Obsessive-compulsive disorder: Tools for recognizing its many expressions

,

Applied Evidence

Obsessive-compulsive disorder: Tools for recognizing its many expressions

J Fam Pract. 2006 March;55(3):217-222

By

Lisa J. Merlo, PhD

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References

1. Douglass H, Moffit TE, Dar R, McGee E, Silva P. Obsessive-compulsive disorder in a birth cohort of 18-year-olds: Prevalence and predicators. J Am Acad Child Adolesc Psychiatry 1995;34:1424-1431.

2. Karno M, Golding JM, Sorenson SB, Burnam MA. The epidemiology of obsessive-compulsive disorder in five US communities. Arch Gen Psychiatry 1988;45:1094-1099.

3. Pauls DL, Alsobrook JP, Phil M, Goodman WK, Rasmussen SA, Leckman JF. A family study of obsessive-compulsive disorder. Am J Psychiatry 1995;152:76-84.

4. Mataix-Cols D, Rauch SL, Baer L, et al. Symptom stability in adult obsessive-compulsive disorder: Data from a naturalistic two-year follow-up study. Am J Psychiatry 2002;159:263-268.

5. Koran L, Thienemann M, Davenport R. Quality of life for patients with obsessive-compulsive disorder. Am J Psychiatry 1996;153:783-788.

6. Piacentini J, Bergman RL, Keller M, McCracken J. Functional impairment in children and adolescents with obsessive-compulsive disorder. J Child Adolesc Psychopharmacol 2003;13S-1:S61-S69.

7. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th ed. Washington, DC: American Psychiatric Association; 1994.

8. Murphy TK, Sajid M, Soto O, et al. Detecting pediatric autoimmune neuropsychiatric disorders associated with streptococcus in children with obsessive-compulsive disorder and tics. Biolog Psychiatry 2004;55:61-68.

9. Flament MF, Whitaker A, Rapoport JL. Obsessive compulsive disorder in adolescence: An epidemiological study. J Am Acad Child Adolesc Psychiatry 1988;27:764-771.

10. Practice Parameters for the assessment and treatment of children and adolescents with obsessive-compulsive disorder. J Am Acad Child Adolesc Psychiatry 1998;37:27S-45S.

11. Geffken GR, Storch EA, Lewin A, Adkins J, Merlo LJ, Murphy TK. Development of the Pediatric OCD Disturbance Scale: Assessing ego-syntonic OCD. Paper presented at the Anxiety Disorders Association of America Annual Meeting 2005; Seattle, Wash.

12. March JS, Mulle K. OCD in Children and Adolescents: A Cognitive-Behavioral Treatment Manual. New York: Guilford Press; 1998.

13. Black DW, Gaffney GR, Schlosser S, Gabel J. Children of parents with obsessive-compulsive disorder—a 2-year follow-up study. Acta Psychiatrica Scandinavica 2003;107:305-313.

14. Silverman WK, Albano AM. The Anxiety Disorders Interview Schedule for DSM-IV: Child and Parent Versions. San Antonio, Tex: Psychological Corporation; 1996.

15. Kaufman J, Birmaher B, Brent D, Rao U. Schedule for Affective Disorders and Schizophrenia for School-Age Children-Present and Lifetime version (K-SADS-PL): Initial reliability and validity data. J Am Acad Child Adolesc Psychiatry 1997;36:980-988.

16. First MB, Gibbon M, Spitzer RL, Williams JBW. User’s guide for the structured clinical Interview for DSM-IV for Axis I Disorders: Research Version (SCID-I, version 2.0, final version). 1996.

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18. Goodman WK, Price LH, Rasmussen SA, Mazure C. The Yale-Brown Obsessive Compulsive Scale: II Validity. Arch Gen Psychiatry 1989;46:1006-1011.

19. Scahill L, Riddle MA, McSwiggin-Hardin M, Ort SI. Children’s Yale-Brown Obsessive Compulsive Scale: Reliability and validity. J Am Acad Child Adolesc Psychiatry 1997;36:844-852.

20. Arrindell WA, de Vlaming IH, Eisenhardt BM, van Berkum DE, Kwee MGT. Cross-cultural validity of the Yale-Brown Obsessive Compulsive Scale. J Beh Therapy Exper Psychiatry 2002;33:159-176.

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23. Storch EA, Bagner DM, Merlo LJ, et al. Florida Obsessive-Compulsive Inventory: Development, Reliability, and Validity, 2005.

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Practice recommendations

For a person with symptoms suggestive of obsessive-compulsive disorder (OCD), inquire about a family history of OCD or other anxiety disorders, either of which increases the likelihood of a diagnosis of OCD.
Keep in mind that, with children, symptoms suggestive of OCD may simply indicate developmentally appropriate rituals.
Become familiar with the alternative methods of assessment to facilitate evaluation in your particular office setting.
Consider OCD when a patient exhibits or complains of intrusive thoughts, anxiety-based avoidance of places or objects, excessive reassurance-seeking, or repetitive behaviors/rituals (B).

Has a parent in your practice reported odd behavior in their child (eg, new fears or rituals) following a streptococcal viral illness? Does your dialogue with an adult patient reveal undue anxiety about hygiene or personal safety? These examples are just 2 of many that signal a person may be suffering from obsessive-compulsive disorder (OCD)—a relentless, debilitating disorder if unrecognized and left untreated.

