~oumnlofAdolescence
1990, 13, 157-169
Adolescents with obsessive-compulsive disorder: a case note review of consecutive patients referred to a provincial regional adolescent psychiatry unit MARK
ALLSOPP*
AND
CHRISSIE
VERDUYNt
A number of clinical descriptions of Obsessive-Compulsive Disorder (OCD) in adolescence are available but are often of small numbers of cases with highly selective recruitment methods. We describe the findings of a systematic case note review of 44 consecutive OCD patients referred to Oxford Regional Adolescent Unit between 1974 and 1984. The relative frequencies of previously described features of the condition in this age group are presented. Many patients had problems with peer relationships and social isolation, which often preceded the onset of other symptoms by many years. The management of the cases and outcome at discharge are outlined.
INTRODUCTION
The importance of the adolescent years in relation to the onset and development of Obsessive-Compulsive Disorder (OCD) has long been recognized. Black (1974) reviewing data from eight large-scale studies of adult patients found that the highest incidence of first symptoms occurred between the ages of 10 and 15 years, by which age the illness had started in approximately onethird of cases. Onset before the age of 20 years was found in at least 50 per cent of adult cases by Pollitt (1957) and Kringlen (1965). Flament et al. (1988) found a minimum point of prevalence of 0.35 per cent in screening a general school population of adolescents. Treatment had been sought for only onefifth of the cases they identified. There are a number of previous descriptions of adolescents with OCD presenting clinically. Adams (1973) included a number of adolescents in his large series of children with the disorder. Forster and Holthausen (1979) described ten adolescent cases treated as in-patients. They drew attention to the low frequency of resistance to OCD symptoms, the relatively low rates of
*Reprint requests should be addressed to Mark Allsopp, Senior Registrar in Child and Adolescent Psychiatry, The Park Hospital for Children, Old Road, Headington, Oxford. t Principal Clinical Psychologist, Bolton General Hospital, Farnworth, Bolton BL4 OJR. 0140-1971/90/020157 + 13 $03.00/O
0
1990 The Association for the Psychiatric Study of Adolescents
158
M. ALLSOPP
AND C. VERDUYN
pronounced affective symptoms, and ubiquity of involvement of family members in symptomatology in these cases, pointing out that this differs from the clinical picture characteristically seen in adults. Rapoport et al. (1981) described nine cases compared with controls on a battery of neurophysioin EEG sleep studies, logical and neuropsychological tests. Differences dichotic listening, and two-flash threshold were found but the significance of these is unclear. Most recently Swedo et al. (1989) have reported findings on 70 children and adolescents consecutively referred to their clinic at the National Institute of Mental Health U.S.A. They take an ethological perspective in reporting the similarity in the content of OCD symptoms between childhood patients and those presenting as adults. There are also several follow-up studies of children and adolescents with this disorder, e.g. Warren, (1965) ; Hollingsworth, Tanguay, Grossman and Pabst (1980) ; Allsopp and Verduyn, (1989). These suggest that in at least 50 per cent symptoms persist into adult life and provide evidence of continuing disruption of psychosocial adjustment. The use of behavioural response prevention techniques as described by Rachman and Hodgson (1980) with adolescent OCD patients has been reported in a number of individual case reports (e.g. Hallam, 1974; Green, 1980). These techniques involve persuading patients to refrain from carrying out rituals. Initially this causes an increase in distress and anxiety which is contained using a variety of behavioural and cognitive management techniques. With persistence, however, both rituals and distress diminish to the point where the patient can be encouraged to practise control in situations which had previously caused exacerbation. As described by Levy and Meyer (1971)th e t ec h m‘q ue required intensive and continuous supervision but more recently this has been found to be unnecessary except in the most severe cases. Bolton, Collins and Steinberg (1983) d escribed a series of 15 adolescent inpatients treated in this way. Six showed complete remission with behavioural response prevention and a further three showed a significant improvement in symptoms so that 60 per cent of the series gained some benefit. Steinberg (1983), however, described a number of difficulties in the use of behavioural response prevention techniques in the adolescent age group. Patients are often very secretive. Resistance to symptoms often being absent or fluctuating, compliance may be poor or variable. General adjustment difficulties towards adult figures may increase the problems of supervision and control of the treatment programme. This, together with the tendency to involve family members in symptomatology, may make it hard to obtain the full co-operation of parents. Conduct disorder may co-exist as described in two cases by Bolton and Turner (1984). S ometimes symptoms may not be in evidence away from the home setting. Many of these problems were evident in a series described by Apter, Bernhout and Tyano (1984) of eight in-patients for whom behav-
