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Obsessive compulsive disorders in adolescence
]Ttner~lalofAdeJle:¢~nce T988, 11, r83~I04
O b s e s s l "Ve c o m p u l s t "V ie disorders
in adolescence
A. APTER AND S. TYANO This article ur experience with ~4 adolescent cases of Obsessive Compulsive (OCD). In contradistinction to other reports in the literature, our results were quite good with these patients. Although,we used recommended treatment measures (exposure in vivo and elomipramine drug
useful. Our conclusion is that non-specific milieu therapy toads to recove~ in a majority of adolescent obsessive compulsives, We are not sure as to how long these remissions will last on follow-up. INTRODUCTION Obsessive Compulsive Disorder ( O C D ) c ~ ~ a severely handic ng illness and is considered by some to be terra m most psychiatric treatments (InseI, Murphy, Cohen, Alterman, Kilt and L m n O!a, 2983). In this eondifioa, tile patient becomes occupied with thoughts in which, in fact, he is not very interested. H e is acutely aware of impulses which lead him to actions which he does not enjoy b u t which it is quite impossible 6or him m omit (Freud, I916 ). Compulsive ritualization is inherent in normal childrea. Piaget has identified this phenomenon in infants and Gesel[ states that at a - 3 years of age, the child can display complicated ritualistic symptoms (Judd, I965). Hotlingsworth, Tanguay, Grossman and Pabst (I98o) have observed that ritual behaviot~r is a common m e t h o d of anxiety reduction among children aged between four and seven years. D u N n g latency, normal play of all children is replete with evidence of ritualistic and compuIsl"Ve behaviour; stepping or not stepping on p a v e m e n t cracks and touching s u ~ e s s i v e lamp-posts are some impressive examples (Judd, ~ 5 ) . Sarnoff (z re ob ive cornpuNive symptoms as part of the "cognitive organLzlng peNod" of late latency (8-I~ years). He writes of frequent transient symptorns of this nature related to control of affects. Reprint requests tu Dr A. At)tcr~ Ge|m Psychiatric HospitM~ P.O~ Box 7~, Peta|t Tikva, israel ¢9ioo.
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A. A P T E R A N D 8. T Y A N O
These affects are ass~iated w~th wishes to de t h i n ~ forMdden by the parents. The affect thus reflects guilt over rebellion. The ~lationship be n this transient normal behaviour and the hiatric disorder is very unclear. Traditionally, OCD is considered to derive from a failure to resolve adequately conflicts of ambivalence which the youngster experiences and must deal wit h at the stage of toilet training (Evans, ~98z). Thus, it is not surprising that obsessionals are preoccupied with cleanliness and dirt. The most common defense mechanisms found are those of isolation, undoing and reaction formation, rl e symptoms displayed can be seen as the opposite of a wi.~h which may or may not be unconscious. Children may have prolonged washing compulsions and a desire to he clean and good to counteract their aggressive wishes, but their underIying hositlity wilt still emerge m the form of interfering with the action of others, e,g,, monopolization of the bathroom (Evans, ~982). q'here is some evidence that OCD may have a ncurobiologlcal basis. Elkins, Rapoport and Llt"~" sky (1 980) have reviewed the genetic and neuropsyehologieal test evidence in this regard. In addition, they point to the association with Tou rette's syndrome and the benefits in OCD of psychosurgery and psychopharmacology as supporting their e lamu " that OCD has an underlying organic cause. Behar el el. (i 984) reported that adolescent OCD patients had higher mean ventricular-brain ratios (v-b-r) than matched controls on computerized tomography (CT) scaT"~'s. This may imply some form of brain atrophy. On neuropsychologieal testing, these adole3cents had spatial-perceptual deficits similar to those found in people with frontal iobe lesions of the brain. Some of these patients also had a high frequency of age-inappropriate s~ynkmesias-" ' (subtIe movement and coordination difficulties) and left hemibody signs, The autho~ concluded that their findin~ su sted right eerebraI involvement in the pathogenesis of OCD. Recently, there has also been some interest in serotonin, an important neurotransmitter in the brain as being aetiotogicaHy involved in OCD. The evidence for this in aduhs has recently been reviewed by Zohar and Inset (i987). I ley found that the administration of a seretonin agonist, m-ehlorophenylpiperazine (m-cpp) caused pr~Jfound behavioural ef%cts in OCD patients but not in healthy controls. These changes included exacerbation of the OCD symptoms. This did not appear to be related to any anxiogenic effect of m-cpp. They also four~d that the anti-depressant drug, clomipramine, which has great serotonergic e"ffacts ~ was much more potent in alleviating OCD symptoms than deshnipramine, a non-serotonergie anti-depressant drug. Working with adolescent 0 C D patients, Flament, Rapoport, Murphy, Berg
OBSESSIVE COMPULSIVE DISORDERS
I8 5
and Lake (i987) found that clomipramine's t h e r a ~ u t i c activity was c l ~ e l y cerrelated with pre-treatment platelet serotonin concentration and monoamine-oxida~e activity, It was also correlated with the decrease of beth measures during clomipramme a~mm stratmm This, they concluded, s u ~ e s t s that c omlpmmmes serotonergic effects may be e~sentiN for its anti-obsessional activity. In addition, Btumenson and Berenhout (I985) have pointed out that many cases of OCD followed an epidemic of eneepha|itis at the beginning of the century, and OCD may result from degenerative lesions of the brain, uremia, and diabetes insipidus. In our own series of !4 children, two cases seemed to have an organic basis. One boy of ~o developed severe obsessive ruminations about whether or not he would "marry a nasty woman", following a cerebral bleed due to head trauma. T h r e e months later, he was completely recovered and has remained so after five years' follow-up, Another x3-year-old youngster developed very severe OCD soon after a mild case of m u m p s with bilateral paretitis but no meningeal signs. He too recovered ltmn eight weeks and is still doing well Iive years later. Prevalence OCD in childhood is a rare psychiatric illness that has been estimated to occur in at most I per cent of child psychiatric inpatients (Judd, I965) and only o-z per cent of child outpatiems (Ho!li orth et aL, ~98o). No cases of O C D were found among more. than ~ooo Io- and I x-year-Nds on the Isle of W (Rutter0 T i Whir ) ~97o). However, Freud (I916) cites six m eight years as the usual a ~ at which obsessive symptoms appear. K n n g l e n (I965) noted that one-half of his 91 adult patients ~ d become ill before age 20 and one-fifth of them become ill before age 2o (one-fifth of them b ~ o r e puberty). Rapaport et all (~98I) stated that o n e - t h i ~ of adult b e ~ n before age i 5 and the actual perce childhood onset may be much higher because many adult O C D patients relate that concealed their symp for years before social functioning deteriorated. In our own series ef cases from the a d d nt unit at Geha Hospital over six ieears (January I98o m Dec x985), we have seen ~4 cases out of a total intake of 496 patients, i.e., 2"8 per cent. In almost all cases, the diagnosis had been missed by the referring psychiatrist and we feel that the incidence of O C D among adolescents may be much higher than is generally realized. T e n of the 14 patients were misdiagnosed ~ being psychotic of schizophrenic, affective and oNanic etiology. Two were thought to be severely depressed and one oppositional. I n the latter ease, admission was due to school refusal which was later realized to be a severe case of "primary obsessional slowness".
