SCOTT CLACK, BSc, ND

Dr. Scott Clack is the founder of Touchstone Naturopathic Centre, Oakville, Ontario

Parents of children with obsessive compulsive behaviors often tell me that their greatest concern is the antisocial impact. They worry that their child’s hyper-focus on topics or activities that don’t interest most other children will leave them subject to bullying, or being isolated during school or extracurricular activities. The behaviors can also affect life in the home, among family members, and in interactions with the extended family.

Obsessive compulsive disorder (OCD) is known to affect 1–3%¹⁵ of the general population. Patients’ symptoms are characterized by obsessions (recurring and/or persistent thoughts, urges, or images that affect their daily lives and interactions with others) and/or compulsions (repetitive behaviors that an individual feels compelled to perform in response to an obsession or according to rules that must be rigidly applied). In some cases the behaviors are ritualistic. Onset of OCD is often reported in childhood between the ages of 7 to 10 years, with a second group tending to experience onset of symptoms after puberty.

If there is sudden “overnight” onset of initial OCD symptoms, the case may be classified as PANDAS (pediatric autoimmune neuropsychiatric disorder associated with streptococcus) or PANS (pediatric acute neuropsychiatric syndrome). In “typical” OCD, the onset of symptoms is more gradual.

OCD is described as a chronic disorder with a fluctuation of symptoms (waxing and waning), even if an episodic course is described in some cases. Some patients will have good and bad days, while others may experience periods of remission only to have symptoms return later. OCD cases may present with other symptoms or disorders: anxiety, depression, autism and eating disorders are commonly reported.⁸

Our integrative team approach

At Touchstone Naturopathic Centre, our practitioner team members—a naturopathic doctor, holistic nutritionist, and acupuncturist—coordinate efforts to treat a variety of pediatric developmental disorders, ranging from autism to ADHD, learning disabilities, OCD, and tics or Tourette syndrome. All developmental conditions are considered to be multi-factorial in origin, meaning that there is no single cause and likely no single treatment that will resolve the child’s problems or behaviors. It’s necessary to consider genetic (i.e. genomic) ^5,8 influences, metabolic dysfunction, as well as lifestyle (diet, sleep) and environmental factors including toxic exposures and bioaccumulation (infections, heavy metals, chemicals).

Each case is carefully examined to learn whether the child is producing appropriate neurotransmitters, if their methylation and detoxification function is suboptimal or impaired, and if mitochondrial function is interfering with normal biochemistry.

We have treated many children for OCD. In some cases this is the main complaint, but often OCD symptoms are part of a more complex psychiatric or neurodevelopmental condition. Taking a detailed health history usually provides important clues to one or more underlying causes for OCD. Most cases will require a comprehensive treatment approach, based on testing and clinical history, to support a child’s innate ability to heal and overcome the challenges of OCD. Integrated behavioral therapy will be important in some cases.

Assessment, analysis and treatment

In our practice, the initial patient assessment usually includes a physical examination and select lab work. The initial tests often recommended are Organic Acids Test, IgG food sensitivity testing, complete blood count (CBC), assessments for iron/ferritin, calcium, magnesium, vitamin D and zinc levels, plus Antistreptolysin O (ASO) titers and Anti-DNase B if the marker is available (currently not available in Ontario, Canada).

As treatment progresses, in the event there is minimal improvement, the child will be tested for heavy metal exposure and bioaccumulation. If the child has obvious and significant digestive symptoms, a Comprehensive Stool Analysis test is recommended. If digestive symptoms are mild or absent but there is a history of frequent antibiotic use, a stool microbiology panel is ordered to assess levels of probiotic bacteria and potential bacterial or yeast pathogens.

Streptococcal infections appear to be a prime trigger for acute onset of OCD¹⁵ and tics/Tourette’s in 60-70% of children treated at Touchstone. The diagnosis of PANDAS or PANS is slowly gaining greater acceptance in the medical system thanks to research that links various test markers (ASO, anti-basal ganglia antibodies,¹ antineuronal antibodies, antienolase)¹² with patient symptoms.  Currently a diagnosis is made on the basis of symptoms and coincidence with Streptococcus (GAS) infections. At Touchstone, patients with OCD who are known to have had (or are suspected of having) strep infections associated with their OCD are treated with botanical medicines (goldenseal,^11,16 olive leaf extract),² homeopathic remedies or nosodes, and acupressure rebalancing (the NAET approach). A similar approach was previously featured in the article “Success! Naturopathic Treatment for Severe OCD, Anxiety, ADHD and Tourette’s” on Latitudes.org.

