Treatments for Obsessive-Compulsive Disorder (OCD)

Featured pediatric expert

Michael Chu, MD

Dr. Michael Chu is a board-certified child and adolescent and adult psychiatrist at Children’s Health of Orange County (CHOC). He is a volunteer assistant clinical professor at University of California, Irvine. He completed his medical school and adult psychiatry residency at University of Maryland, School of Medicine, and completed a child and adolescent psychiatry fellowship at University of California, San Diego, Rady Children’s Hospital. Dr. Chu specializes in consultation-liaison psychiatry and acute psychiatric care.

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Transcription

Melanie Cole (Host): Welcome to Long Live Childhood, a pediatric health and wellness podcast presented by CHOC. Together, we can keep kids happy and healthy. I’m Melanie Cole. And today, we’re discussing treatments for obsessive-compulsive disorders. Joining me is Dr. Michael Chu. He’s a child and adolescent psychiatrist with Children’s Health of Orange County.

Dr. Chu, thank you so much for joining us today. We’ve been hearing more about the mental health crisis in our children lately. This is something a little bit different. Before we get into OCDs, can you tell us a little bit about yourself and your expertise in this topic?

Dr. Michael Chu: Yeah. Thank you, Melanie, so much for having me on. So I’m a consultation liaison pediatric psychiatrist. I see children and adolescents with psychiatric comorbidities hospitalized on the medical floors at CHOC. Some of the patients I see struggle with obsessive-compulsive disorder. It’s a really important topic for us to talk about. It really does cause a lot of this distress for some of these patients, along with their families.

Melanie Cole (Host): I agree with you. So let’s talk about OCDs. Tell us a little bit about what they are. You can describe some of the epidemiology. One of the most important questions parents have is the difference between clinical obsessive-compulsive disorder and excessive worrying. This worrying and anxiety are something we’re all experiencing right now. There’s like this kind of global sense, yes?

Dr. Michael Chu: Yes, absolutely, especially during the COVID pandemic. I think you’re absolutely right that the first thing you start off with is obsessive-compulsive disorder. It should really be formally diagnosed by a medical professional. In order they receive that diagnosis really, patients do undergo a very, very thorough assessment. And that can only be done through like a medical professional. And to kind of start us off, OCD is really comorbid with a lot of other anxiety disorders, so it is difficult to definitely kind of tease out sometimes, so that’s why it’s really important to kind of see a medical professional to get an accurate diagnosis.

To start this off, the prevalence of obsessive-compulsive disorder among children and adolescents really range from around 1% to 3%, which is really similar to the prevalence in adults. There is slightly higher prevalence in females versus males, just slightly a little bit more. And there’s typically a bimodal peak of onset in terms of kind of OCD symptoms. First onset could typically present sometime around the age of eight to twelve years old. And there’s a second peak of onset somewhere later in late adolescence and young adulthood.

Melanie Cole (Host): Well, thank you for telling us the age that they begin to manifest themselves. But I’d like you to really discuss some of the signs and symptoms for parents. But the difference between that excessive worrying and anxiety that people feel and that clinically diagnosed OCD, are there some differences that we can point to as you’re telling us those symptoms?

Dr. Michael Chu: Of course. So some signs and symptoms of people struggling with obsessive-compulsive disorder, really it kind of can be characterized by people struggling with obsessions or compulsions or both of them. That’s kind of quintessential in terms of people with OCD. So symptoms of OCD can be like waxing and waning and even range with differences in severity.

You could think of OCD as more of a worry or cognitive phenomenon, typically of security concerns or feeling something is not right or they have to do something just right or something bad would happen. When you think of obsession, you could really think of obsessions as being recurrent or persistent thoughts or urges or images that are like experienced as intrusive and unwanted. You could think of these as obsessive things that pop into someone’s head. And it’s like they really don’t want these thoughts, but they’re just kind of very intrusive in their head.

That’s quite different than anxiety in general, which we think more like anxious about, generalized worries about different things. With obsessions, it’s more particular and it’s more recurrent kind of specific thoughts. A lot of these times, individuals would try to ignore or suppress these thoughts. That can lead to what we would call compulsions, which are repetitive behaviors or mental acts that a person may feel driven to perform in order to reduce some of the distress from these obsessions. The key here to really know is that people can have obsessions and compulsions, but in order to have obsessive-compulsive disorder, the symptoms must cause clinically significant distress or impairment.

Melanie Cole (Host): So just to clarify that a little bit, Dr. Chu, when you have those intrusive thoughts, if a person is having those kinds of things, whether you know the old sort of standby, we’ve heard about washing hands, we’ve heard about walking in and out of a room a certain number of times, checking things before you leave, those kinds of things. But the intrusive thoughts that tell you that something bad will happen or these visions that something bad is going to happen, are those all part of that diagnosis? Can you speak a little bit about if we know any of these causes? Is this a genetic thing? Tell us a little bit about.

Dr. Michael Chu: I wish we had all the answers to etiology or the cause of OCD. Unfortunately, a lot of the times in mental health, we don’t know. However, we do know it is a brain disorder. There are many, many research studies looking into this already, clarifying some of the apparent brain circuits going on that may be leading up to OCD symptoms. So we do know it is a brain disorder. Unfortunately, at this time, we don’t know exactly like what causes it, but there’s definitely a genetic component. As we do know, family history does play a role. And we do know it is quite comorbid with other psychiatric illnesses, particularly anxiety. We do know there’s a genetic component and we do know it’s a biological illness, but it’s hard for us to say exactly at this time the etiology.

Melanie Cole (Host): So if a child does have signs and symptoms, what are some things the parent or caregiver can do to support them as they start to notice this. We take them, what, first to our pediatrician, start this process of trying to figure it out. What can we do as parents to help our child other than just saying, “Oh, that’s not going to happen,” “Oh, you don’t have to do that,” because I imagine that’s what plenty of parents do at the beginning.