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A, A
E R A N D S. T Y A N O
T a b l e I, Patient characteffstics
Case
No, x
Age at
Sex
re[erral
M
76
R umina-
Onset Checking Cleaning ~2
+
+
dons
Slown~s Severit~
+
+
3
z
F
13
9
+
+
+
-
3
3 4 5 6 7 8 9
M M M M F F F
13 ~z ~o xS ~fi 15 ~6
z~ i~ io Io 8 ~4 !a
+ + + + + +
+ + + + -
+ -+ + +
+ + + --
3 3 3 3 3 3 3
ro tr
M M
I6 x3
x2 ~I
+ +
+ -
+ +
+ -
3 3
I2 t3 ~4
F
r6
I4
~
~
~
+
3
M
r7
~5
-
+
+
-
3
M
t6
~4
-
+
+
+
3
* T i m e spent each day dominated b y s y m p t o m s : o ~ symptom free; J ~ less than ~ hour; 2 -~ i - 4 huurs; 3 "~ more than 4 hours.
M E T HO D A N D R E S U L T S
P~esentation a n d exanttnatton~ R a p a p o r t et aL ( i 9 8 i ) , i n a d e s c r i p t i o n o f n i n e cases of O C D aged i 3 - I 7, r e p o r t " t h e m o s t s t r i k i n g f e a t u r e of t h e s e eases was t h e severity o f p s y c h o p a t h o l o g y in t h e a b s e n c e of f o r m a l t h o u g h t d i s o r d e r . T h e s e p a t i e n t s ' ~ l a t e d n e ~ a n d Se n s l b l e d i s c u ~ i o n of t h e i r p r o b l e m s w a s i n a l m o s t eerie c o n t r a s t to t h e i r i n c a p a c i t y . R i t u a l s a n d o b ~ s i v e t h o u g h t s o c c u p i e d m o s t of t h e i r d a y a n d c a u s e d t h e m d i f f i c u l t y in m ~ t i n g a n y w a r d r o u t i n e " . Bolton, C o l l i n s a n d S t e i n b e r g (z983) d e l i n e a t e two m a i n k i n d s o f c o m p u l s i o n in c h i l d r e n : c h e c k i n g a n d c l e a n i n g . T h i s is in a c c o r d a n c e w i t h o u r o w n e x p e r i e n c e . C h e c k i n g i n c l u d e s " s a f e - m a k i n g " r i t u a l s b e f o r e g o i n g to bed. T a b l e z s h o w s t h e d i s t r i b u t i o n of s y m p t o m s in o u r o w n series (14 cases i n five y e a r s ) . T h e t a b l e is d e s i g n e d to be c o m p a r e d w i t h t h a t of Bolton et at., (1983) b u t i n c l u d e s a s e p a r a t e c o l u m n for p r i m a r y o b s e s s i o n a l s l o w n e s s ( R a c h m a n , x974) w h l c n was r e l a t i v e l y c o m m o n in o u r s a m p l e . T h e l a t t e r s y m p t o m is well k n o w n in its b e n i g n f o r m to t h e f a m i l i e s of m a n y h e a l t h y a d o l e s c e n t s ! H o w e v e r , in o u r p a t i e n t s , this was an e x t r e m e l y d e b i l i t a t i n g s y m p t o m w h e r e t h e p a t i e n t m a y h a v e taken several h o u r s to c o m p l e t e the m o s t s i m p l e tasks s u c h as w a s h i n g or dressing. T h e s l o w n e s s is p r i m a r y in
OBSESSIVE COMPOLSIVE DISORDERS
~87
that it is not secondary to obsessions or compulsions. T h i s symptom was so severe in one patient that retarded depression and even eatatonia were considered in the differential diagnosis. T e n of our 14 patients involved the family in their rituals. T h i s was often very extreme, causing much anguish to the family members. One rural girl forced her family to shower outside in the freezing cold to avoid contamination of the house. Another youngster forced his mother to spend hours r u b b i n g "imaginary" dirt off door knobs, whilst another forced his father to start every car journey from the beginning each time their car was overtaken from the left! In three cases, the adolescent hid his rituals from the family until he stopped functioning completely. One girl with a hysterical pre-morbld personality seemed to derive a great deal of satisfaction from publicizing her rituals dramatically. T h e obsessional ideas were often dramatic and bizarre. A x 3-year-old girl had an image of the Holy Being's penis which constantly intruded her mind. When her male therapist attempted a thought-stopping technique to alleviate the obsession, she then became obsessed with the image of the therapist's penis! Another felt that his eyes were being "destroyed" ~nd had to touch them continuously. Many of the adolescents were so perfectionistic that they could not do their school work for fear of making mistakes.
All the patients were described as healthy, well-functioning individuals before the onset of the disease, However, i r of the patients showed definite personality trends befor~ the onset of the illness. T w o girls definitely had histrionic traits, one had been quite schizoid and another very introverted. T w o of the boys were antis6cial in their behav[our prior to being hospitalized and four other boys tended to be compulsive. Case 3 had cyclothymic swings in his past. An interesting feature of the present sample was that eight of the z4 patients had a W I S C - R score of over ~3 o and all the others had above average
Severity at refet~'al As our group of O C D adolescents were atl in-patients, it is not surprising that they were severely ill, T h e y had all stopped going to school, were avoiding all social contacts and were in conflict with their families. T h e y all spent more than 5 ° per cent of the day involved in their rituals. All our patients were assessed on a structured psychiatric interview with the childhood disorders and schizophrenic (Kiddie-SADS), T h i s includes an assessment of functioning called the childhood version of the Global Assessment Scale (Kiddie-GAS). T h i s scale assesses severity on a zero to ioo
i88
A. APTER AND S. q ' YA NO T a b l e 2.
Case No.
