OCD

Obsessive Compulsive Disorder (OCD)

Table of Contents for OCD

Clinical Pathway and Rating Scales for OCD

Clinical Pathway***needs update

Rating Scales

Assessment and Diagnosis ***Needs update

Common Signs and symptoms of OCD

Irritability, Anger, Temper tantrums

Worries or Intrusive Thoughts (Obsessions)

Unpleasant, unwanted, or silly thoughts, ideas, images, worries
Thoughts are intrusive and keep coming back over and over again leading to attempts to suppress, neutralize them
Examples:
- Repeated thoughts of germs or dirt harming you/others

Habits or Rituals (Compulsions)

Behaviors that you feel you must do although may have insight they do not make sense.
Difficult to stop engaging in ritual despite trying to resist.
Performing the ritual often reduces the anxiety, distress temporarily, will feel rituals prevent a feared event/situation.
Can feel frustrated, angry, or heightened anxiety if you are prohibited from completing the rituals.
Examples:
Washing your hands over and over again even though they are not really dirty
Counting up to a certain number while doing certain things

Excessive and time-consuming

Interferes with social, family, school functioning.

DSM-5 Criteria for Obsessive Compulsive Disorder (OCD)
Obsessions	“WORRIES,” recurrent thoughts, urges, or images experienced as intrusive or unwanted and cause distress/anxiety leading to an attempt to ignore, suppress, or neutralize them with another thought or action (compulsion)
Compulsions	“RITUALS OR HABITS,” behaviors that feel necessary in response to an obsession or according to rules that must be applied rigidly to reduce anxiety/distress or prevent a feared event or situation. However, the behaviors may or may not be connected to what they are designed to neutralize or are clearly excessive.
Presence of Obsessions or Compulsions or BOTH Obsession or Compulsions are time-consuming or cause clinical impairment functionally (school, family, social). Not better explained by substances, another medical, or mental disorder

Focused Clinical Assessment (Clinical Pearls for History Taking)

Focused clinical history	Obtain history on Past & Current obsessions (intrusive thoughts), compulsions & severity through CY-BOCS rating scale Onset Often pre-pubertal Insidious onset (common) Course/Duration: Often wax and wane
Collateral history	Gather collateral from family, school, other care takers.
Assess for functioning in multiple domains	Family relationships Peer relationships School/Academic functioning
Assess for acute stressors	Acute stressors: stressors in family life, peer/social relationships, school/academic stressors etc
Assess for Trauma history, chronic stress	Neglect, physical, sexual or emotional abuse Screen for ACES
Longitudinal clinical hx of symptoms	Onset, course of symptoms Behavioral concerns in earlier childhood years Screen for developmental concerns (i.e. Developmental delay, Autism Spectrum Disorder) Distinguish from normal childhood behavior. Recurrent worries and ritualistic behavior are common and can be normal at various stages of development. True obsessions and compulsions are intrusive, distressing, and impair function.

Differential diagnosis

Anxiety disorders (Phobia, Perseveration with worries)
Depression (Guilty ruminations)
Somatic Symptom and related disorders (Illness anxiety disorder, Somatic symptom disorder)
Autism Spectrum Disorder (Rigid, repetitive behaviors)
Psychotic disorders (Delusional preoccupation)
Eating disorders (Ritualized eating behaviors)
Body dysmorphic disorders

Comorbidities

Highly comorbid with childhood OCD

Tic disorder
Anxiety Disorders (GAD, Social anxiety, Panic, phobia)
Depression
Eating Disorders

