If you’ve ever struggled with picking your skin due to anxiety, you’re not alone.
On Monday, singer Donna Missal posted a selfie on Instagram, showing noticeable red spots between her eyebrows. She captioned the photo:
got very anxious last night and picked my skin. feeling pretty depressed. 12th show in a row tonight in dallas but still gonna give everything i got because what else is there to do? forgive myself + get a coffee + keep it moving #tour
A post shared by Donna Missal (@donnamissal) on Mar 18, 2019 at 8:32am PDT
Though few of us have experienced the anxiety that comes from performing in multiple back-to-back shows on tour, the struggle of skin picking because of anxiety is something many may relate to.
According to WebMD, some people use repetitive actions like picking at a scab or the skin around their nails because it relieves stress. This might be especially true for folks with anxiety who may feel high levels of stress frequently.
I Googled it, finding out it was an actual thing recognized in the medical community as dermatillomania or excoriation disorder… It was so strange to me that my lifetime “habit” was considered a disorder, said to be triggered by anxiety.
Even though I knew that, I just viewed it as something I did, not that it would have a name. I now talk about it as part of my anxiety and how it affects me in a physical way, whereas I might not have before since I only saw it as a habit. This has been helpful, but I don’t do it any less. I do it when I am thinking, when I am anxious, when I am lonely and when I am trying to sleep, just to name a few times. I get nervous about social events, pick my skin, and then I am nervous that people will notice the scabs on my face so I do it even more. It is a horrible cycle.
Many who struggle with substance use disorders also meet the diagnostic criteria for one or more psychiatric disorders. Those struggling with drug or alcohol addiction, or an eating disorder are also commonly found to face an anxiety disorder, bipolar disorder, depression, personality disorder or schizophrenia.
The Correlation Between Mental Illness and Substance Misuse
The coexistence of mental illness alongside an addiction or chemical dependency is known as a co-occurring disorder or a dual diagnosis. Co-occurring disorders require a specialized approach to therapy and a highly individualized plan that can evaluate and treat both problems. Unless clients receive treatment that target both their mental illness and addiction, they will more than likely leave treatment prematurely or relapse quickly.
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According to the National Alliance on Mental Illness, the problem is extremely common. About 33 percent of individuals with a mental health illness also struggle with substance abuse. Nearly half of those with a severe psychiatric disorder like bipolar disorder or schizophrenia also struggle with addiction. Over 33 percent of alcoholics also exhibit signs of a mental illness.
Depending on the degree and severity of multiple symptoms, clients with co-occurring disorders often suffer for a long period time without an accurate diagnosis. It’s very common for only one disorder to be treated, which decreases the changes of long term, lasting recovery.
Someone suffering from dual diagnosis has two separate co-occurring disorders but they can be related and intertwined. No one person suffers from co-occurring disorders in the same way. A mental or mood disorder can precede an addiction and vice versa.
The most important thing to keep in mind is that for an accurate dual diagnosis, both conditions have to be present at the same time and a plan is formulated to treat both simultaneously.
Dual Diagnosis Treatment
Up until the 1980s, addictions to drugs and alcohol were considered separate problems from mental health disorders. Clients who exhibited both had to first detox at a rehab facility before being treated for their mental health illnesses. For the last 30 years, substance abuse treatment counselors and psychiatric professionals have worked together to better understand and treat co-occurring disorders and integrate treatment plans.
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Dual Diagnosis Symptoms
Different combinations of substances and mental health conditions impact the presence of symptoms that can lead to an accurate dual diagnosis. Symptoms of a mental illness are often very similar to the symptoms of addiction and drug withdrawal. Drug or alcohol use can temporarily hide the effects of certain mental health disorders. Substance abuse can trigger a psychiatric relapse in patients with severe conditions like schizophrenia or schizoaffective disorder. An undiagnosed mental health disorder can precipitate an episode of heavy drug abuse.
Most co-occurring disorders emerge when a client self medicates with a substance to escape from the symptoms of a mood disorder. Common symptoms and behaviors of a co-occurring disorder can include:
Using drugs, alcohol or compulsive behaviors to relieve intense anxiety, depression or mood swings
Psychiatric symptoms like depressive episodes, flashbacks or panic attacks after drinking heavily or using drugs
Withdrawing from friends, family and social activities
Experiencing problems with employment, housing or relationships
Using emergency services for acute intoxication, self-injury or suicide attempts
Legal difficulties, homelessness or incarceration as a result of behavioral problems and substance abuse
Drug or alcohol withdrawal symptoms
Extreme changes in behavior
High tolerance to substances being abused
Perceived inability to function without alcohol or drugs
Self-medicating is the use of a substance, drugs, alcohol or food, for the purpose of cessation or escape from a mood disorder. An example of self-medication who drinks to excess or abuses drugs to escape the pains of anxiety or depression. A dual diagnosis plan treats the underlying cause of the mood disorder while also treating the addiction or dependence that has developed with ongoing substance abuse. As a substance is abused over a long period of time, a resistance to it is built up which requires an increase in frequency of use which leads to addiction. Self medicating can mask root symptoms of a mood disorder which leads to misdiagnosis .
Dual Diagnosis Programs
Dual diagnosis recovery programs integrate mental health treatment with addiction therapy to promote equal healing on both levels. These program can include:
Medically supervised detox
Individually tailored recovery program
Peer support groups
Behavioral modification courses
Holistic therapies like acupuncture, yoga, meditation
Dual diagnosis treatment should be customized to meet the needs of the individual, giving you the very best chance at success. If you or someone you love is struggling with both mental illness and addiction, you can find the help you need from a rehab facility that specializes in co-occurring disorders.
Treating patients with a Dual Diagnosis, a mental health condition combined with an addictive disorder requires a highly individualized, integrated approach to therapy. Residential rehab facilities provide a structured environment for clients who face special challenges in their journey to recovery. At a residential treatment center, where the stressors and distractions are removed, clients can devote all their time and attention to learning new coping skills and building a stronger sense of self-worth.
When a dual diagnosis is involved, it can be hard to distinguish between the symptoms of a psychiatric illness and the signs of drug or alcohol addiction. Recognizing the need for treatment is the first step in getting the help you need to restore balance and health to your life. If you see signs that indicate that it’s time for you or a loved one to reach out for help, it’s always best to be on the safe side. If you have any reason to believe that someone you care about needs treatment, contact a mental health specialist near you for an evaluation. Your decision to help someone in your life get into residential rehab may help prevent the serious consequences of substance abuse, such as incarceration, loss of key relationships or incarceration.
Entering a residential rehab facility can be a scary prospect, especially for those with a co-occurring disorder. Depression, anxiety and emotional instability can create an intense fear of the unknown. Patients with social phobias may be terrified of group meetings, while those with obsessive-compulsive disorder may have difficulty living in an unfamiliar environment. At a residential facility that specializes in dual diagnosis treatment, they train staff members to expect these responses and to provide the most comfortable atmosphere possible.
