Month: August 2018

What is anxiety?

It’s defined as excessive, persisting worry over an imminent event such as death or illness — or even minor events such as being late for an appointment or other uncertain outcomes.

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Feeling anxious is common and can affect anyone, at any age. Episodes can range in seriousness and frequency.

But consistent worrying and fear can be problematic to healthy function.

That’s why knowing the type of anxiety you have can be helpful to finding a solution, says Elizabeth Duval, Ph.D., an assistant professor of psychiatry with Michigan Medicine.

Types of anxiety disorders

Anxiety disorders are broken down into five major types:

• Generalized anxiety disorder: Chronic anxiety characterized by exaggerated worry and tension, usually focused on future events and outcomes.

• Obsessive-compulsive disorder: Recurrent, unwanted thoughts (obsessions) or repetitive behaviors (compulsions). Behaviors are often performed with the hope of preventing or shaking off obsessive thoughts. But that provides only temporary relief; not performing them markedly increases anxiety symptoms.

• Panic disorder: Unexpected and repeated episodes of intense fear accompanied by physical symptoms.

• Post-traumatic stress disorder: Develops after exposure to a terrifying event or ordeal in which grave physical harm occurred or was threatened.

• Social anxiety disorder: Overwhelming anxiety and excessive self-consciousness in everyday social situations.

Anxiety and panic attacks

Although anxiety may fuel a panic attack, it’s a separate condition that can be gradual and chronic. (That’s why there’s no such thing as an “anxiety attack.”)

Panic attacks, by contrast, are marked by an intense and overwhelming sense of fear or dread in response to an imminent threat. Panic attacks, often brief, are brought on by the body’s “fight or flight” response — a natural and adaptive process that helps fight off danger or run from it.

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This process can be triggered any time we perceive ourselves to be in harm’s way — and it can happen within the context of any anxiety or stress disorder.

“If someone has a fear of dogs, encountering an unfamiliar dog could trigger a panic attack,” Duval says. “Someone who has social anxiety or worries about being judged negatively by others might have a panic attack when giving a speech or introducing themselves to new people.”

Symptoms of a panic attack

For some people, panic attacks seem to come out of the blue or are triggered by uncomfortable sensations in the body, Duval says.

Signs of a panic attack include:

• Racing heart

• Shortness of breath

• Trembling or shaking

• Chest discomfort

• Feeling of choking

• Nausea or stomach distress

• Tingling in extremities

• Lightheadedness

• Changes in sensory experiences (e.g. tunnel vision)

• Feeling cold or hot

• Sweating

• Feeling like things are unreal or unfamiliar

• Fear of dying or fear of losing control

A panic attack would include at least four of these symptoms, Duval says.

She notes that panic attacks can come on quickly and peak, or be at their worst, within 10 minutes. Most attacks resolve relatively quickly, within 30 minutes for most people.

Nor are they dangerous: “Panic attacks do not last forever; panic will subside on its own, even if you don’t do anything,” Duval says.

How to stop a panic attack

If a panic attack occurs, what do you do?

Duval suggests “grounding” yourself — or becoming aware of your surroundings and sensory experiences. This can be achieved by deep breathing, for example.

SEE ALSO: 3 Easy Anxiety Relief Exercises You Can Use Anywhere

“A big part of stopping a panic attack is to ride out the initial intensity and let it come down,” she says. “Sometimes being present in the moment can be helpful. Orient yourself to your surroundings.”

While panic attacks aren’t uncommon, you shouldn’t have to live in fear. Frequent attacks become a problem when they are causing distress and causing you to withdraw from activities or responsibilities.

“Sometimes people will become afraid they might have another panic attack and will begin avoiding doing activities that might bring one on,” Duval says. “This can cause significant impairment.

“If panic attacks or anxiety are making it difficult to live life the way you want, or if they’re causing distress, it might be time to seek out professional help.”

Panic attack treatment and prevention

Cognitive behavioral therapy and selective serotonin reuptake inhibitors (SSRIs) are the first-line, evidence-based treatments for anxiety. These treatments can be used separately or in combination.

Cognitive behavioral therapy focuses on identifying and addressing anxiety-related thoughts and behaviors. It often involves meeting with a therapist weekly and practicing hands-on strategies each day to manage anxious thoughts and behaviors.

