Cannabis and Mental Health: Obsessive Compulsive Disorder (OCD)

Obsessive Compulsive Disorder (OCD) is a mental health condition that is often misunderstood and misrepresented by the public to some degree. Such misunderstandings may stem from the media’s frequent inaccurate depictions of the disorder and similar conditions like it. Other causes may be due to its similar symptoms to other medical conditions. 

Whatever the case may be, it is time we better understand OCD and other mental health conditions like it. 

Despite an increase in public awareness, portrayals of OCD are often incorrect. The often hyperbolic, comedic depiction of an OCD patient that includes hoarding of niche items and excessive cleaning may play a part in some symptoms. However, it does not accurately summarize what diagnoses OCD.

In fact, OCD symptoms vary by person. Furthermore, the condition equally affects men and women of all ethnic backgrounds at a rather frequent rate. One in 40 adults, and one in 100 children in the United States have OCD.  

Symptoms of the disorder include spending an hour or more each day obsessing over thoughts, images, impulses and/or compulsions. These thoughts become a seemingly unstoppable force, rapidly looping in a person’s mind over and over. Anxiety builds as the person tries to find ways to cope or relieve the internal tension. Compulsions, commonly known as rituals, are employed in an attempt to control these obsessions. Over time, the process tends to disrupt or derail the person’s quality of life over time. 

OCD is often incorrectly associated with the similarly named Obsessive Compulsive Personality Disorder (OCPD). People with OCPD believe in their own routines despite it resulting in possibly detrimental results. Patients often seek control of situations and other aspects of their lives to maintain their habits. With OCPD, a person is focused on perfection, which may lead them to repeat tasks numerous times.

In some cases, OCD has been miscategorized as being on the autism spectrum. This is likely due to both patients often having a preoccupied focus on specific interests. The confusion can be compounded as the two conditions can coexist together. Coexisting conditions are common in OCD. Possible conditions include anxiety and depression as well as bipolar disorder, ADHD, eating disorders and Tourette’s syndrome, among others. 

OCD can also lead to the development of related disorders. These include body dysmorphia, hoarding, hair pulling, skin picking and other conditions focused on picking or chewing certain parts of the body.

At this point, no definitive causes for OCD have been identified. It is thought that a combination of factors, including genetics and a person’s environment, can have a role. 

Studies have shown cannabis may help address OCD symptoms. A 2008 analysis of two patients noted a “significant symptom improvement” when they used medical cannabis or the man-made cannabis-derived drug Dronabinol. 

In 2015, an analysis of 49 studies found that CBD reduced anxiety behaviors in OCD as well as several other conditions. They included generalized anxiety disorder (GAD), panic disorder (PD), post-traumatic stress disorder (PTSD) and social anxiety disorder (SAD). The analysis noted another 2015 study which found that CBD reduced subjects’ behavior to bury a marble for up to seven days. 

In recent news, a 2019 pilot research study of 14 patients aims to understand if smoked THC or CBD can reduce OCD symptoms. The research completed in March of 2019. It has not published its results as of this article’s filing.

Like lab studies, some medical professionals believe cannabis could be a treatment option as well. 

Mitchell Sadar is a clinical psychologist with a specialty in measuring brain waves using biofeedback activity. He believes cannabis may help some OCD patients. 

The 30-plus year medical professional explained that OCD symptoms may stem from “deviant brainwave patterns.” A lack of normal alpha activity may make a person vulnerable to OCD and other anxiety symptoms, according to Sadar. He believes cannabis may help resolve the issue. 

“Cannabis typically increases alpha activity…in the case of OCD associated with a lack of alpha activity, cannabis would be expected to have a beneficial effect,” Sadar elaborated. 

He added that cannabis could be detrimental in other cases, such as when a patient has increased alpha activity. “The bottom line is that cannabis may or may not be helpful depending on the underlying EEG endophenotype.”

While High Times attempted to contact those affected by OCD, none were able to provide us with their personal accounts by the time of this article’s submission. To better understand the patient perspective, we turned to anecdotal evidence supplied over the past few years. Several discussions can be found in online forums. An assortment of responses supports Sadar’s assessment. 

A 2017 Quora thread offered both pros and cons on the issue. One person claimed that cannabis lowered their inhibitions while lessening anxiety. They added that cannabis use made them a more affable person. Another said using cannabis helped them notice when they fall into thought loops. On the other hand, a respondent in the thread claimed that their symptoms were worse when consuming THC. They did not elaborate further. 

The same mixed results were found on Reddit. In one thread, a person claimed cannabis helped them focus, while another reported feeling intense fear and a state of panic.

Few anecdotes about minors could be readily found online. However, a July 2010 ABC News report profiled a California mother Judy Mendoza and her son, Ryan. She claimed that cannabis helped her then 12-year-old son cope with severe OCD brought on by pediatric autoimmune neuropsychiatric disorder associated with streptococcal infections, or PANDAS. 

Ryan’s symptoms were so bad that violent meltdowns could be triggered by everyday occurrences like the wind and the number six. The condition intensified to a point that Ryan asked his mother to kill him to relieve the pain. Judy tried cannabis after using numerous opiate medications. A positive early response prompted the family to continue Ryan on a once-daily cannabis pill with additional liquid drops for when his anxiety became severe. 

Now nearly a decade old, the Mendoza’s story is one many continue to face. Some studies, coupled with stories like the Mendozas, paint a positive picture for cannabis treatments. That said, uncertainty remains over THC as a treatment. With its ability to work for some, it may appear to be the wonder drug many see it as. However, for others, THC can prove to be detrimental. 

As such, it is highly recommended that you or your loved ones speak with a physician before incorporating cannabis into any OCD treatments.

Direct link from brain’s emotion circuit to movement circuit

“This finding is very exciting as it is the first time that a comprehensive circuit mechanism has been found showing how emotional states can influence movement through connections in an area of the brain called the basal ganglia, a region involved in guiding behavior,” says Associate Professor Xin Jin, senior author on the paper. “We did not previously know much about this pathway, so it brings about a whole new paradigm for examining psychiatric disorders as well as spinal cord injury.”

It was previously believed that the brain’s emotion and movement loops worked like parallel closed circuits, operating independently to relay important information. However, researchers suspected that there could be some influence of emotion on movement due to the observation that, in neuropsychiatric conditions such as depression, decreased physical movement is a symptom and could be linked to disrupted emotional processing and reduced motivation. Yet, scientists did not know much about the connections within each circuit or how the circuits might interact.

“We wanted to explore how emotion information reaches the movement circuitry in the brain by using a combination of cutting-edge viral and optogenetic techniques,” says Sho Aoki, co-first author and postdoctoral fellow in the Jin lab.

The scientists sought to trace these circuits in rodent models to better understand each step of neuronal communication. They focused on the emotion and movement brain loops, starting from a region involved in emotion (the medial prefrontal cortex) and a region involved in movement (the primary motor cortex). They used multiple genetic and viral tracing tools, including a technique developed by Salk Professor Ed Callaway’s lab, to observe how each loop was organized in the brain.

To the researchers’ surprise, they found a one-way communication pathway from the emotion loop to the movement loop through an area located deep in the brain called the basal ganglia. The basal ganglia, which includes structures involved in guiding behavior, essentially acts as a crossroads for the emotion circuit to directly influence the movement circuit to control action. To confirm their results, the authors used optogenetics, a technique that uses light to control cells, to investigate the precise function of the neurons in this region. They also studied each neural circuit in isolation from the rest of the brain and confirmed the novel pathway.

“Psychiatric diseases such as depression and anxiety can alter actions in a dramatic way by either decreasing or increasing movement. This mechanism represents a likely way that emotional states are related to changes in action control in psychiatric diseases,” says Jin.