What to Expect at Mental Health Rehab
Assessment and evaluation are the first stages of the rehab process. When you enter a facility, you’ll be evaluated by an addiction specialist (a psychiatrist, psychologist, counselor or social worker) who will gather information about your recent substance use, your current and past medical history, and your psychiatric symptoms. The assessment phase is crucial for developing an individualized treatment plan that addresses both your mental health condition and your substance use disorder
Residential vs. Outpatient
What makes residential treatment so effective for patients with a dual diagnosis? At a residential facility, fully integrated care may be easier to provide. Integrated care refers to combined treatment for an addiction and a psychiatric disorder. When both conditions are treated at the same time, the patient has a greater chance of making a full recovery, according to the National Alliance on Mental Illness (NAMI).
Here are a few ways that integrated care lends itself to a residential environment:
Patients who need intensive monitoring for heavy substance abuse or acute psychiatric symptoms can receive clinical care 24 hours a day.
Clinical professionals and recovery resources are gathered in a single setting, where patients can focus exclusively on their rehabilitation.
In a residential setting, there’s more time to foster trust between caregivers and dual diagnosis patients.
Patients who have trouble with denial or low motivation can receive specialized attention and encouragement without the distractions of daily life.
Patients can go through rehabilitation at their own pace in a secure, supportive environment.
Peer group support is stronger in residential facilities, where dual diagnosis patients can share advice and hope with other clients who have similar concerns.
Outpatient treatment programs are useful and effective for patients who require a lower level of supervision. Outpatient counseling and group meetings take place at rehab facilities, mental health centers and clinics in many communities. Services are generally provided during daytime or evening hours, and patients go home at night.
While the cost of outpatient care is usually lower than the cost of residential services, the lack of structure and supervision places patients at a greater risk of relapse.
In a study published in Drug and Alcohol Review, researchers at Dartmouth Psychiatric Research Center compared the effectiveness of residential treatment programs with outpatient programs for dual diagnosis patients. Their study showed that outpatient care was less effective than residential treatment in up to 50 percent of cases. Participating in outpatient rehab requires a higher level of motivation and compliance, which may not be present in a patient who has a severe mental illness. The structured setting of a residential community provides a sense of security and safety that isn’t available in an outpatient clinic or treatment center.
Pharmacological therapy is a vital component of residential dual diagnosis treatment. In a residential treatment program, patients undergo thorough evaluation to assess their recent history of substance abuse (if any), their psychiatric history and their current symptoms. Medications may be prescribed to relieve the symptoms of anxiety or depression, to control flashbacks, or to reduce cravings for drugs or alcohol. Prescription drugs used to support recovery from a dual diagnosis include:
SSRIs: Selective serotonin reuptake inhibitors, or SSRIs, are a class of antidepressants that help to restore healthy levels of serotonin, a neurotransmitter that influences mood, appetite and energy levels. SSRIs like fluoxetine (Prozac), citalopram (Celexa) and sertraline (Zoloft) are prescribed for the treatment of depression, obsessive-compulsive disorders, eating disorders and many other psychiatric conditions.
Anti-anxiety medications: Medications used to treat anxiety disorders include beta-blockers, which help to manage the physical symptoms of panic attacks, and buspirone, a medication used to treat generalized anxiety disorder. Benzodiazepines like lorazepam (Ativan) and alprazolam (Xanax) are sometimes prescribed for the short-term control of severe anxiety, but because these drugs can be addictive, they must be used with care in Dual Diagnosis individuals.
Antipsychotic medications: Antipsychotic medications like aripiprazole (Abilify), clozapine (Clozaril) and risperidone (Risperdal) are used to treat severe, persistent mental health disorders like bipolar disorder and schizophrenia.
Anti-addiction medications: For dual diagnosis patients who are addicted to alcohol or opiates, drugs like naltrexone (ReVia, Vivitrol) and buprenorphine (Suboxone) are prescribed to help reduce cravings and maintain long-term abstinence. Methadone may be prescribed to minimize withdrawal symptoms in patients who are addicted to heroin or other opiates.
At a residential mental health rehab, individual therapy may be modeled on one or more of these therapeutic schools:
Cognitive Behavioral Therapy (CBT): The goal of CBT is to change destructive thought patterns and behaviors that interfere with the patient’s desire to lead a more productive, fulfilling life. CBT can be used in the treatment of mental disorders like depression or anxiety, as well as in the treatment of addictive behavior. The coping skills that patients learn in CBT can empower them to manage their moods, fears or flashbacks without the help of drugs or alcohol.
Motivational Interviewing (MI): Motivational interviewing arose from the need to provide a more supportive, compassionate form of therapy to dual diagnosis patients. According to Professional Counselor, MI is designed to help patients with low levels of motivation and compliance find a reason to recover. MI is a nonjudgmental school of therapy that accepts the client’s level of readiness to change instead of attempting to force recovery.
Dialectical behavior therapy (DBT): Originally developed for the treatment of chronically suicidal patients, the principles of DBT have been applied successfully to addiction treatment and rehabilitation. Dual Diagnosis patients can benefit from this innovative approach to therapy, which focuses on mindfulness, self-acceptance and the regulation of emotional responses.
What to Bring to a Rehab Facility
When you’re admitted to a rehabilitation facility, you’ll need to bring certain personal items and you may also be presented with a list of prohibited items.
Below are some of the basics you’ll need:
Personal identification, such as a driver’s license or passport
A contact list of family members, friends and physicians
Comfortable clothing, footwear and workout gear
Personal toiletries, such as soap, shampoo. Products containing alcohol are prohibited.
Electronic devices, such as clocks, hair dryers and CD players
Reading material (pornography may be prohibited)
Cameras, clothing that advertises drugs or alcohol, incense, candles and cigarette lighters are not allowed at some facilities. The use of cell phones and laptop computers may be limited, but most facilities will allow you to bring these items with you. Your admissions team will advise you on what to bring to the facility before you enroll.
Mental Health Aftercare
According to the U.S. Department of Health and Human Services, peer support is crucial to long-term recovery. Aftercare services can fulfill a number of functions: offering emotional strength, providing education or information about addiction, helping you connect with community resources (transportation, healthcare, affordable housing, etc.), or introducing you to social groups that can give you a sense of belonging.
Aftercare services help you maintain the coping skills you learned in rehab, so you can continue to build the healthy, fulfilling life you want after you graduate from a recovery program. Even as you go through detox and rehab, your treatment team will work on identifying the tools and skills that you’ll need to be successful after you finish the program.
Aftercare can continue for as long as you’re committed to a healthy, meaningful life. People who stay stable despite a mental illness diagnosis often attribute their success to participation in aftercare services like self-help groups, 12-step meetings, alumni organizations, or volunteer activities that support recovery. These activities can help you stay connected to other people who share your goals and values — people who can motivate and inspire you as you create the future you really want.
The following services fulfill one or more of these functions:
Counseling and therapy
Family education and counseling
Relapse prevention therapy
Outpatient recovery services
Sober living homes
Covering the Cost of Mental Health Rehab
In 2014 the passage of the Affordable Care Act required both individual and group insurance policies to cover care for mental health issues or substance use disorders. However, the extent of what’s covered varies significantly depending on what type of plan you have. Some luxury-level rehab facilities don’t accept insurance but most psychiatric hospitals do since they obviously have a heavy medical component. In general, facilities that advertise as addiction rehabs that offer dual diagnosis support or detox also accept insurance since prescription medication, whether for drug withdrawal or treating mental illness, necessitates physicians on staff. Again though, this isn’t always the case to be sure to call each facility to confirm what their policy is.
