Pediatric OCD & Related Disorders

What is the impact of early-onset OCD on development?

• Social functioning / peer relationships

• Family relationships

• Academic performance since it often coincides with the start of formal schooling

What are some examples of how OCD disrupts functioning?

Concentration problems due to intrusive thoughts

Chronic anxiety and distress can reduce resilience and coping skill development

Internalized shame or guilt may contribute to depression or low self-worth

What is the Prevalence of OCD in children?

• A lifetime prevalence of about 2% in children

• Point prevalence of 0.5-1% of the pediatric population experiences this at any given time

• This disorder is more common in boys than girls in childhood, with a gender ratio of 2:1

• By adolescence, this gender ratio almost becomes equal

What is OCD?

Distressing, intrusive obsessive thoughts and/or repetitive compulsive physical or mental acts.

What are Obsessions?

Persistent and intrusive thoughts, urges, or images that are experienced as intrusive and unwanted, and generally cause significant anxiety or distress

What are Compulsions?

Repetitive behaviors or mental acts that an individual feels driven to perform in response to an obsession or according to specific, inflexible rules, or to reduce anxiety or distress

What are some common obsessions in childhood onset of OCD?

Contamination fears, harm or injury fears, superstitions and magical thinking, religious or moral fears, feeling states, etc

What are some common compulsions in childhood onset of OCD?

Cleaning/washing, checking, counting/repeating actions a certain number of times, arranging objects, list making, avoiding, etc

What are intrusive thought obsessions?

Unwanted thoughts that are distressing and obsesive.

What is egodystonic?

Unwanted, distressing, and inconsistent with an individual’s self-perception, values, and beliefs

What are the DSM-5 criteria of OCD?

1. Presence of obsessions, compulsions, or both

2. The obsessions or compulsions are time-consuming or cause clinically significant distress or impairment in social, occupational, or other important areas of functioning

3. The obsessive-compulsive symptoms are not attributable to the physiological effects of a substance

4. The disturbance is not better explained by the symptoms of another mental disorders

What is the approximate rate of comorbidity in children with OCD?

50-70%

What are some comorbid disorders that occur in children with OCD?

Anxiety disorders, ADHD, ODD, vocal and motor tics disorders, learning disorders, eating disorders, depression, and SUDs

What is the onset, course, and outcome of OCD?

• The mean age is 9-12 years with two peaks: Early childhood and late adolescence/early adulthood

• More common in boys than girls in childhood

• 2/3 of children continue to have the disorder 2-14 years after being diagnosed

What are the causes of OCD?

• Biology - Changes in body after exposure to virus

• Learned - Observing family members

• Cognitive - Inflated sense of responsibility for others

• Stressful life events - Traumatic events may increase risk

• Neurodevelopmental - Abnormalities in brain structure and function

What are the Features of Typical OCD?

• Onset: Gradual

• Symptom pattern: Progressive

• Course: Chronic, fluctuating

• Trigger: None clear

• Scope of symptoms: Primarily OCD

• Neuro/Physical Signs: Rare

What are the Features of PANS/PANDAS?

• Onset: Abrupt

• Symptom Pattern: Sudden, full intensity

• Course: Episodic (acute → remission)

• Trigger: Infection / immune-related

• Scope of Symptoms: Multisystem

• Neuro/Physical Signs: Common (tics, motor decline, urinary issues)

What are PANS & PANDAS?

Conditions that occur when the immune system mistakenly affects parts of the brain (especially those controlling behavior and movement). Can lead to sudden OCD symptoms, tics, anxiety, panic, regression in skills, sensory sensitivities, urinary issues, etc

What are PANS?

A broader condition which can be triggered by various infections, immune dysfunction, and environmental factors

What are PANDAS?

A subtype of the syndrome where the conditions are specifically linked to strep infections (strep throat, scarlet fever)

Did you review the assessment chart and tools/notes for PANS/PANDAS?

Yes

What is the Children’s Yale-Brown Obsessive Compulsive Scale?

A semi-structured interview with a child between the ages of 6-17 and parent where there are 5 core items asked for obsessions and compulsions each, and each item is rated from 0-4. Clinician must count up the sum of the points, and the score correspond to the severity of the disorder

What are some treatment for children with OCD?

Cognitive-behavioral therapy & Exposure and response prevention

What is ERP and how does it help a child with OCD?

ERP involves repeatedly exposing the child to situations or stimuli that trigger the child’s obsessions and helping them to resist the compulsions.

It must be done in a developmentally appropriate manner where the initial exposures are not too difficult so as to increase the child’s confidence and motivation to continue. Avoid accommodating the child’s rituals or compulsions

True or False: Square breathing is effective in ERP since it helps calm the patient down and prevents the obsessive thoughts and compulsions

False

What are the features of Pediatric OCD?

• Age of Onset: 7-12 years

• Symptom Presentation: Symmetry/ordering, contamination fears, magical thinking, less insight (think disorder beliefs are true)

• Comorbidity: ADHD, tic disorders, separation anxiety, ODD

• Family Involvement: High family accommodation

• Course & Prognosis: Episodic; may improve or worsen at puberty

What are the Features of Adult OCD?

• Age of Onset: Later onset; sometimes continuation from childhood

• Symptom Presentation: Checking, mental rituals, hoading, greater insight

• Comorbidity: Depression, substance use, other anxiety disorders

• Family Involvement: More self-management; family influence still possible

• Course & Prognosis: More chronic

What is Trichotillomania?

A DSM-5 disorder characterized by the repeated pulling out of hair, resulting in hair loss, causes distress or impairment

Why is Trichotillomania categorized under OCD?

