Eur Child Adolesc Psychiatry (2013) 22 (Suppl 1):S23S28

DOI 10.1007/s00787-012-0357-7

REVIEW

Obsessivecompulsive disorders
Per Hove Thomsen

Published online: 4 December 2012

Springer-Verlag Berlin Heidelberg 2012

Abstract Three major changes will probably be introduced in the DSM-5 regarding obsessivecompulsive disorder: OCD will be classified in the diagnostic category
obsessivecompulsive and related disorders, the clinician
should consider the degree of insight into a symptomatology (good to poor insight) and a subtype of tic-related
OCD will be introduced. The recommended treatment for
OCD is CBT, in severe cases with addition of SSRI
treatment.
Keywords

OCD
Tics
Insight
Treatment

Introduction
Obsessivecompulsive disorder (OCD) is characterized by
obsessions and compulsions. The condition has had different terminology throughout history. Going back to the
1,500 century, more cases of OCD have been described [1],
and later Sigmund Freud described the rat man [2]. OCD
was included in previous versions of the DSM-classification system, but the diagnosis was rare in European child
and adolescent psychiatry until the early 90s [35].
In 1953, Bakwin described obsessive ideas and compulsive behaviour in very young children as being common, although not as symptoms of a disorder, but rather
elements of normal development [6]. These conclusions
were formally presented by Piaget [7] and later replicated
by Leonard et al. [8] using generally accepted criteria for

P. H. Thomsen (&)
Department of Child and Adolescent Psychiatry,
rhus University Hospital, Harald Selmers Vej 66,
A
8240 Risskov, Denmark
e-mail: per.hove.thomsen@ps.rm.dk

the OCD diagnosis. Rapoport and her team [911] made

extremely detailed and extensive analysis of American
children and adolescents with OCD who were referred for
treatment. They found that child OCD populations showed
almost similar phenomenology compared with adult
patients.
Epidemiological studies conducted in different parts of
the world have shown that OCD is an often chronic and in
many cases disabling condition affecting 13 % of a paediatric population [1215]. In the following, the discussion
and proposals for major changes in the DSM-5 will be
described. The rationale and background for the proposed
changes have previously been presented by Leckman et al.
[16].

Changes in DSM-5
Obsessivecompulsive disorder is proposed to be classified
in the diagnostic category obsessivecompulsive and related disorders including obsessivecompulsive disorder,
body dysmorphic disorder, hoarding disorder, hair
pulling disorder (trichotillomania), skin picking disorder,
substance induced obsessivecompulsive or related disorders, obsessivecompulsive or related disorder attributable
to another medical condition and obsessivecompulsive or
related disorder not elsewhere classified. The proposed
criteria in the DSM-5 are shown in Table 1.
In the working group of the DSM-5 on OCD, there has
been a debate about whether or not OCD should be classified as an anxiety disorder. In the DSM-IV, OCD is
classified in the section of anxiety disorders and in the
ICD-10, OCD is classified in the section of neurotic, stressrelated and somatoform disorders. Table 2 presents the
pros and cons for a classification as an anxiety disorder.

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Eur Child Adolesc Psychiatry (2013) 22 (Suppl 1):S23S28

