Obsessive Compulsive Disorder (OCD)

There are a few scales you can use as part of assessment, but in and of themselves are not completely diagnostic. In children, you can administer the CY-BOCS Checklist (Children’s Yale-Brown Obsessive Compulsive Scale) to ascertain current and past symptoms. You can use serial CY-BOCS severity rating scales to monitor patient progress [13]. For older adolescents and adults, you can administer the DOCS Dimensional Obsessive-Compulsive Scale. A total score >21 has about 70% sensitivity and 70% specificity in distinguishing OCD from other anxiety disorders [1].

Cognitive Behavioral Therapy (CBT) remains the first line treatment for OCD, specifically Exposure and Response Prevention (ERP). ERP systematically desensitizes the person by exposing them to situations that generate anxiety in a safe setting while preventing the patient from performing compulsions [14; 16]. For initial treatment of OCD, the efficacy in symptom reduction is equivalent between ERP and ERP+SSRI. ERP has been shown to be superior to SSRI monotherapy [14]. 

If CBT with ERP is ineffective or only partially effective after 13-20 sessions, or symptoms are particularly disabling, an SSRI can be added [11; 14]. Sertraline is approved for children 6 and older [18]. Fluoxetine and fluvoxamine are approved for children 8 and older [16; 17]. Paroxetine is approved for OCD in adults but not in children and should not be used in the pediatric populations [9]. Paroxetine typically should not be prescribed for youth under age 18 due to safety concerns surfaced by the FDA, American Academy of Child and Adolescent Psychiatry and other regulatory bodies relating to this medication being more activating, and having some potential for dependence and withdrawal with use. An adequate trial of SSRI is typically 8-12 weeks, of which 4-6 weeks should be at the maximum tolerable dose, before declaring treatment non-response. For the management of OCD with SSRIs, often doses at the higher end of the therapeutic range is needed to observe significant symptomatic relief and treatment response. 

Additionally, thoughtful psychoeducation and counseling play an important role in treating children and adolescents with OCD. Intrusive thoughts/obsessions in OCD are ego-dystonic, meaning that they do not align with the patient’s true feelings and values [4; 8]. It is this clash between a patient’s true feelings/opinions and these intrusive thoughts that makes them so distressing. Explaining this to patients can help them to understand that these thoughts are not related to underlying desires or moral failures, which can provide a lot of comfort. Additionally, it is important to provide counseling to family members to ensure that they do not unintentionally reinforce compulsive behaviors by participating in rituals (such as providing excessive reassurance).