Dr. Phil Kronk: Is obsessive-compulsive disorder a biological brain-based disorder?

For decades, Obsessive-Compulsive Disorder (OCD) was viewed in terms of underlying anxiety. In many ways, it was seen as more of a “mental” problem than a biological disorder. That has changed.

In the latest 5th edition of the psychiatry’s diagnostic manual, OCD has been moved from the anxiety section to one called, “Obsessive-Compulsive and Related Disorders.” What are these related disorders?

They include: Hording Disorder, Trichotillomania (Hair-Pulling Disorder,) Excoriation (Skin-Picking) Disorder and Body Dysmorphic Disorder, which involves a preoccupation with perceived defects or flaws in one’s physical appearance.)

OCD can be found alongside of these other disorders, as well as being closely related to anxiety disorders (which is why it follows the anxiety diagnoses in the diagnostic manual.)

OCD also has a prominent cognitive aspect. First, the amount of insight a patient has about his OCD should be assessed. Secondly, along with medication, OCD is treated by cognitive behavioral therapy, though some choose to use only behavioral treatments.

Why do so, if OCD is a brain-based biological disorder?

Because ongoing research and clinical findings have found that your brain, and its complicated neural circuits, can be changed by either therapy or medication.

But which neural brain circuits are thought to make one develop OCD?

First, I must share that these nerve circuits are considered to cause OCD due to impaired misfiring.

These misfiring’s fail to control responses. The obsessive, impulsive aspects of OCD make one unable to stop initiating actions. The compulsive aspects make one unable to terminate ongoing actions once they are started.

No matter how much feedback the compulsive individual receives, he or she cannot adapt (and change) their behaviors, even after negative feedback. One begins to understand how much mental suffering and despair the patient with OCD can experience.

The nationally known psychopharmacologist, Stephan Stahl, M.D. (and author of over 500 articles and chapters) writes that the balance between the ventral striatum and the dorsal striatum areas of one’s brain may be impaired. In addition to this impaired neural circuit loop, other important inputs from the brain’s hippocampus, amygdala and prefrontal cortex are contributory.

Dr. Stahl writes that drug addiction is also related to the impaired interaction of the ventral and dorsal areas of the striatum.

Others have called the neural circuit from the prefrontal cortex to the caudate nucleus (of the basal ganglia area of the brain) the “worry circuit.”

The neural circuits of someone with OCD have been characterized as being in “brain lock.”

The latest thinking about OCD is that it is not goal-directed behavior to reduce anxiety, but that it consists of “habits provoked mindlessly from a stimulus in the environment.”

Cognitive behavioral therapy uses “exposure and response prevention” treatment. This involves gradual exposure to anxiety provoking situations.

Medication treatment for OCD usually involves one of the SSRI’s, such as Prozac, often at a high dosage, and augmented with an atypical antipsychotic, when needed. Deep-brain stimulation is an experimental treatment.

[This is the third column in a series on OCD this month. Future columns will look at how one ‘experiences’ OCD, as well as detailed explanations of helpful medication and cognitive therapy treatments.]

Phil Kronk, M.S., Ph.D. is a semi-retired child and adult clinical psychologist and neuropsychologist. He has a doctorate in clinical psychology and a postdoctoral degree in clinical psychopharmacology. Dr. Kronk writes a weekly online column on mental health for the Knoxville News Sentinel’s website, knoxnews.com. He can be reached at (865) 330-3633.

‘You are more than your mental illness’: What this woman with OCD wants you to know

From model Gisele Bundchen to TODAY’s Carson Daly, there’s been a lot of discussion about panic disorder and generalized anxiety disorder. But there’s another common form of anxiety that hasn’t been as widely discussed: obsessive compulsive disorder, or OCD.

According to the Anxiety and Depression Association of America, over 2 million American adults live with OCD, a disorder characterized by recurring thoughts and behaviors or compulsions.

TODAY sat down with one young woman with OCD, Nicole Zelniker, 23, to talk about the stigmas around the disorder, as well as what she learned from her coping.

What people often get wrong about OCD

“I think the biggest misunderstanding people have is that it’s just about cleaning or being a clean person,” Zelniker told TODAY. “I feel like a lot of what is portrayed in the mainstream media … is just a person who likes to clean and washes their hands a couple extra times a day or checks the door extra times a day and it’s not really a big deal.”

In fact, you might be able to recall a time someone referred to an individual as “so OCD” because he or she likes to keep things organized or clean. While it may seem harmless, it trivializes the condition and can make a person feel badly about themselves, researchers say.

“When I was younger, I would wash my hands so much that they would bleed … I couldn’t touch things because I was afraid that they were coated in germs and that it was going to be bad for me,” she said. “It was something I couldn’t fully articulate why. But it’s something that your brain does.”

Zelniker was diagnosed with OCD at age seven after her mother saw how it was affecting her at school and at home.

“Because I wasn’t the type of OCD that my friends were seeing in the mainstream media, I actually had a moment where I was maybe in middle school when I told a friend that I had OCD and she was really confused and she told me that I didn’t and she told me that I didn’t know what I was talking about,” Zelniker remembered.

On getting help

“When I was young, I was in and out of therapy. And it hasn’t historically been something that’s worked for me, but it’s worked for a lot of my friends,” she said.

She found that medication, along with lifestyle changes, has helped the most. Making time to unwind after a long day, or on the weekend and curl up with a great novel makes her happy. She also practices self-care by doing things she enjoys like buying smoothies, having quiet time to read or spending time with friends.

“Find a group of people you feel comfortable reaching out to,” she said. Besides strong support from her mom and sister, she credits a college friend with helping her take control of her mental health when she was suffering in college.

“My friend encouraged me to seek out help and get back on medication,” she said.

Researchers have studied how social support helps people, finding that there is indeed a positive, measurable impact across all ages.

