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Obsessive compulsive disorder can occur in both children and adults. It is characterized by obsessions (repeated thoughts or images which cause distress) and compulsions (repetitive behaviors or rituals) These symptoms are often associated with significant anxiety and depression. The affected individual often fears that he is "'going crazy."

Obsessions may often involve thoughts which seem unacceptable to the individual, so that he or she feels ashamed. Because of this, many people keep their thoughts a secret and suffer silently. In the past decade, there have been advances in the behavioral and pharmacological treatment of Obsessive Compulsive Disorder.

Diagnosis and Treatment of OCD in Children and Adolescents

Obsessive-Compulsive Disorder in Adults

Books for Children and Adolescents with OCD

Our Presentations on OCD in Children

Separation Anxiety Disorder See our article on this topic

Obsessive-Compulsive Disorder in Children and Adolescents

Carol E. Watkins, M.D.

Introduction

At one time, Obsessive Compulsive Disorder (OCD) was believed to be fairly rare. When it was diagnosed, it seemed resistant to treatment. In the past decade, we have learned that it is much more prevalent. Community surveys of adolescents have suggested that at any given time, 1% to over 3% are experiencing symptoms of OCD. Children as young as 5 or 6 can show full-blown OCD. Between 30% and 50 % of adults with OCD reported that their symptoms started during or before mid-adolescence. Fortunately, there are now more effective treatments for OCD. In many ways the symptoms and treatments of OCD in both children and adults follow the same general principles. However, children differ from adults cognitively, developmentally and physiologically. Because of this, we modify techniques based on the particular stage of childhood or adolescence.

Symptoms and Features of OCD

In order to meet DSM-4 criteria for OCD, the individual must have either obsessions or compulsions. In actuality, most children and adolescents have both.

The Diagnostic and Statistical Manual of the American Psychiatric Association (DSM-4) defines obsessions as follows:

1.     Recurrent and persistent thoughts, impulses or images that are experienced, at some time during the disturbance, as intrusive and inappropriate and that cause marked anxiety or distress

2.     The thoughts, impulses, or images are not simply excessive worries about real-life problems.

3.     The person attempts to ignore or suppress such thoughts, impulses, or images, or to neutralize them with some other thought or action.

4.     The person recognizes that the obsessional thoughts, impulses, or images are a product of his or her own mind (not imposed from without as in thought insertion)

The DSM-4 defines compulsions as:

1.     Repetitive behaviors (e.g. hand washing, ordering, checking) or mental acts (e.g. praying, counting, repeating words silently) that the person feels driven to perform in response to an obsession, or according to rules that must be applied rigidly.

2.     The behaviors or mental acts are aimed at preventing or reducing distress or preventing some dreaded event or situation; however, these behaviors or mental acts either are not connected in a realistic way with what they are designed to neutralize or prevent or are clearly excessive.

The DSM-4 also requires:

1.     The obsessions or compulsions cause marked distress, are time consuming (take more than 1 hour per day), or significantly interfere with the person's normal routine, occupational (or academic) functioning, or usual social activities.

2.     At some point during the course of the disorder, the person has recognized that the obsessions or compulsions are excessive or unreasonable. Note: This does not apply to children

Evaluation

When a clinician is evaluating a child or adolescent for possible OCD, it is important to do a thorough work up. The clinician should meet with the child and ask specific questions about obsessions and compulsions. He or she should also meet with parents or other primary caregivers. Information from school and other outside sources is also useful. If there are obsessions or rituals that occur only at school, it is important to know about them, so that they can be addressed too. The parents and usually the child may also fill out checklists such as the YBOCS (Yale-Brown Obsessive Compulsive Scale) These help to determine the baseline number and severity of the symptoms. Since OCD can be associated with other disorders, the clinician should look other childhood psychiatric disorders.

Most individuals with OCD, even young ones, are at least intermittently aware that their symptoms do not make logical sense. However, young children are less capable of abstract thought, so their degree of insight may not be as good.

Causes

There have been several theories about the cause of OCD. These include psychodynamic, learning theories, and neuro-biological. When we discuss cause, it is important to make it clear that we are looking at Obsessive Compulsive Disorder, not an obsessive, perfectionistic personality style. An obsessive-compulsive personality disorder is different from true Obsessive-Compulsive Disorder. There may be some overlap or it may have a different origin.

