Pediatric OCD & Related Disorders

PEDIATRIC OCD & RELATED DISORDERS

Obsessive Compulsive Disorder (OCD)

• Characterized by distressing, intrusive obsessive thoughts and/or repetitive compulsive physical or mental acts.
• Children with OCD experience recurrent, time-consuming (more than 1 hour a day), and disturbing obsessions and compulsions (Evans & Leckman, 2006).
• Obsessions: Persistent and intrusive thoughts, urges, or images that are experienced as intrusive and unwanted, and generally cause significant anxiety or distress.
• Compulsions: Repetitive behaviors or mental acts that an individual feels driven to perform in response to an obsession or according to specific, inflexible rules.

Commonly Reported Obsessions:

• Contamination
• Safety
• Doubting one's memory or perception
• Scrupulosity (need to do the right thing, fear of committing a transgression, often religious)
• Need for order or symmetry

Intrusive Thought Obsessions

• Unwanted thoughts that are distressing and obsessive.
• Examples:
  • Harm someone, jump off something
  • Sexually inappropriate (did I violate a moral code, unacceptable sexual activity?)
• Lead to compulsive avoidance of something and reassurance seeking to reduce anxiety
• Cause extreme anxiety and distress
• Interrupt ongoing activity
• Egodystonic

Categories, Examples, and Obsessions/Compulsions

• Cleaning/Contamination
  • Obsession: What if I get an incurable disease from touching something someone else touched?
  • Compulsion/Ritual: Excessive handwashing, avoiding touching objects.
• Responsibility for Harming Someone
  • Obsession: What if I left my hairdryer or the toaster oven on and my family burns to death? What if I gave my cat the wrong food and they die?
  • Compulsion/Ritual: Repeated checking, asking family to check, texting family requesting pictures of items in "off" position.
• Sexual/Moral Code Forbidden thoughts
  • Obsession: Unwanted thoughts about sexual relationships. Fear of losing control and touching someone or oneself sexually in school or with family.
  • Compulsion/Ritual: Replacing the thought with 10 “good ones”. Seeking reassurance, avoiding situations.
• Religion
  • Obsession: Thoughts of God in a sexual way. Thinking I hate God and fear that now bad things will happen.
  • Compulsion/Ritual: Praying a certain number of times in a specific way.
• Symmetry/Order
  • Obsession: Odd numbers are bad luck and will cause something bad to happen. School books must be in a special order, or I will fail my test. Light switches must be in a certain position in each room.
  • Compulsion/Ritual: Arranging books in a specific order. Making a sound after hearing a certain word. If you tap your right shoulder, you must tap your left.

Associated Emotions/Thoughts

• Anxiety
• Fear something bad will happen
• Disgust
• Something isn’t just right and makes me uncomfortable
• Avoidance “I must avoid___ ”
• Parent may believe the child doesn’t have symptoms-just avoiding

DSM 5 Criteria for OCD

• (A) 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 sometime 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.
• (B) 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.
• (C) 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.
• (D) The disturbance is not better explained by the symptoms of another mental 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.
• Kids typically have insight.

Prevalence of OCD in Children and Adolescents

• About 1% to 2% of children and adolescents suffer from OCD.
• According to epidemiological studies, at any given time, almost 90% of children with OCD do not undergo treatment.
• OCD is more common in boys than girls in childhood, with a gender ratio of 2:1.
• By adolescence, this gender ratio almost becomes equal.

Comorbidity

• Comorbid disorders occur in approximately 50-70% of children.
• Most common:
  • Anxiety disorders
  • ADHD
  • ODD
  • Vocal and motor tics disorders.
  • Learning disorders
  • Eating disorders
  • Depression
  • Substance use disorders

Onset, Course, and Outcome of OCD

• The mean age at onset of OCD is 9 to 12 years with two peaks:
  • Early childhood
  • Late adolescence/early adulthood
• More common in boys than girls in childhood, (2:1)
• Adolescence this gender ratio almost becomes equal.
• Waxes and wanes/ Chronic course frequently
• Two-thirds of children continuing to have the disorder 2 to 14 years after being diagnosed.

