Is juvenile obsessive-compulsive disorder a developmental subtype of the disorder? A review of the pediatric literature

Functional impairment in clinical samples of Norwegian and Swedish children and adolescents with obsessive-compulsive disorder

The aims of the present study were to examine OCD-related impairments in clinical cases of childhood OCD and to replicate and extend previous research on OCD-related impairments.

METHOD

Sixty-eight patients aged 8-17 years recruited from four child psychiatric outpatient clinics in Norway and Sweden with a confirmed DSM-IV diagnosis of OCD were included in the study. All patients and their parents were interviewed for diagnosis and comorbidity (KSADS),OCD symptoms and severity (CY-BOCS), and global impairment (CGAS). OCD-specific impairments were assessed by means of the Child OCD Impact Scale (COIS), a 58 item questionnaire with parallel parent and child versions.

RESULTS

Overall, the majority of patients suffered from substantial impairments. The impact of OCD symptoms was found to be most severe at home, but impairments were also prominent in situations related to school and social settings.

CONCLUSIONS

Our study supports findings of previous research suggesting multiple impacts of OCD symptoms on children's psychosocial functioning. We conclude that impairment issues should be further addressed in future research to establish a better empirical basis for the understanding of different aspects of OCD-related impairment.

Familial and sporadic subtypes of early-onset Obsessive-Compulsive disorder

BACKGROUND

Family studies of Obsessive-Compulsive (OCD) indicate there is substantial heterogeneity in the familiality of the disorder. This study was done to determine whether there are differences between familial and sporadic probands with early-onset OCD in obsessive-compulsive (OC) symptom categories and comorbid psychiatric diagnoses.

METHODS

We ascertained 50 OCD probands ranging in age from 10 to 19 years with an onset of OC symptoms before age 15 years. All probands were directly assessed with semistructured diagnostic interviews; their first-degree and second-degree relatives were directly or indirectly assessed with similar diagnostic instruments. Descriptive data were compared in 33 familial and 17 sporadic OCD probands using logistic regression to control for age, gender, and age at onset of OC symptoms.

RESULTS

Ordering compulsions were significantly more common in the familial OCD probands. Aberrant grooming behaviors were significantly more frequent in the familial subgroup with skin picking contributing significantly to that difference. Anxiety disorders other than OCD were also significantly more frequent in the familial subgroup with phobic disorders contributing significantly to that difference.

CONCLUSIONS

The results indicate that familial and sporadic forms of early-onset OCD may be differentiated by ordering compulsions, aberrant grooming behaviors, and anxiety disorders other than OCD.

A family study of obsessive-compulsive disorder with pediatric probands

Obsessive-compulsive disorder (OCD) is a heterogeneous disorder of unknown etiology. We examined the lifetime history of obsessions, compulsions, and OCD in the first- and second-degree relatives of 35 pediatric probands with OCD and 17 controls with no psychiatric diagnosis. All available first-degree relatives were directly interviewed blind to proband status with two semi-structured interviews. Parents were also interviewed to systematically assess the family psychiatric history of first- and second-degree relatives. Best-estimate lifetime diagnoses were made using all available sources of information. Data were analyzed with logistic regression by the generalized estimating equation method and with robust Cox regression models. The lifetime prevalence of definite OCD was significantly higher in case than control first-degree relatives (22.5% vs. 2.6%, P < 0.05). Compared to controls, case first-degree relatives also had significantly higher lifetime rates of obsessions and compulsions (both P < 0.05). There was no significant difference between case and control second-degree relatives in lifetime rates of OCD. First-degree relatives of case probands with ordering compulsions had a significantly higher lifetime rate of definite and subthreshold OCD than relatives of case probands without ordering compulsions (45.4% vs. 18.8%, P < 0.05). The lifetime prevalence of definite OCD was significantly higher in case first-degree relatives with a history of tics than in case first-degree relatives without a tic history (57.1% vs. 20.9%, P < 0.01). The results provide further evidence that early-onset OCD is highly familial and suggest that two clinical variables are associated with its familial aggregation.