SSRIs are taken daily and can help adjust levels of the neurotransmitter serotonin in the brain, which can affect mood and anxiety. There are many types of SSRIs. A medication provider will determine which one is best for you and will meet with you regularly to monitor benefits and side effects.

SEE ALSO: Using Cognitive Behavioral Therapy to Treat Teen OCD

Duval doesn’t recommend avoidance strategies or using substances such as drugs or alcohol to cope with or abstain from anxious feelings or panic attacks. Incorrect use of substances, including prescriptions, can interfere with relationships and work.

“It is a way to mask or avoid the anxiety; we’re not giving ourselves ways to manage it that are going to decrease it long term,” Duval says.

Instead, she suggests finding strategies to manage the attacks or reduce the anxiety around having a panic attack.

“The challenge is that oftentimes the more we try to prevent something, the more it will happen,” Duval says. “A big part of managing anxiety and panic is finding ways to face it.”

This is often the focus of treatment: “If people are having a lot of panic attacks, we’re going to want to be working with them to help identify their specific anxiety triggers and find ways to manage those triggers.

“We can’t prevent the triggers from occurring, but we can change the way we respond.”

For more information, visit the Anxiety and Depression Association of America or the University of Michigan Anxiety Disorders Program.

If you’re here, you’re probably prone to anxiety, and hunting online for people who’ve lived through experiences like yours. Those with generalized anxiety disorder (or other forms of anxiety disorder) know how exhausting it can be, and even physically painful. Anxiety can also cloud your judgment, making it hard to trust people close to you — even yourself. And for the people close to you who don’t have anxiety, understanding those anxious feelings and reactions can be frustrating.

Anxiety is also frequently dismissed as “just stress,” something everyone experiences from time to time. Conversely, some medical professionals can be quick to attribute too much to anxiety when a patient admits to having it. There’s no doubt that having anxiety can be a challenging, painful, and isolating experience, but if there’s any good news to be taken from the decades-long increase in reported anxiety and depression, it’s that there is more and more good writing being published on the subject. Here are six books that you (or an anxious person you know) might find illuminating, insightful, and even life-changing.

For a well-told history: My Age of Anxiety, by Scott Stossel

In a tone both educational and deeply personal, Stossel takes readers back through decades of anxiety research and the numerous scientific and medical interventions considered “treatments” over time. Though he’s compassionate toward anxiety sufferers (especially being one himself), he also manages to make anxiety (or at least some of the popular thinking around it) funny. Though reviewers say the book’s historical research is “exhaustive,” they’re also nearly unanimous in their praise of its humanity and relatability. If you want a better understanding of your anxiety disorder, or are curious to learn more about how our culture understands and treats it, this is a must-read.

Dana Kamaradova,¹ Martin Brunovsky,² Jan Prasko,¹ Jiri Horacek,² Miroslav Hajda,¹ Ales Grambal,¹ Klara Latalova¹

¹Department of Psychiatry, University Hospital Olomouc, Olomouc, Czech Republic; ²National Institute of Mental Health, Klecany, Czech Republic

Background: The underlying symptomatology of obsessive–compulsive disorder (OCD) can be viewed as an impairment in both cognitive and behavioral inhibition, regarding difficult inhibition of obsessions and behavioral compulsions. Converging results from neuroimaging and electroencephalographic (EEG) studies have identified changes in activities throughout the medial frontal and orbital cortex and subcortical structures supporting the cortico-striato-thalamo-cortical circuit model of OCD. This study aimed to elucidate the electrophysiological changes induced by autobiographical and general anxiety scenarios in patients with OCD.
Methods: Resting-state eyes-closed EEG data were recorded in 19 OCD patients and 15 healthy controls. Cortical EEG sources were estimated by standardized low-resolution electromagnetic tomography (sLORETA). The changes in the emotional state were induced by two different scenarios: the autobiographical script related to patient’s OCD symptoms and the script triggering general anxiety.
Results: During the resting state, we proved increased delta activity in the frontal, limbic and temporal lobe and the sub-lobar area in OCD patients. In a comparison of neural activities during general anxiety in OCD patients and the control group, we proved an increase in delta (parietal, temporal, occipital, frontal and limbic lobes, and sub-lobal area), theta (temporal, parietal and occipital lobes) and alpha-1 activities (parietal lobe). Finally, we explored the neural activity of OCD patients during exposure to the autobiographic scenario. We proved an increase in beta-3 activity (left frontal lobe).
Conclusion: Our study proved differences in neural activation in OCD patients and healthy controls during imagination of general anxiety. Exposure to the autobiographic OCD scenario leads to activation of left frontal brain areas. The results show the possibility of using specific scenarios in OCD therapy.

