Trastorno Obsesivo Compulsivo.pptx

1. Trastorno Obsesivo
Compulsivo
ADOLFO SÁNCHEZ ESCOBAR
RESIDENTE PSIQUIATRÍA

2. INTRODUCCIÓN
Obsesiones y/o compulsiones.
50 percent of all cases have their onset in childhood and adolescence
Diferencia entre niños y adultos: Evolución.
Pauls DL, Alsobrook JP 2nd, Goodman W, et al. A family study of obsessive-compulsive disorder. Am J Psychiatry
1995; 152:76.
Janowitz D, Grabe HJ, Ruhrmann S, et al. Early onset of obsessive-compulsive disorder and associated
comorbidity. Depress Anxiety 2009; 26:1012.

3. EPIDEMIOLOGÍA
Prevalencia a lo largo de la vida 1-3%
21 % of OCD cases had onset by age 10 years
Pediatric OCD Niños>Niñas
The cross national epidemiology of obsessive compulsive disorder. The Cross National Collaborative Group.Weissman MM, Bland RC, Canino GJ, Greenwald S, Hwu HG,
Lee CK, Newman SC, Oakley-Browne MA, Rubio-Stipec M, Wickramaratne PJ
J Clin Psychiatry. 1994 Mar; 55 Suppl():5-10
The epidemiology of obsessive-compulsive disorder in five US communities.Karno M, Golding JM, Sorenson SB, Burnam MA Arch Gen Psychiatry. 1988 Dec;
45(12):1094-9.
Eichstedt JA, Arnold SL. Childhood-onset obsessive-compulsive disorder: a tic-related subtype of OCD? Clin Psychol Rev 2001; 21:137.

4. Any psychiatric disorder, 63 to 97 percent
Mood disorder, 13 to 70 percent
Anxiety disorder, 13 to 70 percent
Disruptive behavior disorder, 3 to 57 percent
Tic disorder/Tourette’s syndrome, 13 to 26
percent
Speech/developmental disorders, 13 to 27
percent
Enuresis, 7 to 37 percent
Pervasive developmental disorder, 3 to 7 percent
Eating disorders, particularly in adolescents
Geller DA, Biederman J, Griffin S, et al. Comorbidity of juvenile obsessive-compulsive
disorder with disruptive behavior disorders. J Am Acad Child Adolesc Psychiatry
1996; 35:1637.
Geller D, Biederman J, Jones J, et al. Is juvenile obsessive-compulsive disorder a
developmental subtype of the disorder? A review of the pediatric literature. J Am
Acad Child Adolesc Psychiatry 1998; 37:420.
Geller DA, Biederman J, Jones J, et al. Obsessive-compulsive disorder in children and
adolescents: a review. Harv Rev Psychiatry 1998; 5:260.
Geller D, Petty C, Vivas F, et al. Examining the relationship between obsessive-
compulsive disorder and attention-deficit/hyperactivity disorder in children and
adolescents: a familial risk analysis. Biol Psychiatry 2007; 61:316.
Geller DA. The promise and challenge of obsessive-compulsive disorder research. Biol
Psychiatry 2007; 61:263.
Geller D, Petty C, Vivas F, et al. Further evidence for co-segregation between pediatric
obsessive compulsive disorder and attention deficit hyperactivity disorder: a
familial risk analysis. Biol Psychiatry 2007; 61:1388.
Sobin C, Blundell ML, Karayiorgou M. Phenotypic differences in early- and late-onset
obsessive-compulsive disorder. Compr Psychiatry 2000; 41:373.

5. PATOGÉNESIS
Etiología: Desconocida
Loop CSTC
Saxena S, Rauch SL. Functional neuroimaging and the neuroanatomy of
obsessive-compulsive disorder. Psychiatr Clin North Am. 2000;23:563–586.
Genetic risk
factors
Changes in
cellular function
Altered
neurotransmitter
signaling
Fronto-striatal-
thalamic
circuitry
Loop CSTC

6. Autosomal dominant or co-dominant model
The glutamate transporter SLC1A1 on chromosome 9 was implicated as a positional candidate
gene for pediatric OCD
Nestadt G, Lan T, Samuels J, et al. Complex segregation analysis provides compelling evidence for a major gene
underlying obsessive-compulsive disorder and for heterogeneity by sex. Am J Hum Genet 2000; 67:1611.
Willour VL, Yao Shugart Y, Samuels J, et al. Replication study supports evidence for linkage to 9p24 in obsessive-
compulsive disorder. Am J Hum Genet 2004; 75:508.