Additionally, this unidirectional communication may be relevant for recovery from spinal cord injury. Researchers previously focused on movement centers of the brain because spinal cord injury is a movement issue; however, since these results suggest emotional states can influence brain movement centers, experiencing positive emotions such as motivation may aid patients in the recovery process. Activating emotion centers could likewise stimulate movement centers and facilitate recovery, according to the Salk co-first authors Jared Smith, a postdoctoral fellow, and Hao Li, a senior research associate. Further, these results suggest that emotional states could directly influence sports performance. So, Jin advices, maybe the next time you feel anxious during a game, just calm down and let the action take care of itself.

OCD, PTSD symptoms overlap

Findings published in Psychiatry Research revealed significant overlap between self-reported PTSD and obsessive-compulsive disorder symptoms.

“Numerous case studies have documented the co-occurrence of these disorders following exposure to a traumatic event,” C. Laurel Franklin, PhD, and Amanda M. Raines, PhD, of the Southeast Louisiana Veterans Health Care System in New Orleans and the Tulane University School of Medicine, wrote. “One possibility for the high degree of co-occurrence between these two disorders is symptom similarity.”

Franklin and Raines examined symptom endorsement and overlap between OCD and PTSD in 117 trauma-exposed veterans.

At a VA hospital, participants were administered self-report assessments — such as the Dimensional Obsessive-Compulsive Scale (DOCS) and the PTSD Checklist for DSM-5 (PCL-5) — as part of a routine clinical care. For analysis, the researchers first examined rates of PTSD, OCD and co-occurring PTSD/OCD using clinical cut scores on self-report measures, then calculated a series of correlations for the PCL-5 total score, DOCS total score and DOCS subscale scores, and lastly paired DOCS and PCL-5 items for similarity in item content.

Based on self-report assessment of clinical cut scores, the results showed that 81% of veterans met for probable PTSD and 74% met for OCD. Chi square analyses also revealed frequent overlap of endorsement across items with similar content, according to the findings.

Using Pearson product-moment correlation, Franklin and Raines found a strong positive association between PCL-5 and DOCS total scores (r = 0.6; P .001), which remained significant after controlling for self-report depressive symptom severity (r = 0.48; P .001). In addition, they reported links between PCL-5 total scores and DOCS subscales scores: contamination concerns (r = 0.32; P = .002); responsibility for harm (r = 0.55; P .001); unacceptable thoughts (r = 0.71; P .001); and symmetry concerns (r = 0.42; P .001).

“To our knowledge, this study is the first to explore symptom overlap using an outpatient sample of veterans and self-report scales that more accurately assess the constructs of interest,” Franklin and Raines wrote. “Given the significant overlap, caution should be used when using self-report solely to assess PTSD and OCD particularly in traumatized samples.” – by Savannah Demko

Disclosure: The authors report no relevant financial disclosures.

Obsessive-compulsive disorder: All you need to know – symptoms of OCD, causes, treatment

Obsessive-compulsive disorder: All you need to know- symptoms of OCD, causes, treatment

New Delhi: Obsessive-compulsive disorder (OCD) is a common mental disorder that affects people of all ages and walks of life. Like a needle getting stuck on an old record, OCD causes the brain to get stuck on a thought or action. For example, the person may check the stove 20 times to make sure it’s really turned off, or wash hands until the skin peels off. The person doesn’t derive any pleasure from performing these repetitive behaviours and anxiety is generated by the obsessive thoughts. OCD consists of obsessions and compulsions.

OCD is seen in 2-3 per cent adult population and 1 per cent in children and adolescents. Obsessions are involuntary thoughts, images, or impulses that occur over and over again in the patients’ mind. They don’t want to have these ideas but they can’t stop them. These obsessive thoughts are disturbing and distracting. Compulsions are behaviours or rituals that the patient feels driven to act out again and again. Usually, compulsions are performed in an attempt to make obsessions go away. For example, if the patient is afraid of contamination, he might develop elaborate cleaning rituals. However, the relief never lasts. In fact, the obsessions come back stronger and the compulsions often end up causing anxiety themselves as they become more demanding and time-consuming. This is the vicious cycle of OCD.

Signs and symptoms of obsessive-compulsive disorder

Scientists have classified the many symptoms of OCD into four major categories:

  • Washers: Repeated thoughts of dirt and contamination followed by repeated washing and cleaning
  • Doubters, Checkers and Counters: Repeated illogical doubts followed by repeated checking and counting
  • Arrangers: Repeated thoughts of symmetry and things being just right followed by repeatedly arranging things
  • Sinners: Repeated thoughts of sinning or taboo thoughts or sacrilegious thoughts or forbidden actions and in response repeated compulsive ritualistic behaviours

Causes of obsessive-compulsive disorder

The exact causes are not fully known. However, research suggests a combination of genetic, psychological and environmental factors can make a person more likely to develop the condition. A stressful childhood environment or an emotionally traumatic event might trigger a psychotic episode. The main theory is the severe decrease of the neurochemical serotonin in certain parts of the brain.

Treatment for obsessive-compulsive disorder

OCD is typically treated with medications, psychological counselling, family counselling to understand the illness and motivate family members to help.

No matter how overwhelming your OCD symptoms may seem, there are many ways in which you can help yourself. Some of the most powerful strategies are to eliminate the compulsions that keep your obsessions going. Here are some tips that can help you cope with OCD:

  • Relabel – don’t avoid your fears. Try to resist or delay the relief seeking compulsions. When the OCD thought arises, try to relabel it as just an OCD thought.
  • Reattribute – tell yourself it’s not me it’s my OCD.
  • Refocus – shift your attention and do something else when the OCD thought comes such as exercise, listening to music, reading, playing a video game, etc.
  • Revalue – do not believe your OCD thought. Tell yourself it has no meaning.
  • Write down your OCD thoughts and worries.
  • Exercise regularly.
  • Get enough sleep.
  • Avoid addictions.
  • Practice relaxation techniques like yoga and deep breathing.
  • Reach out for support – meet your nearest psychiatrist, counsellor or mental health professional.

Disclaimer: The author, Dr Shaunak Ajinkya, Consultant Psychiatrist, Kokilaben Dhirubhai Ambani Hospital, is a guest contributor and a part of our medical expert panel. Views expressed are personal)

"Euphoria" displays the real-world problems of teenagers

The first season of “Euphoria” on HBO was a whirlwind phenomenon. Despite only being eight episodes, the complex drama showed its viewers a different point of view of a not so typical teenager. Euphoria explores various situations, from losing their virginity before junior year to becoming more aggressive with a parent. All of “Euphoria’s”characters have a traumatic backstory that makes the show more intriguing. 

The music played during montages throughout the season expresses how characters are feeling, by themselves or in a group. For example, whenever rap music is played a character would be getting ready for a party, “getting hyped.” Alternative music is played when a character, Rue, is getting high.

At the beginning of each episode viewers get a look into the lives of different characters. This method is a nice introduction to the characters and builds up what’s to come for the rest of the episode.

At a young age, the show’s protagonist Rue, played by Zendaya, was diagnosed with several mental disorders, such as obsessive compulsive disorder, attention deficit disorder, general anxiety disorder and impulsive bipolar disorder. The only time she didn’t feel as if she were crazy was when a nurse put her on valium at the hospital. That was the beginning of her downward spiral. Rue’s drug abuse had gotten so out of hand that she almost dies of an overdose.

 Zendaya is known for playing Rocky and K.C on the Disney Channel programs “Shake it Up” and  “K.C Undercover” as well as for playing Anne in “The Greatest Showman” and M.J. in “Spider-Man: Homecoming” and “Spider-Man: Far From Home.” It is exciting to see her play this role. showing  she can be a serious actress. 

