Handbook of Child

and Adolescent
Obsessive-Compulsive
Disorder
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Handbook of Child
and Adolescent
Obsessive-Compulsive
Disorder

Edited by

Eric A. Storch
Gary R. Geffken
Tanya K. Murphy
University of Florida

LAWRENCE ERLBAUM ASSOCIATES, PUBLISHERS

2007 Mahwah, New Jersey London
Copyright © 2007 by Lawrence Erlbaum Associates, Inc.
All rights reserved. No part of this book may be reproduced in any
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Lawrence Erlbaum Associates, Inc., Publishers

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Library of Congress Cataloging-in-Publication Data

Handbook of child and adolescent obsessive-compulsive disorder / [ed-

ited by] Eric A. Storch, Gary R. Geffken, and Tanya K. Murphy.
p. cm.
Includes bibliographical references and index.
ISBN 978-0-8058-5766-5 — 0-8058-5766-4 (cloth )
ISBN 978-0-8058-6254-6 — 0-8058-6254-4 (pbk.)
ISBN 1-4106-1600-5 — 1-4106-1600-2 (e book)
1. Obsessive-compulsive disorder in children—Treatment—Hand-
books, manuals, etc. 2. Obsessive-compulsive disorder in adoles-
cence—Treatment—Handbooks, manuals, etc. I. Storch, Eric A.
II. Geffken, Gary R. III. Murphy, Tanya.
[DNLM: 1. Obsessive-Compulsive Disorder—diagnosis. 2. Adolescent.
3. Child. 4. Obsessive-Compulsive Disorder—therapy. 5. Psycho-
therapy—methods. WM 176 C737 2007]
RJ506.O25C66 2007
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Books published by Lawrence Erlbaum Associates are printed on acid-

free paper, and their bindings are chosen for strength and durability.

Printed in the United States of America

10 9 8 7 6 5 4 3 2 1
EAS: For Jill, my dream come true.
 Contents

Foreword ix
Wayne Goodman

Preface xi

About the Editors xv

1 Obsessive-Compulsive Disorder: A Historical Overview 1

Pedro G. Alvarenga, Ana G. Hounie, Marcos T. Mercadante,
Euripedes C. Miguel, and Maria Conceição do Rosario

2 Obsessive-Compulsive Disorder in Children and Adolescents: 17

Diagnosis, Comorbidity, and Developmental Factors
Phoebe S. Moore, Amy Mariaskin, John March,
and Martin E. Franklin

3 Obsessive-Compulsive Spectrum Disorders 47

R. Douglas Shytle and Berney Wilkinson

4 Assessment of Pediatric Obsessive-Compulsive Disorder 67

Lisa J. Merlo, Eric A. Storch, Jennifer W. Adkins, Tanya K. Murphy,
and Gary R. Geffken

5 Psychological Theories of Obsessive-Compulsive Disorder 109

Jonathan S. Abramowitz, Steven Taylor, and Dean McKay

vii
viii CONTENTS

6 Neurobiology, Neuropsychology, and Neuroimaging of Child 131

and Adolescent Obsessive-Compulsive Disorder
David R. Rosenberg, Frank P. MacMaster, Yousha Mirza,
Phillip C. Easter, and Christian J. Buhagiar

7 Pediatric Autoimmune Neuropsychiatric Disorders Associated 163

with Streptococcal Infections
Michael J. Larson, Eric A. Storch, and Tanya K. Murphy

8 Genetics of Obsessive-Compulsive Disorder: Evidence 175

from Pediatric and Adult Studies
Paul Daniel Arnold and Margaret A. Richter

9 Cognitive-Behavioral Treatment of Pediatric Obsessive- 213

Compulsive Disorder
Eric A. Storch, Kelly O’Brien, Jennifer Adkins, Lisa J. Merlo,
Tayna K. Murphy, and Gary R. Geffken

10 Psychopharmacology of Pediatric Obsessive-Compulsive 243

Disorder
Daniel A. Geller

11 Clinical Challenges in the Treatment of Pediatric OCD 273

Kimberli R. H. Treadwell and David F. Tolin

12 Family-Based Treatment of Early Onset Obsessive- 295

Compulsive Disorder
Julia M. Berkman, Jennifer B. Freeman, Abbe M. Garcia,
and Henrietta L. Leonard

13 The Function of the Family in Childhood Obsessive- 313

Compulsive Disorder: Family Interactions and Accommodation
Lara J. Farrell and Paula M. Barrett

