Profiles of Behavioral and Emotional Disorders

For many years, mental health professionals thought of OCD as a rare disease because only a small minority of their patients had the condition. The disorder often went unrecognized because many of those afflicted with OCD, in efforts to keep their repetitive thoughts and behaviors secret, failed to seek treatment. This led to underestimates of the number of people with the illness. However, a survey conducted in the early 1980s by the National Institute of Mental Health (NIMH)--the Federal agency that supports research nationwide on the brain, mental illnesses, and mental health--provided new knowledge about the prevalence of OCD. The NIMH survey showed that OCD affects more than 2 percent of the population, meaning that OCD is more common than such severe mental illnesses as schizophrenia, bipolar disorder, or panic disorder.  Likewise, recent studies indicate that OCD occurs in 1-2% of youth. Thus, OCD strikes people of all ethnic groups and ages. Males and females are equally affected. The social and economic costs of OCD were estimated to be $8.4 billion in 1990 (DuPont et al, 1994).

Although OCD symptoms typically begin during the teenage years or early adulthood, children DO develop the illness, even during the preschool years. Studies indicate that at least one-third of cases of OCD in adults began in childhood. Suffering from OCD during early stages of a child's development can cause severe problems for the child. It is important that the child receive evaluation and treatment by a knowledgeable clinician to prevent the child from missing important opportunities because of this disorder.

Obsessions
These are unwanted ideas or impulses (more than excessive worries about real-life problems) that repeatedly well up in the mind of the person with OCD, despite the person trying to ignore or suppress it. Persistent fears that harm may come to self or a loved one, an unreasonable concern with becoming contaminated, or an excessive need to do things correctly or perfectly, are common. Again and again, the individual experiences a disturbing thought, such as, "My hands may be dirty--I must wash them"; "My clothes aren't clean, I must change them"; or "If I don't touch my chin to my shoulder, something terrible will happen." These thoughts are persistent, intrusive, unpleasant, produce a high degree of anxiety, or may subject the parents or other family members into situations where they must accommodate the child's unreasonable demands. Sometimes the obsessions are of a violent or a sexual nature, or concern illness.

Compulsions
In response to their obsessions, many youth with OCD resort to repetitive behaviors called compulsions. The most common of these are washing and checking. Other compulsive behaviors include counting (often while performing another compulsive action such as hand washing), repeating, hoarding, touching, or endlessly rearranging objects in an effort to keep them in precise alignment with each other. Mental problems, such as mentally repeating phrases, list-making, or checking are also common. These behaviors generally are intended to prevent or reduce distress or some dreaded event, ward off harm to the person with OCD or others. Some children and adolescents with OCD have regimented rituals while others have rituals that are complex and changing. Performing rituals may give the person with OCD some relief from anxiety, but it is only temporary. At times, the child may demand that other family members never touch or move the child's personal belongings, or may insist upon special care to ensure that the child's kitchen utensils or clothes are extra clean before the child is willing to use them.

Insight
Youngsters with OCD show a range of insight into the senselessness of their obsessions. Sometimes, especially when they are not actually having an obsession, they can recognize that their obsessions and compulsions are unrealistic. At other times they may be unsure about their fears, believe strongly in their validity, or even resist any suggestions that their fears or rituals are unreasonable.

Resistance
Children and adolescents with OCD may struggle to banish their unwanted, obsessive thoughts and to prevent themselves from engaging in compulsive behaviors. Many are able to keep their obsessive-compulsive symptoms under control during the hours when they are at school, but over the months or years, resistance may weaken, and when this happens, OCD may become so severe that time-consuming rituals take over the sufferers' lives, making it hard for them to continue activities outside the home.

Shame and Secrecy
OCD sufferers often attempt to hide their disorder rather than seek help. Often they are successful in concealing their obsessive-compulsive symptoms from friends and even family members. An unfortunate consequence of this secrecy is that youth with OCD usually do not receive professional help until years after the onset of the disorder. By that time, they may have learned to work their lives--and family members' lives--around the rituals.

Long-lasting Symptoms
OCD can last for years, even decades. The symptoms may become less severe from time to time, and there may be long intervals when the symptoms are mild or seem to disappear altogether. But for manyindividuals with OCD, the symptoms are chronic.

What causes it?

The specific cause of OCD has not been determined. There have been, and continue to be, many studies being conducted to determine the cause(s) of this disorder.

Genetic. Many genetic studies published over the past twenty years have repeatedly shown that OCD is hereditary. Early age of onset of OCD may present a significant increase in the risk among the first-degree relatives. However, it is important to note that not all studies demonstrate that it runs in families.

Auto-immunity. It has been theorized that post-streptococcal auto-immunity may be a factor in some cases of OCD. Criteria have been developed to characterize this subgroup, designated by the acronym PANDAS, Pediatric Auto-Immune Neuropsychiatric Disorder Associated with Streptococcal Infections. The criteria, based on knowledge of Syndenham's Chorea and clinical observations of the first group of youth with Streptococcal-triggered OCD, are: 1) prepubertal symptom onset; 2) presence of tics and/or OCD; 3) episodic clinical course of symptom severity; 4) association with group A-Beta-hemolytic streptococcal infection; and 5) association with neurological abnormality. Also, the occurrence of the antibodies, D8/17 positive B-cells, has been found to be significantly higher in patients with childhood-onset OCD.

Neurological. Much research has centered on certain areas of demonstrated brain dysfunction, notably in the frontal-lobe-limbic-basal-ganglia circuits. There have been observations of increased rates of obsessive and compulsive symptoms in neuropsychiatric disorders resulting primarily from basal ganglia disease, such as Sydenham Chorea and Tourette Syndrome. Neuroimaging studies of young OCD patients have shown smaller striatal volumes and disturbances in the structure and the function of the corpus callosum. In addition, functional neuroimaging studies have demonstrated increased metabolic rates in the ventral prefrontal cortical regions. Lastly, one brain chemical (a neurotransmitter called serotonin) has been implicated as having a role in OCD, and this is evidenced by the success of specific medications, the Selective Serotonin Reuptake Inhibitors (SSRI's) in the treatment of OCD.

How is it diagnosed?

To assess whether a child or adolescent has OCD, a mental health practitioner must ascertain that the patient is exhibiting obsessions, compulsions, or both as defined above. In addition, several questions must be asked: Are the obsessions-compulsions time consuming, i.e. more than an hour a day? Do they create distress and significantly interfere in the person's normal routine/activities/relationships? If the answers to these two questions are positive, the diagnosis of OCD may be considered.

In addition, the practitioner must also ascertain that there is not another disorder present to which the obsession-compulsion may be related, and that the obsession-compulsion is not an effect of a substance or general medical condition.

If all of these conditions are met, a youngster may be given a diagnosis of OCD, and the appropriate treatment or combination of treatments may then be tailored to his or her needs.