Table 1 The proposed DSM-5 criteria for F00 Obsessivecompulsive disorder

A. Presence of obsessions, compulsions, or both:
Obsessions are defined by (1) and (2):
1. Recurrent and persistent thoughts, urges or images that are experienced, at some time during the disturbance, as intrusive and unwanted and
that in most individuals cause marked anxiety or distress
2. The individual attempts to ignore or suppress such thoughts, urges or images, or to neutralize them with some other thought or action (i.e.
by performing a compulsion)
Compulsions are defined by [1] and [2]:
1. Repetitive behaviours (e.g. hand washing, ordering, checking) or mental acts (e.g. praying, counting, repeating words silently) that the
individual feels driven to perform in response to an obsession, or according to rules that must be applied rigidly
2. The behaviours or mental acts are aimed at preventing or reducing anxiety or distress, or preventing some dreaded event or situation;
however, these behaviours or mental acts either are not connected in a realistic way with what they are designed to neutralize or prevent or
are clearly excessive
B. The obsessions or compulsions are time consuming (for example, take more than 1 h a day) or cause clinically significant distress or
impairment in social, occupational, or other important areas of functioning
C. The obsessivecompulsive symptoms are not attributable to the direct physiological effects of a substance (e.g. a drug of abuse, a
medication) or another medical condition.
D. The content of the obsessions or compulsions is not better accounted for by the symptoms of another DSM-5 disorder (e.g. excessive
worries in Generalized Anxiety Disorder; ritualized eating behaviour in an Eating Disorder; hair pulling in Hair Pulling Disorder
(Trichotillomania), skin picking in Skin Picking Disorder; stereotypies in Stereotypic Movement Disorder; preoccupation with appearance
in Body Dysmorphic Disorder; preoccupations with objects in Hoarding Disorder; preoccupation with substances or gambling in
Substance Use and Related Disorders; preoccupation with serious illness in Illness Anxiety Disorder; preoccupation with sexual urges or
fantasies in a Paraphilia; preoccupation with impulses in Impulse Control Disorders; guilty ruminations in Major Depressive Disorder;
thought insertion or delusional preoccupations in a Psychotic Disorder; or repetitive patterns of behaviour in Autism Spectrum Disorder).
Indicate whether OCD beliefs are currently characterized by:
Good or fair insight: The individual recognizes that OCD beliefs are definitely or probably not true, or that they may or may not be true
Poor insight: The individual thinks OCD beliefs are probably true
Absent insight: The individual is completely convinced OCD beliefs are true
Specify if:
Tic-related OCD: The individual has a lifetime history of a chronic tic disorder

Table 2 Classification of OCD as an anxiety disorder

In favour:
OCD often is comorbid with anxiety disorders
Symptoms of anxiety are often seen
Response to CBT and SSRI in OCD is similar to that in anxiety disorders
Against:
Symptoms of anxiety are not always seen (hoarding, symmetry, tic-related)
Neurobiological findings indicate involvement of other loops in the brain
Subpopulations (especially in children and adolescents have higher rates of comorbidity with developmental disorders such as ADHD, TS,
ASD).

The proposed diagnostic category of obsessivecompulsive

and related disorders will include OCD, body dysmorphic
disorder, hoarding disorder, hair pulling disorder (trichotillomania), skin picking disorder, substance-induced obsessive
compulsive or related disorders, obsessivecompulsive or
related disorder attributable to another medical condition, and
obsessivecompulsive disorder or related disorder not elsewhere classified.
Looking in detail upon the diagnostic criteria, the following issues have been discussed:

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Criterion A Should the separate definitions of obsessions

and compulsions as delineated by DSM-IV (in contrast to ICD10) be maintained? Should the expression impulse be changed
to urge? Should inappropriate be changed to unwanted?
Criteria B Should the 1-h duration of the criteria be
maintained?
OCD subtypes Should OCD be subdivided into specific
OCD subtypes or according to OC-symptom dimensions?
Regarding criterion A DSM-IV defines obsessions and
compulsions somewhat differently than ICD-10. It is

Eur Child Adolesc Psychiatry (2013) 22 (Suppl 1):S23S28

recommended that separate definitions of obsessions and

compulsions remain in criterion A. The working group
found that the use of the term urge may more accurately
reflect the most common symptoms of OCD than impulse
[16]. They also stated that the word urge might decrease
confusion of impulse disorders with OCD. It is further
recommended that the expression inappropriate should be
changed to unwanted because this is less value latent.
As seen in criterion A-1, OCD is defined by symptoms
that cause marked anxiety or distress. It has been discussed
whether this should be modified or deleted. Data from
many clinical trials and longitudinal studies found evidence
that anxiety and distress should be maintained in the definition of obsessions [17, 18] and data from large studies
found that people with OCD experience moderate or severe
anxiety or distress from their obsessions. However, at the
same time, some studies have shown that not all obsessions
generate marked anxiety or distress [19]. Based on these
findings, the working group recommended that the phrase
cause marked anxiety or distress be modified to describe
that obsessions usually cause marked anxiety or distress.
In the DSM-IV criteria, it had been stated that a person
with OCD recognises that the obsessional thoughts are a
product of his or her own mind (not imposed from without
as in thought insertion). These criteria are important to
differentiate OCD from worries about real-life problems
seen as part of a generalised anxiety disorder and especially
from psychotic thoughts as seen as part of schizophrenia or
other psychotic disorders. These aspects of differential
diagnosis are now addressed in criterion D.
Many patients with OCD, children, adolescents and
adults, expose avoidant behaviour in order to reduce distress and anxiety [20]. The working group recommended
that the phenomenon of avoidance be discussed more
clearly, but that it may be premature to add it to the
criterion.
Regarding criterion B It is stated that obsessions and
compulsions should cause marked distress and are time
consuming, for instance taking more than 1 h a day. It has
been discussed if the time requirement could be further
detailed. It is important that the time criterion differentiate
clinically significant from clinically non-significant symptoms. However, the working group did not find any evidence-based suggestions to improve this time criterion at
the moment and stated that more than 1 h a day may be a
useful example rather than an absolute requirement.
Regarding criterion D It is specified that the content of
the obsessions and compulsions is not restricted to symptoms of eating disorder, trichotillomania, body dysmorphic
disorder, etc. It is recommended that the list is extended to
include compulsive sexual behaviour, preoccupation with
gambling or other relevant behaviours in behavioural
addictions or other impulsive control disorders.