It is recurrent pulling out of one’s hair that is done to relieve a sense of anxiety preceding it. There is pleasure or gratification when pulling out the hair. There are failed, repeated attempts to stop.

What are the types of trichotillomania?

Focused hair pulling and automatic hair pulling

What is focused hair pulling?

Involves deliberate and conscious pulling, usually in response to unpleasant thoughts and feelings. Adolescents engaging in this experience distress before the act and relief immediately after it

What is automatic hair pulling?

Habitual plucking, usually outside the person’s awareness while engaging in some other task and may not be in response to distress

What are some misconceptions of trichotillomania?

• This is the same as self-harm

• This is seen in highly anxious people

• Signs of serious underlying pathology

• These people were mistreated

What are some associated problems with trichotillomania?

Low self-esteem, shame, isolation, social anxiety, dental problems, and trichophagia

What is trichophagia?

Ingestion of hair that can result in the formation of gastrointestinal hair-masses, causing obstructions that may require surgical intervention

What is the onset and comorbidity of trichotillomania?

• Onset is usually insidious/subtle and aggravates with psychological stress.

• Symptoms tend to peak in early adulthood

• Symptoms are comorbid with OCD with almost 9% of people with OCD also suffering from trichotillomania

What are the treatment for trichotillomania?

Behavior therapies, acceptance and commitment therapy, medications, habit reversal training

What is habit reversal training?

Using other behaviors to replace the hairpulling

What are the steps in Habit Reversal Training?

1. Awareness Training → learning to recognize early signs

2. Competing Response Training → practicing an alternative action when the urge is felt (i.e., clenching fists, squeezing a stress ball, etc)

3. Stimulus Control → parents help reduce cues (i.e., providing fidget toys)

4. Reinforcement and Support → Rewards and encouragement are given for using coping strategies

What is Excoriation?

Recurrent skin picking which results in skin lesions and scarring and infections, with repeated attempts to stop the behavior

What is the Prevalence & Onset of Excoriation?

• Onset often in early adolescence

• Lifetime prevalence: About 1-2%

• More common in females

What are the biological factors of OCD & related disorders?

• Cortico-striato-thalamo-cortical (CSTC) circuit involvement

• Serotonin dysregulation

• Genetic predisposition

Describe the CSTC Dysregulation

• Overactive drive from the striatum → strong urge to perform a behaivor

• Reduced top-down control from the PFC → difficulty resisting urges

• Temporary relief reinforces the habit via dopamine pathways

What are the Primary Functions and Clinical Relevance of the Caudate Nucleus?

• Primary Function: Cognition, planning, goal-directed behavior

• Clinical Relevance: OCD obsessions, cognitive rigidity

What are the Primary Functions and Clinical Relevance of the Putamen?

• Primary Function: Motor execution, habits

• Clinical Relevance: Compulsive rituals, repetitive behaviors

What are the Primary Functions & Clinical Relevance of the Nucleus Accumbens?

• Primary Function: Reward, motivation

• Clinical Relevance: Urge-driven behaviors, reinforcement of habits

What are the Psychological & Environmental Factors of OCD & Related Picking Disorders?

• Triggered by stress, anxiety, or boredom

• Acts as a self-soothing or tension-reducing behavior

• Reinforced by temporary relief after picking

• May begin as as habitual or sensory behavior that becomes compulsive

What are the treatments and interventions for OCD & Related Picking Disorders?

• Habit Reversal Training (HRT)

• Stimulus Control (i.e., cover mirror, wear gloves, etc)

• CBT

• Family involvement (i.e., reduce shame and provide support)

• SSRIs

Why is body dysmorphic disorder on the obsessive-compulsive spectrum?

• People who struggle with their body image could perceive their body in a preoccupated way (obsessive thinking), which could lead to fix and check on it (compulsions)

What are some important points about BDD?

• It has been referred to as “imagined ugliness”

• Used to be considered a somatic symptom disorder, however was relocated to be on the OCD spectrum

• Often comorbid with OCD

• Ideas of reference are common in BDD

What is idea of reference?

They are false, often distressing beliefs that others or events directly relate to them (i.e., the delusion that someone laughing automatically means that they are talking about their body part)

What is the prevalence of BDD?

• Mostly occurs during adolescence, at around 1-2%

• Studies suggest symptoms typically emerge at 13 and diagnosis at 16

• Higher rates in females

How does BDD affect Children?

• Leads to high levels of stress and psychosocial problems

• Associated with functional impairment and wanting of plastic surgery

• The earlier the age of onset, the higher the risks of negative developmental impact and comorbid disorders

  • Higher risk of suicide

What are the Similarities Between OCD and BDD?

• Obsessive, intrusive, repetitive thoughts

• Age of onset

• Associated anxiety and emotional distress

True or False: Underlying core beliefs in BDD focus more on unacceptability of the self. Moral repugnance is unusual

True

True or False: BDD patients have greater insight compared to OCD patients

False

What are the most common preoccupations of the body?

Skin, hair, head, and face

What are the criteria for BDD in the DSM-5?

• Preoccupation with one or more perceived defects or flaws in physical appearance that are not observable or appear slight to others

• The individual has performed repetitive behaviors or mental acts in response to the appearance concerns

• The apearance preoccupation is not better explained by concerns with body fat or weight in an individual whose symptoms meet diagnostic criteria for an eating disorder

What is muscle dysmorphia?

The individual is preoccupied with the idea that his/her body build is too small or insufficiently muscular

What are some treatments for individuals with BDD?

• CBT

• Exposure and Response Prevention

• Family Involvement

• Psychoeducation (this is a disorder, not vanity)