash, she may contract some disease or
germs may jeopardize her own as well as her family members’ health. She
also refuses to play with other children. Though she attends school she
takes two hours before she is ready for the school van. She uses so much
water that her sibs have hardly any water to take bath. Recently rather than
entering from classroom door, she sneaked through the window to avoid
touching ‘dirty’ door knob. The teacher punished her for being naughty
and called her parents to school.
Obsessions are repetitive thoughts, images, or impulses that are distressing
to the patient and compulsions are mental or physical acts done in order to
relieve the anxiety.
Most common obsessions in children and adolescents include excessive
concerns about contamination (dirt, germs, and illness), harm coming to
the self or others (e.g. parents might be kidnapped), doing the right thing
(i.e. scrupulosity), reassurance, or intrusive sexual thoughts. Sometimes
the need (urge) for evenness, order, or exactness may be described, with an
accompanying feeling of ‘‘incompleteness.’’ The most common compulsive
rituals are washing, repeating, checking, counting, touching, arranging, and
hoarding 2. Obsessions and compulsions seen in adults are similar to those
seen in children, but the obsessions are more age appropriate (e.g. children
worry that they may be kidnapped or that their parents may be killed). It is
not unusual for the OCD symptoms to change over time, and most children
will have had most of the symptoms at some time in the course of their.8
Although childhood onset OCD is similar to adult OCD in many aspects
childhood-onset OCD is more likely to be associated with tic disorders
and disruptive behavior disorders such as attention-deficit/hyperactivity
disorder. Individuals who have childhood-onset OCD are more likely to
have first-degree relatives who have OCD. Although there is a male:female
predominance in childhood-onset OCD, the opposite is true for adult-onset
OCD. Finally, patients who have childhood-onset OCD appear to have a more
favorable outcome.9
Table 17.1 gives the incidence of obsessions and compulsions in child-
adolescent OCVD.
The phenomenology of OCD in these studies is similar to that reported in
a group of 70 young patients in USA.11,12
Common symptoms of pediatric OCD obsession are listed in Table 17.2.

Ch-17.indd 368 24-04-2015 16:02:44

 Obsessive Compulsive Disorder 369
Table 17.1:  Obsessions and compulsions in child-adolescent OCD in India10 (n = 58)
Obsessions Compulsions
Contamination 62% Cleaning and washing 69%
Aggression 57% Repeating 52%
Sex 22% Checking 47%
Religion 22% Ordering 29%
Symmetry 34% Counting 15%
Somatic 12% Hoarding 7%
Hoarding 7%
Miscellaneous obsessions 65% Miscellaneous compulsions 47%

Table 17.2:  Common symptoms of pediatric obsessive compulsive disorder obsessions

Obsessions Compulsions
Concerns with dirt, germ exposure, fears of illness Cleaning rituals
Fears of harm befalling self or others Checking
Need for symmetry, order, exactness Repeating behaviors
Need to save or hoard Ordering or arranging
Excessive moral, religious, or sexual concerns Confessing, reassurance seeking

Screening for OCD

The short OCD screener (SOCS)13 is given in Table 17.3 each question is
answered by ticking the box that most applies.

DIFFERENTIAL DIAGNOSIS OF OCD IN CHILDREN

Possible differential diagnoses of obsessive-compulsive disorder in children
and adolescents is given in Box 17.3.
• Subclinical compulsive behaviors: These are defined as behaviors lying
within the normal range that do not impair the child’s development.
• Rituals that help the child to process experiences and obtain security: These
are calming rather than stress-inducing behaviors.
• Compulsive behavior in the setting of medical illness: This does not have
the same functional significance as compulsive behavior in OCD.
• Obsessive thoughts arising in the setting of another axis I disorder, such
as a phobia, eating disorder, or depression: The content of such thoughts
is related exclusively to central aspects of the axis I disorder. Depressive
brooding, for example, is ego syntonic.
• Obsessive-compulsive personality disorder: This is experienced as ego
syntonic, and the typical obsessions and compulsions of OCD are absent.
• Schizophrenia and delusional disorders: The distinguishing features of
OCD are ego-dystonia and preserved reality testing.