“I still now have those racing, obsessive thoughts that kind of feel like they’re ricocheting around in your mind, and that’s something even if I can’t ever get rid of,” she said, “but it’s something I’ve learned to cope with.”

What she wants people to know about medication

While medication isn’t for everyone, and isn’t a one-stop solution, it can drastically help mental health patients. For Zelniker, it’s helped her mange fear.

“When you take a medicine for a physical disease, the whole point is that it helps you with a disease. (Mental health) isn’t any different. It’s beyond your control,” she said.

Advice for anyone struggling

Zelniker hopes young people like herself can help change the culture surrounding mental health.

“Mental health doesn’t define you,” she said. “I am a journalist. I am a New Yorker. I am a woman. I am so many other things than my mental illness.”

“Don’t be afraid to get help.”

Mental illness on the rise in America

SAN DIEGO, Oct. 16, 2018 — Approximately 1 in 5 American adults will experience some form of mental illness in any given year, according to the National Alliance on Mental Illness (NAMI). This accounts for approximately 44 million U.S. adults, or 18.6 percent of the entire U.S. adult population.

According to NAMI, the current number of American adults stricken with a mental illness is staggering:

  • 1 percent live with schizophrenia
  • 6 percent live with a bipolar disorder
  • 9 percent will experience a major depressive episode
  • 1 percent suffer from an anxiety disorder, such as post-traumatic stress disorder, obsessive-compulsive disorder or a variety of phobias
  • 7 million adults suffer from substance abuse, with 40.7 percent having a concurrent mental illness

GEOGRAPHIC LOCATION AND MENTAL HEALTH

The states of Massachusetts, Vermont, Maine, North Dakota and Delaware have the lowest incidences of mental illness in the country, a fact that could be attributed to access to responsive mental health treatment programs.

Having an untreated mental illness could play a significant role in criminal or homicidal behavior, especially if substance abuse or unemployment is also prevalent, according to David Kopel, research director for Independence Institute.

image via https-::pixabay.com:en:board-chalk-psychology-1030589:board-1030589_960_720.jpg

UNTREATED MENTAL ILLNESS CAN LEAD TO CRIME

Admissions to mental hospitals have declined over recent decades, due to decreasing popularity over concerns regarding poor treatment of their inpatients. Conversely, since the 1950s there has been a significant increase within prison populations of inmates with mental illnesses.

According to Kopel, reducing the human and financial costs of violent crimes caused by those with mental illnesses is critical, and “90 days in a mental hospital might avoid the need for 10 years in prison.”

Approximately 15 percent of state prisoners and 24 percent of jail inmates likely have a psychotic disorder, according to the Department of Justice in a story by Ana Swanson and published in the Washington Post.
The ability to provide early identification and intervention for those displaying symptoms that might be indicative of mental illness would be a big step towards compassionate recovery and crime prevention.

Crime in America has become a highly politicized and polarizing issue.
Often, when tragedy strikes, social and political leaders seize the opportunity to bring their viewpoints to the national stage in order to further their own ideology.

As Americans come to terms with the prevalence of mental illness, there is a chance to create sound and realistic policies that move away from historically negative stigma and ideology and move toward both individual and national healing opportunities.

Creating more avenues for appropriate reporting of any suspected mental illness and requiring mandatory, compassionate treatment for those who are diagnosed would be a major step forward to helping solve the country’s current mental health crisis.

image via https-::pixabay.com:en:mental-health-mental-illness-women-1420801:mental-health-1420801_960_720.jpg

There are undeniable gaps in the mental health system that need to be bridged.
Sue Abderholden, MPHA, executive director of NAMI Minnesota, offers the following ideas, which would make crossing the bridge from mental illness to mental health easier, while simultaneously building safer communities.

  • Adequate availability of psychiatrists and mental health providers
  • No waiting lists for community services and inpatient treatment options
  • A 24-hour crisis team in every community
  • Employment and housing options
  • Effective case management and care coordination among mental health professional and organizations
  • Treatment programs for those with dual diagnoses
  • Opportunities for screening and early intervention
  • Unlimited access to mental health treatment

Early identification of a mental illness and access to appropriate treatment options is a sound, compassionate approach towards facilitating individual healing and making American communities much safer.

Until next time, enjoy the ride in good health!

OCD, My Exhausting Best Friend

I obviously need a new best friend.

Most people wouldn’t guess that I’m constantly tortured by disturbing thoughts. I’ve hosted live TV shows and given speeches in front of large audiences. During the LSAT, a few friends from college sat next to me because they said I had a calming energy. They had no idea of the internal storm always raging in my mind.

As far as acting on my thoughts and fears, I don’t: I’m possibly the most boring man on earth. I’m married with kids, don’t drink or get into bar fights. This makes sense. “Themes of O.C.D. have no absolutely no implication about the character of a person,” Dr. Phillipson said.

David Adam, author of the memoir “The Man Who Couldn’t Stop,” told me, “O.C.D. makes everything harder.” His book describes how he confronted his own O.C.D., which involved an intense, irrational fear of contracting H.I.V. We agreed that O.C.D., like all mental health afflictions, is not an artistic muse or creative gift but is ultimately unfair, with no complimentary benefits. Even though he likens his condition to being a recovering alcoholic, Mr. Adam was thankfully able to treat his O.C.D. and eventually write two books after he did a form of behavioral therapy called exposure and response prevention.

This is the most successful treatment for O.C.D., and it involves repeated exposure to the fearful thoughts without giving into the short-term relief delivered by compulsions. The trick is that you can’t outthink the disorder, you can’t outargue it, you can’t outrun it. You have to make the voluntary choice to confront it. It’s like inviting Pennywise the Clown, the demon from Stephen King’s “It” who feeds off your fears, over for a nice cup of tea. For example, if you’re obsessed with germs and contamination, then you have to abandon your compulsions and instead use public toilets and avoid repeatedly washing your hands. You choose to sit with the threat. Eventually, your brain habituates to the threat and is even bored by it, realizing there is nothing to fear.

