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Surgery for obsessive compulsive disorder sufferers is safe and effective

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Public release date: 3-Jun-2013

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Contact: Stephanie Burns
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BMJ-British Medical Journal

Around half of patients with extreme OCD respond well to psychosurgery treatment

Around half of people with an extreme form of obsessive compulsive disorder responded well to a type of psychosurgery that proved to be safe and effective, according to research published online in the Journal of Neurology, Neurosurgery, Psychiatry.

Researchers from Canada have now recommended physicians should consider this approach in helping people with OCD who have not responded to any other type of treatment.

Obsessive compulsive disorder (OCD) is a psychiatric disease which leads to anxiety-provoking thoughts (obsessions) causing repeated, time-consuming behaviors (compulsions) that might or might not provide temporary relief. Around 1 to 2% of the population is thought to have OCD that is severe enough to disrupt their life.

Standard treatments for the disorder are antidepressant medication and/or psychotherapeutic help such as cognitive behavioural therapy, but other studies have shown that such treatment does not help relieve symptoms for between 20-30% of patients.

Psychosurgery for OCD is sometimes carried out, but is rare and few studies have examined the benefits of this surgery.

Researchers from the Department of Neurological Sciences at Universit Laval, Quebec, therefore, decided they would study the efficacy and possible complications of one type of such surgery bilateral anterior capsulotomy in patients with severe OCD who had not responded to any other treatments over a long time period.

Nineteen patients were studied who had a severe form of OCD that had not responded to drugs or psychotherapeutic treatment. All of these patients underwent psychosurgery in the form of bilateral capsulotomy between 1997 and 2009.

They were evaluated before the surgery and then periodically afterwards for two years as well as being contacted again at an average of seven years after their operation to check on their progress.

Using a tool called the Yale-Brown Obsessive Compulsive Scale (Y-BOCS), the researchers measured the patients’ symptom severity. A patient with an improvement rate of over 35% in the Y-BOCS score was considered a responder, while a patient with a 25% improvement was considered a partial responder.

Their results showed that 36.8% of the patients responded fully to the procedure and 10.5% were considered partial responders, meaning that almost half of the patients (47.3%) responded to the surgery.

At the end of the study, three out of the 19 patients had recovered from their OCD, three were in remission (meaning their symptoms were reduced to a minimum level) and no deaths were reported. Only two patients had permanent surgical complications.

They concluded: “We are aware of the many ethical and sociopolitical considerations related to psychosurgery, but we think that such surgery is appropriate under thoughtful regulation, particularly when the disorder is chronic, intractable to non-invasive treatment modalities and when surgery is the last therapeutic option.”

[Bilateralstereotactic anterior capsulotomy for obsessive-compulsive disorder: long-term follow-up. Online First doi 10.1136/jnnp-2012-303826]


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Surgery for Obsessive Compulsive Disorder Sufferers Is Safe and Effective …

Researchers from Canada have now recommended physicians should consider this approach in helping people with OCD who have not responded to any other type of treatment.

Obsessive compulsive disorder (OCD) is a psychiatric disease which leads to anxiety-provoking thoughts (obsessions) causing repeated, time-consuming behaviors (compulsions) that might or might not provide temporary relief. Around 1 to 2% of the population is thought to have OCD that is severe enough to disrupt their life.

Standard treatments for the disorder are antidepressant medication and/or psychotherapeutic help such as cognitive behavioural therapy, but other studies have shown that such treatment does not help relieve symptoms for between 20-30% of patients.

Psychosurgery for OCD is sometimes carried out, but is rare and few studies have examined the benefits of this surgery.

Researchers from the Department of Neurological Sciences at Université Laval, Quebec, therefore, decided they would study the efficacy and possible complications of one type of such surgery — bilateral anterior capsulotomy — in patients with severe OCD who had not responded to any other treatments over a long time period.

Nineteen patients were studied who had a severe form of OCD that had not responded to drugs or psychotherapeutic treatment. All of these patients underwent psychosurgery in the form of bilateral capsulotomy between 1997 and 2009.

They were evaluated before the surgery and then periodically afterwards for two years as well as being contacted again at an average of seven years after their operation to check on their progress.