Mother -
3
F~mity ~tho Father
Siblings
Paranoid personality disorder
4
Bipolar affeetive disorder Major depression
Alcoholism, organic brain syndrome
6
Borderline
7
g ~ v e aggresswe pc~ona|~ty disorder
urgamc oram syndrome
--
9
I tistrion~ pe~tmality disorder Dysthymia
-
-
m
Io zI lz 13
-
Paranoid p e ~ r | a H t y disorder ~
Dysthymia Compulsive personality disorder ~
Mental retardatmrJ ~pduet di~rder
I4
range with detailed explanations as to what each range of Io units implies. This scale has proved to be reliable in our hands (Apter and Tyano, i983). All our patients had scores of less than 4o on this rating, implying severe impairment. AII were Category 3 severity according to Bolton et aL ( r 9 8 3)~ m o r e than four h o u ~ a day dominated by symptoms. Marked family pathology was a feature of xo of the x4 eases, akhough there did not seem to be any diagnostic specificity (Table ~). AssocT;at2bn with otker psyc ~zatnc illnesses "Eating, sexual behaviour, gambling or drinking, when engaged in excess, may be referred to as "compulsive*'. However, in these cases, the individual derives pleasure from the actual behaviour and only wants to stop because of the sec~ndary deleterious consequences. Many clinicians regard O C D as a *~neur~is" and therefore erroneously as a mild condition. H er, severe O C D is n misdi osed as schizophrenia and obsessions and compulsions may ~ c u r transiently during the prodromal phase of schizophrenia. T h e y may also occur as part of Gitles de la Tourette syndrome.
OBSESSIVE COMPULSIVE DISORDERS
t8 9
A~fe ' azsoraer "' - N often associated wztt " OCD but the exact nature of this t ctive relationship is unclear. As with the patients of Rapaport et aL (I98~), our o w n series of eases showed a high incidence of depression ($" i x out of t4) Another patient on c]orimlpramine therapy developed mania which responded to withdrawal of the drug. All our patients showed negative dexamethasone uppressmn test results and their H 3 tmtpramme binding was no different from that of controls. DISCUSSION Although many authors feel that conventional insight-oriented therapy for ehl dren and adolescent ohsessives is not useful (Bolton e t a L , i983, Flament, Rapaport, Berg, Seeery and Kilts, I985), we have found this method quite rewarding with some of our patients. Anthony (i97i) has divided therapy of obsessional children and adolescents into four stages. Firstly, the child is encouraged to talk about his peculiar sym s whhout being mocked, criticized or punished. He can also express his r at the re~reussions his illness brings about in his home environment. Sec y, the patient attempts to use the therapist in the same way he u s ~ his mother, as a pa~ieipant in his ceremonials. When the therapist refuses, a stormy situation ensues. Then stage three comes about and the child's defenses become less inflexible. There is messiness and aggresslon~which can be very trying for parents! Lastly, frank oedipal wishes and thoughts begi9 to e m e r ~ and then treatment proceeds as for other neurotic children. Judd (I965) has also reported favouraMe results with psychotherapy for o sive ~uildren while Evans (x982) regards this as the treatment "of choice" for adolescents ~ t h th~ disorder. The fast decade has -witnessed great progress in the behavioural treatment of obsessive computsive disorder (Marks, i98i ; Steketee, Foa and Grayson,
~982). It is postulated that there is an evoking stimulus that triggers obsessions and these evoked responses can themselves become further evoking stimuli in * a V*ICROUS circle. When the patient is exposed to the evoking stimulus for a p~zlonged period of time, the response tualty subsides. Thus, treatment consists of s~rchLng for the situations " w h i c h compulsive rimals, and then pe~uading the patient to maintain contact w i ~ them until he or she b~ornes used to them. During exposure treatment, patients are usually instructed to refrain from rituals between treatment sessions (response prevention).
~9o A. APTER AND S. TYANO Steketee et al, (i98z) conclude that deliberate in vivo exposure in combination with response prevention is the most effective treatment for obsessive compulsive adults. The in vivo exposure mainly affects the anxiety/discomfort associated with cues for ritualizing whilst the response prevention primarily affects the compulsive behaviour. T ~ a t m e n t gains can be maintained by irnaginal exposure. This is especially so when the patient fears catastrophe (e~g., death, disease, house burning down) following exposure to the stimuli. When obsessive thoughts are present without rituals, the technique of thought-stopFdng is su ted. In this pro~dure, the patient is relaxed and is asked to think of the ire thought. The therapist shouts"stop!" to dispeI the thought and the patient is then taught m whisper and then m mnploy a subvocat command. The thoughts can a!so be stopped by shocking himself with a portable "shockbox" or strapping an elastic band against his wrist (Marks, x98I). The most extensive report of these techniques with adolescent patients is that of Bolt~n et aL (~983). Their first choice of treatment for out-patient work was self-imposed response prevention with self-monitoring of symtoms. In m~Jst cases, this was supplemented by engaging the parents in response prevention, either passively (by refusal to participate in the child's ritual) or actively by verbal or physical (in the ease of younger adolescents) restraint. Thus, work witt~ parents centered around buttressing the parents' authority and increasing their tolerance of the child's distress and hostility. This was facilitated by instruction and modelling, the setting of specific tasks in and out of the therapy, and the modification of invalid beliefs. In severe cases, the patient was hospitalized and staff-imposed external control of responses was instituted. In one case, the authors report the use of flooding, i.e., prolonged exposure to highly feared stimuli with complete or near-complete response prevention. Seven of their x5 patients were completely recovered after treatment and another six showed marked improvement. The problems encountered included: failure to engage the child's cooperation; too extensive a range and diversity of the compulsive behaviour substitution of the suppressed ritual by another; and concomitant conduct d~sorder. One patient who su from primary o ional stowness was t by prompting, pacing and partiNpant modelling. This pr mine of therapy was described in detail by Ctark, Surgrim and Bolmn (I98z). A[th treatment gains were initially pronnising) they were ~ot mair~xained on gradual fading of the intervention. For another detailed case r e ~ r t , the reader is re to that of G (~9~). n0.y, Flamentet al. (i985) published double-blind controlled s o[
O B S E S S ! VE C O M P U LSI VE D I S O R D E R S
r9r