OBSESSIVE
COMPULSIVE
DISORDER
159
ioural programmes had to be abandoned. Other treatment outcome studies include the report by Flament et al. (1985) of the successful use of the antidepressant drug clomipramine with a series of 19 patients age 10 to 18, and that of Apter and Tyano (1988), concerning the use of psychodynamic or supportive psychotherapy for 11 adolescent in-patients some of whom also received clomipramine. While the clinical features and management difficulties characteristic of OCD in adolescence are described, their relative frequency is not clear as studies often involve small numbers of cases with considerable selectivity. The aim of the present study was to describe, retrospectively, the characteristics of consecutive cases referred to a provincial Regional Adolescent Unit in England over the period of 11 years. It was hoped in this way to obtain a series of sufficient size to estimate the frequency of clinical features while limiting selectivity to that of a secondary referral centre. As the treatment method of choice throughout the period of the study was a programme of response prevention techniques combined when possible with family work it was anticipated that some estimate of the frequency of difficulties with this treatment method could also be obtained.
METHOD
The review was undertaken on all cases referred to Highfield Family and Adolescent Unit, Oxford between and including the years 1974 and 1984. Prior to 1974 unit records were incomplete. Some patients referred after 1984 were still in treatment at the unit at the time of the review. All patients coded as ICD 9:300.3 (Obsessive Compulsive Neurosis) on discharge were identified using the computer records of The Oxford Data Linkage Project, Unit of Clinical Epidemiology, Oxford. The reliability of this information was tested by a cross-check with unit records over a 4 year period with 100 per cent case identification. Discharge summaries were examined on all those identified (N = 52). Those cases who had a summary diagnosis of ObsessionalCompulsive Disorder or Neurosis were included (N = 40). The case notes of the remainder together with those of seven patients who were coded on discharge as Anakastic Personality Disorder (ICD 9 :301.4) during the study period were examined. Of these four cases who conformed to the criteria set out by Judd (1965) o f a well defined constellation of obsessive-compulsive symptoms [following the description of adult cases by Stern and Cobb (1978)], without symptoms of other major psychiatric disorder and severe enough to interfere with general functioning were included. The clinical notes of each of the 44 identified cases were examined systematically for information relating to demographic variables, symptomatology, family, management and short term outcome.
160
M. ALLSOPP
AND
C. VERDUYN
FINDINGS
General During the 11 year period of the study 44 cases of OCD were seen representing 1.3 per cent of referrals. There were 27 cases admitted as inpatients (61.4 per cent representing 4.9 per cent of all admissions during the study period). The sex ratio was roughly equal (21 girls, 23 boys). Admission rates and ages of onset and assessment between the sexes did not differ significantly. The number of first born or only children did not differ from that expected by chance alone. All cases were within the normal range of intelligence. The mean age at referral was 15.2 years (median 15.4, S.D. 1.43, range 12.0-18.4 years). The mean age of onset of symptoms was 12.5 years (median 13.0, S.D. 2.0, range 8-17 years). The mean period between onset of symptoms and referral, representing delay in referral, was thus 2.7 years (median 2.5, S.D. 1.9, range 0.5-7.6 years). Serious physical illness was recorded in the histories of only three cases. Two boys had both rapidly recovered from head injuries following road traffic accidents requiring hospitalization prior to onset of OCD. One patient had recurrent asthma. Eight cases had developmental problems; two had bilateral partial hearing loss, one specific language delay, 3 small stature (
1990, 13, 157-169
Adolescents with obsessive-compulsive disorder: a case note review of consecutive patients referred to a provincial regional adolescent psychiatry unit MARK
ALLSOPP*
AND
CHRISSIE
VERDUYNt
A number of clinical descriptions of Obsessive-Compulsive Disorder (OCD) in adolescence are available but are often of small numbers of cases with highly selective recruitment methods. We describe the findings of a systematic case note review of 44 consecutive OCD patients referred to Oxford Regional Adolescent Unit between 1974 and 1984. The relative frequencies of previously described features of the condition in this age group are presented. Many patients had problems with peer relationships and social isolation, which often preceded the onset of other symptoms by many years. The management of the cases and outcome at discharge are outlined.
