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Ola Omar Shahin
Department of Psychiatry, Cairo University Over the last decade studies conducted on children and adolescents with Obsessive- compulsive disorder (OCD) both in clinical setting and in the community shown that the specific features of OCD are essentially identical in children, adolescents and adults However, in children and adolescents the disorder is accompanied by a wide range of co morbidity, including mood disorder, anxiety disorder, learning difficulties and or tic disorder. In recent years body of data has supported the notion of an obsessive- compulsive spectrum disorder. Is based on similarities among disorders across several domains including symptomatology, associated clinical features possible etiology, familial transmission and response to selective pharmacological or behavioral treatment. Several approaches have been put forward each based on a rather different framework. Overlaps exist among these approach indicating that the neurobiology of OCD and related disorders is increasingly consolidated. (Int. J. Ch. Neuropsychiatry, 2004, 1(1): 1-20)
anxiety disorder learning difficulties and or on children and adolescents with obsessive- compulsive disorder (OCD) both in clinical, as a differential entity characterized with setting and in the community shown that the intrusive thoughts or repetitive behavior specific features of OCD are essentially; identical In children adolescents and adults It classical compulsive disorder The concept is is a disorder of heterogeneous origin with based on similarities among disorders across distressing, time consuming and functionally associated clinical features (age of onset, impairing It is frequently associated with clinical course and co morbidity) possible severe disruption to academic performance, etiology, familial transmission and response peer relation ship and family functioning.1 to selective pharmacological or behavioral However, in children and adolescents the disorder is accompanied by a wide range of have been put forward each based on a rather The International Journal of Child Neuropsychiatry Vol. 1 (1) - Sep. 2004 different framework. Overlaps exist among neurobiology of OCD and related disorders (hypochondriasis). Rituals may be in the picking) or driven forces of impulse control criteria for OCD are similar in children and (pathological gambling, sexual compulsions, in adults. Obsessive-compulsive disorder is addiction, borderline personality disorder). characterized by a range of obsessions that These common features suggest an overlap are defined as recurrent persistent thoughts, disturbing ideas, impulses and images as well control discords, somatoform disorders and intrusive and senseless repetitive behavior performed according to certain rules or in a consisted of 3 distinct symptom clusters; the stereotyped fashion that the person feel first cluster includes disorder of impulse driven to perform in response to obsessions, control (intermittent explosive disorder, gambling, Trichotillomania, paraphillias, demonstrated in one study that 30% to 50 % pleasure producing behavior irrespective to of OCD children have poor or little insight seeking behavior, defect in harm avoidance, likely to be focusing on contamination and cleaning. Rituals such as; washing, checking, repeating, touching, checking and counting are the most common in children. They are exaggerated preoccupation with appearance, not required to recognize that obsession or weight or body sensation as in the case body compulsions are excessive or unrealistic. dysmorphic disorders, eating disorders and Rituals in the form of washing, checking, repeating, touching, counting, are the most common in children who tend to change their disorder, Tourette's syndrome, Epilepsy and diagnostic symptom profile. It occurs in a disorders. The obsessions may be in the form phenomenological features, age of onset, and course of illness, co morbidity, family history dimorphic disorder) preoccupation with body and sometimes responsiveness to treatment sensation (depersonalization), preoccupation several disorders have been suggested to be prove to share common neurophysiological or biological substrates and possible related disorders in pediatric obsessive-compulsive youngsters. It makes the management more Co morbidity:
