ocd case study in india pdf

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• Indian J Psychiatry
• v.52(Suppl1); 2010 Jan

An overview of Indian research in obsessive compulsive disorder

Y. c. janardhan reddy.

Department of Psychiatry, National Institute of Mental Health and Neurosciences (NIMHANS), Hosur Road, Bangalore - 560 029, Karnataka, India

Naren P. Rao

Sumant khanna.

Obsessive-compulsive disorder (OCD) was considered a relatively rare disorder until about two decades ago. Since then, considerable advance has been made in understanding the various aspects of OCD that include epidemiology, clinical features, comorbidity, biology and treatment. In the last one decade, there has also been interest in a group of related disorders called obsessive-compulsive spectrum disorders. There is substantial research from India on various aspects of OCD, particularly from the National Institute of Mental Health and Neurosciences (NIMHANS), Bangalore. We attempt to review all the relevant Indian data on OCD.

ADULT OBSESSIVE-COMPULSIVE DISORDER

Epidemiology.

There is only one epidemiological study from India.[ 1 ] The study found lifetime prevalence of 0.6%. This rate is considerably lower compared to the 2-3% rate reported in the European and North American studies.[ 2 , 3 ] However, similar low rate ranging from 0.5-0.9% was observed in a study from Taiwan.[ 4 ] It is not clear why lifetime prevalence rate of OCD is lower in some countries although the rates are not very low compared to the conservative estimate of 1% rate of OCD.[ 5 ] However, further research is needed into the epidemiological aspects of OCD in India since the data available is limited.

Phenomenology of obsessive-compulsive disorder in adults

Phenomenology has been an important area of research in the field of OCD that has attracted the attention of Indian researchers. The earliest such study was by Dutta Ray in 1964[ 6 ] followed by a series of articles by Akhtar et al . on phenomenology and socio-cultural determinants of symptoms in OCD,[ 7 – 9 ] Chakraborty and Banerji, in a study that compared 200 “obsessionals” with 200 controls reported a high rate of family history of obsessional illness (26%) and premorbid obsessional personality (26%).[ 10 ] Two other studies also reported high rates of obsessive personality.[ 11 , 12 ]

Khanna et al . in an exploratory study examined whether a reactive-endogenous dichotomy exists.[ 13 ] Acute onset and fluctuating course was significantly commoner in the reactive subgroup. In an attempt to clarify the nosological status of OCD, Gojer et al . compared 53 cases of OCD with an equal number of subjects with depression and anxiety neurosis.[ 14 ] There were more similarities in the OCD and anxiety neurosis group than the depressive group.

Khanna and Channabasavanna developed a classificatory system for obsessions and compulsions based on form and content.[ 15 , 16 ] Obsessions were categorized into six categories of form and twelve categories of content and compulsions in to four categories of form and eight categories of content. In the same sample of patients, phenomenology was analyzed using cluster analysis.[ 17 ] Four reliable clusters were derived using variables present in 10-90% of the subjects: Washing, checking, thoughts of past and embarrassing behavior. Depression occurred as a unique cluster. Subtypes of OCD were also examined in the same sample.[ 18 ] The study showed that washers and checkers are valid subtypes of OCD.

In another study,[ 19 ] 222 consecutive subjects were evaluated using the Yale-Brown Obsessive-Compulsive Scale (Y-BOCS) symptom checklist[ 20 ] and the Scale for Assessment of Form and Content (SFC).[ 21 ] The data was subjected to factor analysis with varimax rotation. The main factors that emerged were washers, checkers, hoarding and two pure obsession factors. The obsession groups had a preponderance of sexual and religious themes. The findings are largely in concordance with those of studies from other parts of the world suggesting similarity across cultures.[ 22 , 23 ] The study, however, supports separating obsessions from compulsions because two pure obsession factors emerged, which is in keeping with the findings of the two previous studies.[ 24 , 25 ] Three recent studies of OCD in adults have also used the Y-BOCS to measure obsessive-compulsive symptoms.[ 19 , 26 – 28 ] The phenomenology of OCD in these studies is similar to that described in the western population.[ 29 ]

Jaisoorya et al . examined gender differences in OCD.[ 30 ] Males had an early onset of OCD, and had a higher prevalence of symmetry/religious obsessions, miscellaneous compulsions, and comorbid attention deficit hyperactivity disorder (ADHD). Females had higher prevalence of cleaning compulsions and comorbid trichotillomania.

Kamath et al . examined suicidal behavior in 100 consecutive DSM-IV OCD patients;[ 28 ] 59% had ‘worst ever’ (lifetime) suicidal ideation and 28% had current suicidal ideation. History of suicidal attempt was reported in 27% of the subjects. Major depression, unmarried status and hopelessness were the major risk factors for suicidal behavior.

Gururaj et al . assessed the family burden, quality of life and disability in OCD patients and compared them with patients with schizophrenia of comparable severity.[ 31 ] Patients with schizophrenia had higher family burden but were comparable to OCD patients with respect to quality of life and disability. The study showed that OCD patients were associated with significant disability, poor quality of life and high family burden comparable to schizophrenia.

Insight into obsessive-compulsive disorder

Traditionally, OCD is described as a condition in which patients have good insight into their symptoms. The DSM-IV field trial demonstrated a broad range of insight with 30% having poor insight.[ 32 ] Subsequent studies have also reported poor insight in 15-36% of patients with OCD.[ 33 – 36 ] The DSM-IV has added a new OCD specifier: “With poor insight” which involves a lack of recognition that the symptoms are unreasonable or excessive.[ 37 ]

There is paucity of data regarding the clinical correlates and treatment response of poor insight in OCD. A significant limitation of most of the studies is that they did not use validated measure of insight. Only one study[ 33 ] used the Brown Assessment of Beliefs Scale (BABS) developed specifically to assess insight.[ 38 ] In a recent Indian study, demographic and clinical correlates of poor insight OCD, and the association between response to specific serotonin reuptake inhibitors (SSRIs) and baseline insight was examined in a sample of 100 DSM-IV OCD subjects by using the BABS as a measure of insight.[ 27 ] The sample had 25 subjects with poor insight and the remaining 75 had good insight. Those with poor insight had earlier age-at-onset, more severe illness, higher comorbidity rate particularly major depression, over representation of miscellaneous obsessions and hoarding and poorer treatment response. The study suggests that OCD with poor insight could be a distinct subtype. That a significant proportion of OCD patients have poor insight has important treatment implications. Patients with poor insight could easily get misdiagnosed as psychotic and treated accordingly. The study suggests that drug treatment response is poor in those with poor insight. The finding is in sharp contrast to the findings of a previous study that reported that degree of insight at baseline did not predict response to sertraline.[ 33 ] It is clinically pertinent to examine if poor insight patients do better with addition of neuroleptics. There is, however, no evidence as yet to suggest that those with poor insight respond better to augmentation with antipsychotics. On the other hand, a few studies have shown that insight improves after treatment with SSRIs.[ 35 , 36 ]

Comorbidity

Studies of comorbidity are varied and have examined a broad range of topics including spectrum disorders, comorbidity with schizophrenia and bipolar disorder and even prevalence of OCD in Parkinson’s disease.

Obsessive-compulsive (OC) spectrum disorders have over the past few years emerged as a unique and fascinating category of related conditions.[ 39 ] Jaisoorya et al . examined the prevalence of putative OC spectrum disorders in a large sample of OCD subjects (n = 231) in comparison with relatives of neurologically ill patients (n = 200).[ 26 ] Prevalence of tic disorders (39% vs. 12%), hypochondriasis (13% vs. 0), BDD (3% vs. 0) and trichotillomania (3% vs. 0) were significantly greater in OCD subjects compared to controls. However, the prevalence of sexual compulsions, pathological gambling, eating disorders, and depersonalization disorder was not greater in the OCD subjects compared to controls. The findings of this study suggest that tic disorders, hypochondriasis, BDD, and trichotillomania are perhaps part of the OC spectrum disorders. The evidence for exclusion of other disorders from the hypothesized OC spectrum is not conclusive because of the rarity of the occurrence of some of these disorders in the study sample. The findings are somewhat similar to those of a study that reported high rates of BDD, hypochondriasis and low rate of eating disorders and most impulse control disorders other than pathological skin picking.[ 40 ] Only one patient in the sample had an eating disorder. The finding is in sharp contrast to a previous study that reported high rates of eating disorders among OCD patients.[ 41 ]

This divergence should be viewed in the light of the rare reporting of eating disorders in Asian countries[ 42 , 43 ] but could well be a correlate of cultural beliefs and attitudes that have been identified as significant contributing factors in the development of eating disorders.[ 43 ] Jaisoorya et al . examined the differences between tic related and non tic related OCD with respect to sociodemographics, symptom profile, and comorbidity.[ 44 ] Tic related OCD had an early age at onset, over representation of males, aggressive obsessions, cleaning compulsions and comorbid trichotillomania.

In a chart review of comorbidity in 218 OCD subjects, 17% had major depression, 6% dysthymia, and 7% any anxiety disorder.[ 45 ] Comorbidity rates were low and there were not many differences between those with and without comorbidity except that female subjects were more likely to have depression. Kalra et al . compared OCD with and without comorbid Axis I disorders in a sample of 54 subjects and found that those with comorbidity had higher scores on depression and OCD severity scales.[ 46 ] The study findings were in tune with earlier literature from rest of the world. Gupta et al . examined level of comorbid depression in patients with OCD, psychotic depression and chronic medical illness.[ 47 ] All three groups had moderate to high levels of depression, with OCD group intermediary between psychotic depression and physical illness. However, the OCD group had more life events than depression or physical illness.

Rajkumar et al .[ 48 ] studied the clinical profile of schizophrenic patients with and without comorbid OCD (50 in each group). Schizo-obsessive patients had higher rates of paranoid symptoms and first-rank symptoms of schizophrenia. They had lower anergia, higher depression scores, more comorbid personality disorders, and disability. Significant correlations were observed between OCD severity scores and schizophrenia symptom dimension scores. Authors concluded that “schizo-obsessive” schizophrenia may be a distinct subtype with unique clinical characteristics.

A retrospective chart analysis of 15 cases OCD with psychosis found that obsessive doubts, washing and checking compulsions were the most common OC symptoms.[ 49 ] Twelve cases had a diagnosis of schizophrenia, while three had atypical psychosis. About half the patients had First Rank symptoms of schizophrenia. Nearly three-fourth of the sample showed significant improvement on treatment with a combination of antipsychotic and antiobsessional drugs.

Zutshi et al .[ 50 ] examined differences between bipolar OCD and non-bipolar OCD. Bipolar OCD was associated with episodic course, a higher family loading for mood disorders, and higher rates of comorbid depression, social phobia and generalized anxiety disorder. In majority of the patients, OCD predated bipolar disorder and OCD worsened during depression and improved during mania. Authors concluded that OCD in those with bipolar disorder may be pathophysiologically related to bipolar disorder.

Harbishettar et al .[ 51 ] systematically assessed OC symptoms and OCD in 69 Parkinson’s disease patients and matched medically ill controls. There was no difference between the groups with respect to OC symptoms, OCD both clinical and subclinical and tics. Also, there was no relationship between severity of Parkinson’s disease and OC symptoms. Authors speculated that different circuitry may be involved in the pathophysiology of OCD and Parkinson’s disease although basal ganglia involvement may be common to both the disorders.

Course and outcome

There is limited literature on the long-term course and outcome of OCD. In an 11-13 year follow-up study of 75 subjects with OCD, Reddy et al .[ 52 ] reported a favorable outcome in majority of the subjects: 43% had no OCD, 33% had subclinical OCD and only 24% had clinical OCD. Median time to reach ‘no OCD’ and ‘subclinical’ status was 42 months and 84 months respectively. Interestingly, 37% were in true remission (‘no OCD’ and not on any treatment) for a median period of 132 months. Those who had ‘mixed’ OCD and Axis I comorbidity had poorer outcome. Age of onset and duration of illness had no effect on outcome. Optimistic outcome reported in this study is somewhat different from the findings of studies from other parts of the world which have reported lower rates of remission. Previous studies included samples that were severe and chronically ill with high rates of comorbidity. The subjects in the study by Reddy et al . were largely self-referred, moderately ill, and did not have history of treatment resistance. The findings of this study, therefore, could be generalized for patients routinely seen in the outpatient consultation at clinics and secondary-care hospitals in India.

Math et al .[ 53 ] in another follow-up study explored if the long term outcome of ‘predominantly obsessive’ subjects differs from that of ‘mixed’ OCD. They studied the five to six-year course and outcome of 54 patients with ‘predominantly obsessions’ and 54 with ‘mixed’ subtype of OCD. The course of the illness was similar in both and a majority (72%) did not have clinical OCD at follow up.

In another study, Shetti et al .[ 54 ] examined the differences between SSRI responders and non responders. They assessed 67 SRI responders and 55 non responders. Base line severity of illness, comorbid major depression, sexual obsessions, washing and miscellaneous compulsions, early age at onset, ‘mixed’ OCD and poor insight were associated with poor response to SRIs.

NEUROBIOLOGY

Neurotransmitters in obsessive-compulsive disorder.

A serotonergic hypothesis of OCD was suggested originally by the observed differential efficacy of SRIs in alleviating OCD symptoms.[ 55 ] Since then, numerous studies of peripheral receptor binding in the blood or concentrations of serotonin metabolites in cerebrospinal fluid have been performed but have yielded inconsistent results.[ 56 ] Pharmacological challenge studies provide another indirect approach. By administering serotonergic agents and measuring endocrine and behavioral responses, investigators have attempted to study the central serotonergic functioning in OCD. It is observed that OCD patients become significantly more anxious and dysphoric after administration of meta-chlorphenyl-piperazine (mCPP), a 5-HT receptor agonist.[ 55 ] In addition, obsessive-compulsive symptoms worsen. However, there appears to be blunted cortisol and prolactin response in response to mCPP. In an attempt to replicate these findings, mCPP was administered orally in a randomized double-blind design to 34 OCD patients who were either drug-naïve or drug-free for a minimum of four weeks.[ 57 ] The cortisol and prolactin responses were contrasted with those of 18 drug-free healthy subjects. The OCD patients showed significantly blunted cortisol and prolactin responses to mCPP challenge as compared to normal subjects. However, mCPP did not produce any significant exacerbation of obsessive-compulsive symptoms in the patients. These findings are suggestive of a serotonin (5-HT) receptor hyporesponsivity in the HPA axis. Even though previous studies indicate a hyperresponsivity of the 5-HT receptor system as shown by significant symptom worsening following serotonergic challenge,[ 58 , 59 ] the Indian study failed to replicate those results.[ 58 ] It was postulated that the 5-HT receptor hyporesponsivity in the HPA axis may be a biological “trait marker” of OCD, and may not be directly involved in the mediation of symptomatology of the disorder. It could also be inferred that the discrepancy among studies regarding the behavioural responses to mCPP challenge may in part be due to differences in the basic environmental conditions across various studies.[ 60 ] In a previous study by the same group, an endocrinological blunting in the absence of a behavioural increase in obsessive-compulsive symptoms was documented after oral administration of mCPP; however, when exposure was incorporated into the paradigm, with oral mCPP, exacerbation of obsessive-compulsive symptoms was noted.[ 61 ]

A normal endocrinological response after treatment with clomipramine was also independently documented.[ 62 ] It is a matter of conjecture whether stimulation of noradrenergic system by the α2 adrenergic antagonistic action of mCPP, or behavioral exposure conditions during the challenge procedure are also partly responsible for the symptom exacerbation as noted in previous studies.[ 57 ]

In summary, pharmacological challenge studies and other studies that have explored serotonergic hypothesis in OCD, have very limited evidence to support a primary serotonergic dysfunction in OCD.[ 63 ] However, a modulation of serotonergic system clearly plays a role in effective pharmacotherapy of at least a significant proportion of OCD patients.