clomipraminc on t 9 adoleseents (aged I ~ x S , mean x4 -+ z- 3 years) with OCD. They used a crossover design with each patient being his/her own control. Ttley concluded that the drug was effective in relieving obses~onai symptoms and that this action was quite specific: in contrast with obsessive symptoms, depression and anxiety did not change fignifieandy during the study, tn fact, these latter features were minimal from the outset. Significant improvement was seen a ~ r three weeks, as well as after five weeks on the drug, which is slightly quicker than the rate of amelioration reported %r adults. However, not alI the s u N e c u ~ n ~ i t e d from the drug and within the five-week tria}, most re ders did not recover fially, er, improvernent consisted of a decrea~d intensity of the .symptoms Mtiq thNr daily life. Rituals could be resisted without the occurrence of anxiety. Patients with rituals tended m respond lz~tter than those with obsessive thoughts. This finding is similar m that with behaviour therapy, but not to that of Insel et M. in adults on the effect of Clomipramine. T h e doses used were between Ioo and 2oo m # a y and art similar m those used in adults. Side effects were quite common) mainly the anticholinergic effects seen with tri~,clic antide nts. Integrated ospttat treatment of adolescents " ] expene ' n ee I"n the adolescent unit at The following represents the cunlca Geha Hospital over the last five years. This is a locked ward which seiwes the whole of I~rael. The indications for admission to this unit are based on severity of symptoms and inability to function, lrrespecuve of diagnosis, tn eihgenee, or medical condition (the unit is attached to a large genera| hospital), Most of the patients are ~dmitted after failure of prolonged outpatient, day or open ward treatment. The basle philosophy of the unit is a psychodynamic one. However, other treatment approaehe~biologicat, special education, family therapy and behavioural modification~are often integrated into the treatment plan. Discipline is firm, patients are encouraged to be neat and tidy and must participate in the ward school programme as well as in soci..~ and vocational activities. In addition to our routine comprehensive diagnostic work-up, all our patients were evaluated by the behaviour therapy clinic at Geha Hospital. However, in only three of t4 patients was it. ible to car~¢ out a systematic hehaviour therapy treatment plan because of the secretiveness and ~sistance m change by our adolescent p a t i e n t , ~ i s adolescent response to therapy was also described by Bolton et aL " t s ) r ~istanee. Our (t983). However, they were able to overcome their patten ""
xgz
A. APTER AND S. TYANO
failure to succeed may be due to the low staff-patient ratio on the ward and to lack of experience with behaviouml methods by a primarily psychodynamically oriented treatment team. In view of this, the patients were evaluated for psychotherapy according to an assessment of their ego strength and capacity for an in-depth relationship. On this basis, six eases were given intensive psyehodynamieatly oriented therapy and five cases suppom e and "educational" therapy. T h e former was given by staff psychologists or senior child psychiatry registrars, the latter by pediatric registrars on their s~x-month psychiatric rotation. I s consisted of frequent ~5- to 3o-minute sessions with the patient and his family~ Encouragement was given, and treatment options and rehabilitation po~ibilitie~ were discussed. T h e nature M present-day understanding of the illness was also given. A~I the patients had a rich antasy life (Judd, x965). Many of the girls were extremely concerned with masturbation and g~ilt over sexual i m p u l s e . One of the girls (Case No. 8) speeitically eonneeted the onset of her obsessive symptoms with the onset of masturbation. She felt that the rituals helped to ' T h e boys had frequent homosexua divert her thought from sin, . I impulses and were very anxious about these feelings. For both these urges seemed to ' be more obsessive in nature than a sign of significant gender i dentlty problems. The patients were often very hostile to one or both parents but felt very guilty about this. Eleven of the I4 patients had very strict and rigid moral codes. Six of the 14 patients received clorimipramine as an adjunctive therapy and four responded very well to the drug, In addition to the usual anticholinergic symptoms, one patient became manic and one bad an epileptic fit. All side-effects receded after withdrawal o( the drug. One boy who did not respond to clorimipramine and a trial of behaviour therapy did Ernprove with Apra'zolam (z- 5 rng/daily for six weeks). All of the patients on medication also received psychotherapy. CONCLUSION -I n our series, response to the has proved to be surprisingly good. EIeven out of ~4 patients were much improved withi~ three to four months of therapy and the other three patients also showed fair impro t. Th~se r~uIts are somewhat at odds with those reported in the literature. Holli rth et aL (I98O) found s out of io c still itt after follow-up, while Rapapo~ et aL (I98I) stated that 50 per cent of childhood and adolescent O C D remain chronic. Bolton e t a L (i 983) reported su in 3 of ~5 cases but attributed this sp ally m aviour therapy, which was la unsuccessful in our treatment p amine.
OBSESSIVE COMPULSIVE DISORDERS
r93
T h i s good prognosis may have several explanations. O C D in adolescence may be a cyclic disorder, and it is possible that a spontaneous remission dtte to the natural histor¢ of the disease is being witnessed. T h e milieu with its demands and standards may be an indirect form of response-prevention therapy. ( T h e lack of privacy in a fairly crowded ward also interfered with ritual performance). Lastly, our assessment was "sub,~ective" and did not use specific inventories (e.g. F i a m e n t et al.~ I985). Nevertheless, the ira.prove-m e a t of the patients was quite drmnatic in ~I of the patients and all have mMntained the i m p r o v e m e n t over a s~x, m o n t h to fly y e a r follow-up. REFERENCES
Anthony, E, ~. (~97z). ,?V,euro~escfChiMren bt the Child. Freddman, A. M. and Kaplan, H. I, (Ed~), New York: Atheneum. Ap~er, A. and Tyano, S. (~983). The use 'of a structured interview with hospitafized adolescents in Israel. Tenth International Congress of.International A~soeiation of Child Psychiatry and Allied Professions. Behar, D., Rapoport, J, L., Bery, C. J., Denckla~ M. B., Mann, L., Cox, C., Fedin, P., Zahn, T, and Wotfman, M. G. (t984). Computerized tomography and neuropsyehologieal t~t measures in adolescents with Obsessive Compulsive Disorder. Blumensohn, R. and Berenhout, E. (i985). Obsessive compulsive d er of children. S~urnal of the J~rael t Association CV HI 3-4, 59-7I. BoRon, D., ~Ilins~ S. and Stein D. (~#3)* The treatment of o i-re compulsive diso in adoI : a repo~ of i 5 cases. Bn'tish ffour~,al qf.~2~hiat~,~ 142, Clark, D., Surg ml, Io and Bokoa, D. (t98z). Primary obsesmonal slowness, a outing programme.... w~t"h a i3-year-oId~ adolescent. Behavimtr Reseamh ,~ Therapy 20~ r •
*
Elkins, R,, Rapoport, J, and Lipsky, A, (~98o). Obsessive compulsive disorder of childhood and adolescence, a neuroblc)logical viewpoinL ffour~lal of the A.,ne~ican Academy of Child Psychiatry 19, 54-524, Ev~ns, J. (r98~). Adolescent and Preadolescent Psyc/daoy. London: Academic Press. F~ament, M,, Rap0port, J., Berg, C., Sceery, W. and Kilts, C, (t98S). Clorimipramine tream!ent of childhood obsessive er~mpulsive disorder, Archives tff General Psychiat~, 42, 977~983. Fl~ment, M. F~, Rapoport, J. I.. Murphy, D. L.~ Berg, C. J, and Lake, C. R. (i987) Biochemical ehange~ during the clomipramlne tree,meat of childhood Obsessive Compulsive Disorder. Amhives gfGenera[ 44, zzg--zz 5. Freud, S. (x9~6)~ The e t3~ttrMuctoly Lectures on ann . London: George Allen & Unwin. Green, D. R. ( t 9 ~ ) . A ~havioural approach to the treatment of ona! 6tunis: an I ~ad°~e~ent- ease study. Jou~tal cence 3, ~97"z99, Ho |mgeworth, C. E,, Tanguay, P. E., Gro~atan, L. and Pzbs~ P. (x98o). Long-terra outcome of obsessive compulsive disorders in childhood, Journal qf the American ' qfClmtd Psychiatry I9, I 3 4 - ~ . Inse[, T,, Murphy, D,, Cohen, R.~ Aiterman, l., Kilt, C. and lAnnota~ M" (~983) . Obsessive compulsive disorder and double blind trial of chlorimpramine and ehlorgyIine. Archi~;~s of CLenerMl~sych&ttty 40, 6o5-6tz.
