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Criteria for OCD

The presence of either obsessions or compulsions that are excessive, unreasonable produce distress or are time consuming (take more than 1 hour a day).


Obsessions are more than simple worries. They are persistent thoughts, images, or impulses that cannot be pushed away of one’s mind and cause significant distress.

examples: Aggressive obsessions (bad things to happen), guilt about lying or intrusive rude thoughts.


Repetitive behaviors or mental acts that the person feels obligated to perform. They are aimed at preventing some dreaded event but are clearly excessive or unrealistic.

examples: rituals to protect themselves from illness or injury, compulsive need to confess.



aggressive, sexual, religious or bodily focused






counting, arranging, ordering or repeating




cleaning and washing




hoarding and collection


Obsessive-compulsive behavior takes time and energy and limits what the child or adolescent can do. But it also tends to involve the people around the patient like family and friends. Seeing the child suffering may bring out the hope that symptoms will go away if everyone aids in performing the activities. But this kind of family assistance does not relieve the child’s anxiety. Sometimes, parents involve themselves in the rituals and become stuck in a pattern of behaviors that do not bring relief but only more pain.

Often, the children may lack or have a diminished awareness of their behaviors and this makes the treatment more difficult. This is called to have poor insight into their condition and at times the clinical picture appears to suggest psychosis.

Obsessive- compulsive behaviors…


… can often be found in a variety of other disorders like:

Tics and Tourette’s syndrome

  • In addition to tics, O-C Behavior is fairly common


  • Preoccupations with Hair Pulling are often OC-Type


  • O-C Behavior if often present in children with Autistic Spectrum problems

PANDAS (pediatric autoimmune neuropsychiatric disorders associated with streptococcal infection)

  • Possibly, a number of OCD cases are related with this condition

Eating Disorder

  • The obsessions and compulsions may be part of the specifics of the eating patterns

Body dysmorphic disorder

  • excessive preoccupation with a perceived defect of the physical appearance

Obsessive Compulsive Personality Disorder

  • it is a personality disorder in which the individual is driven by inflexible need for order, control, perfectionism at the expense of flexibility and even efficiency




Is not rare, may affect more than 1% of children. Probably  many do not meet full criteria to diagnose the condition but impairment is present. It tends to be more frequent in families where there is a history for this disorder. Boys and girls tend to be equally affected. In children and adolescents the course tends to be generally favorable with up to 40-60% of the children improving or experiencing remission of symptoms 2 years later.  The  ones not improving significantly may have  a course with fluctuating improvements and setbacks or may have a chronic course.

The risk of persistence increases if there are more severe co-occurring disorders, in cases of earlier onset, the longer the symptoms last or if the initial symptoms have been treatment resistant.


Out of the children with OCD…


80% have also another disorder  (it is rather rare to be the only issue)

30% have another Anxiety Disorder

30 % have a Mood Disorder

25% have a Disruptive Behavior Disorder (like Oppositional Defiant Disorder, Attention Deficit Hyperactivity Disorder )

20% have Tics or Tourette’s

5% have an Autistic Spectrum Disorder (PDD)


PANDAS – Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal Infections

  • Consists of abrupt onset or exacerbations of OCD and tic disorder related to two (2) documented streptococcal infections.
  • PANDAS has been suggested to represent an autoimmune disorder caused by the cross-reaction of streptococcal bacteria and certain brain structures (basal ganglia).
  • Some blood tests that are often done are antistreptolysin O, anti-DNAase B but it is unclear whether this correlates with clinical severity, symptom types or history.


OCD – Cognitive-Behavioral Model

OCD involves “intrusive and distressing thoughts, impulses, or images about possible harm coming to oneself or others”, which must then be neutralized through counter thoughts or behaviors to prevent harm or negative consequences from occurring.

Individuals with OCD assume that the intrusive thoughts are a sign that something terrible will happen, so they engage in all types of neutralizing, undoing, and compensatory behaviors (checking, washing, ordering, meaningless rituals, self-statements) in order to prevent negative outcomes.

The idea is that the OCD is maintained by the irrational belief that each time that an obsession occurs a compulsion needs to be performed. Alternatively, if one gets to the point where in the presence of an obsession one manages to block the compulsion, the OCD fades.

Exposure and response prevention (ERP) – is one of the most effective treatments in OCD and is based on a behavioral principle called classical extinction.  Basically,  one makes any effort not to engage in their compulsions. The espectation is that something terrible will happen but in fact nothing does. As a result, the fear and the obsessions diminish.


Exposure and response prevention (ERP)


  1. Develop a hierarchy of obsessions and compulsions, listed in order from least to most distressing
  2. Start with the least distressing item and do the Exposure that can be done by imagining the situation or by actually exposing oneself in real life to the situation (for example touching a doorknob)
  3. The exposure will elicit a desire to perform the compulsion.
  4. The patient’s compulsive response must be prevented.
  5. Repeated exposure in the absence of the compulsions leads to the reduction (extinction) of the anxiety (distress).
  6. Move on to the next item on the hierarchy and so on.
  7. Booster sessions may be required if obsessions begin to provoke anxiety again.


Developing the hierarchy of obsessions and compulsions

  • Try to think of all the obsessions present at the current time and the compulsions are needed to be performed to reduce the distress.
  • Now, try to think of the distress associated with not being able to complete each listed ritual. Rate it 1 to 10 where 10 is the biggest distress ever and 1 the lowest.
  • Re-organize your list starting with the lowest scores


Medication management

The best evidence for the medical management of OCD is present with a group of  antidepressants.

Some of the most frequently used antidepressants in the treatment of OCD are: fluoxetine, sertraline and clomipramine.

The treatment needs to be maintained for at least 10-12 weeks to have a clear sense of the result.

If , after 10-12 weeks the results are absent or minimal a number of strategies may be employed.

Talk with your physician about options.



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