OBSESSIVE-COMPULSIVE DISORDER (OCD) in Children & Adolescents

Transcription

1 OBSESSIVE-COMPULSIVE DISORDER (OCD) in Children & Adolescents E. JOHN KUHNLEY, MD July 14, 2015 American Association of Christian Counselors (AACC) Counseltalk Webinar

2 Learning Objectives Participants will: 1. Identify the core neurobiological deficits underlying Obsessive- Compulsive Disorder (OCD). 2. Identify key interview and assessment strategies that can assist in determining the diagnosis of Obsessive-Compulsive Disorder (OCD), differential diagnostic possibilities and comorbid conditions. 3. Explore medications and empirically supported treatments for children with Obsessive-Compulsive Disorder (OCD), including individual treatments and attachment-based parent training.

3 DSM-5: Obsessive-Compulsive and Related Disorders Obsessive-Compulsive Disorder (OCD) Body Dysmorphic Disorder (BDD) perceived defects or flaws in physical appearance Hoarding Disorder Trichotillomania: hair-pulling disorder Excoriation Disorder: skin picking OTHER Substance/Medication-Induced Obsessive-Compulsive and Related Disorder (due to substance intoxication or withdrawal or to a medication) Obsessive-Compulsive and Related Disorder due to another medical condition Other Specified Obsessive-Compulsive and Related Disorder (e.g., body-focused repetitive behavior disorder, obsessional jealousy) Unspecified Obsessive-Compulsive and Related Disorder

4 DSM5: Obsessive-Compulsive and Related Disorders These conditions may overlap with each other and with other conditions Clinical screening is essential to identify specific conditions (differential diagnosis) and comorbid (occurring together) conditions Diagnostic specificity increases likelihood of more effective (and specific) treatment All of these conditions are often missed or misdiagnosed Many individuals suffer in silence and experience shame Confusion may result when people misdiagnose themselves by putting a diagnosis on normal behavior

5 Developmentally Normal Preoccupations and Rituals Children develop normal preoccupations, rituals, and habits, often encouraged by and essential to their society and specific culture Many are age-related (learning rules) Disorder refers to distress and impairment in function when they persist beyond normal developmentally appropriate periods or become excessive

6 Obsessions involve the following: Repeated thoughts, impulses or mental images that are intrusive and inappropriate, and that cause marked anxiety or distress These thoughts are not simply excessive worries about real-life problems The person tries to ignore or suppress the thoughts, or the person tries to neutralize them with some other thought or action The person realizes that the obsessive thoughts are the product of his or her own mind (This Does Not Apply to Children)

7 Compulsions involve the following: Repeated behaviors (e.g., hand washing, putting things in a certain order, checking to make sure a particular action has been done) or mental acts (e.g., praying, counting, repeating words silently). The person feels driven to perform these actions in response to an obsession or according to rigid rules. These behaviors are aimed at preventing or reducing distress, or at preventing some dreaded event from occurring. However, the behaviors are either clearly excessive or not linked in a realistic way to the threat they are meant to neutralize. (continued)

8 Obsessive-Compulsive Disorder At some point, the person recognizes that the obsessions or compulsions are excessive or unreasonable. The obsessions or compulsions lead to at least one of the following reactions: Marked distress Time-consuming thoughts or behaviors (> an hour a day) Significant interference w/normal routine or social relationships Significant impairment of function in social or academic settings

9 Risk Factors noted in DSM-5 Temperamental Factors: Greater internalizing symptoms, Higher negative emotionality, and Behavioral inhibition in childhood. Environmental Factors: Physical & sexual abuse in childhood & other stressful or traumatic events Sudden onset of OC symptoms with post-infectious autoimmune syndrome (e.g., PANDAS may account for 10% or more). Genetic and physiological: Rate of OCD among first-degree relatives of adults with OCD is approx. 2x Rate of OCD among first-degree relatives of individuals with onset of OCD in childhood or adolescence is increased 10x Dysfunction in the orbitofrontal cortex, anterior cingulate cortex, and striatum have been most strongly implicated.