Ch-17.indd 369 24-04-2015 16:02:44

 370 RAP—23: Hot Topics

Table 17.3:  Short OCD screener

No A bit A lot
1 Does your mind often make you do things, such as checking or
touching things or counting things, even though you know you do
not really have to
2 Are you particularly fussy about keeping your hands clean?
3 Do you ever have to do things over and over a certain number of
times before they seem quite right?
4 Do you ever have trouble finishing your school work or chores
because you have to do something over and over again?
5 Do you worry a lot if you've done something not exactly the way
you like?
When answering the next two questions, please think of what was
Mentioned in the first five questions, especially those that you have
answered ‘A Lot’ Or ‘A Bit’:
6 Do these things interfere with your life?
7 Do you try to stop them?

A SOCS score of 6 or more differentiated OCD cases with a sensitivity of 0.97 AND The specificity
was 0.88. Thus the screener identifies almost all true cases of OCD.

Box 17.3:  Differential diagnosis

• Developmentally normative rituals and superstitions
• Other anxiety disorders
• Tic disorders and Tourette's syndrome
• Pervasive developmental disorders (PDD)
• Psychotic disorders
• Hypochondriasis

• Autistic disorders: Obsessive-compulsive manifestations in autistic

persons are generally experienced as ego-syntonic and do not cause
distress.
• Obsessive-compulsive spectrum disorders: Obsessions and compulsions
can be difficult to distinguish from hypochondriasis, dysmorphophobia,
and impulse-control disorders.
• Apparently compulsive tics (e.g. in complex motor tic disorders): Tics and
compulsions are sometimes very hard to tell apart. Tics are characterized
by bodily tension; the behaviors are not goal-directed, nor are they
connected with fears or anxieties, and it is difficult or impossible to
suppress them voluntarily.
• Stereotypic behaviors, e.g. in autistic or mentally retarded persons: These
are experienced as pleasurable by the affected persons, as they offer a
means of self-stimulation during sensory deprivation, or, alternatively, a
means of distraction during sensory overload.
• Rigidity in ADHD: This can be regarded as an attempt to regain control
over the inner chaos of one’s own mental world.

Ch-17.indd 370 24-04-2015 16:02:44

 Obsessive Compulsive Disorder 371
COMORBID CONDITIONS
The incidence of Toilette’s disorder in patients with OCD is 5–7 %. Some
20–30% of patients with OCD have a history of tics.6
In children, attention-deficit/hyperactivity disorder (ADHD) is often
associated with OCD. Children with early onset OCD have been found to
have higher incidence of tic disorder amongst first degree relatives.
Other anxiety disorders—personality disorders are also commonly
associated with OCD.
Frequency of comorbidities encountered in pediatric OCD is given in
Table 17.4.
Three Indian studies have systematically examined the comorbidity in
juveniles with OCD.14-16 Rates of comorbid major depression, dysthymia, and
bipolar disorder have ranged from 14–23%, 0–2 and 0–2% respectively.

TREATMENT
Treatment of OCD can be broadly divided into psychotherapeutic
interventions and pharmacotherapy (Tables 17.5 and 17.6).
Although cognitive behavioral therapy (CBT) alone, combined CBT plus
SSRI medication, and SSRI medication alone all are considered acceptable
initial treatments for children who have OCD,17 CBT alone is an appropriate
initial treatment for children who have conditions of mild-to-moderate
severity.18 In comparison with medication, CBT is notable for having a
more robust and longer-lasting symptom reduction effect. For children who
have more severe symptoms, less insight, and resistance to psychotherapy,
combined treatment with medication and CBT may be most effective.

