MRI scans show that people diagnosed with OCD who have undergone CBT have intensified connectivity between key brain networks.
Researchers have used brain scans to measure changes in the cerebral activity of people with obsessive-compulsive disorder after undergoing a type of cognitive behavioral therapy. They found that the connectivity of key brain networks is improved, suggesting new targets for therapy.
Obsessive-compulsive disorder (OCD) is a condition marked by inescapable, intrusive thoughts that cause anxiety (hence “obsessive”), and repetitive, ritualistic behaviors aimed at reducing that feeling (hence “compulsive”).
OCD can be a debilitating condition and can severely impair daily functioning. The National Institutes of Mental Health estimate that, in the United States, the yearly prevalence of OCD amounts to 1 percent of the total adult population. Around half of these cases are deemed “severe.”
Treatments for OCD include the administration of selective serotonin reuptake inhibitors and cognitive behavioral therapy (CBT), a type of therapy that aims to improve damaging mind associations.
Researchers from the University of California, Los Angeles – who were led by Dr. Jamie Feusner – have conducted a study aiming to find out whether and how CBT might change levels of activity and network connectivity in the brains of people diagnosed with OCD.
They explain that although the efficacy of CBT in treating OCD has been previously explored, this is likely the first study to use functional MRI (fMRI) to monitor what actually happens in the brains of people with OCD after exposure to this kind of therapy.
The researchers’ findings were recently published in the journal Translational Psychiatry.
Changes in key brain regions following CBT
The team specifically targeted the effects of exposure and response prevention (ERP)-based CBT, which entails exposure to triggering stimuli and encouraging the individual to wilfully resist responding to those stimuli in the way that they normally would.
For the study, 43 people with OCD and 24 people without it were recruited. The results for the two groups were later compared, at which point the 24 individuals without OCD were taken as the control group.
All the participants diagnosed with OCD received intensive ERP-based CBT on an individual basis in 90-minute sessions on 5 days per week, for a total of 4 weeks.
Participants from both groups underwent fMRI. Those diagnosed with OCD, who had received CBT, were scanned both before the treatment period and after the 4 weeks of treatment. Participants from the control group, who did not undergo CBT, also had fMRI scans after 4 weeks.
When the scans of participants with OCD were compared, the results from before exposure to CBT and after it were found to be largely contrasting.
The researchers noticed that the brains of people with OCD exhibited a significant increase in connectivity between eight different brain networks, including the cerebellum, the caudate nucleus and putamen, and the dorsolateral and ventrolateral prefrontal cortices.
The cerebellum is involved with processing information and determining voluntary movements, while the caudate nucleus and putamen are key in learning processes and controlling involuntary impulses.
The dorsolateral and ventrolateral prefrontal cortices are involved with planning action and movement, as well as regulating certain cognitive processes.
Dr. Feusner and team point out that an increased level of connectivity between these cerebral regions suggests that the brains of the people who underwent CBT were “learning” new non-compulsive behaviors and activating different thought patterns.
He suggests that these changes may be novel ways of coping with the cognitive and behavioral idiosyncrasies of OCD.
“The changes appeared to compensate for, rather than correct, underlying brain dysfunction. The findings open the door for future research, new treatment targets, and new approaches.”
Dr. Jamie Feusner
First study author Dr. Teena Moody adds that being able to show that there are quantifiable positive changes in the brain following CBT may give people diagnosed with OCD more confidence in following suitable treatments.
“The results could give hope and encouragement to OCD patients,” says Dr. Moody, “showing them that CBT results in measurable changes in the brain that correlate with reduced symptoms.”
(Reuters Health) – People taking antidepressants for anxiety,
obsessive-compulsive disorder (OCD) and post-traumatic stress
disorder (PTSD) are more likely to relapse when they stop using
these drugs than when they remain on medication, a research
Researchers analyzed the combined results from 28 previously
published studies with a total of 5,233 participants who had been
on antidepressants for up to one year. Patients were randomly
assigned to either continue medication or switch to placebo, or
Over the next year, patients who discontinued treatment were
roughly three times more likely to relapse than people who
remained on antidepressants, researchers report in The BMJ.
“Patients and their doctors should be aware that discontinuing
antidepressants within a year is associated with increased
relapse risk,” said lead study author Dr. Neeltje Batelaan of the
VU University Medical Center in Amsterdam.
“This should be taken into account when discussing
discontinuation,” Batelaan said by email. “It does not imply that
all patients should remain on antidepressants for the rest of
That’s because the majority of patients who discontinue
antidepressants do not relapse, and because relapse sometimes
occurs even when patients are still taking these medications,
Overall, relapse occurred in about 36 percent of people who
switched to placebo and 16 percent of those who remained on
antidepressants, the study found.
And among the patients who did relapse, this happened more than
three times faster for people switched to placebo than for
individuals kept on antidepressants.
It’s not exactly clear why some patients relapsed, but it’s
unlikely to have been caused by withdrawal symptoms among the
people who discontinued treatment, Batelaan said.
Many antidepressants work by altering the way certain chemicals
in the brain such as serotonin, dopamine and norepinephrine
transmit signals involved in controlling emotions and moods.
Stopping antidepressants is thought to change how these brain
chemicals function, which may lead to relapse in some people.
Side effects of antidepressants can include nausea, weight gain,
sexual dysfunction, insomnia, blurred vision and constipation.
One limitation of the study is that it included only patients who
had been taking these medications for up to a year, making it
likely that all or most of the participants didn’t need to halt
treatment due to side effects.
Another drawback of the study is its reliance primarily on
published studies funded by drug companies, which the authors
note might bias the results toward showing the benefits of
continuing antidepressant treatment.