Using a tool called the Yale-Brown Obsessive Compulsive Scale (Y-BOCS), the researchers measured the patients’ symptom severity. A patient with an improvement rate of over 35% in the Y-BOCS score was considered a responder, while a patient with a 25% improvement was considered a partial responder.

Their results showed that 36.8% of the patients responded fully to the procedure and 10.5% were considered partial responders, meaning that almost half of the patients (47.3%) responded to the surgery.

At the end of the study, three out of the 19 patients had recovered from their OCD, three were in remission (meaning their symptoms were reduced to a minimum level) and no deaths were reported. Only two patients had permanent surgical complications.

They concluded: “We are aware of the many ethical and sociopolitical considerations related to psychosurgery, but we think that such surgery is appropriate under thoughtful regulation, particularly when the disorder is chronic, intractable to non-invasive treatment modalities and when surgery is the last therapeutic option.”

Different Ways to Eliminate Depression

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Skin picking gets status as distinct disorder

Angela Hartlin’s legs are covered with small bloodied sores that overlay myriad scars, ghost-like  reminders of similar lesions that have dotted her skin for years.

For more than decade, she has been obsessively picking at the skin on her legs, chest and face — sometimes for many hours at a time — and she can’t find a way to stop.

Hartlin suffers from skin picking disease, a disorder classified for the first time as a distinct entity in the just revised psychiatric bible, the Diagnostic and Statistical Manual of Mental Disorders, or DSM-5.

Skin picking, or dermatillomania as it’s formally known, was long considered an offshoot of obsessive-compulsive disorder (OCD). And that has made it difficult for those with the condition to get treatment, or even to have it recognized by many as anything more than a bad habit.

Hartlin, who lives in Halifax, says there are no medical specialists in her province who can provide treatment for skin picking disease, or even acknowledge it as a separate diagnosis on the spectrum of psychiatric disorders.

“I went through years, I just felt so embarrassed and had so much shame,” says Hartlin, 26, who began digging at her skin at about age 13. “I thought I was the only one for years, and I think that is the worst part, that disorders such as this feed into that isolation and make it worse.”

Often she will pick at her skin — what she perceives as in-grown hairs on her legs, or bumps and blemishes on her chest and arms — without conscious awareness while watching TV or sitting at her computer.

Even sleep brings no respite: “I wake up with blood on my legs. I wake up sometimes and I have blood on my fingers from picking at my legs while I’m asleep.”

At other times, the picking is more deliberate, triggered by a trip to the bathroom, where she can get entrenched in an episode she feels powerless to stop.

“It takes up a lot of time. If I don’t go to bed at a certain time, by about midnight, then I get stuck in the bathroom for well over an hour,” she explains. “But when I was younger, like about 20, I used to get caught up in the bathroom for eight hours.

“And sometimes I didn’t realize how much time had passed. Sometimes I did but I was just … I had to keep going to get that feeling.”

She has trouble explaining the feeling: it does seem to relieve anxiety and it has a component of self-gratification, a cathartic sense of accomplishment that she has successfully removed what she sees as  defects on her skin.

“I’m in a zone where it’s just such a fixation that I can’t do anything else. I can’t think of anything else or focus on anything else. I have to do that.”

Toronto psychiatrist Dr. Peggy Richter says everyone picks at their skin to a certain degree, whether that’s popping a pimple, squeezing a blackhead or pulling off a scab.

“This is normal behaviour,” says Richter, director of the clinic for OCD and related disorders at Sunnybrook Health Sciences Centre, who specializes in treating skin picking and trichotillomania, or compulsive hair pulling.

“But is this a recurrent problem that we have to work at stopping? No. For most of us, it’s an isolated event.

“Whereas for these folks, they may have damaged their skin to such a point that they are significantly distressed and very self-conscious about the impact on their appearance and how others perceive them,” Richter says.

“The reality of the impact may be such that they’re not comfortable going out on a bad picking day because they have raw red areas on their face, for example, that are painful. So maybe they’re calling in sick for work a few days a month after a bad episode.”

Among Richter’s patients are parents who won’t take their children to school after a bad picking bout the night before, and some who have dug at their skin so much they need stitches.