Obsessive-compulsive disorder phenotypes: implications for genetic studies

Obsessive-compulsive disorder (OCD) clinical presentation is remarkably diverse, and can vary both within and across patients over time. This variability in the phenotypic expression has led to the hypothesis that OCD is a heterogeneous disorder and that this heterogeneity obscures the findings of clinical, natural history and treatment response studies and complicates the search for vulnerability genes. A complete understanding of what comprises OCD and the underlying etiological mechanisms will require a dramatic change in how the disorder is conceptualized. In this review, several different approaches that may represent the first steps in this reconceptualization are discussed. These approaches include (1) narrowing the phenotype to identify categorically defined more homogeneous and mutually exclusive subtypes of OCD, (2) considering OC symptom dimensions as quantitative components of the more complex OCD phenotype and (3) broadening the phenotype to include other etiologically related conditions. A combined dimensional approach within distinctive subgroups is proposed as probably the most effective in helping to identify the heritable components of OCD. By identifying heritable components of OCD, it should be possible to find genes for these separate components. The review continues with the illustration of the possible role of some epigenetic risk and protective factors in the OCD presentation and the relevance of examining associated traits and/or endophenotypes to enhance our ability to understand the genetic basis of OCD. To conclude, we discuss the variability in treatment outcome and the significance of the development of specific pharmacological and/or behavioral based therapies tailored to each of these phenotypes.

Current directions in pediatric obsessive-compulsive disorder

Pediatric OCD, a chronic and impairing condition, is not uncommon. Diagnosis is often difficult given the secrecy of many patients and co-occurring psychopathology. CBT alone or CBT with concurrent SSRI therapy are considered the first-line treatment. Nevertheless, relatively few mental health professionals are adequately trained in CBT for OCD. For example, in a national survey of 79 clinicians treating pediatric OCD in Norway, less than 33% of clinicians reported using exposure/response prevention (or similar techniques) despite rating CBT as a favorable approach to treatment. Limited access to professionals proficient in CBT may result in the prescription of pharmacotherapy alone or pharmacotherapy with other concurrent psychotherapies (that are not demonstrated as efficacious). Clearly, improving the referral network to experts trained in CBT for OCD is necessary to provide efficacious treatment, associated with reduced rates of relapse. Intensive CBT may extend resources to families without access to trained professionals in their area, given the potential for effective therapy in a succinct time period. Accordingly, in addition to the controlled trial evaluating CBT, pharmacotherapy, and combined treatment, initial investigations of intensive CBT for pediatric patients appear necessary. Additionally, intervention studies for children with significant comorbid psychopathology should be pursued.

Obsessing/worrying about the overlap between obsessive-compulsive disorder and generalized anxiety disorder in youth

In the treatment of anxious youth, children's symptom presentations cannot always be readily distinguished as indicative of obsessive-compulsive disorder (OCD) or generalized anxiety disorder (GAD). Following a definition and brief description of the phenomenology, epidemiology, and treatment of OCD and GAD in youth, consideration is given to factors that contribute to the proximity of the two disorders. In an effort to better understand the distinctive and overlapping features of these neighboring disorders, we review (a) obsessions and worry, with reference to process, form, content, and metacognitive beliefs, and (b) the literature on pathological worry and covert compulsions. Studies from the adult literature are considered throughout, and the absence of related work with samples of youth, within a developmental framework, is highlighted. Suggestions for future research are offered.

Cluster analysis of obsessive-compulsive spectrum disorders in patients with obsessive-compulsive disorder: clinical and genetic correlates

BACKGROUND

Comorbidity of certain obsessive-compulsive spectrum disorders (OCSDs; such as Tourette's disorder) in obsessive-compulsive disorder (OCD) may serve to define important OCD subtypes characterized by differing phenomenology and neurobiological mechanisms. Comorbidity of the putative OCSDs in OCD has, however, not often been systematically investigated.

METHODS

The Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition , Axis I Disorders-Patient Version as well as a Structured Clinical Interview for Putative OCSDs (SCID-OCSD) were administered to 210 adult patients with OCD (N = 210, 102 men and 108 women; mean age, 35.7 +/- 13.3). A subset of Caucasian subjects (with OCD, n = 171; control subjects, n = 168), including subjects from the genetically homogeneous Afrikaner population (with OCD, n = 77; control subjects, n = 144), was genotyped for polymorphisms in genes involved in monoamine function. Because the items of the SCID-OCSD are binary (present/absent), a cluster analysis (Ward's method) using the items of SCID-OCSD was conducted. The association of identified clusters with demographic variables (age, gender), clinical variables (age of onset, obsessive-compulsive symptom severity and dimensions, level of insight, temperament/character, treatment response), and monoaminergic genotypes was examined.