INTRODUCTION
The importance of the adolescent years in relation to the onset and development of Obsessive-Compulsive Disorder (OCD) has long been recognized. Black (1974) reviewing data from eight large-scale studies of adult patients found that the highest incidence of first symptoms occurred between the ages of 10 and 15 years, by which age the illness had started in approximately onethird of cases. Onset before the age of 20 years was found in at least 50 per cent of adult cases by Pollitt (1957) and Kringlen (1965). Flament et al. (1988) found a minimum point of prevalence of 0.35 per cent in screening a general school population of adolescents. Treatment had been sought for only onefifth of the cases they identified. There are a number of previous descriptions of adolescents with OCD presenting clinically. Adams (1973) included a number of adolescents in his large series of children with the disorder. Forster and Holthausen (1979) described ten adolescent cases treated as in-patients. They drew attention to the low frequency of resistance to OCD symptoms, the relatively low rates of
*Reprint requests should be addressed to Mark Allsopp, Senior Registrar in Child and Adolescent Psychiatry, The Park Hospital for Children, Old Road, Headington, Oxford. t Principal Clinical Psychologist, Bolton General Hospital, Farnworth, Bolton BL4 OJR. 0140-1971/90/020157 + 13 $03.00/O
0
1990 The Association for the Psychiatric Study of Adolescents
158
M. ALLSOPP
AND C. VERDUYN
pronounced affective symptoms, and ubiquity of involvement of family members in symptomatology in these cases, pointing out that this differs from the clinical picture characteristically seen in adults. Rapoport et al. (1981) described nine cases compared with controls on a battery of neurophysioin EEG sleep studies, logical and neuropsychological tests. Differences dichotic listening, and two-flash threshold were found but the significance of these is unclear. Most recently Swedo et al. (1989) have reported findings on 70 children and adolescents consecutively referred to their clinic at the National Institute of Mental Health U.S.A. They take an ethological perspective in reporting the similarity in the content of OCD symptoms between childhood patients and those presenting as adults. There are also several follow-up studies of children and adolescents with this disorder, e.g. Warren, (1965) ; Hollingsworth, Tanguay, Grossman and Pabst (1980) ; Allsopp and Verduyn, (1989). These suggest that in at least 50 per cent symptoms persist into adult life and provide evidence of continuing disruption of psychosocial adjustment. The use of behavioural response prevention techniques as described by Rachman and Hodgson (1980) with adolescent OCD patients has been reported in a number of individual case reports (e.g. Hallam, 1974; Green, 1980). These techniques involve persuading patients to refrain from carrying out rituals. Initially this causes an increase in distress and anxiety which is contained using a variety of behavioural and cognitive management techniques. With persistence, however, both rituals and distress diminish to the point where the patient can be encouraged to practise control in situations which had previously caused exacerbation. As described by Levy and Meyer (1971)th e t ec h m‘q ue required intensive and continuous supervision but more recently this has been found to be unnecessary except in the most severe cases. Bolton, Collins and Steinberg (1983) d escribed a series of 15 adolescent inpatients treated in this way. Six showed complete remission with behavioural response prevention and a further three showed a significant improvement in symptoms so that 60 per cent of the series gained some benefit. Steinberg (1983), however, described a number of difficulties in the use of behavioural response prevention techniques in the adolescent age group. Patients are often very secretive. Resistance to symptoms often being absent or fluctuating, compliance may be poor or variable. General adjustment difficulties towards adult figures may increase the problems of supervision and control of the treatment programme. This, together with the tendency to involve family members in symptomatology, may make it hard to obtain the full co-operation of parents. Conduct disorder may co-exist as described in two cases by Bolton and Turner (1984). S ometimes symptoms may not be in evidence away from the home setting. Many of these problems were evident in a series described by Apter, Bernhout and Tyano (1984) of eight in-patients for whom behav-
