Obsessive Compulsive Disorder (2 page)

Diagnosis and characteristics of OCD in young people
In order to fulfil a diagnosis of OCD, an individual must experience either obsessions or compulsions. Obsessions are recurrent and persistent thoughts, 1

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impulses or images (e.g. thoughts of becoming ill or images of a loved one dying) that are experienced at some time as intrusive and inappropriate and cause marked anxiety or distress (American Psychiatric Association, 1994).

Consequently, the person attempts to ignore, suppress or neutralise them with some other thought or action.

Compulsions are repetitive behaviours (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 (American Psychiatric Association, 1994). The aim of compulsions is to prevent or reduce distress or prevent a dreaded event or situation. However, they are not connected in a realistic way to the obsession or are clearly excessive. For example, a young person may experience an intrusive thought that they may suddenly become unpopular and rejected by their friends and carry out a compulsion of holding a good thought in their head, such as a memory of a happy time, in order to try to prevent the thought coming true. Many compulsions are visible to others and with young people, others (such as family members or teachers) may notice and become concerned about these behaviours before they are aware of any obsessions.

Although individuals often recognise that the obsessions or compulsions are excessive or unreasonable, in young people this is not necessary for a diagnosis. Finally, obsessions or compulsions must either cause marked distress, be time-consuming (taking more than an hour a day), or significantly interfere with their normal routine, academic or occupational functioning, or usual social activities or relationships (American Psychiatric Association, 1994).

OCD is characterised by obsessive thoughts or compulsive behaviours which significantly interfere with everyday functioning.

Emily was a 15-year-old girl, who kept worrying that her parents or brother would become ill and die. This began two years ago, after a girl in her class died of leukaemia. Shortly before this, she could recall watching a television advert for a kitchen cleaner that showed brightly coloured germs spread everywhere. As a result, she avoided touching things that she felt other people would touch afterwards, like light switches and door handles, or if she did have to touch them she would try to use a tissue to limit possible contamination. She carried out compulsions, including excessive showering and washing her hands if she felt they were unclean or after touching anything she felt was ‘germy’.

She also described feeling contaminated if there was any mention of illness or death and would wash or shower herself to remove the sense of being contaminated. If she was unable to carry out compulsions or avoid contamination, she became extremely distressed that her thought
Introduction to obsessive compulsive disorder
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of her family being ill or dying would come true and that she would have caused it.

Studies suggest that OCD in young people is characterised by a range of different types of obsessions and compulsions. The most common obsessions in young people include worries about dirt and contamination, thoughts of something terrible happening and concerns about illness or death (Thomsen, 1999). In younger children concerns about contamination, aggression and exactness or symmetry are most common (Franklin
et al.
, 1998; Geller
et al.
, 2001; Riddle
et al.
, 1990; Swedo
et al.
, 1989b). As children get older the types of obsessions may change to include obsessions of a sexual or religious nature. This is consistent with cognitive theories of OCD, which suggest that the content of obsessions reflects the issues that are important to the individual at that time (Salkovskis, 1985).

The most common compulsions in young people include washing, checking, repeating, ordering/arranging and counting (Thomsen, 1999). However, symptoms generally change over time and it is unusual for young people to only ever carry out one type of compulsion (Hanna, 1995; Rettew
et al.
, 1992; Wever and Rey, 1997). Swedo and Rapoport (1989) suggest that compulsions without obsessions are more common in childhood and that this may be because young children lack the cognitive ability to be able to articulate their internal cognitive processes. Compulsions without obsessions are frequently tactile (e.g. touching, tapping or rubbing rituals) and may occur more often in young people with a comorbid tic disorder (Leckman
et al.
, 1995).

Research suggests that OCD has a significant impact on the lives of young people and their families. Allsopp and Verduyn (1988) suggest that childhood OCD is associated with significant disruption in academic, home and social functioning. In a study by Piacentini
et al.
(2003), around 90 per cent of young people participating reported that OCD affected their functioning in one area, while just under half reported significant OCD-related problems in each of the three areas assessed (school, home and socially).

The two most common OCD-related problems were concentrating on schoolwork and doing homework. Impairment appeared to be associated with the severity of OCD symptoms, rather than factors such as age or gender.

• The most common obsessions include worries about dirt and contamination, thoughts of something terrible happening and concerns about illness or death.

• The most common compulsions in young people include washing, checking, repeating, ordering/arranging and counting.

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Epidemiology

Research indicates that around 1 per cent of teenagers have OCD. Estimates of the prevalence and incidence in young people vary between 0.1 per cent and 4 per cent of the population across different countries (Flament
et al.
, 1988; Heyman
et al.
, 2001). There are no studies that have measured the prevalence in young people year on year and the majority of studies have been carried out with older children, not prepubertal children. Nevertheless, Heyman
et al.
(2001) suggest a continuing increase in numbers of cases from the age of 5 to 15 years. The variation in prevalence estimates may be accounted for by differences in diagnostic criteria, the methods of ascertain-ment (such as differences in the way interviews are conducted and whether they are conducted by clinicians or lay interviewers) and the motives of those taking part in the studies (for example, one of the higher estimates was found in a sample of teenage army recruits in Israel). In both the Flament
et al.
(1988) and Heyman
et al.
(2001) studies the majority of young people had not been diagnosed by clinical services and were not receiving treatment.

Around 1 per cent of teenagers have OCD.

Age and triggers for onset

There appear to be two periods in life when OCD commonly begins, one around puberty, the second in early adulthood (Pauls
et al.
, 1995; Rasmussen and Eisen, 1992). This is likely to reflect developmental transitions to increasingly independent lifestyles. Although it is extremely rare, there have been cases of children as young as three or four years of age developing OCD.

