CCPR: Tell us about your work in the field of obsessive-compulsive disorder (OCD). 

Dr. Fitzgerald: I study OCD using functional MRI and EEG. Only half of kids and teens with OCD respond to exposure and response prevention (ERP), so we are looking for new approaches. We’ve discovered task control networks, brain circuits that either make it difficult to stop sticky thoughts or create too many sticky thoughts. If patients can “turn on” these networks, they become more able to set aside bothersome thoughts, eg: “This obsession doesn’t make sense—I’m not acting on it.”

CCPR: Why are co-occurring conditions important in OCD?

Dr. Fitzgerald: Most kids and teens with OCD have co-occurring conditions. These make it harder for youth with OCD to respond to ERP. 

CCPR: What are the most common co-occurring conditions with OCD?

Dr. Fitzgerald: Up to 60% of patients with OCD, ­including kids and teens, have separation anxiety, generalized anxiety disorder (GAD), and/or social anxiety disorder (Geller DA et al, J Am Acad Child Adolesc Psychiatry 1996;35(12):1637–1646). Anxiety disorders share common mechanisms with OCD. With separation anxiety, an intrusive thought about something preventing them from ever seeing their parent might lead to clinging behavior. Disentangling OCD and GAD can be difficult. GAD involves everyday worries—being a good friend, student, or family member. OCD concerns are less realistic: for example, “I’m going to stab someone because that thought popped into my head.” Anxiety disorders are triggered by a real-life situation, whereas OCD obsessions are intrusive, often “out of the blue.” 

CCPR: What other conditions co-occur with OCD?

Dr. Fitzgerald: About 30% of patients with OCD have disruptive behavior disorders, such as attention-deficit/hyperactivity disorder (ADHD) and oppositional defiant disorder (ODD). Sometimes obsessions are distracting and look like inattention. I lean away from diagnosing ODD in youth with OCD because oppositionality is often driven by obsessions and compulsions—for example, when obsessions are intense and the child or teen does the compulsion even if it’s getting in the way of family life or school. When a child refuses to stay in their seat at school because of compulsive urges that drive them to, say, run to the bathroom to wash their hands, it may look like they have ODD. Depression becomes more common with OCD in adolescence and occurs in as many as 50% of adult patients with OCD (Peris TS et al, J Psychiatr Res 2017;93:72–78). 

CCPR: How common is co-occurring bipolar disorder (BD) with OCD?

Dr. Fitzgerald: Children and teens with BD seem compulsively driven. However, BD is exceedingly rare in children. It can occur in pediatric OCD but is not a comorbidity we typically see—6% of adults with BD have comorbid OCD, associated with earlier-onset bipolar symptoms (Saunders EFH et al, Depress Anxiety 2012;29(8):739–746). 

CCPR: What about OCD and autism?

Dr. Fitzgerald: Autism spectrum disorders (ASDs) are associated with concrete perseverative thinking that can be mistaken for obsessions and repetitive behaviors that can look like the compulsions of OCD, but instead stem from autism-related stereotypic interests. On the other hand, ASD-affected kids can have OCD too. Youth with ASDs tend to have limited insight about obsessions (ie, ability to wonder whether an idea is true). Concrete thinking in ASDs may lead to a face-value interpretation of the obsession (Porth R and Geller D, Compr Psychiatry 2018;86:25–30). For example, youth with ASDs who have obsessions about being harmed by others might have more trouble realizing that these thoughts are intrusive and not likely to happen. Sometimes the obsession is so intense that it seems psychotic.

CCPR: What about OCD, ADHD, and tics in pediatric autoimmune neurologic syndrome (PANS) or pediatric autoimmune neurologic disorder associated with strep (PANDAS)? 

Dr. Fitzgerald: While some people see OCD as a component of PANS/PANDAS, I lean away from the concept of PANS/PANDAS, even with a documented strep infection. Research has been unable to show a relationship between strep infections and OCD symptoms (Leckman JF et al, J Am Acad Child Adolesc Psychiatry 2011;50(2):108–118.e3). 