Keywords: anxiety, obsessive–compulsive disorder, autobiographical script, electroencephalography, cognitive-behavior therapy

Every time I hear someone say they are “so OCD” because they frantically cleaned their kitchen that morning, I feel a surge of disappointment in my stomach.

Over the years, we have become conditioned to believe that obsessive compulsive disorder (OCD) is nothing more than liking your shoes lined up, having to count to a certain number or organising your cupboards with labels.

A guide to reducing everyday anxiety

Not only has this become a misconception due to people using the condition as a description for their personality quirks, but even TV shows have added to the stigma – such as Channel 4’s Obsessive Compulsive Cleaners, which added to the belief that having OCD is all about getting down on your hands and knees to scrub a toilet over and over again.

While people often use the term lightheartedly, they don’t realise the damage they’re doing. But this isn’t exactly their fault. It’s a frequent misunderstanding. It’s a misunderstanding that has gone on for too long, and is demoralising to those seriously suffering with the disorder.

As part of OCD, an obsession is an unwanted or unpleasant thought, image or urge that repeatedly enters your mind, causing feelings of anxiety. These can be severe, intrusive thoughts – the fear that if you don’t wash your hands a certain number of times, you will contaminate yourself or someone else. The fear that if you don’t repeatedly check your oven, the house might set on fire. Or the fear that not properly turning the taps off – and doing so over and over again – will cause a flood.

Checking the oven, washing your hands and things like that are the compulsion. And the compulsion is done to ease the anxiety the obsessions cause.

Of course, this isn’t just a standard check. It’s non-stop. Going back to the taps and the oven to check you really did turn it off – because a voice in your head tells you that you didn’t, and that something bad is going to happen, is not a one-off.

These are rituals that can take hours out of your day-to-day life – for some, making it impossible to even leave the house.

There are so many subtypes of the disorder that people aren’t aware of – and they can cause a sufferer such extreme anxiety and feelings of guilt and shame that they do not talk about them.

Harm OCD, for instance, will cause a sufferer to have intrusive thoughts about harming people. They may hide knives away, fearing that they will actually carry out the thoughts. Or maybe they’ll refuse to drive, convincing themselves that they’ll steer the car into someone. Of course, a person with OCD will not act on these feelings. According to cognitive behavioural therapist Helen Tyrer, a person with OCD is actually less likely to harm anyone else due to how overwhelming the fears are. But the thoughts make you think otherwise.

There are also even darker subtypes, including paedophillia OCD (POCD), which causes a person to have awful thoughts about children. They may worry that they are a danger around children. That they might harm a child. Again, these people are not actually in any way harmful – but they will go on to avoid being around children, be that by cancelling on a nephew’s birthday party, or avoiding going near schools or parks.

The intrusive thoughts about harming children are the obsession, while avoiding certain scenarios to prevent danger is the compulsion.

Alongside POCD, other serious subtypes include post-partum OCD – where a mother becomes obsessively scared of harming her child, and sexuality OCD – where a person becomes convinced that they are gay, even when they are not. This can be incredibly confusing for a person with this condition, who is unable to define their sexuality due to their thoughts.

I was officially diagnosed with OCD last year. I had been suffering with a number of symptoms. I was washing my hands up to 60 times, scared that if I didn’t, I’d contaminate myself or someone else and make them sick. It sounds silly, but I worried that if I or someone else became sick because of my own hands they would die.

Other symptoms included taking an hour to get into bed, from frantically checking plugs and light switches, worried that there would be an electrical fire in the night. Leaving the house would be a nightmare for the fear of the doors being unlocked and someone breaking in, and I found myself obsessed with the thought that I’d killed someone while driving and being unable to remember it. At its worst, my OCD was a terrible, debilitating condition that reduced me to tears and even made me question my own life. I felt like I wasn’t living, merely existing, consumed by terrible thoughts and tiresome rituals.

Dr Fiona Challacombe, clinical psychologist at the Centre for Anxiety Disorders and Trauma, Maudsley Hospital and King’s College Hospital, explains that OCD is often thought of as a cleaning disorder or, worse, she says, a “behavioural quirk”.

