Vol. 2, No. 11 / November 2003

Germ warfare: Arm young patients to fight obsessive-compulsive disorder

A 'toolbox' of cognitive skills and medications can help children and adolescents reclaim their lives.

John S. March, MD, MPH
Professor and chief, child and adolescent psychiatry
Department of psychiatry and behavioral sciences
Program in child and adolescent anxiety disorders
Duke University Medical Center, Durham, NC

Martin E. Franklin, PhD
Assistant professor of psychiatry
Center for the Treatment and Study of Anxiety
Department of psychiatry
University of Pennsylvania School of Medicine Philadelphia

Edna B. Foa, PhD
Professor of psychiatry
Center for the Treatment and Study of Anxiety
Department of psychiatry
University of Pennsylvania School of Medicine Philadelphia

Adam, age 10, is extremely distressed at school. Because of obsessional contamination fears, he avoids contact with other children and refuses to eat in the cafeteria. He washes his hands 20 times per day and changes his clothes at least three times daily.

His primary obsessions involve contact with bodily fluids—such as saliva or feces—and excessive concerns that this contamination would cause him serious illness.

Adam’s parents say their son’s worries about dirt and germs began when he entered kindergarten. They sought treatment for him 2 years ago, and he has been receiving outpatient psychotherapy since then. They have brought him to an anxiety disorders specialty clinic for evaluation because his obsessive-compulsive symptoms are worsening.

When treating patients such as Adam, our approach is to use cognitive-behavioral therapy (CBT) and adjunctive drug therapies to relieve their symptoms and help them reclaim their lives. Diagnosis of pediatric OCD is often delayed, and few children receive state-of-the-art treatment.¹ The good news, however, is that skillful CBT combined, as needed, with medication is highly effective.

‘Contaminated’ mother. Adam becomes distressed when he comes in contact with objects that have been touched by others (such as doorknobs). He is especially anxious when these items are associated with public bathrooms or sick people.

Adam’s mother is a family physician who has daily patient contact. In the last 6 months, Adam has insisted that his mother change her work clothes before she enters his room, touches him, prepares his food, or handles his possessions.

As in Adam’s case, the family often gets caught up in a child or adolescent’s obsessive rituals (Box 1).² After a detailed discussion with Adam and his parents and because his symptoms were severe, we recommended combined treatment with sertraline and CBT. Adam was willing to consider CBT and medication because he recognized that he was having increasing difficulty doing the things he wanted to do in school and at home.

Snapshot of pediatric OCD
Approximately 1 in 200 children and adolescents suffer from clinically significant OCD.³ They experience intrusive thoughts, urges, or images to which they respond with dysphoria-reducing behaviors or rituals. Common obsessions include:

• fear of dirt or germs
• fear of harm to oneself or someone else
• or a persistent need to complete something “just so.”

Corresponding compulsions include hand washing, checking, and repeating or arranging.

OCD appears more common in boys than in girls. Onset occurs in two modes: first at age 9 for boys and age 12 for girls, followed by a second mode in late adolescence or early adulthood.

Two practice guidelines address OCD in youth: an independent expert consensus guideline⁴ and the American Academy of Child and Adolescent Psychiatry’s practice parameters for OCD.⁵

For uncomplicated OCD, these guidelines recommend CBT as first-line treatment. If symptoms do not respond after six to eight sessions, a selective serotonin reuptake inhibitor (SSRI) is added to CBT.

For complicated OCD, medication is considered an appropriate initial treatment. Complicated OCD includes patients who:

• display severe symptoms—such as with scores >30 on the Children’s Yale-Brown Obsessive Compulsive Scale (CY-BOCS)
• or have comorbidity such as depression or panic disorder that is likely to complicate treatment.

Keys to successful treatment
OCD is remarkably resistant to insight-oriented psychotherapy and other nondirective therapies. The benefits of CBT, however, are well-established, with reported response rates of >80% in pilot studies.^6,7 Although confirming studies have yet to be conducted, successful CBT for pediatric OCD appears to include four elements (Table 1).

Exposure and response prevention (EX/RP) is central to psychosocial treatment of OCD.^7,8 In specialized centers, exposure can be applied intensively (three to five times per week for 3 to 4 weeks).⁹ In most practices, however, exposure is more gradual (weekly for 12 to 20 weeks). With repeated exposure, the child’s anxiety decreases until he or she no longer fears contact with the targeted stimuli.^8,10

Not ‘misbehavior.’ Children—and less commonly adolescents—with this disorder may not view their obsessions as senseless or their compulsions as excessive. Even when insight is clearly present, young OCD patients often hide their symptoms because of embarrassment or fear of being punished for their behavior.