10 Suicide Risk noted in DSM-5 Suicidal thoughts occur at some point in as many as about half of individuals with OCD. Suicide attempts are also reported in up to one-quarter of individuals with OCD; the presence of comorbid major depressive disorder increases the risk.

11 Parent Report of Presenting Problems Children who are secretive, parents report: Temper tantrums (when their compulsions are prevented or interrupted) Decreased school performance (redoing work, seeking perfection, time spent in rituals) Food restrictions (rituals arranging food, not touching; fears of contamination or becoming fat) Dermatitis (washing) Social & academic performance may be okay until rituals become severe Parents may believe it is just a phase and learn to accommodate to the child s condition May take 5-8 years to reach clinical attention It is a chronic condition with waxing and waning course

12 Obsessions Symptom Dimensions Compulsions Aggression, Religious, Sexual, Somatic Contamination Doubts Hoarding Symmetry, Precise Arranging Checking, Praying, Seeking Reassurance, Undoing Actions Cleaning, Washing Checking Hoarding Repeating, Ordering, Counting, Arranging, Straightening Until Just Right" Mercadante, MT et al.

13 Impact on Life of the Child (and Adult) Shame, suffering in silence, low self-esteem, depression, anger, exhaustion, missing out on so much! Skin lesions & infections (washing, etc.) Lack of attention due to obsessions and compulsions, School (occupational) failure Impaired social interactions Impact on the family (enabling, anger, resentment)

14 OCD Scenarios I can t sleep at night because I have to keep getting up to check the doors and the oven and the alarm clock. I ll get up twenty times a night and wake up exhausted. Sometimes I have to get up to go to the bathroom even when I went a few minutes ago. I count almost constantly. I count tiles and bricks and poles. I need things to end up in even numbers. If they don t end in an even number then I need to find something similar to count so the numbers will be even. I have trouble finishing my homework in school. I m so obsessed with everything being perfect that I ll rewrite the same thing over and over, erasing it until there are holes in the paper.

15 OCD Scenarios My OCD causes me a lot of embarrassment. I pick my fingers until they bleed. I feel the need to count things. I obsess over things until I feel stressed and panicky and sometimes get agitated around people. I can tell other people are uncomfortable around me but I can t stop. I m obsessed with cleaning, sometimes cleaning the same thing over and over again. I can t relax if there s anything out of place. I have certain rituals when I clean such as turning the hot water on first then the cold and if I don t do it right I have to start over. I m constantly worried about germs and getting sick. Every time I feel bad I feel convinced there is something wrong with me and then I panic and go to the doctor. I feel like I m ill but they can t find anything wrong. I feel compelled to touch things. Sometimes I feel like something bad will happen if I don t touch something. I know it s a superstition but I can t stop.

16 OCD Scenarios My family doesn t understand my OCD. They think that I m just looking for attention. They don t understand that I can t help doing the things I do. They tell me to just get over it. But I can t help it. I have obsessive thoughts about everything, replaying conversations in my head over and over again. Worrying about the future. I m afraid to go out because I m afraid I ll do something that makes people uncomfortable. I m constantly apologizing for things and I can tell that it annoys people. But I feel so bad if everything I do isn t perfect that I feel I need to apologize.

17 The Neural Bases for OCD Functional imaging studies have reported with remarkable consistency hyperactivity in the orbitofrontal cortex (OFC) anterior cingulate cortex (ACC) and caudate nucleus Converging evidence from various lines of research supports a causal role for the cortico-basal ganglia-thalamo-cortical loops that involve the OFC and ACC in the pathogenesis of OCD in children and adults. Maia, TV et al., Dev Psychopathol ; 20(4):

18 Frontal cortical-striatal-thalamiccortical circuit Orbital Frontal Cortex Thalamus Basal Ganglia

19 Assessment Seek information from as many sources as possible (teacher, noncustodial parent, day care, previous treatment providers) Full psychiatric, medical, developmental, family, social, academic history Children s Yale-Brown Obsessive Compulsive Scale (CY-BOCS), Psychological Testing, Achenbach CBCL, Vanderbilt Parent & Teacher Reports.