Psychodynamic: Freud classified Obsessive Compulsive Disorder as a psychoneurosis. The roots of the illness lay in a disturbance in the sexual life or development of the child. Freud did recognize that one's heredity and innate constitution contributed to the development of the disorder. In Freud's theory of infantile sexuality, the child goes through the stages of oral, anal and oedipal sexual interest. If the child does not successfully progress through each phase, he may develop later difficulties. During early childhood, sometimes during or just before the oedipal phase, there might be a conflict between the ego (the mediating and observing entity) and the id (the source of sexual and destructive energy). The ego solves the conflict by setting up a way of reducing the effect of the id. In some cases, the solution is an unstable one. Part of the unstable compromise might be regression to the earlier anal level of development. Such an individual might have a tendency to hoard and a horror of throwing things away. Other obsessive symptoms such as checking might be seen as a way of dealing with the unwanted intrusion of hostile oedipal wishes. (Such as a boy wishing his father dead so he could marry his mother.) If one needed to repeatedly check faucets, it might be a defense against a childhood wish to flood the house and thus kill the father. The symptoms may start to express themselves years later when something happens to weaken the ego and its shakier defenses.

It is possible that these psychodynamic formulations are more relevant to individuals with obsessive or compulsive personality traits rather than to individuals with true OCD.

Biological: Most recent research studies point toward a biological basis for OCD. However, there may be subtypes of OCD. Different subtypes may have distinct biological mechanisms. As research continues, the understanding of the neurological and related biochemical mechanisms will improve. PET Scans (a kind of brain scan that shows levels of brain activity in specific areas.) have shown abnormalities in the sub-orbital cortex (the underside of the front part of the brain) and the basal ganglia.  A striking abnormality was increased activity in the sub-orbital cortex. When patients were successfully treated, whether with psychotherapy or medication, the brain scan studies resembled those individuals without OCD. Serotonin seems to be involved in mediating the interaction between these two parts of the brain.

Some cases of OCD may be associated with Tourette's Disorder. Tourette's is characterized by multiple tics. (involuntary rapid movement or vocalization) Individuals with Tourette's may also have OCD symptoms, and Attention Deficit Disorder. Tourette's is often inherited. Relatives of individuals with Tourette's may have OCD without the tics. Finally, recent research has suggested that some cases of OCD may be related to the bacteria, B-hemolytic streptococcus. This syndrome is referred to as PANDAs. Antibodies may attack segments of the brain to produce an acute onset of OCD symptoms. Similar antibodies may cause rheumatic heart disease. More research is needed in this area. However, if the OCD starts suddenly, around the same time as an upper respiratory illness, one might consider a throat swab to check for the presence of B-hemolytic streptococcus infection. If the bacteria are present, further tests, treatment with an antibiotic and a referral to a specialized center might be considered.

Associated disorders

Tourette's Disorder is more likely to be present in boys and in children who develop OCD at a younger age. It is important to identify this disorder because treatment may need to be modified. Children and adolescents with OCD are more likely to have Attention Deficit Disorder, learning disorders oppositional behavior, separation anxiety disorder and other anxiety disorders. Some of the anxiety disorders have similarities to OCD and are called obsessive-compulsive spectrum disorders. These include tricotillomania, (compulsive hair pulling and twirling, ) body dysmorphic disorder (the obsession that part of one's body is unattractive or misshapen) and habit disorders such as nail biting and scab picking. The exact relationship between these two spectrum disorders and true OCD is not yet entirely clear.

Consequences of OCD

If not treated, OCD tends to be a long-term disorder. Some individuals experience waxing and waning symptoms over the years. Others experience progressive worsening of their OCD until they are housebound and spend much of their days involved in obsessions and rituals. Chronic anxiety disorders may lead to depression. If a child spends a great deal of time obsessing or engaging in mental rituals, he or she may have trouble focusing on the school lessons. Individuals who need to repeatedly erase and rewrite assignments may need to spend hours of time of homework and lose time for friends and family. This same individual may not be able to finish projects because the work is never "just right." Some children and teens may become oppositional if others attempt to interrupt their rituals. For the large number of individuals who manage to hide their symptoms, the cost may simply be years of anxiety and low self-esteem.