Jules, played by Hunter Schafer, is a transgender transfer student who befriends Rue, and their connection grows to unimaginable heights. Her presence helps Rue stay clean. Schafer is known for modeling, but she has skills in acting. To be playing a character like this must take a lot of studying, since she is not a transgender actress. She plays Jules as if she knew this character or someone who is like Jules. I wonder how Schafer feels in these intense scenes with Nate and his Father Cal. Jules had an awful childhood. Her mother didn’t accept her for who she is and tricked Jules into staying at a mental institution for years. Jules wanted someone to love her, so she would have sex with random guys. The last guy she slept with is the father of one of her classmates, Nate Jacobs, played by Jacob Elordi.

The cinematography of the show is superb. One scene in the first episode shows Rue snorting drugs in the bathroom. As she comes out, the hallway begins to spin. This gives the viewer an insight into how Rue feels: chaotic. “Euphoria” is a show whose writing doesn’t follow the stereotypes seen in “safe” teen stories. For instance, Nate is an overprotective boyfriend who likes to hold his girlfriend, Maddy, the head cheerleader, on a leash. Also, they like to get back at each other, meaning they will cheat. But they always seem to come back together even though their relationship is unhealthy. 

Overall, Euphoria is show for teens and about teens. It’s a raw perspective on a new reality, a new normal. It’s nice to see something controversial. Something that is truthful. It gives people something to talk about other than politics.

Fighting the Shame of Skin Picking

For many people with body-focused repetitive behaviors, though, the predominant effects are cosmetic, and the consequences emotional and social.

Mindy Mitchell, an insurance agent who lives in Shelbyville, Tenn., noticed in August 2017 that her elder daughter, Alyssa, who was 9, had begun to pull hair from her scalp. Within six months, Alyssa was bald but for a strip along her crown.

Ms. Mitchell, who is 36, was alarmed, but unsure of what to do. Kids at school began to tease Alyssa for her baldness, calling her names like “cancer girl.”

“Her having to explain that 20 times a day is really upsetting,” Ms. Mitchell said. She took Alyssa to be fitted for a wig.

When Ms. Mitchell eventually searched online, she came across the nonprofit TLC Foundation for Body-Focused Repetitive Behaviors, a patient-advocacy organization for the disorders. The organization works to promote awareness of the behaviors so that affected people can better understand their conditions and seek evidence-based treatment, said Jennifer Raikes, its executive director.

The group maintains an online database of clinicians with relevant experience, and convenes an annual conference for patients, family members, clinicians and researchers. Ms. Mitchell and Alyssa were among more than 440 attendees at this year’s gathering in Chantilly, Va., in May. Alyssa befriended other kids who came — some of whom also wear wigs. Ms. Mitchell left with some recommendations for treatment options for Alyssa close to home.

Hyperactivity Symptoms in Women and Girls with ADHD: Children and Adults

Like most people with an ADHD diagnosis, I discovered my condition in the context of failing to meet school-related expectations. In third grade, I was lucky enough to have a teacher suggest that my regular inattentiveness might be related to attention deficit hyperactivity disorder (ADHD or ADD). This was shocking and perplexing and life-changing because, at that time, most educators only thought to attribute the condition to disruptive and hyperactive children — not well-behaved, quiet daydreamers like me. I was never oppositional, defiant, or difficult. In fact, I was overly cautious and obsessed with following the rules.

One time, I was very mildly punished because I accidentally stayed outside after recess had ended. Instead of acting out because small infractions like these felt beyond my control, I apologized profusely, cried, and was thoroughly embarrassed. I held my struggles close to my heart and kept them secret. I never told my parents about instances like these, or that I constantly failed to keep myself from blurting out in English in a Spanish-immersion school where that was forbidden.

Regardless, my parents and teachers noticed that I lost everything, daydreamed constantly, and was thoroughly unmotivated to do my homework. I was initially diagnosed with primarily inattentive ADHD. Though I accepted the diagnosis and felt some relief, it did not help explain the struggles I felt outside of the classroom. No one connected the dots from my ADHD to my chronic lethargy, sleeplessness, ruminating thoughts, or emotional irregularities. My diagnosis explained a lot, but it did not explain the constant hyperactivity I held within myself.

That hyperactivity manifested in quiet ways when I was a child. I chewed on the ends of pencils, bit my sleeves, chewed my hair, ate paper, tapped my foot, felt mildly anxious, picked my scabs, and felt a strange overwhelming need to blow out candles at restaurants. Beginning in middle school, I became increasingly self-conscious of these habits. My hyperactivity became more and more tortuous as I bottled it up inside.

I became extremely socially anxious, couldn’t sleep at night, developed certain obsessions, had periodic panic attacks, and became deeply sad. I eventually started taking SSRIs for generalized anxiety disorder in high school. I could no longer hide the fact that I hadn’t slept for three days straight, or that once or twice I called my parents in tears when seized by the terror that I was being targeted by malevolent insects. I developed certain obsessions — like the possibility that my family would die, or that I had done something awful but forgotten about it.

[Self-Test: Symptoms of ADHD in Women]

I also became secretly obsessed with discovering what was wrong with me. Did I have obsessive compulsive disorder? Did I have a personality or a mood disorder? Or maybe I was just sad and anxious? I kept ADHD at the back of my mind, but I didn’t even begin to relate it to my ongoing struggles.

I never considered talking to my doctor about experimenting with different ADHD medications or dosages, though I always suspected that my medication had little to no effect on me. Medical professionals suggested that I required a very low dosage, since my lack behavioral problems was equated with having ADHD of lesser severity. What’s more, I had outgrown my previous academic struggles in elementary school — at least outwardly. Though I procrastinated constantly, couldn’t bring myself to study for exams, and often skipped boring classes, I got mostly As. I quickly gave up on reading Shakespeare when my attention wandered, but I used sparknotes and was a strong writer. I loved more ADHD-friendly literature and was obsessed with mathematics, therefore had no issues excelling in those areas. Since I no longer performed poorly in school, everyone considered my ADHD treated. For the longest time, I thought that ADHD was a learning disability, not a mental illness. Therefore, I vaguely suspected the diagnosis was a mistake all along, or that I had simply outgrown it.

When my brain wouldn’t give me a break, I felt terminally broken, confused, and sick. I constantly searched for answers but couldn’t find them. Why did I exhibit strong OCD symptoms, but then seemingly move on from them for months at a time? Why was I selectively misophonic — driven to rage or anxiety by certain noises, but only if I was already uneasy or trying to focus on something? Why was getting out of bed in the morning so hard? Why was I so avoidant and afraid of failing?

I swallowed these questions whole because I was still foolishly ambitious and felt optimistic about college. I grossly overestimated what I was capable of handling in college. I enrolled in the honors college at my university and tried double majoring in English and Physics — all while pursuing my somewhat promising dream of being a successful musician. I had also entirely underestimated the role my family played in keeping me on track in high school. Left to my own devices, I floundered miserably. As I tried to keep my head above water, I quickly realized that I had to drop the honors college and only pursue one degree if I was going to survive.

[Self-Test: Obsessive-Compulsive Disorder in Adults]

I began seeing a therapist to address my disturbing obsessive thoughts and deep sadness. My therapist reasonably posited that I may be dealing with untreated OCD and suggested that I talk to my doctor while she helped offer strategies to deal with my obsessions. I readily accepted her prognosis and became optimistic again. I ignored the suspicion that the new diagnosis didn’t account for the fact that my obsessions tend to inexplicably fade away for long periods of time before materializing once again. Or that, though they kept me up at night, the obsessions didn’t seem to be the root of my issues during the day. Still, it was easier to believe OCD had been the root of my problems; it was, at least, an answer that validated the pain I felt.

I also re-evaluated my medication, and with a doctor’s approval, started taking ​bupropion as a substitute for my ADHD medication and SSRIs. Bupropion is a norepinephrine-dopamine reuptake inhibitor (NDRI), which can sometimes help treat ADHD as well as mood disorders. I didn’t believe my ADHD was very severe at all, so I figured that forgoing stimulants would be a non-issue. The doctor I spoke to briefly on the phone enthusiastically agreed.