7. Subtipo Autoinmune
basal ganglia inflammation and resultant OCD, tic and/or ADHD symptoms
Swedo SE, Leonard HL, Mittleman BB, et al. Identification of children with pediatric
autoimmune neuropsychiatric disorders associated with streptococcal infections by a
marker associated with rheumatic fever. Am J Psychiatry 1997; 154:110

8. Complicaciones perinatales
Perinatal trauma is significantly higher in tic-related OCD
Drug exposure in utero has been found to predict increased severity of tic-related OCD
Pediatric OCD patients may also be more likely to have mothers who became ill during
pregnancy necessitating medical intervention
Lensi P, Cassano GB, Correddu G, et al. Obsessive-compulsive disorder. Familial-developmental history,
symptomatology, comorbidity and course with special reference to gender-related differences. Br J Psychiatry
1996; 169:101.
Mathews CA, Bimson B, Lowe TL, et al. Association between maternal smoking and increased symptom severity in
Tourette's syndrome. Am J Psychiatry 2006; 163:1066.
Geller DA, Wieland N, Carey K, et al. Perinatal factors affecting expression of obsessive compulsive disorder in children and
adolescents. J Child Adolesc Psychopharmacol 2008; 18:373.

10. Jonathan Tting,
GuopingFeng Neurobiology of obsessive–compulsive disorder: insights into
neural circuitry dysfunction through mouse genetics. Current Opinion in Neurobiology, Volume
21, Issue 6, December 2011, Pages 842-848.

12. Neuroimágenes
Reduced striatal gray matter
Increased anterior cingulate cortex gray matter
Psychotropic-naïve pediatric patients with OCD had larger thalamic
Amygdala volume ratios were increased
Kim JJ, Lee MC, Kim J, et al. Grey matter abnormalities in obsessive-compulsive disorder: statistical parametric
mapping of segmented magnetic resonance images. Br J Psychiatry 2001; 179:330.
Szeszko PR, MacMillan S, McMeniman M, et al. Brain structural abnormalities in psychotropic drug-naive pediatric
patients with obsessive-compulsive disorder. Am J Psychiatry 2004; 161:1049.
Gilbert AR, Moore GJ, Keshavan MS, et al. Decrease in thalamic volumes of pediatric patients with obsessive-
compulsive disorder who are taking paroxetine. Arch Gen Psychiatry 2000; 57:449.

13. Neuroquímica
Serotonin and key metabolites:
(N-acetyl-aspartate, choline, creatine/phosphocreatine, and glutamate)
Abudy A, Juven-Wetzler A, Sonnino R, Zohar J. Serotonin and beyond: a neurotransmitter perspective of OCD. In: O
bsessive Compulsive Disorder: Current Science and Clinical Practice, Zohar J (Ed), Wiley-Blackwell, Hoboken, N
J 2012. p.220.
Russell A, Cortese B, Lorch E, et al. Localized functional neurochemical marker abnormalities in dorsolateral
prefrontal cortex in pediatric obsessive-compulsive disorder. J Child Adolesc Psychopharmacol 2003; 13 Suppl
1:S31.
Rosenberg DR, MacMaster FP, Keshavan MS, et al. Decrease in caudate glutamatergic concentrations in pediatric
obsessive-compulsive disorder patients taking paroxetine. J Am Acad Child Adolesc Psychiatry 2000; 39:1096.

14. The core feature of compulsive-repetitive behavior is not unique to OCD. In fact, this feature is
central to an extensive group of broader neuropsychiatric disorders.
Search out common circuitry defects
40%
Chao HT, Chen H, Samaco RC, Xue M, Chahrour M, Yoo J, Neul JL, Gong S, Lu HC, Heintz N, et al. Dysfunction in GABA signalling mediates autism-like stereotypies and Rett
syndrome phenotypes. Nature. 2010;468:263–269

15. Leyfer OT, Folstein SE, Bacalman S, Davis NO, Dinh E, Morgan J, Tager-Flusberg H, Lainhart JE. Comorbid psychiatric
disorders in children with autism: interview development and rates of disorders. J Autism Dev Disord. 2006;36:849–
861