In a study by Khanna et al . there was a blunted growth hormone, cortisol and ACTH response to clonidine in OCD.[ 64 ] On qualitative analysis three possible responses of growth hormone were obtained: Accentuation (>10 ng/ ml), normal (5-10 ng/ml) and attenuation (<10 ng/ml). Most patients with an accentuated response were patients with compulsions, pure obsessions were significantly more likely to have blunted responses. The study findings suggest noradrenergic dysfunction in OCD and also imply noradrenergic heterogeneity in the observation that pure obsessions tend to have a more down regulated noradrenergic system as compared to the compulsives. Based on their work, Khanna et al . concluded that serotonergic hypothesis may not explain all the abnormalities seen in OCD and that complex interactions between various neurotransmitters as well as the environmental conditions may be necessary to cause OCD.[ 57 ]

Soft neurological signs

Thirty-seven drug free non-depressed OCD subjects and 20 normal healthy volunteers were screened for SNS.[ 65 ] The OCD subjects had significantly more total SNS as compared to normals. These findings were most marked in the frontal lobe functions. There was a trend towards significance in temporal lobe functions, while other test findings were not impaired. If individual items were studied the problems were predominantly in complex motor tasks. There was no significant laterality effect.

Electrophysiological studies

Most electrophysiological studies in OCD have either tried to localize the site of the disorder at a structural or functional substrate, or have been based on the associated increased autonomic arousal. Khanna concluded that in most cases there was no obvious EEG abnormality in OCD; when it was present it was likely to be a non-specific disturbance in the temporal and frontotemporal regions.[ 66 ]

In OCD there was a decreased power in the nondominant frontomedial and posterior temporal regions in the computerized EEG analysis. There were no significant differences in the coherence observed from these sites.[ 67 ] The study suggested nondominant frontomedial hypofunctioning to be associated with OCD.

In a study of resting middle latency auditory and visual evoked potentials in 50 OCD subjects and 40 normal controls, there were no significant differences between the two groups for amplitude and latency or left-right ratios.[ 68 ] The study did not support any laterality deficit in OCD and was inconsistent with the hypothesis of left frontal lobe dysfunction in OCD.[ 69 ] A more prolonged post imperative negativity and a higher amplitude of the late component of the Contingent Negative Variation (CNV) has been repeatedly recorded.[ 66 ] OCD patients exhibited higher amplitude of the ‘late’ component of the CNV. The role of the mesencephalic reticular formation with modulation by the frontal granular cortex in the genesis of these potentials has been stressed.

Bereitschafts potential has been found absent or to have a decreased onset latency in 44 subjects with OCD.[ 70 ] A deficit of the complex motor programming circuit similar to those observed in Gilles de la Tourette syndrome has been put forth on the basis of this observation.[ 70 ] Based on the evidence from electrophysiological, neuropsychological, scan, lesion, and psychosurgical studies, Khanna also proposed an integrated model of possible frontal dysfunction in OCD with associated dysfunction in other areas of the brain such as cingulum and basal ganglia.[ 66 ]

Immunological factors

Khanna et al . documented increased levels of serum immunoglobulins in OCD subjects as compared to normal controls, with specific reference to IgG.[ 71 ] The IgG levels were high even after clinical improvement. The authors speculated that the immunological abnormality could be a marker of vulnerability to OCD. They also discussed the possibility that the immunological dysfunction could be due to an unidentified infectious agent or an autoimmune process. As an extension of the hypothesis, viral antibodies were measured in the blood[ 72 ] and cerebrospinal fluid (CSF) of OCD subjects.[ 73 ] IgG viral antibodies for herpes simplex virus-1 (HSV-1), varicella zoster, cytomegalo virus, measles and mumps were studied in 76 subjects with OCD and compared with 55 normal healthy volunteers. There was a significantly higher titer for HSV-1 antibodies in both serum and CSF. The sera: CSF ratios were suggestive of intrathecal synthesis. The study on viral antibodies in CSF suggests a role for HSV-1 in OCD. However, caution needs to be exercised in interpreting the finding because of certain methodological issues raised in the paper by the authors.

Exploration of the contribution of immunological mechanisms in the manifestation of OCD continued in a recent study by Bhattacharya et al . that investigated the presence of auto antibodies directed against the basal ganglia or thalamus in the serum as well as CSF of 23 OCD patients compared with 23 matched psychiatrically normal controls using western blot.[ 74 ] They further investigated CSF amino acid (glutamate, GABA, taurine, and glycine) levels and examined the extent to which these levels were related to the presence of auto - antiibodies. There was evidence of significantly more binding of CSF auto - antiibodies to homogenate of basal ganglia as well as to homogenate of thalamus among OCD patients compared to controls. There was no significant difference in the pattern of binding between patients and controls using serum. CSF glutamate and glycine levels were also significantly higher in OCD patients compared with controls, and CSF glycine levels were also significantly higher in those OCD patients who had auto - antiibodies compared to those without. The study implicates autoimmune mechanisms in the pathogenesis of OCD and also provides preliminary evidence that auto antobodies against basal ganglia and thalamus may cause OCD by modulating excitatory neurotransmission.

In support of the possible immunological mechanisms in the causation of at least some forms of OCD, a few clinical studies have examined the association between infections and OCD. A study reported OCD in some cases of Herpes Simplex encephalitis.[ 75 ] In a study of 20 subjects with rheumatic chorea, four subjects (20%) had OCD.[ 76 ] The relationship between OCD and rheumatic chorea and Pediatric, Autoimmune, Neuropsychiatric Disorders Associated with Streptococcal infections (PANDAS) is well known.[ 77 ] Considering the association between rheumatic fever and OCD, and possible long term neuropsychiatric sequelae in those with history of rheumatic fever because of possible autoimmune insult to basal ganglia, a study recently examined the prevalence of OCD in adults with Rheumatic Heart Disease (RHD).[ 78 ] Of the 100 subjects with RHD, 10 had clinical OCD. This rate is at least five-fold higher than the reported global general population rate of OCD[ 5 ] and over 15-fold higher than the 0.6% rate of OCD in India.[ 1 ] The finding lends support to the hypothesis that OCD could be a long term complication of autoimmune basal ganglia insult in childhood just as RHD is a long term sequel of autoimmune damage to the heart. The results of this study need to be replicated in a controlled study.

Chakrabarty et al . investigated glutamatergic dysfunction linked to immune pathogenesis in 21 OCD patients and 18 healthy controls by collecting CSF.[ 79 ] They estimated glutamate levels and found that OCD patients had higher glutamate levels. Age, gender, duration of illness, severity of illness did not have any effect on glutamate levels.

NEUROPSYCHOLOGY

Neuropsychological studies have provided important clues in understanding the neurobiological basis of OCD. As neuropsychological deficits are potential endophenotype markers, studies have examined patients in symptomatic phase, recovered phase and also in unaffected first degree relatives.

Trivedi et al .[ 80 ] examined executive functions, vigilance and spatial working memory in 30 OCD patients and 30 age and education matched control subjects. OCD patients had significant deficits in all the cognitive domains. There was a positive correlation between severity of illness and attention deficits but there was no correlation between duration of illness and cognitive dysfunction. A study by Tarafder et al .[ 81 ] examined neuropsychological disposition and executive functions in 20 OCD patients and 20 matched normal healthy controls. Subcortical-cerebellar-spinal domain was found to be associated with cognitive style and executive functions, affirming the neurobiological basis of the disorder.

Rao et al . examined neuropsychological deficits in 30 recovered OCD patients in comparison with 30 matched healthy controls.[ 81 ] They were assessed on tasks for attention, executive function, memory and intelligence. Patients had significant deficits in tests of set shifting ability, alternation, response inhibition and non verbal memory. There was no correlation between illness related variables neuropsychological deficits. The study findings suggest neuropsychological deficits are possibly state independent.

In a recent study by Viswanath et al . 25 unaffected siblings of probands with familial OCD in comparison with 25 matched healthy controls had significant deficits in tests of decision making and behavioral reversal but not in other tests of attention, executive function, intelligence and memory.[ 82 ] The deficits are consistent with the proposed neurobiological model of OCD involving the orbitofrontal cortex and suggest that the deficits could be potential endophenotypes in OCD.

Family studies

Methodologically sound studies in the last decade have reported higher morbid risk for OCD among first-degree relatives of OCD probands[ 83 , 84 ] but Indian studies have reported either no increase in morbid risk[ 85 ] or much less than what was previously reported.[ 86 ] The rate of OCD in 135 first-degree relatives of 33 adult OCD probands was comparable to the rate in 148 adults from the general population in the study by Guruswamy et al .[ 85 ]

In the family study of juvenile OCD, that examined first-degree relatives of 35 juvenile OCD probands and 34 matched normal controls,[ 86 ] the morbid risk for OCD among relatives of OCD probands was 5%, while none of the relatives of controls had OCD. In addition, none of the relatives had Tourette syndrome and only one relative of OCD proband had chronic tics. The study concluded that most juvenile cases of OCD were nonfamilial and unrelated to tic disorders, while only a few were familial.

Sagnik et al . examined familiality of washers and checkers by interviewing first-degree relatives of 25 checkers, 30 washers and 40 psychiatrically normal control probands.[ 87 ] The morbid risk of OCD was significantly higher among relatives of checker probands (19.4%) than in the relatives of washer (8.7%) or control probands (5.4%), while the morbid risk for relatives of washer and control probands was not significantly different. In all, 67% of the checker relatives with OCD were checkers, while 54% of the washer relatives with OCD were washers. The study provided preliminary evidence of familiality of the checker subtype of OCD.

Miscellaneous

Chakraborty et al . examined the role of oxidative stress in pathogenesis of OCD.[ 88 ] They estimated serum Thiobarbituric Acid Reacting Substances (TBARS) formed as a result of free radical lipid peroxidation in 39 newly diagnosed drug free OCD patients and 33 disease free control subjects. Patients had significantly higher TBARS than controls. In addition, there was a strong positive correlation between TBARS and the disease severity. The study suggests that oxidative stress induced increased free radical are generated in OCD patients.

OCD IN CHILDREN AND ADOLESCENTS

Demographics.

In all the studies of OCD in children and adolescents reported from India, males have outnumbered female subjects.[ 86 , 89 – 91 ] Male preponderance in juvenile OCD is consistent with the previous clinical studies of juvenile OCD justifying the argument that gender distribution in OCD is developmentally sensitive.[ 92 ]

Phenomenology

A study by Khanna and Srinath from India was one of the earliest studies to systematically examine the clinical profile of OCD in children in comparison with the OCD in adults.[ 93 ] In this sample, obsessions were less frequent compared to compulsions. Obsessions of harm, religion, and impersonal images were commonly reported. Washing, praying, touching, counting and spitting were the common compulsions.

Recent studies from India[ 89 , 90 ] have examined the phenomenology of OCD in children using the chilldren’s version of the Yale-Brown Obsessive-Compulsive Scale (CY-BOCS), the instrument that is widely used all over the world.[ 94 ] In a study of 58 children and adolescents, all aged 16 years and below,[ 90 ] contamination obsessions were the commonest (62%), followed by obsessions related to aggression (57%), symmetry (34%), sex (22%), religion (22%), somatic (12%), and hoarding (7%). Regarding compulsions, cleaning and washing was the commonest (69%) followed by repeating (52%), checking (47%), ordering (29%), counting (15%), and hoarding (7%). The miscellaneous obsessions and compulsions were present in 65% and 47% of the subjects respectively. The phenomenology of OCD in these studies is similar to that reported in a group of 70 young patients at the National Institute of Mental Health (NIMH) in USA.[ 95 ]

In one study,[ 91 ] the phenomenology in juvenile OCD was compared with that of adult-onset OCD and juvenile-onset adult OCD, in view of the previously reported findings that juvenile OCD could be phenotypically different from adult OCD[ 96 , 97 ] and juvenile-onset adult OCD.[ 98 ] Obsessions related to contamination and compulsions related to checking and miscellaneous types were common in juvenile OCD. In addition, the mean Y-BOCS score was greater in the juvenile OCD and juvenile-onset adult OCD subjects compared to the adult-onset OCD subjects suggesting greater severity of OCD in the juvenile groups. The variations in the clinical manifestations support developmental variability in the expression of OCD. However, they are not consistent with specific variations reported in previous studies.[ 97 , 98 ] For example, OCD in juveniles was associated with a higher frequency of aggression/catastrophic obsessions, hoarding and saving compulsions.[ 97 ] Sexual obsessions were selectively more prevalent in adolescents compared with children or adults. It is possible that sexual and aggressive obsessions were underrepresented in this sample due to the fact that the subjects kept them secret because of embarrassment and possible guilt associated in revealing them. However, there could also be a true cross-cultural variation in the phenotypic manifestation of OCD.

Psychiatric comorbidity is common in adults with OCD. Similarly, studies of juvenile OCD have found high rates of comorbid major depression (10%-73%), anxiety disorders (26%-76%), and tic disorders (17%-59%).[ 89 ] Three Indian studies have systematically examined the comorbidity in juveniles with OCD.[ 89 – 91 ] Rates of comorbid major depression, dysthymia, and bipolar disorder have ranged from 14-23%, 0-2%, and 0-2% respectively. Among anxiety disorders, rates of panic disorder, social phobia, specific phobias, overanxious disorder and separation anxiety disorder ranged from 0-6%, 0-13%, 5-7%, 0-7%, and 5-7% respectively.

