a case study of ocd

• Case report
• Open access
• Published: 11 July 2020

Obsessive compulsive disorder in very young children – a case series from a specialized outpatient clinic

• Veronika Brezinka   ORCID: orcid.org/0000-0003-2192-3093 1 ,
• Veronika Mailänder 1 &
• Susanne Walitza 1  

BMC Psychiatry volume  20 , Article number:  366 ( 2020 ) Cite this article

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Paediatric obsessive-compulsive disorder (OCD) is a chronic condition often associated with severe disruptions of family functioning, impairment of peer relationships and academic performance. Mean age of onset of juvenile OCD is 10.3 years; however, reports on young children with OCD show that the disorder can manifest itself at an earlier age. Both an earlier age of onset and a longer duration of illness have been associated with increased persistence of OCD. There seems to be difficulty for health professionals to recognize and diagnose OCD in young children appropriately, which in turn may prolong the interval between help seeking and receiving an adequate diagnosis and treatment. The objective of this study is to enhance knowledge about the clinical presentation, diagnosis and possible treatment of OCD in very young children.

Case presentation

We describe a prospective 6 month follow-up of five cases of OCD in very young children (between 4 and 5 years old). At the moment of first presentation, all children were so severely impaired that attendance of compulsory Kindergarten was uncertain. Parents were deeply involved in accommodating their child’s rituals. Because of the children’s young age, medication was not indicated. Therefore, a minimal CBT intervention for parents was offered, mainly focusing on reducing family accommodation. Parents were asked to bring video tapes of critical situations that were watched together. They were coached to reduce family accommodation for OCD, while enhancing praise and reward for adequate behaviors of the child. CY-BOCS scores at the beginning and after 3 months show an impressive decline in OCD severity that remained stable after 6 months. At 3 months follow-up, all children were able to attend Kindergarten daily, and at 6 months follow-up, every child was admitted to the next level / class.

Conclusions

Disseminating knowledge about the clinical presentation, diagnosis and treatment of early OCD may shorten the long delay between first OCD symptoms and disease-specific treatment that is reported as main predictor for persistent OCD.

Peer Review reports

Paediatric obsessive compulsive disorder [ 1 ] is a chronic condition with lifetime prevalence estimates ranging from 0.25 [ 2 ] to 2–3% [ 3 ]. OCD is often associated with severe disruptions of family functioning [ 4 ] and impairment of peer relationships as well as academic performance [ 5 ]. Mean age of onset of early onset OCD is 10.3 years, with a range from 7.5 to 12.5 years [ 6 ] or at an average of 11 years [ 7 ]. However, OCD can manifest itself also at a very early age - in a sample of 58 children, mean age of onset was 4.95 years [ 8 ], and in a study from Turkey, OCD is described in children as young as two and a half years [ 9 ]. According to different epidemiological surveys the prevalence of subclinical OC syndromes was estimated between 7 and 25%, and already very common at the age of 11 years [ 10 ].

Understanding the phenomenology of OCD in young children is important because both an earlier age of onset and a longer duration of illness have been associated with increased persistence of OCD [ 11 , 12 , 13 ]. One of the main predictors for persistent OCD is duration of illness at assessment, which underlines that early recognition and treatment of the disorder are crucial to prevent chronicity [ 10 , 14 , 15 ]. OCD in very young children can be so severe that it has to be treated in an inpatient-clinic [ 16 ]. This might be prevented if the disorder were diagnosed and treated earlier.

In order to disseminate knowledge about early childhood OCD, detailed descriptions of its phenomenology are necessary to enable clinicians to recognize and assess the disorder in time. Yet, studies on this young population are scarce and differ in the definition of what is described as ‘very young’. For example, 292 treatment seeking youth with OCD were divided into a younger group (3–9 years old) and an older group (10–18 years old) [ 17 ]. While overall OCD severity did not differ between groups, younger children exhibited poorer insight, increased incidence of hoarding compulsions, and higher rates of separation anxiety and social fears than older youth. It is not clear how many very young children (between 3 and 5 years old) were included in this study. Skriner et al. [ 18 ] investigated characteristics of 127 young children (from 5 to 8) enrolled in a pilot sample of the POTS Jr. Study. These young children revealed moderate to severe OCD symptoms, high levels of impairment and significant comorbidity, providing further evidence that symptom severity in young children with OCD is similar to that observed in older samples. To our knowledge, the only European studies describing OCD in very young children on a detailed, phenotypic level are a single-case study of a 4 year old girl [ 16 ] and a report from Turkey on 25 children under 6 years with OCD [ 9 ]. Subjects were fifteen boys and ten girls between 2 and 5 years old. Mean age of onset of OCD symptoms was 3 years, with some OCD symptoms appearing as early as 18 months of age. All subjects had at least one comorbid disorder; the most frequent comorbidity was an anxiety disorder, and boys exhibited more comorbid diagnoses than girls. In 68% of the subjects, at least one parent received a lifetime OCD diagnosis. The study reports no further information on follow-up or treatment of these young patients.

In comparison to other mental disorders, duration of untreated illness in obsessive compulsive disorder is one of the longest [ 19 ]. One reason may be that obsessive-compulsive symptoms in young children are mistaken as a normal developmental phase [ 20 ]. Parents as well as professionals not experienced with OCD may tend to ‘watch and wait’ instead of asking for referral to a specialist, thus contributing to the long delay between symptom onset and assessment / treatment [ 10 ]. This might ameliorate if health professionals become more familiar with the clinical presentation, diagnosis and treatment of the disorder in the very young. The purpose of this study is to provide a detailed description of the clinical presentation, diagnosis and treatment of OCD in five very young children.

We describe a prospective 6 month follow-up of five cases of OCD in very young children (between 4 and 5 years old) who were referred to the OCD Outpatient Treatment Unit of a Psychiatric University Hospital. Three patients were directly referred by their parents, one by the paediatrician and one by another specialist. Parents and child were offered a first session within 1 week of referral. An experienced clinician (V.B.) globally assessed comorbidity, intelligence and functioning, and a CY-BOCS was administered with the parents.

Instruments

To assess OCD severity in youth, the Children Yale-Brown Obsessive Compulsive Scale CY-BOCS [ 21 ] is regarded as the gold standard, with excellent inter-rater and test-retest reliability as well as construct validity [ 21 , 22 ]. The CY-BOCS has been validated in very young children by obtaining information from the parent. As in the clinical interview Y-BOCS for adults, severity of obsessions and compulsions are assessed separately. If both obsessions and compulsions are reported, a score of 16 is regarded as the cut-off for clinically meaningful OCD. If only compulsions are reported, Lewin et al. [ 23 ] suggest a cut-off score of 8. In their CY-BOCS classification, a score between 5 and 13 corresponds to mild symptoms / little functional impairment or a Clinical Global Impression Severity (CGI-S) of 2. A score between 14 and 24 corresponds to moderate symptoms / functioning with effort or a CGI-S of 3. Generally, it is recommended to obtain information from both child and parents. However, in case of the very young patients presented here, CY-BOCS scores were exclusively obtained from the parents. The parents of all five children reported not being familiar with any obsessions their child might have. In accordance with previous recommendations [ 23 ], a cut-off point of 8 for clinically meaningful OCD was used.

Patient vignettes

Patient 1 is a 4 year old girl, a single child living with both parents. She had never been separated an entire day from her mother. At the nursery, she suffered from separation anxiety for months. Parents reported that the girl had insisted on rituals already at the age of two. In the evening, she ‚had‘ to take her toys into bed and had got up several times crying because she ‚had to‘ pick up more toys. In the morning, only she ‚had the right‘ to open the apartment door. When dressing in the morning, she ‚had‘ to be ready before the parents. Only she was allowed to flush the toilet, even if it concerned toilet use of the parents. Moreover, only she ‘had the right’ to switch on the light, and this had to be with ten fingers at the same time. If she did not succeed, she got extremely upset and pressed the light button again and again until she was satisfied. The girl was not able to throw away garbage and kept packaging waste in a separate box. In the evening, she had to tidy her room for a long time until everything was ‚right‘. Whenever her routine was changed, she protested by crying, shouting and yelling at her parents. Moreover, she insisted on repeating routines if there had been a ‚mistake‘. In order to avoid conflict, both parents adapted their behavior to their daughter’s desires. In the first assessment with the parents, her score on the CY-BOCS was 15, implying clinically meaningful OCD. Psychiatric family history revealed that the mother had suffered from severe separation anxiety as a child and the father from severe night mares. Both parents described themselves as healthy adults.

Patient 2 is a four and a half year old boy, the younger of two brothers. He was reported to have been very oppositional since the age of two. Since the age of three, he insisted on a specific ritual when flushing the toilet – he had to pronounce several distinct sentences and then to run away quickly. Some months later he developed a complicated fare-well ritual and insisted on every family member using exactly the sentences he wanted to hear. If one of these words changed, he started to shout and threw himself on the floor. After a short time, he insisted on unknown people like the cashier at the supermarket to use the same words when saying good-bye.Moreover, he insisted that objects and meals had to be put back to the same place as before in case they had been moved. When walking outside, he had to count his steps and had to start this over and over again. In the morning, he determined where his mother had to stand and how her face had to look when saying good-bye. In order to avoid conflict, parents and brother had deeply accommodated their behavior to his whims. On the CY-BOCS, patient 2 reached a score of 15, which is equivalent to clinically meaningful OCD. Neither his father nor his mother reported any psychiatric disorder in past or present.

Patient 3 is a 4 year old boy referred because of possible OCD. Since the age of three, he had insisted on things going his way. When this was not the case, he threw a temper tantrum and demanded that time should be turned back. If, for example, he had cut a piece of bread from the loaf and was not satisfied with its form, he insisted that the piece should be ‘glued’ to the loaf again. Since he entered Kindergarten at the age of four, his behavior became more severe. If he was not satisfied with a certain routine like, for example, dressing in the morning, he demanded that the entire family had to undress and go to bed again, that objects had to lie at the same place as before or that the clock had to be turned back. In order to avoid conflict, the parents had repeatedly consented to his wishes. His behavior was judged as problematic at Kindergarten, because he demanded certain situations to be repeated or ‚played back‘. When the teacher refused to do that, the boy once run away furiously. On the CY-BOCS, patient 3 reached a score of 15. The mother described herself as being rather anxious (but not in treatment), the father himself as not suffering from any psychiatric symptoms. However, his mother had suffered from such severe OCD when he was a child that she had undergone inpatient treatment several times. This was also the reason why the parents had asked for referral to a specialist for the symptoms of their son.

Patient 4 is a 5 year old girl, the eldest of three siblings. Since the age of two, she was only able to wear certain clothes. For months, she refused to wear any shoes besides Espadrilles; she was unable to wear jeans and could only wear one certain pair of leggings. Wearing warm or thicker garments was extremely difficult, leading to numerous conflicts with her mother in winter. Socks had to have the same height, stockings had to be thin, and slips slack. When dressing in the morning, she regularly got angry and despaired and engaged in severe conflicts with her mother; dressing took a long time, whereas she had to be in Kindergarten on time. Her compulsions with clothes seemed to influence her social behavior as well; she had been watching other children at the playground for 40 min and did not participate because her winter coat did not ‚feel right‘. She started to join peers only when she was allowed to pull the coat off. She also had to dry herself excessively after peeing and was reported to be perfectionist in drawing, cleaning or tidying. Her CY-BOCS score was 15, equivalent to clinically meaningful OCD. Both parents described themselves as not suffering from any psychiatric problem in past or present. However, the grandmother on the mother’s side was reported to have had similar compulsions when she was a child.

Patient 5 was a four and a half year old girl referred because of early OCD. She had one elder brother and lived with both parents. At the age of 1 year, patient 5 was diagnosed with a benign brain tumor (astrocytoma). The tumor had been removed for 90% by surgery; the remaining tumor was treated with chemotherapy. The first chemotherapy at the age of 3 years was reasonably well tolerated. Shortly thereafter, the girl developed just-right-compulsions concerning her shoes. When the second chemotherapy (with a different drug) was started at the age of four, compulsions increased so dramatically that she was referred to our outpatient clinic by the treating oncologist. She insisted on her shoes being closed very tightly, her socks and underwear being put on according to a certain ritual, and her belt being closed so tightly that her father had to punch an additional hole. She refused to wear slack or new clothes and was not able to leave the toilet after peeing because ‘something might still come’; she used large amounts of toilet paper and complained that she wasn’t dry yet. She also insisted on straightening the blanket of her bed many times. She was described by her mother as extremely stressed, impatient and irritable; she woke up every night and insisted to go to the toilet, from where she would come back only after intense cleaning rituals. In the morning, she frequently threw a severe temper tantrum, including hitting and scratching the mother, staying naked in the bathroom and refusing to get dressed because clothes were not fitting ‚just right‘or were not tight enough. Shortly after the start of the second chemotherapy, the girl had entered Kindergarten which was in a different language than the family language. Moreover, her mother had just taken up a new job and had to make a trip of several days during the first month. Although the mother gave up her job after the dramatic increase in OCD severity, the girl’s symptoms did not change. As an association between chemotherapy and the increase in OCD symptoms could not be excluded, the treating oncologist decided to stop chemotherapy 2 weeks after patient 5 was presented with OCD at our department. At the moment of presentation, she arrived at Kindergarten too late daily, after long scenes of crying and shouting, or refused to go altogether. She reached a score of 20 on the CY-BOCS, the highest score of the five children presented here. Her father described himself as free of any psychiatric symptoms in past or present. Her mother had been extremely socially anxious as a child.

None of the siblings of the children described above was reported to show any psychiatric symptoms in past or present (Table  1 ).

The five cases described above show a broad range of OCD symptomatology in young children. Besides Just-Right compulsions concerning clothes, compulsive behavior on the toilet was reported such as having to pee frequently, having to dry oneself over and over again as well as rituals concerning flushing. Other symptoms were pronouncing certain words or phrases compulsively, insisting on a ‘perfect’ action and claiming that time or situations must be played back like a video or DVD if the action or situation were not ‘perfect enough’. The patients described here have in common that parents were already much involved in the process of family accommodation. For example, the parents of patient 3 had consented several times to undress and go to bed again in order to ‘play back’ certain situations; they had also consented turning back the clock in the house. The parents of patient 2 had accommodated his complicated fare-well ritual, thus having to rush to work in the morning themselves. However, all parents were smart enough not just to indulge their child’s behavior, but to seek professional advice.

Treatment recommendations

Practice Parameters and guidelines for the assessment and treatment of OCD in older children and adolescents recommend cognitive behavior therapy (CBT) as first line treatment for mild to moderate cases, and medication in addition to CBT for moderate to severe OCD [ 24 , 25 ]. However, there is a lack of treatment studies including young children with OCD [ 26 ]. A case series with seven children between the age of 3 and 8 years diagnosed with OCD describes an intervention adapted to this young age group. Treatment emphasized reducing family accommodation and anxiety-enhancing parenting behaviors while enhancing problem solving skills of the parents [ 27 ]. A much larger randomized clinical trial for 127 young children (5 to 8 years of age) with OCD showed family-based CBT superior to a relaxation protocol for this age group [ 14 ]. Despite these advances in treatment for early childhood OCD, availability of CBT for paediatric OCD in the community is scarce due to workforce limitations and regional limitations in paediatric OCD expertise [ 28 ]. This is certainly not only true for the US, but for most European countries as well.

When discussing treatment of OCD in young children, the topic of family accommodation is of utmost importance. Family accommodation, also referred to as a ‘hallmark of early childhood OCD’ [ 15 ] means that parents of children with OCD tend to accommodate and even participate in rituals of the affected child. In order to avoid temper tantrums and aggressive behavior of the child, parents often adapt daily routines by engaging in child rituals or facilitating OCD by allowing extra time, purchasing special products or adapting family rules and organisation to OCD [ 29 , 30 , 31 ]. Although driven by empathy for and compassion with the child, family accommodation is reported to be detrimental because it further reinforces OCD symptoms and avoidance behavior, thus enhancing stress and anxiety [ 4 , 32 ].

Parent-oriented CBT intervention

At the moment of first presentation, the five children were so severely impaired by their OCD that attendance of (compulsory) Kindergarten was uncertain. All parents reported being utterly worried and stressed by their child’s symptoms and the associated conflicts in the family. However, no single family wanted an in-patient treatment of their child, and because of the children’s young age, medication was not indicated. Some families lived far away from our clinic and / or had to take care of young siblings.

Therefore, a CBT-intervention was offered to the parents, mainly focusing on reducing family accommodation. This approach is in line with current treatment recommendations to aggressively target family accommodation in children with OCD [ 15 ]. Parents and child were seen together in a first session. The following sessions were done with the parents only, who were encouraged to bring video tapes of critical situations. The scenes were watched together and parents were coached to reduce family accommodation for OCD, while enhancing praise and reward for adequate behaviors of the child. Parents were also encouraged to use ignoring and time-out for problematic behaviors. As some families lived far away and had to take care of young siblings as well, telephone sessions were offered as an alternative whenever parents felt the need for it. Moreover, parents were prompted to facilitate developmental tasks of their child such as attending Kindergarten regularly, or building friendships with peers. The minimal number of treatment sessions was four and the maximal number ten, with a median of six sessions.