She adds that though OCD is distressing to live with, it can be treated – most commonly with cognitive behavioural therapy (CBT) or with Selective serotonin reuptake inhibitors (SSRIs), both of which are recommended by the National Institute for Health and Care Excellence (NICE) as first line treatments.

With all of this in mind, we need to start recognising OCD for the life-destroying illness it really is. We need to educate ourselves, and others, too.

Not just to battle the old-fashioned misconceptions surrounding a very misunderstood condition, but to allow those suffering to feel like just that – sufferers – and not as though their illness is some form of ongoing joke between people who just don’t get it.

We need to do better. We can do better. And understanding OCD for what it really is – and what it’s most definitely not – can only take us a step forward in reducing the stigma surrounding mental illness that we sadly still face today.

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The Independent has launched its #FinalSay campaign to demand that voters are given a voice on the final Brexit deal.

Sign our petition here

In 2013, Jerusalem-based BrainsWay began marketing a new type of brain stimulation device that uses magnetic pulses to treat major depressive disorder.

Now, thanks to positive results in a study of 100 patients, the company has received approval from the U.S. Food and Drug Administration (FDA) to market the device for a second psychiatric condition—obsessive-compulsive disorder (OCD).

Katie Hayes, Blake Poland and Mark Hathaway

This summer, wildfires erupted in California, torrential rains flooded parts of Japan, and record-breaking temperatures led to a number of heat-related deaths around the globe. Disasters like these are augmented by climate change, and scientists say extreme weather like this will increase and worsen as climate change accelerates.

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And it’s impacting our mental health.

Given the scale of climate change, it makes sense that people are worried about its impacts. And worry can lead to depression, anxiety, and persistent fear. While worry can be a motivator for action, it can also have the opposite effect, leaving us feeling powerless, overwhelmed and apathetic.

As research scientists who study the interaction between ecology and human health, we’re interested in the ways that climate change impacts our mental health.People can experience everything from altruism, a sense of personal growth, and strong sense of community to post-traumatic stress disorder, panic, and anxiety after a climate-related extreme weather event. While less is known about the positive mental health effects from climate change, the impacts of climate-related extreme weather on mental illness is better established. For example, one year after Hurricane Katrina struck New Orleans, researchers found an increased prevalence of PTSD, mental illness, and suicidal thoughts and plans. Research also suggests that climate change affects pre-existing mental health conditions. One study found that climate change exacerbated obsessive-compulsive disorder, with participants expressing obsessive-compulsive tendencies over wasting water, gas, and electricity; and obsessive fears about flooding and drought.

Like the other impacts of climate change, mental health impacts disproportionately affect different groups. Researchers, like epidemiologist Anthony McMichael, have noted that climate change amplifies existing social inequities. Indigenous people, the poor, seniors, children, and people of color bear the greatest burden of a changing climate.

So what is being done to address the mental health consequences of climate change? Recent scholarship—by us and others—shows that in many places, community-based responses are facilitating recovery, hope, and action.

Here are five community-based programs that are helping people confront—and cope with—the mental health consequences of climate change.

1. REACH NOLA breaks down barriers to provide mental health care after Hurricane Katrina

REACH NOLA is a New Orleans nonprofit collaborative of community-based faith groups, academics, health practitioners, and social service providers to address the mental health recovery of those impacted by Hurricane Katrina. In 2006, REACH NOLA established the Mental Health Infrastructure and Training Project to respond to the mental health effects of the hurricane. MHIT is a mental health care capacity-building project that provides guidance on mental health care training and implementation in at-risk communities.

Research documents how MHIT emerged after the hurricane in the lower 9th ward. The neighborhood was one of the hardest hit in New Orleans and predominantly made up of low-income African Americans with little access to mental health care. Noting the mental health needs of the neighborhood and gaps in care, the president of the Holy Cross Neighborhood Association in the lower 9th ward teamed up with other organizations and mental health clinicians to found REACH NOLA and, subsequently, the MHIT project. Because the HCNA was already a trusted resource to neighborhood residents, it was able to help mental health clinicians reach community members in need.