A. APTER AND S. TYANO t94 Judd, L. L. (I96S). Obsessive compulsive neurosis in children. Archive, of General iatty 12, 12£~-i43. Kringlen, E. (x965)~ Obse~iona) neurotics: a long-term follow-up, ffournal of iato, 111,709-722. Marks, I. (I98x). Review of behavioural psychotherapy. I: Obsessive-compulsive disorders. American Journal of Psychiat~ 138(5), 584-592. Rachman, S. (x974). Primary obsessional stowne~, l~haviourI?esearch ~ TherqI~ 12,
9-z8.
Rapoport, J., Elkins, R., Langer, D., Sceery, W., Buchsbaum, M., Gillin, J., Murph, D., Zhan, T., Lake, R, Ludlow, C. and Mendelson, W. (x98I). childhood obsessive-compulsive disorder. Ameffcanffoumal of Psychiat~ 138 (i a), I545-I 554Sarnoff, C. (I976). lmteno,. New York: Jason Aronson. Steketee, G., Foa, B. and Grayson, J. (I98z). Recent advances in the behavioural treatment of obsessive compulsive disorder. Archives of General I~ychiat~ 39, ~365-I37 r. Zohar, J. and In~l, T. R. (I987). Obsessive Compulsive Disorder: psychobiological approaches to diagnosis, treatment and pathophysiology. Biological Psychiat~ ~ , 66,7-687.
O b s e s s l "Ve c o m p u l s t "V ie disorders
in adolescence
A. APTER AND S. TYANO This article ur experience with ~4 adolescent cases of Obsessive Compulsive (OCD). In contradistinction to other reports in the literature, our results were quite good with these patients. Although,we used recommended treatment measures (exposure in vivo and elomipramine drug
useful. Our conclusion is that non-specific milieu therapy toads to recove~ in a majority of adolescent obsessive compulsives, We are not sure as to how long these remissions will last on follow-up. INTRODUCTION Obsessive Compulsive Disorder ( O C D ) c ~ ~ a severely handic ng illness and is considered by some to be terra m most psychiatric treatments (InseI, Murphy, Cohen, Alterman, Kilt and L m n O!a, 2983). In this eondifioa, tile patient becomes occupied with thoughts in which, in fact, he is not very interested. H e is acutely aware of impulses which lead him to actions which he does not enjoy b u t which it is quite impossible 6or him m omit (Freud, I916 ). Compulsive ritualization is inherent in normal childrea. Piaget has identified this phenomenon in infants and Gesel[ states that at a - 3 years of age, the child can display complicated ritualistic symptoms (Judd, I965). Hotlingsworth, Tanguay, Grossman and Pabst (I98o) have observed that ritual behaviot~r is a common m e t h o d of anxiety reduction among children aged between four and seven years. D u N n g latency, normal play of all children is replete with evidence of ritualistic and compuIsl"Ve behaviour; stepping or not stepping on p a v e m e n t cracks and touching s u ~ e s s i v e lamp-posts are some impressive examples (Judd, ~ 5 ) . Sarnoff (z re ob ive cornpuNive symptoms as part of the "cognitive organLzlng peNod" of late latency (8-I~ years). He writes of frequent transient symptorns of this nature related to control of affects. Reprint requests tu Dr A. At)tcr~ Ge|m Psychiatric HospitM~ P.O~ Box 7~, Peta|t Tikva, israel ¢9ioo.
~84
A. A P T E R A N D 8. T Y A N O
These affects are ass~iated w~th wishes to de t h i n ~ forMdden by the parents. The affect thus reflects guilt over rebellion. The ~lationship be n this transient normal behaviour and the hiatric disorder is very unclear. Traditionally, OCD is considered to derive from a failure to resolve adequately conflicts of ambivalence which the youngster experiences and must deal wit h at the stage of toilet training (Evans, ~98z). Thus, it is not surprising that obsessionals are preoccupied with cleanliness and dirt. The most common defense mechanisms found are those of isolation, undoing and reaction formation, rl e symptoms displayed can be seen as the opposite of a wi.~h which may or may not be unconscious. Children may have prolonged washing compulsions and a desire to he clean and good to counteract their aggressive wishes, but their underIying hositlity wilt still emerge m the form of interfering with the action of others, e,g,, monopolization of the bathroom (Evans, ~982). q'here is some evidence that OCD may have a ncurobiologlcal basis. Elkins, Rapoport and Llt"~" sky (1 980) have reviewed the genetic and neuropsyehologieal test evidence in this regard. In addition, they point to the association with Tou rette's syndrome and the benefits in OCD of psychosurgery and psychopharmacology as supporting their e lamu " that OCD has an underlying organic cause. Behar el el. (i 984) reported that adolescent OCD patients had higher mean ventricular-brain ratios (v-b-r) than matched controls on computerized tomography (CT) scaT"~'s. This may imply some form of brain atrophy. On neuropsychologieal testing, these adole3cents had spatial-perceptual deficits similar to those found in people with frontal iobe lesions of the brain. Some of these patients also had a high frequency of age-inappropriate s~ynkmesias-" ' (subtIe movement and coordination difficulties) and left hemibody signs, The autho~ concluded that their findin~ su sted right eerebraI involvement in the pathogenesis of OCD. Recently, there has also been some interest in serotonin, an important neurotransmitter in the brain as being aetiotogicaHy involved in OCD. The evidence for this in aduhs has recently been reviewed by Zohar and Inset (i987). I ley found that the administration of a seretonin agonist, m-ehlorophenylpiperazine (m-cpp) caused pr~Jfound behavioural ef%cts in OCD patients but not in healthy controls. These changes included exacerbation of the OCD symptoms. This did not appear to be related to any anxiogenic effect of m-cpp. They also four~d that the anti-depressant drug, clomipramine, which has great serotonergic e"ffacts ~ was much more potent in alleviating OCD symptoms than deshnipramine, a non-serotonergie anti-depressant drug. Working with adolescent 0 C D patients, Flament, Rapoport, Murphy, Berg
OBSESSIVE COMPULSIVE DISORDERS
I8 5