14 School Issues in Children With Obsessive-Compulsive 333

Disorder
Deborah Roth Ledley and Radhika V. Pasupuleti

15 Obsessive-Compulsive Disorder in the Primary Care Setting 351

David C. Rettew

Author Index 379

Subject Index 403

 Foreword

The past decades have witnessed numerous advances in the treatment of ob-
sessive-compulsive disorder (OCD). As happens with many conditions, the
literature on children has lagged behind that of adults. The editors of this
collection on pediatric OCD recognized the need for a new text on the topic
given advances in knowledge in many areas of research. With growing
awareness that childhood onset OCD is common and may represent a mean-
ingful subtype of OCD with unique management challenges, a volume dedi-
cated to the condition is justified and timely. Advances in efficacy of
psychopharmacological intervention in pediatric OCD and concerns about
side effect profiles of antidepressants in children and adolescents emerged
after publication of existing texts. Likewise, new information has emerged
from controlled trials with cognitive behavioral therapy (CBT). Given that
these are the two evidence-based treatments for OCD, this merits an up-
dated review.
In addition to treatment, we have also seen significant advances in the as-
sessment and neurobiology of pediatric OCD. Genetic, neuroimaging and
immunological advances are all included. This text exemplifies the highest
level of integration on evidence based healthcare for pediatric OCD and
captures the background of thought on OCD leading to this comprehensive
and in-depth integration of scientific discovery. Research relevant to the set-
tings of the family, school and primary care is covered in this text, as are OCD
spectrum disorders and comorbidities. This book meets the need to dissemi-
nate information to the international community of psychiatry, psychology,
neuroscience, family practice and pediatric medicine, nursing, and pedagogy.
Antiquated and outdated knowledge of pediatric OCD hinders the recogni-
tion of this condition and referral of those children suffering with this condi-
tion for appropriate treatment.

ix
x FOREWORD

Our understanding of OCD has grown exponentially in recent decades.

This area of scientific inquiry will continue to flourish. At this time, the edi-
tors of this book have developed the most comprehensive collection of writ-
ings by leading researchers. The book will undoubtedly guide researchers
and practitioners to formulate new questions that will further elucidate this
condition.

—Wayne Goodman, MD
Professor and Chairman
Department of Psychiatry, University of Florida
 Preface

As adults, we recall our childhood days of avoiding stepping on cracks so as

not to “break our mother’s back,” or insisting that our father check under
the bed every night to insure the absence of monsters. Repetitive play, super-
stitions, and ritualistic games are typical aspects of child development. How-
ever, practitioners are faced with the question of what to do when these
superstitious and ritualistic behaviors stop being normal and cross the line
into more clinically relevant, worrisome behavior.
Previously thought rare, obsessive-compulsive disorder (OCD) in chil-
dren and adolescents has been identified as one of the most common psychi-
atric illnesses affecting youth with point-prevalence rates of 1% to 4% of the
general youth population. Without clinical attention, OCD is associated
with significant social, academic, and familial impairment, and tends to per-
sist into adulthood.
Over the past two decades, practitioners have witnessed a great expansion
in understanding about the etiology, neurobiology, treatment, and assess-
ment of childhood OCD. For example, evidence from controlled trials has
accumulated suggesting that cognitive-behavioral therapy (CBT), with or
without medication, is the front-line treatment for pediatric OCD. Similarly,
tremendous advances in knowledge about pharmacological interventions
and mechanisms of action have been made. Yet, despite these significant ad-
vances, a compilation of the extant knowledge base does not exist. As a re-
sult, the dissemination of information about effective treatments, etiology,
and accurate assessment has been hindered greatly. Although several books
or chapters discuss the nature and treatment of pediatric OCD within the
context of a larger text that covers a broad range of childhood psychopathol-
ogy, these volumes generally do not cover in great depth many of the topics
that the present text covers. When conceptualizing this edited collection, we
included topics that span the spectrum of issues linked to childhood OCD in
xi
xii PREFACE

an effort to make this book applicable for a wide audience. With this in mind,
particular strengths of this work include the wide breadth of coverage and
utility for numerous disciplines, including psychiatrists, psychologists, social
workers, pediatricians, graduate students in mental health professions, and
other mental health professionals.
The chapters contained in this volume were designed to provide compre-
hensive, current reviews about the phenomenology, neurobiology, assess-
ment, and treatment of childhood OCD in a manner that captures the
complexities of this condition as well as uncovering areas in need of future
study. The text covers Diagnosis and Assessment, Etiology, Treatment, and
School and Family Issues.
Dr. Alvarenga and colleagues open the volume with a detailed history of
OCD, focusing on early perceptions of OCD, significant milestones in the
field, and future directions. In chapter 2, Dr. Moore and colleagues review
the epidemiology and phenomenology of pediatric OCD, with special atten-
tion to comorbid conditions commonly occurring in the context of OCD.
Drs. Douglas Shytle and Berney Wilkinson discuss psychiatric conditions
that are commonly found in youth with OCD in chapter 3. Dr. Lisa Merlo
and her colleagues provide an overview of recent advances in assessment in
chapter 4, including an introduction to several new assessment instruments
that are included in reproducible forms.
In Etiology, Dr. Jonathan Abramowitz and his colleagues (chap. 6) explore
psychological theories relevant to OCD and its etiology. In chapter 7, Dr.
Tanya Murphy and colleagues review the history, potential etiology, clinical
features, and currently accepted treatments for Pediatric Autoimmune
Neuropsychiatric Disorders Associated with Streptococcus (PANDAS). In
chapter 8, Drs. Paul Arnold and Margaret Richter provide a comprehensive
and critical review of the literature regarding the probabilistic genetic deter-
minants of OCD.
Dr. Eric Storch and his colleagues cover Treatment with a discussion of
the nature and application of cognitive-behavioral therapy. This chapter is
notable for its pragmatic nature and inclusion of reproducible handouts. Dr.
Daniel Geller provides a comprehensive review in chapter 10 of neuropsych-
iatric models of pediatric OCD and their relation to pharmacological man-
agement. Dr. Geller includes detailed information about medication
treatment of childhood OCD with particular attention to relevant outcome
data. In chapter 11, Drs. Kimberli Treadwell and David Tolin address clinical
challenges common to treating pediatric OCD patients, focusing on issues
such as noncompliance, comorbidity, and family issues. In chapter 12, Dr.
Julia Berkman and her colleagues present a model for the treatment of early-
onset OCD, highlighting the role of family members in intervention.
Finally, Family and School, addresses factors relevant to working with pe-
diatric patients. In chapter 13, Drs. Lara Farrell and Paula Barrett review the
literature on family interactions among OCD patients, highlighting the role
PREFACE xiii

of family factors in predicting treatment outcome and symptomatic relapse.