that co morbidity is the rule where as OCD as an only diagnosis is the exception in children and adolescence. The overall lifetime co disorders can be viewed along a-continuum morbidity has been shown to be as high as compulsive end and underestimation of harm have one or more additional axis I diagnosis. compulsivity include disorders like body dysmorphic disorder, anorexia nervosa and hypochondriasis. Disorders characterized by developmental disorders and enuresis .As substantial impulsivity, include; disorders of many as 1/3 lo 1/2 of children with OCD has impulse control such as Trichotillomania a current or past-history of another anxiety disorder. Overanxious and separation anxiety appear to be the most frequent in children. biological framework of hyperfrontality and Panic and generalized anxiety is the most increased Seretonergic sensitivity associated with compulsive disorder and hypofrontality sensitivity i.e. reduced activities of these deficit hyperactivity disorders, specific variables, on the impulsive group disorder.13 developmental disorders, anxiety disorders and Tourette's disorder, often occurring years compulsivity it is to decrease discomfort and Using the minimal exclusion criteria in a alleviate anxiety associated with rituals while in impulsivity it is to obtain gratification and morbidity was found in 69% of the sample. to illicit pleasure. Both may be present in the same individual and the common inability to disorder, 20% with mood disorder, 19% with inhibit or delay an action or a repetitive disorders in families of OCD children may few symptoms and minimal severity at one The International Journal of Child Neuropsychiatry Vol. 1 (1) - Sep. 2004 or even a spectrum of behavior. They code for proteins that are expressed in specific cells in specific brain region in a regionally predisposition to the specific behavior that gives the different variation in phenotypes. TS, OCD and ADHD could be related in this way to TS gene product in brain region. It neurobiological substrate which in turn is not phenomenological distinct and this in turn genetic factors and neurobiological factors have been cited as possible aetiological degree relatives of children and adolescents with trichotillomania. It appears that most youngsters with this condition do not have I. Genetic Factors and Family Studies:
found to be; highly correlated with body Janet thought it is likely that constitutional or high rate of mood disorder anxiety disorder, been cited as possible etiological factors in OCSDs. A genetic susceptibility for OCD is spectrum on the basis of high rates of OCD suggested by the familial links between OCD and Tourette's disorder. The family genetic suggested that, chronic multiple tics and II. Organic Factors
constitute different manifestations of the first suggested by, the association of OCD with the neurological insults and diseases. Clinical studies demonstrated the presence of an elevated level of either disorder reported adverse neurological and perinatal events in in 1/3 of first-degree relatives suggesting a bi-directional relationship. Also, prevalence trauma, cerebral hemorrhage encephalitis and multiple sclerosis have been reported.20 Numerous brain insults resulting in basal relatives of OCD, than among relatives of ganglia damage e.g. head injury, brain tumor, reported to be related to the onset of OCD. can produce a vastly different phenotype Patients with known basal ganglia illness genes. The genes do not code for a behavior selective Serotonine reuptake inhibitors (SSRIs). Considerable evidence implicates PANDAS: Perhaps the most exciting
Serotonergic dysfunction in the neurobiology work in the field of OCD is the relationship of obsessive propulsive spectrum disorders.23 (Neurological version of Rheumatic fever). role in compulsive and impulsive disorders. Compulsive disorders arc always associated symptoms is increased in pediatric patients with increased frontal lobe activity and with Sydenham's chorea. It is an autoimmune increased sensitivity of specific Serotonine receptor subsystem. In contrast, decreased misdirected antibodies from a streptococcal infection. A new syndrome termed Pediatric Autoimmune Neuro-psychiatric Disorder" measured by cerebrospinal fluid metabolite 5 subgrouping calling for immunomodulatory treatment. It is characterized by prepubertal onset of OCD, tic disorders, hyperactivity or vulnerability different from a late onset also show irregularities in 5HT function. Patients with compulsive impulsive disorders supported by the associated leucocyte marker is known to be related to rheumatic fever, response to 5HT agonist mCPP. Compulsive and detection of antineuronal antibodies disorders, such as, anorexia nervosa, OCD, D8/17 in peripheral blood. Several children and Tourette's disorder tend to report blunted prolactin response. They show dysphoria and was triggered by GABHS infection have fear of eating, as a prominent obsession reported, compulsive urges On the other hand patients stressing the associated severe loss of weight within a short period of time from the onset Trichotillomania,and pathological gamblers demonstrated increased prolactin response to proposal of OCD and anorexia as spectrum dysphoric response. The partial agonists mCPP has been reported to produce symptom III. Neurochemical Dysfunction:
