Obsessive-Compulsive Disorder (OCD) in children: When it is not just a phase

[David Baxter PhD]

Obsessive-Compulsive Disorder (OCD) in Children?when it is not just a phase
by Dr. Elaine Ducharme, Your Mind, Your Body
February 1st, 2011

Obsessive-Compulsive Disorder (OCD) in children is a type of anxiety disorder. People with OCD have mental hiccups (obsessions) that make them feel anxious or uncomfortable. Their illness then tricks them into trying to eliminate that feeling by performing certain rituals over and over. These rituals are called compulsions. One in 200 young people suffers from OCD. This means that there are 3-4 youngsters in every average size elementary school and up to 20-30 in every high school. It is important to note that OCD is not just excessive worries about real life situations. Nor is it the fairly typical style of many children who like structure and routine. In order to qualify as true OCD they following criteria must be met:

• There are recurrent obsessions or compulsions severe enough to be time consuming, cause marked distress or significant impairment.
• The individual recognizes that the thoughts are a product of his own mind.
• The individual feels driven to perform certain behaviors even though they are not connected to what they are designed to neutralize.
• The individual recognizes the obsessive thoughts or repetitive behaviors are excessive or unreasonable. (Not always so in young children).
• The obsessions or compulsions generally take up more than one hour per day.

One of the problems with OCD is that the compulsions that kids do to feel better don?t seem to make much sense. Parents often try to use sensible measures to stop the OCD. They may try punishments or rewards that rarely work, because sensible measures don?t work very well against nonsensical OCD. As a result, parents, kids and everyone living in the household get frustrated. Sometimes, the obsessions and compulsions take up so much time that normal activities like eating a meal, getting to bed or getting up in the morning take hours to complete.

There is really good news, however, about the treatment for OCD. The most effective treatment for OCD is called Cognitive-Behavioral Therapy or CBT. John March, M.D. has written a wonderful book for kids and their families called Talking Back to OCD. Dr. March encourages parents to put their child back in charge of the OCD. Kids are encouraged to create a nickname for the illness in order to help them remember that they are separate from the OCD. They are then taught to make a symptom chart to identify the most mild symptoms to the most severe symptoms. This allows them to figure out where they can begin to fight back. They learn to develop a variety of tools that they can use to help them tolerate the anxiety that occurs when they ignore OCD?s instructions to perform rituals. This allows them to break OCD?s hold on them. Tools include such things as relaxation techniques, watching the episode pass like a cloud, shouting back at the OCD and even distraction. As the child realizes that when they do not listen to the OCD their anxiety generally decreases quite quickly they develop they emotional strength and self confidence to tackle more difficult OCD issues.

Essentially, this type of treatment is known as Exposure and Response Prevention. It is important to understand that every time a person performs the ritual to decrease the anxiety, they are essentially increasing the overall anxiety. Simply put, the more they do the ritual the worse it gets. This is because they continue to reinforce the idea that if they don?t perform the ritual something bad will happen. Only when they don?t perform the ritual and see that nothing bad happens will they be able to stand up to the OCD. Most often kids and parents benefit from working with a psychologist or other mental health professional trained in the use of CBT.

It is important to know that some children with very severe OCD symptoms may need medication to help them decrease their anxiety levels to a point where they can really learn CBT. This, in no way, means the individual is a failure or not strong enough to ?do it without meds?. Remember, OCD is a brain disorder. The obsessions and compulsions that we see among kids and adults alike are very similar. Typical themes include contamination, doubt, order, impulses to do bad things and sexual imagery.

One more point. Occasionally a child develops very severe symptoms of OCD, practically overnight, after being ill with a strep infection. It is important to consult your physician whenever your child has a sudden change in behavior. In this way, you can be certain your child receives the most appropriate treatment.

