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DOI 10.1007/s00787-012-0357-7
REVIEW
Obsessivecompulsive disorders
Per Hove Thomsen
Abstract Three major changes will probably be introduced in the DSM-5 regarding obsessivecompulsive disorder: OCD will be classified in the diagnostic category
obsessivecompulsive and related disorders, the clinician
should consider the degree of insight into a symptomatology (good to poor insight) and a subtype of tic-related
OCD will be introduced. The recommended treatment for
OCD is CBT, in severe cases with addition of SSRI
treatment.
Keywords
Introduction
Obsessivecompulsive disorder (OCD) is characterized by
obsessions and compulsions. The condition has had different terminology throughout history. Going back to the
1,500 century, more cases of OCD have been described [1],
and later Sigmund Freud described the rat man [2]. OCD
was included in previous versions of the DSM-classification system, but the diagnosis was rare in European child
and adolescent psychiatry until the early 90s [35].
In 1953, Bakwin described obsessive ideas and compulsive behaviour in very young children as being common, although not as symptoms of a disorder, but rather
elements of normal development [6]. These conclusions
were formally presented by Piaget [7] and later replicated
by Leonard et al. [8] using generally accepted criteria for
P. H. Thomsen (&)
Department of Child and Adolescent Psychiatry,
rhus University Hospital, Harald Selmers Vej 66,
A
8240 Risskov, Denmark
e-mail: per.hove.thomsen@ps.rm.dk
Changes in DSM-5
Obsessivecompulsive disorder is proposed to be classified
in the diagnostic category obsessivecompulsive and related disorders including obsessivecompulsive disorder,
body dysmorphic disorder, hoarding disorder, hair
pulling disorder (trichotillomania), skin picking disorder,
substance induced obsessivecompulsive or related disorders, obsessivecompulsive or related disorder attributable
to another medical condition and obsessivecompulsive or
related disorder not elsewhere classified. The proposed
criteria in the DSM-5 are shown in Table 1.
In the working group of the DSM-5 on OCD, there has
been a debate about whether or not OCD should be classified as an anxiety disorder. In the DSM-IV, OCD is
classified in the section of anxiety disorders and in the
ICD-10, OCD is classified in the section of neurotic, stressrelated and somatoform disorders. Table 2 presents the
pros and cons for a classification as an anxiety disorder.
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OCD subtypes
The validity of OCD subtypes has been analysed in clinical
work and various research projects. A possible subtype of
early onset patients is of special relevance for paedopsychiatric OCD. This group is usually characterised by a
predominance of boys to girls and a more common link to
Tourettes syndrome or tics or other developmental disorders. Some studies have indicated that the early onset
subtype is representing a more severe type of OCD which
is more genetically loaded [22].
Another subtype of OCD in children with OCD symptoms has been proposed as part of the so-called paediatric
autoimmune neuropsychiatric disorder associated with
streptococcus (PANDAS). Swedo et al. [23] identified this
possible subgroup which developed OCD symptoms following infections with group A beta-haemolytic streptococci. Clinical studies and some recent studies based on
animal models seem to support the existence of the PANDAS subtype [24, 25]. However, the use of antibiotics in
treatment and prophylaxis still remains controversial and it
seems that PANDAS can lead to a broader spectrum of
developmental disorders in addition to just OCD. The
DSM-5 working group recommended that PANDAS
should be discussed in the text, but will not suggest a
specific listing as a subtype of OCD.
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Tic-related OCD
Clinical guidelines
Assessment
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In many children, an adolescents OCD may have distressed the patient for a long time before relevant assessment and diagnostics are performed. In smaller children,
parents may sometimes face difficulties in differentiating
between OCD rituals and parts of normal development.
Smaller children are not always capable of clearly
expressing their sensations and the possible distress
imposed by the symptoms. During the assessment of OCD,
it is important to gather information from both the child as
well as the parents and it is recommended that the interview with the children is also undertaken without the
presence of the parents because many symptoms are
shameful and embarrassing for the patients.
It is recommended that information from early professional contacts are gathered, that the developmental history
of the child is described, that the child (and parents) is
interviewed by the use of a broad diagnostic interview
(in order to collect information on possible comorbid disorders) and that a specific diagnostic interview or questionnaire is
used. The Childrens YaleBrown ObsessiveCompulsive
Scale (CY-BOCS) is recommended as it has been extensively
used in clinical and research studies [32].
Treatment
The treatment of OCD in children and adolescents is based
on a thorough assessment of the severity of OCD and the
presence of comorbid disorders. The evidence-based
treatment of OCD in children and adolescents includes
psychoeducation and reduction of psychosocial stress,
cognitive behavioural psychotherapy and medication. The
available treatment options are outlined in Fig. 1. For
all children and adolescents, psychoeducation is recommended [33]. In cases of OCD with mild function
impairment, a psychologist or the general practitioner
should consider guided self-help which includes support
and information for the family. In cases of moderate to
severe functional impairment, cognitive behavioural therapy should be offered. Principals with exposure and
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Conclusion
OCD is a relatively common disorder affecting 13 % of
children and adolescents. Untreated, it often has a chronic
course, but it can be treated effectively with CBT and
medication (SSRI). The DSM-5 does not introduce major
changes in the diagnostic criteria and classification of
OCD. It is suggested that the new classification should
consider the degree of insight into obsessions and compulsions according to good or fair insight, poor insight or
illusional OCD beliefs. Furthermore, it is suggested that a
subtype of tic-related OCD is introduced.
