How Does Obsessive-Compulsive Disorder Develop in Young People?

What you need to know

• Obsessive-compulsive disorder (OCD) often develops during adolescence, a time of significant brain development.
• Research suggests juvenile OCD involves difficulties with complex decision-making and adapting to changes, rather than simple learning or reward processing.
• A proposed framework links these cognitive difficulties to disruptions in the development of brain systems for complex reasoning and decision-making.
• Understanding how OCD emerges during adolescence could lead to better early detection and treatment approaches.

Understanding OCD in Young People

Obsessive-compulsive disorder (OCD) is a mental health condition characterized by intrusive, distressing thoughts (obsessions) and repetitive behaviors or mental acts (compulsions) that a person feels driven to perform. While OCD can affect people of all ages, it often first appears during adolescence. In fact, about 25% of all OCD cases begin by age 14. This timing is significant because adolescence is a period of major brain development and reorganization.

Despite the importance of understanding how OCD develops in young people, most OCD research has focused on adults. This review aims to bring together what we know about OCD in adolescents, how it compares to adult OCD, and how it relates to normal brain development during the teenage years.

Decision-Making and Learning in OCD

One might expect that people with OCD would show clear differences in how they make decisions or learn from rewards and punishments. However, research findings in this area have been mixed.

Some studies have found that adults with OCD are more risk-averse, meaning they’re more likely to avoid potential losses even if it means missing out on potential gains. However, other studies, including some with adolescents who have OCD, haven’t found this pattern. Instead, research suggests that people with OCD may have more subtle differences in how they process rewards and make decisions.

For example, some studies have found that people with OCD are less sensitive to rewards, or that they make more random choices when it comes to potential gains. These patterns have been seen in both adults and adolescents with OCD.

When it comes to learning from experience, the findings are also mixed. Some studies have found that people with OCD take longer to adjust their behavior when the rules of a task change. However, this finding hasn’t been consistent across all studies, especially in research with adolescents who have OCD.

Complex Decision-Making and Flexibility

While simple decision-making and learning tasks often don’t show clear differences in OCD, more complex tasks tend to reveal difficulties. People with OCD, both adults and adolescents, often struggle with tasks that require them to shift between different strategies or to build a complex understanding of how a task works.

For example, people with OCD often have trouble with “set-shifting” tasks, where they need to switch from one rule to another. They also tend to have difficulties with planning tasks and with tasks that require them to learn complex patterns of cause and effect.

These difficulties seem to be specific to OCD and are not seen in the same way in other mental health conditions. For instance, people with depression or schizophrenia often show difficulties with simpler aspects of these tasks, while people with OCD struggle more with the most complex parts.

This pattern suggests that OCD might involve problems with building or using complex mental models of how things work, rather than simpler issues with learning or decision-making.

Habits and Compulsions

OCD is often associated with repetitive behaviors that seem habitual. Some researchers have suggested that OCD might involve an imbalance between habitual behavior and goal-directed behavior.

Studies with adults have found some evidence that people with OCD are more likely to keep following a learned behavior even when it’s no longer rewarded. This has been interpreted as evidence of stronger habit formation. However, recent research has questioned whether these tasks really measure habits in the way we thought they did.

An alternative idea is that people with OCD might have trouble switching between habitual and goal-directed behavior as needed. This could explain why they sometimes get stuck in repetitive behaviors even when they know these behaviors aren’t helpful.

Interestingly, while this area has been studied quite a bit in adults with OCD, there’s very little research on habit formation in adolescents with OCD. This is an important gap, because understanding how these patterns develop could help us understand whether excessive habits are a cause or a consequence of OCD.

Indecisiveness and Information Gathering

People with OCD often report difficulty making decisions. This has been studied using tasks where people can gather as much information as they want before making a choice.

In these tasks, both adults and adolescents with OCD tend to gather more information before making a decision. This pattern of “indecisiveness” seems to be specifically related to OCD symptoms, rather than to anxiety or depression more broadly.

Recent research using computational modeling (a method for simulating mental processes) suggests that this indecisiveness might be due to a reduced sense of urgency in decision-making. In other words, people with OCD might not feel the same pressure to make a decision quickly that most people do.

Confidence and Metacognition

Another area of interest is how people with OCD judge their own thoughts and decisions. Many studies have found that adults with OCD report lower confidence in their decisions across various types of tasks.

This low confidence seems to be related to OCD symptoms. For example, giving people false feedback to lower their confidence can increase doubts and checking behaviors similar to those seen in OCD.

However, it’s not just about overall low confidence. Recent research suggests that people with OCD might have trouble accurately judging how well they’re performing on a task. This ability to evaluate our own mental processes is called metacognition.

Interestingly, while these patterns have been well-studied in adults with OCD, there’s very little research on confidence and metacognition in adolescents with OCD. This is an important area for future research, as understanding how these patterns develop could help explain how OCD emerges.

Brain Changes in Juvenile OCD

Studies of brain structure and function in adolescents with OCD have found differences primarily in circuits connecting the frontal lobes and the striatum, a part of the brain involved in learning and decision-making.

One key area that shows alterations in juvenile OCD is the dorsomedial prefrontal cortex, including the dorsal anterior cingulate cortex. This region is involved in monitoring our actions and their outcomes. In adolescents with OCD, this area often shows increased activity, particularly when processing errors or unexpected outcomes.

Other areas that show differences in juvenile OCD include the orbitofrontal cortex and adjacent regions, as well as the striatum. These areas are involved in complex decision-making, inhibitory control (the ability to stop or change an action), and processing rewards.

Importantly, all of these brain areas undergo significant development during adolescence in typically developing individuals. Recent research has found that adolescents with high levels of OCD symptoms show reduced growth in some of these areas compared to their peers.

A New Framework for Understanding Juvenile OCD

Based on these findings, the authors propose a new framework for understanding how OCD develops in young people. This framework suggests that OCD might involve disruptions in the development of brain systems for complex reasoning and decision-making.

The framework proposes that the brain contains multiple systems for reasoning and decision-making, ranging from simple to complex. These systems develop at different rates, with the most complex systems maturing last, during adolescence.

In OCD, the development of these complex reasoning systems might be disrupted. This could explain why people with OCD often struggle with complex decision-making tasks, but not simpler ones.

The framework also suggests that there might be problems with how these different reasoning systems are coordinated. This could explain why people with OCD sometimes get stuck in repetitive behaviors even when they know these behaviors aren’t helpful.

Conclusions

• OCD often emerges during adolescence, a time of significant brain development.
• Research suggests that juvenile OCD involves difficulties with complex decision-making and adapting to changes, rather than simple learning or reward processing.
• These cognitive difficulties might be linked to disruptions in the development of brain systems for complex reasoning and decision-making.
• More research is needed to understand how patterns of confidence and metacognition develop in adolescents with OCD.
• Understanding how OCD emerges during adolescence could lead to better early detection and treatment approaches.

This new framework provides a way to bring together findings from different areas of research on OCD. It also suggests new directions for future research, particularly in understanding how OCD develops over time in young people. By better understanding this process, we may be able to develop more effective ways to identify OCD early and provide targeted treatments.