abnormalities in OCD patients [Hollander et al., 1993]. Although these results are not always replicated, mCPP act as an agonists at followed the discovery of relative efficacy of 5HT1 receptor site, as an antagoinst at 5 HT3 The International Journal of Child Neuropsychiatry Vol. 1 (1) - Sep. 2004 and a mixed agonists and antagonist at 5HT2 evidence for dopaminergic dysfunction in receptor site. Platelet monoamine oxidase peripheral indicator of serotonin function was also lowered in impulsive disorders.13,8 clinical observation that neuroleptics such as HIAA overall or in subgroups of patients preferentially block central dopaminergic D2 responsive to 5HT reuptake blockers. Patients receptor, partially suppress tics in most with bulimia nervosa have been reported to patients where as dopaminergic agonist such have persistent disturbance of brain 5HT activity and frequently benefit from SRI Now, there are a whole host of childhood evidence is rapidly accumulating to suggest violent suicidal behavior have decreased levels of CSF 5HIAA. Patients successfully Autism, ADHD, and Tourette's disorder. The decreased 5 HT receptors in frontal region.7,8 striking differences in phenotypes suggest not seem to have a different dysregulation in only the importance of dopaminergic system to the normal conduct of, motor, cognitive differential response to SRI treatment (longer therapeutic lag and higher dose response in compulsive disorders and rapid response that tends to diminish with time in impulsive C) Glutametergic Neurotransmitters It is unlikely that the neurotransmitter, dysregutation can be attributed to just one compared to normal control. Following SSRI reduction in the basal ganglia may account glutametergic concentration in the caudate for elevated levels of presynaptic transporter, associated with reduction in OCD symptoms. decarboxylase that have been reported in Glutametergic Serotonine modulation may be Tourette's syndrome. Increased D2 receptor involved in the pathogenesis of OCD.27,28 level in Caudate nucleus may suggest the dopaminergic involvement. In a study using PET with tracer F18 flurodopa in Tourrette's disorder was associated with accumulation of structural neuroimaging in youngsters with caudate and right midbrain which provides studies revealed the existence of defects in the frontal orbital basal ganglia thalamus compulsive disorders, while hypofrontality control, with decreased volume of caudate hypermetabolism and right-sided abnormal increased size of genue of corpus callosum, decreased frontal glucose metabolic rate.13 striatal volume in pediatric OCD patients that anorexia nervosa showed an abnormal degree was negatively correlated with the severity of of temporal lobe asymmetry. This may reflect symptom It might be related to increased an underlying primary cerebral abnormality myelinization of fibers in that area. The basal in the limbic system that has clear connection ganglia appear to play a crucial role, through their extensive connection to sensorimotor hypothalamus. It links the disturbance to the cortical function, emotional response and ganglia abnormalities similar to finding ubiquitous repetitive activities and rituals that characterize the daily behavior of young either anorexia nervosa or bulimia nervosa exercise for serialization and categorization, revealed reduction of both total white and others serve to reduce anxiety by reinforcing object constancy at times of separation or ventricles and cortical sulci that are strongly related with weight loss. MRI also reported reduction in subcortical region mainly in size of thalamus and midbrain. This reduction is obsessive concerns about symmetry or order more in anorectic than in bulimic patient.30 and obsessive insistence on sameness are glucose metabolism in orbitofrontal cortex in persist beyond age 4 to 5 years they are adaptation and increased level of parental frontal region with decreased blood flow in obsessionality. In later childhood formalized games, hobbies and collections are common The International Journal of Child Neuropsychiatry Vol. 1 (1) - Sep. 2004 substituting permissible satisfaction for punishment and deprivation. The reason why they fail as adjustive techniques is that they offer transient tension- reaction. External therefore lends itself well to the general type boundaries of the disorder are permeable with a large degree of overlap with other of Hierarchical analysis suggested by Herbert psychiatric disorder and an association with through at least 3 conceptual frameworks. The 1st defines obsession in term of basic behavioral dimension of repetitiveness. This repetitive phenomena (e.g. preservation-tics) compulsions