Even so, the results add to a large body of evidence already
suggesting that patients on antidepressants may be more prone to
relapse when they discontinue treatment than when they remain on
medication, said Dr. Ronald Pies, a psychiatry researcher at SUNY
Upstate Medical University in Syracuse, New York, and Tufts
University School of Medicine in Boston.
“If the patient has a fairly severe or recurrent anxiety disorder
that has not responded to cognitive-behavioral therapy alone, the
use of an antidepressant for up to a year and possibly longer can
be justified, owing to the risk of relapse with medication – so
long as the patient is tolerating the treatment reasonably well,”
Pies, who wasn’t involved in the study, said by email.
“Not all patients will need long-term medication,” Pies added.
“In fact, the study found that most patients do well when
SOURCE: http://bit.ly/2x0HP3o The BMJ, online September 13, 2017.
Rita Levi Montalcini Department of Neuroscience, A.O.U. San Luigi Gonzaga, University of Turin, Turino, Italy
Abstract: The term accommodation has been used to refer to family responses specifically related to obsessive–compulsive (OC) symptoms: it encompasses behaviors such as directly participating in compulsions, assisting a relative with obsessive–compulsive disorder (OCD) when he/she is performing a ritual, or helping him/her to avoid triggers that may precipitate obsessions and compulsions. At the opposite side, family responses to OCD may also include interfering with the rituals or actively opposing them; stopping accommodating OC symptoms or actively interfering with their performance is usually associated with greater distress and sometimes even with aggressive behaviors from the patients. This article summarizes progress of the recent research concerning family accommodation in relatives of patients with OCD. Family accommodation is a prevalent phenomenon both among parents of children/adolescents with OCD and relatives/caregivers of adult patients. It can be measured with a specific instrument, the Family Accommodation Scale, of which there are several versions available for use in clinical practice. The vast majority of both parents of children/adolescents with OCD and family members of adult patients show at least some accommodation; providing reassurances to obsessive doubts, participating in rituals and assisting the patient in avoidance are the most frequent accommodating behaviors displayed by family members. Modification of routine and modification of activities specifically due to OC symptoms have been found to be equally prevalent. Specific characteristics of patients (such as contamination/washing symptoms) and of relatives (the presence of anxiety or depressive symptoms or a family history positive for another anxiety disorder) are associated with a higher degree of family accommodation; these family members may particularly benefit from family-based cognitive–behavioral interventions. In recent years, targeting family accommodation has been suggested as a fundamental component of treatment programs and several interventions have been tested. Clinicians should be aware that family-based cognitive–behavior therapy incorporating modules to target family accommodation is more effective in reducing OC symptoms. Targeting family accommodation may be as well relevant for patients treated pharmacologically.
Keywords: obsessive–compulsive disorder, family accommodation, cognitive–behavior therapy, treatment response
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Effects of maintenance lithium treatment on serum parathyroid hormone and calcium levels: a retrospective longitudinal naturalistic study
Albert U, De Cori D, Aguglia A, Barbaro F, Lanfranco F, Bogetto F, Maina G
Neuropsychiatric Disease and Treatment 2015, 11:1785-1791
NEW ORLEANS — Up to 30% of patients with obsessive-compulsive disorder (OCD) are not helped at all or are inadequately helped by current pharmacotherapies, according to Jon Grant, MD, JD, MPH, professor of psychiatry and behavioral neuroscience at the University of Chicago, in his presentation at the 2017 US Psych Congress.
“Most people tend to think of OCD as an innocuous, silly problem based on television,” Dr. Grant said, “but it is an incredibly serious mental health problem.”
OCD is characterized by recurrent distressing ideas and recurring behaviors designed to reduce the anxiety caused by the obsessions. While onset occurs earlier in boys than in girls, OCD affects both genders equally. Additionally, the age of onset appears to be bimodal, occurring either during childhood (mean age 10 years) or during adolescence or young adulthood (mean age 21 years).
Dr. Grant highlighted the importance of screening and diagnosis, emphasizing that patients with OCD should be assessed regarding their conviction that their obsessive beliefs are accurate.
Without treatment, remission rates for OCD are low (approximately 20%), but higher response and remission rates are reported with appropriate treatment, with early diagnosis and treatment leading to improved outcomes.
The US Food and Drug Administration (FDA) has approved the serotonin reuptake inhibitor clomipramine, as well as the selective serotonin reuptake inhibitors (SSRIs) fluoxetine, fluvoxamine, paroxetine, and sertraline for the treatment of OCD.
According to head-to-head comparisons, all SSRIs are equally effective. Dr. Grant also acknowledged that while some patients are uncomfortable with the fact that medication doses for OCD are higher than they are for depression, those higher doses are crucial for symptomatic improvement.
Nonpharmacologic treatments are also effective options for OCD. Cognitive-behavioral therapy (CBT) attempts to reduce patient anxiety by implementing experiments that will force the patient to confront fallacies in their thinking about cause and effect.
Another treatment option for OCD is exposure and response prevention therapy (ERP), which consists of repeated, prolonged exposures to fear-eliciting stimuli or situations with instructions for the patient to refrain from his or her compulsive behaviors.
The purpose of this practice is to allow the patient to experience a reduction in the fear response and to learn that the anxiety will reduce naturally if he or she does not make efforts to avoid it. As many as 60% to 85% of patients report substantial symptom reduction with ERP; the large amount of empirical data supporting ERP over CBT make it a first-line treatment for OCD.
Grant J. Obsessive-compulsive disorder: treatment with psychotherapy and pharmacotherapy. Presentation at: Psych Congress; September 16-19, 2017; New Orleans, LA.
