Trauma and OCD – A Case of a Boy with Dark Fears

Yamini Kannappan*, Tinu Thambi, Aishwariya Ramesh

Department of Psychiatry, Kauvery Hospital, Chennai, Tamilnadu, India

*Correspondence author: [email protected]

Abstract

Obsessive-compulsive disorder (OCD) is a common disorder that often begins in childhood and is frequently unrecognized, underdiagnosed, and undertreated. OCD is characterized by recurrent obsessions (unwanted ideas, thoughts, images, or urges) and compulsions (repetitive behaviours or mental acts) designed to ward off risk and/or to ease distress. Paediatric OCD is distinct from occasional uncomfortable thoughts and common childhood worries. It is more intense and persistent and the experience of OCD is more disturbing and senseless than everyday worries. The following case describes a 11-year-old boy who had developed intrusive thoughts and images of his family dying, post-mortem being performed on them, and associated compulsive behaviours such as reassurance seeking and performing namÄz. The treatment plan and its components are surmised.

Keywords: Obsessive-compulsive disorder, trauma, death

Background

Post-traumatic obsessive-compulsive disorder is increasingly recognized as a distinct subtype of obsessive-compulsive disorder (OCD) by researchers. OCD is a neuropsychological phenomenon characterized by intrusive, repetitive thoughts or images and associated uncontrollable need to perform repetitive acts [1]. In a lot of pediatric cases, OCD closely follows a traumatic event that had elicited high level of disgust or fear [2,3]. However, recent findings have pointed to the western and non-western population deviating in the precursors. In the western population, substance abuse is the trigger unlike trauma for the eastern population [4]. The post-trauma subtype is also marked by a distinct neurocognitive functioning [5]. Our case represents a 11-year-old boy diagnosed with post-traumatic obsessive-compulsive disorder, the fascinating factors that precipitated the onset of symptoms, and the treatment provided.

Case Presentation

A 11-year-old male, Muslim, studying sixth standard, had been referred to the Psychiatric department due to complaints of repetitive intrusive thoughts and images regarding family dying for the past 3-4 days, reassurance seeking, fear of death, headache, and crying spells for the past 11 days. The symptoms had begun after overhearing his mother (nurse) talk on call with her colleague early morning regarding the sudden death of a known individual, causes unknown, and postmortem that’ll be performed for them. He had been fearful the next two days after which he developed intrusive thoughts which progressed to an experience like hearing a voice that said that he and his family will die, postmortem will be done, and they will experience a lot of pain. Although he can listen in class, these thoughts are always noted to be in the background. He would repeatedly ask his parents ‘Will everybody die?’. When he expresses these concerns, he experiences a reduction in anxiety. Occasionally, when the symptoms worsen, he starts performing namaz and/or crying. The presentations were further explored, and a detailed history was obtained. Since the start of the pandemic, repeated handwashing, and obsessive cleaning were present. He also had history of preoccupation/concern related to death. When his mother had to undergo a complicated delivery 11 months back, he was highly concerned for her health. Similarly, four months back when his grandfather passed away, he had come up with a lot of questions related to death. After the phone call incident, whenever he was around his parents or brother, he would get intrusive thoughts about them dying and undergoing a postmortem. When watching TV sometimes there would be scenes related to death, he would close his eyes and avoid seeing it. The thoughts were most predominant when he was alone. Psychometric assessments were conducted which involved Y-BOCS, SCT, and TAT. He was diagnosed with obsessive-compulsive disorder with trauma as the precipitating factor for his recent symptoms. His treatment involved Pharmacotherapy and Cognitive Behavior Therapy (CBT)/ Exposure Response Prevention (ERP). Family Inclusive Treatment with parents involved psychoeducation, discouraging reassurance being given to the child or any advice, and teaching ways to handle various behaviors. After just two sessions (Table 1) with the child there was a drastic reduction in symptoms. On follow-up it was observed that he was maintaining well.