The good news is, there are so many different ways to get help now. If treatment isn’t available near you, changes are help isn’t very far. Sometimes it’s best to completely remove yourself from the environment you associate with active addiction or untreated mental health issues in order to begin the healing process.
Highly neurotic men are significantly more likely to suffer from erectile dysfunction and incontinence after prostate surgery, potentially risking their recovery, according to a new study.
The research suggests personality tests may improve care for patients with prostate cancer, which is the most common cancer for UK men, with just under 50,000 new cases per year.
The findings showed men who tested highly for neuroticism were on average 20 per cent more likely to suffer adverse reactions, including “erectile dysfunction, urinary leakage and bowel problems” after radical prostatectomy, the surgical removal of all of the prostate gland.
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Between a quarter and a fifth of men in developed countries are considered highly neurotic.
Until now, differences in outcomes from prostate cancer surgery had been thought to be largely due to differences in surgical technique and the circumstances of the cancer.
However, the research, which was presented at the European Association of Urology Congress in Barcelona, shows that personality may also be a contributory factor to surgical outcomes.
The researchers said their findings suggest doctors may need to consider testing for personality types to ensure prostate cancer patients receive the best care.
For the study, researchers surveyed 982 men who had undergone prostate surgery – specifically radical prostatectomy at the University Hospital in Oslo, Norway.
Most of those participants (761 men) reported on their recovery from surgery while also self-reporting on neuroticism with a standard questionnaire.
Of those participants, 22 per cent scored high for neuroticism, in line with most national surveys in developed countries, and showed significantly worse scores when surveyed on their recovery.
Lead researcher, Professor Karol Axcrona, from Akershus University Hospital, Norway, said: “Around a fifth of the men scored highly for neuroticism, which is pretty much what would be expected – these men showed significantly more adverse effects after prostate cancer surgery.
“This mirrors work which has shown the effect of personality on disease recovery in general, but we still need to see this work replicated in other studies.”
He added: “Neuroticism is not an illness, but a basic personality trait, like extraversion or openness; we all have some degree of neuroticism.
“What we found was that those patients who show a greater tendency towards neuroticism have worse outcomes three years after prostate cancer surgery.
“This is a real effect, and doctors need to take account of this, in the same way that we would take physical factors into account before and after cancer treatment.”
Agencies contributed to this report
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When Samantha Jean would bump into—or even brush past—her middle-school classmates, she would immediately feel dirty. As soon as she got home from school, Jean would shower, throw out any clothes that had come into contact with potential germs, and wash her hands until they were raw. That was 15 years ago in Buffalo, New York, but Jean—now 28—still battles these same fixations: She has obsessive-compulsive disorder, or OCD, and she’s never sure when some new bizarre belief will take over her brain.
With OCD, people can have unwanted and repeated thoughts and feelings that can lead to repetitive behaviors to help address or get rid of the obsessive thought. For Jean, her obsession was that everything is dirty; her compulsion was to wash and keep things clean. It wasn’t until then-13-year-old Jean’s parents took her to therapy that she was diagnosed with OCD and received treatment, including medication. Check out these 8 early signs of OCD to take seriously.
That’s when she started to understand what it means to live with the disorder. “I remember one of my therapists said you might not always be afraid of germs but [OCD] will always be there and it’ll come back in different ways,” Jean says. “The obsessions don’t always stay the same.”
Courtesy Samantha Jean
The obsessions and compulsions aren’t always visible, either
One of the common misconceptions about OCD is that it exclusively relates to orderliness, cleaning, and perfectionism. But that’s not what Rose Cartwright, 32, experienced. Awful, debilitating, intrusive thoughts—a type of OCD that is sometimes called Pure O—exploded into Cartwright’s world when she was 15 years old. “It was this nightmarish level of anxiety from the get-go,” she says. “I didn’t understand where these thoughts were coming from; I thought the fact that I had these thoughts was evidence enough that I had done something terrible.”
Someone with Pure O experiences obsessive, unwanted ideas and performs compulsions or rituals as a result. David Austern, PsyD, clinical instructor of psychiatry at NYU Langone Health, notes that the term Pure Oisn’t often used in the medical community anymore and could be a bit misleading. That’s mainly because treatment for Pure O and OCD is the same. One distinction for sufferers, though, is that with Pure O the compulsion and or ritual is a mental response that isn’t visible (unlike Jean’s hand washing).
Cartwright remembers taking the GCSE exams—standardized tests in England—a year later, at age 16, and thinking that these thoughts would never end. “I remember going into those exams and sitting in the exam hall and trying to do these tests and having intrusive thoughts every second that my pen was on the page, and thinking, ‘Is this my life now?’ because it had been literally a year of 24-7 thoughts,” she says. Learn these 8 surprising causes of OCD.
“I would wake up in the morning and have a few seconds where I forgot where I was or who I was, and then I would have my very first intrusive thought, and then I would have them all day every day until I went to bed at night,” Cartwright says.
Michael Clement/Courtesy Made of Millions
As the years passed, her thoughts shifted to sexuality, about orientation and commitment. As a result, she avoided films with sexual content, physical contact with people, and social occasions.
There is one effective treatment that is used most often
Cartwright found that her search for answers landed her online, where she diagnosed herself before seeing a series of doctors and therapists for OCD through her early 20s. Each of them had a different therapeutic approach; some prescribed medication, which didn’t provide much relief. “They just kind of took the top off the anxiety and the bottom off the depression, but they did nothing to lessen the intensity or the frequency of the thoughts themselves,” she says. Make sure you know these 9 signs you could have an anxiety disorder.
In her mid-20s, Cartwright met with a therapist in the United States who finally diagnosed her with OCD and treated her with exposure therapy. This type of treatment, also called exposure and response therapy (ERP), is a type of cognitive behavioral therapy that is the front-line treatment for OCD, according to Dr. Austern. “ERP is designed to have people face the fears that their OCD is essentially telling them they must avoid by doing something, thinking something, or avoiding something because if they confront these obsessions, whatever the content of them is, it is going to be unbearable,” Dr. Austern says.
After educating the patient and normalizing the experience, Dr. Austern says, doctors will help the ERP patient rank the situation he or she is avoiding according to how challenging it would be to face that situation without performing a ritual. The patient then goes into that situation without doing the ritual, such as saying a phrase, counting, or avoiding something.
“If it is something that people might call Pure O, it gets a little trickier because we need to know what they are doing in their minds,” Dr. Austern says. “And we can’t necessarily observe the ritual in the room.” The goal is to have patients get used to the discomfort of these situations and learn that they can face it without performing a ritual.
Cartwright believes, however, that there is no one-size-fits-all OCD treatment. “Everyone has to figure that out, and I’m still in the process of figuring that out myself,” she says. “It’s not sort of a game with different levels, and then you get to the end level and you’re done. It’s an evolving process.” For Jean, that includes both cognitive therapy and medication.
Cartwright’s therapy process gave her relief, confidence, and some clarity to pitch a piece on her story to the Guardian. “I knew by then that this was something that was being experienced in secret by thousands, if not millions,” Cartwright says. “So I just felt compelled to tell my story. It wasn’t a choice—it had an energy all its own.”