Australians with severe mental health problems are being regularly barred from the national disability insurance scheme, prompting fears that under-resourcing and a lack of expertise are compromising decision-making.
Peak mental health bodies say they are receiving “alarming” reports “on a daily basis” of people with diagnosed psychosocial disabilities being denied access to the NDIS.
A list of 16 recent cases, obtained by Guardian Australia, shows packages have been refused to people with decades-long histories of schizophrenia, major depressive disorders, bipolar and severe anxiety.
In one case, access was refused to a person with a 40-year diagnosed history of paranoid schizophrenia, who experiences delusional thoughts and visual and auditory hallucinations, has been admitted to hospital at least five times, and given regular depot injections.
In another, funding was denied to an individual with a three-decade long diagnosis of major depression, anxiety disorder, and obsessive compulsive disorder, because the NDIS could not be satisfied the person was permanently impaired.
The peak body representing Victoria’s community mental health services, Vicserv, has seen 50 rejection cases in the past two weeks, all for individuals previously on the waitlist for state mental health services or in receipt of commonwealth-funded mental health programs.
It says only eight assessors have been employed to deal with mental health applications – a claim the national disability insurance agency (NDIA) disputes.
The access team faces a vast workload.
By July, it had approved 6,093 people with psychosocial disabilities, mostly in NSW and Victoria. More than 1,200 new participants were added in the last three months of 2016-17 alone.
The NDIS estimates 64,000 people with a long-term psychosocial disability will be approved for support in the next three years, although the mental health sector believes the true number will be closer to 90,000.
The Vicserv chief executive, Angus Clelland, has written to social services minister, Christian Porter, to express his alarm.
Clelland said those denied NDIS support would end up in hospitals or other parts of the health system, particularly in Victoria, where he said funding has been diverted from existing mental health services to the NDIS.
“There’ll be a disaster across the country, really,” Clelland told Guardian Australia.
“Victoria is my main concern, but given the magnitude of the problems that we’re seeing already, if we start amplifying it across the rollout regions … we’re already seeing thousands of people in Victoria who will miss out,” he said.
Clelland is concerned assessors, despite lacking sufficient expertise, are ignoring or disregarding the evidence of GPs and psychiatrists.
“The impression that we’ve got is that because there’s only eight people nationally doing that access work, they’re trained in applying legislation, so if it doesn’t meet the tick-box test, then people aren’t getting through,” he said. “I think there’s huge pressure for them, workload-wise, to make this work. Inevitably those pressures will translate to the access decisions that are being made.”
An NDIA spokeswoman said there were several hundred delegates involved in assessing and approving plans, and that specialist resources were “being developed” to help with applications for psychosocial disability support.
“These specialist mental health staff are able to also provide support to all members of the national access team regarding technical matters related to psychosocial disability,” she said.
Data from NDIS trials shows those with a mental illness are much less likely to be approved than those with a physical disability. One in four applications for mental health support were deemed ineligible, compared with one in nine for the rest of the scheme.
Frontline community mental health workers, speaking on condition of anonymity, are growing despondent as they deal with a system that fundamentally misunderstands the nature of mental health. They say mental health has been treated as an afterthought in a scheme designed primarily for physical disabilities.
A glaring example, support workers say, is the requirement for participants to prove they are permanently impaired. The notion is at odds with the approach of modern mental health treatment, which emphasises recovery and the potential for positive long-term outcomes.
Support workers, desperate to get their clients onto the NDIS, now spend their days trying to prove their clients cannot recover from their mental health problems.
“People are reading these reports about themselves which might describe a very bleak situation … that notion of permanency, that’s not something typically in mental health that we talk to people about,” one support facilitator told Guardian Australia.
“We have this idea of recovery, people can change, their lives will improve. But with NDIS you really can’t say that kind of thing. [You say] this is their life, and they’ll never improve and this is permanent,” she said.
The facilitator has had three out of four clients rejected for NDIS support. One of the rejected clients – a trauma victim with severe anxiety and depression – does not leave her home or answer calls from strange numbers.
Her NDIS request form was sent to her in the post and a follow-up call was made from a blocked number. Without the help of support workers, she would have remained oblivious to the NDIA’s communications.
“That’s part of the lack of understanding: they send a letter, they call on a private number. Our clients don’t answer private numbers, they don’t get their mail. So they really need to have that understanding,” she said.
The NDIA spokeswoman said the mainstream mental health system would continue to cater for the “broader group of people” who need support outside the NDIS. She said the agency was also reviewing pathways to the NDIS and considering the recommendations of a recent joint standing committee report, which looked at psychosocial support under the NDIS.
Like most in the sector, leading mental health expert and former Australian of the year Patrick McGorry supports the notion of the NDIS. But he said mental health had again been treated as the “poor cousin”. He said the requirement to prove permanence of disability was not compatible with mental health treatment and its focus on recovery.
“They do not gel in any way, it’s like oil and water. That’s the problem,” McGorry said.
“We’ve ended up being the poor cousin … we’ve been shoehorned into a system that’s very physically focused,” he said.
An outreach worker, speaking on condition of anonymity, said his experience with the NDIS varied immensely, and that the agency’s handling of mental health had improved over time. But he complained of significant delays in decision-making, which caused anxiety among clients. He also criticised inconsistencies in the way decisions over who could access the NDIS were made.
“There was one case in particular that I was actually quite floored by, and it speaks to that inconsistency,” he said.
“That’s one person who’s been linked in with our service for as long as I’ve been there, not only was there mental health issues, but there was intellectual disability as well.”
Community Mental Health Australia, a coalition of the eight state and territory peak community mental health organisations, has warned the NDIS is at a crossroads.