might be classified into one of and hence has high sensitivity. The 2nd level resistance, feelings of interference, slowness, prohibitions, precautions and expectations or indecision and paralysis. These increase the more positively; they may symbolically, and discriminating power of concept, but are not good enough to exclude clinical phenomena gratification of " Id " impulses.33 such as the forced thinking of epilepsy or the repetitious and transient compulsive behavior of brain-damaged patients. The 3rd level development related to anal - sadistic phase. includes criteria such as insightlessness, Normally the impulses associated with anal- prototypical contents involving violence, dirt, sadistic phases are modified in the Oedipal and succeeding stages of development. If sadistic impulses remain as components of Prevalence:
Ordinarily these impulses will be controlled and disguised by character traits and may not significantly affect the individual function in the ordinary course of daily living. They remain however as fixation points, which patients suggested that 30 to 50% of them may under certain circumstances give rise to childhood or adolescent Intrusive images 6%, repetitive actions 27%, urges to repeat 49%, combine to produce the clinical symptoms of distressing, Subclinical OCD in adolescents obsessive manifestations and symptoms in children attending psychiatric clinics, it was samples of children is generally lower than found that the most prevailing obsessions were contamination and self-injury and was children's ritualistic activity tends to be anxiety. The most common rituals were Hand washing, ordering, touching and counting.40 of bulimia nervosa as a clinical diagnosis in a community sample found it to be less than 1- prevalence rate of 4.1% in Newzeland with other psychiatric disorder in 75% to 84%. In reported by their parents to have tics31 The prevalence rate of juvenile OCD of 3% and a prevalence of body dysmorphic disorder is 0.1-1.0%. Co morbidity with OCD may be up samples meet full DSMIV criteria of OCD, The lifetime prevalence estimates of the other youngsters lend to have obsession and full syndrome of classical autistic disorder compulsions that tail to meet the criteria by are 2-5/10000. Symptoms typically present virtue or by being reporting symptoms that by the age of 3 and often begin in infancy.1 Age:
two years, but still there is an increase incidence in the teenage and early adult in adolescents, school students had a higher disorders usually have an age of onset in late adolescents or in the early twenties. There is a lag between the onset of illness and clinical 83.3% of OC positive symptoms were in 1st presentation. Thus, OCD appears to have a bimodal peak of incidence. Body dysmorphic family history of psychiatric illness had disorders often present in late adolescence to early twenties. Pica starts as early as 18-24 Aggressive obsession, contamination, and months and, declines sharply after 3 years of religious obsessions as well as cleaning, age. Anorexia usually starts as early as 8 years of age up to 30 years with bimodal compulsions were significantly higher in the peak at 13-14 and 17-18 years. Until recently, very few cases of bulimia below the age of 14 19.6 % of those with positive OC symptom years were reported, with rare cases under the with higher presentation in male group.14 The International Journal of Child Neuropsychiatry Vol. 1 (1) - Sep. 2004 Kleptomania. Males seem to predominate in the highest apparent prevalence in children between 7 and 11 years. The initial symptoms chondriasis4. It is not clear whether the of Tourette's disorder most frequently appear in pre-puberty from ages 5-10 years. Initially, neuroantomical or sociocultural Factors.13 they may resemble transient motor tics of Sex
psychiatric entities. Some of these disorders representation or a slight preponderance in Feeding and Eating Disorders
boys, pediatric clinical OCD patients show a male to female ratio of approximately 3:2. disorders belong to obsessive-compulsive Juvenile OCD subjects but still spectrum eating disorder patients may exhibit the full related disorders tend to differ with respect including; pathological doubt, symmetry and contamination worries repeating, checking sample of Egyptian students was found to he 1) Rumination
prevalent among the younger female students This rather rare condition is defined as in first-born subjects. Aggressive obsessions, fear of contamination, religious obsessions commonest among the sample. 19.6% of the subjects fulfilled the ICD criteria for OCD.14 children. The onset is usually within the expressed in both sexes. Females tend to pull their hair and injure themselves while males are more likely to explode, set fire and act development. It is relatively rare and is dysmorphic disorders, compulsive bings and in this group of patients characterization Is the compulsive eating of non-nutritive clinically and neurobiological. Anorexic obsessive thoughts recorded include fear 4) Bulimia nervosa
