What is Obsessive Compulsive Disorder?

Obsessive Compulsive Disorder (OCD) is one of the most common psychiatric illnesses affecting young people.

OCD is an illness in which obsessions and/or compulsions are present. Obsessions are unwanted thoughts, images or impulses which cause distress. Compulsions are behaviors or actions performed to alleviate the distress caused by unwanted intrusive
thoughts. To be diagnosed with OCD, the obsessions or compulsions must last for more than one hour a day, or cause significant distress, or significantly impair daily functioning.

Avoidance of various stimuli — objects, persons, images, thoughts, etc. — that trigger obsessions and compulsions is common in OCD, which affects approximately 2%-3% of all children and adolescents in the United States. Although adults with OCD are usually aware that the obsessions or compulsions are unreasonable or excessive, this insight is not always present in children and adolescents.

What are some typical obsessions and compulsions?

Common obsessions include unrealistic fears of being contaminated, of causing harm to others, and of incompleteness. These obsessions can include blasphemous and/or strange sexual thoughts, a problem with the lack of symmetry or a need for certainty. Typical compulsions include repetitive behaviors such as rereading, rewriting, checking, cleaning, counting, ordering, and doing something over and over again until it feels “just right.” OCD-affected individuals compulsively seek reassurance by asking the same question repeatedly, despite having already received the answer.

What age groups are at risk for OCD?

OCD is an illness that affects children, adolescents and adults. In large population studies, it was discovered that one-half to two-thirds of adult OCD cases started in childhood.

Although OCD does occur at earlier ages, there are generally two peak ages for the onset of OCD. The first peak of onset occurs in preadolescence between 10-12 years of age. The second peak occurs in adulthood in the 20’s and early 30’s.

Is there a cure for OCD?

Unfortunately, at the present time there is no cure for OCD. However, there are treatment approaches that have been proven to control OCD symptoms in many cases. The “gold standard” of treatment for OCD includes both medications and cognitive-behavior therapy. Anti-OCD medications control symptoms, but do not “cure” the disorder. This means that the positive effects of an anti-OCD medication only occur as long as the drug is being taken. Even while taking antiobsessional
medications, some symptoms continue but are less severe.

Are treatments for children different from those for adults?

Management of OCD is very similar in all age groups. Behavior therapy approaches for young people are modified to be more “childfriendly” and accessible to a child’s understanding.

When are medications used in childhood and adolescent OCD?

Medication is considered when children are experiencing significant OCD-related impairment or distress, and when cognitive-behavioral therapy is unavailable or only partially effective. The benefits must be judged to out- weigh the risks when medications are used.

What types of medications are used in OCD?*

Anti-OCD medications are classified as antidepressants. But, only those antidepressants affecting the brain chemical serotonin most effectively treat OCD. Serotonin reuptake inhibitors (SRIs) comprise the standard anti-OCD medications, which include all selective serotonin reuptake inhibitors (SSRIs) and one of the tricyclic antidepressants (TCA). SSRIs (citalopram/ Celexa; escitalopram/Lexapro; fluoxetine/Prozac; fluvoxamine/Luvox; paroxetine/Paxil; and sertraline/Zoloft) and the TCA clomipnamine (Anafranil) successfully treat OCD independently of their effects on depression.

The FDA placed a black-box warning to alert prescribing doctors and patients that special care be taken when any antidepressant medications are used to treat depression and other disorders such as obsessive-compulsive disorder (OCD) in children and adolescents. The FDA reported an increase in spontaneous reports of suicidal thoughts and/or behavior among children receiving medication, but there is no evidence that these suicidal thoughts or behaviors lead to an increased risk of suicide.

How do OCD medications work?

Anti-OCD medications work by affecting the brain chemical identified as serotonin. Serotonin allows certain brain cells (called neurons) to communicate with other brain cells. Anti-OCD drugs interfere with the recycling of serotonin, allowing it to spend more time outside cells, thereby affecting other cells. How or why this reduces obsessions and compulsions is not fully understood.

Which anti-OCD medication should be tried first?

Serotonin reuptake inhibitors (SRls) are important for treating acute conditions, as well as maintenance regimens in children and adolescents. All of the SSRIs work equally well, but on an individual basis one may work better than the others, requiring a process of trial and error supervised by the child’s psychiatrist. Side effect profiles or a positive family history of response may be used as a rationale for an SSRI choice. There is some indication that clomipramine may be more effective than SSRIs. However, given their preferable side effect profiles, SSRls remain the first line of medical treatment.

What are the side effects of anti- OCD medications?

SSRls have side effects that may include stomach upset, drowsiness, agitation and headaches. Rare side effects include behavioral activation in children and adolescents - mood switching to an unusually happy state or suicidal thoughts. Close monitoring by the treating psychiatrist is necessary.

What is the best medication dosage for OCD in children and adolescents?

The best dose of anti-OCD medication is determined on an individual case-by-case basis. The smallest amount of medicine that effectively treats the young person’s OCD is preferred. However, most children metabolize medications quite rapidly, and relieving OCD symptoms often requires the use of higher, adult-sized doses.

How long does it take for medication to work and what duration is recommended?

All anti-OCD medications work slowly. Medication is often first considered when the child’s OCD is severe, and both the child and family are in distress. However, it may take up to two or three months to see improvement in the OCD. Also, ongoing improvement of OCD may continue between I 2 weeks and one year after starting medication.
Optimal duration of treatment for OCD in children is unknown. Many clinicians recommend 9 to I 8 months of treatment after symptom resolution/stabilization, followed by a very gradual decrease in dosage. Relapse upon discontinuation of medications is more common than relapse when cognitive-behavior therapy is used.

What else is effective in treating OCD?

Cognitive-behavior therapy should always be considered as a treatment for OCD, alone or in addition to medication. This is a safe and effective treatment for OCD in children and adults. Exposure and Ritual Prevention (ERP) is a type of cognitive-behavior therapy designed to decrease anxiety by exposing individuals to the stimuli that cause their distress, then having them resist urges to engage in their usual behaviors ( rituals or compulsions).While the patient remains exposed to the feared stimulus, anxiety dissipates over time as the stimulus loses its anxiety-provoking nature. Supportive dynamic psychotherapy is effective for OCD, but it is important to find a therapist with specific behavioral training in ERP.

What is the Obsessive Compulsive Foundation?

The Obsessive Compulsive Foundation (OCF) is a not-for-profit mental health organization. Its mission is to increase research into, treatment for and understanding of Obsessive Compulsive Disorder.
The OCF’S resources and activities include:

  • Publish a bimonthly OCD Newsletter
  • Website: www.ocfoundation.org
  • Organized Chaos, a webzine for teens and young adults
  • Compulsive Hoarding section on the main website
  • Annual three-day conference
  • Promotion of support groups and OCF affiliates
  • Behavior Therapy Institutes for training mental health professionals to treat OCD
  • OCF Research Awards
  • The OCF Genetics Collaborative
  • Distribution of articles, pamphlets, books and tapes about OCD and related disorders

DISCLAIMER: The information contained in this publication is not intended to provide medical advice. This information is intended only to keep you informed. It is strongly advised that you check any medications or treatments with a qualified mental health provider.

This booklet was written for the OCF by S. Evelyn Stewart, M.D

What can I do to help!

Join the OC Foundation and become a partner in our efforts to eradicate OCD. The search for a cure will take a long time and be very expensive. The Foundation needs your help to continue its vital education and service programs and to sup- port research in this field.