Of considerable interest is the comorbid relationship between tic disorders, disruptive behavior disorders and juvenile OCD. Rates of TS have varied from 11-15% and that of other tic disorders from 17-59%.[ 89 ] In the three Indian studies, rates of TS and chronic tics are in the range of 8-11% and 2-23% respectively. In the follow-up study by Leonard et al . TS was present in 15% of the sample and any tics in 59% of the sample.[ 99 ] The rate of TS in the Indian juvenile OCD samples is somewhat comparable to the rates in previous studies, but the overall rate of tic disorders and, in particular, chronic tics are somewhat lower. In a recent study, the clinical profile of OCD+ tics patients was examined in juvenile OCD, juvenile-onset adult OCD and adult-onset OCD subjects.[ 91 ] Miscellaneous compulsions such as touching, tapping, rubbing, blinking, staring etc (73% vs. 45% vs. 32%) and pathological doubts (40% vs. 13% vs. 9%) and ADHD (26% vs. 3% vs. 0) were over represented in the juvenile OCD group compared to the other two groups. The miscellaneous compulsions of the type reported in this study were also reported in previous studies of OCD patients with tics[ 100 , 101 ] but the obsessions are not similar to the ones reported in other studies that found mainly excess of aggressive, sexual, and symmetry obsessions.[ 101 , 102 ] Further, the elevated rate of ADHD in juvenile OCD with tics support the previous observations that ADHD, tics and OCD commonly co-occur in juvenile OCD[ 99 , 103 ] and are possibly interrelated sharing a common pathophysiology.[ 104 ]

Comorbid ADHD is considered by some to be a developmental marker of juvenile OCD.[ 105 ] In the study by Leonard et al .[ 106 ] the rate of ADHD was 26% and in the studies by Geller and colleagues,[ 97 , 105 , 107 ] the rate of ADHD was as high as 57%. In the three Indian studies, rates of ADHD ranged from 3 to 18%.[ 89 – 91 ] The rates of ADHD in Indian samples are considerably lower than the rates reported in previous studies. The samples in the previous studies by Geller and colleagues were recruited from a specialized pediatric OCD program, whereas the Indian samples were largely “self-referred” and this difference in the ascertainment method might possibly explain the variation in the rates across the samples. However, at least in one study,[ 91 ] the 18% rate of ADHD was higher than the 5-10% rate reported in community samples.[ 108 , 109 ] The elevated rate of ADHD in juvenile OCD in this study is consistent with the findings of previous studies[ 97 , 105 , 107 ] although the rate of ADHD is much lower than the 51-57% in children and 36-39% in adolescents reported in the studies by Geller and others.[ 97 , 107 ]

In the study by Jaisoorya et al . juvenile OCD was compared with adult-onset OCD, using multinomial logistic regression analysis.[ 91 ] There was positive association of chronic tics, ADHD, major depressive disorder, and Body Dysmorphic Disorder (BDD) with juvenile OCD. The TS showed an almost significant association with juvenile OCD. The BDD also had a positive association with juvenile-onset adult OCD. In addition regression analysis (juvenile-onset adult OCD vs. adult-onset OCD), showed positive association between social phobia, chronic tics and MDD and juvenile-onset adult OCD. These findings suggest that there are age-specific correlates of the disorder across the life cycle. Further, the findings suggest that OCD in juveniles is perhaps a developmental subtype of OCD with specific correlates such as high rate of ADHD and tic disorders.[ 96 , 97 , 107 ]

COURSE AND OUTCOME OF JUVENILE OBSESSIVE-COMPULSIVE DISORDER

Follow-up studies of OCD in children and adolescents have reported low rates of remission.[ 106 , 110 – 112 ] Similarly, studies of adult OCD have reported worse course in those with early onset of illness.[ 113 , 114 ] However, studies on long-term course and outcome of OCD in juveniles are few and many have small sample sizes. We discuss here a two to nine year follow-up study of 58 children and adolescents with DSM-III-R OCD from India.[ 90 ] The subjects were largely ‘self-referred’ (93%) and ‘drug-naïve’ (90%) at the time of consultation. None had received any form of psychotherapeutic intervention and none were treatment refractory at the time of first consultation. Most were treated with medications and only a few of them with a combination of medicines and exposure and response prevention. At the time of follow-up, only 29% were still receiving medication. The median duration without any treatment at the time of follow-up was 49 months. At follow-up, 62% of the subjects were in full remission or had ‘no OCD’ (Total Y-BOCS score = 0 to 3), 17% had subclinical OCD (Y-BOCS score, 4-15) and only 21% had clinical OCD (Y-BOCS>15). The median time to achieve full remission was 24 months and subjects were symptom free for a mean of 41 months prior to follow-up assessment. However, the most significant finding is that 28 subjects (48%) were in true remission (full remission and not on any treatment) and were not receiving treatment for a mean period of 58 months. Duration of follow-up and age-at-onset emerged as significant predictors of full remission. The odds of younger subjects having full remission or no OCD outcome were 1.5 times that of older subjects. Those who had ‘no OCD’ at follow-up had earlier age-at-onset of illness.

The high rate of ‘true remitters’ is in sharp contrast to the 6% rate in the study by Leonard and others.[ 106 ] The rate of clinical OCD (21%) at follow-up is low compared to the high rates of clinical OCD (35%-68%) reported in previous studies.[ 106 , 110 – 112 , 115 ] Favorable prognosis in this study could be due to several reasons. First, the sample was largely ‘self-referred’, ‘drug-naïve’, moderately ill, with relatively low rate of comorbidity (55%). In the classic study by Leonard et al ., the subjects were severely and chronically ill with history of treatment resistance in 75% of them and 100% comorbidity.[ 106 ] Second, a low rate of tic disorders (16%) and ADHD (3%) could have contributed to better prognosis.

The study findings suggest that juvenile OCD, at least, in self-referred, drug-naïve outpatient clinical samples has a good prognosis. The findings can be generalized to psychiatric hospital settings in India and perhaps to general psychiatric practice settings in the Western countries.

Indian research on various aspects of OCD has shown broad similarities with that of research from the other parts of the world. Clinical profile of OCD seems to be similar to what is described in the literature. Comorbid patterns also appear to be similar across cultures. Follow-up studies have shown that prognosis is favorable in the long-run. There is evidence from a large Indian study that tic disorders, hypochondriasis, BDD and trichotillomania are perhaps part of the putative OC spectrum disorders. However, eating disorders are uncommon in patients with OCD.

Biological research in OCD in India has paralleled the interest in the area in other parts of the world. There seems to be a consensus that serotonergic hypothesis may not explain all the abnormalities in OCD and that complex interactions between various neurotransmitters as well as environmental factors may be necessary to cause OCD. Although not a single case of PANDAS has been reported from India, several studies have shown the possible role of immunological factors in the causation of OCD.

Substantial research has been carried out in juveniles with OCD. The rates of ADHD and TS are somewhat lower in Indian samples compared to those from other parts of the world. There is a suggestion that juvenile OCD could be a developmental subtype of the disorder. Juvenile OCD seems to have a favorable prognosis.

There is surprisingly limited amount of data from India on treatment aspects of OCD. Currently, at NIMHANS, Bangalore there is ongoing research on various aspects of OCD such as clinical profile, course, biology and treatment.

Source of Support: Nil

Conflict of Interest: None declared

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Case Study of a Middle-Aged Woman’s OCD Treatment Using CBT and ERP Technique

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Research Article | DOI: https://doi.org/10.31579/2690-8794/102

• Deepshikha Paliwal 1*
• Anamika Rawlani 2

1 M.Sc. Clinical Psychology, Dev Sanskriti University, Ranchi, India. 2 M.Phil Clinical Psychology, RINPAS Ranchi, India.

*Corresponding Author: Deepshikha Paliwal, M.Sc. Clinical Psychology, Dev Sanskriti University, Ranchi, India.

Citation: Deepshikha Paliwal and Anamika Rawlani (2022) Case Study of a Middle-Aged Woman’s OCD Treatment Using CBT and ERP Technique. Clinical Medical Reviews and Reports 4(3): DOI: 10.31579/2690-8794/102

Copyright: © 2022, Deepshikha Paliwal, This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Received: 01 September 2021 | Accepted: 04 December 2021 | Published: 10 January 2022

Keywords: OCD; CBT; ERP; salkovskis’s model

Introduction : This is a case report of a middle-aged woman, who was experiencing “obsessive” thoughts related to the “Bindi” (decorative piece wear by women on the forehead) and cleaning “compulsions”. Present case report discusses the patient’s assessment, case formulation, treatment plan and the effectiveness of the CBT and ERP sessions in reducing OCD symptoms.

Methodology: The patient was treated with Cognitive Behavior Therapy (CBT) along with Exposure Response Prevention (ERP) technique. The assessment of the case was done with the Y-BOCS rating scale, Beck’s Depression Inventory, Obsessive Beliefs Questionnaire, and Behavior Analysis Performa which suggested the higher severity level of the patient’s symptoms. Parallel to the assessment sessions, detailed case history related to the onset of the problem, difficulties faced because of the disorder, childhood incidences, family chart, marital issues, and medical history were discussed with the patient. Based on the reported details, the case was formulated according to the Salkovoskis inflated sense of responsibility model.  After the case formulation, the treatment plan was designed which involved ERP sessions and restructuring of the cognitive distortions (beliefs, thoughts, and attitude). 

Results: After the completion of the twenty-five therapy sessions, the patient reported improvement in the coping of anxiety-provoking thoughts and reduced level of the washing compulsions. The effects of the therapy were checked and found maintained up to two months follow up.

Conclusion: CBT and ERP technique is an effective treatment in reducing obsessive and compulsive symptoms of the patient. 

Have you ever felt like a sudden urge to hurt somebody? What if such urges continuously appear in your head? What would you do to stop these urges? Would you be able to continue your day to day life normally with such urges?  Clinical Psychologists studied the repetitive occurrence of unwelcoming thoughts, urges, doubts, and images which create anxiety. They gave it the term “Obsessions”. These obsessions are dreadful, frightening, and intolerable to the extent that they might hinder the natural flow of one’s personal, professional, and social life. The person who suffers from such anxiety-provoking thoughts tries to deal with the distress caused by such ‘obsessions’ by adopting some behavior or activity which temporarily relieve them from the anxiety and the feared consequences. This behavior could be anything like washing hands, cleaning, repeatedly checking the door, or repeating some phrases in the head. Psychologists called such repetitive behaviors or activities as “Compulsions”. According to APA (1994), if the presence of obsessions and/or compulsions is time-consuming (more than an hour a day), cause major distress, and impair work, social, or other important functions then the person will be diagnosed with Obsessive-Compulsive Disorder (OCD). Recent epidemiological studies suggest that OCD affects between 1.9 to 2.5% of the world population at some point in their lives, creating great difficulties on a professional, academic and social level (DSM-IV-TR, 2001). OCD affects all cultural and ethnic groups and, unlike many related disorders, males and females are equally affected by this disorder (Rasmussen & Eisen, 1992). OCD is one of the most incapacitating of anxiety disorders having been rated as a leading cause of disability by the World Health Organization (1996).  The major cause of OCD is still unknown; there could be some genetic components responsible for it (DSM-5). Child abuse or any stress-inducing event could be the risk factor involved in the history of OCD patients. The severity of the symptoms related to obsessions and compulsions provides the basis of the diagnosis in OCD which rules out any other drug-related or medical causes. Clinical Psychologists use rating scales like Y-BOCS (Fenske & Schwenk, 2009), self-reports, and Behavior Analysis Performa to assess the severity level of the symptoms. Based on the severity, the treatment plan is designed. Treatment of OCD involves psychotherapy and antidepressants. Psychotherapy such as Cognitive Behavior Therapy (CBT) is an effective psycho-social treatment of OCD (Beck, 2011). In CBT, a “problem-focused” approach is used to treat the diagnosed psychological disorder by challenging and changing core beliefs, negative automatic thoughts, and cognitive distortions of the patient. CBT involves Exposure Response Prevention (ERP) as a technique to treat OCD in which the patient is exposed to the cause of the problem and not allowed to repeat the ritual behavior (Grant, 2014).  ERP has promising results with 63% of OCD patients showing favorable responses after following the therapy sessions (Stanley & Turner, 1995). 

This is a case of a 31 years old woman, who belongs to a middle socio-economic background, currently living with her in-laws, husband, and daughter. The patient was experiencing obsessive thoughts related to the contamination spread by ‘bindi’ along with the compulsive behavior of washing and cleaning from the last five years. The patient reported that she always tried to check the contact of ‘Bindi’ with anything because that contact makes her incapacitate to control the situation. She took two and three hours (on daily basis) in washing and cleaning her home, scrubbing her daughter, cleaning the daughter’s school bag after returning from school, husband’s bag, and other usable items, so that she can stop the contamination from spreading everywhere. The patient has a history of facing interpersonal issues with family members since her childhood. Her father was alcohol dependent and the mother was the patient of depression. The financial condition of the family was not good. When the patient was 17 years old, her father died due to kidney failure, and her mother got hospitalized because of depression. From a very young age, the patient had to bear the responsibility of the family by taking tuitions. At first, she developed the fear of contamination at the age of 19, when she was in her graduation’s first year, for that she was taken to the Psychiatrist. She responded well to the medicines and stopped showing all the symptoms. At the age of 25, when the patient got pregnant she again developed the fear of contamination, which made her husband and in-laws uncomfortable and family disputes began. Her husband took her to the psychiatrist who referred her for the psychotherapy but she didn’t attend the psychotherapy sessions properly and continuously lived with the obsessions and compulsions up to the present referral where the patient was assessed with Y-BOCS rating scale, BDI, EBQ, and Behavioral Analysis Performa. Based on the assessment, she was diagnosed with OCD having symptoms of obsessions related to the contamination by ‘Bindi’ and washing compulsions. Detailed case history related to the onset of the problem, childhood incidences, family history, marital history, medical history, and other relevant information were also collected. The case was formulated according to Salkovoskis’s inflated sense of responsibility model as the patient’s reported details were signifying the negative interpretations of her responsibility for self and others. After the case formulation, the treatment plan was designed which involved sessions of ERP technique along with the alteration of cognitive distortions (ideas, beliefs, and attitudes) through the cognitive restructuring method of CBT. 

1. Yale-Brown Obsessive-Compulsive Scale (YBOCS): 

In cognitive-behavioral studies, Y-BOCS is used to rate the symptoms of OCD. This scale was designed by Goodman et al. (1989) to know the baseline and the recovery rate of the ‘severity of obsessions’, ‘severity of compulsions’ and ‘resistance to symptoms’. This is a five-point Likert scale that clinicians administer through a semi-structured interview in which a higher score indicates higher disturbances. The excellent psychometric properties of this scale quantify the severity of the obsessions and compulsions as well as provide valuable qualitative information which makes it very useful for both diagnosis of the OCD and the designing of its treatment plan. 

2. Beck Anxiety Inventory (BAI):

Aaron T. Beck (1988) developed BAI as a four-point Likert scale which consists of 21 items of ‘0 to 3’ scores on each item (Higher score means higher anxiety). If the Patient’s scores are from 0 to 7 then interpret as ‘minimal anxiety’, 8 to 15 as ‘mild anxiety’, 16 to 25 as ‘moderate anxiety’, and 30 to 63 as ‘severe anxiety’.  BAI assesses common cognitive and somatic symptoms of anxiety disorder and is considered effective in discriminating between the person with or without an anxiety disorder. This scale provides valuable clinical information but is not used by clinicians for diagnostic purposes. 

3. Obsessive Belief Questionnaire (OBQ):

OBQ is used to assess the beliefs and appraisals of OCD patients which are critical to their pathogenesis of obsessions (OCCWG, 1997, 2001). This scale consists of 87 belief statements within six subscales which represent key belief domains of OCD. The first subscale is ‘Control of thoughts’ (14 items), the second is ‘importance of thoughts’ (14 items), third is, responsibility (16 items), fourth is ‘intolerance of uncertainty’ (13 items), the fifth is an overestimation of threat (14 items), and sixth is ‘perfectionism’ (16 items). Response on this measure is the general level of agreement of the respondents with the items on a 7 point rating scale that ranges from (-3) “disagree very much” to (+3) “agree very much”. On the respective items summing of the scores is done to calculate the subscale scores.

