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Expert Q&A

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How can I help my child with OCD make decisions?

Asked by E, suburban Maryland

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My 11-year-old daughter got a diagnosis of obsessive-compulsive disorder (OCD) about six months ago. She is not currently on any medication but has been regularly seeing a therapist.

While she does have compulsive routines, which we have been successfully working on with exposure and response prevention therapy (ERP) (very long showers, bedtime routines, etc.), these routines do not appear to be compulsions to relieve anxiety. And when they are focused on, it is fairly easy to change them.

However, the bigger problems crop up over decision-making. When there are two options of equal weight in her mind (buy or pack lunch, flip-flops or sneakers) it can, on occasion, cause a massive panic attack and major tantrums. However, this does not happen consistently.

Additionally, some serious anxiety-ridden episodes can occur when something doesn't happen the way she wants it to or thinks it should. Again, there does not appear to be any specific obsession or thoughts relating to bad or harmful things that might happen if the wrong decision is made. Just an extreme need to make sure she makes the right decision and a lack of control to move beyond the issue at that time. She often asks for help in making decisions but doesn't want someone else to make the decision for her.

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Mental Health Expert Dr. Charles Raison Psychiatrist,
Emory University Medical School

Expert answer

Dear E: Long ago, when I first started teaching resident physicians, I tended to be a stickler for details. With the passing of the years, however, I realized that the essence of psychiatric diagnosis boils down to a simple question, "Given what we know about mental illness, does this particular patient's story make sense?" If yes, then one can be fairly sure of how to proceed with an appropriate treatment. If no, then you've got to find out more information until things do make sense.

Just as an aside, I don't think I've ever met a patient whose history did not make psychiatric sense if I really got the full story. I can't think of a patient who left me baffled who didn't also leave me with a sense that there was key information that the patient or the patient's family did not want to (or could not) tell me.

So why am I telling you all this? Because your daughter's case is one that makes complete psychiatric sense, and you've done a beautiful job of laying out the issues in very few words. The two primary symptoms with which your daughter struggles, indecision and behavioral rigidity, are as integral to obsessive-compulsive disorder as are more famous symptoms, such as fear of germs and repeated hand-washing.

Indeed, I can't say it any better than two Australian researchers who wrote several years ago that "compulsive individuals are habitually indecisive, and indecision reaches its pathological apex in obsessive-compulsive disorder (OCD)."

Although many people with OCD do primarily manifest classic symptoms such as fear of contamination, a need to count or a need for things to be symmetrical, it is just as common for individuals with OCD to suffer most from symptoms that are less well-known, none of which is more common than indecision. And indecision is always at its worst when the patient is presented with two options that are equally desirable.

A story from a patient of mine illustrates this. My patient was a young man who had an addiction to both Pepsi and Dr Pepper. In the beginning, his problem was limited to the multiple times per day that he would visit the soft drink machine and be unable to choose which drink to select. One day, on a whim, he banged the Pepsi and Dr Pepper buttons simultaneously, leaving the drink he would receive to fate. This practice relieved his anxiety for a few months, but over time he became obsessed with the need for chance to deliver him an equal number of each soft drink per day.

This evolved into a ritual that required many hours in which he would wander from soft drink machine to soft drink machine, simultaneously banging both buttons. He couldn't sleep until the number of each drink he received on any given day was equal, which -- as you might imagine -- meant that many evenings were spent wandering from machine to machine instead of spending time with his family. The story might be amusing, except that it led to a painful divorce. ...

I hope that what I've written clarifies the fact that your daughter's problem with indecision is directly related to her OCD. Indecision is a symptom in its own right and doesn't need any additional obsessional content about bad things happening if the wrong decision is made. It's not the outcome that bothers patients as much as the raw problem of a making a choice.

In this, as in almost everything, people with OCD are suffering from a truth of the world that most of us ignore: in this case that every decision requires that we give up the choice we didn't make.

T.S. Eliot articulated this beautifully in his poem "Burnt Norton": "Footfalls echo in the memory/ Down the passage which we did not take/ Towards the door we never opened. ..."

The fact that your daughter is receiving exposure and response prevention therapy indicates that you know what you are doing, because this is the behavioral treatment of choice for OCD and is at least as effective as medications. I recommend you discuss your daughter's symptoms of indecision and behavioral rigidity with her therapist and discuss how these very common OCD problems might be worked on therapeutically using ERP-type strategies.

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