Children and Adolescents are Different from Adults

The DSM-4 criteria for children and adults differ for the criterion on insight. An adult generally is at least intermittently aware that the obsessions or compulsions are unrealistic. Most of the time, this is also true for children and adolescents. However some children, particularly young ones, may not have the cognitive capacity to understand the nature of the obsessions or compulsions. Oppositional children or adolescents may not want to admit that there is something awry with their behavior. In that case, a therapeutic alliance with a clinician may enable him or her to discuss his or her real feelings about the symptoms. Family issues are different for children.  The child’s cognitive development necessitates some changes in the psychotherapeutic approach. If medications are used, the physician must consider the child’s smaller size and different metabolism.

Treatment

In this article, we will focus on medication and cognitive-behavioral psychotherapy. There are other psychodynamic, play therapy and family therapy approaches to the treatment of OCD.

Once a child has been diagnosed with OCD, we need to decide which treatment or treatments to use first. Many clinicians prefer to start off with cognitive-behavioral psychotherapy. If there is no response or only a partial response, medication may then be added. There circumstances in which it is appropriate to start medication and psychotherapy simultaneously or even to start with medication alone. Moderate to severe OCD may merit starting with a combined approach. If a child or adolescent is extremely resistant to the idea of psychotherapy, one might consider starting with medication alone.

Cognitive-Behavioral Psychotherapy

It would be difficult to discuss this topic without giving a great deal of credit to John March MD and his collaborators. They have developed, tested, and disseminated specific information that includes a detailed protocol for treatment of childhood OCD.

Near the beginning of this type of therapy, the child and family are educated about the biological basis of OCD. Even young children can gain some understanding of this concept if it is presented in an age-appropriate manner. For young children, I often draw an outline of the brain and let them color round and round to signify the repetitive thoughts and actions. Older children and adolescents may appreciate pictures of brain imaging studies. I have used the pictures in the introduction section of the book, Brain Lock by Jeffrey Schwartz, MD. These pictures vividly show the differences in brain activity between affected and unaffected individuals.

When the child and family realize the biological basis of the disorder, they find it easier to externalize the symptoms. The symptoms are the fault of the disease, not the individual or family. Children continue to need more concrete models and concepts throughout the therapy. Often one may help them conceptualize the OCD or OCD symptoms as an unpleasant or silly creature. The child may also want to give this creature a name. In the illustrated children’s book, Blink, Blink, Clop, Clop, Why Do We Do Things We Can’t Stop? The OCD is named "OC Flea", and is drawn as an unattractive, silly but non-threatening creature. Subsequent therapy helps the child shrink, squash, boss or drive away the OCD.

As the therapy progresses, the child should begin to expose himself to the anxiety-provoking object or situation and then try to avoid performing the usual compulsion. This is called exposure and response prevention. It may have to be done gradually because it can cause the child to experience significant anxiety. The child himself should have an important role in determining how quickly he wants to move through these steps. The parents can help with this too by reducing and then eliminating reassurances when a child asks obsessive questions. At the same time, they should be supportive and avoid blaming the child if he is unable to avoid performing some of the compulsions.

The child may benefit from learning relaxation techniques and learning mental self-monitoring. Other specific techniques may help individual children tolerate the anxiety engendered by the exposure and response prevention.

When the symptoms are eliminated or at least reduced to a tolerable level, the therapist should talk to the child and parents about the future. Symptoms may start to come back at a later date. They should review the symptoms and discuss how to deal with them. Some individuals come in for intermittent refresher sessions.

Medication

Recent advances in medication have added to our treatment options. In the past few years there have been more studies testing these medications specifically on children. In general, children who need medication respond to the same medications used for adults with OCD. The FDA has approved some of these medications for use in children with OCD. However, a physician may, after discussion with the family, elect to use a medication that technically is only approved for adults. Families should be aware that in the fall of 2004, the FDA issued the following advisory on the use of antidepressants in children and adolescents.

1. Clomipramine, (Anafranil) ages 10 and up     
2. Fluvoxamine, (Luvox) ages 8 and up    
3. Sertraline, (Zoloft) ages 6 and up.     
4. Fluoxetine, (Prozac) approved for adults and for children ages 7 and up for depression and OCD    
5. Paroxetine (brand name Paxil) approved for adults.