20 Questions regarding the nature and severity of obsessive symptoms Have you ever been bothered by thoughts that do not make any sense and keep coming back to you even when you try not to have them? When you had these thoughts, did you try to get them out of your head? What would you try to do? Where do you think these thoughts were coming from?

21 Questions regarding the nature and severity of compulsive symptoms Has there ever been anything that you had to do over and over again and could not resist doing, such as repeatedly washing your hands, counting up to a certain number, or checking something several times to make sure you had done it right? What behavior did you have to do? Why did you have to do the repetitive behavior? How many times would you do it and how long would it take? Did these thoughts or actions take more time than you think makes sense? What effect did they have on your life?

22 Differential Diagnosis and/or Comorbidity Major depressive disorder (30-70%) Panic disorder (14%, 35% lifetime incidence) Body dysmorphic disorder (14.5%) Generalized anxiety disorder (20%) Social phobia and simple phobia (24%) ADHD Tourette syndrome (5-7%) Other tic disorders (20-30%) Trichotillomania Neurodermatitis (itchy skin worsened by scratching) Idiopathic torticollis (painfully twisted and tilted neck) Substance abuse Eating disorders

23 Imaging Studies Functional MRI and PET scanning have shown increases in blood flow and metabolic activity in the orbitofrontal cortex, limbic structures, caudate, and thalamus, with a trend toward right-sided predominance. In some studies, these areas of overactivity have been shown to normalize following successful treatment with either SSRIs or CBT. These imaging modalities, while of value for research, are not indicated for normal workups.

24 PET Scans from a patient reported in S. Saxena et al., Arch Gen Psychiatry, 59:250 61, 2002.

25 Functional Neuroimaging of OCD Three brain areas the orbitofrontal cortex (OFC), the anterior cingulate cortex (ACC), and the head of the caudate nucleus have been consistently implicated in a large number of resting, symptom provocation, and pre/post-treatment studies of adults with OCD. These areas: (a) are hyperactive at rest in adults with OCD relative to healthy controls, (b) become more active with symptom provocation, and (c) no longer show hyperactivity at rest following successful treatment with either medication or cognitivebehavioral therapy Maia, TV et al., Dev Psychopathol ; 20(4):

26 Intervention Non-pharmacologic Listening, Education & Reassurance Lifestyle changes (Exercise, Sleep, Nutrition, etc.) Goal-Setting, Problem-Solving Anxiety & Stress Management Relaxation, Breathing, Visual Imagery Meditation CBT, Exposure & Response Reduction Pharmacologic (Serotonergic Medications) Adults: possibly neurosurgical

27 Exposure & Response Prevention Consistent research suggests that with skilled therapists and ideal conditions, more than 75% of patients respond to EX/RP, and up to 40% achieve minimal symptoms. But not all patients benefit. Multiple studies reveal 25% to 30% of patients who begin EX/RP discontinue treatment prematurely and of those who complete treatment, up to 24% do not respond.

28 Several neurotransmitters are thought to play a role in OCD, anxiety, depression & other conditions Gamma-amino-butyric acid (GABA) inhibits the firing of neurons. GABA appears to help quell anxiety. Serotonin helps regulate mood, sleep, appetite, and sexual drive, memory and learning. Low levels of serotonin have been linked to anxiety and depression. Norepinephrine helps regulate arousal, sleep, and blood pressure. Excess amounts of norepinephrine may trigger anxiety. Dopamine Enables movement and influences motivation. Some evidence suggests that there may be a link between low dopamine and social anxiety disorder, and between excess dopamine and OCD. Glutamate is the major excitatory neurotransmitter

29 Medications Of childhood psychiatric disorders, OCD has the best evidence-based data supporting pharmacologic treatment and the largest number of FDA-approved medications for use in children However less than 50% of patients respond to first-time single-agent treatment with a reduction of 25-40% in severity of symptoms. Multiple trials and adjunctive combinations often are necessary. Doses necessary for OCD are higher than for anxiety or depression

30 Medications FDA Approved for Children with OCD Fluvoxamine (Luvox) FDA down to age 8 Fluoxetine (Prozac) FDA down to age 7 Sertraline (Zoloft) FDA down to age 6 Clomipramine (Anafranil) FDA down to age 10 2 nd line due to side effects Non- FDA but used clinically: Citalopram (Celexa) Escitalopram (Lexapro) Paroxetine (Paxil) Venlafaxine (Effexor)

31 Medications Benzodiazepines raise GABA levels in the brain. (Not useful for OCD) SSRIs slow the reuptake of serotonin Dual Reuptake Inhibitors Venlafaxine and Duloxetine slow the reuptake of serotonin and norepinephrine Buspirone increases serotonin activity while decreasing dopamine activity.