I didn’t feel any better, but I kept faith in bupropion and kept upping my dose until I wasn’t allowed to increase it any further. I then lied to myself and my doctors, and told them I was seeing an improvement in my symptoms. Meanwhile, I lost my previous ability to precariously balance my academic responsibilities. I managed to maintain allowable grades, but I was at the brink of hurting myself. I continued to spiral downward, while frantically protecting the facade that I was doing well.

I was late to work and class every day, and sometimes completely forgot to go. I quit my job because I suspected that I was about to be fired, and I lied to my professors about struggling with migraines when they expressed concern over my absences and apparent sudden disengagement in class discussions. I felt overwhelmingly ashamed, guilty, and lost as I tried to reconcile the high expectations I’ve always had for myself with my helpless lack of motivation.

The end of my freshman year came to a boiling point when I found myself having to write 10 pages of a 12-page research paper the night before it was due. I created an extremely dangerous strategy to kick my dopamine-starved brain into action; the night before an essay was due, I would sacrifice sleep, drink about seven cups of coffee, and tell myself that I only had two options: finishing the assignment or ending my life. I made it to the end of the year, but confessed to my parents that I wasn’t sure I could handle going back, which took them by complete surprise. My parents found me a therapist, while strongly advising me to create a resume and find a job to keep myself active. Without the school-related anxiety, I couldn’t even bring myself to write a resume during those three whole months, let alone get a job. My self-esteem was at an all-time low and I felt like a huge disappointment.

That summer, I rummaged through my parents file cabinet and, in a desperate search to discover what on earth was wrong with me, reconnected with old documents related to my ADHD diagnosis. I read school reports dating all the way back to preschool in which teachers expressed that I was well-behaved but did not grasp material as quickly as expected and was always staring out the window. I then went through a psychoeducational evaluation that documented clear inconsistencies and divergences in the way my brain operates. Although my visual sequencing skills were reported above the 99th percentile, my visual memory was reported in the 0.4th percentile as a result of my inability to concentrate. I have clear strengths, but I struggle to efficiently utilize them with my serious deficiencies.

I felt a sudden wave of cathartic relief and frustration. I don’t just have ADHD, I have REALLY bad ADHD! No wonder life is hard for me. I’m living with what I’ve learned to accept as a beautiful and unique but hilariously inefficient brain. I did further research into the condition I almost thought had fallen upon me by accident or mistake. The explanation for my difficulties that I so desperately yearned for had been there in plain sight since I was 9 years old.

No one had told me that my ADHD accounted for my hypersensitivities, obsessions, lack of motivation, and sleeplessness. No one told me that visible hyperactivity only manifests in 25% of children and 5% of adults with the condition. I never yelled, rebelled or distracted others, but I internalized the whirring in my brain, kept it from interfering with others, and came dangerously close to hurting myself as a result. I became deeply frustrated by the fact that many people (including educators and medical professionals) still believe that hyperactivity from ADHD is only a problem when it’s socially disruptive.

At the same time, I found peace with myself, stopped searching for answers, and started accepting my endlessly annoying brain with loving compassion. My sophomore year, I started taking Adderall in conjunction with SNRIs for generalized anxiety and mood disorder. Adderall almost immediately helped me see the forest through the trees and envision a non-disastrous outcome for my life. I remember calling my dad to tell him that I finally felt healthy, engaged, and optimistic again. I no longer felt like I was constantly driving a car that was leaking steering fluid and had no brakes. When I hung up the phone, I burst into actual tears of joy. I was so relieved to finally believe it when I told my parents that I felt happy, and that they don’t have to worry about me.

I still struggle daily with my ADHD, but I also recognize the color it adds to my life — the unique and valuable way it makes me approach problems; the resilience it forces; and the passion and focus it reserves for the things I care about.

[Self-Test: Generalized Anxiety Disorder in Adults]

Updated on September 3, 2019

New Law Aims to Help Struggling New Parents Get Help

Postpartum depression — more properly known as perinatal mood and anxiety disorder — affects 1 in 7 new mothers. And yet not many parents or doctors know how to recognize symptoms or treat it. A new Texas law, which took effect Sept. 1, puts in place some steps to make treatment easier.

The law establishes a five-year, statewide plan to set up a treatment network and resources. The plan is supposed to improve awareness about the illness for the public and care providers, reduce the stigma associated with it, establish a community health provider referral network and figure out how to use existing funds to assist with screening, referrals and supportive services.

How to Get Help

Christy Doering
972-696-9207 (text or call)

Kim Kertsburg
214-300-5333 (text or call)


Bina Bird
817-676-8858 (text or call)


Michele Davidson

While this kind of legislated plan cannot hurt, it may not be enough to help, either, said Ann Smith, president of Postpartum Support International. Misinformation and stigma make it hard to admit to the illness and to recognize and treat it. What’s more, many care providers simply don’t have the training.

With celebrities like Chrissy Teigen and Gwyneth Paltrow sharing their own experiences with perinatal disorders, the issue is starting to be less stigmatized, but there’s still a lot of misinformation and fear out there.

The best-known name for the disorders — postpartum depression — is in itself a misconception. Many parents don’t experience or exhibit any symptoms of depression and don’t seek help because they don’t feel depressed, Smith said.

Frequently, the disorder presents as anxiety. Those who do feel depressed might still not want to seek treatment because of the stigma surrounding metal illness in this country or because they’re afraid they won’t be believed. Others are told by family or friends that they’re making it up or that they can just pray the pain away. Neither of these is true, Smith said.

“People don’t realize how common this is, because they don’t talk about it. I have so many moms who say, ‘Well, all the other moms are having such a good time.’ No, they’re not (necessarily),” said Christy Doering a Plano-based therapist and social worker.

Becoming a new parent is the biggest change most people will go through in a lifetime. And while being overwhelmed is normal, if you can’t sleep when the baby is sleeping, haven’t bonded with the baby, worry that you’re being a terrible parent, even when you’re caring for the baby or are having an internal dialogue that seems illogical, that’s all OK, but it’s not normal, Doering said. But you can get help and get better.

Symptoms range from simply not feeling right or feeling as though life isn’t as good as it used to be and being anxious, to not being able to get out of bed or eat. Anyone feeling like this is not to blame, Smith said. 

For Smith, who had the disorder with her second and third children, it manifested as severe agitation and anxiety. Her pregnancies and births were relatively easy, and she had never had mental health issues. Although 50% of parents who have a perinatal disorder have had a previous mental health issue, it can happen with no prior history.

Smith’s experience was roughly 30 years ago, when much less was known about the illness. Because she was a trained nurse midwife, she had heard the term “postpartum depression.” She knew something was wrong, but she didn’t feel depressed. Instead, she was anxious, she couldn’t sleep and she couldn’t focus on reading long enough to finish a sentence. It was as though she was two seconds away from a terrible accident all the time.

“I felt like I had had 1,000 cups of coffee. I felt like I couldn’t breathe,” she said. “It was a really frantic feeling.”

Smith knows now that her body was stuck in a fight-or-flight reaction. But back then she still thought it was a hormonal reaction or a thyroid issue.

Eventually she muddled through the confusion and found a psychiatrist who understood just enough to prescribe her an early version of the medication patients receive today. She started to sleep and gradually got better. By the time her child was about a year old, she felt wounded, but mostly like herself.

The second time it happened, it was no less painful but less frightening. She knew what to do.

The good news, Smith said, is that a lot more is known about the illness now than when she had it. It is very treatable and almost everyone gets better, especially if they get treatment early.

“We say, ‘You are not alone, you’re not to blame, and with the proper help, you will be well,’” Smith said.

And, although this is another common misconception, even though treatment commonly involves medication, it is not addictive or personality-altering and doesn’t prohibit breastfeeding, Smith said.