Myo-inositol is one of the most effective natural supplements used in cases where OCD⁴ behaviors develop. The challenge can be finding the appropriate dose, which ranges from 3 to 12, and possibly up to 18 grams per day. Inositol is directly involved in serotonin and dopamine activity, a root problem in OCD. Fortunately its sweet taste and availability in powder make it a relatively easy supplement to administer, especially for younger children.  N-acetyl cysteine (NAC) has been showing positive results for OCD in recent years.¹⁴ The primary action of NAC is on the glutaminergic pathways. It is also reported to help in many psychiatric or neurologic cases where patients are not responding well to typical treatments.

Most children with OCD we see in our clinic have low iron stores (i.e. ferritin), and concurrently suffer from food intolerances and yeast and/or bacterial overgrowth in the GI tract. Dietary modifications involve an elimination diet based on the IgG results. A 2012 case study⁶ outlined a successful outcome for a young patient with OCD who eliminated gluten in his diet, improving up to 75 to 90% of his normal behavior state (other integrative treatments were also given to this patient).  It should be noted that the 7-year-old boy in this case report was determined to have gluten sensitivity, not celiac disease. See the full article  Integrative Medicine Approach to Pediatric Obsessive Compulsive Disorder and Anxiety: A Case Report.  

Other dietary advice that is strongly recommended to families include eliminating food additives and dyes, increasing intake of vegetables to eight servings per day, and optimizing  consumption of organic, non-GMO fruits, vegetables and meats.

If digestive symptoms are reported, digestive enzymes, probiotic supplements, and GI healing formulas (botanical/nutritional supplements such as licorice, marshmallow, L-glutamine) are recommended. This approach emphasizes the importance of repairing the natural gastrointestinal barrier to aid in reducing food sensitivities and restoring the gut/brain connection. When indicated, children are encouraged to take an omega-3 supplement, iron, and zinc.¹⁸  Iron, tyrosine (an amino acid), zinc and vitamin C are important for dopamine synthesis which can impact temperament and adrenal function. Zinc is also important for proper digestion, as it stimulates stomach acid secretion.

The need for other supplements that support neurotransmitter, methylation and transsulfation metabolism will be indicated by the Organic Acids test. These supplements could include vitamin B6 (or PLP/P5P), 5-MTHF (or folinic acid), methylcobalamin,¹⁷ tyrosine, methionine, magnesium¹⁰ and calcium. Methylcobalamin is often prescribed to be given by subcutaneous injections to children with autism following biomedical protocols; this could be a consideration in OCD if the methylmalonic acid levels (OAT) are significantly elevated. Liposomal methylcobalamin supplements are more readily available and can effectively boost methylation without injections. Deficiencies in trace elements are considered to play a critical role in serotonin and dopamine signaling.¹⁰

Homeopathic therapies

Homeopathic remedies and formulas are recommended in most cases, and can be important when other treatments lead to suboptimal results. Homeopathic remedies for chronic conditions need to be individualized; there is not a one-size-fits-all. Recently a patient reported significantly reduced tics after taking the homeopathic remedy Zincum metallicum. Other top constitutional homeopathic remedies considered for OCD include Hyoscyamus, Nux vomica, Medorrhinum, and Pulsatilla. The streptococcinum nosodes, given in 200CH, 1M and 10M potencies over several weeks, may be essential in cases that herbal medicines or antibiotics have helped but have not completely resolved the situation. The use of the nosode reflects one of the key homeopathic principles, of “like curing like.”

As a final comment, it is important that parents understand that treatment and recovery can be a long-term process. Depending on the situation, cases may require 12 (or more) months of treatment for full recovery. While positive improvements can usually be noted within the first 2-3 months, families should be prepared for temporary setbacks signaling that treatment isn’t complete. Future treatment options at Touchstone, to help non- or partial-responders, is to investigate the effects of allergies and environmental toxin exposures (e.g., phthalates, pesticides, BPA) on the mechanisms behind OCD.

References:

