CASE Anxious and self-injurious
A, age 6, is forcibly inserting her finger into her nose repeatedly until she bleeds profusely, as many as 20 times per day. She is not nose-picking but is jabbing her finger into her nose as far as possible in a repetitive ramming motion. Less frequently, she inserts her finger into her vagina, resulting in chronic urinary tract infections (UTIs). She has bedtime checking rituals; worries that her parents will die; has a fear of vomiting to the point where she stopped eating normally and lost 5 lb in 6 months; intense fear of storms; refusal to use public bathrooms; and involuntary throat clearing, facial grimacing, and lip twitches.
A’s symptoms began at age 3. There is no history of physical or sexual abuse. She does well in school, but these behaviors have had a significant impact on her social functioning. She is not taking any medications and has been in weekly cognitive-behavioral therapy (CBT) for the last year. A has had several UTIs but otherwise is physically healthy.
Which diagnosis best describes A’s condition?
a) non-suicidal self-injury (NSSI)
b) generalized anxiety disorder (GAD)
c) obsessive-compulsive disorder (OCD)
d) Tourette’s disorder (TD)
The authors’ observations
A is causing herself to bleed and says she wants to stop this behavior. Onset of NSSI typically is age 12 to 14 and could be accompanied by traits of cluster B personality disorders.1 In A’s case, her age and absence of any stated desire to relieve stress or intense negative affective states rules out NSSI.
Because A has multiple and frequent fears, worries, and anxieties that have been present for years and have caused significant functional impairment, a diagnosis of GAD is warranted. Because she has had both motor and vocal tics for more than 1 year, she also meets diagnostic criteria for TD (Table 1).
In young children, OCD manifests primarily with compulsive behavior, such as excessive hand washing, counting, and ordering, that interferes with functioning. Although A has bedtime checking rituals, she has no significant functional impairment from these rituals alone. A’s finger-insertion behavior could be interpreted as a complex motor tic or as a compulsion, in which case impairment was significant enough to justify a diagnosis of OCD.
Many individuals with OCD report the need to engage in compulsive behavior to decrease anxiety or until they experience a “just right” feeling.2 However, neither A nor her mother reported the need for the “just right” feeling. The child recognized the urge to put her finger in her nose and did experience relief of anxiety after drawing blood. Although A said that she was unable to control her hands, she was observed frequently touching the side of her nose in an attempt to avoid inserting her finger in her nose.
Compulsive behavior that results in self-injury typically is not seen in OCD except in children with severe neurologic complications, low intellectual functioning, psychosis, or autism.3
It often is difficult to determine if complex motor or vocal tics are compulsions (Table 2). Indeed, the same biologic mechanisms are thought to be implicated in TD and OCD.4 A significant percentage of children with OCD have tics, and patients often report that they are unable to distinguish between compulsions and complex tics.5 Therefore, we thought that a reasonable differential included both TD and OCD, but more careful assessment over time was required.
A has been receiving CBT for more than 1 year but her symptoms were worsening, which prompted her parents to seek evaluation in our clinic. Because of the level of interference with daily functioning and significant distress, our priority was developing a treatment plan that has the best chance of quickly reducing symptom severity and frequency. The results of the large-scale Pediatric OCD Treatment Study (POTS), which evaluated children age 7 to 17, and the Child/Adolescent Multimodal Anxiety Study, which evaluated children age <12, indicated that the combination of CBT with a selective serotonin reuptake inhibitor (SSRI) reduced OCD symptoms more than either modality alone.6,7 Considerations for using SSRIs in this age group include:
- the risk of behavioral activation
- poor tolerability
- lack of an evidence base for dosage optimization.
The American Academy of Child and Adolescent Psychiatry’s Preschool Psychopharmacology Working Group’s guidelines for treating anxiety in preschoolers state that pharmacotherapeutic intervention can be considered when symptoms are intolerable and adequate psychotherapy interventions have been tried.8 In A’s case, she had been receiving CBT for a year without improvement in symptoms; therefore, initiating medication was indicated, as well as an examination of therapeutic modalities being used.