Table 17.4:  Comorbid diagnoses in pediatric obsessive-compulsive disorder7

Disorder Frequency
Anxiety disorders (generalized anxiety disorder, separation anxiety, social phobia) 26–42
Mood disorders 11–62
Tic disorders 11–26
Attention-deficit/hyperactivity disorder 16–20
Disruptive behavior disorders (oppositional defiant disorder, conduct disorder) 9–19

Table 17.5:  Treatment approach in OCD

Characteristic Treatment approach
Mild to moderate OCD CBT alone or medication alone
Moderate to severe OCD CBT + Medication
No insight
No engagement in CBT
Comorbid depression or anxiety

Ch-17.indd 371 24-04-2015 16:02:44

 372 RAP—23: Hot Topics

Table 17.6:  Medications and dose ranges for pediatric obsessive compulsive disorder
Medication Dosage (mg/day)
Fluoxetine 20–60
Sertraline 50–200
Fluvoxamine 50–200
Paroxetine 20–60
Escitalopram 5–20
Citalopram 20–60
Clomipramine 50–200

Similarly, for patients who have comorbid depression or other anxiety

disorders, it is appropriate to provide combined treatment if possible.
Among patients aged 7–17 years with OCD and partial response to SRI use,
the addition of CBT to medication management compared with medication
management alone resulted in a significantly greater response rate, whereas
augmentation of medication management with the addition of instructions
in CBT did not.19

PHARMACOTHERAPY

Fluoxetine
Fluoxetine showed superiority over placebo for treatment of childhood
OCD.20 A crossover study21 used fixed doses of 20 mg, but proposed that
clinical treatment be started at a lower dose because behavioral activation
occurred as an adverse effect in a few children, prompting one to leave the
study early because of suicidal ideation. The maximum dose was extended
to 80 mg with no withdrawals because of adverse effects, suggesting that
fluoxetine is effective across the full dose range in children with OCD.

Fluvoxamine
A placebo-controlled multicenter study reported fluvoxamine’s efficacy in
children aged 8–17 years, as measured by the CY-BOCS.22 It noted significant
improvement as early as week 1, which continued to the trial end-point at
week 10 the trial suggested that fluvoxamine has satisfactory efficacy and
tolerability in childhood OCD.

Sertraline
A large RCT has examined sertraline alone, CBT alone, sertraline combined
with CBT, or pill placebo in children and adolescents.23 The active treatments
were well tolerated but the lack of a matched control treatment for CBT limited
conclusions about relative efficacy. Sertraline alone and in combination with
CBT was efficacious compared with pill placebo. An analysis of the pooled
data from the childhood OCD studies compared ‘numbers needed to treat’

Ch-17.indd 372 24-04-2015 16:02:44

 Obsessive Compulsive Disorder 373
with ‘numbers needed to harm’ and revealed a positive risk ratio and no
suicidal acts for sertraline in children and adolescents.24

Paroxetine
Paroxetine was well tolerated in a multicenter RCT by Geller et al (2004),25
who reported efficacy for the drug (10–50 mg) in children and adolescents
7 years of age and older. However, response rates decreased with increasing
psychiatric comorbidity.
A comparison of SRI treatment trials in child and adult OCD found it
impossible to discriminate between the efficacy and tolerability of SRIs in the
two groups, implying a similar treatment response in both.26

Clomipramine
In a multicenter study involving children and adolescents with OCD, a
37% improvement in Children’s Yale–Brown Obsessive–Compulsive Scale
(CY-BOCS) score was recorded with clomipramine, compared with an 8%
improvement with placebo.27
A 10-week double-blind crossover trial showed clomipramine to be
superior to desipramine at reducing OCD symptoms.28 Response to treatment
with clomipramine was not predicted by age at onset, duration and severity
of illness, type of symptom, or plasma drug concentrations. In this study, 64%
of the participants who received clomipramine as the first active treatment
showed signs of relapse during desipramine treatment.

Psychotherapy
The most studied and effective treatment for Child and adolescent OCD is
cognitive behavior therapy. CBT uses the principle of exposure and response
prevention (ERP).29
Figure 17.1 shows how ERP works in OCD. Obsessive thoughts generate
anxiety and distress which in turn causes compulsions. The compulsive
symptoms, supported by irrational beliefs, are intended to neutralize this
anxiety and distress. The compulsions provide immediate relief and thereby

Fig. 17.1:  Exposure with response prevention mechanism

Ch-17.indd 373 24-04-2015 16:02:44

 374 RAP—23: Hot Topics

become strongly reinforced, ultimately becoming repetitive and habitual.

