The differential diagnosis for OCD includes psychotic disorders, complex tics, other anxiety disorders, and obsessive-compulsive personality disorder. Often a patient with OCD recognizesthat the intrusive thoughts are created by their own brain, whereaspsychotic patients feel they are not created by them. This may beless clear in youth. A delusional fixation on appearance in body dysmorphic disorder and impulsive hair pulling to relieve anxiety or tension in trichotillomania can be confused with OCD. Obsessive-compulsive personality disorder is a character styleinvolving preoccupation with orderliness, perfectionism, andcontrol. No true obsessions or compulsions are present.
Pervasive developmental disorders, also known as autism spectrum disorders (ASDs), consist of five disorders: autism, Asperger syndrome, childhood disintegrative disorder, Rett syndrome, and pervasive developmental disorder not otherwise specified.
Onset of these disorders is in infancy and preschool years. Hallmarks of these disorders include impaired communication and impaired social interaction as well as stereotypic behaviors, interests, and activities. Mental retardation is common, with a few children showing remarkable isolated abilities (savant or splinter skills).
ASDs are seen in less than 1% of the population with equal prevalence among all racial and ethnic groups. The prevalence is greater in boys (except for Rett syndrome), but girls with the disorders tend to be more severely affected.
Differentiating features of the pervasive developmental disorders are listed in Table 20-1.
Treatment of ASD is symptomatic and multimodal. Atpresent there are no treatments for the core symptoms ofASDs. Antipsychotics (risperidone, olanzapine, quetiapine,aripiprazole, ziprasidone, paliperidone, haloperidol, thioridazine) are used for aggression, agitation, irritability, hyperactivity, and self-injurious behavior. Anticonvulsants and lithium can be used for aggression. Naltrexone has been usedto decrease self-injurious behavior, presumably by blockingendogenous opioids. Selective serotonin reuptake inhibitors are given for anxiety, perseveration, compulsions, depression,and social isolation. Stimulants are useful for hyperactivityand inattention (better response with Asperger syndrome).There are reports of significant worsening of irritability andaggression in some patients treated with stimulants. Alpha-2agonists (guanfacine, clonidine) are used for hyperactivity,aggression, and sleep dysregulation, although melatonin isfirst-line medication for sleep dysregulation. Behavioralmanagement training for parents is useful in teaching protocols to help their child learn appropriate behavior. Special educational services should be individualized for the child. Occupational, speech, and physical therapy are oftenrequired. Referral for disability services and support is oftenwarranted. Potentially useful therapies tailored to the individual include applied behavioral analysis, discrete trialtraining, and structured teaching. There is a need for family support groups and individual supportive counseling for parents. The prognosis for autism is guarded. There are no known methods of primary prevention. Treatment and educational interventions are aimed at decreasing morbidity andmaximizing function.