Michael Clement/Courtesy Made of Millions
Her story caught the attention of Aaron Harvey and motivated his search for as much information as possible about Pure O. Harvey, who grew up in the suburbs of Orlando, Florida, started having his own intrusive thoughts around eight years old. He didn’t tell anyone in his home or school about his internal struggles—and ended up grappling with them on his own for more than 20 years. “The idea of who you are and what your character is starts to crumble in front of you because you are sort of defining yourself, and those thoughts and images make you question who you are and what you’re capable of,” he says. Know these 8 signs that you could have OCD.
Ironically, his psychotherapist of six months had no idea that his symptoms were OCD. Dr. Austern notes that OCD is a specialty, so fewer therapists have extensive OCD training. There are, however, online resources for individuals who think they are experiencing OCD, such as beyoncocd.org.
Over the next two years, Harvey experimented with different medications and some exposure therapy and consulted various psychiatrists who offered many different diagnoses. Much like Cartwright and unlike Jean, Harvey didn’t find much comfort in medication.
Sharing personal experiences with OCD and mental health issues are key
And as Harvey learned more and more about Pure O, he also dealt with some anger. “I was angry that this whole thing could have been prevented when I was 13 if there was better information available,” he says. “My parents worked in health care, I’m in a middle-class family, my parents are together, I was raised in a happy and healthy family, as a white male in America, and with all of my privilege, this information did not arrive to my family or me.”
This lack of information promotes the misconceptions about OCD that promote its informal use in casual lingo. Jean—who doesn’t identify with the term Pure O—isn’t offended by this lax usage, but says it’s good to start making people aware of what it really means. “People who say ‘I’m OCD’ obviously could never know how scary and debilitating real obsessive-compulsive disorder is,” Jean says. “It’s definitely just a lack of awareness.”
Harvey doesn’t judge people who use the term “OCD” as an adjective either, but he too thinks more education is necessary, especially about the types of compulsions he and Cartwright have that aren’t visible, and specifically about Pure O. It’s hard for people to understand Pure O because it isn’t as visual as other OCD tropes, he notes. “All of these avoidance things are actually the real compulsion,” Harvey says. “That’s why ‘pure’ is an important phrase because it kind of feels like things are purely happening in your head.”
Both the misconceptions about OCD and his own anger about the lack of information online motivated Harvey to spread awareness and advocate. He reached out to Cartwright, thanking her for writing her story, and together they created intrusivethoughts.org. Now the pair is building up Made of Millions—a website dedicated to inspiring grassroots change to combat the stigma of mental health. Try these 9 natural treatments for OCD.
Harvey says that coming out with his own story on the platform wasn’t something he looked forward to, but he knew it was the right thing to do because of the positive impact it would have on others. “Obviously it’s a scary thing, but once I did it, I felt good because I was able to use what I do for a living—advertising, design, creative, marketing, writing—and use all that skill that I acquired over the last decade and bring that into something that actually needs to reach people,” he says.
Michael Clement/Courtesy Made of Millions
Cartwright hopes that Made of Millions will provide people who are suffering with the space to share their stories and explore the emotional side of mental health, beyond the therapy courses and information about medical treatment that other sites offer. “We want to hear from people in different countries about what their experiences are and what their stories are and learn from that, and I think that that’s quite different from feeling like you’ve reached a conclusion and you’ve got conclusions to dispense and teach people,” Cartwright says. Next, check out these 6 proven ways to cope with obsessive-compulsive disorder.
Sadly, that’s not true for everyone that suffers from anxiety—which is a sizable number of people. According to the Anxiety and Depression Association of America, anxiety disorders affect about 40 million people—that’s almost one in five people. Women suffer more than men, and children aren’t immune either. According to the National Institute of Mental Health, about 25 percent of kids age 13 to 18 suffer from an anxiety disorder. Generalized anxiety disorder is the most common form of anxiety, but there are other types such as panic disorders, social anxiety disorder, and obsessive-compulsive disorder. Treatments vary depending on the disorder and individual but therapy, medication, self-care and avoiding triggers help. You’re not alone—check out the 14 things only people with anxiety can understand.
In the study, researchers assessed alcoholism, social anxiety disorder, generalized anxiety disorder, panic disorder, agoraphobia, and specific phobias through interviews with 2,801 adult Norwegian twins.
Social anxiety disorder had the strongest association with alcoholism, and it predicted alcoholism over and above the effect of other anxiety disorders. In addition, social anxiety disorder was linked with a higher risk of later developing alcoholism, whereas other anxiety disorders were not.
The research appears in the journal Depression and Anxiety.
The findings suggest that interventions aimed at prevention or treatment of social anxiety disorder may have an additional beneficial effect of preventing alcoholism.
“Many individuals with social anxiety are not in treatment. This means that we have an underutilized potential, not only for reducing the burden of social anxiety, but also for preventing alcohol problems,” said lead author Dr. Fartein Ask Torvik, of the Norwegian Institute of Public Health.
“Cognitive behavioral therapy with controlled exposure to the feared situations has shown good results,” Torvik said.
Therefore the discovery of the association may have a silver lining as talk therapies are effective in reducing this form of anxiety and may now play a factor in also reducing the incidence of alcoholism.
People with OCD, or obsessive compulsive disorder, may experience obsessive thoughts, or compulsive, repetitive behaviors.
Some people report having both – and the symptoms can be quite severe.
Now, researchers are developing a new approach to treating OCD that targets a specific receptor in the brain.
Obsessive compulsive disorder is a chronic mental disorder where thoughts you don’t want become behaviors you can’t stop. And it can severely impact the quality of life. One expert knows first-hand, because she’s also a patient.
Elizabeth McIngvale, PhD, is an assistant professor at Baylor College of Medicine.
“I’ve lived with OCD since childhood. I was diagnosed when I was 12 and have been in treatment ever since,” she said.
She used to ask her mom if it was okay when wanting to touch something at school, for example.
“Then it transferred into a lot of contamination rituals, spending a lot of time in the shower. Fearing I hadn’t done something enough, I wasn’t clean enough. I was going to contaminate other people,” McIngvale said.
OCD is rooted in fear, which feeds anxiety and brings about the unwanted behavior. Currently, psychologists offer cognitive behavioral therapy, which is the most common treatment.
Exposure and responsive prevention is a type of CBT that exposes patients to the thing they fear. Prozac and Anafranil are approved medications that can be given to children. For adults, doctors may prescribe Zoloft or Paxill to help symptoms.
But now, Baylor College of Medicine researchers are studying something new.
They’re looking at medications that target glutamate in the brain, a neurotransmitter that sends signals to other cells.
“Some recent information suggests that there might be a third messenger that naturally occurs called glutamate. Thereby having an improved response to antidepressants,” said researcher Eric Storch, PhD.
Drugs used to treat Alzheimer’s and ALS appear to show promise in targeting glutamate OCD patients.
For McIngvale, who might only get several minutes a day without intrusive thoughts, it’s clearly critical to find a better way. She started the Peace of Mind Foundation, to offer resources and support groups for OCD patients.
“I can understand someone’s pain and I can truly believe with all my belief system, that they can get better,” she said.
Sweaty palms, jarring heart palpitations, light-headedness, sudden
difficulty breathing, stomach cramps, dissociation—
anxiety surpasses average nervousness. It is physical, exhausting, and debilitating. People struggling with
chronic anxiety often have issues moving through their day-to-day tasks and
are sometimes left feeling as if they don’t have control over their mind or
including general anxiety disorder, post-traumatic stress disorder,
obsessive-compulsive disorder, social anxiety disorder, panic disorder, and
While many people experiencing anxiety seek professional help,
less severe cases can often be alleviated with a few natural solutions:
Natural herbs and supplements
Before pharmaceuticals, humans had to rely on raw environmental elements.
