Psychodynamic: Freud classified Obsessive Compulsive Disorder as a psychoneurosis. The roots of the illness lay in a disturbance in the sexual life or development of the child. Freud did recognize that one's heredity and innate constitution contributed to the development of the disorder. In Freud's theory of infantile sexuality, the child goes through the stages of oral, anal and oedipal sexual interest. If the child does not successfully progress through each phase, he may develop later difficulties. During early childhood, sometimes during or just before the oedipal phase, there might be a conflict between the ego (the mediating and observing entity) and the id (the source of sexual and destructive energy). The ego solves the conflict by setting up a way of reducing the effect of the id. In some cases, the solution is an unstable one. Part of the unstable compromise might be regression to the earlier anal level of development. Such an individual might have a tendency to hoard and a horror of throwing things away. Other obsessive symptoms such as checking might be seen as a way of dealing with the unwanted intrusion of hostile oedipal wishes. (Such as a boy wishing his father dead so he could marry his mother.) If one needed to repeatedly check faucets, it might be a defense against a childhood wish to flood the house and thus kill the father. The symptoms may start to express themselves years later when something happens to weaken the ego and its shakier defenses.

It is possible that these psychodynamic formulations are more relevant to individuals with obsessive or compulsive personality traits rather than to individuals with true OCD.

Biological: Most recent research studies point toward a biological basis for OCD. However, there may be subtypes of OCD. Different subtypes may have distinct biological mechanisms. As research continues, the understanding of the neurological and related biochemical mechanisms will improve. PET Scans (a kind of brain scan that shows levels of brain activity in specific areas.) have shown abnormalities in the sub-orbital cortex (the underside of the front part of the brain) and the basal ganglia. A striking abnormality was increased activity in the sub-orbital cortex. When patients were successfully treated, whether with psychotherapy or medication, the brain scan studies resembled those individuals without OCD. Serotonin seems to be involved in mediating the interaction between these two parts of the brain.

Some cases of OCD may be associated with Tourette's Disorder. Tourette's is characterized by multiple tics. (involuntary rapid movement or vocalization) Individuals with Tourette's may also have OCD symptoms, and Attention Deficit Disorder. Tourette's is often inherited. Relatives of individuals with Tourette's may have OCD without the tics. Finally, recent research has suggested that some cases of OCD may be related to the bacteria, B-hemolytic streptococcus. This syndrome is referred to as PANDAs. Antibodies may attack segments of the brain to produce an acute onset of OCD symptoms. Similar antibodies may cause rheumatic heart disease. More research is needed in this area. However, if the OCD starts suddenly, around the same time as an upper respiratory illness, one might consider a throat swab to check for the presence of B-hemolytic streptococcus infection. If the bacteria are present, further tests, treatment with an antibiotic and a referral to a specialized center might be considered.

Associated Disorders

Tourette's Disorder is more likely to be present in boys and in children who develop OCD at a younger age. It is important to identify this disorder because treatment may need to be modified. Children and adolescents with OCD are more likely to have Attention Deficit Disorder, learning disorders oppositional behavior, separation anxiety disorder and other anxiety disorders. Some of the anxiety disorders have similarities to OCD and are called obsessive-compulsive spectrum disorders. These include tricotillomania, (compulsive hair pulling and twirling, ) body dysmorphic disorder (the obsession that part of one's body is unattractive or misshapen) and habit disorders such as nail biting and scab picking. The exact relationship between these two spectrum disorders and true OCD is not yet entirely clear.

Consequences of OCD

If not treated, OCD tends to be a long-term disorder. Some individuals experience waxing and waning symptoms over the years. Others experience progressive worsening of their OCD until they are housebound and spend much of their days involved in obsessions and rituals. Chronic anxiety disorders may lead to depression. If a child spends a great deal of time obsessing or engaging in mental rituals, he or she may have trouble focusing on the school lessons. Individuals who need to repeatedly erase and rewrite assignments may need to spend hours of time of homework and lose time for friends and family. This same individual may not be able to finish projects because the work is never "just right." Some children and teens may become oppositional if others attempt to interrupt their rituals. For the large number of individuals who manage to hide their symptoms, the cost may simply be years of anxiety and low self-esteem.

Children and Adolescents are Different from Adults

The DSM-4 criteria for children and adults differ for the criterion on insight. An adult generally is at least intermittently aware that the obsessions or compulsions are unrealistic. Most of the time, this is also true for children and adolescents. However some children, particularly young ones, may not have the cognitive capacity to understand the nature of the obsessions or compulsions. Oppositional children or adolescents may not want to admit that there is something awry with their behavior. In that case, a therapeutic alliance with a clinician may enable him or her to discuss his or her real feelings about the symptoms. Family issues are different for children. The child's cognitive development necessitates some changes in the psychotherapeutic approach. If medications are used, the physician must consider the child's smaller size and different metabolism.