childhood ocd case study

• 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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Competing interests

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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Case Study of an Adolescent Boy with Obsessive Compulsive Disorder

Susan S. Woods, Ph. D.

Youth Services, Department of Psychiatry, University of Michigan

P.Q. is a boy from Ohio, thirteen years, nine months of age. He was admitted to

Children’s Psychiatric Hospital on an emergency basis on 28 March 1975. He had

been noted by both parents to have had increasing emotional difficulties since the

previous summer. Thes.e became worse during the week prior to .his admission. His

symptoms were primarily of an obsessive ritualistic nature involving repetitious

behavior, compulsive repetitive hand washing, and gradual elaboration of rituals

around bedtime. During the week before admission he was described as

“immobilized to the point that he cannot get out of bed”, spending the larger part of

his waking hours in rituals, and being generally unable to function. His primary

symptom on.admission was that he found members of his family and certain objects

“germy” and was therefore “unable to deal with them” His father believed the

problem began in mild form during the previous summer, following a visit to his

maternal grandmother. One incident during this visit involved a trip to a

convalescent hospital, with P. subsequently being concerned and upset by sick or

damaged people, He started then by being unable to wear certain clothing because

“it was contaminated.” As time went by, areas of the house became off-limits to

him. Similarly, he felt that one of his stepbrothers “was unclean” (germy), a situation

that soon extended to all the members of the family. They were all felt to be

contaminated, with the exception of his father. His stepmother however felt that P.

had been having difficulty for a substantially longer period of time. in fact, it seems

that his symptoms had been apparent to some degree for several years, having

started some months after his mother’s death. The stepmother described the

appearance of what proved to be a long series of “strange habits” about five years

earlier during the summer. For instance, he began hopping every so many steps.

That was followed by repetitive smelling of the table and the walls, eye-blinking,

head-jerking and pausing with hands in

148 Obsessional Neuroses

praying position before entering rooms. Simultaneously, his peer relationships

deteriorated and for a year or so now his brothers and stepbrothers had been teasing him

about this behavior. More recently they had developed a strong hatred of him. Further, his

symptoms had been increasing very noticeably for the five months previous to the referral

to this institution. Thus, shortly before this happened, the Q.’s received a call from P.’s

school one evening stating that P, had been trying to get through the door and out of his

classroom for a period of over two hours. This Fall P. was referred for evaluation

somewhere else, and therapy was recommended and begun on a weekly basis with a

psychologist affiliated with the Department of Pediatrics of Ohio State University.

Three weeks prior to his admission here P. reported that he had “lost the key” to his

mental processes. His parents were uncertain as to the meaning of this and could think of

no precipitating events either within the family or with P.’s personal life.

Dr. and Mrs. Q. (P.’s stepmother) were eager for adMission at Children’s Psychiatric

Hospital and it has subsequently become obvious that they are relieved by his absence and

reluctant to have him rejoin the family unit. The Q.’s are involved in marital therapy at the

present time in Ohio, the marriage having become very rocky as a result of the stresses of

P.’s psychopathology.

P. expresSed concern upon admission that there would be retarded or weird children at

C.P.H. He was relieved after seeing the place because he saw no “weirdos” and found the

hospital to look “very clean.”

From the beginning P. has had a generally positive attitude toward admission, seeing it

as “the only way to get rid of my problem.” He can be expected at times to resent the

family’s splitting him off or scapegoating him as the one with the problems,

Description Of The Child

P. is a small, thin adolescent who has been described as an, Oliver Twist type. Indeed

he often walks around with a haunted expression, hair falling into his eyes, shirttail

hanging out, holes in.

hiS pants, etc.

Clinical Examples 149

He hardly gives the impression of a. compulsive personality, judging from his unkempt

appearance. There have been occasions when he takes care as to how he looks. These

times usually accompany a trip home or an outing with his family where he has enjoyed

Upon admission most of his clothes were rather old and shabby. He explained that he

had plenty of “cool” clothes but that they became germy after his trip to his grandmother’s

home. Finally P. was having to use safety pins to hold his pants together, wore no socks

and had large holes in his sneakers (the only shoes he would wear). He was upset, crying

when the staff finally felt that his father should be approached to ask him to buy P. some

new clothes. Dr. Q. was angry and somewhat embarrassed, explaining that P. had many

new articles of clothing including new shoes but to his and the family’s endless frustration

P. wouldn’t wear them. Dr. Q. finally bought P. some trousers and socks and a new pair of

sneakers. P. was amazed and overjoyed that his father had bothered to buy him clothes

and had spent so much money on him.

Generally P.’s behavior in the various areas of the milieu were consistent. Upon arrival

everyone was concerned about his need for repetition; for example, on his first morning at

breakfast he felt a need to throw away and retrieve his milk carton numerous times,

stating he had to “think right.” Showers and bedtime preparation were another source of

concern, often consuming the better part of the evening. Any attempt to interrupt the

rituals or hurry P. were met by his whining and crying that people didn’t understand him

or his problem. A staff member commented that he had rarely seen such pain in another

human being.

Group activities in the school and with his ward group also became problematic.

Briarwood Mall (a large, new shopping center near the hospital) for example was germy

because it was so “modern and weird.” The arboretum later became off-limits because it

bordered a cemetery. Most recently anything related to magic i.e., the color black,

sparkles, glitters, psychodelic posters, record album covers, or book covers, movies about

ghosts or witches, have produced enormous fear and given P. difficulties when trying to

“think right.”

Classroom behavior has been good and appropriate for the most part with occasional

problems with some students. After Passover P.

150 Obsessional Neuroses

developed an intense interest in Judaism, making a Star of David in Occupational

Therapy and wearing it around his neck. For a time another class member drew swastikas

on the blackboard, During TB’s vacation this rivalry became so intense that P. spent most

of his class time in the hall voluntarily and began to carry a transitional object, a ceramic

bunny, which he had made in Occupational Therapy. In P.’s Occupational Therapy group

he is the oldest member the other children ranging from ages eight to ten. The group has

changed from five to three members since P. was admitted. It is reported that P.’s

intelligence, gross and fine motor skills and creativity all appear to be age appropriate or

higher. Initially P. did not accomplish much, He spent much time•perfecting his projects.

The planning and organizational aspects of. the project were difficult for P. For example,

he wanted to make a Star of David and it was suggested to him to bend the wire to the

desired angles. He rejected this suggestion and became involved in finding a mathematical

formula to approach the problem. P. spent the remainder of the hour, approximately thirty

minutes, attempting to devise a mathematical formula. He became anxious and frustrated

with being unable to solve the problem. The next day however he was able to enter the

shop and just bend the wire to the desired angle, This seems to be P.’s approach to

problems—many times he must try to find a means of ordering or perfecting a project

before he is able to work at a more appropriate pace.

Initially P. remained apart from the group. He appeared very anxious and withdrawn.

He spoke only when addressed and interacted minimally with other group memberi. As he

became more comfortable with the others he began to interact more. He appeared to be

more at ease and seemed to enjoy the group. It appears that this group of younger children

allows him to regress to behavior inappropriate for his age i.e., making animal noises etc.

P. approached his occupational therapist on several occasions, asking about her

family and her. practice of Judaism. These conversations were precipitated by her

announcement to the group that she was taking several days off for Passover. Of late there

have been no questions concerning Judaism.

P.’s concern about a family have been brought up on a number of occasions in the

group. Once he made a family of ceramic rabbits and in a childlike manner stated “a

family—isn’t that cute?”

Clinical Examples 151

Generally P. relates N,vell to ward staff and peers and is not considered a behavior

P,’s relationship to two of his ward staff have been significant. K. and J. became

vehicles for P.’s lingering phallic-oedipal conflicts, and were loved objects. P.

frequently told K. that he wanted J. to tuck him in at night, He became anxious when

he discovered his liking for J. was greater than that for K., and he found it difficult to

understand that both could be loved .in different ways at the same time.

After K. left, P.’s liking for J. as a maternal object developed into a “crush.” He

discussed her constantly in therapy, voicing his anger after learning she was married

but seeing how futile his desires were because “she is a lot older than me,” He wanted

to be “mature” to win her attention.

During J.’s vacation P. decided that she was germy since she flew through the

“Bermuda Triangle.” Their relationship was over as far as P. was concerned. P. also

knew thatbpon J.’s return she would become a primary staff and thus have relatively

little to do with him, He attempted to leave her before she left him.

