Children with anxiety disorders experience a wide array of symptoms, such as fear, worry, negative thoughts, and more. Some children also experience subclinical obsessive and compulsive symptoms (OCS) without having full-syndrome obsessive-compulsive disorder (OCD). But despite the prevalence of OCS among youth with anxiety, there is little known about which anxiety disorders are most closely linked to OCS, and how OCS impacts the severity of anxiety.
Kate Fitzgerald, MD, a child psychiatrist at NewYork-Presbyterian and Columbia, has observed the co-occurrence of anxiety disorders and OCS firsthand in her patients and in her research. She was the senior author on a recently published paper that sought to identify the baseline prevalence, comorbidity, and clinical implications that subclinical OCS has in youth with anxiety disorders. Below, Dr. Fitzgerald discusses the findings from her recent study and the implications for future treatment.
Research Goals
We know that anxiety disorders are highly comorbid with OCD, and that OCD can be harder to treat. We also know that children with anxiety can experience subclinical obsessions and/or compulsions that typically fall along the same lines as the common themes we see in OCD – contamination, harm, symmetry, and others – without having to be diagnosed with OCD.
However, these symptoms are frequently overlooked in children, often going undetected and untreated because they overlap with more widely acknowledged symptoms of other anxiety disorders. We were interested in understanding how OCS presents in children with anxiety disorders and specifically in learning if there were types of anxiety disorders that coalesce more with OCS.
These symptoms are frequently overlooked in children, often going undetected and untreated because they overlap with more widely acknowledged symptoms of other anxiety disorders.
— Dr. Kate Fitzgerald
To our knowledge, it was unknown whether OCS clusters with one type of anxiety more than another. That’s important to understand because it has implications for treatment, given that OCD can sometimes make anxiety harder to treat. Therefore, we sought to:
- Compare OCS in pediatric patients with anxiety versus healthy youth.
- Determine which anxiety disorder(s) associate most with OCS.
- Determine relationships between OCS, anxiety severity, and functional impairment.
Our hypothesis was that OCS symptoms would cluster more with generalized anxiety disorder and separation anxiety disorder. We also predicted that more severe OCS would be associated with greater severity of anxiety symptoms and functional impairment.
Research Methods
The study included 206 youth – 158 who met the diagnostic criteria for an anxiety disorder and 48 healthy controls. To be included in the study, an anxiety disorder needed to be the primary source of distress and impairment, which we established through clinician interviews with the participants using the Kiddie Schedule for Affective Disorders and Schizophrenia-Present and Lifetime Version (K-SADS-PL). A primary diagnosis of OCD was criteria for exclusion; however, if someone had a diagnosis of both an anxiety disorder and OCD, but the biggest source of daily interference and distress in their day-to-day life was caused by the anxiety disorder, they could be included in the study. Consistent with prior work, many of our participants met diagnostic criteria for two or more anxiety disorders.
We used youth self-reporting as the primary measure of OCS as well as what parents reported, and measured anxiety severity, global severity of illness, and overall functioning using established assessment scales administered by a trained clinician.
Key Findings
Of the participants with anxiety disorders:
- 122 had generalized anxiety disorder
- 73 had social anxiety disorder
- 48 had a specific phobia
- 43 had separation anxiety
- 8 had an unspecified anxiety disorder
Additionally, 101 of the participants met the criteria for more than one anxiety disorder, while only seven participants with a primary anxiety diagnosis also met the diagnostic criteria for OCD.
We went into this study expecting to see a correlation between OCS and separation anxiety based on past literature. What we ended up finding was that generalized anxiety disorder was the most tightly clustered with OCS and also with the self-report measure assessing risk for the later emergence of OCD. We were also expecting to uncover that the anxious youth with the most OCS would have the greatest level of functional impairment; however, we were surprised to find out that was not the case.
We went into this study expecting to see a correlation between OCS and separation anxiety based on past literature. What we ended up finding was that generalized anxiety disorder was the most tightly clustered with OCS and also with the self-report measure assessing risk for the later emergence of OCD.
— Dr. Kate Fitzgerald
Future Implications
This was the first study of its kind of look at OCS prevalence and impact on pediatric patients with anxiety disorders. For me, the main takeaway is that if you have a patient with generalized anxiety, the clinician should assess for the presence of comorbid OCS or OCD.
I think it’s important for clinicians to be aware that there is a continuum of repetitive thoughts (obsessions) and behaviors (compulsions) that can appear in children, spanning from the worries and avoidance of anxiety all the way to the intrusive thoughts and rituals of OCD. It may be more common for kids who have excessive everyday worries to also have repetitive thoughts and behaviors that fall on the far end of the continuum. As mental health professionals, we should all pay close attention to those signs and symptoms and use them to inform our treatment approaches. Pediatric patients with generalized anxiety who also exhibit OCS may be most likely to benefit from exposure-focused cognitive behavioral therapy (CBT) which is the gold standard treatment for OCD. Starting such patients in exposure therapy — the less likely their symptoms will evolve into more severe OCD later in life.
I think it’s important for clinicians to be aware that there is a continuum of repetitive thoughts (obsessions) and behaviors (compulsions) that can appear in children, spanning from the worries and avoidance of anxiety all the way to the intrusive thoughts and rituals of OCD.
— Dr. Kate Fitzgerald
I am currently working on a new study of children with OCD that continues to build off the work of the previous study. These children are 8 to 12 years old, very near illness onset, and will be trying a novel treatment strategy called cognitive control training and CBT with exposure and response prevention, at no cost. We’ll be giving them a game to play on an iPad that helps strengthen cognitive control, which in turn helps them do the hard work required for exposure and response prevention. We just started recruiting for it and I’m very excited to see how it plays out. Families of children with OCD may contact us to participate in this study at [email protected].