Causes of OCD

• Specific pathways unknown.
• Biology- changes in body after exposed 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.

Assessment

• Dimensional Obsessive Compulsive Scale (DOCS)
• Categories:
  • Concerns about germs and contamination
  • Concerns about harm, injury or bad luck
  • Unacceptable thoughts
  • Concerns for symmetry, completeness or things to be “just right”

Treatment

• Cognitive-behavioral therapy (CBT)
• Exposure and response prevention (ERP) repeatedly triggering the child’s obsessions (exposure) and helping them to resist the compulsions (response prevention) over a series of exposures.
• Must be done in a developmentally appropriate manner.
• Initial exposures shouldn’t be too difficult (mild distress). This will increase the child confidence and motivation to continue.
• Educate, involve and support parents.
• Avoiding accommodating child’s rituals/compulsions can be difficult because child is in distress.
• Make exposures fun for the child.
• Ex: Playing “contaminated Jenga” , Baking cookies with food items touching one another that child is uncomfortable with, or not allowing hand washing after each step.

Medication

• SSRI- 35% reduction in symptoms, effects begin within 2 weeks.
• At two months, they plateau
• 2/3 of children respond to medication

Related Disorders

Trichotillomania (Hair-Pulling Disorder)

• A DSM-5 disorder characterized by the repeated pulling out of hair, resulting in hair loss; causes distress or impairment.
• Moved in the DSM-5 to Obsessive Compulsive Disorders
  • Recurrent pulling out of one’s hair resulting in noticeable hair loss.
  • An increasing sense of anxiety immediately before pulling out the hair or when resisting the behavior.
  • Pleasure, gratification, or relief when pulling out the hair.
  • Repeated attempts to stop fail.
  • The disturbance is not accounted for by another mental disorder and is not due to a general medical condition (i.e., dermatological condition).
  • The disturbance causes significant distress or impairment in social, occupational, or other important areas of functioning.

Trichotillomania Types:

• Focused hair pulling: involves deliberate and conscious pulling, usually in response to unpleasant thoughts and feelings.
  • Adolescents engaging in focused pulling experience distress before the act and relief immediately after it.
• 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.
• People often start compulsive hair-pulling around the ages of 11-15; although it can begin at a much younger or older age.
• The symptoms also may be triggered by pubertal hormonal changes.

Misconceptions

• This is the same as self-mutilation
• This is seen in highly anxious people
• Sign of serious underlying pathology.
• These people were abused.

Associated Problems

• Low self-esteem
• Shame
• Isolation
• Social anxiety
• School avoidance
• Dental problems
• Trichophagia- More than 20% of patients eat the hair after pulling it out
• This can be more embarrassing to the patient than the pulling.
• They hide this from clinicians as well as loved ones.
• Physical consequences: The ingestion of hair can result in the formation of gastrointestinal hair-masses which cause obstructions that may require surgical intervention

Onset And Comorbidity Of Trichotillomania:

• Typically emerges in early adolescence, the mean age being 11.8 years.
• Onset is usually insidious(Slow) and aggravates with psychological stress.
• Symptoms tend to peak in early adulthood, unlike OCD which peaks in adolescence.
• Trichotillomania occurs in less than 1% of the general population.
• Symptoms are comorbid with OCD with almost 9% of people with OCD also suffering from trichotillomania.
• Trichotillomania can be attributed to similar hereditary causes as OCD with 5% patients having a relative with OCD.
• Both the disorders are associated with the dysfunction of the striatum.
• Surprisingly, medication for OCD is not found to be as effective for trichotillomania, hinting at a possible difference between the two.

