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OBSESSIVE-COMPULSIVE DISORDER IN CHILDREN AND ADOLESCENTS - Coggle Diagram
OBSESSIVE-COMPULSIVE DISORDER IN CHILDREN AND ADOLESCENTS
EPIDEMIOLOGY
Obsessive-Compulsive Disorder (OCD) is a psychiatric condition marked by intrusive thoughts and repetitive behaviors.
Previously thought rare in youth, studies now estimate its prevalence among children and adolescents at 0.25%–4%
If left untreated, symptoms can last a long time, causing severe functional impairment in many areas of life, including the home, school, and social settings.
Paediatric OCD is associated with an increased risk of acquiring other psychiatric illnesses in maturity.
AETIOLOGY
Pediatric OCD's etiology is complex, with genetics playing a significant role, supported by twin and family studies showing a heritability of 45%–65%
Genetic influence appears greater in pediatric than adult cohorts.
Genome-wide association studies suggest a polygenic influence, involving genes related to serotonin, dopamine, and glutamate.
Neuropsychological models implicate alterations in frontostriatal circuitry, particularly hyperactivation of the orbitofrontal cortex.
Treatment studies show reduced orbitofrontal activation following cognitive behavior therapy (CBT).
An emerging subgroup, termed PANS (Pediatric Acute-Onset Neuropsychiatric Syndrome), presents sudden-onset OCD and/or tics post-streptococcal infection, with broader neuropsychiatric symptoms.
Treatment approaches targeting immune and infectious causes are explored, but standard therapies also show efficacy.
ASSESSMENT AND DIAGNOSIS
OCD diagnosis in youth often faces delays due to factors like embarrassment, poor insight, and symptom heterogeneity.
The Short OCD Screener (SOCS), a six-question screening tool, demonstrates a high sensitivity of 97% in detecting OCD
Although not diagnostic, positive screenings require further assessment, including detailed history-taking and individual interviews, crucial for addressing sensitive obsessions that may be withheld in family settings.
TREATMENT
Cognitive Behavioral Therapy (CBT) with Exposure and Response Prevention (E/RP).
CBT, typically delivered over 12-20 sessions, focuses on gradual exposure to feared situations while refraining from compulsions
Randomized controlled trials (RCTs) show CBT reduces symptoms by 40%-65%, with gains lasting up to 18 months.
CBT is recommended as first-line treatment for mild to moderate cases
Selective Serotonin Reuptake Inhibitors (SSRIs)
SSRIs, such as sertraline and fluvoxamine, are effective when CBT alone is insufficient.
Combined CBT and SSRIs yield superior outcomes compared to either treatment alone. Brief CBT instructions alone are not as effective as full CBT or medication alone.
TREATMENT-RESISTANT OCD
Some young people with OCD do not respond to CBT or SSRIs, while others have residual symptoms post-treatment.
Comorbidities like tic disorders and externalizing disorders may impact treatment response. For instance, those with tic disorders may respond better to CBT than SSRIs.
Modifications, such as combining CBT with parent management for externalizing disorders, may be beneficial.
Individuals with Autism Spectrum Disorders (ASDs) may also require modified CBT protocols.
If initial treatments fail, additional trials of SSRIs or clomipramine may be considered.
Augmenting SSRI medication with a low dose of a dopamine antagonist may improve response rates for non-responders.
exposure-based CBT remains the preferred option, as risperidone augmentation shows less favorable outcomes.
FUTURE DIRECTIONS
Dissemination of quality CBT for pediatric OCD is hindered by geographical barriers and therapist shortages.
Research aims to enhance accessibility, exploring methods like telephone or web-camera-delivered CBT and internet-based CBT with minimal therapist input.
Efforts also focus on improving CBT outcomes, particularly for non-responders.
Family therapy targeting dynamics like family conflict and parental blame shows promise as an adjunct to CBT
Pharmacologically, d-cycloserine (DCS) augmentation of CBT for OCD is investigated, but findings are mixed, requiring further research for validation.
CONCLUSIONS
OCD often begins in childhood and can persist into adulthood, causing significant distress and impairment
It is ranked by the WHO as one of the most impairing illnesses.
National guidelines recommend evidence-based treatments such as CBT, often combined with medication.
inadequate provision of CBT limits access to effective treatments.
Current research focuses on developing more accessible and economical formats of CBT, as well as understanding the genetic and biological basis of OCD, including its relationship with infections/autoimmunity, to offer new treatment possibilities.
DIAGNOSTIC CRITERIA AND CLASSIFICATION
Obsessive-Compulsive Disorder (OCD) in young people shares similarities with adults but differs in terms of insight into obsessions and compulsions due to underdeveloped meta-cognitive skills.
It's important to distinguish between true compulsions and normal routines in children, with compulsions causing distress or impairment.
Historically classified as an anxiety disorder, OCD is now categorized separately in DSM-5 under "OCD and related disorders," acknowledging key differences in phenomenology and etiology compared to other anxiety disorders.
This section also includes disorders characterized by repetitive thinking and behavior such as body dysmorphic disorder, hoarding disorder, and trichotillomania.
DIFFERENTIAL DIAGNOSIS
Autism Spectrum Disorders (ASDs) and OCD
Behaviours in ASD may resemble compulsions, however actual compulsions are usually preceded by obsessions, provide respite from anxiety, and are ego-dystonic.
Comorbid OCD and ASD are common, and treating OCD in ASD can improve functioning.
OCD and Tic Disorders
OCD and tic disorders can overlap, but tics are largely involuntary, while compulsions are deliberate actions to relieve anxiety.
Complex tics are simpler than compulsions
Psychosis and OCD
Distinguishing between psychosis and OCD can be challenging, especially when obsessions have a bizarre nature.
Some individuals with OCD experience "transformation obsessions" or aggressive thoughts, which may resemble delusions.
However, with OCD, individuals often retain some understanding of the absurdity of their fears , and the obsessions are unlikely to be part of a larger delusional system.
Presence of other OCD symptoms and absence of hallucinations or thought disorder can aid in the differentiation between OCD and psychosis.
ABSTRACT
Childhood and adolescent Obsessive-Compulsive Disorder (OCD) is a debilitating condition characterized by intrusive thoughts and repetitive rituals.
This review examines the current understanding of its causes, mechanisms, assessment, and treatment.
Recommended treatments include cognitive-behavioral therapy and serotonin reuptake inhibitors, with factors contributing to treatment resistance outlined.