Obsessive-compulsive disorder (OCD) is a mental health condition that affects many people. OCD has a genetic predisposition and frequently has a familial presentation. It is a neuropsychiatric condition affecting certain connections between the frontal brain and the deeper midbrain. The neurotransmitter serotonin plays a crucial role in not only its pathology but also in treatment considerations. The usual age of onset in children is around 9-10 years of age, with an incidence of 1-3%.
OCD has a mild to moderate progression course, and many individuals and families tend to dismiss it as a quirk in a child’s personality. The disorder is episodic and can be exacerbated by stress. At times OCD can become more severe and create more dysfunction and impairment in a person’s daily functioning, prompting families to seek help. It is not uncommon that families with a child with OCD present to a clinician’s office with other concerns such as depression, anxiety, or school problems. Frequently, therapists or doctors will not have an OCD diagnosis on their radar and will not consider this disorder in their differential diagnosis. Many kids and sometimes their families see the thoughts and rituals associated with OCD as parts of someone’s personality. They might feel embarrassed discussing them with others, believing that people might think that they are “weird.”
There are many variations in the clinical presentation of OCD. Dr. John March, a national expert on this disorder, says OCD is like “31 flavors” ice cream. You might present with chocolate or pistachio flavor, yet this does not change the fact that it is still ice cream. Most people are familiar with the most common form of OCD that presents with contamination obsessions and excessive hand-washing rituals, but—when it presents in other ways, such as intrusive thoughts of hurting loved ones or fears of shouting blasphemous comments in church—these presentations might be confused with auditory hallucinations. In cases like this, the child may be diagnosed and treated for psychosis—an extremely rare condition in childhood.
I will share a brief clinical composite vignette to illustrate this point. Johnny was a 12-year old male that I evaluated after a psychiatric hospital discharge. He noted that he was admitted for “depression, psychosis, and suicidality.” In my interview, he said he had been afflicted for several weeks by thoughts (his voice) telling him to stab himself or his mother. These thoughts made him very anxious and frightened. He was adamant that he did not want to hurt himself or his mother. These thoughts led him to recruit his mother to constantly inspect the house for sharp objects and lock them up in drawers. On further evaluation, we determined that he was not “depressed, psychotic, suicidal, or homicidal.” His mother noted that she conspired with Johnny, helping him hide and lock up these sharp objects to reassure and placate him. I pointed out that this would most likely reinforce the obsessions and rituals.
Another presentation that typically appears in the younger child population of 5–8-year-olds is Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal Infections (PANDAS). This variety of OCD has a faster and more intense presentation and may require working closely with the pediatrician to treat the strep infection.
Some patients present with only mental obsessions (doubts, “sinful thoughts,” perfectionism) and mental rituals (counting, checking, excessive procrastination) vs. behavioral observable rituals. These varieties are more challenging to identify and diagnose. The clinician needs to be suspicious and almost wear a “detective cap” to make the correct diagnosis. Of course, it is also essential to look for other commonly encountered conditions, like depression, anxiety, trauma, or behavioral problems that can mask OCD.
It is essential to reach a correct OCD diagnosis, as this will guide the recommendation of the most effective treatment. Clinicians must establish a trusting, nonjudgmental, and caring relationship with patients and their families. Many people with OCD are very guarded and reluctant to disclose their obsessions due to magical thinking—the idea that if they share their fears, these might become a reality. Imagine you are in the middle of a Los Angeles freeway, stuck in a traffic jam, and moving is complicated. Similarly, the person with OCD recognizes that they are stuck; their “mental traffic is jammed.” Here the role of the family members is enormously important, as they become coaches who support the patient as they recover (for example, by not reinforcing their rituals and reminding them that what they are experiencing is related to OCD).
There are several very effective, evidence-based treatments for OCD. The most effective intervention is a form of psychotherapy called Cognitive Behavioral Therapy (more specifically, Exposure and Relapse Prevention (CBT-ERP)). But this requires specialized behavioral care expertise, and sometimes it is difficult to find a therapist that uses this modality effectively, especially with its modified version for children.
Medications can also be effective, especially Selective Serotonin Reuptake Inhibitors (SSRIs). Examples of SSRIs include Sertraline and Fluoxetine or an older medication, Clomipramine. The most effective approach is the combination of CBT-ERP and an SSRI medication, which studies have proven effective with the best outcomes. Stress can precipitate the condition, and as such, helping the person manage stress better through regular exercise, relaxation techniques, and becoming more adept at monitoring stress levels in their lives can be helpful.
Lastly, it is essential to note that most people tend to minimize the severity of OCD and avoid seeking help because of biases in our thinking (for example, we may say that “I check things a few times, wash my hands multiple times a day or obsess over some issues, but I don’t see the problem”). These thoughts and rituals can keep someone stuck, unable to move ahead with their tasks and responsibilities for hours. The biggest concern with OCD is that it prevents a person with adequate skills from carrying out their daily activities, and they will frequently feel “bullied and enslaved” by OCD.
I hope that this summary of OCD can shed some light and guidance to patients suffering from this disorder, help families support their loved ones, and assist clinicians that encounter this condition in becoming more adept at recognizing the needle in the haystack and seeking added training on how to diagnose OCD and explore effective treatment options.
