Obsessive-compulsive disorder in childhood: a behavioral approach to management.

Obsessive-compulsive disorder is characterized by obsessions or compulsions. Obsessions are unwanted and senseless thoughts, images, or impulses that occur repeatedly. Obsessions are experienced as unwanted and involuntary by the patient and can focus on such themes as contamination, aggression, orderliness, religion, sex:, doubt, or loss of possessions. Compulsions are ritualistic but seemingly purposeful behaviors that are often performed in response to an obsession. These compulsive behaviors, either observable or mental, alleviate or neutralize anxiety associated with the obsession. The patient fears the outcome should he or she not perform the ritual, despite the knowledge that the fear is irrational. Because the ritual does not entirely relieve the fear, the impulse to repeat the ritual returns. Common compulsive behaviors include hand-washing, checking, arranging, touching, repeating, or hoarding. Table 1 summarizes diagnostic criteria according to the American Psychiatric Association. l Obsessive-compulsive disorder occurs at some point during a lifetime in approximately 2.5 to 3 percent of the population; it is equally common in men as in women, and one-third of the cases begin by the age of 15 years.2 As with many other psychiatric illnesses, patients might not seek care until years after the onset of the disease. A variety of causes have been proposed: behavioral, developmental, biochemical, psychological, and genetic. Familial tendencies have been seen in obsessive-compulsive disorder. In one sample of children with obsessive-compulsive disorder, 71 percent had a parent with either full-blown obsessive-compulsive disotder or obsessive-compulsive symptoms.3 The symptoms of obsessive-compulsive disorder have also previously been viewed as extreme variants of normal developmental rituals