32 Summary OCD occurs in 1% of Children and 2% of adolescents In childhood, OCD is chronic, waxes and wanes, and individuals often suffer silently while experiencing shame and multiple comorbidities & impairments CBT is the treatment of choice for mild to moderate OCD while medication plus more intense CBT is indicated in moderate to severe OCD, especially when accompanied by multiple comorbidities Individuals experience response rates of 50% and reduction of impairment of 50%

33 While wandering a deserted beach at dawn, stagnant in my work, I saw a man in the distance bending and throwing as he walked the endless stretch toward me. As he came near, I could see that he was throwing starfish, abandoned on the sand by the tide, back into the sea. When he was close enough I asked him why he was working so hard at this strange task. He said that the sun would dry the starfish and they would die. I said to him that I thought he was foolish. There were thousands of starfish on miles and miles of beach. One man alone could never make a difference. He smiled as he picked up the next starfish. Hurling it far into the sea he said, "It makes a difference for this one." I abandoned my writing and spent the morning throwing starfish. Loren Eiseley

34 References If Your Adolescent Has an Anxiety Disorder by Edna B. Foa, Ph.D., and Linda Wasmer Andrews. Oxford University Press Managing Obsessive Compulsive Disorder in Children and Adolescents by Jennifer L. Shoenfelt, MD; and Christina G. Weston, MD; Series Editor: Paulette Marie Gillig, MD, PhD Treatment of Anxiety Disorders: Does Mechanism Matter by Philip T. Ninan, MD (Supplement to Psychiatric Times September 2005 Issue 3 of 4.) Essential Psychopharmacology, by Stephen Stahl (2002) Child & Adolescent Psychiatry, by Cheng & Myers (2005)

35 Glutamate Modulators in the Treatment of Obsessive-Compulsive Disorder Established treatments for OCD 3/4 patients, but refractory disease remains distressingly common, and many treatment responders continue to experience considerable morbidity. This article summarizes investigations of OCD response to: Memantine, Riluzole, Ketamine, D-cycloserine, Glycine, N-acetylserine, Topiramate, and Lamotrigine. Pittenger, C; Psych Annals, 2015, June; 45:

36 Glutamate Dysregulation Resistance to usual treatments (40% 60% of OCD patients) Several lines of neurochemical and genetic evidence suggest that glutamate dysregulation may contribute to OCD The evidence for glutamate dysregulation in OCD is provocative but remains inconclusive.

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38 Resources Useful Web sites include the following: The National Institute of Mental Health (NIMH), Obsessive-Compulsive Disorder, OCD The Mayo Clinic, Obsessive-compulsive disorder (OCD) WebMD, Obsessive-Compulsive Disorder Madison Institute of Medicine's Obsessive Compulsive Information Center which provides information and a monthly newsletter for individuals with OCD symptoms of scrupulosity about religious/moral issues).

39 Resources The Obsessive-Compulsive Foundation is a self-help and family organization founded in 1986 that offers information and resources regarding OCD and related disorders (including contact information for various types of affiliated support groups, contact information listing psychiatrists and therapists who are experienced in the treatment of OCD, research opportunities, and book reviews).

40 Olivia, age 11 Olivia is an 11-year-old girl who has experienced deterioration in academic performance over the past year. She has developed increased anxiety and often refuses to go to school. She has conflict with parents including struggles to get ready to go anywhere on time. Teachers report she fails to turn in classwork and homework because it is not good enough.