Response predictors. A key to CBT in children or adolescents is that they come to see obsessions and compulsions as symptoms of an illness. The symptoms, therefore, require a skillfully applied “antidote,” as taught by the clinician and implemented by the child, family, and others on the child’s behalf.

Besides overt rituals, three response predictors include the patient’s:

• desire to eliminate symptoms
• ability to monitor and report symptoms
• willingness to cooperate with treatment.

CBT may be difficult with patients younger than age 6 and will invariably involve training the parents to serve as “coaches;” a CBT protocol for patients ages 4 to 6 is under investigation (H. Leonard, personal communication). CBT also can be adapted for patients with intellectual deficits.¹¹

A ‘tool kit.’ Successful exposure therapy for OCD relies on equipping children and adolescents with the knowledge and skills to battle the illness. They often have tried unsuccessfully to resist OCD’s compulsions and must be convinced that EX/RP techniques will work. Using a “tool kit” concept reminds young patients that they have the implements they need to combat OCD (Table 2).

A ‘germ ladder’ and ‘fear thermometer.’ Adam’s tools include a stimulus hierarchy called a “germ ladder,” which the therapist and Adam create collaboratively. It ranks stimuli from low (his own doorknob) to very high (public toilets, sinks, and door handles).

As part of his treatment, Adam begins to touch objects in his room and house while voluntarily refraining from ritualizing. He uses another tool—a fear thermometer—to record his distress level on a scale of 1 to 10 during and after these exposures.

Adam discovers that when he comes into contact with less-threatening items his fear ratings typically return to baseline within 20 to 30 minutes. This insight helps him modify his assessment of the risk they pose.

During office visits, he confronts similar items around the clinic, with the therapist providing encouragement and instruction for additional exposure homework. Eventually Adam works on the clinic’s public bathroom, which he perceived to be relatively clean but less so than his own bathroom. After fear in response to this bathroom is reduced, the therapist and Adam graduate to more-public facilities, such as the bathrooms at Adam’s pool and the local train station.

Exposure therapy. EX/RP is most successful when the child—rather than the therapist—chooses exposure targets from a hierarchy of fears,² particularly when the list includes behaviors the child is resisting. In a collaborative spirit, the child takes the lead in placing items on the hierarchy and deciding when to confront them.

The therapist and child revise the hierarchy periodically, which demonstrates progress and allows them to add items as the child overcomes fears that cause less distress.

Reducing need for reassurance. Adam has a habit of repeatedly asking his mother whether contact with particular objects in public is risky. By the third treatment session, he and the therapist agree that he will try to refrain from asking such questions.

His mother, in turn, is asked to reiterate the rationale for response prevention whenever Adam slips. She will offer encouragement and support without answering “OCD’s questions.”

Adjunctive drug therapy
While Adam is working with the behavioral therapist to reduce his anxieties and need for reassurance, he is also receiving gradually increasing dosages of sertraline. As discussed, he is considered a candidate for CBT plus medication because of his symptoms are severe. Drug treatment can benefit most pediatric OCD patients.

SSRIs. Two SSRIs are approved for pediatric OCD—fluvoxamine for ages 8 to 18 and sertraline for ages 6 to 18. Most SSRIs are likely effective for OCD in youth (Table 3),^12-14 although reports have suggested a link between paroxetine and suicidality in pediatric patients. Other options may be more suitable choices unless further evidence supports the use of paroxetine as a first- or second-line agent for pediatric OCD.

Clomipramine—a nonselective tricyclic—was the first medication studied in treating OCD in children and adolescents. It is now usually considered only after two or three failed SSRI trials because of its potential for cardiac toxicity.^15-17

Dosing. Fixed-dose studies suggest that dosing schedules for OCD are similar to those used for depression. For example, sertraline, 50 mg/d, or fluoxetine, 20 mg/d, are as effective as higher dosages.¹⁸

The common misconception that OCD requires higher dosages likely results from:

• increasing the dosage too early in the time-response window for a drug effect to emerge
• giving medication without concomitant exposure therapy.¹⁹

Delayed response. Although many patients respond early to an SSRI, others do not respond until 8 or even 12 weeks of treatment at therapeutic dosages. It often takes 3 to 4 weeks for evidence of benefit to emerge, so wait at least 3 weeks between dosage increases. Maintain therapeutic dosages at least 6 to 8 weeks before changing agents or beginning augmentation therapy.

Two-barrel approach. In treating Adam, we began with sertraline, using a flexible titration schedule keyed to whether he experienced OCD symptom remission.