Dr. Deborah Ledley and Ms. Radhika Pasupuleti, in chapter 14, analyze the
problems youth with OCD routinely encounter in the school setting, such as
academic problems, stigma, isolation and peer victimization. A significant
strength of this chapter is the discussion of clinical strategies specific to the
school and recommendations to professionals on assisting families with
working with schools on education plans. Finally, in chapter 15, Dr. David
Rettew reviews guidelines for the assessment and treatment of OCD within a
primary care setting. Particularly innovative is the inclusion of an assessment
template that will enable primary care practitioners to identify and connect
patients with appropriate treatment approaches.
Each of the chapters within this volume contains a wealth of knowledge.
Perhaps the greatest contribution of this textbook, however, is the synergy
with which it addresses the complexity of childhood OCD and emphasizes
the elements inherent to the condition. As editors, it is our hope that the
reader is left to consider issues inherent to effective assessment and treat-
ment. It is crucial for health care professionals, both within and outside the
mental health profession, to collaborate in patient care and educate the
other about their field. With this in mind, our wish is that this text will serve
bridge disciplines and stimulate additional discussion and scholarship on
childhood OCD.
 About the Editors

Eric A. Storch, PhD, received his doctorate in Clinical Psychology from

Columbia University. He is currently an Assistant Professor in the Depart-
ments of Psychiatry and Pediatrics. Dr. Storch’s research interests are in
childhood and adult OCD, peer relationships, and measurement evaluation.
He has published more than 85 peer-reviewed papers focused on OCD, anxi-
ety disorders, and related topics, and made numerous presentations at pro-
fessional meetings. He is highly regarded in psychological treatment for
OCD, particularly with regards to treatment refractory cases. He also has a
special interest in the development and validation of OCD assessment mea-
sures.
Gary K. Geffken, PhD, is an Associate Professor of Clinical Psychology in
the Department of Psychiatry at the University of Florida Health Science
Center with additional academic appointments in Pediatrics, and Clinical
and Health Psychology. Dr. Geffken has special expertise in the psychological
treatment of Obsessive Compulsive Disorder. He directs the Cognitive-Be-
havioral Therapy Program of the Department of Psychiatry’s Treatment Pro-
gram for Refractory Obsessive-Compulsive Disorder. He has published
numerous scientific studies and chapters primarily on the psychological and
family issues of children.
Tanya K. Murphy, MD, is an Associate Professor in the Department of
Psychiatry at the University of Florida, Dr. Murphy is a board-certified child
psychiatrist who also holds a Master of Science in Clinical Investigation. She
is Director of the Pediatric Anxiety and Tic Disorder Clinic at the University
of Florida in Gainesville, Florida. Dr. Murphy’s current research efforts are
aimed at understanding the role of infections and immune dysfunction in the
onset of childhood psychiatric disorders. She is a member of the National

xv
xvi ABOUT THE EDITORS

Tourette Syndrome Association Medical Advisory Board and Regional Ob-

sessive-Compulsive Foundation Scientific Advisory Board. The author of
several book chapters and journal articles, she is also a reviewer for multiple
prestigious journals.
 1
Obsessive-Compulsive
Disorder: A Historical Overview

Pedro G. Alvarenga
Ana G. Hounie
Marcos T. Mercadante
Euripedes C. Miguel
Maria Conceição do Rosario
University of São Paulo Medical School

Obsessions have an intriguing connection with human beings. They can

develop from any thought, feeling, fear, or image and therefore can be pres-
ent in our daily expressions of art, love, science and religion. Obses-
sive-compulsive disorder (OCD) is sometimes called the disease of doubt:
Patients often doubt their thoughts, their senses, and their own beliefs
(Rosario-Campos et al., 2001). Very frequently, they end up feeling
trapped by the lack of certainty. OCD is also known as the disease of secrets
(Rosario-Campos, et al., 2001). Patients hide their symptoms for shame or
fear of being criticized. Some spend years looking for help, often without
success.
In general, psychiatric concepts have changed over time. The same has
happened with the definitions and knowledge related to OCD. For instance,
once thought to be a rare disorder, we currently know that OCD affects 1%
to 3% of the world population, independent of gender, religion or socioeco-
nomic status (Karno & Golding, 1991; Kessler et al., 2005). The main objec-
tive of this chapter is to give an overview of the history of OCD.

1
2 ALVARENGA ET AL.

