Letters to the Editor
Early-Onset Obsessive–Compulsive Disorder
Dear Editor:
Studies have reported high prevalence rates (6-month prevalence of 0.5% to 1%) of obsessive–compulsive disorder (OCD) in children and adolescents (1). Although the childhood onset-age of OCD in most clinical samples has ranged from age 6 to 11 years (2), the disorder has been found in children as young as age 3 years. We report the case of patient with early-onset OCD who presented for psychiatric consultation many years after the onset of illness.
Case Report
Mr A, age 16 years, is a slow-to-warm-up high-school student from a middle socioeconomic background. He presented for the first time to the clinic with a 2½-year history of school refusal and irritability. On clarification, it was apparent that from a very young age (even before age 5 years) he was excessively concerned about dirt. He would avoid looking at the toilet, even while using it, take an abnormally long time washing his face (his clothes getting wet in the process) and bathing, and would not allow anyone to use his towels. He would also avoid using toilets outside his own house whenever he went on a trip. About 2½ years before presenting to the clinic, he also began to have obsessive images of a dirty bathroom and toilet. Further, he began to fear that he would forget lessons studied and, hence, fail to answer either in class or during examinations. Consequently, he avoided exams and refused to go to school. He also thought that people were talking about him on the road and had checking compulsions yielding to these obsessive doubts, fears that books given to friends might get lost, compulsive reassurance seeking, repeated intrusive ruminations about events during the day, and thoughts that he would be responsible for something bad happening. He was also found to have a history suggesting separation anxiety disorder of childhood, sibling rivalry, and oppositional tendencies, for which psychiatric consultation had not been sought. The family history suggested unspecified mental illness in his maternal grand-aunt and maternal uncle, possible depressive illness in his paternal great-grandmother, and subclinical obsessive–compulsive symptoms in his mother’s maternal uncle. Although he had poor insight and was uncooperative for treatment at the time of presentation, he started showing response to sertraline (up to 150 mg daily). Later, he started cooperating with exposure- and response-prevention therapy for his contamination obsessions and with audioexposure therapy for his obsessive fear of forgetting lessons learned. At the end of 4 weeks’ inpatient treatment, his obsessions and compulsions showed significant improvement.
This case highlights the fact that OCD may have onset at a very early age and is in keeping with the earlier findings of early onset being associated with male sex and positive family history (3). The long time-lag before this case actually presented to a psychiatrist indicates the need for increased awareness among professionals, especially because the illness arises at a developmentally important period.
References
1. Zohar A. The epidemiology of obsessive compulsive disorder in children and adolescents. Psychiatr Clin North Am 1999;8:445.
2. Piacentini J, Graae F. Childhood obsessive–compulsive disorder. In: Hollander E, Stein DJ, editors.
Obsessive–compulsive disorders: etiology, diagnosis, and treatment. New York: Marcel Dekker; 1997. p 23.
3. Swedo S, Rapoport J, Leonard H, Lenane M, Cheslow D. Obsessive–compulsive disorder in children and adolescents: clinical phenomenology of 70 consecutive cases. Arch Gen Psychiatry 1989;46:335.
Dr Sagnik Bhattacharyya, DPM, DNB, MD; Dr Girishchandra BG, DPM, DNB;
Dr Sumant Khanna, MD, MNAMS, MRCPsych, PhD
Bangalore, India
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