RESULTS

Cluster analysis of the OCSDs in our sample of patients with OCD identified 3 separate clusters at a 1.1 linkage distance level. The 3 clusters were named as follows: (1) "reward deficiency" (including trichotillomania, Tourette's disorder, pathological gambling, and hypersexual disorder), (2) "impulsivity" (including compulsive shopping, kleptomania, eating disorders, self-injury, and intermittent explosive disorder), and (3) "somatic" (including body dysmorphic disorder and hypochondriasis). Several significant associations were found between cluster scores and other variables; for example, cluster I scores were associated with earlier age of onset of OCD and the presence of tics, cluster II scores were associated with female gender and childhood emotional abuse, and cluster III scores were associated with less insight and with somatic obsessions and compulsions. However, none of these clusters were associated with any particular genetic variant.

CONCLUSION

Analysis of comorbid OCSDs in OCD suggested that these lie on a number of different dimensions. These dimensions are partially consistent with previous theoretical approaches taken toward classifying OCD spectrum disorders. The lack of genetic validation of these clusters in the present study may indicate the involvement of other, as yet untested, genes. Further genetic and cluster analyses of comorbid OCSDs in OCD may ultimately contribute to a better delineation of OCD endophenotypes.

Impulsive disorders in Japanese adult patients with obsessive-compulsive disorder

In this study, we sought to characterize obsessive-compulsive disorder (OCD) patients with impulsive features, and to determine whether they constitute a distinct subtype of OCD. Therefore we systematically assessed impulse control disorders and other impulsive conditions categorized as obsessive-compulsive spectrum disorders (OCSDs) in 153 Japanese adult patients with OCD. Forty-five subjects (29%) had concurrent impulsive disorders, and they were differentiated from other OCD patients on a range of demographic features (e.g., younger age at onset), and clinical features (e.g., pervasive and severe psychopathology, and poor treatment outcome). However, on logistic regression, none of these variables predicted comorbid impulsivity. The findings appear to support the argument that OCD patients with impulsive features constitute a subtype of OCD. However, further research is necessary to determine whether impulsivity should be conceptualized as lying on a spectrum with compulsivity or as a dimension that is orthogonal to compulsivity.

A critical evaluation of obsessive-compulsive disorder subtypes: symptoms versus mechanisms

Recently, experts have suggested that obsessive-compulsive disorder (OCD), a highly heterogeneous condition, is actually composed of distinct subtypes. Research to identify specific subtypes of OCD has focused primarily on symptom presentation. Subtype models have been proposed using factor analyses that yield dimensional systems of symptom categories, but not necessarily distinct subtypes. Other empirical work has considered the role of neuropsychological functioning and comorbidity as part of a comprehensive scheme for subtyping OCD. The identified dimensions from all of these studies have implications for the treatment of OCD. In this article, we review the research on subtypes of OCD, focusing on subtype schemes based upon overt symptom presentation and neuropsychological profiles. We also review research pertinent to alternative subtyping schemes, both conceptually and methodologically. The research is critically examined and implications for treatment are discussed. Recommendations for future investigations are offered.

Early- versus late-onset obsessive-compulsive disorder: investigating genetic and clinical correlates

There is increasing evidence that obsessive-compulsive disorder (OCD) is mediated by genetic factors. Although the precise mechanism of inheritance is unclear, recent evidence has pointed towards the involvement of the serotonergic and dopaminergic systems in the disorder's development. Furthermore, early-onset OCD appears to be a subtype that exhibits distinct clinical features and that is associated with greater familial loading. In the present investigation, South African OCD patients (n=252) were stratified according to age of onset and were clinically assessed. Additionally, selected variants in genes encoding serotonergic and dopaminergic components were investigated in a Caucasian OCD subset (n=180). This subgroup was further stratified to evaluate the role that these candidate genes may play in the genetically homogeneous Afrikaner subset (n=80). Analysis of the clinical data revealed an association between early age of onset and an increased frequency of tics, Tourette's disorder, and trichotillomania (TTM). The genetic studies yielded statistically significant results when the allelic distributions of genetic variants in the dopamine receptor type 4 gene (DRD4) were analysed in the Caucasian OCD cohort. These data support a role for the dopaminergic system, which may be relevant to the development of early-onset OCD.