One man, who primarily excavates in-grown hairs in his beard area and often creates deep lesions, began stitching himself with a needle and thread because he got tired of going to the emergency department, she says.

“And he’s extremely distressed and very self-conscious and experiencing pain because of it. And he had significant scarring, very significant scarring, with a very real objective impact on his appearance because of it.

“But he could not stop.”

Sarah Roberts, a PhD candidate who works with a University of Montreal team that researches  obsessive disorders like skin picking, says many of those afflicted don’t use only their nails. Implements like nail files and tweezers are also employed to gouge out imperfections in their skin, which can lead to infection.

“The criteria for almost any DSM disorder involves distress or impairment in functioning,” Roberts notes. “So we’re talking about someone who has to see the doctor because their skin is infected because they picked at it so much.”

Richter said the exact cause of dermatillomania isn’t known, but it occurs more in families with a history of OCD spectrum disorders, suggesting there is a complex genetic vulnerability to the disorder.

An estimated one to four per cent of the population may have the disorder, with women more often affected. But prevalence studies are not definitive, and indeed research of any kind on the condition is relatively sparse.

Treatment primarily involves cognitive behavioural therapy, specifically habit reversal, says Richter, who has treated about 100 patients with skin picking and hair pulling over the last decade or so.

While only about half have recovered fully, overall about 80 to 90 per cent have seen improvement.

“They may still pick but it’s more limited, they have a better sense of control,” she says, adding that one treatment tactic is introducing “competing responses” such as squeezing a stress ball or clenching one’s fists — activities incompatible with picking.

Besides dealing with the physical, there are also emotional issues to tackle — often a long-standing sense of worthlessness and self-disgust, adds Richter.

Those feelings can impair the ability to have relationships, especially with a romantic partner.

“Imagine how you feel about getting into an intimate relationship with a possible serious life partner when your skin looks like you have cigarette burns all over it or raw patches that would make it painful to be touched.”

Hartlin, a child and youth care worker, says she avoided dating for a long time, afraid that a guy would discover her secret affliction.

“My actual mantra that I kept saying in my head for years, over and over, was that nobody could accept the mess on my body, let alone the mess inside my head that caused it.”

But for the last three years, she has been in a relationship with a man she met online, and a month ago they got engaged.

He is supportive and encouraging, she says, and built her website aimed at helping others with the disorder (www.skinpickingsupport.com). Her self-published book from 2009, “Forever Marked: A Dermatillomania Diary,” can be ordered through the site.

Now that the DSM-5 officially recognizes skin picking disease, that should lend legitimacy to people  struggling to overcome the disorder and hopefully expanded treatment resources across the country, she says.

“Because I’ve had so many run-ins with doctors, and other people have as well, other sufferers, of doctors not understanding, of doctors chastising. I had a mental health nurse in my area a few years back, she told me that I needed to ’grow up.’

“Now you can just open up that (DSM-5) book and show this.”

Hartlin says her skin picking has been less severe since she “came out,” and she advises others with the condition to stop hiding and seek help, perhaps by starting with the Canadian Body Focused Repetitive Behaviours Support Network (www.facebook.com/CanadianBFRB).

“For now I’m spreading the awareness and that’s my main goal, because that’s what makes me truly happier,” she says.

Of course, there’s no question she wants to be done for good with the compulsion to rend her skin.

“I’ve learned to live life with this and be happy,” she says. “But if I actually found a way to stop doing this, then that would just be an added bonus in my life.”

Also online:

International OCD Foundation: www.ocfoundation.org/uploadedFiles/MainContent/Find—Help/Skin%20Pick ing%20Disorder%20Fact%20Sheet.pdf

Social Anxiety Symptoms And Three Ways of Treating Social Anxiety

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Events for people with disabilities

Aspire of Western New York, in conjunction with Southeast Works, is sponsoring an all-day conference, “Aging with Developmental Disabilities,” from 8:30 a.m. to 3:30 p.m. Thursday at the Millennium Hotel, 2040 Walden Ave., Cheektowaga. Regional experts will discuss issues related to the aging of developmentally disabled adults, current medical thinking, behavioral strategies for caregivers, and end-of-life issues. The invited speakers are Drs. Colin McMahon, medical director, Aspire of WNY; Kenneth Garbarino, gerontologist, Kaleida Health; Sanjay Gupta, adult and geriatric psychiatry; Kathleen Grimm, Center for Hospice and Palliative Care; Patricia Bomba, vice president and medical director, Geriatrics at Excellus BlueCross BlueShield. The cost is $30 and includes lunch. To register, mail payment to Peggie Giambra, Aspire of Western New York, 2356 North Forest Road, Getzville. For more information, call 505-5505.