Three of the five children (patients 3, 4 and 5) were raised in a different language at home than the one spoken at Kindergarten. This can be interpreted as an additional stressor for the child, possibly enhancing OCD symptoms. Instead of expecting their child to learn the foreign language mainly by ‚trial and error‘, parents were encouraged to speak this language at home themselves, to praise their child for progress in language skills and to facilitate playdates with children native in the foreign language.

Three and six months after intake, assessment of OCD-severity by means of the CY-BOCS was repeated. Table  2 shows an impressive decline in OCD-severity after 3 months that remained stable after 6 months. At 3 months follow-up, all children were able to attend Kindergarten daily, and at 6 months follow-up, every child was admitted to the next level of Kindergarten or, in the case of patient 4, to school.

We report on five children of 4 and 5 years with very early onset OCD who were presented at a University Department of Child and Adolescent Psychiatry. These children are ‚early starters‘with regard to OCD. As underlined in a recent consensus statement [ 10 ], delayed initiation of treatment is seen as an important aspect of the overall burden of OCD (see also [ 19 ]). In our small sample, a CBT-based parent-oriented intervention targeting mainly family accommodation led to a significant decline in CY-BOCS scores after 3 months that was maintained at 6 months. At 3 months, all children were able to attend Kindergarten daily, and at 6 months, every child was admitted to the next grade. This can be seen as an encouraging result, as it allowed the children to continue their developmental milestones without disruptions, like staying at home for a long period or following an inpatient treatment that would have demanded high expenses and probably led to separation problems at this young age. Moreover, the reduction on CY-BOCS scores was reached without medication. The number of sessions of the CBT-based intervention with the parents varied between four and ten sessions, depending on the need of the family. Families stayed in touch with the therapist during the 6 month period and knew they could get an appointment quickly when needed.

A possible objection to these results might be the question of differential diagnosis. Couldn’t the problematic behaviors described merely be classified as benign childhood rituals that would change automatically with time? As described in the patient vignettes, the five children were so severely impaired by their OCD that attendance of Kindergarten – a developmental milestone – was uncertain. Moreover, parents were extremely worried and stressed by their child’s symptoms and associated family conflicts. In our view, it would have been a professional mistake to judge these symptoms as benign rituals not worthy of diagnosis or disorder-specific treatment. One possible, but rare and debated cause of OCD are streptococcal infections, often referred to as PANS [ 33 ]. However, in none of the cases parents reported an abrupt and sudden onset of OCD symptoms after an infection. Instead, symptoms seem to have developed gradually over a period of several months or even years. In the case of patient 5 with the astrocytoma, first just-right compulsions appeared at the age of three (after the first chemotherapy), and were followed by more severe compulsions at the age of four, when – within a period of 6 weeks – a new chemotherapy was started, the mother took up a new job and the patient entered Kindergarten. Diagnosing the severe compulsions of patient 5 as, for example, adjustment disorder due to her medical condition would not have delivered a disorder-specific treatment encouraging parents to reduce their accommodation. This might have led to even more family accommodation and to more severe OCD symptoms in the young girl. Last but not least, a possible objection might be that the behaviors described were stereotypies. However, stereotypies are defined as repetitive or ritualistic movements, postures or utterances and are often associated with an autism spectrum disorder or intellectual disability. The careful intake with the children revealed no indication for any of these disorders.

Data reported here have several limitations. The children did not undergo intelligence testing; their reactions and behavior during the first session, as well as their acceptance and graduation at Kindergarten were assumed as sufficient to judge them as average intelligent. Comorbidities were assessed according to clinical impression and parents’ reports. The CBT treatment was based on our clinical expertise as a specialized OCD outpatient clinic. It included parent-oriented CBT elements, but did not have a fixed protocol and was adjusted individually to the needs of every family. Last but not least, no control group of young patients without an intervention was included.

Conclusions and clinical implications

We described a prospective 6 month follow-up of five cases of OCD in very young children. At the moment of first presentation, all children were so severely impaired that attendance of Kindergarten was uncertain. Parents were deeply involved in accommodating their child’s rituals. Because of the children’s young age, medication was not indicated. Therefore, a minimal CBT intervention for parents was offered, mainly focusing on reducing family accommodation. CY-BOCS scores at the beginning and after 3 months show an impressive decline in OCD severity that remained stable after 6 months. At 3 months follow-up, all children were able to attend Kindergarten daily, and at 6 months follow-up, every child had been admitted to the next grade. OCD is known to be a chronic condition. Therefore, in spite of treatment success, relapse might occur. However, as our treatment approach mainly targeted family accommodation, parents will hopefully react with less accommodation, should a new episode of OCD occur. Moreover, parents stay in touch with the outpatient clinic and can call when needed.

The clinical implications of our findings are that clinicians should not hesitate to think of OCD in a young child when obsessive-compulsive symptoms are reported. The assessment of the disorder should include the CY-BOCS, which has been validated in very young children by obtaining information from the parent. If CY-BOCS scores are clinically meaningful (for young children, a score above 8), a parent-based treatment targeting family accommodation should be offered.

By disseminating knowledge about the clinical presentation, assessment and treatment of early childhood OCD, it should be possible to shorten the long delay between first symptoms of OCD and disease-specific treatment that is reported as main predictor for persistent OCD. Early recognition and treatment of OCD are crucial to prevent chronicity [ 14 , 15 ]. As children and adolescents with OCD have a heightened risk for clinically significant psychiatric and psychosocial problems as adults, intervening early offers an important opportunity to prevent the development of long-standing problem behaviors [ 10 , 19 ].

Availability of data and materials

All data generated or analyzed during this study are included in this published article [and its supplementary information files].

Abbreviations

Obsessive compulsive behavior

Child Yale-Brown Obsessive Compulsive Scale

Cognitive Behavior Therapy

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Department of Child and Adolescent Psychiatry and Psychotherapy, University Hospital of Psychiatry Zurich, University of Zurich, Neumünsterallee 3, 8032, Zurich, Switzerland

Veronika Brezinka, Veronika Mailänder & Susanne Walitza

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Contributions

V.B. conducted the diagnostic and therapeutic sessions and wrote the manuscript. V.M. was responsible for medical supervision and revised the manuscript. S.W. supervised the OCD treatment and research overall, applied for ethics approval and revised the manuscript. All authors have read and approved the manuscript.

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Correspondence to Veronika Brezinka .

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the study was approved by the Kantonale Ethikkommission Zürich, July 22nd, 2019.

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V.B. and V.M. declare that they have no competing interests. S.W. has received royalties from Thieme, Hogrefe, Kohlhammer, Springer, Beltz in the last 5 years. Her work was supported in the last 5 years by the Swiss National Science Foundation (SNF), diff. EU FP7s, HSM Hochspezialisierte Medizin of the Kanton Zurich, Switzerland, Bfarm Germany, ZInEP, Hartmann Müller Stiftung, Olga Mayenfisch, Gertrud Thalmann, Vontobel-, Unisciencia and Erika Schwarz Fonds. Outside professional activities and interests are declared under the link of the University of Zurich www.uzh.ch/prof/ssl-dir/interessenbindungen/client/web/

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Brezinka, V., Mailänder, V. & Walitza, S. Obsessive compulsive disorder in very young children – a case series from a specialized outpatient clinic. BMC Psychiatry 20 , 366 (2020). https://doi.org/10.1186/s12888-020-02780-0

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A True Story of Living With Obsessive-Compulsive Disorder

An authentic and personal perspective of the internal battles within the mind..

Posted April 3, 2017

• What Is Obsessive-Compulsive Disorder?
• Find a therapist to treat OCD

Contributed by Tiffany Dawn Hasse in collaboration with Kristen Fuller, M.D.

The underlying reasons why I have to repeatedly re-zip things, blink a certain way, count to an odd number, check behind my shower curtain to ensure no one is hiding to plot my abduction, make sure that computer cords are not rat tails, etc., will never be clear to me. Is it the result of a poor reaction to the anesthesiology that was administered during my wisdom teeth extraction? These aggravating thoughts and compulsions began immediately after the procedure. Or is it related to PANDAS (Pediatric Autoimmune Neuropsychiatric Disorder Associated with Streptococcal infection) which is a proposed theory connoting a strange relationship between group A beta-hemolytic streptococcal infection with rapidly developing symptoms of obsessive-compulsive disorder in the basal ganglia? Is it simply a hereditary byproduct of my genetic makeup associated with my nervous personality ? Or is it a defense tactic I developed through having an overly concerned mother?

The consequences associated with my OCD

Growing up with mild, in fact dormant, obsessive-compulsive disorder, I would have never proposed such bizarre questions until 2002, when an exacerbated overnight onset of severe OCD mentally paralyzed me. I'd just had my wisdom teeth removed and was immediately bombarded with incessant and intrusive unwanted thoughts, ranging from a fear of being gay to questioning if I was truly seeing the sky as blue. I'm sure similar thoughts had passed through my mind before; however, they must have been filtered out of my conscious, as I never had such incapacitating ideas enter my train of thought before. During the summer of 2002, not one thought was left unfiltered from my conscious. Thoughts that didn't even matter and held no significance were debilitating; they prevented me from accomplishing the simplest, most mundane tasks. Tying my shoe only to untie it repetitively, continuously being tardy for work and school, spending long hours in a bathroom engaging in compulsive rituals such as tapping inanimate objects endlessly with no resolution, and finally medically withdrawing from college, eventually to drop out completely not once but twice, were just a few of the consequences I endured.

Seeking help

After seeing a medical specialist for OCD, I had tried a mixed cocktail of medications over a 10-year span, including escitalopram (Lexapro), fluoxetine (Prozac), risperidone (Risperdal), aripiprazole (Abilify), sertraline (Zoloft), clomipramine (Anafranil), lamotrigine (Lamictal), and finally, after a recent bipolar disorder II diagnosis, lurasidone (Latuda). The only medication that has remotely curbed my intrusive thoughts and repetitive compulsions is lurasidone, giving me approximately 60 to 70 percent relief from my symptoms.

Many psychologists and psychiatrists would argue that a combination of cognitive behavioral therapy (CBT) and pharmacological management might be the only successful treatment approach for an individual plagued with OCD. If an individual is brave enough to undergo exposure and response prevention therapy (ERP), a type of CBT that has been shown to relieve symptoms of OCD and anxiety through desensitization and habituation, then my hat is off to them; however, I may have an alternative perspective. It's not a perspective that has been researched or proven in clinical trials — just a coping mechanism I have learned through years of suffering and endless hours of therapy that has allowed me to see light at the end of the tunnel.

In my experience with cognitive behavioral therapy, it may be semi-helpful by deconstructing or cognitively restructuring the importance of obsessive thoughts in a hierarchical order; however, I still encounter many problems with this type of technique, especially because each and every OCD thought that gets stuck in my mind, big or small, tends to hold great importance. Thoughts associated with becoming pregnant , seeing my family suffer, or living with rats are deeply rooted within me, and simply deconstructing them to meaningless underlying triggers was not a successful approach for me.

In the majority of cases of severe OCD, I believe pharmacological management is a must. A neurological malfunction of transitioning from gear to gear, or fight-or-flight, is surely out of whack and often falsely fired, and therefore, medication works to help balance this misfiring of certain neurotransmitters.

Exposure and response prevention therapy (ERP) is an aggressive and abrasive approach that did not work for me, although it may be helpful for militant-minded souls that seek direct structure. When I was enrolled in the OCD treatment program at UCLA, I had an intense fear of gaining weight, to the point that I thought my body could morph into something unsightly. I remember being encouraged to literally pour chocolate on my thighs when the repetitive fear occurred that chocolate, if touching my skin, could seep through the epidermal layers, and thus make my thighs bigger. While I boldly mustered up the courage to go through with this ERP technique recommended by my specialist, the intrusive thoughts and compulsive behaviors associated with my OCD still and often abstain these techniques. Yes, the idea of initially provoking my anxiety in the hope of habituating and desensitizing its triggers sounds great in theory, and even in a technical scientific sense; but as a human with real emotions and feelings, I find this therapy aggressive and infringing upon my comfort level.

How I conquered my OCD

So, what does a person incapacitated with OCD do? If, as a person with severe OCD, I truly had an answer, I would probably leave my house more often, take a risk once in a while, and live freely without fearing the mundane nuances associated with public places. It's been my experience with OCD to take everything one second at a time and remain grateful for those good seconds. If I were to take OCD one day at a time, well, too many millions of internal battles would be lost in this 24-hour period. I have learned to live with my OCD through writing and performing as a spoken word artist. I have taken the time to explore my pain and transmute it into an art form which has allowed me to explore the topic of pain as an interesting and beneficial subject matter. I am the last person to attempt to tell any individuals with OCD what the best therapy approach is for them, but I will encourage each and every individual to explore their own pain, and believe that manageability can come in many forms, from classic techniques to intricate art forms, in order for healing to begin.

Tiffany Dawn Hasse is a performance poet, a TED talk speaker , and an individual successfully living with OCD who strives to share about her disorder through her art of written and spoken word.

Kristen Fuller M.D. is a clinical writer for Center For Discovery.

Facebook image: pathdoc/Shutterstock

Kristen Fuller, M.D., is a physician and a clinical mental health writer for Center For Discovery.

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Case Report: Obsessive compulsive disorder in posterior cerebellar infarction - illustrating clinical and functional connectivity modulation using MRI-informed transcranial magnetic stimulation

Urvakhsh Meherwan Mehta Roles: Conceptualization, Data Curation, Formal Analysis, Funding Acquisition, Investigation, Methodology, Writing – Original Draft Preparation, Writing – Review & Editing Darshan Shadakshari Roles: Data Curation, Investigation, Resources, Writing – Review & Editing Pulaparambil Vani Roles: Data Curation, Investigation, Methodology, Supervision, Writing – Review & Editing Shalini S Naik Roles: Methodology, Project Administration, Writing – Review & Editing V Kiran Raj Roles: Data Curation, Formal Analysis, Visualization, Writing – Review & Editing Reddy Rani Vangimalla Roles: Data Curation, Formal Analysis, Visualization, Writing – Review & Editing YC Janardhan Reddy Roles: Supervision, Writing – Review & Editing Jaya Sreevalsan-Nair Roles: Formal Analysis, Investigation, Visualization, Writing – Review & Editing Rose Dawn Bharath Roles: Conceptualization, Formal Analysis, Investigation, Methodology, Supervision, Visualization, Writing – Review & Editing

This article is included in the Wellcome Trust/DBT India Alliance gateway.

Obsessive Compulsive Disorder, Cerebellar cognitive affective syndrome, Neuromodulation, Functional brain connectivity, Cerebellar infarct, Theta burst stimulation

Revised Amendments from Version 1

The new version provides more clinical details about the patient, in response to the review comments raised. These include details and justifications for past treatment, iTBS treatment details, rationale for performing an MRI scan and follow-up information beyond the earlier reported period of three months.

See the authors' detailed response to the review by Shubhmohan Singh See the authors' detailed response to the review by Peter Enticott

Introduction

Cortico-striato-thalamocortical circuitry dysfunction is central to an integrated neuroscience formulation of obsessive-compulsive disorder (OCD) 1 , 2 . However, more recent large-scale brain connectivity analyses implicate the role of the cerebello-thalamocortical networks also 3 . Here, we report a case of OCD secondary to a cerebellar lesion. We test the mediating role of the cerebellum in the manifestation of OCD by manipulating the frontal-cerebellar network using MRI-informed transcranial magnetic stimulation (TMS).

Case report

A 21-year-old male, an undergraduate student from rural south India, presented to our emergency with suicidal thoughts. History revealed three years of academic decline, pathological slowness in routine activities (e.g., bathing, eating, dressing up, and using the toilet), repetitive ‘just-right’ behaviors (e.g., wiping his mouth after eating, clearing his throat, pulling down his shirt, mixing his food in the plate and walking back and forth until ‘feeling satisfied’). As a result, he spent up to three hours completing a meal or his toilet routines. Before presentation to us, he had received trials with two separate courses of electroconvulsive therapy (ECT) – six bitemporal ECTs at first, followed by nine bifrontal) spaced about two months apart. ECT was prescribed because of a further deterioration in his condition over the prior 18-months, with reduced oral intake, weight loss, grossly diminished speech output, and passing urine in bed (as he would remain in bed secondary to his obsessive ambitendency, as disclosed later). His oral intake and speech output improved with both ECT treatments, only to gradually worsen over the next few weeks. Given the potential catatonic phenomena (withdrawn behaviour and mutism) in the background of ongoing academic decline, slowness and stereotypies, he was also treated with oral olanzapine 20mg for eight weeks and risperidone 6mg for six weeks with minimal change in his slowness and repetitive behaviors. He did not receive any antidepressant medications. Psychotherapy was also not considered given the limited feasibility due to the severe withdrawal and near mutism. We could not elicit any contributory clinical history of prodromal or mood symptoms from adolescence when we evaluated his past psychiatric and medical history. Two months after the last ECT treatment, he presented to our emergency services with suicidal thoughts. He was admitted, and mental status examination revealed aggressive (urges to harm himself by jumping in front of a moving vehicle or touching electric outlets) and sexual obsessions with mental compulsions and passing urine in bed (as he could not go to the toilet in time due to obsessive ambitendency). The Yale-Brown Obsessive-Compulsive Scale (YBOCS) severity score was 29 4 . He had good insight into obsessions, but not the ‘just right’ repetitive behaviors; it was, therefore, challenging to engage him in psychotherapy. We treated him with escitalopram 40mg and brief psychoeducation before being discharged. After three months, his obsessions had resolved, but pathological slowness, ‘just right’ phenomena, and passing urine in bed had worsened (YBOCS score 31).