and Lake (i987) found that clomipramine's t h e r a ~ u t i c activity was c l ~ e l y cerrelated with pre-treatment platelet serotonin concentration and monoamine-oxida~e activity, It was also correlated with the decrease of beth measures during clomipramme a~mm stratmm This, they concluded, s u ~ e s t s that c omlpmmmes serotonergic effects may be e~sentiN for its anti-obsessional activity. In addition, Btumenson and Berenhout (I985) have pointed out that many cases of OCD followed an epidemic of eneepha|itis at the beginning of the century, and OCD may result from degenerative lesions of the brain, uremia, and diabetes insipidus. In our own series of !4 children, two cases seemed to have an organic basis. One boy of ~o developed severe obsessive ruminations about whether or not he would "marry a nasty woman", following a cerebral bleed due to head trauma. T h r e e months later, he was completely recovered and has remained so after five years' follow-up, Another x3-year-old youngster developed very severe OCD soon after a mild case of m u m p s with bilateral paretitis but no meningeal signs. He too recovered ltmn eight weeks and is still doing well Iive years later. Prevalence OCD in childhood is a rare psychiatric illness that has been estimated to occur in at most I per cent of child psychiatric inpatients (Judd, I965) and only o-z per cent of child outpatiems (Ho!li orth et aL, ~98o). No cases of O C D were found among more. than ~ooo Io- and I x-year-Nds on the Isle of W (Rutter0 T i Whir ) ~97o). However, Freud (I916) cites six m eight years as the usual a ~ at which obsessive symptoms appear. K n n g l e n (I965) noted that one-half of his 91 adult patients ~ d become ill before age 20 and one-fifth of them become ill before age 2o (one-fifth of them b ~ o r e puberty). Rapaport et all (~98I) stated that o n e - t h i ~ of adult b e ~ n before age i 5 and the actual perce childhood onset may be much higher because many adult O C D patients relate that concealed their symp for years before social functioning deteriorated. In our own series ef cases from the a d d nt unit at Geha Hospital over six ieears (January I98o m Dec x985), we have seen ~4 cases out of a total intake of 496 patients, i.e., 2"8 per cent. In almost all cases, the diagnosis had been missed by the referring psychiatrist and we feel that the incidence of O C D among adolescents may be much higher than is generally realized. T e n of the 14 patients were misdiagnosed ~ being psychotic of schizophrenic, affective and oNanic etiology. Two were thought to be severely depressed and one oppositional. I n the latter ease, admission was due to school refusal which was later realized to be a severe case of "primary obsessional slowness".
I86
A, A
E R A N D S. T Y A N O
T a b l e I, Patient characteffstics
Case
No, x
Age at
Sex
re[erral
M
76
R umina-
Onset Checking Cleaning ~2
+
+
dons
Slown~s Severit~
+
+
3
z
F
13
9
+
+
+
-
3
3 4 5 6 7 8 9
M M M M F F F
13 ~z ~o xS ~fi 15 ~6
z~ i~ io Io 8 ~4 !a
+ + + + + +
+ + + + -
+ -+ + +
+ + + --
3 3 3 3 3 3 3
ro tr
M M
I6 x3
x2 ~I
+ +
+ -
+ +
+ -
3 3
I2 t3 ~4
F
r6
I4
~
~
~
+
3
M
r7
~5
-
+
+
-
3
M
t6
~4
-
+
+
+
3
* T i m e spent each day dominated b y s y m p t o m s : o ~ symptom free; J ~ less than ~ hour; 2 -~ i - 4 huurs; 3 "~ more than 4 hours.
M E T HO D A N D R E S U L T S
P~esentation a n d exanttnatton~ R a p a p o r t et aL ( i 9 8 i ) , i n a d e s c r i p t i o n o f n i n e cases of O C D aged i 3 - I 7, r e p o r t " t h e m o s t s t r i k i n g f e a t u r e of t h e s e eases was t h e severity o f p s y c h o p a t h o l o g y in t h e a b s e n c e of f o r m a l t h o u g h t d i s o r d e r . T h e s e p a t i e n t s ' ~ l a t e d n e ~ a n d Se n s l b l e d i s c u ~ i o n of t h e i r p r o b l e m s w a s i n a l m o s t eerie c o n t r a s t to t h e i r i n c a p a c i t y . R i t u a l s a n d o b ~ s i v e t h o u g h t s o c c u p i e d m o s t of t h e i r d a y a n d c a u s e d t h e m d i f f i c u l t y in m ~ t i n g a n y w a r d r o u t i n e " . Bolton, C o l l i n s a n d S t e i n b e r g (z983) d e l i n e a t e two m a i n k i n d s o f c o m p u l s i o n in c h i l d r e n : c h e c k i n g a n d c l e a n i n g . T h i s is in a c c o r d a n c e w i t h o u r o w n e x p e r i e n c e . C h e c k i n g i n c l u d e s " s a f e - m a k i n g " r i t u a l s b e f o r e g o i n g to bed. T a b l e z s h o w s t h e d i s t r i b u t i o n of s y m p t o m s in o u r o w n series (14 cases i n five y e a r s ) . T h e t a b l e is d e s i g n e d to be c o m p a r e d w i t h t h a t of Bolton et at., (1983) b u t i n c l u d e s a s e p a r a t e c o l u m n for p r i m a r y o b s e s s i o n a l s l o w n e s s ( R a c h m a n , x974) w h l c n was r e l a t i v e l y c o m m o n in o u r s a m p l e . T h e l a t t e r s y m p t o m is well k n o w n in its b e n i g n f o r m to t h e f a m i l i e s of m a n y h e a l t h y a d o l e s c e n t s ! H o w e v e r , in o u r p a t i e n t s , this was an e x t r e m e l y d e b i l i t a t i n g s y m p t o m w h e r e t h e p a t i e n t m a y h a v e taken several h o u r s to c o m p l e t e the m o s t s i m p l e tasks s u c h as w a s h i n g or dressing. T h e s l o w n e s s is p r i m a r y in
OBSESSIVE COMPOLSIVE DISORDERS
~87
that it is not secondary to obsessions or compulsions. T h i s symptom was so severe in one patient that retarded depression and even eatatonia were considered in the differential diagnosis. T e n of our 14 patients involved the family in their rituals. T h i s was often very extreme, causing much anguish to the family members. One rural girl forced her family to shower outside in the freezing cold to avoid contamination of the house. Another youngster forced his mother to spend hours r u b b i n g "imaginary" dirt off door knobs, whilst another forced his father to start every car journey from the beginning each time their car was overtaken from the left! In three cases, the adolescent hid his rituals from the family until he stopped functioning completely. One girl with a hysterical pre-morbld personality seemed to derive a great deal of satisfaction from publicizing her rituals dramatically. T h e obsessional ideas were often dramatic and bizarre. A x 3-year-old girl had an image of the Holy Being's penis which constantly intruded her mind. When her male therapist attempted a thought-stopping technique to alleviate the obsession, she then became obsessed with the image of the therapist's penis! Another felt that his eyes were being "destroyed" ~nd had to touch them continuously. Many of the adolescents were so perfectionistic that they could not do their school work for fear of making mistakes.
