Obsessive Compulsive Disorder (OCD)
Obsessive Compulsive Disorder (OCD)
General and supportive measures
ICD-10 code: F42.9
DESCRIPTION
Obsessions:
These are persistently recurring thoughts, impulses or images that are experienced as intrusive, inappropriate and not simply excessive worries about realistic problems. Children may not experience these as distressing but the obsessions may interfere with day-to-day functioning. The child may try to suppress, ignore or neutralise them with another thought or action. Obsessions are not pleasurable or voluntary.
Compulsions:
Repetitive behaviours or mental acts that a person feels driven to perform in response to an obsession or according to a rigidly applied rule in order to reduce distress or to prevent some dreaded outcome. The behaviour or mental acts are not connected in a realistic way with what they are supposed to prevent or are excessive.
Compulsions are easier to diagnose than obsessions in children, as they are observable. Most children have both obsessions and compulsions. Adult symptoms are stable over time whereas children’s may be variable. The content differs and may reflect the different developmental stages. Adolescents have higher rates of sexual and religious obsessions than children, and children and adolescents have more harm obsessions, e.g. death or illness to self or loved ones, than adults.
- Comorbid conditions:
- rheumatic fever,
- streptococcal throat infection [paediatric autoimmune neuropsychiatric disorders associated with streptococcal infections (PANDAS)], and
- tic disorders, ADHD, anxiety and depressive disorders, ODD, and impulse-control disorders.
DIAGNOSTIC CRITERIA (DSM 5)
This requires the presence of obsessions, compulsions or both that are time-consuming or cause distress or functional impairment. General medical illnesses, other psychiatric disorders and the effects of substances should be excluded. Specifiers include the degree of insight and presence of tic disorders.
GENERAL AND SUPPORTIVE MEASURES
- Provide cognitive behavioural therapy (CBT), if available and appropriate.
- Exposure-based interventions (e.g. contact with 'dirt' in a child with contamination fears), thought stopping techniques, 'response prevention' (i.e. blocking of rituals).
A suitably qualified professional should carry out these interventions.
MEDICINE TREATMENT
OCD in children and adolescents is often resistant to treatment and high dosages of medication are often needed for long periods. Full therapeutic effect may take up to 8–12 weeks. Dosages should be gradually increased.
- Fluoxetine, oral, 0.5 mg/kg/day.
- Dose range: 20 - 40 mg daily.
- Recommended average dose: 20 - 40 mg.
However, fluoxetine may only be available in 20 mg capsules, in which case citalopram tablets can be used initially, titrated to 20 mg and then changed to fluoxetine 20 mg.
OR
- Citalopram, oral, 0.4 mg/kg/day.
- Dose range: 5 - 40 mg daily.
- Recommended average dose: 10 - 20 mg/day.
Duration of treatment: 6 months after resolution of OCD symptoms.
REFERRAL
- Twelve years and under.
- Poor response to adequate trial of cognitive behavioural therapy and medication, i.e. persistence of obsessions and/or compulsions, with impairment in functioning after 12 weeks.
- Co-morbid conditions.
Standard Treatment Guidelines and Essential Medicines List for South Africa, Hospital Level, Paediatrics, 2023 Edition
Chapter 14: Child & Adolescent Psychiatry,: Child & Adolescent Psychiatry, 14.6 Obsessive Compulsive Disorder (OCD)