Tormenting Thoughts and Secret Rituals Page 16

  Mrs. Kaufmann could make no sense of it. Sometimes she thought he performed rituals in order to avoid work, such as when he stayed in the bathroom for an hour rather than cleaning up his room. Other times, she thought he was doing them for attention, such as when he would insistently demand that she take him to the store to buy countless items that he said he needed for his homework. Most often, though, Jerry’s behaviors seemed too strange and self-defeating to be purposeful. So she blamed herself. “He was my child, he wasn’t normal, therefore it was my fault,” she recalls thinking. She often went to bed crying.

  Just as she could find no coherent way to make sense of Jerry’s rituals, Mrs. Kaufmann could find no satisfactory way to deal with them. She tried reasoning with Jerry, explaining to him that unless he became more productive and stopped the rituals, he was not going to be able to compete in the world. She tried being more strict. (“I became a nagging mother, and I’m not proud of it.”) Frequently she ended up going along with the rituals: driving Jerry where he said he needed to go, putting up with his lateness, and tenderly applying cream to his chapped hands.

  Throughout junior and senior high school, Jerry’s compulsions took up at least one to two hours every day. Ordering or “just so” rituals became a major problem. Jerry recalls that he would sit for an hour lining up the books on his bookshelf, pushing them back a few at a time, checking them, then nudging them forward again, so that there was not a bit of waviness in the line. Washing rituals became quite complex. Wearing heavy rubber gloves, using scalding water, he would scrub his face, hair, and genital area until they were red and sore. For each washing, he needed clean sponges, which created a logistical problem. Routinely exhausting the supplies of sponges in nearby stores, he would anxiously check the shelves each day, waiting for them to be restocked. Homework prompted many different rituals, including compulsive shopping for paper, pencils, compasses, slide rulers, and other school supplies. On one occasion, Mrs. Kaufmann had to cancel the family’s lines of credit when she found that Jerry was charging over a hundred dollars a month for such items. These were miserable years for both mother and son.

  Jerry graduated in the bottom third of his high school class, despite having an impressive IQ measured later at 124. He then took a try at college. In retrospect, he never had a chance. Away from home for the first time, beset by compulsive rituals, separated from his only source of love and support, he quickly became severely depressed and suicidal. The college psychologist recommended hospitalization. The Kaufmanns asked where it would be best to send him. The answer was the internationally renowned Menninger Clinic in Topeka, Kansas.

  Jerry was admitted to Menninger on June 16, 1969, and discharged on May 16, 1970. The records from his hospitalization show that on admission his diagnosis was “obsessive-compulsive disorder” and his prognosis was “guarded.” Eleven months later, when his debt-ridden parents could no longer afford the cost of his care, which now stood at $50,000, Jerry was discharged, his condition “unchanged.” His rituals were no better, his prognosis was still “guarded.” The treatment provided Jerry—the same as for all patients at Menninger at that time—was state-of-the art Freudian therapy. Deep-seated parent-child conflicts were presumed to be the underlying cause of all major psychiatric disorders, and the therapist’s job was to make the patient aware of these and help him deal with them. In Jerry’s case, OCD was attributed specifically to “a symbiotic relationship with a potentially devouring mother.”

  “I took it very personally,” Mrs. Kaufmann told me. “I said to myself, ‘Okay, kid, you really did it this time.’ I went to pieces.” It took many years and the help of a therapist before she was able to rid herself of a persistent sense of personal failure.

  After Menninger, Jerry continued to suffer severe OCD. Washing and cleaning rituals occupied two to three hours every day. Out in the world, even though a personable and bright man, he could not hold a job. A marriage also failed. Jerry moved back home.

  In the 1980s, hearing of new and better therapies for OCD, Jerry came to see me for treatment. Progress since then has been rather slow; Jerry has continued to suffer moderate to severe symptoms. Presently, however, his life is in an upswing: He is holding down a full-time job, has been “dating” his exwife, and is optimistic about his future.

