Obsessive-compulsive disorder in children and adolescents. Epidemiological and clinical aspects

Obsessive-compulsive disorder (OCD) in children and adolescents is apparently a much more common disorder than previously believed. The literature on OCD in children and adolescents is reviewed, and OCD is described as a severe disorder with a poor prognosis for about half of the patients. The clinical picture seems to be the same across different cultures. The most common symptoms are obsessions about dirt and contamination and washing rituals.     

Obsessive-compulsive disorder with and without tics in an epidemiological sample of adolescents

OBJECTIVE: This study was undertaken to discriminate subtypes of obsessive-compulsive disorder in adolescents. METHOD: Forty individuals with obsessive-compulsive spectrum disorders were ascertained from an epidemiological sample of 861 adolescents. Interviews were conducted by child psychiatrists using semistructured diagnostic interviews, including a clinician-rated Yale-Brown Obsessive Compulsive Scale. Discriminant analysis was performed to compare the scores on the Yale-Brown scale of groups with and without comorbid tics and to compare boys and girls. RESULTS: Adolescents with tics were more prone to aggressive and sexual images and obsessions than were adolescents without tics; these differences could not be wholly attributed to sex differences. CONCLUSIONS: The subtypes among unreferred adolescents are similar to those of adult patients with obsessive-compulsive disorder with and without Gilles de la Tourette syndrome. Subtypes evident in adulthood may be established relatively early in the natural course of obsessive-compulsive disorder.     

Obsessive-compulsive disorder and separation anxiety

Little is known about the effects of intracavitary brachytherapy (ICB) performed in the presence of pyuria resulting from external beam pelvic irradiation for cervical cancer (CC). A retrospective study of one decade of ICB for CC showed that brachytherapy was performed in the presence of pyuria in 26 women. Twelve women without pyuria during ICB served as a control group. Antibiotic therapy was routinely administered during intracavitary application. The crude survival rate at 5 years was 39% in patients with pyuria and 42% in women without pyuria; the corresponding local recurrence rates were 23% and 17%; the serious complication rates were 12% and 0% respectively. Intracavitary brachytherapy in the presence of pyuria may have a limited adverse effect on the outcome of women with cancer of the cervix.     

Obsessive-compulsive disorder in elderly patients

Obsessive-compulsive disorder (OCD) is a common illness which starts in young adulthood and persists into late life. OCD is associated with dysregulation of the serotonin system and may also be related to the dysregulation of dopamine. When OCD starts in an elderly patient, either an organic or a neurological diagnosis should be considered. Clomipramine and serotonin reuptake inhibitors are the mainstay of treatment for OCD. Choice of a particular agent should be based on the patient's previous response and the adverse effect profile of the drug. Pharmacokinetics should also be a consideration due to age-related changes in hepatic and renal function leading to increased plasma concentrations as well as prolonged elimination half-lives of these agents. Behavioural therapy, in addition to pharmacological management, is essential to treat compulsions and to improve response.     

Obsessive-compulsive disorder limited to pregnancy

Two patients with fulminant amebic colitis with colon perforation and concomitant liver abscess were collected over the last 5 years. One patient underwent emergency laparotomy to treat amebic cecal perforation. Diverted ileostomy saved his life. The ileostomy was successfully reversed 6 months later. The other patient underwent 4 laparotomies with more invasive procedures in less than 1 month due to sequential complications of amebiasis. Colon resection with enterostomy miraculously allowed him to survive. In comparison with the latter, who underwent more aggressive surgery and experienced more catastrophic complications, the former with conservative surgery had a smoother clinical result. Thus, conservative operation for colon perforation due to amebiasis is recommended. Besides, thanks to the alertness of doctors, the favorable age of the patients, the advent of new antiamebic and antimicrobial agents, excellent hyperalimentation, the great improvement in medical facilities and postoperative care, the two critical patients eventually survived after several operations, and had a better outcome as compared with the high mortality rate of 87.5% in our hospital 2 decades earlier.     