Age differences in an animal model of obsessive–compulsive disorder: participation of dopamine

The putative age difference in the effect of chronically administered quinpirole (0.125 and 0.5 mg/kg, 11 injections) on alternation in a T maze was studied. Male juvenile (43 days old) and adult (around 90 days old) rats exhibited similar control values of alternation. In adults, quinpirole (0.5 mg/kg) produced a drastic perseveration after 10 and 11 injections (mean number of repetitive choices of 3.4 and 3.1, respectively); conversely, in juvenile, such treatment produced a less marked perseveration (mean number of repetitive choices of 1.7 and 2.1, for the 10th and 11th injection, respectively). We also studied the age difference in the protective actions of clomipramine subchronically administered (15 mg/kg, three times) on the quinpirole-induced perseveration. Clearly, as previously demonstrated, in adult animals, this tricyclic antidepressant completely prevented the drug-induced perseveration (mean number of repetitive choices of 1.7); while in juvenile, animals only produced a weak action (mean number of repetitive choices of 1.8). Data agreed with basic research showing a hyposensitivity of juvenile animals to dopaminergic agonists and with clinical findings suggesting a weaker effect of clomipramine treatment in youth. These results reinforce perseveration in a T maze as a useful animal model for studying age differences in obsessive-compulsive disorder (OCD).

Sex differences on spontaneous alternation in prepubertal rats: implications for an animal model of obsessive-compulsive disorder

Sex differences in the prevalence of obsessive-compulsive disorder (OCD) in prepubertal children have been described. Deficits on spontaneous alternation behavior (SAB) have been proposed as an animal model of OCD.

OBJECTIVES

To explore possible sex differences in the ontogeny of SAB and in the effect of the 5-HT1A agonist, 8-OH-hydroxy-2 (di-n-propylamino)-tetralin (8-OH-DPAT) in an animal model of OCD.

METHODS

The ontogeny of SAB and the perseveration produced by 8-OH-DPAT were compared between male and female prepubertal rats.

RESULTS

Males alternated their arm choose from postnatal day 32 onwards, while females perseverated in the chosen arm until postnatal day 38. The mean number of repetitive choices remained close to 1 in males from postnatal day 23 onwards, but females showed a mean number of repetitive choices higher than 1.5 until the end of the test. The 8-OH-DPAT (0.125, 0.5 and 2.0 mg/kg, 15 min) produced perseveration in males but not in females.

CONCLUSIONS

These data show important sex differences in the ontogeny of SAB and the effect of 8-OH-DPAT in a model of OCD. Such differences could be relevant for the sex differences in the prevalence of childhood OCD.

Long-term outcome of pediatric obsessive-compulsive disorder: a meta-analysis and qualitative review of the literature

OBJECTIVE

To review the extant literature on the long-term outcome of child/adolescent-onset obsessive-compulsive disorder (OCD).

METHOD

Medline and Psychlit databases were systematically searched for articles regarding long-term outcomes of child/adolescent-onset OCD. Meta-analysis regression was applied to evaluate predictors and persistence of OCD.

RESULTS

Sixteen study samples (n = 6-132; total = 521 participants) in 22 studies had follow-up periods ranging between 1 and 15.6 years. Pooled mean persistence rates were 41% for full OCD and 60% for full or subthreshold OCD. Earlier age of OCD onset (z = -3.26, P = 0.001), increased OCD duration (z = 2.22, P = 0.027) and in-patient vs. out-patient status (z = 2.94, P = 0.003) predicted greater persistence. Comorbid psychiatric illness and poor initial treatment response were poor prognostic factors. Although psychosocial function was frequently compromised, most studies lacked comprehensive outcome measures.

CONCLUSION

Long-term persistence of pediatric OCD may be lower than believed. Future studies should include broader measures of outcome including symptomatic persistence and functional impairment in multiple domains.

Elevated brain serotonin transporter availability in patients with obsessive-compulsive disorder

BACKGROUND

A central serotonergic dysfunction is considered to be involved in the pathophysiology of obsessive-compulsive disorder (OCD). The aim of this study was to investigate the serotonin transporter availability in patients with OCD as an in vivo marker of the central serotonergic system.

METHODS

Nine unmedicated (7 drug-naive) patients with OCD and 10 healthy control subjects were included and received single photon emission computed tomography (SPECT) 20.75 +/- 1.51 hours after injection of a mean 147.20 +/- 6.74 MBq [(123)I]-2beta-carbomethoxy-3beta-(4-iodophenyl)tropane ([(123)I]beta-CIT). As a measure of brain serotonin transporter availability, a ratio of specific-to-nonspecific [(123)I]beta-CIT binding for the midbrain-pons (V(3)" = [midbrain/pons-occipital]/occipital) was used.