INITIAL DESCRIPTIONS OF OCD

Ancient descriptions suggest that obsessive-compulsive (OC) symptoms

have been a matter of concern throughout human history. For example, to-
day what is called compulsive behavior could be represented by a metaphor
based on the ancient myth of Sisyphus. As a punishment from the gods in the
underworld, Sisyphus was compelled to roll a big stone up a steep hill; but be-
fore it reached the top of the hill the stone always rolled down, and Sisyphus
had to begin all over again. This cycle continued on and on for eternity. In
addition, OC symptom descriptions have been identified, quite consistently,
since the 17th century. At that time, obsessions and compulsions were often
described as symptoms of religious melancholy and sufferers were considered
to be possessed by outside forces (Jenike et al., 1998; Salzman & Thaler,
1981). The Malleus Maleficarum (“The Witch Hammer”), first published in
1486 by the Dominicans, contains what has been considered the first de-
scription of OCD (Shapiro, Shapiro, Young, & Feinberg, 1988). The Malleus
served as a guidebook during the Inquisition, helping the inquisitors in the
identification, prosecution, and dispatching of Witches (Del Porto, 1994;
Kramer & Sprenger, 1486/1991). In the 10th chapter of this guidebook, the
authors described how men can be obsessed by the devil and compelled to
act against their own thinking (Kramer & Sprenger, 1486/1991). In 1553,
Inácio de Loyola described his own “scruples” that forced him to give ex-
haustive confessions (Loyola, 1991). In his 1691 sermon on religious melan-
choly, John Moore, Bishop of Norwich, England, described a phenomena he
observed in people he referred to as obsessed individuals. He explained that
these individuals experience “naughty, and sometimes blasphemous
thoughts that start in their minds, while they are exercised in the worship of
God, despite all their endeavors to stifle and suppress them” (Mora, 1969,
pp. 163–174). Not surprisingly, the most popular treatment method at that
time was exorcism, which sometimes reportedly resulted in therapeutic ben-
efits (Krochmalik & Menzies, 2003).

EARLY PSYCHIATRIC DESCRIPTIONS OF OCD

IN EUROPEAN PSYCHIATRY

By the first half of the 19th century, along with other changes in medical
thinking, OCD shifted from the religious to the scientific field of enquiry.
Modern concepts of OCD began to evolve in Europe, when psychiatry was
strongly influenced by intellectual streams coursing through philosophy,
physiology, chemistry and other biological sciences (Del Porto, 1994). OC
symptoms were first considered to be a type of “insanity” or madness
(Berrios, 1995, pp. 3–13). Obsessions in which insight was preserved were
gradually distinguished from delusions, in which insight was not preserved.
Compulsions were also distinguished from impulsions, which included a
1. HISTORY OF OCD 3

great number of paroxysmal and stereotyped behaviors (Del Porto, 1994).

During that period of time, psychiatrists disagreed about whether the
grounds of OCD lay in disorders of the will, the emotions, or the intellect
(Berrios, 1995; Del Porto, 1994).
In 1838, Jean-Etienne Dominique Esquirol, the favorite student of Philippe
Pinel at the Salpêtrière Hospital, first described a psychiatric disorder quite
similar to the contemporary concept of OCD (the case report of “Mademoi-
selle F.”). He classified it as a form of monomania, a kind of partial insanity
(Esquirol, 1838). Esquirol moved between defining OCD as a disorder of the
intellect or the will (Esquirol, 1838). Pinel, along with his disciple, hypothe-
sized that the origins of this mental illness resided in the “passions of the soul”
and believed this “madness” did not fully and irremediably affect patient’s rea-
soning (Del Porto, 1994). Esquirol (1838) argued that, because his patients
were aware that their obsessions were irresistible, they possessed a certain de-
gree of insight, calling the obsessions “délire partiel” (partial delusions).
Across Europe, early medical descriptions, which correspond to contem-
porary definitions of OCD, focused on different aspects of the disorder. Eng-
lish psychiatrists emphasized the religious perspective and melancholic
features, whereas the French school identified loss of will and anxiety as the
principal symptoms of the disorder. Dagonet (1870, pp. 5–32, 215–259), for
example, considered compulsions as a form of “folie impulsive” (impulsive in-
sanity) in which violent and irresistible impulses overcame the subjects’ will
and were manifested through obsessions and compulsions. Magnan (1893,
pp. 109–426) described the “folie des dégénérés” (degenerative insanity),
indicating cerebral pathology due to defective heredity.
The emergence of the “neurosis” concept was first introduced by Cullen
in 1777, and further developed when Morel defined OCD as “délire émotif”
(delusion of the emotions), which he believed to be originated from a pathol-
ogy of the autonomic nervous system (Morel, 1866, pp. 385–402, 530–551).
Morel was the first author to place OCD among disorders of emotion due to
its anxiety component, reinforcing the “neurotic” aspects of the disorder. To-
wards the end of the 19th century, Legrand du Saulle, based on a clinical ob-
servational study, described OCD as “insanity with insight,” warning,
however, that psychotic symptoms could be present sometimes (Legrand du
Saulle, 1875). Moreover, other terms to define OCD throughout the 19th
century were employed by French psychiatrists: “Manie sans délire” (mania
without delusion); “folie raisonnante” (reasonable madness); “idée fixes” (un-
changeable ideas); “idée irresistible” (irresistible ideas); “délire de toucher”
(touching delusion); “délire avec conscience” (delusion with conscience); and
“folie de doute” (doubt insanity; Berrios, 1989, pp. 283–295, 1995; Del Porto,
1994).
Whereas the emotive and volitional aspects of OCD were emphasized in
France, German writers considered it, along with paranoia, as an intellectual
disorder and deemed irrational thoughts as neurological events with cogni-
4 ALVARENGA ET AL.

