OCD; obsessive-compulsive disorder
Case in Point: Obsessive-Compulsive Disorder
A 4-year-old girl presented with “spinning” thoughts of about 2 weeks’ duration. The girl had initially been seen by her primary care provider, who had diagnosed her as having generalized anxiety and had initiated hydroxyzine 10 mg up to 4 times daily. She had responded well to the hydroxyzine, with some relief from the troublesome thoughts, but the therapeutic effects had lasted fewer than 6 hours. After 4 days, she was referred to a pediatrician.
Examination results revealed that the girl was troubled by persistent thoughts about trees falling on her (Figure) and had become afraid of leaving the house. She was fearful of going to school or into public places because she was afraid that she would shoot laser bolts from her eyes. In addition, when she saw someone wearing glasses, she became afraid that she would break them. Bedtime became difficult because she felt overwhelmed by the troubling thoughts and was afraid to sleep alone. She would cling to her parents at night in an attempt to transfer the thoughts to them. She had developed a coping mechanism of “pulling thoughts” from her mind with a gesture at her forehead, and throwing them to her father, whom she believed could better handle them. Although her appetite had not changed, she had become noticeably less active and more fatigued.
Her past medical and family history were noncontributory. She was a full-term infant with unremarkable growth and development. Her immunizations were current, and she had no antecedent illness prior to the emergence of the intrusive thoughts. Her parents described her previous demeanor as mildly anxious. She was the only child of married parents, and there was no report of emotional or social upheaval in the home. In a few months, she was due to start kindergarten and had been expressing some anxiety about the transition prior to the onset of her illness.
Physical examination results revealed that her vital signs were normal and her growth parameters were at the 75th percentile for height and the 70th percentile for weight. She was well groomed and well dressed. Her eye contact was good, but she appeared wary of the examiner. She frequently made a motion of pulling thoughts from her head to toss them to her dad, and she often whispered to her parents. The girl readily answered questions and was cooperative. The rest of the examination results were unremarkable.
Based on the girl’s behavior and intrusive thoughts, the pediatrician diagnosed her as having obsessive-compulsive disorder (OCD). She was subsequently prescribed fluoxetine 5 mg daily and began psychotherapy. Hydroxyzine was continued briefly as needed at bedtime. Over the course of several weeks, she was able to gradually return to school and normal functioning.
OCD is a disorder characterized by unwanted, intrusive thoughts coupled with repetitive, intensely driven behaviors performed in an effort to diminish the thoughts. Functional impairment must be present to make the diagnosis. The prevalence of OCD in pediatric patients is estimated to be 1% to 4%.1,2 More than half of adults with OCD experienced the onset of the disorder in childhood.1 Prior to puberty, the male-to-female ratio for OCD is approximately 3 to 2. After puberty the ratio shifts, and both sexes are equally affected, with a slightly higher rate among females.1