4. Behavior Analysis Performa

This study used ‘Behavior Analysis Performa’ to do the functional analysis of the patient’s behavior. This Performa collects the details of the patient’s behavioral excess, deficits, and assets, his or her motivational factors behind maintaining and reinforcing ill behaviors, as well as, the medical, cultural, and social factors which contributed to the development of the illness. 

Based on the reported details and the assessment, the case was formulated according to the Salkovoskis model (1985). This model suggests that the patient’s main negative interpretation revolves around the idea that his or her actions might have harmful outcomes for self or others. This interpretation of responsibility increases selective attention and maintains negative beliefs (Salkovskis, 1987). Here, in this case, the patient had to face the disturbing family environment which significantly has a role in the formation of maladaptive schemas related to her negative view of self, the world, and the future. The patient’s beliefs assessment reports signified that her major dysfunctional assumptions were ‘if harm is very unlikely, I should try to prevent it at any cost’ and ‘if I don’t act when I foresee danger then I am to blame for any consequences’. Intrusive thought for her was that ‘bindi contaminates dirt’ and neutralizing action for this intrusive thought was ‘washing and cleaning things’. She paid her keen attention to the thought that ‘I should not be get touched with bindi’ and misinterpreted and over signified it by avoiding bindi and preventing the contamination. Her safety behavior included avoiding going out, (especially beauty parlors and cosmetic shops), and getting touched with anyone on roads and market places. The result of such avoidance was tiredness, anxiousness, aggressiveness, and distressed mood state. The graphical representation of the case formulation is shown in Appendix 1 at the end of this paper.

After the case formulation, the treatment plan was designed. The patient had dysfunctional assumptions related to her responsibility for self and others. She had obsessions related to the contamination spread by ‘Bindi’ associated with washing and cleaning compulsions. As she was taken by her husband for the therapy, so it was important to socialize her and her family with the OCD to develop insight for the disorder. After socializing them with OCD, they were taught the basic structure of the cognitive behavior model that how patient’s thoughts, emotions, physical sensations, and behavior all are interrelated and affect each other in a vicious circle. 

In the preparatory phase, the patient was introduced with the ERP technique, how does it work and how much her cooperation and will power are required for the success of this technique. After introducing the ERP technique to her, behavioral analysis was done with the patient by using a down-arrow method to make the list of the situations she uses as safety strategies and maintains her negative beliefs.

In the next session, the patient was told to imagine her exposure with different situations which she avoids and asked her to rate the level of anxiety in all the situations on a scale of 1 to 10. After this imaginary exposure, a hierarchy was made from the least anxiety-provoking event to the high anxiety-provoking event. Here is the list of different situations which the patient rated based on the level of anxiety:

In this phase, the patient was gradually exposed with the least anxiety-provoking situation to the highest-anxiety provoking situation. The patient’s husband worked as a co-therapist and accompanied her in all the situations and observed her anxiety levels and other behaviors. The patient was asked to rate her anxiety level on a scale of 1 to 10 after every exposure.

• In the first step of exposure, patient was instructed to go out with the husband in the market area where ‘Bindi’ was hanging on the walls , she was instructed to watch them from some distance and observe her level of anxiety varying with time . She was strictly instructed not to avoid the situation and to face the anxiety levels without skipping. In the next session, she was asked what she exactly felt when she was watching the bindi packets, she replied that at first sight of bindi she felt disgusted and wanted to go away but she gave self instructions to her that these are very far and cannot contaminate her so she kept sitting there and with time her anxiety level also came down.   
• In the second step of the hierarchy she was instructed for sitting at a distance from the cosmetics shop and observe the ladies entering and purchasing bindi there , her husband was told to work as a co-therapist and checks the anxiety levels and reactions of his wife during the exposure. In the next session, she was again asked for the thoughts and levels of anxiety during the observation, husband reported that at first she showed some anger and was looking very anxious while observing the ladies with bindi but when he reminded her about the nature of therapy, she managed to sit there and sometime later became relaxed.   
• In the third step of the hierarchy patient was instructed to enter into the cosmetic shop and remain stand there for a short while without purchasing anything and to face the levels of anxiety varying with time. In the session, she was asked to report the anxiety level. She reported that just when she entered the shop she was trying to not get touched with anything and felt like she would lose her control and became very anxious but with self instructions she managed herself to stand there after sometime anxiety level came down and she felt little relaxed.   
• In the fourth step, the patient was instructed to enter into the cosmetic shop and to purchase some common items other than ‘Bindi’ . In the next session, husband reported that she was attentively noticing the shopkeeper’s movements. Though, she purchased some ribbons but denied to touch them and asked him to put them in his bag and told him to give only the fixed amount of ribbon’s cost to the shopkeeper so that exchange could not be needed from shopkeeper’s contaminated hands. The husband also observed that during the whole exposure, the patient was looking very distressed and anxious and was involved in safety strategies and managed to calm down only when he reminded her about the process of therapy. The patient was then asked to report her anxiety level in this step of exposure.  
• In the fifth step, patient was instructed to go into the market and purchase a packet of small colorful bindi and face the anxiety levels . In the next session, she was asked to express the anxiety and rate it on a scale of 1 to 10. The patient reported that when she was purchasing the bindi, she felt dreadful and thought that she would take bath after returning home. Somehow, she purchased the packet and gave it to the husband to put it in his bag. After returning home, she got involved in her daughter’s work but thoughts of washing and bathing were going on in her mind. Later on, she could not get the time for bathing and she instructed herself to bath in the morning, after this thought she felt very relaxed and had this feeling of winning over her obsessions.   
• In the sixth step, patient was instructed to purchase some colorful bindi packets and try to keep them with herself and strictly prevent herself from hand-washing for one hour. In the next session, she reported that this time she was not that anxious while purchasing bindi packets but after putting them in her bags she was trying to avoid getting touched with her daughter and mother in law because her mother in law would enter into the kitchen and contaminate everything. Meanwhile, her daughter ran towards her and hugged her. Immediately, she became very restless and angry with the daughter and thought about to wash her. However, she felt incapacitated as her daughter ran everywhere in the house and touched everything. She got anxious but managed this thought of contamination and decided to not wash anything. After this, she felt relaxed.   
• In the seventh step of the hierarchy, the patient was instructed to apply a small bindi on her forehead and restricted to not wash her hands for at least four hours . In the next session, she reported that she applied the bindi and her husband and her mother-in-law were feeling very happy but she felt anxious and closed her fist for not touching anything till hand-washing. After some time, in other household works, she forgot about it but suddenly when she realized that she had applied bindi, she immediately washed her hands but even then kept wearing it for the whole day.   
• In the eighth step, the patient was instructed to apply red color velvet medium size Bindi and prevent hand washing for minimum of two hours . In the next session, she reported that now her level of anxiety has fallen down and now she feels less anxious after applying bindi and managed to not wash her hands for two hours without any much restlessness.   
• In the ninth step of the hierarchy, the patient was instructed to apply red color velvet medium size Bindi and prevent hand washing for minimum of four hours and try to make herself normal and gradually start touching things in these hours. In the next session, she reported that now she feels capable to face her feelings of disgust with bindi and manages to make her mind for not washing things after getting touched with the bindi. Though some thoughts of contamination keep coming in between but she immediately reminds herself that ‘Bindi’ can’t contaminate anything.  
• In the tenth step of hierarchy, the patient was instructed to apply bindi on her forehead and keep some of them in her bag preventing washing her hands for maximum hours possible. In the next session, she reported that now she feels more capable to conquer over her thoughts of contamination and more determined to not washing and cleaning after such obsessions.

With each ERP session, the patient came to realize that the nature of anxiety is that it goes up with the triggering event but with the passage of time, automatically comes down. She also developed the insight that she had fear from the thoughts of contamination and with its associated anxiety more than ‘Bindi’ itself. 

After the ERP sessions, the patient was given two booster sessions in which she was taught the ways to deal with the anxiety after the termination of therapy in her day to day life situations. In those sessions, she was asked to imagine her home, her room, and herself with Bindi on her forehead and doing household chores like cooking, cleaning the things, etc. When the patient was asked to express herself during the imagination, she reported that she is feeling more confident now to stick on her thought that bindi can’t contaminate, it’s her idea and there is no use of washing hands and other things because of the fear of contamination. Her husband and mother-in-law were also instructed to remind her again and again about the things she learned during the therapy sessions. After the declaration of the patient that she is feeling better now and ready to face the anxiety on her own, therapy sessions were terminated.

One month later, the patient was contacted for the follow-up and asked about her coping with the anxiety through telephonic conversation. She reported that thoughts of contamination came in her mind but she is in better condition than previous after taking the ERP sessions.

After two months, the patient came for the session again with the complaints that sometimes she became weak and washed her hands with the thought of contamination. After washing, she repented on her behavior which lowers down her confidence in conquering over the illness. Then she was instructed that washing hands strengthens the thought of contamination so she should avoid it as much as possible but this doesn’t mean that she has not gained anything with the therapy, she was reminded about her previous condition that how much it was unbearable for her to even think about the bindi but now she is applying it on her forehead which shows that only the traces of the illness left, most of it is already recovered. In this way, the patient became relaxed and felt more determined to continue with the learnings during the sessions.

After the termination of the therapy sessions, the patient’s obsessive and compulsive symptoms were found reduced on the Y-BOCS symptom checklist:

With the graded exposure sessions, her anxiety level also came down from the rating of 10 in the beginning sessions to the rating of 4 in the endings sessions on a scale of 1 to 10.

The patient’s BAI score was also fallen down from pre-intervention- 36 (Extreme level of anxiety) to post intervention- 13 (mild level of anxiety) which suggests 36% reduction in the anxiety level of the patient.

Previous research findings considered CBT as the most promising treatment of OCD (Stanley & Turner, 1995; Foa et al, 1999). CBT emphasizes the integration of cognitive-behavioral strategies like discussion techniques (Guided Discovery) and behavioral experiments (ERP) to formulate the problem and direct the treatment. Therapists try to identify the key distorted beliefs along with patients and allow them to test their beliefs which develop and maintain compulsive behaviors. This case identified the contamination with ‘Bindi’ as the pathological belief which was maintaining the compulsive behaviors of washing and cleaning. The cognitive hypothesis of Salkovoskis (1985) proposed that the origin of obsessional thinking lies in normal intrusive ideas, images, thoughts, and impulses which a person finds unacceptable, upsetting, or unpleasant. The occurrence and content of these intrusive cognitions are negatively interpreted as an indication that the person may be ‘responsible for harm’ or ‘prevent the harm’. Such an interpretation is likely followed by emotional reactions such as anxiety or depression. These emotional reactions lead to discomfort and neutralizing (Compulsive) behaviors like washing, cleaning, checking, avoidance of situations related to the obsessive thought, seeking reassurance, and attempts to exclude these thoughts from the mind. The present case supported this hypothesis of Salkovoskis’s model as intrusive thought of the patient was contamination spread by ‘Bindi’ which negatively interpreted as ‘I can avoid the likely harms by avoiding the contamination spread by Bindi’, such negative interpretation was raising her anxiety levels, making her attentive selective towards the ‘Bindi’, maintaining her compulsive acts and complying her to adopt the safety strategies.

Rachman (1983) predicted that behavioral experiments, in which the patient is exposed to the feared object, these intrusive thoughts are challenged by changing the pattern of thinking and behaving. Hodgson & Rachman (1972) initiated the series of clinical studies on patients with contamination and predicted that immediate washing reduces the anxiety. In one of their experimental study, they noted a similar degree of anxiety reduction when the patient was asked not to perform a compulsive act for one hour.  They termed this phenomenon as ‘spontaneous decay’ which was established as the basis of ERP. Also, Foa & Kozak (1986) proposed that exposure techniques activate the network of cognitive fear and patients get new experience which is different from the existing pathological beliefs. This case confirmed this hypothesis as the patient initially thought that her exposure with ‘Bindi’ might cause some uncertain consequence with her but prolonged exposures provided her new experience that she could manage with her fear and anxiety which resulted in the improved coping with obsessional beliefs about contamination and urge to wash and clean. Her improved coping is evident in the statistically significant reduction of her scores on the standard measures like the Y-BOCS symptom checklist, BAI, and OBQ. 

The results of this case study add on the value of CBT (that involves ERP technique) in the treatment of obsessive thinking related to the ‘fear of contamination’ and compulsive behavior of ‘washing and cleaning’. However, there is a need for more such case studies with more precision and effective treatment designs to provide valuable information related to the nature of OCD and its treatment.

In this case of OCD, patient’s symptoms were reduced to a manageable level and found maintained for two months which provides an evidence of the effectiveness of CBT and ERP technique in the treatment of OCD.

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Clinical practice guidelines for Obsessive-Compulsive Disorder

Janardhan Reddy, Y.C.; Sundar, A. Shyam; Narayanaswamy, Janardhanan C.; Math, Suresh Bada

Department of Psychiatry, OCD Clinic, National Institute of Mental Health & Neurosciences (NIMHANS), Bangalore, Karnataka, India

Address for correspondence: Y. C. Janardhan Reddy, Professor of Psychiatry, NIMHANS, Bangalore 560029, Karnataka, India. E-mail: [email protected]

Participants of expert group on CPG for Obsessive Compulsive Disorder

Adarsh Tripathi, Om Prakash Singh, Paramjeet Singh, Tushar Jagawat, M, Aleem Siddiqui, K.K. Verma, D.M. Mathur

INTRODUCTION

Obsessive-compulsive disorder (OCD) is a common psychiatric illness with lifetime prevalence of 1-3% [ 1 ]. It is the fourth-most common psychiatric illness and a leading cause of disability. OCD is associated with significant impairment in functioning, quality of life and disability. If untreated, OCD is a chronic illness with a waxing and waning of symptoms. A recent meta-analysis of long-term naturalistic prospective studies demonstrated that nearly a half of patients experience remission with much higher rates of remission in Indian patients compared to those in the west [ 2 ]. Early diagnosis and appropriate treatment may improve outcomes. Despite OCD being a common mental illness, most seek treatment after several years of suffering. Those who suffer from OCD tend to be secretive about their symptoms and suffer from shame and embarrassment. Less than a third of OCD sufferers receive appropriate pharmacotherapy and even less receive evidence-based psychotherapy.

The hallmarks of OCD are presence of obsessions and compulsions. Obsessions are repetitive, unwanted, intrusive thoughts, images or urges that are mostly ego-dystonic and cause severe distress or anxiety. Compulsions (or rituals) are repetitive behaviours or mental acts that are performed in response to an obsession to reduce anxiety/distress or prevent a dreaded consequence. Obsessions and compulsions are time consuming, distressing and are often resisted unsuccessfully. Clinical manifestations of OCD are remarkably similar across cultures and geographic locations. Common obsessions and compulsions and symptom dimensions identified through factor-analytical studies are shown in Table 1 .