When the individual tries to resist performing the compulsive act, the anxiety
and distress return, along with associated obsessive thoughts, thus a cycle of
obsessive and compulsive symptoms gets established.
The ERP for children teaches them to identify triggers of obsessive
thoughts, to voluntarily practice exposing themselves to these triggers, and
subsequently to refrain from performing the compulsive behaviors. The
treatment relies upon the principle of desensitization, in which the anxiety
and distress associated with the obsessive thoughts is diminished gradually
through repetitive exposure. For the exposure and desensitization to occur,
patients must resist performing their compulsive rituals and tolerate the
resulting distress. The most challenging and important aspect of this therapy
with children involves helping the child to develop insight and to come to see
the obsessive-compulsive symptoms as oppressive and separate from their
own motives and interests. Otherwise, the child may be extremely resistant
and view the therapist as an adversary. The therapist also works with the
child to reduce irrational beliefs and cognitive distortions associated with
the obsessive and compulsive symptoms. Children also learn how to manage
anxiety without avoidance through cognitive and behavioral relaxation
techniques.23
So far, there have been two major randomized controlled trials of CBT
for childhood OCD. Barrett and colleagues studied a sample of 77 patients
aged 7–17 years assigned randomly to individual CBT, group CBT, or a wait
list control.30 Both active treatments included a protocol to involve parents
and siblings in the treatment. Patients in active treatment arms of the study
showed very high rates of remission (88% for individual CBT and 76% for
group CBT), whereas none of the patients in the wait list control achieved
remission. These effects were quite durable at 12- and 18-month follow-up.30
The multicenter Pediatric OCD Treatment Study23 investigated 112
patients assigned randomly to one of four treatment conditions, two of
which included a standardized CBT protocol. Both CBT alone and CBT in
combination with sertraline therapy resulted in a significantly higher rate of
remission (39% and 53.6%, respectively) than either sertraline therapy alone
or placebo. In both studies, higher symptom severity and family dysfunction
predicted a less favorable response to treatment. In the Pediatric OCD
Treatment Study, a family history of OCD was associated with a six-fold
decrease in the effectiveness of the psychotherapy. These results suggest the
need for the development of effective therapeutic approaches to support
families and to help parents become effective allies in the treatment.

D-cycloserine to Enhance Exposure and Response Prevention

Recent investigations have explored augmenting exposure-based cognitive-
behavioral therapy with the NMDA partial agonist D-cycloserine. However,
a recent study found no significant advantage of D-cycloserine over placebo.

Ch-17.indd 374 24-04-2015 16:02:44

 Obsessive Compulsive Disorder 375
The effects of CBT may not be augmented or accelerated when D-cycloserine
is administered after sessions.31

Behavioral Family Intervention

Cognitive, developmental, and symptom differences, and most specifically
the ‘‘embeddedness’’ in the family context play an important role in
assessing and treating early onset OCD. Freeman and colleagues32 have
proposed that the family context is an important vehicle for treatment
delivery, and behavioral family intervention (BFI) is an important paradigm
in the treatment of childhood disorders. Behavioral family intervention
involves parents, teachers, significant others as “behavior change agents’’
or ‘‘mediators.’’ By dealing with the affective and cognitive aspects of the
parent-child relationship as well as the targets of intervention, BFI is likened
to a ‘‘cognitive-behavioral family intervention.” This suggests that a different
conceptual approach is needed for younger children and that treatment
designed for older children cannot be just extrapolated downward.

Family Therapy
An assessment of the family usually is a necessary component of an
evaluation of an adolescent with OCD. By dealing with the specific family
dynamic issues and their resulting obstacles to engage in treatment, the
family can participate in the OCD treatment plan of the identified patient in
constructive and positive ways.33 Although there are no systematic studies of
family therapy, it may be useful to address issues of family discord, marital
difficulties, and inappropriate roles or boundaries, which interfere with the
adolescent’s ability to participate in treatment for his or her OCD.