16. MANIFESTACIONES CLÍNICAS Y CURSO
The nature of obsessions and compulsions differ between youths and adults. Detecting
obsessions can be more difficult in children , compulsions can usually be observed.
Religious and sexual obsessions
Chan SW, Harmer CJ, Goodwin GM, Norbury R. Risk for depression is associated with neural biases in emotional
categorisation. Neuropsychologia 2008; 46:2896.
Geller DA, Biederman J, Faraone S, et al. Developmental aspects of obsessive compulsive disorder: findings in
children, adolescents, and adults. J Nerv Ment Dis 2001; 189:471.
Selles RR, Storch EA, Lewin AB. Variations in symptom prevalence and clinical correlates in younger versus older
youth with obsessive-compulsive disorder. Child Psychiatry Hum Dev 2014; 45:666.

17. Meta-analysis of 521 children/adolescents with OCD in 22 longitudinal studies found that, in 40
percent of cases, full OCD persisted (range = 1 to 15.6 years). in 60 percent of cases
subthreshold OCD symptoms persisted.
earlier age of onset of OCD, increased duration of illness, and inpatient OCD treatment were
associated with greater persistence of the disorder
The best studied, standardized scale is the Children’s Yale-Brown-Obsessive-Compulsive Scale
(CY-BOCS)
Stewart SE, Geller DA, Jenike M, et al. Long-term
outcome of pediatric obsessive-compulsive disorder: a
meta-analysis and qualitative review of the literature.
Acta Psychiatr Scand 2004; 110:4.
Scahill L, Riddle MA, McSwiggin-Hardin M, et al.
Children's Yale-Brown Obsessive Compulsive Scale:
reliability and validity. J Am Acad Child Adolesc Psychiatry
1997; 36:844.

18. DIAGNÓSTICO
A. Presence of obsessions, compulsions, or both:
•Obsessions as defined by:
-1. Recurrent and persistent thoughts, urges, or images that are experienced, at some time
during the disturbance, as intrusive and unwanted, and that in most individuals cause marked
anxiety or distress.
-2. The individual attempts to ignore or suppress such thoughts, urges, or images, or to
neutralize them with some other thought or action (ie, by performing a compulsion).

19. •Compulsions as defined by:
-1. Repetitive behaviors (eg, hand washing, ordering, checking) or mental acts (eg, praying,
counting, repeating words silently) that the individual feels driven to perform in response to an
obsession, or according to rules that must be applied rigidly.
-2. The behaviors or mental acts are aimed at preventing or reducing anxiety or distress or
preventing some dreaded event or situation; however, these behaviors or mental acts either are
not connected in a realistic way with what they are designed to neutralize or prevent, or are
clearly excessive.
•Note: Young children may not be able to articulate the aims of these behaviors or mental acts.

20. ●B. The obsessions or compulsions are time-consuming (eg, take more than 1 hour per day) or
cause clinically significant distress or impairment in social, occupational, or other important
areas of functioning.
●C. The obsessive-compulsive symptoms are not attributable to the physiological effects of a
substance (eg, a drug of abuse, a medication) or another medical condition.
●D. The disturbance is not better explained by the symptoms of another mental disorder

21. •Excessive worries, as in generalized anxiety disorder
•Preoccupation with a defect in appearance, as in body dysmorphic disorder
•Difficulty discarding or parting with possessions, as in hoarding disorder
•Hair pulling, as in trichotillomania (hair-pulling disorder)
•Skin picking, as in excoriation (skin-picking) disorder
•Stereotypies, as in stereotypic movement disorder
•Ritualized eating behavior, as in eating disorders
•Preoccupation with substances or gambling, as in substance-related and addictive disorders
•Preoccupation with having an illness, as in illness anxiety disorder
•Sexual urges or fantasies, as in paraphilic disorders
•Impulses, as in disruptive, impulse-control, and conduct disorders
•Guilty ruminations, as in major depressive disorder
•Thought insertion or delusional preoccupations, as in schizophrenia spectrum and other psychotic disorders
•Repetitive patterns of behavior, as in autism spectrum disorder