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Insight into OCD symptoms It is clearly stated that at

least at some point during the course of the disorder, the
patient with OCD must recognise that the obsessions and
compulsions are excessive or unreasonable. However, it is
also stated that this criterion does not apply to all children.
Studies have shown, however, that some patients with
OCD have poor or even absent insight.
From a dimensional point of view, obsessions may be
on a spectrum from ego-dystonic symptoms to egosyntonic delusional beliefs. Some studies have shown
that even adult patients with OCD may have constant
delusional beliefs, being certain that their feared consequences would actually occur [21]. In the DSM-IV, the
specifier with poor insight was introduced. Given that
the insight varies in OCD patients, it was recommended
by the working group that DSM-IV criterion B is deleted
and that a broader range of insight options is included
(i.e. good or fair insight, poor insight or delusional OCD
beliefs). This change may improve differentiation
between OCD beliefs and psychotic disorders and would
allow compatibility with the insight specifiers proposed
for other disorders in the OCD spectrum such as body
dysmorphic disorder. However, it is recommended that
the clinicians ability to use this insight specifier is
assessed.

OCD subtypes
The validity of OCD subtypes has been analysed in clinical
work and various research projects. A possible subtype of
early onset patients is of special relevance for paedopsychiatric OCD. This group is usually characterised by a
predominance of boys to girls and a more common link to
Tourettes syndrome or tics or other developmental disorders. Some studies have indicated that the early onset
subtype is representing a more severe type of OCD which
is more genetically loaded [22].
Another subtype of OCD in children with OCD symptoms has been proposed as part of the so-called paediatric
autoimmune neuropsychiatric disorder associated with
streptococcus (PANDAS). Swedo et al. [23] identified this
possible subgroup which developed OCD symptoms following infections with group A beta-haemolytic streptococci. Clinical studies and some recent studies based on
animal models seem to support the existence of the PANDAS subtype [24, 25]. However, the use of antibiotics in
treatment and prophylaxis still remains controversial and it
seems that PANDAS can lead to a broader spectrum of
developmental disorders in addition to just OCD. The
DSM-5 working group recommended that PANDAS
should be discussed in the text, but will not suggest a
specific listing as a subtype of OCD.

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Table 3 OCD in patients with Tourettes syndrome

Obsessions
Apparently no difference between patients with OCD or Tourettes syndrome
Compulsions
Frequently touching, knocking, rubbing, self-harm, need for symmetrical actions, counting, staring, winking, balancing things, things need
to give a just right feeling, etc
Cleaning, washing, anxiety of contamination is seen more rarely