We then obtained a plain and contrast brain MRI, to rule out an organic aetiology given the atypical nature of symptoms (apparent urinary incontinence) and the poor treatment response. The MRI revealed a wedge-shaped lesion in the right posterior cerebellum, suggestive of a chronic infarct in the posterior inferior cerebellar artery territory ( Figure-1A ). MR-angiogram revealed no focal narrowing of intracranial and extracranial vessels. Electroencephalography, cerebrospinal fluid analysis, autoimmune and vasculitis investigations were unremarkable. Echocardiogram was normal and the sickling test for sickle cell anemia was also negative. We specifically inquired about history of loss of consciousness, seizures or motor incoordination, but these were absent. His neurological examination with a detailed focus on cerebellar signs was unremarkable. The International Cooperative Ataxia Rating Scale (ICARS) score was zero. The Cerebellar Cognitive Affective Syndrome (CCAS) scale revealed >3 failed tests – in domains of attention, category switching, response inhibition, verbal fluency, and visuospatial drawing, suggestive of definite CCAS 5 .

Cerebellar lesion detection ( A & B ), its functional connectivity map ( C ) and MRI-guided transcranial magnetic stimulation delivery ( D ). Average blood oxygen level-dependent (BOLD) signal time-series were extracted from voxels within a binarized lesion-mask that overlapped with the right crus II ( 1A & 1B ). This was used as the model predictor in a general linear model to determine the brain regions that temporally correlated with the lesion-mask using FSL-FEAT 11 . The resultant seed-to-voxel connectivity map (z-thresholded at 4) was used to identify the best connectivity of the seed with voxels in the pre-supplementary motor area (pre-SMA; MNI x=3; y=13; z=58; 1C ). Six-hundred pulses were delivered as triplet bursts at theta frequency and 90% of the resting motor threshold (50 Hz; 2s on; 8s off) using a MagPro X100 (MagVenture, Denmark) device under MR-guided neuronavigation using the Brainsight stereotaxic system (Rogue Research, Montreal, Canada) with a figure-of-eight coil held with the handle in line with the sagittal plane, pointing toward the occiput to stimulate the pre-SMA site ( 1D ).

MRI-informed neuromodulation

Owing to inadequate treatment response and the possibility of OCD secondary to the cerebellar lesion, we discussed with the patient about MRI-informed repetitive transcranial magnetic stimulation (rTMS) and obtained his consent. The presence of a lesion involving a node (cerebellum) within the cerebello-thalamo-cortical circuit – a key pathway for error monitoring 6 and inhibitory control 7 – cognitive processes typically impacted in OCD prompted us to utilize a personalized-medicine approach to treatment. We acquired a resting-state functional-MRI echoplanar sequence (8m 20s; 250-volumes) in duplicate – before, and one-month after rTMS treatment on a 3-Tesla scanner (Skyra, Siemens), using a 20-channel coil with the following parameters: TR/TE/FA= 2000ms/30ms/78; voxel=3mm isotropic; FOV=192*192.

Image processing was performed using the FMRIB Software Library (FSL version-5.0.10) 8 . Figure 1 describes how we obtained a seed-to-voxel connectivity map to identify the best connectivity of the cerebellar lesion-seed with voxels in the pre-supplementary motor area (pre-SMA; MNI x=3; y=13; z=58) – a commonly used site for neuromodulation in OCD 9 . This area demonstrates connections with the non-motor (ventral dentate nucleus) parts of the posterolateral cerebellum 10 and contributes to error processing and inhibitory control along with the cerebellum 7 .

We augmented escitalopram with rTMS, administered as intermittent theta-burst stimulation (iTBS) to the pre-SMA coordinates ( Figure-1D ). Six-hundred pulses were delivered as triplet bursts at theta frequency and 90% of the resting motor threshold (50 Hz; 2s on; 8s off) using a MagPro X100 (MagVenture, Farum, Denmark) device under MR-guided neuronavigation using the BrainSight stereotaxic system (Rogue Research, Montreal, Canada) with a figure-of-eight (MagVenture MCF-B-70) coil held with the handle in line with the sagittal plane, pointing toward the occiput to stimulate the pre-SMA site. We hypothesized that iTBS 12 to the pre-SMA could adaptively engage the cerebellum lesion, with which it shares neuronal oscillation frequencies, and hence improve the disabling symptoms. He received 27 iTBS sessions, once daily over the next month. Following ten sessions, he began to show a reduction in his repetitive behaviors, and by the 15 th session, he acknowledged that his behaviors were irrational. The YBOCS severity score had reduced to 24 (~22.5% improvement), which remained the same, even at the end of 27 sessions of iTBS treatment. There was no change in the CCAS and ICARS scores. The clinical benefits remained unchanged until three months of follow-up. Subsequently, we observed a gradual reversal to pre-TMS symptom severity. Maintenance TMS was suggested but was not feasible due to logistic reasons and therefore he was initiated on oral fluoxetine that was gradually increased to 80mg/day, with which we observed minimal change in symptoms over the next four months.

Post-neuromodulation functional connectivity visualization

The pre- and post-rTMS scans 13 were parcellated into 48-cortical, 15-subcortical, and 28-cerebellar regions as per the Harvard-Oxford 14 and the Cerebellum MNI-FLIRT atlases 15 . Average BOLD-signal time-series from each of these nodes, obtained after processing within FSL version-5.0.10, were then concatenated to obtain a Pearson’s correlation matrix between 91 nodes, separately for the pre- and post-TMS studies.

We analyzed the two 91 × 91 matrices using the Rank-two ellipse (R2E) seriation technique for node clustering 16 ( Figure 2 ). This technique reorders the nodes by moving the ones with a higher correlation closer to the diagonal. Thus, blocks along the diagonal of the matrix visualization show possible functional coactivating clusters.

Rank-two ellipse seriation-based visualization of correlation matrix before ( A ) and after ( B ) rTMS treatment. The dotted-black boxes denote the cerebellar network and other connected networks, where the green boxes show the inter-network overlap. Thus, we see that the overlapped region in ( 2A ) has now transitioned to three different overlapped areas in ( 2B ), which shows the increase in the overlap between modular networks after treatment. Cerebellar nodes are denoted in black, cortical nodes in blue and subcortical nodes in green. The lesion node (right crus II) and the region of neuro-stimulation are given in red; R2E= Rank-two ellipse.

We observed (a) extended connectivity of the cerebellar network after iTBS treatment as evidenced through its diminished modularity – the larger cerebellar cluster/block had an increased overlap with both anterior and posterior brain networks as observed along the diagonal in ( Figure 2B ), and (b) formation of better-defined sub-clusters within the larger cerebellar cluster indicating improved within-network modularity of distinct functional cerebellar networks [e.g., vestibular (lobules IX and X) and cognitive-limbic (crus I/II and vermis)].

Conclusions

We illustrate a case of OCD possibly secondary to a posterior cerebellar infarct, supporting the role of the cerebellum in the pathophysiology of OCD 3 . That OCD was perhaps secondary to the posterior cerebellar lesion is supported by several lines of evidence. Firstly, there seemed to be a possible temporal correlation between the duration of OCD and the chronic nature of the cerebellar lesion. Despite the challenges in inferring a precise temporal relationship based on clinical history, the signal changes with free diffusion and atrophy indicated that the infarct was indeed chronic, supporting the symptom onset at about three years before presentation. Previous studies have indeed reported OCD in posterior cerebellar lesions 17 – 19 . Secondly, the clinical phenotype was somewhat atypical, characterized by severe ambitendency, precipitating urinary incontinence, and poor insight into compulsions along with comorbid CCAS. Thirdly, our patient was resistant to an anti-obsessional medication but improved partially with neuromodulation of the related circuit. The MRI-informed iTBS engaged the lesion-area by targeting its more superficial connections in the frontal lobe. The changes in clinical observations paralleled the changes in cerebellar functional connectivity – enhanced within-cerebellum modularity and expanded cerebellum to whole-brain connectivity.

This report adds to the growing evidence-base for the involvement of the posterior cerebellum in the pathogenesis of OCD. Drawing conclusions from a single case study and the absence of a placebo treatment will prevent any confirmatory causal inferences from being made. The opportunity to examine network-changes that parallel therapeutic response in an individual with lesion-triggered psychiatric manifestations not only helps mapping symptoms to brain networks at an individual level 13 but also takes us a step further to refine methods to deliver more effective personalized-medicine in the years to come.

Data availability

Underlying data.

Harvard Dataverse: PICA OCD Raw fMRI files NII format. https://doi.org/10.7910/DVN/X12BZD 20 .

This project contains the following underlying data:

- postTMS_fmri.nii (raw post TMS fMRI file)

- preTMS_fmri.nii (Raw pre TMS fMRI file)

Reporting guidelines

Harvard Dataverse: PICA OCD case report CARE guidelines for case reports: 13-item checklist. https://doi.org/10.7910/DVN/2XKSXL 21 .

Data are available under the terms of the Creative Commons Zero "No rights reserved" data waiver (CC0 1.0 Public domain dedication).

Written informed consent for publication of their clinical details and clinical images was obtained from the patient.

Acknowledgments

We thank our patient and his parents for permitting us to collate this data for publication.

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Comments on this article Comments (0)

Open peer review.

Competing Interests: No competing interests were disclosed.

Reviewer Expertise: Cognitive neuroscience

• Respond or Comment
• COMMENT ON THIS REPORT

Is the background of the case’s history and progression described in sufficient detail?

Are enough details provided of any physical examination and diagnostic tests, treatment given and outcomes?

Is sufficient discussion included of the importance of the findings and their relevance to future understanding of disease processes, diagnosis or treatment?

Is the case presented with sufficient detail to be useful for other practitioners?

• This is a very interesting case report, even without the intervention component (which itself is a fascinating approach to neuromodulation). I particularly appreciated the approach to regional (SMA)
• This is a very interesting case report, even without the intervention component (which itself is a fascinating approach to neuromodulation). I particularly appreciated the approach to regional (SMA) targeting, which involved resting state fMRI to detect functional connectivity with the affected cerebellar region. The report itself is very clear and well-written.
• ECT appears to have been provided in the context of a depressive episode, but were other (e.g., psychotherapy, pharmacotherapy) treatments initially trialled? It would be useful to present any clinical history from adolescence, although this may not be feasible.
• Please describe the reason for conducting MRI; why was this not undertaken earlier?
• Was iTBS the “standard” course (i.e., 600 pulses, trains comprising 3 pulses at 50 Hz, repeated for 2 seconds at 5 Hz, followed by an 8-second ITI)? How was intensity determined (e.g., 70%RMT, 80%AMT)? Specify the stimulator, coil type, and neuronavigation method.
• Given that the duration of both the cerebellar lesion and OCD symptoms seems quite unclear, it is somewhat difficult to suggest a temporal relationship (as stated in the Conclusion).
• Was the patient followed-up over a longer-term period? I would be interested to know if these improvements are lasting (i.e., longer than 3 months), although again this might not be possible. 

Reviewer Expertise: Neuromodulation, psychiatry

• Author Response 11 Sep 2020 Urvakhsh Mehta , Department of Psychiatry, National Institute of Mental Health and Neurosciences, India, Bangalore, 560029, India 11 Sep 2020 Author Response We thank this reviewer for the time taken to provide constructive feedback and the encouraging comments on this report.    Competing Interests: None We thank this reviewer for the time taken to provide constructive feedback and the encouraging comments on this report.    We thank this reviewer for the time taken to provide constructive feedback and the encouraging comments on this report.    Competing Interests: None Close Report a concern Reply -->

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• Shubhmohan Singh , Postgraduate Institute of Medical Education and Research, Chandigarh, India
• Peter Enticott , Deakin University, Geelong, Australia

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Module 5: Obsessive Compulsive Disorder and Stressor Related Disorders

Case studies: ocd and ptsd, learning objectives.

• Identify OCD and PTSD in case studies

Case Study: Mauricio

Case Study: Cho

Possible treatment considerations for Cho may include CBT or eye movement desensitization and reprocessing (EMDR). This could also be coupled with pharmaceutical treatment, such as anti-anxiety medication or anti-depressants to help alleviate symptoms. Cho will need a trauma therapist who is experienced in working with adolescents. Other treatment that may be helpful is starting family therapy as well to ensure everyone is learning to cope with the trauma and work together through the painful experience.

Link to Learning

To read more about the ongoing issues of PTSD in violent-prone communities, read this article about a mother and her seven-year-old with PTSD .

Think It Over

If you were a licensed counselor working in a community that experienced a high rate of violent crimes, how might you treat the patients that sought therapeutic help? What might be some of the challenges in assisting them?

• Case Studies. Authored by : Christina Hicks for Lumen Learning. Provided by : Lumen Learning. License : Public Domain: No Known Copyright
• Desk top. Located at : https://www.pickpik.com/desk-top-desk-notebook-keyboard-desktop-shallow-116155 . License : Public Domain: No Known Copyright
• Lightning strike. Authored by : John Fowler. Located at : https://www.flickr.com/photos/snowpeak/3761397491 . License : CC BY: Attribution

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Case Study: Obsessive-Compulsive Disorder

In a previous article we reviewed a range of treatments that are used to help clients suffering from obsessive-compulsive disorder (OCD). In this edition we showcase the case study of Darcy [fictional name], who worked with a psychologist to address the symptoms and history of her OCD.

Marian, a psychologist who specialised in anxiety disorders, closed the file and put it into the filing cabinet with a smile on her face. This time she had the satisfaction of filing it into the “Work Completed” files, for she had just today celebrated the final session with a very long-term client: Darcy Dawson. They’d come through a lot together, Darcy and Marian, during the twelve years of Darcy’s treatment for Obsessive-Compulsive Disorder, and they had had a particularly strong therapeutic alliance.

Marian reflected on the symptoms and history which had brought Darcy into her practice.

Obsessions at age nine

Now 37, Darcy reckoned that she had begun having obsessions around age nine, soon after her beloved grandma had died. Already grieving the loss of the person she was closest to in life, Darcy experienced further alienation – and resultant anxiety — when her father relocated the family from the small town in Victoria where they lived to Melbourne. Adjusting to big-city life wasn’t easy for someone as anxious as Darcy, and she soon found that she was obsessing. She had fears of being hit by a speeding car if she stepped off the kerb. She feared that the new friends she began to develop in Melbourne would be kidnapped by bad people. And she was terrified that, if she didn’t do an elaborate prayer routine at night, all manner of terrible things would befall her family.

The prayer routine, relatively simple at first, grew to gigantic proportions, containing many rules and restrictions. Darcy believed that she had to repeat each family member’s full name 15 times, say a sentence that asked for each person to be kept safe, promise God that she would improve herself, clap her hands 20 times for each person, kneel down and get up 5 times, and then put her hands into a prayer position while bowing. She “had” to do this routine at least 10 times each night, and if she made a mistake anywhere along the way, she had to start totally over again from the beginning, or else something bad would happen to her parents or little brother. Once she went flying to her mother’s side in the kitchen, tears streaming down her face, because she couldn’t get her “prayers” right. Darcy was certain that she was a huge disappointment to God and everybody.

Just like Granddad

Marian had asked Darcy if her parents were similar at all, and Darcy couldn’t think of many ways in which they were. Then she remembered something. “Ah,” she said, “my parents aren’t having these awful thoughts like me, but I remember my mum often telling me, ‘You’re just like your grandfather.’” Darcy’s grandfather had died when she was only five, so she didn’t have strong recollections of him, but there were two images that she always remembered about him: Grandfather standing by the kitchen sink in their farmhouse, washing his hands – always washing his hands. And if they decided to take a walk around the farm, he would take a seeming eternity to check that all the windows and doors were locked, even though they were on good terms with everyone within a ten-mile radius!

Obsessions and compulsions worsen through Uni

Marian had felt huge compassion for Darcy as she outlined the course that the disorder had taken. While the intrusive thoughts waxed during high-stress times and waned when Darcy felt relatively stable, there was nevertheless a general broadening of the obsessions – and resultant compulsion to do certain repetitive acts – throughout Darcy’s growing-up years. In high school, for instance, Darcy began to have an aversion to looking at any woman with a scoop-neck top on, going so far as to grab a glass and pretend to be holding it high up near her lips (as if to drink) if she had to talk to someone dressed in any but the most conservative top. In that way, she felt, she would be blocked from seeing what she should not see and thus sinning. Short skirts were also a problem, as Darcy feared that she was looking at people in inappropriate ways, and was offensive.

If anyone at a party crossed their legs while she was looking at them, Darcy assumed that they had done that because they were offended by her having glanced at them; she feared that they would think she was looking at their crotch area. She prayed constantly for forgiveness, but ended up ceasing hugs to family and friends because she felt like a hypocrite. Of course, not feeling that she could/should touch anyone made for huge social problems, and dating anyone became impossible: a huge punishment for a friendly extravert like Darcy. She petitioned God relentlessly, asking to be a better, less sinful person. It did not seem to help.