RESULTS

Mean specific-to-nonspecific ratios showed a 25% higher midbrain-pons [(123)I]beta-CIT binding in the patients as compared with healthy controls (2.26 +/-.37 vs. 1.81 +/-.23, p <.01). The difference remained significant after adjustment for clinical variables and controlling for age and gender. Stratification of the patients according to onset of the disorder revealed significant differences between controls and patients with early (childhood, adolescence) but not late (adult) onset of OCD.

CONCLUSIONS

The study provides evidence of a serotonergic dysfunction in patients with OCD and suggests a serotonergic component in the pathophysiology of the disorder.

Influence of age and tic disorders on obsessive-compulsive disorder in a pediatric sample

BACKGROUND

Obsessive-compulsive disorder (OCD) is a heterogeneous disorder with emerging data suggesting that age of onset and/or the presence of tics may define clinically important subgroups.

OBJECTIVE

This study set out to evaluate the impact of age and tic disorders on the symptom profile in a pediatric sample of patients with OCD ascertained from a specialty clinic.

METHODS

Eighty children with OCD (50 boys, 30 girls) were assessed for symptom type, severity, age of onset, presence of a tic disorder, and functional status. Each child's most impairing obsessions and compulsions were identified and compared by age category (above and below the age of 11 years) and according to the presence or absence of a tic disorder.

RESULTS

The mean age of the sample was 11.1 +/- 3.19 years (range 4-18 years). The most common obsessions reported were contamination and worries about harm. Common compulsions included washing and rituals to prevent harm. The only significant differences across age groups were the percentage of religious worries and slightly higher severity of obsessions in the adolescent age group (p < 0.05). The presence of tics was associated with increased frequency of repetitive behavior unrelated to harm avoidance (p < 0.05). Children without a history of tics were more likely to describe incidents of contamination, washing, and repetitive request for reassurance (p < 0.05 for each).

CONCLUSION

In this convenient sample of clinically ascertained children, there were few phenotypic differences in children above or below the age of 11 years. Differences in the distribution of OCD symptoms according to the presence or absence of tics, which has been documented in adult samples, were evident in this sample.

Family-based treatment of early-onset obsessive-compulsive disorder

Despite a meaningful common core of symptoms observed across the life span, there are particularly unique features of early-onset (prepubertal) obsessive-compulsive disorder (OCD) that make consideration of early presentation different from adolescent or adult onset and that may have important implications for treatment. This article will first review the unique features of early-onset OCD, focusing particular attention to the developmental and familial context of these children's symptoms. The literature on behavioral family interventions for other childhood disorders, specifically anxiety, as well as that on family processes (e.g., parent-child interactions) in families of children with OCD will be reviewed. The pediatric OCD cognitive-behavioral therapy (CBT) literature (CBT alone and CBT plus medication) will also be reviewed, focusing on current evidence-based treatment guidelines. Finally, a model of family-based treatment for young children with OCD and some preliminary pilot data will be presented.

Group behavioral therapy for adolescents with tic-related and non-tic-related obsessive-compulsive disorder

Prior research supports the distinction between tic-related and non-tic-related obsessive-compulsive disorder (OCD) based on phenomenologic, etiologic, and neurobehavioral data. The present study examines whether response to psychosocial treatment differs in adolescents, depending on the presence of comorbid tics. Nineteen adolescents, 12-17 years of age, participated in 7-week, uncontrolled trial of group cognitive-behavioral treatment (CBT) for OCD. Eight of the patients had tic-related and eleven had non-tic-related OCD. The group CBT program included psycho-education, exposure and response prevention, cognitive strategies, and family involvement. Significant improvement was observed for all subjects on the Yale-Brown Obsessive Compulsive Scale ratings of obsessions, compulsions, and total OCD symptoms. Outcomes were similar for subjects with tic-related and non-tic-related OCD. These preliminary results suggest that the presence of comorbid tic disorders may not attenuate response to behavioral group treatment among adolescents.

Does comorbid attention-deficit/hyperactivity disorder impact the clinical expression of pediatric obsessive-compulsive disorder?