Dr. Phillipson said people should first choose to forgive themselves for having O.C.D. If everyone had our misfiring brains, the whole world would behave exactly like us. Second, he advised against using negative imagery and instead welcoming our “best friend’s warning” but then choosing to ignore it. “The goal of the treatment is to make the thoughts irrelevant,” he said, “it’s not to make the thoughts go away.”

O.C.D. has exhausted me. I’m tired of suffering. I’m now doing exposure and response prevention, voluntarily exposing myself to my fears. It’s terrifying and often excruciating, like walking through a gauntlet of horrors without a shield or sword, armed only with belief and resolute conviction.

All the while, I’m working to abandon shame and guilt about my mental health disorder and to embrace the “best friend” I didn’t ask for.

Wajahat Ali (@WajahatAli) is a playwright, lawyer and contributing opinion writer.

Follow The New York Times Opinion section on Facebook and Twitter (@NYTopinion), and sign up for the Opinion Today newsletter.

Opinion | O.C.D., My Exhausting Best Friend – The New York Times

I obviously need a new best friend.

Most people wouldn’t guess that I’m constantly tortured by disturbing thoughts. I’ve hosted live TV shows and given speeches in front of large audiences. During the LSAT, a few friends from college sat next to me because they said I had a calming energy. They had no idea of the internal storm always raging in my mind.

As far as acting on my thoughts and fears, I don’t: I’m possibly the most boring man on earth. I’m married with kids, don’t drink or get into bar fights. This makes sense. “Themes of O.C.D. have no absolutely no implication about the character of a person,” Dr. Phillipson said.

David Adam, author of the memoir “The Man Who Couldn’t Stop,” told me, “O.C.D. makes everything harder.” His book describes how he confronted his own O.C.D., which involved an intense, irrational fear of contracting H.I.V. We agreed that O.C.D., like all mental health afflictions, is not an artistic muse or creative gift but is ultimately unfair, with no complimentary benefits. Even though he likens his condition to being a recovering alcoholic, Mr. Adam was thankfully able to treat his O.C.D. and eventually write two books after he did a form of behavioral therapy called exposure and response prevention.

This is the most successful treatment for O.C.D., and it involves repeated exposure to the fearful thoughts without giving into the short-term relief delivered by compulsions. The trick is that you can’t outthink the disorder, you can’t outargue it, you can’t outrun it. You have to make the voluntary choice to confront it. It’s like inviting Pennywise the Clown, the demon from Stephen King’s “It” who feeds off your fears, over for a nice cup of tea. For example, if you’re obsessed with germs and contamination, then you have to abandon your compulsions and instead use public toilets and avoid repeatedly washing your hands. You choose to sit with the threat. Eventually, your brain habituates to the threat and is even bored by it, realizing there is nothing to fear.

Dr. Phillipson said people should first choose to forgive themselves for having O.C.D. If everyone had our misfiring brains, the whole world would behave exactly like us. Second, he advised against using negative imagery and instead welcoming our “best friend’s warning” but then choosing to ignore it. “The goal of the treatment is to make the thoughts irrelevant,” he said, “it’s not to make the thoughts go away.”

O.C.D. has exhausted me. I’m tired of suffering. I’m now doing exposure and response prevention, voluntarily exposing myself to my fears. It’s terrifying and often excruciating, like walking through a gantlet of horrors without a shield or sword, armed only with belief and resolute conviction.

All the while, I’m working to abandon shame and guilt about my mental health disorder and to embrace the “best friend” I didn’t ask for.

Wajahat Ali (@WajahatAli) is a playwright, lawyer and contributing opinion writer.

Follow The New York Times Opinion section on Facebook and Twitter (@NYTopinion), and sign up for the Opinion Today newsletter.

Dr. Phil Kronk: Do you have real worries or obsessive ruminations?

      Worry does not empty tomorrow of its sorrow, it empties today of its strength.” “Corrie Ten Boom

      “Sorrow looks back, Worry looks around, Faith looks up.” Ralph Waldo Emerson

There are enough things to worry about in the everyday world—finances, raising children—without the added burden of having intrusive, unwanted obsessive ruminations.

Such worrisome over-thinking can become all-consuming, emotionally devastating and socially destructive.

Along with compulsive behaviors, such obsessions are part of the diagnostic category of an “Impulsive-Compulsive Disorder.” They are felt to be brain-based and localized in brain circuits that are mis-firing.

As I have said before in past columns, intrusive, obsessive thoughts are similar to a fever. They are a warning sign that something is wrong with your body. The negative feelings that one has about having obsessive thoughts or behavioral compulsions must not make you feel embarrassed, shameful, guilty or socially isolated. They must be acknowledged as being a medical problem that must be treated by a combination of medication and cognitive therapy.

A person with an obsessive-compulsive disorder should seek the help of both a physician and a clinical psychologist.

Obsessive-compulsive disorder often waxes and wanes over time for many who suffer from it. In the short run, cognitive therapy can help quiet the thoughts down. I tell patients it is similar to turning down a radio, so that it blends into background noise.

I always recommend that treatment for obsessive thoughts first involve learning how to relax oneself through progressive relaxation techniques. The next step is to counter the negative messages of the thoughts, by realizing that they are brain-related symptoms. These negative thoughts need to be countered with positive, affirmative statements that you and your therapist work on together.

The goal is to change one’s own relationship to one’s intrusive thoughts. And to learn what are real worries.

Psychologists have written about “real” worries. They involve, for example, bereavement and grief. (In fact, others often tell us that we have been grieving too long. They are wrong!)

PTSD is another diagnostic disorder with worry in its make-up. Its therapeutic relief is complex and not easily done. One must respect the rate at which the victim heals.