When Darcy began University, the experience was defined by a series of irrational obsessions. She would worry incessantly about having written something offensive on an email or an assignment. Walking around campus, she would pick up rubbish: papers that she had never seen before; she would worry that she might have written something on one of them. She feared that she would accidentally hurt one of her fellow students by something that she might do or say. By this time Darcy was repeating certain phrases over and over again to ward off disaster. She was amazed that she was getting through school at all (she often made straight A’s), because her rampant perfectionism caused her to take at least twice as long as other students to complete assignments, and she still wasn’t happy then. The anxiety and depression were overwhelming Darcy to the point where she recognised that she could barely function and something needed to change.

The Uni psychologist says, “You’re fine”

Marian shook her head in amazement as she recalled how Darcy’s first attempts to find out what was wrong with her had been fruitless; all the health professionals had completely missed the OCD! Upon first coming to Marian, Darcy had recounted how getting along to the University psychologist in her senior year was a “non-event”. He had asked a few questions, chatted to her about her schoolwork, told her she was basically fine, and then told her to go see a psychiatrist, who merely prescribed a sleeping pill. Darcy had taken this, as instructed, because the intrusive thoughts in her mind often did keep her from sleeping, but when she was awake she still had the thoughts and the horrible compulsion to perform the anxiety-alleviating acts: routines which now occupied several hours each day. Moreover, Darcy’s parents still didn’t believe that anything was wrong with her; they even found it funny that she was “quirky” like her grandfather.

Age 25: Treatment begins

Darcy was to graduate and spend another three years being held prisoner by her out-of-control mind before a chance meeting of her mother with a specialist in OCD at a conference. The specialist didn’t live in Melbourne, but – by incredible coincidence – he had a highly recommended colleague who did: Marian. Marian recalled with some fondness how Darcy had sat in her office during the first session, shedding tears of joy at being truly “seen”: both as a person and in her disorder. When Marian had issued the magical words, “Obsessive-Compulsive Disorder”, Darcy had been surprised – after all, her sense of OCD was people who continually washed their hands – but she also felt like she had just been given the key to her prison. Her treatment began soon after.

Marian worked intensively with Darcy at first, and then steadily. She helped Darcy get onto an even keel emotionally first by raising her serotonin levels (which had been quite low). Marian then began the laborious process of helping Darcy to change her habits of thinking: the assumptions that she made, the irrationalities that controlled her behaviour, and the intrusive obsessions that seemed to take over her life. Marian helped Darcy to see the importance of an exercise regimen, a good diet, and a stillness practice. Darcy joined an online support group, and Marian and Darcy enlisted the help of Darcy’s family and a few close friends. Partway through the therapy, Darcy was even able to come off the medications: a goal she had long sought, because she had married a “wonderful” man and they wanted to start a family.

At 37, Darcy is a happy and fulfilled person, with a solid marriage and an eight-year-old daughter. She believes that she worries about her “like a normal mother”, rather than in the obsessional way she used to pray in order to protect her family from imagined harm. She still petitions God, as she is active in her church, but now the petitions are free of the superstitious routines she used to perform, and she is quick to be thankful for her many blessings.

Unwanted thoughts still come to her, but now she has tools to focus elsewhere, and when the intrusive thoughts come, Darcy knows how to keep them from causing her to repeat irrational acts in a compulsive way. She knows that she will probably always be managing her disorder, as there is no cure for OCD. But the difference now is that she controls it, rather than having it control her. As far as Darcy is concerned, Marian gave her back her life.

Marian smiled again as she recalled Darcy’s journey and her original fear of being a “disappointment to God and everyone”. Indeed, Marian felt blessed to have had Darcy as a client.

This article is an extract of the upcoming Mental Health Academy “OCD and OCPD Case Studies” CPD course. Click here for a full list of currently available MHA continuing professional development courses.

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Case Study of a Middle-Aged Woman’s OCD Treatment Using CBT and ERP Technique

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Research Article | DOI: https://doi.org/10.31579/2690-8794/102

• Deepshikha Paliwal 1*
• Anamika Rawlani 2

1 M.Sc. Clinical Psychology, Dev Sanskriti University, Ranchi, India. 2 M.Phil Clinical Psychology, RINPAS Ranchi, India.

*Corresponding Author: Deepshikha Paliwal, M.Sc. Clinical Psychology, Dev Sanskriti University, Ranchi, India.

Citation: Deepshikha Paliwal and Anamika Rawlani (2022) Case Study of a Middle-Aged Woman’s OCD Treatment Using CBT and ERP Technique. Clinical Medical Reviews and Reports 4(3): DOI: 10.31579/2690-8794/102

Copyright: © 2022, Deepshikha Paliwal, This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Received: 01 September 2021 | Accepted: 04 December 2021 | Published: 10 January 2022

Keywords: OCD; CBT; ERP; salkovskis’s model

Introduction : This is a case report of a middle-aged woman, who was experiencing “obsessive” thoughts related to the “Bindi” (decorative piece wear by women on the forehead) and cleaning “compulsions”. Present case report discusses the patient’s assessment, case formulation, treatment plan and the effectiveness of the CBT and ERP sessions in reducing OCD symptoms.

Methodology: The patient was treated with Cognitive Behavior Therapy (CBT) along with Exposure Response Prevention (ERP) technique. The assessment of the case was done with the Y-BOCS rating scale, Beck’s Depression Inventory, Obsessive Beliefs Questionnaire, and Behavior Analysis Performa which suggested the higher severity level of the patient’s symptoms. Parallel to the assessment sessions, detailed case history related to the onset of the problem, difficulties faced because of the disorder, childhood incidences, family chart, marital issues, and medical history were discussed with the patient. Based on the reported details, the case was formulated according to the Salkovoskis inflated sense of responsibility model.  After the case formulation, the treatment plan was designed which involved ERP sessions and restructuring of the cognitive distortions (beliefs, thoughts, and attitude). 

Results: After the completion of the twenty-five therapy sessions, the patient reported improvement in the coping of anxiety-provoking thoughts and reduced level of the washing compulsions. The effects of the therapy were checked and found maintained up to two months follow up.

Conclusion: CBT and ERP technique is an effective treatment in reducing obsessive and compulsive symptoms of the patient. 

Have you ever felt like a sudden urge to hurt somebody? What if such urges continuously appear in your head? What would you do to stop these urges? Would you be able to continue your day to day life normally with such urges?  Clinical Psychologists studied the repetitive occurrence of unwelcoming thoughts, urges, doubts, and images which create anxiety. They gave it the term “Obsessions”. These obsessions are dreadful, frightening, and intolerable to the extent that they might hinder the natural flow of one’s personal, professional, and social life. The person who suffers from such anxiety-provoking thoughts tries to deal with the distress caused by such ‘obsessions’ by adopting some behavior or activity which temporarily relieve them from the anxiety and the feared consequences. This behavior could be anything like washing hands, cleaning, repeatedly checking the door, or repeating some phrases in the head. Psychologists called such repetitive behaviors or activities as “Compulsions”. According to APA (1994), if the presence of obsessions and/or compulsions is time-consuming (more than an hour a day), cause major distress, and impair work, social, or other important functions then the person will be diagnosed with Obsessive-Compulsive Disorder (OCD). Recent epidemiological studies suggest that OCD affects between 1.9 to 2.5% of the world population at some point in their lives, creating great difficulties on a professional, academic and social level (DSM-IV-TR, 2001). OCD affects all cultural and ethnic groups and, unlike many related disorders, males and females are equally affected by this disorder (Rasmussen & Eisen, 1992). OCD is one of the most incapacitating of anxiety disorders having been rated as a leading cause of disability by the World Health Organization (1996).  The major cause of OCD is still unknown; there could be some genetic components responsible for it (DSM-5). Child abuse or any stress-inducing event could be the risk factor involved in the history of OCD patients. The severity of the symptoms related to obsessions and compulsions provides the basis of the diagnosis in OCD which rules out any other drug-related or medical causes. Clinical Psychologists use rating scales like Y-BOCS (Fenske & Schwenk, 2009), self-reports, and Behavior Analysis Performa to assess the severity level of the symptoms. Based on the severity, the treatment plan is designed. Treatment of OCD involves psychotherapy and antidepressants. Psychotherapy such as Cognitive Behavior Therapy (CBT) is an effective psycho-social treatment of OCD (Beck, 2011). In CBT, a “problem-focused” approach is used to treat the diagnosed psychological disorder by challenging and changing core beliefs, negative automatic thoughts, and cognitive distortions of the patient. CBT involves Exposure Response Prevention (ERP) as a technique to treat OCD in which the patient is exposed to the cause of the problem and not allowed to repeat the ritual behavior (Grant, 2014).  ERP has promising results with 63% of OCD patients showing favorable responses after following the therapy sessions (Stanley & Turner, 1995). 

This is a case of a 31 years old woman, who belongs to a middle socio-economic background, currently living with her in-laws, husband, and daughter. The patient was experiencing obsessive thoughts related to the contamination spread by ‘bindi’ along with the compulsive behavior of washing and cleaning from the last five years. The patient reported that she always tried to check the contact of ‘Bindi’ with anything because that contact makes her incapacitate to control the situation. She took two and three hours (on daily basis) in washing and cleaning her home, scrubbing her daughter, cleaning the daughter’s school bag after returning from school, husband’s bag, and other usable items, so that she can stop the contamination from spreading everywhere. The patient has a history of facing interpersonal issues with family members since her childhood. Her father was alcohol dependent and the mother was the patient of depression. The financial condition of the family was not good. When the patient was 17 years old, her father died due to kidney failure, and her mother got hospitalized because of depression. From a very young age, the patient had to bear the responsibility of the family by taking tuitions. At first, she developed the fear of contamination at the age of 19, when she was in her graduation’s first year, for that she was taken to the Psychiatrist. She responded well to the medicines and stopped showing all the symptoms. At the age of 25, when the patient got pregnant she again developed the fear of contamination, which made her husband and in-laws uncomfortable and family disputes began. Her husband took her to the psychiatrist who referred her for the psychotherapy but she didn’t attend the psychotherapy sessions properly and continuously lived with the obsessions and compulsions up to the present referral where the patient was assessed with Y-BOCS rating scale, BDI, EBQ, and Behavioral Analysis Performa. Based on the assessment, she was diagnosed with OCD having symptoms of obsessions related to the contamination by ‘Bindi’ and washing compulsions. Detailed case history related to the onset of the problem, childhood incidences, family history, marital history, medical history, and other relevant information were also collected. The case was formulated according to Salkovoskis’s inflated sense of responsibility model as the patient’s reported details were signifying the negative interpretations of her responsibility for self and others. After the case formulation, the treatment plan was designed which involved sessions of ERP technique along with the alteration of cognitive distortions (ideas, beliefs, and attitudes) through the cognitive restructuring method of CBT. 

1. Yale-Brown Obsessive-Compulsive Scale (YBOCS): 

In cognitive-behavioral studies, Y-BOCS is used to rate the symptoms of OCD. This scale was designed by Goodman et al. (1989) to know the baseline and the recovery rate of the ‘severity of obsessions’, ‘severity of compulsions’ and ‘resistance to symptoms’. This is a five-point Likert scale that clinicians administer through a semi-structured interview in which a higher score indicates higher disturbances. The excellent psychometric properties of this scale quantify the severity of the obsessions and compulsions as well as provide valuable qualitative information which makes it very useful for both diagnosis of the OCD and the designing of its treatment plan. 

2. Beck Anxiety Inventory (BAI):

Aaron T. Beck (1988) developed BAI as a four-point Likert scale which consists of 21 items of ‘0 to 3’ scores on each item (Higher score means higher anxiety). If the Patient’s scores are from 0 to 7 then interpret as ‘minimal anxiety’, 8 to 15 as ‘mild anxiety’, 16 to 25 as ‘moderate anxiety’, and 30 to 63 as ‘severe anxiety’.  BAI assesses common cognitive and somatic symptoms of anxiety disorder and is considered effective in discriminating between the person with or without an anxiety disorder. This scale provides valuable clinical information but is not used by clinicians for diagnostic purposes. 

3. Obsessive Belief Questionnaire (OBQ):

OBQ is used to assess the beliefs and appraisals of OCD patients which are critical to their pathogenesis of obsessions (OCCWG, 1997, 2001). This scale consists of 87 belief statements within six subscales which represent key belief domains of OCD. The first subscale is ‘Control of thoughts’ (14 items), the second is ‘importance of thoughts’ (14 items), third is, responsibility (16 items), fourth is ‘intolerance of uncertainty’ (13 items), the fifth is an overestimation of threat (14 items), and sixth is ‘perfectionism’ (16 items). Response on this measure is the general level of agreement of the respondents with the items on a 7 point rating scale that ranges from (-3) “disagree very much” to (+3) “agree very much”. On the respective items summing of the scores is done to calculate the subscale scores.

4. Behavior Analysis Performa

This study used ‘Behavior Analysis Performa’ to do the functional analysis of the patient’s behavior. This Performa collects the details of the patient’s behavioral excess, deficits, and assets, his or her motivational factors behind maintaining and reinforcing ill behaviors, as well as, the medical, cultural, and social factors which contributed to the development of the illness. 

Based on the reported details and the assessment, the case was formulated according to the Salkovoskis model (1985). This model suggests that the patient’s main negative interpretation revolves around the idea that his or her actions might have harmful outcomes for self or others. This interpretation of responsibility increases selective attention and maintains negative beliefs (Salkovskis, 1987). Here, in this case, the patient had to face the disturbing family environment which significantly has a role in the formation of maladaptive schemas related to her negative view of self, the world, and the future. The patient’s beliefs assessment reports signified that her major dysfunctional assumptions were ‘if harm is very unlikely, I should try to prevent it at any cost’ and ‘if I don’t act when I foresee danger then I am to blame for any consequences’. Intrusive thought for her was that ‘bindi contaminates dirt’ and neutralizing action for this intrusive thought was ‘washing and cleaning things’. She paid her keen attention to the thought that ‘I should not be get touched with bindi’ and misinterpreted and over signified it by avoiding bindi and preventing the contamination. Her safety behavior included avoiding going out, (especially beauty parlors and cosmetic shops), and getting touched with anyone on roads and market places. The result of such avoidance was tiredness, anxiousness, aggressiveness, and distressed mood state. The graphical representation of the case formulation is shown in Appendix 1 at the end of this paper.

After the case formulation, the treatment plan was designed. The patient had dysfunctional assumptions related to her responsibility for self and others. She had obsessions related to the contamination spread by ‘Bindi’ associated with washing and cleaning compulsions. As she was taken by her husband for the therapy, so it was important to socialize her and her family with the OCD to develop insight for the disorder. After socializing them with OCD, they were taught the basic structure of the cognitive behavior model that how patient’s thoughts, emotions, physical sensations, and behavior all are interrelated and affect each other in a vicious circle. 

In the preparatory phase, the patient was introduced with the ERP technique, how does it work and how much her cooperation and will power are required for the success of this technique. After introducing the ERP technique to her, behavioral analysis was done with the patient by using a down-arrow method to make the list of the situations she uses as safety strategies and maintains her negative beliefs.

In the next session, the patient was told to imagine her exposure with different situations which she avoids and asked her to rate the level of anxiety in all the situations on a scale of 1 to 10. After this imaginary exposure, a hierarchy was made from the least anxiety-provoking event to the high anxiety-provoking event. Here is the list of different situations which the patient rated based on the level of anxiety:

In this phase, the patient was gradually exposed with the least anxiety-provoking situation to the highest-anxiety provoking situation. The patient’s husband worked as a co-therapist and accompanied her in all the situations and observed her anxiety levels and other behaviors. The patient was asked to rate her anxiety level on a scale of 1 to 10 after every exposure.