The main medications used for OCD are Clomipramine (brand name Anafranil) and the Selective Serotonin Reuptake Inhibitors. There are several other medications that may be added if those medications produce only a partial response.

Clomipramine is chemically similar to the older tricyclic antidepressants. Its efficacy in OCD seems to be related to its ability to decrease serotonin reuptake. It used to be the only effective drug for OCD. At this point, it is usually not the first line drug for children with OCD. This is because of several potential side effects. It can be sedating. It can also cause dry mouth and eyes. It has been associated with some changes in EKGs. (A measure of the heart rate and the electrical conduction within the heart.) Because children may be more sensitive to this cardiac effect, we usually monitor EKGs and heart rate in children on Clomipramine. Despite this, when used carefully, it has helped many children and adolescents with OCD.

There are now several SSRI medications. They include Fluoxetine (brand name Prozac) Fluvoxamine (brand name Luvox) Paroxetine (brand name Paxil) and Sertraline (brand name Zoloft). All seem to be effective at reducing the symptoms of OCD, but different ones may be best for individual patients. Fluoxetine has the advantage of being available in liquid form. Using the liquid, one can start at very small doses and titrate the dose gradually. Common side effects include headache, GI complaints, tremor, agitation, drowsiness and insomnia. These medications may affect how other drugs are broken down in the liver. One must use caution when mixing medications. If a child taking an SSRI, it is a good idea to consult one’s physician or pharmacist before taking other prescription or even non-prescription medications. Many children take a long time to achieve a good response to medication. 10 to 12 weeks is not uncommon. Some children will respond to one medication but not to another.

Dealing with Recurrences

Education about OCD often an early part of the therapy. Both parents and child are included. It is important for them to continue the education process. A good understanding of the disorder can help the child and family feel a greater sense of mastery and control.

The process of education should extend on after the end of the therapy. It can occur through reading age-appropriate books, attending support groups or having group therapy with peers. I have listed some recommended books and support groups at the end of the article. Secrecy and shame are common in individuals with OCD. Education and the support of others can help the individual keep the disorder in perspective.

Children and families should be aware that OCD can be chronic and that symptoms may return months or years later. Some children will schedule "check up" sessions every six months or each year. If symptoms reoccur, they may return to therapy for a shortened version of their previous treatment.

Suggested readings and Internet Links

Brain Lock: Free Yourself from Obsessive-Compulsive Behavior by Jeffrey M. Schwartz 1996, Regan Books. This book is primarily aimed at adults. However, I have found it useful for adolescents and for relatives of the child or adolescent with OCD. Dr. Schwartz discusses both the causes and symptoms of OCD. He then suggests a four-step self-help approach to help the individual deal with the symptoms of OCD. For those who do not want to read the entire book, he provides a summary of the basics of the four steps near the end of the book. Some individuals may be able to use the book to deal with the OCD by themselves. I prefer to use it with patients as an adjunct to therapy and as a reminder between sessions.

Blink, Blink, Clop, Clop: Why Do We Do Things We Can't Stop? by Moritz and Jablonsky, ChildsWork, ChildsPlay (1998) This illustrated book explains OCD to elementary-aged children. It uses the metaphor of farm animals who are tormented by "O.C.Flea." It can be a useful story early on in the child's therapy. This book is probably best read with or to a child. Some of the concepts and vocabulary are more advanced and should be explained.

OCD in Children and Adolescents: A Cognitive-Behavioral Manual by John March and Karen Mulle1998, The Guilford Press. This book is fairly technical and is aimed at psychiatrists and other mental health professionals. This book contains the excellent cognitive-behavioral protocol that Dr. March has been using successfully with children and adolescents with OCD. The book also discusses in more depth special considerations in treating OCD as it occurs in children.

AACAP, (1998) Practice Parameters for the Assessment and Treatment of Children and Adolescents with Obsessive-Compulsive Disorder, Journal of the American Academy of Child & Adolescent Psychiatry, 37:10;27s-45s.

American Psychiatric Association (1994) Diagnostic and Statistical Manual of Mental Disorders, 4th Edition (DSM-IV) Washington, D.C. American Psychiatric Association.

