Obsessive Compulsive Disorder (OCD)
part 6

When researchers follow children with OCD for years, many children still show signs of OCD 2-7 years later.  About 43% of children still have the diagnosis of OCD, which means disabling obsessions and/or compulsions.  About 11% had no sign of OCD whatsoever.  The remaining 46% showed some signs of OCD, but not enough to make a diagnosis.  It is very hard to predict who will be the lucky ones who get rid of it forever, and who will not.  No factor, including age, sex, type of OCD, or insight into the illness has been proven to be a good predictor.  Most researchers think, however, that comorbidity and family problems make a bad outcome more likely.

Many people are afraid that they will go crazy when they have OCD.  If being crazy means schizophrenia, then they shouldn't worry.  It is extremely unlikely that routine OCD will turn into an illness like that.

Pediatric OCD usually comes on between age 7 and 12, but can come much earlier.  Between two and four percent of all children have OCD.  That means that in most elementary schools in our area, about 5-10 children have it.  It is a little more common in males than females.  This wouldn't be so bad if those children were identified with OCD and then treated for it.  The problem is it is not picked up.  In most surveys children or adolescents, most of the children who are found to have OCD have never gone for professional help, even though the disorder is quite disabling.  Sadder yet, of the few who get professional help, almost none are correctly identified as having OCD.  Most are thought to have some sort of family problem.  Sadder still is the fact that even when OCD is identified, most children are not given appropriate treatment.

Jocelyn was sexually assaulted at age 8 by a neighborhood boy who was 14.  It was terrible, but she told her mother after the second time and the boy was charged and sentenced to a youth prison.  Two years later, Jocelyn was doing poorly in school and seemed preoccupied with getting things done just right.  She also became mildly depressed.  She was seen in a local mental health centre and entered into 8 months of counseling for sexual abuse.  She was referred to a psychiatrist for something to help her horrible insomnia.  It came out that part of her insomnia was due to horribly complex mental rituals and compulsions.  In the end, as Joceyln would tell you, the sexual assault was nothing compared to the agony she experienced from lifelong OCD.

Co-morbidity is the tendency of certain diseases and disorders to run together.  For example, High blood pressure and Diabetes occur more often together than one would expect.  OCD that comes to the attention of professionals in Canada is usually accompanied by some other neuropsychiatric disorder.  When I initially see a child with OCD, I spend a lot of time trying to figure what else they might have.  Over 75% of children with OCD will have had at least one other psychiatric disorder in their lives.   The most common co-morbid conditions are:

Sometimes people who are depressed develop obsessions or compulsions when they get depressed.  Other times people develop depression who already have OCD.  This is very, very common.  In fact, the most common reason for a person with OCD to end up in our clinic is not OCD, but depression.  It seems that they can manage the OCD as long as they don't have to battle depression, too.

This includes Attention Deficit-Hyperactivity Disorder, Oppositional Defiant disorder, and Conduct disorder.  Lots of times one disorder or the other is the main problem.  The other less noticeable disorder isn't really noticed until the first one goes away.  Having Oppositional Defiant Disorder along with OCD can make treatment of OCD very, very difficult.

Christian was hyper ever since he could walk and no one ever doubted the diagnosis.  However, he responded well to some simple behavioral interventions once he reached school age.  At age 8 he developed a ordering compulsion that took over his life for two years.  Not until his OCD was under control did his ADHD become a problem again.

OCD is one of the anxiety disorders, but there are a few others.  It is not uncommon to see a child with 3 or 4 anxiety disorders.  These include panic disorder, numerous phobias, generalized anxiety disorder, and Social phobia.

All of the learning disorders are more common in children with OCD than in children without OCD.  It is important to be aware of these, especially when you are trying to teach children about the disorder and design a treatment program.

Tics are sudden movements of the body that last only a few moments.  They also can be sounds.  Some are simple, like blinking, while others are more complex, like clearing your throat and then twitching the head.  These are very common in persons who have OCD.  Approximately 55% of people with OCD have had tics at one time or another during their lives.  About 15% of those with OCD have Tourettes Disorder, which is tics to a disabling degree.  The cause of OCD and tic disorders is probably the same (see below).

There are a number of psychiatric disorders that are like OCD, but not exactly.  Nail biting and hair pulling (trichotillomania)) are two that are more commonly seen in children.  More rarely pediatric OCD is accompanied by Body dysmorphic disorder, where a person is obsessed with one part of the body being somehow extremely ugly, fat, or deformed.