The group’s executive director, Amanda Bresnan, said the scheme risked losing the already fragile trust of those experiencing mental health problems. If that occurred, many would simply stop engaging altogether.
“We understand that the pressure is coming from government. When they are being told you’ve got to sign up 200,000 by this particular date, and when you don’t have resources to do it, things are going to fall by the wayside,” Bresnan said.
“But these are people with complex conditions requiring support, and that’s what we should be thinking about,” she said. “We’re starting to see this evidence, it’s not just one or two outliers, as the NDIS usually says, it’s actually starting to become a systemic issue.”
She used to wash obsessively until her hands bled, run up and down the stairs 270 times before breakfast of half a Weet-Bix and water, and was locked in a hell where the number four ruled her life, forcing her into senseless rituals of twisting door knobs and turning pages four times, believing if she didn’t she would die.
After 10 years of crippling anxiety, hiding her symptoms in shame, now 23-year-old Genevieve Mora is speaking out to remove the stigma around anxiety disorders.
She runs an organisation, Voices of Hope, with a friend, and on Monday is speaking at the organisation’s first public event to raise awareness about mental illness.
“I’m sharing my own experience because I want others to feel less ashamed,” says Mora.
It was not easy to open up.
“It was something I had been putting off for months and months. One night, I was lying in bed thinking about all the reasons why I didn’t want to share my story [and] I decided I had to do it.
“How was the stigma going to change, how [would] future generations and those suffering not feel ashamed unless I spoke out, told my story and let people know that it’s okay to not be okay and that you can get through.”
Mora feels that there is less public understanding about anxiety and Obsessive-Compulsive Disorder than depression.
“It’s amazing that depression is being spoken about a lot more openly than it used to be, and I hope that other mental illnesses begin to get discussed more openly too. Many mental illnesses work together. In my case, OCD, depression, anorexia and anxiety.
“Until recently I was happy to talk openly about them all, but kept my eating disorder a secret. I felt a massive sense of shame and worried hugely that people would judge me for my past.
“Eating is such a huge part of our culture and people find it hard to understand why I couldn’t just eat and be better. If only it was that easy.”
CD is defined as having obsessive, uncontrollable thoughts and performing deliberate repetitive actions. It usually starts during childhood or in teenage years and is genetic.
For some it can be a minor irritation, but for others it can become a debilitating illness.
According to the Mental health Foundation, the most effective treatment is a combination of psychological therapy and medication, which is succesful in 80-90 per cent of cases.
Mora says OCD is often not taken seriously. “It’s a term that is thrown around a lot – for example: ‘My room is so clean, I’m so OCD’. I just brush it off, but it is a little frustrating, as my struggle with OCD nearly killed me and it’s a very real and huge issue for many people.”
Mora thinks there needs to be more recognition about how anxiety can affect young people – and the fact it is on the rise.
“There’s a lot of pressure on young people not only with study commitments but social media which could be playing a big part in this rise.
“What people post on social platforms often doesn’t depict their reality. It’s easy to post an edited pic and look like your life is perfect, but everyone has a story and nobody is happy 24/7. Everyone has bad days.
“There’s a lot of pressure to act and be a certain way. I’ll often see girls commenting ‘my goal’ on a picture of someone that has been edited.”
Mora thinks schools need to speak more openly about mental illness.
“I know for a fact that there were at least 10 girls in my year at school fighting a silent battle when I was.
“Having programmes set in place within schools is important. We recently got back from a nationwide school tour and at one school the kids we talked to were as young as 11. We had kids coming up to us after and thanking us and wanting to talk because they now knew that they needed some help in dealing with what they were feeling.”
Her own anxiety began at just 10 years old, when she started to worry about leaving the house because of “an irrational fear of teenagers”.
She would wash her hands till they bled, and performed rituals from the moment she woke until the moment she got to sleep. If she didn’t complete rituals such as doing things in fours she believed there would be terrible consquences.
“I thought either my parents or sister would die or I would die or someone I love would get hurt in a car crash.”
She turned to food and exercise, “to find something I could control”.
Eating too became an obsession. “I would run 270 times up and down the stairs before allowing myself breakfast of half a Weet-Bix with water.”
“I began to hate life, hate myself, and wished myself dead. I would wake up each morning and wish I hadn’t.
“I ate less and less to the point where I was barely eating at all and exercising a few hours a day”.
When her weight plummeted to dangerous levels – she weighed just 48kg despite being 184cm – she was referred to hospital.
She packed an overnight bag. In the end she stayed for 12 weeks.
“There are a lot of people who are struggling terribly with no place to go, who are turned away from hospital because they haven’t attempted to take their life, even though they are suicidal.
“I was one of the lucky ones to get the intense treatment I did because I was physically in danger.”
In hospital she met someone who became significant in her own recovery – a 2-year-old girl with a chronic illness, which made Mora want to fight against her own illness.
“She and her family became a massive part of my journey and to this day are some of the most important people in my life. I often talk about her as ‘the silver lining’ of my hideous illness. I cannot imagine life without her.”
Despite this, she says it is a “tough battle”.
“Fighting a mental illness takes huge strength, and it shouldn’t be seen as a weakness. It’s an exhausting battle, trying to do the opposite of what the nasty voices in your head are telling you to do 24 hours a day.
“Every part of me wanted to be well again, to be socialising with friends, eating freely, to be able to read a book without having to read the page four times.”
Nadine Isler, Registered Psychologist at Anxiety New Zealand, said anxiety disorders were on the rise though experts were not clear on exactly why.
“It can affect almost every area of a person’s life – their relationships, their health, their life goals and of course general mental health – the individual may believe they are the only ones who suffer from these thoughts and compulsions, feel guilty, or as though they are ‘going crazy’.”