Gender Identity Disorder involves another form of over-thinking that needs to be better understood and accepted by the general public. The question, “Am I stuck in the wrong body?” is not easily answered.

Another overwhelming, anxiety-producing thought that patients share is the question, “Is this life I am living real?” or “What if I wake up and find that this is not reality?”

Some fear that they will wake up some day and find that the reality by which they live is not real.

Sometimes, I find that such fearful doubting is due to a significant depression. Sometimes, it is due to an unexpressed past trauma. Sometimes, it is a refusal to look at an upcoming negative life event, such as financial reality.

Obsessive individuals also worry if they are in the right reality. The answer I give them is supportive and non-authoritative. I tell them, no matter what reality you find yourself in, you should try to be happy and secure with the one you find yourself in. Being doubtful is not a reason to feel unhappy.

Obsessive worrying can include “content that is odd, irrational, or of a seemingly magical nature.” Another way to differentiate obsessive worrying from normal, or even other types of anxiety, is by the fact that compulsive behaviors are often present.

As the psychologist, Adam Phillips, Ph.D. is famous for saying, “The past influences everything, but dictates nothing.” I find solace in such a belief in hope. I try to share such a hope for all who suffer from what seems like over-whelming fearful and negative thoughts.

[This is the second column this month on a series about obsessive thinking and compulsive behaving. A future column will look at the impaired brain circuits thought to be underlying this disorder.]

Phil Kronk, M.S., Ph.D. is a semi-retired child and adult clinical psychologist and clinical neuropsychologist. Dr. Kronk writes a weekly online column on mental health for the Knoxville News Sentinel’s website, knoxnews.com. He can be reached at (865) 330-3633.

Let’s Talk About Anxiety

Anxiety in teens and children is increasingly common, and it’s the most prevalent mental health diagnosis among adolescents in the U.S. In spite of that, it’s rarely discussed openly in our community, which largely continues to stigmatize mental health issues. An upcoming screening of a powerful documentary intends to jumpstart a much-needed conversation about anxiety and normalize this common struggle.

On Tuesday evening, October 16, the Parent School Partnership of Yeshivat Noam will be hosting a community-wide screening of the compelling IndieFlix documentary “Angst: Raising Awareness Around Anxiety.” This film is a must-see for parents, educators and others who care for children or teens with anxiety. The film’s goal is to help viewers identify and understand the symptoms of anxiety and encourage them to reach out for help; to destigmatize, normalize and offer hope.

“Angst” engagingly and thoughtfully explores anxiety, its causes and effects and ways of dealing with it. The film features candid interviews with kids and teens who suffer, or have suffered, from anxiety, and what they’ve learned about it. “Angst” includes commentary from mental health professionals, and the screening next week will be followed by a live panel of experts who will field questions and further the conversation.

Many individuals experience an anxiety disorder, but particularly in communities that don’t discuss the problem, those who suffer often feel like their situation is rare or unique. According to the National Institutes of Mental Health, the prevalence of any anxiety disorder (including generalized anxiety disorder, obsessive-compulsive disorder, and specific phobias) in adolescents in the U.S. is 31.9 percent. That means this is an important, if not pressing, topic for many families, including those in our community.

According to Dr. John Duffy, clinical psychologist and best-selling parenting author, “The teenagers in the film describe their suffering with stunning openness, grace and courage…the filmmakers were able to capture what so many of my young clients are suffering in these complicated days: the bullying, perfectionism, panic, obsession, and too often, hopelessness…. Whether you are a teenager, parent, educator or a mental health professional, you simply need to see this movie, and soon. And every school needs to screen this film. It’s that important.”

Chani Oshinsky, a Teaneck resident who saw the film at a private screening this spring, found it eye-opening. “‘Angst’ really helps educate adults so they can validate their children’s or students’ struggles and help them, instead of dismissing or misunderstanding them,” she says.

Notes Dr. Jerry Bubrick, senior director of the Child Mind Center, “In our world there is a stigma attached to mental health disorders. People see anxiety as a personal failing rather than a medical condition; they see it as something to be ashamed of, rather than something to be treated. In reality, anxiety is universal. It doesn’t discriminate—and it’s very treatable. We just need to acknowledge it and talk openly first.”

The firsthand accounts of kids and teens in the film describing their experiences tend to strike a chord with viewers, many of whom have seen their children or students struggle similarly. The film and expert panel on Tuesday will address some of the different ways that anxiety presents in children, which can often be misunderstood by adults, including parents and educators.

Loretta Paley, co-chair of Yeshivat Noam’s Parent-School Partnership, was instrumental in arranging the upcoming screening after she saw the film last year. “I feel that it’s so critical for everyone in our community to see this film, to stop stigmatizing these kids, and to finally understand what they’re going through so we can help them. There needs to be a big change in how we view mental health concerns, and we’re hoping that ‘Angst’ contributes to that change.”

The film and expert panel will take place at Yeshivat Noam Middle School on Tuesday, October 16, at 8 p.m. Admission is free and the event is open to the community. “Angst” is recommended for teens and adults but may be too intense for younger viewers. For questions, please email [email protected]

By Talia Marmon, Ph.D.


Dr. Talia Marmon is a clinical psychologist.

John Green on how he deals with Obsessive-Compulsive Disorder and "thought spirals"

While you may not have heard of the author John Green, be assured that the teenagers in your life have. He is America’s answer to J.K. Rowling, with his mega best-sellers spawning blockbuster movies. Green has become wildly popular thanks largely to his loyal teenage audience. Green is also the rare literary talent who doubles as a podcaster and a YouTube star.

His success stems from his intuitive understanding of adolescents, his ability to meet them on their level and on their devices. To those who consider today’s teens a disaffected tribe, rarely glancing up from their phones and video games, John Green offers a counter narrative.

