Obsessi

veCompul
sivedisor
derinChi
l
drenandAdol
escent
s
Aar
yaKr
ishnanRajal
akshmi,MBBS,
MD

Scope
Epi
demi ol
ogy
Pathophysi
ology
Cli
nicalf
eatures
Assessment
Management
CourseandPr ognosi
s

Epi
demiol
ogy
OCD–commonandsevereNeuropsy
chiat
ri
cdisor
der
Aff
ect
s1to3%ov
eral
lpopul
ati
on.Lifet
imepreval
ence–2.
3%

(
Rusci
o,2010)
Oneoft
op10causesofgl
obal
disabi
l
ity

(Lee,2019)
Epidemiology
Twopeaks: youngadul
thood(mean19.5yr
s)andadol
escence( mean-14y
rs)
(DSM 5,2013)
Recentinternati
onalmult
isi
terepor
t-<18onset–50%ofthesampl e
(Dell
’
Osso, 2016)
Epidemiology
Epi
demiol
ogy
Meanageofonset
-10.3± 2.5year
s
Meanageofascer
tai
nment -13.2year
s
Ear
li
eronseti
nmales(25%mal eshaveonset<10)
I
nfemalesthesl
opeissteepestinadolescenty
ears
(Rusci
o2010)

Epidemiology -Comor bidity

Comor bidit
yi sther ule-74%hadat l
east1comor biddiagnosis
Comor bidit
y-lowerr esponse, remissionwi
thCBT
Disrupti
veBehav iorDisor der-t
herapeuti
cchallenge
Ti
cdi sorders,ADHD-al termedi cati
onapproach
Bipolardisorders-chal l
engesSSRIuse
Assessf or’OCspect r
um’ conditi
ons-BDD,BFRB
Autism Spect rum Disor ders
(Storchetal,2008)
Pathophy si
ology -Neur ocircuit
ry

Pathophy si
ology-Neur
opsy
chol
ogy
I
mpai r
ment si n:
Executiv
ef uncti
on
Attent
ion
Visuo-
spat i
alfuncti
oni
ng
Shortterm memor y
Processingspeed
(Lee,
2019,
Gel
l
er2012)
Pathophysi
ology
-Neur ot
ransmitt
ersyst
ems
Serotoni
nergi
csy stems–SSRIs,geneassoci
ati
ons
Dopami ner
gicsystems-Anti
psychot
icaugmentat
ion,
genet
ics
Glutamater
gicsystems
 (Lee,
2019)
Genetics
Familystudies-OCDi
smor epreval
enti
nrel
ati
vest
hanGenpop–10-12%v s1t
o3%
Heri
tabil
ity
-45t o65%forchi
ldhoodonsetOCDvs27to45%adaul
tonset
(Lee,2019)
Genetics

(Lee,
2019)
Genet
ics
Candi
dat
egeneappr
oach

Ani
mal
model
s Gene
SAPAP3

SLI
TRK5
HOXB8

SLC1A1/
EAAC1

(Lee,
2019)
Genetics
Recenteffort
s-GenomeWideAssociati
onStudi
es -4t odat
ewi t
hv ary
ingfi
ndi
ngs
Geneticpathwaysli
nkupt
otheglut
amet er
gicsy
stem cal
li
ngforagentsthatwor
k
thi
sway(Ri l
uzol
e,Memati
ne,NAC)
Conclusi
on-polygeni
cmodelofvul
nerabil
i
ty

(Lee,
2019)
I
mmunologicalbasi
s
PANDAS(Pediatr
icAutoimmuneNeur
opsy
chi
atr
icdi
sor
derAssoci
atedwi
th
St
rept
ococcali
nfect
ion)-Swedo
I
mmunol ogi
calbasi
s
Pedi
atr
icAcuteNeuropsy
chi
atr
icsy
ndr
ome(
PANS)
I
mmunol ogical basis
PANDAS/ PANSt reatmentresear
ch
 Ant ibioticprophyl
axis
 I VI
G
 Cor ticosteroids
 NSAI DS
 Ther apeut icplasmaexchange
 Tonsi ll
ectomy
I
mmunol ogical basis
Abroaderst ateofNeur oinfl
ammati
onandorAut
oimmuni
tyi
nOCD
Cli
nical f
eat ures
Cont i
nui tywi t
hadul tpr esentation
Mostsubj ectshadmul t
ipleobsessi onsandcompul sionst hathadchangeov erti
me
i
nt heircont entandsev erit
y
Dev el
opment al t
hemes, l
imi t
edi nsight
(Hanna, 1995)
Cli
nical f
eat ures
Compul sionswi thoutclearobsessi ons-commoneri ny oungerchi l
dren
Ritualsapar tfrom typicalcompul sions(br eathing,blinking)
Mostcommonobsessi ons: f
earofacat astrophi cev ent,cont aminati
on,
sexual /somat i
ct hemes, excessi vescruples/ guilt
Mostcommoncompul sions: washi ng,checking, order i
ng, repeat
ing
(AACAPpr acticeparamet ers,
2012)
Cli
nical f
eat ures
Sensor yphenomena-phy sical
/ment alarecommon
Sensor yov er-
responsi venessandhy persensitivi
tyfrequent -upto32%t act
il
e
hyper sensi ti
vityintreatmentseeki ngkids
Just -
rightper cept i
onsar ev erycommon–upt o51%ofmi xedOCpopul ati
onsand
precede/ i
nst i
gatecompul sions.
Sensor yphenomena-seent obemoder atelyassoci atedwi thcompul si
onsev er
it
y
andi mpai r ment
Justr ightper cept i
ons-associ ationwithpoor ertreatmentr esponse