OBSESSIVE
COMPULSIVE
DISORDER
159
ioural programmes had to be abandoned. Other treatment outcome studies include the report by Flament et al. (1985) of the successful use of the antidepressant drug clomipramine with a series of 19 patients age 10 to 18, and that of Apter and Tyano (1988), concerning the use of psychodynamic or supportive psychotherapy for 11 adolescent in-patients some of whom also received clomipramine. While the clinical features and management difficulties characteristic of OCD in adolescence are described, their relative frequency is not clear as studies often involve small numbers of cases with considerable selectivity. The aim of the present study was to describe, retrospectively, the characteristics of consecutive cases referred to a provincial Regional Adolescent Unit in England over the period of 11 years. It was hoped in this way to obtain a series of sufficient size to estimate the frequency of clinical features while limiting selectivity to that of a secondary referral centre. As the treatment method of choice throughout the period of the study was a programme of response prevention techniques combined when possible with family work it was anticipated that some estimate of the frequency of difficulties with this treatment method could also be obtained.
METHOD
The review was undertaken on all cases referred to Highfield Family and Adolescent Unit, Oxford between and including the years 1974 and 1984. Prior to 1974 unit records were incomplete. Some patients referred after 1984 were still in treatment at the unit at the time of the review. All patients coded as ICD 9:300.3 (Obsessive Compulsive Neurosis) on discharge were identified using the computer records of The Oxford Data Linkage Project, Unit of Clinical Epidemiology, Oxford. The reliability of this information was tested by a cross-check with unit records over a 4 year period with 100 per cent case identification. Discharge summaries were examined on all those identified (N = 52). Those cases who had a summary diagnosis of ObsessionalCompulsive Disorder or Neurosis were included (N = 40). The case notes of the remainder together with those of seven patients who were coded on discharge as Anakastic Personality Disorder (ICD 9 :301.4) during the study period were examined. Of these four cases who conformed to the criteria set out by Judd (1965) o f a well defined constellation of obsessive-compulsive symptoms [following the description of adult cases by Stern and Cobb (1978)], without symptoms of other major psychiatric disorder and severe enough to interfere with general functioning were included. The clinical notes of each of the 44 identified cases were examined systematically for information relating to demographic variables, symptomatology, family, management and short term outcome.
160
M. ALLSOPP
AND
C. VERDUYN
FINDINGS
General During the 11 year period of the study 44 cases of OCD were seen representing 1.3 per cent of referrals. There were 27 cases admitted as inpatients (61.4 per cent representing 4.9 per cent of all admissions during the study period). The sex ratio was roughly equal (21 girls, 23 boys). Admission rates and ages of onset and assessment between the sexes did not differ significantly. The number of first born or only children did not differ from that expected by chance alone. All cases were within the normal range of intelligence. The mean age at referral was 15.2 years (median 15.4, S.D. 1.43, range 12.0-18.4 years). The mean age of onset of symptoms was 12.5 years (median 13.0, S.D. 2.0, range 8-17 years). The mean period between onset of symptoms and referral, representing delay in referral, was thus 2.7 years (median 2.5, S.D. 1.9, range 0.5-7.6 years). Serious physical illness was recorded in the histories of only three cases. Two boys had both rapidly recovered from head injuries following road traffic accidents requiring hospitalization prior to onset of OCD. One patient had recurrent asthma. Eight cases had developmental problems; two had bilateral partial hearing loss, one specific language delay, 3 small stature (