Family Background and Personal History

Mother: P.’s mother, H.Q., is deceased. A slim, dark-haired woman, she married P.’s

father in 1952, and suffered a reactive depression upon leaving her mother. After the

birth of each child except P. she suffered post-partum depressions. At each of these

times Mrs. Q.’s mother would come to aid her daughter. Mrs. Q. felt her mother could

“magically” help her to improve. Mrs. Q.’s mother was described in one report as an

“aggressive unloving woman. Mrs. Q. seemed to thrive on her criticism.”

Mrs. Q. was admitted to N,P,1. on four separate occasions for severe anxiety and

depression, She was expecting P. during her fourth hospitalization. This is a part of

the report of her psychiatrist:

If I were to speculate on some of the psychodynamics, I feel that unconsciously

Mrs. Q, felt she won the oedipal struggle against her mother. The patient’s mother is

a very hostile and aggressive woman who constantly yells and degrades the patient.

Mrs. Q. felt that she

152 Obsessional Neuroses

must have done something wrong and therefore felt guilty. We can see that since

childhood and especially since the patient has been married any symbolic libidinal or

aggressive energy (such as buying a house, having children, etc.) makes the patient

very anxious and depressed as a reaction to her guilt and she seeks the reassurance and

acceptance of her mother via the mother’s hostile and degrading comments. The patient

described a very hostile, symbiotic, sadomasochistic relationship that she had with her

mother. She felt she always had to go to her mother who in turn would berate and

belittle her, in order that Mrs, Q. should feel that she was still loved and accepted by

her mother.

The patient went on to describe that she would even provoke situations as a a child

which would ’cause her mother to yell at her and this would reassure the patient that

her mother still “cared for her,” Mrs. Q.’s mother exhibited both overtly hostile and

passive aggressive attitudes toward the child and the only way that Mrs. Q. could

retaliate was in her own passive-aggressive way by dawdling or doing things just the

opposite from the way that her mother wished.

During her hospitalization Mrs. Q. expressed suicidal thoughts and fears of harming

her children.

During her last pregnancy (P.) Mrs. Q. was told by her mother that she should never

have any more children because she couldn’t care for the ones she already had.

. Mrs. Q. went to her father as a child for emotional support and felt he loved her more

than he did his wife.

Mrs. Q. had a sister whom she viewed as “the bad daughter” and felt she had to be “the

good daughter.” Mrs. Q.’s sister has also been hospitalized for depression.

Mrs. Q. was always involved in aggressive battles throughout her life. In college she

and her husband-to-be were in the. same class. She was the valedictorian and he the

salutatorian. She went on to obtain a master’s in chemistry. On her third admission to the

psychiatric ward she talked about her husband’s attitude, stating he felt her

hospitalization was not necessary and that she was taking the easy way out.

Mrs. Q. was tremendously conflicted about motherhood. She felt

Clinical Examples 153

One can assume that during this period there was little emotional energy for nurturing

the young children in. the home.

she was still a child and wanted to be a child, Mother’s Day was apparently an enormous

symbol for her. She was admitted once just before Mother’s Day complaining that she

“couldn’t handle her life.” On another admission she became “preoccupied”, staring into

space and complaining of being frightened after a conversation among the patients

regarding Mother’s Day.

On Mother’s Day 1970 Mrs. Q. took an overdose of barbiturates and died two days

Father: R.Q. is a forty-five-year-old physician somewhere in the State of Ohio. He and

his wife were both originally from Boston where they met and married while attending

the university.

The couple moved several times early in the marriage, to Arizona, New Mexico, and

finally to Detroit, where Dr. Q. completed his residency in medicine..

Dr. Q. was seen twice on Mrs. Q.’s first admission in 1960. He was quite anxious and

seemed uncomfortable. He also seemed depressed and agitated, stating that he was unable

to concentrate on his work. He intellectualized -a great’ deal, saying that he thought his

reaction was a typical one to a depressed wife. He added that he was quite ldnely and did

not like being away from his wife. He felt that if he could be with her he could be

supportive of her as he had been in the past. Dr. Q. felt that the only person he could

accept reassurance from was a doctor who was treating his wife. Dr. T. (wife’s therapist)

called Dr. Q. daily to support him and tell him of his wife’s progress. Dr. Q.. felt that this

was not very effective in easing his anxiety but that it was all he had to hold onto. Dr. Q.

also stated that when his wife was depressed he felt depressed too and when she felt better

he felt better. The report of the treating psychiatrist goes as follows:

The highly interdependent nature of the relationship described above was confirmed

by Dr. Q.’s statements to me that he thinks his own willingness to be constantly

available to his wife tended to feed her dependency on him and that the two of them

seemed locked ,together in the ups and downs of this depressions

154 Obsessional Neuroses

Dr. Q. placed a great deal of emphasis on the kind or quality of therapy his wife

might be receiving. He was concerned that she be treated by a staff psychiatrist rather

than a resident, He resented seeing a social worker about-his adjustment to his wife’s

illness. Remnants of this are still visible in Dr. Q.’s wondering why neither he nor P.

saw psychiatrists at C.P.H. He asked about his son’s therapist’s credentials. P. too

shares these feelings, frequently asking what a social worker is, what M. S. W. stands

for, and on one occasion commenting that he believed his therapist could probably

help him as well as a senior psychiatrist. Dr. Q. is a rigid, obsessive-compulsive

character himself. This became evident in his endless ramblings from subject to

subject during the time of history taking. It was impossible for him to get through

recounting a simple event without trying also to include every minute detail of his

association to the event. He feels that his memory is poor and confused and he never

ends satisfied that he has really told the story “right.” He described himself as having a

“stubborn streak.”

Stepmother: This is the report of the parent’s therapist: During the summer

following P.’s mother’s death, – Dr. Q. arranged for a housekeeper, now Mrs. S. Q , to

come into the home. She had just divorced her first husband and was supporting three

sons from her first marriage. Her sons were away at camp during the first few weeks

after she came to the job, and she recalls that P. was the first of the Q. boys to make

friends with her, She had a great deal of time to devote to P. during these weeks and it

was only when her own children returned that she and Dr. Q. began going together. P.

then began to distance himself from her, When the marriage became imminent the

following fall, P.’s siblings reacted quite angrily and P.’s more quiet reaction seemed to

go unnoticed. Following the marriage P. became more and more withdrawn. He

especially had difficulty accepting her youngest son, who is described as being quite

different from P., i.e., rough and aggressive.

The family moved in 1971 to Toledo, where Dr. Q, practices. P.’s siblings were very

unhappy about the move and again their more obvious behavior pushed P.’s into the

background. One had problems in school and another became very depressed. O. cried

frequently, withdrew, developed colitis. At his school’s suggestion a began

Clinical Examples 155

psychiatric treatment of problems described as “similar to P.’s.” This treatment has

been ongoing to the present time. Mrs. Q. described the relationship between herself

and 0. at that time as very poor. 0. is described as being much like his mother, the first

Mrs. Q., bright and close to his dad. P. was closest to 0. of all his sibs and would often

try to emulate him (this relationship has now dete’riorated to the point that the boys

rarely speak). As relationships became more strained throughout this period it was

more and more difficult for Dr. and Mrs. Q. to communicate with each other about the

children. In 1971 the Q.’s daughter, B., was born. According to both parents her birth

was greeted quite positively by the older children. Currently B. is the only sibling

within the family with whom P. is willing to interact on his home passes and she is the

only child who inquires when he is coming home.

Developmental history: P.’s mother was hospitalized at N,13

.1, for the third and

fourth time during her pregnancy with P., for symptoms . of anxiety and depression.

She was admitted and discharged in May of 1961 and readmitted in June of 1961. Just

before Mother’s Day in 1961 she phoned her psychiatrist and described suicidal

thoughts. This pregnancy was obviously a strain for Mrs. Q. and increased her fears of

inadequacy about motherhood.

P. Was born two weeks early as was the pattern of all Mrs. Q.’s children. Labor

lasted one hour and ten minutes. P. was a six-pound, eleven-ounce infant delivered

under caudal, anesthesia. Mrs. Q. recovered quickly with no complications for either

mother or son. P. was breast-fed.

from birth and follow-up interviews with Mrs. Q. at

N. P.1. found she experienced this as pleasant and took pride in the care of her infant.

P. was described as a peaceful sleeper and he slept completely throughout the night

very early .on.

P. developed atopic dermatitis which Dr. Q. described as a red rash occurring in the

creases of his body. He said that P. did not seem to be uncomfortable with this. For

several weeks P. was put on a special diet in an attempt to determine the source of his

allergy. Dr. Q. again recalls no difficulty or food refusal during this time and the

special diet was finally stopped as the pediatrician seemed to feel it was not helping

diagnostically.