The starting dosage of 50 mg was titrated to 150 mg over 8 weeks while he was receiving behavioral therapy. We made adjustments with a time-response window of 2 to 3 weeks, allowing us to observe a response to each dosage escalation.

Adam’s OCD symptoms responded well to CBT plus sertraline. The maximum drug effect helped him confront the most difficult EX/RP tasks at the top of his stimulus hierarchy, which he attacked near the end of treatment.

Lessons learned. Multicenter trials have taught important lessons about drug therapy for OCD:

• OCD patients experience little or no placebo effect, unlike patients with depression.
• Clinical effects may appear as early as 2 to 3 weeks after medications are started and plateau at 10 to 12 weeks.
• Partial response is the rule; SSRIs reduce OCD symptoms by about 30%—which correlates with “moderately” to “markedly” improved ratings on patient satisfaction measures.
• Side effects and magnitude of improvement are comparable in pediatric and adult medication trials.

Managing resistant OCD
Adequate SSRI monotherapy trials fail to relieve OCD symptoms in one-third of patients. Some patients benefit from combination therapy—such as an SSRI plus risperidone—especially when comorbid schizotypal personality disorder or a tic-spectrum disorder is present.

Drug switching or augmentation trials often produce only partial response and cause unnecessary suffering. A more effective strategy for many patients is to augment drug treatment with CBT until symptoms normalize.

On the other hand, augmentation is appropriate when nonresponse or partial response to SSRI monotherapy leaves a patient clinically symptomatic and functionally impaired. Clonazepam, clomipramine, and the amino acid L-tryptophan have been used successfully. Lithium and buspirone also have been tried but seem not to be effective in controlled studies in adults and anecdotal experience in youth.

When augmenting an SSRI, adding clomipramine, 25 to 50 mg/d, is a reasonable choice. However, fluoxetine or paroxetine can inhibit clomipramine metabolism by cytochrome P-450 (CYP) 2D6, with potential for cardiac arrhythmias or seizures. Sertraline or fluvoxamine are less likely to elevate clomipramine levels.²⁰ Fluvoxamine may be the most compatible SSRI with clomipramine because it inhibits CYP 1A2—the enzyme that demethylates clomipramine to its inactive desmethyl metabolite—thereby preserving more of the active parent compound.

Clinical evidence suggests that augmentation’s success may depend in part on a patient’s comorbidities. For example, clonazepam may be particularly helpful for children with comorbid panic symptoms.

Maintenance therapy
We typically provide 14 weekly CBT sessions, followed by monthly contacts for a few months to ensure than a patient’s gains are maintained. Standard procedure with drug therapy is to continue maintenance treatment for up to 1 year, although some have suggested continuing maintenance treatment indefinitely.

See also "Acute-onset OCD may be bacterial," Box 2.