tive representation. In 1868, Griesenger published three cases of

“Grubelnsucht,” characterized as a ruminatory and questioning illness
(Bergener, 1987). Westphal (1878, pp, 734–750) ascribed obsessions to a dis-
ordered intellectual function and used the term “Zwangsvorstellung” (com-
pelled presentation or idea). In fact, Westphal was the first to describe OCD
as it is currently defined in the classification manuals, including integrity of
intelligence, absence of affective causal pathology, inability to suppress the
intrusive thoughts, and recognition of the bizarreness of the representations.
Interestingly, he also considered heritability as a prominent etiological factor.
In England, the term “Zwangsvorstellung’ was translated as “obsession,”
whereas in the United States it was translated as “compulsion.” The term
obsessive-compulsive emerged as an agreement between the two definitions
(Berrios, 1995; Del Porto, 1994).

JANET AND THE PSYCHASTHENIA CONCEPT

In the last quarter of the 19th century, there was a shift towards a more psy-
chological view of psychiatric disorders and the definition of OCD as “neur-
asthenia” emerged (Berrios, 1995; Laplanche & Pontallis, 2001). First
coined by George Miller Beard in 1869, the “neurasthenia” concept in-
cluded OC symptoms, as well as numerous other psychiatric symptoms such
as fatigue, anxiety, headache, impotence, neuralgia, and depression, among
others. It was explained as resulting from the exhaustion of the central ner-
vous system’s storage of energy attributed to civilization (Beard, 1869). In
the beginning of the 20th century, both Pierre Janet (1859–1947) and
Sigmund Freud (1856–1939) isolated OC symptoms from neurasthenia. In-
fluenced by Morel and Legrand du Saulle, Pierre Janet (1903) proposed that
obsessional patients possessed an abnormal personality, with features such as
anxiety, excessive worrying, lack of energy, and doubting. They described the
successful treatment of compulsions and rituals with techniques consistent
with the later development of behavior therapy (Pitman, 1987; Rachman &
Hodgson, 1980).
Based on a study of 325 patients (with obsessions, compulsions, tics, and
body dysmorphic features), Janet suggested that obsessions and compulsions
were primitive psychological operations derived from diverted nervous en-
ergy (Janet, 1903). Thus, in his classical work, “Les Obsessions et la Psychas-
thenie,” Janet proposed that obsessions and compulsions arise in the third
(final) stage of the psychasthenic illness and described the important role
played in the psychasthenic mental state by symptoms defined as “forced agita-
tions” separated into a mental group (obsessions), a motor group (tics) and an
emotional group (dysmorphophobia; Janet, 1903). This symptomatology is
very similar to the current descriptions of the obsessive-compulsive spectrum
(Stein & Hollander, 1995). The first stage of psychastenia would correspond to
what it is now called obsessive-compulsive personality disorder. The second
1. HISTORY OF OCD 5

stage (forced agitations) would be represented by some symptoms of the OC

spectrum disorders. Despite the relevance of this contribution for the under-
standing of the psychopathology of OCD, 100 years later, “Les Obsessions et la
Psychasthenie” has not been translated into English.

FREUD AND THE PSYCHOANALYTICAL

PERSPECTIVE

Sigmund Freud explored the human mind and developed his approach to
psychology as a comprehensive method and a therapeutic technique to treat
neurosis and other mental disorders. His idea that the mind works through
unconscious processes and that the main cause of neurosis is the repression
of painful memories sequestered from consciousness holds a central place in
psychology today (Laplanche & Pontallis, 2001). Different from the descrip-
tive work produced at his time, Freud was searching for ways of understand-
ing the etiology of the disorders he observed, and how the symptoms
evolved, in a similar way to the challenges faced by modern neuroscience.
In 1895, the term obsessive neurosis “Zwangsneurose”) was first mentioned
in Freud’s paper about “anxiety neurosis” (Freud, 1895/1976, pp. 83–85). In
his study, “Further Remarks on the Neuro-psychoses of Defense,” Freud pro-
posed a revolutionary theory for the existence of obsessional thinking in
which he defined obsessive ideas as “transformed self-reproaches that have
re-emerged from repression and that always relate to some sexual act that
was performed with pleasure in childhood” (Freud, 1896/1976, pp.
181–185). Freud developed a concept of obsessive neurosis that influenced
and then drew on his ideas of mental structure, mental energies, and defense
mechanisms. This concept included intellectualization and isolation (ward-
ing off the effects associated with the unacceptable ideas and impulses), un-
doing (carrying out compulsions to neutralize the offending ideas and
impulses) and reaction formation (adopting character traits exactly opposite
of the feared impulses; Laplanche & Pontallis, 2001).
A great proportion of Freud’s thinking about obsessive neurosis was for-
mulated in 1909 with his famous description of the case of “The rat man,” in
which Freud described the psychoanalytical treatment of a 29-year old man
who developed certain impulses (Zwangshandlung) against aggressive and
sexual obsessions since his early childhood. Later in his life, the patient came
across a senior military officer who conveyed a particularly sadistic method of
punishment that involved confining rats and placing them in the victim’s
anus (Freud, 1909/1976). At this moment, Freud’s patient reportedly started
obsessing that his dead father and a young lady he liked could have suffered
this type of torture. Although the patient expressed horror as he mentioned
it in his analysis, Freud interpreted it as one of “horror at pleasure of his own
desires, of which he himself was unaware.” The precipitating cause of this
man’s obsessions was never clearly identified by Freud or by the patient him-
6 ALVARENGA ET AL.