Tic-related OCD

Clinical guidelines

OCD and TS are often comorbid to each other and there is

evidence of a genetic relationship [26]. Common similarities and differences between pure OCD and OCD in
children with TS are shown in Table 3. In Tourettes
syndrome, the feeling of just right is more prominent than
in OCD. In pure OCD, the child more often believes that
something terrible will happen if the ritual in question is
not performed. There may be more mental rituals in
Tourettes syndrome with OCD than in pure OCD. In
Tourettes syndrome, the impulse or urge has its origin
peripherally, whereas it has a cognitive origin in OCD.
In conclusion, the working group found scientific evidence for the inclusion of a tic-related subtype of OCD into
the DSM-5. This also makes sense clinically because ticrelated cases may be less likely to respond to SSRIs alone
and may need augmentation with an antipsychotic
medication.
The working group did not find evidence for listing an
early onset subtype of OCD. There is a common overlap
between early onset cases with tic-related OCD; they both
have high comorbidity rates of other developmental disorders (such as ADHD) and they often show a male
predominance.
The validity of obsessivecompulsive symptom dimensions has also been discussed by the working group.
In many clinical studies, also in children and adolescents
[27, 28], the most consistent dimensional subtypes have a
distinction between washers, checkers, patients with
hoarding and symmetry and patients with aggressive
obsessions. However, the working group concludes that
subtypes according to obsessivecompulsive symptom
dimensions are not required in order to diagnose OCD. In
addition, many studies show that temporal stability of
symptom dimensions occur in many patients, but not in all.
In terms of treatment response, some studies have shown
differences between patients with hoarding or symmetry
(low response rates) and patients with contamination and
cleaning behaviour (higher response rates) [2931]. The
working group recommends that OCD symptoms are
described in the text, but are not used yet as a specifier in
the diagnostic criteria.

Assessment

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In many children, an adolescents OCD may have distressed the patient for a long time before relevant assessment and diagnostics are performed. In smaller children,
parents may sometimes face difficulties in differentiating
between OCD rituals and parts of normal development.
Smaller children are not always capable of clearly
expressing their sensations and the possible distress
imposed by the symptoms. During the assessment of OCD,
it is important to gather information from both the child as
well as the parents and it is recommended that the interview with the children is also undertaken without the
presence of the parents because many symptoms are
shameful and embarrassing for the patients.
It is recommended that information from early professional contacts are gathered, that the developmental history
of the child is described, that the child (and parents) is
interviewed by the use of a broad diagnostic interview
(in order to collect information on possible comorbid disorders) and that a specific diagnostic interview or questionnaire is
used. The Childrens YaleBrown ObsessiveCompulsive
Scale (CY-BOCS) is recommended as it has been extensively
used in clinical and research studies [32].
Treatment
The treatment of OCD in children and adolescents is based
on a thorough assessment of the severity of OCD and the
presence of comorbid disorders. The evidence-based
treatment of OCD in children and adolescents includes
psychoeducation and reduction of psychosocial stress,
cognitive behavioural psychotherapy and medication. The
available treatment options are outlined in Fig. 1. For
all children and adolescents, psychoeducation is recommended [33]. In cases of OCD with mild function
impairment, a psychologist or the general practitioner
should consider guided self-help which includes support
and information for the family. In cases of moderate to
severe functional impairment, cognitive behavioural therapy should be offered. Principals with exposure and

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S27

Fig. 1 Treatment options for

people with OCD. Children and
young people: Overview of
treatment pathway for OCD
CBT Cognitive behavioural
therapy, ERP exposure response
prevention, SSRI selective
serotonin reuptake inhibitor

response prevention can be combined with cognitive

methods.
There is a limited body of literature describing the differences between group and individual-based therapy. So
far, there is no indication that one is better than the other,
so the choice must depend on local expertise and experience and patient and family preferences [33, 34].
In cases with lack of response to CBT or where patients
cannot engage in CBT, treatment with selective serotonin
reuptake inhibitors (SSRI) should be added or introduced.
The SSRI should only be used after assessment and diagnosis by a child or adolescent psychiatrist. Especially in
young children, one should use low starting doses. In most
countries, either sertralin or fluvoxamine has a marketing
authorisation for use in OCD in children older than 6 or
8 years [35].
If a lower dose of medication is ineffective, one should
increase the dose until the therapeutic response is obtained,
monitoring carefully for adverse events. One should
increase the dose gradually also taking into account the
delayed therapeutic response (which may be up to
12 weeks) and, naturally, the patients age. Patients and
their families should be informed about the possibility of
an increase in suicidal behaviour, self-harm or hostility in
the beginning of a treatment with SSRI. If an SSRI is
prescribed, it should be used in combination with concurrent CBT if possible [33, 34].
If the child responds to an SSRI, treatment should be
continued for at least 6 months after remission (i.e.
symptoms are not clinically significant and the patient is
fully functioning for at least 12 weeks). In a few studies,
clomipramine has shown its efficacy in treating children
with OCD. However, clomipramine should only be used in
cases where SSRI is not effective. Before initiation of
treatment with clomipramine, an ECT should be carried out

and information given regarding toxicity in overdose to the

family.
Treating with augmentation therapy has been described
in more reports. Although large randomised controlled
trials are still lacking, the best described drugs for augmentation are risperidone and abilify [36, 37].