All the patients were described as healthy, well-functioning individuals before the onset of the disease, However, i r of the patients showed definite personality trends befor~ the onset of the illness. T w o girls definitely had histrionic traits, one had been quite schizoid and another very introverted. T w o of the boys were antis6cial in their behav[our prior to being hospitalized and four other boys tended to be compulsive. Case 3 had cyclothymic swings in his past. An interesting feature of the present sample was that eight of the z4 patients had a W I S C - R score of over ~3 o and all the others had above average
Severity at refet~'al As our group of O C D adolescents were atl in-patients, it is not surprising that they were severely ill, T h e y had all stopped going to school, were avoiding all social contacts and were in conflict with their families. T h e y all spent more than 5 ° per cent of the day involved in their rituals. All our patients were assessed on a structured psychiatric interview with the childhood disorders and schizophrenic (Kiddie-SADS), T h i s includes an assessment of functioning called the childhood version of the Global Assessment Scale (Kiddie-GAS). T h i s scale assesses severity on a zero to ioo
i88
A. APTER AND S. q ' YA NO T a b l e 2.
Case No.
Mother -
3
F~mity ~tho Father
Siblings
Paranoid personality disorder
4
Bipolar affeetive disorder Major depression
Alcoholism, organic brain syndrome
6
Borderline
7
g ~ v e aggresswe pc~ona|~ty disorder
urgamc oram syndrome
--
9
I tistrion~ pe~tmality disorder Dysthymia
-
-
m
Io zI lz 13
-
Paranoid p e ~ r | a H t y disorder ~
Dysthymia Compulsive personality disorder ~
Mental retardatmrJ ~pduet di~rder
I4
range with detailed explanations as to what each range of Io units implies. This scale has proved to be reliable in our hands (Apter and Tyano, i983). All our patients had scores of less than 4o on this rating, implying severe impairment. AII were Category 3 severity according to Bolton et aL ( r 9 8 3)~ m o r e than four h o u ~ a day dominated by symptoms. Marked family pathology was a feature of xo of the x4 eases, akhough there did not seem to be any diagnostic specificity (Table ~). AssocT;at2bn with otker psyc ~zatnc illnesses "Eating, sexual behaviour, gambling or drinking, when engaged in excess, may be referred to as "compulsive*'. However, in these cases, the individual derives pleasure from the actual behaviour and only wants to stop because of the sec~ndary deleterious consequences. Many clinicians regard O C D as a *~neur~is" and therefore erroneously as a mild condition. H er, severe O C D is n misdi osed as schizophrenia and obsessions and compulsions may ~ c u r transiently during the prodromal phase of schizophrenia. T h e y may also occur as part of Gitles de la Tourette syndrome.
OBSESSIVE COMPULSIVE DISORDERS
t8 9
A~fe ' azsoraer "' - N often associated wztt " OCD but the exact nature of this t ctive relationship is unclear. As with the patients of Rapaport et aL (I98~), our o w n series of eases showed a high incidence of depression ($" i x out of t4) Another patient on c]orimlpramine therapy developed mania which responded to withdrawal of the drug. All our patients showed negative dexamethasone uppressmn test results and their H 3 tmtpramme binding was no different from that of controls. DISCUSSION Although many authors feel that conventional insight-oriented therapy for ehl dren and adolescent ohsessives is not useful (Bolton e t a L , i983, Flament, Rapaport, Berg, Seeery and Kilts, I985), we have found this method quite rewarding with some of our patients. Anthony (i97i) has divided therapy of obsessional children and adolescents into four stages. Firstly, the child is encouraged to talk about his peculiar sym s whhout being mocked, criticized or punished. He can also express his r at the re~reussions his illness brings about in his home environment. Sec y, the patient attempts to use the therapist in the same way he u s ~ his mother, as a pa~ieipant in his ceremonials. When the therapist refuses, a stormy situation ensues. Then stage three comes about and the child's defenses become less inflexible. There is messiness and aggresslon~which can be very trying for parents! Lastly, frank oedipal wishes and thoughts begi9 to e m e r ~ and then treatment proceeds as for other neurotic children. Judd (I965) has also reported favouraMe results with psychotherapy for o sive ~uildren while Evans (x982) regards this as the treatment "of choice" for adolescents ~ t h th~ disorder. The fast decade has -witnessed great progress in the behavioural treatment of obsessive computsive disorder (Marks, i98i ; Steketee, Foa and Grayson,
~982). It is postulated that there is an evoking stimulus that triggers obsessions and these evoked responses can themselves become further evoking stimuli in * a V*ICROUS circle. When the patient is exposed to the evoking stimulus for a p~zlonged period of time, the response tualty subsides. Thus, treatment consists of s~rchLng for the situations " w h i c h compulsive rimals, and then pe~uading the patient to maintain contact w i ~ them until he or she b~ornes used to them. During exposure treatment, patients are usually instructed to refrain from rituals between treatment sessions (response prevention).