Consequently, there are a number of herbal supplements known to improve the
mental and physical manifestations of anxiety, stress, and panic.
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and is an adaptogen—a
substance that helps modulate the body’s response to tension,
overstimulation, and trauma. Ashwagandha can be ingested in the form of a
capsule or powder. It can be easily purchased from online retailers
specializing in organic, all-natural supplements.
Chamomile also has a
clinically meaningful impact on anxiety levels, and its use dates back to ancient Egyptian, Roman, and Greek cultures.
Primarily known for its presence in calming teas, a study using refined
chamomile extract showed an improvement in anxiety symptoms and
During exercise, the body releases endorphins, which
are hormones that supply a burst of energy and help increase your mood.
It’s these endorphins that produce the feeling of euphoria post-exercise,
often referred to as the “runners high.”
in the wellness community as one of the most effective physical activities
to reduce the symptoms of anxiety disorders, along with other movements
that engage the full body and focus on the alignment of breath and
to improve the relationship between the brain, breath, and body.
Unfortunately, meditation can be especially hard for those with an anxiety
disorder. Racing thoughts, a common and persistent symptom of anxiety, can
be hard to shake during a meditation session. But the purpose of meditation
isn’t to erase these worrisome thoughts; it’s learning how to live
alongside them without fear or self-judgement.
Mindfulness-based meditation is the primary meditation method used in the
treatment of anxiety disorders. The practice focuses on learning to detach
from obsessive, intrusive, or anxious thoughts, primarily by concentrating
one’s awareness on the sensations present in the body at that moment.
Studies have shown that a consistent meditation practice
symptoms of distress in those who meet the criteria for anxiety disorders
classified in the American Psychiatric Association’s Diagnostic and
Statistical Manual of Mental Disorders (DSM-5).
While these natural methods can have a positive influence on those
combatting an anxiety disorder, severe cases of anxiety may require
professional medical intervention. It’s important to seek professional care
if anxiety symptoms cannot be self-managed. Anti-anxiety medications, like
SSRIs, can be life-saving, along with consistent counseling. If you or
someone you know is experiencing a mental health crisis, these hotlines
provide 24/7 support:
This content is not intended to be a substitute for professional
medical advice, diagnosis, or treatment. The information on this web
site is for general information purposes only. Always seek the advice
of your physician or health care provider on any matters relating to
A few weeks ago, someone sent an email to our Ask Dr. Mayim column, and it seems to have struck a nerve with a lot of people. The question was about constantly going over past conversations to the point of spending years worrying about things said or done. You can read my full answer here, but the gist of it was I recommend a therapist to help with these kinds of perseverative thoughts. I also suggested that 12 step programs such as Al-Anon can help with thoughts like this if the person has been touched by the disease of alcoholism; sometimes these kinds of thoughts are driven by fear or excessive responsibility.
After we posted the Ask Dr. Mayim article, follow-up questions came pouring in about obsessing. So I recruited one of my oldest friends who is a licensed psychologist specializing in Cognitive Behavioral Therapy, Dr. Jacob Gisis, to help answer the most pressing ones. Here are Dr. G’s answers to some of your questions along with some of my input!
Mayim Bialik: I had recommended seeing a therapist, but in what specific ways can a therapist actually help with obsessive thoughts? Dr. Jacob Gisis: I agree with your recommendation to see a therapist, and I’d specify even further that it ought to be a cognitive behavioral therapist. Someone who specializes in CBT is important because it’s the fastest and most efficient way to treat virtually all anxiety based disorders, which this is likely an example of.
Part of treating these kinds of difficulties is that we want to define a desired end state. And—this obviously reflects my background in neuroscience—we want to recondition the nervous system so that it actually produces that desired end state and an integral part of that is to generally relax it. So what most cognitive behavioral therapists would do, in appreciation of it being an anxiety based disorder, is to start by teaching a relaxation technique to decrease anxiety levels overall.
Once that relaxation is put in place, then the goal is to not feel like the individual has to review past experiences or memories. We want to help them be less interested in those thoughts when they come up. It’s not easy to do. It’s generally a gradual process. There’s training in terms of what to do with the mind when these things come up and there are various options.
My orientation is toward assisting my clients with deciding what they want to do with their minds instead. In other words, what experiences do they desire to have and what mental processes are going to facilitate them having those experiences? Oftentimes mindfulness, which tends to be defined as a non negatively judgmental present-focused awareness, is the goal and one path toward it involves focusing on sensory experience and then not judging it negatively. However, like I said, it is really up to the client to determine what they want to experience and then we usually work together to see to that.
The abbreviated way to describe that process is that there are ways to train your mind to direct yourself away from obsessing and it takes a certain amount of effort at first but then it becomes second nature.
It does require effort and with repetition you are establishing a new circuit; a new neural network. The nervous system is trained to engage in a new pattern that’s been repeated. We truly are creatures of habit!
Someone asked a related question about worrying and losing sleep over future conversations.
These kinds of thoughts are generally associated with anxiety as they involve considerations of hypothetical negative future events. Anxiety can be thought of as future fear. Treatment is similar to what I briefly outlined earlier. As it’s anxiety-inducing to review potentially negative future conversations and as anxiety and sleep are not friends, unfortunately, it’s quite common for sleep to be adversely affected.
Someone asked if this type of obsessing can be related to aging. This woman says her husband has started obsessing with the past and he’s in the beginning stages of Parkinson’s Dementia. And she also has a neighbor in her 70s who won’t speak to her because of something she said three years ago. Can this be related to aging or is it more that we see these things in dementia?
It can be. One way to think of that connection is as related to the neural pruning that occurs with aging. We have fewer nerve cells and fewer cognitive and behavioral patterns accessible to us as we age and as our brains degenerate. And if this kind of obsessing is something you are doing quite regularly because your anxiety is pushing you to do it and you don’t have much awareness of how to manage it because you’re not working with a cognitive behavioral therapist, then it’s quite likely to become a very dominant pattern.
Someone asked, “Why is worse at night when I am trying to fall asleep?”
It could be the case of idle mind. That you’re not actively focused on something else. Then, there is more room for your anxious parts to hijack control of your thinking parts. Some people have elevated anxiousness related to darkness. At nighttime, our visual system, which is our primary sensory system, doesn’t work as well and we could feel more vulnerable and, therefore, more anxious.
Can this be indicative of a larger issue?
It is usually a symptom of an anxiety disorder, or commonly, Obsessive Compulsive Disorder.
Is there a “normal” amount of overthinking? When do you know it is a problem?
I would suggest that just about everyone overthinks at some time or another. I would suggest an even stronger statement that all of the dimensions of any mental health diagnosis—maybe with the exception of psychotic diagnoses—are relevant and exist in everybody to some extent. It’s not like people who carry these diagnoses have different brain parts than what others have. It is just usually a matter of degree. Some criteria we look at to determine how problematic this is are: Is it getting in the way of other goals, occupational functioning, sleep, social functioning, your familial life? Usually those are the criteria that determine whether we consider this pathological or not.