Dr. Q. says that he recalls very few specifics regarding the P.’s age at

156 Obsessional Neuroses

the various early developmental milestones, However he feels that P. accomplished most

things just a bit earlier than his two older brothers. For example, he believes his son held

his head up quite early, was responsive to external stimuli and began picking up. and

playing with crib toys at a very early age. Although he cannot recall when P. was weaned

it seems that it was fairly early and he does recall that by the age of one P. was feeding

himself, While recounting this history Dr, Q. often interjected that he recalled his wife

being troubled and anxious and on’many occasions emotionally tied up within herself. He

says that even though Mrs. Q. took good physical care of the children he feels now that

they probably were emotionally, neglected.

P. toilet trained himself at age two and half “almost overnight,” Dr. Q. does not recall

the development of P.’s speech but does remember that once he began talking he talked

almost incessantly. P, rarely played with children his own age, preferring to spend his

time with adults or playing with his older brothers,. When P. went to

kindergarten at age five, Dr. Q. recalls him telling long stories about what had happened

at the end of the day. He also recalls himself and P.’s mother being amused at what a long

story P. could make out of a very small event. The father remembers no difficulty in

separation from Mrs. Q. when P. began kindergarten.

The following information was learned from the second Mrs. Q.: Mrs. Q. said that by

the time she met P, at age seven almost all of his interests and interpersonal relationships

centered on adults. He struck her as being a very dependent but cooperative child. She

even described Him as “a model child.” She recalls that he always liked to have his things

in order although he was not really fastidious. It was always quite difficult for him to get

off to school•in the mornings as it was quite a chore to get through all of his routines. By

the age of twelve P,’s compulsive mannerisms and rituals had become a point of great

contention between him and his siblings. Mrs. Q. remembers that approximately ten

months prior to P.’s hospitalization his brothers began to noticeably withdraw from him

and make fun of him. Before long all of the siblings seemed to be angry with P. It was

also during this year, fall of 1973, that P,’s grandfather died. Although the parents would

not characterize P.’s relationship with his grandfather as a close • one, he did visit with the

grandparents annually and seemed to greatly

Clinical Examples 157

enjoy walking downtown with his retired grandfather and being a part of the

interaction with all of his grandfather’s “old cronies.” When the grandfather died the

maternal grandmother sent • the grandfather’s personal watch to O. rather than to P.

Dr. Q. •stated somewhat resentfully that this was typiCal of his former mother-in-law,

that is, to be more interested in a tradition of giving a gift to the oldest grandchild

rather than giving it to the one who had been closest to her husband.

The summer prior to this hospitalization all three of the older Q. boys were invited

to visit the grandmother. True to form, •only P. accepted the invitation and remained

with the grandmother for about three weeks. .Upon his return from this trip Mrs. Q.

states that she began really pushing for help for P.

Possibly Significant Environmental Circumstances

Timing of the Referral: The timing of the referral seems to have coincided with the

severe manifestation of the obseSsive compulsive neurosis, however the problem in

earlier more manageable stages seems to have been present for some time longer.

Since P. often has difficulties determining when events happened and how long he has

experienced difficulty, both the extent and duration of his symptoms are still

unknown, He believes, however, in agreement with his father, that the major

disturbance began last Summer after a visit to his maternal grandmother in

Connecticut.

This visit was an event for P. each year.. He was the only grandchild who enjoyed

these trips to Connecticut and last summer he went alone. This was P.’s first trip to his

grandmother’s after his grandfather had died of a heart ‘attack a year before. P. had felt

very close to his grandfather, more than to his grandmother whom he described as

“mean and al vays telling me what to do.” It is significant that P. was concerned to

maintain the ties with his mother’s parents. P. is also the only child who wants to

practice Judaism, something which is frowned upon by the rest of the family but

which was highly regarded by P.’s mother, It seems P. is trying very hard to keep his

mother alive in a sense by holding onto the significant objects in her life.

Causation of the Disturbance: Four areas can be delineated as causally significant:

1.158 ObsessionalNeuroses

2. The mother’s suicide. H.Q.’s suicide is a pivotal issue in P.’s psycho- pathology. He failed to mourn her loss, fearing that to express his feelings would be

against his father’s wishes. He is now engaged in the draining process of keeping

her alive (which he believes his father, a physician, failed to do) by holding onto

her traditions. as previously mentioned, Significantly P.’s stepmother is neither

Jewish nor religious and he resents the fact that the family has given up all Jewish

traditions. A particular blow came on P.’s thirteenth birthday when his father

offered him money and said that would take the place of being bar rnitzvahed. P.

felt this cheapened what is to him an important event – symbolizing his “becoming a

man.”.

In therapy P. had tremendous difficulty remembering his mother or any experiences

they shared. He vividly remembered, however, the day she died and described it several

times. The most significant aspects seem to have been when his mother was taken to the

ambulance. She opened her eyes for a second and looked at P. He also remembered how

angry his father became when P. told a neighbor that his mother was

1. The father’s remarriage. P. was initiallS

, warm and accepting of the present

Mrs. Q. before she married his father. After the marriage their relationship

deteriorated, She describes P. as acting like “a twoyearTold.”

The division between old family and new has continued to worsen. P. cannot accept

his stepbrothers especially now that they “have changed.” What this change entails

is their move into adolescence with a concommitant increase in foul language, rough

behavior and less care in personal hygiene.

1. The father-son relationship, ,In one session, P. described his relationship

with his father as being like the song, “Little Boy Blue and the Man in the Moon,”

where a little boy all through his life asks for time with his father but the father is

always too busy. Later the father retires and wants to be with his son but the son by

that time has his own life and says he’s too busy to see his father.

P. has tremendous difficulty expressing his feelings to his dad. He perceives him as

all-knowing and all-powerful but very inaccessible. P. is visibly elated by the grief times

he spends with his father but it seems he does not convey this when he is actually with

his father. Dr. Q. describes P.’s behavior when they are together as passive, bored and

Clinical Examples 159

angry toward sibs. When P. and his father are together they talk about science. P becomes

anxious when he runs out of things to say to his dad. (This happens in therapy too.) He

needs a mental script Well planned out before he feels comfortable.

Dr. Q. is a rigid, authoritarian person who seems to have provided an atmosphere

where P.’s feelings could not be exhibited. Childish emotions of glee or anger were

scorned. To show them meant to risk rejection and withdrawal of IOW. P. learned from an

early age to control himself, to measure up, to be adult in order to obtain parental

acceptance.

4. Adolescence. P. wants to be a man but fears outdoing his dad. He has tried to avoid

any competition with him so far, Now he is beginning to see that his father may have

problems but at the same time he has decided that all doctors are perfect and able to

overcome all difficulties.

Physically P. is small and underdeveloped. This concerns him because he wants to

be strong so he can “beat people” in games and frequently taLks of beating people up

when they upset him.

He likes to be with younger children so he can be superior but resents their childish

Adolescence has also raised the unresolved oedipal issues which are central to P.’s

difficulties.

Possibly Favorable Influences: P. is a bright, interesting, and interested child. He

relates well to peers and staff and relates warmly to particular staff, mainly women. He is

an attractive . child and is frequently described as cute.

His interests are varied and socially he is quite sophisticated.

His parents though severely troubled themselves have engaged in marital counseling. It

family is trying hard to get back on its feet. What place P. will have upon

reuniting with the family is hard to guess. P. has tremendous motivation in thearapy. He

is insightful and frequently makes his own interpretations which are often accurate.

160 Obsessional Neuroses

Assessments of Development

Drive Development

development

P. is developmentally a preadolescent. He has brodd interests in art, science, music,

especially popular music, i.e., John Denver and the Beatles. He has good relationships

with peers and adults but has difficulty when peers exhibit aggression which could be a

physical threat, or when staff is authoritarian. He expresses dislike for the rules that are

imposed and would like to liVe in the wilderness all alone, free from society’s restrictions.

Oral Phase: The oral remnants are seen in P.’s occasional sucking motions and sounds

at the end of therapy sessions, in. his dislike of young children, and in the oral-sadistic

rituals around food (putting food into his mouth and then taking it out, difficulty entering

the dining room). He also has difficulty swallowing (he must think right) and he cannot

eat, for example, at the Detroit Zoo because it is surrounded by cemeteries. (Notice the

anal-sadistic connotations of this.)

Anal phase: P. strives to control his anal-sadistic impulses and fantasies with rituals and

obsessive thoughts. One such fantasy he described as “the pool of imagination, a horrible,

dirty, black gooey place that wants to pull me into it. Sometimes my eyes fall in.”

Whenever he thinks of this he must repeat what he has been doing to avoid anxiety.

