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تسجيلات دكتور شريف رفعت بلينكات مباشره وتدعم الاستكمال

تسجيلات دكتور شريف رفعت بلينكات مباشره وتدعم

الاستكمال


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Anxiety Disorder: Obsessive-Compulsive Disorder

Anxiety Disorder: Obsessive-Compulsive Disorder

Author: W Douglas Tynan, PhD, Chief Psychologist, Nemours Health and Prevention Division Programs; Director, Primary Care Mental Health Program, A I duPont Hospital for Children; Consulting Psychologist, Nemours Clinical Management

Introduction

Obsessive-compulsive disorder (OCD) is a significant neurobiological disorder that severely can disrupt academic, social, and vocational functioning. The major feature of this disorder is recurring obsessions and compulsions that interfere with a person’s life. Once believed to be relatively rare in children and adolescents, OCD now is believed to affect as many as 2% of children. Among adolescents with OCD, the literature indicates that very few receive an appropriate and correct diagnosis, and even fewer receive proper treatment. This finding is unfortunate because effective cognitive, behavioral, and pharmacologic treatments are now available. border= border=

Pathophysiology

Diagnosis of obsessive-compulsive disorder (OCD) is not exclusionary. Other anxiety disorders, tic disorders, and disruptive behavior disorders, as well as learning disabilities, are common comorbidities with OCD. Other obsessive-compulsive type disorders, such as body dysmorphic disorder, trichotillomania, and habit problems (eg, nail biting) are less common, but certainly not rare.

OCD is considered a neuropsychiatric disorder. In the history of treatment, insight-oriented psychotherapy did not appear to improve OCD, and psychodynamic understanding was not helpful. OCD symptoms do not appear to represent intrapsychic conflicts within individuals. Indeed, relatively few OCD behaviors exist, and they are experienced in much the same manner by patients, regardless of their interpersonal histories.

Frequency

In the United States, obsessive-compulsive disorder (OCD) is substantially more common in children and adolescents than once believed and has a 6-month prevalence of approximately 1 in 200 children and adolescents, while the prevalence of OCD occurring at any time during childhood is assumed to be 2-3 per 100 children. Among adults with OCD, interview data indicate that one third to one half developed the disorder during childhood. Unfortunately, this disorder often goes unrecognized in children and adolescents.

In one epidemiologic survey, 18 children were found to have OCD, and only 4 were receiving any professional mental health care. Not one of these 4 was diagnosed properly. Reasons advanced for the underdiagnosis and lack of treatment include some factors specific to OCD, including the secretiveness of the disorder and lack of insight by the patients. Also, many of the symptoms of OCD are found in other disorders, leading to misdiagnosis.

OCD has been studied most comprehensively at the National Institute of Mental Health with referred patients, who likely represent more severe cases. In those studies, the modal age of onset was 7 years; the mean age was 10.2 years. These figures imply the possible existence of an early-onset group and a second group with onset in adolescence. Boys are more likely to have a prepubertal onset and a family member with OCD or Tourette syndrome. Girls are more likely to have onset of OCD during adolescence. OCD is more common in whites than African American children in clinical samples. However, epidemiologic data suggest no differences in prevalence as a function of ethnic group or geographic region.

Clinical Course

Recurring obsessions and/or compulsions causing distress or interfering with a person’s life characterize obsessive-compulsive disorder (OCD). Obsessions are defined as recurrent and persistent thoughts, images, or impulses that are egodystonic, intrusive, and, for the most part, acknowledged as senseless. Obsessions usually are accompanied by dysphoric affect, such as fear, doubts, and disgust. Children and adolescents with OCD typically first try to ignore, suppress, or deny obsessive thoughts and may not report the symptoms as egodystonic or senseless. However, by trying to neutralize excessive thoughts, individuals with OCD very quickly change their behaviors by performing some type of compulsive actions, which are repetitive purposeful behaviors performed in response to the obsession. Usually, these repetitive actions follow certain rules or are quite stereotyped.