22. Consideraciones especiales
Normal development — It is imperative that normal developmental factors be ruled out. Certain
repetitive, ritualistic behaviors can be seen at certain stages of the child’s development. As
examples, children developing normally may be fascinated with symmetry or superstitions for
periods of time.
Early onset psychosis — Although patient insight into the unreal nature of his or her obsessions
can distinguish OCD from psychotic disorders in adults, this is not necessarily true in children.
The failure of treatment to respond to OCD treatment can be indicative of psychosis.
Autism spectrum disorders — Obsessive and compulsive behaviors can occur as part of autism
spectrum disorders. While OCD patients often experience their symptoms as ego-dystonic,
typically, the repetitive and stereotypic behaviors seen in autism spectrum disorders are not
found to be excessive or problematic

23. TRATAMIENTO
Leve – moderado : CBT
Severo : ISRS + CBT
Severo no hay CBT: ISRS
Pauls DL, Alsobrook JP 2nd, Goodman W, et al. A family study of obsessive-compulsive disorder. Am J Psychiatry
1995; 152:76.
Pediatric OCD Treatment Study (POTS) Team. Cognitive-behavior therapy, sertraline, and their combination for
children and adolescents with obsessive-compulsive disorder: the Pediatric OCD Treatment Study (POTS)
randomized controlled trial. JAMA 2004; 292:1969.

24. CBT
The program is delivered in five phases of treatment:
●Psychoeducation
●Cognitive training
●Mapping OCD
●Graded exposure and response prevention (ERP)
●Relapse prevention and generalization training

25. Clinical trial randomly assigned 96 youth (age 10 to 18 years) to receive CBT (12 sessions), brief
CBT (5 sessions) waitlisted
Patients in both treatment groups experienced reduced OCD symptoms compared to the control
group
Bolton D, Williams T, Perrin S, et al. Randomized controlled trial of full and brief cognitive-behaviour therapy
and wait-list for paediatric obsessive-compulsive disorder. J Child Psychol Psychiatry 2011; 52:1269.

26. No respuesta al inicio de CBT:
No significant differences were seen in outcomes between treatment groups. However, nearly half of
patients in each treatment group (50 percent for CBT, 45.4 percent for sertraline) experienced reduced
OCD symptoms.
Skarphedinsson G, Weidle B, Thomsen PH, et al. Continued cognitive-behavior therapy versus sertraline for children
and adolescents with obsessive-compulsive disorder that were non-responders to cognitive-behavior therapy: a
randomized controlled trial. Eur Child Adolesc Psychiatry 2015; 24:591.
clinical trial randomly assigned 54 youth (age 7 to 17 years) who failed to respond to an initial course
of CBT 14 sessions
receive either 10 additional CBT treatment sessions, or treatment with sertraline, over 16 weeks

27. Frecuencia y duración
14 hour-long sessions over a 12-week period in sessions with the child and one or more family
members
supplemented by ten-minute phone sessions most weeks
Barrett P, Healy-Farrell L, March JS. Cognitive-behavioral family treatment of childhood obsessive-compulsive
disorder: a controlled trial. J Am Acad Child Adolesc Psychiatry 2004; 43:46.
Himle JA, Rassi S, Haghighatgou H, et al. Group behavioral therapy of obsessive-compulsive disorder: seven vs.
twelve-week outcomes. Depress Anxiety 2001; 13:161.

28. Farmacoterapia
Eficacia demostrada en monoterapia:
SSRIs; fluoxetine, fluvoxamine, and sertraline & clomipramine
paroxetine, citalopram, or escitalopram: No tienen eficacia demostrada. Paroxetina sí, pero no
pueden haber síntomas depresivos comórbidos !! Ojo.
Geller DA, Wagner KD, Emslie G, et al. Paroxetine
treatment in children and adolescents with obsessive-
compulsive disorder: a randomized, multicenter,
double-blind, placebo-controlled trial. J Am Acad Child
Adolesc Psychiatry 2004; 43:1387.