  Onset in childhood is common for obsessive-compulsive disorder. Recent studies indicate that half of all cases start before age eighteen—a considerably higher percentage than that seen in any other major psychiatric disorder. Given that 1–2 percent of people suffer OCD at some time during their lives, as many as one person in a hundred will develop it early on.

  If this were an infectious disease, it would be considered an epidemic. The magnitude of the OCD problem, however, goes unrecognized. A 1988 study of 2,000 New Jersey adolescents found eighteen to have OCD, but only four cases had been diagnosed.

  OCD can, indeed, begin at an extraordinarily young age. A case has been described of an eighteen-month-old boy who anxiously arranged and rearranged his toys all day long. A patient of mine started to have symptoms at age three, repeatedly circling around trees certain numbers of times. His repeating rituals worsened over the next few years to include entering and leaving rooms, turning on and off the TV, and compulsively swallowing in sets of three, six, nine, or a dozen times.

  Approximately one OCDer in twenty develops clear symptoms by age six. A student touchingly recalled the start of her OCD in first grade. Every day she would keep the other children waiting at the bus stop while she ran across the street and stepped up and down on the curb. She was ridiculed by other children, misdiagnosed by a school professional as autistic, and referred to a low-functioning “special ed” class. Not until college was she diagnosed as having OCD.

  A few differences stand out between the early childhood form of OCD and that seen later on. Very young children most frequently perform ordering and counting rituals, whereas washing and cleaning are more common after six or seven. Another contrast is that young children typically do not appreciate the inappropriateness of their compulsions, whereas older OCDers, as a rule, have this insight. Lastly, epidemiological studies show that boys outnumber girls in childhood and adolescent OCD by a ratio of up to two to one. This disparity may be related to OCD’s frequent association with a disorder of primarily male children, Tourette’s syndrome.

  The prepubertal years are the most common time prior to adulthood for the arrival of OCD symptoms. A ten-year-old’s OCD looks essentially the same as that seen in a person of forty: contamination obsessions predominate, and after that obsessions involving danger to self or loved ones, need for symmetry, sexual fears, and scrupulosity. A typical case is an eighth-grade girl who suddenly found herself with an overwhelming fear of contracting AIDS. She would spend an hour washing herself in the bathtub each night before bed and would not allow herself to be touched until the next morning. In school she made frequent excuses to go to the restroom to vigorously scrub her hands. She would refuse to use the school toilets because they were too “dirty” and as a result developed severe constipation.

  The onset of OCD in childhood or adolescence tends to predict a chronic course. In the largest systematic followup of pediatric OCDers treated with medications and behavior therapy, researchers found that after two to seven years only 11 percent were free of significant obsessions and compulsions, and 70 percent required ongoing medication treatment.

  There is one pernicious aspect of childhood OCD that is often overlooked: Severe symptoms can seriously impede social development. Researchers studied seventeen OCDers between the ages twelve and seventeen with marked obsessions and compulsions. They found a general lack of peer acceptance, along with shortcomings in skills fostering cooperation and intimacy, such as initiating conversations and inviting others to join them. The unfortunate results of bypassing the intensive social learning experiences of adolescence are illustrated by Jerry’s case.

  The Burden Shouldered by Parents

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ringing up a child with more-than-mild OCD is always an imposing task. Parents become frustrated that their child cannot be reasoned out of rituals and angry when he or she will not stop them. They blame themselves for their child’s symptoms, assuming they are somehow responsible. They often dread that their child may be developing some sort of a psychotic disorder.

  The burden is partly lifted when parents find good professional help. They come to realize that OCD is a biological disorder, limited in its severity, and that they are not responsible for it. Further, they are provided much-needed structure for dealing with the disorder at home. But parents never get completely off the hook. Behavior therapy presents its own dilemmas, such as deciding when a child is showing attention-seeking behavior and deciding when to enforce behavioral limits. Furthermore, obsessions and compulsions make children moody and irritable. On top of that, because OCD children are unusually bright, loving, and dependent, parents tend to identify closely with them and to suffer their setbacks with great anguish.