Many people experience intrusive thoughts and exhibit repetitive behaviours. A diagnosis of OCD is made only if symptoms are time consuming (e.g., more than an hour per day), distressing or cause significant interference in functioning. This is reflected in DSM-5 diagnosis of OCD and in the upcoming ICD-11 [ 3 ]. The ICD-11 criteria for OCD are likely to be very similar to the DSM-5 criteria [ 3 4 ]. The ICD-11 may include an insight specifier along the same lines as DSM-5. There are sweeping changes to the description of OCD in the proposed ICD-11. Duration criteria and subtyping of OCD may be removed in the revision for lack of evidence and clinical relevance. In ICD-10, a diagnosis of OCD was discouraged in the presence of schizophrenia, tic disorder or depression. This criterion too may be removed paving the way to make a diagnosis of OCD even in the presence of these comorbid disorders.

Another major change to the diagnosis of OCD is creation of OCD and related disorders in DSM-5 (and in the ICD-11) and exit from the group of anxiety disorders. Many disorders are included in this group: body dysmorphic disorder (BDD), trichotillomania (TTM), skin picking disorder, hoarding disorder, substance/medication-Induced obsessive-compulsive and related disorder and obsessive-compulsive and related disorder due to another medical condition. In the upcoming ICD-11, few other conditions find a place in this group that include tic disorders, hypochondriasis and olfactory reference syndrome. All these disorders are grouped together based on shared clinical features (e.g., repetitive behaviours), comorbidity patterns, familiality, neuropsychological deficits, treatment response and importantly shared brain circuitry abnormalities. Hoarding disorder which may not share many features with OCD is grouped along with OCD because of historical association with OCD and obsessive-compulsive personality disorder.

Comorbidity

OCD is often comorbid with other psychiatric disorders. It is important to assess all patients with OCD for associated psychiatric comorbidity since they may have an effect on treatment outcome if left untreated. Depression and anxiety disorders are present in over a half of patients seeking treatment for OCD. Common comorbid disorders are listed in Table 2 . Those with early onset OCD, in particular those with onset in childhood have high rates of attention deficit hyperactivity disorder (ADHD), oppositional defiant disorder (ODD) and tic disorders.

Bipolar disorder, in particular type 2, is reported to be not uncommon in OCD [ 5 ]. Similarly, OCD is not uncommon in those with primary diagnosis of bipolar disorder [ 6 7 ]. OCD when comorbid with bipolar disorder tends to run an episodic course [ 8 ] with worsening of symptoms in depressive phases and improvement in hypomania/ mania phases. It is important to recognise OCD-bipolar comorbidity because of treatment implications. The specific serotonin-reuptake inhibitors (SSRIs) traditionally used to treat OCD may induce switch to mania or rapid cycling course.

Obsessive-compulsive symptoms and OCD are not uncommon in schizophrenia. Nearly a third of schizophrenia patients report OC symptoms or OCD. Presence of OCD may have a negative effect on the long-term course of schizophrenia. Therefore treatment of OCD with SSRIs and cognitive-behavior therapy (CBT)/behavior therapy (BT) may have to be considered although there is not much of systematic evidence supporting their efficacy in treatment of OCD in schizophrenia.

COMMON INGREDIENTS OF MANAGEMENT PLAN

Common ingredients of managing OCD include the following:

• Detailed assessment of symptoms and comorbid patterns including suicidal behaviours either by unstructured clinical interview alone or supplementation with structured assessments.
• Decision on setting for treatment (outpatient vs. inpatient care depending upon the severity, treatment resistance etc.)
• Detailed psychoeducation of the patient and family member (s) about OCD, its course and treatment options including duration of treatment.
• Choice of treatment: drugs vs. CBT vs. combination
• In the Indian context, SSRIs are first-line treatments preferred over CBT because of feasibility, affordability and limited number of trained therapists. CBT may be considered if SSRIs alone are not beneficial.
• Discussion on side-effects of drugs; in women risks vs. benefits of drugs during pregnancy and in the post-partum period
• Follow-up plan after initiating treatment

ASSESSMENT AND EVALUATION

In routine clinical practice, use of structured / semistructured interviews and rating scales may not be necessary. They are optional. However, they may be used when the clinician needs supplementary information. A list of useful instruments in the assessment of OCD is provided in Table 3 .

The Yale-Brown Obsessive-Compulsive Scale (YBOCS) is the most widely used severity rating scale for OCD in both adults [ 9 ] and children [ 10 ] and is considered a gold standard instrument to measure severity of OCD. It is a 10-item observer-rating scale, also available as self-rated instrument. It measures the overall severity of obsessive-compulsive symptoms for the preceding week. The YBOCS is a global measure of symptoms and does not provide severity of individual symptom dimensions. A total score of ≥ 16 is considered to be indicative of clinically significant OCD. The YBOCS severity scale also has an associated symptom check list of 15 categories of obsessions and compulsions including miscellaneous symptoms. The checklist elicits both current (1 month) and past symptoms.

On the YBOCS item-11 insight scale, the insight is graded as follows: 0 = excellent (fully rational thinking), 1= good insight (readily acknowledges absurdity or excessiveness but has some lingering doubts), 2 = fair insight (reluctantly admits absurdity, but waivers; has some unrealistic fear but no fixed conviction), 3 = poor insight (overvalued ideas; maintains they are not unreasonable or excessive, but acknowledges validity of contrary evidence), and 4 = lack of insight (delusional). A higher score on the Y–BOCS item-11 indicates poorer insight.

FORMULATING A TREATMENT PLAN

Formulating a treatment begins with correct diagnosis of OCD as per the DSM or ICD classificatory systems. When feasible a structured clinical interview is recommended to obtain a comprehensive account of patient's problems. Once a diagnosis is established, a detailed assessment of symptom profile is mandatory. Family members often accommodate patient's rituals and contribute to poor outcome. In most severely ill patients, an elaborate family assessment may be needed. Once assessment is complete, short-term and long-term goals of treatment have to be established. Enhancing treatment adherence is a vital aspect of formulating a treatment plan. It is important to educate patients about lag in the onset of action of drugs and that improvement may occur over several months of continuous treatment. Brief education about basic principles of psychotherapy should be explained if psychotherapy is being planned. Essentials of formulating a treatment plan are summarized in Table 4 . All patients and their immediate family members should be provided psychoeducation about OCD ( Table 5 ).

CHOICE OF TREATMENT SETTINGS

In the Indian scenario, treatment is either on an outpatient or an inpatient basis. Outpatient treatment is usually sufficient for most OCD patients who are mild to moderately ill and for those who are likely to be adherent to treatment. Patients may be followed-up at periodic intervals, initially once in a month or two and subsequently at longer intervals depending upon the response to treatment and tolerability and side-effects. Hospital treatment may be considered for those who are at high suicide risk, dangerous to self or others, and intolerant to side-effects. Many severely ill and treatment-resistant patients may require prolonged (2-3 months) hospitalization for intensive treatment with CBT and for rationalization of pharmacotherapy. Inpatient care may also be required for severe depression, mania or psychosis that may be comorbid with OCD. Admission in rehabilitation services may be necessary for some patients who may not have benefited from standard treatments including inpatient care.

PHARMACOLOGICAL TREATMENT

The clinical practice guideline is framed based on a review of relevant scientific literature. As a first step, we framed relevant questions which arise in the minds of the practitioner while treating a patient suffering from OCD. A literature search was conducted in PubMed to answer these questions. We also reviewed the existing guidelines on treatment of OCD [ 11 12 13 14 ]. After a thorough literature review, the treatment strategies were rated based on the Strength of Recommendation Taxonomy (SORT) [ 15 ].

Consistent evidence from multiple randomized controlled trials (RCT) constitutes the highest level of evidence for a recommendation. However, the external validity of RCTs has been questioned due to the rigid protocols in undertaking the studies. A practitioner may make a clinical decision based on the available evidence considering other relevant factors that influence the decision making process. A non-exhaustive list of these factors might include psychiatric and other medical comorbidities, previous treatment trials, affordability, accessibility, hypersensitivity, side-effect profile, patients’ values etc.

RELEVANT CLINICAL ISSUES

First-line pharmacological treatment for ocd.

Meta-analyses of RCTs show that selective-serotonin reuptake inhibitors (SSRIs) are significantly more effective than placebo in the treatment of OCD [ 16 ]. SSRIs are associated with many adverse effects but are usually well tolerated. The only other medication which has shown to be consistently effective in OCD is the serotoninergic tricyclic antidepressant clomipramine. Clomipramine has been found to be significantly more effective than placebo in multiple RCTs and meta-analysis of RCTs [ 16 ]. Network meta-analysis comparing the efficacy of clomipramine vs. SSRIs failed to find any efficacy advantage over SSRIs [ 16 ]. Most head-to-head comparison trials have not found any significant difference between the efficacy of clomipramine and SSRIs [ 17 ]. Further, meta-analyses and individual RCTs have found that the tolerability of clomipramine is worse than that of SSRIs [ 13 17 ]. The anticholinergic, cardiac and neurological side effects of clomipramine may be problematic in this regard.

CONSIDERING THE CONSISTENT EFFICACY AND BETTER TOLERABILITY, GUIDELINES RECOMMEND SSRIs AS FIRST LINE TREATMENT FOR OCD ( TABLE 6 ).

Choice of ssri.

Meta-analyses comparing the different SSRIs [ 16 ] and direct head-to-head comparisons [ 17 18 ] have not shown superiority of any one SSRI over the other. SSRIs differ to some extent in their propensity to cause certain adverse effects and drug interactions. However, there is no unequivocal evidence to suggest that these differences may be clinically meaningful. Recently, concerns have been raised regarding cardiac adverse effects with high dose of citalopram, which is commonly used in OCD. Hence, high-dose citalopram may be used with caution in those with risk for arrhythmias.

THE PRACTITIONER IS RECOMMENDED TO CHOOSE AN SSRI FOR AN INDIVIDUAL PATIENT BASED ON FACTORS SUCH AS PREVIOUS RESPONSE, COMORBIDITY, TOLERABILITY, ACCEPTABILITY, ADVERSE EFFECTS, COST AND DRUG INTERACTIONS.

Dose of ssri.

It is generally recommended that OCD be treated with a higher dose of SSRI than that used in depression ( Table 5 ). A meta-analysis of fixed-dose comparison studies have found a greater efficacy with higher doses of SSRI (60-80 mg fluoxetine equivalent) compared to medium (40-50 mg fluoxetine equivalent) and low doses (20-30 mg fluoxetine equivalent) [ 19 ]. However, all three dose ranges were significantly more effective than placebo. The increased efficacy comes at the cost of poor tolerability as evidenced by increased dropouts due to adverse effects [ 19 ]. A review of individual fixed-dose comparison studies found that the dose-response relationship is more evident for escitalopram, fluoxetine and paroxetine, while it is less clear-cut for citalopram and sertraline [ 17 ]. Clomipramine has not been tested in such fixed dose comparison studies. However, most studies have employed a flexible dosing at 150-250 mg [ 17 ]. It should be remembered that there is likely to be inter-individual differences in pharmacokinetic profile of drugs due to intrinsic variations in drug metabolism and drug interactions.

GUIDELINES RECOMMEND TREATMENT OF OCD WITH HIGHER DOSE OF SSRIs. HOWEVER, IF AN INDIVIDUAL PATIENT IS NOT ABLE TO TOLERATE HIGHER DOSE, LOW TO MEDIUM DOSE TREATMENT CAN BE CONSIDERED.

Duration of trial and dose titration.

A recent meta-analysis of 17 RCTs found that SSRIs separate from placebo as early as 2 weeks and that majority of improvement occurs early on in the course of treatment [ 20 ]. However, improvements seen early in the course of treatment may not be always clinically meaningful. In many patients, clinically meaningful improvements may be seen only after weeks or months of treatment. It is recommended that an adequate trial of a SSRI (or clomipramine) should be at least for 12 weeks to account for the lag in the onset of action. The APA guidelines recommend upward titration to the maximum FDA-approved doses by 4-6 weeks and continuation in that dose for another 6-8 weeks or so to determine efficacy [ 11 ]. Certain clinical and biological predictors of treatment response to SSRIs have been identified but they are not robust predictors ( Table 7 ).

GUIDELINES RECOMMEND CONTINUING MAXIMALLY TOLERATED EFFECTIVE DOSE OF A SSRI FOR AT LEAST 12 WEEKS FOR JUDGING ITS EFFICACY. GUIDELINES ALSO RECOMMEND DOSE ESCALATION TO EFFECTIVE DOSE RANGES WITHIN 4-6 WEEKS AND CONTINUATION IN THE SAME DOSE FOR ANOTHER 6-8 WEEKS.

2. other medications that can be tried as monotherapy in ocd.

Venlafaxine, a serotonin-norepinephrine reuptake inhibitor with preferential serotonergic action, has been studied in comparison to paroxetine in a double blinded study and clomipramine in a single blinded study. The studies found no difference in the efficacy between venlafaxine and the comparator agents in acute control of OCD. Given the absence of evidence from placebo-controlled trials, venlafaxine is not the first-line treatment for OCD. Hence, the guidelines consider venlafaxine as a second-line monotherapy agent in the treatment of OCD.

Mirtazapine has been studied as a monotherapy in two small open-label trials with inconsistent findings. Therefore, mirtazapine cannot be recommended as monotherapy in treatment of OCD.

3. Treatment strategy for non-responders to first-line treatment

Definitions of treatment outcome [ 21 ] are given in Table 8 . Estimates suggest that around 40-70% patients show an adequate response to a trial of SSRI with a remission rate of 10-40% [ 16 ]. Clinicians often face the subsequent challenge of partial and non-response to SSRIs. Continuing improvement has been noticed with prolonged trial of SSRIs as discussed above. Hence, the initial trial may be continued further if there is evidence of ongoing improvement. A general treatment algorithm for OCD and for non-responders to SSRIs is shown in Figures 1 and 2 respectively.

a. Switching to another medication

Switching to another first-line medication has been found to be effective; experts provide a rough estimate of 40-50% response rate for the second SSRI and decreasing response rates with further trials. Switching to a second SSRI is suggested for non-responders to a first SSRI. In partial responders, changing medication may entail loss of the response to the earlier medication. Hence, switching is recommended in partial responders only if there are severe persisting symptoms or upon failure of other augmenting strategies such as CBT and atypical antipsychotics.

b. Switching / Augmenting with CBT/BT

It is uncertain whether initiating a combination of BT/CBT simultaneously with SSRI is advantageous compared to either treatment alone. However, CBT/BT has been proven to be effective as an augmenter in partial/non-responders to SSRIs [ 18 22 23 ]. Where feasible, CBT/BT is a potential first-line augmenting option for partial/non-responders to SSRI treatment.

c. Augmenting with another medication ( Table 9 )

The following medications have been commonly tried as augmenters to SSRIs. Atypical antipsychotics, risperidone and aripiprazole have the best evidence.

i Antipsychotics

Antipsychotics are the most widely studied augmenting agents of SSRIs [ 23 ]. The literature on antipsychotic augmentation is fraught with methodological limitations including small sample sizes, varying doses and duration of treatment with both antipsychotics and concomitant SSRIs, varying degree of treatment resistance etc. Two recent meta-analyses of 14 RCTs on antipsychotic augmentation found that antipsychotic as a group was significantly more effective than placebo in decreasing YBOCS scores [ 24 25 ]. About a third of patients responded to antipsychotic augmentation. Aripiprazole and risperidone are consistently found to be effective as augmenting agents. The evidence for haloperidol should be interpreted with caution as it was based on a single study. A fairly large RCT comparing CBT, risperidone and pill placebo augmentation of SSRI found that risperidone did not separate from placebo in augmenting efficacy [ 26 ]. This study has raised questions on the efficacy of risperidone as an augmenter. Quetiapine and olanzapine have not been consistently found to be effective, while other antipsychotics have not been studied adequately. Meta-analyses do not throw any light on adequate dose and duration of antipsychotic treatment [ 24 ]. Antipsychotics should be used in low doses (e.g., 1-3 mg of risperidone, 5-10 mg aripiprazole) for a period of at least 8 weeks for an adequate trial. Use of antipsychotics in the long-run should be considered after weighing the benefits and risks of long-term use.