Some compulsions observed include behaviors such as washing, counting, or lining up of objects. Other compulsions are covert mental acts such as counting or reading a passage again and again. These compulsions also serve to reduce the anxiety produced by the obsessive thoughts. If something interferes with or blocks the compulsive behavior, the child feels heightened anxiety or fear and can become quite upset and oppositional.

The diagnostic criteria for OCD specify that a child or adolescent may have either obsessions or compulsions, although nearly all children with this disorder have both. The symptoms must cause some distress, consume more than 1 hour per day, or must significantly interfere with school, social activities, or important relationships. The Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) is quite clear that at some point, patients affected with OCD need to recognize that their obsessions come from within their own minds and are not worries about genuine problems. In a similar way, compulsions must be observed as excessive or unreasonable. Thus, the clinician does not include nightly bedtime rituals or other typical normative daily patterns as suggestive of this disorder.

Although most adolescents and some children with OCD recognize the senselessness of the disorder, the requirement of insight into the disorder is not required for the diagnosis of OCD in children. As with many neuropsychiatric disorders, a chronic waxing and waning of symptoms occurs in the chronic disorder of OCD. Thus, many families choose not to seek treatment because the symptoms have decreased independent of treatment in the past.

Another requirement to make the diagnosis is that specific content of obsessions cannot be related to another psychiatric diagnosis (eg, obsessive thoughts about food may be the result of an eating disorder, paranoid thoughts may be related to a psychotic thought disorder). Not confusing OCD with normal ritualistic behavior of childhood is important. Most children exhibit typical, age-dependent, compulsive behaviors. Frequently, young children prefer that events occur in a particular way, they insist on specific bedtime or mealtime rituals, and they become distressed if these rituals are disrupted.

Cross-sectional research of ritualistic behavior in children demonstrates that these behaviors appear when the individual is aged approximately 18 months, peak when the individual is aged approximately 2-3 years, and decline afterward. Presence of these behaviors appears to be related to mental age; thus, children who are mentally retarded and have cognitive levels at a developmental age of 2-3 years may have higher rates of compulsive behaviors, which are appropriate to their cognitive levels of development. These behaviors are best understood by acknowledging that they involve mastery and control of their environment, and, usually, they decrease to low levels by middle childhood. As a child ages, compulsive behaviors are replaced by hobbies or focused interests. Normative compulsive behaviors can be discriminated from OCD on the basis of content, timing, and severity. Normative compulsive behaviors do not interfere with daily functioning.

One of the leading causes of death of patients with OCD is suicide. Estimates reflect as many as 10% of patients with OCD make suicide attempts in adolescent and adult years.

Usual Behavioral Features

Sets of common obsessions and compulsions are observed in pediatric individuals with obsessive-compulsive disorder (OCD). Typically, these sets are described best as “just so” behaviors, in which certain things have to be arranged or performed in a particular way to relieve the anxiety. The most clinically useful and detailed symptoms checklist is included in the Yale-Brown Obsessive-Compulsive Scale. The most common theme of obsessions are contamination themes, and the related compulsive behavior is washing, usually compulsive handwashing. Along with contamination themes, problems with aggressive obsessions, sexual obsessions, the need for symmetry and order, obsessions about harm to oneself or others, and the need to confess exist. These excessive thoughts result in the common compulsive behaviors of washing, repeating, checking, touching, counting, arranging, hoarding, or praying.

When overt, observable compulsive behaviors are relatively easy to observe to make the diagnosis (eg, washing, repeating, checking, touching); covert behaviors (eg, counting, praying, reading something again and again) are harder to assess and evaluate. If OCD is suspected and if a child is taking an extremely long time to complete some tasks, a high likelihood exists that the child may be engaged in one of these covert rituals.Evaluation

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Publication Date: 2007-08-29

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