Why OCD Is Often Misdiagnosed in Teens

Why OCD Misdiagnosis Happens: Invisible Symptoms of OCD in Teens

While OCD misdiagnosis can happen for a variety of reasons, including a teen’s presenting symptoms and practitioner experience, there are some common underlying reasons for overlooked OCD symptoms in teens. Below, we look at what those might be, and why they frequently leave OCD misdiagnosed – or completely undiagnosed. 

Hidden Mental Compulsions

Some OCD compulsions might be observable to the outside world, but many teenagers experience what therapists call “mental compulsions.” These can take a few forms, including things like:

• Silently reflecting deeply on memories.
• Mentally repeating phrases.
• Seeking ongoing reassurance.
• Overanalyzing thoughts.
• Trying to neutralize distressing mental images.

Let’s unpack the last point, neutralizing distressing mental images, and how it can manifest, as it’s something that comes up frequently. When it comes to this, a teenager might suddenly experience an intrusive thought around something like:

• A loved one being injured.
• Pushing someone in front of a car.
• Blasphemous or religiously offensive scenes.
• Sexual images they find disturbing.
• Making another kind of mistake that harms someone.

The images are unwanted, so we refer to them as “ego-dystonic” – meaning they go against the person’s values and wishes. In order to make the horrible feeling or image go away, the teenager with OCD then likely engages in some kind of mental compulsion, which can look like:

• Thinking of a sequence of objects in order. 
• Repeating a reassuring phrase over and over. 
• Mentally “replacing” the image with a positive one.
• Repetitive praying.
• Counting to a certain number, or in a certain order.
• Reviewing memories to prove they would never do the thing they fear.

Because these compulsions happen internally, parents, teachers, and even healthcare professionals may not recognize them as OCD symptoms.^[1] In fact, they may not see or know about them at all. 

Teenage Shame and OCD

Research conducted in 2021 added to the challenge of misdiagnosed OCD in teens, as it found that many teenagers feel ashamed or frightened by their intrusive thoughts and actively hide symptoms because of this. This reaction is understandable. Imagine how hard it would be to admit you have an ongoing thought about killing your beloved family dog, for example. As a result of this secrecy and shame, the same research found that OCD often remains undetected until it begins significantly affecting:^[2] 

• School.
• Relationships.
• Daily functioning. 

An important part of a treatment professional’s role is helping teenagers understand that there is nothing to be ashamed of. OCD is deeply challenging, but it’s something we can take practical steps to work through together. Adolescents don’t have to handle it alone.

Behavior Mistaken for Defiance

Irritability, avoidance, perfectionism, reassurance-seeking, or emotional outbursts are not unusual in teenage behavior.  But as a result of this hormonal stage of development, OCD symptoms may sometimes be interpreted as behavioral problems, or even teenage behavioral “norms.” Without careful assessment of the fears and compulsions driving these behaviors, the underlying condition may be overlooked.^[3]

High Rates of Comorbidity

OCD frequently overlaps with: 

• Attention-deficit hyperactivity disorder (ADHD).
• Autism spectrum disorder (ASD).
• Tic disorders.
• Anxiety disorders.
• Depression.
• Eating disorders.
• Behavioral difficulties. 

This symptom overlap can make distinguishing between diagnoses particularly challenging, especially when another condition appears more obvious during an assessment.^[4][5] We’ll explore a few of these “relatives” of OCD below.