Cases That Test Your Skills

A 10-year-old boy with ‘voices in my head’: Is it a psychotic disorder?

Current Psychiatry. 2018 April;17(4):45-46,51-55

References

1. Diagnostic and statistical manual of mental disorders, 5th ed. Washington, DC: American Psychiatric Association; 2013.
2. Geller D, Biederman J, Jones J, et al. Is juvenile obsessive-compulsive disorder a developmental subtype of the disorder? A review of the pediatric literature. J Am Acad Child Adolesc Psychiatry.1998;37(4):420-427.
3. Huppert JD, Simpson HB, Nissenson KJ, et al. Quality of life and functional impairment in obsessive-compulsive disorder: A comparison of patients with and without comorbidity, patients in remission, and healthy controls. Depress Anxiety. 2009;26(1):39-45.
4. Sobel W, Wolski R, Cancro R, et al. Interpersonal relatedness and paranoid schizophrenia. Am J Psychiatry.1996;153(8):1084-1087.
5. Meares A. The diagnosis of prepsychotic schizophrenia. Lancet. 1959;1(7063):55-58.
6. Poyurovsky M, Weizman A, Weizman R. Obsessive-compulsive disorder in schizophrenia: Clinical characteristics and treatment. CNS Drugs. 2004;18(14):989-1010.
7. Kouris S. Methylphenidate-induced obsessive-compulsiveness. J Am Acad Child Adolesc Psychiatry. 1998;37(2):135.
8. Woolley JB, Heyman I. Dexamphetamine for obsessive-compulsive disorder. Am J Psychiatry. 2003;160(1):183.
9. Geller DA. Obsessive-compulsive and spectrum disorders in children and adolescents. Psychiatr Clin N Am. 2006;29(2):352-370.
10. Evans DW, Milanak ME, Medeiros B, et al. Magical beliefs and rituals in young children. Child Psychiatry Hum Dev. 2002;33(1):43-58.
11. Amir N, Freshman M, Foa E. Family distress and involvement in relatives of obsessive-compulsive disorder patients. J Anxiety Disord. 2000;14(3):209-217.
12. Practice parameter for the assessment and treatment of children and adolescents with obsessive-compulsive disorder. J Am Acad Child Adolesc Psychiatry. 2012;51(1):98-113.
13. Pediatric OCD Treatment Study (POTS) Team. Cognitive-behavior therapy, sertraline, and their combination for children and adolescents with obsessive-compulsive disorder: The Pediatric OCD Treatment Study (POTS) randomized controlled trial. JAMA. 2004;292(16):1969-1976.
14. Franklin ME, Sapyta J, Freeman JB, et al. Cognitive behavior therapy augmentation of pharmacotherapy in pediatric obsessive-compulsive disorder: The Pediatric OCD Treatment Study II (POTS II) randomized controlled trial. JAMA. 2011;306(11):1224-1232.
15. Wagner KD, Asarnow JR, Vitiello B, et al. Out of the black box: treatment of resistant depression in adolescents and the antidepressant controversy. J Child Adolesc Psychopharmacol. 2012;22(1):5-10.
16. Sakolsky DJ, Perel JM, Emslie GJ, et al. Antidepressant exposure as a predictor of clinical outcomes in the treatment of resistant depression in adolescents (TORDIA) study. J Clin Psychopharmacol. 2011;31(1):92-97.
17. Findling RL. How (not) to dose antidepressants and antipsychotics for children. Current Psychiatry. 2007;6(6):79-83.
18. Varigonda AL, Jakubovski E, Bloch MH. Systematic review and meta-analysis: early treatment responses of selective serotonin reuptake inhibitors and clomipramine in pediatric obsessive-compulsive disorder. J Am Acad Child Adolesc Psychiatry. 2016 Oct;55(10):851-859.e2.
19. Mancuso E, Faro A, Joshi G, et al. Treatment of pediatric obsessive-compulsive disorder: a review. J Child Adolesc Psychopharmacol. 2010;20(4):299-308.

TREATMENT Combination therapy

In keeping with American Academy of Child and Adolescent Psychiatry guidelines on treating OCD (Table 3¹²), we start M on fluoxetine 10 mg/d. He also begins CBT. Fluoxetine is slowly titrated to 40 mg/d while M engages in learning and utilizing CBT techniques to manage his OCD.

The authors’ observations

The combination of CBT and medication has been suggested as the treatment of choice for moderate and severe OCD.¹² The Pediatric OCD Treatment Study, a 5-year, 3-site outcome study designed to compare placebo, sertraline, CBT, and combined CBT and sertraline, concluded that the combined treatment (CBT plus sertraline) was more effective than CBT alone or sertraline alone.¹³ The effect sizes for the combined treatment, CBT alone, and sertraline alone were 1.4, 0.97, and 0.67, respectively. Remission rates for SSRIs alone are <33%.^13,14

SSRIs are the first-line medication for OCD in children, adolescents, and adults (Table 3¹²). Well-designed clinical trials have demonstrated the efficacy and safety of the SSRIs fluoxetine, sertraline, and fluvoxamine (alone or combined with CBT) in children and adolescents with OCD.¹³ Other SSRIs, such as citalopram, paroxetine, and escitalopram, also have demonstrated efficacy in children and adolescents with OCD, even though the FDA has not yet approved their use in pediatric patients.¹² Despite a positive trial of paroxetine in pediatric OCD,¹² there have been concerns related to its higher rates of treatment-emergent suicidality,¹⁵ lower likelihood of treatment response,¹⁶ and its particularly short half-life in pediatric patients.¹⁷

Clomipramine is a tricyclic antidepressant with serotonergic properties that is used alone or to boost the effect of an SSRI when there is a partial response. It should be introduced at a low dose in pediatric patients (before age 12) and closely monitored for anticholinergic and cardiac adverse effects. A systemic review and meta-analysis of early treatment responses of SSRIs and clomipramine in pediatric OCD indicated that the greatest benefits occurred early in treatment.¹⁸ Clomipramine was associated with a greater measured benefit compared with placebo than SSRIs; there was no evidence of a relationship between SSRI dosing and treatment effect, although data were limited. Adults and children with OCD demonstrated a similar degree and time course of response to SSRIs in OCD.¹⁸

Treatment should start with a low dose to reduce the risk of adverse effects with an adequate trial for 10 to 16 weeks at adequate doses. Most experts suggest that treatment should continue for at least 12 months after symptom resolution or stabilization, followed by a very gradual cessation.¹⁹

Continue to: OUTCOME Improvement in functioning

A 10-year-old boy with ‘voices in my head’: Is it a psychotic disorder?

References

TREATMENT Combination therapy

The authors’ observations

Pages

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