Niagara Frontier Radio Reading Service is hosting a “Book and Media Super Sale” fundraiser at 8 a.m. Friday and Saturday at 1199 Harlem Road, Cheektowaga. For sale will be books, books-on-tape/CDs, videos, DVDs, CDs and cassettes. Donations for the sale can be dropped off at the same location. Proceeds will benefit the Niagara Frontier Radio Reading Service, which broadcasts daily readings of newspapers, magazines, books and other printed matter to area print-handicapped people, who are given “reading radios.” For more information, call 821-5555.

Parent Network of Western New York is offering a free workshop, “Valued Outcomes,” for Medicaid service coordinators and habilitation providers, from 9 a.m. to noon Wednesday at its offices at 1000 Main St. Participants will learn about valued outcomes and their importance. Group discussion and activities are included. Staff workers responsible for writing residential and daily habilitation plans are encouraged to attend. For more information or to register, call 332-4170 or visit www.parentnetworkwny.org.

Native American Community Services, 1005 Grant St., provides assistance to developmentally disabled individuals and their families in both Erie and Niagara counties through the Medicaid Services Coordination Program. Services can be provided to off-reservation Native Americans as well as other Western New York community members. For more information, call 874-4460.

Aspire of Western New York is hosting its 23rd annual “Going for the Green” golf tournament fundraiser from 12:30 p.m. to 9 p.m. Monday at Brookfield Country Club, 5120 Shimerville Road, Clarence. For details about sponsorship opportunities, call Megan Babirad at 505-5514 or email mbabirad@aspirewny.org.

Western New York Independent Living Inc. is offering “Freedom Through Art,” a support group, at noon every first Tuesday of the month at its offices, 3108 Main St. The group will explore cultures, traditions and inspirations through eclectic art forms to discover more about self-identity and others. It is open to the public, people with disabilities, and to family members and friends of people with disabilities. For more information, call Jeff and Megan Ostrowski at 836-0822, Ext. 114; Ivan Ortiz, Ext. 145; or Pat Petrosino, Ext. 165.

The Mental Health Association of Erie County will host an obsessive-compulsive disorder support group from 1 to 3 p.m. Thursday at 999 Delaware Ave. Also available are support groups for depression, anxiety, panic disorder, pain management and female trauma survivors. Groups are free. For more information, call 886-1242.

Headway of Western New York will offer support groups Tuesday in its offices at 976 Delaware Ave. The Life Support Group for people with brain injury and their families will meet from 1 to 2:30 p.m.; Peer Support Group and Caregivers Support Group will both meet from 6:30 to 8 p.m. For more information, call 408-3100 or visit www.headwayofwny.org.

Cantalician Center Community Services, 665 Hertel Ave., provides employment, vocational training, evaluations, social programming and Medicaid service coordination for people with developmental disabilities. For more information, call 874-0913.

Items of timely events may be submitted by fax, 856-5150 or by mail to City Desk, Events for People with Disabilities, The Buffalo News, P.O. Box 100, Buffalo, NY 14240.

About Neuro Physiotherapy

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Hockey Night in CanadaPenguins’ Vokoun has overcome plenty to get to this point

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For anybody who believes Tomas Vokoun eventually will falter and surrender the Pittsburgh Penguins crease back to Marc-Andre Fleury this spring, you may want to know the veteran goalie’s story.

The 36-year-old Czech has overcome his share of setbacks and he’s not about to let an opportunity like pushing the Penguins past the Boston Bruins in the Eastern Conference final, which begins Saturday in Pittsburgh (CBC, CBCSports.ca, 8 p.m. ET), slip away.