Conclusion
OCD is a relatively common disorder affecting 13 % of
children and adolescents. Untreated, it often has a chronic
course, but it can be treated effectively with CBT and
medication (SSRI). The DSM-5 does not introduce major
changes in the diagnostic criteria and classification of
OCD. It is suggested that the new classification should
consider the degree of insight into obsessions and compulsions according to good or fair insight, poor insight or
illusional OCD beliefs. Furthermore, it is suggested that a
subtype of tic-related OCD is introduced.
Conflict of interest The corresponding author states that there are
no conflicts of interest. This article is part of the supplement The
Future of Child and Adolescent Psychiatry and Psychology: The
Impact of DSM 5 and of Guidelines for Assessment and Treatment.
This supplement was not sponsored by outside commercial interests.

References
ber Zwangsvorstellungen. Arch Psychiat
1. Westphal C (1878) U
Nervenkr 8:734750
2. Rottemanden Freud S (1991) Bemrkninger om et tilflde
af tvangsneurose. Hans Reitzels Forlag, Kbenhavn
3. Thomsen PH (1990) Child and adolescent psychiatric inpatients
in Denmark. Demographic and diagnostic characteristics of
children and adolescents admitted from 1970 to 1986. A registerbased study. Nord Psykiatr Tidsskr 44:337343

123

S28
4. Rutter M, Tizard J, Yule W, Graham P, Whitmore K (1976)
Reserach report: Isle of Wight Studies, 19641974. Psychol Med
6(2):313332
5. Berman L (1942) Obsessive-compulsive neurosis in children.
J Nerv Ment Dis 96:2639
6. Bakwin H, Bakwin RM (1953) Behaviour disorders in children.
Saunders, Philadelphia
7. Piaget J (1937) The construction of reality in the child. Basic
Books, New York
8. Leonard HL, Goldberger EL, Rapoport JL, Cheslow DL, Swedo SE
(1990) Childhood rituals: normal development or obsessive
compulsive symptoms? J Am Acad Child Adolesc Psychiatry
29(1):1723
9. Rapoport JL (1986) Childhood obsessive compulsive disorder.
J Child Psychol Psychiatry 27(3):289295
10. Rapoport JL, Swedo SE, Leonard HL (1992) Childhood obsessive
compulsive disorder. J Clin Psychiatry 53(4 suppl):16
11. Swedo SE, Rapoport JL, Leonard HL, Lenane M, Cheslow D
(1989) Obsessivecompulsive disorder in children and adolescents. Clinical phenomenology of 70 consecutive cases. Arch
Gen Psychiatry 46:335342
12. Flament M, Whitaker A, Rapoport JL, Vies MD, Berg CZ,
Kalikow K et al (1988) Obsessive compulsive disorder in adolescence: an epidemiological study. J Am Acad Child Adolesc
Psychiatry 27(6):764771
13. Karno M, Golding JM, Sorenson SB (1988) The epidemiology of
obsessivecompulsive disorder in five US Communities. Arch
Gen Psychiatry 45:10941099
14. Thomsen PH (1993) Obsessivecompulsive disorder in children
and adolescents. Self-reported obsessivecompulsive behaviour
in pupils in Denmark. Acta Psych Scand 88:212217
15. Heyman I, Fombonne E, Simmons H, Ford T, Meltzer H,
Goodman R (2001) Prevalence of obsessivecompulsive disorder
in the British nationwide survey of child mental health. Br J
Psychiatry 179:324329
16. Leckman JF, Denys D, Simpson HB, Mataix-Cols D, Hollander E,
Saxena S et al (2010) Obsessivecompulsive disorder: a review of
the diagnostic criteria and possible subtypes and dimensional
specifiers for DSM-V. Depress Anxiety 27(6):507527
17. Stein DJ, Fineberg NA, Bienvenu OJ, Denys D, Lochner C,
Nestadt G et al (2010) Should OCD be classified as an anxiety
disorder in DSM-V? Depress Anxiety 27(6):495506
18. The Pediatric OCD Treatment Study (POTS) Team (2004)
Cognitive-behavior therapy, sertraline, and their combination for
children and adolescents with obsessivecompulsive disorder.
The Pediatric OCD Treatment Study (POTS) randomized controlled trial. JAMA 292(16):19691976
19. Mancebo MC, Greenberg B, Grant JE, Pinto A, Eisen JL, Dyck I
et al (2008) Correlates of occupational disability in a clinical
sample of obsessivecompulsive disorder. Compr Psychiatry
49(1):4350
20. Srensen CB, Kirkeby L, Thomsen PH (2004) Quality of life with
OCD. A self-reported survey among members of the Danish OCD
Association. Nord J Psychiatry 58:231236
21. Foa EB, Kozak MJ, Goodman WK, Hollander E, Jenike MA,
Rasmussen SA (1995) DSM-IV field trial: obsessivecompulsive
disorder. Am J Psychiatry 152(1):9096