Unconsciously he is, as his stepmother described, “a two year .old” expressing

ambivalence, sado-maSochism, tendencies toward stubbornness and rebelliousness.

Rdaction formation is P.’s main defense. The move toward adolescence has undoubtedly

contributed heavily to this pattern,

Phallic-oedipal: P. describes himself as “curious George” and expresses an interest in

sex. He developed a “crush” on one of his female child-care-workers but he found this

relationship odd when in therapy he saw her as both girlfriend and mother and said “but

you can’t have sex with your mother,”

Generally P. idealizes adults, particularly men but fears his own adulthood because it

might lead him to be better than his dad,

Clinical Examples 161

P. is just beginning the adolescent phase and has not reached phase dominance. He is

expressing an interest in sex though he is having difficulty with feelings of

embarrassment. He has recently begun to discuss some of his sexual feelings in therapy.

Often they have a decided oedipal component. Recently too he has shown some interest in

a twelve-year-old girl in his class and behaved quite appropriately with her, as opposed to

infantile behavior with another girl.

b. Libido distribution

i. Cathexis of self,

Primary narcissism: P. does not have difficulty in primary narcissism. Secondary

narcissism: P. considers himself to be intelligent with a good sense of humor, however

physically his estimation of himself goes way down.. He fears he is

inadequate, not

strong, uncoordinated and thus unable to successfully compete in athletics or engage in

physical fighting with peers. To some degree his older brother’s move into adolescence

was threatening to P. and may be responsible for the symptom formation to some extent.

He believes he never got enough love or attention from his father. He desperately tries

to prove himself to his dad but is always disappointed to learn how his dad “didn’t notice”

how happy he was to be with him. His chief complaint now is that his dad is strong and

capable, so why shouldn’t he let P. come home on weekends?

P. has developed a split between his natural mother as a good mother and his

stepmother as the bad mother. He can no longer have needs satisfied by his real mother

and he fears rejection by 1-

tisstepmother.

P. is highly invested in his memories and fantasies of his mother. He recalls that when

he was about four he and his mother had mumps. The whole family was concerned about

them. P. became deaf in one ear because of his illness. He is identifying with his mother

now and says he is a replica of her because he is hospitalized “for being crazy,” He

fequently talks of suicide when difficult material is raised in therapy. One day he even

said that he tried to commit suicide by cutting his wrist with a comb but it only made

white scratches. He said that he wasn’t interested in really killing himself, he just

wondered what other people would think if he did.

His goal now is to be like his father. He wants to be a doctor (a

162 Obsessional Neuroses

neurologist) so he can learn how the brain works. He depends on his father to supply

him with the guidelines so he will not fail. His father told him “a healthy body is a

healthy mind,” after his admission to C. P. H. P. immediately began an exercising

.program. He runs contests with himself. He wants to set records, which mean

winning to him, for instance brushing his teeth every night for a year. His favorite

hero is Einstein.

His relationships with other people are warm and accepting. However, once a strong

relationship develops and any hint of rejection is present he rejects before he can be

rejected. When he learned K,D. was leaving, K. became “germy.” When P,’s primary

staff was taken away from him and assigned to another child, she became germy. He

now realizes what this behaVior means and says that if he likes someone a lot they

can’t be germy for very long,

P. is dependent on external objects to regulate his self-esteem. However he is

capable of independent action and thought, the only motivation seeming to be self- satisfaction. He has difficulty accepting praise, usually laughing or saying “sure, sure,”

but it is obvious that he likes it an agrees with it,

ii. Cathexis of objects

P. has the capacity to form and maintain relationships with peers and adults. It often

seems that the peers who become objects of competition are rejected, for example,

brothers, and a friend from Ann Arbor whom he had not seen in several years. P. was

excited about seeing this friend again but this fifteen-year-old had matured and grown

quite .a lot in the meantime. P. felt weak and small by comparison and has not

contacted his friend since. Very recently, he has expressed interest in seeing him

again. –

P, attempts to control adults with his problems. “1. can’t do that because of my

problem” This has led to concern on staffs part as to how much to push or give in to

“the problem.” At first P. would take over an hour for an evening shower, and bedtime

rituals were an agony for all involved in his care.

P.’s closest and most enjoyable relationships have been with female peers or staff.

He was very proud when a young girl from fourth level showed some interest in him

(gave him a yo-yo and sat next to him at a movie) but was somewhat embarrassed

since she was “too young” for him, His relationship with J, (female staff) has been

primarily positive

Clinical Examples 163

but very much tied to oedipal conflicts. Recently he has shown some interest in a twelve- year-old girl in his class and feels she is “the right age for him” “not half as old or twice as

old” as with his other two female interests. P.’s relationship with K.D. was good but he

felt K. was not strong enough at first. Later he felt that K. was one of the few people who

could “really understand me.” Strong authoritarian men are seen as “fair” by P. though he

resents their orders.

2. Aggression

The expression of aggressive impulses has been one of P.’s major areas of conflicts.

Until quite recently he has denied angry feelings, particularly those addressed toward his

father. However a great deal of aggressive energy is bound up in his rituals and obsessive

thinking, which ward off his expressed fantasy of hitting people over the head with coke

bottles (particularly vacationing staff) or sending authoritarian staff through a bologna

slicer! For example, if he thinks of putting someone through a bologna slicer he must put

them back through to make them all right again (thinking right).

Aggression is also seen in his tremendous need to control the environment. Angry

crying spells and stubborn refusals often accompany change of plans for any

unanticipated event,

P.’s aggression not only inflicts pain on the environment but is most often more painful

to him. He feels trernend ously *anxious and guilty over his aggressive thought, and the

rituals also serve as punishment for his self-peiceived “badness.”

Ego and Superego Development

a. Ego apparatus: his ego apparatuses are intact.

b. Ego functions:

Affected by and interfered with by his psychopathology, he is nevertheless clearly a

highly intelligent child with reading skills, mathematical reasoning, and mathematical

fundamental skills above his chronological age.

a. Ego reactions to danger situations:

P.’s fears are lodged in the external world in the form of fear of loss of objects. The id

impulses are also feared characteristically because they may force him to become out of

control and do things (show anger

164 Obsessional Neuroses

or aggression) which would be severely punishable by his superego. d. Defensive system:

Denial: P.’s obsessional substitutions utilize magic and rituals and are a defense which

fosters power and strength in a world where he feels helpless and weak.

Rationalization: Since P. fears the “weakness” he thinks is implied in tender feelings,

he recently denied his anger and sorrow at the vacation of an important P . C. W by

claiming she had a “right” to the vacation and he should not.feel bad because it was her

“right” to go away.

Intellectualization: Enormous energy is spent in .holding back feelings by

intellectualization. P. has such an explosive need to love and hate (punish) his father for

rejecting him and/ or his mother but the only way he can deal with his father is through

scientific discussion, He feels anxious if he is with his father without some specific

intellectual topic to discuss, Unfortunately his father relates to P. in the same way.

Reaction-formation: Classic obsessive concerns for cleanliness, order, being good, are

perceived as knowing the rules and following them, according to P.’s pattern.

Paradoxically, he expresses a great longing to live in the wilderness free from human rules

and regulations and living exactly the way he please.

P. also belches frequently and then immediately bows his head and whispers “excuse

me please” sometimes three or four tlines in a row.

Doing and undoing: P. uses this defense in many areas but perhaps the most suggestive

is his need to read a line and then “unread” it, For example, read backwards, This may

indicate his need to know or his fear of knowing or the ramifications of the quest for

knowledge, related to the suppression of information regarding his mother and her death.

Extensive use of displacement, isolation of affect and content are noticeable,

e. Secondary interference of defense activity with ego achievements:

P.’s defensive system keeps him vulnerable to the fears he experiences in every new

situation. It prevents him from learning by experience. He is so involved in creating

reasons not to be somewhere or not to express feelings that he is virtually paralyzed by a

system where there is no relief and where every day poses a threht of defeat, f, Affective

states and responses:

P. is capable of expressing a wide range of affective responses. He is

Clinical Examples 165 •

a sensitive child and the potential loss of loved objects evokes anger, hate and guilt. It is

only recently and only to certain staff members that P, is able to tell how he feels. Sad

affects are usually masked by imitation crying or sarcasm,

P.’s self-esteem is low and this is particularly evident when gifts or praise are given to

him, He says he never felt anyone gave him anything because they loved him but only

because they wanted to “satisfy him,” The only area where he acknowledges success and

accepts praise is with his intelligence. Though P. is capable of affective responses and

often displays them appropriately, his behavior becomes inappropriate when he is moved

by a person important to him

P. is still somewhat egocentric and narcissistic. For example, he feels everyone

thinks the way he does, and should, therefore, understand his problem, He is

terrified of the anger of others especially – if it might result in physical confrontation,

Authoritarian people are disliked and criticized even when he believes their rules are fair

and right. He whimpers and cries and impotently feigns rage when forced to do something

he doesn’t want to do.. Often his responses can be described as overreaction. Usually the

anger or hurt is not long-lasting though he tends to hold a grudge against those who have

caused him to display negative affects.

