"Lion" by Nicole
and Treatment of Obsessive Compulsive Disorder in Children and Adolescents
Compulsive Disorder in Adults
and Social Phobia
in the Elderly
Related to OCD
Anxiety in Young Children
E. Watkins, MD
Northern County Psychiatric Associates
Normal anxiety and fear tends to follow
a developmental sequence. These tendencies seem to be hard-wired and seem to
have a developmental purpose. Infants commonly show a fearful response to loud
noise or the sudden loss of physical support. Reluctance to be separated from
one's caregiver is a normal, healthy response in young children and indicated
the development of healthy attachment. When a child starts to walk on its own,
fear of strange animals is an adaptive response. Performance anxiety can appear
in late childhood and social phobia in adolescence.
Some degree of separation anxiety is a
sign that the preschooler has developed healthy attachments to loved ones. In
many cases, it stops within 3-4 minutes after the parent leaves.
Temperament. Some children seem more
irritable and clingy as infants, have more trouble establishing a regular daily
schedule, and have more difficulty with transitions. (This is more enduring than
a couple of months of colic) Such children may be more vulnerable to separation
anxiety. Such a child may require more work and attention. However, having a
more difficult temperament, does not invariably lead to problems in later
Normal Development of Separation: Most
common times for separation fears: eight months, twelve months and anywhere
between 18 months to three years. Separation anxiety generally emerges around
nine months of age and peaks around 12-24 months. The child's crying and
clinging can express two different messages. First, the child may cry when the
parent leaves because they fear that the parent will be gone forever. The second
situation is when the child, often after a fairly good day, begins to cry when
the parent returns. This is because the parent's return reminds the child of how
he or she felt when the parent left. Sometimes, children between one and two
years of age may walk or crawl away themselves, and then become anxious at the
separation they themselves have created. Separation anxiety generally decreases
between 2 and 3 years of age. The child often tends to be shy with strangers,
but morning separations become easier. The degree of separation difficulty may
vary from day to day. One day, the child may be anxious to go and another day,
clingy and sad. Many two-year-olds go through a phase when they prefer a
particular parent. This can exhaust the desired parent and make the other parent
feel unloved. The child has more of a drive toward independence. Still
transition times can be difficult, and lead to temper tantrums.
For toddlers, those who have had either
very few or very frequent separations from loved ones experience the most
separation anxiety. Adults too experience anxiety when separated from loved
ones, but it is usually not so overwhelming. The adult has a better concept of
time and has had more experience dealing successfully with separation.
Factors that may contribute to
- Minor or major illness
- Changes in the household routine
- Family changes such as birth of a
sibling, divorce, death or illness.
- Change in caregiver or routine at day
- Parents usually are not the cause of
the separation anxiety, but they can make things worse or better.
Factors that may reduce the chances of
developing separation anxiety
- Start occasionally using a babysitter
by six months of age. This helps the child tolerate short periods away from
the parent and encourages him or her to build trust in other adults.
- Even though children of this age do
not engage in cooperative play, start contact with peers by 12 months. By
age three, the child should be experiencing play groups.
- Some form of preschool may be helpful
by age 3 or 4. This is especially important for children who seem overly
dependent on their parents.
Supporting a child through periods of
- Positive experiences with caregivers,
short times at first.
- Help child become familiar with new
surroundings and people before actually leaving the child there.
- Rituals (bedtime and morning)
- "Lovie" or
"Cuddly" Represents closeness to parents. If possible, allow the
child to take the "Lovie" along.
- Do not give in. Let the child know
that he or she will be all right.
- Remind the child of previous brave
things he or she has done. Talk about how a fictional character might handle
- Let child know, in words he or she
can understand that you appreciate how distressing it must be to be
separated from loved ones. Understanding and acceptance, but not excessive
- Never make fun of a child's
separation distress. Do not scold child for it.
- Do not bribe child to mask the
distress. If you plan a special activity after you pick the child up, let it
- Focus on the positive things that
happened in daycare. Don't let them dwell on fears or imagination of what
- Minimize fears by limiting scary TV
- If it is an older child, consider
introducing him or her to some of the children who are to be in the class
and arranging play dates in advance.
- Preparing the child--reading books
about going to preschool, pretending about going on voyages or quests.
- Make shopping for school supplies a
special event just for that child.
- Expect a child to be more tired and
possibly more irritable than usual when he or she starts Kindergarten or
First grade for the first few weeks.
- When leaving, give a quick kiss and
hug and cheerfully say goodbye.
- Don't prolong your departure or come
back several times.
- Don't sneak out of the room.
- Even if you feel that a strict
teacher or a bully might be part of the problem, keep your child going to
school while these problems are being handled.
- If your child does stay home, do not
make it an extra fun, gratifying day.
The Anxious Parent--Suggestions for
- Teacher should introduce self to
child and invite the child to play with toys or have a snack.