• In the first step of exposure, patient was instructed to go out with the husband in the market area where ‘Bindi’ was hanging on the walls , she was instructed to watch them from some distance and observe her level of anxiety varying with time . She was strictly instructed not to avoid the situation and to face the anxiety levels without skipping. In the next session, she was asked what she exactly felt when she was watching the bindi packets, she replied that at first sight of bindi she felt disgusted and wanted to go away but she gave self instructions to her that these are very far and cannot contaminate her so she kept sitting there and with time her anxiety level also came down.   
• In the second step of the hierarchy she was instructed for sitting at a distance from the cosmetics shop and observe the ladies entering and purchasing bindi there , her husband was told to work as a co-therapist and checks the anxiety levels and reactions of his wife during the exposure. In the next session, she was again asked for the thoughts and levels of anxiety during the observation, husband reported that at first she showed some anger and was looking very anxious while observing the ladies with bindi but when he reminded her about the nature of therapy, she managed to sit there and sometime later became relaxed.   
• In the third step of the hierarchy patient was instructed to enter into the cosmetic shop and remain stand there for a short while without purchasing anything and to face the levels of anxiety varying with time. In the session, she was asked to report the anxiety level. She reported that just when she entered the shop she was trying to not get touched with anything and felt like she would lose her control and became very anxious but with self instructions she managed herself to stand there after sometime anxiety level came down and she felt little relaxed.   
• In the fourth step, the patient was instructed to enter into the cosmetic shop and to purchase some common items other than ‘Bindi’ . In the next session, husband reported that she was attentively noticing the shopkeeper’s movements. Though, she purchased some ribbons but denied to touch them and asked him to put them in his bag and told him to give only the fixed amount of ribbon’s cost to the shopkeeper so that exchange could not be needed from shopkeeper’s contaminated hands. The husband also observed that during the whole exposure, the patient was looking very distressed and anxious and was involved in safety strategies and managed to calm down only when he reminded her about the process of therapy. The patient was then asked to report her anxiety level in this step of exposure.  
• In the fifth step, patient was instructed to go into the market and purchase a packet of small colorful bindi and face the anxiety levels . In the next session, she was asked to express the anxiety and rate it on a scale of 1 to 10. The patient reported that when she was purchasing the bindi, she felt dreadful and thought that she would take bath after returning home. Somehow, she purchased the packet and gave it to the husband to put it in his bag. After returning home, she got involved in her daughter’s work but thoughts of washing and bathing were going on in her mind. Later on, she could not get the time for bathing and she instructed herself to bath in the morning, after this thought she felt very relaxed and had this feeling of winning over her obsessions.   
• In the sixth step, patient was instructed to purchase some colorful bindi packets and try to keep them with herself and strictly prevent herself from hand-washing for one hour. In the next session, she reported that this time she was not that anxious while purchasing bindi packets but after putting them in her bags she was trying to avoid getting touched with her daughter and mother in law because her mother in law would enter into the kitchen and contaminate everything. Meanwhile, her daughter ran towards her and hugged her. Immediately, she became very restless and angry with the daughter and thought about to wash her. However, she felt incapacitated as her daughter ran everywhere in the house and touched everything. She got anxious but managed this thought of contamination and decided to not wash anything. After this, she felt relaxed.   
• In the seventh step of the hierarchy, the patient was instructed to apply a small bindi on her forehead and restricted to not wash her hands for at least four hours . In the next session, she reported that she applied the bindi and her husband and her mother-in-law were feeling very happy but she felt anxious and closed her fist for not touching anything till hand-washing. After some time, in other household works, she forgot about it but suddenly when she realized that she had applied bindi, she immediately washed her hands but even then kept wearing it for the whole day.   
• In the eighth step, the patient was instructed to apply red color velvet medium size Bindi and prevent hand washing for minimum of two hours . In the next session, she reported that now her level of anxiety has fallen down and now she feels less anxious after applying bindi and managed to not wash her hands for two hours without any much restlessness.   
• In the ninth step of the hierarchy, the patient was instructed to apply red color velvet medium size Bindi and prevent hand washing for minimum of four hours and try to make herself normal and gradually start touching things in these hours. In the next session, she reported that now she feels capable to face her feelings of disgust with bindi and manages to make her mind for not washing things after getting touched with the bindi. Though some thoughts of contamination keep coming in between but she immediately reminds herself that ‘Bindi’ can’t contaminate anything.  
• In the tenth step of hierarchy, the patient was instructed to apply bindi on her forehead and keep some of them in her bag preventing washing her hands for maximum hours possible. In the next session, she reported that now she feels more capable to conquer over her thoughts of contamination and more determined to not washing and cleaning after such obsessions.

With each ERP session, the patient came to realize that the nature of anxiety is that it goes up with the triggering event but with the passage of time, automatically comes down. She also developed the insight that she had fear from the thoughts of contamination and with its associated anxiety more than ‘Bindi’ itself. 

After the ERP sessions, the patient was given two booster sessions in which she was taught the ways to deal with the anxiety after the termination of therapy in her day to day life situations. In those sessions, she was asked to imagine her home, her room, and herself with Bindi on her forehead and doing household chores like cooking, cleaning the things, etc. When the patient was asked to express herself during the imagination, she reported that she is feeling more confident now to stick on her thought that bindi can’t contaminate, it’s her idea and there is no use of washing hands and other things because of the fear of contamination. Her husband and mother-in-law were also instructed to remind her again and again about the things she learned during the therapy sessions. After the declaration of the patient that she is feeling better now and ready to face the anxiety on her own, therapy sessions were terminated.

One month later, the patient was contacted for the follow-up and asked about her coping with the anxiety through telephonic conversation. She reported that thoughts of contamination came in her mind but she is in better condition than previous after taking the ERP sessions.

After two months, the patient came for the session again with the complaints that sometimes she became weak and washed her hands with the thought of contamination. After washing, she repented on her behavior which lowers down her confidence in conquering over the illness. Then she was instructed that washing hands strengthens the thought of contamination so she should avoid it as much as possible but this doesn’t mean that she has not gained anything with the therapy, she was reminded about her previous condition that how much it was unbearable for her to even think about the bindi but now she is applying it on her forehead which shows that only the traces of the illness left, most of it is already recovered. In this way, the patient became relaxed and felt more determined to continue with the learnings during the sessions.

After the termination of the therapy sessions, the patient’s obsessive and compulsive symptoms were found reduced on the Y-BOCS symptom checklist:

With the graded exposure sessions, her anxiety level also came down from the rating of 10 in the beginning sessions to the rating of 4 in the endings sessions on a scale of 1 to 10.

The patient’s BAI score was also fallen down from pre-intervention- 36 (Extreme level of anxiety) to post intervention- 13 (mild level of anxiety) which suggests 36% reduction in the anxiety level of the patient.

Previous research findings considered CBT as the most promising treatment of OCD (Stanley & Turner, 1995; Foa et al, 1999). CBT emphasizes the integration of cognitive-behavioral strategies like discussion techniques (Guided Discovery) and behavioral experiments (ERP) to formulate the problem and direct the treatment. Therapists try to identify the key distorted beliefs along with patients and allow them to test their beliefs which develop and maintain compulsive behaviors. This case identified the contamination with ‘Bindi’ as the pathological belief which was maintaining the compulsive behaviors of washing and cleaning. The cognitive hypothesis of Salkovoskis (1985) proposed that the origin of obsessional thinking lies in normal intrusive ideas, images, thoughts, and impulses which a person finds unacceptable, upsetting, or unpleasant. The occurrence and content of these intrusive cognitions are negatively interpreted as an indication that the person may be ‘responsible for harm’ or ‘prevent the harm’. Such an interpretation is likely followed by emotional reactions such as anxiety or depression. These emotional reactions lead to discomfort and neutralizing (Compulsive) behaviors like washing, cleaning, checking, avoidance of situations related to the obsessive thought, seeking reassurance, and attempts to exclude these thoughts from the mind. The present case supported this hypothesis of Salkovoskis’s model as intrusive thought of the patient was contamination spread by ‘Bindi’ which negatively interpreted as ‘I can avoid the likely harms by avoiding the contamination spread by Bindi’, such negative interpretation was raising her anxiety levels, making her attentive selective towards the ‘Bindi’, maintaining her compulsive acts and complying her to adopt the safety strategies.

Rachman (1983) predicted that behavioral experiments, in which the patient is exposed to the feared object, these intrusive thoughts are challenged by changing the pattern of thinking and behaving. Hodgson & Rachman (1972) initiated the series of clinical studies on patients with contamination and predicted that immediate washing reduces the anxiety. In one of their experimental study, they noted a similar degree of anxiety reduction when the patient was asked not to perform a compulsive act for one hour.  They termed this phenomenon as ‘spontaneous decay’ which was established as the basis of ERP. Also, Foa & Kozak (1986) proposed that exposure techniques activate the network of cognitive fear and patients get new experience which is different from the existing pathological beliefs. This case confirmed this hypothesis as the patient initially thought that her exposure with ‘Bindi’ might cause some uncertain consequence with her but prolonged exposures provided her new experience that she could manage with her fear and anxiety which resulted in the improved coping with obsessional beliefs about contamination and urge to wash and clean. Her improved coping is evident in the statistically significant reduction of her scores on the standard measures like the Y-BOCS symptom checklist, BAI, and OBQ. 

The results of this case study add on the value of CBT (that involves ERP technique) in the treatment of obsessive thinking related to the ‘fear of contamination’ and compulsive behavior of ‘washing and cleaning’. However, there is a need for more such case studies with more precision and effective treatment designs to provide valuable information related to the nature of OCD and its treatment.

In this case of OCD, patient’s symptoms were reduced to a manageable level and found maintained for two months which provides an evidence of the effectiveness of CBT and ERP technique in the treatment of OCD.

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Home / Blog / Obsessive Compulsive Disorder – Sophie’s story

Obsessive Compulsive Disorder – Sophie’s story

Sophie is a 26-year-old mental health advocate who has lived with OCD for 11 years. She won a Bill Pringle Award with Rethink Mental Illness for her poem on managing OCD in 2019 and has spoken publicly about her experience on radio and on social media. She is open and vocal about mental health and mental illness because she knows first-hand how isolating and scary it can be in the beginning.

“I just felt guilty all the time about every small thing that, before OCD, wouldn’t really have bothered me at all, and I needed people to tell me I was a good person.”

Obsessive compulsive disorder

OCD is a chronic and potentially debilitating mental health condition in which an individual has uncontrollable (“obsessive”) thoughts or images and compulsive behaviours that can be distressing, frightening and upsetting.

The myths that annoy me – and the truth about them

Ocd is characterized by the desire to keep yourself and/or your space clean..

False. While the compulsion to clean isn’t unheard of among individuals with OCD, cleanliness and OCD aren’t mutually exclusive and the compulsion to clean shouldn’t be considered a choice or desire. Instead, they may feel that it is mandatory in order to find relief.

Everyone is “a little bit OCD.”

False. You cannot be a “little bit” OCD. OCD isn’t an adjective – it’s a complex disorder that affects only 1-2% of people and can be incredibly difficult to manage without the appropriate treatment and care.

OCD can be cured.

False . While this may sound daunting, OCD can be effectively controlled and managed with treatment that suits the individual, allowing them to live a healthy, happy life.

My symptoms When my OCD first started I thought it was simply anxiety, but after doing some research into mental health I realised it was OCD. I felt guilty and paranoid for most of the day with very little relief, overthinking every little bit of whatever thought or image was in my head at the time. I would wake up with palpitations and struggle sleeping because I couldn’t stop ruminating. Logical thought takes a back seat with OCD. When your brain wants to convince you that you’re a bad person, it will give you lots of evidence to try and support it. When you don’t know how to fight back, it can be truly terrifying – you’re defenceless.

My lowest moments I began to worry about leaving the house because I couldn’t determine what situation might trigger another intrusive thought, and that lack of control over your own thought process can completely take over your daily life. When I did leave the house, I would avoid the people or things that were involved in my thoughts, otherwise I struggled to cope. I would experience the same recurring intrusive thought or image for months at a time and would only find (albeit short-lived) peace when I was completely distracted.

I haven’t experienced many compulsions, but my primary one was reassurance-seeking or “confessing.” I constantly felt guilty for my thoughts and at my lowest point, when it became overwhelming, I would find myself asking my mum or partner to remind me that I am a good person, but my brain didn’t seem to want to believe it. It was a terrifying circle – an intrusive thought would come in, I’d panic and ruminate, find someone to “confess” to and the process would start all over again. This lasted for a number of years before I discovered that it was only making my OCD worse.

My way forward After two failed attempts at seeking help via public and private mental health services, I admittedly haven’t been very lucky with professional help and so had to learn to manage my OCD on my own, with the additional support of a select few trusted friends and family. As such, I trained in mental health first aid and undertook a lot of personal research, not only to help myself but to help others like me. I’m the nominated mental health champion at my place of work, though I generally remain a passionate advocate for mental health in all aspects of my life, and I will continue to help others for as long as I possibly can. I also love to write and have found solace in writing about my OCD via reflective poetry.

Why I’m sharing my story When I felt my lowest, when I felt there was no escape, it wasn’t professional help that ultimately helped me but the experiences of others with OCD or who know about OCD. It was the advice of mental health charities, the blog pages of people with lived experience and the never-ending stream of support I had that helped me to help myself. I’m very proud that I can now manage my OCD successfully and, if I ever find myself feeling low or overwhelmed, I know that I can overcome it. I see my OCD as an enduring and experienced reflection of myself – it is no longer a threat.

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Obsessive-compulsive disorder: Evidence-based treatments and future directions for research

Correspondence to: Caleb W Lack, PhD, Assistant Professor, Department of Psychology, University of Central Oklahoma, Edmond, OK 73034, United States. ude.ocu@kcalc

Telephone: +1-405-9745456 Fax: +1-405-974851

Over the past three decades, obsessive-compulsive disorder (OCD) has moved from an almost untreatable, life-long psychiatric disorder to a highly manageable one. This is a very welcome change to the 1%-3% of children and adults with this disorder as, thanks to advances in both pharmacological and psychological therapies, prognosis for those afflicted with OCD is quite good in the long term, even though most have comorbid disorders that are also problematic. We still have far to go, however, until OCD can be described as either easily treatable or the effective treatments are widely known about among clinicians. This review focuses on the current state of the art in treatment for OCD and where we still are coming up short in our work as a scientific community. For example, while the impact of medications is quite strong for adults in reducing OCD symptoms, current drugs are only somewhat effective for children. In addition, there are unacceptably high relapse rates across both populations when treated with pharmacological alone. Even in the cognitive-behavioral treatments, which show higher effect sizes and lower relapse rates than drug therapies, drop-out rates are at a quarter of those who begin treatment. This means a sizable portion of the OCD population who do obtain effective treatments (which appears to be only a portion of the overall population) are not effectively treated. Suggestions for future avenues of research are also presented. These are primarily focused on (1) increased dissemination of effective therapies; (2) augmentation of treatments for those with residual symptoms, both for psychotherapy and pharmacotherapy; and (3) the impact of comorbid disorders on treatment outcome.

INTRODUCTION

Thirty years ago, being diagnosed with obsessive-compulsive disorder (OCD) was about the closest thing the psychiatric world had to being given a life sentence. In addition to being seen as extremely rare, prognosis for those with a diagnosis of OCD was very poor, with no effective truly pharmacological or psychological treatments available[ 1 ]. Today, however, a diagnosis of OCD does not carry this loss of hope for the future and poor treatment outcomes. Instead, clinicians now have at their disposal both pharmacological and psychological treatments that are remarkably effective for the majority of patients[ 2 ]. Still, though, there are further advances that need to be made, to continue improving treatment effectiveness and patient outcomes.

OCD is characterized by intrusive, troubling thoughts (obsessions), and repetitive, ritualistic behaviors (compulsions) which are time consuming, significantly impair functioning and/or cause distress[ 3 , 4 ]. When an obsession occurs, it almost always corresponds with a massive increase in anxiety and distress. Subsequent compulsions serve to reduce this associated anxiety/distress. Common obsessions include contamination fears, worries about harm to self or others, the need for symmetry, exactness and order, religious/moralistic concerns, forbidden thoughts (e.g., sexual or aggressive), or a need to seek reassurance or confess[ 5 ]. Common compulsions include: cleaning/washing, checking, counting, repeating, straightening, routinized behaviors, confessing, praying, seeking reassurance, touching, tapping or rubbing, and avoidance[ 6 ]. Unlike in adults, children need not view their symptoms as nonsensical to meet diagnostic criteria[ 7 ].

In the United States, the lifetime prevalence rate of OCD is estimated at 2.3% in adults[ 8 ] and around 1%-2.3% in children and adolescents under 18[ 9 ]. There are also a fairly substantial number of “sub-clinical” cases of OCD (around 5% of the population[ 10 ]), where symptoms are either not disturbing or not disruptive enough to meet full criteria and yet are still impairing to some degree. There is strong evidence that cultural differences do not play a prominent role in presence of OCD[ 11 , 12 ], with research showing few epidemiological differences across different countries[ 13 - 15 ] and even between European and Asian populations[ 16 ]. There are, however, cultural influences on symptom expression. In Bali, for example, heavy emphasis on somatic symptoms and need to know about members of their social network is found[ 17 ], while type of religious upbringing has been related to different types of primary obsessions, such as emphasis on cleanliness and order in Judaism, religious obsessions in Muslim communities, aggressive aggressions in South American samples, and dirt and contamination worries in the United States[ 13 , 18 - 20 ].

While OCD is equally present in males and females in adulthood, the disorder is heavily male in pediatric patients[ 21 ]. There are some differences in comorbidity as well[ 22 ]. Among men, hoarding symptoms are most often associated with GAD and tic disorders, but in women social anxiety, PTSD, body dysmorphic disorder, nail biting, and skin picking are more often observed[ 8 , 23 ].

Presentation of OCD symptoms is generally the same in children and adults[ 24 ]. Unlike many adults, though, younger children will not be able to recognize that their obsessions and compulsions are both unnecessary (e.g., you don’t really need to wash your hands) and extreme (e.g., washing hands for 15-20 s is fine, but 5 min in scalding water is too much) in nature. In young children, compulsions often occur without the patient being able to report their obsessions, while adolescents are often able to report multiple obsessions and compulsions. Children and adolescents are also more likely to include family members in their rituals and can be highly demanding of adherence to rituals and rules, leading to disruptive and oppositional behavior and even episodes of rage[ 25 ]. As such, youth with OCD are generally more impaired than adults with the same type of symptoms[ 26 ].

Up to 75% of persons with OCD also present with comorbid disorders[ 8 ]. The most common in pediatric cases are ADHD, disruptive behavior disorders, major depression, and other anxiety disorders[ 27 ]. In adults, the most prevalent comorbids are social anxiety, major depression, and alcohol abuse[ 10 ]. Interestingly, the presence of comorbid diagnoses predict quality of life (QoL) more so than OCD severity itself in both children[ 28 ] and adults[ 29 ]. Different primary O/C are also associated with certain patterns of comorbidity, in both adults and youth[ 30 ]. Primary symmetry/ordering symptoms are often seen with comorbid tics, bipolar disorder, obsessive-compulsive personality disorder, panic disorder, and agoraphobia, while those with contamination/cleaning symptoms are more likely to be diagnosed with an eating disorder. Those with hoarding cluster symptoms, on the other hand are especially likely to be diagnosed with personality disorders, particularly Cluster C disorders.