Treatment for Trichotillomania

• Behavior Therapy
  • Habit reversal training. Using other behaviors to replace the hairpulling.
  • Technology can be used- Self monitoring App
  • Three most critical components:
    • Awareness training
    • Competing response training (incompatible)
    • Social/Parental support
• CBT
• Acceptance and Commitment Therapy (ACT). Accepting the urge without acting on it.
• Medications in conjunction with psychotherapy.

Body Dysmorphic Disorder (BDD)

• On the obsessive-compulsive spectrum. Why?
• Associated with an intense preoccupation with perceived or imagined flaws in appearance (American Psychiatric Association, 2013).
• We see compulsive behaviors in this disorder.

More on BDD

• It has been referred to as “Imagined Ugliness”
• Used to be considered a somatic symptom disorder; however, the similarities to OCD prompted relocation in the DSM-5
• Often comorbid with OCD
• Ideas of reference are common in BDD
• People are talking about them in a negative way, referencing their disfigurement etc.

Development and Prevalence of BDD

• Mostly occurs during adolescence, at around 1-2%
• Studies suggest symptoms typically emerge at 13 and diagnosis at 16.
• However, there is mixed data.
• Higher rates in females.

Body Dysmorphic Disorder in Children

• Leads to high levels of stress and psychosocial problems.
• Associated with functional impairment and wanting of plastic surgery.

Comorbidities:

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

Similarities and Differences Between BDD and OCD

• Similarities
  • Obsessive, intrusive, repetitive, thoughts
  • Excessive time dedicated to rituals- Mirror checking, grooming
  • Age of onset
  • Associated anxiety and emotional distress
  • 10 % attempt suicide
• Differences
  • Underlying core beliefs in BDD focus more on unacceptability of the self -- e.g., being unlovable, inadequate, worthless. Moral repugnance is unusual
  • BDD patients have poorer insight. ~2% of OCD patients are currently delusional vs 27%-39% of BDD patients
  • Compulsive behavior doesn’t relieve anxiety
  • 25% percent attempt suicide

Areas of Focus in BDD

• Head and Face 55%
• Skin 20%
• Arms/Legs 7%
• Genitalia 5%
• Overall Body 13%

Behaviors in BDD

• Obsessive mirror checking
• Looking in reflective surfaces
• Grooming/Primping Excessively
• Camouflaging (hats, clothes, scarves, wigs, masks etc.)
• Avoidance behaviors
• Comparing body part
• Social media comparisons/unrealistic
• Reassurance seeking

BDD in a Child Sample

• Thirty-three children and adolescents: Bodily preoccupations most often focused on the skin (61%) and hair (55%).
• All had compulsive behaviors:
  • Camouflaging (e.g., with clothing) 94%,
  • Comparing 87%
  • Mirror checking 85%
  • 94% impairment in social functioning
  • 85% in academic functioning
  • 38% psychiatric hospitalizations
  • 21% suicide attempt.

Treatment Outcomes in Sample Population

• Ten (53%) of 19 subjects treated with SSRI showed significant improvement in symptoms.
• Twelve (36%) subjects received surgical, dermatological, or dental treatment, with a poor outcome

Using the DSM-5 Criteria for Diagnosis

• Preoccupation with one or more perceived defects or flaws in physical appearance that are not observable or appear slight to others.
• At some point during the course of the disorder, the individual has performed repetitive behaviors (e.g., mirror checking, excessive grooming, skin picking, reassurance seeking) or mental acts (e.g., comparing his or her appearance with that of others) in response to the appearance concerns.
• The preoccupation causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.
• The appearance preoccupation is not better explained by concerns with body fat or weight in an individual whose symptoms meet diagnostic criteria for an eating disorder.
• Specify if:
  • With muscle dysmorphia: The individual is preoccupied with the idea that his or her body build is too small or insufficiently muscular. The specifier is used even if the individual is preoccupied with other body areas, which is often the case.
• Specify if:
  • Indicate degree of insight regarding BDD beliefs (e.g., ”I look ugly” or ”I look deformed”).
  • With good of fair insight | With poor insight | With absent insight/delusional beliefs. (APA, 2013)