Obsessive Compulsive Disorder in Adults
Glenn Brynes, PhD, MD

Description of symptoms

"Imagine you are getting up in the morning. You know you will need to go to the bathroom, but the thought of accidentally touching the doorknob is frightening. There may be dangerous bacteria on it. Of course you cleaned the entire bathroom yesterday, including the usual series of disinfectant spraying, washing and rinsing. As usual it took a couple of hours to do it the right way. Even then you weren't sure whether you had missed an area, so you had to re-wash the floor. Naturally the doorknob was sprayed and rubbed three times with a bactericidal spray. Now the thought that you could have missed a spot on the doorknob makes you very nervous. Maybe you should have cleaned it another time? Carefully you put on your laundered slippers and think to yourself repeatedly, "The Lord will protect me from all germs; I will fear no evil", and cross the floor to the bathroom, careful to do it in exactly 10 steps. On some days you spend so much of your time checking, cleaning and arranging things, there is little time left for other matters."

This description might give you some sense of the tormented and anxious world that people with Obsessive Compulsive Disorder (OCD) live in. It is a world filled with dangers from outside and from within. Often elaborate rituals and thoughts are used to ward off feared events, but no amount of mental or physical activity seems adequate, so doubt and anxiety are often present.
Obsessions are thoughts or images that seem to intrude into a person's mind. While he generally knows they are his own thoughts, he can't control them, and finds them very disturbing. They may take the form of fears of something terrible happening to himself, his friends or family, often as a result of his own actions or neglect.

Compulsions are behaviors that usually are repetitive and stereotyped. They may take the form of actions or thoughts. The compulsive behaviors are intended to reduce the anxiety engendered by obsessions. People who do not have OCD may perform behaviors in a ritualistic way, repeating, checking, or washing things out of habit or concern. Generally this is done without much if any worry. What distinguishes OCD as a psychiatric disorder is that the experience of obsessions, and the performance of rituals, reaches such an intensity or frequency that it causes significant psychological distress and interferes in a significant way with psychosocial functioning. The guideline of at least one hour spent on symptoms per day (American Psychiatric Association 1994; Goodman et al. 1989b) is often used as a measure of "significant interference." However, among patients who try to avoid situations that bring on anxiety and compulsions, the actual symptoms may not consume an hour. Yet the quantity of "time lost" from having to avoid objects or situations would clearly constitute interfering with functioning. Consider, for instance, a welfare mother who throws out more than $100 of groceries a week because of contamination fears. Although this behavior has a major effect on her functioning, it might not consume one hour per day.
Patients with OCD describe their experience as having thoughts (obsessions) that they associate with some danger. The sufferer generally recognizes that it is his own thought, rather than something imposed by someone else (as in some paranoid schizophrenic patients). However the disturbing thought cannot be dismissed, and simply nags at him. Something must then be done to relieve the danger and mitigate the fear. This leads to actions and thoughts that are intended to neutralize the danger. These are the compulsions. Because these behaviors seem to give the otherwise "helplessly anxious" person something to combat the danger, they are temporarily reassuring. However, since the "danger" is typically irrational or imaginary, it simply returns, thereby triggering another cycle of the briefly reassuring compulsions. From the standpoint of classic conditioning, this pattern of painful obsession followed by temporarily reassuring compulsion eventually produces an intensely ingrained habit. It is rare to see obsessions without compulsions.
The two most common obsessions are fears of contamination and fear of harming oneself or others. The two most common compulsions are checking and cleaning (Foa and Kozak 1995).

OCD Can Mimic Other Disorders

An OCD sufferer with an intense fear of contamination might avoid the object of his fear by staying home, and thus become housebound as in agoraphobia. The distinction becomes apparent when the reason for staying home is investigated.

Obsessive Compulsive Disorder may manifest with fears of contracting severe illnesses, such as cancer, venereal diseases or AIDS. These somatic obsessions may resemble hypochondria. Despite the similarities, the OCD patient will often have a typical history of various obsessions and compulsive symptoms that are not primarily somatic (e.g. fears of hitting someone, compulsions to count or check).

OCD can result in depression as well as avoidant behavior that resembles specific or social phobias. The degree of anxiety experienced in connection with the obsessions may be so pervasive that it can resemble generalized anxiety disorder.
 
