When Obsessive-Compulsive Disorder (OCD) Requires Residential Treatment

Severe OCD: Obsessions and Compulsions Take Up Significant Time Every Day

Obsessive-Compulsive Disorder (OCD) is defined by the Diagnostic and Statistical Manual of Mental Disorders, Volume Five (DSM-V) as a neurological disorder that’s part of a larger group of mental health disorders known as anxiety disorders. Common anxiety disorders include generalized anxiety disorder (GAD), separation anxiety, social anxiety disorder (SAD), panic disorder, and post-traumatic stress disorder, among others.

Anxiety disorders are one of the most commonly diagnosed mental health disorders among children and adolescents. Symptoms of OCD typically between age 10-12, which is considered early onset, or age 18-25, which is considered late onset. In some instances, OCD appears in children between ages 4-10, but these cases are rare.

Mental health professionals categorize anxiety disorders – including OCD – on a spectrum from mild to moderate to severe. The frequency, intensity, and duration of symptoms determine where any individual case of OCD occurs on the severity spectrum:

Mild OCD:

• In a child or adolescent with mild OCD, symptoms are uncomfortable, disruptive, and take up a small amount of time each day. Children and adolescents with mild OCD respond well to professional treatment and support.

Moderate OCD:

• In a child or adolescent with moderate OCD, symptoms are more uncomfortable, disruptive, and take up more time each day than mild OCD symptoms. Children and adolescents with moderate OCD may respond well to treatment, but treatment typically occurs more frequently, and it typically takes a child or teen more time to lean to manage their OCD symptoms.

Severe OCD:

• In a child or adolescent with severe OCD, symptoms are extremely uncomfortable, disruptive, and take up several hours each day. In some cases of severe OCD in children and adolescents, symptoms dominate their entire day, every day. Severe OCD typically does not respond well to initial treatment, and requires intensive, immersive support and specialized therapeutic approaches.

The World Health Organization once identified severe OCD as “one of the most disabling illnesses by lost income and decreased quality of life.”

That’s the type of OCD this article is about: severe OCD. We’ll discuss how parents of teens with OCD can determine when symptoms of OCD escalate from mild to moderate or moderate to severe. We’ll also address the significant complications teens with OCD may experience if their OCD is left untreated.

Spoiler alert: untreated OCD can be debilitating and lead to a host of additional problematic mental health complications.

First, though, we’ll offer a clinical definition of OCD, describe common obsessions and compulsions, and offer basic statistics on the prevalence of OCD among teens in the U.S.

What is Obsessive-Compulsive Disorder?

The DSM-V defines OCD as the presence of obsessions and compulsions that occupy no less than an hour a day and result in significant psychological and emotional distress. Obsessions are thoughts, patterns of thoughts, or mental images that cause disruptive levels worry, stress, or anxiety in the people who have them. Compulsions are behaviors performed by an individual in response to the disruptive patterns of thought associated with their obsessions.

Teen OCD: Common Obsessions

• High level of fear of contamination from germs or dirt
• Excess worry about danger or harm:
  • Includes personal worries and worry about family and friends
• Significant fear of losing items with personal meaning or importance
• Need to see perfect symmetry in common objects
• Preoccupation with specific words or numbers
• Intense worry about being imperfect in any way

Teen OCD: Common Compulsions

• Excessive and repetitive cleaning. This may include:
  • Repetitive handwashing
  • Repetitive cleaning of objects, items, or surfaces that are already clean
• Avoiding touching things other people have touched. In teens, this may include:
  • Avoiding school lunchrooms
  • Avoiding potentially dirty or unclean public places, such as school bathrooms
• Checking/rechecking windows and doors at home for safety
• Extreme resistance to throwing away meaningful personal possessions
• Constant rearranging of objects at home or school to make them orderly and symmetrical
• Constant, disruptive revision of schoolwork, in class or at home
• Repetitively performance of tasks until they meet specific personal standards of perfection
• Repetitive, disruptive counting of ordinary objects
• Doing specific activities or executing personal rituals exactly the same way every time

Let’s clarify something here. Almost everyone has their way of doing things. A person washing dishes may load the dishwasher the same way every time. A person who loves running may put on their special running socks and shoes the same way every time. Some people go through an identical ritual every time they get in the driver’s seat of a car or perform the same end of day routine every time they get home from work or school.