Isler said symptoms could show up as early as pre-school age, though it often went undiagnosed until a few years later.
“There is help though, and with help comes hope. I have enormous respect for anyone who has recognised they have a problem and does the hard work to get well … it’s certainly not easy, but definitely worth it.”
Now well, Mora lives in Auckland and works as a teacher aide while auditioning for acting roles, and the organisation Voices of Hope also takes up a lot of her time.
Since making a YouTube video of her experience she has been overwhelmed with support from people she knows and strangers from all over the world.
“It gives people hope and that’s more than I could have wished for … I made myself very vulnerable but it has all been so worth it.
“I feel a huge weight off my shoulders. I can live authentically and I am proud of where I am today.”
She has a message for other young people experiencing anxiety symptoms.
“People need to learn to love themselves and not compare themselves to others. Easier said than done, I know. Social pressure can create a lot of anxiety.
“It’s also important to acknowledge that some mental illnesses have no cause other than some of us are born with a tendency to depression or anxiety.
“But whatever the reason it’s vital to reach out and get help.”
How to fight: an evening focusing on the practical ways to fight suicidal thinking and mental illness
Monday, 7pm to 8pm
EVENT Cinemas, Westfield Albany.
WHERE TO GET HELP:
If you are worried about your or someone else’s mental health, the best place to get help is your GP or local mental health provider. However, if you or someone else is in danger or endangering others, call police immediately on 111.
Dear Dr. Roach • I have a grandson who pinches his face. He just graduated from high school and will be going to college in the fall. He does not like to be around people, and when I ask him where or what would he like to go or do, he says nowhere. He does play a lot of games on his phone and TV. I have watched him and am very concerned. He does it several times a day. — D.F.
Answer • Many conditions are associated with repeatedly touching the face, and I can’t guess reliably what his might be. The list is fairly long, and includes anxiety disorders, obsessive-compulsive disorder, ADHD, Tourette’s syndrome and autism spectrum illnesses. The fact that he has done so well at school is reassuring.
If I were the physician seeing him, I would want much more information about his developmental history, school evaluations and any psychological assessments that might have been done. Interviewing his family could be very helpful. If it weren’t clear to me at that point, I would recommend a psychiatric evaluation.
Dear Dr. Roach • Earlier this year, my 59-year-old brother was diagnosed with atrial fibrillation. He underwent a cardioversion successfully, and the cardiologist put him on an anti-arrhythmia drug (amiodarone) and a blood thinner (Xarelto) indefinitely.
After four months, he suffered a major GI bleed event. A colonoscopy showed diverticulosis, which they concluded was what caused the event. He was recommended for lifelong medication.
Can a person with diverticulosis be on a blood thinner like Xarelto without a major risk of GI bleeding? Also, if the cardioversion got his heart beating normally again, and he is on an anti-arrhythmic drug, must he be on a blood thinner? — A.J.F.
Answer • There always is a risk of a serious GI bleed in someone taking an anticoagulant such as warfarin or one of the newer drugs, like Xarelto. However, for many people, there is less risk of a major bleed than there is of a stroke.
One tool for doing so is the CHA2DS2-VASc (pronounced “chads-vasc’’) score, which estimates the risk for stroke in someone with atrial fibrillation.
This does not look at the risk of bleeding, but a history of diverticulosis is not considered a major risk for bleeding. More than 80 percent of people who had a stroke with atrial fibrillation were not getting the recommended treatment.
Dr. Roach regrets that he is unable to answer individual letters, but will incorporate them in the column whenever possible. Readers may email questions to ToYourGoodHealth@med.cornell.edu or request an order form of available health newsletters at 628 Virginia Drive, Orlando, Fla. 32803. Health newsletters may be ordered from rbmamall.com.
To feel anxious at times is normal, and all people experience it now and then. However, showing extreme, unreasonable, and constant anxiousness and fear about things is a psychiatric illness, medically termed as an anxiety disorder.
Anxiety disorders include obsessive compulsive disorder, panic disorder, social anxiety disorder, post-traumatic stress disorder, and so on. The most common anxiety disorder is generalized anxiety disorder (GAD). Many people are affected by more than one anxiety disorder concurrently, known as comorbidity. Surveys have shown that GAD is the most comorbid of anxiety disorders.
The coexistence or overlap of disorders increases the complexities of diagnosis and treatment for both the psychiatrist and the patient.
Comorbidities of GAD
The most common comorbidities of GAD are major depressive disorder (MDD), bipolar disorder (BD), and substance use disorder (SUD), due to the similar symptoms of these disorders.
GAD and Major Depressive Disorder
GAD presents with uncontrolled and persistent worry about a range of things like job, family, and financial status. It is a kind of floating condition, where the person drifts from one worry to the next without end in such as way that it has an impact on their normal activities. MDD,often simply referred to as depression or clinical depression, is a serious mood disorder that also affects normal life. Patients with anxiety from a very young age, displaying low self-esteem, pessimism, and severe stress is accompanied by perpetual feelings of sadness or loss of interest over a long duration of time (more than 2 weeks in order for a diagnosis to be made).
Patients at both initial and severe stages of GAD have episodes of depression (MDD). Longitudinal studies have found variations in the appearance of MDD in patients with GAD. In these studies, (a) one-third of patients showed signs of GAD leading to MDD; (b) one-third had symptoms of MDD leading to GAD; and finally (c) one-third of them had the onset of both GAD and MDD simultaneously. More than 70% of patients with lifetime GAD are also found to have lifetime MDD. Studies of twins have revealed that the same genetic factors of risk have a hand in both GAD and MDD. However, whether the patient develops GAD or MDD first depends on how they react to the environmental stressors in their life.