OUTCOME
The OCD can be a chronic condition that persists into adulthood. Early
recognition and treatment might prevent chronicity. Pediatric OCD may
follow a waxing and waning course, a chronic stable course, or may be
characterized by dramatic exacerbations and remissions. Follow-up studies
of OCD in children and adolescents have reported low rates of remission.34-36
Similarly, studies of adult OCD have reported worse course in those with early
onset of illness.37-38 Reddy et al. in their Indian follow-up study of 58 children
and adolescents with DSM-III-R OCD for two to nine year.39 The subjects were
largely ‘self-referred’ and ‘drug-naïve’ at the time of consultation. 48% were
in true remission (full remission and not on any treatment) and were not
receiving treatment for a mean period of 58 months. Duration of follow-up
and age-at-onset emerged as significant predictors of full remission. The
high rate of ‘true remitters’ is in sharp contrast to the 6% rate in the study by
Leonard and others.40 Better prognosis in this study could be due to moderate
severity, relatively low rate of comorbidity.

Ch-17.indd 375 24-04-2015 16:02:44

 376 RAP—23: Hot Topics

SUMMARY AND CONCLUSION

The OCD, having its onset in childhood and adolescence in one-third to half
of the adult cases, is characterized by obsessions and compulsions, leading
to significant distress and affecting family relations and school performance.
Repetitive intrusive ideas, images and impulses are perceived as one’s own,
leading to distress. To reduce this, the subject performs compulsions, the
stereotyped acts (which are observable) or mental acts. In the etiology,
biological, psychological and social factors are important. Serotoninergic
mechanisms are of special importance. Depression, other anxiety disorders
and tic disorders are comorbidities. Cognitive behavior therapy as well as
SSPIs and other medications, alone or in combination, are effective. Complete
recovery may occur. Others may suffer from fluctuating course characterized
by remissions and exacerbations.

KEY LEARNING POINTS

ƒƒ Obsessive compulsive disorder is a disorder characterized various
obsessions and compulsions resulting in subjective distress as well
as socio-occupational impairment.
ƒƒ Various biological, psychological and social factors play a role in
development of this disorder.
ƒƒ Diagnosis is based on presence of obsessions and compulsions
which are time consuming, distressing and disabling.
ƒƒ In most cases the diagnosis is delayed, patient tends to secretive,
only when behavior becomes observable or comorbid condition like
depression sets in, patients come to professional attention.
ƒƒ Treatment involves cognitive behavior psychotherapy alone or
combination of psychotherapy and pharmacotherapy especially
specific serotonin reuptake inhibitors.
ƒƒ Outcome is variable with complete recovery or fluctuating course
with exacerbations and remissions.

REFERENCES
1. American Psychiatric Association. Diagnostic and Statistical Manual of Mental
Disorders, 5th edn. Arlington VA: APA 2013.
2. Rutter M. Isle of Wight studies, 1964–1974. Psychol Med 1976;6:313-332.
3. Flament MF, Whitaker A, Rapoport JL, et al. Obsessive compulsive disorder in
adolescence: An epidemiological study. J Am Acad Child Adolesc Psychiatry
1988;27:764-771.
4. Swedo SE, Leonard HL, Garvey M, et al. Pediatric autoimmune neuropsychiatric
disorders associated with streptococcal infections: clinical description of the first 50
cases. Am J Psychiatry 1998;155:264-271.
5. Lewin Adam B, John P. Obsessive-compulsive disorder of infancy, childhood,
and adolescence. In: Sadock BJ, Sadock VA, Ruiz P (Eds): Kaplan and Sadock’s
Comprehensive Textbook of Psychiatry, 9th edn. Philadelphia: Lippincott Williams &
Wilkins 2009:3671-3678.