What is the impact of attention-deficit/hyperactivity disorder (ADHD) on the phenotypic expression of pediatric obsessive-compulsive disorder (OCD). We examined phenotypic features, and functional and clinical correlates in youths with OCD, with and without comorbid ADHD, from a large sample of consecutively referred pediatric psychiatry patients. Although comorbid ADHD had no meaningful impact on the phenotypic expression or clinical correlates of OCD, it was associated with higher rates of compromised educational functioning compared with other OCD youths. Our findings suggest that the OCD phenotype runs true and is not impacted by comorbid ADHD in youths diagnosed with both OCD and ADHD. In such affected youths, both disorders contribute to morbid dysfunction and require treatment. More work is needed to determine whether OCD plus ADHD represents a developmentally and etiologically distinct form of the OCD syndrome.

Early- and late-onset obsessive-compulsive disorder in adult patients: an exploratory clinical and therapeutic study

It has been suggested that early- and late-onset forms of obsessive-compulsive disorder (OCD) may stem from different neurobiological substrates manifesting themselves through particular phenotypic profiles. Our study aimed to assess the existence of clinical and therapeutic differences between adult patients with early- and late-onset OCD (EOCD and LOCD, respectively). Sixty-six patients with OCD were consecutively recruited among individuals seeking treatment in a university hospital clinic for anxiety and depressive disorders. Patients with EOCD (n=33) and LOCD (n=33) were compared and contrasted with regard to clinical and therapeutic characteristics using the two tailed t test for continuous variables and the Pearson's goodness of fit Chi-square test for categorical ones; Fisher's exact test was employed when indicated. We found that, compared to their LOCD counterparts, adult patients with EOCD were characterized by (1) male gender predominance, (2) greater number of clinically significant obsessions and compulsions, (3) higher frequency of rituals repetition, (4) increased severity of obsessive-compulsive symptoms at baseline, and (5) greater number of required therapeutic trials during the follow-up. However, no significant differences between groups were noted in the final treatment outcome. Our results are consistent with previous studies suggesting that EOCD may represent a more severe subtype of this disorder.

Age differences in the sensitivity to clomipramine in an animal model of obsessive-compulsive disorder

RATIONALE

Subtypes of obsessive-compulsive disorder (OCD) related to age could determine differential response to treatment.

OBJECTIVES

To explore possible age differences in the effect of clomipramine in an animal model of OCD.

METHODS

The deficits on spontaneous alternation produced by 8-OH-DPAT and the preventing actions of clomipramine, desipramine and WAY 100635 were compared between young and adult rats.

RESULTS

No age differences were found in spontaneous alternation. The 5-HT(1A) agonist, 8-OH-DPAT (0.031, 0.125, 0.5 and 2.0 mg/kg, -15 min) produced perseveration in young and adult rats. However, young rats were sensitive to a lower dose of 8-OH-DPAT. Clomipramine (10 mg/kg per three administrations) completely prevented the action of 8-OH-DPAT (0.5 mg/kg) in adult rats. However, this treatment as well as higher doses (15 mg/kg 3 administrations) or injected for longer periods (10 mg/kg 5 administrations) produced weak protective effects (versus 0.125 mg/kg 8-OH-DPAT) or had no action (versus 0.5 mg/kg 8-OH-DPAT) in young animals. WAY 100 635 (0.5 mg/kg) blocked the action of 8-OH-DPAT (0.5 mg/kg) in both young and adult rats. Desipramine (10 mg/kg/3 administrations) lacked of a preventive effect on the 8-OH-DPAT (0.5 mg/kg) action. This result indicated that the 5-HT(1A) receptor is involved in the deficits on spontaneous alternation produced by 8-OH-DPAT.

CONCLUSIONS

The present data shows important age differences in the effect of clomipramine in a model of OCD. Such differences could be relevant for the age variations in the response to treatment in clinical practice.

Obsessive-compulsive disorder with and without tics in a clinical sample of children and adolescents

The purpose of this study was to discriminate subtypes of obsessive-compulsive disorder (OCD) in a clinical sample of children and adolescents. Sixty OCD patients were assessed in two outpatient psychiatric clinics; 15 patients had a lifetime history of tics and 45 patients had no tic history. Interviews were conducted with the patients and their parents by a child psychiatrist using the Children's Yale-Brown Obsessive Compulsive Scale (CY-BOCS). The symptom checklist of the CY-BOCS was used to categorize obsessions and compulsions. Discriminant function analysis was used to compare the two groups in their symptomatology. There was no difference between the two groups in seven obsession categories. However, there was a significant difference between the two groups in seven compulsion categories. Ordering, hoarding, and washing compulsions were more common in those with no tic history. The results indicate that tic-related OCD may be differentiated from non-tic-related OCD early in life by the presence or absence of certain compulsive symptoms.