Obsessive-compulsive disorder in schizophrenia: epidemiologic and biologic overlap

AF64A (ethylcholine mustard aziridinium ion) was stereotaxically administered bilaterally (1 nmol/side) into rat lateral cerebral ventricles. Choline acetyltransferase (ChAT) activity and ChAT mRNA levels were measured at predetermined time points in the septo-hippocampal pathway and striatum, both well identified as rich in cholinergic neurons. AF64A caused a rapid but transient increase in ChAT mRNA (167%, P < 0.05) and ChAT activity (164%, P < 0.01) in the septum. By day 7 post treatment, there was a significant decrease in ChAT mRNA (42.5% of control, P < 0.05) in the septum although the ChAT activity still stayed high. This decreased ChAT mRNA level in the septum lasted for at least four weeks, and was paralleled by a long-lasting decrease in ChAT activity in the hippocampus. In the striatum, on the other hand, there were no observed changes in either ChAT activity or ChAT mRNA. These data suggest that the long term effect of AF64A on the septo-hippocampal cholinergic pathway may, at least in part, be due to an action of AF64A on gene expression in the cholinergic neuron. The difference in the response to AF64A between the septo-hippocampal and striatal cholinergic systems might be due to their difference in neuron types.     

DSM-IV field trials for oppositional defiant disorder and conduct disorder in children and adolescents

OBJECTIVE: The purpose of the field trials for oppositional defiant disorder and conduct disorder was to select valid diagnostic thresholds for these disorders and to compare the psychometric properties of DSM-IV criteria for oppositional defiant disorder and conduct disorder with previous DSM diagnostic formulations. METHOD: Structured diagnostic interviews, standardized clinician's validation diagnoses, and multiple measures of impairment were obtained for 440 clinic-referred children and adolescents aged 4-17 years. RESULTS: A diagnostic threshold of four symptoms of oppositional defiant disorder optimized identification of impaired children, improved agreement somewhat with the clinician's validation diagnosis, and had somewhat better test-retest agreement than DSM-III-R. In the case of conduct disorder, the optimal time window for ascertainment of symptoms was clarified. A diagnostic threshold of three symptoms of conduct disorder maximized accurate identification of impaired children and agreement with the clinician's validation diagnosis and resulted in slightly better test-retest agreement than DSM-III-R. Compared with the DSM-III-R definition, the DSM-IV definition of oppositional defiant disorder was somewhat more prevalent, but the prevalence of conduct disorder was essentially unchanged. CONCLUSIONS: DSM-IV definitions of oppositional defiant disorder and conduct disorder are somewhat better than DSM-III-R definitions in terms of internal consistency and test-retest agreement, and the validity of the DSM-IV definition of oppositional defiant disorder is slightly better than that of DSM-III-R.     

Recurrence of major depressive disorder in hospitalized children and adolescents

Global studies of within-group genetic variation have revealed a tendency for some traits, but not all, to show higher heterozygosity in sub-Saharan African populations. Although excess African diversity has been interpreted as reflecting a greater "age" of sub-Saharan African populations, more recent research has shown that this excess is more likely a consequence of a larger African long-term effective population size. The observation that certain traits, particularly classic genetic markers and RFLPs, do not show this pattern has been interpreted as ascertainment bias. Here, I examine another possible factor: that excess African heterozygosity is in part a function of mutation rate. Simple equilibrium and nonequilibrium models of absolute excess heterozygosity are examined. The results indicate that there is little excess African heterozygosity for traits with low mutation rates and greater excess heterozygosity for traits with moderate to high aggregate mutation rates. Observed data are consistent with these models. Also, depending on population size and time depth, traits with high levels of mutation might show less excess heterozygosity than those with moderate to high mutation rates. Another measure of diversity, mean sequence divergence, shows an increase in excess diversity for traits with high mutation rates.     

