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Sensory Integration Disorder with OCD and Depression in a Child
Agwani, Knox & Adams
Key words: Obsessive-Compulsive Disorder, OCD, Sensory Integration Disorder, SID, depression, children
Background: Obsessive-compulsive disorder is a fairly common diagnosis in the child and adolescent population, and is often accompanied by other psychiatric diagnoses.
Sampling and Methods: A ten-year-old female patient is described with depressive symptoms and compulsions, including wearing up to twenty layers of clothing at a time, as well as enuresis. A literature search for the differential diagnoses of depressive disorder NOS, Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal Infections (PANDAS), sensory integration disorder (SID), as well as OCD, was performed using Pubmed.
Results: A diagnosis of obsessive-compulsive disorder, depressive disorder NOS, and enuresis was made and PANDAS as well as SID were ruled out. The patient was treated with an antidepressant in conjunction with cognitive behavioral therapy and exhibited marked improvement in mood and compulsions.
Conclusion: Cognitive-behavioral therapy in combination with antidepressants was successful in the treatment of depression accompanied by comorbid psychiatric illnesses.
Obsessive-compulsive disorder is a psychiatric disorder characterized by recurrent thoughts, impulses, or compulsions which are intrusive and cause significant anxiety and distress. It is a fairly common diagnosis in the child and adolescent population and can manifest itself in a variety of ways, making its diagnosis difficult at times. OCD is recognized as a disorder commonly observed in adulthood, but studies have shown that its prevalence rate is 1-4% among adolescents also . The disorder is also highly associated with comorbid psychiatric conditions, especially anxiety and depression, and is often chronic  In one study 80% of children diagnosed with OCD suffered some other psychiatric diagnosis in their lifetime . In sensory integration disorder (SID), children generally sense tactile stimuli normally but perceive it abnormally. The disorder can be broken down into hyper- or hyposensitive categories. Children with hyposensitive problems may seek out sensory stimuli, as was the case with this patient. Difficulty with sensory integration can also present in a number of other psychiatric illnesses, including autism spectrum diseases, attention-deficit –hyperactivity disorder, and an inheritable condition called hypokalemic sensory overstimulation disorder .
We describe in this case a female with OCD accompanied by depressive symptoms, and enuresis.
The patient is a ten-year-old Caucasian female referred because of obsessions and compulsions including wearing up to twenty layers of clothing each day relating to the need for sensory or tactile stimulation that the bulk of the clothing provided. She also reported depressive symptoms such as depressed mood, hopelessness, and poor appetite, although it was unclear whether her reduced appetite was secondary to the initiation of Prozac some weeks earlier for depression and anxiety. Other problems included enuresis and multiple UTI’s, raising the concern of possible sexual abuse.
Delving further into the OCD history, the patient’s mother reported that she has been wearing several layers of shirts, pants, shorts, and up to three belts around her thorax, as well as rubber bands around her arms to hide the excessive layers of shirt sleeves. Her mother also admitted that the patient was compulsive about painting her toenails and constantly smoothing and pulling back her hair. These behaviors had become ritualized, with the girl wearing the clothing to bed every night and becoming highly distraught (crying, pleading) when forced not to do these things. Interestingly, when the patient went swimming she did not feel the need for extra layers.
Her past psychiatric history was significant for anxiety since childhood but no hospitalizations. She also had enuresis 1-2 times per week despite treatment with Ditropan as well as repeated UTI’s for which she was seeing a psychiatrist. It was thought that the infections were due to the multiple layers of underwear she wore and not sexual abuse, which she and her parents denied on multiple occasions. At the age of 4 she became “panicky” and refused to go outside in the wind, near dogs, or to preschool. Symptoms improved after treatment with Prozac which was discontinued at age 6 and remitted at the age of 9 with compulsions related to needing to protect herself.
Family history was significant for alcoholism, schizophrenia, and bipolar disorder.
Interestingly enough, the mother reported numerous streptococcal infections as a child, raising the possibility of PANDAS as a trigger for her OCD behaviors.
During the initial interview she showed insight into her obsessions and compulsions and stated that she wanted to “get better” and that she “didn’t dress right”.