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Correspondent Jon Wertheim with John Green

Jon Wertheim: Let’s talk about teenagers.

John Green: 60 Minutes’ core audience, I understand.

Jon Wertheim: (LAUGH) It’s trending, uh… well, you know. You write a lot about teenagers.

John Green: Yeah.

Jon Wertheim: Why this cohort?

John Green: They’re doing so many things for the first time and there’s an intensity to that. You know, there’s an intensity to falling in love for the first time and also there’s an intensity to asking the big questions about life and meaning that just isn’t matched anywhere else.

Jon Wertheim: You’ve said before that adults underestimate teenagers.

John Green: Well, I think sometimes teenagers maybe don’t have the language to talk to us in ways that seem compelling to us. And maybe that makes it easy for us to dismiss them or think of them as less intellectually curious or intellectually sophisticated than we are. But I don’t think that’s true at all.

John Green’s books, in the YA — or young adult — genre dominate best-seller lists and while the stories take place in the U.S., They echo worldwide, having been translated into 55 languages.

Jon Wertheim: Lithuanian, Slovenian, Croatian.

John Green: Yeah, yeah It’s really wonderful to have your books travel to places you’ve never been. I mean it’s a weird but really beautiful experience.

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His most famous book, “The Fault in Our Stars,” was a best-seller for more than three years.

And adapted to a hit film in 2014 that grossed more than $300 million. Tinged with tragedy, the story follows two teenagers with cancer who fall in love – heavy, and heady stuff for an adolescent audience.

Jon Wertheim: The subjects you deal with are quite weighty. Death and suicide and cancer. A lot of teenagers haven’t had these experiences per se, but these books resonate with them. How is that?

John Green: Maybe lots of teenagers haven’t had these particular experiences, but I do think they know of loss, and they know of grief, and they know of pain. Maybe the particulars of an experience aren’t universal, but the feelings are.

One reason he connects so well with teenagers? At age 41, Green is still a kid at heart.

His youthful spirit drives more than book sales. It made him a YouTube star.

In 2007, the early days of YouTube, John Green and his kid brother Hank began sharing videos as a way to stay in touch with each other.

In short order, and in lockstep with the growth of YouTube, the Greens’ videos amassed a huge audience, now nearly a billion total views strong. This online video platform in turn fueled John Green’s readership.

Jon Wertheim: They play off each other.

John Green: Yeah. In a way, they’re different sides of the same coin, right? Because what interests me really is the idea of connecting with a viewer or with a reader without having to like actually talk to them and look at them and all that.

This preference, Green said, is the legacy of his own socially awkward adolescence.

Jon Wertheim: Who do you envision are your readers?

John Green: I don’t envision a reader.

Jon Wertheim: You don’t.

John Green: I think in some ways I’m writing back to my high school self  to try to communicate things to him, to try to offer him some kind of comfort or consolation.

Jon Wertheim: Who was that guy?

John Green: I had a difficult time in high school. I wasn’t a very good student and I had a lot of self-destructive impulses and I felt scared all the time.

Jon Wertheim: What were you scared of?

John Green: The short answer is everything.

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He explores those fears in his most recent book, “Turtles All the Way Down,” a best-seller for 50 straight weeks since it debuted at number one. Its theme: obsessive-compulsive disorder, OCD, based on Green’s own. For this book, he obeyed that time honored rule of the craft: write what you know.

John Green: I wanted to try to give people a glimpse of what it is. I wanted to try to put them, you know, at least a little bit inside of that experience.

Jon Wertheim: You use the word “thought spiral.” What does that mean?

John Green: The thing about a spiral is that it– it goes on forever, right? Like, if you zoom in on the spiral it can keep tightening forever. And that for me is the nature of obsessive thought that it’s this inwardly turning spiral that never actually has an end point. So it might be I’m eating a salad and it suddenly occurs to me that somebody might have bled into this salad. Now, they probably didn’t.

Jon Wertheim: This is what you’re thinking?

John Green: But this is what I’m thinking. And instead of being able to move on to a second thought, that thought just expands and expands and expands and expands. And then, I use compulsive behaviors to try to manage the worry and the overwhelmedness that that thought causes me.

Jon Wertheim: So how do you get out of this coil, and how do you break this infinity?

John Green: I have a few strategies. I exercise. That’s probably the biggest thing. Exercise is pretty magical in my life. I don’t enjoy it. (LAUGH) I don’t relish the thought of going for a run but it is very helpful because I can’t think.

John Green lives in Indianapolis, where his life comes short on stress, long on anonymity. He and his wife, Sarah Urist Green, a curator and online art educator, are parents of a son, age 8, and daughter, 5. Sarah began reading his manuscripts when they started dating 14 years ago.

Sarah Green: And I was really nervous because I really liked John, and I knew that if the book was bad it wasn’t gonna work. (LAUGHTER)

Jon Wertheim: The relationship wasn’t going to work. Not the book wasn’t going to work.

Sarah Green: No, no. The book might have worked or not, but I couldn’t be dishonest about, about that and if I didn’t like it, sorry.

John Green: I mean, I’m super glad I didn’t know that at the time. (LAUGHTER) I don’t think I coulda handled that pressure.

Jon Wertheim: Unfiltered criticism.

Sarah Green: Yeah, (LAUGH) yeah.

John Green: Yeah.

Jon Wertheim: John, do you remember when you told Sarah about your OCD?

John Green: I don’t know that it was an event so much as it was a process. And part of getting to know me was understanding that I had problems with anxiety.

Sarah Green: There was never a moment where John kind of sat me down and said, “I have OCD.” Um, it was more of a gradual process– where we were able to kind of put this label on it.  And so I can’t say that I would ever wish it to go away, because it’s a– it’s a part of him.

John Green: I– I’d like it to go away, (LAUGH) for the record.

