When obsessive-compulsive symptoms are a red flag

Contemporary PEDS JournalVol 36 No 3
Volume 36
Issue 3

Teenagers who display certain obsessive-compulsive symptoms, even without a diagnosis of obsessive-compulsive disorder (OCD), may be at higher risk for other serious psychiatric problems.

headshot of Ran Barzilay, MD, PhD

Ran Barzilay, MD, PhD

Prevalence of obsessive-compulsive symptoms-maybe not enough to warrant an official diagnosis-are more common than clinicians may think and could lead to more serious psychological issues, particularly in teenaged girls, a new report reveals.

The study, published in the Journal of the American Academy of Child and Adolescent Psychiatry,1 reviewed the prevalence of self-reported obsessive-compulsive symptoms in more than 7000 teenagers to find patterns that might raise red flags for further psychiatric evaluation. Participants in the study underwent psychiatric interviews, including screening for obsessive-compulsive symptoms. The research team found that obsessive-compulsive symptoms were common in 38.2% of the cohort who did not seek mental health care, but only 3% met the threshold for a diagnosis of obsessive-compulsive disorder (OCD). Overall, these symptoms were most common in females after puberty.

Ran Barzilay, MD, PhD, a child and adolescent psychiatrist and research associate at the Lifespan Brain Institute at the Children’s Hospital of Philadelphia, Pennsylvania, and University of Pennsylvania Perelman School of Medicine, Philadelphia, led the study along with Raquel Gur, MD, PhD, director of the Lifespan Brain Institute. Gur established the Philadelphia Neurodevelopmental Cohort (PNC) used to complete the study.

“Whereas for most these symptoms are not associated with serious psychiatric conditions, some obsessive-compulsive symptoms are associated with serious psychiatric conditions like depression, suicide ideation, and psychosis,” Barzilay says. “Specifically, we found that intrusive bad thoughts-violent, sexual, thoughts of having done/said something wrong-are associated with serious psychiatric conditions. Other obsessive-compulsive symptoms, such as those related to cleaning and/or contamination, are relatively benign.”

When obsessive-compulsive becomes OCD

Obsessive-compulsive symptoms are characterized by repetitive thoughts, urges, or mental images and/or repetitive behaviors, according to the report, and these symptoms can become intrusive and debilitating in some cases. Formal diagnosis of OCD affects 2% to 4% of all children and adolescents but goes undetected in as many as 90% of cases, the study notes.

Although repetitive and ritualistic behaviors are part of normal child development, as children age these behaviors may no longer be needed to reach age-appropriate goals later in childhood. Also, whereas these behaviors do decrease in most children as they reach the teenaged years, the studies show a surge in obsessive-compulsive symptoms around eighth grade. The research team also notes that for adult-onset OCD, symptoms typically begin in the teenaged years and can present with other psychiatric comorbidities, such as depression, psychosis, and suicidal thoughts. For adolescents, obsessive-compulsive symptoms also have been associated with decreased school and behavioral function.

The goal of the study was to evaluate the prevalence and heterogeneity of obsessive-compulsive symptoms, as well as to identify patterns in obsessive-compulsive symptom presentations that might warrant further evaluation or intervention. The study is the first and largest to evaluate obsessions and compulsions, as well as their comorbidities, spanning both prepubescent and postpubescent age groups. Overall, almost 40% of the teenagers studied endorsed at least 1 obsession or compulsion. Those who endorsed these symptoms had a higher prevalence of depression, psychosis, and suicidal ideation, as well as lower levels of global function, according to the report.

The symptoms were classified into 4 groups-bad thoughts, repeating or checking, symmetry, and cleaning or contamination. Bad thoughts were especially associated with serious psychopathy beyond obsessive-compulsive behaviors, according to the report, whereas cleaning and contamination were not.

The research team suggests these results may indicate that behaviors of the bad-thoughts variety may be used in the future to flag an individual as at risk for major psychiatric conditions including a formal OCD diagnosis, depression, psychosis, or suicidal ideation. Specifically, the report suggests that screening for specific symptoms in the bad-behaviors category might be important for assigning risk levels to patients with these symptoms who are at a higher risk for serious psychiatric conditions. Further research is needed to make specific clinical guidelines, the report notes.

What clinicians should do

Barzilay says it’s important to note that the study is not about having an OCD diagnosis but having obsessive-compulsive symptoms and how these symptoms might relate to other serious psychiatric conditions in young persons in some cases.

“Obsessive-compulsive symptoms are common but for most do not mean that the child/adolescent has OCD,” he says. “Clinicians should be aware that some obsessive-compulsive symptoms, specifically bad intrusive thoughts, are associated with serious psychiatric conditions and, therefore, it might be prudent for clinicians to actively probe for these symptoms, and if present consider them as a flag that requires more thorough psychiatric evaluation.”

Barzilay says he hopes the study will raise awareness about these symptoms for pediatricians and help them recognize when more evaluation or intervention is needed.


“Just being aware of how common obsessive-compulsive symptoms are and probing for their presence may be important for pediatricians, especially concerning bad intrusive thoughts,” Barzilay says. “Once a clinician becomes aware of the presence of obsessive-compulsive symptoms, it can be a ‘window’ through which he or she can probe for more serious psychiatric conditions and facilitate early intervention or prevention of conditions like depression.”



1. Barzilay R, Patrick A, Calkins ME, et al. Obsessive-compulsive symptomatology in community youth: typical development or a red flag for psychopathology? J Amer Acad Child Adolesc Psychiatry. 2018. In press. Available at: https://www.jaacap.org/article/S0890-8567(18)31975-0/fulltext. Accessed February 2, 2019.

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