GAD and Bipolar Disorder
Formerly called manic depression, bipolar disorder is characterized by extreme mood variations, from high to low; at high, the patient is over-exultant, while at low he may harbor suicidal thoughts for no particular reason. It has been found that 51% of patients with BD have another anxiety disorder, which actually worsens the illness. Due to this comorbidity, BD patients tend to have:
Younger age of onset
Lower quality of life
Lower chance of recovery
Increased risk of substance abuse, and, most importantly
Greater lifetime suicidal tendencies
The average period of euthymia (normal positive state of mind) in BD with comorbid GAD is found to be less than half of that in patients with BD alone. Surveys have shown suicide attempts of 62% and 53% in BD and current and lifetime GAD comorbidity patients, respectively, as opposed to 22% in patients with BD alone.
Impulsiveness tends to be heightened in BD and current GAD patients, even after adjustments are made for age, gender, and presence of other comorbid anxieties.
GAD and Substance Use Disorder
Research studies have shown a significant link between patients of GAD and substance use or abuse. Most people with GAD are unaware of their illness and try to ease their anxiety by self-medication using alcohol or drugs.
One-third of individuals with GAD are victims of SUD, though they are mostly known to use and not abuse substances. A mutual pattern exists between these two disorders, which follow three pathways:
Anxiety leading to substance use
Substance use/abuse leading to anxiety
Genetic risks that are central to both GAD and SUD.
A survey carried out in the USA had an odds ratio of 9:5 for dependence on drugs in the presence of GAD.
In spite of the extremely high rate of comorbidity, only half of the patients with GAD receive treatment, suggesting that the other half is probably resorting to self-medication. According to estimates, in the USA alone about 3.1% of adults met the criteria for GAD in 2016. More women are said to be affected by GAD, though the reason for this is unknown.
Psychiatrists are still at crossroads as to how they should approach treatment considerations, and whether to treat each disorder separately or in parallel? Should treatment for one be completed and then the next one started? Future research on the standard clinical care for comorbidities of anxiety disorders should be undertaken to explore this issue further.
“If people feel comfortable, they should talk about this because there are more people out there that we don’t even know about,” said Lisa Cormier of Leominster, who lives with Obsessive Compulsive Disorder. SENTINEL ENTERPRISE / JOHN LOVE
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LEOMINSTER — There were nights where Lisa Cormier would finally pull into her garage hours after leaving work and frantically check the front of her car for dents or drops of blood.
“I’d think I injured somebody or even killed somebody,” she said. “I’d first have to go back and check and check and check. I’d think ‘OK, there’s nobody in the road, but what if I hit them and they went into the woods?’ Then I’d say ‘What if somebody’s watching me and they got my license plate number and there’s a murder and now they’re coming after me?'”
There never was any murder, and no one has ever been hit by Cormier’s Honda CRV. The only thing she ever ran over were the potholes on Litchfield Street, which frequently triggered her severe obsessive-compulsive disorder.
For Lisa Cormier, OCD incidents were at their height seven years ago, when her symptoms were most severe. With help from a mix of treatments she now feels that she has the strongest control she’s ever had over her illness, and has since transformed herself into a resource for other sufferers. SENTINEL ENTERPRISE / JOHN LOVE
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Obsessions like these are common with people diagnosed with OCD and can be frequently trigged by everyday occurrences like a bump in the road.
For Cormier, these incidents were at their height seven years ago, when her symptoms were most severe. With help from a mix of treatments she now feels that she has the strongest control she’s ever had over her illness, and has since transformed herself into a resource for other sufferers.
“It might not make sense to others, but to me, it’s like if I don’t do something a certain amount of times, my son’s going to get killed while he’s away at college,” she said. “I’ve been to so many therapists and psychiatrists for medication, but I actually now feel like I’ve got a grip on it.
Cormier explained that she first began exhibiting symptoms of OCD, and the depression and anxiety it creates, when she was about 12 years old, but it wasn’t until she was in her 20s that she was actually diagnosed.
Though many associate the disorder with stereotypes of germaphobia or compulsive neatness, Cormier’s illness manifests itself through repeated behaviors or mental rituals. The nagging worry everyone experiences over turning off the stove or closing a window could derail her entire day. When the disorder was at its worst, Cormier was traveling back and forth between her house and the hair salon she works at 10-15 times to make sure she locked the door, stretching an ordinarily 10-minute commute into two hours.
About seven years ago she also started having to deal more with a mental ritual of worrying that her younger sister, who was in perfect health, would suddenly pass away.
“Basically it was a lot of phone calls and worrying about me or obsessing that something was going to happen. And I’m perfectly fine,” said Linda Vitone, Cormier’s sister.
Vitone said this kind of ritual had been going on for years but had worsened around the time of her divorce. Following Cormier’s treatment in the psychiatric facilities of McLean Hospital in Belmont, Vitone said she’s noticed a noticeable change with her sister.
“She’s doing a lot better, but we still have to take it day by day,” she said.
Cormier spent several weeks at McLean Hospital in 2010, where treatment of her and other obsessive-compulsive patients focused on immersing them in their fears and rituals.
“There was a young boy I remember who was afraid of door handles. He would have to sit there for two hours and hold a door handle, which sounds so mean, but they had to do it,” she said.
Other patients included a woman whose compulsive handwashing ritual had turned her skin to a raw red from her fingertips to her biceps and another woman who was staying in the shower for seven hours a day because she never felt clean enough.
“She was still there when I left, and I often think of her,” Cormier said.
To stop obsessing over the idea of her sister’s death, Cormier was required to write about what it would be like if her sister actually did die, writing up the details of a fictional narrative for four hours every day.