and nail biting this is to be interpreted as a distorted form of instinctual seeking of gratification and a defense against loss 3) Anorexia nervosa
intermittently or typically after the unset disturbed body image, obsessive fears of attempts to reduce weight via restricted relatively rare in children below 12 years pills or excessive exercise. In children, carried out secretly the onset of anorexia The International Journal of Child Neuropsychiatry Vol. 1 (1) - Sep. 2004 children, which shows either affection of girls and boys or a higher prevalence for Impulse Control Disorders
and the patterns of Serotonergic function characterized by impulsivity or aggression and lack of control. Affected individuals drive pleasure arousal and gratification from their impulsive behavior. Males and females can both express impulsivity but they do so in different ways. Males are more likely to gamble, explode and set lire. Females are 1. Trichotillomania (TTM)
that is characterized by an irresistible result in extensive disfiguring hair loss. Average age at onset is 10.6 years. Child in juvenile patient. Comorbid depression is often the treatment of choice for these 2- Onycophagia (Nail-Biting)
neurobiology. These include inability to inhibit repetitive ego dystonic behavior, and adults. It is usually an expression of manifestation, it is primarily a symptom of deep underlying disorder. It is usually To resolve this conflict, the patient bites his nails, thus denies his hostility, injure Behavioral therapy may help. It is shown 3. Temper Outbursts
Here the child works himself into a rage. Tic Disorders
The cluster of disorders included simple, and crying. It may be associated by, head transient or chronic motor or vocal tics It banging Il is a type of attention seeking also include complex moloi and vocal tic( originates from the basal ganglia. Those Tourette's Syndrome
4. Kleptomania
irresistible impulse to steal objects not disorders. It is a sudden motor stereotype compulsive phenomena. Evidence indicates that it is a chronic familial disorder with motor and vocal tics, which are defined as behavioral sequences5 30-40% of Tourette's Serotonergic transmission in the genesis Tourette's patients feel need to perform tics until they are completed or "Just right"19 The International Journal of Child Neuropsychiatry Vol. 1 (1) - Sep. 2004 abnormal sized of the basal ganglia on the left side and left putamen and reduction in autistic disorder is 2-5 per 10,000. The onset is typically by the age of 3 years The first probands Visual spatial dysfunction similar identifiable impairment is that of social skills to that found in OCD have been reported in that can be observed as early as 6 months of body movement and repetitive behavior seen innervations in caudate and striatum nucleus in autistic syndrome may be easily described have been strongly implicated in Tourette's as obsessive compulsive symptom but seems different in nature. Autistic children usually lack insight in their behavior. A high rate caudate appear to account for some of the plasma suggested an elevation of Serotonin symptom severity. The hyperinnervation by dopaminergic receptor would over determine level,was found to be, rated high on scales of phenomenology of TS related conditions as, anxiety, depression and OCD. Thus, blood recurrent obsessional thoughts compulsions Serotonin levels may be familial and possibly associated with genetic liability to specific which portion of the striatlal ,pallidal or Catecholamine and related metabolites and Serotonergic dysfunction is also suggested. an increase in dopamine metabolite HVA in associated with increased stereotype and than that in OCD patients without tics19. There is as well increased expression of symptoms associated with Tourette's but not significantly related to repetitive behavior in the tics themselves. However, neuroleptic autism. The involvement of high Serotonin addition to SSRI is helpful in treatment of level associated with repetitive behavior and autistic disorder in addition to the expression Pervasive Developmental Disorders