The descriptor “postpartum” is also misleading, since 30% of cases of this illness start during pregnancy, she said. It’s important to start checking on women while they are still pregnant.

But, even mandated universal screenings and education campaigns cannot address the issues if there aren’t treatment possibilities.

“The only time that it really helps is if there’s teeth behind it,” Smith said.

That’s where Texas’ legislation might fall short — the resources behind diagnosis and education efforts to treat and heal those who experience the disorders.

To start, it’s important to understand that what happens is not a weakness. Perinatal mood and anxiety disorder is an illness and can be treated effectively. It is also critical that the treatment is provided by professionals who have been trained to understand and recognize the illness. General care providers cannot be expected to know exactly what to do, but they must be able to recognize the gap in their knowledge and know that they need to pass the patient along to a specialist, Smith said.

Another concern Smith hears is that the parent’s children will be taken away. Any professional trained to understand what is going on will not try to take children away from the patient, she said.

That includes incidents of postpartum obsessive-compulsive disorder. In these cases, parents have recurring intrusive thoughts, often many times a day, of something terrible happening to their baby, sometimes even of doing it themselves.

Although this is frightening, it too is treatable, Smith said. A parent will know that the thoughts are not real and will have no urge to act upon them. Most parents are very ashamed and have a hard time admitting to these thoughts, which makes it hard to seek treatment, but if they do, they will get better.

Where the postpartum illnesses do risk harm to the child is with postpartum psychosis — a break from reality. This is very rare and different from obsessive-compulsive disorder.

“Intrusive thoughts after somebody has a baby, those are very common, but only 1 in 1000 women will have postpartum psychosis,” Doering said.

The key difference is that even in the case of the worst thoughts associated with perinatal OCD, the parent is horrified by them, whereas with postpartum psychosis, the parent believes she is doing the child a favor.

Understanding that delineation is important for new parents, family, friends and care providers. Parents experiencing postpartum psychosis will sound clearly delusional. Psychosis frequently has a religious element. Sufferers are often hyperactive and have hallucinations that lead them to believe that ending the child’s life will eliminate or prevent suffering and send it to a better place.

“The sad thing is that it’s usually an act of love,” Smith said.

An attack of psychosis is a medical emergency. It is very clear and not hard to detect. If you encounter someone with postpartum psychosis, Smith recommends contacting a family member, staying with the person and calling 911 if necessary.

“It is very clear that someone is talking to someone who is not in the room,” she said.

The disorders can also affect the non-birth parent, male or female. One in 10 men experiences a postpartum disorder. The onset is often sudden, and men tend to become aggressive and hostile, develop substance abuse problems or withdraw, Smith said.

Of course, it’s normal for new parents to be exhausted, to worry some, to wonder if they’re doing it right and even to feel a bit of grief, knowing life is never going to be the way it was before the baby, Smith said. But perinatal disorders go beyond those feelings.

“It’s a visceral thing. When it happens to you, I think it’s very clear that there’s something very wrong with you,” she said.

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Medical professionals need to be trained to recognize, treat and refer. And those treating parents must offer them safe, private spaces to talk and to feel OK admitting to their feelings, Smith said.

Doering wishes that Dallas had intensive dedicated services for moms who need serious help, particularly with postpartum psychosis. She pointed to a program in North Carolina that is just for women with the disorder and one in the United Kingdom that even allows moms to bring their babies. In Dallas, there isn’t enough funding for breakout programs, and parents who need treatment are often slotted into groups with a variety of mental health concerns, which isn’t the best environment for recovery, she said.

Dallas has a number of therapists trained to diagnose and treat perinatal mood and anxiety disorders, including Doering, who is also a resource for referral to other professionals. When she gets a call, email or text, she has a checklist she goes through to figure out what the caller’s needs are and how best to address them. However people reach out, it is possible to direct them to help.

“It will be OK,” she said. “These are some of the most treatable versions of mental health issues around.”

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New research: Online treatment for obsessive-compulsive symptoms found to increase access to effective treatment

Researchers find internet-delivered cognitive behavior therapy effective in treating OCD, having potential to reduce extreme waitlists currently experienced at specialist anxiety clinics


  • 300,000 Australians live with obsessive-compulsive disorder (OCD), many of whom experience barriers to receiving help and treatment.
  • One-third (38%) of those who access the self-guided internet-delivered cognitive behavior therapy (ICBT) experienced clinically significant improvements in symptoms.
  • Those living in rural and regional Australia or whose symptoms prevent them from seeing a psychologist, can now access this form of treatment, free of charge.

Researchers at Macquarie University have proven the effectiveness of online treatment for those living with obsessive-compulsive disorder, revealing a viable solution to overcome barriers to treatment including location and cost.

The new research, published in August in the Journal of Anxiety Disorders, analysed the results of a free internet-delivered program in bettering patient outcomes, which found 38% of participants had a clinically significant improvement in symptoms three months following treatment.

Approximately 300,000 Australians are affected by OCD each year. 1 OCD symptoms include repetitive and unwanted thoughts, mental images, or doubts, which are called obsessions. To cope with the distress of these obsessions, many people living with OCD perform rituals or compulsions.

Previous research in this space has found that many Australians would rather self-manage their care if they sought treatment for an anxiety disorder, rather than seek professional help from a psychologist.2

Online services, such as the OCD program tested in this research, are proving increasingly important for those who face obstacles in receiving help for anxiety disorders, explains lead author Dr Bethany Wootton, an Honorary Senior Research Fellow at Macquarie University.

“Cost, location, and a reluctance to seek help are just some of the barriers faced by those living with obsessive-compulsive disorder and other anxiety disorders,” says Dr Wootton.

“Being able to develop and implement online services, such as the one analysed in our research, mitigates these barriers, provided they are effective.”

Self-guided intervention for those living with OCD symptoms, not only overcomes barriers to care, but also provides cost saving benefits, as little clinician time is needed during the process.

People who experience lower prevalence conditions, such as OCD, can also benefit from access to online treatment, as not all clinicians are specifically trained in OCD treatment. Standardised online treatment courses can offer more consistent and effective treatment options for those in rural and regional areas who may not have access to the right specialist.

The researchers completed a randomised controlled trial comparing the self-guided internet-delivered cognitive behavior therapy to a waitlist control group, and then compared results at pre-treatment and post-treatment, and followed people up 3 months later.

The results revealed 27% of patients who used the self-guided ICBT had clinically significant symptom improvements post-treatment, and 38% experienced improvements by the three-month post-treatment follow-up session.

“It’s important that patient groups that have severe barriers to care are not disadvantaged from seeking the help they need,” says Associate Professor Blake Dear, of Macquarie University, who assisted with the research.

“Our findings have implications across a number of anxiety disorders, as well as other mental health disorders, to warrant a move to more accessible treatment options, especially for those living in regional and rural Australia.”

The researchers have now received a grant from the International OCD Foundation to continue their work, including research into predictors of response to treatment.

A clinician-guided version of the internet-delivered cognitive behavior therapy for obsessive-compulsive symptoms is available for free on the MindSpot website:

Dear B, Karin E, Titov N and Wooton B M. Self-guided internet-delivered cognitive behavior therapy (ICBT) for obsessive-compulsive symptoms: A randomized controlled trial. Journal of Anxiety Disorders. August 2019.