self, but Freud correlated them to the patient’s ambivalent feelings

(hate–love) about his father and his doubts concerning sexual orientation
(Del Porto, 1994). Later, in “Totem and Taboo,” Freud illustrated OC symp-
toms from social and anthropological perspectives, in which compulsions,
like primitive rituals, were assumed to be human efforts to magically modify
the external world and to prevent catastrophes (Freud, 1913/1976).
In 1926, Freud reformulated his theories about the origin of OC symp-
toms. Thus, in the article “Inhibition, Symptom, and Anxiety,” Freud postu-
lated that OC symptoms, as well as melancholia, derived from the ego’s fear
of the superego punishment (Freud, 1926/1976). Thus, contrary to his previ-
ous publications, Freud considered that obsessive-compulsive neurosis ex-
isted as a syndrome separated from the “anal-erotic” character, defined by
scrupulous, rigid and controlling traits of personality (Laplanche & Pontallis,
2001). Nevertheless, according to Freud, an “anal character” could predis-
pose to the development of OC symptoms, a description that brings up the
concept of a “continuum” between these disorders. These definitions have
some resemblance with the current differentiation between OCD (obses-
sional neurosis) and obsessive-compulsive personality disorder (Krochmalik
& Menzies, 2003).
All descriptions just discussed referred to adult patients. During that pe-
riod of time, there was a belief that obsessions could only be present in people
with a high degree of knowledge about themselves, and therefore could not
be present in children. Contrary to these ideas, a recent epidemiological
study reported that about half of the subjects interviewed met criteria for a
DSM–IV disorder sometime in their life, with first onset usually in childhood
or adolescence (Kessler et al., 2005). Most importantly, median age of onset
was much earlier for anxiety disorders, compared to the other disorders as-
sessed (Kessler et al., 2005). In the following, we present an overview of OCD
descriptions in children and adolescents through history.

DESCRIPTIONS OF EARLY-ONSET OCD

In 1903, Pierre Janet reported the case of a 5-year-old boy presenting with
“repetitive thoughts,” similar to “mental tics” (Leonard & Rapoport, 1991).
This is considered to be the first description of OCD in childhood. In his
book Obsessive Children, Adams described 49 children with OC symptoms,
highlighting the higher proportion of boys in his sample (39 boys and 10 girls;
Adams, 1973). In 1965, Skoog reported that “obsessive neurosis” started
earlier than most of the psychiatric problems. At least in his sample, 15.5% of
the patients had had the onset of the OC symptoms before the age of 19.
Among these, in 10% of the patients, the symptoms started before age 14
and for 6% of them the OC symptom onset was before age 10 (Skoog, 1965).
Until the 1980s, descriptions of OCD in children and adolescents were
rare and limited by small sample sizes. It was only in 1989 that the NIMH
1. HISTORY OF OCD 7

published the first longitudinal study of OCD children and adolescents using
specific diagnostic criteria defined by the DSM–III (American Psychological
Association [APA], 1980). They interviewed 5596 students from eight dif-
ferent schools and found prevalence rates of 0.4% (Flament et al., 1989).
The authors emphasized that the rates would probably be underestimated
because some of the more severe cases could not be attending school or could
be among the 557 students that did not return their questionnaires (Flament
et al., 1989). Zohar et al. (1992) reported, in Israeli adolescents, a prevalence
of 3.5% for OCD, including subclinical cases (Zohar et al., 1992). Valleni-
Basilie et al. (1994) found even higher prevalence rates with 3% meeting cri-
teria for OCD and 19% for the presence of OC symptoms. Another epidemi-
ological study of the prevalence of self-reported OCD at age 18 including 930
individuals found a 1-year prevalence rate of 4% (Douglass, Moffitt, Dar,
McGee, and Silva, 1995).
More recent studies of children and adolescents with OCD have also re-
ported, compared to adults, higher prevalence of OCD in boys, higher comor-
bidity with tic disorders, and higher rates of both OCD and tics among their
first-degree family members. For instance, Swedo, Rapoport, Leonard,
Lenane, and Cheslow (1989) described that 20% of the initial NIMH sample
developed tics, even though having tics was an exclusion criteria for partici-
pating in the study. The aforementioned clinical and epidemiological stud-
ies—which showed that OCD is, in fact, a common disorder affecting adults,
adolescents, and children from different countries, independent of race, reli-
gion or socioeconomical status—changed the history of OCD. Some other
heuristic changes in the history of OCD are presented in the following section.

