Authors: Vikas Menon
Categories: Case Report, Family accommodation, juvenile obsessive-compulsive disorder, obsessional images
Source: Industrial Psychiatry Journal
Obsessive-compulsive disorder (OCD) is one of the more disabling and potentially chronic anxiety disorders that occurs in several medical settings. However, it is often under-recognized and under-treated. The condition is now known to be prevalent among children and adolescents. Obsessional images as a symptom occur less frequently than other types of obsessions. In this report, we describe a young boy who presented himself predominantly with obsessional images. The diagnostic and treatment challenges in juvenile OCD are discussed.
Keywords: Family accommodation, juvenile obsessive-compulsive disorder, obsessional images
Obsessive-compulsive disorder (OCD) is a clinically heterogeneous disorder with many possible subtypes.[1] The lifetime prevalence of OCD is around 2-3%.[2] Evidence points to a bimodal distribution of the age of onset, with studies of juvenile OCD finding a mean age at onset of around 10 years, and adult OCD studies finding a mean age at onset of 21 years.[2,3] Treatment is often delayed in childhood OCD as sufferers tend to view their symptoms as nonsensical and are often embarrassed to talk about it. Among the different forms of obsessions described, obsessional images are encountered less frequently in clinical practice. In this report, we discuss the case of a young boy who presented himself with predominantly obsessional images.
A 12-year-old boy studying in the 8^th^ grade was brought to the Psychiatry Outpatient Department with complaints of academic decline. Upon exploration the boy reported 2 years duration of symptoms that were characterized by intrusive, unpleasant and repetitive gory images of people engaged in violence or soaked in blood that interfered with his ability to study. He would have distressing palpitations, tremors and fearfulness simultaneously when he experiences these images and stated that they were contrary to his innate “peaceful nature” and “habitual thinking patterns.” He recognized these as absurd and irrational but claimed to be powerless in stopping them. Techniques to counter them like chanting hymns did not provide any tangible relief. Other repetitive behaviors like putting on switches repeatedly and counting objects in sets of five were being done by him as it “just didn’t feel right otherwise.” Of these, he clearly identified the repeated occurrence of the unpleasant images as the one that distressed him the most. When he presented to us, his scholastic performance was on the decline and this had led to strained relations with his parents. Initial explanations by the patient that he was “unable to concentrate” cut no ice with his family. It was only when the child mustered enough courage to tell his mother the details about the repeated images that his parents decided to seek help for him. The child was developmentally normal. Physical examination was unremarkable. Screening for organicity was negative. We made a diagnosis of OCD and he was started on 50 mg of fluvoxamine which was subsequently hiked to 100 mg. In addition, 0.5 mg of clonazepam was added to control the anxiety symptoms. Psychoeducation was given to the parents and child in order to alleviate their distress and reduce critical/hostile comments by the family. Currently with this regimen, the patient reports 50% improvement and his school performance has improved to their subjective satisfaction.
The above case is being reported for its rather unique and different presentation and to highlight the issues involved in diagnosis and management of pediatric OCD cases. Washing, grooming, checking rituals, and preoccupation with disease, danger, and doubt are the most commonly reported symptoms in childhood onset OCD.[4] However, in this case, obsessional images were the predominant symptom. OCD in children often takes inordinate time to come to clinical attention because patients may not readily describe their symptoms and family may not be willing to consider psychological causation as in the present case. Often family may inadvertently reinforce the compulsive behaviors of their off springs by compensating/participating in them and thus allowing them to continue functioning thinking that these behaviors will die a natural death. This phenomenon has been referred to as “family accommodation” in OCD and has been found to be correlated with poor family functioning and negative attitudes towards the patient.[5] Therefore, it is important to interview the parents and other associated family members about the context and burden of the obsessive-compulsive symptoms in children. This must be combined with a detailed assessment of the dysfunction in various areas – scholastic/self-care and socialization in order to elicit the true impact of symptoms. Structured instruments like the Children's Yale Brown Obsessive-Compulsive Scale[6] are available to measure the symptom severity in young. Recently, a self-report version has been developed and found to correlate well with the original version.[7] This may be beneficial in settings like ours where clinician time and resources are limited. It has been proposed that juvenile OCD may be a developmental subtype of the disorder with its own unique correlates that differ from adult OCD. Some of the differences noted are the higher male preponderance, increased familial loading, frequent lack of insight, comorbidity with attention-deficit hyperactivity disorders, major depression, tic disorders, and poorer response to treatment with antiobsessional medications in juvenile OCD.[3,8] This could have important implications for case management and research. More work needs to be done to outline the course of juvenile OCD and to ascertain the persistence of clinical features into adulthood.
Obsessive-compulsive disorder is a common disabling psychiatric condition that occurs across the life span. The diagnosis and management of pediatric OCD cases offer unique challenges. Clinicians must be alert to the possibility of obsessive-compulsive symptoms when evaluating children with emotional and behavioral disorders. We propose that screening questions to rule out OCD must be a part of routine mental status examination in children and adolescents. The management must include a combination of pharmacologic and behavioral treatments that are likely to have variable success rates.