Genetics of OCD

The prevalence of OCD in the United States is estimated to be 2-3%. Thus 5-7 million Americans have this illness. Studies of OCD patients and their families have established a 10% prevalence of OCD in first degree relatives (an additional 8% have a subclinical degree of OCD symptoms). The genetic connection seems to be higher if the onset of OCD is before age 14. In studies of twins, there is a 63% concordance rate for OCD in identical twins.
Treatment of OCD
Prior to studies in the 1980's, the usual view of OCD was that it was a relatively rare disorder with a poor prognosis. However, in addition to it being now recognized to be much more common (2-3% prevalence rate), it is generally seen to be treatable, with some 60%–80% of patients showing at least some response to treatment.
It is generally thought that the serotonin system in the brain is involved in the pathology of OCD, since the pharmacological agents that have been shown to be effective in the treatment of this disorder generally increase the availability of this neurotransmitter. These include the serotonin re-uptake inhibitors: clomipramine, fluoxetine, sertraline, paroxetine, fluvoxamine, and citalopram.
Behavioral therapy—specifically ERP [Exposure and Response Prevention]—has been successfully used for the treatment of OCD. The idea behind ERP is that compulsions provide only a temporary reduction of the anxiety produced by obsessions. Furthermore, the only way to experience more permanent relief is to habituate (grow tolerant of…"used to") the anxiety caused by the obsession without performing the compulsion. Habituation is the key factor, and clinicians proceed by first identifying triggers for and situations that bring on obsessional thoughts and compulsive behaviors and then developing a graduated hierarchy of anxiety based on the patient's report. The patient "challenges" him- or herself with the least anxiety-provoking items first and then moves up the hierarchy. In addition to exposure, the patient is instructed to refrain from carrying out the associated rituals.

Heidi was afraid of germs and dirt. She felt very uncomfortable whenever she had to go into a bathroom. She carried tissues with which to open the bathroom door, and had to wash her hands several times before leaving the bathroom. The door was then opened with a paper towel. If she accidentally touched the door, she had to wash all over again.
For her ERP treatment, Heidi was told to spent 10 minutes sitting on a chair in her bathroom without washing her hands. This was to be repeated each day for a week. Initially she felt very uncomfortable, and greatly wished to clean her hands. She found herself thinking of the dirt and "germs" that she felt must be everywhere in the bathroom. However with much effort she was able to tolerate this. Once she had 'mastered' this she was told to increase the time from 10 to 20 minutes. She was still uncomfortable, but was a bit surprised that spending twice as long didn't mean being twice as uncomfortable. Indeed after about 10 minutes, she felt somewhat relieved that nothing terrible had occurred. Further extending the time to 30 minutes simply led to her feeling that nothing was going to happen if she spent more time not washing. Once Heidi had mastered this, she was told to touch the inside of the sink, and not wash her hands for 10 minutes. Since she regarded the sink as one of the moderately dirty places in the bathroom, this presented a new challenge for her. As she mastered one level of discomfort, she was moved on to the next more challenging level, until she finally was able to use the bathroom without intolerable anxiety and without her usual rituals.
An added benefit of behavioral treatment is its long-term efficacy. Unlike pharmacotherapy, whose beneficial effects do not last in the great majority of patients after medication is withdrawn, behavioral therapy has shown continued efficacy in follow-up studies ranging from 1 to 6 years, although booster sessions may be required.

Summary

Obsessive Compulsive Disorder is more common than generally believed 20 years ago. It appears to be largely a neuropsychiatric condition, rather than a product of overly strict upbringing (as was once believed). Although OCD can have a paralyzing impact if not properly diagnosed and treated, there are fortunately behavioral and pharmacological approaches available that can help many of the sufferers from this potentially devastating illness.

Our practice, located in Lutherville and Monkton, Maryland, has psychiatrists and therapists who are experienced at treating obsessive compulsive disorder. We are experienced in providing both medications and cognitive-behavioral psychotherapy. We see patients from Baltimore County, Carroll County and Harford County. Because of our Monkton office is close to the state border, we see a number of patients from York County, Pennsylvania. For more information about our practice, see our home page www.ncpamd.com

 
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