BASED ON THE AVAILABLE EVIDENCE, ARIPIPRAZOLE AND RISPERIDONE MAY BE CONSIDERED THE FIRST CHOICE FOR PHARMACOLOGICAL AUGMENTATION

Ii. glutamatergic agents.

There is a strong theoretical rationale supporting the use of glutamatergic drugs in OCD. The following glutamatergic agents have been studied in OCD [ 23 ]:

• Memantine: found effective in 2 double blinded and one single blinded RCT.
• Lamotrigine: found effective in 2 double blinded RCTs
• Topiramate: effective in 2 small double-blind RCTs, but poorly tolerated
• Riluzole: inconsistent results in two RCTs
• N-acetylcysteine: conflicting results from three RCTs, has to be studied further.

BASED ON THE EVIDENCE AND ITS RELATIVELY BETTER TOLERABILITY, MEMANTINE IS PREFERRED OVER LAMOTRIGINE AS THE FIRST CHOICE GLUTAMATERGIC AUGMENTING AGENT.

Iii. serotonergic agents.

5HT-3 antagonists including ondansetron and granisetron are reported to be effective and well tolerated in small RCTs [ 27 ]. However, due to the methodological limitations of the individual studies, 5HT-3 antagonists are recommended as second line augmenting agents along with glutamatergic agents.

Preliminary evidence suggests that clomipramine can be an effective augmenting agent. Clomipramine and SSRI combination should be used cautiously, especially with fluoxetine and fluvoxamine, as they may increase clomipramine related adverse effects (including serious events like seizures, cardiac effects, serotonin syndrome) due to pharmacokinetic interactions. Clomipramine augmentation of SSRI may be tried but adequate precautions need to be taken keeping in mind the potential adverse effects of the combination.

Mirtazapine augmentation has been found to hasten the response with no significant long term benefits [ 23 ] and hence may be considered as an augmenting agent in partial responders and non-responders.

iv. Other augmenting agents

Buspirone, lithium and clonazepam have not been found effective and hence are not recommended as augmenting agents. The safety and efficacy of psychostimulants and opioid drugs have to be systematically studied before they are recommended for routine clinical use. Intravenous ketamine has been found to have acute anti-obsessive effects in a “proof-of-concept” study, which needs replication and long term evaluation before the strategy can be recommended for routine clinical use.

d. Other experimental strategies

While there appears to be some short-term benefits for intravenous clomipramine in treatment resistant patients, the long term benefits are uncertain. This formulation is not available in India and is not recommended at present for clinical use. There are a few uncontrolled trials demonstrating the utility of higher than recommended doses of SSRIs (up to 400 mg of sertraline, 40-50 mg of escitalopram) in resistant patients. This strategy should be considered experimental and may be used only in resistant patients after exhausting other regular safer options.

ROLE OF OTHER NON-SOMATIC TREATMENTS

Around 20% of patients do not respond to available pharmacological and psychological treatments. Neuromodulatory and neurosurgical treatments targeting the cortico-striato- thalamo-cortical (CSTC) circuits have been tried in resistant patients.

NON-INVASIVE BRAIN STIMULATION TECHNIQUES

1. electroconvulsive therapy(ect).

ECT has not been systematically evaluated for the treatment of OCD. Available evidence, in the form of case reports and case series, do not provide evidence for the efficacy of ECT [ 28 ]. Hence, ECT is not recommended as a treatment for OCD and may be considered for the treatment of comorbid conditions like severe mood and psychotic disorders, if indicated.

2. Repetitive transcranial magnetic stimulation (rTMS)

rTMS entails the possibility of non-invasive and focal stimulation of superficial cortical regions, thereby increasing or decreasing their excitability based on the frequency of stimulation. The regions implicated in OCD are usually not accessible with available technology of rTMS. Hence rTMS has been tried in superficial cortical regions which have connections with other deeper structures implicated in OCD. Controlled trials of low frequency or high frequency rTMS over either dorsolateral prefrontal cortex (DLPFC) have yielded conflicting results but low frequency rTMS over supplementary motor area (SMA) and orbitofrontal cortex (OFC) appear promising [ 29 ]. However, the evidence has not been very consistent. Overall, the findings have to be replicated in larger samples with long term follow-up. There is no convincing evidence that beneficial effects persist for longer than the trial period. The guideline recommends rTMS as an intervention for further research and not for routine clinical use.

3. Transcranial direct current stimulation (tDCS)

tDCS is another focal and superficial cortical modulatory intervention, which either increases or decreases the excitability of the underlying cortex depending on the polarity of the stimulating electrode. There are only a few case reports and an open-label trial on tDCS in OCD. It has to be evaluated more systematically before it can be recommended for clinical use in OCD.

NEUROSURGICAL PROCEDURES

1. ablative neurosurgery.

Ablative neurosurgical procedures involve producing lesions in specific regions of the CSTC circuit, which is hypothesized to be dysfunctional in OCD. Reliable lesions can be produced with the help of “invasive” stereotactic surgery or “non-invasively” with the help of image guided gamma radiation. Anterior cingulotomy and a refined version of capsulotomy known as ‘gamma ventral capsulotomy’ are practiced in treatment refractory OCD in a few centers. Due to the irreversible nature, these procedures are generally employed in treatment refractory patients ( Table 10 ). Evidence primarily in the form of uncontrolled studies suggests that around 40-60% of patients improve over 6-24 months following surgery. There is some suggestion that capsulotomy may be more effective procedure in OCD [ 30 ] and that its efficacy may be similar to that of deep brain stimulation (DBS) [ 31 ]. Surgery may be associated with short-term and persistent adverse effects including personality changes, seizures and cognitive adverse effects although rates are not high.

2. Deep brain stimulation

Deep brain stimulation (DBS) is a potentially reversible procedure involving high frequency stimulation of implanted electrodes in the brain. Although the mechanism of action is poorly understood, it is hypothesized to modify dysfunctional circuits. DBS for OCD has been evaluated in sham controlled studies targeting nucleus accumbens, ventral capsule/ventral striatum, anterior limb of internal capsule, ventral caudate and subthlamic nucleus. A recent meta-analysis found a responder rate of 60% with a mean YBOCS reduction of around 45% [ 32 ]. DBS is an invasive procedure and is associated with short term and long term adverse effects. Further, the battery needs to be replaced periodically which may be quite expensive. DBS can be recommended in carefully selected refractory OCD patients ( Table 10 ) after discussion regarding the pros and cons of the procedure.

The neurosurgical procedures are not curative in nature and the procedures are only one aspect of a comprehensive treatment program which should continue following surgery.

Surgical procedures may be considered only in selective patients after careful evaluation of patients for treatment refractoriness, severity of illness and comorbidities. Patients should be explained about the realistic possibility of benefits and risks. They should be evaluated by an independent team consisting of a psychiatrist, a neurologist and a neurosurgeon for suitability for surgery. The treatment should be conducted under close collaboration of a team of psychiatrist, neurosurgeon, radiotherapist, imaging specialist and psychologist with close monitoring of adverse effects. Suggested criteria for suitability to undergo surgery are shown in Table 10 .

PSYCHOLOGICAL TREATMENTS FOR OCD ( TABLE 11 )

A. cognitive behavioral therapy (cbt) / exposure and response prevention (erp).

Consistently, CBT/ERP has been shown to be efficacious in the treatment of OCD [ 33 ]. All treatment guidelines have suggested the use of CBT as a first-line treatment option. CBT for OCD includes ERP.

CBT/ERP is a first-line treatment option for OCD. ERP is the most important component of CBT along with belief modification. When facilities are available, CBT/ERP monotherapy may be recommended in mild to moderately ill patients. In severely ill patients a combination of CBT and SSRI is recommended.

CBT as an augmentation strategy

It is uncertain whether initiating a combination of CBT/ERP and SSRI is advantageous compared to either treatment alone. However, CBT/BT is found to be effective in augmenting SSRIs in partial/non-responders to SSRIs [ 34 ]. A recent study found CBT to be superior to risperidone and placebo in augmenting SSRIs in OCD [ 35 ]. Patients in the CBT group had significantly greater reductions in OCD symptom severity compared with participants taking risperidone or placebo. Risperidone was not superior to placebo on any outcome measures.

When facilities for CBT are available, CBT / BT is recommended as the first line augmenting strategy in partial/non-responders to SSRI treatment.

Mode of CBT/ERP delivery and adaptations

Although various models are available for CBT in OCD, the major components are psychoeducation, development of symptom hierarchy, cognitive restructuring and ERP ( Table 12 ). The method of conducting ERP has been found to be important with ‘therapist-assisted’ ERP producing a greater change in symptom severity. Therapist-guided exposure is better than self-guided exposure. The numbers of CBT sessions have varied between 12 and 20 sessions across various studies. It has ranged from intensive daily 2 hour sessions for 5 days a week for 3 weeks to less intensive twice weekly sessions in other studies.

Even though group CBT has been compared with individual CBT, the results have been mixed. While a couple of studies have reported comparable efficacy for group and individual forms of CBT, some other studies demonstrated the superiority of individual mode of CBT compared to the group CBT. Another adaptation of CBT which has been examined in the recent years is the internet based CBT (ICBT) and computerized CBT. They are found to be effective compared to supportive therapy / relaxation methods [ 36 37 ].

Where resources are available, 15-20 hours of therapist assisted CBT / BT may be considered. The evidence for ICBT and computerized CBT is very preliminary and it may be recommended in certain circumstances where regular face-to-face CBT is not feasible.

B. Other Psychological therapies

1. acceptance and commitment therapy.

This therapy aims to improve psychological flexibility through the practice of acceptance and mindfulness in addition to commitment and behavior modification exercises. Preliminary evidence suggests its benefits but it needs to be tested and compared with CBT in larger samples.

2. Stress management and relaxation training

These have been conventionally used in many studies as control arm in studies CBT. Stress management and relaxation training may have non-specific effects but there is no evidence suggesting their efficacy in treatment of OCD.

3. Mindfulness based cognitive therapy

Mindfulness based therapy is thought to be useful in OCD. Preliminary data suggests its utility in treating OCD. Protocols for RCT are published but there is no published evidence in the literature in clinical population.

4. Family inclusive treatments

Family-inclusive treatment (FIT) approaches aim to include the family members in the treatment so as to improve the family functioning, facilitate behavioral therapy etc. Studies targeting family accommodation of obsessive-compulsive symptoms report greater improvements in patient functioning. Family members may be encouraged to participate in CBT since family accommodation of symptoms is associated with poorer treatment outcomes.

The other forms of psychological therapies with isolated studies include adjunct motivational interviewing to ERP and Eye Movement Desensitization and Reprocessing (EMDR). There is one study examining the role of brief dynamic therapy in OCD with negative result. In addition, the potential benefits of adding D-cycloserine prior to ERP sessions has been examined in few studies.

MANAGEMENT AS PER THE DIFFERENT PHASES OF ILLNESS

Acute phase.

This includes decision on choice of treatment modality (SSRI vs. CBT), implementation of treatment, monitoring for the response and side-effects, and planning for sequential treatment trials if initial treatments failed to produce satisfactory improvement.

Maintenance treatment (How long the treatment should be continued?)

There is evidence for ongoing improvement with continued use of SSRIs and clomipramine in long term continuation studies for a period of up to 1 year[ 18 ]. Guidelines recommend continuation of SSRIs / clomipramine for at least 1-2 years after achieving remission. Clinical experience dictates that discontinuation of medication beyond that period may be associated with increased chance of relapse. Hence discontinuation of medications should be carefully considered based on individual patient factors including severity and duration of illness, past history of relapse on discontinuation, residual symptoms, comorbidities etc. Most patients may require continued pharmacotherapy to prevent relapses. Medications are generally recommended to be continued at the same dose that resulted in improvement, unless the dosage is not tolerated.

MANAGEMENT OF COMORBID CONDITIONS

Depression and anxiety disorders.

Most common co-occurring illness is major depression. The Pharmacological treatment strategy does not change much, however in severe depression CBT/ERP for OCD needs to kept on hold until the patient recovers from depression. Severe depression with prominent suicidal ideas needs to be evaluated thoroughly and ECT may be considered if indicated. Comorbid dysthymia is common and may require individual therapy.

Comorbid anxiety disorder needs to be treated aggressively since untreated anxiety disorder may contribute to poor treatment outcome. Comorbid anxiety disorders may require CBT in addition to SSRIs.

Tic disorders

Tic disorders show best response to antipsychotics (haloperidol, pimozide, risperidone and aripirazole). Although antipsychotics may be more effective, adrenegic α 2 agonists (clonidine and guanafacine) may be tried first to treat tics in view of adverse effects associated with antipsychotics. Habit-reversal therapy (HRT) is a potential first-line treatment option instead of or in combination with pharmacotherapy.

OCD patients with tic disorders may require a combination of an SSRI and an antipsychotic. There is evidence that OCD comorbid with tic disorders may not respond satisfactorily to SSRI alone.

Bipolar Disorder

Comorbid bipolar disorder calls for a different treatment strategy because SSRIs are well known to cause/exacerbate hypomania or mania. Mood stabilization should be the primary goal in treating OCD-bipolar patients [ 38 ]. In many patients with comorbid bipolar disorder, OCD often manifests / increases in severity in depressive episodes but improves in mania / hypomania episodes. In such patients, treatment with mood stabilizer alone may be considered. If OCD persists outside of the mood episodes, CBT may be preferred over SSRIs. However, if patient requires an SSRI, it has to be prescribed under the cover of mood stabilizers or an atypical antipsychotic.

OC symptoms and OCD are not uncommon in those with schizophrenia; up to 25% of the schizophrenia patients report clinically significant OCD symptoms. SSRIs may be used in treating OCD comorbid with schizophrenia, but there is limited published evidence. Some atypical antispychotics such as clozapine, risperidone and olanzapine may induce or even worsen OCD symptoms. In case of drug-induced OC symptoms, if feasible, one may consider reducing dose or changing to another antipsychotic.