Dr. Michael Chu: You know, I think you bring up really the main thing that parents can do, is really getting the child mental health professional help to get that diagnosis and treatment and to not ignore it, because do know earlier intervention is quintessential and really does help with prognosis and does help with treatment. And another important role that parents can really do to help their children with mental health struggles is to support them and be there for them. And this may really include a lot of parental validation for their child without reinforcing compulsive behaviors for OCD. Additionally, children with OCD can also feel ashamed and feel stigmatized too, so it’s important to provide some age-appropriate psychoeducation along with really empowering these children.

And some additional things parents can also do besides getting these children professional help is also getting them connected with additional school services, like supporting interventions, like an individualized education plan or even a 504 plan, that can sometimes help these children with giving them maybe more time on tests or more time on homework assignments or other accommodations to help these children struggling with OCD.

Melanie Cole (Host): So Dr. Chu, what do you mean by validate without reinforcing? I think for parents, it would be helpful for you to clarify what that means, because we can validate it, but how does that necessarily follow that we’re not reinforcing whatever the obsessive compulsive disorder is?

Dr. Michael Chu: Absolutely. So, what I mean by validation is really validating the child’s experience of distress and also be with them in that distress. Let them know that, as a parent, you do recognize how distressful these obsessions and compulsions are, but not to reinforce the compulsion. So, if a child feels like they have an obsessive thought and they have like a compulsive behavior to relieve some of that obsessive thought, the idea is to try the not reinforce compulsive behaviors that relieves the obsessive thought, but to still provide that parental validation to help with the experience of distress.

Melanie Cole (Host): So then, Dr. Chu, let’s talk about therapy and treatment options for OCDs. Tell us a little bit about what’s available.

Dr. Michael Chu: Treatment for OCD can be very effective. And like I was saying earlier, studies have shown early intervention is better. The first-line treatment for most children is typically therapy, particularly exposure response prevention. It’s also known as ERP, which is a subtype of CBT. And some children would benefit from both ERP and medications. Overall, there is about a 30% to 60% response to treatment. Some children may not respond to first-line therapies and treatment options. Recovery does take time and it could take several months to recover.

Melanie Cole (Host): Well, as you’re talking about these options for therapy, where does medicational treatment come in? Because some parents have heard that this is chemical or they’re not sure if there’s something like that going on? Where do interventions like that come into play in this picture?

Dr. Michael Chu: OCD is definitely a neurochemical brain circuit imbalance, and both therapy and medications can help with that. Studies have shown that therapy does cause changes in brain circuits and does help with restoring normality. Medications do kind of cause neurochemical changes, but therapy itself can also cause neurochemical changes.

For children with OCD, typically we do start with therapy as first line. This is the first-line treatment for most children. Studies have shown therapy is really effective. Particularly a type of therapy you really want to use is cognitive behavioral therapy, particularly exposure response prevention. That should be the first-line treatment.

However, in patients who have more severe forms of OCD or with a family history of OCD, studies have shown that it may be helpful to consider starting these patients on both therapy and then medication. Again, the therapy would be CBT or exposure response kind of prevention and the medication we typically start for first-line is a selective serotonin re-uptake inhibitor. What we use typically in pediatric psychiatry is fluoxetine and sertraline as kind of first-line treatments, but there are definitely some other options in terms of SSRIs too.

Melanie Cole (Host): Thank you so much. What great information. So as we wrap up, Dr. Chu, and you’ve told us about cognitive behavioral therapy and the medicational interventions and the signs and symptoms, now wrap it up with what you would like family and caregivers to know about OCDs in their child and when it’s time to see a specialist at Children’s Health of Orange County.

Dr. Michael Chu: OCD is something that’s very, very treatable. The earlier the intervention, the better. Diagnosis of OCD can be very complicated. The first line is getting connected with your pediatrician at CHOC. If your pediatrician sees your child and thinks that maybe there is some kind of concern for OCD, then your pediatrician would help with some of that referral to a psychologist or a psychiatrist for further treatment.

We do know OCD is very, very treatable with either medications or therapy. Therapy is usually first-line and medications are usually second-line, but some children get both. And we do know, with treatment, children do recover quite well. The earlier the intervention is better.

Some symptoms as a parent you could watch out for in terms of cluing you in, in terms of if your child does have OCD or not, or anxiety, I think it’s really kind of thinking big picture. Like if you notice they are struggling with a lot of distress and having poor performance in school or is struggling with peer interactions, with interactions with other adults or with people and they’re having worries in their mind, or even more particularly obsessive intrusive thoughts that pop into their head and it’s causing them to stress, then definitely that’s a call to really help get your child connected with mental health services here at CHOC.

In addition, I would just like to let people to know also in terms of therapy gains, we would usually think of therapy response typically within the first eight weeks of weekly CBT or specifically exposure response prevention therapy. So even within the first eight weeks, you will start seeing some response. In terms of treatment with medications, with a selective serotonin reuptake inhibitor, we typically even see like a response in treatment within two weeks, but typical response can sometimes take up to 12 weeks. So some of this treatment does take time and it’s not like a magical pill or magical therapy that someone does for a day or two and suddenly gets better. It is a lot of hard work on both the child and the parents. But it’s definitely very treatable.

Melanie Cole (Host): Thank you so much, Dr. Chu, for joining us today. For more mental health tips and more information on treatments for obsessive compulsive disorder, please visit CHOC.org/mentalhealth. Thanks so much for listening to Long Live Childhood, a pediatric health and wellness podcast presented by CHOC. Together, we can keep kids happy and healthy. Remember to share on your social channels as we’re all learning from the experts at CHOC together. I’m Melanie Cole.

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