41 Olivia, age 11 After establishing rapport with Olivia she disclosed that for years she had thought she was crazy and was reluctant to talk about her thoughts. She had intrusive fears of what might happen and tried to keep things in perfect order to prevent bad things from happening but did not want to tell anyone for fear that would cause bad things to happen or others would think she was crazy.

42 Olivia, age 11 She was referred to CBT and made some gains but was in danger of school failure. Medication recommendation and education resulted in acceptance by Olivia and parents. Sertraline was started at 25 mg a day for 2 weeks with no response but good tolerability after initial nausea. Increased dose of 50 mg obtained some relief and no additional side effects.

43 Olivia, age 11 Olivia improved in school and passed. She made continued progress in CBT. Reduction of sertraline dose to 25 mg resulted in intensification of OCD. Dose was increased to 50 mg with return of response. Over the next year psychosocial stressors aggravated her condition and increase of sertraline to 100 mg achieved good response. She continued to make progress in therapy and functional improvement for several years and maintained sertraline when she left for college as a very organized young woman.

44 Stop Obsessing! How To Overcome Your Obsessions And Compulsions Paperback August 1, 1991 by Edna B. Foa (Author), R. Reid Wilson Ph.D. (Author)

45 DSM-5 Obsessive-compulsive personality disorder (OCPD) Although obsessive-compulsive personality disorder and OCD have similar names, the clinical manifestations of these disorders are quite different. Obsessive-compulsive personality disorder is NOT characterized by intrusive thoughts, images, or urges or by repetitive behaviors that are performed in response to these intrusions; OCPD involves an enduring and pervasive maladaptive pattern of excessive perfectionism and rigid control. If an individual manifests symptoms of both OCD and OCPD, both diagnoses can be given. Comorbidity ranges from 23% to 32%. The essential feature of OCPD is a preoccupation with orderliness, perfectionism, and mental and interpersonal control, at the expense of flexibility, openness, and efficiency. This pattern begins by early adulthood and is present in a variety of contexts. Estimated prevalence ranges from 2.1% to 7.9%.

46 Obsessive Compulsive Disorder and Related Anxiety Issues in Children Gary Sibcy, Ph.D. July 14 th, 2015 Counseltalk Webinar

47 Physic al Cognit ive Behav ior

48 Physical Autonomic Nervous System Sympathetic--Gas Fight Flight Freeze Parasympathetic Brake Slows us down Relaxation Sleep Digestion Alarm System

49 Cognitive Bias to Danger Confirmation bias Seek and ye shall find Selective attention Overestimation of danger Underestimation of coping

50 Behavior Safety Behavior things you do that make you feel better Compulsions Rituals Avoidance Behavior

51 How Safety and Avoidance Work to Maintain Anxiety Whenever you use a compulsion or avoid a feared situation: It positively reinforces that thought: That was a really dangerous situation, good thing I avoided it. It negatively reinforces the behavior That is, you escape something that was unpleasant (namely, the feelings of anxiety) which increases the chances the next time you face feared situation you will use the same compulsion or the avoidance behavior.

52 Goals of Exposure Corrective Learning Increase Tolerance for Anxiety Fear Reduction Within exposure Between exposure Increased sense of self-efficacy Improved quality of life

53 The Worry Hill

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63 Trouble Shooting The concept of modularity Structured Flexibility (Chorpita, 2007) Use the absolute core four structure when possible, Add structured modules when you run into obstacles

64 Core Treatment Protocol

65 Modularity

66 Other Resources Chorpita, B. F. (2007). Modular cognitive-behavioral therapy for childhood anxiety disorders. New York: Guilford Press March, J. S., & Mulle, K. (1998). OCD in children and adolescents: A cognitive-behavioral treatment manual. New York: Guilford Press. March, J. S., & Benton, C. M. (2007). Talking back to OCD: The program that helps kids and teens say "no way"-- and parents say "way to go". New York: Guilford Press. Wagner, A. P. (2002). What to do when your child has obsessive-compulsive disorder: Strategies and solutions. Rochester, N.Y.: Lighthouse Press. Wagner, A. P., & Jutton, P. A. (2004). Up and down the worry hill: A children's book about obsessive-

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