Personality disorders

20% of the participants suffer from at least one comorbid personality disorder (PD). The most common are obsessive-compulsive, narcissistic and anxious avoidant personality disorders. Presence of PD can complicate the course and outcome. OCD patients with different comorbid PDs differ in their therapeutic response to treatment. Borderline, obsessive-compulsive and schizotypal personality disorders can contribute to poor outcome. There are no systematic studies comparing the effects of treatment in OCD coexisting with PD. Generally it is agreed upon that a combination of medications, CBT-ERP and individual therapy are advocated.

OCD during pregnancy and lactation

Medication should be guided primarily by its safety data, severity of the illness, and benefit vs. risk to the developing fetus. For newly diagnosed OCD during pregnancy and in the post-partum period, CBT/ERP is the preferred option [ 39 ]. Pre-pregnancy counseling for all women should include planning pregnancy, folate supplementation, discussion with patient and spouse regarding options, and active liaison with obstetricians, ultrasonologists and pediatricians.

Following is the summary of SSRIs in pregnancy and lactation:

• If the patient is symptom-free for a long period, an attempt may be made to withdraw the SSRI gradually. However, a risk of relapse following discontinuation should be discussed.
• Benefits vs. risks of continuing SSRIs during pregnancy should be discussed keeping in mind the fact that OCD can relapse following discontinuation.
• SSRIs as a group do not appear to be major teratogens.
• SSRIs, paroxetine in particular have been associated with increased risk for cardiac malformations (septal defects) (1.5-2%), as compared to the general population (1%) but the evidence is inconsistent. Paroxetine may be avoided; it is less safe than the other SSRIs.
• Some studies have reported an association between SSRI use in first trimester and anencephaly, craniosynostosis, and omphalocele. However, it must be emphasized that the risks are rare and absolute risks are small.
• When taken in late pregnancy, SSRIs may increase the risk of persistent pulmonary hypertension by more than twofold in the newborn (absolute risk, 3 infants per 1000 exposed vs. 1.2 infants per 1000 unexposed).
• SSRIs have also been associated with decreased gestational age, low birth weight and spontaneous abortion
• Following birth, serotonergic toxicity and antidepressant discontinuation symptoms may manifest, therefore it is important to liaise with pediatricians.
• Sertraline, fluvoxamine and paroxetine are present in very low concentrations in plasma of breast-fed infants (<3% of maternal dose). It is surmised that they are relatively safe during breast feeding. With fluoxetine and citalopram, infants can receive up to 15% of the maternal dose.

OCD in child and adolescent population

SSRIs and clomipramine are efficacious in treating OCD and are superior to placebo with modest effect size [ 40 ]. CBT has superior efficacy compared to SSRIs in children [ 40 ]. A combination of CBT and SSRI seems to have no additional advantage over CBT alone indicating that SRI treatment adds little to concomitant CBT. However, combined treatment is better than SSRI alone. In partial responders to SSRIs, adding CBT is superior and efficacious as compared to continuing a SSRI. In view of superior efficacy of CBT, many guidelines advocate CBT as the first line treatment in children. In children, where facilities are available, CBT may be preferred over SSRIs as the first-line treatment. In children with severe OCD, a combination of CBT and SSRI is recommended over SSRI alone. SRIs are the alternative first-line treatment for OCD in children in situations where CBT is either not available or the child cannot comply with CBT.

SSRIs in medically ill

SSRIs are generally safe in patients with cardiovascular problems. Citalopram (? Escitalopram) is associated with arrhythmias but the risk is low and may not be clinically significant, but may be used with caution or avoided in those at risk for arrhythmias. SSRIs are widely used to treat depression in diabetes. They may improve diabetic parameters: improvement in HbA1c levels, reduced insulin requirement, enhanced insulin sensitivity and improved glycemic control. SSRIs are not hepatotoxic, but they need to be used in lower doses and with caution in the presence of significant hepatic impairment since all SSRIs are biotransformed in liver. All SSRIs are metabolized by the Cytochrome P450 system and fluoxetine, fluvoxamine, and paroxetine also significantly inhibit P450 enzymes. Therefore, these agents may potentially interfere with wide variety of other medications. Interactions with other drugs need to be considered, particularly in elderly who are likely to be on many medications for other medical conditions. Citalopram / escitalopram and sertraline do not substantially inhibit P450 enzymes and therefore are associated with less drug interactions. All SSRIs are renally excreted. Depression is common in those with chronic kidney disease (CKD) and end stage renal disease (ESRD). If indicated SSRIs are the preferred antidepressants. SSRIs such as paroxetine, citalopram and escitalopram may have to be administered in lower doses in CKD and ESRD in the background of compromised renal functions. Since many patients with CKD and ESRD also suffer from cardiovascular disorders, citalopram (and perhaps escitalopram) may be used with caution since high doses of citalopram is associated with QTc prolongation and torsades de pointes.

Side Effects of SSRIs

The dosage of anti-obsessive drugs is usually higher than the usual anti-depressant dose; hence it is important for the clinician to discuss regarding the common side-effects. This issue is important because patients need to be on medications for a long duration. Sometimes an adjustment in dose or a switch in the time of the day the dose is taken is all that is needed. Rarely, stopping a particular medication and switching to another medication may be required. Side-effects of SSRIs and possible remedies are given in Table 13 .

Recommendations are summarized in Table 14 . The SSRIs and CBT are the first-line treatment options for OCD. CBT alone may be tried in mild to moderately ill patients if facilities for CBT are available. In severe OCD, a combination of SSRI and CBT is recommended. In the Indian context, SSRIs are the preferred first-line treatment for OCD because of limited resources for delivering CBT. SSRIs are effective, well tolerated and safe. For partial responders and non-responders to SRIs, CBT is an effective augmenting agent followed by atypical antipsychotics. Although an attempt may be made to taper and stop SSRI after 1-2 years of sustained remission, most patients may require indefinite continued treatment with a SSRI. DBS and ablative surgery may be considered in chronic, severe OCD if other established treatment options have failed to produce any clinically significant improvement.

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• Open access
• Published: 11 July 2020

Obsessive compulsive disorder in very young children – a case series from a specialized outpatient clinic

• Veronika Brezinka   ORCID: orcid.org/0000-0003-2192-3093 1 ,
• Veronika Mailänder 1 &
• Susanne Walitza 1  

BMC Psychiatry volume  20 , Article number:  366 ( 2020 ) Cite this article

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Paediatric obsessive-compulsive disorder (OCD) is a chronic condition often associated with severe disruptions of family functioning, impairment of peer relationships and academic performance. Mean age of onset of juvenile OCD is 10.3 years; however, reports on young children with OCD show that the disorder can manifest itself at an earlier age. Both an earlier age of onset and a longer duration of illness have been associated with increased persistence of OCD. There seems to be difficulty for health professionals to recognize and diagnose OCD in young children appropriately, which in turn may prolong the interval between help seeking and receiving an adequate diagnosis and treatment. The objective of this study is to enhance knowledge about the clinical presentation, diagnosis and possible treatment of OCD in very young children.

Case presentation

We describe a prospective 6 month follow-up of five cases of OCD in very young children (between 4 and 5 years old). At the moment of first presentation, all children were so severely impaired that attendance of compulsory Kindergarten was uncertain. Parents were deeply involved in accommodating their child’s rituals. Because of the children’s young age, medication was not indicated. Therefore, a minimal CBT intervention for parents was offered, mainly focusing on reducing family accommodation. Parents were asked to bring video tapes of critical situations that were watched together. They were coached to reduce family accommodation for OCD, while enhancing praise and reward for adequate behaviors of the child. CY-BOCS scores at the beginning and after 3 months show an impressive decline in OCD severity that remained stable after 6 months. At 3 months follow-up, all children were able to attend Kindergarten daily, and at 6 months follow-up, every child was admitted to the next level / class.

Conclusions

Disseminating knowledge about the clinical presentation, diagnosis and treatment of early OCD may shorten the long delay between first OCD symptoms and disease-specific treatment that is reported as main predictor for persistent OCD.

Peer Review reports

Paediatric obsessive compulsive disorder [ 1 ] is a chronic condition with lifetime prevalence estimates ranging from 0.25 [ 2 ] to 2–3% [ 3 ]. OCD is often associated with severe disruptions of family functioning [ 4 ] and impairment of peer relationships as well as academic performance [ 5 ]. Mean age of onset of early onset OCD is 10.3 years, with a range from 7.5 to 12.5 years [ 6 ] or at an average of 11 years [ 7 ]. However, OCD can manifest itself also at a very early age - in a sample of 58 children, mean age of onset was 4.95 years [ 8 ], and in a study from Turkey, OCD is described in children as young as two and a half years [ 9 ]. According to different epidemiological surveys the prevalence of subclinical OC syndromes was estimated between 7 and 25%, and already very common at the age of 11 years [ 10 ].

Understanding the phenomenology of OCD in young children is important because both an earlier age of onset and a longer duration of illness have been associated with increased persistence of OCD [ 11 , 12 , 13 ]. One of the main predictors for persistent OCD is duration of illness at assessment, which underlines that early recognition and treatment of the disorder are crucial to prevent chronicity [ 10 , 14 , 15 ]. OCD in very young children can be so severe that it has to be treated in an inpatient-clinic [ 16 ]. This might be prevented if the disorder were diagnosed and treated earlier.

In order to disseminate knowledge about early childhood OCD, detailed descriptions of its phenomenology are necessary to enable clinicians to recognize and assess the disorder in time. Yet, studies on this young population are scarce and differ in the definition of what is described as ‘very young’. For example, 292 treatment seeking youth with OCD were divided into a younger group (3–9 years old) and an older group (10–18 years old) [ 17 ]. While overall OCD severity did not differ between groups, younger children exhibited poorer insight, increased incidence of hoarding compulsions, and higher rates of separation anxiety and social fears than older youth. It is not clear how many very young children (between 3 and 5 years old) were included in this study. Skriner et al. [ 18 ] investigated characteristics of 127 young children (from 5 to 8) enrolled in a pilot sample of the POTS Jr. Study. These young children revealed moderate to severe OCD symptoms, high levels of impairment and significant comorbidity, providing further evidence that symptom severity in young children with OCD is similar to that observed in older samples. To our knowledge, the only European studies describing OCD in very young children on a detailed, phenotypic level are a single-case study of a 4 year old girl [ 16 ] and a report from Turkey on 25 children under 6 years with OCD [ 9 ]. Subjects were fifteen boys and ten girls between 2 and 5 years old. Mean age of onset of OCD symptoms was 3 years, with some OCD symptoms appearing as early as 18 months of age. All subjects had at least one comorbid disorder; the most frequent comorbidity was an anxiety disorder, and boys exhibited more comorbid diagnoses than girls. In 68% of the subjects, at least one parent received a lifetime OCD diagnosis. The study reports no further information on follow-up or treatment of these young patients.

In comparison to other mental disorders, duration of untreated illness in obsessive compulsive disorder is one of the longest [ 19 ]. One reason may be that obsessive-compulsive symptoms in young children are mistaken as a normal developmental phase [ 20 ]. Parents as well as professionals not experienced with OCD may tend to ‘watch and wait’ instead of asking for referral to a specialist, thus contributing to the long delay between symptom onset and assessment / treatment [ 10 ]. This might ameliorate if health professionals become more familiar with the clinical presentation, diagnosis and treatment of the disorder in the very young. The purpose of this study is to provide a detailed description of the clinical presentation, diagnosis and treatment of OCD in five very young children.

We describe a prospective 6 month follow-up of five cases of OCD in very young children (between 4 and 5 years old) who were referred to the OCD Outpatient Treatment Unit of a Psychiatric University Hospital. Three patients were directly referred by their parents, one by the paediatrician and one by another specialist. Parents and child were offered a first session within 1 week of referral. An experienced clinician (V.B.) globally assessed comorbidity, intelligence and functioning, and a CY-BOCS was administered with the parents.

Instruments

To assess OCD severity in youth, the Children Yale-Brown Obsessive Compulsive Scale CY-BOCS [ 21 ] is regarded as the gold standard, with excellent inter-rater and test-retest reliability as well as construct validity [ 21 , 22 ]. The CY-BOCS has been validated in very young children by obtaining information from the parent. As in the clinical interview Y-BOCS for adults, severity of obsessions and compulsions are assessed separately. If both obsessions and compulsions are reported, a score of 16 is regarded as the cut-off for clinically meaningful OCD. If only compulsions are reported, Lewin et al. [ 23 ] suggest a cut-off score of 8. In their CY-BOCS classification, a score between 5 and 13 corresponds to mild symptoms / little functional impairment or a Clinical Global Impression Severity (CGI-S) of 2. A score between 14 and 24 corresponds to moderate symptoms / functioning with effort or a CGI-S of 3. Generally, it is recommended to obtain information from both child and parents. However, in case of the very young patients presented here, CY-BOCS scores were exclusively obtained from the parents. The parents of all five children reported not being familiar with any obsessions their child might have. In accordance with previous recommendations [ 23 ], a cut-off point of 8 for clinically meaningful OCD was used.

Patient vignettes

Patient 1 is a 4 year old girl, a single child living with both parents. She had never been separated an entire day from her mother. At the nursery, she suffered from separation anxiety for months. Parents reported that the girl had insisted on rituals already at the age of two. In the evening, she ‚had‘ to take her toys into bed and had got up several times crying because she ‚had to‘ pick up more toys. In the morning, only she ‚had the right‘ to open the apartment door. When dressing in the morning, she ‚had‘ to be ready before the parents. Only she was allowed to flush the toilet, even if it concerned toilet use of the parents. Moreover, only she ‘had the right’ to switch on the light, and this had to be with ten fingers at the same time. If she did not succeed, she got extremely upset and pressed the light button again and again until she was satisfied. The girl was not able to throw away garbage and kept packaging waste in a separate box. In the evening, she had to tidy her room for a long time until everything was ‚right‘. Whenever her routine was changed, she protested by crying, shouting and yelling at her parents. Moreover, she insisted on repeating routines if there had been a ‚mistake‘. In order to avoid conflict, both parents adapted their behavior to their daughter’s desires. In the first assessment with the parents, her score on the CY-BOCS was 15, implying clinically meaningful OCD. Psychiatric family history revealed that the mother had suffered from severe separation anxiety as a child and the father from severe night mares. Both parents described themselves as healthy adults.

Patient 2 is a four and a half year old boy, the younger of two brothers. He was reported to have been very oppositional since the age of two. Since the age of three, he insisted on a specific ritual when flushing the toilet – he had to pronounce several distinct sentences and then to run away quickly. Some months later he developed a complicated fare-well ritual and insisted on every family member using exactly the sentences he wanted to hear. If one of these words changed, he started to shout and threw himself on the floor. After a short time, he insisted on unknown people like the cashier at the supermarket to use the same words when saying good-bye.Moreover, he insisted that objects and meals had to be put back to the same place as before in case they had been moved. When walking outside, he had to count his steps and had to start this over and over again. In the morning, he determined where his mother had to stand and how her face had to look when saying good-bye. In order to avoid conflict, parents and brother had deeply accommodated their behavior to his whims. On the CY-BOCS, patient 2 reached a score of 15, which is equivalent to clinically meaningful OCD. Neither his father nor his mother reported any psychiatric disorder in past or present.