How strep throat may spark OCD and anxiety in some kids

One night in December 2013,
Hans Korbmacher awoke in a fury. The book-loving, introverted 10-year-old was
feverish, agitated and gnawing on his tongue. He headed downstairs, leaped onto
an ottoman and threw his hands over his head, startling his parents. He was
“clearly not present,” says his mother, Heather Korbmacher.

the same thing happened two weeks later, she thought fevers may have induced
Hans’ bizarre behavior. A nurse said it could be the flu. Meanwhile, Hans’
condition worsened. He was anxious and volatile. His handwriting, once a model
of penmanship, morphed into angry scribbles. And he became a peculiarly picky

a behavioral specialist for schools in Bellingham, Wash., tried to manage Hans’
symptoms on her own. “It was working OK during those first five months, until
it was absolutely not,” she says. Extreme rages came weekly and then daily,
keeping Hans out of school. He punched holes in walls and ripped down curtains.
The worst part: Hans was acutely aware that something was very wrong. He
pleaded with his parents to make it stop. “He would beg us to kill him,”
Korbmacher says.

doctors’ appointments later, a psychiatrist suggested that Hans’ symptoms stemmed
from obsessive-compulsive disorder, or OCD. The diagnosis seemed off base to
Korbmacher until she read online about a rare form of OCD with a mouthful of a
name: pediatric autoimmune neuropsychiatric disorder associated with
streptococcal infections, or PANDAS for short. Hans had all but one of the
listed symptoms.

immediately had Hans tested for a strep infection. A throat swab came back
negative, but blood tests revealed that he had four times the typical levels of
immune molecules that the body produces in response to a strep infection. 

PANDAS is as puzzling for researchers as it is for the families that struggle with it. Scientists studying the condition propose that the string of psychiatric symptoms is triggered by infection with Group A Streptococcus, one of the most common childhood illnesses (SN: 3/2/19, p. 7). In some children, a faulty immune response to the infection may mistakenly attack brain cells, causing behavior to go haywire.

researchers have yet to nail down which brain cells are harmed. And it’s not
clear why countless children get strep, yet so few develop PANDAS symptoms.
With so much uncertainty about how strep could affect the brain, some experts
doubt whether PANDAS is a separate disorder from OCD and whether it’s truly
triggered by strep. Amid the debate, families searching for help get mixed

Some children with PANDAS symptoms experience an abrupt decline in fine motor skills, such as drawing. On the left is a drawing done during an acute episode. On the right is the same child’s art after a treatment.S. Swedo et al/Pediatrics and Therapeutics 2012

have begun to fill in some gaps in understanding, and some say the field is on
the cusp of explaining the biology underlying PANDAS. “We’re at a point where
the basic science research is just progressing at lightning speed,” says Susan
Swedo, the developmental pediatrician who coined the term PANDAS. But other
researchers are much more reserved, saying a heap of work still remains.

Support for a connection between the body’s reaction to an infection and changes in mental health comes from recent studies linking infections and inflammation with several more common psychiatric disorders, including schizophrenia, depression, Alzheimer’s disease and autism. As scientists delve deeper into these intriguing links, the hope is that new ways to detect and treat these conditions will come into focus.

A questioned discovery

Swedo described PANDAS in
the 1990s while studying a childhood condition called Sydenham chorea. The rare
disorder can occur with rheumatic fever, the heart condition that can develop
when a Group A strep infection goes untreated. Patients with Sydenham chorea
uncontrollably jerk their limbs and bodies.

found reports suggesting that some patients with Sydenham chorea also have
psychiatric problems. “Those children were noted to have a lot of obsessional
fears about contamination, about harm coming to their parents,” says Swedo, a
scientist emeritus at the National Institutes of Health in Bethesda, Md., and
chief science officer of the PANDAS Physicians Network. The children “had
separation anxiety, emotional [instability] and even frank psychotic symptoms.”

Swedo and colleagues found that some children with Sydenham chorea displayed obsessive symptoms that came on suddenly. The researchers observed a similar abrupt onset of symptoms in some children with OCD. In many of these children, surges in obsessive behaviors followed strep infections.

After evaluating a separate group of 109 children with sudden-onset OCD, Swedo’s team determined that 50 of the youngsters represented a distinct subgroup whose symptoms appeared out of the blue and then waxed and waned over time, seemingly in step with strep infections. The researchers published their findings in 1998 in the American Journal of Psychiatry.

To date, a PANDAS diagnosis is defined solely by its symptoms. There is no definitive lab test. (One company markets a PANDAS blood test, but evidence suggests it doesn’t actually work.) Swedo says it’s possible that as many as 1 in 400 children in the United States have the condition. But strep expert Ellen Wald, who also thinks that PANDAS is a distinct condition, disagrees with that estimate. “My guess is that it’s quite a bit lower than that,” says Wald, a pediatrician at the University of Wisconsin School of Medicine and Public Health in Madison.

Some experts aren’t convinced that PANDAS is even real. After Swedo first described PANDAS, skeptical clinicians aired concerns in medical journals, questioning whether the evidence supports calling PANDAS a condition. With missives lobbed back and forth between the skeptics and PANDAS proponents as recently as July, little has been resolved.

Mink, a pediatric neurologist at the University of Rochester Medical Center in
New York, is a skeptic. He says he sees around 25 patients with suspected
PANDAS each year but has yet to come across a case that checks off all the
criteria for the condition. Mink argues that these patients most likely have
traditional OCD or Tourette syndrome, a tic disorder that involves compulsive
movements or outbursts.

parents are often disappointed with diagnoses without a clear-cut cause, Mink
says. PANDAS offers a straightforward trigger. “Everybody knows about strep
infections,” he says.

The link between strep and PANDAS is tenuous at best, say Mink and pediatric neurologists Donald L. Gilbert of Cincinnati Children’s Hospital and Harvey Singer of Johns Hopkins School of Medicine in a commentary in the August 2018 Journal of Pediatrics. The research that came after Swedo’s initial reports is a mixed bag; some studies find that strep occurs just as often in children diagnosed with OCD or Tourette syndrome as it does in children meeting PANDAS criteria.

These conflicting results led Swedo and other PANDAS researchers in 2012 to propose a broader condition called pediatric acute-onset neuropsychiatric syndrome, or PANS. The new diagnosis describes children who suddenly develop dramatic obsessive symptoms and other psychiatric signs with or without a preceding infection.

Wald says it may never be possible to prove without question that PANDAS stems from strep. The time between infection and the onset of psychiatric symptoms may vary from weeks to months. By then, standard strep throat swabs would come back negative. But that doesn’t negate the possibility that a strep connection, or that PANDAS itself, exists, she says. “It’s sort of time for us to say there are many unknowns here, but let’s try to keep an open mind and really try to learn about how common it is and how [to] approach it.”

Mind-body connection

Early evidence reviewed in June in Nature Reviews Neurology suggests that immune factors, such as autoimmunity, inflammation or even infections, play a role in several conditions once thought to be primarily psychiatric, including those below.

Schizophrenia  Studies suggest that
patients with schizophrenia experience chronic inflammation, an imbalance of
inflammatory molecules and overactive microglia, the primary immune cells of
the brain.

 As with schizophrenia, depression has been
tied to shifts in inflammatory molecules and microglial activation. New data
also suggest that some antidepressants work, in part, by reducing inflammation.

Alzheimer’s disease  Excess inflammation and overactive microglia may play a role in the neurodegenerative disease. Infections with herpes simplex virus also have been linked with an increased risk of developing Alzheimer’s (SN: 7/21/18, p. 10).

Autism  Children whose mothers get bacterial or viral infections during pregnancy have a greater chance of developing autism. In some cases of autism, mothers’ antibodies may have attacked the developing fetal brain.

Rogue immunity

Researchers studying PANDAS
are focusing on wayward immune pathways that may underlie the condition. When
foreign particles such as strep bacteria invade, the body unleashes proteins
called antibodies to target and neutralize the threat. But sometimes this
defense system turns on its host, resulting in autoimmune conditions, such as
multiple sclerosis and lupus.

strep infections are so common, most children may have anti-strep antibodies
circulating in their bloodstream from time to time. But in the case of PANDAS,
these antibodies are thought to attack the brain.