(Hought
on,2020)
Assessment
Needtoscreenforsy
mpt
oms
Obsessi ons“ Doy ouhav er epeatedt hought s,ur
ges,i
mpulsesthatupsetyou,
make
youanxi ousadt haty oucannotsuppr ess?
Youngerki ds: “Doy ouhav ewor riest hatwon’ tgoaway ?
”
Exampl eshel p
Compul si ons: “Doy ouev erhav et odot hingsoverandoveragaineventhoughyou
don’twantt oory ouknowt heydon’ tmakesense. .
?”
Youngerones: “Doy oudot hi
ngsov erandov erorhavehabit
syoucan’tstop?
”
Oftenneedt oi nferobsessi ons(av oidance)
Parentrepor tsonCBCL
Assessment
Standard-CY- BOCS-cl inicianadmi nistered
10item anchor edor dinal scale(0t o4)
1.Ti mespent
2.Di stress
3.I nter ference
4.Resi st ance
5.Cont rol
• Scor esdi stingui shsev er
it
y :8t o15( mild)
,16to23(moder at
e)and
>24(sev ere)
• Sy mpt om checkl i
stofov er60sy mpt oms
Assessment
Standard-CY- BOCS-cl inicianadmi nistered
10item anchor edor dinal scale(0t o4)
1.Ti mespent
2.Di stress
3.I nter ference
4.Resi st ance
5.Cont rol
• Scor esdi stingui shsev er
it
y :8t o15( mild)
,16to23(moder at
e)and
>24(sev ere)
• Sy mpt om checkl i
stofov er60sy mpt oms
Assessment
Screenf orcomor bidity
Screenf ormedi cal il
lnesses
Fami l
yhi stor y
Fami l
yaccommodat i
on
Educational ev al
uat ion
Treatment
CBT, SSRI s

Tr
eatment
CBT-recommendedfi
rstl
inei
npedi atr
icOCD
CBTf orOCD–ExposureandResponsePr ev enti
onwitht hegoal
ofhabi
tuat
ion
Tr
eatment
POTS(Pediatr
icOCDtr
eatmentstudy)–al andmar kstudy
3tr
eat mentsi
tes,
4ar
ms: Ser
tral
ine,CBT,Combi ned,Placebo
Outcome-YBOCsscorecompar i
sonsandr emi ssionr
ates
Remi
ssi
on:
Combi
ned(
53%)=CBT(
39%)>ser
tral
i
ne(
21%)
>Pl
acebo(
3%)

Treatment-CBTvari
ati
ons
FamilybasedCBT
GroupCBT
I
nternetCBT
Treatment-Moderat
orsofr
esponset
oCBT
Severi
ty
I
mpai rment
Comor bi
dill
ness
Familyaccommodat i
on
I
nsight

(Garci
a,2010)
Treatment-Pharmacotherapy
SSRIsarefirstl
i
ne
Clomipramine
Augment ati
onrole-At
ypicalant
ipsy
chot
icsandot
her
s

Treat
ment -Pharmacotherapy
SSRIs–f i
rstl
inemedi cat
ion
Moderatetosev ereOCD
Comor bi
dDepr essiv
edisorder
Multi
pleRCTs
Treat
ment -Pharmacotherapy

Tr
eat
ment
-Phar
macot
her
apyVsCBT
Treatment-Pharmacotherapy
SSRI-well
t ol
erat
ed
‘
Startlow,
gosl ow’….
’
wai tl
onger,gohi
gher
’?
10–12weekopt i
maltri
al dur
ati
on

Treatment-r
esi
stance
Treatment–ref
ractoryOCD: afai
lur
etorespondtoanadequatecourseofCBTand
atleast2SRImedicati
on(2SSRI sORSSRI+Cl omipr
amine)
Response-25–35%r eductioni
nYBOCSscor es
AdequateCBT–at least8to10weekl ysessi
onsbyatrai
nedtherapi
st
AdequateSSRItr
ial-at
least10-12weeksatthemaximum tol
erabledose

Treatment-resistance-Appr oaches:
Rightdiagnosis?Opt i
mum t reatment ?
Scopef ormaxi mizingdose/dur at
ion?
Moder ati
ngfact ors?
Augment ati
onopt i
ons:Clomi pramine,Anti
psychot
ics,
Glutamater
gicagent
s(NAC,
Ril
uzole,Memant i
ne,d-Cl
y coserine),Buspi
rone,
Benzodiazepi
nes)
Neurostimulati
on

Treat
ment -Comor bidil
lnesses
Ticdi
sorder -Addant ipsychoti
cmedi cati
on, al
phaagonist
s
Bipol
ardisor der-Pri
orit
izemoodst abili
zati
on
ADHD–pr ior i
ti
zeOCDt reat
ment ,
sti
mul antrel
atedconcer
ns,
Atomoxet
ine/Al
pha
agoni
stchoi ces
ASD-phenomenol ogi
cal/diagnosti
cchal l
enges,SSRIt
reat
ment
DBD-behav ioral t
reatments

Longterm pr
ognosis
NORDLOTS(Nor di
cLong-t
erm OCDtreat
mentstudy)
Norway,Denmark,Sweden
N=269aged7t o17yrs
14weeksCBT
Nonresponders(YBOCS>15):16weeksofSert
rali
ne/CBT
Fol
low-upofupto3y ear
s-73%remit
tedand90%r emit
ted

Longterm prognosis
OurMAof11st udies
-62%r emi
tted(YBOCS<10)
Av er
age10poi ntreduct
ioni
nYBOCSscor
eov
eramean3y
earf
oll
ow-
up
Fut
uredirections
Pat
hophy si
ol ogical
basis-i
mmune-medi
atedbasis
Neuroi
magi ng
Per
soncent er edPredict
orsoft
reat
mentresponse
Medicat
ion/augment ati
on
Neurost
imul ation