Genome-wide linkage analysis of families with obsessive-compulsive disorder ascertained through pediatric probands

The goal of this study was to identify chromosomal regions likely to contain susceptibility alleles for early-onset obsessive-compulsive disorder (OCD). A genome scan was done in 56 individuals from seven families ascertained through pediatric OCD probands; 27 of the 56 subjects had a lifetime diagnosis of definite OCD. Denser mapping of regions on chromosomes 2, 9, and 16 was subsequently done with those subjects and ten additional subjects from the largest family in the study. Direct interviews were completed with 65 of the 66 genotyped individuals. Relatives were interviewed blind to proband status. Of the 65 interviewed individuals, 32 had a lifetime diagnosis of definite OCD. Three of the seven probands had a history of Tourette disorder. Two of the 25 relatives with OCD had a tic history, whereas none of the 33 relatives without OCD had tics. The genome scan consisted of 349 microsatellite markers with an average between-marker distance of 11.3 centiMorgan (cM). Fine mapping was done with 24 additional markers at an average spacing of 1.6 cM. Parametric and nonparametric linkage analyses were conducted using GENEHUNTER(+). The maximum multipoint LOD score with a dominant model was 2.25 on 9p. However, with fine mapping and additional subjects, that LOD score decreased to 1.97. The maximum multipoint nonparametric LOD* score was 1.73 on 19q. The maximum multipoint LOD score with a recessive model was 1.40 on 6p. The results provide suggestive evidence for linkage on 9p and identify regions requiring further study with much larger samples.

Developmental aspects of obsessive compulsive disorder: findings in children, adolescents, and adults

Although juvenile obsessive compulsive disorder (OCD) is increasingly recognized as a putative developmental subtype of the disorder, comparisons among children, adolescents, and adults with OCD have been lacking. We aimed to evaluate clinical correlates of OCD in three developmentally distinct groups. Subjects comprised children, adolescents, and adults meeting DSM-III-R and DSM-IV criteria for OCD referred to separate specialized OCD clinics. All subjects were systematically evaluated with structured diagnostic interviews and clinical assessments by OCD experts. Specific clinical correlates and symptom profiles were associated with the disorder in different age groups. These findings support a hypothesis of developmental discontinuity between juvenile and adult OCD and identify age specific correlates of the disorder across the life cycle. Further work is needed to validate whether juvenile-onset OCD represents a true developmental subtype of the disorder.

Regional cerebral blood flow abnormalities in early-onset obsessive-compulsive disorder: an exploratory SPECT study

OBJECTIVE

Recent epidemiological and clinical data suggest that obsessive-compulsive disorder (OCD) may be subtyped according the age of onset of obsessive-compulsive symptoms. The regional cerebral blood flow (rCBF) single photon emission computed tomography (SPECT) technique was used to investigate whether the pathophysiology of OCD differs between early- and late-onset OCD subjects.

METHOD

Resting rCBF was measured in 13 early-onset (<10 years) and 13 late-onset (>12 years) adult OCD subjects and in 22 healthy controls. Voxel-based rCBF comparisons were performed with statistical parametric mapping.

RESULTS

Early-onset OCD cases showed decreased rCBF in the right thalamus, left anterior cingulate cortex, and bilateral inferior prefrontal cortex relative to late-onset subjects (p < .0005, uncorrected for multiple comparisons). Relative to controls, early-onset cases had decreased left anterior cingulate and right orbitofrontal rCBF, and increased rCBF in the right cerebellum, whereas late-onset subjects showed reduced right orbitofrontal rCBF and increased rCBF in the left precuneus. In early-onset subjects only, severity of obsessive-compulsive symptoms correlated positively with left orbitofrontal rCBF.

CONCLUSIONS

rCBF differences in frontal-subcortical circuits between early-onset and late-onset OCD subjects were found, both in location and direction of changes. These results provide preliminary evidence that brain mechanisms in OCD may differ depending on the age at which symptoms are first expressed.