She was dressed in two tank tops, a bathing suit top and two bottoms, and shorts. She appeared anxious and spoke softly throughout the assessment, and was tearful on three occasions, primarily when speaking about her past therapist. Her mood was sad with a congruent affect, and was cooperative throughout the session. Her activity was slightly low and her thought content was marked by worries about harm to herself and others as well as others knowing about her “problems”. Intelligence was above average and there were no suicidal or homicidal thoughts. Physical exam was unremarkable. ASO titers drawn approximately three months after initiation of outpatient treatment were negative.
A diagnosis of OCD, depressive disorder NOS, and enuresis was given. Outpatient cognitive behavioral therapy was initiated beginning on a weekly basis in addition to medical treatment with 30mg of Prozac daily. On the first visit the patient was evaluated using the Robert Apperception Test and found to have no evidence of a thought disorder. Early sessions focused on externalizing the OCD problem, forming a treatment team with the patient’s therapist and parents, identifying triggers to compulsions such as getting dressed and people dying, and repeating “leave me alone, I’m not gonna let you beat me” several times when having compulsions to layer clothing. The patient agreed to let her mother count the number of layers she wore each day in return for a reward. New goals were set each week to decrease the number of layers worn.
The patient progressed steadily but had several setbacks correlating with stress in starting a new school year and preoccupations with having “accidents” related to her enuresis. Coping, thought stopping, and distraction were used to relieve anxiety, as well as techniques in muscle relaxation, deep breathing, and imagery to help her cope. Cycles of family conflict and arguments were also addressed during sessions.
Less than three months after beginning therapy and treatment, bedwetting and UTI’s ceased and there was a significant increase in interactions of the patient with her peers. Approximately five months into treatment she was significantly less anxious and down to three tops and four bottoms, and at seven months was wearing just one layer of clothing daily and was calm with an appropriate affect.
The patient’s presentation in this case made it difficult to pin-point an exact diagnosis initially. Her depressive symptoms coupled with traits of both OCD and SID complicated the picture of pure obsessions and compulsions. The need for continuous tactile pressure or stimulation as well as a consultation with a urologist who stated that her incontinence may have been related to a sensory integration disorder led to consideration of SID. Children with SID with hyposensitivity-related difficulties may seek out sensory stimuli, as was the case with this patient. The patient in this case did not display any characteristics often associated with SID (such as autism, autism-spectrum disorders, and ADHD) and was deemed average to above average intelligence with good performance at both school and home. The successful use of CBT and anxiety-decreasing techniques against the patient’s compulsions favored the diagnosis of OCD instead but SID could not be ruled out initially due to the need for sensory stimuli that the bulk of the patient’s clothes provided.
Another diagnosis considered was PANDAS. The patient was known to have met three of the five criteria for a diagnosis of PANDAS to be made, including presence of OCD, pre-pubertal onset of symptoms, and association with group A streptococcal infections . The patient’s mother did report a recent GAS infection and multiple GAS infections throughout the patient’s childhood. However, there was no known strep infection around that time that the symptoms first began or remitted and there was an insidious onset of chronic symptoms which argues against the diagnosis of PANDAS . An ASO titer performed was found to be negative.
Having ruled out some of the less likely diagnoses in this case, the likelihood of explaining the symptoms with OCD alone or in combination with a depressive disorder became more likely. These diagnoses were further supported based on the positive outcomes attained fairly quickly with the use of cognitive behavioral therapy. A meta-analysis of existing literature on the subject has found family-based CBT to perhaps be the most promising therapy for young children with OCD yet is often inadequately utilized. [7, 8]. This case report supports these findings as shown by the successful treatment of childhood OCD and depression with CBT in combination with antidepressant medication in decreasing compulsions and bed-wetting and improving social interaction and mood. The use of rewards, thought-blocking, and relaxation techniques including deep breathing most certainly contributed to the success in therapy, as did a compliant patient and family. Additional follow-up in the future would be necessary in this case to track the long term success of the use of CBT as an adjunct to medication.
Sufian Agwani, MD
Child and Adolescent Psychiatry Fellow
University of Toledo Medical Center
Michele Knox, Ph.D.
Associate Professor of Psychiatry
Director of Psychology Training
University of Toledo
P. Bellanti. D. Adams
The University of Toledo, College of Medicine
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Copyright Priory Lodge Education Limited 1994 onFirst Published December 2008