  In a survey of OCD parents conducted in 1993, the Obsessive-Compulsive Foundation found that more than 80 percent reported significant disruption of family life, particularly the loss of normal closeness in family relationships. Major problems identified in OCD sufferers were depression, lack of motivation, and inconsiderate behavior. Major problems for family members were excessive arguing and being drawn into rituals. Parents’ greatest concerns were the future well-being of the OCDer and how they themselves could get back to enjoying life normally.

  Parents of OCDers must, indeed, strive to lead a normal life—this is crucial for both parents and the affected child. In order to do this, it is necessary to maintain a rational view of OCD and to avoid becoming overly involved in a child’s symptoms. The OC Foundation has several pamphlets that can be helpful, including, “Learning to Live with OCD,” by Barbara Van Noppen, “Obsessive-Compulsive Disorder in Children and Adolescents,” by Hugh Johnson, and “A Survival Guide for Family,” published by Obsessive Compulsives Anonymous. This last suggests that parents keep reminding themselves, “We didn’t cause our child’s OCD, and we can’t cure our child’s OCD.”

  Early Warning Signs

  All children have at least a few rituals. Toddlers come to expect routines in feeding and bathing; four- and five-year-olds show rituals involving bedtime stories and the careful arrangement of their toys. How is a parent to decide whether these behaviors indicate OCD? A 1990 study, “Childhood Rituals: Normal Development or Obsessive-Compulsive Symptoms?” determined the following general guidelines.

  Normal rituals begin at age two and begin to fade by five or six, whereas OCD rarely begins earlier than five and then progressively worsens. Normal childhood rituals commonly involve orderliness and superstition (especially “lucky numbers”), whereas OCD usually entails washing, checking, or repeating. Normal rituals are accepted by children as normal, whereas OCD is regarded as something that sets them apart. And normal rituals can be skipped without a problem, whereas omitting an OCD ritual causes marked distress.

  The factor of overriding importance in deciding whether any type of childhood rituals should be taken seriously is whether they are interfering significantly in a child’s life. If rituals are detracting from a child’s ability to learn, have fun, and develop social relationships, they may well represent clinical OCD and should be evaluated. It should be kept in mind that OCD children, like adults, will usually attempt to hide their rituals. Here are some of the early signs to look for.

  • Large blocks of time spent alone in the bedroom or bathroom.

  • Excessive time taken to perform simple tasks.

  • Overconcern for minor details.

  • Routinely staying up late to finish homework.

  • Strong emotional outbursts in reaction to trivial matters.

  • Avoidance of certain activities.

  • A need for constant reassurance, particularly about cleanliness.

  TREATING OCD IN CHILDHOOD AND ADOLESCENCE

  Back in the days when Jerry developed OCD, mental health professionals, especially psychiatrists, sometimes did more harm than good. Back then, parents were blamed for many psychiatric problems that have since been identified as clear-cut neurobiological brain disorders. When I started psychiatric training in 1971, Tourette’s syndrome, now known to be genetic, was attributed to parental rejection. Autism, now recognized as a severe biochemical disease of childhood, was attributed to the psychological effects of a chillingly remote “refrigerator mother.” Schizophrenia, now also known to be a biochemical brain disease, was ascribed to a “schizophrenogenic mother” who “double-binded” her child by simultaneously requesting one behavior while nonverbally reinforcing its opposite. And OCD, it was hypothesized, was due to “an overdose of parental perfectionism.” Inestimable damage was done to both parents and children by these erroneous psychodynamic theories.

  What would have happened, one might speculate, if Jerry had developed OCD in the 1990s rather than the 1950s, and if he had received good treatment? In all likelihood, his life would have been dramatically different. Behavior therapy and the SRI medications, the same two treatments that are effective in adults, are also markedly helpful in children and adolescents. The largest study to date on the treatment of severe OCD in this age group found that combined treatment with behavior therapy and medications resulted in half of the patients being markedly improved and four fifths significantly so.