DEVELOPMENT OF CLASSIFICATION MANUALS

Classification manuals were developed as an attempt to facilitate communi-

cation between clinicians and researchers, and also as a demand from insur-
ance companies and mental health systems. Even though some manuals,
such as the Research Diagnostic Criteria (RDC: Spitzer, Endicott, and Rob-
bins, 1978) already existed, it was only in 1980, with the publication of the
DSM–III (APA, 1980) that more precise meanings were introduced to ter-
minology. The DSM–III proposed categorical diagnoses, divided in discrete
mental disorders defined by observable criteria and with an atheoretical per-
spective to the validity of individual categories (Maser & Paterson, 2002).
With its operational criteria, greater reliability in diagnosis was achieved and
a significant number of studies on psychopathology were conducted. There-
fore, whereas the DSM–III was based largely on consensus among experts,
successive revisions had the benefit of an increasingly large empirical litera-
ture (Maser & Paterson, 2002).
The DSM–III and the newer versions, the DSM–III–R (APA, 1987), the
DSM–IV (APA, 1994), and the DSM–IV–TR (APA, 2000) became the most
8 ALVARENGA ET AL.

widely used classification manuals. Even though the International Classifica-

tion of Diseases, 10th Edition, (ICD–10), developed by the World Health Or-
ganization (WHO) is considered by physicians to be the official medical
classification system in most countries, the DSM–IV (Andrews, Slade, & Pe-
ters, 1999) and the DSM–IV–TR are more popular among mental health
professionals. This may be due to the influence of American psychiatry on
specialized journals for research publication. The influence of the
DSM–III–R has been so strong that even the WHO developed the ICD–10
based on the DSM system.
The classification of OCD is very similar across manuals. However, OCD
is classified in the DSM–IV–TR as an anxiety disorder, whereas in ICD–10 it
is a stand-alone disorder. For a definite OCD diagnosis, ICD–10 requires that
obsessional symptoms or compulsive acts (or both) must be present on most
days for at least 2 consecutive weeks and be a source of distress or interfer-
ence with activities. The obsessional symptoms should have the following
characteristics: (1) they must be recognized as the individual’s own thoughts
or impulses; (2) there must be at least one thought or act that is still resisted
unsuccessfully, even though other symptoms may be present that the sufferer
no longer resists; (3) the thought of carrying out the act must not in itself be
pleasurable; and (4) the thoughts, images, or impulses must be unpleasantly
repetitive (World Health Organization [WHO], 1992).
Both the DSM–IV and the DSM–IV–TR maintain that an individual
must experience a significant disturbance in normal functioning, or engage
in obsessive-compulsive activity for at least 1 hour per day, to be given a diag-
nosis of OCD. Further, the individual must recognize the irrationality of
thoughts and behaviors; though this criterion is not required for children and
adolescents (APA, 1994; 2000). A specification of poor insight may be added
to the diagnosis of OCD when an individual does not recognize that the ob-
sessions and compulsions are excessive or unreasonable (APA, 1994; 2000).
The DSM–IV and the DSM–IV–TR also incorporated the definition of
“mental rituals,” now described as a compulsion. Contrary to the DSM–III
(APA, 1980) and ICD–10 (WHO, 1992), the DSM–IV and the DSM–IV–
TR do not require the exclusion of other axis-I diagnoses such as Tourette’s
syndrome, schizophrenia, and mood disorders to the diagnosis of OCD
(Jenike et al., 1998). Additionally, in ICD–10 and previous DSM definitions,
a diagnosis of OCD implied that the individual could generally recognize
that his or her fears were irrational or unreasonable throughout the life of his
or her disorder. It was only in the DSM–IV that a “poor insight” subtype was
added in order to account for a number of individuals who appear to fail to
accept the senselessness of their OC symptoms (Marazziti et al., 2002).
In summary, it is possible to say that the development of the DSM has been
a landmark in psychiatry. Nevertheless, it has some shortcomings. For in-
stance, they have to meet the needs not only of the clinical and research
community but also the needs from insurance companies and welfare sys-
1. HISTORY OF OCD 9

tems. This creates complexity that could limit the acceptance of some im-
provements in the classification of patients, such as the use of a dimensional
perspective for diagnosis.

TREATMENT RESPONSE AND NEUROBIOLOGICAL

FINDINGS

Another landmark in the history of OCD was the demonstration of efficacy

of both behavior therapy and the serotonin re-uptake inhibitors in the treat-
ment of OCD patients. These reports gave clues to the neurobiological path-
ways involved in the etiology of OCD. For instance, in 1966, Meyer reported
the successful treatment of two OCD cases with behavioral therapy (Meyer,
1966). Since then, there have been numerous studies showing the efficacy of
both behavior therapy and cognitive-behavioral therapy in adults (Cordioli
et al., 2003; Foa et al., 2005; Marks, 1981) and also children and adolescents
(Barrett, Healy, & March, 2003; Barrett, Healy-Farrell, & March, 2004;
March et al., 2004; Piacentini, 1999) with OCD.
In 1967, intravenous clomipramine was reported to be successful in the
treatment of 10 to 15 OCD cases (Thoren et al., 1980). The efficacy and
specificity of serotoninergic antidepressants in the treatment of OC symp-
toms (Hollander, 1998; Pigott, Sheila, & Seay, 1999) and the evidence of ab-
normalities in platelet serotonin transporter (Sallee, Richman, Beach,
Sethuraman, & Nesbitt, 1996) reinforced the hypothesis that serotoninergic
pathways are implicated in the genesis of OC symptoms.
There is also a consistent body of information implicating specific
cortico-basal ganglia circuits in OCD. The primary source of this data is
neuroimaging studies, including functional neuroimaging studies. Baxter
(1992) proposed an interesting theory suggesting that OC symptoms derive
from dysfunction of the cerebral loops, originating, respectively, from the
orbitofrontal cortex (OFC) and anterior cingulated cortices, projecting into
the caudate nucleus and reaching the thalamic relay. More recent studies
have reinforced this theory. Aouizerate et al. (2004) reported increased ac-
tivity in the OFC bilaterally or in the right side, frequently associated with an
increased functional activity in the bilateral anterior cingulated cortices, the
bilateral or right head of the caudate nucleus and the bilateral or right
thalamus. Provocation tests using fMRI found bilateral activation of the
OFC, anterior cingulated cortices, caudate nucleus and amygdala (Breiter et
al., 1996). Studies with magnetic resonance spectroscopy found decreased
levels of the neuronal loss marker N-acetyl-aspartate in the cingulated gyrus,
right or left striatum and left and right thalamus in patients with OCD
(Aouizerate et al., 2004).
In the 1980s, clinical, genetic, treatment response, and neuroimaging
studies have demonstrated the association between at least a subgroup of
OCD patients and other childhood disorders, such as tic disorders and
10 ALVARENGA ET AL.