Almost all adults and children with OCD report that their obsessions cause them significant distress and anxiety and that they are more frequent as opposed to similar, intrusive thoughts in persons without OCD[ 31 ]. In terms of QoL, persons with OCD report a pervasive decrease compared to controls[ 28 ]. Youth show problematic peer relations, academic difficulties, sleep problems, and participate in fewer recreational activities than matched peers[ 32 , 33 ]. Overall, there is a lower QoL in pediatric females than males[ 28 ], but in adults similar disruptions are reported[ 29 ]. When compared to other anxiety disorders and unipolar mood disorders, a person with OCD is less likely to be married, more likely to be unemployed, and more likely to report impaired social and occupational functioning[ 34 ].

EMPIRICALLY SUPPORTED TREATMENTS

There are both pharmacological and psychological treatments for OCD that are supported by research evidence[ 35 - 38 ]. Overall, pharmacology with serotonin reuptake inhibitors (SRIs) shows large effect sizes in adults (0.91[ 39 ]), but only moderate effect sizes in youth (0.46[ 40 ]).Unfortunately, even with effective medication, most treatment responders show residual symptoms and impairments. There is also a very high relapse rate seen across numerous studies (between 24%-89%[ 41 ]). SRIs can be successfully supplemented with adjunctive antipsychotics, but even then only a third of patients will show improvements and there are serious health concerns with their long-term usage[ 42 ]. Metanalyses and reviews have not shown that the five selective SRIs (including fluoxetine,, paroxetine, fluvoxamine, sertraline, and citalopram) or the non-selective SRI clomipramine differ among each other in terms of effectiveness in either adults or pediatric patients[ 39 , 40 ]. Across subtypes of OCD, however, there are medication differences seen (for a review see[ 43 ]). For example, the presence of tics appears to decrease selective SRI effects in children[ 44 ], but it is unclear if it has the same effect in adults. Another known difference is that patients who have OCD with comorbid tics respond better to neuroleptic drugs than those who have OCD without tics[ 43 ].

The psychological treatment of choice for OCD, in both adults and children and backed by numerous clinical trials, is cognitive-behavioral therapy (CBT), particularly exposure with response prevention (EX/RP)[ 45 ]. It is superior to medications alone, with effect sizes ranging from 1.16-1.72[ 46 , 47 ]. While there is a lower relapse rate than in medications (12% vs 24%-89%), it is important to note that up to 25% of patients will drop out prior to completion of treatment due to the nature of treatment[ 48 ]. The course of therapy generally lasts between 12-16 sessions, beginning with a thorough assessment of the triggers of the obsession, the resultant compulsions, and ratings of the distress caused by both the obsession and if they are prevented from performing the compulsion. A series of exposures are then carefully planned through collaboration between the therapist and client and implemented both in session and as homework between sessions[ 49 - 52 ].

As in the medication research, differences in response to CBT have been found across populations. For instance, it has been seen that those with hoarding cluster symptoms respond less well to CBT, in part due to reluctance to engage in exposures and poor insight[ 53 ]. Accommodation by family members in pediatric clients has been found to be predictive of poorer treatment response as well[ 54 ]. Intriguingly, group therapy that uses CBT and EX/RP has been shown to be equally as effective as individual therapy in some studies[ 55 ] but less effective in others[ 56 ]. For persons with mild OCD, computer-assisted self-treatment has been shown to be very effective (see for a review[ 57 , 58 ]).

FUTURE DIRECTIONS FOR RESEARCH

Although the treatment of OCD is remarkably advanced compared to 30 years ago, there are a number of areas where improvements can be made. First, treatment dissemination, particularly for CBT and EX/RP, remains an issue[ 59 ]. While reasons for this are many, certain steps can and should be undertaken to improve dissemination. For instance, efforts have been made to incorporate technology into the treatment of adult OCD with a number of successes (for a review see[ 57 ]), and there are increasing efforts to extend these findings into the realm of pediatric OCD. As educational efforts aimed at training new mental health practitioners alone are not sufficient, dissemination of both the safety and effectiveness of exposure-based therapies to both the general public and existing, already licensed mental health clinicians (psychiatrists, psychologists, counselors, and social workers) must be made a priority.

Second, although many patients respond to first-line interventions to some degree, partial response is frequent with many continuing to exhibit residual OCD symptoms, particularly to medication monotherapy. Pharmacological treatment augmentation options remain limited and under-researched. One promising approach involves targeting the extinction learning core to EX/RP with d-cycloserine[ 60 ], a partial agonist at the NMDA receptor in the amygdala. Preliminary results in adults[ 61 , 62 ] and youth with OCD[ 63 ] show promising results and suggest the need for further trials and refinement of methodology and dosage. In terms of psychotherapy augmentation, the primary issue in need of addressing would be the high drop-out rate. Therapy may need to be augmented with some sort of motivational enhancement module for those unwilling or too distressed to engage in exposures[ 64 ], or new strategies for exposure-reluctant patients may need to be developed.

Third, given the high comorbidity rates seen in persons with OCD, it is important to examine what impact that has on treatment[ 65 , 66 ]. Although a substantial body of literature has shown that for most anxiety disorders comorbidity does not diminish the impact of treatment (see for a review[ 67 ]), research on OCD is mixed. Having primary OCD with comorbid PTSD has been found to decrease response rate[ 68 ], while OCD and comorbid GAD was shown to increase dropout rates and decrease treatment response[ 65 ]. In contrast, others studies have shown no negative impact on OCD treatment from comorbid anxiety problems in adults[ 65 ] or children[ 66 , 69 ]. As such, both more research on how certain comorbidity patterns impact treatment and the most optimal therapeutic methods to address the differential patterns should be conducted[ 70 ]. Such methods could include novel combinations of pre-existing treatments (e.g., combining parent management training with CBT for youth with OCD and disruptive behavior[ 71 ] or the use of motivational enhancement techniques[ 72 - 74 ]).

Although this may sound trite, there is truly not a better time in history to have OCD than the present, given the multiple effective pharmacological agents, the presence of a very effective psychological therapy, and an ever-increasing understanding of the disorder itself. This is not, however, the time to sit back and pat our collective backs in triumph. Instead, we must continue to advance treatment for OCD in both adults and youth. Above, I have outlined several potential avenues of research and how they will benefit those who continue to suffer from OCD despite the advances of the last 30 years. With the continued efforts of clinicians and researchers the world over, the next 30 years should see a further explosion in our ability to decrease symptomatology and increase the QoL of those with this fascinating disorder.

Peer reviewer: Feryal Cam Celikel, MD, Associate Professor of Psychiatry, Gaziosmanpasa University School of Medicine, 60100 Tokat, Turkey

S- Editor Wang JL L- Editor A E- Editor Zheng XM

• Introduction
• Conclusions
• Article Information

Patients diagnosed with obsessive-compulsive disorder (OCD) manifested deficient neurite density compared with healthy controls (HCs), specifically in the superior (S) section of the right (R) lateral occipital cortex and the right angular gyrus, extending to the posterior (P) division of the R supramarginal gyrus. The blue trace refers to the gray matter skeleton, and the red-yellow coloration, with brighter shades indicating significant alterations in the highlighted gray matter skeleton voxels and darker shades delineating an imaginary wrapper for visual emphasis, serves purely for visualization purposes and does not indicate alteration in severity. A indicates anterior; I, inferior; and L, left.

Compared with healthy controls patients with obsessive compulsive disorder displayed significantly deficient gray matter volume in (A) the left (L) medial parietal structures, ie, the precuneus and the posterior cingulate gyrus, and (B) right (R) medial frontal structures, ie, the medial orbital gyrus and the gyrus rectus. A indicates anterior; I, inferior; P, posterior; S, superior.

GMV1 and GMV2 refer to the gray matter volume values within the left medial parietal cluster and the right medial frontal cluster (ie, cluster 1 and 2, as defined in eTable 1 in Supplement 1 ), respectively. THK refers to the cortical thickness value within the left fusiform cluster (ie, cluster thickness 1, as defined in eTable 2 in Supplement 1 ). GYR1 and GYR2 refer to the gyrification values within the right lateral frontal cluster and the left middle cingulate cluster (ie, cluster gyrification 1 and gyrification 2, as defined in eTable 2 in Supplement 1 ), respectively. Thickness of lines indicates strength of correlation. AD indicates axial diffusivity; DTI, diffusion tensor imaging; GBSS, gray matter-based spatial statistics; HC, healthy control; MD, mean diffusivity; NDI, neurite density index; NODDI, neurite orientation dispersion and density imaging; OCD, obsessive-compulsive disorder; SBM, surface-based morphometry; TBSS, Tract-Based Spatial Statistics; VBM, voxel-based morphometry

eMethods 1. Eligibility and Exclusion Criteria

eMethods 2. Magnetic Resonance Image Acquisition

eMethods 3. Processing of Multishell Diffusion-Weighted MR Images

eMethods 4. Processing of Single-Shell Diffusion-Weighted MR Images

eMethods 5. Processing of T1 Images

eMethods 6. Whole Brain Analyses of Morphological Metrics

eMethods 7. Post Hoc Anatomical Connectivity Analyses

eMethods 8. Post Hoc Construction of Networks of Brain Metrics

eMethods 9. Post Hoc Analyses of Networks of Brain Metrics

eMethods 10. Post Hoc Correlational Analyses With Symptoms

eMethods 11. Post Hoc Machine Learning-Based OCD vs HC Classification

eAppendix 1. Demographic Characteristics

eAppendix 2. OCD-Associated Alterations of Gray Matter Microstructure

eAppendix 3. OCD-Associated Alterations of Gray Matter Morphology

eAppendix 4. OCD-Associated Alterations of White Matter Morphology and Microstructure

eAppendix 5. Emergence of a Pathological Brain Network Among Patients With OCD

eAppendix 6. Correlations Between Nodes of OCD Pathological Brain Network and Clinical Symptoms

eAppendix 7. Performance of Pathological Brain Network in Identifying OCD Patients

eAppendix 8. Supplemental Discussion

eTable 1. Gray Matter Volume Alterations in Patients With OCD

eTable 2. Gray Matter Surface Morphological Alterations in Patients With OCD

eTable 3. Performance Comparison of Brain Metrics for OCD Patient Identification

eTable 4. Performance Comparison of Brain Metric Combinations for OCD Patient Identification

eFigure 1. The Complete Workflow for Analyzing Neuroimaging Data

eFigure 2. Results of the NODDI-GBSS Analysis

eFigure 3. Results of the Voxel-Based Morphometry

eFigure 4. Results of the Surface-Based Morphometries

eFigure 5. Results of the White Matter TBSS Analysis

eFigure 6. Correlations Between Clinical Symptoms and Nodes of the Pathological Brain Network in OCD Patients

eFigure 7. Receiver Operating Characteristic (ROC) Curves of HC vs OCD Classifiers Based on Different Combinations of Brain Metrics

eReferences.

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Zhang X , Zhou J , Chen Y, et al. Pathological Networking of Gray Matter Dendritic Density With Classic Brain Morphometries in OCD. JAMA Netw Open. 2023;6(11):e2343208. doi:10.1001/jamanetworkopen.2023.43208

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Pathological Networking of Gray Matter Dendritic Density With Classic Brain Morphometries in OCD

• 1 Shanghai Mental Health Center, Shanghai Jiao Tong University School of Medicine, Shanghai, China
• 2 Department of Psychology, University of Cambridge, Cambridge, United Kingdom
• 3 Institute of Science and Technology for Brain-Inspired Intelligence, Fudan University, Shanghai, China
• 4 Shanghai Key Laboratory of Psychotic Disorders, Shanghai, China
• 5 Mental Health Branch, China Hospital Development Institute, Shanghai Jiao Tong University, Shanghai, China
• 6 Now with Nanjing Brain Hospital Affiliated to Nanjing Medical University, Nanjing, China
• 7 Now with Beijing Anding Hospital, Capital Medical University, Beijing, China

Question   Is obsessive-compulsive disorder (OCD) associated with altered dendritic morphology and are such alterations associated with other brain structural metrics?

Findings   In this case-control study including 108 patients with OCD matched with 108 healthy controls, patients with OCD exhibited deficient neurite density in the right lateral occipitoparietal regions, along with alterations in gray matter volume, thickness, gyrification, and white matter diffusivity in multiple cortical regions. These metrics formed a pathological brain network associated with OCD symptoms, supporting the concept of connectopathy that offers a potential framework for interpreting the association between morphological anomalies.

Meaning   These findings suggest that in vivo imaging of gray matter dendritic density could serve as a valuable tool for understanding OCD and developing neuroimaging-based biomarkers.

Importance   The pathogenesis of obsessive-compulsive disorder (OCD) may involve altered dendritic morphology, but in vivo imaging of neurite morphology in OCD remains limited. Such changes must be interpreted functionally within the context of the multimodal neuroimaging approach to OCD.

Objective   To examine whether dendritic morphology is altered in patients with OCD compared with healthy controls (HCs) and whether such alterations are associated with other brain structural metrics in pathological networks.

Design, Setting, and Participants   This case-control study used cross-sectional data, including multimodal brain images and clinical symptom assessments, from 108 patients with OCD and 108 HCs from 2014 to 2017. Patients with OCD were recruited from Shanghai Mental Health Center, Shanghai, China, and HCs were recruited via advertisements. The OCD group comprised unmedicated adults with a Diagnostic and Statistical Manual of Mental Disorders (Fourth Edition) ( DSM-IV ) diagnosis of OCD, while the HCs were adults without any DSM-IV diagnosis, matched for age, sex, and education level. Data were analyzed from September 2019 to April 2023.

Exposure   DSM-IV diagnosis of OCD.

Main Outcomes and Measures   Multimodal brain imaging was used to compare neurite microstructure and classic morphometries between patients with OCD and HCs. The whole brain was searched to identify regions exhibiting altered morphology in patients with OCD and explore the interplay between the brain metrics representing these alterations. Brain-symptom correlations were analyzed, and the performance of different brain metric configurations were evaluated in distinguishing patients with OCD from HCs.

Results   Among 108 HCs (median [IQR] age, 26 [23-31] years; 50 [46%] female) and 108 patients with OCD (median [IQR] age, 26 [24-31] years; 46 [43%] female), patients with OCD exhibited deficient neurite density in the right lateral occipitoparietal regions (peak t  = 3.821; P  ≤ .04). Classic morphometries also revealed widely-distributed alterations in the brain (peak t  = 4.852; maximum P  = .04), including the prefrontal, medial parietal, cingulate, and fusiform cortices. These brain metrics were interconnected into a pathological brain network associated with OCD symptoms (global strength: HCs, 0.253; patients with OCD, 0.941; P  = .046; structural difference, 0.572; P  < .001). Additionally, the neurite density index exhibited high discriminatory power in distinguishing patients with OCD from HCs (accuracy, ≤76.85%), and the entire pathological brain network also exhibited excellent discriminative classification properties (accuracy, ≤82.87%).

Conclusions and Relevance   The findings of this case-control study underscore the utility of in vivo imaging of gray matter dendritic density in future OCD research and the development of neuroimaging-based biomarkers. They also endorse the concept of connectopathy, providing a potential framework for interpreting the associations among various OCD symptom–related morphological anomalies.

Obsessive-compulsive disorder (OCD) is a prevalent and debilitating mental disorder, 1 affecting 2.3% of individuals in the US 2 and 2.4% of individuals in China. 3 Emerging evidence suggests that alterations in dendritic morphology, and thus synaptic plasticity, may contribute to the pathogenesis of OCD. 4 However, in vivo neurite morphology imaging remains limited. Several OCD-associated genes, including DLGAP1 , DLGAP3 , and SHANK3 , regulate dendritic spine morphology. 4 , 5 Canine models exhibiting OCD-like behaviors have corroborated this link. 6 In silico analysis of these genes has revealed proteins regulating postsynaptic dendritic spine formation, affecting dendritic spine morphology directly. 7 Elevated plasma levels of microRNA-132 and microRNA-134 in patients with OCD suggest a potential impact on dendrite number and synapse formation in the cerebral cortex. 8 A 2022 postmortem investigation identified a general decrease in dendritic spine density in the orbitofrontal cortex of patients with OCD. 9 These findings suggest that neurite morphology, specifically gray matter dendritic morphology, is altered in OCD. Nevertheless, this hypothesis remains underexplored, leaving the degree and distribution of these alterations largely unknown. In this study, we used neurite orientation dispersion and density imaging (NODDI) to model microstructural features directly related to neuronal morphology, including nerve density and directional dispersion. 10 While NODDI has revealed microstructural alterations in various psychiatric disorders, 11 - 13 its application in OCD research has hitherto been unexplored, to our knowledge.

Previous studies using classic brain morphometries have identified widespread structural alterations across the brain in patients with OCD, including frontal, temporal, parietal, limbic, cerebellar, and striatal regions. 14 - 17 However, these alterations, alongside changes in interregional connectivity, 18 - 20 within or beyond the cortico-striatal-thalamo-cortical (CSTC) circuit, 21 - 23 have not been holistically elucidated, thus impeding the interpretation of in vivo dendritic morphology imaging within the context of conventional brain metrics.