Table 1: Psychological intervention

PSYCHOTHERAPY

Session 1

Externalizing OCD, calling it an enemy – the child named it ‘Satan’
Creating the distress hierarchy
Modifying/reducing compulsions
Addressed avoidance behaviors and taught coping statements

Session 2

Explained the ride up and down the worry hill concept
Used a Race analogy with patient’s favorite car Ferrari
Taught to use coping statements for obsessive thoughts. E.g., ‘if anything happens, we will go to the hospital and get treatment’

Table 2 Fear ladder

Trigger Situation	SUDS (%)
When alone	100
When sitting near parents	90
When watching TV and coming across scenes of funeral or accident	90
When seeing a lorry/ambulance outside	80
When engaging in studies/writing	70
When with brother	50

Discussion

Trauma and OCD have a long history of co-occurrences. Obsessive-compulsive disorder and post-traumatic stress disorder, both anxiety-based disorders, share some common characteristics such as exaggerated perceptions of threat, intrusive memories, and avoidance behaviors. Two common factors have been identified to play a predominant role in the inception and sustenance of such disorders, namely threat acquisition/conditioning and extinction. In a lot of OCD cases, trauma had been a precursor. Sometimes, the relationship may be wrongly oversimplified to make it seem like trauma was the only reason for developing the disorder. Although in the present case the boy had developed new compulsions after the trauma, it was not the starting point of his symptoms. He had already been engaging in cleaning compulsions during the pandemic. Despite the pandemic itself being a fear-provoking situation, there seems to be a pattern of symptoms engendered by some incident. This points to a clear genetic disposition to the disorder. Lafleur et al. [6] study on this link arrived at a similar conclusion that trauma was a significant coefficient for OCD (60%) after heritability which is estimated at 30-40% [7]. A review paper on OCD and trauma streamlined this link to distress threshold [8]. Some individuals with genetic predisposition are bestowed with lower distress tolerance threshold and may end up using maladaptive coping strategies. This highlights the importance of parenting, teaching the child proper coping methods when it is noticed that they are unable to cope with certain adverse events.

There have been other such cases reported in literature. One such case series in the Indian population similarly followed post-traumatic OCD in 17 patients, three of them aged less than 18yrs [9]. A significant number of the patients had developed OCD after death related trauma, but unlike ours it wasn’t anticipatory and thus grief-focused interventions were provided. The nature of the trauma must hence to be considered carefully while designing interventions.

Exposure Response Prevention (ERP), moving beyond the Emotion Processing Theory, helps in extinction learning and retention using multiple strategies. Start with externalizing the symptoms which has proven to a highly effective and appropriate technique for children. It builds self- confidence in the child, which also helps in treatment adherence. The following are some methods that can be used in the pediatric population to assist the inhibitory learning process [10].

Expectancy violation: Helping the child identify if the obsessive fear occurs as expected through exposure.
Stimulus variability: Introducing variability in stimuli can help inhibitory learning.
Elimination of ‘safety signals’: Preventing the child from using ritualized methods for self-comfort such as mental negation or reassurance from parents.
Compound extinction: Combining multiple triggers into one exposure experiment.

Finally, it is important to distinguish thoughts and voices in juvenile cases. Most often children come with complaints of hearing a voice, but when probed further it would be identified as intrusive thoughts. This perception could be due to the high ego-dystonic nature of the content. This is not to be mistaken for hallucinations. Thus, obtaining an elaborate case history and careful analysis is requited for accurate diagnosis.

Conclusion

Trauma, when a pertinent factor in OCD, must be analyzed carefully for effective utilization in treatment. While some may benefit from grief-oriented therapy, it may not be suitable for all. Externalizing the symptoms and following it up with a variety of extinction learning and retention strategies can prove to be effective. When tailored specifically for the case, resolution can be achieved swiftly as seen in our case. Parents must be vigilant for child’s coping methods and assist them in building appropriate strategies.

Acknowledgements

None.

Competing interest

None.

Consent

Verbal consent was obtained from the mother for the report.

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