Superego Development

a. Superego:

P.’s superego is overly developed, punitive, nonpleasure-giving, unrelenting, and

constricting, The superego introjects which contribute to this pattern stem from the anal

and phallic-oedipal stage based primarily on his overly restrictive father and his perhaps

uninvolved, distant or permissively ambivalent mother. He felt he had to be good to win

parental approval. “Bad behavior” meant risking parental rejection, The id has a need to

discharge its persistent drive and the ego is left as the battleground for the two opposing

sides. Normal childish feelings of gratitude, happiness, excited joy, sorrow, or pain and

anger came to be viewed as weaknesses to be avoided, denied or isolated, so that he could

be the good, calm, placid child he felt his parents desired.

a. Superego ideals:

166 Obsessional Neuroses

The most obvious and most frequently mentioned superego ideal stems from his

identification with the aggressor (father) and his wish to outdo or overcome his father.

He wants to be a brain surgeon who will find the definitive cure for cancer and be the

first to perform successfully brain and spinal-cord transplants. Not only will he be the

first but he will be nationally famous and admired.

a. Other types of ideal formation:

Certainly his desire to become a physician is an appropriate ego ideal as his

intelligence and latent personality strengths suggest. It is clear also that even as an ego

ideal there is the apparenridentification with the aggressor” and his own self-desribed

“little-boy-blue” phenomenon.

a. Development of the total personality:

In general P. has not reached age-appropriate development and may be found in the

preadolescent stage. His over-all development suggests an initial ease in the

developmental milestones without disruption.

There is no noted separation-anxiety in Anna Freud sense of the word, and since he

was the youngest child in the original family there was no conflict there. His illness,

mumps, along with his mother at age four, served to increase his identification with

her and left a permanent reminder of their shared experience.

P. did not want to attend nursery school (possibly a fear of • separation). He recalls

(or has been told) that he stubbornly refused to go and would not dress himself or

allow himself to be dressed for the occasion. This is reminiscent of his present

aggressive behavior around bedtime rituals. Ile states with pride “and 1 never did go to

nursery school.”

School itself was not a problem and both parents recall delight in observing P.’s

reaction to it. We can only speculate that the kind of disturbance observed -now, with

its anal-sadistic qualities, indicates difficulties stemming from the anal phase, though

toilet training-wasn’t a problem. The mother’s frequent depressions may have

contributed to these difficulties along with his father’s authoritarianism. Mrs. Q.’s

depressions continued to the phallic-oedipal stage and we may assume P. felt he could

have given her more suppoil and protection than his father did. The mother’s suicide at

the beginning of his latency caused an upset in this relatively peaceful period and sent

P. back to using the

Clinical Examples 167

defenses of an earlier developmental level and caused a hiatus in further growth.

Latency was accomplished, as seen in his adequate move from play to work, but the

damage was there, P. recalls that his repetitions began at about eight or nine years of

age, soon after mother’s death and his father’s remarriage. The suppression of

information about his mother and the birth of another child served to reinforce P.’s

feeling of being.

left out and unncessary.

The threatening arrival of adolescence was probably the last straw in P.’s ability to

ward off the instinctual impulses and oedipal conflicts tha t we r e then r e ignit ed.

P, is now beginning to feel that he needs his father less than before and this can be

seen as a sign of the impending move into adolescence. P. finds this very upsetting

however, because of his paradoxical view of loving and hating his “all-powerful”

Assessment of Fixation Points and Regressions

There is a fixation to the anal-sadistic and phallic-oedipal stages, with defenses

against regression to oral wishes and fantasies, This can be seen in his obsessive

compulsi-ve behavior and need to re-enact the oedipal situation. There are also some

elements of regression to oral sadism as exemplified in his food rituals.

Assessment of Conflicts

P.’s conflicts have an internal and internalized nature. The internal conflicts are:

(1) general ambivalence—his decision making is tortured, as when he wanted to give

his stepmother a Mother’s Day present but felt to do so might make her unhappy, even

though he also thought it might make her happy; (2) masculinity vs. femininity; and

(3) sadism vs. Masochism.

The internalized conflicts reflect the internalization of previously external conflicts.

There are regressive traces of the oral, anal and phallic-oedipal phases: (1) oral: eating

difficulties previously mentioned; (2) anal: reflected in his fears of aggression, death,

and his reference to death wishes, concerns with germs and magic; (3) phallic-oedipal:

as seen in his crushes and wish to re-enact the oedipal triangle.

168 Obsessional Neuroses

The latter is expressed in jealousy of his therapist and a female ward staff whenever

separations are imminent or when they are observed by P. to be interacting with male

staff. P. is also expressing some concern that his problems will make his therapist

depressed, necessitating her treatment as an inpatient at N. P. I. There is an obvious

sadistic wish here since he is angry about her impending vacation but there is also

guilt .perhaps reminiscent of the guilt he felt for not “making his mother happy” and

thus preventing her depreisions and subsequent suicide, for which he no doubt feels

responsible.

Assessment of Some General Characteristics

Frustration tolerance: 1

1s frustration tolerance is poor because of the pervasive

nature of his obsessions and compulsions. He feels he must do his repetitions even

though they take up a lot of time, If he is pushed beyond his own limit he will cry and

become very stubborn and accuse people of not understanding him or his problem.

Attitude toward anxiety: P. is engaged in a constant struggle to avoid anxiety. The

defenses he uses create the illusion of power and control and temporarily reduce_

At present, P.’s anxieties are so severe that he invests more and more time in

warding them off. His obsessive rituals consume most of his time and overshadow all

other events in his life. Despite their initial intensity they became worse during a

period when P. began to ask questions about his mother and to criticize his father’s

handling of her death. After this the obsession took on a more magical representation

(voodoo), attempting to hide the death wish he felt toward his father.

Sublimation potential: In view of the -present behavior crisis it is difficult to judge

the true sublimation potential, One can assume that it is quite high judging by his

latency-age creativity. For example, P. is making a report on the state of Israel,-This

reflects his search for an identity and his questioning about his mother. However this

has been interfered with and is now a problem for P. He may substitute.the study of

Saudi Arabia because he ‘feels that –

too many magical events happened in the creation

of the state of Israel, that the number 13 appears very often in its history. The one

example he uses is that Israel

Clinical. Examples 169 .

was formed on 13 May 1948; Robert was born on the 13th of the month and his mother

died on the 13th of the month.

Progressive vs. regressive tendencies: P. has a tremendous desire to move forward

and be rid of his problem. He has the potential for progressive movement. He also

acknowledges a disbelief that he will ever be without it or that certain areas of conflict

will cease to concern him. There is also an element of fear of what would happen if he

were no longer obsessive.

He wants to become an adolescent, mature, date, marry, go to medical school but all of

these things pose the threat of failure or worse, success (outdoing father). Sometimes P.

regresses, especially in O.T. groups when he is with younger children. Fear of a

classmate and separation from a teacher several weeks ago prompted P.’s need for a

transitional object, a small clay rabbit which he had made in 0.T. was carried to school

and brought to therapy.

There are a cornbination of permanent regressions which cause extraordinary

developmental Strain, and crippling symptom formation according to the location of the

fixation point and the amount of ego superego involvement. The symptomatic picture is

that of an obsessive compulsive neurosis.