As a 5-11, 240-pound man, if you saw me on the street you would not think anything is wrong with me. The truth though is far different — I have endured Obsessive Compulsive Disorder, depression and anxiety for most of my life.
My first incident occurred when I was just four years old. I watched Thriller and saw Michael Jackson turn into a werewolf. It traumatized me. When I started kindergarten, I would hide underneath tables because I was afraid my teacher would turn into a werewolf. I started seeing a psychiatrist shortly thereafter (around five years old).
However, my behaviour didn’t get better. If anything, it got worse.
A couple of years later, I had just come up from my basement when I had the irresistible compulsion to go back down, this time with the lights off. I felt the need to repeatedly go up and down the stairs with the lights off, walking further and further into the basement each time. In my teenage years, I displayed other “weird” behaviours — when one ended, another new compulsion began.
Some activities started consuming my life — like when I needed to repeatedly wash my hands, check my car to see if I accidentally hit someone, walk backwards down stairs, take frequent showers or brush my teeth for nine minutes (and exactly nine minutes). I cleaned my body with Lysol wipes. I tapped the floor with my foot and a table with my hand nine times to protect people I loved. If something added up to a bad number then I would use nine to make up for it.
As I grew older, my compulsions controlled my life. When I went to nightclubs with friends I would stand in four directions irrespective of where I was.
I often had to ask if I could work from home (sometimes for weeks at a time) because my compulsions worsened.
I remember my first panic attack. I was walking in a mall with friends, laughing and joking when all of sudden I felt my chest tighten up. I had difficulty breathing. I started to sweat and told my friends I needed to go to the hospital. Very concerned, they told me to take deep breaths, since I was too focused on the fear! My next panic attack occurred while eating, when I felt food going slowly down my throat. I went to the ER, only to find out again I was fine.
I experienced many more panic attacks. Each time I felt drained and tired afterward. I eventually stopped going to public places, fearing another panic attack and worrying that my OCD would go out of control. Needless to say, my relationships started to suffer.
My friends would pick me up and I would have to duck to go to their house. I covered my face with my hands in the car so no one could see me. My girlfriend had to take me out when no one was around.
Depression followed. I isolated myself from everyone and stopped speaking to friends. I cried frequently. Yet, despite my struggles, part of me said, “I can’t give up.” I kept fighting each and every day.
Sylvester Stallone is my hero so I had to be a fighter.
The breakthrough came one morning when I finally addressed a scary fact: to change my life, I needed to change myself. I did not want to struggle anymore so I decided enough is enough. I had faith in God and most importantly, I had faith in myself. I walked outside feeling like a free man.
It was extremely difficult — my mind started playing games. I felt the further I walked from home, the more likely I would suffer a panic attack. But this time it was different — this time I confronted those thoughts. I continued walking. Every day I would walk — going further and further, slowly but steadily, taking deep, steady breaths every time.
After suffering agoraphobia for about four years, I eventually started going out more, socializing and meeting friends. I felt unstoppable. I was breaking free and making steady progress with depression, anxiety and OCD. Actively challenging my negative thoughts paid off.
Today I write inspirational articles and am happier and full of passion.
You deserve to be happy, too. Whatever you are going through, you will beat it. Nothing will bring you down and nothing can stop you. You are strong. You are loved, valued, worthy, and important.
You are not alone. I am not only a person with OCD, depression and anxiety, I am a fighter. And you could be, too.
Danny Gautama lives in Windsor where he writes inspirational articles for mental-health organizations and is working on an inspirational book.
With characters like Sheldon Cooper and Monk, we’ve seen OCD in television for a while. But just how well do they represent and respect the condition?
First, just what is OCD? As defined by Psychiatry.org, Obsessive-Compulsive Disorder is:
An anxiety disorder in which time people have recurring, unwanted thoughts, ideas or sensations (obsessions) that make them feel driven to do something repetitively (compulsions). The repetitive behaviors, such as hand washing, checking on things or cleaning, can significantly interfere with a person’s daily activities and social interactions.
The average person may experience obsessive thoughts and repeated behaviors, but they are usually infrequent and do not disrupt daily life, and are therefore not considered OCD. For those with OCD, they are basically incapable of not thinking about their compulsions, and being prevented from following through with the resulting routine can cause them extreme distress.
What people fail to realize, or likely just don’t care about, is that while OCD affects a small portion of the population, it is one of the top ten most common mental illnesses, and is regularly classified as one of the leading disabling conditions, along with bipolar disorder and schizophrenia. OCD can ruin lives, plain and simple. Not just the lives of the people with the condition, but those around them bear the brunt of it. And misrepresenting that struggle for the sake of a laugh isn’t doing the people suffering from it, or the general public’s understanding of it, any good.
A regular misconception about OCD is that its about tidiness, and people who really want something in a particular order are exhibiting OCD symptoms. While ordering and arranging is definitely an example of a compulsion, OCD is not as simple as wanting your desk in a certain order. Usually, if someone says, “I’m so OCD about my _____”, odds are they’re not actually suffering from OCD, but possibly a personality disorder, OCPD, less severe than true OCD.
For people with OCD, they’re plagued with persistent and unwelcome thoughts that result in heightened anxiety, followed by the drive to perform a behavior or act to relieve the anxiety. The National Institute of Mental Health lists common obsessions as including:
Fear of germs or contamination
Unwanted forbidden or taboo thoughts involving sex, religion, or harm
Aggressive thoughts towards other or self
Having things symmetrical or in a perfect order
Entertainment websites have published lists of the best characters with OCD in movies and TV, but usually include characters who do not have OCD but are exhibiting traits commonly mistaken for it, resulting in the continued misunderstanding and misrepresentation of OCD. For example, the character of Monica from ‘Friends’ is often argued to have OCD, specifically for her cleaning compulsion. While Monica had been shown to feel a need to clean everything to an extreme level and is likely experiencing Obsessive Compulsive Personality Disorder, there have been only a few depictions of her possibly having true OCD. Monica reacted to Rachel cleaning the apartment by staying awake at night obsessing over the placement of shoes, as well as showing up at the apartment of a woman Ross went out with, offering to clean her apartment and admitting that she couldn’t relax knowing the apartment was in horrible shape. However, it’s unlikely someone with OCD would obsess over the cleanliness of a place he/she doesn’t go to and has no direct connection to.
With shows like ‘Friends’ and ‘Big Bang Theory’, the problem is the compulsions are primarily played for laughs without seriously showing the effect not completing such a compulsion can have on someone. In ‘Big Bang Theory’, Sheldon is regularly shown being afraid of germs, the compulsion to knock multiple times, and other traits related OCD. But a handful of times we’ve seen Sheldon interrupted during his ritual of knocking, with his resulting actions played for comedic effect until the interrupter, usually a giggling Penny, allows him to finish the action. However, in reality, the failure of someone with OCD to complete their ritual, as well as that person attempting to fight that which they are well aware is illogical, can have very serious issues that are far from comedic. In the case of ‘Big Bang Theory’, we have a character experiencing a tremendous inner battle while one of his best friends stands by watching and being amused by it. However, Sheldon doesn’t fully fit into OCD since he’s exhibited little, if any, acknowledgement that his obsessions and rituals are illogical. In Sheldon’s mind, everything he does is perfectly acceptable and reasonable, making him more OCPD than OCD. Another way the show doesn’t treat the condition with respect is that Sheldon’s issues are treated as something that others find to be completely annoying, instead of providing Sheldon with the understanding and support he really needs, and even instigating an episode for their own amusement.