Just the fact that Vokoun has 300 career NHL wins after he wasn’t selected in the 1994 NHL entry draft until the ninth round (226th overall) is an accomplishment. Twenty-two other goalies were taken before the Montreal Canadiens called Vokoun’s name.

So he had to start at the bottom of the North American professional ranks with the 1995-96 Wheeling Thunderbirds of the ECHL. These were difficult times for Vokoun. He didn’t speak English. He didn’t have a West Virginia driver’s licence. He wanted to go home. But he stuck it out.

After Wheeling’s season concluded, Vokoun was promoted to the AHL Fredericton Canadiens and started one playoff game. He made his NHL debut the following season, but allowed four goals on 14 shots in a period of action against the Philadelphia Flyers. He swiftly was returned to Fredericton. At that point, it didn’t look like he was going to pass Jocelyn Thibault or Jose Theodore on the Canadiens depth chart.

So he was left unprotected in the 1998 expansion draft. The Nashville Predators snapped him up. He started to rapidly develop under Predators goalie coach Mitch Korn who, earlier in his career, worked with Dominik Hasek in Buffalo.

Korn, however, was concerned about his new protégé. He thought Vokoun may have obsessive-compulsive disorder (OCD), an anxiety disorder characterized by intrusive thoughts that produce uneasiness, apprehension, fear or worry. This is not exactly the kind of mental state ideal for an NHL goalie.

Vokoun’s father had OCD. Sure enough, the younger Vokoun was tested and diagnosed with OCD. He was prescribed medication to combat the disorder and that immediately helped.

In 2005, with the entire hockey community watching because the NHL season was cancelled due to a lockout, Vokoun helped guide the Czech Republic to gold over Canada at the world championship.

He figured his time was now and enjoyed his best season to date when the NHL re-opened for business in 2005-06. But as the Predators approached the playoffs, again something wasn’t right with Vokoun.

He had mysterious back pain. The diagnosis of exactly what was wrong did not come easy. It turned out that he suffered from blood clots caused by a condition called thrombophlebitis of the pelvis. His recovery called for blood thinners. As a result, he was forced to miss the playoffs that spring.

In fact, prior to replacing Fleury for Game 5 of the Penguins’ opening-round series against the New York Islanders, Vokoun had not played in a Stanley Cup playoff game since 2007. 

He did win a second world championship in 2010. But he also became known for one of those fluky lowlights in November 2009, when Vokoun was injured by Florida Panthers teammate Keith Ballard who, after his team surrendered a goal, swung his stick and hit Vokoun. The Panthers goalie suffered a lacerated ear and was rolled off the ice on a stretcher to be treated at a nearby hospital.

Vokoun sat on the bench with the Washington Capitals last year and watched an unheralded Braden Holtby play well enough to get the Capitals to Game 7 of the second round.

Meanwhile, Pittsburgh failed to advance to the second round for the second successive post-season. Penguins general manager Ray Shero, who was an assistant GM with Nashville when Vokoun was there, needed some insurance in case Fleury’s erratic play in the playoffs continued.

Fleury hasn’t been the same since those big stops he made against Detroit’s Henrik Zetterberg and Nicklas Lidstrom in the dying seconds of the Penguins’ Stanley Cup-clinching victory at Joe Louis Arena on June 12, 2009.

So Shero traded for Vokoun, who wears sweater No. 92 — the reverse of his preferred No. 29 — at the NHL draft a year ago. He performed well for Pittsburgh in the regular season. He set a franchise record with a shutout streak of 187 minutes 30 seconds in late March.

He has rescued the Penguins in the post-season with a 6-1 mark and .941 save percentage (second to Los Angeles Kings goalie Jonathan Quick at .948) since he supplanted Fleury as No. 1 in Pittsburgh, a position he has no plans on giving up.

Goalies in 1994 NHL draft

Vokoun was the 23rd goalie taken in the 1994 draft. Check out the quality netminders selected before Vokoun in the ninth round:

1st round

2nd round

4th round

5th round

6th round

7th round

8th round

9th round

Follow Tim Wharnsby on Twitter @WharnsbyCBC

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