Preparation for Child Psych PRITE and Boards
Revision as of 15:25, 31 October 2012 by Eugene Grudnikoff MD (Talk | contribs) (Diagnosis)

Jump to: navigation, search

Introduction

Epidemiology

OCD in children and adolescents often goes unrecognized and undiagnosed due to its idiosyncratic, not always obvious nature.

  • Point prevalence of pediatric OCD is 0.25% (British study 5-15 y.o., Heyman I, IntRevPsych 2003);
  • Overall pediatric prevalence rate is 1-2% (USA studies, Apter A, JAACAP 1996)
  • Incidence of OCD peaks during two developmental periods, pre-adolescents (mean 10 y.o.), and young adults (mean 20 y.o.). (Geller D, March J, Practice Parameter, JAACAP 2012)
  • Childhood onset of OCD is more common in boys with a 3:2 ratio, (Lewis text p.550) while M:F ratio of OCD in adults is 1:1.

Genetic and non-genetic factors

  • OCD has a significant familial/genetic component with higher concordance rates in monozygotic twins vs. dizygotic twins.
  • Environmental triggers and immunological cross-reactions, particularly to Strep infection had been implicated.
    • PANDAS - Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcus, is attributed to immune response to Group A Strep, which can cause cross-reactivity and inflammation of basal ganglia. This can produce (the somewhat controversial) syndrome of PANDAS, which involves tics, OCD, and hyperactivity.

Developmental trajectory

  • Insistence on certain rituals and routines is common and normal in toddlers and pre-schoolers, as long as family functioning is not disrupted and a child can tolerate some disruption in the ritual (JACAAP parameter 2012)
  • Severity of pediatric OCD may diminish and become sub-clinical with time.
  • OCD is more likely to persist in youth with younger age of onset and longer duration of symptoms.
  • Also more likely to persist are religious, hoarding, and sexual subtypes of OCD.
  • Separation anxiety is a common comorbidity in children with OCD.

Presentation

Children may have compulsions without obsessions.

Common obsessions

  • The most common obsessions in children and adolescents involve aggressive and catastrophic worries (e.g death of parent); these become less common in adults. (Geller DA, J Nerv Men D/o 2001)
  • Sexual and religious obsessions are more common in adolescents.
  • Contamination worries are common throughout the developmental spectrum.

Common compulsions

  • Most common compulsions across the developmental spectrum involve checking, cleaning, and ordering rituals.
  • Hoarding compulsions are more common in children in adolescents and become less common in adults. (Geller DA, J Nerv Men D/o 2001)

Diagnosis

Criteria

Differential diagnosis

  • Pervasive developmental disorders involve stereotypies and rituals as the core criteria. OCD symtpoms are generally egodystonic and are accompanied by anxiety and fears.
  • Tourette's and tic disorders have significant comorbidity with OCD, and it is often difficult to distinguish complex tics from compulsions.

Comorbidities

A number of disorders have overlapping symptoms or behavioral manifestations with OCD; they have been termed obsessive-compulsive-related disorders (Hollander E, J Clin Psych 1996)

  • preoccupation with bodily sensations or appearance: body dysmorphic disorder, anorexia nervosa, hypochondriasis.
  • impulsive disorders: sexual compulsions, trichotillomania and self-injurious behaviors, pathological gambling, kleptomania.
  • neurologic disorders: Tourette's and tics, torticollis, Sydenham's choreas, autism, PANDAS.

Treatment

POTS trial

The Pediatric OCD Treatment Study (POTS) was a 12-week randomized controlled trial (JAMA, 2004).

  • n=112 randomized to 4 groups (CBT alone, sertraline alone (SER), combination (COMB), and placebo);
  • Remission rates were statistically similar for CBT and COMB groups (39% and 53%).
  • COMB group was superior to SER (21% remission rate) and placebo (3.6%).