Here’s how they did it: Before health practitioners entered the community, HCNA community leads provided residents with information and education about depression and the potential for other mental health effects related to disastrous events like the hurricane. The aim was to dispel pervasive stigmas about mental health that would keep people from accessing help. Mental health practitioners then provided treatment to residents. They also trained lower 9th ward residents to offer mental health aid, who were then employed as community health workers in their neighborhood. This opportunity provided mental health services, employment, new career opportunities, and opportunities for residents to be stewards in their neighborhood’s recovery.

2. “Safe Spot” trains businesses and organizations in psychological first aid after a super flood

Bridging community institutions with mental health care providers is a common approach to providing care after a climate-related disaster. The community of High River, Alberta, was left with mental health concerns long after government money and disaster response assistance dried up. In 2013, the town experienced a super flood that displaced the entire town of 13,000 people and resulted in four deaths. According to public health surveillance research, as well as stories from residents, many townspeople reported anxiety, trouble sleeping, and post-traumatic stress disorder following the flood.

In response, the town is currently implementing a mental health initiative called Safe Spot, which trains employees of business and agencies in psychological first aid to support community well-being. An orange dot in the windows of businesses lets community members know that they have a safe space to talk about, and seek support for, their mental health from trained community members. If someone is experiencing a crisis and they need support before they are able to access formal counseling or professional services, they can seek support from a local business or agency who has been trained in psychological community care. The idea is that every door is the right door to support community mental health and well-being.

3. The Transition Town Movement provides a space for connection and environmental activism

Transition Town initiatives throughout the United States, Canada, and around the world are part of a community-driven grassroots movement to help people cope with climate change, peak oil, and ecological degradation. At the heart of the movement is inner transition work, which is based on the idea that the relationship that we have with the natural world is a direct reflection of the relationship we have with our inner landscape.

Individual community members are supported through their inner transitions by community groups. These groups provide a space for residents to talk about fears and concerns about climate change, support each other in building community resilience, and provide opportunities to explore plans to transition to a low-carbon future. According to a study on the adoption of the transition model in 10 towns in Australia, researchers found it helped individuals develop lifestyle changes to reduce carbon emissions. They also found that developing an eco-spiritual connection helped individuals—especially women—incite action on climate change.

In the U.S., Transition U.S. is building a nationwide campaign to support community resilience and emergency preparedness. Called Ready Together, the campaign aims to prepare communities for environmental disasters—like climate-augmented extreme weather—through educational materials and action-oriented toolkits. The initiative is currently being launched with plans to include podcasts, webinars, workshops, and a Ready Together handbook to prepare communities for disasters. The campaign targets physical preparedness as well as mental health needs after a disaster.

4. Transformative processes to reconnect people with themselves and their environment

In some cases, communities are supporting individuals’ spiritual growth to help them cope with climate change. The Work That Reconnects is a group process for cultivating spiritual growth first developed by Joanna Macy in the U.S. and now facilitated by trained educators around the globe. It’s rooted in the belief that addressing climate change and other ecological crises starts with cultivating appreciation and gratitude for the Earth. At the same time, the facilitated groups provide safe places where people can share feelings of fear, doubt, guilt, and even despair. Recognizing that we experience pain about climate change because we are connected to all life and future generations—and understanding that we are not alone in experiencing this—can empower action.

The process employs a wide variety of meditative and interactive practices, many involving the use of the imagination to stimulate creativity and cultivate empathy. In a Work That Reconnects workshop led by Mark Hathaway for undergraduate environmental studies students at the University of Toronto, one student wrote in their reflection that the approach “highlights the interconnectedness of the participants with one another, as well as with the greater world, which once again leads to an emotional connection.” Another student wrote that the process built a sense of empowerment and helped them experience “the capacity to instigate change.”

5. One Earth Sanga: the online community that supports spiritual growth and ecological awareness

Some community-based mental health programs also help people reckon with the inequality that’s exacerbated by climate change. One Earth Sanga is an online platform that helps people respond to the climate crisis through Buddhist teachings and its EcoSattva training program. This platform was co-founded by two Buddhist environmentalists, Kristin Barker and Lou Lenard, and was created in partnership with the Insight Meditation Community in Washington state. The online platform provides a digital space to learn, reflect, and take action on climate change.

One of the teachings on this platform—and highlighted in its training program—is about confronting Whiteness and addressing privilege as a necessary part of confronting climate change. The equity training that One Earth Sanga provides can be an important reckoning for many who sympathize with people on the front lines of climate change but may not recognize the role privilege and Whiteness plays in shielding them from many of the social, emotional, physical, and mental health consequences of climate change.