Thus, this investigation not only aimed to examine variations in gray matter dendritic morphology in OCD but also to explore their interplay with classic brain morphometries. Specifically, multimodal brain images were used to highlight microstructural alterations of neurite morphology and classic morphometric aberrations among patients with OCD. Voxel-wise analysis of microstructural measures derived from NODDI and skeletonized via gray matter-based spatial statistics (GBSS) 12 , 24 was conducted to identify potential anomalies in gray matter neurite morphology in OCD. Additionally, classic morphometries identified widespread anomalies across the brain in patients with OCD. Subsequently, a post hoc comparison of the interrelationships among identified brain metrics was conducted between healthy individuals and patients with OCD via a network approach. Associations with clinical symptoms were also explored. Different combinations of brain metrics were further evaluated for distinguishing patients with OCD from healthy individuals to explore the development of neuroimaging-based biomarkers.

This case-control study was approved by the ethics committee of Shanghai Mental Health Center. All participants provided written informed consent. We followed the Strengthening the Reporting of Observational Studies in Epidemiology ( STROBE ) reporting guideline for observational studies.

Patients with OCD were recruited from the outpatient clinic of Shanghai Mental Health Center, were assessed using the Mini International Neuropsychiatric Interview by psychiatrists, and completed the Yale-Brown Obsessive Compulsive Scale (Y-BOCS) to confirm a Diagnostic and Statistical Manual of Mental Disorders (Fourth Edition) ( DSM-IV ) diagnosis of OCD with minimal comorbidity. Healthy controls (HCs) were recruited via advertisements and were assessed by a trained psychiatrist to exclude DSM-IV diagnoses of any psychiatric disorder (eMethods 1 in Supplement 1 ). All participants completed the Hamilton Anxiety Rating Scale, 24-item Hamilton Depression Rating Scale, and State-Trait Anxiety Inventory to assess anxiety and depression levels.

Multimodal neuroimaging data were acquired from a Simens VERIO 3T scanner (eMethods 2 in Supplement 1 ) and analyzed per modality 25 (eFigure 1 in Supplement 1 ). Multishell diffusion-weighted images ( b  = 1000 s/mm 2 and b  = 2000 s/mm 2 ) were used to assess neurite morphology via the NODDI Matlab Toolbox 10 in Matlab version R2019b (MathWorks), which derived neurite density index (NDI) and orientation dispersion index maps that were subsequently skeletonized via the NODDI GM-based spatial statistics (NODDI-GBSS) 24 in FMRIB Software Library version 5.0.10 (eMethods 3 in Supplement 1 ). Additionally, conventional diffusion tensor imaging (DTI) measures, 26 including fractional anisotropy, mean diffusivity (MD), axial diffusivity (AD), and radial diffusivity, were derived from the single-shell diffusion-weighted images ( b  = 1000 s/mm 2 ) via tensor fitting and were subsequently skeletonized via the Tract-Based Spatial Statistics (TBSS) 27 , 28 in FMRIB Software Library (eMethods 4 in Supplement 1 ). T1-weighted brain images underwent voxel-based morphometry 29 for gray matter probability maps and surface-based morphometry for morphological metrics, including cortical thickness, 30 gyrification, 31 complexity, 32 and sulcal depth 33 (eMethods 5 in Supplement 1 ), using the CAT12 and SPM12 toolboxes in Matlab.

To address inconsistent literature and minimize preconceived bias, we used whole-brain analyses to identify OCD-associated brain structural alterations (eMethods 6 in Supplement 1 ). To test whether the diagnostic groups differed while controlling for age, sex, and education, the skeletonized parameter maps derived from the diffusion-weighted images underwent nonparametric voxelwise permutation analyses using the randomize function of FMRIB Software Library, and the parameter maps derived from the T1-weighted images underwent parametric voxelwise or vertexwise analyses in SPM12, with multiple comparisons corrected to control type I errors. Moreover, we examined whether the anatomical connectivity 34 , 35 to the morphologically altered brain regions was impaired, and, if so, whether such impairments were mediated 36 , 37 by the corresponding morphological metrics (eMethods 7 in Supplement 1 ).

To explore the interplay between dendritic and other brain alterations associated with OCD, we compared the intermetric associations between groups through network analysis. 38 The previously identified brain metrics served as nodes of the network and the partial correlations between them as edges. Specifically, we constructed 2 separate networks of brain morphological metrics (eMethods 8 in Supplement 1 ), one for either diagnostic group, and compared their edge weight stability, global strength, and network structure 39 to assess network structural disparities (eMethods 9 in Supplement 1 ), using bootnet version 1.5 and NetworkComparisonTest version 2.2.1 packages in RStudio version 1.3 (Posit Software).

We used Spearman rank correlation to assess brain-symptom correlations among patients with OCD. To investigate whether the collective information of all brain metrics indicating morphological alterations was symptomatically associated, we applied unsupervised hierarchical clustering to group the patients with OCD based solely on their brain data and explored potential discrepancies in Y-BOCS total scores among these subgroups (eMethods 10 in Supplement 1 ). These analyses were performed with SPSS statistical software version 26 (IBM). All statistical tests upheld a significance threshold of P  < .05, with both unadjusted and adjusted P values for multiple comparisons.

We investigated the performance of various combinations of brain metrics in discriminating patients with OCD from healthy individuals (eMethods 11 in Supplement 1 ). We assessed the performance of each brain metric as the single input variable, followed by evaluating 4 combinations of the brain metrics obtained from the 4 metric-deriving procedures (NODDI + GBSS, DTI + TBSS, voxel-based morphometry, and surface-based morphometry), 2 combinations of brain metrics from the 2 image modalities (diffusion and T1), and a combination of all previously identified brain metrics. Logistic regression–based and support vector machine–based classifiers were used. These analyses were conducted in Matlab. Data were analyzed from September 2019 to April 2023.

This study included 108 unmedicated patients with OCD (median [IQR] age, 26 [24-31] years; 46 [43%] female) and 108 HCs (median [IQR] age, 26 [23-31]; 50 [46%] female) matched for age, sex, and education level ( Table ). The 2 diagnostic groups were demographically matched ( Table ; eAppendix 1 in Supplement 1 ). The median (IQR) education level was 16 (15-17) years for HCs and 16 (15-16) years for patients with OCD.

We discovered significantly lower NDI among patients with OCD compared with HCs ( Figure 1 ; eFigure 2 and eAppendix 2 in Supplement 1 ), specifically in the superior section of the right lateral occipital cortex (peak t  = 3.821; corrected P  = .03) and the right angular gyrus (peak t  = 3.446; corrected P  = .03), extending to the posterior division of the right supramarginal gyrus (peak t  = 2.292; corrected P  = .04). Furthermore, patients with OCD showed deficient degree centrality of the right lateral occipital and inferior parietal cortices after adjusting for age, sex, and education (F 1,211  = 4.245; P  = .04; η 2  = 0.020), indicating significantly impaired anatomical connectivity linking these 2 regions to others. This anatomical connectivity alteration was completely mediated by the local NDI (eFigure 2 in Supplement 1 ).

Compared with HCs, patients with OCD displayed significantly deficient gray matter volume in the left medial parietal structures (ie, precuneus and posterior cingulate gyrus; peak t  = 4.62; corrected P  = .001) ( Figure 2 A) and right medial frontal structures (ie, medial orbital gyrus and gyrus rectus; peak t  = 4.49; corrected P  = .03); ( Figure 2 B; eFigure 3, eTable 1, and eAppendix 3 in Supplement 1 ). In addition, patients with OCD demonstrated significantly deficient cortical thickness in the left fusiform gyrus (peak t  = 4.35; corrected P  = .04) (eTable 2 in Supplement 1 ) and disrupted local gyrification in right lateral frontal structures (ie, right superior and middle frontal gyri; peak t  = 3.73, corrected P  = .008) and left middle cingulate gyrus (peak t  = 3.61; corrected P  = .02) (eFigure 4 in Supplement 1 ). Interestingly, the degree centrality of the brain regions exhibiting gray matter morphological anomalies was not significantly altered among patients with OCD.

Regarding white matter, we identified an extensive area of significantly greater white matter AD (peak t  = 4.852; corrected P  = .006) and MD (right-lateralized; peak t  = 4.797; corrected P  = .03) among patients with OCD compared with HCs (eFigure 5 and eAppendix 4 in Supplement 1 ). Furthermore, the global strength of anatomical connectivity between all possible pairs of cortical regions among patients with OCD was significantly impaired after controlling for age, sex, and education (F 1,211  = 5.235; P  = .02; η 2  = 0.024). This impairment was partially mediated by the AD and MD in the highlighted regions serially (eFigure 5 in Supplement 1 ).

Notable differences were observed in the intermetric connections between HCs and patients with OCD ( Figure 3 ). In HCs, the only positive correlation was observed between gray matter volume indicators, with other intermetric associations absent. Conversely, among patients with OCD, all brain metrics were correlated with at least 1 other metric. Furthermore, a substantial difference was seen in the correlation stability coefficient of the brain metric network between groups, with a coefficient of 0.593 for patients with OCD, indicating a stable network, but a coefficient of 0.046 for HCs, indicating an unstable network. Additionally, a higher global strength of the brain metric network in patients with OCD (sum of all edge weights: HCs, 0.253; patients with OCD, 0.941; P  = .046) and a significant network structural difference between groups (maximum edge difference, 0.572; P  < .001) were found. These findings suggest that certain dissociated brain metrics in HCs were pathologically connected among patients with OCD, indicating the emergence of a pathological brain network unique to patients with OCD (eAppendix 5 in Supplement 1 ).

The brain alterations of a larger extent were generally correlated with more severe symptoms (of 6 significant correlations, 2 survived multiple comparison corrections) (eAppendix 6 and eFigure 6 in Supplement 1 ). Moreover, all 8 nodes of the pathological brain network together effectively differentiated patients with greater overall severity from those with milder overall symptoms, as measured by the Y-BOCS total score. These results collectively indicate an association between neurological phenomena and symptoms.

The NDI at the right occipitoparietal regions outperformed all other brain metrics in classification accuracy, area under the curve values, and sensitivity, and ranked second in specificity (eFigure 7, eTable 3, and eAppendix 7 in Supplement 1 ). Additionally, the node derived from NODDI + GBSS outperformed those derived from DTI + TBSS (eTable 4 in Supplement 1 ). Combining these nodes yielded better classification than combining those from T1 images. Notably, the node derived from NODDI + GBSS outperformed all nodes derived from T1 images combined.

This case-control study used multishell diffusion images to explore gray matter dendritic morphology in an innovative approach to neuroimaging changes in OCD. Our primary findings showed a pronounced deficit in neurite density in the right lateral occipitoparietal regions among patients with OCD that completely mediated the impaired anatomical connectivity linking local regions to others. These findings offer valuable insights into the neural basis of OCD, and the high discriminative power of the neurite density index in differentiating patients with OCD from HCs highlights the significance of in vivo gray matter dendritic density imaging. The dendritic density, along with metrics displaying widespread morphological anomalies across the brain, demonstrated interconnections among patients with OCD but not among HCs, indicating the presence of a pathological brain network for OCD. Importantly, different nodes of this network were linked to various comorbid symptoms. Moreover, the complete pathological brain network provided relevant information for assessing the overall severity of OCD, showing the potential of the pathological brain network approach for OCD research and the development of neuroimaging-based biomarkers for OCD.

This may be the first study to examine microstructural changes in dendritic morphology associated with OCD. Among patients with OCD, we identified deficient neurite density in the right occipitoparietal regions. As dendrites are the primary constituents of neurites in gray matter, we infer that patients with OCD exhibit deficient dendritic density in these regions. Functionally, these regions are part of the occipitoparietal circuit of the dorsal visual pathway, crucial in spatial perception and the formation of egocentric frames of reference. 40 Indeed, patients with OCD exhibit deficits in spatial information memory 41 , 42 and visual-spatial perception, 43 consistent findings also observed among adolescent patients with OCD. 44 Recent research also has reported decreased intrinsic functional connectivity within the dorsal visual pathway 45 or the lateral visual network 46 in OCD but increased functional connectivity between the right superior lateral occipital cortex and the left lateral parietal cortex, which was positively correlated with symptom severity. 47 Additionally, selective serotonin reuptake inhibitor treatment increases metabolic activity in the right superior occipital cortex with corresponding symptomatic and neuropsychological improvements. 48 Increased provocation-induced activation 49 and reduced gray matter volume 50 - 52 have also been documented in these areas. Given the close association between dendritic morphology and synaptic plasticity, we found that the deficient dendritic density in the right lateral occipitoparietal regions completely mediated the disruption of anatomical connectivity from local to elsewhere. These results highlight the neural changes potentially impacting functioning in OCD, serving as a bridge connecting structural and functional brain anomalies in OCD and warranting further investigations into the association of deficient dendritic density with brain functional and cognitive anomalies.

Patients with OCD are often claimed to have anomalies in CSTC circuits, 53 including striatum, thalamus, prefrontal cortex, and anterior cingulate cortex. 54 Alterations are observed in various CSTC aspects, including resting-state functional connectivity 55 and magnetic resonance imaging (MRI) spectroscopy. 56 , 57 Some of our observations support this theory, revealing disrupted gyrification in right frontal and left cingulate regions, alongside deficient gray matter volume in right medial frontal regions. This region is implicated in cognitive inflexibility in OCD, indicated by more errors in attentional set-shifting. 20 However, accumulating evidence, including the ENIGMA OCD consortium, suggests OCD-related brain alterations beyond frontostriatal circuits. 21 - 23 , 58 Some of our results align with this, showing deficient neurite density in right inferior parietal cortex, consistent with the ENIGMA consortium’s report of thinned inferior parietal cortex among adult and pediatric patients with OCD 59 and an Adolescent Brain Cognitive Development study of children with repetitive thoughts and actions implicating changes in the inferior parietal cortex and precuneus. 60

The importance of altered brain network connectivity for psychiatric disorders 61 is increasingly recognized. Our study found widespread white matter anomalies, evidenced by greater AD and MD, in patients with OCD. These results align with previous findings, 21 although we found no significant changes in fractional anisotropy, suggesting possible axonal swelling without substantial axonal damage in OCD. Previous studies investigating white matter morphology have reported mixed DTI findings, 21 , 62 reflecting the heterogeneity of OCD, 63 although also supporting the concept of connectopathy. 64 Crucially, our identification of morphological alterations in regions without apparent anatomical connectivity impairment implies connectopathy mechanisms beyond deficits simply in anatomical connectivity.

To further investigate neural substrates of OCD from a connectopathy perspective, we analyzed covarying associations among brain metrics displaying morphological alterations, regardless of the metric deriving methods (eAppendix 8 in Supplement 1 ). The covariance among the morphological metrics reflected the coordination of brain morphology shaped by genetic and environmental influences. 65 Our study discovered that the brain metrics displaying neurite or macroscopic morphological alterations in patients with OCD were disconnected in healthy participants but were connected in patients with OCD. This covariance pattern deviates from the typical form of connectopathy with disrupted interregional connectivity 66 , 67 ; thus, this pathological brain network is a distinctive feature of OCD, aligning with the concept of connectopathy and shedding light on latent pathological or etiological factors coordinating specific brain metrics for patients with OCD. Moreover, some nodes of this pathological network were correlated with patients’ symptoms, suggesting a potential parallel to the symptom network for OCD. 68

We further explored the potential of brain morphological metrics as a neuroimaging-based biomarker for OCD. Our findings show that the dendritic density at right occipitoparietal regions is a promising feature for classifying patients with OCD and HCs, outperforming other individual metrics. Additionally, the brain metrics derived from diffusion-weighted images were more effective than those derived from T1-weighted images for HC vs OCD classification, consistent with prior research. 69 Comparing our results with prior similar-sized single-site studies, the brain metrics presented in this study exhibit comparable or even enhanced classification performance. 70 Note that some studies have reported better performance, 71 , 72 possibly influenced by medication or imaging modality. While our preliminary findings suggest the potential utility of these brain metrics, particularly gray matter dendritic density, further validation studies using independent data sets and feature selection procedures are warranted.

Several limitations should be considered. First, the included patients with OCD were medication-free for at least 8 weeks before brain scanning, but we cannot completely rule out their prior use of psychiatric medications. As previous medication likely affects brain morphology and the performance of HC vs OCD classification, 70 , 73 future studies with exclusively patients who are drug naive would be beneficial. Second, our data were cross-sectional. Longitudinal data would be invaluable for elucidating the roles of the identified dendritic changes in OCD pathogenesis. Third, this study only included adult patients. Since OCD is sometimes considered a neurodevelopmental disorder, future investigations into gray matter dendritic density alterations in pediatric patients are warranted. Fourth, although our network analysis assessed statistical outcomes independently of input data selection criteria, 74 it might still be susceptible to the selective inference problem. 75 Nevertheless, our findings based on post hoc analyses still present well-substantiated hypotheses awaiting further validation in independent data sets. Fifth, the machine learning–based HC vs OCD classification using brain metrics may overestimate its performance. Future studies should use more rigorous validation procedures in independent data sets to systematically assess the potential biomarker candidates.