Obsessive-compulsive disorder: diagnosis and treatment in the primary care setting

BACKGROUND: Obsessive-compulsive disorder is a common anxiety disorder found in 1 to 2 percent of the population. Obsessions are recurrent and persistent thoughts that cause marked anxiety or distress. Compulsions are repetitive behaviors or mental acts done to prevent or reduce anxiety. Patients might underreport symptoms or complain of coexisting depression or anxiety instead. The primary care physician is often the first to encounter this disorder in patients. METHODS: The authors cared for and observed a patient with obsessive-compulsive disorder at a family practice office and used her case to illustrate a literature review gathered by means of a MEDLINE search. RESULTS AND CONCLUSIONS: A combination of patient education, selective serotonin reuptake inhibitors, and behavioral techniques allow the family physician to maximize patient recovery and play a major role in the diagnosis and treatment of obsessive-compulsive disorder.     

Obsessive-compulsive disorder in pregnancy, the puerperium, and the premenstruum

BACKGROUND: Recent reports suggest that pregnancy and the puerperium may precipitate or exacerbate obsessive-compulsive disorder (OCD). The influence of this illness on other reproductive events, such as the premenstruum, is unknown. We examined retrospectively the relationships of pregnancy, the puerperium, and premenstruum to the course of OCD in 57 women. METHOD: Women outpatients with OCD meeting DSM-III-R criteria completed a standardized telephone interview administered by a psychiatric resident. They were asked retrospectively about the clinical course of their illness premenstrually and during and after pregnancy. RESULTS: Of 72 women eligible for the study, 79% (N = 57) completed the interview. Premenstrual worsening of OCD was described by 24 (42%) of the 57 women, and 12 (21%) described premenstrual dysphoria. Of the 57 women, 38 (67%) had been pregnant at least once; 31 (54%) had delivered at least one child. Pregnancy was associated with the onset of OCD in only 5 (13%) of the 38 women. Of the 29 women with preexisting OCD who became pregnant, 20 (69%) described no change in symptoms during pregnancy, 5 (17%) described worsening, and 4 (14%) described improvement. Postpartum exacerbation of OCD symptoms was reported by 7 (29%) of the 24 women with preexisting OCD who completed full-term pregnancies. Nine (37%) of the 24 women with both preexisting OCD and completed pregnancies also reported postpartum depression. CONCLUSION: The premenstrual and postpartum exacerbation of OCD symptoms in some women suggests that the course of this disorder may, in some cases, be influenced by changes in gonadal hormones. Our finding that women with OCD may be at increased risk for postpartum depression underscores the importance of careful postpartum evaluation of women with OCD to prevent maternal and infant morbidity.     

A prospective study of bipolar disorder in children and adolescents from India

In the light of new opportunities for structural arrangements in Germany calling for higher co-operation between physicians in private practice, determinants for diagnostic and therapeutic co-operation need to be examined. In the present study, 130 general practitioners were asked in regard to four typical primary care indication groups whether they prefer to diagnose and treat the patients on their own or in co-operation with colleagues. This self-assessment was validated using the data from 2,069 physician-patient contacts: physicians preferring therapy in co-operation actually referred patients three times more often. Concerning both gastro-intestinal and rheumatic disorders, physicians' preferences for diagnostic and therapeutic co-operation are highly correlated (phi = 0.491 and 0.528 respectively); preferences for diagnostic and therapeutic co-operation across indications are not as strongly correlated (phi = 0.334 and 0.397 respectively). However, there is no general indication-independent attitude towards co-operation for individual physicians: Indication and type of services are two factors which--probably in addition to others--affect co-operation independently. We confirm earlier conclusions that the detailed analysis of provider and patient characteristics together with the actual patient management on a case by case basis is a powerful tool for health services research.     

Panic disorder in children and adolescents: new developments, new directions

Reviewed panic attacks and panic disorders in children and adolescents critically and highlighted new developments. It is concluded that panic attacks and panic disorder are common in adolescence and that they are responsive to cognitive-behavioral treatment regimens. It is also concluded that although panic attacks and panic disorder are less common in children, they are nonetheless present. It is important to note, however, that their expression in childhood may vary from the clinical features seen in adolescence and adulthood. Specifically, it is suggested that most panic attacks in childhood are associated with particular events and are not unexpected or "out of the blue." Moreover, noncatastrophic interpretations of the symptoms of panic prevail. A developmental model for the onset, course, and correlates of panic in children is put forth.     