Evidence-Based Treatment Guidelines for OCD

Non-medication***Needs update

****Needs Feedback/Update****

Psychoeducation

Avoidance is one of the key parts of anxiety and OCD symptoms. When something makes us anxious, we tend to avoid it (flight response) or engage in maladaptive behaviors (rituals, habits) which then temporarily relieves the anxiety. However, most of the things that we worry about we can’t avoid forever, and the more we avoid or engage in maladaptive behaviors to lessen the anxiety the bigger and stronger the anxiety, maladaptive habits get. Like in the studying procrastination example, the longer you put off studying for a test, the more the anxiety builds. This creates a feedback loop where the more anxious someone is, the more they avoid, or engage in a maladaptive behavior and the bigger the anxiety gets.
Exposures are a strategy for stopping this feedback loop. Exposures are the opposite of avoidance; you expose yourself to what’s making you anxious instead of avoiding it. While this increases your anxiety short term, with continued exposures your anxiety goes down. This is due to a process called habituation where your body gets used to things over time. Exposures are approached in a step-wise manner; you start by exposing yourself to something that’s a little anxiety-provoking and practice tolerating that. Once that’s okay, you gradually practice exposures to medium and then very anxiety-provoking things. For instance, if someone is afraid of snakes, they might start by talking about snakes, then looking at pictures, then a video, gradually working up to managing their anxiety while seeing a live snake.

Parent and School Supports

Psychoeducation to destigmatize and reframe presenting symptoms is important because children are often secretive about their OCD symptoms, so they may be misinterpreted.
Work with parents and schools to gradually decrease ways they are accommodating for and reinforcing OCD symptoms.

Psychotherapy

Exposure and Response Prevention Therapy (ERP)

Exposure and Response Prevention (ERP) is a form of Cognitive Behavioral Therapy (CBT) in treating Obsessive Compulsive Disorders (OCD).
ERP is time-limited therapy, usually 12-20 sessions, involving both the child and family.
The patient is gradually exposed to their fears in a controlled setting and learns how to resist the compulsion.

Medication ***Needs update

First-line recommended medication: Selective Serotonin Reuptake Inhibitor (Fluoxetine, Sertraline, Fluvoxamine)
Indications
Severe OCD (CY-BOCS scores 24 and above)
Limited improvement with therapy in moderate OCD (CY-BOCS scores 16-23)
OCD symptoms interfering with ability to engage in therapy, exposures.
SSRI treatment response may take 8-12 weeks at adequate treatment dose
If symptoms do not improve, switch to different SSRI.
May consider SSRI gradual taper after atleast >12 months of maintaining remission status to prevent relapse.
SSRI treatment algorithm ***needs update ***

SSRI Dosing Guidelines for OCD **Edit Table with Design Team***

FDA approved Drug	Starting Dose (mg)		Typical Dose Range (mg) (Mean dose)
FDA approved Drug	Pre-adolescent	Adolescent	Typical Dose Range (mg) (Mean dose)
Sertraline (Zoloft)	12.5 - 25	25-50	50-200 (178)
Fluoxetine (Prozac)	2.5 - 10	10-20	10-80 (25)
Fluvoxamine(Luvox)	12.5-25	25-50	50-300 (165)

Adapted from Practice parameter for the assessment and treatment of children and adolescents with obsessive-compulsive disorder. (2012). Journal of the American Academy of Child and Adolescent Psychiatry, 51(1), 98–113. https://doi-org.ucsf.idm.oclc.org/10.1016/j.jaac.2011.09.019

Provider Tipsheets and Resources

PCP Tipsheets ***needs upload/update

Clinical Pathway ***needs update

Online Resources

Family Resources for OCD

Handouts***update needed**

Online Resources *** update needed

Book Recommendations***need to update/keep vs delete***

Book Recommendations:

For parents:
- Freeing Your Child from Obsessive-Compulsive Disorder: A Powerful, Practical Program for Parents of Children and Adolescents by Tamar E. Chansky, PhD

For teens:
- Talking Back to OCD: The Program That Helps Kids and Teens Say "No Way" -- and Parents Say "Way to Go" by John S. March, MD

For younger kids (to read together with parents):
- Up and Down the Worry Hill: A Children's Book about Obsessive-Compulsive Disorder and its Treatment by Aureen Pinto Wagner, PhD and illustrated by Paul A. Jutton
- What to Do When Your Brain Gets Stuck: A Kid's Guide to Overcoming OCD by Dawn Hubner, PhD and illustrated by Bonnie Matthews