The series ‘Monk’ is known for being one of the better portrayals of OCD, but wasn’t without its own shortcomings. Many times, the character of Monk was depicted as phobic, rather than compulsive, showing a fear of touching things but not the repeated behaviors. Also, much like other comedies addressing the subject, Monk’s behaviors are mostly shown as charming quirks, rather than the debilitating and time-consuming rituals they most often are.
The show ‘Scrubs’ was also praised for its depiction of OCD, in a season 3 episode with guest star Michael J. Fox playing Dr. Kevin Casey. Though Dr. Casey’s compulsions of touching everything while saying “bink” is meant for laughs, the show take a serious turn to show the dark effect of the disorder when Dr. Casey is struggling with still washing his hands over two hours after finishing surgery.
Outside of the fictional reality of these shows, Howie Mandel has become a real world example of OCD. Originally known for his stage act where he’d put a rubber glove on his head and blow it up through his nose, no one knew that the bit was only possible due to the numerous rubber gloves Mandel kept on him so he wouldn’t have to touch certain things. While it was known that Mandel preferred fist bumping over handshaking, It wasn’t until he let it slip during an appearance on the Howard Stern show that people found out the extent of his OCD. But even after that, his condition was still the butt of jokes by others while he served as Kelly Ripa’s co-host, purposely making Howie uncomfortable just to see how he’d react.
“So what’s the problem if a TV show doesn’t give an accurate depiction of OCD? It’s just entertainment.” True, it’s entertainment, but it’s also perpetuating myths and misconceptions about OCD, and doing so in a way that is consumed by more people than the actual facts of the disorder. Regardless of the fact that the show is a work of fiction, it is still influencing the way people perceive the condition, and if the show is making light of it or playing it off as just being a “neat freak”, that viewer is less likely to understand it or take it seriously in life.
Recently, pictures of a business vehicle using OCD as a tagline for their garage organization services were shared online to vastly differing responses. While many didn’t see a problem with it and found it funny, commenters who have OCD, or have loved ones with the condition, were slammed for either pointing out the incorrect correlation to OCD, or saying its in bad taste. A few years ago, a young girl went viral after posting a picture of a Christmas sweater at Target that used OCD as its theme. The young girl was berated and insulted by a multitude of internet trolls, saying she was just a millennial snowflake, a p*ssy, and just needed to get over it.
No one is saying that we can’t have a laugh at the condition. Just that the humor should not be at the expense of misrepresenting the condition, or not truly showing the depths of the condition. Yes, they’re just comedies, but its leading to a major misunderstanding of the condition, and mental health in general, which our society today does not take as seriously as it should.
Steve Slavin was 48 years old when a visit to a psychologist’s office sent him down an unexpected path. At the time, he was a father of two with a career in the music industry, composing scores for advertisements and chart toppers. But he was having a difficult year. He had fewer clients than usual, his mother had been diagnosed with cancer, and he was battling anxiety and depression, leading him to shutter his recording studio.
Slavin’s anxiety—which often manifested as negative thoughts and routines characteristic of obsessive-compulsive disorder (OCD)—was nothing new. As a child, he had often felt compelled to swallow an even number of times before entering a room, or to swallow and count—one foot in the air—to four, six or eight before stepping on a paving stone. As an adult, he frequently became distressed in crowds, and he washed his hands over and over to avoid being contaminated by other people’s germs or personalities. His depression, too, was familiar—and had caused him to withdraw from friends and colleagues.
This time, as Slavin’s depression and anxiety worsened, his doctor referred him to a psychologist. “I had had an appointment booked for weeks and weeks and months,” he recalls. But about 10 minutes into his first session, the psychologist suddenly changed course: Instead of continuing to ask him about his childhood or existing mental-health issues, she wanted to know whether anyone had ever talked to him about autism.
By coincidence, a relative had mentioned autism to Slavin two days prior, wondering if it might explain why he dislikes social situations. Slavin knew little about the condition but had conceded it was possible. By the time his therapy session ended, his psychologist was almost certain: “She said to me that I’ve either got high-functioning autism or some kind of brain damage,” Slavin recalls with a chuckle. Only a few years earlier, a doctor had finally diagnosed him with OCD. His new psychologist diagnosed him with autism as well.
At first glance, autism and OCD appear to have little in common. Yet clinicians and researchers have found an overlap between the two. Studies indicate that up to 84 percent of autistic people have some form of anxiety; as much as 17 percent may specifically have OCD. And an even larger proportion of people with OCD may also have undiagnosed autism, according to one 2017 study.
Part of that overlap may reflect misdiagnoses: OCD rituals can resemble the repetitive behaviors common in autism, and vice versa. But it’s increasingly evident that many people, like Slavin, have both conditions. People with autism are twice as likely as those without to be diagnosed with OCD later in life, according to a 2015 study that tracked the health records of nearly 3.4 million people in Denmark over 18 years. Similarly, people with OCD are four times as likely as typical individuals to later be diagnosed with autism, according to the same study.
In the past decade, researchers have begun to study these two conditions together to work out how they interact—and how they differ. Those distinctions could be important not only for making correct diagnoses but also for choosing effective treatments. People who have both OCD and autism appear to have unique experiences, distinct from those of either condition on its own. And for these people, standard interventions for OCD, such as cognitive behavioral therapy (CBT), may provide little relief.
Obsessions and compulsions can strike anyone: It’s common to worry about having left the oven on or to rifle anxiously through a purse in search of keys. “They’re really part of the normal experience,” says Ailsa Russell, clinical psychologist at the University of Bath in the United Kingdom. Most people find ways to dismiss those unpleasant thoughts and move on. Among people with OCD, though, those worries build up over time and disrupt daily functioning.
Some people, like Slavin, count steps or breaths to quell their terror that something bad will happen. Others describe themselves as ‘checkers,’ who investigate—again and again—that they’ve done a task properly. Still others are ‘cleaners,’ who wash constantly in response to a fear of filth and contamination. “Mostly, people with OCD realize it’s not that rational,” Russell says, but feel trapped by their worries and rituals.
The overlap between OCD and autism is still unclear. People with either condition may have unusual responses to sensory experiences, according to a 2015 analysis. Some autistic people find that sensory overload can readily lead to distress and anxiety. Slavin, for example, dreads police sirens and the peal of doorbells, which he likens to a bomb exploding in his nervous system. Some researchers say the social problems people with autism experience may contribute to their anxiety, which is also a component of OCD. Not being able to read social cues might lead people to become isolated or be bullied, fueling anxiety, the reasoning goes. “It’s complicated to tease out anxiety from autism,” says Roma Vasa, director of psychiatric services at the Kennedy Krieger Institute in Baltimore, Maryland.
These shared traits make autism and OCD difficult to distinguish. Even to a trained clinician’s eye, OCD’s compulsions can resemble the ‘insistence on sameness’ or repetitive behaviors many autistic people show, including tapping, ordering objects and always traveling by the same route. Untangling the two requires careful work.