Empirical evaluation of DSM-IV generalized anxiety disorder criteria in children and adolescents

Evaluated the Diagnostic and Statistical Manual of Mental Disorders (4th ed. [DSM-IV], American Psychiatric Association, 1994) generalized anxiety disorder (GAD) criteria in children and adolescents. Clinic-referred children meeting criteria for DSM-IV GAD, those meeting criteria for another DSM-IV anxiety disorder, and normal children participated in a structured interview and completed self-report questionnaires. Groups were compared in terms of interview and self-report measures to examine convergent and discriminant validity. In addition, developmental differences, cross-informant symptom and syndrome agreement, and validity of parent and child report were determined. Finally, the symptoms comprising the GAD associated symptom criterion (Criterion C) were examined in terms of rate of endorsement and predictive power. Results showed that parameters of worry differentiated children with GAD from those with other anxiety disorders and controls. Developmental differences in the sample did not appear to necessitate a separate criteria set for the classification of generalized anxiety in children of this age. Symptoms from GAD Criterion C evidenced moderately high rates of endorsement and acceptable predictive power. Overall, the DSM-IV GAD criteria for children and adolescents are supported, but further evaluation is necessary before firm conclusions can be drawn.     

Obsessive-compulsive disorder responsive to electroconvulsive therapy in an elderly woman

An elderly woman with a long history of obsessive-compulsive disorder (OCD) was treated with electroconvulsive therapy (ECT) after intractable depression developed. OCD had been well established for many years before onset of the depressive symptoms. After ECT, there was resolution of both OCD and depression. The patient eventually had relapse and was treated with maintenance ECT.     

Obsessive-compulsive disorder and ventromedial frontal lesions: clinical and neuropsychological findings

Using whole cell recording techniques, we distinguished immature from mature stages of development in auditory thalamic neurons of rats at ages P5 to P21. We compared voltage responses to injected currents and firing patterns of neurons in ventral partition of medial geniculate body (MGBv) in slices. Resting potential, input resistance and membrane time constant diminished to mature values between P5 and P14. Responses of young neurons to hyperpolarizing pulses showed delayed inward rectification; after P13, this was obscured by a rapid onset of another inward rectifier. All neurons possessed tetrodotoxin (TTX)-sensitive, depolarization-activated rectification, implying persistent Na+-current involvement. Despite a slightly higher voltage threshold for spiking, the current threshold was lower in younger neurons. Young neurons fired a short latency spike with afterhyperpolarization whereas older neurons exhibited a slow ramplike depolarization before tonic firing. Large currents caused continuous firing in all neurons. Before day P13, a high threshold Ca2+ spike (HTS) often was appended to action potentials. The low threshold Ca2+-spike (LTS) was too small in amplitude to evoke action potentials before P11 but produced a single spike at P12 and P13 and burst firing with HTS after P13. MGBv neurons have mature properties after P14, relevant for reactions to sound and the oscillations of slow-wave sleep.     

Rage attacks in children and adolescents with Tourette''s disorder: a pilot study

BACKGROUND: Sudden, explosive episodes of rage occur in a significant number of clinically referred children with Tourette's disorder and cause considerable psychosocial morbidity. The etiology of these symptoms is unknown. We conducted a pilot study of 12 consecutive children with Tourette's disorder and rage attacks to determine whether comorbidity of Tourette's-associated disorders is related to these symptoms. METHOD: Twelve consecutive children with Tourette's disorder who presented with rage attacks were evaluated, including 2 females and 10 males. Tourette's disorder diagnosis, presence of comorbid disorders, and tic severity were assessed using DSM-IV diagnostic criteria and standardized rating scales. RESULTS: All 12 children met diagnostic criteria for Tourette's disorder, obsessive-compulsive disorder (OCD), and attention-deficit/hyperactivity disorder (ADHD). Two children were also diagnosed with comorbid oppositional defiant disorder, and 4 children were diagnosed with comorbid conduct disorder. None of the subjects met diagnostic criteria for a mood disorder. All subjects had only mild tic severity. CONCLUSION: The clinical phenomenon of rage attacks in children with Tourette's disorder resembles intermittent explosive disorder and may reflect specific underlying neurologic disturbances. This pilot study suggests that rage attacks in Tourette's disorder may be related to the presence of comorbid disorders.     

