Atypical Symptom Presentations in Pediatric OCD

little girl sitting in dark hallway
little girl sitting in dark hallway
Unexpected presentations of OCD can put children at risk of receiving diagnoses or treatments that do not address their underlying obsessions.

Some children with obsessive compulsive disorder (OCD) present with atypical symptoms that are not represented in the Children’s Yale Brown Obsessive Compulsive Scale symptom checklist and/or lead to unexpected behaviors that cannot readily be identified as OCD-related, thereby putting them at risk of receiving diagnoses or treatments that do not address their underlying obsessions. Two of these categories of atypical symptoms are illustrated in a study recently published in Comprehensive Psychiatry.

The study sought to describe 2 distinct types of atypical symptom presentations found in 24 children with OCD, showing how these symptoms are part of a larger clinical picture, rather than a feature of an alternate condition such as psychosis or autism spectrum disorder. 

Twelve of the children had obsessions rooted in a primary sensory experience (such as auditory, olfactory, or tactile) that they found intolerable and which was sometimes linked to specific people or objects. To soothe or avoid the associated sensory discomfort, patients were driven to engage in time-consuming repeated behaviors. Many of these patients struggled with ordinary activities such as eating or wearing clothing and can be at risk of seeming to exhibit symptoms of autism spectrum disorder, especially when the patient has a level of self-awareness that leads them to conceal the obsession behind the behaviors.

The other 12 children had obsessions rooted in people, times, or places they viewed as disgusting, abhorrent, or horrific, and which led to contamination fears connected to any actions or thoughts they saw as related to these obsessions. These kinds of contamination obsessions could result in concrete contamination concerns but more often resulted in abstract, magical-thinking fears of specific, highly ego-dystonic states of being. When the fear was a reaction to a particular individual or individuals, the obsession most often resulted in avoidance behaviors designed to placate a fear of acquiring a characteristic or trait of the individual by contagion. Patients exhibiting these symptom presentations are at risk of being diagnosed with psychosis.

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Study investigators conclude, “[awareness] of the broader spectrum of obsessional ideation related to abhorrent experiences and sensory discomfort as drivers of compulsive behaviors will facilitate recognition of these more obscure forms of OCD in youth. Future revisions of our nosology should include categories for primary sensory integration disorders because, until they are more formally recognized, their prevalence and potential for clinical impairment will remain unclear.”

Disclosures: Dr Geller has received funding from the NIMH, the American Academy of Child and Adolescent Psychiatry, American Psychiatric Press, Eli Lilly, Pfizer, Glaxo Smith Kline, Forest, Neurocrine Bioscience, Biohaven and the PANDAS Network. Ms Porth has no conflicts to report.


Porth R, Geller D. Atypical symptom presentations in children and adolescents with obsessive compulsive disorderCompr Psychiatry. 2018;86:25-30. doi:10.1016/j.comppsych.2018.07.006