29. Eficacia
A 2003 meta-analysis of 12 short-term clinical trials with a total of 1044 children and
adolescents with OCD found serotonergic antidepressants (SSRIs and clomipramine) to reduce
OCD symptoms compared to placebo 95% CI 0.37-0.55
Geller DA, Biederman J, Stewart SE, et al. Which SSRI? A
meta-analysis of pharmacotherapy trials in pediatric
obsessive-compulsive disorder. Am J Psychiatry 2003;
160:1919.
12-week clinical trial randomly assigned 187 children and adolescents aged 13 to 17 years
to receive sertraline (up to 200 mg/day) or placebo, (42 versus 26 percent)
March JS, Biederman J, Wolkow R, et al. Sertraline in
children and adolescents with obsessive-compulsive
disorder: a multicenter randomized controlled trial.
JAMA 1998; 280:1752.

30. Efectos Secundarios
Generalmente son bien tolerados en niños y adolescentes. Dosis dependiente.
headache
abdominal pain
nausea,
diarrhea
sleep changes
agitation.

31. Administración
SSRIs are typically initiated at a low dose (eg, the equivalent of 25 mg of sertraline) for the first
week and titrated up gradually (eg, every two to four weeks) to a therapeutic dose which is then
given a 12-week trial
If the clinical response is not adequate, subsequent gradual adjustments, six to twelve weeks
For treatment refractory pediatric OCD
●SSRI
●A second SSRI
●Augmentation of serotonergic reuptake inhibitor (SRI)
with atypical antipsychotic
●Combination of SSRI and clomipramine

32. Clomipramina VS ISRS
Although available research in children suggests that clomipramine is more efficacious than
SSRIs in pediatric OCD, SSRIs are the preferred treatment because they are better tolerated and
safer than clomipramine.
Prior to taking clomipramine, children/adolescents should be screened for cardiovascular illness
and an EKG should be obtained
Typically started at 25 mg/day for 1 to 2 weeks. If the patient experiences an inadequate
response, the dose can be increased at two-week intervals in increments of 25 mg/day to a
maximum of 200 mg/day
Sánchez-Meca J, Rosa-Alcázar AI, Iniesta-Sepúlveda M, Rosa-Alcázar A. Differential efficacy of cognitive-
behavioral therapy and pharmacological treatments for pediatric obsessive-compulsive disorder: a meta-
analysis. J Anxiety Disord 2014; 28:31.

33. Clomipramina & ISRS
therapeutic effects of clomipramine may be improved and adverse effects reduced with the
addition of a low dose of a selective serotonin reuptake inhibitor (SSRI) (eg, 10 to
20 mg/day of fluoxetine).
When using clomipramine, patients should avoid grapefruit and grapefruit juice, which can raise
the mean plasma concentration of clomipramine .
Cuidado con Sd serotoninérgico.
Simeon JG, Thatte S, Wiggins D. Treatment of adolescent obsessive-compulsive disorder with a clomipramine-
fluoxetine combination. Psychopharmacol Bull 1990; 26:285.
Figueroa Y, Rosenberg DR, Birmaher B, Keshavan MS. Combination treatment with clomipramine and selective
serotonin reuptake inhibitors for obsessive-compulsive disorder in children and adolescents. J Child Adolesc
Psychopharmacol 1998; 8:61.
Vandel P, Regina W, Reix I, et al. [Grapefruit juice as a contraindication? An approach in psychiatry]. Encephale 1999;
25:67.

34. Antagonistas D2
Risperidone can be initiated at 0.25 mg/day and increased weekly in 0.25 mg increments to a
maximum of 1.5 to 2 mg/day. ONE MONTH TRIAL
Youth treated with atypical antipsychotics are vulnerable to serious metabolic side effects.
Children, especially pre-adolescents, are more sensitive to side effects than other patients,
particularly to weight gain, diabetes, carbohydrate abnormalities
Fitzgerald KD, Stewart CM, Tawile V, Rosenberg DR.
Risperidone augmentation of serotonin reuptake
inhibitor treatment of pediatric obsessive compulsive
disorder. J Child Adolesc Psychopharmacol 1999;
9:115.
Pharmacotherapy of Child and Adolescent Psychiatric Dis
orders, 3rd ed., Rosenberg DR, Gershon S (Eds), Wile
y-Blackwell, United Kingdom 2012.
Entonces Haloperidol?

35. Otros
Negative results have been in trials of other augmentation strategies in treatment of pediatric
OCD:
●Lithium augmentation of SSRI and clomipramine
●Buspirone augmentation of SSRIs
●Thyroid-hormone augmentation of clomipramine

36. Copyrights apply

37. Gracias