1. Aguilera-Albesa S,Crespo-Eguílaz N, Del Pozo JL, Villoslada P, Sánchez-Carpintero R. Anti-Basal Ganglia Antibodies and Streptococcal Infection in ADHD. J Atten Disord. 2015 Apr 16.
2. Ali NH, Faizi S, Kazmi SU.Antibacterial activity in spices and local medicinal plants against clinical isolates of Karachi, Pakistan. Pharm Biol.2011 Aug;49(8):833-9.
3. Atmaca M, Tezcan E, Kuloglu M, Kirtas O, Ustundag B. Serumfolate and homocysteine levels in patients with obsessive-compulsive disorder. Psychiatry Clin Neurosci. 2005 Oct;59(5):616-20.
4. Camfield DA,Sarris J, Berk M. Nutraceuticals in the treatment of obsessive compulsive disorder (OCD): a review of mechanistic and clinical evidence. Prog Neuropsychopharmacol Biol Psychiatry. 2011 Jun 1;35(4):887-95.
5. Cappi C,Brentani H, Lima L, Sanders SJ, Zai G, Diniz BJ, Reis VN, Hounie AG, Conceição do Rosário M, Mariani D, Requena GL, Puga R,Souza-Duran FL, Shavitt RG, Pauls DL, Miguel EC, Fernandez TV. Whole-exome sequencing in obsessive-compulsive disorder identifies rare mutations in immunological and neurodevelopmental pathways. Transl Psychiatry. 2016 Mar 29;6
6. Couture DC, Chung MK, Shinnick P, Curzon J, McClure MJ, LaRiccia PJ. Integrative Medicine Approach to Pediatric Obsessive-Compulsive Disorder and Anxiety: A Case Report. Glob Adv Health Med.2016 Jan;5(1):117-21.
7. Cunningham MW, Cox CJ. Autoimmunity against dopamine receptors in neuropsychiatric and movement disorders: a review of Sydenham chorea and beyond. Acta Physiol (Oxf).2016 Jan;216(1):90-100.
8. den Braber A,Zilhão NR, Fedko IO, Hottenga JJ, Pool R, Smit DJ, Cath DC, Boomsma DI. Obsessive-compulsive symptoms in a large population-based twin-family sample are predicted by clinically based polygenic scores and by genome-wide SNPs. Transl Psychiatry. 2016 Feb 9;6
9. Goodwin GM. The overlap between anxiety, depression, and obsessive-compulsive disorder. Dialogues Clin Neurosci.2015 Sep;17(3):249-60.
10. Grimaldi L. The central role of magnesium deficiency in Tourette’s syndrome: causal relationships between magnesium deficiency, altered biochemical pathways and symptoms relating to Tourette’s syndrome and several reported comorbid conditions. Med Hypotheses.2002 Jan;58(1):47-60.
11. Hwang BY, Roberts SK, Chadwick LR, Wu CD, Kinghorn AD. Antimicrobial constituents fromgoldenseal (the Rhizomes of Hydrastis canadensis) against selected oral pathogens. Planta Med. 2003 Jul;69(7):623-7.
12. Nicolini H, López Y, Genis-Mendoza AD, Manrique V, Lopez-Canovas L, Niubo E, Hernández L, Bobes MA, Riverón AM, López-Casamichana M, Flores J, Lanzagorta N, De la Fuente-Sandoval C, Santana D. Detection of anti-streptococcal, antienolase, and anti-neural antibodies in subjects with early-onset psychiatric disorders. Actas Esp Psiquiatr.2015 Mar-Apr;43(2):35-41. Epub 2015 Mar 1.
13. Nissen JB,Hansen CS, Starnawska A, Mattheisen M, Børglum AD, Buttenschøn HN, Hollegaard M. DNA Methylation at the Neonatal State and at the Time of Diagnosis: Preliminary Support for an Association with the Estrogen Receptor 1, Gamma-Aminobutyric Acid B Receptor 1, and Myelin Oligodendrocyte Glycoprotein in Female Adolescent Patients with OCD. Front Psychiatry. 2016 Mar 18;7:35.
14. Oliver G,Dean O, Camfield D, Blair-West S, Ng C, Berk M, Sarris J. N-acetyl cysteine in the treatment of obsessive compulsive and related disorders: a systematic review. Clin Psychopharmacol Neurosci. 2015 Apr 30;13(1):12-24.
15. Orefici G,Cardona F, Cox CJ, Cunningham MW. Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal Infections (PANDAS). In: Ferretti JJ, Stevens DL, Fischetti VA, editors.  “Streptococcus pyogenes: Basic Biology to Clinical Manifestations” [Internet]. Oklahoma City (OK): University of Oklahoma Health Sciences Center; 2016- Feb 10.
16. Scazzocchio F, Cometa MF, Tomassini L, Palmery M. Antibacterial activity ofHydrastis canadensis extract and its major isolated alkaloids. Planta Med. 2001 Aug;67(6):561-4.
17. Sharma V, Biswas D. Cobalamin deficiency presenting as obsessive compulsive disorder: case report. Gen Hosp Psychiatry.2012 Sep-Oct;34(5):578.
18. Shohag H,Ullah A, Qusar S, Rahman M, Hasnat A. Alterations of serum zinc, copper, manganese, iron, calcium, and magnesium concentrations and the complexity of interelement relations in patients with obsessive-compulsive disorder. Biol Trace Elem Res. 2012 Sep;148(3):275-80.
19. Türksoy N, Bilici R, Yalçıner A, Ozdemir YÖ, Ornek I, Tufan AE, Kara A.VitaminB12, folate, and homocysteine levels in patients with obsessive-compulsive disorder. Neuropsychiatr Dis Treat. 2014 Sep 9;10:1671-5.