Reposted with permission from our media associate YES! Magazine.

August 21, 2018

Researchers examined whether adjunctive gabapentin or memantine and standard treatment with a selective serotonin-reuptake inhibitor (SSRI) might lead to further improvements in patients with OCD.

Supplementing standard obsessive-compulsive disorder (OCD) medication with glutamatergic medication such as gabapentin and memantine has no additional positive effect in patients with OCD, according to research published in the Journal of Psychiatric Research.

To determine whether adjunctive gabapentin or memantine and standard treatment with a selective serotonin-reuptake inhibitor (SSRI) might lead to further improvements in patients with OCD researchers conducted a double-blind placebo-controlled trial in which 99 outpatients with OCD (average age 29.59) were randomly assigned to receive one of three treatments for 8 weeks: fluoxetine plus gabapentin, fluoxetine plus memantine, or fluoxetine plus placebo.

Researchers used the Yale-Brown Obsessive Compulsive Scale to rate patients’ OCD symptoms at baseline, 4 weeks, and trial completion. To be included in the study, participants were required to have a baseline score of ≥15 points. Mean scores at baseline differed significantly between groups: 18.70 for gabapentin, 16.36 for placebo, and 16.39 for memantine.

Neither the gabapentin nor the memantine group demonstrated significant score change over time. The placebo group was actually found to have a superior Time X Group interaction, with an overall average reduction of 4.24 points. In comparison, gabapentin dropped 4.03 points and memantine dropped 3.15 points (P =.042).

There were no significant differences between the groups in response rates from baseline to 4 and 8 weeks. Adverse events in the memantine group tended toward rash; in the placebo group toward anxiety; and in the gabapentin group toward drowsiness, anxiety, and drowsiness plus anxiety.

The researchers reported several study limitations, including the risk for unknown confounding factors inherent in outpatient treatment such as family issues and job strains.

“The key finding of the present study was that neither adjuvant gabapentin nor adjuvant memantine had better effects on symptoms of OCD than a placebo,” said the researchers. “The present pattern of results therefore adds to the current literature on the treatment of this disorder in that adjuvant memantine and adjuvant gabapentin does not appear to be justified.”

Reference

Farnia V, Gharehbaghi H, Alikhani M, et al. Efficacy and tolerability of adjunctive gabapentin and memantine in obsessive compulsive disorder: double-blind, randomized, placebo-controlled trial [published online July 21, 2018]. J Psychiatr Res. doi:10.1016/j.jpsychires.2018.07.008

OCD is often treated with psychotherapy and antidepressant medication, but TMS has been explored as an option.

About 2.3% of adults in the US have OCD at some point in their lifetime, and the condition is more common in women than men.

The most common side effect in the clinical trial was headache, which occurred in 37.5% of the treatment group and 35.3% of the sham treatment group. Other possible side effects were mild, and included temporary jaw or face pain, muscle spasms or twitching, and neck pain.

The device shouldn’t be used if you have any other implants or metallic devices in or near your head, such as cochlear implants, stents, aneurysm clips or coils, and vagus nerve stimulators, among others. And jewelry and hair barrettes are a problem too.

“During treatment with the device, the patient must use earplugs to reduce exposure to the loud sounds produced by the device,” according to the FDA, and anyone who has had a seizure should discuss it with their doctor before undergoing the treatment.

The marketing approval was through a program for low- to moderate-risk devices that are new, and there’s no equivalent device already available to patients.

“Transcranial magnetic stimulation has shown its potential to help patients suffering from depression and headaches,” Carlos Peña, director of the Division of Neurological and Physical Medicine Devices in the FDA’s Center for Devices and Radiological Health, said in a statement. “With today’s marketing authorization, patients with OCD who have not responded to traditional treatments now have another option.”

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August 17, 2018

No significant moderators were identified for treatment outcome, suggesting that baseline characteristics cannot be used to predict the effect of adjunct d-cycloserine on children with OCD.

A study published in the Journal of Affective Disorders assessed the efficacy of d-cycloserine with cognitive behavioral therapy (CBT) for the treatment of pediatric obsessive-compulsive disorder (OCD). No significant moderators were identified for treatment outcome, suggesting that baseline characteristics cannot be used to predict the effect of adjunct d-cycloserine on children with OCD.  