Ch-17.indd 376 24-04-2015 16:02:44

 Obsessive Compulsive Disorder 377
6. John AP, Obsessive-compulsive disorder: A-Z including genetics. In: Gupte S (Ed):
Recent Advances in Pediatrics-16. New Delhi: Jaypee 2016:232-240.
7. Pauls DL. The genetics of obsessive compulsive disorder: A review of the evidence.
Am J Med Genet C Semin Med Genet 2008;148C:133-139.
8. Kaplan BJ, Sadock VA. Obsessive-compulsive disorder of infancy, childhood, and
adolescence In: Sadock BJ, Sadock VA (Eds): Kaplan and Sadock’s Synopsis of
Psychiatry,10th edn. Philadelphia: Lippincott William and Wilkins 2007:1271-1273.
9. Hanna GL. Demographic and clinical features of obsessive-compulsive disorder in
children and adolescents. J Am Acad Child Adolesc Psychiatry 1995;34:19-27.
10. Reddy YC, Srinath S, Prakash HM, et al. A follow-up study of juvenile obsessive-
compulsive disorder from India. Acta Psychiatr Scand. 2003;107:457-464. 
11. Geller DA, Biederman J, Faraone S, et al. Developmental aspects of obsessive
compulsive disorder: findings in children, adolescents, and adults. J Nerv Ment Dis
2001;189:471-477.
12. Swedo S, Rapoport J, Leonard H, Lenane M, Cheslow D. Obsessive-compulsive
disorder in children and adolescents: Clinical phenomenology of 70 consecutive
cases. Arch Gen Psychiatry 1989;46:335-341.
13. Uher R, Heyman I, Mortimore C, Frampton I, Goodman R. Screening young people
for obsessive compulsive disorder. Br J Psychiatry 2007;191:353-354.
14. Reddy YC, Srinath S, Prakash HM, Girimaji SC, Sheshadri SP, Khanna S, et al.
Comorbidity in juvenile obsessive-compulsive disorder: a report from India. Can J
Psychiatry 2000;45:274-278. 
15. Reddy YC, Srinath S, Prakash HM, et al. A follow-up study of juvenile obsessive-
compulsive disorder from India. Acta Psychiatr Scand 2003;107:457-464. 
16. Jaisoorya TS, Janardhan Reddy YC, Srinath S. Is juvenile obsessive-compulsive
disorder a developmental subtype of the disorder. Findings from an Indian study? Eur
Child Adolesc Psychiatry 2003;12:290-297. 
17. American Academy of Child and Adolescent Psychiatry. Practice parameters for the
assessment and treatment of children and adolescents with obsessive-compulsive
disorder. J Am Acad Child Adolesc Psychiatry 1998;37(Suppl 10):27S-45S.
18. Barrett PM, Farrell L, Pina AA, Peris TS, Piacentini J. Evidence-based psychosocial
treatments for child and adolescent obsessive-compulsive disorder. J Clin Child
Adolesc Psychol 2008;37:131-155.
19. Franklin ME, Sapyta J, Freeman JB, et al. Cognitive behavior therapy augmentation
of pharmacotherapy in pediatric obsessive-compulsive disorder: The Pediatric
OCD Treatment Study II (POTS II) randomized controlled trial. JAMA  2011
21;306:1224-1232.
20. Liebowitz MR, Turner SM, Piacentini J, et al. Fluoxetine in children and adolescents
with OCD: a placebo-controlled trial. J Am Acad Child Adolesc Psychiatry 2002;41:
1431-1438.
21. Riddle MA, Scahill L, King RA, et al. Double-blind, crossover trial of fluoxetine and
placebo in children and adolescents with obsessive-compulsive disorder. J Am Acad
Child Adolesc Psychiatry 1992;31:1062-1069.
22. Riddle MA, Reeve EA, Yaryura-Tobias JA, et al. Fluvoxamine for children and
adolescents with obsessive-compulsive disorder: a randomized, controlled,
multicenter trial. J Am Acad Child Adolesc Psychiatry 2001;40:222-229.
23. Pediatric OCD Treatment Study. Cognitive-behavior therapy, sertraline, and their
combination for children and adolescents with obsessive-compulsive disorder:
The Pediatric OCD treatment study (POTS) randomized controlled trial. JAMA
2004;292:1969-1976.