- Offer to have the parent stay a
while, leave the child alone briefly with the teacher and then return.
- Suggest to the parent that he or she
try role playing with the child to rehearse the separation.
- Teacher could have a ritual for the
parent leaving the child.
- If the child is in an absolute panic,
ask parent to stay until the child is quieter. Teacher should ask parent to
comfort child in a firm, loving voice.
- Teacher should never criticize child
for feeling sad or anxious.
- Child is inconsolable for more than 2
- Repeated physical complaints in the
morning before preschool.
- Separation anxiety continuing into
elementary school years and interfering with activities that other children
do at that particular age.
- No separation anxiety at any time.
- School refusal in an older child or
adolescent is often a more serious problem. In such a case, the parent
should seek professional help early.
Separation Anxiety Disorder
Diagnosis and Symptoms: Severe,
persistent anxiety about being separated from home or parents. The anxiety must
be severe enough to interfere with normal activities. The child generally shows
distress when separated from parents, and worries that the parents may suffer
harm when away from the child. When separated, the child may have nightmares and
sleep problems. Physical symptoms such as nausea, headaches and abdominal pain
may occur before or during a separation. The diagnosis is not made if the
symptoms are part of another disorder such as Pervasive Developmental Disorder,
or a psychotic disorder. (These diagnoses are rarer and usually more serious
than separation anxiety disorder)
- Behavioral--Parents and child may
benefit from counseling. Parent education and family therapy are often
beneficial. In some cases, the child may also benefit from individual play
therapy. Coordination is a key factor. The family should make sure that the
mental health provider is willing to make the effort to coordinate between
the pediatrician, the school and the family. Extended family may also need
to be involved. The parents need to develop a consistent morning plan to
help support the child in going to school. The school or day care providers
and the school nurse are often included in the plan so that the responses to
the child are consistent. If the child frequently complains of physical
symptoms in the morning, the pediatrician should do a thorough physical exam
to rule out any physical causes. Once this has been done, the pediatrician
can reassure the parents and child if they call about the symptoms. If
physical symptoms show a sudden change, the parents may need to have the
child examined again. Once a particular symptoms has been carefully
considered, it is often best not to do repeated medical evaluations of the
same symptom. It is ideal if one or both parents are home and awake when the
child leaves for school. If another caregiver is designated to see the child
off to school, this individual should be involved in the therapy. I try to
avoid home schooling in such children because it tends to become
self-perpetuating. For many anxiety disorders, including phobias and COD,
the best therapy is to face one's fears consistently. Daily school
attendance often leads to symptom remission.
- Medication. This is needed for a
minority of children who have persistent symptoms, resistant to behavior
modification and psychotherapy. There have been significant strides in
knowledge of psychiatric medications for children. A number of studies have
shown that Imipramine (Tofranil) can help separation anxiety disorder.
However, one needs to follow EKGs (heart tests) and blood tests for safety
reasons. Sometimes, high doses were necessary for improvement. In the past
10-15 years, a new class of antidepressant medications has made treatment of
childhood depression and anxiety disorders safer and more effective. The
SSRIs, Prozac, Zoloft, Paxil etc. When used carefully and monitored closely,
can help separation anxiety disorder. At this point, an SSRI would be the
medication of choice instead of Imipramine.
The Good-bye Book by
Into the Great Forest: A story for children away
from their parents for the first time by
Going to Daycare by Fred Rogers
Disorder in Children and Adolescents
Carol E. Watkins, MD
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
Symptoms and Features of
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)
obsessions as follows:
- 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
- The thoughts, impulses, or images are
not simply excessive worries about real-life problems.
- The person attempts to ignore or
suppress such thoughts, impulses, or images, or to neutralize them with some
other thought or action.
- 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:
- 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
- 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:
- 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.
- 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
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.
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
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.
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.
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
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.
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
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.
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.
- Clomipramine, (Anafranil) ages 10 and
- Fluvoxamine, (Luvox) ages 8 and up.
- Sertraline, (Zoloft) ages 6 and up.
- Fluoxetine, (Prozac) approved for
adults, approved for treatment of deprssion in children aged 8 and up.
- Paroxetine (brand name Paxil)
approved for adults. (not recommended for children: warning sent out June
- Citalopran and Escitalopran (Celexa and
Lexapro) approved for adults
- Venlafaxine (Effexor and Effexor XR) not
recommended for children-advisory sent out by Wyeth August 2003.
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. Several of these medications are available in liquid form,
but you may have to special-order them. Using the liquid, one can start at very small doses and titrate the dose
gradually. Common side effects of these medications 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.
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
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
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
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
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
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.
Description of symptoms
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
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
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.
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
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
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
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.
Obsessive Compulsive Disorder is more
common than generally believed 20 years ago. It appears to be largely a
neuropsychiatries 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.
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.