Clinical correlates of obsessive compulsive disorder in children and adolescents referred to specialized and non-specialized clinical settings

The objective of this study was to assess the extent of referral bias by comparing children and adolescents with Obsessive Compulsive Disorder (OCD) ascertained through a specialized pediatric OCD and a general child psychiatry clinic. Subjects were juveniles meeting DSM-III-R and DSM IV criteria for OCD referred to a general pediatric psychopharmacology clinic and to a specialized OCD clinic within the same academic medical center. Subjects were evaluated clinically and with structured diagnostic interviews using the Kiddie SADS-E. OCD was identified in 8.6% of the general psychiatry clinic subjects. The only differences between ascertainment sources in clinical or sociodemographic characteristics of OCD subjects were higher rates of social phobia and ADHD in the non-specialized clinic, while specialty clinic subjects had a greater lifetime severity of OCD and were more likely to have received treatment of their OCD. Because we found limited evidence for referral biases, our results suggest that findings from studies using either of these sources may generalize to the other. It also suggests that pooling subjects from the two sources is justified. Nevertheless, because some group differences did emerge, researchers should acknowledge referral bias as a potential limitation of their work.

Childhood-onset obsessive-compulsive disorder: a tic-related subtype of OCD?

Obsessive-compulsive disorder (OCD) is a psychiatric condition characterized by recurrent obsessions or compulsions that cause significant impairment or distress. Although OCD was once perceived to be relatively rare in childhood, current estimates suggest that as many as half of all adult OCD cases may have their onset in childhood or adolescence. In general, there appears to be a great deal of continuity between the clinical presentation of OCD in children and that in adults. Yet, numerous differences have also been found between child and adult OCD, including differences in sex distribution, patterns of comorbidity, and degree of familial loading. These differences raise the issue of whether obsessive-compulsive symptoms that have their onset in childhood, but perhaps persist into adult life, are meaningfully different from those that emerge de novo in adulthood. In this article, current research on child- and adult-onset OCD is critically reviewed. It is proposed that child-onset OCD represents a phenomenologically and etiologically distinct subtype of OCD, bearing a close genetic relationship to tic-disorders and possibly sharing a common or similar pathogenesis. Clinical implications of the child- versus adult-onset OCD distinction are discussed.

[Quantitative electroencephalography in obsessive-compulsive disorder: preliminary results]

The predictive value of quantitative electroencephalography (EEGq) was investigated with regard to the pharmacological treatment of 10 non-medicated obsessive-compulsive disorder (OCD) patients diagnosed according to DSM-IV criteria. The following variables were selected: bipolar relative power in alpha band for Cz-C3, Cz-C4, T3-T5, T4-T6, T3-F7 and T4-F8; bipolar relative power in theta band for Cz-C3, Cz-C4, T3-T5, T4-T6, T3-F7 and T4-F8; and monopolar relative power in theta band for Fp1, Fp2, F7, F3, Fz, F4 and F8. There was statistically significant deviations in five patients with regard to bipolar relative power in alpha band for central regions when compared to normative data bank (control group). This group of patients had a significantly lower age of OCD onset and worse response to pharmacotherapy with serotonin reuptake inhibitors.

Obsessive compulsive disorder in childhood

Obsessive compulsive disorder (OCD) involves obsessions and compulsions that cause impairment and distress, and which interfere with children's developmental adaptation and daily functioning. Furthermore, OCD often disrupts peer and family relationships and school performance and may compromise physical health. Once considered rare, recent epidemiologic studies report prevalence rates ranging from 1% in prepubertal children to 4% in adolescents. In addition, children with OCD are at high risk for comorbid psychopathology. Recent theoretic formulations for OCD encourage the integration of both psychological and biological perspectives. To fully understand the cause and course of OCD, integrated assessment of psychological and biological vulnerability as well as prospective longitudinal studies are needed.

Childhood obsessive-compulsive disorder: a review

Obsessive-compulsive disorder (OCD) holds a particular interest for child psychiatrists because of the high proportion of cases with onset in childhood and adolescence. Over the last two decades, substantial progress has been made in describing OCD in children and adolescents and in developing and implementing effective treatments. In addition, research on the phenomenology, neurobiology, and psychopharmacology of OCD has led to its current conceptualization as a developmental neuropsychiatric disorder. In this article, the fourth in a series on OCD, the authors summarize the most recent data on the phenomenology, etiology, neurobiology, and treatment of OCD in children and adolescents.