Until the last 15 years or so, many people thought that there was some deep and dark secret in the minds of people who had OCD.  When it did occur in children, it was assumed to be due to some family problem or difficulty in growing up.  We now know that while these can affect OCD, OCD is not caused by this sort of thing.  OCD is about as physical as Diabetes, Asthma, and other common pediatric illnesses.  In fact, there is more known about the physical causes of OCD than most other neuropsychiatric disorders.  At this point, most of the evidence points to two causes of OCD, genetics and infections.

OCD runs in families.  About 30% of teenagers with OCD have a relative in their immediate family with OCD or some signs of OCD.  When OCD appears early in childhood, it is even more likely that there will be family members with the disorder.  Other studies have not found as much OCD as this in relatives, but have found lots of other anxiety disorders besides OCD in the relatives.  In families where OCD seems to be inherited, often times tic disorders are found, too.  The usual pattern is for the males in the family to be more likely to have tic disorders and the females to be more likely to have OCD.  However, the opposite is not uncommon. These studies show that OCD runs in families, but it doesn't point to an exact cause.  Other studies do point to certain problems in the brain.

Many people have heard of CT scans.  They are very fancy x-rays of the brain. There are some other tests which can be used to investigate the brain which are like CT scans.  These include MRI, PET, and MRS.  These pictures of the brain show that children and adults with OCD have some abnormalities in the brain.  They involve the part of the brain above the eyes (Orbital area), and some of the structures that are deep down in the brain (Basal Ganglia and Thalmus).  This research suggests that somehow the communication between these areas is not right in OCD.

It is not uncommon to hear people say that someone has a "chemical imbalance" in their brain.  A lot of work has been put into trying to determine if there is a chemical imbalance in OCD.  There is quite a bit of evidence to suggest that one chemical messenger, Serotonin, is very involved.  All the drugs which help OCD affect this chemical messenger in one way or another.  Tests of the spinal fluid also suggest that this chemical is involved.  Unfortunately, the more scientists find out about the chemistry of OCD in the brain, the more confusing and complicated it gets.  Five years ago, we didn't know that Serotonin can attach to nerve cells in the brain in many different ways and cause a host of different things.  Although we know Serotonin is involved, now the question is which part?  Is the problem one of the ten or so plugs or receptors that Serotonin attaches to?  Is the real problem another chemical?  Where in the brain are these Serotonin receptors messed up, if they are?  Although a lot more is now known about what causes OCD, scientists are still a long way from having the final answer.

One way of learning about what causes OCD may easily come from some research in the last couple of years on how infections can cause OCD.  Many people have heard of Rheumatic fever.  This is a heart disease that is caused by a person getting Strept throat and then in the process of fighting off the infection, the person's body starts confusing the cells on the heart valves with the strept bacteria.  So the person's body attacks the strept bacteria and the heart valves.  As a result, the heart valves are damaged.  It has been known for years that the same thing can happen in the brain.  During the course of a strept infection, a person's infection fighting system confuses strept and the outside of nerve cells in the brain.  As a result, the person's infection fighting system attacks the strept and also certain cells of the brain.  This is the same part of the brain, Basal Ganglia, which has been found to be part of the problem in OCD.  People who got this have something called "Syndenham's Chorea".  They have a movement disorder which was sort of like tics.  Then researchers found out that they had a lot of OCD symptoms, too.  Now it has been discovered that some people who have this problem with their infection fighting system attacking their brain will not get a movement disorder at all but just very severe OCD.  The signs and symptoms can be just the same as the genetic variety.  It usually comes on very suddenly.  Usually it goes away after awhile.  Sometimes it happens in a person who already has mild OCD.  It has a strange name.  It is called PANDAS.  This stands for pediatric autoimmune neuropsychiatric disorder associated with streptococcal infections.  No one knows how often it occurs, but everyone agrees it is quite rare.  The big question right now is what to do about it and how to diagnosis it.  On one extreme, some doctors give something like kidney dialysis if they think a person has this.  Others give penicillin.  At the moment, if I see someone who has signs of this, I do some lab tests.  If they were positive, I would get a few more opinions.  What is reasonable to do for this seems to change every few months right now.

Like half the kids in his grade 2 class, Jonathan got sick this winter.  His sister got Strept throat, so did his brother.  Jonathan only missed a few days of school and never ended up taking any antibiotics, as he wasn't very sick at all.  Two days later he could not sleep for anything.  He could not fall asleep.  He would come into his parent's bed crying about "bad thoughts" that wouldn't stop.  During the day he was exhausted.  He started washing his hands over and over trying to get something "bad" off of them.  He went to his family doctor and an appointment was made with a psychiatrist in a few weeks.  By the time the appointment came, these problems were almost gone.  They canceled their appointment.  This is a disguised version of the closest thing I have seen to PANDAS.