References

1. Kendall PC, Southam-Gerow MA. Issues in the transportability of treatment: the case of anxiety disorders in youths. J Consult Clin Psychol 1995;63(5):702-8.
2. March J, Mulle K. OCD in children and adolescents: A cognitive-behavioral treatment manual. New York: Guilford Press, 1998.
3. Flament MF, Whitaker A, Rapoport JL, et al. Obsessive compulsive disorder in adolescence: an epidemiological study. J Am Acad Child Adolesc Psychiatry 1988;27(6):764-71.
4. March J, Frances A, Kahn D, Carpenter D. Expert consensus guidelines: treatment of obsessive-compulsive disorder. J Clin Psychiatry 1997;58(suppl 4):1-72.
5. King R, Leonard H, March J. Practice parameters for the assessment and treatment of children and adolescents with obsessive-compulsive disorder. J Am Acad Child Adolesc Psychiatry 1998;37(10, suppl):27-45.
6. March JS. Cognitive-behavioral psychotherapy for children and adolescents with OCD: a review and recommendations for treatment. J Am Acad Child Adolesc Psychiatry 1995;34(1):7-18.
7. Franklin ME, Kozak MJ, Cashman LA, et al. Cognitive-behavioral treatment of pediatric obsessive-compulsive disorder: an open clinical trial. J Am Acad Child Adolesc Psychiatry 1998;37(4):412-19.
8. March JS, Mulle K, Herbel B. Behavioral psychotherapy for children and adolescents with obsessive-compulsive disorder: an open trial of a new protocol-driven treatment package. J Am Acad Child Adolesc Psychiatry 1994;33(3):333-41.
9. Franklin ME, Tolin DF, March JS, Foa EB. Treatment of pediatric obsessive-compulsive disorder: A case example of intensive cognitive-behavioral therapy involving exposure and ritual prevention. Cognit Behav Pract 2001;8(4):297-304.
10. March J, Mulle K. Manualized cognitive-behavioral psychotherapy for obsessive-compulsive disorder in childhood: a preliminary single case study. J Anxiety Disord 1995;9(2):175-84.
11. Franklin ME, Rynn M, March JS, Foa EB. Obsessive-compulsive disorder. In: Hersen M (ed). Clinical behavior therapy: adults and children. New York: John Wiley & Sons, 2002:276-303.
12. March JS, Biederman J, Wolkow R, et al. Sertraline in children and adolescents with obsessive-compulsive disorder: a multicenter randomized controlled trial. JAMA 1998;280(20):1752-6.
13. Riddle MA, Reeve EA, Yaryura-Tobias JA, et al. Fluvoxamine for children and adolescents with obsessive-compulsive disorder: a randomized, controlled, multicenter trial. J Am Acad Child Adolesc Psychiatry 2001;40(2):222-9.
14. Geller DA, Hoog SL, Heiligenstein JH, et al. Fluoxetine treatment for obsessive-compulsive disorder in children and adolescents: a placebo-controlled clinical trial. J Am Acad Child Adolesc Psychiatry 2001;40(7):773-9.
15. Leonard H, March J, Rickler K, Allen A. Pharmacology of the selective serotonin reuptake inhibitors in children and adolescents. J Am Acad Child Adolesc Psychiatry 1997;36(6):725-36.
16. DeVeaugh-Geiss J, Moroz G, Biederman J, et al. Clomipramine hydrochloride in childhood and adolescent obsessive-compulsive disorder—a multicenter trial. J Am Acad Child Adolesc Psychiatry 1992;31(1):45-9.
17. Wilens TE, Biederman J, March JS, et al. Absence of cardiovascular adverse effects of sertraline in children and adolescents. J Am Acad Child Adolesc Psychiatry 1999;38(5):573-7.
18. Greist JH, Jefferson JW, Kobak KA, et al. A 1-year double-blind placebo-controlled fixed dose study of sertraline in the treatment of obsessive-compulsive disorder. Int Clin Psychopharmacol 1995; 10(2):57-65.
19. Marks IM. Drug versus behavioral treatment of obsessive-compulsive disorder. Biolog Psychiatry 1990;28(12):1072-3.
20. Leonard HL, March J, Rickler KC, Allen AJ. Pharmacology of the selective serotonin reuptake inhibitors in children and adolescents. J Am Acad Child Adolesc Psychiatry 1997;36(6):725-36.
21. Leonard HL, Swedo SE. Paediatric autoimmune neuropsychiatric disorders associated with streptococcal infection (PANDAS). Int J Neuropsychopharmacol 2001;4(2):191-8.
22. Perlmutter SJ, Leitman SF, Garvey MA, et al. Therapeutic plasma exchange and intravenous immunoglobulin for obsessive-compulsive disorder and tic disorders in childhood. Lancet 1999;354(9185):1153-8.

Related Resources

• Chansky TE. Freeing your child from obsessive compulsive disorder: A powerful, practical program for parents of children and adolescents. New York: Crown Publishing Group, 2001.
• March JS, Mulle K. OCD in children and adolescents: A cognitive behavioral treatment manual. New York: Guilford Press, 1998.
• Moritz EK, Jablonsky J. Blink, blink, clop, clop: Why do we do things we can’t stop? An OCD storybook. Newton, MA: Professional Books, 1998.
• Wagner AP. Up and down the worry hill: A children’s book about obsessive compulsive disorder and its treatment. Rochester, NY: Lighthouse Press, 2000.

Drug Brand Names

Buspirone • BuSpar
Citalopram • Celexa
Clomipramine • Anafranil
Clonazepam • Klonopin
Escitalopram • Lexapro
Fluoxetine • Prozac
Fluvoxamine • Luvox
Paroxetine • Paxil
Risperidone • Risperdal
Sertaline • Zoloft

Disclosure
Dr. March receives research support from Pfizer Inc., Eli Lilly and Co.,
and Wyeth Pharmaceuticals and is a speaker for and/or consultant to Solvay Pharmaceuticals, Pfizer Inc., GlaxoSmithKline, Wyeth Pharmaceuticals, Novartis Pharmaceuticals Corp., and Shire Pharmaceuticals Group.

Dr. Franklin and Dr. Foa report no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.

ACKNOWLEDGMENT
Preparation of this manuscript was supported in part by National Institute of Mental Health grants 1 K24 MHO1557 and 1 R10 MH55121 to Dr. March and by contributions from the Robert and Sarah Gorrell family and the Lupin Family Foundation.