Patient 3 is a 4 year old boy referred because of possible OCD. Since the age of three, he had insisted on things going his way. When this was not the case, he threw a temper tantrum and demanded that time should be turned back. If, for example, he had cut a piece of bread from the loaf and was not satisfied with its form, he insisted that the piece should be ‘glued’ to the loaf again. Since he entered Kindergarten at the age of four, his behavior became more severe. If he was not satisfied with a certain routine like, for example, dressing in the morning, he demanded that the entire family had to undress and go to bed again, that objects had to lie at the same place as before or that the clock had to be turned back. In order to avoid conflict, the parents had repeatedly consented to his wishes. His behavior was judged as problematic at Kindergarten, because he demanded certain situations to be repeated or ‚played back‘. When the teacher refused to do that, the boy once run away furiously. On the CY-BOCS, patient 3 reached a score of 15. The mother described herself as being rather anxious (but not in treatment), the father himself as not suffering from any psychiatric symptoms. However, his mother had suffered from such severe OCD when he was a child that she had undergone inpatient treatment several times. This was also the reason why the parents had asked for referral to a specialist for the symptoms of their son.

Patient 4 is a 5 year old girl, the eldest of three siblings. Since the age of two, she was only able to wear certain clothes. For months, she refused to wear any shoes besides Espadrilles; she was unable to wear jeans and could only wear one certain pair of leggings. Wearing warm or thicker garments was extremely difficult, leading to numerous conflicts with her mother in winter. Socks had to have the same height, stockings had to be thin, and slips slack. When dressing in the morning, she regularly got angry and despaired and engaged in severe conflicts with her mother; dressing took a long time, whereas she had to be in Kindergarten on time. Her compulsions with clothes seemed to influence her social behavior as well; she had been watching other children at the playground for 40 min and did not participate because her winter coat did not ‚feel right‘. She started to join peers only when she was allowed to pull the coat off. She also had to dry herself excessively after peeing and was reported to be perfectionist in drawing, cleaning or tidying. Her CY-BOCS score was 15, equivalent to clinically meaningful OCD. Both parents described themselves as not suffering from any psychiatric problem in past or present. However, the grandmother on the mother’s side was reported to have had similar compulsions when she was a child.

Patient 5 was a four and a half year old girl referred because of early OCD. She had one elder brother and lived with both parents. At the age of 1 year, patient 5 was diagnosed with a benign brain tumor (astrocytoma). The tumor had been removed for 90% by surgery; the remaining tumor was treated with chemotherapy. The first chemotherapy at the age of 3 years was reasonably well tolerated. Shortly thereafter, the girl developed just-right-compulsions concerning her shoes. When the second chemotherapy (with a different drug) was started at the age of four, compulsions increased so dramatically that she was referred to our outpatient clinic by the treating oncologist. She insisted on her shoes being closed very tightly, her socks and underwear being put on according to a certain ritual, and her belt being closed so tightly that her father had to punch an additional hole. She refused to wear slack or new clothes and was not able to leave the toilet after peeing because ‘something might still come’; she used large amounts of toilet paper and complained that she wasn’t dry yet. She also insisted on straightening the blanket of her bed many times. She was described by her mother as extremely stressed, impatient and irritable; she woke up every night and insisted to go to the toilet, from where she would come back only after intense cleaning rituals. In the morning, she frequently threw a severe temper tantrum, including hitting and scratching the mother, staying naked in the bathroom and refusing to get dressed because clothes were not fitting ‚just right‘or were not tight enough. Shortly after the start of the second chemotherapy, the girl had entered Kindergarten which was in a different language than the family language. Moreover, her mother had just taken up a new job and had to make a trip of several days during the first month. Although the mother gave up her job after the dramatic increase in OCD severity, the girl’s symptoms did not change. As an association between chemotherapy and the increase in OCD symptoms could not be excluded, the treating oncologist decided to stop chemotherapy 2 weeks after patient 5 was presented with OCD at our department. At the moment of presentation, she arrived at Kindergarten too late daily, after long scenes of crying and shouting, or refused to go altogether. She reached a score of 20 on the CY-BOCS, the highest score of the five children presented here. Her father described himself as free of any psychiatric symptoms in past or present. Her mother had been extremely socially anxious as a child.

None of the siblings of the children described above was reported to show any psychiatric symptoms in past or present (Table  1 ).

The five cases described above show a broad range of OCD symptomatology in young children. Besides Just-Right compulsions concerning clothes, compulsive behavior on the toilet was reported such as having to pee frequently, having to dry oneself over and over again as well as rituals concerning flushing. Other symptoms were pronouncing certain words or phrases compulsively, insisting on a ‘perfect’ action and claiming that time or situations must be played back like a video or DVD if the action or situation were not ‘perfect enough’. The patients described here have in common that parents were already much involved in the process of family accommodation. For example, the parents of patient 3 had consented several times to undress and go to bed again in order to ‘play back’ certain situations; they had also consented turning back the clock in the house. The parents of patient 2 had accommodated his complicated fare-well ritual, thus having to rush to work in the morning themselves. However, all parents were smart enough not just to indulge their child’s behavior, but to seek professional advice.

Treatment recommendations

Practice Parameters and guidelines for the assessment and treatment of OCD in older children and adolescents recommend cognitive behavior therapy (CBT) as first line treatment for mild to moderate cases, and medication in addition to CBT for moderate to severe OCD [ 24 , 25 ]. However, there is a lack of treatment studies including young children with OCD [ 26 ]. A case series with seven children between the age of 3 and 8 years diagnosed with OCD describes an intervention adapted to this young age group. Treatment emphasized reducing family accommodation and anxiety-enhancing parenting behaviors while enhancing problem solving skills of the parents [ 27 ]. A much larger randomized clinical trial for 127 young children (5 to 8 years of age) with OCD showed family-based CBT superior to a relaxation protocol for this age group [ 14 ]. Despite these advances in treatment for early childhood OCD, availability of CBT for paediatric OCD in the community is scarce due to workforce limitations and regional limitations in paediatric OCD expertise [ 28 ]. This is certainly not only true for the US, but for most European countries as well.

When discussing treatment of OCD in young children, the topic of family accommodation is of utmost importance. Family accommodation, also referred to as a ‘hallmark of early childhood OCD’ [ 15 ] means that parents of children with OCD tend to accommodate and even participate in rituals of the affected child. In order to avoid temper tantrums and aggressive behavior of the child, parents often adapt daily routines by engaging in child rituals or facilitating OCD by allowing extra time, purchasing special products or adapting family rules and organisation to OCD [ 29 , 30 , 31 ]. Although driven by empathy for and compassion with the child, family accommodation is reported to be detrimental because it further reinforces OCD symptoms and avoidance behavior, thus enhancing stress and anxiety [ 4 , 32 ].

Parent-oriented CBT intervention

At the moment of first presentation, the five children were so severely impaired by their OCD that attendance of (compulsory) Kindergarten was uncertain. All parents reported being utterly worried and stressed by their child’s symptoms and the associated conflicts in the family. However, no single family wanted an in-patient treatment of their child, and because of the children’s young age, medication was not indicated. Some families lived far away from our clinic and / or had to take care of young siblings.

Therefore, a CBT-intervention was offered to the parents, mainly focusing on reducing family accommodation. This approach is in line with current treatment recommendations to aggressively target family accommodation in children with OCD [ 15 ]. Parents and child were seen together in a first session. The following sessions were done with the parents only, who were encouraged to bring video tapes of critical situations. The scenes were watched together and parents were coached to reduce family accommodation for OCD, while enhancing praise and reward for adequate behaviors of the child. Parents were also encouraged to use ignoring and time-out for problematic behaviors. As some families lived far away and had to take care of young siblings as well, telephone sessions were offered as an alternative whenever parents felt the need for it. Moreover, parents were prompted to facilitate developmental tasks of their child such as attending Kindergarten regularly, or building friendships with peers. The minimal number of treatment sessions was four and the maximal number ten, with a median of six sessions.

Three of the five children (patients 3, 4 and 5) were raised in a different language at home than the one spoken at Kindergarten. This can be interpreted as an additional stressor for the child, possibly enhancing OCD symptoms. Instead of expecting their child to learn the foreign language mainly by ‚trial and error‘, parents were encouraged to speak this language at home themselves, to praise their child for progress in language skills and to facilitate playdates with children native in the foreign language.

Three and six months after intake, assessment of OCD-severity by means of the CY-BOCS was repeated. Table  2 shows an impressive decline in OCD-severity after 3 months that remained stable after 6 months. At 3 months follow-up, all children were able to attend Kindergarten daily, and at 6 months follow-up, every child was admitted to the next level of Kindergarten or, in the case of patient 4, to school.

We report on five children of 4 and 5 years with very early onset OCD who were presented at a University Department of Child and Adolescent Psychiatry. These children are ‚early starters‘with regard to OCD. As underlined in a recent consensus statement [ 10 ], delayed initiation of treatment is seen as an important aspect of the overall burden of OCD (see also [ 19 ]). In our small sample, a CBT-based parent-oriented intervention targeting mainly family accommodation led to a significant decline in CY-BOCS scores after 3 months that was maintained at 6 months. At 3 months, all children were able to attend Kindergarten daily, and at 6 months, every child was admitted to the next grade. This can be seen as an encouraging result, as it allowed the children to continue their developmental milestones without disruptions, like staying at home for a long period or following an inpatient treatment that would have demanded high expenses and probably led to separation problems at this young age. Moreover, the reduction on CY-BOCS scores was reached without medication. The number of sessions of the CBT-based intervention with the parents varied between four and ten sessions, depending on the need of the family. Families stayed in touch with the therapist during the 6 month period and knew they could get an appointment quickly when needed.

A possible objection to these results might be the question of differential diagnosis. Couldn’t the problematic behaviors described merely be classified as benign childhood rituals that would change automatically with time? As described in the patient vignettes, the five children were so severely impaired by their OCD that attendance of Kindergarten – a developmental milestone – was uncertain. Moreover, parents were extremely worried and stressed by their child’s symptoms and associated family conflicts. In our view, it would have been a professional mistake to judge these symptoms as benign rituals not worthy of diagnosis or disorder-specific treatment. One possible, but rare and debated cause of OCD are streptococcal infections, often referred to as PANS [ 33 ]. However, in none of the cases parents reported an abrupt and sudden onset of OCD symptoms after an infection. Instead, symptoms seem to have developed gradually over a period of several months or even years. In the case of patient 5 with the astrocytoma, first just-right compulsions appeared at the age of three (after the first chemotherapy), and were followed by more severe compulsions at the age of four, when – within a period of 6 weeks – a new chemotherapy was started, the mother took up a new job and the patient entered Kindergarten. Diagnosing the severe compulsions of patient 5 as, for example, adjustment disorder due to her medical condition would not have delivered a disorder-specific treatment encouraging parents to reduce their accommodation. This might have led to even more family accommodation and to more severe OCD symptoms in the young girl. Last but not least, a possible objection might be that the behaviors described were stereotypies. However, stereotypies are defined as repetitive or ritualistic movements, postures or utterances and are often associated with an autism spectrum disorder or intellectual disability. The careful intake with the children revealed no indication for any of these disorders.

Data reported here have several limitations. The children did not undergo intelligence testing; their reactions and behavior during the first session, as well as their acceptance and graduation at Kindergarten were assumed as sufficient to judge them as average intelligent. Comorbidities were assessed according to clinical impression and parents’ reports. The CBT treatment was based on our clinical expertise as a specialized OCD outpatient clinic. It included parent-oriented CBT elements, but did not have a fixed protocol and was adjusted individually to the needs of every family. Last but not least, no control group of young patients without an intervention was included.

Conclusions and clinical implications

We described a prospective 6 month follow-up of five cases of OCD in very young children. At the moment of first presentation, all children were so severely impaired that attendance of Kindergarten was uncertain. Parents were deeply involved in accommodating their child’s rituals. Because of the children’s young age, medication was not indicated. Therefore, a minimal CBT intervention for parents was offered, mainly focusing on reducing family accommodation. CY-BOCS scores at the beginning and after 3 months show an impressive decline in OCD severity that remained stable after 6 months. At 3 months follow-up, all children were able to attend Kindergarten daily, and at 6 months follow-up, every child had been admitted to the next grade. OCD is known to be a chronic condition. Therefore, in spite of treatment success, relapse might occur. However, as our treatment approach mainly targeted family accommodation, parents will hopefully react with less accommodation, should a new episode of OCD occur. Moreover, parents stay in touch with the outpatient clinic and can call when needed.

The clinical implications of our findings are that clinicians should not hesitate to think of OCD in a young child when obsessive-compulsive symptoms are reported. The assessment of the disorder should include the CY-BOCS, which has been validated in very young children by obtaining information from the parent. If CY-BOCS scores are clinically meaningful (for young children, a score above 8), a parent-based treatment targeting family accommodation should be offered.

By disseminating knowledge about the clinical presentation, assessment and treatment of early childhood OCD, it should be possible to shorten the long delay between first symptoms of OCD and disease-specific treatment that is reported as main predictor for persistent OCD. Early recognition and treatment of OCD are crucial to prevent chronicity [ 14 , 15 ]. As children and adolescents with OCD have a heightened risk for clinically significant psychiatric and psychosocial problems as adults, intervening early offers an important opportunity to prevent the development of long-standing problem behaviors [ 10 , 19 ].

Availability of data and materials

All data generated or analyzed during this study are included in this published article [and its supplementary information files].

Abbreviations

Obsessive compulsive behavior

Child Yale-Brown Obsessive Compulsive Scale

Cognitive Behavior Therapy

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V.B. conducted the diagnostic and therapeutic sessions and wrote the manuscript. V.M. was responsible for medical supervision and revised the manuscript. S.W. supervised the OCD treatment and research overall, applied for ethics approval and revised the manuscript. All authors have read and approved the manuscript.

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V.B. and V.M. declare that they have no competing interests. S.W. has received royalties from Thieme, Hogrefe, Kohlhammer, Springer, Beltz in the last 5 years. Her work was supported in the last 5 years by the Swiss National Science Foundation (SNF), diff. EU FP7s, HSM Hochspezialisierte Medizin of the Kanton Zurich, Switzerland, Bfarm Germany, ZInEP, Hartmann Müller Stiftung, Olga Mayenfisch, Gertrud Thalmann, Vontobel-, Unisciencia and Erika Schwarz Fonds. Outside professional activities and interests are declared under the link of the University of Zurich www.uzh.ch/prof/ssl-dir/interessenbindungen/client/web/

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Brezinka, V., Mailänder, V. & Walitza, S. Obsessive compulsive disorder in very young children – a case series from a specialized outpatient clinic. BMC Psychiatry 20 , 366 (2020). https://doi.org/10.1186/s12888-020-02780-0

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DOI : https://doi.org/10.1186/s12888-020-02780-0

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