So much so that, in 2015, fresh off the spectacular success of “The Fault In Our Stars,” Green decided to take a chance and go off the anti-anxiety medication he’d been taking for years.

Jon Wertheim: Why did you do that?

John Green: Well, ’cause I bought into this old romantic lie that– in order to write well– you need to sort of, like, be free from all of these mind-altering substances or whatever. And the consequences were really dire, unfortunately. And– and I– I’m lucky that they weren’t catastrophic, but they were serious. And coming out of that experience I found myself wanting to try to give some sort of form or structure—um, to this fear that I had lived with for my– most of my life.

These John Green fans call themselves “Nerdfighters” – part of a community that now includes hundreds of thousands of members around the world. The Nerdfighters formed in response to green misreading the name of a video game, “Aerofighters.”

Jon Wertheim: What’s a Nerdfighter?

John Green: A Nerdfighter is a person who fights for nerds.

Jon Wertheim: Not against nerds?

John Green: No.

Jon Wertheim: These are empowered nerds.

John Green: Yeah. Obviously we’re pro-nerd. (LAUGH) Really what it’s about is being enthusiastic. Being nerdy is really about how you approach what you love.

Jon Wertheim: Unabashedly.

John Green: Yeah.

Jon Wertheim: All five of you, proud, unapologetic nerds.

Presley: Oh yeah. Yep.

Ben: We take the name with pride.

We met these Nerdfighters last June. They were attending the ninth annual VidCon, a YouTube conference John and Hank Green created to help online video fans and creators meet in person. These five told us they were especially grateful to John Green for writing about his anxiety in “Turtles All the Way Down.”

Becky: It’s reassuring for sure.

Jack: For someone who does experience anxiety, he like, articulates things I could never articulate before. Which both, like, makes me feel seen but also helps me, like, understand and sort of, you know, feel better from different things.

Presley: Yeah, there’s this metaphor of a spiral in the book, and that was one of the most useful things I’ve ever come across in describing my own anxiety. And we use it in the house all time. And being around this community of people that was so loving  really made me grow to be a better person than I would have without it.

Presley at seven years old: I am a homeschooled child… and you all are my favorite teachers.

This was her – Presley Alexander – when she was just seven years old and she first came into the John Green orbit, not by reading one of his books but by watching him on Crash Course, the educational YouTube series that he started with his brother Hank in their manic signature style.

The videos offer lessons in the humanities and sciences with more than eight million subscribers, they are now offered as part of the curriculum in classrooms around the country. On account of his popularity across platforms, Green cuts a figure he never would have imagined when he was a teenager: something akin to a rock star.

Jon Wertheim: I want to know what your high school self would have thought if– if they saw you now.

John Green: Uh, my high school would be very– very happy and excited. (LAUGH) I’m embarrassed to admit. Uh, I wish that weren’t the case.

Hank Green: That’s a great– that’s a great way to put it. I agree completely.

The Green brothers are exceptionally supportive of each other, especially when it comes to John’s OCD – described so vividly in his latest book.

Jon Wertheim: “Turtles All The Way Down.” What was it like for you to read that?

Hank Green: It did help me understand John better. And– and, but– but in general be more empathetic toward people who deal with anxiety and OCD.

Jon Wertheim: What’d you learn about him?

Hank Green: The extent to which sometimes he is at the mercy of his own mind.

Jon Wertheim: But did it cause you to reexamine or reassess moments in your childhood?

Hank Green: Yeah, I mean, there– there have definitely been times in, you know, when John had a less stable life where I think, like, the family was worried about him. You know, those, the– the–

John Green: With good reason. (LAUGHTER)

Lately, there’s a lot less to worry about. With his multimedia, multimillion-dollar empire, John Green is using his pen, his keyboard and his video camera to normalize teenage social awkwardness and also to destigmatize mental illness.

Jon Wertheim: You’ve said that it’s important for young people to be able to see successful, productive adults challenged by mental illness.

John Green: Yeah.

Jon Wertheim: Expand on that.

John Green: Well, I have a really wonderful life. I have a really rich, fulfilling life. I also have a pretty serious chronic mental health problem. And those aren’t mutually exclusive. And the truth is that lots of people have chronic mental health problems, and still have good lives.

Produced by Sarah Koch and Chrissy Jones

Dr. Phil Kronk: What you should know about obsessive thoughts and compulsive behaviors

“Everybody is dealing with how much of their own aliveness they can bear and how much they need to anesthetize themselves.” Adan Phillips, Ph.D.

 “To grow up is to discover what one is unequal to.” Adam Phillips, Ph.D.

You are not alone if you suffer from an anxiety. At times, the world can feel overwhelming.

While we tend to see television commercials for depression or for bipolar disorder, the reality is that anxiety disorders are the most common form of mental suffering in our country.

One of five adults report some form of anxiety each year, but only slightly more than one third of these individuals receive treatment and relief from their suffering.

This month, in this column, I would like to focus on obsessive-compulsive forms of thinking and behaving.

For decades, mental health professionals viewed obsessive-compulsive disorder (OCD) as purely one type of anxiety disorder. While anxiety is certainly an important experienced component of OCD, today it is diagnosed as an “impulsive-compulsive disorder.”

Today, many clinicians and researchers realize that OCD is related to impaired neural brain circuits. I will share where mental health professionals believe these impaired neural brain circuits are located in one of the next columns.

Obsessions are intrusive and unwanted thoughts, urges or images that cause distress or anxiety.

Compulsions are repetitive behaviors or mental actions (such as counting, etc.) that a person performs in a rigid way in an attempt to respond to and alleviate an obsession.

Such anxiety can affect anyone. The singer-songwriter, Fiona Apple, shares that she “had a really bad obsessive-compulsive disorder.” She remembered that “At its worst, I was compelled to leave my house at three o’clock in the morning and go out in the alley because I just knew that the paper-towel roll I threw in the recycling bin was uncomfortable, like it was lying the wrong way, and it should be down in the garbage.”