123

Eur Child Adolesc Psychiatry (2013) 22 (Suppl 1):S23S28

22. Thomsen PH, Leckman JF (2000) Obsessivecompulsive disorder and the anxiety spectrum in children. CNS spectrums 5(6
(supplement 4)):1823
23. Swedo SE, Leonard HL, Garvey MA, Mittleman BB, Allen AJ,
Perlmutter SJ et al (1998) Pediatric autoimmune neuropsychiatric
disorders associated with streptococcal infections: clinical
description of the first 50 cases. Am J Psychiatry 155:264271
24. Mell LK, Davis RL, Owens D (2005) Association between
streptococcal infection and obsessivecompulsive disorder.
Tourettes syndrome, and tic disorder. Pediatrics 116:5660
25. Singer HS, Mink JW, Loiselle CR, Burke KA, Ruchkina I,
Morshed S et al (2005) Microinfusion of antineuronal antibodies
into rodent striatum: failure to differentiate between elevated and
low titers. J Neuroimmunol 163(12):814
26. do Rosario-Campos MC, Leckman JF, Curi M, Quatrano S,
Katsovitch L, Miguel EC et al (2005) A family study of earlyonset obsessivecompulsive disorder. Am J Med Genet Part B
Neuropsychiatr genet 136B(1):9297
27. Nikolajsen KH, Nissen JBB, Thomsen PH (2010) Obsessive
compulsive disorder in children and adolescents. Symptom
dimensions in a naturalistic setting. Nord J Psychiatry 65(4):
244250
28. Mataix-Cols D, Pertusa A, Leckman JF (2007) Issues for DSM-V:
how should obsessive-compulsive and related disorders be classified? Am J Psychiatry 164:13131314
29. Saxena S, Brody AL, Maidment KM, Baxter LR (2007) Paroxetine treatment of compulsive hoarding. J Psychiatr Res 41:
481487
30. Mataix-Cols D, Marks IM, Greist JH, Kobak KA, Baer L (2002)
Obsessivecompulsive symptom dimensions as predictors of
compliance with and response to behaviour therapy. Psychother
Psychosom 71(5):255262
31. Stein DJ, Andersen EW, Overo KF (2007) Response of symptom
dimensions in obsessivecompulsive disorder to treatment with
citalopram or placebo. Revista Bras Psiquiatr 29:303307
32. Goodman WK, Price LH, Rasmusen SA, Riddle M, Rapoport JL
(1991) Childrens YaleBrown obsessive compulsive scale
(CY-BOCS). Department of Psychiatry, Yale University School
of Medicine, New Haven
33. National Institute for Health and Clinical Excellence (2005)
Obsessivecompulsive disorder. Quick reference guide.
http://guidance.nice.org.uk/nicemedia/live/10976/29945/29945.pdf
34. OKearney RT, Anstey KJ, von Sanden C (2006) Behavioural
and cognitive behavioural therapy for obsessive compulsive
disorder in children and adolescents (Review). Cochrane Database of Systematic Reviews 4
35. Ivarsson T, Kornr H, Skarphedinsson G, Axelsdottir B, Biedil
S, Heyman I et al (2012) Selective reuptake inhibitors (SRIs) for
obsessive compulsive disorder (OCD) in children and adolescents. A systematic review (in preparation)
36. Bloch MH, Landeros-Weisenberger A, Kelmendi B, Coric V,
Bracken MB, Leckman JF (2006) A systematic review: antipsychotic augmentation with treatment refractory obsessivecompulsive disorder. Mol Psychiatry 11(7):622632
37. Mancuso E, Faro A, Joshi G, Geller DA (2010) Treatment of
pediatric obsessivecompulsive disorder: a review. J Child
Adolesc Psychopharmacol 20(4):299308