 

[br350]

Dr. Baxter:

Thank you for this post. I believe I had the seeds and beginnings of OCD as a young child. I remember rituals coming and going and not thinking too much of them. I am an identical twin and we both had our rituals, though they were different. I had times in my life, probably the teens in particular, when I remember an easing up of these rituals because I was so busy with school, work etc. I don't remember my parents even knowing about these rituals. If they did, they did not make much of them. I do remember when performing the rituals being perplexed at why I felt I had to 'get it right'. For instance, having to tap my toothbrush, when done brushing, on the edge of the sink a certain number of times before putting it in its holder.

If I could, I'll reiterate a bit of what I posted in my Introduction post as a new member to the forum. I've been a long time OCD sufferer with hypochondria as my main presentation. I am 44 and this began in earnest in my early 20's. I suffered from general anxieties and fears (sometimes intense) even as a child, but it really all coalesced after the sudden, unexpected death of my mother at the age of 41 (I was 20). After that, my health anxieties blossomed greatly and there began my road with depression (sometimes severe), anxiety, OCD and hypochondria.

Unlike some hypochondriacs, I do not doctor shop and I know that my illness fears are mainly rooted in my thought processes. When I have symptoms, I panic, look them up on the internet and process to panic more! I have been on/off medication for a number of years (currently on) and have resisted trying ERP because I feel that it does not address my basic, root fear of death and dying. After all, how can CBT help me to stop fearing death? Isn't that an instinctual, basic human fear that we all possess (or most of us) to some degree? For me, it is just overwhelming and obviously unhealthy.

I am reading Dr. David Burns' book "When Panic Attacks" and feel I am ready to really try and give his CBT techniques a shot. I realize I have nothing to lose as I have already lost so many precious years in a state of worry and panic to the OCD.

The OCD specialist I have seen off/on over the years strongly believes in ERP, even for my fear of death. I weakly tried writing the scripts and doing the ERP process with him but did not find it very effective. In fact, it was just depressing reading scripts about illness, death, etc. I do acknowledge I did not give it a fair shake and, now, years later, am willing to try the various techniques that Dr. Burns has presented in his book. I'm curious if you know if his techniques have truly worked with health anxiety (hypochondria) fears.

Thanks in advance.

 

[David Baxter PhD]

The book I recommend for OCD worrying is Brain Lock by Jeffrey M. Schwartz. While ERP is still identified as the treatment of choice and works well for some patients with OCD compulsions (rituals), the process can often spike anxiety to the point where anxiety avoidance becomes a major issue, especially in the more "pure O" form of OCD where obsessive thoughts and worrying are more the problem.

Cognitive strategies that promote recognizing the inherent cognitive distortions (catastrophizing, all-or-nothing thinking, etc.), combined with the mindfulness strategy of letting the obsessive thoughts pass by (or through or around) you ("oh there's that OCD thought again, it's just a thought, let it go", watching the thought pass by you and recede into the distance instead of paying undue attention to it and giving it power) are in my experience far more effective for clients experiencing a lot of anxiety and for clients with the "pure O" type of OCD.

Certain medications are also helpful: Luvox (fluvoaxamine), Prozac (fluoxetine), and Zoloft (sertraline) are SSRIs with known antiobsessional properties. These may be especially useful at the beginning of treatment or when the patient's stress or anxiety is higher than normal, but some patients with OCD benefit from taking it long term (years or life-long) rather than short term (months to a couple of years).
Another helpful book is Getting Control by Lee Baer.

 

[br350]

Dr. Baxter, thank you for your reply. I'm familiar with Dr. Schwartz' 4 R's and their role in addressing OCD. I did try these, fleetingly, some years ago. I have a little difficulty with the concept as I feel it is a form of distraction, in a way, rather than full on facing of fears and learning to address them head on. To label the OCD as 'not me' and part of an illness almost seems like denial or avoidance in some way. I'm not sure. I will need to give Brain Lock another look and revisit the 4 R's. Again, I appreciate your thoughts and recommendation. I know that behavioral therapy in one form or other is going to be the best approach.

 

[Been there Done that]

I also think it is sometimes very difficult to tell which is my thoughts and which ones are OCD. I use thought stopping to halt the thoughts and it helps but this too is an ongoing battle.