OCD usually develops in a gradual way, but can also develop acutely, often in response to an adverse life event (Lensi
et al.
, 1996; Rachman and Hodgson, 1980). McKeon
et al.
(1984) found significantly more life events in the 12 months prior to the onset of the OCD, compared to a non-clinical control group. In our clinical experience, OCD in young people often appears to develop following bullying, difficulties with friends and illness or death within the family. Thomsen (1999) describes divorce and marital disharmony as significant, as well as triggering experiences such as illness or accidents.

• In young people, OCD commonly begins around puberty, but can occur in children as young as three or four years of age.

• Whilst it often develops in a gradual way, it can also develop acutely, often in response to an adverse life event.

Gender

Studies suggest that when OCD develops before puberty, boys outnumber girls by more than two to one (Geller
et al.
, 1998; Rasmussen and Eisen, 1992; Zohar, 1999). However, by the time young people reach adulthood, OCD affects men and women equally (Karno
et al.
, 1988), although there are differences in symptoms, with more women experiencing contamination fears and washing and cleaning compulsions and more men with obsessional slowness or sexual obsessions (Marks, 1987; Lensi
et al.
, 1996).

When OCD develops before puberty, boys appear to outnumber girls, but by the time young people reach adulthood, there is no gender difference.

Seeking treatment

It appears that only around half of young people with OCD ask for any help (Flament
et al.
, 1988; Heyman
et al.
, 2001). The reasons for not seeking help are likely to include: a lack of awareness or understanding of the problem (by family members as well as young people); a fear that if the obsessional worry is verbalised this may increase the likelihood of it coming true; embarrassment; a fear of what others may think of them or how they may be treated and what might happen to them if they seek professional help. Many people with OCD report intense feelings of shame and humili-ation due to the nature of their obsessive thoughts. They may often recognise that checking or washing will not in reality change anything, but feel powerless to stop. As a result, they may be less likely to seek help. On top of this, when individuals seek help they may not initially disclose information about the OCD (Torres
et al.
, 2007). This may be because the individual feels ashamed to report the nature of their symptoms or because professionals are not asking the right questions. Stobie
et al.
(2007) found that adults with OCD waited on average eight and a half years between their obsessional symptoms interfering significantly with their lives and being diagnosed.

Only around half of young people with OCD ask for any help.

Raj was a 13-year-old boy, who described an incident where he had seen his younger sister in the bath and felt sexually aroused. After this, he became convinced that he might become a paedophile and specifically that he wanted to sexually abuse his sister. As a result, 6

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he tried desperately to try to push this thought out of his mind and prayed that he would be ‘strong enough’ not to carry out his thoughts.

Because he felt he was on the brink of acting on them, he avoided being alone with his sister. He felt that he was a monster and was terribly ashamed of his thoughts. Although his family noticed him become depressed and more and more socially withdrawn, they were unsure why this was. He was unable to talk to any of his family members about it as he believed that they would be disgusted by him and not love him any more.

Course and prognosis

As treatment has evolved and improved over the years it is difficult to be clear about the natural course and outcome of OCD. Early follow-up studies suggested that the course of OCD was variable and that young people often experience a chronic but fluctuating course, with a waxing and waning of symptoms (Bolton
et al.
, 1995; Thomsen and Mikkelson, 1995). This is consistent with long-term follow-up studies with adults (e.g. Skoog and Skoog, 1999). However, there is reason to believe that as treatments improve, the prognosis is more hopeful. Stewart
et al.
(2004) completed a meta-analysis of follow-up studies. Not all studies involved treatment, and of those that did, treatment was variable and included CBT, psychotherapy, family therapy, medication, electroconvulsive therapy and even surgery.

They found that 60 per cent of young people no longer met criteria for OCD with follow-ups of up to 15 years. However, it is difficult to be clear from this about the longitudinal course of untreated OCD or what factors predict a good outcome in treatment. They were able to identify factors that contributed to poorer outcomes and these included earlier age of onset, initial OCD severity, a longer duration of symptoms prior to diagnosis, the presence of a comorbid tic or mood disorder and any family psychiatric history.

Wewetzer
et al.
(2001) followed up young people with OCD for an average of 11 years into adulthood. All the young people received either in-patient or outpatient treatment in specialist child and adolescent mental health services. Of the 36 per cent of young people who remained affected by OCD, over two-thirds had at least one further clinical disorder, such as anxiety or depression. Just over 70 per cent of all the young people continued to suffer from a mental health problem, including OCD, social phobia, depression, dysthymia and personality disorders.

As treatment has evolved and improved over the years it is difficult to be clear about the natural course and outcome of OCD.

Differential diagnosis and comorbidity

OCD is only one reason why children repeat actions. Young children below the age of ten years often have quite fixed routines and rituals at bedtime. For instance, children at this age may insist that their parents kiss them in particular ways or have a particular soft toy with them before the light is switched off. While very young children are unlikely to provide a clear reason for the rituals, older children may say that the soft toy or ritual prevents the appearance of monsters or other feared outcomes (see Troster, 1994; also Thelen, 1981). Children’s games may also contain reasoning similar to that seen in OCD; for instance, children may sing ‘Don’t step on the cracks or the bogey-man will get you’ while walking along a paved area. In this case, however, the fear is usually imaginary, rather than real. The key issue in understanding whether the behaviour is consistent with OCD is the degree to which the routines and rituals become dysfunctional and interfere with everyday life.