In most cases, these are habits. Habits meet clinical criteria for OCD when they’re married to emotional states, and an individual performs them because they believe not performing them would have significant negative consequences.

Now let’s look at the prevalence of OCD among U.S. teens.

How Common is Teen OCD?

The following data is available from the National Institute of Mental Health (NIMH), the International OCD Foundation (IOCDF), and the Centers for Disease Control (CDC). We include data on co-occurring disorders – also known as dual diagnosis or co-morbidity – because those figures are directly relevant to our next topic: how to recognize when OCD escalates from mild to moderate or moderate to severe.

But first, the data.

Teen OCD: Facts and Figures

• Prevalence:
  • 2.0% of teens (12-17) reported OCD symptoms in the past year
    • That’s about half a million teens
  • 40% of teens with OCD had chronic, recurring OCD
  • The average age of onset is about 10 years old
• Co-Occurring Disorders (OCD + Another Mental Health Disorder)
  • 70% of youth and teens with OCD have co-occurring disorders
• Common Co-occurring Disorders in Teens with OCD:
  • Other anxiety disorders
  • Mood disorders: depression and bipolar disorder
  • Eating disorders
  • Attention-deficit/hyperactivity disorder
  • Substance use disorder (SUD)
• Prevalence of Co-Occurring Disorders Among People with OCD
  • Additional anxiety disorder: 76%
  • Mood disorder: 63%
  • ADHD: 55.9%
  • SUD: 38.6%

This information makes it clear that clinical OCD rarely occurs on its own. Experts indicate that OCD has a greater chance of escalating, becoming severe, and becoming treatment resistant when:

• An individual has poor awareness of the reality of their symptoms. This is a state called overvalued ideation, or OVI. People with OVI are convinced their obsessions are real. They recognize other people may not agree, but they think other people are, in a word, wrong. The presence of OVI exacerbates OCD, makes it resistant to treatment, and can cause mild or moderate OCD to escalate to severe OCD.
• Another mental health disorder is present. Additional disorders that cause the most complications are psychosis, schizophrenia, depression, and additional anxiety disorders.
• An alcohol or substance use disorder (AUD or SUD) is also present.

Those are the factors that can lead to escalation. Now let’s discuss how parents of teens with OCD can tell when their OCD escalates to a level that requires inpatient treatment.

When OCD Escalates: What are the Signs?

In the article Severe OCD by Jonathan D. Huppert and Edna B. Foa, the authors indicate that mild and moderate OCD respond well to cognitive behavioral therapy (CBT) sessions at least twice a week with an experienced therapist. While those individuals learn to manage their symptoms and prevent significant disruption, individuals with severe OCD face greater challenges. Here’s what the Huppert and Foa conclude about those cases:

“Patients with severe OCD symptoms seem to benefit more from intensive daily treatment, as it allows the therapist to troubleshoot any problems on a daily basis and it promotes motivation for improvement. Patients whose OCD is so severe that it prevents them from participating in outpatient treatment may benefit from treatment delivered in an inpatient unit that specializes in the treatment of OCD.”

If severe OCD requires immersive treatment in an inpatient setting, then how can parents tell when OCD become severe?

The answer is embedded in the definitions for mild, moderate, and severe OCD we present above. Specifically, the answer revolves around the time a teen with OCD spends dealing with obsessions and compulsions and the amount of disruption the symptoms cause.

In other words, severe OCD that may require immersive residential treatment is characterized by:

Frequency of obsessions and compulsions:

• When mild or moderate OCD wherein obsessions and compulsions occupy around an hour a day changes to 4 hours or more a day to every minute of every day, that’s a red flag for escalation.

