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may have many possible causes. One possible cause that has generated
particular interest is a streptococcal infection that initiates an autoimmune
response that damages the individual’s own basal ganglia – a condition
often referred to as PANDAS (PaediatricAutoimmuneNeuropsychiatric
DisordersAssociated withStreptococcal infections). Though PANDAS is a
relatively new label and the source of some controversy, the association
between post-streptococcal conditions and obsessive-compulsive symp-
toms has long been recognised in Sydenham chorea, the neurological
manifestation of rheumatic fever.
Treatment
Given widespread misunderstanding of OCD, it is vital to educate affected
individuals – along with their parents, teachers and classmates – about the
disorder. As regards specific therapy, both cognitive-behavioural therapy
and medication can be very effective in children and adolescents.
Psychological management of compulsions often begins with an initial
period of diary keeping. The child or adolescent then helps to draw up a
hierarchy of compulsions, ranging from the easiest to tackle to the hardest
(most anxiety-provoking). Starting with the easiest, the affected individual
is encouraged and helped to avoid carrying out the compulsion. When all
goes well, this ‘exposure with response prevention’ only leads to a tempo-
rary surge of anxiety, followed by a more lasting reduction in the compul-
sive drive. Obsessions that have no obvious behavioural accompaniment
(ruminations) may be harder to tackle using behavioural approaches, but
can usually be treated in the same way as there is almost always an asso-
ciated avoidance, even if there is no clear compulsion. Family work can be
particularly helpful when family members are being drawn into the rituals.
Medication has an important role in many cases, whether as an adjunct
or an alternative to psychological approaches. Selective serotonin reuptake
inhibitors (SSRIs) or clomipramine are particularly effective, and are gen-
erally well tolerated even by children as young as 6 years old. They should
be started at low doses and slowly titrated upwards. Long-term mainte-
nance medication may be needed, particularly if previous discontinuation
has led to relapses despite adequate psychological therapy directed to
relapse prevention. Immunotherapy, including plasma exchange, has been
used to treat acute-onset OCD after a streptococcal infection; though some
dramatic responses have been reported, it is still too early to recommend
this as standard treatment.
Prognosis
Unlike some other emotional disorders of childhood and adolescence,
OCD seems to be remarkably persistent; even years later, only a minority
have recovered fully without treatment. Even with optimal treatment, a