Risperidone in children and adolescents with pervasive developmental disorder: pilot trial and follow-up

Dopamine receptor antagonists, particularly haloperidol, have been the most effective medications in currently available double-blind placebo-controlled studies for treating the disruptive behaviors often associated with pervasive developmental disorder (PDD). The rationale for trying risperidone in this population includes its dopamine-blocking activity; its seemingly lower incidence of tardive dyskinesia when compared to standard neuroleptics; the possibility that risperidone may ameliorate the social withdrawal of PDD, as it does the negative symptoms in schizophrenia; and substantial effects on serotonergic neurotransmission, which has been shown to be dysregulated in some patients with PDD. This study was an open-label pilot trial of risperidone in 6 subjects (aged 7-14 years, mean = 10.7) who met DSM-III-R criteria for a PDD diagnosis. The mean optimal dose was 2.7 mg daily (range 1-6). Mean duration of risperidone administration was 5.2 months (range 1-8). Despite the small sample size, risperidone treatment appeared to be associated with significant improvements in ratings of angry affect (p = 0.04) and lability of affect (p = 0.03) and with a trend (p = 0.10) toward a reduction of mean hyperactivity scores. Clinical Global Improvement scale ratings were statistically significant (p < 0.001). Increased sociability was reported in 3 subjects by their parents and family following the study. Three patients continued on risperidone for over 2 years, and none showed any loss of its apparent therapeutic effects. Weight gain was observed in 5 of 6 patients, with a median increase of 5.4 kg (12 lbs) in 7 weeks. Other side effects included transient sedation, increased salivation, and stereotypies. One child showed a worsening of pre-existing tic and phobic symptoms after 5 months of successful monotherapy. No loss of therapeutic effect was noted in the 3 subjects who remained on risperidone for over 2 years, but 1 patient developed hepatotoxicity and another developed withdrawal dyskinesia, similar to her prior experience with haloperidol. Overall, 5 of the 6 patients derived significant clinical benefits from risperidone. Pharmacologic alternatives for treating behavioral symptoms in PDD are need, and risperidone may be a promising possibility.     

Sudden gains in prolonged exposure for children and adolescents with posttraumatic stress disorder.

Objective: Our objective was to examine sudden gains during developmentally adjusted prolonged exposure for posttraumatic stress disorder (PTSD) among children and adolescents. We hypothesized that sudden gains would be detected and would be predictive of treatment outcome and follow-up. Method: Sixty-three youngsters (ages 8–17) completed a developmentally adjusted protocol for the treatment of pediatric PTSD (Foa, Chrestman, & Gilboa-Schechtman, 2008). Participants' posttraumatic and depressive symptoms were assessed before each treatment session, as well as at approximately 3 and 12 months after treatment termination. We measured posttraumatic symptoms with the Child PTSD Symptom Scale (Foa, Johnson, Feeny, & Treadwell, 2001) and measured depressive symptoms with the Beck Depression Inventory (Beck, Ward, Mendelson, Mock, & Erbaugh, 1961) and the Children's Depression Inventory (Kovacs, 1981, 1982). Results: Sudden gains were found among 49.2% of participants and constituted 48.6% of the total reduction in posttraumatic symptoms. Compared to individuals who did not experience sudden gains, individuals who experienced sudden gains reported lower levels of posttraumatic symptoms, F(1, 61) = 14.4, p