Anxiety is rarely experienced by itself for many individuals. Depression often accompanies an anxiety disorder in half of those diagnosed with an anxiety disorder.

While the average age for an obsessive-compulsive disorder’s onset is around nineteen years of age, children also experience such symptoms.

In the next four weeks, in this column on mental health, I would like to share the extent of the destructiveness of the tendency to ruminate for individuals with obsessive-compulsive behaviors. I will also share some techniques to quiet the ruminations.

The need for perfection will be addressed, and the strain it can place on an individual. Guilt and shame are often intertwined with an over-concern about what others are thinking of us.

The obsessive-compulsive’s need to control will be addressed. So, will the need to be “sure.” And, the need, by some, to known what exactly reality is.

The difference between anxiety and fear will be addressed, as will be the fact that anxiety has both a biological and a cognitive etiology.

This is important because effective treatment for obsessive thoughts/urges and compulsive actions needs to have a dual form of combined treatment. Both cognitive therapy and medication can be effective in bringing relief and ending suffering.

Phil Kronk, M.S., Ph.D. is a semi-retired child and adult clinical psychologist and clinical neuropsychologist. Dr. Kronk has a doctorate in clinical psychology and a postdoctoral degree in clinical psychopharmacology (the use of drugs to treat mental disorders.) His year-long internship in clinical psychology was served at the University of Colorado Medical School. Dr. Kronk writes a weekly, Friday online column on mental health for the Knoxville News Sentinel’s website, knoxnews.com. He can be reached at (865) 330-3633.

 

Dr. Phil Kronk: What you should know about obsessive thoughts and …

“Everybody is dealing with how much of their own aliveness they can bear and how much they need to anesthetize themselves.” Adan Phillips, Ph.D.

 “To grow up is to discover what one is unequal to.” Adam Phillips, Ph.D.

You are not alone if you suffer from an anxiety. At times, the world can feel overwhelming.

While we tend to see television commercials for depression or for bipolar disorder, the reality is that anxiety disorders are the most common form of mental suffering in our country.

One of five adults report some form of anxiety each year, but only slightly more than one third of these individuals receive treatment and relief from their suffering.

This month, in this column, I would like to focus on obsessive-compulsive forms of thinking and behaving.

For decades, mental health professionals viewed obsessive-compulsive disorder (OCD) as purely one type of anxiety disorder. While anxiety is certainly an important experienced component of OCD, today it is diagnosed as an “impulsive-compulsive disorder.”

Today, many clinicians and researchers realize that OCD is related to impaired neural brain circuits. I will share where mental health professionals believe these impaired neural brain circuits are located in one of the next columns.

Obsessions are intrusive and unwanted thoughts, urges or images that cause distress or anxiety.

Compulsions are repetitive behaviors or mental actions (such as counting, etc.) that a person performs in a rigid way in an attempt to respond to and alleviate an obsession.

Such anxiety can affect anyone. The singer-songwriter, Fiona Apple, shares that she “had a really bad obsessive-compulsive disorder.” She remembered that “At its worst, I was compelled to leave my house at three o’clock in the morning and go out in the alley because I just knew that the paper-towel roll I threw in the recycling bin was uncomfortable, like it was lying the wrong way, and it should be down in the garbage.”

Anxiety is rarely experienced by itself for many individuals. Depression often accompanies an anxiety disorder in half of those diagnosed with an anxiety disorder.

While the average age for an obsessive-compulsive disorder’s onset is around nineteen years of age, children also experience such symptoms.

In the next four weeks, in this column on mental health, I would like to share the extent of the destructiveness of the tendency to ruminate for individuals with obsessive-compulsive behaviors. I will also share some techniques to quiet the ruminations.

The need for perfection will be addressed, and the strain it can place on an individual. Guilt and shame are often intertwined with an over-concern about what others are thinking of us.

The obsessive-compulsive’s need to control will be addressed. So, will the need to be “sure.” And, the need, by some, to known what exactly reality is.

The difference between anxiety and fear will be addressed, as will be the fact that anxiety has both a biological and a cognitive etiology.

This is important because effective treatment for obsessive thoughts/urges and compulsive actions needs to have a dual form of combined treatment. Both cognitive therapy and medication can be effective in bringing relief and ending suffering.

Phil Kronk, M.S., Ph.D. is a semi-retired child and adult clinical psychologist and clinical neuropsychologist. Dr. Kronk has a doctorate in clinical psychology and a postdoctoral degree in clinical psychopharmacology (the use of drugs to treat mental disorders.) His year-long internship in clinical psychology was served at the University of Colorado Medical School. Dr. Kronk writes a weekly, Friday online column on mental health for the Knoxville News Sentinel’s website, knoxnews.com. He can be reached at (865) 330-3633.

 

Comorbid Considerations Q&A: Treating Bipolar Disorder, Depression, Anxiety, or Autism Alongside ADHD

Comorbidity is the rule, not the exception, in most psychiatric practices. Clinicians today must possess a thorough and nuanced understanding of disparate conditions in order to effectively diagnose and treat their patients’ symptoms attention deficit disorder (ADHD or ADD).

This is the overarching principle of Dr. Anthony Rostain, professor of psychiatry and pediatrics at the Perelman School of Medicine at the University of Pennsylvania and attending and supervising psychiatrist at the Children’s Hospital of Pennsylvania and the University of Pennsylvania Health System. Dr. Rostain — who is triple boarded in pediatrics, adult psychiatry, and child and adolescent psychiatry — was interviewed recently for an Ask the Experts webinar hosted by The American Professional Society of ADHD and Related Disorders (APSARD). This is the first of five articles based on his responses to questions from Dr. Gregory Mattingly of Washington University School of Medicine about aspects of treating ADHD. This article is presented for general educational purposes, not medical advice.

