Drawing by an adolescent in the OCD program at Western Psychiatric Institute & Clinic. Patients are encouraged to draw pictures of their OCD as a way of externalizing it.
Dr. Andrew Gilbert leads an intensive four-day-per-week group therapy for children and adolescents who have obsessive-compulsive disorder at the UPMC Children and Adolescent Services facility on the South Side.
By Pohla Smith Pittsburgh Post-Gazette
Nicole, a 16-year-old who lives on her family's farm in Cambria County, couldn't stop worrying about her animals, especially her 200 chickens. To ease her anxieties, she would check on them -- by her count a couple times every waking hour she wasn't in school.
"Chickens are the worst. She checks them, counts them, picks them up to see if they ate enough -- she can tell by feeling their gizzard," her mother, Connie, said.
"To her, she can tell if they're stressed. She would bring them into the house; they are all her family. She has to pray about her animals. If they were hurt or lost, she would pray until she could find it. ... She'd be out until 2 or 3 or get up at daybreak to look for them."
Nicole even played a radio tuned in to a preacher for her chickens. She couldn't help herself.
She suffers from obsessive-compulsive disorder, a mental illness defined by the National Institute of Mental Health as "an anxiety disorder ... characterized by recurrent, unwanted thoughts (obsessions) and/or repetitive behaviors (compulsions)." For example, a sufferer might be obsessed with germs and deal with that anxiety by washing his or her hands so often they become red and raw.
OCD is fairly common, in adults and kids. The Obsessive Compulsive Foundation says that 1 in 50 adults have OCD and that twice that many have had it at some point in their lives. According to the American Academy of Child & Adolescent Psychiatry, it occurs in as many as 1 in 200 children and adolescents.
"There are two different ranges of onset, the adult-onset type and the childhood-onset type," said Dr. Andrew Gilbert, medical director of the Obsessive-Compulsive Disorder Intensive Outpatient Program for Children and Adolescents of UPMC's Western Psychiatric Institute & Clinic. In the latter, 7 1/2 to 12 1/2 is the average age of onset.
"I was in the sixth grade when I got my first OCD," Nicole remembered. She had contamination obsessions and when she got home from school frequently washed herself if peers had bumped into her.
"I couldn't concentrate. ... People thought I was weird," she said. "I had little twitches, little movements I couldn't control. My mom called them tics."
One obsession-compulsion led to another -- just before she became obsessed with her chickens, her mother said, she obsessed over the farm's cows. And concerns about her chickens aren't her only obsessions: She also worries excessively about her horses, dogs and cats, although not as badly as she does about her chickens. Nevertheless, by this past fall, Nicole had had enough.
"I couldn't take it any more," she said. "I was up half the night crying and stuff. ... Being a teenager is already stressful. You've got a graduation project [to work on], you've got the PSSA test. ...
"Some kids are rude and tease you and I'd get embarrassed if they caught me in an OCD activity."
Nicole asked her mother, who said she also suffers from OCD, to get her some help. After a couple visits to doctors and to Children's Hospital of Pittsburgh, she found it in early December in the award-winning program directed by Dr. Gilbert.
He diagnosed her primary obsession-compulsion as "aggressive/checking." She has intrusive thoughts that harm will come to the animals on the farm and her OCD tells her to frequently and ritualistically count and check to make sure they're healthy.
Childhood OCD experts have devised a system for rating the severity of a patient's OCD -- called the CYBOCS, which stands for the Children's Yale Brown Obsessive Compulsive Scale. It runs from 1 to 40, with anything 15 or under considered mild and anything over 23 severe. When Nicole entered the program, she scored a 23, putting her OCD right on the cusp of moderate to severe.
The WPIC program is one of just a few intensive outpatient treatment programs that are specialized for children and adolescents in the nation.
The intensive programs meet more often than conventional therapy programs but less often than round-the-clock residential programs. Dr. Gilbert's charges, limited to no more than 16 at a time, meet after school four times a week for a total of nine hours.
The young patients -- they range in age from 5 to 18, 19 if still in high school -- receive group psychotherapy from a staff that includes Drs. Gilbert and Fadi Maalouf, both board-certified child and adolescent psychiatrists; two full-time therapists with graduate degrees in social work and several graduate school interns. There also is a social worker assigned to the families, who are charged with helping their children do "homework assignments" each night after therapy.
The treatment, called "cognitive behavioral therapy," or CBT, is "evidence-based," which means it is built upon the result of research studies, "preferably," Dr. Gilbert said, "randomized control trials that are published in peer review journals." The CBT is customized to each patient's cognitions, or (in this case, obsessive) thoughts, and (compulsive) behaviors.
" 'Cognitions' refer to thoughts, and OCD patients often have distorted thoughts that make them feel very anxious," Dr. Gilbert said. "The therapy is aimed at helping patients change their distorted thoughts and anxiety by stopping repetitive behavior.
"Behavior therapy is exposure with response prevention, or ERP," he added. "The idea behind it is that with repeated exposure, anxiety generally will get better after sufficient contact with a feared stimulus."
Dr. Gilbert and his staff explain their therapy to their patients by using the analogy of jumping into a swimming pool: It feels cold at first and you want to get out, but if you stick it out long enough, you will get used to the temperature and have a lot of fun with your friends.
Sometimes cognitive behavior therapy is not enough for these patients, of whom, Dr. Gilbert said, at least 50 percent will have other disorders such as bulimia or anorexia nervosa. In those cases, or for patients whose CYBOCS scores are in the moderate-to-severe range, medications also are employed.
"The medications that we use are predominantly SRI, seratonin reuptake inhibitors," Dr. Gilbert said. That family of drugs is used primarily for depression and includes such well-known trade names as Prozac, Zoloft and Paxil.
Nicole has made quick and steady progress without drug therapy. After about a month in the program, she recently scored a 3 on the CYBOCS scale, and the doctors are considering cutting back on her time in ERP. Eventually she will be graduated from the program -- the average stay is 10 weeks -- and referred for conventional, less intense and less frequent therapy closer to her home.
Her ERP in group therapy meant looking at pictures of chickens and thinking about her chickens without being able to ease her anxieties about them by checking on them.
Her homework was to look at her chickens without checking or counting them.
"The idea behind [ERP] is with repeated exposure, the anxiety will get better," Dr. Gilbert said.
"It's very difficult therapy," he added. "It's very stressful. You provoke anxiety and then stop the thing that neutralizes the anxiety. So you teach them if they ride it out, the anxiety will go down. That's habituation."
"I think I've improved," Nicole said. "I used to visit [the chickens] twice an hour. Now I only go when necessary ... [and] we're still working on it."
For more information about the Western Psych program call Liz Gorr at 412-488-4186.
To find help in areas outside greater Pittsburgh and for other information about OCD visit the Web site of the Obsessive Compulsive Foundation of Western Pennsylvania at www.ocfwpa.org or, nationally, the Obsessive Compulsive Foundation at www.ocfoundation.org.