CCPR: Are there other explanations for OCD after a strep infection?

Dr. Fitzgerald: Being sick is stressful, and more stress often exacerbates obsessions and compulsions, especially in those who obsess about getting sick. ERP and SSRIs work with kids with OCD after strep or with elevated strep antibody titers, but not antibiotics. PANDAS has less stigma, framing OCD as “medical,” but OCD is medical—it’s a neurological condition. 

CCPR: So how do you assess for co-occurring conditions with OCD?

Dr. Fitzgerald: Do a comprehensive psychiatric evaluation. Interview both parent and child, considering antecedents and consequences of behaviors. If a child appears inattentive, the obsession may be distracting and look like ADHD. Still, some kids report obsessions and mind wandering occurring at separate times, revealing both OCD and ADHD. A child with OCD might develop depression if they become hopeless that their OCD might never improve. This leads to sadness and withdrawal, and treatment needs to address both OCD and depression.

CCPR: How do co-occurring anxiety disorders impact treatment? 

Dr. Fitzgerald: Exposure helps anxiety disorders, but other components of cognitive behavioral therapy for anxiety, such as relaxation and ­problem-solving, reduce anxiety and run counter to the goal in OCD, which is about tolerating anxiety: “One germ won’t kill me. I don’t need to wash my hands again. I’ll feel anxious, but that will go away.”

CCPR: How do you manage competing treatment components for comorbidities with OCD?

Dr. Fitzgerald: Prioritize the more impairing symptoms or conditions. If the patient has a specific phobia about getting into a car that prevents them from attending school, it takes priority over compulsive handwashing when the handwashing has little impact on the day-to-day functioning of the child. 

CCPR: Tell us about treating OCD with ADHD. 

Dr. Fitzgerald: Stimulants or alpha agonists can help kids focus during exposure therapy, but SSRIs and ERP are the primary treatments for OCD. Watch for motor restlessness as you titrate SSRIs since this can look like the fidgetiness of ADHD but is just a side effect that can be resolved by lowering the dose or switching to a different SSRI. Also, if a child is undoing a bad thought with a good one, they can look inattentive. Ask carefully about what is distracting the patient: “Is it the busy room or the bad thoughts that keep you from finishing your classwork?” You might choose ERP and/or an SSRI rather than a stimulant. 

CCPR: How do you manage ODD with OCD?

Dr. Fitzgerald: From the point of view of the patient, oppositionality is understandable. The child is frightened, not spiteful. Treat the OCD and the apparent ODD should ease. 

CCPR: Does depression make it harder to engage patients in OCD treatment? 

Dr. Fitzgerald: Yes, and I might recommend medications straightaway because SSRIs can treat both depression and OCD. Exposure is hard work, but if the depression remits, the patient may engage better and respond more readily to exposure and response prevention. SSRIs can cause motor restlessness, which can be mistaken for hypomania. In these cases, consider lowering the dose or changing to a different SSRI. 

CCPR: Tell us about treating OCD with BD. 

Dr. Fitzgerald: Stabilize the BD before addressing the OCD, using a mood stabilizer first then ERP for OCD. If the OCD is so impairing that the patient cannot engage in ERP, then continue the mood stabilizer and slowly add an SSRI at a low dose, carefully monitoring mood and OCD symptoms. Keep in mind that BD is characterized by euphoria, grandiosity, and racing thoughts that must be distinguished from the anxiety and obsessions that occur in OCD. It’s important to establish that the core symptoms of BD are present and do not stem from OCD. 

CCPR: What about treating OCD in autistic children and teens?

Dr. Fitzgerald: Eric Storch has developed exposure-based CBT for OCD in youth with ASDs (Iniesta Sepúlveda M et al, Child Psychiatry Hum Dev 2018;49(1):9–19). In SSRI- and ERP-refractory patients, augmentation with a low-dose second-generation antipsychotic (eg, risperidone) could be considered since this class of medication can reduce aggression in autism and may augment SSRI effects in OCD. Autism, OCD, and psychosis can coexist, but “first do no harm” is my approach, so I save second-generation antipsychotics for last as they have more side effects than SSRIs or ERP, and I discuss with families that we will need to monitor carefully with extended evaluation. 