Substantial impairment:

• When mild or moderate OCD that has marginal impact on family, school, or social life begins to prevent a teen from participating in family, school, or social life altogether, that’s a red flag for escalation.

Lack/Absence of insight (OVI):

• When mild or moderate OCD accompanied by reasonable insight changes to severe OCD with OVI, that’s a red flag for escalation. Meaning that when a teen goes from understanding their symptoms are a function of their disorder to believing that everyone is wrong about their symptoms and they’re right, they’ve escalated to the point they may need residential treatment.

Co-occurring disorders:

• When mild or moderate OCD is accompanied by disorders such as PTSD, depression, or an alcohol/substance use disorder (AUD/SUD), or when SUD or AUD develops in response to they symptoms of OCD, that’s a red flag for escalation.

We should take a moment to address that last bullet point. In addition to contributing to the severity of OCD, a teen with OCD may use alcohol or drugs to deal with the disruptive and uncomfortable symptoms of OCD. This is a phenomenon called self-medication. When self-medication for OCD occurs, it creates a negative cycle: the self-medication becomes a disorder by itself, which exacerbates OCD and causes it to escalate.

Therefore, AUD and SUD are both causes and results of untreated OCD. Untreated OCD can be debilitating and make daily life almost unbearable. In an attempt to make life bearable, self-medication can backfire, and make a bad situation worse. In addition to self-medication alccohol and drugs, a teen with severe OCD may also engage in self-harming behaviors known as non-suicidal self-injury – another phenomenon which puts teens at significant risk.

However, recent research shows hope for people with severe OCD.

Residential Treatment for Teens With OCD: Does it Work?

Teens with severe OCD who participate in an immersive program at an adolescent residential treatment center can learn to manage their symptoms and mitigate the disruption and discomfort they cause. A standard OCD treatment plan includes individual therapy with a psychiatrist or counselor who specializes in youth and adolescent OCD.

The most widely used therapeutic approach for teen OCD is a combination of cognitive behavioral therapy (CBT) and exposure response therapy (ERP), while the most widely used medications for OCD are SSRI anti-depressants and tricyclic anti-depressants.

The latest data on severe, treatment-resistant OCD shows that a new approach to immersive, intensive treatment can work when less immersive approaches to treatment don’t. Research on a CBT/ERP based program called “The Bergen 4-Day Intensive” showed that:

• 73% of participants were in remission four months after completing treatment
• 72% of participants achieved long-term recovery at a four-year post-treatment check in
• 69% of participants were in remission at a four-year post-treatment check in

These results should give hope to teens and families living with severe OCD. They show the value of both immersive, intensive treatment and the CBT/ERP model.

But why does this approach work?

We’ll answer that now.

Residential Treatment: Dedicated Time to Healing, Recovery, and Skill-Building

In a residential program for OCD, teens live on-site, receive a full day of treatment every day, and often have assignments to keep them busy in the evening. Data shows immersive residential programs for OCD can provide help and relief to teens. Parents of teens with severe, disruptive, debilitating OCD should consider the benefits of immersive treatment:

• Teens spend in an environment dedicated solely to their treatment
• They have time for individual sessions with experienced mental health specialists
• They spend time in group therapy and have the advantage of peer support. Hearing the stories of people who have been through what they’ve been through can increase both time-in-treatment and facilitate treatment progress
• Teens participate in a wide range of therapeutic activities designed to help them learn and practice the practical skills they need to manage their OCD symptoms.

Of all the advantages of residential treatment for teen OCD, that last bullet point describe what might be the most important one: teens have time to practice what they learn and develop recovery skills with direct input from the treatment community. That includes counselors, therapists, and peers. They get to try out their new skills and get immediate feedback about their effectiveness. This means that when they complete their course of treatment, they’re ready. They leave treatment prepared with a toolbox of skills they know can help them thrive at home, at school, and in social situations. For a teenager with severe OCD, that’s a recipe for success.