Obsessive Compulsive Disorder (OCD)
part 7

Like all neuropsychiatric disorders, OCD is diagnosed based on the history, physical signs, and lab tests.  There is no lab test that will show that a person has OCD.  There are some that are highly suggestive of PANDAS.

When I talk to children or teenagers or their parents about OCD, I want to ask them about all the different obsessions and compulsions.  I also want to ask them about all of the co-morbid disorders, especially other anxiety disorders, depression, and tics.  I want to know how the disorder started and what has been done to treat it.

The only part of the physical examination that is useful is the part which is done to look for tics.  Other wise I am looking for signs of OCD - trouble managing the disorder in my office, touching things, having to enter a certain way, and preoccupations with certain themes.  I also want to see how depressed they are.

I only get lab tests done if there are some unusual features to the history and examination.  I also get lab tests if I suspect PANDAS.

This is the easiest thing to do.  Unless you specifically ask, most people won't tell you about their OCD symptoms.  It is just too embarrassing.  Often another problem, like depression or ADHD, gets diagnosed because it is the most obvious.  The solution?  Every child and their parents should be asked a few screening questions about OCD.

The most common error here is diagnosing OCD based on obsessions or compulsions, but forgetting to check and see if they are disabling.  Many children and adolescents have obsessions that are certainly unusual, but not disabling them in any way.

The other error of this type is missing some other physical cause.  Rarely, things like epilepsy, eating disorders, psychosis, Autism, head injuries, tumors, and poisons can cause OCD.  Of all these, tumors are the most worrisome to most people.  Tumors may initially present with just OCD, but within a short time, other neuropsychiatric symptoms become prominent.  If a person has a normal neurological exam and a classic OCD history with a family history, It is not worth worrying about.  However, in an atypical case with other neurologic signs, it is a concern.  Obviously such children will get a much more aggressive work-up with labs and x-rays.

There are three categories of treatments for OCD.

1. Treatments which have been carefully researched and have been found to be effective.  This includes cognitive-behavior therapy and medications.

2. Treatments which have been studied some and are useful in certain circumstances.  This includes family therapy, relaxation techniques, and surgery.  These are not of interest to the general reader and I have not included information about them.

3. Treatments that have not been carefully researched but are still used by people anyway.  This includes diet and nutrition therapy, psychoanalysis, all sorts of other psychotherapies, group therapy, and many, many more.  Many of these treatments in this third group may be effective and they may be safe, but I don't know.  Usually I don't know because there isn't enough careful scientific research on the treatment.  The fact that something worked for OCD in 10 people in one clinic doesn't mean it is time to try it on others outside of a research setting.  Sometimes I don't know about the treatment because it is just too new.  Then my approach is to find out, or find someone who I respect who knows.

That leaves us with the first and main category............................................

Cognitive behavioral treatment of OCD is based on two principles, exposure and response prevention.  It is a "doing" treatment, not an understanding and counseling treatment.  It involves a lot of homework.

This means exposing yourself to the thing that makes you anxious.  For example, if a person is having disabling compulsions to order things, they might expose themselves to clutter for five minutes without touching anything.  A fear of germs might be treated by touching a sink in a public washroom.  In a sense, it is facing the thing you fear a little bit at a time until you have finally conquered it.  Sometimes, people start by just imagining they have exposed themselves to something.

This is preventing a person from doing a compulsion or mental act.  If you are a checker, it means preventing yourself from checking things by having someone with you or a physical barrier.  It may mean at first just preventing yourself from checking for a short amount of time.

This works on what a person is thinking, not what they are doing.  When you are doing cognitive therapy, you are learning what thoughts you are thinking and then learning techniques to control these thoughts.  A common one in the treatment of OCD in children is labeling these OCD thoughts as not your own.  This technique is used to encourage children to talk to their OCD as if it were a bad guy.  For example, a girl who kept obsessing about getting AIDS would be taught to label these thoughts as from the OCD , and not her.  Then she would learn some ways to tell these thoughts to "get out of town".  Other techniques involve thought stopping, were you do something physical to stop obsessing which you have learned in therapy, like snapping a rubber band on your wrist ever time you start obsessing.  This is a hard thing to describe without examples.

Like most things, the best way to understand Cognitive behavioral treatment is to see how it works with examples.  Here are those same ill children from the first section and how they could be treated with a combination of exposure and response prevention and Cognitive therapy.  Click on the child's name to go back to the page with that example.

The treatment began with Jonathan making some large "9s" on four papers and putting them up in the office when he was seen.  The therapist talked with him about how he felt and how he might try to manage this with deep breathing, and saying certain thoughts to himself.  The homework was to go home and make some more 9s and hang them up in your room and see if your temper went out of control.  The next home work was to draw with a pen a 9 on your hand for a day.  The next homework would be to make a small light pencil 9 on the back of every worksheet that you do. With each step, Jonathan's parents were involved and were there to help him from getting anxious using some relaxation techniques like deep breathing and thinking of something relaxing.  This was exposure.

The cognitive therapy involved talking with Jonathan about how exactly his temper was going to go out of control, what exactly he thought he was going to do to people, and how unlikely that really was.  Then Jonathan was taught to say something over and over which he came up with himself.  So he came up with, "I have never beat up anyone and I never will".  When he was exposed to 9s, he would say this, he would also imagine these words as missiles which were blowing up the attacking OCD spacecraft.

Jonathan did all this and it worked to a certain degree.  He never did draw the 9s on his hand or paper.  He thought that was just too "risky".  However, he really got into the idea of "shooting down" OCD spacecraft, and that was enough for him to stop avoiding 9s and get his marks back up.