of ß cell cell autoimmune marker that was proved to be present in OCD proband with response to SRI, supports the classification It is a pervasive developmental disorder social deficits, speech and communication associated with hypoperfusion in the left dysfunction was suggested. Others stressed also found to be high in families of BDD. the impairment to be in right hemisphere This in addition to similarities in clinical dysfunction responsible for impairment in supports its clssification as an OCDSD.13 between OCD & BDD is in the ideational established for the treatment of autism. Some content of the obsessional symptoms where are used to treat the core symptoms, current the content in BDD reflects a sense of self as psychiatric disorder or associated medical disease. SSRI seem promising in improving global severity and dimensional deficits in feelings in BDD cause sense of shame and autism including; compulsive, obsessional symptoms, involuntary movements and some social and language deficits. They do not complex ideation content consistent with have the seizure or cardiac risks associated pharmacological, psychotherapy family and demonstrate over value ideas and delusional Somatoform Disorders
case reports and exploratory studies that SR blocker such as Clomipramine, Fluoxetine Body Dysmorphic Disorder (BDD :
and Fluvoxamine are superior to standard This disorder is characterized mainly by an excessive concern with imagined or over
Mood Disorders
valued defects in bodily appearance. Areas of concern focus primarily on the face and head with obsess ional ideas about committing but can also include feet hands and sexual suicide and ruminate a great deal about their body parts In juvenile patients, these somatic self-worth and love. Mood disorders with obsessions may represent the only symptom. It is more common in adolescents than in frequently in OCD patients and represent a pre-pubertal children and may present with therapeutic challenge. OCD patient treated preoccupation and dissatisfaction with hair- with SSRT can develop a clinical syndrome excessive mirror checking, repeated request dysphoric mood, aggression, reckless acts impulse dyscontrol and impaired insight. situations for fear of exposing the perceived When a depressive syndrome appears in an population and co morbidity with OCD may reach up to 38% Family history of OCD was The International Journal of Child Neuropsychiatry Vol. 1 (1) - Sep. 2004 Childhood Psychosis
pharmacological treatment of juvenile OCD with psychotic OCD have more severe form studies proved Serotonergic system to be of the illness and poorer treatment response specifically responsible for the wide range of compulsive patients. In addition, lower levels compulsive and impulsive disorders have a of functioning and worse long-term outcome baseline function in neurochemical substrate. Novel pharmacological approaches such as multiple targeted pharmacotherapies for each in childhood and mentioned that one of the OCSDs display a preferential response to forms is "Pseudoneurotic Syndrome" that SRIs and behavioral therapy nor epinephrine occurs in early or mid childhood. It is marked reuptake inhibitors on the other hand have not been effective. The OCSDs are less well obsessions, anxiety, phobias, stereotype movements and compulsive activities with boundaries. She also described a term called "Pseudopsychopathic Syndrome" that is seen BDD, hypochondriasis and anorexia nervosa in children of 10 years of age or older who may respond preferentially to SRIs. Because they stimulate the 5 HT activity, symptoms paranoid ideation, compulsive aggression and potentially dangerous behavior with little work to desensitize or down regulate 5 HT Epilepsy
disorders have a long lag period before they specific forms of epilepsy. Forced thinking respond to SRI however after the initial as a cognitive aura that may be experienced response it can be maintained through giving as a stereotypic out of context and irrational an adequate trial with high enough dose. thoughts, is to be distinguished from OCD Impulsive disorders have a quicker response to SRIs, but their response can decrease over time with continued treatment. Therefore, automatic writing. There is no clear evidence once the patient is initially stabilized13 that OCD is more prevalent in epileptics than occasionally serious problem that appears in pediatric subjects and may preclude SSRIs It appears that the heterogeneous pattern initially without concomitant addition of mood stabilizer or atypical neuroleptics. It is a dose related phenomenon and has a late were found to be equally effective to reduce onset (after 4 weeks). It appears that in OCD symptoms for children and adolescent as individual treatment for children with the symptoms it may cause behavioral inhibition disorder. It has also shown considerable success with certain OCSDs. The technique cause difficulties for the treated child11. For augmentation strategies may be considered. patients. This technique involves graduated neuroleptic if a tic or schiz-otypal personality simultaneous prevention of anxiety reducing involved in OCSDs, particularly those with provoking stimulus and no longer relies on simple motor symptoms, such as Tourette's syndrome or trichotillomania