My child who has OCD has the most horrendous rages. Why is this?
Anger in children who have OCD is not unheard of. Rage Attacks in Paediatric Obsessive-Compulsive Disorder was a study done recently to examine how rage manifests in kids with OCD. The study says that routine assessments are helpful since “rage contributes to impairment over and above obsessive-compulsive symptom severity and may be related to worse prognosis and treatment outcome.”
I find that NOT accommodating my child’s rituals triggers his rage. What causes this to happen?
Not assisting with a child’s rituals is one thing that will initially increase their anxiety, and when this goes off the scale, extreme anger can follow, but the rage, as the study suggests, is actually a demonstration of intense fear. Often, it is easy to give in to prevent the rage and reduce a child’s fears; however, complying with OCDs rules doesn’t give them the chance to disprove their fears.
But I sometimes have to comply given that my child’s rages are potentially dangerous.
Yes, this is understandable, especially when it involves possible harm to themselves, or others. For this reason the study reinforces that treatment needs to be tailored to a child’s unique clinical needs, and to determine if the rage attacks are a bi-product of OCD and not something else.
What is meant by a bi-product of OCD?
Research says that there are two types of anger (D. S. Wheeler). These are instrumental and reactive (Dr. McKinnie Burney). The study points out that instrumental anger is defined as a negative emotion that is expressed as delayed or hidden. This involves a planned goal of revenge usually motivated by some memory of a past hurt or aggravation. By contrast, reactive anger comes out as an overt response. This is seen as an immediate angry response that usually pertains to a perceived threatening or fear provoking event. Reactive anger is what is commonly seen in a child who feels under obsessional threat, among other factors.
I’m pretty sure my son’s anger is reactive due to obsessional triggers, but how can I be sure?
Practitioners and researchers use an Anger Assessment Rating Scale (AARS), which is an anger assessment instrument developed to measure the intensity and frequency of anger expression in adolescents. If this assessment hasn’t been carried out, this can be discussed with your child’s treatment team. Angry outbursts are also seen in children who have attention deficit hyperactivity disorder (ADHD) and oppositional defiance disorder (ODD). These would be taken into account during diagnostic assessment, hence anger being either a bi-product of OCD or ADHD, ODD, co-morbidity or something else, such as meltdowns observed in children who are on the autism spectrum.
What does a unique treatment package involve?
This involves cognitive behavioural therapy (CBT) with exposure response prevention (ERP). Cognitive therapy teaches emotion-management strategies to help diffuse high levels of anger. It also helps with faulty interpretations that a child attaches to their intrusive thoughts – e.g., “I had a harming thought, this must mean I’m a bad person.” Cognitive therapy is the foundation for starting ERP – ERP is the behavioural side of CBT. If a child’s OCD symptoms are moderate-severe, or if they are depressed, medication might also be administered as part of their treatment package. This is usually a selective serotonin reuptake inhibitor (SSRI) which helps balance serotonin levels. Once this kicks in and depression lifts and/or OCD symptoms are passively reduced then CBT/ERP treatment usually has better results.
How else would you describe faulty interpretations and how to correct these?
Here is a further example.
Faulty interpretation: “My mother put dirty laundry in the washing machine and didn’t wash her hands afterwards. Then she touched me and I kept thinking that everyone’s germs from the clothes and washing machine had transferred on to me (thinking error); It felt like germs were crawling all over me and I needed to decontaminate for two hours (faulty belief) but my mother called time on my shower and it sent me into a rage (low frustration tolerance).”
Alternative interpretation: “My mother put dirty laundry in the washing machine and didn’t wash her hands afterwards; and then she touched me. It’s highly unlikely that germs passed from the clothes and washing machine onto her hands and then to me (thinking error corrected). It felt like germs were crawling all over me, yet feelings are not based on hundred percent factual evidence (healthier belief). I can shower, then let my mother call time because this will teach me to tolerate the germy feeling until it subsides. By bearing with associated anxiety until the symptoms reduce naturally will eventually help decrease my urge to compulsively decontaminate (increased frustration tolerance).”
Can you expand on the meaning of decreased and increased frustration tolerance?
Yes, low frustration tolerance is a behavioural challenge for children who have OCD and/or anger management problems. Children believe that if something is too hard to handle they cannot do it. In OCD a child hasn’t yet learned to build distress tolerance. So when family members resist colluding with a child’s rituals they will be more likely to demonstrate reactive anger, and until they build distress tolerance.
Can you give a summary of how ERP works?
Yes, what happens is that a child agrees to face their listed fears one at a time (exposure) while resisting the urge to ritualise (response prevention). As they continue to do this in graded steps they start to understand that they are able to manage the anxiety associated with their fear-related obsessions, which builds distress tolerance. When anxiety and fear is better managed frustration tolerance also increases.
A recent study examined how rage manifests in children who have OCD. The ARRS rating scale can help determine if the anger is instrumental or reactive. Co-morbidity sometimes occurs where for example OCD and another condition might occur together. Still treatment to address anger in children who have OCD with or without overlapping problems includes CBT with ERP, medication, and anger management.
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