One crucial distinction, the 2015 analysis found, is that obsessions spark compulsions but not autism traits. Another is that people with OCD cannot swap the specific rituals they need, Vasa says: “They have a need to do things a certain way, otherwise they feel very anxious and uncomfortable.” By contrast, autistic people often have a repertoire of repetitive behaviors to choose from. “They’re just looking for anything that’s soothing; they’re not looking for a particular behavior,” says Jeremy Veenstra-VanderWeele, professor of psychiatry at Columbia University.
Clinicians, then, have to probe why a person engages in a particular action. That task is doubly difficult if the person cannot articulate her experience. Autistic people may lack self-insight or have verbal, communicative or intellectual challenges, which leads to misdiagnoses and missed diagnoses, like Slavin’s.
Clinicians long overlooked Slavin’s OCD and autism, although he was no stranger to a psychologist’s office growing up in the suburbs of northwest London. He did not speak for his first six years and says his memories are peppered with frequent visits to speech therapists and psychiatrists. Even after he began talking, he was socially withdrawn and disliked eye contact. He was plagued with anxieties and stomachaches.
At around 11, he was diagnosed with ‘infantile schizophrenia’ and prescribed valium and lithium. Doctors warned his parents that he might need to be institutionalized for life. Instead, he attended a progressive boarding school and graduated, as he puts it, a “slightly more functional” person. He pursued his passion for music, met his wife Bonnie and started a family.
His autism diagnosis so many years later was empowering, he says, but it also raised new complications. When he spoke with clinicians, for example, his autism always seemed to eclipse his other challenges, including an auditory-processing disorder. “Once you’ve had a diagnosis of autism, doctors say ‘Oh, it’s because of the autism,’ and they don’t look at the nuances,” he says. He found that no one could tell him whether a particular behavior was a result of his OCD or his autism—or what to do about it.
Answers to Slavin’s questions may emerge as more researchers study autism and OCD together. Just 10 years ago, virtually no one did that, says Suma Jacob, associate professor of psychiatry at the University of Minnesota in Minneapolis. When she told people she was interested in researching both conditions, “top advisers in the field said you have to pick one,” she says. That’s changing, in part because researchers have come to appreciate how many people have both conditions.
Jacob and her colleagues are tracking the appearance of repetitive behaviors—which could be linked to autism or OCD—by age 3 in thousands of children. “From the brain perspective, these [conditions] are all related,” she says.
In fact, scientists have found some of the same pathways and brain regions to be important in both autism and OCD. Brain imaging points to the striatum in particular, a region associated with motor function and rewards. Some studies suggest that people with autism and people with OCD both have an unusually large caudate nucleus, a structure within the striatum.
Animal models, too, implicate the striatum. Veenstra-VanderWeele is studying autism and OCD using rodents that show repetitive behaviors. In both conditions, he and other neuroscientists have found anomalies within the brain’s cortical-striatal-thalamic-cortical loop; this system of neural circuits runs through the striatum and plays a part in how we start and stop a behavior, as well as in habit formation. Another line of inquiry highlights interneurons, which often inhibit electrical impulses between cells: Disrupting interneurons in the striatum can create twitching, anxiety and repetitive behaviors in mice that appear similar to traits of OCD or Tourette syndrome.
Among male mice specifically, interfering with interneurons in the striatum also leads to sharp drops in social interaction, forging a tenuous connection to autism. “Lo and behold, the mice also had social deficits identical to what we’ve seen in [animal models] associated with autism,” says Christopher Pittenger, director of the OCD Research Clinic at Yale University, who led this work. For that reason, he says, interneurons might be a common treatment target for both autism and OCD.
Some of the shared wiring researchers are uncovering could reflect a genetic overlap. The 2015 Danish study found that people with autism are more likely than controls to have relatives with OCD. But genetic comparisons of the two conditions thus far have yielded contradictory results or been hampered by how little is known about the genetics of OCD. “We know much more about the genetics of autism than we do about OCD, almost embarrassingly so,” Pittenger says. That gap could explain why a 2018 meta-analysis of genome-wide association studies—encompassing more than 200,000 people with 25 conditions, including autism and OCD—found no shared common variantsbetween OCD and autism.
Unpublished work from another group suggests that rare ‘de novo mutations,’ which occur spontaneously, can significantly increase the risk of having autism or OCD. Some of the genes the researchers linked to both diagnoses relate to immune functioning, suggesting that an interaction between environmental factors and the immune system might play a role. Another gene on that shared list, CHD8, regulates gene expression.
Until scientists can connect these preliminary findings to pathways, new drug treatments are a long way off. But people who have both conditions do have other routes for finding help.
On a chill evening in December, people across the U.K. dial in to a monthly ‘OCD Autism Support Group’ meeting organized by OCD Action, a U.K.-based charity for people with OCD. The group size varies from one session to the next, but on this particular night, just days before Christmas, there are only four callers.
During the session, a woman named Michelle (everyone on the call uses first names only) explains that she cannot leave the house unless she is convinced all the switches and appliances are turned off. Thomas loses hours of the day to showering. Both talk about social difficulties—and how that can make them anxious. They often worry about what people think of them and whether their repetitive behaviors, caused by OCD or autism, make them appear strange to others.
As with most support-group meetings, the call reassures its participants that they are not alone. The callers also share updates and tips, such as using a timer to cut down on the time spent on hand-washing. Three of the callers mention CBT, which can help people understand and manage their obsessions and compulsions. As with other talk therapies, though, CBT isn’t always effective for people with autism. The therapy did not help Slavin, for example.
He suspects that he was unable to follow his therapist’s approach due to his auditory-processing difficulties and cognitive inflexibility, which he attributes to his autism. “Many people on the spectrum have a problem picturing a situation and picturing how it could have a different outcome, so traditional CBT doesn’t always work,” he says. Slavin instead manages his OCD—with mixed success—using antidepressants.
Some researchers are trying to adapt CBT for people with autism by, among other things, “making sure that somebody can notice and rate their emotional state,” Russell says. Working with her colleagues at King’s College London, Russell found in a pilot study that the modified methods help some adults with both autism and OCD manage their anxiety. Drawing on the success of a subsequent larger trial, she and her colleagues published a guide for clinicians in January.
A more personalized variation of CBT might also work for people who have both autism and OCD. Various schemes include involving parents in sessions, adjusting the language to meet an autistic person’s ability, using visuals and offering children rewards. One trial is comparing these adaptations with standard CBT in more than 160 children who have both autism and OCD. The unpublished results suggest that standard CBT is beneficial, but an individualized approach is best of all.
Slavin sees the merits of more personalized treatment options, although he hasn’t tried it himself. Working with OCD Action and nonprofit advocacy groups for autism, he has come to appreciate the diversity that exists in both conditions. “It’s almost like you need a different diagnosis for every single person, a different category for every single person, because everyone is so different,” he says.
A decade after his autism diagnosis, Slavin is eager to share his experiences, in part to counteract the lack of resources he initially faced. In 2010, he launched a website and, later, a YouTube series to describe what he has learned about life with autism.
“I just see [autism] as a set of circumstances that you can use to your benefit to say ‘Okay, I’m going to forgive myself if I don’t quite understand things in the way other people do,’” Slavin says. “You can almost enjoy being a bit quirky, a bit different in some ways… [but] OCD, there’s just nothing good about that.”
In October, he published a book that chronicles the progress he has made. For now, at least, the book’s title begins: “Looking for Normal.”
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