Sydenham’s chorea. This was a milestone in the history of OCD and was fol-
lowed by two lines of research. One of them investigated the association be-
tween OCD and tics and the other one tried to explore the immunological
hypothesis for OCD etiology.
The association between OCD and TS has been suggested since the origi-
nal descriptions of Gilles de la Tourette in 1885 (Tourette, 1885), and has
been reinforced by clinical (Miguel et al., 1997); genetic (Grados, Walkup, &
Walford, 2003; Leckman et al., 2003; Paul, Alsobrook, Goodman, Rasmus-
sen, & Leckman, 1995; Rosario-Campos et al., 2005); and treatment re-
sponse studies (Diniz et al., 2004). Interestingly, the link between
Sydenham’s chorea and tics had been described in the 19th century
(Kushner, 1998). Recently, environmental factors have been implicated in
the genesis of OCD. In the past 10 years, a group of prepubertal children with
abrupt onset of OCD and tics following infection by specific strains of
ß-hemolytic streptococci has been identified (Swedo et al., 1997). The asso-
ciation between streptococcal infection and these neuropsychiatric disor-
ders has been attributed to antibodies directed against invading bacteria that
cross-react with basal ganglia structures and other findings involving immu-
nological markers (Mercadante, 2001). Swedo and colleagues name this sub-
group of neuropsychiatric disorders with the acronym PANDAS (Pediatric
Autoimmune Neuropsychiatric Disorders Associated with Streptococcus;
Swedo et al., 1998). The validity of PANDAS as an independent entity has
been discussed. Although potentially promising for these highly selected
patients, active immunomodulatory therapies require further validation by
controlled double-blind protocols (Singer, 1999).
Regarding an evolutionary and ethologic perspective, contemporary re-
search has been correlating a variety of ritualistic and grooming behaviors in
animals with OCD and related disorders. Based on phenomenological as-
pects and pharmacological response, Rapoport, Ryland, and Kriete (1992)
proposed that canine acral lick dermatitis could be an animal model of OCD.
Furthermore, Leckman and Mayes (1994) considered some normal cogni-
tive, affiliative, grooming, and reproductive behaviors mediated by oxytocin
in rodents to contain elements that are similar to OC symptoms. Anecdotal
data and a recently completed cerebrospinal fluid study provided evidence
that some subtypes of OCD are related to oxitocin dysfunction. Based on
these findings, Leckman and Mayes (1994) hypothesized that preoccupa-
tions and behaviors associated with early phases of romantic love and early
parental love could be considered normal physiological behaviors bridging a
continuum with OCD.

CONCLUSIONS

The literature has come a long way since the initial descriptions of OC symp-
toms as a punishment by the Greek gods or as evil influences on the patient’s
1. HISTORY OF OCD 11

soul. Although the pathophysiology of OCD remains unknown, the ad-

vances in psychiatry and neuroscience have provided strong evidence for a
neurobiological basis of the disorder. Some of these advances include more
accurate epidemiological studies, the development of classification manuals
and the improvement in technology used in genetic, neuroimaging, and
treatment response studies.
Currently, OCD is viewed as a heterogeneous neuropsychiatric disorder,
with different clinical presentations reflecting possible different subtypes. In
the search for putative OCD genes, the more promising strategies have fo-
cused on early-onset OCD patients, OCD patients with tics, and also on spe-
cific OC symptom dimensions (Miguel et al., 2005; Rosario-Campos et al.,
2005). Another strategy to differentiate the OCD phenotype has been the
study of spectrum disorders associated with OCD.
Furthermore, it is important to note that even though research has
evolved considerably since the early descriptions of OCD, it is clear that we
will not be able to understand the mechanisms underlying OCD or to find
genes and etiological factors if we rely only on technological tools. Based on
the history of OCD, it is possible to optimize the power of the modern ap-
proaches, allowing us to more appropriately approach the current chal-
lenges. Similar to clinicians hundreds of years ago, we see value in observing
patients in a very comprehensive and exhaustive manner. Although our
technology has improved, we see the continuing importance of observing,
listening and taking care of the ones who have the disease.

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