In particular, some studies suggest that the rogue antibodies target a cluster of brain structures called the basal ganglia that governs motor control and emotions and has been implicated in OCD. A lab study reported in 2006 showed that antibodies from the blood of PANDAS patients latch onto tissue collected from human basal ganglia. And in a brain-imaging study of 17 PANDAS patients published in 2015 in the Journal of Child Neurology that same region showed signs of inflammation. Similar inflammation was seen in a small study in adults with traditional OCD reported in 2017 in JAMA Psychiatry.

The connection to antibodies also comes from rats exposed to strep. The animals showed deposits of antibodies in the basal ganglia as well as spikes in the brain chemical dopamine, researchers reported in 2012 in Neuropsychopharmacology. The exposed rats also exhibited behavioral quirks that mimic PANDAS symptoms, such as faulty motor control and compulsive grooming. The findings suggest that antibodies binding to this region disrupt brain signaling and may change behavior, too.

for Mink and other skeptics, the existing data are still too shaky to mark
PANDAS as a separate condition with autoimmune roots. A big problem is that studies
searching for specific cells targeted within the basal ganglia and elsewhere in
the brain have yielded inconsistent results. “That’s where I think the evidence
is so weak that I find that there’s little to really support this as a
hypothesis,” Mink says.

contrast, researchers studying an autoimmune condition called anti-NMDA
receptor encephalitis, which also spurs psychiatric symptoms, can point to a
protein on certain cells in the brain where rogue antibodies bind. In this
condition, antibodies attack receptors for the brain chemical glutamate. The
attack brings on an array of symptoms including seizures and hallucinations.

The latest PANDAS data, however, offer a new cellular suspect. In a study reported in Brain, Behavior and Immunity in 2018, researchers looked for antibody binding in a part of the basal ganglia called the striatum. The team focused on cells called cholinergic interneurons. Other work has shown that those cells are depleted in the brain in patients with Tourette syndrome.

blood serum from five children meeting PANDAS criteria into the striatum of
mouse brains, the researchers found that antibodies known to respond to strep
attached to about 80 percent of cholinergic interneurons. In mouse brains given
serum from children with no PANDAS symptoms, the same antibodies latched onto
less than half of the cells. Preliminary work from the same laboratory suggests
that cholinergic interneurons fire less when tagged by these antibodies.

together, the findings may explain what anti-strep antibodies do in the brain,
says lead researcher Chris Pittenger, a psychiatrist and neurobiologist at the Yale
School of Medicine. But the results also raise questions: Are the findings
biologically meaningful if antibodies from children without PANDAS also
attached to a sizable portion of the striatal interneurons?

doesn’t expect these findings to apply to all children with PANDAS. The
condition may comprise several subtypes with distinct profiles of antibodies
and neural targets. “I would call it one small step in what I hope will be a
clarification of what’s going on in PANDAS and which kids actually have what
pathology,” he says. Another step, Pittenger says, is to see if serum from
children with traditional OCD or Tourette’s also binds excessively to
cholinergic interneurons.

Breached barrier

Another team of researchers
wants to know how antibodies circulating in the blood cross the blood-brain
barrier to reach the brain. That border of tightly connected blood vessels
typically wards off invading molecules.

one possible pathway into the brain, neuroscientist Dritan Agalliu and colleagues
at Columbia University Irving Medical Center infected the nasal passages of
mice with strep bacteria and tracked the movements of a type of immune
responder, T cells called Th17 cells.

T cells are sort of these double-edged sword cells,” Agalliu says. Like antibodies,
Th17 cells help fight off infections, but can sometimes bring harm to healthy
cells. In particular, Th17 cells release inflammatory molecules that can poke
holes in the blood-brain barrier, which researchers have seen in multiple sclerosis.

After several rounds of strep, Th17 cells originating in the mouse equivalent of tonsils accumulated in the animals’ brains, Agalliu’s team reported in 2016 in the Journal of Clinical Investigation. Most of the T cells pooled in the olfactory bulb, a brain region that receives odor signals from nerve cells, or neurons, extending from the nasal passages. Th17 cells responding to strep may travel along this neuronal highway to infiltrate the brain, Agalliu says.

Leaky vessels 

In one hypothesis, Th17 immune cells, which respond to repeated strep infections, travel from the nose along nerve cells to the brain’s olfactory bulb. There, the Th17 cells cause leaks in the blood-brain barrier, allowing strep antibodies to leave the bloodstream and enter the brain. 

T. Tibbitts

Source: T. Dileepan et al/J. Clin. Investig. 2016

researchers also found a leaky blood-brain barrier and deposits of antibodies
in the olfactory bulb, suggesting that the Th17 cells could carve a path for
the antibodies to enter the brain. To confirm this idea, the researchers
repeated their experiment in mice genetically engineered to lack Th17 cells.
The preliminary results show that antibodies can’t access the brain in these
mice. Th17 cells may be key to allowing antibodies into the brain.

work also hints at why so few children with strep show signs of PANDAS.
Successive strep infections may be partly responsible, Agalliu says. His team
found that Th17 cells opened a pathway to the brain only after mice were
infected with strep at least three times.

Another likely contributor is a genetic predisposition (SN: 9/2/00, p. 151). In their latest unpublished work, Agalliu and colleagues have identified several genetic variants that stand out in children with PANDAS symptoms. The affected genes all regulate parts of the immune system, such as the ability to dampen an immune reaction. In children with PANDAS, Agalliu says, “the immune response seems to be persistent for a longer period of time than what we normally see.”

Seeking treatment

As researchers try to
untangle the biological roots of PANDAS, families faced with alarming symptoms
grapple with uncertainty about how to help their children. Clinicians still disagree
on the right treatment approach, and only a few options have been studied in
rigorous trials. Proposed treatments are backed mostly by case reports and
small trials, many of which lacked a placebo comparison group.

PANDAS experts tout the use of antibiotics to treat the strep infections that
may underlie the condition. In her own experience, Swedo has found that starting
antibiotics at the first signs of PANDAS is enough to reverse the condition
altogether in patients whose strep infections are still active but maybe hadn’t
been detected and treated.

really remarkable how much of a difference prompt treatment of that infection
can be,” she says. Some clinicians even recommend extended courses of
antibiotics to fend off future infections. But there’s no compelling evidence
that long-term antibiotics are warranted, Mink says. Strep infections tend to
respond well to a single round of antibiotics, and unnecessary use could bring
on side effects such as severe diarrhea. Chronic use also invites antibiotic
resistance. “It’s a public health concern as well as an individual health concern,”
he says.

Hans Korbmacher at home
After PANDAS struck Hans Korbmacher at age 10, he was kept out of school by extreme anxiety and emotional outbursts.Courtesy of Heather Korbmacher

particularly severe cases, clinicians may turn to a more invasive treatment
aimed at resetting a malfunctioning immune system. The procedure, intravenous
immunoglobulin, or IVIG, is an infusion of antibodies stripped from the blood
of thousands of healthy donors. The goal is for the new antibodies to bind to
and disable the patient’s harmful ones. IVIG is also used to treat
Guillain-Barré syndrome and other autoimmune conditions.

This was the approach Hans Korbmacher’s doctors took after seven months of antibiotics did little to improve the boy’s condition. In October 2015, nearly two years after his initial symptoms emerged, Hans received IVIG. Heather Korbmacher started noticing changes in her son about two weeks later.

morning, she found Hans sitting peacefully at the dining room table eating
breakfast. He was wearing shorts and a T-shirt instead of pajamas, the only
clothes his sensitive skin could stand at the height of his illness. As
Korbmacher uttered a passing “I love you” to her son. Hans said he loved her
too — something she hadn’t heard in over a year. “I just stood there and cried
because I knew that my son was back,” she says.

improved gradually over the next six months. He is now 15 and fully recovered,
says Korbmacher, who wrote a book about her family’s experience. “He is healthy
in his body and healthy in his mind and able to access his life again.”