  SRI medications have been used in the treatment of childhood OCD for approximately a decade. Whether used singly or in conjunction with behavior therapy, most children are significantly helped by these agents. Clomipramine (Anafranil), the most studied SRI in children, has been proven to reduce OCD symptoms an average of 30 percent—usually sufficient to make OCD tolerable. Placebos, sugar pills, on the other hand, have little effect. All the SRI medications in current use for the treatment of adult OCD—fluoxetine (Prozac), sertraline (Luvox), paroxetine (Paxil), and fluvoxetine (Luvox)—appear to be equally effective in children.

  In treating childood and adolescent OCD, the SRI medications should be prescribed cautiously. There is insufficient data at this point to completely rule out the possibility that they may cause damage to the developing nervous system. Medication treatment should not, however, be sacrificed out of excessive and irrational fears. The SRI medications have been used by tens of millions of people, so far have proven very safe, and are highly unlikely to possess an undetected major toxicity. A great deal more damage is done, in my opinion, by doctors and parents who withhold SRI medications than by those who employ them. Given the problems in social development that can occur as a result of childhood OCD, it is especially important to treat this age group aggressively. If any of my three young children developed obsessions and compulsions that interfered with learning, having fun, or developing social relationships, I would first try behavior therapy, and then if the symptoms were not adequately controlled I would quickly start medications.

  Fortunately, behavior therapy has proven to be very effective in children. The general approach used is similar to that with adults, the goal being exposure to obsessions and prevention of compulsions. In treating children, a key point to emphasize is the separation of individual identity from OCD symptoms. This emphasis allows children to feel good about themselves even when suffering bad symptoms, and it sets the stage for actively fighting the disorder with behavior therapy. Helping a child gain distance from OCD can be accomplished by presenting the disorder as a “short circuit,” or a “jammed” area of the brain that keeps on sending messages when it shouldn’t—something the child is not responsible for but he or she can fix by resisting the performance of rituals. John March and Karen Mulle’s excellent book on the treatment of childhood OCD, How I Chased OCD off My Land, suggests asking the child to give OCD a name, such as “germy,” or “schoolyard bully.” The child is then encouraged to look on behavior therapy for OCD as a battle with a bad guy. The therapist is the coach and the
parents are cheerleaders. This approach works so well that OCD is often controlled after just a few sessions. A recent case illustrates how easily many children with OCD can be treated.

  The Case of Darren

  “He comes to the table with his hands raised like a surgeon!” Darren’s mother complained, shooting a glance at her slightly embarrassed but otherwise serene eight-year-old. She further explained that her son spent ten minutes washing his hands before each meal and that he excused himself from the table mid-meal to wash them some more. Because of his reddened and cracked hands, an appointment had been scheduled with a dermatologist.

  Other embarrassing behaviors prevented the family from eating out. If served a hamburger, Darren insisted on holding it in a napkin and ate only the part that never touched the napkin. French fries and potato chips he took directly from the plate with his mouth.

  The strange behaviors were not limited to mealtime. Darren had also stopped playing with all his battery-operated toys, announcing that he might get sick from them; and he quit riding his bike after his wheel came too near a battery.

  Darren’s mother assured me that he had never before had any type of mental, or physical, problems. His development was entirely normal, and he was doing well in school. He was an especially loving child who still enjoyed spending hours in his mother’s lap. This mother was in shock. She had no idea what was going on.

  When I questioned Darren as to why he was behaving in this strange manner, at first he fidgeted and said he didn’t know. But when I pressed him for an answer, he allowed, “I’m scared I’ll die or get sick from eating something.” In a hemming and hawing manner, he also added, “My mind is telling me that I will be sick from batteries. I can’t get that out of my head.”