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The Relationship Between Adverse Childhood Experiences, Symptom Severity, Negative Thinking, Comorbidity, and Treatment Response in Youth with Obsessive-Compulsive Disorder

• Original Article
• Published: 22 December 2022
• Volume 55 , pages 1201–1210, ( 2024 )

Cite this article

• Mariana Vazquez 1 ,
• Amanda Palo 1 ,
• McKenzie Schuyler 2 ,
• Brent J. Small 4 ,
• Joseph F. McGuire 5 ,
• Sabine Wilhelm 2 , 3 ,
• Wayne K. Goodman 1 ,
• Daniel Geller 2 , 3 &
• Eric A. Storch 1  

844 Accesses

3 Citations

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Although youth and adults with obsessive-compulsive disorder (OCD) endorse elevated incidence of exposure to traumatic life events during childhood, the existing literature on adverse childhood experiences (ACEs) and OCD is mixed and studies focusing on pediatric OCD are limited. The present study examines the relationship between ACEs and OCD onset, symptom severity, negative cognitive patterns, comorbidity, and cognitive-behavioral therapy (CBT) response in 142 children and adolescents with OCD. ACEs were ascertained from parent reports. Most parents reported child exposure to ACEs. Out of the parents who reported ACEs, 50% reported ACE exposure prior to OCD diagnosis and 50% reported ACE exposure after OCD diagnosis. No significant associations between ACEs and comorbidity or CBT response were found, suggesting that CBT for pediatric OCD is effective regardless of ACE exposure. Family financial problems were associated with increased obsessive-compulsive symptom severity and negative thinking. Implications for research and practice are discussed.

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Please contact the corresponding author for data used in this study.

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Research reported in this publication was supported by a grant to Dr. Storch (1R01MH093381) and a grant to Dr. Geller from the National Institute of Mental Health (5R01MH093402). Research reported in this publication was also supported by the Eunice Kennedy Shriver National Institute of Child Health & Human Development of the National Institutes of Health under Award Number P50HD103555 for use of the Clinical and Translational Core facilities. The views contained within this manuscript are those of the authors and do not reflect those of the National Institutes of Health.

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Mariana Vazquez, Amanda Palo, Wayne K. Goodman & Eric A. Storch

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Brent J. Small

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Ms. Vazquez, Ms. Schuyler, Dr. Palo, Dr. Geller, Dr. McGuire, Dr. Goodman, and Dr. Storch conceptualized the project. Ms. Vazquez, Ms. Schuyler, and Dr. Palo drafted the manuscript. Drs. Small and McGuire led data analysis with support from Ms. Vazquez, Ms. Schuyler, Dr. Palo, Dr. Geller, and Dr. Storch. Drs. Storch, Geller, McGuire and Small engaged in data collection. All authors critically reviewed the manuscript and approved of submission.

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Correspondence to Eric A. Storch .

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Dr. Storch discloses the following relationships: consultant for Biohaven Pharmaceuticals and Brainsway; Book royalties from Elsevier, Springer, American Psychological Association, Wiley, Oxford, Kingsley, and Guilford; Stock valued at less than $5000 from NView; Research support from NIH, IOCDF, Ream Foundation, and Texas Higher Education Coordinating Board.

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Vazquez, M., Palo, A., Schuyler, M. et al. The Relationship Between Adverse Childhood Experiences, Symptom Severity, Negative Thinking, Comorbidity, and Treatment Response in Youth with Obsessive-Compulsive Disorder. Child Psychiatry Hum Dev 55 , 1201–1210 (2024). https://doi.org/10.1007/s10578-022-01488-4

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DOI : https://doi.org/10.1007/s10578-022-01488-4

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Case study: behavioral treatment of obsessive-compulsive disorder in a boy with comorbid disruptive behavior problems

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• 1 Clinical Psychology, University of Pittsburgh, USA.
• PMID: 9549966
• DOI: 10.1097/00004583-199804000-00023

Comorbid psychiatric conditions often complicate the treatment of childhood obsessive-compulsive disorder (OCD). Behavioral treatment of OCD using exposure plus response prevention for a boy with disruptive behavior disorders and two previous unsuccessful medication trials is described. Treatment was adapted to his developmental level, his mother was highly involved in treatment, and a contingency management program contained his disruptive behavior so that he could participate in therapy. Posttreatment and 2- and 6-month follow-up measures indicated marked improvement in OCD symptoms. The possibility of successful behavioral treatment of OCD in medication-free children with disruptive behavior problems is highlighted.

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Case Report: Treatment of a Comorbid Attention Deficit Hyperactivity Disorder and Obsessive–Compulsive Disorder With Psychostimulants

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The data analyzed in this study is subject to the following licenses/restrictions: identifying/confidential patient data cannot be shared. Requests to access the data should be directed to the corresponding author.

Introduction: Attention deficit hyperactivity disorder (ADHD) is a common disease in childhood and adolescence. In about 60% of pediatric patients, the symptoms persist into adulthood. Treatment guidelines for adult ADHD patients suggest multimodal therapy consisting of psychostimulants and psychotherapy. Many adult ADHD patients also suffer from psychiatric comorbidities, among others obsessive–compulsive disorder (OCD). The treatment of the comorbidity of ADHD and OCD remains challenging as the literature is sparse. Moreover, the impact of psychostimulants on obsessive–compulsive symptoms is still unclear.

Case Presentation: Here, we report on a 33-year-old patient with an OCD who was unable to achieve sufficient remission under long-term guideline-based treatment for OCD. The re-examination of the psychological symptoms revealed the presence of adult ADHD as a comorbid disorder. The patient has already been treated with paroxetine and quetiapine for the OCD. Due to the newly established diagnosis of ADHD, extended-release methylphenidate (ER MPH) was administered in addition to a serotonin reuptake inhibitor. After a dose of 30 mg ER MPH, the patient reported an improvement in both the ADHD and the obsessive–compulsive symptoms. After discharge, the patient reduced ER MPH without consultation with a physician due to subjectively described side effects. The discontinuation of medication led to a renewed increase in ADHD and obsessive–compulsive symptoms. The readjustment to ER MPH in combination with sertraline and quetiapine thereafter led to a significant improvement in the compulsive symptoms again.

Conclusion: The present case shows that in ADHD and comorbid obsessive–compulsive disorder, treatment with psychostimulants can improve the obsessive–compulsive symptoms in addition to the ADHD-specific symptoms. To our knowledge, this is only the second case report describing a treatment with ER MPH for an adult patient with OCD and ADHD comorbidity in the literature. Further research, especially randomized controlled trials, is needed to standardize treatment options.

Introduction

Attention deficit hyperactivity disorder (ADHD) is a frequent mental disorder with childhood onset and a worldwide prevalence of at least 2.8% ( 1 ). It is characterized by the three core symptoms of attention deficit, hyperactivity, and impulsivity manifesting since childhood ( 2 ). Adult ADHD is also commonly associated with different comorbidities ( 3 , 4 ), particularly obsessive–compulsive disorder (OCD). The prevalence of OCD comorbidity in patients with ADHD varies widely in the literature, ranging from 1 to 13% ( 5 ). On the other hand, ADHD prevalence in patients with OCD has been reported as ranging from 0 to 23% ( 5 ). The high co-occurrence of these disorders has raised questions about their diagnoses, neurobiology, and treatment.

It has been discussed that the ADHD-like symptoms in OCD, for example inattention, may have contributed to the inconsistency of the reported co-occurrence rates. Furthermore, familial link between OCD and ADHD, disturbances in attention, and executive function and the high comorbidity of tic disorders are common features of these two disorders ( 6 – 9 ).

On the other hand, these disorders have reverse fronto-striatal abnormalities ( 5 ). OCD patients exhibit increased fronto-striatal activity and functional connectivity ( 5 ). In contrast, ADHD is found to be associated with hypoactivity in the prefrontal and striatal brain regions and a reduced fronto-striatal activity ( 5 ). Despite these differences, a shared dysfunction in the medio-fronto-striato-limbic brain region was reported in addition to disorder-specific dysfunctions ( 10 ).

Psychostimulants such as methylphenidate are regarded as the first-line treatment for ADHD. They increase prefrontal activation and improve both clinical symptomology and neurocognitive functioning in ADHD by modulating dopamine reuptake. Guidelines for the treatment of OCD recommend serotonin reuptake inhibitors as first-line pharmacotherapy, which are thought to modulate fronto-striatal hyperactivity. In the case of partial response to serotonin reuptake inhibitors, an augmentation therapy with antipsychotics has also been shown to have a useful effect ( 11 ).

Although the pharmacotherapy of each of these disorders has been well-established, the effective treatment and management of patients with comorbid ADHD and OCD remains challenging. While stimulant medication is recommended as the first-line treatment for ADHD, findings suggest that its use in OCD may exacerbate the OCD symptoms. To our knowledge, there have been only a few studies, mostly case reports and case studies, reporting on the pharmacotherapy of this comorbidity. Some of these reports have shown that the use of stimulants may cause obsessive–compulsive symptoms as side effects ( 12 – 14 ), while others have reported a decline of OCD symptoms under stimulant therapy ( 15 , 16 ).

In this report, we present a case of an adult patient with comorbid ADHD and OCD treated successfully with stimulants and serotonin reuptake inhibitors.

