ABSTRACT
Obsessive-compulsive disorder (OCD) is defined by the presence of obsessions and/or compulsions, a definition which applies to children and adolescents, as well as adults. According to both ICD-10 (WHO, 1992) and DSM-IV (American Psychiatric Association; APA, 1994), OCD is defined by the presence of either obsessions and/or compulsions with the following clinical description of each: Obsessions are recurrent, persistent ideas, thoughts, images, or impulses, which are egodystonic and regarded as being senseless or repugnant. Attempts are made to ignore or suppress them. Compulsions are repetitive and seemingly purposeful for actions which are performed according to certain rules, or in a stereotyped fashion. The action is not an end in itself, but is designed to produce, or prevent some further event or situation. The activities are not realistically connected to the action, it is designed to produce or prevent, or it may be clearly excessive. The act is performed with a sense of subjective compulsion, coupled with a desire to resist the compulsion (at least, initially). A compulsion can be in the form of visible manifestation of stereotyped repetitive behaviour, although mental rituals are just as common. Mental rituals describe the phenomenon of performing compulsions within the child's mind, for example counting, saying specific phrases or words, calculating etc. These mental rituals are frequently just as disabling to the child as are overt compulsions. In diagnosing, one must include severity aspects. The obsessions or compulsions must be a significant source of distress to the individual, or interfere with social, or role functioning. DSM-IV include a new subcategory: OCD with poor insight. In DSM-IV field studies (Foa and Kozak, 1995) it was found that approximately 5% of adult OCD patients had, what they defined as constant poor insight. That is, the obsessions or compulsions were not clearly egodystonic. Furthermore, the patients were unable to rationalize and detach themselves from the symptoms, and therefore, were unable to recognise that their behaviour was both bizarre and illogical. Foa and Kozak (1995) also found that at some stage of their illness, approximately 25% of patients were not rational enough to describe their obsessions or compulsions as being egodystonic. The introduction of this sub-category leads to increased difficulty in distinguishing clearly between overvalued ideas, discrete psychotic symptoms and obsessions. In many children, this subcategory with poor insight might well apply. Frequently, children have poorer insight with regard to their symptoms (in particular, younger children) and are frequently resistant to their symptoms. Children and adolescents are, also, less secretive with regard to their symptoms than adult patients. ICD-10 does not include “obsessions with poor insight” as a diagnostic criterion. However, different subtypes are used: one subtype is used primarily with compulsions, one with obsessions, and one with both obsessions and compulsions. The majority of children and adolescents have both compulsions and obsessions, although there is a tendency that some patients show compulsions without obsessions (particularly in the case of children).
