[Obsessive-compulsive symptoms in children and pre-adolescents: clinical observation of inpatients].

I investigated the phenomenology of obsessive-compulsive disorder (DSM-IV) in 22 children and pre-adolescents (8 boys and 14 girls, 6-15 years old, mean 12.2 years) admitted to the psychiatric ward of Kanagawa Children's Medical Center between 1989 and 1996. Some patients were concomitantly diagnosed with psychotic disorder, or eating disorder (DSM-IV). Girls dominated boys, and all cases except a girl were over ten years old. Patients were divided into four types according to their obsessive-compulsive symptoms. Type I (7 cases, 31.8%): Recurrent idea and repetitive behavior were painful. The patients recognized these ideas and behaviors to be a product of their own mind. They also recognized the behavior to be excessive or unreasonable, and tried to resist at least while the symptoms were mild. Four patients showed good courses, but in three patients showed severe obsessive-compulsive symptoms that persisted for a long time after admission. Type II (13 cases, 59.1%) consisted of 2 subtypes. Type IIa (10 cases, 45.5%): The obsession or compulsion was recurrent and distressful, but insight into the problem was unclear or poor. We noted 4 Type IIa patients with this type resisted their symptoms, but the others' did not. This type was the most prevalent of the four types, and seemed to be the main type of obsessive-compulsive disorder among children and pre-adolescents. Type IIb (3 cases, 13.6%): Compulsion dominated obsession. The subjects experienced distress from their severe compulsion, but seldom complained of it. Furthermore, patients could hardly discern and resist their symptoms. So it resembled obsessive desire for the maintenance of sameness, or stereotypy in developmental disorders. Patients recognized the idea or the behavior to be the product of their own mind. Severe symptoms persisted for a long time after admission. Type III (2 cases, 9.1%): The patients experienced their recurrent idea and repetitive behavior as agonizing. They had insights that their obsession or compulsion was excessive or unreasonable, and tried to resist it. The symptoms were similar to those of psychoses, but patients did not have definite psychotic symptoms. Severe symptoms persisted for a long time after admission. Categorization according to obsession and compulsion supported the criteria for obsessive-compulsive disorder in DSM-IV. It showed concretely that a number of children and adolescents with severe obsessive-compulsive symptoms had marginal features of the symptoms. Of 20 cases excluding 2 cases classified as atypical type III, seven patients (35.0%) understood that their symptoms were excessive or unreasonable, and 10 cases (50.0%) showed objective resistance to their symptoms. However, insight or resistance to the obsessive-compulsive symptom was not as stable as that in adult patients with such symptoms, and vacillated during the course of the disease.