Case Presentation

In November 2017, a 33-year-old patient presented at our ADHD outpatient clinic in the Department of Psychiatry and Psychotherapy at the University Hospital of Leipzig for diagnostic clarification. During a previous psychiatric examination organized by the federal employment agency, a tentative ADHD diagnosis was made for the first time. The patient reported impulsiveness and physical restlessness that had persisted since childhood. He stated that he could hardly sit still or stay in one place for a longer period of time. He also described a lack of concentration and problems sustaining attention in given tasks (see Table 1 for the summary of clinical manifestations). In order to relax physically, he started practicing martial arts and has been doing a lot of gardening lately.

Summary of the clinical manifestations of ADHD and OCD.

ADHD, attention deficit hyperactivity disorder; OCD, obsessive–compulsive disorder .

A mental status examination was conducted according to the AMDP System ( 17 ). The patient was oriented with regard to time, place, person, and situation. He was friendly and cooperative in personal contact. In motor activity, he demonstrated restlessness (fidgeting with the legs, playing with the fingers, and partly increased body tension). He described his mood as slightly dysphoric; his affect was broad. He showed no evidence of delusions, hallucinations, or ideas of reference, but he had poor impulse control, attention deficits with quick distractibility, as well as concentration and short-term memory problems. The thought process was lightly circumstantial, but apart from that without a pathological finding. He did not display any sleep or eating disorders. Any kind of suicidal ideations were denied. The patient demonstrated insight into his mental disorder and was motivated for therapy. These aspects were also confirmed by a senior psychiatrist.

In further exploration, the patient stated that he had been suffering from an OCD since about the age of 10. At that time, a classmate had had an eye tumor, and in this context, he had first developed a washing compulsion for which a first presentation to a psychiatrist had taken place. Later on, he showed compulsive behavior in the form of compulsive counting and ritualized touching things and obsessive thoughts (fear of aliens and the special meaning of the color “blue”). These obsessions began after he watched a film about aliens as a teenager, which frightened him enormously although he does not believe in aliens. Overall, obsessive and compulsive symptoms have been affecting his life in many ways, but especially his work life, disrupting his functionality. He had been treated as an inpatient and outpatient several times, yet the OCD symptoms would still occupy 3–4 h per day (see Table 1 ). In addition, ambulatory psychotherapy (anamnestically cognitive behavioral therapy) had only helped him to a limited extent. However, the existing concentration problems were described as independent of obsessive–compulsive disorder. The current medication at the first visit consisted of paroxetine 30 mg/day and quetiapine 100 mg/day.

The patient also reported that, in the past, he had been drinking a lot of alcohol to compensate for his compulsions and impulsiveness. However, alcohol had disinhibited him in parts even more, and it had come to physical confrontations several times. He had lost control in situations in which he felt provoked. In the past, criminal proceedings had also been brought against him in this context. In the course of time, he developed an alcohol addiction. At the time of the first visit to our outpatient clinic, he had been completely abstinent from alcohol for 6 years. Drug consumption was also negated, which could also be confirmed by a toxicological screen at the inpatient admission.

The following information was gathered on the past psychiatric history: a first inpatient treatment because of the OCD (ICD-10: F42.2) took place in 2006. During that time, a suspected diagnosis of paranoid schizophrenia (ICD-10: F20.0) was made and treatment with risperidone 1.5 mg/day, olanzapine 10 mg/day, and lorazepam 1 mg/day was started. Risperidone was discontinued due to akathisia, and the patient was then treated with olanzapine 10 mg/day and paroxetine 20 mg/day. In 2008, the patient was treated in a day clinic for 1.5 months, where an OCD (ICD-10: F42.2) and an immature personality accentuation were diagnosed. During this treatment, the dose of sulpride was increased from 200 to 400 mg/day, which was prescribed during the outpatient treatment. Subsequently, sulpride was switched to paroxetine 60 mg/day. In 2009, the patient was hospitalized again due to worsening of the OCD symptoms. In 2012, an alcohol withdrawal treatment was completed. The discharge medication consisted of paroxetine 60 mg/day and olanzapine 10 mg/day. The diagnoses then consisted of alcohol dependence (ICD-10: F10.2), alcohol withdrawal syndrome (ICD-10: F10.3), OCD (ICD-10: F42.2), personality accentuation (ICD-10: F60.9), and an unspecified form of schizophrenia (ICD-10: F20.8). In 2013, another alcohol withdrawal treatment due to a relapse followed. Since then, he has been abstinent of alcohol according to his own statement. Discharge medication consisted of paroxetine 60 mg/day and promethazine 25 mg as needed. Since 2015, the patient has been undergoing an outpatient behavioral therapy treatment, without achieving complete remission of the OCD so far.

While there were no relevant diseases in the medical anamnesis, the family history revealed that his mother had been diagnosed with schizophrenia and his father had a history of alcohol addiction.

After the initial presentation in our outpatient clinic (December 2017), detailed diagnostic tests were performed, including the Diagnostic Interview for ADHD in adults (DIVA) and ADHD-specific questionnaires [Conners Adult ADHD Rating Scales (CAARS)—Self-Report: Long Version ( 18 ), Wender Utah Rating Scale (WURS), and Adult ADHD—Self-Report Scale (ADHD-SB)] as well as other questionnaires (e.g., Personality Styles and Disorder Inventory). The subjective assessment of ADHD-relevant symptoms was clearly significant in terms of inattention and hyperactivity, as well as temperament, affective instability, emotional overreaction, and impulsiveness. The CAARS revealed an ADHD index in percentile rank of 88, a DSM-IV Inattentive symptom scale in percentile rank of 98, a DSM-IV Hyperactive–Impulsive scale in percentile rank of 86, and a DSM-IV ADHD Symptoms Total in percentile rank of 96 (see Table 2 ). Available school reports were also reviewed: in primary school reports, the patient was described as an eager and endeavored student, who was partly distracted and showed fluctuations in cooperation with other students. A somewhat unfriendly behavior toward classmates was also reported. These descriptions were in accordance with the self-report of the patient and indicate the presence of ADHD in childhood. The available findings as well as the biographical and current anamnesis strongly suggested the diagnosis of ADHD in adulthood.

The patient's scores on CAARS (in percentile rank) and Y-BOCS.

ADHD, attention deficit hyperactivity disorder; ER MPH, extended-release methylphenidate; CAARS, Conners adult ADHD rating scales; DSM-I, DSM-IV inattentive symptoms; DSM-Hy/I, DSM-IV hyperactive–impulsive symptoms; DSM-Total, DSM-IV ADHD symptoms total; Y-BOCS, yale–brown obsessive compulsive scale .

Due to the complex comorbidity of psychiatric illnesses, the patient was admitted to our inpatient unit in January 2018 for medication adjustment. At that time, the Yale–Brown Obsessive Compulsive Scale (Y-BOCS) ( 19 ) was performed to assess the severity of the OCD symptoms. Concerning the last 7 days, the patient affirmed seven out of 37 typical obsessive thoughts and seven of 21 typical compulsive behaviors. In the severity rating, the patient reached a total score of 18 points, of which eight points were scored in the obsessive thoughts scale and 10 points were on the compulsive behavior scale. The laboratory tests showed a mild folic acid deficiency, which was substituted accordingly. Electrocardiography, electroencephalography, as well as magnetic resonance imaging of the brain showed no abnormal findings.

In accordance with existing literature, we switched the medication from paroxetine 30 mg to sertraline 50 mg/day because of the lack of therapy response to paroxetine treatment for many years ( 20 , 21 ). A psychostimulant treatment with extended-release methylphenidate (ER MPH) was initiated. ER MPH was gradually dosed up to 30 mg/day. Under this medication, not only the ADHD symptoms but also his OCD symptoms improved, so that sertraline could subsequently be reduced to 25 mg/day. At this time, the patient stated that his OCD had almost completely disappeared and that the time he spent with obsessive thoughts and compulsive actions had decreased severely. Furthermore, he felt more balanced and reported that he did not get into conflicts so quickly anymore. As the restlessness decreased, quetiapine could also be reduced and eventually stopped.

One day before discharge (after 42 days on board), Y-BOCS and CAARS were applied again. The patient reported observing one out of 37 typical obsessive thoughts and one of 21 typical compulsive behaviors in the last 7 days. In the severity rating, the patient reached a total score of seven points (five points for obsessive thoughts and two points for compulsive behavior). The CAARS resulted in an ADHD index in percentile rank of 5, a DSM-IV Inattentive symptom scale in percentile rank of 10, a DSM-IV Hyperactive–Impulsive symptom scale in percentile rank of 14, and a DSM-IV ADHD Symptoms Total in percentile rank of 10 (see Table 2 ). The medication at discharge consisted of ER MPH 30 mg/day and sertraline 25 mg/day.