Dr. Mattingly: Mood disorders, bipolar disorder, and emotional dysregulation all occur with great regularity alongside symptoms of ADHD. As a clinician, how do you balance treating your patients for ADHD and for these and other comorbid conditions?

Dr. Rostain: The majority of patients seeking psychiatric treatment arrive with not just attention deficit disorder, but also a variety of mood disorders, anxiety disorders, substance use disorders, and the like. As clinicians, we must expect that adults with ADHD — particularly those who have not ever been treated or those who have been treated for ADHD but continue to experience impairing symptoms of the disorder — will come to us with complex presentations.

For this reason, my rule of thumb is this: Complete a comprehensive history regarding every aspect of the person’s past and present functioning, as well as a thorough history of past treatments for psychiatric disorders. That is the sine qua non of good care.

[Free Download: 9 Conditions Often Linked to ADHD]

The four most common conditions diagnosed alongside ADHD are bipolar disorder, depression, anxiety, and autism spectrum disorder.

1. ADHD and Bipolar Disorder

Data from the National Comorbidity Study suggests that, among people with ADHD, almost 20% report having some form of bipolar spectrum disorder. These patients not only have inattention, impulsivity, and hyperactivity, but also the severe mood swings and/or prolonged downturns associated with bipolar disorder.

In treating patients with comorbid ADHD and bipolar disorder, clinicians have historically been concerned about the possibility that stimulant treatment might induce or exacerbate bipolar mania. Thus, a mood stabilizer, if not already part of the treatment plan, should be introduced to minimize the chances of triggering mania.

The bigger challenge, as we have come to understand bipolar disorder better, has to do with the persistent depressive states that affect patients with both bipolar disorder and ADHD. Because stimulants don’t significantly improve the mood of patients with bipolar depression, I suggest treating bipolar depression first and saying to your patient, “Once your mood is more stable and/or you’re no longer as depressed then we can address your cognitive difficulties, your inattention, your problems with sustaining effort.”

[Self-Test: Bipolar Disorder in Adults]

I am asked frequently: What is your point of view on treating patients for bipolar disorder who are already successfully using stimulant medications? Does it make sense to keep patients on ADHD medications while initiating treatment for bipolar disorder? For example, a recent trial found that children with both ADHD and bipolar who were treated for both ADHD and bipolar had the best outcomes of any patients treated for bipolar disorder.

This is important. There is no reason to stop a medication that’s been helpful when you’re trying to treat a second condition. The bipolar patients I worry about using stimulants are college-aged students and/or people who are not getting enough sleep. With that rare exception, there is no reason not to use a stimulant while you’re treating the aspect of bipolar disorder that remains a problem.

2. ADHD and Depression

Both depression or dysthymia — either longstanding low-level depression or more severe depression — present frequently in patients with ADHD. The notion now is to introduce a medication such as bupropion (Wellbutrin) initially. Once the patient shows improvement in their mood, the clinician can decide how to add a stimulant to address ADHD symptoms.

There’s no simple algorithm for adding stimulants to medications for depression. The evidence suggests that stimulants can be effective in conjunction with these medications, but it is important to watch for side effects such as cardiovascular problems, weight loss or insomnia. As long as these basic functions are monitored carefully, you can proceed safely with stimulants.

[Self-Test: Depression in Adults]

It turns out that clinicians in the depression unit here at the University of Pennsylvania are more and more inclined to add stimulants to boost effective antidepressants. It is a fascinating time to be in psychiatry as we learn that the persistent cognitive impairments and/or inattentiveness or distractibility that many patients experience with depression can be helped by prescribing stimulants as an adjuvant for treatment-resistant depression.

3. ADHD and Anxiety

I am frequently asked by residents in my clinic how to disentangle anxiety from ADHD. Truth be told, it’s very difficult to do.

Anxiety can interfere greatly with both performance and focus. Thus the first step is to probe the patient’s history to understand how anxiety presents itself. In patients with both anxiety and ADHD, the two conditions feed one another. If the patient’s anxiety is largely performance anxiety — centering on difficulties with task performance or, in the case of a prior history of ADHD, on school, interpersonal or occupational difficulties caused by the patient’s ADHD-driven lack or reliability — then my advice is to treat the ADHD first.

If, on the hand, the patient presents with obsessive-compulsive disorder (OCD), longer-standing generalized anxiety disorder, or panic disorder, then I start a treatment plan directed at the anxiety itself. Some clinicians use Atomoxetine because it addresses both ADHD and comorbid anxiety. I have also come to appreciate the use of alpha agonists for people with anxiety and ADHD, especially those who have had a bad response to stimulants.

[Self-Test: Symptoms of Generalized Anxiety Disorder]

4. ADHD and Autism

Until the DSM-5, we were not supposed to diagnose autism and ADHD simultaneously, an error that has now been corrected. For patients with both conditions, ADHD stimulant medications have an effect size slightly lower than would be observed for patients without autism, but the data is clear that treatment for ADHD is warranted. The effect size in autism patients might be 0.5 instead of 0.7 or 0.7 instead of 0.9 for different stimulant classes. Nevertheless, there is absolutely no reason not to use doses that are comparable to any other patient to start with.

As long as your patient is not having side effects, start the dosage low and increase it slowly — continuing until the patient has a clinical response. As a rule, I try both methylphenidate and amphetamine so I can judge which is more effective. In cases of patients with sensory difficulties, I sometimes use the new liquid and oral disintegrating tablet (ODT) formulations of ADHD stimulant medications.

Medication efficacy is challenging to assess when your patient cannot report well or is not able to observe the effects of medications. You need good collateral information, such as the usual teacher or parent data, and you also need to observe the patient’s performance on tasks presented in the office.