Researchers extracted data from a controlled trial in which children (7-17 years of age) were randomly assigned to receive either d-cycloserine with CBT (n=70) or placebo with CBT (n=72). Outcome measures included improvements on the Children’s Yale-Brown Obsessive-Compulsive Scale (CY-BOCS) and on the Clinical Global Impressions Scale-Severity. Researchers also assessed various baseline factors, including sociodemographic characteristics, family accommodation of the child’s OCD, anxiety and depression symptoms, level of impairment caused by OCD, and the presence of externalizing behaviors.  

No baseline variables were found to moderate the effects of d-cycloserine augmentation on CBT outcome. As such, it remains unclear which patient demographics may most benefit from adjunct d-cycloserine. However, researchers identified several factors associated with a lower likelihood of achieving remission across both treatment modes, including higher family accommodation scores (odds ratio [OR], 0.94; 95% CI, 0.91-0.98), higher impairment scores (OR, .95, 95% CI, 0.92-0.99), higher depression scores (OR, 0.96; 95% CI, 0.92-0.99), and higher externalizing scores (OR, 0.93; 95% CI, 0.88-0.98). Additionally, worse scores on the CY-BOCS at baseline were associated with higher levels of impairment, higher levels of depression and anxiety, higher family accommodation (all P .001), and higher externalizing behavior scores (P =.024). Higher Clinical Global Impressions Scale-Severity scores at baseline were correlated with a previous history of depression (P .05), higher impairment and depression scores (both P .001), and more severe externalizing symptoms (P =.022). Endorsement of the “insight” item on the CY-BOCS at baseline was associated with linear improvements over time (P =.03).

These results identify several predictive factors for remission in children with OCD and may be useful for clinicians in tailoring their treatment approach, although the impact of adjunctive d-cycloserine requires further investigation.

See full study for a list of disclosures.

Reference

Wilhelm S, Berman N, Small BJ, Porth R, Storch EA, Geller D. D-cycloserine augmentation of cognitive behavioral therapy for pediatric OCD: predictors and moderators of outcome [published online July 20, 2018]. J Affect Disord. doi: 10.1016/j.jad.2018.07.042

Abstract

For children and adolescents with uncomplicated psychiatric disorders, pediatricians are often the first prescriber of psychiatric medications. Mental health disorders commonly treated by pediatricians include attention-deficit/hyperactivity disorder (ADHD), depression, and anxiety. There are several safe and effective first-line medications for these disorders. For ADHD, stimulants and nonstimulants can be used as first-line interventions. For anxiety and depression, selective serotonin reuptake inhibitors are well-established treatments and often well-tolerated. With appropriate support and training, pediatricians can increase access for children to necessary mental health treatments. [Pediatr Ann. 2018;47(8):e311–e316.]

Before treatment, 70 percent of patients were classified as having severe O.C.D., and nearly three-quarters had previously been in therapy. Some 42 percent were taking antidepressants. The study did not have a control group.

At the Weill Cornell program, the participants, ages 10 to 15, practice exposures in a mock class. Dr. Falk gives them assignments to induce anxiety based on their individual triggers. She told the 12-year-old in the red tie and blazer — who is petrified of not acting “right” out of fear it will cause something bad to happen — to “be really inappropriate and rude, and eat in the middle of class and make a mess.”

She instructed a 12-year-old girl in a Harry Potter “Butterbeer” T-shirt to write about what she did on her recent birthday. The child has many compulsive behaviors involving writing and often has to erase and rewrite, something that causes problems in school.

For a 10-year-old with braces and a purple streak in her hair whose O.C.D. is triggered by not knowing certain things, Dr. Falk instructed the other kids to “tell me something secret and rude” that she couldn’t hear.

As class got underway one day, the boy, at Dr. Falk’s urging, ditched his tie and blazer. He was eating an orange. “Make fun of me,” encouraged a 14-year-old who has spent most of the session doodling.

The girl with the writing compulsion put down her pen and wailed. “Oh my god. It looks like an ‘I’ with a top hat on it,” she said, staring at her paper.

Dr. Falk looked it over. “I can understand it perfectly,” she said. “Let it go, which is going to be better for you long-term.”

Before the kids left, Dr. Falk wrote a new homework assignment on a colorful notecard for each of them, more exposures to complete before the next group meeting — the very next day.