Hans Korbmacher running
In the months after receiving IVIG, or intravenous immunoglobulin, Hans Korbmacher started to improve. Today he is a healthy and active 15-year-old.Courtesy of Heather Korbmacher

was a game changer for Hans, according to his mother. But the procedure is not
without risks. Patients receiving IVIG may have allergic reactions and
headaches severe enough to require hospitalization. And it’s costly. Korbmacher
was stuck with an estimated $17,000 out-of-pocket cost until she convinced her
insurance company to cover the procedure.

The scientific evidence backing IVIG to treat PANDAS is also unsettled. A 1999 clinical trial in 29 PANDAS patients reported in the Lancet found that the therapy suppressed obsessive-compulsive behaviors and anxiety. But a more recent trial in 35 children, published in 2016 in the Journal of the American Academy of Child Adolescent Psychiatry, failed to show that IVIG performed any better than a placebo.

who led both trials, says crucial design flaws stunted the later study. For
example, any patient whose symptoms did not noticeably improve could receive an
extra infusion of IVIG at the end of the trial. Researchers at the University
of Arizona are planning a new trial with a more rigorous design to address
these disparate results.

proposed PANDAS treatments are less controversial. PANDAS advocates and
skeptics alike support the use of cognitive behavioral therapy and
neuropsychiatric drugs such as selective serotonin reuptake inhibitors, which
have been shown to be effective in treating childhood OCD. However, these
treatments haven’t been tested in controlled trials with PANDAS patients.

forward, it’s most important to get clearer data in the hands of clinicians who
are seeing patients with suspected PANDAS, Mink says. For example, the field
still lacks a natural history study to follow children who meet PANDAS criteria
without any type of intervention. Though it would be hard to convince families
to simply watch and wait, this approach would help determine whether a distinct
PANDAS population truly exists, and what defines it, before treatments are

who gets hate mail when he shares his skepticism publicly, says he’s open to
shifting his stance if compelling findings arise. “There are reasonable people
that have differing opinions here,” he says. “But what we really need to
resolve those opinions is not going to be who speaks the loudest or who has the
most advocacy groups on their side. It’s really going to come down to what’s
the evidence.”

PTSD is not just for veterans, it’s a trauma disorder that affects millions

Research shows that individuals who suffer with post-traumatic stress disorder, better known as PTSD, have experienced severe trauma at some point in their lives. The trauma could come in the form of sexual assault, a natural disaster, a car accident or anything that would prompt someone to have a harrowing reaction.

However, many believe that PTSD is a mental health condition that affects only those who have come back home from war, but this is not the case.

“We must see PTSD, and other trauma-related disorders, as mental health issues that face many survivors of human rights violations,” said Tina Kempin Reuter, associate professor in the University of Alabama at Birmingham’s College of Arts and Sciences and director for UAB Institute for Human Rights. “Whether they’re survivors of genocide, ethnic cleansing, racial or ethnic persecution, and other forms of direct and indirect violence, many of these individuals continue to battle their traumas across their lifetime.”

PTSD affects 3.5 percent of the U.S. adult population, according to the National Alliance on Mental Illness, or approximately 8 million Americans who live with the condition. Approximately 37 percent of people diagnosed with PTSD display serious symptoms.

The root cause of PTSD is a traumatic event, but the symptoms are what overwhelm people to the point where it is diagnosable. People with PTSD often have recurring, distressing and upsetting memories of the trauma, and continually have upsetting memories that are hard to stop.

Symptoms can include flashbacks, night sweats, insomnia, panic attacks, and isolating themselves from friends and family.

U.S. National Library of Medicine research indicates that, when people experience trauma firsthand, it changes the brain. Several areas of the brain are involved. A stress response includes the amygdala, hippocampus and the prefrontal cortex. PTSD and trauma can cause lasting changes in those areas of the brain.

There are other disorders and mental health conditions that can appear along with PTSD, including generalized anxiety disorder, obsessive compulsive disorder, depression, borderline personality disorder and substance abuse.

Many who experience PTSD also may struggle with suicidal ideation and may attempt to take their life.

How to cope with trauma

PTSD is not necessarily preventable because individuals cannot control when trauma happens. However, they can be equipped to cope with the trauma afterward.

Reuter says it is vital to seek mental health treatment in the form of therapy and, if needed, a psychiatrist, after someone experiences a traumatic event.

“Significant barriers can prevent many individuals living with PTSD and other trauma-related disorders from seeking the treatment they need,” Reuter said. “These barriers include lack of access or knowledge about mental health resources, lack of insurance to pay mental health providers, physical disability or other disability preventing individuals to access care, discrimination, and the stigma often associated with seeing a counselor.”

Reuter says that, in recent years, the global mental health community has worked to address these and other barriers by promoting “e-counseling” — that is, communicating with therapists and mental health professionals over the phone or computer. 

“Programs like BetterHelp can assist people living with PTSD to find and utilize the counseling they need,” Reuter said. “We hope that, as more individuals living with PTSD take advantage of these services, they are able to live fuller and healthier lives.”

Reuter notes that PTSD is a treatable mental illness, and many experiencing it are not alone. Seeking help from a mental health professional is a first step, whether that is working with someone in their local area or finding the help of an online counselor, like one at UAB partner BetterHelp, which provides treatment plans for those suffering with PTSD.

Healing from trauma can be difficult, but it is possible. If you are experiencing PTSD, seek help from available resources. And if you know someone who is experiencing PTSD, encourage them to do the same. The Substance Abuse and Mental Health Services Administration national helpline is 1-800-662-HELP (4357).

Apathy Associated With Depressive Symptoms in Patients With Obsessive-Compulsive Disorder

Apathy was associated with depressive symptoms and deficits in executive functioning in patients with obsessive-compulsive disorder (OCD), according to study data published in the Journal of Neuropsychiatry and Clinical Neurosciences.

Investigators recruited adult patients from the University Department of Adult Psychiatry, Hôpital de la Colombière in Montpellier, France. The study cohort comprised 25 patients with OCD, 24 with schizophrenia, and 24 healthy controls. Participants were administered the Lille Apathy Rating Scale and the Beck Depression Inventory-II to capture apathy levels and depressive symptoms, respectively. Additional measures were employed to assess sensitivity to punishment and reward, the presence and intensity of dysfunctional attitudes, cognitive functioning, and executive functioning. Between-group differences in apathy were tested using one-way analysis of variance; correlational tests were conducted in the OCD group to capture associations between apathy and other clinical variables.

Age and gender distributions were comparable between study groups. The majority of participants were men (69.9%). Each clinical group scored significantly higher than control subjects on depression (both P .001). Individuals with OCD were significantly more sensitive to punishment compared with individuals with schizophrenia (P =.017) and healthy controls (P .001). A significant effect of group for apathy total score was observed (P ≤.0001), with both clinical groups scoring much higher than the control subjects. Effect of group remained significant after corrections for education level and depression. In patients with OCD, apathy total score was mainly associated with depression, and also positively correlated with defeatist performance beliefs and dysexecutive function.

Per these data, apathy may play a central role in the disability caused by OCD. Given the small sample size, however, results must be extrapolated with care.

“The fact that depression is the variable most associated with apathy indicates that apathetic symptoms in patients with OCD should be considered as secondary rather than primary symptoms,” investigators noted.

“The addition of psychological interventions specifically targeting both depression and defeatist performance beliefs to exposure and prevention response could be considered as an adjunctive treatment for OCD patients with high levels of apathy,” they concluded.


Raffard S, Capdevielle D, Attal J, Novara C, Bortolon C. Apathy in obsessive-compulsive disorder and its psychological correlates: comparison with individuals with schizophrenia [published online July 3, 2019]. J Neuropsychiatry Clin Neurosci. doi:10.1176/appi.neuropsych.19010018