“At first I had written it very general, but then I was told to write what her kids would wear at the funeral like it was really happening,” she said. “It was exhausting.”
The treatment freed Cormier of that particular ritual and helped her develop coping mechanisms for the other ones. She said she’s also had some recent success with transcranial magnetic stimulation, a noninvasive procedure that uses magnetic fields to simulate nerve cells in the brain and improve symptoms of depression.
Apart from the medical treatments she has received, Cormier also credits her family and friends with getting her to a more confident and comfortable place.
“It’s always had its ups and downs, but we get through it. You just need to have a little patience,” said her husband, Steven.
As her condition has improved, Cormier has turned her attention to helping those just being diagnosed with obsessive-compulsive disorder. She started writing about her experiences through social media and eventually had people reaching out to her to ask for advice.
“To my surprise I’ve had many, many people messaging me, either asking to meet me at Panera Bread to talk or wanting to know about magnetic treatments or what doctors I’ve seen,” she said. “The first thing I always say is that I’m not a doctor and I’m not a nurse, but I have had many different experiences.”
A lot of times Cormier will put together packets of information for the newly diagnosed that list treatment options, support resources, and doctors she’s found helpful.
She’s also become an active fundraiser and participant in the annual 1 Million Steps 4 OCD Walk, which promotes awareness of the disorder and raises money for the International OCD Foundation. Last December she was featured in McLean Hospital’s Deconstructing Stigma exhibit at Logan International Airport, which depicted images of mental health patients and information on their roads to recovery.
“If people feel comfortable, they should talk about this because there are more people out there that we don’t even know about,” Cormier said. “What I’ve learned is that nobody should suffer alone.”
The Sussex County affiliate of the National Alliance on Mental Illness (NAMI), in partnership with Family Partners of Morris Sussex, will offer the “NAMI Basics”course on Wednesday evenings beginning October 11. NAMI Basics is a free six-session course for parents/guardians of children and teens with emotional, behavioral or mental health challenges. The course will be held Wednesdays, 6:30-9:00 p.m., at Family Partners of Morris Sussex, 67 Spring Street, Newton, NJ.
The course will be taught by two parents who have experienced mental health and behavioral challenges with their own children. The comprehensive curriculum covers Attention Deficit Disorder, Major Depression, Bipolar Disorder, Conduct Disorder, Oppositional Defiant Disorder, Anxiety Disorders, Obsessive Compulsive Disorder, and Childhood Schizophrenia. Parents of children on the autism spectrum may also find the course helpful.
Course participants will gain empathy and insight into the emotional experience of the child living with mental health and behavioral challenges. As caregivers, they will learn more effective listening, communication and problem-solving skills. Acknowledgment of the stresses and strains on the family, including siblings, will be an important component of the course.
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Current research related to the biology of mental health challenges is covered in the course, along with how to get an accurate diagnosis for a child. Treatment options are discussed, including how medications work and their pros and cons in the treatment of children. Families will learn how to find supports and services within the school system and the community.
A theme of the NAMI Basics course is that “No one should have to face this journey alone!”
For more information, or to register for the course, call 201-532-2267 or 973-214-0632 or email firstname.lastname@example.org. Class size is limited to 15. Interested parents/guardians are urged to register as soon as possible.
For more information about NAMI Sussex, visit www.nami-sussex-nj.org. For more information about Family Partners of Morris and Sussex, visit www.familypartnersms.org.
Obsessive-compulsive disorder (OCD) is characterized by repetitive, unwanted, intrusive thoughts (obsessions) and irrational, excessive urges to do certain actions (compulsions). Although people with OCD may know that their thoughts and behavior don’t make sense, they are often unable to stop them.
Symptoms typically begin during childhood, the teenage years or young adulthood, although males often develop them at a younger age than females. More than 2 percent of the U.S. population (nearly 1 out of 40 people) will be diagnosed with OCD during their lives.
Most people have occasional obsessive thoughts or compulsive behaviors. In an obsessive-compulsive disorder, however, these symptoms generally last more than an hour each day and interfere with daily life.
Obsessions are intrusive, irrational thoughts or impulses that repeatedly occur. People with these disorders know these thoughts are irrational but are afraid that somehow they might be true. These thoughts and impulses are upsetting, and people may try to ignore or suppress them.
Examples of obsessions include:
• Thoughts about harming or having harmed someone
• Doubts about having done something right, like turning off the stove or locking a door
• Unpleasant sexual images
• Fears of saying or shouting inappropriate things in public
Compulsions are repetitive acts that temporarily relieve the stress brought on by an obsession. People with these disorders know that these rituals don’t make sense but feel they must perform them to relieve the anxiety and, in some cases, to prevent something bad from happening. Like obsessions, people may try not to perform compulsive acts but feel forced to do so to relieve anxiety.
Examples of compulsions include:
• Hand washing due to a fear of germs
• Counting and recounting money because a person is can’t be sure they added correctly
• Checking to see if a door is locked or the stove is off
• “Mental checking” that goes with intrusive thoughts is also a form of compulsion
The exact cause of obsessive-compulsive disorders is unknown, but researchers believe that activity in several portions of the brain is responsible. More specifically, these areas of the brain may not respond normally to serotonin, a chemical that some nerve cells use to communicate with each other. Genetics are thought to be very important. If you, your parent or a sibling, have an obsessive-compulsive disorder, there’s close to a 25 percent chance that another immediate family member will have it.
A doctor or mental health care professional will make a diagnosis of OCD. A general physical with blood tests is recommended to make sure the symptoms are not caused by illegal drugs, medications, another mental illness, or by a general medical condition. The sudden appearance of symptoms in children or older people merits a thorough medical evaluation to ensure that another illness is not causing of these symptoms.