or those with psychotic features such as BDD or delusional identification of the behavioral antecedent OCD. Halloperidol and Pimozide have been and then substitution with a less problematic behavior has been reported to be effective in and its correlation with the development of using systematic desensitization, exposure antibodies reacting to neuronal tissue in basal ganglia generated greater interest both as; pharmacological and educational intervention implication of antibiotics for streptococcal infection, can affect OCD and Tourettes's refractory patients, neurosurgery may be streptolysin 0 titre (ASOT) or Anti-DNAs B- considered in addition to medication. Patient shared clinical features between the OCD and behavioral therapy has greater improvement behavioral therapy as the first treatment of adolescence is the rule. Single diagnosis is the exception. They may call for more work adolescents with mild or moderate OCD on children Yale-Brown obsessive compulsive childhood are characterized by the inclusion scale. The efficacy of individual CG family of developmental disorders together with therapy and group behavioral family therapy feeding and eating disorders, tic disorders, The International Journal of Child Neuropsychiatry Vol. 1 (1) - Sep. 2004 is needed for understanding of subtypting and childhood psychosis and organic disorder. more specific characterization of OCSDs. preservative pattern in early years of the abnormalities in the subcortical and fronto- disorder has lead to consideration of a broad temporal cortical regions with disturbed group of behavior in relation to OCD. It is neurocortical circuit connections in some of the spectrum disorders. Further research work is needed to elaborate its role in the genesis of development seem quite distinct from OCD, as these have no predictive behavior within a adolescents are needed to evaluate the effect of SRI and compare it with other medications for There are some other repetitive unwanted behavior of childhood onset that fall into the OCD spectrum crossing the current diagnostic Less rigorous data are available for the categories such as; TTM and Onycophagia, effect of other psychotherapeutic modalities in that may actually be variants of OCD but are OCSDs. Further studies are also needed to still not responsive to treatment profile unique psychotheraputic measures in the management Kleptomania have been suggested candidates for OCD spectrum with behavioral response to Pharmacological response to SRI suggests the role of 5HT in the etiology of OCSDs. Still, 1. Hollander E. and Rosen J. (2000): Obsessive some of the spectrum disorders have limited or compulsive spectrum disorders. A review. In Maji M., SartoriousN., Okasha A., ZoharJ. no response and need augmentation therapy (eds). Obsessive compulsive disorder. WPA series. Evidence and experience in psychiatry. neurotransmitters in the pathogenesis of OCD. 2. Brynsaka A, (1998): Obsessive compulsive disorder in children and adolescent; A literature review part II psychiatry, pol. Jan-Feb 32 (I): 3. Cardona X., Avila A. (2000): Obsessive chorea might be related to CNS autoimmune compulsive disorder and structural cerebral Alterations. Description of 3 cases. Neurologia concerning the effect of immunosuppressive treatment as well as the effect of long-acting 4. Stein DJ. (2000): Advances in neurobiology of obsessive compulsive disorder. Implication for neurobiological findings concerning the wide Psychiatric. Clin. North. Am J Sep. 23 (3) 545- range of all OCSDs are challenging. Family and genetic findings suggest that this spectrum 5. Diagnostic and Statistical Manual of Mental might be different phenotypic presentation of Disorder 4 Ed. (DSM-VI) (1994): American an underlying gene or genes. Further research psychiatric Association. Washington D.C. 6. Castellanos X.F. (1998): Tic disorder and 17. Paul Barrett , Larra Healthy-farrell and Johns psychopharmacology. Btimothy Walsh E.D.Am treatment of childhood OCD : A controlled trial J. of American academy of child & Adolescent 7. Cohen L.S., Simeon D.,Hollander E. and Stein 18. Bradley S'., Thomas P. (2000): Tourette's syndrome: what are we really imaging. In Ernst Diagnosis, Etiology, Treatment Marcel Deker M., Rumsey M.J., Coyle T.J. (eds.). Functional neuroimaging in child psychiatry Textbook. 