In this article, we explain the relative advantages of evaluative tools available (which can also help distinguish OCD in children from developmentally appropriate rituals).

In part 2 of this article (to be published in the April 2006 Journal of Family Practice), we discuss how to find professionals appropriately trained in cognitive-behavioral therapy (CBT), and recommend strategies for employing pharmacotherapy.

The tragedy of unrecognized OCD

OCD is an anxiety disorder characterized by recurrent or persistent thoughts, impulses, or images experienced as intrusive or distressing (obsessions), and repetitive behaviors or mental acts (compulsions) often performed in response to an obsession.

Estimates in the early 1980s suggested that OCD affected less than 1% of adults and children, but lifetime prevalence of OCD is now known to be between 2% to 4% in the US.^1,2

OCD begins in childhood for as many as 80% of cases,³ and it follows a chronic, unremitting course.⁴ Impairments in vocational, academic, and social and family functioning are often substantial.^5,6 And patients are often unable to work, attend school, or socialize.

Diagnosis: telltale clues, reliable evaluation tools

Consider a diagnosis of OCD when a patient exhibits or complains of intrusive thoughts (eg, specific phrases, worries, images, or numbers), anxiety-based avoidance of certain places (eg, public restrooms) or objects (eg, doorknobs), excessive reassurance-seeking, or repetitive behaviors/rituals (eg, checking, cleaning, hoarding).

FAST TRACK

OCD should be diagnosed when symptoms cause significant distress or impairment

Common intrusive thoughts (obsessions) and repetitive behaviors (compulsions) are listed in TABLES 1 AND 2, respectively. According to the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV),⁷ OCD should be diagnosed only if these symptoms cause significant distress or impairment to the individual; however, subclinical presentations of OCD are also relatively common. DSM-IV diagnostic criteria for OCD are outlined in TABLE 3.

TABLE 1
Common obsessions in OCD

CATEGORIES	OBSESSIVE CONCERNS
Contamination	Dirt; germs; animals/insects; illnesses; bodily waste; contaminants; household cleaners; “sticky” substances; spreading contamination, germs, illnesses, etc
Aggression	Harming self or others (even accidentally); causing harm to self or others due to thoughts or behaviors; acting upon aggressive impulses; blurting out inappropriate words/phrases; stealing or breaking things; causing something terrible to happen; frightening/violent images
Sexual	Forbidden/perverse sexual thoughts, images; disturbing sexual impulses, desires; homosexuality; molestation; sexual acts toward others
Hoarding/saving	Losing things; throwing away objects that might be important
Magical thinking	Lucky/unlucky numbers, colors, names, etc
Health/body	Contracting illness (especially if fatal or rare); appearance; physical abnormalities (real or imagined)
Mortality/religion	Dying and not going to Heaven; offending God; being sinful; morality/perfection; right/wrong
Miscellaneous	Knowing/remembering certain things; saying things exactly right; not saying certain words/phrases; intrusive images sounds, words, music, numbers, etc
Adapted from the Yale-Brown Obsessive-Compulsive Scale^14-15 and the Children’s Yale-Brown Obsessive-Compulsive Scale.¹⁶

TABLE 2
Common compulsions in OCD

CATEGORIES	COMPULSIVE RITUALS
Washing & cleaning	Excessive/ritualized handwashing, showering, bathing, toothbrushing, grooming, toileting; cleaning clothing/personal items; avoiding “contaminated” objects/places
Checking	Checking locks, alarms, school supplies, homework, toys, books, etc; checking associated with washing, dressing, undressing, somatic concerns; checking that did/will not harm self or others; checking that nothing terrible did/will happen; checking for mistakes
Repeating	Rewriting; rereading; recopying; retying (eg, shoelaces); erasing; going in/out door or taking items in/out of schoolbag; getting up/down from seat; repeating words/phrases
Counting	Counting objects; mental counting (especially up to a “magic” number); counting steps, chewing, hair-brushing, etc
Ordering/arranging	Lining up objects in a certain way; arranging things in specific patterns; making objects/piles/groups “even”; making things symmetrical; “balancing” actions (eg, doing thing on the right and on the left)
Hoarding & saving	Keeping unimportant/unnecessary items and/or trash; storing items of no particular value; having difficulty throwing things away; sorting through trash to ensure that nothing important has been thrown away
Superstitions	Touching/tapping routines to prevent bad things from happening; avoiding stepping on cracks, lines, etc; avoiding “unlucky” objects/places
Reassurance-seeking	Asking a parent to repeatedly answer the same questions; asking parents to describe what they are doing/planning to do; forcing family members to do things in a certain way or at a certain time; forcing family members to avoid certain things/activities
Miscellaneous	Mental rituals; needing to tell/ask/confess; ritualized eating behaviors; excessive list-making; needing to touch/tap/rub; needing to do things until it feels “just right” hair-pulling; measures to prevent something bad from happening
Adapted from the Yale-Brown Obsessive-Compulsive Scale^14-15 and the Children’s Yale-Brown Obsessive-Compulsive Scale.¹⁶