To be diagnosed with OCD, a person must have:
• Obsessions, compulsions or both
• Obsessions or compulsions that are upsetting and cause difficulty with work, relationships, other parts of life and typically last for at least an hour each day
A typical treatment plan will often include both psychotherapy and medications, and combined treatment is usually optimal.
• Medication, especially a type of antidepressant called a selective serotonin reuptake inhibitor (SSRI), is helpful for many people to reduce the obsessions and compulsions.
• Psychotherapy is also helpful in relieving obsessions and compulsions. In particular, cognitive behavior therapy (CBT) and exposure and response therapy (ERT) are effective for many people. Exposure response prevention therapy helps a person tolerate the anxiety associated with obsessive thoughts while not acting out a compulsion to reduce that anxiety. Over time, this leads to less anxiety and more self-mastery.
Though OCD cannot be cured, it can be treated effectively.
This article was supplied by members Mental Health America of Daviess County with information from the National Alliance on Mental Illness www.nami.org. For more information on Mental Health America of Daviess County or to learn about mental health resources available in the area, call 812-254-2423 or visit dcmha47501.wixsite.com/dcmha.
This is the third article in a series about anxiety.
Q: What are anxiety and anxiety disorders in children?
A: Anxiety often arises during childhood. Research suggests biology and environment can be factors in the development of anxiety. Early traumatic events can reset the normal fear-processing so that it is overly reactive to stress.
Generalized Anxiety Disorder frequently starts in adolescence or young adulthood. Children and teens worry excessively when they have GAD. They worry about their grades in school and their performance in sports. They also worry about catastrophes, such as war or earthquakes. Children with GAD can experience physical symptoms that make it difficult to function and interfere with their daily lives. The above information is from a National Institute of Health 2016 revision.
On the website, very well-known author Katherine Lee addressed the question of anxiety disorders in children. The first type is Generalized Anxiety Disorder. Children with GAD have constant, excessive and uncontrollable fears. The fears are about grades, family problems, sports, being on time and natural disasters (as mentioned previously). These children with GAD often are perfectionists. They can have trouble sleeping, experience irritability and find it hard to concentrate in school.
Another anxiety disorder common in toddlers is Separation Anxiety Disorder. It can occur initially when a parent or caregiver leaves the room. As children who are older attend daycare, preschool or kindergarten, they can experience separation anxiety. Separation anxiety usually goes away as children become familiar with a new environment.
However, even in grade school, children might experience excessive fear and anxiety when separated from a parent. Children in grade school with separation anxiety can be reluctant to attend school or to sleep alone. Lastly, children with SAD might fear something bad will happen to them or their parents when they are separated.
Children with Obsessive-Compulsive Disorder have repeated thoughts they cannot control called obsessions. They might feel driven to perform rituals and routines, called compulsions, to control their thoughts and lessen their anxiety. A child who has OCD spends a lot on time or rituals such as hand washing, counting, repeating words or repeatedly checking and rechecking things like door locks to control unpleasant image, thoughts or feelings.
Post Traumatic Stress Disorder can develop after children witness or experience a life-threatening event such as a car accident. Many children recover quickly following a traumatic episode. However, those children who experienced the event directly or those children who lack strong support symptoms can develop PTSD. They can continue to have nightmares, flashbacks, insomnia, depression, and intense anxiety and fear. Children can re-enact the traumatic event when playing. Children might withdraw and avoid people, places and activities for months following the traumatic event.
Children with phobias have intense, irrational fears about something specific, such as dogs, needles, thunderstorms, flying and heights. Children with phobias are less likely to be able to put their fears in perspective or realize their fears are unrealistic, whereas adults are more able to rationalize their phobias into proportion.
Early diagnosis and treatment are important for effective treatment of children’s anxiety disorders. When anxiety disorders in children are untreated, they have a detrimental effect on children and can lead to problems in developing friendships, problems in school and low self-esteem.
The following information has been written by William L. Mace, Ph.D., a clinical psychologist in private practice. He noted a recent program on television in which mental health experts spoke about childhood anxiety. Beginning at age 4, 9 percent of preschoolers had developed Childhood Anxiety Disorder. By age 6, children presented with Separation Anxiety. By age 10, some children had Generalized Anxiety Disorder with an overlay of Social Anxiety.
There is some evidence childhood anxiety disorders can lead to adult mental disorders. One in every five young adults between 18 and 28 reported an anxiety event in the previous 12-month period. The inability to deal effectively with anxiety gets greater over time because any maladaptive coping mechanism must be dealt with first before addressing the underlying anxiety.
Experts found the only social stigma associated with Childhood Anxiety came from parents who refused to acknowledge it. Children can have Childhood Anxiety for one to seven years before parents accept the problem and then they might begin to comfort and overprotect the child, thus preventing the child from learning to cope. Childhood symptoms can include stomach aches before school, too much time spent playing computer games and avoidance of many everyday social encounters.
Behavioral therapies either with or without medication have proven effective in treating anxiety, especially anxiety in children. One of the significant reasons for the spike in anxiety among teens is the increase in the use of technology. An example is the device called a “fidget spinner.” Originally made to help children with anxiety, ADHD and autism, sales have been explosive, particularly among children, teens and young adults.
Smartphones, computers, video games and other technical devices have a mesmerizing or hypnotic effect on users. Children become addicted to technology, and any attempts to dislodge them or disrupt their use results in their anxiety. One of the main problems with technology is it tends to replace time spent in independent, creative play, time spent outdoors and interactive socialization with other children.
• Next week’s article will begin a discussion of anxiety disorders in adults.
Judy Caprez is professor emeritus at Fort Hays State University.
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