CCPR: What do you tell parents or colleagues who ask about PANS/PANDAS? 

Dr. Fitzgerald: I tell them that good research shows that antibiotics don’t help OCD in kids with high antistreptolysin O (ASO) titers or OCD after a strep infection. Treat strep with antibiotics, but don’t treat OCD with antibiotics. Small studies looked at IVIG or plasmapheresis to remove antibodies to strep, but these interventions are invasive and there is no conclusive evidence that they work. SSRIs and ERP work whether or not the OCD is preceded by a strep infection. 

CCPR: Tell us more about using medications for OCD with co-occurring conditions. 

Dr. Fitzgerald: SSRIs are first line for OCD, typically at a high dose, although they are patient specific. Recent research by Michael Bloch shows that responders benefit as early as two weeks, whereas those who no benefit by two to four weeks may need to switch to a different medication (Varigonda AL et al, J Am Acad Child Adolesc Psychiatry 2016;55(10):851–859.e2). Different SSRIs can be effective in different patients. If the first SSRI doesn’t work, try a second and even a third. 

CCPR: When you see an initial response to the OCD, do you hold the dose steady? 

Dr. Fitzgerald: In most cases, I take that two-week signal as a reassurance and push the dose. If I see no more improvement at one month or side effects, I tend to switch to a different SSRI. 

CCPR: If the SSRI doesn’t work, do you try clomipramine?

Dr. Fitzgerald: I avoid clomipramine due to anticholinergic side effects. Practice guidelines suggest trying three SSRIs first before other agents. If you have a partial response to an SSRI, you might augment with a low dose of clomipramine, perhaps at bedtime because it can be sedating. 

CCPR: What else do you augment with? 

Dr. Fitzgerald: The best augmentation is exposure and response prevention. Antipsychotic augmentation would be for severe impairment, but also appropriate if there is comorbidity with severe depression, BD, bipolar depression, autism with aggression, or the rare psychotic condition. I rank risperidone first for severe OCD, then aripiprazole, and then olanzapine. However, olanzapine has so much weight gain that I never use it. Quetiapine (Seroquel) and ziprasidone (Geodon) seem less effective based on small clinical trials. 

CCPR: What is the prognosis for OCD with co-occurring conditions? 

Dr. Fitzgerald: ERP seems to be more durable than medications, but there haven’t been many longitudinal studies to look at outcomes. Generally, about 45% of OCD-affected youth who are treated with an SSRI and/or ERP achieve remission by early adulthood (Bloch MH et al, Pediatrics 2009;124(4):1085–1093). For patients with pediatric OCD in remission, I taper very slowly over months. If OCD symptoms escalate, we use ERP. But it’s valid to stay on maintenance SSRIs because active OCD, with or without other conditions, can lead to more problems than those associated with staying on an SSRI.

CCPR: Treatment for OCD is hard to find. How do social determinants such as poverty and cultural differences impact treatment for OCD with co-occurring conditions?

Dr. Fitzgerald: For patients from lower socioeconomic status, it’s hard to get specialty care (and sometimes any care!) for childhood psychiatric conditions, including OCD. And it’s harder for people in these situations to find clinicians experienced in treating combinations of these conditions. We need better treatments that are more effective and can reach more patients. This is why research to improve treatments at all levels—from basic mechanisms to dissemination and implementation—is so important. 

CCPR: What other treatment approaches are people investigating to reach at-risk communities? 

Dr. Fitzgerald: John Walkup is researching internet-based exposure and response prevention. Rachel Marsh and I are studying OCD in kids ages 8–12, using a cognitive training video game app that trains inhibitory control. Our study will look at whether exercising control ahead of ERP can boost response to the ERP itself. If it’s a stand-alone treatment, you wouldn’t need a therapist, and it would be easy to disseminate. For patients interested in participating in our study, please look us up at Columbia University. We will be enrolling children with OCD starting fall of 2023!

CCPR: Thank you for your time, Dr. Fitzgerald.