This case-control study found deficient neurite density in the right lateral occipitoparietal regions of patients with OCD, a robust discriminator of OCD, compared with healthy individuals. It highlights the potential of in vivo gray matter dendritic morphology imaging in future OCD research and biomarker development. Moreover, the brain metrics indicating OCD-associated neurite and macroscopic morphological alterations constituted a symptomatically related pathological brain network in OCD, providing a framework for interpreting the associations between various morphological abnormalities.

Accepted for Publication: October 4, 2023.

Published: November 13, 2023. doi:10.1001/jamanetworkopen.2023.43208

Open Access: This is an open access article distributed under the terms of the CC-BY License . © 2023 Zhang X et al. JAMA Network Open .

Corresponding Authors: Zhi Yang, PhD, Beijing Anding Hospital, Capital Medical University, 5# An Kang Ln, Xi Cheng District, Beijing 100088, China ( [email protected] ); Qing Fan, MD, PhD, Shanghai Mental Health Center, Shanghai Jiao Tong University School of Medicine, 600# S Wan Ping Rd, Xu Hui District, Shanghai 200030, China ( [email protected] ).

Author Contributions: Drs Zhang and Fan had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis. Dr Zhang, Ms Zhou, and Mr Chen contributed equally to this work as co–first authors.

Concept and design: Zhang, Chen, Yang, Fan.

Acquisition, analysis, or interpretation of data: All authors.

Drafting of the manuscript: Zhang, Zhou, Yang, Robbins, Fan.

Critical review of the manuscript for important intellectual content: Zhang, Chen, Guo, Yang, Robbins, Fan.

Statistical analysis: Zhang, Guo, Yang.

Obtained funding: Fan.

Administrative, technical, or material support: Chen, Fan.

Supervision: Yang, Fan.

Conflict of Interest Disclosures: Dr Robbins reported receiving personal fees from Cambridge Cognition. No other disclosures were reported.

Funding/Support: This work was supported by the Shanghai Jiaotong University “Star of Jiaotong University” Medical Engineering Cross Research Fund Key Project (award No. YG2021ZD28), National Natural Science Foundation of China (award No. 81771460, 32100885, and 81971682), General Project of Shanghai Municipal Health Commission (award No. 202140054), Academic Leader of Health Discipline of Shanghai Municipal Health Commission (award No. 2022XD025), Key Laboratory of Psychotic Disorders (award No. 13dz2260500), Natural Science Foundation of Shanghai (award No. 20ZR1472800), Shanghai Sailing Program (award No. 20YF1441900), Qihang Foundation of Shanghai Mental Health Center (award No. 2019-QH-02), Institution-level Project of Shanghai Mental Health Center (award No. 2020-YJ03).

Role of the Funder/Sponsor: The funders had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Data Sharing Statement: See Supplement 2 .

Additional Contributions: The authors acknowledge using ChatGPT (GPT-3.5, OpenAI) for text editing to improve the fluency of the English language in the preparation of this manuscript. The authors affirm that the original intent and meaning of the content remained unaltered during editing, and that ChatGPT had no involvement in shaping the intellectual content of this work. The authors assume full responsibility for upholding the integrity of the content presented in this study.

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19 Interesting Facts About OCD to Help Us Understand

Y ou undoubtedly know a demanding individual who organizes their wardrobe by color or a germaphobe who always has a supply of hand sanitizer on hand. However, OCD, short for obsessive-compulsive disorder, is not always indicated by peculiarities like these.

Obsessive-compulsive disease ( OCD ) is a mental anxiety disorder that causes recurrent thoughts or ideas about various things. These can include fears of violence, dirt, or intruders, injuring loved ones, engaging in sexual activity, or maintaining an excessively clean environment. These behaviors and thoughts can significantly impact your daily life and often require treatment.

19 Interesting Facts About OCD

Whether you have OCD or know someone who does, learning about this complicated disorder is essential. Here are 19 interesting facts about OCD you should be aware of.

1. Famous People Suffer From OCD

Many famous people are known to have OCD, from celebrities to scientists. These notable figures include Charles Darwin, Cameron Diaz, Harrison Ford, Albert Einstein , and Daniel Radcliffe. David Beckham is probably the most famous celebrity with OCD, as he is quite open about his disorder.

2. OCD Causes Anxiety

If you have OCD, chances are you also have anxiety. Constant obsessive thoughts and the need to stick to routines and follow rituals can cause severe anxiety in people, especially in unknown situations where they can’t follow these compulsions.

Some of the most common OCD symptoms that are caused by anxiety or can cause stress include:

• Repeatedly checking things, like if the door is locked or the oven is off.
• Rearranging things to ensure a specific order or symmetry.
• Counting the number of objects in front of them or letters and words in a sentence.
• Repeating actions in multiples, such as switching the light off and on five times. Some people will repeat the action until it feels like it’s been done a ‘good’ amount of times.

3. A Fear of Dirt or Getting Dirty Can Be a Sign of OCD in Children

OCD symptoms usually appear in adolescence, but early signs can be spotted in children. One of them is a fear of dirt . We all know that children love to get dirty as they play; it causes parents a lot of laundry and grief. However, if your child is wary of getting dirty, this could be an early sign that they may develop OCD.

Of course, this is not true for every child. Other symptoms you can look out for include a strict need for order and precision, constantly making things symmetrical, repetitive handwashing, preoccupation with bodily waste, and unusual rituals such as repeating words you say or needing to walk over certain things, like cracks, in a specific way.

These signs are often quirks in kids that they usually grow out of. However, if it’s interfering with their daily lives, it might be worth chatting with your pediatrician or GP.

4. Children Won’t Realise Their Behavior Is Odd

The main difference between OCD in adults and children is that adults usually know that their actions or thoughts are not typical. Children, however, won’t pick up on that and won’t usually come to you and say something is wrong. 

They’re not as aware of their behavior as adults and thus won’t notice if they switch the kitchen light on and off ten times or walk on their toes up the stairs.

5. Around 1.2% of Adults in the US Have OCD

The National Institute of Mental Health (NIMH) has estimated that around 1.2% of adults in the United States have OCD. Diane Davey, the program director at the Obsessive Compulsive Disorder Institute at McLean Hospital and a registered nurse, has stated that OCD is not an exotic illness and is actually very common.

Chances are good that you know someone who has OCD. However, people with OCD often feel ashamed of their disorder and will try to hide it. So, the person making jokes about having OCD definitely doesn’t actually suffer from it just because they like to organize their closet every week.

6. There Are Many Symptoms of OCD

The main symptoms of OCD can be divided into two categories:

• Obsessions: Recurrent and persistent urges, thoughts, or impulses.
• Compulsions: Repetitive behaviors or behaviors the individual feels driven to do in response to an obsession.

7. There Are Many Types of OCD

OCD can be subdivided into different types that depend on the symptoms shown by the individual. These include:

• Checking: A constant need to check that certain things are done or working fine, such as if the oven is off or the smoke detector has batteries.
• Contamination: A fear of dirt, germs, or any sort of contamination. Symptoms include repetitive cleaning, washing, and disinfecting.
• Hoarding: The compulsive need to collect things and keep possessions even if there’s no space for them.
• Symmetry: The constant need to arrange things in a specific way to avoid anxiety and distress.
• Rumination: Intrusive thoughts that are usually violent, sexual, or religious in nature.

8. A Not So Well Known Form of OCD Is Called Pure Obsessions

Rumination, or Pure Obsessions OCD, is usually the form of OCD that is portrayed on TV and in movies. However, it’s only one form of OCD and is usually very misunderstood. It is characterized by sexually inappropriate and even highly violent thoughts. 

These can include fears of homosexuality, blasphemous images, and even child molestation. People with this type of OCD don’t know how to control or stop these thoughts and don’t have any uncontrollable actions that make them feel better and make the thoughts go away for a while.

9. People Don’t Know That Hoarding Is a Form of OCD

Have you ever watched the show Hoarders and wondered how these people could allow themselves to live in such disastrous environments? Well, OCD is usually the cause of that. 

This form of OCD is characterized by a compulsive need to collect and keep worthless items such as newspapers, magazines, milk cartons, plastic bags, etc., in case they might need them in the future. 

10. OCD Doesn’t Discriminate – It Affects All Types of People

Research states that around 2.3% of people will suffer from a form of OCD at some point in their lives. There is no difference in the rates of OCD among men and women; ethnicity and culture don’t usually significantly affect who might develop OCD. 

The current risk factors are as follows:

• Gender: Men and women are equally likely to develop OCD in adolescence. However, males are more likely to develop OCD during adulthood.
• Age: Individuals are more likely to develop OCD in late adolescence. The risk of developing OCD drops as you get older.
• Genetics: Having family members with OCD does increase the risk that you might develop it. The closer the person is to you (your mother/father is more immediate than your aunt/uncle), the higher the risk. If your family member’s OCD started in childhood or adolescence, the risk is even higher that you will develop OCD.
• Brain Structure: Research isn’t entirely clear on this one. However, it is believed that there is a connection between OCD and irregularities in the brain.
• Traumatic Events: Traumatic and stressful events, such as sexual abuse, illness, or the death of a loved one, can increase your risk of developing OCD.

11. OCD Could Be Genetic

For the most part, we don’t know what causes OCD to appear. However, researchers have found that the brains of people with OCD are different in some ways from people without OCD. Specifically, there’s a difference in the circuit that links important parts of the brain, like the thalamus, striatum, and parts of the frontal cortex. There is excessive activity in the frontal regions of the brains of OCD sufferers, which can contribute to intrusive thoughts and overwhelming anxiety.

It also tends to run in families and could be because of the difference in brain structure being a genetic factor. If your parent or sibling has OCD, the chances are higher that you might develop it too.

12. OCD Is Not Psychosis but More a Form of Anxiety

Even though it may feel like your intrusive and compulsive thoughts make you lose touch with reality, OCD does not cause psychosis. People with this disorder don’t actually dissociate from reality as people with schizophrenia might. 

Individuals with OCD are very aware of their symptoms and their thoughts. They know it’s completely irrational, just like anxious people understand their feelings can be unreasonable. However, as much as they know their symptoms, people with these disorders cannot stop them from occurring.

13. There Is Likely No OCD Gene, Even if It’s Genetic

OCD is incredibly complex, and even though there is proof of different brain structures and that the disorder runs in families, no single OCD gene has been identified. The leading theory is that people in the same families usually deal with similar traumas and life experiences that can heighten the risk of OCD. 

However, and yes, this is confusing; a genetic link has also been identified. In a study of twins and OCD, it has been proven that if one twin has the disorder, the other is more likely to develop it. Basically, OCD is extremely complicated and has stumped many scientists and researchers.

14. It’s Rare, but Some Children Have Developed OCD After a Strep Infection

Most children who have a strep infection recover fully with no issues. However, some children have started developing obsessive thoughts or compulsions a few weeks after the infection has cleared up. This can be in the form of personality changes, mood swings, and separation anxiety.

Children who develop these symptoms may have PANDAS (Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal Infections). If your child develops any strange behaviors after a strep infection, it might be worth assessing them with your GP.

15. OCD Is Not Just a Fear of Germs

According to the American Psychiatric Association , people with OCD have widely varying obsessions that are usually more than just a fear of germs. Some individuals indeed have an aversion to dirt, germs, and bodily fluids. However, others have thoughts about harming others or themselves or getting a disease. 

Some people obsess over perfection and will ensure everything is done correctly or placed symmetrically. Some people are overly superstitious and will go to all lengths to avoid black cats and cracks in the pavement. OCD has many symptoms to varying degrees and is quite complicated to diagnose correctly.

16. Life Events Can Trigger OCD Episodes

In a study done in 2012 published in the Psychiatry Research Journal , researchers have identified that three major traumatic events are linked to OCD symptoms, especially in women. These include hospitalization of a family member, loss of a valuable object, or major personal physical illness.

However, less serious events can also trigger OCD symptoms to show face. An E.coli outbreak that is only limited to meat can still trigger a vegetarian with OCD to start worrying if they have E.coli, even though they don’t come into contact with meat.

17. OCD Is Usually Co-Morbid With Other Disorders

If you have OCD, the chances are high that you also have another mental illness, such as ADHD, depression , anxiety disorders, eating disorders, or substance abuse. 

The presence of other conditions makes identifying OCD so complicated, as the signs can overlap with symptoms from other illnesses. If someone has Tourette’s syndrome and OCD, the OCD diagnosis might be missed because of overlap with the repetitive behaviors of Tourette’s syndrome.

18. Therapy and Medication Are First Line Treatments

When you get diagnosed with OCD, your therapist will usually recommend two types of treatments – cognitive behavioral therapy (CBT) and oral medication such as Fluoxetine (Prozac) and Sertraline (Zoloft). 

These two are usually used together to lessen the severity of OCD symptoms. According to the International OCD Foundation, around 70% of people find relief in their OCD symptoms while using medication and/or undergoing therapy.

19. OCD Is Chronic

Unfortunately, there is no cure for OCD. Treatment has proven quite effective for symptoms of the disorders, though, and many people have found relief from their constant obsessions and compulsions. 

Just because you are diagnosed with OCD does not mean your life has to be severely impacted. If you think you might have some symptoms that are interfering with your daily life, it’s always best to talk to a professional and know there is help available.

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When Is the Best Time to Work Out?

It’s an age-old question. But a few recent studies have brought us closer to an answer.

By Alexander Nazaryan

What is the best time of day to exercise?

It’s a straightforward question with a frustrating number of answers, based on research results that can be downright contradictory.

The latest piece of evidence came last month from a group of Australian researchers, who argued that evening was the healthiest time to break a sweat, at least for those who are overweight. Their study looked at 30,000 middle-aged people with obesity and found that evening exercisers were 28 percent less likely to die of any cause than those who worked out in the morning or afternoon.

“We were surprised by the gap,” said Angelo Sabag, an exercise physiologist at the University of Sydney who led the study. The team expected to see a benefit from evening workouts, but “we didn’t think the risk reduction would be as pronounced as it was.”

So does that mean that evening swimmers and night runners had the right idea all along?

“It’s not settled,” said Juleen Zierath, a physiologist at the Karolinska Institute in Sweden. “It’s an emerging area of research. We haven’t done all the experiments. We’re learning a lot every month.”

No single study can dictate when you should exercise. For many people, the choice comes down to fitness goals, work schedules and plain old preferences. That said, certain times of day may offer slight advantages, depending on what you hope to achieve.

The case for morning exercise

According to a 2022 study , morning exercise may be especially beneficial for heart health. It may also lead to better sleep .

And when it comes to weight loss, there have been good arguments made for morning workouts. Last year, a study published in the journal Obesity found that people who exercised between the hours of 7 a.m. and 9 a.m. had a lower body mass index than counterparts who exercised in the afternoon or at night, though it did not track them over time, unlike the Australian study, which followed participants for an average of eight years.

Of course, the biggest argument for morning exercise may be purely practical. “For a lot of people, the morning is more convenient,” said Shawn Youngstedt, an exercise science professor at Arizona State University. Even if rising early to work out can be challenging at first , morning exercise won’t get in the way of Zoom meetings, play dates or your latest Netflix binge.

The case for afternoon exercise

A few small studies suggest that the best workout time, at least for elite athletes, might be the least convenient for many of us.

Body temperature, which is lower in the morning but peaks in late afternoon, plays a role in athletic performance. Several recent small studies with competitive athletes suggest that lower body temperature reduces performance (though warm-ups exercises help counter that) and afternoon workouts help them play better and sleep longer .

If you have the luxury of ample time, one small New Zealand study found that it can help to nap first. As far as the rest of us are concerned, a Chinese study of 92,000 people found that the best time to exercise for your heart was between 11 a.m. and 5 p.m.

“The main difference is our population,” Dr. Sabag said. While his study was restricted to obese people, the Chinese study was not. “Individuals with obesity may be more sensitive to the time-of-day effects of exercise,” he said.

The case for evening exercise

This latest study may not settle the debate, but it certainly suggests that those struggling with obesity might benefit from a later workout.

Exercise makes insulin more effective at lowering blood sugar levels, which in turn fends off weight gain and Type 2 diabetes, a common and devastating consequence of obesity.

“In the evening, you are most insulin resistant,” Dr. Sabag said. “So if you can compensate for that natural change in insulin sensitivity by doing exercise,” he explained, you can lower your blood glucose levels, and thus help keep diabetes and cardiovascular disease at bay.

One persistent concern about evening exercise is that vigorous activity can disturb sleep. However, some experts have argued that these concerns have been overstated.

The case that it may not matter

While many of these studies are fascinating, none of them is definitive. For one thing, most are simply showing a correlation between exercise times and health benefits, not identifying them as the cause.

“The definitive study would be to actually randomize people to different times,” Dr. Youngstedt said, which would be phenomenally expensive and difficult for academics.

One thing public health experts do agree on is that most Americans are far too sedentary. And that any movement is good movement.

“Whenever you can exercise,” Dr. Sabag urged. “That is the answer.”

In a recent edition of his newsletter that discussed the Australian study, Arnold Schwarzenegger — bodybuilder, actor, former governor — seemed to agree. He cited a 2023 study suggesting that there really isn’t any difference in outcomes based on which time of day you exercise. In which case, it’s all about what works best for you.

“I will continue to train in the morning,” the former Mr. Universe wrote. “It’s automatic for me.”

Alexander Nazaryan is a science and culture writer who prefers to run in the early evening.

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