Ch-17.indd 377 24-04-2015 16:02:45

 378 RAP—23: Hot Topics

24. March JS, Biederman J, Wolkow R, Safferman A, Mardekian J. Sertraline in children

and adolescents with obsessive-compulsive disorder: A multicenter randomized
controlled trial. JAMA 1998;280:1752-1756.
25. Geller DA, Wagner KD, Emslie G, et al. Paroxetine treatment in children and
adolescents with obsessive-compulsive disorder: A randomized, multicenter,
double-blind, placebo-controlled trial. J Am Acad Child Adolesc Psychiatry
2004;43:1387-1396.
26. Fineberg N, Brown A. Pharmacotherapy for obsessive compulsive disorder. Adv
Psychiatr Treat 2011;17:419-434.
27. DeVeaugh-Geiss J, Moroz G, Biederman J, et al. Clomipramine hydrochloride in
childhood and adolescent obsessive-compulsive disorder: a multicenter trial. J Am
Acad Child Adolesc Psychiatry 1992;31:45-49.
28. Leonard HL, Swedo SE, Rapoport JL, et al. Treatment of obsessive compulsive
disorder with clomipramine and desipramine in children and adolescents: A double-
blind crossover comparison. Arch Gen Psychiatry 46:1088-1092.
29. Barrett PM, Farrell L, Pina AA, Peris TS, Piacentini J. Evidence-based psychosocial
treatments for child and adolescent obsessive-compulsive disorder. J Clin Child
Adolesc Psychol 2008;37:131-155.
30. Barrett PM, Farrell LJ, Dadds M, Boulter N. Cognitive-behavioral family treatment
of childhood obsessive-compulsive disorder: long-term follow-up and predictors of
outcome. J Am Acad Child Adolesc Psychiatry. 2005;44:1005-1014.
31. David MC, Cynthia T, Benedetta M, et al. Cognitive-behavioral therapy with post-
session d-cycloserine pilot augmentation for paediatric obsessive-compulsive
disorder: randomised controlled trial. Br J Psychiatry 2014;204:77-778.
32. Freeman J, Garcia A, Fucci C, et al. Family-based treatment of early-onset obsessive-
compulsive disorder. J Child Adolesc Psychopharmacol 2003;13:S71-80.
33. Piacentini J, Bergman RL, Chang S, et al. Controlled comparison of family cognitive
behavioral therapy and psycho-education/relaxation training for child obsessive-
compulsive disorder. J Am Acad Child Adolesc Psychiatry 2011;50:1149-1161.
34. Thomsen PH. Obsessive-compulsive disorder in children and adolescents: Predictors
in childhood for long-term phenomenological course.  Acta Psychiatr Scand 1995;
92:255-259. 
35. Thomsen PH, Mikkelsen HU. Course of obsessive-compulsive disorder in children
and adolescents: A prospective follow-up study of 23 Danish cases. J Am Acad Child
Adolesc Psychiatry 1995;34:1432-1440. 
36. Wewetzer C, Jans T, Müller B, et al. Long-term outcome and prognosis of obsessive-
compulsive disorder with onset in childhood or adolescence.  Eur Child Adolesc
Psychiatry 2001;10:37-46. 
37. Skoog G, Skoog I. A 40-year follow-up of patients with obsessive-compulsive
disorder. Arch Gen Psychiatry 1999;56:121-132.
38. Garcia AM, Sapyta JJ, Moore PS, et al. Predictors and moderators of treatment
outcome in the Pediatric Obsessive Compulsive Treatment Study (POTS I). J Am
Acad Child Adolesc Psychiatry 2010;49:1024-1033, quiz 1086.
39. Reddy YC, Srinath S, Prakash HM, et al. A follow-up study of juvenile obsessive-
compulsive disorder from India. Acta Psychiatr Scand 2003;107:457-464. 
40. Leonard HL, Swedo SE, Lenane MC, et al. A 2 to 7-year follow-up study of 54 obsessive-
compulsive children and adolescents. Arch Gen Psychiatry. 1993;50:429-423.

Ch-17.indd 378 24-04-2015 16:02:45

View publication stats