8. Hollander E., DelGiudic Asch G.y Simon L., Shemidler J. et al., (J999): B Lymphocyte 19. Leonard H.L., Leanne M.C., Swedo S.E., antigen D8/17 and repetitive behaviors in (1992): Tic and Tourette's disorder. A 2-7 year 9. Flament F.M., Cohen D. (2000): Child and follow up study of 54 obsessive compulsive adolescent obsessive compulsive disorder. A children. Am. J. Psychiatry 149: 1244-1251. review; In Maj M., Sartorious N., Okasha A., 20. Swedo S.E., Leonard H.L., Mittlentan BB et al., Zohar J., lst ed. 2000. John Wileys sons LTD. (1997): Identification of children with pediatric 10. Flament M. and Cohen D. (1999): Comorbidity and spectrum disorder in childhood onset associated with streptococcal infections by a marker associated with rheumatic fever- Am. J. 11. Geller D., Biederman J., Grffin S. et al (1996): 21. Cohen L.S., Simeon D., Hollander E. and Stein Comorbidity of Juvenile obsessive compulsive J.D. (2000): Obsessive compulsive spectrum disorder. In Hollander H., Stein D (eds.) disorder with disruptive behaviour disorder. J- Obsessive compulsive disorders; Diagnosis, Am. Acad. Child Adolesc. Psychiatry 35: 1637- Etiology, Treatment Marcel Deker Inc. New 12. Reddy V.C., Ready P.S., Srinulh S., Khanna S., 22. Henrry C.M., Perlmuller J.J., Swede E.S. (1999): Anorexia OCD and streptococcus. J. Comorbidity in Juvenile obsessive compulsive Am. Acad. Child. Adolesc. Psychiatry. 38: 3 23. Eddy M.F. Walbroehl G.S. (1998): Recognition disorder. Am. Fam Physician Apr 1; 57(7) 24. Kaye W.H., Greene C.G., Moss H., et al. Diagnosis,Etiology. Treatment. Marcel Deker. (J998): Alteration in Seretonine activity and psychiatric symptoms after recovery of Bulimia 14. Okasha A, Ragheb K., Attia A.H. et al. (2001) : Prevelancc of obsessivecompulsive symptoms 25. Ernst M, Zametw J.A., Jons H.P. et al (1999): High presynaptic dopaminergic activity in children with Tourette's Disorder. J. Am. Acad. 15. March J, Frances A, Kah D et al (1997a) expert Child. Adolesc. Psychiatry January 38(1), 86- consensus guidelines: Treatment of obsessive – compulsive disorder. J clin psychiatry 58:1. 26. Ernst M., Zametzin A.J., Matochik J.A Johns 16. Dennis P., Cantwll S., Michael R. (1995): dopaininergic activity in ADI ID adults; a Adolescent psychiatry; Modem approaches, (l'luorine-18) Flurodopapositeron emission tomography study. 1. Neuro Sc: 18:5901-5907. The International Journal of Child Neuropsychiatry Vol. 1 (1) - Sep. 2004 27. Moore G.J., Mac Master P.P., Stewart C and 36. Berganza C-f., Cazall L, Gailan, Mezzich J, Rosenberg D.R. (1998): Caudate glutamatergic changes in paroxietine therapy to pediatric scale. Revista Latinoamerican de Psicologia. obsessive-compulsive disorder. J. Am. Acad. 37. Valleni -Basile L.A., Garrison CZ, Waller A, et 28. Rosenberg D.R., Mc Master F.P., Parrish J.K. al, (1996): Incidence of OCD in a community et al., (1998): 1-HMRS measurement of caudate sample of young adolescents. J. Am. Acad. paroxetine therapy for pediatric OCD. Ernst M., 38. Apter A, FaLLon T.L., King R.A., Ratzon, Rumsus M.J. and Coyle T.J (eds.). Functional neuroimaging in child Psychiatry Cambridge. compulsive characteristics. From symptom to 29. Giedd, J. Vaituzis A.C., Hamburger S.D. et al, (1996): Quantitative MRI of the temporal lobe 39. El-Rakhaway M. (1992): An Egyptian study amygdala and hippocampus in normal human development; Ages 4-18.J- Compar. Neuro, 30. Chowdhury U., Gordon. L., Lask B, (2000): graduate childhood studies. Department of Eating disorders in Ernst M., Rumyey MJ. And Coylc J. (ed.s.) Functional neuroimaging in 40. Hollander E. (1998): Treatment of obsessive Child Psychiatry. Cambridge University Press compulsive spectrum disorder with SSRI. Br. 31. Peterson &&, Riddle M.A, Cohen D.J., et ul., 41. Morialy J., Compos Costa D., Schmitz B., Tourette's syndrome using three dimensional (1995): Brain perfusion abnormalities in Gilles resonance images. Neurology, 43: 941-949. de la Tourret's syndrome. Br. J. Psychiatry 167, 32. Castle D.J., Groves A (2000): The internal and external boundaries of obsessive compulsive 42. Rose E.A., Porcerelli J.H, Neal A. K (2000): disorder. Aust NZ J. Psychiatry. April ; 34 (2); Board Fam. Pract. Sept.-Oct; 13 (5): 353-8. 33. Pronko N.H. (I966): Obsession- Compulsion. 43. Abdel-Rahman S. (1987): Childhood Neurosis Textbook of abnormal psychology. Williams & in "Essentials in Child Psychiatry" Pp. 189-198 44. Schmidt U., Hodes M, and Treason J. (1992): 34. Nemiach l.C., (1967): Psychoneurotic disorder Early onset anorexia nervosa who is at risk? depressive reaction. In "Freeman A.M., Kaplan 45. Stein D.J. Hollander E., Cohen L., Simeon A, H.I., (ed.)". Comprehensive textbook of Aronowitz R. (1995): Serotonergic resposivity psychiatry. Williams & Wilkins. Baltimore. in trichotillomania neuroendocrine effects of 35. Zohar A.H., Ratzosin G., Pauls D.L., el.al., m.chlorophenyl-perazin. Biolog. Psychiatry 37: (J992): An epidemiological study of obsessive compulsive disorder and related disorders in 46. Lepkifker E., Darmon P.N., Ziv R., Lancu I., Israeli. Adolescents. J. Am. Acad. Child. Horesh N., Koller M. (1999): The treatment of kleptomania with serotonin reuptake Inhibitors. Clinical Neuropharmacol Jan-Feb, 22 (1) 40-3.

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