Conflict of interest The corresponding author states that there are
no conflicts of interest. This article is part of the supplement The
Future of Child and Adolescent Psychiatry and Psychology: The
Impact of DSM 5 and of Guidelines for Assessment and Treatment.
This supplement was not sponsored by outside commercial interests.
References
ber Zwangsvorstellungen. Arch Psychiat
1. Westphal C (1878) U
Nervenkr 8:734750
2. Rottemanden Freud S (1991) Bemrkninger om et tilflde
af tvangsneurose. Hans Reitzels Forlag, Kbenhavn
3. Thomsen PH (1990) Child and adolescent psychiatric inpatients
in Denmark. Demographic and diagnostic characteristics of
children and adolescents admitted from 1970 to 1986. A registerbased study. Nord Psykiatr Tidsskr 44:337343
123
S28
4. Rutter M, Tizard J, Yule W, Graham P, Whitmore K (1976)
Reserach report: Isle of Wight Studies, 19641974. Psychol Med
6(2):313332
5. Berman L (1942) Obsessive-compulsive neurosis in children.
J Nerv Ment Dis 96:2639
6. Bakwin H, Bakwin RM (1953) Behaviour disorders in children.
Saunders, Philadelphia
7. Piaget J (1937) The construction of reality in the child. Basic
Books, New York
8. Leonard HL, Goldberger EL, Rapoport JL, Cheslow DL, Swedo SE
(1990) Childhood rituals: normal development or obsessive
compulsive symptoms? J Am Acad Child Adolesc Psychiatry
29(1):1723
9. Rapoport JL (1986) Childhood obsessive compulsive disorder.
J Child Psychol Psychiatry 27(3):289295
10. Rapoport JL, Swedo SE, Leonard HL (1992) Childhood obsessive
compulsive disorder. J Clin Psychiatry 53(4 suppl):16
11. Swedo SE, Rapoport JL, Leonard HL, Lenane M, Cheslow D
(1989) Obsessivecompulsive disorder in children and adolescents. Clinical phenomenology of 70 consecutive cases. Arch
Gen Psychiatry 46:335342
12. Flament M, Whitaker A, Rapoport JL, Vies MD, Berg CZ,
Kalikow K et al (1988) Obsessive compulsive disorder in adolescence: an epidemiological study. J Am Acad Child Adolesc
Psychiatry 27(6):764771
13. Karno M, Golding JM, Sorenson SB (1988) The epidemiology of
obsessivecompulsive disorder in five US Communities. Arch
Gen Psychiatry 45:10941099
14. Thomsen PH (1993) Obsessivecompulsive disorder in children
and adolescents. Self-reported obsessivecompulsive behaviour
in pupils in Denmark. Acta Psych Scand 88:212217
15. Heyman I, Fombonne E, Simmons H, Ford T, Meltzer H,
Goodman R (2001) Prevalence of obsessivecompulsive disorder
in the British nationwide survey of child mental health. Br J
Psychiatry 179:324329
16. Leckman JF, Denys D, Simpson HB, Mataix-Cols D, Hollander E,
Saxena S et al (2010) Obsessivecompulsive disorder: a review of
the diagnostic criteria and possible subtypes and dimensional
specifiers for DSM-V. Depress Anxiety 27(6):507527
17. Stein DJ, Fineberg NA, Bienvenu OJ, Denys D, Lochner C,
Nestadt G et al (2010) Should OCD be classified as an anxiety
disorder in DSM-V? Depress Anxiety 27(6):495506
18. The Pediatric OCD Treatment Study (POTS) Team (2004)
Cognitive-behavior therapy, sertraline, and their combination for
children and adolescents with obsessivecompulsive disorder.
The Pediatric OCD Treatment Study (POTS) randomized controlled trial. JAMA 292(16):19691976
19. Mancebo MC, Greenberg B, Grant JE, Pinto A, Eisen JL, Dyck I
et al (2008) Correlates of occupational disability in a clinical
sample of obsessivecompulsive disorder. Compr Psychiatry
49(1):4350
20. Srensen CB, Kirkeby L, Thomsen PH (2004) Quality of life with
OCD. A self-reported survey among members of the Danish OCD
Association. Nord J Psychiatry 58:231236
21. Foa EB, Kozak MJ, Goodman WK, Hollander E, Jenike MA,
Rasmussen SA (1995) DSM-IV field trial: obsessivecompulsive
disorder. Am J Psychiatry 152(1):9096
123