~9o A. APTER AND S. TYANO Steketee et al, (i98z) conclude that deliberate in vivo exposure in combination with response prevention is the most effective treatment for obsessive compulsive adults. The in vivo exposure mainly affects the anxiety/discomfort associated with cues for ritualizing whilst the response prevention primarily affects the compulsive behaviour. T ~ a t m e n t gains can be maintained by irnaginal exposure. This is especially so when the patient fears catastrophe (e~g., death, disease, house burning down) following exposure to the stimuli. When obsessive thoughts are present without rituals, the technique of thought-stopFdng is su ted. In this pro~dure, the patient is relaxed and is asked to think of the ire thought. The therapist shouts"stop!" to dispeI the thought and the patient is then taught m whisper and then m mnploy a subvocat command. The thoughts can a!so be stopped by shocking himself with a portable "shockbox" or strapping an elastic band against his wrist (Marks, x98I). The most extensive report of these techniques with adolescent patients is that of Bolt~n et aL (~983). Their first choice of treatment for out-patient work was self-imposed response prevention with self-monitoring of symtoms. In m~Jst cases, this was supplemented by engaging the parents in response prevention, either passively (by refusal to participate in the child's ritual) or actively by verbal or physical (in the ease of younger adolescents) restraint. Thus, work witt~ parents centered around buttressing the parents' authority and increasing their tolerance of the child's distress and hostility. This was facilitated by instruction and modelling, the setting of specific tasks in and out of the therapy, and the modification of invalid beliefs. In severe cases, the patient was hospitalized and staff-imposed external control of responses was instituted. In one case, the authors report the use of flooding, i.e., prolonged exposure to highly feared stimuli with complete or near-complete response prevention. Seven of their x5 patients were completely recovered after treatment and another six showed marked improvement. The problems encountered included: failure to engage the child's cooperation; too extensive a range and diversity of the compulsive behaviour substitution of the suppressed ritual by another; and concomitant conduct d~sorder. One patient who su from primary o ional stowness was t by prompting, pacing and partiNpant modelling. This pr mine of therapy was described in detail by Ctark, Surgrim and Bolmn (I98z). A[th treatment gains were initially pronnising) they were ~ot mair~xained on gradual fading of the intervention. For another detailed case r e ~ r t , the reader is re to that of G (~9~). n0.y, Flamentet al. (i985) published double-blind controlled s o[
O B S E S S ! VE C O M P U LSI VE D I S O R D E R S
r9r
clomipraminc on t 9 adoleseents (aged I ~ x S , mean x4 -+ z- 3 years) with OCD. They used a crossover design with each patient being his/her own control. Ttley concluded that the drug was effective in relieving obses~onai symptoms and that this action was quite specific: in contrast with obsessive symptoms, depression and anxiety did not change fignifieandy during the study, tn fact, these latter features were minimal from the outset. Significant improvement was seen a ~ r three weeks, as well as after five weeks on the drug, which is slightly quicker than the rate of amelioration reported %r adults. However, not alI the s u N e c u ~ n ~ i t e d from the drug and within the five-week tria}, most re ders did not recover fially, er, improvernent consisted of a decrea~d intensity of the .symptoms Mtiq thNr daily life. Rituals could be resisted without the occurrence of anxiety. Patients with rituals tended m respond lz~tter than those with obsessive thoughts. This finding is similar m that with behaviour therapy, but not to that of Insel et M. in adults on the effect of Clomipramine. T h e doses used were between Ioo and 2oo m # a y and art similar m those used in adults. Side effects were quite common) mainly the anticholinergic effects seen with tri~,clic antide nts. Integrated ospttat treatment of adolescents " ] expene ' n ee I"n the adolescent unit at The following represents the cunlca Geha Hospital over the last five years. This is a locked ward which seiwes the whole of I~rael. The indications for admission to this unit are based on severity of symptoms and inability to function, lrrespecuve of diagnosis, tn eihgenee, or medical condition (the unit is attached to a large genera| hospital), Most of the patients are ~dmitted after failure of prolonged outpatient, day or open ward treatment. The basle philosophy of the unit is a psychodynamic one. However, other treatment approaehe~biologicat, special education, family therapy and behavioural modification~are often integrated into the treatment plan. Discipline is firm, patients are encouraged to be neat and tidy and must participate in the ward school programme as well as in soci..~ and vocational activities. In addition to our routine comprehensive diagnostic work-up, all our patients were evaluated by the behaviour therapy clinic at Geha Hospital. However, in only three of t4 patients was it. ible to car~¢ out a systematic hehaviour therapy treatment plan because of the secretiveness and ~sistance m change by our adolescent p a t i e n t , ~ i s adolescent response to therapy was also described by Bolton et aL " t s ) r ~istanee. Our (t983). However, they were able to overcome their patten ""
xgz
A. APTER AND S. TYANO
failure to succeed may be due to the low staff-patient ratio on the ward and to lack of experience with behaviouml methods by a primarily psychodynamically oriented treatment team. In view of this, the patients were evaluated for psychotherapy according to an assessment of their ego strength and capacity for an in-depth relationship. On this basis, six eases were given intensive psyehodynamieatly oriented therapy and five cases suppom e and "educational" therapy. T h e former was given by staff psychologists or senior child psychiatry registrars, the latter by pediatric registrars on their s~x-month psychiatric rotation. I s consisted of frequent ~5- to 3o-minute sessions with the patient and his family~ Encouragement was given, and treatment options and rehabilitation po~ibilitie~ were discussed. T h e nature M present-day understanding of the illness was also given. A~I the patients had a rich antasy life (Judd, x965). Many of the girls were extremely concerned with masturbation and g~ilt over sexual i m p u l s e . One of the girls (Case No. 8) speeitically eonneeted the onset of her obsessive symptoms with the onset of masturbation. She felt that the rituals helped to ' T h e boys had frequent homosexua divert her thought from sin, . I impulses and were very anxious about these feelings. For both these urges seemed to ' be more obsessive in nature than a sign of significant gender i dentlty problems. The patients were often very hostile to one or both parents but felt very guilty about this. Eleven of the I4 patients had very strict and rigid moral codes. Six of the 14 patients received clorimipramine as an adjunctive therapy and four responded very well to the drug, In addition to the usual anticholinergic symptoms, one patient became manic and one bad an epileptic fit. All side-effects receded after withdrawal o( the drug. One boy who did not respond to clorimipramine and a trial of behaviour therapy did Ernprove with Apra'zolam (z- 5 rng/daily for six weeks). All of the patients on medication also received psychotherapy. CONCLUSION -I n our series, response to the has proved to be surprisingly good. EIeven out of ~4 patients were much improved withi~ three to four months of therapy and the other three patients also showed fair impro t. Th~se r~uIts are somewhat at odds with those reported in the literature. Holli rth et aL (I98O) found s out of io c still itt after follow-up, while Rapapo~ et aL (I98I) stated that 50 per cent of childhood and adolescent O C D remain chronic. Bolton e t a L (i 983) reported su in 3 of ~5 cases but attributed this sp ally m aviour therapy, which was la unsuccessful in our treatment p amine.
OBSESSIVE COMPULSIVE DISORDERS
r93
T h i s good prognosis may have several explanations. O C D in adolescence may be a cyclic disorder, and it is possible that a spontaneous remission dtte to the natural histor¢ of the disease is being witnessed. T h e milieu with its demands and standards may be an indirect form of response-prevention therapy. ( T h e lack of privacy in a fairly crowded ward also interfered with ritual performance). Lastly, our assessment was "sub,~ective" and did not use specific inventories (e.g. F i a m e n t et al.~ I985). Nevertheless, the ira.prove-m e a t of the patients was quite drmnatic in ~I of the patients and all have mMntained the i m p r o v e m e n t over a s~x, m o n t h to fly y e a r follow-up. REFERENCES
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