After discharge, the patient attended our ADHD outpatient clinic for regular follow-ups. On his first visit (1 day after the discharge), he reported a good response to the medical therapy with ER MPH and assured that he did not notice any side effects. He expressed the wish to increase the sertraline dose from 25 to 37.5 mg/day. In the following visit after 26 days, the patient reported unspecific anxiety and panic attacks and claimed to have reduced ER MPH to 10 mg on his own responsibility after having read the package leaflet and worrying about potential side effects. Thus, the remaining medication consisted of sertraline 50 mg/day and quetiapine 25 mg/day, which he started again without a consultation with our outpatient clinic.

In March 2018, a month later after the discharge, a second inpatient admission was initiated after an emergency contact of the patient with the ward. He described an increase in obsessive–compulsive symptoms and restlessness and reported that he suffered from panic attacks and sleep disorders and that he lost his appetite. The patient observed severe mood swings and distrust toward other people. The medication at administration consisted of ER MPH 10 mg/day, sertraline 37.5 mg/day, and quetiapine 25 mg as needed. However, he reported that he did not want to continue to take ER MPH. Therefore, therapy with atomoxetine was started as ER MPH was discontinued. Due to the worsened symptomatology, the sertraline dose was increased to 150 mg/day and quetiapine was dosed up to 125 mg/day. However, the OCD symptoms worsened further after the discontinuation of ER MPH despite increasing the doses of sertraline and quetiapine. After weighing up the symptoms before and after treatment with ER MPH, we decided together with the patient to restart the treatment with ER MPH. Physical well-being and a reduction of the OCD and ADHD symptoms were described after switching the medication from atomoxetine to ER MPH. On the first day of the switch, we performed Y-BOCS and CAARS again. For the last 7 days, the patient reported observing four of 37 typical obsessive thoughts and four of 21 typical compulsive behaviors. In the severity rating, the patient reached a total score of 20 points, of which 11 points were on the scale of obsessive thoughts and nine points were on the scale of compulsive behavior. The CAARS showed an ADHD Index in percentile rank of 76, a DSM-IV Inattentive symptom scale in percentile rank of 54, a DSM-IV Hyperactive–Impulsive scale in percentile rank of 82, and a DSM-IV ADHD Symptoms Total in percentile rank of 69 (see Table 2 ).

An improvement of compulsive thoughts and joyfulness was observed when sertraline was added. The patient was discharged in April 2018 (after 27 days on board) into outpatient care at the ADHS outpatient clinic. Five days after discharge, CAARS and Y-BOCS were performed again: the patient reported observing two of 37 typical obsessive thoughts and four of 21 typical compulsive behaviors within the last 7 days. In the severity rating, the patient reached a total score of 18 points, of which 10 points were on the scale of obsessive thoughts and 8 points were on the scale of compulsive behavior. The CAARS revealed an ADHD Index in percentile rank of 42, a DSM-IV Inattentive symptom scale in percentile rank of 38, a DSM-IV Hyperactive–Impulsive scale in percentile rank of 35, and a DSM-IV ADHD Symptoms Total in percentile rank of 35 (see Table 2 ). Discharge medication consisted of ER MPH 10 mg/day, quetiapine 125 mg/day, and sertraline 200 mg per/day. A timeline of this case presentation is shown in Figure 1 .

Timeline of events and medication.

Discussion and Conclusions

In this case report, we present a case of successful treatment with psychostimulants in an adult patient with ADHD and comorbid OCD. Due to the late diagnosis of ADHD (in addition to an apparent misdiagnosis of schizophrenia and personality disorder), no effective treatment was initiated in his early life, resulting in an impacted quality of life up to now. After diagnosing ADHD, we treated the patient with ER MPH in addition to antidepressants for OCD treatment and observed that the adjunctive use of ER MPH resulted in enhanced treatment response. Contrary to reports in the literature, treatment with a stimulant did not cause a worsening of the OCD symptoms. Rather, the patient reported a severe decrease in OCD symptoms, which was also observable by the treatment team. A second administration was necessary due to a worsening of the OCD and ADHD symptoms occurring after the patient had reduced the dose of ER MPH on his own, because he was worried about side effects, which he had never actually experienced during the inpatient treatment. This case highlights the importance of frequent reassessment of comorbid conditions in the case of low treatment response to serotonin reuptake inhibitors and psychotherapy in patients with OCD. Untreated ADHD as a comorbid condition to OCD may reduce the treatment response on the OCD, as shown in previous studies ( 22 ).

Recognizing ADHD and OCD comorbidity is important for the clinical course of these disorders considering that the onset of OCD is significantly higher in adults with childhood ADHD symptoms and that the comorbidity is associated with more severe OCD symptoms and their persistence ( 23 , 24 ). Despite the increasing awareness and interest in ADHD, many affected adults are still underdiagnosed and untreated ( 25 ). The overlap of ADHD symptoms with several other psychiatric disorders, including mood disorders, substance abuse, and anxiety, and the high incidence of comorbid psychiatric conditions are probable reasons for the high number of missed ADHD diagnoses in adults ( 1 , 4 ).

On the basis of neuroimaging findings, structural and functional abnormalities in ADHD and OCD have been reported ( 26 ). A shared dysfunction in the mesial frontal cortex has been shown in patients with ADHD and OCD. On the other hand, disorder-specific dysfunctions were found in the caudate, cingulate, and parietal brain regions in patients with ADHD and in the lateral prefrontal cortex in OCD patients ( 27 ). Furthermore, fronto-striatal hypoactivity was observed in ADHD, whereas OCD shows fronto-striatal hyperactivity, which is also associated positively with symptom severity ( 10 ). Regarding structural abnormalities, a recent meta-analysis reported that patients with OCD have larger insular–striatal regions, whereas patients with ADHS have smaller ventrolateral prefrontal/insular–striatal regions ( 28 ). Nonetheless, apart from these disorder-specific abnormalities, both disorders show a similar neuropsychological impairment in executive functions.

Despite the high prevalence of OCD and ADHD comorbidity, only a few reports on the treatment of this comorbidity exist. Most of these studies were performed in child and adolescent populations, and as far as we know, only one was conducted in an adult population ( 14 ). Some of the case reports described obsessive–compulsive symptoms as a side effect of MPH treatment in patients with ADHD ( 12 – 14 , 29 – 32 ). However, a few studies also described a decrease of the obsessive–compulsive symptoms with MPH treatment ( 15 , 16 ). The latter results are in line with our findings. Still, there are no longitudinal and clinical controlled trials investigating the effect of MPH on the treatment of ADHD and OCD comorbidity. Although this case presentation is the first published report of a positive effect of ER MPH for the treatment of ADHD and OCD comorbidity in an adult patient, it also has certain limitations. This case report describes only one patient and a psychostimulant treatment with ER MPH in addition to the therapy with sertraline and quetiapine instead of a monotherapy. Also, it cannot be determined whether the patient took his medication regularly as prescribed after the first discharge.

The present case report highlights that treatment with psychostimulants in addition to a serotonin reuptake inhibitor can improve the obsessive–compulsive symptoms as well as the ADHD-specific symptoms in patients with ADHD and OCD comorbidity. Still, the treatment of this comorbidity remains challenging. Underdetection, misdiagnosis, as well as delay in the diagnosis of this comorbidity may cause a reduction in quality of life and low treatment response. Treating both disorders concurrently may help to decrease the symptom severity of both conditions. Monitoring the progress may also support the treatment process, allowing improvement of the treatment compliance as well as observing side effects. Yet, longitudinal and clinical controlled trials are needed to gain more information about the treatment of this comorbidity and to observe the treatment response longitudinally.

Data Availability Statement

Ethics statement.

Written informed consent was obtained from the individual(s) for the publication of any potentially identifiable images or data included in this article.

Author Contributions

ED-S and MS were the main authors of the manuscript. ED-S performed the literature research on the comorbidity of ADHD and OCD. Both authors participated substantially in the writing and editing of the final manuscript.

Conflict of Interest

MS has received speaker fees from Lilly, Medice Arzneimitte Pütter GmbH & Co. KG and Servier and was an advisory board member for Shire/Takeda. The remaining author declares that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Acknowledgments

We acknowledge support from the German Research Foundation (DFG) and Leipzig University within the program of Open Access Publishing. We thank Tina Stibbe for her English editing.

Supplementary Material

The Supplementary Material for this article can be found online at: https://www.frontiersin.org/articles/10.3389/fpsyt.2021.649833/full#supplementary-material